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Comparative Study
. 2018 Jul 24;15(7):e1002620.
doi: 10.1371/journal.pmed.1002620. eCollection 2018 Jul.

Reducing the Burden of Dizziness in Middle-Aged and Older People: A Multifactorial, Tailored, Single-Blind Randomized Controlled Trial

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Free PMC article
Comparative Study

Reducing the Burden of Dizziness in Middle-Aged and Older People: A Multifactorial, Tailored, Single-Blind Randomized Controlled Trial

Jasmine C Menant et al. PLoS Med. .
Free PMC article

Abstract

Background: Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms.

Methods and findings: We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions.

Conclusions: A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people.

Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Conflict of interest statement

I have read the journal’s policy, and the authors of this manuscript have the following competing interests: SRL has designed the PPA (FallScreen), which is commercially available through Neuroscience Research Australia. NT is an author of the Wellbeing Plus Course, the psychological intervention used in this trial. However, NT does not receive any financial or personal benefit from this intervention. All other authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. CONSORT diagram (CONSORT; GPCOG; DHI).
CONSORT, Consolidated Standards of Reporting Trials; DHI, Dizziness Handicap Inventory; GPCOG, General Practitioner assessment of Cognition.
Fig 2
Fig 2. Percentage of intervention group participants (n = 154) assigned to the range of intervention combinations (CBT; VR).
CBT, cognitive-behavioural therapy; VR, vestibular rehabilitation.

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Grant support

This study was funded by the Australian National Health and Medical Research Council (project 1026726 awarded to SRL, JCM, AM, JC, NT, KD). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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