By Marcello Cherchi, MD PhD
For patients
There is not yet any clear evidence that hearing amplification (such as with hearing aids or cochlear implants) improves balance or reduces the risk of falls.
For clinicians
Overview
Literature documents an associative relationship between hearing loss and the clinically meaningful outcome of fall risk. Literature also documents that hearing loss is associated with imbalance. Given these observations, it is tempting to postulate a chain of causal relationships (hearing loss impairs balance, and impaired balance increases fall risk), which in turn suggests that treatment of hearing loss should reduce fall risk. However, most literature on this topic fails to find any clear evidence that treatment of hearing loss brings about any reduction in fall risk — which (given that the original relationships are associative rather than causal) should not be surprising. Thus, while hearing amplification has clear benefits for verbal communication, patients should not expect that hearing amplification will improve their balance or reduce their fall risk.
Introduction
The relationships between hearing loss, balance and falls is complex. Studies approach these relationships differently, and often reach discrepant conclusions.
Observations and postulated relationships
Before analyzing the arguments on this topic, we need to isolate the relationships that have been observed or suggested.
Hearing seems to play a role in humans’ balance
Humans have a limited echolocation ability (Flanagin et al. 2017; Schornich et al. 2012; Schornich et al. 2013; Thaler and Goodale 2016; Tirado et al. 2021; Wallmeier et al. 2013; Wallmeier et al. 2015), and it has been shown that auditory input enhances a person’s spatial awareness and perception of movement (Campos et al. 2018).
Hearing amplification may improve some parameters of balance
Some studies have indeed suggested that hearing amplification may improve certain parameters of a person’s balance, whether this amplification is with hearing aids (Negahban et al. 2017; Rumalla et al. 2015) or cochlear implants (Mazaheryazdi et al. 2017; Shayman et al. 2017; Weaver et al. 2017). The possible benefit of hearing amplification for some parameters of balance is interesting, but whether this is clinically meaningful remains unclear.
Relationship between imbalance and falls
Some studies suggest that impairment of balance increases the risk of falls (Muir et al. 2010). At some level this seems intuitive, and usually leads to the idea that improving balance should also decrease the risk of falls — even though that is a logical non-sequitur.
Falls
Falls are usually regarded as a “clinically meaningful” outcome due to their attendant injuries and other costs to an individual and to society. By some estimates, “falls and their sequelae cost more than $50 billion every year” in the United States alone (Campos et al. 2023).
Association between hearing loss and increased fall risk
Hearing loss is associated with an increased risk of falls (Jiam et al. 2016; Powell et al. 2021; Tiase et al. 2020). By some estimates, “older adults with hearing loss are at 2.4 times greater risk of falls than their normal hearing peers” (Campos et al. 2023).
Several lines of argument
Studies have used (explicitly or implicitly) different lines of argumentation when analyzing these relationships.
Argument 1 (“hearing loss is associated with increased fall risk, so amplification should reduce risk of falls”) is simpler because its conclusion relies on only one relationship:
-
-
- Relationship: Hearing loss is associated with increased fall risk.
- Conclusion: Therefore, successful treatment of hearing loss should decrease fall risk.
-
Argument 2 (“hearing loss is associated with imbalance, which in turn is associated with increased fall risk, so amplification should reduce risk of falls”) is more complex because its conclusion relies on two relationships:
-
-
- First relationship: Hearing loss is associated with impaired balance.
- Second relationship: Imbalance is associated with increased risk of falls.
- Conclusion: Therefore, successful treatment of hearing loss should improve balance, and thereby decrease fall risk.
-
Note that the “final common pathway” of both arguments pertains to fall risk (irrespective of whether there is the intermediate relationship of balance).
If we take “fall risk” as the outcome of interest, then it turns out it is unclear whether hearing amplification decreases the risk of falls.
- Large studies of this question mostly conclude that there is no clear evidence to support the claim that hearing amplification decreases the risk of falls (Heitz et al. 2019; Riska et al. 2021; Riska et al. 2022).
- In contrast, a study of insurance claims reported that, “Use of HAs [hearing aids] is associated with delayed diagnosis of… injurious falls among older adults with HL [hearing loss]” (Mahmoudi et al. 2019). Another study concluded that its “findings suggest that use of hearing aids — especially consistent hearing aid use — is associated with lower odds of experiencing a fall or being classified as at risk for falls in older individuals with hearing loss” (Campos et al. 2023). But even these studies are merely demonstrating an association; as one study admitted, “Although we have shown an association between use of HAs and reduced risk of physical and mental decline, randomized trials are needed to determine whether, and to what extent, the relationship is causal” (Mahmoudi et al. 2019).
In other words, a crucial problem with most of the studies of this question is that they document observations of associative relationships rather than causal ones.
One way of interpreting these data is that hearing loss and falls are different manifestations of some common (not yet identified) underlying disorder (such as age-related attrition of global vestibulo-cochlear function), and thus treating hearing loss with amplification does not reduce fall risk because amplification does not influence the underlying cause of increased fall risk.
An analogy might be the case of a brain tumor with mass effect and involvement of part of the cerebral cortex. This underlying disease (brain tumor) could cause seizures (due to disruption of the cerebral cortex) and headaches (due to the mass effect). Although anti-epileptic medication might improve seizures, it is unlikely to have any effect on headache because the anti-epileptic medication does not address the mass effect of the tumor.
Conclusions
Most literature on the relationships between, on the one hand, hearing loss, and on the other hand, imbalance and/or falls, suggests associative relationships, not causal ones. While hearing amplification offers clear benefits for verbal communication, we advise patients that — despite marketing campaigns by the manufacturers of hearing aids — there are not (yet) any data to suggest that hearing amplification will bring about clinically meaningful improvement in balance, nor that hearing amplification will reduce fall risk.
References
Campos J, Ramkhalawansingh R, Pichora-Fuller MK (2018) Hearing, self-motion perception, mobility, and aging. Hear Res 369: 42-55. doi: 10.1016/j.heares.2018.03.025
Campos L, Prochazka A, Anderson M, Kaizer A, Foster C, Hullar T (2023) Consistent hearing aid use is associated with lower fall prevalence and risk in older adults with hearing loss. J Am Geriatr Soc 71: 3163-3171. doi: 10.1111/jgs.18461
Flanagin VL, Schornich S, Schranner M, Hummel N, Wallmeier L, Wahlberg M, Stephan T, Wiegrebe L (2017) Human Exploration of Enclosed Spaces through Echolocation. J Neurosci 37: 1614-1627. doi: 10.1523/JNEUROSCI.1566-12.2016
Heitz ER, Gianattasio KZ, Prather C, Talegawkar SA, Power MC (2019) Self-Reported Hearing Loss and Nonfatal Fall-Related Injury in a Nationally Representative Sample. J Am Geriatr Soc 67: 1410-1416. doi: 10.1111/jgs.15849
Jiam NT, Li C, Agrawal Y (2016) Hearing loss and falls: A systematic review and meta-analysis. Laryngoscope 126: 2587-2596. doi: 10.1002/lary.25927
Mahmoudi E, Basu T, Langa K, McKee MM, Zazove P, Alexander N, Kamdar N (2019) Can Hearing Aids Delay Time to Diagnosis of Dementia, Depression, or Falls in Older Adults? J Am Geriatr Soc 67: 2362-2369. doi: 10.1111/jgs.16109
Mazaheryazdi M, Moossavi A, Sarrafzadah J, Talebian S, Jalaie S (2017) Study of the effects of hearing on static and dynamic postural function in children using cochlear implants. Int J Pediatr Otorhinolaryngol 100: 18-22. doi: 10.1016/j.ijporl.2017.06.002
Muir SW, Berg K, Chesworth B, Klar N, Speechley M (2010) Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: a prospective study. Phys Ther 90: 338-47. doi: 10.2522/ptj.20090163
Negahban H, Bavarsad Cheshmeh Ali M, Nassadj G (2017) Effect of hearing aids on static balance function in elderly with hearing loss. Gait Posture 58: 126-129. doi: 10.1016/j.gaitpost.2017.07.112
Powell DS, Morales EEG, Pletnikova S, Deal JA, Reed NS (2021) Self-Report Hearing and Injury or Falls in Older Adults from the National Health and Information Survey. Semin Hear 42: 66-74. doi: 10.1055/s-0041-1726016
Riska KM, Peskoe SB, Gordee A, Kuchibhatla M, Smith SL (2021) Preliminary Evidence on the Impact of Hearing Aid Use on Falls Risk in Individuals With Self-Reported Hearing Loss. Am J Audiol 30: 376-384. doi: 10.1044/2021_AJA-20-00179
Riska KM, Peskoe SB, Kuchibhatla M, Gordee A, Pavon JM, Kim SE, West JS, Smith SL (2022) Impact of Hearing Aid Use on Falls and Falls-Related Injury: Results From the Health and Retirement Study. Ear Hear 43: 487-494. doi: 10.1097/AUD.0000000000001111
Rumalla K, Karim AM, Hullar TE (2015) The effect of hearing aids on postural stability. Laryngoscope 125: 720-3. doi: 10.1002/lary.24974
Schornich S, Nagy A, Wiegrebe L (2012) Discovering your inner bat: echo-acoustic target ranging in humans. J Assoc Res Otolaryngol 13: 673-82. doi: 10.1007/s10162-012-0338-z
Schornich S, Wallmeier L, Gessele N, Nagy A, Schranner M, Kish D, Wiegrebe L (2013) Psychophysics of human echolocation. Adv Exp Med Biol 787: 311-9. doi: 10.1007/978-1-4614-1590-9_35
Shayman CS, Earhart GM, Hullar TE (2017) Improvements in Gait With Hearing Aids and Cochlear Implants. Otol Neurotol 38: 484-486. doi: 10.1097/MAO.0000000000001360
Thaler L, Goodale MA (2016) Echolocation in humans: an overview. Wiley Interdiscip Rev Cogn Sci 7: 382-393. doi: 10.1002/wcs.1408
Tiase VL, Tang K, Vawdrey DK, Raso R, Adelman JS, Yu SP, Applebaum JR, Lalwani AK (2020) Impact of Hearing Loss on Patient Falls in the Inpatient Setting. Am J Prev Med 58: 839-844. doi: 10.1016/j.amepre.2020.01.019
Tirado C, Gerdfeldter B, Karnekull SC, Nilsson ME (2021) Comparing Echo-Detection and Echo-Localization in Sighted Individuals. Perception 50: 308-327. doi: 10.1177/03010066211000617
Wallmeier L, Gessele N, Wiegrebe L (2013) Echolocation versus echo suppression in humans. Proc Biol Sci 280: 20131428. doi: 10.1098/rspb.2013.1428
Wallmeier L, Kish D, Wiegrebe L, Flanagin VL (2015) Aural localization of silent objects by active human biosonar: neural representations of virtual echo-acoustic space. Eur J Neurosci 41: 533-45. doi: 10.1111/ejn.12843
Weaver TS, Shayman CS, Hullar TE (2017) The Effect of Hearing Aids and Cochlear Implants on Balance During Gait. Otol Neurotol 38: 1327-1332. doi: 10.1097/MAO.0000000000001551
