Section 4: Elderly

Vestibular Rehabilitation of Older Adults with Dizziness

Dizziness and imbalance are common dysfunctions in the elderly. Vestibular rehabilitation therapy is an effective method to alleviate chronic dizziness in patients with vestibular dysfunction. Transcranial direct current stimulation has reportedly improved balance function in patients with vestibular dysfunction.

This study was conducted to investigate the therapeutic efficacy of vestibular rehabilitation combined with transcranial direct current stimulation in elderly patients with vestibular dysfunction.

In a double-blinded randomized controlled trial, 36 elderly patients with chronic vestibular dysfunction were randomly assigned to either vestibular rehabilitation and transcranial direct current stimulation (n = 18) or vestibular rehabilitation alone (n = 18) group. The transcranial stimulation protocol consisted of multisession bifrontal electrical stimulation of the dorsolateral prefrontal cortex (2 mA intensity and 20 min duration), followed by rehabilitation exercises. The vestibular rehabilitation protocol consisted of habituation and adaptation exercises combined with gait exercises during a three week period. The primary outcome of this study was the dizziness handicap inventory score, and the secondary outcomes were activities-specific balance confidence and Beck anxiety inventory scores.

For the dizziness handicap score, the repeated-measures analysis of variance showed a significant main effect of “time”, “stimulation” and stimulation × time interaction effect. There was a significant reduction in the overall dizziness handicap score with “time” for both the groups, which was more pronounced in the vestibular rehabilitation and electrical stimulation group. In terms of activities-specific balance confidence change scores, we found a significant main effect of “time” and “stimulation” main factors, but this effect for stimulation × time interaction was not significant. For the Beck anxiety score, we observed a significant main effect of “time”, but no evidence for the main effect of the “stimulation” factor.

Bifrontal transcranial direct current stimulation in combination with vestibular rehabilitation therapy is a promising approach to improve chronic vestibular symptoms in the elderly.

Osteopathic manipulative treatment (OMT) has been increasingly adopted by osteopathic practitioners to treat dizziness from neuro-otologic disorders. However, no systematic review has investigated effectiveness of OMT on benefit outcomes and harm outcomes associated with OMT for these conditions. The current protocol will provide pooled effect estimates for effectiveness of OMT for neuro-otologic disorders.

The following databases will be searched: CINAHL, Embase, Ovid MEDLINE, AMED, Ovid Emcare, PEDro, PubMed, PsycINFO, OSTMED.DR, and CENTRAL. Eligible randomized controlled trials and observational studies published in English will be reviewed. Target outcomes are change in dizziness, frequency of falls, quality of life (QOL), disability, and return to work; harm outcomes are dropouts due to ineffectiveness, adverse effects, and all-cause dropout rates. Studies investigating individual types of OMT techniques will be pooled. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment tool will be used for data synthesis and to assess evidence quality. We will report effect estimates with weighted mean differences or standardized mean difference (SMD) for continuous outcome and odds ratios with 95% confidence intervals for binary outcomes.

Our findings will be of importance to patients and osteopathic practitioners and will identify key areas for future research.

The elderly often present with dizziness to Medical, Neurology, and Otorhinolaryngology (ENT) outdoor departments. Vertigo is common in older adults and has diverse causes. The diagnostic process must distinguish between otologic, central, medical, and psychogenic etiologies based on history, clinical examination, relevant otological tests, and appropriate imaging. Furthermore, in a substantial fraction of patients, a clear etiology may not be easy to determine. Medications are required to be used with greater caution in older adults as they are more prone to side effects. Vestibular and balance physical rehabilitation therapy is often helpful and should be utilized in those situations. Falls and fractures secondary to vertigo can ultimately be reduced by the above-mentioned measures and thus the potential societal burden as the population continues to age.

To compare a computer-assisted home exercise program with conservative home-training following printed instructions in the rehabilitation of elderly patients with vestibular dysfunction.

Single-blind, randomized, controlled trial.

Geriatric department of a university hospital.

Patients with chronic dizziness due to vestibular dysfunction (N=63) were randomly assigned to either rehabilitation in the clinic followed by computer-assisted home exercises (intervention group: n=32) or rehabilitation in the clinic followed by home exercises according to printed instructions (control group: n=31).

Patients in the intervention group received assisted rehabilitation by a computer program.

Measurements at baseline and at 8 and 16 weeks were compared. These included the One Leg Stand Test, Dynamic Gait Index, Chair Stand Test, Motion Sensitivity Test, Short Form-12, Dizziness Handicap Inventory, and visual analog scale.

Both groups improved significantly during 16 weeks of rehabilitation. However, neither t tests nor repeated-measures analysis of variance demonstrated any significant differences between the 2 groups. The overall compliance rate to computer program exercises during 16 weeks was 57%.

A computer-assisted program to support the home training of elderly patients with vestibular dysfunction did not improve rehabilitation more than did printed instructions.

The aim of this study is to determine whether clinical and instrumental examination of balance can predict the risk of falls in elderly patients with instability.

Study design: It is a case control study, with cases defined by falls in the last year, developed in a third level university hospital.

Seventy patients aged 65 years or more who met at least one of the following inclusion criteria: (a) at least one fall in the last year; (b) spend more than 15 s during the timed up and go test (TUG); (c) a score of less than 68% average balance in the sensory organisation test (SOT) of the computerised dynamic posturography (CDP); or (d) at least one fall in the CDP-SOT.

Intervention: TUG test, CDP-SOT, CDP centre of gravity balancing (CG) and limits of stability (LOS), Dizziness Handicap Inventory (DHI) test and short FES-I test.

Main outcome measures: Number of steps and time (TUG), average balance and use of sensorial information (CDP-SOT), speed and directional control (CDP-CG and LOS), DHI score and short FES-I score.

Comparing subjects without falls (non-fallers) vs subjects with at least one fall (fallers) in the last year, fallers obtain worse scores than non-fallers in condition 2 (p = 0.043) and use of somatosensory information (p = 0.039). Comparing subjects with five falls or less (non-multiple-fallers) vs subjects with more than five falls (multiple-fallers), multiple-fallers obtain worse scores than non-multiple-fallers in overall balance (p = 0.023), condition 6 (p = 0.036), directional control (swaying (p = 0.006) and LOS (p = 0.023)) and short FES-I score (p = 0.007).

The three most useful parameters for identifying unstable elderly patients at particularly high risk of repeated falls are mean balance in the CDP SOT, directional control of CDP LOS and short FES-I score.

Benign Paroxysmal Positional Vertigo is highly prevalent in elderly people. This condition is related to vertigo, hearing loss, tinnitus, poor balance, gait disturbance, and an increase in risk of falls, leading to postural changes and quality of life decreasing.

To evaluate the outcomes obtained by clinical trials on the effectiveness of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises in the treatment of Benign Paroxysmal Positional Vertigo in elderly.

The literature research was performed using PubMed, Scopus, Web of Science and PEDro databases, and included randomized controlled clinical trials in English, Spanish and Portuguese, published during January 2000 to August 2016. The methodological quality of the studies was assessed by PEDro score and the outcomes analysis was done by critical revision of content.

Six studies were fully reviewed. The average age of participants ranged between 67.2 and 74.5 years. The articles were classified from 2 to 7/10 through the PEDro score. The main outcome measures analyzed were vertigo, positional nystagmus and postural balance. Additionally, the number of maneuvers necessary for remission of the symptoms, the quality of life, and the functionality were also assessed. The majority of the clinical trials used Otolith Repositioning Maneuver (n = 5) and 3 articles performed Vestibular Rehabilitation exercises in addition to Otolith Repositioning Maneuver or pharmacotherapy. One study showed that the addition of movement restrictions after maneuver did not influence the outcomes.

There was a trend of improvement in Benign Paroxysmal Positional Vertigo symptomatology in elderly patients who underwent Otolith Repositioning Maneuver. There is sparse evidence from methodologically robust clinical trials that examined the effects of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises for treating Benign Paroxysmal Positional Vertigo in the elderly. Randomized controlled clinical trials with comprehensive assessment of symptoms, quality of life, function and long-term follow up are warranted.

A vertigem posicional paroxística benigna é altamente prevalente em idosos. Esta condição está relacionada a vertigem, perda auditiva, zumbido, equilíbrio precário, distúrbios da marcha e aumento do risco de quedas, levando a mudanças posturais e redução da qualidade de vida.

Avaliar os desfechos obtidos por ensaios clínicos sobre a eficácia da Manobra de Reposicionamento de Otólitos e de exercícios de Reabilitação Vestibular no tratamento de vertigem posicional paroxística benigna em idosos.

A pesquisa da literatura foi realizada usando bancos de dados do PubMed, Scopus, Web of Science e PEDro e incluiu ensaios clínicos controlados randomizados em inglês, espanhol e português, publicados de janeiro de 2000 a agosto de 2016. A qualidade metodológica dos estudos foi avaliada pelo escore PEDro e a análise dos desfechos foi realizada por revisão crítica do conteúdo.

Seis estudos foram totalmente revisados. A idade média dos participantes variou entre 67,2-74,5 anos. Os artigos foram classificados de 2 a 7/10 pelo escore PEDro. As principais medidas de desfecho analisadas foram vertigem, nistagmo posicional e equilíbrio postural. Além disso, o número de manobras necessárias para a remissão dos sintomas, a qualidade de vida e a funcionalidade também foram avaliados. A maioria dos ensaios clínicos usou Manobra de Reposicionamento de Otólitos (n = 5) e 3 artigos realizaram exercícios de RV, além de Manobra de Reposicionamento de Otólitos ou farmacoterapia. Um estudo mostrou que a adição de restrições de movimento após a manobra não influenciou os resultados.

Houve uma tendência de melhora na sintomatologia da vertigem posicional paroxística benigna em pacientes idosos submetidos à Manobra de Reposicionamento de Otólitos. Existem evidências escassas de ensaios clínicos metodologicamente robustos que examinaram os efeitos dos exercícios de Manobra de Reposicionamento de Otólitos e Reabilitação Vestibular para o tratamento da vertigem posicional paroxística benigna nos idosos. Ensaios clínicos controlados randomizados com avaliação abrangente de sintomas, qualidade de vida, função e acompanhamento de longo prazo são justificados.