Prognosis and Survival of Older Patients With Dizziness in Primary Care: A 10-Year Prospective Cohort Study

Vincent A. van Vugt; Gülsün Bas; Johannes C. van der Wouden; Jacquelien Dros; Henk C.P.M. van Weert; Lucy Yardley; Jos W. R. Twisk; Henriëtte E. van der Horst; Otto R. Maarsingh

doi:10.1370/afm.2478

Article Figures & Data

Figures

Tables
Additional Files

Download figure
Open in new tab
Download powerpoint
Download figure
Open in new tab
Download powerpoint
Figure 1
Kaplan-Meier survival curves for patients assigned to dizziness subtype vertigo.^a
^aPanel assigned subtype by at least 2 out of 3 panel members. Patients with vertigo compared with patients who were not assigned to this subtype.
Download figure
Open in new tab
Download powerpoint
Download figure
Open in new tab
Download powerpoint
Figure 2
Kaplan-Meier survival curves for patients with different primary causes of dizziness.
^aLocomotor disease, neurologic disease (excluding cerebrovascular disease), adverse drug effect, metabolic or endocrine conditions, impaired vision, other causes, and unclear cause.

View popup

Table 1

Baseline Characteristics of Patients (N = 417)

Characteristic	Value
Demographics
Age, mean (range), y	79 (65.0-95.0)
Sex, female, No. (%)	307 (73.6)
Ethnic background, No. (%)
Dutch native	342 (82.0)
Western immigrant	31 (7.4)
Non-Western immigrant	44 (10.6)
Level of education
Low, No. (%)	297 (71.2)
Middle or high, No. (%)	120 (28.8)
Living situation, community-dwelling, No. (%)	397 (95.2)
Smoking, No. (%)	62 (14.9)
Medical history
Cardiovascular disease, No. (%)
Hypertension	239 (57.3)
Ischemic heart disease	111 (26.7)
Arrhythmia	94 (22.5)
Heart valve disease	58 (13.9)
Myocardial infarction	57 (13.7)
Ear, nose, and throat disease, No. (%)
Benign paroxysmal positional dizziness	40 (9.8)
Ménière’s disease	27 (6.5)
Acoustic neuroma	1 (0.2)
Neurologic disease, No. (%)
Migraine	79 (18.9)
Stroke	66 (15.8)
Parkinson disease	7 (1.7)
Epilepsy	6 (1.4)
Multiple sclerosis	1 (0.2)
Locomotor disease, No. (%)
Osteoarthritis of the knee	120 (28.8)
Osteoarthritis of the hip	78 (18.7)
Psychiatric illness, No. (%)
Depressive disorder	101 (24.2)
Anxiety disorder	75 (18.0)
Other, No. (%)
Diabetes	78 (18.7)
Cataract	199 (47.7)
Macular degeneration	27 (6.5)
Drugs per patient, mean (SD)	4 (3.0)
Polypharmacy (>5 drugs), No. (%)	138 (33.0)
Dizziness characteristics
Onset of dizziness symptoms, No. (%)
2-4 weeks	30 (7.2)
1-6 months	98 (23.5)
6-24 months	110 (26.4)
2-10 years	120 (28.8)
>10 years	59 (14.1)
Characteristic	Value
Demographics
Age, mean (range), y	79 (65.0-95.0)
Sex, female, No. (%)	307 (73.6)
Ethnic background, No. (%)
Dutch native	342 (82.0)
Western immigrant	31 (7.4)
Non-Western immigrant	44 (10.6)
Level of education
Low, No. (%)	297 (71.2)
Middle or high, No. (%)	120 (28.8)
Living situation, community-dwelling, No. (%)	397 (95.2)
Smoking, No. (%)	62 (14.9)
Medical history
Cardiovascular disease, No. (%)
Hypertension	239 (57.3)
Ischemic heart disease	111 (26.7)
Arrhythmia	94 (22.5)
Heart valve disease	58 (13.9)
Myocardial infarction	57 (13.7)
Ear, nose, and throat disease, No. (%)
Benign paroxysmal positional dizziness	40 (9.8)
Ménière’s disease	27 (6.5)
Acoustic neuroma	1 (0.2)
Neurologic disease, No. (%)
Migraine	79 (18.9)
Stroke	66 (15.8)
Parkinson disease	7 (1.7)
Epilepsy	6 (1.4)
Multiple sclerosis	1 (0.2)
Locomotor disease, No. (%)
Osteoarthritis of the knee	120 (28.8)
Osteoarthritis of the hip	78 (18.7)
Psychiatric illness, No. (%)
Depressive disorder	101 (24.2)
Anxiety disorder	75 (18.0)
Other, No. (%)
Diabetes	78 (18.7)
Cataract	199 (47.7)
Macular degeneration	27 (6.5)
Drugs per patient, mean (SD)	4 (3.0)
Polypharmacy (>5 drugs), No. (%)	138 (33.0)
Dizziness characteristics
Onset of dizziness symptoms, No. (%)
2-4 weeks	30 (7.2)
1-6 months	98 (23.5)
6-24 months	110 (26.4)
2-10 years	120 (28.8)
>10 years	59 (14.1)
Frequency, No. (%)
Continuous	42 (10.1)
Daily	195 (46.8)
Weekly	105 (25.2)
Monthly	50 (12.0)
Annually	25 (6.0)
Duration of symptoms, No. (%)
<10 seconds	110 (26.4)
10-60 seconds	78 (18.7)
Several minutes	71 (17.0)
Several minutes to 1 hour	22 (5.3)
>1 hour	35 (8.4)
Constant when present	26 (6.2)
Combination of durations	75 (18.0)
Diagnostic tests
Psychiatric diagnosis according to
PRIME-MD PHQ, No. (%)
Major depressive syndrome	53 (12.7)
Panic disorder	19 (4.6)
Other anxiety syndrome	42 (10.1)
MDS, PD, or OAS	90 (21.6)
Panel evaluation
Dizziness subtype, No. (%)
Presyncope	288 (69.1)
Vertigo	171 (41.0)
Disequilibrium	166 (39.8)
Other dizziness	7 (1.7)
No consensus	16 (3.8)
Number of dizziness subtypes per participant, No. (%)
1	217 (52.0)
2	137 (32.9)
3	47 (11.2)
No consensus	16 (3.8)
Primary cause of dizziness, No. (%)
Cardiovascular disease (including cerebrovascular disease)	237 (56.8)
Peripheral vestibular disease	60 (14.4)
Other (psychiatric illness, locomotor disease, neurologic disease [excluding stroke], adverse drug effect, impaired vision, metabolic or endocrine conditions, or unclear disease)	120 (28.8)

MDS = major depressive syndrome; OAS = other anxiety syndrome; PD = panic disorder; PRIME-MD PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.

View popup

Table 2

Hazard Ratios of Mortality in Participants for Different Dizziness Subtypes

Dizziness Subtype	No. of Persons	No. of Deaths	Person Years	Incidence Rate (95% CI) per 1,000 Person Years	Compared With Participants Without This Subtype
Dizziness Subtype	No. of Persons	No. of Deaths	Person Years	Incidence Rate (95% CI) per 1,000 Person Years	Unadjusted HR (95% CI)	Adjusted HR (95% CI)^a
Vertigo	171	58	1,213	47.81 (36.30-61.80)	0.64 (0.47-0.88)	0.62 (0.40-0.96)
Presyncope	288	126	1,903	66.21 (55.15-78.83)	1.36 (0.96-1.92)	1.23 (0.82-1.85)
Disequilibrium	161	65	1,039	62.55 (48.27-79.72)	1.09 (0.80-1.49)	1.26 (0.85-1.87)
Other dizziness	7	2	48	41.70 (5.50-150.63)	0.67 (0.17-2.71)	0.76 (0.18-3.18)

HR = hazard ratio; PRIME-MD PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
↵a Adjusted for age, sex, ethnicity, level of education, preexistent cardiovascular disease and/or stroke, diabetes, polypharmacy (defined as >5 types of daily medication), an anxiety or depressive disorder according to the PRIME-MD PHQ, and the number of assigned dizziness subtypes.

View popup

Table 3

Hazard Ratios of Mortality in Participants for Different Primary Causes of Dizziness

Primary Cause of Dizziness	No. of Persons	No. of Deaths	Person Years	Incidence Rate per 1,000 Person Years (95% CI)	Unadjusted HR (95% CI)	Adjusted HR (95% CI)^a
Cardiovascular disease	237	113	1,495	75.61 (62.31-90.90)	Reference	Reference
Peripheral vestibular disease	60	13	495	26.25 (13.98-44.89)	0.32 (0.18-0.56)	0.46 (0.25-0.84)
Psychiatric disease	41	15	264	56.88 (31.84-93.82)	0.72 (0.42-1.20)	0.89 (0.49-1.61)
Other causes^b	79	28	516	54.42 (36.04-78.38)	0.69 (0.46-1.05)	0.66 (0.43-1.02)

HR = hazard ratio; PRIME-MD PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
↵a Adjusted for age, sex, ethnicity, level of education, preexistent cardiovascular disease and/or stroke, diabetes, polypharmacy (defined as >5 types of daily medication), an anxiety or depressive disorder according to the PRIME-MD PHQ and the number of assigned dizziness subtypes.
↵b Locomotor disease (n = 15), neurologic disease (excluding cerebrovascular disease) (n = 12), adverse drug effect (n = 10), metabolic or endocrine conditions (n = 3), impaired vision (n = 2), other causes (n = 3), and unclear cause (n = 34).

View popup

Table 4

DHI Scores and Patterns of Substantial Impairment at Follow-Up

DHI Score	No. of Persons	Mean DHI Score, No. (SD)	Sustantially Impaired (DHI ≥30), %
Baseline (n = 415)	415	36.3 (19.9)	60.7
6-month follow-up (n = 374)	374	28.0 (23.6)	42.2
10-year follow-up (n = 103)	103	31.1 (25.0)	47.7
Patterns of substantial impairment due to dizziness (DHI ≥30) (n = 100)^a
Never substantially impaired			34
Substantially impaired at 1 or 2 measurements			40
Substantially impaired at all 3 measurements			26

DHI = dizziness handicap inventory.
↵a Only participants who completed a DHI at baseline, 6-month, and 10-year follow-up were included in this analysis. Although 103 participants filled out the 10-year measurement, 3 of these participants missed the 6-month measurement.

View popup

Table 5

Mean Differences in DHI Scores and Odds Ratios to Develop Substantial Dizziness-Related Impairment After 10 Years for Dizziness Subtypes (N = 103)

Subtypes	No. of Persons	Baseline Values		Compared With Participants Without This Subtype

		Mean DHI (SD)	DHI ≥30, %	Unadjusted MD in DHI Score (95% CI)	Adjusted MD in DHI Score (95% CI)^a	Unadjusted OR for DHI ≥30, OR (95% CI)	Adjusted OR for DHI ≥30, OR (95% CI)^a
Vertigo	47	34.6 (19.3)	48.9	8.24 (1.12-15.37)	5.13 (−2.66 to 12.91)	1.25 (0.64-2.43)	1.15 (0.44-2.96)c
Presyncope	68	29.5 (16.5)	47.1	−3.74 (−11.39 to 3.90)	−8.07 (−16.03 to −0.10)	0.89 (0.44-1.79)	0.54 (0.21-1.40)
Disequilibrium	66	33.0 (18.3)	51.4	6.20 (−1.29 to 13.69)	2.84 (−5.80 to 11.49)	1.73 (0.85-3.49)	1.73 (0.64-4.66)
Other dizziness	3	46.0 (21.1)	66.7	2.15 (−19.48 to 23.78)	0.47 (−18.50 to 19.43)	1.08 (0.16-7.15)	0.87 (0.18-4.21)

DHI = dizziness handicap inventory; MD = mean difference; OR = odds ratio; PRIME-MD PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire
↵a Adjusted for age, sex, ethnicity, level of education, preexistent cardiovascular disease and/or stroke, diabetes, polypharmacy (defined as >5 types of daily medication), an anxiety or depressive disorder according to the PRIME-MD PHQ, and the number of assigned dizziness subtypes.

View popup

Table 6

Mean Differences in DHI Scores and Odds Ratios to Develop Substantial Dizziness-Related Impairment After 10 Years for the Primary Cause of Dizziness (N = 103)

Primary Cause of Dizziness	No. of Persons	Baseline Values		Unadjusted MD in DHI Score (95% CI)	Adjusted MD in DHI Score (95% CI)^a	Unadjusted OR for DHI ≥30, OR (95% CI)	Adjusted OR for DHI ≥30, OR (95% CI)^a
Primary Cause of Dizziness	No. of Persons	Mean DHI (SD)	DHI ≥30, %	Unadjusted MD in DHI Score (95% CI)	Adjusted MD in DHI Score (95% CI)^a	Unadjusted OR for DHI ≥30, OR (95% CI)	Adjusted OR for DHI ≥30, OR (95% CI)^a
Cardiovascular	50	28.8 (17.4)	42.0	Reference	Reference	Reference	Reference
Peripheral vestibular	23	34.1 (18.1)	56.5	2.60 (−6.67 to 11.87)	3.10 (−5.14 to 11.34)	1.33 (0.56-3.20)	1.46 (0.52-4.08)
Psychiatric	12	38.5 (23.2)	58.3	3.39 (−8.44 to 15.22)	1.31 (−9.43 to 12.06)	1.22 (0.43-3.44)	1.01 (0.32-3.25)
Other causes^b	18	30.6 (17.8)	50.0	−1.00 (−11.11 to 9.12)	3.76 (−5.24 to 12.76)	1.22 (0.48-3.12)	1.63 (0.61-4.30)

DHI = dizziness handicap inventory; MD = mean difference; OR = odds ratio; PRIME-MD PHQ = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
↵a Adjusted for age, sex, ethnicity, level of education, preexistent cardiovascular disease and/or stroke, diabetes, polypharmacy (defined as >5 types of daily medication), an anxiety or depressive disorder according to the PRIME-MD PHQ, and the number of assigned dizziness subtypes.
↵b Locomotor disease (n = 0), neurologic disease (excluding cerebrovascular disease) (n = 2), adverse drug effect (n = 5), metabolic or endocrine conditions (n = 0), impaired vision (n = 1), other causes (n = 1), and unclear cause (n = 9).

Additional Files

Figures
Tables

Supplemental Appendixes, Figures, & Table2

Files in this Data Supplement:

Supplemental data: Appendixes - PDF file
The Article in Brief

Prognosis and Survival of Older Patients With Dizziness in Primary Care: A 10-Year Prospective Cohort Study

Vincent A. van Vugt , and colleagues

Background Dizziness is a common problem among older patients in primary care but is complex for clinicians to measure and diagnose. The diagnostic process is particularly challenging in older patients with dizziness, because the cause of their dizziness is usually multifactorial. Determining the cause of dizziness might help in choosing an appropriate treatment. The research team originally conducted a 2006 prospective cohort study with 417 older adults with dizziness (mean age 79 years) in primary care. At that time, participants received a full diagnostic evaluation by a physician and were classified into four dizziness subtypes: presyncope, vertigo or disequilibrium. The participants were further classified by causes of dizziness, with cardiovascular disease and peripheral vestibular disease being the most common causes. The objective of the current study was to follow participants ten years later to investigate the long-term prognosis of older patients with dizziness in primary care and their mortality and impairment outcomes.

What This Study Found In this 10 year follow up study, 169 (40.5%) of the participants from the previous study had died. Many of the patients still alive at follow-up reported experiencing substantial dizziness-related impairment (47.7%). There was no significant difference in substantial impairment between different subtypes or primary causes of dizziness. Those classified in the vertigo subtype had significantly lower mortality rates than the other subtypes after 10 years. Patients with dizziness caused by peripheral vestibular disease had a lower mortality rate than that of patients with cardiovascular disease.

Implications

These results provide new insights in the prognosis of older patients with dizziness in primary care. The large percentage of older patients that report experiences of long-term substantial dizziness-related impairment indicates that current treatment strategies in primary care may be suboptimal.