Prevention of oral diseases for the older person (Part 2).

Older adults often experience poorer levels of oral health than younger adults, especially if they have become dependent on a third party to support their daily oral care routine. However, the deterioration of oral health does not need to be a part of the ageing process. Most oral diseases are largely preventable with the daily removal of dental plaque that forms on teeth and dentures, using a fluoride toothpaste, eating a healthy diet and reducing any tobacco consumption. The dental team have a duty of care to ensure that older people receive evidence-based oral health preventative advice tailored to the individual, taking into account individual risk factors that can increase with age. This can include the clinical application of topical fluoride and minimally invasive dentistry. Older people at an increased risk of poor oral health include those with cognitive conditions, physical impairments and certain medical conditions. Care home residents face particular barriers to attaining a satisfactory standard of oral care which are discussed herein. Good oral health preventative routines must be established early after the diagnosis of progressive chronic conditions and will help to prevent the need for dental intervention later in life when treatment can be more difficult to tolerate. Inclusion of oral health prevention within health policy and legislation is necessary to improve the oral health for older people living in all health and care settings.

Prevention of oral diseases for the older person (Part 1).

Older adults often experience poorer levels of oral health than younger adults, especially if they have become dependent on a third party to support their daily oral care routine. However, the deterioration of oral health does not need to be a part of the ageing process. Most oral diseases are largely preventable with the daily removal of dental plaque that forms on teeth and dentures, using a fluoride toothpaste, eating a healthy diet and reducing any tobacco consumption. The dental team have a duty of care to ensure that older people receive evidence-based oral health preventative advice tailored to the individual, taking into account individual risk factors that can increase with age. This can include the clinical application of topical fluoride and minimally invasive dentistry. Older people at an increased risk of poor oral health include those with cognitive conditions, physical impairments and certain medical conditions. Care home residents face particular barriers to attaining a satisfactory standard of oral care which are discussed herein. Good oral health preventative routines must be established early after the diagnosis of progressive chronic conditions and will help to prevent the need for dental intervention later in life when treatment can be more difficult to tolerate. Inclusion of oral health prevention within health policy and legislation is necessary to improve the oral health for older people living in all health and care settings.

Motorist disorientation syndrome; clinical features and vestibular findings.

BACKGROUND: Motorist Disorientation Syndrome (MDS) is a term used to describe patients who primarily experience symptoms of dizziness/disorientation whilst in a motor car [21]. There is uncertainty about the relevance of vestibular dysfunction and whether this disorder could instead be a visually induced dizziness (VV) or part of a functional disorder similar to Persistent postural perceptual dizziness (PPPD). OBJECTIVE: We present the largest case-series to date of patients whose main complaint is of illusions of movement of self/vehicle when driving, characterising features of this group. METHODS: 18 subjects underwent detailed clinical assessment including validated questionnaires. A subset of patients underwent vestibular function testing. RESULTS: Mean onset age was 42 years, with no gender preponderance. Mean symptom duration was 6.39 years and was significantly longer in women. 50% reported moderate or severe handicap. Vestibular abnormalities were found in 60% of subjects tested. There was no significant difference in VSS total score between those with MDS and vestibular migraine (p = 0.154) with both having higher scores than healthy controls (p = 0.002, 0.000 respectively). CONCLUSIONS: MDS represents consistent symptoms, with high symptom burden, comparable to vestibular migraine. Vestibular deficits were not a consistent feature and similarities to VV and PPPD exist.

Gwên am Byth: a programme introduced to improve the oral health of older people living in care homes in Wales - from anecdote, through policy into action.

Introduction and context This paper describes how research and evidence influenced Welsh Government policy to fund a programme (Gwên am Byth - A Lasting Smile) with the aim of improving the oral health of older people living in care homes. It describes how collaborative multi-agency working supported development and delivery of the programme. The context was policy in Wales. This included the Welsh Government response to the public inquiry into Mid Staffordshire NHS Foundation Trust, the report into care homes by the Older People's Commissioner for Wales, and the Welsh Government Health and Care Standards for Wales which include a standard relating to oral health. The aim was to introduce a programme, Gwên am Byth, to support 'oral hygiene and mouth care for older people living in care homes through the development of a consistent all-Wales approach'; this aligns with contemporaneous NICE guidelines.Materials and methods Recurrent Welsh Government funding was identified to support a community dental service (CDS) led programme (Gwên am Byth). A multi-professional team led the development and testing of materials and resources to support the programme, underpin training for care home staff, and allow them to assess and provide safe mouth care for residents. A Welsh Health Circular was published to ensure a consistent all-Wales approachResults New staff have been employed in all health boards, and an assessment tool has been developed and is in the final stages of validation. All Wales resources have been published for induction, training and education, and to support care home staff. Evidence-based care plans have been produced which link to individual residents' risks and needs. There is close working with other health and social care professionals. By March 2019, half of all care homes were participating in the programme to a greater or lesser extent. Over 5,000 health and care staff had been trained, and over 5,600 residents had been assessed and supported with delivery of an individual mouth care plan. There has been positive feedback from care home staff, residents, carers and CDS staff, although barriers to delivery remain.Discussion This paper describes programme delivery in the four years since Gwên am Byth began. The drivers for change are described and the need to influence Welsh Government policy decisions when funding was available. The authors discuss issues which can impact on the pace of change, and ways in which health and care staff can effectively work together to implement improvements.Conclusions Starting with a blank page, a national programme has been established with the aim of improving the oral health of older people living in care homes in Wales. The paper describes the lessons learnt in implementing the programme and notes that Welsh Government has recognised the value of Gwên am Byth by committing to double the recurrent programme funding.

Severe antithrombin deficiency in pregnancy: Achieving adequate anticoagulation.

Antithrombin deficiency is identified as one of the most potent risk factors for venous thromboembolism during pregnancy. Therapeutic low molecular weight heparin is recommended, but it can be difficult to attain sufficient anticoagulation since low molecular weight heparin requires antithrombin to exert its anticoagulant effect. We carried out a multicentre case-series assessing the dose of low molecular weight heparin required to achieve therapeutic anti-activated factor X levels in pregnant women with antithrombin deficiency. We assessed 27 pregnancies in 18 women with severe antithrombin deficiency, which we defined as an antithrombin level of <0.55 IU/ml (with or without prior venous thromboembolism) or an antithrombin level < 0.8 IU/ml and a personal history of venous thromboembolism. Our data illustrate the need for high doses of low molecular weight heparin to achieve therapeutic anti-activated factor X levels (average 20,220 IU/day). All pregnancies ended in live birth (excluding one elective termination), although intrauterine growth restriction occurred in five (18%).

Effect of Developmental Binocular Vision Abnormalities on Visual Vertigo Symptoms and Treatment Outcome.

BACKGROUND AND PURPOSE: Customized vestibular rehabilitation incorporating optokinetic (OK) stimulation improves visual vertigo (VV) symptoms; however, the degree of improvement varies among individuals. Binocular vision abnormalities (misalignment of ocular axis, ie, strabismus) may be a potential risk factor. This study aimed to investigate the influence of binocular vision abnormalities on VV symptoms and treatment outcome. METHODS: Sixty subjects with refractory peripheral vestibular symptoms underwent an orthoptic assessment after being recruited for participation in an 8-week customized program incorporating OK training via a full-field visual environment rotator or video display, supervised or unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state. As no significant effect of OK training type was noted for any variables, data were combined and new groups identified on the basis of the absence or presence of a binocular vision abnormality. RESULTS: A total of 34 among 60 subjects consented to the orthoptic assessment, of whom 8 of the 34 had binocular vision abnormalities and 30 of the 34 subjects completed both the binocular function assessment and vestibular rehabilitation program. No significant between-group differences were noted at baseline. The only significant between-group difference was observed for pre-/post-VV symptom change (P = 0.01), with significant improvements noted only for the group without binocular vision abnormalities (P < 0.0005). Common vestibular symptoms, posturography, and the FGA improved significantly for both groups (P < 0.05). DISCUSSION AND CONCLUSIONS: Binocular vision abnormalities may affect VV symptom improvement. These findings may have important implications for the management of subjects with refractory vestibular symptoms.Video Abstract available for insights from the authors regarding clinical implication of the study findings (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A115).

Balance, falls risk, and related disability in untreated vestibular schwannoma patients.

Background Many vestibular schwannoma (VS) patients complain of balance dysfunction; however, validated standardized assessments are lacking. The relative contribution of imbalance and factors like anxiety to disability is unknown. Because imbalance significantly affects quality of life in this group and vestibular rehabilitation may improve outcomes, determining the severity of balance dysfunction is important to understand long-term rehabilitation needs. Aim To assess functional balance (Vertigo Symptom Scale-Vertigo [VSS-VER] and Functional Gait Assessment [FGA]) and the relative contribution of symptom severity (VSS-VER), ambulant posture (FGA), and anxiety symptoms (Vertigo Symptom Scale-Anxiety [VSS-SA]) to disability in untreated patients. Methods Patients not exposed to surgery completed the VSS, Vertigo Handicap Questionnaire (VHQ), and FGA. VSS scores were compared with migrainous vertigo (MV) patients, a mixed neuro-otological group, and healthy controls. Results A correlation was found between decreased FGA and increasing age (r = - 0.35; p < 0.01), female sex (r = 0.42; p = 0.001), increasing handicap (r = - 0.55; p < 0.001), and symptom severity (r = - 0.52; p < 0.001). In 12 of 21 patients (57%) > 60 years of age the FGA score was ≤ 22 suggesting increased falls risk. VSS-VER scores were higher than in healthy controls (p < 0.001) but lower than MV (p < 0.001) and mixed neuro-otology controls (p < 0.001). VSS-SA scores in VS patients with balance symptoms were higher than normal controls (p < 0.05) and correlated with handicap (r = 0.59; p < 0.001) and symptom severity (r = 0.74; p < 0.001). After controlling for age and sex, the VSS-VER, VSS-SA, and FGA explained 47% of the variation in VHQ scores. Conclusion Older VS patients are at significant risk of falls. Balance symptoms are more severe than in healthy controls but less than other neuro-otological patients. Balance symptom severity, anxiety symptoms, and ambulant posture were significant contributors to disability and should be the focus of vestibular rehabilitation strategies.

Randomized trial of supervised versus unsupervised optokinetic exercise in persons with peripheral vestibular disorders.

BACKGROUND: Visual vertigo (VV) symptoms improve only when customized vestibular rehabilitation (VR) integrates exposure to optokinetic stimuli (OK). However, equipment is expensive, biweekly sessions are not standard practice, and therapy is often unsupervised. METHODS: A controlled, parallel-group comparison was made of patients' responses to an 8-week customized program incorporating OK training via a full-field visual environment rotator (group OKF) or DVD (an optokinetic disc or drum rotating at 40° or 60° s(-1)), supervised (group OKS) or unsupervised (group OKU). A total of 60 participants with chronic peripheral vestibular symptoms were randomly allocated to 1 of 3 treatment groups: group OKF (n = 20) or OKS (n = 20), in which participants attended weekly sessions and were prescribed customized home exercises incorporating the DVD, or group OKU (n = 20) who practiced customized exercises and the DVD unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state. RESULTS: No significant between-group differences were present at baseline or at post interventions. All groups showed significant within-group improvements for vestibular (ie, lightheadedness), VV, and autonomic symptoms (P < .05). Posturography and FGA improved significantly for groups OKF and OKS (P ≤ .01) as well as anxiety scores for group OKS (P < .05) and depression for group OKF (P < .05). Migraine significantly affected VV improvement (migraineurs improved more; P = .01). The drop-out rate was 55% for group OKU and 10% for each supervised group (P < .01). CONCLUSIONS: The DVD may be an effective and economical method of integrating OK into VR. However, rehabilitation should be supervised for greater compliance and improvements, particularly for postural stability and psychological state.

Accessing escalators: a central vestibular disorder after posterior fossa tumor removal.

About 20% of childhood tumors originate within the central nervous system. Progress in assessment and treatment of these lesions has led to improved survival rates. We describe a patient with a posterior fossa ependymoma who despite a remarkable recovery following treatment has been frustrated by difficulty in using escalators. Such symptom selectivity is explained by specific vertical visuomotor and high-frequency vestibular deficits disrupting the execution of this complex motor act.

Sensory dysmodulation in vestibular migraine: an otoacoustic emission suppression study.

OBJECTIVES/HYPOTHESIS: To seek evidence of sensory dysmodulation in auditory brainstem reflexes in patients with vestibular migraine by studying suppression of otoacoustic emissions (OAEs) by contralateral noise. STUDY DESIGN: A prospective case-control study. METHODS: The authors measured contralateral suppression of OAEs in a group of 33 interictal patients with definite vestibular migraine (migrainous vertigo) according to the strict diagnostic criteria of Neuhauser (2001), and compared them with 31 nonmigrainous controls with matching age and sex distributions. Suppression values were then compared with previously published departmental normative data. In three patients, recordings were compared in the ictal and interictal states. RESULTS: OAE suppression was reduced in 11/33 patients, and 3/31 controls (P = .022 chi(2) test). Binary logistic regression analysis confirmed that the presence of vestibular migraine was significantly associated with abnormal suppression, but no such relationship was seen for symptoms of phonophobia or disease duration. The amplitude of variability between the ictal and interictal state was out of the normal range in 2 out of the 3 patients in whom such recordings were made. CONCLUSIONS: These results provide support for the notion of interictal auditory sensory dysmodulation in an as yet unidentified subset of migraineurs with vestibular migraine.

Genetic and functional characterisation of the P/Q calcium channel in episodic ataxia with epilepsy.

Mutations in CACNA1A, which encodes the principal subunit of the P/Q calcium channel, underlie episodic ataxia type 2 (EA2). In addition, some patients with episodic ataxia complicated by epilepsy have been shown to harbour CACNA1A mutations, raising the possibility that P/Q channel dysfunction may be linked to human epilepsy. We undertook a review of all published CACNA1A EA2 cases and this showed that 7% have epilepsy--representing a sevenfold increased epilepsy risk compared to the background population risk (P<0.001). We also studied a series of 17 individuals with episodic ataxia accompanied by epilepsy and/or clearly epileptiform electroencephalograms (EEGs). We screened the entire coding region of CACNA1A for point mutations and rearrangements to determine if genetic variation in the gene is associated with the epilepsy phenotype, and measured the functional impact of all missense variations on heterologously expressed P/Q channels. We identified two large scale deletions and two new missense mutations in CACNA1A. When expressed, L621R had little detectable effect on P/Q channel function, while the other missense change, G540R, caused an approximately 30% reduction in current density. In nine patients we also identified the previously reported non-synonymous coding variants (E921D and E993V) which also resulted in impairment of P/Q channel function. Taken together, 12 of the 17 patients have genetic changes which decrease P/Q channel function. We conclude that variants in the coding region of CACNA1A that confer a loss of P/Q-type channel function are associated with episodic ataxia and epilepsy. Our data suggest that functional stratification of all variants, including common polymorphisms, rare variants and novel mutations, may provide new insights into the mechanisms of channelopathies.

Vertigo as a migraine trigger.

BACKGROUND: It is reported in some individual patients that vestibular stimuli can trigger migraine attacks. This study used a case-control design to examine systematically the hypothesis that vertigo induced by vestibular stimulation (rotation/caloric testing) can act as a specific migraine trigger. METHODS: A total of 123 new patients attending neuro-otology or neurology clinics were studied with questionnaires and physician interview to ascertain migraine history according to International Headache Society criteria. A total of 79 who underwent rotation/caloric vestibular testing (test group) were compared with 44 control patients in whom no such testing was carried out (control group). The principal outcome measure was the occurrence of a migraine attack within 24 hours of exposure to vestibular stimulation. RESULTS: Of those participants with a past history of migraines, 19/39 (49%) of the test group experienced a migraine in the study time window, compared with 1/21 (5%) of the control group. Binary logistic regression analysis confirmed that vestibular testing was associated (p < 0.05) with migraine attacks. CONCLUSIONS: The results indicate that induced vertigo can act as a migraine trigger, a finding with implications for the diagnosis of patients with episodic vertigo and migraine headache. While such patients may well have basilar migraine or migrainous vertigo, alternatively, another disorder causing episodic vertigo (e.g., benign paroxysmal positional vertigo or Ménière disease) may be triggering migraine headaches.

The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness.

Patients with chronic vestibular dysfunction often experience visually-induced aggravation of dizzy symptoms (visual vertigo; VV). The Situational Characteristics Questionnaire (SCQ), Computerized Dynamic Posturography or Rod and Frame Test (RFT) are used to assess VV symptoms. This study evaluates whether correlations exist between these three tests, their ability to identify patients with VV and whether emotional state correlates with VV symptoms. Tests were completed by 20 normal controls (Group NC), 20 patients with vestibular dysfunction plus VV (Group VV) and 13 without VV (Group NVV). Additionally, the Vertigo Symptom Scale (VSS-V) was applied to quantify general, non-visually induced vertigo (dizziness, lightheadedness and/or spinning) and imbalance. Autonomic (VSS-A) and psychological symptoms (Hospital Anxiety and Depression questionnaire; HAD) were also assessed. With the SCQ 100% of Group VV scored outside normal ranges and scores differed significantly between Group VV and both Groups NC and NVV. RFT values were not significantly different between groups; only 15% of patients scored outside normal ranges. Posturography scores were abnormal for 50% of patients; significant differences were noted between Groups NC and VV for composite scores and ratios 3/1, 4/1, 5/1 and 6/1 (indicative of abnormal sensory re-weighting). There were no correlations between the three data sets in patients. Anxiety and depression scores significantly differed between Groups NC and VV but not between patient groups; this indicates that psychological symptoms may be present in either patient group. The SCQ can be used to corroborate an initial clinical diagnosis of VV and quantify its severity in patients with vestibular dysfunction. Posturography data suggested patients with VV have a sensory re-weighting abnormality. The rod and frame test results and posturography findings agree less with the clinical diagnosis of VV. Psychological symptoms may need to be addressed.

Deficient auditory interhemispheric transfer in patients with PAX6 mutations.

PAX6 mutations are associated with absence/hypoplasia of the anterior commissure and reduction in the callosal area in humans. Both of these structures contain auditory interhemispheric fibers. The aim of this study was to characterize central auditory function in patients with a PAX6 mutation. We conducted central auditory tests (dichotic speech, pattern, and gaps in noise tests) on eight subjects with a PAX6 mutation and eight age- and sex-matched controls. Brain magnetic resonance imaging showed absent/hypoplastic anterior commissure in six and a hypoplastic corpus callosum in three PAX6 subjects. The control group gave normal central auditory tests results. All the PAX6 subjects gave abnormal results in at least two tests that require interhemispheric transfer, and all but one gave normal results in a test not requiring interhemispheric transfer. The left ear scores in the dichotic speech tests was significantly lower in the PAX6 than in the control group. These results are consistent with deficient auditory interhemispheric transfer in patients with a PAX6 mutation, which may be attributable to structural and/or functional abnormalities of the anterior commisure and corpus callosum, although the exact contribution of these two formations to our findings remains unclear. Our unique findings broaden the possible functions of PAX6 to include neurodevelopmental roles in higher order auditory processing.

Simulator based rehabilitation in refractory dizziness.

UNLABELLED: Patients with chronic vestibular symptoms are common in neurological practice but the most effective treatment remains an open question. The purpose of our study was to conduct a controlled, between-group comparison of patients' responses to a customised exercise regime (Group C, for customised) versus treatment additionally incorporating simulator based desensitisation exposure (Group S, for simulator) integrating whole-body or visual environment rotators. Forty chronic peripheral vestibular patients who had previously undergone conventional vestibular rehabilitation without notable improvement were randomly assigned into Group C or S. Individuals attended therapy sessions twice weekly for eight weeks and were provided with a customised home programme. Response to treatment was assessed at four-week intervals with dynamic posturography, vestibular time constants, and questionnaires concerning symptoms, symptom-triggers and emotional status. At final assessment posturography and subjective scores had significantly improved for both groups, although Group S showed greater improvement. A statistically significant improvement for visual vertigo symptom scores was noted only for Group S (p < 0.01; total improvement 53.5 %). Anxiety and depression levels significantly decreased for both groups; improvements were significantly correlated particularly to improvements in visual vertigo (SCQ) (p < 0.01; r = 0.53 and r = 0.57, respectively). Significant differences were noted between groups (p = 0.02) for posturography scores. Vestibular time constants showed no notable change in either group. CONCLUSIONS: Both groups improved but exposure to simulator motion gave overall better results. These effects were also observed in psychological symptoms and partly relate to simulator effects on visual vertigo symptoms. Visual motion and visuo-vestibular conflict situations should be incorporated in the rehabilitation of patients with refractory dizziness.

An unusual case of X-linked adrenoleukodystrophy with auditory processing difficulties as the first and sole clinical manifestation.

X-linked adrenoleukodystrophy (X-ALD) is characterized by demyelination that is associated with a deficient beta-oxidation of very long chain fatty acids. We report the unusual case of a male adult with X-ALD who was diagnosed at the age of 26 by a brain MRI performed because his brother had been diagnosed with a rapidly deteriorating form of X-ALD. His sole symptom was hearing difficulties in the presence of a normal audiogram since childhood. He has remained stable for seven years. Central auditory testing in our patient revealed severe deficits in several auditory processes. These findings correlated with involvement of the auditory pathway at the level of the trapezoid body, and posterior corpus callosum in particular, on his brain MRI. This case highlights not only the need for thorough audiological investigation of the patient who complains of hearing difficulties in the presence of a normal audiogram, but also that audiological investigations could be of value in the phenotypic evaluation of cases with adrenoleukodystrophy.

Effectiveness of the particle repositioning maneuver in benign paroxysmal positional vertigo with and without additional vestibular pathology.

OBJECTIVE: We compared the treatment outcome of patients with benign paroxysmal positional vertigo unassociated with additional objective evidence of vestibular pathology (BPPV) with that in patients who did demonstrate additional vestibular pathology on standard neurotologic testing (BPPV+). STUDY DESIGN: An open, retrospective, record-based study. SETTING: Specialized outpatient dizziness clinic. PATIENTS AND METHODS: We reviewed 58 unselected patients with a Dix-Hallpike test demonstrating positioning nystagmus characteristic of BPPV, who were treated during the past 4 years with the particle repositioning maneuver. Before treatment, all patients underwent detailed clinical and laboratory neurotological testing. MAIN OUTCOME MEASURES: The treatment outcome was assessed with regard to persistence of symptoms and the presence of positioning nystagmus on Dix-Hallpike testing. RESULTS: Seventy-eight percent of patients with BPPV no longer demonstrated characteristic positional nystagmus after 1 particle repositioning maneuver compared with 71% of patients with BPPV+ (p = 0.56) who did, whereas 13% of the BPPV and 14% of the BPPV+ group required more than 1 treatment to be rendered nystagmus negative on Dix-Hallpike testing (p = 0.89). However, 14% of patients with BPPV remained dizzy, compared with 63% patients from the BPPV+ group, despite a negative Dix-Hallpike test after treatment (p = 0.0018). Patients with horizontal canal paresis (n = 15) had a better outcome than patients with central vestibular dysfunction (n = 7, p = 0.006). Etiologic factors seemed to affect outcome-patients with idiopathic BPPV and those with a preceding acute vestibular neuronitis had a tendency for a better outcome than BPPV patients with any other etiology (p = 0.058). CONCLUSION: Our study demonstrates that patients with BPPV+ do not have a worse prognosis with respect to resolution of positional nystagmus, on performing the particle repositioning procedure, compared with patients with uncomplicated BPPV. However, they do suffer incomplete resolution of symptoms because of a coincidental anterior or horizontal canal dysfunction and otolithic or central vestibular dysfunction. It appears that the majority of patients with BPPV+ need further vestibular rehabilitation after the particle repositioning maneuver.