Vestibular disease

Presbyvestibulopathy (age-related dizziness and gait instability)

This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.

For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.

What is presbyvestibulopathy?

Dizziness and gait instability increase with age because balance and other body systems deteriorate with age. Both are often complicated by one or more other conditions (comorbidities) that can affect balance function. The intake of several medications also plays a role.

Age-related dizziness and gait instability are one of the most common problems experienced by older people. The cause is often difficult to determine and varies greatly from person to person. Another name for it is presbyvestibulopathy, which means age-related loss of balance function.

Older people with dizziness have a much higher risk of falls and injuries. Falls in older people are also particularly serious. They carry a high risk of broken bones, dislocations or serious head injuries.

Between 20 - 30 % of senior citizens fall every year. Falls are the most common cause of hospitalization among seniors. Almost 90% of people over the age of 80 are likely to have a balance disorder, which increases the risk of falling. With a mortality rate of 20%, falls are the most common cause of accidental death in people over 65.

Dizziness and unsteady gait can also lead to a fear of falling. This fear leads to an even greater risk of falling. Half of older adults who have already fallen once are afraid of falling again. Of those who have never fallen, around 30% are afraid of falling.

Dizziness and balance disorders can severely impair the quality of life of older people. They impair mental (cognitive) function, mobility and independence as well as general health and well-being.

Deterioration of the individual parts of the vestibular system is normal in old age. The incidence of dizziness due to a problem with the vestibular system in older people remains uncertain. Researchers' estimates range from around 20% to 40-50% or possibly even higher.

Dizziness in older people is often caused by diseases that have nothing to do with the vestibular system. The likelihood of having one or more non-vestibular conditions (comorbidities) that contribute to dizziness and balance problems also increases with age. Older people can suffer from vestibular and non-vestibular dizziness at the same time.

Dizziness is responsible for 75% of primary care visits in people over 65. It affects the daily lives of 30% of seniors over the age of 70.

The likelihood of dizziness increases with age. By the age of 80, 60% of people will have seen a doctor about dizziness at some point in their lives. And almost 70% of people over 90 suffer from dizziness on a daily or weekly basis.

Summary

What causes presbyvestibulopathy?

The brain receives and processes information from the balance sensors in the inner ear (vestibular system), the eyes (visual system) and the sensors in the muscles and joints (proprioceptive system) to keep the body balanced when standing or walking. Signals are also sent to control eye movements so that the gaze remains stable during movements. If part of the balance system fails or the information does not match, this can lead to dizziness or unsteadiness in gait. As part of the normal ageing process, each part of the delicate and complex balance system gradually becomes impaired with age.

The most common vestibular balance disorders in older people include

Benign paroxysmal positional vertigo (BPLS)
With increasing age, the crystals (otoliths) in the inner ear become less dense and vary in size. They are also replaced more slowly. These changes lead to a higher probability of being affected by BPLS. This disorder is the most common vestibular disorder in older people. By the age of 70, a third of people have had BPLS at least once. People with osteoporosis are up to three times more likely to develop BPLS. Older people may not specifically complain of dizziness (vertigo) if they have BPLS.

Bilateral vestibulopathy
Bilateral vestibulopathy means that the balance part of the inner ear (vestibular system) no longer functions on both sides. It is often overlooked as a cause of dizziness and an unstable gait in older people.

Symptoms include staggering when walking, especially in the dark and on uneven ground. Some people also have blurred or "jumpy" vision (oscillopsia). Symptoms are most noticeable when vision is restricted (e.g. in the dark or with eyes closed) or when walking slowly.

Causes include medications that are toxic to the vestibular system (vestibular toxicity) and pre-existing bilateral (affecting both ears) Meniere's disease. In older people, bilateral vestibular loss is sometimes associated with peripheral neuropathy. In about 50% of cases, no specific cause can be identified.

Neuritis Vestibularis
Neuritis Vestibularis is a disease that causes a sudden, severe attack of vertigo, usually accompanied by nausea and vomiting. This attack can last for days. Vestibular neuritis does not come and go. It is a one-off, serious event. But after the attack, sufferers can have balance problems and dizziness for weeks or months. The age-related degeneration of several systems makes it more difficult for older people to recover from vestibular neuritis.

Vestibular migraines are rather unusual in older people.

Other causes and risk factors for age-related dizziness and balance disorders are:

  • Combination of disorders
    Age-related dizziness and balance disorders are often caused by a combination of disorders (comorbidities) that affect muscles, joints and nerves as well as brain function and vision. The risk is increased with 3 or more disorders.
  • Medication
    One or more side effects of many prescription and over-the-counter medications can affect balance. Taking 4 or more medications increases the risk of visual disturbances, drowsiness, dizziness and impaired judgment. Medications commonly associated with dizziness in the elderly include:
    • Anticonvulsants
    • Antidepressants
    • Medication for anxiety (anxiolytics)
    • Sedatives, including hypnotics
    • Strong painkillers (analgesics)
    • Muscle relaxants
    • Medication for the prevention and treatment of cardiac arrhythmias (antiarrhythmic drugs)
    • Chemotherapy
  • Gait instability
    Walking speed decreases with age. After the age of 60, it decreases by around 1% each year. Gait unsteadiness is related to how well an older person's sensory system, mental processes (cognition) and ability to move (locomotion) function. The inability to walk and talk at the same time is a sign of deterioration. Older people with dementia fall more often than cognitively healthy people of the same age.
  • Fear of falling
    Fear of falling is one of the biggest concerns for many older people with an unsteady gait. It can lead to a downward spiral, as reduced self-confidence leads to inactivity, physical decline and a higher likelihood of falling.
  • Loss of muscle mass
    The loss of muscle mass, especially in the trunk and legs, begins after the age of 50. Up to a third of previous muscle mass can be lost. The loss affects the strength and performance of the legs. Common causes are lack of exercise, diseases such as arthritis and stiffness and pain in the joints (polymyalgia rheumatica or PMR). The loss of muscle mass is an important risk factor for gait disorders and falls. All these factors increase the risk of falling. Another name for the loss of muscle mass is sarcopenia.
  • Vision problems
    Vision problems that are often associated with ageing are
    • the eyes take longer to adjust to darker or lighter areas
    • Reduced depth perception
    • Gait instability due to changes in spectacle prescription or adaptation to varifocals
    • Cataracts
    • Macular degeneration
  • Dehydration
    Poor hydration is more likely with age. The part of the brain that tells us we are thirsty becomes less active at the age of 65. Even mild dehydration can lead to dizziness. Dehydration can occur especially in warm weather or during increased activity. In addition, older adults are more likely to:
    • have impaired kidney function
    • do not consume fluids due to incontinence
    • Taking medication that increases the urge to urinate
    • have mobility problems that make going to the toilet difficult
  • Blood pressure abnormalities
    These include high blood pressure (hypertension), low blood pressure (hypotension) and a drop in blood pressure when standing up from a lying or sitting position (postural/orthostatic hypotension). All 3 conditions can cause dizziness and increase the risk of falling.
  • Cognitive problems
    These include memory problems, confusion, difficulty thinking or solving problems. Judgment may be impaired and increase the risk of falling.
  • Bladder or bowel problems
    Incontinence or the urge to urinate can cause you to rush to the toilet several times a day and night. Combined with an unsteady gait, this can increase the risk of falling.
  • Foot problems
    These include numbness, corns, calluses, bunions, ingrown or thick nails and ulcers. Foot problems can make it more difficult to remain physically active, leading to an increased risk of falling.
  • Alcohol consumption
    The ageing body is less able to process alcohol, especially when it is combined with medication. This is associated with an increased risk of falling.
  • Central vertigo
    Central vertigo is caused by a disorder of the central nervous system (brain and spinal cord). It is caused by damage to the vestibular structures and pathways. A sudden blockage of the blood vessels leading to the brain can cause sudden dizziness and/or loss of balance. This may be due to an ischemic stroke in the inner ear (labyrinth infarction) or in the brain. Dizziness and an unstable gait are often the first symptom of degenerative diseases such as Parkinson's, cerebellar disorders (also called ataxias) and dementia (including normal pressure hydrocephalus, Alzheimer's and white matter disease).
  • Cardiovascular diseases
    Problems with the heart rate or heart rhythm as well as a previous heart attack can lead to dizziness and balance problems.
  • Cervical spondylosis
    This is a type of osteoarthritis that leads to deterioration of the vertebrae, discs and ligaments in the cervical or neck spine. Sometimes these changes can affect the blood supply to the brain, causing dizziness and even blackouts.

Dizziness is a vague term. When applied to older people, it almost always indicates a complex combination of overlapping symptoms. The symptoms tend to be episodic. Among the most common are:

  • Rotational vertigo
  • Drowsiness
  • Presyncope - the feeling of fainting
  • Balance disorders
  • Spatial disorientation - the inability to correctly determine the position of the body in space
  • Blurred vision

Many older people cannot describe their dizziness with just one of these symptoms. About half have two or more "types" of dizziness. Older patients generally report less rotational vertigo and more non-specific vertigo than younger patients with the same condition.

Other symptoms may include

  • Nausea and vomiting
  • Diarrhea
  • Changes in heart rate and blood pressure
  • Fear or panic
  • Motion intolerance
  • Instability and unsteady gait, especially when making sudden turns

Diagnosis of presbyvestibulopathy

If you feel dizzy or have lost your balance, you should first make an appointment for a full examination with your GP. It is important that you try to describe the symptoms in as much detail and accuracy as possible. The doctor needs this information to find out where the problem is coming from.

Age-related dizziness and balance disorders usually have a complex combination of overlapping symptoms. They are notoriously difficult to assess as there is a likelihood that two or more (chronic) conditions are present in combination with a normal age-related deterioration of the vestibular system. You may be referred to one or more specialists. A series of medical tests may be ordered.

General practitioners, emergency physicians and vertigo and vestibular therapists may perform a positioning test to determine BPLS. A vestibular function test may be performed. A referral to a diagnostic testing center is required for thorough testing.

Some test results can be of particular importance in older people. For example, the sole presence of asymmetry of the vestibulo-ocular reflex (VOR) is an important predictor of falls.

Clinicians may customize some tests to account for problems with the joints, muscles or cognition.

Sometimes dizziness is a sign of a serious and potentially life-threatening condition, usually a stroke. The risk of a more serious diagnosis increases with age. If you feel dizzy and experience any of the following signs, you should see a doctor or emergency room immediately or call 911:

  • Fever of 39.4°C or more.
  • Chest pain/heart palpitations or symptoms of a stroke. Stroke symptoms are treated as a medical emergency and usually include headache, fainting, double vision, facial numbness, slurred speech or difficulty swallowing, weakness in an arm or leg, and difficulty walking. Symptoms of a brainstem stroke can be more complex and include dizziness, lightheadedness and severe unsteadiness of gait, without the typical features of most strokes (such as weakness in an arm or leg).
  • Fainting or collapse.
  • Behavioral changes.
  • New, different or severe headaches.
  • Persistent spinning dizziness that lasts longer than a few minutes.
  • History of a stroke.

Risk factors for a stroke, such as diabetes and high blood pressure.

Treatment of presbyvestibulopathy

A common misconception about treating elderly vertigo patients is that vertigo is a normal part of aging and therefore cannot be treated. Fortunately, this is not true. Age-related dizziness and gait instability can indeed be treated and symptoms reduced.

The correct diagnosis is crucial for successful treatment. Treatment must be multifactorial and specific to the conditions causing the dizziness and gait unsteadiness. To find out if your dizziness and gait unsteadiness are related to a normal aging process or if it is a change due to a disorder or disease, it may be necessary for you to see multiple specialists. A multidisciplinary team approach of health professionals is best.

Treatment and management strategies include:

Therapy option

Vestibular rehabilitation

Vestibular rehabilitation, an exercise therapy, is helpful for most vestibular disorders. The goal of the training is to teach the brain to better regulate balance and respond to signals from the vestibular and visual systems. Research shows that the effectiveness of vestibular rehabilitation does not change with age. There is evidence that it improves postural control, dizziness symptoms, emotional health and reduces the risk of falls even in older patients without a specific diagnosis. Bilateral vestibulopathy can be most effectively treated with vestibular rehabilitation, which includes targeted balance training combined with gait training.
Vestibular rehabilitation exercises are generally designed to

  • Reduce dizziness in conjunction with exercise
  • improve visual clarity and balance
  • improve joint mobility and strength to reduce the risk of falling
  •  

Therapy option

Adjustment of drug treatment 

Medication that causes dizziness or balance problems should be reduced or changed if possible. Always talk to your doctor before reducing or stopping a medication.

Therapy option

Cognitive behavioral therapy

Cognitive behavioral therapy can help with anxiety related to dizziness and balance problems.

Therapy option

Sport and exercise

Staying active and exercising can help prevent falls. Successful strategies for preventing falls include balance exercises at least three times a week. The exercises should be challenging and gradually increase in difficulty.

Therapy option

Elimination of fall risks

Creating a safer environment at home can reduce the risk of falls. More than half of all falls occur at home. Tripping hazards are the biggest danger at home.

Therapy option

Healthy diet

A healthy diet can improve the balance and general health of older people. Eat plenty of fruit, vegetables and protein. Stick to the recommended intake of calcium and vitamin D.

Therapy option

Walking training

Gait abnormalities can be treated by a physiotherapist or occupational therapist. For example, walking speed can be improved through gait training. Aids such as a cane, a walking aid or hip protectors may be recommended.

Therapy option

Overcoming anxiety

The fear of falling can be treated and managed with a variety of strategies.

Therapy option

Strength training

Low muscle mass (sarcopenia) can be improved by fast strength training in combination with sufficient protein. Training with a wobble board can increase the strength of the feet and ankles. The core muscles are a good basis for controlling movement and maintaining balance. It can be improved through a range of exercises on the floor or in the pool, as well as through Pilates or yoga. For people who are not mobile, the exercises can also be performed in a seated position.

Therapy option

Training muscle coordination and control

Muscle coordination and control can be improved through activities such as walking, dancing, table tennis, swimming pool exercises, yoga and tai chi. Some of these exercises can even be adapted to be performed in a seated position.

Treatment of comorbidities

Treatment for other conditions and disorders associated with dizziness and balance problems will depend on the condition. Talk to your healthcare team.

What happens next?

What you can expect in the future.

If the cause of presbyvestibulopathy is unclear or the symptoms are not alleviated by the various treatments, the focus should be on improving functional abilities.

The effects of one or more concurrent illnesses (comorbidity) in older people are currently being researched. For example, a link has recently been established between orthostatic hypotension and an increased risk of dementia. Future research will hopefully raise awareness of these and other conditions that affect us in old age and improve prevention.

In order to keep this patient information as short as possible, we have not included a detailed list of references. However, this can be requested at any time at info@ivrt.de.

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