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in general , declines in bodily function and cognition due to aging are considered normal 
 and part of an inevitable process1 .
particularly , hearing loss causes social isolation , depression , and 
 loss of self - esteem in older adults4 , 5 . in the united states ,
hearing loss is the 
 most common chronic condition of older people after hypertension and arthritis6 , and it was reported that almost two - thirds 
 of elderly people over 70  years of age are affected by hearing loss7 .
such a high prevalence of hearing loss is of concern in 
 korea , where the elderly population aged 65 or over is increasing significantly , and was 
 12.66% of the total population as of aug 20148 .
hearing is an important variable to be considered in the assessment of cognitive 
 function9 , and hearing loss is 
 associated with incident dementia10 .
it 
 has been reported that among the elderly , hearing loss is associated with falls , and gait 
 speed also slows when hearing loss is high11 . on the other hand ,
other studies have suggested that hearing loss 
 is not a major risk factor of a fall12 , 
 and the absence of correlation between the auditory and vestibular systems has also been 
 suggested13 .
generally , as people get older , hearing , cognition , and balance abilities deteriorate . 
 however , the relationships among hearing loss , cognition and balance ability have not been 
 fully established .
therefore , this study was conducted to determine the relationships among 
 hearing loss , cognitive function and balance ability in community - dwelling older adults .
twenty - nine males and 17 females ( 46 ) elderly individuals aged over 65  years old who were 
 attending a senior welfare center in the local community of pohang city were enrolled in 
 this study .
the general characteristics of the study subjects are as follows : the mean age , 
 height , and weight of the subjects were 75.96 ( 6.37 ) years old , 161.78 ( 8.61 ) cm , 63.74 
 ( 8.86 )  kg , respectively .
subjects were informed of the purpose , procedure , and method of the study and 
 they gave their consent to participation in this study .
individuals with asymmetric hearing loss 
 whose pure tone average ( pta ) difference measured by audiometry was larger than 10 db in 
 both ears14 , persons who used hearing 
 aids , persons who had difficulty walking independently , persons who used walking aid tools , 
 person who experienced pain during standing with one foot or walking , persons who had 
 neurological diseases , such as stroke , persons who had surgical operations on the lower 
 limbs or spine in the past six months , or persons who complained of chronic dizziness were 
 excluded from the study .
audiometry was performed by a professional audiologist using an entomed sa 204 audiometer 
 ( entomed , sweden ) with tdh-39 headphones ( madsen electronics , denmark ) .
the first test was 
 conducted with tones of 0.25 , 0.5 , 1 , 2 , 4 , and 8 khz , and then the better ear hearing level 
 ( behl ) threshold was established by checking the speech - frequency pta of the threshold at 
 0.5 , 1 , 2 , and 4 khz . according to the criteria suggested by the world health organization 
 ( who ) , hearing losses of 25 db or less are considered normal , 2640 db slight , 4160 db 
 moderate , 6180 db severe , and 81 db or more are categorized as profound hearing loss15 .
thus , we set the criterion of hearing 
 loss as a behl value in excess of 25 db . cognition was assessed using the korean mini - mental state examination ( k - mmse)16 .
this examination tool is widely used as a 
 simple dementia test tool in south korea , and the mmse has been modified for korean cultural 
 characteristics .
this test comprises five subscales and the total score is 30 points . in 
 general ,
balance ability was measured using the timed up and go ( tug ) test and the one - leg stance 
 test ( olst ) .
this test is fast and requires no special equipment or training , so it is widely 
 used in clinical practice17 .
the subjects 
 were seated in a chair with a back support and arm rests , and a cone - shaped object was put 
 in front of them at a distance of 3  m. then , the subjects stood up from the chair and walked 
 at a normal comfortable gait speed to the cone - shaped object , walked around it , then walked 
 back and sat in the chair .
after one practice , 
 subjects performed two tug tests and the results were recorded .
this test is cheap 
 and easy to perform , is economical with time , does not require any special equipment , and 
 little test training is required18 . 

subjects stood on one leg and if the raised foot touched the floor or the other leg , or if 
 the other foot moved , the test was stopped and the time recorded .
descriptive data are reported as the 
 mean and standard deviation or number of subjects ( n ) .
pearson s correlation coefficient was 
 calculated to assess the relationships among age , behl value , k - mmse , tug , and olst .
the 
 mann - whitney u test was used to determine the differences in cognition and balance ability 
 between the hearing loss and normal hearing groups . a p - value < 0.05 was considered 
 statistically significant .
the measured average values of the subjects were as follows : pta of the right ear was 36.1 
 ( 13.4 ) db and that of the left ear was 35.6 ( 13.9 ) db , while the behl value was 33.6 ( 13.1 ) 
 db .
the tug time was 8.9 ( 1.8 ) seconds , and that of 
 the olst score was 12.7 ( 10.1 ) seconds .
furthermore , the distribution of subjects according 
 to hearing grade were : 16 normal , 18 slight , 9 moderate , and 3 with severe hearing loss . 
 therefore , the normal hearing group comprised 16 subjects and the hearing loss group 
 comprised 30 .
table 1table 1.correlations among age , hearing , cognition , and balance in older adultsbehlk - mmsetugolstage0.5330.4210.4950.409behl0.2620.1790.387p < 0.01 .
behl : better ear hearing level at 0.5 - 4 khz ; k - mmse : korean 
 mini mental state examination ; tug : timed up and go ; olst : one - leg stance test shows the correlation analysis results of the age , behl , k - mmse , tug , and olst 
 values of the subjects .
age significantly correlated with behl ( 0.533 , p < 0.01 ) , k - mmse 
 ( 0.421 , p < 0.01 ) , tug ( 0.495 , p < 0.01 ) , and olst ( 0.409 , p < 0.01 ) .
behl showed 
 a significant negative correlation with olst ( 0.387 , p < 0.01 ) , whereas no correlation 
 was found with k - mmse ( 0.262 , p > 0.05 ) or tug ( 0.179 , p > 0.05 ) .
a comparison of the 
 results of the normal hearing and hearing loss groups revealed there was no significant 
 difference in the tug times ( p > 0.05 ) , whereas the olst time showed a significant 
 difference between the normal hearing and hearing loss groups ; the average rank of the 
 normal hearing group was 29.1 , and that of the hearing loss group was 20.5 ( table 2table 2.differences in cognition and balance ability according to the presence of hearing 
 lossnormal hearing(n = 16)hearing loss(n = 30)k - mmse ( score)27.13.2 ( 26.2)26.62.6 ( 22.1)tug ( sec)8.71.4 ( 23.1)9.02.0 ( 23.7)olst ( sec)18.112.0 ( 29.1)9.87.7 ( 20.5)all values are meanssd ( mean rank ) .
k - mmse : korean mini 
 mental state examination ; tug : timed up and go ; olst : one - leg stance test ) .
behl : better ear hearing level at 0.5 - 4 khz ; k - mmse : korean 
 mini mental state examination ; tug : timed up and go ; olst : one - leg stance test all values are meanssd ( mean rank ) .
k - mmse : korean mini 
 mental state examination ; tug : timed up and go ; olst : one - leg stance test
this study aimed to determine the relationships among age - related hearing loss , cognition , 
 and static and dynamic balance abilities in elderly persons over 65  years old who were 
 living in the local community of pohang city .
changes in hearing and cognition , as well as in balance abilities are considered normal as 
 people get older . in this study ,
lin 
 et al.7 conducted audiometry with 717 
 older adults . they reported a 63.1% prevalence of hearing loss , defined as a decline in 
 speech frequency pta in the better ear of more than 25 db .
enrietto et al.13 conducted a longitudinal study with 57 
 older adults and reported that the pure tone threshold increased by about 1 db every year . 

another study found evidence of changes in cognitive functions which were related to 
 aging19 . in the present study ,
k - mmse 
 decreased as age increased , indicating cognitive function declines with aging . in relation 
 to aging and balance ,
bohannon20 
 conducted a meta - analysis to verify the normative reference times for tug of elderly 
 persons .
the mean tug times were 8.1 seconds for persons aged 60 to 69  years , 9.2 seconds 
 for persons aged 70 to 79  years , and 11.3 seconds for persons aged 80 to 99  years .
briggs et 
 al.18 conducted a timed balance test 
 with 71 non - institutionalized elderly women .
with respect to age related decreases in the balance 
 function , fukuda21 explained that it is 
 related to delays in central processing . in the present study ,
the tug time increased as age 
 increased ( r = 0.495 , for age and tug ) , while the olst time decreased as the age increased 
 ( r = 0.409 , for age and olst ) .
these results indicate that as age increases , dynamic and 
 static balance abilities decrease . in relation
to hearing loss and cognition , a previous study suggested that the risk of 
 dementia increases with hearing loss severity , and that over one - third of the risk of 
 incident dementia was associated with hearing loss10 .
naramura et al.22 reported that hearing level significantly correlate with age , 
 hearing severity score , and mmse and self - rating depression scale ( sds ) values . 

purchase - helzner et al.12 investigated 
 the relationship of hearing loss and osteoporotic fractures and attempted to determine 
 cognitive impairment by means of a modified mmse version .
they reported that poor cognitive 
 function was found in 13% of the normal hearing group , in 14.2% of the mild hearing loss 
 group , and in 12.8% of the severe hearing loss group .
this result indicates there was no 
 significant cognitive impairment associated with hearing loss . in the present study , the 
 correlation coefficient for behl and k - mme was r = 0.262 , showing there was no correlation 
 between hearing and cognition function .
thus , it will be necessary to conduct a longitudinal 
 study using a larger sample size to further test this hypothesis in the future . in relation to hearing loss and balance , li et
al.11 evaluated gait speed using hearing and a 20-foot ( 6.1 meter ) walk 
 way with 1,180 adult subjects aged 5069  years .
they reported that gait speed slowed by 0.05 
 m / s with every 25 db of hearing loss , indicating a correlation between gait speed and 
 hearing loss .
in addition , viljanen et al.23 studied whether a mean hearing acuity ( behl 0.54 khz ) can prevent 
 a fall , as well as whether it is correlated with postural balance .
they reported that 
 subjects with poor hearing acuity showed a greater risk of fall and worse postural control . 
 on the other hand
, purchase - helzner et al.12 studied the relationship between hearing and risk factors of 
 fractures and falls .
they reported that the annual fall rate had no correlation with hearing 
 grade , and that hearing grade showed no significant difference in relation to total hip bone 
 mineral density , in accordance with age and bmi .
in addition , enrietto et al.13 verified the age - related changes in the 
 auditory and vestibular systems .
however , they found no significant correlations between the 
 ptas of the auditory test and vestibular test results . in our study , as hearing loss became 
 worse , olst times became shorter , a negative correlation ( r = 0.387 ) .
however , olst time 
 did not correlate with tug , which is measure of dynamic balance ability .
moreover , the olst 
 time was significantly shorter in the hearing loss group than in normal group , which 
 indicates hearing is related to static balance ability .
the present study showed that the hearing , cognition , and balance abilities of elderly 
 individuals declines as they get older .
however , no correlations among hearing , dynamic balance , and cognitive 
 functions were found .
a possible explanation for this result is that there was only a small 
 number of subjects with moderate and severe hearing loss .
thus , it will be necessary to add 
 more subjects with moderate to severe hearing loss in a future study .
it is evident that 
 hearing loss has a negative effect on cognitive functions and balance abilities .
therefore , 
 it is desirable that elderly persons start hearing loss treatment as early as possible , to 
 minimize decreases in cognitive functions and balance abilities due to hearing loss . also , 
 balance training and exercises should be considered to improve the quality of life and to 
 prevent falls by the elderly . future research will need to determine the relationships of 
 other physical abilities with hearing loss , cognition , and balance abilities in various 
 living environments , as well as the effects of hearing aids .
[ purpose ] the purpose of this study was to determine the relationships among hearing 
 loss , cognition , and balance ability in elderly individuals . [ subjects and methods ] in 
 total , 46 elderly individuals over 65  years of age who were attending senior welfare 
 centers participated in this study . through a hearing test , the speech frequency pure tone 
 average in the better ear was checked . 
 we set a criterion of hearing loss if the better 
 ear hearing level ( behl ) value was 25 db or more . 
 cognition ability was evaluated using 
 the korean mini - mental state examination ( k - mmse ) . 
 dynamic balance ability was evaluated 
 by the timed up and go ( tug ) test , and static balance ability was tested using a one - leg 
 stance test ( olst ) . 
 [ results ] the ages of the subjects were all related to behl , tug , 
 k - mmse , and olst . 
 behl had a negative correlation with olst , whereas it had no correlation 
 with k - mmse or tug . 
 the hearing loss group had a significantly shorter olst time than the 
 normal hearing group . 
 [ conclusion ] as elderly individuals get older , their hearing and 
 cognition , as well as their balance abilities deteriorate . 
 the results of this study 
 indicate there is a significant correlation between hearing loss and static balance .