Auditory Contributions to Postural Steadiness in Older Adults With and Without Hearing Loss

By: LaCorey Cunningham, SPT

 

Background:

As a student in the Doctor of Physical Therapy program at UNC, I had the pleasure of working primarily with older adults during my past two clinical rotations and they have become a patient population that I have increasingly grown to love. When interacting with these patients, I am often reminded of how fortunate I am to still have valuable relationships with both my maternal and paternal grandparents, whom are all still very active. As someone who is extremely family-oriented, it is important to me to remain abreast to current evidence in order to preserve the health and independence of my grandparents and to empower my geriatric patients and their families to do the same. During my acute care clinical rotation, I witnessed first-hand the detrimental effects that falls can have in this population and I was moved by the continued decline that can occur as a result. Witnessing how imperative it is to assess for falls risk early on and to quickly intervene for optimal outcomes in these patients, I developed an interest in falls prevention that led to my participation in this project.

When presented the opportunity to work with Vicki Mercer, PT, PhD on a pilot study investigating the potential auditory contributions to postural steadiness in older adults, I was eager to get on board. I instantly reflected on these clinical experiences and how much I enjoyed conducting Senior Fitness Testing and other falls assessments at the Carol Woods Retirement Community as a part of our PHYT 736: Physical Therapy for Older Adults coursework with Carol Giuliani, PT, PhD, FAPTA. This pilot study offered clinical research experience that I aimed to gain prior to graduating and would facilitate interprofessional collaboration in a field in which I am less familiar with. Though I have worked with many older adults with hearing impairments, I had a minimal understanding on how it can impact their independence and social participation and may contribute to an increased risk of falls.

As physical therapists, it is imperative to provide comprehensive falls risk assessments and interventions for the older adult populations in order to avoid adverse outcomes, such as falls-related injuries and fatalities. Therefore, I was excited to explore a new potential risk factor that could increase the safety and maintain the independence of my future older adult patients.

 

Statement of Need:

Falls occur in over 25% of adults aged 65 years and older and can cause a wide range of adverse outcomes, including bone fractures, head injuries, increased healthcare costs, increased risk of recurrent falls, and even falls-related fatalities.¹ Consequently, many older adults develop a fear of falling that further increases their risk of sustaining another fall.¹ Falls-related deaths of older adults in the United states are on the incline, increasing by 31% from 2007 to 2016,² and thus, illuminating the value of continued research on risk factors and interventions aimed at mitigating falls. Similarly, falls-related deaths of older adults in North Carolina have increased from 47.0 per 100,000 residents in 2005 to 67.3 per 100,00 residents in 2014, demonstrating that falls is also a well-known threat to older adults within our local community.

Preliminary evidence indicates that older adults with hearing impairments are associated with a higher incidence of falls, increased risk of recurrent falls, and reduced postural stability.^3–5 For every 10dB of hearing loss, the odds of sustaining an annual fall for an older adult increases by 3.8%,⁵ placing older adults with mild hearing impairment or worse at a 1.4-times increased risk of falls compared to those with normal hearing.⁶ Therefore, research that adds to existing evidence of this auditory contribution to postural steadiness and/or investigates potential mechanisms behind the association of hearing loss and increased risk of falls in older adults is of clinical value. Findings from this Capstone project and future pilot study may help identify a gap in clinical guidelines for falls risk assessment and interventions. This could also offer future implications for physical therapists to emphasize auditory screens, refer to audiologists, and/or educate our hearing-impaired patients on the benefits of consistent hearing aid use and the risks of incompliance when working with the older adult population.

 

Purpose:

The purpose of my capstone project is to review existing literature and propose a pilot study that investigates the potential mechanism behind the auditory contribution to maintaining postural steadiness in community-dwelling older adults with and without hearing loss. It aims to explore the hypothesis that older adults utilize auditory cues as an orienting reference to maintain postural stability with and without hearing impairment. The products from the project will be used to develop methods for a future a feasibility study that will set the groundwork for a sufficiently powered study that investigates whether on and functioning hearing aids can improve static postural steadiness in older adults with hearing loss.

 

Products:

In this capstone project, I was able to create a literature review, evidence table, and a protocol for our pilot study in order to prepare for submission and approval by the Institutional Review Board (IRB). Due to COVID-19 and unforeseen circumstances, our timeline for the IRB submission was unfortunately prolonged and thus, preventing participant recruitment and data retrieval. Therefore, the main product of my capstone will be the  IRB application draft and supplementary materials. I have listed a description for my completed products below.

IRB Application Draft for Postural Steadiness in OA

The main product of my capstone is a draft copy of our IRB submission.We received funding from the NC traCS to complete our pilot study of 20 participants, but are submitting the IRB for a larger study of 60 participants total. This study will be implemented in Fall 2020 with minor changes due to the current impact of COVID-19.

Literature Review

This literature review examines existing evidence that suggests an association between hearing loss and falls risk, investigates the impact of hearing aid use and balance performance, and proposes potential mechanisms behind the auditory contributions to postural steadiness in community-dwelling older adults. It helped justify the need for our pilot study and was utilized to construct the Background section of the IRB application.

Evidence Table

In order to facilitate discussions on the design and rationale for our pilot study, I created an evidence table from the research discussed in my literature review. For each study, the evidence table describes the participant eligibility requirements, testing conditions, outcome measures, study results, and implications for future research. Information from this table helped guide decisions on our methods and procedures and identified areas in need of additional research in order to support our rationale.

Pilot Study Protocol

Since I was unable to participate in subject recruitment and data retrieval for my capstone project, I created a protocol for our pilot study that details our objectives for the study, methods for participant recruitment, screening/assessment, and study design, with evidence-based rationale for our decisions. There is also a brief discussion on clinical implications for physical therapists. Lastly, the appendix includes a sample of the participant screening questionnaire and a table for baseline characteristics of the participants. Aspects of this protocol was individually researched and collaboratively discussed with my research team acknowledged below.

 

Evaluation:

In order to evaluate my performance on this project, I created a feedback form that incorporates both my personal goals and general requirements for the capstone. At the completion of the project, I plan to share this form with members of the research team for a final evaluation. Although I originally planned to provide presentations to audiology students to solicit their assistance with the project, I still hope to share this online post with interested students and encourage their feedback using this form. Lastly, for anyone reviewing this project, I would greatly appreciation your honest feedback and evaluation of the products posted at this time.

 

Capstone Project Feedback Survey: https://unc.az1.qualtrics.com/jfe/form/SV_56jFyJsNBswrOId

 

Self-Reflection

When presented the opportunity to work with a faculty member on clinical research, I was eager to gain experience in both conducting research and working with a population I enjoy, but I knew this would be a challenging process. However, as a first-generation undergraduate and professional student, I consistently seek ways to step out of my comfort zone and take advantages of opportunities that will aid in my personal, spiritual, and professional growth. Without previous experience in conducting research, I knew there would be a learning curve in terms of demonstrating proficiency in critical literature review, understanding rationale behind study design and statistical analyses, and producing written products at the standards of an entry-level professional and/or doctoral student. I aimed to balance these challenges with the gratifying opportunity to assist with recruitment and data retrieval of a small sample of participants. However, I quickly realized how tedious it can be to submit an IRB application for the first time and when combined with the pandemic of COVID-19, my capstone project saw many changes.

What I enjoyed most about this process was the opportunity to collaborate with professionals within the audiology and hearing sciences division, in order to construct a sound pilot study that could receive funding from NCtraCS and approval by the IRB committee. I was able to learn more about audiologic assessments and how hearing impairments effect the older adult community and appreciated the unique ideas presented on how to investigate potential mechanisms of spatial localization during our team discussions. By having very different schedules, this collaboration highlighted importance of maintaining open and timely communication, which revealed an area of improvement for me. However, I consistently aimed to address in the later stages of the project.

With the new direction of my capstone focusing on the written materials associated with our pilot study, I aimed to create products of appropriate academic rigor while simultaneously making it comprehensive across professions in order to uphold the health literacy aspect of the project and to facilitate interprofessional collaborations. I aimed to be intentional with explaining profession-related jargon—for both physical therapy and audiology—which often required additional research for the latter. As our research question began to change, I had to expand on the evidence identified in my critically appraised topic (CAT) created during our PHYT 752 Evidence Based Practice course, but I felt more competent in doing so by the completion of the coursework. Furthermore, participation in this study enhanced my understanding of various statistical analyses and study methodologies with the additional help and support of my research team acknowledged below.

I appreciated all of the support from the people below that helped me to persevere throughout the adversities presented in my third and final year on this project. I truly gained a valuable experience and developed a deeper appreciation for evidence-based practice and feel more empowered to do so as a future clinician!

 

Acknowledgements

I want to extend my deepest gratitude to my Capstone Advisor, Dr. Mercer, and my research team for their continued support, guidance, and assistance throughout my Capstone project.

Thank you to Vicki Mercer, PT, PhD, (an Associate Professor in the Division of Physical Therapy and a licensed physical therapist with expertise in clinical and laboratory assessment of postural control in older adults) for remaining flexible, empathetic, and supportive throughout this project. Despite your commitments to other capstone committees, you sacrificed your time to maintain open communication with me, whether in-person or off-site, and provided assistance along the way. Furthermore, thank you for identifying this unique area of research and providing your clinical expertise!

Special thanks to John Grose, PhD (Professor in the Department of Otolaryngology-Head and Neck Surgery and the Department of Allied Health Sciences) and Philip Griffin, AuD (an Assistant Professor in the Division of Speech and Hearing Sciences and a clinical audiologist), who both provided pivotal input to the auditory aspect of our research. I appreciate you both for sacrificing your time and contributing your clinical expertise to our project. You consistently remained considerate of my capstone requirements and fostered my learning in a new discipline throughout this collaboration.

I also want to thank Johnny Copeland, an undergraduate and prospective physical therapy student, for providing additional insight and assistance with the project and remaining eagerly responsive in our communications. I know you will be a valuable asset to the future implementation of the pilot study.

I would also like to thank my academic advisor, Michael Gross PT, PhD, FAPTA, for providing additional support and solutions in the midst of the unforeseen changes. You helped foster my professional growth by consistently challenging me throughout this process.

Furthermore, I want to thank Debbie Thorpe, PT, PhD, for facilitating the capstone project, providing guidance throughout this process, and demonstrating empathy towards students who were impacted by COVID-19.

I also want to thank everyone who takes the time to review this project and/or provides feedback through my evaluation form. These responses will be carefully reviewed and utilized to continue my professional development. I want to thank my family and friends who supported me remotely (while practicing social distancing) when creating the final drafts of my products. Lastly, thank you to my classmates of UNC DPT Class of 2020. I couldn’t have made it this far without your support!

 

 

References:

1. Hartley G, Kirk-Sanchez, N. Fall Risk in Community-Dwelling Elders . PT Now 2013. Available at: https://www.ptnow.org/ClinicalSummaries/quick-detail/fall-risk-in-communitydwelling-elders. Accessed November 29, 2019.
2. CDC Injury Center. Deaths from Falls. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost/deaths-from-falls.html. Accessed May 1, 2020.
3. Pluijm SMF, Smit JH, Tromp EAM, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos. Int. 2006;17(3):417-425. doi:10.1007/s00198-005-0002-0.
4. Viljanen A, Kaprio J, Pyykkö I, Sorri M, Koskenvuo M, Rantanen T. Hearing acuity as a predictor of walking difficulties in older women. J. Am. Geriatr. Soc. 2009;57(12):2282-2286. doi:10.1111/j.1532-5415.2009.02553.x.
5. Kamil RJ, Betz J, Powers BB, et al. Association of hearing impairment with incident frailty and falls in older adults. J Aging Health 2016;28(4):644-660. doi:10.1177/0898264315608730.
6. Agmon M, Lavie L, Doumas M. The Association between Hearing Loss, Postural Control, and Mobility in Older Adults: A Systematic Review. J Am Acad Audiol 2017;28(6):575-588. doi:10.3766/jaaa.16044.
7. Image source: Getty Images. AARP. https://www.aarp.org/health/conditions-treatments/hearing-resource-center/