Integrated Care of Older Adults: The Many Potential Contributions of Audiologists

The rapidly aging population is creating major challenges for the health care system. Efforts abound to address the health, economic, and social policy threats posed by the increase in life expectancy attending technological and medical innovations contributing to the demographic revolution. From a public health perspective, a priority is ensuring a healthy life span, namely living a long life uncomplicated by damage from the environment, lifestyle, or disease. Brain health, participation in activities, remaining physically active, and maintaining social connections are essential ingredients to living better with more healthy and fewer sick years.

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Table 1: Declines in Physical and Mental Capacity Listed in Module 1 of the ICOPE Guidelines.

Table 2: Behaviors Associated With Hearing Difficulties That Should Trigger Referral to a Hearing Health Care Professional.

Table 3: Effective Strategies for Compensating for Hearing Difficulties in Clinical Settings.

Integrated care, which requires a multidisciplinary team of professionals working together to address the multidimensional needs of older adults, is a new direction in health care delivery for older adults. ¹ The WHO Guidelines on Integrated Care for Older People (ICOPE) provide an evidence-based list of community-level interventions that health care professionals could/should adopt to prevent, slow, or reverse declines in the physical and mental capacities unique to older adults. ² Setting the stage for an integrated care model, the ICOPE guidelines identify six common problems people experience as they age that impact daily function and should be addressed by a team of health care professionals. Table 1 lists the physical capacities prioritized in the ICOPE guidelines, which range from hearing and memory issues to mobility and independent function. The ICOPE guidelines suggest that declines in any of the functions listed in Table 1 could be predictors of mortality and loss of independence and early markers of declines in intrinsic capacity. The term intrinsic capacity refers to a combination of physical, mental, and psychological capacities, as well as functional ability, which individuals draw on to engage in the activities they value in the environment the individual inhabits. ² According to ICOPE, the physical, mental, and psychological capacities listed in Table 1 are critical to functional ability yet are often overlooked by health care professionals. ²

A threat to well-being, each domain of function should be assessed by a team of health care professionals and any indicator of compromised function should trigger a referral and should ultimately inform the development of a comprehensive care plan. ² The ICOPE team concluded that hearing status is typically underdetected and undervalued and, although the quality of evidence regarding the value of screening and -management of interventions is low, hearing is essential to communication. In short, the benefits of most hearing health care interventions and the advantages of managing hearing loss outweigh the disadvantages and costs of ignoring hearing difficulties. It is therefore incumbent on hearing health care professionals to educate integrated care team members on how to recognize presence of hearing loss, when and to whom to refer, and how to communicate with persons with hearing loss and comorbid conditions further compromising intrinsic capacity.

THE ROLE OF AUDIOLOGISTS ON INTERPROFESSIONAL TEAMS

According to ICOPE, the conditions listed in Table 1 tend to be interrelated and do require a patient-centered approach to assessment and management with communication integral to this service delivery approach. Effective communication is at the heart of a patient-centered philosophy, and evidence regarding satisfaction with quality of care and patient-provider communication suggests that older persons (i.e., Medicare beneficiaries) with self-rated hearing difficulties have expressed significant dissatisfaction with care and with health care provider communication. ^3,4 In fact, the majority of published studies on physician-patient communication have rarely considered or mentioned hearing status of participants as a factor, which may impact communication in health care settings. ⁵ Sadly, the culture of health care delivery does not appear to include recognizing or accommodating the needs of persons with hearing loss. This tendency to overlook hearing status likely has a direct -impact on adherence with and recall of physician recommendations, information exchange, and ability to self-manage. Knowledge of hearing status is of especially important when working with persons with dementia given emerging data on the links between hearing status and dementia including the possible role the positive impacts of improved audibility on selected behaviors and on outcomes on neuropsychologic diagnostic testing. Similarly, the ability to communicate effectively is highly valued in hospice and palliative care settings where audiologists are rarely included as part of the care team. ⁶

Given the invisible burdens of hearing loss, audiologists can and should play an active role in helping to mitigate the negative effects on outcomes of unrecognized or untreated hearing difficulties. Putting a more positive spin on our role, since communicating with health care providers is dependent in large part on audition and since patient satisfaction and health outcomes are increasingly tied to Medicare reimbursement, the return on investment of audiologist’s serving in an advisory capacity on health care teams cannot be overstated.

Recognizing the presence of hearing difficulties, especially as they relate to the cognitive aging continuum ranging from normal age-related changes to dementia/major neurocognitive disorder (MaNCD), is often a challenge. The fact that the prevalence and risk of dementia exponentially increases with age, coupled with the overlap in symptoms and behaviors associated with dementia and hearing loss, underscores the import of health care professionals being able to recognize the symptoms, risk factors, and behaviors associated with hearing loss as distinct from dementia. Some of the behaviors typical of persons with hearing loss and with which health care professionals should be familiar are listed in Table 2. There are still many additional overlapping behaviors between dementia and hearing loss (e.g., disengaging socially, difficulty remembering information orally discussed, or decreased processing time) that are not included in Table 2. Given the plethora of communication strategies available to augment communication with persons hearing difficulties, Table 3 includes tips to share with team members to help optimize audibility. It is important that team members understand that persons with hearing loss and any level of cognitive decline will be more focused, less fatigued, and more adherent if they adopt some or all of the strategies listed in Table 3 during their clinical encounters. Above all, health care professionals should assume that patients over 80 years of age will have hearing difficulty and from the outset should be told to ask about hearing, if their patient owns hearing aids, whether they are using them, and, if not, if they would like you to wear a personal amplifier to make it easier to hear and understand. It is important to underscore that despite the high prevalence and negative consequences, age-related hearing loss tends to be overlooked, the consequences misunderstood, and the need for interventions dismissed. When acting as an interprofessional team member, remember to emphasize that only about one in five adults with hearing loss use hearing aids, the majority of persons who could benefit from cochlear implantation do not pursue this option, and persons with hearing loss wait between 8 to 10 years before pursuing assistance. It can be helpful to explain the difference between prescription hearing aids and over-the-counter (OTC) hearing aids as a health care professional whom the patient trusts; audiologists can be very influential in encouraging their patients to purchase hearing care services. Finally, it is important that team members understand that their perspective can help optimize quality of life and help insure that persons with hearing loss are functioning in a safe and supportive environment.

CONCLUDING REMARKS

Increasingly promoted as a means for improving accessibility, affordability, and the quality of health care and as essential for achieving desired health outcomes and limiting costs, integrated care is especially important for older adults with complicated needs. ⁷ Interprofessional collaboration and partnerships are integral dimensions of integrated care as is a person-centered focus. At the centrality of integrated care, an integral part of patient satisfaction, is addressing the expressed physical, social, and psychological needs of the patient. ⁷ Since at the micro-level the patient’s needs are a priority, good and effective communication is essential if health, well-being, and social care are to be integrated. Evidence abounds that audiologists should leverage to insure that increasingly, we be part of integrated care teams if not for direct patient involvement than to address how to recognize hearing loss in persons with complex needs, especially persons with dementia, and how health care professionals can most effectively communicate with persons with hearing/communication challenges.