The Vestibular System and Fall Risk
If you are a physical therapist working with older adults in a community setting, you might be concerned that vestibular therapy is out of your skill set. While it is true that vestibular assessment is a specialized skill, keeping this system on your radar is essential for balance and fall risk assessment.
Older adults presenting for balance assessment or fall risk management are often not seen in a setting where vestibular function would be evaluated. Even with earnest attempts to comply with current fall risk screening recommendations, the vestibular system may be overlooked. 1
Often vestibular disorders are associated with dizziness and vertigo. But even if an individual does not have vertigo or dizziness, or it has resolved a long time ago, vestibular function could still be impaired.
Vestibular Function Reduces with Age
Age is associated with reduction in vestibular function. With each decade there is typically further decline.2 If you’re working with older adults, chances are good that you are seeing vestibular dysfunction daily, even if it’s not diagnosed and even if they are not reporting dizziness
In a sample of people with an average age of 75 who were referred for evaluation for fall risk, 73% had a measurable vestibular dysfunction after diagnostic testing.
Dizziness is one of the possible criteria for diagnosing age-related vestibular loss (presbyvestibulopathy), and dizziness is more common with increased age. Still, dizziness is not necessary for a diagnosis – imbalance, gait disturbance, and falls can also be symptoms instead. 3 Hypofunction (reduced vestibular function) may occur gradually over time and may not be perceived as vertigo.
Vestibular Dysfunction is a Fall Risk
Balance declines with age but is highly variable. One possible source of variability is vestibular dysfunction.
Among age-matched adults, fallers were more likely to have reduced vestibular function.
- 80% of a group with unexplained falls were later diagnosed with vestibular dysfunction compared to 18% of an age-matched group with no fall history. 1
The majority of fallers diagnosed with vestibular impairment (70%) reported no dizziness or vertigo. - 68% of a group of patients who sustained a hip fracture after a fall had a vestibular disorder compared to 36% of an age-matched control group. 4
Similarly, those with vestibular disorders are more likely to fall. The graph shows similar findings in 2 studies comparing fall history in older adults who did or did not have a vestibular disorder. Groups were age-matched in both studies. Falls were double in the vestibular group.
- In adults between 65 and 74, 51% of those with bilateral vestibular disorders fell compared to 25% of those in the general population. 5
- The rates were 48% vs. 24% with and without a vestibular disorder (determined by a head thrust test).
Over the years, central compensation mechanisms can keep obvious functional deficits at bay. But at some critical point both peripheral and central changes overcome compensation and function deteriorates. 2
Appropriate Exercises Can Improve Vestibular Function
Abundant research supports that therapy can improve functional impairments related to vestibular loss in older adults.8,9 This can improve balance, confidence, and risk for falls. Exercises that encourage use of the vestibular system can provide the stimulus for change.
Traditional static and dynamic balance exercises are helpful and do improve balance when appropriately dosed. But they do not involve eye-head movements and do not challenge balance in different visual environments. Exercises designed specifically to induce these challenges help foster the adaptation needed and improve central processing of signals. Based on careful evaluation, the therapist may also choose to train other sensory systems to compensate. For example, evidence shows that with bilateral hypofunction gaze stabilization exercises are key10, but somatosensory reweighting may also be effective11. The key is customized exercises based on specific deficits.
Vestibular dysfunction, including BPPV and hypofunction, is an often-overlooked reason for imbalance and falls. Proper assessment will guide treatment and help your patients improve function, symptoms, and fall risk.
Want more information? Here are some further resources.
- Interested in upping your game in vestibular rehab? Check out one of the certification courses available. You can find a list here.
- If you’re not ready to commit to full certification but want to learn more about aging and the vestibular system, check out this comprehensive review.
- For review of the anatomy and physiology of the vestibular system, complete with animations, see here.
- Need to refer a patient to a vestibular specialist? Here is a resource.
1. Liston MB, Bamiou DE, Martin F, et al. Peripheral vestibular dysfunction is prevalent in older adults experiencing multiple non-syncopal falls versus age-matched non-fallers: a pilot study. Age Ageing. 2014;43(1):38-43. doi:10.1093/ageing/aft129
2. Iwasaki S, Yamasoba T. Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System. Aging Dis. 2015;6(1):38. doi:10.14336/AD.2014.0128
3. Agrawal Y, Van de Berg R, Wuyts F, et al. Presbyvestibulopathy: Diagnostic criteria Consensus document of the classification committee of the Barony Society. J Vestib Res. 2019;29(4):161-170. doi:10.3233/VES-190672
4. Kristinsdottir EK, Jarnlo GB, Magnusson M. Asymmetric vestibular function in the elderly might be a significant contributor to hip fractures. Stand J Rehabil Med. 2000;32(2):56-60. doi:10.1080/003655000750045550
5. Herdman SJ, Blatt P, Schubert MC, Tusa RJ. Falls in patients with vestibular deficits. Am J Otol. 2000;21(6):847-851.
6. Balatsouras D, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign paroxysmal positional vertigo in the elderly: current insights. Clin Interv Aging. 2018;13. doi:10.2147/CIA.S144134
7. Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2000;122(5):630-634. doi:10.1016/S0194-5998(00)70187-2
8. Ricci NA, Aratani MC, Doná F, Macedo C, Caovilla HH, Ganança FF. A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults. Braz J Phys Ther. 2010;14:361-371. doi:10.1590/S1413-35552010000500003
9. Martins e Silva DC, Bastos VH, de Oliveira Sanchez M, et al. Effects of vestibular rehabilitation in the elderly: a systematic review. Aging Clin Exp Res. 2016;28(4):599-606. doi:10.1007/s40520-015-0479-0
10. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022;46(2):118-177. doi:10.1097/NPT.0000000000000382
11. Haran FJ, Keshner EA. Sensory Reweighting as a Method of Balance Training for Labyrinthine Loss. J Neurol Phys Ther. 2008;32(4):186-191. doi:10.1097/NPT.0b013e31818dee39
