A Little Tipsy with a Case of Vestibular Dysfunction
Abstract & Commentary
By Allan J. Wilke, MD, MA. Dr. Wilke is Professor and Chair, Department of Integrated Medicine, Ross University (Bahamas); he reports no financial relationship to this field of study. This article originally appeared in the Oct. 29, 2009, issue of Internal Medicine Alert. At that time it was reviewed by Gerald Roberts, MD, Assistant Clinical Professor of Medicine, Albert Einstein College of medicine, New York, NY. Dr. Roberts reports no financial relationship to this field of study.
Synopsis: One-third of adults older than age 40 has vestibular dysfunction.
Source: Agrawal Y, et al. Disorders of balance and vestibular function in US adults: Data from the National Health and Nutrition Examination Survey, 2001-2004. Arch Intern Med 2009;169:938-944.
Falls, especially in the elderly, can be a medical disaster with great morbidity and mortality. One cause of falls is dysfunction of the vestibular system whose components are vertigo and imbalance. Balance depends on maintenance of gaze and preservation of postural stability, which in turn, relies on intact vestibulo-ocular and vestibulo-spinal reflexes. These investigators went to the National Health and Nutrition Examination Survey (NHANES) to answer the question, "What is the prevalence of vestibular dysfunction (VD) in the United States?" Between 2001 and 2004, NHANES tested the balance of 6,785 people. In addition to the usual NHANES physical, they underwent balance testing. The Modified Romberg Test of Standing Balance on Firm and Compliance Support Surfaces is a 4-part, sequential test of the vestibular system, vision, and proprioception. The investigators focused on the fourth test condition, the ability to maintain balance on a foam-padded surface with eyes shut. Subjects were deemed to have failed the exam if they needed to open their eyes, moved their arms or legs to maintain balance, or began to fall within 30 seconds. Participants who failed test condition 4 were defined as having VD. This was a representative sample of adults ≥ 40 years; 49% were male, 57% were white. Exclusion criteria included the inability to stand unassisted, report of dizziness, weighing more than 275 lbs, having a waist circumference greater than a safety belt, blindness, and lower extremity amputation. After excluding these subjects and subjects who did not participate in the physical exam, 5,086 subjects remained. The volunteers took a balance questionnaire for history of dizziness or falls within the last 12 months.
A total of 257 participants failed 1 of the first 3 conditions, excluding them from participation in the fourth. Another 86 participants had missing data, leaving 4,743. Fully 35% failed the fourth condition. Predictors of failure included increasing age, lower education level, ≥ 20 pack-years of smoking, and history of hypertension, diabetes, dizziness, and falls. Almost 85% of subjects ≥ 80 years failed; one-third of the 50-59 years cohort and one-half of the 60-69 years cohort failed. Having a high school diploma was protective. Gender, race, and ethnicity did not predict failure. Hearing loss and VD were closely related. Although the incidence of dysfunction was 49% among subjects with self-reported dizziness, 32% of asymptomatic subjects also failed. A history of falls almost doubled the chance of VD (34% vs. 65%).
Commentary
The implications of this report are huge, given the aging of our society, the increasing incidence of diabetes, and the enormous costs associated with falls. The drop in smoking rates will mitigate this, but I suspect that it will not outweigh the other factors. Most physicians do not have the specialized equipment used to test balance in this study, but they could screen with a standard Romberg exam or refer the patient to a physical therapy department with the equipment. Given the data above, I recommend that everyone older than age 50 and those younger with one of the other predictors of VD or hearing loss should be screened. The screening is low-risk and inexpensive. The next question is, "What do you do with someone who has vestibular dysfunction?" Customized exercise programs,1 especially Tai Chi,2 appear promising. Another question is how frequently the screening should be repeated. I could find no published guidelines, but since it is safe and easy, an annual screening seems reasonable.
References
1. Giray M, et al. Short-term effects of vestibular rehabilitation in patients with chronic unilateral vestibular dysfunction: A randomized controlled study. Arch Phys Med Rehabil 2009;90:1325-1331.
2. McGibbon CA, et al. Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: Preliminary report. BMC Neurol 2005;5:3.
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