Claudia Hawley, MA, CCCA, has been—for lack of a better term—a mobile audiologist zipping around the Minneapolis-St. Paul area for more than four decades.
A lover of red stick-shift vehicles, some of which she has admittedly totaled in accidents, she has finally relented and now drives a “boring” black BMW as she visits schools, Occupational Safety and Health Administration (OSHA) sites, and halfway houses.
Her schedule also includes evaluating the elderly at extended-stay or long-term care facilities (nursing homes, assisted living, etc.).
She has found a frustrating system of navigating the troubled waters of red tape (Medicare, Medicaid, Medical Assistance), high turnover rates at the facilities, and other hurdles like patients regularly losing their hearing aids.
Because Hawley does not dispense hearing aids, she often finds these seniors still without hearing aids when she returns six months or even a year later, waiting on replacements or on the original devices she prescribed.
“Seniors are not getting what they are supposed to be getting,” said Hawley. “The patients who I see want a hearing aid, but there is no easy way to get them… Patients are not getting what they signed up for.”
What she sees is a disconnect between the audiologist, the dispenser of hearing aids, and insurance companies that are “not responding in a timely fashion, if at all.”
A MATTER OF PUBLIC CONCERN
Amber Willink, PhD, an associate professor at the University of Sydney's Menzies Centre for Health Policy and a health services and policy researcher by training, came to this issue examining the Medicare program and what it does and does not offer.
“Hearing treatment is excluded from the Medicare program, so I began to look at what impact that was having on access to services and hearing aids,” said Willink, who is also a core faculty member at the Johns Hopkins Cochlear Center for Hearing and Public Health. From a research perspective, she and her colleagues have been trying to show how much of an impact hearing loss makes on other health outcomes, health care costs, and patient-provider communication.
“It's very hard to address hearing loss if it isn't considered a priority by care providers or nursing home administrators,” said Willink. “It's also very hard to address hearing loss if it requires treatment to be paid for completely by the individual.”
Two-thirds of people ages 70 and older have bilateral hearing loss, and almost three-quarters have hearing loss in at least one ear (JAMA Otolaryngol Head Neck Surg. 2017 Jul; 143: 733–734.). And yet, according to multiple studies, as low as nine percent of them wear hearing aids.
The reason for the discrepancy, as is the case with other items not viewed as necessities by those on fixed incomes, is money.
“Without some financial protection from the high cost of hearing aids and services, many individuals will choose to go without than pay $4,500 for a pair of hearing aids,” said Willink.
Willink is hopeful that the Over-the-Counter (OTC) Hearing Aid Act of 2017 will be an impetus for lower-cost and good-quality options to address mild-to-moderate hearing loss. She cautioned, though, that financial support is still required to access hearing services from audiologists and devices for those with severe to profound hearing loss.
Kim Fishman, MA, is among the several audiologists whom Hawley has enlisted to dispense hearing aids to seniors. “I've been getting her to help me,” said Hawley. “She sees some of my patients [for fittings]. She has an easy office to get to, but I'm not going to inundate her.”
Like Hawley, Fishman is not shy about voicing her concerns about the dysfunctional system.
“The problem is in Medicare,” said Fishman, who has regularly seen nursing home patients throughout her career. “The laws are so hard under Medicare, as compared to Medicaid for all.”
Fishman, who has her own practice, Chears Audiology, in the heart of Minneapolis, added that she is fine with selling hearing aids over the counter, but also expressed concerns about the present landscape leading into the era of the OTC Hearing Aid Act.
COGNITIVE LOSS VS. HEARING LOSS
An important related issue, Hawley noted, is the conflation of whether a senior in extended care has cognitive impairment or hearing loss. In many cases, it is both, but she sees the hearing part easily written off as a cognitive issue. She has seen many cases, often in short- and long-term facilities, where the resident was suddenly responsive to the world around him or her with amplification assistance.
Of note, the Lancet Commission's 2017 report on dementia showed that hearing loss was most prominent among the modifiable risk factors, at nine percent.
“I think the joint effect of both cognitive decline and hearing loss on communication is underappreciated,” said Nicholas Reed, AuD, CCC-A, an assistant professor at Johns Hopkins Bloomberg School of Public Health and a colleague of Willink's at the Cochlear Center for Hearing and Public Health. He has definite feelings about where cognition and hearing loss collide and create confusion, but does not believe it needs to be that way. “It is possible to access hearing with pure tone among persons with cognitive deficits and assess cognition with tests that don't rely on auditory input and, thus, it is possible to distinguish which is contributing to communication issues.”
But when it comes to the level and quality of care in facilities—nursing homes, assisted living, etc.—Hawley's experience has taught her that not all are created equal. Fair or not, it makes for unfair treatment.
“Some are conscientious and advocate well,” she said. “There are some who do a good job, and some whose attitude is ‘Eh, it doesn't matter.’
“I remember a female patient who the staff said was demented. It turns out that she just didn't hear them. [The staff] has to know what the patient's hearing abilities are. As an audiologist, I wish we could sit down and discuss how hearing loss really works. It could be as simple as, ‘Maybe the patient just didn't hear what you said.’ We have done things to improve this, and the staff will be on it, but then things change. Some facilities have a lot of turnover, some don't.”
Fishman expressed similar concerns from her experiences.
“In a nursing home, the reality is that [the staff] turns over so much,” said Fishman. “It comes down to helping other people, like the staff, know how to help [the residents]. There's the problem. The bottom line with nursing homes is care and follow-up. A lot of times, it is frustrating. It's too much. It can be hard to be in there.”
HEARING TESTS IN NURSING HOMES
According to Willink, when an individual begins a nursing home stay, a staff member of the nursing home (usually a nurse) will conduct an initial assessment that includes two questions related to hearing: (1) ability to hear (with hearing aid or hearing appliances if normally used) and (2) hearing aid or other hearing appliances used.
“These assessments that include questions on hearing are conducted annually,” she said. “Our preliminary analysis shows that these assessments conducted by nursing home staff underreport hearing issues compared to what the individuals self-report their hearing troubles to be.”
The reality, according to Cristian Pimentel, RN, a nurse at an unnamed facility in New Jersey, is much more challenging and fluid.
“It's hard to distinguish between the two on the field,” said Pimentel. “Some patients exhibit both—and you end up treating one condition and discover the other later. Some patients are nonverbal, and some have a flat affect, so it's hard to tell if they can hear you. Some patients yell at you when they talk, while others just don't tell you if they find it hard to hear you.”
“One of many hearing-related challenges nursing homes and senior facilities face is that hearing loss is under diagnosed and not considered a priority,” said Willink, drawing from her research. She points to several reasons for this, such as individuals living in nursing homes often having significant competing—and often serious—health priorities.
“What needs to be more broadly appreciated is how hearing loss can impede the management of one's health and well-being if there are communication breakdowns between the individual and carer,” she noted.
CHALLENGES ON THE FRONT LINES
Those on the front lines in these facilities and those responsible for direct patient care have a different view.
Pimentel has been on the field going on six years now. While working in long-term senior care was not his original goal in nursing since he wanted to be a psychiatric nurse, he finds that working in long-term senior care has exposed him to different cases that are good for his overall growth as a nurse.
“In my experience at nursing homes, the top hearing-related challenge is dealing with the stubborn ones, the ones who deny the fact that they have hearing loss,” he said. He also noted encountering patients who are often confused and ones who are physically and/or verbally aggressive.
“It gets frustrating for the staff,” he shared. “And you'll need to spend extra time on their care. For my shift at 11 a.m. to 7 p.m., there are only three staff members on my floor, one nurse, and two nursing assistants for 39 patients. It gets crazy.”
Nonetheless, Pimentel said his co-workers are trained to look for signs of hearing loss.
“We have been briefed on what to look for—the signs and symptoms of hearing loss, especially if the patient is taking some ototoxic drugs,” he said. “Sometimes we catch the problem on time, but there are times when we can't.
“One nurse for 39 patients, plus the family members, doctors, and other staff members who are looking for your attention—it gets difficult to keep track of everything.”
Pimentel confirmed that hearing tests of patients are part of the admission process, but then it becomes intermittent and somewhat out of the control of the nurses.
“Depending on the orders from the doctors, we typically check once or twice a year as needed,” he said.
Even among residents who have hearing aids, critical issues persist as they tend to lose or misplace their hearing aids.
“That's another problem we face,” said Pimentel, who said the nursing staff relies heavily on white boards to communicate. In his observation, those who tend to lose hearing aids have some form of cognitive impairment.
“Pocket talkers or just a simple white board and pen would be more appropriate for some residents in my opinion. Less likely to lose them, less painful, less complicated. The easier they are to use, the more that residents will likely use them.”
As a way to get on top of the issue, while dealing with a multitude of other issues, ranging from patients wandering around and alarms going off, Pimentel sees only one path toward improvement: “More staff and training.”
“We need to lower patient-to-nurse ratio so we can provide better care for our residents.”
Editor's note: Read our Q'A with Nicholas Reed, AuD, CCC-A on Hearing Care in Nursing Homes athttps://bit.ly/3eJo99K.
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