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Vertigo in elderly patients: a review of 164 cases in Brazil.

Abstract

The author conducted a study to identify and categorize those vestibular disorders that were the most common among elderly patients at his private clinic over a 20-year period. He reviewed the records of 735 patients aged 65 to 90 years. The most common diagnosis was vertigo and/or disequilibrium, which occurred in 164 patients (22.3%). Of this group, 121 patients (73.8%) had a peripheral vestibular disorder and 43 (26.2%) had a central vestibular disorder. The characteristics of these cases are discussed.

Introduction

The inner ear is known to be sensitive to gradual alterations resulting from age. The term presbycusis is commonly used to designate the auditory changes that result from increasing age. Many individuals, however, maintain good hearing throughout their lives. Davis described presbycusis as a direct consequence of increased rigidity of the inner ear membranes and the reduced speed of transmission of nerve impulses in the central nervous system. (1) Other hearing disorders can be attributed to vascular, metabolic, or autoimmune diseases rather than a consequence of aging.

The clinical manifestations of vestibular disorders in elderly patients are also frequently considered to be a direct consequence of the aging process, but healthy elderly patients rarely present with them. These disorders are also probably a result of vascular, metabolic, or degenerative diseases or neurologic conditions that affect the central vestibular pathways. (2)

Vestibular disorders in elderly patients are clinically important, and they have attracted the attention of many investigators. (3-10) In this article, the author describes his study of vertigo in the elderly.

Patients and methods

The goal of this retrospective study was to analyze a group of elderly patients in order to categorize their vestibular syndromes. The study was based on 735 patients, aged 65 to 90 years, who had been examined sequentially from January 1990 through December 2009 at the author's private otolaryngology clinic in Sao Paulo.

The most frequent clinical complaints in this group were hearing loss, respiratory problems, and vestibular disorders. Of the latter, the most common were vertigo and/or disequilibrium, which had occurred 164 of the 735 patients (22.3%). This group was made up of 69 men (42.1%) and 95 women (57.9%). Their age distribution is shown in table 1.

Each of these patients had given a detailed clinical history, and each had undergone a complete ENT examination followed by audiologic and vestibular testing:

* Audiologic testing included pure-tone audiometry, determination of speech reception and speech discrimination scores, and acoustic immitance testing. In some patients, electrocochleography and/or auditory brainstem response testing had also been performed.

* The vestibular examination included a Romberg test, gait and cerebellar tests, evaluation of spontaneous and semi-spontaneous nystagmus, the Dix-Hallpike maneuver for postural vertigo, pendulum eye-tracking, evaluation for optokinetic nystagmus, torsion swing testing, and caloric testing employing the Hallpike two-temperature technique. Nystagmus was recorded with a three-channel device according to the vector nystagmography technique developed by Padovan and Pansini. (11) Patients who exhibited either definite or suspected central signs were also tested for dissociated nystagmus, with the movements of each eye recorded on a different channel. (12)

Laboratory testing and radiologic imaging had been ordered when deemed necessary. All patients who had a central vestibular disorder and those with a clinical history suggesting a neurologic disorder underwent computed tomography (CT), magnetic resonance imaging (MRI), or both. Some patients were referred for neurotologic examination after having undergone neuroradiologic imaging.

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A total of 18 patients had significant prodromic signs. There were 4 cases of uncompensated diabetes mellitus, 2 cases of cerebral vascular accidents, and 1 case each of Takayasu arteritis, Paget disease, liver transplantation, portal hypertension, coronary artery bypass surgery, external carotid artery occlusive syndrome, cerebellar tumor treated with stereotactic radiosurgery, sequelae of meningitis, carcinoma of the pancreas tail, non-Hodgkin lymphoma, ovarian carcinoma, and breast carcinoma; the last 3 patients had undergone chemotherapy.

This study was approved by the Council on Ethics of the Albert Einstein Hospital in Sao Paulo.

Results

Audiologic findings. All patients presented with some degree of sensorineural hearing loss. However, after the audiograms were adjusted for each patient's age according to the Glorig and Davis normal age-related average, (13) it was found that 38 of the 164 patients (23.2%) had normal hearing for their age. Another 68 patients (41.5%) had a high-frequency hearing loss that was more intense than the Glorig and Davis average, 43 patients (26.2%) had both a high- and low-frequency loss, 13 patients (7.9%) had a profound unilateral hearing loss, 1 patient (0.6%) had a mixed unilateral hearing loss, and 1 had a bilateral mixed loss.

Despite the high incidence of hearing loss, speech discrimination scores were within the expected ranges for 160 of the 164 patients (97.6%); the remaining 4 patients (2.4%) had abnormally low scores.

Vestibular findings. The vestibular evaluation showed normal responses in 36 patients (22.0%) and abnormal responses in 128 (78.0%). Among the latter group, 58 patients (35.4%) had unilateral hyporeflexia and 22 (13.4%) had bilateral hyporeflexia, while 40 (24.4%) had symmetrical vestibular hyperreflexia. A directional preponderance of postcaloric nystagmus was observed in 3 patients (1.8%), unilateral vestibular areflexia in 3 others, and bilateral areflexia in 2 (1.2%).

Horizontal spontaneous nystagmus was seen in 22 patients (13.4%).

Central vestibular signs were found in 32 of the 164 patients (19.5%). Eleven other patients (6.7%) presented with neurologic disorders that were diagnosed by imaging. The central vestibular signs observed in the 32 patients included 14 cases (8.5% of the entire study group) of dissociated nystagmus (which was always associated with one or more other central signs), 5 cases (3.0%) of bidirectional semi-spontaneous nystagmus, 4 cases (2.4%) of vestibular decruitment (torsion swing responses smaller in amplitude than caloric responses, 3 cases (1.8%) of semi-spontaneous nystagmus in different directions of the gaze, 3 cases of spontaneous nystagmus that did not influence the torsion swing and caloric tests, 2 cases (1.2%) of vertical spontaneous nystagmus, 2 cases of alternating spontaneous nystagmus, and 1 case each (0.6%) of absent fixation effect with eyes open, perverted nystagmus, and inverted nystagmus.

Diagnostic categories. On the basis of the clinical history and audiologic, vestibular, laboratory, and imaging investigations, the 164 patients were divided in two groups: 121 patients (73.8%) had a peripheral vestibular disorder and 43 (26.2%) who had central vestibular involvement. The diagnosis of a peripheral disorder was based on the absence of central vestibular signs on vestibular testing and imaging and the absence of evidence of neurologic disease. Eleven patients with a neurologic problem that was diagnosed by CT or MRI had vestibular tests devoid of characteristic central signs (table 2).

The most common causes of the peripheral vestibular disorders were a metabolic vestibular disorder or a reduced vestibular response (table 3). In the 43 patients with a central vestibular disorder, the most common cause was a degenerative disorder (table 4).

Twenty-three of the 164 patients (14.0%) had a history of falling. Five of them sustained a fracture; in fact, 1 had sustained multiple fractures. Of the 4 patients with a single fracture, 2 had broken the femur neck, 1 had broken the head of the humerus, and 1 had ruptured a dorsal vertebra. The first 3 patients required surgery for prosthesis insertion.

Five patients reported a loss of consciousness for short intervals, and 4 experienced repeated drop attacks.

Discussion

In this population of 735 older patients, approximately 20% had a vestibular disorder. This percentage is significantly lower than those quoted in the literature, which have ranged from 45 to 65%. (3-5,7) One possible explanation is that the patients in this study belonged to a social group that had easy access to medical assistance (they were among only about 5% of the Brazilian population that has access to private physicians and hospitals) and that they were more concerned with their health than is most of the general population.

Vestibular testing was conducted with vector nystagmography on three separate channels. (11,14) This technique provides an accurate measurement of the velocity of the slow component of the nystagmus, and it is capable of recording rotatory eye movements.

Approximately three-fourths of the patients in the present study had a peripheral vestibular disorder. Among the rest, two-thirds had a central disturbance that became evident on vestibular testing, and the others were diagnosed on the basis of CT or MRI. A few patients had been referred by a neurologist after they had undergone CT or MRI. It has been demonstrated that the vestibular examination is very sensitive in diagnosing posterior fossa disorders, but it is less sensitive for supratentorial lesions. (15)

Still, vestibular testing can detect central disturbances that are not shown on imaging scans. As a result, they are of great importance for evaluating elderly patients with disequilibrium. It is known that some physicians do not order vestibular tests for their patients in order to avoid causing them discomfort; however, this attitude can multiply a patients problems. (3)

An attempt was made to determine the etiology of the vestibular disorder whenever possible. For this reason, tables 3 and 4 show the patients' diagnoses rather than the results of their vestibular tests.

Peripheral disorders. The most common diagnosis in the 121 patients with a peripheral disorder was a metabolic disorder (35.5%), usually related to carbohydrate metabolism. (16-18) It must be mentioned that in young patients, the most frequent carbohydrate metabolic disorder is reactive hypoglycemia secondary to hyperinsulinemia; in elderly patients, metabolic disorder is usually related to different degrees of type II diabetes, with periods of hypoglycemia usually resulting from medications or inadequate diets; these patients have a good prognosis once their medication and nutrition regimens become reorganized. A small number of patients presented with hypoglycemia caused by brush border membrane disease, which interferes with the intestinal absorption of carbohydrates.

Vestibular neuronitis was first described by Hallpike at a medical meeting in 1949; this report was subsequently published by Dix and Hallpike in 1952. (19) Unfortunately, vestibular neuronitis is often confused with vestibular neuritis. In the latter, a patient experiences a single episode of intense vertigo that is related to a unilateral loss of vestibular function. The former is characterized by recurrent episodes of vertigo without any hearing symptoms. Vestibular neuronitis can be of vascular origin or it can occur as the result of a loss of neural elements. Clinically, it is characterized by reduced vestibular responses, either unilateral or bilateral. This was the second most common cause of vertigo (27.3%) among patients with a peripheral vestibular disorder in the present study. The best therapeutic results were obtained with vestibular rehabilitation.

Meniere disease was also observed (13.2% of the patients with a peripheral disorder), even though it is not characteristic of this age group; indeed, many of these patients had already developed this disease in their younger years. One of these patients needed surgery, but the others responded to clinical treatment.

Degenerative changes in the cervical vertebrae, which are common among the elderly, can eventually cause vestibular symptoms, which occurred in 7.4% of the patients with a peripheral disorder in this study.

Perilymphatic fistula (5.8%) is possibly related to developmental defects in temporal bones, since it seems to affect only patients whose ears are particularly sensitive to physical efforts or atmospheric pressure changes. It too is not characteristic of this age group.

Physical trauma (2.5%) can vary from simple labyrinthine commotion to petrous fractures. In the latter circumstance, the vestibular symptoms can last from a few weeks to several months. Occasionally, compensation is inadequate and surgery is required. All of these patients, including the ones who undergo surgery, require vestibular rehabilitation in order to achieve adequate compensation.

Delayed endolymphatic hydrops is an uncommon disorder in which the patient develops a hydrops many years after a sudden hearing loss of viral origin. (20) This hydrops can develop in either the ipsilateral ear or the contralateral ear. The 2 cases in this series (1.7%) were ipsilateral, and both patients were treated clinically.

Another 2 patients (1.7%) had an autoimmune hearing loss, and both were treated with a corticosteroid. One of these patients had a contraindication to systemic corticosteroids, so transtympanic injections were administered instead.

One patient (0.8%) had a glomus tympanicus tumor, 1 had unilateral otosclerosis with dizziness (McCabe syndrome), 1 had panic syndrome, 1 had benign paroxysmal postural vertigo (which responded well to repositioning maneuvers), 1 had toxic labyrinthitis caused by inhalation of paint solvents, and 1 had sudden deafness accompanied by intense vertigo of vascular origin.

Central disorders. Among the 43 patients with a central vestibular disorder, approximately half (51.2%) had a degenerative disorder. The recognition of dissociated nystagmus was important in the diagnosis of these patients, since qualitative nystagmus dissociation is related to lesions of the medial longitudinal fasciculus and is common in degenerative central nervous system disorders. (12)

Hydrocephalus ex vacuo (20.9%) is fairly common in elderly patients. It is often associated with disequilibrium rather than vertigo. Some patients who were treated with low-pressure ventricular shunts experienced relief from their symptoms.

The use of diuretics (11.6%) to control blood pressure can cause central vestibular disturbances by reducing cerebral blood flow. Actually, all medications for hypertension reduce cerebral blood flow, but diuretics and beta blockers are the two that are most frequently associated with orthostatic hypotension and vertigo. (21,22)

Two patients (4.7%) had basilar artery insufficiency as a result of long-standing cervical syndrome.

Of the remaining patients, 1 patient each (2.3%) presented with a temporal lobe meningioma, a vestibular schwannoma, diffuse encephalopathy, cerebral cisticercosis, and cranial trauma.

Falls. Vestibular disorders in elderly patients reduce their postural controls, which affects their gait and transitional activities such as moving from a supine to a sitting position or from sitting to standing. (23)

Falls are common among these patients. According to orthopedists' estimates, approximately 60% of falls are simple accidents, while some 20% are the result of a neurologic disturbance and 20% are the result of a vestibular disorder. Falls make patients feel insecure, and they diminish quality of life, with consequences for general health. They also contribute to increased costs of medical treatment. Therefore, the diagnosis and treatment of vestibular disorders in elderly patients is of the utmost importance for the maintenance of their quality of life.

The incidence of falls in this study (14.0%) was significantly less than the numbers reported in other studies. (4-7,10) This can be attributed to the better-than-average social, economic, and health status of the present patient population.

Modern medicine has at its disposition a number of drugs that can (1) effectively block or stimulate vestibular function, (2) improve inner ear circulation, (3) correct metabolic problems, and (4) stabilize autoimmune disorders. The careful selection of a drug regimen depends on an equally careful diagnosis. Dietary changes should also be useful in correcting metabolic problems secondary to poor eating habits. Vestibular rehabilitation can be very useful in the treatment of vestibular problems, particularly in elderly patients.

In conclusion, elderly patients often present with vertigo and/or disequilibrium. The diagnosis depends on a careful clinical history and neurotologic examination, complemented by laboratory testing and imaging when needed.

The medications used by these patients must be carefully evaluated, since they can induce or intensify vestibular symptoms. It is particularly important to control the use of diuretics and medications that induce hypoglycemia or reduce cerebral blood flow.

In addition to the prescription of adequate medical treatment, physicians must take into consideration the use of vestibular rehabilitation, which is of great value to elderly patients in terms of preventing falls and maintaining a good quality of life.

A comparison of this series of patients with others in the medical literature suggests that a concern for health and access to medical treatment in an elderly population reduce the incidence of serious vestibular disorders as well as the number of falls.

References

(1.) Davis H. A functional classification of auditory defects. Ann Otol Rhinol Laryngol 1962;71:693-704.

(2.) Mangabeira Albernaz PL. Aspectos otoneurologicos na velhice. Acta AWHO 1982;1(3):93-5.

(3.) Garcia FV. Disequilibrium and its management in elderly patients. Int Tinnitus J 2009;15(1):83-90.

(4.) Siqueira FV, Facchini LA, Piccini RX, et al. Prevalence of falls and associated factors in the elderly [in Portuguese]. Rev Saude Publica 2007;41(5):749-56.

(5.) Levencron S, Kimyagarov S. Frequency and reasons for falling among residents of the geriatric center [in Hebrew]. Harefuah 2007;146(8):589-93, 647.

(6.) Bouras T, Stranjalis G, Korfias S, et al. Head injury mortality in a geriatric population: Differentiating an "edge" age group with better potential for benefit than older poor-prognosis patients. J Neurotrauma 2007;24(8):1355-61.

(7.) Gazzola JM, Gananca FF, Aratani MC, et al. Circumstances and consequences of falls in elderly people with vestibular disorder. Braz J Otorhinolaringol 2006;72(3):388-92.

(8.) Liu B, Liu C, Chen XW, et al. Investigation and analysis of the baseline data of 3432 patients with vertigo [in Chinese]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2008;30(6):647-50.

(9.) Katsarkas A. Dizziness in aging: The clinical experience. Geriatrics 2008;63(11):18-20.

(10.) Walther LE, Nikolaus T, Schaaf H, Hormann K. Vertigo and falls in the elderly. Part 1: Epidemiology, pathophysiology, vestibular diagnostics and risk of falling [in German]. HNO 2008;56(8):833-41.

(11.) Padovan I, Pansini M. New possibilities of analysis in electronystagmography. Acta Otolaryngol 1972;73(2):121-5.

(12.) Mangabeira Albernaz PL. Dissociated eye movements: A clinical study. Acta Otolaryngol 2005;125(5):495-8.

(13.) Glorig A, Davis H. Age, noise and hearing loss. Ann Otol Rhinol Laryngol 1961;70:556-71.

(14.) Mangabeira Albernaz PL, Gananca MM, Caovilla HH, et al. Atlas de Vecto-Electronistagmografia. Sao Paulo: Ache; 1984.

(15.) Mangabeira Albernaz PL, Gananca MM, Pontes PA. Modelo operacional do aparelho vestibular. In: Mangabeira Albernaz PL, Gananca MM, eds. Vertigem. 2nd ed. Sao Paulo: Moderna; 1976:29-36.

(16.) Mangabeira Albernaz PL, Fukuda Y. Glucose, insulin and inner ear pathology. Acta Otolaryngol 1984;97(5-6):496-501.

(17.) Mangabeira Albernaz PL, Fukuda Y, Vilela MP, Miszputen SJ. Vestibular disorders caused by defective enzyme mechanisms in the small intestine. Acta Otolaryngol 1985;99(3-4):330-5.

(18.) Mangabeira Albernaz PL. Inner ear disorders induced by impaired carbohydrate metabolism--a long term follow up. In: Lim DJ, ed. Meniere's Disease and Inner Ear Homeostasis Disorders. Proceedings of the 5th International Symposium. Los Angeles: House Ear Institute; 2005:326-7.

(19.) Dix MR, Hallpike CS. Thepathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341-54.

(20.) Mangabeira Albernaz PL. Unusual cases of delayed endolymphatic hydrops. Acta Otolaryngol 2007;127(4):335-9.

(21.) Fagan SC, Ewing JR, Levine SR, et al. Assessing the effects of antihypertensive medication on cerebral blood flow: Demonstrations in internal carotid artery occlusion. DICP 1991;25(12): 1299-1301.

(22.) Mangabeira Albernaz PL. Diureticos como causadores de vertigens centrais. Acta AWHO 1989;8(3):128.

(23.) Mira E. Improving the quality of life in patients with vestibular disorders: The role of medical treatments and physical rehabilitation. Int J Clin Pract 2008;62(1):109-14.

Pedro Luiz Mangabeira Albernaz, MD, PhD

From the William House Association of Otology and the Department of Surgery, Albert Einstein Hospital, Sao Paulo, and the Federal University of Sao Paulo, Brazil.

Correspondence: Prof. Pedro Luiz Mangabeira Albernaz, Department of Surgery, Albert Einstein Hospital, Av. Albert Einstein, 627, Pavilion A-l, Room 117. Sao Paulo, SP 05652-000, Brazil. E-mail: albernaz@einstein.br
Table 1. Age distribution in the vertigo and/or
disequilibrium group (N = 164)

Age, yr      n (%)

65 to 70   66 (40.2)
71 to 75   44 (26.8)
76 to 80   26 (15.9)
81 to 85   20 (12.2)
86 to 90    8 (4.9)

Table 2. Distribution of peripheral and central
disorders (N = 164)

Type                                       n (%)

Peripheral vestibular disorder           121 (73.8)
Central vestibular disorder diagnosed     32 (19.5)
  by vestibular testing
Central disorder diagnosed by imaging     11 (6.7)

Table 3. Diagnoses in patients with a peripheral
vestibular disorder
(n = 121)

Diagnosis                                                n (%)

Metabolic vestibular disorder                          43 (35.5)
Unilateral or bilateral reduced vestibular responses   33 (27.3)
Meniere disease                                        16 (13.2)
Cervical syndrome                                       9 (7.4)
Perilymphatic fistula                                   7 (5.8)
Trauma                                                  3 (2.5)
Delayed endolymphatic hydrops                           2 (1.7)
Autoimmune hearing loss                                 2 (1.7)
Glomus tympanicus tumor                                 1 (0.8)
McCabe syndrome                                         1 (0.8)
Panic syndrome                                          1 (0.8)
Benign paroxysmal postural vertigo                      1 (0.8)
Toxic labyrinthitis                                     1 (0.8)
Sudden deafness and vertigo                             1 (0.8)

Table 4. Diagnoses in patients with a central
vestibular disorder (n = 43)

Diagnosis                           n (%)

Degenerative disorder             22 (51.2)
Hydrocephalus ex vacuo             9 (20.9)
Use of diuretics                   5 (11.6)
Basilar artery insufficiency       2 (4.7)
Meningioma of the temporal lobe    1 (2.3)
Vestibular schwannoma              1 (2.3)
Diffuse encephalopathy             1 (2.3)
Cerebral cysticercosis             1 (2.3)
Cranial trauma                     1 (2.3)
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Title Annotation:ORIGINAL ARTICLE
Author:Albernaz, Pedro Luiz Mangabeira
Publication:Ear, Nose and Throat Journal
Geographic Code:3BRAZ
Date:Aug 1, 2014
Words:3499
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