Preventing falls among elderly patients may not be the first (or even the second) thing audiologists think of when treating hearing loss, but hearing healthcare professionals are often the front line in protecting this fragile population.
Not only are audiologists particularly well positioned for triaging and referring patients who are at risk of falling, said Phillip L. Wilson, AuD, they can perform some inexpensive, simple, and informal tests in their offices to identify patients at risk. Dr. Wilson, a clinical professor in the School of Behavioral and Brain Sciences at the University of Texas at Dallas, said audiologists must simply be aware of their patients’ medical history and make appropriate referrals.
Audiologists can—and should—approach fall prevention from a vestibular point of view, but even practitioners who focus on hearing testing and fitting hearing aids can understand and assess the factors that contribute to falls, said Devin L. McCaslin, PhD, an associate professor in the Department of Hearing and Speech Sciences, Division of Audiology, at Vanderbilt University School of Medicine in Nashville.
Patricia A. Gaffney, AuD, an associate professor of audiology at Nova Southeastern University in Fort Lauderdale, FL, said she agreed, noting the importance of understanding the interrelated factors contributing to fall risk—polypharmacy, vision problems, and patients who are unsteady or use a cane or walker.
CONSEQUENCES OF FALLING
In fact, the importance of preventing falls cannot be overstated in older patients because a fall often signals that a patient's health is likely to deteriorate. The physical effects of falling are far-reaching, said Dr. Wilson. Elderly patients who fall and break a hip or other bone or sustain a head injury can become immobilized and have to relocate from independent living to assisted living, he said.
The Centers for Disease Control and Prevention (CDC) has estimated that about one-third of U.S. adults over 65 fall each year, more than half of which occur at home, according to the National Institutes of Health. About 20 percent to 30 percent of people who fall suffer from hip fractures, head trauma, and lacerations, all of which interfere with mobility and increase the risk of subsequent death, according to the CDC.1
Falls are also associated with sizable healthcare costs for patients. The CDC estimated that the total direct medical costs of older adults’ falls in 2013 was $34 billion.2 The direct and indirect costs of falls in older adults is expected to increase to $67.7 billion by 2020.
The prevalence of self-reported falls among older adults may also be rising, according to a research letter.3 Researchers analyzed data from 1998 through 2010 among adults 65 and older included in the Health and Retirement Study conducted by the University of Michigan Institute for Social Research on behalf of the National Institute of Aging. “Falling” was defined as at least one self-reported fall in the preceding two years. The two-year prevalence of self-reported falls among all adults in the study increased from about 28 percent in 1998 to 36 percent in 2010.
THE PATIENTS AS A WHOLE
Audiologists play an integral role in fall prevention from a vestibular point of view, but they first “need to look at the patient as a whole, with a multifactorial approach to care,” said Dr. Gaffney.
Dr. Gaffney and an interdisciplinary team of internists, neurologists, physical therapists, occupational therapists, optometrists, pharmacists, geriatricians, and psychologists work to reduce falls in patients and assess patient risk. While physical therapists conduct various standing tests to assess the patient's functional balance, she provides an assessment of the individual's vestibular function.
“If falls prevention is anything, it's interdisciplinary. People very rarely have only one risk factor,” said Dr. McCaslin. Consequently, various healthcare specialists are needed to create a comprehensive but concise fall risk assessment and to decide on any necessary treatment.
IDENTIFYING PATIENTS AT RISK
A fall risk assessment should be easy to administer in a short period of time and use valid, reliable, and quantifiable measurements, said Dr. McCaslin, noting that portable assessments allow practitioners to visit nursing homes and other facilities. Several factors need to be addressed when conducting an evaluation and creating customized treatment plans for patients, he said.
Assessments should include a thorough medical history that inquires about any underlying health problems that could contribute to falls, he noted. Patients with movement disorders and osteoporosis are at an increased fall risk, for example, as are patients with disorders that affect the legs and feet, such as arthritis, that also affect balance, said Dr. Wilson.
Patients taking four or more medications at a time are also at an increased risk of falling because of drug interactions, he said. Diabetic patients with peripheral neuropathy can experience balance problems, and lung disease and cardiovascular conditions can cause deconditioning and problems with mobility, contributing to falls, Dr. Wilson said.
Orthostatic hypotension, also called postural hypotension, can also make patients feel dizzy or lightheaded and contribute to falls, Dr. McCaslin said. Visual function, including acuity and contrast sensitivity, is an important consideration, he said, as is somesthesia, which provides valuable information to patients about their environment. Reaction time also affects a patient's ability to catch a fall. Other factors to consider are poor postural stability, gait, and vestibular function, he said.
A risk assessment must also look at decreased cognitive function, which may prevent a patient from being aware of his environment and cause inactivity and depression, which can affect the patient's desire to exercise and increase deconditioning, Dr. Wilson said. Environmental hazards in the home, such as poor lighting, loose rugs, bathtubs without safety support bars, and stairs with poor railings can also increase fall risk, he added.
Risk-of-falls assessment is within the scope of audiological practice, according to the American Academy of Audiology and the American Speech-Language-Hearing Association, said Dr. McCaslin.
The elderly fall for reasons unrelated to vestibular disorders, but “you have to rule out vestibular causes,” said Dr. Wilson. Even audiologists who focus on providing hearing aids for patients have a background in and knowledge of vestibular problems, he said.
Audiologists in private practice who do not have access to a fall clinic or who do not focus on vestibular testing can determine whether patients are at risk of falling by conducting a medical history, said Dr. Wilson. They also may want to collaborate with physical therapists or primary care physicians who can provide more comprehensive assessments and referrals to specialists at hospitals or balance centers, he said.
Hearing healthcare professionals should consider videonystagmography, a vestibular evoked myogenic potential (VEMP) test, a video head impulse test (vHIT), and a rotational chair test to patients they suspect are at risk of falling because of dizziness, Dr. Gaffney said. Audiologists may also assess balance and postural stability with posturography techniques, Dr. McCaslin said.
Hearing healthcare professionals can also check functional balance and stability with simple tools, using little equipment, such as a Romberg test, in which patients stand with their feet together on a piece of foam, said Dr. Gaffney. Audiologists then evaluate patients for sway as the patient stands with his eyes open and closed. A single-leg stance test is another valuable tool; failure to stand on one leg significantly correlates with falling risk. “You don't need any equipment for this, and the test provides a good snapshot of a person's postural stability,” Dr. Gaffney said. “People are often on one foot, whether it's when taking a step, walking up the stairs, or putting on clothes.”
A timed “up and go” test in which patients get up from a chair, walk three meters, turn around, come back, and sit down within a specified amount of time considered normal for their age is another simple assessment, Dr. Wilson said. If patients cannot complete this task within the specified timeframe, they likely have a balance problem.
The Fukuda stepping test is another relatively easy test. It requires patients to walk in place for 50 steps with their arms in front of them at a 90-degree angle and their eyes closed. How much the patient's body rotates to one side or the other can indicate a vestibular problem. The Berg Balance Scale and the Dynamic Gait Index are more formalized balance assessment tools for audiologists to consider, said Dr. Gaffney.
Hearing healthcare professionals can also use simple screening tests such as a mini-mental state examination for cognitive impairment and the Beck Depression Inventory to help detect other risk factors for falls, Dr. McCaslin said. Patients can easily fill these out before an appointment, and audiologists can refer patients to the appropriate professionals for additional evaluation if they indicate a problem.
PIECES OF THE PUZZLE
Increased awareness among audiologists of their role in fall prevention is needed to help identify patients at risk, Dr. McCaslin said. “I don't know that everyone is asking patients if they have problems with balance or if they've fallen,” he said, reiterating that taking a medical history is a perfect opportunity to ask address this issue.
Ensuring that the fall risk assessment test is sensitive, precise, and relatively short can be challenging, Dr. McCaslin said. Patient follow-up is also critical. “You want to find out a year later whether the person had any falls or what worked and what did not as far as fall prevention,” he said.
No one thing makes a person fall, Dr. Gaffney said. “Audiologists are just one piece of the puzzle,” she said, and coordinating the schedules of various practitioners to create an effective interdisciplinary clinic can be difficult. Once the team is in place, however, audiologists and hearing healthcare providers can more easily play an important part in the overall fall prevention plan, she said.
Reimbursement can also be problematic. One of the biggest challenges for audiologists “is that the only thing they get paid for is vestibular testing,” Dr. Wilson said. This makes it important to develop a broad range of tests outside the hospital that are relatively easy and quick to administer, he said.
HEARING AND FALLING
Further underscoring the audiologist's role in fall prevention is research evaluating whether hearing impairment may contribute to balance problems. Dr. McCaslin and his colleagues conducted a study of 185 patients with hearing impairment who underwent quantitative assessments of peripheral and central vestibular system function consisting of electro- or videonystagmography and sinusoidal harmonic acceleration testing.4 The researchers found that 73 percent of subjects had a problem with inner ear balance.
Dr. Wilson and his colleagues also conducted a study in collaboration with researchers at the University of North Texas Health Science Center to examine differences in balance and gait in people with and without hearing loss. They evaluated 10 subjects with hearing loss and 10 controls, all between 50 and 80. Those who had normal hearing had better balance and walked faster on a treadmill than those with hearing loss. Researchers also found that when they put hearing aids on the individuals with hearing loss and allowed them to acclimate to the devices, their walking speed and balance improved.
“It's my opinion that when people wear hearing aids and hear better, they have more cognitive resources to pay attention to their balance,” Dr. Wilson said. Hearing aids may provide improved signal-to-noise ratio and directional hearing, but “you could also theorize that anything that improves awareness of the environment could be helpful for balance.” Further research will include a larger number of subjects to acquire more data, he said.
Recent research also suggests that hearing aids may help older adults improve postural stability, potentially preventing falls.5 Patients acquire sound information through their hearing aids that helps them identify a landmark on which to adjust and maintain balance, Dr. McCaslin said.
Another study evaluated 2,017 participants in the 2001-2004 cycles of National Health and Nutrition Examination Survey (NHANES) to determine whether patients with more hearing loss had a higher risk of falls. They theorized that the audiological and vestibular systems deteriorate with age, affecting balance.6 The investigators found that those with a 25-decibel hearing loss were nearly three times more likely to have a history of falling. Every additional 10 decibels of hearing loss increased the chances of falling 1.4-fold. This finding held true even when researchers accounted for other risk factors for falling. Excluding participants with moderate to severe hearing loss from the analysis did not change the results.
Other research has addressed hearing loss and its relationship with cognitive decline.7 This assessment of 894 older adults found that peripheral hearing was significantly related to several cognitive measures assessing processing speed, executive function, and memory in addition to global cognitive status. The researchers noted that these results and previous published data indicate a relationship between peripheral hearing and cognition, but the underlying mechanisms are still not understood. If you don't address hearing loss, this group may be at risk for having cognitive deficits, and “we know that having a cognitive deficit is a risk factor for falls,” Dr. McCaslin said.