1

Introduction

Dizziness is a common problem, particularly in the elderly, and the dizzy patient represents a major diagnostic challenge. Drachmann and Hart reported 4 types of dizziness: vertigo, lightheadedness, disequilibrium, and those types that do not fit into any of the previous 3 categories. Vertigo indicates probable vestibular pathology, whereas lightheadedness suggests a cardiovascular disorder; disequilibrium describes imbalance or unsteadiness and may indicate a central neurologic disorder. The fourth category of “others” is a repository for poorly defined dizziness with a multifactorial etiology.

Orthostatic hypotension (OH) is one of the miscellaneous causes of nonspecific recurrent dizziness and can cause symptoms such as presyncope, especially while standing. The possibility that psychologic or psychiatric symptoms may be consequences of vestibular dysfunction has been proposed . Anxiety and panic are often associated with nonspecific recurrent dizziness, and it is difficult to establish if they are the cause or a consequence . The aim of this study is to define to what extent OH is present in dizzy patients and determine whether anxiety and depression are a factor in causing dizziness.

2

Materials and methods

The study included 63 consecutive subjects affected by nonspecific recurrent dizziness while standing up or in the orthostatic position (group A) and 27 asymptomatic volunteers recruited from the hospital staff and their relatives (group B). All the enrolled subjects gave their informed consent before their inclusion in the study.

Exclusion criteria for group A were the presence of rotatory vertigo and of other neurologic symptoms or signs. Moreover, subjects affected by diabetes, heart disease other than systemic hypertension, and neurologic diseases were not included in the study group.

All patients underwent otoscopy, pure tone audiometry, and vestibular tests based on bedside examination (the Dix-Hallpike and Pagnini McClure maneuver, the head impulse test, head-shaking test, and mastoid-vibration test) and a bithermal energy test. The vestibular tests were carried out under video-oculography recording. All subjects admitted to the study group presented a normal outcome at the vestibular examination. In older subjects, hearing loss caused by age was occasionally found.

Group A (patients) was composed of 24 men (38%) and 39 women (62%); mean age was 59 years (SD, 18 years; range, 16-91 years). Of these patients, 25 (40%) had history of systemic hypertension and were receiving medical therapy. Group B (controls) was composed of 15 men (55% ) and 12 women (45%); mean age was 51 years (SD, 14 years; range, 21-77 years); 9 of them (33%) had a history of systemic hypertension.

In all cases (groups A and B), systolic (SBP) and diastolic (DBP) pressure, heart rate, and oxygen saturation were measured. The clinical characteristics of patients and volunteers admitted to the study are summarized in Table 1 . Differences in sex and age between the 2 groups ( Table 1 ) were not significant on the χ ² test or Student t test ( P > .05).

All patients included in groups A and B were evaluated for anxiety and depression by the same physician who had been trained for the use of the Italian version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) Axis I Disorders (SCID-I) . The SCID-I is a well-known standardized tool for making the major DSM-IV Axis I diagnoses that allow the interviewer to phrase questions in a manner appropriate to the patient’s cognitive abilities to detect current episodes or lifetime occurrences of mental disorders . For the aim of our study, only current episodes of anxiety or depression were considered in the results section.

To determine the presence of OH, they were then submitted to the head-up tilt test (HUTT). The HUTT protocol was the same one used in a previous study we did : we carried out the HUTT in a quiet, dark environment, with room temperatures between 20°C and 24°C, at least 2 hours after a light meal. Intake of current therapy was not interrupted. We recorded a continuous electrocardiogram and pulsoxymetry. Manual blood pressure reading was obtained from the right arm with a mercury column sphygmomanometer, whereas heart rate was recorded on an electrocardiographic monitor. Patients had previously been examined by a cardiologist. We measured blood pressure during the first, fifth, and tenth minute, while the patient was in the supine position with safety belts fastened. The tilt table was then gently tilted head up until an angle of 70° was reached. With the patient in the orthostatic position, we measured blood pressure every minute during the first 5 minutes of tilt, then at the 8th, 10th, 12th, 15th, and 20th minute. The duration of the tilt was 20 minutes to detect cases of delayed OH . We considered reactions to tilt as hypotensive when, at any time during the HUTT, the SBP decreased by 20 mm Hg or greater or the DBP decreased by 10 mm Hg or greater relative to the last supine measurement. We defined supine hypertension as SBP of 140 mm Hg or more and/or DBP of 90 mm Hg or more during the 10-minute supine phase before the test . During the HUTT, all patients and control subjects had sinus rhythm, and only minor ST-tract alterations were observed.

2

Materials and methods

The study included 63 consecutive subjects affected by nonspecific recurrent dizziness while standing up or in the orthostatic position (group A) and 27 asymptomatic volunteers recruited from the hospital staff and their relatives (group B). All the enrolled subjects gave their informed consent before their inclusion in the study.

Exclusion criteria for group A were the presence of rotatory vertigo and of other neurologic symptoms or signs. Moreover, subjects affected by diabetes, heart disease other than systemic hypertension, and neurologic diseases were not included in the study group.

All patients underwent otoscopy, pure tone audiometry, and vestibular tests based on bedside examination (the Dix-Hallpike and Pagnini McClure maneuver, the head impulse test, head-shaking test, and mastoid-vibration test) and a bithermal energy test. The vestibular tests were carried out under video-oculography recording. All subjects admitted to the study group presented a normal outcome at the vestibular examination. In older subjects, hearing loss caused by age was occasionally found.

Group A (patients) was composed of 24 men (38%) and 39 women (62%); mean age was 59 years (SD, 18 years; range, 16-91 years). Of these patients, 25 (40%) had history of systemic hypertension and were receiving medical therapy. Group B (controls) was composed of 15 men (55% ) and 12 women (45%); mean age was 51 years (SD, 14 years; range, 21-77 years); 9 of them (33%) had a history of systemic hypertension.

In all cases (groups A and B), systolic (SBP) and diastolic (DBP) pressure, heart rate, and oxygen saturation were measured. The clinical characteristics of patients and volunteers admitted to the study are summarized in Table 1 . Differences in sex and age between the 2 groups ( Table 1 ) were not significant on the χ ² test or Student t test ( P > .05).

All patients included in groups A and B were evaluated for anxiety and depression by the same physician who had been trained for the use of the Italian version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) Axis I Disorders (SCID-I) . The SCID-I is a well-known standardized tool for making the major DSM-IV Axis I diagnoses that allow the interviewer to phrase questions in a manner appropriate to the patient’s cognitive abilities to detect current episodes or lifetime occurrences of mental disorders . For the aim of our study, only current episodes of anxiety or depression were considered in the results section.

To determine the presence of OH, they were then submitted to the head-up tilt test (HUTT). The HUTT protocol was the same one used in a previous study we did : we carried out the HUTT in a quiet, dark environment, with room temperatures between 20°C and 24°C, at least 2 hours after a light meal. Intake of current therapy was not interrupted. We recorded a continuous electrocardiogram and pulsoxymetry. Manual blood pressure reading was obtained from the right arm with a mercury column sphygmomanometer, whereas heart rate was recorded on an electrocardiographic monitor. Patients had previously been examined by a cardiologist. We measured blood pressure during the first, fifth, and tenth minute, while the patient was in the supine position with safety belts fastened. The tilt table was then gently tilted head up until an angle of 70° was reached. With the patient in the orthostatic position, we measured blood pressure every minute during the first 5 minutes of tilt, then at the 8th, 10th, 12th, 15th, and 20th minute. The duration of the tilt was 20 minutes to detect cases of delayed OH . We considered reactions to tilt as hypotensive when, at any time during the HUTT, the SBP decreased by 20 mm Hg or greater or the DBP decreased by 10 mm Hg or greater relative to the last supine measurement. We defined supine hypertension as SBP of 140 mm Hg or more and/or DBP of 90 mm Hg or more during the 10-minute supine phase before the test . During the HUTT, all patients and control subjects had sinus rhythm, and only minor ST-tract alterations were observed.