Getting older is no walk in the park, we understand that. But reaching your advanced years is a blessing not all get to experience. As we get older, the tiny balance organs in your inner ear, your vestibular system, gradually become less sensitive. Just like getting wrinkles and grey hair, it is a normal part of getting older. This natural age-related vestibular decline is known as presbyvestibulopathy (PVP), or age related deconditioning.

It is a common and mild form of vestibular loss that can affect steadiness, walking and confidence, especially in busy or dark environments. The good news is even though your vestibular system changes with age, your balance can improve with the right exercises and activity. Your brain can relearn to use the remaining balance signals and strengthen other systems to compensate. The more strategies you have to regain your balance, the better the chances that you won’t fall.

Your vestibular system is your body’s gyroscopes. You have two vestibular systems that are snugly embedded in your temporal bones, one left and one right. This is a part of your skull in your hairline above and around your ear. You may have heard the phrase “temporal headache” to describe pain in this area. Deeper within the bone, tucked into its own special compartment or vestibule, sits your vestibular apparatus.

The hard bony labyrinth protects the soft membranous labyrinth, in the same way as the skull protects the brain. The bony labyrinth is filled with perilymphatic fluid that has a similar composition to cerebrospinal fluid, while the membranous labyrinth is filled with endolymph, with a similar composition to intracellular fluid. These different recipes of fluid result in different viscosities, which is important for the functioning of your gyroscopes.

You have five organs that sense movement and body position on each side, three semicircular canals (SCC) and two otoliths.

• posterior SCC
• anterior SCC
• horisontal/lateral SCC
• utricle
• saccule

These organs communicate with your brain via your vestibulocochlear nerve, CN VIII.

Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you can safely and gracefully navigate an incline or maintain your balance on a lawn chair on soft grass.

Your semicircular canals detect changes in velocity. These three canals are at right angles to one another and communicate with the opposing SCC of the opposite side. That means your right posterior SCC communicates with your left anterior SCC. The SCC can be described as the x,y and z axes of a 3D graph. Nerve impulses are generated when hair cells at the base of the semicircular canal, the ampulla, are deflected because of the movement of endolymph, almost like seaweed in a current.

The otoliths detect changes in linear acceleration and gravity. Your utricle relays the change of linear speed, like the movement in a car. While your saccule detects gravitational change in an elevator. This phenomenon also works with hair cell deflection, but less so in a hydrodynamic principle. Your two otoliths still have to relay information from a 3-dimensional world. Because force = mass x acceleration, otoconia solves this problem. Calcium carbonate crystals, otoconia, provide the mass for this equation. The otoconia lie embedded in the macula on top of the hair cells of the otoliths. Head movement, like nodding yes/no or side to side, is the acceleration. The angles and interplay between the utricle and saccule’s hair cell deflection can relay information in all 3 dimensions!

You have experienced this in the real world: once you have reached a steady speed, in a car, plane or elevator, the deflection of hair cells stops and you are not aware of the movement anymore, only when the speed of travel changes again.

Time waits for no one. This age related decline happened in the background while you were living. It is the result of cumulative “wear and tear” on your vestibular system. In most cases the damage is the result of multiple factors over time, like the ear infection you had while training for the midmar mile, the yearly sinusitis inflammation or the vascular changes when you had to start taking blood pressure and cholesterol medication.

The structure of the semicircular canals and otoliths change as you age, while hair cells responsible for initiating action potential messages for your nerves become less. Your nerves and brain pathways become less sensitive to the information from your balance organs. Your otoconia can clump or break down, increasing your risk for developing BPPV.

Your symptoms are not solely due to vestibular decline alone, as your vision and proprioception also changes with age, which can affect your confidence and stability while walking. Muscle mass declines too, slowing down your reaction time.

Because these changes happen gradually over time on both sides, the effects are less significant that someone who suffers from an acute vestibular neuritis or bilateral vestibulopathy.

• Inflammation
• Infection
• Ototoxic medications, like aminoglycoside antibiotics (gentamicin) or chemotherapy
• Cardiovascular risk factors, like hypertension
• Trauma, like barotrauma, car accidents or falls

All presbyvestibulopathy is scary, frustrating and debilitating. People tend to be patient and sympathise with injuries they can see and understand. Because vertigo is poorly understood by anyone who hasn’t experienced it themselves, it will be difficult to explain to family and colleagues what you are going through. The fact that age related vestibular symptoms may fluctuate also confuses people who expect all recovery to be linear.

When both vestibular apparatus are affected, you will rely completely on other strategies, like your vision. So walking in the dark will feel impossible. Depending on the extent of the decline to your vestibular apparatus, you may have other strategies available.

If we consider that the entire you has aged with your vestibular apparatus we need to remember that you may have had other injuries and surgeries in your life that can also affect your mobility, confidence and balance. Like hip/knee replacements, fractures or spinal fusions. This will also affect your treatment plan and expected outcome.

Our physiotherapists can identify if any central pathology is causing your symptoms, with visual and balance screening. Or is your vertigo caused by a different structure within the vestibular apparatus?

We make use of a bedside evaluation, which means all tests are done in the consultation room by your therapist or yourself. The experience of your physiotherapist is important to understand your history, vertigo type, duration of attacks, and what aggravates your vertigo.

We understand the physiological stages you’ll go through, and custom-fit your treatment program. Our physiotherapists can guide you so that you understand what you are experiencing and are able to make responsible decisions about your care.

Audiogram testing is necessary if you have noticed any new or worsening hearing loss. Presbyvestibulopathy is associated with hearing loss, but it may be necessary to rule out other pathology, like Meniere’s Disease or a vestibular schwannoma.

Your physiotherapist can refer you to an audiologist for your hearing test.

Electronystagmography (ENG) is a specialised audiology tests that identifies functional problems with the vestibular system by measuring eye movement with vestibular stimulation, by moving your eyes, head or a caloric test. This can determine the exact vestibular organ affected and the extent of the dyscrepancy between the left and right vestibular apparatus.

Your physio will refer you if necessary.

An MRI scan can be used to rule out any other pathology, like a space-occupying vestibular schwannoma. This image can only be ordered by your specialist and is not needed to confirm normal, age related vestibular decline.

• Keep physically active — walking, tai chi or gentle balance classes help maintain stability.
• Make sure your vision and hearing are checked regularly.
• Ensure good lighting at home and remove tripping hazards, like rugs and slip on shoes.
• Rise slowly from bed or chairs to prevent dizziness.
• Stay hydrated and review medications that may affect your balance with your GP.
• Eat regular and balanced meals to maintain healthy blood sugar levels.

• Misuse of vestibular suppressant medication

Taking motion sickness medication for prolonged periods of time can suppress any type of compensation from occurring.

• Fall risk

When you avoid movement because of fear of falling, you may lose the bit of balance strategies you have left. Many times patients, or their families, only seek help once they have fallen. The risk for sustaining other injuries, like fractures, increase as we age. Don’t wait this long before you seek help.

• Waiting too long

The biggest risk with chronic vertigo symptoms is developing persistent postural perceptual dizziness (PPPD). PPPD/3PD is a chronic condition causing constant dizziness of varying intensity, usually first triggered by an intense attack. It is worsened by movement, such as being in a car, and perceiving your surroundings as moving when they are not.

• Misdiagnosis

Many people are diagnosed with BPPV as the cause of their dizziness, when it is not.

• Misconceptions about treatment

When patients are wrongly diagnosed with BPPV, they expect a quick fix with a repositioning manoeuvre. Rehabilitation takes time and effort. No recovery is linear; there will be bad days, and you may feel frustrated and afraid. Nothing worthwhile is easy; be patient and put in the work.

 Our priority is to determine the extent of your disability and your risk of falling. Vestibular rehabilitation is then aimed at addressing your unique situation and challenges. Your rehabilitation program will be custom designed to challenge and condition you. Adaptation and habituation exercises reduce dizziness, by improving visual acuity during head movements, improves postural stability and reduces your risk of falling. Balance training and a progressive walking program aids in your dynamic stability and confidence when moving in real life situations. This gives your brain and body more strategies to adapt to your environment by encouraging the correct the compensation.

The current clinical guidelines recommend, from strong research evidence, that patients with presbyvestibulopathy do their exercises three-five times/day for 20-40 minutes for seven weeks.

The guidelines prescribe continuing with vestibular rehabilitation until your goals are met, symptoms resolved or a plateau is reached.

Everyone has a unique situation and set of goals, we aim to get you safer and feeling better in the quickest time possible.

• An audiologist can fit suitable hearing aids if your hearing is also affected.
• A General Practitioner can prescribe anti emetics/vestibular suppressants for symptom relief. This is only recommended in the acute/sub acute stage (onset-3 months), as continuous use can delay compensation and cause prolonged symptoms.
• A psychologist may assist you with implementing cognitive behavioural therapy (CBT) into your lifestyle.
• Neuro optometry evaluation may be needed if you have suffered from a traumatic injury, like concussion from a fall.
• Lifestyle management of low blood pressure or fluctuating blood sugar should also be considered and discussed with your GP.
• Home safety modifications, like good lighting, removing rugs or installing hand rails in bathrooms can be very useful.

Vestibulocochlear implants (VCI) are currently being trailed in Europe. This investigational procedure combines the better known cochlear implant to restore hearing, with a vestibular implant into the semicircular canals to improve balance. The implanted electrodes respond to movement stimuli to directly stimulate the vestibular nerves. This in turn improves balance, postural control and vision stabilisation. It is not yet available to the general public.

• Cerebrovascular Accident (CVA/stroke)

Acute onset dizziness lasting 24 hours or more needs to be screened for central origin which may potentially be life threatening. PICA/AICA strokes pre dome may be new onset dizziness. If you have vascular risk factors, like hypertension or aterosclerosis, see your doctor.

• BPPV Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo occurs more often as we age. This is very intense, rotational vertigo of short duration caused by position change. It is easily treatable with repositioning maneouvres.

• Pharmacological interaction

Many medications can cause dizziness due to the effect on your blood pressure or heart rate, make sure to have your list of chronic medications for your health care provider.

• Labyrinthine concussion

Vertigo caused by a traumatic injury, like a fall or accident, can last hours to days

• Postural Orthostatic Tachycardia Syndrome (POTS)

An increase in resting heart rate of 30 beats per minute on standing can cause dizziness, fatigue, lightheadedness and palpitations.

• Vestibular decline
• Age related vestibular deconditioning
• Presbyvestibulopathy
• Vestibular hypofunction
• Vestibulopathy