The Role of the Audiologist in Fall Risk Assessment
AudiologyOnline: We can all appreciate the risks that accidental falls pose to older adults and that the prevalence of hearing loss tends to increase with age, but are falls particularly problematic for audiology patients?
Justin Burwinkel, AuD: You’re right. Accidental falls pose a significant and particular risk to audiology patients. There is a plethora of factors that can help explain why we see higher rates of falls among our patients compared to their aged-matched peers.
Firstly, the shared neurological and vascular pathways of the cochlea and vestibular end-organs means that the hearing and balance systems are frequently susceptible to common comorbidities. Conditions associated with metabolic syndrome, for instance, can impact both systems concurrently, as well as our other sensory systems that can further contribute to compromised postural control, like low-vision and peripheral neuropathy.
Moreover, the negative impact of hearing loss on situational awareness also increases our patients’ susceptibility to experiencing postural disturbances that can result in falls. It’s obvious to us that auditory cues play a vital role in our ability to detect environmental hazards, such as the presence of a pet near one’s feet or changes in walking surfaces. However, studies have also demonstrated that artificially manipulating the sounds perceived from one type of walking surface to resemble those of a different type of walking surface can alter the listener’s walking behavior. The research we’ve seen in that area underscores the critical role that auditory biofeedback has in navigating the environment safely. Another study reported increased postural sway with controlled deprivation to auditory cues, through simulated conductive hearing losses, with the use of earplugs.
Even beyond the immediate risk of not having the full auditory picture of one’s environment, hearing loss can have long-term consequences on our patients’ falls risk factors that are mediated by their cognitive and physical abilities. The increased cognitive load associated with hearing impairment can potentially divert essential cognitive resources away from tasks crucial to sensory integration and executive control during ambulation. The propensity for experiencing greater social isolation due to hearing difficulties can further compound the problem. Reduced social activity and the onset of depression are known to contribute to a decline in physical activity, which can often lead to accelerated muscle loss, decreased flexibility, and a diminished ability to walk and maintain balance—particularly during a balance disturbance.
The complex interplay between sensory impairments, as well as their impacts on our patients’ lifestyle and reactive capacity, ultimately renders audiology patients more vulnerable to falls. As hearing healthcare providers, I believe it is important for us to recognize our role in intervention and contribute meaningfully to comprehensive care strategies that help mitigate our patients’ risk for falls.
AudiologyOnline: How do you believe Audiologists can contribute to falls prevention?
Justin Burwinkel, AuD: I believe audiologists are in a unique position to help address the risk of falls for a variety of reasons, but let’s start with the fact that hearing loss is—itself—a modifiable risk factor. We are able to prescribe amplification systems that can improve environmental awareness and support social interaction. By helping to foster more robust social engagement, audiologists can effectively help to keep patients physically active as well, which is key to older adults maintaining their musculoskeletal system as they age.
Healthable hearing aids like, Genesis AI, further extend the positive impact audiologists can have in managing falls risk. Not only can Genesis AI hearing aids alert others in the event that the wearer sustains a fall, but their physical activity tracking capabilities can also serve to further encourage patients to adopt healthier and more physically active routines that can hopefully ward off falls before they happen.
Audiologists, by way of training and experience, may also be able to help identify symptoms of disordered balance function. Even audiologists primarily focused on hearing aid dispensing can receive training to perform basic falls risk screenings. Additionally, audiologists can make informed referrals for more extensive diagnostic evaluations when necessary.
Furthermore, the customary practice of involving communication partners in our patients’ office visits can actually allow audiologists to contribute to falls prevention in some unique and impactful ways. From the moment we greet our patients in the waiting room, we can begin observing their movements and interactions with their communication partners and caregivers. We can quickly gain valuable insights into a patient’s physical abilities, hesitations and tendencies, and then ask pertinent questions about their independence in performing activities of daily living as part of our case history and lifestyle interview. These interactions can also provide a valuable opportunity to educate communication partners, who can later play a crucial role in helping patients implement falls prevention strategies once they go home.
AudiologyOnline: Are there specific challenges or barriers that audiologists might face in implementing falls risk screening, and how can these be overcome?
Justin Burwinkel, AuD: Time constraints pose a significant challenge. Audiologists often find their time limited, particularly when working with patients facing a myriad of physical and cognitive difficulties. To overcome this barrier, I recommend that each audiologist assess the available tools and plan an efficient process tailored to their situation. This way, they can allocate their time effectively without compromising the quality of care. Every increment more that we, collectively as a profession, can do to help identify and manage falls risk factors will ultimately be a net benefit to our patients.
Secondly, while audiologists receive training in diagnosing vestibular pathologies, specific training in falls risk assessment may be lacking. Equipping audiologists with targeted education relating to fall prevention is a crucial next step for our profession. This education should cover practical approaches to screening in a busy audiology clinic, along with guidance on evidence-based interventions once a patient is identified as being at risk for falls. By bridging these knowledge gaps, audiologists can feel more confident in incorporating falls risk screening into their clinical routine.
Billing concerns are another challenge that audiologists may face when considering implementing clinical falls risk management activities. This is an area where our professional organizations can help their members to understand the relevant billing codes and reimbursement options. In certain settings, appreciating the value of falls prevention in improving overall patient health and well-being can contribute to justifying the time spent on these activities, even when the path to reimbursement is unclear.
Professional liability concerns may also act as a deterrent for some audiologists in implementing falls risk management into their practice. Each of our professional organizations have indicated that conducting risk of falling assessments is within the audiologist’s scope of practice. Receiving additional training and implementing standardized protocols like the Centers for Disease Control and Prevention’s (CDC) “Stopping Elderly Accidents Deaths & Injuries” (STEADI) falls risk assessment protocols, may help alleviate concerns about providing this type of care.
AudiologyOnline: Can you elaborate on how audiologists can efficiently incorporate these screenings and assessments into their clinical routines?
Justin Burwinkel, AuD: Whenever we want a clinician to add something new to their routine, I know it needs to be both impactful and efficient. In the case of falls risk management, audiologists have options ranging from simply screening for common risk factors to full-on fall and balance risk management. I believe most audiologists will land somewhere in the middle, and I think that’s perfectly acceptable.
Audiologists can quickly integrate falls risk screenings into their routine by simply incorporating some specific case history items into their intake forms or lifestyle interviews. The CDC’s STEADI toolkit includes a "Stay Independent" brochure with a 12-item questionnaire that is both attractive and patient-friendly. A positive response to more than four items or a positive answer to any one of three “key questions”—whether the patient has fallen in the past year, feels unsteady when standing or walking, or worries about falling—indicates the need for additional falls risk assessment.
I also refer fellow audiologists to the research of our colleagues Robin Critter and Julie Honaker, who found good sensitivity in detecting potential fallers based on scores from audiologic self-assessments such as the Hearing Handicap Inventory for the Elderly (HHIE) and Dizziness Handicap Inventory (DHI). In combination with a question about the number of medications the patient takes and functional test, the sensitivity based on a positive finding from any one of those four measures increased to 92% sensitivity with 100% specificity when there was, instead, a negative finding for all of those measures. (Criter & Honaker, 2017).
After identifying a patient as potentially at risk for falls, audiologists can choose from several follow-up options, depending on the time available and their individual comfort level with providing these types of services. The least demanding option might be to simply make a general referral back to primary care or to the patient’s gerontologist.
However, if you are looking to provide a deeper level of care, the CDC’s STEADI initiative outlines a comprehensive risk assessment algorithm that covers a range of functional domains, many of which are within the Audiologist’s scope to either assess or screen for. Most audiologists would feel comfortable administering the suggested functional gait, strength, and balance tests with some basic training on the test measures and their scoring. These tests only take about 5 minutes to administer and only require a chair, a stopwatch, and a ten-foot walkway. It’s also within the audiologists' scope to perform postural blood pressure measurements, vision screenings, home fall hazards counseling, depression screenings, reaction time measurements, and basic medication reviews. There are also more comprehensive functional balance test batteries that could be considered, such as the Mini Balance Evaluation Systems Test (Mini-BESTest).
AudiologyOnline: What strategies do you think can be employed to increase audiologists' awareness and confidence in administering falls risk assessments?
Justin Burwinkel, AuD: Increasing provider confidence in their ability to administer falls risk screenings and assessments is incredibly important. About a decade ago, Jessie Patterson and Julie Honaker published survey findings indicating that, although 75% of audiologists felt that risk of fall assessment was within their scope of practice, fewer than 12% believed they were sufficiently trained to implement it themselves (Patterson & Honaker, 2014). Fortunately, there are now an increasing number of resources available to support audiologists in this endeavor.
One of the other key resources that I point colleagues to is the Centers for Disease Control and Prevention's (CDC) online STEADI toolkit. The CDC provides clinical and provider education materials that are not only informative but also practical. Moreover, the CDC's training section (https://www.cdc.gov/steadi/training.html) offers video demonstrations illustrating how to conduct and score the functional gait, strength, and balance tests that they recommend. Scoring sheets, case studies, sample referral forms, a fall risk factors checklist, and a list of recommended community-based risk mitigation programs can also be found on the STEADI webpage. These tools were all designed to help support the integration of falls risk assessments into already busy clinical routines.
In addition to the CDC’s resources, audiologists can explore audiology-specific falls risk management continuing education opportunities. Audiology Online offers several webinars dedicated to falls risk management, and I’ve noticed that there has been a growing emphasis on fall risk management at national and state academy meetings as well.
After familiarizing yourself with the screening and assessment measures, the best way to feel confident in implementing them with your patients is to practice administering them with someone who isn’t particularly at risk. I’d suggest practicing with colleagues, your front-office staff, and any students that you might be supervising first. Follow the CDC’s written instructions, go step-by-step, and review their instructional videos if necessary. You’ll likely find that falls risk screening and assessment can be much more approachable than you had imagined it being.
AudiologyOnline: How can audiologists collaborate with other healthcare professionals to ensure a multidisciplinary approach to falls risk management?
Justin Burwinkel, AuD: As I mentioned earlier, one approach is for audiologists to make a general referral back to primary care or the patient’s gerontologist. However, when specific deficits are identified through screening questions or functional measures, audiologists can play a pivotal role in helping their patients begin to be conscious of and, therefore, able to address those. For example, we can recommend additional assessment from a physical therapist or another audiologist who specializes in vestibular assessments.
If polypharmacy (defined as taking four or more medications and supplements) is identified as a potential risk factor, it's worth appreciating that the CDC has devoted significant effort to educating pharmacists, who play a central role in fall risk management. Pharmacists already help manage the potential interactions between medications prescribed to a patient by multiple physicians, so they can be valuable allies in bringing concerns about falls risk to the attention of the various prescribing physicians and pursuing appropriate therapeutic alternatives on behalf of the patient.
Regardless of how an audiologist chooses to implement falls risk management into their clinical practice, they should always exercise professional judgment. This involves considering the time available for patient interaction, their scope of practice, and their personal proficiency in administering various assessments and making appropriate recommendations.
Criter, R. E., & Honaker, J. A. (2017). Fall risk screening protocol for older hearing clinic patients. International Journal of Audiology, 56(10), 767–774. https://doi.org/10.1080/14992027.2017.1329555
Patterson, J. N., & Honaker, J. A. (2014). Survey of Audiologists’ Views on Risk of Falling Assessment in the Clinic. Journal of the American Academy of Audiology, 25(4), 388–404. https://doi.org/10.3766/jaaa.25.4.10