Patient C.L. a 92 year old female is seen at AIB for complaints of imbalance, falls and independent ambulation. She uses a wheeled walker. The patient was last seen in 2001 for a right ear PC-BPPV and successfully treated with GRM. At that time there were no reports of imbalance, hearing loss, or vision issues. She has been free of any positional vertigo or associated dizziness since that time. Over the past 10 years, however, she reports having at least 8 serious falls resulting in fractures of both knees, wrists, and multiple vertebrae. During this period she has had an untreated bilateral sensori-neural hearing loss (now wears binaural amplification), glaucoma resulting in low binocular vision and low vitamin D serum levels. She has not fallen since using the wheeled walker and has a daily regimen of walking for at least an hour a day.

Results were negative for any active or acute vestibular findings.  Rotary Chair produced strong and symmetrical gain levels with bidirectional rotation.  There was no spontaneous or provoked nystagmus in any VNG sub-tests, including modified Hallpike positioning. C-VEMPs were absent bilaterally.

As reported by Roberts and Gans, 2006 (visit dizzy.com Research for reprint) patients with non otologic history with BPPV may not have any other labyrinthine deficits. Patients with prior history of successfully treated BPPV, however, continue to age and be subject to a variety of medical and non ear-related conditions that put them at elevated fall risk through the life-cycle including:

1. Low vision (Lord, 2006)
2. Hearing loss- untreated (Lin et. al. 2011)
3. Absent c-VEMPs  (Zapala and Brey,2004)
4. Low vitamin D levels  (Beauchet et. al., 2011)
5. History of active BPPV (Agarwal et al 2005)

Treatment Objectives and Recommendations:

1. Allow patient to age in place safely.
2. Fall risk management strategies including; patient education, home safety, continued use of the wheeled walker along with physician approved daily exercise.
3. Monitor vitamin D levels and treat accordingly.
4. Continue use of binaural amplification.
5. On going management of the glaucoma and low vision needs.