I recently evaluated a 73-year-old physician who is a long-standing hearing aid user with mild to moderate sensorineural hearing loss. While exploring his “hearing loss journey,” he shared that “the audiogram does not reflect the severity of the communication challenges with which he contends.” He opined that he has been able to overcome many of his work-related difficulties; however, when noting his responses to the Hearing Handicap Inventory (HHI), he remains frustrated and embarrassed with the breakdowns he experiences at home when communicating with family and friends in person or over the phone or when watching television.
He described the situational stresses as often overwhelming and an impediment in and of itself. I evaluated his aided speech understanding ability in the presence of competing noise, and conducted some speech tests with and without the advantage of visual cues. His performance in the “laboratory setting” confirmed some of his subjective experiences. I reviewed available options to supplement his hearing aids, and offered him communication strategies to assist him with self-management. We concluded what I considered to be a productive clinical encounter.
I returned to my office, began scanning the Web of Science to try to better understand his complaints, and came across an article, “Self-Assessed Hearing Handicap in Older Adults with Poorer-Than Predicted Speech Recognition in Noise,” by Eckert, et al. (J Speech Lang Hear Res. 2017;60:251 http://bit.ly/2td4VR6).
The data of Eckert and colleagues substantiated the patient's experiences, and validated my observations that perhaps the stress and distress he was experiencing may be affecting his ability to cope with and communicate in different social environments. Their findings lend support to one of the assumptions underlying our decision to develop the HHI, namely that factors beyond audibility contribute to the individual variability inherent in self-reports of psychosocial hearing difficulties.
MEASURING SELF-REPORTED HEARING ISSUES
Participants (N=162) in their study completed speech-in-noise testing using Revised SPIN (R-SPIN) sentences, and responded to questions on the NASA Task Load Index. The latter is a self-report measure that quantifies the effort and frustration experienced while performing a given task, namely the R-SPIN test in this case. The effort question asks how hard the participant had to work to accomplish their level of performance, while the frustration question asks how insecure, discouraged, irritated, stressed, and annoyed the participant felt while performing the R-SPIN task.
Most participants had mild-to-moderately severe and gradually sloping sensorineural hearing loss that is typical of middle-aged to older adults seen in routine audiology tests. In general, participants with more hearing loss and reported more hearing handicaps were more likely to have poorer-than-predicted speech recognition scores on the SPIN. Notably, participants with relatively good hearing also performed poorer than predicted, and many reported a significant hearing handicap. In a sense, the findings of Eckert, et al., corroborate those of Tremblay and colleagues who, in their study on the prevalence and risk factors associated with self-reported hearing difficulty, found that 12 percent of participants with normal hearing experienced self-reported daily life communication experiences and listening difficulties based on their responses to a subset of items in the HHI (Ear Hear. 2015;36:e290 http://bit.ly/2tcR4tZ).
The data of Eckert, et al., demonstrate that reduced speech audibility did not solely explain why people with speech recognition problems experienced self-reported hearing handicap in the social (N=3) and emotional domains (N=4; J Speech Lang Hear Res. 2017 http://bit.ly/2td4VR6). Table 1 lists the factors strongly associated with scores on the R-SPIN low-context observed predicted differences. In short, participants experienced psychosocial handicaps as a result of their self-reported communication problems, particularly in social settings. Stated differently, participants who reported feeling frustrated, embarrassed, irritable, uncomfortable, and left out in social settings were more likely to have poorer-than-predicted speech recognition for sentences with low semantic context.
The role of social, psychological, and environmental factors in speech understanding has recently received considerable attention with the advent of the Framework for Understanding Effortful Listening (FUEL) developed at the Eriksholm Workshop on Hearing Impairment and Cognitive Energy. The FUEL model posits that the intersection between the appraisal of one's capacity to communicate in a given social environment, motivation, stigma, and self-efficacy modulates how one responds to listening demands. The decision to not communicate because of frustration, embarrassment, feeling left out, and discomfort jeopardizes communicative adequacy and hence social participation (Ear Hear. 2016; 37: 92S http://bit.ly/2tcWhCr; J Speech Lang Hear Res. 2017 http://bit.ly/2td4VR6). Indeed, the data of Hogan, et al., support the explanatory model that communicative stress is higher and well-being lower when there's a poor fit between a person's coping capacity and demands of the social and physical environments (Disabil Rehabil. 2015;37:2070 http://bit.ly/2komHxp).
LESSONS TO BE LEARNED
Concluding that it is not necessarily the effort and frustration during speech recognition that explains speech understanding difficulties, Eckert, et al., posited that it is the multiple negative communication experiences, particularly in social settings, that appear to account for much of the individual variability in self-reported hearing handicap. These findings have numerous implications for clinical practice, especially considering the interconnectedness of speech understanding and cognition and the scrutiny under which audiologists are now operating. Their findings underscore the importance of top-down processing and the role of language level and contextual semantic cues, which, regardless of age, are useful resources that can be optimized. Clinicians should make the most of age-related cognitive gains such as cognitive knowledge (e.g., vocabulary, experience) when helping older adults self-manage the communication deficits of age-related hearing loss (Am J Audiol. 2015;24:108 http://bit.ly/2tdiTme). If self-assessed communication difficulties combined with threshold elevation and reductions in audibility can in fact help explain the experience of hearing handicap, then clinicians must focus their efforts on helping to reduce the stress experienced in various social and physical listening environments.
To counteract stress, clinicians must also consider the value of promoting patient resilience, the ability to cope with and recover from adverse experiences. Clinicians can help patients build resilience through counseling, rehabilitation, and encouraging involvement in social groups and communication planning with the family (Fry & Keyes. Cambridge University Press, 2010; Reich, Zoutra, & Hall. Guilford Press, 2010). As part of patient rehabilitation, clinicians should provide older patients with coping and communication strategies for stressful situations that they may perceive to be new, unpredictable, and even threatening—situations Pichora-Fuller dubbed as “NUTS” (Table 2). Emphasizing supportive social networks is key as this variable is strongly associated with hearing aid satisfaction (Ear Hear. 2015;36:664 http://bit.ly/2td5nin). By building resilience and self-confidence in managing hearing and listening impairments, audiological interventions may become part of the new aging frontier that employs social competency to address cognitive decline and promote a better quality of life.