J Int Adv Otol 2024; 20(1): 76-80   •   DOI: 10.5152/iao.2024.231181

Review

Frailty of the Vestibular System in the Super-Aging
SocietyTadashi Kitahara1 , Tomoyuki Shiozaki1 , Hiroshi Hosoi2
Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, Kashihara, Japan
Medicine Based Town Research Center, Nara Medical University, Kashihara, Japan

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ORCID iDs of the authors: T.K. 0000-0001-9598-6287, T.S. 0000-0003-1619-5087, H.H. 0009-0006-0001-8325.
Cite this article as: Kitahara T, Shiozaki T, Hosoi H. Frailty of the vestibular system in the super-aging society. J Int Adv Otol. 2024;20(1):76-80.

Vestibular frailty and presbyvestibulopathy, including benign paroxysmal positional vertigo (BPPV), can cause dizziness among elderly patients.
Vestibular frailty and presbyvestibulopathy may contribute to the onset of the vicious circle of falling–bone fracture–prolonged bedridden status–senile dementia. Treatment interventions for vestibular frailty and presbyvestibulopathy should be based on vestibular rehabilitation rather
than vestibular implantation or regeneration. In acute BPPV, the otolith repositioning maneuver can be used to return otolithic debris to theutricle. At the chronic remission stage, there are nutritional guidelines for improving bone density in otolith organs and rehabilitation guidelines
for activating otolith organs to prevent exfoliation. Moreover, sleeping in the head-up position can prevent free-floating debris from entering thesemicircular canal. Throughout their old age, the psychiatric care/support is also indispensable to keep their initiative against vestibular frailty.
KEYWORDS: Aging society, benign paroxysmal positional vertigo, peripheral vestibular loss, presbyvestibulopathy, vestibular frailty, vestibular
rehabilitation

INRODUCTION
Vestibular Frailty and Presbyvestibulopathy
In the peripheral vestibular system, vestibular otolith end organs sense linear/gravitational acceleration, while the semicircular
canals sense rotational acceleration. Acute damage to these organs results in rotatory vertigo or a floating sensation, followed byautonomic symptoms such as nausea and vomiting. Therefore, rehydration and acute-phase symptomatic treatment should beadministered, especially to elderly patients with dizziness. According to the disease statistics for vertigo/dizziness at the Vertigo/Dizziness Center at Nara Medical University (Figure 1), most peripheral vestibulopathies in elderly patients are derived from presbyvestibulopathy, including benign paroxysmal positional vertigo (BPPV).1,2 Accordingly, it is important to address concerns regarding
vestibular frailty, including age-related disorders of other organs related to body balancing, in the upcoming super-aging society.
The Bárány Society established the diagnostic criteria for presbyvestibulopathy (Table 1), which were published in the Journal of
Vestibular Research in 2019.3 Subsequently, the Japan Society for Equilibrium Research (JSER) established its criteria and publishedthem in 2021. These diagnostic criteria for presbyvestibulopathy are based on otology/neurotology examination results and are
crucial for the implementation of vestibular implantation4 and vestibular regenerative medicine.5 Vestibular frailty can be classified
as central or peripheral presbyvestibulopathy, which can be further classified into presbycanalopathy and presbyotolithopathy(Figure 2).
Pathology of Vestibular Frailty
Presbycanalopathy has a slow progression involving a gradual decline in the number of hair cells in the semicircular canal. Human
autopsy studies have reported a 40% reduction in the number of sensory hair cells in the semicircular canals in patients aged ≥70years compared with healthy adults.6 Specifically, the number of type I sensory hair cells markedly decreases with age. An imbalance between bilateral neural activity in the vestibular system lacks clinical manifestations if age-related vestibular compensatory
regulation is achieved. However, delayed compensation or decompensation significantly reduces the patient’s quality of life (QOL)

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Corresponding author: Tadashi Kitahara, e-mail: tkita​hara@​naram​ed-u.​ac.jp​
Received: April 20, 2023 • Revision requested: September 19, 2023 • Last revision received: September 25,
2023 • Accepted: October 1, 2023 • Publication Date: January 31, 2024
Available online at www.advancedotology.org

Content of this journal is licensed under aCreative Commons Attribution-NonCommercial
4.0 International License.

Kitahara et al. Frailty of the Vestibular SystemFigure 1. Disease statistics for patients visiting a vertigo/dizziness center at Nara Medical University from May 2014 to April 2018. The circle chart on the left
represents the disease statistics for all patients with dizziness in the Vertigo/Dizziness Center at Nara Medical University. The circle chart on the right represents
the disease statistics for patients with dizziness aged >60 years in the Vertigo/Dizziness Center at Nara Medical University. Among patients with benign
paroxysmal positional vertigo (BPPV) and unknown causes (unknown), including presbyvestibulopathy (PVP), the proportion of PVP reaches up to 50% and 80%
on the left and right, respectively.

due to persistent motion-evoked rotatory sensations. Accordingly,
presbycanalopathy is exclusively considered a chronic condition.
Presbyotolithopathy is characterized by a gradual decrease in thenumber of hair cells in the otolith, resulting in a floating sensation due to otolithic deterioration. Human studies have reported a25% reduction in the number of sensory hair cells in the otolith inpatients aged ≥70 years compared with healthy adults.6 Moreover, avolumetric decrease and morphological changes in otoconia due toaging have been reported.7 Similar to semicircular canals, successfulvestibular compensation does not cause clinical problems; however,decompensation significantly reduces the QOL due to a persistentmotion-evoked floating sensation. This condition can be classified as
chronic presbyotolithopathy. However, acute presbyotolithopathy
may occur due to BPPV, which occurs due to increased otolith exfoliation and migration of the exfoliated otoliths into the semicircular
Table 1. Diagnostic Criteria for Presbyvestibulopathy
Each of the criteria A through D has to be fulfilled.3
A. Chronic vestibular syndrome (at least 3 months duration) with at least 2of the following symptoms:
1. Postural imbalance or unsteadiness
2. Gait disturbance
3. Chronic dizziness
4. Recurrent falls
B. Mild bilateral peripheral vestibular hypofunction documented by at least
1 of the following:
1. VOR gain measured by vHIT between 0.6 and 0.8 bilaterally
2. VOR gain between 0.1 and 0.3 upon sinusoidal stimulation on arotatory chair (0.1 Hz, Vmax = 50-60°/s)
3. Reduced caloric response (sum of bithermal maximum peak SPV oneach side between 6 and 25°/s)
C. Age ≥60 years
D. Not better accounted for by another disease or disorder
SPV, slow-phase velocity; vHIT, video head impulse test; Vmax, maximum velocity; VOR,
vestibulo-ocular reflex.

canals. The resulting acute imbalance increases the risk of falls andfractures among elderly patients. Acute presbyotolithopathy can becured through spontaneous regression of the otolith debris in thesemicircular canal or by returning this debris through the otolith
repositioning maneuver. Frequent recurrence and/or chronicity ofthese symptoms significantly reduce the QOL.
The number of primary vestibular afferents decreases by 20%
between the ages of 30 and 60 years; moreover, the number of vestibular nucleus neurons other than those in the superior nucleus significantly decreases with age.6
Vestibular Frailty and Healthy Life Expectancy
Given the upcoming super-aging society, it is important to establish
interventions for vestibular frailty and presbyvestibulopathy, which
may represent the onset of the vicious circle of falling–bone fracture–
prolonged bedridden status–senile dementia, to improve healthy life
expectancy and reduce medical costs (Figure 2). A recent review indicated that approximately 40% of the risk factors for dementia weremodifiable, including physical inactivity, social isolation due to physical inactivity, and depression due to social isolation, which accounted
for 2%, 4%, and 4% of the cases, respectively.8 Accordingly, prevention of vestibular frailty and presbyvestibulopathy may indirectlyreduce the risk of dementia by approximately 10%.
Interventions against vestibular frailty and presbyvestibulopathy
should consider the prevention of the age-related decrease in thenumber of cells in the peripheral vestibular apparatus, cell degeneration, and functional deterioration, as well as deterioration of
the central vestibular system and an individual’s ability to interact
with visual and somatosensory information. The aforementioned
age-related deterioration is influenced by both environmental andgenetic factors. Environmental factors can be primarily addressed byimproving lifestyle habits. For example, it is recommended to correct
unbalanced eating habits that lead to arteriosclerosis and smoking
habits that cause vasospasms. Moreover, sufficient fluid, calcium, andvitamin D intake is recommended to maintain vestibular end organs,
while physical training is recommended to enhance the interactionof the inner ear with visual, somatosensory, and central vestibular

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J Int Adv Otol 2024; 20(1): 76-80

Figure 2. Vicious circle of vestibular frailty in the super-aging society. Vestibular frailty could result in the onset of the following vicious circle: falling, bone
fracture, prolonged bedridden status, and senile dementia. Accordingly, vestibular frailty should be managed to improve healthy life expectancy and suppress
health-care costs in the upcoming super-aging society.

information. These mitigations environmental factors may also modify genetic factors to minimize cell damage and functional deterioration due to genetic fragility before the establishment of vestibular
regenerative medicine.

Treatment of Vestibular Frailty
The treatment of elderly patients with vertigo/dizziness is determined based on the classification of vestibular frailty. In peripheral and central presbyvestibulopathy, there remains no cure forFigure 3. MAHOROBA vestibular rehabilitation. We have established a step-by-step vestibular rehabilitation program termed as MAHOROBA for treating
patients with dizziness. MAHOROBA is a word derived from ancient texts in the eighth century of prefecture, Japan, which means a peaceful and wonderfulplace.1178

Kitahara et al. Frailty of the Vestibular System

Figure 4. Effects of the head-down vs. head-up sleep position on vertiginous
sensation in patients with benign paroxysmal positional vertigo (BPPV). A
paired t-test confirmed that the visual analog scale (VAS) scores for vertiginous
sensation in the head-up sleep group were significantly lower than those in
the head-down sleep group at both the third and sixth postintervention
months.17

aging-related cell damage or functional decline. Therefore, addressing the aforementioned environmental factors is the only prevention
intervention for age-related decline. In case this is unsuccessful, thesubsequent intervention is vestibular rehabilitation, which enhances
the cooperation of the damaged inner ear with the visual, somatosensory, and central vestibular organs.
Peripheral presbyvestibulopathy can be classified as presbycanalopathy or presbytolithopathy. Chronic canal/otolithic disorders andsuperior/inferior vestibular neuropathy are characterized by persistent rotatory/floating sensations during head and body movement.
Various vestibular rehabilitation interventions for these symptoms
have been reported.9-11 However, a recent review found no significant among-intervention differences in the treatment outcomes.12
Figure 3 illustrates the MAHOROBA vestibular rehabilitation, which
involves simple and rational incorporation of visual and somatosensory information according to the patient’s condition.11
As mentioned earlier, acute imbalance increases the risk of falls among
elderly patients. Aging is unlikely to cause acute damage to the semicircular canal; instead, it is likely to be caused by an inner ear disease
unrelated to age. Contrastingly, acute otolithic disorders due to aging
are common, including BPPV caused by the detachment of utricle
otoconia and their migration into semicircular canals. The diagnosis
and treatment guidelines for BPPV were established by the Bárány
Society in 2015,13 with the JSER subsequently publishing its guidelines
in 2017.14 The semicircular canal into which utricle debris have entered
can be identified based on the type and direction of the observednystagmus. These detached debris in the semicircular canal can be
returned to the utricle through the otolith repositioning maneuver(Epley and Lempert). In case this intervention is unsuccessful, symptomatic treatment using intravenous drips and/or oral medications
can be performed for several weeks until the utricle debris in the semicircular canal is naturally metabolized and completely removed.15
The recurrence and chronicity of BPPV symptoms are exacerbated withaging, especially among women aged above 60 years.1,2 Most patientswith intractable BPPV cannot receive adequate treatment given thelack of medications for preventing or removing floating debris. Thereare 2 simple treatment approaches for such refractory cases, namely(1) prevention of otolith exfoliation and (2) prevention of migration of
the exfoliated otoliths into the semicircular canal. Otolith exfoliation
can be prevented by correcting unbalanced eating habits that lead toarteriosclerosis and smoking habits that cause vasospasm; moreover,fluid, calcium, and vitamin D intake should be promoted to improveblood flow and function of otolith organs.16 Additionally, there are
rehabilitation guidelines for promoting the activation of otolithorgans. Finally, there are sleep guidelines that recommend avoiding
the stereotyped right or left head position and reducing the burdenof gravity on the otolith organs during sleep. Regarding the prevention of migration of the exfoliated otoliths into the semicircular canal,
maintaining a sufficiently high head position during sleep reduces
the migration of detached otolithic debris to the semicircular canal,
which promotes complete recovery.17,18 A randomized controlled trial
demonstrated that this sleep position can improve subjective dizziness symptoms (Figure 4); however, it is important to ensure this sleep
position does not cause neck and/or lower back pain.
CONCLUSION
1.		Vestibular frailty and presbyvestibulopathy, including BPPV, cancause dizziness among elderly patients (Figure 1).
2.		Vestibular frailty and presbyvestibulopathy may contributeto the onset of the vicious circle of falling–bone fracture–prolonged bedridden status–senile dementia (Figure 2).
3.		Treatment interventions for vestibular frailty and presbyvestibulopathy should be based on vestibular rehabilitation rather
than vestibular implantation or regeneration (Figure 3).
4.		In acute BPPV, the otolith repositioning maneuver can be used
to return otolithic debris to the utricle. At the chronic remission
stage, there are nutritional guidelines for improving bone density in otolith organs and rehabilitation guidelines for activating
otolith organs to prevent exfoliation. Moreover, sleeping in thehead-up position can prevent free-floating debris from entering
the semicircular canal (Figure 4).
5.		Throughout their old age, the psychiatric care/support is alsoindispensable to keep their initiative against vestibular frailty.
Peer-review: Externally peer-reviewed.
Acknowledgments: We wish to thank Dr. Masashi Choubi, a registered statistician (Certificate number: 622017), for helpful advice on statistical analyses.
We also thank Editage (https​://ww​w.edi​tage.​com/)​ for editing a draft of themanuscript.
Author Contributions: Concept – T.K.; Design – T.K.; Supervision – H.H.;
Resources – T.K.; Materials – T.S.; Data Collection and/or Processing – T.S.; Analysis and/or Interpretation – T.S.; Literature Search – T.S. Writing – T.K.; CriticalReview – H.H.
Declaration of Interests: The authors have no conflict of interest to declare.
Funding: This study was supported in part by a JSPS KAKENHI grant (20232025), AMED (Grant number: 18dk0310092h000a), and a Health and Labour
Sciences Research Grant for Research on Rare and Intractable Diseases(H29-Nanchito (Nan)-Ippan-031) from the Ministry of Health, Labour, and Welfare of Japan.

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