BOSTON—Dizziness is a particular danger among the elderly, but extra care taken by physicians can help ease their problems and help keep older patients functioning, panelists said at the 2010 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, held here Sept. 26-29.
Treatment tactics used for younger patients might not always be suitable for elderly patients, they said, but new therapy tools can help the elderly feel less helpless against the sensation of being off balance.
Concerns about dizziness in elderly patients come as the Baby Boomer generation ages, bringing a huge number of new, older patients, said David Eibling, MD, chair of the AAO-HNS’ Geriatric Otolaryngology Committee. “A tsunami of Baby Boomers is just now hitting the Medicare and Medicaid ages,” he said.
And they will demand a lot from their health care providers, he said. “The elderly folks are not only living longer but they are maintaining a higher level of function,” Dr. Eibling said. “So that, for them, quality of life achieves an even greater significance than it has in prior years.”
Treatment Options
The term “dizziness” suffers somewhat from an identity crisis that might make it difficult for physicians to address in elderly patients, said Michael E. Hoffer, MD, director of the Spatial Orientation Center at the Naval Medical Center San Diego. While dizziness is thought of as a vestibular disorder, it is often influenced by factors that are not vestibular, such as eye disorders, peripheral vascular disease and arthritis of the cervical spine, Dr. Hoffer said.
“It’s unclear whether what we call presbystasis is truly a vestibular disorder or simply the impact of the other diseases associated with aging,” he said. Dysequilibrium Associated with Aging (DAA) might be a more appropriate term, he said.
A common approach to dizziness, just trying to prevent falling, doesn’t serve patients well enough, Dr. Hoffer said. “The fear of going outside because of the risk of falling or the embarrassment is tremendously isolating,” Dr. Hoffer said. “A lot of our hospitals, because of recent rules and laws, have falls prevention programs. That’s not enough…. We need function programs in target areas so that people no longer feel isolated.”
A common malady causing dizziness among the elderly is benign paroxysmal positional vertigo (BPPV), sudden, brief periods of mild to intense dizziness brought on by a change in someone’s head position or by lying down, turning over, or sitting up in bed. It’s usually not life threatening, except when it increases the chance of falling.
But that’s exactly what happens in the elderly, said Joel Goebel, MD, professor and vice chairman of otolaryngology and director of the Dizziness and Balance Center at Washington University School of Medicine in Saint Louis. Simply standing in your kitchen and looking up at an item on a high shelf can bring about a dangerous situation in an elderly person, he said.
“Your stabilizing mechanisms don’t work quite as well as they used to when you were younger, so you get the same attack, you get the same overwhelming sensation of vertigo, but you’re not able to handle the few seconds as you tipped,” he said.
BPPV, as it is widely accepted, is caused by the dislodging of otoconia, particles of calcium carbonate, from the part of the inner ear called the uticle. Repositioning can help ease the symptoms, but the problem often recurs.
“We really don’t know what happens to those otoconia,” Dr. Goebel said. “Some of us believe that they dissolve, some of us believe that they only stick. I believe they only stick because they keep coming back, these attacks come back.”
Illustrations of repositioning techniques to treat BPPV “make me shiver” sometimes, he said, because they show patients’ heads hanging off the edges of a doctor’s table, which might be very difficult, or even dangerous, for an elderly patient.
Using alternate approaches, such as placing the examination chair or table in the Trendelenburg position in which the feet are above the rest of the body, might be better for the elderly, he said, emphasizing that it’s the position of the head that is the most important, not the position of the body.
Rehabilitating patients with BPPV should involve treating the acute BPPV spells first, then assessing a patient’s instability in posture with posturography and gait analysis. He said physicians should be aware of other possible contributing factors, such as Parkinson’s disease, peripheral neuropathy or normal pressure hydrocephalus (NPH).
Kim Gottshall, PhD, head of Vestibular Rehabilitation Comprehensive Combat and Complex Casualty Care at the Naval Medical Center in San Diego, said that physicians trying to physically rehabilitate a dizzy, elderly patient should take care to tailor the patient’s care properly. Peripheral neuropathy, orthopedic issues and sensory loss are a few of the factors that might be contributing to the problem, she said.
“Patients come to us as geriatric patients with multifactorial problems,” she said. “And we have to choose from our exercises what type of rehab programs are we going to develop for them and what kind of devices we can use to make it interesting and have them be compliant with the program that we develop.”
Dr. Gottshall said there are several questionnaires that can be used to get a sense of a patient’s quality of life and determine what they want to do that they can’t. In response to demands from patients, the Functional Gait Assessment was developed, which is based on the traditional Dynamic Gait Index, but with three new tasks, including “gait with narrow base of support,” walking backwards, and walking with the patient’s eyes closed.
There are also virtual reality exercises, in which a patient uses computer simulation to complete common tasks or take part in games that improve balance. The objective should be to meet the patient’s goals for therapy more exactly, she said.
“We can ask them six to eight weeks later and say, ‘Oh, you’re compensated,’ and yet they don’t feel like they can go out into the environment of their house and be successful and not be anxious,” Dr. Gottshall said.
Prevention
That said, it is still a fact that falls are among the most serious problems associated with dizziness among the elderly, said Yael Raz, MD, assistant professor of otolaryngology at the University of Pittsburgh School of Medicine.
Studies have found that 35 to 40 percent of healthy adults age 65 or older fall at least once a year. And those with disequilibrium fall four times more frequently than controls, other studies have found. Plus, 95 percent of hip fractures result from falls and 25 percent of patients with hip fractures die within one year, Dr. Raz said.
She said otolaryngologists should address fall prevention, even if the source of the dizziness does not stem from the inner ear. Ways to intervene include promoting exercise, addressing vision problems and exploring a reduction in medication, she said.
“I think we all have a tendency to think, ‘Oh, they’re coming for dizziness but it’s not an inner ear problem, this is not vestibular in origin,’ and send them off to another specialist,” she said. “Those visits represent a chance to make an intervention that could have a huge impact.”