(PP1501) It’s Time to Widen Our Lens: Evaluation and Management of Elderly Patients with Presbyvestibulopathy

Audiologists who evaluate and manage vestibular function, are tasked to help elderly patients maintain independence and safety. Presbyvestibulopathy, is a common vestibular condition in the aging population, leading to age-related vestibular system decline. This poster presents two elderly patients with comparable symptoms including imbalance, impaired postural control, and a history of recurrent falls. Comprehensive vestibular evaluation revealed bilateral vestibular system dysfunction, consistent with the diagnostic criteria for presbyvestibulopathy; however, both patients presented with complex medical factors that added to the overall symptomatology. The pertinence of comprehensive and interprofessional management for this patient demographic will be further detailed.


 

Summary: 



Objective and Rationale
Audiologists who evaluate and manage vestibular function, are tasked with the important responsibility to help our elderly patients maintain independence and safety. Falls are a leading cause of injury in the older adult population causing longstanding physical and emotional distress on patients and their families. Nearly half of older adults over 60 years of age will suffer from physiologic decline of peripheral and central vestibular systems (Bates et al., 1997; Bartl et al., 2009). Vestibular pathology in older adults causes deleterious effects on overall balance and gait function, thus increasing the risk of falling. This patient demographic is at an increased risk due to age-related sensory degradation of not only the vestibular system, but also visual, somatosensory, and hearing systems in addition to changes in central nervous system processing to elicit motor output responses. Elderly patients must also navigate concomitant comorbidities, polypharmacy, and delayed functional recovery due to neuromuscular decline. These factors combined facilitate a negative feedback loop which further increases fall risk, fear of falling, and reduces overall balance confidence. Therefore, there is an imperative role on the part of audiologists to mitigate the risk of falling and improve the safety of our elderly patients; however, the vestibular system is just one piece of the complex and heterogenous puzzle. Successful management of this patient population should be comprehensive and include a multidisciplinary approach, as treatment for vestibular dysfunction alone may not be enough. This concept will be exemplified by a presentation of two clinical cases.













Design





Case presentations
Two patients ages 61 and 87 years old, presented with similar symptoms of imbalance, postural instability, and a history of recurrent falls resulting in significant injury. Both patients denied pertinent otologic concerns other than non-bothersome subjective tinnitus, bilaterally. Comprehensive vestibular evaluation was recommended to further investigate vestibular system contributors to their imbalance complaints. The following clinical questions were developed prior to testing:

Clinical questions

1. 
   Are there any indications of vestibular system dysfunction to account for the patients’ reported symptoms? If yes, what are the functional implications of the vestibular deficits?
   


2. 
   Given the high rate of falls, what other factors (both intrinsic and extrinsic) should be considered?
   

Results and Conclusions





Answering clinical question – 1: Objective testing revealed bilateral vestibulo-ocular hypofunction in both cases. Additionally, significant findings included diffuse central vestibular findings, most likely attributed to age-related decline of central vestibular pathways. Both patients were diagnosed with presbyvestibulopathy, as examination findings were consistent with the criteria outlined by the Barany Society (Agrawal, 2019).
Answering clinical question – 2: Moreover, the patients’ histories suggested age-related decline across multiple domains including postural control and gait, vision, somatosensory, hearing, and vestibular systems. The patients presented with other fall risk factors including physiological contributors, polypharmacy, cardiovascular disease, diabetes, and Vitamin D deficiency. Their complex and multifactorial presentation will be further explored via a series of tables listing intrinsic and extrinsic fall risk factors. Vestibular audiologists should consider the referenced intrinsic and extrinsic reasons for symptoms of imbalance and falls, as vestibulopathy is often not the only contributing factor.