Downstream Consequences of Aging is a bi-monthly series written by guest columnist Barbara Weinstein, PhD.
A quality reporting program designed to improve the quality of care for Medicare beneficiaries, the Physician Quality Reporting System (PQRS) gives participating providers an opportunity to assess the quality of care delivered to patients. PQRS, first covered in 2013 at HHTM, continues to roll out scheduled changes in the US healthcare system affecting all providers, including audiologists.
Audiologists Reporting Requirements in 2016
Effective 2016, audiologists who bill traditional Medicare Part B must complete one or more of the following quality measures when conducting an evaluation and submitting a claim form:
- Verification of current medications
- Screening for clinical depression if performing a tinnitus assessment including a follow-up plan at least once per calendar year
- Falls risk assessment and falls risk plan of care once per year if you are performing a vestibular evaluation
- Screening for tobacco use/cessation
- Referral for otologic evaluation for patients with acute or chronic dizziness
While the falls risk assessment is only required of audiologists performing a vestibular assessment, I am going to attempt to make the case for querying all persons with age related hearing loss regarding their falls history.
Why A Falls Risk Assessment?
The leading cause of injury among adults aged 65 years or older, between 30 to 40 percent of adults 65 years or older, fall at least once per year (Moyer, 2012). In 5 to 10 percent of cases, a fracture, laceration or head injury ensues (Moyer, 2012).
Interestingly, among older adults admitted to a hospital for accidental falls and hip fractures, more than two thirds had hearing difficulties, half had vision problems, and one third had both vision and hearing impairments (Grue, Kirkevold, & Ranhoff, 2009). These data confirm the findings of Tinetti et al. (1995), who reported that hearing impairments were more common among older patients admitted for falls than among the general older population.
The economics of falls are tremendous. The average inpatient cost for injury from falls in older adults is $35,000, and cost of follow up care increases with age (CDC, 2015). In 2013, the estimated direct medical costs of fall related injuries in adults aged 65 and older totaled $34 billion, with costs projected to increase in the future (CDC, 2015).
What is the Evidence Linking Hearing Loss to Falls?
Evidence linking hearing status to falls underscores the import of shifting our attention to falls risk as part of the intake. The facts are clear:
- A significant association exists between impaired hearing and impaired mobility (Schneider, et al., 2010)
- Balance difficulties, self reported hearing and visual difficulty are associated with fear of falling (FOF); FOF is associated with avoidance of activities and restriction of activity level thereby reducing their independence levels and quality of life (Viljanen, Kulmala, Rantakokko, et al., 2012)
- Significant hearing loss is associated with reduced physical activity levels which affects muscle strength and balance, increasing risk of falling (Gispen, Chen, Genther, et al., 2014; Tinetti et al. 1995)
- Hearing loss is associated with slow gait speed (Li, et al., 2012).
- Older women with poor hearing acuity are at higher risk for falls than those with good hearing, with higher fall risks partially explained by poorer postural control (Viljanen, Kaprio, Pyykko, Sorri, et al., (2009).
- Loss of vestibular function is prevalent in older adults with loss of semicircular canal function more prevalent than loss of otolith function (Davalos-Bichara & Agrawal, 2014)
- Men and women with self reported vision and hearing impairment are associated with increased risk of falls and falls injury (Lopez, McCaul, Hankey, et al., 2011).
- Impaired ambulation and self reported impaired hearing loss are predictive of mortality (Feeny, Huguet, et al., 2012).
Why the Connection?
Theories abound as to the connection between hearing loss and mobility limitations. Some have theorized that impaired hearing may contribute to increased cognitive load which affects attentional and cognitive resources important for maintaining posture and balance (Gispen, et al., 2014; Woolacott & Shumway-Cook, 2002). Others reason that hearing provides acoustic information about the environment, enabling older adults to notice and hopefully avoid environmental hazards which may lead to falls (Viljanen, Kaprio, Pyykko, Sorri, et al., 2009).
Coexisting vision, hearing, and balance difficulties, may have an additive debilitating effect on mobility than a single sensory loss because of the loss of possible compensatory sensory resources (Viljanen, Kulmala, Rantakokko, et al., 2012). Regarding FOF, coexisting sensory deficits may interfere with reception of compensatory information about their body position and the environment, increasing one’s FOF which in turn jeopardizes outdoor mobility (Viljanen, Kulmala, Rantakokko, et al., 2012). Of course the physiological connection between the hearing and balance mechanisms may contribute to functional impairments, as well.
Given the downward spiral from a fall, to loss of confidence and fear of falling, to restriction on physical and social activity levels, and loss of independence, it is important to identify interventions which may in fact serve as a buffer. Perhaps hearing aid use, use of hearing assistive technology during physical therapy, or auditory-vestibular rehabilitation can provide the auditory cues, or reduce the cognitive load when walking and talking. Screening for falls risk and exploring the impact of our interventions on FOF and falls risk may be an important opportunity for helping to optimize quality of life of persons with hearing loss.
What is an Audiologist To Do?
The answer is quite easy. Merely include the following two questions in your case history:
- Have you experienced a fall in the last year?
- In the past 12 months, have you had a problem with balance or walking?
When counseling your patients regarding communication strategies, suggest that they not walk and talk at the same time given the cognitive resources required for both activities which are strained of course when a hearing loss is thrown in to the mix. Make sure to encourage new hearing aid users to pay attention to auditory warning signs in the environment which hearing aids may now bring in to focus. Finally, encourage social engagement so critical to quality of life and safety. Restored hearing and communication are integral to social engagement and restoration of acoustic cues may in fact help our patients navigate their environments thereby increasing walking confidence and competence (Mikkola, Polku, Portegijs, et al., 2015).
I could be dreaming but PQRS may actually be opening up new opportunities for audiologists…..a disruptive innovation if you will.
Centers for Disease Control and Prevention (CDC). 2015a. “Costs of Falls Among Older Adults.” (June 15, 2015)
Davalos-Bichara, M. & Agrawal, Y. (2014). Normative results of healthy older adults on standard clinical vestibular tests. Otology & Neurootology. 35:297-300.
Feeny, D., Huguet, N., McFarland, B., Kaplan, M., et al., (2012). Hearing, mobility, and pain predict mortality: a longitudinal population-based study. Journal of Clinical Epidemiology. 65: 764-777.
Gispen, F., Chen, D., Genther, D., et al., (2014). Association between hearing impairment and lower levels of physical activity in older adults. JAGS. 62: 1427-1433.
Grue, E., Kirkevold, M., & Ranhoff, A. (2009). Prevalence of vision, hearing, and combined vision and hearing impairments in patients with hip fractures. Journal of Clinical Nursing. 18: 3037-3049.
Li. L., Simonsick, E., Ferrucci, L., et al. (2012). Hearing loss and gait speed among older adults in the United States. Gait Posture; 38:25–29.
Lopez, D., McCaul, K., Hankey, G., et al., (2011). Falls, injuries from falls, health related quality of life and mortality in older adults with vision and hearing impairment—Is there a gender difference. Maturitas. 69: 359-364.
Mikkola, T., Polku, H., Portegijs, E., et al., (2015). Self-Reported Hearing Status Is Associated with Lower Limb Physical Performance, Perceived Mobility, and Activities of Daily Living in Older Community-Dwelling Men and Women. JAGS. 63:1164–1169 .
Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly. Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.
feature photo courtesy of shannon christy