Vertigo,
Tinnitus, and Hearing Loss in the Geriatric Patients
Authors
Nemer Al-Khtoum, MD*
*From department of otolaryngology,
Royal medical services.
Correspondence:
Dr. Nemer Al-Khtoum. P.O. Box 1834 Amman 11910 Jordan.
E-mail: nemer72@gmail.com
|
Abstract:
Objective: to study the
vestibular function in two groups of elderly patients
based on their complaints of vertigo, tinnitus and hearing
disorders.
Patients and Methods: we assessed 40 patients aged
65 years or over. The 40 elderly subjects comprised two
different groups characterized as follows:
Group A: comprising 20 subjects in which participants
performed weekly activities, formed by 19 female and 1
male subjects;
Group B: comprising 20 subjects who complained of vertigo
and came to the Department of otolaryngology by medical
indication, formed by 17 female and 3 male subjects.
Patients underwent detailed history taking and a through
general examination, systemic examination, otoneurological
examination and relevant audio vestibular studies.
Results: there is statistical significant difference
between both groups, concerning the complaints of vertigo
and tinnitus, which were more prevalent in group B. The
computerized eletronystagmography revealed that most individuals
had normal diagnosis; however, there was a predominance
of vestibular disorders in the elderly, such as Deficit
Peripheral Vestibular Syndrome and Irritative Peripheral
Vestibular Syndrome.
Conclusion: Vertigo, tinnitus and hearing loss
largely affect elderly subjects, especially the ones that
do not have an active life, as opposed to those that perform
different activities in elderly groups. Vestibular disorders,
detected by vectoelectronystagmography were similar in
both studied groups.
Key words: Vertigo, tinnitus
, hearing loss.
|
We will all be geriatric individuals
one day. As we age, we face many physical and emotional changes
that can affect our level of function and well-being. Our baby-boomer
population is aging, and people are living longer. We must maintain
our functional independence in the elderly and address the needs
of our older generation. Rehabilitation of geriatric patients
is imperative for the patients' well-being and for society,
so that we can thrive socially and economically.
Care of the elderly patient involves
some fundamental premises which must be taken into account in
treatment by otolaryngologists. Often multiple diseases coexist
in these patients, which often present a diagnostic dilemma
in treatment. The elderly also suffer from a unique set of illnesses,
which only occur in old age. Illnesses can present with unusual
symptoms without common symptoms of pain and fever, which may
lead to diagnostic dilemmas.
One of the greatest challenges in the
geriatric population is their ability to communicate their problems,
needs, and desires in a medical setting. Hearing impairments
can hamper a patient's ability to express himself or herself
clearly or to understand questions or commands. This is an enormous
burden on the patient, the caregiver, and the psychiatrist as
they work to achieve rehabilitation goals. Addressing these
issues on the patient's initial visit can ameliorate problems
and prevent frustration and further difficulties.
Vertigo is reported by about 30% of
people aged over 65 years,1, 2,3,4,5 and in the United States
it is the most common presenting complaint in office practice
among patients aged over 75 years.3 Vertigo is a difficult diagnostic
problem in elderly people as it has many potential causes and
patients often find it difficult to articulate the nature of
their symptoms.
Vertigo, tinnitus, and hearing loss
symptoms are usually attributed to the vestibular system. However,
these symptoms may be the most obvious signs of a more complex
presentation, especially in geriatric patients. Vertigo may
be described as dizziness, faintness, lightheadedness, disorientation,
or disequilibrium. Subjective vertigo is an illusion of movement
of oneself, whereas objective vertigo is an illusion of movement
of objects around oneself. Tinnitus is the perception of sound
in the absence of an acoustic stimulus and may have a buzzing,
roaring, whistling, or hissing quality or may involve more complex
sounds that vary over time. Tinnitus is usually accompanied
by hearing loss. 6
The clinician can evaluate the cause
of vertigo in 3 basic categories: peripheral, central, and systemic.
7-10 Vestibular functions belong to the peripheral category
with the exception of the central nerve system and vascular
supply, which compose the central category. Vestibular dysfunctions
found in the systemic category may be important in the geriatric
patient because they occur as a result of side effects from
medications (eg, anticonvulsants, hypnotics, antihypertensives,
alcohol, analgesics, and tranquilizers) or an underlying systemic
pathologic condition (diabetes, hypothyroidism).
Knowing that the occurrence of vertigo
and falls is frequent in the elderly, it is important to assess
their vestibular function so as to detect diagnostic, prognostic,
prophylactic and therapeutic implications in this population.
The present study intended to study
the vestibular function in two groups of elderly patients based
on their complaints of vertigo, tinnitus and hearing disorders.
The sample of this study was conducted in the Department of
Otolaryngology, Royal Medical Services (Jordan).
After institutional ethical committee
clearance and written informed consent, we assessed 40 patients
aged 65 years or over.
The 40 elderly subjects comprised two
different groups characterized as follows:
Group A: comprising 20 subjects in which
participants performed weekly activities, formed by 19 female
and 1 male subjects;
Group B: comprising 20 subjects who
complained of vertigo and came to the Department of otolaryngology
by medical indication, formed by 17 female and 3 male subjects.
Patients underwent detailed history taking and a through general
examination, systemic examination, otoneurological examination
and relevant audio vestibular studies. Audiological tests included
pure tone audiometry with tone decay, speech discrimination
and short increment sensitivity index (SISI) tests. Vestibular
evaluation comprised of balance tests, examination of spontaneous
nystagmus, positional tests, electronystagmography (VENG) with
bithermal caloric tests, craniocorpography (CCG) and brain stem
evoked response audiometry (BERA). ENG studies consisted of
spontaneous and positional nystagmus and caloric stimulation.
Radiological tests like x-ray of mastoids, cervical spines,
internal auditory meatus, CT scan and MRI of brain were done
beside serum biochemistry for blood sugar, Glucose Tolerance
Test, Renal Function Test, Liver function test and hematological
investigations like hemogram, were done as and when required.
There was statistically significant
difference between the groups regarding the presence of vertigo
(Table 1) and tinnitus (Table 2), in which we
detected higher incidence of vertigo and tinnitus complaints
among patients in group B.
Table 1. Distribution of elderly subjects in groups A
and B according to presence or absence of vertigo
|
Group
|
A
|
B
|
Total
|
|
With
vertigo
|
12 (60%)
|
18 (90%)
|
30 (75%)
|
|
Without
vertigo
|
8 (40%)
|
2 (10%)
|
10 (25%)
|
|
Total
|
20 (100%)
|
20 (100%)
|
40 (100%)
|
Table 2. Distribution of elderly
subjects in groups A and B according to presence or absence
of tinnitus
|
Group
|
A
|
B
|
Total
|
|
With
vertigo
|
9 (45%)
|
15 (75%)
|
24 (60%)
|
|
Without
vertigo
|
11 (55%)
|
5 (25%)
|
16 (40%)
|
|
Total
|
20 (100%)
|
20 (100%)
|
40 (100%)
|
There was no statistically significant
difference between the groups as to presence or absence of hearing
complaint (Table 3).
Table 3. Distribution of elderly
subjects in groups A and B according to presence of hearing
disorder
|
Group
|
A
|
B
|
Total
|
|
With
vertigo
|
10 (50%)
|
11 (55%)
|
21 (52.5%)
|
|
Without
vertigo
|
10 (50%)
|
9 (45%)
|
19 (47.5%)
|
|
Total
|
20 (100%)
|
20 (100%)
|
40 (100%)
|
As to spontaneous nystagmus (closed and opened eyes) and directional
nystagmus, we detected absence of both in all studies subjects.
Upon studying Horizontal Pendular Tracking
(RPh) (Tables 4), the statistical analysis did not produce
significant association between type of RPh and the Groups.
As most of the elderly in both groups had RPh types I and II,
with type I RPh more prevalent in Group B and type II in Group
A.
Table 4. Distribution of elderly
subjects according to groups A and B and presence of Horizontal
Pendulum Tracking
|
Group
|
A
|
B
|
Total
|
|
Type
I
|
3 (15%)
|
12 (60%)
|
15 (37.5%)
|
|
Type
II
|
15 (75%)
|
7 (35%)
|
22 (55%)
|
|
Type III
|
2 (10%)
|
1 (5%)
|
3 (7.5%)
|
|
Type IV
|
0 ( 0.0%)
|
0 (0.0%)
|
0 (0.0%)
|
|
Total
|
20 (100%)
|
20(100%)
|
40(100%)
|
In the investigation of ventricular
pendulum tracking (RPv) (Table 5) we could observe that
in this test, type I RPv was more prevalent in elderly people
in Group B, type III RPv was more prevalent in elderly in Group
A, and most of the subjects in both Groups had type II RPv.
Data analysis revealed statistically significant differences
between the groups. In the present study, we did not consider
type II pendulum tracking as a signal of central involvement
because visual disorders may interfere in the analysis of this
test.
Table 5. Distribution of elderly
subjects according to groups A and B and presence of Vertical
Pendulum Tracking
|
Group
|
A
|
B
|
Total
|
|
Type
I
|
1 (5%)
|
8 (40%)
|
9 (22.5%)
|
|
Type
II
|
12 (60%)
|
11 (55%)
|
23 (57.5%)
|
|
Type
III
|
7 (35%)
|
1 (5%)
|
8 (20%)
|
|
Type
IV
|
0 ( 0.0%)
|
0 (0.0%)
|
0 (0.0%)
|
|
Total
|
20 (100%)
|
20(100%)
|
40(100%)
|
Table 6. Distribution of elderly
subjects according to groups A and B and presence of Horizontal
Optokinetic Nystagmus
|
Group
|
A
|
B
|
Total
|
|
Symmetrical
|
20 (100%)
|
18 (90%)
|
38 (95%)
|
|
Asymmetrical
|
0 (0.0%)
|
2 (10%)
|
2 (5%)
|
|
Total
|
20 (100%)
|
20 (100%)
|
40 (100%)
|
Results from Horizontal Optokinetic Nystagmus led us to realizing
that most elderly patients in both groups presented symmetry
and there was no statistically significant difference in the
comparison between the groups.
Concerning the results obtained in PRPD
(peri-rotatory nystagmus - NPR) (Table 7), we observed
that in this task most of the studied subjects presented symmetry
of NRP, more predominant in group A.
Table 7. Distribution of elderly
subjects according to groups A and B and presence of Peri-Rotation
Nystagmus
|
Group
|
A
|
B
|
Total
|
|
Symmetrical
|
20 (100%)
|
16 (80%)
|
36 (90%)
|
|
PD
to the R
|
0 (0.0%)
|
1 (5%)
|
1 (2.5%)
|
|
PD
to the L
|
0 (0%)
|
2 (10%)
|
2 (5%)
|
|
Arreflexia
Bilat.
|
0 ( 0.0%)
|
1 (5%)
|
1 (2.5%)
|
|
Total
|
20 (100%)
|
20(100%)
|
40(100%)
|
Arrefl. Bilat.= Bilateral
Arreflexia
PD to the R = Directional predominance to the right
PD to the L = Directional predominance to the left
As per Post-caloric nystagmus (Table 8) most elderly
patients presented normal reflex response to caloric test. However,
a reasonable number of elderly patients presented abnormalities
in the test, and the most frequent affection was labyrinthic
predominance. There was no statistically significant association
in the comparisons between the groups.
Vestibular assessment using computerized VENG (Table 9)
demonstrated that most elderly patients presented normal diagnosis.
However, there were some cases of vestibular disorders in the
elderly, with predominance of deficit peripheral vestibular
syndrome and irritative peripheral vestibular syndrome. We did
not observe pathognomonic signals of central affections in the
vestibular exam. Statistical analysis demonstrated that there
were no statistically significant associations in group comparisons.
Table 8. Distribution of elderly
subjects according to groups A and B and presence of Post-caloric
Nystagmus
|
Group
|
A
|
B
|
Total
|
|
normorreflexia
|
12 (60%)
|
11 (55%)
|
23 (57.5%)
|
|
PD
to the R
|
2 (10%)
|
3 (15%)
|
5 (12.5%)
|
|
PL
to the R
|
1 (5%)
|
2 (10%)
|
3 (7.5%)
|
|
PL
to the L
|
3 (15%)
|
2 (10%)
|
5 (12.5%)
|
|
Hyperreflexia
|
1 (5%)
|
1 (5%)
|
2 (5%)
|
|
Arreflexia
Bilat.
|
0 (0.0%)
|
1 (5%)
|
1 (2.5%)
|
|
Did
not perform
|
1 (5%)
|
0 (0.0%)
|
1 (2.5%)
|
|
Total
|
20 (100%)
|
20(100%)
|
40(100%)
|
Arrefl. Bilat.= Bilateral
Arreflexia
PD to the R = Directional predominance to the right
PL to the R = Labyrinthic predominance to the right
PL to the L = Labyrinthic predominance to the left
Table 9. Distribution of elderly
subjects according to groups A and B and conclusion of vectoelectronystagmographic
exam
|
Group
|
A
|
B
|
Total
|
|
Normal
|
15 (75%)
|
13 (65%)
|
28 (70%)
|
|
SVP
D to R, Comp
|
2 (10%)
|
2 (10%)
|
4 (10%)
|
|
SVP
D to L, Comp
|
1 (5%)
|
1 (5%)
|
2 (5%)
|
|
SVP
D to R, Desc.
|
0 (0.0%)
|
1 (5%)
|
1 (2.5%)
|
|
SVP
I
|
2 (10%)
|
3 (15%)
|
5 (12.5%)
|
|
Total
|
20 (100%)
|
20(100%)
|
40(100%)
|
SVP D to the R, comp. = Deficit peripheral vestibular
syndrome to the right, compensated
SVP D to L, comp. = Deficit peripheral vestibular syndrome to
the left, compensated
SVP D to R, desc. = Deficit peripheral vestibular syndrome to
the right, decompensate
SVP I = Irritative peripheral vestibular syndrome
Vertigo is a common complaint of older
persons. As a presenting problem in primary care, it increases
in frequency with age, so that it is the fourth most common
complaint of geriatric patients and the most common complaint
of persons 85 years of age and older. For the physician, it
is difficult to assess because it is a symptom that cannot be
directly measured and it can arise from a wide variety of causes.
Vertigo can result from abnormalities of any system related
to postural control, including the cerebral cortex, basal ganglia,
brain stem, cerebellum, vestibular portion of the inner ear
and eighth nerve, proprioceptive nerve endings in the neck or
lower extremities and their associated peripheral nerves, skeletal
muscle, autonomic nervous system, and the cardiovascular system.
Several recent studies have verified that vertigo rarely represents
a life-threatening condition, but that older persons with persistent
vertigo often limit their activities because of fear of provoking
the vertigo, fear of falling, physical deconditioning, or depression
secondary to the vertigo.
Older persons may accept dizziness as
a symptom of aging without seeking treatment. Others may become
alarmed, associating dizziness with life-threatening stroke
or cardiovascular disease. Despite the etiology, however, dizziness
represents a significant hardship for many elderly persons.
Despite appropriate medical work up and interventions, the person's
life might continue to be greatly affected by dizziness. In
many cases, the diagnosis is not identified, or dizziness persists
despite diagnosis and treatment. Quality of life may be impaired,
and falls and other injuries may result.
Studies have shown that approximately
one quarter to one third of elderly in the community are dizzy.11,12
One study showed that 1 in 10 respondents suffered from current,
handicapping dizziness.13 Many patients report dizziness to
their primary care provider (PCP), and 5% to 10% of new primary
care visits are for dizziness.14
In our study, we detected higher incidence
of vertigo complaint in subjects in group B. We may infer that
the complaint of vertigo was less frequent in those that presented
an active life, who had social, physical and intellectual activity.
The results we found confirm the studied literature in which
it was reported that vertigo is a symptom that affected 61%
of all people aged over 70 years, present in 50% to 60% of the
elderly people who live at home or in 81% to 91% of the elderly
seen in geriatric outpatient units. The highest prevalence of
vertigo in elderly subjects would be owed to high sensitivity
of auditory and vestibular systems to clinical problems located
in other parts of the body and to the process of functional
deterioration of these systems resultant from aging. 15
The tinnitus complaint had its higher
incidence also in Group B subjects. Thus, similarly to the vertigo
complaint, we could infer that the incidence of tinnitus complaint
is higher in subjects that have little physical, social and
intellectual activity. The results were similar to those found
in the studied literature that showed incidence of tinnitus
of about 79.4% in the geriatric population. The statistics of
the National Institute of Health (USA) 15 demonstrated the prevalence
of tinnitus complaints (17%) in the population of patients that
came to the institution, especially the elderly.
As to presence or absence of hearing
loss complaint, even though there was no statistically significant
difference between the groups, we could observe that Group B
presented higher values than Group A. This study is similar
to the studied literature because it shows prevalence of hearing
loss complaint of 13% of the population that go to institutions,
especially to the elderly. 15
For Spontaneous (opened and closed eyes)
and Directional Nystagmus, we observed absence of both types
in all studied elderly subjects, similar to many previous studies.
As to pendulum tracking test, we could observe that both for
horizontal and vertical tasks, most of the elderly presented
type II pendular nystagmus. We also detected high incidence
of type III pendular nystagmus, especially in Group A.
Horizontal optokinetic nystagmus was
symmetrical in most of the elderly subjects, in both groups,
knowing that Optokinetic nystagmus in general is symmetrical
and present gains in the normal range or is slightly decreased
in peripheral vestibular pathologies.
As to the results obtained in PRPD - Peri-rotation nystagmus
- we observed that only 5% of the assessed elderly had abnormalities
to this type of nystagmus, which was similar to other studies
that showed abnormalities in only 2.9% of the patients, characterized
by the directional predominance of peri-rotation nystagmus.
The Caloric test - post-caloric nystagmus
- produced most normal reflex results among the elderly; however,
there were a considerable number of cases that had abnormal
result in the test, and the most frequent finding was labyrinthic
predominance. This result is similar to that of other studies,
which stated that unilateral hyporeflexia of post-caloric nystagmus
was a common affection to vestibular assessment of elderly patients.
16
The results obtained from the vestibular
assessment carried out with computerized VENG demonstrated that
most elderly subjects presented normal diagnosis. However, there
were some cases of vestibular affections in the elderly, with
similar proportions of deficit peripheral vestibular syndrome
and irritative peripheral vestibular syndrome.
We did not observe any pathognomonic signals of central affection
in the vestibular exam.
-Vertigo has major impact in the elderly,
which can lead to reduction of their social autonomy, given
that they have to reduce their daily life activities, because
of the predisposition to falls and fractures, bringing suffering,
body immobility, fear to fall again and high costs to the healthcare
system.
-Vertigo, tinnitus and hearing loss
largely affect elderly subjects, especially the ones that do
not have an active life, as opposed to those that perform different
activities in elderly groups.
-vestibular disorders, detected by vectoelectronystagmography
were similar in both studied groups.
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