“In one of the file cabinets, there was a sheet from the Maryland Department of Aging that explained if you have any of these diseases—diabetes, cardiovascular, chronic kidney, Alport syndrome, Crohn's syndrome, all of those things—you need to get your hearing checked,” she recalled. “I made a copy of the information and just assumed everybody knew it.”
Fast-forward another 25 years, and Dowd is digesting the news that a close family member has just been diagnosed with late-onset diabetes.
“I casually mentioned to a family member working in the diabetes field that we needed to keep a closer check on my mother-in-law's hearing due to the diabetes diagnosis. He said, ‘I've never heard of that link before,’” recalled Dowd. “I asked what agency supplied diabetes information, and he said the Centers for Disease Control and Prevention [CDC].”
What followed were multiple discussions between Dowd and CDC staff members, who eventually admitted they had never heard of any association between diabetes and hearing loss. Dowd responded congenially, providing decades of published research on the established link. When her CDC contact responded with additional research on the topic, Dowd knew her contact understood. In 2016, the CDC reported to her they'd begin including hearing checks in future recommendations for diabetes care.
Although it marked a victory for Dowd, for audiology, and for patient care as a whole, it was only the beginning of the audiologist's work to raise awareness about the link between hearing loss and chronic disease. That year, she established The Audiology Project, a nonprofit that works in collaboration with the American Academy of Audiology, the Academy of Doctors of Audiology, and the American Association of Diabetes Educators to advocate for audiologic monitoring of hearing and balance problems associated with chronic disease.
GROWING EVIDENCE BASE
Supporting the efforts of The Audiology Project are several recent studies that further established the evidence base on the co-occurrence of hearing loss with a slate of chronic conditions.
In 2008, researchers documented a higher rate of hearing loss among adults with diabetes compared with those without diabetes. The findings led researchers to conclude that “[h]earing impairment is common [emphasis added] in adults with diabetes, and diabetes seems to be an independent risk factor for the condition” (Ann Intern Med. 2008;149(10). A year later, another study reported a significant association between low-frequency hearing loss and cardiovascular disease (Laryngoscope. 2009;119(3):473).
In 2011, a study linking hearing loss with all-cause dementia grabbed headlines in both the medical and mainstream press alike. A handful of similar studies followed. “Whether hearing loss is a marker for early-stage dementia or is actually a modifiable risk factor for dementia,” wrote the researchers in the landmark paper, “deserves further study” (Arch Neurol. 2011;68:214-220).
While experts continue to work out evidence on correlation vs. causation, practicing audiologists see the effects of comorbidities of chronic disease in their patients every day. Poor dexterity, memory loss, vision impairment, immobility, and emotional disorders are realities for many patients that affect their hearing care.
For audiologists like Laura Tocci, AuD, CCC/A, the director of audiology at Montefiore Health System in Bronx, NY, there are two stories for every patient—the story told by hearing test results carefully plotted on a graph and the story told by the patient in front of her. She never acts on the former without a full understanding of the latter.
“We have a standard recommendation based on what's on paper. But when I have a person in front of me, I'm going to alter my recommendations based on the patient's needs,” she said. “That hearing loss on that graph can be experienced differently depending on who the person is.”
Matching the right recommendation with the right patient, especially those burdened with additional chronic issues, can bring light to otherwise dark situations. With the help of hearing aids, patients can better hear and understand recommendations for self-management from their primary care providers and specialists. Those who undergo hospitalization can converse with caregivers and physicians. Others can engage with friends and family and experience the psychological and cognitive benefits of social interaction again.
In one patient with mental illness, a hearing aid prescribed by Tocci allowed for the reunification of a family previously separated.
“The thing that is most heartbreaking, especially in people with comorbidities, is the isolation they feel from hearing loss,” Tocci said. “When they can communicate, and their families can communicate with them, it brings them closer together. It doesn't erase whatever the problems are, but it does erase barriers between people.”
To accommodate the variety of disabilities caused by chronic conditions, audiologists adjust routine practices to suit the individual patients. Take hearing aid selection, for instance. Eryn Staats, AuD, the audiology manager at the Ohio State Wexner University Medical Center in Columbus, carefully considers the patient's configuration of hearing loss, lifestyle needs, and comorbidities.
“Will it be easier for them to insert an in-the-ear hearing aid because they have dexterity issues or limited range of motion from their arms and shoulders? Or we might recommend a rechargeable behind-the-ear hearing aid because batteries are small and can be difficult to change for someone with numbness in their hands and fingers,” Staats said. “If they are inclined to lose things, choosing a device that has a find-my-hearing-aid feature through an app would be helpful, so they don't have to replace hearing aids often.”
Geriatric audiologist Larry Engelmann, MS, AuD, the owner of the Audiology Clinic Inc. in Oklahoma City, OK, estimates no less than 95 percent of his patients have comorbidities. One older woman's macular degeneration required an unconventional decision that, in the end, made the most sense for her.
“She was 85 years old when she came in as a new patient. Her daughter accompanied her,” recalled Engelmann. “When I started talking about the color of the hearing aid case to blend with her hair or skin tone, the daughter spoke right up and said those colors won't work because she can't see them. I showed the patient a series of colored hearing aid samples. The only one she could see longer than 30 seconds was lime green. Guess what color her hearing aids are?”
Counseling strategies, too, are routinely streamlined to consider the effects of chronic disease—namely, cognitive impairment. Staats encourages patients who may be likely to experience memory issues down the road not to put off getting hearing aids.
“If cognitive decline or impairment does start, it's ideal if the patient is already familiar with a daily routine of cleaning the hearing aids, placing them in their storage container and charging station, and inserting and removing the aids so the routine stays with them for a while,” said Staats. “This learned pattern of care and use can hopefully reduce the risk of misplacing the hearing aids if memory loss increases.”
For patients already showing slight signs of forgetfulness or early cognitive impairment, sharing basic tips can go far, said Sara Beckerman Lerner, AuD, CCC-A, F-AAA, of ENT and Allergy Associates in New York City.
“There are a lot of tricks we use—reminding patients to always put their hearing aids in the same place every single night, to keep the case in the same place in the kitchen or wherever they take their hearing aids out, to always put the hearing aids back in the case vs. putting in their pants or shirt pocket. A lot of things we think are very routine and common, patients don't automatically know,” said Lerner. “We give them practical tips for setting up a routine instead of setting themselves up for disaster.”
Since patients, and even their referral sources, may be unfamiliar with the association between various chronic conditions and hearing, audiologists commonly provide website recommendations and handouts to allow them to learn more.
“I always explain how their specific health conditions interact with and/or contribute to the audio-vestibular disorder. Most have no idea, nor has anyone else explained these matters to them,” said Engelmann. “For example, explaining how diabetes and audio-vestibular disorders are linked can be a motivating factor for the patient to more carefully manage their diabetes.”
Educational efforts must also consider each patient's limitations.
“With legally blind patients, it is useful to print customized handouts with a large font and good contrast color, and to add pictures with explanations,” said Gloria E. Valencia, AuD, CCC-A, of the University of Cincinnati Audiology Clinic in Ohio. “Keep it simple; perhaps a page long will be enough to address the most important aspects of care and maintenance. Make sure the font is readable and the content is accessible, especially if they use magnified screenings.”
Given the amount of time audiologists spend with patients—often much more than the 10-minute slots allotted to primary care physicians every couple months, audiologists may be the first to notice issues emerging in patients with comorbidities that require physician investigation. To promote integrated care, referrals back to their primary care provider or specialist, depending on the issue, are essential in such cases. While audiologists may decide to share their concerns with the patient, it's best to emphasize that this is not a diagnosis but rather a recommendation to follow up with a physician. A report to the physician explaining the symptoms of concern, a phone call if the matter is urgent, should be par for the course.
“While we are not necessarily trained to diagnose and treat the comorbidities, we do have a responsibility to maintain a watchful eye rather than turning a blind eye to something that is obvious or even a subtle change in our patient's overall health,” said Engelmann.
“Audiologists diagnose and treat more than ears and brains. We are caring for people and their families. We must approach our patients with a holistic attitude.
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