Community-dwelling older adults with balance impairment show a moderate increase in fall risk, although further research is required to refine how balance measurement can be used in clinical practice
- Correspondence to Lillemor Lundin-Olsson
Department of Community Medicine and Rehabilitation, Physiotherapy, Umea University, SE-901 87 Umea, Sweden;
Falls present the most common cause of injury in old age and pose a serious threat to public health. Not only the physical injuries of falls can be devastating, but also simply the fear of falling can have major implications for quality of life, as well impacting on the level of physical activity, ability and participation in the community. Much research has been done to determine the most important risk factors for falls and fall-related injuries in older people living in residential care settings and in the community. Impaired gait and balance are among the most consistently reported factors that increase the risk of falling; other commonly reported factors include old age, history of falls, impaired vision, medical conditions and use of multiple medications.
Results of the thorough systematic review and meta-analysis by Muir and colleagues confirm that balance impairment is associated significantly with an increased risk of falling in community-dwelling older adults. However, their overall risk values are smaller than previously reported. This may be explained by the inclusion of observation studies with (1) community-dwelling older adults who had undergone a clinical balance assessment before a 1-year follow-up of falls and fall-related injuries and (2) multi-variate regression analyses that produced risk estimates of balance impairment that were adjusted for other factors known to increase the risk of falling.
Even though numerous studies over the years have focused on the identification of those who are prone to falls, many of them have also included older adults in residential care settings or used a retrospective design to collect data on those who have experienced falls. Notably, only 23 studies met the inclusion criteria of this review and 13 of those were based on six common data sources. Moreover, balance measurement tools with different units of measurement were used, the length of the follow-up varied between studies and the fall outcomes represented different categories: any falls, recurrent falls, injurious falls and falls resulting in a fracture. The outcomes were defined in different ways and in several studies definitions were lacking. The methodological quality of the studies was rated as low to moderate. The current review shines light on the wide variations in methods used across studies that together obstruct meta-analysis. There is a need for well-designed studies with prospective cohort design that use a common set of outcome definitions and measures.1
Exercise prevents falls
For the purpose of preventing falls, balance impairments in older adults are important to detect. A recent Cochrane review on the prevention of falls in community-dwelling older adults concluded that multi-component (eg, balance and strength) exercise performed in group, and individually prescribed exercise programmes carried out at home effectively reduced the risk of falling.2 This result supports the evidence that impaired balance is an important risk factor and, moreover, it is potentially modifiable or remediable with appropriate interventions.
Balance measurement tools
Muir and colleagues found that three quarters of the studies reported that balance impairment was associated significantly with the risk of falling in unadjusted analyses. When taking other well-known fall risk factors into the analyses, balance impairment still qualified as an independent risk factor in more than half of all the studies. A gap of knowledge remains regarding the choice of balance measurement tools. The authors concluded that there is not sufficient evidence to recommend a single, best measurement tool to identify fall risk. Nevertheless, they found that balance impairment assessed by some measurements are associated with an increased risk but not by others. Measurements indicating an increased risk included a decreased medio-lateral base of support (tandem stand, tandem gait and one leg stand), a scale of standing and walking that was developed to identify fall risk (Performance Oriented Mobility Assessment)3 and body sway. The Berg Balance Scale4 and the Timed Up&Go5 were among those without any association to falls. Even though there are no clear-cut differences between the measurements, one might speculate that in the latter measurements, the strategies on how to perform the mobility tasks most often are not restricted by instructions and that these measurements are known to have ceiling effects in general populations of community-dwelling older adults. An important issue for future research is to find a measurement tool with sound measurement properties for risk identification that is practical to use for community-dwelling older adults.