[Vertigo and falls in the elderly. Part 1: epidemiology, pathophysiology, vestibular diagnostics and risk of falling]

[Current aspects of vertigo and dizziness in advanced age]

Vertigo and dizziness in advanced age are common complaints in daily clinical practice. The otorhinolaryngologist holds a central position in the differential diagnostic clarification. Age-related disorders (e.g. benign positional vertigo, presbyvestibulopathy, otholith functional disorders) arise due to a physiological, individually distinct and objectively detectable reduction in the sensitivity of sensory and extrasensory elements of the vestibular system. They may reach pathological significance if these dysfunctions affect the physical and emotional well-being (e.g. gait disturbances and falls with subsequent morbidity). Disorders accompanying aging (e.g. neurological, cardiovascular or psychiatric) can occur simultaneously with age-related changes in sensory function. The identification, especially with respect to the risk of falling in older people and the development of individual therapeutic strategies is an interdisciplinary task. Besides a causative therapy, strength, coordination and balance training contribute to the treatment of equilibrium disorders and falls from the perspective of evidence-based medicine.

Current diagnostic procedures for diagnosing vertigo and dizziness

Vertigo is a multisensory syndrome that otolaryngologists are confronted with every day. With regard to the complex functions of the sense of orientation, vertigo is considered today as a disorder of the sense of direction, a disturbed spatial perception of the body. Beside the frequent classical syndromes for which vertigo is the leading symptom (e.g. positional vertigo, vestibular neuritis, Menière’s disease), vertigo may occur as main or accompanying symptom of a multitude of ENT-related diseases involving the inner ear. It also concerns for example acute and chronic viral or bacterial infections of the ear with serous or bacterial labyrinthitis, disorders due to injury (e.g. barotrauma, fracture of the oto-base, contusion of the labyrinth), chronic-inflammatory bone processes as well as inner ear affections in the perioperative course. In the last years, diagnostics of vertigo have experienced a paradigm shift due to new diagnostic possibilities. In the diagnostics of emergency cases, peripheral and central disorders of vertigo (acute vestibular syndrome) may be differentiated with simple algorithms. The introduction of modern vestibular test procedures (video head impulse test, vestibular evoked myogenic potentials) in the clinical practice led to new diagnostic options that for the first time allow a complex objective assessment of all components of the vestibular organ with relatively low effort. Combined with established methods, a frequency-specific assessment of the function of vestibular reflexes is possible. New classifications allow a clinically better differentiation of vertigo syndromes. Modern radiological procedures such as for example intratympanic gadolinium application for Menière’s disease with visualization of an endolymphatic hydrops also influence current medical standards. Recent methodical developments significantly contributed to the possibilities that nowadays vertigo can be better and more quickly clarified in particular in otolaryngology.

Vertigo in elderly patients: a review of 164 cases in Brazil

The author conducted a study to identify and categorize those vestibular disorders that were the most common among elderly patients at his private clinic over a 20-year period. He reviewed the records of 735 patients aged 65 to 90 years. The most common diagnosis was vertigo and/or disequilibrium, which occurred in 164 patients (22.3%). Of this group, 121 patients (73.8%) had a peripheral vestibular disorder and 43 (26.2%) had a central vestibular disorder. The characteristics of these cases are discussed.

Visual and proprioceptive contributions to postural control of upright stance in unilateral vestibulopathy

Preserving upright stance requires central integration of the sensory systems and appropriate motor output from the neuromuscular system to keep the centre of pressure (COP) within the base of support. Unilateral peripheral vestibular disorder (UPVD) causes diminished stance stability. The aim of this study was to determine the limits of stability and to examine the contribution of multiple sensory systems to upright standing in UPVD patients and healthy subjects. We hypothesized that closure of the eyes and Achilles tendon vibration during upright stance will augment the postural sway in UPVD patients more than in healthy subjects. Seventeen UPVD patients and 17 healthy subjects performed six tasks on a force plate: forwards and backwards leaning, to determine limits of stability, and upright standing with and without Achilles tendon vibration, each with eyes open and closed (with blackout glasses). The COP displacement of the patients was significantly greater in the vibration tasks than the controls and came closer to the posterior base of support boundary than the controls in all tasks. Achilles tendon vibration led to a distinctly more backward sway in both subject groups. Five of the patients could not complete the eyes closed with vibration task. Due to the greater reduction in stance stability when the proprioceptive, compared with the visual, sensory system was disturbed, we suggest that proprioception may be more important for maintaining upright stance than vision. UPVD patients, in particular, showed more difficulty in controlling postural stability in the posterior direction with visual and proprioceptive sensory disturbance.

[The eye, vision and vertigo]

Although ocular alterations alone rarely cause vertigo, the ophthalmologist can play an important role in the interdisciplinary context by testing visual function. Assessment of ocular motility is the most important individual examination in the diagnostic evaluation of vertigo. Methods that analyze specific visual functions, like the dynamic visual acuity test, may play an important role in the future. In addition to neuro-ophthalmologic disorders, ocular alterations are also receiving increasing attention. They are postulated to be a key element in the development of multifactorial age-related vertigo. However, further investigation is required to confirm this supposition and to define the influence of disturbances in specific visual qualities, e.g. visual acuity, visual field, binocular vision, anisometropia, multifocal correction, higher order aberrations and metamorphopsia.

[Falls and fall risk factors. Are they relevant in ENT outpatient medical care?]

BACKGROUND AND OBJECTIVE

The risk of falling increases with age. The problem of falls in medical care constantly rises in priority due to demographic changes in Germany. Therefore, the risk of falling should be assessed in all patients. The present study was intended to evaluate the frequency of falls in daily ENT outpatient medical care and the importance of risk factors.

PATIENTS/METHODS

A multicentre study was performed in six outpatient facilities based on a survey of falls and fall risk factors in patients living at home (n = 673) aged 60 years and older.

RESULTS

Falls are a frequent problem in the elderly. A total of 23% had one and 13.7% more than one fall within the previous year. Of these, 15% suffered injury, while only 13% used some form of fall prevention. Joint pain and problems of the hip and lower extremities (42.6%), abnormal gait (41.3%), dizziness and balance disorders (38%) as well as impaired activities of daily living (35%) are the most common risk factors for falls and multiple falls in all age groups. Impaired hearing is a fall risk factor in elderly patients.

CONCLUSIONS

Falls are a frequent problem in patients in ENT outpatient medical care. Fall prevention is advisable in the context of an interdisciplinary approach.

[Degeneration and osteoporosis of the spine. Is there a modified procedure?]

Reduced bone quality due to osteoporosis poses a fundamental problem in spine surgery instrumentation. The consequences observed most often are insufficient implant anchoring and adjacent fractures. In cases of manifest osteoporosis, several modern anchoring possibilities are at our disposal that, to differing degrees, increase the stability of the instrumentation. Cement augmentation of a fractured vertebra by means of kyphoplasty or vertebroplasty verifiably leads to significantly better pain reduction than conservative treatment does, at least in the short-term postoperative course. A difference between these two techniques has not yet been substantiated. The rate of adjacent fractures occurring after cement augmentation is not higher than in conservatively treated patients.