title: Impairment reduction in older dizzy people in primary care: study protocol for a cluster randomised controlled trial.
abstract: BACKGROUND
  The management of dizziness in older patients is primarily diagnosis-oriented. However, in 40% of older patients with dizziness, GPs are not able to identify an underlying cause, and a number of common underlying causes of dizziness cannot (or hardly) be treated. In this study we will investigate the effectiveness of a prognosis-oriented approach in the management of dizziness in older patients. This prognosis-oriented approach comprises identification of patients at risk for chronic dizziness with persistent impairment by identifying risk factors for an unfavourable course of dizziness. Patients at risk for chronic dizziness with persistent impairment will be offered treatment addressing the identified modifiable risk factors.
  
  
  METHODS
  This study will be performed in primary care. An intervention study and a validation study will be conducted in a three-arm cluster randomised design. In the intervention study we will investigate a risk factor guided multi-component intervention. The risk factor guided intervention includes: (1) medication adjustment in case of three or more prescribed fall-risk-increasing drugs, (2) stepped care in case of anxiety disorder and/or depression, and (3) exercise therapy in case of impaired functional mobility. The primary outcome measure is dizziness-related impairment, which will be assessed with the Dizziness Handicap Inventory. Secondary outcome measures are quality of life, anxiety disorder and depression, use of fall-risk-increasing drugs, dizziness frequency, fall frequency, and healthcare utilization.
  
  
  CONCLUSIONS
  This study is, to date, the first study that will investigate the effectiveness of a prognosis-oriented approach for reducing dizziness-related impairment in older people in primary care. Offering treatment that addresses identified modifiable risk factors to patients at high risk for chronic dizziness is unique. The pragmatic design of this study will enable evaluation of the outcomes in real-life routine practice conditions. An effective intervention will not only reduce dizziness-related impairment, but may also decrease healthcare utilization and healthcare costs. The previously developed risk score that will be validated alongside the intervention study will enable GPs to identify patients at high risk for chronic dizziness with persistent impairment.
  
  
  BACKGROUND
  Netherlands Trial Register (identifier: NTR4346), registration date 15 December 2013.
authors.affiliation: Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands. stam.h@vumc.nl.
authors.forename: Hanneke
authors.initials: H
authors.lastname: Stam
authors.affiliation: Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands. j.vanderwouden@vumc.nl.
authors.forename: Johannes C
authors.initials: JC
authors.lastname: van der Wouden
authors.affiliation: Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands. he.vanderhorst@vumc.nl.
authors.forename: Henriëtte E
authors.initials: HE
authors.lastname: van der Horst
authors.affiliation: Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands. o.maarsingh@vumc.nl.
authors.forename: Otto R
authors.initials: OR
authors.lastname: Maarsingh
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control*; D000367:Age Factors; D000368:Aged; D002908:Chronic Disease; D002985:Clinical Protocols; D004185:Disability Evaluation; D004244:Dizziness / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D005081:Exercise Therapy; D005260:Female; D006801:Humans; D008297:Male; D054539:Medication Therapy Management; D008603:Mental Health; D051346:Mobility Limitation; D009426:Netherlands; D019338:Polypharmacy; D011320:Primary Health Care; D011788:Quality of Life; D012107:Research Design; D018570:Risk Assessment; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome