We report the case of a 65-year-old woman who presented with persistent FOF 1 year after an episode of RHS, even though her serial CGAs showed recovered balance and no additional falls. Previous reports regarding older adults with RHS have mainly focused on the treatment of facial palsy, postherpetic neuralgia, and disease prognosis. However, the impact of RHS on older adults’ physical, psychological, and social functioning has rarely been reported, despite the fact that functional status is one of the most crucial determinants of older adults’ quality of life. To the best of our knowledge, this is the first report to describe a patient with FOF and functional deterioration after an RHS episode.
The classic symptom triad of RHS consists of ipsilateral facial paralysis, otalgia, and vesicular rash over the external auditory canal. Furthermore, VZV could affect not only the 7th cranial nerve but also other cranial nerves, most commonly the 8th cranial nerve. Symptoms of 8th cranial nerve dysfunction, including vertigo, dizziness, poor balance, tinnitus, and hearing loss have been reported in patients with RHS [9]. According to recent studies, 26–37% of patients with RHS developed vertigo [16,17,18]. One study showed that vertigo in all patients disappeared with conservative treatment during the hospitalization period [18]. Another study reported that vertigo in a patient lasted up to 7 months [16]. Among patients with acute peripheral facial palsy (RHS and Bell’s palsy), older people were more likely to develop dizziness, vertigo, and poor balance than younger ones [18]. In the present study, the 65-years-old patient had the classic RHS triad, as well as dizziness, vertigo, and poor balance. Due to this patient’s age, she may have a higher tendency to develop vertigo.
FOF was previously defined as “post-fall syndrome,” which indicated that it was a psychological trauma after a fall [7]. However, nowadays, we know that FOF is also present among older adults who have no history of falling [19, 20]. Therefore, other factors are likely involved in the development of FOF apart from falls. The etiology of FOF is multifactorial. Age, female sex, low self-rated health status, depression, functional dependence in ADLs, dizziness, and problems with gait and balance were risk factors reported to be associated with FOF [6]. Among them, age remains significantly associated with FOF in various studies. In other words, older adults are particularly prone to FOF. The patient in this study had many associated risk factors, including older age, female sex, previous falls, dizziness, and imbalance. In addition, the patient’s repeated falls were precipitated by dizziness and imbalance. However, after the SPPB improved with no additional falls, her FOF persisted.
According to the literature, FOF can lead to various consequences [6]. Physically, it can cause decreased physical activity or poorer physical health [20,21,22,23,24], and functionally, it can cause avoidance of activities, lack of engagement in any given activity, and eventual loss of functional independence [21, 23, 25,26,27]. Psychosocially, FOF can lead to reduced social activities [20, 23, 28], depression [29, 30], and low quality of life [20, 21, 28, 29]. Because of FOF, the patient in this study lost her IADLs. In the long term, this further impaired her social activity and led to her social withdrawal. Additionally, over 50% of patients with facial palsy experience psychological distress and social withdrawal [31]. Therefore, it can be surmised that older adults with FOF after RHS are more likely to experience social withdrawal.
Several effective intervention strategies have been proven to manage FOF, including exercise [32], cognitive behavioral therapy [33], Tai Chi combined with cognitive behavioral therapy [34], and guided relaxation with imagery [35]. CAPABLE (Community Aging in Place—Advancing Better Living for Elders), a home-based program enhancing individual capacity and home environmental supports, can help subjects improve their confidence when performing ADLs without falling [36]. Furthermore, understanding the risk factors of FOF may be useful in developing multidimensional strategies to address FOF [6]. The patient in this study was referred to a physical therapy center for balance training, and the patient’s SPPB improved within 3 months.
In the TUG test, the participants are asked to rise from a chair, walk 3 m, turn, walk back to the chair, and sit down. It measures balance, gait speed, and functional capacity [37]. According to a previous study, the fear of falling in community-dwelling older women is associated with frailty, dynamic balance, and gait deficit. Furthermore, the TUG test predicts a fear of falling in this population [38]. In our study, the patient’s SPPB and balance test improved after rehabilitation; however, she needed more time to complete the TUG test. Based on the patient’s minor reduction of IADL and self-reported FOF, we suspected that the increase in TUG score was related to FOF.
This report completed a year-round serial CGA follow-up, including balance, ADLs, IADLs, muscle strength, and fall assessments. We observed functional changes in this patient after RHS. The limitation of this report is the lack of instruments used to quantify FOF, such as the amended Falls Efficacy Scale or Survey of Activities and FOF in the Elderly. However, the SQ-FAR is still a well-recognized screening tool for FOF [14].
In conclusion, RHS not only results in peripheral facial palsy and otalgia but can also cause dizziness and imbalance, which are risk factors for FOF. In older adults, FOF is a complex health concern that can result in impairment of daily activities and psychosocial functioning. A comprehensive understanding of FOF can assist in the early detection and initiation of interventions with which to reduce its negative consequences. Clinicians should be cautious about falls and FOF, especially in patients with RHS, and should develop multidimensional strategies to prevent functional loss and quality of life impairment after RHS.