Severe Dizziness Related to Postural Instability, Changes in Gait and Cognitive Skills in Patients with Chronic Peripheral Vestibulopathy

THIEME Original Research Severe Dizziness Related to Postural Instability, Changes in Gait and Cognitive Skills in Patients with Chronic Peripheral Vestibulopathy Almir Resende Coelho1,2 Júlia Licursi Lambertti Perobelli1 Lilian Shizuka Sonobe1 Camila Giacomo de Carneiro Barros1 Daniela Cristina Carvalho de Abreu1 1 Department of Health Sciences, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil 2 Department of Physiotherapy, Universidade de Franca, Franca, SP, Brazil 3 Escola de Educação Física e Esporte de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil Renato Moraes3 Address for correspondence Almir Resende Coelho, Departamento de Ciências da Saúde, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Avenida Bandeirantes 3.900, Ribeirão Preto, SP, CEP:14049-900, Brasil (e-mail: ; ). Int Arch Otorhinolaryngol 2020;24(1):e99–e106. Abstract Keywords ► vestibular diseases ► aging ► dizziness ► rehabilitation Introduction Peripheral vestibular disorders can lead to cognitive deficits and are more common in elderly patients. Objective To evaluate and correlate cognitive, balance and gait aspects in elderly women with chronic peripheral vestibular dizziness, and to compare them with elderly women without vestibular disorders. Methods Twenty-two women presenting peripheral vestibular dizziness episodes for at least six months participated in the study. The individuals were categorized by dizziness severity level: moderate (n ¼ 11) or severe (n ¼ 11). The control group (n ¼ 11) included women showing no vestibulopathy, light-headedness or dizziness. Cognitive assessments and semi-static and dynamic balance assessments were performed with the Balance Master (Neurocom International, Inc., Clackamas, OR), while the Dizziness Handicap Inventory provided a score for the severity of the symptoms. The groups were submitted to statistics of inference and correlation between cognitive, balance and stability variables. Results The group with severe dizziness showed higher sway speed of the center of pressure in the anteroposterior direction, smaller step length, and slower gait than the control group. Regarding the cognitive variables, the group with severe dizziness symptoms presented significant correlations with stability and gait variables. Conclusion The relationship between cognitive aspects, balance and gait was stronger in women with severe dizziness than in those with no vestibulopathy. Introduction Adequate postural control allows people to perform their functional activities succesfully, through the integration of perception and action systems and high-level processes. The vestibular system, which participates in the sensory processes, has the function of picking up information about head position, movement, acting forces and inertia during the execution of different activities.1 received May 11, 2018 accepted June 18, 2019 DOI https://doi.org/ 10.1055/s-0039-1695025. ISSN 1809-9777. The proper function of the vestibular system may be impaired by vestibulopathies, whose symptoms, such as dizziness and imbalance, decrease the ability to perform ordinary and social activities. According to the international classification of vestibular disorders of the Bárány Society, dizziness can be defined as a sensation of disturbance or impairment in spatial orientation, without a false or distorted sense of self-movement (of a Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil e99 e100 Severe Dizziness Related to Postural Instability Coelho et al. rotational type). And vertigo is when there is a sense of selfmovement (of the rotational type), even when there is no actual body movement on the axis itself or during normal head movement.2 Studies have reported that the prevalence of dizziness increases with age, affecting  14% of the population aged 18 to 39 years, and 28% of the population aged 40 to 59 years; the condition may affect up to 85% of the population aged 70 years or older.3 Another common symptom of aging is cognitive decline, which is characterized by loss of short-term memory and lack of concentration and attention, impairing the achievement of adaptive and anticipatory responses and the strategies used for navigation, disturbance management, and to avoid obstacles.4 Vestibulopathies can influence the interrelations in the central nervous system (CNS) through damage to the labyrinthine organ and the vestibular nerve up to its entrance in the brainstem, in which cases the dysfunction is peripheral, or through modifications in the vestibular nuclei, whose origin is central.5 Considering these interrelations of peripheral and central origin, recent studies have reported the influence of the vestibular system in cognition, mainly related to the perception of self-motion, bodily self-awareness, spatial navigation, spatial learning, spatial memory, and object recognition memory.6 However, few studies4,7,8 have tackled the details and complexity of each of these components. Little is known about the relationship between the vestibular system and distinct nonspatial cognitive aspects and its correlation with balance deficits; additionally, the severity of dizziness is often overlooked in the existing studies. Furthermore, studies describing vestibular disorders usually do not distinguish patients with different durations of symptoms; special attention should be given to the patients who have already been treated for otoneurological symptoms. This differentiation is paramount, because the cognitive, balance and functionality responses may vary depending on the clinical characteristics of the individuals. Taking these factors into consideration, the present study was designed to evaluate and correlate cognition, balance and gait in elderly women with chronic peripheral vestibular dizziness who had not responded to conventional vestibular rehabilitation (VR) and compare the results with data from elderly women without perception of dizziness or any vestibular disorder. Material and Methods Sample Definition The sample consisted of 22 elderly women (60 years old) who had peripheral vestibular dizziness episodes for at least six months. The diagnosis of peripheral dizziness was confirmed through anamnesis, caloric tests and computerized vector electronystagmography at the Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery of Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC/FMRP-USP). These patients were divided into two groups according to their symptoms using the dizzness handicap inventory (DHI): the moderate dizziness group (MDG; n ¼ 11) and the severe dizziness group (SDG; International Archives of Otorhinolaryngology Vol. 24 No. 1/2020 n ¼ 11). The control group (CG; n ¼ 11) consisted of elderly women with no vestibulopathy, light-headedness or dizziness. The CG was recruited from the comm (...truncated)