Development of a diagnostic protocol for dizziness in elderly patients in general practice: a Delphi procedure

Diagnostic tests recommended for the clinical assessment of patients with wrist complaints, an e-Delphi study

BACKGROUND

Evidence-based practice for history-taking and physical examination in the evaluation of wrist complaints is limited.

PURPOSE

To create a set of recommended diagnostic tests for the clinical assessment of patients with undifferentiated wrist complaints.

STUDY DESIGN

An e-Delphi study, following the recommendations on conducting and reporting Delphi studies, was performed.

METHODS

In this e-Delphi study, a national multidisciplinary panel of experts was invited to inventory diagnostic tests, based on several case scenarios, for the probability diagnosis in patients (age ≥18 years) with undifferentiated wrist complaints. Four case scenarios were constructed and presented to the expert panel members, which differed in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks) of the complaints. In consecutive rounds, the experts were asked to rate the importance of the inventoried diagnostic tests. Finally, experts were asked to rank recommended diagnostic tests for each case scenario.

RESULTS

Merging all results, the following diagnostic tests were recommended for all case scenarios: ask whether a trauma has occurred, ask how the complaints can be provoked, ask about the localization of the complaints, assess active ranges of motion, assess the presence of swelling, assess the difference in swelling between the left and right, assess the deformities or changes in position of the wrist, and palpate at the point of greatest pain.

CONCLUSIONS

This is the first scientific study where experts clinicians recommended diagnostic tests when assessing patients with undifferentiated wrist complaints, varying in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks).

Presbycusis and balance disorders in the elderly. Bibliographical review of ethiopathogenic aspects, consequences on quality of life and positive effects of its treatment

At this time, we still do not have adequate knowledge and awareness of the consequences of hearing loss in the elderly on quality of life. Similarly, there is also insufficient information on the relationship of presbycusis and balance disorders with other comorbidities. Such knowledge can contribute to improve both prevention and treatment of these pathologies, to reduce their impact on other areas such as cognition or autonomy, as well as to have more accurate information on the economic impact they generate in society and in the health system. Therefore, with this review article we aim to update the information on the type of hearing loss and balance disorders in people over 55 years of age, and their associated factors; to analyze the impact on the quality of life of these people and the one which can be generated at a personal and population level (both sociological and economic) if an early intervention in these patients is pursued.

Clinical Profiles of Elderly Patients Presenting with Persistent Dizziness

BACKGROUND

Dizziness among elderly patients is primarily treated in emergency and primary care centers. However, the causes and comorbidities responsible for dizziness in the elderly may differ in tertiary health care centers.

OBJECTIVE

To determine the subtypes of persistent dizziness and to evaluate the number of contributory causes of dizziness among elderly patients.

METHODS AND MATERIALS

This observational cross-sectional study comprised of 130 patients aged >60 years. A detailed history of existing comorbidities was obtained. A standardized comprehensive evaluation of all patients was done using an International Delphi procedure. Data from each patient was independently reviewed for major and contributory causes of dizziness. Chi square test was used to find the association between dizziness and various contributing factors.

RESULTS

Presyncope was the most frequent dizziness subtype (71.5%). Majority of patients showed one dizziness subtype (54.6%) and three contributory causes of dizziness (40.6%). An adverse effect of drug was the most common contributory cause for dizziness (20%). The most frequent underlying cause of dizziness was noted to be cardiovascular disease (40%), followed by peripheral vestibular disease (22.3%) and neurological disease (19%). Sixty six percent of the patients were identified with more than one contributing cause for dizziness.

CONCLUSION

Primary care physicians need to anticipate that many elderly dizzy patients can have more than one cause of dizziness. A systematic and planned approach can help the clinician to effectively treat dizziness in the elderly.

Prognosis and Survival of Older Patients With Dizziness in Primary Care: A 10-Year Prospective Cohort Study

PURPOSE

The prognosis of older patients with dizziness in primary care is unknown. Our objective was to determine the prognosis and survival of patients with different subtypes and causes of dizziness.

METHODS

In a primary care prospective cohort study, 417 older adults with dizziness (mean age 79 years) received a full diagnostic workup in 2006-2008. A panel of physicians classified the subtype and primary cause of dizziness. Main outcome measures were mortality and dizziness-related impairment assessed at 10-year follow-up.

RESULTS

At 10-year follow-up 169 patients (40.5%) had died. Presyncope was the most common dizziness subtype (69.1%), followed by vertigo (41.0%), disequilibrium (39.8%), and other dizziness (1.7%). The most common primary causes of dizziness were cardiovascular disease (56.8%) and peripheral vestibular disease (14.4%). Multivariable adjusted Cox models showed a lower mortality rate for patients with the subtype vertigo compared with other subtypes (hazard ratio [HR] = 0.62; 95% CI, 0.40-0.96), and for peripheral vestibular disease vs cardiovascular disease as primary cause of dizziness (HR = 0.46; 95% CI, 0.25-0.84). After 10 years, 47.7% of patients who filled out the follow-up measurement experienced substantial dizziness-related impairment. No significant difference in substantial impairment was seen between different subtypes and primary causes of dizziness.

CONCLUSIONS

The 10-year mortality rate was lower for the dizziness subtype vertigo compared with other subtypes. Patients with dizziness primarily caused by peripheral vestibular disease had a lower mortality rate than patients with cardiovascular disease. Substantial dizziness-related impairment in older patients with dizziness 10 years later is high, and indicates that current treatment strategies by family physicians may be suboptimal.

Identifying Key Risk Factors for Dizziness Handicap in Middle-Aged and Older People

OBJECTIVES

More than 10% of people aged 50 years and older report dizziness. Despite available treatments, dizziness remains unresolved for many people due in part to suboptimal assessment. We aimed to identify factors associated with dizziness handicap in middle-aged and older people to identify targets for intervention to address this debilitating problem. A secondary aim was to determine whether factors associated with dizziness differed between middle-aged (<70 years) and older people (≥ 70 years).

DESIGN

Secondary analysis of baseline and prospective data from a randomized controlled trial.

SETTING AND PARTICIPANTS

In total, 305 individuals aged 50 to 92 years reporting significant dizziness in the past year were recruited from the community.

METHODS

Participants were classified as having either mild or no dizziness handicap (score <31) or moderate/severe dizziness handicap (score: 31‒100) based on the Dizziness Handicap Inventory. Participants completed health questionnaires and underwent assessments of psychological well-being, lying and standing blood pressure, vestibular function, strength, vision, proprioception, processing speed, balance, stepping, and gait. Participants reported dizziness episodes in monthly diaries for 6 months following baseline assessment.

RESULTS

Dizziness Handicap Inventory scores ranged from 0 to 86 with 95 participants (31%) reporting moderate/severe dizziness handicap. Many vestibular, cardiovascular, psychological, balance-related, and medical/medications measures were significantly associated with dizziness handicap severity and dizziness episode frequency. Binary logistic regression identified a positive Dix Hallpike/head-roll test for benign paroxysmal positional vertigo [odds ratio (OR) 2.09, 95% confidence interval (CI) (1.11‒3.97)], cardiovascular medication use [OR 1.90, 95% CI (1.09‒3.32)], high postural sway when standing on the floor with eyes closed (sway path ≥160 mm) [OR 2.97, 95% CI (1.73‒5.10)], and anxiety (Generalized Anxiety Disorder Scale 7-item Scale score ≥8) [OR 3.08, 95% CI (1.36‒6.94)], as significant and independent predictors of moderate/severe dizziness handicap. Participants aged 70 years and over were significantly more likely to report cardiovascular conditions than those aged less than 70 years old.

CONCLUSIONS AND IMPLICATIONS

Assessments of cardiovascular conditions and cardiovascular medication use, benign paroxysmal positional vertigo, anxiety, and postural sway identify middle-aged and older people with significant dizziness handicap. A multifactorial assessment including these factors may assist in tailoring evidence-based therapies to alleviate dizziness handicap in this group.

Development of Military Concussion Readiness Inventory for Dizziness and Balance

Purpose

The objective of this study was to develop and establish content validity of a new instrument titled the Military Concussion Readiness Inventory for Dizziness and Balance (MCRI-DB). The MCRI-DB was intended to recognize functional impairments and predict readiness for return-to-duty in service members who experienced mild traumatic brain injury (mTBI).

Methods

Nineteen male service members were included in a nominal group technique (NGT) process to produce items for the MCRI-DB. Items were categorized according to the International Classification of Functioning, Disability and Health (ICF) and were sent to 13 physical therapy experts through a Delphi survey to determine content validity. The consensus to include an item was defined as an agreement of at least 70% of the participants.

Results

The NGT produced 222 items with 108 duplicates removed. The ICF categorization linked 84 of the items to 36 unique ICF Codes, 9 items were not linkable to the ICF due to the complex nature of the activity, and 21 items were removed. After three rounds of the Delphi survey, 68 items were included in this instrument.

Conclusion

In this study, we successfully combined the use of service members' experiences with expert opinion to determine content validity of the MCRI-DB. This instrument may be used for assessment of service members who have experienced mTBI to help identify environmental factors, functional activities, and body functions that may reduce the safe and efficient fulfillment of their duties and determine their ability to return-to-duty. Further research is needed to develop the psychometric properties of the instrument fully.

Role of Electronystagmography in Diagnosis of Secondary BPPV in Elderly Patients with Vertigo: A Retrospective Study

Elderly population is frequently affected by vertigo which affects their mobility and makes them vulnerable to fall and other morbidities. Often these patient visit neurologist and are often subjected to CT scan, MRI brain etc. to rule out a central cause of vertigo; whereas majority of these patients suffer from vestibular cause of vertigo. A schematic approach by detailed history, simple tests for vestibular functions like Dix Hallpike, supine roll and head impulse test give important clue to diagnosis. Often the diagnosis is benign paroxysmal positional vertigo (BPPV) which is treated by repositioning maneuver. There are often other vestibular causes which may be diagnosed by Electronystagmography (ENG), electrocochleography and other tests. This study was undertaken to study occurrence of secondary BPPV utilizing various parameters of ENG. The study group comprised of 131 patients from the neuro-otology proforma data base at ENT centre and vertigo clinic from January 2015 to December 2017. Inclusion criterion was male and female aged 51 years and above presenting with dizziness, imbalance, rotational vertigo, unsteadiness as the chief complaint. Exclusion criterion was BPPV relieved after Epley's maneuver, Otitis externa, acute Otitis media, Suppurative Otitis media, pre existing neurological condition and history of ear surgery. Neuro-otology Data obtained and the ENG findings were tabulated in the master chart and the observations interpreted and transferred to Claussen's butterfly chart. The study group comprised of 58 male (44.27%) and 73 female (55.73%) with a male female ratio of 1:1.25. ENG exhibited 36 patients (27.49) to have recurrent BPPV, 53 (40.45%) were found to have unilateral/bilateral canal paresis. Meniere's disease was diagnosed in 39 (29.77%) patients and brain stem pathology identified in 3 (2.29%) cases.

Development of post-disaster psychosocial evaluation and intervention for children: Results of a South Korean delphi panel survey

OBJECTIVE

This study aimed to administer a Delphi panel survey and provide evidence for the development of a psychological intervention protocol for use after disasters in South Korea.

METHOD

A three-round Delphi survey was conducted. In all rounds, respondents answered open- or closed-ended questions regarding their views on i) the concept of disaster, ii) evaluation, iii) intervention, and iv) considerations in a disaster. Data from Round 1 were subjected to content analysis. In Round 2, items with content validity ratios (CVRs) greater than 0.49 were included, and in Round 3, items with a CVR≥0.38 were accepted.

RESULTS

The response rates for the Delphi survey were high: 83% (n = 15, Round 1), 80% (n = 16, Round 2), and 86% (n = 24, Round 3). The data collected during this survey showed a need for a support system for children; for preventive strategies, including disaster readiness plans; for the protection of children's safety; and for the development of post-disaster psychosocial care.

CONCLUSIONS

The panel experts reached a consensus regarding the steps they considered critical in post-disaster evaluation and intervention. The findings suggest a unified model for advancing the development of the Korean version of an intervention protocol for children and adolescents exposed to traumatic events.

Diagnostic protocols-A consultation tool still to be discovered

RATIONALE

Experienced primary care physicians handle most illnesses to everyone's satisfaction despite limited resources of time and means. However, cases can be multifaceted in that harmless-presenting symptoms may also be warning signals or an indicator of a health disorder that too infrequently presents in family practice to be diagnosed correctly. On the basis of these observations, RN Braun developed 82 diagnostic protocols for a structured recording of various complaints.

METHOD

All consultations during the years 2001 to 2014, in which 1 author (WF) had used diagnostic protocols in her single-handed practice, were analyzed retrospectively regarding reasons for encounter, diagnostic classification, and long-term outcome.

RESULTS

During the period, a diagnostic protocol was used 1686 times. It was applied at a rate of approximately 5% of 2500 new complaints annually, most often (1366 times) for febrile conditions. In 320 consultations for other complaints, 43 different diagnostic protocols were applied. Among them, the "tabula diagnostica" for various undifferentiated symptoms was used most frequently (n = 54), followed by diagnostic protocols for headache (n = 45), dizziness (n = 36), precordial pain (n = 20), nonspecific abdominal pain (n = 15), low back pain (n = 14), hypertension (n = 12), diarrhea > 1 week (n = 12), epigastralgia (n = 11), depression (n = 10), polyarthralgia (n = 8), cough, and lower abdominal pain (each n = 7). A final diagnosis was established in less than 20% of cases.

CONCLUSIONS

This observational study from routine practice gives an insight how diagnostic protocols helped to manage complex patient presentations. A broader use of diagnostic protocols could investigate the potential of this consultation tool to handle the complexity of primary health care. The use of a standardized diagnostic approach could stimulate research, in particular on managing common complaints/undifferentiated illness and their inherent diagnostic uncertainty.

Tailored multifactorial intervention to improve dizziness symptoms and quality of life, balance and gait in dizziness sufferers aged over 50 years: protocol for a randomised controlled trial

Background

Dizziness is a frequently reported symptom in older people that can markedly impair quality of life. This manuscript presents the protocol for a randomised controlled trial, which has the main objective of determining the impact of comprehensive assessment followed by a tailored multifaceted intervention in reducing dizziness episodes and symptoms, improving associated impairments to balance and gait and enhancing quality of life in older people with self-reported significant dizziness.

Methods

Three hundred people aged 50 years or older, reporting significant dizziness in the past year will be recruited to participate in the trial. Participants allocated to the intervention group will receive a tailored, multifaceted intervention aimed at treating their dizziness symptoms over a 6 month trial period. Control participants will receive usual care. The primary outcome measures will be the frequency and duration of dizziness episodes, dizziness symptoms assessed with the Dizziness Handicap Inventory, choice-stepping reaction time and step time variability. Secondary outcomes will include health-related quality of life measures, depression and anxiety symptoms, concern about falling, balance and risk of falls assessed with the physiological fall risk assessment. Analyses will be by intention-to-treat.

Discussion

The study will determine the effectiveness of comprehensive assessment, combined with a tailored, multifaceted intervention on dizziness episodes and symptoms, balance and gait control and quality of life in older people experiencing dizziness. Clinical implications will be evident for the older population for the diagnosis and treatment of dizziness.

Trial registration

The study is registered with the Australia New Zealand Clinical Trials Registry ACTRN12612000379819.

[The differential diagnosis of recurrent episodes of vertigo]

Recurrent episodes of vertigo are one of the most frequent reasons of referrals for medical help. In the Russian medicine, the development of vertigo is traditionally associated with a cerebral vascular pathology. It is suggested that correctly planned clinical neurovestibular study may identify the signs of a balance disorder of peripheral and central genesis.

OBJECTIVE

To increase the effectiveness of the differential diagnosis of peripheral and central vertigo in patients with recurrent episodes of balance disorders using the protocol of neurovestibular examination ALGORITM.

MATERIAL AND METHODS

The study included 120 outpatients with preliminary diagnoses of cerebral ischemia and autonomic vascular dystonia.

RESULTS

Signs of lesion of peripheral and central regions of the vestibular system were found in 43.5 and 17.5% patients, respectively. Benign positional vertigo was the most frequent cause of vertigo while chronic cerebral ischemia was identified in 16.5% of the patients.

CONCLUSION

Neurovestibularexamnation using the protocol ALGORITM is important for assessment of the level of vestibular system lesion. Iitis necessary to use it in complex examination of patients with complaints of vertigo.

Development of Self-Management Indicators for Chronic Hepatitis B Patients on Antiviral Therapy: Results of a Chinese Delphi Panel Survey

Objective

This study aimed to develop a set of indicators that could be used to measure and monitor the self-management performance for chronic hepatitis B (CHB) patients on antiviral therapy in China.

Methods

A two-round Delphi study via e-mail correspondence was conducted, with a group of 30 Chinese experts. The Delphi questionnaire consisted of 53 indicators identified from a literature review. Experts rated and scored the importance of indicators on a five-point Likert scale. Consensus was considered to be reached if a median score in the top tertile (4-5) and ≥80% of panel ratings in the top tertile (4-5) after Round 2. The included indicators were validated with a group of 106 CHB patients.

Results

The response rates for the first and second rounds were 90.9% (n=30) and 86.7% (n=26), respectively. Three new indicators were suggested in the first round. 55 indicators were included in the second round after modified. 45 (81.8%) indicators achieved on the level of consensus, all of which had an inter-quartile range of 1 or below. The final set included 4 domains and 45 indicators which were well accepted and understandable by CHB patients.

Conclusion

This Delphi study produced a set of 45 self-management indicators for CHB patients on antiviral therapy in China. These indicators could be used to measure and monitor the patients’ self-management performance, with the goal of improving the quality of life in this population.

Electrophysiological analysis shows dizziness as the first symptom in human T cell lymphotropic virus type-associated myelopathy/tropical spastic paraparesis

Dizziness is a symptom in human T cell lymphotropic virus type-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and may occur due to vestibulospinal tract dysfunction. This tract can be assessed by an electrophysiological test called vestibular-evoked myogenic potential (VEMP). The aim was to correlate the result of VEMP generated by acoustic stimuli and dizziness in individuals with human T cell lymphotropic virus type 1 (HTLV-1)-asymptomatic infection and HAM/TSP. VEMP was recorded from the sternocleidomastoid muscle of 60 HTLV-1-negative adults (60±8 years) and 60 individuals infected with HTLV-1, 30 being asymptomatic (59±8 years) and 30 with HAM/TSP (59±8 years). In all groups, 90% of the participants were women. VEMP was generated by acoustic stimuli (short tone bursts), with an intensity of 118 dBHL and band-pass filter from 10 Hz to 1,500 Hz, and presented 200 stimuli at a frequency of 1,000 Hz with a record time of 60 ms. Of 60 HTLV-1-negative individuals, 14 (23%) reported dizziness; VEMP was normal in all. In the HTLV-1-asymptomatic group, 11(37%) complained of dizziness (p=0.31); VEMP was altered in four (40%) subjects with dizziness and in one (5%) without dizziness (p=0.00). In the group with HAM/TSP, dizziness was reported by 17 (57%) subjects (p=0.002); VEMP was altered in 11 (64%) with dizziness and in 5 (38%) without dizziness (p=0.15). Dizziness without an apparent etiology in HTLV-1-asymptomatic carriers deserves attention in terms of a possible subclinical spinal cord involvement that can be clarified through spinal electrophysiological tests. Damage of the vestibulospinal tract seems to occur in the early stages of HAM/TSP.

International experts' perspectives on a curriculum for psychologists working in primary health care: implication for Indonesia

Enhancing primary health care to incorporate mental health services is a key strategy for closing the treatment gap for people with mental disorders. The integration of psychological care into primary health care is a critical step in addressing poor access to mental health specialists. As the psychology profession is increasingly called upon to prepare psychologists for primary health care settings, an international experts' consensus is valuable in guiding the development of a high-quality curriculum for psychologists working in the primary health care context. A Delphi method was used to gain a consensus on the most appropriate roles and training for psychologists. Initial constructs and themes were derived from a detailed literature review and sent to 114 international experts in primary mental health care from five continents. Overall, 52 experts who participated agreed that psychologists should have wide-ranging roles and skills including clinical, health promotion and advocacy skills. This study has identified the specific roles and training needed by psychologists to enable them to work more effectively in primary health care settings. The consensus will inform the development of a curriculum for psychologists working in primary health care in Indonesia, and is part of a broader suite of studies.

Pain and anxiety mediate the relationship between dizziness and falls in older people

OBJECTIVES

To identify medical, psychological, and physiological mediators of the relationship between dizziness and falls in older adults.

DESIGN

Secondary analysis of a prospective cohort study.

SETTING

Community.

PARTICIPANTS

Five hundred sixteen community-dwelling adults aged 73 to 92.

MEASUREMENTS

Participants completed questionnaires related to health and psychological well-being and underwent a tilt table blood pressure test, the Physiological Profile Assessment (PPA; vision, reaction time, proprioception, postural sway, and quadriceps strength), and leaning balance tests. Prospective falls data were collected using monthly calendars for 12 months. Participants were categorized into dizzy and nondizzy groups based on self-report of dizziness, vertigo, and light-headedness.

RESULTS

Two hundred seventeen (42%) participants reported vertigo or dizziness (10%), light-headedness (16%), or both (16%). The dizzy participants were significantly more likely to report neck and back pain, past transient ischemic attacks, and feeling dizzy upon upright tilting. They also had poorer balance and less strength and scored higher on measures of depression and anxiety (P < .05). There were no blood pressure measurement-related differences between the groups. Dizziness increased the risk of multiple falls in an unadjusted analysis (relative risk (RR) = 1.55, 95% confidence interval = 1.08-2.23). After controlling for PPA scores, neck and back pain and anxiety were mediators that reduced the RR of the relationship between dizziness and faller status the most (14%) in a modified Poisson regression model.

CONCLUSION

Suffering from neck and back pain and anxiety were mediators of the relationship between dizziness and falls after controlling for poor sensorimotor function and balance. Older people with dizziness might benefit from interventions targeting these mediators such as pain management and cognitive behavioral therapy.

Syncope and near-syncope as a multifactorial problem in geriatric inpatients: Systemic hypotension is an underrated predictor for syncope exclusively

PURPOSE

Syncope (SC) and near-syncope (NS) are still misunderstood syndromes. Aim of study was to determine the risk factors for SC, NS, as well as for both entities (SC/NS) in geriatric inpatients reporting these events within the last year, irrespectively of the reason of admission to hospital.

MATERIAL AND METHODS

The retrospective study covered 250 patients, consecutively admitted to the geriatric ward. Patients were assigned to the three models: SC and/or NS in total, n=106; isolated NS, n=72; SC with co-existing NS, if any, n=34, and compared with patients without any such events (n=144). The patients underwent a comprehensive geriatric assessment and complete clinical investigation. The binary logistic regression was applied to predict risk factors for each of the models.

RESULTS

Falls were most predictive for NS model (OR 35.4; 95% CI 10.3-121.1), and systemic hypotension for SC model (OR 92.9; 95% CI 6.1-1421.0). The highest specificity (85%) and sensitivity (81%) were found for the SC/NS model, with the highest contribution by falls (OR 18.1; 95% CI, 7.6-45.2), orthostatic hypotension (OR 8.1; 95% CI, 3.5-18.5), a history of stroke or transient ischemic attack, treatment with an angiotensin receptor blocker, plasma creatinine >1.4mg/dL, negatively self-rated health, vertigo, pathology of carotid arteries, and lack of hypertension.

CONCLUSIONS

Syncope and near-syncope in geriatric inpatients have multifactorial and cumulative aetiology, with blurred, frequently overlapping boundaries between them. The falls, postural hypotension, and/or brain hypoperfusion of different origin seem to be most predictive of the both events, however low systemic blood pressure was predictive for the syncope exclusively.

Impact of dizziness on everyday life in older primary care patients: a cross-sectional study

Background

Dizziness is a common and often disabling symptom, but diagnosis often remains unclear; especially in older persons where dizziness tends to be multicausal. Research on dizziness-related impairment might provide options for a functional oriented approach, with less focus on finding diagnoses. We therefore studied dizziness-related impairment in older primary care patients and aimed to identify indicators related to this impairment.

Methods

In a cross-sectional study we included 417 consecutive patients of 65 years and older presenting with dizziness to 45 general practitioners in the Netherlands from July 2006 to January 2008. We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. Our primary outcome was impact of dizziness on everyday life measured with the Dutch validated version of the Dizziness Handicap Inventory (DHI). After a bootstrap procedure (1500x) we investigated predictability of DHI-scores with stepwise backward multiple linear and logistic regressions.

Results

DHI-scores varied from 0 to 88 (maximum score: 100) and 60% of patients experienced moderate or severe impact on everyday life due to dizziness. Indicators for dizziness-related impairment were: onset of dizziness 6 months ago or more (OR 2.8, 95% CI 1.7-4.7), frequency of dizziness at least daily (OR 3.3, 95% CI 2.0-5.4), duration of dizziness episode one minute or less (OR 2.4, 95% CI 1.5-3.9), presence of anxiety and/or depressive disorder (OR 4.4, 95% CI 2.2-8.8), use of sedative drugs (OR 2.3, 95% CI 1.3-3.8) , and impaired functional mobility (OR 2.6, 95% CI 1.7-4.2). For this model with only 6 indicators the AUC was .80 (95% CI .76-.84).

Conclusions

Dizziness-related impairment in older primary care patients is considerable (60%). With six simple indicators it is possible to identify which patients suffer the most from their dizziness without exactly knowing the cause(s) of their dizziness. Influencing these indicators, if possible, may lead to functional improvement and this might be effective in patients with moderate or severe impact of dizziness on their daily lives.

Diagnostic indicators of anxiety and depression in older dizzy patients in primary care

BACKGROUND

Dizzy patients with both psychological and physical symptoms tend to have high levels of disability and are at risk of remaining symptomatic and disabled. The objective of this study was to develop a prediction model for the presence of anxiety and/or depression in older dizzy patients in primary care.

METHODS

We performed a cross-sectional study among 415 older patients consulting their primary care physician for persistent dizziness. Participants underwent a standardized, comprehensive evaluation and completed self-administered questionnaires regarding anxiety and depression (PRIME-MD Patient Health Questionnaire [PHQ]) and dizziness-related disability (Dizziness Handicap Inventory). To determine the diagnostic indicators of anxiety and/or depression, we used multiple logistic regression analysis with ''presence of Panic Disorder, Other Anxiety Disorder, or Major Depressive Disorder'' as dependent variable. Potential diagnostic indicators included dizziness-related disability, patient characteristics (age, sex, history of anxiety, and history of depression), and dizziness characteristics (description of dizziness, provoking circumstances, associated symptoms, onset, frequency, duration, and avoidance of activities because of dizziness).

RESULTS

According to the PHQ, an anxiety and/or depressive disorder was present in 90 patients (22%), of whom 35 reported no medical history of anxiety or depression, nor current pharmacological treatment for these disorders. In the final model, dizziness-related disability, a history of depression, and accompanying fear were associated with an increased odd of anxiety and/or depression, whereas tinnitus and rotational dizziness were associated with a decreased odd of anxiety and/or depression. The model showed good calibration (Hosmer-Lemeshow P value of .46) and discrimination (adjusted area under the receiver operating characteristic curve [AUC] after bootstrapping of .82).

CONCLUSIONS

Primary care physicians should consider the existence of anxiety and depression in older patients presenting with dizziness. After external validation, our model may contribute to better recognition and hence better management of anxiety and depression in older patients with dizziness in primary care.

Profiling dizziness in older primary care patients: an empirical study

Background

The diagnostic approach to dizzy, older patients is not straightforward as many organ systems can be involved and evidence for diagnostic strategies is lacking. A first differentiation in diagnostic subtypes or profiles may guide the diagnostic process of dizziness and can serve as a classification system in future research. In the literature this has been done, but based on pathophysiological reasoning only.

Objective

To establish a classification of diagnostic profiles of dizziness based on empirical data.

Design

Cross-sectional study.

Participants and Setting

417 consecutive patients of 65 years and older presenting with dizziness to 45 primary care physicians in the Netherlands from July 2006 to January 2008.

Methods

We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. We used the results of these tests in a principal component analysis for exploration, data-reduction and finally differentiation into diagnostic dizziness profiles.

Results

Demographic data and the results of the tests yielded 221 variables, of which 49 contributed to the classification of dizziness into six diagnostic profiles, that may be named as follows: “frailty”, “psychological”, “cardiovascular”, “presyncope”, “non-specific dizziness” and “ENT”. These explained 32% of the variance.

Conclusions

Empirically identified components classify dizziness into six profiles. This classification takes into account the heterogeneity and multicausality of dizziness and may serve as starting point for research on diagnostic strategies and can be a first step in an evidence based diagnostic approach of dizzy older patients.

Geriatric vestibulopathy assessment and management

PURPOSE OF REVIEW

This review discusses the demographics of dizziness in the older person, the evaluation of the older dizzy patient and how the treatment of dizziness in older patients differs from that in younger individuals.

RECENT FINDINGS

Seven percent of all visits to primary care physicians for patients older than 65 years of age are for dizziness, and dizziness is the most common complaint for patients older than 75 years. In a German study, the 12-month prevalence of vertigo in the general population was 5% with an incidence of 1.4% in adults overall. For individuals aged 60-69 the 12-month prevalence was found to be 7.2% and in individuals 70 years of age or older 8.9%. Data from the United States National Health and Nutrition Examination Surveys indicated that the prevalence of vestibular dysfunction for individuals in the seventh decade of life, eighth decade of life, and older was 49.4, 68.7, and 84.8 percent, respectively. Only subtle age effects are seen on caloric and rotational testing whereas vestibular evoked myogenic potentials (VEMPs) change somewhat with age. Particle repositioning for benign paroxysmal positional vertigo combined with vestibular rehabilitation is more effective than only performing the repositioning maneuver. Tai Chi appears to be an effective intervention for older adults at risk for falling.

SUMMARY

When caring for an older dizzy patient always assess medication use, perform a Dix-Hallpike maneuver, obtain orthostatic vital signs, discuss fall risk precautions, and consider referral for vestibular rehabilitation.

Where there is no evidence: use of expert consensus methods to fill the evidence gap in low-income countries and cultural minorities

BACKGROUND

In both developing countries and in relation to cultural minorities there have been calls to scale up mental health services and for evidence-informed policy and practice.

EVIDENCE BASED MEDICINE

The evidence based medicine movement has had a major influence in improving practice. However, implementation of this approach has some major difficulties. One that has been neglected is the situation where there is no relevant evidence. This situation is more likely to occur for healthcare decisions in developing countries or for cultural minorities within developed countries, because resources do not exist for expensive research studies.

CONSENSUS METHODS

Consensus methods, such as the Delphi process, can be useful in providing an evidence base in situations where there is insufficient evidence. They provide a way of systematically tapping the expertise of people working in the area and give evidence that is readily applicable for a particular country and culture. Although consensus methods are often thought of as low in the hierarchy of evidence, consensus is central to the scientific process. We present four examples where the Delphi method was used to assess expert consensus in situations where no other evidence existed: estimating the prevalence of dementia in developing countries, developing mental health first aid guidelines in Asian countries, mental health first aid guidelines for Australian Aboriginal people, and modification of the concept of 'recovery' for Australian immigrant communities.

CONCLUSION

Consensus methods can provide a basis for decision-making and considered action when there is no evidence or when there are doubts about the applicability of evidence that has been generated from other populations or health system settings.

Causes of persistent dizziness in elderly patients in primary care

PURPOSE

Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness.

METHODS

We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness.

RESULTS

From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness.

CONCLUSIONS

Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.