This is the first in a series of more technical posts on healthy ageing, in which Dr Kyra Neubauer shares her 30-year experience of working with older people.

Good balance is the secret of human success. An upright posture and the ability to walk on two legs was an important moment in human evolution—freeing up the hands for making and using complex tools, social communication, and other stuff. Anthropologists even credit bipedal locomotion with an important role in the expansion of brain size.

Good balance is also key to healthy ageing. Poor balance affects confidence and mobility, and more importantly, is a major cause of falls in older people. It is estimated that over a third of over 65s and half of over 80s fall each year, with many having multiple falls.

Falls can come with injuries, which can be devastating for the individual and extremely costly for health and social care systems. Each year, about 350,000 Americans fall and break a hip and around 40 percent end up in a nursing home. A quarter of those are never able to walk again. In the UK, fragility fractures from falls cost the NHS approximately 4.4 billion each year. (These are low-impact fractures related to underlying osteoporosis, which we will look at in a later post). In the over 65s this is the leading cause of death from injury. It is estimated that globally nearly 17 million years of life were lost from falls in 2017.

The good news is that there are many strategies to improve balance and prevent falls, including taking the advice of the late UK health guru, Dr Michael Mosely, who advocated standing on one leg while brushing your teeth.

How balance works
Balance is orchestrated by several body systems:

• Vision: The eyes play a central role in balance and preventing falls.
• The inner ear and brain: The vestibular system is part of the nervous system that controls balance. It includes the inner ear, the brainstem and cerebellum (both at the back of the brain) and the nerves that connect the inner ear to the brain.
• Proprioceptive system: This part of the nervous system tells us where our limbs are in space, without us needing to look. It involves nerves in the limbs which connect to the brain.
• Muscles: Muscle strength in the lower body, back and legs is necessary to keep the body stable.
• Cardiovascular system: A healthy heart and blood vessels ensure adequate blood pressure. If blood pressure is too low, it can cause light headedness or fainting.
• Cognition: Our normal thinking processes allow us to assess risk and react when external situations alter.

Balance is at its peak when we are around 30 years old. It declines as we age, when these systems become less effective, or are affected by disease.

Causes of falls

Some of the causes of falls are obvious. Any number of eye diseases can affect vision, dementia can affect the ability to assess risk when walking, damage to the nervous system from conditions such as a stroke or multiple sclerosis can cause weakness and affect balance, etc.

Some other causes of deterioration of our health are less obvious. Many medications can affect balance and blood pressure. For example, blood pressure medications can be too effective, especially as people age, so they may need to be reduced or stopped. Medications which have sedative side effects such as antidepressants, antiepileptics, some antihistamines and sleeping aids may also cause balance issues or affect reaction times. Just taking four or more of any medications increases the risk of falls.

Pain, especially in the lower limbs affects walking, and if this is also combined with any physical changes such as arthritis, it increases the risk of falls.

If a fall is preceded by light headedness, or there is a definite or possible loss of consciousness then tests are needed to rule out diseases like epilepsy or abnormalities in the heart or vascular system.

If falls are associated with vertigo, this is due to an abnormality either in the inner ear, the hind brain or connections in between. A common condition that causes short-lived vertigo is benign paroxysmal positional vertigo (BPPV), a condition involving the inner ear. This can present without symptoms of vertigo and may explain frequent falls. It can easily be treated

Experts have concluded there are at least 400 risk factors for falls. In addition to those mentioned above, these include poor sleep, inappropriate shoes, Vitamin D deficiency, inactivity and not using walking aids when needed. There are also issues related to visual correction—not using glasses when needed; the use of varifocals or bifocals outdoors when walking, which increases risk of tripping.

Alcohol is a serious cause of falls in any age group, but as we age our ability to process alcohol is slower and our brains are more susceptible to its effects.

There is an abundance of scientific studies showing that regular exercise can improve balance and reduce falls. One systematic review examined evidence from 116 studies covering 25,160 older people and concluded that overall, exercise reduced the rate of falls by 23%. Exercises that specifically challenged balance, and involved more than three hours a week practice, were the most effective—potentially reducing falls by 42%. The review also showed the positive effect of exercise in people living with Parkinson’s Disease and cognitive impairment.

 Tai chi and yoga are very effective in improving balance:

• Tai chi: Tai chi is a gentle form of exercise that can be described as movement meditation. It depends on muscular strength, particularly in the legs, and good coordination. The systematic review above showed that tai chi may reduce the rate of falls by 19%, as well as reducing the number of people who experience falls by 20%. Another study compared the rate of falls in two groups, one doing tai chi and the other doing multi-modal exercise (balance, aerobic, strength, flexibility). They found that over six months the tai chi group fall rate was 36% less.
• Yoga: The many different forms of yoga include posture, breathing and sometimes meditation. While the evidence for yoga is less clear than for tai chi, many studies point to promising outcomes. For example, a review of six trials with over 300 older people (over 60 years) showed that yoga had a small effect on improving balance and a medium effect in improving physical mobility. Another study of participants over 65 years showed that a four-week yoga course in a care home led to significant improvements in balance as well as positive changes in the psychosocial aspects of health, such as promoting of calmness and happiness in older men and reducing fatigue, nervousness and depression in older women

There are other activities more targeted to improving balance that can be practiced at home or in the gym. These include Wii balance boards, dance mats and virtual reality systems. The Standing Tall program offers an online falls exercise programme delivered with iPad technology. Gait adaptation training (GAT) has also been shown to be effective. This is training where participants are taught how to make rapid voluntary adjustments in the way they walk, in response to obstacles. 

In the UK some local authorities and gyms offer falls prevention programmes. But for these to be effective they need to be overseen by experts, and participants need to attend at least twice a week for six months. And for lasting benefits they must be maintained once the programme is over.

Falls services
Many hospitals in the UK offer falls services and you should be able to find out from your doctor if there is a local service, and whether you meet their inclusion criteria.

In an ideal service you should have a comprehensive history taken of your falls, including near misses and your risks for falling. They should ask about previous injuries and fractures. In the UK a single fall when you are 65 years or older should entitle you to a falls assessment.

As part of the assessment, the team should look at your mobility and fracture risk factors. They should also ask about medications and the home environment. If there are indications of fracture risk, they should do blood tests. If you have issues with fainting, dizziness or loss of consciousness you will need to be referred for more comprehensive investigations.

If you have a risk of fractures, the falls service should not only offer advice but ideally offer strength and balance classes and refer you for further investigation and management. Hip fracture reduction needs both falls management but also specific lifestyle advice and medications to reduce fracture risk

Research and experience over decades have demonstrated that tailored programmes by healthcare professionals can be highly effective in reducing falls. For example, in the 1990’s Glasgow set up a comprehensive falls and fracture liaison service for the city. This was so successful that between 1998 and 2008 hip fracture rates fell 7.3%, when in the UK as a whole hip fracture rates rose by 17%.

But the problem in most healthcare systems has been to find adequate staff and funding to deliver interventions effectively. And the programmes that exist are not always comprehensive.

In the words of an Age UK 2013 report “Despite… the huge potential these exercise programmes hold in helping to make dramatic improvements in quality of life and achieve significant cost savings, older people continue to have limited access to evidence-based falls prevention programmes. Where these programmes are available, the vast majority are altered or scaled down to an average duration of 12 weeks or less.”

Yet we know that a ‘dose’ of at least 50 hours with three hours per week ongoing exercise is necessary to reduce falls

Do it yourself
The good news is that if you haven’t fallen—or indeed even if you have—there are things you can do now to significantly reduce your risk of falling. In addition to exercise (discussed above), and general health (sleep, diet, alcohol, hydration etc.) strategies include:

• Eyes: Regular eye tests to ensure visual problems are addressed; wearing glasses when needed; using single focus lenses when walking; having cataracts removed.
• Feet: Supportive shoes; seeing a podiatrist for significant foot pain.
• Generalised pain: Painkillers can increase the risk of falls but so does pain to an equal measure, so when used sensibly painkillers are important.
• Medication: Regular medication reviews, including blood pressure checks if you are on medications for high blood pressure or any that might reduce BP.
• Home environment: Good lighting especially on stairs; no trip hazards such as poorly fitted carpets etc. If you have had falls, asking for an occupational therapist to review your home can be very helpful.

The booklet “Get up and Go”, by the Chartered Society of Physiotherapists is a useful and accessible guide on balance and falls.

References

• Ganz DA, Latham NK. Prevention of falls in community-dwelling older adults N Engl J Med 2020;382:734-43
• The National Council on Ageing, Get the facts on falls prevention
• UK government:Falls: applying All Our Health
• UKHSA blog: The human cost of falls.
• James SL, Lucchesi LR, Bisignano C et al The global burden of falls; global, regional and national estimates of morbidity and mortality from the global burden of disease study 2017 Inj Prev 2020;26:i3-11
• Falls in older people, assessing risk and prevention. Clinical guidance, 2013
• Sherrington, C., Fairhall, N., Kwok, W.et al.Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act 17, 144 (2020). 
• Fuzhong L, Harmer P, Fitzgerald K et al Effectiveness of a TherapeuticTai Ji Quan Intervention vs a Multimodal Exercise Intervention to Prevent Falls Among Older Adults at High Risk of Falling A Randomized Clinical Trial JAMA Intern Med.2018;178(10):1301-1310
• Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis 2022 Jun;61(2):85-92
• Krejčí M, Hill M, Kajzar J, Tichy M, Hošek V Yoga Exercise Intervention Improves Balance Control and Prevents Falls in Seniors Aged 65+ Slovenian J Pub Health 2022 Jun; 61(2): 85–92.
• Skelton D, Neil F (2009) NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006-2010: An Evaluation 2007-2009.