Poor Balance: Causes, Assessment and Treatment

How balance works

Staying upright depends on three sensory inputs, processed by the brain:

• inner ear (vestibular system): senses head movement and gravity
• vision: shows where you are in your surroundings
• proprioception: nerves in the feet, ankles and joints sense position and the ground

The brain, especially the cerebellum, combines these signals and sends commands to muscles to correct posture. Strength, joint flexibility and reaction time determine how well you recover from a stumble. When one input is lost, the others compensate, which is why many people with neuropathy become unsteady in the dark.

For quick help deciding what an episode of unsteadiness might mean, see balance problems.

Common causes of poor balance

In older adults, poor balance usually results from several of these at once.

How doctors assess balance

History

Questions include previous falls, how and when unsteadiness happens, whether there is spinning (vertigo) or lightheadedness, worsening in the dark, and a full medicine review.

Simple tests

• Timed Up and Go: stand from a chair, walk 3 m (10 ft), turn, walk back and sit. Taking 12 seconds or more suggests higher fall risk.
• 30-second chair stand: how many times you can stand from a chair without using your arms.
• 4-stage balance test: feet side by side, semi-tandem, tandem and one leg, 10 seconds each.
• Romberg test: standing with feet together, eyes open then closed.
• Dix-Hallpike maneuver for BPPV.

Further checks

• blood pressure lying and standing
• vision and foot examination, sensation and reflexes
• blood tests: B12, glucose, thyroid, blood count
• hearing and vestibular tests, brain imaging or nerve studies as needed

Treatment

Exercise

Balance and strength exercises are the most effective way to prevent falls. Programs such as tai chi, the Otago exercise program and supervised physical therapy reduce falls by around a quarter or more. Aim for balance training at least 3 times a week.

Examples to practice safely near a counter:

• standing on one leg, building to 30 seconds
• heel-to-toe walking along a line
• sit-to-stand repetitions without using your hands
• heel and toe raises
• side-stepping

Vestibular rehabilitation

A specialist physical therapist uses head and eye movement exercises to help the brain compensate for inner ear problems. Repositioning maneuvers such as the Epley maneuver treat BPPV in minutes.

Medicine review

Reducing or stopping sedatives, sleeping pills and unnecessary blood pressure medicines can make a large difference. Never stop prescribed medicines without talking to your doctor.

Treating the cause

Cataract surgery, foot care and proper footwear, Parkinson's treatment, B12 replacement, treating orthostatic hypotension, and managing diabetes.

Home safety

• remove loose rugs and clutter
• add grab bars in the bathroom and rails on both sides of stairs
• use night lights
• wear supportive, low-heeled, non-slip shoes
• use a cane or walker if recommended, fitted by a therapist
• consider a medical alert device if you live alone

Frequently asked questions

What causes poor balance in older adults?

Usually several factors combine: age-related changes in the inner ear, weaker leg muscles, nerve damage in the feet, poor vision, low blood pressure on standing, and medicines such as sedatives. Parkinson's disease, stroke and arthritis are also common contributors.

How can I improve my balance?

Regular balance and strength exercises, such as tai chi, standing on one leg near support, heel-to-toe walking and sit-to-stand practice, improve balance at any age. A physical therapist can design a safe program. Also check your vision, shoes and medicines.

When should I see a doctor about poor balance?

See a doctor if you have fallen, feel unsteady, hold on to furniture to walk, or your balance is getting worse. Get emergency care for sudden loss of balance with weakness, numbness, speech problems or severe headache.

Can poor balance be a sign of something serious?

Sometimes. Sudden poor balance can signal a stroke. Gradual unsteadiness can be an early sign of Parkinson's disease, normal pressure hydrocephalus, neuropathy or vitamin B12 deficiency. Many causes are treatable once identified.