Peripheral Neuropathy and Balance

Symptoms

Sensory nerves (most common) - Tingling, "pins and needles," crawling or buzzing. - Numbness or reduced feeling, often starting in the toes and moving upward in a "sock" pattern, later in the hands in a "glove" pattern. - Burning, stabbing, electric or aching pain, often worse at night. - Extreme sensitivity, where even a bedsheet is painful. - Not feeling heat, cold, pain or injury. - Feeling as though walking on cotton wool or stones.

Motor nerves - Weak ankles or feet, tripping over toes, foot slap or "foot drop." - Muscle cramps, twitching and wasting.

Balance and position sense - Unsteadiness, worse in the dark or with eyes closed, such as when washing the face or in the shower. - Difficulty with stairs and uneven ground.

Other nerves (autonomic) - Dizziness on standing, sweating changes, constipation, bladder or sexual problems, especially with diabetes; see dizziness when standing: postural hypotension in older adults.

Common causes

• Diabetes, the leading cause; good sugar control slows damage; see diabetes after 60: a home care guide.
• Vitamin B12 deficiency, common in vegetarians and in people on certain long-term medicines; see vitamin B12 in older vegetarians.
• Alcohol overuse; see alcohol and medicines in older adults.
• Kidney disease, liver disease, thyroid disease.
• Medicines, including some used for cancer, heart problems, infections and other conditions; never stop a medicine yourself, but tell the doctor about symptoms; see medicine side effects families should watch for.
• After shingles; see shingles and nerve pain in older adults.
• Spinal narrowing and nerve root problems; see spinal stenosis and sciatica: walking, pain and aids.
• Unknown cause, which happens in a fair number of cases despite thorough testing.

What the doctor may do

• History and examination: reflexes, sensation (touch, pinprick, vibration, temperature), strength, balance and walking.
• Blood tests: sugar (HbA1c), B12, folate, thyroid, kidney and liver function, blood count, and others.
• Nerve studies (nerve conduction and electromyography), imaging or other tests if needed.
• A review of all medicines, supplements and alcohol.
• A foot examination for sores, deformities, circulation and footwear.

Treating the cause and the symptoms

• Treat the cause where possible: tighter, safe sugar control with the diabetes team; replacing a deficient vitamin as the doctor directs; treating thyroid or kidney disease; reviewing a causative medicine.
• Nerve damage may improve slowly or only partly, and the aim is often to halt progress, ease pain and prevent complications.
• Nerve pain is managed with medicines selected by the doctor, which differ from ordinary painkillers and need careful, gradual use in older adults; do not use leftovers or other people's tablets; see painkillers and older adults and chronic pain in older adults: a whole-person approach.
• Do not start vitamin or "nerve tonic" tablets without tests. Some products contain doses that can themselves harm nerves; see supplements and medicine interactions: a safety guide.
• Non-drug help: physiotherapy, gentle exercise, warmth for comfort (carefully; see below), relaxation, sleep care and sometimes TENS after a clinician's advice; see tens unit guide.

Daily foot care: the most important habit

Numb feet cannot warn of injury. Check and protect them every day; see neuropathy foot care, diabetic foot care at home and diabetic foot ulcers: prevention.

• Inspect both feet daily, including soles, heels, between toes and around nails, in good light, using a mirror or a family member's help if bending or vision is difficult. Look for redness, blisters, cuts, cracks, swelling, colour change, corns, ingrown nails and fungal patches.
• Wash daily in lukewarm water, tested with the elbow or a thermometer or by another person, not with the numb foot; dry gently, especially between the toes.
• Cut nails straight across, or ask a podiatrist or nurse to do so if vision, grip or flexibility is poor; see nail, hair and foot care for the dependent elderly.
• Never walk barefoot, indoors or outdoors, including on hot floors, wet bathrooms and temple stones.
• Check inside shoes for pebbles, rough seams or folds before wearing; wear clean, seamless, dry socks.
• Choose well-fitting, closed, cushioned shoes with a wide toe box and non-slip soles; see choosing shoes for older feet and insoles for foot pain. Buy shoes in the afternoon when feet are largest, and break them in slowly.
• Avoid heat sources: hot water bottles, heating pads, heaters near feet, hot sand and very hot water; see hot water and scald safety for older skin and hot pack safety for older skin.
• Do not cut corns or calluses at home, or use medicated corn plasters or harsh chemicals.
• Treat any break in the skin as important; clean, cover and have a doctor or nurse examine it the same day if it does not heal quickly, particularly in diabetes; see wound care at home for older adults.
• Check hands too, if numb: gloves for gardening, care with knives, kettles and cooking pots; see kitchen safety for older adults and auto-off kettle and stove safety.

Balance and fall prevention

Loss of foot feeling is a major cause of falls; see falls risk assessment at home.

• Light up the route: night lights from bed to toilet, bright bulbs on stairs; see motion night lights for seniors and lighting and contrast at home. Neuropathy makes people rely on sight for balance, so darkness is risky.
• Clear floors: remove loose rugs, cables and clutter; see flooring, rugs and trip hazards.
• Bathroom: non-slip mats, grab bars, a shower chair and a handheld shower; see non-slip bath mats guide, grab bar buying guide and bathroom safety checklist for seniors.
• Stairs: handrails on both sides, contrast tape on step edges; see stairs, steps and thresholds.
• Stand up slowly, pausing before walking, particularly if dizzy.
• Walking aid: a stick, frame or rollator widens the base of support and gives extra sensory information; a physiotherapist can recommend and fit; see how to choose a walking stick, stick or walker: which one does my parent need and walking stick rubber tips.
• Footwear indoors: supportive, non-slip footwear, not loose slippers or socks on smooth floors.
• Alcohol and sedating medicines worsen balance; ask the doctor to review medicines; see polypharmacy and deprescribing: taking fewer, better medicines.
• If a fall happens, see what to do after a fall and how to get up after a fall.

Exercises for balance and strength

A physiotherapist can tailor a programme, which commonly includes: - Ankle and foot exercises: toe lifts, heel raises, ankle circles, picking up a towel with the toes. - Leg strengthening: sit-to-stand from a chair, leg raises, resistance bands; see resistance band routine for seniors. - Balance practice near a counter or sturdy support: feet together, one foot in front of the other, standing on one leg for a few seconds, gradually progressing; a balance pad can add challenge once stable; see balance exercises for seniors and balance pad guide. - Walking, with proper footwear and a safe, even path; see walking programme for older adults.

Always have a sturdy support and a helper within reach for new balance exercises; stop for dizziness, pain, chest discomfort or breathlessness. Do not exercise barefoot if feet are numb.

Living well with neuropathy

• Sleep: pain at night is common; see insomnia in older adults: sleep hygiene and when to get help.
• Mood: chronic nerve symptoms can lead to low mood and anxiety; see depression in older adults. If your parent speaks of hopelessness, seek help the same day; Tele-MANAS (14416) is India's national mental health helpline (check the current number); 112 for emergencies.
• Nutrition: balanced meals and, for those with diabetes, a plan from a dietician; see nutrition for diabetes after 60.
• Alcohol: reduce or avoid.

When to see a doctor

See a doctor soon for new numbness or tingling, pain at night, weakness, falls or near-falls, any foot sore, blister, colour change or swelling, ingrown nail, and for burning feet that disturb sleep.

Call 112 or go to hospital at once for: - Sudden weakness or numbness in the face, arm or leg, speech difficulty or confusion: possible stroke; see stroke warning signs and the first hour. - Rapidly worsening weakness in both legs or arms, or difficulty breathing or swallowing. - Back pain with new numbness in the groin or loss of bladder or bowel control. - A hot, red, swollen foot with fever, a spreading infection, black skin, a foul smell or severe pain in someone with diabetes. - A fall with injury, or inability to get up.

When to ask a professional

Ask the doctor to find the cause with blood tests and review of medicines. Ask a podiatrist or diabetic foot clinic for regular foot checks and nail care. Ask a physiotherapist for balance training and aids, an occupational therapist for home changes, and a pharmacist before any supplement. Seek urgent help for the emergency signs.