Dizziness is a debilitating symptom that affects 10-30% of middle-aged and older people. People with dizziness often report poor health outcomes including reduced quality of life, depression, fear of falling and falls. With advancing age, dizziness becomes more prevalent and has more causes. Hence, it is difficult for clinicians to establish objectively a diagnosis and deliver effective interventions. Although some studies have used multifaceted therapies to improve dizziness, they have been limited by small sample sizes and short follow-up periods or have focused on a select sample of people (e.g. those with vestibular deficits) thus preventing generalisability of the results.

The aim of our randomised-controlled trial was therefore to investigate the effects of a six-month tailored multifactorial dizziness intervention compared with no treatment on dizziness-related impairment, dizziness symptoms frequency, stepping and gait in middle-aged and older people with self-reported dizziness. Three-hundred and five people aged 50 years and older (mean (SD) age: 67.8 (8.3) years, 62% women) living in the community volunteered to participate in the trial. To participate, people had to report having experienced at least one significant episode of dizziness in the past 12 months but not receiving treatment for dizziness at the time of trial entry, have no cognitive impairment or degenerative neurological condition and be able to walk 20m without difficulties with or without a walking aid. The study protocol was registered on the Australia New-Zealand Clinical Trial Registry prior to recruitment began (ACTRN 12612000379819) and a protocol paper was also published that details the study methodology. The baseline assessment included a comprehensive set of tests and questionnaires: vestibular function and balance, leg strength, vision, cardiovascular function, medical and dizziness history, medications, quality of life, anxiety and depression. A team of geriatricians, vestibular physiologist, vestibular physiotherapist, clinical psychologist, exercise physiologists and study coordinator met fortnightly to advise one or more therapy based on the participants’ individual results at baseline. Then, participants were randomly allocated to a no-intervention control group (n = 151) or a 6-month multifaceted individualised intervention (n=154). The intervention groups’ participants whose results did not show any objective deficit (21% [n=32]) were not provided with a therapy but instead were sent a letter outlining that their results were within normal range.

The interventions are as follows: 1) Vestibular rehabilitation (35% [n = 54]): delivered by a vestibular physiotherapist and consisting of canalith repositioning manoeuvre(s) in the case of Benign Paroxysmal Positional Vertigo or, one or more session(s) of vestibular rehabilitation (gaze stabilisation and balance exercises) supplemented by home-based exercises, in the case of other peripheral vestibular conditions. 2) Cognitive-behavioural therapy (19% [n = 29]): for participants with anxiety, depression and /or fear of falling. The therapy was delivered via an online or booklet-based program and supplemented with regular telephone support from a registered psychologist. There were five sessions and a weekly homework assignment, over eight weeks. 3) Home-based exercise programme (24% [n = 37]): The Otago program to train balance and lower-limb strength. The program was delivered over six months by an exercise physiologist who prescribed the exercises over 6 visits to the intervention participants’ homes. Participants were encouraged to exercise at least 3 times a week for 30 minutes each time. 4) Medical management (40% [n = 62]): this intervention included, for simple cases, letters to the participants’ General Practitioner to recommend medication review, advice on blood pressure management. For complex cases, such as participants with multiple complex comorbidities and high fall risk, referrals to an outpatient Falls Clinic staffed by a Geriatrician and a Physiotherapist were organised.

All participants were also asked to provide monthly reports on their dizziness episodes during the 6-month follow-up period.

The primary outcomes were: 1) the dizziness handicap inventory which assesses emotional, physical and functional aspects of dizziness (rated between 0-56 with higher scores representing higher burden), 2) frequency of dizziness episodes during the 6-month follow-up, 3) choice-stepping reaction time, requiring participants to step forward, to the side or backwards as fast as possible onto computerised mat panels corresponding to stimuli displayed on a monitor screen in front of them , and 4) gait variability, assessed as step time variability (standard deviation) during 3 walking trials at self-selected speed.

Secondary outcome measures included a composite measure of fall risk (the Physiological Profile Assessment), orthostatic hypotension, dynamic balance, fear of falling, anxiety, depression, neuroticism. All primary and secondary outcome measures were assessed at baseline and re-assessment, six months later. Generalised linear models controlling for baseline performance were used to compare between-group performance in the continuous primary and secondary outcome measures at re-assessment. Negative binomial regressing adjusting for length of follow-up were used to compared dizziness episodes frequency between groups. All analyses were conducted with an intention-to-treat approach. Compared to the control group, there was a small (4-point) but clinically meaningful greater reduction on the dizziness handicap inventory for participants in the intervention group at 6 months.

Thus, the multifaceted tailored intervention was effective in reducing dizziness-related impairment. The multifaceted intervention did not, however, affect balance, gait or the frequency of dizziness episodes. The individual interventions were effective in managing the specific aspects of dizziness that they targeted: falls risk (composite physiological function) for the home-based exercise programme, anxiety for the cognitive-behavioural therapy, and balance for the vestibular rehabilitation therapy.

Our findings suggest that prescribing middle-aged and older people a multifaceted individualised intervention of evidence-based therapies directly targeting their deficits relative to vestibular disorders, poor balance, anxiety and/or inappropriate medications significantly reduces dizziness-related impairment. It does not appear, however, to improve physical function - even though the exercise program did.

Our findings provide a health care model whereby community-based dizziness clinics could use existing healthcare services to implement tailored and multifaceted dizziness interventions to reduce dizziness handicap in middle-aged and older people.