Abstract
Background
Fall incidents are a rising problem amongst older people and can have multiple causes. Vestibular disturbances such as benign paroxysmal positional vertigo (BPPV) are often not recognized as risk factors. The aim of our study is to determine the prevalence of BPPV in an older population referred to the geriatric falls clinic. Second, we aim to examine whether there is a reduction in the number of fall incidents and severity of fall incidents after a successful repositioning manoeuvre in patients with BPPV.
Methods
Dutch adults, aged ≥ 65 years, referred to the specialised falls clinic with an increased risk of falling were included. Subjects with additional neuro-otologic disorders or with severe disability were excluded. All participants were subjected to diagnostic manoeuvres to determine whether they had BPPV. If positive, they were treated with a canalith repositioning manoeuvre and were followed up according to regular care. Participants were asked to recall the number and severity of fall incidents of the past six months at time of inclusion. During follow-up, they were asked to record every fall incident and the corresponding severity in a provided falls diary. After follow-up, fall incidents were compared between participants with and without BPPV and within participants with BPPV before and after treatment.
Results
A total of 79 (56%) out of 142 eligible subjects agreed to participate and were included. Fifty-eight (73%) were female and the median age was 82 years (± 6). We found a total of 15 subjects (19%) with BPPV of whom 7 (47%) reported no complaints of BPPV. We found no differences in the number and severity of fall incidents between the groups in the 6 months prior to inclusion. We determined a significant reduction of the number of fall incidents 6 months after treatment within the BPPV group (p = 0.04).
Conclusion
Approximately one-fifth of geriatric patients presenting to the falls clinic appeared to have BPPV and half of these patients reported no complaints of BPPV. BPPV seems to contribute to the risk of fall incidents in older people. Since treatment is easy to perform and likely to reduce fall incidents, we think it is of great importance to routinely check for BPPV in older patients with an increased risk of falling.
Trial registration
Approval by the medical ethics review board of Leiden University Medical Centre (September 28th 2018; trial number: P18.113) and the institutional review board of Gelre Hospitals (October 16th 2018, trial number: 18.39).
Keywords: Benign paroxysmal positional vertigo, Older people, Fall incidents
Introduction
According to the World Health Organisation (WHO) every year 28% to 35% of the older population (≥ 65 years) fall and this number increases with age [1]. Fall incidents can lead to injuries, hospital admissions or even to death. Lethal falls have tremendously increased over the past years [2]. Factors that might have contributed to this increase could be an improved awareness and reporting of falls, the fact that older people live longer, and the fact they remain living independently as long as feasible [3, 4]. Fall incidents are multifactorial and require interdisciplinary interventions [5]. Recently, there has been increased attention on vestibular causes of falls in the elderly, particularly benign paroxysmal positional vertigo (BPPV). The 2022 World Falls Guidelines and the 2024 Dutch Guidelines for the prevention of falls in the elderly have included new recommendations for preventing falls that may be associated with underlying BPPV [6, 7]. They recommended performing positional tests when vertigo is reported.
BPPV has a lifetime prevalence of 2.4% and is characterized by sudden and brief spinning sensations initiated by a change of head position [8–11]. A widely accepted hypothesis of the cause of BPPV is the detachment of degenerated otoconia from the otolithic membrane in the utricle, dislocating into the semicircular canals. When the head position changes, the clotted otoconial debris moves downwards due to gravity, resulting in endolymphatic flow and deflection of the cupula in the semicircular canal. This elicits vertigo and a typical nystagmus congruent with the affected semicircular canal [12].
BPPV is easy to treat with a canalith repositioning manoeuvre, including a few simple head movements, performed with the aim to move the free-floating otoconia from the semicircular canal back into the utricle [13–15]. The most common ones are the Epley or Semont manoeuvre which lead to symptom resolution in 85% of the cases [16]. A recent systematic review and meta-analysis showed that BPPV increased the odds of falls and negatively impacted gait [17]. The authors also concluded that repositioning manoeuvres reduced the odds of falls, improved gait as well as reduced fear of falling in people with BPPV.
Studies conducted so far demonstrated a variable prevalence of BPPV in the older population. Oghalai et al. recorded the presence of dizziness using a questionnaire and a neuro-otologic examination and found a prevalence of undiagnosed BPPV in 9% of a public, inner-city geriatric population, accompanied by a high occurrence of fall incidents [18]. Van der Zaag-Loonen et al. found BPPV to be present in 1.4% of older patients with complaints of dizziness [19]. However, by asking patients whether they experienced dizziness typical for BPPV, in this study a selection was made in advance. Studies focusing on older patients with BPPV showed that people can have BPPV without the typical symptoms, making the prevalence reported in the former study probably an underrepresentation of the true prevalence of BPPV in the older population [20, 21]. Although these studies focused on older patients, the authors did not select patients based on an increased fall risk. More recently, Hyland et al. retrospectively demonstrated that approximately 25% of patients diagnosed with BPPV and an increased fall risk experienced no complaints of dizziness [22]. The fact that patients can have BPPV without the typical symptoms is probably linked to impaired vestibular perception due to old age (‘vestibular agnosia’) [23].
The abovementioned new recommendations of the World Falls Guidelines and the Dutch Falls Guidelines recommend to perform positional tests only when vertigo is reported. This conflicts with the findings of the aforementioned studies, which suggest that a substantial number of patients with BPPV may not experience vertigo in daily life, likely due to vestibular agnosia. Using the new recommendations, these patients will still be overlooked [23].
Therefore, our primary aim of our study was to determine the prevalence of BPPV in an older population with an increased risk of falling referred to the geriatric outpatient falls clinic. Second, we aimed to examine whether there was a reduction in the number of fall incidents and severity of fall incidents after a successful repositioning manoeuvre.
Methods
We performed a single-centre, pre-post screening study in our dizziness clinic in Apeldoorn, The Netherlands. From November 2018 until December 2021 we asked older subjects with an increased risk of falls to participate. We used the following inclusion criteria: understanding of the Dutch language, age 65 years or over, referred to the specialised falls clinic of the geriatric outpatient clinic, and an increased risk of falls (≥ 4 points) according to the ‘Self-Rated Fall Risk Questionnaire (FRQ) for older adults’, developed by ‘the Greater Los Angeles VA Geriatric Research Education Clinical Center’, validated by Rubenstein et al. and adapted with permission by the American ‘Centers for Disease Control and Prevention’ [24]. Subjects were excluded from participation if they suffered from any other active neuro-otologic disease which could mimic BPPV or if they had other diseases causing an impediment for diagnostic manoeuvres. All subjects were routinely examined by a geriatric consultant and a geriatric nurse. The geriatric nurse identified risk factors for falling, determined the level of fear of falling and assessed home safety. The geriatric consultant completed the FRQ, performed a physical examination and decided which additional tests or imaging were necessary. If subjects fulfilled the inclusion criteria they were referred to our dizziness clinic. We contacted all referred subjects by telephone to further explain our study and to check for eligibility. For all subjects willing to participate, we scheduled appointments to obtain written informed consent and to perform diagnostic manoeuvres.
Baseline characteristics
At the time of inclusion, we recorded baseline characteristics, such as sex, age, smoking habits, alcohol consumption, current complaints of positional dizziness, relevant medical history, and the use of medication that could affect fall risk.
We asked subjects whether they were currently smoking tobacco and whether they consumed at least one unit of alcohol per week. In addition, we assessed current complaints of dizziness during four typical head movements: turning over in bed, lying down in bed, bending over, and looking up. Since it was established that dizziness with turning over in bed is most suggestive for BPPV, we decided that subjects experiencing dizziness with turning over in bed together with at least one more typical head position were considered to have positional dizziness [20]. In case subjects did not experience dizziness during turning over in bed, they had to experience dizziness during all other three head positions in order to record it as positional dizziness.
We collected relevant medical history data, such as orthostatic hypotension (OH), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), cardiovascular diseases (CVD), and ocular diseases by asking subjects during inclusion and by researching their medical files.
The use of relevant medication, such as benzodiazepines, psychotropics, antiarrhythmics, and antihypertensives was documented for all subjects.
To determine the prevalence of BPPV in older patients with an increased risk of falling, a sample size calculation was not applicable. Between November 2018 and December 2021 all eligible, subsequent patients presenting at the geriatric outpatient falls clinic were asked to participate.
Data collection
All subjects included were subjected to diagnostic manoeuvres according to the Clinical Practical Guideline BPPV [13]. To determine whether subjects had a posterior canal BPPV, we used the Dix-Hallpike manoeuvre [25]. To examine horizontal canal BPPV, we used the supine roll test [26]. According to the criteria of the Bárány Society, a diagnostic test was considered positive when it elicited a typical positional dizziness with or without a typical positional nystagmus [27]. Most often, subjects experience a typical positional dizziness with a typical positional nystagmus, corresponding with a diagnosis of definite BPPV. However, in some cases, the number of otoconia in the semicircular canal may be sufficient to produce subjective vertigo symptoms but insufficient to provoke a vestibulo-ocular reflex. Therefore, when subjects experienced characteristic dizziness during diagnostic manoeuvres without observable nystagmus, we recorded these cases as possible BPPV, in accordance with the Bárány Society consensus document [27]. A positional nystagmus was recorded using Frenzel goggles or videonystagmography. If a diagnostic manoeuvre was positive, subjects were treated with the appropriate canalith repositioning manoeuvre, with a maximum of three times per visit, and were followed up after two weeks according to our regular care.
At time of inclusion as well as after six months of follow-up, subjects were asked about the number and severity of fall incidents in the past six months. A fall incident was defined as an unplanned drop to the ground or a lower level, caused by tripping, slipping, or losing balance. For every documented fall incident, we scored the severity with the following options: no consequences, pain killers, visit to the general practitioner, visit to the emergency department, or admitted to the hospital. At time of inclusion we asked subjects to recall the number and severity of their fall incidents in the past six months. During follow-up, subjects were asked to record every fall incident and the corresponding severity in a provided falls diary. The most severe consequence of a fall incident per subject was documented. For further analysis, we compiled the five outcomes into two groups. The first group consisted of subjects who were not examined in the hospital after a fall incident and therefore received out of hospital care. This group consisted of subjects who indicated the following severity after a fall incident: ‘no consequences’, ‘pain killers’, and ‘visit to the general practitioner’. The second group, i.e. subjects who received hospital care, consisted of subjects transported to the hospital, i.e. ‘examination at the emergency department’ and ‘admitted to the hospital’.
Outcomes and data analysis
For our primary study outcome, we determined a prevalence with a 95%-confidence interval for the number of subjects with BPPV within the group of older people with an increased risk of falls. No a priori sample size calculation was performed.
To analyse our secondary outcome (i.e., number and severity of fall incidents), we first tested for differences between subjects with and without BPPV. To determine whether there were differences in the number of fall incidents we used the Mann–Whitney U test, for differences in the severity of fall incidents the Fisher Exact test.
Next, we tested for differences within the group of subjects with BPPV before and after treatment. The Wilcoxon signed rank test was used to test differences in the number of fall incidents and the McNemar test to test binary outcomes within this group.
Ethics approval and informed consent
The study was approved by the medical ethics review board of Leiden University Medical Center (trial number: P18.113) and the institutional review board of Gelre Hospitals (trial number: 18.39) on September 28th 2018 and October 16th 2018, respectively. All study participants gave written informed consent.
Results
A total of 187 subjects were screened by a geriatric consultant and 142 eligible subjects were referred from the geriatric outpatient clinic to our dizziness clinic (Fig. 1). Seventy-nine subjects (56%), with a mean age of 81 years (SD 6 years) and of whom 58 (73%) were female, were willing to participate. Sixty-three subjects, with a mean age of 81 years (SD 6 years) and including 40 females (64%), refused participation for various reasons as summed up in Table 1. We found no statistical differences between the included subjects and nonparticipating subjects regarding age and sex.
Fig. 1.
Flowchart of the screening of a cohort of patients referred to the specialised falls clinic. (*) no consistent recording by geriatric consultants of patients referred to the specialised falls clinic. (**) no consistent recording by geriatric consultants of not meeting inclusion criteria. FRQ: self-rated Fall Risk Questionnaire; BPPV: benign paroxysmal positional vertigo
Table 1.
Reasons for subjects and/or their caregivers not to participate in the study
| Reasons (n = 63) | Number of patients (%) |
|---|---|
| Too many other appointments in the hospital | 17 (27) |
| Poor physical condition | 10 (17) |
| Preference for no further analysis to high fall risk | 8 (13) |
| No complaints of dizziness | 6 (9) |
| Dependent on other people for transport | 5 (8) |
| Recommended by physical therapist/GP | 4 (6) |
| Fear for manoeuvres | 3 (4) |
| Not able to contact | 2 (3) |
| Unknown | 8 (13) |
Poor physical condition not allowing multiple repositioning manoeuvres and extra hospital visits as estimated by the subjects or their caregivers, GP general practitioner
Prevalence of BPPV
Out of 79 subjects we diagnosed fifteen subjects (19%, 95% CI 12—29) with BPPV. In eleven out of fifteen subjects (73%) the diagnostic manoeuvre elicited a positional dizziness with a typical nystagmus congruent with the diagnosis definite BPPV. Four subjects (27%) showed a typical positional dizziness without a nystagmus and were diagnosed with possible BPPV.
Definite BPPV
Ten out of eleven subjects had a posterior canal BPPV (p-BPPV) and one subject was diagnosed with a definite horizontal canal BPPV (h-BPPV). Nine out of ten p-BPPV subjects were treated with the Epley manoeuvre and one subject was treated with the Semont manoeuvre [14, 15]. The single h-BPPV subject was treated with a Gufoni manoeuvre [28]. Data from the two-week follow-up visit were available for ten of the eleven subjects. In six subjects the diagnostic manoeuvre was negative. Two subjects had a persistent posterior canal BPPV on the ipsilateral side. One subject had a posterior canal BPPV on the contralateral side. The one subject diagnosed with a horizontal canal BPPV still had a horizonal canal BPPV on the ipsilateral side. At the third visit, one subject was diagnosed with a persistent posterior canal BPPV on the ipsilateral side. No subject contacted the clinic for a fourth visit.
Possible BPPV
Four subjects (27%) showed a typical positional dizziness without a nystagmus and were diagnosed with possible BPPV [23, 29]. Three out of four subjects experienced dizziness during the Dix-Hallpike manoeuvre and therefore were treated with an Epley manoeuvre appropriate for posterior canal BPPV. One subject experienced dizziness during the supine roll test. Since the affected side was undetermined, the subject was treated with a head shake manoeuvre [30]. All four subjects visited the clinic after two weeks. Three subjects experienced no vertigo symptoms during the diagnostic manoeuvre anymore. For the one subject treated with the headshake manoeuvre for possible horizontal canal BPPV, the diagnostic manoeuvre now showed definite posterior canal BPPV and the subject was treated with an Epley manoeuvre. No subject contacted the clinic for a third visit.
Baseline characteristics
We compared the baseline characteristics of subjects with and without BPPV (Table 2) and found no differences between the groups regarding age, sex and smoking. A tendency towards alcohol consumption was seen in the group with BPPV (OR 2.9 [0.9–9.1], p = 0.08). Subjects with BPPV had a significant lower body mass index (BMI) than subjects without BPPV (mean difference 3.6 [0.7–6.5] p = 0.01). Subjects in the group with BPPV significantly more often experienced positional dizziness (OR 3.8 [1.2–12.2], p = 0.03). We found no differences between the groups regarding fall incidents in the past six months, relevant medical history or the use of relevant medication.
Table 2.
Baseline characteristics
| BPPV (n = 15) | No BPPV (n = 64) | OR/MD (95% CI) | p value | |
|---|---|---|---|---|
| Age in years (mean, SD) | 81 (± 6) | 82 (± 6) | −1.2 (−4.3 – 2.0) | 0.5 |
| Female (n, %) | 12 (80) | 46 (72) | 1.6 (0.4–6.2) | 0.7 |
| Smoking (n, %) | 0 (0) | 2 (3) | - | 1 |
| Alcohol (n, %) | 9 (60) | 22 (34) | 2.9 (0.9–9.1) | 0.08 |
| BMI (mean, SD) | 24.8 (± 3.6) | 28.5 (± 5.1) | 3.6 (0.7–6.5) | 0.01 |
| Fall incident < 6 months (n,%) | 10 (67) | 42 (66) | 1 (0.3–3.4) | 1 |
| Positional dizziness (n, %) | 8 (53) | 14 (23) | 3.8 (1.2–12.2) | 0.03 |
| COPD (n, %) | 2 (13) | 12 (19) | 0.7 (0.1–3.4) | 0.9 |
| OH (n, %) | 4 (27) | 15 (24) | 1.2 (0.3–4.3) | 1 |
| Depression (n, %) | 2 (13) | 14 (22) | 0.5 (0.1–2.7) | 0.7 |
| DM (n, %) | 4 (27) | 23 (36) | 0.6 (0.2–2.3) | 0.7 |
| CVD (n, %) | 14 (93) | 51 (80) | 3.6 (0.4–29.7) | 0.4 |
| Cataract (n, %) | 7 (47) | 34 (53) | 0.8 (0.3–2.4) | 0.9 |
| Macular degeneration (n, %) | 1 (7) | 6 (9) | 0.7 (0.1–6.2) | 1 |
| Vitamin supplements (n, %) | 10 (67) | 36 (62) | 1.6 (0.5–5.1) | 0.7 |
| Calcium supplements (n, %) | 3 (20) | 17 (29) | 0.7 (0.2–2.8) | 0.9 |
| Benzodiazepines (n, %) | 4 (27) | 18 (31) | 0.9 (0.3–3.3) | 1 |
| Psychotropics (n, %) | 3 (20) | 14 (24) | 0.9 (0.2–3.6) | 1 |
| Antiarrhythmics (n, %) | 6 (40) | 17 (29) | 1.8 (0.6–6.0) | 0.5 |
| Antihypertensives (n, %) | 10 (67) | 39 (67) | 1.3 (0.4–4.2) | 0.9 |
BPPV benign paroxysmal positional vertigo, OR odds ratio, MD mean difference, CI confidence interval, SD standard deviation, n number, BMI body mass index, fall incident an unplanned drop to the ground or a lower level, caused by tripping, slipping, or losing balance, COPD chronic obstructive pulmonary disease, OH orthostatic hypotension, DM diabetes mellitus, CVD cardiovascular disease
Differences between groups with and without BPPV
Table 3 shows the results of the analysis between the subjects with and without BPPV regarding the number and severity of fall incidents in the six months prior to inclusion. Ten out of 15 subjects (67%) from the BPPV group and 42 out of 64 subjects (66%) from the group without BPPV had a fall incident in the six months prior to inclusion. We found no statistically significant differences between the two groups regarding the number and severity of fall incidents.
Table 3.
Differences between subjects with fall incidents with BPPV (n = 10) and without BPPV (n = 42) in number and severity of fall incidents in the 6 months prior to inclusion
| BPPV | No BPPV | p value | |
|---|---|---|---|
| Self-reported number of fall incidents (median, min/max) | 2 (1–3) | 2 (1–15) | 0.9 |
| Severity of fall incidents (n, %)a | 1 | ||
| Out of hospital care | 8 (80) | 32 (78) | |
| In hospital care | 2 (20) | 9 (22) |
BPPV benign paroxysmal positional vertigo, fall incident an unplanned drop to the ground or a lower level, caused by tripping, slipping, or losing balance
a = data of one subject missing in the ‘no BPPV’ group; n = number; ‘out of hospital care’ = no examination in the hospital needed; ‘in hospital care’ = examination or admission to the hospital needed
Differences within the BPPV group after treatment
Table 4 shows a comparison of the results of the subjects in the BPPV group (n = 15) at six months before treatment with the results six months after treatment. We observed a significantly lower number of fall incidents (p = 0.04) six months after a repositioning manoeuvre. Before treatment, two subjects received in hospital care for their fall incident, whereas six months after a repositioning manoeuvre, all subjects with a fall incident were treated out of the hospital.
Table 4.
Differences in fall incidents within the BPPV group (n = 15) between 6 months prior to and 6 months after treatment
| Six months prior to treatment (n = 15) | Six months after treatment (n = 15) | p value | |
|---|---|---|---|
| Number of subjects with fall incidents < 6 months (n, %) | 10 (67) | 6 (40) | 0.22 |
| Self-reported number of fall incidents (median, min–max) | 2 (1–3) | 1.5 (1–2) | 0.04 |
| Severity of fall incidents (n, %) | - | ||
| Out of hospital care | 8 (80) | 6 (100) | |
| In hospital care | 2 (20) | 0 |
Fall incident an unplanned drop to the ground or a lower level, caused by tripping, slipping, or losing balance, n number
Discussion
This prospective study shows the prevalence of BPPV in an older population with an increased risk of falling and demonstrates a positive effect of treatment on fall incidents. Fall incidents are multifactorial, however the contribution of BPPV on fall incidents has barely been investigated. For that reason, our dizziness centre collaborated with the geriatric department in our hospital to determine the prevalence of BPPV in an older population referred to the geriatric consultant because of an increased risk of falls.
First, we found that 19% of our study population had BPPV. This percentage is lower than the recently reported prevalence of 39% by Hyland et al., who retrospectively screened a cohort of over 600 patients from a falls and balance clinic for BPPV [22]. The retrospective design and the cohort from a falls and balance clinic may have introduced selection bias, potentially increasing the prevalence. We chose to solely include patients referred to a specialised falls clinic with an increased risk of falling according to the Falls Risk Questionnaire (FRQ). Although a score of four points (the cut-off value indicating elevated risk) was relatively easy to reach for individuals who had fallen in the past six months (2 points) and who were advised to use a walking aid (2 points), we acknowledge that this approach may have excluded individuals with BPPV who had a low to moderate risk of falling.
Second, we aimed to examine whether there was a reduction in the number and severity of fall incidents six months after a successful repositioning manoeuvre in older subjects with BPPV. Before treatment we counted a median of two fall incidents per person. Six months after treatment the median number was reduced to 1.5 (p = 0.04), which suggests a preventive effect of the treatment. Comparing our result with the studies of Jumani et al. and Ganança et al., discussed in the meta-analysis of Pauwels et al. and presenting a reduction of median fall incidents per person of 1.7 and 2.3, respectively, the reduction in our study seems small [31, 32]. However, these two studies had a retrospective design eliciting a possible information bias on the registration of fall incidents and a selection bias on including patients with available data on falls. Although the magnitude of our result seems small, we think this outcome of a prospective analysis is clinically relevant nonetheless, since even a small reduction in fall incidents could be meaningful in the prevention of morbidity and mortality. Before treatment for BPPV, two patients were treated in the hospital because of the severity of their fall incident. Even though our small group size prevented us to statistically test for differences before and after treatment regarding the severity of fall incidents, after treatment none of the patients reported a fall incident with the necessity of in-hospital treatment.
We found no statistical significant differences between patients with and without BPPV regarding age, sex, smoking, alcohol consumption, a specific medical history or the use of specific medication increasing the risk of falling. Not surprisingly, patients with BPPV experienced positional dizziness more often than patients without BPPV. An interesting finding is that eight patients with BPPV reported no complaints of positional dizziness which is almost half of the patients (47%) diagnosed with BPPV. This is a higher percentage than the 26% found by Hyland et al. which could correspond with the possible inclusion of patients with prior balance complaints [22]. Also, our criteria to assign subjects with complaints of positional vertigo might have been more conservative than the selection of patients with dizziness by Hyland et al., possibly resulting in this higher percentage. Nonetheless, our and former results confirm that older patients can have BPPV without experiencing the typical symptoms such as positional dizziness, which could be a result of vestibular agnosia [20, 21, 23, 33].
Limiting positional tests to cases where vertigo is reported, as recommended by previous studies and the current Falls Guidelines, will result in missed diagnoses and treatments [6, 34].
Patients with BPPV had a significantly lower BMI than patients without BPPV. This could be an incidental finding since no other studies have reported this relation. One retrospective case–control study specifically analysed whether cardiovascular risk factors, including BMI, were associated with the risk of BPPV and found no relation [35]. However, a recently published retrospective study reported an association between BPPV and poor nutritional status using a serum marker rather than BMI [36].
A strong point of our study was the inclusion of a vulnerable and dependent geriatric population. However, the choice of population also resulted in difficulties in inclusion. Almost half of the referred patients were unwilling to participate, mostly because of logistical limitation to visit our dizziness clinic or because of their physical condition. Moreover, the geriatric consultants decided whether a patient was physically able to participate. This could have caused bias in selection. Another limitation is the possible information bias caused by the fact that we asked patients to recollect the number and severity of fall incidents until six months prior to the start of the study. To reduce this bias during the study, we asked patients to document every fall incident and the corresponding severity. Lastly, our study sample was rather small. This was partly due to the high number of patients declining participation. Another reason was that our study was partly conducted during the COVID-19 pandemic. For several months only urgent care was provided in the hospital and it was temporarily forbidden to allow patients to participate in medical research. After a while, medical research with human subjects was allowed again but patients were still reluctant to participate out of fear of infection by the SARS-CoV-2 corona virus in the hospital.
Although our findings contribute to a better understanding of the prevalence of BPPV among older adults at high risk of falls, we recommend that future research adopt a more comprehensive, multi-centre design with improved accessibility to diagnostic and therapeutic manoeuvres. This approach would help achieve larger sample sizes and reduce logistical barriers that may limit patient participation.
Conclusion
Approximately one-fifth of geriatric patients presenting at a falls clinic appeared to have BPPV and half of these patients reported no complaints of BPPV. BPPV seems to be a ‘silent contributor’ when it comes to the risk of fall incidents in older people. Elderly patients with BPPV will be overlooked when limiting positional tests to patients who report dizziness or vertigo, as recommended by the current World Falls Guidelines. Since treatment is likely to reduce the number of fall incidents in patients with BPPV, we think it is of great importance to routinely check for BPPV in older patients with an increased risk of falling.
Acknowledgements
We would like to thank Carla Colijn for her contributions in contacting all eligible patients as well as in developing the dataset.
Abbreviations
- BMI
Body Mass Index
- BPPV
Benign Paroxysmal Positional Vertigo
- CI
Confidence Interval
- COPD
Chronic Obstructive Pulmonary Disease
- CVD
Cardio-Vascular Disease
- DM
Diabetes Mellitus
- FRQ
Falls Risk Questionnaire
- OH
Orthostatic Hypotension
- OR
Odds Ratio
- SD
Standard Deviation
- WHO
World Health Organisation
Authors’ contributions
Substantial contributions to the conception: BM, RL, and TB; Design of the work: BM, RL, PS, and TB; Analysis: BM, TS, PB, and TB; Interpretation of data: BM, TS, PB and TB; Writing—draft: BM and TB; Substantively revised: all authors. All authors have approved the submitted version and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Funding
This work was supported solely from institutional and/or departmental sources from the Apeldoorn Dizziness Centre, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.