·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific Seminars

Geriatric Medicine: Doctor I'm so Dizzy! Demystifying and Being Mindful of Medications in the

Geriatric Patient

Ronna New, DO, FACOFP

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary.

Name of CME Activity: ACOFP 53rd Annual Convention and Scientific Seminars

Dates and Location of CME Activity: April 6-9, 2016, The San Juan Puerto Rico Convention Center

Your presentation(s):

Friday, April 8, 2016 from 3:00pm-5:00pm: Geriatric Medicine: Doctor, I’m So Dizzy! Demystifying Dizziness and

Being Mindful of Medications in the Geriatric Patient

Name of Faculty/Moderator: _Ronna D. New, DO, FACOFP

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Signature: Date: 01/15/16

Ronna New, DO, FACOFP

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Deadline: Friday, January 15, 2016

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Doctor, I’m so dizzy!Demystifying Dizziness & Being Mindfulof Medications in the Geriatric Patient

Ronna D. New, DO, FACOFP

Director of Medical Education, NE Region

Program Director, Family Medicine Residency Program

Mountain States Health Alliance/Johnston Memorial Hospital – Abingdon, VA

Disclosure Statement of Financial Interest

• I DO NOT have a financial interest/arrangement or affiliation that could be perceived as a real or apparent conflict of interest in the

context of the subject of this presentation.

Objectives

At the conclusion of this session, the participant will:

• identify the most common causes of dizziness and syncope in the geriatric patient

• understand the evaluation of dizziness and syncope in the geriatric patient

• know the management of dizziness and syncope in the geriatric patient

• understand principles of prescribing cardiovascular medications and polypharmacy concerns in the geriatric patient

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DI~Z~Z~IN~E~S~S

“Lightheadedness, giddiness, wooziness, spinning,

floating, spaciness, whirling……….”

Dizziness, Important and Complex

• Dizziness is a common symptom in older adults

• Prevalence of 4-30% and increases with age

• Classification of dizziness is difficult

• Concern exists for serious causes

• Specific therapy is often not available

• And…. 50% of cases have multiple causes

Dizziness, Refresher of Terms

• Refers to various abnormal sensations relating to the perceptions of the body’s relationship to space

• VERTIGO is the sensation that the body or the environment is spinning, rotational sensation

• PRESYNCOPE is the feeling of lightheadedness and impending faint

• DISEQUILIBRIUM is a sense of imbalance that involves the legs or trunk without a sensation in the head (on standing or walking)

• OTHER is vague or floating feeling and the patient has a hard time describing it

• MIXED is the most common type

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Dizziness as a Geriatric Syndrome

• Associated with increased risk of falls, functional disability, nursing home placement, and death

• Single causes are numerous and variable –mostly in younger patients

• In the geriatric patient, causes are usually multifactorial – over 50%

• Accounts for 7 million visits to the office a year

Causes of Vertigo in the Geriatric Patient

Vestibular disorders

• Benign paroxysmal positional vertigo (BPPV)

• Ménière disease

• Ototoxic medications (such as aminoglycosides, diuretics, NSAIDs)

• Acoustic neuroma

• Cerebrovascular disease

Causes of Vertigo

Peripheral Vestibular Disorders

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Benign Paroxysmal Positional Vertigo (BPPV)

• Episodic inner ear disorder

• Aggravated or brought on by changes in position (eg, turning, rolling over, bending over)

• Spells are often brief (5–15 sec) and milder than other types of vertigo

• Probably results from changes in endolymphaticpressure during head movements resulting from dislodged otoconia in semicircular canal

MÉNIÈRE DISEASE

• Idiopathic inner ear disorder

• Repeated episodes of tinnitus

• Fluctuating hearing loss with sensation of fullness in ears

• Severe vertigo

• Eventual progressive sensorineural hearing loss

• Frequency and severity of vertigo may improve as hearing loss worsens

Causes of Vertigo

Central Vestibular Disorders

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Brain Tumors

• Account for less than 1% of dizzy patients

Acoustic neuroma• most common tumor associated with

dizziness

• presents more commonly with tinnitus and hearing loss

• usually unilateral

Others

• Cerebrovascular disease can cause vertigo, but it is usually associated with other neurological findings

• Multiple sclerosis can cause vertigo and is not an uncommon early manifestation of that disease

• Dizziness secondary to cervical arthritis can also present with vertigo

Presyncope• Sensation of near-fainting

• Sign of decreased cerebral perfusion

• Cardiac causes Electrical: tachy- or bradyarrhythmias

Structural, esp. aortic outflow obstruction

• Vascular causes (ex, orthostatic hypotension, vagal stimulation, dehydration)

• Postural change (with or without orthostatic hypotension)

• Postprandial hypotension

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Disequilibrium• Sensation of being unsteady when standing or, in particular, walking

• Many factors can contribute to imbalance:

Vascular disorders

Tumors

Proprioceptive disorders (neuropathies)

Visual problems (refractory errors, cataracts, macular degeneration)

Musculoskeletal disorders (arthritis, muscle weakness, post-acute deconditioning)

Gait disorders (CVA, Parkinson’s Disease, cerebellar disorders)

Other Forms of Dizziness• Best reserved as a description for patients who do not

experience vertigo, presyncope, or disequilibrium

• Patient may describe “lightheadedness,” “wooziness,” or other nonspecific sensations

• The most prominent consideration is a psychiatric cause (depression, anxiety, somatoform disorders)

• Other underlying disease to look for: anemia, heart failure, DM, and hypothyroidism

• Also, consider carotid sinus hypersensitivity or carotid sinus syndrome (although less common)

What about drug toxicity?

Think Meds, Meds, Meds….

“When an elderly patient presents with a status change, unless proven otherwise, it should be assumed to be a medication related problem.”

» Jerry Gurwitz MD, director of Meyers Primary Care Institute, @ UMASS: nationally recognized expert on the safe use of medications in the elderly

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Medications and Dizziness• In older adults, prescription drug toxicity is an

important contributor to dizziness• Greater than 5 medications is a risk factor• Certain drugs are more frequently implicated:

Those that cause orthostasis or CNS effects

Cardiovascular or antihypertensive drugs

Psychotropic medications

Aminoglycosides

NSAIDs

Antihistamines and anticholinergics

Be Mindful of Medications• Examples of Medications• Cardiac Meds: α-blockers, β-blockers, ACEIs,

diuretics, nitrates, clonidine, hydralazine, methyldopa, reserpine, dipyridamole

• CNS: antipsychotics, opioids, Parkinson’s Dxmeds, muscle relaxants, TCAs

• Urologic: antimuscarinic agents for UI, PDE-5 inhibitors

• Caffeine, alcohol, nicotine

Commonly Used Anticholinergics• Oxybutynin (be aware of TD patches)• Diphenhydramine• Hydroxyzine• H2 Blockers (cimetidine, ranitidine)• Narcotic analgesics• Benzodiazepines• Tricyclic Antidepressants• Antipsychotic agents• Trazodone• SSRIs• OTC Meds! (GERD meds, allergy meds, “PM” agents,

bladder control agents)

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Evaluation of Dizziness in the Geriatric Patient

History - the most useful part of the evaluation• Elicit the patient or family/caregiver’s own description of the event

without prompting

• Learn:

Whether the dizziness is characterized by any of 3 sensations: spinning, fainting, or falling

Whether there is a positional effect on symptoms

Frequency and duration of symptoms

What other symptoms are associated with dizziness (specifically ask about hearing loss and focal neurological symptoms)

What medications the patient is taking (any new medications, recent ER or urgent care visits)

Evaluation of Dizziness in the Geriatric Patient

Physical Examination

• Take blood pressure and pulse while patient is supine and after standing for 12 min

• Test vestibular system including with Dix-Hallpikemaneuver

• Perform cardiac examination, test hearing and vision and observe for nystagmus

• Observe for balance and gait difficulties

Evaluation of Dizziness in the Geriatric Patient

Diagnostics

• Laboratory

In patients with chronic dizziness, check hematocrit, glucose, electrolytes, renal function, vitamin B12, folic acid, thyrotropin

• Audiometry May help if cochlear symptoms are present (tinnitus,

asymmetric hearing loss) Abnormal results may indicate Ménière disease or,

rarely, a tumor

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Evaluation of Dizziness in the Geriatric Patient

Diagnostics

• Vestibular testing

• Neuroimaging (CT, MRI) occasionally warranted

• ECG if cardiac cause suspected

• Tilt-table testing only in select patients with postural hypotension or syncope

Management of Dizziness: Vertigo

Source: GRS Teaching Slides

Management of Dizziness: Presyncope

Source: GRS Teaching Slides

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Management of Dizziness: Disequilibrium

Source: GRS Teaching Slides

Management of Dizziness: Mixed

Source: GRS Teaching Slides

Common causes orcoexisting conditions

Treatment

Medications: antianxiety drugs, antidepressants, anticonvulsants, antipsychotics, antihypertensives, anticholinergics

Discontinue, substitute, or reduce the dosage of offending medication

Combination of any of the above causes

Multifactorial intervention

What about Syncope in the Geriatric Patient?

• Sudden, transient loss of postural tone and consciousness (not due to trauma) with spontaneous full recovery

• Accounts for: About 3% of emergency department visits

2%–6% of hospital admissions

• 80% of those hospitalized for syncope are aged 65+

• Generally caused by reduced cerebral perfusion In older adults, may be multifactorial

Possible causes are numerous

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What normally prevents syncope?

• 1/3 of blood volume pools in legs while standing

• Reflex pathways facilitate venous return and increase cardiac output

Baroreceptor reflex

Sympathetic renal stimulation

Veno-arteriolar axon reflex

Abdominal-respiratory pump

What happens as we age?Pathophysiology of Syncope: Effects of Aging

• Reflex mechanisms are less responsive

Decreased ability to increase heart rate in response to

sympathetic stimulation

Increased sensitivity to effects of dehydration and vasodilator

drugs

• Comorbidities that affect postural responses are

common (ex, DM, Parkinson’s Dx)

• Meds, Meds, Meds…..Medications may further impair

postural reflexes (eg, vasodilators, antidepressants, -

blockers, -blockers, tricyclic antidepressants)

Natural History of Syncope

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Common Causes of SyncopeReduced Cardiac Output• Cardiac causes

Rhythm disturbances

Structural heart diseases: aortic stenosis, hypertrophic cardiomyopathy

Coronary artery disease

• Reduced intravascular volume Dehydration

Bleeding

• Pulmonary causes Massive pulmonary embolus

• Medications causing reduced cardiac output

Common Causes of SyncopeAltered Peripheral Vascular Resistance• Several syndromes are associated with acute vasodilation of the

arterial and venous beds and relative or absolute bradycardia

• Functional autonomic reflexes

Vasovagal

Carotid sinus syndrome

Situational: swallowing, micturition, defecation

• Structural autonomic insufficiency

Primary conditions: pure autonomic failure, multisystem atrophy

Secondary conditions: diabetes mellitus, spinal cord lesions, uremia

• Medications causing altered peripheral resistance

Evaluation of Syncope in the Geriatric Patient

History• Precipitants? Eating, Urinating, Defecating, Coughing, Medications,

Emotional Stress, Physical Exertion, Turning of Head?

• Prodromal Symptoms? Chest pain, Palpitations, Dyspnea,

Diaphoresis, Presyncope, Nausea, Emesis?

• Witnesses? Duration, Appearance of Patient

• Comorbid Conditions? Such as CAD, DM, etc

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Syncope Caused by Arrhythmia

• Prior to event

Occurs in any position, <5 sec warning

No precipitant; palpitations rare

• During event

Flaccid tone; pulse faint or absent

Blue, ashen skin

Incontinence (rare)

• Recovery

Rapid and complete

Vasovagal Syncope “the common faint”

• Prior to event Aborted if person lies flat

Seconds to minutes of warning

Precipitant present; nausea/diaphoresis common

Visual changes

• During event Motionless; relaxed tone; slow, faint pulse

Pale color; dilated, reactive pupils

• Recovery Fatigue, nausea, and diaphoresis common

No retrograde amnesia

Syncope Caused by Seizure

• Prior to event Occurs in any position

No warning or prodrome

• During event Rigid tone; rapid pulse; elevated BP

Tonic eye deviation common

Frothing at mouth

• Recovery Slow, incomplete

Disorientation; focal neurologic findings

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Evaluation of Syncope in the Geriatric Patient

Physical Examination

• Orthostatic blood pressure and pulse

• Carotid pulse examination

• Cardiac examination (murmurs, extra heart sounds)

• Lung examination

• Neurologic examination for focal deficits

• Stool for occult blood

Evaluation of Syncope in the Geriatric PatientDiagnostics• ECG for all syncopal older adults• Ambulatory ECG

Among patients able and willing to operate loop recorders, diagnostic yield is ~25%

• Implantable loop recorders

May increase ability to establish diagnosis in patients with syncope who have no structural heart disease

• Echocardiography

• Tilt-table testing

• Electrophysiologic studies

• Neurologic testing (MRI and CT, plus EEG) if focal neurologic signs or symptoms are present, or if the history suggests seizure

Evaluation of Syncope in the Geriatric Patient

• ECG establishes diagnosis in only 5% of patients with syncope• Echo is of low yield in absence of cardiac symptoms or history,

but unsuspected findings are noted in up to 10% of these pts• Tilt table testing is useful in patients with suspected vasovagal

and unexplained syncope, who do not have a suspected cardiac cause. But, it is positive in 11% of asymptomatic geriatric patients.

• It is advised that men over 45 and women over 55 have stress testing prior to tilt table testing so that a positive tilt table test does not delay the diagnosis of coronary ischemia

• EP studies?-for pts with structural dx & unexplained syncope

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When do you do Tilt Table Testing?

• Indicated in the diagnosis of recurrent syncope where initial history, physical, and appropriate neuro and cardiac exams have been non-diagnostic

• May also be appropriate in patients with single syncopal episodes who have sustained injuries during the attack or who suffered syncope while driving

• May be useful in the geriatric patient who has suffered multiple unexplained falls

• Relative contraindications include proximal coronary artery stenosis, critical mitral stenosis, severe left ventricular outflow stenosis, and known cerebrovascular stenosis

Management of Syncope in the Geriatric Patient

• Treat the underlying cause/disorder

• In geriatric patients, remember the cause is likely multifactorial.

Treatment of multiple possible causes is often necessary.

• Discontinuation of medications that increase the risk of syncope is

imperative and must be given attention early in the management

• Orthostatic hypotension? Really investigate

medications (change or d/c), increase salt and

water intake, consider caffeine

• Postprandial hypotension? Avoid alcohol

and large carb meals. Try caffeine and the

newspaper!

Recurrent Syncope Without Known Cause

• Help patients avoid harm to themselves or others

• Consider recommending against driving for several months

and resuming if patient remains recurrence-free (American

Heart Association guidelines)

• Many states have reporting laws or restrictions regarding

driving with a history of syncope

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References

• Arthur, W and Kaye, G Important Points The Clinical Evaluation of Patients with Syncope Postgraduate Medical Journal vol77(904),pg 99-102

• Fenton, A et al, Vasovagal Syncope, Annals of Internal Medicine volume 133(9) 7,pg 714 -725• Gatzoulis, K and Toutouzas P Neurocardiogenic Syncope: Aetiology and Management, Drugs,

Volume 61(10), pg 1415- 1423• Geriatrics Review Syllabus Teaching Slides, American Geriatrics Society• Matthias ,C To Stand On One’s Own Legs Clinical Medicine, volume 2(3), pg 237 -245• Murphy MD, Patrick – University of Louisville Geriatrics Teaching Slides• Parry, S and Kenny, R Tilt Table Testing in the Diagnosis of Unexplained Syncope, Quarterly Journal

of Medicine, Volume 92(11),pg 623 – 629• Sloane, P et al, Dizziness: State of The Science Annals of Internal Medicine volume 134(9 part 2 )

supplement, pg 823 -832• Tinetti, M et al Dizziness Among Older Adults: A Possible Geriatric Syndrome, Annals Of Internal

Medicine, volume 132(5), pg 337 -344• Image slide 18, source: dangersofpolypharmacy.wordpress.com• Image slide 21, source: aurorahealthcare.org• Image slide 36, source: peoplespharmacy.com• Image slide 44, neuroblog.brain-dynamics• Image slide 45, medicinenet.com/dementia_pictures_slideshow/article.htm

Thank you!