Authors: Lily Leitner Berrin, BA; Colleen M. McQuown, MD, FACEP

Edited By: Angel Li MD; Shan Liu MD, SD

Updated: 9/24/2021

Case Study

An 85-year-old male presents to the Emergency Department with dizziness. He describes his symptoms as dizziness and feeling off balance when he stands. He denies a spinning sensation but states he has a fear of falling when standing. He was hospitalized at another hospital recently for congestive heart failure and a fall and was discharged seven days ago. There had been no injury from the fall, but he had been unable to get up from the floor without the assistance of a neighbor who found him down. He did not feel recovered when he was discharged and he has been feeling worse for the past four days. He is staying at his daughter’s house because he does not feel comfortable going up the stairs at his house, where he lives alone. He has become more sedentary over the last year since his wife passed away. His daughter says she has been trying to help him, but he has been unable to bathe because he is afraid he will fall in the shower. She wishes someone would review his medication list because she does not think the discharge instructions from the other hospital included everything he has been taking.

Objectives

By the end of this module, the student will be able to: 

1. Create a broad differential diagnosis for dizziness and weakness for an older patient in the ED
2. Identify causes of dizziness and weakness associated with acute illness
3. Understand how to assess an older patient presenting with dizziness and weakness 
4. Recognize the association of dizziness and weakness with other geriatric syndromes such as frailty 
5. Understand how to do safe discharge planning for an older patient with dizziness and weakness and provide appropriate resources 
6. Recognize the utility of interventions to improve functional status and prevent harm in older patients including medication deprescribing, pill organizers, and home fall risk modifications.

Introduction

Nonspecific complaints, such as dizziness and generalized weakness, are common presenting symptoms for older patients in the Emergency Department (ED). Dizziness is a challenging complaint in older patients, and as many as one in five patients over the age of 65 experience dizziness or balance problems annually (Lin, 2012). Descriptions of dizziness are often vague, as it is unclear if the patient is experiencing vertiginous symptoms or lightheadedness related to pre-syncope or syncope, leading to a broad differential diagnosis. Dizziness in an older patient is recognized as a syndrome, caused and defined by multiple underlying factors, making diagnosis and treatment challenging (Tinetti et al, 2000). Similarly, generalized weakness and fatigue are common and non-specific ED complaints among older patients, and have been noted to be the fifth most common chief complaint in the ED after trauma, dyspnea, chest pain, and abdominal pain (Bhalla et al., 2014). 

When approaching an older patient with dizziness and weakness, determine if his/her symptoms are due to an immediate life-threatening etiology or a more insidious cause. While the causes of dizziness and generalized weakness are often benign, these presentations in an older person can have devastating effects on a patient’s quality of life and functional status if not recognized and treated appropriately. Both generalized weakness and dizziness, regardless of etiology, increase the risk of fall, traumatic brain injury, hospitalization after a fall, and mortality in an older patient (Choi, 2019). 

Initial Actions and Primary Survey

Older patients presenting with weakness and dizziness can vary in their degree of distress at initial presentation. The initial impression of the patient is important for determining next steps. As with all ED presentations, a primary assessment and evaluation of dizziness and weakness in an older patient should begin with vital signs and an assessment of alertness, followed by checking for cardiac arrhythmia and acute stroke symptoms. If this initial assessment is abnormal for any reason, immediate action should be taken to stabilize the patient. The differential and management of unstable patients or those who require an acute stroke workup for focal weakness will not be covered in this chapter.

Presentation

Once a patient is stable, complete a thorough history to assess risk factors for common etiologies of weakness and dizziness. In addition, a thorough description of symptoms should be elucidated before completing a physical exam. When evaluating an older patient in the ED, it is important to gather information from a caregiver or support person. If the patient came from a nursing home or assisted living facility, call the facility. If they have a spouse, adult child, or personal caregiver, they can help provide collateral information.

History of Present Illness

For generalized weakness, determine the following:

• persistent or transient
• sudden or insidious onset

For dizziness, to determine the following: 

• pre-syncope/syncope, vertigo, or disequilibrium
• presence of prodrome 
• positional elements, like standing or sitting
• exertional or at rest
• time of day 
• loss of consciousness 
• nausea or vomiting

Review of Systems

A thorough review of systems is critical, as this can help determine other associated symptoms that may be causing the dizziness or weakness. Systems that should be included are:

• General: fatigue, anorexia, insomnia 
• Infectious: fever, chills
• Cardiac: palpitations, dyspnea, chest pain, syncope, near syncope
• Eye: change in vision, pain
• Pulmonary: cough, shortness of breath, sputum production
• GI: diarrhea, constipation, nausea, vomiting, abdominal pain, melena
• Neurologic: numbness, tingling, headache, difficulty with gait  
• Urinary: dysuria, trouble with urination, frequency
• Skin: rashes, lesions 
• Musculoskeletal: pain, swelling
• Psychiatric: change in mood, feeling hopeless, difficulty with memory 

Past Medical History and Medications

A review of past medical history and medications can assist in determining a patient’s risk factors. In addition, it is important to review a current medication list and clarify if the patient is taking  his/her medications appropriately and as prescribed, including any supplements or over the counter medication. For information on polypharmacy and potentially inappropriate medications for older patients, see the Beer’s List (AGS Beer’s List).Given up to one in four presentations of dizziness in an older patient have been attributed to medications, medication review is incredibly important in an initial assessment (Maarsing et al., 2010; Lin et al, 2012). 

One must ask questions to establish a baseline for mentation and functional status and any recent deviations. Is it important to ask if the patient completes their instrumental activities of daily living (IADLs), like doing the laundry, shopping, preparing food, and paying bills. Also, ask if the patient completes their activities of daily living (ADLs), like toileting, bathing, and dressing. It is also important to determine how well the patient ambulates, and whether they walk independently or use a walker, cane, or wheelchair. 

Social History

• Living situation
• Support people or caregivers
• Transportation 
• Missed appointments
• Housing
• Substance use including alcohol and illicit drugs

Vital Signs

• Heart Rate
• Blood pressure
• Orthostatic vitals
• Respiratory rate
• Oxygen saturation

Physical Exam

The physical exam should be targeted based on the patient’s presentation, history, and consideration of signs of elder mistreatment and neglect.

• General: appearance, cleanliness, frailty, alertness and orientation 
• HEENT: mucous membranes, conjunctival pallor, unequal pupils 
• Cardiac exam: auscultation, rate, rhythm, murmurs, peripheral edema, capillary refill
• Pulmonary: auscultation, work of breathing, use of accessory muscles
• GI: abdominal pain, tenderness, distension
• GU: suprapubic tenderness, costovertebral angle tenderness
• Neurologic: NIH stroke scale, cranial nerves II-XII, strength in all extremities, cerebellar testing, gait assessment, Romberg, Dix Hallpike, Head Impulse Nystagmus Test of Skew (HINTS) exam* 
• MSK: muscle atrophy or wasting, rib tenderness, cervical and vertebral tenderness
• Skin: swelling, rashes, ecchymosis, skin tears, pressure ulcers, jaundice
• Psychiatric: affect, mood, eye contact, memory and cognition 

*A complete cerebellar exam should be done to look for a posterior circulation stroke. If a patient has episodic vertigo, you can perform the Dix-Hallpike maneuver. If vertigo is continuous, the HINTS exam can be done to determine if their vertigo is peripheral or central, although the validity of these exams in the ED is debated; specific training in performing the exam may eliminate ED validity concerns (Dmitriew et al, 2021; Halker et al, 2008).

Differential Diagnosis

Note: there is a significant amount of overlap between the differential diagnosis for generalized weakness and dizziness

Table 1: Differential Diagnosis of Generalized Weakness 

Table 2: Differential Diagnosis for Dizziness 

Emergency Department Evaluation

Laboratory evaluation and imaging should be tailored to the individual presentation. Some patients may not require any testing if their history or physical point to a specific diagnosis or unmet functional or social need. If one is unable to narrow down the patient’s differential diagnosis when presenting with generalized weakness, consider laboratory testing for anemia, electrolyte abnormality, and COVID-19. Patients with abnormal neurologic findings require imaging and possible consultation. Patients with delirium or altered mental status require a multifactorial workup to discover the cause. 

In addition to diagnostic testing, it is important to evaluate for unmet needs and geriatric syndromes. Screening for functional impairment (ADLs and IADLs), cognitive impairment, delirium, caregiver burden, food insecurity, fall risk/mobility, elder mistreatment, social support, polypharmacy/medication compliance, access to follow up care, housing, depression, and loneliness may shed light on the patient’s condition. It is also important to consider what matters to the patient when deciding on a workup and treatment plan. Asking the patient “what is important to you” is helpful for understanding their wishes. Often, responsibility to care for pets or spouses, fear of hospitalization/institutionalization, desire to avoid additional medications, fear of falling, spirituality, and consideration of their caregiver/family’s ability to assist are issues that frequently are discussed. These issues must be addressed when engaging in shared decision-making to come up with a treatment plan. If a patient identifies a caregiver or family member, it should be clarified if the ED team can contact that caregiver and involve them in the plan of care. All patients considered for discharge should have a trial of ambulation that includes any assist devices they typically use at home. 

To assist patients in the ED, consider providing hearing amplifiers or magnifiers if they do not have their hearing aids or reading glasses. Provide food and drink when not contraindicated to avoid harm that occurs during long ED visits. Provide doses of home medications if the patient would miss their regular timing while in the ED. Avoid tethers (wires, catheters) and encourage safe ambulation and comfortable seating while in the ED to prevent bedsores and stiffness.

Treatment and Disposition

Treatment should be specific to the cause of the patient’s symptoms while minimizing harm. Specific treatments for diagnoses will not be covered here, but in general, try to avoid medications that are potentially inappropriate for age, a patient’s chronic medical condition, or will interact with medications they already take (AGS Beers List). Consider medication discontinuation if a specific medication or polypharmacy seems to be contributing to the patient’s symptoms. 

If the patient has a seemingly reversible medical cause of their dizziness and weakness requiring hospitalization, admit him or her to the hospital. Some patients can be placed in observation units for brief monitoring or to get a consultation within the next 24 hours. When admitting an older patient, it is important to weigh the risk of iatrogenicity and decline in functional status after hospitalization with the benefit of admission, and to align the treatment plan with his/her long term goals of care.

For unmet needs or nonspecific symptoms, a multidisciplinary team may need to be mobilized that includes social work, physical therapy (PT), occupational therapy, pharmacy, and primary care. Having an ED algorithm and plan already in place for positive screens for delirium, cognitive impairment, or fall risk, along with order sets, ED flow pathways, discharge instructions, and follow up plans is helpful. Patients with gait disturbances who would benefit from ambulatory assist devices should have them provided and should be instructed in proper use. Encourage home use of an emergency alert device for patients at risk for falls or who live alone. Home fall risk modifications such as ramps and grab-bars should be recommended if necessary. If a patient is not taking their medication correctly, consider the use of pill organizers or alarms. Follow up referrals to neurology, audiology, ophthalmology, otolaryngology, cardiology, podiatry, or psychiatry should be considered based on diagnosis. Understanding hospital and community resources, such as fall clinics, Area Agency on Aging programs, transportation assistance, meal delivery services, home health aides, and caregiver support programs can assist with safe discharge. Encourage all patients to follow up with a primary care provider and assist the patient with new patient referrals if needed.

Pearls and Pitfalls

• Presentations of dizziness in older adults may mean vertigo, lightheadedness, generalized weakness, near syncope, or malaise 
• Consider a broad differential of acute and nonacute medical conditions and social situations that may be contributing to the symptoms
• It is important to determine functional status of your patient during assessment and before discharge 
• Discuss the patient’s goals of care and wishes, especially when engaging in shared-decision making with the patient
• Obtain collateral information from caregivers and family members and include them in care discussions, while respecting patient autonomy
• Avoid unnecessary hospitalization and medication use in older patients if possible, however if safe discharge is not possible, admission may be required

Case Study Resolution

Vital Signs: HR 65, BP 140/85

Orthostatic: BP 140/80, HR 65 (lying) and BP 110/60, HR 65 (standing)

Exam: The patient had trace lower extremity edema. Heart auscultation was regular rate and rhythm without murmurs. His lungs were clear to auscultation bilaterally and he was breathing without distress. The patient’s strength was assessed in bed and was within normal limits. Sensation and cranial nerves II-IIX were intact. Negative nystagmus, normal finger to nose, NIH Stroke Scale of 0, unable to do Dix Hallpike because changes in position made him feel lightheaded. His gait was shuffling and slow, and he had a hard time getting up from the bed without assistance.  

Notable labs: Creatinine 2.3, previous baseline 1.6. Electrolytes and complete blood counts were within normal limits.

The patient’s medication prescription from the outside hospital included torsemide, which was new for him. The patient had also received his furosemide in the mail from an auto-refill from his primary care doctor. He did not realize that they were both diuretics and was taking them both, causing dehydration, orthostatic hypotension, and acute kidney injury. He was on a total of 17 medications for his various medical problems and had them all in bottles rather than a pill organizer. He was on a beta-blocker which blunted any tachycardic response to his orthostatic hypotension. After IV hydration, the patient was no longer orthostatic, but still had difficulty walking without assistance, stating he still had a fear of falling. The patient was placed in observation so that he could have a PT assessment in the morning. The provider spoke with his daughter to discuss interventions like a pill organizer, shower chair, and installing grab bars, as well as continued PT to address his instability. He was discharged from observation after a PT evaluation and was encouraged to see his primary care doctor within the next week. A one month follow up phone call revealed that the patient was back at home with the home modifications complete, was participating in PT weekly, and he denied any more falls or hospitalizations.

References

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