www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Anxiety
and
depressive
disorders
in
elderly
with
chronic
dizziness
of
vestibular
origin
夽
Érica
Toledo
Piza
Peluso
a,∗,
Maria
Inês
Quintana
b,
Fernando
Freitas
Gananc
¸a
caProfessionalMaster’sPrograminBodyBalanceRehabilitationandSocialInclusion,UniversidadeAnhangueradeSãoPaulo,
SãoPaulo,SP,Brazil
bDepartmentofPsychiatryandMedicalPsychology,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
cDepartmentofOtolaryngologyandHeadandNeckSurgery,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
Received26February2015;accepted8April2015 Availableonline9October2015
KEYWORDS
Elderly; Anxiety; Depression; Dizziness
Abstract
Introduction:Dizziness isone ofthe most prevalent symptoms inthe elderly. Anxiety and depressionarecommonindizzyadultpatients,butthereisscarceinformationabout comor-biditybetweenvestibulardisturbancesandpsychiatricdisordersintheaged.
Objective: Toassesstheprevalenceofanxietyanddepressiondisordersinelderlywithchronic dizzinessofvestibularorigin.
Methods:TransversalstudythatusedtheBrazilianversionoftheCompositeInternational Diag-nosticInterview2.1toassessanxietyanddepressivedisordersinelderlypatients(≥60years old)withchronicdizziness.
Results:Mostofthe44patientsincludedinthestudywerefemale(88.6%)withameanageof 71years(±7.5),68.1%hadexperienceddizzinessfor1yearormore.Themostprevalent diag-nosiswasbenignparoxysmalpositionalvertigo(52.3%).Theprevalenceofgeneralizedanxiety disorderandspecificphobiasduringlifewere29.5%and22.7%,respectively,and,inthelast 12months,18.2%and15.9%.Therewasnopatientwithpanicdisorder,agoraphobiaorsocial phobia.Theprevalenceofdepressivedisorderduringlifewas45.4%,and,inthelast12months, were11.3%.
Conclusion: Agedpatientswithchronicdizzinesshadhighprevalenceofsomementaldisorders. © 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/).
夽
Pleasecitethisarticleas:PelusoÉTP,QuintanaMI,Gananc¸aFF.Anxietyanddepressivedisordersinelderlywithchronicdizzinessof vestibularorigin.BrazJOtorhinolaryngol.2016;82:209---14.
∗Correspondingauthor.
E-mail:[email protected](É.T.P.Peluso). http://dx.doi.org/10.1016/j.bjorl.2015.04.015
PALAVRAS-CHAVE
Idoso; Ansiedade; Depressão; Tontura
Transtornosansiososedepressivosempacientesidososcomtonturacrônica deorigemvestibular
Resumo
Introduc¸ão:A tontura é um dos sintomas clínicos mais prevalentes entre idosos. Sintomas ansiosos edepressivossãofrequentesem pacientesadultos nãoidososcomtontura, porém hápoucainformac¸ãosobreacomorbidadedasdoenc¸asvestibularesetranstornosmentaisem idosos.
Objetivo:Avaliaraprevalênciadetranstornosansiososedepressivosemidososcomtontura crônicadeorigemvestibular.
Método: Estudo de corte transversal que utilizou como instrumento a versão brasileira do Composite International Diagnostic Interview 2.1 (CIDI)para avaliar transtornos ansiosos e depressivosemidosos(≥60anos)comtonturacrônica.
Resultados: Foramincluídos44pacientes,amaioriadogênerofeminino(88,6%),idademédia de71anos,68,1%apresentavatonturahámaisdeumano,e52,3%apresentavamdiagnósticode vertigemposicionalparoxísticabenigna.Aprevalênciadetranstornodeansiedadegeneralizada efobiasespecíficasnavidafoide29,5%e22,7%,respectivamente,e,nosúltimos12meses,de 18,2%e15,9%respectivamente.Nãohouvecasosdetranstornodopânico,agorafobiaefobia social.Aprevalênciadetranstornodepressivonavidafoi45,4%,e,nosúltimos12meses,foi 11,3%.
Conclusão:Encontrou-se elevada prevalência de certos transtornos mentais em idososcom tonturacrônica.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publi-cado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença CC BY (https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Dizziness is the main symptom of vestibular diseases and
one of the most prevalent symptoms in the population,
being found even more often among the elderly.1,2
Sev-eral factors may contribute to the onset of dizziness or
aggravate this condition in individuals in this age group,
includingthe aging of systems related to bodilybalance,
presence of chronic diseases associated with continuous
use of drugs and, sometimes, with polypharmacy, among
others.3
Dizzinesscanbeintense,leadingtolossofbalanceand
tofalls; usually itsonsetis accompanied byauditory and
neurovegetativesymptoms.Inaddition,manypatients
suf-feranintenseemotionaldistressandsymptomsofanxiety
anddepression.4,5Thephysicalandpsychologicalsymptoms
limit physical and social activities of patients, and may
affectdramaticallytheirqualityoflife.6Patientspresenting
withassociatedpsychologicalsymptomsarethosewhoare
morelikelytoremainsymptomaticanddisabled,withthe
highestlevelsofdisability.4,7
Severalstudieshaveevaluatedtheemotionalaspectsof
non-elderlyadultpatientswithdizzinessofvestibular
ori-gin,reportinghighprevalenceofsymptomsofanxietyand
depression.4,8---10Ontheotherhand,theliteratureisscarce
ontheemotionalaspectsofelderlypeoplewithdizzinessof
vestibularorigin.
Anxiety anddepression can be evaluatedasdiagnostic
categoriesorasacontinuum,usingsymptomscales.These
formsof assessmentareknownascategorical and
dimen-sional,respectively.11
Studiesthatchoose thedimensionalapproachevaluate
symptoms of anxiety and depression through instruments
that measure their intensity, as the Geriatric Depression
Scale(GDS),theBeckDepressionInventory(BDI),the
State-Trait Anxiety Inventory (STAI), the Hospital Anxiety and
DepressionScale(HADS),andothers.
Studies evaluatingelderly patients with vestibular
dis-eases by these instruments identified high prevalence of
depressiveand/oranxietysymptoms.12---14
Fewstudiesusethecategoricalapproachinpatientswith
chronicdizzinessorvestibulardisease.Thisapproach
pro-videspsychiatricdiagnosesaccordingtocurrentpsychiatric
classifications, includingthe InternationalClassification of
Diseases,10thedition(ICD-10),andtheDiagnosticand
Sta-tisticalManualoftheAmericanPsychiatricAssociation,4th
edition(DSM-IV).
Persoonsetal.15usedthePRIME-MDPHQfortrackingthe
presence of psychiatric(somatoform,anxiety and
depres-sive)disordersin268patientswithcomplaintsofdizziness
(withorwithoutvestibulardisorder)withmeanageof48.2
years(SD 12.9).The authors founda prevalence of 35.8%
ofanxiousor depressivedisorders,andpanicdisorderwas
themostprevalent.Patientswithpsychogenicdizzinesshad
higherratesofpsychiatricdisorders.
Eckhardt-Henn et al.16 evaluated 189 consecutive
patientsaged19---64yearswithdizziness,usingastructured
interview to assess the prevalence of mental disorders;
theirresultsindicatedthat68.2%hadapsychiatric
(somato-form,anxietyordepressive)disorder.Comorbiditiesamong
patients with vestibular disease and psychiatric disorder
vestibular disease were observed in 52.1%. The most
prevalentdiagnosis wasthat of anxiety and phobic
disor-ders (30.0% of the total sample), followed by depressive
disorders(28.0%ofthetotalsample).
The comorbidity of various organic vertigo syndromes
and psychiatric disorders was assessed by Eckhardt-Henn
et al.17 in a sample of 68 patients with mean age of 49
years (SD=14 years), compared to a control group of 30
healthy people, using a structured psychiatric interview
(SCID-I).Highrates of psychiatriccomorbiditywerefound
in patients with Ménière’s disease (57.0%) and vestibular
migraine(65.0%),especiallywithanxietyanddepressive
dis-orders.Patientswithbenignparoxysmalpositionalvertigo
(BPPV)andvestibularneuritishadratessimilartothoseof
controlgroup(20.0%).
Wefoundnostudiesaddressingtheassociationof
dizzi-nessof vestibularorigin andmental disordersfocusingon
theelderlypopulation.
The prevalenceofmentaldisordersinthisagegroupis
differentfromthat inyoungadults.Inaddition,thereare
differencesin terms of etiology,symptoms,evolution and
managementoftheseclinicalconditionsinrelationtoother
agegroups.11,18
The aim of this study was to evaluate the prevalence
ofanxietyanddepressivedisordersinelderlypatientswith
chronicdizzinessofvestibularorigin.
Methods
Studydesign:cross-sectionalcohort
Studylocationandparticipants
Data collection was conducted from September 2012 to
September 2013 in Laboratório de Pesquisas do Programa
deMestradoProfissionalemReabilitac¸ãodoEquilíbrio
Cor-poral e Inclusão Social of Universidade Anhanguera, São
Paulo.Consecutive elderlypatients(≥60years)with
com-plaintsofdizzinessforatleast3monthsandwithadiagnosis
ofvestibulardiseaseconfirmedthroughclinicalassessment
performed by an otolaryngologist, which included history,
physical examination and vestibular examinations, were
evaluated.
Patientswhowereperformingvestibularrehabilitation,
patientswhofailedtorespondtothequestionnairesdueto
conditionsthatcouldcompromisethecommunication,and
patientswithmemorycomplaintswereexcluded.
Instruments
CompositeInternationalDiagnosticInterview,version 2.1(CIDI2.1)
Anxiety and depressivedisorders were assessed using the
Brazilian version of the Composite International
Diagnos-tic Interview, version 2.1 (CIDI 2.1). This instrument is a
standardized and fully structured interview with the aim
to diagnosing and classifying mental disorders. CIDI was
developed in 1980 by the World Health Organization in
collaboration with the US Alcohol, Drug Abuse and
Men-tal Health Administration (ADAMHA). This instrument can
beappliedinepidemiologicalstudies,clinicaltrialsandat
researchcentersbytrainedlayinterviewers.19InBrazil,CIDI
2.1.wasvalidated by Quintana et al.19 Its sensitivityand
specificity for depressivedisorders was82.5% and 92.8%,
respectively, andfor phobic---anxiety disorders,80.6% and
93.5%,respectively.CIDIconsistsof14sections,with10
sec-tionsfordiagnosticpurposes.Inthecurrentstudy,weused
D(Phobia,AnxietyandPanic)andE(DepressiveDisorders)
sections.The diagnoseswereestablishedaccordingtothe
InternationalClassification of Diseases, 10th edition
(ICD-10),takingintoaccounttwoperiods:thepatient’slifetime
andhis/herlast12months.Weevaluatedthefollowing
anx-ietydisorders:generalizedanxietydisorder(GAD),specific
phobias,agoraphobia,socialphobiaandpanicdisorder.The
depressivedisordersevaluatedweredepressiveepisode(of
mild,moderateor severeintensity) andrecurrent
depres-sion.
Questionnaireforsocio-demographicandclinical dataofpatients
Statisticalanalysis
Theresultswereanalyzeddescriptively.Absoluteand
rela-tivefrequenciesofresponsesforcategoricalvariableswere
presented,andmeanandstandarddeviationforcontinuous
variableswerecalculated.
Ethicalaspects
Theprojectwasapprovedby theEthicsCommitteeofthe
UniversidadeAnhanguera,SãoPaulo(protocol113/10).All
patientsincludedinthestudyreadandsignedtheInformed
andFreeConsentForm.Patientswhowereidentifiedwith
anyoftheevaluateddisordersorwithsignificantemotional
distress at the time of the interview were advised and
referredtospecialistservices.
Results
The sample consisted of 44 patients aged 60---90 years
withmean ageof71 yearsandstandard deviation(SD)of
7.5years.Therewasfemalepredominance (88.6%)among
patients.Schoolingrangedfrom1to15yearsofstudy,with
amean of 5.7(SD=3.7)years of study.Eighteen patients
(40.9%)weremarried and onlyone wasinpaid work;the
otherswereretired.
Astootoneurologicdata,ahigherprevalenceofvertigo
(61.4%)was noted; amongthese patients, 45.5% suffered
dailydizziness,and68.1%ofallpatientsreporteddizziness
formorethanoneyear.The mostprevalentotoneurologic
diagnosiswasBPPV(52.3%).
With respectto mental disorders, GAD states, specific
phobiasand depression were identified. Duringtheir life,
there wasa predominance of depressive disorder states,
especiallymoderateor severedepressiveepisodes;onthe
otherhand,inthelast12monthstherewasahigher
preva-lenceofGAD.Nopatientswerediagnosedwithagoraphobia,
socialphobiaandpanicdisorder.
TheprevalenceofmentaldisordersisshowninTable1.
Inthesample,8patients(18.2%)wereperformingsome
Table1 Prevalenceofanxietyanddepressivedisorders, accordingtoICD-10,inelderlypatients withchronic dizzinessof vestibularorigin(n=44).
Disorder Lifetime
(n)
Lifetime (%)
12months (n)
12months (%)
GADa 13 29.5 8 18.2
Specificphobias 10 22.7 7 15.9
Depression(total) 20 45.5 5 11.4
Episode 15 34.1 3 6.8
Mild --- --- ---
---Moderate 9 20.5 3 6.8
Severe 6 13.6
---Recurrentdepression 5 11.4 2 4.6
aGeneralizedanxietydisorder.
Discussion
With regard to socio-demographic characteristics of the
sample,ourparticipantswerepredominantlyfemale,which
is in accordance withthe highest prevalence of dizziness
andvestibulardiseasesinthisgroup.2,3,20Inrelationto
clin-icalandneurotologicalaspectsofpatients,BPPVstoodout;
thisisthe vestibulardiseasemostcommonly found inthe
elderly.3,21 Mostoftheelderlyinthissamplehaddizziness
foroverayear.
Theelderlyinthisstudyshowedanxietydisorders(GAD
and specific phobias) and moderate-to-severe depressive
disordersintheirlifetimeandinthelast12months;some
patientshadrecurrentdepression.Nopatientwasdiagnosed
withpanicdisorder,agoraphobia,andsocialphobia.
The lifetime prevalence was muchhigher than that in
thelast12 months.Oneexplanationfor thisdifferenceis
thelifespanofelderlypatients,becauseinthisagegroup
thepatient hasa muchhighercumulativerisk.22
Further-more,anxietyanddepressivedisordersaremoreprevalent
inyoungadultsversuselderlypeople,withonset
concentra-tionoftheseconditionsuntilthefifthdecadeoflife.22
Elderly patients in this study exhibitedseveral factors
that are mentioned in the literature as risk factors for
development of anxiety and depression, including poor
schooling, female gender, retirement, and presence of
chronicdisease.18,23
VianaandAndrade,22 intheirstudywithaprobabilistic
sampleof 5037adultsliving inthemetropolitanregionof
SãoPauloandusingCIDI2.1,found8.9%oftheelderly(≥65
years)withspecificphobias,4.5%withTAGand11.8%with
depressivedisordersintheirlifetime.Theprevalence
var-iedsignificantlyaccordingtogender,beinghigherinwomen
(16.5%,4.5%and23%,foreachofthedisordersabove
men-tioned,respectively).
When compared with the prevalence in the
commu-nity aforementioned, it is observed that the prevalence
oflifetimedepressiveandanxietydisordersinthecurrent
sampleis muchhigherthan thatfound in thecommunity,
evenwhenthecomparisontakesintoaccountonlyfemale
patients.
Thisfindingmaysuggestthatthereisincreased
suscep-tibility tothe developmentof clinical pictures of chronic
dizzinessinindividualswithhistoryofdepressiveoranxiety
disorders.However,ithasnotbeenpossibletocorroborate
thishypothesisintheliterature,sincenostudiesassessing
patientswithmentaldisordersbeforeandaftertheonsetof
dizzinesswerepublished.
Regardingthe prevalence in thelast 12 months in the
currentstudy,18.2%ofpatientswerediagnosedwithGAD,
15.9%withspecificphobiasand11.3%withdepression.
In America, Byers et al.24, using CIDI on a
probabilis-ticsampleof2575community-basedindividualsaged≥55,
indicatedthat,inthelast12months,6.5%hadspecific
pho-bias,2.0%hadGAD,and4%hadmajordepression.Itcanbe
seen that the prevalence of GAD,phobias and depression
in ourstudywerehigher thanthoseinthe studyby Byers
etal.24
When comparedto community-based studies of
preva-lenceofpsychiatricdisordersusingthesameinstrumentas
thepresent study,itcan beobservedthattheprevalence
of anxiety and depressive disorders in this study was
much higher. However, it should be emphasized that the
diagnosesin thisstudywerebasedontheclassificationof
ICD-10; onthe other hand, other population studies used
theclassificationof DSMIV,which canleadtodifferences
in prevalence due todifferent diagnosticcriteriaused by
theseclassifications.
Thecomparisonofthisstudyversusstudiesthatassessed
patientswithdizzinessshouldtakeintoaccounttwoaspects.
First,therearefewstudiesevaluatingpsychiatricdisorders
inpatientswithdizziness,andnotoneofthemassessedonly
elderlypatients.Anotheraspectlimitingthecomparisonis
theuseofdifferentdiagnostictools,psychiatric
classifica-tion systems(DSM-IV) and samples(for instance, patients
withpsychogenicdizziness).
The study byPersoons et al.15 evaluatedpatients with
complaintsofdizziness; 53.4%hadvestibulardisease,and
27.2% had psychogenicdizziness. In addition,the authors
usedaninstrumentforpsychiatricdisorderscreening,which
mayexplain thehigher prevalencefound in theirsample.
Another aspect tobe taken into account is that patients
olderthan75yearshadbeenexcludedfromthestudy;and
themeanageoftheirpatientswasmuchlowerthanthatin
thecurrentstudy.
In the study by Eckhardt-Henn et al.16 assessing the
prevalence of psychiatric disorders in patients with
com-plaints of dizziness, younger patients were included (up
to65 yearsold),and mosthad novestibulardisease, but
betweensamplesmayhaveinfluencedthehigherprevalence
ofpsychiatricdisordersfoundbytheauthorsofthatstudy
(68.2%).Despitethisdifference,theseauthorsfoundsimilar
resultstothoseinourstudywithrespecttospecific
disor-ders:30%ofthetotalsampleinEckhardt-Hennetal.study16
hadarecentdiagnosis ofanxietyandphobicdisorders---a
figuresimilartothatfoundinourstudy(34.1%inthelast12
months).Ontheotherhand, theprevalenceofdepressive
disorderswaslower(11.3%inthepast12months)thanthat
inEckhardt-Hennetal.’study(28%).16
InanotherstudybyEckhardt-Hennetal.17 including68
patientswithvestibulardisease,theseauthorsobserved a
higher prevalence of psychiatric disorders versus that in
thecurrentstudy.Thisdiscrepancymaybepartlyexplained
bydifferencesinthesamples.Eckhardt-Hennetal.17
sam-ple excluded elderly people, and most had a diagnosis
of vestibular migraine, Meniere’s disease and vestibular
neuritis. Patientswith BPPV, representing more than half
of our sample, showed the lowest percentage of
comor-bidity with psychiatric disorders (10.0% were diagnosed
withanxietydisorder,and10.0%haddepression)--- results
compatiblewiththecurrentstudywithrespectto
depres-sion.
A second aspect tobe addressed is the comparisonof
results of this study, which held a categorical approach,
with other studies that conducted a dimensional
evalua-tion(symptomsofanxietyanddepression)inpatientswith
vestibulardisease.Symptomsofanxietyanddepressionare
commoninelderlypatientswithvestibulardiseases,
affect-ingabout50%ofpatients.10,13,14
The differencebetween thehighprevalenceofanxiety
and/ordepressivesymptomsandtherelativelylower
preva-lenceofanxietyanddepressivedisordersisexpected,since
morestringentcriteriaareusedforthediagnosis ofthese
disorders.11 This discrepancy reflects differencesbetween
categoricalanddimensionalassessments,thatare
comple-mentaryandcannotbedirectlycompared.
Wemusthighlightsomelimitationsofthisstudy.Thisis
across-sectionalstudy;thus,itisnotpossibletoclaimthe
existenceofacausallinkamongpsychiatricdisorders
ver-sus vestibulardiseases inthe elderly. Longitudinalstudies
withlargersamplesareneeded,inordertoobtainabetter
understandingofthisrelationship.
In spite of these limitations, this study indicates that
thereis significant comorbidity of vestibular diseases and
emotionalproblemsintheelderlywithchronicdizziness,as
wellastheneedforaninterdisciplinaryapproachtothese
patients.
Psychological and/or psychiatricassessment isrelevant
totheidentification ofpatients,inwhomemotional
prob-lemsmusttobedirectlyaddressed,andcancontributetoa
betteroutcomeforvestibulardiseasesandtoimprovethe
patient’squalityoflife.
Conclusion
Elderlypatients withchronic dizzinessofvestibularorigin
haveahighprevalenceofgeneralizedanxietydisorder,
spe-cificphobiasandmajordepression intheirlifetimeandin
thelast12months.Therewerenopatientswithpanic
dis-order,agoraphobiaandsocialphobia.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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