|Year : 2019 | Volume
| Issue : 1 | Page : 1-5
Vertigo among elderly people: Current opinion
Santosh Kumar Swain1, Nishtha Anand1, Satyajit Mishra2
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Otorhinolaryngology, Sahid Laxman Nayak Medical College, Koraput, Odisha, India
|Date of Web Publication||14-Oct-2019|
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Vertigo or dizziness is a common handicapping clinical entity seen in elderly population. Its prevalence increases along with age. Vertigo among elderly people is a strong predictor of falls which is an important cause for accidental death. Vertigo or balance disorder in elderly people is a major public health problem and needs proper attention by trained clinician. Its etiology varies from peripheral cause to central causes or combined. A detail patient history and clinical examination are often essential for revealing the cause. The majority of causes for vertigo in elderly patients are of benign paroxysmal positional vertigo followed by migrainous vestibulopathy, idiopathic vestibulopathy, and vestibular neuritis. Proper diagnosis and management help to make a better and quality life in elderly patients suffering with vertigo. This review article describes etiology, epidemiology, clinical presentations, diagnosis, and current treatment of vertigo among elderly persons.
Keywords: Benign paroxysmal positional vertigo, elderly, peripheral vertigo, vertigo
|How to cite this article:|
Swain SK, Anand N, Mishra S. Vertigo among elderly people: Current opinion. J Med Soc 2019;33:1-5
| Introduction|| |
Balance of the body is always essential in all activities of daily living. Balance is a dynamic process, and its maintenance requires vestibular system, the visual system, the proprioceptive system, and the central nervous system. Impairment of any of the component leads to imbalance or vertigo. Vertigo is one of the important clinical symptoms which have a negative influence on the well-being among elderly population. Dizziness or vertigo is a common symptom among elderly people. There is a rise of elderly persons visiting the vertigo clinic with the complaint of dizziness. This may be due to gradual diminishing of vestibular function in elderly population and increase in life expectancy. Balance of the elderly depends on several factors including vestibular, visual, somatosensory structures, joint mobility, cognition, and adequate sensory function. The sensory structures are often impaired by certain diseases of the aging such as metabolic, cardiovascular, psychological, central nervous system disorders, diabetic neuropathy/retinopathy, cataracts, macular degeneration, senility of central, and peripheral vestibular system. There are certain factors such as sedentary lifestyle, self-medication, and polypharmacy which are aggregative to the balance of the body in elderly persons. The vertiginous disorders are often difficult to diagnose in older population, who frequently associated with comorbidities and potential causes for physical notability. Vertigo in elderly person may lead to falls in the elderly and often associated with high rate of morbidity and mortality. Although vertigo in old age represents life-threatening conditions, they are most often benign and self-limited diseases. Although vertigo is a common clinical problem among elderly age, there are few studies available in medical literature for vertigo in elderly age. This review article describes details of etiopathology, epidemiology, clinical presentations, diagnosis, and current treatment of the vertigo among elderly patients.
| Etiopathology|| |
The term vertigo or dizziness defines a variety of symptoms due to disorders of spatial orientation and motion perception such as illusion of rotatory motion or feeling of unsteadiness which hamper to achieve a stable posture, gaze, and gait. Aging of a person leads to progressive degeneration of the vestibular system along with neuromuscular, musculoskeletal, and sensory systems of the body. The term presbyastasis is often used to describe the age-related disequilibrium. Vertigo or dizziness is an important clinical symptom seen in the clinical practice and often seen in the older population. Vertigo is often contributed by several factors such as aging, old age associated with taking chronic use of drugs, and sometimes polypharmacy. Vestibular function, proprioception, and vision along with central connection to the brain play a vital role for maintaining balance. There are two factors responsible for vertigo in elderly population which is a major health-care problem. The first factor is the rise of elderly population in the present day due to improved health-care facilities in the country. The second factor is rising of the balance problems as increasing of the age. Elderly persons have often difficulty in sensory function, central nervous functions, and skeletal and neuromuscular functions. The chronic diseases in elderly persons such as atherosclerosis may cause damage to the labyrinthine functions and lead to peripheral vascular occlusion. Diabetes mellitus often accelerates atherosclerosis and leads to peripheral neuropathy. It is often challenging for knowing the exact meaning of dizziness complained by the patient. Age-related degeneration occurs at the neural structures such as vestibular receptors, central vestibular neurons, visual, proprioceptive pathways, and cerebellum. The hair cells of the vestibular organs and nerve fibers in the vestibular nerves reduced with age. Age-related neural deficits are seen largely in semicircular canals followed by saccular function, whereas utricle remains less affected in age-related degeneration. Central vestibular diseases are due to lesions at the central nervous system which integrate to the balance information. This type of damage occurs from space-occupying lesions such as tumors or aneurysms at the brain stem or stroke. Central disorders causing vertigo are often generalized symptoms such as dizziness, light-headedness, unsteadiness, or ataxia. The etiology of vertigo in elderly age is given in [Table 1].
| Epidemiology|| |
There is very little known about the epidemiological characteristics of vertigo in elderly population. Vertigo is a common clinical symptom seen in elderly people, and around 30% elderly persons in community present with vertigo. The prevalence of vertigo increases with age where 54% of elderly people over 90s present dizziness for 6 months. In elderly age, falls are major cause for accidental death after the age of 65 years where dizziness is one of the strongest factors for this disability. In one study, 1-year prevalence of old age person presenting to their family physician with vertigo was 88.3%. Vertigo is frequently encountered among medical referral or inpatients of the hospital as a primary or associated clinical symptom.
| Clinical Presentation|| |
Dizziness or vertigo is the most common clinical presentations in elderly person above the age of 65 years. Benign paroxysmal positional vertigo (BPPV) is the most common peripheral cause of vertigo where patients present with brief recurrent episodes of vertigo which occur following changes in the head position. Patients of vestibular neuronitis present with severe giddiness without any hearing loss and often preceded by upper respiratory tract infections. In Ménière's disease, the patient presents with triad of fluctuating symptoms of rotatory vertigo with tinnitus and ipsilateral hearing loss. Patients of migrainous vertigo often present with episodic headache and associated with vertigo. Many times, older population faces fall due to vertigo. Multiple neurosensory impairments may lead to vestibular symptoms in the old age. Concomitant decline in vision, proprioception, and/or neuromuscular function causes dizziness. Vestibulopathy in old age is more likely to report slow or incomplete resolution of their symptoms as central compensation works less effectively in old age. Sometimes, multisensory dizziness may be coined as a distinct diagnostic entity in elderly age group. The precise sensations of the patient regarding the dizziness are often helpful for better diagnosis. Vertigo refers to illusion of the movement and feels the movement of surrounding objects. The presyncope means feeling of lightheadedness, whereas disequilibrium refers to unsteadiness. Elderly population is often affected with vertigo which affects their mobility and leads to fall and other morbidities. Vertigo may be intense and sometimes accompanied by auditory and neurovegetative symptoms. Many times, the patient presents with intense emotional distress and shows anxiety and depression. Elderly patients with vertigo have high chance of mental disorders such as anxiety, depression, and phobias. The psychological symptoms limit social activities of the patients and affect their quality of life. Patients presented with psychological symptoms are more prone to disability in the form of mental and physical disability.
| Diagnosis|| |
There is always a challenge for clinician for getting a complete, meaningful, and treatment-oriented diagnosis of elderly vertigo patients. Good clinical history taking is often a tough task for clinician. The history of the patient such as symptoms of vertigo, medical history, medications, and alcohol intake if any should be documented. A good history taking is vital for assessing a patient with vertigo and helpful for the diagnosis in around 70% of the patients. Many times, elderly patient of vertigo is vague, inconsistent, or contradictory in describing the clinical symptom. No single symptom is enough for giving a definite diagnosis as elderly patients often have more than one cause for dizziness. Detailed examinations such as head-and-neck examinations, otoscopy, Dix–Hallpike test, and visual acuity and physical examinations such as pulse, blood pressure, and tests for orthostatic hypotension are essential for getting the diagnosis. The response of the caloric test depends on different factors such as external auditory canal volume, temporal bone thickness, and blood supply of the temporal bone which are affected by the age of the patient. Many studies revealed that caloric test response increases in the middle age with peak at 50–70 years and decreases modestly afterward. The abnormality in each semicircular canal can be assessed by head impulse test (HIT). Cervical and ocular vestibular evoked myogenic potentials (VEMPs) provide reliable information for utricle and saccular function independently. VEMP test evaluates the saccule and inferior vestibular nerve. The nonvestibular proprioceptive and visual sensory part of the balance and their central connection can be assessed by dynamic computed posturography. Neurological examinations such as examination of lower limb, tendon reflexes, and tandem gait are helpful to rule out central causes of vertigo. Routine audiological test like pure tone audiometry is done in all cases of vertigo to rule out certain diseases such as Ménière's disease, labyrinthitis, and acoustic neuroma, where concomitant cochlear lesions are seen. Few investigations such as random blood glucose, hemoglobin estimation, electrocardiogram, pure tone audiometry, and psychological questionnaire are helpful for the management of vertigo in elderly population. Patients of elderly vertigo often visit neurophysicians and are subjected to different investigations such as computed tomography scan and magnetic resonance imaging to rule our central cause of vertigo. Many times, simple tests such as Dix–Hallpike test, HIT, and supine roll test are enough to give clue for the diagnosis. The investigations such as electronystagmography (ENG), electrocochleography, and other tests may be used for the diagnosis. Simple tests for diagnosis and specific treatment help elderly population comfortable and avoid unnecessary medication on vertigo management. The craniocorpography test is a simple and informative test to evaluate the functional status of the vestibulospinal system and documents the rotation or deviation of the patient during performing Unterberger's stepping test with eyes closed. Smooth pursuit and optokinetic nystagmus are related with vestibulo–ocular reflex (VOR) which is diminished with age. The prevalence of vertigo is higher in the elderly and responds less effectively to the treatment and presents with recurrence. Special issues related to vertigo among elderly are in relation to difficulties for obtaining accurate history, falls, and some difficulty for performing diagnostic and therapeutic maneuvers which should be done slowly and cautiously to avoid any orthopedic and vascular complications.
| Treatment|| |
The successful treatment of elderly vertigo patients aims at reducing the disequilibrium and minimizes the risk of fall. Treatments of vertigo among elderly persons include treatment of specific conditions such as BPPV, pharmacological treatment of vertigo, and nausea with vomiting. Patients need counseling and reassurance. Patient often needs specific vestibular rehabilitation and prophylaxis for vertigo. BPPV is a common clinical entity for causing vertigo in elderly age. It is one of the most treatable causes of vertigo. Particle repositioning exercises like the Epley maneuver is the mainstay of treatment for BPPV. In a meta-analysis, 74% of patients of BPPV who had undergone the Epley maneuver got the clinical resolution of the symptoms. Brandt–Daroff exercises may be performed at home for BPPV and useful for recurrent attack although the treatment outcome is less than the Epley maneuver. However, the treatment of BPPV is sometimes difficult in the elderly for several causes. Patient with restricted neck mobility may have problems during head rotation in the Epley maneuver. In this situation, examination couch may be used where the head position is lowered 30° so that the head and trunk are reclined during maneuver and further reclination of the head is not needed. There is another alternative maneuver called Semont maneuver which does not need any kind of head reclination. In case of obese or frail patient, it is difficult for rapid body swing in case of Semont maneuver. The cognitive problems and fear for falling or dizzy interfere with performing self-treatment at home. Medications in vertigo of elderly person are often useful in case of acute phase of vertigo such as Meniere's disease, labyrinthitis, and acute vestibular neuronitis. In vestibular neuronitis, the symptomatic treatment with drugs like antiemetics and vestibular sedatives such as prochlorperazine or cyclizine are often helpful in the first few days of the acute attack. The duration of the treatment in vestibular neuronitis should not be done for more than a few days as they delay the central compensation mechanism and long-term recovery. Pharmacological treatment of acute vertigo is useful for symptomatic relief of vertigo in elderly persons. The treatment of migrainous vertigo includes standard treatment of migraine which includes analgesic, antiemetics, and 5HT1-receptor agonists like sumatriptan. The triggering factors for migraine should be avoided, and the prophylactic medications such as beta-blockers or tricyclic antidepressants are helpful for preventing recurrent attacks of migrainous vertigo. In case of dizziness due to postural hypotension, offending medications are first stopped. Patients are advised to stand up slowly and in stages. Sometimes, thigh-high thromboembolic deterrent stocking is helpful in postural hypotension, but this is not useful in case of peripheral vascular diseases. Peripheral selective α1-adrenergic agonist like midodrine is useful. A long-term antivertigo medication in old age is avoided as it obstructs vestibular compensation and again increases the chance of falls. Vestibular rehabilitation includes series of exercises such as adaption exercises, habituation exercises, substitution exercises, balance exercises, gait exercises, and general condition exercises. The adaption exercises aim to improve the VOR and include head movement with focus on a fixed target point. Habituation exercises aim to extinguish pathologic positionally provoked responses, whereas substitution exercises aim to learn alternative strategies to compensate for the deficits. Certain devices are designed to reduce fall and improve the overall mobility of elderly people. Devices such as walkers and canes widen the base of support and increase the somatosensory feedback. The footwear can be redesigned for enhancing the stability and balance of the body. Surgery for the vertigo is suggested when conservative treatment does not give adequate relief or in case of surgically correctible pathology of the peripheral vestibular system. The surgical procedures are labyrinthectomy, vestibular nerve section, posterior semicircular canal occlusion, and endolymphatic sac decompression. Sometimes, the etiology for vertigo in elderly patients is not found and is attributed as presbyastasis treated with vestibular rehabilitation therapy. The majority of elderly people should accept the need for caution and agree that they must walk slowly, turn more carefully, and expect their to be less steady than it was in young age. Vertigo among the elderly is a significant clinical problem with limited treatment options, warranting global research on biological strategies to regenerate or repair the vestibular organs to restore the functions. The use of gene therapy in managing vertigo appears promising in animal models of vestibular dysfunctions. In addition to discoveries of potential newer treatment for inducing vestibular hair cells, there have also been advances in scientific tools, which will help future studies and produce a new horizon for biological treatment toward inner ear or vestibular diseases.
| Conclusion|| |
Vertigo is a common complaint observed during elderly individuals. It is often due to the modest decline of vestibular function by aging process. A clinical history and detailed neuro-otological examinations are essential for assessing the vertigo among elderly population. The etiology of vertigo among the elderly is more likely to be vestibular or peripheral in origin. Dix–Hallpike test should be done in all cases of vertigo among elderly persons. If Dix–Hallpike test is positive, the Epley maneuver should be done. ENG is often done in vertigo protocol during managing vertigo among elderly population. Reduced vestibular function due to aging is a very common cause for vertigo or imbalance in elderly population. Vestibular rehabilitation exercises have great role for treating the vertigo in elderly people. The potential treatment options such as molecular and gene therapies for restoring vestibular dysfunction are considerable.
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