The influence of nonaudiological variables on audiological rehabilitation outcomes

Biopsychosocial Classification of Hearing Health Seeking in Adults Aged Over 50 Years in England

Objectives:

Approximately 10 to 35% of people with a hearing impairment own a hearing aid. The present study aims to identify barriers to obtaining a hearing aid and inform future interventions by examining the biopsychosocial characteristics of adults aged 50+ according to 7 categories: (i) Did not report hearing difficulties, (ii) Reported hearing difficulties, (iii) Told a healthcare professional about experiencing hearing difficulties, (iv) Referred for a hearing assessment, (v) Offered a hearing aid, (vi) Accepted a hearing aid, and (vii) Reported using a hearing aid regularly.

Design:

The research was conducted using the English Longitudinal Study of Aging wave 7 with data obtained from 9666 adults living in England from June 2014 to May 2015. Cross-sectional data were obtained from a subset of 2845 participants aged 50 to 89 years of age with a probable hearing impairment measured by hearing screening (indicating a hearing threshold of >20 dB HL at 1 kHz or >35 dB HL at 3 kHz in the better ear). Classification according to hearing health-seeking category was via participants’ self-report. Participants in each category were compared with people in all subsequent categories to examine the associations between each category and biopsychosocial correlates (sex, age, ethnicity, educational level, wealth, audiometric hearing level, self-reported health status, cognitive performance, attitudes to aging, living alone, and engagement in social activities) using multiple logistic regression.

Results:

The proportions of individuals (N = 2845) in categories i to vii were 40.0% (n = 1139), 14.0% (n = 396), 4.5% (n = 129), 4.0% (n = 114), 1.2% (n = 34), 7.7% (n = 220), and 28.6% (n = 813), respectively. Severity of hearing impairment was the only factor predictive of all the categories of hearing health-seeking that could be modeled. Other correlates predictive of at least one category of hearing health-seeking included sex, age, self-reported heath, participation in social activities, and cognitive function.

Conclusions:

For the first time, it was shown that 40.0% of people with an audiometrically identified probable hearing impairment did not report hearing difficulties. Each of the five categories of hearing health-seeking that could be modeled had different drivers and consequently, interventions likely should vary depending on the category of hearing health-seeking.

The Circle of Care for Older Adults With Hearing Loss and Comorbidities: A Case Study of a Geriatric Audiology Clinic

Purpose Older adults seeking audiologic rehabilitation often present with medical comorbidities, yet these realities of practice are poorly understood. Study aims were to examine (a) the frequency of identification of selected comorbidities in clients of a geriatric audiology clinic, (b) the influence of comorbidities on audiology practice, and (c) the effect of comorbidities on rehabilitation outcomes. Method The records of 135 clients ( M _age = 86 years) were examined. Information about comorbidities came from audiology charts (physical paper files) and hospital electronic health records (EHRs). Data about rehabilitation recommendations and outcomes came from the charts. Focus groups with audiologists probed their views of how comorbidities influenced their practice. Results The frequency of identification was 68% for visual, 50% for cognitive, and 42% for manual dexterity issues; 84% had more than one comorbidity. Also noted were hypertension (43%), falls (33%), diabetes (13%), and depression (16%). Integrating information from the audiology chart and EHR provided a more complete understanding of comorbidities. Information about hearing in the EHR included logs of outpatient audiology visits (75% of 135 cases), audiologists' care notes for inpatients and long-term care residents (25%), and entries by other health professionals (60%). Modifications to audiology practice were common and varied depending on comorbidity. High rates of success were achieved regardless of comorbidities. Conclusions In this clinic, successful outcomes were achieved by modifying audiology practice for clients with comorbidities. Increased interprofessional communication among clinicians in the circle of care could improve care planning and outcomes for older adults with hearing loss.

Hearing loss and quality of life

OBJECTIVE

We sought to identify multidimensional factors associated with health-related quality of life (HRQoL) for use in developing an inventory in which HRQoL is a core concept in evaluating the impact of hearing loss and the efficacy of rehabilitative interventions.

METHOD

A qualitative approach was used in which we posed two major questions to a focus group consisting of eight adults with self-reported, bilateral sensorineural hearing loss of varying degrees. In essence, those questions were: (1) How do you define quality of life?, and (2) Can you describe specific incidents in your everyday life in which your hearing loss has impacted your quality of life? The discussion was embedded within a framework that utilized a modification of the Critical Incident Technique (CIT). We used well-established analytic techniques to translate the data into unitized thought units, which we coded into meaningful categories. Response frequency was used to determine the salience of responses in addressing the research questions.

RESULTS

Participants defined QoL in terms of a number of primary dimensions, most of which were directly or indirectly associated with specific recalled incidents in which those dimensions have played a notable role in contributing to their QoL.

CONCLUSIONS

The use of well-established methods to gather and analyze qualitative data generated by self-report techniques offers a promising direction for developing a standardized inventory for identifying the factors that impact QoL for persons with hearing loss and for evaluating the success of intervention strategies aimed at improving their HRQoL.

Improving Hearing Aid Self-Efficacy and Utility Through Revising a Hearing Aid User Guide: A Pilot Study

PURPOSE

This pilot study aimed to investigate whether revising a hearing aid user guide (HAUG) is associated with improved hearing aid self-efficacy and utility performance.

METHOD

In Part 1, an HAUG was evaluated using the Suitability Assessment of Material (SAM) and readability formulas (Flesch Reading Ease [Flesch, 1943], Flesch-Kincaid Readability Formula [Kincaid, Fishburne, Rogers, & Chissom, 1957], and Simple Measure of Gobbledygook [McLaughlin, 1969]). The HAUG was revised using results from the SAM and best practice guidelines. The revision included generating a video. In Part 2, 30 adults with hearing impairment were randomly assigned to use either the original guide (N = 15) or the revised guide and video (N = 15) to perform a utility task. Participants' self-efficacy was measured using the Basic and Advanced Handling subscales of the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids questionnaire. SAM and readability were compared between the original and revised guides (Doak, Doak, & Root, 1996).

RESULTS

SAM and readability were improved following the revision. Participants in the revised guide group performed significantly better on the utility task and on the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids subscales than participants in the original guide group.

CONCLUSIONS

These results are encouraging as they indicate that there is scope to influence self-efficacy and utility performance through the use of appropriate HAUGs.

Hearing loss and disability exit: Measurement issues and coping strategies

Hearing loss is one of the most common conditions related to aging, and previous descriptive evidence links it to early exit from the labor market. These studies are usually based on self-reported hearing difficulties, which are potentially endogenous to labor supply. We use unique representative data collected in the spring of 2005 through in-home interviews. The data contains self-reported functional and clinically-measured hearing ability for a representative sample of the Danish population aged 50-64. We estimate the causal effect of hearing loss on early retirement via disability benefits, taking into account the endogeneity of functional hearing. Our identification strategy involves the simultaneous estimation of labor supply, functional hearing, and coping strategies (i.e. accessing assistive devices at work or informing one's employer about the problem). We use hearing aids as an instrument for functional hearing. Our main empirical findings are that endogeneity bias is more severe for men than women and that functional hearing problems significantly increase the likelihood of receiving disability benefits for both men and women. However, relative to the baseline the effect is larger for men (47% vs. 20%, respectively). Availability of assistive devices in the workplace decreases the likelihood of receiving disability benefits, whereas informing an employer about hearing problems increases this likelihood.

Racial/Ethnic and Socioeconomic Disparities in Hearing Health Care Among Older Americans

OBJECTIVE

Hearing impairment is highly prevalent, but little is known about hearing health care among older minority adults.

METHOD

We analyzed nationally representative, cross-sectional data from 1,544 older adults ≥ 70 years with audiometry and hearing care data from the 2005-2006 and 2009-2010 National Health and Nutritional Examination Surveys.

RESULTS

After adjusting for age and speech frequency pure tone average, Blacks (odds ratio [OR] = 1.68, vs. Whites) and those with greater education (OR = 1.63, ≥ college vs. < high school) were more likely to report recent hearing testing, while White older adults and those with greater socioeconomic status were more likely to report regular hearing aid use (all ps < .05). Based on a multivariate analysis, Blacks were not more likely than Whites to use hearing aids despite being more likely to have had recent hearing testing.

DISCUSSION

Racial/ethnic and socioeconomic disparities exist in hearing health care and represent critical areas for research and intervention.

Exploring the Relationship Between Hearing Aid Self-Efficacy and Hearing Aid Management

Hearing loss is a highly prevalent condition affecting a significant portion of the adult population. Hearing aids are an effective and common rehabilitation strategy for individuals with hearing loss. A wide range of factors, however, can hamper and even preclude successful hearing aid use. Self-efficacy, a concept that reflects perceptions of one's ability to perform particular tasks or behaviors, has been shown to be an important factor in the successful management of chronic illness including conditions such as diabetes, cardiovascular disease, as well as arthritis and other sources of chronic pain. Improving or strengthening patients' self-efficacy beliefs can improve health outcomes. The role of self-efficacy in the management of hearing loss and hearing aids is still being explored; hence, the extent to which, and the ways in which, self-efficacy may be related to audiologic outcomes remains largely unexplained. The purpose of this article is to examine emerging evidence regarding the relationship between perceived self-efficacy and rehabilitation outcomes among adult hearing aid users and to discuss an apparent discrepancy between patients' reported self-efficacy and their demonstrated skill in managing hearing aids.

Feasibility of ecological momentary assessment of hearing difficulties encountered by hearing aid users

OBJECTIVES

Measurement of outcomes has become increasingly important to assess the benefit of audiologic rehabilitation, including hearing aids, in adults. Data from questionnaires, however, are based on retrospective recall of events and experiences, and often can be inaccurate. Questionnaires also do not capture the daily variation that typically occurs in relevant events and experiences. Clinical researchers in a variety of fields have turned to a methodology known as ecological momentary assessment (EMA) to assess quotidian experiences associated with health problems. The objective of this study was to determine the feasibility of using EMA to obtain real-time responses from hearing aid users describing their experiences with challenging hearing situations.

DESIGN

This study required three phases: (1) develop EMA methodology to assess hearing difficulties experienced by hearing aid users; (2) make use of focus groups to refine the methodology; and (3) test the methodology with 24 hearing aid users. Phase 3 participants carried a personal digital assistant 12 hr per day for 2 weeks. The personal digital assistant alerted participants to respond to questions four times a day. Each assessment started with a question to determine whether a hearing problem was experienced since the last alert. If "yes," then up to 23 questions (depending on contingent response branching) obtained details about the situation. If "no," then up to 11 questions obtained information that would help to explain why hearing was not a problem. Each participant completed the Hearing Handicap Inventory for the Elderly (HHIE) both before and after the 2-week EMA testing period to evaluate for "reactivity" (exacerbation of self-perceived hearing problems that could result from the repeated assessments).

RESULTS

Participants responded to the alerts with a 77% compliance rate, providing a total of 991 completed momentary assessments (mean = 43.1 per participant). A substantial amount of data were obtained with the methodology. It is important to note that participants reported a "hearing problem situation since the last alert" 37.6% of the time (372 responses). The most common problem situation involved "face-to-face conversation" (53.8% of the time). The next most common problem situation was "telephone conversation" (17.2%) followed by "TV, radio, iPod, etc." (15.3%), "environmental sounds" (9.7%), and "movies, lecture, etc." (4.0%). Comparison of pre- and post-EMA mean HHIE scores revealed no significant difference (p > 0.05), indicating that reactivity did not occur for this group. It should be noted, however, that 37.5% of participants reported a greater sense of awareness regarding their hearing loss and use of hearing aids.

CONCLUSIONS

Results showed participants were compliant, gave positive feedback, and did not demonstrate reactivity based on pre- and post-HHIE scores. We conclude that EMA methodology is feasible with patients who use hearing aids and could potentially inform hearing healthcare (HHC) services. The next step is to develop and evaluate EMA protocols that provide detailed daily patient information to audiologists at each stage of HHC. The advantages of such an approach would be to obtain real-life outcome measures, and to determine within- and between-day variability in outcomes and associated factors. Such information at present is not available from patients who seek and use HHC services.

Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: a review of the literature

OBJECTIVES

This descriptive summary of the literature provides an overview of the available studies (published between January 1980 and January 2009) on correlates of help-seeking behavior for hearing loss, hearing-aid uptake, hearing-aid use, and satisfaction with the device.

METHODS

Publications were identified by structured searches in Pubmed and Cinahl and by inspecting the reference lists of relevant articles. The articles covered different stages that a person with hearing impairment may go through: prior to hearing aid fitting, the period covering the fitting and the period post hearing aid fitting. Inclusion of articles occurred according to strict inclusion and exclusion criteria. Data were extracted by two independent researchers. Thirty-nine papers were included that identified 31 factors examined in relation to the four outcome measures. These covered personal factors (e.g., source of motivation, expectation, attitude), demographic factors (e.g., age, gender) and external factors (e.g., cost, counseling). Only two studies covered the actual fitting process. There was only one factor positively affecting all four outcome variables. This was self-reported hearing disability. The vast majority of studies showed no relationship of age and gender with any of the outcome domains.

DISCUSSION AND CONCLUSION

Whereas research of the last 28 years yielded valuable information regarding relevant and irrelevant factors in hearing aid health care, there are still many relevant issues that have never been investigated in controlled studies. These are discussed.

Electrophysiological correlates of listening effort: neurodynamical modeling and measurement

An increased listing effort represents a major problem in humans with hearing impairment. Neurodiagnostic methods for an objective listening effort estimation might support hearing instrument fitting procedures. However the cognitive neurodynamics of listening effort is far from being understood and its neural correlates have not been identified yet. In this paper we analyze the cognitive neurodynamics of listening effort by using methods of forward neurophysical modeling and time-scale electroencephalographic neurodiagnostics. In particular, we present a forward neurophysical model for auditory late responses (ALRs) as large-scale listening effort correlates. Here endogenously driven top-down projections related to listening effort are mapped to corticothalamic feedback pathways which were analyzed for the selective attention neurodynamics before. We show that this model represents well the time-scale phase stability analysis of experimental electroencephalographic data from auditory discrimination paradigms. It is concluded that the proposed neurophysical and neuropsychological framework is appropriate for the analysis of listening effort and might help to develop objective electroencephalographic methods for its estimation in future.

On the cognitive neurodynamics of listening effort: a phase clustering analysis of large-scale neural correlates

An increased listening effort represents a major problem in humans with hearing impairment. Neurodiagnostic methods for an objective listening effort estimation could revolutionize auditory rehabilitation. However the cognitive neurodynamics of listening effort is not understood and research related its neural correlates is still in its infancy. In this paper we present a phase clustering analysis of large-scale listening effort correlates in auditory late responses (ALRs). For this we apply the complex wavelet transform as well as tight Gabor Frame (TGF) operators. We show (a) that phase clustering on the unit circle can separate ALR data from auditory paradigms which require a graduated effort for their solution; (b) the application of TGFs for an inverse artificial phase stabilization at the alpha/theta-border enlarges the endogenously driven listening effort correlates in the reconstructed time- domain waveforms. It is concluded that listening effort correlates can be extracted from ALR sequences using an instantaneous phase clustering analysis, at least by means of the applied experimental pure tone paradigm.

Formal auditory training in elderly hearing aid users

It is of paramount importance to install hearing rehabilitation programs for the elderly. Aim: to check the efficacy of a forma auditory training program for elderly patients fitted with hearing aids for at least three months, by means of speech recognition tests and self-assessment questionnaires. Methods: longitudinal contemporary cohort study. We selected 13 elderly hearing aid users, using intra-canal hearing aids in both ears, from both genders, with average age of 65.3 years. This group was randomly divided in Experiment Group and Control Group. The Experiment Group underwent seven formal auditory training sessions, aiming at stimulating their hearing skills for hearing closing, memory, attention, background figure and binaural integration. The participants were assessed by three behavioral tests and one self assessment questionnaire. Results: The elderly from the Experiment Group had significantly better performance in the assessments after auditory training in comparison to the Control Group. Conclusion: the formal auditory training program in a soundproof booth, associated with the use of hearing aids, improves speech recognition performance and reduces the perception of auditory handicap for the elderly who use intra-canal hearing aids.

Objective estimation of the listening effort: towards a neuropsychological and neurophysical model

Modern hearing aid fitting could be revolutionized by the availability of objective methods for the listening effort estimation. However experimental and theoretical research dealing with this subject is still in its infancy. In this paper we present first results towards a neuropsychological and neurophysical model for the objective estimation of the listening effort by electroencephalographic data. Our model is based on intended endogenously driven top-down projections represented by corticothalamic feedback dynamics for auditory stream selection and their large-scale correlates in auditory evoked late responses. The predictions of the presented model are compared to experimental data obtained during different auditory tasks which required a graduated effort for their solutions. The experimental data verified the model predictions.It is concluded that the proposed neuropsychological and neurophysical modeling of stream selection provides an appropriate framework for listening effort estimation. The presented preliminary results of an ongoing study are encouraging,however, further focal research is necessary in order to estimate in how far the presented model and future extensions might support modern hearing aid fitting in practice.

Issues associated with the measurement of psychosocial benefits of group audiologic rehabilitation programs

The purpose of this review is to describe the psychosocial effects of hearing loss, review the literature that has attempted to measure the psychosocial benefits of group audiologic rehabilitation programs, and offer suggestions for the design of future studies. The psychosocial aspects of hearing loss are multidimensional and may include the emotional, cognitive, interpersonal, behavioral, and physical responses to hearing loss. As a result of the stigma of hearing loss, individuals may isolate themselves, avoid social interactions, and/or bluff their way through communication breakdowns. Participation in group audiologic rehabilitation programs is a straightforward way to deal with the stigma and the loss of social identity associated with hearing loss, and these groups are an ideal forum for teaching communication strategies. Yet, the literature on the efficacy of group audiologic rehabilitation has produced equivocal results. Several factors may have contributed to the lack of psychosocial benefits reported in the literature, including the theoretical framework upon which the program was designed, the actual class content, the effectiveness of the outcome measures, and the demographic characteristics of the participants in the programs. Future research should determine (1) if the theoretical framework and/or the content covered in group audiologic rehabilitation programs influences the psychosocial outcomes, (2) if instructor training influences psychosocial outcomes, (3) the ideal test battery to assess the psychosocial benefits of group audiologic rehabilitation programs, (4) the participant demographic and personality characteristics that influence psychosocial outcomes, and (5) whether experienced hearing aid users have different hearing-loss related psychosocial needs than new hearing aid users.

Audiologic management of older adults with hearing loss and compromised cognitive/psychoacoustic auditory processing capabilities

The number and proportion of older adults in the United States population is increasing, and more clinical audiologists will be called upon to deliver hearing care to the approximately 35% to 50% of them who experience hearing difficulties. In recent years, the characteristics and sources of receptive communication difficulties in older individuals have been investigated by hearing scientists, cognitive psychologists, and audiologists. It is becoming increasingly apparent that cognitive compromises and psychoacoustic auditory processing disorders associated with aging may contribute to communication difficulties in this population. This paper presents an overview of best practices, based on our current knowledge base, for clinical management of older individuals with limitations in cognitive or psychoacoustic auditory processing capabilities, or both, that accompany aging.

The Application of Self-Efficacy Principles to Audiologic Rehabilitation: A Tutorial

Purpose

The purpose of this tutorial is to provide a comprehensive overview of the self-efficacy framework and its application to audiologic rehabilitation.

Method

A literature review was conducted on self-efficacy and its relevance to successful interventions in several health domains. Specific recommendations were presented for audiologic rehabilitation procedures that will enhance self-efficacy.

Conclusions

As is the case in other health domains, clinical intervention by audiologists will be more effective when incorporating a self-efficacy framework in the audiologic rehabilitation process.

Effects of age on auditory and cognitive processing: implications for hearing aid fitting and audiologic rehabilitation

Recent advances in research and clinical practice concerning aging and auditory communication have been driven by questions about age-related differences in peripheral hearing, central auditory processing, and cognitive processing. A "site-of-lesion'' view based on anatomic levels inspired research to test competing hypotheses about the contributions of changes at these three levels of the nervous system. A "processing'' view based on psychologic functions inspired research to test alternative hypotheses about how lower-level sensory processes and higher-level cognitive processes interact. In the present paper, we suggest that these two views can begin to be unified following the example set by the cognitive neuroscience of aging. The early pioneers of audiology anticipated such a unified view, but today, advances in science and technology make it both possible and necessary. Specifically, we argue that a synthesis of new knowledge concerning the functional neuroscience of auditory cognition is necessary to inform the design and fitting of digital signal processing in "intelligent'' hearing devices, as well as to inform best practices for resituating hearing aid fitting in a broader context of audiologic rehabilitation. Long-standing approaches to rehabilitative audiology should be revitalized to emphasize the important role that training and therapy play in promoting compensatory brain reorganization as older adults acclimatize to new technologies. The purpose of the present paper is to provide an integrated framework for understanding how auditory and cognitive processing interact when older adults listen, comprehend, and communicate in realistic situations, to review relevant models and findings, and to suggest how new knowledge about age-related changes in audition and cognition may influence future developments in hearing aid fitting and audiologic rehabilitation.

The two faces of presbyacusis: hearing impairment and psychosocial consequences

A study of hearing disability and handicap was performed in a sample of elderly persons living in an urban area of Göteborg, Sweden. The aim was to describe the psychosocial consequences of presbyacusis. For this purpose, elderly persons with fairly uncontaminated presbyacusis were chosen. The study group consisted of 154 persons (59 men and 95 women) between the ages of 70 and 91 with a median age of 78 years. The methods used included a self-assessed hearing instrument, pure-tone audiometry, and registration of desired services regarding rehabilitative audiology. The questionnaire included 26 items, 20 of them within four areas: assessment of normality, communication, quality of life and environment/orientation. The results showed that the assessment, whether the hearing was normal or not, was correlated with audiometrically measured hearing. Many of the participants expressed concern that their hearing had deteriorated. Communication situations with background noise were troublesome for many of the participants, but they had only minor problems when performing daily activities like shopping. The quality of life in general was only mildly affected by hearing loss. Items regarding environment and orientation showed varying results. Some everyday aspects of listening were related to hearing ability, but directional hearing was not correlated with measured hearing. In spite of the participants' worry about hearing deterioration, only 8% requested hearing aids as a result of the examination.