EYE ON THE ELDERLY—Screening for hearing loss, risk of falls: A hassle-free approach

,

Applied Evidence

EYE ON THE ELDERLY—Screening for hearing loss, risk of falls: A hassle-free approach

J Fam Pract. 2009 September;58(9):471-477

PDF Download

References

1. Johnson CE, Danhauer JL, Koch LL, et al. Hearing and balance screening and referrals for Medicare patients: a national survey of primary care physicians. J Am Acad Audiol. 2008;19:171-190.

2. U.S. Preventative Services Task Force Screening for Hearing Impairment. In: Guide to clinical preventative services: a report of the U.S. Preventative Services Task Force. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996:393-405.

3. Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among effective clinical preventative services: results of a systematic review and analysis. Am J Prev Med. 2006;31:52-61.

4. Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72:81-88.

5. Ries PW. Prevalence and characteristics of persons with hearing trouble: United States, 1990-91. Vital Health Stat 10. 1994;No. 188.-

6. Healthy People 2010. Hearing health progress review. http://www.nidcd.nih.gov/health/healthyhearing/what_hh/progress_review_04.asp. October 20, 2004. Accessed March 19, 2005.

7. Campbell VA, Crews JE, Moriarty DG, et al. Surveillance for sensory impairment, activity limitation, and health-related quality of life among older adults–United States, 1993-1997. MMWR CDC Surveill Summ. 1999;48:131-156.

8. Keller BK, Morton JL, Thomas VS, et al. The effect of visual and hearing impairments on functional status. J Am Geriatr Soc. 1999;47:1319-1325.

9. Kramer SE, Kapteyn TS, Kuik DJ, et al. The association of hearing impairment and chronic diseases with psychosocial health status in older age. J Aging Health. 2002;14:122-137.

10. National Council on Aging. The consequences of untreated hearing loss in older persons. ORL Head Neck Nurs. 2000;18:12-16.

11. Chia EM, Wang JJ, Rochtchina E, et al. Hearing impairment and health-related quality of life: the Blue Mountains Hearing Study. Ear Hear. 2007;28:187-195.

12. Dalton DS, Cruickshanks KJ, Klein BE, et al. The impact of hearing loss on quality of life in older adults. Gerontologist. 2003;43:661-668.

13. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment: a randomized trial. Ann Intern Med. 1990;113:188-194.

14. Pugh KC. Health status attributes of older African-American adults with hearing loss. J Natl Med Assoc. 2004;96:772-779.

15. Strawbridge WJ, Wallhagen MI, Shema SJ, et al. Negative consequences of hearing impairment in old age: a longitudinal analysis. Gerontologist. 2000;40:320-326.

16. Gates GA, Murphy M, Rees TS, et al. Screening for handicapping hearing loss in the elderly. J Fam Pract. 2003;52:56-62.

17. Card RO. How to conduct a “Welcome to Medicare” visit. Fam Pract Manag. 2005;12:27-29, 31, 32.

18. Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. 1983;25:37-42.

19. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA. 1988;259:2875-2878.

20. Valente M, Abrams H, Benson D, et al. Guidelines for the audiologic management of adult hearing impairment. Audiol Today. 2006;18:32-36.

21. Chisolm TH, Johnson CE, Danhauer JL, et al. A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults. J Am Acad Audiol. 2007;18:151-183.

22. Beynon GJ, Thornton FL, Poole C. A randomized, controlled trial of the efficacy of a communication course for first time hearing aid users. Br J Audiol. 1997;31:345-351.

23. Chisolm TH, Abrams HB, McArdle R. Short- and long-term outcomes of adult audiological rehabilitation. Ear Hear. 2004;25:464-477.

24. Cranney AB, Coyle D, Hopman WM, et al. Prospective evaluation of p and quality of life in women with hip fractures. J Rheumatol. 2005;32:2393-2399.

25. Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly. Cochrane Database Syst Rev. 2009(4);CD000340.-

26. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomized clinical trials. BMJ. 2004;328:680.-

27. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141-158.

28. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896-903.

29. Jacobson GP, Calder JH. A screening version of the Dizziness Handicap Inventory (DHI-S). Am J Otol. 1998;19:804-808.

30. Rocchiccioli JT, Sanford J, Caplinger B. Polymedicine and aging. Enhancing older adult care through advanced practitioners. GNPs and elder care pharmacists can help provide optimal pharmaceutical care. J Gerontol Nurs. 2007;33:19-24.

31. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710-715.

32. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2004;(2):CD003162.-

33. Macias JD, Massingale S, Gerkin RD. Efficacy of vestibular rehabilitation therapy in reducing falls. Otolaryngol Head Neck Surg. 2005;133:323-325.

34. Tremblay KR, Barbe CE. Preventing falls in the elderly. 2005. Colorado State University. http://www.ext.colostate.edu/PUBS/consumer/10242.html. Accessed August 13, 2009.

Falls risk: Make use of assessment tools

Each year, approximately 30% to 40% of elderly adults living independently fall, and the incidence increases with age.⁴ Falls frequently cause injuries, such as hip fractures, and reduce HRQoL.²⁴ Strong evidence supports the efficacy of a multifaceted approach for identifying and reducing risk of falls in this patient population.^25,26 A review of more than 3000 falls indicated that about one-third were the result of accidents or environmental hazards, and nearly another third were caused by gait problems, balance disorders, or weakness.²⁷

FAST TRACK

Can your patient stand from a sitting position, walk a few paces, turn around, and return to her chair in 30 seconds?

Means of determining risk of falls. As with hearing assessment, you can gauge older patients’ risk of falls during routine visits or annual exams. For patients’ first Medicare visit, the AAFP Medicare preventive exam encounter form¹⁷ includes 2 items in the “Functional Ability/Safety Screen” section that cover the leading causes of falls. Item 1 asks, “Was the patient’s Timed Up & Go test unsteady or longer than 30 seconds?” This simple test requires patients to stand from a sitting position, using their arms for support; walk a few paces, turn around, and return to their chair to sit. The test is sensitive to, and specific for, identifying elderly people living independently who are at risk of falls.²⁸

The Dizziness Handicap Inventory–Screening version (DHI-S) (FIGURE 2),²⁹ is a 10-item patient self-assessment questionnaire that takes fewer than 5 minutes to complete. You can also use the DHI-S to supplement the Timed Up & Go test in judging a patient’s postural control.

FAST TRACK

The DHI-S form to assess falls risk is a 10-item questionnaire that can be completed in fewer than 5 minutes.

Possible reasons for poor performance on the Timed Up & Go test are vestibular dysfunction or other balance disorders that require a careful evaluation. Cross-checking the “Medications, supplements, and vitamins” list in the “Medical/Social History” section of the Medicare encounter form may reveal use of a drug or multiple drugs (particularly likely if the patient sees different physicians) that commonly contribute to falls.³⁰

Patients’ descriptions of “Past personal illnesses and injuries,” also covered in the encounter form, or their accounts of situations that provoked dizziness, may help you identify the presence of a disorder such as benign paroxysmal positional vertigo, which increases the risk of falls.³¹

In weighing whether to treat such a disorder yourself or to refer, keep in mind that the evidence strongly supports the efficacy of referring patients to otolaryngologists or audiologists for further diagnosis and treatment.³² Vestibular rehabilitation is effective for elderly patients with stable but symptomatic and uncompensated central deficits.³³

FIGURE 2
Dizziness Handicap Inventory-Screening version (DHI-S)

Source: Jacobson GP, et al. Am J Otol. 1998.²⁹ Reprinted with permission.
*The higher the score, the greater the need for further evaluation.

Item 3 on the AAFP Medicare encounter form¹⁷ probes for hazards in the home, asking: “Does your home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs or have poor lighting?” Strong evidence supports the efficacy of a home hazard assessment and modification in preventing falls. However, during the brief time allotted for an office visit, asking patients to recall and describe every potential hazard in their homes is impractical. The PATIENT HANDOUT (HOW TO REDUCE YOUR RISK OF FALLS) details the causes of falls in older people and preventive measures that patients or their families may be able to implement at home.

PATIENT HANDOUT

How to reduce your risk of falls

Injuries from a fall can range from bruises and cuts to more serious problems, like a broken hip. Fortunately, most falls can be prevented. If you’ve fallen recently or think you might have a balance problem, tell your doctor immediately.

Am I in danger of falling?

People fall more as they get older because of changes that come with age, such as poor vision, balance problems, weak muscles, and arthritis. Cluttered, poorly lit living quarters also increase the risk. You are more likely to fall if you:

have fallen before
don’t get much exercise and have weakness in your legs
are unsteady when you walk
are taking medicines that can contribute to falls, such as sedatives or antidepressants, or take 4 or more different medications
have medical problems such as Parkinson’s disease, osteoporosis, heart disease, or low blood pressure—or if you have had a stroke.

How can I protect myself at home?

You can minimize the risk of falling at home by taking these steps:

Keep the floors free of clutter. Remove things you can easily trip over, such as throw rugs, electrical cords, piles of paper, and clothing.
Make sure you have good lighting throughout the house, and put night lights in your bedroom, bathroom, hallways, and stairs.
Have railings installed in the bathtub and shower and around the toilet, and use nonskid mats in the tub and shower area.
Keep items within easy reach in the kitchen.
Put handrails on the stairs. (Using bright paint or strips of tape on the railing will make it easier to see.)
Wear shoes with firm, nonskid soles. Don’t wear house shoes, such as flip-flops or loose slippers, or shoes with heels higher than 1 inch.

What else can I do to protect myself?

Get your eyes checked regularly. Wear your glasses as prescribed, and clean them often to improve visibility.
Stay active and exercise often to keep your muscles and bones strong. Ask your doctor about weight-bearing exercise, and what you can do to improve your balance.
Eat a healthy diet, with plenty of calcium and vitamin D. Limit consumption of alcoholic beverages (have no more than 2 drinks a day).
Take care of your feet. If they hurt, tell your doctor.
Ask the doctor whether you need a cane or other walking aid.
Have your doctor go over all your medicines to see if you’re taking anything that can make you dizzy or sleepy.
Get up very slowly. When you’re getting out of bed, sit on the side for a few minutes before you stand up. Getting up too quickly can make you feel dizzy or lose your balance.
If you live alone, get an emergency alert system that you can wear around your wrist or neck and press to call for help if you fall and can’t reach the phone.

Where can I get more information?

American Geriatrics Society
212-308-1414
http://www.americangeriatrics.org

National Center for Injury Prevention and Control
770-488-1506
http://www.cdc.gov/ncipc/falls/#PDF

National Institute on Aging
http://www.niapublications.org/engagepages/falls.asp

U.S. Consumer Product Safety Commission
http://www.cpsc.gov/CPSCPUB/PUBS/701.html

Sources: Rao SS. Am Fam Physician. 2005⁴; Tremblay KR, et al. Colorado State University. 2005.³⁴