The development of a new questionnaire for cognitive complaints in vertigo: the Neuropsychological Vertigo Inventory (NVI)

Abstract

Vertigo patients frequently complain of emotional and associated cognitive problems, yet currently, there is no satisfactory questionnaire to measure these associated problems. In the present paper, we propose a new internet-based Neuropsychological Vertigo Inventory (NVI; French) that evaluates attention, memory, emotion, space perception, time perception, vision, and motor abilities. The questionnaire was created using four steps: (1) open interviews with patients suffering from vertigo; (2) semi-structured interviews with an analysis grid to quantify and define the various cognitive and emotional problems reported by the patients; (3) a first version of an internet questionnaire tested on 108 vertigo participants; and (4) the selection of subscale items using principal component analyses (PCA). From the development phase, the revised NVI was composed of seven subscales, each with four items (28 items). In the validation phase, Cronbach’s alphas were performed on the revised NVI for total and each subscale score, and to test extreme groups validity, the analyses of covariance (ANCOVAs) taking into account age were performed between 108 vertigo and 104 non-vertigo participants. The Cronbach’s alphas showed good to satisfactory coefficients for the total and for all subscale scores, demonstrating acceptable reliability. The extreme groups validity analyses (ANCOVAs) were reliable for the total scale and for four subscales. Supplementary analyses showed no effect of hearing difficulties and an inverse age effect for attention and emotion subscales, with reduced problems with increased age in the vertigo participants. The NVI provides a useful new questionnaire to determine cognitive and emotional neuropsychological complaints that are associated with vertigo.

Full text

1 23
European Archives of Oto-Rhino-
Laryngology
and Head & Neck
ISSN 0937-4477
Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-016-4135-x
The development of a new questionnaire
for cognitive complaints in vertigo: the
Neuropsychological Vertigo Inventory
(NVI)
Emilie Lacroix, Naima Deggouj, Samuel
Salvaggio, Valérie Wiener, Michel Debue
& Martin Gareth Edwards

1 23
Your article is protected by copyright and
all rights are held exclusively by Springer-
Verlag Berlin Heidelberg. This e-offprint is
for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at link.springer.com”.

OTOLOGY
The development of a new questionnaire for cognitive complaints
in vertigo: the Neuropsychological Vertigo Inventory (NVI)
Emilie Lacroix
1,2,3
•Naima Deggouj
1,2
•Samuel Salvaggio
3
•Vale
´rie Wiener
1,2
•
Michel Debue
1
•Martin Gareth Edwards
2,3
Received: 24 February 2016 / Accepted: 3 June 2016
ÓSpringer-Verlag Berlin Heidelberg 2016
Abstract Vertigo patients frequently complain of emo-
tional and associated cognitive problems, yet currently,
there is no satisfactory questionnaire to measure these
associated problems. In the present paper, we propose a
new internet-based Neuropsychological Vertigo Inventory
(NVI; French) that evaluates attention, memory, emotion,
space perception, time perception, vision, and motor abil-
ities. The questionnaire was created using four steps: (1)
open interviews with patients suffering from vertigo; (2)
semi-structured interviews with an analysis grid to quantify
and define the various cognitive and emotional problems
reported by the patients; (3) a first version of an internet
questionnaire tested on 108 vertigo participants; and (4) the
selection of subscale items using principal component
analyses (PCA). From the development phase, the revised
NVI was composed of seven subscales, each with four
items (28 items). In the validation phase, Cronbach’s
alphas were performed on the revised NVI for total and
each subscale score, and to test extreme groups validity, the
analyses of covariance (ANCOVAs) taking into account
age were performed between 108 vertigo and 104 non-
vertigo participants. The Cronbach’s alphas showed good
to satisfactory coefficients for the total and for all subscale
scores, demonstrating acceptable reliability. The extreme
groups validity analyses (ANCOVAs) were reliable for the
total scale and for four subscales. Supplementary analyses
showed no effect of hearing difficulties and an inverse age
effect for attention and emotion subscales, with reduced
problems with increased age in the vertigo participants.
The NVI provides a useful new questionnaire to determine
cognitive and emotional neuropsychological complaints
that are associated with vertigo.
Keywords Dizziness Vertigo Balance Questionnaire 
Neuropsychological function
Introduction
Vertigo is a common symptom that occurs in various
central and peripheral pathologies, and has been reported to
affect up to 48.3 % of the north-eastern France population
[1]. The term vertigo is usually defined as a feeling that
things are spinning or moving around [2–5]. However, in
the general population, this term is frequently associated
with symptoms in dizziness (feeling of being light-headed
or ‘swimmy’), visual perception, and/or balance. All these
symptoms could be sustained by overlapping cerebral
networks, notably the vestibular system [6–8]. Damage to
this system could lead to vertigo/dizziness/imbalance, but
also to more general cognitive or emotional complaints.
For example, abnormal emotional processing and vertigo
symptoms have been frequently reported in Me
´nie
`re’s
disease (MD) [9–12], leading to a profound deterioration of
patients’ quality of life [13].
&Emilie Lacroix
emile.lacroix@uclouvain.be
1
Department of Oto-Rhino-Laryngology and Head and Neck
Surgery, Cliniques universitaires Saint-Luc, Universite
´
Catholique de Louvain, Brussels, Belgium,
10, Avenue Hippocrate, 1200 Bruxelles, Belgique
2
Institute of Neuroscience (IONS), Universite
´Catholique de
Louvain, Louvain-la-Neuve, Belgium
3
Institute for Research in Psychological Science (IPSY),
Universite
´Catholique de Louvain, Louvain-la-Neuve,
Belgium
123
Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-016-4135-x
Author's personal copy

In addition to the frequent association between vertigo
and emotional disorders, clinician reports suggest that
vertigo patients also frequently complain of associated
cognitive symptoms, including attention, memory, and
space perception. For example, Grimm et al. [14] reported
evidence of memory, disorientation, anxiety, and mood
problems in patients with perilympathic fistula associated
with mild cranio-cervical trauma. Since in this paper,
research has either followed-up the study by evaluating
cognitive disorders (with behavioural experiments) or by
evaluating emotional disorders (with questionnaires) asso-
ciated to vestibular/vertigo disorders. In these latter studies,
the majority of the questionnaires used to evaluate emo-
tional disorders have particularly focused on anxiety and
depression symptoms.
The role of anxiety in vertigo has been intensively
investigated, showing that the percentage of vertigo
patients (and dizziness) with anxiety can vary from 13.3 %
[15] to 28.3 % [16]. Anxiety is considered to be either an
indirect cause of vertigo in vestibular disorders, or the
consequence of the vestibular affection [17–19]. In support
of the latter, the evolution of anxiety presented by some
patients with vestibular neuritis has been explained, at least
partially, by a specific anxious personality style (such as
insecure personality type) [20]. The psychological distress
(anxiety and depression) associated with vertigo is more
linked to the severity of the vertigo (evaluated by the
Dizziness Handicap Inventory—DHI) compared to the type
of disease causing the vertigo (Me
´nie
`re’s disease,
vestibular neuritis, etc.) [21].
For behavioural research, the study by Grimm et al. [14]
reported a series of cognitive symptoms in patients with
perilymph fistula associated with mild cranio-cervical
trauma. These patients showed significant impairments in
cognitive tasks, such as block design and paired associate
learning despite having normal intellectual functioning.
Following this original work, research focused on the
potential links between visuo-spatial cognition and
vestibular function. Specific spatial navigation path deficits
have been reported in patients with compared to without
vestibular deficits [22–26]. Brandt et al. [25] showed that
patients with acquired chronic bilateral vestibular loss from
neurofibromatosis type 2 had more difficulties to find an
immersed platform in a virtual variant of the Morris water
task if the patient had to remember the location of the
platform compared to when the platform was always pre-
sent during the task. These results were correlated to hip-
pocampal atrophy (16.9 %), demonstrating a relation
between vestibular impairment and memory. However, the
performance on the classical Weschler Memory Scale did
not show any significant difference between patients and
control participants, suggesting that the impairment was
specific to spatial memory in the navigational task.
A related field of research has focused on measuring the
influence of vestibular stimulation on cognitive perfor-
mance in healthy (non-vestibular) participants. For exam-
ple, Galvanic vestibular stimulation has been shown to
modify attention on a line bisection task, creating a bias
towards the side of stimulation [27]. In addition, rotatory
vestibular stimulation has been shown to alter self-centred
mental imagery, demonstrating a role of vestibular function
in perspective [28].
Despite the growing body of the literature about the role
of vestibular function in visuo-spatial cognitive processing,
few studies have investigated (in a single instrument), the
subjective cognitive complaints of vertigo patients. Instead,
most questionnaires that have investigated vertigo have
evaluated physical symptoms and their impact on patient
quality of life (mostly from an emotional point of view).
The DHI is the most commonly used questionnaire in
vertigo. Its original internal consistency (Cronbach’s Alpha
from 0.72 to 0.89) and test–retest reliability [interclass
correlation coefficient (ICC) from 0.72 to 0.97] are con-
sidered as established [29]. However, the validity has been
investigated only with item-total correlation instead of
factor analysis [30,31]. Furthermore, there are only a few
questions about cognitive complaints (difficulty of reading
and difficulty to concentrate).
Other questionnaires have used general patient quality
of life not specific to vertigo or dizziness [30]. In Table 1,
we summarise the different questionnaires that have been
used in research for evaluating vertigo/dizziness symptoms
and their impact on quality of life and/or on the emotional
statute of the patients. None of these questionnaires eval-
uated specific cognition disorders that could be linked to
vestibular impairments.
In the present paper, we propose a new questionnaire,
for the first time specifically evaluating physical, emo-
tional, and cognitive complaints in one single inventory.
Our aim was to provide a new accurate clinical tool to
refine the diagnosis of vertigo patients. As a newly devel-
oped instrument, our new questionnaire must show some
psychometrics qualities. Reliability could be evaluated
through the reproducibility/repeatability of participants’
score after a certain period (test–retest reliability), in
another form of the questionnaire (parallel form reliabil-
ity), or it could also be evaluated through the internal
consistency of the items within each subscale [32]. This
last option was used to confirm each of the subscales and
the total score of our new questionnaire using Cronbach’s
alpha analyses. In addition, validity (does our new ques-
tionnaire measure what it intends to measure) could be
demonstrated using face, content, criterion-related, con-
struct, concurrent, predictive, discriminant, convergent, or
extreme groups validity analyses [32]. In this study, we
choose to explore extreme groups validity to show that
Eur Arch Otorhinolaryngol
123
Author's personal copy

participants with vertigo had a higher score of complaints
compared to control participants, and thus, that our new
questionnaire is valid for the specific vertigo population.
We first present the methods and results for the develop-
ment of the NVI questionnaire, followed by the methods
and results for the extreme groups validity of the NVI
questionnaire.
Development of the NVI questionnaire
Methods
Participants, design, and procedure
The NVI questionnaire was created using a four-step pro-
cess. First, we conducted open interviews on patients suf-
fering from vertigo (following various vestibular disorders,
such as vestibular neuritis, MD, etc.) who consulted in the
Ear-Nose and Throat Department of our clinic. Second,
from these open interviews, we created a grid of general
question categories and we performed a semi-structured
interview with a new group of 14 vertigo patients to define
different subcategories of cognitive complaints. We for-
mulated 17 general question categories using ‘‘before/
after’’ questioning, such as ‘‘how was your memory before
your balance difficulties?’’, with supplementary sub-ques-
tions used to facilitate patient responses if they could not
find a spontaneous answer. The 17 question categories
consist of difficulties in: (1) general perception of balance;
environment perception in (2) dynamic or (3) static con-
ditions; (4) fine motor skills; (5) spatio-temporal orienta-
tion; (6) two-dimensional motor abilities; (7) three-
dimensional motor abilities; (8) two-dimensional repro-
duction abilities; (9) three-dimensional reproduction abili-
ties; (10) two-dimensional mental imagery abilities; (11)
three-dimensional mental imagery abilities; (12) mental
rotation; (13) planning; (14) attention; (15) memory; (16)
emotions, and (17) other complaints (17). In the third step,
we created a first version of the questionnaire by selecting
the seven most relevant question categories that we
renamed as subscales of cognitive complaints based on the
previous steps. These subscales were Space Perception;
Time Perception; Attention; Memory; Emotion; Vision;
and Motor. Each subscale was composed of six items
making a total of 42 (for example, ‘‘I read slowly’’ in
Vision Subscale. To ensure that each question was clearly
understandable, we pre-tested the first original version of
the questionnaire on naı
¨ve control participants (25) and
corrected any unclear items.
Table 1 Classification of commonly used questionnaires and their related domains in vestibular studies
Instrument (abbreviation name) Domains evaluated References
Physical
symptoms
Daily activities/
quality of life
Emotion Cognition
Activities-specific Balance Confidence (ABC) X [33]
Activity of Daily Living Questionnaire (ADLQ) X [34]
Dizzy Factor Inventory (DFI) X X X 2 questions [35]
Dizziness Handicap Inventory (DHI) ?short form X X X 2 questions [29]
European Evaluation of Vertigo (EEV) X [36]
Falls efficacy scale X [37]
Medical outcomes study short form 36 (SF-36) X X X [38]
Meniere’s Disease Patients-Oriented Severity Index (MD-POSI) X X X 2 questions [39,40]
Modified falls efficacy scale (MFES) X [41]
Patient Heath Questionnaire (PHQ-9) X X 1 question [42]
Prototype Questionnaire (PQ) X X X 2 questions [43]
Situational Characteristics Questionnaire (SitQ) X [44]
UCLA Dizziness questionnaire (UCLA-DQ) X X X [45]
Vestibular Activities and Participation (VAP) X X 1 question [46]
Vertigo-Dizziness-Imbalance Questionnaire (VDI) X X X 2 questions [47]
Vertigo Handicap Questionnaire (VHQ) X X [48]
Vertigo Symptom Scale (VSS) ?short form X 1 question [49]
Vestibular Disorders of Daily Living Scale (VADL) X [23,50]
Vestibular Rehabilitation Benefit Questionnaire (VRBQ) X X X 1 question [51]
Eur Arch Otorhinolaryngol
123
Author's personal copy

The final step of the questionnaire development
involved new participants completing the questionnaire
online. The participants rated each item using a five-point
Likert scale (1, never; 2, rare; 3, sometimes; 4, very often;
5, permanently). This was selected to reduce the time
needed to complete the questionnaire and to provide the
patient with an opportunity to make a non-dichotomous
response. We added a ‘‘Distractor’’ subscale to analyse
extreme groups validity. We expected to observe signifi-
cant differences between vertigo and non-vertigo partici-
pants in the target subscales, but no difference in the
distractor subscale. Differences for this last subscale would
suggest a higher level of non-specific complaints in vertigo
participants. In addition to the online questionnaire, addi-
tional demographic questions were given to the partici-
pants. These included questions asking for the sex, age,
associated health conditions, etc., of the participant.
The questionnaire was sent to vertigo participants
through patient associations in Belgium using the internet
platform Limesurvey
Ò
(https://www.limesurvey.org). One
hundred and eight vertigo participants completed the
questionnaire. Vertigo participants were mostly female
(69) and right-handed (94). Their mean age was
54.3 ±15.2 years. The participants were recorded as suf-
fering from vertigo due to their positive answer to the
question, ‘‘Do you suffer from vertigo?’’. More than the
half of the participants (58) indicated that they suffered
from vertigo for more than five years, and that they
experienced vertigo several times a day (52). The majority
of the participants (78) also suffered from associated
deafness or hard of hearing (D/HOH). Due to the online
administration of the questionnaire, the exact degree of
hearing loss was uncertain or unknown. Of the D/HOH
participants, some indicated that they wore the conven-
tional hearing aids (21) or cochlear implant (33).
The procedure of the online questionnaire first involved
a description of the questionnaire and a consent by the
participant to participate in the study. After consent was
given, the demographic questions were given to the par-
ticipant. This was followed by the main NVI questionnaire.
The items of the questionnaire were randomly assigned by
the internet platform to each participant. All procedures
performed in studies involving human participants were in
accordance with the ethical standards of the institutional
and/or national research committee and with the 1964
Helsinki declaration and its later amendments or compa-
rable ethical standards.
Analyses
We conducted principal component analyses (PCA) on
each pre-defined subscale and on the total score to refine
the NVI. Analyses were performed with R commander
[52,53]. We determined the items most correlated to the
cognitive subscale and to keep homogeneity, we chose to
remove the two items less represented for each subscale.
This included the same reduction process for the distractor
subscale. After this reduction, the final total number of
items was 28, and the total score for the NVI was 140
without the distractors items (four for each of the seven
subscales).
Results for structural validity and internal
consistency
Table 2shows the results of the PCA for the percentage of
variance for each subscale, before and after the item
reduction for vertigo participants. The results show that
most of the selected subscales after item reduction (to four
items) explained more than 50 % of variance. The sub-
scales of time perception and motor appeared to be more
heterogeneous, with less internal consistency than the other
subscales (matched to the distractor subscale). Cronbach’s
alpha confirmed good internal consistency for the total
scale (without distractors), and for the subscales ‘‘space
perception’’, ‘‘attention’’, and ‘‘memory’’ (Cronbach alpha
coefficients at or higher than 0.8). A satisfactory internal
consistency was demonstrated for two more of the seven
subscales (Cronbach alpha coefficients greater than 0.7 for
‘‘emotion’’ and ‘‘vision’’). Consistently with the PCA, the
items for the ‘‘time perception’’ and ‘‘motor’’ and for the
distractor subscales were lower, but acceptable for sub-
scales containing only four items as suggested by Bradley
[32] (Cronbach alpha coefficients below 0.7) (see Table 2).
Table 2 Percentage of variance explained before and after PCA and
Cronbach’s alpha on vertigo participants (after PCA)
Categories Percentage of
variance explained
(N=108)
Cronbach’s
alpha
(N=108)
Before
PCA
a
After
PCA
b
After PCA
b
Space perception 53.23 65.31 0.82
Time perception 37.19 46.88 0.52
Attention 51.15 62.33 0.80
Memory 54.92 63.39 0.80
Emotion 47.07 60.58 0.77
Vision 42.16 57.03 0.75
Motor 29.26 40.85 0.50
Distractor 30.21 42.63 0.55
Total (without distractors) 0.88
a
Before items reduction
b
After items reduction
Eur Arch Otorhinolaryngol
123
Author's personal copy

Extreme groups validity of the NVI
Methods
Participants, stimuli, and procedure
To analyse the extreme groups validity, we used the same
data from the sample of 108 vertigo participants and data
collected from 104 additional control participants (mean
age 43 ±13.2 years). The control group was mostly
female (77) and right-handed (83). They were recorded as
control participants due to their negative response to the
question, ‘‘Do you suffer from vertigo?’’. Some of the
participants (21) suffered from associated deafness or hard
of hearing (D/HOH). Due to the online administration of
the questionnaire, the exact degree of hearing loss was
uncertain or unknown. Some of the 21 D/HOH participants
wore conventional hearing aids (5) or cochlear implants
(4). The comparison between age for the 104 control and
108 vertigo participants was significant [F(1.210) =32.7,
p=0.000; with younger control participants] and age was
taken into account as a covariate in the analyses. The
stimuli and procedure was the same as that described in
step four in the previous section.
Data analysis
We performed analyses of covariance (ANCOVA) analy-
ses using SPSS-22 (SPSS Inc., Chicago, IL). Analyses were
corrected with Bonferroni-adjusted pvalues for multiple
testing, and the factor of age was added as a covariate for
the total score and for all subscales with vertigo and
D/HOH as independent variables. Partial eta-squared (g
p
2
)
was used to measure effect size [0.0099, 0.0588, and
0.1379 for small, medium, and large effects, respectively,
as recommended by Cohen [54] and Richardson [55]. The
age effect was also analysed with Spearman’s rho corre-
lation coefficient.
Supplementary analyses evaluated the role of hearing
difficulties in the sample. This was included, as it is well
known that vestibular impairments (that can lead to ver-
tigo) are frequently associated with hearing difficulties
(odds ratio of 1.9–2.3 [56,57]. It has also been shown that
D/HOH persons might develop different attentional abili-
ties (e.g., enhanced peripheral visual attention) [58–60].
Results for extreme groups validity and age effect
After controlling for age, we found a significant extreme
groups validity of having vertigo (e.g., difference between
vertigo and control participants) for four of the seven
subscales: motor subscale, F(1.207) =30.51, p=0.000,
and g
p
2
=0.128; vision subscale, F(1.207) =31.90,
p=0.000, and g
p
2
=0.134; attention subscale,
F(1.207) =20.43, p=0.000, and g
p
2
=0.090; and emo-
tion subscale, F(1.207) =23.54, p=0.000, and
g
p
2
=0.102). There was also a significant effect for the
total score, F(1.207) =27.90, p=0.000, and g
p
2
=0.119].
Participants with vertigo had higher scores (more com-
plaints) on all subscales and on the total scale (see
Table 3). As expected, we found no significant effect of
vertigo for the distractor subscale, but more surprisingly,
three other subscales did not show significant effects:
memory, F(1.207) =3.379, p=0.067, and g
p
2
=0.016,
space perception, F(1.207) =0.720, p=0.397, and
g
p
2
=0.003, and time perception, F(1.207) =1.45,
p=0.230, and g
p
2
=0.007) subscales.
The ANCOVA analyses showed significant main effects
of age for attention F(1.207) =8.71, p=0.03, and
g
p
2
=0.04 and emotion subscales, F(1.207) =21.56,
p=0.000, and g
p
2
=0.094. Spearman’s rho correlation
coefficient analyses showed an inverse correlation between
age and total NVI score for vertigo participants
(r
s
=-0.303 and p=0.001). This effect was also present
for the subscales of attention, emotion, and vision
(r
s
=-0.271 and p=0.005; r
s
=-0.473 and p=0.000;
and r
s
=-0.303 and p=0.001, respectively). There were
no significant correlations for the non-vertigo group (see
Table 4for the complete results). The supplementary
analyses of D/HOH showed no significant effects.
Discussion
This present paper provides a new questionnaire, the NVI,
specifically adapted to measure the self-reported associated
neuropsychological cognitive (attention, memory, emotion,
space perception, time perception, vision, and motor)
problems in patients suffering from vertigo. The ques-
tionnaire was created in four steps, and the final revised
version was composed of seven subscales, each with four
items (28 items). Reliability of the NVI was performed
using Cronbach’s alphas and this showed a good to satis-
factory internal consistency for the total score and for five
subscales. The remaining two subscales were less consis-
tent (time perception and motor subscale), suggesting that
the items were perhaps less well-defined. However, for
subscales of four items, it has been suggested that a lower
Cronbach’s alpha value is acceptable [32]. Furthermore,
our choice to use PCA on each predetermined subscale was
justified by the questionnaire novelty. We used focus group
and semi-structured patient interviews to classify items into
subscales based on common content, and then to reduce
item number by PCA. As the time perception and motor
subscales were defined from the original patient interviews
in the development phase of the NVI, we were concerned
Eur Arch Otorhinolaryngol
123
Author's personal copy

by the fact that some specific complaints could be missed.
For example, a patient with a higher score on these par-
ticular items and subscales would probably express a
higher degree of difficulties in these domains. Excluding
these responses could lead to the potential to miss these
difficulties. This is why we propose to keep the two sub-
scales in the final version of the NVI. However, future
studies should determine whether keeping the two less
valid subscales is worthwhile. Content validity of the items
composing these subscales (and the other subscales) could
be re-examined through specific method, such as the use of
Content Validity Index [61].
The extreme groups validity of the NVI was evaluated
using ANCOVAs that tested age as a covariate. The results
showed significant differences between vertigo and non-
vertigo participants for the total and four subscale scores.
The three subscales that did not show significant differ-
ences between participants with and without vertigo were
time perception, memory, and space perception. For the
subscale of time perception, it is possible that the lack of
extreme groups validity could be explained by the previous
demonstrated lower internal validity. For the space per-
ception subscale, the absence of significant difference was
surprising. The Cronbach’s alphas showed a good internal
consistency (0.821), and we would have expected a sig-
nificant difference between vertigo and non-vertigo par-
ticipants based one the previous literature (see [62] for an
extensive review). There are a number of explanations that
can explain the lack of effect for the space perception
subscale. One potential explanation could be linked to the
item specificity that composed this subscale. Here, and
based on the interviews conducted during the development
of the NVI, items were linked to bodily orientation in space
(‘‘I have a bad orientation sense’’; ‘‘I have difficulty to find
my way on a map’’ etc.). Items in the ‘‘vision’’ subscale
were linked to visual attentional abilities and visual acuity
(‘‘I read slowly’’, ‘‘I experience visual fatigue in computer’’
etc.). This difference in these two subscales refers to dif-
ferent cognitive concepts, one oriented on body perception
in space, and the other oriented on visual attention
involving vision process/visual acuity. It might be that
these two subscales are both associated with what has been
defined in the literature as visual spatial cognition, but here,
separated by two scales.
A second explanation is that spatial perception (or
navigational abilities) might be truly altered in patients
with vestibular disorders [22,24,63–65], but that the
impairment could be rapidly compensated, or reduced
through vestibular rehabilitation [66]. Furthermore, spatial
perception may be more difficult to self-evaluate because
of the temporary characteristic of their affection in vertigo.
A final explanation could be that the literature reporting
spatial difficulties are particularly true for defined
vestibular pathologies rather than for subjective vertigo
symptoms. Spatial perception disorders may, therefore, be
Table 3 Average score (M) and standard deviation (SD) for NVI total and subscales scores for each participant sample
Scales Vertigo
(N=108)
Non-vertigo-participants
(N=104)
Deaf/HOF participants
(N=99)
Non-Deaf/HOF participants
(N=113)
Space perception 8.89 (3.97) 8.81 (3.46) 8.62 (4.00) 9.05 (3.46)
Time perception 6.14 (2.16) 5.96 (1.51) 5.95 (2.14) 6.14 (1.60)
Attention 10.27 (3.57) 8.78 (2.88) 9.55 (3.65) 9.53 (3.03)
Memory 9.80 (3.65) 8.71 (2.64) 9.57 (3.62) 9.00 (2.85)
Emotion 11.47 (3.52) 9.85 (2.61) 10.84 (3.50) 10.53 (2.94)
Vision 9.82 (3.62) 7.58 (2.32) 8.99 (3.59) 8.49 (2.91)
Motor 11.21 (3.24) 8.99 (2.64) 10.43 (3.09) 9.85 (3.20)
Distractor 14.06 (3.12) 14.70 (2.53) 14.21 (3.19) 14.51 (2.53)
All items (except distractors) 67.61 (15.69) 58.67 (12.30) 63.94 (16.49) 62.59 (13.17)
Values are expressed as M (SD)
Table 4 Spearman rank correlation among participants’ age and NVI
total and subscales scores
Age of Vertigo
participants
(N=108)
Age of non-vertigo
participants
(N=104)
Space perception -0.128 -0.026
Time perception -0.090 -0.002
Attention -0.271* -0.187
Memory 0.070 -0.025
Emotion -0.473** -0.094
Vision -0.303** -0.015
Motor -0.116 -0.134
Distractor -0.174 0.010
Total -0.303** -0.106
Values are Spearman correlation coefficients: ** correlation is sig-
nificant at 0.001 level (two-tailed); * correlation is significant at the
0.005 level (two-tailed)
Eur Arch Otorhinolaryngol
123
Author's personal copy

less prevalent in subjects responding to our questionnaire
than in patients diagnosed with a defined vestibular
disorder.
More research is needed to determine if a difference
truly exists between vestibular and vertigo patients. This
could be disentangled in future studies by analysing the
subscale specifically in patients with complete or partial
vestibular disorders in comparison to patients with vertigo
from another origin.
In addition to the main study, we also observed inter-
esting age effects. It is already well known that with
increased age, there are increased frequencies of vertigo
and vestibular disorders [67–69], as well as reduced cog-
nition and increased emotional problems [70–74]. Based on
these findings, we might have expected that increased age
might have led to more complaints in the NVI (higher
scores). However, on the contrary, we observed an inverse
age effect, where increased age was related to a reduction
in cognitive complaints in the vertigo patients (particularly
for the attention and emotion subscales). One potential
explanation for this effect could be linked to the fact that
younger people tend to be more active, and so the impact of
vertigo and their cognitive associated complaints might be
more detrimental than for less active people. It has been
reported that vertigo patients have a tendency to stay at
home and avoid some activities that can increase their
discomfort [48,75]. Younger people may not always the
same opportunity to stay at home, and so they may be more
exposed to higher frequencies of physical and cognitive
discomfort than adults of increased age.
In conclusion, the NVI has been developed in response
to the lack of instruments to detect neuropsychological
problems associated with vertigo. Our goal was to create a
new inventory that could detect specific subjective
impaired cognition in vertigo patients, and provide a sim-
ple to use, reliable clinical tool that is quick to administer.
With the NVI, we have created a bridge between the
classical questionnaires that investigate the emotional side
of vertigo, and the behavioural experiments that focus on
the cognitive difficulties associated with vertigo. Our
results shed light on vertigo patients subjective (self-re-
ported) problems in a more extended view than that of the
previous questionnaires that mostly assessed emotional
symptoms and/or quality-of-life (see Duracinsky et al. for
an extensive review [30]). We also bring new information
that could lead to a better comprehension of vestibular-
associated disorders. We show that cognitive processes are
more perceived as dysfunctional by vertigo patients
themselves, and importantly, we can no longer limit the
participant’s complaints to the uncontrollability and
unpredictability of the vertigo, such as is the case with
critical life events [76].
As a potential new clinical instrument, some comple-
mentary research is needed to complete this first study. For
example, a forward–backward translation procedure is
necessary to make the original NVI available in other
languages. This rigorous procedure guarantees that the
original meanings of each item are preserved. Future
research should also evaluate test–retest effects and con-
vergent validity with other scales. If the NVI is to be used
for a diagnosis of vertigo/vestibular associated cognitive
problems, it will be necessary to determine a cutoff score.
This could be used to determine which patients with ver-
tigo might benefit from a more comprehensive neuropsy-
chological assessment. This direction might be critical, as
the difficulties described by these patients might lead to
vertigo patients requiring a higher use of health care [16]
and leading to substantial costs for society [77]. Cognitive
rehabilitation therapies should be developed for vertigo
patients, as it has been shown that cognitive deficits may
persist even after complete vertigo recovery [76].
Acknowledgments This study was funded by the Saint-Luc hospital
Foundation. The authors would like to specially thank Ce
´dric Taverne
for his helpful comments regarding the data analyses, the members of
the E.N.T department and the Centre d’audiophonologie of Cliniques
Universitaires Saint-Luc for their comments and feedback on the
questionnaire development, and for all of the participants of the study.
Compliance with ethical standards
Funding This study was funded by the Cliniques universitaires
Saint-Luc Foundation (no grant number).
Conflict of interest All the authors have no competing interests to
report.
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards (Clinical-Trial-Number NCT02533739).
Informed consent Informed consent was obtained from all individ-
ual participants included in the study.
References
1. Bisdorff A, Bosser G, Gueguen R, Perrin P (2013) The epi-
demiology of vertigo, dizziness, and unsteadiness and its links to
co-morbidities. Front Neurol 4:29. doi:10.3389/fneur.2013.00029
2. Drachman DA, Hart CW (1972) An approach to the dizzy patient.
Neurology 22:323–334. doi:10.1212/WNL.22.4.323
3. Baloh RW (1998) Vertigo. Lancet 352:1841–1846. doi:10.1016/
S0140-6736(98)05430-0
4. Perrin P, Vibert D, Van Nechel C (2011) E
´tiologie des vertiges.
EMC oto-rhino-laryngologie. Elsevier, Paris, pp 1–21
5. Bisdorff AR, Staab JP, Newman-Toker DE (2015) Overview of
the International Classification of Vestibular Disorders. Neurol
Clin 33:541–550. doi:10.1016/j.ncl.2015.04.010
Eur Arch Otorhinolaryngol
123
Author's personal copy

6. Bense S, Stephan T (2001) Multisensory cortical signal increases
and decreases during vestibular galvanic stimulation (fMRI).
J Neurophysiol 85:886–899
7. Helmchen C, Ye Z, Sprenger A, Mu
¨nte TF (2013) Changes in
resting-state fMRI in vestibular neuritis. Brain Struct Funct.
doi:10.1007/s00429-013-0608-5
8. Besnard S, Lopez C, Brandt T et al (2015) Editorial: the
vestibular system in cognitive and memory processes in mam-
malians. Front Integr Neurosci. doi:10.3389/fnint.2015.00055
9. Orji F (2014) The influence of psychological factors in Meniere’s
disease. Ann Med Health Sci Res 4:3–7. doi:10.4103/2141-9248.
126601
10. Bremond G, Vidal A, Bertoni R (1970) Psychopathologic factors
in Meniere’s disease. Sem Hop 46(Suppl):73–79
11. House JW, Crary WG, Wexler M (1980) The inter-relationship of
vertigo and stress. Otolaryngol Clin North Am 13:625–629
12. Kirby SE, Yardley L (2009) Cognitions associated with anxiety
in Me
´nie
`re’s disease. J Psychosom Res 66:111–118. doi:10.1016/
j.jpsychores.2008.05.027
13. Monzani D, Casolari L, Guidetti G, Rigatelli M (2001) Psy-
chological distress and disability in patients with vertigo.
J Psychosom Res 50:319–323. doi:10.1016/S0022-3999(01)
00208-2
14. Grimm RJ, Hemenway WG, Lebray PR, Black FO (1989) The
perilymph fistula syndrome defined in mild head trauma. Acta
Otolaryngol Suppl 464:1–40. doi:10.3109/00016488909138632
15. Yardley L, Owen N, Nazareth I, Luxon L (1998) Prevalence and
presentation of dizziness in a general practice community sample
of working age people. Br J Gen Pract 48:1131–1135
16. Wiltink J, Tschan R, Michal M et al (2009) Dizziness: anxiety,
health care utilization and health behavior—results from a rep-
resentative German community survey. J Psychosom Res
66:417–424. doi:10.1016/j.jpsychores.2008.09.012
17. Furman JM, Redfern MS, Jacob RG (2006) Vestibulo-ocular
function in anxiety disorders. J Vestib Res 16:209–215
18. Hanes Da, McCollum G (2006) Cognitive-vestibular interactions:
a review of patient difficulties and possible mechanisms. J Vestib
Res 16:75–91
19. Savastano M, Maron MB, Mangialaio M et al (1996) Illness
behaviour, personality traits, anxiety, and depression in patients
with Meniere’s disease. J Otolaryngol 25:329–333
20. Godemann F, Linden M, Neu P et al (2004) A prospective study
on the course of anxiety after vestibular neuronitis. J Psychosom
Res 56:351–354. doi:10.1016/S0022-3999(03)00079-5
21. Hong SM, Lee H-J, Lee B et al (2013) Influence of vestibular
disease on psychological distress: a multicenter study. Oto-
laryngol Head Neck Surg 148:810–814. doi:10.1177/
0194599813476476
22. Pe
´ruch P, Borel L, Gaunet F et al (1999) Spatial performance of
unilateral vestibular defective patients in nonvisual versus visual
navigation. J Vestib Res 9:37–47
23. Cohen HS, Kimball KT (2000) Development of the vestibular
disorders activities of daily living scale. Arch Otolaryngol Head
Neck Surg 126:881–887
24. Schautzer F, Hamilton D, Kalla R et al (2003) Spatial memory
deficits in patients with chronic bilateral vestibular failure. Ann
New York Acad Sci 1004:316–324
25. Brandt T, Schautzer F, Hamilton Da et al (2005) Vestibular loss
causes hippocampal atrophy and impaired spatial memory in
humans. Brain 128:2732–2741. doi:10.1093/brain/awh617
26. Hu
¨fner K, Hamilton D, Kalla R (2007) Spatial memory and
hippocampal volume in humans with unilateral vestibular deaf-
ferentation. Hippocampus 17:471–485. doi:10.1002/hipo
27. Ferre
`ER, Longo MR, Fiori F, Haggard P (2013) Vestibular
modulation of spatial perception. Front Hum Neurosci 7:660.
doi:10.3389/fnhum.2013.00660
28. Deroualle D, Borel L, Deve
`ze A, Lopez C (2015) Changing
perspective: the role of vestibular signals. Neuropsychologia
79:175–185. doi:10.1016/j.neuropsychologia.2015.08.022
29. Jacobson GP, Newman CW (1990) The development of the
Dizziness Handicap Inventory. Arch Otolaryngol Head Neck
Surg 116:424–427. doi:10.1001/archotol.1990.01870040046011
30. Duracinsky M, Mosnier I, Bouccara D et al (2007) Literature
review of questionnaires assessing vertigo and dizziness, and
their impact on patients’ quality of life. Value Heal 10:273–284.
doi:10.1111/j.1524-4733.2007.00182.x
31. Asmundson G, Stein M, Desmond I (1999) A factor analytic
study of the dizziness handicap inventory: does it assess phobic
avoidance in vestibular referrals? J Vestib Res 9:63–68
32. Bradley C (1994) Handbook of psychology and diabetes: a guide
to psychological measurement in diabetes research and practice.
Harwood Academic Publishers, Chur
33. Powell LE, Myers AM (1995) The Activities-specific Balance
Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci
50A:M28–M34
34. Black FO, Angel CR, Pesznecker SC, Gianna C (2000) Outcome
analysis of individualized vestibular rehabilitation protocols. Am
J Otol 21:543–551
35. Hazlett RL, Tusa RJ, Waranch HR (1996) Development of an
inventory for dizziness and related factors. J Behav Med
19:73–85. doi:10.1007/BF01858175
36. Megnigbeto CA, Sauvage JP, Launois R (2001) The European
Evaluation of Vertigo (EEV) scale: a clinical validation study.
Rev Laryngol Otol Rhinol (Bord) 122:95–102
37. Tinetti ME, Richman D, Powell L (1990) Falls efficacy as a
measure of fear of falling. J Gerontol 45:P239–P243
38. Ware JEJ, Sherbourne CD (1992) The MOS 36-item short-form
health survey (SF-36). I. Conceptual framework and item selec-
tion. Med Care 30:473–483
39. Murphy MP, Gates GA (1999) Measuring the effects of
Meniere’s disease: results of the Patient-Oriented Severity Index
(MD POSI) version 1. Ann Otol Rhinol Laryngol 108:331–337
40. Gates GA (2000) Clinimetrics of Meniere’s disease. Laryngo-
scope 110:8–11. doi:10.1097/00005537-200003002-00003
41. Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ (1996) Fear
of falling revisited. Arch Phys Med Rehabil 77:1025–1029.
doi:10.1016/S0003-9993(96)90063-5
42. Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9:
validity of a brief depression severity measure. J Gen Intern Med
16:606–613. doi:10.1046/j.1525-1497.2001.016009606.x
43. Morris AE, Lutman ME, Yardley L (2008) Measuring outcome
from vestibular rehabilitation, Part I: qualitative development of a
new self-report measure. Int J Audiol 47:169–177. doi:10.1080/
14992020701843129
44. Jacob RG, Lilienfeld SO, Furman JMR et al (1989) Panic dis-
order with vestibular dysfunction: further clinical observations
and description of space and motion phobic stimuli. J Anxiety
Disord 3:117–130. doi:10.1016/0887-6185(89)90006-6
45. Honrubia V, Bell TS, Harris MR et al (1996) Quantitative eval-
uation of dizziness characteristics and impact on quality of life.
Am J Otol 17:595–602
46. Alghwiri AA, Whitney SL, Baker CE et al (2012) The develop-
ment and validation of the vestibular activities and participation
measure. Arch Phys Med Rehabil 93:1822–1831. doi:10.1016/j.
apmr.2012.03.017
47. Prieto L, Santed R, Cobo E, Alonso J (1999) A new measure for
assessing the health-related quality of life of patients with vertigo,
dizziness or imbalance: the VDI questionnaire. Qual Life Res
8:131–139. doi:10.1023/A:1026433113262
48. Yardley L, Putman J (1992) Quantitative analysis of factors
contributing to handicap and distress in vertiginous patients: a
questionnaire study. Clin Otolaryngol Allied Sci 17:231–236
Eur Arch Otorhinolaryngol
123
Author's personal copy

49. Yardley L, Masson E, Verschuur C et al (1992) Symptoms,
anxiety and handicap in dizzy patients: development of the
Vertigo symptom scale. J Psychosom Res 36:731–741. doi:10.
1016/0022-3999(92)90131-K
50. Cohen HS, Kimball KT, Adams AS (2000) Application of the
vestibular disorders activities of daily living scale. Laryngoscope
110:1204–1209. doi:10.1097/00005537-200007000-00026
51. Morris AE, Lutman ME, Yardley L (2009) Measuring outcome
from vestibular rehabilitation, part II: refinement and validation
of a new self-report measure. Int J Audiol 48:24–37. doi:10.1080/
14992020802314905
52. Ihaka R, Gentleman R (1996) A language for data analysis and
graphics. J Comput Graph Stat 5:299–314
53. R Core Development Team (2004) R: a language and environ-
ment for statistical computing. Vienna
54. Cohen J (1988) Statistical power analysis for the behavioural
sciences, 2nd edn. Academic Press, New York
55. Richardson JTE (2011) Eta squared and partial eta squared as
measures of effect size in educational research. Educ Res Rev
6(2):135–147
56. Koo J-W, Chang MY, Woo S et al (2015) Prevalence of
vestibular dysfunction and associated factors in South Korea.
BMJ Open 5:e008224. doi:10.1136/bmjopen-2015-008224
57. Agrawal Y, Ward BK, Minor LB (2013) Vestibular dysfunction:
prevalence, impact and need for targeted treatment. J Vestib Res
23:113–117. doi:10.3233/VES-130498.Vestibular
58. Dye MWG, Hauser PC (2014) Sustained attention, selective
attention and cognitive control in deaf and hearing children. Hear
Res 309:94–102. doi:10.1016/j.heares.2013.12.001
59. Sladen DP, Tharpe AM, Ashmead DH et al (2005) Visual
attention in deaf and normal hearing adults: effects of stimulus
compatibility. J Speech Lang Hear Res 48:1529–1537. doi:10.
1044/1092-4388(2005/106)
60. Bavelier D, Dye MWG, Hauser PC (2006) Do deaf individuals
see better? Trends Cogn Sci 10:512–518. doi:10.1016/j.tics.2006.
09.006
61. Lynn M (1986) Determination and quantification of content
validity. Nurs Res 35:382–385
62. Smith PF, Zheng Y (2013) From ear to uncertainty: vestibular
contributions to cognitive function. Front Integr Neurosci 7:84.
doi:10.3389/fnint.2013.00084
63. Peruch P, Borel L, Magnan J, Lacour M (2005) Direction and
distance deficits in path integration after unilateral vestibular loss
depend on task complexity. Brain Res Cogn Brain Res
25:862–872. doi:10.1016/j.cogbrainres.2005.09.012
64. Borel L, Redon-Zouiteni C, Cauvin P et al (2014) Unilateral
vestibular loss impairs external space representation. PLoS One
9:1–10. doi:10.1371/journal.pone.0088576
65. Borel L, Lopez C, Pe
´ruch P, Lacour M (2008) Vestibular syn-
drome: a change in internal spatial representation. Neurophysiol
Clin 38:375–389. doi:10.1016/j.neucli.2008.09.002
66. Cohen HS, Kimball KT (2002) Improvements in path integration
after vestibular rehabilitation. J Vestib Res 12:47–51
67. Agrawal Y, Carey JP, Della Santina CC et al (2009) Disorders of
balance and vestibular function in US adults: data from the
National Health and Nutrition Examination Survey, 2001–2004.
Arch Intern Med 169:938–944
68. Gassmann KG, Rupprecht R (2009) Dizziness in an older com-
munity dwelling population: a multifactorial syndrome. JNHA J
Nutr Heal Aging 13:278–282. doi:10.1007/s12603-009-0073-2
69. Jonsson R, Sixt E, Landahl S, Rosenhall U (2004) Prevalence of
dizziness and vertigo in an urban elderly population. J Vestib Res
14:47–52
70. Salthouse TA (2009) When does age-related cognitive decline
begin? Neurobiol Aging 30:507–514. doi:10.1016/j.neurobiola
ging.2008.09.023
71. Ro
¨nnlund M, Nyberg L, Ba
¨ckman L, Nilsson L-G (2005) sta-
bility, growth, and decline in adult life span development of
declarative memory: cross-sectional and longitudinal data from a
population-based study. Psychol Aging 20:3–18. doi:10.1037/
0882-7974.20.1.3
72. Brockmole JR, Logie RH (2013) Age-related change in visual
working memory: a study of 55,753 participants aged 8–75. Front
Psychol 4:1–5. doi:10.3389/fpsyg.2013.00012
73. Lee H, Baniqued PL, Cosman J et al (2012) Examining cognitive
function across the lifespan using a mobile application. Comput
Hum Behav 28:1934–1946. doi:10.1016/j.chb.2012.05.013
74. Blazer D (2003) Depression in late life: review and commentary.
J Gerontol Med Sci 58A:249–265. doi:10.1093/gerona/58.3.
M249
75. Yardley L, Redfern MS (2001) Psychological factors influencing
recovery from balance disorders. J Anxiety Disord 15:107–119
76. Seligman M, Johnston J (1973) A cognitive theory of avoidance
learning. In: McGuigan F, Lumsden D (eds) Contemp. approa-
ches to Cond. Learn. Washington (DC), pp 69–110
77. Saber Tehrani AS, Coughlan D, Hsieh YH et al (2013) Rising
annual costs of dizziness presentations to US Emergency
Departments. Acad Emerg Med 20:689–696. doi:10.1111/acem.
12168
78. Redfern MS, Talkowski ME, Jennings JR, Furman JM (2004)
Cognitive influences in postural control of patients with unilateral
vestibular loss. Gait Posture 19:105–114. doi:10.1016/S0966-
6362(03)00032-8
Eur Arch Otorhinolaryngol
123
Author's personal copy