Things We Can Do To Better Meet The Needs Of Our Hearing Im - PowerPoint Presentation

Slide1

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

Robert W. Sweetow, Ph.D.

University of California, San FranciscoSlide2

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, 2002Slide3

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 paceSlide4

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 HearingSlide5

Threshold elevation can account for nearly all of the changes in speech perception with age (in quiet or in less demanding listening environments.)

Humes 1996Slide6

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 2003Slide7

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)Slide8
Slide9
Slide10
Slide11

Disadvantage of elderly in SNR for difficult sentence material (PL = Predictability low; PH = Predictability high)

Frisina and Frisina, 1997Slide12
Slide13
Slide14

Critical Bandwidth increases with Aging

(lack of lateral inhibition)

Sommers and Gehr, 1997Slide15

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)Slide16

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)Slide17

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 a

negative impact on the processing of simple and complex stimuli in the elderly.Slide18

“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 AgingSlide19

Young brain activity is more lateralized

Old brain activity is more distributedSlide20

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 processingSlide21

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.Slide22

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 gapsSlide23

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 complianceSlide24

1. Develop a better clinical testing protocol to define the elderly patient’s global communication needsSlide25

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 OAEsSlide26
Slide27

Elements of Communication

(Kiessling, et al,

2003; Sweetow and Henderson-Sabes, 2004)Slide28

Potential impediments to achieving mastery of these elements

Hearing loss

Neural plasticity and progressive neurodegeneration

Global cognitive decline

Maladaptive compensatory behaviors

Loss of confidenceSlide29

Are we really testing communication?Slide30

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, 2003Slide31

The biggest mistake we currently make may be…

Making hearing aids the focus of our attention, when the focus should be…

Enhancing communicationSlide32

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 therapySlide33

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

DexteritySlide34

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 AssessmentSlide35

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 AssessmentSlide36

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.Slide37

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?Slide38

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?Slide39

CCP interpretation

50+ = Confident

40-50 = Cautiously certain

30-39 = Tentative

Below 29 = InsecureSlide40

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 muteSlide41

Hearing aid patients by age

%

Age (years)

From Strom, Hearing Review, 2001Slide42

Requirements for trying amplification

Problems need to be solved

Emotional needs to be addressedSlide43

Assessing Motivation

Source : internal vs. external

Level: handicap

perception

desire

to rehabilitate

Don’t fit an unmotivated patientSlide44

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, 1998Slide45

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 habitsSlide46

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” expectationsSlide47

Probe Microphone Measures

Still relevant?

Issues with open fit hearing aids

Counseling implicationsSlide48

Do prescriptive formulas work for older people?

Testing without aid of visual cues

Vision testingSlide49
Slide50
Slide51
Slide52

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 interpretationSlide53

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 processSlide54

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 interpretationSlide55

Characteristics of Amplification Tool

(COAT)

Newman and Sandridge

Assesses

Motivation

Expectations

Preferences

Cosmetics

Cost considerations

http://www.audiologyonline.com/management/uploads/articles/sandridge_COAT.docSlide56

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.

Slide57

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

RFCSlide58

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 Slide59

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.Slide60

4. Extend rehabilitation beyond hearing aids

Group therapy

Individual therapySlide61

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?????Slide62

Does peripheral hearing loss lead to central auditory dysfunction

If so, can anything be done to compensate?Slide63

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 bandsSlide64

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 reimbursementSlide65

Aural (auditory, audiologic) rehab……

Should NOT be considered an add-on!

Incorporate it at the very beginning Slide66

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 1998Slide67

Group AR

Active communication education program

(Hickson, 2007)

Learning to Hear Again

(Wayner and Abrahamson, 1996).

Mayo Clinic program

(Hawkins, 2004)Slide68

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 levelsSlide69

MW

Difference in Average MW Score – 1

st

to 4

th

quarterSlide70

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)Slide71

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

LazinessSlide72

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 Slide73

5. Employ effective methods to enhance complianceSlide74

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

Slide75

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 Slide76

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 remindersSlide77
Slide78

Thanks for Listening