Balance and Aging by Charlotte Shupert, Phd, with Contributions by Fay Horak, Phd, PT Oregon Health & Science University, Portland, Oregon

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Balance and Aging By Charlotte Shupert, PhD, with contributions by Fay Horak, PhD, PT Oregon Health & Science University, Portland, Oregon

One of the leading health concerns for in the feet and legs; and degeneration of people over the age of 60 is falling, which the vestibular system. is often related to balance problems. The percent of people falling increases from Balance is also dependent on muscle 40% to 65% to 82% with each decade strength, joint mobility, and healthy feet. after age 65 years. A sedentary lifestyle, painful arthritis or diseases of bones and muscles can The consequences of falls can be compromise strength, mobility, and the disastrous; between 12% and 67% of base of foot support. elderly adults who fracture a hip die Balance control also depends on healthy within one year. Even if a bone is not brain function across many brain areas. fractured during a fall, falls cause pain The brain needs to process and interpret and injury while reducing future mobility sensory information, select appropriate and quality of life. As a result, major balance strategies, and adapt and learn scientific efforts are devoted to deter- new strategies with practice. As we age, mining the causes of falling in older adults brain processing can slow down, which in an attempt to reduce this significant results in slower balance responses. health hazard. People with cognitive problems also have balance problems, showing the Causes of imbalance in older people importance of higher level brain Balance in walking and standing is processing in balance control. dependent on many factors. Good balance requires reliable sensory input Because balance is a complex function, from the individual’s vision, vestibular there is often no single identifiable cause system (the balance system of the inner of falls in an elderly person. However, ear), and proprioceptors (sensors of older people with chronic dizziness or position and movement in the feet and imbalance are two to three times more legs). The elderly are prone to a variety likely to fall in comparison with older of diseases that affect these systems, people who do not experience these including cataracts, glaucoma, diabetic problems.1 Table 1 summarizes the retinopathy, and macular degeneration, factors that increase risk of falls in which all affect vision; peripheral seniors listed in order of highest risk. neuropathy, which impairs proprioception Experiencing a previous fall in the last

year is the highest risk factor for a future multiple problems are present. In such fall. cases, the trouble in any one system may not be severe, but the combined effects Risk-Factors for Falls Risk may be enough to cause a serious Fell in past year 5X problem with balance. For example, an Weakness 4.4x elderly individual with age-related, mild Peripheral Neuropathy 3.0 degeneration in vestibular function may Balance 2.9 not complain of dizziness until they Slow Gait 2.9 develop postural hypotension, or light- Cane 2.6 headiness when quickly moving from sit Vision 2.5 to stand due to a new medication, low Arthritis 2.4 blood pressure or a cardiovascular ADL Deficit 2.3 problem. In fact, slow, age-related loss Depression 2.2 of vestibular function is usually not Cognitive decline 1.8 associated with dizziness, although it is Ages >80 1.7 associated with imbalance and falls. > 5 medications 1.7 However, peripheral neuropathy resulting in poor position sense in the feet and Dizziness legs, results in more severe balance Symptoms of a sense of lightheadedness problems and falls than vestibular or disorientation (dizziness) and/or a mild problems, although a combination of both to violent spinning sensation (vertigo) vestibular and proprioceptive deficits can can have a variety of causes: vestibular be devastating to balance control. (inner ear) disorders, central nervous system disorders (such as stroke), The aging vestibular system cardiovascular problems (including low or Most people are familiar with the high blood pressure), low blood sugar, problems associated with the aging infection, hyper-ventilation associated of senses such as vision and hearing. with anxiety attacks, medication side However, the vestibular system is effects or interactions between drugs, or another sensory system that often an inadequate or poorly balanced diet. gradually begins to function poorly with Dizziness, or an abnormal sense of spatial age, leading to a diminished quality of orientation, should not be confused with life. disequilibrium or a sense of imbalance or unsteadiness. The vestibular system is a complex A thorough evaluation by a physician is structure of fluid-filled tubes and cham- usually necessary to help sort out these bers that constitutes part of the inner different possible causes of dizziness to ear. Specialized nerve endings inside arrive at a correct diagnosis. This task these structures detect the position and can be even more complicated when movement of the head and also detect

the direction of gravity. The signals sent collected within a part of the inner ear. from the nerves of the vestibular system This debris, called otoconia, is made up of are critically important to the brain’s small crystals of calcium carbonate ability to control balance in standing and (sometimes referred to colloquially as walking and also to control certain types “ear rocks”). With head movement, the of reflexive eye movements that make it displaced otoconia shift in the fluid, possible to see clearly while sending false signals to the walking or running. A tendency to fall brain and causing dizziness or and symptoms of vertigo. Usually the vertigo Anatomical studies have associated with BPPV lasts only dizziness should shown that the number of a few seconds per episode and not be dismissed nerve cells in the vestibular is not associated with severe as unavoidable system decreases from about balance problems. age 55. Blood flow to the consequences of inner ear also decreases with aging but may be Symptoms of BPPV are almost age. Idiopathic bilateral important signs always precipitated by a change (occurring on both sides) of a disease that in head position. Getting out of vestibular loss becomes more might be cured bed, looking up and rolling over severe as age progresses. or controlled. in bed are common motions that When the vestibular system cause vertigo in patients with is damaged by any cause, an BPPV. Some people feel dizzy individual may experience dizziness and and unsteady when they tip their heads balance problems. However, the gradual, back to look up. age-related loss of vestibular nerve endings can result in severe balance Ménière’s disease is another vestibular problems without any associated disorder that causes dizziness. Ménière’s dizziness. This type of slow loss of disease produces a recurring set of vestibular function may be first noticed as symptoms as a result of abnormally large difficulty walking or standing, especially amounts of a fluid called endolymph in the dark while on soft or uneven collecting in the inner ear. These surfaces (such as thick carpet or symptoms typically include spontaneous, a forest path). violent vertigo, fluctuating hearing loss, ear fullness, and/or tinnitus. Specific vestibular disorders in older adults The incidence of Ménière’s disease Of all vestibular disorders, benign (number of new cases per year) is paroxysmal positional vertigo (BPPV) is difficult to assess. Estimates vary widely, one of the most common in older adults. in part because of the variability in BPPV causes vertigo, a strong sense of a diagnostic criteria across studies. The spinning world, due to debris that has prevalence, however (all cases within a

population), is generally known to problems before a serious fall. Having a increase with age. physician and pharmacist work to minimize the number of medications an Other vestibular disorders that may occur older person is taking can go a long way in older adults include vestibular neuritis to reducing potential side-effects and (inflammation of the vestibular branch of interactions causing dizziness and the vestibulo-cochlear nerve, resulting in imbalance and has been shown to reduce dizziness or vertigo but no change in falls. Taking good care of the feet by hearing) and ototoxicity (exposure to wearing good shoes and maintaining certain chemicals that damage the inner healthy nails and skin is particularly ear or the vestibulo-cochlear nerve, which important for good balance. In addition, sends balance and hearing information making sure that the elderly person’s from the inner ear to the brain). Some environment is safe (with good lighting, types of chemotherapy for cancer secure footing, clear walkways, handrails treatment and high doses of particular and anti-skid devices in bathrooms, etc.) types of antibiotics can be ototoxic. can help prevent falls and their attendant Ototoxicity can result in temporary or injuries. permanent disturbances of hearing, balance, or both. A tendency to fall and symptoms of dizziness should never be dismissed as Precautions unavoidable consequences of aging but Although the problem of imbalance in may be important signs of a disease that older persons can be complex, there are might be cured or controlled. The elderly a few simple precautions that everyone have a higher risk of contracting many can follow to help ensure an active old different kinds of diseases. As a result, age. Balance in standing and walking is at the average elderly person is more likely least partly a skill that older adults can to have a disease that interferes with learn to maintain and/or improve, and it balance than a younger person. The is dependent on good general physical vestibular system should not be ruled out condition. Therefore, sound nutritional as a source of these symptoms. and health habits—including regular exercise, such as walking, strength The ability to move about freely is an training and participating important factor in the quality of life for in Tai Chi—can go a long way toward both younger and older people, and a preventing balance trouble. healthy vestibular system is vitally important to freedom of movement. In older people, a regular physical examination by a doctor familiar with the Reference problems of aging, such as a geriatrician, 1. Ko CW, Hoffman HJ, Sklare DA. can help identify and correct potential Chronic Imbalance or Dizziness and

Falling: Results from the 1994 options, coping tips, and contact informa- Disability Supplement to the tion for medical specialists may be found National Health Interview Survey by visiting the Web site of the Vestibular and the Second Supplement on Disorders Association (VEDA) Aging Study. Twenty-ninth vestibular.org. In addition to reading MidWinter Meeting of the information displayed on Web pages, Association for Research in visitors can download and print many of Otolaryngology (ARO); National VEDA’s short publications for free. Institute on Deafness and Other Communication Disorders (NIDCD). © Vestibular Disorders Association Feb. 2006. 2. National Institutes on Aging (NIA) VEDA’s publications are protected under of the NIH website. copyright. For more information, see our permissions guide at vestibular.org.

This document is not intended as a substitute Further reading for professional health care. Additional information about vestibular disorders, diagnosis and treatment

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