The effects of age-related hearing loss and hearing aids on balance and falls-risk

Age-related hearing loss is a generally underrecognized risk factor for falls^1–3; it has also been associated with balance and mobility-related problems such as unstable posture^4–9 and slower walking speed¹⁰. However, the mechanisms underlying the associations between age-related hearing loss and mobility problems are poorly understood and, as such, strategic falls prevention strategies or balance enhancement interventions are not well-defined in this population. One hypothesis to explain the association between age-related hearing loss and falls is the cognitive load hypothesis. This hypothesis suggests that poorer hearing leads to greater listening effort (requiring more cognitive resources to listen) at the expense of concurrently performed and competing mobility-related tasks¹¹. Another hypothesis is the spatial sounds hypothesis, which suggests that hearing loss restricts the use of sound cues from the environment that can be used to perceive self-orientation in space, thereby compromising balance. One potential solution to address these hearing loss related challenges to mobility are hearing aids, which could reduce cognitive load by improving speech perception¹² and increasing access to spatial sound cues. However, there is a lack of consensus on whether hearing aids support balance and/or reduce falls-risk, particularly under common, everyday conditions^{13,14,15–29}.

Ecologically valid testing environments: virtual reality

While most everyday activities occur in complex, multisensory environments, the majority of previous experimental studies investigating the effects of hearing loss on balance have been conducted in highly controlled, isolated laboratory settings or sound booths. It is possible, that the most pronounced costs to balance (when having to listen at the same time) may be observed within challenging, realistic environments and/or when performing more complex tasks common to everyday life^30–32. One method of increasing the complexity and realism of testing conditions in a controlled and safe manner is to use immersive, multisensory virtual reality technologies.

Current research

In the current study, older adults with normal hearing and older adults with age-related hearing loss who used hearing aids completed a standing balance task in a realistic, multisensory virtual reality environment (a busy city intersection). Participants’ balance was measured when they were either simply standing at the virtual intersection (single-task), or when they stood at the intersection while also listening to multiple talkers speaking to them at the same time (dual-task). During these dual-task conditions of standing-while-listening, we evaluated participants’ abilities to stay balanced (centre of pressure at the feet as a measure of postural sway) and their ability to listen (accuracy in repeating back spoken digits by multiple talkers). We were primarily interested in whether balance performance was compromised when participants had to balance and listen at the same time compared to when they just had to balance alone (i.e., dual-task costs to balance). Importantly, we examined whether using hearing aids could support balance in participants with hearing loss, particularly under dual-task conditions when they had to manage the demands of listening and balancing at the same time. We also examined whether, overall, older adults with hearing loss had greater dual-task costs to balance than older adults with normal hearing.

Finally, in order to make the experimental tasks more challenging and realistic, we manipulated task difficulty, including modifying balance difficulty (standing on a soft surface compared to standing on a firm surface), modifying listening difficulty (repeating back more digits compared to fewer digits), and modifying visual complexity (eyes open viewing the busy city intersection scene compared to eyes closed with no visual scene). Because spatial sounds are expected to support balance and because hearing aids may improve access to these spatial sounds, we also manipulated the presence or absence of spatial sounds (common city noises such as water fountains, pedestrian crossing signals compared to no sounds). Overall, it was expected that balance would be increasingly less stable under these various challenging conditions, particularly for older adults with hearing loss, but that balance would be improved by the use of hearing aids and through the availability of spatial sounds.

Study procedures

This experiment took place in StreetLab at the KITE Research Institute, University Health Network, a fully immersive, projection-based virtual reality system with surround sound (see Fig. 1) and an integrated force platform to measure balance. The virtual environment consisted of a 6-lane intersection in Toronto. 

Results

When examining listening performance, as expected, higher accuracy was observed in the normal hearing group compared to the hearing loss group and the hearing loss group performed better when they were wearing their hearing aids compared to when they were not. Also unsurprisingly, both groups had higher listening accuracy in the easier listening condition (fewer compared to more digits), but interestingly listening accuracy was also higher when the postural task was less challenging (standing on a firm surface compared to standing on a compliant surface). Another novel finding was that the availability of potentially distracting visual information also influenced listening performance; specifically, listening performance was better when participants closed their eyes, which may suggest that potentially distracting visual information further impacted listening performance by increasing the cognitive load.

When looking at our primary outcome of interest (i.e., balance), we found that hearing aids did not remarkably improve balance overall. We also did not find any effects of spatial sounds on postural outcomes indicating that, under these complex conditions, spatial sound cues did not appear to stabilize posture. Overall, the effects of systematically manipulating different sensory motor task demands were varied and nuanced. However, an interesting pattern was observed. Specifically, when balance and listening task complexity was perhaps “too easy” or “too difficult”, minimal dual-task costs to balance were observed. This is likely because, when the tasks were too easy, participants could manage these demands well (incurring no dual-task costs to balance). On the other hand, when the tasks became too difficult, participants may have neglected the listening task all together (likely protecting the more safety-relevant task of balancing) thereby also incurring no dual-task costs. Importantly, what is considered “too easy” or “too difficult” is entirely relative and will differ between participant groups. For example, what is mildly difficult for some individuals (e.g., older adults with normal hearing) may be much more difficult for other individuals (e.g., older adults with hearing loss).

Implications

Taken together, these results contribute to our fundamental understanding of how age-related hearing loss and hearing aids affect balance-related outcomes under realistic, complex, multisensory, multitasking conditions.

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