2. Disclosure belangen NHG spreker
(Potentiële) belangenverstrengeling
None
Voor bijeenkomst mogelijk relevante relaties met bedrijven
Sponsoring of onderzoeksgeld
Honorarium of andere (financiële) vergoeding
Aandeelhouder
Andere relatie, namelijk …
Funding by The Netherlands Organisation for Health Research and Development (ZonMw-HGOG-programma)

3. Effectiveness of a multifactorial intervention for dizziness in older people in primary care: a cluster randomised controlled trial
Hanneke Stam, AIOTHO VUmc (presenting)
Johannes C. van der Wouden
Jacqueline G. Hugtenburg
Jos W.R. Twisk
Henriëtte E. van der Horst
Otto R. Maarsingh

4. Introduction (1) Dizziness in older people
Dizziness occurs frequently in older people
10% visit their GP at least 1/y because of dizziness
Often chronic
60% experience moderate/severe impact on daily living
Associated with depression, lower self-rated health, reduced social activity, increased fall risk
Aetiology
Broad etiologic spectrum of peripheral, central (neurological) and general medical causes for dizziness
No diagnosis in 40%
Multifactorial geriatric syndrome?

5. Introduction (2) Approach to dizziness in older people
Diagnosis-oriented approach
Older dizzy patient presents at general practitioner
Diagnosis
Prognosis
Treatment
Targeting the cause of dizziness
Combined diagnosis- and prognosis-oriented approach
Diagnosis
Older dizzy patient presents at general practitioner
Patient tailored treatment
Targeting modifiable risk factors and underlying dizziness cause
Prognosis

6. Introduction (3) A prognosis-oriented approach
Estimating the prognosis of dizziness  target potentially modifiable risk factors for an unfavourable course
Predicting an unfavourable course of dizziness (i.e. significant dizziness-related impairment at 6 months follow-up, Dros et al1)
Chronic dizziness
Standing still (provoking circumstance)
Trouble with walking or (almost) falling (associated symptom)
Polypharmacy (≥5 drugs)
No Diabetes mellitus
Anxiety or depressive disorder
Impaired functional mobility
1Dros J, Maarsingh OR, Beem L, et al. Functional prognosis of dizziness in older adults in primary care: a prospective cohort study.
J Am Geriatr Soc 2012; 60(12):

7. Aim and methods (1)
Is a prognosis-oriented approach effective in reducing dizziness?
Cluster RCT comparing a multifactorial risk factor guided intervention with usual care in older dizzy patients in general practice
Patients recruited from 45 general practices in The Netherlands
Inclusion criteria:
Age ≥ 65 years
Consulted the GP in the preceding 3 months
Significant dizziness-related impairment (DHI ≥30)
Primary outcome: dizziness-related impairment after 1 year
Secondary outcomes: quality of life (QoL), dizziness frequency, fall frequency, anxiety and depression, number of prescribed
Fall Risk Increasing Drugs (FRIDs)

8. Methods (2) Intervention group
Intervention patients received 1,2 or 3 risk factor guided interventions
FRID medication adjustment in case of ≥3 prescribed FRIDs
Stepped mental health care in case of anxiety disorder / depression
Exercise therapy in case of impaired functional mobility
Control group
Usual care
GPs of control practices were not informed about the intervention and did not receive any training
* interventions started simultaneously when ≥1 was applicable
* unrestricted access to usual care
GPs of control practices were asked to provide care as recommended in the NHG guideline “Dizziness”

9. Results (1) Baseline characteristics of study population
Patient characteristics measured at baseline.
Figures are number (percentage) unless stated otherwise
Intervention group
(n=83)
Control group
(n=85)
Demographic characteristics
Women
58 (69.9)
57 (67.1)
Age (years), mean ±SD (range 65-96)
78.6 ±7.0
79.0 ±7.6
No of chronic diseases, mean ±SD (range 0-6)
2.4 ±1.4
2.5 ±1.4
Psychiatric disease
29 (34.9)
30 (35.3)
Impaired functional mobility
22 (26.5)
25 (29.4)
Dizziness characteristics
DHI score, mean ±SD (range 30-88)
53.8 ±15.4
48.2 ±14.4
Onset of dizziness
1-4 weeks
1 (1.2)
2 (2.4)
1- 6 months
11 (13.3)
12 (14.1)
months
15 (18.1)
years
42 (50.6)
31 (36.5)
> 10 years
14 (16.9)
15 (17.6)
Medication characteristics
No of drugs, mean ±SD (range 0-17)
7.2 ±3.5
7.6 ±3.4
≥ 3 FRIDs
59 (71.1)
62 (72.9)
Patient characteristics measured at baseline.
Figures are number (percentage) unless stated otherwise
Intervention group
(n=83)
Control group
(n=85)
Demographic characteristics
Women
58 (69.9)
57 (67.1)
Age (years), mean ±SD (range 65-96)
78.6 ±7.0
79.0 ±7.6
No of chronic diseases, mean ±SD (range 0-6)
2.4 ±1.4
2.5 ±1.4
Psychiatric disease
29 (34.9)
30 (35.3)
Impaired functional mobility
22 (26.5)
25 (29.4)
Dizziness characteristics
DHI score, mean ±SD (range 30-88)
53.8 ±15.4
48.2 ±14.4
Onset of dizziness
1-4 weeks
1 (1.2)
2 (2.4)
1- 6 months
11 (13.3)
12 (14.1)
months
15 (18.1)
years
42 (50.6)
31 (36.5)
> 10 years
14 (16.9)
15 (17.6)
Medication characteristics
No of drugs, mean ±SD (range 0-17)
7.2 ±3.5
7.6 ±3.4
≥ 3 FRIDs
59 (71.1)
62 (72.9)
Intervention group:
Medication adjustment 59
Stepped mental health care 29
Exercise therapy 22
1 intervention 60
2 interventions 19
3 interventions 4
GPs of control practices were asked to provide care as recommended in the NHG guideline “Dizziness”

10. Results (2) Intervention effects
Primary outcome: dizziness-related impairment
No significant differences between intervention group and control group
DHI difference [95% CI -5.66;4.28]; p=0.79
Secondary outcomes
Number of FRID prescriptions
The intervention proved effective in reducing number of FRIDs
FRID difference [95% CI -0.89;-0·06]; p=0.02)
QoL, dizziness frequency, fall frequency, anxiety disorder and depression
zou hierbij aangeven op welke momenten je gemeten hebt, mag ook mondeling.

11. Results (3) Intervention adherence
Refusal and withdrawal significantly higher for stepped mental health care and exercise therapy (p <0.001)
Refusal and withdrawal significantly higher in patients eligible for ≥ 2 interventions (p <0·001)

12. Conclusion
The multifactorial intervention for dizziness in older patients proved ineffective in improving dizziness-related impairment
FRID medication adjustment  significant reduction FRIDs
No significant intervention effects on other secondary outcomes
Low uptake of and adherence to stepped mental health care and exercise therapy
It remains unclear whether a multifactorial intervention , with effective impact on all its risk factors, would affect dizziness

13. Discussion
Many researchers suggested multifactorial treatment for older dizzy people  reconsider whether this is feasible in daily practice
Offer multifactorial treatment for dizziness in a step-wise approach?
Essential to engage patients in designing future research to increase trial feasibility
Many researchers suggested multifactorial treatment for older dizzy people  reconsider whether this is feasible in daily practice
Multifactorial treatment could also be offered in a step-wise approach, potentially gradually increasing to more intensive therapies so that less burdensome therapies are applied first and more intensive therapies are only offered when the preceding therapies would not decrease dizziness symptoms
During baseline assessment of the RODEO study a lot of patients have asked us whether there was a pill available that would stop their dizziness. The fact that many patients asked about a ‘magic pill’, together with the low uptake of and adherence to stepped mental health care and exercise therapy, brought us to the idea that investing a lot of time and effort to get rid of their dizziness was too much of a burden for a substantial number of dizzy patients. It is important that researchers are aware of the fact that their ideas of a new promising intervention might not match the preferences of the target population

14. Questions?