What is the initial approach to a patient presenting with dizziness and confusion?

Initial Approach to a Patient Presenting with Dizziness and Confusion

The initial approach to a patient with dizziness and confusion should include a systematic evaluation to distinguish between peripheral and central causes, with particular attention to potentially life-threatening conditions requiring urgent intervention. 1, 2

Risk Stratification

• Evaluate for "alarming symptoms" that suggest serious underlying pathology, including syncope during exertion, syncope in lying position, absence of external factors, family history of sudden cardiac death, or slow recovery from syncope 2
• Assess for risk factors of central neurological causes, which include age ≥65 years, ataxia symptoms, focal neurological symptoms, history of previous stroke, and diabetes mellitus 3
• Consider that stroke can present with isolated dizziness without other neurological symptoms in approximately 11% of cases 2

Focused History

• Focus on timing (acute vs episodic vs chronic) and triggers (positional, spontaneous) rather than the specific descriptor the patient uses 1
• Determine if the patient is describing true vertigo (sensation of rotation or spinning) versus other forms of dizziness (lightheadedness, disequilibrium) 1
• Inquire about associated symptoms such as hearing loss, tinnitus, or aural fullness which may suggest specific diagnoses like Ménière's disease 1
• Document the onset, duration, and frequency of symptoms to help differentiate between conditions 4

Physical Examination

• Perform a complete neurological examination to assess for focal deficits 1
• Conduct the HINTS (Head-Impulse, Nystagmus, Test of Skew) examination to help distinguish between peripheral and central causes of vertigo 1, 4
• Perform the Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV) 1
• Assess for nystagmus, noting the direction, duration, and triggers 1
• Measure orthostatic blood pressure to evaluate for postural hypotension 4

Diagnostic Testing

• Do not routinely order radiographic imaging for patients who meet diagnostic criteria for BPPV unless there are additional signs/symptoms inconsistent with BPPV 2
• Consider MRI with diffusion-weighted imaging for patients with:
  • Acute persistent vertigo with neurological deficits 1, 2
  • HINTS examination suggesting central pathology 2
  • Risk factors for stroke 1
• Note that CT imaging has a low detection rate (<1%) for central nervous system pathology in patients with normal neurologic examination 2, 5
• Laboratory testing should be targeted based on clinical suspicion and may include complete blood count, glucose, and electrolytes 6

Common Diagnoses to Consider

• Peripheral causes (generally benign):

  • Benign paroxysmal positional vertigo (BPPV): brief episodes triggered by head movement 1
  • Vestibular neuritis: episodic vertigo not associated with specific triggers 4
  • Ménière's disease: vertigo with unilateral hearing loss and tinnitus 1

• Central causes (may require urgent treatment):

  • Stroke or TIA in the posterior circulation 1
  • Demyelinating diseases 1
  • Central nervous system lesions 1

• Other causes:

  • Medication side effects 1
  • Metabolic disorders (including hypoglycemia) 1
  • Anxiety or panic disorder 1
  • Postural hypotension 1

Initial Management

• For BPPV: Perform canalith repositioning procedures (e.g., Epley maneuver) 2
• For vestibular neuritis: Consider vestibular suppressant medications and vestibular rehabilitation 4
• For Ménière's disease: Recommend dietary modifications (sodium restriction, avoiding caffeine/alcohol/nicotine) and consider a limited course of vestibular suppressants during acute attacks 2
• For central causes: Urgent neurological consultation and appropriate management based on etiology 1

Common Pitfalls to Avoid

• Failing to recognize that dizziness can be a symptom of serious central nervous system pathology 3
• Over-reliance on symptom quality descriptions rather than timing and triggers 1, 4
• Routine use of vestibular suppressant medications for BPPV, which may delay recovery 2
• Failure to recognize that 25-50% of patients with recurrent BPPV may have associated vestibular pathology requiring additional evaluation 2
• Not considering that benzodiazepines carry significant risk for dependence and should be used sparingly 2

Follow-up

• Reassess patients within one month after initial treatment to document resolution or persistence of symptoms 2
• Evaluate patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 2
• Consider referral to specialists (neurology, otolaryngology, cardiology) for persistent or complex cases 2