Date Published: July 24, 2018
Publisher: Public Library of Science
Author(s): Jasmine C. Menant, Americo A. Migliaccio, Daina L. Sturnieks, Cameron Hicks, Joanne Lo, Mayna Ratanapongleka, Jessica Turner, Kim Delbaere, Nickolai Titov, Daniela Meinrath, Catherine McVeigh, Jacqueline C. T. Close, Stephen R. Lord, Alexander C. Tsai
Abstract: BackgroundDizziness 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 findingsWe 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.ConclusionsA 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 registrationAustralian New Zealand Clinical Trials Registry ACTRN12612000379819.
Partial Text: Dizziness is common in older people: prevalence rates in the community range between 10% and 30% [1–4] and increase with age [1,2,5]. Dizziness is often associated with a marked increase in self-reported functional disability [1,6], depressive symptoms [3,4], decreased participation in social activities, poor self-reported health, and reduced falls efficacy . In addition, the risk of experiencing multiple falls is significantly heightened among older people who report dizziness in the past , and this is likely to translate into an increased number of fall-related injuries. In fact, cross-sectional analysis from the 2008 United States National Health Interview Survey reveals that, among people who had reported a fall in the past 12 months, those who had reported dizziness or balance problems in that time were at 1.5-fold–increased odds of injury from the fall compared with their healthy peers (46% versus 36%) , and this association remained significant after controlling for age and sex . Dizziness is a subjective complaint that is commonly referred to by patients as vertigo, light-headedness, imbalance, or a ‘floating sensation’; terms that have traditionally been associated with vestibular, cardiovascular, balance, and psychological disorders, respectively. An additional complication is the variation in the natural course of dizziness that is very dependent on etiology, i.e., differential patterns in the progression from mild to severe forms, the addition of secondary symptoms such as anxiety, and potential spontaneous regression.
A total of 424 individuals were assessed for eligibility to participate in the study. Predominantly because they did not satisfy the inclusion criteria or declined to participate (Fig 1), 119 participants were deemed ineligible. Between 15 October 2012 and 2 March 2015, 305 people were recruited, consented to participate, and were then randomly allocated to the control (n = 151) or intervention (n = 154) groups. The included participants (62% women; n = 190) were aged 50 to 92 years (mean [SD]: 67.8 [8.3]). All had intact cognitive function according to their performance on the GPCOG tool of cognitive impairment. Participants in the 2 groups were well-matched with regard to baseline characteristics (Table 1).
This study investigated the effects of a multifactorial tailored intervention on dizziness handicap, frequency of dizziness episodes, and physical function in a sample of middle-aged and older people suffering from dizziness. Overall, our intervention significantly improved dizziness handicap. Given that around 12% of the community aged over 50 years report dizziness , using comprehensive objective assessment and individualized evidence-based interventions has the potential to offer a more effective and efficient approach to this common problem.
Our randomized controlled trial provides evidence that a multifactorial, tailored pragmatic approach, involving evidence-based therapies, is effective in improving dizziness handicap in a sample of community-living people aged 50 years and over self-reporting dizziness. Our findings therefore support the implementation of a multifactorial assessment combined with tailored interventions to reduce self-perceived disability associated with dizziness in middle-aged and older community-living people.