Tailoring Audiology Services to Today’s Seniors In a recent online chat, audiologist Kathleen Cienkowski discussed the role of new technologies and common-sense strategies in addressing hearing needs of older adults. Overheard
Overheard  |   February 01, 2018
Tailoring Audiology Services to Today’s Seniors
Author Notes
  • Kathleen Cienkowski, PhD, CCC-A, is associate department head and assistant professor in the Department of Speech, Language and Hearing Sciences at the University of Connecticut. She is an affiliate of ASHA Special Interest Group 7, Aural Rehabilitation and its Instrumentation. cienkowski@uconn.edu
    Kathleen Cienkowski, PhD, CCC-A, is associate department head and assistant professor in the Department of Speech, Language and Hearing Sciences at the University of Connecticut. She is an affiliate of ASHA Special Interest Group 7, Aural Rehabilitation and its Instrumentation. cienkowski@uconn.edu×
Article Information
Hearing & Speech Perception / Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Special Populations / Older Adults & Aging / Overheard
Overheard   |   February 01, 2018
Tailoring Audiology Services to Today’s Seniors
The ASHA Leader, February 2018, Vol. 23, online only. doi:10.1044/leader.OV.23022018.np
The ASHA Leader, February 2018, Vol. 23, online only. doi:10.1044/leader.OV.23022018.np
Participant: If a participant was to remember or put into practice only one idea from your session, what should that one key takeaway be?
Kathleen Cienkowski: The one message I would like everyone to take away is that working with older adults has changed considerably. The patients of “years ago” with limited activities, limited knowledge about technology and limited hearing knowledge are no more.
Participant: How can one overcome objections from elderly patients who desperately need hearing aids but refuse to wear them due to the perceived negative stigmas?
Cienkowski: Our patients today want more from their rehabilitative experience to account for their lifestyle. Just because patients are older does not mean that they are any less conscious of cosmetics or stigma. I think the approach is two-fold. One, from the public health perspective, we need to get the word out that hearing loss is not limited to older adults. It affects adults of all ages. The second part is, of course, counseling. It’s all about letting the patients tell their stories and helping them recognize that hearing loss is impacting their lives perhaps in more ways than they might think. You can always try the “your hearing loss is more noticeable than your hearing aid” line, but I think taking a patient-centered approach and including the family is critical.
Participant: I appreciate your advocating for the necessity of collaborative care, and the importance of teaching patients problem-solving skills, as well as technical skills, to manage their hearing environment and ability to communicate effectively.
Cienkowski: Thank you. We know that collaborative care is so critical with older adults. I think if we could work more closely with primary doctors and gerontologists, this would really help to get to our patients.
Participant: In regard to the study that used caloric restrictions as a means to medically manage age-related hearing loss, did they mention what the caloric restrictions were?
Cienkowski: The work exploring caloric restriction was based on animal research. I don’t know what the caloric equivalent would be for humans. It’s an interesting area of exploration, but as I’ve noted, the work is largely investigational at this point and something to consider in the future. We have used diet restrictions in other areas such as patients with Meniere’s or tinnitus.
Participant: We try to complete the HHIE (Hearing Handicap Inventory for the Elderly), which gives us talking points that are relevant to the particular person to show them how hearing loss is impacting them. Have you found this to be useful?
Cienkowski: The HHIE is a great tool. It’s quick and easy to score, which adds to its usefulness from a clinical perspective. I don’t think clinicians have the time to administer something that is too lengthy or involved to score. In our clinic the COSI (Client Oriented Scale of Improvement, http://leader.pubs.asha.org/article.aspx?articleid=2531173) has been found useful as a counseling tool.

Sometimes I think that we tend to only think about listening environments for children. Older adults are often in very poor acoustic settings.

Participant: Apart from HMOs and Medicare Advantage Plans, are there any other current initiatives to gain insurance or third-party payment for hearing aids?
Cienkowski: Reimbursement is certainly a hot topic. There are number of factors to consider: Medicare/Medicaid sets guidelines that may be adopted by other insurance payers, how individual states implement the regulations, and what role unions and other employers play in this process. I know that ASHA has been talking with the FDA (Food and Drug Administration) regarding the new over-the-counter (OTC) legislation and what guidelines might be set. That is very much a priority. I believe that holds true for the other professional bodies. At the state level, I believe there is a lot of variability. I think that the ASHA website contains a wealth of information on insurance and reimbursement. In my own state, one of the larger insurance plans changed for state employees, and our clinic was inundated with requests for hearing aids that are now partially covered.
Participant: Many of my patients, even in their 90s, are socially active and end up in listening environments with poor acoustics and a lot of background noise. What strategies would you give them to deal with these poor settings when they report a great deal of difficulty understanding speech? This is after the necessary changes in hearing aid settings.
Cienkowski: Sometimes I think that we tend to only think about listening environments for children. Older adults are often in very poor acoustic settings. I encourage clinicians to ask the patients to walk through a typical day. What activities are patients engaged in? What is the environment like? Will a hearing aid work well in that setting? We as audiologists know that hearing aids work best in a near field or close distance. But our patient may assume that they work no matter what. Patients need to be mindful of where they sit, what acoustic modifications can be made and when something other than a hearing aid might work best. Especially in a long-term-care setting or senior center, I would consider the use of simple acoustic treatments (drapes or maybe carpet, although that doesn’t always work well) and practice with seating yourself to your “hearing advantage.” I like to remind patients that the sound comes in your ear but you listen with your brain. And if you think about your brain like any other part of the body, it might need training to get better at listening, especially in background noise.

If you think about your brain like any other part of the body, it might need training to get better at listening, especially in background noise.

Participant: As more elderly patients embrace technology, do you find that this population is doing more self-research online on hearing loss and hearing aids?
Cienkowski: Absolutely. Patients come in “armed and dangerous,” so to speak. I’m joking there a bit, but yes, I do find that patients today know a lot more about how devices work and how devices might pair with other devices (like a phone to a computer or a hearing aid to a computer). And as a result, their expectations are higher. Patients ask a lot of good questions which we need to be able to answer using language that is not too technical. As an audiologist, you should have a good list of web resources that you can share with your patients—ones that you think have accurate and reliable information that is written in a patient-centered manner (following good health literacy guidelines).
Participant: The high cost of hearing aids may discourage or limit their adoption and use by older adults, especially those with pressing financial needs. Are the rates of favorable hearing aid outcomes better in those European countries where health care systems alleviate the financial burden by giving hearing aids to citizens for free?
Cienkowski: I think that might depend on whom you ask that question of—but no, in general adoption rates are not tremendously higher in those countries where hearing aids are offered free of cost. While slightly higher, we don’t see adoption rates approaching more than 50 percent in those countries, either. Which raises another interesting question that is related to the larger social or public health issue. Why is hearing loss (HL) not considered to be a serious health condition?
There is often the perception that HL is just a natural part of “getting old” and you shouldn’t have to do something about it. But I think if patients think about the impact on communication and quality of life, then the limitations of not doing something about hearing loss become apparent. That’s why I like the “tell me about your day” line, because it gets patients thinking about how often they use their hearing, even for little things like waking up or ordering coffee through a drive-through.
Participant: I cannot stress enough to newer clinicians the importance of understanding that the seniors of today are very different from years ago. Although more technologically advanced, we still need help.
Cienkowski: So true, especially those baby boomers who come to the clinic expecting that a device will interface with all of their technologies. Answering the phone should be an easy task, not one that needs to take five or six steps. It’s also true that among that age group they remember that they should practice good hearing health. This is the group that loves concerts and recreational activities. We want to make sure that they don’t incur further auditory damage by noise exposure. We should also consider that even those with normal peripheral hearing may begin to have difficulties hearing in background noise due to changes in the central or cognitive systems. Quite a few online programs are available now that target that group in particular with brain training. [The idea is to] keep those pathways active so that your brain can continue to distinguish between relevant and irrelevant information.
Participant: We have a problem billing for the time spent in auditory training. Most patients have difficulty affording amplification. How do you bill for auditory training, or is it part of your hearing aid fitting?
Cienkowski: Excellent question. You are correct that audiologists, because they are seen as diagnosticians in the insurance realm, have difficulty receiving reimbursement for these services. That is one of the advantages, if you will, of bundling—you can roll that into your cost. I have seen clinics that break down the cost of their services (unbundled) and charge a fee for the training. I also know clinics that recommend online training options and have the patients pay for the online services directly. At my setting, I run a summer retreat that incorporates intensive training, and patients pay a retreat fee for the time spent. I should note—speech-language pathologists can bill for auditory training, as they are viewed as providing rehabilitation, but their reimbursement varies depending on insurance plans.
Participant: A very difficult acoustic situation for older adults is the dining room in their senior community, and hearing aids are of very little help, even with the small group at their table. Suggestions?
Cienkowski: The dining room and the Bingo—the two worst places I think. First, in terms of the room itself, look for acoustic treatments (curtains) and tennis balls on the chair feet of the bottom of walkers. Movement across the floor creates a lot of noise. Second, a remote mic to hear folks at the table can be helpful if the hearing aid technology supports it. Many companies offer good accessory options these days. If it is difficulty with listening to one talker, like the Bingo caller, a large area loop can be helpful for many, as long as they have a t-coil. I would also suggest that patients think about good communication habits. It’s amazing how quickly we can forget things like “only one person should talk at a time” or to face the person you are listening too.
Participant: What do you think the impact over-the-counter hearing aids will have on the stigma of hearing aids?
Cienkowski: There are a couple of things that I hope will impact hearing aid stigma in a positive way. First, OTC, whether you are for it or against it, has drawn a lot of attention to the needs of individuals with hearing loss. As more people become aware that hearing loss affects so many more people than we know, we can hope that helps to lessen some of the stigma. The second thing is that people seem to have all sorts of things in their ears these days. It’s sometimes hard to know if you are looking at the latest cochlear implant technology or a bluetooth device. And again, as society gets used to seeing things in ears, perhaps there won’t always the reaction of, “Oh, that must be a hearing aid.” I think there is an opportunity here for us as audiologists to make the public more aware of the importance of hearing, the impact of hearing loss and the value of what we do as professionals.
March 8, 2018
Kathleen Aspinall
Good article, bad picture
Dr. Cienkowski shares helpful insights into providing services to older adults. However, I am appalled that the picture chosen to accompany the article shows someone (clearly not an audiologist) trying to put a left hearing aid into a right ear. ASHA, I expect better from you!
March 21, 2018
Vangie Neeley
Lovely Article, Horrible photo
Unfortunately, I am accustomed to viewing pictures with hearing aids displayed incorrectly. However, I was shocked and appalled that in my very own profession on page 3 of the March 2018 issue of ASHA Leader is a photo above the caption Tailoring Audiology Services to Today’s Seniors of a “professional” placing a hearing aid in the incorrect ear of a “patient”. Shame is my feeling regarding this huge goof. Shame that others may think we are not knowledgeable enough nor do we care enough to show the correct placement in our professional journal. Shame that I am part of an organization that is not knowledgeable enough nor cares enough to proof something like this.

Do better, get it right ASHA Leader!

Warm regards,

Vangie Neeley

Vangie Neeley, AuD, CCC-A
Doctor of Audiology
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February 2018
Volume 23, Issue 2