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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

The

institutionalized

elderly:

sociodemographic

and

clinical-functional

profiles

related

to

dizziness

,

夽夽

Tábada

Samantha

Marques

Rosa

a,∗

,

Anaelena

Braganc

¸a

de

Moraes

b,c

,

Valdete

Alves

Valentins

dos

Santos

Filha

a,d,e

aPostgraduatePrograminHumanCommunicationDisorders(PPGDCH),UniversidadeFederaldeSantaMaria(UFSM),SantaMaria,

RS,Brazil

bDepartmentofStatistics,UniversidadeFederaldeSantaMaria(UFSM),SantaMaria,RS,Brazil cEpidemiology,UniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,RS,Brazil dSpeechTherapyCourse,UniversidadeFederaldeSantaMaria(UFSM),SantaMaria,RS,Brazil

ePostgraduatePrograminCommunicationSciences---HumanCommunication,UniversidadeFederaldeSantaMaria(UFSM),

SantaMaria,RS,Brazil

Received10September2014;accepted2February2015 Availableonline11December2015

KEYWORDS

Elderly;

Long-stayinstitution fortheelderly; Healthprofile; Dizziness

Abstract

Introduction:Dizzinessisamongthemostcommoncomplaintsintheelderlypopulation.

Objective: Todeterminethesociodemographicandclinical-functionalprofilesof institutional-izedelderlypeoplerelatedtodizziness.

Methods:Cross-sectional prospective study with institutionalizedelderlypeopleaged 60 or more years.A questionnaireonsociodemographicandclinical-functional characteristicswas applied,andananamnesisofoccurrenceofdizzinesswasheld,aswellastheDizzinessHandicap Inventoryquestionnaire.

Results:48.9%oftheelderlysubjectshaddizziness.Themeannumbersofdiseasesand medica-tionsassociatedwithdizzinesswere,respectively,4.5diseasesand7.8medications.Wefound asignificantassociationbetweentheoccurrenceofdizzinessanddiseasesofthe musculoskele-talsystem,sub-connectivetissueandgenitourinarysystem,aswellastheuseofmedications forthemusculoskeletalsystem.ThescoresforhandicapdegreeinfunctionalDHIwere signif-icantlyhigheramong elderlysubjectswhoneededwalkingaids,whohadsufferedfalls,and thosemanifestinganxiety.

Pleasecitethisarticleas:RosaTSM,deMoraesAB,dosSantosFilhaVAV.Theinstitutionalizedelderly:sociodemographicand clinical-functionalprofilesrelatedtodizziness.BrazJOtorhinolaryngol.2016;82:159---69.

夽夽Institution:UniversidadeFederaldeSantaMaria(UFSM),SantaMaria,RS,Brazil.Correspondingauthor.

E-mail:samarqs@hotmail.com(T.S.M.Rosa). http://dx.doi.org/10.1016/j.bjorl.2014.12.014

(2)

Conclusion:Oursampleincludedsubjectsofadvancedage,primarilywomen,whowere institu-tionalizedlessthanfiveyears,withmultiplediseasesandpolypharmacyusers.Theypresented long-standing short-duration mixed dizziness, that occurred more than once a month and affectedmainlythefunctionalaspect.

© 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/).

PALAVRAS-CHAVE

Idoso;

Instituic¸ãodelonga permanênciapara idosos;

Perfildesaúde; Tontura

Oidosoinstitucionalizado:perfissociodemográficoeclínico-funcionalrelacionadosà tontura

Resumo

Introduc¸ão:Atonturaestáentreasqueixasmaiscomunsdapopulac¸ãoidosa.

Objetivo:Determinarosperfissociodemográficoeclínico-funcionaldeidosos institucionaliza-doscomrelac¸ãoàtontura.

Método: Estudo prospectivo transversal, com idosos institucionalizados com ≥ 60 anos de idade.Foiaplicadoumquestionárioreferenteàscaracterísticassociodemográficase clínico-funcionais, assim como foi feita anamnese sobre a ocorrência de tontura, e aplicado o questionárioDizzinessHandicapInventory.

Resultados: 48,9%dosidososapresentaramtontura.Asmédiasdonúmerodedoenc¸ase medica-mentosassociadosàtonturaforam,respectivamente,4,5doenc¸ase7,8medicamentos.Houve associac¸ãosignificativaentreocorrência detontura edoenc¸asdosistemaosteomuscular,do tecido subconjuntivo e do aparelho geniturinário, bemcomo usode medicamentos para o sistemamusculoesquelético.OsescoresdograudehandicapnoDHIfuncionalforam significa-tivamentemaioresparaosidososquenecessitavamdeauxílioàmarcha,paraosquetiveram quedaeparaosqueapresentaramansiedade.

Conclusão:Amostracaracterizadapormulheresdeidadeelevada,commenosdecincoanos deinstitucionalizac¸ão,commúltiplasdoenc¸asemedicamentos.Apresentamtonturamista,de curtadurac¸ão,comsurgimentoháanos,manifestando-semaisdeumavezaomês,prejudicando principalmenteoaspectofuncional.

© 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

Humanagingcompromisescertainskillsofthecentral

ner-voussystem(CNS),andaffectsareasresponsibleforsignal

processing from the vestibular, visual and proprioceptive

systems.Thesesensorysystemsareessentialfor

maintain-ing body balance and when affected, negatively impact

the ability to change adaptive reflexes,1 responsible for

postural control and orientation of the body relative to

space.2

Dizzinessis amongthemost commoncomplaintsinthe

elderly and may be characterized as a sense of

giddi-ness,afeelingof‘‘light-headedness’’,asenseofimminent

fall,instability,afloatingsensation,vertigo,atendencyto

deviate when walking, body imbalance, falls, and spatial

disorientation, among others.3 These changes may result

infractures,lossofmobility anddependenceonothersto

performdailyactivities.4

Intheworld’spopulation,10---15%ofpeoplehave

dizzi-ness,andthiscomplaintranksseventhplaceamongthose

most frequently found in women, and is the fourth most

common complaint among men. After 65 years, balance

changesareconsidered tobethemostcommonsymptoms

inthegeriatricpopulation,reachingaprevalenceof85%.5

ThreeoutoffourAmericansaged70orolderhavepostural

balanceproblems.6The causesofdizzinessmaybe

associ-ated withorganicand/or psychicdysfunction,whichhave

extra-vestibular (visual, neurological,emotional) or

vesti-bularorigin.7,8

Inordertoquantifyinterferencesfromphysicaland

func-tional/emotional dizzinesson daily activities ofa subject

suffering vertigo, aspecific questionnaire called Dizziness

HandicapInventory (DHI)wasdeveloped andvalidated by

Jacobson and Newman,9 with the aim of evaluating the

self-perception of the incapacitating effects caused by

dizziness.10InastudyinwhichDHIwasapplied,allelderly

subjectstestedshowedchangesinqualityoflife;physical

aspectswerethemostaffected,andfunctionalaspectswere

themostaffectedinolderindividuals.11

People with dizziness usually report difficulty with

mental concentration, memory loss and fatigue. Besides

generatingphysicalinsecurity,thesesymptomscanleadto

psychicinsecurity,irritability,lossofself-confidence,

(3)

Alsoinvolvedindizzinessinadditiontothefactors

men-tionedabove,alargenumberoftheelderlypopulationtake

multiple medicines (polypharmacy)because theyalso are

afflicted with a high number of comorbidities that bring

about physiologicalchangesin theirpharmacokineticsand

pharmacodynamics;thisadds totheongoing degenerative

process.13

The number of drugsused bythe elderlypopulation is

amajorriskfactorforiatrogenicevents,withan

exponen-tial relationship betweenmagnitude ofpolypharmacy and

the likelihoodof adverse reactions, druginteractions and

theuseofinappropriatedrugs.14Thus,elderlypeople

resid-ing in long-stay institutionsfor the elderly (LSIEs)are at

increased risk for iatrogenic events, due to disabling

dis-eases,frailtyandlow functionality,15 sometimesrequiring

drugprescription.

The use of tools to investigate the clinical-functional

status of elderly people with and without body balance

disorders,and therelationship tosociodemographic

char-acteristics, canadd informationtoassistthesearch for a

timelydiagnosisandamoreeffectivetherapeutic

orienta-tion.

Thus, the aim of this study is to determine the

socio-demographicand clinical-functionalprofiles of

insti-tutionalizedelderlysubjectsrelatedtodizziness.

Methods

Thisis across-sectionalhistoricalcohortstudy,conducted

inthreephilanthropiclong-stayinstitutionsfortheelderly

fromAugust2013toJanuary2014.Thestudywasapproved

by the Research Ethics Committee under opinion number

322,139 onits 20June 2013session. In orderto obtain a

FreeandInformedConsentTerm(FICT),wecompliedwith

therecommendationsfromResolutionnumber466/2012of

the National Council of Health, which regulates research

involvinghumanbeings.

The subjects signedtheFICT formafter readingit and

withtheirconcerns andquestionsalreadyclarified by the

researcher.Forthosepresentingsomemotorand/orvisual

disabilitythatpreventedthemfromwriting,theformwas

signedbytheheadoftheinstitution.

For sample selection, the following inclusion criteria

were considered: individuals aged ≥60 years, according

to Decree number 1,395/GM of the National Health

Pol-icy for the Elderly,16 residing in a charitable long-stay

home. Individualspresenting neurological disorders;

judg-ment, language and/or cognition loss, or dementia, who

werenotbeingabletounderstandthenecessaryprocedures

for theassessment ofstudy variables,would notagreeto

takepartinthestudyorsigntheFICTform,wereexcluded

fromthisstudy.

Thiswasaconsecutive,conveniencesampletotaling142

elderlysubjects.Ofthese,44wereexcludedbecausethey

fell below the minimum cutoff level of 10 points in the

evaluation of the Mini-Mental State Examination (MMSE)

measuringtheabilityofunderstandingandverbal

communi-cation,accordingtoFolstein,FolsteinandMcHugh.17 Thus,

thefinalsampleconsistedof98elderlyindividuals;32were

maleand66female.

Becauseofthelimitedinformationoneducationinthe

medical records of the elderly subjects, and considering

that the classification of Folstein, Folstein and McHugh17

presentslargescorerangesforthecategorizationof

demen-tia,wedecidedinfavorofthatclassificationinthisstudy.

Theevaluationsof theelderlysubjectswereheld

individ-uallyinaroommadeavailablefortheseactivitiesineach

LSIE. A meeting withthe head of each institution to

dis-cusstheoperationalorganizationofthisresearch,hadbeen

completedpreviously.

At first, the elderly were evaluated through a

ques-tionnairecomposedof openandclosedquestionsduringa

face-to-faceinterview.Thisinstrumenthadbeenpreviously

testedwith30seniors,andthenecessarycorrectionswere

made.Forelderlysubjectspresentingdifficultyof

expres-sionofspokenlanguage,theassistanceoftheircaregivers

wasrequested,andforthosewhoshowedfatigueduringthe

interviewanadditionalinterviewwasscheduled.

Thestudyvariableswereclassifiedassocio-demographic

(gender,age,skincolor,maritalstatus,educationandtime

sincebeinginstitutionalized),whichwereobtaineddirectly

frommedicalrecords,andclinical-functional.The

clinico-functionalgroupincludedthenumberandtypeofdiseases

anddrugs,classifiedaccordingtotheInternational

Classifi-cationofDiseases(ICD-10)andtheAnatomicalTherapeutic

Chemical(ATC)ClassificationIndex,theuseofwalkingaids,

theoccurrenceoffalls,fracturesinupperandlowerlimbs

relatedtofalls,asubjectiveperceptionofvisionand

hear-ing(verypoor,poor,fair,good,orexcellent),thefrequency

ofphysicalactivityandemotionalissuessuchaspresenceor

absenceofanxietyanddepression,andwhetherthesubject

wasundergoingpsychologicaland/orpsychiatrictreatment.

It should be noted that the diagnosis of diseases and

prescribeddrugs was obtained directly from the medical

recordsofeachelderlysubject,forwhichtheLSIE’sdoctors

wereresponsible.

Subsequently, a history was obtained concerning the

occurrenceof dizziness, and information about its onset,

type,triggeringfactors,intensity andduration,frequency,

interference withdaily activities, and any

neurodegener-ative manifestations, habitsand subjective perception of

dizziness, as, classified according to the Visual Analogue

Scale(VAS),wasregistered.

Finally, the DHI questionnaire, developed by Jacobson

and Newman9 and containing 25 questions assessing

self-perceptionoftheincapacitatingeffectscausedbydizziness

(emotional,physicalandfunctionalaspects),wasapplied.

Thisquestionnairewasadaptedtotherealityof

institution-alizedelderlypersons.Toanalyzetheresults,threepossible

answerswereconsideredinthequestionnaire,withthe

fol-lowingscores:yes=4points;sometimes=2points,andno=0

points.Themaximumpossiblescoresinemotional,physical,

andfunctionaldomainswere32,36,and32points,

respec-tively,totalingapossiblemaximumscoreof100points.For

thetotal DHI score, the higherthe value, the higher the

degreeofdisabilityoftheelderlysubjectinthecontextof

dizziness.

To analyze statistical data, we initially conducted

a descriptive analysis and, later, an inferential

analy-sis using non-parametric tests: chi-square, Fisher exact,

(4)

Table1 Distributionoffrequenciesofinstitutionalizedelderlypeoplewithrespecttosociodemographicaspectsanddizziness (n=98).

Variable Categories Numberofelderly subjects(%)

Numberofelderlysubjects withdizziness(%)

p-value

Gender Male 32(32.7) 14(29.2) 0.471 Female 66(67.3) 34(70.8)

Skincolor Caucasian 77(78.6) 39(81.2) 0.703 Black 15(15.3) 7(14.6)

Mixed-race 6(6.1) 2(4.2)

Maritalstatus Single 50(51.0) 25(52.0) 0.506 Married 2(2.0) 2(4.2)

Separated 3(3.1) 1(2.1) Widowed 39(39.8) 19(39.6) Divorced 4(4.1) 1(2.1)

Schoolinga Illiterate 14(14.3) 6(12.5) 0.840

Incompleteelementaryschool 73(74.5) 36(75.0) Completeelementaryormore 11(11.2) 6(12.5)

Age(years) 60---70 25(25.5) 9(18.7) 0.245

71---80 42(42.9) 24(50.0)

≥81 31(31.6) 15(31.3)

Timesincebeing institutionalized (years)

0.1---4.9 55(56.1) 31(64.6) 0.155

5---9.9 29(29.6) 13(27.1)

≥10 14(14.3) 4(8.3)

Total 98(100.0) 48(100.0)

Chi-squaretest,orFisher’sexacttest.

aIncompleteelementaryeducation,1---4yearsofschooling;completeelementaryeducationormore,5yearsofschooling.

significancewassetat 5%.Analyseswereperformed using

theSTATISTICA9.1software.

Results

Our sample consisted of 98 institutionalized elderly

sub-jects,withameanageof 76.3years(±8.5),ranging from

60to94 years.The meantimeof institutionalization was

5.6years(±6.9),rangingfrom2.4monthsto42years.With

respecttodizzinesscomplaints(n=48),48.9%reportedthat

theyexperienced dizziness.Therewasnosignificant

asso-ciation of dizziness with the socio-demographic variables

considered.

Table1liststhedistributionofelderlysubjectsaccording

tosocio-demographicvariables,andtheirassociation with

theoccurrenceofdizziness.

Table2showsdataontheprevalenceofdiseasesamong

theelderly,andassociationswiththeoccurrenceof

dizzi-ness.

Table 3 lists data onthe frequency distribution of the

typesofdrugsused,aswellasassociationswiththe

occur-renceofdizziness.

Themeannumberofassociateddiseasesper

institution-alizedelderlysubjectwas4.5(±1.6),withamaximum of

8;10elderlypatients(10.2%)presented1or2diseases,39

(39.7%)had3or4diseases,and48(48.9%)had≥5diseases.

Astothenumberofmedicationsused,wefound7.8(±3.7)

drugsperelderlysubject,withamaximumof17drugs.All

theelderlysubjectsinthisstudyweretakingsomekindof

medication.

Table4showstheprevalenceofotherclinical-functional

characteristics: use of walking aids, occurrence of falls,

physical activity,anxiety, depression, and the association

ofthesevariableswiththeoccurrenceofdizziness.

Althoughithasbeenshownthattheoccurrenceoffalls

andpresenceofanxietyanddepressionhavenosignificant

associationwithdizziness,ourfindingsdemonstrate

impor-tant numerical differences with regard to complaints of

dizzinessamongelderlypeoplewithor withoutsuch

mor-bidities.

Historical data revealed that 29.2% of elderly patients

with dizziness had suffered fractures due to falls, but a

significant association (p=0.562) was not found. As for

self-perceptionofsightandhearing,ahighnumberof

sub-jects chose the ‘‘normal’’ option for both sight (40.8%)

and hearing (36.7%). Considering only those who

experi-enced dizziness, the ‘‘poor’’ option was chosen for both

sight(35.4%)andhearing(37.5%).Wemustemphasizethat,

considering the group of elderly patients with dizziness,

60.4% are or were in psychological treatment, and 16.6%

areorwerereceivingpsychiatrictreatment.

Table 5 shows the characteristics of dizziness (onset,

type,triggeringfactors,durationandfrequency).

Regarding self-perception of the intensity of dizziness

by the elderlyas measured by EVA,a meanof 6.2 points

(±1.1)(range:3---8points)wasobtained.Therewasno

(5)

Table2 Clinical-functionalcharacteristicsofinstitutionalizedelderlypeopleandassociationbetweenthetypesandnumber ofdiseasesandoccurrenceofdizziness(n=98).

Typesofdiseases Numberofelderly subjects(%)

Numberofelderlysubjects withdizziness(%)

p-value

Infectiousandparasitary 5(5.1) 1(2.1) 0.362

Neoplasias(tumors) 5(5.1) 4(8.3) 0.200

Blood 5(5.1) 4(8.3) 0.200

Endocrine 53(54.0) 23(47.9) 0.311

Mentaldisorders 41(41.8) 21(43.8) 0.838

Nervoussystem 91(92.8) 43(89.6) 0.264

Eyesandadnexa 25(25.5) 12(25.0) 1.000

Circulatorysystem 71(72.4) 32(66.7) 0.260

Respiratorysystem 9(9.1) 2(4.2) 0.160

Digestivetract 61(62.2) 34(70.8) 0.099

Musculoskeletalsystem 55(56.1) 33(68.8) 0.016a

Genitourinarytract 29(29.5) 19(39.6) 0.046a

Numberofdiseases

≤2 11(11.2) 3(6.2) 0.200

≥3 87(88.8) 45(93.8)

Blood,bloodandhematopoieticorgans,andimmunedisorders;Endocrine,nutritionalendocrineandmetabolicdiseases;mental disor-ders,mentalandbehavioraldisorders.Chi-squareorFisher’sexacttest.

a Significantassociation(p0.05).

theintensityofdizzinessintheagegroups.However,in

rela-tiontogender, menshowedsignificantlyhighervaluesfor

intensityofdizzinesscomparedtowomen(p=0.012).

Considering only those elderly individuals who

com-plained of dizziness, we identified that the most

com-promised daily activity was physical activity (87.5%).

Neuro-vegetativesymptomswereidentifiedin52.1%ofthe

elderly;thesymptomsmostcommonlyreportedwere

nau-sea (29.2%), tachycardia (18.8%), sweating and diarrhea

(4.2%). Among the habits of the elderly with dizziness,

coffee consumption was the most frequently mentioned

(87.5%),followed by the consumption of ‘‘chimarrão’’(a

typeoftea)(58.3%),sugar(56.3%),andtobacco(6.3%).

Table 6 lists a comparison of the scores for DHI

sub-scaleswithrespecttotheuseof walkingaids,occurrence

offalls, physical activity,anxiety and depression, aswell

asdescriptivemeasuresoftotalDHIscoresbygender,age,

time since being institutionalized and the significance in

thecomparisonofthesescores.Althoughtheoccurrenceof

depression,eitherpreviousorcurrent,wasnotsignificantly

associatedwithdizziness,ahigherpercentageofdizziness

intheelderlycurrentlydepressedwasfound.

Table3 Clinical-functionalcharacteristicsofinstitutionalizedelderlypeopleandtheassociationbetweentypesandnumber ofdrugsandtheoccurrenceofdizziness(n=98).

Typeofdrug Numberofelderly subjects(%)

Numberofelderlysubjects withdizziness(%)

p-value

Otoneurological 20(20.4) 12(25.0) 0.321

Cardiovascularsystem 67(68.3) 30(62.5) 0.279

Digestivetract 82(83.6) 43(89.6) 0.172

Nervoussystem 88(89.7) 42(87.5) 0.520

Hematologicalsystem 1(1.0) 1(2.1) 0.490

Muscularsystem 55(56.1) 33(68.8) 0.016a

Respiratorysystem 8(8.1) 1(2.1) 0.060

Hormonalpreparations 55(56.1) 24(50.0) 0.309

Ophthalmological 24(24.4) 12(25.0) 1.000

Numberofdrugsa

1or2 7(7.1) 3(6.3) 0.506

3or4 14(14.3) 5(10.4)

≥5 77(78.3) 40(83.3)

Muscularsystem,musculoskeletalsystemandsub-connectivetissue;digestivetract,digestiveandmetabolictract;hormonal prepara-tions,systemichormonalpreparations.Chi-squareorFisher’sexacttest.

(6)

Table4 Clinical-functionalcharacteristicsofinstitutionalizedelderlypeopleand associationwith occurrenceofdizziness (n=98).

Variables Categories Numberofelderly subjects(%)

Numberofelderlysubjects withdizziness(%)

p-value

Walkingaid Yes 54(55.2) 30(62.5) 0.149 No 44(44.8) 18(37.5)

Fallsa Yes 73(74.5) 39(81.2) 0.133

No 25(25.5) 9(18.8)

Physicalactivity Doesnotpractice 6(6.1) 2(4.2) 0.117

Everyday 25(25.6) 8(16.7)

Weekly 32(32.6) 20(41.6)

Biweeklyormore 35(35.7) 18(37.5)

Anxiety Yes 85(86.8) 42(87.5) 0.213

No 13(13.2) 6(12.5)

Depression Yes 80(81.7) 43(89.6) 0.080

No 18(18.3) 5(10.4)

Chi-squaretestorFisherexacttestforassociation.

aDuringtheinstitutionalizationperiod.

With respectto functional DHI,statistical valueswere

significantlyhigherforthoseparticipantswhoneededsome

helptowalk,forthosewhosufferedfalls,andforthose

pre-sentinginananxietystate.InthecomparisonoftotalDHI

scores, according tosocio-demographic variables (gender,

age,andtimesincebeinginstitutionalized),nosignificant

differenceswerefound,butwedididentifyadirect

propor-tionalrelationshipbetweentheageoftheelderlyandtotal

DHIscore.

Discussion

Over the years, the sensory and motor systems

respon-sible for maintenance of equilibrium suffer degenerative,

infectiousandtraumaticprocessesthathindertheiroptimal

functioning.18

Although there was no significant association with

thosesocio-demographiccharacteristicsweconsideredwith

respecttotheimportanceoftheprevalenceofdizzinessin

Table5 Featuresofdizzinessininstitutionalizedelderlysubjects(n=48).

Variable Categories Numberofelderlysubjects withdizziness(%)

Onset Days 4(8.3)

Weeks 3(6.2) Months 13(27.0) Years 28(58.5) Type Rotational 20(41.6) Instability 5(10.4) Imbalance 26(54.1)

Fall 1(2.0)

Triggeringfactors Turntheheadfromsidetoside 19(39.7) Quicklyliftthetrunk 17(35.4) Standupfastfromasittingposition 10(20.8) Extendtheheadbackwards 2(4.1) Duration Longduration 21(42.6)

Shortduration 27(57.4) Frequency Everyday 17(35.4) Morethanonceamonth 26(54.2) Lessthanonceamonth 5(10.4)

(7)

Table6 Comparison between scoresofDHIsubscales andtotal DHIscore versusclinical-functional andsociodemographic aspectsofinstitutionalizedelderlypeople(n=48).

Variables DHI(p-value)

Clinical-functional Physical Functional Emotional Total Walkingaid 0.416 0.013a 0.295 0.046a

Falls 0.567 0.046a 0.219 0.081

Physicalactivity 0.073 0.643 0.129 0.344

Anxiety 0.820 0.042a 0.103 0.201

Depression 0.392 0.073 0.219 0.141

Medianofscores(min---max) 12(0---26) 12(0---26) 17(0---34) 40(2---80)

Sociodemographicfeatures TotalDHI

(min---max) Q1;Median;Q3 Mean± SD p-value

Gender

Male(n=14) 20.0---66.0 34.0;41.0;52.0 42.6± 12.1 0.641

Female(n=34) 2.0---80.0 32.0;40.0;50.0 39.5±18.6

Age(years)

60---70(n=9) 6.0---56.0 32.0;40.0;48.0 37.3± 16.0 0.728

71---80(n=24) 2.0---68.0 31.0;40.0;50.0 39.4±16.7

81ormore(n=15) 4.0---80.0 32.0;44.0;56.0 43.8±18.2

Institutionalizationtime(years)

0---4.9(n=31) 2.0---80.0 32.0;42.0;56.0 41.2± 18.2 0.823

5---9.9(n=13) 2.0---66.0 32.0;40.0;50.0 38.4±15.9

≥10(n=4) 28.0---52.0 33.0;40.0;47.0 40.0± 9.9

DHI,DizzinessHandicapInventory;Q1,1stquartile;Q3,3rdquartile;SD,standarddeviation.

Mann---WhitneyUorKruskal---Wallistests.

a Statisticalsignificanceforp0.05.

theelderly,wefoundthatagreatnumberof

institutional-izedelderlypersons(48.9%)complainedofdizziness;thisis

similartothe study by Borges,Garcia andRibeiro,19 who

identified a prevalence of 58.0% for dizziness complaints

intheirgroupofinstitutionalizedelderlypersons.Inother

studieswithcommunity-basedolderadults,theprevalence

ofdizzinesswasreportedtobe42%and45%.20,21

In the present study, 70.8% of the elderlypeople with

dizziness,werefemale,whichisinlinewithstudiesinthe

literature that found 53%20 and 80%22 of female patients

amongelderlypeoplewithvestibulardisorders.Thiscould

beexplained by agreater concern onthe part of women

to seek medical advice, compared to men,20,22 and also

bythefactthat,withmenopause,womenaremoreprone

toheart disease, suggesting a strictrelationship between

bloodpressureandfemalehormones.23 Withregardtoskin

color,mostelderlypatientswithdizziness(81.2%)were

Cau-casian,thoughthislackedstatisticalsignificance.Nostudies

werefoundestablishinganassociationofskincoloror

eth-nicdatawiththeoccurrenceofdizzinessintheelderly.In

studiespublished,whiteskincolorwaspresentin67.0%,24

80.5%,25 and 90.0%26 of institutionalized elderly persons,

similartoourstudy(78.6%ofolderpeoplewithwhiteskin

color).

As tomaritalstatus, most elderlysubjects weresingle

(51.0%). Other studies have found 38.9%27 and 63.0%24 of

single elderly subjects. No studies were found analyzing

dizzinessassociatedwithmaritalstatusinthispopulation.

Inthisstudy,thelevelofeducation‘‘completed

elemen-tary or more’’ occurred in 12.5% of elderly patients with

dizziness; most subjects withsuch symptom (75%) stated

an ‘‘incomplete elementary education’’; this association

lacked statistical significance. In the reviewed literature,

17.5%28and30.8%21 ofelderlypatientswithbalance

disor-dershad‘‘completedelementaryeducationormore.’’

Agreaterlevelof educationis thoughttoexerta

posi-tiveinfluenceinmaintainingbrainstructuresandincreasing

synapticdensity,whichhelpstoreducethedamagesuffered

bytheCNSwithaging.29

In this study, the majority of institutionalized elderly

subjectswerein the71---80 yearsrange,witha meanage

of 76.3 years,similar tothe study by Borges,Garcia and

Ribeiro19 thatfoundameanof74.6yearsfor

institutional-izedelderlypeople.Inanotherlongitudinalstudy,27.0%of

non-institutionalizedelderlysubjectsaged>65years

com-plainedofdizzinessduring thepreceding six months,and

54.0%ofthoseaged>70yearsreportedit,30whichisinline

withourfindings:57.1%prevalenceforelderlysubjectsaged

71---80years.

Oursubjectshadameanof5yearsand6monthssince

being institutionalized, affirming data from a study that

reported 5 years and 8 months.31 It is believed that the

institutionalization processoccurs because the elderlydo

nothaveadequatephysical,andpsycho-social,conditionsto

livealone,andsometimestheydonothavefamilysupport

(8)

Intheanalysisofclinical-functional characteristics,we

identifiedastatisticallysignificantdifferencebetweenthe

occurrenceof dizzinessand diseasesof the

musculoskele-talsystem,sub-connectivetissueandgenitourinarysystem,

withaprevalenceof56.1%and39.6%,respectively.Despite

the lack of a significant association, diseases of the

ner-vous system have been identified as the most prevalent

characteristics (89.6%). In the literature, lower

percent-ages were identified for diseases of the musculoskeletal

system and sub-connective tissue (41.2%),32 genitourinary

tract(12.5%)28andnervoussystem(10%).28

Itisimportanttonotethatchangesintheosteo-articular

systemsuchasphysiologicalosteopenia,cartilaginousaging,

sarcopeniaandreductionin nerveconduction velocityare

stronglyassociatedwiththeagingprocess.Painand

disor-dersof themusculoskeletal systemarethemost frequent

complaintsoftheelderly,andrheumaticdiseasesalsohad

ahigherincidencewithadvancingage,suchas

osteoporo-sis, osteoarthritis, and polymyalgia rheumatica.33 In the

samecontext,researchersstatethatdiseasesofthe

circu-latoryandmusculoskeletalsystems,asaresultofperipheral

and/orcentralinvolvement,canmanifestthemselvesinthe

formofbalancedisordersandcausesofinstability.2

Accordingtotheliterature,despitethelackof

neurologi-calsymptomsorsignsintheelderlypopulationdizzinessmay

arisein association with central nervoussystem diseases,

suchasvertebrobasilarinsufficiencyandmultiplesclerosis.

Thesediseasescanaffecttheperipheralvestibularsystem,

resultinginconcomitantlabyrinthinesymptomsandsigns.34

Regardingthenumberofdiseasesaffectingtheelderly,

wefoundameanof4.5diseases,with48.9%reportingfive

or more associated diseases. Although it lacked a

signifi-cantstatisticalcorrelation,wefoundthat93.8%ofelderly

patientswithdizzinesshavethreeor moreassociated

dis-eases.AsurveyofelderlyresidentsinthecityofCuiabá(MT)

revealedthepresenceofthreeormorediseasesin42.0%of

thesubjectswithdizziness.21Inanotherstudyconsistingof

institutionalizedelderlysubjects,thisoccurrenceindicated

a7.3timesgreaterchanceofhavinganepisodeofdizziness,

comparedtothosewhohadnodiseasesatall.35

Althoughmoreelderlysubjectstookmedicationsforthe

nervoussystem(89.6%),thedigestivesystem(83.6%)andthe

cardiovascularsystem (68.3%), thosetaking medicines for

themuscularsystem(57.3%)werestatisticallysignificantly

morelikelytoexperiencedizziness.

Astudy conductedin Finlandrevealed that

institution-alizedelderlysubjectswithoutdizzinesstookanaverageof

7.9drugsperperson,indicatingthatpolypharmacyinLSIEsis

stillacurrentproblem.36Inthepresentstudy,wefoundthat

ourpopulationusedameanof7.8medicationsperelderly

person,withamaximum numberof 17drugs,aswell asa

high incidence(83.3%) of subjectstaking 5 or more

med-ications.This findingreflects the international literature,

in which 74% of the elderly were in a state of

polyphar-macy, defined as taking more than five medications per

patient.37

Theprevalenceofpolypharmacyishighinvarioushealth

sectors,withaveragenumbersof9.9---13.6medicinestaken

by hospitalized patients; up to seven for patients in the

intensivecareunit,and7.2---8.1medicationsper

institution-alizedpatient.15Accordingtotheliterature,thehigherthe

consumptionofdrugsbytheelderlysuchasantipsychotics,

sedatives, antidepressants, antihypertensives, analgesics

andanxiolytics,thegreaterthepossibilityofpotential

inter-actionsandsideeffectsofdrugs,Almostallareassociated

withvertigo,imbalanceandepisodesoffalls.30

Inthisstudy,despite thelack of significantassociation

betweenclinical-functionalcharacteristicsof

institutional-izedelderlypersonsandoccurrenceofdizziness,therewasa

decreasingprevalenceof89.6%,87.5%and81.2%for

depres-sion, anxiety and falls, respectively, showing a clinically

importantrelationship.

Asforthe depressionassociatedwithdizzinessin

insti-tutionalized elderlypeople, in this study a prevalence of

89.6%wasobserved;thisdatacontrastswithasurveywhich

found a prevalence of 37.3% among elderly subjects in

thecommunity.21 Elderlypatientswithahighernumberof

depressivesymptomsaremorelikelytohavedizziness

com-paredtothosewithfewersymptoms;inaddition,theyalso

tendtoexperiencethefollowingconsequences:decreased

functionalperformanceindailyactivities,anxietyand

inse-curity,andinthecourseoftimetheseindividualsmayhave

moodchanges,thusworseningdepression.4

Withregardtofalls,thepresentstudyfoundhigh

preva-lence,differingfromotherstudiespublishedthatreported

aprevalenceof50.0%,1962.3%26 and14.9%.38

When asked about their self-perceived sightand

hear-ing, 35.4% and 37.5% of the elderly with dizziness,

respectively, chose a ‘‘poor’’ option. In another study

involvingcommunity-basedelderswithdizziness,an

occur-renceof visual(100%) andhearing(41%) impairmentswas

identified.21

Elderlypersonstend toshowinvolvementof other

sys-tems relatedtovestibularfunction,includinghearingand

visual impairment.28 Hearing impairment and presence of

vertigoareconditionsresultingfromthehighsensitivityof

auditory and vestibularsystems to commonclinical

prob-lems inthe process ofaging. These individualscommonly

indicatethattheirvisualsystemalsosufferstheeffectsof

advancing age,andocular changes, suchascataractsand

glaucoma,thatareresponsibleforadecreaseinvisual

acu-ity,andwhichcontributestostaticanddynamicinstability

ofthebody.2

Themainconsequenceofthenaturalagingprocessofthe

vestibularsystemisadegenerationofthevestibulo-ocular

reflex(VOR),39 theresultof whichis instabilitywithbody

rotation and, consequently, a deviation when walking.40

Withitsorigininthesemicircularcanals,VORoperates by

generatingeyemovementsatthesamespeedashead

move-ment,butintheoppositedirection,41 inordertomaintain

astablevisualfieldduringheadmovement,42thusallowing

acrisp,cleanimageevenduringmovement.41

Regardingdizzinesscomplaints,thepopulationofelderly

patients in our study reported that their episodes began

morethanoneyearago(58.5%).Ourdatadiffersfromthat

obtained inthe study bySouza,22 that showedthat 54.0%

reported an onset occurring five or more yearsago, thus

demonstratingthechronicnatureofdizzinessinthat

popu-lation.

Inourstudy,therewasapredominanceofnon-rotational

dizziness,definedasanimbalance,in54.1%oftheelderly

subjects, similar to the result obtained by Ferreira and

Yoshitome,38whofoundaprevalenceof46.2%.However,our

(9)

dizzinessin38.0%oftheelderlypopulationinthecityofSão Paulo.

Thetriggeringfactorsfordizzinessmoreoftenreported

by the elderly in this study were turning the head from

side toside (39.7%) and lifting thetrunk quickly (35.4%).

Some authors state that postural hypotension is

associ-ated with an increased risk of dizziness and falls.28,38 It

is common for older people to report various types of

movements being associatedwith dizziness. Studies show

that up to 74% of older people reported more than one

triggering activity resultingin dizziness,4,30 withthemost

frequently cited being rising from a decubitus position

(range of 45.9---58.0%)28 and turning the head (range of

25.8---67.5%).24Keepingtheheadstillinanypositionwasthe

mostcommonlyreportedtriggeringfactorfordizziness;this

wasidentifiedin60%oftheelderly.22Suchheadmovements

orpositionspromoteexcitationofthevestibularsystemand

oftencausevertigoandothertypes ofdizziness,asin the

casesofbenignparoxysmalpositionalvertigo(BPPV)

preva-lentinolderpatients.28

Short-term dizzinesswaspresent in 57.4%of the

insti-tutionalized elderly participants, in line with the studies

of Gassmann and Rupprecht30 and of Souza,22 in which

theprevalencewas48.9%and44%,respectively. Forthose

elderly who reported long-term dizziness this can be

explained by the difficulty in obtaining a full vestibular

compensationbytheagingpopulation.28

When askedabout thefrequencyof dizziness,54.2%of

theelderlyinourstudyreportedanoccurrenceofepisodes

ofmorethanonceamonth,whichagreeswiththefindingsof

Souza,22whofoundasporadicfrequencyofdizzinessin66%

ofelderlysubjects.Thatauthoralsoreportedthataregular

andconstantoccurrenceofdizzinessisusuallyseeninolder

peoplewithamorepronouncedanddisablingclinicaltype

ofdizziness.

Regardingself-perceptionofdizzinessintensityas

mea-suredbyEVA,inthecurrentstudyanaverageof6.2points

(±1.1)wasreported(minimumandmaximumscores:3and8

points,respectively),similartothefindingsofastudywith

elderly people with vestibular dysfunctionthat showed a

meanof6.62 points(±2.45)withminimumandmaximum

scoresofzeroand10,respectively.28Ourmalesubjectsalso

showedasignificantlystrongerintensityof dizziness(EVA)

whencomparedtowomen.However,wecouldnotfindany

studies investigatingthis association to compare withour

findings.

EVA is the most used tool for assessing the

subjec-tive perception of patientswith respecttothe degree or

intensity ofdizziness,43 postural instability,44 and/or body

imbalance.40,45

Inourstudy,thedailyactivitymostimpairedwas

physi-calactivity(87.5%).Astudyincludingactiveandsedentary

elderlysubjectsfromthecommunitynotedthatthegroup

ofsedentaryseniors(33%)hasmorecomplaintsofdizziness

thantheactiveones(20%).46

A prevalenceof neuro-vegetativesymptomsin

associa-tion with dizziness was reported by 52.1% of the elderly

subjects,whichagreeswithstudiesshowinganassociation

betweendizzinessandneuro-vegetativesymptomsand

psy-chological changes.3,28 In this study, the most commonly

reportedeatinghabitwascoffeeconsumption(87.5%).One

studysuggests thatcertaineatinghabitssuch asthe

con-sumptionofcoffee,matetea(‘‘chimarrão’’) andsugar,as

wellassmoking,amongothers,shouldbeavoidedbyelderly

patients with balance disturbances, as these habits may

exacerbatecochleovestibularsymptoms,makingthe

vesti-bularcompensationevenslower.47

Inthecurrent study,DHIfunctionaldomainindices are

significantlyhigherforolderpeoplewhoneedwalkingaids,

suffer falls, and for those who show anxiety, a finding

whichagrees witha studythat evaluatedelderlypatients

withchronic vestibulardisease andobserved a significant

association betweenfalls and functional DHI(p=0.010).48

AccordingtoPeresandSilveira,49thefunctionaldomainof

DHIis important tothe qualityof life of seniors, sinceit

interferes with the individual’s dependence on the social

context.

Scherer,Lisboaand Pasqualotti5 identifieda significant

difference(p=0.02)inthefunctionalaspectforcomplaints

ofbodyimbalance. Theirfindingsdifferfromstudies that

investigatedthemostimpairedfunctionaldomaininelderly

patientswithdizziness,withmeansof16.80and8.60points,

respectively.48,50

In the current study, we could identify a directly

pro-portional,butnotsignificant,relationshipbetweenelderly’s

ageandtotalDHIscore;thatis,forolderseniors,ahigher

totalDHIscorewasfound.Thisfindingisinlinewithastudy

that observed greater commitment of functional aspects

withincreasingage,butdidnotfindthesamerelationship

betweentotalDHIscoreandthepatient’sage.10

Changes in balance resulting from dizziness trigger a

series of psychosocial consequences that are manifested

throughnegativefeelings,interferingwithactivitiesofdaily

lifeoftheaffectedindividuals.11,34

Inviewof theseconsiderations,thisstudy makesclear

the need for interventions for the elderly in long-stay

institutions,aiming atprevention,promotion andpossible

rehabilitationofthehealthofinstitutionalizedelderly

per-sons,withtheobjectiveof reducingtheincidenceoffalls

andtheresultingconsequencesofsuchaccidents.

Conclusions

The typical elderly subject in our study of subjects with

dizzinessliving in long-stayinstitutions wasan unmarried

Caucasian women aged over 70 years, who did not

com-pleteanelementarylevelof educationandwhohadbeen

institutionalizedlessthanfiveyears.Shehadmultipleother

comorbidities, took multiple mediations, experienced a

mooddisorder,andwasundergoingpsychologicaltreatment.

Asagroup,oursubjectsindicatedthattheyhadpoorvisual

and auditory acuity, and experienced imbalance episodes

followedbyshort-duration vertigo,that hadbeen present

foryears,occurredmorethanonceamonth,weretriggered

byheadandbodymovementsandmainlyaffectedfunctional

aspects.

Conflicts

of

interest

(10)

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Imagem

Table 1 Distribution of frequencies of institutionalized elderly people with respect to sociodemographic aspects and dizziness (n = 98).
Table 2 Clinical-functional characteristics of institutionalized elderly people and association between the types and number of diseases and occurrence of dizziness (n = 98).
Table 4 Clinical-functional characteristics of institutionalized elderly people and association with occurrence of dizziness (n = 98).
Table 6 Comparison between scores of DHI subscales and total DHI score versus clinical-functional and sociodemographic aspects of institutionalized elderly people (n = 48).

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