Considering a Cochlear Implant? You’re Never Too Old.

Is there  an age limit for cochlear implant recipients? I asked this question of several cochlear implant surgeons around the country. Their answer? Never.

All have implanted patients in their 90s and, as Anil Lalwani, of New York-Presbyterian/Columbia University Irving Medical Center said, he “routinely” operates on patients over 80. His oldest patient is 93.

Surgeon Jay Rubinstein, at the University of Washington Medical Center, has performed cochlear implant surgery on a 96-year-old. Like the others, he thinks chronological age is -not the issue, it’s a person’s overall health.

In other words, it’s not so much how many years you’ve lived as how well your body has held up. In April 2014, Mollie Smith, 99, became the oldest cochlear implant recipient in Europe.

Cochlear implant surgery takes about two to three hours and requires general anesthesia or heavy sedation, so the ability to tolerate anesthesia is essential. Even so, a 2009 study by Dr. Lalwani and others, found that cochlear implantation in the elderly carries minimal risk from anesthesia.

One of the important preexisting conditions that may preclude surgery is moderate or severe heart and/or lung disease, which could make anesthesia potentially dangerous, said Rick Hodgson, a surgeon with Head and Neck Surgical Associates in Portland, Ore. The oldest patient he has implanted was 92 and he’s doing well, Dr. Hodgson said, noting that as a surgeon he looks more at “biologic age than chronological age.”

Darius Kohan, an otologist-otolaryngologist in New York (who was my cochlear implant surgeon at New York Eye and Ear Infirmary), told me he implanted a patient who was 95 years 6 months old. The patient is still using the implant 21/2 years after surgery.

Even dementia may not be a disqualifier, the surgeons said, assuming that the patient is not violent or likely to destroy the external parts of the implant. A study published last summer on implantees with dementia found a significant cognitive improvement a year later. The patients also received regular auditory rehabilitation. It was not clear from the study whether it was the implant itself or the aural rehab that made the difference in improved cognitive abilities.

Jack Wazen, a surgeon and  partner at the Silverstein Institute and director of research at the Ear Research Foundation in Sarasota, Fla. (and a fellow board of trustees member with me for the Hearing Loss Association of America), was the most conservative of those interviewed on the question of dementia, saying he routinely implants those with mild to moderate cognitive decline, but not those with severe decline.

All agree on the importance of auditory rehab for older patients. As Dr. Hodgson put it, “Auditory rehab helps get the most out of the process. This is amazing and life-changing technology, so why wouldn’t we want to maximize the impact on someone’s life?” He added that younger implant recipients might still be in the workforce and get stimulation from their everyday environment. The older recipients are less likely to get that stimulation. Also important, as all the surgeons agreed, is a social support system. This doesn’t necessarily mean a companion in the home, but a regular conversation partner is essential. Social interaction is important in general for quality of life.

The one issue on which the surgeons differed was which ear to implant: the worse or the better one. With younger implantees, the decision is usually to implant the worse ear, to preserve the natural hearing in the good ear, often using a hearing aid in the good ear. But an elderly person may have been deaf for some time in the bad ear, and thus less likely to benefit from the implant.

Although most said that they would consider implanting the deaf ear, they might not if the ear had been deaf for a long period of time. Dr. Wazen specified five years or more. Dr. Hodgson pointed out that “the longer the duration of hearing loss, the higher the chance of diminished benefit due to deterioration of sensory elements in the inner ear.”

Both Dr. Lalwani and Dr.  Kohan said they would implant the worse ear. Dr. Kohan’s reasoning is that if the patient is still able to hear with the hearing aid ear, there may still be enough plasticity in the brain, with crossover from the nonhearing ear, to make an implant in the deaf ear function. Dr. Lalwani went further: “I would always implant the deaf ear. One does not lose anything from doing so. If the outcome is less than satisfactory, the other ear could always be implanted down the road.”

As for outcomes, all the physicians agreed that older recipients do well with cochlear implants. Dr. Kohan mentioned benefits like delayed mental deterioration, better quality of life and more independence.

Dr. Wazen is completing a study comparing the results among patients over 80 with those under 80. The study found no differences in healing or complication rates. All patients did better with the cochlear implant than they had with a hearing aid. The study did find that speech recognition scores with implants were better in the younger group. This may be due to a number of factors, Dr. Wazen said, “including length of deafness, poorer cognitive function [in the older group] and aging changes in the brain.”

So if your doctor recommends an implant, go for it, no matter what your age. “When elderly patients tell me they are too old for a CI,” Dr. Rubinstein said, “I tell them age is not important unless they are a cheese.”

This post first appeared on AARP Health on February 22, 2016.

What Would Helen Keller Do?

 

“Blindness cuts us off from things, but deafness cuts us off from people.”

Bouton: What Would Helen Keller Do?

                                                                       Helen Keller — Pictorial Press Ltd / Alamy Stock Photo

Did Helen Keller actually say this? No one knows.

She did express the idea in different ways. In one letter she wrote, “The problems of deafness are deeper and more complex, if not more important, than those of blindness. Deafness is a much worse misfortune. For it means the loss of the most vital stimulus — the sound of the voice that brings language, sets thoughts astir and keeps us in the intellectual company of man.”

Helen Keller lost her vision and her hearing when she was 19 months old, from an infection that was probably scarlet fever or meningitis. Like many toddlers at that age, she had some spoken language, which was presumably lost in the trauma of her illness.

Today Helen Keller’s parents would be offered the option of cochlear implants and speech therapy. Because she was also blind, conventional sign language would not be an option. The Deaf-Blind today use a form of sign language called fingerspelling,  or tactile sign language, which Keller herself used. She also learned to speak, although her speech was labored and difficult to follow.

Those with serious hearing loss often cite this quote. Although cochlear implants and hearing aids restore hearing, it may be to limited degree. Even with additional assistive devices and good lip-reading, a person with severe to profound hearing loss may still have trouble following speech in any but ideal circumstances. I know, because I’m one of them.

Nevertheless, I am certain that, given her blindness, Helen Keller would have embraced today’s cochlear implant technology. In a remarkable historic video, Keller speaks about the loss not of sight or hearing but fluid speech:

“It is not blindness or deafness that bring me my darkest hours. It is the acute disappointment in not being able to speak normally. Longingly I feel how much more good I may have done, if I had only acquired normal speech. But out of this sorrowful experience I understand more clearly all human striving, wanted ambitions, and infinite capacity of hope.”

When she died in 1968, at 87, the New York Times cited her many accomplishments: “she was graduated from Radcliffe; she became an artful and subtle writer; she led a vigorous life; she developed into a crusading humanitarian who espoused Socialism; and she energized movements that revolutionized help for the blind and the deaf.” She was a “symbol of the indomitable human spirit.”

It is hard to imagine that she could have “done more good” with the ability to speak. But her quotes suggest that she would have embraced the chance to hear “the sound of the voice that brings language, sets thoughts astir and keeps us in the intellectual company of man” — and to respond with speech.

Katherine Bouton is the author of “Living Better With Hearing Loss: A Guide to Health, Happiness, Love, Sex, Work, Friends … and Hearing Aids,” and a memoir, “Shouting Won’t Help: Why I — and 5o Million Other Americans — Can’t Hear You”. Both available on Amazon.com.

This essay first appeared in a slightly different form on AARP Health.

Can’t Hear These Iconic Sounds of Spring?

It may be time to get your hearing checked.

 

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Birdsong. Where ever you live in the United States, the great spring bird migration happens at this time of the year. Warblers, tanagers, grosbeaks, orioles, thrushes, vireos fly through on their way from winter homes in the tropics, singing as they wing their way north.eastern-bluebird-c-dorrie-holmes-320 One of my favorites is the eastern bluebird, a very early arrival in my part of Western Massachusetts, claiming its backyard house in February. I realized only this spring (an early one in the east) that bluebirds sing. Here’s a YouTube video. Hope you can hear it!

I was unable to find specific decibel levels for bird songs, which vary according to species of course, but I did come upon a study that found that urban sparrows sing at a higher pitch than they used to, to compete with traffic noise.

Pattering rain. Louder than snowfall but nothing like the deluge of a summer downpour. A moderate rainfall measures about 50 decibels.

Leaves rustling in the breeze are just 20 decibels, close to the softest sound most humans can hear.

Spring peepers. I always thought these were newly hatched frogs, but a “spring peeper” is a member of the tree frog family. The high-pitched sound is a chorus of males, looking for mates. Click here for a picture of the peeper’s balloon-like throat, which makes the sound

Insects. I can’t find any information about the decibel level of a bee buzzing – but it’s good to be able to hear it, especially if it’s near your ear. A buzzing mosquito, on the other hand, comes in at 37 dB, and should be audible.

Squirrels, according to expert Robert Lishak, have a regular language, from “kuk” (a sharp bark of alarm, usually repeated three times) to “quah” (the predator is still in sight but not quite as threatening) to the “quah moan.” Dr. Lishak describes the quah moan as sounding like a “chirp followed by a meow.” “Muk Muk” is a soft buzzing or huffing noise, possibly a male mating call. These vary in decibel level with the softest, the muk-muk, around 20 decibels. You’ll need sharp hearing to hear that one.

Picnics. The crinkle as you open that bag of chips only increases your appetite, and the satisfying crunch as you bite into one makes you want to keep on eating. Healthier foods also have inviting sounds. Thinks of the crunch of a bite of celery, the snap of a carrot. The pop/hiss of a soda can is another familiar picnic sound.

America’s Pastime. How loud is the sound of that bat hitting the baseball? The crack of the bat actually varies in pitch and intensity, depending not only on how hard the ball is thrown and where exactly it meets the bat, but on the kind of hit it produces.

Fun reading: Moonshot: The Analytic Value of the Crack of the Bat, by Robert Arthur. This 2014 analysis of baseball bat sounds found that a line drive in general produced the highest frequency sound, amplified by sound systems in a stadium or on TV or radio. This is followed by the sound of a home run (second loudest), a ground-ball hit, and a ground-ball out.

According to a similar article in The New York Times, a ball hit in the sweet spot has a sharp crack, a ball hit on either side will thunk. The crack may alert an experienced outfielder to the trajectory of the ball before he can visualize it.

Share your favorite spring sound in the comments box, below.

First published on AARP Conditions and Treatments, 3/19/16

Dear Abby, Please Think Again!

Dear Abby, your response to “Trapped in a Situation” about her hearing-impaired husband “Norm” almost made me weep. “Wife of deaf husband seeks to cope in new place.” I wonder what deaf husband thinks of all this.

Yes, of course Norm should inform the retirement community director about his hearing loss. But why did you stop there?

Norm and Trapped are moving to a retirement community. That means that most of the residents will be 70-plus, maybe a lot older. Two-thirds of 75 year olds have hearing loss, and the number goes up with every year. Norm will have lots of company.

Norm and Trapped may not realize how many other residents have hearing loss because even the aged are embarrassed by age. The stigma of age as it relates to hearing aids remains powerful right up till the last for many people. If Norm is open and honest about his hearing loss, I think he’ll find that others are too.

Norm has a cochlear implant. They are very visible. No one is going to mistake him for a 45 year old with perfect hearing. Because his hearing loss is visible, he’s in a perfect position to educate others – and help himself as well. If he’s open about his hearing loss, others will be too.

Trapped says they use assistive devices at home. These can be used in the dining room room, and so can other technology and techniques for better hearing.

The worst thing Norm can do is stay in his room for dinner. Hearing loss is hard, yes, but it’s much harder for those who withdraw and isolate themselves. The consequences are well documented and include depression and cognitive impairment. Norm needs to get out there and be active.

I can’t help wondering if Trapped isn’t the one bothered by this, rather than Norm. I was struck by her choice of pseudonyms. Norm? As in normal? Wishful thinking.

Healthy aging is what we all aim for. Retirement communities are set up to encourage as much activity and participation as possible. And there’s a good reason for that. The alternative is depressed, demented old people spending the day in their rooms. Surely Trapped doesn’t want this for her Norm.

Good News! For a change.

Good news for people with hearing loss.

Last week CMS, which runs Medicare and Medicaid, reversed itself on an earlier proposal to eliminate coverage for bone-anchored cochlear implants, like Cochlear’s Baha and Oticon’s Ponto.

This is good news for two reasons.

First, it preserves coverage for an important and expensive technology. People with certain kinds of hearing loss, including that resulting from acoustic neuroma, can’t be treated with hearing aids or conventional cochlear implants. The bone-anchored devices, which have been implanted in 40,000 Americans since they were approved by the FDA and accepted for Medicare reimbursement in January 2006, affect people of all ages. Only 20 percent of these 40,000 procedures was covered by Medicare, according to the Hearing Industries Association. And in fact when CMS made its original proposal to end coverage it noted that it wouldn’t save Medicare a substantial amount of money.

Medicare’s decision not only ensures that these devices will continue to be available on Medicare but also will have a so-called ripple affect. Private insurance companies often follow Medicare’s lead in coverage guidelines.

And these devices are expensive (although not as expensive as conventional cochlear implants, which both Medicare and private insurers generally cover). Cochlear Americas estimated that the national average “bundled” rate (which includes physician and audiologist services), is $9732 if the surgery is done on a hospital outpatient basis.

The second piece of good news is that this was accomplished as a result of a public campaign against the proposed changed. Cochlear Americas got it started but CMS received more than 4,070 comments, and 11,300 signatures on a petition, according to the Acoustic Neuroma Society. The people’s voices were heard!

Let’s all remember that the next time CMS or some other seemingly behemoth government agency proposes to cut back coverage of an essential device or procedure.

An Invisible War Wound

An Invisible War Wound: Out of sight, and mostly out of mind.

When we think about the injuries our servicemen and -women endure, on this Veterans’ Day, we naturally focus on major life-changing injuries like Traumatic Brain Injury and Post-Traumatic Stress Disorder. We worry about suicide in veterans. We see veterans struggling to learn to walk again with prosthetic limbs or learning to hug a child using a prosthetic arm. These are all horrifying consequences of war and no one would minimize them.

But there is a war wound we don’t see, and for the most part don’t think about. Hearing loss and tinnitus are the two largest categories of disability in the military, and have been for some time.

These are not comparable injuries in terms of the scale of destruction, and they are not life-threatening. They are often secondary to TBI or other debilitating injuries. But they’re permanent. And long after a veteran has begun to recover from these other wounds physically and emotionally, he (or she) begins to realize the hearing loss or tinnitus is not going away.

Captain Mark A. Brogan of the United States Army was injured in a suicide bomb attack in 2006. He spent months in a coma at Walter Reade Medical Center. It was not until his traumatic injuries had been treated that he began to think about his hearing loss, and to realize how it and his TBI were entwined.

At a panel discussion with other veterans earlier this year, he talked about the lasting effect of the TBI on his hearing. The part of the brain that controls speech perception was injured in the blast, and combined with the injury to the ear itself made speech very difficult to understand.

Hearing loss and tinnitus also combine negatively with other injuries. Trouble hearing in a noisy place can trigger his PTSD, said Sean Lehman, US Air Force,. The PTSD in turn exacerbates the tinnitus. “It makes my brain get irrational, you know? It makes my PTSD more difficult to deal with.”

Sgt. Lehman sustained third-degree burns over 40% of his body, and his physical injuries obscured the fact that he’d also lost his hearing — for almost two and a half years. “Things I considered unimportant turned out to be important,” he told the audience. It was only when his three-and-a-half year old daughter was impatient with her father’s inability to hear her that he sought help for his hearing loss.

In June Captain Brogan and a panel of other veterans gave a workshop at the annual Hearing Loss Association of America Convention. They are part of a group called Heroes With Hearing Loss, and they’ve banded together not only to raise awareness of hearing loss in veterans but also to give veterans the opportunity to talk about hearing loss to another vet.

“I was 25 years old at the time,” Captain Brogan recalled when he realized the severity of his hearing loss. “I don’t want to wear these [hearing aids], you know. Are you kidding me? You, know, I’m young, freshly out of the military.” The others nodded in agreement. “It was a battle to accept it. Kind of a grieving process. It’s something that visibly says, ‘Hey you’ve got a problem.’”

Sean and the others all talked about the issue of credibility, how important it is for an injured vet to hear from other vets ways to come to terms with it.

Master Sgt., Donald Doherty, a retired Marine and veteran of Vietnam, lost his hearing as a result of gunfire and artillery noise. “Noise is an occupational hazard for warfighters,” he said.

“Marines, and anyone in the armed forces, have been instilled with a sense of pride, the need to act independently, to do it yourself. It’s a sign of weakness if you reach out for help.” But, he added, you begin to realize you do need help. You realize it’s affecting “not only yourself but everyone around you.”

Sgt. Lehman was the first to use the word “credibility” about the trust soldiers put in each other. “Dr. Jones [Amanda E. Jones, Aud-D, CCC-A)] can tell me what works, and I’ll listen. But if Mark tells me, I’ll take his word for it.”

Don Doherty, who is also now on the Board of Trustees of HLAA, points out that “Veterans recognize the noise hazard but make the sacrifice willingly because it’s their duty and mission.” But, he says, “My brothers in arms need to reach out to the VA and get tested. Too many of them don’t.”

Sean Lehman asked Dr. Jones what differences she noticed between “normal” patients and veterans, who, he added – getting laughs from the others on the panel, “we all know are not normal.”

Dr. Jones estimated it took an average of 15 years for a veteran to address the issue of hearing loss. It’s partly a question of dealing with other medical conditions, she said, but it’s also a matter of pride. Eventually, she added, it becomes a matter of acceptance: “I’ve got an issue and I have to do something about it.”

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These invisible injuries take on a larger significance not only because it is difficult for veterans to come to terms with the loss — but also because society is likely to ignore it.

“‘I would love to hire a veteran with a disability; they will get top priority when I hire new associates,” a potential employer might say. Joyce Bender, who runs a search firm that helps place people with disabilities, says that what they really mean is, “Send me a veteran with a visible disability,”

This is not to say that an employer should not go ahead and hire the veteran with the visible disability – it’s good for the soul and it’s good for business. But don’t ignore the vet with a hidden disability: PTSD, mental illness — and yes, hearing loss.

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Both the Hearing Loss Association of America and the Hearing Health Foundation have online resource centers for Veterans.

Heroes for Hearing Loss travels nationwide and can be contacted at HeroesWithHearingLoss.org

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Originally published on November 10, 2014 by Katherine Bouton in What I Hear, Psychology Today.