Module 17 · Populations

Age-related vestibular loss

Presbyvestibulopathy and ageing of the VOR
Clinical vignette
A 78-year-old woman is referred after two falls in the past year. She reports a sense of being unsteady on her feet, particularly at night, but no rotational vertigo and no oscillopsia. Examination is normal apart from mildly reduced bilateral ankle position sense. Bedside head impulses are equivocal. vHIT shows lateral canal gain of 0.78 right and 0.74 left, with occasional small overt saccades bilaterally.
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Presbyvestibulopathy

The age-related decline in vestibular function — termed presbyvestibulopathy, in analogy to presbyacusis — is a recognised diagnostic entity. The Bárány Society draft criteria define it as a chronic unsteadiness or oscillopsia in a patient over 60, with bilaterally reduced vHIT gain (0.6 to 0.8 on the lateral canals) — that is, deficits that are too mild to meet bilateral vestibulopathy criteria but too marked to be considered within normal limits for the age band.

What the literature shows

In the most cited adult normative study[McGarvie LA 2015], McGarvie et al. sampled 130 healthy subjects aged 18 to 89. They found:

  • Mean lateral canal gain held remarkably stable until approximately age 70 (mean 0.96, SD 0.08).
  • Beyond age 70, mean gain declined modestly to approximately 0.92 with somewhat wider variance (SD 0.10).
  • Vertical canal gains declined more in parallel, with mean posterior canal gain falling from 0.87 below 70 to 0.82 above 70.

The age-related decline is real but modest. Most healthy 75-year-olds still have lateral canal gains above 0.85. A 70-year-old with bilateral lateral canal gains of 0.65 has more than age-expected loss and warrants investigation rather than dismissal.

Why falls in older adults aren't (usually) just vestibular

Falls in older adults are nearly always multifactorial: visual decline, peripheral neuropathy, joint position sense loss, motor slowing, cognitive distraction, polypharmacy, and yes — some vestibular component. Singling out the vestibular contribution is hard because most older fallers have several systems failing simultaneously. The clinical question is rarely "is the vestibular system involved?" (it usually is, at least mildly) but "is the vestibular system the dominant contributor to the falls?". Severe bilateral vestibular loss (gain < 0.5) probably is. Mild bilateral loss (gain 0.65–0.80) probably isn't alone, but contributes.

Vestibular contribution worth chasing

The combination of mildly reduced vHIT gain plus prominent corrective saccades in an older adult who falls particularly in the dark or on uneven ground deserves vestibular rehabilitation. Even modest improvement in gaze stabilisation and balance under challenging conditions can reduce fall rates. Identifying who benefits requires both the vHIT findings and a functional assessment — vestibular dynamic visual acuity testing, or a CTSIB-style sensory integration assessment.

Key teaching points

  • Modest age-related decline in vHIT gain is real but typically does not cross the "abnormal" threshold until very late in life.
  • Presbyvestibulopathy: gain 0.6–0.8 bilaterally in older adults with chronic unsteadiness, not meeting BVP criteria.
  • Falls in older adults are multifactorial; isolated mild vHIT changes rarely explain falls alone.
  • Rapid progression of bilateral vestibular loss in an older adult should prompt consideration of CANVAS rather than assuming ageing.

References

  1. McGarvie LA, MacDougall HG, Halmagyi GM, Burgess AM, Weber KP, Curthoys IS. The video head impulse test (vHIT) — age-dependent normative values of VOR gain in healthy subjects. Frontiers in Neurology 2015;6:154. doi:10.3389/fneur.2015.00154
  2. Strupp M, Kim JS, Murofushi T, Straumann D, Jen JC, Rosengren SM, Della Santina CC, Kingma H. Bilateral vestibulopathy: diagnostic criteria consensus document of the Classification Committee of the Bárány Society. Journal of Vestibular Research 2017;27:177–89. doi:10.3233/VES-170619
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