Dizziness and Vertigo _________________________________________________________________________
RISK FACTORS FOR FALLS IN THE ELDERLY Falls typically result when age-related and environmental (e.g., unfamiliar surroundings, unsafe walking surface) risk factors intersect. Gait and balance impairment are the most consistent risk factors, followed by medications (e.g., benzodiazepines, antidepressants) and polypharmacy [182]. Older patients may have multiple risk factors, including vestibular dysfunction, cerebrovascular disease, cervical spine disorders, physical deconditioning, and postural hypotension. Visual impairment is common and promotes multisensory deficit [181; 183]. Postural control and balance rely on sensory input from proprioceptive and vestibular systems. Age-related changes in these systems impair postural control and increase the risk of falls; they include loss of proprioceptive sensitivity in the lower extremities and loss of labyrinthine hair cells, vestibular ganglion cells, and nerve fibers in the vestibular system [182]. Compounding the loss of proprioceptive and vestibular func- tion are age-related changes in the CNS, including neuronal loss and neurotransmitter depletion, causing further impair- ments in postural control [182]. ASSESSMENT OF FALLS RISK A targeted history and physical exam can identify patients at risk for falling. All older patients, especially patients with a dizziness/vertigo diagnosis, should be asked at least once yearly about falls [182]. Questions for initial screening of falls risk include [21]: • Have you had a fall in the past year? How many times? Were you injured? • Do you feel unsteady when standing or walking? • Do you worry about falling? With positive response, the clinician can perform a more detailed assessment or refer the patient to a specialist [21]. Treatment should be directed at the most readily modifiable fall risk factor(s) [181]. Clinicians should counsel patients and their families on the risk of falls with any balance, dizziness, or vestibular disorder, especially the frail elderly, who are more susceptible to seri- ous injury from falling. Counseling should occur during the initial diagnosis and can include assessment of home safety, activity restrictions, and the need for home supervision until symptoms resolve. Healthcare providers should also ask about dizziness while driving, which may require intervention to prevent patient and public injury or fatality [21; 181; 184].
CONSIDERATIONS FOR NON-ENGLISH- PROFICIENT PATIENTS As a result of the evolving racial and immigration demograph- ics in the United States, interaction with patients for whom English is not a native language is inevitable. Because patient education is such an important aspect of the care of patients with dizziness/vertigo, it is each practitioner’s responsibility to ensure that information and instructions are explained in such a way that allows for patient or caregiver understanding. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding diagnos- tic procedures, treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered. CONCLUSION Knowledge advances are transforming the clinical care of patients with dizziness and vertigo. A paradigm-changing classification system and diagnostic algorithm for dizziness and vertigo affords greater diagnostic ease and accuracy for clinicians. An expanded understanding of the vestibular system highlights the relationship of anxiety to vestibular dysfunction. The differentiation of potentially dangerous cerebrovascular mimics of benign vertigo and dizziness enhances early detec- tion and rapid intervention. The important contribution of vestibular dysfunction to risk for falls in the elderly has been clarified, as falls are a leading cause of disability and death from injury in this population. Despite the demonstrated efficacy of repositioning therapy for the management of BPPV and the ease with which this can be used in the primary care setting, patients with BPPV frequently experience delayed diagnosis, unnecessary testing, and non-recommended treatment. Thus, continuing education has an important role in helping to ensure that clinicians and their patients benefit from current concepts, tools of evaluation, and strategies for managing diz- ziness and vertigo.
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