10.14639/0392-100X-N1908
The term “presbystasis” refers to a common clinical condition in the elderly, characterised by a multifactorial and progressive impairment of balance. The pathophysiology may be related to various concomitant factors including central nervous system diseases, peripheral neuropathy, osteoarticular disorders (leading to a reduction of the speed gait), and cardiovascular or visual disorders, but it may also be a consequence of deficits of the peripheral or central vestibular system (which is generally represented by a bilateral and symmetric vestibular dysfunction). Benign paroxysmal positional vertigo (BPPV) is far from being rare in subjects over the age of 70 years. Nowadays, presbystasis represents one of the main causes of accidental falls in the elderly leading to a reduction in quality of life and life expectancy. The aim of our work was to review the current literature on presbystasis, focusing on the role of the vestibular system in the pathogenesis and on the possibilities offered by vestibular rehabilitation in the management of these subjects. Other clinical conditions related to the disorder are also discussed.
text/xml
1827-675X
1908
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Luciano Bubbico
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ACTA Otorhinolaryngologica Italica
rehabilitation
The social problem of presbystasis and the role of vestibular rehabilitation in elderly patients: a review
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2023-05-23
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1
Luciano Bubbico
2023/05/23
10.14639/0392-100X-N1908
227
Department of Sensorineural Disabilities, INAPP/Italian Institute of Social Medicine, Rome, Italy
1827-675X
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en
234
The social problem of presbystasis and the role of vestibular rehabilitation in elderly patients: a review
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:227-234; doi: 10.14639/0392-100X-N1908




Review


The social problem of presbystasis and the role
of vestibular rehabilitation in elderly patients: a review
Il problema sociale della presbistasia e il ruolo della riabilitazione vestibolare
nell’anziano: una revisione della letteratura
Roberto Teggi1, Marco Familiari1, Rosa Alessia Battista1, Omar Gatti1, Iacopo Cangiano1, Mario Bussi1,
Luciano Bubbico2
1
 Department of Otolaryngology, Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital,
Vita – Salute University, Milan, Italy; 2 Department of Sensorineural Disabilities, INAPP/Italian Institute of Social Medicine, Rome, Italy


SUMMARY
The term “presbystasis” refers to a common clinical condition in the elderly, characterised by a
multifactorial and progressive impairment of balance. The pathophysiology may be related to
various concomitant factors including central nervous system diseases, peripheral neuropathy,
osteoarticular disorders (leading to a reduction of the speed gait), and cardiovascular or visual
disorders, but it may also be a consequence of deficits of the peripheral or central vestibular
system (which is generally represented by a bilateral and symmetric vestibular dysfunction).
Benign paroxysmal positional vertigo (BPPV) is far from being rare in subjects over the age
of 70 years. Nowadays, presbystasis represents one of the main causes of accidental falls in the
elderly, leading to a reduction in quality of life and life expectancy. The aim of our work was to
review the current literature on presbystasis, focusing on the role of the vestibular system in the
pathogenesis and on the possibilities offered by vestibular rehabilitation in the management of
these subjects. Other clinical conditions related to the disorder are also discussed.
KEY WORDS: dizziness, frail elderly, accidental falls, postural balance, rehabilitation
                                                                                                      Received: November 9, 2021
RIASSUNTO                                                                                             Accepted: October 17, 2022
Il termine presbistasia si riferisce a una condizione di comune riscontro negli anziani, ca-
ratterizzata da un progressivo e multifattoriale disordine dell’equilibrio; la fisiopatogenesi        Correspondence
può originare dalla concomitanza di diversi fattori, tra i quali patologie del sistema ner-           Roberto Teggi
voso centrale, da una neuropatia periferica, disordini osteoarticolari (che provocano una             Department of Otolaryngology, Head and Neck
                                                                                                      Surgery, Scientific Institute of Hospitalization and
riduzione della velocità di marcia), patologie del sistema cardiovascolare e visivo, ma può
                                                                                                      Care San Raffaele Hospital, Vita – Salute Universi-
anche avere come concausa deficit del sistema vestibolare periferico e centrale; soprattutto          ty, via Olgettina 60, 20132 Milan, Italy
la Vertigine Parossistica Posizionale Benigna (VPPB) è comune nei soggetti di età superio-            Tel. +39 02 26432172. Fax +39 02 26433508
re a 70 anni. La presbistasia rappresenta oggi una delle principali cause di cadute negli             E-mail: teggi.roberto@hsr.it
anziani e ha come conseguenza una riduzione dell’aspettativa e qualità di vita. Scopo del
nostro lavoro è stato quello di rivedere la recente letteratura focalizzandoci sul ruolo del
                                                                                                        How to cite this article: Teggi R, Familiari M,
sistema vestibolare nella patogenesi e sulle possibilità terapeutiche offerte dalla riabilita-
                                                                                                        Battista RA, et al. The social problem of pres-
zione vestibolare. Sono state inoltre riassunte nella review le altre concause del disturbo.            bystasis and the role of vestibular rehabilita-
PAROLE CHIAVE: instabilità, anziano fragile, caduta, equilibrio, riabilitazione vestibolare             tion in elderly patients: a review. Acta Otorhi-
                                                                                                        nolaryngol Ital 2023;43:227-234. https://doi.
                                                                                                        org/10.14639/0392-100X-N1908

Introduction                                                                                          © Società Italiana di Otorinolaringoiatria
                                                                                                      e Chirurgia Cervico-Facciale
The term presbystasis refers to age-related functional modification in struc-
tures related to equilibrium, including the vestibular system. Dizziness and                                         OPEN ACCESS
vertigo in older patients frequently have a multifactorial aetiology 1,2. In par-                     This is an open access article distributed in accordance with
                                                                                                      the CC-BY-NC-ND (Creative Commons Attribution-Non-
ticular, the term “dizziness” indicates a condition of impaired balance and is                        Commercial-NoDerivatives 4.0 International) license. The
one of the main causal factors of falls in an advanced age. In addition, aging of                     article can be used by giving appropriate credit and mentio-
                                                                                                      ning the license, but only for non-commercial purposes and
the peripheral and central vestibular system can lead to a chronic disequilib-                        only in the original version. For further information: https://
rium and to an increased risk of falls 1.                                                             creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Balance disorders in the elderly represent a significant prob-        Materials and methods
lem of utmost importance within society. In fact, an increase
                                                                      A review of the literature was performed on different databases
in their frequency with aging, especially in the very old, leads
                                                                      including PubMed and SCOPUS according to the “Preferred
to a remarkable increase in falls with consequent increases in
                                                                      Reporting Items for Systematic Reviews and Meta-analyses”
healthcare costs. In navigation tasks, three cues play a role,
                                                                      (PRISMA) guidelines, as summarised in Figure 1. We used
namely vision, proprioception and the vestibular system, with
                                                                      the following strings: “Presbystasis”, “Dizziness in Elderly”,
the latter being a sensor of self-movement for both linear and
                                                                      “Vestibular Impairment in Elderly”, “Balance Disorders and
angular acceleration and also acting as a graviceptor. All the
                                                                      Elderly”. A total of 12,596 original articles were found. Only
three cues are involved in the disorder, while the peripheral
                                                                      articles published from 2000 and in English were considered,
and central nervous systems, musculoskeletal system, medica-
                                                                      and only those with keywords Dizziness\Vestibular Impair-
tions and other factors often play a substantial role. In many
                                                                      ment\Balance Disorders AND Elderly were included.
instances, subjects do not report a true vertigo due to periph-
eral vestibular disorders, and it is likely that these are cases of
dizziness due to presbystasis 2. Recent studies have highlight-       Results
ed that 20%-30% of persons experience episodic dizziness in           A total of 95 publications were obtained and after critical
a 12-month period. This percentage dramatically increases in          evaluation 45 were included in the review (Fig. 1).
older people and in women. In those over 80 years, the preva-
lence of dizziness is reported to be more than 80% 3,4. In the        Non-vestibular and multifactorial presbystasis
US, every year about 7.5 million patients access an emergency         Several publications underline that dizziness in the elderly is
department or outpatient clinic for dizziness and vertigo 5-7. In     a multifactorial disorder. Central nervous system diseases of
a survey on dizziness in elderly in the US, around 20% of over        different origin, such as cerebrovascular pathologies, parkin-
65 subjects reported a problem with dizziness or imbalance            sonism, Alzheimer’s disease and dementia, may contribute to
in the preceding 12 months 8. In another survey, the authors          a decreased equilibrium, causing dizziness and an increased
reported that most dizzy subjects over 65 years were evalu-           risk of falls by impairing control of critical functions 1,19,20.
ated by different specialists, who administered therapies with        Loss of fine muscle control, postural imbalance, involuntary
diuretics and benzodiazepines with poor results; moreover,            movements, and prolongation of reaction time usually play a
imaging and other clinical exams did not correlate with more          destructive role in terms of balance disorders and dizziness.
tailored therapy 9.                                                   Psychogenic disorders such as anxiety and depressive syn-
In older people, chronic dizziness increases the risk of ac-          drome are often correlated with dizziness 19,20. They some-
cidental falls with a subsequent decrease in the quality and          times represent a comorbidity in patients affected by pe-
expectancy of life. According to the Prevention of Falls              ripheral vestibular dysfunction, while in others they may
Network Earth (ProFaNE), falls are defined as an unex-                cause or be caused by a state of dizziness. Clinical assess-
pected event in which subjects come to rest on the ground,            ment and in-depth investigation of these conditions is cru-
floor, or lower level. The incidence of falls is 30-60% per           cial to better characterise the patient.
year in the elderly with subsequent injuries, hospitalisation,        Cardiovascular diseases, such as hypertension, orthostatic
or even death in 10-20% of cases 1. Moreover, the clinical            hypotension and atrial fibrillation 1, by impacting regula-
consequences of accidental falls in older patients represent          tion of blood pressure and oxygen supply to the brain, are
an important cause of mortality and have high management              frequently involved in dizziness and feeling slightly off
costs in US and Europe 1,10. In the US, the costs of falls ex-        balance. Being frequent in older patients, these conditions
ceed $ 20 billion yearly 11,12. The risk of falls significantly       may be controlled by daily control and appropriate thera-
alters the quality of life in the elderly and the fear of falling     peutic actions. Postural hypotension, above all, is strongly
greatly reduces their activities 13. Moreover, dizziness and          associated with a risk of falls and may occur due to dehy-
subsequent fear of falling are correlated to depressive status        dration, medications and autonomic neuropathy. Therefore,
and reduction in self-autonomy and self-control, with subse-          many authors underline that management of postural hypo-
quent functional disabilities and social isolation 4,13,14. In pa-    tension should be considered to reduce the risk of falls 21-24.
tients aged over 70 years, vestibular dizziness occurs in 15%,        Progressive vision worsening with aging due to several
whereas non-vestibular dizziness occurs in 20%-70% 13,15-18.          physiological modifications in visual acuity, contrast and
The aim of this work is to review the current literature on pres-     glare sensitivity, dark adaptation, accommodation, and
bystasis, focusing on the role of the vestibular system in the        depth perception also plays an important role 25-29. More-
pathogenesis of the disorder and on the possibilities offered by      over, in older adults the risk of developing pathologies
vestibular rehabilitation in the management of these subjects.        such as cataracts, glaucoma, and macular degeneration is



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Figure 1. Search strategy flowchart. * 1985; ** for duplication.


increased. The elderly suffering from hypertension and             involved 1. Since medications have been linked to a high
diabetes mellitus often present an increased risk of retin-        risk of falls in older people, discontinuation or, if not pos-
opathy. Essentially, visual impairment leads to the patient        sible, dose reduction, is recommended, in particular for
to misunderstand spatial information, distances and edge           psychotropic drugs 21.
of images with increased risk of imbalance and falls 30,31.        Proprioception disorders such as peripheral nerve impair-
In patients with visual disorders, vision should be always         ment due to alcoholism, diabetes mellitus, vitamin B12
assessed and these should be treated 21.                           deficiency, chemotherapy and osteoarticular diseases such
Different classes of drugs can have an impact on equilib-          as arthritis and spondylosis may also play a role 30.
rium. In fact, depending on their direct activity or pos-          Armstrong et al. showed that in older patients there is a
sible toxic effects, medications may cause somnolence,             high prevalence of multisensorial impairment, involving
reduce attention threshold, decrease peripheral nervous            not only vision and hearing but also the vestibular system,
perception (affecting both exteroception and proprio-              leading to increased disability overall 32.
ception) and impair muscular strength. Among others,               Moreover, the role of genetic factors in presbystasis has been
antidepressants, anxiolytics, antipsychotics, some anti-           hypothesised, as in presbycusis 5. Results on non-vestibular
biotics, chemotherapy and anticholinergic drugs can be             contributions in presbystasis are summarised in Table I.



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Presbystasis of vestibular origin                                                   and vestibular neuritis] 33,34. The most common cause of
Peripheral vestibular dysfunction is one of the most fre-                           vertigo and dizziness is represented by BPPV 15,35 and it
quent causes of dizziness in the elderly [especially benign                         has been demonstrated that otoconial degeneration and
paroxysmal positional vertigo (BPPV), Menière’s disease,                            fractures occur with aging. Regarding vestibular neuritis,


Table I. Multiple disorders contributing to presbystasis reported in publications underlying non-vestibular causes.
 Author                              Sample numerosity                 Performed tests            Clinical condition       Results\intervention\conclusions
 Gleason et al., 2009      19
                                             172                   Mini mental scale (MMSE)            Dementia              Minimal decrements of MMSE
                                                                                                                           correlated with increased risk of fall
 Muir et al., 2020 20           Meta-analysis of 21 publications        Performed tests           Different subsystems             Increased risk of fall
 American Geriatric Society,            Meta-analysis                          -                    Vision impairment
 2011 21                                                                                          Postural hypothension
                                                                                                  Cognitive impairment
 Tinetti et al., 1994 22                     301                   Full medical assessment        Postural hypotension;      Multiple-risk-factor intervention
                                                                                                     use of sedatives;      strategy resulted in a significant
                                                                                                      use of at least         reduction in the risk of falling
                                                                                                     four prescription
                                                                                                       medications;
                                                                                                  impairment in arm or
                                                                                                        leg strength
 Close et al., 1999 23                       184                   Full medical assessment        Postural hypotension; Multiple risk factors intervention leads
                                                                                                     use of sedatives;       to a decreased number of falls
                                                                                                  impairment in arm or
                                                                                                        leg strength
 Davison et al., 2005 24                 128 fallers                     24 hours ECG            49% (63) of recordings Increased risk of fall in subjects with
                                      100 case controls                                             in fallers and 41%              ECG abnormalities
                                    Both 75 years or older                                         (41) of recordings in
                                Matched for other comorbidities                                  controls were abnormal
 Lord et al., 1991 25                 95 (mean age 82)                 Vision, vestibular,           Vision, vestibular,        Proprioceptive, visual and
                                                                     proprioceptive tests             proprioceptive,       muscoloskeletal disorders mainly
                                                                          Stabilometry                muscoloskeletal          correlated with presbystasis
 Clark et al., 1993 26                 81 (mean age 83)            Full medical examination           Cardiovascular,    Impaired cognition, abnormal reaction
                                                                        with an attention                respiratory,      to any push or pressure, history of
                                                                      on cardiovascular,                neurological,     palpitations were predictive for falls
                                                                   respiratory, neurological,            psychiatric
                                                                        gastrointestinal,
                                                                         haemopoietic,
                                                                          genitourinary
 Jack et al., 1995 27                        200                    Full visual examination              Vision              Fallers have a high prevalence of
                                                                                                                                     visual impairment
 Lord et al., 1992 28                         50                    Six tests of sensorimotor        Proprioception       27% of fallers had poor proprioception
                                                                              function                 Drugs use                Psychoactive-drug use was
                                                                   Use of psychoactive drugs                                       associated with falling
 Nevitt et al., 1989 29                325 (age over 60)                  Clinical history          Proprioception         Multiple risk factors increase risk of
                                                                                                 Neurological disorders                      falls
 Zetterberg, 2015 31                        Review                    Visual examination                Vision              Increased presbystasis in subjects
                                                                                                                                   with visual impairment
 Armstrong et al., 2021 32                     -                   Hearing, vision, olfaction,                                 Multiple sensory impairment
                                                                     proprioception, and                                         correlated with risk of fall
                                                                      vestibular function
 Kannus et al., 2005 45                     Review                  Multiple interventions                                 Suggested regular exercise, vitamin
                                                                                                                            D and calcium supplementation,
                                                                                                                              withdrawal of psychotropic
                                                                                                                              medication, cataract surgery




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vestibular compensation in the elderly can be lacking or in-                          Results in vestibular contributions in presbystasis are sum-
effective due to decreased vestibular function of the intact                          marised in Table II.
side, visual function and proprioception.
A vestibular ocular reflex (VOR) gain impairment in older                             Non-vestibular and vestibular rehabilitation in presbystasis
people has been demonstrated with several methods, es-                                A multidisciplinary diagnostic-therapeutic programme and
pecially caloric and rotational tests, head thrust test, and                          physiotherapy are necessary to improve rehabilitative results
cervical and ocular vestibular evoked myogenic potentials                             and quality of life in non-vestibular-related dizziness, and seem
(cVEMPs – oVEMPs). In the elderly, c- and oVEMPs have                                 to be more effective than medical therapy 13,38-40. Vestibular re-
decreased amplitude and increased latency. Studies with                               habilitation represents an effective tool in disorders such as
posturography demonstrated a decreased balance control                                presbystasis and post-labyrinthitis vestibulopathy and should
in this group due to decreased function of the above-men-                             be performed at least 3-4 times per week. Modifications in
tioned systems. Moreover, some studies have highlighted                               therapy are also an important strategy, such as discontinuing
cellular loss in vestibular organs 15. In addition to otoconia                        antihistamines, anticholinergic drugs and benzodiazepines 2.
fragmentation and loss of hair cells in cristae ampullaris                            Physical exercises may vary on a case-by-case basis de-
of semicircular canals and maculae of saccule and utricle,                            pending on the patient’s disorder (unilateral or bilateral
decreased vascularisation of the inner ear, vermian atrophy,                          peripheral vestibulopathy) and symptoms (imbalance, ver-
and a reduction in the number of vestibular nuclei in neu-                            tigo, oscillopsia, fear of falls, nausea and anxiety), even
rons and cerebellar Purkinje cells have been described in                             though most rehabilitation programmes commonly in-
association with aging 1,2.                                                           volve eye and head movements. Moreover, rehabilitation
Interestingly, Biju et al. showed in a recent publication that                        is reported to be more effective in unilateral vestibulopathy
the vestibular system plays an important role in fall risk                            than in bilateral cases 41.
of patients suffering from Alzheimer’s disease and, in par-                           Some recent studies on vestibular rehabilitation in older
ticular, that better semicircular canal function is linked to a                       Parkinson subjects have demonstrated its effectiveness 42.
lower risk of falls 36,37.                                                            Moreover a Virtual Reality system, which can also be used


Table II. Studies reporting vestibular contributions in presbystasis.
 Author                     Sample numerosity               Performed tests                   Clinical condition              Results\intervention\conclusions
 Tuunainen et al.,                       38                  Vestibular tests           Vestibular deficits were present         Progressive loss of balance is a
 2011 34                                                Mini Mental Scale (MMSE)        in the large majority of subjects     disorder involving vestibular, system,
                                                                                                                                 oculomotricity, visual acuity and
                                                                                                                                           proprioception
 Lindell et al., 2021 35                 55               Full vestibular testing              Vestibular deficits          40 subjects were fallers, 11 presented
                                                                                                                                               a BPPV
 Biju et al., 2022 36                     -                Full vestibular tests          Comorbidity for Parkinson’s        Better semicircular canal function was
                                                                                                  disease                      significantly associated with lower
                                                                                                                                         likelihood of falls
 Teggi et al., 2017 37                   58               Video-head impulse                                                Decrease of vestibulo-oculomotor reflex
                                                                                                                               gain in the elderly. The decrease of
                                                                                                                            canal function may therefore play a role
                                                                                                                                 in the risk of falls in the elderly
 Tuunainen et al.,                       55                   Rehabilitation                     Presbystasis                          Reduced risk of falls
 2013 46
 Socher et al., 2012 38                  12                   Rehabilitation                   Menière’s disease            Effective in improving quality of life and
                                                                                                                              risk of falls also in subjects over 80
 Gomes Patatas et al.,                   22                   Rehabilitation                       Dizziness                Effective in improving quality of life and
 2009 39                                                                                                                      risk of falls even in subjects over 80
 Brito et al., 2021 41               111 elderly              Rehabilitation                       Dizziness                Improve of instability, DHI questionnaire
                                                                                                                                         and quality of life
 Abasi et al., 2022 42            11 elderly with             Rehabilitation                       Dizziness                 Positive effects on oculomotor function
                                Parkinson’s disease                                                                                         and balance
 Zak et al., 2022 43             Elderly with frailty   Rehabilitation with virtual                Dizziness                     Effective in bringing in desirable
                                 syndrome fall risk               reality                                                              therapeutic outcomes
DHI: dizziness-handicap-inventory.




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R. Teggi et al.




at home, has been demonstrated to be useful in the treat-                          While geriatric studies have been published mainly in the
ment of elderly with presbystasis 43.                                              years around 1990-2000, some recent investigations have
Results on rehabilitation are summarised in Table III.                             focused on the vestibular contribution in instability in the
                                                                                   elderly, using recently introduced diagnostic tools such as
Discussion                                                                         video-head impulse test and video-Frenzel. The role of a
                                                                                   vestibular disorder in these subjects has likely been un-
Balance disorders, in particular presbystasis, are frequent                        derestimated in past works and a vestibular examination is
conditions, especially in elderly patients. Dizziness and                          necessary in routine evaluation in our opinion.
imbalance may have several causes; in many cases, its mul-                         Presbystasis in older subjects generally involves bilateral
tifactorial pathogenesis is due to impairment of several sys-                      and symmetric vestibular dysfunction found at vestibular
tems, and in particular the vestibular, visual, nervous and                        examination. Further clinical manifestations of presbystasis
musculoskeletal systems 15,44.                                                     can be slowed gait and reduced response to sudden motion 2.
Impairment of the somatosensory system is correlated with                          Tuunainen et al. described four variants of loss of balance
aging due to static and dynamic muscle spindle modifica-                           with aging, called “presbyequilibrium”, through analysis
tions, reduction of Pacini and Meissner’s receptors, plan-                         of clinical findings with posturography and video-oculog-
tar tactile sensitivity, joint position perception, lower limb                     raphy:
weakness, and reduction in strength and speed, with subse-                         • episodic presbyvertigo syndrome: episodic vertigo pro-
quent extension of reaction time; moreover, in the elderly                            voked by physical activity and cases of BPPV;
there is also a modification in gait that is slower, shorter                       • postural presbyequilibrium: postural instability with po-
and wider compared to younger subjects 30.                                            sitional and gravity-dependent worsening;
Therefore, multifactorial fall risk assessment and interven-                       • frail syndrome: decrease in muscle strength and coor-
tion is advisable 21.                                                                 dination, need for assistance, continuous dizziness and
Prevention of falls is crucial to prevent injuries and consists                       falling sensation;
of balance training, vitamin D and calcium supplementa-                            • autonomic vertigo syndrome: syncope, near-syncope
tion, reduction of psychotropic drugs, cataract surgery and                           and floating sensation with positional changes, linked
individual home-hazard assessment 45.                                                 with a high risk of falls 46.
As mentioned above, the psychological condition of the pa-                         Vestibular rehabilitation is often effective even in subjects
tient should also be assessed, since psychogenic disorders                         with comorbidities for neurological disorders and modifi-
such as anxiety may be associated.                                                 cation in medical therapy may also be warranted.


Table III. Studies reporting results about the role of vestibular rehabilitation.
 Author                Sample numerosity Age (years)                  Type of rehabilitation                                Results
 Socher et al.,                      12             35-86          Five sessions of vestibular       Significant improvements in DHI scores for all aspects
 2012 38                                                                   rehabilitation
 Gomes Patatas et                    22             16-87         Two-three times daily for at   All the DHI scores reduced significantly after vestibular
 al., 2009 39                                                            least six weeks     rehabilitation; general improvements in the quality of life after
                                                                                                             customised vestibular rehabilitation
 Sulway et al.,                       -              -                      -                  Vestibular rehabilitation improves symptoms of imbalance,
 2019 40                                                                                        falls, fear of falling, oscillopsia, dizziness, vertigo, motion
                                                                                                sensitivity and secondary symptoms such as nausea and
                                                                                                                              anxiety
 Brito et al., 2021 41               113           60-88     Immersive virtual reality-based         The immersive virtual reality-based sensorimotor
                                                               sensorimotor rehabilitation,   rehabilitation is a useful tool in elderly patients, that can lead
                                                            three times a week for 6 weeks to a reduction of symptoms associated with mental disorders
 Abasi et al., 2022 42               11         65.16 (mean Vestibular rehabilitation for 24       Positive effects on oculomotor function and balance
                                                    age)    sessions (3 sessions per week)
 Zak et al., 2022 43                  -              -                      -                   Modern technologies (virtual reality) in frail patients may
                                                                                                  complement the traditional model of rehabilitation by
                                                                                                 enabling to return to the pre-frail stage, simultaneously
                                                                                                        enhancing both motor and cognitive function
DHI: dizziness-handicap-inventory.




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Correct management should include an adequate rehabili-          Ethical consideration
tative programme in addition to quality of life assessment.      This study was approved by the Institutional Ethics Com-
In fact, rehabilitation is largely used to improve postural      mittee of San Raffaele hospital for a larger study on dizzi-
stability and quality of life perception in elderly patients     ness (protocol number 104/INT/2020).
suffering from multifactorial dizziness 13.                      The research was conducted ethically, with all study pro-
Finally, in the COVID-19 era, the possibility to perform         cedures being performed in accordance with the require-
rehabilitation with a physiotherapist may be troublesome         ments of the World Medical Association’s Declaration of
in the elderly, since hospital access may be limited. New        Helsinki.
devices have been proposed to make home rehabilitation           Written informed consent was obtained from each partici-
possible and to avoid a hospital setting, and some are al-       pant/patient for study participation and data publication.
ready available; we believe that this may be the future for
rehabilitation of older people, not only for its efficacy on     References
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                                                                 11
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Funding
                                                                 13
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RT: manuscript writer; MF, RAB, OG, IC: articles research;       15
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