December 1, 2013 Features

Life in Balance

By assessing older patients' risk of falling and offering advice to reduce the likelihood of falls inside and outside the home, audiologists can help keep patients active and upright.

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At 72, Mrs. G. enjoyed an independent, active life: She maintained her household and drove herself to many family and community activities, including attending events with her grandchildren and volunteering for her church. However, Mrs. G.'s life changed drastically in the summer of 2012 when she fell down a flight of stairs in her home, the same stairs she climbed daily. The fall caused a sprained wrist and significant bruising to her hip, and although her scrapes and bruises healed, she was left with an overwhelming fear of falling again.

Fall Prevention

She now fears climbing those familiar stairs or even leaving her home, and no longer participates in volunteer activities. She feels helpless and sees herself as a burden to her family members, who now drive her to the grocery store, launder her clothes and perform other activities of daily living that she once handled with confidence. Mrs. G.'s increased dependence and fear of falling have, unfortunately, put her at an increased risk that her fear will come true. Statistically, it is highly likely that Mrs. G. will fall again within the next six months.

Fall Prevention

Each year, more than 1 million healthy, U.S. adults experience debilitating falls, and that number will rise as the aging population grows to 25 percent of the total national population by 2040, according to the U.S. Centers for Disease Control and Prevention. Among this group, one out of three people will sustain a fall over the span of a year, the CDC estimates, costing the country $55 billion to treat, and the likelihood of future falls increases after someone sustains a fall because of such factors as pain, fear of falling again, and loss or perceived loss of balance. Falls are one of the leading causes of death in those 65 or older and a common cause of hospital admissions and injuries, especially hip fractures for women and traumatic brain injuries for men.

Aside from the obvious physical injury, falls also can hurt older adults' mental health, threatening their independence (as with Mrs. G.). Her physical injuries healed but she lost confidence in her sense of balance and feared falling again.

The result? Reduced ability to perform daily activities, compromised quality of life and increased risk of future falls.

The remedy? There is, of course, no one remedy, but audiologists and other medical professionals can play a pivotal role in predicting the likelihood of falls and helping to prevent them.

However, as audiologists working with senior clients who are at a high risk for falls, what signs should alert us—and how can we identify a client's risk of falling and make recommendations to prevent future falls? Half of audiology senior patients report a fall in the past year, and even more report a fall at some point in their lifetime, according to an in-press article by Robin Criter and Julie Honaker in the Journal of the American Academy of Audiology (see sources online). Therefore, we need to know the risk factors and when to make the right recommendations.

Fall risk factors

Factors that may put a person at risk for falling include reduced vestibular and balance function, which results in unstable vision when the head is in motion and increased postural sway when standing and walking. Audiologists need to be vigilant to recognize these factors—per our scope of practice—but vestibular disorders are not the only issues to consider.

A patient's age is actually the most telling sign of fall risk. Normal age-related physiologic changes can result in slower reflexes, increased postural sway, decreased muscle and bone strength, and poor visual acuity—and all contribute to the risk of falling. Additional risk factors include a history of falls, cognitive impairment, depression, use of assistive devices, arthritis, impaired activities of daily living and even hearing loss.

According to reports in the journals Age and Ageing and Preventative Medicine (see sources online), approximately 30 percent of people who fall report hearing difficulties—a strong correlation between the two conditions. This association seems plausible, given that hearing loss often leads to social isolation. And living a more sedentary lifestyle often results in decreased muscle tone, strength and overall endurance—which further increase risk. Chronic medical conditions also make falls far more likely, as does the use of four or more prescription medications.

Although a majority of falls result from personal factors, environmental factors also are a common cause. These can include, for example, poor lighting, unsafe stairways, irregular floor surfaces, loose rugs or improper footwear. Therefore, professionals should consider both personal and environmental factors when evaluating risk of falls.

Although the risk of falling increases with advanced age, younger patients—particularly those with significant vestibular or balance difficulties and/or any of the factors outlined above—also may be at risk of falling and present with significant falling concerns. Indeed, falls are a concern for any patient at the audiology clinic, and incorporating questions related to falls into the audiological case history may help audiologists to put a person on the correct path to prevention.

Incorporating fall prevention

Although audiologists primarily provide services for older adults, few have experience with falling risk assessment. Many professionals cite lack of time or resources as a barrier.

However, there is an efficient and cost-effective solution to this valid concern: Clinicians need to ask all older clients about falls they've experienced in the past year, as well as any history of previous falls. This initial dialogue may help the patient better understand the effects of his or her falls and concerns about future falls, which may, in turn, increase the likelihood of further, similar discussions with other health care professionals.

Additional topics to discuss with the patient may include:

  • Number and type of prescription medications.
  • Presence of dizziness or vertigo.
  • Environmental factors.
  • Comorbid conditions.
  • Depression.
  • Use of mobility aids.
  • Postural hypotension.

In a recent survey (in Jessie Patterson and Julie Honaker's in-press article in the Journal of the American Academy of Audiology; see sources online), more than two-thirds of audiologists indicated that they do not ask questions about falls, suggesting that administering an in-depth interview may present a problem for time-challenged professionals. The same survey also suggests that many audiologists only incorporate falls prevention in vestibular and balance clinics. However, audiologists in general practice are in a unique position to recognize potential falling risk factors—especially hearing loss—and can make direct recommendations, including hearing amplification to better localize sound, and improve overall quality of life. And simply asking clients about their fall history and balance issues takes only a few minutes.

If the patient answers any of these questions positively, it suggests he or she may be at risk of falling, and could benefit from a risk assessment and possibly a prevention program that could avert a future fall.

Employing a family-centered care approach significantly improves quality of life and therapeutic outcomes and, therefore, audiologists also should ask family members and caregivers questions about falls and falling concerns. Additional topics to discuss with the family members and caregivers may include:

  • What led to the fall.
  • If the fall has resulted in limitations in activities of daily living.
  • Fall-related injuries.
  • Reports of dizziness or vertigo.

The CDC offers additional triage and assessment guidelines as part of its Stopping Elderly Accidents, Deaths & Injuries program. These tools provide clinicians with additional readily available, cost-effective assessment options that take little time and may provide additional evidence to support suspicion of risk of falling. Additionally, we can counsel our patients on common environmental falling risk factors, and provide helpful hints to reduce falls inside and outside the home. Some of these tips may include:

  • Wear sensible, properly fit shoes with nonskid soles.
  • Avoid shoes with extra-thick soles.
  • Keep the home well-lit.
  • Remove boxes, newspapers, electrical cords and phone cords from walkways.
  • Secure loose rugs with slip-resistant backing.
  • Store clothing, dishes, food and other household necessities within easy reach.
  • Use nonslip mats in the bathtub or shower.
  • Repair loose floorboards and carpeting right away.
  • Install easily accessible or glow-in-the-dark switches in room entrances.
  • Place night lights in the bedroom, bathroom and hallways.

There are many reasons for falls; therefore, they require multidisciplinary care. But audiologists shouldn't feel the need to tackle the problem alone. A team approach to assessment, management and education of risks can make significant improvements in patients' quality of life. But our role should be to start the conversation with our patients and their families regarding falls, make appropriate recommendations for audiological or multidisciplinary care, and educate patients and their families on falling risk and prevention.

As a profession, we may not have standards in place for falling risk assessment and prevention, but we can take small steps toward achieving this goal by asking fall-related questions early to get patients on the path to prevention. As with all aspects of audiology, early intervention should be our top priority.

Julie A. Honaker, PhD, CCC-A, is an assistant professor and director of the Dizziness and Balance Disorders Lab in the Department of Special Education and Communication Disorders at the University of Nebraska–Lincoln. julie.honaker@unl.edu

Robin E. Criter, AuD, is a doctoral candidate at the University of Nebraska–Lincoln and an affiliate of ASHA Special Interest Groups 6, Hearing and Hearing Disorders: Research and Diagnostics; and 8, Public Health Issues Related to Hearing and Balance. robin.criter@huskers.unl.edu

Jessie N. Patterson, MS, an AuD/PhD student at the University of Nebraska–Lincoln, works with Julie Honaker on post-concussion balance assessments with the University of Nebraska-Lincoln Athletic Department. jnpatterson7@gmail.com

cite as: Honaker, J. A. , Criter, R. E.  & Patterson, J. N. (2013, December 01). Life in Balance. The ASHA Leader.

Sources

American Geriatric Society (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older people. Journal of the American Geriatrics Society, 59, 148–157.

Criter, R. E., & Honaker, J. A. (in press). Falls among older adults: Characteristics and risk within the audiology clinic. Journal of the American Academy of Audiology.

Gillspie, L. D. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Review, 9, 1–408.

Gopinath, B., Hickson, L., Schneider, J., McMahon, C.M., Burlutzky, G., et al. (2012). Hearing-impaired adults are at increased risk of experiencing emotional distress and social engagement restrictions five years later. Age and Ageing, 41, 618–623.

Honaker, J. A., & Kretschmer L. W. (in press). Impact of fear of falling for patients and caregivers: perceptions before and after participation in vestibular and balance rehabilitation therapy. American Journal of Audiology.

Jacobson, G. P., & Shepard, N. T. (Eds.) (2008). Balance function assessment and management. San Diego: Plural.

Patterson, J. N., & Honaker, J. A. (in press). Survey of audiologists' views on risk of falling assessment in the clinic. Journal of the American Academy of Audiology.

Stevens, J. A., Ballasteros, M. F., Mack, K. A., Rudd, R. A., DeCaro, E., & Adler, G. (2012). Gender differences in seeking care for falls in the aged Medicare population. American Journal of Preventative Medicine, 43(1), 59–62.

Stevens, J. A., Corso, P. S., Finkelstein, E. A., & Miller, T. R. (2006). The costs of fatal and non-fatal falls among older adults. Injury Prevention, 12, 290–295.

Stevens, J. A., Mack, K. A., Paulozzi, L. J., & Ballesteros, M. F. (2008). Self-reported falls and fall-related injuries among persons aged ≥65 years—United States 2006. Journal of Safety Research, 39, 345–349.

Vincent, G. K., & Velkoff, V. A. (2010). The next four decades. The older populations in the United States: 2010 to 2050, populations and projections. Retrieved from http://www.census.gov/prod/2010pubs/p25-1138.pdf (2013, June).



  

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