Dr. Wallhagen is Professor, Department of Physiological Nursing, and Director, John A. Hartford Center of Geriatric Nursing Excellence, and Dr. Pettengill is Assistant Adjunct Professor and Project Director, Hearing Impairment Project, Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, California.
This research was supported by an R01 grant from the National Institute of Nursing Research. The authors thank the project research nurses (Karin Luikart and Kay Bolla) and the data manager (David Geller) for their work on the project and insights into many of the evolving issues raised by the participants.
Address correspondence to Margaret I. Wallhagen, PhD, APRN, BC, AGSF, Professor, Department of Physiological Nursing, School of Nursing, University of California, San Francisco, N631, 2 Koret Way, San Francisco, CA 94143-0610; e-mail: firstname.lastname@example.org.
In this study, 91 older adults with hearing impairment were interviewed and asked whether their primary care providers had ever inquired about or initiated screening for hearing loss. A total of 85% indicated there had been no physician inquiry, and additional data demonstrated that the rate of inquiry was unrelated to either objective or subjective levels of hearing loss. In addition, interview narratives revealed that hearing impairment was sometimes dismissed by primary care providers, with detrimental consequences for both the individuals with hearing impairment and their communication partners. Nurses could positively influence the initiation of treatment for hearing loss by incorporating screening techniques into their assessment routines.
Deficits in hearing acuity become increasingly common with age, affecting approximately 30% of adults older than age 65, nearly 50% of those age 75 and older, and more than 50% of nursing home residents (Cobbs, Duthie, & Murphy, 2002; National Institute on Deafness and Other Communication Disorders, n.d.; U.S. Department of Health and Human Services, 2005). In addition to being prevalent, hearing loss is associated with multiple negative outcomes, including isolation, depression, functional decline, and possibly cognitive decline (Arlinger, 2003; Dalton et al., 2003; Valentijn et al., 2005). Hearing loss also negatively affects the individuals’ spouses and their other personal relationships (Kochkin & Rogin, 2000; Kramer, Allessie, Dondorp, Zekveld, & Kapteyn, 2005; Stark & Hickson, 2004; Wallhagen, Strawbridge, Shema, & Kaplan, 2004).
In addition to the negative effects of hearing loss on quality of life, recent studies suggest that lack of auditory stimulation leads to brain changes (Fine, Finney, Boynton, & Dobkins, 2005; Kaltenbach, Zhang, & Finalayson, 2005; Palmer, Nelson, & Lindley, 1998) and that auditory acuity and cognitive performance may be associated (Valentijn et al., 2005; Wallhagen, Strawbridge, & Shema, 2003). Because cognitive impairment among older adults is a growing concern, the concurrent assessment and treatment of hearing loss may be vital. Furthermore, older adults often have multiple comorbid conditions requiring ongoing self-management activities; thus, the ability to correctly hear and interpret what practitioners relate is critical. Lack of adherence to medical regimens is a common finding among older adults (Vik, Maxwell, & Hogan, 2004) and may be exacerbated by undetected hearing loss.
The range of problems associated with hearing impairment support recommendations that screening for hearing loss and referral for follow up be regarded as an essential component of primary care for older adults (American Academy of Family Physicians, 2005; American Speech-Language-Hearing Association, n.d.; Bogardus, Yueh, & Shekelle, 2003; Cohen, Labadie, & Haynes, 2005; Institute of Medicine, 1992; U.S. Preventive Services Task Force, 1996). Screening for hearing loss is also now recommended as part of a comprehensive physical for older adults joining Medicare for the first time (Card, 2005; Centers for Medicare & Medicaid Services, 2006). Individuals are also more likely to seek evaluation and treatment for hearing loss when it is recommended by physicians (Kochkin, 2004). Nurse-based screening for hearing impairment in primary care settings could be especially helpful in identifying early losses in hearing acuity, which may facilitate early intervention, treatment, and adaptation (Tolson, 1997; Wallhagen, Pettengill, & Whiteside, 2006).
However, recent findings suggest that hearing loss is rarely screened for or addressed in primary care settings (Bogardus et al., 2003; Cohen et al., 2005; Newman & Sandridge, 2004), with an estimated screening rate among older adults as low as 12.9% (Kochkin, 2005). In addition, approximately 20% of individuals in the United States who could benefit from a hearing aid actually have or use one (Cox, Alexander, & Gray, 2005; Kochkin, 2005; National Institute on Deafness and Other Communication Disorders, n.d.).
To enhance understanding of these issues, this study explored whether primary care providers ever asked about or screened for hearing loss among a sample of older adults whose hearing impairment was untreated and was verified by standard audiometric testing at the time of entry into this study. The study also explored the effects that lack of inquiry or follow up may have had on the older adults, on the basis of narratives from in-depth interviews. The findings are discussed in relation to their implications for nursing practice and future research.
Design and Sample
Data were collected as part of an ongoing longitudinal qualitative/quantitative study designed to explore and describe the experiences of hearing impaired older adults and their communication partners. Typically, participants were recruited while seeking information about hearing loss testing or treatments from clinics or centers that performed hearing evaluations or provided informational seminars on hearing loss. Interested individuals responded to flyers posted in reception areas or to information packets provided by hearing professionals or office personnel.
Potential participants were then screened via telephone to determine if they met the following inclusion criteria:
- Age 60 or older.
- Ability to read and understand English.
- Cognitively capable of providing informed consent.
- Presence of a willing communication partner.
- Residence within 1.5 hours travel distance of the study center.
Eligible participants had untreated hearing loss and either had no prior experience with hearing aids or had not worn hearing aids within the past year. Each participant was paid a total of $100 for completion of three interviews over 1 year.
Baseline interviews, conducted by interviewers trained in qualitative data collection and in interviewing older adults with hearing loss, took place before or close to the time of the initial hearing evaluation at a place that was convenient for the participants, typically in their homes. Partners were interviewed, usually at the same time, in separate locations (e.g., another room in the home). In addition, after obtaining consent consistent with requirements of the Health Insurance Portability and Accountability Act, audiograms that were performed during this initial hearing evaluation were obtained from the sites.
During the interviews, the interviewers were attuned to any communication difficulties or fatigue and offered the individual with hearing loss the opportunity to use an assistive listening device, if needed. Responses were clarified if any misunderstandings appeared to occur in participants’ interpreting the questions.
Participants with hearing loss were asked to discuss whether their primary care provider had ever (recently or in the past) inquired about their hearing or screened them for hearing loss, independent of any complaints the participants with hearing loss may have expressed. Additional questions were asked to clarify whether discussions about hearing were initiated by the participant or the primary care provider. At the completion of the interview, the participants completed a set of questionnaires that asked about the history of their hearing loss symptoms, prior hearing evaluations, and prior use of hearing aids.
After each interview was transcribed, the researchers used constant comparative qualitative methods to analyze the data for narrative describing any primary care visit and content analysis to delineate the number of individuals whose primary care provider had discussed or asked about their hearing. If the participant with hearing loss could not recall whether the primary care provider had asked about or screened for hearing loss and if interpretation of the response was difficult or conflicting, participants were classified as unclear.
Subjective hearing impairment was measured using the 10-item (Short Form) version of the Hearing Handicap Inventory for the Elderly (HHIE-S) (Ventry & Weinstein, 1982; Weinstein, 1994; Weinstein, Spitzer, & Ventry, 1986). Participants rate the emotional and social impact of hearing loss under different circumstances using three response options (Yes = 4 points, Sometimes = 2 points, No = 0 points). Item ratings are summed. Total scores range from 0 to 40, with scores of 10 and higher suggesting that individuals experience their level of hearing loss as a handicap (Lichtenstein, Bess, & Logan, 1988).
Audiograms from the hearing evaluations accomplished during the period surrounding participant enrollment measured hearing thresholds at frequencies ranging from 250 Hz to 8,000 Hz. Level of hearing loss is typically summarized by averaging thresholds across three or four frequencies. Because the most frequent cause of hearing loss among older adults is presbycusis (Beers & Jones, 2005; Gates & Mills, 2005), which usually involves greater loss of hearing acuity for high-pitched sounds, a high frequency pure tone average (HFPTA) was used to define level of hearing loss. For the purposes of this study, HFPTA was calculated as the average of hearing thresholds at 1,000 Hz, 2,000 Hz, and 4,000 Hz in the ear that was most impaired (Cruickshanks et al., 1998; McBride, Mulrow, Aguilar, & Tuley, 1994). On the basis of the HFPTA findings, participant hearing loss was further categorized as normal (0 dB to 25 dB), mild (26 dB to 40 dB), moderate (41 dB to 70 dB), severe (71 dB to 90 dB), or profound (91 dB to 110 dB) (Beers & Jones, 2005).
A total of 91 older adults with currently untreated hearing impairment were recruited from 19 different sites offering hearing health services. Participants ranged in age from 60 to 93 (mean age = 73, SD = 7.5). Fifty-seven percent were men, 68% were married or partnered, 67% were graduates of post-high school education, 67% were retired, and 90% were White. Nearly 75% of the participants reported undergoing audiometric testing for hearing loss at some point in the past, and 15% reported having tried hearing aids.
Of the 91 participants, 82 (90%) had clear recollection about whether their primary care provider had ever inquired about their hearing. Among those with clear recall, 85% (n = 70) reported that their primary care provider had never proactively asked about nor screened them for hearing loss. Notably, if those without clear recall (11%, n = 9) were to be conservatively included in the group reporting that their provider had inquired about their hearing, the percentage of those not screened remains high (77%).
On the basis of the HFPTA categories, 33% of the participants had mild, 58% had moderate, and 7% had severe or profound hearing loss. Two individuals (2%) had HFPTA scores that were within normal limits, but both scored high on the HHIE-S, suggesting that they viewed their hearing loss as having a considerable negative impact. The HHIE-S mean score at baseline for all participants with hearing impairment was 19.4 (SD = 8.5), with 88% scoring above the cut-off point of 10. Whether the primary care provider did or did not inquire about or screen for hearing loss was unrelated to either the subjective level of reported impact or the objective level of hearing loss determined by audiometric testing (Table).
Table: Primary Care Provider Inquiry by Levels of Objective and Subjective Hearing Loss
During the baseline interviews, most participants reported that if hearing loss was discussed at all with their primary care provider, they were the ones to initiate the discussion, usually because their specific health care plan required a referral to obtain a hearing evaluation. In addition, the interview data suggested that hearing loss was not only not discussed, but also discounted by some primary care providers when the issue was raised. Three participants exemplified this, reporting that, after finally realizing they were having problems hearing, the response from their provider was not helpful:
- I finally had my ears checked by a doctor…. He [primary care provider] didn’t really wanna do it, he said it was just normal for me to lose my hearing a little bit ’cause I was getting older, but I felt it was too rapid, happened too quickly, I felt.
- But she [my doctor]… knows that I have a hearing loss because I’ve asked her to repeat things. And I told her. But she never recommended that I do anything about it.
- My personal physician…I see him, at least once a year for a checkup, and he’ll say, “Well, what other problems are you having?” And I say, “Well, my wife accuses me of not hearing well,” And he just (laughs) scoffs it off, he says, “Well, wives do that.” He didn’t encourage me to do anything.
The wife of this last participant with hearing loss validated his report in her interview and highlighted the negative impact such experiences can have. She said:
He [her husband] said, “Well, I told Dr. _____ today that my wife says that I don’t listen to her,” and [the doctor] just laughed and said, “Oh my wife tells me the same thing.” And blew him off.... He [her husband] said something to the doctor about it, leading him into it, but the doctor discouraged him from thinking he had a problem. I was [furious]!
Another participant with hearing loss who had acknowledged and was concerned about her hearing loss noted, “Whenever I go there, she [the doctor] checks my ears and she said, ‘Very nice. You really keep them clean.’” But the provider never screened the participant’s hearing level or referred her for further evaluation.
Even audiologists did not always attend to concerns about problems hearing. One participant whose hearing loss greatly affected her ability to participate in her favorite activities noted:
This is the thing that’s always bugged me,… for the last 4 or 5 years.… I kept telling my provider, “You know, I’m just having, I’m missing chunks of dialogue. Is this me, or what?” And [the audiologist said], “Oh your hearing is fine. You have some loss, but you know, not worth recommending for a hearing aid.”
As exemplified by the communication partner (participant’s wife) quoted above, discounting of the importance of hearing loss by the primary care provider can lead to further denial by the individual with hearing loss or to inappropriate attribution of the problems being experienced, which can lead to significant stress. Another communication partner reflected on a similar situation in which the primary care provider had told her husband that he also tuned his wife out. She went on to note:
I could just… go and slap that doctor…. [Because] this could’ve been remedied years ago…. If he [her husband with hearing loss] hadn’t gone to the [clinic] and gotten tested… we’d still be… dealing with this and he’d be still thinking it’s his memory, and I’d be still thinking he was just ignoring me.
Given that adult-onset hearing loss typically comes on slowly, many participants were not fully aware of their loss or denied its significance, often for years, especially when they had concerns about having to wear a hearing aid. The importance of having a primary care provider who specifically addresses hearing loss and initiates the testing process was often noted, as exemplified by the following quote from one participant with hearing impairment:
The doctors have to also push a little bit more on the hearing thing.… This thing developed over time. The doctors… have to… say, you know, I gotta check your hearing. Every year… that should be part of the examination…. They just don’t check.
In this study, a very large percentage of participants reported that their primary care provider had never asked them about their hearing, independent of their initiating the topic themselves. It is also interesting to note that the low rate of provider inquiry did not appear to be associated with the level of hearing loss, whether measured objectively via audiometry or subjectively using the HHIE-S. This suggests that hearing loss among older adults is largely unaddressed across all levels of hearing loss. Samples of the narrative data also revealed how several providers discounted the importance of hearing difficulties, thereby rendering the symptoms as unworthy of follow up. In addition, other narratives pointedly demonstrate the detrimental effects of unrecognized hearing loss, on both the affected individuals and the people closest to them.
Although compelling, these results must be considered in light of several limitations. First, the rates of primary care provider hearing inquiry and screening are based on participants’ recall and self-report and could not be verified by other means (e.g., observation, systematic chart review). Second, data are not available to eliminate the possibility that the provider had received an earlier hearing evaluation indicating hearing loss and therefore believed it was not an effective use of time to perform additional screens.
However, several points mitigate these limitations. The interview question specifically asked whether the participant had “ever” been asked about or screened for hearing loss. In addition, follow-up questions were consistently posed to further clarify whether any inquiry or screening had occurred. In addition, the communication partners often validated the participants’ report. Furthermore, these findings are consistent with the 15% to 18% screening rate found among older adults who were asked whether they had been screened for hearing loss during physical examinations during the past 6 months (Kochkin, 2001). Some participants with hearing impairment also admitted they would “fake” understanding to avoid acknowledging their hearing loss under a variety of hearing circumstances, which may include visits to their primary care provider. And, as noted by participants in this study and others (Yueh, Shapiro, MacLean, & Shekelle, 2003), primary care settings are less likely to bring to light the signs and symptoms of hearing difficulties because office visits occur under ideal hearing circumstances where the interchange is usually in a relatively quiet environment with face-to-face communication. Finally, the audiograms from the initial assessments performed during the baseline period of the current study would not have been available to the primary care providers when these key questions were asked during the interview. If the providers did in fact have results from previous hearing evaluations indicating the participant had some level of hearing loss, this should make hearing loss an active problem to discuss. Follow-up discussion and assessment should have been part of these older adults’ ongoing primary care. However, the findings indicate that the hearing impairment among these older adults still remained largely unaddressed and untreated.
Implications for Gerontological Nurses
These findings add to recent research suggesting that hearing loss is an overlooked geriatric syndrome in primary care settings—an assessment gap that can have significant negative consequences. Thus, even with consideration of the limitations, these results provide important information for nurses who work with older adults and raise questions for clinical practice and future research. As noted above, many professional groups recommend screening and follow up for hearing impairment in older adults, and Healthy People 2010 includes the goal to improve the hearing health of the nation through early detection, treatment, and rehabilitation (U.S. Department of Health and Human Services, 2000). The nursing profession is uniquely positioned within the health care system to take a leading role in overcoming this disparity by initiating screening and providing information that will facilitate effective and timely treatment in primary care settings. Nurses can serve a key function in screening, identifying individuals with potential hearing loss and emphasizing the importance of follow-up assessments with a hearing professional.
Routine screening is not difficult or time consuming. Various methods are available, easy to use, and inexpensive (McBride et al., 1994; Smeltzer, 1993; Yueh et al., 2003). Even single-item, self-report questions about hearing, such as “Do you feel you have a hearing loss?”, “Do you have a hearing problem now?”, or “Would you say you have any difficulty hearing?”, provide enough data to make a referral for further testing, when compared with standard, pure-tone audiometry. (Bagai, Thavendiranathan, & Detsky, 2006). Using the HHIE-S as a screening tool can also delineate the emotional and social impact experienced by the individual. This tool can be completed independently by the individual while waiting for the office visit and handed to the provider as a reminder to follow up on hearing evaluation as appropriate.
At the very least, nurses should be aware of the degree to which this syndrome is being overlooked. Because hearing impairment is a barrier to effective communication and is associated with multiple negative outcomes, the timely screening and treatment of hearing loss is imperative. It can not only enhance patient functionality and quality of life, but also potentially prevent the brain from forgetting how to hear. Nurses can play an especially important role because of their direct contact with older adults and professional commitment to patient education. If screening for hearing loss among older adults were to become a regular part of nursing assessment, some of the negative effects of untreated hearing loss could be prevented or reduced.
Hearing loss, a common problem affecting older adults, significantly affects individuals’ well-being, as well as their close relationships, and should be an important focus in primary care settings. However, data from this study suggest it is rarely assessed. Nurses can play an essential role in overcoming this problem by incorporating screening into their routine assessments.
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Primary Care Provider Inquiry by Levels of Objective and Subjective Hearing Loss
||HFPTA Levels (Ear That Is Most Impaired)
|Primary Care Provider Inquiry
||Normal (0 dB to 25 dB)
||Mild (26 dB to 40 dB)
||Moderate (41 dB to 70 dB)
||Severe (71 dB to 90 dB)
||Profound (91 dB to 110 dB)
||Mean HHIE-S Score