BALANCE
AND
FALLS IN
ELDERLY
Every body falls regardless of age ,
experiences all through out life
In children and young adults , are of minor
consequence
Fall in elderly are the major cause of
morbidity and mortality – the consequence
extending minor injury to the significant loss
of functional independence and even death
▪ Mortality
▪ Morbidity
▪ Fractures
▪ Soft tissue injuries
▪ Head trauma
▪ Joint distortions and dislocations
▪ Loss of confidence - fear of falling
▪ Restricted activity
•15% falls result in serious injury
•Leading cause of mortality due to injury in over
75
•5% falls result in fracture 1% hip
•1/3 hip fractures can no longer live independently
and 25% are dead at 6 months
•14,000 people die every year
from hip #
Community-Dwelling:
41% environment related
13% weakness, balance or gait disorder
8% dizziness or vertigo
Nursing Home:
16% environment related
26% weakness, balance or gait disorder
25% dizziness or vertigo
Mechanisms of Fall
Contributing
Intrinsic : factors Extrinsic :
Aging, poor balance Home hazards
Occurrence of falls
No injuries
Fall Outcomes
Soft tissues Loss of Disability,
Fractures
injures, Confidence reduced
trauma quality of life
Causes of Falls
Intrinsic Factors (host )
▪ Acute Conditions
▪ Chronic Conditions
▪ Medications used to treat acute and chronic conditions
▪ Activity and behavioral
Extrinsic factors
▪ Environment
Often Multi-factorial
▪ Diabetic patient with severe OA of knee
▪ Peripheral neuropathy
▪ Failing vision
Diseases that can cause fall can be
classified by organ system
▪ Neurological
▪ Cardiovascular
▪ Musculoskeletal
▪ Foot Disorders
Neurological Disorders Contributing
to Falls
▪ Impaired Sensory Input
▪ Visual (e.g. macular degeneration)
▪ Vestibular (e.g. benign positional vertigo)
▪ Proprioceptive (e.g. diabetic peripheral neuropathy)
▪ Motor Weakness or Control (e.g. stroke, Parkinson’s Disease)
▪ Cerebellar Disorders (e.g. ataxia)
▪ Cognitive Disorders
Cardiovascular Disorders Contributing to
Falls
▪ Arrhythmias
▪ Severe peripheral edema
Musculoskeletal Factors Contributing to Falls
Joint Pain
Previous Fractures
Skeletal or Joint Deformities
Unstable Joints
Spine osteoarthritis with neurological
involvement
Foot Disorders Contributing to Falls
▪ Painful conditions
▪ Joint deformities
▪ Improperly fitted or risky shoes (e.g. slippery
soles, high spiked heels)
The phenomenon of constant displacement
and correction of the position of the center of
gravity within the base of support
components
· anteroposterior (AP) sway： ~ 5-7 mm at
quiet stance in young adults
Mechanism： The high
center of mass of the
human body and the small
base of support in standing
posture place the body in
unstable equilibrium,
resulting in constant
displacement of the body
pivoting about the ankle
joint
Based with relatively small disturbance of base of
support
COG perturbed forward or backward
The Tibialis anterior activated first followed by the
quadriceps response
A perturbation in opposite direction induce forward
sway would stimulate the Gastrocnemius –
hamstring response
Forward sway……. Gastrocnemius & Hamstrings
Backward sway…… Tibialis Anterior & Quadriceps.
More forceful perturbation
Person standing on narrow or unstable base
of support
Proximal to distal sequences
Primary movement occur as a COG moves
rapidly back and forth
occur if the COG is displace beyond the limit
of the base of support
Necessary to regain balance because neither
the ankle and hip strategies is sufficient to
move the COG BACK OVER THE BASE OF
SUPPORT
Slowness of sensory information processing
Slow of nerve conduction velocity 20 to 30 ms
incidence of proximal to distal sequence
reaction time
static sway and increase the number of step
require to recover balance after perturbation
Increase in the joint stiffness
Decrease in the ROM
Decline in muscle strength
Sensory system
Visual acuity , contrast sensitivity and depth
perception decline
Change in vestibular –ocular reflex
Mild Proprioceptive and vibration loss in older
adults
To prevent further falls
To prevent serious injury - especially fracture
Evaluation
Falls in the elderly are generally multi-factorial
Risk of falling increases with the number of
predisposing conditions
Identify all potential contributing problems by
systematic clinical evaluation
Evaluation forms the basis for specific treatments
and preventive strategies
Goals are to identify:
▪ Reversible conditions and environmental factors
▪ Modifiable impairments
▪ Fixed disabilities requiring compensation
FALL HISTORY
ONSET
ENVIRONMENTAL FACTOR
ACTIVITIES AT THE TIME OF FALL
PRESENCE OF VERTIGO
CURRENT MEDICATION
DIRECTION OF FALL
1.ETIOLOGICAL
ASSESSMENT ➢ C- CENTRAL PROCESSING
➢ FEED BACK
A- SENSORY SYSTEM ➢ FEED FORWARD
➢ VISION 2. FUNCTIONAL
➢ PROPIOCEPTION ASSESSMENT
➢ VIBRATION
➢ VESTIBULAR ➢ STANDING REACH
➢ MOBILITY SKILL
B- EFFECTOR SYSTEM
➢ STRENGTH 3.ENVIRONMENTAL
➢ ROM ASSESSMENT
➢ ENDURANCE
Interaction of patient and
home
Evaluation – “Get Up and Go” Test
Task Observations
Sit in a chair at a comfortable height Sitting balance
Stand without using arms to help if Balance when standing
possible Proximal leg muscle strength
Judgment (to lock wheelchair if applicable)
Close eyes at rest
Walk Step height and length, sway, unsteadiness
Turn around Stability, number of steps (> 4 increases risk)
Walk back to chair and sit down Balance when sitting down
Interventions
Goals are to:
▪ Minimize risk of falling
▪ Preserve mobility and independence
Multi-component interventions should be
based on the evaluation
Preventive strategies should address intrinsic
and environmental factors
Falls in Older Adults
Interventions
Medical
Rehabilitative
Environmental /Behavioral
Examples of Medical Interventions
Manage acute medical problems that may have
contributed to the fall (s)
Assess and treat postural hypotension
Adjust medication (s) if indicated
Reduce alcohol intake if indicated
Optimize management of chronic medical conditions
that increase fall risk
Ophthalmology assessment for visual problems
Evaluate for treatable causes of neuropathy if present
Assess and treat osteoporosis in those at risk
Intervention strategies
RISK FACTOR
INTERVENTION
• Visual impairment • Glasses, cataracts
• Cognitive impairment • minimise
• Depression • treat
Examples of Rehabilitative Interventions
Gait and balance training
▪ Physical Therapy
▪ Tai Chi
Strengthening exercises for muscular weakness
Physical therapy modalities for pain (e.g. heat, cold, ultrasound,
massage, etc.)
Balance exercises for vestibular
Ensure patient has correct walking aid and uses it appropriately
Training in safe performance of daily activities
Braces – e.g. ankle-foot orthotics (AFO) for foot drop
Shoe orthotics for painful foot problems and leg length
discrepancy
Examples of Environmental and Behavioral
Interventions
Bathroom modifications: grab bars, raised toilet seat,
rubber mat in tub or shower
Improve lighting, use of night light
Remove obstacles from walking paths
Stair safety
Proper storage of items
Bed and chairs at appropriate height
Proper footwear and clothing
Hip protectors for those at high risk
