Manor Field Surgery Blog 10 Dizziness (three-part series) 

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As a young doctor and even as an ageing one, patients presenting with symptoms of dizziness are usually the ones that we leave until last, passing, if possible, to the back of the queue, the end of the day. 

This is not because we do not like people who are dizzy, rather, it is such a tricky condition and at times difficult to understand. (Doctors being (for the most) human, like to do the easy things first).   

I thought I would re-kindle my Manor Field blogs after yesterday’s over-65 flu clinic, during which it was apparent to me that many of our patients use Facebook and follow our surgery page. One lady surprised me with, ‘I’ve seen you on Facebook’ (picture below). 

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This suggested to me, that using my blog to convey health information might be a good idea. (If you are a Facebook reader and want to check out my blog, there is a link at the end.) 

Back to dizziness. 

I plan to discuss this in three parts as that is how I break-it down in my head when trying to determine the cause of a patient’s symptoms. 

I will start with postural hypotension, as this is the only area of dizziness in which I can claim any degree of expertise. In following weeks, I will discuss the middle-ear (semi-circular canals and all that) then the cerebellum (the part of the brain that controls balance).   

There are other causes of dizziness and I will touch on them. 

Postural hypotension. 

This is something I have discussed in several blogs and on Facebook. You might call it my favourite condition, not because it is something I particularly like, more because it is so often missed or under-diagnosed by other doctors, is potentially so debilitating to those experiencing it and can be treated quite easily. 

What is it? 

Postural, or as it is sometimes called, Orthostatic hypotension (or Orthostatic Intolerance) relates to the symptoms associated with a fall in blood pressure when a person changes posture, from lying or sitting to standing. 

It is mostly experienced as a feeling of unsteadiness or light-headedness; some people feel so topsy-turvy they need to sit or lie down immediately after standing. 

For a few, if they can’t immediately lie or sit down, they can fall, for some this coincides with a loss of consciousness – blanking-out. 

To explain how this works I need people to join me for a short course in physiology, otherwise known as human plumbing.   

So long as we are alive, we have blood sloshing around inside us. Blood is mostly liquid with some other components – red blood cells containing iron which give it it’s colour, white blood cells that fight infection and other innumerable chemicals, hormones, and biological substances.   

This means, blood obeys, for the most, the same rules as water. 

Blood runs around the body in blood vessels, arteries, and veins, pumping in a circle from the lungs to the heart then out to the body and back again to the heart then lungs. 

circulation

We call this circulation. First discovered by William Harvey, an English physician in the 1620’s. 

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Now you have that picture in your mind, imagine water, or blood, whichever your prefer flowing up hill. The steeper the hill, the harder it will be to get the liquid to the top. To get that liquid ‘up’ requires energy, that’s the pump and functioning pipes – arteries or veins. You also need enough fluid. 

If you do not have enough fluid, the arteries or veins are not doing what they should or your heart is struggling, the blood does not flow and not enough reaches your head. 

If you do not have enough blood reaching your head you feel dizzy. If there is not enough for anything longer than a few seconds you risk losing consciousness. 

Hopefully, this has given you an understanding of what might be called in textbooks, the fluid-dynamics of blood. 

It is nothing fancy. When I syphon my fish-tank water into a bucket I’m applying the same strategy or, when I sip a drink through a straw. 

‘All this is very well, yet, you said it was easy to treat,’ some of you might be thinking. 

I need to explain a little more before I talk treatments. 

First has to do with the blood vessels, you see, they are not like the plastic tube I use to syphon dirty aquarium water, as they are capable of stretching and contracting, they can change their diameter depending on several factors – they can expand when more blood is required to reach a part of the body, your stomach, for example, after a meal requires more blood than at other times, or the muscles in your legs after you have exercised. 

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To supply more blood, the heart pumps harder and the blood vessels dilate. 

If the heart pumps harder and the blood vessels do not dilate you get high blood pressure, which is a topic for another day, if the blood vessels dilate and the heart does not pump-out more blood, your blood pressure drops and, yes, dizziness. 

There is more to this than I have written here and, I am not a physiologist, hopefully it has provided enough explanation to act as a primer in understanding some of what happens when doctors (through tablets) or disease (through effects on blood vessels) or medicines (through all sorts of mechanisms) influence blood pressure. 

Do you ever feel light-headed when you stand-up? 

When you get out of bed in the morning do you wobble and need to sit down? 

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That is often all it takes to reach a diagnosis of postural hypotension. 

This condition can occur semi-naturally if someone is dehydrated, this is easily remedied with a pint of water. If it happens regularly, and leads to you over-balancing or falling, that is the postural hypotension and is something I can treat. 

How do we diagnose this condition? 

When people are healthy, the natural response for your blood pressure is to increase a little when you change position. This enables your heart to pump blood to your head. 

When you are sitting your heart had less work to do than when you are standing. Standing is more uphill than sitting. 

We can measure this easily with blood pressure recordings. 

Lying and standing.   

It is that simple. 

You can read how to check your own measurements here. 

If your blood pressure lying is 120/80, it should either stay the same or increase when you change from lying-down to standing. From 120/80 to 130/85, for example. When you lie down again it should drop-back to 120/80 (or so, blood pressure naturally goes up and down through the day and from minute to minute).   

(The blood pressure doctors use to diagnose ‘hypertension’ is when people are sitting, again, a different subject). 

If your blood pressure drops from lying to standing, say 120/80 to 100/50, you likely have postural hypotension. 

It is that simple. 

The occasional drop is not usually significant and may be related to a degree of dehydration, it might happen if you have a cold or the flu and are feeling under the weather. 

Consistent drops of more than 20 mmHg (millimetres of mercury) over 10 is consistent with the diagnosis. (20 the higher or systolic reading, 10 the lower or diastolic reading) 120/80 = 120, systolic blood pressure (when your heart is contracting), 80, diastolic blood pressure (when your heart is resting in-between beats). 

What should you do if you find your blood pressure is dropping and it’s making you feel dizzy? 

First, sit down, then, talk to your doctor. 

We can help! 

The treatment might take a little while – we have first to establish the cause of what is happening, yet we should be able to make you feel much better. 

‘I quite like the feeling, why medicalise?’ You might think, and I agree, this is always a question when you are thinking of involving a doctor or other clinician. 

The problem with postural hypotension is that it tends to have two peaks, one when people are in their adolescence and growing and are quite fit, they may naturally have a low blood pressure (young folk call this a ‘head rush’); this is something that most people grow-out of. 

As we age, our blood pressure tends to increase, this leads to all manner of bad things such as heart, cerebrovascular (brain) and kidney disease and is a major focus of Western Medicine, that is treating hypertension – high blood pressure. 

As folk age, or other conditions intercede, such as diabetes, some start to develop postural hypotension which raises other complications. 

The most significant, particularly for older people (the definition of older is anyone who is older than you) when the effects of ageing can impair balance, coordination, and reflexes. 

All of this can result in one of the biggest risks to the wellbeing of older people – falls. 

If a younger person falls (anyone younger than you), they usually recover quickly, they might look daft, but the injury if any tends to be minor. 

As people age, the risk of falling increases and with it the risk of severe injury, especially fractures. 

In older people we need to do everything we can (that is ‘we’ as a society and ‘we’ as doctors and nurses and others in health and social care) to reduce the risk of falling which is a major contributor to loss of independence and reduction in quality of life. 

Older people fall more frequently than younger, when they fall the results can be worse; postural hypotension can result in a significantly increased risk of falling. 

That is one of the reasons it is important to investigate and treat. 

Other reasons relate to the potential harm of inadequate blood supply, even temporarily over a period of months and years to what we call end-organs, the brain and kidneys in particular. Postural hypotension has been linked to the development of dementia. 

I debated whether to include that last sentence as I don’t want to scare anyone, and indeed, the risk is probably small, yet, even small reductions in risk are potentially valuable. 

Treatment? Might be as straightforward as stopping a culprit medicine or increasing the salt in your diet, you might even require blood-pressure raising medicine. 

Get in touch if you have any questions! r.kersh@nhs.net 

If you enjoyed this blog, please give me a smile or a thumbs-up, if you are a patient and like our surgery, you could write a review. 

Be well and take care and part two will follow soon. 

 

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