Benign Paroxysmal Positional Vertigo, Vestibular Ageing and Falls in Older Adults: Mechanistic Pathways and Clinical Implications.

This narrative review synthesises current evidence on the mechanistic pathways linking benign paroxysmal positional vertigo (BPPV), age-related vestibular decline, and fall risk among older adults. In the context of ageing, BPPV involves otoconia fragmentation and dislodgement, alongside altered endolymph dynamics, lead to impaired multisensory integration and reduced postural stability. Concurrently, vestibular ageing involves progressive degeneration of peripheral and central vestibular structures, leading to diminished gaze stabilisation, weakened vestibulo-spinal reflexes, and reduced adaptive capacity, thereby increasing vulnerability to falls. Four interrelated mechanistic pathways are identified through which BPPV contributes to falls in older adults: (1) episodic vertigo as a direct fall trigger, (2) chronic disequilibrium following BPPV episodes, (3) gait alterations and instability, and (4) cognitive and psychological mediators, including fear of falling and increased attentional demands. These mechanisms are further amplified by frailty and reduced physiological reserve in later life. The review underscores the importance of integrating fall risk profiling and frailty assessment into the clinical management of vestibular disorders in older adults. Comprehensive evaluation of dizziness severity, balance performance, and gait parameters is essential to improve diagnostic precision and guide targeted rehabilitation strategies. Management of BPPV in older adults requires interventions that balance mechanistic efficacy with geriatric safety, including modified canalith repositioning manoeuvres and individualised vestibular rehabilitation tailored to age-related vestibular decline. Addressing psychological sequelae, particularly fear of falling, is also critical, as maladaptive behaviours may exacerbate functional decline, reduce quality of life, and perpetuate fall risk in this population.