Chapter 32 Unsteadiness and vertigo in the elderly

Case 32.1

History

Paul, 75 years of age, presents with a 4–5 month history of unsteadiness, fatigue and generalised weakness. He describes the episodes of unsteadiness more as a feeling of ‘light-headedness’. He states that it is quite unpleasant and often occurs at inconvenient times (usually when he is busy doing something). He feels as if he is going to faint, and needs to sit or lie down. Two days ago he fainted, but thinks that he regained consciousness within moments of passing out.

Paul also complains of a 2 month history of breathlessness, which is worse when he lies down. He is on no medication, is a non-smoker, and states that he has a reasonably healthy lifestyle. There are no other symptoms.

Questions

1. What is your differential diagnosis? Explain your choices.

2. What term is used to refer to dyspnoea which is worse when lying down?

Physical examination

• Pulse rate: 90/min low volume; blood pressure: 125/95, afebrile.

• Apex beat displaced 3 cm laterally.

• Chest: a few crackles are auscultated bilaterally.

• A systolic murmur is heard best in the 2nd right intercostal space. Peripheral pulses are equal and present and there are no carotid bruits.

Questions

3. What information can you obtain from each of the following signs:

a pulse 90/min and low volume

b blood pressure: 125/95

c apex beat displaced 3 cm laterally

d crackles bilaterally

e the type of murmur?

4. Can you now narrow your differential diagnosis? Which is the most likely?

5. What investigations will Paul need to have once he has been referred to a specialist?

6. What are the most common causes of this disorder?

7. Explain why Paul feels light-headed, especially when he is busy.

8. Why is he getting breathless?

Case 32.2

Bev is an elderly relative who complains of episodes of feeling light-headed. These usually occur when she gets out of bed, or when rising from her recliner chair. The feeling lasts about 20–30 seconds, but occasionally it is severe enough that she has to lie down. The symptoms disappear following a return to the original position. The episodes never occur when she is lying in bed, or while sitting in a straight-backed chair. There is no nausea or vomiting associated with the episodes, and a system review reveals no additional symptomatology.

Bev has mild hypertension, for which she has been prescribed Lasix (furosemide).

Questions

1. What is the most likely cause of Bev’s symptoms?

2. What simple examination technique can you do in order to verify this? If your diagnosis is correct, what would you expect to find?

3. What are the most common causes of this disorder?

4. Are there any complications that may arise from this condition?

Case 32.3

History

Angus is an 80-year-old man who presents with a 1 month history of episodic light-headedness, which often necessitates a need to lie down and rest. The episodes cease within minutes of resting. He finds it difficult to describe the feeling, but states that it is often associated with nausea. The episodes are not associated with any other symptoms. He has not noticed any hearing loss or tinnitus at any time. The episodes occur more frequently when he is hanging out his washing or carrying shopping bags.

System review indicates pain in his lower limbs when he walks for more than about 10 minutes on a flat surface, or after 1 minute when climbing stairs. The pain disappears once he rests for a couple of minutes. He has not noticedany sensory changes in his legs, but states that his muscles feel ‘tired’ when the pain occurs. These symptoms have been present for about 2 years, and he has not consulted a doctor since he believed that this was quite normal for a man of his age.

He sees an optometrist annually to assess his vision, as he wishes to maintain his driver’s licence.

He is a smoker, overweight, lives alone, and drinks socially.

Physical examination

Questions

1. What is your differential diagnosis for:

a his lower limb pain

b the episodes of light-headedness?

2. Explain why the blood pressure is lower on the left side, compared to the right.

3. Why was he initially asked about the presence of hearing loss and tinnitus?

4. Explain the relationship between:

a his light-headedness, and the activities that most commonly precipitate it

b his lower limb pain and walking.

5. What is the most likely diagnosis for his upper limb presentation? What is the most likely diagnosis for his lower limb presentation? Define these disorders.

6. What investigations are required to confirm your diagnoses from question 5?

7. Explain the pathogenesis of both diagnoses.

Case 32.4

History

An 80-year-old female, Judith, presents with multiple episodes of dizziness. She describes the dizziness as if the world is spinning around her. When she has these episodes, she feels nauseous and sometimes vomits. The episodes commenced about 1 year ago, shortly after having a myocardial infarct. Each episode lasts around 20 minutes. She does not believe that she has suffered from any hearing loss, and has had no tinnitus.

Judith had a long history of angina prior to her infarct, and still has episodes of pain if she over-exerts herself.

She takes anginine (glyceryl trinitrate) when necessary. Judith has also been diagnosed with chronic peridiverticulitis, and had a hysterectomy for endometrial carcinoma when she was 65 years old.

Questions

1. Using only this information, list the possible causes of Judith’s dizziness. Justify your answer.

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