A Geriatric Perspective on Benign Paroxysmal Positional Vertigo

Seasonality of benign paroxysmal positional vertigo : A retrospective study from Central Europe

BACKGROUND

Although benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in clinical practice, factors influencing the pathophysiology remain not fully understood.

OBJECTIVE

Here we aim to investigate possible seasonal influences on the occurrence of BPPV in Vienna, a city located in a Central European country with pronounced seasonal fluctuations.

METHODS

We retrospectively investigated data from 503 patients presenting with BPPV to the outpatient clinics of the Medical University of Vienna between 2007 and 2012. Analyses included age, gender, type of BPPV, seasonal assignment, as well as daylight hours and the temperature in Vienna at symptom onset.

RESULTS

Out of 503 patients (159 male, 344 female, ratio 1:2.2; mean age 60 ± 15.80 years), most patients presented with posterior (89.7%) and left-sided (43.1%) BPPV. There was a significant seasonal difference (χ2 p = 0.036) with the majority of symptoms occurring in winter seasons (n = 142), followed by springtime (n = 139). Symptom onset did not correlate with the average temperature (p = 0.24) but on the other hand very well with daylight hours (p < 0.05), which ranged from 8.4 h per day in December, to an average of 15.6 h in July.

CONCLUSION

Our results show a seasonal accumulation of BPPV during winter and springtime, which is in line with previous studies from other climatic zones, suggesting an association of this seasonality with varying vitamin D levels.

Preceding Benign Paroxysmal Positional Vertigo as a Trigger for Persistent Postural-Perceptual Dizziness: Which Clinical Predictors?

OBJECTIVE

Persistent postural-perceptual dizziness (PPPD) is a syndrome described as secondary, when it is the consequence of an organic disorder (s-PPPD), or primary, when no somatic triggers can be identified. We evaluated a group of patients diagnosed as s-PPPD, with Benign Positional Paroxysmal Vertigo (BPPV) as the main somatic trigger, with the aim of identifying the predictive clinical elements of evolution towards PPPD.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

We evaluated 126 patients diagnosed with PPPD; 54 patients were classified as p-PPPD (43%) and 72 as s-PPPD (57%). Of these, 51 patients had BPPV as a somatic trigger of PPPD, and in this group, we evaluated the prevalence of some clinical features (age, sex, latency between the onset of BPPV and the final diagnosis, recurrence of BPPV and the presence of migraine headache) for comparison with a group of patients who suffered from BPPV without an evolution towards PPPD (control group).

RESULTS

In the group with PPPD secondary to BPPV, we found a significantly higher mean age and a longer latency between the onset of BPPV and the final diagnosis compared to the control group. No difference between the two groups was found regarding sex, recurrence rate and the presence of migraine headache.

CONCLUSIONS

The parameters most involved as potential precipitants of PPPD after BPPV were the age of the patients and a long latency between the onset of BPPV and the final diagnosis; the mean age of the subjects who developed PPPD following BPPV was significantly higher. These findings lead us to emphasize the importance of the early identification and treatment of BPPV, especially in older patients.

Geriatric benign paroxysmal positional vertigo: a single-center study

OBJECTIVE

To compare the clinical features, risk factors, distribution of Benign Paroxysmal Positional Vertigo (BPPV) subtypes, and effectiveness of canalith repositioning between geriatric and non-geriatric patients with BPPV.

METHODS

A total of 400 patients with BPPV were enrolled. Canalith repositioning was performed according to the semicircular canals involved. Patients were divided by age into a geriatric group (≥60 years) and a non-geriatric group (20-59 years). Clinical characteristics, potential age-related risk factors, distribution of subtypes, and effectiveness of canalith repositioning were compared between the groups.

RESULTS

Female sex was significantly more common in all age groups, with a peak female-to-male ratio of 5.1:1 in the group aged 50-59 years. There was a higher proportion of men in the geriatric group. A history of disease associated with atherosclerosis was significantly more common in the geriatric group (p < 0.05). Migraine was significantly more common in the non-geriatric group (p = 0.018), as was posterior canal BPPV. The horizontal canal BPPV (especially horizontal canal BPPV-cupulolithiasis), and multicanal BPPV subtypes were more common in the geriatric group, whereas anterior canal BPPV was more common in the non-geriatric group. Two canalith repositioning sessions were effective in 58.0% of the geriatric cases and in 72.6% of the non-geriatric cases (p = 0.002). There was a tendency for the effectiveness of canalith repositioning to decrease with increasing age.

CONCLUSION

BPPV was more common in women. However, the proportion of men with BPPV increased with age. Elderly patients often had a history of diseases associated with atherosclerosis (i.e., hypertension, diabetes, and hyperlipidemia). The horizontal canal BPPV (particularly horizontal canal BPPV-cupulolithiasis) and multicanal BPPV subtypes were more common and the anterior canal BPPV subtype was less common in elderly patients. The effectiveness of canalith repositioning may decrease with age. Therefore, older patients should receive more comprehensive medical treatment.

LEVEL OF EVIDENCE: 4

The reliability of a subtype-determining questionnaire in efficient benign paroxysmal positional vertigo diagnosis in geriatrics

Introduction

Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, especially for older adults, exposes patients to the lethal risk of falling. However, the diagnosis of BPPV in this population can be more elusive as they present few characteristic symptoms. Therefore, we explored the application of a subtype-determining questionnaire in BPPV diagnosis among the geriatric population.

Methods

Patients were assigned to the aware and unaware groups. In the aware group, the technician would directly test the suspected canal indicated by the questionnaire, whereas, in the unaware group, the technician performed the regular positional test. The diagnostic parameters of the questionnaire were examined.

Results

The accuracy, sensitivity, and specificity of questions 1-3 for diagnosing BPPV were 75.8, 77.6, and 74.7%, respectively. Question 4 demonstrated an accuracy of 75.6% in ascertaining the BPPV subtype, question 5 showed an accuracy of 75.6% in determining the affected side, and question 6 yielded an accuracy of 87.5% in distinguishing canalithiasis or cupulolithiasis. Examination time was shorter in the aware group than that in the unaware group (P < 0.05). No difference was found between the two groups for treatment time (P = 0.153).

Conclusion

This subtype-determining questionnaire is practical in daily use and capable of providing instructive information for an efficient diagnosis in geriatric patients with BPPV.

Older Adults with Vestibular Disorders and Hip Fractures Have High Rates of Meclizine Use

OBJECTIVES

To examine the risk factors for hip fracture in patients with vestibular disorders and the association between antihistamine use and hip fracture in patients with vestibular disorders.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Tertiary academic medical center.

METHODS

A retrospective review of adult patients with hip fracture based on International Classification of Diseases, Tenth Revision (ICD-10) code S72 from January 2013 to December 2019 who had previously been diagnosed with a vestibular disorder based on ICD-10 codes H81-83, A88.1, and R42.

RESULTS

A total of 201 patients were identified meeting the inclusion criteria. The average age at the time of hip fracture was 78.8 years and the majority were female (64.7%). Most patients were diagnosed with nonspecific dizziness (60.2%) or vertigo (23.9%). Those with a peripheral vestibular disorder included benign paroxysmal positional vertigo (BPPV) in 13.4% and Ménière's disease in 2.5%. Overall, meclizine was prescribed to 38.3% of patients, including 29.9% of patients before hip fracture. Meclizine was prescribed to 66.7% of patients with BPPV. Patients were seen for vestibular symptoms 0.67 ± 2.51 years before hip fracture, and 98 patients (48.8%) presented with vestibular concerns within 1 year prior.

CONCLUSION

Patients with vestibular disorders who sustain a ground level fall resulting in hip fracture are a vulnerable population of predominantly older adults with multiple comorbidities. Patients were frequently diagnosed with dizziness or vertigo rather than more specific causes being identified. Multifactorial interventions to prevent hip fractures in older adults have been recommended; however, this study suggests that meclizine use was common among patients diagnosed with dizziness, vertigo, or BPPV before hip fracture.

Association between otolin-1 and benign paroxysmal positional vertigo: A meta-analysis

Background

There is increasing research on the potential of inner ear proteins as serum biomarkers for the diagnosis and prognosis of various inner ear diseases. Among them, benign paroxysmal positional vertigo (BPPV) is the most common vestibular disease. Notably, otolin-1, an inner ear-specific protein, is detectable in the serum of most patients with BPPV patients. Therefore, we found a need to conduct this meta-analysis to determine the relationship between otolin-1 in serum and BPPV.

Methods

This meta-analysis was conducted by searching PubMed, EMBASE, Cochrane Library, Google Scholar, and China Network Knowledge Infrastructure databases for the eligible original studies in Chinese or English published between January 2010 and February 2022. Data were collected and pooled by using the mean differences (MDs) corresponding to 95% confidence intervals (CIs). Heterogeneity among these studies was assessed by using I² statistics and the adopted fixed or random-effect mode thereafter. Egger's and Begg's tests were also used to assess the publication bias.

Results

This meta-analysis included six articles with a total of 585 participants. Serum otolin-1 levels were remarkably increased in patients with BPPV as compared to that in healthy controls (MD: 165.38, 95% CI: 110.13-220.64, p < 0.00001). However, Egger's and Begg's tests have indicated no publication bias, and the results were reliable based on the sensitivity analysis.

Conclusion

This meta-analysis indicated that there is a higher serum level of otolin-1 in patients with BPPV than in healthy controls. Therefore, otolin-1 may serve as a biomarker for the onset of BPPV.

Risk Factors of Residual Dizziness After Successful Treatment for Benign Paroxysmal Positional Vertigo in Middle-Aged and Older Adults

Objective

The purpose of this study was to analyze risk factors of residual dizziness (RD) after successful treatment for benign paroxysmal positional vertigo (BPPV) in middle-aged and older adults.

Methods

181 patients with BPPV, after successful canalith repositioning maneuver (CRM) treatment, were recruited. All patients were divided into the middle-aged group (aged 45–59 years, n = 101) and the older group (over 60 years, n = 80). The clinical characteristics were recorded, including age, gender, numbers of maneuvers, involved canal, affected side, RD, comorbidities, dizziness handicap inventory score, and generalized anxiety disorder's 7-item scale score.

Results

The incidence of RD in the older group was significantly higher than that of the middle-aged group (p = 0.033). Multivariate logistic regression analysis shows that age (odds ratio = 1.042, p = 0.006), moderate to severe dizziness (odds ratio = 2.017, p = 0.034), and moderate to severe anxiety (odds ratio = 2.228, p = 0.017) were independently associated with RD in middle-aged and older adults.

Conclusion

Older adults exhibited higher incidence of RD after successful treatment for BPPV. Age, moderate to severe dizziness, and moderate to severe anxiety were independent risk factors of RD in middle-aged and older adults.

Examining Migraine as a Predictor of Benign Paroxysmal Positional Vertigo Onset, Severity, Recurrence, and Associated Falls

Introduction: The comorbidity of migraine and benign paroxysmal positional vertigo (BPPV) is well-established, yet the impact of migraine on the BPPV phenotype remains understudied.

Methods: A retrospective analysis of patients at a tertiary dizziness/vertigo clinic diagnosed with BPPV from 2015 and 2020 was conducted. The study's primary outcomes were the age of BPPV onset, Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls.

Results: In our cohort of 255 BPPV patients, 44.7% had a history of migraine. Those with migraine had an earlier age of BPPV onset than individuals without migraine (60.2 vs. 65.4, p = 0.0018). Migraineurs and non-migraineurs did not differ in their DHI (44.7 vs. 41.6, p= 0.44), recurrence rates (48.3% vs. 40.4%, p= 0.21), and falls (32.5% vs. 37.6%, p = 0.39). Among individuals with horizontal canal BPPV, a higher proportion of migraineurs experienced falls than non-migraineurs (50.0% vs. 6.3%, p = 0.02).

Conclusions: Migraineurs experience BPPV at a younger age than those without migraine. This finding suggests that migraine, which has been shown to cause inner ear damage, predisposes individuals to developing BPPV earlier. Migraine was also associated with a higher rate of falls among patients with horizontal canal BPPV, indicating that a migraine history may impact the phenotype of BPPV.

The perception of family members regarding patient's vertigo and imbalance

INTRODUCTION AND OBJECTIVES

Family members play a major role in the assessment and final result of the treatments of patients. The goal of the present study was to evaluate how much the perception of patients' family members could be trusted regarding the vertigo and imbalance which they experienced.

MATERIALS AND METHODS

A cross-sectional study was conducted on 110 patients and their family members who were referred to the Central Vestibular Clinic in Mashhad from April 2018 to September 2019. Family members were categorized as spouses, children, and other relatives of patients. Patients and their family members separately completed the Dizziness Handicap Inventory (DHI) by the paper and pencil method. DHI has a high reliability, validity, and internal consistency.

RESULTS

Mean DHI scores of patients and their family members were 45.35±20.24 and 42.01±22.83, respectively. The correlation between DHI scores of patients and family members, except children, were significant (p<.05).

CONCLUSION

A relatively weak to moderate relationship between the perception of patients and their family members, except children, was found. They were more aware of the physical aspects of vertigo and imbalance than the emotional ones.

Dizziness and benign paroxysmal positional vertigo among retirement home residents: a cross-sectional descriptive and interventional study

Background

The prevalence of dizziness increases with age. We aimed to determine the point prevalence of dizziness and, in particular, of benign paroxysmal positional vertigo (BPPV) among retirement home residents. Furthermore, we aimed to evaluate the efficacy of a 2-axis turntable based BPPV treatment.

Methods

We contacted all large retirement homes in or around the city of Zurich (Switzerland). 10 retirement homes (with a total of 536 residents) agreed to participate in this study. 83 rejected inquiries by residents led to a potential study population of 453 residents. After a structured interview evaluating the presence and characteristics of dizziness, all willing patients were tested for positional vertigo and nystagmus on a portable and manually operated 2-axis turntable that was transported to the retirement home. Testing consisted of the Dix-Hallpike and supine roll maneuvers to both sides. Participants were immediately treated with the appropriate liberation maneuver whenever BPPV was diagnosed. Otherwise, taking the resident’s medical history, a neuro-otological bedside examination, and a review of the available medical documentation was used to identify other causes of dizziness.

Results

Out of the 453 residents, 75 (16.6%; average age: 87.0 years; 68% female) were suffering from dizziness presently or in the recent past and gave their consent to participate in this study. Among the participants tested on the turntable (n = 71), BPPV was present in 11.3% (point prevalence). Time-related properties, triggering factors and qualitative attributes of vertigo or dizziness were not significantly different between the dizzy participants with and those without BPPV. In all BPPV patients, appropriate liberation maneuvers were successful.

Conclusions

BPPV could be demonstrated in about one tenth of retirement home residents with dizziness or recent dizziness. Such point prevalence of BPPV translates to a much higher yearly prevalence if one assumes that BPPV is not present on every day. Our finding suggests that retirement home residents suffering from dizziness should be regularly tested for BPPV and treated with appropriate liberation maneuvers, ideally on turntable to reduce strain.

Trial registration

ClinicalTrials.gov Identifier NCT03643354.

The Reliability of Anamnestic Data in the Management of Clostridium Tetani Infection in Elderly

Background: Tetanus infection remains a significant complication of wounds. Because most tetanus treatment guidelines rely on anamnestic data collected directly from patients, the congruence between anamnesis and laboratory evidence must be verified, especially in the elderly population.

Aim: Assess, in both the geriatric population (>65) and the non-geriatric one, the reliability of anamnestic data for managing patients with tetanus-risk wounds, identified categories of populations most exposed to non-vaccination coverage, and assessed the agreement of the Tetanos Quick Stick (TQS) results with the therapy performed (administration of tetanus vaccine or immunoglobulin).

Methods: In this retrospective single-center observational study, patients were asked their immunization status against tetanus vaccination. The decision to administer a vaccine or immunoglobulin was therefore clinical and based on anamnestic criteria. The TQS test was then given to patients who were unaware of their immunity status. Patients who thought they knew it but were not sure were given the TQS test to determine whether the anamnestic collection was supported by the test. The TQS test results were compared with the anamnestic data.

Results: Most patients, geriatric and not geriatric, did not know their immune status. Among those who reported knowing their immune status, there was no agreement between the vaccine coverage declared by patients and the TQS test results (p < 0.001), mainly in geriatric patients but also in the control group. Elderly and women had significantly lower positive TQS test results (p < 0.001). There was a statistically significant discrepancy (p < 0.001) between the therapy based on anamnestic data and the TQS test results.

Conclusion: The reliability of anamnestic data for the management of patients with tetanus-risk wounds is low and decreases with age, becoming minimal in geriatric patients. Elderly and women are less likely to have an effective vaccination status against tetanus.

The frequency and impact of undiagnosed benign paroxysmal positional vertigo in outpatients with high falls risk

BACKGROUND

The frequency and impact of undiagnosed benign paroxysmal positional vertigo (BPPV) in people identified with high falls risk has not been investigated.

OBJECTIVE

To determine the frequency and impact on key psychosocial measures of undiagnosed BPPV in adult community rehabilitation outpatients identified with a high falls risk.

DESIGN

A frequency study with cross-sectional design.

SETTING

A Community Rehabilitation Program in Melbourne, Australia.

SUBJECTS

Adult community rehabilitation outpatients with a Falls Risk for Older People in the Community Screen score of four or higher.

METHODS

BPPV was assessed in 34 consecutive high falls risk rehabilitation outpatients using the Dix-Hallpike test and supine roll test. Participants were assessed for anxiety, depression, fear of falls, social isolation and loneliness using the Hospital Anxiety and Depression Scale, Falls Efficacy Scale-International and De Jong Gierveld 6-Item Loneliness Scale.

RESULTS

A total of 18 (53%; 95% confidence interval: 36, 70) participants tested positive for BPPV. There was no significant difference between those who tested positive for BPPV and those who did not for Falls Risk for Older People in the Community Screen scores (P = 0.555), Hospital Anxiety and Depression Scale (Anxiety) scores (P = 0.627), Hospital Anxiety and Depression Scale (Depression) scores (P = 0.368) or Falls Efficacy Scale-International scores (P = 0.481). Higher scores for the De Jong Gierveld 6-Item Loneliness Scale in participants with BPPV did not reach significance (P = 0.056).

CONCLUSIONS

Undiagnosed BPPV is very common and associated with a trend towards increased loneliness in adult rehabilitation outpatients identified as having a high falls risk.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV.

METHODS

Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined.

RESULTS

Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007).

CONCLUSIONS

Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Vertigo: Streamlining the Evaluation through Symptom Localization

Vertigo is defined as the illusion of internal or external motion. The evaluation of a patient with vertigo in the primary care setting should not necessarily focus on providing a specific diagnosis. Rather, the physician should aim to localize the lesion. This practice streamlines the workup of patients. This article provides detailed information regarding appropriate organ system-based clinical history and the clinical workup of vertigo. Additional signs and symptoms that can facilitate appropriate referral and treatment are highlighted. Although disorder-specific treatments exist the mainstay of therapy for vertigo-induced pathology is physical therapy.

The perception of family members regarding patient's vertigo and imbalance

INTRODUCTION AND OBJECTIVES

Family members play a major role in the assessment and final result of the treatments of patients. The goal of the present study was to evaluate how much the perception of patients' family members could be trusted regarding the vertigo and imbalance which they experienced.

MATERIALS AND METHODS

A cross-sectional study was conducted on 110 patients and their family members who were referred to the Central Vestibular Clinic in Mashhad from April 2018 to September 2019. Family members were categorized as spouses, children, and other relatives of patients. Patients and their family members separately completed the Dizziness Handicap Inventory (DHI) by the paper and pencil method. DHI has a high reliability, validity, and internal consistency.

RESULTS

Mean DHI scores of patients and their family members were 45.35±20.24 and 42.01±22.83, respectively. The correlation between DHI scores of patients and family members, except children, were significant (p<.05).

CONCLUSION

A relatively weak to moderate relationship between the perception of patients and their family members, except children, was found. They were more aware of the physical aspects of vertigo and imbalance than the emotional ones.

Current Insights into Treating Vertigo in Older Adults

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.

Benign Paroxysmal Positional Vertigo and the Increased Risk of Ischemic Stroke: A Nested Case-Control Study Using a National Cohort Sample

A recent population cohort study reported that benign paroxysmal positional vertigo (BPPV) was a risk factor for ischemic stroke. This study investigated the risk of ischemic and hemorrhagic strokes in patients with BPPV. A nested case-control study used the data from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. We used data of patients aged ≥50 years obtained from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. A total of 15,610 patients with ischemic stroke and 4,923 patients with hemorrhagic stroke were matched for age, sex, income, residential location, hypertension, diabetes, and dyslipidemia with 62,440 and 19,692 controls, respectively. History of BPPV was evaluated in the stroke and control groups. Crude and adjusted odds ratios (ORs) for stroke in patients with BPPV were analyzed using stratified logistic regression analysis. Subgroup analyses were performed for age and sex. Notably, 3.7% (572/15,610) of patients with ischemic stroke and 2.7% (1,702/62,440) of the control subjects reported a history of BPPV (P < 0.001). The adjusted OR for BPPV in patients with ischemic stroke was 1.35 (95% confidence interval (CI) 1.22-1.49, P < 0.001). Patients with ischemic stroke showed higher ORs for BPPV in the subgroup of women. Patients with hemorrhagic stroke did not show a high OR for BPPV. Ischemic stroke patients demonstrated the increased OR for BPPV in subjects aged ≥50 years old.

Monthly and seasonal variations in benign paroxysmal positional vertigo

BACKGROUND

Several studies on seasonal variation in benign paroxysmal positional vertigo (BPPV) have been reported. However, the association between season and BPPV remains controversial; thus, further study is required.

OBJECTIVE

We analyzed patients with BPPV to evaluate monthly and seasonal variations.

METHODS

Patients with BPPV seen between 2013 and 2017 were retrospectively enrolled in this study. Differences among the months and seasons of BPPV visits were analyzed. Patients were divided into two groups according to age (65 years or older and younger than 65 years) and sex, respectively, and the differences were analyzed in each group.

RESULTS

There was no significant difference in the monthly or seasonal distribution of BPPV in the 1,216 patients. There was also no significant difference in the monthly or seasonal distribution in the older and younger groups or in male and female patients.

CONCLUSIONS

There was no significant difference in the monthly or seasonal distribution of patients with BPPV. Additional studies on seasonal variation in BPPV are required in terms of not only vitamin D levels but also other associated factors.

Unhealthy Lifestyle Is an Important Risk Factor of Idiopathic BPPV

Background: Benign paroxysmal positional vertigo (BPPV) is a self-limiting and recurrent disease but the cost is considerable. The number of patients with BPPV increased significantly under the quarantine policy in Hangzhou. The unhealthy lifestyle risk factors of BPPV have not yet been investigated. Thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of BPPV. Methods: One hundred and sixty three patients with idiopathic BPPV aged 22-87 years (BPPV group), and 89 aged 23-92 years sex-matched control subjects (non-BPPV group) were enrolled in this study. All BPPV patients received a definitive diagnosis which excluded secondary BPPV. Non-BPPV cases excluded BPPV, sudden deafness, Meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. We obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. To get the time of physical activities and recumbent positions, we asked the patient or their family from February 2020 to June 2020, and the rest of the patient's information was acquired by phone or WeChat. Data Analyses: The t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. For each factor, odds ratios were calculated with 95% confidence intervals (CIs). Moreover, test equality of two or more receiver operating characteristic (ROC) analyses were applied to the physical activities, and recumbent position time; area under curve (AUC) measures were calculated with 95% CIs and compared with each other. Results: The BPPV group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or VD supplementation in univariate logistic regression analyses (P < 0.05). Poor physical activities and prolonged recumbent position time were independently associated with BPPV in multiple logistic regression models (OR = 18.92, 95% CI: 6.34-56.43, p = 0.00 and OR = 1.15, 95% CI: 1.01-1.33, p < 0.04). In the comparison of ROC curves of recumbent position time and physical activities in identifying BPPV, AUCs were 0.68 (0.61-0.74), and 0.68 (0.63-0.73), respectively. Conclusion: We conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for BPPV patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, CHD, and CI, may not be.

Benign Paroxysmal Positional Vertigo in the Elderly: A Single-center Experience

OBJECTIVES

Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral academic center.

PATIENTS

The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included.

MAIN OUTCOME MEASURES

Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM).

RESULTS

Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM.

CONCLUSION

The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.

Evaluation of bone mineral density and 25-(OH) vitamin D levels in middle-aged and elderly women with recurrent benign paroxysmal positional vertigo

Background: Middle-aged and elderly perimenopausal women are prone to developing BPPV without definite cause. Objectives: This study aimed to investigate the correlation between bone mineral density (BMD), 25-(OH) vitamin D, and serum calcium levels in patients with benign paroxysmal positional vertigo (BPPV) in middle-aged and elderly women.Material and methods: A total of 103 women with two or more recurrent BPPV episodes (group A) and 80 age-matched healthy controls (group B) were recruited. All subjects had BMD and serum 25-(OH) D levels measurements taken, and the results were compared.Results: BMD was reduced in group A, and the proportion of osteoporosis was higher than in group B (p = .039). The BMD T-score and 25-(OH) vitamin D level were lower in group A than in group B (p = .004 and p < .0001, respectively). In group A, the BMD T-score was lower (p = .017) and serum 25-(OH) vitamin D level was higher (p < .0001) in premenopausal women than in menopausal women.Conclusions and Significance: Our study found that middle-aged and elderly women with recurrent BPPV, especially postmenopausal women, may present decreased BMD and serum vitamin D levels.

Clinical Characteristics and Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) manifests itself as a paroxysm of vertigo and nystagmus lasting several seconds, which is self-limiting. The clinical characteristics and risk factors for the recurrence of BPPV in different ages have not yet been investigated.

Materials and Methods: A retrospective observational study was conducted in the Department of Neurology in Beijing Tiantan Hospital from July 2009 to June 2015. The study included 1,012 patients aged 18–93 years. All patients received the definitive diagnosis and canalith repositioning maneuvers treatment and finally accomplished follow-up. Demographic variables, potential recurrence risk factors, neurological examination, and laboratory indexes were assessed.

Data Analyses: The t-test or chi-squared test was first performed for group comparison, then logistic regression analysis was used to investigate the risk factors of BPPV recurrence.

Results: The 1-year recurrence rates of BPPV patients after reposition maneuvers were, respectively, 22.79% (aged 18–45 years), 23.92% (aged 45–60 years), 28.89% (over 60 years). The recurrence rates among the three groups have no statistically significant difference. Logistic regression analysis shows that women BPPV patients have more recurrence risks than do men. Ménière's disease (odds ratio = 6.009, 95% confidence interval: 2.489–14.507, p < 0.001), hypertension (odds ratio = 1.510, 95% confidence interval: 1.095–2.084, p = 0.012), migraine (odds ratio = 2.534, 95% confidence interval: 1.164–5.516, p = 0.019), and hyperlipemia (odds ratio = 1.419, 95% confidence interval: 1.024–1.968, p = 0.036) were risk factors for the recurrence of BPPV in patients.

Conclusion: We conclude that Ménière's disease, hypertension, migraine, and hyperlipemia may be independent risk factors for the recurrence of BPPV in patients, but aging does not increase the recurrence risk.

A Relationship Between Blood Levels of Otolin-1 and Vitamin D

OBJECTIVE

Low vitamin D levels have been associated with and could play a role in the pathogenesis of idiopathic benign paroxysmal positional vertigo (iBPPV). Since otoconia degeneration contributes to iBPPV and a lack of vitamin D may impact otoconia structure and integrity, we proposed a negative association between vitamin D levels and levels of a proposed circulatory biomarker for otolithic degeneration, otolin-1.

STUDY DESIGN

Cross-sectional clinical study.

SETTING

Clinical research center.

PATIENTS

Seventy-nine men and women ranging in age from 22 to 95 years old without known vertigo.

INTERVENTIONS

Diagnostic.

MAIN OUTCOME MEASURES

Blood levels of 25-OH vitamin D and otolin-1.

RESULTS

Previously, we had reported higher otolin-1 levels in older age groups. The majority of the subjects (83%) had vitamin D levels that were below 40 ng/ml. Vitamin D level was lowest in the young and increased with age before declining in subjects 70 years of age and older (p = 0.005). There was a negative correlation between vitamin D and otolin-1 levels of subjects over 70 (r = -0.36, p = 0.036).

CONCLUSION

Our results demonstrate a relationship between vitamin D and otolin-1. The majority of our subjects had abnormally low vitamin D levels, but only those over 70 years of age showed a negative correlation with high otolin-1 levels. We postulate that a seasonal drop in vitamin D may not be sufficient for otoconia fragmentation and ultimately iBPPV, rather, chronically low vitamin D maybe required to induce otoconia degeneration.

Caloric tests in clinical practice in benign paroxysmal positional vertigo

Background: The value of caloric tests in benign paroxysmal positional vertigo (BPPV) patients is unclear. Objectives: To analyze the features and clinical significance of caloric tests in BPPV patients. Materials and methods: About 2192 patients (256 BPPV and 1936 non-BPPV) who complained of dizziness triggered by movement, accompanied by the symptom of hearing loss or a history of vertigo, participated in this prospective clinical study. All subjects received a caloric test, 213 BPPV patients underwent follow-up for at least 6 months after canalith repositioning procedures (CRPs). Results: (1) The abnormal canal paresis (CP) prevalence of BPPV was 57%. (2) The curative rate of single CRP decreased during follow-up from 90.1% after 7 days to 61% after 6 months and was significantly lower in patients with (54.1%) than in those without (70.1%) an abnormal CP at 6 months post-treatment (p = .01). (3) The recurrent rate was significantly higher in BPPV patients with abnormal CP (25.2%) than with normal CP (12.5%; p = .017). Conclusions and significance: Patients with abnormal CP needed more CRPs and were more prone to relapse. The value of the caloric test in treatment planning and predicting recurrence in BPPV patients should be emphasized.

Benign paroxysmal positional vertigo in the elderly: current insights

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.

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

OBJECTIVES

Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

METHODS

We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

EXPECTED RESULTS

The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients' quality of life, functioning and participation.

CONCLUSIONS

The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.

Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin

Background

Intracranial hemorrhage is the most devastating complication in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC). It can be either spontaneous or caused by head trauma. We sought to address the prevalence, clinical characteristics, and prognosis of traumatic and spontaneous intracranial hemorrhages in AF patients on OAC.

Methods

Multicenter FibStroke registry of 5,629 patients identified 592 intracranial hemorrhages during warfarin treatment between 2003 and 2012.

Results

A large proportion (40%) of intracranial hemorrhages were traumatic. Of these, 64% were subdural hemorrhages (SDHs) and 20% intracerebral hemorrhages (ICHs). With respect to the spontaneous hemorrhages, 25% were SDHs and 67% ICHs. Patients with traumatic hemorrhage were older (81 vs 78 years, p = 0.01) and more often had congestive heart failure (30% vs 16%, p < 0.01) and anemia (7% vs 3%, p = 0.03) compared to patients with spontaneous hemorrhage. Admission international normalized ratio (INR) values (2.7 vs 2.7, p = 0.79), as well as CHA₂DS₂-VASc (median 4 vs 4, p = 0.08) and HAS-BLED (median 2 vs 2, p = 0.05) scores, were similar between the groups. The 30-day mortality after traumatic hemorrhage was significantly lower than after spontaneous hemorrhage (25% vs 36%, p < 0.01).

Conclusions

A significant proportion of intracranial hemorrhages in anticoagulated AF patients were traumatic. Traumatic hemorrhages were predominantly SDHs and less often fatal when compared to spontaneous hemorrhages, which were mainly ICHs. Admission INR values as well as CHA₂DS₂-VASc and HAS-BLED scores were similar in patients with spontaneous and traumatic intracranial hemorrhage.

Clinicaltrialsgov identifier

NCT02146040.

Hemorrhagic stroke after Epley maneuver: a case report

BACKGROUND

This is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults.

CASE PRESENTATION

A 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit.

CONCLUSION

The Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.

Age-Related Increase in Blood Levels of Otolin-1 in Humans

OBJECTIVE

To test the hypothesis that age-related demineralization of otoconia will result in an age-related increase in blood levels of otoconia matrix protein, otolin-1.

STUDY DESIGN

Cross-sectional observational clinical trial.

SETTING

Clinical research center.

PATIENTS

Seventy nine men and women ranging in age from 22 to 95 years old.

INTERVENTIONS

Diagnostic.

MAIN OUTCOME MEASURES

Blood levels of otolin-1 in relation to age.

RESULTS

Levels of otolin-1 of subjects divided into four age groups (1: 20-30 [n = 20], 2: 50-65 [n = 20], 3: 66-80 [n = 20], 4: 81-95 [n = 19] years old) demonstrated an increasing trend with age. The difference between otolin levels of groups 2 and 3, as well as, (p = 0.04) and 2 and 4 (p = 0.031) were statistically significant, but there was no significant difference between the two oldest groups.

CONCLUSIONS

Otolin-1 blood levels are significantly higher in patients older than 65 years of age. This is consistent with previous scanning electron microscopy findings of age-related otoconia degeneration and increased prevalence of benign paroxysmal positional vertigo (BPPV) with age. Normative data provided here can serve as important reference values against which levels from BPPV patients can be compared with further evaluate otolin-1 as a circulatory biomarker for otoconia degeneration.

Idiopathic benign paroxysmal positional vertigo in the elderly: a long-term follow-up study

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral-type vertigo in the elderly. While some studies have investigated BPPV among the elderly, no study has focused on the isolated idiopathic BPPV (iBPPV) in the elderly.

AIMS

To investigate the clinical features and recurrence rate in elderly patients diagnosed with iBPPV.

METHODS

The authors prospectively reviewed the medical records of 627 patients diagnosed with BPPV, and a total of 370 patients fulfilled the inclusion criteria. The subjects were divided into two groups by age (experimental group ≥65 years and control group 17-64 years), and the gender, numbers of canalith reposition maneuver (CRM) for successful treatment, time elapsed from onset of symptoms to clinic visit, the affected semicircular canal, and the 1- and 5-year recurrence proportion were analyzed.

RESULTS

The gender, numbers of CRM for successful treatment, affected semicircular canal, and the 1- and 5-year recurrence proportion showed no statistically significant difference between two groups (p > 0.05). The only exception was the experimental group which took a longer duration from manifestation of symptoms to hospital visit than control group (student's t test, p = 0.021).

DISCUSSION

Several previous studies report that the elderly with iBPPV shows more protracted clinical course and much higher recurrence rate than younger adult. Unlike those reports, our study showed no significant differences about the clinical features and recurrence rate between age groups.

CONCLUSION

The elderly with iBPPV could be treated as effective as general population.

Reduction of bone mineral density in native Chinese female idiopathic benign paroxysmal positional vertigo patients

OBJECTIVE

This study aimed to investigate the clinical association between idiopathic benign paroxysmal positional vertigo (BPPV) and reduction of bone mineral density (BMD).

METHODS

BMD was measured in 78 native Chinese female de novo idiopathic BPPV patients and 126 healthy controls using dual-energy X-ray absorptiometry. We compared the mean T-scores and abnormal BMD prevalence between the two groups.

RESULTS

The mean T-scores were significantly lower in idiopathic BPPV patients than in healthy controls. The prevalence of osteopenia and osteoporosis were significantly higher in idiopathic BPPV patients than in healthy controls (65.4% vs 48.4%, p=0.013).

CONCLUSION

BMD reduction may be associated with idiopathic BPPV occurrence.

An Abbreviated Diagnostic Maneuver for Posterior Benign Positional Paroxysmal Vertigo

Introduction

Benign paroxysmal positional vertigo (BPPV) secondary to canalolithiasis of the posterior semicircular canal is perhaps the most frequent cause of vertigo and dizziness. One of its properties is a high response rate to canalith repositioning maneuvers. However, delays in the diagnosis and treatment of this entity can range from days to years, depending on the setting. Here, we present an abbreviated variation of the Dix–Hallpike maneuver, which can be used to diagnose this disease. It is similar to the standard maneuver but can be performed without an examination bed/table and requires only a backed chair (a difference that we feel is very important in settings where a clinical bed/table is not readily available).

Methods

A diagnostic assessment study was conducted in 163 patients who presented with vertigo or dizziness.

Results

The abbreviated test had fairly good sensitivity (80%) and high specificity (95%) for diagnosing posterior BPPV.

Discussion

This new diagnostic maneuver may serve as a screening procedure for quickly identifying this pathology. This will allow patients to be more directly treated, without requiring unnecessary referrals or full vestibular testing, and will be especially useful in primary care settings or heavily overloaded otolaryngology or neurology departments.