Vertigo in Older Adults

Vertigo and dizziness is a common complaint among older adults. Globally, 1 in 10 people are affected by Vertigo. In India, a 2001 survey estimated that 0.71% of the rural population (about 90 lakh people) are affected. This greatly impacts daily life and is a major risk factor for falls, which makes it particularly concerning. Dr Aditi Sinha, an ENT Specialist from Mumbai highlights the need for increased awareness on this highly prevalent symptom.

What is vertigo?

Vertigo represents one of the most common problems in the elderly; the term vertigo usually describes a sense of spinning and rotatory motion. It differs from the term dizziness (floating sensation) and/or imbalance (loss of balance, unsteadiness), even if in the clinical practice all these terms are often used as interchangeably. Vertigo isn’t a disease or a condition on its own but a symptom of an underlying condition.

Why is vertigo a matter of concern in the elderly?

Among the multiple causes of vertigo-episodes in the elderly, vestibular(inner ear related) disorders are frequently reported as the most common. The age-related deterioration of peripheral vestibular function seems to be linked to a decreased number of vestibular hair cells and neurons, although alterations affecting the central pathways are also reported. Ageing is a process that involves the entire body, with the deterioration of multiple systems; the onset of an acute or a chronic condition could dramatically affect a frail equilibrium causing a general deterioration of the health condition. Considering the different diseases that may arise in the elderly, vertigo and dizziness present a prevalence above 30%, frequently associated with other systemic conditions. The fact that many vertigo patients present multiple etiologies, suggests that vertigo in the elderly is a multidisciplinary issue. Clinical studies confirm that audiovestibular, cardiovascular and neurological condition represent the vast majority of diagnoses causing this disorder, particularly in the elderly.

Vertigo by itself and its underlying causes significantly impact the quality of life. There is a severely increasing risk of falls, which are estimated to cause 50% of all unintentional deaths in patients of this age.

Is it a progressive condition?

The cause of your vertigo plays a big role in how long your symptoms will last or how the severity will abate or progress. Identifying the cause of your vertigo can help find a treatment that works to prevent episodes from occurring. If vertigo is the result of a health complication you're not treating, vertigo symptoms may become worse. You can begin to experience long-term physical and mental health complications as a result of NOT treating the underlying cause for your vertigo.

What are the different types of vertigo? Pls explain briefly.

There are two most common forms of vertigo: central and peripheral. There are drugs and other treatments for both types. Finding out which one you've got and what's causing it can help you and your doctor decide how to manage it. Peripheral type is the most common type of vertigo. 

Difference between the 2 types of Vertigo:

What are the signs or symptoms of vertigo? 

Vertigo is different from dizziness. This is because the sensations from vertigo make you feel like your surroundings are moving, or that you’re moving when you’re actually standing still. Dizziness typically causes you to feel woozy or lightheaded. Vertigo episodes may come and go and cause sudden, severe episodes of disorientation. They can also be incredibly mild, or be chronic and last for longer periods of time.

Other symptoms of vertigo include:

• Nausea
• Sweating
• Vomiting
• Abnormal or unusual eye movements, such as jerking
• Loss of balance
• Ringing in the ears
• Hearing loss

When should a person be referred to an ENT?

In my view, there are some key indications when a GP should refer the patient to an ENT Specialist or the patient can directly approach one. These are : 

• A patient with acute and severe symptoms not responding to standard anti- vertigo medications and management. 
• Chronic or long standing vertigo 
• Undiagnosed vertigo 
• History of ear complaints associated with vertigo such as - earache, ear discharge, ear blockage, ear fullness, deafness, ringing/buzzing/whistling(tinnitus) in ears, ear trauma, ear surgery, barotrauma or acoustic trauma.
• Any type of vertigo not responding to treatment - intractable vertigo 
• Elderly with vertigo and other concurrent systemic illnesses where quality of life is impacted
• History of one or multiple falls due to vertigo 

What causes dizziness or imbalance in older adults?

Dizziness in older adults can have many possible causes. It could be due to an underlying health condition, a new medication, an inner ear disturbance, or a combination of factors.

1. Cardiovascular issues
   Any cardiovascular issue that reduces your heart’s ability to pump blood throughout your body can cause dizziness. Sudden drops in blood pressure that occur with position changes, called orthostatic hypotension, can also cause brief bouts of dizziness. Additionally, conditions that result in poor blood circulation and inadequate blood flow to the brain can leave you dizzy. These may include heart attack, heart arrhythmia, cardiomyopathy, transient ischemic attack and stroke
    
2. Neurological conditions
   Certain chronic neurological conditions, such as multiple sclerosis and Parkinson’s disease, can lead to progressive loss of balance.
    
3. Medications
   Certain medications may cause dizziness as a side effect. The most common medications that may cause dizziness in older people include anti-seizure drugs, antidepressants, sedatives or tranquilizers and medications to lower blood pressure. Often, drug-induced dizziness may resolve once your body gets used to the medication. If the dizziness doesn’t resolve or worsens, discuss options with your doctor.
    
4. Other causes of dizziness in older people can include:
   • Low iron (anemia): Low iron in your blood reduces the amount of oxygen in your body. Along with dizziness, people experience weakness, fatigue, and pale skin.
   • Hypoglycemia (low blood sugar): Symptoms of low blood sugar include dizziness, confusion, sweating, and anxiety. Low blood sugar is most common in people with diabetes.
   • Carbon monoxide poisoning: Exposure to carbon monoxide is usually also associated with nausea, weakness, chest pain, and confusion.
   • Dehydration and overheating: A loss of fluids can cause dizziness, especially if you’re taking certain medications.

What are the causes of vertigo in the elderly?

Most cases in the elderly are caused by a problem in the inner ear, which controls your balance. The most common causes of the inner ear trouble that leads to peripheral vertigo in elder persons are:

• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuronitis
• Meniere's disease

There are some other conditions of the inner ear that also lead to peripheral vertigo, including: 

• Labyrinthitis
• Perilymph fistula
• Superior semicircular canal dehiscence syndrome (SSCDS)

Central vertigo seen in the elderly can be caused by a disease or injury to the brain, such as:

• Head injuries
• Illness or infection
• Multiple sclerosis
• Migraines
• Brain tumours
• Strokes
• Transient ischemic attacks ("mini" strokes that last for a short time and don't cause permanent damage)

BPPV :The most common type of vertigo is benign paroxysmal positional vertigo (BPPV). Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo, accounting for over half of all cases. A sudden change of your head’s position can trigger it. In older people, going from a lying down position to standing up may trigger BPPV. Loose calcium-carbonate crystals, called otoconia, within the fluid-filled semicircular canals of the inner ear cause BPPV. While vertigo and BPPV are not considered serious conditions, they can increase the risk of falls for older adults.

Meniere’s Disease: While less common than BPPV, Meniere disease is another balance disorder that affects the inner ear. It usually only affects one ear. It often causes periods of dizziness.

People with Meniere disease may also experience hearing loss in the affected ear, loss of balance and tinnitus (ringing in the ears). Meniere disease is a chronic condition. The condition often goes into remission after a few years with medications and lifestyle strategies. 

Vertigo symptoms may also be caused by more serious conditions like tumors, cerebellar hemorrhage, multiple sclerosis, or other neurological conditions.

How is vertigo diagnosed?

• Medical History
  To diagnose vertigo, your doctor relies on information about your medical history, including details about your symptoms. They may ask what the sensation of movement or dizziness feels like, how often it occurs, whether it occurs more frequently when you move a particular way or at certain times of the day, and whether you also experience hearing loss or ringing in the ears. Your doctor may also ask if anyone else in your family has been diagnosed with a condition affecting balance or hearing. Additionally, they want to know if you have had an infection, injury, or surgery in the ear or brain. Your doctor will also inquire about how vertigo affects your everyday life and whether it interferes with your daily routine. Some people develop anxiety as a result of vertigo, causing them to remain indoors or worry about the cause of symptoms. Talking to your doctor about these issues may help determine the best treatment.
• Physical Examination
  An otolaryngologist performs a detailed ear, nose, and throat physical exam to look for signs and symptoms of the cause of vertigo. Your doctor may also examine your eye movements or ask you to track an object from one point in space to another. If you have trouble with this task or experience rapid eye movements or blurred vision, your doctor may refer you to an eye doctor for further testing.
• Hearing Tests
  An audiologist conducts a variety of hearing tests, also called audiometric tests, to gather information about the ear. Hearing tests help doctors assess whether there is a problem with the nerve that connects the inner ear to the brain and whether dysfunction affects both ears. A hearing test takes place in a soundproof booth while wearing headphones. For about 30 to 60 minutes, an audiologist evaluates different parts of your hearing using Pure Tone and Impedance Audiometry. In otoacoustic emissions testing (OAE), a sensitive probe that produces a combination of sounds is introduced into the ear canal. If the inner ear is functioning properly, small hair cells in the ear—tiny sensory receptors that detect vibrations and convert them to electrical signals for the brain to interpret—send back an echo when stimulated by sound. The probe can detect this echo, indicating how well the inner ear is functioning.
• Videonystagmography Testing
  Videonystagmography is used to evaluate the function of the inner ear using a series of visual and sensory tests. The inner ear constantly sends signals to your eye muscles to help the head and body maintain balance. This type of testing allows audiologists to record and interpret eye movements and confirm whether inner ear dysfunction is responsible for vertigo. During the first part of testing, you wear a pair of goggles specially designed to illuminate your eyes using infrared light, which your eyes can’t detect. A video camera with an infrared lens is built into the goggles and records your eye movements during the test. This allows you to focus on the visual stimuli in the test. While wearing the goggles, you are seated in front of a large television screen. Your audiologist guides you through the testing. A variety of shapes, objects, and spots of light appear on the screen, and you are asked to perform certain tasks with your eyes while keeping your head still. These tasks may include following a colored light as it moves across the screen in different directions or tracking an object as it jumps around the screen.

  Your audiologist also uses caloric, or temperature, testing to stimulate the inner ear with gentle bursts of warm or cold air. They are trying to determine how dizzy this makes you feel. The infrared goggles record your eye movements while caloric testing takes place. Afterward, your audiologist analyzes the eye movement data obtained by the goggles and looks for patterns indicating an inner ear disorder as the cause of vertigo.

• Rotational Chair Testing
  Audiologists use rotational chair testing to obtain more information about whether vertigo is of peripheral or central origin. In a lab, you are seated in a mechanized chair that slowly rotates. You wear special goggles that record your eye movements while you are in the chair. Audiologists analyze your eye movements and interpret how they relate to the health of the inner ear.
• Additional Tests
  Additional tests of the inner ear may be suggested for certain conditions. In vestibular evoked myogenic potentials (VEMP) testing, audiologists measure a natural response of the vestibular system and neck muscles to certain sounds. Electrocochleography (ECochG) helps determine if fluid buildup causes excess pressure in the inner ear, which can lead to vertigo symptoms. An audiologist may also utilize these tests to measure the response of the inner ear to sound stimuli.
• MRI Scans
  In some people with vertigo—in particular, those who also have hearing loss—doctors may recommend an MRI scan to obtain a closer look at the inner ear and surrounding structures. MRI scans use a magnetic field and radio waves to create computerized, three-dimensional images of the ear and the nerve that carries signals from the inner ear to the brain. An MRI scan may reveal a buildup of fluid or inflammation in the inner ear or a growth on the nerve.
• Neurological Testing
  If hearing or sensory tests indicate vertigo of central origin, doctors may refer you to a specialist for neurological testing and treatment.

  

Dr. Aditi Sinha is an ENT Specialist- Head & Neck Surgeon with over a decade of clinical experience across leading hospitals in Mumbai. She currently practices at Masina Hospital (Byculla) Inlaks General Hospital(Chembur), Dhanwantari Hospital & Research Center(Dadar) and Sanghvi JB Trust Clinic & Hospital(Matunga), Mumbai.

Her chief areas of clinical interest are deafness, vertigo and allergy management.