Unsteadiness and vertigo in the elderly

Chapter 32 Unsteadiness and vertigo in the elderly

Case 32.1

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

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

a pulse 90/min and low volume

Cardiac output is low, and the pulse rate has increased to compensate for this. Alternatively, the low volume pulse may indicate obstruction of blood flow to, or within, the upper limb.

b blood pressure: 125/95

This is an unusual reading, as his diastolic pressure is elevated, but his systolic pressure is normal for his age. The pulse pressure is only 30 mm Hg, and when taken together with the other signs, it is highly suggestive of aortic stenosis.

c apex beat displaced 3 cm laterally

Indicates an enlarged heart, most likely left-sided.

d crackles bilaterally

In relation to the other clinical features, this would suggest the presence of fluid in the lungs. (Crackles can also occur in other disorders (eg: fibrosing alveolitis). However, Paul’s clinical features do not support this diagnosis.

e the type of murmur

Suggests aortic stenosis.

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

The most likely scenario is aortic stenosis which is causing pulmonary oedema and left ventricular insufficiency.

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

Chest X-ray, electrocardiogram (ECG), and echocardiography.

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

• Under 60 years: usually due to post-rheumatic fever or congenital causes.

• 60–75 years: calcified congenital bicuspid valve.

• Over 75 years: degenerative calcification.

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

An increase in physical activity requires a greater flow of blood to the musculoskeletal system, thus causing a reduction of blood flow to the brain. Light-headedness can then occur. This usually results in Paul stopping or decreasing his physical activity, improving blood flow to the brain. The generalised weakness and fatigue are a result of his body not receiving the necessary requirements for its needs.

Case 32.2

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

Orthostatic hypotension (aka postural hypotension).

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

Take her blood pressure in the supine position, then immediately after in the standing position. Orthostatic hypotension is diagnosed if there is a minimum of 20 mm Hg drop in systolic blood pressure, and a 10 mm drop in diastolic blood pressure when moving to the standing position.

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

The individual may fall and/or injure themselves and/or lose consciousness.

Case 32.3

1. What is your differential diagnosis for:

a his lower limb pain

The history and physical examination findings are characteristic of peripheral vascular disease, which is most commonly a consequence of atherosclerosis (with or without superimposed thrombus).

b the episodes of light-headedness

The presence of vascular disease in one part of the body should make the practitioner aware of the possibility of vascular disease elsewhere. The history suggests that there may be reduced blood flow to the brain. This may be due to a decrease in cardiac output or obstruction to arteries supplying the brain. It may also be related to a labyrinthine disturbance.

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

His blood pressure, as well as the pulse volume in the radial and brachial arteries, in his left limb is less than that in the right limb. The difference in the blood pressure is quite large. This suggests some reduction in blood flow to the left upper limb. The difference in blood pressure between the left and right limbs is probably reflecting the differences in blood flow to each limb.

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

Angus presents with light-headedness and nausea. Some patients confuse the feeling of light-headedness with vertigo. If Angus does suffer from vertigo rather than light-headedness, then it is possible that a labyrinth disorder may be the cause. Some labyrinthine pathologies present with hearing loss and tinnitus, in addition to vertigo.

4. Explain the relationship between:

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

He relates the light-headedness to events in which he requires an increase in muscle activity in his upper limbs. In other words, the increase in muscle activity in the left upper limb appears to correlate with deprivation of blood to his brain, causing ‘dizziness’. The bruit heard on auscultation corresponds to the site of the subclavian artery. There may be an obstruction in this vessel which is causing the interesting relationship between upper limb activity and dizziness. The likely diagnosis is ‘subclavian steal syndrome’.

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.

His upper limb symptoms are most likely due to subclavian steal syndrome. This rare disorder involves an obstruction of the subclavian artery, proximal to the vertebral artery origin. When the upper limb of that side is exercised, there is insufficient blood available due to this obstruction. As a result, blood is ‘stolen’ from the vertebral artery, which requires reversal of blood flow in the vertebral artery, causing a reduction of blood arriving at the brain.

His lower limb symptoms are typical for peripheral vascular disease, with partial obstruction of the lower limb arteries. This is most likely a result of atherosclerosis. Although peripheral vascular disease may be used to describe a range of disorders of peripheral arteries, veins or lymphatics, common usage generally restricts it’s application to disorders of arterial obstruction in the limbs.

7. Explain the pathogenesis of both diagnoses.

For subclavian steal syndrome, please refer to reference 3 at the end of this chapter.

For peripheral vascular disease, please refer to reference 4 at the end of this chapter.

Case 32.4

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

Possible diagnosis	Justification
DDX 1: transient ischaemic attacks (TIA) in the vertebro-basilar system	• Description of attacks resembles vertigo, a common symptom of vertebro-basilar insufficiency • Episodes last less than 1 hour • History of recent infarct • She has ischaemic heart disease, which suggests that she may have atheroma in other vessels which may be causing ischaemia
DDX 2: labyrinthine disorder	• Description of attacks resembles vertigo, a major feature of labyrinthine disorders
DDX 3: postural hypotension	• Patients may confuse vertigo with light-headedness
DDX 4: medication with anginine	• Anginine is a vasodilator, which may cause a fall in blood pressure, and a feeling of light-headedness
DDX 5: hypoglycaemia	• Patients may confuse vertigo with light-headedness
DDX 6: cervicogenic	• May cause vertigo

2. Compile a ‘problem list’ for this patient.

• Unexplained vertigo.

• Ischaemic heart disease.

• Chronic peridiverticulitis.

3. Why was Judith asked to describe the precise nature of her dizziness?

To determine if it was true vertigo, or the more common feeling of ‘light-headedness’.

4. Is it possible that her dizziness is related to her myocardial infarct 1 year earlier?

Yes. A mural thrombus may form over damaged tissue, which may then send small emboli to the brain, resulting in ischaemia. If the embolus is small, and dissolves rapidly, then the ischaemia is only transient.

5. What type of drug is anginine? How does it work?

Anginine is glyceryl trinitrate. It is a vasodilator, which thus dilates the coronary arteries, allowing more oxygen to reach the tissues. Its use in angina is for relief of pain. In this disorder, coronary arteries are narrowed due to atheromatous plaques (with or without superimposed thrombi), which results in decreased oxygen availability for cardiac tissue, especially during exercise. The pain occurs due to a build up of metabolites formed during anaerobic respiration. This drug, by causing vasodilation, allows more oxygen to reach the tissues, which encourages aerobic respiration, reduction of pain-inducing metabolites, and hence relief of pain.

Tags: Cases in Differential Diagnosis for the Physical and Manipulativ

Dec 26, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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