Introduction

Falls and fall-related injuries are a common and serious problem for older people. People aged 65 years and older have the highest risk of falling, with 30 per cent of people older than 65 years and 50 per cent of people older than 80 years falling at least once a year.¹

The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the National Health Service (NHS) more than £2.3 billion per year. Therefore, falling has an impact on quality of life, health and healthcare costs.¹

The National Institute for Health and Care Excellence (NICE)¹ identifies the following as a comprehensive, multifactorial assessment for those who have fallen or are at risk of falling: identification of falls history; assessment of gait, balance and mobility, and muscle weakness; assessment of osteoporosis risk; assessment of the older person's perceived functional ability and fear relating to falling; assessment of visual impairment; assessment of cognitive and neurological examination findings; assessment of urinary incontinence; assessment of home hazards; and cardiovascular examination and medication review.

Notably absent from this list is any mention of dizziness and/or vestibular dysfunction. Pothula et al.^{Reference Pothula, Chew, Lesser and Sharma2} and Oghalai et al.^{Reference Oghalai, Manolidis, Barth, Stewart and Jenkins3} clearly identified that 80 per cent of people presenting to an accident and emergency department with an unexplained fall have symptoms of vestibular dysfunction. One could rationalise that assessing balance, gait and neurological examination would encompass the vestibular system. However, none of the most commonly used tests in an older persons' falls clinic, which includes the Romberg, the Tinetti, and the Timed Up and Go tests, have been specifically or sufficiently studied in people with vestibular impairment to support their sole use in vestibular assessment.⁴ The Timed Up and Go test and the Dynamic Gait Index have been shown to predict increased fall risk in those with vestibular dysfunction, but do not predict vestibular dysfunction in those with higher fall risks.^{Reference Whitney, Marchetti, Schade and Wrisley5}

Ageing is associated with degradation of the vestibular apparatus, including degeneration of otoconia, degeneration of hair cells, loss of vestibular afferents, and a reduction in the number of hair cells in the vestibular nuclei.^{Reference Furman, Raz and Whitney6} As such, the older adult may not experience or report rotational vertigo in the same way a younger person may.^{Reference Furman, Raz and Whitney6–Reference Allen, Ribeiro, Arshad and Seemungal8} Often the report will be of a vague imbalance or dizziness, a veering of the gait, and/or generalised disproportionate fatigue. In fact, we know 50 per cent of those with benign paroxysmal positional vertigo (BPPV) will not report vertigo, instead identifying issues with balance and difficulty with tasks.^{Reference Furman, Raz and Whitney6–Reference Allen, Ribeiro, Arshad and Seemungal8} Lawson and colleagues^{Reference Lawson, Bamiou, Cohen and Newton9} found that older individuals with undiagnosed BPPV were more commonly referred to falls services, rather than specialist ENT services, because of the likelihood of multiple aetiologies for the falls and dizziness.^{Reference Lawson, Bamiou, Cohen and Newton9} They found that the high prevalence of atypical vestibular impairment in older adults required the inclusion of bedside vestibular screening within falls clinics to ensure appropriate assessment and treatment, supporting Furman and colleagues’ guidance that a Dix–Hallpike manoeuvre should be performed on all patients aged over 65 years.^{Reference Furman, Raz and Whitney6,Reference Lawson, Bamiou, Cohen and Newton9,Reference Lawson and Bamiou10}

Benign paroxysmal positional vertigo is becoming increasingly recognised as the commonest cause of vertiginous dizziness and imbalance. The prevalence of BPPV increases with age such that it is seven times higher in those aged 65 years and over, relative to those aged 15–40 years.^{Reference Ji and Zhai11} Vestibular dysfunction significantly contributes to falls in the elderly,^{Reference Ji and Zhai11} with falls and related injuries (e.g. fractures, joint dislocations and head injury) being rated as the sixth highest cause of death.^{Reference Sterling, O'Connor and Bonadies12}

Although large-scale, randomised, controlled trials have not been delivered yet to influence NICE guidance,¹ the World Falls Guideline has included vestibular disorders within its scope, encouraging investigative questioning.^{Reference Montero-Odasso, van der Velde, Martin, Petrovic, Tan and Ryg13} There are many smaller-scale studies demonstrating the significance of specific vestibular screening in the older population. Liston and colleagues^{Reference Liston, Bamiou, Martin, Hopper, Koohi and Luxon14} found that 80 per cent of those presenting to a falls clinic had unidentified vestibular impairment that was missed in usual falls clinic screening. Some were identified as having BPPV; however, the study also highlighted imbalance and vestibular deficits, with gaze and/or postural instability, recognising the more insidious, age-related degradation of the balance system.^{Reference Fernández, Breinbauer and Delano7}

Vertigo and dizziness are experienced by 30 per cent of those aged over 60 years, increasing to 85 per cent in those aged over 80 years.^{Reference Fernández, Breinbauer and Delano7} In addition, those with vestibular dysfunction and self-reported dizziness are 12 times more likely to fall without targeted vestibular assessment.^{Reference Agrawal, Carey, Della Santina, Schubert and Minor15} Hence, the signs for peripheral and central vestibular dysfunction can be missed and the opportunity to provide advantageous intervention wasted.

The inclusion of routine testing for BPPV in falls clinics and for those at risk of falling is well supported by the evidence as being both clinically and cost-effective. Testing and treatment require no specialist equipment, no specific environment, and can be performed by any suitably trained clinician.¹⁶