Peripherally or centrally determined?

In elderly patients, symptoms of vertigo are common. A systematic clinical examination can identify the most common causes. A careful medical history is essential. There are several diagnostic index tests for stroke risk estimation.

Around one third of people over 65 years of age are affected by symptoms of vertigo [1]. The general practitioner is often the first port of call, although the diagnostic workup is relatively complex due to the broad spectrum of possible causes. This is because dizziness is not a uniform clinical picture, but a non-specific leading symptom of a number of etiologically different diseases of different disciplines (e.g. neurology, ENT, psychosomatics). According to current S3 guidelines [2], about 40% of cases evaluated by the general practitioner can be attributed to benign paroxysmal positional vertigo (BPPV) or one of the following causes: cervicogenic and vestibular vertigo (also in addition to BPPV), orthostasis, arrhythmias, polyneuropathy, drug side effects, cerebral circulatory disorders, migraine, Meniere’s disease, obstructive heart disease. BPPV is a spinning vertigo that occurs when the head or body is displaced. It lasts less than a minute, and patients also complain of nausea, vomiting, and oscillopsia. It can be easily detected by placing the patient on the side of the affected ear. Then a rotating and vertical to the forehead beating nystagmus occurs.

It is essential that the time course is recorded!

The key anamnestic questions in the presence of vertigo symptoms relate to the following areas [3]: Type of vertigo, accompanying symptoms, time course, trigger, onset. The underlying causes of vertigo can be divided into three subgroups: neuro-otological, internal, psychiatric disorders [4]. Through a focused history and simple neurological examination, vertigo sympromas can be assigned to one of the following main categories [5]: Vertigo with illusion of movement (“vertigo”) and nystagmus indicates a vestibular cause and is further differentiated according to the duration of the attacks and divided into peripherally and centrally caused disorders. Vertigo without movement illusion (diffuse vertigo, “dizziness”) is differentiated into presyncopal, psychophysical or multisensory vertigo according to general medical findings (circulatory situation, musculoskeletal system, etc.) and neurological examination. According to the Barany Society, the three main vestibular syndromes can be divided according to the time course as follows [6]:

Acute vestibular syndrome (AVS): >24h (days to weeks): Neuritis vestibularis, stroke, et al.
Episodic vestibular syndrome (EVS): <24h (seconds to hours); position-dependent syndrome; triggers present (e.g., head movement/position): Meniere’s disease, vestibular migraine, TIA, orthostatic dysregulation, et al.
Chronic vestibular syndrome (CVS): months to years (permanent vertigo): bilateral vestibulopathy, cerebellar neurodegenerative disease, functional vertigo, et al.

Meniere’s disease is a disorder of the inner ear of unknown cause characterized by attacks of rotational vertigo, fluctuating hearing loss, tinnitus, and a feeling of pressure in the ear [7,8]. According to diagnostic criteria of various international professional societies, Meniere’s disease is almost certainly present if the following symptoms are present: at least two spinning attacks lasting from 20 min to 12 hours; unilateral neurosensory hearing loss in the low and middle frequency range in at least one sound audiogram obtained during or after an attack; fluctuating otologic symptoms (hearing loss, tinnitus, pressure sensation) in the affected ear; no other diagnosis that could explain the symptoms. A diagnosis of Meniere’s disease is less certain but likely if the following criteria are met: at least two attacks of rotatory vertigo lasting from 20 min to 24 hours; fluctuating otologic symptoms (hearing loss, tinnitus, pressure sensation) in the affected ear; no other diagnosis that could explain the symptoms.

“HINTS” in acute vertigo informative.

For the differentiation between peripheral and central causes of acute vestibular syndrome, the examination of the so-called HINTS triad (head impulse test, gaze direction nystagmus, vertical divergence) is diagnostically groundbreaking. Regarding concomitant symptoms, the following symptoms indicate vestibular causes: Nausea, vomiting, balance disorders, oscillopsia. If neurological abnormalities occur together with the vertigo symptoms, a cause in the central nervous system must be assumed. In the case of hearing disorders, tinnitus and ear pressure, the dizziness symptoms are most likely due to a problem in the inner ear. Headache and sensitivity to light are typical accompanying symptoms of migraine. If patients become black-eyed, orthostatic dizziness or presyncope should be considered. Palpitations, tremors, and panic may occur in the context of a functionally phobic problem (formerly also called “psychogenic vertigo”); balance disorders may also occur. Medication history should also be performed in detail in elderly patients with vertigo. Dizziness is a possible side effect of medications of various substance classes. This can be verified using a list of medications that patients take on a regular basis.

Is there a risk of stroke?

In acute vertigo without nystagmus, diagnostic index tests (combinations of anamnestic and clinical signs) can help estimate stroke risk. Those with the best diagnostic predictive power (sensitivity, specificity) are listed in Table 1 . Spontaneous acute onset of dizziness without preceding triggers increases the risk of cerebral ischemia as a cause by 3.5-fold [9]. If this is suspected, referral to a neurologist should be made.

Referral to specialists in various disciplines should also be considered in the following cases [2]: If cardiac arrhythmias or evidence of obstructive heart disease with dizziness are detected, cardiologic evaluation is indicated. Referral to neurology should always be made when neurologic disease is first suspected. In case of one of the following suspected diagnoses, it is recommended to initiate an ENT workup: M. Meniere’s disease, acoustic neuroma, hearing impairment, or with questionable vestibular genesis (exception BPPV). Whether psychosomatics and psychotherapy are consulted for psychogenic vertigo is a matter of judgment. If cervicogenic vertigo is suspected, referral to specifically trained treatment personnel may be indicated. Surgery/angiology should be considered if “subclavian steal syndrome” is suspected . If the vertigo symptoms are attributed to a genesis that cannot be precisely identified in the context of geriatric multimorbidity, this is an indication to consider geriatric rehabilitation/outpatient geriatric complex treatment.

Multimodal combination therapy recommended

Antivertiginosa are indicated for short-term use only, after which a switch can be made to combination therapy of cinnarizine plus dimenhydrinate (antihistamine) if tolerated and no contraindications are present [2]. The use of betahistine is recommended for vertigo associated with Meniere’s symptom complex. Alternatively, the phytotherapeutic Vertigoheel can be prescribed, it has a comparable efficacy. In case of functional vertigo (former term: “psychogenic vertigo”), which is fluctuating and intensifies with phobic cue stimuli, the pathomechanism should be explained to patients in psychoeducational therapy. Desensitization can be performed with exposure therapy combined with pharmacotherapy (e.g., selective serotonin reuptake inhibitors, SSRIs). Diffuse apprehension is generally common among sufferers of vertigo symptoms. However, according to the S3 guideline [2], highly sedating psychotropic drugs (e.g., benzodiazepines) are not indicated. If the dizziness problem is expected to persist over a long period of time, education should be provided about the need for the best possible adaptation to the symptoms. Physical methods such as freeing maneuvers and balance training usually provide relief from benign paroxysmal positional vertigo (BPPV), one of the most common causes of dizziness in elderly patients. There should be about five training sessions per week.

Balance training and physical therapy are generally treatment options for dizziness in the elderly, which have been shown to alleviate symptoms. Recent research findings also indicate that online-supported training over a 6-week period can increase the effects of conventional therapy for dizziness symptoms [11]. The web-based training includes background information on vertigo symptoms on the one hand and video-based instructions of various physiotherapeutic exercises on the other. Each training session can be adapted to the individual symptom expression. The Vertigo Symptom Scale-Short Form (VSS-SF) was used to measure the progression of vertigo symptoms.

Literature:

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Vertigoheel: Swiss Drug Compendium, https://compendium.ch