Causes of persistent dizziness in elderly patients in primary care

[Dizziness from an internistic perspective]

Dizziness is a common symptom with many potential causes. Medical and especially cardiac aetiologies are associated with a poor overall prognosis such that identification of the underlying cause is essential. This article gives an overview of possible causes of dizziness, how the differential diagnoses should be investigated, and describes potential therapeutic approaches to the treatment of the most important underlying conditions.

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.

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.

The effect of accompanying anxiety and depression on patients with different vestibular syndromes

Objective

This study aims to investigate the situation of vertigo disorder combined with anxiety and depression in patients with different types of vestibular syndrome.

Methods

A total of 330 patients with vertigo in otolaryngology outpatient department were selected, and clinical information such as age, gender, and scores of Dizziness handicap inventory (DHI), Generalized anxiety disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) were collected. Analyzed the differences among acute vestibular syndrome (AVS), episodic vestibular syndrome (EVS) and chronic vestibular syndrome (CVS) in terms of age, gender, comorbid anxiety and depression, and the multivariate ordered logistic regression analysis was used to evaluate the relationship between the above factors and the degree of vertigo disorder.

Results

The three types of vestibular syndrome had no significant difference in age composition, sex composition, anxiety and depression. There was no significant difference in the probability of anxiety and depression among vertigo patients of different ages and genders. The total score of vertigo disorder and each sub-item score were higher in patients with anxiety and depression. Patients with anxiety mainly manifested in EVS and CVS, while patients with depression mainly manifested in EVS and AVS. The probability of increased vertigo in anxious patients was 4.65 times that of non-anxious patients, and the probability of increased vertigo in depressed patients was 3.49 times that of non-depressed patients. Age and gender had no statistically significant effect on the degree of vertigo. In patients with EVS, anxiety and depression had a significant effect on the degree of vertigo; in patients with CVS, anxiety had a significant effect on the degree of vertigo, but depression had no significant effect.

Conclusion

Age and gender do not significantly affect the degree of vertigo disorder and mental state in various vestibular syndromes. Instead, anxiety and depression are the risk factors for aggravating the degree of vertigo disorder, and manifest differently in each type of vestibular syndrome. Therefore, it is necessary to use a quick scale tool to conduct a standardized screening of the psychological status of patients with vertigo.

Effectiveness of an evidence-based care pathway to improve mobility and participation in older patients with vertigo and balance disorders in primary care (MobilE-PHY2): study protocol for a multicentre cluster-randomised controlled trial

BACKGROUND

Vertigo, dizziness or balance disorders (VDB) are common leading symptoms in older people, which can have a negative impact on their mobility and participation in daily live, yet, diagnosis is challenging and specific treatment is often insufficient. An evidence-based, multidisciplinary care pathway (CPW) in primary care was developed and pilot tested in a previous study. The aim of the present study is to evaluate the effectiveness and safety of the CPW in terms of improving mobility and participation in community-dwelling older people with VDB in primary care.

METHODS

For this multicentre cluster randomised controlled clinic trial, general practitioners (GP) will be recruited in two regions of Germany. A total of 120 patients over 60 years old with VDB will be included. The intervention is an algorithmized CPW. GPs receive a checklist for standardise clinical decision making regarding diagnostic screening and treatment of VDB. Physiotherapists (PT) receive a decision tree for evidence-based physiotherapeutic clinical reasoning and treatment of VDB. Implementation strategies comprises educational trainings as well as a workshop to give a platform for exchange for the GPs and PTs, an information meeting and a pocket card for home care nurses and informal caregivers and telephone peer counselling to give all participants the capability, opportunity and the motivation to apply the intervention. In order to ensure an optimised usual care in the control group, GPs get an information meeting addressing the national guideline. The primary outcome is the impact of VDB on participation and mobility of patients after 6 month follow-up, assessed using the Dizziness Handicap Inventory (DHI) questionnaire. Secondary outcomes are physical activity, static and dynamic balance, falls and fear of falling as well as quality of life. We will also evaluate safety and health economic aspects of the intervention. Behavioural changes of the participants as well as barriers, facilitating factors and mechanisms of impact of the implementation will be investigated with a comprehensive process evaluation in a mixed-methods design.

DISCUSSION

With our results, we aim to improve evidence-based health care of community-dwelling older people with VDB in primary care.

TRIAL REGISTRATION

DRKS, DRKS00028524 retrospectively registered on March 24, 2022.

[Dizziness from an internistic perspective]

Dizziness is a common symptom with many potential causes. Medical and especially cardiac aetiologies are associated with a poor overall prognosis such that identification of the underlying cause is essential. This article gives an overview of possible causes of dizziness, how the differential diagnoses should be investigated, and describes potential therapeutic approaches to the treatment of the most important underlying conditions.

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.

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 Diagnostic Pathways: Factors Impacting Setting, Provider, and Diagnosis at Presentation

OBJECTIVE

Ensuring that patients with dizziness present to the most appropriate level of care and provider are key goals of quality and cost improvement efforts. Using a symptom-defined cohort of adults presenting for dizziness evaluations, we aimed to identify patient factors associated with ambulatory clinic vs emergency department (ED) presentations, evaluating provider specialty, and assigned diagnoses.

STUDY DESIGN

Cross-sectional study.

SETTING

OptumLabs Data Warehouse (OLDW), a longitudinal, real-world data asset with deidentified administrative claims.

METHODS

We performed a cross-sectional analysis of adults (older than 18 years) who received new dizziness diagnoses (2006-2015) and identified factors associated with setting and provider at initial presentation using multivariable regression models.

RESULTS

Of 805,454 individuals with dizziness (median age 52 years, 62% women, 29% black, Asian, or Hispanic), 23% presented to EDs and 77% to clinics (76% primary care, 7% otolaryngology, 5% cardiology, 3% neurology). Predictors of ED presentation were younger age, male sex, black race, lower education, and medical comorbidity. Predictors of primary care clinic presentation were older age and race/ethnicity other than white. Nonetiologic symptom diagnoses alone were assigned to 51% and were most associated with age older than 75 years (odds ratio, 2.90; 95% CI, 2.86-2.94).

CONCLUSION

Adults with dizziness often present to a level of care that may be higher than is optimal. Differential care seeking and diagnoses by age, sex, and race/ethnicity reflect influences beyond dizziness presentation acuity. Targeted patient resources, triage systems, provider education, and cross-specialty partnerships are needed to direct dizzy patients to appropriate settings and providers to improve care.

The Validity of Three New Driving Simulator Scenarios: Detecting Differences in Driving Performance by Difficulty and Driver Gender and Age

OBJECTIVE

We explored the convergent and discriminant validity of three driving simulation scenarios by comparing behaviors across gender and age groups, considering what we know about on-road driving.

BACKGROUND

Driving simulators offer a number of benefits, yet their use in real-world driver assessment is rare. More evidence is needed to support their use.

METHOD

A total of 104 participants completed a series of increasingly difficult driving simulation scenarios. Linear mixed models were estimated to determine if behaviors changed with increasing difficulty and whether outcomes varied by age and gender, thereby demonstrating convergent and discriminant validity, respectively.

RESULTS

Drivers adapted velocity, steering, acceleration, and gap acceptance according to difficulty, and the degree of adaptation differed by gender and age for some outcomes. For example, in a construction zone scenario, drivers reduced their mean velocities as congestion increased; males drove an average of 2.30 km/hr faster than females, and older participants drove more slowly than young (5.26 km/hr) and middle-aged drivers (6.59 km/hr). There was also an interaction between age and difficulty; older drivers did not reduce their velocities with increased difficulty.

CONCLUSION

This study provides further support for the ability of driving simulators to elicit behaviors similar to those seen in on-road driving and to differentiate between groups, suggesting that simulators could serve a supportive role in fitness-to-drive evaluations.

APPLICATION

Simulators have the potential to support driver assessment. However, this depends on the development of valid scenarios to benchmark safe driving behavior, and thereby identify deviations from safe driving behavior. The information gained through simulation may supplement other forms of assessment and possibly eliminate the need for on-road testing in some situations.

Prevalence of Vestibular Disorders in Independent People Over 50 That Experience Dizziness

People aged over 50 are the most likely to present to a physician for dizziness. It is important to identify the main cause of dizziness in order to develop the best treatment approach. Our goal was to determine the prevalence of benign paroxysmal positional vertigo (BPPV), and peripheral and central vestibular function in people that had experienced dizziness within the past year aged over 50. One hundred and ninety three community-dwelling participants aged 51–92 (68 ± 8.7 years; 117 females) were tested using the clinical and video head impulse test (cHIT and vHIT) to test high-frequency vestibular organ function; the head thrust dynamic visual acuity (htDVA) test to test high-frequency visual-stability; the dizziness handicap inventory (DHI) to measure the impact of dizziness; as well as sinusoidal and unidirectional rotational chair testing to test low- to mid-frequency peripheral and central vestibular function. From these assessments we computed the following measures: HIT gain; htDVA score; DHI score; sinusoidal (whole-body; 0.1–2 Hz with 30°/s peak-velocity) vestibulo-ocular reflex (VOR) gain and phase; transient (whole-body, 150°/s² acceleration to 50°/s constant velocity) VOR gain and time constant; optokinetic nystagmus (OKN) gain and time constant (whole-body, 50°/s constant velocity rotation). Our study showed that BPPV, and peripheral or central vestibular hypofunction were present in 34% of participants, suggesting a vestibular cause to their dizziness. Over half (57%) of these with a likely vestibular cause had BPPV, which is more than twice the percentage reported in other dizzy clinic studies. Our findings suggest that the physical DHI score and VOR time constant were best at detecting those with non-BPPV vestibular loss, but should always be used in conjunction with cHIT or vHIT, and that the htDVA score and vHIT gain were best at detecting differences between ipsilesional and contralesional sides.

Improving mobility and participation of older people with vertigo, dizziness and balance disorders in primary care using a care pathway: feasibility study and process evaluation

BACKGROUND

Community-dwelling older people are frequently affected by vertigo, dizziness and balance disorders (VDB). We previously developed a care pathway (CPW) to improve their mobility and participation by offering standardized approaches for general practitioners (GPs) and physical therapists (PTs). We aimed to assess the feasibility of the intervention, its implementation strategy and the study procedures in preparation for the subsequent main trial.

METHODS

This 12-week prospective cohort feasibility study was accompanied by a process evaluation designed according to the UK Medical Research Council's Guidance for developing and evaluating complex interventions. Patients with VDB (≥65 years), GPs and PTs in primary care were included. The intervention consisted of a diagnostic screening checklist for GPs and a guide for PTs. The implementation strategy included specific educational trainings and a telephone helpline. Data for mixed-method process evaluation were collected via standardized questionnaires, field notes and qualitative interviews. Quantitative data were analysed using descriptive statistics, qualitative data using content analysis.

RESULTS

A total of five GP practices (seven single GPs), 10 PT practices and 22 patients were included in the study. The recruitment of GPs and patients was challenging (response rates: GP practices: 28%, PT practices: 39%). Ninety-one percent of the patients and all health professionals completed the study. The health professionals responded well to the educational trainings; the utilization of the telephone helpline was low (one call each from GPs and PTs). Familiarisation with the routine of application of the intervention and positive attitudes were emphasized as facilitators of the implementation of the intervention, whereas a lack of time was mentioned as a barrier. Despite difficulties in the GPs' adherence to the intervention protocol, the GPs, PTs and patients saw benefit in the intervention. The patients' treatment adherence to physical therapy was good. There were minor issues in data collection, but no unintended consequences.

CONCLUSION

Although the process evaluation provided good support for the feasibility of study procedures, the intervention and its implementation strategy, we identified a need for improvement in recruitment of participants, the GP intervention part and the data collection procedures. The findings will inform the main trial to test the interventions effectiveness in a cluster RCT.

TRIAL REGISTRATION

Projektdatenbank Versorgungsforschung Deutschland (German registry Health Services Research) VfD_MobilE-PHY_17_003910, date of registration: 30.11.2017; Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00022918, date of registration: 03.09.2020 (retrospectively registered).

Relationship Between Chronic Conditions and Balance Disorders in Outpatients with Dizziness: A Hospital-Based Cross-Sectional Study

Background

Balance dysfunction is common in adult outpatients with dizziness, especially those who are older, which can lead to catastrophic outcomes such as falls. The aim of this study was to investigate the association between chronic conditions and balance disorders in patients with dizziness, especially those who are elderly.

Material/Methods

A cross-sectional study was conducted in adult outpatients diagnosed with dizziness referred to the Department of Otolaryngology at Beijing Tongren Hospital from September 2017 to August 2018. All of the patients completed a self-administered, structured questionnaire. Demographic data and information on history of chronic conditions were collected and the patients were divided into 2 groups based on whether their balance was normal or abnormal.

Results

Three hundred and thirty-two patients were included in this study, 168 in the normal balance group and 164 in the abnormal balance group. The incidence of chronic conditions, including hypertension and diabetes, in the abnormal balance group was higher than that in the normal balance group (all P<0.05). In subgroup analysis based on age, in those who were aged ≥60 years, the prevalence of chronic diseases was higher in the abnormal balance group than in the normal balance group (P=0.002), while there was no difference in age between the groups with abnormal and normal balance. Hypertension (OR: 2.268; 95%CI: 1.038–4.957; P<0.05) was a risk factor for balance disorders in elderly patients rather than those who were younger (P>0.05).

Conclusions

Our results show that chronic conditions are associated with balance function in older patients with dizziness. Thus, specialists should consider chronic conditions, especially hypertension, in elderly patients with dizziness.

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.

Vestibular rehabilitation in Europe: a survey of clinical and research practice

Vestibular rehabilitation (VR) is practiced across Europe but little in this area has been quantified. The aim of this study was to investigate current VR assessment, treatment, education, and research practices. This was an online, cross-sectional survey with 39 VR specific questions and four sections: demographics, current practice, education, and research. The survey was disseminated through the Dizzynet network to individual therapists through country-specific VR special interest groups. Results were analysed descriptively. A thematic approach was taken to analyse open questions. A total of 471 individuals (median age 41, range 23 - 68 years, 73.4% women), predominately physiotherapists (89.4%) from 20 European countries responded to the survey. They had worked for a median of 4 years (range < 1 - 35) in VR. The majority (58.7%) worked in hospital in-patient or out-patient settings and 21.4% in dedicated VR services. Most respondents specialized in neurology, care of the elderly (geriatrics), or otorhinolaryngology. VR was reported as hard/very hard to access by 48%, with the main barriers to access identified as lack of knowledge of health care professionals (particularly family physicians), lack of trained therapists, and lack of local services. Most respondents reported to know and treat benign paroxysmal positional vertigo (BPPV 87.5%), unilateral vestibular hypofunction (75.6%), and cervicogenic dizziness (63%). The use of vestibular assessment equipment varied widely. Over 70% used high-density foam and objective gait speed testing. Over 50% used dynamic visual acuity equipment. Infrared systems, Frenzel lenses, and dynamic posturography were not commonly employed (< 20%). The most frequently used physical outcome measures were the Clinical Test of the Sensory Interaction of Balance, Functional Gait Assessment/Dynamic Gait Index, and Romberg/Tandem Romberg. The Dizziness Handicap Inventory, Visual Analogue Scale, Falls Efficacy Scale, and the Vertigo Symptom Scale were the most commonly used patient reported outcome measures. Adaptation, balance, and habituation exercises were most frequently used (> 80%), with virtual reality used by 15.6%. Over 70% reported knowledge/use of Semont, Epley and Barbeque-Roll manoeuvres for the treatment of BPPV. Most education regarding VR was obtained at post-registration level (89.5%) with only 19% reporting pre-registration education. There was strong (78%) agreement that therapists should have professionally accredited postgraduate certification in VR, with blended learning the most popular mode. Three major research questions were identified for priority: management of specific conditions, effectiveness of VR, and mechanisms/factors influencing vestibular compensation and VR. In summary, the survey quantified current clinical practice in VR across Europe. Knowledge and treatment of common vestibular diseases was high, but use of published subjective and objective outcome measures as well as vestibular assessment varied widely. The results stress the need of improving both training of therapists and standards of care. A European approach, taking advantage of best practices in some countries, seems a reasonable approach.

The assessment of the balance system in cranial artery stenosis

INTRODUCTION

Vertigo and balance disorders are a significant clinical problem, especially in elderly patients. The narrowing of cranial vessels may be asymptomatic or produce neurological symptoms. Very often nonspecific signs of ischemia occur, such as headache, vertigo, or dizziness.

OBJECTIVE

The objective of the study was to assess the effect of carotid and vertebral arteries stenosis on the function of the equilibrium organ on the basis of electronystagmography and posturography.

MATERIAL

The study was conducted in 63 patients, presenting with carotid and vertebral arteries stenosis. The control group consisted of 32 healthy persons.

METHODS

All patients were subjected to precise audiological and otoneurological diagnostic examinations. Prior to being qualified for the study, patients were subjected to the assessment of arteries by means of Doppler ultrasonography. The vestibular organ was assessed by means of physical examination as well as by electronystagmography and posturography testing.

RESULTS AND CONCLUSIONS

The study revealed statistically significant reduction in the results of the equilibrium organ assessments in patients with carotid and vertebral arteries sclerosis as compared to the control group. Abnormal ENG records in the study group patients were observed particularly in the pendulum test, optokinetic test, and the assessment of positional nystagmus, possibly indicating disturbances within the central part of the equilibrium system. Disturbed blood flow in arteries had also an important impact on spinovestibular reflexes and resulted in disturbed postural stability control. On the basis of the conducted studies, it is concluded that diagnostic examinations for carotid and vertebral artery stenosis should be performed in patients with equilibrium system disorders.

[Clarification of dizziness in old age : Interdisciplinary diagnostic process]

The clinical symptom dizziness encompasses a broad range of complaints. The prevalence among older adults is high. Over the course of 1 year 50% of people over 80 years old, 30% of those between 70-80 years old and 20% between 60-70 years old contact a physician as a result of dizziness. The diagnostic process has to be well organized. The medical history and clinical examination are frequently underestimated but in many cases are crucial. Extensive investigations should only be carried out in cases of a firmly suspected diagnosis. A good interdisciplinary cooperation can positively influence the diagnostic process. The awareness of red flags also helps to detect emergency patients with dizziness. This article discusses the differential diagnosis of dizziness in older adults and provides appropriate recommendations for the diagnostic process.

Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review

Background

Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered.

The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC).

Methods

A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed.

Results

Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied.

The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators.

Conclusions

In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience.

Trial registration

PROSPERO 2018 CRD42018087689.

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.

A Smartphone-based gaming system for vestibular rehabilitation: A usability study

BACKGROUNDVestibular dysfunctions result in a wide range of impairments and can have debilitating consequences on a person's day-to-day activities. Conventional vestibular rehabilitation is effective but suffers from poor therapy compliance due to boredom. Virtual reality technology can make training more engaging and allow precise quantification of the training process. However, most existing technologies for vestibular rehabilitation are expensive and not suitable for use in patients' homes and most clinics. In this pilot study, we developed and evaluated the usability of a smartphone-based head-mounted display (HMD) for vestibular rehabilitation and quantified the simulator sickness induced by the system.METHODSTwo adaptive training games were developed to train discrete and rhythmic head movements in the pitch and yaw planes. The usability and simulator sickness associated with the system were evaluated in a single testing session on healthy subjects and patients with unilateral vestibular dysfunction. Additionally, the head movement kinematics measured during training was also analyzed using different movement quality measures.RESULTSA total of 15 healthy subjects and 15 patients underwent testing with the system. Both groups found the system to be highly usable (>80 score on the system usability scale). Following 20-30 min training with the system, healthy subjects reported minimal simulator sickness symptoms. On the other hand, patients reported a higher incidence rate for symptoms, which could have been the result of their vestibular condition.CONCLUSIONThe current study demonstrated the usability and safety of a smartphone-based system for vestibular rehabilitation. The system is compact, and affordable thus has the potential to become an excellent tool for home-based vestibular rehabilitation.

Clinical Profiles of Elderly Patients Presenting with Persistent Dizziness

BACKGROUND

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

OBJECTIVE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Dizziness and its association with walking speed and falls efficacy among older men and women in an urban population

Background

Dizziness is common among older people and falling is a feared complication.

Aim

The purpose of this study was to investigate the presence of dizziness and its association with falls, walking speed and fear of falling, including sex differences, among 79-year-olds. Secondary purposes were to describe the relationship between dizziness and falls to number of medications and diseases.

Method

The study consisted of the fifth cohort of Gothenburg’s H70 birth cohort studies. A sample of 662 79-year-olds (404 women, 258 men) were investigated with questions regarding dizziness, previous falls and falls efficacy [estimated according to the falls efficacy scale Swedish version (FES (S))]. Functional tests included self-selected and maximal walking speed over 20 m.

Results

Dizziness was reported among 51% of the women and by 58% of the men (p = 0.12). Approximately, 40% had fallen during the past 12 months (41% women, 38% of the men, p = 0.48). Dizziness was related to a higher risk of falls among women (OR 2.63 (95% CI 1.67−4.14, p < 0.0001), but not among men (OR 1.07, 95% CI 0.63−1.82, p = 0.8). Dizzy individuals had lower scores on FES (S) (p < 0.01), more medications (p < 0.001) and diseases (p < 0.001) than those without dizziness. Participants who reported dizziness walked 10% slower than participants without dizziness (p < 0.001).

Conclusion

Women with dizziness more often reported falls compared to women without dizziness—a trend that was not seen among men. Persons with dizziness walked slower. Many medications increased risk of falling; hence, number of medications alone might help pinpoint risk groups for falling.

Screening for Vestibular Disorders Using the Modified Clinical Test of Sensory Interaction and Balance and Tandem Walking With Eyes Closed

OBJECTIVES

Determine accurate cut-points and optimal combinations of screening tests of balance to detect patients with vestibular disorders.

STUDY DESIGN

Case-control study.

SETTING

Out-patient tertiary care.

SUBJECTS AND METHODS

Community-dwelling adults, without known neurological deficits or significant musculoskeletal disorders, including patients with vestibular disorders and healthy controls without vestibular disorders were tested while standing on medium density compliant foam with feet together and eyes closed under three head movement conditions, head stationary, and head moving in yaw and pitch at 0.33 Hz, for up to 30 seconds per trial. Dependent measures were trial duration, number of head movements during head movement trials, trunk kinematic measures, and number of correct tandem steps during tandem walking trials.

RESULTS

Receiver operator characteristics (ROC), sensitivity and specificity, and specific cut-points were calculated. Individual tests had moderate ROC values, from 0.67 to 0.84. ROC values were higher in the head moving trials than the head stationary trial and best for subjects aged 40 to 79. Using combined analyses of two or more tests, including published data on tandem walking, ROC values were higher, 0.80 to 0.90. Age- and sex-related performance differences were found.

CONCLUSION

Balance skills in standing and walking differ, so testing both skills is optimal and increases the likelihood of finding a deficit. Patients should be compared to age-appropriate norms. Kinematics and number of head movements were not very useful. This combined set of rapid, low-tech balance tests is useful in an initial approach to screening patients who may have vestibular disorders.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Relationship between vestibular dysfunction and quality of life in climacteric women

The hormonal changes in climacteric women may affect the vestibular system; however, it is not clear in the literature whether the presence of vestibular dysfunction associated with climacteric is related to poorer quality of life. The study sample was composed of 374 women (40-65 years). Socioeconomic and demographic data, menopausal status, practice of physical exercises, presence or absence of vestibular dysfunction, hypertension and diabetes, anthropometric measurements and quality of life (using the Utian Quality of Life Scale - UQoL) were collected. Statistical analyses were performed using the Pearson test, Anova, T-test, and multiple regression considering a significance level of 5%. A significant relationship was found between vestibular dysfunction and health (p = 0.02) and emotional (p = 0.01) domains of the UQoL. In addition, physical activity, menopausal status, body mass index (BMI), waist-hip ratio (WHR), household income and diastolic blood pressure (DBP) mean also remained significantly related to quality of life. A relationship between vestibular dysfunction and quality of life for health and emotional domains in climacteric women was observed.

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.

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.

Aortic valve stenosis awareness in Austria-results of a nationwide survey in 1001 subjects

Despite the prognostic significance of severe aortic valve stenosis, knowledge is limited in the general population. To document the status quo for Austria, knowledge about valvular heart disease/aortic valve stenosis was documented in 1001 participants >60 years of age. 6.7% of respondents were knowledgeable of aortic valve stenosis, with 1.6% being concerned about the condition (24.1% cancer, 18.8% Alzheimer’s disease, 15.1% stroke). 29.5% were familiar with valvular heart disease (76.7% heart attack, 36.9% stroke). Only 1/3 reported auscultation by their general practitioner (GP) at least every third visit. Typical symptoms of aortic valve stenosis were likely to be reported by 50%. After exposure to further information on aortic valve stenosis, only 20% reported to be more concerned and ready to obtain more disease-related information. Awareness of surgical and catheter-based treatment options was claimed by 77% of respondents. Awareness campaigns on valvular heart disease are warranted to improve patient care in Austria.

Working-age adults' perspectives on living with persistent postural-perceptual dizziness: a qualitative exploratory study

OBJECTIVES

To (a) explore the experiences of persistent postural-perceptual dizziness (PPPD), formerly chronic subjective dizziness on the personal, work and social lives of working-age adults; (b) enhance current understandings of the condition and its impact on the lives of working-age adults and (c) highlight points for consideration and importance to clinical practice.

METHODS

This qualitative exploratory study drew on interpretive descriptive methodology. Working-age adults (n=8) diagnosed with PPPD were recruited from a single New Zealand community-based specialist clinic. Data from interviews (n=8) and postinterview reflections (n=2) were analysed using thematic analysis.

RESULTS

Three themes were constructed: (1) It sounds like I'm crazy-referring to the lack of medical, social and self-validation associated with PPPD; (2) I'm a shadow of my former self-representing the impact of the condition on sense of self and life trajectory and (3) How will I survive?- highlighting individual coping processes.

CONCLUSION

This study contributed to the existing body of knowledge by highlighting the complexity and fluidity of experiencing PPPD. It also drew attention to the tension between the acute illness framework that forms the basis of many therapeutic interactions and the enduring psychosocial support needs of the person experiencing PPPD. The findings highlighted that contextual factors need to be taken into account and that a person-centred and biopsychosocial approach, rather than a condition-specific biomedical approach, is needed for care to be perceived as meaningful and satisfactory.

Patient screening for early detection of aortic stenosis (AS)-review of current practice and future perspectives

In Europe, approximately one million people over 75 years suffer from severe aortic stenosis (AS), one of the most serious and most common valve diseases, and this disease burden is increasing with the aging population. A diagnosis of severe symptomatic AS is associated with an average life expectancy of 2-3 years and necessitates a timely valve intervention. Guidelines for valve replacement therapy have been established but only a proportion of patients with symptomatic AS actually receive this life-saving treatment. The decision for valve intervention in asymptomatic patients with severe AS is often more challenging and likely results in fewer patients receiving treatment in comparison to their symptomatic counterparts. This article reviews the epidemiology and clinical manifestations of AS, the associated economic burden of AS to the healthcare system, the diagnosis of AS and the possible mechanisms for the introduction of routine screening in elderly patients. Elderly patients typically visit healthcare providers more frequently than younger patients, thereby providing increased opportunities for ad hoc AS screening and this, along with raising patient awareness of the symptoms of AS, has the potential to result in the earlier diagnosis and treatment of AS and increased patient survival.

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.

Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial

BACKGROUND

Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms.

METHODS AND FINDINGS

We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions.

CONCLUSIONS

A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Chiropractic treatment including instrument-assisted manipulation for non-specific dizziness and neck pain in community-dwelling older people: a feasibility randomised sham-controlled trial

Background

Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness.

Methods

This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65–85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms.

Results

Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic (n = 13) or sham (n = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n = 150 or n = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial.

Conclusions

Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000653763. Registered 13 June 2013.

Trial funding: Foundation for Chiropractic Research and Postgraduate Education (Denmark).

The Dizzy Patient: Consider a Second Diagnosis

BACKGROUND

Many patients with dizziness complain about >1 type of dizziness and therefore there may be ≥2 coexisting diagnoses.

OBJECTIVE

To determine how often a second or third diagnosis is present in a patient with dizziness and to establish what are the most common combinations of diagnoses.

STUDY DESIGN

Prospective, observational study in a tertiary center.

RESULTS

A consecutive cohort of 621 patients was included in the study. In 187 patients (30.1%) a second diagnosis was present. Within this group a third diagnosis was present in 35 (5.6%) patients. The most common second diagnosis was an anxiety disorder (50.1%).

CONCLUSIONS

Patients with dizziness frequently present themselves with >1 type of dizziness caused by 2 or 3 different diseases. In our study 30% of patients with dizziness have >1 diagnosis. Anxiety disorder is the most common second diagnosis.

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.

[Syncope, falls and vertigo]

Dizziness/vertigo, falls and syncope are among the most common reasons for seeking medical care. As clinical entities they share common pathogenetic and clinical features and differences. The diagnostic work-up can often be initiated in a general practitioner's or internist's practice and, if necessary, completed in an interdisciplinary emergency unit. Simple diagnostic tools can be used in an outpatient setting to obtain valuable diagnostic information. First and foremost, it is important to differentiate between prognostically favorable clinical events and potentially serious disease. In younger patients diagnostic procedures should primarily focus on potential structural cardiac disease and/or primary arrhythmia. The same applies to elderly patients in whom, however, multicausal clinical symptoms and severe complications in the case of falls are characteristic. Elderly patients frequently require the involvement of various clinical specialties to investigate a broad spectrum of potential differential diagnoses in an interdisciplinary diagnostic approach, which is not always available in practice. In the emergency unit, decisions regarding inpatient care need to be made individually. In elderly patients, inpatient care is sometimes necessary not only due to acute disease, but also in order to ensure social care. Geriatric day hospitals may be a suitable option for some of these patients.

Analysis of National Pharmacovigilance Data Associated with Statin Use in Korea

The aim of this study was to evaluate clinical manifestations, age distribution and risk factors of adverse drug reactions (ADRs) of statins. Korean Adverse Event Reporting System (KAERS) database records (July 2009-June 2014) on statin-treated adults were used. ADRs classified as 'certain', 'probable' and 'possible' based on the WHO-Uppsala Monitoring Centre criteria were analysed. The frequency of ADRs was compared between adults (18-64 years) and older people (age ≥65 years) groups. In total, 2161 ADRs from 1690 patients (579, 34.3% older people) were included for analysis. Mean patient age and ADRs per patient were 60.46 ± 12.72 years and 1.28, respectively. ADRs were reported with atorvastatin (48.4%), rosuvastatin (23.0%), pitavastatin (10.4%) and simvastatin (9.1%). The frequent ADRs were gastrointestinal (421 events, 19.5%), musculoskeletal (331, 15.3%), skin (312, 14.4%) and hepatobiliary disorders (286, 13.2%). Skin disorders were significantly more frequent in adults compared to those in older patients (16.3% versus 12.4%, p = 0.021). Common clinical symptoms were myalgia (263 events, 12.2%), dyspepsia (133, 6.2%) and pruritus (103, 4.8%). Myalgia was more frequently reported in adults (12.7% versus 9.5%, p = 0.039) and dizziness was more frequent in older people (3.4% versus 5.8%, p = 0.015). According to KAERS data, leading statin ADRs were gastrointestinal and musculoskeletal disorders. Myalgia and dyspepsia were the common clinical symptoms.

Age-related differences in Fukuda stepping and Babinski-Weil tests, within-day variability and test-retest reliability

BACKGROUND

The Fukuda stepping and Babinski-Weil tests are associated with unperceived body rotation and linear displacements in young adults, but performance in older adults on these two tests has yet to be determined.

AIM

The main purpose was to compare the performance and reliability of the Fukuda stepping and Babinski-Weil tests in young and older adults.

METHODS

Fifty older and 50 young adults executed three trials of each test on day 1 (test) and day 2 (retest). Lateral and longitudinal displacements and body rotation relative to the starting position were measured. Means and standard deviations (SD) were compared between the two groups with Mann-Whitney tests. Test-retest reliability was assessed with intra-class correlation coefficients (ICC). Foot preference was determined from the score on the Waterloo Footedness Questionnaire and correlated with test scores.

RESULTS

Lateral and longitudinal displacements were significantly larger in older than young participants on the Fukuda stepping test (p < .01) and significantly smaller on the Babinski-Weil test (p < .001). Older participants displayed a significantly smaller SD on the three Babinski-Weil test trials (p < .001). Displacement and rotation measures ICC ranged between 0.25 and 0.77 in older and between 0.58 and 0.80 in young participants. Foot preference correlated with rotation on the Fukuda stepping test in young (p < .05), but not in older participants (p > .05).

DISCUSSION AND CONCLUSION

Linear displacements, but not body rotation, were different between older and young adults. There was no clear age-related differences in test-retest reliability, but the moderate reliability indicates that performance can vary from day to day in both age groups.

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.

Guided and unguided internet-based vestibular rehabilitation versus usual care for dizzy adults of 50 years and older: a protocol for a three-armed randomised trial

INTRODUCTION

Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages.

METHODS AND ANALYSIS

A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners.

ETHICS AND DISSEMINATION

The ethical committee of the VU University Medical Center approved ethics and dissemination of the study protocol. The insights and results of this study will be widely disseminated through international peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Pre-results, NTR5712.

Is there a link between dizziness and vision? A systematic review

PURPOSE

The aim of this study was to systematically review the literature to investigate the link (if any) between vision and dizziness.

METHODS

Medline, CINAHL, AMED, Web of Science and The Cochrane Library were searched with keywords chosen to find articles which investigated the causes of dizziness and considered vision as a possible trigger. Citation chaining of all included papers was performed in addition to the hand searching of all reference lists. Unpublished literature was identified using www.opengrey.eu. The review considered studies involving adults which link, measure or attempt to improve any aspect of vision in relation to dizziness.

RESULTS

Nine thousand six hundred and eighty one possible references were found, and the abstracts were screened independently by two reviewers to determine if they should be included in the study. Thirteen papers were found which investigated whether dizziness was linked to an assessment of vision. Visual impairment measures were crude and typically self-report, or Snellen visual acuity with little or no measurement details. Five studies found an independent link between dizziness and vision, five found a weak association (typically finding a link when univariate analyses were used, but not when multivariate analyses were used), and three found no association. Studies finding a strong link were usually cross-sectional with a large study population whereas those finding a weak association had relatively small numbers of participants. Studies which did not find an association used a broad definition of dizziness that included the term light-headedness, an unreliable Rosenbaum near visual acuity chart or an unusual categorisation of visual acuity.

CONCLUSIONS

This review suggests that dizziness (although likely not 'light-headedness') is linked with poor vision although further studies using more appropriate measures of vision are recommended.