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Hearing Screening in the Community :
What is the future?
Krishan Ramdoo
Clinical ENT Research Registrar, Dept of Ear Nose & Throat – Head & Neck Surgery
Northwick Park Hospital, London, England
Audiology and Hearing Devices 2015
Northwick Park Hospital
Audiology and Hearing Devices 2015
 One of the largest integrated care trusts in the country, bringing together
hospital & community services across Brent, Ealing & Harrow.
 Established on 1 October 2014, employing more than 8,000 staff & serve a
diverse population of approximately 850,000.
 Our Trust looks after:
 Central Middlesex Hospital
 Community services across Brent, Ealing and Harrow, including Clayponds
Rehabilitation Hospital, Meadow House Hospice, Denham Unit and Willesden
Centre
 Ealing Hospital
 Northwick Park Hospital
 St Mark’s Hospital
Audiology and Hearing Devices 2015
Contents
 Case Study
 Background
 Aim
 Methods and Materials
 Results
 Discussion
 Reducing costs
Audiology and Hearing Devices 2015
Case Study

72 year old lady, admitted to hospital with worsening
confusion over the last 6 months.

Lives in Nursing home, staff have noticed decreased
interaction with others

Treated for Urinary Tract Infection

Audiogram performed– found to have presbycusis

Fitted with aid and followed up

Marked improvement noticed with interaction between
family and staff.
Audiology and Hearing Devices 2015
Background : Global problem
 World Health Organisation: proportion of people aged
over 60 is growing faster than any other age group.
 360 million persons in the world with disabling hearing
loss (5.3% of the world’s population). Of this 360 million,
91 % are adults.
 The Global Burden of Disease study (WHO 2008) ranked
hearing loss as the 8th most important contributor to
years lost through disability
Audiology and Hearing Devices 2015
Background: National problem
 In the UK the government has highlighted that with an ageing
population, hearing loss is something that needs to be
addressed.
 UK figures suggest 10.3 million people aged over 65 years .
 Health economist calculations have published that the Cost per
annum for hearing loss and deafness is estimated to be
£30billion
 Related to direct costs and also larger costs of dealing with
heath and social impact of hearing loss
 This has prompted the calls for a National Hearing Screening
Program for the over 65s.
Audiology and Hearing Devices 2015
Background
 Throughout the UK the pathway to access ear care
services is extremely disjointed and we have had firsthand experience of this in our local clinical environment.
 Presbycusis is common
 Linked with social isolation and depression
 Elderly patients have complex medical and social needs.
 Hearing loss often overlooked
 Opportunistic screening advocated by British Geriatric
Society
Audiology and Hearing Devices 2015
Background
 75% of individuals who live in care homes could have a
hearing loss.
 Extrapolate to 2032, 620,000 older people will be living in
care homes and of these, almost 500,000 will have
hearing loss.
 1/3 of older patients with hearing loss have never had a
hearing test.
Audiology and Hearing Devices 2015
Aim
 Determine the prevalence of undiagnosed hearing loss in
the North London Care Home Environment.
 Look at the feasibility of portable hearing screening
utilising smartphone technology.
 Establish the need for development of a Communitybased hearing loss screening programme.
Audiology and Hearing Devices 2015
Which Screening tool?
Audiology and Hearing Devices 2015
Bagai A, et al. Does this patient have hearing
impairment? JAMA 2006
Yes
Referred for
Pure Tone
Audiometry and
GHABP
Question:
Do you suffer
from hearing
loss?
No
Fail
Whisper Test
Pass
No further input
Audiology and Hearing Devices 2015
Bagai A, et al. Does this patient have hearing
impairment? JAMA 2006

Referred to Audiology if:


Answer ‘Yes’ to screening question (71% chance HL over
25dB)
Failed whisper test (86% chance HL over 25dB)

‘No’ on screening question + ‘Pass’ on Whisper test:

3% chance of hearing loss over 25dB
Audiology and Hearing Devices 2015
Ramdoo K et al. Opportunistic Screening in
Elderly inpatients. SAGE 2014
 Use of method in Hospital Inpatients on medical / careof-the-elderly wards, admitted for other medical
problems.
 Results:
 33% of patients suffering with undiagnosed hearing loss.
Audiology and Hearing Devices 2015
Methods & Materials
 Hearing screening using Bagai model
 Agreement with Local Nursing Homes to carry out
screening
 Inclusion criteria:
 Patients > 65 yrs
 Residents at Nursing Homes in the North London area
 Verbal consent to screening
 Exclusion criteria
 Active ear disease
 Lack capacity
Audiology and Hearing Devices 2015
Materials and Methods II
 Whisper test
 All tests performed by same individual in designated quiet room
 Whisper at 30dB or 30dB above background
 Pure Tone Audiometry
 Performed by a Community Audiologist
 Outcome measures
 Prevalence of undiagnosed hearing loss
 Screen:aid ratio
 Evaluation of community based screening
Audiology and Hearing Devices 2015
Results I
 56 patients screened
 Age 68-98 years (mean 84.5)
Audiology and Hearing Devices 2015
Results II
Question:
Do you suffer from
hearing loss? (56)
Yes: 20 (36%)
Referred for Pure
Tone Audiometry
and GHABP: 42
(75%)
No: 36 (64%)
Whisper Test
Fail: 22 (39%)
Pass: 6
(11%)
Unsuitable:
8 (14%)
No further input
Audiology and Hearing Devices 2015
Results III
Referred for Pure Tone Audiometry
and GHABP: 42 (75%)
Tested: 26
(62%)
Suitable for Hearing
aid: 26 (62%)
Mild: 27%,
Moderate:42%,
Severe: 31%
Declined: 5
(12%)
Unsuitable: 11 (26%)
Reported HL: 12
Failed whisper: 14
Audiology and Hearing Devices 2015
Discussion I
 62% suitable for hearing aids
 Significant unmet need in vulnerable patients
 62% referred for hearing aids
 Screen:Aid ratio = 2:1
 Likely to have effect of Quality of Life, communication, social
interaction, +/- care needs
 2 part hearing screen:
 Simple, reproducible, effective
Audiology and Hearing Devices 2015
Discussion II
 Limitations:
 Background noise
 Audiometry difficult in infirm
 May also have difficulty with hearing aids
Audiology and Hearing Devices 2015
Portable Screening
 The use of smartphones and tablets in healthcare are
rising continually. Their portability and accessibility
provide novel solutions to a number of medical problems.
Audiology and Hearing Devices 2015
Portable screening – how good is it?
 A prospective study assessing the feasibility for the
use of a tablet application, to perform opportunistic
screening for hearing loss in the over 60s, in an
outpatient setting.
Audiology and Hearing Devices 2015
Methods and Materials
 50 participants were recruited over the age of 60, who were
visiting our outpatient department for non ear-related
complaints
 Exclusion criteria:
 Patients with previously diagnosed
significant otological history.
hearing
loss
or
 A hearing test was performed with the “EarTrumpet” iPad app
and validated against Pure Tone Audiometry.
 Otoscopy and whisper test were also carried out.
Audiology and Hearing Devices 2015
Results
•
The tablet application correctly diagnosed the
presence of moderate to severe hearing loss
(>40dB threshold)
•
On average, the application overestimated the
hearing loss by 9.5 dB compared to PTA.
Audiology and Hearing Devices 2015
Results II
 Sensitivity of 95% and a specificity of 77%
 30% suitable for hearing aids.
PORTABLE HEARING SCREENING IS SENSITIVE
AND FEASIBLE
Audiology and Hearing Devices 2015
Reducing costs
 Changing our referral pathway will
significantly reduce costs
 Development of new technology to bring
services to patients
Audiology and Hearing Devices 2015
Current Pathway
Audiology and Hearing Devices 2015
Proposed new pathway
Audiology and Hearing Devices 2015
Reducing costs
 Referral costs to Primary care are expensive
 A full Audiometric examination including follow up is £524
 Some patients have simple wax:
 64% in the Nursing home had simple wax
 Ear irrigation is regarded as unsafe as not under direct
vision
 Cost of referral is £128
 In our hospital alone we had 266 new patients in one
month for audiological assessment.
 Patient costs.
Audiology and Hearing Devices 2015
What’s the solution?
 Bringing services to the patient, which environment
 New studies…..benefits patients
 Having an all in one kit
 Enables hearing screening
 Ear examination
 Intervention (wax removal) if required
 We have developed a patented kit to provide this.
 Prototype phase
 Cheap and disposable
Audiology and Hearing Devices 2015
Conclusion
 High prevalence of undiagnosed hearing loss in elderly
residents in the North London Care home environment.
 High prevalence of hearing loss with opportunistic
screening using a portable device
 There is the need to change pathways and integrate
technology in to this.
 Saving on referral costs and better care for patients.
Audiology and Hearing Devices 2015
Questions?
Audiology and Hearing Devices 2015
References

1. WHO Ageing figures 2012.

2. Population ageing statistics – House of Commons Ageing statistics – February 2012.

3. Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older adults in Beaver
Dam, Wisconsin. The Epidemiology of Hearing Loss Study. Am J Epidemiol. 1998;148(9):879-886.

4. JAMA. 2006 Jan 25;295(4):416-28. Does this patient have hearing impairment?Bagai A,
Thavendiranathan P, Detsky AS

5. Relationship between sensory hearing loss and depression in elderly people: a literature review.
Millán-Calenti JC, Maseda A, Rochette S, García-Monasterio I. Rev Esp Geriatr Gerontol. 2011 JanFeb;46(1):30-5.

6. NICE guidelines: Dementia Issue date NOV 2006, revised JAN 2011.

7. A world of silence: a case for tackling hearing loss in care homes. October 2012, Action for
Hearing loss (formerly RNID).

8. Commission on Hearing loss – The real cost of Hearing Loss – September 2014
Adult Deafness 2014