Balance Problems: Causes and What Helps

How balance works

Your brain keeps you upright by combining three streams of information:

• The inner ear (vestibular system): fluid-filled canals and sensors detect head turning, tilting and movement.
• Vision: tells the brain where you are relative to your surroundings.
• Proprioception: sensors in the feet, ankles, knees and neck tell the brain where your body is.

The cerebellum at the back of the brain coordinates these signals with your muscles. Blood pressure must also be enough to keep the brain supplied when you stand. A problem with any of these can cause imbalance, and older adults often have several small problems that add up.

Types of balance problems

Common causes of balance problems

Inner ear disorders

• BPPV: tiny calcium crystals slip into the wrong canal of the inner ear. Turning over in bed, lying down, or looking up triggers brief spinning lasting under a minute. It is the most common cause of vertigo and is easily treated.
• Vestibular neuritis and labyrinthitis: inflammation of the balance nerve or inner ear, usually after a virus. Severe spinning and vomiting last days, followed by weeks of unsteadiness. Labyrinthitis also affects hearing.
• Ménière's disease: attacks of vertigo lasting 20 minutes to hours, with fluctuating hearing loss, ringing and fullness in one ear.
• Vestibular migraine: vertigo or imbalance with or without headache, in people with migraine.
• Acoustic neuroma: a slow-growing benign tumor on the balance nerve, causing one-sided hearing loss, tinnitus and gradual imbalance.

Blood pressure and circulation

Orthostatic hypotension is a drop in blood pressure on standing. You feel lightheaded or dim-sighted for a few seconds after getting up. Dehydration, blood pressure medicines, diabetes, Parkinson's disease and prolonged bed rest are common causes.

Nerves, muscles and joints

• Peripheral neuropathy: numbness in the feet from diabetes, alcohol, B12 deficiency or chemotherapy means you cannot feel the ground well. Imbalance is worse in the dark.
• Weak legs: muscle loss with age or inactivity.
• Ankle instability: after repeated sprains, damaged ligaments and position sensors make the ankle feel weak and give way, reducing balance on that leg. Balance training on one leg is the main treatment.
• Arthritis of the hips, knees or feet.

Brain and nervous system

• Stroke and TIA: sudden imbalance, often with other signs. Strokes in the cerebellum may cause imbalance and vertigo alone, which is why sudden severe imbalance always needs assessment.
• Parkinson's disease: stooped posture, shuffling steps, and poor recovery from a stumble.
• Multiple sclerosis, brain tumors, normal pressure hydrocephalus and inherited ataxias.
• Concussion.

Medicines and alcohol

Sedatives, sleeping pills, antidepressants, anti-seizure medicines, opioids, blood pressure medicines and some antibiotics (aminoglycosides, which can damage the inner ear) all affect balance. Taking four or more medicines raises fall risk. Alcohol directly impairs the cerebellum.

Vision

Cataracts, new glasses (especially bifocals or varifocals), and loss of vision in one eye affect balance.

Balance problems in older adults

Balance naturally declines with age, but falls are not inevitable. About one in four adults aged 65 and over falls each year in the US. Common contributors are weak legs, several medicines, poor eyesight, neuropathy, low blood pressure on standing, foot problems and home hazards. A fall risk assessment, a medicine review and a strength and balance program can substantially reduce falls.

Accompanying symptoms and what they suggest

• Hearing loss, tinnitus or ear fullness: inner ear disorder such as Ménière's, labyrinthitis or acoustic neuroma.
• Nausea and vomiting: vestibular neuritis, labyrinthitis, or a cerebellar stroke.
• Numbness or tingling in the feet: neuropathy.
• Tremor, stiffness and slow movement: Parkinson's disease.
• Headache with sensitivity to light: vestibular migraine.
• Slurred speech, double vision, facial droop or one-sided weakness: stroke, an emergency.

How doctors find the cause

• History: whether it is spinning, lightheadedness or unsteadiness, how long episodes last, triggers, hearing changes, medicines and falls.
• Examination: eye movements, walking, standing with feet together and eyes closed (Romberg test), sensation in the feet, and blood pressure lying and standing.
• Dix-Hallpike test: moving your head and lying you back quickly to trigger BPPV.
• Head impulse test and other bedside tests that help separate inner ear from brain causes.
• Hearing test and specialized balance tests such as videonystagmography (VNG).
• Blood tests: blood count, glucose, B12, thyroid.
• MRI of the brain when a brain cause is suspected.

Treatment for balance problems

• Repositioning maneuvers: the Epley maneuver moves the crystals back in BPPV and often works in one or two sessions.
• Vestibular rehabilitation: a physical therapist teaches eye, head and balance exercises that help the brain adapt to inner ear damage.
• Strength and balance training: programs such as tai chi reduce falls in older adults.
• Medicine review: reducing or switching sedating or blood pressure medicines.
• Short-term medicines: anti-nausea medicines for a few days during acute vertigo. Long-term use slows recovery.
• Treat the cause: diuretics and diet for Ménière's, fluids and compression stockings for low blood pressure, B12 replacement, Parkinson's medicines.
• Aids: a cane or walker, good lighting, removing trip hazards, grab bars and supportive shoes.

Frequently asked questions

Does a damaged eardrum cause balance problems?

A perforated eardrum by itself usually affects hearing, not balance, because balance sensors are in the inner ear, deeper inside. However, the injury or infection that tore the eardrum can sometimes affect the inner ear, causing vertigo. Dizziness after an ear injury should be checked by a doctor.

Can a weak ankle affect balance?

Yes. After repeated sprains, damaged ligaments and position sensors in the ankle send less accurate information to the brain, so the ankle feels unstable and balance on that leg is poorer. Physical therapy with single-leg balance exercises and strengthening usually helps a lot.

What causes sudden balance problems?

Sudden balance problems are most often caused by an inner ear problem such as vestibular neuritis or BPPV, or by a drop in blood pressure. Stroke is the most important serious cause. Sudden imbalance with weakness, speech problems, double vision or a severe headache needs emergency care.

What is the most common cause of balance problems in older adults?

Usually several factors combine: weaker leg muscles, multiple medicines, poorer eyesight, nerve damage in the feet and low blood pressure on standing. BPPV is the most common single inner ear cause. A fall risk assessment can identify which factors to fix.

What exercises help balance problems?

Standing on one leg near a counter, heel-to-toe walking, sit-to-stand exercises and tai chi all improve balance. People with inner ear disorders benefit from vestibular rehabilitation exercises taught by a physical therapist. Practice daily and safely, with something sturdy to hold.