Balance and Fall Prevention: Strategies for Intervention

Balance and fall prevention strategies are important not only for older adults, but for everyone.  According to the  Center for Disease Control the number of fall deaths in people younger than 65 has increased 20%.  And for people 65 and older, the numbers are even higher:

• 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 serious and even fatal consequences, fall prevention strategies are important.  The good news is there are easy and simple steps you can take to prevent falls.  But first, let’s talk about the components of balance.

• 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 and Fall Prevention:  The Visual System

Components of vision that affect balance include visual acuity, depth perception, and contrast sensetivity.

Visual Acuity is the clarity or sharpness of vision.  Cataracts are the most common cause of visual acuity loss in people over age 40 and cataract surgery dramatically decreases the number of falls due to poor vision.  People who had cataract surgery on one eye had a 78% decrease in the risk of falls the year after surgery.   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 people who reported dizziness dropped from 52 percent to 38 percent 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 switching to multi-focal lenses.  In fact, all people who wear multi-focal lenses, not just people who have cataract surgery, have been shown to have increased fall rates.

Depth perception is your ability to see objects in three dimensions, including their size and how far away they are from you.  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 is the ability to distinguish between an object and the background behind it. 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 and Fall Prevention:  The Sensory-Motor System

The sensory-motor system is the loop in which sensory information is sent to the brain through the sensory nerves when they are stimulated by touch, vision, hearing and position in space.  The brain interpretes that information and sends information through the motor nerves to the muscles that directs how they react.

One aspect of sensation is proprioception - the ability to know where we are in space.   It is what lets you know where your feet are and approximately what direction they are pointed when you are sitting at a desk, even though you can't see them.  As we age, proprioception decreases.  And when proprioception begins to fail, we may misjudge or misstep.  That misjudgment could result in a dangerous fall. 

The motor aspect of the sensory-motor system relies on good flexibility and strength.  Muscle weakness, especially in the legs, is one of the most important risk factors for falls. People with weak muscles are more likely to fall than are those who maintain their muscle strength, as well as their flexibility and endurance.

Balance and Fall Prevention:  The Vestibular System

The vestibular system tells the brain where the head and body are orientated in comparison to gravity.  It is comprised of 3 semicircular canals, 5 sensory organs, Hair cells.  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 eight cranial nerve - the vestibular nerve.  If the vestibular system is not working correctly, symptoms can 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 and Fall Prevention:  Who Falls?

Multiple studies have compared those who fall to those who do not fall.  From these studies, risk factors for increased risk of fall include:

• 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 people over 65 years of age: 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.  In people 80 years and older, vision, hearing impairments and loss of feeling in the feet increases by 40-50% compared with persons aged 70-79 years. 

So what are some balance and fall prevention stratagies you can use?  Although some of the factors that contribute to falls are out of your control, the first step is to manage areas you can control. Fall prevention occurs in two primary ways:

1. Treatment of medical and psychological factors 
2. Modifying the living environment

Balance and Fall Prevention:  Treatment Stratagies

Stay Strong and Flexibile: Regular physical activity helps everything!  It helps cognition and mental health.  It helps bone strength and digestive function.  It protects against cancer and other medical maladies. And it helps preserve proprioception and prevent age-related decline in proprioception. For many, joining and exercise class or continuing their work-out routine at does the trick.  For others, you may need help from physical therapy. Your 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.

Your program may include specific balance training, targeted strength training, pain management or treatment for neuropathy.  Your therapist will work with you to develop an individualized treatment program to help you re-gain the strength you need to reduce your risk of falls.  

Balance and Fall Prevention:  Environmental Modifications

Did you know that 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.  And this is one of the areas occupational therapists specialize in.  By watching a person maneuver about his or her living environment, your therapist can determine which areas increase your 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 your therapist will help you evaluate include:

Footwear:  Your therapist will help you choose shoes that provides stability and a non-skid surface.  This is important for good balance.  Sometimes limits in range of motion and/or strength cause difficulty bending down to apply footwear.  Because of this, people often wear loose fitting slippers.  Your therapist will help you identify adaptive equipment such as elastic shoe laces, long-handled shoehorns, reachers, shoes with Velcro fasteners, or orthopedic shoes to help you reduce your risk of falls.

Flooring:  It is easy to catch your feet or mobility device on thick carpets or throw rugs and loose your balance.  Remove them or replace them with hard flooring or carpet with uncut low pile.  Be mindful of patterned carpets - some can throw off your depth perception and should be avoided.  Area rugs should have nonskid backings.  

Lighting and Contrast:

Good lighting is important to balance and fall prevention.  At night, having to get up in a darkened bedroom reduces the visual component of the balance system.  So leave a bathroom light on or use a night light in darkened areas to improve your ability to see.  Try using light switch plates that contrast the color of the wall to improve your ability to turn on a light quickly.  If you have difficulty with glare or are sensitive to bright lights, make sure your lighting is bright enough but not too bright.  And position light sources to eliminate glare and shadows. Good contrast on stair edges are important for balance & fall prevention.  Patterned carpets on stairs can disguise step edges and must be avoided.  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:  

Grab Bars:  Because most bathrooms have a limited amount of space, walkers typically don't fit in bathrooms.  People often hand onto doorknobs, bare walls, sinks and towel bars to help keep their balance.  But these structures are either not stable or not designed to support someone's weight.   Grab bars provide stability and are designed to support a person's body weight if installed properly.  

Toilets:  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.

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.

Furniture:

Chairs that are low or without armrests are difficult to transfer on and off of. So a seat height between 17 - 19 inches is ideal. Furniture risers can be placed on the legs of chairs or beds to increase floor to seat height.  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, because they 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.

Tables:  Drop-leaf and pedestal-type tables tend to tip over when weight is applied to the edge and should be avoided.

Beds:  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.

Carts:

Rolling carts 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