How should a patient with balance issues be evaluated and treated?

Evaluation and Management of Balance Issues

Patients with balance issues require immediate fall risk screening using three standardized questions, followed by targeted balance training programs and assistive device prescription when indicated, with vestibular rehabilitation as the primary intervention for persistent symptoms. 1

Initial Assessment and Risk Stratification

Critical Screening Questions

• Ask all patients: "Have you fallen in the past year? How many times? Were you injured?", "Do you feel unsteady when standing or walking?", and "Do you worry about falling?" 1
• Document that among community-dwelling adults aged >65 years, 1 in 3 falls annually, with a 12-fold increased fall risk when vestibular symptoms are present 1
• Perform the Timed Up and Go test—time >12 seconds indicates increased fall risk and necessitates intervention 2

Exclude Treatable Vestibular Conditions First

• Perform the Dix-Hallpike maneuver immediately to rule out BPPV, which affects 9% of elderly patients undergoing geriatric assessment and is highly treatable with 80% success after 1-3 canalith repositioning procedures (Epley maneuver). 1
• Look for brief episodic vertigo lasting seconds to minutes triggered by head movements, which characterizes BPPV 3
• Check for unilateral hearing loss, tinnitus, or aural fullness suggesting Ménière's disease 3

Comprehensive Balance Evaluation

• Assess all sensory systems: visual acuity testing, vestibular function, and somatosensory/proprioceptive pathways 4
• Evaluate anticipatory postural reactions during functional behaviors using standardized tests like the Berg Balance Scale (most commonly used, 36% of assessments) or Timed Up-and-Go test (48% of assessments) 4, 5
• Screen for cognitive impairment using Mini-Cog or Memory Impairment Screen, as cognitive deficits significantly increase fall risk 2
• Conduct depression screening with PHQ-2, as late-life depression contributes to falls 2

Identify Underlying Causes

• Review all medications focusing on high-risk drugs: antihypertensives, diuretics, sedatives, anticonvulsants, psychotropic drugs, and vestibular suppressants 1, 2
• Assess for chronic conditions: hypertension (present in 32.4% of elderly with balance disorders), diabetes mellitus (13.8%), arthritis (8.1%), and heart disease (4.4%) 6
• Evaluate for stroke-related ataxia if cerebellar signs present—ataxia occurs in 68-86% of patients with brainstem stroke 4
• Check for presbyvestibulopathy in elderly patients with age-related vestibular decline 1

Treatment Algorithm

Primary Intervention: Balance Training Programs

All patients with poor balance, low balance confidence, fear of falls, or fall risk should receive a balance training program (Class I, Level A recommendation). 4

Specific Balance Training Components

• Prescribe balance training exercises 3 or more days per week with strength training twice weekly 2
• Include balance-specific activities (practice responding to challenges in standing) and general activities (strengthening exercises, gait activities) 4
• Progress to more challenging training activities over the course of treatment 4
• Consider Tai Chi or similar balance-focused exercise programs to reduce fall risk 2
• Implement postural training and task-oriented therapy for patients with ataxia (Class IIb, Level C recommendation) 4

Common pitfall: Water-based programs have not been shown to be beneficial for balance and should be avoided 4

Assistive Devices and Orthotics

Prescribe and fit patients with an assistive device (cane, walker) or orthosis (ankle-foot orthosis) when appropriate to improve balance (Class I, Level A recommendation). 4

• More than half of patients with mobility impairments require an assistive device 2
• Ensure proper fitting and provide training in device use to prevent the device itself from becoming a fall hazard 2
• For rollators, assess hand-motor coordination to manage hand-brakes on slopes 2
• Document with appropriate ICD-10 codes: history of falls (Z91.81), abnormality of gait and mobility (R26.9), or dizziness and giddiness (R42) 2

Vestibular Rehabilitation Therapy

For persistent dizziness that fails initial treatment, refer for vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk. 3, 2

• Include habituation exercises, gaze stabilization, balance retraining, and fall prevention 3
• Can be delivered as self-administered home exercises or supervised therapy with a vestibular therapist 1

Medication Management

Avoid vestibular suppressants like meclizine for chronic balance issues, as they may worsen balance and increase fall risk. 2, 7

• Meclizine causes drowsiness and has anticholinergic effects that impair balance 7
• Conduct comprehensive medication review with attention to polypharmacy 2
• Consider discontinuing psychotropic medications if present 2

Important caveat: Meclizine is only indicated for acute vertigo associated with vestibular system diseases, not chronic balance disorders 7

Environmental Modifications

• Arrange occupational therapy home assessment with direct intervention 2
• Remove loose rugs and floor clutter, ensure adequate lighting throughout the home, install grab bars in bathrooms 2
• Recommend properly fitting non-skid footwear 2

Red Flags Requiring Urgent Evaluation

Obtain MRI brain without contrast immediately for patients with: 3

• Focal neurological deficits on examination
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache
• Failure to respond to appropriate vestibular treatments
• High vascular risk (hypertension, age >50, diabetes, prior stroke) with acute vestibular syndrome

Critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits, so normal neurologic exam does not exclude stroke 3

Follow-Up and Monitoring

• Reassess gait stability with Timed Up and Go test at follow-up visits 2
• Monitor for recurrence of falls, as patients with prior falls are at high risk 2
• Consider bone health evaluation with DEXA scan to assess fracture risk 2
• Continue multifactorial interventions with ongoing medication review and environmental modification 2