BALANCE AND FALL

IN ELDERLY
 Presented by:
Dr. Anna Zaheer, PT
UIPT, UOL
Balance:
The ability to maintain the center of gravity over
the base of support within a given sensory
environment
Static balance: The ability to hold a position

Dynamic balance: The ability to transition or

move between positions
SENSORY COMPONENTS OF
BALANCE
 Somatosensory systems
 - cutaneous receptors in soles of the feet
 - muscle spindle & Golgi tendon organ information
 - ankle joint receptors
 - proprioreceptors located at other body segments
 Vestibular system
 - located in the inner ear
 - static information about orientation
 - linear accelerations, rotations in the space
 Visual system
 - the slowest system for corrections
MOTOR COMPONENTS OF
BALANCE
1. Reflexes

 Vestibulo-occular Reflex (VOR)

 Allows the coordination of eye & head movements.
 Vestibulospinal Reflex (VSR)
 Ithelps to control movement & stabilize the body. (via. Righting like
labyrinthine, optical, body on head righting)
 The VSR permits stability of the body when the head moves and is
important for the co ordination over the trunk over the extremities in
upright posture.

2. Automatic postural responses:

Operate to keep the center of gravity over the base of support in

response to a stimulus or unexpected perturbation such as slip in a
crowded place.
Automatic postural responses
Ankle strategy
Hip strategy
Stepping & reaching strategy
• When the COG is outside of the BOS, a strategy is
required (shift, step or stumble) is required to prevent a
fall. (INHERENT FALL PREVENTION)
• Strategies are automatic
• Occur 85 to 90 msec after the perception of
instability is realized
3. Anticipatory postural control:
Similar to automatic postural control but occurs prior to and in preparation for the
perturbation
Anticipatory postural adjustments
Aim: to counteract the destabilizing
consequences of a Voluntary
movement.
Failure to produce this
adjustment – increases the risk of
falling
Volitional postural control:
Postural control under conscious control. Self-initiated
perturbations that are strongly influenced by prior
experience and instruction
Center of gravity:
An imaginary point in space, calculated biomechanically from
measured forces and moments, where the sum of all the
forces equals zero. In a normal person standing quietly, it is
located just forward of the spine at about the S2 level.
Base of support

The body surfaces that experience pressure as the result of body

weight and gravity. In standing, the base of support is the soles of
the feet; in sitting, it is the thighs and buttocks. The narrower the
base of support, the more difficult the balance task.
Limits of stability:
The limits to which a body can move in Any direction without
either falling (as the center of Gravity exceeds the base of
support) or establishing a new base of support by stepping or
reaching (to relocate the base of support under the center of
gravity)
Balance strategies:
Stereotypic sequences of muscle activity used to maintain
upright. The most commonly suggested include the ankle, hip,
and stepping strategies.
 PHYSIOLOGY OF BALANCE

Balance, the ability to maintain the center of gravity over the base of support
within a given sensory environment, is composed of several subcomponents
and influenced by several systems.
 PHYSIOLOGY OF BALANCE

Human balance is a complex neuro-musculoskeletal process involving the sensory

detection of body motions, integration of sensorimotor information within the central
nervous system (CNS), and programming and execution of the appropriate
neuromuscular responses.
The organization of the human balance system
 BALANCE ASSESSMENT
Red flags - urgent referrals to physician for workup
• Unexplained central nervous system signs.
• sensory, or cognitive changes
• Unexplained cranial nerve dysfunction
• Unexplained sudden or unilateral hearing loss especially if
accompanied by vertigo
• Two or more falls in the previous 4 weeks
• Inconsistencies in clinical examination
Assessment of balance in elderly
 Underlying Components of balance control to be assessed include,
 Muskuloskeletal
 Sensory
 Motor &
 Cognitive
 Balance tasks to be assessed includes
 Self Report Measures
 Quiet standing (static)
 Active standing (dynamic)
 Sensory manipulation
 Vestibular
 Functional scales
 Dual task & Multiple Task
Assessment of gate

 It is a multi task test: have 2 parts

 Balance sub test: 9 items (4 static & 5 dynamic)
 Gait sub test : 8 test
 Focused on
 Maintenance of position
 Postural response to perturbation
 Gait mobility
 Equipment needed
 Chair, walk way; patient can use usuan walking aid
Effect of aging in postural control
and balance
 The Sensory System

 With Aging:
 Vision may decrease in acuity, contrast sensitivity, and depth
perception.
 The vestibular system may undergo age- related changes, resulting in
dizziness and unsteadiness.
 There may be a decrease in proprioception and vibration.
 The Central Processing System
 Aging may result in:
 Slowing of sensory information
 Slowing of nerve conduction velocity
 Increased postural sway
 Increased incidence of co-contractions
 Cognitive Area
 High level Sensory Adaptation
 Decreased ability to shift from the use of one sensory input to other for poster
control
 Attention
 Increased attention required for the Postural Control
 Poorer performance in Dual Tasks (in Cognitive & postural tasks)
 The Effector System
 Aging may result in:
 Decreased muscle strength
 Decreased ROM and flexibility
 Increased “stiffness” of connective tissue
 Aging may result in cardiovascular changes
Influence of other systems

 Cognitive & behavioral factors…

 Attention
 Cognition
 Judgment
 Memory
 Depression
 Emotional liability
 Agitation
 Denial of impairment.
Fall risk factors in older adults

2 classifications,
 Classification 1

 Intrinsic (internal) Risk factors

 Extrinsic (external) Risk factors
 Acquired Risk factors

 Classification 2

 Modifiable Risk Factors

 Non-Modifiable Risk Factors
Classification 1

 Intrinsic (internal) risk factors

 Examples- Age, osteoporosis, vision loss, dementia

 Extrinsic (external) risk factors:

 Examples- Medications, footwear, assistive devices, environment

 Acquired risk factors:

 Examples- Facility or hospital admission due to health change or
decline (new environment), delirium due to illness, increased
disability due to injury
Classification 2

 Modifiable risk factors

 Examples: Muscle weakness, poor balance, exercise level,
medications, environmental lighting, footwear
 Non-modifiable risk factors
 Examples: Age, chronic conditions, disability, dementia, vision loss
TREATMENT
Rx.

 Regular exercise
 Medication review
 Vision exams
 Home safety evaluation
Fall prevention

 Individual risk assessment

 Regular strength & balance exercise
 Gait & assistive device training
 Medication review & management
 Management of chronic conditions
 Vision correction
 Education
 Home safety improvements
Specific recommendations

EXERCISE:

 Older people who have had recurrent falls should be offered long-
term exercise and balance training (B).
 Tai Chi C’uan is a promising type of balance exercise,although it
requires further evaluation before it can be recommended as the
preferred balance training
ENVIRONMENTAL MODIFICATION

 When older patients at increased risk of falls are discharged from the
hospital, a facilitated environmental home assessment should be
considered (B).
 In a subgroup of older patients, a facilitated home modification
program after hospital discharge was effective in reducing falls
 Medication

 Patients who have fallen should have their medications reviewed

and altered or stopped as appropriate in light of their risk of future
falls. Particular attention to medication reduction should be given to
older persons taking four or more medications and to those taking
psychotropic medications
 Assistive Devices

 Studies of multifactorial interventions that have included assistive

devices (including bed alarms, canes, walkers (Zimmer frames), and
hip protectors) have demonstrated benefit. However, there is no
direct evidence that the use of assistive devices alone will prevent
falls. Therefore, while assistive devices may be effective elements of
a multifactorial intervention program, their isolated use without
attention to other risk factors cannot be recommended
Behavioral and Educational Programs
 Although studies of multifactorial interventions that have included
behavioral and educational program have demonstrated benefit,
when used as an isolate intervention, health or behavioral
education does not reduce falls and should not be done in isolation
(B)
 A structured group educational program among community-
dwelling older people did not reduce the number of falls but did
achieve short-term benefits in attitudes and self-efficacy (Class I).
 Practice guidelines in the emergency department did not alter
documentation of falls risk factors, causes of falls, consequences of
falls, or the implementation of practice guidelines
 Bone Strengthening Medications
 It reduce fracture rates. But not reduce the rates of falls.
 Visual Intervention
 Fall-related hip fractures were higher in patients with visual impairment.
 Footwear Interventions
 For Women: Static and dynamic balance were better in low-heeled
rather than high-heeled shoes or than the patient’s own footwear.
 For men: foot position awareness and stability were best with high
midsole hardness and low mid-sole thickness. Static balancewas best in
hard-soled (low resistance) shoes.
 TREATMENT
The exercises prescribed need to challenge the patient's balance and
therefore are ones that may make them stumble or fall. Upper
extremity support changes the sequence of muscle activation so that
it originates in the upper extremities. This alteration in the sequence
of muscle activity is not usually desirable if the goal of treatment is
independent ambulation without an assistive device. For standing
exercises, having the patient stand in a corner of the room with a
chair in front of them provides a surface on all sides that can catch
the patient, minimizing the chance of injury. It is unknown how
frequently balance exercises need to be performed for maximum
improvement.
THANKS