Fall Prevention: Patient-Centered Outcomes
A recent article in Time (Rhodan, 2015) ranked audiologist as the top growing career in America, attributing this to the projected growth of our aging population. Aging patients will need continued assessment and management of hearing and balance concerns—two known risk factors for falls. Falls continue to rank as one of the most devastating and life-altering occurrences facing older adults. Falls remain an ever-present threat to independent living and greatly impact quality of life for patients and their families. The prevalence of falls is high. Approximately 1 in 3 older adults sustains a fall each year (Deandrea et al., 2010), and nearly three quarters of older audiology patients report a fall within their lifetime (Criter & Honaker, 2013). The consequences of falls range from physical injury (e.g., fractures) to psychological distress in the form of depression, anxiety, fear of falling, and decline in overall balance confidence. These consequences not only lead to activity restriction and avoidance, but contribute to a rise in health care costs. It is time for our profession to start talking about falls.
Fall Risk Factors
Many falls are preventable, but prevention is contingent upon our understanding of the factors placing an individual at risk of falling. Both extrinsic hazards, such as medication use, and intrinsic factors, such as chronic disease and age, can place someone at risk of falling. The type and number of risk factors are vast and may include a history of previous falls, history of fracture, low mobility, activity restriction, and decreased reaction time. An individual need not have multiple factors to be at risk of falling; often, falls result from a singular risk factor or event. Undoubtedly, advanced age is the most commonly known risk factor, with a 1.12 odds ratio of falling based on advanced age (Deandrea et al., 2010). Furthermore, age-related changes have significant consequences on both our sensory (vision, vestibular, and somatosensory) and motor systems, contributing to our balance function.
Maintaining stable balance and gait relies on proper sensory integration and integrity of motor output to coordinate reflexive muscle responses. All factors within our balance system deteriorate with age. Therefore, gait and balance disorders increase with advanced age, and both significantly contribute to the risk of falling. There are numerous medical conditions and risk factors associated with balance disorders, ranging from psychiatric conditions (anxiety and depression) to neurological disorders (cerebellar dysfunction, multiple sclerosis, dementia, Parkinson's disease, and stroke). Falls are a common problem for patients with Parkinson's disease or Parkinsonian syndromes, which lead to increased morbidity and mortality for these individuals. The prevalence of falling and onset of fear of falling are high for people with these conditions. The number and type of prescription medications (e.g., sedatives) can also contribute to balance dysfunction and increased risk of falling. Thus, it is essential that directed case history questions for all patients target type of chronic medical conditions and prescription medications. For a more comprehensive review of medical conditions and risk factors that impair balance and gait function, please refer to the article “Gait and Balance Disorders in Older Adults” (Salzman, 2010).
Fall risk is also highly associated with sensory (vestibular, visual, somatosensory, and hearing) disorders, and understanding this relationship is of utmost importance for audiologists who are assessing and managing both hearing and vestibular function. Age-related vestibular sensory system changes include hair cell decline in vestibular end organs (both the maculae and crista), vestibular neuron reduction, and reduced vestibulo-ocular reflex (VOR) gain. Objective indications of reduced vestibular function measure are shown in patients at risk of falling. A recent study by Agrawal et al. (2012) measured age-related decline in semicircular canal function via dynamic visual acuity heath thrust (htDVA) and otolith (saccule and utricle) function via vestibular evoked myogenic potentials (VEMP). For adults over the age of 70, significant bilateral decline was found in VEMP amplitude; however, a greater degree of decline was indicated for semicircular canal function. The authors speculated that this greater decline in semicircular canal function via htDVA may be due to oculomotor system decline. Reduction in head impulse gain has also been reported in healthy adults over the age of 70, and this is directly correlated with reduction in gait speed (Agrawal, Davalos-Bichara, Zuniga, & Carey, 2013). Moreover, abnormal head impulse testing is associated with a previous history of falls; subjects with abnormal head impulse testing reported a higher number of falls within a pervious 5-year period and demonstrated slower gait speed on a 4-meter walk test. Indeed, age-related changes to our vestibular system increase our risk of falling and contribute to symptoms and signs of dizziness and unsteadiness—two of the most commonly reported symptoms for older adults. However, it is important to recognize that dizziness and unsteadiness complaints may be due to other intrinsic medical conditions (e.g., diabetes, cardiovascular disease, anxiety, and depression) and extrinsic factors (e.g., medication use).
Both central and peripheral visual impairments increase falling risk. Adequate visual input is imperative to provide details of the external environment. Diminished visual acuity, depth perception, and contrast sensitivity are common visual changes with increased age. Eye conditions, such as glaucoma, macular degeneration, and cataracts, negatively impact visual acuity and increase the likelihood of sustaining a fall. Presbyopia or farsightedness is one of the most common age-related vision impairments, and many older adults also suffer from myopia or nearsightedness. Multifocal lenses (bifocals, trifocals, and progressive lenses) are the most common type of corrective lenses prescribed for older adults. Although multifocal lenses allow for convenient near and distance vision, they impair depth perception and contrast sensitivity—both factors that reduce stepping precision and contribute to a decline in balance control. This increases the odds of sustaining a fall.
Numerous somatosensory changes—for example, decreased vibratory sensation and reduced number of cutaneous and joint mechanoreceptors—are results of aging. These changes directly impair our ability to navigate the external environment by altering our perception of position and movement. Moreover, the effects of age on the motor system contribute to muscle mass decline, decrease in muscle strength, and changes in reaction time. Indeed, advanced age and sensory and motor systems decline have a direct effect on our postural control system. Body sway increases with advanced age, limiting our ability to maintain quiet stance and stable gait.
As indicated earlier, hearing loss is also correlated with falling risk; however, this link is not well understood. As with symptoms of dizziness, hearing loss is often one of many chronic health conditions that increase the odds of sustaining a fall. Approximately one third of older adults who fall also indicate hearing difficulty (Stevens et al., 2012). Hearing loss may simply be concomitant with the underlying changes to the vestibular system or an isolated factor impeding spatial awareness necessary for adequate balance function (Lin & Ferrucci, 2012). Hearing loss is also associated with self-reported falls within a 12-month period (Criter & Honaker, 2013). Lin and Ferrucci (2012) identified an increased likelihood of reporting a fall for every 10 dB increase in hearing loss. A loss of balance function is high both for patients with hearing loss and for those undergoing surgical treatments for hearing impairment. In a prospective evaluation of cochlear implant recipients, Stevens, Baudhuin, and Hullar (2014) found decreased balance performance post-operatively and increased falling risk for the older participants enrolled in the study. However, the use of hearing aids has been shown to improve balance performance in challenging static stance positions (e.g., tandem stance and standing on foam). The use of hearing aids demonstrated an increase (in seconds) in the ability to maintain static stance positions, ranging from a 5- to 8-second improvement over unaided conditions (Rumalla, Karim, & Hullar, 2014). Further research on the use of hearing aids and the effect on balance function is necessary. Such research should use larger sample sizes and different populations with hearing loss.
The aim of fall prevention is to reduce the risk and rate of falls for those at risk of falling--both individuals who have and those who have not experienced a fall. The Centers for Disease Control and Prevention and National Council on Aging provide references to evidence-based fall prevention programs, such as Tai Chi. The effectiveness of fall prevention programs was recently summarized in a Cochrane Systematic Review (Gillespie et al., 2012). The large, systematic review of more than 150 trials and approximately 79,000 community-dwelling older participants found exercise intervention programs focusing on multicomponent intervention highly effective at reducing falling risk and the rate of future falls. These programs included both group intervention and home-based programs targeting intrinsic and extrinsic factors. However, results from the review indicated that multifactorial interventions were unsuccessful at reducing falling risk. Emotional reactions following falls are often the residual outcome. Fractures may heal, but fear of another fall remains the greatest concern and contributor to activity restriction in older adults.
Addressing the emotional aspects of falls (fear, anxiety, and depression) is typically not the focus of fall prevention intervention programs, and this may be the source for continued falling risk. These emotional reactions are common for patients after a fall. Increased burden and anxiety are often placed on loved ones (i.e., caregivers). The impact of falls on caregivers can also significantly hinder fall prevention and rehabilitation (Honaker & Kretschmer, 2014). Utilizing a patient-centered approach to fall prevention, by involving both patients and caregivers in strategies to reduce falls, may significantly improve quality of life and clinical outcomes. A movement toward patient-centered outcomes research is extending into falling risk, with approval by the National Institute on Aging of the first large-scale randomized controlled trial of fall prevention strategies. This trial is the first of its kind to collectively involve investigators, patients, and stakeholders in identifying falling risk factors, implementing fall prevention strategies, and documenting falling risk outcomes (Patient-Centered Outcomes Research Institute, n.d.).
Patient-centered outcomes are also in line with The International Classification of Functioning, Disability and Health (IFC) established by the World Health Organization (2001) and patient-centered outcomes research. The IFC provides a framework to evaluate the functioning and disability of patients. Specifically, it comprises four functioning components (body functions, body structures, activity, and participation) and three disability components (impairments, activity limitations, and participation restrictions), as well as consideration for environmental factors influencing the functional status of a patient. Utilizing the framework provides a rich description of the individual's functional status and strengthens decisions regarding disability. The IFC also recognizes that family members may demonstrate a decline in the level of functioning due to their loved one's health condition (i.e., third-party disability). Caring for a loved one with a health condition (e.g., falls) is stressful, and the caregiver may experience adverse psychological outcomes as well as functional decline due to caring for a loved one. Indeed, preventing falls is important not only for older adults but also for their caregivers, and reducing the impact of falls does not stop with the patient.
In summary, falls are a very real concern for both patients and caregivers presenting to an audiology clinic. Given that multifactorial exercise and home-based interventions significantly reduce the rate of falls, it is time for our profession to start a movement toward fall prevention to improve patient outcomes. Age and age-related changes to sensory systems are major contributors to falling risk. Starting a conversation with our patients about falls may put patients and their loved ones on the right path to fall prevention.
About the Author
Julie A. Honaker, PhD, CCC-A, is an associate 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. Dr. Honaker earned her PhD in audiology from the University of Cincinnati in 2006 and completed a postdoctoral training fellowship at the Mayo Clinic, Rochester, Minnesota, in 2009. Her research program is focused on clinical research and clinical decision analysis pertaining to patients with vestibular disorders across the lifespan. She has two distinct lines of research relating to her overarching theme of vestibular and balance sciences: (1) risk of falling assessment and prevention and (2) vestibular and balance consequences post-head injury.
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