Benign paroxysmal positional vertigo in the elderly: current insights

Clinical Interventions in Aging Dovepress open access to scientific and medical research Review Open Access Full Text Article Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 37.59.46.207 on 21-Dec-2018 For personal use only. Benign paroxysmal positional vertigo in the elderly: current insights This article was published in the following Dove Press journal: Clinical Interventions in Aging DG Balatsouras 1 G Koukoutsis 1 A Fassolis 1 A Moukos 1 A Apris 2 Department of ENT, Tzanion General Hospital of Piraeus, Piraeus, Greece; 2 Department of ENT, Nicosia General Hospital, Nicosia, Cyprus 1 Prevalence Correspondence: DG Balatsouras 23 Achaion Street – Agia Paraskevi, Athens, P.C. 15343, Greece Tel +30 21 0600 4683 Fax +30 21 0459 2671 Email Vestibular symptoms and dizziness are a usual and significant problem in the elderly, where their prevalence has been estimated to be 30% in persons older than 60 years,1,2 and approaching 50% after the age of 85 years.1 The presence of dizziness constitutes a major predictor of falls in the elderly, which are the leading cause of accidental death after the age of 65 years.3 Dizziness has increased prevalence in women4 and is a major factor for disability in persons beyond 65 years of age.5 Common causes of vertigo in the elderly may manifest differently, with a more confusing set of symptoms, as patients tend to report rotatory vertigo less and nonspecific dizziness and instability more than younger patients with the same condition.6 A specific feature of balance disorders in elderly is that older patients complain less of rotatory vertigo and more often of nonspecific unsteadiness and dizziness than younger persons with a similar disease.6 The main feature of dizziness in the elderly is the gradual multisensory deterioration of balance. Vestibular and proprioceptive functions are affected and the impairment of their central integration along with various other sensory inputs that are related to aging, including vision and hearing, constitute the phenomenon of presbyequilibrium, occasionally called multisensory dizziness.7 Accordingly, dizziness in the elderly is actually a multifactorial geriatric syndrome manifesting in multiple ways and involving several organic systems, such as sensory, neural and cardiovascular.8 Although most types of dizziness in the elderly are benign, 2251 submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2018:13 2251–2266 Dovepress © 2018 Balatsouras et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/CIA.S144134 Powered by TCPDF (www.tcpdf.org) Abstract: Balance disorders, unsteadiness, dizziness and vertigo in the elderly are a significant health problem, needing appropriate treatment. One third of elderly patients with vertigo were diagnosed with benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness in both primary care specialist Neurology and Ear Nose Throat settings. BPPV presents a specific paroxysmal positional nystagmus which can be obtained using the appropriate diagnostic positional test and can be treated effectively using specific therapeutic maneuvers. This review presents current insights into the diagnostic, pathogenetic and therapeutic aspects of BPPV in the elderly. BPPV in older patients does not differ significantly from BPPV in younger patients, with regard to pathogenesis, diagnosis and treatment. However, in older patients, its prevalence is higher and it responds less effectively to treatment, having a tendency for recurrence. Specific issues which should be considered in the elderly are: 1) difficulty in obtaining an accurate history; 2) difficulty in performing the diagnostic and therapeutic maneuvers, which should be executed with slow and gentle movements and extremely cautiously to avoid any vascular or orthopedic complications; and 3) the relation between BPPV and falls. Keywords: dizziness, vestibular, benign paroxysmal positional vertigo, balance, elderly Dovepress Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 37.59.46.207 on 21-Dec-2018 For personal use only. Balatsouras et al in a few patients however, there underlies a serious and probably life-threatening cause, such as a stroke, which occurs more commonly in older patients.9 Barin and Dodson2 divided the underlying causes of disequilibrium and dizziness in the elderly into three broadly defined types: 1. Age-related deterioration of acuity in sensori-motor pathways in conjunction with decline of integration processes within the central nervous system. These types of impairment, which are common in older adults, may be considered a normal part of aging. 2. Pathologies that may evoke dizziness in persons of any age but are more common in older persons, either due to increased susceptibility because of age-related processes or due to increased probability of exposure to these factors with the passage of time. 3. Finally, an assortment of environmental and lifestyle factors, which may be responsible for increased frequency of balance disorders and dizziness in older persons. These may include limited mobility, absence of activities and frequent use of medications, having the common adverse reaction of dizziness. Benign paroxysmal positional vertigo (BPPV) may be included in the second category, because although it may manifest at any age, it is much more common in the elderly, owing to the continuous degradation of the maculae of the sensory otolith organs of the vestibule. In the National Health Interview Survey conducted in 2008 in the USA, more than 7 million Americans exceeding 65 years of age complained of balance disorders. The most common causes that were reported included adverse reactions to medication (11.3%), infections of the inner ear (11.0%), heart disease (8.6%) and loose otoliths (7.9%), which probably indicates a diagnosis of BPPV.10 Regarding patients referred to otolaryngologists or Neurotology clinics, BPPV is by far the most common diagnosis in patients with dizziness, especially in the elderly.11 It has been reported that a diagnosis of BPPV is established in 17%–42%12 of patients with vertigo. In a registry with data from 4,105 vertigo patients collected during a 28-month period from 618 centers in 13 countries presented 26.9% were diagnosed with BPPV.13 The 1 year prevalen (...truncated)