Importance of balance in older people

Importance of balance in older people: definition and physiological basis

The balance can be defined as the capacity of the organism to maintain the centre of gravity within the support base at rest, during walking and in response to external disturbances. In older people, stable balance function is associated with safer movement and less risky daily activities. Its alteration is associated with postural instability and increased likelihood of falls, a relevant event because of its potential functional and clinical repercussions at this stage of life.

Physiological components of equilibrium

• Sensory systemsVisual (orientation and spatial reference), vestibular (angular and linear accelerations of the head) and somatosensory-proprioceptive (information from feet, ankles, joints and vibration).
• Central integrationSignal processing and integration of signals in the brainstem, cerebellum and cortex to estimate body position and select appropriate postural strategies.
• Motor responseAdjustment of postural reflexes, tonic control and strength-coordination of limbs and trunk, with reaction times according to demand.

With ageing, physiological changes may occur that influence these components: decreased visual acuity and contrast sensitivity, presbyvestibular, reduced plantar sensitivity or proprioceptive impairment, and sarcopenia with reduced strength and power. Increased latencies in postural reflexes and variations in haemodynamic regulation, such as orthostatic hypotension, may also be observed. Polypharmacy and chronic diseases (e.g. peripheral neuropathies, osteoarthritis or parkinsonism) may interact with these systems. Individual clinical assessment helps to identify which mechanisms are most compromised and to guide prudent and personalised decisions.

Importance of balance in older people and its relationship with falls, fractures and autonomy.

The balance in the older people depends on the integration of vision, proprioception, vestibular function and muscle strength. With age, these systems may show physiological changes and be affected by neurological, cardiovascular or musculoskeletal diseases. This deterioration reduces postural stability and the ability to react to disturbances, which is associated with an increased likelihood of falls, especially during walking, turning and transitions from sitting to standing.

The relationship between compromised equilibrium and fragility fractures is relevant: a stumble or imbalance can trigger low-energy falls which, in the presence of osteoporosis or other bone fragility factors, are associated with hip, wrist or vertebral fractures. Beyond bone damage, a fall can lead to contusions, head injuries or complications arising from immobilisation, with variable clinical impact depending on comorbidities and concomitant medication.

Balance disturbances also have an influence on the functional autonomy. Fear of falling can lead to limiting daily activities, leading to deconditioning, loss of muscle mass and power (sarcopenia) and reduced social participation. This cycle of inactivity can hinder basic and instrumental tasks of daily living, increasing dependency. Multiple factors often converge to modulate risk and functional impact:

• Visual, vestibular or proprioception deficits (e.g. peripheral neuropathy).
• Muscle weakness and sarcopenia.
• Neurological and cognitive disorders.
• Orthostatic hypotension and other cardiovascular disorders.
• Polypharmacy and medication with sedative effect or hypotensive.
• Osteoporosis and environmental factors such as poor lighting or obstacles in the home.

Importance of balance in older people: warning signs, dizziness and when to consult

The balance in older people depends on the integration between the vestibular system, vision, proprioception, muscle strength and neurological function. With age, physiological changes, certain chronic diseases and some drugs may increase instability and the risk of falls, with possible consequences such as fractures or loss of autonomy. A prudent clinical approach prioritises the identification of triggers, assessment of the environment and review of medication.

Warning signs

They constitute warning signsThe following symptoms may be present: fall with head injury, loss of consciousness, sudden weakness or numbness on one side of the body, sudden alteration of speech or vision (including double vision or sudden visual loss), sudden severe headache, chest pain, palpitations, shortness of breath, fever or neck stiffness. The occurrence of acute onset instability, rapid worsening or focal neurological symptoms suggests causes requiring priority assessment.

Dizziness in the elderly

The dizziness is a non-specific term that may correspond to: vertigo (spinning sensation, often positional or with head movement), presyncope (fainting sensation, sometimes due to orthostatic hypotension, (e.g., dehydration or arrhythmias), imbalance (unsteadiness in walking, common in peripheral neuropathies, visual disturbances or osteoarthritis) and non-specific dizziness (possible influence of anxiety or drugs). The polypharmacy and sedatives, antihypertensives or hypoglycaemic agents are associated with an increased likelihood of dizziness and unsteadiness.

When to consult

It is considered urgent consultation when dizziness or unsteadiness is accompanied by acute neurological symptoms, loss of consciousness, chest pain, dyspnoea, sudden severe headache or sudden visual/auditory disturbances. Persistent or recurrent dizziness, repeated falls, instability limiting daily activities, progressive worsening, symptoms on standing consistent with orthostatic hypotension, dehydration, recent changes in medication or suspected adverse effects require priority medical assessment.

Importance of balance in older people: causes and risk factors (vision, inner ear, strength, drugs)

The balance is crucial for safe walking, turning and standing without incident. In older people, its impairment is often multifactorial and is associated with an increased risk of falls, injuries and loss of autonomy. Identifying the causes and risk factors The more frequent use of the system helps to understand why some contexts (changes in lighting, uneven surfaces, fatigue) are more challenging for stability.

Sensory systems: vision and inner ear

The vision provides references for distance, relief and movement. Acuity, contrast sensitivity and peripheral or night vision may decrease with age, and cataracts, macular degeneration or glaucoma alter depth perception. Multifocal spectacles can distort the location of steps or curbs during walking, and insufficient lighting increases visual demand. The inner ear (vestibular system) reports head orientation and accelerations; its age-related decline and conditions such as benign paroxysmal positional vertigo may cause dizziness, unsteadiness or oscillopsia. Ototoxicity of some compounds is also an issue. When vision and vestibular are compromised simultaneously, instability often becomes more evident.

Strength and postural control

The muscle strength and the power of the lower limbs support corrective reactions that keep the centre of gravity within the base of support. Sarcopenia, slowed reaction time, joint stiffness and gait disturbances hinder ankle and hip strategies to regain stability after minor stumbling or pushing. Physical deconditioning and chronic pain can amplify these limitations.

Drugs

The drugs influence balance through effects on the central nervous system, blood pressure and blood glucose. The polypharmacy and groups such as benzodiazepines, hypnotics, antipsychotics, antidepressants with sedative effect, anticholinergics, opioids, diuretics and some antihypertensives are associated with drowsiness, blurred vision, orthostatic hypotension or dizziness. Recent dose changes, drug combinations and alcohol consumption may increase these effects in older people.

Importance of balance in older people: clinical assessment and safe measures to care for balance at home and in the community

The assessment of the balance in older people is multidimensional and often combines medical history, physical examination and functional tests safe and secure. Sensory factors (vision, vestibular system and proprioception), lower limb strength and power, gait and posture, cognitive and affective function, as well as common co-morbidities (e.g, neuropathy, vestibular disorders, arthrosis, stroke sequelae). The polypharmacy and drugs with a sedative or hypotensive effect may influence stability; also the orthostatic hypotension and foot and footwear disorders. Clinical tools such as Timed Up and Go, unipodal support or static balance tests, together with measurement of blood pressure in different positions and gait assessment, provide information on the risk of falls, which should be interpreted together and with caution.

Safe measures at home:

• Safe environmentContinuous and night-time lighting, removal of loose cables and carpets, non-slip surfaces, visual contrast on steps, firm handrails and grab rails in bathrooms; arrange objects at mid-height to avoid climbing on chairs.
• FootwearClosed, with non-slip sole and low heel; check fit and wear.
• Postural habits: to sit up gradually (from lying down to sitting, then standing) to reduce instability associated with abrupt changes.
• Strengthening and balanceProgressive, low-load programmes (e.g., repeated rising from the chair, walking with changes of direction, practices such as Tai Chi) may be useful; selection and dosage should be individualised.
• Assistive devicesWalking aids: cane or walker adjusted to height and used with proper technique; keep in good condition.
• Clinical factorsVision and hearing checks, foot care, regular checks of medication and possible effects on balance.
• Practical supportThe following features should be provided: shower seats, non-slip mats, accessible support surfaces and telephones or buzzers within easy reach.

Safe measures in the community:

• ItinerariesPrefer regular, well-lit pavements, avoid slippery or very uneven surfaces, and plan for breaks at benches or support areas.
• Mobility: correct use of assistive devices outdoors; avoid carrying objects that shift the centre of gravity or limit the view of the ground.
• Transport and accessibilityChoose options with visible handrails and steps; climb up and down with stable support.
• Personal organisationConsider weather conditions that increase the risk of slipping and sliding, and consider the following: non-dragging clothing, medical identification and accessible telephone; consider weather conditions that increase the risk of slipping.
• Guided physical activityCommunity-based strength and balance programmes with qualified supervision can promote safe and sustained practice.
• Visual and hearing healthupdate optical corrections and hearing aids where appropriate, as they contribute to spatial orientation.