Barbara Weinstein’s “Downstream Consequences of Aging” appears bi-monthly at HearingHealthMatters.org. Today’s post is part 2 of a series on reframing the clinical conversation with older adults.
The hearing healthcare delivery landscape is in transition with the emphasis being placed on affordability and access. President Trump’s signing of the 2017 Food and Drug Reauthorization Act, guarantees that a new category of OTC hearing aids will be forthcoming within the next few years.
Hearing Loss as a Social Construct with Consequences
The top-down changes are an opportunity for audiologists to revisit and reframe our approach to clinical practice with the emphasis on the patient rather than on the technology.
We must engage with persons with hearing loss in new and better ways with a focus on the environmental and psychosocial underpinnings of age related hearing loss, I have posed five myths held by held by stakeholders in hearing health care. I follow each myth by my thoughts about how audiologists might broaden our framework for addressing the experiences of persons with hearing loss.
Perhaps approaching hearing loss as a social construct with consequences in large part depending on the interaction between the persons with hearing loss and their physical and social environments might help us to optimize outcomes associated with their clinical encounter.
Myth I. Audiologist=Hearing Aid Salesperson
I recently conducted an informal survey of members of the local HLAA Chapter regarding their perceptions of the hearing health care services which they received. The consensus was that audiologists sell hearing aids and are not educated or skilled at assisting persons with hearing loss self manage the communication challenges posed by hearing loss.
To put it mildly, I was shocked by these very strong convictions. We need to position ourselves as hearing/communication ambassadors whose primary focus is to help parsons with hearing loss overcome the communication barriers caused by their loss of hearing. We are the experts who can help persons with hearing loss self manage the social and physical environments in which they live and interact, thereby enhancing the quality of their interactions and enabling them to remain socially engaged.
Bottom line, social engagement is the key to long life and adds to life expectancy. The most important outcome of our clinical encounters should be to help our patients maintain their participation in meaningful social and intellectual activities and the technology we dispense is a means to this end.
Myth 2. Hearing Aids Prevent or Forestall the Onset of Senile Dementia
The evidence to date is clear……hearing aids DO NOT prevent dementia. BUT, hearing aids, when fit correctly in the context of a rehabilitation program, can optimize communication function thereby facilitating social engagement (measured in terms of contact with family and friends participation in social activities, and quality of interactions).
Hearing assistance may reduce the burden on cognitive processing, especially in challenging listening environment. Further, by helping persons maintain social enagement and social connectedness, hearing aids may in fact have a protective effect thereby reducing the risk of developing dementia (Fratiglioni, Wang, Ericsson, Maytan, and Winblad, 2000).
Consider the argument that hearing aids are a cognitive reserve enhancing and lifestyle intervention which when fit and used properly will help persons with hearing loss remain intellectually stimulated and socially engaged.
Myth 3. The Audiologist Knows Best and Told Me I am a Candidate for Hearing Aids
Shared decision making (SDM) and preference based treatment should guide clinical practice. A bidirectional process between a clinician and a patient suffering from a preference-sensitive condition (e.g. hearing loss), SDM helps the patient decide among multiple acceptable intervention choices in accordance with their lifestyle preferences (Spatz, Krumholz & Moulton, 2017).
Since persons with hearing loss often opine that they would like to be offered a range of options, SDM using patient decision aids (PDAs) is an ideal approach to engaging patients in a transparent manner when there are multiple treatment options from which to choose, High quality evidence based patient decision aids delineating the options, their risks and benefits can help facilitate patient course of action especially when there is more than one reasonable option (Stacey, Bennett, Barry, et al., 2011).
To date, patients are told that hearing aids have a clear advantage in terms of health outcomes but with the availability of hearables, self fitting hearing aids, PSAPs, to name a few a more broad based conversation may be in order. The majority of respondents to my survey lamented the fact that it took an average of three different audiologist visits before they were convinced that they were receiving high quality care. It is noteworthy that the factors associated with patient judgments of high quality health care include participation in decision making, self management support, and involvement in care processes (Maskrey & Gordon, 2017).
Myth 4. Clinical Encounters are Patient Focused and Centered
Respondents to my survey overwhelmingly commented that their audiologist did not take the time to learn about them; they rarely inquired about their “hearing loss journey.” We must take the time to learn more about our patients.
To ensure that we are meeting our patient’s needs we should understand the motivations, priorities, and preferences of our patients. Engagement means ensuring that our patients are active participants in their care and that our patient’s lifestyle informs the discussion of treatment options. Make sure to:
- inquire about the availability of social support network so critical to hearing aid satisfaction;
- understand your patient’s activity levels-whether they are socially active;
- gain insight in to their satisfaction with the quality and quantify of their social contacts.
The latter information must inform counseling, It goes without saying that understanding our patients’ hearing challenges in communicative environments (e.g at home, with family members, in large group meetings) is key, and understanding how they self manage their hearing problems can help optimize outcomes. Table 1 lists some sample questions which you may pose.
Table 1. Sample Questions Regarding Self-Management of Hearing Loss
Myth 5. The Focus of Clinical Encounters is on Helping Patient to Self Manage their Hearing Loss
Audiologists and persons with hearing loss differ on this point as respondents were uniform in their comments that “it is all about the technology,” and they learned about self management through “trial and error.” Self-management is a critical component of hearing health care delivery (Powers, Bardsley, Cypress., et al.,2015). According to Hogan, et al.,(2015) physical stress is higher and wellbeing is lower when the fit between the person’s hearing related coping ability is mismatched with the demands or social ability to self manage in challenging social or physical environments (Hogan, Reynolds, & Byrne, 2012).
Stated differently, low self-confidence due to hearing impairment combined with poor perceived self-rated capacity to manage hearing and listening impairments were closely associated with lower quality of life ratings. In short, anxiety seems to increase and self confidence decreases as self management skills decline. Note also that Hogan, et al., (2015) found that “objective” measures of hearing status (i.e. the audiogram) did not correlate with self-reported physical and mental health outcomes.
To support and optimize self-management skill development and maintenance it is important to take advantage of opportunities before, during, and after the clinical encounter. That is, it is critical that we assess our patient’s self-management skill set, availability of support mechanisms (e.g. family members, HLAA) and factors that may serve as barriers to self-management including stigma or “fear of being found out!’
Table 2 lists some self management intervention strategies for promoting and optimizing hearing aid use (Barker, Mackenzie, Elliott., et al., (2016).
Table 2. Self-management Strategies (Barker, Mackenzie, Elliott, et al. (2016)
Audiologists must remain part of the solution to communication challenges posed by hearing loss and should be the go to professional for persons with hearing loss. Our patients must understand and experience the value added of working with an audiologist for ALL of their hearing health care needs.
In anticipation of top down changes in the hearing health care delivery system, we must reflect and prepare to initiate bottom up changes including a re-envisioning of the audiology Scope of Practice, our approach to the clinical encounter and associated outcomes. We should renew our focus on rehabilitation in support of helping patients to self-manage the stress and challenges associated with hearing loss. The latter was the foundation for the birth of the Profession of Audiology.
In closing, I concur with Alhanbali, et al. (2017) who underscored the import of educating persons with hearing loss about how to minimize the communication challenges posed by hearing loss and to make every effort to include social/psychological factors in our work with persons with hearing loss.
Alhanbali, S., Dawes, P., Lloyd, S. & Munro, K. (2017). Hearing handicap and speech recognition correlate with self reported listening effort and fatigue. Ear and Hearing. Oct 31 2017 published ahead of print.
Barker, F., Mackenzie, E., Elliott, L., et al., (2016). Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Database of Systematic Reviews. Cochrane Database of Systematic Reviews. No 8.
Hogan, A., Phillips, R., Brumby, S., et al., (2015). Higher social distress and lower psycho-social wellbeing: Examining the coping capacity and health of people with hearing impairment. Disability and Rehabilitation. Jan 5 2015, published online.
Hogan A, Reynolds K, Byrne D. (2012). Identity, social position, wellbeing and health: insights from Australians living with hearing loss. In: Banwell C, Ulijaszek S, Dixon J, eds. When culture impacts health. United States: Academic Press: pp. 95–104.
Maskrey, N., & Gordon, A. (2017). Shared understanding with patients. JAMA Internal Medicine.177: 1247-1248.
Spatz, E., Krumholz, H. & Moulton, B. (2017). Prime Time for Shared Decision Making. JAMA. 317: 1309-1310.
Powers, M., Bardsley, J., Cypress, M., et al. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics . Diabetes Care. 38:1372-82.
Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, et al. (2011). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011; (10).
Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly. Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.
feature photo courtesy of shannon christy