What is the recommended treatment for balance difficulty in an older adult with cerebral small‑vessel (white‑matter) disease presenting with gait instability or frequent falls?

Treatment of Balance Difficulty in White Matter Disease

Implement a structured multifactorial intervention program centered on gait training with balance exercises, comprehensive medication review (especially psychotropic withdrawal), and fall prevention strategies, as these have Grade B evidence for reducing falls in community-dwelling older adults with gait and balance impairments. 1

Initial Assessment Requirements

Before initiating treatment, perform a comprehensive fall evaluation that includes:

• History of fall circumstances, current medications, acute/chronic medical problems, and mobility levels 1
• Examination of vision, gait and balance, lower extremity joint function, and basic neurological function (mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, cortical/extrapyramidal/cerebellar function) 1
• Cardiovascular assessment including orthostatic blood pressure measurements (supine and upright), as orthostatic hypotension accounts for 6-33% of falls presenting as syncope in older adults 2
• "Get Up and Go Test" to assess functional mobility 1

Core Treatment Components (All Grade B Evidence)

1. Gait Training and Balance Exercises

Initiate structured gait training with balance training as a primary component, delivered either as supervised vestibular rehabilitation therapy or home-based exercise programs. 1, 3

• Balance training specifically targets the motor control deficits caused by white matter tract disruption, particularly in the corpus callosum and periventricular frontal regions that connect prefrontal cortex to motor areas 4, 5
• Vestibular rehabilitation can be self-administered or supervised by a vestibular therapist, incorporating gaze stabilization, balance training, and habituation exercises 3
• Research demonstrates that white matter lesions in the centrum semiovale and periventricular frontal lobe correlate with reduced gait velocity and stride length, making targeted balance training essential 4, 5

2. Medication Review and Modification

Systematically review and reduce or eliminate high-risk medications, particularly psychotropic agents, as this intervention has strong evidence for fall reduction. 1, 2

High-risk medications to target for deprescription include:

• Psychotropic medications (benzodiazepines, antipsychotics, tricyclic antidepressants) 1, 2
• Cardiovascular agents (diuretics, β-blockers, calcium channel blockers, ACE inhibitors, nitrates) 2
• Vestibular suppressants (antihistamines) should not be used routinely 1, 2
• Narcotics and dopamine agonists/antagonists 2

3. Assistive Device Assessment

Provide advice on appropriate use of assistive devices based on gait assessment findings. 1

• Patients with stride length reduction and increased stride width variability (common in white matter disease) 4 may benefit from walking aids
• Ensure proper fitting and training in device use to prevent device-related falls

4. Treatment of Postural Hypotension

If orthostatic hypotension is identified (≥20 mmHg systolic or ≥10 mmHg diastolic drop), implement management strategies including medication adjustment, hydration, compression stockings, and education on positional changes. 1

5. Environmental Modification

Assess and modify home environmental hazards including poor lighting, tripping hazards, and unsafe conditions. 1, 2

• This intervention has Grade C evidence but is low-risk and should be included 1

What NOT to Do

Do not prescribe vestibular suppressant medications (antihistamines, benzodiazepines) as primary treatment for balance difficulty in white matter disease. 1

• These medications are ineffective for chronic balance impairment and increase fall risk through sedation and cognitive impairment 1, 2
• They may mask symptoms without addressing underlying pathophysiology

Special Considerations for White Matter Disease

While the above interventions have the strongest evidence, understand that:

• Gait impairment in white matter disease results from disruption of white matter tracts connecting motor regions, particularly affecting stride length, velocity, and stride width 4, 5
• Loss of white matter integrity in normal-appearing white matter (detected on diffusion tensor imaging) contributes to gait disturbances beyond visible white matter lesions 5
• The corpus callosum, especially the genu, shows the strongest association with gait performance, suggesting that interhemispheric connectivity is critical 5
• Despite severe white matter burden, pure small vessel disease causes relatively mild gait impairment compared to elderly patients with multiple comorbidities 6, suggesting that aggressive management of vascular risk factors and comorbidities is essential

Referral Indications

Refer to a geriatrician or specialist if:

• No improvement after implementing multifactorial interventions 1
• Focal neurological signs develop (suggesting stroke or myelopathy) 2, 7
• Suspected Parkinson's disease or other neurodegenerative disorder 2
• Patient requires specialized vestibular rehabilitation beyond primary care capacity 3

Long-Term Management

Continue vascular risk factor management (blood pressure control, antiplatelet therapy if indicated, statin therapy) as small vessel disease is potentially preventable and progressive 8, 4