Aging, hearing loss, and hearing aids: myths revisited.

Hearing loss, which affects more than 9 million people age 65 or over (Adams & Benson, 1991), is the third most common chronic condition in elderly individuals (Ventry & Weinstein, 1983). Numerous anatomical and physiological changes occur in the auditory system as a result of the aging process (Hull, 1989). An older adult may have a hearing loss attributed to natural changes in the auditory system that occur with age (presbycusis), or he or she may have degenerative changes in the central auditory nervous system. Either type of change may affect a person's communicative function.

Because presbycusis can result from changes to different parts of the auditory system, conductive, sensorineural, and mixed types of hearing loss may be associated with these changes (Gulya, 1990). Typically, hearing loss evidenced in older adults is bilateral, with more loss in the high frequency range accompanied by difficulty understanding speech, especially in the presence of background noise. Changes from aging of the central auditory nervous system are quite common and affect the understanding and processing of speech. Because hearing loss is sensorineural and permanent in most cases of presbycusis, medical treatment is not indicated.

The primary rehabilitation approach for older persons with hearing loss is fitting with amplification and/or assistive listening devices (ALD's) and counseling; ironically, only a small percentage of these individuals seek the services of an audiologist to obtain amplification, ALD's, or aural rehabilitation, while most passively accept that hearing loss is a part of aging and that treatment is unavailable. Yet, hearing loss is known to cause psychological and social difficulties because it interferes with a person's ability to communicate effectively. Hearing loss, particularly when it develops late and is progressive in nature, can decrease independence, quality of life, and self-esteem in the older adult.

To gain a better understanding of the problems associated with hearing loss and aging, the relationship between sensory deficit and adverse psychosocial consequences in the elderly was studied by Bess, Logan, and Lichenstein (1990) at the Bill Wilkerson Hearing and Speech Center, in Nashville, Tennessee. This study was designed to examine the relationship between hearing loss in older persons and their scores on a standardized validated measure of functional status. The test used to assess functional health status was the Sickness Impact Profile (SIP), a 36-item self-administered questionnaire that assesses psychological function in a behavioral context.

The SIP has three main scales: physical (ambulation, mobility, body care/movement), psychosocial (social interaction, communication, alertness, and emotional behavior) and overall (combining all the scales). The higher the SIP score, the greater the functional loss. Normative data, gathered on unimpaired young adults, yielded scores between 2 and 3. A mean perceived functional loss score of 6.6 was obtained for elderly individuals without hearing loss, whereas scores for elderly individuals with hearing loss averaged 18.9. This study demonstrated a strong association between hearing loss and increased behavioral dysfunction in the elderly. Even mild hearing losses were found to impose negative effects on function.

Communication problems resulting from hearing loss can also impede medical treatment, strain family relations, and limit or restrict previously enjoyed activities (Weinstein, 1991b). People who cannot hear well tend to withdraw socially rather than face embarrassment from frequent misunderstandings of statements and inappropriate responses. If forced into a social situation, people with a hearing loss may take the path of least resistance, that is, to become non-communicative rather than attempt to answer a question they did not understand. As a result of their withdrawal, they experience unwanted isolation and a deterioration in their quality of life. Despite the social consequences of hearing loss, older adults wait an average of 10 years before seeking audiologic assistance (Weinstein, 1989). Audiologists have witnessed rapid technological advances in the design of personal hearing aids. A wide variety of hearing aid selection considerations such as changes in types of microphones, noise suppression circuits, frequency response capability, programmability, and miniaturization have changed the quality of amplification that is available (Compton, 1991). These developments, along with improved selection and fitting techniques, have yielded more benefit from amplification for older adults. In spite of the abundance of technological advances, many elderly individuals with hearing loss are dissatisfied with their hearing aids.

Although there have been rapid advances in hearing aid design, hearing aids are not always capable of resolving each individual's unique communication difficulties. In addition to wearing hearing aids, individuals with hearing loss also may need and benefit significantly from ALD's. The use of ALD's improves the signal-to-noise ratio (SNR) and, as a result, speech in the presence of background noise becomes easier to understand. ALD's can be used alone or in conjunction with a hearing aid and can be beneficial in a number of listening situations, including listening alone (radio, television, stereo), listening in a one- to-one conversation (in person or on the phone), or listening in a variety of group situations (Compton, 1991).

Why is it that so many older people reject the use of amplification? According to a survey conducted by Franks and Beckmann (1985), the major reason for this is cost. Another factor is the negative view that many people have concerning hearing aids. Also, some people may be biased against amplification based on the opinions of misinformed professionals or friends who have had unpleasant experiences with hearing aids (Hull, 1989). Prospective hearing aid wearers often ask such questions as, "Will I hear too much background noise with my hearing aid?" or "Will I end up paying for hearing aids and not wearing them?"

Research has demonstrated that for some, a hearing aid carries a stigma of old age and disability (LIbby, 1990). For these people, a hearing aid calls attention to what is often referred to as the "invisible handicap." Others feel that their hearing loss is not serious enough to warrant taking action or are told by their physician, "Nothing can be done to help your condition because you have nerve deafness." Additional reasons for rejecting hearing aids include amplification of background noise, limited social contacts, and difficulty with manipulation of the controls.

In some cases, the individual denies the hearing loss until the loss is severe enough to affect psychosocial behavior (Weinstein, 1991b). Individuals may believe that other people will be more accepting of them if they deny their loss. For some persons, however, a perception that their hearing loss is worsening or a recommendation by an ear, nose, and throat specialist (otolaryngologist), audiologist, or spouse will facilitate using a hearing aid.

Hearing aid use can have a positive impact on a person's everyday living situation, including the ability to work productively, maintain personal relationships, socialize comfortably, and communicate easily (Radcliffe, 1992). The use of hearing aids is known to aid communication, social and emotional function, and cognitive status. In addition, improvements in quality of life, independence, and productivity have been reported (Weinstein, 1991a). To further enhance everyday listening situations, it is essential that people with hearing loss inform others about their specific communication needs and develop effective coping strategies and behaviors.

The use of hearing aids has proven to be successful in reversing depression in some adults. A randomized controlled study to evaluate quality-of-life changes, hearing loss, and the actual benefits of hearing aids was conducted by Mulrow et al. (August 1990) at the Audie L. Murphy Memorial Veterans Hospital and the University of Texas Health Science Center, San Antonio (Radcliffe, 1992). The researchers studied 188 elderly veterans who were identified as having a hearing loss by a screening survey.

A comprehensive battery of disease-specific and generic quality-of-life measures was administered at baseline, at 6 weeks, and at 4 months. At the beginning of the study, 82 percent of the subjects reported adverse effects on their quality of life as a result of hearing loss, and 24 percent were depressed. The subjects were then randomly assigned either to receive a hearing aid or to join a waiting list for one. At the time of followup, researchers found that subjects who had received hearing aids had significantly improved scores for social and emotional function, communication function, cognitive function, and depression, as compared to those assigned to the waiting list.

According to Mulrow, "Many of the subjects with new hearing aids reported that they started going out socially or that they spent more time with their families and friends than when they could not hear as well" (Radcliffe, 1992). Despite this evidence, lack of motivation for hearing aid use is the greatest obstacle to successful aural rehabilitation (Weinstein, 1991b).

If audiologists are going to challenge this lack of motivation, they need to ensure that hearing aids are perceived as psychologically acceptable, easily manipulated, and providing appropriate amplification (Weinstein, 1991b). Because people have difficulty accepting aging, acceptance of the need for a hearing aid is also difficult. Early use of hearing aids and/or assistive listening devices should be encouraged by primary care physicians. In addition, individuals with hearing loss should be routinely referred to self-help support groups, which can provide fellowship and access to an abundance of educational and technical information.

The American Speech-Language-Hearing Association (ASHA) conducted two focus groups in 1990 with consumers to gather information about consumers' awareness of and attitudes towards hearing loss (Powell, Adams, & Rinehart, 1990). Results indicated that participants in the two consumer focus groups did not exhibit any familiarity with or interest in hearing loss beyond their own individual experiences. They were not interested in different types of hearing loss or treatments. A common theme among all the focus group participants was the amount of their denial when it came to admitting that they might have a hearing problem. Very often, the decision to have a hearing test and to get a hearing aid was made reluctantly by the individual with hearing loss and only after considerable prodding from a spouse or loved one.

In addition, few of the focus group participants understood the role that audiologists play in the diagnosis and treatment of hearing loss. The most common approach to seeking treatment among these individuals was to consult their general practitioner. Participants of the focus groups indicated that they would be interested in obtaining information about hearing loss if the subject were relevant to them and the materials were readily available and educational.

In 1984, the Hearing Industries Association (HIA) commissioned a study of people with hearing loss (Kochkin, 1990). A short screening questionnaire was mailed to 80,000 homes as a means of identifying households that include a person with hearing loss, hearing instrument owners, non-owners who would admit or recognize their hearing loss, and individuals who did not admit or recognize their hearing loss. A comprehensive 120-question survey was sent to 1,050 non-owners and 550 owners of hearing instruments.

Based on analysis of the data, HIA arrived at a number of conclusions:

* A significant number of "nerve damage" respondents were told by medical professionals that hearing instruments would not help them.

* Clients with slight/mild and unilateral losses did not receive positive recommendations for hearing instrument trial.

* Physician recommendations for hearing instruments were shown to be biased toward the older client.

The HIA survey also found that family doctors, audiologists, and ear, nose, and throat specialists are heavily influenced by the client's motivation to hear better and the client's degree of hearing loss. Physicians, particularly ear, nose, and throat specialists, are the most conservative with respect to whether they will recommend hearing instruments, even if the client is highly motivated.

In 1989, as a result of the 1984 survey data, HIA began conducting programs to educate physicians on the importance of hearing screening and on the importance of their referral of individuals with hearing loss to appropriate professionals for help (Kochkin, 1991). In 1989, when HIA began its physician education programs, 15.1 percent of clients indicated that their physician had screened them for hearing loss. In the autumn of 1990, clients screened by their physician for hearing loss had increased to 20.2 percent. At the end of 1990, HIA abandoned its physician education program in favor of other priorities and, coincidentally, clients screened for hearing loss by their physician declined to 18 percent.

Literature has demonstrated the value of functional assessment tools in screening individuals for hearing aid candidacy prior to hearing aid selection. Ventry and Weinstein (1983) developed a screening protocol, the Hearing Handicap Inventory for the Elderly (HHIE-S), which identifies elderly persons who perceive that they may experience problems in their daily lives as a result of their hearing loss. The HHIE-S involves a pure-tone hearing screen and administration of a 10-item self-assessment inventory that quantifies the perceived emotional and social effects of a hearing loss.

A score of 10 to 40 constitutes a fail on the HHIE-S and a score of 0 to 8 constitutes a pass. A score of 0 to 8 represents no handicap, a score of 10 to 22 signifies a mild to moderate handicap, and a score of 24 to 40 indicates a significant communication handicap. The HHIE-S accurately identifies individuals with a significant communication handicap (24 points and above) 96 percent of the time. A hearing handicap inventory and an increase in speech understanding in noise at high levels are two measures that may be predictors of hearing aid candidacy (Gordon-Salant, 1991).

Once it has been determined that an older person is a candidate for hearing aid use, careful consideration must then be given to several factors in selecting an appropriate amplification device. One factor is style. A prominent reason for the rejection of hearing aids is that they call attention to hearing loss. In-the-ear (I-T-E) hearing aids are preferred to behind-the-ear (B-T-E) by most persons in the adult population.

Unfortunately, some geriatric individuals have difficulty physically manipulating the I-T-E hearing aid controls. Difficulties include volume control manipulation, battery replacement, and proper insertion of the hearing aid into the ear. For users with decreased visual acuity or limited manual dexterity, B-T-E hearing aids and/or assistive listening devices may be more appropriate.

Another drawback of I-T-E hearing aids is the lack of a strong, functional telephone coil (T-coil). A T-coil is a magnetic induction pickup coil mounted inside the hearing aid. One advantage of having a T-coil control on a hearing aid is it allows a person to use the hearing aid with the telephone without interference from environmental sounds. The T-coil also can be used with some group amplification systems and TV listening devices (Pollack, 1988).

A second factor to consider in selecting an appropriate amplification device is the degree of amplification provided, which is referred to as the gain of the instrument. Studies have demonstrated that the amount of amplification preferred by a hearing aid user over the age of 60 is less than would be recommended by various hearing aid fitting strategies. Another important consideration is whether to fit the individual with one (monaural) or two (binaural) hearing aids. The fitting of binaural amplification is preferred because of enhanced speech discrimination capability in noise and improved localization ability, which is difficult to achieve with a monaural fitting. However, for some elderly individuals (frail elderly over age 80, for example), managing two hearing aids may prove too complicated.

Other considerations include the variety of noise suppression circuitry available. No one noise reduction technique is optimal for all elderly listeners; therefore, each individual's unique listening needs must be assessed (Gordon-Salant, 1991). Seven human factors have been reported (Mueller & Davies, 1987) that must also be considered when fitting the elderly patient with a hearing aid: loss of dexterity, loss of memory retention ability, insecurity, fear of the aid, fear of doing without the aid, children or family concerns, and the tendency to panic if something goes wrong with the aid. At least five of these factors could be affected by the ease with which a patient can manipulate the hearing aid.

The use of a hearing aid should be considered as only part of a comprehensive aural rehabilitation plan designed by an audiologist specifically for the individual. Older adults constitute a heterogenous population with unique strengths and weaknesses. To improve the communication status of the geriatric client with a hearing loss, it is essential that the individual's capabilities and limitations be identified (McCarthy, 1987). Thirty percent of newly fit hearing instrument wearers cease to use the instrument within the first 3 months because they have forgotten how to insert the instrument or manipulate the controls. For most older adults, the extent of their knowledge about amplification devices is limited to the newspaper advertisements they have seen.

Once a hearing aid has been selected, the audiologist develops an orientation/rehabilitation program for the individual. Hearing aid orientation sessions assist clients to obtain the maximum benefit from hearing aids and have been found to result in both long-term and short-term satisfaction (Smedley & Schow, 1990). Group programs have been shown to have several advantages, including opportunities for problem solving, reinforcement, and motivation. Hearing aid orientation sessions should allow time for the individual to practice and become comfortable with inserting the hearing aid and manipulating the controls.

New hearing aid users, especially older adults, may require several sessions to learn to use a hearing aid properly and to develop coping/listening strategies and techniques. Vision, mobility, or dexterity problems must be accommodated. An individual may have a well-fit hearing aid and know how to use it but may still need to learn to use the instrument in a variety of listening environments (e.g., in noise, at a distance, and in reverberant conditions).

Rehabilitation sessions will emphasize the rewards that are gained by demonstrating that hearing aids actually do provide increased communication capability at home and/or in the workplace (Weinstein, 1991b). Communication typically involves the person with hearing loss and family members; therefore, significant others should always be included in the rehabilitation process and should be encouraged to attend sessions pertaining to adjustment to the hearing loss and using the hearing aid.

Summary

Hearing aid technology advances every year. Most people with hearing loss, a large percentage of whom are over 65 years old, are candidates for hearing aids or other assistive devices. Hearing loss, the third most common chronic condition in older people, is a major determinant of function in this population. Hearing loss is known to have a potential negative effect on the quality of life and can interfere with a perons's activities of daily living.

The earlier the hearing loss is identified by appropriate screening measures and evaluation and treatment by an audiologist, the earlier an individual can benefit from the use of amplification (Ventry & Weinstein, 1983).

Goals of hearing aid use for the elderly should be to increase communication and ensure the individual's ability to function independently and safely in his or her environment. Realistic and meaningful expectations should be set with the emphasis being placed on the benefit gained for each person (e.g., increased ability to enjoy television, radio, and theater, or an increased ability to participate in family dialogue and decision making).

Positive attitudes and support of family, physicians, friends, and colleagues is often instrumental in adjusting to amplification and assisting the client to maximize communication skills. The person with a hearing loss should be made aware that the isolation, lowered self-esteem, depression, and decreased independence associated with hearing loss can be temporary (Weinstein, 1991b). Professional assistance provided by audiologists and ongoing affiliation with local chapters of self-help support groups can alleviate these debilitating symptoms.

Bibliography

1. Adams, P.F., & Benson, V. (1991). Current estimates from the National Health Interview Survey, 1990. Vital Health Statistics, 10(181).

2. Bess, F., Logan, S., & Lichenstein, M. (1990). Functional impact of hearing loss in the elderly. In E. Cherow (Ed.), Proceedings of the Research Symposium on Communication Sciences and Disorders and Aging (pp. 144-149). Rockville, MD: American Speech-Language-Hearing Association.

3. Compton, C.L. (1991). Clinical management of assistive technology users: Issues to consider. In G.A. Stude-baker, F. H. Bess & L.B. Beck (Eds.), The Vanderbilt hearing-aid report II (pp. 301-318). Parkton, MD: York Press.

4. Gordon-Salant, S. (1991). Special amplification considerations for elderly individuals. In G.A. Studebaker, F.H. Bess, & L.B. Beck (Eds.), The Vanderbilt hearing-aid report II (pp. 245-260). Parkton, MD: York Press.

5. Gulya, A.J. (1990). Aging: Structural and physiological changes of the auditory and vestibular mechanisms. In E. Cherow (Ed.), Proceedings of the Research Symposium on Communication Science and Disorders and Aging (pp. 126-133). Rockville, MD: American Speech-Language-Hearing Association.

6. Franks, J.R., & Beckmann, N.J. (1985). Rejection of hearing aids: Attitudes of a geriatric sample. Ear and Hearing, 6, 161-166.

7. Hull, R.H. (1989). The hearing impaired older adult. In R.H. Hull & K.M. Griffin (Eds.), Communication disorders in aging (pp. 91-102). Newbury Park, CA: Sage Publications.

8. Kochkin, S. (1991). MarkeTrak II: More M.D.'s give hearing tests, yet hearing aid sales remain flat. The Hearing Journal, 44(2), 24-35.

9. Kochkin, S. (1990). One more time...What did the 1984 HIA Market Survey say? The Hearing Journal, 4(11), 10-20.

10. Libby, E.R. (1990). Ask the non-buyer "Why?" Hearing Instruments, 41(11), 26.

11. McCarthy, P. (1987). Aural rehabilitation. In H.G. Mueller & V. C. Geoffrey (Eds.), Communication disorders in aging, assessment and management (pp. 437-463). Washington, DC: Gallaudet University Press.

12. Mueller, H.G., & Davies, J. (1987). Hearing aid selection. In H. G. Mueller & V. C. Geoffrey (Eds.), Communication disorders in aging, assessment and management (pp. 408-436). Washington, DC: Gallaudet University Press.

13. Pollack, M. C. (1988). Electroacoustic characteristics. In M.C. Pollack (Ed.), Amplification for the Hearing-Impaired (pp. 21-101). Orlando, FL: Grune & Stratton, Inc.

14. Powell, Adams & Rinehart (1990). Audiology Marketing Program, Focus Group Research, Rockville, MD: American Speech-Language-Hearing Association.

15. Radcliffe, D. (1992). Hearing loss and hearing restoration: Costs, benefits, and quality of life. The Hearing Journal, 45(9), 11-18.

16. Smedley, T.C., & Schow, R.L. (1990). Frustrations with hearing aid use: Candid observations from the elderly. The Hearing Journal, 43(6), 21-27.

17. Ventry, I., & Weinstein, B. (1983, July). Identification of elderly people with hearing problems. ASHA, pp. 37-47.

18. Weinstein, B. (1989). Geriatric hearing loss: Myths, realities, resources for physicians. Geriatrics, 44(4), 42-58.

19. Weinstein, B. (1991a). Hearing aids and the elderly: Audiologic and psychologic considerations. In G. A. Studebaker, F.H. Bess, & L. B. Beck (Eds.), The Vanderbilt hearing-aid report II (pp. 261-268). Parkton, MD: York Press.

20. Weinstein, B. (1991b, December). Hearing aids at my age: Why bother? ASHA, pp. 38-40.

New Video Series on Hiring, Selecting, and Working with Interpreters

Educational Interpreting: A Practical Approach. Consumer Awareness, Rights, and Responsibilities Video Series.

The first two programs in a new videotape series for deaf and hearing people who use the services of or hire interpreters in schools, classrooms, and other teaching and learning situations in kindergarten through 12th grade are now available.

Produced by the National Technical Institute for the Deaf, a college of Rochester (New York) Institute of Technology, this series of seven videotape programs describes the skills, responsibilities, ethics, and role of professional educational interpreters. In addition, the series details for the consumer expectations and strategies appropriate for working effectively with interpreters. The first two tapes in the series are now available for purchase. Each tape is captioned and includes a companion booklet.

"The role of interpreters in the educational system is vital and complex," notes Jeanne Wells, project director and assistant professor in NTID's Center for Sign Language and Interpreting Education.

The public school system is the largest employer of educational interpreters in the country. Yet administrators and K-12 teachers currently have limited information on hiring and working with interpreters in the classroom.

"We hope that this series will break new ground by providing a practical approach for consumers to work effectively with educational interpreters so that all students are provided with optimal communication access throughout their elementary and secondary education," says Wells.

Some of the topics in this comprehensive series include an introduction to the work of educational interpreters; strategies for promoting effectiveness between teachers, students, and educational interpreters; guidelines for hiring and scheduling qualified educational interpreters; techniques for conducting evaluations of interpreting skills and performance as well as identifying ethical and professional standards; advocacy issues; and strategies useful in requesting and arranging for the services of interpreters in community and postsecondary settings.

The videos were shot on location in classrooms across the country. They show educational interpreters practicing their profession in various learning situations and working with students who have different communication and learning needs. The scenes highlight the diversity of interpreting assignments that educational interpreters are likely to encounter and also underscores the need for schools to hire trained and qualified interpreters.

For more information about individual video titles or other details, call Jane Lehmann at [phone] (voice/TTY) or write Rochester Institute of Technology, National Technical Institute for the Deaf, Sign Language and Interpreting Education, Lyndon Baines Johnson Building, 52 Lomb Memorial Drive, Rochester, NY 14623-5604. The first two tapes in the series are $30 each and include a companion booklet.

Now celebrating its 25th anniversary, NTID is the world's largest technological college for deaf students. One of eight colleges of RIT, NTID was created by Congress and is funded primarily by the U.S. Department of Education. NTID represents the world's first effort to educate large numbers of deaf students within a college campus planned primarily for hearing students. Among RIT's 13,000 full- and part-time students are more than 1,100 deaf students from the United States and other countries who study and reside on the RIT campus. NTID's 25th anniversary symbol, the flowering crabapple tree, represents the growth of NTID's students and the strength of Institute programs.