Focused Treatment Plan for Older Adults With Impaired Hearing According to the 2000 United States Census survey, there are 35 million Americans over the age of 65, representing the fastest-growing segment of the population. Aging adults often are characterized as suffering poor health, deteriorating cognitive function, and withdrawal from activity. The reality is that most older men and women ... Features
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Features  |   August 01, 2003
Focused Treatment Plan for Older Adults With Impaired Hearing
Author Notes
  • Dean C. Garstecki, is a dually certified research audiologist and professor and chair of communication sciences and disorders at Northwestern University. He has authored more than 70 journal articles and textbook chapters and given over 200 professional presentations on topics in hearing loss management in adults and professional ethics.
    Dean C. Garstecki, is a dually certified research audiologist and professor and chair of communication sciences and disorders at Northwestern University. He has authored more than 70 journal articles and textbook chapters and given over 200 professional presentations on topics in hearing loss management in adults and professional ethics.×
  • Susan F. Erler, is adjunct assistant professor of communication sciences and disorders at Northwestern University. Her research interests include factors influencing adjustment to hearing impairment among older adults and gender-specific attitudes related to hearing impairment and amplification. She has authored articles and textbook chapters and given more than 50 professional presentations on topics related to hearing loss management in adults.
    Susan F. Erler, is adjunct assistant professor of communication sciences and disorders at Northwestern University. Her research interests include factors influencing adjustment to hearing impairment among older adults and gender-specific attitudes related to hearing impairment and amplification. She has authored articles and textbook chapters and given more than 50 professional presentations on topics related to hearing loss management in adults.×
Article Information
Hearing Disorders / Special Populations / Older Adults & Aging / Features
Features   |   August 01, 2003
Focused Treatment Plan for Older Adults With Impaired Hearing
The ASHA Leader, August 2003, Vol. 8, 4-20. doi:10.1044/leader.FTR1.08142003.4
The ASHA Leader, August 2003, Vol. 8, 4-20. doi:10.1044/leader.FTR1.08142003.4
According to the 2000 United States Census survey, there are 35 million Americans over the age of 65, representing the fastest-growing segment of the population. Aging adults often are characterized as suffering poor health, deteriorating cognitive function, and withdrawal from activity. The reality is that most older men and women defy such myths, leading active lives that demand effective communication.
Unfortunately, hearing loss is common among these adults, affecting 25% of those 65–74 years and 40% of those 75 years and older. Degenerative changes in the cochlea result in presbycusis, which is manifested by bilateral, sensorineural, high-frequency hearing loss, accompanied by declining ability to understand speech. Hearing impairment threatens interactions with others. Perhaps of greater concern are the effects of hearing impairment on personal independence, safety, and medical care. In all, hearing loss has the potential to diminish quality of life.
Aural rehabilitation typically has focused on the selection and fitting of hearing aids. In addition to reducing communication problems, hearing aid use may have a positive effect on psychosocial well-being and quality of life. Despite such advantages, adherence to treatment regimens is limited, with nearly 80% of hearing aid candidates choosing not to follow recommendations to use amplification.
Psychosocial factors affect adaptation to hearing loss and, ultimately, quality of life. Results of recent investigations underscore the need to include assessments in addition to traditional audiometric measures. For example, Bridges and Bentler (1998) found differences in life satisfaction and symptoms of depression among older adults who reported no hearing loss, adults who used amplification successfully, and adults who discontinued use of a hearing aid. Assessment of psychosocial variables not only increases understanding of an individual’s resources and needs, but provides a means of monitoring the effectiveness of hearing loss management.
Factors Affecting Hearing Loss Management
In an effort to better meet the rehabilitation needs of older adults with impaired hearing, we conducted a series of investigations focused on factors influencing hearing loss management. The following questions were posed:
  • What personal and social factors influence hearing loss management?

  • What are typical communication patterns and needs among older adults?

  • What factors influence acceptance and use of hearing aids among older adults?

Two groups participated in these studies: older men and women with impaired hearing, of whom 50% were hearing aid users, and women in three age groups (35–45, 55–65, and 75–85) with age-normal hearing (see Garstecki & Erler, 1996, 1998, 1999, 2001.) Assessments included measures of hearing, hearing handicap, locus of control, depression, ego strength, social support, intelligence, hearing aid performance, and demographics.
The impact of hearing impairment on personal and social function is most pronounced among older women. Results suggest that although older men and women with impaired hearing are similar in their general health, activity level, and financial condition, feelings of self-worth, isolation, security, depression, and need for social-emotional support vary. Older men report fewer personal adjustment problems associated with impaired hearing and are more likely to deny such problems exist. In contrast, older women are more likely to report annoyance, anger, and aggravation due to their hearing loss, along with greater tension and anxiety. Differences are also evident in life experiences, interests, and coping styles.
Variability in communication patterns and needs is apparent among older adults. For example, older women assign greater importance to effective communication in social settings, whereas older men rate work and home settings as requiring most effective communication. Older adults vary in their use of communication strategies, demonstrating a preference for nonverbal rather than verbal strategies. However, older women who use hearing aids defy this trend and frequently use verbal strategies. Overall, older men and women prefer positive to maladaptive strategies to address communication breakdowns.
Older men and women also vary in the characteristics that distinguish hearing aid users from non-users. In comparison to women who choose not to use amplification, adherent women acknowledge its benefits and demonstrate greater internal control, fewer symptoms of depression, and greater use of verbal strategies to cope with difficult communication situations. In contrast to men who choose not to use amplification, adherent men differ demographically (i.e., more education, better health, and more income) and report more support from family and friends to cope with hearing loss, realistic expectations regarding the benefits of amplification, and greater self-confidence.
In all, limited hearing aid uptake and variance in reported hearing aid benefit reflects the heterogeneity of the older adult population. Adherence decisions are affected by interactions among factors such as gender, perception of control, ego strength, and symptoms of depression, as well as severity of the hearing loss, cost of amplification, perceived benefit, and stigma. Consideration of such factors individually can aid the development of client-specific aural rehabilitation plans.
How to Create a Needs-Based Aural Rehabilitation Plan
Older adult-focused treatment plans are most effective when they synthesize the results of comprehensive assessment with the observed and expressed needs of the client. To begin this process, gather the client’s hearing-related history. In addition to determining onset, cause, and consequences, obtain information about general health, co-morbid health conditions, educational background, employment, and caregiving demands. These sociodemographic resources and burdens influence the client’s ability and willingness to manage hearing problems. Examine rehabilitation needs in three areas: sensory device use, communication, and counseling. Although we recommend numerous assessments in the following paragraphs, you should select those instruments that are most appropriate and efficacious for individual clients.
Sensory device needs are established by comprehensive hearing evaluation, assessment of current amplification function and benefit, report of communication needs (e.g., employment status, activities, listening environments), and selection and trial of new hearing aids and/or assistive listening devices. For current hearing aid users, instruments such as the Abbreviated Profile of Hearing Aid Benefit (APHAB) should be used to monitor hearing aid benefit in specific situations or under particular listening conditions. Another useful sensory device assessment is the Satisfaction with Amplification in Daily Life scale (SADL), which analyzes sources of dissatisfaction with hearing aids.
Use objective and subjective assessments to identify communication needs. Standard measures of word recognition, the Hearing in Noise Test (HINT), and understanding of connected discourse (e.g., speechtracking) are useful. Presentation methods should include auditory-only, auditory-visual, in quiet, in varying levels and types of background noise, and at various distances between speaker and listener. Central auditory testing is desirable.
Self-report of communication needs can be obtained using the Hearing Handicap Inventory for the Elderly (HHIE) or the Hearing Handicap Inventory for Adults (HHIA), which provide information about the situational and emotional impact of impaired hearing. The Client Oriented Scale of Improvement (COSI) can be used by the client and clinician to identify and prioritize specific communication problems. The Communication Profile for the Hearing Impaired (CPHI) yields scores for self-perceived communication performance at home, in social situations, and at work.
Structured interviews are useful for obtaining information about counseling needs. The clinician should prepare a list of questions related to emotional reactions to hearing loss (e.g., “Do you feel embarrassed/sad/anxious because of your hearing loss?”); knowledge of hearing loss and its treatment (e.g., “Do you understand the cause of your hearing loss?” or “Would you like to know more about assistive listening devices?”); and interactions with others (e.g., “Are you concerned about asking others to repeat/speak louder?” or “Do you feel dependent on others because of your hearing loss?”).
Client responses should be followed with “tell me more” probes. For example, if clients express feelings of anxiety related to their hearing loss, it is important to discover under what circumstances, with which communication partners, and/or how often such feelings occur. Listen for positive responses to determine what the individual finds helpful and supportive and, again, follow responses with probes to determine how a specific client interprets “helpful” behavior. In addition to the interview, you should note observations of behavior and interaction.
Standardized assessments can be used to measure emotional function. There are many instruments that are appropriate for older adults and quick to administer. The Symptom Checklist-90-R (Derogatis, 1994) yields a global score of emotional status as well as scale scores for nine specific measures (e.g., depression, anxiety, hostility). The CES-Depression Scale (Radloff, 1977), Geriatric Depression Scale (Yesavage & Brink, 1983), and Beck Anxiety Scale (Beck, Epstein, Brown, & Steer, 1988) provide information related to specific aspects of personality that may influence hearing loss management. Results of the Multidimensional Health Locus of Control measure (Wallston & Wallston, 1978) yield information about health management styles. Specifically, clients who are more internal (i.e., they want to be in charge of health care decisions) can be differentiated from those who defer to the judgments of professionals. Hearing loss-specific information also should be gathered. The personal adjustment scales of the CPHI are useful for this purpose. Compare scores for these measures by age and gender to normative data. (Note that there is currently no single source for all of these measures. The Multidimensional Health Locus of Control is available online; the others are copyrighted and must be ordered from publishers or authors.)
How to Create an Individualized Plan
Once the assessment process is completed, the client and clinician then discuss self-identified needs and needs indicated by assessment outcomes. The clinician may use an evaluation record to help counsel the client about the range of needs to consider as well as current functional levels and levels of concern. The evaluation record should include hearing history, demographic data (health, education, socioeconomic status), activity level, sensory device information (hours of use, satisfaction, objective/subjective benefit), communication function (self-assessment and objective measurements), personal adjustment to hearing loss, and social support.
For each category, the client and clinician should indicate their level of concern. Note that the evaluation record does not report the specific outcomes of assessments, but rather provides a forum for discussing all aspects of the rehabilitation process that will lead to individualized treatment goals. Categories rated by the client to be of great concern (scores of 5 or 6), even if they are not scored as highly by the clinician, are strong indicators of the types of problems that have prompted that person to seek professional assistance and should be given priority when goals are established. Inconsistencies in rating (e.g., the client rates a category of no concern and the clinician rates it of great concern) must be discussed to determine the source of such a discrepancy. For example, communication performance in noise may be rated high by the clinician, based on the results of word-recognition testing. Yet, the client may rate this category of little or no concern because his or her lifestyle rarely demands communication in noise.
As the individualized rehabilitation plan evolves, all participants should be identified. In addition to the client and clinician, it must be determined if significant others and/or other professionals should be involved in the treatment plan. The who, where, when, how long, and at what cost for rehabilitation must be specified when treatment is initiated.
The rehabilitation plan must be built on goals that reflect the individual client’s self-perceived needs. For many clients, an argument may be made for addressing more than one issue at a time (i.e., sensory device use, communication, emotional adjustment counseling). The clinician will assist the client in prioritizing rehabilitative needs and from those develop appropriate treatment objectives. Behavioral objectives must support the overall goals of rehabilitation and specify a means for assessing performance over time.
Effective individualized aural rehabilitation should be a dynamic process. Treatment plans and progress must be periodically re-evaluated to determine if modifications are needed. Changes are indicated when there is a lack of progress, the client identifies additional or changed needs, or the client’s auditory, physical, or personal status changes. Modifications may be made by altering the amount of service and/or the service provider, by referring the client to appropriate professionals or organizations, or by making methodological changes.
Despite the high incidence of hearing loss among older adults, few men and women choose to use amplification and even fewer participate in aural rehabilitation programs. Results of recent research suggest that the impact of impaired hearing varies among this population. Further, men and women differ in the resources and burdens that influence hearing loss management. Our information suggests that determining the rehabilitative needs of the client and engaging the client in the development of an individualized treatment plan will enhance adjustment to hearing loss and adherence to the use of amplification.
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August 2003
Volume 8, Issue 14