What is the recommended treatment for Benign Paroxysmal Positional Vertigo (BPPV) in an elderly female?

Treatment for BPPV in Elderly Female

Canalith repositioning procedures (CRP), particularly the Epley maneuver, should be the first-line treatment for benign paroxysmal positional vertigo (BPPV) in elderly females due to high success rates of 61-95% after a single treatment. 1

Diagnosis Confirmation

• Confirm diagnosis using the Dix-Hallpike maneuver for posterior canal BPPV (most common)
  • Look for characteristic torsional, upbeating nystagmus
• Use Supine roll test for horizontal canal BPPV if Dix-Hallpike is negative 1
• Routine imaging or vestibular testing is not recommended unless additional symptoms unrelated to BPPV are present 1

Treatment Algorithm

First-Line Treatment

1. Canalith Repositioning Procedures (CRP)

   • Epley maneuver is the most validated technique with 61-95% success rate after single treatment 2, 1
   • Alternative procedures based on canal involvement:
     • Semont maneuver (Liberatory Maneuver) - 71-94% success rate
     • Gufoni Maneuver for horizontal canal BPPV
     • Barbecue Roll Maneuver (Lempert maneuver) for horizontal canal BPPV 1

2. Repeat CRP if needed

   • Success rates increase to 90-98% with repeated procedures 1
   • Reassess within 1 month to document resolution or persistence of symptoms 2

Second-Line/Adjunctive Treatment

1. Vestibular Rehabilitation Therapy (VRT)

   • Consider as adjunctive therapy, not as a substitute for CRP 2
   • Particularly beneficial for elderly patients with:
     • Residual dizziness after successful CRP
     • Preexisting balance deficits
     • CNS disorders
     • Increased fall risk 2, 3
   • VRT improves dynamic balance better than CRP alone in elderly BPPV patients 3

2. Medication Management

   • Do not routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines) 2
   • Limited short-term use only for:
     • Severe autonomic symptoms (nausea, vomiting)
     • Patients who refuse CRP
     • Severe symptoms after CRP 2
   • If medications are necessary, use with caution:
     • Start with lower doses in elderly (increased sensitivity)
     • Limit duration to prevent dependence and interference with vestibular compensation
     • Monitor for side effects: sedation, confusion, unsteady gait 1

Special Considerations for Elderly

1. Increased prevalence and impact

   • BPPV prevalence in patients >60 years is 7 times greater than in younger adults 2
   • Higher risk for falls, depression, and impairments in daily activities 1
   • May present atypically with imbalance rather than classic vertigo 4

2. Treatment effectiveness

   • Elderly patients may have lower success rates with repositioning maneuvers 4
   • Higher recurrence rates (approximately 36%) 1, 4
   • May require more follow-up visits and repeated treatments

3. Safety precautions

   • Assess for contraindications: cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies 2, 1
   • Modified techniques may be required for patients with physical limitations 1
   • Rare but serious adverse events have been reported (e.g., hemorrhagic stroke) 5
   • Monitor for nausea during repositioning (reported in 16.7-32% of patients) 2

Follow-up Care

• Reassess within 1 month after treatment 2, 1
• No postprocedural restrictions are needed after CRP 1
• Provide education about:
  • Safety concerns related to BPPV
  • High recurrence rate (36%)
  • Importance of follow-up 1
• Consider longer follow-up for elderly patients due to higher recurrence rates 4

Treatment Effectiveness

The Epley maneuver is superior to observation alone, with evidence showing resolution of BPPV in 56% of treated patients compared to 21% with observation or sham procedures 6. Outcomes for the Epley maneuver are comparable to Semont and Gans maneuvers, but superior to Brandt-Daroff exercises 6.