Geriatric Dizziness Evolving Diagnostic and Therapeutic Approaches for the Emergency Department Alexander X. Lo, MD, PhD a, *, Caroline N. Harada, MD b,c INTRODUCTION Dizziness is a common, 1,2 but challenging complaint in the elderly because descrip- tions of symptoms are often vague and require a broad differential diagnosis. 3,4 Previ- ousl y beli ev ed to repr esent a discrete di agnosis related to specif ic me di cal conditions, Supported by a grant from the John Hartford Foundation. a Department of Emergency Medicine, Universi ty of Alabama Birmingham, OHB 251, 619 19th Street South, Birmingham, AL 35249-7013, USA; b Birmingham Veterans Affairs Medical Center, 700 19th Street South, Birmingham, AL 35233, USA; c Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama Birmingham, CH-19-201, 1720 2nd Avenue South, Birmingham, AL 35294, USA * Corresponding author. E-mail address: [email protected]KEYWORDS Dizziness Geriatrics Vertigo Stroke KEY POINTS Dizziness is a common but challenging complaint in the elderly because it is often difficult to describe and encompasses a br oad dif ferential di agnosis from the life threat ening to the relatively benign. Di zzines s in the elder ly pati ent must be app roached as a sy ndrome, not a dis cr ete medic al diagnosis. The history is often critical to determinin g the most likely cause of dizziness . Common tes ts in the eva luatio n of dizziness, including magnetic resonance imaging, have subopt imal sensitivity and specificity, and an overall lack in empiri c validat ion. The community or clinic physician evaluating a geriatric patient complaining of dizziness that is not clearly chronic or does not have a known benign cause, such as benign parox- ysmal positional vertigo, should immediately refer the patient to the emergency depart- ment to rule out serious causes, such as a stroke. Even with comprehens ive diagnost ic testing, the true cause may still be elusiv e. Disposition decisions are not straightforward. The risk of discharging a patient with an unclear cause of dizziness must be weighed against the adverse eff ects of hospital admis- sions. Clin Geriatr Med 29 (2013) 181–204 http://dx.doi.org/10.1016/j.cger.2012.10.004 geriatric.theclinics.com 0749-0690/13 /$ – see front matter 2013 Elsevier Inc. All rights reserved.
G e r i a t r i c D i z z i n e ssEvolving Diagnostic and Therapeutic Approaches
for the Emergency Department
Alexander X. Lo, MD, PhDa,*, Caroline N. Harada, MD
b,c
INTRODUCTION
Dizziness is a common,1,2 but challenging complaint in the elderly because descrip-tions of symptoms are often vague and require a broad differential diagnosis.3,4 Previ-ously believed to represent a discrete diagnosis related to specific medical conditions,
Supported by a grant from the John Hartford Foundation.a Department of Emergency Medicine, University of Alabama Birmingham, OHB 251, 619 19thStreet South, Birmingham, AL 35249-7013, USA; b Birmingham Veterans Affairs Medical Center,
700 19th Street South, Birmingham, AL 35233, USA;
c
Department of Medicine, Division ofGerontology, Geriatrics and Palliative Care, University of Alabama Birmingham, CH-19-201,1720 2nd Avenue South, Birmingham, AL 35294, USA* Corresponding author.E-mail address: [email protected]
KEYWORDS
Dizziness Geriatrics Vertigo Stroke
KEY POINTS
Dizziness is a common but challenging complaint in the elderly because it is often difficultto describe and encompasses a broad differential diagnosis from the life threatening to therelatively benign.
Dizziness in the elderly patient must be approached as a syndrome, not a discrete medicaldiagnosis.
The history is often critical to determining the most likely cause of dizziness.
Common tests in the evaluation of dizziness, including magnetic resonance imaging, havesuboptimal sensitivity and specificity, and an overall lack in empiric validation.
The community or clinic physician evaluating a geriatric patient complaining of dizziness
that is not clearly chronic or does not have a known benign cause, such as benign parox-ysmal positional vertigo, should immediately refer the patient to the emergency depart-ment to rule out serious causes, such as a stroke.
Even with comprehensive diagnostic testing, the true cause may still be elusive.
Disposition decisions are not straightforward. The risk of discharging a patient with anunclear cause of dizziness must be weighed against the adverse effects of hospital admis-sions.
Clin Geriatr Med 29 (2013) 181–204http://dx.doi.org/10.1016/j.cger.2012.10.004 geriatric.theclinics.com
0749-0690/13/$ – see front matter 2013 Elsevier Inc. All rights reserved.
dizziness is now understood to be a geriatric syndrome, caused and defined bymultiple underlying factors,5,6 and is recognized for its complexity. Although the diag-nosis and management of dizziness have been investigated in many studies, expertson the condition have nonetheless highlighted the limited evidence.5,7,8 Most patientswith dizziness have a benign condition; however, a small number (<5%) harbora serious and potentially life-threatening cause.9 Posterior circulation stroke isperhaps the most challenging cause, because patients can have symptoms that areidentical to peripheral vertigo. National trends show a steady increase in computedtomography (CT) and magnetic resonance imaging (MRI) studies for patients withdizziness in the emergency department (ED),2 yet this practice is not uniform.9 Thekey issue is how to identify the serious causes of dizziness while being cost-efficient and avoiding unnecessary diagnostic tests.
EPIDEMIOLOGY
A 2012 review using the National Health Interview Survey, which is a national database,reported that 19.6% of people aged 65 years and older had dizziness or balance prob-lems in the previous year.10 This estimate is comparable with the quoted prevalencerange of 21% to 29% in other community-based and population-based surveys of elderlypersons in the United States6,11 and the United Kingdom.12Data on the incidenceof dizziness is lacking, particularly in elderly persons, although a Dutch populationsurveyestimated an incidence rate of 47.1 per 1000 person-years across all ages.13
In the United States, dizziness accounts for 2.6 million (or 3.3%) of ED visits peryear. The rate of visits increases with age and is higher among women.1 It is unclearwhat particular features of dizziness prompt these patients to seek care in the ED asopposed to their primary care provider.
TEMPORAL CHARACTERISTICS OF DIZZINESS
Dizziness tends to be episodic; fewer than 5% of patients with dizziness report havingcontinuous symptoms.6,14 Estimates of the frequency of symptoms have variedacross different study populations. A community survey found 35% reported havingdizziness daily, 14% weekly, and 51% monthly.6
THE UNDERLYING CAUSE OF DIZZINESS
The causes of dizziness in the older adult are many and varied ( Fig. 1 ). Studies havevaried on the distribution of underlying causes for dizziness The discrepancy stemsfrom the differences between study populations (eg, community vs clinic patients,all ages vs elderly), sampling methods (eg, random sample vs volunteers), case defi-nition (eg, stroke vs central vertigo) and diagnostic criteria (eg, physician impression vsICD-9 diagnostic codes). In a study of the National Hospital Ambulatory Medical CareSurvey (NHAMCS) 1993 to 2005 sample, Newman-Toker and colleagues1 found 15%of all patients with dizziness had predefined dangerous diagnoses, including 4% withstroke. Otovestibular causes accounted for 32.9%, mental disorders 7.2%, and
among specifically coded cardiovascular diseases, arrhythmia (3.2%) was codedmore often than angina (0.9%) or myocardial infarction (0.8%). Diagnoses were basedon ICD-9 codes, but 22.1% of cases received only a symptom diagnosis withouta diagnosis of the cause (eg, dizziness).
Outpatient clinic surveys have reported that as much as 6% of dizziness is due tostroke,5 but the reported proportion of stroke and cardiovascular diseases was ashigh as 15% in 1 small ED series.15 The risk of serious diagnoses increases with age.
In the national ED sample reported by Newman-Toker and colleagues,1 the risk washigher in the elderly, with 21% of dangerous diagnoses in persons 50 years and older,compared with 9% in those less than 50 years. A psychiatric cause of dizziness, oftenconsidered a diagnosis of exclusion, is also less likely in older patients, whereas moreserious underlying causes are more likely.1,16 Even though the proportion of dizzinessdue to stroke is small, data from a small series found a remarkably high mortality rate of
40% from cerebellar strokes presenting as dizziness,
17
supporting the argument infavor of using costly resources to rule out strokes in the dizzy elderly patient.
RISK FACTORS FOR DIZZINESS
Aside from increasing age and female gender, several clinical characteristics havebeen independently associated with dizziness as shown in Table 1. These datawere derived from multivariate analyses of 3 population-based studies from the United
Fig. 1. Underlying causes of dizziness in the elderly. Conditions requiring rapid diagnosis inthe ED are shown in bold italic type.
States,6 the United Kingdom,12 and the Netherlands.13 Tinetti and colleagues6 also re-ported a dose-response relationship involving these characteristics, whereby theprevalence of dizziness increased with increasing number of characteristics present,from 10% in persons with none to 68% in persons with 5 or more, supporting thehypothesis that dizziness in the elderly has a multifactorial cause. The lack of robustprospective data prohibits the establishment of a true cause and effect relationship.18
IMPACT OF DIZZINESS
The most obvious impact of dizziness in the elderly is a fall. Dizziness increases the risk of falls in the elderly,19–21 with approximately half of patients with vestibular disease report-ing a fall, and half of thatgroup reporting more than1 fall inthe past year.21 Accidental fallshave been reported to increase the risk of head injury in theelderly,22andtheelderlyareatincreased risk of mortality from a traumatic head injury compared with younger people.23
Even in the absence of a fall or trauma, dizziness alone negatively affects functionand quality of life in the elderly. The adverse effects of dizziness include increasedanxiety, decline in function, fear of falling, limitations of activities in everyday life, along
with an indirect substantial health care cost.18,24,25 Two separate population-basedstudies have found that between 50% and 60% of patients with dizziness reportedmoderate to severe limitations on everyday life.24,25
The economic impact of dizziness is also worth considering. Patients presenting tothe ED with dizziness, compared with those without, were higher users of health careresources because they were more likely to arrive by ambulance, undergo CT or MRIimaging studies, stay longer in the ED, and be admitted to the hospital.1
Table 1
Patient and clinical characteristics associated with dizziness
Characteristic
Tinetti et al,6
2000 (US)Stevens et al,
12
2008 (UK)
Maarsingh
et al,13
2010 (TheNetherlands)
OR 95% CI OR 95% CI OR 95% CI
Female NR 1.81 1.38–2.38 NR
Living alone NR NR 1.3 1.2–1.4
Educationa NR NR 1.2 1.1–1.3
5 medications 1.3 1.01–1.68 NR NR
Depression 1.36 1.02–1.8 2.17 1.56–3.01 NR
Anxiety 1.69 1.24–2.30 NR NR
Poor hearing 1.27 0.99–1.63 1.81 1.35–2.43 NR
Poor vision NR 1.72 1.23–2.39 NR
Any cerebrovascular disease NR NR 1.3 1.1–1.5
Any cardiovascular disease NR 1.34 0.91–1.96 NR
Past myocardial infarction 1.31 1.00–1.71 NR NR
Hypertension NR NR 1.2 1.1–1.3
Abnormal heart rhythm NR 1.85 1.23–2.77 NR
Grip strength Third vs first quintile NR 0.67 0.46–0.98 NRFourth vs first quintile NR 0.41 0.25–0.68 NRFifth vs first quintile NR 0.58 0.32–1.00 NR
Abbreviation: NR, not reported.a Education compared elementary versus college/university.
THE DIAGNOSTIC APPROACH TO THE PATIENT WITH DIZZINESS
Overview
The challenge for the ED physician taking care of a dizzy elderly patient is to rule outpotentially life-threatening causes of dizziness, identify the cause of dizziness (to the
extent possible), and design a management plan. Overlap exists in the presentation of benign and dangerous dizziness, and seemingly benign features, such as isolateddizziness, can mask a potentially life-threatening cause, although this is rare(<1%).26,27
A detailed list of recommended history, physical examination, laboratory tests andimaging studies, and their rationales are provided in Table 2, and more elaboratediscussions on their respective usefulness or accuracy are discussed in the followingsections. The discussions address the global complaint of dizziness in the ED, beyondvertigo alone. The application of history and physical examination components todifferentiate peripheral versus central vertigo is also discussed.
History
Dizziness is a self-reported subjective symptom that is vulnerable to different interpre-tations by both patients and physicians.5,28,29 The symptom parameters introduced byDrachman and Hart30 have helped to establish some consistency in its definition bycategorizing dizziness into vertigo, presyncopal lightheadedness, disequilibrium,and other dizziness ( Table 3 ).
Although the dizziness subtypes of Drachman and Hart can be very helpful, as manyas 56% of patients described symptoms that fit into multiple rather than individual
discrete subtypes.6,31
This was especially true for older adults. Tinetti and colleagues6
reported 59% with loss of balance, 33% with vertigo, 42% with presyncope, and 17%with other sensations, in addition to at least 1 of the other subtypes. One study withmore than 300 patients reported that more than half of patients were vague, inconsis-tent, or contradictory in describing their symptoms.28 In addition, a population-basedstudy of ED patients found that a report of vertigo, compared with other dizzinesssymptom subtypes, could not differentiate the presence or absence of stroke.26 Incontrast, another study reported that a description of dizziness as vertigo accuratelypredicted an underlying peripheral vestibular disease with a sensitivity as high as87%.32
Specific historical features, including frequency, tempo, onset, triggers, and asso-ciated symptoms of dizziness have been found to be useful in distinguishing betweenperipheral and central causes of vertigo ( Table 4 ).4,7,33 A systematic review byTarnutzer and colleagues7 explored the accuracy of various clinical history elementsto discriminate between peripheral and central vertigo. They found that multipleprodromal dizziness episodes, age more than 50 years, and a normal result for thehead impulse test were strong predictors of stroke, whereas the absence of dangerous signs in the head impulse-nystagmus-test of skew (HINTS) battery of tests( Table 5 ) was a very strong (negative likelihood ratio of 0.02) predictor of vestibularneuritis. HINTS is discussed below in Physical Examination section.
A retrospective analysis of 907 consecutive patients presenting to a university EDwith dizziness incorporated the application of the ABCD2 scoring system for transientischemic attack (TIA). This study determined a potential usefulness for the ABCD2score as a stroke screen in patients with dizziness.34 The ABCD2 TIA score incorpo-rates Age, Blood pressure, Clinical features, Duration and Diabetes to predict the riskof stroke after a TIA.35,36 Critics have challenged its usefulness based on the relativelysmall proportion of patients with confirmatory neuroimaging (35%), the biased referral
of a tertiary patient population with greater likelihood of dizziness with serious(cerebrovascular) causes, the reliance on chart review, and the modest calculatedsensitivity (86%) and specificity (58%).37 Nonetheless, the lack of an alternative
decision aid and wide practice variability merit further investigation of the usefulnessof this instrument as a screening tool for dizziness related to stroke. Inclusion of olderpatients in future studies is critical.
Medication History
As many as 1 in 4 cases of dizziness have been attributed to medications.10,38
Different classes of commonly prescribed medications can exert effects via multiple
Table 2
(continued )
Symptoms and Characteristics Rationale
Head, eyes, ears, nose, and throat
Ear examination Rule out otitis media, mastoiditis; test hearing
Vestibular examination Dix-Hallpike for BPPV or other tests of vestibulardizziness (see text)
Neurologic examination
Eye examination Evaluate for nystagmus (see Table 4) or visionchanges (may suggest stroke)
Speech/language Dysarthria or aphasia suggests stroke
Motor examination Focal weakness suggests stroke; global weaknesssuggests deconditioning
Adapted from Tusa RJ, Gore R. Dizziness and vertigo: emergencies and management. Neurol Clin2012;30(1):61–74. vii–viii; Kerber KA. Vertigo and dizziness in the emergency department. EmergMed Clin North Am 2009;27(1):39–50. viii.
pathways ( Table 6 ). Many psychiatric and antiepileptic medications cause dizzinessthrough effects on the central nervous system. Cardiac medications, especially anti-hypertensive medications such as beta-blockers and calcium channel blockers,have been independently associated with dizziness6 and can cause a drop in bloodpressure, leading to a presyncopal type of dizziness. Diuretics can theoretically causesufficient hypovolemia to cause dizziness. Any ototoxic drug, such as aminoglycosidicantibiotics, can cause dizziness through otovestibular effects.39,40 When inquiringabout medications, it is important to identify new medications or new dosages of usualmedications that may have preceded the current episode of dizziness.
Physical Examination
Whether the patient is seen in a general practice clinic or the ED, a thorough examina-tion is recommended, with special attention paid to the otolaryngologic and neurologicexaminations. The physical examination serves the dual purpose of confirminga benign vestibular cause of dizziness if present, while simultaneously screening forsigns and symptoms that could signal a possible underlying neurologic or cardiaccause that is more serious.
Table 5
Accuracy of HINTS
Test Sensitivity (%) Specificity (%) NLR PLR
Head impulse test 85 95 0.16 18.39
Gaze-evoked nystagmus 38 92 0.68 4.51
Test of skew 30 98 0.71 19.66
HINTS 98 85 0.02 NR
Abbreviations: NLR, negative likelihood ratio; PLR, positive likelihood ratio.Data from Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a stroke?
A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011;183(9):E571–92.
Table 6
Medications that may cause dizziness
Hypothesized Mechanism Medication Category
Central nervous system AnticonvulsantsAntidepressantsAntipsychoticsAnxiolytic/sedativeMood stabilizers
Adapted from Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. MedClin North Am 2006;90(2):291–304; Tinetti ME, Williams CS, Gill TM. Dizziness among older adults:a possible geriatric syndrome. Ann Intern Med 2000;132(5):337–44.
Classic teaching suggests several physical examination maneuvers that can beused to distinguish peripheral from central vertigo.4 A summary of physical examina-tion findings that can help distinguish peripheral from central vertigo4,7,33,41–44 isprovided in Table 4. The Dix-Hallpike45 (or Nylan-Barany) test (see Fig. 2 ) has beenthe main confirmatory examination for benign paroxysmal positional vertigo (BPPV)for years, but 1 review found only modest to moderate sensitivity (59%–87%).43 TheSide-Lying maneuver has been recommended as an alternative maneuver for patientsunable to participate in the Dix-Hallpike, but had a sensitivity of only 65%.43 Theseestimates were derived from samples of fewer than 30 patients and the gold standardagainst which these maneuvers are measured is usually clinical judgment, which isarguably subjective.46 Although the Dix-Hallpike maneuver is sensitive for posteriorsemicircular canal BPPV, 10% of BPPV affects the horizontal semicircular canal;the Supine Roll test can be used in these cases,47 but sensitivity and specificity forthis test have not been determined. A description of the Supine Roll test is availableonline at http://www.mayoclinicproceedings.org.
Fig. 2. Dix-Hallpike maneuver. (1) The patient sits upright while the examinee rotates thepatient’s head 45 to one side. (2) With eyes open, the patient lies back with head hangingslightly below the level of the examination table while the examiner observes for nystagmusand inquires about subjective vertigo. Latency, duration, and direction of nystagmus shouldbe noted. (3) If negative, repeat the maneuver with patient’s head rotated to the oppositeside. (From Tusa RJ. Vertigo. Neurol Clin 2001;19:39; with permission.)
Recent studies have proposed a specific battery of tests termed HINTS (horizontalhead impulse test, nystagmus and test of skew) that can be performed at the bedsideand with 100% sensitivity and 96% specificity, based on 101 patients identified froman academic hospital ED and inpatient stroke service.48 Results did not separate EDpatients from the stroke service. The accuracy of HINTS and its component tests froma systematic review are shown in Table 5. HINTS awaitsfurther validation studies in otherpatient populations, especially the elderly, before it proves to be an effective predictionrule.7 A video demonstration of the HINTS battery of tests is available online at http:// stroke.ahajournals.org/content/suppl/2009/10/01/STROKEAHA.109.551234.DC1.html.
In a review of the accuracy of dizziness tests involving 26 studies, Dros andcolleagues43 found that none was conducted exclusively in elderly patients; only 1 studyreported a median age greater than 65 years (79 years, range 33–90 years) and theremainder of the studies that reported age had a mean age ranging from 47 to 64 years.49
Laboratory Tests
Laboratory studies help to rule out metabolic, toxicologic, infectious, and cardiaccauses of dizziness. Complete blood counts and basic metabolic panels should, if possible, be interpreted in the context of prior results, as certain chronic abnormalities(eg, anemia, kidney disease) may be more common in the elderly. When a cardiaccause is suspected, clinicians are encouraged to lower their threshold for orderingcardiac enzymes, as acute coronary syndromes can be subtle in the elderly.50
Radiologic Studies
CT and MRI studies of the brain are often recommended to investigate serious causes
of dizziness. There are currently no guidelines and little evidence to clarify the role of brain imaging studies in dizziness. There is large variation in the use of brain imagingfor ED patients with dizziness although increased imaging rates did not translate intohigher rates of stroke diagnoses.9 Given the increasing rates of CT scans in the ED,51 itis not surprising that a recent study on the efficiency of brain CT scans for patients pre-senting to the ED with dizziness found that only 6% of all CT scans identified a centralnervous system cause, such as a stroke or intracranial mass.26
CT scans of the head are used primarily to evaluate for acute intracranial bleeds,skeletal injuries, anatomic changes (hydrocephalus, midline shift, cerebral atrophy),or space-occupying lesions. The sensitivity of CT scans in diagnosing acute ischemic
strokes is poor (16%).7 Diffusion-weighted MRI is more sensitive, especially forpathology in the posterior circulation but is far from perfect, with only 83% sensitivityoverall and 80% in the first 24 hours.7,52
Among northern California hospitals, there was a 1.5-fold difference in the use of head CT and a 6.4-fold difference in the use of brain MRI for patients with dizzinessin the ED, even after adjusting for site differences. Higher use of CT and MRI didnot translate into an increase in stroke diagnosis.9
In a retrospective study of ED patients with vertigo or dizziness based on ICD-9codes who underwent a head CT scan, only 2.2% (10/448) of initial head CT scanshad a positive finding, and of those, only 7 of the 10 represented an acute process.
Of the 448 initial studies, 87 received a follow-up MRI within an unspecified timeperiod, but MRI changed the CT diagnosis from a false-negative to a true-positiveprocess in 16% of cases and acutely in 8% of cases. The investigators concludedthat CT had a low diagnostic yield, and from a cost standpoint, represented only $1of usefulness for every $63.81 of CT expenditure, although the potential cost savingsassociated with hospitalization and overall costs of a misdiagnosed case were notincluded in the analysis.53 Another study found a 0% diagnostic yield for stroke or
other intracranial abnormalities from head CT of 344 ED patients and concluded thathead CT studies were not cost-effective for the evaluation of dizziness.54
TREATMENT OF DIZZINESS
Pharmacologic Therapies for Vertigo Symptoms
There are 2 categories of pharmacologic therapies for dizziness ( Table 7 ): those thatoffer symptom relief and those that are disease specific. Symptom relief medicationsare known as vestibular suppressants, which can be used to reduce the sensation of movement in vertigo and, in some cases, the associated motion sickness symptoms(usually nausea, vomiting, or diarrhea).
Unfortunately there are few high-quality studies confirming the efficacy of thesemedications. Meclizine is the most commonly used medication for vestibular
Suppress histamine activity inbrain vomiting center, alsoblock acetylcholinergicactivity
On the Beers list55 ofpotentially inappropriatemedications for older adultsdue to concern foranticholinergic side effectsa
Benzodiazepines(diazepam, lorazepam)
Enhance inhibitory effect ofg-aminobutyric acid investibular system
On the Beers list of potentiallyinappropriate medicationsfor older adults due toconcern for cognitiveimpairment, falls, fractures,and motor vehicle accidents
On the Beers list of potentiallyinappropriate medicationsfor older adults due toconcern for anticholinergicside effectsa
Anticholinergics(scopolamine)
Block acetylcholinergicactivity in vestibular nucleusof brain
On the Beers list of potentiallyinappropriate medicationsfor older adults due toconcern for anticholinergic
side effectsa
a Anticholinergic side effects include confusion, dry mouth, constipation, blurry vision, and urinaryretention.
Data from American Geriatrics Society Beers Criteria Update Expert Panel. American GeriatricsSociety updated Beers Criteria for potentially inappropriate medication use in older adults. J AmGeriatr Soc 2012;60(4):616–31; Hain TC, Uddin M. Pharmacologic treatment of vertigo. CNS Drugs2003;17(2):85–100; and Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale andanticholinergic adverse effects in older persons. Arch Intern Med 2008;168(5):508–13.
diagnoses in the United States.56 A literature search revealed only 2 randomizedcontrolled trials of meclizine for symptoms of vertigo. One randomized, double-blind, placebo-controlled study of 12 subjects reported that meclizine was no betterthan placebo for reducing vertigo symptoms on the first day of treatment, although itwas superior to placebo by the seventh day.57 Another study of 40 subjects demon-strated that meclizine was equivalent to thiethylperazine in reducing symptoms of vertigo.58
Vestibular suppressants are not appropriate for BPPV and should not be used indis-criminately for all types of vertigo.47,59 One study of ED management of vestibulardiagnoses throughout the United States demonstrated the widespread inappropriateuse of meclizine (which was prescribed in 59% of cases of BPPV). They noted thatphysicians were prescribing vestibular suppressants for the diagnosis of dizzinesswithout tailoring therapy to address the specific cause of the dizziness, such as thesignificant underuse of corticosteroids for vestibular neuritis.56
Current recommendations are that vestibular suppressants should be used foracute vertigo only and should be tapered quickly, because of concerns that thesemedications inhibit the brain’s natural ability to compensate for vertigo overtime.33,60,61 Most medications used to treat vertigo are associated with a high riskof adverse effects for older adults (see Table 7 ), so prescribing these medicationsappropriately is all the more difficult in the geriatric population. One common practicethat should certainly be avoided in older patients is the prescription of 2 medicationssimultaneously for vertigo: one to suppress the vertigo itself and another to combatassociated nausea. The risk of adverse drug reactions and drug interactions in olderpatients increases significantly as the number of medications increases.
Bottom line: Disease-specific therapies and vestibular rehabilitation are preferredover nonspecific symptomatic treatment. All the vestibular suppressants are consid-ered high risk for use in older adults, so they should be reserved for extreme caseswhen symptoms are severely limiting. In those cases, a vestibular suppressant suchas meclizine can be used at the lowest possible dose for the shortest possible time.Patients should receive counseling on the risks of these medications at the timethey are prescribed.
Therapies Directed at Specific Diagnoses
It is worthwhile focusing on disease-specific pharmacologic treatment of the 3 most
common causes of peripheral vertigo.
BPPV
Current guidelines recommend avoiding vestibular suppressants in favor of canalithrepositioning maneuvers, such as the Epley maneuver, and possibly also pursuingvestibular rehabilitation.47,59 This recommendation is based on 2 studies62,63 of vestibular suppressants, one of which failed to show superiority to placebo and an-other that showed that canalith repositioning maneuvers were superior to medication.Vestibular suppressants can be used for brief periods in patients with severe symp-toms, especially if needed for patients to be able to tolerate canalith repositioning
maneuvers.TheEpley maneuver ( Fig. 3 ) is used to reposition canaliths in the posterior semicircular
canal.64,65 Epley reported a 100% success rate in his series of 30 patients.65 Thismaneuver has been shown to be both easy to use and effective at diagnosing BPPVby general practitioners in the clinic.66 In the ED, the Epley maneuver has been reportedto be efficacious versus a sham maneuver in 1 randomized clinical trial that used a 10-point vertigo severity score. In this study, Epley-treated patients reported a median
improvement of 6 points and sham-treated patients 1 point improvement ( P 5 .001).67One reported complication following the Epley maneuver was the sensation of falling.68
Bottom line: Canalith repositioning maneuvers are first-line treatment; use of vestib-ular suppressants should be avoided.
Vestibular neuritis
Vestibular suppressants can be useful for symptomatic relief of vestibular neuritiswhen used in the first 3 days of symptoms.69,70 In addition, corticosteroids havebeen demonstrated to speed up the resolution of symptoms.61 In a prospectiverandomized, double-blind trial of methylprednisolone, valacyclovir, or placebo
involving 141 patients with vestibular neuritis, methylprednisolone increased therecovery of vestibular function from 40% to 62% 1 year after onset of symptoms.71
The mean age of the subjects in this study was 46 to 52 years; the oldest subjectwas 71 years old. Antiviral medication was not useful.71 A subsequent prospective,randomized, controlled trial of 30 patients showed that prednisone may enhance earlyrecovery, but the oldest subject was 72 years old and the mean age was 48 years. 72
However, a recent meta-analysis of 3 prospective, randomized, controlled trials
Fig. 3. Epley maneuver. (1) The patient sits upright with head turned 45 toward theaffected ear. (2) Lay the patient down with head hanging slightly below the level of theexamination table for 30 seconds. (3) Turn the head 90 toward the unaffected side andhold for 30 seconds. (4) Roll the patient onto his or her side to turn the head a further90 toward the unaffected side. The head should now be almost facing the floor. Holdfor 30 seconds. (5) Sit patient upright. (6) Some experts recommend keeping head uprightfor 24 hours after the maneuver. (From Rakel RE. Conn’s current therapy 1995. Philadelphia:WB Saunders; 1995. p. 839; with permission.)
(including the 2 studies mentioned earlier) reported that although caloric testing resultswere improved with corticosteroids, symptomatic recovery from acute vestibularneuritis was not, thus casting some uncertainty on the role of steroids.73 Anotherimportant factor in the management of this condition is that, in some patients, symp-toms may persist for months to years, so if after 3 days the patient still has significantsymptoms, a referral for vestibular rehabilitation should be made.
Bottom line: In days 1 to 3 of symptom onset, the authors still advocate the use of steroids (prednisone 1 mg/kg initially tapered off over 20 days) in older patients inwhom steroids are low risk. Vestibular suppressants can be added for symptom relief,but should be stopped after day 3. Symptoms usually resolve spontaneously evenwithout treatment.70
Meniere’s disease
There is little evidence to guide the management of Meniere’s disease.61 Betahistine isan antihistamine available in Europe, but a Cochrane review in 2001 concluded there
was insufficient evidence to confirm efficacy for Meniere’s disease.74 Other commonlyused treatments include those aimed at lowering endolymphatic pressure, such asmaintaining a diet low in sodium (less than 1–2 g of salt daily) and diuretics (usuallya combination of hydrochlorothiazide and triamterene). These treatments have notbeen rigorously evaluated for efficacy. A 2006 Cochrane review identified no articlesthat met their threshold for inclusion.75 Patients who fail medical management areusually sent for surgical interventions, including endolymphatic sac decompressionand intratympanic injections.76
Bottom line: Although there is little high-quality evidence to support any of thecurrent treatments, a low-salt diet and diuretics are generally better tolerated by olderadults than antihistamines or other vestibular suppressants. Systemic steroids canalso be tried in patients who are low risk, but if symptoms are difficult to control medi-cally, surgical interventions may be required.
Other conditions with disease-specific therapies
Vestibular migraine responds well to antimigraine therapies.60,61,76 Psychogenicvertigo should be treated with benzodiazepines or antidepressants.60 Episodic ataxiatype 2 responds to acetazolamide and 4-aminopyridine can also be used, althoughthis is based on several nonrandomized studies.61
Vestibular Rehabilitation
Several studies have shown the benefits of vestibular rehabilitation, which is a struc-tured program of movement exercises aimed at retraining the vestibular system todecrease symptoms and permit return to normal activities.77–81 Unfortunately, thesestudies tend to be small and inconsistent in the type of vestibular rehabilitation andoutcomes measured. Vestibular rehabilitation is delivered by a specially trained phys-ical or occupational therapist, however, 1 study demonstrated that nurses ina primary care clinic can be trained to administer effective vestibular rehabilitation.77
Currently, this therapeutic option is used in only a small fraction of patients with
chronic dizziness.82 Although vestibular rehabilitation is effective for most patients,10% to 66% of patients do not experience improvement in symptoms.82,83 Researchis needed to better define which patients are most likely to benefit from vestibularrehabilitation.83
Any patient can be referred for vestibular rehabilitation from the ED, but those mostlikely to benefit are those suffering from acute or chronic vertigo caused by peripheralvestibular dysfunction.84 Vestibular rehabilitation is also appropriate for patients with
central causes of vertigo, although complete recovery is rare.79,84 Because of the risksassociated with vestibular suppressant medications for older patients, vestibular reha-bilitation is an important and underused option for treatment of vertigo. For patientsunable to complete formal vestibular rehabilitation, a simple regimen of low-levelphysical activity has been shown to help elderly patients with chronic dizzinessovercome a fear of falling and improve quality of life.85
OUTPATIENT AND PREHOSPITAL MANAGEMENT OF THE DIZZY PATIENT
The evaluation and management of dizziness can be challenging due to (1) the subjec-tive nature of the patient’s symptom complaint, (2) the absence of an objective and reli-able measure of dizziness, and (3) the suboptimal accuracy of bedside examinations.
Therefore, the authors propose the following courses of action. If the patient has anestablished benign and recurrent condition, such as BPPV, and is being evaluated bythe primary care provider most familiar with the patient, then the physician can take
a conservative route. This course relies on an office-based evaluation and focuseson symptomatic relief. However, if the physician suspects a more serious cause,then more in-depth evaluation is required.
As cardiovascular and cerebrovascular causes are two of the more worrisome causesof dizziness,26,86 this subset of patients with suspected serious causes should bereferred to the ED.4 The purpose of this emergent referral is to rule out a stroke or cardiacevent. In preparation, a complete medical and medication history will be most helpful tothe ED, especially information on allergies and use of anticoagulants. More importantly,communicating the neurologic examination in the clinic to the ED physician will helpestablish a baseline and determine if neurologic deficits are progressing.
Outpatient providers should avoid any delay if a stroke is suspected to optimize thetime to treatment, especially if the patient might be a candidate for thrombolysis of ischemic strokes. In such situations, immediate transfer to the nearest ED by emer-gency medical services is recommended. The treatment window for acute thrombol-ysis with tissue plasminogen activator (t-PA) in acute ischemic stroke has traditionallybeen designated as 3 hours beginning at the onset of symptoms.87 Subsequent treat-ment trials, however, have extended the treatment window to 4.5 hours; cerebrovas-cular reperfusion therapy for appropriate patients within this extended treatmentwindow enhances favorable disability outcomes at 90 days (52.4% vs 45.2%; oddsratio [OR] 1.34, 95% confidence interval [CI] 1.02–1.76) at the cost of higher rates of intracranial hemorrhages (27.0% vs 17.6%; P 5 .001) but without significant differ-ence in 90-day mortality (7.7% vs 8.4%; P 5 .68).88
ED MANAGEMENT
Patients whose dizziness symptoms are new or different from previous episodes are of particular concern. The priority for the ED is to rule out a dangerous cause of dizziness.In particular, an ST-segment elevation myocardial infarction (STEMI) and an acutestroke must be ruled out, as these two disease entities have a specific time windowwithin which optimal treatment should be administered.87–90 Screening for an acute
stroke is enhanced by the use of the Cincinnati Prehospital Stroke Scale, which hasbeen demonstrated to be reproducible and valid.91 The process of ruling out STEMI,stroke, and other serious causes of dizziness benefits from the process of ruling ina peripheral vestibular cause.4 A recommended ED diagnostic pathway is shown inFig. 4.
Both CT and MRI are imperfect studies, and even negative results do not rule outa stroke with absolute certainty. In cases of suspected stroke with negative MRI
studies, the ED physician should consult a neurologist and may choose to admit thepatient for close observation and repeat MRI if the suspicion for stroke is strong, giventhe imperfect sensitivity of MRI in the acute setting.7 In a single academic center, dizzi-ness accounted for 16% of all neurology consultations from the ED.92 In some cases,an otolaryngologist may also be consulted for vestibular problems refractory toconventional therapy (medications, canalith repositioning maneuvers).
CLINICAL AND MEDICOLEGAL PITFALLS
Given the complexities of diagnosing and managing dizziness in the elderly, it isreasonable to anticipate that unintentional errors may occur.
Few studies have evaluated the accuracy of physician’s dizziness assessments.Royl and colleagues93 found that among German patients presenting with vertigoto the ED, 44% of the diagnoses were incorrect, based on further evaluation by
Fig. 4. A recommended pathway for the ED management of the older dizzy patient. a CPSS,Cincinnati Pre-Hospital Stroke Scale, a 3-item stroke scale designed for rapid screening forstroke by evaluating for facial droop, arm drift, and abnormal speech. The scale is reproduc-ible (interclass correlation 0.92, 95% CI 0.89–0.93), with any of the 3 items having a sensitivityof 66% and a specificity of 87%. (Data from Kothari RU, Pancioli A, Liu T, et al. CincinnatiPrehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999;33(4):373–8.)
neurologists. Seven percent of patients had a more serious diagnosis mistaken asbenign, and 23% were given a serious diagnosis that was later labeled benign. A Canadian study of 493 neurologic consultations from the ED for all neurologic prob-lems found agreement between the referring ED physician and the final diagnosis bythe neurologist in only 66% of cases, disagreement between ED diagnosis and finalneurologist diagnosis in 17%, and disagreement between both ED diagnosis andinitial neurologist diagnosis and the final neurologist diagnosis in 5%. In addition,the consulting neurologist’s initial diagnosis agreed with the final neurologist diag-nosis 80% of the time.94 As many as 35% of patients presenting to the ED withdizziness that was ultimately confirmed as cerebrovascular events were initiallymisdiagnosed.26
Presently, no ED-based prediction rule exists to guide the diagnosis of stroke inpatients presenting with dizziness. Data from Hong Kong showed that age 65 yearsor more (OR 5 6.13, 95% CI 1.97–19.09), ataxia symptoms (OR 5 11.39, 95%CI 2.404–53.95), focal neurologic symptoms (OR 5 11.78, 95% CI 1.61–86.29),previous stroke (OR 5 3.89, 95% CI 1.12–13.46), and diabetes mellitus (OR 5 3.57,95% CI 1.04–12.28) predicted central causes of dizziness.95 Kerber and colleagues96
found that the description of nystagmus in the ED medical records conflicted with theED physician’s diagnosis of peripheral vestibular process in 81% of cases. UsingNHAMCS data, Newman-Toker and colleagues56 concluded that there is overuse of CT and underuse of MRI in patients given a final diagnosis of BPPV or acute vestibularsyndrome. These studies suggest that targeted specialized training for ED staff andtrainees can be helpful in the diagnosis and management of dizziness.
Given the difficulties in identifying the true cause of an older patient’s dizziness, it
may be tempting to adopt a conservative approach to disposition and simply hospi-talize all elderly patients presenting with dizziness. Recent data caution against thisapproach, as hospital admissions for older adults independently increase the risk of loss of independence, decline in function, and delirium.97,98
Although the geriatric patient with dizziness represents a high-risk population, anintracranial hemorrhage is unlikely.9,27 Safe disposition can be extremely difficult,especially if the dizziness has not resolved. If available, a geriatric consultation isrecommended. Alternatively, either a discussion with the patient’s primary careprovider or a more thorough patient assessment that includes function and homesafety assessment may be helpful. However, in a busy setting, such as a high-
volume ED, the latter is not practical. In such situations, admitting the patient to obtaina more comprehensive workup will prove to be the best approach. If a dizzy patient issent home directly from the ED, it is essential to ensure that a family member or friendis available to provide 24-hour supervision until the symptoms abate or resolve.
The dizzy patient is at increased risk for falls99 and fall-related injuries100 and there-fore must be carefully evaluated for injuries. Head trauma can result in short-termamnesia, which further complicates the history. Subtle fractures may also be lessapparent on plain radiographs in the setting of significant osteopenia. If acute trau-matic injuries in the setting of dizziness are suspected, a thorough trauma assess-ment, including primary, secondary, and tertiary surveys, may be indicated.
Any physician attempting either the Epley or horizontal head impulse test in the olderpatient must exercise caution and avoid forceful or jarring movements. No specifictraumatic injuries involving the Epley maneuver have been reported. However, themedical literature includes several case reports of serious complications after spinalmanipulation, including vertebral fracture, spinal cord injury, vertebrobasilar vascularinjury, and disk herniation.101,102 Allowing the patients to move their heads at their ownpace during the HINTS test may optimize patient safety.
At discharge, patients diagnosed with peripheral vestibular dizziness or in whom a life-threatening cause has been ruled out, should be provided with the following:
Referral: Patients should be referred to their primary care provider for follow-upwithin 1 to 2 weeks or sooner if symptoms return. Referral for vestibular rehabil-itation, if available locally, can help patients with vestibular retraining.
Treatment: When indicated, a prescription for any of the medications discussedearlier should be provided. For patients with BPPV, instructions for canalithrepositioning maneuvers are helpful. Videos for maneuvers are also availableonline at www.youtube.com.103
Diagnosis: An underlying cause for the dizziness should ideally be given as thediagnosis (eg, vestibular neuritis, hypoglycemia) rather than a symptom (eg,dizziness, vertigo not otherwise specified).
Return instructions: Patients should call the emergency service (9-1-1) and return tothe ED for any worrisome signs or symptoms such as (1) signs of stroke (diffi-culty speaking, sudden loss of vision, sudden weakness, or paralysis), (2) chestpain, (3) difficulty breathing, (4) palpitations or irregular heartbeat, (5) syncope, or(6) head trauma.
FUTURE DIRECTIONS
Further research is needed to optimize the ED management of the dizzy patient. Studiesare needed to better understand the epidemiology of dizziness, as well as the diag-
nostic accuracy of bedside tests, how best to identify patients whose dizziness isdue to stroke, and which therapies are best to mitigate the symptoms of vertigo.Disease-specific therapies also need extensive investigation. Cost-effectivenessstudies would be invaluable in optimizing ED management. Older adults should bea particular focus of future research, as diagnosis can be more challenging and treat-ment options are limited. This type of research is challenging because of the lack of consistent diagnostic criteria, the wide diversity of causes of dizziness, the rarity of some of the causes, and because symptoms often resolve spontaneously with time.
SUMMARY
As shown by the often discrepant data on geriatric dizziness, there is limited evidenceto guide bedside diagnostic, therapeutic, or disposition decision making for the geri-atric patient with dizziness in the ED. Sloan and Dallara3 compared the evidence ongeriatric dizziness with the story of the three blind men, each of whom describeddifferent parts of the elephant and had different impressions of what an elephant lookslike. Despite such ambiguity, dizziness is a common complaint. The clinician is facedwith the dilemma of choosing between taking a conservative approach by assuminga benign cause or committing costly and increasingly limited resources to pursuea relatively infrequent but potentially devastating underlying cause. It is our hope
that future research will illuminate the true nature of the elephant.
REFERENCES
1. Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits
to US emergency departments: cross-sectional analysis from a nationally repre-
sentative sample. Mayo Clin Proc 2008;83(7):765–75.
24. Dros J, Maarsingh OR, Beem L, et al. Impact of dizziness on everyday life in older
primary care patients:a cross-sectional study. Health QualLife Outcomes2011;9:44.
25. Murphy SL, Dubin JA, Gill TM. The development of fear of falling among
community-living older women: predisposing factors and subsequent fall
events. J Gerontol A Biol Sci Med Sci 2003;58(10):M943–7.
26. Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness,
vertigo, and imbalance in the emergency department: a population-based
study. Stroke 2006;37(10):2484–7.
27. Kerber KA, Burke JF, Brown DL, et al. Does intracerebral haemorrhage mimic
benign dizziness presentations? A population based study. Emerg Med J
2012;29(1):43–6.
28. Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient
reports of dizziness symptom quality: a cross-sectional study conducted in an
acute care setting. Mayo Clin Proc 2007;82(11):1329–40.
29. Stanton VA, Hsieh YH, Camargo CA, et al. Overreliance on symptom quality in
diagnosing dizziness: results of a multicenter survey of emergency physicians.
Mayo Clin Proc 2007;82(11):1319–28.
30. Drachman DA, Hart CW. An approach to the dizzy patient. Neurology 1972;
22(4):323–34.
31. Sloane PD, Baloh RW. Persistent dizziness in geriatric patients. J Am Geriatr Soc
1989;37(11):1031–8.
32. Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with
severe dizziness. J Am Geriatr Soc 1999;47(1):12–7.
33. Tusa RJ, Gore R. Dizziness and vertigo: emergencies and management. Neurol
Clin 2012;30(1):61–74, vii–viii.34. Navi BB, Kamel H, Shah MP, et al. Application of the ABCD2 score to identify
cerebrovascular causes of dizziness in the emergency department. Stroke
2012;43(6):1484–9.
35. Rothwell PM, Giles MF, Flossmann E, et al. A simple score (ABCD) to identify
individuals at high early risk of stroke after transient ischaemic attack. Lancet
2005;366(9479):29–36.
36. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement
of scores to predict very early stroke risk after transient ischaemic attack. Lancet
2007;369(9558):283–92.
37. Maarsingh OR, van der Wouden JC. Letter by Maarsingh and van der Woudenregarding article, “Application of the ABCD2 score to identify cerebrovascular
causes of dizziness in the emergency department”. Stroke 2012;43(8):e78
[author reply: e79].
38. Maarsingh OR, Dros J, Schellevis FG, et al. Causes of persistent dizziness in
elderly patients in primary care. Ann Fam Med 2010;8(3):196–205.
39. Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo.
Med Clin North Am 2006;90(2):291–304.
40. Ishiyama G, Ishiyama A, Kerber K, et al. Gentamicin ototoxicity: clinical features
and the effect on the human vestibulo-ocular reflex. Acta Otolaryngol 2006;
126(10):1057–61.41. Adams ME, Heidenreich KD, Kileny PR. Audiovestibular testing in patients with
Meniere’s disease. Otolaryngol Clin North Am 2010;43(5):995–1009.
42. von Brevern M, Zeise D, Neuhauser H, et al. Acute migrainous vertigo: clinical
and oculographic findings. Brain 2005;128(Pt 2):365–74.
43. Dros J, Maarsingh OR, van der Horst HE, et al. Tests used to evaluate dizziness
44. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998;339(10):
680–5.
45. Dix MR, Hallpike CS. The pathology symptomatology and diagnosis of certain
common disorders of the vestibular system. Proc R Soc Med 1952;45(6):
341–54.
46. Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign parox-
ysmal positional vertigo through the Dix-Hallpike and side-lying maneuvers:
a critically appraised topic. Neurologist 2008;14(3):201–4.
47. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign
paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139(5 Suppl
4):S47–81.
48. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute
vestibular syndrome: three-step bedside oculomotor examination more sensitive
than early MRI diffusion-weighted imaging. Stroke 2009;40(11):3504–10.
49. Chan TP. Is benign paroxysmal positional vertigo underdiagnosed in hospital-
ised patients? Hong Kong Med J 2008;14(3):198–202.
50. Canto JG, Fincher C, Kiefe CI, et al. Atypical presentations among Medicare
beneficiaries with unstable angina pectoris. Am J Cardiol 2002;90(3):248–53.
51. Kocher KE, Meurer WJ, Fazel R, et al. National trends in use of computed
tomography in the emergency department. Ann Emerg Med 2011;58(5):
452–462.e3.
52. Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and
computed tomography in emergency assessment of patients with suspected
acute stroke: a prospective comparison. Lancet 2007;369(9558):293–8.
53. Lawhn-Heath C, Buckle C, Christoforidis G, et al. Utility of head CT in the eval-uation of vertigo/dizziness in the emergency department. Emerg Radiol 2012.
[Epub ahead of print].
54. Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan:
is it cost effective? Emerg Med J 2005;22(4):312.
55. American Geriatrics Society Beers Criteria Update Expert Panel. American Geri-
atrics Society updated Beers Criteria for potentially inappropriate medication
use in older adults. J Am Geriatr Soc 2012;60(4):616–31.
56. Newman-Toker DE, Camargo CA Jr, Hsieh YH, et al. Disconnect between
charted vestibular diagnoses and emergency department management deci-
sions: a cross-sectional analysis from a nationally representative sample.Acad Emerg Med 2009;16(10):970–7.
57. Schmitt LG, Shaw JE. Alleviation of induced vertigo. Therapy with transdermal
scopolamine and oral meclizine. Arch Otolaryngol Head Neck Surg 1986;
112(1):88–91.
58. Jungert S. Comparative investigation between thiethylperazine and meclizine in
vertigo of different genesis. Acta Otorhinolaryngol Belg 1978;32(3):264–72.
59. Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign
paroxysmal positional vertigo (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology. Neurology
2008;70(22):2067–74.60. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;
17(2):85–100.
61. Strupp M, Thurtell MJ, Shaikh AG, et al. Pharmacotherapy of vestibular and
ocular motor disorders, including nystagmus. J Neurol 2011;258(7):1207–22.
62. McClure JA, Willett JM. Lorazepam and diazepam in the treatment of benign
70. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003;348(11):
1027–32.
71. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the
combination for vestibular neuritis. N Engl J Med 2004;351(4):354–61.
72. Shupak A, Issa A, Golz A, et al. Prednisone treatment for vestibular neuritis. Otol
Neurotol 2008;29(3):368–74.
73. Goudakos JK, Markou KD, Franco-Vidal V, et al. Corticosteroids in the treatment
of vestibular neuritis: a systematic review and meta-analysis. Otol Neurotol
2010;31(2):183–9.74. James AL, Burton MJ. Betahistine for Meniere’s disease or syndrome. Cochrane
Database Syst Rev 2001;(1):CD001873.
75. Thirlwall AS, Kundu S. Diuretics for Meniere’s disease or syndrome. Cochrane
Database Syst Rev 2006;(3):CD003599.
76. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician 2005;71(6):
1115–22.
77. Yardley L, Donovan-Hall M, Smith HE, et al. Effectiveness of primary care-based
vestibular rehabilitation for chronic dizziness. Ann Intern Med 2004;141(8):
598–605.
78. Strupp M, Arbusow V, Maag KP, et al. Vestibular exercises improve central ves-tibulospinal compensation after vestibular neuritis. Neurology 1998;51(3):
838–44.
79. Kammerlind AS, Hakansson JK, Skogsberg MC. Effects of balance training in
elderly people with nonperipheral vertigo and unsteadiness. Clin Rehabil
81. Yardley L, Barker F, Muller I, et al. Clinical and cost effectiveness of booklet
based vestibular rehabilitation for chronic dizziness in primary care: single blind,
parallel group, pragmatic, randomised controlled trial. BMJ 2012;344:e2237.82. Krebs DE, Gill-Body KM, Parker SW, et al. Vestibular rehabilitation: useful but not
universally so. Otolaryngol Head Neck Surg 2003;128(2):240–50.
83. Hall CD, Cox LC. The role of vestibular rehabilitation in the balance disorder
patient. Otolaryngol Clin North Am 2009;42(1):161–9, xi.
84. Whitney SL, Rossi MM. Efficacy of vestibular rehabilitation. Otolaryngol Clin
85. Ekwall A, Lindberg A, Magnusson M. Dizzy - why not take a walk? Low level
physical activity improves quality of life among elderly with dizziness. Geron-
tology 2009;55(6):652–9.
86. Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary
cardiovascular disease true vertigo? A systematic review. J Gen Intern Med
2008;23(12):2087–94.
87. Tissue plasminogen activator for acute ischemic stroke. The National Institute of
Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med
1995;333(24):1581–7.
88. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours
after acute ischemic stroke. N Engl J Med 2008;359(13):1317–29.
89. Cannon CP, Braunwald E. Time to reperfusion: the critical modulator in thrombol-
ysis and primary angioplasty. J Thromb Thrombolysis 1996;3(2):117–25.
90. Zijlstra F, Patel A, Jones M, et al. Clinical characteristics and outcome of patients
with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by
primary coronary angioplasty or thrombolytic therapy for acute myocardial
infarction. Eur Heart J 2002;23(7):550–7.
91. Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: repro-
ducibility and validity. Ann Emerg Med 1999;33(4):373–8.
92. Hansen CK, Fisher J, Joyce N, et al. Emergency department consultations for
patients with neurological emergencies. Eur J Neurol 2011;18(11):1317–22.
93. Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and
misdiagnoses. Eur Neurol 2011;66(5):256–63.
94. Moeller JJ, Kurniawan J, Gubitz GJ, et al. Diagnostic accuracy of neurolog-
ical problems in the emergency department. Can J Neurol Sci 2008;35(3):335–41.
95. Cheung CS, Mak PS, Manley KV, et al. Predictors of important neurological
causes of dizziness among patients presenting to the emergency department.
Emerg Med J 2010;27(7):517–21.
96. Kerber KA, Morgenstern LB, Meurer WJ, et al. Nystagmus assessments docu-
mented by emergency physicians in acute dizziness presentations: a target
for decision support? Acad Emerg Med 2011;18(6):619–26.
97. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities
of daily living in older adults hospitalized with medical illnesses: increased
vulnerability with age. J Am Geriatr Soc 2003;51(4):451–8.98. Gill TM, Allore HG, Holford TR, et al. Hospitalization, restricted activity, and
the development of disability among older persons. JAMA 2004;292(17):
2115–24.
99. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons
living in the community. N Engl J Med 1988;319(26):1701–7.
100. Beckman A, Hansson EE. Fractures in people with dizziness: 5-year follow-up.
J Am Geriatr Soc 2011;59(9):1767–9.
101. Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med
2002;112(7):566–71.
102. Tamburrelli FC, Genitiempo M, Logroscino CA. Cauda equina syndrome andspine manipulation: case report and review of the literature. Eur Spine J 2011;
20(Suppl 1):S128–31.
103. Kerber KA, Burke JF, Skolarus LE, et al. A prescription for the Epley maneuver:
www.youtube.com? Neurology 2012;79(4):376–80.
104. Colledge NR, Wilson JA, MacIntyre CC, et al. The prevalence and characteris-
