Older patients with persistent postural-perceptual dizziness exhibit fewer emotional disorders and lower vertigo scores


Based on the international classification of vestibular disorders and the PPPD diagnostic criteria and exclusion criteria, a total of 122 PPPD patients hospitalized in the vertigo ward of Nanjing Brain Hospital from February 2018 to July 2021 were enrolled.

The inclusion criteria involved meeting the following five conditions at the same time: 1. There is dizziness, instability and non-spinning vertigo for more than 3 months with (1) a persistent fluctuation in symptoms, and (2) these symptoms do not have to last all day. 2: There are no specific inducing factors, but the condition can be exacerbated by (1) upright posture, (2) active or passive movement (independent of direction and posture), and (3) moving visual stimulation or complex visual patterns. 3. The condition is induced by acute/chronic/episodic vestibular diseases, other systemic diseases and psychological distress: (1) when induced by acute/paroxysmal diseases, the symptoms can initially be relieved or intermittent, but they transform into a persistent course of disease; (2) when induced by a chronic disease, the symptoms appear slowly and then gradually aggravate. 4. The symptoms cause significant distress and dysfunction. 5. Other diseases cannot better explain the symptoms.

The exclusion criteria were as follows: (1) dizziness caused by systemic disease (including Parkinson’s disease, Alzheimer’s disease, sleep apnea syndrome, etc.); (2) dizziness caused by toxic substances and drugs; (3) dizziness caused by various withdrawal syndromes, including abstinence; (4) schizophrenia or mania or the consumption of related psychiatric medications; and (5) inability to complete the test due to illiteracy, intellectual disability or other reasons.

Standard protocol approvals, registrations, and patient consents

This study was approved by the local ethics committee and was performed in accordance with the Helsinki Declaration of 1975. The data are anonymous, and the requirement for informed consent was therefore waived.


All the patients were from the vertigo ward of Nanjing Brain Hospital and met the diagnostic criteria of PPPD. The patient’s detailed medical case characteristics (characteristics of vertigo/dizziness attacks, course of disease, accompanying symptoms, duration, inducing factors, attack and frequency, etc.), past history and personal history were collected. In terms of medical history, we focused on the history of central vestibular diseases, such as cerebral infarction, intracerebral hemorrhage, intracranial tumors and other diseases, as well as the history of peripheral vestibular diseases, such as benign paroxysmal positional vertigo (BPPV), vestibular neuritis (VN), vestibular migraine (VM), and vestibular paroxysmia (VP). A neurophysical examination and vertigo bedside physical examination were conducted. Then the doctor communicated with the patients, explained the follow-up examination and questionnaire survey, and finally the patients signed the notice and other documents. Then, the patients were individually administered questionnaires in a separate room, such as Dizziness handicap inventory (DHI), Activities-specific balance confidence (ABC) scale, Beck anxiety inventory and Patient health questionnaire-9 items (PHQ-9), which were conducted by trained doctors or nurses. The patients were examined for vestibular function within 24 h after admission, including the Vestibular ocular reflex (VOR) and Alternate binaural bithermal caloric test. Keep the patient quiet and conscious when completing the questionnaire. Other relevant examinations, such as brain magnetic resonance imaging (MRI), neck vascular ultrasound, transcranial Doppler (TCD), cardiac ultrasound, routine blood tests and blood biochemistry tests, were conducted based on the patient’s condition.

The patients were divided into the youth group (≤ 40 years old), middle-aged group (41–59 years old), older adults group 1 (60–75 years old), and older adults group 2 (≥ 75 years old) based on age, and then additionally were divided into the secondary-PPPD (s-PPPD) and primary-PPPD (p-PPPD) groups based on whether or not the PPPD was secondary to an organic disease.

Emotional disorders were diagnosed based on the medical history and medical records provided by the patients. If the patient had a high DHI or Beck score with no previous history of emotional disorders, we administered the Hamilton Anxiety/Depression Rating Scale and Zung’s Self Rating Anxiety/Depression Scale; if the patient scored high on these scales, we asked psychiatrists to confirm the diagnosis after consultation.

We record the feelings of dizziness described by the patients in as much detail as possible; these included feelings of spinning (of the self or the environment), fullness, heaviness, lightness in the head, difficulty focusing, unsteadiness, rocking, bouncing, waving, or bobbing. After analyzing the descriptions, we divided feelings of dizziness into hree categories: rotational, unsteadiness, and lightheadness. Each patient could experience one or more of these feelings. For each patient, the feelings of dizziness was determined by the trained doctor in the vertigo ward.

We divided the duration of dizziness into four groups: less than 1 min, 1–60 min, 1–24 h and more than 24 h. The duration of dizziness was determined according to the longest duration of the most frequent spells of dizziness and was carried out by the trained doctor in the vertigo ward.

We recorded the accompanying symptoms, such as headache, nausea, phono-/photophobia, loss of hearing, and innitus, and then determined the proportion of these symptoms experienced in each group. We also accessed the basic diseases of patients, such as hypertension, type 2 diabetes mellitus, coronary atherosclerotic heart disease, and stroke, based on the medical history and medical records provided by the patients. Then we determined the proportion of different kinds of basic diseases in each group and the total proportion of basic diseases in each group.

Relevant evaluation scales

Dizziness handicap inventory (DHI)

The DHI is widely used in the diagnosis and treatment of dizziness and balance disorders. The scale includes 25 items (0 = no, 2 = sometimes, 4 = yes) and evaluates the situation of the patients with dizziness within three subcategories: emotional (E; 9 items, 36 maximal score), functional (F; 9 items, 36 maximal score) and physical handicap (P; 7 items, 28 maximal score). The range of DHI scores is from 0 to 100. The patients are instructed by doctors to rate the items by themselves, where 0 means that the vertigo disease had no impact on the patient. The higher the overall score was, the more severe the influence of vertigo on the patients. Through clinical verification, it was found that DHI has good internal consistency (α = 0.920)5. We recorded the total DHI score and the scores on terms E, F and P for each patient.

Activities-specific balance confidence (ABC) scale

The ABC scale is a 16-item self-assessment scale designed to assess confidence in maintaining balance. The ABC scale ranges from 0 to 100%, and the score ranges from 0 to 160. The ABC scale evaluates the completion of daily activities, including walking around the house, bending down to pick up objects and getting on the bus. The ABC scale has good internal consistency (α = 0.96) and good test–retest reliability and results in a stable total score when retested within 2 weeks6. We recorded the ABC score (0 to 160) of each patient.

Beck anxiety inventory

This is a self-assessment scale with a total possible score of 63 points for 21 items. The items were rated on a 4-point scale to assess the degree of annoyance experienced by the subjects by a variety of anxiety symptoms. It is suitable for adults with anxiety symptoms7. The Beck anxiety inventory has high internal consistency and high test–retest correlation and shows good simultaneous validity. Beck anxiety inventory scores are highly correlated with scores on the Symptom Checklist-90 (SCL-90) anxiety scale, Hamilton anxiety scale (HAMA) and State Trait Anxiety Inventory (STAI)8. We recorded the scores on each item and the total score of each patient.

Patient health questionnaire-9 items (PHQ-9)

The PHQ-9 is a questionnaire for diagnosing depression, assessing severity and monitoring treatment response. The PHQ-9 shows no significant ethnic differences across multiple populations (α = 0.79–0.89) and is easy to use9. We recorded the scores on each item and the total score of each patient.

Vestibular examination

Vestibular ocular reflex (VOR)

As assessed by vHIT (ICS Impulse), the patient’s vision was fixed on a target 1.5 m in front of him or her and evaluated by performing 20° rotations around three planes with small amplitude, high acceleration and passive head rotation. At least 10 suitable head rotation pulses were recorded during each test. A vHIT gain of less than 0.7 was considered pathological. The vHIT gain asymmetry index was calculated as follows: (difference between ipsilateral and contralateral gain/sum of ipsilateral and contralateral gain) × 100%. A vHIT gain asymmetry index of more than 10% is considered pathological. We recorded the VOR values of the six semicircular canals of each patient to estimate their peripheral vestibular system function. Any semicircular canal with a VOR less than 0.7 was considered abnormal. The proportion of abnormal VOR in each group was recorded.

Alternate binaural bithermal caloric test

The peak slow phase velocity (SPV) was measured by video oculography (ICS Chartr 200 VNG/ENG); the patient was in the supine position with the head at 30° to horizontal, the ears were irrigated with cold air (24 °C) and hot air (50 °C), and the maximum nystagmus velocity within 90 s was recorded. Based on the Jongkees index formula, if the canal paresis (CP) value was greater than 25%, it was defined as abnormal. The proportion of abnormal results on the alternate binaural bithermal caloric test in each group was recorded.


Data were processed by SPSS 26.0 (IBM, Chicago, IL, USA). The measurement data that were normally distributed are expressed as the mean ± standard deviation (SD), and the comparison between groups was performed by one-way ANOVA, which requires homogeneity in statistical variance. If the variance was not uniform, differences were evaluated by the Kruskal–Wallis test. Categorical variables are expressed as frequencies and percentages. When comparing more than two groups or factors, we used the chi-square test. Correlations were measured with Pearson’s r. If the frequency was less than 5, Fisher’s exact test was used, and P < 0.05 was considered to be statistically significant.

Ethics approval

This study was approved by the Ethics Committee of Nanjing Brain Hospital and exempted from the application for informed consent.

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