How to identify balance disorders and reduce fall risk
A multifactorial risk assessment, correction of hearing impairment, exercise, and an optimized home environment can help prevent imbalance-related falls.
PRACTICE RECOMMENDATIONS
› Utilize a falls-prevention program for older patients that focuses on balance and functional exercises. A
› Perform a multifactorial assessment of the risk of falls in older patients that includes optimizing medications, managing comorbidities, and addressing environmental hazards. B
› Use a systems-based approach to presentations of imbalance to direct your clinical judgment and highlight the need for referral to specialists for management and rehabilitation. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The medical and surgical histories are key pieces of information. The history of smoking, alcohol habits, and substance use is relevant.
A robust medication history is essential to evaluate a patient’s risk of falling. Polypharmacy—typically, defined as taking 4 or more medications—has been repeatedly associated with a heightened risk of falls.53,59-61 Moreover, a dose-dependent association between polypharmacy and hospitalization following falls has been identified, and demonstrates that taking 10 or more medications greatly increases the risk of hospitalization.59 Studies of polypharmacy cement the importance of inquiring about medication use when assessing imbalance, particularly in older patients.
Physical examination
A focused and detailed physical examination provides insight into systems that should be investigated:
- Obtain vital signs, including orthostatic vitals to test for orthostatic hypotension62; keep in mind that symptoms of orthostatic dizziness can occur without orthostatic hypotension.
- Examine gait, which can distinguish between causes of imbalance (TABLE 2).21,40,63-70
- Perform a cardiac examination.
- Assess visual acuity and visual fields; test for nystagmus and identify any optic-nerve and retinal abnormalities.
- Evaluate lower-limb sensation, proprioception, and motor function.
- Evaluate suspected vestibular dysfunction, including dysfunction with positional testing (the Dix-Hallpike maneuver71). The patient is taken from sitting to supine while the head is rotated 45° to the tested side by the examiner. As the patient moves into a supine position, the neck is extended 30° off the table and held for at least 30 seconds. The maneuver is positive if torsional nystagmus is noted while the head is held rotated during neck extension. The maneuver is negative if the patient reports dizziness, vertigo, unsteadiness, or “pressure in the head.” Torsional nystagmus must be present to confirm a diagnosis of benign paroxysmal positional vertigo.
- If you suspect a central nervous system cause of imbalance, assess the cranial nerves, coordination, strength, and, of course, balance.
CASE
Mr. J’s physical examination showed normal vital signs without significant postural changes in blood pressure. Gait analysis revealed a slowed gait, with reduced range of motion in both knees over the entire gait cycle. Audiometry revealed symmetric moderate sensorineural hearing loss characteristic of presbycusis.
Diagnostic investigations
Consider focused investigations into imbalance based on the history and physical examination. We discourage overly broad testing and imaging; in primary care, cost and limited access to technology can bar robust investigations into causes of imbalance. However, identification of acute pathologies should prompt immediate referral to the emergency department. Furthermore, specific symptoms (TABLE 17-56) should prompt referral to specialists for assessment.
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