Prospective evaluation of unexplained syncope, dizziness, and falls among community-dwelling elderly adults.

BACKGROUND: Unexplained syncope, dizziness, and falls may present a difficult diagnostic challenge to primary care and emergency room physicians. The aim of this study was to evaluate a diagnostic algorithm in the assessment of a cohort of community-dwelling elderly people with symptoms of unexplained syncope, falls, or dizziness.
METHODS: Fifty-four consecutive elderly patients (mean age + SD = 76.4 + 8.0 years, range 61-91) were assessed over a 12-month period. Presenting symptoms were syncope in 33 patients (61.1%), unexplained falls without loss of consciousness in 10 patients (18.5%), and dizziness without loss of consciousness in 11 (20.4%), and true vertigo in 2 patients (3.7%). Patients were assessed systematically using the algorithm, followed up until a diagnosis was made, and appropriate preventive therapy or advice given.
RESULTS: Diagnoses were obtained in 41 patients (75.9%). Of the 33 patients with syncope, the cause was identified in 23 (69.7%) as follows: vasovagal in 12, arrhythmia in 5, hypotensive drugs in 3, orthostatic hypotension in 2, and major anxiety with hyperventilation in 1. The cause of syncope remained uncertain in 10 patients. Among the 10 patients with nonsyncopal falls, the cause was identified in 9 as follows: drop attacks with associated knee osteoarthritis or quadriceps muscle weakness in 3, orthostatic hypotension in 2, and single cases of cerebellar ataxia, Parkinson's disease, otologic vertigo, and vertebrobasilar insufficiency. Of 11 patients with dizziness, 4 had vasovagal syncope, 2 had orthostatic hypotension, 2 had otologic vertigo, one had carotid sinus syndrome, and the cause remained obscure in 2. Nineteen of the 41 patients (46.3%) had at least one other abnormality that was possibly contributory to their symptoms. Five of the 13 patients without a clearcut diagnosis had abnormalities of possible significance, including first-degree heart block with fascicular block in 2 patients and individual patients with severe hypertension, aortic valve disease, and vasodepressor carotid sinus hypersensitivity.
CONCLUSION: A targeted, problem-oriented algorithm indicates the diagnosis in three quarters of elderly patients with unexplained syncope, falls, and dizziness.