BPPV in the Elderly

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Clinical Section / Original Paper

Gerontology

DOI: 10.1159/000351204

Benign Paroxysmal Positional Vertigoin the Elderly

Angel Batuecas-Caletrioa Gabriel Trinidad-Ruizb Christiane Zschaeckc

Juan Carlos del Pozo de Diosa Laura de Toro Gilc Victor Martin-Sancheza

Eduardo Martin-Sanzc

aOtoneurology Unit, Hospital Universitario de Salamanca, Salamanca, bOtoneurology Unit, Complejo Hospitalario

Universitario, Badajoz, and cOtoneurology Unit, Hospital Universitario de Getafe, Getafe, Spain

Introduction

Dizziness in elderly patients is so common that it is of-ten dismissed as a normal age-related phenomenon. How-ever, just like in younger patients, the primary goal shouldbe to find the underlying cause of the patients symptoms,which may lead the way to specific treatment [1].

Dizziness has a strong negative influence on the qual-ity of life of the patients and is closely connected to theperception of disability [2].

Benign paroxysmal positional vertigo (BPPV) is theterm most commonly used to describe a disease with a ty-pical clinical presentation thought to be caused by free-floating particles leaving the macula of the utriculus andentering one of the semicircular canals, usually the poste-rior one or, more rarely, the horizontal or superior ones [3].

BPPV is the most common diagnosis at vertigo clinics,and the age at onset is most commonly between 60 and

70 years, with elderly people being at increased risk [4]reaching 10% in people over 80. This figure provides suf-ficient justification for routine Dix-Hallpike testing in alldizzy patients aged above 60. There have been quite a fewolder patients who denied any positional vertigo even onspecific questioning and then had typical vertigo and ny-stagmus on positional testing [1].

As a result of the misconception, older patients withtreatable causes of dizziness, for example BPPV, will

Key Words

Benign paroxysmal positional vertigo Unsteadiness

Imbalance Vertigo Falls

Abstract

Background: Benign paroxysmal positional vertigo (BPPV) is

the most frequent peripheral vertigo in the elderly. It is a well-

characterized entity and generally easy to treat.Objective: To

evaluate the main symptoms, time to consult for the problem,

vertigo characteristics, treatment and follow-up in patients

over 70 with BPPV. Methods: This was a retrospective coh-ort study. Four hundred and four patients were diagnosed to

have BPPV (between January 2006 and December 2012); 211

of them were 70 years old (mean 77.7 years) and 193


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DOI: 10.1159/000351204

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often experience a longer duration of symptoms prior toreceiving a diagnosis [5].

The diagnosis of BPPV is confirmed by the Dix-Hallpikepositioning test or the roll test in cases of horizontal canal

variant BPPV. The diagnosis of BPPV of the posteriorsemicircular canal is based on the clinical finding of a

transient, upbeating, torsional nystagmus with the upperpoles of the eye beating toward the undermost ear whenthe patient is rapidly positioned into the lateral head-hanging position; this is known as the Dix-Hallpike test.For BPPV of the horizontal semicircular canal, the dia-gnosis is based on history and features of the positioningnystagmus provoked by a quick turn of the head to eitherside with the patient lying supine (Pagnini-Mc-Cluresmaneuver). It is a paroxysmal, purely horizontal direction-changing nystagmus directed toward the uppermost ear(apogeotropic) with cupulolithiasis or toward the under-most ear (geotropic) with canalithiasis [6].

Possible factors causing BPPV include cupulolithiasis,in which particles from otoconia attach to the cupula ofthe semicircular canal, and canalithiasis, in which theseparticles float freely within the endolymph of the canal.It has been proposed that displaced particles in the canalarising from senile otoconial degeneration are the lead-ing cause of idiopathic BPPV in old age [7].

The particle repositioning maneuvers are easy to per-form and are effective to treat the BPPV in the elderly.The most common maneuvers are Epley or Semont ma-neuver for posterior semicircular canal, Lempert or bar-becue maneuver for horizontal semicircular canal andcontralateral Epley or Yacovino maneuver for anteriorsemicircular canal. Sometimes, the particle repositioningcombined with vestibular rehabilitation can be more ef-fective and improve the gait of the patient immediatelyafter repositioning [8].

Material and Methods

The study design is a retrospective cohort follow-up study. Pati-ents referred between 2006 and 2012 were included in the study.

The subjects that participated in the study were outpatientsreferred to three referral hospitals from Spain with symptoms ofvertigo or unsteadiness. After taking a detai led clinical history, acomplete neuro-otological bedside examination was performed.

Inclusion criteria were: (1) BPPV of the posterior or superiorsemicircular canal with a positive Dix-Hallpike maneuver, and (2)BPPV of the horizontal semicircular canal with a positive McClures maneuver.

Exclusion criteria were: (1) orthopedic disorders, severeinternal diseases or mental disorders which could influence thephysical performance; (2) no valid clinical history or neuro-oto-

logical examination; (3) any symptom of the central nervous sy-stem which could mimic a peripheral vertigo.

Patients with other pathologies concerning the vestibular sys-tem or atypical nystagmus were excluded.

In order to determine whether the variables tested had a dif-ferent distribution in elderly patients and younger patients, a sec-ond group was created using simple aleatory sampling among pa-tients


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The more frequent known precipitants were cranioen-cephalic trauma (6.2%), immobilization (3.3%) or oto-logic surgery (2.3%), and no differences between groupswere observed. The majority of the patients in both groupsdid not have known precipitants for their BPPV, so wepresume they were idiopathic.

Focusing on the semicircular canal, the posterior semi-circular canal was mostly affected in both groups (82.5%).Horizontal semicircular canal (10.4%) and superior semi-circular canal (5.9%) were less frequently impaired. Onlyin 4 patients were several canals affected. Canalithiasiswas present in 84.9% of patients and cupulolithiasis in15.1% of patients. No differences were found betweengroups (2, p = 0.55).

Once the affected canal was identified, patients weretreated by its corresponding repositioning maneuver.The Epley maneuver was performed in 330 patients(81.5%), Lempert maneuver in 30 (7.4%), Semont in 8

(2%), Yacovino in 8 (2%) and several in 29 (7.1%).For those patients with a posterior canal BPPV, com-

plete resolution in the first weekly revision after treat-ment was significantly more frequent (2, p = 0.002 whencompared with the rest of the BPPV variants, in bothadult and elderly groups; table 1).

Patients 70 years old and older took longer to consultfor their problem than patients under 70 years old (Mann-Whitney U, p = 0.002; table 1). Indeed, age and waitingtime were found to be correlated (Spearmans rho, p =0.007). No differences between groups were observed whencomparing intake of vestibular sedatives (2, p = 0.75).

When comparing clinical presentation, unsteadinesswas the main symptom in 31.3% of the elderly group pa-tients, and 10.6% in the adult group. This difference wasproven to be highly statistically significant (2, p = 1 106;table 1).

When treating patients 70 years old, 3 or moremaneuvers were needed in 12.3% of the cases, whichwas proven to be statistically significant (2, p = 0.022)compared with 5.7% of patients


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low-up, with the aim of proving or discarding our assum-ption. The results obtained by applying the described filterwere statistically significant for both life tables (Wilcoxon,p = 0.009) and Kaplan-Meier (log rank, p = 0.001; fig. 2).

Discussion

There are two key points in our study. Patients 70years old frequently report dizziness or imbalance as theclinical presentation of VPPB and, usually, they take lon-ger to consult for their problem. Moreover, treating VPPBin elderly people is more difficult than in young people,as shown in our results, when comparing the proportionof complete resolution at the first visit after treatment,

and the frequency of recurrences [9].Older adults with balance disorders often initially turnto their general practitioner or a geriatrician. Given thatabout 9% incidence of unrecognized BPPV in older adultshas been reported [10], and as described in our results,

vertigo is not always the main symptom of the patient.Both the general practitioner and geriatrician should beable to make the diagnosis of BPPV because of the highincidence of this entity in the elderly [11].

As found in other studies, the right ear is predomi-nantly affected [12, 13]. It has been suggested that pro-longed lying may facilitate the deposition of otoconia onthe cupula or contribute to their loosening from the utri-cle. This mechanism might also explain why the lateral-ity of BPPV often corresponds to the preferred side of

lying during sleep [14].Elderly patients with BPPV usually complain of multi-ple symptoms and do not always describe a rotatory crisis;sometimes, patients report dizziness or imbalance like inour study [15].

Generally, physical activity is significantly lower inpatients with BPPV, mainly in elderly patients. Elderlypatients show less daily leisure and household activity.Indeed, this disease increases the incidence of falls, thusincreasing the chance of fractures, head trauma, hospi-talizations, and depression. This risk of falls is signifi-cantly increased in those elderly patients with an associ-

ated BPPV [10], so it is advisable to manage it and its mul-tiple variants to minimize the potential morbidity of theirfalls [16].

There are few reports regarding the changes of otoco-nial morphology with aging, not only saccular degenera-tion but utricular degeneration in which giant otoconiamay appear through the loss of the controlled inhibitionof mineralization with aging [7, 17, 18].

Treatment of BPPV can be difficult in the elderly forseveral reasons. Patients with decreased neck mobilitymay have problems achieving sufficient head rotationand reclination as required for the Epley maneuver. Al-ternatively, one can apply Semonts maneuver. Perform-ing the maneuver is much easier when a second therapistsupports the patient from behind [1].

Particle repositioning maneuver improves quality oflife in BPPV patients in the long-term when compared toleaving BPPV untreated. The improvement in physicaland social functioning and mental health perception ismaintained after particle repositioning maneuver [15].It is possible because the canalith repositioning proce-dure is effective in increasing the limit of stability andreducing body oscillation under conditions of inaccurate

somatosensory information and visual-vestibular inter-action [19].Despite the benefits of the BPPV treatment with

canalith repositioning maneuvers, affected elderly pa-tients frequently show recurrences. A good follow-up ofthese patients is mandatory in order to diagnose the re-currences early. Some studies have estimated that re-currence occurs in approximately 50% of cases followedup in the medium and long term and, sometimes, re-

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Cumulativesurvival

0 5 10 15 20 25Follow-up (months)

Survival functions

Age groups

70 and older

Under 70

70 and older-censored

Under 70-censored

Fig. 2. Time-to-event (recurrence) distribution across both groups.24-month follow-up estimation (Kaplan-Meier procedure; logrank test, p = 0.001).


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Gerontology

DOI: 10.1159/000351204

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peated [20]. In our case, recurrence appeared in 23.5%of patients, close to that given by others authors. On theother hand, the timing of recurrence is important be-cause symptoms most likely return in the first year offollow-up in elderly people [12]. Although no statisticaldifferences were found, when the long-term recurrence

was studied in both age groups, a different behavior wasobserved over the course of the 2 first years when theolder group showed a greater probability of recurren-ce. Therefore, we should consider extending the follow-up of our patients in order to detect the greater risk ofrecurrence.

The resolution of balance disorders leads to an imp-rovement in patients independence and social life thanksto a reduction in the risk of falling and an increase in his/her self-esteem [3, 11].

In our opinion, the Dix-Hallpike test and Mc Clurestest should be performed in older patients with dizziness,

although the patient does not explain the spinning sensa-tion with positional changes. Not to miss treatable causesof dizziness like BPPV is imperative in older patients.

Conclusions

Although BPPV is known to be a frequent conditionin elderly people, sometimes patients do not complainabout attacks of vertigo but dizziness or imbalance. Gen-erally, elderly patients take longer to go to the outpatientclinic despite losing quality of life.

BPPV treatment with particle repositioning maneu-vers is highly effective, but recurrences in older people aremore frequent than in younger people, and the probabil-ity of not achieving complete resolution in the first visitis higher. For these reasons, an intensive follow-up shouldbe considered for elderly patients affected by BPPV.

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BPPV in the Elderly