Theoretical framework for "unexplained" dizziness in the elderly: The role of small vessel disease

Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire

BACKGROUND AND PURPOSE

Vigilance towards balance has been proposed to underpin various chronic dizziness disorders, including persistent postural-perceptual dizziness (PPPD). The objective of this study was to develop (through patient input) a validated balance-specific measure of vigilance that comprehensively assesses the varied ways in which this construct may manifest.

METHODS

We developed the Balance Vigilance Questionnaire (Balance-VQ) through patient and clinician feedback, designed to assess vigilance towards balance. We then validated the questionnaire in 497 participants consisting of patients diagnosed with chronic dizziness disorders (including 97 individuals diagnosed with PPPD) and healthy controls.

RESULTS

The final six-item Balance-VQ was shown to be a valid and reliable way to assess vigilance towards balance. Scores were significantly higher in individuals diagnosed with PPPD compared to controls. Although scores were also higher in the PPPD group compared to individuals with diagnosed vestibular disorders other than PPPD, Balance-VQ scores did not discriminate between the two groups when confounding factors (including dizziness severity) were controlled for. Scores did, however, independently discriminate between the PPPD group and individuals who experience dizziness in daily life, but who have not been diagnosed with a neuro-otological disorder.

CONCLUSIONS

Our findings confirm that the Balance-VQ is a valid and reliable instrument for assessing vigilance towards balance. As symptom vigilance has been identified as a key risk factor for developing chronic dizziness following acute vestibular symptoms or balance disruption, we recommend using the Balance-VQ as a screening tool in people presenting with such symptoms.

Predictors of persistent postural-perceptual dizziness (PPPD) and similar forms of chronic dizziness precipitated by peripheral vestibular disorders: a systematic review

BACKGROUND

The literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed.

METHODS

We systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

We identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed.

CONCLUSIONS

After acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.

A link between frontal white matter integrity and dizziness in cerebral small vessel disease

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Idiopathic dizziness in older people is associated with more vascular risk.

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Idiopathic dizziness is also associated with impaired balance and cognition.

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These findings co-occur with more frontal markers of cerebral small vessel disease.

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Small vessel disease may contribute to dizziness through its effects on balance.

One in three older people (>60 years) complain of dizziness which often remains unexplained despite specialist assessment. We investigated if dizziness was associated with vascular injury to white matter tracts relevant to balance or vestibular self-motion perception in sporadic cerebral small vessel disease (age-related microangiopathy). We prospectively recruited 38 vestibular clinic patients with idiopathic (unexplained) dizziness and 36 age-matched asymptomatic controls who underwent clinical, cognitive, balance, gait and vestibular assessments, and structural and diffusion brain MRI. Patients had more vascular risk factors, worse balance, worse executive cognitive function, and worse ankle vibration thresholds in association with greater white matter hyperintensity in frontal deep white matter, and lower fractional anisotropy in the genu of the corpus callosum and the right inferior longitudinal fasciculus. A large bihemispheric white matter network had less structural connectivity in patients. Reflex and perceptual vestibular function was similar in patients and controls. Our results suggest cerebral small vessel disease is involved in the genesis of dizziness through its effect on balance.

The Relationship Between Patent Foramen Ovale and Unexplained Dizziness: A Prospective Analysis in China

INTRODUCTION

Patent foramen ovale (PFO) is potentially associated with abnormal embolisms, and it results in mixing of arteriovenous blood when its right-to-left shunt (RLS) emerges. Present studies have found that PFO is a risk factor that can lead to many diseases. However, few studies have examined the relationship between PFO and dizziness.

METHODS

This study was a large single-center, prospective, controlled study. From March 2019 to March 2021, we recruited patients with dizziness were divided into two groups: "explained" and "unexplained". All patients were submitted to contrast-enhanced transcranial Doppler ultrasound and screened for PFO. Transesophageal heart ultrasound or right heart catheterization was used to confirm PFO. Additionally, multiple factors were collected and statistical analysis was performed between the two groups.

RESULTS

Among the 244 patients included, 123 were in the "explained" group and 121 were in the "unexplained" group. The prevalence of PFO in the "explained" group was 34 (27.4%) compared to 79 (64.7%) in the "unexplained" group. In the "explained" group, 7 were RLS level IV, 6 were level III, 7 were level II, and 14 were level I. For the "unexplained" group, the numbers of patients with levels IV, III, II and I were 27, 26, 12 and 14, respectively. Univariate analysis revealed that PFO (χ²= 34.77, P < 0.001) and age (t = -3.49, P < 0.001) seemed to be potential risk factor candidates for "unexplained" dizziness. In multiple regression analysis, age (OR = 0.97; 95% CI 0.95-0.99) and the prevalence of PFO (OR = 4.37; 95% CI 2.50-7.63) were statistically significant. Massively shunted PFO showed more pronounced risk factors (OR = 8.76; 95% CI 4.04-19.03).

CONCLUSION

There was a high prevalence of PFO and a greater RLS level in unexplained dizziness. PFO and age were independent risk factors for unexplained dizziness. When treating with unexplained dizziness, especially among young people, we must pay attention to the presence of PFO.

The Impact of Coronavirus Disease 2019 Epidemic on Dizziness/Vertigo Outpatients in a Neurological Clinic in China

Objective: This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) epidemic on dizziness/vertigo outpatients in a neurological clinic in China. Methods: Against the background of the COVID-19 epidemic, the data of patients who visited the neurological clinic of Beijing Chaoyang Hospital West Branch during the pandemic (February 1-May 30, 2020) and the corresponding period in 2019 (February 1-May 30, 2019) were analyzed, and patients with dizziness/vertigo from these two periods were compared to discover their demographic features and etiologic distribution according to their age and sex. Result: The absolute number of neurological outpatients decreased from 14,670 in 2019 to 8,763 in 2020 (-40.3%), with a corresponding decline in dizziness/vertigo patients (2019: n = 856; 2020: n = 1,436, -40.4%). Dizziness/vertigo was more common in women than men in these two periods (2019: women = 63.6%; 2020: women = 63.1%, p = 0.82). The overall etiology distribution was different among all disorders between the two periods (p < 0.001). There was an increase in benign paroxysmal positional vertigo (BPPV) (2019 vs. 2020: 30.7 vs. 35%, p < 0.05) and psychogenic/persistent postural perceptual dizziness (PPPD) (2019 vs. 2020: 28.5 vs. 34.6%, p < 0.05) while a decrease in vascular vertigo during the epidemic (2019 vs. 2020: 13 vs. 9.6%, p < 0.05). During the epidemic, the top three causes of dizziness/vertigo were BPPV (35%), psychogenic/PPPD (34.6%), and vascular vertigo (9.6%). A female predominance was observed in BPPV (women = 67.7%, p < 0.05) and psychogenic/PPPD (women = 67.6%, p < 0.05). In addition, the etiology ratio of different age groups was significantly different (p < 0.001). The most common cause for young and young-old patients was BPPV, and the most common cause for middle-aged and old-old patients was psychogenic/PPPD. Conclusion: The absolute number of outpatients with dizziness/vertigo during the COVID-19 pandemic was reduced during the early period of the COVID-19 outbreak. BPPV and psychogenic/PPPD were more abundant, and vascular vertigo was less frequent. Based on those data, health-care management policy for dizziness/vertigo and mental disorder should be developed during the outbreak of COVID-19 and other infective diseases.

Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (pre-dementia) stage

The paper presents experts' opinion on the clinical manifestations and diagnosis of chronic cerebrovascular disease (CVD) (chronic cerebral ischemia (CCI) and dyscirculatory encephalopathy (DEP)) at the pre-dementia stage. It is noted that DEP/CCI is a common diagnosis in Russian neurological practice, the criteria for which have not been updated for a long time. DEP/CCI most often develops in the presence of cerebral small artery (CSA) disease (cerebral microangiopathy (CMA)), the severity of which can be quantified by magnetic resonance imaging. The main clinical manifestation of DEP/CCI is cognitive impairment that may be subjective or moderate at the pre-dementia stage. Emotional disorders (apathy, depression, anxiety) and instability are considered as possible manifestations of CSA disease. It is noted that headache and vestibular vertigo are not caused by chronic CVD; while in patients with CMA, they are usually associated with other diseases (primary headache, peripheral vestibular vertigo, and vestibular migraine). The diagnosis of DEP/CCI should be based on the presence of cognitive impairment, reliable neuroimaging signs of CVD, and the exclusion of another cause of cognitive impairment.

Consciously processing balance leads to distorted perceptions of instability in older adults

Background

Persistent dizziness without a clear cause is common in older adults. We explored whether an anxiety-driven preoccupation with consciously processing balance may underpin the distorted perceptions of unsteadiness that characterises ‘unexplained’ dizziness in older adults.

Methods

We experimentally induced anxiety about losing one’s balance (through a postural threat manipulation) in a cohort of asymptomatic older adults and evaluated associated changes in perceived stability, conscious movement processing and postural control. These outcomes were also assessed when performing a distracting cognitive task designed to prevent anxiety-related conscious movement processing, in addition to during baseline conditions (ground level).

Results

Despite a lack of increase in postural sway amplitude (p = 0.316), participants reported reductions in perceived stability during postural threat compared to baseline (p < 0.001). A multiple linear regression revealed that anxiety-related conscious movement processing independently predicted perceptions of instability during this condition (p = 0.006). These changes were accompanied by alterations in postural control previously associated with functional dizziness, namely high-frequency postural sway and disrupted interaction between open- and closed-loop postural control (ps < 0.014). While the distraction task successfully reduced conscious processing (p = 0.012), leading to greater perceived stability (p = 0.010), further increases in both postural sway frequency (p = 0.002) and dominance of closed-loop control (p = 0.029) were observed.

Conclusion

These findings implicate the role of conscious movement processing in the formation of distorted perceptions of unsteadiness, suggesting that such perceptions may be modifiable by reducing an over-reliance on conscious processes to regulate balance.

Neurological update: dizziness

The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.