Things We Can Do To Better Meet The Needs Of Our Hearing Impaired Patients

1. Things We Can Do To Better Meet The Needs Of Our Hearing Impaired Patients Robert W. Sweetow, Ph.D. University of California, San Francisco

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

11. Disadvantage of elderly in SNR for difficult sentence material (PL = Predictability low; PH = Predictability high) Frisina and Frisina, 1997

14. Critical Bandwidth increases with Aging (lack of lateral inhibition) Sommers and Gehr, 1997

15. 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)

16. Binaural interference “Difficulty with bilateral amplification in some elderly patients might be attributable to “age-related progressive atrophy and/or demyelination of corpus callosal fibers, resulting in delay or other loss of the efficiency of interhemispheric transfer of auditory information.” Chmiel et al (1997)

17. 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.

18. Cortical network effects in Aging “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

19. Young brain activity is more lateralizedOld brain activity is more distributed

20. 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

21. 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.

22. 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

23. 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

24. 1. Develop a better clinical testing protocol to define the elderly patient’s global communication needs

25. 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

27. Elements of Communication (Kiessling, et al,2003; Sweetow and Henderson-Sabes, 2004)

28. Potential impediments to achieving mastery of these elements • Hearing loss • Neural plasticity and progressive neurodegeneration • Global cognitive decline • Maladaptive compensatory behaviors • Loss of confidence

29. Are we really testing communication?

30. 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

31. The biggest mistake we currently make may be… • Making hearing aids the focus of our attention, when the focus should be… • Enhancing communication

32. 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

33. 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

34. Communication Needs Assessment 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

35. 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)

36. Communication Confidence ProfilePlease 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.

37. 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?

38. 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?

39. CCP interpretation • 50+ = Confident • 40-50 = Cautiously certain • 30-39 = Tentative • Below 29 = Insecure

40. 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

41. Hearing aid patients by age % Age (years) From Strom, Hearing Review, 2001

42. Requirements for trying amplification • Problems need to be solved • Emotional needs to be addressed

43. Assessing Motivation • Source : internal vs. external • Level: handicap perception • desire to rehabilitate • Don’t fit an unmotivated patient

44. 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

45. 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

46. 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

47. Probe Microphone Measures • Still relevant? • Issues with open fit hearing aids • Counseling implications

48. Do prescriptive formulas work for older people? • Testing without aid of visual cues • Vision testing