Disability has been defined as the expression of a physical or mental limitation in a social context (Nagi. Praeger, 1979). It is the difference between a person's capabilities and the demands of his or her social and physical environments. Echoing this relationship between personal abilities and the external environment, the Ecologic Theory of Aging (ETA) notes that aging is profoundly influenced by a person's physical environment and coping skills (Lawton. Springer, 1982). As such, personal and environmental resources significantly influence how successfully one ages (Wahl. In: Dannefer & Phillipson, eds. Sage, 2012). Specifically, Lawton and Nahemow conceptualized aging to involve the interchange or fit between a person (P) and his or her environment (E), or P-E fit, and concluded that this fit gains increasing importance in determining quality of life as the person grows older (In: Eisdorfer & Lawton, eds. APA, 1973). As part of the P-E fit framework, Lawton concluded that: (1) The physical environment has the potential to impose significant constraints later in life; (2) technology is an important tool for older adults to cope and interact with their environment, which is why they must come to understand technology; and (3) technology, when used effectively, can help support declining competencies (Springer, 1989; Wahl. Sage, 2012).
Digital hearing aids and hearing assistive technologies were not even a consideration when Lawton published his seminal work. However, a fundamental assumption of ETA was that different combinations and types of personal competence, including sensory statuses and environmental characteristics, interact to determine an older adult's optimal level of functioning (APA, 1973). In fact, these observations dovetail well with the findings of Hogan, et al., who concluded that the social impact of hearing loss can be partly attributed to a person's anxiety, which results from his or her perceived capacity to manage hearing and listening impairments in challenging environments (Disabil Rehabil. 2015;37:2070 http://bit.ly/2komHxp). In short, the poorer the fit between a person's coping capacity (i.e., the ability to self-manage) and the demands of the environment (e.g., presence of noise or other distractions, distance from the sound source), the greater the psychosocial impact.
WHAT IS AN AUDIOLOGIST TO DO?
The implications are simple: Audiologists must work closely with patients with hearing loss in using strategies effectively to manage their physical and social environments, and continually monitor their function. The fact that older adults (over 65 years old) are predicted to live for more than half of their remaining years with at least mild levels of hearing loss underscores the need for the continued presence of audiologists in the lives of their patients. Audiologists must focus on helping patients become agents of change in their own lives by helping them develop a proactive attitude toward the use of hearing technology (Sage, 2012).
TIPS FOR ONGOING ASSESSMENT
Considering the ETA framework and the interplay of biological, behavioral, and environmental factors, there are several points of entry for intervention (Smedley & Syme, eds. National Academies Press, 2000). Despite providing patients with technical resources such as hearing aids, audiologists tend to fall short in helping patients use their improved hearing and speech comprehension to successfully meet the demands of their social and physical environments. Audiologists must make a conscious effort to do a better job of helping patients cope with challenging situations in the face of functional and cognitive decline. Here are some tips for ongoing patient assessment and management to prevent the onset of disabling experiences resulting from age-related hearing loss.
1. On an annual basis, reach out and assess how the patient is doing with his or her hearing aids using data logging, patient-reported outcome measures, and communication partner reports.
Data logging: This should be used to customize hearing aid fit and gather information about the patient's hours of hearing aid use in selected situations.
Self-reported psychosocial hearing difficulties: Quantify self-reported and spouse-reported psychosocial hearing difficulties. If there is evidence of residual disability (e.g., score in the Hearing Handicap Inventory screening or spousal version exceeds 12) after using hearing aids for one year, further action is needed, such as hearing aid adjustment and guidance for strategic self-management.
2. Promote and optimize the patient's efficacy in self-management in various social and physical environments.
Data logging: Counsel regarding self-management in accord with the P-E fit model. The better the fit, the less the stress and social impact. As shown in Figure 1, it is critical that the demands of the environment do not exceed the ability of the patient to meet or cope with them.
Self-reported psychosocial hearing difficulties: Several tools to optimize self-management include auditory-cognitive group rehabilitation and online or multimedia counseling on environment-specific hearing and communication strategies. Buoying behavioral competence in selected environments may contribute to the patient's social well-being, as this will encourage engagement, strengthen social ties, increase activity levels, and even buffer against cognitive decline (National Academies Press, 2000).
Active engagement with one's social and physical environments is a prerequisite for successful aging, and self-management of communication challenges is a key ingredient. It is critical for patients to develop interpersonal relations and engage in productive activities that involve effective exchange of information in various listening environments (Gerontologist. 1997;37:433 http://bit.ly/2koteYP). And it is the professional responsibility of audiologists to monitor patients and ensure their effective use of hearing technology and self-management skills in these environments.