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Meg Wallhagen, PhD, GNP-BC, AGSF, GFSA, FAAN�Director, UCSF Center of Gerontological Nursing Excellence

Member, HLAA-CA Board

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Hearing Loss - Its Effect on the Brain, Cognitive Function and Social Relationships

Objectives

• Review the prevalence of hearing loss across the life span
• Consider the importance of hearing to safety as well as to physical, psychological, and cognitive health
• Review why others often don’t appreciate what it’s like and why this complicates effective communication
• Discuss the impact of hearing loss on an individual, their family & community, and in the healthcare system
• Discuss strategies to promote effective communication in various settings – home, community, healthcare setting

Tinnitus

• Subjective noise: only the person can hear it
• Other types are sometimes described but generally are rare: Objective tinnitus: ; Neurological tinnitus
• Can be described as: ringing, hissing, static, crickets, screeching, whooshing, roaring, pulsing, ocean waves, buzzing, dial tones, even music.
• Associated with HL but can occur before or be the major complaint
• Per Military.com, Tinnitus is the number one disability among Veterans; over 150,000 veterans were diagnosed with tinnitus in 2015 and nearly 1.5 million veterans are currently receiving disability benefits for it.

Hearing

Warning

Connection to our

Environment

Engagement with

Others

Cognitive

Stimulation

Safe Health Care Communication

Prevalence of Hearing Loss (%)

• <50 8.8%
• 50-59 13.3%
• 60-69 26.8%
• 70-79 54.6%
• 80- 81.5%

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Goman & Lin. Prevalence of Hearing Loss by Severity in the United States.

Am J Public Health. 2016; 106:1820–1822. doi:10.2105/AJPH.2016.303299

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Prevalence of Hearing Loss (%)

26.8%

56.8%

81.5%

AGE CATEGORIES

Depression

Isolation

Loneliness

Low self

esteem

Impaired

Relationships

Altered Functional

Status

Altered

Cognition

Hearing & Changes with Age

Hair Cells

9

From: http:// mda06xz.webnode.

com/mechanism-of-transduction/

From: Google search

How We Hear & What Changes with Age

Auditory Cortex Tonal Relationships

X

X

X

X

X

X

X

X

Age Related Hearing loss is not like

wearing ear plugs!

Hearing loss is a distortion & muffling of sound,

NOT just a decrease in sound

Nice Weather Isn‘t It ?

Age Related Hearing loss is not like

wearing ear plugs!

Hearing loss is a distortion of sound,

not just a decrease in sound

Nice Weather Isn’t it?

Words Often Misunderstood/Misheard

Rhyming or similar words are often very difficult to distinguish and can be misinterpreted

• Time - Dime
• Cat - Cap
• Bread - Thread
• Pool – Cool
• Dull Boy – Doughboy

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.

Masks further muffle sounds

Especially Filter hi frequency

3 – 13dB of potential loss

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What’s the Brain Connection?

Some Auditory Connections

www.bluetreepublishing.com

https://medicine.yale.edu/lab/arnsten/research/neuronal/

Hearing Loss and Cognition � Possible Links?

• Social Isolation; Isolation is linked to cognitive decline
• Underlying neurological factor => age related sensory and cognitive changes (The “Common Cause Hypothesis”)
• Decreased brain stimulation/auditory input leading to brain changes (“use it or lose it”; Neurons change if not stimulated)
• Effort needed just to listen challenges other parts of the brain and information received may be distorted – lost/distorted information (The ”Cognitive Load” theory)
• Brain changes with aging impact hearing
• Probably no one cause for the association and there are multiple risk factors for dementia
• We don’t know if hearing aids will delay cognitive decline

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Still – �Many Reasons to Address Hearing Loss

• Makes listening less of an effort
• Relationships
• Staying engaged – socially or in work settings
• It’s a risk factor for falls and for delirium
• You can miss or misinterpret important information
• It may lessen one’s risk for cognitive decline or delay its onset

Return on Investment

The Cost of Misunderstanding

• Once you know he asked me something and I gave him a completely incorrect answer and then he said, smilingly, ‘well you really should have your hearing attended, you know’
• We were talking about an illness to a family member, and all of the time that the woman was talking, she was smiling. And I assumed that this meant the situation was improving and it turned out it was not, so I was making inappropriate response. I don’t think it bothered anyone but me when I finally realized it.

Impact on Perceptions of Others and Relationships

We’d be having these conversations and he would never respond. And that really, at first, I took it personally, like I thought he wasn’t paying attention to me or he wasn’t listening to me, and I was so offended. And then it took me a long time to catch on that he couldn’t hear me.

Perceptions of Others in the Healthcare Setting

• [A] patient can be assumed disoriented if not answering questions correctly. It can be very difficult to assess a patient who cannot hear what you are asking them. (MD)
• Prior to the board (erasable communication board), everyone on the team thought he was demented. He wasn’t. Old, sick, frail yes - demented no. (NP)
• An elderly man whom people assumed had dementia; he did not and felt very belittled. (Chaplain)

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Wallhagen, MI et al. Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners. Journal of Pain and Symptom Management, 2019

Impact of HL on Healthcare Communication and Readmissions

• Medicare Current Beneficiary Survey, a nationally representative rotating panel survey.
• Non-institutionalized individuals aged 65 and older who responded between 2010 and 2013 and had at least one inpatient claim at an acute care hospital
• 11.6% characterized their hearing difficulties as sufficiently severe that they had trouble communicating with their doctor or other medical personnel.
• Those who reported trouble communicating had, on average, 32% greater odds of hospital readmission.

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Chang, JE et al. Hospital Readmission Risk For Patients With Self-reported Hearing Loss And Communication Trouble. Research letter to the editor. JAGS 00:1–2, 2018

Impact of HL on Healthcare Communication and Readmissions

• Qualitative analysis of semi-structured interviews with 100 adults ≥60 found 57 reported some degree of HL; higher rates in adults ≥80; 50% had had audiometric testing; 26% used a HA.
• 43% (n=43) reported having misheard a physician and/or nurse in a primary care or hospital setting.
• Frequency of mishearing did not vary by age group.
• Themes on the clinical context included: general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, and use of language.

Cudmore, V et al. Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting.

JAMA Otolaryngology–Head & Neck Surgery October 2017 Volume 143, Number 10

Impact on Person – Having to Self Advocate Constantly

• Having to prepare in advance – checking labs, having notes and questions ready because there is no “brain power” left after working to hear the discussion.
• Constantly having to tell practitioners and other staff that they have difficulty hearing and then keep reminding.
• Missing their name being called or not hearing the number called when at the lab or elsewhere.

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Communication – A Two Way Street

Speaker

Listener

Interpreter

Speaker

Listener

Interpreter

Communication – A Two Way Street

Speaker

Listener

Interpreter

Speaker

Listener

Interpreter

Fatigue

Distraction

Noise

Emotions

Common Emotions R/T Hearing Loss�Person with HL

• Frustrated & Sad because we can’t hear
• Feeling left out with loss of valued activities
• Sense of Loss
• Decreased Meaningful Conversations
• Fear about potential loss
• Significant relationships or work/job
• Feeling “stigmatized”–internalized/projected
• Fatigue r/t effortfulness of listening

.

Common Emotions R/T Hearing Loss�Communication Partner

• Feeling ignored, especially initially
• Frustration related to -
• Having to repeat & information misunderstood
• Believing/assuming more is heard and understood than is actually heard and understood
• Loss of a valued relationship
• Effortful of remembering to use effective communication strategies
• Tendency to minimize talking

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.

Impact of Hearing Loss�Health Care System

• Misunderstandings instructions
• Not able to have time to share your desires regarding treatment plans
• Practitioners not having the time to do a thorough assessment
• Not hearing your name called

Barriers to Hearing Healthcare

• Under-appreciation of the impact of hearing loss on health related and psychological outcomes,
• Denial, stigma, lack of awareness on the part of both the primary care practitioner and individual with hearing loss,
• Lack of screening for hearing loss in primary care or other health care settings,
• Under-utilization of hearing aids and other assistive listening devices, and
• Cost of hearing related care (lack of Medicare and many other insurances coverage)

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Hearing Healthcare System

35

Consumer/Family

Hearing

Healthcare

Specialist

Primary Care

Provider/ENT

Pre-entry

Entry

HHC

So What Strategies Can We Use To Communicate Effectively?

• With Partners/Spouses/Family

• With Friends and Colleagues

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• At Work

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• In the Health Care Setting

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.

There are things that can help

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Technology

Assistive Listening Devices

Medicare: Determining Coverage� Have to Meet Three Conditions

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• Falls within a defined Medicare benefit category

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• Reasonable and necessary for diagnosis or treatment

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• Not statutorily excluded from coverage

Medicare Exclusionary Clause

• Section 1862(a)(1):  (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services—
• (7) where such expenses are for routine physical checkups, eyeglasses…., hearing aids or examinations therefor, or immunizations (except as otherwise allowed under section 1861(s)(10) and subparagraph (B), (F), (G), (H), or (K) of paragraph (1));

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Strategic Approaches: � Not for want of trying

• Claude Pepper: HR1127: A bill to amend Title XVIII (Medicare) of the Social Security Act to include dental care, eye care, hearing aids, physical checkups and foot care among the items and services for which payment may be made under the supplementary medical insurance program, and to provide safeguards against consumer abuse in the provision of these items and services (1977)
• HR504 (Bilirakus) and S1837 (Brown): Medicare Hearing Enhancement and Auditory Rehabilitation (HEAR): To amend Title VIII of the Social Security Act to cover hearing aids and auditory rehabilitative services (2009)
• No Further Action

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Strategic Approaches: Small steps

• H.R.1646/S.1019�Title: Hearing Aid Assistance Tax Credit Act �Sponsor: Rep McCarthy, Carolyn [NY-4] (introduced 3/19/2009 and referred to House Committee on Ways and Means.
• Amends the Internal Revenue Code to allow a nonrefundable income tax credit of up to $500 for the purchase of a qualified hearing aid for an individual who is either: (1) age 55 or older; or (2) is claimed as a dependent of the taxpayer. Denies such tax credit to any taxpayer whose modified adjusted gross income exceeds $200,000.
• Very small credit given cost of hearing aids and not helpful to those who don’t pay taxes�

Strategic Approaches: Get into the System

• Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA PL 108-173)
• Provides for an initial preventive physical exam (IPPE) with health risk appraisal (“Welcome to Medicare” exam)
• Includes a review of functional ability and safety including hearing
• PPACA: Title IV: Prevention Of Chronic Disease And Improving Public Health, Sec. 4103
• Annual Wellness Visit
• Risk assessment and planning but does specifically address issues like hearing loss
• Welcome exam:
• one time visit, no follow-up, and does not require any specific approach to hearing loss assessment

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Over the Counter Hearing Aids

• Summary: S.670 — 115th Congress Over-the-Counter Hearing Aid Act of 2017 – Warren/Grassley
• Amends the Federal Food, Drug, & Cosmetic Act to require the Food and Drug Administration (FDA) to categorize certain hearing aids as over-the-counter hearing aids and issue regulations regarding those hearing aids.
• **These are for Mild to Moderate HL; Only for Adults
• The regulations must: (1) provide reasonable assurances of safety and efficacy; (2) establish output limits and labeling requirements; and (3) describe requirements for the sale of hearing aids in-person, by mail, or online, without a prescription.
• State and local governments may not establish or continue in effect requirements specifically applicable to hearing products that are not identical to FDA requirements and that restrict or interfere with the servicing or sale of over-the-counter hearing aids.
• The FDA must update and finalize its draft guidance on hearing products. The guidance must clarify which products are medical devices.

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Hearing Aid Costs

• A single unit – average price ranges $1,200 – 3,500
• Usually not paying for the hearing aid but the “bundled service” that comes with it – follow-up, adjustments, # of return visits
• Don’t need the most expensive versions – they keep adding programs and upgrades so last years’ models can be great.
• Efforts to ”unbundle” services to promote transparency
• Always ask questions and shop around

Battery Sizes and Colors

Prices for 60 can range from approximately $15 - 30

Open battery door &

slide battery out

Remove protective

covering

from new battery

Insert new battery with

+ side up

Wait 2 minutes

or more

before closing door

Changing The Battery

How do hearing aids work ? (Simplest)

Microphone

Amplifier

Speaker (receiver)

What can hearing aids do ?

• Make speech easier to hear
• The do not restore normal hearing
• Filter the sounds to “fit” the hearing loss

Low Pitch

Hi Pitch

Soft

Loud

E.g. Bigger boost for high pitched sounds than low pitched sounds when hearing for high pitched sounds is worse

adapted from: http://www.lhh.org/about_hearing_loss/understanding/audiogram.html

Hearing Aid Compatible Cell-Phones

• HAC Rating system: how the wireless handset and hearing aids can work together.
• Microphone mode (M)
• Telecoil or T-coil mode (T)
• Scale of 1-4.
• Higher “M” or “T” ratings are better.
• FCC considers mobile handsets to be HAC for microphone mode if they are rated at least M3 and HAC for telecoil mode if they are rated at least T3.
• Regulations allow individual to test device before purchasing.

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Don’t Lose a HA When Wearing A Mask

Masks with behind the head ties

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Clips to connect hearing aids to one’s glasses

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Strap with “buttons” to tie mask behind one’s head

Cochlear Implants

https://www.hearingloss.org/hearing-help/technology/cochlear-implantable-devices/

• External & internal parts

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• Sound waves enter through the microphone & processor converts sound into a digital code that’s transmitted across the skin to the internal component.

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• Internal component sends sound to the electrodes.

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• Electrodes stimulate the hearing nerve.

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• The hearing nerve sends signals to the brain to process.

Cochlear Implant vs A Hearing Aid

Alternatives to Hearing Aids – Examples: PSAPs

Bose HearPhones

IQbuds² Max

Etymotic Bean

SoundHawk

Personal Sound Amplifiers

NOT advertised for HL – Watch sound output so not too loud

Mild to Moderate Hearing Loss

Coming – Over the Counter Hearing Aids that will be regulated

Personal Amplifiers

Special alarm systems

Assistive Listening Devices

Listening systems

Amplified Phones

TV listening systems

Captioned phones

Voice to Text Apps

CART

• CART = Computer Assisted Realtime Translation
• Transcribing of all audio live, usually onsite
• Helps even people without hearing aids or significant loss

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Telecoils and Induction Loop Systems

From: Hearingloop.org

Neck loop

Underpinning Open Communication

• Awareness of the impact of hearing loss
• Sound simulations on the internet may help
• Emphasize HL is not a decrease in sound but usually a distortion of sound – key frequencies are missing
• Appreciate that HAs and CIs do NOT solve hearing loss; they do NOT correct the underlying problem - they amplify key frequencies so hearing is less effortful.
• Acknowledge the various surrounding factors that can influence one’s ability to hear
• Emphasize the desire to communicate and when you may be too tired to listen well.

Tips to Hear Better

• Stand so person speaking has the light on their face and is not in front of a window or in a shadow
• Ask for a quite area or to have fans and other noisy devices turned off
• Let people know you have difficulty hearing – friends, health care providers, receptionist - everyone
• Read lips – now more difficult with masks
• Consider the context/topic
• Try to be rested when hearing is especially important & ask for things to be in writing
• Use assistive listening devices

What others can do: � Tips to Enhance Hearing

• Face the person with hearing loss and make sure lighting is adequate
• Don’t cover your mouth when talking
• Speak at a normal rate and don’t shout
• Lower your pitch slightly
• If asked to repeat, rephrasing with different words may help
• Avoid critical conversations when you both are tired
• Write down information when it’s important

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Hearing Aids

• Should be comfortable – but…
• They are not like glasses – we can’t put them on and suddenly “hear” - our brains have to re-learn how to listen and hear again
• It takes some time to adapt – wearing them is important - you usually have to return several times to maximize benefit and get them ‘tuned’
• They do not work well in situations with very poor acoustics – have realistic expectation and share this with family
• Make sure all your questions are answered.
• “Purchasing a Hearing Aid” available from the Hearing Loss Association of America
• Use other assistive devices – check if the HA has a telecoil; know you can get a captioned phone; know your ADA rights

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Thank You

Questions