For Seniors, Balance is Essential
Dizzy Spells Are Common and Treatable at 60-Plus -- But Not to Be Ignored
By Mary-Ellen Phelps Deily
Tuesday, October 16, 2001
In December 1997, Richard L. Moyer's world started spinning.
The 72-year-old was on the golf course "just standing talking to somebody," he said. Then, "all of a sudden, I started to sway." Moyer, who had spent 20 years in the Navy and never experienced even a twinge of motion sickness, feared a heart attack – until, seconds later, the harrowing sensation passed.
But his problems had just begun. Over the following three years, Moyer experienced dizzy spells that grew in intensity and duration. Some lasted for hours.
"I really couldn't do anything I wanted to do," he recalled. "I never knew when [the dizziness] was going to hit. . . . You can't believe how miserable that is."
Today, the Shermans Dale, Pa., resident is feeling fine, and he credits his recovery to treatment at Johns Hopkins Hospital for Meniere's disease, an inner-ear condition that can trigger severe dizziness. "I plan to do things now," Moyer said. "I don't have to fear getting dizzy."
Harry Weiss, an 86-year-old who lives in a Bethesda retirement community, has suffered brief, less severe bouts of dizziness. He is "occasionally and distressingly" dizzy, and he has no idea why. "I think I've been stopped by dizziness for many, many years now," Weiss said. "The doctors never seem to know how to deal with it. Their eyes seem to glaze over when you say you're dizzy."
Weiss and Moyer are among the many seniors who suffer from dizziness and balance problems. While these conditions can strike at any age, they fall disproportionately on older people. According to an analysis by the National Institute on Deafness and Other Communication Disorders (NIDCD), about 6.2 million Americans report chronic dizziness or balance problems, about half of them seniors. Nationally, around 9 percent of the 65-and-over population report suffering from balance problems.
And it's not just prevalence that makes balance an important issue for seniors. Older people are more likely to hurt themselves seriously if they fall – and to suffer greater disability afterward.
"Usually a fall in an older person is going to impair their functioning," said Sandra Sewell, a registered nurse and clinical specialist in geriatrics who serves as the program manager for community care management at Suburban Hospital in Bethesda. Particularly for frail elderly individuals with other health issues, she said, falls can be devastating.
Brain Tumor or Allergy?
Unfortunately, the symptom of dizziness can be a sign of a bewildering range of underlying conditions, from the relatively benign to the potentially fatal: low blood pressure, brain tumors, vision problems, stroke, allergies, head trauma, nutritional deficiencies and many more. Still, doctors and patients agree that seeking out medical attention early is crucial, and not only to rule out or treat serious conditions. Balance problems of more benign origin can often be treated easily – but if they are not, older people with problems that should be only mild and correctable may suffer reduced quality of life unnecessarily.
"When the nurse says you have a 75-year-old patient with dizziness, you don't know which of 20 different ways you're going to be going," said Robert Dobie, director of NIDCD's Division of Extramural Research. NIDCD, part of the National Institutes of Health, studies hearing, balance, smell, taste, voice, speech and language.
Dobie's first priority is understanding what the patient is experiencing. He begins by barring the word "dizzy" from all discussions. "We banish it from our conversation because it's too vague," he said.
Dobie gets patients to describe their symptoms in more specific terms and then usually can assign the case to one of four categories, all relatively common among older people. "Getting it narrowed down" is crucial, Dobie said. "The majority of patients . . . have symptoms that can be improved."
If they feel as if things around them are moving or that they're moving when they're not, that's vertigo, a condition typically related to the inner ear. Vertigo can be caused by ear infection, ear trauma or the loosening of calcium crystals within the ear due to aging.
If they feel as if they're going to fall down, disequilibrium. This type of dizziness can be associated with inner-ear problems, medication side effects, arthritis or neurological problems, to name a few possibilities. The drugs most likely to cause disequilibrium are ones that affect the brain, including sedatives, painkillers, anti-seizure medications and antidepressants. Drinking alcohol while on medication can also trigger the sensation.
If they feel as if they're going to faint, that's presyncope, which may indicate a heart, medication or blood vessel problem. Often, blood pressure medicines are the culprit. In some cases, they'll lower a patient's blood pressure too much and bring on the fainting feeling.
Unfortunately, many cases fall into a fourth, unspecified category. Dobie refers to patients in this group as having "lightheadedness" or "nonspecific dizziness." Although the lack of a clear diagnosis can be troubling to the patient, generally the people in this category don't have anything seriously wrong, Dobie said.
At the Extremes
Probably the most common cause of vertigo is something called benign paroxysmal positional vertigo, or BPPV. People with BPPV experience vertigo – or nausea or lightheadedness – when they turn their heads or just roll over in bed. To understand how BPPV affects people, imagine feeling as if you've just stepped off a very fast merry-go-round – when you haven't.
The attacks are brought on by loose calcium crystals or debris in a person's ear. In the case of younger people, a head injury can be the cause. With older people, degeneration of the ear's vestibular system may be to blame.
Unsettling as the condition is, it's often quite curable. In fact, doctors can perform a series of gentle maneuvers that rotate a patient's head and body in such a way that the crystals within the inner ear float back into place. In some cases, doctors have the patient turn their heads themselves. In others, patients are strapped to a table that rotates as they lie still. Either way, the process is noninvasive, takes as little as 10 minutes and is performed in doctor's offices rather than a hospital setting. With the crystals back in place, the vertigo should stop. If crystals come loose again, the treatment can be repeated.
Then there is dizziness that indicates something really serious. For example, dizziness can indicate stroke when it is paired with a number of neurological symptoms, such as a loss of consciousness, difficulty talking, the inability to move an arm or leg, or vision changes such as the appearance of blind spots. Anyone with these symptoms should seek immediate medical attention, Dobie said.
Examining Past and Present
Of course, not every diagnosis will be as straightforward as BPPV or stroke. So in many cases physicians need to probe deeper. The patient's medical history is essential, said John P. Carey, assistant professor of otolaryngology/head and neck surgery at Johns Hopkins University in Baltimore. Carey generally administers a range of hearing and balance tests. But he also wants to know about medical problems patients have faced in the past. Even those with no apparent connection to balance could make a difference, he said.
For instance, Carey believes migraines can lead to balance problems long after the painful headaches have stopped. Often, migraine-related dizziness can be treated by adjusting a patient's diet, cutting out such things as caffeine, chocolate and red wine. Regular aerobic exercise and a sleep schedule help as well, Carie advised. If those treatments fail, medication may be needed.
Equally important is what's going on in a patient's life beyond the dizziness. Carey, who treats Moyer and others with balance problems, recommends that patients provide their doctors with a complete list of the medications they're taking. The patient should indicate if they've just started or stopped taking a particular drug.
Finally, Carey advised that patients keep a dizziness diary where they jot down when and how spells hit them. Documenting that attacks come when you're standing up or reaching for something, for example, can make the doctor's job a lot easier. "It's very important for patients to be very observant," he said.
As for treatments, they can vary as much as diagnoses. For some, the cure may be as simple as the elimination of a particular drug or a change in dosage. For others, a special diet designed to cut salt intake and thereby reduce water retention in the inner ear may help. Less frequently, doctors may recommend medication. Very occasionally, surgery on the ear's balance mechanism may be required.
Fear of Falling
It's not just the physical aspect of dizziness that creates problems. Particularly among the elderly, dizziness can pack a powerful psychological wallop.
"For someone who's 83, a fall is really frightening," said Sewell of Suburban Hospital. "It can make them lose their confidence."
The hospital's community care management program provides a variety of health and outreach services to the elderly, and complaints of dizziness among its clientele are not uncommon. Sewell said her organization takes a holistic approach to fall prevention generally and to its causes, including dizziness. That entails asking questions about a person's lifestyle and how dizziness has affected it, and perhaps making a plan for how to cope with dizzy spells.
Sewell's staff is interested in such mundane things as whether a person takes hot showers. If the water's too hot, it could touch off a blood pressure problem that brings on a feeling of dizziness or lightheadedness. Another common irritant starts with the very common act of reaching over one's head to get something. Sewell said she knows of many cases in which women, in particular, have craned their necks back as they reached for something, pinching off the blood supply in their neck momentarily and touching off a woozy feeling.
What's important is helping patients persevere and keeping their fears from getting the better of them. "As we get older, we see the consequences of things," Sewell said. "Just think about it when you were 16 or in your early twenties, all the things you did without thinking."
Sewell also advises her clients to take it easy. Moving too fast can touch off a moment of low blood pressure, when blood doesn't pump quite quickly enough to keep up with the burst of activity, resulting in lightheadedness or dizziness. Her advice: "You get up fast when somebody's at the end of the hall handing you a $100 bill. [Otherwise,] you get there when you get there."
Richard Moyer knows what it's like to have your life almost stolen away by dizziness. Although Meniere's disease – the cause of his dizziness – frequently starts in middle age, it didn't catch up with Moyer till he was in his late sixties. But when it did get him, it hit him hard.
His troubles were so severe that he feared driving and mostly kept close to home. He even missed a reunion with Navy buddies that he'd been planning to attend. Dizziness put "a clamp on everything," he said.
That's why he was so relieved when his doctor got him an appointment at Johns Hopkins. The physicians there determined that he was a good candidate for a treatment involving injection of the antibiotic gentamicin into the inner ear. Gentamicin essentially deadens the faulty balance mechanism in an ear affected by Meniere's disease. The body compensates for the drug's effect by relying on a person's one good ear for balance.
After the injection, Moyer underwent physical therapy to improve his balance and learned exercises to train his eyes to help steady him. For him, it's been a miracle cure. "The help is great," he said. "I am just so pleased."
Today, Moyer, who runs his own business making golf clubs, is an outspoken advocate for seeking medical help as soon as dizziness strikes.
"Don't let it go," he advised. "Get help as soon as you can."