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1 REVIEW ARTICLE pissn: eissn: Korean J Clin Geri 2014;15(2): 노인어지럼증에대한임상적이해 이동국 대구가톨릭대학교의과대학신경과학교실 Clinical Understanding to Dizziness in the Elderly Dong-Kuck Lee Department of Neurology, Catholic University of Daegu, School of Medicine, Daegu, Korea Dizziness is a broad term used to describe a variety of sensations such as vertigo, unsteadiness, lightheadedness, and similar symptoms. Dizziness is a common and potentially serious complaint among the elderly. Left untreated, it can lead to falls and serious injuries. The prevalence of dizziness increases steadily with age. Although debate is still ongoing about the underlying causes of this increase in prevalence, there is universal agreement on its devastating consequences and high physical, emotional, and financial toll on the older population. It is estimated that one-fourth to one-third of the population older than 65 years has experienced some form dizziness. The history is often critical to determining the most likely causes of dizziness. Especially medications as a risk factor for dizziness in the older adult population. Older individuals who suffer from dizziness appear to be at significantly higher risk of accidental falls and consequent injuries. Therefore the strong association between falls and symptoms of dizziness and imbalance highlights the importance of understanding the causes of these symptoms and designing effective methods for managing them in the older population. When possible, a multidisciplinary approach with an integrated strategy is more effective in the diagnosis and management of dizziness because the understanding the underlying causes often span multiple systems. Key Words: Dizziness, Older 서론 어지럼증 (dizziness) 은노인에서흔히볼수있는증상이다. 그러나대부분노인들이어지럼증에대해서는모호하거나애매하게표현하는경우가많다. 특히나이가들수록더어지러워지는것은연령에따른생리적변화와더불어전정계, 고유감각 (proprioception) 계, 시각계, 운동계, 및중추통합 (integration) 계등과균형계의퇴행등 이그원인으로생각된다. 80세이상되는사람들중 15 40% 이상에서어지럼증을호소한다. 젊은사람들에비해노인어지럼증은일상생활에심각한장애를일으키고더만성적으로생기며훨씬더다양한원인에의해발생한다. 어지럼증의진단에가장중요한것은상세한병력청취이다. 감별진단을위해선전정계의해부및생리에대한이해와각질환의특징적인증상및징후을알고어지럼증환자를진찰할수있어야한다. 특히노 Received: September 19, 2014 Revised: December 16, 2014 Accepted: December 16, Corresponding author: Dong-Kuck Lee Department of Neurology, Catholic University of Daegu, School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu , Korea Tel: , Fax: , dklee@cu.ac.kr Copyright C 2014 The Korean Academy of Clinical Geriatrics This is an open access article distributed under the term s of the C reative Com m ons Attribution N on-c om m ercial License ( licenses/by-nc/3.0) which perm its unrestricted non-comm ercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 46 Korean J Clin Geri 2014;15(2):45-55 인어지럼증은단순한진단명이라기보다는포괄적인증후군 (syndrome) 으로생각하고다각적으로접근하는것이중요하다. 본론 1-14) 1. 병력 어지럼증이란공간에서지남력변화또는불균형 (diseqilibrium) 으로인한불쾌한감각을표현하는비특이적용어이다. 병적인어지럼증은크게현기, 불균형, 전실신 (presyncope), 및정신생리적어지럼증등으로구분한다. 병력, 어지럼증유발검사, 및진찰등을통해대부분의어지럼증은감별진단이가능하다. 현기는긴장형전정활동의불균형으로인한운동착각이다. 현기는대부분회전성으로나타나며세반고리관이나중추연결에이상이있다는것을나타내는것이다. 몸이한쪽으로쏠리는감이나넘어지려는것은이석 (otolith) 의이상을나타낸다. 현기는안구진탕 (nystagmus), 자세불균형, 메스꺼움, 구토, 또는진동시 (oscillopsia) 등을동반한다. 중추성보단말초성현기에서땀, 창백, 메스꺼움, 및구토등의자율신경이상증상이잘나타난다. 노인성현기의흔한원인으로는양성발작성체위성현기, 바이러스성신경미로염, 외상, 독소, 및후뇌또는미로허혈등이있다. 젊은성인현기의흔한원인으로는메니에르병, 바이러스성신경미로염, 외상, 및독소등이있다. 불균형이란비현기성정적 (static) 또는동적인 (dynamic) 자세균형에문제가생긴상태를말한다. 불균형상태의환자들은자주불안정하고균형이맞지않아넘어지려한다. 불균형상태는크게감각성과운동성으로나눈다. 감각성불균형은고유감각장애, 전정기능장애, 시력- 전정부조합, 및다발성감각장애등으로인한공간지각력의이상때문에발생한다. 감각성불균형은어두운장소에서더악화되며 Romberg 징후가자주양성으로 Table 1. Drug associated with dizziness Drug Syndrome Mechanism Alcohol 1. Vertigo(positional) 1. Reversible changes in cupula specific gravity 2. Motor disequilibrium(ataxia) 2. Cerebellar dysfunction a. reversible after acute intoxication b. permanent after long-term abuse Aminoglycosides Sensory disequilibrium or vertigo, oscillopsia, Irreversible damage to labyrinthine hair cells hearing loss Anticonvulsants Motor disequilibrium(ataxia) Cerebellar dysfunction 1. Reversible after acute intoxication 2. Potentially irreversible after chronic phenytoin intoxication Antidepressants Presyncope Orthostatic hypotension Antihypertensives Presyncope Orthostatic hypotension Antimalarial agents Sensory disequilibrium or vertigo, hering loss, Variably reversible damage to labyrinthine hair cells and tinnitus Antipsychotics Presyncope Orthostatic hypotension Cis-platinum Sensory disequilibrium or vertigo, hearing loss, variably reversible damage to labyrinthine hair cells and tinnitus Cytosine arabinoside Motor disequilibrium (ataxia) variably reversible damage to cerebellar Purkinje cells Ethacrynic acid Sensory disequilibrium or vertigo, hearing loss, Irreversible damage to cerebellar Purkinje cells and tinnitus 5-Fluorouracil Motor disequilibrium (ataxia) Reversible inhibition of cerebellar metabolism by metabolites Furosemide Sensory disequilibrium or vertigo, hearing loss, Reversible inhibition of enzymes in cochlea and tinnitus Minocycline Sensory disequilibrium or vertigo, and tinnitus Reversible vestibular toxicity Salicylates Sensory disequilibrium or vertigo, hearing loss, and tinnitus Reversible inhibition of metabolic activity of labyrinthine hair cells and/or cochlear neurons Sedative-hypnotics Mixed disequilibrium Reversible depression of CNS integration areas

3 이동국 : 노인어지럼증에대한임상적이해 47 나타난다. 운동성불균형은중추및말초신경계중운동신경로의이상이나기계적인자들의장애로인해나타난다. 중추성원인으로는추체로, 추체외로, 및소뇌등에문제가생긴경우이고말초성은말초신경, 신경근육접합부, 및근육의이상으로인해운동성불균형이생긴다. 운동성불균형은어두운곳에가거나눈을감아도더악화되지는않는다. 전실신은곧의식을잃을것같은감각으로힘이빠지고메스꺼우며땀이나고속이불편하다. 그외에도얼굴이창백해지고눈이침침해지며암점 (scotoma) 도생기고두통, 가슴이두근거림, 이상감각및손발이수축되는것같는증상도보인다. 전실신은뇌대사가갑자기전반적으로장애가와서생긴다. 그런원인으로는뇌허혈, 저혈당, 및저산소증등이있다. 그외에도심박출량의감소, 말초혈관수축기능의저하, 뇌혈관수축, 정맥순환부전, 및혈량저하증 (hypovolemia) 등이있다. 과호흡이나저혈당상태에서도진정한실신은드물다. 전실신은누우면회복된다. 정신생리적어지럼증은막연하고모호한어지럼증으로급성또는만성불안이있는사람들이잘호소한다. 이런어지럼증은기분에따라증상이변한다. 특히복잡하고답답한환경, 갇힌공간, 또는심한스트레스받는상황에서잘발병한다. 이런어지럼증에서는얼굴이창백해지는일은없고누워도호전되지않는다. 모든어지럼증환자를진찰할때는항상약물과의연관성을생각해보아야한다. 어지럼증을잘일으키는약물로는 Table 1, 2 등이있다. 특히노인들은귀독성 (ototoxicity) 약물을자주먹고신체예비력 (reserve) 은떨어져있으며신장기능도약하므로약물에의한이독성이잘생긴다. 어지럼증의감별진단에필요한병력은 Table 3, 4와같다. 특히현기의발병 (onset), 기간, 경과및자율신경, 청신경, 및중추신경계동반증상을잘살펴보는것이감별진단에중요하다. 현기를해부학적위치에따라감별진단하는데도움이되는신경증상은 Table 5와같다. 어지럼증은머리운동, 기침재채기, 또는큰소리등에 Table 2. Medications that often cause dizziness in older adults Class of Medication 1-Adrenergic antagonists Alcohol Aminoglycosides Anticonvulsants Antidepressants Anti-Parkinson medication Antipsychotics -blockers Calcium channel blockers Class 1a antiarrhythmics Digitalis glycosides Diuretics Narcotics Oral sulfonylurea Vasodilators Anticoagulants Antidementia agents Antihistamines: sedating Antirheumatic agents Anti-infectives: anti-influenza agents, antifungals (oral), quinolones Antithyroid agents Anxiolytics Attention-deficit/hyperactivity disofder agents Cholesterol-lowering agents Bronchodilators Skeletal muscle relaxants Urinary and gastrointestinal antispasmodics Possible Mechanism Orthostatic hypotension Hypotension, osmotic effects Ototoxicity Orthostatic hypotension, cerebellar dysfunction Orthostatic hypotension Orthostatic hypotension Orthostatic hypotension Hypotension or bradycardia Hypotension, vasodilation Torsades de pointes Hypotension Volume contraction, vasodilation CNS depression, torsades de pointes Hypoglycemia Hypotension, vasodilation Bleeding complications Bradycardia, syncope Torsades de pointes Vestibular disturbance Torsades de pointes Bone marrow toxicity CNS depression Cardiac arrhythmias Hypotension Hypotension central anticholinergic effects central anticholinergic effects

4 48 Korean J Clin Geri 2014;15(2):45-55 의해악화된다. 2. 원인어지럼증은다양한원인에의해발생한다. 말초현기의원인과중추현기의원인들은 Table 6 9와같다. 이아니다. 특히노인에서여러가지신체가능이떨어진상태이거나뇌졸중또는치매가있는경우에는더욱진찰이힘들다. 만약가끔씩어지럼증이있는경우라면유발시켜보는것도좋다. 머리를빠르게회전시키거나 caloric 검사를하면현기가유발된다. 과호흡을하면전 3. 진찰어지럼증을호소하는환자를진찰하는것은쉬운일 Table 3. Key features in history Vertigo Auditory symptoms Headache Associated neurology Medication Risk factors for cerebrovascular accident or transient ischaemic attack Past history Acute onset or more gradual Preceding or precipitating factors Hearing loss Tinnitus Ear discharge or pain Sense of fullness or blockage in the ear Before, during or after the vertigo Diplopia Other visual disturbance Dysarthria or dysphagia Paraesthesia or muscle weakness Aminoglycosides Anticonvulsant Previous angina or myocardial infarction Diabetes mellitus Hypertension Smoking Atrial fibrillation Head injury Chronic ear infections Migraine Table 5. Neurologic symptoms associated with vertigo due to lesions at different anatomic sites Inner ear ㆍ Hearing loss ㆍ Tinnitus Internal auditory canal ㆍ Facial weakness ㆍ Hearing loss ㆍ Tinnitus Cerebellopontine angle ㆍ Facial numbness ㆍ Facial weakness ㆍ Hearing loss ㆍ Tinnitus ㆍ Extremity incoordination Brainstem ㆍ Diplopia ㆍ Facial numbness ㆍ Facial weakness ㆍ Dysarthria ㆍ Dysphagia ㆍ Extremity weakness ㆍ Extremity incoordination ㆍ Extremity numbness Cerebellum ㆍ Extremity incoordination Table 4. History in the differential diagnosis of vertigo Associated symptoms Condition Onset Duration Course Autonomic* Auditory CNS Benign paroxysmal positioning vertigo Abrupt Seconds Episodic +++ Seizures Abrupt Seconds/Minutes Episodic /+ ++ Migraine Abrupt Minutes Episodic Vertebrobasilar insufficiency/tia Abrupt Minutes/hours Episodic Meniere s syndrome Abrupt Hours Episodic Trauma Abrupt Days Monophasic Stroke Abrupt Days Monophasic Vestibular neuronitis Subacute Days Monophasic /++++ Toxic Subacute/chronic Days Monophasic Posterior fossa mass Subacute/chronic Days varies : never, +: uncommon, ++: common, +++: typical, ++++: universal. TIA: transient ischemic attack. *Autonomic symptoms (sweating, pallor, nausea, vomiting) are much more common and much more severe with vertigo of peripheral origin (labyrinth or eighth nerve) than with vertigo of CNS origin. Auditory symptoms generally only occur if the vascular event involves either the inner ear or the acoustic nerve.

5 이동국 : 노인어지럼증에대한임상적이해 49 Table 6. Common causes of dizziness Vertigo Disequilibrium Type Dizziness, light headedness Cause Benign paroxysmal positional vertigo, Meniere disease, labyrinthitis, vestibular neuronitis, inner ear autoimmune diesease, perilymphatic fistula, migraine*, labyrinthine concussion*, transverse temporal bone fracture, vertebrobasilar ischemia, lateral medullary infarct (Wallenberg syndrome), cervical injury Peripheral neuropathy, acoustic neuroma*, ototoxic drugs, cerebellar atrophy, cerebellar infarction, tumors of the posterior fossa, aging, multiple sclerosis*, Wernicke encephalopathy Cardiac arrhythmia, vasovagal reaction, postural hypotension, systemic viral or bacterial infection, hypoglycemia, hyperglycemia, electrolyte disturbances, thyrotoxicosis, anemia, psychophysiologic, adverse drug reaction, ocular dizziness due to rapid vision change (after cataract surgery, a change in a corrective prescription) *May also present with dizziness, May also present with vertigo. Table 7. Common causes of peripheral vertigo Benign paroxysmal positional vertigo Bacterial or viral infections Vestibular neuritis Meniere disease Labyrinthine ischemia or hemorrhage Tumor Trauma Temporal bone fracture Labyrinthine concussion Perilymphatic fistula (fistula may also be caused by cholesteatoma) Metabolic disorders Diabetes mellitus Uremia Hypothyroidism Paget disease Acute alcohol intoxication Ototoxicity Aminoglycosides Cisplatin Autoimmune inner ear disease Superior semicircular canal dehiscence syndrome 실신이유발되며이때입주위나발목에이상감각과연축 (spasm) 이동반될수도있다. 기립저혈압을알기위해선누운상태와선상태에서맥박과혈압을측정한다. 선상태에서 3분지나수축기혈압이 20 mmhg 또는이완기혈압이 10 mmhg 이상떨어지면기립저혈압이라고한다. 그러나기립저혈압증상을보여도일부에서는서서 10분이상지나도혈압이떨어지지않는경우도있다. 어지럼증을호소하는모든환자에서는눈, 귀, 심혈관계, 신경계, 및전정계기능을잘살펴야한다. 특히안구진탕은중추성과말초성어지럼증을감별하는데중요하므로모양, 악화및억제인자들을잘봐야한다. 병 Table 8. Common causes of central vertigo Neurologic complications of ear infections Epidural, subdural, intraparenchymal brain abscess Meningitis Brain stem or cerebellar TIA or stroke Migraine Tumors Trauma Cerebellar degeneration syndromes Alcoholic, familial; etc. Disorders of the craniovertebral junction Basilar impression Atlantoaxial dislocations Chiari malformations MS Seizure 적안구진탕은자발성으로도나타나고안구와머리위치를변동해도나타난다. 말초전정안구진탕을억제하는가장중요한방법은고정 (fixation) 이다. 중추및말초안구진탕의특징적인소견은 Table 10 12와같다. Dix-Hallpike 검사는양성돌발성체위현기같이체위에따라유발되는안구진탕의진단에유용하다. 특히 caloric 검사는말초전정병변을진단하는데중요하다. 또한눈을감은상태와눈을뜬상태에서직렬 (tandem) 보행을하는것도중추성과말초성어지럼증을진단하는데도움이된다 (Table 13 15). 4. 검사어지럼증은병력과진찰을통해대부분진단된다. 그러나중추성과말초성어지럼증을감별하기위해선적절한검사를선택적으로이용해야한다. 진단에도움이되는검사들로는청력검사, 뇌간청각유발전위, 뇌영상

6 50 Korean J Clin Geri 2014;15(2):45-55 Table 9. Common causes of dizziness in the elderly for different types of symptoms Smptom Subtype Likely cause Comments Vertigo Position-induced BPPV If nystagmus does not match BPPV, consider central pathologies, If induced by neck rotation, consider cervical vertigo Acute-onset persistent with neurologic signs Stroke Tumors Degenerative diseases Labyrinthtis vestibular neuritis Meiniere's disesase Migraine Acute ischemia involving vestibular structures can mimic vestibular neuritis Acute-onset persistent without neurologic signs Differential diagnosis is based on presence of hearing loss Acute-onset persistent without Late-onset Meniere's is possible but not common. neurologic signs Migraines lack progressive auditory symptoms. Transient ischemic attacks should be considered in patients with vascular risk factors Disequilibrium Acute or rapidly progressive Stroke Autoimmune or postinfectious disease should also be considered. May include severe oculomotor abnormalities Presyncope Lightheadedness, nonspecific Worse in the absence of other sensory inputs Bilateral vestibular loss Usually includes history of ototoxicity. Hearing loss of oscillopsia may be present Worse in the absence of vision with numbness/weakness Proprioception and somatosensory loss Often associated with peripheral neuropathy associated with metabolic disorders, diabetes, or renal failure With bradykinesia, rigidity, tremor Parkinson disease Frontal lobe or other basal ganglia disorders With speech disorder, lack of coordination, intention tremor cerebellar lesions The imbalance is usually the same with or without vision Isolated disequilibrium, gait difficulty, lightheadedness Disequilibrium of aging Often accompanied by borderline diffuse central findings but no other specific complaints With blood pressure drop on postural hypotension Associated with reduced blood volume, standing autonomic disorders, or chronic use of hypertension medications Abnormal cardiac examination Heart valve disease When 24-h electrocardiogram is abnormal, Arrhythmia indicates transient arrhythmia Induced by fear or anxiety Vasovagal attacks Decline in heart rate and blood pressure leads to decrease in cerebral blood flow Associated with fear, anxiety, Psychogenic Often accompanied by autonomic symptoms depression Table 10. Clinical features of peripheral and central spontaneous vestibular nystagmus Peripheral Central Appearance ㆍJerk ㆍMixed linear and rotatory ㆍJerk or pendular ㆍMay be pure linear or pure rotatory ㆍUnidirectional (beats away from hypofunctioning labyrinth) ㆍMay change direction with gaze in different directions Fixation ㆍInhibits nystagmus ㆍLittle effect Associated symptoms and signs ㆍ Severe vertigo ㆍ Severe nausea ㆍ Hearing loss and tinnitus common ㆍ No central nervous system symptoms or signs ㆍ Mild or absent vertigo ㆍ Mild or absent nausea ㆍ Hearing loss and tinnitus uncommon ㆍ Central nervous system symptoms and signs common 검사, 안진계 (nystagmography), 및 caloric 검사등이있다. 만약진단이힘들면신경과와이비인후과의사들의자문도필요하다. 5. 감별진단어지럼증이중추성인지말초성인지를감별하는것은중요하다. 현기와기타다른형태의어지럼증을감별하

7 이동국 : 노인어지럼증에대한임상적이해 51 Table 11. Clinical features of peripheral and central positional vestibular nystagmus Peripheral Central Latency ㆍ1 45 seconds ㆍNone Appearance ㆍJerk ㆍMixed upbeat rotatory ㆍUnidirectional ㆍJerk or pendular ㆍMay be pure linear or pure rotatory ㆍMay change direction with gaze in different directions Fixation ㆍInhibits nystagmus ㆍLittle effect Duration ㆍ<60 seconds ㆍPersists Fatigability ㆍLessens and may disappear on repetition ㆍPersists Associated symptoms and signs ㆍ Severe vertigo ㆍ Severe nausea ㆍ Hearing loss and tinnitus common ㆍ No central nervous system symptoms or signs ㆍ Mild or absent vertigo ㆍ Mild or absent nausea ㆍ Hearing loss and tinnitus uncommon ㆍ Central nervous system symptoms and signs common Table 12. Features of peripheral and central vertigo Sign or symptom Peripheral (Labyrinth or vestibular nerve) Central (Brainstem or Cerebellum) Direction of associated nystagmus Unidirectional, fast phase opposite lesiona* Bidirectional (direction-changing) or unidirectional Purely horizontal nystagmus without Uncommon May be present torsional component Purely vertical or purely torsional nystagmus Never present No inhibition Visual fixation Inhibits nystagmus usually absent Tinnitus and/or deafness Often present usually absent Associated central nervous system abnormalities None Extremely common (diplopia, hiccups, cranial neuropathies, dysarthria) Common causes Benign paroxysmal positional vertigo, infection (labyrinthitis), vestibular neuritis, Meniere's disease, labyrinthine ischemia, trauma, toxin Vascular, demyelinating, neoplasm *In Meniere's disease, the direction of the fast phase is variable, Combined vertical-torsional nystagmus suggests BPPV. Table 13. Key features on examination Eye movements Nystagmus Ears Hearing Other neurology Gait and balance Range of movement Diplopia Gaze evoked or spontaneous nystagmus Ratatory, horizontal, vertical or mixed Direction of gaze in which most pronounced Does it change direction on changing direction of gaze Tympanic membrane for any perforation Whispered voice at arm's length with other ear occluded Weber's and Rinne's test to determine whether sensorineural or conductive deafness Cranial and peripheral nerves Romberg's test Ability to stand and walk unaided 기위해서는어지럼증이돌발적, 아급성, 또는만성인지알아보고발병이주기적인지또는일회성인지알아보아야한다. 또는어지럼증의지속시간도알아본다. 또한어지럼증이현기, 불균형, 전실신, 또는정신과어지 럼증인지감별한다. 동반증상으로메스꺼움이나구토같은자율신경이상, 청력소실이나이명같은청신경증상, 또는복시, 얼굴감각이상, 또는사지마비같은중추신경계증상이있는지확인한다. 또한 Dix-Hallpike 검사,

8 52 Korean J Clin Geri 2014;15(2):45-55 Table 14. Common components of physical examination System Examination Comments Vestibular Dix-Halpike May require special accommodations for patients who are frail or have neck of back problems Head impulse When positive, almost always indicates a peripheral vestibular lesion. When negative, does not rule out peripheral lesions Spontaneous nystagmus Use Fenzel lenses to eliminate fixation Pneumatic otoscopy/valsalva Look for horizontal nystagmus in perilymph fistula of torsional/vertical nystagmus in superior canal dehiscence Hearing Use tuning forks Vision Static visual activity Check both monocular and binocular vision Dynamic visual activity Look for significant drop in visual acuity during head movement Proprioception Temperature/pain/vibration Check for neuropathies Motor Muscle tone/strength Lower extremity weakness is a fall risk factor (musculoskeletal) Gait Check tandem walking for different abnormal patterns Postural stability/sensory integration Romberg test with eyes open and closed while standing on a solid surface or foam Coordination Past-pointing, heel-knee, or similar tests Oculomotor Gaze motility/nystagmus Look for restricted range of motion and nystagmus Saccade/tracking Assess both accuracy and velocity of both slow and fast eye movements Cardiovascular Orthostatic drop in blood pressure Look for drop of greater then 20mmHg in systolic blood pressure of drop of greater than 10mmHg in diastolic blood pressure on standing Irregular heart rhythm Can be intermittent Psychogenic Cognition Questionnaire-based assessment such as Mini-Mental State examination Anxiety Questionnaire-based assessment such as Beck anxiety inventory Hyperventilation test can be helpful Depression Questionnaire-based assessment such as Geriatric Depression Scale Handicap Questionnaire-based assessement such as Dizziness Handicap inventory 과호흡, 또는머리회전 (rotation) 같은유발방법으로어지러운증상이나오는지본다. 특히두위변환검사중 Dix-Hallpike 검사는말초성두위현훈의진단을위해가장흔히이용되는방법이다. 이검사법은우선눕혔을때환자의어깨가침대끝에닿을수있을정도의적당한위치에환자를앉힌후검사자는환자의머리를양손으로잡은다음머리를 45도돌린상태에서빠르게뒤로눕혀침대끝에서환자의머리가 45도각도로지면을향하도록한다 (Figure 1). 이검사를하기전에는우선환자를안심시킨상태에서온몸의긴장을풀도록해야한다. 또한검사에의해현훈이유발되면환자는자동적으로눈을감는경향이있으므로환자에게검사도중눈을뜨고있도록이야기해주어야한다. 두위변환후적어도 20초이상두위를유지하여안진의잠복기와지속시간, 및시간경과에따른크기변화를기록하여진단한다. 두위변환검사는양성돌발성체위성어지러움의국소진단에유용한검사법인데중요한것은어떤두위변환에서안진이나오는가보다어떤성분의안진이나오는가하 는것이다. 특히이검사는뒤반고리관 (posterior semicircular canal) 또는앞반고리관에서기원하는양성돌발성체위성어지러움의진단에유용하다. 그러나예를들어양성돌발성체위성어지러움이의심되는환자에서우측 Dix-Hallpike 검사에서향지성안진이나타나더라도수평성분의향지성안진이나오는경우에는뒤반고리관의결석이기보다는측반고리관의반고리결석 (canalolithiasis) 일가능성이높다. 한편혹시약물에의한어지럼증인지도확인한다. 또한진찰상안구진탕이나지시검사 (pastpointing) 등전정불균형증상이있는지확인한다. 6. 치료어지럼증의치료는형태와원인에따라다양하다. 일반적으로는증상치료이며근본원인을확인하고교정하는것이치료의핵심이다. 예를들어현기에서는전정진정제를쓰면호전되지만전실신과불균형에서는반대

9 이동국 : 노인어지럼증에대한임상적이해 53 Table 15. Distinguishing among common peripheral and central vertigo syndromes Cause Peripheral Vestibular neuritis Benign paroxymal positional vertigo Meniere's disease Vestibular paroxysmia Perilymph fistula Central Stroke/TIA History of vertigo Single prolonged episode Positionally triggered episodes May be triggered by salty foods Abrupt onset; spontaneous of positionally triggered Triggered by sound or pressure changes Abrupt onset; spontaneous Duration of vertigo Associated Symptoms Physical examination Days to weeks Nausea, imbalances "Peripheral" nystagmus, positive head thrust test, imbalance <1 min Nausea Characteristic positionally triggered burst of nystagmus Hours Unilateral ear Unilateral low-frequency hearing loss fullness, tinnitus, hearing loss, nausea Seconds Tinnitus, Usually normal hearing loss Seconds Stroke, >24 hr; TIA, usually minutes Hearing loss, hyperacusis Brain-stem, cerebellar Multiple sclerosis Subacute onset Minutes-weeks Unilateral visual loss, diplopia, incoordination, ataxia Neurodegenerative disorders Migraine Familial ataxia syndromes May be spontaneous of positionally triggered Onset usually associated with typical migraine triggers Acute-subacute onset; usually triggered by stress, exercise, of excitement Nystagmus triggered by loud sounds or pressure changes Spontaneous "central" nystagmus; gaze-evoked nystagmus; usually focal neurologic signs "central" types of rarely "peripheral" types of spontaneous of positional nystagmus; ususally other focal neurologic signs Minutes-hours Ataxia "central"types of spontaneous or positional nystagmus; gaze-evoked nystagmus; cerebellar, extrapyramidal and frontal signs Seconds-days Headache, visual aura, photo-/phonoph obia Normal interictal exam. Ictal examination may show "peripheral" or "central"types of spontaneous or positional nystagmus. Hours Ataxia "Central" types of spontaneous or positional nystagmus,; ictal, or even interictal, gaze-evoked nystagmus; ataxia; gait disorders Figure 1. Dix-Hallpike test. 로악화된다. 말초성급성현기에서는전정운동을하면효과를보지만전실신, 불균형, 및정신과적어지럼증에서는도움이되지않는다. 어떤형태의어지럼증도넘어짐을조심해야한다. 특히노인에서는잘못넘어지면심각한문제가생길수있으므로주변환경, 실내외조명, 신발, 보조기, 바닥재및기타안전장치등에신경을써야한다. 흔히쓰이는항현기약의종류와용량은 Table 16과같다. 약제는환자의증상을보고임상경험에따라선택한다. 특히메스꺼움과구토를동반하는급성중증현기는정말힘드므로항현기약과더불어진정제와항구토제를같이쓰면효과적이다. 만성재발성현기에서는어떤자세와운동시현기가발생하는지를파악한다음전

10 54 Korean J Clin Geri 2014;15(2):45-55 Table 16. Dosage and common effects of antivertigo medications Drug Dose Sedation Antiemetic Anticholinergic EPS* Confusion Other Diazepam (valium) 5 10 mg po or IV q4 6 h Respiratory depression Dimenhydrinate mg po or (Dramamine) IM q4 6 h Droperidol (Inapsine) mg IM or IV q12 h Hypotension, tachycardia Meclizine (Antivert) mg q4 6 h Phenobarbital 30 mg po or IV q6 8 h Prochlorperazine 5 10 mg po/im q6 8h; (Compazine) 25 mg pr q12 h; or mg IV q6 8 h Promethazine mg (Phenergan) po/im/pr q4 6 h Trimethobenzamide 250 mg po q6 8 h; 200 mg pr/im q6 8 h Respiratory depression Hypotension Hypotension 정기관이적응할수있도록반복적으로적응운동을한다. 적응운동중생기는현기와자율신경증상을조절하기위해항현기약을쓰는것도도움이된다. 그러나항현기약은증상이호전되면되도록빨리중단하여전정기능이신속하게회복되도록하는것이좋다. 특히노인어지럼증으로인한낙상을예방하기위해선청력과시력검사를규칙적으로하고주머니에손을넣지않고천천히걸으며굽이낮고바닥이평평한신발을신고마루에카펫을깔며조명을밝게하고욕실에몸을지탱할손잡이를설치하며바닥물기는항상제거하고침대옆에등을달아어두운상태에서는나가지않게하며전선, 걸개, 가구등발걸음에걸리는장애물을없애고넘어질때는무릎을구부리면서그자리에천천히주저앉도록평소에교육시킨다. 결론 나이가들수록더자주생기는어지럼증은임상적으로아주흔한증상이다. 병적인어지럼증은크게현기, 불균형, 전실신, 및정신과적어지럼증등으로구분한다. 만성적으로자주생기는노인어지럼증은생활에큰불편함을일으킨다. 특히노인들은약물에의한귀독성이잘생기므로노인어지럼증에서는반드시약력을확인해봐야한다, 진찰할때는귀, 눈, 심혈관계, 신경계, 및전정계이상을잘살펴야한다. 만약어지럼증이주관적 이거나애매할때는유발시켜보는것도진단에도움이된다. 현기를억제하는약을쓰면전실신과불균형이악화되기도한다. 전실신, 불균형, 및정신과적어지럼증에서는전정운동이나항현기약이도움이되지않는다. 어지럼증은주관적이던객관적이던상당히힘든증상이므로다양한원인을파악하여적극적으로치료하는것이좋다. 특히노인에서는어지럼증을호소한후잘넘어지므로항상주의해야하며생활환경도안전하게해두어야한다. 노인어지럼증은전반적인신체기능저하에의한포괄적증후군이라생각하고다각적으로접근하는것이중요하다. REFERENCES 1.Macleod D, McAuley D. Vertigo: clinical assessment and diagnosis. British Journal Hospital Medicine 2008;69: Kerber KA, Baloh RW. Dizziness, vertigo, and hearing loss. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Neurology in clinical practice. 5th ed. New York: Butterworth Heinemann Elsevier, 2008: Lanska DJ. Vertigo and other forms of dizziness. In: Corey-Bloom J, David RB. Clinical adult neurology. 3rd ed. New York: Demosmedical, 2009: Ropper AH, Samuels MA. Deafness, dizziness, and disorders of equilibrium. Adams and Victor's Principles of Neurology. 9th ed. New York: McGraw Hill, 2009: Storper IS, Kirk roberts J. Dizziness, Vertigo, and Hearing Loss. In: Rowland LP, Pedley TA. Merritt's Neurology. 12th

11 이동국 : 노인어지럼증에대한임상적이해 55 ed. New York: Lippincott Williams & Wilkins, 2010: Barin K, Dodson EE. Dizziness in the elderly. Otolaryngol Clin N Am 2011;44: Shoair OA, Nyandege AN, Slattum PW. Medication-related dizziness in the older adult. Otolaryngol Clin N Am 2011; 44: Baloh RW, Jen J. Hearing and equilibrium. In: Goldman L, Schafer AI. Goldman's Cecil medicine. 24rd ed. New York: Saunders Elsevier, 2012: Greenberg DA, Aminoff MJ, Simon RP. Disorders of equilibrium. Clinical neurology. 8th ed. New York: McGraw Hill, 2012: Walker MF, Daroff RB. Dizziness and Vertigo. In: Longo DL, Fauci AS, Kasper DL, Longo DL, Hauser SL, Larry Jameson J, Loscalzo J. Harrison's Principles of internal medicine. 18th ed. New York: McGraw Hill, 2012: Wazen JJ, Ghossaini SN, Wycherly BJ. Hearing loss & Dizziness. In: Brust JCM. Current diagnosis & treatment neurology. 2nd ed. New York: McGraw Hill, 2012; Lo AX, Harada CN. Geriatric dizziness evolving diagnostic and therapeutic approaches for the emergency department. Clin Geriatr Med 2013;29: 김지수. 안진. In; 이원상, 이정구, 정경천, 박병림, 한규철. 임상편형의학. 초판. 서울 ; 대한평형의학회, 2005; 구자원, 박현민. 전기안진검사. In; 이정구. 어지러움. 3 판. 서울 ; 단국대학교출판부 국문요약 어지럼증은현기, 불안정, 불균형, 또는어찔거림같은다양한감각을포함하는포괄적인용어이다. 어지럼증은아주흔하며특히노인에서는심각한문제를일으킬수있는증상이다. 만약치료하지않고두면넘어져서심한손상을일으킬수도있다. 나이가들면서어지럼증의유병률은점차증가한다. 유병률의증가이유는아직도자세히는모르지만노인어지럼증이신체적, 감정적, 및경제적으로심각한문제를일으킨다는것에대해서는대부분의견이일치한다. 65세이상의 1/4 1/3 이상에서어지럼증을경험한다. 어지럼증에서는상세한병력이진단에가장중요하다. 다양한약물은노인어지럼증의중요한원인중의하나이다. 특히노인들은어지러우면더잘넘어진다. 따라서노인을진료해야하는의료진들은어지럼증과넘어짐에대해잘이해하고그원인을파악하여다각적접근을통해적극적으로치료하도록노력해야할것이다. 중심단어 : 어지럼증, 노인