A 77-year-old woman who, over a period of some months, had changed behavior was subsequently admitted to hospital with loss of weight, fatigue and dizziness. Despite intensive examination, no somatic explanation was found. After a month she was diagnosed with depression but discharged because she refused further treatment. She eventually died. It is important to consider that patients with first episode of major depressive disorder in late life (late-onset geriatric major depression), often present with other prominent symptoms than younger persons.

This article reviews the basic concepts underlying the balance system, describes the information provided by dynamic posturography, and explains how the technique complements and expands on the information provided by traditional tests of vestibular function.

Questionnaires assessing symptoms, anxiety and handicap were completed by 127 vertiginous patients. Factor analysis identified four distinct symptom clusters which formed the basis for the construction of scales quantifying the number and frequency of symptoms of:(a) vertigo (of long and short duration);(b) autonomic sensations and anxiety arousal; and (c) somatization. Scores on the vertigo severity scale were significantly related to clinical diagnosis and had near-zero correlations with measures of anxiety. Vertigo severity, autonomic signs and depressed mood each independently contributed to variance in handicap, taking precedence over the relationship between handicap and trait and state anxiety. Our findings suggest that the familiar association between anxiety and vertigo may be mediated principally by autonomic symptomatology arising as a result of somatopsychic and psychosomatic processes.

Workups by physicians in response to five common complaints in a sample of 104 men and women--52 married couples--were evaluated by chart audit. For the total group of complaints, back pain, headache, dizziness, chest pain, and fatigue, the physicians' workups were significantly more extensive for men than they were for women. These data tend to support the argument that male physicians take medical illness more seriously in men than in women.

Balance disorders in elderly patients are associated with an increased risk of falls but are often difficult to diagnose because of comorbid chronic medical problems. We performed a cross-sectional study to determine the prevalence of unrecognized benign paroxysmal positional vertigo (BPPV) and associated lifestyle sequelae in a public, inner-city geriatric population. Dizziness was found in 61% of patients, whereas balance disorders were found in 77% of patients. Nine percent were found to have unrecognized BPPV. Multivariate analysis demonstrated that the presence of a spinning sensation and the absence of a lightheadedness sensation predicted the presence of unrecognized BPPV. Patients with unrecognized BPPV were more likely to have reduced activities of daily living scores, to have sustained a fall in the previous 3 months, and to have depression. These data indicate that unrecognized BPPV is common within the elderly population and has associated morbidity. Further prospective studies are warranted.

Neuhauser H & Lempert T. Vertigo and dizziness related to migraine: a diagnostic challenge. Cephalalgia 2004; 24:83-91. London. ISSN 0333-1024 Vertigo and dizziness can be related to migraine in various ways: causally, statistically or, quite frequently, just by chance. Migrainous vertigo (MV) is a vestibular syndrome caused by migraine and presents with attacks of spontaneous or positional vertigo lasting seconds to days and migrainous symptoms during the attack. MV is the most common cause of spontaneous recurrent vertigo and is presently not included in the International Headache Society classification of migraine. Benign paroxysmal positional vertigo (BPPV) and Ménière's disease (MD) are statistically related to migraine, but the possible pathogenetic links have not been established. Moreover, migraineurs suffer from motion sickness more often than controls. Persistent cerebellar symptoms may develop in the course of familial hemiplegic migraine. Dizziness may also be due to orthostatic hypotension, anxiety disorders or major depression which all have an increased prevalence in patients with migraine.

OBJECTIVE: To compare the findings in dizzy elderly people with those in controls of a similar age to identify which investigations differentiate dizzy from non-dizzy patients and to design an investigational algorithm. DESIGN: Community based study of clinical and laboratory findings in dizzy and control elderly people. SETTING: Research outpatient clinic at a teaching hospital. SUBJECTS: 149 dizzy and 97 control subjects aged over 65 years recruited from a community survey and articles in the local press. MAIN OUTCOME MEASURES: Findings on physical examination, blood testing, electrocardiography (at rest and over 24 hours), electronystagmography, posturography, and magnetic resonance imaging of head and neck (125 (84%) dizzy subjects and 86 (89%) controls); hospital anxiety and depression score; responses to hyperventilation, carotid sinus massage, and the Hallpike manoeuvre. RESULTS: Blood profile, electrocardiography, electronystagmography, and magnetic resonance imaging failed to distinguish dizzy from control subjects because of the frequency of asymptomatic abnormalities in controls. Posturography and clinical assessment (physical examination, dizziness provocation, and psychological assessment) showed significant differences between the groups. A cause of the dizziness was identified from clinical diagnostic criteria based on accepted definitions in 143 subjects, with 126 having more than one cause. The most common diagnoses were central vascular disease (105) and cervical spondylosis (98), often accompanied by poor vision and anxiety. CONCLUSION: Expensive investigations are rarely helpful in dizzy elderly people. The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical examination without recourse to hospital referral.

Patients with panic disorder commonly report symptoms of dizziness and imbalance. We studied the relationship between objective measures of audiovestibular function, phenomenologic, and self-report measures of dysequilibrium and related somatic symptoms in a sample of panic disorder patients with and without agoraphobia, unselected for the complaint of dysequilibrium. Of seventeen patients evaluated by electronystagmography, 71 percent exhibited abnormal vestibular test findings. These latter patients had higher total anxiety ratings than patients without vestibular abnormalities. We conclude that patients with panic disorder warrant evaluation of audiovestibular function.

OBJECTIVE: To identify the causes of dizziness in older patients presenting to the general practitioner and the clinical characteristics at presentation that might guide the general practitioner to the likely cause of dizziness and the most appropriate specialty for subsequent referral if referral is required. DESIGN: A prospective case control study of older patients presenting with dizziness. SETTING: The initial assessment was made in four general practices, three urban practices and one inner city practice (Newcastle). Subsequent investigations were conducted randomly in the Neurocardiovascular Investigation Unit and the Otolaryngology (ENT) Unit at local University hospitals (Newcastle). PARTICIPANTS: Fifty consecutive patients more than 60 years of age presented with dizziness. Twenty-two age- and sex-matched case controls were recruited from the same general practices. MEASUREMENTS: Measurements were of diagnoses attributable to symptoms. RESULTS: Symptoms were of long duration (median 1 year). Forty-six percent of patients had syncope and/or falls in addition to dizziness. Twenty-eight percent had a cardiovascular diagnosis, 18% had a peripheral vestibular disorder, 14% had a central neurological disorder, 18% had more than one diagnosis, and 22% had no attributable cause of symptoms identified. A cardiovascular diagnosis was predicted by the presence of syncope (P <.001), dizziness described as lightheadedness (P <.001), the need to sit or lie down during symptoms (P <.001), pallor with symptoms (P <.001), symptom precipitation by prolonged standing (P <.05), and whether patients had coexisting cardiovascular disease (P <.05). The description of dizziness as "vertigo" predicted a peripheral vestibular disorder (P <.001). The predictive strength of these prognostic indicators was then validated on a separate sample of 50 additional older patients. CONCLUSIONS: Clinical characteristics can predict an attributable cause of dizziness in most older patients and thus guide general practitioners in treatment and appropriate specialist referral. The presence of syncope, falls, or cardiovascular comorbidity increases the likelihood of a cardiovascular diagnosis. Otolaryngological investigations are rarely diagnostic, but vertiginous symptoms do predict peripheral vestibular disorders.

OBJECTIVE: Because the physicians who care for patients with head trauma may be family practitioners or internists, this article provides these physicians some knowledge of the causes and pathophysiology of such trauma with respect to neurologic sequelae to aid in their decisions to seek consultation with neurologists and otoneurologists in diagnosis and management. METHODS: This article reviews the literature concerning differential diagnosis, appropriate evaluation, and possible treatments of patients who exhibit hearing loss and dizziness after head trauma, whiplash injuries, or both. I also relate those findings to my extensive experience with such neurologic problems. FINDINGS: The findings are grouped according to injuries that cause dizziness, including trauma to the brain stem - eighth nerve complex, the semicircular canals (labyrinthine concussion), benign paroxysmal positional vertigo, Meniere's syndrome -- vestibular symptoms, perilymphatic fistula -- vestibular symptoms, and cervical vertigo; and those that cause hearing loss, including trauma to the brain, eighth nerve, middle ear, cochlear concussion, Meniere's syndrome, and perilymphatic fistula.

The evaluation of syncopal children or adolescents relies heavily on a thorough, detailed history and physical examination. All syncope associated with exercise or exertion must be considered dangerous. The ECG is mandatory, but other laboratory tests are generally of limited value unless guided by pertinent positives or negatives in the history and physical examination. The ECG allows screening for dysrhythmias, such as Wolff-Parkinson-White syndrome, heart block, and long QT syndrome, as well as hypertrophic cardiomyopathies and myocarditis. Tilt table testing can be useful in selecting therapy by demonstrating the physiologic response leading to syncope in an individual patient. The most common type of syncope in otherwise healthy children and adolescents is neurocardiogenic or vasodepressor syncope, which is a benign and transient condition. Because syncope can be a predictor of sudden cardiac death, it must be taken seriously, and appropriate screening must be performed.