Balance Issues in Older Adults: An Interview with Dr. Emmanuel Osei-Boamah

Emmanuel Osei-Boamah, M.D., is a primary care physician with Mercy Family Care in Baltimore, Maryland. Double board-certified in geriatric and internal medicine, he has more than 30 years of experience in clinical healthcare. Recently, Dr. Osei-Boamah responded to questions posed by EverydayHealth.com for a feature regarding balance issues in older adults. 

How do you define balance from a clinical perspective in older adults?

Balance in older adults is clinically defined as the ability to maintain control of the body over its base of support to avoid falling, requiring coordinated integration of sensory (visual, vestibular, proprioceptive), neurocognitive, neuromuscular, and musculoskeletal systems. This multisystem integration allows for both static balance (maintaining position without movement) and dynamic balance (moving without losing control).

The clinical conceptualization emphasizes that balance represents a complex physiological process involving multiple contributing systems. Good balance requires integration of sensory information about body position relative to surroundings and the ability to generate appropriate motor responses to control body movement. With aging, progressive loss of functioning in vision, vestibular sense, proprioception, muscle strength, and reaction time contributes to balance deficits.

From a functional perspective, balance is assessed through the ability to perform activities of daily living without falling. Age-related declines in sensory input, central integration, and motor function result in blunted compensatory responses, such that older adults cannot quickly adjust body position when facing environmental hazards. This impaired response is further exacerbated by common comorbidities including diabetes, arthritis, neurologic conditions, stroke, and cognitive disorders.

Clinical assessment typically evaluates both static and dynamic components through standardized tests. Static balance is challenged by decreasing the base of support (progressing from feet apart to feet together to single-leg stance), while dynamic balance is assessed through walking tasks with varying demands.

The ability to control balance during activities of daily living becomes impaired due to deterioration in sensory, cognitive, and musculoskeletal systems, leading to increased fall risk.

Balance impairment is recognized as a strong primary risk factor for falls, with deficits jeopardizing functional independence in older adults. Most guidelines recommend assessing balance through self-reported difficulties with gait and balance, reserving formal testing for those who screen positive.

What makes an exercise specifically effective for building balance rather than strength or flexibility?

Exercises specifically effective for improving balance are characterized by challenges to postural control systems that require dynamic stabilization and sensory integration, distinct from exercises primarily targeting muscle force production or joint range of motion.

Effective balance exercises progressively narrow the support base, advancing from feet apart to feet together, tandem stance, and single-leg stance. This challenges the body's ability to maintain control over the center of mass.

Movements that shift the center of gravity—such as stepping over obstacles, walking on uneven surfaces, or changing directions—require continuous postural adjustments. These dynamic challenges differ fundamentally from static strength exercises.

Balance training engages vestibular, visual, and somatosensory systems simultaneously. Exercises performed with eyes closed or on unstable surfaces force greater reliance on proprioceptive and vestibular input, enhancing sensory processing for postural control.

The most effective programs incorporate movements encountered in daily life, such as reaching, bending, and transitional movements between positions. These “functional exercises” improve motor performance through task-specific training, rather than isolated muscle strengthening.

Balance training differs from flexibility exercises, which aim to increase joint range of motion through sustained muscle lengthening. Balance exercises instead require active neuromuscular coordination to maintain stability during movement.

Unlike strength training, which focuses on maximal force production through progressive resistance, balance exercises emphasize postural control under varying conditions of stability. While strength training may improve balance secondarily through enhanced muscle capacity, specific balance activities provide additional benefits by challenging the neuromuscular control mechanisms.

Evidence suggests balance training requires multidimensional approaches combining center-of-mass control, reaching tasks, and mobility challenges. Programs incorporating gait, balance, coordination, and functional tasks show moderate effectiveness when performed at least three times weekly for three months. The American College of Sports Medicine notes that activities like tai chi, which combine balance, coordination, and proprioceptive training, are particularly beneficial for older adults.

Importantly, specificity matters: adaptations are task-specific rather than transferable, meaning optimal programs should include the full range of postural tasks relevant to an individual's activities.

Why is it important for older adults to practice balance exercises regularly? 

Regular balance exercises are important for older adults because they significantly reduce the risk of falls and fall-related injuries, which are the leading cause of injury-related death in persons aged 65 years or older. Exercise programs that include balance and leg-strengthening components reduce fall rates by approximately 23% compared to control groups.

Falls result from age-related physiological declines in sensory input, central integration, and motor function that impair the body’s ability to quickly adjust position when encountering environmental hazards. Balance exercises directly counteract these age-related deficits by challenging the sensory, cognitive, and musculoskeletal systems through activities that require orientation in space, changes in direction, and control of the center of mass during both static and dynamic situations.

The evidence supporting balance exercise is robust. In a meta-analysis of 64 randomized trials involving over 14,000 individuals, participants in exercise interventions experienced 655 falls per 1,000 patient years versus 850 falls per 1,000 patient years in control groups, representing an absolute risk reduction of 7.2%. The most effective programs specifically target balance and leg strength through functional exercises that focus on movements used in daily life, tai chi, and combined balance plus resistance training.

Long-term exercise programs also reduce injurious falls and fractures. Meta-analysis of moderate-intensity, multi-component training programs (averaging three times per week, 50 minutes per session) showed a 5.8% reduction in falls and 5.5% reduction in injuries.

Effective balance programs require a minimum dose of approximately 50 hours to achieve fall prevention benefits. Both home-based programs (such as the Otago Exercise Program) and group-based programs have demonstrated effectiveness. The American College of Sports Medicine recommends multimodal programs incorporating balance, strength, flexibility, and walking, with tai chi also showing evidence of reducing both injurious and non-injurious falls.

Beyond fall prevention, balance exercises improve multiple dimensions of physical function, including gait speed, the ability to perform activities of daily living, and quality of life. They may also enhance cognitive functions, such as memory and spatial cognition.

How often should older adults perform balance exercises to see meaningful improvements?

Older adults should perform balance exercises two to three times per week to achieve meaningful improvements in balance and fall prevention. Meta-regression analyses suggest this frequency represents the optimal dose for reducing falls and related injuries.

The evidence supporting this recommendation comes from multiple large meta-analyses. Most effective exercise interventions studied by the U.S. Preventive Services Task Force employed two to three sessions per week for 12 months, though intervention durations ranged from two to 30 months. A meta-analysis of long-term exercise programs found that 3 times per week at moderate intensity for approximately 50 minutes per session was the most common and effective frequency.

A minimum total dose of 50 hours appears necessary to achieve effective fall prevention. Most successful programs lasted at least 12 weeks, with nearly one-third continuing for at least one year.

The most effective balance programs include gait, balance, and functional training, combined with strength exercises. These should involve dynamic exercises performed in standing positions that progressively challenge balance. Specific modalities with strong evidence include tai chi (one to three times weekly for 13–48 weeks), the Otago Exercise Program, and multi-component training combining balance, strength, and aerobic activities.

Higher frequencies (four or more times weekly) may not provide additional benefit and could potentially increase fall risk in more vulnerable older adults, possibly due to overtraining effects. The evidence suggests that moderate-intensity, multi-component training with balance exercises performed two to three times weekly represents the safest and most effective regimen for protecting against falls and injuries.

Who should consult a physician before beginning balance exercises?

Those with known cardiovascular, metabolic, or renal disease, or those experiencing symptoms such as chest pain, dizziness, shortness of breath, or changes in balance should consult a physician before starting balance exercises. The American Heart Association recommends medical evaluation for those with established disease or concerning symptoms, as these factors increase the risk of exercise-related adverse events.

Older adults with gait or balance deficits warrant medical evaluation before beginning balance training. Specifically, those with visibly slow gait speed (e.g., <0.6 m per second), gait abnormalities, difficulty holding side-by-side or semi-tandem stances for 10 seconds, inability to rise from a chair without using hands, or preexisting use of an assistive device should be assessed. Additionally, older adults with substantial musculoskeletal pain, neurologic or vestibular symptoms, or cognitive impairment that would limit participation in standard exercise programs may benefit from physical therapy evaluation prior to starting balance exercises.

Cancer survivors at moderate to high risk require medical clearance. Those with peripheral neuropathy, poor bone health, arthritis, lymphedema, presence of prosthesis, or musculoskeletal issues should have stability, balance, and gait assessed before engaging in exercise, with consideration for medical clearance and referral to trained personnel. High-risk survivors—including those with history of lung or major abdominal surgery, ostomy, cardiopulmonary comorbidities (COPD, CHF, CAD, cardiomyopathy), ataxia, severe nutritional deficiencies, severe fatigue, or worsening physical condition—should receive medical evaluation and clearance prior to initiating an exercise program.

Healthy adults planning low- to moderate-intensity balance exercises generally do not need formal medical screening, as requiring medical evaluation could serve as a barrier to healthful exercise. However, men over 45 years and women over 55 years undertaking vigorous exercise who have diabetes mellitus or other cardiovascular risk factors should undergo medical evaluation.

Evidence regarding physician consultation for balance exercises in adults under age 65 without comorbidities is limited.

Dr. Emmanuel Osei-Boamah earned his medical degree from the School of Medical Sciences, Kwame Nkrumah University of Science and Technology, in Kumaski, Ghana, completing his internal medicine residency at St. Agnes Healthcare in Baltimore, Maryland, and his fellowship in Geriatric Medicine at the University of Maryland School of Medicine. He is a member of the American College of Physicians, the American Medical Association, the American Geriatric Society, and the American Medical Directors Association.