Education | Impaired Balance and Fall Risk

Impaired balance or unsteadiness is a frequent complaint among older individuals and represents an important cause of falling. Balance problems contribute to the risk of falling either directly or indirectly (i.e., many individuals with unsteady balance tend to restrict their activities, which can lead to muscle weakness and, in turn, increased fall risk). Balance impairment is also strongly associated to the risk of injurious falls, particularly hip fractures.

Fall-related hip fractures occur as a result of a number of interrelated factors:

  • Loss of bone strength and hip padding (i.e. fat and muscle)
  • Loss of balance
  • Delayed protective responses resulting in a fall
  • Inability to break the impact of a fall
  • Falling on to or near the hip
  • Severity of impact of the fall
  • Floor surface hardness

Balance is maintained by inputs from the sensory and musculoskeletal systems. Sensory information, consisting of visual, vestibular and proprioceptive feedback (i.e., the sense of position), and muscle strength and joint flexibility in the legs are all important in helping to detect and correct balance loss. The loss of any one system, but especially the loss of two or more, effects balance and subsequently increases the risk of falling.

Many factors are responsible for unsteady balance, and older individuals may have many reasons for impaired balance. Important conditions that affect balance include:

  • Cataracts, glaucoma, macular degeneration, and diabetic retinopathy, which all affect vision.
  • Diabetic peripheral neuropathy, which affects position sense in the feet and legs.
  • Neurological disorders, such as Parkinson’s disease and stroke.
  • Arthritis or other diseases of bones and muscles can compromise strength.
  • Cognitive factors, such as fear of falling, dementia, and depression.

Lastly, medications, such as sedatives, tranquilizers, antidepressants, pain relievers and sleep medications, and environmental hazards (e.g., poor lighting, slippery or unstable floor surfaces, faulty footwear, excessive clutter, lack of grab rail support and defective walking devices) can contribute to balance loss and falls.

Strategies to Maintain Balance
Maintaining balance generally requires a multifaceted approach and consists of the following strategies:

Chronic Health Conditions
It’s important to treat and manage all medical conditions, especially those associated with balance loss and fall risk. Review all medications on a regular basis and reduce any unnecessary drugs (i.e., consider disease-specific benefits and adverse effects of individual medications). Monitor high-risk medications, such as psychoactive drugs (e.g., tranquilizers or antidepressants) for adverse effects (i.e., impaired balance is one of the most common manifestations of adverse medication effects).

Sneakers are a good choice; they provide stable traction when walking on slippery floor surfaces. Wearing shoes with thick, soft soles (e.g., jogging shoes) that can affect balance and proprioception or become a tripping hazard by catching in carpeting and should be avoided.

Making available handholds or enablers for beds (side rail or transfer bar), chairs (armrests), and toilets (attached grab rails) is crucial to support balance when rising from a sit-to-stand position, especially in those individuals with unsafe transfers.

Muscle strengthening and proprioceptive training can increase balance, while weight-bearing exercise such as walking or weight training can help minimize bone loss and reduce fracture risk.

Strategies to Reduce Injurious Falls
In those individuals who remain at risk for balance loss, strategies to reduce risk of injury include:

Bed/Chair Alarms
To avoid the risk of falls and injury, individuals with balance impairment often require staff assistance with mobility. Alarms are tools that alert or let nurses know when individuals who shouldn’t be getting out of bed or up from a chair without assistance are doing just that. There are a variety of bed and chair alarms available; all detect unsafe egress. Targeting the type of alarm (e.g., sensor pad, pull string, infrared beam, etc.) to the individual’s clinical condition can greatly improve the effectiveness of alarms.

Hip Protectors
Most hip fractures occur as a result of falling sideways. Hip protectors (i.e., padded underwear that fits over the bony prominence of the hips) are designed to shunt away or absorb the energy of a impact against the hip bones. Targeting the type or style of hip protector to the individual’s clinical condition helps improve adherence with protectors.

Calcium and Vitamin D
These nutrients help keep bones healthy. Optimizing calcium and vitamin D intake through diet or supplementation forms the basis for prevention and treatment of osteoporosis. Calcium supplements should provide 500 to 1,000 mg of elemental calcium per day, and vitamin D supplements should provide 400 to 800 units/day.

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