Diagnosis of geriatric patients with severe dizziness

OBJECTIVE: To identify the causes of dizziness in older patients presenting to the general practitioner and the clinical characteristics at presentation that might guide the general practitioner to the likely cause of dizziness and the most appropriate specialty for subsequent referral if referral is required. DESIGN: A prospective case control study of older patients presenting with dizziness. SETTING: The initial assessment was made in four general practices, three urban practices and one inner city practice (Newcastle). Subsequent investigations were conducted randomly in the Neurocardiovascular Investigation Unit and the Otolaryngology (ENT) Unit at local University hospitals (Newcastle). PARTICIPANTS: Fifty consecutive patients more than 60 years of age presented with dizziness. Twenty-two age- and sex-matched case controls were recruited from the same general practices. MEASUREMENTS: Measurements were of diagnoses attributable to symptoms. RESULTS: Symptoms were of long duration (median 1 year). Forty-six percent of patients had syncope and/or falls in addition to dizziness. Twenty-eight percent had a cardiovascular diagnosis, 18% had a peripheral vestibular disorder, 14% had a central neurological disorder, 18% had more than one diagnosis, and 22% had no attributable cause of symytoms identified. A cardiovascular diagnosis was predicted by the presence of syncope (P <.001), dizziness described as lightheadedness (P <.001), the need to sit or lie down during symptoms (P <.001), pallor with symptoms (P <.001), symptom precipitation by prolonged standing (P <.05), and whether patients had coexisting cardiovascular disease (P <.05). The description of dizziness as "vertigo" predicted a peripheral vestibular disorder (P <.001). The predictive strength of these prognostic indicators was then validated on a separate sample of 50 additional older patients. CONCLUSIONS: Clinical characteristics can predict an attributable cause of dizziness in most older patients and thus guide general practitioners in treatment and appropriate specialist referral. The presence of syncope, falls, or cardiovascular comorbidity increases the likelihood of a cardiovascular diagnosis. Otolaryngological investigations are rarely diagnostic, but vertiginous symptoms do predict peripheral vestibular disorders.