The priorities of elderly patients suffering from dizziness: A qualitative study

Abstract

Background: Integrating patients' priorities can improve the quality of care in general practice. Therefore, we aimed to learn more about patients' priorities in terms of their dizziness complaints. Methods: Patients were recruited by nine general practitioners. Inclusion criteria were an age of at least 65 years and dizziness due to any cause for any duration, assuring heterogeneity of included patients. Semi-structured interviews of 20 patients (12 women, mean age 79 years) were analysed by qualitative content analysis. Results: Patients were very much focused on finding causes for their dizziness, and some found their doctor had not taken the dizziness problem seriously yet. Each patient expressed own theories of aetiology that sometimes revealed apparent misconceptions of possible causes. Treatment aims were prioritised by patients in different ways (wish for recovery, relief or stabilisation). Some patients had not very well understood common therapy options, and interviewees frequently mentioned what they did on their own to face the dizziness (self-help measures). Remarkably, many patients were very much concerned about different aspects of mobility (fear of falling, loss of independence).

Conclusion: These patients' lack of understanding, their resources and concerns indicate the importance of a patient-centred communication about their dizziness complaints.

Key words::

• General practice
• geriatrics
• signs and symptoms
• dizziness
• patient-centred care
• qualitative research

Introduction

Dizziness is a relatively common complaint in general practice, representing 1 to 2% of all consultations (1). Its prevalence increases with age (2), and about 30% of the population above 65 years suffer from temporary or persistent dizziness (3). Besides the broad aetiology spectrum of peripheral, central (neurological) and general medical causes (4), dizziness, in the elderly, has been described as a multifactorial geriatric syndrome (5), in which the accumulated effect of impairments in multiple systems renders a person vulnerable to situational challenges. Moreover, pharmacotherapy options such as betahistine have not yet shown convincing effectiveness in the treatment of dizzy patients even in well-defined disease entities such as Ménière's disease (6). Therefore, despite its high prevalence, dizziness is often difficult to handle in primary care and it seems not appropriate to concentrate solely on identifying discrete diseases that may be causing the dizziness (5).

A key task for the general practitioner (GP) is to discover the reason for consultation, what the patient wants, and to gain an insight into the patient's thoughts and reasoning; in short, the identification of the patient's agenda (7). It has become a matter of fact that a conversational style that responds to the unique needs of patients on the basis of finding common ground can improve doctors' and patients' satisfaction (8,9), compliance (10), and leads to better health outcomes (11,12). The consideration of patients' perspectives should be part of a routine consultation in primary care. Knowing the spectrum of possible wishes, expectations and concerns in a certain disease or population might provide orientation for the GP. Therefore, in the present study we aimed to explore the priorities, in ways of wishes and expectations, of primary care patients regarding their dizziness complaints.

Patients and methods

This qualitative study used semi-structured interviews to explore the priorities, wishes and expectations of elderly patients suffering from dizziness in a primary care setting.

Recruitment of participating GPs and patients

A total of nine GPs were asked to identify patients with dizziness. The GPs were a convenience sample, selected from a list of academic teaching practices registered with the Institute of General Practice at Hannover Medical School. The practitioners were located in both urban and rural settings in the Hannover region. GPs were asked to identify and contact patients from their practice lists. Inclusion criteria were dizziness due to any cause for any duration and an age of at least 65 years. During the selection process GPs were asked to pay attention to heterogeneity in terms of duration and type of dizziness as well as a balanced distribution of gender. Exclusion criteria were dementia, language problems or terminal diseases. 20 patients, 1 to 4 patients per practice, were contacted and all of them gave written informed consent to participation. The study protocol was approved by the ethics committee of Hannover Medical School (approval no. 4291).

Interviews

The interviews were all conducted by the same interviewer (SD), a fourth year medical student, at the patients' homes. The interviews were conducted according to an interview schedule, the development of which had been thoroughly discussed with colleagues in our department in advance. In addition, the schedule had been pre-tested with a 79-year old woman known personally by SD and suffering from dizziness for several years. After the introductory question (e.g. ‘Could you describe how your dizziness started?’) the following questions were part of the interview schedule. The interviewer first asked the patient to describe the psychological impact of his/her problem: ‘Are you disabled/troubled by your dizziness?’ Then SD asked for expectations (e.g. ‘What do you think your doctor will do about your dizziness?’) (13) and for wishes (e.g. ‘Tell me about your preferences as to what your doctor should do for you in terms of your dizziness?’). Spontaneous statements made by the patient regarding their wishes and needs were taken up and investigated with further questions. In particular, episodes in which a reduced quality of life or suffering played a major role were explored in more depth by the interviewer in terms of the resulting needs.

Qualitative content analysis (14)

First, the interviews were transcribed verbatim according to a standardized procedure. Each interview was then analysed by two of the authors independently and by generating codes for each statement reflecting the patients' priorities. Having established codes in order to condense observations from the data, categories were defined in the inductive, iterative reflection process; categories had not been predetermined. Codes and categories were compared and discussed until a consensus was reached.

Results

Characteristics of patients

Of the patients who were interviewed, 12 were female. The mean age of the patients was 79 years with a range from 66 to 94 years. Half of the patients were from rural areas, and the other half from the city of Hannover. They were either single (n = 2), married (n = 10) or widowed (n = 8). The mean duration of the interviews was 19 minutes (range: from 12 to 30 minutes).

Overview of the main findings

Patients rather named general needs instead of specific wishes or expectations; for instance, they were afraid that dizziness would one day prevent them from staying mobile and independent. Altogether, the analysis process revealed six categories related to patients' priorities in terms of dizziness. These categories are aetiology, management, self-help, mobility concerns, doctor's role and coping strategies; they will be used in the following section headings. Since some codes fit into more than one category there is therefore some overlap.

Aetiology

To know the cause of dizziness was the most frequent wish. Most patients wanted their doctor to do more to uncover the underlying aetiology:

When I have a flesh wound, then I know what it is, or an open wound or a fracture. But this, I don't like the look of it. (P 19)

Why is there equipment, if nothing can be found? (P 02)

In addition, individual patients mentioned the lack of recovery or the exclusion of life-threatening conditions as reasons as to why further diagnostic clarification should be initiated. However, a possible benefit was mentioned as a necessary prerequisite prior to the initiation of a search for the cause of the dizziness (compare management).

Nearly every patient had his or her own theories as to what caused their dizziness, all of which are listed in Table I. In some cases the patients' ideas reflected their understanding of their doctor's explanation concerning the aetiology of dizziness.

Table I. Aetiology of dizziness according to patients representing their ideas relating its causes in non-medical terms. Some of the ideas can instead be considered as contributing or related factors.

Physical	Cardiovascular: blood pressure (hypertension, hypotension), variability of pulse, arrhythmia, myocardial infarction, ‘circulation’ Head/brain: stroke, blood circulation, vascular compression, forgetfulness, ‘susceptible brain currents’ Senses: ear, acute hearing loss, tinnitus, sensitive equilibrium organ, eyes, ‘reaction of the nerves’ Mechanical: otoliths, preceding fall Musculoskeletal: back, vertebral column, cervical spine, neck pain, ‘last vertebra’, sacroiliac joint, pelvis, hip, ‘special case’ hip dysplasia, antecedent rachitis, hardening of muscles, “combination” pelvic/ vertebral column/ neck/ jaw
Emotional	Anxiety, strain/nervousness, anger, overwork, care provider for a relative, illness of relative, death of partner, loneliness
General conditions	Influence flu, weather/climate
Predisposition
Age	Menopause
Side effects of medication	Too high dosage (low blood pressure), too many drugs (low blood pressure)
Other	Multicausal, changing, cause determined on the basis of appropriate treatment, different types of dizziness, differentiation dizziness/balance disorder, confuse fainting/dizziness, dizziness as secondary phenomenon, dizziness as red flag for ‘dangerous’, dizziness/vertigo not dangerous

Patients mentioned not only the causes but also triggers of dizziness. Triggers included bending, as well as rotational or jerky movements of the head, and patients also cited eye irritation, bright light, darkness, uneven ground or hot weather. Such functional descriptions gave insight into the patients' relevant daily limitations.

Management

Three different general treatment goals were frequently mentioned. Some patients believed that their dizziness could be cured. Others wanted ‘relief’ as they believed their symptoms could improve. The third group hoped that the intensity of their symptoms would remain stable or—in other words—not deteriorate.

Beyond these general concepts, desires relating to management were subdivided into three groups corresponding to medication, other treatment wishes and referrals. Treatment wishes often depended on the dizziness aetiology perceived by that particular patient. For instance, some patients believed that drugs acting on blood circulation could be helpful against dizziness, if the presumed cause was the ‘head/brain’ (see Table I).

Further treatment options considered by the patients included different forms of physiotherapy (including massage) as well as complementary medicine (namely acupuncture) or the change of the therapeutic strategy such as reducing the amount of the prescribed drugs:

Again, I accumulated a huge amount of drugs in the last months, by different doctors. Now I try to reduce them, as it is getting too much. I would almost have said, I constantly suffer from delirium. (P 13)

Requests for specialist referrals and further investigation in most cases corresponded to the presumed localization of dizziness. However, according to a few patients, referrals should be restricted (compare aetiology), as they were sometimes considered as a stress-factor. Obviously such patients, due to mobility constraints, felt unable to organize specialist consultations, or they were unwilling to do so because previous experiences had not resulted in therapeutic consequences:

If I consult even more doctors then again each one will know something new or different. That unsettles me even more, I don't want that any more. (P 13)

Nor can they help you. You can't get a new spine. (P 17)

The Ear-doctor did noting but a hearing test. Finally, to me, this seems absurd, very absurd. … if I have different arguments, this has nothing to do with hearing, and I have always said, hearing is not the problem. (P 02)

Self-help

Patients often described their own behaviour during episodes of dizziness (self-management). Measures of self-help consisted of sitting down, lying down, or moving slowly; if triggers were known, they were avoided if possible:

And also the light, irritating the eyes. I don't look into the shop-window, instead I walk through dark or quiet streets. (P 15)

General measures of self-help consisted of different kinds of physical exercises. Stress reduction for the prevention of dizziness such as relaxation exercises were observed as being beneficial. Some patients described social contacts and activities as useful, and they appreciated support from families and friends. However, social retreat as a result of being forced to reduce activities was also commented upon. The existence of fellow-sufferers was mentioned as being helpful for coping with the problem of dizziness (compare coping strategies).

Mobility concerns

Nearly every patient was anxious about his or her mobility, and the prevention of dizziness-related falls and their consequences was frequently described as very important:

If only one didn't have to be so anxious any more. (P 12)

Cause if I fell down, they can take me away immediately. (P 06)

Preservation or improvement of mobility were often mentioned as main needs and reflected the importance of staying independent. This was underlined for instance by mentioning a good infrastructure, e.g. the doctor practicing nearby. patients' needs ranged from retaining the ability to leave their home or to cross the street, to the desire to go on a trip or even to go mountaineering. The priority of living in their own home and not being forced into a care home for the rest of their life was also named. The necessity of staying physically able was of particular relevance to those sufferers that were carers for another relative. Performing a care role was even suggested as being responsible for dizziness (Table I: emotional factor).

Doctor's role

Altogether, patients described attitudes towards their doctors that were mainly characterized by trust and respect. Many of the patients recalled good experiences in the past and underlined their doctor's general efforts. Most patients respected their doctor as an expert. However, some referred to the limits of their doctor's knowledge or sometimes helplessness in terms of dizziness:

He can't know everything. You can't expect him to know everything. (P 07)

Some patients accused their doctor of not doing enough for them, e.g. by stating:

In spite of everything, I have the impression that he hasn't taken the dizziness problem seriously yet. (P 09)

Coping strategies

Concerning coping strategies in terms of dizziness a broad spectrum including more active (full of hope) and more passive characteristics (feelings of powerlessness) became obvious. The most frequently encountered coping strategies with respect to the dizziness could be categorized as follows: accepting, coming to terms, trivializing, regaining control and ignoring. The category ‘coping strategies’ can be considered an overarching theme, influencing some other patients' views. Examples for coping strategies are given in the following section:

So when I'm told it is connected to the vertebra of the neck, then I'll accept it. (P 14; acceptance)

Not any more at my age. I can actually live with it. (P 18; coming to terms)

Others feel even worse. (P 14; regaining control)

Discussion

Finding the cause, at least stabilizing the symptoms and preserving mobility through prevention of falls were important priorities of patients suffering from dizziness. However, some patients felt that diagnostic efforts to find causes should be increased but also balanced with possible benefits and minimize inconvenience for the patient. Surprisingly, patients did not seem very well informed about possible causes of dizziness as well as therapy options. Many patients mentioned their use of self-help strategies. Such strategies including awareness of the patients' psychological impairment and coping strategies are important for the doctor to know about as they indicate the resources of particular patients or certain barriers.

Other studies have shown that dizziness can adversely influence different outcome measures such as the quality of life (15) or depression (1,15). As the risk of falling increases as a result of dizziness (1,16), it was consistent that many patients mentioned falling as a main fear in the present study. Another result, the extent of effort in order to adapt to a situation (self-help measures), has already been described earlier (17). However, for example the lack of understanding by relatives mentioned in that study (17) was not generally a concern revealed in our interviews.

Expectations of patients have been investigated in a number of studies in general practice populations. Expectations were either investigated for pre-defined clinical conditions such as cough (18), procedures such as blood taking (19) or psychosocial service delivery (20), health care conditions such as continuity of care (21) or individual prerequisites such as a different cultural background (22). Some studies considered general expectations regarding the consultation of a GP (7,13,23). In the past, the term ‘expectation’ has led to difficult interpretations of study results (13). A patient can have expectations about how a doctor will behave, but not necessarily desire what is expected. Here, we considered this fact by addressing these different aspects. Another possible application of our study is represented by the fact that we provided a solid basis for the development of a disease specific needs-related questionnaire (24). Researchers often develop such items, and the questionnaires consequently often lack patient-centredness, if patients were not involved in the design process (25).

Both GPs and patients constitute, to some extent, a convenience sample, recruitment of patients relied on GPs and was not fully systematic. It is thus possible that GPs addressed patients they considered ‘suitable’. However, in an explorative, qualitative study not aiming to give a representative picture, this is unlikely to be a major problem. Since diagnoses had not systematically been documented, one limitation of the study is that some important causes or intensities of dizziness leading to specific complaints and needs may not be sufficiently represented. Alternatively, it seemed that the variety of the different patients' perspectives had gradually been reached during the sampling process as themes began to reoccur. Moreover, it has been described in a population of elderly dizzy patients that the effect of different kinds of dizziness on outcomes was negligible (1).

Conclusion

It has been shown that in the GP setting searching only for distinct underlying causes of dizziness does not represent an optimal clinical strategy (5,27). Nevertheless, in elderly patients suffering from dizziness possibly serious events as well as treatable entities such as benign paroxysmal vertigo (26) should be ruled out first. However, a multimodal concept based on the patients' priorities, particularly in geriatric patients with unknown or multifactorial causes of dizziness, could be a promising approach to meet their needs more properly than exclusive disease-orientated strategies.

In our study, patients were very much focussed on knowing the causes of the disorder, and in some cases there was a lack of understanding of the problem possibly indicating poor communication of the health provider. Communication should therefore include comprehensive counselling on the most possible nature of the dizziness, for instance if diagnosed as multisensory deficit or geriatric syndrome. Moreover, a shift of attention to the implications of the health problem such as prevention of falls or individual (coping) strategies seems appropriate. Such a patient-centred approach deserves further evaluation in a prospective approach using a questionnaire (24) based on the present results.

Acknowledgements

The authors would like to thank all participating patients and GPs. This study was funded by the German Ministry of Education and Research (grant no. 01GK0611).

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.