This Fall Don t The Role of Audiology in the Evaluation and Management of Presbyasteria

Transcription

1 This Fall Don t The Role of Audiology in the Evaluation and Management of Presbyasteria Richard E. Gans, Ph.D. Executive Director, The American Institute of Balance Adjunct Professor, Nova Southeastern University & University of South Florida 1 Overview Growth of population over 60 years of age. Prevalence of dizziness, vertigo and falls Economic and Social impact. Medical conditions. Management options. Risk of Falling (ROF) indicators. Patient identification and triage. Helping the older adult stay safe and independent.

2 Aging Worldwide world population of persons over age 65 tripled from 205 to 606 million countries (China, India, and the USA).had more than 10 million persons age 60 and over countries had 10 million, 5 countries had 20 million Projected 2 billion persons worldwide will be an older adult. Aging Worldwide Global Population in Billions 2 billion people will be over 60 years of age by in 5 persons. In many developed regions of the world it will be much higher. - Europe will be at 37% and the United States will be at 25%

3 Social and Economic Impact for Health Care By the year 2030 the population of individuals 65 years or older will double. By 2050, population of those 85 years of age or older will quadruple. This will place significant stress on medical economics and health care delivery systems of the United States. Medicare costs will rise to $929 billion Dizziness, Vertigo, Falls Dizziness is the number one complaint of persons over age 70 years. 85% of vertigo and balance dysfunction may be inner ear related. 50% of individuals over age 70 years will experience Benign Paroxysmal Positioning Vertigo (BPPV). Older adults with BPPV have a greater incidence of depression, falls and reduced activities of daily living.

4 Falls: Morbidity and Mortality Falls are the leading cause of traumatic brain injury (TBI) and bone fractures (femur, wrist and hip). Falls are the leading cause of accidental deaths in persons over age 65 years. Falls are the 6th leading cause of death for the elderly. 60% of fall-related deaths occur among individuals who are 75 years of age or older. 20% of those who sustain a hip fracture from a fall will die within a year Of those who do fall, 20% will require placement within a longterm care facility. Falls: Morbidity and Mortality 49% of those who sustain a hip fracture will die within 6 months. 20% will require placement within a long-term care facility. In 2000, falls among the elderly accounted for 1,600,000 ER visits. Hospital Admissions for Hip Fractures among the Elderly , ,000 >500,000

5 Falls: Morbidity and Mortality Annually, 64,000 individuals over 65 years of age will sustain a TBI as a result of a fall 40,000 individuals over 65 years visit ER with TBI suffered as a result of a fall (16,000 of are hospitalized and 4,000 will die) Fall-induced TBI for individuals 80 years of age or older increased by 60% from 1989 to 1998 Total estimated cost for non-fatal TBI-related hospitalizations for falls in individuals 65 years of age or older is over $3,250,000,000. By 2020 costs to Medicare and Medicaid programs and society as a whole from falls by elderly persons will exceed $32,000,000,000. Medical & Lifestyle Considerations Pharmacy Vision Orthopedic Cardiologic Endocrinologic Otologic Life style

6 Pharmacy & poly-pharmacy PDA- Over 1,000 drugs list vertigo as a side effect PDA- 2,000 drugs list dizziness. The effect of poly-pharmacy and drug interaction is nearly infinite. Older adults often are taking numerous prescriptions from a variety of physicians. Older adults taking 4 medication or more are at increased risk of falling (ROF). Vision Low vision secondary to common to agerelated degenerative visual conditions glaucoma macula degeneration diabetic retinopathy retinal stroke

7 Orthopedic arthritis osteoporosis history of fractures, ankle, knee, hip subsequent replacement surgeries all affect biomechanical function. Neurologic history of stroke cerebrovascular and vertebrobasilar insufficiencies.

8 Cardiovascular Circulatory problems in the lower extremities (peripheral arterial disease, diabetes etc.) causing peripheral neuropathy. low cardiac output Aortic stenosis Endocrinologic An almost epidemic increase in the incidence of diabetes and associated capillary and micro-vascular issues leading to: retinopathy neuropathy vestibulopathy All 3 of the primary sensory modalities of equilibrium are affected.

9 Otologic Prevalence of Benign Paroxysmal Positioning Vertigo (BPPV). Estimated that 50% of all persons 70 years and over will develop BPPV. Higher incidence of herpes simplex virus (shingles) in individuals over 50 years of age, leading cause of vestibular neuritis. Estimated that by age 80 years, there is a loss of 50% of vestibular neurons. Increased risk or prior disease-disorder i.e Meniere s, labyrinthitis, vestibular neuritis, Benign Paroxysmal Positioning Vertigo (BPPV): Definition and Pathophysiology Labyrinth- balance portion inner ear Otolith particles fall into the posterior semicircular canal which is inferior to the Utricle. This is a natural occurance. Otoliths with their calcium carbonate composition will normally be absorbed by the calcium poor inner ear fluid on a daily basis.

10 Video When they do not absorb, the heavier otoliths inside the canal pulls the nerve receptor towards the moving debris which causes the strong sense of vertigo when the head is laid back or when looking up. The vertigo and nystagmus will continue until the otoliths settle. This may last 5-20 seconds. Medical conditions associated with BPPV

11 Effect of BPPV on Elderly: Activities of daily living, depression and falls Significantly decreased function of daily living, increased depression x 2 and increased incidence of falls x 2. Ogawali et al 2000 Treatment of BPPV Patient seated head upright - asymptomatic Patient lays backdebris moves causing vertigo and nystagmus Patient is moved onto opposite side causing debris to progress Patient sits upright causing debris to drop down into the Utricle Canalith repositioning is a non-invasive physical maneuver which treats the condition by moving the otolith debris out of the semicircular canal and back into the Utricle where they can be absorbed.

12 BPPV Treatment Efficacy Roberts, Gans, & Montaudo (2006) Review of 3 methods of BPPV treatments indicate a 90% or better success rate. Shingles - herpes zoster The increased prevelance of shingles, Bell s Palsy and is likely due to the opportunistic virus in over age 50 years of age due to reduced immune system.

13 History of vertigo - increased risk At risk patients can be costeffectively evaluated for underlying inner ear dysfunction using modern and non-invasive office procedures. Vestibular and Balance Therapy Dizziness may be reduced through a serial repetition of proving type movement and activities. Challenging dynamic surfaces forces compensation to strengthen weakened sensory systems.

14 Lifestyle Sedentary lifestyle leading to: obesity de-conditioning. This typically begins a domino effect of medical co-morbidities, all of which impair mobility and balance function. Polytechnic University - Hong Kong Research is showing long-term benefit of fitness and wellness through exercise such as Tai Chi.

15 Exercise throughout the lifespan is critical Older adults accepting the importance of regular exercise thoughout their lifespan requires a shift in thinking. Risk of Falling (ROF) Hip Weakness Low vision Diabetes History of falls within past year Untreated Benign Paroxysmal Positioning Vertigo (BPPV) Simple in-office screening procedures: Single leg stance, functional reach test or the stepping Fukuda test in the video may indicate increased fall risk.

16 Patient Education: Helpful Suggestions for Older Adults Be aware of your surroundings. Eliminate excessive clutter. Slow down. Move at your own pace. Use night lights. Use restroom frequently to avoid rushing and before retiring to bed. Limit or avoid alcohol. For older adults, alcohol alone or in combination with medications increases your risk for a fall. Install grab bars in the bathroom and stairways. Patient Education: Helpful Suggestions for Older Adults Increase wattage of light bulbs but be careful of adding too much glare. Remove throw rugs. Arrange frequently used item in cupboards and closets within easy reach to avoid using step stools. Be aware of long or loose fitting clothing that could become entangled underfoot. Be mindful of pets and their toys and water bowls. Wear appropriate and well-fitting footwear. Avoid loose fitting slippers or flip-flops.

17 Conclusions Increased number of older adults will place stress on health care system. Dizziness, vertigo and falls are among leading health care issues effecting quality of life, independence, ability to age in place and medical costs. Identify patients with elevated ROF factors for intervention and management. Help all older patients with safety guidelines. References 1. Gamiz M, Lopez-Escamez J. Health-related quality of life in patients over sixty years old with benign paroxysmal positional vertigo. Gerontology 2004;50: Gans R, Crandell C. Overview of BPPV: evaluating treatment outcomes with clinimetrics. Hear Rev 2000; Oghalai J, Manolidis S, Barth J, Stewart M, Jenkins H. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122: Roberts R, Gans R, Kastner A, Listert JJ. Prevalence of vestibulopathy in benign paroxysmal positional vertigo patients with and without prior otologic history. Int J Audiol 2005;44(4): Tinetti ME. Multifactorial fall prevention strategies: time to retreat or advance. J Am Geriatric Society 2008; 56(8): Tinetti ME, Kumar C. The patient who falls: it s always a trade off. JAMA 2010;303(3): Tinetti, ME et al. Effect of Dissemination of Evidence in Reducing Injuries from Falls, New England Journal of Medicine, 2008; 359:

18 References (Continued) 8. Jacobson, GP, Shepherd, NT, Balance Function Assessment and Management, Plural Publishing, San Diego, Goebel, JA, Practical management of the Dizzy Patient, Lippincott Williams and Wilkins, Philadelphia, Gans, RE, Dizziness, Vertigo and Falls: issues for older adults and practitioners, ENT and Audiology News, March, Seo,T., et al., Immediate Efficacy of Canalith Repositioning Procedure for the Treatment of BPPV, (2007) Journal of Otology and Neurotology, Vol. 28 7: Helinski, JO, et al. Daily Exercise Does Not Prevent Recurrence of Benign Paroxysmal Positional Vertigo, (2008) Journal of Otology and Neurotology, Vol. 29, No.7: Jacobson, Roberts, Gans, et al co-morbidities of BPPV, Gans RE, Dizziness, vertigo and falls in the older adult, ENT and Audiology News, 2011 Resources 1. National Institues of Health, Deafness and other Communication Disorders NDICD; balance_disorders.html 2. National Institutes of Health, NIH Senior Health, Falls and Older Adults; American Institute of Balance 4. American Academy of Neurology 5. National Council on Aging 6. United Nations Department of Economic and Social Affairs Population Division; World Health Organization; Special Thanks to Loren Parnes, M.D., London, Ontario

19 Thank You Education without Boundaries dizzy.com References: Visit dizzy.com - Research and Publications - Dr. Gans blog for video case studies and additional articles/ references 37