Approximately 1 in 4 adults over the age of 65 experience a fall yearly¹. This same patient demographic also tends to demonstrate reduced or absent self-motion perception, a phenomenon known as vestibular agnosia².  As a result, an older patient with postural instability may be seen emergently after a traumatic fall, rather than routinely for an Epley maneuver before the fall³. 

Patient is an 84yo F with a past medical history of atrial fibrillation, diabetes, hypertension, and bilateral sensorineural hearing loss who presented to the balance center after six months of recurrent falls resulting in pelvic, femur, rib, and vertebral fractures. She reported imbalance without vertigo and was unable to clearly identify provocative factors. Extraocular movements, pursuit, and saccades were normal. Bilateral head impulse, head shaking, hyperventilation, and mastoid vibration testing were all negative. Her gait was slow but steady with mild imbalance induced with head movements. Left loaded Dix-Hallpike was negative. However, right loaded Dix-Hallpike was notable for upbeat with right torsional nystagmus for 30 seconds during which the patient had no associated dizziness (video available with QR code). Reversal nystagmus was noted with return to sitting, further suggesting right posterior canal benign paroxysmal positional vertigo (BPPV). A modified Epley maneuver was completed at the initial visit and repeated positioning tests at a follow-up visit one month later were negative. The patient has not had any falls in the 3 months since her initial visit and denied imbalance with activities of daily living.