A Tailored Approach to Dizziness: Take extra caution and care in the elderly, panelists say

But that’s exactly what happens in the elderly, said Joel Goebel, MD, professor and vice chairman of otolaryngology and director of the Dizziness and Balance Center at Washington University School of Medicine in Saint Louis. Simply standing in your kitchen and looking up at an item on a high shelf can bring about a dangerous situation in an elderly person, he said.

“Your stabilizing mechanisms don’t work quite as well as they used to when you were younger, so you get the same attack, you get the same overwhelming sensation of vertigo, but you’re not able to handle the few seconds as you tipped,” he said.

BPPV, as it is widely accepted, is caused by the dislodging of otoconia, particles of calcium carbonate, from the part of the inner ear called the uticle. Repositioning can help ease the symptoms, but the problem often recurs.

“We really don’t know what happens to those otoconia,” Dr. Goebel said. “Some of us believe that they dissolve, some of us believe that they only stick. I believe they only stick because they keep coming back, these attacks come back.”

Illustrations of repositioning techniques to treat BPPV “make me shiver” sometimes, he said, because they show patients’ heads hanging off the edges of a doctor’s table, which might be very difficult, or even dangerous, for an elderly patient.

Using alternate approaches, such as placing the examination chair or table in the Trendelenburg position in which the feet are above the rest of the body, might be better for the elderly, he said, emphasizing that it’s the position of the head that is the most important, not the position of the body.

Rehabilitating patients with BPPV should involve treating the acute BPPV spells first, then assessing a patient’s instability in posture with posturography and gait analysis. He said physicians should be aware of other possible contributing factors, such as Parkinson’s disease, peripheral neuropathy or normal pressure hydrocephalus (NPH).

Kim Gottshall, PhD, head of Vestibular Rehabilitation Comprehensive Combat and Complex Casualty Care at the Naval Medical Center in San Diego, said that physicians trying to physically rehabilitate a dizzy, elderly patient should take care to tailor the patient’s care properly. Peripheral neuropathy, orthopedic issues and sensory loss are a few of the factors that might be contributing to the problem, she said.

“Patients come to us as geriatric patients with multifactorial problems,” she said. “And we have to choose from our exercises what type of rehab programs are we going to develop for them and what kind of devices we can use to make it interesting and have them be compliant with the program that we develop.”