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Disorders of Balance and Vestibular Function in US Adults Data from the National Health and Nutrition Examination Survey, 2001-2004

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Disorders of Balance and Vestibular Function in US Adults Data from the National Health and Nutrition Examination Survey, 2001-2004 ORIGINAL INVESTIGATION Disorders of Balance and Vestibular Function in 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 debilitating Results: From 2001 through 2004, 35.4% of US adults and can lead to catastrophic outcomes such as falls. The aged 40 years and older (69 million Americans) had ves- inner ear vestibular system is an important contributor tibular dysfunction. Odds of vestibular dysfunction in- to balance control. However, to our knowledge, the preva- creased significantly with age, were 40.3% lower in in- lence of vestibular dysfunction in the United States and dividuals with more than a high school education, and the magnitude of the increased risk of falling associated were 70.0% higher among people with diabetes melli- with vestibular dysfunction have never been estimated. tus. Participants with vestibular dysfunction who were The objective of this study was to determine the preva- clinically symptomatic (ie, reported dizziness) had a 12- lence of vestibular dysfunction among US adults, evalu- fold increase in the odds of falling. ate differences by sociodemographic characteristics, and estimate the association between vestibular dysfunction Conclusions: Vestibular dysfunction, as measured by a and risk of falls. simple postural metric, is common among US adults. Ves- tibular dysfunction significantly increases the likeli- Methods: We included data from the 2001-2004 Na- hood of falls, which are among the most morbid and costly tional Health and Nutrition Examination Surveys, which health conditions affecting older individuals. These data were cross-sectional surveys of US adults aged 40 years suggest the importance of diagnosing, treating, and po- and older (n=5086). The main outcome measure was ves- tentially screening for vestibular deficits to reduce the bur- tibular function as measured by the modified Romberg den of fall-related injuries and deaths in the United States. Test of Standing Balance on Firm and Compliant Sup- port Surfaces. Arch Intern Med. 2009;169(10):938-944 HE VESTIBULAR SYSTEM IS IN- of motion) and imbalance owing to distur- tegral to balance control. bances in gaze and postural stability.2,3 In The paired vestibular or- some cases, vestibular dysfunction can cul- gans, housed within the minate catastrophically in a fall,4-6 which temporal bone, include 3 is associated with serious injury and re- Torthogonal semicircular canals (supe- stricted mobility and ranks among the lead- rior, posterior, and horizontal) and 2 oto- ing causes of death among older individu- lith organs (the utricle and saccule). To- als.7-11 The costs of increased needs and gether, the semicircular canals and otolith diminished autonomy associated with falls organs provide continuous input to the also exert a tremendous societal toll.12,13 brain about rotational and translational head motion and the head’s orientation CME available online at relative to gravity.1 This information from the vestibular organs and their central www.jamaarchivescme.com pathways allows for the maintenance of and questions on page 919 gaze and postural stability via the ves- tibulo-ocular reflex and vestibulospinal re- These costs appear to be rising; a recent flex, respectively. Dysfunction of the pe- study found that the prevalence and inci- ripheral vestibular structures cannot be dence of fall-induced injuries increased sig- Author Affiliations: directly observed but can be inferred from nificantly in the past 25 years, even after Department of 14 Otolaryngology–Head and Neck assessment of these reflexes (eg, with ca- adjustment for age. When this increas- Surgery, The Johns Hopkins loric reflex test). ing incidence is considered in relation to University School of Medicine, Vestibular dysfunction is typically char- an aging population, the prospect of a sig- Baltimore, Maryland. acterized by vertigo (ie, an illusory sense nificant public health problem is clear. (REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 10), MAY 25, 2009 WWW.ARCHINTERNMED.COM 938 ©2009 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ on 12/21/2016 Despite this concern and the known contribution of (18.9%) were excluded because they did not participate in the vestibular dysfunction to imbalance and falling, very little NHANES physical examination for various reasons including is known about the epidemiological characteristics of ves- “safety exclusion” and “participant refusal,” resulting in a final tibular dysfunction in the United States. There are no es- sample size of 5086 (81.1% of eligible participants). There were timates of the national prevalence of vestibular dysfunc- no significant differences between included and excluded par- ticipants with respect to sex, age, and race/ethnicity. Sample tion, and it is unknown whether susceptibilities differ across weights for the combined 4-year sample were used, per Na- demographic groups. Even the strength of the association tional Center for Health Statistics guidelines.15 These sample between vestibular dysfunction and falls is unclear. The data weights accounted for individual nonparticipation and pre- are poor in part because diagnosing vestibular dysfunc- served the national representativeness of the sample. tion can be difficult. The symptoms of dizziness and im- balance may be the nonspecific sequelae of numerous im- BALANCE QUESTIONNAIRE AND TESTING pairments, including deficits in vision, proprioception, and musculoskeletal, autonomic, and vestibular function. In ad- Before balance testing, participants were administered a bal- dition, testing for isolated deficits of the vestibular end- ance questionnaire, which determined history of dizziness (“Dur- organs often involves complex tools (eg, electronystamog- ing the past 12 months, have you had dizziness or difficulty raphy, caloric reflex test, or assessment of postural function) with balance?”) and falls (“During the past 12 months, have that complicate widespread application. you had difficulty with falling?”). Balance testing consisted of The National Health and Nutrition Examination Sur- the modified Romberg Test of Standing Balance on Firm and vey (NHANES) is a large-scale, highly powered survey Compliant Support Surfaces. This test examined the partici- that included balance testing for more than 5000 indi- pant’s ability to stand unassisted using 4 test conditions de- signed specifically to test the sensory inputs that contribute to viduals between 2001 and 2004. From these data, we es- balance—the vestibular system, vision, and proprioception. The timate the prevalence of vestibular dysfunction among fourth test condition was designed to test vestibular function US adults aged 40 years and older. We evaluate the in- exclusively: participants had to maintain balance on a foam- fluence of sociodemographic characteristics and com- padded surface (to obscure proprioceptive input) with their eyes mon cardiovascular risk factors on the prevalence of ves- closed (to eliminate visual input). tibular dysfunction. We also consider the association Balance testing was scored on a pass/fail basis. Test failure between vestibular dysfunction and clinically signifi- was defined as participants needing to open their eyes; mov- cant outcomes, specifically falls. Such epidemiological in- ing their arms or feet to achieve stability; or beginning to fall formation can offer critical insight to help control and or requiring operator intervention to maintain balance within possibly prevent a growing burden of fall-induced mor- a 30-second interval. Each participant who failed a test condi- tion was eligible for 1 retest. The protocol for retesting was the bidity and mortality in the US population. same as for the primary examination. Because each successive test condition from 1 to 4 was progressively more difficult than METHODS the condition preceding it, the balance testing component was ended whenever a participant failed to pass a test condition (either during the initial test or the retest, if the participant opted STUDY POPULATION for one). We focused on test condition 4, designed to distin- guish participants who could not stay standing when relying The NHANES is an ongoing cross-sectional survey of the ci- primarily on vestibular input. We categorized participants as vilian, noninstitutionalized population of the United States. Ev- having vestibular dysfunction if they did not pass test condi- ery 2 years, households were approached at random, and per- tion 4. Of 5086 participants, 257 (5.1%) did not pass prior test sons were invited to participate in the NHANES survey if they conditions and thus did not participate in test condition 4. An met a specific demographic profile (based on sex, race/ additional 86 participants (1.7%) had missing data for test con- ethnicity, age, and place of residence) and contributed to the dition 4, leading to a total of 343 excluded participants (6.7%). national representativeness of the sample. In each of the last Further details of balance testing procedures are available at several cycles, 12 000 to 13 000 individuals were selected; the http://www.cdc.gov/nchs/data/nhanes/ba.pdf. participation 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- SOCIODEMOGRAPHIC AND ance testing on a nationally representative
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