Do you often feel unsteady, as if you constantly need to grab onto something to keep from falling?
If you do, you may be balanced challenged, but you’re far from alone.
Balance issues are widespread among older people in the United States. While a problem may seem to develop suddenly, balance is a complex task that involves many parts of your body and brain.
Understanding balance disorders, how balance works, and what you can do to keep or improve your balance is more important than you might think.
How Does Balance Work?
Balance refers to your ability to keep your weight over your base of support—typically your feet if you are standing. Proper balance helps you stay oriented to where you are in space with respect to gravity.
Many body systems work together to make up your sense of balance, including your visual, vestibular, and somatosensory systems.
It’s no surprise that seeing is essential to your balance. Your brain uses your vision to collect information about the position of your head and body with respect to the things and environment around you.
Your vision is also helpful for depth perception, like knowing how far away a step is when going down the stairs.
Your vestibular system lives within the inner ear. It provides vital information to the brain regarding the position of your head. This fluid-filled system works almost like a carpenter’s level you might find at a hardware store. When leaning or turning your head to one side, the inner ear fluid will shift, letting your brain know how to adjust to keep from toppling over.
This system is also important for sensing acceleration and deceleration and knowing when movement changes. These fluid movements cause neurons (nerve cells) to send messages to the brain. Your brain then responds with certain reflexes and responses to help you stay upright.
The somatosensory system consists of many neurons connecting the brain and body regarding sensation. This includes the sensations of touch, pressure, temperature, and body position. Nerves are located in the skin, muscles, and joints to sense movement and angles to tell the brain where you are in space and even what type of surface you are on (soft, firm, sloped, etc.).
Balance combines these systems to give the brain a conclusive overview of where you are, your posture, and what the environment around you is like.
As a result, this information allows your reflexes to help you maintain—or correct—your posture.
The body uses a few basic strategies when you lose your balance to help you recover. These range from minor adjustments (usually only noticed if you pay close attention) to more significant and apparent movements.
The most basic responses include ankle, hip, and stepping reactions.
Ankle strategies are typically the first line of defense for minor adjustments necessary to maintain balance. For example, when you step onto a ramp and your ankles bend to accommodate the change in surface.
The hips are utilized when more significant adjustments are necessary to recover your balance. Typically, your hips and torso will move in opposite directions to keep your weight centered over your feet.
This is the final strategy used to help keep you from falling when you are off balance. For example, if something has bumped into you, knocking you off balance, you will instinctively take a step to try to catch yourself.
Factors That Affect Your Balance
Many things can affect the accuracy and efficiency of your balance, including muscle weakness, vision changes, chronic medical conditions, medication or substance use, and inner ear (vestibular) problems.
Multiple factors mentioned above may play a role for older adults. Many of these things are also part of the normal aging process. In contrast, others are exacerbated by personal factors like illness, injury, or lifestyle. (1)
Many medications have associated side effects that can affect your balance, such as blurred vision, dizziness/lightheadedness, drowsiness, or impaired judgment/alertness.
Some medications are more likely to cause balance issues, including drugs that treat depression, anxiety, blood pressure, heart problems, diabetes, sleep problems, and pain. (2)
Medications may also interact with each other, leading to more dramatic side effects. Generally, the more drugs you take, the higher the chance of having adverse reactions.
Roughly two-thirds of people 65+ years old take at least three prescription medications, and 39% of those 65+ take more than five. (2)
Let your doctor know if you have noticed some of these prescription-related side effects. It is important to regularly discuss all the medications you are taking and try to limit it to only what is necessary to avoid potential side effects.
Chronic medical conditions can also affect your balance, including diabetes, heart disease, stroke, and vision problems.
Diabetes can have a wide range of effects on the body, including damaging blood vessels and nerves when not adequately managed.
Diabetic neuropathy is common, resulting in decreased sensation and/or numbness of the legs, feet, and hands. This will limit your body’s ability to use the somatosensory system (see above) to help maintain balance. Diabetes can also affect your vision. (3)
Similarly, heart disease and similar conditions such as high blood pressure and heart failure also affect your blood vessels.
Since the vestibular system (inner ear, balance organ) is limited in the number of blood vessels supplying blood flow, it can be especially susceptible to loss of blood flow from these conditions, leading to balance problems.
Both heart disease and uncontrolled high blood pressure can put you at higher risk of stroke.
Strokes are most commonly caused by a loss of blood flow to an area of the brain, typically caused by a blood clot. Symptoms following a stroke can vary widely based on the stroke’s location and severity. (3)
Physical Health and Mobility:
Your physical health will also play a significant role in your balance. Strength, flexibility, endurance, and pain affect how well you move and respond to your environment.
Overall, muscle mass naturally decreases as part of the aging process. In addition, many older adults are less active than their younger selves due to fewer responsibilities (work), pain, other chronic health conditions, and various other reasons.
This decrease results in a further reduction of strength and endurance. Muscle weakness and poor endurance can lead to increased difficulty with basic tasks like climbing stairs, walking, or squatting.
Pain also plays a role in balance, especially when there is a pain in the legs or feet. As mentioned above, pain can lead to decreased activity and weakness, but it can also change how you move.
For example, if you have pain on one side, you may change how you walk to put less pressure on the painful joint. This change in mechanics leads to a shift in your center of mass, making you less stable.
Inner Ear Issues (Vestibular Issues):
The inner ear, known as the vestibular system, tells your brain where your head is in space.
In normal aging, changes in the vestibular system anatomy include loss of hair cells, nerve function, and changes to the tiny calcium carbonate crystals (otoconia) and the fluid composition inside the ear.
The loss of hair and nerve cells makes it more challenging for the brain to get accurate information about your head position, which can lead to dizziness or imbalance, especially with faster movements.
Otoconia are crystal-like substances that sit on top of hair cells within the inner ear that sense changes in a position related to gravity. Otoconia can fall loose but usually will dissolve in the fluid that makes up the inner ear.
With aging, however, you can have degeneration of the otoconia and changes to the fluid in the ear, leading to increased difficulty with the dissolving process. If these particles do not dissolve as quickly as they should, they can migrate to other areas of the vestibular system.
This involuntary migration can make you feel dizzy, and often results in an unpleasant spinning sensation known as vertigo. (4)
Consequences of Poor Balance
Balance problems can become dangerous due to the risk of falling. Falls can drastically affect your health and life, especially as you age. Falls can lead broken bones or other injuries. They account for 50% of all accidental deaths among the elderly. (4)
According to the CDC, more than one in four people over 65 falls one or more times annually. Of these events, around 20% result in serious injuries such as a broken bone or a head injury. A fracture to the hip is one of the more common injuries, with 95% of hip fractures being due to a fall. (5)
Furthermore, having a prior fall or imbalance generally creates a fear of falling. When people fear falling, they typically change how and how much they move. As mentioned above, inactivity can increase muscle weakness and put you at a higher risk of falls.
Signs You Should Seek Help For Your Balance:
Symptoms of balance disorders can vary between people. If you are experiencing any (or several) of the below sensations, it may be time to seek help for your balance. (6)
Changes in your walking: shorter steps, shuffling of your feet, wider stance.
Constantly reaching for support when walking in your home
Feeling dizzy, lightheadedness, or room-spinning sensation
Difficulty with depth perception
Changes in your vision or blurring vision
Stumbling when walking
Prior falls or feeling fearful of falling
You can do many things to help your balance and reduce your risk of falls. First and foremost, follow up with your doctor about your medications and potential side effects or drug interactions.
Review your medications regularly with your doctor and pay close attention to side effects if you have recently started a new medication.
If you are newly experiencing or experiencing worsening balance difficulties or dizziness, further follow-up may be required to determine the cause of your symptoms. In some cases, this may require testing
Tests will often include, but are not limited to the following:
Imaging of the brain to look for certain underlying conditions
EMGs to look at nerve function
Evaluation by an otolaryngologist (doctor specializing in the inner ear)
A hearing test with an audiologist
General balance screens
Generally, for balance problems, it is recommended to schedule an appointment with a physical therapist as well. Physical therapists are trained professionals skilled at evaluating and treating the specific issues causing your balance problems.
This may include an evaluation for using an assistive device (cane, walker, etc.), strength training, stretching, walking training, and other balance exercises.
For dizziness symptoms, look for a vestibular-trained physical therapist (or simply a vestibular therapist) to allow for a more in-depth assessment of the inner ear. They will also be able to provide specific exercises targeted at retraining the inner ear and fixing vertigo symptoms from dislodged otoconia.
It is essential to stay active to maintain stability throughout the aging process. You may not be currently experiencing significant issues with your balance. In that case, it can be worth looking into group fitness or balance classes to help you maintain and improve your fitness level to stay ahead of balance issues.
Many group exercise classes exist as well that focus both on general fitness and balance specifically. This includes yoga, Tai Chi, strengthening, stretching, and cardio classes.
Of course, finding a class that matches your current fitness level and one that you enjoy is also important in order to keep you engaged and interested.
Since muscle loss is part of the natural aging process, continuing strength training throughout life is necessary. Strength training is one of the most effective ways to reduce the risk of falls, especially by strengthening the legs. (1)
Finally, there are many things you can do at home to help reduce your risk of falls. Several hazards in the home can be easily changed to make your home safer.
First, try to reduce any clutter or tripping hazards on your floor. This may require help from a family member if you have a lot of things put away that you have a hard time lifting.
Throw rugs are also considered a significant tripping hazard due to the increased height to step over and the risk of them slipping or folding over. It is best to remove any unnecessary throw rugs in your home.
Next, be sure there is always a light on or an easily accessible light source at night when it is dark. We use our vision heavily to help us balance, so walking through a dark house can be a serious concern if you struggle with balance. For example, if you get up to go to the bathroom in the middle of the night, be sure you have a light to help lead the way.
Balance is complex, and various factors, including medications, medical conditions, and overall physical health, can influence your balance.
Balance also involves several body systems, many of which can be trained or maintained to reduce the risk of falls or other common problems.
While some balance issues arise naturally as we age, regular exercise, maintaining a healthy diet, and practicing balance skills are all helpful to keep you strong and stable.
Talk to your doctor or physical therapist about how to address balance disorders so you can keep living your best life with confidence on your feet!
Ishigaki, E. Y., Ramos, L. G., Carvalho, E. S., & Lunardi, A. C. (2014). Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Brazilian journal of physical therapy, 18(2), 111–118. https://doi.org/10.1590/s1413-35552012005000148
Harvard Health Publishing. How medications can affect your balance. March 11, 2019. https://www.health.harvard.edu/staying-healthy/how-medications-can-affect-your-balance
Temple Health. How do chronic conditions affect the balance system? September 16. 2016. https://www.templehealth.org/about/blog/how-do-chronic-conditions-affect-balance-system-part-1
Arshad, Q., & Seemungal, B. M. (2016). Age-Related Vestibular Loss: Current Understanding and Future Research Directions. Frontiers in neurology, 7, 231. https://doi.org/10.3389/fneur.2016.00231
Centers for Disease Control and Prevention. Facts About Falls. https://www.cdc.gov/falls/facts.html
National Institute on Deafness and Other Communication Disorders. Balance Disorders. December 2017. https://www.nidcd.nih.gov/health/balance-disorders