Makindo Medical Notes

Unsteadiness is a common presenting complaint, especially in older adults. It refers to a sensation of imbalance or difficulty maintaining posture and gait, without vertigo (spinning). Causes range from benign anxiety-related imbalance to serious neurological or vestibular disease. A structured approach through history, examination, and targeted investigations is essential.

🗣️ History of Present Illness (HPI)

• Describe onset and duration: acute vs chronic.
• Character: “feeling unsteady” vs vertigo (room spinning).
• Triggers: standing, walking in the dark, turning head, stress/anxiety.
• Associated features:
  • Hearing loss/tinnitus → vestibular disease.
  • Visual disturbance → sensory ataxia.
  • Numbness, weakness, slurred speech → neurological disease.
• Falls history, injuries, or fear of falling.
• Past medical history: diabetes, neuropathy, stroke, B12 deficiency, Parkinson’s, thyroid disease.
• Drug history: sedatives, antihypertensives, polypharmacy in older patients.

🔎 Clinical Examination

• General: Gait observation, tandem walking, use of aids.
• Neurological exam:
  • Cranial nerves: eye movements, nystagmus, dysarthria.
  • Motor: tone, power, reflexes.
  • Coordination: finger–nose, heel–shin, dysmetria.
  • Sensation: proprioception, vibration sense (peripheral neuropathy).
  • Romberg test: worsens with eyes closed → sensory ataxia.
• ENT exam: Tympanic membranes, vestibular signs.
• Cardiovascular: Postural BP, heart sounds, rhythm (arrhythmia if syncope suspected).

⏱️ Time Course & Common Causes

🧪 Investigations

• Blood tests: FBC, U&E, glucose, thyroid, B12/folate.
• Imaging: MRI brain if neurological suspicion; CT head if trauma.
• Vestibular tests: Caloric testing, audiometry if ENT suspected.
• Other: ECG, postural BP, gait/balance assessments (e.g., Timed Up & Go).

🛠️ Management

1. Treat underlying cause:
   • B12 replacement, thyroid correction.
   • Vestibular rehab for labyrinthitis.
   • Medication review (avoid sedatives, polypharmacy).
2. Symptomatic management:
   • Physio-led balance training.
   • Occupational therapy → home adaptations, grab rails, good lighting.
   • Mobility aids: frame/stick can transform confidence in older patients.
   • Address psychological contributors (anxiety management, reassurance).
3. Referral:
   • Neurology: if cerebellar ataxia, MS, or progressive neurological features.
   • ENT: if vestibular disease suspected.
   • Falls clinic / geriatrics: if multifactorial in elderly.

🚨 Red Flags

• Acute unsteadiness + focal neurology → posterior circulation stroke.
• Unexplained falls with loss of consciousness → cardiac arrhythmia or seizure.
• Progressive worsening with neurological signs → tumour, MS, degenerative ataxia.

✅ Take-Home Messages

• Unsteadiness ≠ vertigo → think balance/gait disorders, not spinning.
• In older adults, often multifactorial (vision, proprioception, medications, frailty, anxiety).
• Always check B12, thyroid, medications before over-investigating.
• Acute onset + neurological features → stroke until proven otherwise.