For Better Care for Older Adults, Think Hearing Loss.

Two scholarly papers published this month discussed the impact of hearing loss on patient communication in older adults. Both found that unrecognized hearing loss may have a serious negative impact on health care in the elderly.

In the first, published in the British Medical Journal (BMJ) on January 18, researchers Jan Blustein, a professor of health policy and medicine at NYU, Barbara E. Weinstein professor of audiology at the CUNY Graduate Center, and Joshua Chodosh, a geriatrician at NYU, found that the rate of hearing loss is underestimated in medical settings, and analyzed the effect of undetected hearing loss on doctor-patient communication.

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In the second, published in the Journal of the American Medical Directors Association (JAMDA)  on January 30, the same authors as well as Ellen M. McCreedy, at the Center for Gerontology and Health at Brown University, discussed why hearing loss may be especially disabling in nursing home settings, and provided an estimate of the prevalence of hearing loss in those settings.

Hearing loss in older adults is measured in various ways. One is a catchall number that includes everyone over a certain age:  two-thirds of those over 70 have hearing loss, four-fifths of those over 80 have hearing loss. Sometimes it’s measured by decades: half of those 70-79 have hearing loss; 80 percent of those over 80 do. These figures include everything from mild to profound loss.

Whatever way you count it, however, the elderly experience hearing loss in large numbers. So when the researchers found that federal data indicated that 68 percent of long-term nursing home residents over the age of 70 had “adequate” hearing, it seemed worth investigating.  Was hearing loss just not being recognized in nursing homes? And if so, was it affecting care?

The Federal Data was compiled from the Minimum Data Set (MDS) that all nursing homes are required to report to the federal government. In 2016, nursing homes reported that 68 percent of their residents had “no difficulty in normal conversation, social interaction, or listening to TV.”

That number seemed “implausibly low” to Dr. Blustein and her colleagues. The National Health and Nutrition Survey (NHANES), which is the authoritative source about the rate of hearing loss among adults who live outside of institutional settings, found that only 44% of those 80 and older said that they had “excellent or good” hearing. As the JAMDA paper notes, these two figures are at “striking odds” with each other.

It stands to reason that the rate of hearing loss in nursing home residents should be about the same as that of adults living outside of institutional settings, which would mean that many people in nursing homes and other health care settings are having trouble hearing. They may not be having trouble hearing all the time, but crucial hearing situations are often the noisiest.

Many of those who say they hear adequately probably have mild to moderate age-related hearing loss. Their speech comprehension may be fine in quiet conversation. But nursing homes are far from quiet – studies show that social settings are often very noisy, with televisions blaring, dishes clattering in cafeterias, and residents crying out. Moreover, “high stakes” medical-care situations – emergency rooms, intensive care units, ambulances — tend to be the noisiest. These are also stressful situations, and stress also impacts comprehension.

Hearing aids are one solution, but hearing aid use remains low even in this population. Even if they do have hearing aids, people may leave them at home or in a safe place, to prevent loss or damage.

In both articles, the authors propose easy low-tech solutions for making sure hearing loss doesn’t get in the way of good patient care.

The first is for clinicians to be aware that their elderly patients may have hearing loss, even if they don’t know it. They should also check for impacted cerumen, or ear wax, which can affect hearing.

Every facility should have on hand personal amplifiers that can be shared with patients. The PocketTalker is perhaps the best known. The researchers also mention the Mino and the Sonido Listener. These devices cost about $150.

Health care workers also need to be mindful of communication strategies: they should make sure they have the listener’s attention, face the listener, speak clearly but not too slowly, rephrase rather than repeat words the listener has not understood.

Dr. Blustein (who has hearing loss herself and who serves on the Board of Trustees of the Hearing Loss Association of America, as do I) believes that hearing loss profoundly affects communication with patients. “Those of us with hearing loss often smile and nod so that the world thinks that we understand. It’s much more convenient. It’s easier. A patient may nod and smile, but not really understand what she is being told,” she said in an interview with the BMJ. Busy clinicians, too, may just want to move on, get their work done. So both the patient and the clinician may be contributing to the detriment of good patient care.

Unrecognized hearing loss can also sometimes be misdiagnosed as a cognitive impairment. “I think… my intuition… is that this is one of the great issues,” Dr. Blustein told the BMJ. “It’s sort of low-hanging fruit in clinical medicine, the assumption that someone has cognitive impairment when they don’t respond appropriately.”

Asked why the effect of hearing loss on good communication has remained unrecognized by many doctors, Dr. Blustein replied: “I think disability, generally, is not something that medicine is attracted to. We tend to be attracted to really dramatic, acute illness. Disability is complicated, it takes time.” And, she added, it occurs primarily in older people. “This is dismissed as ‘normal aging’. It’s ageism.”

People with hearing loss share some of the responsibility. Both patients and providers will benefit from the Guide for Effective Communication in Health Care, created by Jody Prysock and Toni Iacolucci. It includes information specifically for patients and their families (including a form that can be filled out in advance of medical interactions and should be entered into patient charts) and for providers. It can be found on the New York City Chapter’s website under Resources, with a link to the national website.

For people with hearing loss, it’s important to be honest, to disclose our disability. For providers, it’s important to recognize that hearing loss may be a factor. It’s a two-way street.

 

For more information about living with hearing loss, read my book “Shouting Won’t Help: Why I and 50 Million Other Americans Can’t Hear You. 

9 thoughts on “For Better Care for Older Adults, Think Hearing Loss.

  1. Good topic – I posted on FB

    *From:* Katherine Bouton [mailto:comment-reply@wordpress.com] *Sent:* Wednesday, January 31, 2018 11:08 AM *To:* nmacklin@hearingloss.org *Subject:* [New post] For Better Care for Older Adults, Think Hearing Loss.

    Katherine Bouton posted: “Two scholarly papers published this month discussed the impact of hearing loss on patient communication in older adults. Both found that unrecognized hearing loss may have a serious negative impact on health care in the elderly. In the first, published i”

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  2. Hearing loss has a serious impact on seniors especially when listening to directions from their physicians. Hearing loss can also be confused with dementia. Personal assistive listening devices will help with one-on-one conversations. I have been hard of hearing since age 4 and now 81. The information mentioned should be sent to social workers who work with seniors and adult children of seniors who have a hearing loss. Sending gift copies of the Hearing Loss Association of America (HLAA) “Hearing Loss” a bi-monthly journal is a good source of information.

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  3. I just wrote this yesterday on my FB page regarding two studies, one called “Lack of ear care knowledge in nursing homes. I asked for responses: I’ve often wondered about this. I remember when my Mom was in a nursing home and the staff kept her hearing aids by the front desk. They often forgot to bring them to her until later in the morning. Does anyone know how they handle this these days? I know they have to worry about theft, or damage or loss, but I can’t imagine being without my hearing devices from the moment I wake up. Anyone?

    –Judy Schefcick Martin

    I am so HAPPY to read your article. I hope it gets a lot of attention. I commented on my own page that I wish I was ten years younger so I would be able to spearhead action on this topic.

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  4. Katherine,

    This is very important. There is something I would like to add, based on personal experiences with my father, as well as an elderly cousin before they died. My father wore hearing aids for a severe or profound impairment and lived in an independent senior citizens’ residence in Teaneck. While the elderly are the most likely to be impaired, they are the least able to manipulate and care for hearing aids, which requires good vision and fine motor coordination, along with some cognitive skills. Often they have started wearing hearing aids late in life, when learning to care for them and adjust them is difficult. Some years ago, I was in upstate NY when my father called to tell me that his hearing aids were broken, I made the 2 1/2 hour drive to Teaneck and discovered that he had put the batteries in backwards. On other occasions I found that the aids were clogged with cerumen. I found someone who worked at the residence and showed him how to change batteries, clean the aids, and adjust the volume. I also got my father an amplified phone, without which, he was completely unable to talk on the phone.

    Some years ago, I called my cousin Fred, who was a well-known economist, living in a wonderful Kendall Residence for seniors in Ithaca. I was rather alarmed because on the phone he sounded rather demented. When I went to visit him, I found that he was completely in tact, still writing academic articles, but that his phone was not amplified, which made it impossible for him to communicate intelligently, and he was feigning hearing me, and therefore responded inappropriately.

    An additional problem for elderly hearing aid users is that they are less able to explain their dissatisfaction with their aids to an audiologist. My father would simply say, “I don’t like the sound,” That does not give the audiologist much to work with in programming the aids to produce better results.

    Jon Taylor

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  5. I find that many seniors who finally purchase hearing aids buy the tiniest hearing aid they can afford. It is usually only for one ear when both ears have a hearing loss and many are not fitted with a telecoil or a program that lowers the background noise. When living in a residential setting a personal assistive listening apparatus with a head set might be a better option for one-on-one conversations.

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