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Careplan

Balance Impairment, Adult

Oct.01.2020

Balance Impairment (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient experiencing an inability to safely or comfortably maintain upright control of the body’s center of gravity relative to the base of support in the given environment.

Key Information

  • Balance is a complex process involving interactions between multiple body systems, including musculoskeletal, neurologic and sensory systems, such as vestibular, visual and somatosensory systems. Assessment and treatment should address the multifactorial components of balance.
  • Poor balance confidence may lead to reduced participation in functional activities. This reduced participation and sedentary behavior may lead to decreased strength, range of motion and endurance, which can further impair balance. It is important to address limitations in balance confidence.
  • Deficits in attention, judgment, memory and cognition directly influence balance abilities, as well as hinder motor learning processes needed to relearn balance skills.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Improved Balance and Postural Control

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Balance Impairment

Signs/Symptoms/Presentation

  • dizziness
  • fear of falling
  • hearing impairment
  • history of fall
  • postural control impaired
  • reliance on arms and hands for support
  • restricts movement to avoid threats to balance
  • unsteady gait
  • vertigo
  • visual impairment
  • wide base of support

Problem Intervention

Optimize Balance and Safe Activity

  • Evaluate balance skills using a validated tool.
  • Screen for and address underlying impairments, such as muscle weakness, sensorimotor, cognitive and postural control deficits.
  • Promote participation in regular daily and physical activity to minimize decline associated with inactivity; provide adaptations as needed.
  • Recommend and facilitate environmental modifications to promote independence and safety, such as grab bars or bath seat; consider a home assessment.
  • Facilitate safe surroundings; keep needed items within reach, such as call light and personal belongings.
  • Provide a safe, barrier-free, uncluttered environment that promotes optimal level of function; ensure adequate lighting, especially at night.
  • Train in and reinforce use of appropriate orthoses, adaptive equipment or assistive devices (e.g., ankle foot orthosis, rolling walker, long-handled adaptive equipment).
  • Facilitate therapeutic interventions, such as balance training, muscle strengthening, trunk training, virtual reality and tai chi, yoga or Pilates exercise.
  • Address sitting balance impairments with interventions, such as supportive seating, positioning devices and therapeutic exercise.

Associated Documentation

  • Activity Management
  • Adaptive Equipment Use
  • Safety Promotion/Fall Prevention
  • Self-Care Promotion

Education

CPG-Specific Education Topics

Overview

  • description

  • signs/symptoms

Self Management

  • activity

  • assistive/adaptive devices

  • home safety

  • prevent skin breakdown

  • provider follow-up

  • rehabilitation therapy

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations

Geriatric

  • Balance disorders are a common cause of falls in older adults and can lead to injury, as well as loss of function, independence and quality of life.
  • Polypharmacy and specific classes of medications, especially those that affect the central nervous system, can lead to balance disorders and should be managed carefully.
  • Gradual decline of vestibular and sensory function with normal aging, sarcopenia and slowing of motor responses contribute to balance impairments. Treatment to improve balance in the elderly is imperative to address these declines.
  • Vitamin D supplementation may improve balance, along with reducing falls and nonvertebral fractures for those with deficiency. Daily doses higher than 2000 IU for the general older adult population may be harmful and no more beneficial than standard doses of 800 IU.

References

  • (2018). Lennon, S., Rambhary, G., Cert, P. G., Verheyden, G (Eds.), Physical management for neurological conditions. London: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Alhasan, H.; Hood, V.; Mainwaring, F. The effect of visual biofeedback on balance in elderly population: A systematic review. Clinical Interventions in Aging. 2017;12, 487. [Metasynthesis,Meta-analysis,Systematic Review]
  • Amorim, J. S. C. D.; Leite, R. C.; Brizola, R.; Yonamine, C. Y. Virtual reality therapy for rehabilitation of balance in the elderly: A systematic review and META-analysis. Advances in Rheumatology. 2018;58, 18. doi:10.1186/s42358-018-0013-0 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Bahureksa, L.; Najafi, B.; Saleh, A.; Sabbagh, M.; Coon, D.; Mohler, M. J.; Schwenk, M. The impact of mild cognitive impairment on gait and balance: A systematic review and meta-analysis of studies using instrumented assessment. Gerontology. 2017;63(1), 67-83. doi:10.1159/000445831 [Metasynthesis,Meta-analysis,Systematic Review]
  • Barker, A. L.; Bird, M. L.; Talevski, J. Effect of pilates exercise for improving balance in older adults: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2015;96(4), 715-723. doi:10.1016/j.apmr.2014.11.021 [Metasynthesis,Meta-analysis,Systematic Review]
  • Cadore, E. L.; Rodríguez-Mañas, L.; Sinclair, A.; Izquierdo, M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults:  A systematic review. Rejuvenation Research. 2013;16(2), 105-114. [Metasynthesis,Meta-analysis,Systematic Review]
  • Chui, K. K.; Jorge, M.; Yen, S.; Lusardi, M. M. (2020). Orthotics and prosthetics in rehabilitation. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Cuevas-Trisan, R. Balance problems and fall risks in the elderly. Physical Medicine and Rehabilitation Clinics. 2017;28(4), 727-737. doi:10.1016/j.pmr.2017.06.006 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Dawson-Hughes, B.; Bischoff-Ferrari, H. A. (2018). In Adult Vitamin D Deficiency: Fracture and Fall Prevention. Vitamin D. (pp.221-227). Cambridge: Academic Press/Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Eibling, D. Balance disorders in adults. Clinical Geriatric Medicine. 2018;34, 175-181. doi:10.1016/j.cger.2018.01.002 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Farlie, M. K.; Robins, L.; Haas, R.; Keating, J. L.; Molloy, E.; Haines, T. P. Programme frequency, type, time and duration do not explain the effects of balance exercise in older adults: A systematic review with a meta-regression analaysis. British Journal of Sports Medicine. 2019;53(16), 996-1002. doi:10.1136/bjsports-2016-096874 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gerards, M. H.; McCrum, C.; Mansfield, A.; Meijer, K. Perturbation-based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatrics & Gerontology International. 2017;17(12), 2294-2303. doi:10.1111/ggi.13082 [Metasynthesis,Meta-analysis,Systematic Review]
  • Ghislieri, M.; Gastaldi, L.; Pastorelli, S.; Tadano, S.; Agostini, V. Wearable inertial sensors to assess standing balance: A systematic review. Sensors. 2019;19(19), 4075. doi:10.3390/s19194075 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gordt, K.; Gerhardy, T.; Najafi, B.; Schwenk, M. Effects of wearable sensor-based balance and gait training on balance, gait, and functional performance in healthy and patient populations: A systematic review and meta-analysis of randomized controlled trials. Gerontology. 2018;64(1), 74-89. doi:10.1159/000481454 [Metasynthesis,Meta-analysis,Systematic Review]
  • Granacher, U.; Gollhofer, A.; Hortobagyi, T.; Kressig, R. W.; Muehlbauer, T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Medicine. 2013;43(7), 627-641. doi:10.1007/s40279-013-0041-1 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gulanick, M.; Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions and outcomes. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Howard, M. C. A meta-analysis and systematic literature review of virtual reality rehabilitation programs. Computers in Human Behavior. 2017;70, 317-327. doi:10.1016/j.chb.2017.01.013 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Huang, H. W.; Nicholson, N.; Thomas, S. Impact of tai chi exercise on balance disorders: A systematic review. American Journal of Audiology. 2019;28(2), 391-404. doi:10.1044/2018_AJA-18-0115 [Metasynthesis,Meta-analysis,Systematic Review]
  • Kauffman, T. L.; Scott, R.; Barr, J. O.; Moran, M. L. (2014). A comprehensive guide to geriatric rehabilitation. Edinburgh: Churchill Livingstone, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Low, D. C.; Walsh, G. S.; Arkesteijn, M. Effectiveness of exercise interventions to improve postural control in older adults: A systematic review and meta-analyses of centre of pressure measurements. Sports Medicine. 2017;47(1), 101-112. doi:10.1007/s40279-016-0559-0 [Metasynthesis,Meta-analysis,Systematic Review]
  • Moral-Munoz, J. A.; Esteban-Moreno, B.; Herrera-Viedma, E.; Cobo, M. J.; Pérez, I. J. Smartphone applications to perform body balance assessment: A standardized review. Journal of Medical Systems. 2018;42(7), 119. doi:10.1007/s10916-018-0970-1 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Moreno-Segura, N.; Igual-Camacho, C.; Ballester-Gil, Y.; Blasco-Igual, M. C.; Blasco, J. M. The effects of the Pilates training method on balance and falls of older adults: A systematic review and meta-analysis of randomized controlled trials. Journal of Aging and Physical Activity. 2018;26(2), 327-344. doi:10.1123/japa.2017-0078 [Metasynthesis,Meta-analysis,Systematic Review]
  • Muir, S. W.; Montero-Odasso, M. Effect of vitamin D supplementation on muscle strength, gain and balance in older adults: A systematic review and meta-analysis . Journal of the American Geriatrics Society. 2011;59(12), 2291-2300. doi:10.1111/j.1532-5415.2011.03733.x Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Okubo, Y.; Schoene, D.; Lord, S. R. Step training improves reaction time, gait and balance and reduces falls in older people: A systematic review and meta-analysis. British Journal of Sports Medicine. 2017;51(7), 586-593. doi:10.1136/bjsports-2015-095452 [Metasynthesis,Meta-analysis,Systematic Review]
  • Osoba, M. Y.; Rao, A. K.; Agrawal, S. K.; Lalwani, A. K. Balance and gait in the elderly: A contemporary review. Laryngoscope Investigative Otolaryngology. 2019;4(1), 143-153. doi:10.1002/lio2.252 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Pendleton, H. M.; Schultz-Krohn, W. (2018). Pedretti's occupational therapy: Practice skills for physical dysfunction. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Saverino, A.; Waller, D.; Rantell, K.; Parry, R.; Mariarty, A.; Playford, E. D. The role of cognitive factors in predicting balance and fall risk in a neuro-rehabilitation setting. PLoS One. 2016;11(4), e0153469. doi:10.1371/journal.pone.0153469 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Swearingen, P. L. (2016). All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Thomas, E.; Battaglia, G.; Patti, A.; Brusa, J.; Leonardi, V.; Palma, A.; Bellafiore, M. Physical activity programs for balance and fall prevention in elderly: A systematic review. Medicine. 2019;98(27) doi:10.1097/MD.0000000000016218 [Metasynthesis,Meta-analysis,Systematic Review]
  • Umphred, D. A.; Lazaro, R. T.; Roller, M. L.; Burton, G. U. (2013). Umphred's neurological rehabilitation. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Wang, J.; Xu, J.; An, R. Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis. Gait & Posture. 2019; doi:10.1016/j.gaitpost.2019.01.002 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Youkhana, S.; Dean, C. M.; Wolff, M.; Sherrington, C.; Tiedemann, A. Yoga-based exercise improves balance and mobility in people aged 60 and over: A systematic review and meta-analysis. Age and Ageing. 2015;45(1), 21-29. doi:10.1093/ageing/afv175 [Metasynthesis,Meta-analysis,Systematic Review]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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