An approach to balance problems and falls in elderly persons

Abstract

Gait instability and falls are common in elderly persons and have devastating consequences, with substantial morbidity and mortality.
Furthermore, they are a precipitant for functional decline, increasing frailty and institutionalisation. The rate of falls and severity of
complications increase with age and frailty. A consequence of falls with or without injury is that at least a third of persons develop a fear of
falling, which leads to functional decline and a progressive decline in gait. The causes of falls in elderly persons are multifactorial and include
physiological changes of ageing, frailty, pathologies, and environmental and situational factors. Maintaining postural control requires a
complex integration of sensory input, central processing, motor co-ordination and musculoskeletal function, which decrease with ageing.
This change, combined with sarcopenia, leads to slowed and weakened postural control and muscle responses, resulting in gait instability
and falls.
The assessment and management of a patient who is at risk of falls or who has fallen require a multidisciplinary approach to identify
and address factors contributing to the fall. The assessment, which includes history, physical examination, and evaluation of gait, postural
control and mental function, is aimed at identifying situational and associated factors surrounding a fall, intrinsic impairments in gait or
pathologies that increase the risk of falls. The components of the assessment comprise a full medical evaluation for pathologies, including
vision, medication review (including over-the-counter medication) with regard to polypharmacy and high-risk medications, psychogeriatric
review, functional status (instrumental activities of daily living (IADLs) and activities of daily living (ADLs)), functional assessment of gait
and balance, and assessment of environmental hazards in the home. Laboratory investigations are guided by clinical suspicions or diagnoses
arising from the medical assessment and screening for common conditions that may increase the risk of falls.
Management and prevention of falls focus on maintaining mobility and balance, and identifying those at risk of a fall for multidisciplinary
assessment and intervention. Intervention to reduce the risk of subsequent falls is targeted at modification of the contributory factors.
Intervention includes management of underlying pathologies, strength and balance training by a physiotherapist, assessment and
modification of environmental hazards in the home by an occupational therapist, medication review and rationalisation of high-risk
medications and polypharmacy, and supplementation of vitamin D where indicated.