Dizziness in older patients in general practice: a diagnostic challenge

Horst, H.E. van der [Promotor]Schellevis, F.G. [Promotor]Weert, H.C.P.M. van [Copromotor

Identifying tests to evaluate in a diagnostic accuracy study for patients with vertigo in general practice: a Delphi study

IntroductionVertigo is a common symptom that strongly impacts patients’ quality of life. More than 80% of patients experiencing vertigo are primarily treated by their general practitioner (GP). The GP’s'diagnostic toolkit' for vertigo has serious limitations, though, because diagnostic accuracy studies on conditions that may cause vertigo have never been performed in a general practice setting. Our aim was to determine which tests should be investigated in a diagnostic accuracy study for patients with vertigo in general practice.MethodWe conducted an online Delphi procedure involving national and international experts. The experts were asked to judge a selection of 40 diagnostic tests based on the Dutch GP guideline on vestibular symptoms, supplemented by tests identified during a systematic review. Panellists were allowed to suggest additional tests after the first round. In case of consensus of at least 70%, a test was included or excluded. We also conducted a secondary sub-analysis of our Delphi procedure to demonstrate non-dominance of Dutch experts within our expert panel. Data were analysed using descriptive statistics and content analysis. Data were analysed using descriptive statistics and content analysis.ResultsA panel of 20 experts from five countries, including 7 specialists in otolaryngology, 6 neurologists and 7 GPs, participated in the Delphi procedure. The panel judged 46 diagnostic tests in total, with 6 additional tests added to the original selection based on suggestions by experts. After the first two rounds (100% response rate), 16 tests were included, 22 tests were excluded and no consensus was reached on 8 tests. During the consensus round, one of the 8 tests was added to the included 16 tests. Of these 17 tests, 15 are recommended by the Dutch GP guideline, supplemented by the non-recommended Tandem walking test and the Romberg test.ConclusionsAn international expert panel reached consensus on 17 tests for vertigo in general practice that should be investigated in a diagnostic accuracy study.Disorders of the head and nec

Reduction Of Dizziness in older people (RODEO)

Background: The management of dizziness in older patients is primarily diagnosis-oriented. However, in 40 % of older patients with dizziness, GPs are not able to identify an underlying cause, and a number of common underlying causes of dizziness cannot (or hardly) be treated. In this study we will investigate the effectiveness of a prognosis-oriented approach in the management of dizziness in older patients. This prognosis-oriented approach comprises identification of patients at risk for chronic dizziness with persistent impairment by identifying risk factors for an unfavourable course of dizziness. Patients at risk for chronic dizziness with persistent impairment will be offered treatment addressing the identified modifiable risk factors. Methods/Design: This study will be performed in primary care. An intervention study and a validation study will be conducted in a three-arm cluster randomised design. In the intervention study we will investigate a risk factor guided multi-component intervention. The risk factor guided intervention includes: (1) medication adjustment in case of three or more prescribed fall-risk-increasing drugs, (2) stepped care in case of anxiety disorder and/or depression, and (3) exercise therapy in case of impaired functional mobility. The primary outcome measure is dizziness-related impairment, which will be assessed with the Dizziness Handicap Inventory. Secondary outcome measures are quality of life, anxiety disorder and depression, use of fall-risk-increasing drugs, dizziness frequency, fall frequency, and healthcare utilization. Discussion: This study is, to date, the first study that will investigate the effectiveness of a prognosis-oriented approach for reducing dizziness-related impairment in older people in primary care. Offering treatment that addresses identified modifiable risk factors to patients at high risk for chronic dizziness is unique. The pragmatic design of this study will enable evaluation of the outcomes in real-life routine practice conditions. An effective intervention will not only reduce dizziness-related impairment, but may also decrease healthcare utilization and healthcare costs