Vestibular disorders in the elderly

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BrazJOtorhinolaryngol.2015;81(1):4---5

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

EDITORIAL

Vestibular

disorders

in

the

elderly

夽

Vestibulopatias

em

idosos

The incidence andprevalence of differenttypes of dizzi-nessandbalancedisordersthataffectboth gendersinold age are high, and even higher in the long-lived elderly. Balancedependsonmany factors,includingtheadequate function of sensory, vestibular, visual, and somatosensory structures;musclestrength;jointmobility; andcognition. Thesensorystructurescanbeimpairedbycommondiseases ofaging,suchascardiovascular,metabolic,psychological, andcentral nervoussystem disorders; retinopathy and/or diabeticneuropathy;cataracts;maculardegeneration;and bysenilityoftheperipheralandcentralvestibularsystem. The all-too-common aspectsof self-medication, polyphar-macy,andsedentarylifestyleareaggravatingorsignificant causativefactors.

Vertigo, feelings of instability or imbalance (with or without the feeling of an imminent fall), light or heavy-headedness, fluctuation, and presyncope/syncope arecommontypesofdizzinessobservedinoldage,occurring aloneorincombination.Thedefinitionofvertigo,previously an exclusive prerogative of rotarydizziness, wasrecently expanded to include any dizzinessassociated with move-ment of the patient or objects in the environment, even if they do not move. Dizziness-related falls are common and can result in severe consequences, such as repeated concussions and the dreaded hip fracture. The quality of lifeof elderlypatientswithvestibulardisordersis greatly impairedbydizziness;thefunctionallimitationsbroughton bythesymptomusuallyresultinsignificantphysicaland psy-chologicalproblems, aswellas theincapacity toperform theactivitiesofdailylivingandworktoagreaterorlesser degree.

Constantacuteorpositionalvertigoandchronicvertigo can be a result of either central or peripheral vestibular disorders.Intheelderly,peripheralvestibulardisordersare muchmorecommonthancentralones. Inadditionto oto-logical and neurological origins, metabolic disorderssuch

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Pleasecitethisarticleas:Gananc¸aMM.Vestibulardisordersin theelderly.BrazJOtorhinolaryngol.2015;81:4---5.

as hypoglycemia, hyperglycemia, hyperinsulinemia, and hypothyroidism; cardiovascular disorders including hyper-tension and hypotension, and other potential causative factors from different parts of the human body must be considered.Inaddition,vertigoofpsychogenicoriginisnot rareandcanbedifficulttodiagnosewhenitoccursin iso-lation;becauseofthephysicaluncertaintyarisingfromit, secondaryanxiety,depression,andpaniccanresult.

Common peripheral vestibular disorders in the elderly include:self-limitingbenignparoxysmalpositionalvertigo, recurrent or persistent; Meniere’s disease or syndrome; vestibularneuritisaffecting the upperor lowervestibular nerve; metabolic labyrinthine disorders; idiopathic bilat-eral vestibular hyporeflexia or areflexia and persistent postural---perceptual dizziness (the new name for chronic subjective dizziness). Proprioceptivedysfunction in cervi-calsyndromesofdifferentetiologiesmayalsobeasource of dizzinessand imbalance. Each of these conditions has itsclinicalandtherapeuticpeculiarities.Vertigoandother typesofdizzinessmaybepresentindifferentdiseasesofthe centralnervoussystem,suchasmigraineanditsequivalents, strokes,tumors,other brainstemorcerebellarsyndromes, andParkinson’sdisease.

In addition to otolaryngology, several other areas of medicine maybe involved inthe diagnosis andtreatment of dizzinessandbalance disordersin theelderlyincluding general practice, geriatrics, neurology, cardiology, oph-thalmology,psychiatry,physiatry, physicaltherapy,speech therapy,and emergencycare. The need for a differential diagnosisoftheconditionsthatcancausedizzinessshould alwaysbegivenspecialattentionbythe otorhinolaryngolo-gistinclinicalroutine.

Thereareseveral diagnosticresources available in our practicefor neurotological assessment, suchasvestibular testing at the bedside; electronystagmography, vecto-electronystagmography,orvideonystagmography;vestibular evoked myogenicpotentials (VEMPs, both ocular and cer-vical); video head impulse test (which complements the findings of caloric testing and ocular andcervical VEMP); staticanddynamicposturography;andbrainstem auditory

http://dx.doi.org/10.1016/j.bjorl.2014.11.001

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EDITORIAL 5

evokedpotentials (BAEPs).These proceduresmaybe use-ful to complement key information extracted from the patienthistory,otorhinolaryngologicalassessment,physical examination,pure tone/vocalaudiometry, andimpedance audiometry.

After diagnosis, the next step is to choose the appro-priate vestibular therapy for the elderly patient in the acuteorchronicphaseofthevestibulardisorder,whichmay include:supervisedvestibularrehabilitation;physical ther-apy;eventualandjudiciousanti-vertigoand/oranti-emetic medication, with due care not to damage the vestibular compensation;andnutritionalcounselingtocorrectdietary errorsand other potentialaggravating factors, aswell as generalandspecific guidelinestopreventfallriskfactors. Differenttypes of invasive procedures maybe performed inspecificsituationsorduringtreatmentofcertainclinical conditionsresistanttoconservativetreatment.

Vestibular rehabilitation and physical therapy, often-associated procedures, are the first-choice treatment for most cases. It is also mandatory to seek control of all underlying comorbidities that may detrimentally impact vestibular dysfunction. Psychotherapy may be necessary, especiallywhen anxiety,depression,and panicemerge as relevantsymptoms,oftenwithoutapparentjustificationat thefunctionalassessmentofthevestibularsystem.The per-sistenceofpsychologicalsymptomscanhinderorpreventa favorableneurotologicalresponsetotherapy.

Considering that otological causes prevail over other etiologies,the participationofthe otolaryngologistinthe assessment of elderly patients with any typeof dizziness and/or imbalance and in the therapeutic management of differentbalancedisordersshouldbeemphasized.

Periodic approaches to educate the geriatric popula-tion,similartotheNational Campaignfor Fall Prevention in the Elderly, sponsored a few years ago by the Brazil-ian Society of Otology, with the support of the Brazilian AssociationofOtorhinolaryngology(Associac¸ãoBrasileirade Otorrinolaringologia --- ABORL-CCF-CCF), provide informa-tiononbalancedisorders;onhowtomaintainsafetyonthe stairsandinthebathroom,kitchen,andbedroom;theuse ofadequatefootwear;andhowtoproceedoutsidethehome environment,etc.Universalpublicpoliciesseektoprioritize actionsaimedatthewelfareoftheelderly.Inthismanner, wearedoingourparttotakepropercareofelderlypatients withvestibulardysfunctions.