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Disorders of Balance and Vestibular Function

Disorders of Balance and Vestibular Function

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Published by: GUIMEDIC ASOCIACIÓN MÉDICA on Aug 09, 2011
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ORIGINAL INVESTIGATION
Disorders of Balance and Vestibular Functionin US Adults
Data From the National Health and Nutrition Examination Survey, 2001-2004
Yuri Agrawal, MD; John P. Carey, MD; Charles C. Della Santina, MD, PhD;Michael C. Schubert, PhD; Lloyd B. Minor, MD
Background
:
Balance dysfunction can be debilitatingand can lead to catastrophic outcomes such as falls. Theinner ear vestibular system is an important contributortobalancecontrol.However,toourknowledge,thepreva-lence of vestibular dysfunction in the United States andthe magnitude of the increased risk of falling associatedwith vestibular dysfunction have never been estimated.The objective of this study was to determine the preva-lence of vestibular dysfunction among US adults, evalu-atedifferencesbysociodemographiccharacteristics,andestimatetheassociationbetweenvestibulardysfunctionand risk of falls.
Methods
:
We included data from the 2001-2004 Na-tionalHealthandNutritionExaminationSurveys,whichwere cross-sectional surveys of US adults aged 40 yearsandolder(n=5086).Themainoutcomemeasurewasves-tibular function as measured by the modified RombergTest of Standing Balance on Firm and Compliant Sup-port Surfaces.
Results
:
From 2001 through 2004, 35.4% of US adultsaged40yearsandolder(69millionAmericans)hadves-tibular dysfunction. Odds of vestibular dysfunction in-creased significantly with age, were 40.3% lower in in-dividuals with more than a high school education, andwere 70.0% higher among people with diabetes melli-tus. Participants with vestibular dysfunction who wereclinicallysymptomatic(ie,reporteddizziness)hada12-fold increase in the odds of falling.
Conclusions
:
Vestibular dysfunction, as measured by asimpleposturalmetric,iscommonamongUSadults.Ves-tibular dysfunction significantly increases the likeli-hoodoffalls,whichareamongthemostmorbidandcostlyhealthconditionsaffectingolderindividuals.Thesedatasuggest the importance of diagnosing, treating, and po-tentiallyscreeningforvestibulardeficitstoreducethebur-denoffall-relatedinjuriesanddeathsintheUnitedStates.
 Arch Intern Med. 2009;169(10):938-944
T
HE VESTIBULAR SYSTEM IS IN
-tegral to balance control.The paired vestibular or-gans, housed within thetemporal bone, include 3orthogonal semicircular canals (supe-rior,posterior,andhorizontal)and2oto-lith organs (the utricle and saccule). To-gether,thesemicircularcanalsandotolithorgans provide continuous input to thebrain about rotational and translationalhead motion and the head’s orientationrelativetogravity.
1
Thisinformationfromthe vestibular organs and their centralpathways allows for the maintenance of gaze and postural stability via the ves-tibulo-ocularreflexandvestibulospinalre-flex, respectively. Dysfunction of the pe-ripheral vestibular structures cannot bedirectlyobservedbutcanbeinferredfromassessment of these reflexes (eg, with ca-loric reflex test).Vestibulardysfunctionistypicallychar-acterized by vertigo (ie, an illusory senseofmotion)andimbalanceowingtodistur-bances in gaze and postural stability.
2,3
Insomecases,vestibulardysfunctioncancul-minate catastrophically in a fall,
4-6
whichis associated with serious injury and re-strictedmobilityandranksamongthelead-ingcausesofdeathamongolderindividu-als.
7-11
The costs of increased needs anddiminishedautonomyassociatedwithfallsalso exert a tremendous societal toll.
12,13
These costs appear to be rising; a recentstudy found that the prevalence and inci-denceoffall-inducedinjuriesincreasedsig-nificantly in the past 25 years, even afteradjustment for age.
14
 When this increas-ing incidence is considered in relation toanagingpopulation,theprospectofasig-nificant public health problem is clear.
CME available online atwww.jamaarchivescme.comand questions on page 919
Author Affiliations:
Department of Otolaryngology–Head and NeckSurgery, The Johns HopkinsUniversity School of Medicine,Baltimore, Maryland.
(REPRINTED) ARCH INTERN MED/VOL 169 (NO. 10), MAY 25, 2009 WWW.ARCHINTERNMED.COM
©2009 American Medical Association. All rights reserved.
 on July 29, 2011www.archinternmed.comDownloaded from 
 
Despite this concern and the known contribution of vestibulardysfunctiontoimbalanceandfalling,verylittleisknownabouttheepidemiologicalcharacteristicsofves-tibulardysfunctionintheUnitedStates.Therearenoes-timates of the national prevalence of vestibular dysfunc-tion,anditisunknownwhethersusceptibilitiesdifferacrossdemographicgroups.Eventhestrengthoftheassociationbetweenvestibulardysfunctionandfallsisunclear.Thedataare poor in part because diagnosing vestibular dysfunc-tion can be difficult. The symptoms of dizziness and im-balancemaybethenonspecificsequelaeofnumerousim-pairments,includingdeficitsinvision,proprioception,andmusculoskeletal,autonomic,andvestibularfunction.Inad-dition, testing for isolated deficits of the vestibular end-organsofteninvolvescomplextools(eg,electronystamog-raphy,caloricreflextest,orassessmentofposturalfunction)that complicate widespread application.TheNationalHealthandNutritionExaminationSur-vey (NHANES) is a large-scale, highly powered surveythat included balance testing for more than 5000 indi-vidualsbetween2001and2004.Fromthesedata,wees-timate the prevalence of vestibular dysfunction amongUS adults aged 40 years and older. We evaluate the in-fluence of sociodemographic characteristics and com-moncardiovascularriskfactorsontheprevalenceofves-tibular dysfunction. We also consider the associationbetween vestibular dysfunction and clinically signifi-cantoutcomes,specificallyfalls.Suchepidemiologicalin-formation can offer critical insight to help control andpossibly prevent a growing burden of fall-induced mor-bidity and mortality in the US population.
METHODS
STUDY POPULATION
The NHANES is an ongoing cross-sectional survey of the ci-vilian,noninstitutionalizedpopulationoftheUnitedStates.Ev-ery 2 years, households were approached at random, and per-sons were invited to participate in the NHANES survey if theymet a specific demographic profile (based on sex, race/ ethnicity, age, and place of residence) and contributed to thenational representativeness of the sample. In each of the lastseveral cycles, 12000 to 13000 individuals were selected; theparticipation rate has ranged from 79% to 84%. Further de-tails of the NHANES sampling process are available.
15
The 2001-2002 and 2003-2004 NHANES performed bal-ancetestingonanationallyrepresentativesampleofadultsaged40yearsandolder.Wecombinedthesetwo2-yearcyclesofdatato analyze 4 years of data, per National Center for Health Sta-tistics recommendations.
15
A total of 21161 people of all agestook part in the NHANES from 2001 through 2004; 6785 par-ticipants(32.1%)wereaged40yearsandolder.Participantswereexcluded from balance testing if they were unable to stand ontheir own, were having dizziness sufficient to cause unsteadi-ness, weighed more than 275 pounds, had a waist circumfer-encethatcouldnotaccommodateproperfittingofthestandard-sized safety gait belt, needed a leg brace to stand unassisted, orhadafootorlegamputation.Inaddition,participantswhoweretotally blind or sufficiently visually impaired to require assis-tanceinfindingtheexaminationroomwereexcludedfrompar-ticipation.Atotalof515participants(7.6%)wereexcludedfrombalancetestingforthesereasons,yieldinganeligiblesamplesizeof 6270 participants. Of these eligible adults, 1184 participants(18.9%) were excluded because they did not participate in theNHANES physical examination for various reasons including“safety exclusion” and “participant refusal,” resulting in a finalsamplesizeof5086(81.1%ofeligibleparticipants).Therewereno significant differences between included and excluded par-ticipants with respect to sex, age, and race/ethnicity. Sampleweights for the combined 4-year sample were used, per Na-tional Center for Health Statistics guidelines.
15
These sampleweights accounted for individual nonparticipation and pre-served the national representativeness of the sample.
BALANCE QUESTIONNAIRE AND TESTING
Before balance testing, participants were administered a bal-ancequestionnaire,whichdeterminedhistoryofdizziness(“Dur-ing the past 12 months, have you had dizziness or difficultywith balance?”) and falls (“During the past 12 months, haveyou had difficulty with falling?”). Balance testing consisted of the modified Romberg Test of Standing Balance on Firm andCompliant Support Surfaces. This test examined the partici-pant’s ability to stand unassisted using 4 test conditions de-signed specifically to test the sensory inputs that contribute tobalance—thevestibularsystem,vision,andproprioception.Thefourth test condition was designed to test vestibular functionexclusively: participants had to maintain balance on a foam-paddedsurface(toobscureproprioceptiveinput)withtheireyesclosed (to eliminate visual input).Balance testing was scored on a pass/fail basis. Test failurewas defined as participants needing to open their eyes; mov-ing their arms or feet to achieve stability; or beginning to fallor requiring operator intervention to maintain balance withina 30-second interval. Each participant who failed a test condi-tionwaseligiblefor1retest.Theprotocolforretestingwasthesame as for the primary examination. Because each successivetestconditionfrom1to4wasprogressivelymoredifficultthantheconditionprecedingit,thebalancetestingcomponentwasended whenever a participant failed to pass a test condition(eitherduringtheinitialtestortheretest,iftheparticipantoptedfor one). We focused on test condition 4, designed to distin-guish participants who could not stay standing when relyingprimarily on vestibular input. We categorized participants ashaving vestibular dysfunction if they did not pass test condi-tion4.Of5086participants,257(5.1%)didnotpasspriortestconditions and thus did not participate in test condition 4. Anadditional86participants(1.7%)hadmissingdatafortestcon-dition4,leadingtoatotalof343excludedparticipants(6.7%).Further details of balance testing procedures are available athttp://www.cdc.gov/nchs/data/nhanes/ba.pdf.
SOCIODEMOGRAPHIC ANDCARDIOVASCULAR RISK VARIABLES
Trainedinterviewersadministereddetailedquestionnaires.
16
Ageat interview was categorized by decade. Race/ethnicity wasgroupedasnon-Hispanicwhite(hereafterreferredtoaswhite),non-Hispanic black (hereafter, black), Mexican American, orother. Education was grouped as less than high school, highschool diploma (including GED [general equivalency di-ploma]), and beyond high school. Of 4743 participants, 33(0.7%) had missing education data.A complete smoking history included the number of yearssmoked and the current number of cigarettes smoked per day.Pack-years of smoking were computed, and participants weredividedintosmokingcategoriesincludingneversmoked,fewerthan 20 pack-years of smoking, and 20 pack-years or more of smoking. There were substantial missing data (313 partici-pants [6.6%]) on the quantity of tobacco smoked, so a sepa-
(REPRINTED) ARCH INTERN MED/VOL 169 (NO. 10), MAY 25, 2009 WWW.ARCHINTERNMED.COM
©2009 American Medical Association. All rights reserved.
 on July 29, 2011www.archinternmed.comDownloaded from 
 
rate category was made for ever smokers with unknown pack-years (after inclusion of this category, 49 participants [1.0%]had missing data). Hypertension was defined based on physi-ciandiagnosis,useofantihypertensivemedication,ameansys-tolic blood pressure higher than 140 mm Hg, or a mean dia-stolic blood pressure higher than 90 mm Hg at the time of examination. Mean blood pressure comprised up to 4 read-ingson2separateoccasions(14participants[0.3%]hadmiss-ingdata).Diabetesmellituswasdefinedbasedonphysiciandi-agnosis,useofantihyperglycemicmedication,an8-hourfastingserum glucose level of 126 mg/dL, or a nonfasting serum glu-coselevelof200mg/dL(toconverttomillimolesperliter,mul-tiply by 0.0555).
AUDIOMETRIC MEASURES
Details of NHANES audiometric testing procedures have beenpublishedpreviously
17
andareavailableathttp://www.cdc.gov /nchs/data/nhanes/au.pdf. Hearing loss was defined as a pure-tone mean of 25 dB or more normal hearing level using fre-quencies of 0.5, 1, 2, and 4 kHz in both ears.
ANALYSIS
 Weestimatedtheprevalenceofvestibulardysfunctionintheover-all population and stratified by sociodemographic characteris-tics. The
2
F statistic was used to test for overall differences inproportions.Multiplelogisticregressionwasusedtoestimatetheodds of having vestibular dysfunction associated with sociode-mographic and cardiovascular risk factors, and to estimate theodds of reporting a fall associated with vestibular dysfunction.All analyses were adjusted for the survey design using theSURVEYproceduresinSASstatisticalsoftware(SASInstituteInc,Cary, North Carolina). Sample weights were incorporated intoallanalysesbyusingtheWEIGHTstatementinSASsoftwareperNational Center for Health Statistics instructions. All preva-lences, odds ratios, and variance estimates are presented fromweighted analyses unless otherwise specified.
P
.05 were con-sidered statistically significant.
RESULTS
Asdeterminedbyfailuretocompletetestcondition4,theoverallprevalenceofvestibulardysfunctionintheUSpopu-lationaged40yearsandolderfrom2001through2004was35.4%,correspondingto69millionAmericans(
Table1
).Theprevalenceofvestibulardysfunctionincreasedmark-edlywithageanddidnotsignificantlydifferbysexoramongwhites,blacks,andMexican-Americans(Table1).Partici-pants in the “other” race/ethnicity category, which in-cluded the categories “other Hispanic” and “other race—includingmultiracial,hadasignificantlyhigherprevalenceofvestibulardysfunction.Individualswithmorethanahighschooleducationhadamarkedlylowerprevalenceofves-tibulardysfunctioncomparedwithindividualswithlessthana high school education. We observed significant differences in the preva-lenceofvestibulardysfunctionbycardiovascularriskchar-acteristics: heavy tobacco use (
20 pack-years), hyper-tension, and diabetes were associated with higher ratesofvestibulardysfunction(Table1).Participantswhore-portedahistoryofdizzinesswerealsomorelikelytohaveevidence of vestibular dysfunction, as were participantswho reported falling in the past 12 months (Table 1).Theinfluenceofdemographiccharacteristicsandcar-diovascular risk factors on the odds of vestibular dys-functionwasevaluatedinmultivariateanalyses(
Table2
).The powerful influence of age persisted in models alsoadjustedforrace/ethnicity,sex,educationallevel,smok-ing,hypertension,anddiabetes,whereasmenandwomenhadequaloddsofvestibulardysfunction.Participantsinthe“other”race/ethnicitycategoryhadsignificantlyhigherodds of risk-adjusted vestibular dysfunction comparedwithwhites,andindividualswithmorethanahighschooleducationmaintainedtheirsignificantlyloweredoddsof vestibulardysfunctioninmultivariateanalyses(Table2). We observed that a history of hypertension was as-sociatedwithaborderlinesignificantincreaseintheoddsofvestibulardysfunction(
P
=.06;Table2).Diabeteswasassociated with a statistically significant increase in theodds of vestibular dysfunction (Table 2). Heavy smok-ing did not increase the odds of vestibular dysfunctionin adjusted analyses (Table 2).Giventhatanatomicallylinkedstructuressubserveves-tibularandauditoryfunction,weevaluatedforassociationsbetweenvestibulardysfunctionandhearingloss.Wefoundthat participants with vestibular dysfunction had signifi-cantlyincreasedoddsofhearinglosscomparedwithpar-ticipantswithoutvestibulardysfunctioninmultivariateanaly-ses(oddsratio,1.9;95%confidenceinterval,1.1-3.1;datanotshown).Priorworksuggeststhatsociodemographicandcardiovascularriskfactorsareassociatedwithhearingloss.
17
Totestwhethertheassociationsweobservedbetweenthesefactorsandvestibulardysfunctionmaybeowingtoconfound-ingassociationsbetweenhearinglossandvestibulardys-function,weadjustedforhearinglossinmultiplelogisticregressionmodelsevaluatingtheassociationbetweenso-ciodemographicandcardiovascularriskcharacteristicsandvestibular dysfunction. The significant influences of age,educationallevel,andhistoryofdiabeteswereunchanged(data not shown). We explored the extent to which vestibular dysfunc-tionwasassociatedwithclinicallysignificantoutcomes,specifically self-reported dizziness and a history of falls.Participantswithvestibulardysfunctionweremorelikelytoreporthavingdizzinessandahistoryoffalls(
Table3
).In unadjusted analyses, vestibular dysfunction con-ferred a significant increase in the odds of self-reporteddizziness and of falling (Table 3). Given that the asso-ciation between vestibular dysfunction and self-reported dizziness or falls could be owing to shared as-sociations with demographic and cardiovascular riskcharacteristics (ie, these factors could be acting as con-founders),weevaluatedtheassociationbetweenvestibu-lar dysfunction and self-reported dizziness and historyof falling in analyses adjusted for age, sex, race/ ethnicity, and cardiovascular risk factors. In these ad- justed analyses, vestibular dysfunction was still associ-ated with a significant increase in the odds of self-reported dizziness and of falling (Table 3). We evaluated the odds of falling among the 26.8% of participants who had measured vestibular dysfunctionandwerealsosymptomatic(n=536).Wefoundthattheseparticipants had a nearly 8-fold increase in the odds of falling (odds ratio, 12.3; 95% confidence interval, 7.9-16.7) compared with participants with neither of these
(REPRINTED) ARCH INTERN MED/VOL 169 (NO. 10), MAY 25, 2009 WWW.ARCHINTERNMED.COM
©2009 American Medical Association. All rights reserved.
 on July 29, 2011www.archinternmed.comDownloaded from 

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