Vestibular Dysfunction and Difficulty with Driving: Data from the 2001-2004 National Health and Nutrition Examination Surveys

Healthcare Utilization Among Adults With Vestibular Vertigo in the United States

OBJECTIVES

Vestibular vertigo has been shown to have a high lifetime prevalence. Previous studies have described the increased morbidities associated with vestibular vertigo.

DESIGN

In this cross-sectional study of the 2016 National Health Interview Study, we sought to explore whether individuals with vestibular vertigo were more likely to utilize healthcare resources compared with those without vestibular vertigo. We characterized utilization of specific healthcare resources including general doctors, specialist doctors, emergency departments, mental health professionals, and others among individuals with vestibular vertigo to better understand how individuals with vertigo interact with the US healthcare system.

RESULTS

In multivariable analyses, participants with vestibular vertigo had an increased number of nights in the hospital in the last 12 months (mean difference = 0.67 days, 95% confidence interval [CI] = 0.37 to 0.97), increased odds of receiving healthcare 10 or more times in the last 12 months (odds ratio = 2.22, 95% CI = 1.99 to 2.48) and increased number of visits to a healthcare professional in the last 2 weeks (mean difference = 0.17 visits, 95% CI = 0.14 to 0.21). In addition, participants with vestibular vertigo had increased odds of visiting both general doctors, specialist doctors, and other healthcare professionals.

CONCLUSIONS

These findings characterize how individuals with vestibular vertigo utilize and interact with healthcare resources compared with those without vestibular vertigo.

Impact and experiences of vestibular disorders and psychological distress: Qualitative findings from patients, family members and healthcare professionals

INTRODUCTION

People with vestibular disorders frequently experience reduced quality of life and challenges with activities of daily living. Anxiety, depression and cognitive problems often co-present with vestibular disorders and can aggravate symptoms and prolong clinical recovery. We aimed to gain in-depth insights into the impact of vestibular disorders and the contribution of psychological factors by exploring multistakeholder perspectives.

METHODS

Semistructured interviews were conducted between October 2021 and March 2022 with 47 participants in the United Kingdom including: 20 patients (age M = 50.45 ± 13.75; 15 females), nine family members (age M = 61.0 ± 14.10; four females), and 18 healthcare professionals. Data were analysed using framework analysis.

RESULTS

Vestibular disorders impact diverse aspects of patients' lives including work, household chores, socialising, and relationships with family and friends. Being unable to engage in valued activities or fulfil social roles contributes to feelings of grief and frustration, affecting identity, confidence, and autonomy. Anxiety and low mood contribute to negative thought processes, avoidance, and social withdrawal, which can impede clinical recovery through reduced activity levels, and end engagement with treatment. Coping strategies were thought to help empower patients to self-manage their symptoms and regain a sense of control, but these require oversight from healthcare providers.

CONCLUSIONS

Daily activity limitations, social participation restrictions, and psychological distress can interact to impact quality of life, sense of self, and clinical recovery amongst people with vestibular disorders. Information and resources could aid societal awareness of the impact of vestibular disorders and help patients and families feel understood. An individualised and comprehensive approach that concurrently addresses mental, physical, social, and occupational needs is likely to be beneficial.

PATIENT OR PUBLIC CONTRIBUTION

Two group meetings were held at the beginning and end of the study with a patient and public involvement network formed of people with vestibular disorders and family members. These individuals commented on the study aims, interview schedule, participant recruitment practices, and interpretation of the themes identified. Two core patient members were involved at all stages of the research. These individuals contributed to the formulation of the interview schedule, development and application of the coding scheme, development and interpretation of themes, and preparation of the final manuscript.

Vestibular Vertigo and Disparities in Healthcare Access Among Adults in the United States

OBJECTIVE

Vertigo and dizziness have a high lifetime prevalence with significant impacts on daily life. We sought to explore differences in access to and ability to afford care among adults with vestibular vertigo by race/ethnicity, income, and insurance type.

DESIGN

This is a cross-sectional study using the 2016 National Health Interview Survey. A total of 32,047 adults who completed the 2016 National Health Interview Survey Balance Supplement were analyzed. We used a previously validated definition of vertigo defined as (1) positional vertigo, (2) rotational vertigo, or (3) recurrent dizziness with nausea and either oscillopsia or imbalance. We examined several self-reported measures of healthcare utilization and access.

RESULTS

Among adults with vestibular vertigo, African Americans had significantly increased odds of delayed care due to lack of transportation; Hispanic ethnicity was associated with decreased odds of skipping medication doses and asking a doctor for a lower-cost medication. Adults with public insurance had significantly lower odds of reporting delayed care due to worry about cost, not receiving medical care due to cost, and delayed filling of a prescription, but had greater odds of reporting delayed care due to lack of transportation. Lack of insurance and lower income were associated with increased odds of delaying and not receiving care due to cost.

CONCLUSION

These findings demonstrate significant differences in access to care among adults with vestibular vertigo in the United States based on race, income, and health insurance status.

Motorist's Vestibular Disorientation Syndrome (MVDS)-Proposed Diagnostic Criteria

Motorist's vestibular disorientation syndrome (MVDS) is a disorder in which patients experience dizziness while driving. MVDS is under-reported in the literature, and in clinical practice, it often goes unrecognized. We identified clinical characteristics of patients with MVDS using data from 24 patients who faced difficulties while driving and were diagnosed with MVDS. Their symptoms, duration of illness, precipitating factors, co-morbidities, history of other neuro-otological disorders, severity of symptoms, and associated anxiety and depression were reviewed. Ocular motor movements were recorded using video-nystagmography. Patients with vestibular disorders that can cause similar symptoms while driving were excluded. The mean age of the patients was 45.7 ± 8.7 years, and most were professional drivers (90.5%). The duration of the illness ranged from eight days to ten years. Most patients presented with disorientation (79.2%) exclusively while driving. The most common triggers for symptoms were higher speeds, i.e., >80 km/h (66.7%), multi-lane roads (58.3%), bends and turns (50%), and looking at other vehicles or signals while driving (41.7%). A history of migraines was reported in 62.5% of the patients, and motion sickness was reported in 50% of the patients. Anxiety was reported in 34.3% of patients, and 15.7% had depression. The video-nystagmography did not show any specific abnormalities. Patients responded to drugs used in prophylactic treatments for migraines such as Amitriptyline, Venlafaxine, Bisoprolol, and Magnesium, and to Pregabalin and Gabapentin. Based on these findings, a classification system and a diagnostic criterion for MVDS were proposed.

Association between Simultaneous Occurrence of Occupational Noise-Induced Hearing Loss and Noise-Induced Vestibular Dysfunction: A Systematic Review

Background

Background: Because of functional and structural similarities between the cochlea and vestibular sensory receptors, vestibular dysfunction could be accompanied by noise-induced hearing loss (NIHL) due to occupational noise exposure. We aimed to evaluate the occurrence of vestibular dysfunction (VD) in individuals with NIHL and occupational noise exposure.

Methods

A systematic literature research was carried out within the databases of PubMed, Scopus, Science Direct, and Web of Science for published articles between 1980 and Jan 5, 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodological quality of the included systematic reviews was assessed with the Joanna Briggs Institute (JBI) checklist. Vestibular system dysfunction parameters were considered as primary outcomes in subjects with NIHL.

Results

We reviewed the evidence (from 19 eligible articles) for VD from noise-induced damage to peripheral vestibular structures. VD can occur after occupational noise exposure or concomitantly with NIHL. Furthermore, this study showed that the saccular organ has a higher susceptibility to noise damage than the vestibular organs of the utricle and semicircular canals (SCCs).

Conclusion

Our results support the role of occupational noise exposure and NIHL as risk factors for developing VD. Further research is needed to investigate the association between the occurrence of VD due to occupational noise exposure or concomitantly with NIHL.

Changes in Measures of Vestibular and Balance Function and Hippocampus Volume in Alzheimer's Disease and Mild Cognitive Impairment

OBJECTIVE

To test the hypotheses that people with Alzheimer's disease and mild cognitive impairment have increased frequency of vestibular impairments and decreased hippocampal volume compared with healthy age-matched controls.

STUDY DESIGN

Retrospective, with some historical controls.

SETTING

Out-patient, tertiary care center.

SUBJECTS

People with mild to moderate dementia diagnosed with Alzheimer's disease and with mild cognitive impairment. Main Outcome Measures: A standard clinical battery of objective tests of the vestibular system, and screening for balance; available clinical diagnostic magnetic resonance imaging (MRIs) were reviewed and postprocessed to quantify the left and right hippocampal volumes utilizing both manual segmentation and computer automated segmentation.

RESULTS

Study subjects (N = 26) had significantly more vestibular impairments, especially on Dix-Hallpike maneuvers and cervical vestibular evoked myogenic potentials (cVEMP), than historical controls. No differences were found between mild and moderate dementia subjects. Independence on instrumental activities of daily living in subjects with age-normal balance approached statistical differences from subjects with age-abnormal balance. MRI data were available for 11 subjects. Subjects with abnormal cVEMP had significantly reduced left hippocampal MRIs using manual segmentation compared with subjects with normal cVEMP.

CONCLUSION

The data from this small sample support and extend previous evidence for vestibular impairments in this population. The small MRI sample set should be considered preliminary evidence, and suggests the need for further research, with a more robust sample and high-resolution MRIs performed for the purpose of hippocampal analysis.

Optimum Response of Air-conduction Induced Ocular Vestibular Evoked Myogenic Potential in Drivers

Context

During driving, the plane of movement in drivers is horizontal. Hence, utricles and vestibulo-ocular reflex (VOR) pathway are over stimulated. The ocular vestibular evoked myogenic potential (oVEMP) is utilized to evaluate the function of utricle and VOR pathway.

Aim

This study aimed to assess the function of utricle and VOR using oVEMP among the drivers and compare it with non-professional drivers.

Study Design

Comparative cross-sectional study.

Methods

A total of 30 non-professional drivers and 30 professional drivers between ages of 18 and 45 years were evaluated in this study. Drivers with minimum of 5 years driving experience and minimum 3 h of driving per day were included. The oVEMPs were recorded for all the participants using alternating polarity 500 Hz tone bursts stimuli.

Statistical Analysis

To calculate mean and standard deviation for all the groups, descriptive statistics was used and for group comparisons Independent t-test, Analysis of Variance, and Mann-Whitney U test were used.

Results

The oVEMP of professional drivers exhibited significant delay in peak latency of N1 and P1 than those of non-professional drivers. Significant delay in P1 latency and reduced peak amplitudes were observed in professional drivers with greater than 10 years of experience on comparison with drivers less than 10 years of experience.

Conclusions

Current study opens a new research in understanding the effect of over-stimulation of vestibular system in drivers. Driving for longer period may have effect on latency and amplitude parameters of oVEMP.

Driving ability in patients with dizziness: a systematic review

PURPOSE

The aim of this systematic review was to identify and evaluate studies dealing with driving performance of dizzy patients or patients with a vestibular disorder.

METHODS

A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. (1) PubMed, Embase, and Cochrane library. (2) Study selection: articles about driving ability and reported driving difficulties in patients with dizziness, or a diagnosed vestibular disorder, were included. (3) Data extraction was performed by two independent authors using predefined data fields: patient's characteristics, diagnostic criteria, sample size, and type of evaluation of driving ability and outcome of the study.

RESULTS

Eight out of 705 articles matched the inclusion criteria but varied widely regarding the study population, study design, and outcome measures. The majority of studies reported a negative impact of dizziness and/or vestibular disorders on self-reported driving ability and car accidents. Yet several studies could not identify any impairment of driving ability.

CONCLUSIONS

Driving ability was negatively affected by dizziness or a vestibular disorder in the majority of included studies with low risk of bias. This systematic review revealed a significant heterogeneity in studies reporting driving performance and contradictory results. We were, therefore, unable to identify a causal relationship between dizziness and driving ability. There is a need for prospective studies in populations with different vestibular disorders using subjective and objective outcome measures that have been validated to evaluate driving performance.

Aging, Vestibular Function, and Balance: Proceedings of a National Institute on Aging/National Institute on Deafness and Other Communication Disorders Workshop

Balance impairment and falls are among the most prevalent and morbid conditions affecting older adults. A critical contributor to balance and gait function is the vestibular system; however, there remain substantial knowledge gaps regarding age-related vestibular loss and its contribution to balance impairment and falls in older adults. Given these knowledge gaps, the National Institute on Aging and the National Institute on Deafness and Other Communication Disorders convened a multidisciplinary workshop in April 2019 that brought together experts from a wide array of disciplines, such as vestibular physiology, neuroscience, movement science, rehabilitation, and geriatrics. The goal of the workshop was to identify key knowledge gaps on vestibular function and balance control in older adults and develop a research agenda to make substantial advancements in the field. This article provides a report of the proceedings of this workshop. Three key questions emerged from the workshop, specifically: (i) How does aging impact vestibular function?; (ii) How do we know what is the contribution of age-related vestibular impairment to an older adult's balance problem?; and more broadly, (iii) Can we develop a nosology of balance impairments in older adults that can guide clinical practice? For each of these key questions, the current knowledge is reviewed, and the critical knowledge gaps and research strategies to address them are discussed. This document outlines an ambitious 5- to 10-year research agenda for increasing knowledge related to vestibular impairment and balance control in older adults, with the ultimate goal of linking this knowledge to more effective treatment.

Association between Bone Metabolism and Vestibular Problems in the Modified Romberg Test: Data from the 2009-2010 Korean National Health and Nutrition Examination Survey

Osteoporosis contributes to the occurrence of falling and vestibular problems, particularly in elderly patients. This study aimed to investigate the association between bone metabolism with vestibular problems and falling. A total of 4054 participants of the Korean National Health and Nutrition Examination Survey (KNHANES) from 2009 to 2010 aged ≥50 years old were surveyed on their history of falling, vestibular problems evaluated by the modified Romberg test, variables involving bone metabolism, and serum levels of vitamin D and alkaline phosphatase. They also underwent dual energy X-ray absorptiometry. The crude (simple) and adjusted odd ratios (ORs) of variables involving bone metabolism for vestibular problems in the modified Romberg test and falling were analyzed using a logistic regression model. A subgroup analysis was performed according to sex and the presence of menopause in females. Vestibular problems in the modified Romberg test group but not the falling group were associated with decreased serum vitamin D levels (p < 0.001; odds ratio (OR) = 0.951; 95% confidence interval (CI), 0.926-0.976). In subgroup analysis according to sex, the post-menopause group showed a higher rate of vestibular problems in the modified Romberg test compared to the pre-menopause group (4.5% vs. 0.7%, p = 0.019). In the post-menopause group, osteoporosis was positively associated with vestibular problems in the modified Romberg test (p = 0.001, OR = 10.971, 95% CI = 2.650-45.414). On the other hand, a history of hormone replacement therapy was negatively related with vestibular problems in this subgroup (p = 0.035; OR = 0.473; 95% CI = 0.239-0.948). A decrease in serum vitamin D levels may impact the vestibular system through neural signaling or by osteoporotic changes of the otic capsule, as well as otolith particles. Decreased estrogen levels in postmenopausal women may make them more prone to osteoporotic changes, which were associated with vestibular problems in the modified Romberg test. Because this is a cross-sectional study, the causal relationship of bone metabolism with vestibular function needs to be investigated.

The Influence of Migraine on Driving: Current Understanding, Future Directions, and Potential Implications of Findings

OBJECTIVE

To review the published findings relevant to migraine and driving performance, with an intent to encourage discussion on research which may broaden understanding in this area and help educate healthcare providers and their patients.

BACKGROUND

Motor vehicle crashes result in more than 35,000 deaths and more than 2 million injuries annually in the United States. Migraine is one of the most prevalent diseases in the world, and many symptoms associated with migraine attacks have the potential to negatively influence driving ability.

METHODS

We reviewed the published findings related to migraine and driving performance. Study findings relevant to symptoms of migraine and their potential effect on driving were also reviewed. This required a more expansive exploration of the literature beyond migraine, for example, review of the literature relating to the effect of pain, sleepiness, visual disturbances, or vertigo on driving. Finally, the potential effects of treatment for migraine on driving were reviewed.

RESULTS

Literature on the effect of migraine on driving performance is sparse and, in general published studies on the topic have a number of limitations. Based on review of the literature pertaining to other disorders, it seems feasible that some symptoms occurring as part of the migraine attack could impact driving performance, although formal study in this area is lacking. Many of the approved treatments for migraine have the potential to impact driving, yet this has not been specifically studied, and the extent to which these risks are communicated to patients is not clear.

CONCLUSION

The impact of migraine on driving performance has been largely neglected, with few studies specifically designed to address the topic, and relevant studies were generally small with limited control of confounders. This area requires more focus, given a potential for impact on road safety.

Sexual dimorphism in vestibular function and dysfunction

It has been recognized for some time that females appear to be overrepresented in the incidence of many vestibular disorders, and recent epidemiological studies further support this idea. While it is possible that this is due to a reporting bias, another possibility is that there are actual differences in the incidence of vestibular dysfunction between males and females. If this is true, it could be due to a sexual dimorphism in vestibular function and therefore dysfunction, possibly related to the hormonal differences between females and males, although the higher incidence of vestibular dysfunction in females appears to last long after menopause. Many other neurochemical differences exist between males and females, however, that could be implicated in sexual dimorphism. This review critically explores the possibility of sexual dimorphism in vestibular function and dysfunction, and the implications it may have for the treatment of vestibular disorders.

Association Between Vestibular Vertigo and Motor Vehicle Accidents: Data From the 2016 National Health Interview Survey

Recent evidence has shown that individuals with vestibular impairment have higher rates of self-reported driving difficulty compared with individuals without vestibular impairment. However, it is unknown whether individuals with vestibular impairment are more likely to be involved in motor vehicle accidents. We used data from the 2016 National Health Interview Survey of U.S. adults to evaluate whether individuals with vestibular vertigo are more likely to experience motor vehicle accidents relative to individuals without vestibular vertigo. In multivariate analysis, vestibular vertigo was associated with an over threefold increased odds of motor vehicle accidents (odds ratio, 3.5; 95% confidence interval, 1.7-7.3). This study supports an association between vestibular dysfunction and driving impairment, and provides a relative risk of motor vehicle accidents associated with vestibular vertigo that clinicians may utilize in counseling patients on the potential safety hazards of driving.

Multisensory Influences on Driver Steering During Curve Navigation

OBJECTIVE

The effects of inertial (vestibular and somatosensory) information on driver steering during curve navigation were investigated, using an electric four-wheel mobility vehicle outfitted with a steering wheel and a portable virtual reality system.

BACKGROUND

When driving, multiple sources of perceptual information are available. Researchers have focused on visual information, which plays a critical role in steering control. However, it is not yet well established how inertial information might contribute.

METHODS

I biased inertial cues by varying visual/inertial gains (doubled, halved, reversed), as drivers negotiated curving paths, and measured steering accuracy and efficiency. I also assessed whether being exposed to inertial biases had an impact on postbias steering by comparing pre- and posttest session performance measures.

RESULTS

Doubling or halving inertial cues had little effect on steering performance. Inertial information only disrupted steering when it was reversed with respect to visual information. Over time, the influence of this extreme inertial bias was reduced though not eliminated. Postbias curve navigation performance was not impacted, likely because participants had learned to disregard, rather than integrate, biased inertial cues.

CONCLUSION

Results suggest that biased inertial information has little influence on curve navigation performance when visual information is available.

APPLICATION

Though inertial cues may be important for open-loop steering, when visual cues are unavailable, their role in closed-loop steering seems less influential. This has implications for driving simulation and suggests that inertial discrepancies due to limitations in motion-cuing capabilities may not be all that problematic for the simulation of closed-loop curve steering tasks.

Saccular Impairment in Alzheimer's Disease Is Associated with Driving Difficulty

BACKGROUND/AIMS

Patients with Alzheimer's disease (AD) experience increased rates of vestibular loss. Recent studies suggest that saccular impairment in mild cognitive impairment (MCI) and AD patients is associated with impaired spatial cognitive function. However, the impact of saccular impairment on everyday behaviors that rely on spatial cognitive function is unknown.

METHODS

We recruited 60 patients (21 MCI and 39 AD) from an interdisciplinary Memory Clinic. Saccular function was measured, and a visuospatial questionnaire was administered to assess whether participants experienced impairments in terms of driving difficulty, losing objects, falls, and fear of falling.

RESULTS

In multiple logistic regression analyses, MCI and AD patients with bilateral saccular impairment had a significant, greater than 12-fold odds of driving difficulty (OR 12.1, 95% CI 1.2, 117.7) compared to MCI and AD patients with normal saccular function, and the association appears to be mediated by spatial cognition as measured by the Money Road Map Test.

CONCLUSION

This study suggests a novel link between saccular impairment and driving difficulty in MCI and AD patients and demonstrates that driving difficulty may be a real-world manifestation of impaired spatial cognition associated with saccular impairment.