May is Better Hearing and Speech month and this year’s theme is “Communication: The Key to Connection.” In a 2015 hearing industry survey, only 10.6% of consumers reported hearing difficulty. Surprisingly though, a 2017 CDC survey revealed that 24% of patients ages 20-69 who reported “excellent” hearing, actually had measureable hearing damage. Addressing this gap between perceived hearing ability and actual hearing loss is a key element to unlocking effective communication between healthcare providers and their patients.
Teens and younger adults are showing higher rates of noise-induced hearing loss, yet the highest percentage of hearing loss is still age-related, especially those over 60. A literature review published in the April Journal of the American Geriatric Society shows few studies acknowledge hearing loss as a factor influencing communications between providers and patients. One of the authors, Dr. Blustein, wanted to know “how we can attend to and improve hearing and understanding so that patients get the best quality care possible.” Several sources make recommendations on how to take hearing loss into account when interacting with patients:
Identify those with, or at risk for hearing loss and refer to a Hearing Healthcare Professional (HHP) if patients answer the following questions affirmatively.
- Do you find it difficult to follow a conversation if there is background noise?
- Can you usually hear and understand what someone says in a normal tone of voice when you can’t see that person’s face?
- Do you feel frustrated with your hearing when talking to family or friends?
- Are you often exposed to loud sounds, either at work or away from work?
Reframe the message:
The way healthcare messages are framed influences the likelihood of people either accepting or rejecting a recommended health behavior. When hearing impairment is viewed as a “condition” (a loss) and test results confirm their “flawed” status, patients tend to avoid discovery, especially if treatments are perceived as negative or they feel powerless to minimize or prevent that loss. Here are ways to reframe the perspective for positive adherence:
- Change the discussion from tests, loss, disability and hearing aids to: prevention, evaluation/assessment, maintaining and/or improving the ability to listen and communicate effectively, and use the term “hearing technology.”
- Focus on “maximal hearing and listening.” Identify the situation the patient has difficulty hearing clearly in, and assure the patient can communicate maximally in work, social and recreational situations.
- Empower patients to use hearing technology that allows them to maintain or increase their self-image.
- Explanations must mirror the perception of the patient. A patient hears “everything” within his hearing range. Sounds outside of that range just don’t exist. It’s not about stubbornness or denial; discuss what the patient would like to hear more of, not what they are missing.
- Normalize hearing healthcare as maintenance of “maximal hearing and listening” throughout life and is as routine as dental, vision and physical exams.
Accommodations to use with patients with hearing loss:
- Minimize ambient noise
- Speak face to face
- Speak in a normal tone of voice, at a regular pace, but allow time for the patient to process and respond.
Patients who feel able to communicate openly and honestly with their healthcare provider, who can hear and understand all the information they need, who feel supported and involved in making decisions about their care, adhere to medical treatment recommendations better. Primary care providers have a significant impact on whether patients follow up with hearing health and/or adopt recommended treatments/technology as well. Effective communication makes a difference in healthcare outcomes.
The American Tinnitus Association and the CDC state 10-15% of Americans (about 50 million) experience “ringing in the ears.” Tinnitus is not a disease, but a sensorineural reaction within the auditory system and parts of the brain that process sound creating the perception of sound when no actual external noise is present. It is one of the most common health conditions in the country and the #1 service-related disability among US veterans.
The majority of those with tinnitus state their symptoms are simply annoying, yet millions report having disabling symptoms that interfere with sleep, social activities or work. In addition to the personal strain of tinnitus, economic consequences of tinnitus are significant and cost society an estimated $26 billion annually due to lost income, productivity and health expenses.
With so many people suffering from tinnitus and with such hefty financial ramifications, knowledge of the differences between fact and fiction affords healthcare providers the best opportunity to improve their patients’ quality of life.
Myths & Truths:
Tinnitus is always ringing in the ears.
Tinnitus can be intermittent, constant or irregular, pulsatile, monaural or binaural, temporary or chronic. Reported perceived sounds include more than just ringing. People hear hissing, static, crickets, screeching, whooshing, roaring, or buzzing which can be quiet as a whisper or loud enough to impede daily activities. Listen to sample tinnitus sounds at: https://www.ata.org/understanding-facts/symptoms.
Only people with hearing loss have tinnitus.
Tinnitus can occur without hearing loss but is more prevalent in people exposed to loud noises or with hearing loss. Sometimes tinnitus can be the first sign of hearing loss in older people; those between 60-69 years have the highest prevalence rates. Other groups at high-risk include: Caucasians, males, active military personnel/veterans, employees working in loud environments, musicians, people who participate in loud recreational events/hobbies like motorsports or hunting.
Tinnitus can manifest from many other health conditions as well: obstruction in the ear canal or middle ear, head or neck trauma, temporomandibular joint disorders, sinus pressure, barometric trauma, traumatic brain injury, ototoxic medications, metabolic/autoimmune/vestibular disorders, tumors.
There is no cure for tinnitus so I just have to learn to live with it.
Unfortunately, many patients still operate with the belief that nothing can be done for their tinnitus. While there is still no scientifically proven cure for most types of tinnitus, many treatment options or tools do exist that help reduce the perceived hardship of tinnitus. Each case of tinnitus is different and the “best” treatment option usually involves implementing multiple strategies:
- General Wellness: A healthy lifestyle and diet supports better auditory function.
- Hearing Instruments: These devices treat hearing loss and can mask tinnitus sound by augmenting environmental noise, forcing the brain to focus on the external sounds. Hearing aids with integrated sound generation technology are especially effective when hearing loss is in the same frequency as the tinnitus.
- Sound Therapies: Numerous products are available that use one or more effective mechanisms of action (masking, distraction, habituation, neuromodulation).
- Behavioral Therapies: Various therapies that address the emotional and behavioral response to their tinnitus. Relaxation, mindfulness, cognitive skills are some coping techniques learned by working with a trained therapist.
- Drug Therapies: No drug is FDA-approved specifically for tinnitus and there are no medications shown to reverse the neural hyperactivity thought to be the root cause of tinnitus. Commonly used medications include antidepressants and antianxiety drugs to manage symptoms of burdensome tinnitus.
Unless provoked by a traumatic physical event (head/neck trauma, concussive trauma), tinnitus is rarely indicative of an emergency medical condition. However, patients with tinnitus symptoms lasting beyond a week, or who are bothered significantly by their symptoms should seek medical care from their primary care provider (PCP) to diagnose or rule out any medical condition that can cause tinnitus. The PCP plays an important role in recommending or referring patients to a specialist with specific capacities in managing tinnitus, which may include an otolaryngologist, audiologist, board certified hearing instruments specialist, neurologist, or behavioral therapist. Tinnitus is a diverse condition unique to each patient and successful treatment and management requires clinical evaluation and multi-disciplinary intervention.
Hearing Loss Increases Risk For Falls
Falls can be devastating for older adults. It is well recognized that the following factors all contribute to the risk of falling: visual problems, dementia/cognitive impairment, balance or mobility issues and multiple medications. However, untreated hearing loss also impacts the fall risk for all adults, even in ages younger than 65.
Facts About Falls from the CDC
- About 1/3 of older adults (65 and older) fall each year but fewer than half tell their PCP.
- Falls can lead to moderate to severe injuries including hip fractures, traumatic brain injury, loss of independence, fear of falling.
- One fall doubles the chance of falling again.
- Fall injuries for the US cost $31 billion annually.
Hearing Loss Facts from the NIDCD
- 14% of people ages 20-69 are diagnosed with hearing loss.
- Age is the main predictor of hearing loss in adults.
- 25% of 65-74 year olds and 50% of those over 75 are diagnosed with disabling hearing loss.
A number of studies provide evidence for the connection between aging, hearing loss and increased risk of falls. Hearing impairment is associated with:
- Reduced mobility/activity levels and fear of falling.
- Slow gait speed.
- Higher fall rates and injuries, especially due to impaired ambulation.
In 2012, researchers Dr. Lin from Johns Hopkins and Dr. Ferrucci from the National Institute on Aging, published results of their study investigating hearing loss and self-re- ported falls in participants aged 40-69. Their findings suggest that the risk of falling increases 3-fold for just a mild hearing loss (25 decibels/dB). Every 10dB of hearing loss increased the odds of falling 1.4-fold. Adjusting for demographic and cardiovascular factors (age, sex, race, education, smoking, diabetes, hypertension, stroke), vestibular balance function and excluding those with moderate to severe hearing loss did not significantly change the results.
The Laryngoscope published a literature review in November 2016 that also supports the connection between hearing loss and falls. Studies included in the meta-analysis used a predetermined definition of hearing loss and information regarding falls were measured by hospital records or self-reports through structured interviews and validated questionnaires. The investigators found that older adults with hearing loss had a 2.39-fold increased risk of falling. Limitations for the reviewed studies and most other studies include cross-sectional versus longitudinal design, small sample size, retrospective self-reporting by participants, and the presence of positive publication bias. Despite these limitations, a consistent result of all the research identifies a significantly increased risk of falling for those with even a mild hearing loss.
Theories about this association stem from the concept that hearing loss increases cognitive load, thereby robbing resources from other systems needed for environmental awareness. “Coexisting vision, hearing and balance difficulties may have an additive debilitating effect on mobility because of the loss of possible compensatory sensory resources.” Also, due to their shared proximity, dysfunction of the cochlea and the vestibular systems may affect each other.
A fall and with or without resulting injuries can reduce confidence and increase fear of falling again. Out of fear, patients may restrict their physical activities, which can lead to a decrease in muscle strength and balance, actually increasing their chance of falling again. Researchers agree on the need for more prospective studies to determine whether auditory and vestibular rehabilitation can modify the risk for falling. In the meantime, collaboration between health care providers and hearing specialists remains critically important for supporting patients’ physical, social and auditory needs.
Patient Expectations & Realities of Hearing Loss Treatments
Approximately 20% of Americans (48 million) have some degree of hearing loss and the prevalence increases with age: 30% of those aged 65 and 50% over 75 experience disabling hearing loss. Medical, psychosocial conditions and overall quality of life (QoL) are negatively linked to untreated hearing loss. The majority of people without hearing loss (68%) report having an excellent QoL or very good physical health while only 39% of people with hearing loss agree. Addressing treatments for each patient’s unique hearing needs and preparing the patient for a successful aural rehabilitation process greatly impact medical health and overall life satisfaction.
Results from the MarkeTrak IX industry survey show that although hearing aid adoption rates are on the rise and satisfaction with hearing devices is high, the majority of patients with a known hearing loss still wait an average of 13 years to purchase hearing devices. Patients cite the following reasons for their decisions:
- Purchasing and using hearing devices: having a compelling hearing test result and increased insurance coverage.
- Taking no action/not buying hearing devices: financial constraints and lack of a perceived need.
- Discontinuing use/returning hearing devices: physical discomfort or performance below expectations (too much background noise, too much feedback and/or poor sound quality).
Unrealistic expectations along with the common misconception that hearing devices instantly “cure” hearing loss can stymie patients’ success with treatment. Hearing Care Providers (HCP) work collaboratively with patients to establish realistic goals and learn new skills to enhance communication. Recommended components of a successful program include:
- Education: Understanding the type and degree of hearing loss, implications for communication, preventative and rehabilitative recommendations, need for referrals to other professionals including physicians and any recommended amplification options is critical for making rehabilitative decisions.
- Realistic Expectations and Goals: Gauging individual needs, goals and expectations determine the successfulness of patients using any prescribed amplification or complying with rehabilitation. No device will restore hearing to “normal” but increasing ease of communication is a realistic expectation. Each patient’s perception of sound is unique and requires a personalized communication needs assessment for the environments he participates in. It is important to note that both patients with hearing devices and those without rate trying to follow a conversation in the presence of noise as the most difficult and least satisfying listening situation. Speech in noise is a universal problem but one that can be addressed well with properly prescribed hearing treatment.
- Hearing Device Follow Up: Expect several follow up appointments for counseling and rehabilitation. Objective and subjective tests performed by the HCP evaluate perceived benefits from hearing devices and identify areas where fine-tuning may be needed, as well as to learn strategies to maximize sound processing.
- Adjustment Counseling: Amplification involves adjusting to the process of learning to hear again. It may take time for the brain to begin responding to certain noises after a lack of stimulation. Different environments present unique and highly subjective listening challenges that may require multiple fitting and adjustments to program devices at comfortable and usable settings.
- Communication Strategies: Hearing is a dynamic process that involves utilizing input from multiple sensory sources beyond just receiving sounds through the ear. Listening skills often decline with hearing loss, so conversations can be improved just by relearning how to increase attention, concentration and interest. Using visual cues and environmental manipulation (where to position in different listening situations like at a restaurant, at a party, in a car) are combined strategies that can also improve communication proficiency.
- Family Support: Involving family members and/or significant others in the patient’s aural rehabilitation is strongly advised. Learning good communication practices like using appropriate speed and volume of speech, limiting background noise, getting the attention of the listener and avoiding communicating from another room support improved interactions.
More PCP’s are discussing hearing issues at appointments and including hearing screening in annual physicals. Primary care physicians (PCP) play a major role in supporting patients’ decision making and follow up with an HCP: “many consider a positive recommendation from their physician to be a key motivator.”
However, because people are averse to the perception of loss and the threat of a medical issue (a perceived loss of health), some tend to avoid the discovery of a condition (refuse the test, or deny the need for testing), especially if they feel powerless to prevent that loss. A simple reframing of the discussion from loss, tests, disability and hearing aids to prevention, evaluation/assessment, maintaining and/or improving listening and communication and using hearing technology can empower patients to take action.
Hearingwellallowspatientstoparticipatemorefullyintheirhealthcareand positively impacts their health status. Primary Care Providers hold a strong influence with patients by presenting hearing assessments as part of maintaining “maximal hearing and listening” throughout life, similar to routine dental, vision or physical exams normalizes hearing healthcare and erases the social stigma of hearing loss.
The relationship between hearing loss, cognitive ability and cognitive decline is receiving significant attention among medical researchers around the world. As the third most common chronic health condition affecting older adults, hearing loss affects about 30% of patients 65 and older and as much as 70-90% of those 85 and older. Basic cognitive skills like working memory, the ability to focus on a speaker in a noisy background or process information quickly, also decline with age. The Alzheimer’s Association reports that 5.1 million people over 65 have Alzheimer’s, the main type of dementia affecting memory and cognitive processing skills and accounts for the sixth leading cause of death in the U.S.
The processes involved in cognition, language and audition are tightly interwoven and interdependent. Hearing can be defined as the perception of sound where listening requires active brain involvement in which meaning is applied to the sound. Understanding speech involves more cognitive ability than just responding to pure tones, though. Attention, inhibition, and executive function, for example, are all required for listening and comprehension of speech. The ability to react appropriately to spoken dialogue also involves using perceptual-motor skills, another cognitive function.
Untreated hearing loss can interfere with cognitive abilities due primarily to the large expenditure of mental effort toward understanding speech. New evidence shows that cognitive decline is more prevalent in elderly people with hearing loss than in those without hearing loss.
In 2013, Frank Lin, MD, PhD, reported in the Journal of the American Medical Association (JAMA) that hearing loss is independently associated with accelerated cognitive decline. Those with hearing loss showed a 30-40% faster cognitive decline than those without hearing loss. The researchers also report that the levels of reduced brain functioning were directly related to the amount of hearing loss.
Two more studies published in the past year not only echo Lin’s findings but also show that treating hearing loss with the use of hearing aids can attenuate that cognitive decline:
A 25-year study published in the Journal of the American Geriatrics Society in 2015 concluded that people with untreated hearing loss had significantly lower scores on the Mini-Mental State Examination (MMSE), a well-established test of cognitive function. They also found that hearing aid use mitigates that cognitive decline.
In a study published in February 2016, Jamie Desjardins, PhD at The University of Texas at El Paso speech-language pathology program shows that hearing aids do improve brain function in people with hearing loss. Desjardins studied a group of 50-60 year olds with bilateral sensorineural hearing loss who had previously never used hearing aids. After two weeks of hearing aid use, tests revealed an increase in percent scores for recalling words in working memory and selective attention tests, and the processing speed at which participants selected the correct response was faster.
Cognitive decline, age-related vision loss, poor motor skills and decreased health literacy are often associated together and patients with cognitive impairment often have deficits in these other areas as well. This can affect how patients understand and incorporate medical instructions and treatments into their lives. Compounding the issue, too, is that symptoms of hearing loss can overlap with those of dementia. In combination with cognitive screening tools like the Mini Mental Status Examination (MMSE), the Clock Drawing Test (CDT), the Mini-Cog Test and the Montreal Cognitive screening assessment (MoCA), thorough hearing evaluations by an audiology specialist support a comprehensive care model to identify hearing needs. Because of the known negative consequences of untreated hearing loss on health and well-being, the National Council on Aging also encourages primary care providers to incorporate hearing loss discussions into routine exams.
Reducing the mental load of understanding speech through better hearing is an important step in liberating more cognitive capacity for other brain functions. However, proper hearing rehabilitation is a complex process and involves more than just using hearing aids. Pathways like shared neuropathic conditions, cognitive load, and social isolation likely contribute to accelerated cognitive decline in people with hearing loss. While new studies are showing improved cognitive function by treating hearing loss with hearing aids, further research is needed to understand how these multiple pathways respond to hearing rehabilitation interventions. “As hearing changes, so do communication ability, cognitive function, and psychological factors…affecting quality of life and the whole person, not just hearing.” A network of specialized providers, including hearing healthcare professionals supports improved health and lifestyle for hearing impaired patients.
“Hearing loss was recently qualified as a risk factor for accelerating brain aging by reducing brain volume and cognitive abilities”