• Vol 7 • July 2005
BPPV in a Geriatric Population
One of the common and treatable vestibular disorders in the
elderly is benign paroxysmal positional vertigo . BPPV is a
clinical entity characterized by rotational vertigo induced by head
position changes in the plane of one of the semicircular canals.
Patients typically complain of attacks of vertigo provoked by ex-
tending or turning the neck, getting up or lying down, or rolling
over in bed. The attacks are often accompanied by a feeling of
unsteadiness and loss of confidence while walking. Sometimes the
vertigo remains unreported by the patient and the main complaint
is loss of balance, especially in older patients. The diagnosis is
confirmed by the Dix-Hallpike positioning testing that shows a
characteristic geotropic, torsional nystagmus when the patient is
dropped back from the sitting position to a head-hanging position
with the head turned 45 degrees to the affected ear .
BPPV is considered to be caused by canalithiasis – i.e.,
otoconial debris, derived from the utricular macula, becomes
trapped in the semicircular canal (most commonly in the pos-
terior semicircular canal) and moves when the head position is
changed quickly in the plane of the canal. This results in inap-
propriate stimulation of the sensory hair cells of the affected
canal and causes vertigo . Disorders affecting the peripheral
vestibular system, such as vestibular neuronitis or head trauma,
may precede the onset of BPPV . However, BPPV is most com-
monly idiopathic and its prevalence increases with age [3,4].
The Epley particle repositioning maneuver is an effective
treatment for BPPV and has been described in detail elsewhere
. Its effectiveness is assessed to be between 70% and 100%
by different authors [5–7]. Some recent studies that dealt with
the problem of BPPV in the geriatric population yielded contro-
versial results [8–14]. However, most of the papers compared
their results with the data of unselected BPPV patients reported
by other authors.
We reviewed and compared the clinical characteristic of el-
derly patients with those of patients representing the general
population who were treated at our dizziness clinic, and tried
to establish possible treatment implications.
Patients and Methods
We reviewed the medical records of patients older than 75 years
with BPPV (posterior canal variant) treated at our dizziness clin-
ic during the years 1998–2004. Their clinical characteristics were
compared with those of 30 consecutive, retrospectively evalu-
ated patients with BPPV (general population of different ages)
who were treated at our clinic during the same years.
The diagnosis was based on a history of recurrent positional
vertigo and the presence of a geotropic torsional nystagmus di-
rected towards the undermost ear on Dix-Hallpike testing. The
observed nystagmus demonstrated the following features: laten-
cy of onset, crescendo-decrescendo course, reversal on returning
the patient to the sitting position, and fatigue on immediate re-
All patients underwent the modified Epley particle reposi-
tioning maneuver performed by the same therapist (L.P.) .
The patients were treated during the diagnostic session. For
patients who experienced severe nausea or vomiting during the
testing (one in the elderly group and two in the general group
of patients), the treatment was postponed to the next session
(3–7 days) and premedication with anti-emetics and sedatives
Background: Benign paroxysmal positional vertigo is a com-
mon and treatable vestibular disorder characterized by attacks of
positional vertigo. Although elderly patients often complain about
unsteadiness, the symptom of positional vertigo is seldom reported.
Several studies on BPPV in the elderly reveal a low success rate
in the treatment of this entity.
Objectives: To assess the clinical characteristics and treatment
outcome of BPPV in elderly patients and to compare them with those
of the general population treated at our dizziness clinic.
Methods: We reviewed the medical records of 23 patients
above age 75 who were treated at our dizziness clinic for BPPV
during the years 1998–2004. Their clinical data, BPPV charac-
teristics and treatment outcome were compared with the data
of 30 consecutive BPPV patients who represented the general
Results: No differences in gender distribution, duration of
BPPV, treatment responsiveness or recurrence rate were found
between elderly patients as compared to the general population.
The duration of the last attack of positional vertigo was found to
be longer in the elderly, probably due to the delay in recognition of
symptoms and accessibility of a dizziness clinic.
Conclusions: Our study shows that BPPV characteristics and
treatment effectiveness, as measured by negative Dix-Hallpike
maneuver, are not age-dependent and there is no need for a
special approach or cautiousness in prognosis prediction. It is
important to search actively for this condition since treatment
leads to amelioration of unsteadiness and improved well-being
in these patients.
Approach to Benign Paroxysmal Positional Vertigo in Old Age
Lea Pollak MD1, Mark Kushnir MD1, Yizchak Shpirer MD2, Yaacov Zomer, MSc2 and Shlomo Flechter MD1
1Department of Neurology and 2Sleep Laboratory Unit, Assaf Harofeh Medical Center, Zerifin, Israel
Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
Key words: benign paroxysmal positional vertigo, elderly
BPPV = benign paroxysmal positional vertigo