Geriatric Implications in Audiology
In geriatric audiology, it is important to review the implications aging has not just on the auditory and vestibular systems, but rather on the patient as a hole. To understand these implications, psychiatric symptoms and use of amplification as treatment, screening measures audiologists have at their dispense to screen for abnormal psychiatric symptoms as well as real-world consequences from vestibular dysfunction will be discussed.
Audiology in Older Adults
When working with geriatric population, it is important to understand that the patient is not just an ear. Rather, audiologist should consider the implications hearing and balance have on older patients. Anxiety and depression are reported symptoms by the older population, but these symptoms are not normal to aging. Boi and colleagues (2010) examined the use of amplification and its effects on depressive symptoms in the elderly. Boi and colleagues (2010) reported statistically significant improvements in the areas of general health, vitality, social functioning, emotional stability, and mental health with the use of amplification by their elderly subjects over the course of 6 months. Additionally, researchers reported that caregivers in lives of the subjects perceived less stress and burden over the course of the study (Boi et al., 2010). This is important because it demonstrates that hearing loss not only affects the patient, but also others involved in the life of the patient. It is also important to consider that tinnitus is often experienced as result of hearing loss and secondary to this phenomenon, depression and anxiety can often be exacerbated (Davis et al., 2016). Fortunately, ear-level devices such as traditional amplification may serve as tinnitus maskers and may help with the perception of tinnitus in patients. It is important for the audiologist to address patient reported tinnitus as the perceived constant ringing can adversely affect the patient’s quality of life.
Additionally, audiologists may use measures to screen for depressive and anxious symptoms which are frequently reported in older adults. Piker and colleagues (2015) reported that the Dizziness Handicap Inventory (DHI) and the Hospital Anxiety and Depression Scale (HADS) are beneficial as a screening tool for identifying psychiatric symptoms in subjects presenting with dizziness. Similarly, when investigating a veteran population, Hu and colleagues (2015) used the Tinnitus Handicap Inventory (THI) to screen for depressive and anxious symptoms. Researchers concluded that an increased score on the functional subscale was related to depression and anxiety-related symptoms (Hu et al., 2015). Knowing that these tools can be used as psychiatric screeners, audiologists can use these measures in order to make proper referrals to mental health professionals including psychologists and psychiatrists.
Along with hearing loss, older patients have an increased prevalence of other conditions that impact sensory and motor function (Davis et al., 2016). For example, visual changes and hearing impairments occur commonly in as adults age. The most common visual impairments in older adults include cataracts, diabetic retinopathy, glaucoma and macular degeneration (Heine ; Browning, 2002). Additionally, in order to compensate for hearing impairment, patients will typically rely on vision for social and communication cues (Whitson et al., 2018). In addition to these conditions, visual acuity decreases and sensitivity to glare increases as a function of age (Whitson et al., 2018). Because of this, clinically audiologists should create a safe environment for their elder patients including use of ramps and railing as well as consideration when providing materials to patients such as printing on non-glossy paper with larger font. Whitson and colleagues (2018) stated that the use of amplification in older adults is beneficial as it can improve the quality of life, cognition, and depressive symptoms. With the implications of dual-sensory losses in this population, audiologists can promote healthy aging by providing amplification.
It is also important for audiologist to consider facilities that care for older adults such as nursing homes. McCreedy and colleagues (2018) reported that urban nursing homes can be particularly loud especially during dining hours where levels can be up to 90 dB. In order to help lessen the cognitive effort it takes older adults to communicate in compromised listening situations, McCreedy and colleagues (2018) report that behavior and environmental modifications as well as assistive listening devices. Because traditional amplification can be costly, audiologists should consider the use of assistive listen devices (ALDs) in these facilities as they are economic and provide amplification. McCreedy and colleagues (2018) additionally report that ALD improve the quality of life and daily activities of elder patients and improve communication with their physicians and family members. Similarly, when considering palliative care, Smith and colleagues (2015) mentioned the use of the teach-back method with the elder population to ensure effective communication and health literacy. When considering environmental modifications to improve communication, McCreedy and colleagues (2018) and Smith and colleagues (2015) similarly suggested using quiet rooms designed to absorb sound and instruct the communication partner to face the individual with hearing loss to optimize visual cues for that individual. The use of these assistive devices and methods should be considered as they can improve social support and feelings of isolation by this access to communication.
In addition to hearing loss, vestibular implications and aging include postural control and delayed reaction times. Redfern and colleagues (2018) used dynamic posturography to evaluate processing speed and postural control. Researchers noted that a decrease in processing speed may lead to an increase disruption in spatial processing (Redfern et al., 2018). As a result of this study, Redfern and colleagues (2018) noted that older adults exhibited more sway with poorer inhibition when compared to younger test subjects. Not only will this delayed reaction time and decision-making speed affect postural control, but this greatly implicates an older adults’ ability to safely operate machinery including driving abilities. Wei and Agrawal (2017) using data from the National Health and Nutrition Examination Surveys (NHANES) aimed to assess vestibular dysfunction including spatial cognition and perceived driving difficulties amongst elder adults. Researchers stated that due to an impairment affecting visuospatial abilities, older adults are typically involved in motor vehicle accidents (Wei & Agrawal, 2017). By using balance testing, a questionnaire, and visual acuity assessment, researchers found that 9.1% of participants reported difficulty while driving and those with vestibular dysfunction had a 2.16 increased odds chance of experiencing difficulties driving (Wei & Agrawal, 2017). This research is important in that considerations for transportation of the elderly should be made in order to maintain safety for the elderly and other drivers. As a result of these studies, audiologists should be mindful in treating not only hearing loss and vestibular dysfunction in the elder adult, but also consider the implications of dysfunction on every day activities.
The patient I conducted my interview with is my grandfather, Jaime Barceló. He is a 79-year-old Hispanic male and lives in Miami, Florida with his wife. Mr. Barceló has a positive reported history of excessive noise exposure as he frequented shooting ranges in his youth. He also reported excessive noise exposure by nature of his job as his father owned a rum company in Puerto Rico and his office was in the same factory as the rum distillery for nearly 20 years. After moving his family from Puerto Rico to Tampa, Florida. Mr. Barceló owned several Hickory Farms franchises, but reported that this was not nearly as loud as his work environment in Puerto Rico. Mr. Barceló denied any history of early onset hearing loss in his family.
Mr. Barceló reported that he was prompted to visit an audiologist in Tampa because he he felt himself being unable to appreciate music and perceived difficulty and frustration understanding his wife and others in noisy environments. At this time, he was diagnosed with a moderate sensorineural hearing loss bilaterally and was adamant about not pursuing amplification because he felt that he was too young at 40 years old to use these devices. Mr. Barceló credits his wife in being proactive about his hearing health and he purchased his first behind-the-ear (BTE) style hearing aids in 1977. Mr. Barceló recalled that in he was still perceiving difficulty communicating in his work environment especially over the telephone. Over the course of the years, he often found himself using closed captioning for watching television and relied heavily on his wife to help clarify when speaking with others. He recalled feeling like he could not participate in social activities that he and his wife would normally attend such as country club parties and dancing. When I asked him about this feeling, he mentioned that he felt that his was limited to sitting at the tables unable to communicate with his friends because of environmental factors like loud music and poor lighting. I also remember growing up watching my grandfather in these situations and even when I would speak face to face with him, he would often turn to his wife for clarification. He jokingly stated that the reason he spoils his wife is because she has been his interpretor for all these years. When asked about telephone use, Mr. Barceló stated that he has tried his best to avoid talking over the phone unless absolutely necessary because it is too frustrating for him to overcome the lack of clarity and distortion of speech. When asked about his preferred method of communication when being face-to-face with someone with his wife present, he jokingly stated that the computer is his “second wife” in that he uses email to send jokes and cartoons to his friends in Puerto Rico. I asked Mr. Barceló if he uses any assistive technologies at home and he reported that he relies heavily on closed captioning while watching television and recalled having a set of TV Ears for several years. Mr. Barceló also received an amplified telephone through his audiologist, but even with this device, he still relies on his wife to answer the telephone or will let the answering machine record the message if she is not able to reach the telephone.
Mr. Barceló also recalled going through about six pairs of hearing aids up until 2013. At that point Mr. Barceló’s hearing progressed to a severe to profound sensorineural hearing loss bilaterally and his word discrimination was poor. His audiologist recommended that he undergo a cochlear implant evaluation as he was an audiometric candidate in both ears. When I asked what his initial feelings were towards undergoing surgery, he reported that his biggest fear was that he would not be able to recognize his wife’s voice and was afraid she would sound like a robot. Mr. Barceló also stated that he initially was concerned that his pacemaker would interfere with this implant, but stated that the audiologist and neuro-otologist worked well to calm his fears about any complications. When I asked Mr. Barceló what the most frustrating part about the implant evaluation was, he stated that the speech-in-quiet testing and speech-in-noise testing were very discouraging, because of his poor performance but showed him that something needed to change. After the evaluation, he was very motivated to pursue this medical treatment. His wife was also encouraging him to pursue this treatment option because he had spent much of his life using traditional amplification and was constantly relying on her for communication.
In 2013 Mr. Barceló received his Cochlear Nucleus 5 processor and was implanted on his right ear and was using a BTE with a dome on the left ear. He stated that the recovery process was long, but was motivated to challenge himself to use the implanted ear as often as he could. He recalled hearing a lot of noise during the first week or so after initial activation. After several months and appointments with his implant audiologist, Mr. Barceló said that he was able to understand speech better even though he stated that every person he spoke with sounded like “Charlie Brown’s teacher.” He also reported that after implantation he would not use a landline telephone unless it was necessary. When I asked him about how he would describe his experience listening to music after implantation, Mr. Barceló reported great disappointment that he was unable to enjoy it equally. In social situations, Mr. Barceló reported that his able to communicate with others without heavily relying on his wife to serve as a translator, but would like to have her close by at all social occasions. Mr. Barceló also jokingly said that his processor needs an English to Spanish translator because its easier for him to understand Spanish speakers.
In October 2018, Mr. Barceló was able to upgrade his processor to the Cochlear Nucleus 7 system because it had been five years since his original implant surgery. The audiologist advised Mr. Barceló that although he qualified to receive an implant for his left ear it would be his decision. When asked about why he chose to continue with traditional amplification for his left ear, he stated that his biggest fear with surgery is that he would be unable to appreciate the tone of his wife’s voice. Additionally, Mr. Barceló was able to order a Cochlear Wireless Mini Mic 2 and Aqua+ with his upgrade. He reported that he was impressed by the Mini Mic 2 and the quality of the signal he was receiving, but he has only used this device with his wife as the user. Mr. Barceló expressed that he is looking forward to using the Aqua+ accessories and enjoy the beach and water activities with his family. With the new sound processor, Mr. Barceló reported that he has noticed an improvement in speech perception and is open to using his iPhone as a mode of communication as he is able to stream telephone calls to his processor. He still is upset that he cannot appreciate music as he used to, but that is something that he has slowly accepted may never be possible. Mr. Barceló admitted that when looking back from the 1970s to now, amplification technology has had great strides and he would not change the steps he made in treating his hearing loss.
Practice of Audiology with Older Adults
In working with older adults clinically, I have found this population to be quite pleasant to interact with whether it is while performing audiological evaluations, hearing aid consultations and fittings and counseling. As I have had several pediatric rotations, I am used to my patient’s throwing tantrums during audiological testing and luckily, I have yet to have a geriatric patient do so. I enjoy working with this population because they are usually thankful just to have an extra set of ears to listen to them. For example, an elderly woman came into a hearing aid check appointment and after I asked if she has been having any issues with the aids, she responded by saying they were perfect, but rather her husband has been giving her trouble. I realized that not only do audiologist have to wear the hat of hearing professionals, but may also need to step in the role of counselor. Knowing what I have learned this semester, I will be mindful when administering questionnaires and inventories to screen for psychiatric symptoms because even though it is not in within the scope of practice for audiologist to diagnose these conditions, it is my job to be aware of my patient and make appropriate referrals to health professionals.
I have also found it interesting sometimes I need to rephrase my instructions and modify my diagnostic techniques, as I do with my pediatric patients, to the older adults that may have other cognitive issues. For example, a patient I saw was wheelchair-bound and was falling asleep during testing and I had to consistently remind her of the task I needed her to complete. This patient made me think about how important it is to schedule appointments when the patient is fully aware of their environment regardless of their comorbidities. I also observed a Lyric patient with dementia who was accompanied by her husband. The audiologist who was fitting the device was a great example of how much patience and understanding it requires when working with these types of patients. The audiologist would constantly remind the patient of what she was doing, why she needed the devices and most importantly not move during insertion of the devices. I enjoy watching the interactions of the older adults and their nurse aides, but have also noticed the importance of instruction patients on proper use and care of their devices so they can be somewhat independent. I have also noticed how some older patients are very stubborn in trying amplification to manage their hearing loss and even when their children essentially beg them to give hearing aids a try. For example, a 93-year-old woman was very hesitant to purchase hearing aids because she could not see the value in investing in hearing aids at this old of an age. The patient’s children were aggressive in trying to convince their mother to make a purchase, but the patient refused. Ultimately, we asked the children I they could exit from the consultation room so that we could discuss the patient’s options in order to make an educated decision about her hearing health.
For the future, when I work in treating older patients, I will keep in mind that just as in the pediatric population, I may need to modify my techniques. I also need to be aware of situations where the use of assistive devices such as Pocket Talkers may be of use in order to allow for effective communication between my patient and their families and healthcare providers. Knowing the changes that occur with the body due to the gaing process, I will be considerate of how I can help my patients whether it be through larger print materials or suggesting the use of ramps and handrails in the clinic if necessary. I also want to make sure that my geriatric patients are independent, within reason, in caring for their devices and knowing when they are defective instead of relying on nurse aides or family members. I also will be sure to be considerate of other comorbidities my patient may be experiencing and strive to focus on my patient as a person, not just an ear.