Balance & Fall Prevention: Strategies for Intervention

Balance

Balance & Fall Prevention:  Strategies for Intervention

Balance & fall prevention are a matter of urgent concern to many older adults and their caretakers.  According to a 2008 report by the Center for Disease Control:

  • One third of those over the age of 65 have a fall every year
  • One out of 10 falls results in a serious or even fatal injury.
  • Falls are a major cause of death in people over the age of 65.

Because a fall can have devastating and even fatal consequences, fall prevention is of utmost importance.  The good news is there are easy and simple steps you can take to prevent falls.

Balance & Fall Prevention:  Balance

Postrual Sway enables motor corrections for balance & fall prevention
Postrual Sway enables motor corrections for balance & fall prevention

Balance is a key component to fall prevention.  Good balance is made up of:

  • Correct sensory information from your eyes (visual system), muscles, tendons, and joints (sensory motor input), and the balance organs in the inner ear (vestibular system).
  • The brain stem making sense of all this sensory information in combination with other parts of the brain.
  • Movement of your eyes to keep objects in your vision stable and keep your balance (motor output).

As we age, postural sway tends to increase and balance control tends to decrease.  Factors that contribute to this change include changes in:

  • Physiological and psychological function
  • Development of diseases
  • Use of drugs that affect the visual, vestibular and proprioceptive function

As a result, if some people slip, trip, or loose their balance it is less likely they will be able to recover equilibrium in time to prevent a fall.

Balance & Fall Prevention:  Who Falls?

Strength and good nutrition are factors in balance & fall prevention
Strength and good nutrition are factors in balance & fall prevention

Frail older adults were matched for age, number of health problems and medications use. Those who fell compared to those who did not had:

  • Higher levels of nutritional risk
  • Poorer leg strength and balance
  • Poorer psychological well-being
  • Female gender
  • Disability of lower extremities
  • Hearing impairment

Sensory impairments are a substantial problem for older Americans: One out of six has impaired vision; one out of four has impaired hearing; one out of four has loss of feeling in the feet; and three out of four have abnormal postural balance testing.  Not only are sensory impairments a problem, but they increase with age: Vision and hearing impairments each double, and loss of feeling in the feet increases by 40% in persons aged 80 years and over compared with persons aged 70-79 years.

 Balance & Fall Prevention:  The Visual System

Visual acuity is how sharp or clear your vision is.
Visual acuity is how sharp or clear your vision is.

Visual Acuity

Visual Acuity is the clarity or sharpness of vision.  Cataracts are the most common cause of vision loss in people over age 40 and cataract surgery dramatically decreases the number of falls due to poor vision.  Patients had a 78% decrease in the risk of falls the year after cataract surgery on one eye.  But . . . the number of falls that required hospitalization doubled between first and second eye cataract surgeries.  This emphasizes the need for timely provision of second eye surgery and appropriate refractive lenses management between surgeries.  Poor visual acuity not only increases risk of fall but can result in dizziness.  The percentage of patients who reported dizziness dropped from 52 percent to 38 percent six months after cataract surgery.  But . . . the percentage of patients who reported falling after surgery dropped only slightly, from 23 percent to 20 percent. Researchers found a significant link between post-operative falls and the patient being switched to multi-focal lenses.  “Unrelated to their cataract surgery status, people who wear multi-focal lenses have been shown to have increased fall rates,” says Dr. Lewerenz from the Lewerenz Medical Center.

Poor depth perception is a significant factor in falls.
Poor depth perception is a significant factor in falls.

Depth Perception

Bifocal/multifocal glasses distort depth perception while walking or climbing stairs. This is because the glasses are usually designed to be used looking down while reading. When the eyes are focused downward while walking looking through these same lenses, depth perception becomes greatly distorted.  Other conditions that affect depth perception include Anisometropia – eyes with differing refractive errors, a cataract in only one eye, macular degeneration or gluacoma when one eye is frequently affected more than the other.

Contrast sensitivity

When contrast sensitivity is impaired, there is a limited ability to see well in low lighting or situations where there is little difference in colors and textures.  Poor contrast sensitivity also can increase your risk of a fall if you fail to see that you need to step down from a curb onto similarly colored pavement. Low contrast sensitivity can occur with eye conditions such as cataracts, glaucoma or diabetic retinopathy.

Balance & Fall Prevention:  The Sensory-Motor System

Good leg strength is an important factor in balance & fall prevention
Good leg strength is an important factor in balance & fall prevention

Weakness

Muscle weakness, especially in the legs, is one of the most important risk factors. People with weak muscles are more likely to fall than are those who maintain their muscle strength, as well as their flexibility and endurance.  Conditions that contribute to muscle weakness include:

Infection: Pneumonia, UTIs, Meningitis

Nutrition & GI Dysfunction:  Vitamin D Deficiency, Dehydration, Malnutrition, Ulcers, Bowel obstruction

Organ Dysfunction:  Thyroid: Hyperthyroidism, Hypothyroidism; Heart: Cardiac insufficiency, arrhythmia; Liver: Hepatitis, Cirrhosis; Kidneys: Renal insufficiency

If weakness is due to a medical condition, you may need help from physical therapy to develop an individualized treatment program to help you re-gain the strength you need to reduce your risk of falls.

Sensory Impairment

San Diego State University’s Daniel Goble, professor in the School of Exercise and Nutritional Sciences, studies “proprioception” — the ability to know where we are in space. And, as we age, proprioception decreases.  “Imagine you are sitting down and you have your feet under a desk,” Goble explained.  “Even without seeing your feet, you know where they are approximately and what direction they are pointing — that’s proprioception,” Goble said. “When proprioception begins to fail, we can’t sense those things and as a result we may misjudge or misstep. In the elderly, that misjudgment could result in a dangerous fall.”  Regular physical activity seems to be a beneficial strategy to preserve proprioception and prevent falls among older subjects. Some studies have demonstrated that the regular physical activity can attenuate age-related decline in proprioception.

Balance & Fall Prevention:  The Vestibular System

The inner-ear vestibular mechanism relates body position to gravity
The inner-ear vestibular mechanism relates body position to gravity

The Purpose of the vestibular system is to determine head and body orientation in comparison to gravity.  It is comprised of:

  • 3 semicircular canals
  • 5 sensory organs
  • Hair cells

Function:  The semicircular canals contain fluid that moves in the opposite direction of the head movement.  The fluid deflects hair cells that line the semicircular canals and fire the 8thcranial nerve (vestibular nerve).  When the vestibular system is not working correctly, symptoms

Fluid moves through the semi-circular canals and trigger hair cells to give orientation
Fluid moves through the semi-circular canals and trigger hair cells to give orientation

include:

  • Dizziness
  • Unsteadiness/Imbalance
  • Vertigo, Nausea
  • Visual Changes
  • Decreased concentration/memory
  • Muscle fatigue/aches
  • Headaches

Putting It All Together- The Brain Stem

Information from your vision, muscles, tendons, joints, and balance organs in your inner ear are all sent to the brain stem.  The brain stem also gets information from other parts of the brain called the cerebellum and cerebral cortex, mostly about previous experiences that have affected your sense of balance.  Your brain can control balance by using the information that is most important for a particular situation.  For example, in the dark, when the information from your eyes is reduced or might not be accurate, your brain will use more information from your legs and your inner ear. If you are walking on a sandy beach during the day, the information coming from your legs and feet will be less reliable and your brain will use information from your visual and vestibular systems more.  Once your brain stem sorts out all of this information, it sends messages to the eyes and other parts of your body to move in a way that will help you keep your balance and have clear vision while you are moving.

Balance & Fall Prevention Strategies

Fall prevention occurs in two primary ways:

  1. Treating physiological and psychological factors & eliminating offending drugs which contribute to balance impairment.
  2. Modifying the living environment.

Treatment

Physical Therapy provides an individualized treatment plan for balance & fall prevention
Physical Therapy provides an individualized treatment plan for balance & fall prevention

Physical therapy can be a critical component to balance & fall prevention.  A physical therapist can help to determine:

  • Which systems are working correctly and which are not
  • If information from these systems are being “put together” or “integrated” correctly.
  • How to improve these systems to keep your balance
  • Which exercises you can do to improve how your body uses all these systems together.

Environmental Modifications

85% of falls happen at home
85% of falls happen at home

Up to 85% of falls occur in the home and simple home modifications can go a long way in fall prevention.  Most falls occur in the bedroom, bathroom, kitchen and stairs.  Risk factors include: low bed heights, poorly equipped chairs and toilets, low-lying objects or floor coverings, poorly visualized door thresholds, slippery (highly polished) floor surfaces or wet floor surfaces, unsecured rugs, and poorly lit walkways and stairs.

To be effective, environment modification must accommodate balance problems and be aesthetically pleasing.  By watching a person maneuver about his or her living environment, a therapist can determine which areas increase risk.  The therapist will observe the client:

  • Walking over all the different ground surfaces in the environment.
  • Transferring from beds, chairs, toilet, in and out of the bathtub or shower, in and out of the car.
  • Reaching up and bending down to retrieve objects from low and high surfaces
  • Navigating stairs.

Other factors to be evaluated include:

Footwear:  

Footwear that provides stability and a non-skid surface is important for good balance.  Range of motion and/or strength limits often cause difficulty bending down to apply footwear.  Because of this, people often wear loose fitting slippers.  Elastic shoe laces, long-handled shoehorns, reachers, shoes with Velcro fasteners, or orthopedic shoes may be necessary to decrease the risk of falls.

Flooring:

Thick carpets should be replaced with ones made of uncut low pile.  Patterned carpets should be avoided.  Area rugs should have nonskid backings.  Throw rugs should be removed.

Good lighting is important to balance & fall prevention
Good lighting is important to balance & fall prevention

Lighting:

Getting up at night in a darkened bedroom reduces the visual function component of the balance system.  Night lights, leaving a bathroom light on, and using light switch plates that contrast the color of the wall and can be illuminated assist with night visibility.  Persons with cataracts experience difficulty with glare, are sensitive to bright lights, and may suffer further visual impairment if lighting is too bright.  Light sources should be positioned to eliminate glare and shadows.

Good contrast on stair edges are important for balance & fall prevention
Good contrast on stair edges are important for balance & fall prevention

Stairs:

Good lighting is essential in stairways.  Patterned carpets or floor coverings disguise step edges and must be removed.  Step edges can be enhanced by painting or taping the edges in a contrasting color.  Handrail should extend at least 12 inches beyond the end of the stairway and should be a contrasting color to the wall.

Bathrooms:  Toilets

Walkers typically don’t fit in bathrooms because of space limitations and balance is assisted by clutching doorknobs, bare walls, sinks and towel bars.

Grab bars provide necessary support for balance & fall prevention
Grab bars provide necessary support for balance & fall prevention

These structures are either not stable or not designed to support the weight of someone.   Grab bars provide stability and are designed to support a person’s body weight if installed properly.  Toilet grab bars that attach to the toilet allow a person to exert maximum force straight downward with the hands and arms which provides support during transfers.  High-rise toilet seats reduce the amount of leg strength required to lower and raise oneself from the toilet and the amount of forward bending required to maintain control during sit to stand.

Bathrooms:  Showers

Slip resistant bath rugs or mats can help reduce slippage on wet surfaces.  Soaps and shampoos should be placed to avoid reaching overhead or stooping.  Grab bars in the shower or bath provide support during entrance and exit.  Tub transfer benches, tub seats or shower seats along with a flexible handheld shower hose enable bathing to be completed in sitting.

Chair risers compensate for limits in leg strength
Chair risers compensate for limits in leg strength

Bedrooms:

Beds height should not be too high or too low.  Beds should be approximately 18 inches in height, measured from the floor to the top of the mattress.  Bed leg risers can be purchased to increase the height of a bed that is too low.

Mattresses that are too soft make pushing up into sitting difficult.  A firm mattress enables support when pushing up.  Bed rails may be added to a bed to provide extra support.  They must be securely fastened to do so.

Kitchen

Chairs that are low or without armrests are difficult to transfer on and off of.  Chairs should have armrests approximately 7 inches above the seat and extend at least 1 inch beyond the seat edge for maximum leverage.  Avoid cross rails on chair legs, which prevent the person’s legs from sliding underneath the seat to assist in rising.  Chair legs should not slide when leaned on.  Chairs should be stable enough to support a person’s weight when leaned on. Drop-leaf and pedestal-type tables tend to tip over when weight is applied to the edge and should be avoided.

Kitchen carts allow safe transportation of objects
Kitchen carts allow safe transportation of objects

Kitchen carts should can be used for transferring items such as food, utensils, and dishes from one part of the room to the next.  Frequently used items should be arranged to they are located between a person’s hip and eye level to avoid reaching up or bending down.

Keep Active!

Keeping active is one of the most important factors to fall prevention.  By being mindful of factors that put you at risk for falling and taking preventative measures will keep you on the road of independence!

Keeping active is one of the best things you can do for balance & fall prevention