Notes on Aural Rehabilitation for Older Adults

Overview of Older Adults in Aural Rehabilitation

• This chapter focuses on individuals aged 61 and older, while acknowledging that definitions of "older" vary.
• The aging population is the fastest-growing segment in American society.
  • Approximately 50 million people in the U.S. are over 65 (about 15% of the population).
  • 69 million are over 60, and 14.6 million are over 85 (as of 2017).
  • By 2025, the number of adults over 65 is projected to reach almost 72 million (about 20% of Americans).
• Older individuals are generally healthier, more prosperous, and better educated than previous generations.
  • In 1982, 25% of individuals over 65 had a chronic disability, dropping to less than 20% in 1999.
  • In 2016, only 9% of individuals over 65 lived below the poverty line, compared to 25% in 1968.
  • The over-50 demographic holds 2.4 trillion in annual income in the U.S. (42% of all income after taxes).
  • In 2017, 86% of older persons held a high school diploma, compared to 28% in 1970.
• By 2035, older people are projected to outnumber children in the U.S. for the first time.

Implications for Aural Rehabilitation

• Speech and hearing professionals will likely have larger caseloads of older patients.
• These patients are relatively healthy, educated, and have financial resources.
• Many expect hearing loss not to impede active lives; approximately 36% of younger seniors expect to work beyond 70.
• The older population includes traditional seniors and baby boomers, differing in values and purchasing habits, influencing aural rehabilitation plan design and implementation.

Traditional Seniors

• Known as the "Just Good Enough" generation, may have experienced WWII deprivations.
• They tend to save money, dislike debt, and value trust, service, and quality.
• Some are resistant to technology, price-oriented, and tend to follow medical advice.
• Likely to have age-related health conditions besides hearing loss.

Baby Boomers

• Born between 1946 and 1965 (approximately 78 million).
• Value active, youthful lifestyles; convenience and cosmetics outweigh price when considering hearing aids and aural rehabilitation services.
• Many are technologically savvy and want to control their health care decisions.
  • 82% belong to at least one social media site; Facebook is the most popular.
  • 13% use LinkedIn, similar to adults aged 18-29.
  • 19% more likely to share content than other age groups.
  • Take action based on social media information, seeking more details.
  • Spend more time online than millennials and outspend them by 2:1.
  • Own 40% of Apple products.

Aural Rehabilitation Blueprint

• A model comprising evaluation and intervention stages, with provision for re-evaluation as patients age and circumstances change.

Activity Limitations and Participation Restrictions

• Evaluation includes determining a patient’s activity limitations and participation restrictions.
• Case history questions:
  • Problems due to hearing loss
  • How listening difficulties affect daily life
  • Activities stopped or made more difficult
  • New activities desired
• Information gathered from family members or caregivers regarding memory, emotional state, motivation, and program feasibility.
• Informal assessment of conversational fluency: frequency of communication breakdowns and repair attempts.
• Gather medical data on:
  • Strokes, memory loss, vision problems, dizziness, medications - may affect participation.
  • Arthritis and muscle weakness - may affect device handling.
  • Ambulation, behavioral changes - may affect communication activities.
  • Dementia and Alzheimer’s disease - may require caregiver assistance, necessitating adjustments in audiological assessment.

Audiological Status and Otologic Health

• Audiological testing similar to that for younger adults, potentially including auditory processing measures.
• Evaluation of otologic health includes checking for impacted cerumen and assessing middle ear pressure and tinnitus.

Audiological Testing Adaptations

• Extended instruction time, with re-instruction if needed, especially for patients with dementia.
• During air or bone conduction testing, tone stimuli may need longer presentation durations.
• Speech recognition testing stimuli may need to be presented with a live voice, face-to-face, outside the test booth in order to avoid disembodied, impersonal voice.
• Possible rest periods, or spreading testing over multiple days, to minimize fatigue.

Temporal-Order Discrimination

• Requires patient attention to the order of auditory stimuli.
• Example: identifying the “different” tone burst sequence in a series.

Dichotic-Syllable Identification

• Presenting two consonant-vowel syllables simultaneously, one to each ear, for identification.

Tinnitus and Older Adults

• Incidence: Between 25% and 30%.
• Negative impact on quality of life.

Other Considerations for Testing

• Cerumen removal may be necessary before testing: older adults have a greater likelihood of impacted cerumen and collapsed ear canals than younger adults, either of which might result in artificial air–bone gaps during audiological testing.
• Insert earphones may be required to ensure that a correct audiogram is obtained because of age-related softening of the cartilaginous tissue of the ear canal.
• Audiology assistant or family member may need to stay with the patient in the test booth.

Presbycusis

• Generic term for age-related hearing loss, typically presenting as a high-frequency hearing loss.
• Physiological causes:
  • Neural: Loss of sensory and supporting cells, nerve fibers, and neural tissue.
  • Metabolic/strial: Changes in blood supply to the cochlea.
• Neurological: Hair cell death and/or degeneration of auditory nerve cell bodies (spiral ganglion).
• Metabolic: Thickening of cochlear tissue membranes, causing capillary occlusion and blood supply loss.
• Possible age-related histopathology in the central auditory system (e.g., shrinking cochlear nucleus volume).
• Contributing factors: Noise exposure, disease, ototoxic agents.
• No medical treatments exist to reverse age-related hearing loss other than cochlear implants.
• Hearing loss increases with age, with men experiencing a greater decline than women.
• Decline in speech recognition accompanies presbycusis.
  • Monosyllabic word recognition scores decline by 13% per decade in men and 6% per decade in women (beyond age 60).
  • Speech recognition difficulties are exacerbated in noisy environments.
  • Discourse/lecture comprehension declines.

Central Presbycusis

• 12% of people over 74 years old.
• Hearing loss characterized by normal thresholds (<40 dB HL) and reduced speech discrimination, especially in noise characterized by normal thresholds (<40$$ dB HL) and reduced speech discrimination, especially in noise.
• Due to weakening of the brainstem and temporal cortex and/or global vascular degeneration.
• Older adults with central presbycusis are twice as likely to have mild cognitive impairment (MCI) compared to those with normal hearing or peripheral presbycusis.
• Using hearing aids to treat hearing loss could greatly delay or prevent the onset of cognitive neurodegeneration.

Auditory Processing

• Decreased auditory processing abilities may occur in addition to or in conjunction with sensorineural hearing loss and decreased word recognition.
• Some older persons cannot discriminate two sounds that differ in pitch, intensity, or duration as well as young persons, and this may reflect decreased auditory processing ability.
• Example test batteries: Test of Basic Auditory Capabilities (TBAC) and Tonal and Speech Materials for Auditory Perceptual Assessment.
• Tasks may include listening to a standard stimulus and selecting differing subsequent stimuli or recognizing time-compressed words.
• Speech recognition difficulties may result from peripheral cochlear pathology or age-related changes in the central nervous system.

Age-Related Brain Changes

• Loss of neurons
• Reduction in synaptic connections
• Changes in neurotransmitter systems
• Changes in neural transmission along the auditory pathway
• Changes in cognitive processing (e.g., information processing, labeling, retrieval, storage)
• Decrement in long-term and short-term memory

Life-Situation Factors

• Include family and social contacts, residency and living arrangements, and personal factors like emotional and mental health, temperament, self-sufficiency, independence, and self-concept.

Family and Social Contacts

• The number and frequency of social interactions can influence morbidity, mortality, and physical functioning.
• More social contacts correlate with reduced loneliness and depression and higher quality of life.
• Marriage expands social networks, providing social contact and support and lowers mortality rates.
• Social contacts facilitate community involvement and motivate hearing loss management.
• Lack of communication partners often deters seeking aural rehabilitation services.
• Hearing loss may trigger a negative feedback loop: social withdrawal, miscommunication resulting in perceptions that they have cognitive decline, and decreased contact from family/friends, perceived anger, frustration, apathy, and anxiety.
• Counseling for family and friends can prevent this loop by teaching them communication strategies and ways to support the older person such as helping them handle a hearing aid or assistive device if necessary.

Residency and Living Arrangements

• Most older people live in private residences, but some reside in nursing homes or assistive living facilities.
• Nursing home residents often have multiple health conditions, and their environments are typically noisier, magnifying communication difficulties.

Personal Variables

• Older people with hearing loss may experience isolation, anger, insecurity, loneliness, shame, and embarrassment, leading to lifestyle changes and diminished quality of life.
• Individual psycho-emotional profile influences reaction to hearing loss.

Mental Health

• Older individuals vary widely in mental health, but depression is not uncommon.
• Up to 13% of community-dwelling older adults and up to 45% of those in nursing homes experience depressive symptoms.
• Triggers: Loss of loved ones, change of residence, decreased ability to perform physical activities, retirement, empty-nest syndrome, decline in general health.
• Hearing loss can magnify negative feelings, decreasing the desire to seek hearing health care.
• Age-related hearing loss is associated with elevated levels of distress, depression, somatization, anxiety, and loneliness.
• The Geriatric Depression Scale is one screening tool for depression often used with older patients.

Temperament

• Stable personality traits influence the ability to cope with hearing loss, for example, measured in terms of "The Big Five":
  • Extroversion
  • Openness to Experience
  • Agreeableness
  • Neuroticism
  • Conscientiousness
• Temperament often relates to the impact of hearing loss. For example, a person might routinely be frustrated by minor irritations and therefore more affected by hearing loss than someone who has an easygoing temperament..

Sense of Self-Sufficiency and Independence

• Hearing loss signals increased dependence, potentially requiring reliance on others for managing communication difficulties.

Self-Concept

• Self-concept influences acceptance of aging and hearing loss. Self-concept often does not match other peoples’ perceptions or an audiological report.

Health Variables

• Physical changes: Wrinkled skin, age spots, gray hair, stiff joints, weakened muscles, decreased manual dexterity.
• Physical fitness influences communication interactions and listening device usability.
• Common conditions relevant to hearing loss:
  • Visual impairment
  • Arthritis
  • Dementia

Visual Impairment

• Physical changes: Lens opacity, pupil shrinkage, weakened eye muscles, optic nerve cell decline.
• Results: Reduced visual acuity, constricted visual field, decreased contrast and color sensitivity, poorer accommodation, delayed adaptation, increased sensitivity to glare.
• Visual impairment is vision loss that cannot be corrected through the use of eyeglasses or contact lenses alone.
• Prevalence increases with age. Approximately 1% of people 74 years old and 3% of people aged 85 years and older have blindness in both eyes
• Problems include interference with reading, driving, or watching television, and can restrict a patient’s ability to live independently.
• Screening tests: Snellen Eye Chart and Pelli–Robson Contrast Sensitivity Chart.
• Vision screening questionnaires are also available, including the Functional Vision Screening Questionnaire for Older People and the National Eye Institute (NEI) Visual Functioning Questionnaire–25.

Implications for Aural Rehabilitation

• Audiological testing: Adjust test booth lighting and mark entry steps with contrasting tape; use high-contrast furniture and minimize glare with evenly distributed incandescent light.
• Speechreading: Reduced visual acuity and contrast sensitivity impair visual speech signal utilization.
• Speech perception training: Focus on auditory stimuli awareness and residual hearing use.
• Communication strategies training: Instruction on communication environment enhancement, such as Come closer. repair strategy.
• Communication environment: Optimal lighting is needed in the communication environment to maximize speechreading because bright lights may cause ocular discomfort; Warm (incandescent) lighting is preferable to harsh or "cold" fluorescent lighting.
• Hearing aids and assistive devices: Accommodate patient's inability to manipulate hearing aid controls, see battery polarity, recognize cerumen buildup, or change the battery by using spending time with the patient so that he or she learns to feel the parts of the hearing aid and learns to adjust it by touch.

Arthritis

• Encompasses more than 100 diseases and conditions and entails a painful inflammation of the joints, surrounding tissues, and other connective tissues.
• Arthritis decreases an individual’s ability to perform fine motor activities.
• May impair the use of listening devices: putting the hearing aid on and taking it off, opening the battery compartment and inserting batteries, removing ear wax and performing other cleaning tasks, operating the controls.
• Recommendations will hinge upon a patient’s ability to handle them. In some cases, it might be more appropriate to recommend an assistive device that has large controls and is easy to manipulate than to recommend a hearing aid.

Dementia

• Generic term for conditions causing irreversible cognitive function decline: gradual memory loss, disorientation, decline in the ability to perform everyday tasks, decline in the ability to process and interpret visual images, and loss of language skills.
• Alzheimer’s disease (AD) is a form of dementia.
• Estimated 5 million Americans suffer from AD.
• Screening instruments: Mini-Mental State, Modified Telephone Interview for Cognitive Status (TICS-M), Clock Test, and Saint Louis University Mental Status Examination (SLUMS).

The Effects of Untreated Hearing Loss

• May reduce quality of life and increase chances of cognitive and physical decline.

Quality of Life

• Untreated hearing loss can lead to negative social and emotional consequences, including less effective social functioning, diminished psychological well-being, poor self-esteem, and reduction in quality of life (e.g., Dalton et al., 2003).

Cognitive Decline

• Linked to accelerated cognitive decline in older adults.
• Hearing loss was independently associated with faster cognitive decline and with increased risk for cognitive impairment (Amieva, Ouvard, Giuloli, Meillon, Rullier, & Dartiges, 2015; Thomas, Audvong, Miller, & Gurgel, 2017).

Balance Disorders

• Older adults with hearing loss are more likely to experience balance disorders and to fall when ambulating than those who do not have hearing loss.
• Poorer hearing might lead to a decreased awareness of one’s spatial environment.

Aural Rehabilitation Intervention

• Older patients may spend time in contemplation and preparation stages, as hearing loss typically progresses slowly.

Hearing Aids

• An audiologist might select one that has easily manipulated battery compartments, especially if manual dexterity is problematic for the patient.
• Remote controls are the answer to some dexterity problems, as are hearing aids with rechargeable batteries, so that battery insertion is not an issue.
• Ample time must be devoted to instructing the patient on how to insert and remove the earmold and how to handle the hearing aid.

Cochlear Implants

• Implants lead to improved communication abilities and psychosocial benefits (Medical complications are comparable between older and younger recipients, suggesting that health-related risks are not problematic (Clark et al., 2012).
• Medical complications are comparable between older and younger recipients, suggesting that health-related risks are not problematic

Assistive Devices and Over-the-Counter Hearing Technology

• Viable alternative is to purchase an over-the-counter personal sound amplifier because hearing aids have a high cost and inconvenience.

Other Services

• Patients may participate in group aural rehabilitation programs after receiving a listening aid or even without obtaining one.
• Family members may participate in the aural rehabilitation program and they may learn how to speak with clear speech.

The Frequent Communication Partner’s Journey

• The frequent communication partner is on a journey, and will pass through a parallel series of phases as the patient.
  1. What is going on?—May confuse hearing loss with cognitive impairment; may experience frustration or anger as a result of less social interaction.
  2. Awareness—May recognize changes in family dynamics; may engage in nagging or encouragement.
  3. Persuasion—May help patient become aware of hearing loss; may consider the implications of moving forward.
  4. Validation—May consider attending the audiological examination with the patient; may begin to understand the implications of hearing loss and the commitment necessary to facilitate patient’s journey.
  5. Rehabilitation—May realize that hearing aids make the hearing loss public; may wonder whose loss it is and consider own role in the enablement process.
  6. Maintenance—May experience joy, relief, or disappointment, depending upon the outcome of rehabilitation; may realize that life has changed irrevocably.

Aural Rehabilitation in the Institutional Setting

• These adults often have other conditions besides hearing loss, including cognitive impairment and physical limitations, such as chronic pain, incontinence, and the need for feeding tubes.
• Residents also tend to be older. About 42% of residents are over the age of 85 years (Department of Health and Human Services, 2015).

Problems Associated with Providing Hearing Health Care

• Managing the hearing loss when the patient may also have dementia. Often patients with dementia also have depression, which can decrease motivation to participate in an aural rehabilitation plan.
• Preventing hearing aids from being lost as a patient may place the hearing aid in a bathrobe pocket, and the robe may end up in the laundry before the aid is removed.
• Maintaining the hearing aids (and cochlear implants and other listening devices).
• Involving the staff in the aural rehabilitation plan and providing in-service training as personnel should be aware of the communication difficulties associated with hearing loss.
• Dealing with the high turnover of facility personnel and scheduling is often difficult because staff changes occur about three times during a 24-hour shift, so all workers may not be available at any given time. Material should be presented at a level of difficulty that is appropriate for the audience and done in a way that maintains interest and attention and maintain empathy for the patient.