things we can do to better meet the needs of our hearing impaired patients robert w. sweetow, ph.d....
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Things We Can Do To Better Meet The Needs Of Our Hearing Impaired Patients
Robert W. Sweetow, Ph.D.University of California, San Francisco
The brain must……
• Detect• Discriminate• Localize• Segregate auditory figure from ground• Perceptually learn new as well as familiar auditory
dimensions• Recognize and identify the source
Phillips, 2002
Problems for older listeners• No problem in ideal listening conditions
– Quiet– One talker– Familiar person– Familiar topic, situation– Simple task, focused activity
• Difficulty in non-ideal listening conditions– Noise– Multiple talkers– Strangers– New topic, situation– Complex task, many concurrent activities– Fast pace
Perceptual and cognitive declines (resource limitations) in elderly
• Speed of processing• Working memory• Attentional difficulties (noise,
distraction and executive control)
Wingfield and Tun, 2001- Seminars in Hearing
Threshold elevation can account for nearly all of the changes in speech perception with age (in quiet or in less demanding
listening environments.)
Humes 1996
In complex perceptual tasks, older listeners are more likely to demonstrate supra-threshold deficits in addition to the effects of reduced audibility. It is
less certain exactly what factors contribute to these deficits.
Pichora-Fuller & Souza 2003
Impact of aging on speech perception
• Even in the absence of hearing loss, older subjects require 3-5 dB higher SNR than young listeners (Schneider, Daneman and Murphy, 2005).
• Older subjects with normal hearing perform approximately the same as young hearing impaired subjects (Wingfield and Tun, 2001)
Disadvantage of elderly in SNR for difficult sentence material (PL = Predictability low; PH = Predictability high)
Frisina and Frisina, 1997
Critical Bandwidth increases with Aging(lack of lateral inhibition)
Sommers and Gehr, 1997
Brainstem changes
• In noise, brainstem and midbrain blood flow increases to a greater degree in young listeners than in older listeners
• Gamma aminobutyric (GABA) diminishes in older (animals)
Binaural interference
“Difficulty with bilateral amplificationin some elderly patients might be attributableto “age-related progressive atrophy and/ordemyelination of corpus callosal fibers,resulting in delay or other loss of the efficiencyof interhemispheric transfer of auditoryinformation.”
Chmiel et al (1997)
Age-related Hearing Loss
It is likely that peripheral, age-related changes result in a partial deafferentation of the central auditory processor.
This result in a series of plastic/pathologic compensatory changes including a down-regulation of inhibitory function (Caspary et al., 1990, 2008; Eggermont and Roberts, 2004; Sörös et al.,2009).
The change in inhibitory function, at the level of A1, has anegative impact on the processing of simple and complex stimuli in the elderly.
“Consistent with the decline-compensation hypothesis, we found reduced activation in auditory regions in older compared to younger subjects, while increased activation in frontal and posterior parietal working memory and attention network was found. Increased activation in these frontal and posterior parietal regions were positively correlated with behavioral performance in older subjects, suggesting their compensatory role in aiding older subjects to achieve accurate spoken word processing in noise.”
Wong et al. 2009; Neuropsychologica
Cortical network effects in Aging
Young brain activity is more lateralized
Old brain activity is more distributed
Listening, Comprehending, Communicating
• Stress during auditory processing draws mental resources away from higher levels of processing
• Making listening easier by improving input will have secondary benefits to higher level processing
Possible cognitive factors in aging
Knowledge is preserved and context is helpful
but there are problems with …..
• Slowing• Working memory• Attention (inhibition of distracters)• Less automatic processing• More trouble coordinating sources of information
All are cognitive consequences if sensory (or motor) abilities are reduced.
Hypothetical Interaction
• Poor hearing but good memory = 25% loss• Poor memory but good hearing = 25% loss• Resultant loss could be only 50% but usually is
more because the impaired memory needs full sensory input (hearing) in order to only create a 25% loss and the poor hearing creates a 25% loss only if the memory is good enough to help fill in the gaps
Five Things We Can Do to Better Meet the Hearing Needs of Older People - Overview
• 1) Develop a better clinical testing protocol to define the elderly patient’s global communication needs
• 2) Match technology to the needs (and abilities) of the patient
• 3) Integrate the patient’s social support structure into rehabilitation
• 4) Extend rehabilitation beyond hearing aids • 5) Employ effective methods to enhance compliance
1. Develop a better clinical testing protocol to define the elderly patient’s global communication needs
What constitutes a “typical” hearing aid evaluation?
• Pure tone audio• Monosyllabic speech testing in quiet • Informational counseling • Sometimes…LDLs, MCLs, and RECDs, sentence
recognition in noise• Perhaps other diagnostic tests such as OAEs
Elements of Communication (Kiessling, et al, 2003; Sweetow and Henderson-Sabes, 2004)
Potential impediments to achieving mastery of these elements
• Hearing loss • Neural plasticity and progressive
neurodegeneration• Global cognitive decline• Maladaptive compensatory behaviors• Loss of confidence
Are we really testing communication?
Current speech perception tests….
• Don’t take the contextual nature of conversation into account
• Don’t take the interactive nature of conversation into account
• Don’t allow access to conversational repair strategies that occur in real life
Flynn, 2003
The biggest mistake we currently make may be…
• Making hearing aids the focus of our attention, when the focus should be…
• Enhancing communication
How to do it?
• All patients should be told at the outset of the appointment (even during the scheduling) that they will be receiving:– a communication needs assessment (CNA)
and– an overall individualized communication
enhancement plan that will consist of…• Education and counseling• communication strategies• hearing aids and / or ALDs• individualized auditory training • group therapy
Relevant domains for assessment
• Communication expectations and needs• Sentence recognition in noise• Tolerance of noise• Ability to handle rapid speech• Binaural integration (interference)• Cognitive skills (working memory, speed of processing,
executive function)• Auditory scene analysis• Perceived handicap• Confidence / self-efficacy• Vision• Dexterity
Measures beyond the audiogram that can be used to define residual auditory function.
Objective procedures• QuickSIN• BKB-SIN • Hearing in Noise Test (HINT)• Listening in Spatialized Noise Sentences (LiSN-S) • Acceptable Noise Levels (ANL)• Binaural interference • Dichotic testing• Listening span (Letter Number Sequencing)• TEN• Rapid (compressed) speech test• Speechreading • Dual-tasking
• Need for screening measures
Communication Needs Assessment
Measures beyond the audiogram that can be used to define residual auditory function.
Subjective measures• Hearing Handicap Inventory for the Elderly – Screening HHIE-S• Communication Scale for Older Adults (CSOA)• Communication Confidence Profile or Listening Self Efficacy
Questionnaire• Communication partner subjective scales (SAC and SOAC)
Combined (objective and subjective) methods• Performance Perceptual Test (PPT)
Communication Needs Assessment
Communication Confidence Profile
Please circle the number that corresponds most closely with your response for each answer.
If you wear hearing aids, please answer the way that you hear WITH your hearing aids.
Sweetow, R and Sabes J. Hearing Journal: (2010); 63:12 ;17-18,20,22,24.
1. Are you confident you can understand conversations when you are talking with one or two people in your own home?2. Are you confident in your ability to understand when you are conversing with friends in a noisy environment, like a restaurant?3. In order to hear better, how likely are you to do things like moving closer to the person speaking to you, changing positions, moving to a quieter area, finding better lighting, etc?4. If you are having trouble understanding, how likely are you to ask a person you are speaking with to alter his or her speech by slowing down, repeating, or rephrasing?5. How sure are you that you are able to tell where sounds are coming from (for example, if more than one person is talking, can you identify the location of the person speaking?)6. Are you confident that you are able to follow quickly-paced conversational material?
7. Are you confident that you can focus on a conversation when other
distractions are present?
8. Are you confident that you can understand a person speaking in large
rooms like an auditorium or house of worship?
9. In a quiet room, are you secure in your ability to understand people
with whom you are not familiar?
10. In a noisy environment, are you confident in your ability to
understand people speaking with whom you are not familiar?
11. Are you confident that you can switch your attention back and forth
between different talkers or sounds?
12. If you are having difficulty understanding a person talking, how likely
are you to continue to stay engaged in the conversation?
CCP interpretation
• 50+ = Confident• 40-50 = Cautiously certain• 30-39 = Tentative• Below 29 = Insecure
2. Match technology to the needs (and strengths) of the patient
• Measure state of readiness“How important is it for you to improve your
hearing right now?”• Identify vital factors necessary to achieve success
including dexterity• Don’t oversell; cost of hearing aids• Use appropriate features
– Automatic (not manual telecoil)– Datalogging (allow for nap time)– Avoid multiple programs, including mute
Hearing aid patients by age
0
10
20
30
40
50
60
70
65+ 45-65 30-44 18-29 <18
%
Age (years)
From Strom, Hearing Review, 2001
Requirements for trying amplification
• Problems need to be solved• Emotional needs to be
addressed
Assessing Motivation
• Source : internal vs. external• Level:
handicap perception • desire to rehabilitate
• Don’t fit an unmotivated patient
Tools to get there
• Help patients tell their stories• Clarify the problems• Help patients challenge themselves• Set goals• Develop a plan• Implement the plan• Conduct ongoing evaluations
Egan, 1998
Returns and exchanges average as high as 20% for hearing aids…….Blaming failure on a single factor is too simplistic
Failure is a product of: • inaudibility• poor benefit/cost ratio • unrealistic expectations and inadequate
counseling• neural plasticity • cognitive changes • poor listening habits
What hearing aids don’t do
• resolve impaired frequency resolution • rectify impaired temporal processing • undo maladaptive listening strategies• Provide proper localization cues*• “properly” reverse neural plastic effects• correct for changes in cognitive function• meet “unrealistic” expectations
Probe Microphone Measures
• Still relevant?• Issues with open fit hearing aids• Counseling implications
Do prescriptive formulas work for older people?
• Testing without aid of visual cues• Vision testing
Client Oriented Scale of Improvement COSI
• Self-report questionnaire requiring patient to list 5 listening situations in which help with hearing is required. Post-rehab, the reduction in disability and the resulting ability to communicate in these situations is quantified.
• Takes less than 5 minutes of patient time, 2 minutes professional time for interpretation
Expectations vs. Goals
• Expectations has a product orientation– Patient assumes passive role– Whatever goes wrong is the professional’s
fault• Goals has a rehabilitation orientation
– Patient assumes active role– Patient shares in the process
Characteristics of Amplification Tool COAT
• 9-item measure of non-audiologic information to determine if technology is required.
• Takes 3 minutes of patient time, 2 minutes professional time for interpretation
Characteristics of Amplification Tool
(COAT) Newman and Sandridge
• Assesses – Motivation– Expectations– Preferences– Cosmetics– Cost considerations
http://www.audiologyonline.com/management/uploads/articles/sandridge_COAT.doc
Mini BTE
Look at the pictures of the hearing aids. Please place an X on the picture or pictures of the style you would NOT be willing to use. Your audiologist will discuss with you if your choices are appropriate for you - – given your
hearing loss and physical shape of your ear.
How will your patient (and you) assess outcome?
• Hearing soft sounds• Louder perception• Understanding speech in noise• Listening effort (elevators don’t make travel from
floor 1 to floor 20 more effective, but they do make it easier) !!!!! (Irv Hafter)
• End of day fatigue• Use of new strategies• Quality of life• Benefit or satisfaction• RFC
3. Integrate the patient’s social support structure into rehabilitation
• Identify communication partners and insist on their collaboration (including discussion of communication strategies and home acoustics)
• Senior outreach programs• Group therapy• Recognize need for outside referrals
Perspective of an older adult who lives with hearing loss
• “When you are hard of hearing you struggle to hear;
• When you struggle to hear you get tired;• When you get tired you get frustrated;• When you get frustrated you get bored;• When you get bored you quit.
4. Extend rehabilitation beyond hearing aids
• Group therapy• Individual therapy
Definition of an auditory processing disorder Jerger and Musiek, 2000
• An auditory processing disorder is a deficit in the processing of information in the auditory modality. It may be related to difficulty in listening, speech understanding, language development, and learning. These problems can be exacerbated in unfavorable acoustic environments.
• What does a peripheral disorder do?????
Does peripheral hearing loss lead to central auditory dysfunction
If so, can anything be done to compensate?
So why should AT be expected to produce benefit?
• Acuity and sensitivity are lower level functions• Higher level functions (i.e. speech in noise)
require more complex (hierarchical) processing (such as hemifields and temporal analysis) that may utilize multiple channels of perceptual processing not governed by critical bands
What happened to Aural Rehabilitation?
• declined because outcome measures concentrated on auditory training and speechreading and didn’t consider emotional and psychological by-products
• boring?• too speech pathology like?• too time consuming?• lack of reimbursement
Aural (auditory, audiologic) rehab……
Should NOT be considered an add-on!
Incorporate it at the very beginning
Repair Strategies (synthetic)
• Repeat all or part of message• Rephrase message• Elaborate message• Simplify the message• Indicate the topic of conversation• Confirm the message• Write the message• Fingerspell the message• Nonspecific repairs:
– What? Huh? Pardon?
» Tye-Murray 1998
Group AR
• Active communication education program (Hickson, 2007)
• Learning to Hear Again (Wayner and Abrahamson, 1996).
• Mayo Clinic program (Hawkins, 2004)
LACE (Listening and Communication Enhancement)
• Cognitive– Auditory Working Memory– Speed of Processing
• Degraded and competing speech– Background noise– Compressed speech– Competing speaker
• Context / Linguistics• Interactive communication
All of the above are designed to enhance listening and communication skills and improve confidence levels
Difference in Average S/B Score1st to 4th Quarter
0 10 20 30 40 50 60 70-15
-10
-5
0
5
Subject
(dB
SN
R)
Difference in Average CS Score1st to 4th Quarter
0 10 20 30 40 50 60 70-25
-20
-15
-10
-5
0
5
10
Subject
(dB
SN
R)
Difference in Average TC Score1st to 4th Quarter
0 10 20 30 40 50 60 70-30
-25
-20
-15
-10
-5
0
5
10
Subject
(dB
SN
R)
Difference in Average TW Score1st to 4th Quarter
0 10 20 30 40 50 60 70-2
-1
0
1
2
3
Subject
(dB
SN
R)
Difference in Average TW Score1st to 4th Quarter
0 10 20 30 40 50 60 70
-4
-3
-2
-1
0
1
Subject
(dB
SN
R)
MWDifference in Average MW Score – 1st to 4th quarter
Why do individuals with similar losses differ so much?
• Subtle reorganization could produce diverse presentations by scattering the deficit in neural space
• Individuals’ brains differ (i.e. variations in fissural patterns and propensities for adaptation and recovery)
Why audiologists don’t recommend comprehensive aural rehabilitation
• Belief that hearing aids alone are adequate• Lack of belief in outcome measures• Belief that additional resources (time, money) are
required• Lack of reimbursement • Reluctance to ask patients to spend more time or
money• Inertia• Laziness
The biggest unresolved questions
• Will audiologists recommend it? – Impact on return for credit rate?
• Will patients do it? – Cost of effort– They do for physical therapy
• Why? – MD recommendation– Immediate modeling of therapy after surgery
5. Employ effective methods to enhance compliance
Reasons patients don’t comply
• Denial of the problem • The cost (money, time, risk of failure) of the
treatment • The difficulty of the regimen • The unpleasant outcomes or side-effects of the
treatment • Lack of trust in the professional• Apathy • Previous negative experience
More reasons
• Symptoms improve before treatment is finished
• Life-style changes are too hard to make• Work and family demands interfere with
following the therapy correctly • Patients come to identify the treatment with
their illness
Suggestions
• Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way
• Simplify instructions and treatment regimen as much as possible.
• Have systems in place to generate treatment and appointment reminders
LACE CE and Compliance
In Clinic At Home0
10
20
30
40
50
* Patients training at home maychoose not to upload data
Where Patient Completed Session 1
Perc
en
t o
f p
ati
en
ts u
plo
ad
ing
at
least
10 s
essio
ns
(%)
Thanks for Listening