Presbyequilibrium in the oldest old, a combination of vestibular, oculomotor and postural deficits

364 Aging Clin Exp Res, Vol. 23, No. 5-6

Key words: BPPV, dizziness, oldest old, positional nystagmus, postural stability.Correspondence: Ilmari Pyykkö, MD, Department of Otolaryngology, University Hospital of Tampere, Teiskontie 35, Tampere 33521,Finland.E-mail: [email protected] March 2, 2010; accepted in revised form September 1, 2010.First published ahead of print March 29, 2011 as DOI: 10.3275/7623

Presbyequilibrium in the oldest old, a combinationof vestibular, oculomotor and postural deficits

Aging Clinical and Experimental Research

Eeva Tuunainen1, Dennis Poe2, Pirkko Jäntti3, Kirsi Varpa4, Jyrki Rasku4, Esko Toppila5

and Ilmari Pyykkö1

1Department of Otolaryngology, University of Tampere and University Hospital of Tampere, Finland,2Children's Hospital Boston, Department of Otolaryngology, Boston MA, USA, 3Department of GeriatricMedicine, Seinäjoki Central Hospital, Finland, 4Department of Computer Sciences, University of Tampere,Finland, 5Finnish Institute of Occupational Health, Helsinki, Finland

ABSTRACT. Background and aims: Dizziness, im-paired balance and fear of falling are common com-plaints in the elderly. We evaluated the association ofvestibular symptoms with vestibular findings in the el-derly by posturography and video-oculography (VOG).Methods: We studied 38 oldest old subjects (≥85 yrs,mean age 89) living in a residential home. Vestibularsymptoms were taken with a structured questionnaire,the Mini Mental State Examination (MMSE) was scoredand any falls were recorded over a period of 12 months.Posturography was measured with a force platformand eye movements were measured by video-oculogra-phy. Results: In the majority of the elderly, vestibular ab-normalities were found, such as reduced vestibulo-ocu-lar reflex gain 6/38, spontaneous nystagmus 5/38, gazedeviation nystagmus 5/38, head shaking nystagmus9/38, pathologic head thrust test 10/38, and positionalnystagmus 17/38. Posturography demonstrated twomajor findings: the body support area was limited andthe use of vision for postural control was reduced. Inprincipal component analysis of the vertigo, four majorfactors described elements of failure in the vestibularand other systems important to maintenance of bal-ance: episodic vertigo, postural instability, multisys-tem failure (frail) and presyncopal imbalance. These fourfactors were associated in different degrees to vestibu-lar abnormalities and falls. During the follow-up period,in 19 elderly (19/38), one or more falls were recorded.Conclusions: Progressive loss of balance in the aged, or“presbyequilibrium,” is a complex and incompletelyunderstood process involving vestibular, oculomotor, vi-sual acuity, proprioception, motor, organ system andmetabolic weaknesses and disorders. These factors pro-

vide a potential basis for streamlining diagnostic eval-uations and aiding in planning for effective therapy. Inoldest old, these problems are magnified, increasingthe need for additional expertise in their care, which maybe met by training specialized healthcare staff.(Aging Clin Exp Res 2011; 23: 364-371)©2011, Editrice Kurtis

INTRODUCTIONDizziness ranks among one of the most common

complaints in medicine, affecting in some forms ap-proximately 40% of the general population (1). It is es-pecially prevalent in the aging population (2). In a cohortstudy in Gothenburg, the daily occurrence of balanceproblems, with or without dizziness, was present in 33%among elderly at age 70, and increased to 50% at 80years or more (3).

The elderly understand and describe their dizziness inmany ways (3) and often tend to under-report their symp-toms (4). They commonly use various non-specific termsto describe their complaints of balance disorders, such asvertigo, general unsteadiness, dizziness, lightheadedness,fainting, or other illusory sensations as indications ofmedically specific symptoms of true vertigo. In addition,fear of falling, gait disorders, postural mismatch or oscil-lopsia may also be an expression of dizziness. Primary careclinicians and geriatricians commonly underdiagnose ormisdiagnose dizziness and vertigo in the elderly (5). In astudy by Lawson et al. of 59 patients with Benign Parox-ysmal Positional Vertigo (BPPV), 31 (59%) were referredto Fall and Syncope Unit instead of ENT (6). The authorsconcluded that diagnosing BPPV in elderly may be difficult,particularly as this group frequently has more than one type

Presbyequilibrium in the oldest old

Aging Clin Exp Res, Vol. 23, No. 5-6 365

of dizziness symptoms, sometimes including vertigo, pos-tural dizziness (raising the suspicion of orthostatic hy-potension), and even symptoms from multiple co-mor-bidities and coexisting cardiovascular disorders.

Obtaining an accurate history is of utmost importancewhen searching for the etiology of disequilibrium com-plaints, but it is often difficult to understand exactly what apatient is experiencing. In the literature, the terms “dizzi-ness” and “vertigo” suggest some link to the sites of originof symptoms, non-specific dizziness tending to be associatedwith non-vestibular sites and vertigo generally related to thevestibular (mostly semicircular canal) system. Generalized im-balance symptoms and misperceptions of movementshave been less specifically related to the vestibulo-spinal sys-tem or central motor control functions (7). These distinctionsmay not be entirely justified in the elderly, as there is a poorconnection between vestibular findings and symptoms (7).The elderly often under-perceive or under-report true ver-tigo (8). As there will be unreliability in the reporting of dis-equilibrium complaints in the elderly, efforts have beenmade to improve the sensitivity and specificity of vestibulartesting to aid in the diagnostic process. However, there areonly limited data on vestibular findings in the elderly (9) andit is especially noted that there are no reports of suchfindings in the oldest old.

BPPV is a common cause of dizziness and is probablyquite common in the elderly. It rarely occurs in children (10)but it is more common in older age groups. It has been pro-posed that as much as 50% of all dizziness in the elderly isdue to BPPV (11). In one study, 9% of a group of urban-dwelling elders were found to have undiagnosed BPPV (4).

The purpose of the present study was to evaluatevestibular findings among the oldest old and relate findingsto case histories. We hypothesized that the majority of oursubjects would have vestibular dysfunction and most com-monly suffer from positional vertigo, and that the vestibu-lar deficit is also “manifested” in limited range of posturalconfidence area.

METHODSSubjectsWe performed a study of institutionalized oldest old sub-

jects living in the Koukkuniemi elderly people’s home in thecity of Tampere which, during the study period, housed869 elderly persons. The nursing staff selected two or threeparticipants from every ward, from which 38 elderly wereasked to participate in the clinical study. Inclusion criteriawere that subjects could be physical fit enough to raisethemselves from the chair without assistance and were ableto follow instructions. The City of Tampere institutional re-view board approved the study protocol. The mean age ofsubjects was 88.8 years, range 80-103 years. The studygroup included 31 women and 7 men. Subjects werefollowed for 12 months and their fall rate was evaluated.After 12 months, 32 were alive and 6 had died.

Data collectionSubjects were interviewed by means of a structured

otoneurological questionnaire to obtain uniform and de-tailed histories and symptoms of vertigo from each elderlyperson (12). When necessary, subjects’ interviews wereconfirmed or augmented from interviews with their per-sonal nurses. Details of their medical diseases and dataconcerning falls were retrieved from individual medicalcharts. Nurses responsible were interviewed, to aid in de-termining the etiology of each fall.

The features of dizziness and vertigo were explored tocategorize symptoms expressed by subjects into con-sistent and more precisely defined terms. Dizziness andvertigo were broken down in more detail as rotatory ver-tigo, floating sensation, movement instability, tendencyand fear of falling, sudden loss of balance, and syn-cope. Some related symptoms, such as feeling of unre-ality, loss of vitality and reduced mobility were alsoqueried. The occurrence of vertigo, duration of spells, andprovoking factors such as movements of the head, bodyposition, physical straining and possible neurologicaldisorders, were checked. Subjects’ limitation of activitiesdue to symptoms was rated on a five-step scale be-tween “no interference with activities” to “full bed rest.”Symptoms of hearing loss and associated symptoms,such as nausea or vomiting, were queried.

The Mini Mental Status Examination (MMSE) scoremeasures cognitive ability (attention, memory, language,calculations) with a maximum score of 30; 24 and underindicate some impairment (13).

Video-oculography (VOG)Both eyes were measured independently in commer-

cially available video-oculography (Micromedical Tech-nologies, Inc. Chatham, Illinois, USA). In the test, eyeswere covered by transparent video-goggles. Subjectscould visualize their surroundings and fix their gaze on ob-jects. Their eyes were illuminated with infrared lamps with-in the video goggles for presentation of a video monitor.The video-oculography (VOG) signal was sampled at a fre-quency of 25 Hz and fed into a portable computer. In-ternal algorithms calculated the position and movement ofthe iris in order to quantify eye movements.

The VOG was calibrated with a light bar placed 1.2 min front of the subject, covering a visual field of 40 de-grees. The light bar consisted of LEDs illuminated bythe program, and the calibration was made with alter-nating saccades at 20 degrees of visual angle.

Spontaneous nystagmus was recorded during a 45-s tri-al in the dark (video goggles covered) by asking subjects tolook forward. Gaze deviation nystagmus was thereafterrecorded by asking subjects to keep the gaze first to the farright for 20 s and then to the far left. The vestibulo-ocu-lar reflex (VOR) was recorded first in light and then witheyes covered. Subjects maintained their gaze fixed forward

E. Tuunainen, D. Poe, P. Jäntti et al.


and on the midline, while the examiner rotated the headabout 20 degrees back and forth at a rate of 1 Hz for 15sec. Head-shaking nystagmus was achieved by subjectsshaking their heads rapidly on both sides 20 times witheyes covered. Head thrust was recorded by turning thehead quickly from each side to the middle line with eyescovered. Saccades were recorded by asking subjects tostare at a light spot and follow it as rapidly as they couldwhen the bar was jumping from 5 to 40 degrees visual an-gle in pseudo-random order. Smooth pursuits were mea-sured by asking subjects to stare at a light spot whichmoved sinusoidally in the bar.

Positional manoeuvers were conducted with subjects sit-ting on a bed and asking them to hold tightly onto thewrists of the examiner. Subjects were then brought rapid-ly to a lateral decubitus position with the head tilted 45 de-grees to the side (toward the bed). This position wasmaintained for up to five minutes or until the nystagmusceased. Thereafter, subjects were raised, passing throughthe sitting position, and brought to the lateral decubitusposition on the contralateral side, with the head tilted 45degrees toward the bed. The test was conducted with eyescovered and any nystagmus was recorded. Also noted waswhether the test had provoked vertigo.

The oculomotor responses to the test were evaluatedvisually by spontaneous nystagmus and head thrust testand with software analysing voluntary eye movements tocalculate reaction time, accuracy and velocity of sac-cades, and gain of smooth pursuit. Due to problemswith binocular vision caused by aging, only the reactiontime of saccades was used in calculations. Pathological out-comes were considered to be the presence of spontaneousor gaze nystagmus, the nystagmus produced by the head-shaking test, and abnormal saccades from head thrusttests, according to Halmaqui. In VOR testing, deviation ofthe eyes from the central position to the side was scoredas abnormal.

PosturographyForce platform posturography technique was used

(14, 15). Postural performance ranges were determinedfor antero-posterior direction and for lateral direction. Pos-tural stability was evaluated in visual and non-visual con-ditions. Sway velocity and maximum amplitude of bodysway were used as outcome variables. Romberg’s quotientwas calculated (mm/s).

StatisticsResults on vertigo were analysed by factorial analysis

with varimax rotations. Associations were evaluated withcorrelation analysis by Pearson’s test for continuous vari-ables and Kendal’s tau analysis for class variables. Mod-eling of factors describing presbyequilibrium was made bylinear regression analysis. The Mann-Whitney U-test wasused to assess differences between binary variables.

RESULTSClinical symptoms and MMSEIn clinical evaluation, three subjects had cerebellar atax-

ia, one had undergone craniotomy after trauma, and onehad cerebrospinal shunt (Table 1). Five subjects hadParkinson's disease. In six subjects, visual problems causedimpairment in voluntary eye movement tests, due to dis-parity of gaze nystagmus (1), cataract (2), parafoveal fix-ation (1), hemianopsia (1) and/or strabismus (1). Due tofrailty and/or dementia, complete positional and vestibu-lar testing could not be carried out in 5 subjects.

Subjects were followed-up for 12 months. One ormore falls were recorded for 19 of them. In 19 no fallswere recorded. After a 12-month follow-up, 6 subjects haddied and 32 were living. Their mean MMSE scores duringthe study were 20.5, range 6-30. Fifteen subjects hadMMSE scores <24, and 23 had 24 or better.

Vertigo, dizziness and balance symptomsOf the 38 subjects, 26 (68%) had dizziness or vertigo

in their recent history, the nature of which was further ex-plored with subsequent specific questions. Most subjectshad more than one type of complaint (Fig. 1).

12.0

10.0

8.0

6.0

4.0

2.0

0

Cou

nt

1 2 3 4 5 6 7 8

12

6

5 5

3 3 3

1

Symptom combinations

N. elderly

Parkinson’s disease 5Cerebellar degeneration 3Craniotomy or shunt 2Visual impairment 6

n

Table 1 - Clinical signs among elderly subjects.

Fig. 1 - Prevalence of vertigo and its symptoms. 1=No Vertigo;2=Poor Postural Stability; 3=Rotation+Floating+Poor PosturalStability; 4=Syncope with other symptoms (rotation, floating, poorpostural stability); 5=Rotation; 6=Rotation+Floating; 7=Rota-tion+Poor Postural Stability; 8=Syncope. Numbers within bars in-dicate number of subjects.



Vertigo was described as constant in 11 subjects,episodic in 12, and both constant and episodic in three.The duration of episodic attacks (n=15) was few sec-onds (1-5 sec) in four subjects, up to 5 minutes in seven,and up to 4 hours in four. The intensity of attacks variedfrom slight to severe. In ten subjects, the attacks were sosevere that they either had to rest (five) or symptoms con-tinued despite resting (five). Head movement was themost common provocative factor (Table 2)

Factorial analysisWe performed principal component analysis (Varimax

rotation) to identify internal associations of vertigo, dizzi-ness and impaired balance. In this analysis, four major com-ponents were identified, which described 75% of the da-ta. The four components were further classified by theircharacteristics and named to describe their component of“presbyequilibrium”. Associations are listed in Table 3.

The factors and their components were:1. Episodic presbyvertigo syndrome (Factor 1) con-

tained characteristics indicating "episodic vestibular changes".Subjects had vertigo provoked by physical strain or activi-ty, often accompanied by nausea during the attack. Subjectssuffered from poor postural stability (instability, combinedwith subjective feeling of falling) and tended to experienceepisodes of sudden instability. BPPV in vestibular testing was

correlated with episodic presbyvertigo syndrome (r=0.383,p=0.035). We used a linear regression model to search forvariables associated with Factor 1. Orthostatism (p=0.004),vertigo during rising (p=0.074) and falls (p=0.001) ex-plained 53.7% of the variation of Factor 1. The model wassignificant (p=0.001).

2. Postural presbyequilibrium (Factor 2). Subjects ex-perienced postural imbalance, and gravity-dependent po-sitional changes could provoke attacks. BPPV tended tocorrelate negatively with this category (r=-0.279,p=0.060). In modeling explanatory items for factor 2, fallswas the only factor included in the model and explained12.3% of the variability.

3. Frail syndrome (Factor 3) was characterized bypoor muscle strength and coordination, and the need forassistance in movements. Subjects preferred to use theirhands to assist themselves when rising from a chair andused supporting devices for walking. They reported morecontinuous dizziness, associated with subjective feelings offalling. In modeling explanatory items for Factor 3, a lin-ear regression model was significant, consisting of reducedVOR (p=0.001), vertical nystagmus (p=0.006) and gazenystagmus (p=0.059), and the model explained 43.8% ofthe variability.

4. Autonomic vertigo syndrome (Factor 4) was char-acterized by episodes suggesting autonomic compro-

No interference Slight Moderate Strong

Intensity of vertigo 3 2 5 5Provocation of head movement 0 8 6 1

n

Table 2 - Intensity of vertigo attacks and triggering of vertigo by head movement among 15 subjects who indicated occurrence of ver-tigo spells.

Rotated Component Matrix

Component

Episodic Paroxysmal postural Frail Autonomic

Vertigo 0.844Floating 0.750 0.414Fall tendency 0.484 0.612Imbalance 0.876Syncope 0.915Frequency of attacks 0.895Duration of attacks 0.907Intensity of attacks 0.924Nausea severity 0.704Sudden postural derangements 0.454 0.592Positional changes 0.354 0.756 0.339Movement restrictions 0.872Rising from chair 0.838

n

Table 3 - Outcome of factorial analysis and correlation coefficients. Four factors named based on components of factor.



vertical down-beating type (4 out of 5). Gaze nystagmuswas correlated with reduction in VOR (r=0.670,p<0.001). In addition, gaze deviation nystagmus wascorrelated with cerebellar lesions (r=0.716, p<0.001). Areduction in smooth pursuit was correlated with pro-longed latency of saccades in the random saccade test(r=0.583, p<0.001).

Neither age nor gender correlated with any of theVOG variables; nor did any of the histories of balance dis-orders, tendency to fall, instability, vertigo or dizziness cor-relate with VOG variables. Poor mobility was correlatedwith positional nystagmus of central type (r=0.457,p=0.010).

Central positional nystagmus was correlated withvestibular frail syndrome (r=0.469, p=0.008), and BPPVwith episodic presbyvertigo syndrome (r=0.323,p=0.035).

MMSE scores were classified to normal (≥24) and re-duced (<24), and were lower in subjects with vertical nys-tagmus (r=0.392, p=0.024) and central positioning nys-tagmus (r=0.383 p=0.012). In other VOG measurementsno significant differences were observed. Nevertheless, inthe Mann-Whitney U-test, those with low MMSE scoreshad significantly reduced quality of life (p=0.030) andexperienced lower vitality and energy (p=0.027). No dif-ferences in mortality or accidental falls were observedbetween the MMSE groups.

Measurement of postural stabilityThe posturography could not be performed to 12

subjects due to their current health. Both visual andnon-visual conditions were measured, except in one sub-ject in whom non-visual conditions could not be measured(Table 4). The mean Romberg quotient in sway velocity(mm/s) was 1.27 (SD 0.29) and in sway maximum am-plitude (cm) 1.34 (SD 0.33). These values are low, indi-cating poor use of vision for postural stabilization amongthe oldest old. These with vertigo in positioning testingshowed a low Romberg quotient (r=0.416, p=0.035

mise, including syncope, near-syncope or a floating sen-sation, which were all provoked by positional changes.These subjects fell more than eight times during the 12-month follow-up. Syncopal presbyequilibrium tended tocorrelate with the falls (r=0.252, p=0.067). In modelingFactor 4, a model consisting of low MMSE score(p=0.059) and smooth pursuit deficit (p=0.054) was sig-nificant, and explained 23.1% of the variability.

Video-oculography resultsPositioning testing for benign positional vertigo was

studied in 31 subjects. The test could not be carried outin 5 subjects, due to their current health status. Despiteextreme care to handle each elderly subject gently dur-ing positional testing, one subject lost consciousness fora few seconds, and two vomited. Seventeen (17/31) hadpositional nystagmus. The presence of nystagmus in po-sitioning testing was correlated with a sensation of ver-tigo (r=0.471, p=0.007) except for 4 out of 17 subjectswho had nystagmus but did not report any vertigo and3 out of 17 without nystagmus who reported moderateor severe vertigo. Three subjects had positional nys-tagmus in bilateral positions. Positional nystagmus wasfurther classified either as peripheral or central, based onabnormalities in oculomotor testing (vertical nystag-mus, gaze deviation nystagmus) and on case-histories ofbrain diseases or disorders (CSF drain, infarction, cere-bellar damage). Eight subjects were classified as havingthe central type of positional vertigo. Nine were classi-fied as BPPV, representing the peripheral type of vertigo(Table 3).

In analysing the internal dependencies of VOG vari-ables, nystagmus in positioning testing correlated signif-icantly with reduction of gain in VOR (r=0.376, p=0.037)and with gaze deviation nystagmus (r=0.361, p=0.046).Peripheral positional vertigo was accompanied by slight tomoderate vertigo sensation (r=0.401, p=0.025), butcentral positional vertigo was not.

Spontaneous nystagmus was most commonly of the

Test/dysfunction Pathological Normal N. tested

Spontaneous nystagmus 5 29 34Positional nystagmus in Dix Hallpike 17 14 31Vertigo in positional test 16 15 31Gaze nystagmus 5 30 35VOR 6 26 32Head-shaking nystagmus 9 24 33Refixation saccades in head thrust test 10 23 33Saccades 26 8 34Smooth pursuit 17 3 20

VOR: vestibulo-ocular reflex at 1 Hz.

Table 4 - Abnormal vestibular and oculomotor responses in VOG among oldest old.



for sway velocity, and r=0.502, p=0.011 for swaymaximum amplitude).

The postural limits and leaning tests could only becarried out in 8 subjects, as these tasks were even moredemanding. The antero-posterior range of postural stabilitywas on average 2.0 cm (median value 1.2 cm, SD 2.4cm) and in lateral direction 1.3 cm (median value 1.2 cm,SD 2.9 cm). The results indicated limitation of the posturalconfidence area in the subjects. The MMSE scores werecorrelated with poor postural control on the force platform(r=0.529, p=0.003).

DISCUSSIONDeterioration of balance is an insidious process, starting

in late middle age (16). Most often, the elderly cope withthis deterioration by using avoidance strategies, instead ofre-challenging their balance in complex environmentaldemands. In this study, symptoms of vertigo and dizzinesswere prevalent in 68% of the institutionalized elderly.Noteworthy was the fact that the nursing staff did not ad-dress this problem with balance excercises or rehabilitation.Although several studies have demonstrated the associationof dizziness and poor balance with falls, it is often difficultto determine the underlying mechanism of poor balanceand vestibular symptoms in the elderly (17). We demon-strate in this study that in aging, there is a powerful limi-tation of the postural confidence area, and the oldest olddo not use sight adequately to control their postural sta-bility. We also demonstrate that a significant proportion ofthe elderly have positional nystagmus due to other vestibu-lar and oculomotor abnormalities. Nevertheless, no singleitem in the case histories reliably predicts fallers fromnon-fallers, nor could we discriminate, on the basis ofposturography or oculomotor testing, subjects with a his-tory of falls from those without.

Symptoms of vertigo and dizzinessThe evaluation of dizziness in geriatric patients is often

a frustrating experience for the physician. This may be be-cause of difficulties in sorting through the multiple symp-toms that geriatric patients often have; the lack of specificphysical examination findings or diagnostic tests for bal-ance disorders; and the wide range of potential causes ofbalance disorders. Patients are often empirically givenvestibular sedatives, which have significant side-effects inthis age group. They may simply be dismissed as beingold. Alternatively, they may undergo exhaustive and ex-pensive non-directed medical and imaging studies, to-gether with serial consultant opinions.

We further classified the balance-related symptomsby factorial analysis and could observe four different en-tities describing the “presbyequilibrium”. The factorsshowed different association with VOG and posturogra-phy measurements, and these too may help to directphysician toward the underlying pathology. Episodic

presbyequilibrium (Factor 1) contained characteristics in-dicating "episodic vestibular changes". Subjects had vertigoprovoked by physical strain or activity, often accompaniedby nausea during the attack. Subjects suffered from poorpostural stability (instability, combined with subjectivefeelings of falling, and tended to experience episodes ofsudden instability). In postural presbyequilibrium (Factor 2),subjects experienced postural imbalance and rotational ver-tigo attacks that could occur suddenly and of short dura-tion more than twice a month. The positional changescould provoke the attacks. The frail presbyequilibrium (Fac-tor 3) was characterized by poor muscle strength and co-ordination, and the need for assistance in movements.Subjects preferred to use their hands to assist them-selves when rising from a chair and used supporting de-vices for walking. This group was noteworthy for con-tinuous dizziness associated with subjective feelings offalling. The symptom entity described by VOR deficitcorrelated with this group. Lastly, syncopal presbyequi-librium (Factor 4) was characterized by episodes of syn-cope, nearsyncope or a floating sensation and could beprovoked by positional changes. It was associated withpoor memory and defective smooth pursuit. Subjectswith syncopal presbyequilibrium fell more than eighttimes during the 12-month follow-up period.

These four different factors carry out important mes-sages for physicians treating or examining the elderly. Thefrail presbyequilibrium group needs vestibular rehabilita-tion with muscle strength training to prevent falls. The syn-copal presbyequilibrium group needs medical attention fordiagnosis and treatment. Neurocardiogenic syndrome(NCS) is an important entity to concider in the advancedaged population, since it may be the reason for their poorbalance performance and falls. Episodic and posturalpresbyequilibrium needs vestibular and medical work-upto reveal the pathophysiological mechanisms and to allowproper vestibular treatment in those who will benefitfrom it. Epidemiologically, problems with vertigo, dizzinessand postural imbalance are so vast in the elderly that geri-atricians and otologists may be insufficient in numbers tobe able to help this population properly. With the rapidgrowth in the geriatric population, it would be beneficialto create a new type of specialized vestibular healthcareprofessional. We deliberately propose that these spe-cially trained individuals may best be termed “geriatricvestibular nurses”, as they must be capable of takingcareful vestibular case histories and performing balanceand vestibular testing, including posturography and video-oculography.

VOG findingsWe observed that the vestibular symptoms did not al-

ways accompany with nystagmus in the positioning test.Our subjects could have vigorous nystagmus without ver-tigo or dizziness, or experience symptoms without any



nystagmus in the test thus confirming previous findingsthat the elderly with BPPV often do not report the clas-sically described symptoms (6). Lawson et al. demon-strated that, when compared with younger patients withBPPV, the elderly were significantly more likely to describedizziness with postural changes (40% vs 14%) and lesslikely to describe rotatory vertigo (40% vs 89%) (6). Ourresults confirm the finding that making a diagnosis ofBPPV in older people may be difficult, particularly asthis group frequently has more than one type of dizziness:postural dizziness symptoms (raising the suspicion of or-thostatic hypotension) and multiple co-morbidities and co-existing cardiovascular diagnoses. Oghalai et al. demon-strated in elderly care centre that not one of the elderlyidentified with BPPV had reported dizziness to their pri-mary care doctors (4). Lawson et al. also reported that theelderly group had no previous provisional diagnosis ofBPPV or positional vertigo made by their primary carepractitioners (6).

As far as we know, there are no previous studies inwhich posturography and VOG have been recordedamong oldest old. In posturography, the most striking find-ing was the limited use of the confidence area applied inthe support of balance in the elderly. As this range was solimited (about 5 cm2), there must be many situationsduring the daily activities in which the balance will fall out-side this confidence area, forcing them to seek for externalsupport to prevent a fall. In our opinion, one of the keyrehabilitation goals in the elderly is to widen their narrowpostural confidence area. Kerber et al. (7) evaluated pos-tural responses in elderly subjects and found an associa-tion of poor balance, accidental falls, with poor out-comes of posturographic measurements. They regardedpostural imbalance as a key factor in explaining acci-dental falls.

In elderly subjects, Bloom and Katsarkas (2) used thepresence of a sensation of spinning and the absence of asensation of lightheadedness in order to predict that an el-derly has BPPV. This may be a useful screening tool toevaluate BPPV during routine work-up of all elderly pa-tients. In our study, absence of vertigo with nystagmus andpresence of vertigo without nystagmus indicate that thismethod may not be accurate in the oldest old.

Once a balance disorder is identified, it is often achallenge to treat. The repositioning manoeuver has agood success rate in curing BPPV (18). Exercises de-signed to habituate the response have also been shown tohasten recovery time (19, 20). Early recognition andtreatment of BPPV in these patients may improve func-tioning and quality of life, although further prospectivestudies are warranted (4).

CONCLUSIONSVertigo and dizziness among the elderly is a complex

and common symptom, to which the failure of many pos-

sible systems may contribute. Vestibular control may bedisturbed by various central or peripheral mechanisms,which are categorized into four main paradigms, to makeetiology easier to identify.

Positional vertigo was prevalent in 55% of institu-tionalized elderly persons. In the majority, specific vestibu-lar abnormalities were found, consisting of reduced VORgain, spontaneous nystagmus, and others. The postur-ography demonstrated two major findings: the posturalconfidence area was severely limited to about 5 cm, andthe use of vision in assisting postural control was re-duced. We used factorial analysis to further classify the bal-ance related symptoms and could observe four differententities describing the “presbyequilibrium”. These fac-tors showed different association with VOG and postur-ography measurements, and may aid in describing un-derlying pathology. The range of problems with vertigo,dizziness and postural imbalance is so vast in the elderlythe geriatricians and otologists may not be capable of han-dling it. Therefore, a new personal category of specializednursing staff should be trained. We provocatively name thegroups as “geriatric nurses”, as they must be capable oftaking careful vestibular case histories and performing bal-ance and vestibular testing, including posturography andvideo-oculography. In fall prevention, this group mayguide the elderly toward different types of rehabilitationprograms or medical examinations, as indicated.

ACKNOWLEDGEMENTSThis work was supported by grants from the EU PROFANE (Pre-

vention of Falls Network Europe) and Pirkanmaa Cultural and ScienceFoundation. This study was carried out with the kind collaboration ofpersonnel of the Koukkuniemi elderly people´s home of Tampere, Fin-land. We thank Dr. Ripsaluoma for providing facilities to conductthe study, and the Department of Physiotherapy of Koukkuniemi for as-sistance in this study.

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Presbyequilibrium in the oldest old, a combination of vestibular, oculomotor and postural deficits