NEW YORK (Reuters Health) – Dizziness in the elderly is caused by cardiovascular disease in over half of patients seen in primary care, according to new research from the Netherlands.

This finding contradicts the results of many other studies that indicate vestibular disease most commonly makes older patients dizzy.

The trial included 417 patients, ages 65 to 95 (mean 78.5), who had symptoms of dizziness for at least 2 weeks. They underwent standardized, comprehensive evaluations, and those who had presyncopal dizziness, palpitations or symptoms provoked by exercise had electrocardiography (EKG).

The most common major contributory causes of dizziness were cardiovascular disease (57%), peripheral vestibular disease (14%), and psychiatric illness (10%). Adverse drug effects, locomotor disease, metabolic or endocrine conditions, neurological disease were each the primary cause of fewer than 5% of cases.

Adverse drug effects were a minor contributory cause in 23% of patients. The authors note that roughly a third of the subjects used more than five drugs and three or more “fall-risk-increasing” drugs.

Three physicians (a family doctor, a geriatrician, and a nursing home doctor) analyzed the data and assigned subtype(s) and cause(s) of dizziness to the patients. More than one subtype and cause could be given.

According to the paper in the May/June Annals of Family Medicine, subtypes were presyncope in 69%, followed by vertigo in 41%, disequilibrium in 40%, and “other dizziness” in 2%.

Lead author Dr. Otto R. Maarsingh, from the VU University Medical Center in Amsterdam, told Reuters Health that one of the objectives of the Dizziness In Elderly Patients (DIEP) study was to provide clinical guidance in the diagnostic approach of older dizzy patients in primary care.

He suggests that the study may be limited by the lack of clinical follow-up and relatively low levels of interrater agreement, which can be attributed to individual clinicians’ diagnostic preferences. Several doctors assigned causes, which is important when a generally accepted reference standard doesn’t exist for conditions that are not easily defined.

He advises doctors to systematically evaluate dizziness to look for “contributory causes that are amenable to treatment, such as an adverse drug effect that can be resolved by adjusting medication, depression or anxiety that might be amenable to psychotherapy, limited stability during walking that can be improved with physiotherapy/balance training, or impaired vision that can be corrected.”

So should patients undergo more rigorous testing than they currently do in the primary care setting?

That’s a difficult question, Dr. Maarsingh told Reuters Health. In general, more rigorous testing doesn’t automatically lead to a better outcome for the patient. Guidelines on dizziness in primary care are mainly expert-based and there is not enough empirical evidence yet that supports a revision of the current norm.

But he still recommends psychiatric testing (e.g. with a self-administered questionnaire like the PRIME-MD), especially because dizzy patients with both psychological and physical symptoms tend to have high levels of disability and are at risk for remaining symptomatic and disabled. And to keep it simple: always perform a medication check, because an adverse drug effect is an important contributory cause of dizziness in older patients.

He added: As a physician examining an older dizzy patient, always ask yourself, am I missing any other contributory cause?

Reference:

Ann Fam Med 2010;8:196-205.