Balance Disorders in Aging

By: Sean Lennox

The trend in demographics that should lead to an overall concern for the American healthcare system is the tremendous growth of people over the age of 65 years. Konrad, Girardi, and Helfert, (1999) reported that there would be almost 40 million adults over the age of 65 by 2010 in the United States. Balance disorders and disorders that lead to instability become more prevalent with age (Salzman, 2010; Sloane, Baloh, and Honrubi, 1989). The three sensory modalities responsible for normal balance and steadiness: vision, vestibular, and proprioception, can become compromised as a result of normal age related changes as well as age-related disease or pathology leading to increased risk of falls and fall related injury (Alvord, 2008; Cronin and Steenerson, 2011; Konrad et al, 1999; Salzman, 2010). The elderly fall more often and with greater consequence as a result of balance and instability issues leading to huge personal costs as well as sky-rocketing health care costs (Alvord, 2008). Over the age of 65, 1 in every 3 adults will suffer from a fall (Sturnieks, George, Lord, 2008), and given the explosion in the number people living today over 65 years of age, falls are a major healthcare crisis (Konrad et al, 1999).  The US National Institutes of Health (Senior Health), (2011) reported 1.6 million emergency room visits as a result of falls. The elderly are less likely to fully recover from a fall, and falls have been linked to increase risk of death especially for individuals over 85 (Cronin and Steenerson, 2011; USNIH, 2011). 

Authors have cautioned clinicians that gait and balance concerns should not be considered just a normal part of aging, as a large proportion of balance complaints occur in conjunction with some known disease process or a composition of different pathologies (Alvord, 2008; Salzman, 2010; Sloane, Baloh, and Honrubi, 1989). However, symmetric vestibular sensory hair cell loss, declining visual acuity, and declining muscular strength and mobility are some examples of known age-related changes to a human’s balance system (Alvord, 2008). These normal age-related declines in function may cause worsening stability and sensory integration during locomotion (Sloane et al, 1989; Sturnieks et al, 2008).  

Many musculoskeletal, cardiovascular, and neurologic disorders are associated with advancing age while also having detrimental effects on gait and balance (Salzman, 2010; Sturnieks et al, 2008). Some common age related pathologies that affect balance, postural stability and gait include: arthritis, orthostatic hypotension, vitamin B-12 deficiency, diabetes mellitus, vestibular disorders such as Benign paroxysmal positional vertigo (BPPV) and vertebrobasilar insufficiency (Konrad, Girardi, and Helfert. 1999). Cardiovascular disease such as atherosclerosis which is highly associated with increased age has a degenerative effect on vision structures, inner ear structures, and the peripheral musculature and nerve tissues which encompass the balance system, and can lead to hemorrhaging and stroke in the brain (Konrad et al, 1999). Orthostatic hypotension has been cited as a major cause of falls in the elderly (Cronin and Steenerson, 2011; Sloane et al, 1989). The patient typically reports severe lightheadedness and presyncope upon rising from lying or sitting down (Jacobson and McCaslin, 2008). Causes of hypotension include cardiovascular disease, poly-pharmacy, and dose related issues for medications to control hypertension (Salzman, 2010). 

Arthritis, vitamin B-12 deficiency, and diabetes mellitus can lead to poor peripheral sensory control of limbs leading to poor gait and postural instability (Salzman, 2010). For arthritis, pain and inflammation of joints make quick movements needed to brace for falls more difficult and overall physical activity becomes difficult leading to physical muscular and skeletal attrition (Konrad et al, 1999). Joint pain has been cited as the most likely contributor to poor gait (Salzman, 2010). Vitamin B-12 deficiency as its name implies is a syndrome that forms as a result of a lack the essential vitamin B-12 adsorption. Vitamin B-12 is involved in immunological responses, and central and peripheral nervous system maintenance and repair (Stabler et al, 1997). The deficiency of vitamin B-12 can cause significant degeneration of the central nervous system and the peripheral and spinal nerves causing balance problems of poor gait and postural stability because of the paresthesia of the extremities as well as the joints (Oh and Brown, 2005). Diabetes mellitus leads to sensory neuropathy for vision and peripheral sensory function in the extremities, leading to an increased risk for tripping over objects and loss of balance on vibrating or slippery surfaces (Konrad et al, 1999; Salzman , 2010). 

Benign paroxysmal positional vertigo (BBPV) is a vestibular impairment that is common as people age, and has been identified as another major cause of falls in the elderly (Cronin and Steenerson, 2011; Konrad et al, 1999; Sturnieks et al, 2008). BPPV is caused physiologically by misplaced otoconia in the semicircular canal as a result of simple age related changes to the semicircular canal, or commonly head trauma (Cronin and Steenerson, 2011). The misplaced otoconia cause transient vertigo when the patient looks up, bends over, or turns in bed.  This momentary vertigo can cause the patient to lose stability and fall. 

Vision is an essential sensory modality for balance as this sense allows a person to avoid obstacles and properly move around in space (Sturnieks et al, 2008). Physiologic deterioration to the eye and eye musculature, as well as vision disorders such as macular degeneration, cataracts, and glaucoma become more common with age, leading to poorer mobility, and identification of objects that could cause falls (Sturnieks et al, 2008).  Sturnieks et al, (2008) recommends the correction of visual deficits as part of falls prevention for the elderly. 

According to the American Academy of Audiology, an Audiologist should be able to properly identify, assess, diagnose, manage, and help in the prevention of balance disorders for all patients, and no other group will need these services more than those over 65 years (Jacobson and McCaslin, 2008). The steps needed to prepare for this increased demand for balance services by the over 65 population include:  improved diagnostic skills training, better inter-professional collaboration, proper and timely referral, improved falls prevention, and evidence based treatment strategies. 

To increase proficiency in balance disorder and falls prevention diagnostics, university Audiology programs will need to be expand and improve balance coursework and practicums to help future Audiologists diagnose patients with balance complaints. As diagnostic protocols are developed for falls prevention clinics, Audiologists will need to become active leaders in forming clinical test batteries. The next step is for Audiologists to become part of a team approach in diagnosing and treating balance disorders. Inter-professional communication and referral will need to be set-up between Audiologists, ENT doctors, physiotherapists, neurologists, internal medicine physicians, and occupational therapists to provide the highest level of patient care in the fall clinic settings (Alvord, 2008; Jacobson and McCaslin, 2008). 

Proper referral to other professionals will only be possible if Audiologists become cognizant of the multitude of pathologies that may be associated with balance and dizziness symptoms which lead to falls, as well as normal age related changes to vision, muscular strength and mobility, and vestibular function (Salzman, 2010).  An Audiologist’s caseload, even in a private practice hearing aid clinic, includes people predominantly over 65 years of age. As such, private practice “hearing focused” Audiologists should have some idea of when a diagnostic balance assessment is necessary, and when there is a risk of falling present, so proper referral to a falls clinic can be made. 

Prevention of future falls as a result of balance disorders should be a high priority to all audiologists (Alvord, 2008; Jacobson and McCaslin, 2008). This means that any patient at risk for a fall based on a balance disorder complaints, or patients who have reported a fall in the past should be referred to a falls prevention program and home safety assessment (Alvord, 2008; Salzman, 2010). 

In some circumstances, audiologists may also be needed to conduct vestibular rehabilitation therapies (VRT) or be able to recommend exercises to do at home. Audiologists can be involved in coordinating home-based VRT, group VRT, and simple exercise programs which have been shown to be effective for the elderly (Cronin and Steenerson, 2011; Konrad et al, 1999; Sturnieks et al, 2008).  Canalith repositioning maneuvers are also within the scope of practice for Audiologists for patients with BPPV (Alvord, 2008). 



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