Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

Chronic Unilateral Vestibular Hypofunction: Insights into Etiologies, Clinical Subtypes, Diagnostics and Quality of Life

Background/Objectives: Chronic unilateral vestibular hypofunction (UVH) can lead to disabling vestibular symptoms and a decrease in quality of life. The aim of this study was to investigate etiologies, clinical subtypes, symptoms, and quality of life (QoL) in patients with chronic UVH. Methods: A retrospective study was performed on 251 UVH patients in a tertiary referral center. Inclusion criteria comprised reduced or absent caloric responses, with a caloric asymmetry ratio ≥25%. Patients with central vestibular pathology, symptom duration <3 months, and incomplete responses to questionnaires were excluded. Patient records were assessed for etiologies, secondary vestibular diagnoses, clinical subtypes, and questionnaires related to QoL. Additionally, multiple linear regression analysis was performed to evaluate factors influencing QoL. Results: Thirteen different etiologies were identified, with Menière's Disease as the most prevalent (31%, n = 79). The most frequently reported secondary vestibular diagnoses were benign paroxysmal positional vertigo (BPPV) (21%, n = 54) and persistent postural perceptual dizziness (PPPD) (19%, n = 47). Five distinct clinical subtypes were identified: recurrent vertigo with UVH (47%), rapidly progressive UVH (25%), idiopathic/unknown UVH (18%), slowly progressive UVH (8%), and congenital UVH (2%). Over 80% of UVH patients experienced moderate-to-severe handicap, as indicated by the Dizziness Handicap Inventory. Approximately 20-25% of UVH patients exhibited moderate-to-severe depression and anxiety, based on the Hospital Anxiety and Depression Scale. Multiple linear regression analyses demonstrated that the presence of PPPD significantly reduced QoL in chronic UVH patients. Conclusions: Chronic UVH is a heterogeneous disorder. Secondary vestibular diagnoses like BPPV and PPPD often co-exist and can significantly impact QoL. A structured diagnostic approach and tailored interventions are crucial to address the diverse needs of UVH patients.

Association between dizziness and future falls and fall-related injuries in older adults: a systematic review and meta-analysis

BACKGROUND

Dizziness is common in older adults, especially in those attending falls services. Yet, the extent to which dizziness is associated with future falls has not been reviewed. This systematic review and meta-analysis assessed the association between dizziness and future falls and related injuries in older adults.

METHODS

EMBASE, CINAHL Plus, SCOPUS and PsycINFO databases were searched from inception to 5 February 2024. The review was registered on PROSPERO (registration ID: CRD42022371839). Meta-analyses were conducted for the associations of dizziness with future falls (including recurrent and injurious falls). Three meta-analyses were performed on different outcomes: any-type falls (≥1 falls), recurrent falls (≥2 falls) and injurious falls.

RESULTS

Twenty-nine articles were included in the systematic review (N = 103 306 participants). In a meta-analysis of 14 articles (N = 46 795 participants), dizziness was associated with significantly higher odds of any-type future falls (OR = 1.63, 95% CI = 1.44-1.84). In another meta-analysis involving seven articles (N = 5630 participants), individuals with dizziness also had significantly higher odds of future recurrent falls (OR = 1.98, 95% CI = 1.62-2.42). For both meta-analyses, significant overall associations were observed even when adjusted for important confounding variables. In contrast, a meta-analysis (three articles, N = 46 631 participants) revealed a lack of significant association between dizziness and future injurious falls (OR = 1.12, 95% CI = 0.87-1.45).

CONCLUSIONS

Dizziness is an independent predictor of future falls in older adults. These findings emphasise the importance of recognising dizziness as a risk factor for falls and implementing appropriate interventions.

Factors Related to Dizziness in Workers With Noise-Induced Hearing Loss in Brazil

OBJECTIVE

The purpose of this study was to describe the factors related to dizziness in workers with noise-induced hearing loss in Brazil.

METHOD

A cross-sectional study was carried out with a sample from noise-induced hearing loss reports (2007-2019). The dependent variable in this study was dizziness, and the independent variables were sociodemographic characteristics, comorbidities, symptoms, and noise characteristics in the work environment. Logistic regression analysis was performed.

RESULTS

A total of 3,824 individuals with noise-induced hearing loss in Brazil were analyzed. The prevalence of dizziness was 23.4% in the sample. Factors associated with dizziness were women (odds ratio [OR]: 2.10; 95% confidence interval [CI] [1.64, 2.69]), hypertension (OR: 1.68; 95% CI [1.38, 2.06]), headache (OR: 6.31; 95% CI [5.26, 7.57]), tinnitus (OR: 3.46; 95% CI [2.82, 4.25]), and continuous noise at the work environment (OR: 1.54; 95% CI [1.22, 1.94]).

CONCLUSIONS

The factors associated with the outcome-dizziness-were gender (female), systemic arterial hypertension, headache, tinnitus, and continuous exposure to workplace noise. Such findings demonstrate the importance of promoting a multifactorial approach to understanding dizziness among workers exposed to occupational noise.

Prospective diagnostic accuracy study of history taking and physical examination for adults with vertigo in general practice: study protocol

INTRODUCTION

Vertigo is a prevalent and burdensome symptom. More than 80% of patients with vertigo are primarily treated by their general practitioner (GP) and are never referred to a medical specialist. Despite this therapeutic responsibility, the GP's diagnostic toolkit has serious limitations. All recommended tests lack empirical evidence, because a diagnostic accuracy study on vestibular disorders ('How well does test x discriminate between patients with or without target condition y?') has never been performed in general practice. The VERtigo DIagnosis study aims to fill this gap.

METHODS AND ANALYSIS

We will perform a diagnostic accuracy study on vertigo of primary vestibular origin in general practice to assess the discriminative ability of history taking and physical examination. We will compare all index tests with a respective reference standard. We will focus on five target conditions that account for more than 95% of vertigo diagnoses in general practice: (1) benign paroxysmal positional vertigo, (2) vestibular neuritis, (3) Ménière's disease, (4) vestibular migraine (VM) and (5) central causes other than VM. As these five target conditions have a different pathophysiology and lack one generally accepted gold standard, we will use consensus diagnosis as a construct reference standard. Data for each patient, including history, physical examination and additional tests as recommended by experts in an international Delphi procedure, will be recorded on a standardised form and independently reviewed by a neurologist and otorhinolaryngologist. For each patient, the reviewers have to decide about the presence/absence of each target condition. We will calculate sensitivity, specificity, predictive values, likelihood ratios and diagnostic ORs, followed by decision rules for each target condition.

ETHICS AND DISSEMINATION

The study obtained approval from the Vrije Universiteit Medical Center Medical Ethical Review Committee (reference: 2022.0817-NL83111.029.22). We will publish our findings in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ISRCTN97250704.

Psychosocial Factors Associated with dizziness and chronic dizziness: a nationwide cross-sectional study

BACKGROUND

Dizziness is a common symptom in adults, and chronic dizziness, such as persistent postural-perceptual dizziness, is also frequently reported and affects the quality of life of patients. This study aimed to identify psychosocial factors related to dizziness and chronic dizziness in a large-scale nationwide cohort.

METHODS

This population-based cross-sectional study used the database of the Eighth Korea National Health and Nutrition Examination Survey in 2020. Data from 4,147 adults over 40 years old were analyzed, and 1,102 adults who experienced dizziness were included in the dizziness cohort. Demographic data, medical conditions, comorbidities, functional status variables, nutritional variables and psychological variables were collected. The pattern of depressive symptoms according to the severity of dizziness was analyzed by network analysis.

RESULTS

The prevalence rate of dizziness was 24.6% in the general population, and chronic dizziness (≥ 3 months) developed in 210 of 1,102 (17.1%) individuals who experienced dizziness. Multiple logistic regression analysis revealed that female sex, stress, and depression were associated with dizziness. Chronic dizziness was related to tympanic abnormalities, diabetes, short sleep duration, and higher levels of stress and depression. Psychomotor retardation/agitation was a central symptom of depression in patients with chronic dizziness.

CONCLUSIONS

This study found sex differences in factors associated with dizziness and identified psychosocial factors linked to chronic dizziness. Focusing on somatic factors rather than depressive symptoms may benefit patients with chronic dizziness.

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.

Vertigo and its burden of disease-Results from a population-based cohort study

Objectives

Vertigo describes symptoms of abnormal movement of the environment or the patient's own body. As such, it affects patients' quality of life, prevents them from following their daily activities, and increases healthcare utilization. The Global Burden of Disease Project aims to quantify morbidity and mortality worldwide. In 2013, a separate disability weight for vertigo was introduced. The aim of this study is to estimate the symptom burden of disease caused by vertigo.

Methods

This study analyzes data from the Gutenberg Health Study (GHS). The GHS is a population-based cohort study representative of the city of Mainz and its district. Participants were asked whether they suffered from vertigo and, if so, how bothered they felt by it, rating their distress on a six-level scale from 1 = little stressful to 6 = extremely stressful.

Results

Eight thousand five hundred and nineteen participants could be included in the study. The overall prevalence of vertigo was 21.6% (95%-confidence interval [CI] [20.7%; 22.5%]). Vertigo prevalence peaked in the age group of 55-64 years. Vertigo annoyance averaged 2.42 (± 1.28). When an annoyance of 3-6 was considered bothersome, the prevalence of bothersome vertigo was 8.1 % (95%-CI [7.5%; 8.7%]). Age-standardized to the European Standard Population 2013, vertigo caused a burden of 2102 years lived with disability per 100,000 population.

Conclusion

In this study, it was found that one in five people suffer at least occasionally from vertigo. This result suggests a significant burden of disease. This burden is reported at the symptom level. Future studies are needed to attribute the burden to specific causes.

Level of Evidence

2.

Outcomes and Patient Experience in Individuals With Longstanding Dizziness

PURPOSE

This study aimed to describe the relationship between changes in pre and post self-perceived dizziness handicap, scores on the patient health questionnaire, and perceptions of patient's value of being evaluated and managed by a multidisciplinary team.

METHOD

Seventy-eight patients completed the Dizziness Handicap Inventory (DHI) and Patient Health Questionnaire-Fourth Edition (PHQ-4) questionnaires post multidisciplinary clinical consultations and testing for the chief complaints of dizziness, unsteadiness, vertigo, or balance problems. The diagnoses of each patient were recorded from the clinical reports of each specialty consultation and were classified as structural, functional, or psychiatric. They were contacted by phone at least 6 months after their visit to obtain feedback regarding their symptoms and overall patient experience.

RESULTS

The change in DHI total score did not differ significantly by diagnosis (p = .56), indicating that patients experienced an improvement in DHI total score regardless of diagnosis. PHQ-4 anxiety scores worsened by a mean of 0.7 points for those with structural diagnoses (p = .04), improved by a mean of 0.7 points for psychiatric diagnoses (p = .16), and improved by a mean of 0.3 points for functional diagnoses (p = .39). Only seven patients would not recommend the team to a family or friend; these patients tended to report worsening DHI total scores (p = .27) compared to the significant improvement in DHI total scores for patients who would make such a recommendation (p < .001). Similarly, only 13 patients did not feel the information they received had a positive impact; these patients tended to report worsening DHI total scores (p = .18) compared to the significant improvement in DHI total scores for patients who did feel the information had a positive impact (p < .001).

DISCUSSION

The assessment and management of patients with chronic dizziness is challenging due to symptoms arising from multiple etiologies. Our finding of a vast difference between high satisfaction and relatively unchanged dizziness handicap suggests that there is value in seeing a multidisciplinary team where consultations are unhurried, care is coordinated, and expectations regarding treatment can be managed.

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Background

Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient.

Materials and methods

Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses.

Results

A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048).

Conclusion

The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.

Measuring the Effect of Smoking or Tobacco Use on Vertigo Among the Adult Population in the Kingdom of Saudi Arabia

Background Smoking is widespread at all ages in Saudi society. In addition, complaints of vertigo are common. A key problem is how smoking affects vertigo and, thus, quality of life. Researchers have investigated the association between smoking and vertigo and found that smoking may be a risk factor for vertigo, but this association is not clear. The current study aims to investigate the association between smoking and vertigo. Materials and methods We conducted a cross-sectional study from March 2022 to January 2023 to investigate the effect of smoking on vertigo in Saudi Arabia's adult population. Results We found that smokers were more prone to vertigo than non-smokers. In addition, the severity of vertigo increases as the number of cigarettes smoked or the length of time in years that the person has smoked increases. Conclusion The findings of the study should inspire more research into the impact of demographic factors on vertigo among smokers.

Chronic diseases and health conditions in adolescents: Sex inequalities

OBJECTIVE

To estimate the prevalence of chronic diseases and health conditions in adolescents from Campinas (São Paulo), investigating sex differences according to age group.

METHODS

This population-based study analyzed data from the ISACamp 2014/15 health survey, with a total of 1,022 adolescents interviewed. The interviewees consisted of 517 boys and 505 girls; 492 of them in the ten to 14 age group and 530 in the 15 to 19 age group. We verified the associations using the χ2 test with Rao Scott adjustment and estimated prevalence ratios (PR) with multiple Poisson regression adjusted for age. Analyses were also stratified by age group.

RESULTS

Respiratory diseases, such as rhinitis (25.3%), sinusitis (15.7%), and asthma (10.9%), were the most prevalent among adolescents. Health complaints were high, especially headaches (39.5%), emotional conditions (34.5%), allergies (27.5%), and back pain (21.3%). More than 22.0% of adolescents reported having three or more health conditions. Girls declared a higher number of health conditions (three or more) than boys (PR=2.27).

CONCLUSION

The study showed that adolescents presented a significant number of health conditions, particularly regarding complaints, indicating the need for clinical care and public policies aimed at controlling and preventing these diseases in this age group.

Exposure to anticholinergic and sedative medication is associated with impaired functioning in older people with vertigo, dizziness and balance disorders-Results from the longitudinal multicenter study MobilE-TRA

Introduction: Anticholinergic and sedative medication is prescribed for various conditions in older patients. While the general association between anticholinergic and sedative medication and impaired functioning is well established, its specific role in older individuals with vertigo, dizziness, and balance disorders (VDB) is still incompletely understood. The objective of this study was to investigate, whether an exposure to anticholinergic and sedative medication is associated with lower generic and lower vertigo-specific functioning in older patients with VDB. Methods: Data originates from the longitudinal multicenter study MobilE-TRA with two follow-ups, conducted from 2017 to 2019 in two German federal states. Exposure to anticholinergic and sedative medication was quantified using the drug burden index (DBI). Generic functioning was assessed by the Health Assessment Questionnaire Disability Index, appraising the amount of difficulties in performing activities of daily living (ADL). Vertigo-specific functioning was measured using the Vestibular Activities and Participation (VAP) questionnaire, assessing patient-reported functioning regarding activities of daily living that are difficult to perform because of their propensity to provoke VDB (Scale 1) as well as immediate consequences of VDB on activities and participation related to mobility (Scale 2). Longitudinal linear mixed models were applied to assess the association of exposure to anticholinergic and sedative medication at baseline and the level of generic and vertigo-specific functioning status over time. Results: An overall of 19 (7 from Bavaria) primary care physicians (mean age = 54 years, 29% female) recruited 158 (59% from Bavaria) patients with VDB (median age = 78 years, 70% female). Anticholinergic and sedative medication at baseline was present in 56 (35%) patients. An exposure to anticholinergic and sedative medication at baseline was significantly associated with lower generic functioning [Beta = 0.40, 95%-CI (0.18; 0.61)] and lower vertigo-specific functioning [VAP Scale 1: Beta = 2.47, 95%-CI (0.92; 4.02)], and VAP Scale 2: Beta = 3.74, 95%-CI [2.23; 5.24]). Conclusion: Our results highlight the importance of a close monitoring of anticholinergic and sedative medication use in older patients with VDB. When feasible, anticholinergic and sedative medication should be replaced by equivalent alternative therapies in order to potentially reduce the burden of VDB.

Impact of osteopathic manipulative techniques on the management of dizziness caused by neuro-otologic disorders: systematic review and meta-analysis

CONTEXT

Osteopathic manipulative treatment (OMT) has been utilized by osteopathic clinicians as primary or adjunctive management for dizziness caused by neuro-otologic disorders. To our knowledge, no current systematic reviews provide pooled estimates that evaluate the impact of OMT on dizziness.

OBJECTIVES

We aimed to systematically evaluate the effectiveness and safety of OMT and analogous techniques in the treatment of dizziness.

METHODS

We performed a literature search in CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database (AMED), EMCare, Physiotherapy Evidence Database (PEDro), PubMed, PsycINFO, Osteopathic Medicine Digital Library (OSTMED.DR), and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2021 for randomized controlled trials (RCTs) and prospective or retrospective observational studies of adult patients experiencing dizziness from neuro-otological disorders. Eligible studies compared the effectiveness of OMT or OMT analogous techniques with a comparator intervention, such as a sham manipulation, a different manual technique, standard of care, or a nonpharmacological intervention like exercise or behavioral therapy. Assessed outcomes included disability associated with dizziness, dizziness severity, dizziness frequency, risk of fall, improvement in quality of life (QOL), and return to work (RTW). Assessed harm outcomes included all-cause dropout (ACD) rates, dropouts due to inefficacy, and adverse events. The meta-analysis was based on the similarities between the OMT or OMT analogous technique and the comparator interventions. The risk of bias (ROB) was assessed utilizing a modified version of the Cochrane Risk of Bias Tool for RCTs and the Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) for observational studies. The quality of evidence was determined utilizing the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

There were 3,375 studies identified and screened, and the full text of 47 of them were reviewed. Among those, 12 (11 RCTs, 1 observational study, n=367 participants) met the inclusion criteria for data extraction. Moderate-quality evidence showed that articular OMT techniques were associated with decreases (all p<0.01) in disability associated with dizziness (n=141, mean difference [MD]=-11, 95% confidence interval [CI]=-16.2 to -5.9), dizziness severity (n=158, MD=-1.6, 95% CI=-2.4 to -0.7), and dizziness frequency (n=136, MD=-0.6, 95% CI=-1.1 to -0.2). Low-quality evidence showed that articular OMT was not associated with ACD rates (odds ratio [OR]=2.2, 95% CI=0.5 to 10.2, p=0.31). When data were pooled for any type of OMT technique, findings were similar; however, disability associated with dizziness and ACD rates had high heterogeneity (I²=59 and 46%). No studies met all of the criteria for ROB.

CONCLUSIONS

The current review found moderate-quality evidence that treatment with articular OMT techniques was significantly associated with decreased disability associated with dizziness, dizziness severity, and dizziness frequency. However, our findings should be interpreted cautiously because of the high ROB and small sample sizes in the eligible studies.

Chronic diseases and health conditions in adolescents: Sex inequalities

ABSTRACT Objective: To estimate the prevalence of chronic diseases and health conditions in adolescents from Campinas (São Paulo), investigating sex differences according to age group. Methods: This population-based study analyzed data from the ISACamp 2014/15 health survey, with a total of 1,022 adolescents interviewed. The interviewees consisted of 517 boys and 505 girls; 492 of them in the ten to 14 age group and 530 in the 15 to 19 age group. We verified the associations using the χ2 test with Rao Scott adjustment and estimated prevalence ratios (PR) with multiple Poisson regression adjusted for age. Analyses were also stratified by age group. Results: Respiratory diseases, such as rhinitis (25.3%), sinusitis (15.7%), and asthma (10.9%), were the most prevalent among adolescents. Health complaints were high, especially headaches (39.5%), emotional conditions (34.5%), allergies (27.5%), and back pain (21.3%). More than 22.0% of adolescents reported having three or more health conditions. Girls declared a higher number of health conditions (three or more) than boys (PR=2.27). Conclusion: The study showed that adolescents presented a significant number of health conditions, particularly regarding complaints, indicating the need for clinical care and public policies aimed at controlling and preventing these diseases in this age group.

Prevalence and Risk Factors of Sarcopenia in Patients with Dizziness

OBJECTIVE

This study aimed to investigate the prevalence of sarcopenia and factors associated with sarcopenia in patients with dizziness.

STUDY DESIGN

This is a cross-sectional study.

PATIENTS

A total of 162 patients 65 years or older with the chief complaint of dizziness or vertigo (dizziness group) and 132 community-dwelling elderly (control group) were recruited during their visit to the otolaryngology clinic between May 2020 and October 2021.

RESULTS

Of the 162 patients with dizziness (dizziness group), 53 (32.7%) were classified as sarcopenia according to the 2019 criteria of the Asian Working Group for Sarcopenia. There were significant differences in the prevalence of sarcopenia between the dizziness group and the control group ( p < 0.01). The factors that significantly affected the sarcopenia, in order of greater odds ratio, were HADS_A, age, and DHI_Total (odds ratio = 1.223, 1.130, and 1.022, respectively).

CONCLUSIONS

The present study shows that (i) the prevalence of sarcopenia in patients with dizziness is higher than a community-dwelling elderly; (ii) patients with dizziness and sarcopenia have higher DHI_functional, DHI_emotional, DHI_total, and HADS_A compared with patients with dizziness but without sarcopenia; and (iii) age, HADS_A, and DHI were associated with sarcopenia in patients with dizziness.

A Deep Learning Model for Three-Dimensional Nystagmus Detection and Its Preliminary Application

Symptoms of vertigo are frequently reported and are usually accompanied by eye-movements called nystagmus. In this article, we designed a three-dimensional nystagmus recognition model and a benign paroxysmal positional vertigo automatic diagnosis system based on deep neural network architectures (Chinese Clinical Trials Registry ChiCTR-IOR-17010506). An object detection model was constructed to track the movement of the pupil centre. Convolutional neural network-based models were trained to detect nystagmus patterns in three dimensions. Our nystagmus detection models obtained high areas under the curve; 0.982 in horizontal tests, 0.893 in vertical tests, and 0.957 in torsional tests. Moreover, our automatic benign paroxysmal positional vertigo diagnosis system achieved a sensitivity of 0.8848, specificity of 0.8841, accuracy of 0.8845, and an F1 score of 0.8914. Compared with previous studies, our system provides a clinical reference, facilitates nystagmus detection and diagnosis, and it can be applied in real-world medical practices.

Referral trajectories in patients with vertigo, dizziness and balance disorders and their impact on health-related quality of life and functioning: results from the longitudinal multicenter study MobilE-TRA

Background

Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning and health-related quality of life (HRQoL).

Methods

Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients’ HRQoL and functioning.

Results

We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning.

Conclusion

Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11060-8.

Dizziness and benign paroxysmal positional vertigo among retirement home residents: a cross-sectional descriptive and interventional study

Background

The prevalence of dizziness increases with age. We aimed to determine the point prevalence of dizziness and, in particular, of benign paroxysmal positional vertigo (BPPV) among retirement home residents. Furthermore, we aimed to evaluate the efficacy of a 2-axis turntable based BPPV treatment.

Methods

We contacted all large retirement homes in or around the city of Zurich (Switzerland). 10 retirement homes (with a total of 536 residents) agreed to participate in this study. 83 rejected inquiries by residents led to a potential study population of 453 residents. After a structured interview evaluating the presence and characteristics of dizziness, all willing patients were tested for positional vertigo and nystagmus on a portable and manually operated 2-axis turntable that was transported to the retirement home. Testing consisted of the Dix-Hallpike and supine roll maneuvers to both sides. Participants were immediately treated with the appropriate liberation maneuver whenever BPPV was diagnosed. Otherwise, taking the resident’s medical history, a neuro-otological bedside examination, and a review of the available medical documentation was used to identify other causes of dizziness.

Results

Out of the 453 residents, 75 (16.6%; average age: 87.0 years; 68% female) were suffering from dizziness presently or in the recent past and gave their consent to participate in this study. Among the participants tested on the turntable (n = 71), BPPV was present in 11.3% (point prevalence). Time-related properties, triggering factors and qualitative attributes of vertigo or dizziness were not significantly different between the dizzy participants with and those without BPPV. In all BPPV patients, appropriate liberation maneuvers were successful.

Conclusions

BPPV could be demonstrated in about one tenth of retirement home residents with dizziness or recent dizziness. Such point prevalence of BPPV translates to a much higher yearly prevalence if one assumes that BPPV is not present on every day. Our finding suggests that retirement home residents suffering from dizziness should be regularly tested for BPPV and treated with appropriate liberation maneuvers, ideally on turntable to reduce strain.

Trial registration

ClinicalTrials.gov Identifier NCT03643354.

Can Type of Dizziness Influence the Vestibular Caloric Test Result?

Background:

The broad range of vestibular tests used to diagnose labyrinth diseases allows for a functional assessment of the vestibular system. Among the many tests performed, the caloric test is considered the gold standard by providing an objective measurement of the vestibular function for each labyrinth.

Objective:

to correlate the different types of dizziness with the caloric test result.

Methods:

a descriptive study was performed based on the previous records of vestibular tests performed on patients with body balance disorders evaluated at Audiology Service between 2000 and 2020. The variables evaluated were sex, age, hearing loss, tinnitus, and caloric test result.

Results:

the sample was composed of 892 patients, 654 (73.4%) women, and 238 (26.6%) men. Normal results were obtained for 57.4% (N = 514) of the individuals, while peripheral disease 40.1% (N = 357), and central disease 2.5% (N = 21) accounted for the remaining. Complaint of vertigo was not common in central disorders (P = .02; OR = 0.17) and instability was associated with bilateral vestibular weakness (P = 0.02; OR = 5.92). Vertigo associated with tinnitus and/or hearing loss was more frequent in the caloric test with peripheral abnormality (P = 0.008).

Conclusion:

complaints of vertigo associated with tinnitus and/or hearing loss must be directed for clinical observation of unilateral peripheral lesion and instability to central disease or bilateral peripheral lesion.

Effect of Virtual Reality Exercises on the Cognitive Status and Dual Motor Task Performance of the Aging Population

Aging is a global phenomenon affecting numerous developed and developing countries. During this process, the functional state of the body, especially the cognitive state, declines. This research investigated the impact of virtual reality exercises on the cognitive status and dual-task performance in the elderly of Tabriz city, Iran. Forty men with a mean age of 71.5 were selected and assigned to either the experimental (n = 20) or control groups (n = 20). Both groups completed the Mini-Mental State Examination for cognitive status. The pre-test was performed through the Timed Up and Go test (TUG) along with a countdown of numbers. Then, the experimental group practiced virtual driving for six weeks, while the control group received no treatment. After the treatment, both groups completed the post-test. At each stage, the test was performed as a dual motor task as well. Data were analyzed using the paired t-test and the independent sample t-test to show the intra-group and inter-group differences, respectively. The results showed a significant improvement in the cognitive status and dual-task performance of the elderly men after the six-week training period, which was also significant compared to the control group. Virtual reality driving can be used to improve the cognitive status and dual task performance of elderly men.

eHealth for Addressing Balance Disorders in the Elderly: Systematic Review

Background

The population is aging on a global scale, triggering vulnerability for chronic multimorbidity, balance disorders, and falls. Falls with injuries are the main cause of accidental death in the elderly population, representing a relevant public health problem. Balance disorder is a major risk factor for falling and represents one of the most frequent reasons for health care demand. The use of information and communication technologies to support distance healthcare (eHealth) represents an opportunity to improve the access and quality of health care services for the elderly. In recent years, several studies have addressed the potential of eHealth devices to assess the balance and risk of falling of elderly people. Remote rehabilitation has also been explored. However, the clinical applicability of these digital solutions for elderly people with balance disorders remains to be studied.

Objective

The aim of this review was to guide the clinical applicability of eHealth devices in providing the screening, assessment, and treatment of elderly people with balance disorders, but without neurological disease.

Methods

A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. Data were obtained through searching the PubMed, Google Scholar, Embase, and SciELO databases. Only randomized controlled trials (RCTs) or quasiexperimental studies (QESs) published between January 2015 and December 2019 were included. The quality of the evidence to respond to the research question was assessed using Joanna Briggs Institute (JBI) Critical Appraisal for RCTs and the JBI Critical Appraisal Checklist for QESs. RCTs were assessed using the Cochrane risk of bias tool. We provide a narrative synthesis of the main outcomes from the included studies.

Results

Among 1030 unduplicated articles retrieved, 21 articles were included in this review. Twelve studies explored different technology devices to obtain data about balance and risk of falling. Nine studies focused on different types of balance exercise training. A wide range of clinical tests, functional scales, classifications of faller participants, sensor-based tasks, intervention protocols, and follow-up times were used. Only one study described the clinical conditions of the participants. Instrumental tests of the inner ear were neither used as the gold-standard test nor performed in pre and postrehabilitation assessments.

Conclusions

eHealth has potential for providing additional health care to elderly people with balance disorder and risk of falling. In the included literature, the heterogeneity of populations under study, methodologies, eHealth devices, and time of follow-up did not allow for clear comparison to guide proper clinical applicability. This suggests that more rigorous studies are needed.

Once-Daily Incremental Vestibular-Ocular Reflex Adaptation Training in Patients With Chronic Peripheral Vestibular Hypofunction: A 1-Week Randomized Controlled Study

BACKGROUND AND PURPOSE

This was a double-blinded randomized controlled study to investigate the effects of once-daily incremental vestibulo-ocular reflex (VOR) training over 1 week in people with chronic peripheral vestibular hypofunction.

METHODS

A total of 24 patients with peripheral vestibular hypofunction were randomly assigned to intervention (n = 13) or control (n = 11) groups. Training consisted of either x1 (control) or incremental VOR adaptation exercises, delivered once daily for 15 minutes over 4 days in 1 week. Primary outcome: VOR gain with video-oculography. Secondary outcomes: Compensatory saccades measured using scleral search coils, dynamic visual acuity, static balance, gait, and subjective symptoms. Between-group differences were analyzed with a linear mixed-model with repeated measures.

RESULTS

There was a difference in the VOR gain increase between groups (P < 0.05). The incremental training group gain increased during active (13.4% ± 16.3%) and passive (12.1% ± 19.9%) head impulse testing (P < 0.02), whereas it did not for the control group (P = 0.59). The control group had reduced compensatory saccade latency (P < 0.02). Both groups had similarly improved dynamic visual acuity scores (P < 0.05). Both groups had improved dynamic gait index scores (P < 0.002); however, only the incremental group had improved scores for the 2 walks involving head oscillations at approximately 2 Hz (horizontal: P < 0.05; vertical: P < 0.02), increased gait speed (P < 0.02), and step length (P < 0.01) during normal gait, and improved total Dizziness Handicap Inventory (P < 0.05).

CONCLUSIONS

Our results suggest incremental VOR adaptation significantly improves gain, gait with head rotation, balance during gait, and symptoms in patients with chronic peripheral vestibular hypofunction more so than conventional x1 gaze-stabilizing exercises.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A336).

Relationship between physical activity and dizziness handicap inventory in patients with dizziness -A multivariate analysis

OBJECTIVE

A few studies have analyzed the physical activity in patients with dizziness. Levels of physical activity using 3-axial accelerometer were reported to be lower in patients with chronic dizziness compared to healthy adults. However, the sample size was small and confounding factors were not adjusted in the study. As the age, balance, anxiety, and depression likely contribute to dizziness, the contribution of physical activity to dizziness should be evaluated after adjusting for these potential confounders. We investigated the relationship between physical activity, postural stability, anxiety, and handicap in patients with dizziness using multivariate analysis.

METHODS

This cross-sectional study included 59 patients with dizziness. The physical activity was measured using a 3-axial accelerometer. We also assessed the Dizziness Handicap Inventory (DHI), Hospital and Anxiety and Depression Scale (HADS), and the total center of pressure path length eyes open and eyes closed (COP_EO, COP_EC). To be eligible for analysis, the participants were required to wear the accelerometer for at least four days, with at least 10 h/day of wear time each day.

RESULTS

There were significant differences in the light physical activity (LPA) and moderate to vigorous intensity physical activity (MVPA) between the mild (DHI ≦30) and severe (DHI > 60) groups. Factors that significantly affected the DHI_T score, in order of greater β, were LPA, COP_EC, female, and HADS_A (β = -0.546, 0.459, 0.437, 0.239, respectively).

CONCLUSIONS

The present study demonstrated that the patients in the severe group had shorter LPA and MVPA times than that of the patients in the mild group. Additionally, LPA was associated with DHI_T in patients with dizziness. Therefore, physical activity, especially LPA (e.g., activities of daily living), may need to be assessed in patients with dizziness.

[Quality of primary care and quality of life from the point of view of older patients with dizziness. Results oft the cohort study MobilE-TRA]

BACKGROUND

The treatment of elderly patients with dizziness/vertigo/balance disorders (VDB) can be challenging for their general practitioner. Patient-centered care with a focus on self-management support could be a possible approach. Primary objective of this study was to investigate the correlations between quality of primary care and health-related quality of life (HRQOL) from the patient's perspective.

METHOD

Data had been collected in the area of Munich and in the area of Dresden between 2017 and 2019. Questionnaires of n = 157 elderly patients from primary care practices in Munich and Dresden were evaluated. Multiple linear regression was used to analyse quality of care, physical activity, depression, and their correlations with HRQOL.

RESULTS

In this cohort of patients aged 65 to 94 no significant correlation between quality of care and HRQOL could be detected. Depression correlated negatively with HRQOL, whereas physical activity showed a positive correlation with HRQOL.

CONCLUSIONS

Physical activity can be beneficial for elderly dizzy patients' HRQOL. Additionally, a potential depression should be taken into account when treating patients with dizziness to improve their HRQOL. The results can be well transferred to elderly patients with VDB. Analysing more patients however, could increase the significance of the results.

Primary care providers perform more neurologic visits than neurologists among Medicare beneficiaries

RATIONALE, AIMS AND OBJECTIVES

Little is known about which medical providers, other than neurologists, are involved in the care of neurologic conditions. We aimed to describe the current distribution of outpatient neurologic care by provider type.

METHODS

We conducted a restrospective, cross-sectional analysis using a 20% national sample claims database that contains information on medical care utilizations from adult Fee-for-Service Medicare beneficiaries in 2015. We identified patient visits for evaluation and management services for common neurologic conditions and by medical provider type. The main outcome was the proportion of visits for neurologic conditions by medical provider type, both in aggregate and across neurologic conditions.

RESULTS

40% of neurologic visits were performed by primary care providers (PCPs) and 17.5% by neurologists. The most common neurologic conditions were back pain (49.3%), sleep disorders (8.0%), chronic pain/abnormality of gait (6.4%), peripheral neuropathy (5.9%), and stroke (5.5%). Neurologists cared for a large proportion of visits for Parkinson's disease (75.6% vs 20.8%), epilepsy (70.9% vs 26.6%), multiple sclerosis (63.9% vs 26.2%), other central NS disorders (54.2% vs 24.9%), and tremor/RLS/ALS (54.0% vs 31.2%) compared to PCPs. PCPs provided a greater proportion of visits for dizziness/vertigo (57.8% vs 9.3%) and headache/migraine (50.4% vs 35.0%) compared to neurologists.

CONCLUSIONS

PCPs perform more neurologic visits than neurologists. With the anticipated increased demand for neurologic care, strategies to optimize neurologic care delivery could consider expanding access to neurologists as well as supporting PCP care for neurologic conditions.

Short Term Efficacy of Modified Epley’s Maneuvre Assisted by Visual Aid Dynamic Device Versus Unassisted Maneuvre for the Treatment of Posterior Canal BPPV

Introduction:

Modified Epley’s maneuver is the recommended treatment for the Posterior Canal (PC) BPPV. To enhance the efficacy of this maneuver, an easy to perform visual aid device (DizzyFIX) guided modified Epley’s maneuver was studied.

Material and Methods:

This prospective, double-blind, randomized study included consecutive patients with PC-BPPV based on clinical history, neuro-otological examination, and positive Dix- Hallpike (DHP) test from January 2018 to March 2019 at a neurology clinic of western India. Patients were randomly assigned treatment with either visual aid device assisted modified Epley’s maneuver, which constituted the case group or by a placebo device guided modified Epley’s maneuver, which constituted the control group. DizzyFIX was used as a visual aid device in the case group. Patients were followed up at one hour and 24 hours with DHP by the blinded examiners to observe for remission.

Results:

Out of 280 patients (140 patients in each group), 6 from the case, and 2 from the controls were lost from the follow-up. Overall, 134 cases were compared to 138 controls. The success rate of remission in the case and the control group at one-hour was 79.19% vs. 48.30%, respectively, with a p-value of 0.003. Similarly, the success rate in the case and control group at 24 hours was 95.27% vs. 80.62%, respectively, with a p-value of 0.011. At 1 hour, unadjusted Odd Ratio (OR) was 4.13, (C.I. 95% 2.02- 8.46) and at 24 hours, it was 4.37, (C.I. 95% 1.39-13.77), which was significant even after adjustment of co-variables (OR 4.02, C.I. 95% 2.34- 8.26) and (OR 4.11, C.I. 95% 2.30- 14.26), respectively.

Conclusion:

For short term treatment of PC-BPPV, DizzyFIX assisted modified Epley’s maneuver is more efficacious than unassisted modified Epley’s maneuver.

Multiple Co-Occurring Vestibular Disorders Identified Using the Dizziness Symptom Profile

Purpose The purpose of the current investigation was to determine the interrelations among vestibular disorders from a data set generated from the patient perspective as compared to previous data generated from the physician's perspective. Method The data for the current investigation originated from a previously published study describing the development of the Dizziness Symptom Profile (DSP; Jacobson et al., 2019). The DSP is a 31-item patient self-report tool designed to help primary care physicians in the development of a differential diagnosis using the patient's level of agreement with each dizziness and symptom-related statement. Responses to these items converge on common vestibular diagnoses and were previously found to agree with ear specialist differential diagnoses 70.3% of the time. Data were collected for 131 subjects (M _age = 56.7 years, 72 women) seen for evaluation in a tertiary dizziness specialty clinic. For this study, the data were analyzed using descriptive statistics to determine the frequency of single diagnoses, multiple diagnoses, co-occurring diagnoses, and patterns of co-occurrence. Results Results indicated that 52.7% of patients endorsed a single vestibular diagnosis and 47.3% endorsed two or more vestibular diagnoses. Benign paroxysmal positional vertigo (BPPV) and vestibular migraine were the most common single diagnoses and also the most common co-occurring diagnoses. As the number of diagnoses endorsed on the DSP increased, so did the percentage of time that BPPV and vestibular migraine would occur. Conclusions Results support and extend the work of others but using data generated from the perspective of the patient. A slight majority of patients endorsed a single disorder, but almost as many patients endorsed more than one vestibular diagnosis. BPPV and vestibular migraine were the most common single vestibular diagnoses and also the most common co-occurring vestibular diagnoses; vestibular migraine was more common when multiple diagnoses were endorsed. Results suggest it is common for patients to volunteer symptoms that cannot be explained by a single vestibular diagnosis. This finding is in agreement with physician-generated diagnosis data. Clinicians should consider the possibility of co-occurring diagnoses in complicated patients or in patients who are not responding optimally to management of a single vestibular disorder. The DSP is a tool that encourages clinicians to consider multiple co-occurring vestibular disorders as the source of patient complaints.

The 25-item Dizziness Handicap Inventory was shortened for use in general practice by 60 percent

OBJECTIVES

The 25-item Dizziness Handicap Inventory (DHI) is the most used questionnaire to assess vestibular symptoms. However, the abbreviated 10-item DHI-S is more suitable for daily practice. The objective of this study was to assess validity, reliability, responsiveness, optimal cutoff point for substantial impairment, and minimally important change (MIC) of the DHI-S in general practice.

STUDY DESIGN AND SETTING

We performed a psychometric questionnaire evaluation in general practice. In a prospective cohort study, 415 adults with vestibular symptoms filled out the DHI at baseline, and 1-week, 6-month, and 10-year follow-up. DHI answers were used to calculate DHI-S scores. We assessed validity by criterion validity (Pearson's r) at each measurement. We used longitudinal measurements for test-retest reliability (intraclass correlation coefficient (ICC)) and responsiveness (r). We determined optimal DHI-S cutoff points for substantial impairment (≥30 DHI) and MIC (>11 DHI) with receiver operating characteristic (ROC) curve analyses.

RESULTS

DHI-S demonstrated excellent criterion validity (r = 0.93-0.96), test-retest reliability (ICC = 0.86), and responsiveness (r = 0.89). DHI-S reliably distinguished substantial impairment and identified MIC, with optimal DHI-S cutoff scores of ≥12 points and >5 points, respectively.

CONCLUSION

The DHI-S is a valid, reliable, and responsive questionnaire that could replace the DHI in general practice.

Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Non-inferiority Clinical Trial

Background and Objective

Vertigo derived from peripheral vestibular disorders is quite frequently encountered in daily clinical practice and can be a severely disabling symptom associated with substantial impairment of health-related quality of life for the affected patients. Betahistine, a structural analogue of histamine and presumably the most widely prescribed anti-vertigo drug worldwide, has previously been shown to be an effective and safe treatment for these patients. The objective of the present study was to evaluate whether the fixed combination of cinnarizine and dimenhydrinate (Arlevert^®) is non-inferior and thus a potentially useful alternative to betahistine dihydrochloride in the treatment of patients suffering from peripheral vestibular vertigo.

Methods

In this prospective, multicenter, double-blind, randomized, non-inferiority clinical trial, outpatients from 8 ENT clinics in Austria, Bulgaria, the Czech Republic and Russia were randomly assigned to receive three times daily one tablet of either the fixed combination cinnarizine 20 mg/dimenhydrinate 40 mg or betahistine dihydrochloride 16 mg for 4 weeks. Primary endpoint was the reduction of the mean vertigo score (MVS), a validated 12-item composite score defined as the mean of 6 vertigo symptoms (dystasia and walking unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, blackout) and 6 trigger factors for vertigo (change of position, bowing, getting up, driving by car/train, head movements, eye movement), after 4 weeks of therapy, as judged by the patient on a 5-point visual analogue scale (VAS). The non-inferiority margin was set to 0.3. Secondary outcomes included the patient’s and investigator’s judgment of global efficacy, the patient’s rating of impairment of daily activities, and safety/tolerability of the treatments.

Results

Three hundred and six patients (mean age 53.5 years, approximately 60% female) were enrolled and randomized to the fixed combination cinnarizine/dimenhydrinate (n = 152) or betahistine (n = 154) groups; 297 patients completed the study and 294 (146 and 148, respectively) were valid for the per-protocol analysis, which was used for the non-inferiority analysis. Treatment with cinnarizine/dimenhydrinate led to a stronger reduction of the MVS [least squares mean (LSM)] after 4-week therapy (primary endpoint) in comparison to betahistine (0.395 vs 0.488; difference: − 0.093, 95% CI − 0.180; − 0.007, p = 0.035); since the upper limit of the two-sided 95% confidence interval was not only below the non-inferiority margin of 0.3, but also entirely below 0, superiority of the fixed combination could be demonstrated. The combination preparation was also more effective after 1 week of therapy and received more favorable patient’s ratings on overall efficacy and impairment of daily activities. Both treatments were very well tolerated. Only 12 patients (3.92%) reported 13 non-serious adverse events; 2 cinnarizine/dimenhydrinate-treated patients discontinued the study prematurely due to adverse events as compared to 5 betahistine-treated patients.

Conclusion

The fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg was found to be not only non-inferior, but superior to betahistine 16 mg in the improvement of peripheral vestibular vertigo. Furthermore, taking into account a good and slightly favorable safety profile, the present study provides evidence that the fixed-combination preparation is a potent and even superior alternative to betahistine in the treatment of vertigo related to peripheral vestibular disorders.

Study Registration

EudraCT No. 2011-004025-27.

Economic burden of vertigo: a systematic review

BACKGROUND

Vertigo, a highly prevalent disease, imposes a rising burden on the health care system, exacerbated by the ageing of the population; and further, contributes to a wide span of indirect burden due to reduced capacity to work or need of assistance in activities of daily living. The aim of this review was to summarise the evidence on the economic burden of vertigo.

METHODS

All original studies published between 2008 and 2018 about the economic evaluation of peripheral or central vestibular vertigo in developed countries were considered eligible, unrestricted to setting, health care provider, or study type.

RESULTS

The electronic search in three databases identified 154 studies from which 16 qualified for inclusion. All studies presented partial economic evaluation referring to a variety of vestibular vertigo including unspecified vertigo. Nine studies presented monetised cost results and seven studies reported health care utilization. Direct costs derived mainly from repeated and not well-targeted consultations at all levels of health care, excessive use of diagnostic imaging, and/or of emergency care. Considerable societal burden was caused by decreased productivity, mainly due to work absenteeism.

CONCLUSION

To the best of our knowledge, this is the first systematic review of the existing evidence of the economic burden of vertigo. The lack of conclusive evidence revealed apparent targets of future research. First, studies of diagnostics and therapies for vestibular disease should include cost-effectiveness considerations. Population-based studies of health services utilization should include simple vestibular assessments to get more reliable estimates of the burden of disease and associated costs on the level of the general population. Further, clinical and population-based registries that include patients with vestibular disease, should consider collecting long-term data of societal burden. Primary data collection should increasingly include assessment of health care utilization e.g. by linking their diagnoses and outcomes to routine data from health insurances.

Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial

OBJECTIVE

To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice.

DESIGN

Pragmatic, three armed, parallel group, individually randomised controlled trial.

SETTING

59 general practices in the Netherlands.

PARTICIPANTS

322 adults aged 50 and older with a chronic vestibular syndrome.

INTERVENTIONS

Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions.

MAIN OUTCOME MEASURES

The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events.

RESULTS

In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial.

CONCLUSION

Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice.

TRIAL REGISTRATION

Netherlands Trial Register NTR5712.

The Prevalence and Persistence of Dizziness in Older European Home Care Recipients: A Prospective Cohort Study

OBJECTIVES

The prevalence of different geriatric syndromes in older home care (HC) recipients is yet to be determined. Dizziness is often regarded as a geriatric syndrome. The natural course of dizziness in older people is still unknown, because of a lack of longitudinal studies. The objective of this study was to investigate the prevalence and persistence of dizziness in HC recipients.

DESIGN

Prospective cohort study.

SETTING

Home care organizations in 6 European countries participating in the EU-funded Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project.

PARTICIPANTS

2616 community-dwelling long-term HC recipients aged 65 years or older.

METHODS

Data were collected at baseline and 6 and 12 months by using the interRAI Home Care instrument (interRAI-HC). Dizziness status was assessed by the number of days people experienced dizziness in the last 3 days (0-3) and later dichotomized for analyses (present or not in the last 3 days). Dizziness persistence was defined as the odds for dizzy people at baseline to also report dizziness at subsequent follow-up moments, compared with people who were not dizzy at baseline. The pattern of dizziness was descriptively analyzed in recipients who completed all measurements. Generalized estimating equations analysis was used to determine the persistence of dizziness symptoms.

RESULTS

The prevalence of dizziness of 2616 eligible HC recipients at baseline was 25.1%, ranging from 16.2% (Belgium) to 39.7% (Italy). The majority of dizzy recipients at baseline also experienced dizziness after 6 and 12 months (79.1%). Dizziness persistence was high at 6 months [odds ratio (OR) 57.8, 95% confidence interval (CI) 43.1-77.5] and at 12 months (OR 30.2, 95% CI 22.3-41.1).

CONCLUSIONS AND IMPLICATIONS

Dizziness in older HC recipients in Europe is common, and dizziness persistence is high. This warrants a more active approach in treating dizziness in older HC recipients.

Improved Oculomotor Physiology and Behavior After Unilateral Incremental Adaptation Training in a Person With Chronic Vestibular Hypofunction: A Case Report

BACKGROUND AND PURPOSE

Traditional vestibular rehabilitation therapies are effective in reducing vestibular hypofunction symptoms, but changes to the vestibulo-ocular reflex (VOR) are minimal. This controlled case report describes an increase in VOR after 6 months of incremental VOR adaptation (IVA) training in a person with chronic unilateral vestibular hypofunction.

CASE DESCRIPTION

The participant was a 58-year-old female with a confirmed (Neurologist P.D.C.) left vestibular lesion stable for 2 years prior to entering a clinical trial examining the effects of daily IVA training. She was evaluated monthly for self-reported symptoms (dizziness handicap inventory), VOR function (video head impulse test), and VOR behavior (Dynamic Visual Acuity test). Intervention consisted of 6 months of 15 minutes per day unassisted training using the IVA training regime with a device developed in our laboratory. The take-home device enables the VOR response to gradually normalize on the ipsilesional side via visual-vestibular mismatch training. The intervention was followed by a 6-month wash-out and 3-month control period. The control condition used the same training device set to function like standard VOR training indistinguishable to the participant.

OUTCOMES

After the intervention, ipsilesional VOR function improved substantially. The VOR adapted both via a 52% increase in slow-phase response and via 43% earlier onset compensatory saccades for passive head movements. In addition, the participant reported fewer symptoms and increased participation in sports and daily activities.

DISCUSSION

Here, a participant with chronic vestibular hypofunction showing improved oculomotor performance atypical for traditional vestibular rehabilitation therapies, subsequent to using the newly developed IVA technique, is presented. It is the first time to our knowledge an improvement of this magnitude has been demonstrated as well as sustained over an extended period of time.

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.

The Interrelations Between Different Causes of Dizziness: A Conceptual Framework for Understanding Vestibular Disorders

Background:

According to population-based studies that estimate disease prevalence, the majority of patients evaluated at dizziness clinics receive a single vestibular diagnosis. However, accumulating literature supports the notion that different vestibular disorders are interrelated and often underdiagnosed.

Objective:

Given the complexity and richness of these interrelations, we propose that a more inclusive conceptual framework to vestibular diagnostics that explicitly acknowledges this web of association will better inform vestibular differential diagnosis.

Methods:

A narrative review was performed using PubMed database. Articles were included if they defined a cohort of patients, who were given specific vestibular diagnosis. The interrelations among vestibular disorders were analyzed and placed within a conceptual framework.

Results:

The frequency of patients currently receiving multiple vestibular diagnoses in dizziness clinic is approximately 3.7% (1263/33 968 patients). The most common vestibular diagnoses encountered in the dizziness clinic include benign paroxysmal positional vertigo (BPPV), vestibular migraine, vestibular neuritis, and Ménière’s disease.

Conclusions:

A review of the literature demonstrates an intricate web of interconnections among different vestibular disorders such as BPPV, vestibular migraine, Ménière’s disease, vestibular neuritis, bilateral vestibulopathy, superior canal dehiscence syndrome, persistent postural perceptual dizziness, anxiety, head trauma, and aging, among others.

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.

Benign paroxysmal positional vertigo in the elderly: current insights

Balance disorders, unsteadiness, dizziness and vertigo in the elderly are a significant health problem, needing appropriate treatment. One third of elderly patients with vertigo were diagnosed with benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness in both primary care specialist Neurology and Ear Nose Throat settings. BPPV presents a specific paroxysmal positional nystagmus which can be obtained using the appropriate diagnostic positional test and can be treated effectively using specific therapeutic maneuvers. This review presents current insights into the diagnostic, pathogenetic and therapeutic aspects of BPPV in the elderly. BPPV in older patients does not differ significantly from BPPV in younger patients, with regard to pathogenesis, diagnosis and treatment. However, in older patients, its prevalence is higher and it responds less effectively to treatment, having a tendency for recurrence. Specific issues which should be considered in the elderly are: 1) difficulty in obtaining an accurate history; 2) difficulty in performing the diagnostic and therapeutic maneuvers, which should be executed with slow and gentle movements and extremely cautiously to avoid any vascular or orthopedic complications; and 3) the relation between BPPV and falls.

Effectiveness of a multifactorial intervention for dizziness in older people in primary care: A cluster randomised controlled trial

OBJECTIVES

Dizziness is common in older people. Physicians are often unable to identify a specific cause for dizziness in older people, even after an extensive diagnostic work-up. A prognosis-oriented approach, i.e. treating modifiable risk factors for an unfavourable course of dizziness, may reduce dizziness-related impairment in older people in primary care.

DESIGN

Cluster randomized controlled trial.

SETTING

45 primary care practices in The Netherlands.

PARTICIPANTS

168 participants aged ≥65y who consulted their general practitioner for dizziness and experienced significant dizziness-related impairment (Dizziness Handicap Inventory (DHI) ≥30). Participants were part of to the intervention group (n = 83) or control group (n = 85), depending on whether they were enlisted in an intervention practice or in a control practice.

INTERVENTIONS

The multifactorial intervention consisted of: medication adjustment in case of ≥3 prescribed fall-risk-increasing drugs (FRIDs) and/or stepped mental health care in case of anxiety disorder and/or depression and/or exercise therapy in case of impaired functional mobility. The intervention was compared to usual care.

OUTCOME MEASURES

The primary outcome was dizziness-related impairment. Secondary outcomes were quality of life (QoL), dizziness frequency, fall frequency, anxiety and depression, use of FRIDs.

RESULTS

Intention-to-treat analysis showed no significant intervention effect on dizziness-related impairment (DHI score difference -0.69 [95% CI -5.66;4.28]; p = 0.79). The intervention proved effective in reducing the number of FRIDs (FRID difference -0.48 [95% CI -0.89;-0.06]; p = 0.02). No significant intervention effects were found on other secondary outcomes. The uptake of and adherence to the interventions was significantly lower in patients eligible for ≥2 interventions compared to patients eligible for one intervention (p<0.001).

CONCLUSIONS

The multifactorial intervention for dizziness in older patients showed no significant intervention effect on most outcomes and adherence to the multifactorial intervention was low. Although multifactorial treatment for older dizzy people seems promising in theory, we question its feasibility in daily practice. Future research could focus on a sequential treatment for dizziness, e.g. measuring effectiveness of various evidence-based therapies in a stepwise approach.

Predicting an Unfavorable Course of Dizziness in Older Patients

PURPOSE

Because dizziness in older people is often chronic and can substantially affect daily functioning, it is important to identify those at risk for an unfavorable course of dizziness to optimize their care. We aimed to develop and externally validate a prediction model for an unfavorable course of dizziness in older patients in primary care, and to construct an easy-to-use risk prediction tool.

METHODS

We used data from 2 prospective cohorts: a development cohort with 203 patients aged 65 years or older who consulted their primary care physician for dizziness and had substantial dizziness-related impairment (Dizziness Handicap Inventory [DHI] ≥30), and a validation cohort with 415 patients aged 65 years or older who consulted their primary care physician for dizziness of any severity. An unfavorable course was defined as presence of substantial dizziness-related impairment (DHI ≥30) after 6 months.

RESULTS

Prevalence of an unfavorable course of dizziness was 73.9% in the development cohort and 43.6% in the validation cohort. Predictors in the final model were the score on the screening version of the DHI, age, history of arrhythmia, and looking up as a provoking factor. The model showed good calibration and fair discrimination (area under the curve = 0.77). On external validation, discriminative ability remained stable (area under the curve = 0.78). The constructed risk score was strongly correlated with the prediction model. Performance measures for risk score cut-off values are presented to determine the optimal cut-off point for clinical practice.

CONCLUSIONS

We developed an easy-to-use risk score for dizziness-related impairment in primary care. The risk score, consisting of only 4 predictors, will help primary care physicians identify patients at high risk for an unfavorable course of dizziness.

Changes in the augmentation index and postoperative orthostatic intolerance in orthopedic surgery: a prospective cohort study

BACKGROUND

Postoperative orthostatic intolerance (OI) can be a major obstacle to early ambulation and its determinants are poorly understood. We aimed to study postoperative changes in vascular tone and their potential association with OI in various orthopedic surgical settings.

METHODS

In this prospective cohort study, 350 patients undergoing total joint arthroplasty under neuraxial anesthesia or spine surgery under general anesthesia were enrolled. We determined the augmentation index (AI) as a measure of vascular tone and studied symptoms of OI using a validated questionnaire at various postoperative time points.

RESULTS

The AI was significantly reduced postoperatively (at spinal resolution in patients with neuraxial anesthesia or two hours postoperatively in general anesthesia) compared with baseline values in all procedures and did not subsequently return to baseline throughout the postoperative period in the majority of patients [252/335 (75.2%); P < 0.001]. The majority [260/342 (76.0%); P < 0.001] of patients had postoperative symptoms of OI. Nevertheless, no association was found between postoperative change in AI from baseline and postoperative symptoms of OI.

CONCLUSIONS

A significantly prolonged decrease in AI and symptoms of OI are common after orthopedic surgery. Nevertheless, an association between the two measures was not observed. While compensatory mechanisms may limit the influence of an AI decrease on symptoms of OI, more research is needed to understand the contributing factors and aid in the identification of patients at risk of OI.

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.

Association between smoking and the peripheral vestibular disorder: a retrospective cohort study

Common inner ear diseases include peripheral vestibular disorder (PVD) and hearing impairment. The association between smoking and peripheral vestibular disorder (PVD) is unclear. We examined associations between smoking and new PVD events. In this retrospective study, we consecutively enrolled 393 participants aged ≥20 years [mean age 65.3 years; males 133 (33.8%)] treated for hypertension, dyslipidaemia, or diabetes mellitus at a primary care clinic between November 2011 and March 2013. Participants were categorized as ever-smokers (including current and past -smokers; divided per <30 and ≥30 pack-years), and never-smokers. New PVD events were reported over a 1-year follow-up period. Hazard ratios (HR) for new onset PVD were estimated using the Cox proportional hazard regression model. Compared to never-smokers, the adjusted HR was 2.22 for ever-smokers and 2.70 for all ever-smokers with ≥30 pack-years among all 393 participants. Among male participants, compared to never-smokers, the adjusted HR was 4.41 for ever-smokers with ≥30 pack-years. A smoking history of ≥30 pack-years was strongly associated with the risk of new onset PVD in males but not, females. This study may assist patients with smoking cessation for the prevention of new PVD events among males.

Vertigo and dizziness in adolescents: Risk factors and their population attributable risk

OBJECTIVES

To assess potential risk factors for vertigo and dizziness in adolescents and to evaluate their variability by different vertigo types. The role of possible risk factors for vertigo and dizziness in adolescents and their population relevance needs to be addressed in order to design preventive strategies.

STUDY DESIGN

The study population consisted of 1482 school-children between the age of 12 and 19 years, who were instructed to fill out a questionnaire on different vertigo types and related potential risk factors. The questionnaire specifically asked for any vertigo, spinning vertigo, swaying vertigo, orthostatic dizziness, and unspecified dizziness. Further a wide range of potential risk factors were addressed including gender, stress, muscular pain in the neck and shoulder region, sleep duration, migraine, coffee and alcohol consumption, physical activity and smoking.

RESULTS

Gender, stress, muscular pain in the neck and shoulder region, sleep duration and migraine were identified as independent risk factors following mutual adjustment: The relative risk was 1.17 [1.10-1.25] for female sex, 1.07 [1.02-1.13] for stress, 1.24 [1.17-1.32] for muscular pain, and 1.09 [1.03-1.14] for migraine. The population attributable risk explained by these risk factors was 26%, with muscular pain, stress, and migraine accounting for 11%, 4%, and 3% respectively.

CONCLUSION

Several established risk factors in adults were also identified in adolescents. Risk factors amenable to prevention accounted for 17% of the total population risk. Therefore, interventions targeting these risk factors may be warranted.

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.

Carotid plaque is a new risk factor for peripheral vestibular disorder: a retrospective cohort study

Many chronic diseases are associated with dizziness or vertigo, as is peripheral vestibular disorder (PVD). Although carotid plaque development is linked to atherosclerosis, it is unclear whether such plaques can lead to the development of PVD. We therefore conducted this study to investigate the presence of an association between carotid plaque and new PVD events.In this retrospective study, we consecutively enrolled 393 patients ≥20 years old who had been treated for chronic diseases such as hypertension, dyslipidemia, and diabetes mellitus for ≥6 months at a primary care clinic (Oki Clinic, Japan) between November 2011 and March 2013. Carotid plaque presence was measured with high-resolution ultrasonography for all patients. During a 1-year follow-up period, an otorhinolaryngologist diagnosed and reported any new PVD events (the main end point). Hazard ratios (HRs) and 95% confidence intervals (CIs) for new PVD occurrence were estimated using the Cox proportional hazard regression model.The mean age of the participants was 65.5 years; 33.8% were men, and 12.7%, 82.4%, and 93.1% had diabetes mellitus, hypertension, and dyslipidemia, respectively. There were 76 new PVD events; patients with carotid plaque had a greater risk of such events (crude HR: 3.25; 95% CI: 1.62-6.52) compared to those without carotid plaque. This risk was even higher after adjusting for traditional risk factors for atherosclerosis (adjusted HR: 4.41; 95% CI: 1.75-11.14).Carotid plaques are associated with an increased risk of new PVD events.