What Predicts Improvement of Dizziness after Multimodal and Interdisciplinary Day Care Treatment?

BACKGROUND: Vertigo and dizziness are common in community-dwelling people and can be treated in specialized multidisciplinary settings. To develop tailored interventions, however, we have to explore risk factors for favorable and unfavorable outcomes. METHODS: We prospectively investigated patients with chronic vertigo and dizziness subjected to our 5-day multimodal and interdisciplinary day care treatment in the Center for Vertigo and Dizziness of Jena University Hospital, Germany. The Vertigo Severity Scale (VSS), the Body Sensations Questionnaire (BSQ), the Hospital Anxiety and Depression Scale (HADS), the Agoraphobic Cognitions Questionnaire (ACQ), the Mobility Inventory (MI), and the burden and intensity of dizziness (using a visual analogue scale) were assessed at baseline (n = 754) and after 6 months (n = 444). In addition, 14 Likert-scaled questions were used to quantify the change in personal attitude and behavior towards the complaints after 6 months. RESULTS: Dizziness-related burden and intensity improved with a large effect size. The largest improvement was seen in the attitudes towards dizziness, the understanding of somatic causes, and the perceived ability to influence dizziness. However, the ability to work and to carry out professional activity was improved to a lesser extent. The overall improvement of dizziness was associated with the absence of a depressive mood, a short duration of vertigo, a lower VSS, a lower perceived intensity of vertigo, and distinct vertigo diagnoses, namely Meniere's disease, vestibular migraine, vestibular neuritis, vestibular paroxysmia, and vestibular schwannoma. Worsening of dizziness/vertigo was associated with depressive symptoms, permanent vertigo, distinct vertigo diagnoses (central vertigo, multisensory deficit), and a higher perceived burden due to vertigo. CONCLUSION: The six-month outcome of patients with dizziness presented to a specialized outpatient clinic appears to be favorable. Nevertheless, people with the abovementioned risk factors at baseline have less benefit and probably need adapted and tailored vertigo interventions to improve long-term outcome.

How Healthcare Utilization Due to Dizziness and Vertigo Differs Between Older and Younger Adults.

BACKGROUND: Vertigo and dizziness are common in older adults. We describe self-reported healthcare utilization because of dizziness and vertigo in older adults attending a tertiary care specialized vertigo center. METHODS: Data from 765 patients (45% were ≥60 years old) with chronic dizziness and vertigo who attended a daycare multimodal treatment program were recorded. Data included sociodemographic parameters, dizziness-related characteristics, the Body Sensations Questionnaire (BSQ), the Agoraphobic Cognitions Questionnaire (ACQ), and the Hospital Anxiety and Depression Scale (HADS). Also, healthcare utilization, including (1) physician and clinical services, (2) hospitalizations in the year before consulting the vertigo center, (3) prescription of drugs and other professional services were included. Descriptive statistics, exploratory data analysis, and regression models were used. RESULTS: Intensity of dizziness was similar in both age groups, however, distress due to dizziness was more severe in younger persons. Dizziness symptoms lasted longer in older adults than in younger persons. Older adults had a somatic diagnosis (74.6 vs. 35.0%) more frequently and reported more falls (37.2 vs. 28.5%) than younger individuals. Anxiety about bodily sensations was higher in younger patients (mean BSQ1 = 9.33 ± 5.6) than in older patients (mean BSQ1 = 6.72 ± 5.4). Older persons had fewer depressive symptoms (mean HADS depression = 5.8 ± 3.6 vs. 6.5 ± 4.1) and less anxiety (mean HADS anxiety = 5.7 ± 3.7 vs. 7.8 ± 4.1) than younger individuals. Younger people were more frequently hospitalized (24.4%) than older adults (16.3%) in the year before consulting the vertigo center. Also, younger patients and patients with non-somatic etiologies had considerably more consultations with healthcare providers than older patients. Older adults received less medication (50.3%), less physiotherapy (41%), and less psychological therapy (11.6%) for vertigo than younger people (59.7, 52.2, 20.4%, respectively). CONCLUSION: Age-associated differences in healthcare utilization were defined in selected patients attending a specialized vertigo center. Since dizziness is frequently a heterogeneous disorder requiring interdisciplinary care, its diagnostic and therapeutic work-up must be improved for older patients with dizziness.

Age-Associated Characteristics of Patients With Chronic Dizziness and Vertigo.

OBJECTIVE: The incidence of dizziness and vertigo is increasing with age, and symptoms lead to significant limitations in daily living and to disability in older patients. METHOD: Data of 1,752 patients with chronic dizziness/vertigo subjected to a tertiary care, specialized interdisciplinary vertigo center were analyzed. Age, gender, symptoms, medical diagnosis, and Dizziness Handicap Inventory (DHI) were collected based on a questionnaire and analysis of associated patient records. The patients were assigned to 3 age groups (< 41, 41-65, and > 65 years). RESULTS: 33.7% of the patients were older than 65 years. Frequency of symptoms and DHI score increased with age. Older patients reported less frequently about coexisting symptoms such as nausea, headache, tinnitus, ear pressure, and visual impairment. Multisensory deficit, central vertigo, bilateral vestibulopathy, and benign paroxysmal positional vertigo were diagnosed increasingly with age, while persistent postural-perceptual dizziness and vestibular migraine were diagnosed in the younger age groups. CONCLUSION: In the diagnostic work-up of older patients age-specific characteristics of dizziness/vertigo have to be considered. The older patient generally is more impaired by the symptoms but possibly will not report typical diagnosis-defining symptoms.

Impact of Common Dizziness Associated Symptoms on Dizziness Handicap in Older Adults.

Background: A cross-sectional observational study was designed to determine the impact of dizziness associated symptoms on the dizziness handicap inventory (DHI) in older adults (≥60 years). Methods: In total, 785 individuals referred to a multidisciplinary dizziness unit were assessed. Participants completed self-report questionnaires with general questions about symptoms of dizziness as well as the DHI. The DHI subscores (physical, functional, emotional) were calculated. Medical diagnoses were collected from the medical records of the patients. One-way MANOVA and networking analysis were used to analyze the impact of dizziness associated symptoms on dizziness handicap. Results: Most patients reported swaying dizziness (60.6%) and feeling of unsteadiness (59.8%) with substantial overlap between the types of dizziness. Most frequent dizziness associated symptoms were ear noise/tinnitus, visual problems, and nausea/vomiting. Network analysis revealed that visual disturbances, headache, and hearing impairment were associated with higher DHI and explained 12% of the DHI variance in the linear regression. In the one-way MANOVA visual problems and headache had an effect on all three DHI subscores, while hearing impairment was associated with the functional and emotional subscores of DHI. Conclusion: Distinct dizziness associated symptoms have substantial impact on dizziness handicap in older adults. A multifactorial assessment including these symptoms may assist in tailoring therapies to alleviate dizziness handicap in this group.

Multimodal treatment of persistent postural-perceptual dizziness.

BACKGROUND: Persistent postural-perceptual dizziness (PPPD) is a chronic disorder with fluctuating symptoms of dizziness, unsteadiness, or vertigo for at least three months. Its pathophysiological mechanisms give theoretical support for the use of multimodal treatment. However, there are different therapeutic programs and principles available, and their clinical effectiveness remains elusive. METHODS: A database of patients who participated in a day care multimodal treatment program was analyzed regarding the therapeutic effects on PPPD. Vertigo Severity Scale (VSS) and Hospital Anxiety and Depression Scale (HADS) were assessed before and 6 months after therapy. RESULTS: Of a total of 657 patients treated with a tertiary care multimodal treatment program, 46.4% met the criteria for PPPD. PPPD patients were younger than patients with somatic diagnoses and complained more distress due to dizziness. 63.6% completed the follow-up questionnaire. All patients showed significant changes in VSS and HADS anxiety, but the PPPD patients generally showed a tendency to improve more than the patients with somatic diagnoses. The change in the autonomic-anxiety subscore of VSS only reached statistical significance when comparing PPPD with somatic diagnoses (p = .002). CONCLUSIONS: Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication. However, large-scale, randomized, controlled trials are still missing. Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness. The study was not designed to detect diagnosis-specific effects, but patients with PPPD and patients with other vestibular disorders benefit from multimodal therapies.

In Older Patients Treated for Dizziness and Vertigo in Multimodal Rehabilitation Somatic Deficits Prevail While Anxiety Plays a Minor Role Compared to Young and Middle Aged Patients.

Objective: Many patients with dizziness and vertigo are of older age. It is still unclear which age-associated factors play a role in the treatment of dizziness and vertigo. Therefore, age-associated characteristics of patients subjected to an interdisciplinary day care approach for chronic vertigo and dizziness were analyzed. Subjects and Methods: 650 patients with chronic dizziness/vertigo subjected to a multimodal vestibular rehabilitation day care program were analyzed. Information concerning age, gender, medical diagnosis, medical consultations, technical diagnostics performed and therapy achieved before attending the clinic were collected. Furthermore, data were gathered using the Vertigo Severity Scale (VSS), Hospital Anxiety and Depression Scale (HADS), Mobility Inventory (MI), as well as the intensity of and the distress due to vertigo/dizziness using visual analog scales. As a follow-up, the VSS, HADS, MI, and the visual analog scales were collected again 6 months after attending the therapy program. Three age groups were compared to each other (<41, 41-65, and >65 years of age). Results: One-third of the patients were older than 65 years. This group had typical diagnoses with mainly organic deficits. In contrast to the dominance of mainly multifactorial, organic deficits the older patients reported less medical consultations, fewer technical diagnostics and even fewer treatments than the younger patients. The elderly scored significantly lower in total VSS, in VSS-V (vestibular-balance subscale), in VSS-A (autonomic-anxiety subscale) and in HADS-anxiety. Psychological diagnoses were clearly associated to the younger patients. 424 patients (65.2%) completed the follow-up questionnaire 6 months after attending the therapy week. The older patients revealed improvements of VSS-V and the Avoidance Alone scale of MI as well as decreased distress due to vertigo/dizziness. Conclusion: In the older patients, who took part in our vestibular rehabilitation program, mainly somatic deficits prevail while anxiety plays a minor role compared to young and middle aged patients. Older patients profited from vestibular rehabilitation especially in mobility and vestibular-balance. Therefore, vestibular rehabilitation programs for the elderly with a focus on physio- and occupational therapeutic interventions and less cognitive behavioral therapy may be reasonable.

Bilateral vestibulopathy with positive Tullio phenomenon.

We describe the case of a 34-year-old patient presenting with the unique combination of bilateral vestibulopathy in combination with noise- and pressure-induced nystagmus. Bilateral vestibular dysfunction was demonstrated by pathological results in video-based head impulse testing as well as in caloric testing. In contrast, cervical vestibular-evoked myogenic potentials were normal, demonstrating normal sacculus function. Due to the positive Tullio phenomenon, semicircular dehiscence syndrome was excluded. Recently, this symptom combination was related to the histopathological finding of vestibular atelectasis. LEVEL OF EVIDENCE: NA.Laryngoscope, 128:1223-1225, 2018.

Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis.

OBJECTIVE: Carotid endarterectomy and stenting have comparable efficacy in stroke prevention in asymptomatic carotid stenosis. In patients with carotid stenosis, cardiac events have a more than threefold higher incidence than cerebrovascular events. Autonomic dysfunction predicts cardiovascular morbidity and mortality, and carotid stenosis interferes with baroreceptor and chemoreceptor function. We assessed the effect of elective carotid revascularization (endarterectomy vs stenting) on autonomic function as a major prognostic factor of cardiovascular health. METHODS: In 42 patients with ≥70% asymptomatic extracranial carotid stenosis, autonomic function was determined by analysis of heart rate variability (total band power [TP], high frequency band power [HF], low-frequency band power [LF], very low frequency band power [VLF]), baroreflex sensitivity (αHF, αLF), respiratory chemoreflex sensitivity (central apnea-hypopnea index), and cardiac chemoreflex sensitivity (hyperoxic TP, HF, LF, and VLF ratios) before and 30 days after revascularization. RESULTS: Patients with endarterectomy were older than patients with stenting (69 ± 7 vs 62 ± 7 years; P ≤ .008) but did not differ in gender distribution and preintervention autonomic function. Compared with stenting, postintervention heart rate variability was higher (ln TP, 6.7 [95% confidence interval (CI), 6.3-7.0] vs 6.1 [95% CI, 5.8-6.5; P ≤ .009]; ln HF, 4.5 [95% CI, 4.1-5.0] vs 4.0 [95% CI, 3.4-4.5; P ≤ .05]; ln VLF, 6.0 [95% CI, 5.7-6.4] vs 5.5 [95% CI, 5.2-5.9; P ≤ .02]); respiratory chemoreflex sensitivity (central apnea-hypopnea index, 5.5 [95% CI, 2.8-8.2] vs 10.0 [95% CI, 6.9-13.1; P ≤. 01]) and cardiac chemoreflex sensitivity (TP ratio, 1.2 [95% CI, 1.1-1.3] vs 1.0 [95% CI, 0.9-1.0; P ≤ .0001]; HF ratio, 1.4 [95% CI, 1.2-1.5] vs 0.9 [95% CI, 0.8-1.1; P ≤ .001]; LF ratio, 1.5 [95% CI, 1.3-1.6] vs 1.0 [95% CI, 0.8-1.1; P ≤ .0001]; VLF ratio, 1.2 [95% CI, 1.1-1.3) vs 1.0 [95% CI, 0.9-1.1; P ≤ .002]) were lower after endarterectomy. Postintervention baroreflex sensitivity did not differ after endarterectomy and stenting. CONCLUSIONS: Autonomic function was better after endarterectomy than after stenting. Better autonomic function after endarterectomy was based on restoration of chemoreceptor but not baroreceptor function and may improve cardiovascular long-term outcome.

Sleep apnea and asymptomatic carotid stenosis: a complex interaction.

BACKGROUND: Carotid arteriosclerosis and sleep apnea are considered as independent risk factors for stroke. Whether sleep apnea mediates severity of carotid stenosis remains unclear. Sleep apnea comprises two pathophysiologic conditions: OSA and central sleep apnea (CSA). Although OSA results from upper airway occlusion, CSA reflects enhanced ventilatory drive mainly due to carotid chemoreceptor dysfunction. METHODS: Ninety-six patients with asymptomatic extracranial carotid stenosis of ≥ 50% underwent polysomnography to (1) determine prevalence and severity of sleep apnea for different degrees of carotid stenosis and (2) analyze associations between OSA and CSA, carotid stenosis severity, and other arteriosclerotic risk factors. RESULTS: Sleep apnea was present in 68.8% of patients with carotid stenosis. Prevalence and severity of sleep apnea increased with degree of stenosis (P ≤ .05) because of a rise in CSA (P ≤ .01) but not in OSA. Sleep apnea (OR, 3.8; P ≤ .03) and arterial hypertension (OR, 4.1; P ≤ .05) were associated with stenosis severity, whereas diabetes, smoking, dyslipidemia, BMI, age, and sex were not. Stenosis severity was related to CSA (P ≤ .06) but not to OSA. In addition, CSA but not OSA showed a strong association with arterial hypertension (OR, 12.5; P ≤ .02) and diabetes (OR, 4.5; P ≤ .04). CONCLUSIONS: Sleep apnea is highly prevalent in asymptomatic carotid stenosis. Further, it is associated with arteriosclerotic disease severity as well as presence of hypertension and diabetes. This vascular risk constellation seems to be more strongly connected with CSA than with OSA, possibly attributable to carotid chemoreceptor dysfunction. Because sleep apnea is well treatable, screening should be embedded in stroke prevention strategies.