Ken is 87 years old and has returned to your clinic for the fourth time in two months. He is now wearing his third pair of high-end digital hearing aids since his initial evaluation. He is dissatisfied with this latest pair because he has difficulty inserting them correctly and changing the batteries, doesn't know why the hearing aids have a little button, and cannot understand conversations around the table because of background noise from others in the dining room at the senior center. Ken's friend has hearing aids from another company and Ken wants to know if those would work better for him. How will you advise him?
Ken is representative of the patients we will increasingly see in our audiology practices in the future. From 2000 to 2030 the number of Americans older than 65 will double from 34.8 million (12% of the population) to 70.3 million (20%). The likelihood that an American reaching the age of 65 will live to age 90 has nearly doubled since 1960. By 2040 an estimated 40% of 65-year-olds will live into their 90s. (From the Experience Corps Web site.)
With increased age comes the increased likelihood of hearing loss. As illustrated in Figure A [PDF], the number of people with hearing loss in the United States is anticipated to increase by almost 20 million over the next 40 years (Kochkin, 2005). In fact, these projections likely underestimate the true prevalence of hearing loss, as they are based on the number of people "admitting" their hearing loss (Kochkin, personal communication). The actual numbers are likely to be much higher as audiometry would reveal mild hearing loss that may not be perceptible to the individual. The increased prevalence of hearing loss will have a significant impact on audiologic practice, as hearing aid adoption rates are clearly associated with advancing age (see Figure 1 [PDF]).
Although these statistics suggest unprecedented opportunities for audiologists involved in the selection and fitting of hearing aids, older patients also may present significant challenges as their approach toward audiologic rehabilitation will be influenced by the physiologic, psychoacoustic, and psychosocial changes that occur with aging. Of course, any discussion of aging begs the question, "How old is old?" There is no such number; it is more effective to understand the effects of aging on the auditory system and their implications for audiologic management. In fact, making assumptions about an individual's auditory and communication capacity on the basis of chronological age alone would be irresponsible, as individual differences do not disappear as we age. Indeed, outcomes with hearing aids likely will be poor without a careful and comprehensive evaluation that includes an assessment of motivation, needs, and expectations.
Age-related hearing loss is associated with various types of auditory system dysfunction, peripheral or central, which accompany aging and cannot be attributed to extraordinary ototraumatic, genetic, or pathological conditions. Hearing loss implies a deficit in absolute thresholds and/or suprathreshold perception (Willott, 1991).
Anatomic and Physiologic Changes
Age-related changes to the auditory system occur from the pinna to the auditory cortex (see summary on p. 16). The implications for audiologic management, including the selection and fitting of hearing aids, will vary with the location and severity of changes in the auditory system. For example, changes to the outer and middle ears likely will have minimal effect on auditory processing and subsequently little influence on hearing aid decisions, with the possible exception of earmold style and material. On the other hand, changes in the inner ear often will have a significant impact on auditory function as the result of a loss of audibility, widening auditory filters, and reduced dynamic range. Age-related cochlear changes frequently lead to difficulties understanding speech in the presence of background noise or multiple talkers or in highly reverberant environments. Despite advances in digital signal processing, hearing aid success may be limited as a function of the extent of sensory cell loss, specifically inner hair cells and spiral ganglion cells.
Changes in the central auditory system may be more problematic because they affect high-level auditory processing such as temporal and binaural processing and occur in addition to changes that affect cochlear structures. Recently, there has been more attention given to the importance of considering the cognitive effects of aging such as cognitive "slowing" and reduced working memory on the outcomes of audiologic intervention and approaches to management (Pichora-Fuller, 2003; Pichora-Fuller & Souza, 2003; Stewart & Wingfield, 2009).
For many individuals, growing old is a rewarding phase of life with increased time to spend with family, travel, or become involved in new, post-retirement activities. For others, however, it is a time of reduced income, increased health issues, loss of loved ones, and loss of purpose. When sensory function deterioration is added to these issues, the effect on quality of life can be significant.
The psychosocial impact of hearing loss on older individuals can be examined within the context of the International Classification of Functioning, Disability, and Health (ICF; WHO, 2001). The WHO-ICF is a bio-psychosocial model that codifies an individual's health condition into the broad dimensions of body structure and function, activity, and participation (Chisolm & Abrams, 2008). Figure 2 [PDF] illustrates how these dimensions interact with the health condition as influenced by environmental (e.g., social attitudes, community resources) and contextual (e.g., income, gender, age) factors.
As an example, Ken, the 87-year-old patient described previously, has an impairment of a body structure (the auditory system) that results in an activity limitation (ability to understand conversations in the dining room) that leads to participation restriction (no longer engages in conversation with tablemates). His disability is further aggravated by environmental factors (poor acoustics and lack of appropriate assistive technology) and personal factors (inability to afford assistive technology). Clearly, this unhappy scenario can lead to additional psychosocial consequences such as depression, loneliness, irritation, anger, insecurity, and social isolation (see Heine & Browning, 2001 for a review of the psychosocial consequences of sensory loss in the elderly).
It is important to note that hearing loss does not usually occur in isolation in the elderly, but is often accompanied by visual impairment as the result of cataracts, diabetic neuropathy, glaucoma, or age-related macular degeneration (Rosenbloom, 1992). It is estimated that 19% of older individuals who are not living in a facility have dual-sensory impairment (Hickson et al., 1999). Dual-sensory impairment creates additional burdens for the older patient and can lead to even deeper social isolation, loneliness, and depression.
Ken brings with him a complex set of needs, wants, expectations, prejudices, medical and psychosocial limitations, and lifetime experiences. It is never appropriate to develop a treatment plan based primarily on an audiogram for any patient, and it is particularly inappropriate for an older individual.
Before any decision about amplification can be made, it is important to consider the patient's motivation, needs, and expectations. This consideration is best accomplished through the following questions:
- Why are you here? The patient's response to this question can reveal his or her motivation for the visit. If the answer is, "I live in a retirement home and want to be able to understand others at the dining room table," then the clinician can be assured that the patient recognizes a problem, has taken ownership of it, and is taking a significant step toward resolution. On the other hand, if he answers, "My daughter set up this appointment. She thinks I can't hear her or the grandchildren," then the success of audiologic management may be limited unless the patient can, through counseling and involvement of family members, accept ownership of the problem and solution. This approach requires counseling skills and time to explore issues around motivation and family dynamics that need to be resolved for successful treatment (for information about counseling, see Luterman, 2008). In absence of strong motivation, the patient may be unwilling to invest the time and effort required to become a successful hearing aid user and will likely reject the hearing instruments.
- What's important to you? If the patient has adequate motivation, the next step is to determine the patient's perceived needs. What does the patient want from the therapeutic experience? A number of needs-assessment instruments are available, including the Hearing Handicap Inventory for the Elderly (HHIE; Ventry & Weinstein, 1982)
and the Abbreviated Profile of Hearing Aid Benefit (APHAB; Cox & Alexander, 1995). The Client-Oriented Scale of Improvement (COSI; Dillon, James, & Ginis, 1997) may be particularly effective because it determines not only the patient's needs, but also the relative importance the patient places on addressing specific needs. The COSI has gained popularity among clinicians who assume that by focusing on and measuring the effects of treating problems relevant to the patient, the outcomes measured will most accurately reflect the true functional impact of intervention as perceived by the patient (Chisolm & Abrams, 2008).
- What do you expect? Although there appears to be no clear relationship between pre-fitting expectations and satisfaction with hearing aids (Cox & Alexander, 2000), understanding the patient's expectations may help in counseling the patient to establish reasonable expectations based on the evaluation. Patient expectations may be unreasonably positive ("hearing aids will help me in all situations") or negative ("everyone will notice that I am wearing hearing aids"). The Expected Consequences of Hearing Aid Ownership (ECHO; described in Cox & Alexander, 2000) is an instrument designed to determine the patient's expectations for hearing aids across several domains, including positive effect, service and cost, negative features, and personal image.
Hearing Aid Selection
In addition to providing the routine audiologic examination, the clinician should consider the physical and cognitive abilities of the patient. The patient's manual dexterity and visual acuity can limit instrument choice to those that are easy to insert, remove, and operate and use a large battery. The patient's cognitive abilities might influence technology decisions such as whether to fit unilaterally or bilaterally or whether to provide automatic or manual options for gain control and program changes. Newer-generation hearing instruments have rechargeable batteries that last up to 24 hours. Automatic features eliminate the need to change programs manually.
Despite the availability of advanced signal-processing instruments, older people with hearing loss will likely continue to experience problems understanding speech in less-than-optimal listening environments. Consequently, part of the hearing aid selection process should consider assistive technology (i.e., the selected hearing instrument should have the capability of incorporating FM, Bluetooth, and/or direct audio input technology). Two excellent reviews of the issues associated with older adults' compromised cognitive and auditory abilities and their implications for audiologic management are provided by Kricos (2006) and Pichora-Fuller and Singh (2006).
Hearing Aid Verification and Treatment Validation
Although real-ear verification of gain and output represents the current standard of audiologic care (American Academy of Audiology, 2005; ASHA, 2006), the use of probe-microphone measures are particularly critical in the elderly population; disappointment and subsequent rejection of hearing instruments because of inadequate or inappropriate gain and/or loudness discomfort could result in the patient's reluctance to pursue amplification. Validating treatment success with a standardized instrument such as the COSI allows the clinician and patient to determine the extent to which treatment goals were achieved and provides an important opportunity to modify the treatment plan to resolve more adequately any unmet or partially met goals.
Regular post-fitting follow-up is critical to treatment success for older people. These patients may forget the new and complex information provided at the hearing aid fitting, including information related to batteries, cleaning, and operation. They are more likely to become frustrated with the quality of amplified sound and the time needed to adjust to amplification. Post-fitting group audiologic rehabilitation programs that focus on counseling and communication skills training may be particularly valuable for this patient population (Abrams et al., 1992; Chisolm et al., 2004; Kricos et al., 1992). The recent development of at-home, computer-based, auditory rehabilitation programs (e.g., LACE™; Sweetow & Sabes, 2006) provides another option for post-fitting intervention for those comfortable with computer technology.
Collaborative self-management (CSM), an emerging treatment approach in managing chronic illnesses, may have implications for successful audiologic management of the older patient with hearing loss. CSM (also referred to as patient self-management) emphasizes the partnership among the health care professional, the patient, and the family that guides the patient's self-management (Hodder, 2007). The role of the provider is modified from a prescriber or director of care to a facilitator who helps the patient take charge of his or her condition, make informed care decisions, and adopt healthy behaviors. The clinician provides information, resources, and supportive care. CSM encourages everyone to work together to help manage the patient's condition, with a focus on the patient's needs, abilities, values, and preferences. Families and others in the patient's support network are welcomed as partners in care who share information and create a care plan together. (Additional information on collaborative self-management can be found on the California Healthcare Foundation's Web site.
Patient self-management can be applied to audiologic care through the following steps:
- Engage patients to help them identify needed changes from their perspective. Engagement involves active listening and obtaining the details about the impact of hearing loss to identify key areas of concern. When patients see that the clinician is interested in their perspective, they are more likely to follow advice and be open to and interested in taking responsibility for their hearing loss.
- Recognize ambivalence and explore importance of treatment to help the patient not only identify why it may be important to "hear better" but to also to identify and accept mixed feelings about treatment ("I want to hear better but I don't want to wear hearing aids ..."). When patients recognize their ambivalence and that ambivalence is accepted and validated by the clinician, they may be more likely to accept change.
- Collaborate in action planning by using a step-by-step strategy that is achievable, specific, and focused on specific behaviors (e.g., "I will wear my hearing aids from 8 a.m. to 10 a.m. on the first day, from 8 a.m. to 12 noon on the second day," etc.).
Older patients can present a significant challenge to audiologists. Changes in the structure and function of the auditory system, combined with age-related visual, physical, cognitive, and psychosocial decline, require careful and comprehensive the management of hearing loss. A clinical protocol that works well for young patients requires modification of all steps, from the determination of motivation and expectations, through the evaluation of visual, dexterity, and cognitive status, to the establishment of post-fitting programs to improve communication. An approach that encourages collaborative self-management may lead to better long-term positive outcomes and improved quality of life for the older patient with hearing loss.