TH Balance and Aging - Vestibular Disorders Association

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Balance and Aging

By Charlotte Shupert, PhD, with contributions by Fay Horak, PhD, PT Oregon Health & Science
University, Portland, Oregon

One of the leading health concerns for in the feet and legs; and degeneration of
people over the age of 60 is falling, which the vestibular system.
is often related to balance problems. The
percent of people falling increases from Balance is also dependent on muscle
40% to 65% to 82% with each decade strength, joint mobility, and healthy feet.
after age 65 years. A sedentary lifestyle, painful arthritis or
diseases of bones and muscles can
The consequences of falls can be compromise strength, mobility, and the
disastrous; between 12% and 67% of base of foot support.
elderly adults who fracture a hip die Balance control also depends on healthy
within one year. Even if a bone is not brain function across many brain areas.
fractured during a fall, falls cause pain The brain needs to process and interpret
and injury while reducing future mobility sensory information, select appropriate
and quality of life. As a result, major balance strategies, and adapt and learn
scientific efforts are devoted to deter- new strategies with practice. As we age,
mining the causes of falling in older adults brain processing can slow down, which
in an attempt to reduce this significant results in slower balance responses.
health hazard. People with cognitive problems also have
balance problems, showing the
Causes of imbalance in older people importance of higher level brain
Balance in walking and standing is processing in balance control.
dependent on many factors. Good
balance requires reliable sensory input Because balance is a complex function,
from the individual’s vision, vestibular there is often no single identifiable cause
system (the balance system of the inner of falls in an elderly person. However,
ear), and proprioceptors (sensors of older people with chronic dizziness or
position and movement in the feet and imbalance are two to three times more
legs). The elderly are prone to a variety likely to fall in comparison with older
of diseases that affect these systems, people who do not experience these
including cataracts, glaucoma, diabetic problems.1 Table 1 summarizes the
retinopathy, and macular degeneration, factors that increase risk of falls in
which all affect vision; peripheral seniors listed in order of highest risk.
neuropathy, which impairs proprioception Experiencing a previous fall in the last

© Vestibular Disorders Association ◦ vestibular.org ◦ Page 1 of 6

year is the highest risk factor for a future multiple problems are present. In such
fall. cases, the trouble in any one system may
not be severe, but the combined effects
Risk-Factors for Falls Risk may be enough to cause a serious
Fell in past year 5X problem with balance. For example, an
Weakness 4.4x elderly individual with age-related, mild
Peripheral Neuropathy 3.0 degeneration in vestibular function may
Balance 2.9 not complain of dizziness until they
Slow Gait 2.9 develop postural hypotension, or light-
Cane 2.6 headiness when quickly moving from sit
Vision 2.5 to stand due to a new medication, low
Arthritis 2.4 blood pressure or a cardiovascular
ADL Deficit 2.3 problem. In fact, slow, age-related loss
Depression 2.2 of vestibular function is usually not
Cognitive decline 1.8 associated with dizziness, although it is
Ages >80 1.7 associated with imbalance and falls.
> 5 medications 1.7 However, peripheral neuropathy resulting
in poor position sense in the feet and
Dizziness legs, results in more severe balance
Symptoms of a sense of lightheadedness problems and falls than vestibular
or disorientation (dizziness) and/or a mild problems, although a combination of both
to violent spinning sensation (vertigo) vestibular and proprioceptive deficits can
can have a variety of causes: vestibular be devastating to balance control.
(inner ear) disorders, central nervous
system disorders (such as stroke), The aging vestibular system
cardiovascular problems (including low or Most people are familiar with the
high blood pressure), low blood sugar, problems associated with the aging
infection, hyper-ventilation associated of senses such as vision and hearing.
with anxiety attacks, medication side However, the vestibular system is
effects or interactions between drugs, or another sensory system that often
an inadequate or poorly balanced diet. gradually begins to function poorly with
Dizziness, or an abnormal sense of spatial age, leading to a diminished quality of
orientation, should not be confused with life.
disequilibrium or a sense of imbalance or
unsteadiness. The vestibular system is a complex
A thorough evaluation by a physician is structure of fluid-filled tubes and cham-
usually necessary to help sort out these bers that constitutes part of the inner
different possible causes of dizziness to ear. Specialized nerve endings inside
arrive at a correct diagnosis. This task these structures detect the position and
can be even more complicated when movement of the head and also detect

© Vestibular Disorders Association ◦ vestibular.org ◦ Page 2 of 6

the direction of gravity. The signals sent collected within a part of the inner ear.

from the nerves of the vestibular system This debris, called otoconia, is made up of

are critically important to the brain’s small crystals of calcium carbonate

ability to control balance in standing and (sometimes referred to colloquially as

walking and also to control certain types “ear rocks”). With head movement, the

of reflexive eye movements that make it displaced otoconia shift in the fluid,

possible to see clearly while sending false signals to the

walking or running. A tendency to fall brain and causing dizziness or
and symptoms of vertigo. Usually the vertigo
Anatomical studies have dizziness should associated with BPPV lasts only
shown that the number of not be dismissed a few seconds per episode and
nerve cells in the vestibular is not associated with severe
system decreases from about as unavoidable balance problems.
age 55. Blood flow to the consequences of
inner ear also decreases with aging but may be Symptoms of BPPV are almost
age. Idiopathic bilateral important signs always precipitated by a change
(occurring on both sides) of a disease that in head position. Getting out of

vestibular loss becomes more might be cured bed, looking up and rolling over

severe as age progresses. or controlled. in bed are common motions that

When the vestibular system cause vertigo in patients with

is damaged by any cause, an BPPV. Some people feel dizzy

individual may experience dizziness and and unsteady when they tip their heads

balance problems. However, the gradual, back to look up.

age-related loss of vestibular nerve

endings can result in severe balance Ménière’s disease is another vestibular

problems without any associated disorder that causes dizziness. Ménière’s

dizziness. This type of slow loss of disease produces a recurring set of

vestibular function may be first noticed as symptoms as a result of abnormally large

difficulty walking or standing, especially amounts of a fluid called endolymph

in the dark while on soft or uneven collecting in the inner ear. These

surfaces (such as thick carpet or symptoms typically include spontaneous,

a forest path). violent vertigo, fluctuating hearing loss,

ear fullness, and/or tinnitus.

Specific vestibular disorders in older

adults The incidence of Ménière’s disease

Of all vestibular disorders, benign (number of new cases per year) is

paroxysmal positional vertigo (BPPV) is difficult to assess. Estimates vary widely,

one of the most common in older adults. in part because of the variability in

BPPV causes vertigo, a strong sense of a diagnostic criteria across studies. The

spinning world, due to debris that has prevalence, however (all cases within a

© Vestibular Disorders Association ◦ vestibular.org ◦ Page 3 of 6

population), is generally known to problems before a serious fall. Having a
increase with age. physician and pharmacist work to
minimize the number of medications an
Other vestibular disorders that may occur older person is taking can go a long way
in older adults include vestibular neuritis to reducing potential side-effects and
(inflammation of the vestibular branch of interactions causing dizziness and
the vestibulo-cochlear nerve, resulting in imbalance and has been shown to reduce
dizziness or vertigo but no change in falls. Taking good care of the feet by
hearing) and ototoxicity (exposure to wearing good shoes and maintaining
certain chemicals that damage the inner healthy nails and skin is particularly
ear or the vestibulo-cochlear nerve, which important for good balance. In addition,
sends balance and hearing information making sure that the elderly person’s
from the inner ear to the brain). Some environment is safe (with good lighting,
types of chemotherapy for cancer secure footing, clear walkways, handrails
treatment and high doses of particular and anti-skid devices in bathrooms, etc.)
types of antibiotics can be ototoxic. can help prevent falls and their attendant
Ototoxicity can result in temporary or injuries.
permanent disturbances of hearing,
balance, or both. A tendency to fall and symptoms of
dizziness should never be dismissed as
Precautions unavoidable consequences of aging but
Although the problem of imbalance in may be important signs of a disease that
older persons can be complex, there are might be cured or controlled. The elderly
a few simple precautions that everyone have a higher risk of contracting many
can follow to help ensure an active old different kinds of diseases. As a result,
age. Balance in standing and walking is at the average elderly person is more likely
least partly a skill that older adults can to have a disease that interferes with
learn to maintain and/or improve, and it balance than a younger person. The
is dependent on good general physical vestibular system should not be ruled out
condition. Therefore, sound nutritional as a source of these symptoms.
and health habits—including regular
exercise, such as walking, strength The ability to move about freely is an
training and participating important factor in the quality of life for
in Tai Chi—can go a long way toward both younger and older people, and a
preventing balance trouble. healthy vestibular system is vitally
important to freedom of movement.
In older people, a regular physical
examination by a doctor familiar with the Reference
problems of aging, such as a geriatrician, 1. Ko CW, Hoffman HJ, Sklare DA.
can help identify and correct potential Chronic Imbalance or Dizziness and

© Vestibular Disorders Association ◦ vestibular.org ◦ Page 4 of 6

Falling: Results from the 1994 options, coping tips, and contact informa-
Disability Supplement to the tion for medical specialists may be found
National Health Interview Survey by visiting the Web site of the Vestibular
and the Second Supplement on Disorders Association (VEDA)
Aging Study. Twenty-ninth vestibular.org. In addition to reading
MidWinter Meeting of the information displayed on Web pages,
Association for Research in visitors can download and print many of
Otolaryngology (ARO); National VEDA’s short publications for free.
Institute on Deafness and Other
Communication Disorders (NIDCD). © Vestibular Disorders Association
Feb. 2006.
2. National Institutes on Aging (NIA) VEDA’s publications are protected under
of the NIH website. copyright. For more information, see our

Further reading permissions guide at vestibular.org.
Additional information about vestibular
disorders, diagnosis and treatment This document is not intended as a substitute
for professional health care.

© Vestibular Disorders Association ◦ vestibular.org ◦ Page 5 of 6

5018 NE 15TH AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · VESTIBULAR.ORG

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