PROPOSED EARS TOOLKIT FOR PRIMARY CARE
Motivated by the prevalence and social and economic costs of dementia, the Gerontological Society of America (GSA) developed the free online KAER toolkit to help primary care providers detect cognitive impairment and dementia at its early stages and make appropriate referrals for follow-up (Table 1).2 GSA considered the Medicare AWV a potential trigger for primary care providers to initiate the detection process.3 The initiative was launched to address the barriers to early detection of cognitive decline and dementia and the link between early detection and early treatment. It also aimed to emphasize the importance of connecting patients and caregivers with community resources for education and support early so they could be involved in making decisions about their care.
Incorporating important concepts from the KAER toolkit, the proposed EARS toolkit includes the following: (a) approaches to kick-start a conversation about hearing loss, (b) tips for recognizing signs and symptoms of hearing difficulties, (c) strategies and key messages to use when discussing hearing loss with older adults and their families, and (d) materials and resources on communication strategies for primary care settings (see Table 2).
EARS. The first step in the model is to kick-start the conversation about the patient's ears, hearing, and communication ability. Marlow and colleagues speculated that individuals with hearing impairment may be reluctant to disclose their hearing difficulty; some may even try to conceal these difficulties to avoid stigma associated with aging.4 Having primary care providers talk about hearing reminds patients and their families that the ability to hear and communicate is critical to one's well-being and that steps are available to maximize one's ability to engage with others. Opening this conversation may encourage patients and their family members to discuss any hearing-related concerns. At this juncture, physicians can discuss some of the negative health outcomes associated with untreated hearing loss such as risk for falls, communication breakdowns, social disengagement, depression, and compromised physician-patient communication.5 Physicians can also emphasize that hearing loss has been linked to cognitive decline and is considered a modifiable risk factor for dementia.6 It is important to advise physicians to be sensitive to behaviors consistent with a hearing-related difficulty, including incorrect/off-topic responses, requests for repetition when being given instructions, requests for someone to speak louder, and visible strains to understand instructions. Considering the high prevalence of cerumen impaction in older adults, physicians should also be encouraged to conduct an otoscopic exam.
ASK . As health care gatekeepers, primary care providers should take the lead role in improving and optimizing patient-practitioner communication starting with hearing heath. Physicians should be encouraged to ask questions about hearing status and hearing access in the patient's social environment. For example, the health care provider can gain insight into a person's auditory integrity by asking, “On a scale of one to 10, how would you rate your hearing and ability to understand others?”7 This open-ended question could lead to specific questions about hearing access in select social environments, such as when watching television, visiting with family and friends, or dining in restaurants. Physicians must understand how the patient self-manages in his or her social context. For example, does the patient continue to engage with others or does he or she avoid situations because of difficulty understanding others? Direct and indirect questioning regarding hearing status yields outcomes similar to those obtained from objective hearing tests.8
RECOMMENDATIONS . This step adopts a tiered approach based on the findings of Vitale, who recently conducted a survey of physicians to determine their attitudes toward and knowledge about hearing loss in older adults.9 If a physician notices any behavior related to a hearing difficulty, he or she should provide a referral to an audiologist. Similarly, if a patient presents with any of the high-risk criteria listed in Table 3 or responds affirmatively to questions about auditory integrity or hearing access, the physician should refer the patient to a local audiologist for a hearing test. Finally, if the otoscopic exam reveals cerumen impaction, the patient should be referred for cerumen management.
Patients who are referred should be encouraged to bring a family member to the appointment. At this point, It is worthwhile for the physician to give the patient a decision aid listing the hearing interventions available for managing hearing loss and its consequences. A sample decision aid is shown in Table 4.
STRATEGIES . Physicians must understand the value of behavioral communication strategies and the importance of sharing these tips with people with hearing impairment. Strategies include limiting the distance between the speaker and listener, speaking slower, making the speaker's face visible to the listener, eliminating background noise, and having one person speak at a time. When dining out or in public areas, people with hearing loss should be encouraged to ask for a seat in a well-lit area in front of a wall, in a corner, or in a booth to minimize background noise. Table 5 summarizes strategies that primary care physicians should share with patients to self-manage hearing difficulties in social environments, while Table 6 lists strategies health care providers should adopt to promote hearing care awareness.
In sum, hearing loss is a highly prevalent condition that often goes unrecognized and untreated. Communication difficulties associated with hearing loss can interfere with the delivery of person-centered care, shared decision-making between patients and physicians, patients’ compliance with medical instructions and directives, and patients’ comprehension of important medical conversations. Effective collaboration between physicians and audiologists, along with a promising tool like EARS, can bring significantly more patients closer to early diagnosis and treatment.
1. Weinstein, Barbara E., PhD. Maximizing Annual Wellness Visits to Promote Hearing Health. The Hearing Journal.
4. Marlow, N., Malaty, J., Jo, A., Tanner, R., de Rochars, V., Carek, P., & Mainous, A. (2017). Hearing impairment and undiagnosed disease: The potential role of clinical recommendations. Journal of Speech, Language and Hearing Research
6. Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., . . . Mukadam, N. (2017). Dementia prevention, intervention and care. The Lancet
, 39, 2673-2734.
7. Millett, P. (2018). Degree of hearing loss versus hearing access. The Hearing Journal.
8. Strawbridge, W. J., & Wallhagen, M. I. (2017). Simple tests compare well with a hand-held audiometer for hearing loss screening in primary care. Journal of the American Geriatrics Society
, 65(10), 2282-2284. doi:10.1111/jgs.15044.
9. Vitale, T. (2019). Screening for Hearing Loss: Physician Attitudes and Practice. Capstone project research project submitted to the Graduate Faculty in Audiology in partial fulfillment of the requirements for the degree of Doctor of Audiology, The City University of New York.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
10. Maslow, K. & Fortinsky, K. (2108). Nonphysician Care Providers Can Help to Increase Detection of Cognitive Impairment and Encourage Diagnostic Evaluation for Dementia in Community and Residential Care Settings. The Gerontologist.
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