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Health & Exercise Forum

CAUSES OF LOSS OF BALANCE: 1st of 3 Columns on Balance Disorders and Falls Prevention

Mar 8, 2009

Dr. Mackarey's Health & Exercise ForumGuest Columnist: Janet M. Caputo, PT, OCS

Contributors: Dr. Louis DeGennaro & Dr. Mark Frattali, Dr. Seth Jones

Northeastern Pennsylvania is home to a large elderly population. Therefore, in the medical community many of the problems we expect to see are age related. Dedicated medical practitioners are in constant search for new knowledge and information to prevent or delay many age related problems. One of the most devastating problems associated with aging is falling. My associate Janet Caputo and I have been involved in case presentations and discussions with Dr. Louis DeGennaro and Dr. Mark Frattali, two local ENT physicians and Dr. Seth Jones, a local neurologist, who treat patients with balance disorders on a regular basis. Dr. DeGennaro and I recently attended a 5-day conference on vestibular disorders at the Cleveland Clinic in Ohio. It will be the purpose of this series of three columns to educated local residents about the risks, causes, treatment and prevention of balance disorders and falls prevention.

Loss of balance causes falls. Falls are a leading cause of injury and death. Thirty percent of women and thirteen percent of men over the age of sixty-five will fall. Twenty to thirty percent of these individuals suffer moderate to severe injuries.
Preventing falls is not an easy task. A good understanding of the causes of loss of balance and knowledge of a few fall prevention suggestions can enhance your balance and reduce your risk of a fall.

The causes of loss of balance which may lead to a fall are divided into three categories: age related changes, medical conditions and medications.

Age Related Changes affecting the sensory system, the musculoskeletal system as well as psychological behavior can negatively impact balance causing a fall:

  • Sensory factors that impact balance are maintained through combined sensory input from the eyes, the joints and the inner ear. Sensory deprivation decreases balance and increases fall risk. Visual changes with aging include a decrease in visual acuity, visual field and depth perception. Decreased joint position sense, (joint proprioception) especially in the legs, leads to increased sway and reliance on vision, which is already impaired. Decreased input from the inner ear (vestibular system) negatively impacts eye stability and head orientation.
  • Musculoskeletal factors with aging can cause unsteadiness during walking: deceased leg muscle strength especially quadriceps, arthritis in low back/hips/knees resulting in leg pain, stooped posture and leg length discrepancies.
  • Psychological factors can also interfere with balance. Fear of falling increases with age. Denial of frailty leads to poor judgment when performing certain tasks. Anxiety and depression not only decreases attention and awareness of environment but may also cause poor sleep leading to drowsiness during the day.

Medical Conditions can also cause loss of balance increasing the risk of a fall:

  • Cardiovascular conditions may cause loss of balance due to dizziness or lightheadedness caused by a sudden change in blood pressure. These include: abnormal heart rhythm, heart attack and heart failure. Orthostatic hypotension is an excessive fall in blood pressure on assuming the upright position (quickly standing up after lying down). Syncope (fainting) is a sudden brief loss of consciousness due to decreased blood flow to the brain. Vertebral artery insufficiency occurs from leaning head back too far compromising arterial blood flow to the brain causing dizziness.
  • Neurologic conditions  can negatively affect sensory input (visual, vestibular and joint proprioception) and motor (muscular) responses and result in loss of balance. These include: multiple sclerosis, epilepsy (seizures), brain tumor, stroke, Parkinson’s disease, peripheral neuropathy, cerebellar degeneration and head trauma.
  • Cognitive conditions contribute to loss of balance because of poor judgment and behavioral problems (e.g. dementia and Alzheimer’s disease).
  • Vestibular conditions cause vertigo (sensation that the room is spinning or moving) resulting in loss of balance. Benign Paroxysmal Positional Vertigo (BPPV) is caused by a change in the position of the head when debris is lodged in a symptomatic part of the inner ear. Labyrinthitis is a viral infection of the inner ear following a cold or flu. Meniere’s disease is a common inner ear problem resulting in vertigo and ringing in the ears.
  • Genitourinary conditions can contribute to loss of balance. For example, individuals with bladder control problems (incontinence) use poor judgment by moving quickly, especially at night, to prevent an “accident”.
  • Endocrine conditions can produce dizziness causing loss of balance.  Hypoglycemia (low blood sugar associated with diabetes) causes dizziness.
  • Gastrointestinal conditions may lead to loss of balance. During defecation syncope, fainting is caused by a decrease in arterial pressure when bearing down to assist a bowel movement. Any condition resulting in dehydration (diarrhea/vomiting), decreases blood volume which may cause lightheadedness and loss of balance

Medications can also negatively effect balance and increase the risk of falls. Interactions between medications as well as the side effects of certain medications can cause dizziness or drowsiness resulting in loss of balance. Theses medications include: tranquilizers, sedatives, anti-depressants, alcohol, diuretics, blood pressure medications, cardiac medications, laxatives and pain killers.

In conclusion, determining who is at risk for a fall is a complex task since many factors including age, disease and medication can affect the outcome. Early intervention to prevent a fall can avoid many costly consequences.