An 82-year-old man is evaluated for dizziness. He has felt dizzy for the past year, and the sensation is worsening. The dizziness occurs primarily when he ambulates; however, it does not bother him while seated or recumbent, and is not accentuated by head turning. He denies a sensation of spinning or movement, headache, focal weakness, palpitations, or muscle pain. He fell twice over the last year, but he did not sustain any significant injuries. His hearing has been poor for several years. He has visual difficulties which makes reading difficult.
He has a history of diet-controlled diabetes mellitus, degenerative joint disease of his knees and hips, hypertension, chronic obstructive pulmonary disease, mild cognitive impairment, hyperlipidemia, and post-herpetic neuralgia. His medications include chlorthalidone, ibuprofen, acetaminophen, lovastatin, and a tiotropium inhaler.
His blood pressure is 136/70 mm Hg supine and 130/72 mm Hg standing, and pulse is 84 /min. There is a 2/6 holosystolic murmur at the apex. Breath sounds are generally decreased. Hearing is grossly decreased in both ears. Vision corrects to 20/70 in both eyes. His cranial nerves are intact. There is no nystagmus. Deep tendon reflexes are symmetric. There is decreased vibration, position, and light touch sensation below the knees bilaterally. He cannot walk heel-to-toe, and the Romberg test is positive. He has a slightly broad-based gait with decreased accessory movement. Rapid alternating movements are decreased symmetrically. His score on a Mini-Mental State Examination is 25/30, decreased from 26/30 one year ago. He answers two depression screening tests normally.
Lab tests, including a complete blood count, comprehensive metabolic panel, B12 level, serum RPR, and thyroid function tests are normal. A hemoglobin A1C is 7.5%. An electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy.
The patient would most likely benefit from which of the following?

Question

An 82-year-old man is evaluated for dizziness.  He has felt dizzy for the past year, and the sensation is worsening.  The dizziness occurs primarily when he ambulates; however, it does not bother him while seated or recumbent, and is not accentuated by head turning.  He denies a sensation of spinning or movement, headache, focal weakness, palpitations, or muscle pain.  He fell twice over the last year, but he did not sustain any significant injuries.  His hearing has been poor for several years.  He has visual difficulties which makes reading difficult.
He has a history of diet-controlled diabetes mellitus, degenerative joint disease of his knees and hips, hypertension, chronic obstructive pulmonary disease, mild cognitive impairment, hyperlipidemia, and post-herpetic neuralgia.  His medications include chlorthalidone, ibuprofen, acetaminophen, lovastatin, and a tiotropium inhaler.
His blood pressure is 136/70 mm Hg supine and 130/72 mm Hg standing, and pulse is 84 /min.  There is a 2/6 holosystolic murmur at the apex.  Breath sounds are generally decreased.  Hearing is grossly decreased in both ears.  Vision corrects to 20/70 in both eyes.  His cranial nerves are intact.  There is no nystagmus.  Deep tendon reflexes are symmetric.  There is decreased vibration, position, and light touch sensation below the knees bilaterally.  He cannot walk heel-to-toe, and the Romberg test is positive.  He has a slightly broad-based gait with decreased accessory movement.  Rapid alternating movements are decreased symmetrically.  His score on a Mini-Mental State Examination is 25/30, decreased from 26/30 one year ago.  He answers two depression screening tests normally.
Lab tests, including a complete blood count, comprehensive metabolic panel, B12 level, serum RPR, and thyroid function tests are normal.  A hemoglobin A1C is 7.5%.  An electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy.
The patient would most likely benefit from which of the following?

Quizplus · Accepted Answer

Dizziness is a common and difficult complaint to evaluate in the aging population, and encompasses different syndromes as shown above. One study found the most common causes of dizziness in various settings (primary care, ED, dizziness clinic) were: peripheral vestibular dysfunction (40%), presyncope and disequilibrium (25%), psychiatric disorder (15%), brainstem vestibular lesion (10%), and uncertain (10%). This patient most likely has disequilibrium (dizziness mainly with walking) that may be due to decreased vision, peripheral neuropathy, deconditioning, decreased peripheral vestibular function, and possible early Parkinson's. Balance training exercises would be the most appropriate next step in addition to improved physical conditioning, vision correction, improving hearing deficiencies, instruction in assistive devices, and evaluation of the patient's living space for safety features. (Choice B) Holter monitor is useful to evaluate for arrhythmias, which is less likely in this patient given the relatively normal EKG and lack of presyncope symptoms. (Choice C) Meclizine is used for symptomatic treatment of vertigo, which is less likely in this patient given the lack of symptoms with head turning. (Choice D) Lovastatin's main side effect is myalgias with elevated CK, and is associated with dizziness < 1% of the time. (Choice E) Tight glycemic control may decrease further progression of diabetic complications (i.e., retinopathy, neuropathy, nephropathy), but it may cause hypoglycemic episodes in the elderly and worsen dizziness. Educational objective: Many dizzy elderly patients may not have a cardiac or central nervous system etiology. Other factors causing dizziness include decreased vision, medications, peripheral neuropathy, deconditioning, and abnormal peripheral vestibular function (most common). Comprehensive balance training exercises may be beneficial in these patients. __________ References: Causes of dizziness in elderly patients in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/20458102) Dizziness in elderly men. (http://www.ncbi.nlm.nih.gov/pubmed/7963205) Dizziness among older adults: a possible geriatric syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/10691583)

An 82-Year-Old Man Is Evaluated for Dizziness