Ménière’s disease in the older patient

Treatment of Ménière’s disease remains multifaceted in the older population. With an unpredictable disease pattern, the significant dizziness, hearing loss and tinnitus experienced can cause significant social isolation. As the population ages,² there will be an increasing need to manage Ménière’s disease holistically in order to minimise the effect the disease has on individuals’ quality of life. Whilst the management has remained consistent over recent years, we will discuss the different aspects of the disease with an update on more recent developments.

What is Ménière’s disease?

Ménière’s is an episodic and fluctuant disease with a chronic course. Presentation is a combination of intermittent episodes of vertigo, tinnitus, aural fullness and sensorineural hearing loss. Patients often present to their GP with a vague description of their symptoms frequently emphasising one dominant symptom. Such an ambiguous presentation can make the diagnosis of Ménière’s disease difficult and often leads to a delay in diagnosis. The differential diagnosis for dizziness is particularly broad in itself.

We have come a long way in managing Ménière’s disease since it was first described in 1861 by Prosper Ménière. His initial work proposed that balance as well as hearing was centrally controlled by labyrinthine organs. This was dismissed for over 40 years until it was histologically proven by Hallpike and Portman.³ However, 155 years on, it remains a disease that presents many challenges.

The UK prevalence of Ménière’s disease is thought to be 0.24%, with higher rates reported in older age.⁴ Both sexes are equally affected and peak onset is estimated to be in the 4th and 5th decade.¹ Uneri et al⁵concluded that Ménière’s disease was the fourth commonest cause of vertigo, dizziness and imbalance in a retrospective review of 601 older individuals seen in two tertiary neurotology clinics. It was found to affect 12.5% of subjects.

Clinical features of Ménière’s disease

Transient unilateral low frequency sensorineural hearing loss with episodes of vertigo should alert clinicians to a likely diagnosis of Ménière’s. There remains no pathognomic test to isolate a diagnosis. If access to audiometry is unavailable then this may best be sought in secondary care. All such patients with unilateral sensorineural hearing loss and/or tinnitus should also have an MRI of the internal auditory meatus to screen for vestibular schwannoma, which presents in a similar way. Whilst the disease often starts as a unilateral hearing loss it has been known to become bilateral in up to 50% of individuals who have had the disease for over 30 years.⁶ Associated signs and symptoms include nausea, vomiting and horizontal nystagmus.

The vague symptoms experienced by individuals allows for a wide range of diagnoses to be considered. Cochlear symptoms, such as the hearing loss, often occur initially and are soon followed by vertigo.⁷ Episodes of vertigo typically last over 20 minutes although can be experienced for several hours. This timeframe of symptoms suggests against a diagnosis of Benign Paroxysmal Positional Vertigo. Prior to an attack individuals often experience a feeling of fullness in the ear as well as tinnitus. This helps differentiate from migraine.

What is particularly distressing for individuals is the unpredictable nature of the disease. Attacks happen at random and often show no symptoms in between. Acute attacks can be managed in the short term with vestibular suppressants including phenothiazines as well as antihistamines and benzodiazepines.⁷

At diagnosis attacks usually occur about five times a year however this decreases as the disease progresses. Reassurance of this is essential when diagnosing individuals. The elderly population is also particularly at risk of falls. Whilst Ménière’s does not result in a loss of consciousness it is particularly important to evaluate an individuals risk of falls. Sudden unexpected falls can occur and are termed ‘an otolithic crisis of Tumarkin’.

Rehabilitation and multidisciplinary team management

An appreciation of the complexity of the disease is required in order to help support individual patients. No cure is available but there is opportunity to improve an individual’s quality of life.

Multidisciplinary team management is even more crucial when managing the condition in older patients. Occupational therapists are essential to enabling older individuals to live in a safe home environment, evaluating the individual’s safety if they suffer from hearing loss as well as dizziness and imbalance. Input at an early stage can reduce unnecessary risks in the home environment. For example, fire safety is essential; individuals with hearing loss unable to be alerted to danger via noise must be provided with alternative methods.

The impact hearing loss can have on an older individual must not be underestimated. It may result in a loss of self-confidence, leading to an increase in social isolation. Lack of confidence to attend a gathering for fear of crossing the road or inability to hear clearly a conversation can lead to individuals being vulnerable to loneliness.

Loneliness is thought to affect up to 40% of the over 65 years old population with 15% of individuals reporting this to be a frequent occurrence. The statistics dramatically rise with individuals over the age of 80 years old.⁸ Depression and anxiety are also commonly associated with Ménière’s disease.^7,9 Patients should be offered hearing aids and be considered for hearing therapy for tinnitus and vestibular physiotherapy to compensate for vestibular insufficiency.

Dizziness and imbalance puts older patients at a much greater risk of falling which then has further consequences in terms of hospital admissions and mortality rates.¹⁰ The uncertainty of relapses provides further distress to individuals who may plan for such an episode and can have a huge impact on their day-to-day confidence. Exploring an individual’s thoughts and concerns about dizziness and imbalance can allow for strategies to be discussed and confidence to be built in order to improve the patient’s perception of the disease.

Lifestyle changes and Ménière’s disease

Lifestyle changes are essential in the management of the older individual dealing with Ménière’s disease. Salt restriction in particular has been found to be of benefit.³ Other triggers such as caffeine, alcohol, cheese and chocolate have been suggested as being beneficial in migrainous vertigo,⁷ the symptoms mirroring that of Ménière’s disease. Ghavami et al¹¹ built upon this idea, suggesting that Ménière’s disease may in fact be an ‘atypical variant of migraine’ and so should be treated similarly. Reducing cardiovascular risk factors may also indirectly have an effect on the management of Ménière’s through reducing co-morbidities.

Surgical management

Surgical management of Ménière’s remains a debated discussion. Since the majority of patients end up having a sustained period of quiescence only a minority need to even be considered for surgical intervention. Endolymphatic sac surgery is considered first-line, particularly in the older patient, with Sood¹² reporting it to be an effective long-term treatment in 75% of patients.

Labyrinthectomy, vestibular nerve section and cochleossaculotomy are all options in cases where conservative management or endolympthatic sac surgery has been unsuccessful. However each operation carries a high risk of permanent hearing impairment and chronic disequilibrium and so are rarely undertaken.¹³

DVLA implications

Ménière’s disease is listed as a declarable disease by the DVLA¹⁴using the DIZ1 form for severe dizziness. Whilst each case is individually evaluated, further questioning includes whether an individual has experienced disabling attacks, has any warning symptoms or has ever experienced a blackout. Many people have early warnings that they are likely to have an episode and so are able to take appropriate actions such as not driving.

If not declared to the DVLA the individual risks a fine of up to £1,000. It is also important to advise patients to inform the company insuring the vehicle being driven.¹⁵ Declaring a diagnosis of Ménière’s disease in itself is not enough to have an individuals licence removed unless they suffering with – sudden and disabling attacks of vertigo’.

Of those individuals who are restricted from driving due to Ménière’s disease, their licences will be reviewed again once – satisfactory control of symptoms has been achieved’.¹⁶ In particular drivers of heavy vehicles are likely to have their licence removed until being symptom free a year after their official diagnosis.¹⁷ However, the intermittent nature of the disease makes it difficult to assess. Being unable to drive can isolate individuals who were previously very independent. This compiled with the additional risk of social isolation in older age must be addressed within general practice in order to minimise its effect.

Conclusions

Approaching Ménière’s disease in the older population requires an appreciation of the wider impact it can have on an individual. Practical approaches to ensure safety as well as reducing social isolation with therapeutic interventions can result in improved quality of life.

Dr Poppy P Mackay, BSc (Hons) Gerontology MBBS

Mr Joseph G Manjaly, consultant otologist, auditory implant & ENT surgeon, University College London Hospitals

Dr Simon CM Croxson, Consultant Physician in Geriatric and Diabetic Medicine

References

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