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HEARING IMPAIRMENT OBJECTIVES Know and understand: • The mechanisms of normal hearing • The common causes of hearing loss • Management and treatment options for hearing loss • Strategies to improve communication with adults with hearing loss Slide 2 TOPICS COVERED • Normal Hearing • Age-related Changes That Can Affect Hearing • Causes and Types of Hearing Loss • Presbycusis • Diagnosing and Treating Hearing Loss • Strategies to Enhance Communication with Hearing-impaired Persons Slide 3 THE IMPACT OF HEARING LOSS • The 4th most common chronic disease among older adults • Often considered benign, but profoundly affects quality of life • May contribute to family discord, social isolation, loss of self-esteem, anger, depression • Treatment can improve quality of life by facilitating interaction with family, friends, and caregivers Slide 4 NORMAL HEARING • Sound energy is transmitted through the external ear to the tympanic membrane and auditory ossicles • Malleus, incus, and stapes transmit vibrations to the oval window of the cochlea • Fluid waves stimulate hair cells and generate sensory potential • An excitatory postsynaptic potential is generated • When threshold is reached, impulses are sent via cochlear neurons to the cochlear nuclei and then to auditory pathways in the brain Slide 5 AGE-RELATED CHANGES THAT CAN INTERFERE WITH HEARING • External ear canal: Walls thin • Cerumen: Becomes drier & more tenacious, increasing likelihood of impaction • Eardrum: Thickens, appears duller • Cochlea: Hair cells are lost, basilar membrane stiffens, auditory structures calcify, cochlear neurons are lost • Stria vascularis: Capillaries thicken, endolymph production decreases, Na+ K+ ATPase activity decreases Slide 6 PREVALENCE OF HEARING LOSS % of population 30 25 20 15 10 5 0 Age 65-75 Age >75 50%–100% of nursing home residents have hearing loss Slide 7 CAUSES AND TYPES OF HEARING LOSS • May be caused by pathology in: External ear canal Middle ear Auditory nerve Central auditory pathways A combination • Categories of hearing loss based on cause: Conductive Sensorineural Mixed Slide 8 SPEECH RANGE ON THE AUDIOGRAM 10 20 30 40 Vowel sounds 50 60 8000 4000 2000 1000 500 70 250 Loudness (decibels) 0 Frequency (Hz) Slide 9 CONDUCTIVE HEARING LOSS (1 of 2) • External ear pathology Ceruminosis Foreign body • Middle-ear pathology Otosclerosis Cholesteatoma Tympanic membrane perforation Middle ear effusion Slide 10 CONDUCTIVE HEARING LOSS (2 of 2) 0 10 20 30 40 50 60 70 80 90 100 Bone conduction, R Bone conduction, L Air conduction, L Frequency (Hz) 8000 4000 2000 1000 500 Air conduction, R 250 Loudness (decibels) Air conduction thresholds are greater than bone conduction thresholds, most likely due to middle ear pathology Slide 11 SENSORINEURAL HEARING LOSS (1 of 2) • Most often from age, noise damage, or ototoxicity • Cochlear disease Most common cause, most often from noise damage • Other causes: Ototoxic medications Genotype Vascular disease Occupational and environmental chemical exposures Autoimmune disease Auditory nerve tumors Slide 12 SENSORINEURAL HEARING LOSS (2 of 2) Air and bone conduction thresholds are the same, most likely due to inner ear damage. The high-frequency pattern of this patient’s hearing loss is typical for presbycusis. Slide 13 PRESBYCUSIS • Sensorineural hearing loss, usually symmetrical; may have central components • Classified by cochlear pathology: Sensory Neural Strial Cochlear conductive Combined or indeterminate • Amplification often helps Slide 14 TYPES OF PRESBYCUSIS (1 of 3) • Sensory presbycusis Loss of sensory hair cells in basal end of cochlea Slowly progressive loss, beginning with higher frequencies Difficulty hearing in presence of background noise Steeply sloping audiogram Treatment: amplification Slide 15 TYPES OF PRESBYCUSIS (2 of 3) • Strial presbycusis A metabolic form of hearing loss Cochlear dysfunction, with atrophy of 30% or more of the stria vascularis Onset in 20s to 60s Mild to moderate hearing loss in most frequencies Usually good speech discrimination Treatment: amplification Slide 16 TYPES OF PRESBYCUSIS (3 of 3) • Neural presbycusis Cochlear neuronal loss of 50% or more Poor speech discrimination Amplification success is difficult • Cochlear conductive presbycusis Changes in stiffness or mass; spiral ligament atrophy Audiogram descends gradually over 5 octaves Speech discrimination impaired Slide 17 DIAGNOSIS OF HEARING LOSS • Many older adults are unaware of their hearing deficit • Hearing loss can be interpreted as cognitive impairment • Tinnitus can be an early sign of hearing loss Slide 18 MIXED HEARING LOSS Bone conduction, L Air conduction, R 0 10 20 30 40 50 60 70 80 90 100 Air and bone conduction thresholds are abnormal, with the greatest difference seen for the left ear 8000 4000 2000 1000 500 This patient has pathology in both the middle and inner ears 250 Loudness (decibels) Bone conduction, R Air conduction, L Bone conduction thresholds for the left ear are measured by masking the right ear Frequency (Hz) Slide 19 DIAGNOSIS OF HEARING LOSS IN PRIMARY CARE • Otoscope: Exclude and treat cerumen impaction • Audioscope: Screens for hearing loss at selected frequencies (0.5, 1, 2, and 4 KHz) and at 2 loudness levels (25 and 40 dB HL) • Screening questionnaire, eg: Hearing Handicap Inventory for the Elderly Brief Hearing Loss Screener Slide 20 WHEN TO REFER TO OTOLARYNGOLOGIST • Asymmetrical hearing loss, which may indicate tumor of posterior pharynx blocking eustachian tube, or auditory nerve tumor • Cerumen impaction not responsive to cerumenolytics, irrigation or manual extraction • History of tympanic membrane surgery or perforation Slide 21 WHEN TO REFER TO AUDIOLOGIST Consult to determine the presence and type of hearing loss, recommend and fit hearing aids, and provide auditory rehabilitation Assessment includes evaluation of pure-tone thresholds for both air and bone conduction, speech-recognition thresholds, speech discrimination, and middle-ear function Slide 22 TREATMENT OF HEARING LOSS • Medical or surgical • Hearing aids • Assistive listening devices • Cochlear implants • Communication strategies Slide 23 MEDICAL OR SURGICAL Medical • Paget’s disease, otosclerosis: bisphosphonates • Sudden hearing loss: corticosteroids or immunosuppressants Surgical • Otosclerosis • Tympanosclerosis Slide 24 HEARING AIDS • Two are better than one • Not everyone benefits, ie, those with: Central auditory processing problems Poor speech discrimination Dementia • Types: Analog (less expensive) Digital (smaller, customizable) Bone conduction (all-in-one headpiece or body aid) • Many available styles Slide 25 EFFECTS AND REHABILITATION OF HEARING LOSS (1 of 3) Degree of Loss Loss in db HL Sounds Difficult to Hear Mild 25 to Whisper 40 Effect on Communication Amplification or Other Assistance Needed Difficulty underHearing aid standing soft needed in specific speech or normal situations speech in presence of background noise Slide 26 EFFECTS AND REHABILITATION OF HEARING LOSS (2 of 3) Degree of Loss Loss in db HL Sounds Difficult to Hear Effect on Communication Amplification or Other Assistance Needed Moderate 41 to 55 Conversational speech Difficulty understanding any but loud speech Frequent need for hearing aid Severe 56 to 80 Shouting, vacuum cleaner Can understand only amplified speech Amplification needed for all communication Slide 27 EFFECTS AND REHABILITATION OF HEARING LOSS (3 of 3) Degree of Loss Loss in db HL Sounds Difficult to Hear Effect on Communication Amplification or Other Assistance Needed Profound ≥81 Hair dryer, heavy traffic, telephone ringer Difficulty even with amplified speech; may miss telephone calls May need to supplement hearing aid with lip-reading, assistive listening devices, sign language Slide 28 STYLES OF HEARING AIDS • Completely in the canal • Canal • In the ear • Behind the ear • Body aid • Bone conduction Slide 29 COMPLETELY-IN-THE-CANAL HEARING AIDS • Degree of hearing loss: Mild to moderate • Advantages Almost invisible Less occlusion of pinna more natural sound Easier to use with headphones, telephone • Disadvantages User’s dexterity may be a problem Small size may limit available features May cost more than canal or in-the-ear aids Shorter battery life Slide 30 CANAL HEARING AIDS • Degree of hearing loss: Mild to moderate • Advantages More cosmetically appealing than larger aids Telecoil available in some models May be able to use with headphones • Disadvantages User’s dexterity may be a problem Small size may limit available features Slide 31 IN-THE-EAR HEARING AIDS • Degree of hearing loss: Mild to severe • Advantages Ease of handling Comfortable fit Options: telecoil, directional microphone More power than completely-in-the-canal or canal aids • Disadvantages More conspicuous than completely-in-the-canal or canal aids May be difficult to use with headphones Slide 32 BEHIND-THE-EAR HEARING AIDS • Degree of hearing loss: Mild to profound • Advantages Greatest power Options: telecoil, directional microphone, direct audio input Earmold can be changed separately • Disadvantages More conspicuous May be more difficult to insert than in-the-ear aids Difficult to use with headphones Slide 33 BODY HEARING AIDS • Degree of hearing loss: Severe to profound • Advantages Greatest separation of microphone from receiver reduces feedback • Disadvantages Most conspicuous Picks up noise from rubbing on clothing Microphone is at chest or on waist but speech is directed at ear level Slide 34 BONE CONDUCTION AIDS • Degree of hearing loss: mild to severe • Advantages Bypasses middle ear Used if ear canal is unable to tolerate aid or earmold Slide 35 ASSISTIVE LISTENING DEVICES • Pocket-sized, personal amplifiers • Transmitter-receiver systems (FM, induction loop, infrared) • Telephone equipment: amplifiers, vibrating and flashing ringer alert devices, text telephones (TTY) • Television listening devices • Vibrating and flashing devices for alarm clocks, Slide 36 smoke alarms, doorbells, and motion sensors COST OF HEARING AIDS AND ASSISTIVE LISTENING DEVICES (1 of 2) Type of Technology Cost Assistive listening devices $150 to $200 Comments Useful for specific situations Analog hearing aids $1000 Smaller aids are more expensive to $1,100 Analog programmable hearing aids $1,150 Smaller aids are more expensive to $1,600 Digital, low end hearing aids $1,200 Similar to analog aid, but with to better sound quality $2,000 Slide 37 COST OF HEARING AIDS AND ASSISTIVE LISTENING DEVICES (2 of 2) Type of Technology Digital, mid-range hearing aid Cost Comments $1,800 Some sound processing included, to eg, a second program, feedback $2,500 control, telecoil Digital, premium hearing $2,500 Multiple features available, eg, aid to background noise suppression, $3,000 feedback management, multiple programs, telecoil Bone conduction hearing aid $400 to $900 Available as all-in-one headpiece or as body aid; used only if in-theear aid or earmold is not tolerated NOTE: Assistive listening devices and hearing aids are not covered by Medicare Slide 38 COCHLEAR IMPLANT • Electronic device that bypasses the function of damaged or absent cochlear hair cells by providing electrical stimulation to cochlear nerve fibers • Implantation requires extensive pre-implant testing, post-implant training, and general anesthesia • Costs are partially covered by most Medicare carriers and insurance companies; may require authorization • Outcomes for adults >65 years are comparable to those of younger adults, with excellent audiologic and quality-of-life measures Slide 39 STRATEGIES TO IMPROVE COMMUNICATION (1 of 2) • Obtain the listener’s attention before speaking • Eliminate background noise as much as possible • Be sure the listener can see the speaker’s lips: Speak face-to-face in the same room Do not obscure the lips with hands, mustaches, or other objects Make certain light shines directly on the speaker’s face, not from behind the speaker Slide 40 STRATEGIES TO IMPROVE COMMUNICATION (2 of 2) • Speak slowly and clearly, but avoid shouting • Speak toward the better ear, if applicable • Change phrasing if the listener does not understand at first • Spell words out, use gestures, or write them down • Have the listener repeat back what he or she heard • Ask the listener the best way to communicate with him or her Slide 41 SUMMARY • Hearing loss occurs commonly among older adults and may lead to reduced quality of life, high medical care costs, and loss of independence • Primary care providers should routinely screen older adults for hearing loss • Treatment options are available for many types of hearing loss Slide 42 CASE 1 (1 of 3) • A 79-year-old man comes to the office because he has increasing difficulty understanding conversations with his grandchildren. Slide 43 CASE 1 (2 of 3) Which of the following is the most likely diagnosis? A. Presbycusis B. Sociocusis C. Ototoxicity D. Acoustic neuroma Slide 44 CASE 1 (3 of 3) Which of the following is the most likely diagnosis? A. Presbycusis B. Sociocusis C. Ototoxicity D. Acoustic neuroma Slide 45 CASE 2 (1 of 3) • A 75-year-old woman comes to the office because she perceives hearing loss. • On examination, both of her ears are impacted with cerumen. Slide 46 CASE 2 (2 of 3) Which of the following types of hearing loss results from impacted cerumen? A. Conductive B. Sensorineural C. Mixed D. Functional Slide 47 CASE 2 (3 of 3) Which of the following types of hearing loss results from impacted cerumen? A. Conductive B. Sensorineural C. Mixed D. Functional Slide 48 CASE 3 (1 of 4) • A 75-year-old man presents for a routine exam. • He states that recently he has had considerable difficulty understanding speech, even when the speaker’s face is within 6 feet of his own. • He wears hearing aids because he has had sensorineural hearing loss for many years, previously described by his audiologist as severe, high-frequency, bilateral symmetric loss. • He has cut back on social engagements because the hearing aids no longer help. Slide 49 CASE 3 (2 of 4) • His score on the Mini–Mental State Examination is 5 points lower than it was last year. • His score on the Hearing Handicap Inventory for the Elderly is now 28, increased from 20 last year. • He is referred to his audiologist, who finds that the patient’s hearing has declined to the level of profound hearing loss and that speech comprehension is consistent with the severity of hearing loss. Slide 50 CASE 3 (3 of 4) Which of the following is the most appropriate recommendation for this patient? A. Cochlear implant B. Inteo hearing aid C. Bone-anchored hearing aid D. Auditory brain-stem implant Slide 51 CASE 3 (4 of 4) Which of the following is the most appropriate recommendation for this patient? A. Cochlear implant B. Inteo hearing aid C. Bone-anchored hearing aid D. Auditory brain-stem implant Slide 52 ACKNOWLEDGMENTS Editor: Annette Medina-Walpole, MD GRS7 Chapter Author: Priscilla Faith Bade, MD, MS GRS7 Question Writer: Barbara E. Weinstein, PhD Pharmacotherapy Editor: Judith L. Beizer, PharmD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2010 American Geriatrics Society Slide 53