I m Weak and Dizzy. Dr. Peter J. Lin Director Primary Care Initiative Canadian Heart Research Centre

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1 I m Weak and Dizzy Dr. Peter J. Lin Director Primary Care Initiative Canadian Heart Research Centre

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

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4 Brain Facts 100 billion neurons 1,000 to 10,000 synapses per neuron (1,000 10,000 other neurons, muscle cells, glands, etc.). 100 trillion synapses Weight ounces ( 3 pounds)

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6 CNS TIA/Stroke Trauma/concussion Encephalitis MS Tumors Migraines CVS Hypotension Cardiac Ischemia Valvular Disease Arrythmias Hematologic Anemia Endocrine Hypoglycemia Hypothyroidism Drug Induced Dehydration Anxiety Vestibular Disorders

7 Four symptom categories A. Sensation of Motion (vertigo) B. Sensation of Impending Faint (pre-syncope) C. Sensation of Losing one s balance (dysequilibrium) D. Ill-Defined Lightheadedness (not A,B,C)

8 Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Characteristics Selected Differentials Vertigo Spinning or Motion Sensation Episodic or Continuous BPPV Meniere s Disease Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage Presyncope Disequilibrium Lightheadedness

9 Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Characteristics Selected Differentials Vertigo Spinning or Motion Sensation Episodic or Continuous BPPV Meniere s Disease Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage Presyncope Feeling Faint, or about to pass out Episodic, may last for seconds, may be alleviated by lying down Dehydration Anemia Cardiac Ischemia Arrhythmia Infection Hypo/Hyperglycemia Disequilibrium Lightheadedness

10 Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Characteristics Selected Differentials Vertigo Spinning or Motion Sensation Episodic or Continuous BPPV Meniere s Disease Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage Presyncope Feeling Faint, or about to pass out Episodic, may last for seconds, may be alleviated by lying down Dehydration Anemia Cardiac Ischemia Arrhythmia Infection Hypo/Hyperglycemia Disequilibrium Unsteady feeling in the lower extremities Continuous, but may vary in intensity Multiple Sensory Deficits Peripheral Neuropathy Vision Loss Lightheadedness

11 Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Characteristics Selected Differentials Vertigo Spinning or Motion Sensation Episodic or Continuous BPPV Meniere s Disease Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage Presyncope Feeling Faint, or about to pass out Episodic, may last for seconds, may be alleviated by lying down Dehydration Anemia Cardiac Ischemia Arrhythmia Infection Hypo/Hyperglycemia Disequilibrium Unsteady feeling in the lower extremities Continuous, but may vary in intensity Multiple Sensory Deficits Peripheral Neuropathy Vision Loss Lightheadedness Vague complaints, nonspecific Medication Related Psychiatric Disorders including Anxiety, Depression, Panic Attacks Hyperventilation

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13 Dizziness - Nonspecific dizziness Many patients with dizziness have neither vertigo, disequilibrium, nor presyncope. Their history is distinguished mostly by its vagueness e.g. feeling of floating, disconnectedness, unreality, (depersonalization) or fear of losing control. These patients tend to have a psychiatric disorder such as anxiety or panic disorder. sleep pattern, loss of appetite, concentration disturbance, and suicidal ideation) and panic symptoms (diaphoresis, flushing, palpitations, chest pressure, paraesthesias, and nausea) should be sought.

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16 Dizziness : Disequilibrium -is a sensation of unsteadiness, not localized to the head, that occurs when walking and that resolves at rest. The most common cause of disequilibrium is "multiple sensory deficits" in elderly patients with reduction in vestibular, visual and proprioceptive function all three of the balance-preserving senses. Exclude peripheral neuropathy / cerebellar degeneration - alcohol consumption, nutrition, diabetes mellitus, and family history Hearing loss would be associated with many causes of gradual vestibular dysfunction, such as acoustic neuroma, so ASK in history.

17 Dizziness : Presyncope is the lightheadedness of a near-faint. Features of a patient s dizziness may suggest specific diagnoses, so sudden onset of presyncope is suspicious for arrhythmia exertional presyncope classically suggests aortic stenosis; presyncope with emotional stress or on urination suggests vasomotor syncope. Presyncope on standing, or orthostatic hypotension, has an enormous differential diagnosis. Medications are a common cause of orthostasis. Peripheral neuropathy is also a common cause, most often from diabetes.

18 Cause of dizziness 3: Presyncope Cause Key feature from history Key sign from examination Orthostatic hypotension (incl. meds, infection) 2-7% Dizziness occurs on assuming upright posture Postural BP drop. Rectal exam (PR blood). Anaemia. Arrhythmia up to 5% Abrupt onset: palpitations Tachy/brady cardia Vasomotor or Vasovagal Situational e.g. Micturitional 1% Previous occurences, emotional distress Ask re events surrounding episode Nil Nil.

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20 Atrial Fibrillation Atrial fibrillation (AF) is the most common heart rhythm disturbance It is estimated that 1 in 4 individuals aged 40 will develop AF Normal rhythm AF Lloyd-Jones DM, et al. Circulation 2004;110:

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24 How common is it that patients with TIA/Stroke present with dizziness? 3.2% of dizzy (any type) patients in ER have TIA/stroke ~1 % of all patients with isolated dizziness have TIA/stroke (translates into large #) 17% of TIA/stroke present with isolated dizziness Kerber. Stroke 2006; 37: *Newman-Toker. Neurology 2008; 70:

25 Migraine Associated Dizziness Underreported Many names: Vestibular migraine, migrainous vertigo, migraine associated vertigo, migraine related vestibulopathy % of migraineurs have dizziness (Bayazit 01; Kayan 1984) Any type Vertigo Lightheadedness Space and Motion intolerance Any duration (seconds to days)- Furman 03 Seconds ~ 20% Minutes ~30% Hours ~30% Days ~ 20-40% Bisdorff. Ther Adv Neurol Disord 2011 Baier, Dieterich. J Neurol 2009 Furman. Curr Opin Neurol Bayazit. Rev Laryngol otol Rhinol 2001 Kayan. Brain 1984

26 Hemoglobin Oxygen Glucose

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28 Definition of Hypoglycemia 1. Development of neurogenic or neuroglycopenic symptoms Neurogenic (autonomic) Trembling Neuroglycopenic Difficulty Concentrating Palpitations Sweating Anxiety Hunger Nausea Confusion Weakness Drowsiness Vision Changes Difficulty Speaking Dizziness 2. Low blood glucose (<4 mmol/l if on insulin or secretagogue) 3. Response to carbohydrate load guidelines.diabetes.ca BANTING ( ) diabetes.ca Copyright 2013 Canadian Diabetes Association

29 Severity of Hypoglycemia Mild Autonomic symptoms present Individual is able to self-treat Moderate Autonomic and neuroglycopenic symptoms Individual is able to self-treat Severe Requires the assistance of another person Unconsciousness may occur Plasma glucose is typically <2.8 mmol/l guidelines.diabetes.ca BANTING ( ) diabetes.ca Copyright 2013 Canadian Diabetes Association

30 Acute = 15g CHO* + 15 minutes recheck ¾ cup OJ 3-4 glucose tablets 3 packs sugar * CHO Carbohydrate Food Choices 6 LifeSavers 1 tablespoon of honey Canadian Diabetes Association Clinical Practice Guidelines. Can J Diabetes 2008;32(Suppl 1):S62 Copyright Canadian Heart Research Centre This presentation may not be reproduced without written authorization from the Canadian Heart Research Centre

31 Network Meta-analysis Comparing Non-Insulin Antihyperglycemic Drugs With PBO as Add-on to Metformin Change in A1C Goal Change in Overall A1C (%) Achieved Body Weight (kg) Hypoglycemia Mean Diff. RR Mean Diff. PBO (Ref) Sulfonylureas Meglitinides TZDs AGIs ND DPP-4 Inhib GLP-1R agonists RR Phung, O. J. et al. JAMA 2010;303: Published online April 14, 2010.

32 Network Meta-analysis Comparing Non-Insulin Antihyperglycemic Drugs With PBO as Add-on to Metformin Change in A1C Goal Change in Overall A1C (%) Achieved Body Weight (kg) Hypoglycemia Mean Diff. RR Mean Diff. PBO (Ref) Sulfonylureas Meglitinides TZDs AGIs ND DPP-4 Inhib GLP-1R agonists RR Phung, O. J. et al. JAMA 2010;303: Published online April 14, 2010.

33 Advance Study - Hypoglycemia may increase the risk of morbidity and mortality in T2DM patients Adjusted hazard ratio for primary and secondary clinical outcomes, ADVANCE patients who developed severe hypoglycemia vs those who didn't End point Major macrovascular event* Major microvascular event* Severe hypoglycemia, n=231 (%) No severe hypoglycemia, n= (%) HR (95% CI) ( ) ( ) All-cause mortality ( ) Cardiovascular mortality ( ) Noncardiovascular mortality ( ) Zoungas S. et al. N Engl J Med 2010; 363(15): AZT-ONGL ON-SL-TW

34 Vertigo An illusion of movement, either of body or of environmentspinning, tilting, and moving sideways but must be some abnormal sensation of movement Sub-classify vertigo according the duration of symptoms, and whether the vertigo is brought on by changes in position or occurs spontaneously. Association of vertigo with hearing loss or tinnitus also provides important diagnostic information.

35 Semi-circular Canal Vision Proprioceptors

36 MisMatch

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51 Caloric Testing

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55 Hallpike Maneuver

56 Epley Maneuver 1. Sit upright. 2. Turn your head to the symptomatic side at a 45 degree angle, and lie on your back. 3. Remain up to 5 minutes in this position. 4. Turn your head 90 degrees to the other side. 5. Remain up to 5 minutes in this position. 6. Roll your body onto your side in the direction you are facing; now you are pointing your head nose down. 7. Remain up to 5 minutes in this position. 8. Go back to the sitting position and remain up to 30 seconds in this position. The entire procedure should be repeated two more times, for a total of three times. During every step of this procedure the patient may experience some dizziness.

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60 Meniere s disease: Characterized by triad of: vertigo tinnitus hearing loss (sensorineural) Chronic relapsing illness (? familial) Due to a build-up of endolymphatic pressure in the labyrinth.

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67 Differentials of Dizziness Dizziness Subtype Type of Sensation Temporal Characteristics Selected Differentials Vertigo Spinning or Motion Sensation Episodic or Continuous BPPV Meniere s Disease Labyrinthitis Vertebrobasilar Ischemia Cerebellar Infarction or Hemorrhage Presyncope Feeling Faint, or about to pass out Episodic, may last for seconds, may be alleviated by lying down Dehydration Anemia Cardiac Ischemia Arrhythmia Infection Hypo/Hyperglycemia Disequilibrium Unsteady feeling in the lower extremities Continuous, but may vary in intensity Multiple Sensory Deficits Peripheral Neuropathy Vision Loss Lightheadedness Vague complaints, nonspecific Medication Related Psychiatric Disorders including Anxiety, Depression, Panic Attacks Hyperventilation

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69 Cawthorne s Head Exercises Exercises are to be carried out for 15 minutes twice a day, increasing to 30 minutes. EYE EXERCISES Look up, then down at first slowly, then quickly, 20 times. Look from one side to the other at first slowly, then quickly, 20, times. Focus on your thumb at arm s length, moving it one foot toward you and back again, 20 times. HEAD EXERCISES Bend head forward then backward with eyes open slowly, later quickly, 20 times. Turn shoulders to right, then to left, 20 times. Bend forward and pick up objects from the ground and sit up 20 times. STANDING Change from sitting to standing and back again, 20 times with eyes open. Repeat with eyes closed. Throw a small rubber ball from hand to hand above eye level. Throw ball from hand to hand under one knee. MOVING ABOUT Walk across the room with eyes open, then closed, 10 times. Walk up and down a slope with eyes open, then closed, 10 times. Walk up and down steps with eyes open, then closed, 10 times. Any game involving stooping or turning is good.

70 Thanks for staying awake.

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