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Teach patients who hear “well enough” the real cost of neglecting hearing loss

Pallarito, Karen

doi: 10.1097/01.HJ.0000387926.59980.59
Cover Story

When consumers refuse to get help for an admitted hearing loss, it's often because they don't realize the amount of harm their diminished hearing is doing to their life. This Cover Story offers a wealth of information that practitioners can use to make reluctant patients understand how much they have to gain by addressing their hearing problems now.

Karen Pallarito is a freelance health writer based in Westchester County, NY, and a frequent contributor to The Hearing Journal.



Excuses for neglecting a hearing loss abound and, no doubt, you've heard quite a few. Many people are reluctant to acknowledge the impairment or they worry that hearing aids will make them look old. Some don't see the value in hearing aids, don't believe they work, or can't readily afford the typical price of $4000 or more a pair. But how many potential patients understand the true cost of living with a hearing impairment?

For persons with hearing loss, their loved ones, and society as a whole, the consequences of untreated hearing loss are substantial and well documented. It affects every facet of life—emotional, mental, and physical. It puts people at risk in an emergency and at a severe disadvantage in social situations. Hearing loss can wreak havoc on the job and in one's personal relationships. It can slow comprehension and diminish one's quality of life.

Yet, given the relatively low uptake of hearing aids—fewer than one in five U.S. adults with hearing loss who could benefit from hearing aids actually wears them, says the National Institute on Deafness and Other Communication Disorders—few people seem to appreciate the vast toll that hearing impairment exacts on them and those around them.

People often aren't aware of their impairment because it came on slowly over the years, or they may be in denial about it, notes Stig Arlinger,, PhD, a professor in the Department of Technical Audiology at Sweden's Linköping University. Ignorance of the consequences of hearing loss and the benefits of modern hearing aids also fuels the inertia, he adds.

And that's where experts say hearing health professionals could make a world of difference—not just selling a hearing aid but helping patients hear and communicate better.

“I really don't believe that most or many, anyway, hearing aid dispensers—both audiologists and hearing instrument specialists—have a good understanding of what the [hearing] loss means to the person,” says Mark Ross, PhD, professor emeritus of audiology at the University of Connecticut and a consultant to the Rehabilitation Engineering Research Center on Hearing Enhancement at Gallaudet University in Washington, DC. Ross, who has had a hearing loss since childhood, adds, “They focus so much on the technology of the hearing aid itself and not really the person with the hearing loss.”



This Cover Story will examine the toll that hearing impairment exacts, barriers to treatment, and what hearing health professionals can do to woo the hearing aid holdouts in their community.

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Untreated hearing loss has serious social and emotional consequences. A National Council on the Aging (NCOA) survey funded by the Hearing Industries Association (HIA)—the largest survey of its kind—provides convincing evidence of the many ill effects. Hearing-impaired adults age 50 and older were found to be more likely to report sadness and depression, worry and anxiety and paranoia than older people who wore hearing aids, according to the 1999 report. They were also less socially active.

In an analysis of the NCOA data, Sergei Kochkin, PhD, executive director of the Better Hearing Institute, and Carole Rogin, executive director of HIA, found that hearing aid users reported significantly lower depressive symptoms, such as weariness, insomnia, and thoughts of death, than non-users. On average, hearing aid use was associated with a 36% reduction in depression.1

As a clinical psychologist in Framingham, MA, who consults with audiologists and counsels audiology patients, Michael Harvey, PhD, is intimately acquainted with the psychosocial aspects of hearing impairment. People with hearing loss are often caught “between two worlds,” he says, because they can't hear as well as hearing people but they're not deaf, so they're not part of the deaf community.

To illustrate, Harvey puts himself in the shoes of a person who lives with a hearing loss and can no longer communicate effectively with others. “I have to pretend to understand because I don't want to feel ashamed,” he says. “People all of a sudden are calling me a snob because I don't respond to their communications.”



It's a recipe for marital discord, says Harvey, a consulting faculty member at the Osborne College of Audiology of Salus University. He explains, the hearing-impaired person gets depressed, anxious and withdraws; in response, the spouse becomes angry, frustrated, and depressed.

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While people may want to believe they can function just fine without hearing aids, there's a growing body of evidence on the harmful cognitive effects of hearing loss. A study in Psychology & Aging provides insights into how hearing loss affects an individual's ability to recall the spoken word, for example.2

Researchers at Brandeis University divided 24 adults, ages 20 to 46, and 24 older adults, ages 67 to 80, into equal groups of 12 based on their hearing acuity—good or poor. Participants were tested on their ability to use a computer mouse to track a moving target on a computer screen. They were also asked to recall aloud as many words as possible from lists of 15 words read at a loud conversation level. The key experiment involved a dual task: tracking a target on a screen while trying to recall the just-read list of words.

When the poor-hearing people, especially the older ones, performed the dual task, “their tracking really suffered,” says lead author Patricia Tun, PhD, adjunct associate professor of psychology and associate director of the Memory and Cognition Laboratory at Brandeis.

It means that people with hearing loss are “having to work harder at what they're hearing, they're not remembering as much, and, if they're doing something else at the same time, like driving or taking notes or whatever, they're doing more poorly on that,” says Tun. “It's showing that even relatively mild auditory challenges can affect your memory and comprehension for what you hear.”

In a follow-up study to be published in the same journal, Tun and colleagues measured how quickly young and old participants with good and poor hearing responded when speech was more complex and delivered at a lower sound level. On this task, older adults with poor hearing had much slower comprehension.

“You can imagine if you don't quite catch onto something in the beginning, and then you don't quite catch what happens next, by the time you get to the end of a whole spiel or story, you could be lost,” she says.

All this has implications for how people with hearing loss function in society. They may not be getting as much critical information as they need, especially if the speech is rapid or complicated, Tun explains. This can create potential difficulties for people when they see their physician, deal with Medicare, or handle tax or other legal matters, she adds.

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Hearing loss also is associated with physical health effects beyond the auditory impairment itself. Overall, people's self-assessment of their health status declines as a function of hearing loss, the Kochkin/Rogin analysis found. Non-users of hearing aids with the most severe hearing losses had the greatest deterioration of health.

An analysis of federal data on sensory impairments, activity limitations, and health-related quality of life among people 65 and older suggests a physical connection as well. Researchers at the Centers for Disease Control and Prevention found that older adults with hearing loss are more likely than those with normal hearing to report hypertension (46.7% versus 44.3%), heart disease (27.6% versus 18.6%), and stroke (11.8% versus 7.8%). They also have greater difficulty with functional activities, such as walking, getting outside, and getting in and out of bed.3

For adults who can't hear high-frequency alarms, hearing loss may also pose a safety hazard. The U.S. Fire Administration says older adults' risk of dying in a fire is 2.5 times greater than that of the general population. An older person with impaired hearing is at greater risk of not responding in time, it says.

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For younger and older adults alike, the workplace can be a minefield, and that's especially true for employees who have a hearing impairment. “If the boss says to you, ‘Don't go over $15,000 on that contract’ and you hear ‘$50,000,’ you can be in big trouble,” says Sam Trychin, PhD, an Erie, PA-based psychologist who conducts classes and workshops for the hearing impaired, their family members, and health professionals.

Hearing loss may also diminish a person's earning potential. Kochkin's research for the Better Hearing Institute shows a linear relationship between hearing impairment and lost income. People with the most profound hearing losses can expect to earn $12,000 less per year than those with milder hearing losses, but wearing hearing aids cuts the income loss by half, the survey found.

Carren J. Stika, PhD, a hearing loss researcher on the adjunct faculty of the School of Speech, Language, and Hearing Sciences at San Diego State University, says the mere act of trying to compensate, day in and day out, for a hearing loss can lead to an ongoing sense of stress. She is particularly concerned about the stress levels of younger adults in the workplace who are reluctant to acknowledge their hearing loss because they don't want to be viewed as inferior to their co-workers.

In Stika's research with focus groups of people with hearing loss, the impact in the workplace was the issue that elicited the most emotional response—even tears. They felt stressed and incompetent and they tended to respond more slowly than their co-workers to something that was said. As a result, she explains, “they were being perceived as not very bright, not very fast, not on the edge.”

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Is it any surprise, then, that hearing loss has been shown in multiple studies to have a negative affect on quality of life?

In one study, researchers at the University of Wisconsin examined data from a 5-year follow-up of 2800 individuals with age-related hearing loss. Participants underwent audiometric testing and answered questions about their communications difficulties, daily functioning, and quality of life. The analysis showed a significant association between the severity of their impairment and reduced quality of life, both in terms of physical and mental functioning.4

But, would hearing aids improve quality of life or merely compound life's hassles? To find out, the American Academy of Audiology Task Force on Health-Related Quality of Life Benefits of Amplification in Adults conducted a meta-analysis, or study of studies, on quality of life. Sixteen studies using generic and/or disease-specific measures of quality-of-life outcomes were included. The studies involved men and women, ages 28 to 95, with mild to profound sensorineural hearing loss and included new and previous hearing aid users.

The task force concluded that hearing aid use improves adults' health-related quality of life by reducing the psychological, social, and emotional effects of hearing loss.5

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Patient compliance with an audiologist's advice can be a tricky thing. A person who is anxious or depressed may need to see a mental health professional before dealing with a hearing impairment. But unless the referral is handled delicately, the patient often will not seek out the help that he or she requires, Harvey observes.

Unfortunately, little is known about either the degree to which psychosocial issues impede treatment for hearing loss or what audiologists can do to increase adherence to a recommended treatment regimen. Denying one's hearing loss, for example, may help buy time to come to grips with the impairment, but what's an appropriate amount of time and what's too long?

Harvey says, “I would love to be funded to work with an audiologist, to be the fly on the wall and interview patients, to really quantify how, why, when, and where psychological issues get in the way.

Patricia Kricos, PhD, professor of audiology at the University of Florida in Gainesville and president of the American Academy of Audiology, has studied differences between hearing aid users and “non-users”—people who gave up using hearing aids. Among her many findings: Non-users reported a significantly greater number of major life events, such as a serious illness or death of a spouse, which they felt impacted their use of hearing aids. It's not clear from the study, though, whether hearing aid discontinuation was the cause or consequence of major life events.



Kricos's own mother, after using hearing aids successfully for several months, stopped wearing them when she had dental work because she felt there were too many events going on in her life and she couldn't deal with all of them. “That's the kind of thing we found in our study, that [non-users] did report more health problems and things like that than people who continue using hearing aids,” she explains.

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Considering the wide-ranging negative effects of hearing loss, why aren't hearing health professionals doing more to ensure that people understand what it means to have a hearing impairment and how to live with it?

“We're in a comfort zone,” says John Greer Clark, PhD, an assistant professor of audiology at the University of Cincinnati and president of the Academy of Rehabilitative Audiology (ARA). Audiology has drifted away from providing rehabilitative services, focusing instead on diagnosis and dispensing, he says. “I think part of it is because of the belief among audiologists that technology is so good now, that's all we really need—and we know that's not true.

Clark says many audiologists avoid providing audiologic rehabilitation because of a perceived lack of time, expertise, or reimbursement. But, he says, those arguments don't add up. For one thing, research suggests that people who receive some sort of rehabilitation training have a substantially lower hearing aid return rate.



“If somebody who bought a couple of hearing aids from me returns them because they didn't work out, I've lost a chunk of money. If I provided group training and they came to it and they didn't return it, I've just been paid quite a bit,” he reasons. Plus, he says, rehabilitation is a great marketing niche because so few audiologists offer it.

While some practitioners insist they provide audiologic rehabilitation, often all they're really doing is teaching patients how to use their hearing aids, clean them, and change the batteries, Clark adds.

Hearing aids are a tool, not a cure, experts say, and patients need to understand what a hearing aid will and won't do, and they need strategies to help them communicate.



“I think that's why a lot of people give up, because maybe they aren't counseled enough about what to expect, and they have these unbelievable expectations,” says Kathy Landau Goodman, AuD, founder and president of Main Line Audiology Consultants, PC, in Narberth, PA, and chair of the Audiology Awareness Campaign, which educates the public about the value of hearing care.

Kricos tells patients that hearing aids will be a huge help, but she also encourages them to attend her free “Living with Hearing Loss” program through the University of Florida Hearing and Speech Clinic “to give them that extra boost.” Over the course of four classes, patients and their family members or friends take a hearing loss inventory, discuss communication strategies, brainstorm solutions for difficult listening conditions, and learn about beneficial technologies, such as the telecoil.

That extra effort, she believes, goes a long way toward bolstering patient satisfaction. “In our clinics, we have a zero return rate for credit,” Kricos says. “Our people leave happy.”

Kochkin contends that hearing professionals could do much more to improve the patient experience. All hearing aid fittings, for example, should include sound booth testing, real-ear measurements, pre- and post-measures of speech or sentence comprehension in quiet and noise, and counseling and aural rehabilitation, he says. In his view, “The hearing aid industry is selling the wrong thing.” What dispensers should be selling, he says, are improvements in quality of life.

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It's like boot camp for people with hearing loss and their partners. For four-and-a-half days in May, a half-dozen or so couples pay $350 (or earn a scholarship) to immerse themselves in hearing loss education. Their days are filled with classes aimed at honing their coping strategies and communication skills. At night, they put their newly acquired skills to the test while sharing a meal, exploring a museum, or attending a concert as a group.

Figure. Di

Figure. Di

The Summer Intensive Aural Rehabilitation Conference (SIARC), which just completed its eighth program, is a pioneer in the field of aural rehabilitation, and it remains an uncommon example of how hearing-impaired individuals and their communication partners can learn to navigate the social and emotional consequences of hearing loss.

Each couple is paired with a University of Texas graduate student in audiology or speech-language pathology to assist and support them throughout the conference. Participants may try different hearing aids and assistive listening devices, for example, and if there's a problem, someone can fix it on the spot.

“The participants are so grateful for what they've been able to learn from the conference and the assistance they've gotten from the students,” says Linda Thibodeau, PhD, a professor in audiology and director of the AuD program at the University of Texas at Dallas. “The students are so grateful that they've chosen to be in this field because they see what they're going to be able to do to make a difference in people's lives because they were able to see it happen during that week.”

University of Florida Professor Patricia Kricos, PhD, the newly installed president of the American Academy of Audiology, served as a SIARC guest speaker one year. That evening, Thibodeau's group dined at an Asian restaurant where the food was prepared at the table.

“Here we all go out and she's got all of these people wired with FM systems and showing the patients, here's how you adjust your hearing aid so you can hear the chef when he's talking and doing his little gig, and oh my gosh, I thought, ‘That's the way to do it. That's really cool,’” Kricos says.

“We no longer have to pin five FM transmitter microphones on our guest speaker to get the signal to everyone's FM receivers,” Thibodeau says. “We can use one FM transmitter microphone and synchronize all the FM receivers to that main channel to receive the signal.”

The group dynamic is one of the keys to the program's success, she says, because the communication partners share their experiences and learn from one another.

Thibodeau explains, “When wives see other wives talking about what worked and what didn't work, that has more validity than me saying to that patient, ‘You know, when you face your husband he'll hear you speak.’ They get it, because they're actually seeing it happen in a group.

Communications partners sometimes learn that they, too, could benefit from a hearing aid.

One year, a man arrived for the day's events without his hearing-impaired wife, who was attending a grandchild's graduation. “That was the one day when he wasn't totally focused on her,” Thibodeau recalls. He didn't think he had much of a hearing problem himself, but after trying a hearing aid and going out to dinner that night, “he was amazed at how much help he could get from that,” she says.



Thibodeau concedes that few practitioners can replicate the SIARC experience, which depends upon grant funding from major hearing aid manufacturers, Phonak's generosity in loaning equipment for participants to use, and the resources of an academic program. But she hopes that graduates of the program who go into private practice will offer patients who purchase hearing aids at least four one-hour-a-week rehabilitation sessions.

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Who knows the consequences of a husband's or wife's hearing loss better than their better half?

At a recent seminar sponsored by the non-profit Ida Institute in Copenhagen, the psychologist and educator Sam Trychin, PhD, spoke to audiologists from around the world about the importance of including “communication partners” in the assessment and treatment of people with hearing loss, something, he says, that “doesn't happen very often,” but yields significant benefits.

“I have hearing loss and when my wife says something to me and I don't understand her, I have a problem. But so does she, and often the communication partners have a better handle on what the effects of the hearing loss on the individual are than the person [with the loss],” Trychin says.

When Trychin offers educational training courses for persons with hearing loss, he almost always works with couples or with a person with hearing loss and one or more communication partners. “I want to know what the issues are on both sides, for the person speaking as well as for the person listening,” he explains.



But do these sorts of interventions really make a difference for the person with hearing loss and his or her partner?

Jill Preminger, PhD, an associate professor in audiology at the University of Louisville, began exploring the impact of hearing loss on significant others after attending a meeting of the local chapter of the Hearing Loss Association of America. Some of the spouses in the audience asked, “What about us? What do you have for us?”

Not everyone is willing to go the extra mile to improve their communication, says Preminger, “but there is a select group out there that is interested in more—more than a hearing aid, more than a cochlear implant. What else can we do to improve communications and quality of life?

To test the effectiveness of educational training programs for spouses, she and her colleague Suzanne Meeks, PhD, randomly assigned 36 people with hearing loss and 36 spouses to a control group or an experimental treatment group. The study appears in the May 2010 Journal of the American Academy of Audiology.6

People with hearing loss in both the control and treatment groups participated in a traditional audiologic rehabilitation program. Spouses in the control group received no treatment, while those in the experimental group took classes in hearing loss communication.

All classes met weekly, over 4 weeks, for 90 minutes, and all participants completed questionnaires before the program, after its completion, and 6 months later.

While there was no change among the spouses in the control group, the spouses who received the training became better aware, over time, of their partners' quality of life. “They actually began to understand better what their partner with hearing loss was going through,” Preminger says.

That's encouraging, she says, because “perhaps then, after the rehabilitation, these spouses would begin to practice more effective communication strategies, making it easier for both them and their partners with hearing loss.”

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1. Kochkin S, Rogin CM: Quantifying the obvious: The impact of hearing instruments on quality of life. Hear Rev 2000;7(1):6–34
2. Tun PA, McCoy S, Wingfield A: Aging, hearing acuity, and the attentional costs of effortful listening. Psychol Aging 24(3):2009:76–166.
3. Campbell VA, Crews JE, Moriarty DG, et al. Surveillance for sensory impairment, activity limitation, and health-related quality of life among older adults—United States, 1993–1997. Morbidity Mortality Weekly Rep 1999;48(8):131–156.
4. Dayna DS, Cruickshanks KJ, Klein BEK, et al.: The impact of hearing loss on quality of life in older adults. Gerontologist 2003;43(5):661–666.
5. Chisolm TH, Johnson CE, Danhauer JL, et al.: A systematic review of health-related quality of life and hearing aids: Final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults. JAAA 2007;18(2):151–183.
6. Preminger JR, Meeks S: An evaluation of an audiologic rehabilitation program for spouses of people with hearing loss. JAAA 2010;21(5).
© 2010 Lippincott Williams & Wilkins, Inc.