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Occam's Razor, Geriatric Syndromes, and the Dizzy Patient
In the 14th century, English philosopher William of Ockham (Occam) stated: Pluralitas non est ponenda sine necessitate, or “Plurality must not be posited without necessity” (1). In medicine, the application of “Occam's razor,” the concept of parsimony in diagnosis, has become firmly entrenched as a fundamental principle. For persons older than 65 years of age, however—especially those who experience dizziness—Occam's razor is often too sharp and cuts too narrowly to be the instrument of choice (2). Senescence, the age-related changes that result in increased vulnerability to impairment and disease and in decreased survival (3), results in at least one chronic illness in most of the Medicare population. The serial accumulation of additional ailments, and of medications for their treatment, is nearly universal with advancing age. The concept of “geriatric syndromes” (4) reflects the recognition of multifactorial disorders that plague the elderly in particular, as the functions of organs and the defenses against disease decline and impairments accumulate.
Dizziness is often distressing to patients and frustrating to physicians because patients have trouble articulating their symptoms precisely and physicians have difficulty identifying and treating a specific disease responsible for the symptom (5, 6). This difficulty stems in large part from the frequently indirect relation between dizziness and any uniquely related disease process. Semantic issues aside, patients generally experience dizziness when the psychophysical mechanisms necessary for normal spatial orientation (7) fail: that is, when they are uncertain of their position or motion in space (8). The term dizziness covers a multitude of evils that may impair or distort orienting sensations; degrade the integration of those sensations into a coherent picture; modify the performance of related motor acts; or …
