Key Facts

Balance and mobility assessment should be performed for all older adults at risk of falls or presenting with mobility difficulties. It informs targeted exercise prescriptions and intervention planning.

Epidemiology

• Gait speed declines approximately 1-2% per year after age 60
• Balance impairment is present in approximately 30% of people >65
• Gait and balance disorders are the second most common cause of falls (after environmental hazards)
• Reduced mobility is strongly associated with institutionalisation and death

Aetiology

Balance and mobility impairment in older adults is usually multifactorial:

• Musculoskeletal: sarcopenia, arthritis, deconditioning
• Neurological: stroke, Parkinson's disease, peripheral neuropathy, cerebellar disease, normal pressure hydrocephalus
• Sensory: visual impairment, vestibular dysfunction, proprioceptive loss
• Cardiovascular: postural hypotension, cardiac failure
• Medications: sedatives, anticholinergics, opioids
• Psychological: fear of falling, depression

Pathophysiology

• Balance requires integration of visual, vestibular, and proprioceptive inputs in the central nervous system
• Age-related changes: reduced muscle mass and strength, slower reaction times, decreased proprioception, reduced visual acuity
• Sarcopenia: loss of muscle mass and function → reduced power generation for postural correction
• Neurodegeneration: affects basal ganglia (gait initiation), cerebellum (coordination), and corticospinal tracts (motor control)

History

• Mobility baseline (independent, walks with aid, wheelchair)
• Recent changes in mobility
• Fear of falling
• Functional capacity (ADLs, IADLs)
• Near-misses and actual falls
• Exercise tolerance

Examination

• Observation of gait: speed, stride length, base width, arm swing, turning, step height
• Romberg test: proprioceptive/vestibular assessment (eyes closed → increased sway)
• Tandem stance/tandem walk: cerebellar assessment
• Functional reach test: forward reach while maintaining balance (normal >25cm)
• Chair stand test: functional lower limb strength
• Joint examination: hip, knee, ankle range of motion and pain
• Neurological examination: tone, power, reflexes, sensation (especially vibration sense/proprioception), coordination

Red Flags

• Sudden-onset gait disturbance (stroke, spinal cord compression)
• Gait with urinary incontinence and cognitive decline (normal pressure hydrocephalus)
• Progressive bilateral weakness (myelopathy, polyneuropathy)
• Festinant gait with freezing (Parkinson's disease)
• Wide-based ataxic gait (cerebellar lesion)

Bedside

• Timed Up and Go (TUG): >12 seconds increased fall risk; >20 seconds high risk
• 30-second Chair Stand Test: number of full stands in 30 seconds
• 4-metre gait speed: <0.8 m/s = slow; <0.6 m/s = significantly impaired
• Berg Balance Scale: if available (scored 0-56)
• SPPB (Short Physical Performance Battery): balance + gait speed + chair stands (0-12)
• Romberg test
• Functional reach test
• Observation of transfers and walking (with and without walking aid)

Bloods

• Vitamin D (deficiency common and correctable)
• B12 and folate (peripheral neuropathy)
• TFTs (hypothyroid myopathy)
• HbA1c (diabetic neuropathy)
• CK (myopathy)

Imaging

• MRI brain: if NPH, cerebellar disease, or stroke suspected
• MRI spine: if myelopathy suspected
• X-ray joints: if arthritic contribution

Special Tests

• Nerve conduction studies: peripheral neuropathy
• Vestibular function tests: if vestibular cause suspected
• Comprehensive geriatric assessment (CGA): holistic assessment

Non-pharmacological

• Targeted exercise programme: based on assessment findings
  • Strength training (resistance exercises for major muscle groups)
  • Balance training (tandem stance, single-leg stance, Tai Chi)
  • Otago Exercise Programme: proven to reduce falls by 35%
• Physiotherapy: individualised programme based on specific deficits
• Occupational therapy: functional assessment, home modifications, assistive devices
• Walking aids: correct selection and fitting (frame, stick, rollator)
• Footwear: well-fitting shoes with good grip
• Falls prevention groups: community-based exercise classes

Pharmacological

• Vitamin D 800-1,000 IU daily: if deficient (improves muscle function)
• Address underlying causes: levodopa for Parkinson's, B12 replacement, thyroid replacement
• Medication review: reduce/stop drugs impairing balance

Surgical/Interventional

• Joint replacement: if severe arthritis limiting mobility
• VP shunt: for confirmed normal pressure hydrocephalus
• Cataract surgery: if visual impairment contributing

Referral Criteria

• Significant gait/balance impairment: physiotherapy and/or falls prevention service
• Suspected neurological cause: neurology referral
• Complex mobility issues in older adults: geriatric medicine referral (CGA)
• Progressive mobility decline: investigate and refer early

• Exercise interventions: reduce falls by 30-40% and improve balance, strength, and confidence
• Gait speed <0.8 m/s: associated with increased mortality and disability
• Fear of falling: responds to exercise-based interventions and CBT
• Untreated mobility impairment leads to progressive disability, social isolation, and institutionalisation
• Early identification and intervention can maintain independence and reduce falls-related morbidity and mortality

Balance and Mobility Assessment Tools Summary

Gait Speed as a Vital Sign