Vestibular disorders are the most common cause of dizziness, accounting for around 45% of all dizziness, regardless of the clinical setting. Despite this, vestibular disorders have historically been poorly managed due to protocols that often miss or misdiagnose those with vestibular dysfunction. Not surprisingly, protocols in the emergency department are focused on identifying life threatening pathologies and vestibular disorders are often missed.
Outdated methodologies, disregard or lack of awareness of best practice guidelines, poor understanding of available vestibular function tests, and reduced clinical appointment times are likely partially to blame in other settings. More on some of the common flaws in current assessment pathways can be found here, here, and here. These management trends likely lead to higher rates of condition chronicity and poorer outcomes for those living with vestibular dysfunction.
It is important to note that even when some vestibular conditions are ideally managed, that does not mean complete lack of dizziness symptoms. Previously my colleague, Alan Desmond, detailed his experience of having vestibular neuritis and living with the chronic side effects of this inner ear injury. His condition was identified and managed promptly. He knew what to expect as far as the symptoms of living with vestibular dysfunction and was still surprised at how impactful the ongoing symptoms were. Now imagine you are a patient having similar symptoms, are either misdiagnosed or receive no diagnosis at all, and yet you are living with ongoing chronic dizziness symptoms with no obvious path to resolution. This would be extremely disheartening and may lead to secondary symptoms impacting many other facets of life.
For those that are correctly identified and treated in a timely manner, often little thought is given to how this may impact other facets of the individual’s life.
Anxiety and Depression
Individuals who have a predisposition to anxiety and/or depression are at a significantly higher risk of psychiatric symptom exacerbation when dealing with dizziness and are also at a higher risk of developing secondary conditions such as persistent postural perceptual dizziness (PPPD).
Vestibular dysfunction has been associated with higher odds of anxiety and depression as well as increased dizziness handicap. Dizziness with concomitant anxiety has also been shown to result in higher rates of health care utilization. Appropriate referrals must be made for dizzy patients with anxiety and depression.
Quality of Life
Patients living with dizziness have been shown to have significantly reduced mental and physical quality of life measures compared to their non-dizzy peers. For those living with vestibular dysfunction, management options such as vestibular rehabilitation have been shown improve quality of life.
Canalith repositioning exercises are also very effective at resolving BPPV symptoms.
Financial Impacts
Dizziness can have significant financial impacts. The annual medical expenses for those with dizziness and vertigo in the United States has been estimated at $48 billion. It is also common to experience reduced work productivity when living with dizziness.
One study showed that 50% of working individuals experienced a reduction in work efficiency and 25% had to change jobs due to the dizziness. Another study showed that 51% of patients with dizziness worked less than expected. Individuals suffering from dizziness are also significantly more likely to fall.
Fall related expenses are costly, accounting for over 50 billion USD annually. Falls can result in activity limitation as well as anxiety and depression.
Other Impacts
Many patients with vestibular dysfunction report symptoms of mental fog or difficulties concentrating. One study showed an 8-fold increased odds of difficulties concentrating or remembering and a 4-fold increased odds of limiting activities due to memory or confusion.
There is even some evidence to support abnormalities in visuospatial abilities in those with vestibular dysfunction. The causal connection for vestibular dysfunction impacting these other functions is currently poorly understood.
I normally counsel patients who bring up brain fog the following way:
“Your inner ear is the gyroscope of the skull and yours does not work properly. As such, your brain is working overtime to just keep you upright. You are having to devote cognitive resources to activities that reflexively work for most others and that can be exhausting.”
Summary
Assessment of patients dealing with dizziness should be holistic. Appropriate referrals must be made for those patients dealing with concomitant anxiety and depression. Current assessment pathways need modification to better assess and treat those with dizziness.
Expedient and accurate evaluations with appropriate treatment(s) have the potential to reduce condition chronicity and minimize the secondary side effects of those suffering from vestibular disorders.
