Development and validation of the Vanderbilt Fatigue Scale for Adults (VFS-A)

Relations Among Multiple Dimensions of Self-Reported Listening Effort in Response to an Auditory Psychomotor Vigilance Task

PURPOSE

Listening effort is a broad construct, and there is no consensus on how to subdivide listening effort into dimensions. This project focuses on the subjective experience of effortful listening and tests if cognitive workload, mental fatigue, and mood are interrelated dimensions.

METHOD

Two online studies tested young adults (n = 74 and n = 195) and measured subjective workload, fatigue (subscales of fatigue and energy), and mood (subscales of positive and negative mood) before and after a challenging listening task. In the listening effort task, participants responded to intermittent 1-kHz target tones in continuous white noise for approximately 12 min.

RESULTS

Correlations and principal component analysis showed that fatigue and mood were distinct but interrelated constructs that weakly correlated with workload. Effortful listening provoked increased fatigue and decreased energy and positive mood yet did not influence negative mood or workload.

CONCLUSIONS

The findings suggest that self-reported listening effort has multiple dimensions that can have different responses to the same effortful listening episode. The results can help guide evidence-based development of clinical listening effort tests and may reveal mechanisms for how listening effort relates to quality of life in those with hearing impairment.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26418976.

Listening-Related Fatigue in New and Experienced Adult Cochlear Implant Users

OBJECTIVES

Active listening in everyday settings is challenging and requires substantial mental effort, particularly in noisy settings. In some cases, effortful listening can lead to significant listening-related fatigue and negatively affect quality of life. However, our understanding of factors that affect the severity of fatigue is limited. Hearing aids and cochlear implants (CIs) can improve speech understanding and thus, potentially, reduce listening effort and fatigue. Some research supports this idea for adult hearing aid users with mild-to-moderate hearing loss, but similar work in CI users is very limited. This study examined (1) longitudinal changes in listening-related fatigue in new and established CI users, and (2) relationships between demographic and audiologic factors and preimplantation and postimplantation listening-related fatigue.

DESIGN

Participants included an experimental group of 48 adult CI candidates receiving either a unilateral implant (n = 46) or simultaneous, bilateral implants (n = 2) and a control group of 96 experienced (>12 months experience) adult CI users (50 unilateral, 46 bilateral). Listening-related fatigue was evaluated using the 40-item version of the Vanderbilt Fatigue Scale for Adults. Experimental group ratings were obtained before implantation and again at 0.5-, 1-, 2-, 3-, 6-, and 12-month(s) postactivation. Control group participants completed the scale twice-upon study entry and approximately 3 months later. Additional measures, including a social isolation and disconnectedness questionnaire, hearing handicap inventory, and the Effort Assessment Scale, were also administered at multiple time points. The role of these measures and select demographic and audiologic factors on preimplant and postimplant fatigue ratings were examined.

RESULTS

Adult CI candidates reported significantly more fatigue, greater self-perceived hearing handicap, greater listening effort, and more social isolation than experienced adult CI users. However, significant reductions in fatigue and effort were observed within 2 weeks postimplantation. By 3 months, there were no significant differences in fatigue, effort, hearing handicap, or social isolation between new CI recipients and experienced CI users. Secondary analyses revealed that age at onset of hearing loss (before or after 2 years of age) and subjective hearing handicap contributed significantly to the variance of preimplantation fatigue ratings (those with higher handicap reported higher fatigue). In contrast, variance in postimplantation fatigue ratings was not affected by age of hearing loss onset but was affected by gender (females reported more fatigue than males) and subjective ratings of effort, handicap, and isolation (those reporting more effort, handicap, and isolation reported more fatigue).

CONCLUSIONS

Listening-related fatigue is a significant problem for many CI candidates, as well as for many experienced unilateral and bilateral CI users. Receipt of a CI significantly reduced listening-related fatigue (as well as listening effort, hearing handicap, and social isolation) as soon as 2 weeks post-CI activation. However, the magnitude of fatigue-related issues for both CI candidates and experienced CI users varies widely. Audiologic factors, such as hearing loss severity and aided speech recognition, were not predictive of individual differences in listening-related fatigue. In contrast, strong associations were observed between perceived hearing handicap and listening-related fatigue in all groups suggesting fatigue-related issues may be a component of perceived hearing handicap.

Reliability and Validity of the Turkish Version of the Vanderbilt Fatigue Scale for Adults

PURPOSE

Listening-related fatigue (LRF) is a prominent topic of research interest. The purpose of this study is to investigate the reliability and validity of the Turkish version of the 40-item Vanderbilt Fatigue Scale for Adults (TR-VFS-A-40).

METHOD

This study included 317 adults with no hearing loss and 260 adults with hearing loss in the study group, totaling 577 adults aged 18-75 years. While 31 adults in the study group did not use any hearing technology, there were 96 hearing aid users and 123 cochlear implant (CI) users. A subset of 80 CI users completed the TR-VFS-A-40 a second time, 2 weeks later, to assess test-retest reliability. Intraclass correlation coefficients were used to assess test-retest reliability. Cronbach's alpha was used to evaluate internal consistency. To examine construct validity, a confirmatory factor analysis (CFA) was performed. For concurrent validity analysis, the Checklist Individual Strength (CIS) and TR-VFS-A-40 scores were analyzed using the Spearman correlation test.

RESULTS

Cronbach's alpha values were excellent for the total scale of .987 and the cognitive, emotional, physical, and social subscales (.953, .954, .955, and .946, respectively). Analyses of concurrent validity revealed strong and significant correlations between CIS and TR-VFS-A-40 scores, indicating a good concurrent validity. The CFA determined that the construct validity of the TR-VFS-A-40 was satisfactory.

CONCLUSION

The TR-VFS-A-40 is a valid and reliable measure of LRF.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25457752.

Listening effort and fatigue among cochlear implant users: a scoping review

Introduction

In challenging listening situations, speech perception with a cochlear implant (CI) remains demanding and requires high levels of listening effort, which can lead to increased levels of listening-related fatigue. The body of literature on these topics increases as the number of CI users rises. This scoping review aims to provide an overview of the existing literature on listening effort, fatigue, and listening-related fatigue among CI users and the measurement techniques to evaluate them.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements were used to conduct the scoping review. The search was performed on PubMed, Scopus, and Web of Science to identify all relevant studies.

Results

In total, 24 studies were included and suggests that CI users experience higher levels of listening effort when compared to normal hearing controls using scales, questionnaires and electroencephalogram measurements. However, executing dual-task paradigms did not reveal any difference in listening effort between both groups. Uncertainty exists regarding the difference in listening effort between unilateral, bilateral, and bimodal CI users with bilateral hearing loss due to ambiguous results. Only five studies were eligible for the research on fatigue and listening-related fatigue. Additionally, studies using objective measurement methods were lacking.

Discussion

This scoping review highlights the necessity for additional research on these topics. Moreover, there is a need for guidelines on how listening effort, fatigue, and listening-related fatigue should be measured to allow for study results that are comparable and support optimal rehabilitation strategies.

Mental Fatigue in Patients with Hearing Loss and/or Tinnitus Undergoing Audiological Rehabilitation-A Pilot Study

BACKGROUND

Both tinnitus and hearing loss are multidimensional. The purpose of this study was to identify and determine the degree of mental fatigue in patients with hearing loss and/or tinnitus participating in audiological rehabilitation, and to examine the self-reported mental fatigue scale (MFS) in this patient group.

METHODS

Patients undergoing audiological rehabilitation at the Department of Audiology and Neurotology, Karolinska University Hospital, Sweden, between 2011 and 2017 who completed a self-reported MFS questionnaire were investigated. Data on 76 patients were analysed in this pilot study. Patients were also assessed using the Tinnitus Handicap Inventory (THI).

RESULTS

The study population had an age range of 38-65 years, and most had normal hearing (37%) or mild to moderate hearing loss (46%). Only 17% had severe to profound hearing loss. A total of 56.5% had tinnitus, of whom 39.5% scored ≥57 on the THI, indicating severe tinnitus, whereas 43.5% reported no tinnitus. The MFS scores, ranging from 13 to 42.5 points, were divided into three severity levels for analysis: 10.5-15, 15.5-20, and ≥20.5. In total, 67% of the patients had MFS scores ≥ 20.5. Importantly, most of the participants (90%) with a THI score ≥ 57 belonged to that group. A significant positive correlation between a high MFS score and severe tinnitus was found.

CONCLUSIONS

The study reveals that severe mental fatigue is more common in patients with severe tinnitus than sole hearing loss.

Development and Validation of a Brief Version of the Vanderbilt Fatigue Scale for Adults: The VFS-A-10

OBJECTIVES

Listening-related fatigue can be a significant problem for adults who struggle to hear and understand, particularly adults with hearing loss. However, valid, sensitive, and clinically useful measures for listening-related fatigue do not currently exist. The purpose of this study was to develop and validate a brief clinical tool for measuring listening-related fatigue in adults.

DESIGN

The clinical scale was derived from the 40-item version of the Vanderbilt Fatigue Scale for Adults (VFS-A-40), an existing, reliable, and valid research tool for measuring listening-related fatigue. The study consisted of two phases. Phase 1 ( N = 580) and Phase 2 ( N = 607) participants consisted of convenience samples of adults recruited via online advertisements, clinical records review, and a pool of prior research participants. In Phase 1, results from item response theory (IRT) analyses of VFS-A-40 items were used to identify high-quality items for the brief (10-item) clinical scale: the VFS-A-10. In Phase 2, the characteristics and quality of the VFS-A-10 were evaluated in a separate sample of respondents. Dimensionality was evaluated using exploratory factor analyses (EFAs) and item quality and characteristics were evaluated using IRT. VFS-A-10 reliability and validity were assessed in multiple ways. IRT reliability analysis was used to examine VFS-A-10 measurement fidelity. In addition, test-retest reliability was assessed in a subset of Phase 2 participants ( n = 145) who completed the VFS-A-10 a second time approximately one month after their initial measure (range 5 to 90 days). IRT differential item functioning (DIF) was used to assess item bias across different age, gender, and hearing loss subgroups. Convergent construct validity was evaluated by comparing VFS-A-10 responses to two other generic fatigue scales and a measure of hearing disability. Known-groups validity was assessed by comparing VFS-A-10 scores between adults with and without self-reported hearing loss.

RESULTS

EFA suggested a unidimensional structure for the VFS-A-10. IRT analyses confirmed all test items were high quality. IRT reliability analysis revealed good measurement fidelity over a wide range of fatigue severities. Test-retest reliability was excellent ( rs = 0.88, collapsed across participants). IRT DIF analyses confirmed the VFS-A-10 provided a valid measure of listening-related fatigue regardless of respondent age, gender, or hearing status. An examination of associations between VFS-A-10 scores and generic fatigue/vigor measures revealed only weak-to-moderate correlations (Spearman's correlation coefficient, rs = -0.36 to 0.57). Stronger associations were seen between VFS-A-10 scores and a measure of perceived hearing difficulties ( rs = 0.79 to 0.81) providing evidence of convergent construct validity. In addition, the VFS-A-10 was more sensitive to fatigue associated with self-reported hearing difficulties than generic measures. It was also more sensitive than generic measures to variations in fatigue as a function of degree of hearing impairment.

CONCLUSIONS

These findings suggest that the VFS-A-10 is a reliable, valid, and sensitive tool for measuring listening-related fatigue in adults. Its brevity, high sensitivity, and good reliability make it appropriate for clinical use. The scale will be useful for identifying those most affected by listening-related fatigue and for assessing benefits of interventions designed to reduce its negative effects.

Listening effort and downstream effects due to hearing loss in children and young people: an online quantitative questionnaire-based observational study

INTRODUCTION

The clinical application of listening effort (LE) is challenging due to the lack of consensus regarding measuring the concept. Correlational analysis between different measuring instruments shows conditional and weak relationships, indicating they capture different dimensions of LE. Current research has suggested possible links between LE and downstream consequences such as fatigue, stress and confidence. One way to clinically measure LE would be to focus on its corollaries. Further research is needed to explore whether tools used to measure these downstream effects can be applied to capture LE. This study explores using existing questionnaire-based outcome instruments to evaluate LE and its associated consequences in children and young people (CYP), with and without hearing loss.

METHODS AND ANALYSIS

One hundred CYP aged 12-17 years with normal hearing and a range of hearing loss levels will be invited to complete a series of online questionnaires (Speech, Spatial and Qualities, Vanderbilt Fatigue Scale-Child, Perceived Stress Scale and Rosenberg Self-Esteem Scale) and a hearing test (Digits in Noise). They will complete the questionnaires at two time points (1) at the end of a rest day and (2) at the end of a workday. Standard demographic and hearing health information will be collected. The sample size was determined pragmatically due to a lack of comparable published data to power the study. Tests are exploratory and for generating hypotheses; therefore, the standard criterion of p<0.05 will be used.

ETHICS AND DISSEMINATION

This study has been reviewed within the funding organisation (Cochlear Research and Development Limited) by an independent and relevant peer reviewer/committee. This study has had a favourable ethics committee review by both NHS ethics and University of Manchester ethics. The study will be disseminated through newsletters, publication and presentations at conferences. The results will be made available to participants on request.

Sensory-Processing Sensitivity Predicts Fatigue From Listening, But Not Perceived Effort, in Young and Older Adults

PURPOSE

Listening-related fatigue is a potential negative consequence of challenges experienced during everyday listening and may disproportionately affect older adults. Contrary to expectation, we recently found that increased reports of listening-related fatigue were associated with better performance on a dichotic listening task. However, this link was found only in individuals who reported heightened sensitivity to a variety of physical, social, and emotional stimuli (i.e., increased "sensory-processing sensitivity" [SPS]). This study examined whether perceived effort may underlie the link between performance and fatigue.

METHOD

Two hundred six young adults, aged 18-30 years (Experiment 1), and 122 older adults, aged 60-80 years (Experiment 2), performed a dichotic listening task and were administered a series of questionnaires including the NASA Task Load Index of perceived effort, the Vanderbilt Fatigue Scale (measuring daily life listening-related fatigue), and the Highly Sensitive Person Scale (measuring SPS). Both experiments were completed online.

RESULTS

SPS predicted listening-related fatigue, but perceived effort during the listening task was not associated with SPS or listening-related fatigue in either age group. We were also unable to replicate the interaction between dichotic listening performance and SPS in either group. Exploratory analyses revealed contrasting effects of age; older adults found the dichotic listening task more effortful but indicated lower overall fatigue.

CONCLUSIONS

These findings suggest that SPS is a better predictor of listening-related fatigue than performance or effort ratings on a dichotic listening task. SPS may be an important factor in determining an individual's likelihood of experiencing listening-related fatigue irrespective of hearing or cognitive ability.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21893013.

Exploring the Correlations Between Measures of Listening Effort in Adults and Children: A Systematic Review with Narrative Synthesis

Listening effort (LE) describes the cognitive resources needed to process an auditory message. Our understanding of this notion remains in its infancy, hindering our ability to appreciate how it impacts individuals with hearing impairment effectively. Despite the myriad of proposed measurement tools, a validated method remains elusive. This is complicated by the seeming lack of association between tools demonstrated via correlational analyses. This review aims to systematically review the literature relating to the correlational analyses between different measures of LE. Five databases were used- PubMed, Cochrane, EMBASE, PsychINFO, and CINAHL. The quality of the evidence was assessed using the GRADE criteria and risk of bias with ROBINS-I/GRADE tools. Each statistically significant analysis was classified using an approved system for medical correlations. The final analyses included 48 papers, equating to 274 correlational analyses, of which 99 reached statistical significance (36.1%). Within these results, the most prevalent classifications were poor or fair. Moreover, when moderate or very strong correlations were observed, they tended to be dependent on experimental conditions. The quality of evidence was graded as very low. These results show that measures of LE are poorly correlated and supports the multi-dimensional concept of LE. The lack of association may be explained by considering where each measure operates along the effort perception pathway. Moreover, the fragility of significant correlations to specific conditions further diminishes the hope of finding an all-encompassing tool. Therefore, it may be prudent to focus on capturing the consequences of LE rather than the notion itself.

A Five-Year Update on the Profile of Adults Undergoing Cochlear Implant Evaluation and Surgery-Are We Doing Better?

OBJECTIVE

To characterize the influence of expanding indications on the profile of adults undergoing cochlear implantation (CI) at a high-volume CI center.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

774 adults undergoing CI evaluation from August 2015 to August 2020.

MAIN OUTCOME MEASURES

Demographics; audiometry; speech recognition; speech, spatial, and qualities of hearing scale (SSQ-12).

RESULTS

Of 745 (96.3%) patients qualifying for implantation, 642 (86.6%) pursued surgery. Median age at evaluation was 69 years; 56.3% were men; 88.2% were Caucasian. Median distance to our center was 95 miles. The majority (51.8%) had public insurance (Medicare, Medicaid), followed by private (47.8%) and military (0.4%). Mean PTA, CNC, and AzBio in quiet and noise for the ear to be implanted were 85.2 dB HL, 15.0%, and 19.2% and 3.5%, respectively. Hybrid/EAS criteria were met by 138 (18.5%) CI candidates, and 436 (77.0%) unilateral CI recipients had aidable contralateral hearing for bimodal hearing configurations. Younger age (odds ratio [OR], 0.96; 95% confidence interval, 0.93-0.99) and non-Caucasian race (OR, 6.95; 95% confidence interval, 3.22-14.98) predicted candidacy. Likelihood of surgery increased for Caucasian (OR, 8.08; 95% confidence interval, 4.85-13.47) and married (OR, 2.28; 95% confidence interval, 1.50-3.47) patients and decreased for those with public insurance (OR, 0.45; 95% confidence interval, 0.29-0.69). A lower SSQ-12 score predicted both candidacy and surgery.

CONCLUSION

Despite expansions in criteria, speech understanding remained extremely low at CI evaluation. Younger age and non-Caucasian race predicted candidacy, and Caucasian, married patients with private insurance and lower SSQ scores were more likely to pursue surgery.

Listening Over Time: Single-Trial Tonic and Phasic Oscillatory Alpha-and Theta-Band Indicators of Listening-Related Fatigue

Objectives

Listening effort engages cognitive resources to support speech understanding in adverse listening conditions, and leads to fatigue over the longer term for people with hearing loss. Direct, neural measures of listening-related fatigue have not been developed. Here, event-related or phasic changes in alpha and theta oscillatory power during listening were used as measures of listening effort, and longer-term or tonic changes over the course of the listening task were assessed as measures of listening-related fatigue. In addition, influences of self-reported fatigue and degree of hearing loss on tonic changes in oscillatory power were examined.

Design

Participants were middle-aged adults (age 37–65 years; n = 12) with age-appropriate hearing. Sentences were presented in a background of multi-talker babble at a range of signal-to-noise ratios (SNRs) varying around the 80 percent threshold of individual listeners. Single-trial oscillatory power during both sentence and baseline intervals was analyzed with linear mixed-effect models that included as predictors trial number, SNR, subjective fatigue, and hearing loss.

Results

Alpha and theta power in both sentence presentation and baseline intervals increased as a function of trial, indicating listening-related fatigue. Further, tonic power increases across trials were affected by hearing loss and/or subjective fatigue, particularly in the alpha-band. Phasic changes in alpha and theta power generally tracked with SNR, with decreased alpha power and increased theta power at less favorable SNRs. However, for the alpha-band, the linear effect of SNR emerged only at later trials.

Conclusion

Tonic increases in oscillatory power in alpha- and theta-bands over the course of a listening task may be biomarkers for the development of listening-related fatigue. In addition, alpha-band power as an index of listening-related fatigue may be sensitive to individual differences attributable to level of hearing loss and the subjective experience of listening-related fatigue. Finally, phasic effects of SNR on alpha power emerged only after a period of listening, suggesting that this measure of listening effort could depend on the development of listening-related fatigue.

Development and Evaluation of Pediatric Versions of the Vanderbilt Fatigue Scale for Children With Hearing Loss

PURPOSE

Growing evidence suggests that fatigue associated with listening difficulties is particularly problematic for children with hearing loss (CHL). However, sensitive, reliable, and valid measures of listening-related fatigue do not exist. To address this gap, this article describes the development, psychometric evaluation, and preliminary validation of a suite of scales designed to assess listening-related fatigue in CHL: the pediatric versions of the Vanderbilt Fatigue Scale (VFS-Peds).

METHOD

Test development employed best practices, including operationalizing the construct of listening-related fatigue from the perspective of target respondents (i.e., children, their parents, and teachers). Test items were developed based on input from these groups. Dimensionality was evaluated using exploratory factor analyses (EFAs). Item response theory (IRT) and differential item functioning (DIF) analyses were used to identify high-quality items, which were further evaluated and refined to create the final versions of the VFS-Peds.

RESULTS

The VFS-Peds is appropriate for use with children aged 6-17 years and consists of child self-report (VFS-C), parent proxy-report (VFS-P), and teacher proxy-report (VFS-T) scales. EFA of child self-report and teacher proxy data suggested that listening-related fatigue was unidimensional in nature. In contrast, parent data suggested a multidimensional construct, composed of mental (cognitive, social, and emotional) and physical domains. IRT analyses suggested that items were of good quality, with high information and good discriminability. DIF analyses revealed the scales provided a comparable measure of fatigue regardless of the child's gender, age, or hearing status. Test information was acceptable over a wide range of fatigue severities and all scales yielded acceptable reliability and validity.

CONCLUSIONS

This article describes the development, psychometric evaluation, and validation of the VFS-Peds. Results suggest that the VFS-Peds provide a sensitive, reliable, and valid measure of listening-related fatigue in children that may be appropriate for clinical use. Such scales could be used to identify those children most affected by listening-related fatigue, and given their apparent sensitivity, the scales may also be useful for examining the effectiveness of potential interventions targeting listening-related fatigue in children.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19836154.

Predictors of Listening-Related Fatigue Across the Adult Life Span

Listening-related fatigue is a potentially serious negative consequence of an aging auditory and cognitive system. However, the impact of age on listening-related fatigue and the factors underpinning any such effect remain unexplored. Using data from a large sample of adults (N = 281), we conducted a conditional process analysis to examine potential mediators and moderators of age-related changes in listening-related fatigue. Mediation analyses revealed opposing effects of age on listening-related fatigue: Older adults with greater perceived hearing impairment tended to report increased listening-related fatigue. However, aging was otherwise associated with decreased listening-related fatigue via reductions in both mood disturbance and sensory-processing sensitivity. Results suggested that the effect of auditory attention ability on listening-related fatigue was moderated by sensory-processing sensitivity; for individuals with high sensory-processing sensitivity, better auditory attention ability was associated with increased fatigue. These findings shed light on the perceptual, cognitive, and psychological factors underlying age-related changes in listening-related fatigue.

Hearing Aids Reduce Daily-Life Fatigue and Increase Social Activity: A Longitudinal Study

People with hearing loss experience fatigue, and it is unknown whether this is alleviated by treatment with hearing aids. The objective of this study was to address this issue and to investigate the possible concomitant effect of hearing-aid fitting on activity levels. An intervention group (n = 53) who were due to be fitted with their first-ever hearing aid(s) and a control group (n = 53) who had hearing loss but no change in hearing aid status-completed a battery of self-report outcome measures four times: once before fitting, and at 2 weeks, 3 months, and 6 months post fitting. Self-report outcome measures at each assessment captured fatigue, listening effort, hearing handicap, auditory lifestyle, social participation restrictions, and work, social and physical activity levels. Hearing-aid fitting led to a significant reduction in listening-related fatigue, but not general fatigue, in the intervention group compared to the control group. Additionally, social activity level increased and social participation restriction decreased significantly after hearing aid fitting in the intervention group compared to the control group. No significant interaction was found between working status and change in listening-related fatigue score. This study is the first to make a longitudinal measurement of fatigue before and after first-ever hearing aid fitting and to identify an increase in social activity level after hearing aid fitting. These findings have important implications for future research and the clinical practice of hearing aid fitting.