What is the best approach to benign paroxysmal positional vertigo in the elderly?

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What is the best approach to benign paroxysmal positional vertigo in the elderly?

J Fam Pract. 2010 May;59(5):295-297

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References

1. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710-715.

2. Lea P, Kushnir M, Shpirer Y, et al. Approach to benign paroxysmal positional vertigo in old age. Isr Med Assoc J. 2005;7:447-450.

3. Salvinelli F, Trivelli M, Casale M, et al. Treatment of benign positional vertigo in the elderly: a randomized trial. Laryngoscope. 2004;114:827-831.

4. Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003;128:719-725.

5. Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol. 2005;26:1034-1040.

6. von Brevern M, Seelig T, Radtke A, et al. Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry. 2006;77:980-982.

7. Tanimoto H, Doi K, Katata K, et al. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65:1299-1300.

8. Simoceli L, Bittar RS, Greters ME. Posture restrictions do not interfere in the results of canalith repositioning maneuver. Rev Bras Otorrinolaringol. 2005;71:55-59.

9. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2000;122:647-652.

10. Sakaida M, Takeuchi K, Ishinaga H, et al. Long-term outcome of benign paroxysmal positional vertigo. Neurology. 2003;60:1532-1534.

11. McClure JA, Willett JM. Lorazepam and diazepam in the treatment of benign paroxysmal vertigo. J Otolaryngol. 1980;9:472-477.

12. Cohen B, DeJong JM. Meclizine and placebo in treating vertigo of vestibular origin. Relative efficacy in a double-blind study. Arch Neurol. 1972;27:129-135.

13. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341:1590-1596.

Posture restrictions are unnecessary
An RCT involving 50 participants (mean age 60.9 years) demonstrated that postprocedure postural restrictions were unnecessary and didn’t improve BPPV remission rates among patients receiving CRM (P=.97). No differences were noted by age or sex.⁸ Two prospective nonrandomized studies found that the recurrence rate of BPPV symptoms was 15% to 18% at 12 months and 37% to 50% at 40 to 60 months.^9,10

Drug studies are scarce, but CRM appears to work better
Studies of drug treatment among patients with BPPV are extremely limited because BPPV as a cause of vertigo is often an exclusion criterion among medication trials. A small (N=20; age range 32-67 years) double-blinded RCT found no difference in dizziness symptom scores for participants with BPPV who took diazepam (5 mg, 3 times daily), lorazepam (1 mg, 3 times daily), or placebo (1 capsule, 3 times daily) over a period of 4 weeks.¹¹

An RCT of 156 patients (mean age 74 years) with BPPV compared a calcium channel blocker (flunarizine, which isn’t available in the United States) with Semont’s liberatory maneuver or no therapy (observation only). Semont’s maneuver was more effective at the 6-month follow-up than either the calcium channel blocker or no therapy; the rates of asymptomatic patients with a negative Dix-Hallpike test at follow-up were 94%, 58%, and 34%, respectively (P<.001).³

Although meclizine is often used in clinical practice, only 1 double-blind RCT from 1972 (N=31, age range 21-77 years) reported improvement in symptoms and physical findings for meclizine compared with placebo in patients with BPPV.¹²

Recommendations

In a review article, Furman and Cass describe the diagnostic maneuver (Dix-Hallpike) and treatment maneuver (Epley) for BPPV.¹³ They recommend using either Epley’s or Semont’s maneuver for initial treatment.

The authors noted that vestibular suppressant medications may decrease the intensity of symptoms but don’t reduce the frequency of recurrent vertigo attacks. Moreover, medications produce unwanted side effects (somnolence, lethargy, worsened balance) and may prove counterproductive by delaying the central nervous system’s adaptation to a peripheral vestibular abnormality.

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What is the best approach to benign paroxysmal positional vertigo in the elderly?

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