Hearing Health Education, Fall-Risk Identification & Audiometric and Balance Monitoring

Hearing Health Education, Fall-Risk Identification & Audiometric and Balance Monitoring

Prevention is a core part of audiology. Besides screening and hearing conservation programs, the Praxis Audiology blueprint tests three related skills: educating the public about the causes, effects, and prevention of hearing and balance disorders; identifying fall risk; and monitoring hearing and balance in people at risk. This section ties those skills together.

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Levels of Prevention

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Educating the Public About Hearing and Balance Disorders

Noise and Safe Listening

• Recreational noise: Concerts, clubs, sporting events, power tools, and personal listening devices can exceed safe levels. Firearms produce impulse peaks of roughly 140 to 175 dB peak SPL, enough to cause permanent damage after a single exposure.
• WHO-ITU H.870 safe listening standard: For personal audio devices, the reference weekly allowance for adults is 1.6 Pa²h per week, about the same sound energy as 80 dBA for 40 hours a week. A stricter mode for sensitive users, including children, uses 0.51 Pa²h per week (about 75 dBA for 40 hours). Compliant devices track exposure and warn users.
• WHO safe listening venues standard (2022): Recommends keeping the average sound level at or below 100 dB LAeq over 15 minutes, monitoring levels live, offering hearing protection, and providing quiet zones.
• Simple rules to teach: If you must shout to be heard at arm's length, the sound is probably hazardous. Turn it down, limit time, or move away, and wear protection.
• Hearing protection for musicians: High-fidelity earplugs (for example, with nominal attenuation of about 9, 15, or 25 dB) reduce sound fairly evenly across frequencies so music sounds natural.
• Programs: NIDCD's "It's a Noisy Planet. Protect Their Hearing." campaign targets preteens and parents, and Dangerous Decibels offers school-based education.

Other Topics for Patient and Community Education

• Ear care: avoid inserting cotton swabs or objects, and recognize when to seek medical care (drainage, pain, sudden hearing loss).
• Sudden sensorineural hearing loss is an emergency: same-day evaluation matters because early treatment improves the chance of recovery.
• Ototoxic risk: patients receiving cisplatin, aminoglycosides, or other ototoxic drugs should know the warning signs (tinnitus, fullness, imbalance, oscillopsia).
• Vaccination prevents many infectious causes of hearing loss (measles, mumps, rubella, meningitis).
• The links between untreated hearing loss and isolation, depression, falls, and dementia risk, and the benefit of early treatment.

Making Education Effective

• Write in plain language (about a sixth-grade reading level for general audiences), use pictures, and avoid jargon.
• Use the teach-back method: ask the person to explain the information in their own words to confirm understanding.
• Tailor materials to the audience's age, culture, and language, and provide translated or captioned versions.

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Identifying Fall Risk

Falls are the leading cause of injury and injury death among older adults; about 1 in 4 adults aged 65 and older falls each year (CDC). Audiologists see many patients with vestibular disorders and age-related hearing loss, so they are well placed to identify fall risk.

Fall Risk Factors

• Vestibular: benign paroxysmal positional vertigo (BPPV), unilateral or bilateral vestibular hypofunction, Ménière's disease, presbyvestibulopathy. BPPV is often unrecognized in older adults; one study found it in about 9% of patients in a geriatric clinic who had not been diagnosed.
• Hearing loss: each 10-dB increase in hearing loss was associated with about 1.4 times higher odds of reporting a fall in a national sample.
• Other medical factors: vision impairment, peripheral neuropathy, lower-extremity weakness, orthostatic hypotension (a drop of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing), cognitive impairment, and urinary urgency.
• Medications: sedatives and hypnotics, antidepressants, antipsychotics, opioids, antihypertensives, and taking many medications (polypharmacy).
• Environmental and behavioral: poor lighting, loose rugs, stairs without rails, unsafe footwear, and fear of falling, which leads to inactivity and deconditioning.

Screening and Assessment Tools

• CDC STEADI (Stopping Elderly Accidents, Deaths and Injuries): screen with three questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? A "yes" prompts further assessment.
• Timed Up and Go (TUG): the person stands from a chair, walks 3 meters, turns, returns, and sits. STEADI uses 12 seconds or longer as a sign of increased fall risk.
• 30-Second Chair Stand and 4-Stage Balance Test (inability to hold a tandem stance for 10 seconds suggests increased risk).
• Gait measures: Dynamic Gait Index (24 points; 19 or less is associated with fall risk) and Functional Gait Assessment (30 points; 22 or less suggests fall risk in community-dwelling older adults).
• Self-report: the Dizziness Handicap Inventory (25 items, 0 to 100) and the Activities-specific Balance Confidence scale (scores below about 67% suggest fall risk in older adults).

Audiologist Actions

• Treat what is within scope: canalith repositioning for BPPV, vestibular rehabilitation (or referral to a vestibular physical therapist), and hearing aid fitting.
• Refer for factors outside scope: physician for medication review and orthostatic hypotension, optometry or ophthalmology for vision, physical or occupational therapy for strength, gait, and home safety.
• Document the fall history and share results with the primary care provider.

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Audiometric and Balance Monitoring

Monitoring means repeated measurement over time to detect change early. Common monitoring programs include:

• Occupational hearing conservation: baseline and annual audiograms with standard threshold shift review (see the OSHA section).
• Ototoxicity monitoring: baseline before treatment, tests during treatment, and post-treatment follow-up, including extended high frequencies (see the ototoxicity section).
• At-risk children: children with congenital CMV, ECMO, meningitis, enlarged vestibular aqueduct, or a family history of progressive loss need scheduled re-evaluation because loss can appear or worsen later.

Vestibulotoxicity Monitoring

Aminoglycosides such as gentamicin and streptomycin are mainly toxic to the vestibular system. Because damage is usually bilateral and symmetric, patients often have no vertigo. Instead they report imbalance (worse in the dark or on uneven ground) and oscillopsia (the visual world bounces during head or body movement, for example while walking). Damage can appear even with normal drug levels and can progress after treatment stops.

There is no single universally adopted vestibulotoxicity protocol. Programs combine:

• symptom checklists at each visit;
• video head impulse testing (falling VOR gain and corrective saccades);
• dynamic visual acuity testing (a loss of three or more lines with head movement suggests vestibular hypofunction);
• rotary chair or caloric testing when the patient can be tested.

Any new oscillopsia or imbalance should be reported to the prescribing physician promptly so the treatment plan can be reconsidered.