Benign paroxysmal positional vertigo among elderly patients in primary health care

Prevalence of benign paroxysmal positional vertigo in a population-based setting among 75-year-olds

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is one of the most frequently diagnosed cause of dizziness among older adults.

OBJECTIVE

To investigate the prevalence of BPPV and positional symptoms of dizziness and nystagmus among 75-year-olds and to identify factors associated with BPPV and positional dizziness and nystagmus.

METHODS

In this cross-sectional population-based study of 75-78-year-olds in Gothenburg, 887 participants were examined with questions regarding dizziness and health and social factors. A total of 681 participants underwent the Dix-Hallpike test or the side-lying test for BPPV using Video Frenzel goggles.

RESULTS

In total 32% reported problems with dizziness (n = 887). The prevalence of BPPV was 4% in the unweighted and 4.5% in the weighted analyses, compensating for selective attrition of women and participants with previous positional dizziness. Positional dizziness without nystagmus was found in 2% and nystagmus without dizziness was found in 9%. Individuals with BPPV and positional dizziness experienced more dizziness in everyday life compared with those with normal tests, while those with positional nystagmus did not.

CONCLUSIONS

The estimated prevalence of BPPV among 75-year-olds was 4.5%. Despite weighted analyses, the true prevalence may be higher since many participants with dizziness refused testing. Dizziness was associated with fear and discomfort so strong that around 20% of the participants declined testing.

Prevalence and Related Factors of Dizziness Among Older Adults: A Cross-Sectional Study in Ardakan City, Iran

BACKGROUND

Dizziness and balance disorders are directly related to aging in humans- Dizziness is one of the most important factors causing the burden of disability after the age of 65. Bearing in mind the increase in the elderly population in Iran and the world and the prevalence of dizziness in old age, early diagnosis of dizziness and determination of the factors affecting its severity facilitate its treatment and are effective in preventing its adverse consequences.

OBJECTIVE

To determine the prevalence of dizziness and its related factors among older adults in Ardakan city, Yazd province, Iran, in 2022.

METHODS

This cross-sectional study was conducted in four comprehensive health centers of Ardakan city with the participation of 260 elderly people aged ≥60 years, who were randomly included in the study. Data were collected using a series of questionnaires which were completed by interviewing the participants. The variables of this study included demographic information, information related to the dizziness status, diseases, medications, use of mobility aids, physical activity level, fear of falling, quality of life and depression.

RESULTS

The prevalence of dizziness among older adults of Ardakan city was 48.5%. In terms of the severity of dizziness, 38.8% had substantial dizziness, and 9.6% had mild dizziness. Dizziness was significantly related to physical activity (p<0.05), fear of falling (p <0.01), depression (p <0.05), history of falling (p <0.01), use of mobility aids (p <0.01), age (p<0.01), education level (p<0.01), gender (p <0.05) and diseases such as high blood pressure (p<0.05), hypothyroidism (p <0.01) and ear diseases(p <0.01). Also, elderly people with dizziness used significantly more medications such as sedatives (p<0.01), antihypertensive drugs (p <0.05) and cytotoxic drugs (p <0.01).

CONCLUSION

About half of the older adults experience dizziness, and this problem is associated with depression, fear of falling, history of falling, low physical activity, age, female gender, ear diseases, high blood pressure, and hypothyroidism. In addition, the use of medications such as anti- hypertensives, sedatives and cytotoxic drugs is related to dizziness. Families with elderly people, doctors and healthcare workers need to be educated and pay more attention to the above.

Associations between cognition, anxiety, depression, and residual dizziness in elderly people with BPPV

Objective

To investigate the associations between cognition, anxiety, depression, and residual dizziness after successful repositioning maneuvers in the elderly with benign paroxysmal positional vertigo (BPPV).

Methods

We enrolled 40 elderly patients with BPPV in our outpatient department. We used the Dizziness Handicap Inventory (DHI), Visual Analog Scale (VAS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder Questionnaire-7 (GAD-7) to assess the degree of dizziness, anxiety, and depression of participants before repositioning therapy, respectively. At the 1-week follow-up after BPPV treatment, each participant will be reassessed and divided into a group with residual dizziness (RD) and a group without residual dizziness (NRD) based on the follow-up DHI score. The Mini-Mental State Examination (MMSE) evaluated the cognitive function of the participants.

Results

The age, gender, duration of BPPV, and involved semicircular canals in the two groups did not show a significant difference. The RD group scored significantly higher on the DHI (p = 0.006), GAD-7 (p < 0.001), and PHQ-9 (p = 0.002) before the repositioning treatment than the NRD group. The two groups had no significant difference in MMSE score (p = 0.381). Anxiety and depression scores before repositioning treatment significantly and positively correlated with follow-up DHI scores (r = 0.678 and 0.522, respectively), but the MMSE score did not significantly relate to it. The univariate linear regression showed that the DHI (p < 0.001), GAD-7 (p < 0.001), and PHQ-9 (p = 0.002) scores before treatment could predict residual dizziness. The multivariate linear regression showed that GAD-7 before treatment was the only significant predictor of residual dizziness (p < 0.001).

Conclusion

The level of dizziness, anxiety, and depression before treatment can predict residual dizziness after successful repositioning maneuvers in the elderly with BPPV. Anxiety may be the strongest predictor of residual dizziness after successful repositioning treatment in elderly BPPV patients.

Feasibility of an inertial measurement unit sensor-based guiding system for benign paroxysmal positional vertigo treatment: A pilot study

Performing an accurate canalith repositioning procedure (CRP) is important for treating benign paroxysmal positional vertigo, because inadequate rotational head angles can result in ineffective otolith mobilization and consequent treatment failure. Specialists-guided Epley maneuver reportedly had mean errors of 13.7°-24.4° while they were significantly larger (40.0°-51.5°) when self-administered. Similar results were obtained for the Barbeque maneuver: mean errors were 9.2°-13.0° by the specialists while they were significantly larger (22.9°-28.6°) when self-administered. Our study aimed to validate the feasibility of an inertial measurement unit sensor-based CRP (IMU-CRP) by analyzing the differences in accuracy in the rotational angles, comparing them with education-based conventional CRP (EDU-CRP). A pilot validation was also performed by analyzing the treatment success rate of IMU-CRP in patients with BPPV. This single-institution prospective, comparative effectiveness study examined 19 participants without active vertigo or prior knowledge of benign paroxysmal positional vertigo and CRP. Participants conducted the Epley and Barbeque roll maneuvers without and with auditory guidance (EDU-CRP vs. IMU-CRP, respectively) twice, and head rotation accuracies were compared. Differences in target angles based on the American Academy of Otolaryngology-Head and Neck Surgery guidelines were considered errors. For BPPV participants, treatment success was assessed based on the presence or absence of nystagmus, vertigo, and dizziness. For all the Epley and Barbeque roll maneuvers steps, the absolute errors were smaller for IMU- than for EDU-CRPs, with significant differences in steps 2-4 and 3-6 of the Epley and Barbeque roll maneuvers, respectively. A learning effect was found in steps 4 and 5 of the Barbeque roll maneuver but not in the Epley maneuver. The treatment success rates after 1 h were 71.4% and 100% for the Epley and Barbeque roll maneuvers, respectively. Real-time feedback on head rotation angles induced more appropriate movements in the Epley and Barbeque roll maneuvers. A guiding device based on head monitoring providing real-time auditory feedback may increase the self-administered CRP success rates in treating benign paroxysmal positional vertigo.

Differential screen and treatment of vestibular dysfunction in an elderly patient: A case report

BACKGROUND/PURPOSE

Concussion sequelae in the elderly is under recognized and negatively impacts quality of life. Labyrinthine concussion (LC) is an uncommon diagnosis, as is multiple canal (MC) benign paroxysmal positional vertigo (BPPV). This case report highlights physical therapist (PT) evaluation and treatment of an elderly male misdiagnosed with LC and successfully treated for MC BPPV.

CASE DESCRIPTION

A 72 year old male presented to his PT 23 days after falling off a ladder, resulting in a mild traumatic brain injury (mTBI). Diagnosed with LC, he was referred to PT due to ongoing symptoms of "falling backwards," poor gait, and diminished mobility. PT examination revealed an atypical BPPV. Thus, the patient was treated in two PT visits, which included canalith repositioning techniques and neuromuscular reeducation.

OUTCOMES

The PT diagnosis was MC BPPV, including the right lateral and left posterior semicircular canals. Initial positive findings of Head Impulse Test, Bow and Lean Test, Dix-Hallpike, and Roll Test were negative on the last visit. Patient-Specific Functional Scale improved from 0 to 9.9 (10 being no limitations). The patient progressed from minimum assistance to independence in bed mobility, transfers, gait, and previous activities.

DISCUSSION

The patient's presentation was atypical in signs and symptoms with a diagnosis of LC. PT examination and intervention successfully resolved the patient's signs and symptoms within two visits. Further research is needed regarding identification and treatment of elderly individuals with head injuries, such as MC BPPV, as well as the efficacy of a PT seeing patients shortly after mTBI.

Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians

Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV.

METHODS

Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined.

RESULTS

Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007).

CONCLUSIONS

Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Asking about dizziness when turning in bed predicts examination findings for benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the single most common cause of vestibular vertigo and is characterised by short episodes of rotational vertigo precipitated by changes in head positions like lying down or turning in bed.

OBJECTIVE

This study aims to assess useful questions when suspecting benign paroxysmal positional vertigo (BPPV) caused dizziness as well as identifying if a single question can be useful in identify or distinguish patients with BPPV from other dizziness aetiology.

METHOD

A total of 149 patients admitted due to dizziness were included. Patients answered a questionnaire and were investigated for BPPV with diagnostic manoeuvres.

RESULT

Two of the 15 questions were of diagnostic importance. Dizziness when laying down or turning in bed, increased likelihood of BPPV by an odds ratio (95% confidence interval) of 60 (7.47-481.70). Continuous dizziness duration as opposed to lasting seconds decreased likelihood of BPPV with an odds ratio of 0.06 (0.01-0.27).

CONCLUSION

Vertiginous attacks by turning or laying down in bed together with dizziness <1 minute, are important questions and strongly related to BPPV. Such questions are important when taking a medical history and may help to early identify BPPV, also for non-medical staff, as well as reduce the need of further investigations.

Investigation of self-reported dizziness in the elderly when lying down or turning over in bed, and possible benign paroxysmal positional vertigo

OBJECTIVES

This study aimed to investigate the rate of dizziness and occurrence of benign paroxysmal positional vertigo in the elderly by physical examination in those reporting dizziness symptoms when lying down or turning over in bed.

METHODS

A total of 498 people, aged 70-85 years, were asked to complete a questionnaire regarding dizziness symptoms. Subjects answering that they became dizzy in bed were asked to participate in a physical examination and diagnostic manoeuvres investigating benign paroxysmal positional vertigo.

RESULTS

A total of 324 participants (65 per cent) completed the questionnaire. More than one-quarter (29 per cent) reported dizziness and 32 (10 per cent) reported dizziness when turning in bed. Of these 32 persons, 22 (69 per cent) underwent a physical examination. Six participants tested positive for benign paroxysmal positional vertigo.

CONCLUSION

Ten per cent of the elderly participants reported positional symptoms, and 6 out of 22 fulfilled diagnostic criteria for benign paroxysmal positional vertigo. Furthermore, benign paroxysmal positional vertigo was established despite a delay between questionnaire completion and investigation, emphasising that this type of dizziness may not be a self-limiting disorder.

Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review

BACKGROUND

Dizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care.

METHODS

We systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms 'dizziness' or 'vertigo' as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates.

RESULTS

We identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière's disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life.

CONCLUSION

There is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Reliability of an anamnestic questionnaire for the diagnosis of benign paroxysmal positional vertigo in the elderly

BACKGROUND

There is common agreement in the literature that it can result in an underestimation of benign paroxysmal positional vertigo (BPPV) in the elderly.

AIMS

The aim of this work was to analyze the role of anamnesis in the diagnosis of BPPV in patients of different ages through the development and validation of a scored questionnaire.

METHODS

The questionnaire is based on the presence/absence of six typical anamnestic features of BPPV. The Mini-Mental State Exam (MMS) was also administered to patients over 65 years of age. Bedsides, examination for BPPV was then carried out, assigning the outcome of the questionnaire and eventual MMS to the final diagnosis for each patient.

RESULTS

The sensitivity and specificity of the questionnaire for high scores (>8) were found to be, respectively, 86 % and 80 % in all patients, 94 and 71 % in those under 65 years of age, 78 and 90 % in patients over 65, and, in particular, 63 and 83 % in those with MMS >24 and 100 and 100 % in those with MMS ≤24.

DISCUSSION

The reliability and average score of the questionnaire were statistically significantly lower in the group of elderly patients without cognitive deficits. The lower reliability of the questionnaire in the geriatric population, rather than the presence of cognitive deterioration, seems to correlate with other comorbidities or simply to a lower mobility of the head triggering positional symptoms.

CONCLUSION

The use of the questionnaire could however reduce the risk of a missed diagnosis of BPPV given its good reliability across all ages.

Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review

Vertigo and dizziness are frequent complaints in primary care that lead to extensive health care utilization. The objective of this systematic review was to examine health care of patients with vertigo and dizziness in primary care settings. Specifically, we wanted to characterize health care utilization, therapeutic and referral behaviour and to examine the outcomes associated with this. A search of the MEDLINE and EMBASE databases was carried out in May 2015 using the search terms ‘vertigo’ or ‘dizziness’ or ‘vestibular and primary care’ to identify suitable studies. We included all studies that were published in the last 10 years in English with the primary diagnoses of vertigo, dizziness and/or vestibular disease. We excluded drug evaluation studies and reports of adverse drug reactions. Data were extracted and appraised by two independent reviewers; 16 studies with a total of 2828 patients were included. Mean age of patients ranged from 45 to 79 with five studies in older adults aged 65 or older. There were considerable variations in diagnostic criteria, referral and therapy while the included studies failed to show significant improvement of patient-reported outcomes. Studies are needed to investigate current practice of care across countries and health systems in a systematic way and to test primary care-based education and training interventions that improve outcomes.

A Geriatric Perspective on Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults. Beyond the unpleasant sensation of vertigo, BPPV also negatively affects older adults' gait and balance and increases their risk of falling. As such it has a profound effect on function, independence, and quality of life. Otoconia are the inner ear structures that help detect horizontal and vertical movements. Aging contributes to the fragmentation of otoconia, whose displacement into the semicircular, most commonly posterior canals, can produce rotatory movement sensations with head movement. BPPV is more commonly idiopathic in older adults than in younger individuals, can present atypically, and has a more-protracted course and higher risk of recurrence. Medications such as meclizine that are commonly prescribed for BPPV can be associated with significant side effects. Dix-Hallpike and Head Roll tests can generally identify the involved canal. Symptoms resolve as otoconia fragments dissolve into the endolymph, but appropriate canalith repositioning (e.g., Epley maneuver) can expedite recovery and reduce the burden of this disorder. Observations suggesting an association between idiopathic BPPV and vitamin D deficiency and osteoporosis indicate that BPPV may share risk factors with other common geriatric conditions, which highlights the importance of moving beyond purely otological considerations and addressing the needs of older adults with vertigo through a systems-based multidisciplinary approach.

The epidemiology of dizziness and vertigo

This chapter gives an overview of the epidemiology of dizziness, vertigo, and imbalance, and of specific vestibular disorders. In the last decade, population-based epidemiologic studies have complemented previous publications from specialized settings and provided evidence for the high burden of dizziness and vertigo in the community. Dizziness (including vertigo) affects about 15% to over 20% of adults yearly in large population-based studies. Vestibular vertigo accounts for about a quarter of dizziness complaints and has a 12-month prevalence of 5% and an annual incidence of 1.4%. Its prevalence rises with age and is about two to three times higher in women than in men. Imbalance has been increasingly studied as a highly prevalent complaint particularly affecting healthy aging. Studies have documented the high prevalence of benign paroxysmal positional vertigo (BPPV) and vestibular migraine (VM), as well as of comorbid anxiety at the population level. BPPV and VM are largely underdiagnosed, while Menière's disease, which is about 10 times less frequent than BPPV, appears to be overdiagnosed. Risk factor research is only at its beginning, but has provided some interesting observations, such as the consistent association of vertigo and migraine, which has greatly contributed to the recognition of VM as a distinct vestibular syndrome.

Understanding patient experiences of self-managing chronic dizziness: a qualitative study of booklet-based vestibular rehabilitation, with or without remote support

OBJECTIVE

This study explores participants' experience of self-management of dizziness using booklet-based vestibular rehabilitation (VR), with or without expert telephone support.

DESIGN

Semistructured qualitative interviews were conducted.

SETTING

Participants were recruited from primary care practices as part of a large RCT.

PARTICIPANTS

Interviews were carried out with 33 people (10 men and 23 women; age 27-84) self-managing chronic dizziness using booklet-based vestibular rehabilitation, with or without expert telephone support.

RESULTS

Data were analysed using inductive thematic analysis. The majority of participants in both groups reported a positive experience of VR therapy, with many participants reporting an improvement in their dizziness symptoms since undertaking the therapy. Participants in the telephone support group felt that a genuine relationship developed between them and their therapist within three short sessions, and described their therapy sessions as reassuring, encouraging and motivational.

CONCLUSIONS

The VR treatment booklet appears to be a valued tool for self-managing chronic dizziness and people appreciate receiving remote telephone support.

TRIAL REGISTRATION NUMBER

NCT00732797.

Fighting for control in an unpredictable life - a qualitative study of older persons' experiences of living with chronic dizziness

Background

Dizziness in older people is associated with disability and reduced quality of life. Few studies have investigated how daily life is affected from the older person’s perspective. Identifying barriers and resources in daily life could guide health care in how to direct efficient interventions. The aim of this study was to explore older persons’ experiences of living with chronic dizziness.

Methods

In this qualitative study seven women aged 74–84 years and six men aged 73–87 years with chronic dizziness (≥3 months) recruited from a primary health care centre in 2012 participated in semi-structured interviews. The interviews were analysed by content analysis.

Results

Interpretation of the interviews resulted in the overall theme “Fighting for control in an unpredictable life” with two themes. The first theme “Striving towards normality” revealed a struggle in daily life in searching for a cure or improvement and finding a way to maintain ordinary life. This process could result in feelings of resignation or adaption to daily life, and factors that supported living with chronic dizziness were described. The second theme “Having a precarious existence” revealed that daily life included being exposed to threats such as a fear of recurrent attacks or of falling, which resulted in an insecure and inflexible way of life. A feeling that symptoms were not taken seriously was described.

Conclusions

The present study showed that older persons with chronic dizziness have needs that are not met by health care. Despite the fact that frequent contact with health care was described, the respondents described barriers in daily life that led to a restricted, inflexible and insecure daily life. Health care should therefore be individually tailored with focus on aspects of daily life, especially safety aspects. Support should also be continued until the older persons with chronic dizziness have developed coping strategies to gain control of their daily life.

Internet-based vestibular rehabilitation for adults aged 50 years and over: a protocol for a randomised controlled trial

INTRODUCTION

Dizziness is highly prevalent in older adults and can lead to falls, fear of falling, loss of confidence, anxiety and depression. Vestibular rehabilitation (VR) exercises are effective in reducing dizziness due to vestibular dysfunction, but access to trained therapists is limited. Providing dizzy patients with booklets teaching them how to carry out VR exercises has been shown to be a cost-effective way of managing dizziness in primary care. Internet-based intervention delivery has many advantages over paper-based methods, including the provision of video instructions, automated tailoring and symptom-related feedback. This trial will examine whether an internet-based VR intervention is (1) effective in reducing dizziness and (2) a cost-effective primary care treatment option.

METHODS/ANALYSIS

This will be a single blind, randomised controlled trial carried out in UK primary care. A stand-alone internet-based VR intervention will be compared with routine care in 262 dizzy patients aged 50 years and over. Measures will be taken at baseline, 3 and 6 months. Our primary outcome measure will be the effectiveness of the intervention in reducing dizziness symptoms compared with routine care at 6 months. Cost-effectiveness will be examined along with the effect of the intervention on dizziness-related disability and symptoms of depression and anxiety. Psychological process variables including expectancy, self-efficacy and acceptance will be explored in relation to adherence and symptom reduction.

ETHICS/DISSEMINATION

This trial has undergone ethical scrutiny and been approved by an NHS Research Ethics Committee, Southampton A REC Reference: 13/SC/0119. The findings of this trial will be disseminated to the scientific community through presentations at national and international conferences, and by publishing in peer review journals. Findings will be disseminated to the public through targeted press releases. This trial will provide valuable information on the role of internet interventions in facilitating self-management in older adults.

TRIAL REGISTRATION NUMBER ISRCTN

86912968.

Benign Paroxysmal Positional Vertigo: An Integrated Perspective

Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, occurs in all age groups. It presents with vertigo on head movement, but in older patients presentation may be typical and thus accounting for a low recognition rate in the primary care setting. It may be recurrent in up to 50% of cases. BPPV is associated with displacement of fragments of utricular otoconia into the semicircular canals, most commonly the posterior semicircular canal. Otoconia are composed of otoconin and otolin forming the organic matrix on which calcium carbonate mineralizes. Otoconia may fragment with trauma, age, or changes in the physiology of endolymph (e.g., pH and calcium concentration). Presentation varied because otoconia fragments can be displaced into any of the semicircular canals on either (or both) side and may be free floating (canalolithiasis) or attached to the cupula (cupulolithiasis). Most cases of BPPV are idiopathic, but head trauma, otologic disorders, and systemic disease appear to be contributory in a subset. Positional maneuvers are used to diagnose and treat the majority of cases. In rare intractable cases surgical management may be considered. A strong association with osteoporosis suggests that idiopathic BPPV may have diagnostic and management implications beyond that of a purely otologic condition.

Vestibular asymmetry predicts falls among elderly patients with multi-sensory dizziness

Background

Dizziness is the most common symptom in elderly patients and has been identified as a risk factor for falls. While BPPV is the most common cause of dizziness among elderly, multisensory deficits is the second, with visual, vestibular and proprioceptive reduced function. Asymmetric vestibular function is overrepresented in elderly persons with hip fractures and wrist fractures and can be accessed for screening.

The objective was to study if vestibular asymmetry, vibration sense, balances performance, postural sway in quiet stance and self-perceived handicap because of dizziness could predict falls among elderly, dizzy patients.

Methods

In this prospective study with one year observation period, 55 patients (41 women, 14 men), 65 to 90 years old (median 80, interquartile range 11) with multisensory dizziness were included.

Vestibular function was screened with the headshake test and vibration sense was assessed using a tuning fork. Balance was assessed with four clinical measures and self-perceived dizziness handicap was assessed by the Dizziness Handicap Inventory. Postural sway was measured using a force plate.

Results

Headshake test were pathologic in 24 patients, which substantially increased the risk of falls (OR 3.4). Thirteen of the 21 patients who had fallen (p = 0.03), and all 6 patients who sustained three falls or more (p = 0.04), had vestibular asymmetry. No other measure could predict the risk of falls (OR 0.55–1.71).

Conclusion

Signs of vestibular asymmetry among elderly with multisensory dizziness could predict falls. Hence, it seems important to address fall-prevention programs to such a group of patients. Simple bedside tests of vestibular asymmetry might be a possibility to screen for one risk factor for falls among elderly.

Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds

BACKGROUND AND AIMS

Studies have shown that 65% of people with dizziness may have a vestibular etiologic diagnosis, possibly benign paroxysmal positional vertigo (BPPV). The diagnosis of BPPV is based on medical history and findings after the Dix-Hallpike test. It is sometimes difficult to perform the Dix-Hallpike test in elderly persons, due to the limited range of motion when extending the neck. In this study, we used a side-lying test to stimulate the posterior semicircular canal, while the head and neck were fully supported on the examination table. The aims of this study were to investigate the prevalence of dizziness and/or impaired balance and BPPV in a population of 75-year-olds by means of a questionnaire and clinical tests, and to compare elderly persons with and without BPPV.

METHODS

A representative population sample of 675 persons completed a questionnaire about dizziness and 571 persons underwent side-lying, static balance and dynamic walking tests.

RESULTS

Subjective dizziness and/or impaired balance were found in 36% of subjects, especially when walking outdoors. A significant gender difference was found, with a higher prevalence in women (40%) compared with men (30%) (p<0.01). BPPV was found in 11% and was significantly more common in women (p<0.01). Elderly individuals with BPPV also displayed significantly impaired balance in static and dynamic balance tests compared with persons without BPPV (p<0.01). Persons with BPPV reported significantly more sub- jective problems with dizziness and balance compared with persons without BPPV (p<0.001).

CONCLUSIONS

Subjective and objective unsteadiness, dizziness and BP- PV are common in the elderly.

Vestibular rehabilitation of older adults with dizziness

The role of rehabilitation for treatment of older adults with dizziness and balance disorders is reviewed. Theories related to functional recovery from peripheral and central vestibular disorders are presented. Suggestions on which older adults might benefit from vestibular rehabilitation therapy are presented. Promising innovative rehabilitation strategies and technologies that might enhance recovery of the older adult with balance dysfunction are discussed.

A three-group comparison of acute-onset dizzy, long-term dizzy and non-dizzy older patients in primary care

BACKGROUND AND AIMS

The hypothesis of increased cardiovascular risk contributing to chronic dizziness has been discussed controversially so far. We investigated older patients suffering from acute (<6 months), chronic (≥ 6 months) or no dizziness, in terms of their cardiovascular risk and other impairments.

METHODS

A cross-sectional three-group comparison of 257 patients (65+) presenting at family medicine surgeries in Germany was performed. Measures of cardiovascular risk, including overall scores, scores of quality of life (SF-12), activities of daily living (ADL), depression (GDS), dizziness handicap (DHI) and patients' needs (DiNA), as well as comorbidity and medication, were compared in univariate and multivariate logistic regression analysis.

RESULTS

In univariate analysis, systolic and diastolic blood pressure were significantly lower in the dizziness groups. The overall cardiovascular risk was not increased in dizzy patients. Anxiety was strongly associated with dizziness, whereas other associations were of marginal importance. In multivariate analysis, age (OR 1.10, 95% CI 1.03-1.17), female gender (OR 2.07, 95% CI 1.01-4.26) and anxiety (OR 2.50, 95% CI 1.03-6.05) were associated with acute dizziness, whereas only female gender was significant in chronic dizziness (OR 1.96, 95% CI 1.02- 3.75). Comparing all dizzy patients with the non-dizzy group, lower systolic blood pressure was also significantly associated with dizziness.

CONCLUSIONS

Results from our sample suggest that low systolic blood pressure is more important for dizziness in older patients than increased cardiovascular risk. Acute-onset and long-term dizzy patients were comparable in many aspects, which makes this classification less clinically important.

Newly diagnosed incident dizziness of older patients: a follow-up study in primary care

Background

Dizziness is a common complaint of older patients in primary care, yet not much is known about the course of incident dizziness. The aim of the study was to follow-up symptoms, subjective impairments and needs of older patients (≥65) with incident dizziness and to determine predictors of chronic dizziness. Furthermore, we analysed general practitioners' (GPs') initial diagnoses, referrals and revised diagnoses after six months.

Methods

An observational study was performed in 21 primary care practices in Germany, including a four-week and six-month follow-up. A questionnaire comprising characteristic matters of dizziness and a series of validated instruments was completed by 66 participants during enrolment and follow-up (after 1 month and 6 months). After six months, chart reviews and face-to-face interviews were also performed with the GPs.

Results

Mean scores of dizziness handicap, depression and quality of life were not or only slightly affected, and did not deteriorate during follow-up; however, 24 patients (34.8%) showed a moderate or severe dizziness handicap, and 43 (62.3%) showed a certain disability in terms of quality of life at the time of enrolment. In multivariate analysis, n = 44 patients suffering from chronic dizziness (dependent variable, i.e. relapsing or persistent at six months) initially had a greater dizziness handicap (OR 1.42, 95%CI 1.05-1.47) than patients with transient dizziness. GPs referred 47.8% of the patients to specialists who detected two additional cases of benign paroxysmal positional vertigo (BPPV).

Conclusions

New-onset dizziness relapsed or persisted in a considerable number of patients within six months. This was difficult to predict due to the patients' heterogeneous complaints and characteristics. Symptom persistence does not seem to be associated with deterioration of the psychological status in older primary care patients. Management strategies should routinely consider BPPV as differential diagnosis.

Falls and dizziness in the elderly

The complaint of dizziness is one of the most common reasons that older adults feel constrained to visit the doctor's office. Because of a growing number of older people in the industrial society the problem grows. Therapeutic process of elderly people with vertigo and dizziness needs more than vestibular diagnostics. In addition to sufficient anamnesis, presence of visual deficits, extrasensory changes and even psychological circumstances are necessary. Frequently the indication and the encouragement of vestibular rehabilitation have significant value. The initiation of fall prevention may also be essential.

Avaliação da manobra de reposicionamento de Epley em indivíduos com vertigem posicional paroxística benigna

OBJETIVO: avaliar os parâmetros estabilométricos após a manobra de reposicionamento de Epley em indivíduos com Vertigem Posicional Paroxística Benigna (VPPB) previamente confirmada através da manobra de Dix-Hallpike. MÉTODOS: estudo experimental que incluiu pacientes que apresentaram VPPB com nistagmo de posicionamento à prova de Dix-Hallpike, avaliados no ano de 2008, no Ambulatório Multidisciplinar de Vertigem, e que foram submetidos à manobra de reposicionamento de Epley e avaliados quanto ao equilíbrio postural pelo exame de Estabilometria, antes e após a citada manobra. RESULTADOS: os 13 indivíduos do gênero feminino com idade variando de 15 a 78 anos com VPPB, previamente confirmados e selecionados para a pesquisa, apresentaram melhora estatisticamente significante em parâmetros estabilométricos verificados da primeira para a segunda avaliação, confirmando melhora do equilíbrio postural, após a manobra de Epley. CONCLUSÃO: nesta pesquisa a manobra de reposicionamento de Epley mostrou-se como um procedimento de intervenção importante para a melhora das respostas do equilíbrio postural em indivíduos com VPPB avaliados pela estabilometria.

An evaluation of the cost-effectiveness of booklet-based self-management of dizziness in primary care, with and without expert telephone support

Background

Dizziness is a very common symptom that often leads to reduced quality of life, anxiety and emotional distress, loss of fitness, lack of confidence in balance, unsteadiness and an increased risk of falling. Most dizzy patients are managed in primary care by reassurance and medication to suppress symptoms. Trials have shown that chronic dizziness can be treated effectively in primary care using a self-help booklet to teach patients vestibular rehabilitation exercises that promote neurological adaptation and skill and confidence in balance. However, brief support from a trained nurse was provided in these trials, and this model of managing dizzy patients has not been taken up due to a lack of skills and resources in primary care. The aim of this trial is to evaluate two new alternative models of delivery that may be more feasible and cost-effective.

Methods/Design

In a single blind two-centre pragmatic controlled trial, we will randomise 330 patients from 30 practices to a) self-help booklet with telephone support from a vestibular therapist, b) self-help booklet alone, c) routine medical care. Symptoms, disability, handicap and quality of life will be assessed by validated questionnaires administered by post at baseline, immediately post-treatment (3 months), and at one year follow-up. The study is powered to test our primary hypothesis, that the self-help booklet with telephone support will be more effective than routine care. We will also explore the effectiveness of the booklet without any support, and calculate the costs of treatment in each arm.

Discussion

If our trial indicates that patients can cost-effectively manage their dizziness in primary care, then it can be easily rolled out to relieve the symptoms of the many patients in primary care who currently have chronic, untreated, disabling dizziness. Treatment in primary care may reduce the development of psychological and physical sequelae that cause handicap and require treatment. There is also the potential to reduce the cost to the NHS of treating dizziness by reducing demand for referral to secondary care for specialist assessment and treatment.

Trial Registration

ClinicalTrials.gov trial registration ID number: NCT00732797

[Presbyvertigo as a cause of dizziness in elderly]

BACKGROUND

dizziness is a frequent complaint in the geriatric population and has a negative impact in the life quality of these individuals.

AIM

to correlate the types of dizziness and alterations in the caloric test and to verify the frequency of presbyvertigo in an elderly population with dizziness.

METHOD

The records of 132 patients aged over 60 and with balance disturbance were reviewed. These patients were evaluated in the Otoneurology Service of the Clinical Hospital of the Federal University of Minas Gerais between the years of 1998 and 2007. The variables considered for analysis were: epidemiologic data, clinical history, associated diseases and the result of the caloric test. Patients with positional and central vertigo were excluded from the analysis.

RESULTS

The research sample consisted of 120 patients, with an average age was of 70 years, being 71% (n=87) of sample women. Vertigo with the duration of a few minutes and of a daily frequency was the most frequent type of dizziness. In relation to the caloric test, normal results were observed in 73% of the sample. Altered results included unilateral weakness (14%), bilateral weakness (10%) and hyperactive caloric response (3%). Correlating the caloric test with the type of dizziness, bilateral weakness was associated with postural instability (p=0.006; IC=2 - 419).

CONCLUSION

dizziness in elderly has many causes. Bilateral weakness of the vestibular function can be related to presbyvertigo and must be considered in aged individuals who present unbalance. Metabolic, psychiatric, disautonomic, orthopedic, visual and proprioceptive disturbances may be the cause of dizziness in aged individuals who present normal vestibular evaluation.

[Vertigo and falls in the elderly: Part 2: Fall diagnostics, prophylaxis and therapy]

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample

OBJECTIVE

To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and determine whether ED patients with dizziness are diagnosed as having a range of benign and dangerous medical disorders, rather than predominantly vestibular ones.

PATIENTS AND METHODS

A cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) used a weighted sample of US ED visits (1993-2005) to measure patient and hospital demographics, ED diagnoses, and resource use in cases vs controls without dizziness. Dizziness in patients 16 years or older was defined as an NHAMCS reason-for-visit code of dizziness/vertigo (1225.0) or a final International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of dizziness/vertigo (780.4) or of a vestibular disorder (386.x).

RESULTS

A total of 9472 dizziness cases (3.3% of visits) were sampled over 13 years (weighted 33.6 million). Top diagnostic groups were otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), neurologic (11.2%, including 4% cerebrovascular), metabolic (11.0%), injury/poisoning (10.6%), psychiatric (7.2%), digestive (7.0%), genitourinary (5.1%), and infectious (2.9%). Nearly half of the cases (49.2%) were given a medical diagnosis, and 22.1% were given only a symptom diagnosis. Predefined dangerous disorders were diagnosed in 15%, especially among those older than 50 years (20.9% vs 9.3%; P<.001). Dizziness cases were evaluated longer (mean 4.0 vs 3.4 hours), imaged disproportionately (18.0% vs 6.9% undergoing computed tomography or magnetic resonance imaging), and admitted more often (18.8% vs 14.8%) (all P<.001).

CONCLUSION

Dizziness is not attributed to a vestibular disorder in most ED cases and often is associated with cardiovascular or other medical causes, including dangerous ones. Resource use is substantial, yet many patients remain undiagnosed.

Troubles de l'équilibre chez le sujet âgé

OBJECTIVES

The purpose of this study was to find cause of dizziness, vertigo and falls in old age and to propose treatment.

MATERIAL AND METHODS

The study was conducted from October 2003 to March 2004 with 100 patients over the age of 75 years: 72 women and 28 men. They complained of unsteadiness, vertigo, or falls.

RESULTS

In this group of patients, 68% were found to have benign paroxysmal positional vertigo, 9% neurologic problems, 5% Meniere disease, 4% vestibular areflexia, 8% a rare cause such as a psychiatric or vascular disorder, and no cause was found in 6%. The diagnosis of Benign Paroxysmal Positional Vertigo is difficult in the elderly because vertigo is often missing and unsteadiness or falls only feeled.

CONCLUSIONS

Our study showed that dizziness or unsteadiness in the elderly must be explored by a complete vestibular examination and treated to improve the well-being of these patients.