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Defining Hearing Loss and its
Consequences
Dr Vinaya K. C. Manchaiah
Senior Lecturer in Audiology
Dept. of Vision and Hearing Sciences
Anglia Ruskin University
Outline
• Hearing as a sense
• Consequences of hearing loss
• Dimensions of hearing loss
• How we classify hearing loss currently
• Is there a need to classify differently?
• Disability models with an emphasis to ICF
• Some insights to way forward
• Hearing as a sense
• Consequences of hearing loss
• Dimensions of hearing loss
• How we classify hearing loss currently
• Is there a need to classify differently?
• Disability models with an emphasis to ICF
• Some insights to way forward
Hearing as a sense
• To explore experiences around the world
• Change of hearing sense over time
• Hearing activities
Cognitive domain: Detection, recognition, localisation, understanding
Emotional domain: Tolerance and pleasantness
• Individual’s priority can change quickly
Environmental and social
factors play a big role
What aspects of hearing are most important?
Clarity - Cognitive domain
• Pleasantness – Emotional domain
Goal of audiological enablement/rehabilitation
Hearing expectation = Hearing experience
Consequences of hearing loss
Negative
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Increased difficulty communicating
Reduced interpersonal interactions
Avoidance and withdrawal from social situations
Increased loneliness, anxiety, irritability, anger and frustration
Psychological problems such as depression
Decreased self-esteem and self-efficacy
Resultant (or increased) relationship problems
Increased risk to personal safety
Reduced ability to appreciate music
Reduced job performance
Reduced activities of daily life
Poor health related quality of life
Positive
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Reduced disturbances from unwanted noise
Development of communication strategies
Affinity to people with hearing impairment and other disabilities
Perceived self development
Using hearing impairment to self advantage
Dimensions of hearing loss
Psychoacoustic
dimensions
Perceptual
experiences
• Threshold sensitivity
• Dynamic range
• Frequency resolution
• Temporal resolution
• Binaural hearing (localisation)
• Upward and downward spread of masking
• Biological (or pathophysiological)
• Social
• Environmental (i.e., physical or acoustic)
• Individual (also include psychological)
Four dimensions of factors which may influence
the perceptual experience of hearing loss
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Biological (or pathophysiological)
Type of hearing loss
Degree of hearing loss
Genetic factors
Pathophysiology
Cognitive functions (e.g., working memory)
Environmental (i.e., mainly referring to physical
and/or acoustic domain)
 Background noise
 Directions of speech and noise
 Orientation in the space
 Number of people in the communication
situation
 Acoustics of the communication situation
(particularly reverberation)
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Social
Communication partners
Employment
Socio-economical status
Culture
Social norms
Individual (also includes psychological)
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Age
Sex
Personality
Family history
Acceptance of hearing loss
Mental toughness
Life-style
• Hearing as a sense
• Consequences of hearing loss
• Dimensions of hearing loss
• How we classify hearing loss currently
• Is there a need to classify differently?
• Disability models with an emphasis to ICF
• Some insights to way forward
How do we classify hearing loss?
Type of hearing loss: Conductive Vs SNHL
Degree/severity of hearing loss
Hearing pathologies (e.g., glue ear,
ANSD, etc)
Audiogram could be misleading
Dimensions of hearing loss
Psychoacoustic
dimensions
Perceptual
experiences
• Threshold sensitivity
• Dynamic range
• Frequency resolution
• Temporal resolution
• Binaural hearing (localisation)
• Upward and downward spread of masking
• Biological (or pathophysiological)
• Social
• Environmental (i.e., physical or acoustic)
• Individual (also include psychological)
Disadvantages of Audiogram
• Patients with similar audiogram are reporting different
communication difficulties (Erdman & Demorest, 1998) – But
rehabilitation approaches planned mainly using audiogram
• Mild category: “Oh its only a mild loss? I’ll wait until it gets more
severe”
• Wording ‘normal’ is misleading
• dB scale in appropriately converted into % of loss (Manchaiah et
al., 2011)
• Does not represent all the dimensions of hearing loss
Important to treat hearing
pathology rather than
“audiogram”
4 outcome variables
• Help seeking
• Hearing aid uptake
• Hearing aid use
• Satisfaction
Number of studies per factor divided over stage
(i.e., prefitting, fitting, postfitting)
Hearing sensitivity (i.e., PTA) and outcome variables
Outcome variable
Number of studies
Result
Help seeking
4
0+++
Hearing aid uptake
3
+++
Hearing aid use
6
00000+
Satisfaction
7
0000+++
Self-reported hearing disability and outcome variables
Outcome variable
Number of studies
Result
Help seeking
3
+++
Hearing aid uptake
3
+++
Hearing aid use
3
+++
Satisfaction
5
+++++
Audiological enablement and/or rehabilitation should be based on the perceived
Or experienced difficulties of the patient rather than the severity or levels of hearing
impairment (Stephens & Kramer, 2009)
• Hearing as a sense
• Consequences of hearing loss
• Dimensions of hearing loss
• How we classify hearing loss currently
• Is there a need to classify differently?
• Disability models with an emphasis to ICF
• Some insights to way forward
Models of disability
• Biomedical
• Social
• Bio-psycho-social
• Cultural
Shifting the focus from cause to impact
Health condition
Body functions/
Body structures
Environmental
factors
Activities
Participation
Personal
factors
The ICF provides an universal conceptual framework
and an international common language for describing
functioning, disability and health
Modified WHO-ICF showing interactions between
impairment, disability, and quality of life
No impairment seen in audiogram but reported
significant hearing disability
• Auditory neuropathy spectrum disorders (ANSD)
• Auditory Processing Disorders (APD)
No measurable hearing loss but some hearing pathology found
Possible impairment but no reported hearing
disability
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•
•
•
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Audiogram: Normal hearing
OAEs present
Fine structure DPOAEs showed some dips
Speech in Noise: Good performance
No reported problems
Panda, 2010 (PhD Thesis)
The classification – Structure and Codes
Detailed-classification
ICF
Body
Functions
Body
Structures
Activities &
Participation
Environmental
Factors
b
s
d
e
b1 – b8
s1 – s8
d1 – d9
e1 – e5
d110 – d999
e110 – e599
d1150 – d9309
e1100 – e5959
b110 – b899
b1100 – b7809
b11420 – b54509
s110 – s899
s1100 – s8309
s11000 – s76009
Personal
Factors
Chapters
2nd
level
3rd level
4th level
Introduction to the ICF
To provide a systematic coding scheme for health care
information systems
b1
b130
b134
b1801
b
•
•
s299
s710
s730
s7301
•
EQ-5D
NHP
Joint mobility
Mobility (general)
Muscle power / Strength
Pain
Stability of joints
Emotional function
Engergy & Drive functions
Gait / Ambulation
Stiffness
Muscle endurance
Sexual functions
INSTRUCTIONS: This survey asks for
Sleep
your views about your health. This
information will help keep track of how
you feel and how well you are able to
do your usual activities.
Joint mobility
Mobility (general)
Muscle power / Strength
Pain
Stability of joints
Emotional function
Engergy & Drive functions
Gait / Ambulation
Stiffness
Muscle endurance
Sexual functions
Sleep
WHODAS
WHOQoL
Joint mobility
Mobility (general)
Muscle power / Strength
Pain
Stability of joints
Emotional function
Engergy & Drive functions
Gait / Ambulation
Stiffness
Muscle endurance
Sexual functions
Sleep
31
SF-36
INSTRUCTIONS: This survey asks for
Answer every question by marking
your views about your health. This
the answer as indicated. If you ar
information will help keep track of how
unsure about how to answer a
you feel and how well you are able to
question, please give the best answer
do your usual activities.
you can.
Answer every question by marking
the answer as indicated. If you ar
unsure about how to answer a
question, please give the best answer
you can.
d170
d230
d410
d415
•
e110
e115
e125
e150
ICF Core Sets for Hearing Loss
Consensuses Conference, Denmark May 2012
Brief version - 27
Comprehensive version - 117
Mean number of responses per patient by
ICF categories (Stephens et al., 2001)
1.8
1.6
1.4
1.2
1
Problem
questionnaire
0.8
Life effect
questionnaire
0.6
0.4
0.2
0
BF
AL
PR
EF
PF
WHO-ICF
• Integrative bio-psycho-social model of functioning &
disability
• An individual’s functioning in a specific domain is an
interaction or complex relationship between the
health condition and contextual factors
 BSA: Common principles of rehabilitation for adults with hearingand/or balance-related problems in routine audiology services
 AAA: Guidelines for the Audiologic Management of Adult Hearing
Impairment
Way forward
• Disability model: WHO-ICF & Self-reported hearing disability
• Lessons from other disciplines (e.g., Intellectual disability)
Previous
Now
• Based in intelligence (i.e., mild, moderate, severe)
• Persons ability
• Person’s skills
• Functioning and community participation
• Causes of their intellectual disabilities
• Epilepsy
• Range of mental disorders experiences
Ways in which PHI, CPs and Clinicians describe
hearing loss
Person with Hearing
Impairment (PHI)
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Difficulty understanding speech in group and noisy situations
Difficulty in having conversation on the telephone
Difficulty following television
Communication
Partners (CPs)
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PHI does not hear well in social situations is embarrassing
Acting as interpreter to PHI
PHI sets the television volume too high which is disturbing
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Type and degree of hearing loss
Audiometric configurations with underlying pathology
Speech recognition scores
Clinician
Four dimensions of factors which may influence
the perceptual experience of hearing loss





Biological (or pathophysiological)
Type of hearing loss
Degree of hearing loss
Genetic factors
Pathophysiology
Cognitive functions (e.g., working memory)
Environmental (i.e., mainly referring to physical
and/or acoustic domain)
 Background noise
 Directions of speech and noise
 Orientation in the space
 Number of people in the communication
situation
 Acoustics of the communication situation
(particularly reverberation)





Social
Communication partners
Employment
Socio-economical status
Culture
Social norms
Individual (also includes psychological)







Age
Sex
Personality
Family history
Acceptance of hearing loss
Mental toughness
Life-style
What we need to considered while planning
management of consequences of hearing loss?
Conclusions
• Defining hearing loss generally drives our
management plan
• No classification would serve all purpose
• Disability measures (i.e., activity limitations
and participation restrictions) and measures
for hearing impairment cannot replace each
other, but are complementary