Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

/pdf/clinical-practice-guideline-benign-paroxysmal-positional-4c8374bric.pdf

Clinical practice guideline: Benign paroxysmal positional vertigo

Background: Older adults with type 2 diabetes are more likely to fall but little is known about risk factors for falls in this population. We determined if diabetes-related complications or treatments are associated with fall risk in older diabetic adults. Methods: In the Health, Aging, and Body Composition cohort of well-functioning older adults, participants reported falls in the previous year at annual visits. Odds ratios for more frequent falls among 446 diabetic participants whose mean age was 73.6 years, with an average follow-up of 4.9 years, were estimated with continuation ratio models. Results: In the first year, 24% reported falling; 22%, 26%, 31%, and 30% fell in subsequent years. In adjusted models, reduced peroneal nerve response amplitude (OR=1.50; 95% CI 1.07, 2.12, worst quartile vs others), higher cystatin-C, a marker of reduced renal function, (OR=1.38; 95% CI 1.11, 1.71, for 1SD increase), poorer contrast sensitivity (OR=1.41; 95% CI 0.97, 2.04, worst quartile vs others), and low A1C in insulin users (OR = 4.36; 95% CI 1.32, 14.46, A1C≤6% vs >8%) were associated with fall risk. In those using oral hypoglycemic medications but not insulin, low A1C was not associated with fall risk (OR = 1.29; 95% CI 0.65, 2.54, A1C≤6% vs >8%). Adjustment for physical performance explained some, but not all, of these associations. Conclusions: In older diabetic adults, reducing diabetes-related complications may prevent falls. Achieving lower A1C levels with oral hypoglycemic medications was not associated with more frequent falls, but, among those using insulin, A1C ≤6% increased fall risk.

https://care.diabetesjournals.org/content/diacare/31/3/391.full.pdf

Diabetes-related complications, glycemic control, and falls in older adults

https://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(14)70176-7.pdf

Diabetes in older people: new insights and remaining challenges

BACKGROUND: intensive or very loose glycemic control may contribute to the risk of falls in diabetic patients. However, studies on diabetes mellitus and the risk of falls have yielded conflicting results. Our objective was to investigate the effect of diabetes mellitus on the risk of falls in older adults by conducting a systematic review and meta-analysis. METHODS: the PubMed and Embase databases were searched for relevant studies published until November 2015. Only prospective cohort studies reporting at least age-adjusted risk estimate of falls compared diabetic to non-diabetic individuals were selected. Diabetes mellitus was ascertained by a combination of medical history and laboratory tests or use of anti-diabetic drugs. RESULTS: a total of six studies involving 14,685 participants were identified. The number of falls in diabetic and non-diabetic individuals was 423 of 1,692 (25.0%) and 2,368 of 13,011 (18.2%), respectively. Diabetes mellitus was associated with an increased risk of falls (risk ratio [RR] = 1.64; 95% confidence intervals [CI] 1.27-2.11) in a random-effects model. Subgroup analyses showed that the risk of falls seemed more pronounced among both gender groups (RR = 1.81; 95% CI 1.19-2.76) than among women (RR = 1.52; 95% CI 1.04-2.21). Diabetes increased 94% (RR = 1.94; 95% CI 1.42-2.63) and 27% (RR = 1.27; 95% CI 1.06-1.52) risk of falls in insulin-treated and no-insulin-treated patients, respectively. CONCLUSIONS: this meta-analysis reveals that older adults with diabetes mellitus are associated with greater risk of falls, and this association is more pronounced in insulin-treated patients.© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com. Language: en

Diabetes mellitus and risk of falls in older adults: a systematic review and meta-analysis

In an increasingly obese and ageing population, type 2 diabetes (T2DM) and osteoporotic fracture are major public health concerns. Understanding how obesity and type 2 diabetes modulate fracture risk is important to identify and treat people at risk of fracture. Additionally, the study of the mechanisms of action of obesity and T2DM on bone has already offered insights that may be applicable to osteoporosis in the general population. Most available evidence indicates lower risk of proximal femur and vertebral fracture in obese adults. However the risk of some fractures (proximal humerus, femur and ankle) is higher, and a significant number fractures occur in obese people. BMI is positively associated with BMD and the mechanisms of this association in vivo may include increased loading, adipokines such as leptin, and higher aromatase activity. However, some fat depots could have negative effects on bone; cytokines from visceral fat are pro-resorptive and high intramuscular fat content is associated with poorer muscle function, attenuating loading effects and increasing falls risk. T2DM is also associated with higher bone mineral density (BMD), but increased overall and hip fracture risk. There are some similarities between bone in obesity and T2DM, but T2DM seems to have additional harmful effects and emerging evidence suggests that glycation of collagen may be an important factor. Higher BMD but higher fracture risk presents challenges in fracture prediction in obesity and T2DM. Dual energy X-ray absorptiometry underestimates risk, standard clinical risk factors may not capture all relevant information, and risk is under-recognised by clinicians. However, the limited available evidence suggests that osteoporosis treatment does reduce fracture risk in obesity and T2DM with generally similar efficacy to other patients.

/pdf/obesity-type-2-diabetes-and-bone-in-adults-3cj2l16ite.pdf

Obesity, Type 2 Diabetes and Bone in Adults

Objectives The aims of this study were to determine the incidence of falls in a group of elderly patients with diabetes and to assess for the prevalence of risk factors for falls in this population. Design This is a population-based study with questionnaire-based interviews. Setting The setting for this study was the London District General Hospital outpatient department. Participants Seventy-seven patients with diabetes, aged over 65 years, randomly selected whilst attending for general diabetic annual review. Patients with dementia, blindness, and immobility and those who were unable to give informed consent were excluded from this study. Measurements The incidence of falls in the last 12 months was used. Information was collected on the incidence of hypoglycaemic episodes, the presence of other medical conditions, visual impairment, and peripheral neuropathy, the use of medications and walking aids, and HbA1C and blood pressure control. Results The incidence of falls was 39%. Falls occurred more frequently in female patients and patients of increasing age. Falls occurred more frequently in patients with poor diabetic control [risk ratio (RR)=7.83 (2.948–20.799), χ 2 value=6.422]; patients requiring assistance with mobility: for those mobile with a stick [RR=1.839 (1.048–3.227), χ 2 =4.619]; and those who had previously suffered a stroke [RR=1.929 (1.143–3.257), χ 2 = 4.615]. Conclusion We provide evidence that poorly controlled diabetes and conditions associated with complications of diabetes are associated with an increased risk of falling in older people. We recommend early recognition of the multiple causes of falls in the older diabetic patient and prompt referral of this group of patients to a specialist falls clinic.

Falls as a complication of diabetes mellitus in older people

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Falls as a complication of diabetes mellitus in older people