Age-Related Hearing Loss for the Physical Therapist: Effects on Postural Control and Strategies to Promote Comprehensive Care in the PT Clinic
Carolyn Mistele, SPT
Background:
Throughout my Doctor of Physical Therapy (DPT) education at UNC, I have been consistently intrigued by neurologic coursework and practical experiences. During clinical rotations, I have noticed a strong interest in balance and functional activity training; and after graduation, I envision myself ideally working with neurologic patients across the lifespan. It is not surprising that when I decided I wanted to participate in research as a third-year elective course, I was drawn to a faculty project that was investigating postural control and balance. I signed on to work with Dr. Vicki Mercer on her pilot study: Role of Auditory Input in Postural Steadiness during Quiet Standing in Older Adults With and Without Hearing Loss. I found this emerging area of research so interesting because I never would have thought that hearing loss and impaired balance were related. I originally intended for my capstone project to report and explain the results from this study, in which we would investigate if the presence of various auditory cues influenced older adults’ postural sway during standing. However, due to COVID-19 restrictions and safety practices delaying the study, I altered the focus of my Capstone project.
While reviewing evidence related to hearing and postural control, I discovered how the fields of physical therapy and audiology may intersect for falls risk, prevention, and intervention. Beyond that, I gained a greater understanding of hearing loss as a whole and how it can affect older adults’ functioning, quality of life, and health outcomes. I was shocked by how little I knew about hearing loss, especially considering the fact that my mother has had bilateral hearing loss for my whole life. The more I learned, the more I determined that all physical therapists should have a baseline understanding of hearing loss and its influences on patient wellness. I decided that a more personally rewarding project for me would be to delve into the subject of age-related hearing loss and share relevant information to the physical therapy field with other PT students and practicing clinicians.
Statement of need/purpose:
Falls are a public health crisis for older adults (age 65 and older), with approximately one in four older adults falling each year.1 A major area of physical therapy practice is falls prevention by addressing impairments and risk factors for falls; however, there is one risk factor that is widely unknown and unaddressed by physical therapists: hearing loss. For older adults, hearing loss is associated with 72% increased odds of falls and an increased incidence of serious injury from a fall (12.7%) compared to normal hearing older adults (7.5%).2,3 For every 10dB of hearing loss, the odds of sustaining a fall increase by 3.8% each year.4 There are approximately 27 million older adults in the United States with hearing loss; therefore, hearing loss may be a major contributor to thousands of falls/year.3 Hearing loss is also associated with frailty, low physical activity levels, gait impairment, social isolation, depression and cognitive decline in older adults.2-4 Therefore, it is crucial that hearing loss is detected and that older adults receive intervention from a hearing specialist to prevent falls and to encourage greater health and wellness.
Older adults comprise a large proportion of physical therapy patients, but current physical therapy education does not adequately address this patient population. In UNC’s DPT curriculum, there is one course, PHYT 736: Physical Therapy for the Older Adult, that focuses on the complexities of geriatric care (ie: polypharmacy, ageism, falls prevention); however, hearing loss is not discussed. Physical therapists should be aware of hearing loss since it is a very common comorbidity that can influence our patients’ wellbeing as well as our ability to communicate with patients during PT sessions.
The purpose of this capstone project is to address this need by providing physical therapists and physical therapy students practical information about hearing loss so they are best equipped to treat their patients as a whole. The project includes a review of relevant evidence about hearing loss and its influence on falls and other negative health effects. It also includes definitions, etiologies and measurements of hearing loss as well as methods of screening for hearing loss and tips for communicating with patients with hearing loss.
Products:
The main product of my capstone project is a narrated VoiceThread presentation that can be used for asynchronous, socially distanced learning: https://unc.voicethread.com/share/17417847/
- To view the VoiceThread without UNC affiliation access, go to https://voicethread.com/register/ and register with your name and email address. Then click on the presentation VoiceThread link https://unc.voicethread.com/share/17417847/ and request access to view. I will approve your request as soon as possible.
- PDF version of the presentation slides for future synchronous presentations, either in-person or virtual: Hearing Loss for the Physical Therapist
I also created a flyer that summarizes the multiple tips provided in the presentation for physical therapists to communicate effectively with a patient with hearing loss. This flyer is meant to be printed and kept in sight or on hand in a PT office as a reminder during future patient encounters: Communication Tips Flyer
Evidence table: Capstone-Evidence-Table
Evaluation:
Throughout the development of my capstone project, I received and incorporated feedback from my advisor and committee members to improve the completeness and comprehensibility of my presentation. I also created an evaluation survey that is presented to audience members at the end of the VoiceThread. https://forms.gle/U9PsfgrKwAavnQ878. From this evaluation, I aimed to receive feedback about the effectiveness and quality of the presentation and about how PTs/SPTs viewed the relevancy and clinical utility of learning about hearing loss. The survey also includes specific sections asking for how the presentation can be improved so I can make adjustments before the project is formally distributed to PT clinics or to upcoming DPT students.
Self-reflection:
Throughout the semesters spent researching hearing loss and postural control and creating this capstone project, I have learned so much about hearing loss assessment, interventions, and implications. From my own learning, I feel much more prepared to work with patients with hearing loss as a clinician. It is very easy for PTs to view hearing loss as an unrelated, mildly inconveniencing comorbidity that is separate from the patient’s PT diagnosis and plan of care. I know that moving forward, I will have a different perspective on hearing loss as a chronic condition that can have significant impacts on my patients’ physical activity level and community participation. I feel more comfortable bringing up the topic of hearing loss with patients because I know that I have the requisite knowledge to discuss hearing loss and hearing aids and to provide patients with a hearing loss screen and appropriate referral information. Some of my initial personal goals for the capstone course were not achieved due to the project focus switching from research to education. However, I did achieve my goals of conducting a comprehensive review of evidence and creating an engaging presentation for PT students and clinicians. Furthermore, I ended up spending my time and efforts on a more personally rewarding topic that I think can benefit my future patients and hopefully the future patients of my audience members.
I am very proud of my final product. Early responses from the feedback evaluation from third year SPTs indicate that physical therapy students find this information relevant and clinically useful (8/8 respondents selecting “strongly agree” in the second section of the survey). Of 8 respondents, feedback about the quality of the presentation has been very positive, and participants indicated a greater likeliness of incorporating a hearing screen into the evaluation of older adults (50% “very likely” and 50% “somewhat likely”). One piece of constructive feedback that may enhance the overall capstone product was: “A clinical quick reference sheet on this topic would be helpful since it is one not commonly covered in our curriculum as PTs.” I created a flyer of communication tips for clinicians to reference, however I did not include other main topics from the presentation. A summary sheet may be a helpful augmentation to the project for those who do not take notes during the presentation.
My next goal is to put the VoiceThread to good use by sharing it with PTs and upcoming SPTs. This presentation could greatly augment the PHYT 736: Physical Therapy for the Older Adult content because it directly relates to older adult falls prevention and it demonstrates the importance of interdisciplinary care for older adults. I plan to send the VoiceThread to the course’s instructor and share it with future students on Sakai. This may allow multiple classes of DPT students to learn more about hearing loss and keep it in mind during their careers. I also hope to distribute the presentation to UNC Healthcare clinicians for asynchronous learning or to present it live via virtual meeting. It is possible that in my future workplaces, I also present this information as an in-service or lunch-and-learn.
Acknowledgements:
I would like to thank the following individuals for their assistance and contributions to this project:
Dr. Vicki Mercer, thank you for your guidance and feedback throughout the capstone course. Your research project has given me insight and experience with the research process and provided the inspiration for my capstone work. I appreciate all of the “big picture” insights you’ve provided about the presentation and its potential audiences as well as your attention to detail as I was fine-tuning final product.
Dr. John Grose, thank you for joining my capstone committee and for your constructive feedback on my VoiceThread content and slides. Our lab meetings contributed to my understanding of how hearing loss is measured and inspired my research into smartphone-based hearing screening tools.
Dr. Jeffrey Shannon, thank you for joining my capstone committee and providing insights from your clinical expertise in audiology. Your feedback augmented the completeness of the discussion of age-related hearing loss and its interventions. I appreciate the time you spent critiquing my presentation, clarifying content points, and providing relevant resources.
Katherine Mistele, thank you for being the inspiration that sparked my interest in hearing loss in the first place! I appreciate the personal insights about living with hearing loss and using hearing aids that you’ve provided as I created my presentation. I also thank you for being my greatest support as I worked on this project and throughout my entire DPT education. It has truly come full circle that the child who was always frustrated by her mother not hearing her or misunderstanding her would end up educating others about hearing loss and its effects on communication!
References:
- Centers for Disease Control and Prevention. Keep on Your Feet—Preventing Older Adult Falls. https://www.cdc.gov/injury/features/older-adult-falls/index.html. Accessed April 12, 2021.
- Jiam NT-L, Li C, Agrawal Y. Hearing loss and falls: A systematic review and meta-analysis. Laryngoscope. 2016;126(11):2587-2596. doi:10.1002/lary.25927
- Mahmoudi E, Basu T, Langa K, et al. Can hearing aids delay time to diagnosis of dementia, depression, or falls in older adults? J Am Geriatr Soc. 2019;67(11):2362-2369. doi:10.1111/jgs.16109
- 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
image: https://labblog.uofmhealth.org/rounds/offsetting-hearing-loss-long-term-consequences-early-diagnoses
12 Responses to “Age-Related Hearing Loss for the Physical Therapist”
Vicki Mercer
Carolyn – Fantastic job on this project! I’ve really enjoyed working with you as part of an interdisciplinary research team. Thank you for your flexibility in adjusting the focus of your project to meet an important educational need, while at the same time continuing to push forward with the research endeavor. I think the educational products you’ve created will be very helpful for clinicians across a range of health professions. As we’ve discussed, you will be asked by the APTA North Carolina Falls Prevention SIG to present a webinar on this topic in December 2021! I know you’ll do a great job with that presentation as well!
Best regards,
Vicki
Debbie Thorpe
Hi Carolyn
You did a fantastic job on your capstone project on how age-related hearing loss affects physical therapy. Your voice thread is professional , evidence-based, and very complete! I really like how you inserted “check your learning” slides in throughout the presentation. Great strategy to enhance learning! You short flyer on communication tips is very practical but contains very pertinent information for therapists and caregivers. You should be very proud of this project. It will definitely add a wealth of information for our DPT curriculum content and have the ability to be shared asynchronously. Well done!! Good luck on the remainder of your clinical rotations!
Best
Debboe
Rachael Fiorentino
Hi Carolyn,
Your Capstone project was interesting and very well done. Thank you for bringing such an important topic to our attention as I am sure this will help all of us as clinicians consider hearing loss with older adults and falls. I personally greatly appreciated your project as I recently and suddenly lost hearing in my right ear and initially struggled with my balance. I wish I had your Capstone in January as you did an excellent job explaining the connection between hearing loss and the vestibular system, audiograms, hearing tests and their importance (I immediately downloaded uHear). Many of the communication tips that you outlined are things that I have had to integrate into my life in order to hear and understand well, particularly as I transitioned from online school in my quiet house to my clinical rotation in the hospital where there is a lot of background noise. I also appreciated that you addressed the new challenges that Covid and wearing masks brings to those who are hearing impaired, as it does not seem like masks are going away any time soon.
One question that I have for you is, do you know if tinnitus accompanies presbycusis, as it does sudden sensorineural hearing loss? I ask because it is the aspect of hearing loss I personally find the most debilitating. While I imagine it does not come directly into play with falls, it is (at least in my experience) disorienting and distracting.
Thank you again for such a well thought out and well researched project, Carolyn. I wish you the best of luck in this last bit of school!
Carolyn Mistele
Hi Rachael,
Thank you for sharing your experience and for your comments. I know we’ve chatted about your sudden sensorineural hearing loss (SSHL) before, and I also really wish that this Capstone presentation was available a few months earlier just to give you a background on the world of hearing loss! I think that without experiencing hearing loss personally or with a close friend/loved one (like me with my mom), people truly don’t have an understanding or appreciation of the all-encompassing effects of hearing loss. One small silver lining to all of the adjustments you’ve had to make over the past few months could be your ability to really empathize with and give life-changing education to you future patients with hearing loss. To answer your question, throughout my research/readings, I’ve seen that tinnitus sometimes occurs with presbycusis, but not always; and it can present in one or both ears. Interestingly, prescription of aids has been found to not only increase audibility of sounds from the environment, but a large proportion of patients also find some relief from their tinnitus with hearing aids. The American Tinnitus Association explains it really well here: https://www.ata.org/managing-your-tinnitus/treatment-options/hearing-aids
kelsikaz
Carolyn,
What an interesting project! I hadn’t really considered the significance of hearing loss on balance in older adults. Further, the extent of my screening for hearing loss is usually the patient asking me to please speak louder. This has been a big issue during COVID, and a few of my patients recently have started wearing see-through masks like the ones you included!
Your handout was especially helpful and clinically useful. I feel that I can use some of the items you suggested when I go into the clinic monday morning.
In your self-reflection you noted that you are more likely to screen for hearing loss and are comfortable doing so now that you have the requisite knowledge; I feel similarly, and after reviewing your project, I feel more confident with screening people as well. I particularly appreciate your suggestion to speak in lower tones, rather than speaking louder. I will start trying this now!
Overall, great job! This is such a useful project and handout, and I think this is really going to make a difference. This is very impressive!
-Kelsi
Carolyn Mistele
Hi Kelsi,
Thank you for your thoughtful response! I’ve really enjoyed perusing through our classmates’ Capstone projects because there are so many topics that I also would not have thought much about. It’s great to see where our peers’ interests/passions led them and how we are already using each other to learn from and improve our daily practice. I’m glad that you feel more comfortable performing hearing loss screening now– I think that a simple screen aligns well with your passion for health and wellness promotion! Interestingly, I’ve had 2 patients during my rotation that use the face masks with clear windows and neither of them have had hearing loss! I’m currently in inpatient rehab, and 2 patients with expressive aphasia were given clear masks, which has helped us interpret their facial expressions. The masks aren’t a perfect solution as I have noticed that they tend to fog up, which impedes lip reading; however, facial expressions still show through. I hope you have a great last few months of clinical rotations and that this information/the handout helps you to be an even more well-rounded clinician.
Brianna Colello
Carolyn,
Wow, congratulations on this amazing Capstone project! I appreciate you bringing light to the role of hearing loss in falls, communication, and all its other impacts. I honestly rarely inquire about my patients ability to hear and never thought to ask the simple question “Do you have difficulty with your hearing?” in any of my evals or treatment sessions. After reviewing your Voicethread and handout, I cannot wait to implement this simple tool and your additional resources about communication with my patients. I believe this can make a huge difference in a persons life! (and will use the smartphone apps to help my grandma realize she is experiencing hearing loss). Thank you for providing such a wonderful presentation and resources on this topic- it will surely help PT’s and future PT’s improve their patient care!
-Bri
Carolyn Mistele
Hi Bri,
Thank you for your kind comments. I’m so glad to hear that you plan to incorporate hearing loss screening with your patients! I’ve noticed myself that even after starting to work on this project, I still have been neglecting to ask my older patients about their hearing. Especially as students, there is so much else going on in a new patient evaluation that it can be easily forgotten. That’s why I think finding a way to systematically add it in to your patient care is so helpful (ie: put in intake forms or in standard history questions). In my presentation, I mentioned how hearing screening should be done in every older adult’s evaluation; but asking about hearing can be just as effective in subsequent treatment sessions if we forget about it during the eval. I hope the hearing screen smartphone app helps to start a conversation about hearing loss with your grandma! Family members often recognize hearing loss before the patients do themselves. I think that first-hand experience with hearing loss can help you to recognize it in others and to recognize its importance!
Rachel Sledge
Hi Carol,
Wow! You did an incredible job gathering data, creating your communication tip sheet, and developing your VoiceThread presentation. I’m so glad that you chose this important topic. Before your presentation I had not considered the role of hearing loss on balance and falls risk in the older adult population. On my current clinical rotation I have a number of patients with presbycusis who I am working with on balance, so this is very clinically relevant for me. Your presentation has also caused me to reflect on the typical set up of outpatient PT clinic environments. Typically we work on balance training in the open gym where there are other therapists working with patients, there’s music playing on the radio, and we’re giving detailed multi-step instructions standing behind the patient in order to guard them. Clearly, this is not an ideal, yet all too common situation. I have also had a number of patients share with me that they have hearing loss, but I wasn’t quite sure if speaking louder, lowering the pitch of my voice, or speaking more slowly was the best approach. I’m sure masking is also making communication more difficult since patients can’t see my face as clearly for visual cues, and the mask muffles sound. Thank you so much for your presentation and sharing this critical information! Well done!
Carolyn Mistele
Hi Rachel,
I’m glad that you found this information relevant and helpful! Thank you for sharing your outpatient experiences. I agree that giving complex instructions without visual cues (patient seeing your face) in a noisy room is not ideal for balance training with presbycusis. However, something to think about is that balance training in this gym setting can actually also be quite useful for real-world training as the gym poses an auditory dual-task. For higher-level patients, balancing with music on and/or during conversation may be quite helpful! Even so, I would still try to explain all of my instructions while facing the patient before the activity starts so you can use simpler cues during the task when the patient can’t see your face. Thank you for your feedback, and I hope that those communication tips come in handy during the rest of your rotation!
Katie Solheim
Hi Carolyn!
What an interesting capstone project! I completely agree that hearing loss is a risk factor many physical therapists do not adequately address as a contributor to falls risk. In reflecting upon recent acute care patient evaluations I have performed in the older adult population, it has become apparent to me that while I frequently ask patients about vision changes, I do not consistently ask about hearing loss, nor have I thought about its relation with balance impairments. I really appreciate that your PowerPoint provides comprehensive background information on the implications of hearing loss on various body systems, in addition to clinically relevant tips and screening methods. Your products will most definitely contribute to improved patient care, and you did an amazing job collecting relevant research on this topic for your evidence table. I have already printed your communication tips handout to reference on clinicals! Your products adequately justify the need for PTs to consider the impact of hearing loss on patient wellness and functional mobility, and your research will serve as an amazing tool for student PTs and PTs to utilize in clinic! I am sure future PT students would be thrived to watch your VoiceThread, especially before their first clinical! Great project!
Best, Katie
Carolyn Mistele
Hi Katie,
Thank you so much for your kind comments. I’m glad that you found the information useful and that the handout is being put to good use! You make a great point about acute care patient evaluations. Based on the evidence I found, I made the project more outpatient-oriented; however, hearing loss can definitely impact inpatient therapy sessions as well. I’m on rotation in acute inpatient rehabilitation right now, and our evaluation template also has a section for visual changes, but not for hearing changes. Visual changes are already deemed important enough to fill in for every patient, but perhaps in the future, hearing changes may also be recognized as an important factor influencing patients’ overall function.