Improving the Quality of Life In Patients With Vestibular Disorders: The Role of Medical Treatments and Physical Rehabilitation

E. Mira

Disclosures

Int J Clin Pract. 2008;62(1):109-114. 

In This Article

Consequences of Vestibular Disorders

The maintenance of balance, clear vision during head movements and correct spatial orientation entail the processing of visual, vestibular and somatosensory afferent input to produce adaptive eye and body movements and a correct spatial sensation.[19] Disequilibrium, blurred vision and dizziness or vertigo may ensue, if there is any sensory deficit, abnormal stimulation or defective central processing. The resultant sensory disturbances and motor impairments may in turn lead to dysfunction in many activities of daily living (ADL) and in social interactions of the patient, with falls and cognitive deficit (particularly in the elderly), symptoms of anxiety-depression and, more generally, impaired QoL, the most notable effects.[11]

With increasing age, vestibular disorders may be manifested by a sensation of unsteadiness and imbalance. As such, vestibular dysfunction is recognized as one of the intrinsic factors leading to increased risk of falls.[11] In a study of 546 patients presenting to an Accident and Emergency Department with no known cause of fall, 80% had symptoms of vestibular impairment with 40% complaining of vertigo.[11] The incidence of falls for patients with bilateral vestibular hypofunction aged 63.2 years (range 30-80 years) has been reported as significantly greater than that reported for the general population aged 65-74 years (51.1% vs. 25%). Moreover, the incidence of falls in patients with vestibular deficits is related to the degree of vestibular loss rather than to age.[20] Data from a cross-sectional study of a public geriatric population also indicate that unrecognized BPPV is relatively common amongst the elderly (9% incidence), and that patients with unrecognized vertigo were more likely to have sustained a fall in the previous 3 months.[21] The identification and treatment of such groups of patients with vertigo and instability are therefore important in order to alleviate their symptoms and reduce their risk for falls.

Psychological disturbance is more common among patients with balance disorders than in patients with many other disorders. Indeed, the comorbidity of vertigo and anxiety is well-established and evidenced in medical literature dating back through the ages.[22] Recent studies have shown that nearly 50% of people complaining of dizziness also report some psychological problems, with more than 25% of dizzy patients presenting symptoms of panic and agoraphobia, and a co-morbid prevalence of dizziness and anxiety of 11%.[23,24,25,26] The question of which comes first, psychogenic dizziness or neuro-otogenic anxiety, was addressed in a retrospective review of patients treated for psychogenic dizziness with or without physical neuro-otologic abnormalities. Three equally prevalent patterns of illness were found: anxiety disorders as the sole cause of dizziness constituted 33% of cases, neuro-otologic conditions exacerbating preexisting psychiatric disorders 34%, and neuro-otologic conditions triggering new anxiety or depressive disorders 33%. It therefore appears that physical neuro-otologic disorders may trigger psychopathology as often as primary anxiety disorders may cause dizziness.[27]

Chronic vertigo is a psychologically disabling symptom as it is difficult for the patient to identify its origin and its nature while recurrent vertigo may lead to anticipatory fear of new unpredictable attacks. For these reasons, vestibular patients are potentially prone to somatisation, the physical expression of psychological or social distress suggestive of underlying psychiatric morbidity.[10,28,29]

In one study of patients with peripheral vestibular disorders, there was a significant correlation between the presence of vestibular symptoms and psychiatric morbidity, which in turn correlated with measures of anxiety, perceived stress and previous psychiatric illness. Half the number of patients experienced significant psychiatric symptoms, with panic disorder with or without agoraphobia and major depression commonly observed.[30] Patients with acute vertigo may also experience extreme anxiety, with the psychological impact contributing to their feeling of disproportionate disability.[31] Psychological factors may therefore aggravate vertigo and retard recovery from balance disorders.[32] In a controlled study evaluating QoL, patients (especially females) suffering from vertigo showed a significant amount of anxiety and depression distress. The fear of becoming dizzy was most closely correlated with the perception of disability. The study highlighted the need for a psycho-education program in collaboration with the otologist/neuro-otologist in order to raise the awareness of the factors that contribute to the deterioration of QoL.[10]

Finally, direct evidence has emerged demonstrating that patients with vestibular disorders exhibit a range of cognitive deficits. Magnetic resonance imaging studies also show that patients with bilateral vestibular damage undergo atrophy of the hippocampus, which correlates with their degree of impairment on spatial memory tasks.[12,33]

Compared with the general population, the general health status in vertigo sufferers is significantly affected by both the presence and severity of vertigo, as measured by the DHI questionnaire.[8] Such patients were observed to have suffered significant role limitations due to physical problems and social functioning or vitality.

Recurrent vertigo often affects patients' daily activities even during periods of remission.[13] Menière's patients often avoid a wide range of situations and activities for fear of provoking or experiencing a sudden attack.[34] For many patients with vestibular impairments, driving is a particularly problematic activity, with 60% of Menière's disease patients stating that driving was difficult, dangerous or both.[35]

Further, the elderly population is at an increased risk for BPPV-associated morbidity. For example, BPPV patients scored poorly in a survey of self-perceived disablement (Vestibular Disorders Activities of Daily Living Scale),[17] while elderly patients with vertigo were more likely to have reduced ADL scores, to have sustained a fall in the previous 3 months and to have concomitant depression.[21]

Evidence is therefore strongly supportive of the hypothesis that dizziness and vertigo may have a significantly negative impact on a patient's health-related QoL.

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