I’m rotating through a community emergency department this month, in which it seems like 40% of the patients I’m seeing have dizziness as some element of their constellation of chief complaints. This is one of the most difficult chief complaints to evaluate in emergency medicine — not only because people use the term “dizziness” to describe a multitude of subjective experiences, e.g. vertigo, syncope/presyncope, generalized weakness, anxiety, ataxia, or any sort of disturbance in mentation. Add in the barriers to effective communication that can accompany elder patients visiting an ED, such as language barriers + hearing/vision issues that accompany aging (imagine a translator on a video phone screaming at a patient who is extremely hard of hearing) and this becomes a tricky subject indeed.
To that end, I reviewed a paper published by a Korean group evaluating dizzy patients in their emergency department: Characteristics of central lesions in patients with dizziness determined by diffusion MRI in the emergency department, by Lee et al.
This was a retrospective review of 902 patients presenting to a single ED with a chief complaint of dizziness over six months. They looked closely at 645 patients (!) who recieved MRI imaging as part of their workup, which showed 23 patients (3.6%) having strokes, the majority in the posterior circulation. The authors then examined the characteristics that best predicted the presence of a central lesion.
Their findings? Predictably, advancing age brought with it a higher likelihood of central etiologies: the rate of central lesions on DWI was 3.9% and 3.5% in patients in their 50s and 60s respectively; 7.4% in 70s and 16.7% in their 80s! Hypertension was more common in patients with strokes (69% versus 36%). Atrial fibrillation was more common. 77% of patients with a central cause reported a more vague non-whirling dizziness compared to 40% in patients without central lesions. Other associated neurologic symptoms were present in about 46% of patients with a central cause, compared to only 3% in those who were MR-negative.
So while this study had all the drawbacks of most retrospective, single-center publications, and may not generalize exactly to the populations I work with, I felt it was useful in terms of giving me at least *some* numbers to use to estimate what proportion of these patients are hiding badness. I will have a much lower threshold to MRI patients who are in their 70s-80s, those with AF who aren’t anticoagulated (though the sensation of palpitations or the diminished cardiac output can contribute to the sensation of dizziness as well), or those who report a “vague non-whirling” sense of dizziness. That last point stands in contrast to what I’ve read in other studies that suggested that the character of dizziness was *not* useful, so that was interesting. When this study was reviewed on EMRAP another thing that Sanjay and Mike mentioned was that older patients often have difficulties cooperating with the exam, accurately reporting/describing their symptoms, and that our threshold for obtaining further diagnostic imaging in these patients should be lower.
More on dizziness to come soon, I’m sure.