CE Home > Occupational Therapy > OT310 Dizziness in Elders: Defined and Differentiated

It’s breakfast time at the local nursing home — Alice’s favorite part of the day. But today, the 80-year-old resident just isn’t feeling right. She sits on the side of her bed, grasping her cane, but afraid to stand. She feels dizzy. In the past, she’s had similar episodes, but chalked them up to an aging body and heart trouble.

When the occupational therapist comes by to see her, she says she feels “heavy” in her head and off-kilter. Her health history includes mild dementia, diabetes, atrial fibrillation, hypertension, and a cataract in her left eye. She takes several medications for these conditions.

Alice might be somewhat comforted to learn that she’s not alone. Dizziness is the fourth most common complaint among elders in primary care settings. It increases in frequency with age, becoming the most common complaint among people 85 and older. Because they are afraid to provoke dizziness and then a fall, elders tend to limit their activities drastically — a response that often leads to depression and some loss of physical function and strength.¹

OTs consider activity in a broader context of occupation to promote the health and participation of people as they engage in occupations. They see clients as occupational beings who wish to experience both independence and interdependence as key mechanisms for well-being. In the Occupational Therapy Practice Framework, dizziness would be considered a client factor and as such, it can affect performance patterns and activity demands, as well as contextual and environmental factors. The demands of an activity, the context in which it is performed, and specific environmental factors can impact the client’s experience of dizziness. Therefore, when evaluating the health of a client, OTs need to understand the associated risks and mediators related to dizziness to enable clients to live life to the fullest.²

Dizziness Differentiated

At one time or other, most people have experienced dizziness, one of the vaguest complaints a therapist faces in practice because what each person calls dizziness differs greatly. Some describe it as poor balance, lightheadedness, wooziness, or spinning, while others may say they feel as if they are about to faint. Trying to put into words what they are feeling can be very difficult. All of this leads to the word dizziness being nearly useless as a one-word description.

To properly care for patients with dizziness, OTs need to be able to differentiate the four types of symptoms — vertigo, disequilibrium (unsteadiness, imbalance), near-syncope (lightheadedness), and nonspecific dizziness,³ any of which can lead to withdrawal from valued occupations.

Vertigo is defined as any abnormal sensation of motion between a patient and his or her surroundings. It is often a spinning sensation, but may also be experienced as a feeling of linear motion or falling. The motion illusion is what’s important, not whether the sensation is due to the person moving or the surroundings moving. The onset of vertigo is often sudden or episodic, and may be accompanied by nausea, vomiting, cold and sympathetic responses related to vestibular hypervigilence or fear: sweat, racing heart, and an unsteady gait. Symptoms of vertigo are predominantly related to client factors impacting sensory processing, specifically disorders of the vestibular system or its connections to the brain. However, they can also be from the brain itself,⁴ as with vertigo due to benign positional vertigo (BPV), labyrinthitis, vestibular neuronitis, Meniere’s disease and vertebrobasilar insufficiency. Balance problems such as these are reported in 9% of the population 65 and older.⁵

Disequilibrium is the impairment of balance without an abnormal sensation in the head. The patient describes feeling unsteady or off balance. The sensation occurs during walking and disappears with sitting or lying down. Elders sometimes refer to this as “dizziness in the feet.” It is often due to a disorder of the motor-control system, multiple-sensory deficits, or, if it is acute, cerebellar hemorrhage.⁶ Symptoms are typically worse in the dark and stability may be regained when external support is provided, such as a cane, grab bars, or railings installed throughout the physical environment, or by providing therapeutic exercises to increase strength and flexibility in the extensor muscles. Overall evaluation of activity demands, performance patterns, and performance skills is needed to ascertain the applicable level of intervention.

Near-syncope is a sensation of impending fainting or loss of consciousness. This feeling usually indicates a cardiovascular disorder and is brought on by an inadequate supply of blood to the brain; for example, with postural hypotension, vasovagal attacks, hyperventilation, or reduced cardiac output.⁷ Pallor, a sensation of roaring in the ears, dimness of vision, and diaphoresis may also be present. Frail elders, particularly those with diabetes or Parkinson’s disease, are susceptible. This condition is usually worse in the morning or after prolonged recumbence, and in some cases, leads to syncope, a transient and usually sudden loss of consciousness.⁸ This condition frequently occurs during participation in areas of occupation, specifically activities of daily living (ADLs) or instrumental activities of daily living. Commonly, clients experience near-syncope during bowel and bladder management.

Nonspecific dizziness is often described by elders as a constant “light-headedness,” “foggy” feeling, “wooziness,” or “heavy-headedness,” and may accompany emotional or psychological conditions, such as severe depressive episodes, anxiety, or panic states.⁶ Nonspecific dizziness can frequently be related to a decline in ADLs, and client habits related to nutrition and fluid intake should be evaluated. Dizziness is a common symptom of dehydration,⁹ and limited fluid intake is a common factor when ADL independence is in decline. Body functions related to memory, energy, and drive can impair a client’s ability to plan and sequence tasks necessary to ensure proper nutritional needs. Sensory functions and pain can limit engagement in performance of occupations that can be reorienting and reorganizing. Engaging in ADLs is necessary for temporal orientation and feelings of social connectedness. Atrophy of the neuromuscular and cardiovascular systems causing poor occupational engagement can create a cycle of overall decline.

Keep in mind that there is some overlap in this area and not every disease fits neatly into a category. In addition to vertigo, vestibular disorders can also produce disequilibrium, nonspecific dizziness and feeling close to fainting. Diabetes mellitus can cause both disequilibrium and near-syncope. Vertigo, disequilibrium, and nonspecific dizziness can all be experienced with multiple sclerosis. Any disease capable of producing anxiety, including vestibular disorders, can cause nonspecific dizziness.

Causes of Dizziness

There are four common rudimentary causes of dizziness in the elderly, and some red flags therapists need to watch for — the aging process, multiple-disease states, the use of various medications and complementary medicines, hard-to-classify causes, and emergency life-threatening conditions. In all cases, dizziness is a symptom, either a primary or secondary aspect of underlying conditions, and not itself a disease. Having good equilibrium is a complicated process, one that many take for granted until it is lost. The ability to orient the body in relation to the environment and maintain equilibrium depends on continual sensory monitoring, including vision; vestibular sensation, an inner-ear process that provides movement and gravity information; proprioception, the sensation of body movements, awareness of posture, and sensation of terrain underfoot along with joint pressure sensation from gravity; touch and hearing. The brain coordinates and integrates these sensory inputs through the vestibular nuclei. Body degeneration or disorders that disrupt the sensory processes or brain function may therefore disturb the ability to orient the body and maintain equilibrium, causing the sensation or symptom of dizziness.¹⁰

Aging: Age-related changes explain much of the dizziness among elders. The most direct changes affect the sensory organs that maintain normal spatial orientation. Visual changes include reduction in glare tolerance, reduction in nocturnal visual acuity, and reduction in the ability to perceive contrast and fixate accurately. Inner ear changes include a prolonged threshold of response and reduction in hair-cell population, both of which affect vestibular function and hearing acuity. Age-related changes in the cardioregulatory system affect blood pressure. Declining muscle tone and endurance are common factors resulting in fatigue, limited occupational engagement, and disequilibrium. Changes in sleep and rest patterns can affect alert performance and engagement, future compounding the causal mechanisms leading to dizziness.

For most elders, dizziness due to age-related changes is usually not acute, although it still may lead to falls, especially when another cause is added, such as the adverse effects of medication, emotional stress, fatigue, or illness. The elderly person who acknowledges dizziness may learn how to manage it, for instance, by walking more slowly and turning more carefully.¹¹ Organizing habits, routines, roles, and rituals around high-risk periods of engagement within multiple contexts is critical.

Disease-related changes: As in normal aging, the sensation of dizziness arises from diseases affecting the sensory organs that monitor spatial orientation and balance. Degenerative diseases of these organs are common as a person ages, including cataracts, glaucoma, macular degeneration, retinal degeneration and vestibular dysfunction.⁸ Any systemic disorder that affects the cardiovascular or neurologic systems increases chronic orthostatic intolerance, hence predisposition to dizziness. Paradoxically, age-related hypertension also increases the risk of hypotension, often resulting in dizziness. Dizziness has been identified as a primary symptom or serious aspect of numerous underlying disorders.

Medication-related causes: Many drugs implicate dizziness as a potential adverse effect. For example, antihypertensive medications (calcium channel blockers, ACE inhibitors,¹² vasodilators, diuretics), often used by elders, may cause light-headedness associated with a sudden drop in blood pressure.¹¹ Other drug classes causing dizziness are antidepressants and sedatives; anti-anxiety drugs; decongestants; antihistamines;¹⁰ and herbal remedies, such as Saint John’s wort, Kava, and ginseng.¹³ Often, elderly people take several drugs, and a strong relationship exists between the number of medications and dizziness.¹¹

Hard-to-classify causes: Many other conditions can induce dizziness, some related to the external or internal environment. Risks associated with low vision, corrective lenses, or a unrecognized decline in vision can distort peripheral vision and confuse position sense.⁶ Cerumen impaction in the inner ear or fluid in the middle ear can induce dizziness. Alcohol and street drugs are another common cause. Poor maintenance of glasses or the physical environment can induce dizziness.

When OTs analyze activities, they do so to understand what is required of the client when performing those activities. The process also includes assessing and analyzing how the act of performing that specific task enhances or impedes the client’s ability to engage in the occupations they value, such as driving to meet a friend for lunch, caring for a loved one, or gardening. As with any public health condition, dizziness in elders often stems not from one causal pathway, but from multiple variables working together. A systematic approach to understand, assess and remediate can require multiple steps during the clinical reasoning process.

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Questions to Consider for the Occupational Profile

General characteristics of dizziness (narrative approach) —

1. Does the patient feel a spinning sensation, a sense of disequilibrium, lightheadedness, wooziness, or a foggy feeling (heavy-headedness)?

2. How severe is it? How often does it occur and at what time of the day? Does it interfere with activities of daily living?

3. Does the dizziness come on suddenly or gradually, and how long does it last? Sudden onset is often due to a new medication or to an acute illness, such as cardiac dysrhythmia or other cardiovascular conditions.⁷ Chronic disequilibrium generally reported as a sudden or stepwise onset is usually secondary to cerebral ischemia or infarction because it involves small vessels.¹⁴

4. Gradual and vague onset that lasts longer is more typical of depression, anxiety, multiple sclerosis (MS), or normal age-related changes. Dizziness with a gradual onset that persists when recumbent may suggest hypoglycemia.⁶

5. Is dizziness brought on by movement or changes in position?

6. When dizziness occurs on walking or turning, is it alleviated by sitting down or being still?

7. Are the dizzy feelings worse in the dark and any situations in which vision is unavailable?6

8. What else provokes the dizziness?

9. Are there any other associated symptoms (d, e, and f are red flags)?
a. Nausea
b. Tingling of fingers and around the mouth
c. Tinnitus
d. Unilateral weakness or numbness
e. Lack of coordination
f. Diplopia usually indicates a brain stem injury,

10. What are the patient’s eating and drinking habits, including alcohol and “recreational” drug use?

11. Is there a history of hypertension, cardiovascular disease, diabetes, anxiety, depression, anemia, neurologic or neuromuscular disease, ear problems, emphysema, head trauma, viral illness, or upper respiratory infection?

12. What prescription medications, over-the-counter drugs, supplements, vitamins, and herbal remedies does the patient take?

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Red Flags

In some cases, dizziness points to a life-threatening condition, such as cerebrovascular accident (CVA), transient ischemic attack (TIA), tumor, aneurysm, or severe persistent hypoglycemia. OTs are in a position to discriminate between symptoms that are less serious and those serious conditions requiring early intervention and alert the physician or nurse practitioner as soon as possible to prevent further complications.

Measure the patient’s blood pressure in supine, sitting, and standing positions, checking for postural hypotension.¹ Call the patient’s primary care provider immediately for emergency care if the symptoms associated with dizziness include slurred speech, blurred or double vision, impaired coordination, unilateral weakness or numbness of an arm or leg, or severe headache. All these symptoms could indicate a severe neurologic problem, such as a TIA or CVA.¹⁴ In addition to lightheadedness, if the person complains of pain in the abdomen, back, or groin, or has sudden weakness or confusion, caregivers should suspect abdominal aneurysm with impending rupture; an emergency situation exists.

Evaluation and Treatment of Dizziness

Occupational therapists play a leading role in identifying dizziness and helping clients return to full engagement of their occupations. The profession uses a theory-based process and each stage of the intervention is influenced by the theory the OT is using. A thorough assessment is crucial because of the range of conditions that include dizziness as a symptom. The ultimate goal is to help identify ways to help control dizziness and improve quality of life. The process of occupational therapy is one of problem solving, systematically gathering relevant information about occupational performance from which targeted intervention can be derived. The clinical reasoning process will include scientific inquiry to understand the medical component of the client’s dizziness, a narrative mechanism to understand the client’s story and experience with the condition, pragmatic concerns such as who is paying for services and what resources are available to this client, as well as ethical concerns such as how to balance the goals of the person receiving services with third party concerns when those are in disagreement.¹⁵

The process can be organized into four steps: (1) Define the problem and identify the desired outcome for therapeutic process; (2) implement actions that will achieve stated outcomes; (3) re-evaluate performance, comparing initial data points to the current situation, and finally; (4) decide on final step to include referring to others and continued treatment to ensure continued success or discharge.

The first step in the process is to define the problem. Dizziness is an abstract term with multiple definitions, any of which are personal to the client. When patients are assessed, OTs should start with an occupational profile, gathering information from the client, the family, and others involved in providing care. Begin with a narrative approach, asking the client to describe the sensation in his or her own words. Many elders can be specific in their descriptions, while others may be unable to give many details. If you have any doubts of the patient’s ability to remember the episode precisely, a family member or other professionals involved in the client’s care may be helpful.

After obtaining a detailed description of the complaint, ask questions about general characteristics of the dizziness, such as a spinning sensation, lightheadedness, or wooziness; its onset and duration; any triggers such as head movement or associated symptoms; and medical history. Research has found that patients with dizziness are better at describing the timing of their symptoms than they are at reporting on the symptoms’ quality. Researchers found pointed questions necessary, in addition to a patient’s description, to uncover all the pertinent information.¹⁶ Once the patient’s description of the problem is identified, the therapist should then evaluate all aspects of occupational performance to include areas of occupation, client factors, performance skills, performance patterns, contextual and environmental concerns, and activity demands. This analysis of occupational performance is necessary for the next step to occur.

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Occupational Analysis

A thorough analysis of how the client engages in occupations and how those occupations are affected areas, such as client factors, context, and activity demands, offers key information about the experience of dizziness. Items to explore as you perform the occupational analysis include:

1. Observe the patient’s general appearance. Does the patient appear anxious?

2. What activities of daily living are impacted by the dizziness; for example, rest and sleep, leisure, social participation, and eating, to name a few?

3. How are the IADLs being impacted, such as caring for a pet or others, community mobility, meal prep, and clean up?

4. Several signs can be of clinical value in the area of performance skills. For example, testing reflexes (Romberg to test proprioception), nystagmus, and other client body functions, can help evaluate client factors’ impact upon performance skills, such as emotional regulation, cognition, and sensory perception.

5. Exploring the contextual aspects of the client’s occupations, such as the physical space, the social context affecting or being affected by the dizziness, the temporal nature of the condition, and the personal factors such as access to resources that would support increased function.

6. Assess the activity demands – how is the client using objects such as adaptive aids (handrails, cane, etc.) or meeting the social demands of his or her life?

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The second step is to implement the plan of action that will get the client back on solid ground. Once life-threatening causes of dizziness have been ruled out, and if no “red flags” are present, the focus is on treating symptoms, preventing recurrence, and ensuring patient safety, particularly through fall prevention. If the person experiences acute dizziness, bed rest and mild sedation may be prescribed. However, symptomatic treatment with sedatives is only marginally effective, and especially in the elderly, there is an increased risk for adverse effects, such as confusion and falls. If the analysis of occupational performance reveals the primary cause of the dizziness is related to sensory processing skills, such as decline in vestibuloproprioceptive competence, then exercises and activities should be prescribed for the patient to restore function in those areas.

When the underlying disorder is identified, the treatment for dizziness can be more specific. A patient with panic states or depression as a predominant cause of dizziness may require an appropriate antidepressant or anti-anxiety agent. However, some antidepressants and anti-anxiety medications can cause postural lightheadedness and may not be necessary if the therapist provides support for emotional regulation through relaxation techniques, greater access to social networks, or a change in rest and sleep habits. If the underlying mechanism appears to be related to poor ADL function, developing a plan to assure adequate nutrition and fluid intake can make a profound difference in function. If fear and anxiety are present due to past falls and there is a new maladaptive compensation strategy to “stay in bed,” for example, assessing the physical environment for unsecured rugs, unsafe bathroom structures, and other fall hazards can solve the problem.

Interventions for resolving client factors associated with sensory perceptual disorders can be important interventions. Optimal use of visual, auditory, and tactile devices can make a big difference, and evaluation and treatment of eye and ear disorders may aid in correcting sensory deficits potentially responsible for dizziness. For example, hearing aids may help, and adequate lighting, including a nightlight, is essential. Many people with multisensory dizziness walk well when touching a wall, banister, or furniture. For those with motor and severe sensory deficits, a physical therapy evaluation and a rolling walker with large wheels may be necessary.¹¹ Tai chi or other exercise may help to improve balance in people with dizziness and disequilibrium. Additional measures to aid patients with dizziness include removal of impacted cerumen and maintaining adequate nutrition and hydration.

Finally, assessing the client’s use of objects, such as shoes or clothing or overreliance on unsteady furniture when more stable objects are required, can be helpful. Environmental adaptations, such as installing handrails in the halls and adequate lighting, particularly for nighttime, may assist the patient with proprioceptive and visual loss to stay oriented and safe. Canes or walkers can help improve balance. Often, those who acknowledge and compensate for normal aging changes learn to avert problems simply by walking more slowly and by turning and changing position more carefully.

The third step is now to re-evaluate the client’s occupational performance and evaluate the efficacy of the interventions provided. Management of patients who have this common and often disabling symptom should include periodic review and support to monitor treatment outcomes and institute additional supportive measures as needed.

The final step of the occupational therapy process is to decide on the ultimate disposition, including referring to other disciplines, continued treatment to ensure continued success, or discharge. While there is no patient organization for dizziness, more information about vestibular disorders can be obtained from the Vestibular Disorders Association at (503) 229-7705 or online at www.vestibular.org. Involving the client, family and other care providers in the discharge process is important and can best assure continued success and the client’s ability to fully engage in those occupations that are most satisfying.

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