In 2020, there were in Portugal 2 345 267 people aged over 65. It is known that vertigo is one of the symptoms that most often leads to the search for medical help by people over 75 years of age. Vertigo is directly related to imbalance and risk of falling . Comparing Portugal with Sweden, countries with equivalent population, 10 million inhabitants, in the second one 48 000 citizens over 65 years old fall each year and about 1 200 dies. This corresponds to 4 deaths per day from direct or indirect causes of falls. Falling causes in the elderly In the elderly, falls have a multifactorial origin . Different situations may have important contributions like: Anemia; Poor nutrition; Cardiovascular diseases, such as arrhythmias, arterial hypertension and others; Diabetes; Neurological diseases such as Parkinson disease, dementia and others; Depression; Multiple pharmacological treatments, which are common at these ages. Often, other problems are present, like: A low body mass index, ie thinness; Limited physical activity; Sometimes cognitive impairment. Vestibular impairment, that is, what is associated with the inner ear responsible for balance, and multisensory balance control cannot be forgotten in the evaluation of elderly. Balance depends on the integration by the central nervous system of information from the vision, vestibule and receptors in the feet, muscles, and joints . With aging, degenerative changes occur in all these structures, and can lead to inappropriate fall prevention strategies. Individual responses to the same deficit level depend above all on compensation by the central nervous system. With age, vision deteriorates as does the ability to use visual information to improve balance control, especially when moving. The use of well-fitting eyeglasses to correct visual deficits and cataract surgery when necessary are of particular importance. The decrease in tactile and vibratory sensitivity that exists in the legs and feet of the elderly, especially associated with neuropathies such as that found in diabetes, increases instability. These issues should be worked on during balance training. Muscle reserve , on which movements such as getting up from a chair, rotating the body, climbing stairs, which require alternating body weight on only one leg, is always compromised in seniors with limited physical activity. Increasing muscle strength is also one of the goals of rehabilitation. Regarding the vestibular system , its structures also show degeneration from birth in the case of hair cells in the semicircular canals, and from middle age onwards in the macules of otolith organs and in the neurons of the vestibular nuclei. This phenomenon is called presbyvestibulopathy and is the reason fot symptoms of vertigo and balance disturbance experienced by seniors. Asymmetry and vestibular functioning deficit condition balance strategies that become inadequate and ineffective. There is a proven link between the side of the femoral neck fracture resulting from the fall and the vestibule that functions poorly or worse. Benign paroxysmal positional vertigo The role of benign paroxysmal positional vertigo as a cause of vertigo and imbalance in the elderly is often underdiagnosed and may contribute for up 33.3% of cases . Thus, even with no clear complaints of positional vertigo, diagnostic maneuvers are mandatory in the evaluation. The role of vestibular function in the hippocampus (structure of the central nervous system) is well documented. A reduction in vestibular functioning results in an atrophy of the hippocampus and impairment of its functioning. This leads to spatial disorientation and memory impairment, that are important for balance and have implications for the development of dementia. Previous experiences, falls or near-falls, with the fear that entail and the consequent associated avoidance behavior, have impacting consequences on quality of life. A multidisciplinary approach The multiple possible causes for senior imbalance require their multidisciplinary approach . The role of General and Family Medicine, of Internal Medicine, integrating the cardiology, neurology, psychiatry, metabolic, orthopedy, aspects, is fundamental. Patients who come to the otoneurology consultation asking for help have almost always followed this path. History and clinical evaluation are of paramount importance. Objectification of vestibular deficits or asymmetries by videonystagmography, video head impulse test and characterization of imbalance by subjective vertical and computerized dynamic posturography is the next step. The ultimate goal is to regain balance. The capacity of compensation by the central nervous system exists and the vestibular rehabilitation program allows the adaptation of the system, even in the elderly . Optokinetic stimulation, training on a dynamic posturography platform, gaze stabilization exercises, balance training at home, awareness of postural deviations and their correction, intervention in the environment to make it safer, stimulation for the adoption of behaviors of active life and socialization, are an integral part of the program. The progress and development of a country is also measured by its autonomous senior citizens, with a gratifying physical, mental and social life. This article was written by the Hospital da Luz otorhinolaryngology team. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
