Aging and Balance

Like many other skills we take for granted, our upright posture and balance are amazing unappreciated functions.  Imagine balancing a five or six foot top-heavy object on a one foot base and you get a sense of how precarious it is for us to stay upright, no less add movement, twists and turns, leaning and bending.  The epitome of balance complexity for me is a basketball player with a six and one-half to seven foot frame leaping and twisting and still managing to come down upright on the ground.  This is all managed by a series of functions that each instantly take in data about one’s position in space, coordinate inputs with each other and make fine adjustments in the time of an eye blink.  Watching a young child learn to walk demonstrates how much time and practice it takes to master this skill.  They spend years learning to master walking and running, constantly trying, falling and learning to interpret the inputs to their nervous system.

There are at least five functions that are associated with our ability to maintain balance:

The vestibular system is imbedded in the bones of the inner ear and is a labyrinth consisting of the semicircular canals curved at different angles and sacs of fluid.  These detect the tilt and movement of your head when motion causes the thick fluid in the tubules and tiny stones in the sacs to move against sensory hairs.

The proprioceptors, the sensory nerves that send signals from joints, skin and muscle indicating where our limbs are in space.

The visual system, which provides sight evidence of where we are relative to our surroundings.

The muscles, which continuously make the instant fine adjustments that hold us in balance or move us to a new position.

The brain, particularly the cerebellum, which coordinates these various other functions by issuing commands and also retrieves stored memories of skills learned through practice.

Loss or malfunction of any of these systems immediately compromises our ability to stay upright, and, unfortunately, with aging many or all of them begin to function sub-optimally.  Sudden loss of just one function (such as the vestibular system in labrinthitis) is devastating because the brain must deal with inputs that are no longer consistent with the others.

Most people as they move into their seventies have age related balance problems.  Just as the tiny hair cells that are involved with hearing deteriorate with aging, so too do the sensory cells related to balance in the vestibular system.  As these cells die off, one has less accurate perception of the position and movement of the head.  In addition, infections, head injury, problems with circulation and Meniere’s disease are all things that can affect the vestibular system.  Similarly, peripheral nerves involved with proprioception become less sensitive and less helpful in determining where our feet and legs are.  Eyesight is often diminished and muscles weaken.  It is typical to lose 25% of muscle mass and strength by age 70 and 50% by age 90.  Diseases such as Parkinson’s Disease, Multiple Sclerosis, Stroke and abnormal heart rhythm can further impair the balance mechanisms.

The obvious danger with balance impairment is falling.  In people over 65, falls are the most common cause of injury and cause over 90% of hip fractures.  So, obviously, it is worth doing everything possible to improve balance and to prevent falls.  Some of the things that can help prevent falls are the following:

Removing clutter and loose throw rugs from your living and working space and using rugs with a non-skid backing

Installing grab rails in your shower or tub and having banisters on all stairs.

Using a night light in the bedroom and bathroom.

Correcting eyesight with glasses.  If you wear reading glasses, don’t go up and down stairs with them on, because it blurs vision of the stairs.  If you have progressive lenses, they can be made with a distance vision area at the bottom to see where your feet are being placed.

If you take medication that can lower your blood pressure and causes dizziness when you stand, discuss it with your physician to see about a lower dose or an alternative medication.

Wear supportive shoes with non-skid soles.

Do balance exercises that can maintain muscle strength and sense of balance.

Maintain vitamin D levels to support bone strength by taking supplements if necessary.

Exercise is one way to improve balance.  The muscles that stabilize us when we are upright include the so-called core muscles.  These include the abdominal muscles, gluteal (buttock) muscles, hip flexors and the muscles of the thigh. Additionally, the muscles of the calf and feet are important.  Exercises that work and strengthen these areas will help with body control and balance.  Studies have shown a modest effect (13%) of exercise in preventing falls, but speaking from personal experience, it is possible to feel much more stable on your feet as a result of focused exercise.

Any of the following activities can be useful to improving muscle sense and balance.  Exercises such as walking, biking and climbing stairs strengthen the muscles of the legs.  Tai Chi is a slow rhythmic activity that works directly on balance and strengthens muscles at the same time.  The same is true for yoga.  Pilates is particularly good for strengthening core muscles and exercises balance as well.  The ideal for those who can afford it is to work with a personal trainer who can design exercises that address one’s particular needs. In my experience it is important to find someone who is used to working with the limitations of older people.

There are exercises that are designed especially for improving balance and can be done at home.  The Mayo Clinic has pictures of a few balance exercises, and Harvard Medical School has published a special report – Better Balance, with exercises that are graded in their difficulty, so it is possible for almost anyone to begin and gradually work up.  Balance is a critical function that we take for granted most of our lives, and it is important to preserve the function as we get older.

Al Martin, M.D., 75, is a former associate professor of medicine at University of California San Francisco Medical Center and Chief Medical Officer of Blue Shield of California. This post was originally published in slightly different form on his Age with Spirit blog.