Benign paroxysmal positional vertigo (BPPV) is a disorder arising in the inner ear. Its symptoms are repeated episodes of positional vertigo—a spinning sensation caused by changes in the position of the head. BPPV is the most common cause of the symptoms of vertigo. The term paroxysmal is used because characteristically this condition is episodic and not continuous, furthermore as the feeling of vertigo appears to be precipitated in specific positions it is called positional even though the symptoms are elicited by rotational movement of the head rather than by the final position of the head.1
It was first described by Barany in 1921 and Dix and Hallpike demonstrated the geotropic and torsional nystagmus with provocation to localise the pathology in the proper ear in 1952. It usually leads to patients complaining of vertigo on extending or turning the neck, getting up or lying down or rolling over in the bed.2 A characteristic of BPPV is absence of any hearing loss in association with dizziness though in the case of the elderly population degenerative processes may cause a simultaneous alteration of auditory systems causing some deafness.3
The estimated incidence of BPPV is between 10.7 to 64 per 100,000 per year, and it increases with age.4,5 A German study has found a lifetime prevalence of 2.4% with a cumulative incidence approaching 10% by age 80.6 It is the commonest cause of vertigo in adults and by the age of 70, 30% of individuals have had the disorder at least once.7,8 BPPV and dizziness are associated with falls and falls represent a significant risk of serious injury and death.9 Treatment of the BPPV by particle repositioning manoeuver (PRM) improves the patient condition and reduces the incidence of falls in the elderly.10


Pathophysiology
The pathology of BPPV originates in the inner ear that contains the three semicircular canals (SCC) oriented perpendicular to each other. The cupula is the structure within the SCCs, which helps in the detection of movement. The exact pathophysiology of BPPV is not yet completely understood but the accepted mechanisms are cupulolithiasis11 and canalithiasis.12
Schukencht postulated that basophilic particles or densities adherent to the cupula rendered the posterior SCC sensitive to gravity causing persistent nystagmus and dizziness when a patient is tilted backward. This is also the reason that the vast majority of BPPV patients suffer from disease originating in the posterior canal.
Epley in 1980 published his theory of canalithiasis causing BPPV, which put forward the idea that the symptoms of this condition are more correctly explained by presence of free moving densities (canaliths) in the posterior SCC. This model is better at explaining the delay, transient nystagmus and improvement of symptoms with change in posture, which is characteristic of this pathology, and has been further corroborated by findings of free densities in the posterior SCC at surgery.13
Various age-related changes in the vestibular system increase the susceptibility of the elderly to develop dizziness. Some of these are the age-related loss of hair cells within the cristae ampullaris of the semicircular canals and the maculae of the saccules and urtricle,14 the reduction of the number of primary vestibular neurons within Scarpa’s ganglion15 and decrease in the number of secondary vestibular neurons within the vestibular nuclei.16
The ageing hypothesis of BPPV proposes that the detachment of otoconia from the macula is the result of degenerative changes in the utricle, possibly due to chronic ischaemia. As the inner ear arteries are end arteries any decrease in blood flow can have a profound effect. There are various triggering factors that have been implicated in the causation of BPPV,17,18.

Presentation and diagnosis
Common situations that provoke vertigo in BPPV are when patients roll into a lateral position in the bed, look upward, or bend forward. The dizziness is often associated with nausea, with or without vomiting. The episode usually lasts for only 10 to 20 seconds and recurs. This is a self-limiting disorder but can persist for several weeks or even years. The presentation in the elderly may be more gradual and sudden deterioration in symptomatology may be caused by decompensation of pre-existing peripheral vestibular pathology.
There are no laboratory or imaging tests to diagnose BPPV. Confirmation of this problem therefore rests with history and physical tests. Screening questions that give a strong indication of the possibility of BPPV can also be used and the presence of a spinning sensation without lightheadedness has a 56% sensitivity for indicating BPPV.19
Sometimes the history itself is very suggestive of the diagnosis and if the patient reports the appearance of the distressing symptoms such as “turning in bed at night, or hanging the washing on the line, or looking under the car” then BPPV should be high on the differential diagnosis list.20
Other questions that can be asked to elicit indicators towards the diagnosis of BPPV are:
1. Do you feel dizzy while turning in the bed?
2. Do you feel dizzy when you turn your head quickly?
3. Do you feel dizzy when you lift your head or upper part of the body off the pillow?
4. Do you veer towards one side on walking?
5. Do you have to hold on to something when you turn quickly?
Among the various physical tests described in literature the one described by Dix and Hallpike21 in 1952 remains most common. The test involves seating the patient on a couch, turning their head by 45 degrees to one side and then bringing them quickly to a position 30 degrees below horizontal. The procedure, if negative on one side is then repeated by turning the head to the other side.
For a positive test the patients’ eyes are observed for the appearance of the typical geotropic and torsional nystagmus. There is a latent period of 5–10 seconds before the nystagmus appears and this is nearly always preceded by an appearance of distress. The nystagmus should be reversed on returning the patient to a sitting position.
Even though the sensitivity of this test in diagnosing BPPV is in the range of 50% to 78%,22,23 this remains the gold standard in confirming the presence of BPPV. There are video examples of this test easily available on the internet.24
In the elderly the Dix-Hallpike manoeuver can be modified to fit the patient’s situation. The patient need not be moved vigorously as the movement of canaliths is dependent on gravity and not on acceleration of the body.
The hyperextension of the neck can also be limited as symptoms can usually be induced by simple turning in the bed. Further help can be provided by having additional assistants to help position the patient and in severe neck or back problems, specialised equipment may be needed.25
Local experience at our institution suggests that using a hospital bed in the head down position facilitates doing the manoeuver, even in the frail elderly.


BPPV and falls
Falls is one of the geriatric giants, causing severe morbidity and mortality. It is the sixth largest cause of death in people aged 65 and above,26 and is responsible for 70% of accidental deaths in those aged 75 and over.27 The causes of falls are legion but one of the complaints that patients frequently present with is dizziness. Depending on the cutoff age of the study participants, type of symptoms studied, and the selection of the participants, it is estimated that half to third of the elderly (>65 years of age) have experienced some form of dizziness28,29 and in the very elderly (>85 years of age) this rises to about half.30
Falls are complex phenomena involving neurological, biomechanical and other factors31 and older adults with a history of dizziness imbalance and similar symptoms are at a higher risk of falling.32,33,34 Balance disorder and dizziness were among the top three causes of falls in the meta-analysis of 12 large studies done in 2006.35
Dizziness has always been hard to quantify, leading to the suggestion that it should be viewed, in the elderly, as a mutifactorial geriatric syndrome involving many different symptoms and originating from many different systems including sensory, neurologic and cardiovascular. In one of the studies, in 80% of the patients with dizziness the cause could be ascribed to cardio-vascular, peripheral vestibular or psychiatric diseases36 and among the peripheral vestibular disorders, BPPV is the commonest finding.
Katsarkas reporting in Geriatrics quoted a figure of 40% of patients older than 70 years being diagnosed with BPPV.37

Management
Once the diagnosis of BPPV is made there are various possibilities regarding treatment. These range from doing nothing to subjecting the patient to various surgical procedures.1

Observation
As BPPV is a self-limiting condition, watchful waiting can be done to let the disease run its course. The advantages of this approach are that the patient is spared being put on more medications (polypharmacy increasing the risk of falls), or being subjected to potentially unpleasant manoeuvers. This approach can though, lead to weeks or months of discomfort for the patient and increases the danger of a fall in the elderly patient while waiting for the resolution of symptoms.

Medications
Vestibulo suppressant medications are not usually helpful as they only mask the problem and are associated with side effects such as drowsiness and extrapyramidal symptoms. In a small (n=20) double blinded RCT comparing placebo to diazepam (5mg, tds) or lorazepam (1mg, tds), no difference in dizziness symptom was noted over a period of four weeks.38

Vestibular rehabilitation (VR)
This comprises exercises customised according to the patient complaint, clinical aspects and vestibulometry findings with modifications according to the clinical evolution of the patient during treatment. Though these have been shown to produce improvement in the patients quality of life irrespective of gender or age,39 the prolonged nature of this approach makes it unsuitable for the elderly population.4

Particle repositioning manoeuvres (PRM)
This is the mainstay of the treatment and can actually be done in the same sitting as the diagnosis. The Epley particle repositioning is effective treatment for BPPV and has a success rate of between 70% to 100%.40 This can be carried out by doctors, physiotherapists, occupational therapists or chiropractors. Similar precautions and modifications as required for the Dix-Hallpike test are used for the modified Epley manoeuvers.
The procedure may need to be repeated to ensure resolution of symptoms and absence of positioning nystagmus. There are other PRMs like Semont manoeuver but due to the vigorous side to side movements involved, they are less suitable for the very elderly population.
In one trial with comparatively elderly patients (mean age 74 years) the calcium channel blocker flunarizine was compared to Semont’s liberatory manoeuvre or no therapy. At the six month follow up the rates for asymptomatic patients with negative Dix-Hallpike test was 94% for Semont’s manoeuver, 58% for flunarizine and 34% for no therapy.41

Surgery
In patients who continue to be distressed by BPPV in-spite of repeated attempts at repositioning the otoliths surgical procedures like labyrinthectomy, posterior canal occlusion, singular neurectomy, vestibular nerve section or transtympanic aminoglycoside application can be tried.
These procedures are invasive and associated with complications like hearing loss and facial nerve damage. Furthermore, a proportion of the elderly patients will be unsuitable for surgery due to the presence of comorbidities.


Treatment characteristics in the elderly
It has been shown that characteristics and treatment responsiveness of BPPV in elderly patients are similar to the general population,42 though there may be a less favorable final functional outcome due to the presence of multiple comorbidities. The multifactorial nature of the reasons for falls in the elderly means that other pathologies like orthostatic hypotension may coexist and need to looked for along with BPPV.
The duration of vertigo before PRM is an indicator for the likelihood of residual dizziness being present after treatment43 44 as is age and anxiety.
A study in Brazil in 2009 showed that all individuals—adults and elderly; men and women significantly benefit from treatment of BPPV,45 while another study the next year looked at 121 patients with BPPV (age range 65 to 89 years) who underwent particle repositioning manoeuvers showed a statistically significant reduction in the number of falls at one year.46


Conclusion
BPPV is the commonest cause of vertigo in the elderly with the incidence rising with age. It is caused by canaliths in the semicircular canals in the inner ear and presents with symptoms of dizziness on particular movement of the head. Various triggering factors can worsen or bring on the symptoms. It causes an increase in incidence of fall in the elderly.
The diagnosis of BPPV depends on typical history and observation of reversible, geotropic and torsional nystagmus on Dix-Hallpike test.
There are various modalities of treatment available but the ease of use of the PRMs and the side effects of the other treatments make Epley, or less commonly the Semont manoeuver, the treatment of choice. The consideration of BPPV as a cause of dizziness, its diagnosis with provocative tests and treatment with PRMs leads to an improved quality of life and reduction in the incidence of falls in these patients.
BPPV should therefore be actively sought for as a cause of dizziness and falls in the elderly patient and its presence should prompt the clinician to institute or arrange for treatment of this common condition.

Conflict of interest: none declared


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