Rehabilitation Assessment: Audiologic Findings Over a 3-Year Period.

People are living longer lives due to advances in medicine, science, and technology. In the past two decades, the population of those people less than 65 years of age grew 19% while the population of those greater than 65 years rose by 56% (Weinstein & Clark, 1989). By the year 2000, people over 65 will constitute 13% of the U.S. population (Weinstein & Clark, 1994). As a result of increased longevity, hearing loss has become more prevalent (O'Rourke, Britten, Gatschet, & Krien, 1993), as there is a direct correlation between age and hearing loss.

Given that a significant percentage of older Americans have hearing loss and that the number of older Americans is increasing, it is clear that hearing health care is important to this segment of society. The provision of hearing health care is particularly important in those areas of medicine that serve the older population, where hearing loss is known to be one of the most prevalent chronic physical disabilities. Rehabilitation medicine is one such area. Unfortunately, many health-care practitioners, including physicians, view hearing impairment as a rather benign problem, viewing it as a non-threat to physical, emotional, or social function (Lavizzo-Mourey & Siegler, 1992). On the contrary, however, hearing loss has been found to impair emotional well-being, social interaction, cognitive assessment, and perceived well-being of affected individuals (Mulrow, 1991; Voeks, Gallagher, & Langer, 1990). It has also been associated with the functional problems of poor general health and reduced mobility (Weinstein & Ventry, 1982). In the health-care setting, people with hearing loss who pretend to understand what is said to them creates a potentially dangerous situation, as case histories and explanations regarding illness, medications, and therapy all rely on verbal interaction (O'Rourk e. al., 1993). Specific to the rehab setting, hearing acuity will have an impact as to how well the individual manages the many types of therapy in which they are involved. Hearing loss is not easily detected by informal assessment alone, and undiagnosed hearing loss can lead to poor communication between the affected person, staff, and significant others. Hearing loss is measurable, treatable, and manageable as long as there are appropriate audiological test protocols in place. Since many people involved in an intensive rehabilitation program are older, it is expected that there would be a need for aural rehabilitation--not only to improve the quality of patient care in the hospital, but more importantly, to improve the quality of life after hospital discharge (Dalzell & Puccia, 1983). While professionals seek to rehabilitate the individual following illness or injury, it is vital that the rehabilitation program is inclusive to incorporate audiological testing and aural rehabilitation into the program. Afterall, how can valid test results be obtained from individuals when they have not correctly heard what was asked of them? How can people fully benefit from any type of rehabilitation when they do not hear well enough to understand, exactly, what is expected of them? In short, how can people effectively socialize and interact with their peers and professionals when they find it difficult to hear and understand what others are saying?

This study was undertaken to determine the hearing sensitivity of people admitted to a hospital-based rehab program and to determine how many of those people who have hearing loss use hearing aids. Specifically, the purpose of this study was to describe a large sample of people admitted to a hospital-based rehab program in terms of admission diagnosis, hearing loss, use of hearing aids, self-perceived hearing handicap, and amount of hearing loss by age. We hypothesized that the outcome of this study would clearly support the inclusion of audiological evaluations in the multidisciplinary assessment of people admitted to a rehabilitation unit.

Method

Subjects

A total of 390 individuals admitted to the rehabilitation unit of a hospital received audiological evaluations. Fifty-three percent were male (N=207) and 47% were female (N=183). Age ranged from 27-100 years with a mean age of 68 years. All subjects were admitted over a 3-year period.

Procedures

All people admitted to this rehab unit received complete audiological evaluations including air, bone, and speech testing within 7 days of hospital admission. Otoscopic checks were performed to insure that the ear canals were free of excessive or occluding cerumen. These procedures were performed in the hospital audiology department by audiologists who were certified by the American Speech-Language-Hearing Association. Results were then presented to the rehabilitation team at the initial patient case conference.

Prior to audiologic testing, subjects were asked the question "How do you think your hearing is?" The answer to this open-ended question gave the audiologist information as to the person's self-perceived heating difficulty. After audiometric testing, hearing threshold levels were averaged for the speech frequencies of 1, 2, & 3KHz. A better-ear average for these frequencies (Bave123) and a worse-ear average (Wave123) were obtained. These frequencies were chosen and averaged because they are the most important frequencies for understanding speech. Bave123 and Wave123, therefore, were the criterion measures to classify an individual's audiometric hearing loss.

It is important to define the difference between hearing impairment and hearing handicap. Impairment is defined as any loss or abnormality of psychological, physiological, or anatomical structure or function, while handicap is defined as the disadvantage for the individual resulting from an impairment that limits or prevents fulfillment of a role that is considered normal for that individual (American Speech-Language-Hearing Association, 1991). People may have hearing impairment (which is identified by a hearing test), but may not view themselves as hearing handicapped. That is, despite having a hearing loss, they do not perceive that the hearing loss is negatively affecting their everyday communication. This is what makes hearing impairment difficult to identify by any means other than an audiological evaluation. A person who denies hearing difficulty may, in fact, have a significant heating impairment.

Hearing aid candidacy was based on degree of hearing loss, indications of hearing difficulty (i.e., self-perceived hearing handicap), and general clinical impression. People who complained of hearing difficulty were counseled regarding their audiologic findings, listening strategies to improve communication, as well as the advantages and limitations of hearing aid use. With their permission, the family/significant other(s) of those people determined to have significant hearing loss were also ii contacted to discuss the hearing loss, hearing aid candidacy, and procedures to obtain a hearing aid. All hearing aid fittings were performed by the audiologist who evaluated the person. People fit with amplification were seen for regular heating aid checks during a 30-day hearing aid trial period. For individuals admitted to the rehabilitation unit already with hearing aids, hearing aid checks were completed to insure adequate functioning and benefit of the hearing aid(s) and to determine their level of independence with hearing aid operation,

Results

There were 6 primary categories for admitting diagnoses, with cardiovascular accident (CVA) accounting for 66.9% of diagnoses. The other 5 categories were as follow: peripheral vascular disease (13.1%), musculoskeletal abnormalities (6.4%), central nervous system degeneration (5.4%), cardiovascular disease (1.5%), and other (6.7%).

Figures 1 and 2 show the better-ear and worse-ear average audiograms by age group. For ease in interpreting audiograms, the following table shows degree of hearing loss associated with each decibel (dB) level:

Hearing Level (dB)   Degree of Hearing Loss

0 - 20 dB            Normal Hearing
21 - 40 dB           Mild Loss
41 - 70 dB           Moderate Loss
> 70 dB              Severe Loss

[Figures 1-2 ILLUSTRATION OMITTED]

There were 11 subjects in the [is less than] 40 age group, 31 subjects in the 40-49 age group, 35 in the 50-59 group, 107 in the 60-69 group, 134 in the 70-79 group, and 72 in the over 80 age group. Clearly, hearing loss in both the better and poorer-heating ears increases by age. On average, the older subjects had a mild hearing loss in the better ear and a mild to moderate hearing loss in the worse ear. Figure 3 shows the average hearing loss for subjects who complained and subjects who did not complain of hearing difficulty. Non-complainers, in fact, did have less hearing loss than complainers. On average, people who complained of hearing difficulty had a mild to moderate hearing loss in the better ear and a moderate to severe loss in the poorer-hearing (worse) ear.

[Figure 3 ILLUSTRATION OMITTED]

Because older subjects were found to have more hearing loss, the percentage of subjects who were hearing aid candidates was also higher for the older age groups, as shown in Figure 4. Over half of all people age 70 and older were considered to be hearing aid candidates.

[Figure 4 ILLUSTRATION OMITTED]

The summary flow chart in Figure 5 shows the 390 subjects with regard to hearing aid candidacy, complaint of hearing difficulty, and use of amplification. The diagram shows that 132 (34%) of all subjects were considered to be heating aid candidates. It should be noted that of the 132 heating aid candidates, 29 (22%) of them denied hearing difficulty, even though their audiometric test results showed significant heating loss. Interestingly, 6 of those 29 people did ultimately obtain amplification and were hearing aid users upon discharge. For the hearing aid candidates who did complain of hearing difficulty, 73 (65%) were using amplification at discharge.

[Figure 5 ILLUSTRATION OMITTED]

Discussion

Our results support the inclusion of audiological assessment as part of the multidisciplinary assessment of people admitted to a hospital-based rehabilitation program. Findings showed that over half of all heating aid candidates were heating aid users at time of discharge due to audiologic intervention and aural rehabilitation with them and their families. We believe this is an important finding, given the fact that in the general population, most adult heating aid candidates do not obtain hearing aids (Fino, Bess, Lichtenstein, & Logan, 1992; Gordon-Slant, Bialostozky, Lichtenstein, Stach, & Weinstein, 1991; Frank & Beckman, 1985). Afterall, the greatest barrier to effective aural rehabilitation is lack of awareness regarding the hearing loss and ways to manage it (Lavizzo-Mourey & Siegler, 1992).

The most common type of heating impairment in this sample was the mild to moderate hearing loss. This type of hearing loss is very difficult to identify without formal audiological evaluation. That is, a person with mild to moderate heating loss may be able to communicate quite well in a one-to-one situation in a quiet environment, but will most likely experience significant difficulty communicating with others in an environment where there is competing noise such as a TV, other patients/medical staff talking, medical equipment, air conditioners, etc. Often, people with mild to moderate hearing loss deny hearing difficulty altogether. In our subject pool, 22% of subjects with significant hearing impairment denied hearing difficulty. A majority (79%) of these subjects refused to try a heating aid; however, 21% of them did ultimately obtain a hearing aid. Our findings support the fact that people who perceive themselves as hearing handicapped are more likely to accept amplification. However, even some of those subjects who did not perceive themselves as hearing handicapped were open to trying a hearing aid after heating test results were explained and they were counseled regarding the benefits and limitations of hearing aid use. For any person in a rehabilitation program, good communication between the individual, staff, and significant others is essential to maximize the rehabilitation process. It is difficult for a person with handicapping hearing impairment to communicate effectively without using hearing aids and/or utilizing various listening strategies. These techniques to enhance communication are addressed during the diagnostic and audiological rehabilitation sessions with the individual going through the rehab program.

Medical intervention and rehabilitation are making it possible for individuals to live longer and more productive lives. Older consumers of health care will continue to demand a health care philosophy which helps them maximize personal independence, dignity, and their contribution to a satisfactory quality of life (Granger, 1984). Addressing the needs of people who are hearing impaired leads to more effective communication and a better quality of life. For this rehab unit, it is not the purpose of the Audiology program to fit everyone who has hearing loss with hearing aids. Making the person and medical staff aware of the presence of hearing loss and how that loss may best be managed is the primary goal. Only then is it possible for the individual and staff to maximize communication and for that person to make an informed decision regarding their hearing health care. Our results are encouraging because most of our hearing impaired subjects were hearing aid users at discharge. Obtaining a heating aid is certainly a good first step in managing a hearing loss.

In the population specific to rehabilitation, required audiological assessment with follow-up aural rehabilitation greatly increased patient/family/staff awareness of heating loss and its functional impact. The inclusion of audiology services in the multidisciplinary assessment of the person in a rehabilitation program can only translate into an improvement in the care delivered to the individual.

References

American Speech-Language-Hearing Association. (1991). The prevention of communication disorders tutorial. ASHA, 33, (suppl. 6), 15-41.

Dalzell, L.E., & Puccia, D.S. (1983). Hearing loss, hearing handicap, and hearing aid candidacy in geriatrics. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, Cincinnati, November 18-21.

Fino, M.S., Bess, F.H., Lichtenstein, M.J., & Logan, S.A. (1992). Factors differentiating elderly hearing aid wearers vs. non-wearers. Hearing Instruments, 43, 6-10.

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

Gordon-Salant, S., Bialostozky, F., Lichenstein, M., Stach, B., & Weinstein, B. (1991). Task force on hearing impairment in aged people. Audiology Today, 3, 17-20.

Granger, C. (1984). A conceptual framework for functional assessment. In C. Granger & G. Gresham (Eds.), Functional Assessment in Rehabilitation Medicine. Baltimore: Williams & Wilkins.

Lavizzo-Mourey, Risa J., & Siegler, Eugenia L. (1992). Hearing impairment in the elderly. Journal of General Internal Medicine, 7, 191-198.

Mulrow, C.D. (1991). Screening for hearing impairment in the elderly. Hospital Practice, 26, 79-86.

O'Rourke, C., Britten, C., Gatschet, C., & Krien, T. (1993). Effectiveness of a hearing screening protocol for the elderly. Geriatric Nursing, 14, 66-69.

Voeks, S., Gallagher, C., & Langer, E. (1990). Hearing loss in the nursing home. Journal of the American Geriatric Society, 38, 141-145.

Weinstein, B., & Clark, L. (1989). An aging society. ASHA, 31, 67-69.

Weinstein, B., & Clark, L. (1994). The educational imperative. ASHA, 36, 35-36.

Weinstein, B., & Ventry, I.M. (1982). Hearing impairment and social isolation in the elderly. Journal of Speech and Hearing Research, 25, 593-599.

Received: August 1994

Revision: December 1994

Acceptance: December 1994

Teri D. Holt, M.S., University of Rochester Medical Center, Department of Audiology and Speech-Language Pathology, Box 629, 601 Elmwood Avenue, Rochester, NY 14642.