Aging is a double whammy. First it weakens the bones, muscles and reflexes. This weakness renders us susceptible to imbalance. Imbalance leads to falls. Falls lead to injuries.
The solution employed by previous generations in handling imbalance was “less mobility to reduce risk of falls”. Pre-boomers (our parents and grandparents) were content in sitting in their favorite chairs with all their needs within reach, spending days knitting or for men, watching TV or sitting by the roadside watching the world go by. That is a big no-no for baby boomers like us. We are armed with better information as far as our health is concerned. We will not be like our parents, we want to move, to play sports, party, dance, and hang out with our friends and families until the day we die.
Unfortunately all these good goals have a few caveats. Being active with aging may sometimes lead to falls and fractures. It starts with a slow-down of reflexes.
In our youth, we have lightning speed in reacting to imbalance. Someone pushes us and we quickly bounce back to a stable position. Whether it is a game of basketball, tennis or football, we swing and jump and turn like nothing can disturb our stability. We can be walking on uneven surfaces or standing on one leg as we pull in our pants or shorts and nothing will make us fall. We can walk pretty well on balance beams. We quickly sway and adjust our center of gravity on some challenging terrains. Heck, some of us might even stand on one leg while juggling three balls and singing a Broadway tune without flinching. This is because our bodies are at their peak - quick reflexes matched by strong and fast muscle and sharp senses.
Sadly, Nature’s law includes the Second Law of Thermodynamics otherwise known as Entropy. Everything must decline. We can in the future regenerate our joints and hearts and other vital organs to make us feel brand new again, yet, what Nature has provided (naturally) cannot be duplicated by humans (Nowadays at least). Humans can approximate the damaged parts of the body but cannot replace them. There is stem cell technology but none of it has for example, regenerated a completely damaged spinal cord. Parkinsons is still fraught with a poor prognosis.There were heart heart transplants and joint replacements but none of them would be as original as before. A broken vase can only be mended or even glued or some parts replaced but the original is gone forever in the name of entropy.
We are born. The moment we start standing upright, gravity pulls us down; our bones and joints degenerate even before they fully mature. Our synovial fluids, the lubricating oil present in our joints, freeze and are replaced by inflammatory cells due to arthritis; or else the fluids disappear until the bones rub against each other eroding precious cartilages leading to osteoarthritis. Our spines have discs partly made of fluids that dessicate as we age. They get narrower and flatter, shrinking the holes where the nerves coming from the spine pass through. This can lead to sciatica or back pain due to pinched nerves or herniated disks to spinal stenosis etc. This leads to all sorts of abnormalities such as poor posture which cause muscle imbalance, which cause muscle pain, which cause more muscle spasms which cause more pain, which cause reduced mobility which cause - well, you get the picture. Have you ever wondered why we lose height as we age? It is the stupid desiccation of intervertebral discs. We start stooping and start losing our balance because the center of gravity is displaced. We start walking relying heavily on stable structures: walls, chairs, tables, sinks. And one day we trip and unable to break the fall, we land on the floor. BAM.
We work. We sit, work and do errands for countless hours until core muscle imbalance takes over. The back muscles are stretched while the front muscles lose muscle tone. Core strength disappears. Our posture deviates from its natural curves. A desk worker in front of the screen for decades may end with a bent neck. A farmer spending hours in the field will have his back bent. A laborer will probably be on a constant moaning by the daily loads he carries. A teacher who stands the whole day may develop bone spurs at her heels, or if sitting at his desk the whole day, develops back pain. Most people call it sciatica . Sciatica has so many etiologies that need multiple evaluations and diagnostics to finally isolate its cause. rates and everyday someone wakes up with shoulder pain, back pain, hip pain, ankle pain, the list goes on and on and on. Again, this may lead to a sudden loss of balance and BAM.
I tell people all the time that loss of balance is a part of life. If we can instantly self-correct it or be able to put a brake on it or slow it down by either holding on some assistive device or a stable structure or even leaning against the wall while gradually lowering oneself to the ground, that is ok. What is not ok is the slip and fall that causes an injury to ligament, muscle, tendon and the most dreaded bone fracture. Especially when one is osteoporotic.
Fractures are manageable in this time and age. It is the pain and disability due to illness that can put one in a bind especially if they are weak in the first place or if they live alone and no one can assist them if needed. It will take at least 8 weeks for full healing of an uncomplicated bone fracture. The ones that are dangerous involve anything from displaced rib fractures, comminuted (multiple fragment) fractures or fractures involving the spine and skull or head.
Balance Definition from PTJ
[Balance is the ability to maintain a stable posture and avoid falling12. Balance requires the integration of sensory information from the eyes, ears, and body3. Balance declines with age, especially after the 50s, due to reduced physical fitness, muscle strength, flexibility, and sensory processing432. Balance problems can increase the risk of falls, injuries, and cognitive decline among older adults412. Balance can also be affected by the way one walks.]
‘For example, says Vincenzo, a member of a joint task force with APTA Geriatrics and the National Council on Aging, older adults who are independent may come into the clinic for another issue, such as knee or back pain, which can often be a risk factor for falls. “Over the last 20 years, we have learned more about the multifactorial components contributing to falls risk, and that it isn’t just about ‘balance,’” Vincenzo says. “Factors such as decreased lower extremity strength, depression, side effects from medications, urinary incontinence, vision, and environment play a role as well.
In a 2021 report, “Emergency Department Visits and Hospitalizations for Selected Nonfatal Injuries Among Adults Aged 65 Years and Older — United States, 2018,” the Centers for Disease Control and Prevention said that unintentional falls accounted for over 90% of emergency department visits and hospitalizations among older adults in 2018. That’s more than 2.2 million ED visits and nearly 655,000 hospitalizations.’
From PTJ
From my own perspective, I often taught in my old clinical days mostly standard static balance exercises that now, looking back, were more diagnostic than therapeutic. Most of these exercises are simple variations of the many tests we utilize in evaluating balance and stability - Tinetti, TUG(Take Up and Go), Berg, Dynamic Gait Index - are a few examples. They were more rooted on weakness and postural deviation and poor proprioception, and speed impediment. Most of them are geared to the younger patient. There were a few I employed such as tandem walking, walking in different directions, balance balls, balance boards, etc.
As I am at the foot of my 60s now and I am slowly realizing balance is multifactorial and there is a bigger component overlooked and that's vestibular.
I feel it when I suddenly turn, I sense some kind of a ‘Whoa!’ reaction because I feel a brief imbalance and I become instantly guarded, this is most especially acute when I suffer from head congestion. And this guarded reaction slows me down, and slowing down in a setting that requires fast reaction (like a loss of balance) is dangerous.
I also slow down in dark spaces, I start looking for other sensory cues, like touching the wall or the bathroom sink to orient myself. This really means that balance is multi-sensory. It requires vision, touch and even sounds for orientation.
Falls in elderly (From PTJ-APTA)
An important cause of falls in the elderly population is the presence of sarcopenia. Sarcopenia can be related to a food decline, a long hospital stay, and/or a long illness. Generally, the elderly have a decrease in mass volume and coordination, with phenotypic changes, such as selective loss of white fibers.
Another cause of falls is the presence of cognitive impairment that is often found in the elderly, especially in those with a long illness, pain, or mood changes.
Postprandial hypotension is a non-physiological reason that causes falls in elderly subjects, probably due to an autonomic system dysfunction or the declining function of the cardiovascular system.
Obesity in the elderly is another cause linked to the increase in falls, probably due to a further decline in muscle mass and neuromuscular function.
Osteoporosis can cause rupture of the femoral neck in elderly subjects, and this event can often confuse the providers, particularly when the patient is uncooperative.
Another cause that leads to motor instability and an increase in the percentage of falls is the decline in the strength of the diaphragm muscle. A decrease in strength and function of the diaphragm causes instability in the back area and leads to falls.
Intrinsic Causes (from PTJ-APTA)
- History of falls: Predisposes one to an increased risk of recurrent falls
- Age: Increased age is associated with decreased reaction time, particularly in step initiation and execution timing.
- Gender: In most elderly individuals, women fall more often than men
- Race: Studies show that Whites fall more often than Africans, Caribbeans, Hispanics, and South Asians.
- Drugs: If more than four medications are taken, the risk of falls is raised significantly. The use of benzodiazepines in the elderly increases the risk of night falls and hip fractures by 44%. Drugs such as antiarrhythmics, digoxin, diuretics, sedatives, and psychotropics also increase the risk of falling substantially.
- Solitary lifestyle: Living alone appears to be a risk factor in falls. Injuries and consequences can be increased if the fallen individual cannot get up from the floor.
- Medical conditions associated with an increased risk in falls include vascular diseases, arthritis, thyroid dysfunction, diabetes, depression, and chronic obstructive pulmonary disease. Vertigo and incontinence are common in populations with falls.
- Impairment in gait and mobility: After the age of 30, strength and endurance decrease by 10% per decade. When strength, power, and endurance are decreased, a slip or trip can turn into a fall. Any lower limb disability can increase the risk of falling, and difficulty rising from a seated position in a chair is associated with an increased risk as well.
- Immobility/Deconditioning: Sedentary individuals fall more than those who are relatively active.
- Fear of falling: Among individuals with a recent fall, up to 70% report fears of falling. Of these individuals, 50% may limit or exclude physical or social activity because of this fear, thereby increasing their fall risk.
- Poor nutrition: Deficiencies in nutrients can result in low body mass index, which is associated with an increased risk of falls. Vitamin D deficiency can result in muscle weakness, osteoporosis, and impaired gait patterns.
- Cognitive disorders: Dementia, poor memory, and a score of under 26 on the Mini-Mental State Exam are all related to an increased risk of falls.
- Impaired vision: Glaucoma, cataracts, visual acuity, the field of vision, and contrast sensitivity lead to an increased risk of falls.
- Foot issues: General pain when walking, calluses, long toe deformities, ulcers, and nail deformities increase balance difficulty and risk of falling.
Testing:
To date, none of the screening tools is able to accurately assess the fall risk among elderly individuals. There are many tools available. Some of which are: The Tinetti Gait and Balance Assessment Tool and The one-legged and tandem stance assessments. Neither of these tests accurately identifies fall risks and are poor predictors. ( PTJ-APTA)