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The Prevalence of Dizziness and Its Association With Functional Disability in a Biracial Community Population

^a Rush Alzheimer's Disease Center, Rush University and Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois
^b Rush Institute for Healthy Aging, Rush University and Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois
^c Department of Neurological Sciences, Rush University and Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois

Neelum T. Aggarwal, Rush Alzheimer\|[apos ]\|s Disease Center, 1645 W. Jackson Boulevard, Suite 675, Chicago, IL 60612 E-mail: nervedocs{at}aol.com.

Decision Editor: William B. Ershler, MD

	Abstract

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Background. Information regarding the prevalence of dizziness and its association with functional disability among African American and white residents from defined community populations is limited.

Methods. A total of 6,158 persons 65 years and older (78.8% of age-eligible persons) completed in-home interviews that included three common measures of self-reported disability: the Katz Activities of Daily Living (ADL) Scale, the Rosow-Breslau Functional Health Scale, and the Nagi Physical Disability Scale. A stratified random sample of 729 persons underwent a detailed evaluation that included questions on the frequency and severity of dizziness, which was defined as having an episode of dizziness or lightheadedness at least once a month.

Results. The overall prevalence of dizziness in this population was 9.6% (95% confidence interval [CI] 7.2–12.0). It increased with age, from 6.6% in those 65–74 years old, to 11.6% in those 75–84 years old, and to 18.4% in those persons 85 years old. It was more common in women (odds ratio [OR] 2.03, 95% CI 0.99–4.19) but was not associated with race. After adjusting for age, sex, and race, dizziness was associated with greater disability on the Rosow-Breslau (OR 2.29, 95% CI 1.18–4.46) and Nagi (OR 2.54, 95% CI 1.48–4.36) measures but not on the Katz ADL Scale (OR 1.18, 95% CI 0.64–2.20).

Conclusions. Dizziness is common among older persons and is associated with functional disability.

MOST information concerning dizziness comes from studies of persons who seek medical attention ^(1)(2)(3). Dizziness is a common problem among older persons, generating an estimated 8 million outpatient visits per year in the United States alone ⁽¹⁾. Several conditions, including benign positional vertigo ⁽⁴⁾⁽⁵⁾, orthostatic hypotension ⁽⁵⁾⁽⁶⁾, and cardiovascular disease ⁽⁵⁾, may lead to dizziness in elderly persons. It has also been associated with age ⁽⁷⁾, female sex ⁽⁷⁾⁽⁸⁾, and anxiety and depression ⁽⁸⁾. The frequency of dizziness reported in clinical settings ranges widely ⁽⁸⁾, due in part to clinic referral patterns and to varying definitions of the condition ^(3)(9)(10). Studies suggest that dizziness, although episodic, is frequently a longstanding symptom ⁽¹¹⁾ and may be associated with disability ⁽⁷⁾⁽⁸⁾. Because it is likely that many older persons with dizziness do not seek medical attention, large population studies are needed to determine its prevalence, its relation to age, sex, and race, and its relation to negative outcomes, such as disability. Few population studies that have examined the prevalence of dizziness among older persons have not depended on receipt of health care to identify subjects ⁽⁷⁾, and information on the relation of dizziness to race is limited.

As part of the Chicago Health and Aging Project, a longitudinal population-based study of common health problems of older persons, we estimated the prevalence of dizziness and its association with functional disability among African Americans and whites from a geographically defined biracial population of Chicago.

	Methods

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Subjects
Subjects for this study were participants in the Chicago Health and Aging Project (CHAP), a longitudinal study of risk factors for Alzheimer's disease and other chronic conditions in a geographically defined biracial community in Chicago. After a complete census in three contiguous neighborhoods (Washington Heights, Morgan Park, and Beverly) on the South Side of Chicago, all persons aged 65 years and over, including those living in nursing homes, were eligible for participation. A total of 6,158 residents (response rate of 78.8%), of whom 60.7% were women and 61.6% were African American, participated in an in-home interview that covered a broad range of health and social problems of older persons and also included brief tests of cognitive function.

A random sample of those interviewed, stratified by age, sex, race, and cognitive performance, underwent a detailed structured clinical evaluation performed by examiners blinded to data collected in the population interview. The median time between the population interview and the clinical evaluation was 4 months. Of the 1,056 subjects sampled for clinical evaluation, 86 died and 9 moved before being asked to participate; 729 (75.9%) of the remaining 961 were evaluated. Of the 729, we had complete data on dizziness for 672 (92.2%), and these data form the basis for the analysis. The study was approved by the Human Investigation Committee of Rush Presbyterian-St. Luke's Medical Center.

Clinical Evaluation and Disability Assessment
The evaluation included a medical history, neurologic examination, cognitive testing, and laboratory testing. A senior neurologist examined each participant and reviewed all clinical evaluation data. All participants were asked whether they had ever been dizzy or lightheaded. If so, they were asked about the frequency and severity of their dizziness episodes. Frequency response categories were once a year or less, several times a year, once a month, several times a month, once a week, or several times a week; severity response categories were not severe at all, slightly severe, somewhat severe, very severe, or extremely. We were most interested in the potential impact of fairly regular episodes on disability. For most analyses, therefore, persons with episodes occurring once a month or more often were considered to have dizziness, and those with less frequent episodes were included among those free of dizziness. The severity categories were condensed into three groups for most analyses: very severe (very or extremely), moderately severe (slightly or somewhat), and not severe.

Three brief self-report measures of disability were used from the EPESE study ⁽¹²⁾. The Katz Activities of Daily Living (ADL) Scale ⁽¹³⁾ assessed whether the subject was able to perform each of the following six activities without help: eating, toileting, bathing, dressing, transferring, and walking across a room. Three items from the Rosow-Breslau Functional Health Scale ⁽¹⁴⁾ assessed the ability to walk half a mile, climb stairs, and do heavy housework. Items developed by Nagi ⁽¹⁵⁾ assessed the level of difficulty performing five physical activities: bending, stooping or crouching, pushing or pulling a large object, reaching above the shoulders, writing or handling small objects, and lifting or carrying 10 pounds of weight. Responses to each of the Nagi items were dichotomized, with moderate difficulty or greater denoting inability to perform that task.

For each disability measure, a summary score was computed by summing the individual items into three categories: no disability, moderate disability, and severe disability. As in other studies ⁽¹⁶⁾, having no or little difficulty corresponded to having no disability in any of the activities. For the Katz scale, limitation in one or two items indicated moderate disability and limitation in three items was considered severe. For the Rosow-Breslau measure, disability in one item was moderate disability; in two or three items, severe. For the Nagi measure, disability in one or two items was considered moderate disability; in three to five items, severe.

Clinical stroke was rated by the neurologist as probable, possible, or not present based on the clinical history of stroke and findings on the exam consistent with stroke. A rating of probable or possible was considered as stroke for all analyses. The subject's best visual acuity (with glasses) was assessed by using a Snellen card. For analyses, visual acuity was categorized by three levels: good (20/40, 20/50, 20/70), intermediate (20/100, 20/200), and poor (20/400, 20/400+). Evaluation of proprioception was conducted by specially trained nurse clinicians as part of a structured neurologic examination. Cardiovascular risk factors included self-report history for angina (ROSE questionnaire) ⁽¹⁷⁾, history of myocardial infarction (MI) or coronary, or coronary occlusion, and history of hypertension taken from the population interview. A total of three blood pressure (BP) measurements were taken from the clinical evaluation: two sitting and one standing (mmHg). Orthostatic (postural) hypotension was defined as a systolic BP difference of 20. Because we did sitting to standing BP rather than supine to standing, we also examined postural hypotension, defined as a systolic BP difference of 10. At the time of the clinical evaluation, medications taken over the previous two weeks that had the potential to cause dizziness were recorded by direct inspection. Use of drugs in the following categories was examined: antidiabetic, cardiac, antihypertensive, antipsychotic, antiparkinsonian, and anticholinergic drugs. Self-report of diabetes was collected at the time of the population interview. Clinical depression was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM III-R) ⁽¹⁸⁾ and was rated by the neurologist as probable, possible, or no depression.

Statistical Analyses
All analyses took into account the unequal probabilities of selection due to the stratified random sample design. Variances were computed using replication-based methods ⁽¹⁹⁾.

We first examined the prevalence of dizziness and the degree to which it was modified by age, sex, and race in simple cross tabulations and by fitting logistic regression models. Next, we examined the association between dizziness and level of disability severity (none, moderate, and severe). We present both simple cross tabulations and the association adjusted for age, sex, and race through the use of ordinal logistic regression (proportional odds) models. For variables that had reasonable rates, we added them to the basic logistic regression models for each outcome singly and examined the change in association between dizziness and disability. Secondary analyses examined the degree to which the association between dizziness and disability might be accounted for in part by stroke, diabetes, or visual acuity and other potential confounding variables. Finally, to examine how frequency and severity of dizziness were related to disability levels, separate ordinal logistic regression models were fitted for each disability outcome with frequency and severity of dizziness as predictor variables.

	Results

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Prevalence of Dizziness
The prevalence of ever having had an episode of dizziness or lightheadedness in our population was 41.4% (95% confidence interval [CI] 37.0–46.0). Almost 80% of these persons had episodes of dizziness either less than once a year or several times a year (Table 1 ). By contrast, 22.6% of those with episodes of dizziness experienced these symptoms at least once a month (Table 1 ). The overall estimated prevalence of dizziness in this community population, weighted to reflect the stratified sampling, was 9.6% (95% CI 7.2–12.0) (Table 2 ). The prevalence increased with age from 6.6% (95% CI 3.2–10.0) of persons 65–74 years old, to 11.6% (95% CI 7.3–16.0) of those 75–84 years old, and 18.4% (95% CI 15.5–21.2) of persons 85 years and older. Prior to adjustment for other variables, prevalence of dizziness appeared greater among women (12.1%, 95% CI 8.5–15.6) than men (5.8%, 95% CI 2.9–8.7) and approximately equal among African Americans (9.8%, 95% CI 6.6–13.0) and whites (9.3%, 95% CI 5.7–12.9). Because age, sex, and race are associated with one another, we also examined their associations with dizziness in analyses that considered all three variables simultaneously. In these adjusted analyses, the odds ratio (OR) of dizziness increased approximately 7% (95% CI 1.03–1.11) for each year of age; women were twice as likely as men to have dizziness (OR 2.03; of marginal statistical significance, 95% CI 0.99–4.19); and dizziness was not related to race (OR 1.33, 95% CI 0.71–2.52) (Table 3 ).

Additional logistic regression analyses were conducted to examine whether frequency or severity of dizziness modified its association with disability. Frequency was associated with disability on the Nagi (OR 2.09, 95% CI 1.41–3.10) and Rosow-Breslau (OR 1.78, 95% CI 1.18–2.68) measures after adjustment for age, sex, and race but not with disability on the Katz scale (OR 1.11, 95% CI 0.73–1.69). There was no significant increase in the prevalence of disability due to severity of dizziness in adjusted analyses for the Katz, Rosow-Breslau, or Nagi measure.

	Discussion

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In this large community study, regular episodes of dizziness was a common problem among older persons. Its prevalence increased with age among persons over the age of 65, and was higher among women but was not associated with race. Dizziness was associated with a twofold increase in the prevalence of disability on two of the three disability measures.

Clinic-based studies indicate that dizziness is among the most common reasons why older persons visit a physician. In one study, it was the most common presenting complaint of patients aged 75 and older visiting an ambulatory clinic ⁽²⁾. The frequency of reports of dizziness in clinical settings varies widely from 5% to 90% ⁽²¹⁾, but because reports from clinics typically reflect the specific referral patterns of each facility, it is likely that many persons with dizziness do not seek medical attention.

Population studies are needed to characterize the prevalence of dizziness and whether it varies by age, sex, or race. Three previous population-based studies have estimated the prevalence of ever having been dizzy or of having been dizzy in the past year. These studies report prevalences ranging from 27% to 34% ^(7)(8)(20). The prevalence of dizziness found in this study is lower because we restricted most analyses to regular episodes, at least once each month. The prevalence of ever having been dizzy was approximately 40%, comparable to previous reports. Our study, like previous population studies, found that the prevalence of dizziness increased with age and was more common in women. Only one previous study, of persons coming to medical attention, examined possible racial differences in dizziness; it also did not find significant differences between African Americans and whites ⁽⁸⁾.

Persons who reported that their dizziness was severe were also asked to characterize their dizzy symptoms. Twenty-eight persons reported the sensation as spinning or turning. The total episodes ever reported of spinning, turning, or moving was between 2 and 10, and the average duration was between 5 seconds and 5 minutes. Of those who complained of the spinning sensation, only 21 saw a physician because of the sensation of dizziness (data not shown). Although these numbers are too small to reliably upweight to the population, they suggest that only a minority of persons with dizziness experience symptoms of vertigo and seek medical attention as a result of dizziness.

The relation of dizziness to functional disability has been examined primarily among persons seeking medical attention ^{(4)(6)(9)(22)}. Kroenke and coworkers ⁽⁴⁾, in their prospective study of dizziness in patients in ambulatory care, reported that more than half of persons with dizziness complained that it interfered with their ADLs. Reports of the relation of dizziness to disability in population studies are conflicting. In one study, dizziness was defined by its effect on daily functioning ⁽⁸⁾. Another study, using data from the Longitudinal Study of Aging (LSOA), reported that among persons without functional disability at baseline, dizziness (defined as sometimes having trouble with dizziness) was not related to incident functional disability 2 years later, after controlling for other potential causes of disability ⁽⁷⁾. It is possible that the association of dizziness with functional disability in this study was due in part to use of a definition requiring at least monthly episodes of dizziness.

Our study suggests that dizziness was associated with disability on the Nagi and Rosow-Breslau scales but not on the Katz scale. The greatest difference between the Katz ADL Scale and the other two measures is that it assesses the most basic activities required for independent living (e.g., toileting, bathing, crossing a small room), whereas the Rosow-Breslau and Nagi measures assess ability to carry out somewhat more demanding but not necessarily crucial activities (e.g., heavy housework, walking one-half mile, pushing large objects). It seems possible, therefore, if the cross-sectional association found in this study reflects an effect of dizziness on disability, that the effect is on ability to perform these more demanding activities; i.e., older persons perceive that episodes of dizziness during these activities might place them at risk of fall or other injury, and therefore they intentionally restrict these activities, but they still retain the ability to carry out the most basic activities. Alternatively, it is possible that persons do not curtail their basic ADLs as measured with the Katz disability scale.

Several strengths of the study increase confidence in its findings. All persons from a geographically defined biracial population were eligible for participation, and high rates of participation were achieved in both the population interview and clinical evaluation. Uniform structured questions regarding the frequency and severity of symptoms were used to define dizziness, and it was defined independent of its effect on daily functioning. Disability was assessed with widely used measures ⁽²³⁾. Finally, the association of dizziness and disability was not the result of confounding from one or more of several variables that could be related to dizziness and disability.

Our study, however, is not without limitations. Our study relies on self-report of dizziness, as well as self-report of disability, as part of a structured interview rather than on a careful evaluation by a skilled neurologist. It is possible, therefore, that some persons with mild dizziness were missed, due to the absence of provoking measures commonly employed in clinical practice. We did not examine the relation of dizziness to direct physical performance measures. It is also possible that persons with dizziness report more problems with ADLs but perform equally well on performance tests. Finally, our study was cross-sectional, making it premature to draw any causal inferences.

Regular episodes of dizziness was a common complaint in this community population of older persons and appeared to be associated with greater occurrence of disability over and above any association with chronic illness, especially in functions involving the lower extremities. Dizziness may be an important factor in continued independent living by older persons. So far, it has received little attention as a risk factor for disability, and physicians should be alerted to its potential impact on daily function in older persons. Future study into underlying conditions that could account for the association between dizziness and disability could have substantial health implications for older persons.

	Acknowledgments

 
This study was supported by grants from the National Institute on Aging (Grants AG11101 and AG10161).

The authors thank Dan Tancredi for his programming assistance and George Dombrowski for data management.

Received December 10, 1998

Accepted October 19, 1999

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