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)

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

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?

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

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): 2263-9

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)

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”

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) 6 - 48 months 15 (18.1) 2 - 10 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) 6 - 48 months 15 (18.1) 2 - 10 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”

Results (2) Intervention effects Primary outcome: dizziness-related impairment No significant differences between intervention group and control group DHI difference -0.69 [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 -0.48 [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.

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)

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

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

Questions? stam.h@vumc.nl