Aural Rehab 2

Q: What is the major goal of AR for adults?

A: To promote conversational fluency with family members, friends, coworkers, and others who matter in the patient's daily life.

Q: Why shouldn't we think of hearing loss as only an “elderly” problem?

A: Hearing loss occurs across the lifespan. Many adults who need and can benefit from AR do not consider themselves elderly. The textbook likewise reports increasing prevalence across adulthood rather than restricting hearing loss to old age.

____ million Americans have hearing loss

50

___% of the global pop. has hearing loss.

20%

Amount w/ hearing loss→ 29-40 y/o

7%

Amount w/ hearing loss→ 41-59 y/o

14%

Q: What factors increase the risk of adult-onset hearing loss?

• occupational/leisure noise exposure

• smoking

• diabetes

• poor cardiovascular health

• obesity

• certain drugs

• alcoholism.

Q: What type of hearing loss is most common among adults with hearing loss?

A: Mild or moderate sensorineural hearing loss.

Q: What frequency pattern is typical?

A: Mid- and high-frequency thresholds are generally poorer than low-frequency thresholds.

AR Plan Should Consider:

Age
Gender
Socioeconomic status
Stage of life
Race, ethnicity, culture
Life factors
Deaf or hard of hearing identity
Social, vocational & home communication difficulties
Psychological well-being
Other hearing-related complaints

Q: What are life stages?

A: Age ranges in which hearing loss may have a different impact.

Q: What are life factors?

A: Conditions that help define someone's life, such as relationships, family, and vocation.

Life Factors Circle Layers (inside to outside)

SELF → HOME (family) → WORK → RECREATION → COMMUNITY

(each divided into

What is the family lifecycle

A: The milestones and emotional/intellectual stages someone passes through as a family member, often described by age, relationship/marital status, and whether/how old their children are.

Home, Social, and Vocational Hearing-Related Communication difficulties + Model

All divided into: communication partners, activities, and sounds within those spaces

It's demonstrating that AR needs should reflect the person's actual communication environments, partners, activities, sounds, and priorities.

Inner ring:

How much time is spent in:

HOME | SOCIAL | VOCATIONAL

Outer ring:

For each setting:

Who do you communicate with?
What do you do?
What sounds matter?

SES can influence whether someone:

• has access to hearing healthcare

• can afford treatment/devices

• has insurance

• can access resources

• understands/navigates health information.

How AR should account for Race, Ethnicity, and Culture

Clock-time

is a type of orientation, driven by the clock and characterized by an adherence to time as a factor in determining the length of an interaction or the time course of an intervention.

(some cultures have this concept of time

Event-time

is an orientation that is process-driven, where issues are pursued to their natural conclusion, no matter how long it takes

Q: Is Deaf cultural membership determined by degree of hearing loss?

A: NO.

It is primarily based on identification with Deaf people/culture, not simply audiometric severity. Two people with identical severe bilateral hearing loss could identify differently and therefore want different services.

Four hallmarks of Deaf culture

1. Shared language — e.g., ASL in the U.S.

2. Behavioral norms

3. Values

4. Traditions

Deaf vs. Hearing Culture

Deaf culture → shared language, beliefs, customs, arts, history, folklore; primarily includes individuals with prelingual hearing loss.

Hearing culture → mainstream culture in which the primary communication mode is spoken language.

Q: What is psychosocial well-being?

A: A person's positive self-image and sense of being an important and integral part of social relationships.

• Because hearing loss directly affects interaction, psychological consequences often connect closely to social consequences.

Self-stigma

Aware of stereotype → Agrees with stereotype → Applies stereotype to self

Example:

“People with hearing loss are old.”
↓
“Yes, that's true.”
↓
“I have hearing loss, therefore I am old.”

Self-stigma can contribute to:

• stress

• shame

• low self-esteem

• degraded self-image

• maladaptive behaviors.

Six Stages to Help-Seeking Journey

PRE-AWARENESS → AWARENESS → MOVEMENT → DIAGNOSIS → REHABILITATION → RESOLUTION

Pre-awareness Stage

The patient doesn't recognize the hearing problem yet.

Awareness Stage

The person begins realizing:

Maybe I have a hearing problem.

Movement Stage

Think:

“I'm going to do something about this.”

The patient begins taking action toward obtaining help.

EX:

Movement → setting up appointment.

Diagnosis Stage

The hearing problem is professionally documented/identified.

Diagnosis → documented problem.

Rehabilitation Stage

The patient begins intervention.

Could involve:

• hearing aids

• auditory training

• communication strategies

• counseling

• other AR services.

Importantly, the stages are not perfectly linear. People may move backward or forward between phases.

Resolution Stage

Also called:

postclinical / adjustment

The patient adjusts to the ramifications of hearing loss and either:

• accepts remaining issues

OR

• returns to rehabilitation because additional/new problems need attention.

⭐ Resolution is NOT permanent.

Someone can think their problems are resolved and later encounter a new problem and return to rehabilitation.

ENTIRE AR Process

Assessment & Planning

Treatment

Rehabilitation

Outcomes assessment

Q: What is a patient-centered orientation?

Care centered on the patient's:

background + current status + needs + wants

AR is designed and delivered accordingly.

Clinical decisions should respect:

patient preferences, needs, and values.

The “meeting of experts”

This is a great exam concept:

Audiologist = expert in audiology
Patient = expert in their own experience of hearing loss

PATIENT-CENTERED vs BIOMEDICAL vs SALES ORIENTATION

Biomedical orientation

Focuses primarily on:

biological disease / organs / hearing mechanisms

Example question:

“When did you first notice your hearing loss?”

Sales orientation

Focuses on:

persuading the patient to obtain services/devices.

Example:

“Have you considered hearing aids?”

Patient-centered orientation ⭐

Focuses on:

the individual and the effect on their life.

Example:

“What are you most concerned about?”

or

“How is your hearing problem disrupting your life?”

Case History

The case history should often feel conversational rather than simply like completing a checklist.

The clinician is essentially learning:

the patient's story.

A good clinician listens carefully and asks questions about real-world difficulties.

Example:

“Tell me more about listening at home.”

This can uncover difficulty with:

• spouse speaking from another room

• running water

• telephone

• doorbell

• workplace communication.

COSI

COSI = Client Oriented Scale of Improvement

Patients nominate up to FIVE situations in which they want to communicate better and rank them by importance.

Why specificity matters

Bad:

“I want to hear better in noise.”

Better:

“I want to hear my friends at Maxwell's on Friday nights after work.”

Specific goals allow clinicians to:

• target intervention

• evaluate improvement

• individualize treatment.

After intervention, patients revisit their goals and rate:

improvement + final communication ability.

Bluffing

pretending to understand when you actually did not hear/understand the message.

**a person may appear to be communicating successfully while actually experiencing substantial communication difficulty.

Patient-centered explanation dos and don’ts

DO:

• keep explanations simple

• involve significant others when appropriate

• write information down

• connect hearing test findings to the person's real-life complaints

• explain what the type of hearing loss means for them.

DON'T:

• overload them with jargon

• assume they understand

• focus only on labels/numbers

• describe audiogram findings without connecting them to everyday experiences.

T/F: A patient’s word-recognition score is NOT their percentage of hearing

T:

ecause word-recognition testing may be presented at an elevated intensity and assesses recognition under specific test conditions.

So:

Degree of hearing loss ≠ percent words correct.

Evidence-based practice in the AR Plan (2 important processes for it)

1. Joint goal setting 2. Shared decision-making

Joint goal setting

A: Clinician + patient (+ often communication partner) form a partnership to identify meaningful goals and desired outcomes.

Shared decision-making

Appreciate/understand the problem → Identify possible options → Consider the options → Patient makes an informed choice

Factors influencing whether someone obtains a hearing aid include:

Subjective factors
→ Do they perceive their hearing as worsening? Do they report difficulty?

Family input
→ Are relatives encouraging or discouraging?

Professional input
→ Recommendations from audiologist/physician/ENT.

Attitudes and values
→ Positive/negative views of hearing aids.

Self-efficacy
→ Does the patient believe they can successfully manage/use the device?

Q: What makes AR for older adults different?

A: Older adults are an extremely heterogeneous population. Two people of the same chronological age can differ dramatically in:

• physical health

• cognitive abilities

• vision

• manual dexterity

• social contacts

• living situation

• emotional health

• independence

• communication needs.

Therefore:

Age alone should NOT determine an AR plan.

Memory loss/dementia may…

affect ability to understand instructions or use hearing aids.

Vision problems may…

→ affect speechreading and ability to manipulate/inspect devices.

Arthritis/muscle weakness may…

→ affect handling hearing aids.

What is presbycusis?

The general/generic term for age-related hearing loss

OLDER → HIGH FREQUENCIES WORSE

Presbycusis commonly presents as high-frequency hearing loss.

Older adults may experience more than peripheral hearing loss.

Some also experience decreased:

auditory processing

• They may have more difficulty distinguishing sounds based on:

  • pitch

  • intensity

  • duration

  • temporal information.

  And listening in noise can be especially difficult.

Hearing loss can cause a ____ involving communication difficulty, withdrawal, emotional distress, and worsening relationships.

negative social feedback loop