Anatomy of a Fall: Balance Disorders After a Stroke

What are the balance disorders that can occur after a stroke and why?

Before explaining balance disorders, it seems useful to me to recall what a stroke is. A stroke (cerebral vascular accident) occurs when a blood clot blocks a cerebral artery (known as ischemic stroke). A stroke can also be caused by the rupture of a cerebral artery (known as hemorrhagic stroke). In both cases, part of the brain is deprived of oxygen and suffers damage. The longer it goes untreated, the more this area of the brain dies.

Such an event often leaves sequelae in the body. Balance disorders may occur if the affected part of the brain directly controls balance, but also when other affected brain areas lead to complications (such as paralysis, weakness on one side of the body or a single limb, difficulty feeling the leg or the floor underfoot, or reduced visual acuity), all of which can result in balance problems.

Other complications following a stroke (cognitive, motor, concentration, or attention disorders) as well as fatigue can also cause balance issues and increase the risk of falls. Fatigue is likely the most underestimated symptom, as it can persist long after a stroke, causing weakness and reduced attention and concentration, particularly in patients over 65.

We know that someone who has had a stroke after age 65 has three times the risk of falling compared to someone of the same age who hasn't had a stroke[1].

It’s truly a major concern for this at-risk population. Additionally, there's a link between depression and fall risks: 30% to 50% of stroke patients who suddenly lose their autonomy fall into depression and are more prone to falling[2].

Balance disorders and the associated fall risks can also be caused by external factors such as poor medication management or an unsuitable environment.

A stroke patient may be taking medications like painkillers, anticoagulants, antidepressants, or diuretics. Patients must be assisted in managing their medication because if they take too much or too little, they may experience significant side effects like incontinence, difficulty managing positional changes, blood pressure drops when getting up, or glucose fluctuations (especially in diabetic patients), all of which can increase fall risks (for example, rushing to the toilet may lead to a fall).

The living environment of a stroke patient needs to be adapted to prevent falls: the presence of rugs, stairs without railings, household obstacles, poor lighting, or even unsuitable shoes or slippers can increase fall risks. Sometimes this even limits their return home. Families don’t always fully understand what a stroke entails and may not realize the extent of the complications and deficits caused by it. It’s important to know that one-third of stroke patients remain disabled in daily life even a year later[3]. The risk of falls remains high, and once a patient falls, they often develop a fear of falling. This fear leads to progressive immobility, which gradually isolates and weakens them and destroys their autonomy. It becomes a vicious circle: the less they move, the more likely they are to fall again when they do move. 

Statistics show that 50% of those who have already fallen once will fall a second time[4], increasing hospitalizations and exacerbating the anxiety of both patients and their loved ones.

What are the most common types of falls among stroke patients?

The most frequent falls occur at home or during transfers when the patient moves from a lying to a standing position, such as going to the shower or toilet. The bathroom and toilet are two environments that trigger many falls. Fortunately, severe injuries are rare, but there are still occasional hospitalizations for femoral neck fractures or cerebral hematomas. When a patient returns to the hospital after a fall, the team conducts a comprehensive reassessment of their balance, compares it with previous evaluations, and discusses the context and causes of the fall with the patient and their loved ones. All these elements influence the patient's care plan.

If the patient deteriorates too much and the family no longer feels capable of caring for them at home, they are sent to a nursing home. These are very difficult situations for caregivers who struggle to understand why the patient continues to fall despite their care and attention. They are often very anxious because their daily life suddenly revolves entirely around the patient, their fall risks, the fear of falling, and the possibility of re-hospitalization.

From another perspective, fall risks are also challenging for healthcare professionals, who, like caregivers, bear responsibility for the patient. If a patient falls during their hospital stay, it's essential to determine why and how it happened to implement preventive and/or corrective measures that ensure the patient’s safety while preserving their autonomy as much as possible. Finding the right balance isn’t always easy.

Each week, fall risk assessments are conducted for older patients undergoing rehabilitation. These tests allow us to track their progress and identify what puts them at the greatest risk of falling. The results are communicated to the medical staff, doctors, and family. Good communication among all those involved in the patient's care journey is essential, especially when patients go home for the weekend. We work with the patient to identify what is difficult or easy and develop a treatment plan to work on their balance. We ensure that the family is well informed of this plan and answer all their questions and concerns. But a zero-risk scenario, unfortunately, does not exist...

Depending on the stroke's sequelae, everything changes. That's why we hold meetings with the family, the doctor, paramedical professionals, and the patient to assess the situation and determine to what extent the patient is aware of their new reality outside the hospital. In the hospital, there is always someone around, the patient receives help, and they benefit from all the necessary and adapted equipment. The floor is flat! Once home for the weekend, they are confronted with "real" life, where everything becomes more complicated (getting up, dressing, washing, moving around), and they realize that it's not so simple and that the risks are high.

What medical care is currently available at the Erasme Hospital (H.U.B) to help stroke patients maintain their balance?

Our team works in close synergy with neurologists, diagnostic and interventional neuroradiologists, emergency doctors, intensivists, neurosurgeons, cardiologists, ENT specialists, and rehabilitation specialists (neuropsychologists, psychologists, physiotherapists, occupational therapists, nurses, and dieticians). This collaboration ensures a rapid response, accurate and early determination of stroke causes, immediate treatment adjustments to minimize recurrence risks, and early rehabilitation to reduce functional impact.

Social workers from the H.U.B visit the patient and their family to assess their need for home support to ease their daily life. Psychologists are available to help the patient and their family come to terms with the loss of their "previous life."

We also provide technical aids (canes, crutches, wheelchairs, and adapted scooters), most of which are reimbursed.

What can the patient and/or caregiver implement at home to prevent falls as much as possible?

We advise patients to have their vision and hearing checked, as these significantly impact balance. We also ensure proper medication management by avoiding side effects and adjusting medications when necessary. We recommend paying attention to the patient’s home environment:

• Remove rugs or use anti-slip mats.
• Have a walker or stable support available.
• Always accompany the patient on stairs.
• Wear appropriate shoes.
• Install a shower seat, grab bars, and, if necessary, a hospital bed.

The important thing is that all aids, both technical and human, are ready as soon as the patient returns home.

If the patient lives alone, they can either return home with maximum home assistance, such as:

• A nurse visiting morning and evening, every day;
• Daycare center stays;
• Family and household assistance.

Or they may move to a nursing home if living independently is no longer feasible between home visits.

[1] Cahit U.,Demet G., Nevzat U., Serhat O., Gazi O. «charactéristics of failing in patients with stroke”. Neurology Neurosurg Psychiatry 2000

[2] ibid

[3]Poindessous, J., Basta, M., Gomis, N., Gonzar, A., & Dupaquier, L. (2019). La rééducation précoce post-AVC. 33(206), 16-19.

[4]Batchelor F., Mackintosh S., Said C., Hill K., “Falls after stroke”, International Journal of Stroke, 2012