Screening for Otologic Functional Impairments in the Elderly: Whose Job is it Anyway?

Among the most prevalent of chronic conditions affecting older adults globally, hearing loss prevalence is increasing and its impact on society growing. Untreated hearing loss diminishes ones ability to communicate and its strong association with depression and cognitive decline adds further to the burden of hearing loss. Hearing health care is rarely included in the traditional medical exam for older adults, it is typically not considered a risk factor for cognitive decline or falls, and it is not a condition for which routine screening has been recommended by the U.S. Preventive Services Task Force. Yet in older adults, disability typically results from many small risks acting together with different people having a different pattern of multifactorial risk (U.S. Preventive Services Task Force, 2010). The importance of preventive hearing health care in primary care is discussed along with a screening strategy with targeted interventions designed to target older at risk adults.

Treatment efficacy: hearing aids in the management of hearing loss in adults.

Hearing impairment in adults is a prevalent chronic condition, associated with psychosocial and quality-of-life handicaps. Recent investigations have demonstrated that individuals with handicapping hearing impairments do indeed benefit from the rehabilitative services offered by audiologists, with the primary intervention being hearing aid provision. My objective here is to review the experimental research, program evaluation data, and case studies documenting the efficacy of hearing aids, with an emphasis on the functional and communicative benefits accruing from hearing aid use. It is hoped that the information contained herein will provide clinicians with outcome data to share with the hearing impaired, toward the goal of encouraging such individuals to take advantage, at least for a trial period, of one of the many technologies available to assist them to function better in their daily lives.

The dizzy patient: stepwise workup of a common complaint.

Dizziness is a common and potentially disabling complaint among older patients. A major consequence of dizziness is falls, which can lead to death or significant functional disability. Dizziness can be separated into four broad categories: vertigo, disequilibrium, near-syncope, and nonspecific. Given its multitude of possible etiologies, dizziness often poses a diagnostic dilemma for the physician. Symptoms can result from a disturbance in any number of balance control systems, including the visual pathways, vestibular apparatus, cardiovascular system, and CNS. In evaluating dizziness, the physician should first obtain a careful medical history and perform a targeted physical examination. Depending upon the organ system involved, an audiologist, otolaryngologist, neurologist, cardiologist, and/or psychiatrist should then be consulted for further assessment and management.

Handicap versus impairment: an important distinction.

In this era of spiraling health care costs, audiologists are being held accountable for the rehabilitative interventions that they are uniquely qualified to deliver. Accountability data in the rehabilitative arena should address the efficacy of short- and long-term treatment. If a treatment such as a hearing aid is dispensed for the purpose of reducing the communicative and psychosocial handicap associated with hearing loss, efficacy data should demonstrate whether such a goal has been attained. Increased attention has been focused on the value of self-assessment questionnaires as instruments that are predictive of candidacy for hearing aids, intent to purchase hearing aids, and outcomes with a given hearing aid treatment. Case studies demonstrate the advantage of engaging the client in the rehabilitative process through the use of responses to self-assessment questionnaires. It is evident that the client's appraisal of the handicapping effect of a given impairment is associated with treatment efficacy.

Age-related hearing loss: how to screen for it, and when to intervene.

Hearing loss is prevalent among older adults and is associated with depression, cognitive decline, reduction in functional status, and emotional and social handicaps. Screening by physicians is important, because older adults tend to underestimate the degree of their hearing impairment. The most important predictor of hearing aid candidacy is not the severity of hearing loss but rather the patient's motivation and perception of the handicapping effects of his/her hearing impairment. A variety of hearing aid styles is available. In-the-ear units and in-the-canal hearing aids are the most popular. New digitally programmable aids are often acoustically superior, but they cost more and require considerable training. Assistive listening devices may be used with or without a hearing aid to amplify sound, television, or telephone conversations.

Test-retest reliability of the hearing handicap inventory for adults.

The test-retest reliability of the Hearing Handicap Inventory for Adults (HHIA) was assessed on a sample of 28 hearing-impaired adults. Reliability estimates were obtained to set the stage for using the HHIA as an outcome measure in aural rehabilitation. The test-retest reliability was quite high (r = 0.97) and the standard error of measurement was low for the HHIA and its screening version (HHIA-S). In light of the psychometric adequacy, the HHIA and HHIA-S have potential as indices of hearing aid benefit in hearing-impaired adults.

Practical method for quantifying hearing aid benefit in older adults.

Self-assessment handicap scales are gaining recognition as objective measures of audiologic intervention, including benefit derived from hearing aid use. A short form of the Hearing Handicap Inventory for the Elderly (HHIE-S) comprised of 10 items (5 emotional and 5 social/situational) was administered to 91 new hearing aid users prior to and 3 weeks following hearing aid provision. A significant reduction in perceived emotional and social/situational effects of hearing impairment was observed following this brief interval of hearing aid use. The magnitude of hearing aid benefit was not affected by pure-tone sensitivity or word recognition ability. Further, a 95 percent confidence interval was established for the HHIE-S (9.3 points) in order to determine a true change in self-perceived handicap and pre- and post-hearing aid fitting for a given subject. Our findings support the use of the HHIE-S as an expedient approach for quantifying hearing aid benefit in a busy clinical practice.

The Hearing Handicap Inventory for Adults: psychometric adequacy and audiometric correlates.

The Hearing Handicap Inventory for the Elderly (HHIE) was modified for use with younger hearing-impaired adults (less than 65 years of age). Similar to the HHIE, the Hearing Handicap Inventory for Adults (HHIA), is a 25-item self-assessment scale composed of two subscales (emotional and social/situational). Replacement questions from the HHIE which form the HHIA focus on the occupational effects of hearing loss. For 67 hearing-impaired adults, the HHIA demonstrated high internal consistency reliability and a low standard error of measurement. Audiometric correlates of the HHIA revealed weak, yet statistically significant relationships with pure-tone sensitivity and supra-threshold word recognition ability. These findings support the use of self-report handicap measures with adults in that audiometric measures alone are insufficient in describing a patient's reaction to their hearing loss.

The quantification of hearing aid benefit in the elderly: the role of self-assessment measures.

The efficacy of disease-specific self-assessment scales, as a measure of hearing aid benefit in the elderly, has recently been documented by several investigators. One of the most robust measures appears to be the Hearing Handicap Inventory for the Elderly (HHIE), an instrument which assesses the emotional and social effects of hearing loss in the elderly. Using the HHIE, statistically and clinically significant improvements in self-perceived handicap have been noted at three week, six week, four month and one year intervals. Interestingly, longitudinal studies have demonstrated that the percentage improvement in hearing handicap is typically sustained when subjects undergo longitudinal testing. The ten item screening version of the HHIE (HHIE-S), which is an effective outcome measure has also been shown to be predictive of hearing aid uptake. The aforementioned findings have implications for rehabilitative programming, quality assurance studies, government and third party payers considering reimbursement of hearing aids.

Measurement of hearing aid benefit in the elderly.

Providing amplification is at the heart of most rehabilitation programs for the elderly. Given the importance of quality assurance, methods of quantifying hearing aid fitting success are needed. This study was designed to assess the adequacy of a self-assessment scale at measuring hearing aid benefit following a 3 week interval of hearing aid use. Forty-five new hearing aid users completed the Hearing Handicap Inventory for the Elderly (HHIE) prior to and following 3 weeks of hearing aid use. Results of the study showed a significant reduction in handicap following 3 weeks of hearing aid use, suggesting the feasibility of using the HHIE as an outcome measure for hearing aid success after a brief interval of hearing aid use. Subjects will be followed longitudinally to determine the best time frame in which to administer this scale.

Test-retest reliability of the Hearing Handicap Inventory for the Elderly using two administration approaches.

Previous investigation with the Hearing Handicap Inventory for the Elderly demonstrated high test-retest reliability for face to face/face to face and paper-pencil/paper-pencil administration techniques. From a practical standpoint, a face to face administration followed by a paper-pencil readministration may be a preferable method. The present study evaluated the latter administration approach in a sample of hearing-impaired elderly men. The high test-retest reliability correlations which emerged suggest that the face to face/paper-pencil measurement technique can be adopted for quantifying changes in self-perceived hearing handicap following audiologic intervention especially when clients are unable to return for hearing aid follow-up.

Geriatric hearing loss: myths, realities, resources for physicians.

The recommended protocol for receiving a hearing aid is: a hearing evaluation to determine candidacy for a hearing aid and/or ALD; an examination by a physician to rule out medical contraindication to hearing aid use; hearing aid selection and fitting by a dispensing audiologist or a hearing aid dealer; hearing aid orientation/counseling. It is well accepted that sensorineural hearing loss is one of the most frequent by-products of the aging process, with prevalence ranging from 30 to 50%. The hearing loss and resulting difficulty understanding speech can have a negative effect on the quality of one's daily activities and, hence, can interfere with the enjoyment of an elderly individual's remaining years. The myths of "hearing loss as an inevitable part of aging" no longer prevail, however. Advances in biomedical technology have enabled the development of smaller hearing aids with wide fitting ranges, making hearing aids a realistic option for the majority of elderly hearing-impaired individuals. To maximize benefit from hearing aids, the elderly must be identified early via routine hearing screening and referred to an audiologist for evaluation and management.

The Hearing Handicap Inventory for the Elderly as a measure of hearing aid benefit.

Hearing impairment in older adults is associated with psychological and social difficulties. The goal of hearing aid fitting is to reduce the perceived handicap resulting from the hearing loss. Measures of self-perceived handicap are being increasingly incorporated into the clinicians armamentarium as an objective measure of the outcome of intervention. Eighteen elderly hearing-impaired males and their spouses responded to the Hearing Handicap Inventory for the Elderly (HHIE) prior to and following 1 year of hearing aid provision. Our findings revealed a significant reduction in the perceived emotional and social effects of hearing impairment following 1 year of hearing aid use. The reduction in perceived handicap, as measured using the HHIE, was greater for the hearing aid users than for their spouses. The findings attest to the construct validity of the HHIE as a measure of hearing aid benefit.

Test-retest reliability of the Hearing Handicap Inventory for the Elderly.

The Hearing Handicap Inventory for the Elderly (HHIE) is a self-assessment tool, composed of emotional and social/situational subscales and designed to measure the perceived effects of hearing impairment in the noninstitutionalized elderly. Previous study has indicated that the HHIE has a high internal consistency, as well as high split-half reliability. The present study was undertaken to examine test-retest reliability associated with the HHIE, as the latter information is prerequisite to the application of the HHIE as a measure of change in perception of handicap which may result from audiologic intervention. Forty-seven noninstitutionalized elderly individuals with sensorineural hearing loss were sampled, using two measurement techniques: face-to-face (N = 20) and paper-and-pencil (N = 27) administration. Test-retest reliability was high for both the face-to-face and paper-and-pencil administration, suggesting that the HHIE has potential as a measure of change resulting from rehabilitation.