Balance

Balance problems and disorders

Balance is an easy thing to take for granted, especially when you’re young. The complex processes by which you stay upright and move gracefully through space—which involve the brain and spinal cord, inner ear, eyes, peripheral nerves, and muscles and bones—are barely noticeable when functioning properly. But balance problems often begin to appear in a person’s later years. It may start with a feeling that your equilibrium is off and can worsen to the point that a fear of falling limits your everyday activities.

Because so many parts of the body are involved in maintaining balance, balance disorders may arise from a wide range of conditions. Medications can cause dizziness. Small nerve fibers in the feet become less sensitive, which can make people unsteady. Just having a severe cold can cause a temporary disruption of your inner ear balance. But physical changes due to aging are the most common reason for a lack of balance.

Balance issues in elderly people are a serious problem. Every 11 seconds, an older adult receives ER treatment for an injury sustained in a fall, with a fall-related fatality occurring every 19 seconds among the elderly. The vast majority of hip fractures (95%) happen when an older person slips and falls. One of the most pernicious aspects of balance issues in seniors is that, once a person’s balance starts to diminish, they can enter a cycle of deterioration—being unsteady or feeling dizzy makes them refrain from physical activity, which exacerbates the underlying age-related changes that cause the lack of balance. Especially after a fall, some seniors develop a fear of falling that makes them tense up, shuffle when they walk, and restrict movement in a way that actually increases the risk of a fall, especially since they’re focused more on falling than on the task at hand.

What causes balance problems?

Loss of balance can be tied to changes (either temporary or long-term) in different organs and systems of the body.

A key area implicated in balance problems is the inner ear’s vestibular system. Movement of fluid within a series of structures including tiny canals, reservoirs and hairlike cells sends signals to the brain communicating the head’s position. Miniscule grains of calcium carbonate move to apply pressure on the hairlike structures whenever the head tilts, alerting the brain to the body’s movement through space. When these structures are damaged, or when vestibular nerve cells decrease with age, we are more likely to experience dizziness and vertigo.

Eyesight is another important balance-related function, since we need a clear sense of our surroundings to stay on our feet (If you doubt this, try standing on one foot with your eyes closed). When someone develops vision problems, their ability to judge distances and depth of field can lead to their losing balance.

Throughout our muscles, joints and tendons, nerves called proprioceptors tell the brain about subtle changes in conditions that call for adjustments, as when you step onto a patch of ice. With lightning speed, the brain sends instructions for how to react. When our muscles and tendons are weak, stiff or slow, we are less likely to avoid a fall.

While aging can affect any of the above systems, so might prescription medications. Drugs can make you feel sleepy (dulling your reflexes), can cause you to feel dizzy, can make your vision blurry, can alter the fluid in your inner ear, and can introduce damage to nerves. Some common drugs associated with balance problems are antidepressants, antihistamines, blood pressure meds, diabetes drugs, heart medications, painkillers and sedatives. Taking multiple drugs further increases risk of balance-related complications. If you’re worried about falls, be sure to ask your doctor about your medications and balance problems that could arise as side effects.

What is losing balance a symptom of?

While things as simple as ear infection and allergies can disrupt equilibrium, loss of balance may be tied to more serious conditions. For some such illnesses, loss of balance is the primary symptom, but for others it may go largely overlooked thanks to seemingly more urgent issues.

Common Conditions that Can Lead to Balance Problem

• Losing balance is the key symptom of benign paroxysmal positional vertigo (BPPV). The miniscule grains of calcium carbonate that usually weigh on the inner ear’s tiny hairlike structures, sending head-position information to the brain, spill out of their normal position. The brain then receives confusing messages, giving the sensation that the room is spinning.
• Labyrinthitis or vestibular neuronitis happens when the tiny structures of the inner ear or nerve that carries the signals to the brain becomes inflamed.
• Meniere disease causes episodic vertigo, ringing in one ear and hearing loss. It happens when there is excess fluid production in the ear canals, disrupting the delicate balance system.
• Eye problems including diabetic retinopathy, glaucoma, cataracts and age-related macular degeneration can all affect balance.
• Arthritis, because it limits range of motion, can cause unbalanced, asymmetrical movements and poor reactions. In fact, every year, half of all arthritis patients report falling.
• Peripheral neuropathy—nerve damage in the extremities—can cause balance problems due to impaired sensory nerves in the feet and sometimes muscle weakness.
• Orthostatic hypotension, very low blood pressure with standing, can lead to lightheadedness, imbalance and falling. Sudden loss of balance might be the first symptom of a stroke.
• Diseases of the central nervous system, such as Parkinson’s, dementia and multiple sclerosis, can all disrupt balance thanks to their effects on nerves and on the parts of the brain associated with body movements.   

How are balance problems diagnosed?

Balance issues in elderly people are common and can result in severe injury from a fall. Any new balance issues or dizziness should prompt a call to your doctor. He or she will do a physical examination, with special attention paid to taking blood pressure lying and standing, watching you walk, and checking nerve sensitivity in your feet.

Depending upon the results of the physical, the doctor may refer you for further testing. An otolaryngologist or otologist might perform a hearing test to see how responsive the hairlike cells of the inner ear are. Age related changes of the inner-ear structures is a common cause of balance issues in seniors.

How to improve balance.

Although it’s typical for balance to diminish with age, there are things you can do to improve it. As with most aspects of health, diet, exercise and proper hydration can help. Review your medications with your doctor to consider if one of them is contributing to poor balance. Even if you haven’t noticed any vision changes, you should get periodic eye exams.

Many activities can help you maintain—or even improve—balance as you age. For example, yoga can improve your flexibility as well as your ability both to hold your body steady and to perform disciplined movements. Tai Chi, a series of fluid, choreographed movements and poses, increases your balance while building muscle strength and stamina. Pilates exercises build strong core muscles and flexibility, essentials for good posture and balance. Because muscle strength is so crucial, you can build balance with strength training—using free weights, machines, bands or simply your body weight through activities like stair-climbing, walking and cycling. Stretching and core exercises help improve posture and balance.

There are also specifically designed balance exercises for seniors. Stand up/sit downs, heel raises, leg lifts, single-leg stances, back bends, tree poses, side squats and lunges, along with many other movements, can help you regain balance over time. Some balance exercises can even be performed while seated. A personal trainer, physical therapist or other expert in how to improve balance can recommend specific exercises for balance targeted to your fitness level and needs.

What is a balance disorder?

Because proper balance requires the interplay of so many bodily systems, a so-called “balance disorder,” in its broadest sense, might be defined as any condition that disrupts a person’s balance.

Benign Paroxysmal Positional Vertigo (BPPV), Labyrinthitis, and Meniere disease are considered “vestibular disorders” because they are problems stemming directly from dysfunction within the vestibular system, a series of miniscule structures and nerves within the inner ear that send signals to the brain regarding the body’s orientation.

But many other conditions can lead to a balance disorder. For example, peripheral neuropathy, a common complication of diabetes, causes impaired sensation in the feet affects balance. Postural hypotension with associated dizziness can also be categorized a “balance disorder.”

Balance disorder exercises

If you have one of these vestibular disorders, your doctor may refer you to a vestibular rehabilitation therapist who can help you overcome the symptoms of dizziness and loss of balance through specialized exercises. For example, since a hallmark of BPPV is that some of the canaliths have moved to the wrong part of the inner ear, a specialist might guide you through an exercise called the Epley Maneuver. You perform a series of carefully guided head movements while sitting and lying down to move the canaliths back into their proper place. Doctors may also suggest balance retraining therapy exercises (also called vestibular rehabilitation), which might consist of multiple head, eye and body movements designed to restore proper vestibular function.

When should I call the doctor about balance problems?

Although it is natural to notice a decrease in your sense of balance starting in your 50s, you should not consider a severe loss of balance to be an inevitability of old age that you must passively accept. There is much that you and your healthcare practitioners can do to improve your quality of life, avoid falls and extend your longevity.

Talk to your doctor whenever you notice increased dizziness and lightheadedness or vertigo (the feeling that the room is spinning). Your doctor may perform a thorough physical examination (including observations of you walking), review the medications you’re taking to see if there are balance-related side effects to individual meds or to drug combinations, and, depending on the results, may order more balance-specific testing to be done.  

You should always tell your doctor if you’ve fallen, even if you weren’t hurt (Similarly, report any uptick in near-falls). Falling is the leading cause of injury for people aged 65 and older. In fact, for people 85 and older, 147 out of 100,000 falls prove fatal. It’s crucial that you seek help for your balance before experiencing severe consequences of a fall such as bone fractures or head injuries.

Many falls occur during the night when people rise suddenly out of bed to use the bathroom. Moving through a dark room in a half-awake state, having abruptly shifted from a reclined to an upright position, is a recipe for disorientation and loss of balance.

Exercises to help improve balance

Balance exercises for seniors improve flexibility, strength and mobility while challenging the inner ear. Start at a level that’s safe for you. If you want to learn how to improve balance, ask your doctor if you should modify any exercises. Warm up first, and engage your core muscles throughout. Mix these exercises for balance with a regular walking regimen.

Balance exercises for seniors

If you’re very unstable, exercise while seated in a firm chair and proceed to more advanced exercises later. To start building your core, squeeze your shoulder blades together as if holding a tennis ball between them for 10 repetitions. Next, try standing up from the chair and then carefully sitting back down for 10 repetitions (Be sure the chair is stationary). If it’s safe for you to do so, stand behind the chair, grasping its back, as you lift one leg out to the side and lower it to the floor. Change feet. Perform 10 repetitions per side.

Once it’s safe for you to work without a chair, perform one to three sets of 10 heel raises, in which you rise onto your toes, maintaining good posture. Next, while focusing on a spot ahead of you, stand with your feet heel to toe and hold the position for from five to 30 seconds. Switch feet. Practice standing with only one foot on the ground, holding the pose for from five to 30 seconds, and again change feet.

At the advanced level, you might try “braiding,” in which you move laterally while crossing the “active” foot in front of and then behind the other. Move right, then left. Another great exercise is the reverse lunge, in which you step backward onto the ball of your right foot, torso perpendicular to the floor and left thigh parallel to it. Switch legs and do one to three sets of 10 repetitions per side.