When Hearing Loss Goes Unnoticed Hearing difficulties can easily be missed in skilled nursing facilities, which means residents receive no or unnecessary treatments. With simple screening, speech-language pathologists can step in to help fill this service gap. Features
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Features  |   June 01, 2015
When Hearing Loss Goes Unnoticed
Author Notes
  • Kathryn Dowd, AuD, CCC-A, is an audiologist in Charlotte, North Carolina. She is an affiliate of ASHA Special Interest Groups 6, Hearing and Hearing Disorders: Research and Diagnostics; and 17, Global Issues in Communication Sciences and Related Disorders. kdowd@carolina.rr.com
    Kathryn Dowd, AuD, CCC-A, is an audiologist in Charlotte, North Carolina. She is an affiliate of ASHA Special Interest Groups 6, Hearing and Hearing Disorders: Research and Diagnostics; and 17, Global Issues in Communication Sciences and Related Disorders. kdowd@carolina.rr.com×
Article Information
Hearing Disorders / Special Populations / Older Adults & Aging / Healthcare Settings / Professional Issues & Training / Features
Features   |   June 01, 2015
When Hearing Loss Goes Unnoticed
The ASHA Leader, June 2015, Vol. 20, 44-49. doi:10.1044/leader.FTR2.20062015.44
The ASHA Leader, June 2015, Vol. 20, 44-49. doi:10.1044/leader.FTR2.20062015.44
The nursing staff at a facility mentioned a resident had a problem with a whistling hearing aid. The staff said a physician had finally fixed the problem. On inspection of the hearing aid, the audiologist discovered that the physician had turned down the volume on the hearing aid. The whistling had stopped, but the resident was receiving no benefit from the device.
A resident was referred for hearing testing. He had been at the facility for three months. In reviewing his chart before administering the audiogram, the audiologist noted the resident had been evaluated for cognitive/communication deficits and had three weeks of speech treatment soon after his admission. An audiogram showed a 70 dB (severe) bilateral sensorineural hearing loss. How did this happen?
Staff at a facility were upset that a resident was identified as having a hearing loss. They felt his hearing was fine and that his confusion was the result of mental illness. A meeting with all staff to discuss the audiogram clarified that the resident had a mild-severe sloping high-frequency hearing loss. The resident could hear people speaking due to better residual hearing in the low frequencies, but could not understand speech because of the severity of his hearing loss in the mid- and high-frequency range. Face-to-face he could “hear” well by lip-reading.
These examples demonstrate some ways in which hearing loss can be mismanaged in skilled nursing facilities (SNFs). As part of their work in these facilities, speech-language pathologists evaluate patients’ speech, language and cognition problems for treatment needs. But before an SLP evaluates a patient, it is important to consider the status of that person’s hearing.
Hearing screenings, which would help identify hearing loss, don’t always take place in facilities, some professionals say. As a result, unidentified and untreated hearing loss may skew the results of speech-language, cognitive and behavioral assessments, as hearing loss can present as confusion, isolation, depression and behavioral problems. Residents with hearing loss also may not recognize the problem, and may feel staff are mumbling.
ASHA’s “Guidelines for Audiology Service Delivery in Nursing Homes” note an 80-percent incidence of hearing loss among SNF residents. This figure is not surprising, given that residents have a high incidence of chronic diseases associated with hearing loss, including diabetes, hypothyroidism, chronic renal disease, cardiovascular disease and Alzheimer’s. Hearing decline has also been linked to some commonly used medications, including some pain medications, loop-inhibiting diuretics, and certain antibiotics and cancer chemotherapeutics. Only hearing screening will uncover the problem and start the process to correct the hearing loss.
Silent epidemic
The Omnibus Budget Reconciliation Act of 1987 mandated evaluation of the physical, mental and psychosocial needs—and communication needs—of residents in long-term care facilities at the time of admission and periodically thereafter. The required evaluation, known as the Minimum Data Set (MDS), includes questions about residents’ ability to hear. Section C of the MDS, “Communication/Hearing Patterns,” contains two questions to determine the functional adequacy of the resident’s hearing. Item C-1 requires the examiner to rate hearing ability (with a “hearing appliance,” if used), and item C-2 asks the examiner to indicate whether the resident has and/or uses a hearing aid.
Typically, an SNF’s assessment nurse is responsible for assessing hearing. A chart review in SNFs would tend to indicate that most residents hear well. But in many cases, no true hearing screening has been done.
A few months ago, I visited the assessment nurse in an SNF to find out how she handles hearing loss assessments for new resident admissions. She said she asks residents if they think they have a hearing loss or if they have ever been tested for hearing problems.
In most cases, she said, there is no indication of hearing loss in the patient records. She also speaks with the residents to determine if they are able to understand. I suggested she ask the questions softly, with a paper hiding her face. The nurse smiled and said, “What a good idea. I never thought of that.”
I showed the nurse a list of chronic diseases and ototoxic medications known to cause hearing loss. She looked up from the paper and smiled again. “Then everyone in our facility needs to be tested,” she said. Bingo!

A review of charts in SNFs tends to indicate most residents can hear well. But in many cases no true hearing screening has been done.

The screening
Because hearing loss is an invisible disability, facilities need an easy and quick way to assess a hearing problem. The lack of a true, routine hearing screening at admission puts more responsibility on the SLP to conduct the hearing screening as part of speech, language and cognition screening.
  • Should the SLP rely on the outcome of the initial nursing assessment for hearing? Probably not. Ask your assessment nurse how he or she determines if there is a hearing loss.

  • Without an audiometer, how can SLPs screen for hearing problems? Conduct an easy hearing screening (see box at end) and review the chronic disease/ototoxic medication records for each resident. If there’s potential for hearing loss, complete the Resident Assessment Protocols and care plan for an audiology referral and list the contributing screening results, medical illnesses and medications as the reasons for the referral.

  • How can a failed screening be referred to an audiologist outside of the facility? Contact local audiologists and ask if they are willing to contract with the nursing facility to provide audiology services for the residents. A contract with the facility lays the groundwork for services and reimbursement with the audiologist.

Without an audiometer, how can SLPs screen for hearing problems? Conduct an easy hearing screening and review the chronic disease/ototoxic medication records for each resident.

When there’s hearing loss
Failing a hearing screening mandates an audiological evaluation. The staff at the SNF should anticipate that:
  • Speech services may be delayed if the resident fails the hearing screening. The hearing loss should be corrected in advance of further assessment and treatment for speech, language or cognition.

  • Hearing evaluation costs may not be covered under Part B Medicare within the first 90 days of the resident’s stay. The SNF pays for the evaluation if the resident is Part A (first 90–100 days).

  • Hearing aids are expensive. Many states have Medicaid resources to cover hearing aids in a skilled facility, but accessing the resources can be challenging.

  • Hearing aids are sophisticated, delicate instruments. The staff now has a responsibility (in addition to many others) to ensure the hearing aids are working and not damaged or lost.

  • The resident may need to go offsite for hearing evaluation and treatment services if the facility does not contract with an audiologist for onsite services. Residents who cannot leave their beds will require onsite audiology services.

Hearing loss is an invisible disability. Only a hearing screening with a medical review of diseases and medications will bring the silent epidemic of hearing loss to light.

When hearing loss is addressed and identified in skilled nursing facilities, residents then need audiologic rehabilitation services. One advantage for audiologists is that SLPs—who are in the SNF more often—can provide this treatment onsite.
Residents wearing hearing aids for the first time may be overwhelmed by sound that’s been missing for many years or by background noise that can interfere with speech understanding. Their devices may cause pain if not inserted properly. These factors underlie the need for services beyond diagnosis and fitting.
Audiologists and SLPs are allies and together provide the range of services needed by residents of long-term care facilities. SLPs can oversee the initial wearing of the hearing aids and report any issues, such as device comfort and volume, to the audiologist.
In addition, SLPs are trained to provide audiologic rehabilitation, and these services are reimbursable by Medicare Part B. SLPs will decide if the services are compensatory or restorative when determining the client’s treatment plan.
Hearing screening for those at risk before assessing speech, language and cognition will help to ensure that SNF residents are able to maximally benefit from services, participate in social interactions, and understand information about their condition and care.
Hearing loss is an invisible disability. Only a hearing screening with a medical review of diseases and medications will bring the silent epidemic of hearing loss to light.
No Audiometer? Try This Screening Protocol

Carry out the screening in a quiet, enclosed room. Stand three to five feet behind the patient, or stand in front of the patient and cover your mouth to eliminate visual cues. Tell the patient in advance that you will use the phrase, “Say the word,” and he or she should repeat only the last word.

Select one of the lists below and present all the words in a normal conversational level.

  1. Shout Vine Take Fell Chalk

  2. Juice Pick Raise Thought Match

  3. Sell Third Love Page Week

  4. Bite Seize Shirt Time Dip

Record the number of words repeated correctly. If the person gets any words wrong in the five-word list, it is possible he or she has a hearing loss. Complete the Resident Assessment Protocol for an audiology referral due to a failed hearing screening.

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June 2015
Volume 20, Issue 6