Comparison of verticality alignment ability between older adults with falls and normal elderlies using a virtual reality system
-
fateme kazemi
,
parisa Jalilzadeh Afshari
,
Saeideh Mehrkian
,
Mohammad Hassan Azarsa
,
Enayatollah Bakhshi
Abstract
Background and Aim: Falls in older adults are a major clinical and public health issue, often linked to dizziness and vestibular dysfunction. Changes in verticality perception, visual dependence, and postural control can increase fall risk. This study compared vestibular–perceptual and and postural control characteristics using a virtual reality system between older adults with and without dizziness-related falls.
Methods: We enrolled 66 older adults in a fall group (n = 33) or a control group (n = 33) based on dizziness-related falls. All participants met the same criteria for cognitive status, sensory function, psychological health, medical stability, and vestibular integrity. We assessed static and dynamic subjective visual vertical (SVV) and used a virtual reality reaching task to measure postural control. Participants also completed self-reported dizziness-related disability and fear of falling measures. We compared groups and ran regression analyses, controlling for age.
Results: Compared to controls, older adults with falls showed greater deviations in static and dynamic SVV and higher visual dependence (p < 0.05). The fall group also had reduced center-of-pressure displacement and trunk excursion during the virtual reaching task. Dizziness-related disability and fear of falling correlated with vestibular–perceptual and postural measures.
Conclusion: Older adults who experience dizziness-related falls exhibit impaired verticality perception, greater reliance on visual cues, and altered postural control. These findings underscore the value of vestibular–perceptual assessments and virtual reality tasks for identifying fall risk and guiding targeted rehabilitation for older adults.
1. Stoodley I, Conroy S. An ageing population: the benefits and challenges. Medicine. 2024;52(11):710-2. [DOI:10.1016/j.mpmed.2024.08.013]
2. Frieson CW, Tan MP, Ory MG, Smith ML. Editorial: Evidence-Based Practices to Reduce Falls and Fall-Related Injuries Among Older Adults. Front Public Health. 2018;6:222. [DOI:10.3389/fpubh.2018.00222]
3. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51-61. [DOI:10.1016/j.maturitas.2013.02.009]
4. Ekvall Hansson E, Magnusson M. Vestibular asymmetry predicts falls among elderly patients with multi-sensory dizziness. BMC Geriatr. 2013; 22;13:77. [DOI:10.1186/1471-2318-13-77]
5. Fernández L, Breinbauer HA, Delano PH. Vertigo and Dizziness in the Elderly. Front Neurol. 2015;6:144. [DOI:10.3389/fneur.2015.00144]
6. Barr CJ, McLoughlin JV, van den Berg ME, Sturnieks DL, Crotty M, Lord SR. Visual Field Dependence Is Associated with Reduced Postural Sway, Dizziness and Falls in Older People Attending a Falls Clinic. J Nutr Health Aging. 2016;20(6):671-6. [DOI:10.1007/s12603-015-0681-y]
7. Jamali M, Carriot J, Chacron MJ, Cullen KE. Coding strategies in the otolith system differ for translational head motion vs. static orientation relative to gravity. Elife. 2019;8:e45573. [DOI:10.7554/eLife.45573]
8. Zu Eulenburg P, Ruehl RM, Runge P, Dieterich M. Ageing-related changes in the cortical processing of otolith information in humans. Eur J Neurosci. 2017;46(12):2817-25. [DOI:10.1111/ejn.13755]
9. Lopez C, Mercier MR, Halje P, Blanke O. Spatiotemporal dynamics of visual vertical judgments: early and late brain mechanisms as revealed by high-density electrical neuroimaging. Neuroscience. 2011;181:134-49. [DOI:10.1016/j.neuroscience.2011.02.009]
10. Dieterich M, Brandt T. Perception of Verticality and Vestibular Disorders of Balance and Falls. Front Neurol. 2019;10:172. [DOI:10.3389/fneur.2019.00172]
11. Totilienė M, Uloza V, Lesauskaitė V, Damulevičienė G, Kregždytė R, Kaski D, et al. Impaired Subjective Visual Vertical and Increased Visual Dependence in Older Adults with Falls. Front Aging Neurosci. 2021;13:667608. [DOI:10.3389/fnagi.2021.667608]
12. Mueller AL, Liebmann LB, Petrak MR, Bahner CM, Weberling LM, Weiss AD, et al. Evaluation of the utricular function with the virtual-subject visual vertical system: comparison with ocular vestibular-evoked myogenic potentials. Acta Otolaryngol. 2020;140(5):366-72. [DOI:10.1080/00016489.2020.1718202]
13. Böhmer A, Mast F. Assessing otolith function by the subjective visual vertical. Ann N Y Acad Sci. 1999;871:221-31. [DOI:10.1111/j.1749-6632.1999.tb09187.x]
14. Stevens JA, Mahoney JE, Ehrenreich H. Circumstances and outcomes of falls among high risk community-dwelling older adults. Inj Epidemiol. 2014;1(1):5. [DOI:10.1186/2197-1714-1-5]
15. Santos MJ, Kanekar N, Aruin AS. The role of anticipatory postural adjustments in compensatory control of posture: 1. Electromyographic analysis. J Electromyogr Kinesiol. 2010;20(3):388-97. [DOI:10.1016/j.jelekin.2009.06.006]
16. Basta D, Todt I, Scherer H, Clarke A, Ernst A. Postural control in otolith disorders. Hum Mov Sci. 2005;24(2):268-79. [DOI:10.1016/j.humov.2005.04.002]
17. Viau A, Feldman AG, McFadyen BJ, Levin MF. Reaching in reality and virtual reality: a comparison of movement kinematics in healthy subjects and in adults with hemiparesis. J Neuroeng Rehabil. 2004;1(1):11. [DOI:10.1186/1743-0003-1-11]
18. Ang GC, Low SL, How CH. Approach to falls among the elderly in the community. Singapore Med J. 2020;61(3):116-21. [DOI:10.11622/smedj.2020029]
19. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9. [DOI:10.1111/j.1532-5415.2005.53221.x]
20. Malakouti K, Fathollahi P, Mirabzadeh A, Salavati M, Kahani S. [Validation of Geriatric Depression Scale (GDS-15) in Iran]. Pejouhesh dar Pezeshki;2007;30(4):361-8. Persian.
21. Jafarzadeh S, Bahrami E, Pourbakht A, Jalaie S, Daneshi A. Validity and reliability of the Persian version of the dizziness handicap inventory. J Res Med Sci. 2014;19(8):769-75.
22. Sadeghi N, Heravi-Karimooi M, Rejeh N, Montazeri A. Translation and initial validation of the Persian version of geriatric fear of falling measure (GFFM). Payesh; 2021;20(3):347-56. [DOI:10.52547/payesh.20.3.347]
23. Alavian S, Taghizade G, Mahdizade H, Behzadipour S. A computerized assessment tool for the upper extremities motor performance in individuals with Parkinson's disease. Biomed Signal Process Control. 2024;87(4):105547. [DOI:10.1016/j.bspc.2023.105547]
24. Cenciarini M, Peterka RJ. Stimulus-dependent changes in the vestibular contribution to human postural control. J Neurophysiol. 2006 May;95(5):2733-50. [DOI:10.1152/jn.00856.2004]
25. Hayashi S, Kamo T, Ogihara H, Tani Y, Hoshino K, Kobayashi K, et al. Effects of subjective visual verticality and visual dependence on balance function in older adults using a smartphone-based virtual reality system. Perception. 2025;54(9):674-88. [DOI:10.1177/03010066251342006]
26. Barra J, Marquer A, Joassin R, Reymond C, Metge L, Chauvineau V, et al. Humans use internal models to construct and update a sense of verticality. Brain. 2010 Dec;133(Pt 12):3552-63. [DOI:10.1093/brain/awq311]
27. Zalewski CK. Aging of the Human Vestibular System. Semin Hear. 2015;36(3):175-96. [DOI:10.1055/s-0035-1555120]
28. Li Y, Smith RM, Whitney SL, Seemungal BM, Ellmers TJ. Association between dizziness and future falls and fall-related injuries in older adults: a systematic review and meta-analysis. Age Ageing. 2024;53(9):afae177. [DOI:10.1093/ageing/afae177]
29. Baccini M, Paci M, Del Colletto M, Ravenni M, Baldassi S. The assessment of subjective visual vertical: comparison of two psychophysical paradigms and age-related performance. Atten Percept Psychophys. 2014;76(1):112-22. [DOI:10.3758/s13414-013-0551-9]
30. Ashish G, Augustine AM, Tyagi AK, Lepcha A, Balraj A. Subjective visual vertical and horizontal: normative values using a software-based test in the Indian population. Indian J. Otol. 2016;22(3): 208-12. [DOI:10.4103/0971-7749.187972]
2. Frieson CW, Tan MP, Ory MG, Smith ML. Editorial: Evidence-Based Practices to Reduce Falls and Fall-Related Injuries Among Older Adults. Front Public Health. 2018;6:222. [DOI:10.3389/fpubh.2018.00222]
3. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51-61. [DOI:10.1016/j.maturitas.2013.02.009]
4. Ekvall Hansson E, Magnusson M. Vestibular asymmetry predicts falls among elderly patients with multi-sensory dizziness. BMC Geriatr. 2013; 22;13:77. [DOI:10.1186/1471-2318-13-77]
5. Fernández L, Breinbauer HA, Delano PH. Vertigo and Dizziness in the Elderly. Front Neurol. 2015;6:144. [DOI:10.3389/fneur.2015.00144]
6. Barr CJ, McLoughlin JV, van den Berg ME, Sturnieks DL, Crotty M, Lord SR. Visual Field Dependence Is Associated with Reduced Postural Sway, Dizziness and Falls in Older People Attending a Falls Clinic. J Nutr Health Aging. 2016;20(6):671-6. [DOI:10.1007/s12603-015-0681-y]
7. Jamali M, Carriot J, Chacron MJ, Cullen KE. Coding strategies in the otolith system differ for translational head motion vs. static orientation relative to gravity. Elife. 2019;8:e45573. [DOI:10.7554/eLife.45573]
8. Zu Eulenburg P, Ruehl RM, Runge P, Dieterich M. Ageing-related changes in the cortical processing of otolith information in humans. Eur J Neurosci. 2017;46(12):2817-25. [DOI:10.1111/ejn.13755]
9. Lopez C, Mercier MR, Halje P, Blanke O. Spatiotemporal dynamics of visual vertical judgments: early and late brain mechanisms as revealed by high-density electrical neuroimaging. Neuroscience. 2011;181:134-49. [DOI:10.1016/j.neuroscience.2011.02.009]
10. Dieterich M, Brandt T. Perception of Verticality and Vestibular Disorders of Balance and Falls. Front Neurol. 2019;10:172. [DOI:10.3389/fneur.2019.00172]
11. Totilienė M, Uloza V, Lesauskaitė V, Damulevičienė G, Kregždytė R, Kaski D, et al. Impaired Subjective Visual Vertical and Increased Visual Dependence in Older Adults with Falls. Front Aging Neurosci. 2021;13:667608. [DOI:10.3389/fnagi.2021.667608]
12. Mueller AL, Liebmann LB, Petrak MR, Bahner CM, Weberling LM, Weiss AD, et al. Evaluation of the utricular function with the virtual-subject visual vertical system: comparison with ocular vestibular-evoked myogenic potentials. Acta Otolaryngol. 2020;140(5):366-72. [DOI:10.1080/00016489.2020.1718202]
13. Böhmer A, Mast F. Assessing otolith function by the subjective visual vertical. Ann N Y Acad Sci. 1999;871:221-31. [DOI:10.1111/j.1749-6632.1999.tb09187.x]
14. Stevens JA, Mahoney JE, Ehrenreich H. Circumstances and outcomes of falls among high risk community-dwelling older adults. Inj Epidemiol. 2014;1(1):5. [DOI:10.1186/2197-1714-1-5]
15. Santos MJ, Kanekar N, Aruin AS. The role of anticipatory postural adjustments in compensatory control of posture: 1. Electromyographic analysis. J Electromyogr Kinesiol. 2010;20(3):388-97. [DOI:10.1016/j.jelekin.2009.06.006]
16. Basta D, Todt I, Scherer H, Clarke A, Ernst A. Postural control in otolith disorders. Hum Mov Sci. 2005;24(2):268-79. [DOI:10.1016/j.humov.2005.04.002]
17. Viau A, Feldman AG, McFadyen BJ, Levin MF. Reaching in reality and virtual reality: a comparison of movement kinematics in healthy subjects and in adults with hemiparesis. J Neuroeng Rehabil. 2004;1(1):11. [DOI:10.1186/1743-0003-1-11]
18. Ang GC, Low SL, How CH. Approach to falls among the elderly in the community. Singapore Med J. 2020;61(3):116-21. [DOI:10.11622/smedj.2020029]
19. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9. [DOI:10.1111/j.1532-5415.2005.53221.x]
20. Malakouti K, Fathollahi P, Mirabzadeh A, Salavati M, Kahani S. [Validation of Geriatric Depression Scale (GDS-15) in Iran]. Pejouhesh dar Pezeshki;2007;30(4):361-8. Persian.
21. Jafarzadeh S, Bahrami E, Pourbakht A, Jalaie S, Daneshi A. Validity and reliability of the Persian version of the dizziness handicap inventory. J Res Med Sci. 2014;19(8):769-75.
22. Sadeghi N, Heravi-Karimooi M, Rejeh N, Montazeri A. Translation and initial validation of the Persian version of geriatric fear of falling measure (GFFM). Payesh; 2021;20(3):347-56. [DOI:10.52547/payesh.20.3.347]
23. Alavian S, Taghizade G, Mahdizade H, Behzadipour S. A computerized assessment tool for the upper extremities motor performance in individuals with Parkinson's disease. Biomed Signal Process Control. 2024;87(4):105547. [DOI:10.1016/j.bspc.2023.105547]
24. Cenciarini M, Peterka RJ. Stimulus-dependent changes in the vestibular contribution to human postural control. J Neurophysiol. 2006 May;95(5):2733-50. [DOI:10.1152/jn.00856.2004]
25. Hayashi S, Kamo T, Ogihara H, Tani Y, Hoshino K, Kobayashi K, et al. Effects of subjective visual verticality and visual dependence on balance function in older adults using a smartphone-based virtual reality system. Perception. 2025;54(9):674-88. [DOI:10.1177/03010066251342006]
26. Barra J, Marquer A, Joassin R, Reymond C, Metge L, Chauvineau V, et al. Humans use internal models to construct and update a sense of verticality. Brain. 2010 Dec;133(Pt 12):3552-63. [DOI:10.1093/brain/awq311]
27. Zalewski CK. Aging of the Human Vestibular System. Semin Hear. 2015;36(3):175-96. [DOI:10.1055/s-0035-1555120]
28. Li Y, Smith RM, Whitney SL, Seemungal BM, Ellmers TJ. Association between dizziness and future falls and fall-related injuries in older adults: a systematic review and meta-analysis. Age Ageing. 2024;53(9):afae177. [DOI:10.1093/ageing/afae177]
29. Baccini M, Paci M, Del Colletto M, Ravenni M, Baldassi S. The assessment of subjective visual vertical: comparison of two psychophysical paradigms and age-related performance. Atten Percept Psychophys. 2014;76(1):112-22. [DOI:10.3758/s13414-013-0551-9]
30. Ashish G, Augustine AM, Tyagi AK, Lepcha A, Balraj A. Subjective visual vertical and horizontal: normative values using a software-based test in the Indian population. Indian J. Otol. 2016;22(3): 208-12. [DOI:10.4103/0971-7749.187972]
| Files | ||
| Issue | Articles in Press | |
| Section | Research Article(s) | |
| Keywords | ||
| vestibular dysfunction ageing falling vertical perception postural control virtual reality | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
kazemi fateme, Jalilzadeh Afshari parisa, Mehrkian S, Azarsa MH, Bakhshi E. Comparison of verticality alignment ability between older adults with falls and normal elderlies using a virtual reality system. Aud Vestib Res. 2026;.
