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\begin{document}

\title{Analysis Of Patient Variables Including Socioeconomic Indicators And
Their Association With Recurrence Rates And Persistence Of Benign
Paroxysmal Positional Vertigo: A retrospective case series}



\author[1]{Christy Moen}%
\author[2]{Georgios Kontorinis}%
\affil[1]{Queen Elizabeth University Hospital}%
\affil[2]{Institute of Neurological Sciences, Queen Elizabeth University Hospital}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\textbf{Key Points}

\begin{enumerate}
\tightlist
\item
  Previous studies have linked recurrent or persistent BPPV to age,
  anxiety or/and depression and medical comorbidity
\item
  Factors such as the socioeconomical status have not been assessed.
\item
  In our retrospective powered cohort we showed that there is a positive
  correlation between recurrent or persistent BPPV and age
\item
  We found no correlation with the presence of underlying
  anxiety/depression and recurrent or persistent BPPV and age.
\item
  While one would have expected that the socioeconomical and educational
  status would have had an impact on recurrent/persistent BPPV, using
  the Scottish Index of Multiple Deprivation, we did not identify such
  link.
\end{enumerate}

\textbf{INTRODUCTION}

Benign Paroxysmal Positional Vertigo (BPPV) is a peripheral vestibular
disorder presenting with momentary periods of vertigo on changes of
position of the sufferer's head. It is the commonest cause of peripheral
vertigo, with an estimated lifetime prevalence of
2.4\%.\textsuperscript{1} BPPV is also one of the most treatable causes
of vertigo, with the mainstay of treatment being repositioning
movements.\textsuperscript{2}

Previous research has shown that BPPV is more common in certain
demographics. In particular, BPPV tends to be not only more common in
older age groups, but also elderly tend to have more episodes of
BPPV.\textsuperscript{3} Although BPPV is often easily treatable, some
patients suffer from persistent BPPV which is refractory to
repositioning manoeuvres.\textsuperscript{4} Patients can also have
recurrence of BPPV, with some studies finding up to 26\% patients will
have a recurrence of their BPPV after initially successful repositioning
movements. Overall, given its high prevalence, BPPV can significantly
affect, at least temporarily, the performance status and the quality of
life of the affected individuals and can present significant burden to
every health system.

Considering how common BPPV is, there are mostly sporadic systematic
efforts to investigate the reasons behind recurrences as well as
persistent BPPV. Indeed, there are few studies which have attempted to
look for socioeconomic risk factors for BPPV, and even fewer which look
specifically at persistence and recurrence of BPPV.

The aims of our study were :

To identify any relationships between patient variables with persistent
or recurrent vertigo.

To identify determine any statistically significant relationship between
socioeconomic circumstances and rates of recurrent or persistent BPPV.

MATERIALS AND METHODS

Basic Settings and Patient Selection

We performed a retrospective case series in academic settings. This
study was approved as audit by the Research Ethical Committee. Local
Caldicott guardian approval was gained for this study.

We analysed the notes of patients presenting to an audiology-led vertigo
clinics in a secondary care service covering 1.2 million population and
tertiary referral service covering 2.2 million population who were
diagnosed and subsequently treated for BPPV. We covered the three-year
time period between end 2018 and beginning 2021. Patients that were
representations were also included and data from previous visits were
collected to ensure accuracy of captured data with detailed
documentation of the precise number of presentations and treatment
sessions.

We included only patients with a confirmed diagnosis of BPPV, i.e. clear
documentation of symptoms consistent with BPPV as well as a positive
Dix-Hallpike manoeuvre or supine log roll test. A positive Dix-Hallpike
manoeuvre was defined as objective nystagmus (observed with naked eye or
with video-Frenzel goggles) and/or subjective vertigo.

Collected Data

We primarily collected data on whether the patient had persistent or
recurrent BPPV.

Persistent BPPV was defined as representing within nine weeks of a
previous session with ongoing BPPV.

Recurrent BPPV was defined as:

any episode happening more than nine weeks after the previous session.

if the patient had a documented complete resolution of their BPPV
symptoms but represented with symptom recurrence.

Resolution was defined as the patient having no subjective vertigo and
no nystagmus on Dix-Hallpike test.

Data collected in this study in this study included patient demographics
(age, age group and gender), side of BPPV, whether the patient had a
vestibular co-morbidity (such as previous vestibular neuronitis or
Meniere's disease) and number of total visits; we also recorded the
presence of anxiety/depression as a medical diagnosis. Age was grouped
into decades.

In order to assess the impact of socioeconomical factors on
recurrent/persistent BPPV, we used the Scottish Index of Multiple
Deprivation (SIMD), a measure of deprivation across 6,976 small areas in
Scotland.\textsuperscript{5} It's based on seven domains: income,
education, employment, health, housing, crime and access to services.
Postcode areas in Scotland are scored and ranked from 1 (most deprived)
to 6976 (least deprived). This index allows for a score of an
individual's deprivation to be calculated and used for analysis.

Analysis

Data were recorded on excel spreadsheets. We utilised RStudio to carry
out our statistical analysis. We used Spearman's rank correlation to
assess for any correlation between variables. The statistical
significance level was set at 0.05.

\textbf{RESULTS}

We identified 138 patients with definite BPPV as the sole cause of their
symptoms. (Table 1). The mean age of the patients was 64 years old
(range 21-95); 74\% of patients were female, while 49\% of patients had
BPPV on both sides, 26\% just on the left side and the remaining 25\% of
patients only had BPPV on their right side. The most common vestibular
co-morbidity in our patients was previous vestibular neuronitis (5\%). A
total of 38\% of patients in our cohort also had a diagnosis of
depression or anxiety. The median number of visits was 6 (range 1-38
visits).

\emph{Recurrent BPPV}

Spearman's correlations were run between certain factors, namely number
of recurrences and age, age group (in decades), SIMD and the presence of
anxiety/depression.

Age group and number recurrences was significantly correlated (p-value =
0.01681, correlation coefficient 0.2032392).

Age and the number of visits was significantly correlated (t = 2.4952,
df = 136, p-value = 0.01378 correlation coefficient 0.2092286).

There was no statistically significant correlation between SIMD and
number of recurrences (t = 1.1368, df = 44.872, p-value = 0.217 ).

There was no statistically significant correlation between
depression/anxiety and number of recurrences~(t = -0.79643, df = 92.191,
p-value = 0.4278).

\emph{Persistent BPPV}

Spearman's correlations were run between certain factors, namely the
presence or not of persistent BPPV and age, age group (in decades), SIMD
and the presence of anxiety/ depression.

There was a statistically significant correlation between age and having
persistent BPPV (t = -2.0008, df = 74.103, p-value = 0.04907).

There was no statistically significant correlation between SIMD and
having persistent BPPV (t = -0.33008, df = 17.56, p-value = 0.7452).

There was no statistically significant correlation between having a
diagnosis of depression or anxiety and having persistent BPPV~(t =
-1.5135, df = 121.14, p-value = 0.1328).

\textbf{DISCUSSION}

Main findings

We identified statistically significant correlation between BPPV
recurrences and age, indicating that recurrences are more likely in the
elderly. We also identified a statistically significant correlation
between age and having persistent BPPV. We did not identify any links
between socioeconomic factors/deprivation in either recurrent or
persistent BPPV. To our knowledge our study represents the first
analysis of the association between socioeconomic variables and
persistent or recurrent BPPV, not demonstrating, as above, any
significant relationship between SIMD and having persistent BPPV, nor
did it show any link between SIMD and having a higher number of
recurrences of BPPV. This result is interesting as most disease
processes appear to have a link with increased
deprivation.\textsuperscript{6}

Additionally, although a larger proportion of our patients had a
diagnosis of the anxiety or depression, no relationship was found
between having anxiety or depression and having more frequent or
persistent BPPV. While previous work by Wei et al showed a statistically
significant relationship between depression and recurrence of BPPV, in
our cohort, we failed to show such correlation.\textsuperscript{7}

Factors affecting recurrent/persistent BPPV

The increased risk of BPPV in older group is well known, and previous
studies have shown the link between age and chance of recurrence of
BPPV. Previous studies have hypothesised the increase in recurrence
rates in older patients may be related to utricular
degeneration.\textsuperscript{8}

This information could be vital for counselling patients in older age
groups regarding their journey with BPPV. Informing them they are more
likely to suffer from more episodes than younger people can both address
expectations regarding prognosis, allow for additional education and
help with managing resources as patients may need to be seen more
frequently in a clinic.

Previous studies have also shown that patients can suffer from multiple
peripheral causes of vertigo such as BPPV, vestibular neuronitis and
Menniere's disease.\textsuperscript{9} However studies have shown that
there is no association between having vertigo inducing co-morbidities
and recurrent BPPV.\textsuperscript{10} In the same large scale
meta-analysis Li et al found thirteen different risk factors for
recurrence of BPPV. Similar to our findings, age was a significant risk
factor, but they also found gender and hypertension to be risk factors
as well.

\emph{Study limitations and strengths}

The main limitations of this study arise from its retrospective
character and the associated bias. Additionally, patient notes extracted
were not randomised, and as such our results may not be entirely
representative of the BPPV population.

Additionally, we did not include further factors that could play a role,
such as vitamin D levels, which have been shown to play a role in
recurrences and their severity.

On the other hand, the present study is powered and the only study
looking into the impact of socioeconomic factors on BPPV, shedding some
light on the commonest peripheral cause of dizziness.

\emph{Conclusions}

Identifying clinical risk factors for recurrent and persistent BPPV is
important when counselling patients after they are given a diagnosis.
This study showed that there is a positive relationship between age and
recurrent BPPV. On the contrary, persistent or recurrent BPPV were not
associated with socioeconomic indicators of health status. Given its
high prevalence and impact on quality of life and health services,
further research is needed to identify methods to help patients who are
prone to recurrent and persistent BPPV.

1. Brevern M von, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et
al. Epidemiology of benign paroxysmal positional vertigo: a population
based study. Journal of Neurology, Neurosurgery \& Psychiatry. 2007 Jul
1;78(7):710--5.

2. Epley JM. The canalith repositioning procedure: for treatment of
benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992
Sep;107(3):399--404.

3. Yang CJ, Kim Y, Lee HS, Park HJ. Bone mineral density and serum
25-hydroxyvitamin D in patients with idiopathic benign paroxysmal
positional vertigo. J Vestib Res. 2018;27(5--6):287--94.

4. Dorigueto RS, Mazzetti KR, Gabilan YPL, Ganan\selectlanguage{ngerman}ça FF. Benign paroxysmal
positional vertigo recurrence and persistence. Brazilian Journal of
Otorhinolaryngology. 2009 Jul 1;75(4):565--72.

5. Scottish Index of Multiple Deprivation 2020 {[}Internet{]}. {[}cited
2022 Jun 4{]}. Available from:
https://www.gov.scot/collections/scottish-index-of-multiple-deprivation-2020/

6. Scottish Index of Multiple Deprivation (SIMD) Indicators as
Predictors of Mortality Among Patients Hospitalised with COVID-19
Disease in the Lothian Region, Scotland During the First Wave: A Cohort
Study {[}Internet{]}. 2021 {[}cited 2022 May 29{]}. Available from:
https://www.researchsquare.com

7. Wei W, Sayyid ZN, Ma X, Wang T, Dong Y. Presence of Anxiety and
Depression Symptoms Affects the First Time Treatment Efficacy and
Recurrence of Benign Paroxysmal Positional Vertigo. Frontiers in
Neurology {[}Internet{]}. 2018 {[}cited 2022 May 29{]};9. Available
from: https://www.frontiersin.org/article/10.3389/fneur.2018.00178

8. Balatsouras D, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign
paroxysmal positional vertigo in the elderly: current insights. Clin
Interv Aging. 2018 Nov 5;13:2251--66.

9. Huppert D, Strupp M, Theil D, Glaser M, Brandt T. Low recurrence rate
of vestibular neuritis: A long-term follow-up. Neurology. 2006 Nov
28;67(10):1870--1.

10. Li S, Wang Z, Liu Y, Cao J, Zheng H, Jing Y, et al. Risk Factors for
the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic
Review and Meta-Analysis. Ear Nose Throat J. 2022 Mar
1;101(3):NP112--34.

\textbf{Hosted file}

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