Clinical Section / Original Paper

Gerontology DOI: 10.1159/000351204

Received: February 14, 2013 Accepted: April 3, 2013 Published online: May 15, 2013

Benign Paroxysmal Positional Vertigo in the Elderly

Angel Batuecas-Caletrio a Gabriel Trinidad-Ruiz b Christiane Zschaeck c Juan Carlos del Pozo de Dios a Laura de Toro Gil c Victor Martin-Sanchez a Eduardo Martin-Sanz c
Otoneurology Unit, Hospital Universitario de Salamanca, Salamanca, b Otoneurology Unit, Complejo Hospitalario Universitario, Badajoz, and c Otoneurology Unit, Hospital Universitario de Getafe, Getafe, Spain
a

Key Words Benign paroxysmal positional vertigo Unsteadiness Imbalance Vertigo Falls

Introduction

Abstract Background: Benign paroxysmal positional vertigo (BPPV) is the most frequent peripheral vertigo in the elderly. It is a wellcharacterized 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 cohort 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 <70 years old (mean 53.82 years). Results: Patients over 70 with BPPV took longer to consult for the problem (Spearman rho, p = 0.01). The frequency of a clinical presentation consisting of unsteadiness or imbalance without vertigo sensation is higher among elderly patients (2, p = 106). The effectiveness of the repositioning maneuver is lower than in patients under 70 (2, p = 0.002), and the recurrences are more frequent (2, p = 0.04). Conclusion: BPPV is a frequent entity in the elderly, and it is necessary to take it into account when older patients complain about imbalance. An appropriate treatment with repositioning maneuvers and prolonged follow-up are required in order to detect recurrences. Copyright 2013 S. Karger AG, Basel

Dizziness in elderly patients is so common that it is often dismissed as a normal age-related phenomenon. However, just like in younger patients, the primary goal should be 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 quality of life of the patients and is closely connected to the perception of disability [2]. Benign paroxysmal positional vertigo (BPPV) is the term most commonly used to describe a disease with a typical clinical presentation thought to be caused by freefloating particles leaving the macula of the utriculus and entering one of the semicircular canals, usually the posterior 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 sufficient justification for routine Dix-Hallpike testing in all dizzy patients aged above 60. There have been quite a few older patients who denied any positional vertigo even on specific questioning and then had typical vertigo and nystagmus on positional testing [1]. As a result of the misconception, older patients with treatable causes of dizziness, for example BPPV, will
Angel Batuecas-Caletrio, MD, PhD Otoneurology Unit, ENT Department University Hospital of Salamanca Pso. San Vicente 58-182, ES37007 Salamanca (Spain) E-Mail abatuc@yahoo.es
Downloaded by: Gyeongsang National Univ. 203.255.32.93 - 7/23/2013 6:41:36 AM

2013 S. Karger AG, Basel 0304324X/13/00000000$38.00/0 E-Mail karger@karger.com www.karger.com/ger

often experience a longer duration of symptoms prior to receiving a diagnosis [5]. The diagnosis of BPPV is confirmed by the Dix-Hallpike positioning test or the roll test in cases of horizontal canal variant BPPV. The diagnosis of BPPV of the posterior semicircular canal is based on the clinical finding of a transient, upbeating, torsional nystagmus with the upper poles of the eye beating toward the undermost ear when the patient is rapidly positioned into the lateral headhanging position; this is known as the Dix-Hallpike test. For BPPV of the horizontal semicircular canal, the diagnosis is based on history and features of the positioning nystagmus provoked by a quick turn of the head to either side with the patient lying supine (Pagnini-Mc-Clures maneuver). It is a paroxysmal, purely horizontal directionchanging nystagmus directed toward the uppermost ear (apogeotropic) with cupulolithiasis or toward the undermost ear (geotropic) with canalithiasis [6]. Possible factors causing BPPV include cupulolithiasis, in which particles from otoconia attach to the cupula of the semicircular canal, and canalithiasis, in which these particles float freely within the endolymph of the canal. It has been proposed that displaced particles in the canal arising from senile otoconial degeneration are the leading cause of idiopathic BPPV in old age [7]. The particle repositioning maneuvers are easy to perform and are effective to treat the BPPV in the elderly. The most common maneuvers are Epley or Semont maneuver for posterior semicircular canal, Lempert or barbecue maneuver for horizontal semicircular canal and contralateral Epley or Yacovino maneuver for anterior semicircular canal. Sometimes, the particle repositioning combined with vestibular rehabilitation can be more effective and improve the gait of the patient immediately after repositioning [8].

logical examination; (3) any symptom of the central nervous system which could mimic a peripheral vertigo. Patients with other pathologies concerning the vestibular system or atypical nystagmus were excluded. In order to determine whether the variables tested had a different distribution in elderly patients and younger patients, a second group was created using simple aleatory sampling among patients <70 years old, attended during the same period. Once the affected semicircular canal was identified, patients were treated by its corresponding particle repositioning maneuver; Epley maneuver for posterior and anterior semicircular canal and Lempert maneuver for horizontal semicircular canal. Exceptionally, the Yacovino maneuver was performed for anterior canal BPPV treatment. All patients were evaluated at weekly intervals after each treatment, and a complete neuro-otological examination was performed again. A new repositioning maneuver was repeated if it was necessary in the follow-up. If a negative Dix-Hallpike or Mc Clures test was observed 711 days after treatment, this was considered successful. Only patients in which we had got a normalization of the Dix-Halpike test after one or several repositioning maneuvers were considered for follow-up. Data Analysis As stated above, the patients were grouped into 2 classes according to age. The first group comprised BPPV patients 70 years old, and the second one, BPPV patients <70 years old. All data were stored in a computer and analyzed with the SPSS 20.0 statistical software package. Age, sex, waiting time for attendance, semicircular canal affected, clinical presentation, precipitants, number of maneuvers needed, resolution in the first weekly visit after treatment, previous intake of vestibular sedatives and finally, recurrence, were analyzed and then compared between the two study groups. Comparison between groups was assessed using the 2 test for testing independence of proportions regarding string variables, Mann-Whitney U for testing differences between means (normal distribution could not be assumed for scale variables arising from Kolmogorov-Smirnov test results), Spearmans rho for testing correlation between scale variables, Wilcoxon test to compare survival distributions obtained using life tables, and log rank (MantelCox) to test the equality of survival functions across groups obtained by the Kaplan-Meier procedure. Probability of p < 0.05 was considered statistically significant.

Material and Methods

The study design is a retrospective cohort follow-up study. Patients referred between 2006 and 2012 were included in the study. The subjects that participated in the study were outpatients referred to three referral hospitals from Spain with symptoms of vertigo or unsteadiness. After taking a detailed clinical history, a complete neuro-otological bedside examination was performed. Inclusion criteria were: (1) BPPV of the posterior or superior semicircular canal with a positive Dix-Hallpike maneuver, and (2) BPPV of the horizontal semicircular canal with a positive Mc Clures maneuver. Exclusion criteria were: (1) orthopedic disorders, severe internal diseases or mental disorders which could influence the physical performance; (2) no valid clinical history or neuro-oto-

Results

Four hundred and four patients were finally included in our study, of which 211 were 70 years old (elderly group), and 193 <70 years old (adult group). Mean age was 77.7 years in the elderly group and 53.82 years in the adult group. No significant difference in gender was found, but the right side was more affected than left side (57.1% right ear vs. 42.9% left ear; 2, p = 0.01). Mean follow-up was similar in both groups (23.685 months in the elderly group and 23.423 in the adult group; p = 0.756, Mann-Whitney U).
Batuecas-Caletrio etal.

Gerontology DOI: 10.1159/000351204

Downloaded by: Gyeongsang National Univ. 203.255.32.93 - 7/23/2013 6:41:36 AM

The more frequent known precipitants were cranioencephalic trauma (6.2%), immobilization (3.3%) or otologic surgery (2.3%), and no differences between groups were observed. The majority of the patients in both groups did not have known precipitants for their BPPV, so we presume they were idiopathic. Focusing on the semicircular canal, the posterior semicircular canal was mostly affected in both groups (82.5%). Horizontal semicircular canal (10.4%) and superior semicircular canal (5.9%) were less frequently impaired. Only in 4 patients were several canals affected. Canalithiasis was present in 84.9% of patients and cupulolithiasis in 15.1% of patients. No differences were found between groups (2, p = 0.55). Once the affected canal was identified, patients were treated 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, complete resolution in the first weekly revision after treatment was significantly more frequent (2, p = 0.002 when compared with the rest of the BPPV variants, in both adult and elderly groups; table1). Patients 70 years old and older took longer to consult fortheir problem than patients under 70 years old (MannWhitney U, p = 0.002; table 1). Indeed, age and waiting time were found to be correlated (Spearmans rho, p = 0.007). No differences between groups were observed when comparing intake of vestibular sedatives (2, p = 0.75). When comparing clinical presentation, unsteadiness was the main symptom in 31.3% of the elderly group patients, and 10.6% in the adult group. This difference was proven to be highly statistically significant (2, p = 1 106; table1). When treating patients 70 years old, 3 or more maneuvers were needed in 12.3% of the cases, which was proven to be statistically significant (2, p = 0.022) compared with 5.7% of patients <70 years old. At the first visit, resolution of BPPV was more frequent in patientsunder 70 (78.8%) than patients over 70 years old (64.5%; 2, p = 0.002; table1). Finally, recurrences were more frequent in the elderly group (23.7%) than in the adult group (15.5%; 2, p = 0.04; table 1). Those recurrences appeared more frequently within the first 2 years of follow-up using the life tables method, but no differences were found between groups regarding survival distributions obtained using this method (Wilcoxon, p = 0.064), or the Kaplan-Meier procedure (log rank, p = 0.073; fig.1).
Benign Paroxysmal Positional Vertigo in the Elderly

Survival functions 1.0

0.8

Cumulative survival

0.6

0.4

0.2

Age groups 70 and older Under 70 70 and older-censored Under 70-censored 0 20 40 60 Follow-up (months) 80 100

Fig. 1. Time-to-event (recurrence) distribution across both groups. 96-month follow-up estimation (Kaplan-Meier procedure; log rank test, p = 0.073).

Table 1. Comparison between age groups: frequency of recur-

rence, complete resolution at the first visit, clinical presentation and waiting time Age groups 70 years <70 years (n = 211) (n = 193) Recurrence Yes 50 (23.7) 30 (15.5) No 161 (76.3) 163 (84.5) Resolution at the first visit Yes 136 (64.5) 149 (78.8) No 75 (35.5) 40 (21.2) Clinical presentation Unsteadiness 66 (31.3) 20 (10.6) Vertigo 145 (68.7) 169 (89.4) Mean time before visit, days 124.84 46.32 2 2 2 0.04 0.002 1106 Statistics p value

MannWhitney U 0.002

Figures in parentheses indicate percentages.

Since we presumed the survival curves to be asymmetric along the first 2 years of follow-up (as shown in the figures), and we found most of the recurrences within this time, we focused the analysis on this particular period, repeating the tests without considering the rest of the folGerontology DOI: 10.1159/000351204

Downloaded by: Gyeongsang National Univ. 203.255.32.93 - 7/23/2013 6:41:36 AM

Survival functions 1.0

0.8

0.6

0.4 Age groups 70 and older Under 70 70 and older-censored Under 70-censored 0 5 10 15 Follow-up (months) 20 25

0.2

Fig. 2. Time-to-event (recurrence) distribution across both groups.

24-month follow-up estimation (Kaplan-Meier procedure; log rank test, p = 0.001).

low-up, with the aim of proving or discarding our assumption. The results obtained by applying the described filter were 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 70 years old frequently report dizziness or imbalance as the clinical presentation of VPPB and, usually, they take longer to consult for their problem. Moreover, treating VPPB in elderly people is more difficult than in young people, as shown in our results, when comparing the proportion of complete resolution at the first visit after treatment, and the frequency of recurrences [9]. Older adults with balance disorders often initially turn to their general practitioner or a geriatrician. Given that about 9% incidence of unrecognized BPPV in older adults has 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 be able to make the diagnosis of BPPV because of the high incidence of this entity in the elderly [11].
4
Gerontology DOI: 10.1159/000351204

As found in other studies, the right ear is predominantly affected [12, 13]. It has been suggested that prolonged lying may facilitate the deposition of otoconia on the cupula or contribute to their loosening from the utricle. This mechanism might also explain why the laterality of BPPV often corresponds to the preferred side of lying during sleep [14]. Elderly patients with BPPV usually complain of multiple symptoms and do not always describe a rotatory crisis; sometimes, patients report dizziness or imbalance like in our study [15]. Generally, physical activity is significantly lower in patients with BPPV, mainly in elderly patients. Elderly patients show less daily leisure and household activity. Indeed, this disease increases the incidence of falls, thus increasing the chance of fractures, head trauma, hospitalizations, and depression. This risk of falls is significantly increased in those elderly patients with an associated BPPV [10], so it is advisable to manage it and its multiple variants to minimize the potential morbidity of their falls [16]. There are few reports regarding the changes of otoconial morphology with aging, not only saccular degeneration but utricular degeneration in which giant otoconia may appear through the loss of the controlled inhibition of mineralization with aging [7, 17, 18]. Treatment of BPPV can be difficult in the elderly for several reasons. Patients with decreased neck mobility may have problems achieving sufficient head rotation and reclination as required for the Epley maneuver. Alternatively, one can apply Semonts maneuver. Performing the maneuver is much easier when a second therapist supports the patient from behind [1]. Particle repositioning maneuver improves quality of life in BPPV patients in the long-term when compared to leaving BPPV untreated. The improvement in physical and social functioning and mental health perception is maintained after particle repositioning maneuver [15]. It is possible because the canalith repositioning procedure is effective in increasing the limit of stability and reducing body oscillation under conditions of inaccurate somatosensory information and visual-vestibular interaction [19]. Despite the benefits of the BPPV treatment with canalith repositioning maneuvers, affected elderly patients frequently show recurrences. A good follow-up of these patients is mandatory in order to diagnose the recurrences early. Some studies have estimated that recurrence occurs in approximately 50% of cases followed up in the medium and long term and, sometimes, reBatuecas-Caletrio etal.

Cumulative survival

Downloaded by: Gyeongsang National Univ. 203.255.32.93 - 7/23/2013 6:41:36 AM

peated [20]. In our case, recurrence appeared in 23.5% of patients, close to that given by others authors. On the other hand, the timing of recurrence is important because symptoms most likely return in the first year of follow-up in elderly people [12]. Although no statistical differences were found, when the long-term recurrence was studied in both age groups, a different behavior was observed over the course of the 2 first years when the older group showed a greater probability of recurrence.Therefore, we should consider extending the followup of our patients in order to detect the greater risk of recurrence. The resolution of balance disorders leads to an improvement in patients independence and social life thanks to 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 Clures test should be performed in older patients with dizziness,

although the patient does not explain the spinning sensation with positional changes. Not to miss treatable causes of dizziness like BPPV is imperative in older patients.

Conclusions

Although BPPV is known to be a frequent condition in elderly people, sometimes patients do not complain about attacks of vertigo but dizziness or imbalance. Generally, elderly patients take longer to go to the outpatient clinic despite losing quality of life. BPPV treatment with particle repositioning maneuvers is highly effective, but recurrences in older people are more frequent than in younger people, and the probability of not achieving complete resolution in the first visit is higher. For these reasons, an intensive follow-up should be considered for elderly patients affected by BPPV.

References
1 Bronstein A, Lempert T: Dizziness. A PracticalApproach to Diagnosis and Management. Cambridge, Cambridge University Press,2007, p 174. 2 Perez N, Garmendia I, Martin E, Boleas MS, Garcia-Tapia R: Health measurement instruments in patients with vertigo. Acta Otorrinolaringol Esp 2000;51:677685. 3 Salvinelli F, Trivelli M, Casale M, Firrisi L, Di peco V, DAscanio L, Greco F, Miele A, Petitti T, Bernabei R: Treatment of benign positional vertigo in the elderly: a randomized trial. Laryngoscope 2004;114:827831. 4 Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS: Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:20672074. 5 Lawson J, Johnson I, Bamiou DE, Newton JL: Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a falls and syncope unit. QJM 2005;98:357364. 6 Perez P, Franco V, Cuesta P, Aldama P, Alvarez MJ, Mendez JC: Recurrence of benign paroxysmal positional vertigo. Otol Neurotol 2012;33:437443. 7 Jang YS, Hwang CH, Shin JY, Bae WY, Kim LS: Age-related changes on the morphology of the otoconia. Laryngoscope 2006;116:9961000. 8 Angeli SI, Hawley R, Gomez O: Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaringol Head Neck Surg 2003;128:719725. 9 Celebiosy N, Bayam E, Gulec F: Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after canalith repositioning maneuvers. Gait Posture 2009;29:520523. 10 Oghalai JS, Manolidis S, Marth JL: Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122:630634. 11 Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR: Falls and instability in the elderly. J Am Geriatr Soc 1998;36:266278. 12 Soto Varela A, Rossi Izquierdo M, Martinez Capoccini G, Labella Caballero T, Santos Perez S: Benign paroxismal positional vrtigo of the posterior semicircular canal: efficacy of Santiago treatment protocol, long term follow up and analysis of recurrence. J Laryngol Otol 2012;126:363371. 13 von Brevern M, Seelig T, Neuhauser H, Lempert T: Benign paroxysmal positional vertigo predominantly affect right labyrinth. J Neurol Neurosurg Psychiatry 2004;75:14871488. 14 Lopez Escamez JA, Gamiz MJ, Fiana MG, Perez AF, Canet IS: Position in bed is associated with left or right location in benign paroxysmal positional vertigo of the posterior semicircular canal. Am J Otolaryngol 2002; 23: 263266. 15 Gamiz MJ, Lpez-Escamez JA: Health-related quality of life in patients over sixty years old with benign paroxysmal positional vertigo. Gerontology 2004;50:8286. 16 Prokopakis E, Vlastos IM, Tsagournisakis M, Christodoulou P, Kawauchi H, Velegrakis G: Canalith repositioning procedures among 965 patients with benign paroxysmal positional vertigo. Audiol Neurootol 2012; 18: 8388. 17 Johnsson LG: Degenerative changes and anomalies of the vestibular system in man. Laryngoscope 1971;81:16821694. 18 Ross MD, Peacor D, Johnsson LG, Allard LF: Observations on normal and degenerating human otoconia. Ann Otol Rhinol Laryngol 1976;85:310312. 19 Kasse CA, Gaspar-Santana G, Alves BrancoBarreiro FC, Coelho Scharlach RC, Gazzola JM, Freitas Gananca F, Dona F: Postural control in older patients with benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2012;146:809815. 20 Brandt T, Huppert D, Hecht J, Karch C, Strupp M: Benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484485.

Benign Paroxysmal Positional Vertigo in the Elderly

Gerontology DOI: 10.1159/000351204

Downloaded by: Gyeongsang National Univ. 203.255.32.93 - 7/23/2013 6:41:36 AM