The World Health Organization (WHO; 2018) estimates that there are approximately 432 million adults living with disabling hearing impairment globally. It is one of the top 10 health conditions associated with disability in older (age ≥60) populations and is the leading cause of years lost to disability within low- and middle-income countries (WHO, 2015). The prevalence of hearing impairment increases with age, ranging from 13.3% in individuals age 50 to 59 to 81.5% in individuals age ≥80 (Goman & Lin, 2016).
Given that hearing impairment is associated with aging, it is particularly prevalent among individuals living in long-term care facilities. In long-term care facilities across eight European countries, hearing impairment was prevalent among 44% of residents (N = 4,007) (Yamada et al., 2014). Similarly, in long-term care facilities in Japan, 42% of residents (N = 1,754) self-reported hearing impairment (Mitoku et al., 2016). Of note, both studies used subjective opposed to objective measures of hearing impairment; and Yamada et al. (2014) measured residual hearing impairment when hearing aids were worn. Thus, prevalence is expected to be larger than that reported in these studies.
Although the prevalence of hearing impairment is significant, RNs, licensed practical nurses (LPNs), and certified nursing assistants (CNAs) in nursing facilities often believe they are inadequately prepared to care for residents with hearing impairment (Azmak, 2018; Höbler et al., 2018; Pryce & Gooberman-Hill, 2013; Ruesch, 2018; Slaughter et al., 2014; Solheim et al., 2016). Given the prevalence and significant consequences of hearing impairment, it is important that nurses adequately manage hearing impairment in nursing facility residents.
The current article is a condensed version of the published practice guideline entitled Nursing Management of Hearing Impairment in Nursing Facility Residents (Meyer & Hickson, 2020). Readers are encouraged to obtain the full guideline, which contains additional essential information (access https://www.UIowaCsomayGeroResources.com).
The purpose of this evidence-based practice guideline is to provide guidelines for nursing care of nursing facility residents who have hearing impairment. The guideline is intended for front-line nursing staff (e.g., RNs, LPNs, CNAs) caring for older adults who have hearing impairment. This guideline will also be useful for directors of nursing, nurse managers, and nursing faculty responsible for gerontological nursing competency evaluations and education on standards of nursing care for hearing impairment in older adults in nursing facilities.
Impact On Hearing Impairment
Hearing impairment impacts individuals' psychosocial health and well-being, as well as their physical health and mortality. Accordingly, hearing impairment has been associated with poorer quality of life (Dalton et al., 2003; Hawkins et al., 2012; Tsuruoka et al., 2001) and health-related quality of life (Carlsson et al., 2015; Chia et al., 2007; Eisele et al., 2015; Gopinath, Schneider, Hickson, et al., 2012). In a prospective, longitudinal study involving 1,968 primary care patients with a mean age of 82.6 years, mild hearing impairment (but not severe/profound hearing impairment) was found to be an important indicator of poorer health-related quality of life among female patients and those with only a primary school education (Eisele et al., 2015). In a smaller, cross-sectional study conducted in a LTC facility involving 60 participants (mean age = 79 years), self-reported hearing disability and hearing handicap were significantly associated with the psychological (e.g., agitation, loneliness) and physical health domains of quality of life (Tsuruoka et al., 2001).
Psychosocial and Psychological Health and Well-Being
The psychosocial and psychological consequences of hearing impairment are numerous and can include loneliness (Pronk et al., 2011; Sung et al., 2016), depression (Brewster et al., 2018; Han et al., 2018; Jayakody et al., 2018; Lawrence et al., 2019; Simning et al., 2018), anxiety (Contrera et al., 2017; Jayakody et al., 2018; Kelly et al., 2011; Lawrence et al., 2020; Simning et al., 2019), psychosis (Linszen et al., 2016), decreased emotional vitality (Contrera et al., 2016), and suicidal ideation (Cosh et al., 2019).
Reasons why hearing impairment can result in poor psychosocial and psychological functioning are related to associated activity limitations and participation restrictions that occur. The WHO's (2001) International Classification of Functioning, Disability, and Health (ICF) defines impairment as negative changes to body structure and function; activity limitations as difficulties in the execution of a task or action; and participation restrictions as problems experienced by an individual in life situations. The overarching term for hearing impairments, activity limitations, and participation restrictions is hearing disability.
Functioning and Disability
A team of international experts in hearing rehabilitation conducted a series of studies, including a systematic review, qualitative interviews with individuals with hearing impairment, and an international consensus survey, to identify and classify the major impacts of hearing impairment according to the ICF (Danermark et al., 2013; Granberg, Dahlström, et al., 2014; Granberg, Möller, et al., 2014; Granberg, Pronk, et al., 2014; Granberg, Swanepoel, et al., 2014). Within the comprehensive ICF Core Set for Hearing Loss that was developed in this international project, 26 categories pertained to impairment (e.g., structure of inner ear) and 42 to activity and participation (e.g., conversing with many people).
In relation to older adults and changes to their hearing, examples of impairment are reductions in the number of outer air cells in the cochlear and asynchrony of the firing of auditory nerve fibers. Typical examples of activity limitations are difficulties understanding speech in the presence of background noise and problems hearing the television at a normal volume (Bennion & Forshaw, 2013; Dillon et al., 1999; Stark & Hickson, 2004). Typical examples of participation restrictions experienced by older adults with hearing impairment are withdrawing from social situations and feelings of isolation (Gopinath, Hickson, et al., 2012; Mick et al., 2014; Pryce & Gooberman-Hill, 2012).
Hearing impairment adversely affects communication and communication is a two-way process. It is therefore not surprising that hearing impairment has also been found to cause activity limitations and participation restrictions for the significant others of older adults with hearing impairment (Kamil & Lin, 2015). The WHO refers to such impacts as third-party disability where a family member, for example, may not have a hearing impairment themselves but they nevertheless experience conversation breakdowns and withdraw from social situations (WHO, 2001).
Not every individual with a given degree of hearing impairment experiences the same activity limitations and participation restrictions; in fact, correlations across measures of impairment, activity limitations, and participation restrictions are moderate at best (Dalton et al., 2003; Stumer et al., 1996). According to the ICF, contextual factors impact how an individual experiences a health condition and thus help explain the everyday impacts of hearing impairment (Meyer et al., 2016); these contextual factors are classified as personal factors or environmental factors (WHO, 2001).
Personal factors are diverse and can include the individual's demographics, attitudes, and concomitant health conditions. Importantly, multimorbidity is particularly common in individuals older than 65 (Wallace et al., 2015), which can impact the experience and subsequent management of hearing impairment in these individuals. Two conditions in particular can exacerbate hearing disability: concomitant visual impairment (i.e., dual sensory loss) (Chia et al., 2006; Guthrie et al., 2018; Guthrie et al., 2016; Turunen-Taheri et al., 2017) and concomitant cognitive impairment/dementia (Guthrie et al., 2018; Slaughter et al., 2014). Within LTC facilities across four countries (Canada, United States, Belgium, Finland), the prevalence of dual sensory loss ranged from 9.7% to 33.9% (Guthrie et al., 2016); and in individuals age >80 in the United States, was reported to be 11.3% (Swenor et al., 2013). In LTC facilities in Canada, the proportion of people reported to have dual sensory loss and cognitive impairment was 29.2% (Guthrie et al., 2018).
Within the ICF Core Set for Hearing Loss, 48 categories of environmental factors were identified as being relevant to hearing impairment (Danermark et al., 2013). In relation to nursing facilities, in particular, O'Halloran et al. (2011) identified seven key factors: (a) the health care provider's knowledge of communication-related impairments (e.g., hearing impairment) and communication devices (e.g., hearing aids), (b) the health care provider's communication skills (e.g., use of face-to-face communication), (c) attitudes (e.g., respect for the patient), (d) individual characteristics (e.g., foreign accent), (e) the presence of family (e.g., communication support), (f) the physical environment (e.g., acoustic environment), and (g) hospital procedures and policies (e.g., staffing).
Physical Health and Mortality
In addition to the commonly acknowledged psychosocial impacts, hearing impairment has been associated with changes in physical health and mortality. Over the past decade, strong evidence from epidemiology studies has identified an association between hearing impairment and cognitive impairment (Fischer et al., 2016; Lin, Ferrucci, et al., 2011; Lin et al., 2013) and incident dementia (Davies et al., 2017; Deal et al., 2017; Ford et al., 2018; Fritze et al., 2016; Lin, Metter, et al., 2011; Su et al., 2017; Wei et al., 2017). A recent systematic review and meta-analysis, based on 36 studies and approximately 20,264 participants, confirmed these observations, albeit noting that the associations were small (Loughrey et al., 2018).
In addition, large scale cross-sectional and prospective observational studies have identified an association between hearing impairment and self-reported physical functioning (e.g., activities of daily living, leisure and social activities, general physical activities) (Chen et al., 2015; Chen et al., 2014; Choi et al., 2016; Liljas et al., 2016), particularly among people with moderate or greater hearing impairment (Gispen et al., 2014; Gopinath, Schneider, McMahon, et al., 2012). There is also a greater risk of frailty (Kamil et al., 2016; Liljas et al., 2017) and increased mortality (Genther et al., 2015) among adults with hearing impairment. For nursing home residents with dual sensory loss, this association with mortality was mediated by involvement in activities; only residents with hearing and vision impairment who were not involved in activities had a higher chance of mortality, relative to residents who did not have dual sensory loss (Yamada et al., 2016).
It should be highlighted, however, that it is not currently known if these associations between hearing impairment and cognitive functioning, physical functioning, and mortality are causal.
Definition of Key Terms
Hearing loss and hearing impairment are terms that are used interchangeably and refer broadly to the loss of audibility of sound associated with abnormalities in the peripheral and/or central auditory systems. The peripheral auditory system includes the outer ear or pinna, middle ear, and inner ear or cochlea. The central auditory system includes the auditory nerve pathways from the acoustic nerve to the cochlear nuclei in the brainstem to the auditory cortex. Hearing impairment is used herein, as it is the term used by the WHO. To describe hearing impairment, four things are usually defined: (a) type of hearing impairment, (b) degree of hearing impairment, (c) configuration of the hearing impairment, and (d) whether it is in one ear only (uni-lateral) or affects both ears (bilateral).
There are three major categories of hearing impairment in older adults:
Conductive hearing impairment results from a physical disruption in the transmission of sound waves through the external or middle ear. Causes of conductive hearing loss include external blockage, perforated eardrum, genetic or congenital abnormality, otitis media, and otosclerosis. The most common cause of conductive hearing impairment in older adults is buildup of cerumen (i.e., wax) in the auditory canal (Walling & Dickson, 2012). As a person ages, the cerumen glands atrophy, therefore cerumen becomes drier and the cilia become coarse and stiff, reducing their function and causing cerumen buildup. The buildup of excessive wax is more prevalent in older adults living in nursing facilities than in older adults living in the community (Hopper et al., 2016).
Sensorineural hearing impairment is the result of damage to the inner ear, including the cochlea or auditory/eighth cranial nerve. Common causes of sensorineural hearing loss include aging, hereditary or genetic factors, viral or bacterial infections, head trauma, noise exposure, and ototoxic medications. The majority of hearing impairment in older adults is sensorineural in nature, with only 2% to 3% reported as having a conductive impairment (Chia et al., 2007).
Mixed hearing impairment is the term used when conductive and sensorineural hearing im-pairment co-occur.
Degree of Hearing Impairment
Descriptive categories are used to summarize results showing the softest sounds a person can hear at a range of frequencies. Different organizations and researchers have developed somewhat different categories and two examples are shown in Table A (available in the online version of this article).
Examples of Commonly Used Categories of Degree of Hearing Impairment
Individuals at Risk for Hearing Impairment
The following are risk factors associated with acquiring hearing impairment:
Older age (Goman & Lin, 2016; Lin, Thorpe, et al., 2011).
Male gender (Agrawal et al., 2008; Goman & Lin, 2016; Lin, Thorpe, et al., 2011; Nash et al., 2011).
White race (Agrawal et al., 2008; Goman & Lin, 2016; Lin, Thorpe, et al., 2011). However, in Lin et al. (2012), skin pigmentation was only associated with hearing impairment in Hispanic individuals.
Excessive noise exposure (Agrawal et al., 2008; Cruickshanks et al., 2015; Nash et al., 2011).
Chronic otitis media (Yen et al., 2015).
Presence of cardiovascular risk factors and/or heart failure (Agrawal et al., 2008; Nash et al., 2011; Sterling et al., 2018).
Diabetes (Cruickshanks et al., 2015; Horikawa et al., 2013; Kim et al., 2017).
Smoking (Agrawal et al., 2008).
Use of ototoxic medications (e.g., cisplatin) (Shorter et al., 2017).
Exposure to chemicals in solvents (Fuente et al., 2013).
Exposure to environmental lead and cadmium (Choi & Park, 2017).
Older individuals frequently exhibit several of these risk factors simultaneously and are at an increased risk for hearing impairment.
Because of the high prevalence of hearing impairment in nursing facility residents, all residents should be screened and assessed for hearing impairment on admission and an ongoing basis (American Speech–Language–Hearing Association [ASHA], 1997; Centers for Medicare & Medicaid Services [CMS], 2015). A timeframe for this ongoing evaluation of nursing facility residents for hearing impairment should minimally coincide with the federally mandated Minimum Data Set (MDS) timelines (i.e., admission, significant change in status, or as needed, but minimally on an annual basis) (ASHA, 1997; CMS, 2015).
Several bedside assessment tools are available for RNs to screen and assess for hearing disability in nursing facility residents. The most common assessment instruments include:
Descriptions and directions for use of these screening/assessment instruments, abnormal assessment findings, and kinds of hearing impairment are shown in Table B (available in the online version of this article).
Bedside Hearing Impairment Assessment/Screening Instruments
Management of Resident's Hearing Impairment
Hearing impairment directly impacts older adults' independence, communication skills, and functional abilities. Regardless of etiology, hearing impairment has a profound effect on nursing facility residents' communication abilities. Residents identified with hearing impairment should be referred to a primary care provider to initiate interventions (cerumen management), or to an ear-nose-throat (ENT) physician and/or audiologist for further detailed hearing tests and hearing rehabilitation. Nursing facility staff can contribute to the physical and emotional well-being of residents with hearing impairments by becoming sensitive to their needs. Intervention strategies include effective communication and the management of hearing devices, such as hearing aids, assistive listening devices (ALDs), and cochlear implants. Many residents will require assistance with hearing devices.
Impairment Level Support
Cerumen Management. Excessive cerumen (wax) can be treated, and this relatively simple treatment is essential to avoid additional unnecessary hearing impairment and, for those residents who wear hearing aids, to ensure that the hearing aid is delivering amplified sound as it should. Wax in the ear canal can stop the hearing aid from working.
The National Institute for Health and Care Excellence (2018) recommends the removal of earwax in a primary care setting, and possible treatments are irrigation of the ear canal using an electronic irrigator, microsuction, or manual removal with a probe. Practitioners who undertake such work should have training and expertise in using the particular technique that is selected and must be aware of any contraindications to the use of any technique. For example, irrigation is contraindicated for residents with a perforated ear drum.
For ear irrigation, also called aural lavage, it is recommended that the wax is softened prior to treatment. This softening can be immediately before ear irrigation or up to 5 days beforehand. Rojahn (2010) conducted a systematic review of the effectiveness of wax softeners (e.g., ceruminolytic agents, saline, water) and concluded that saline or water were just as effective as cerminolytics. If irrigation is not successful on the first attempt, it is recommended to repeat the use of wax softeners or instill water into the ear canal 15 minutes before repeating the ear irrigation. If irrigation is unsuccessful after two attempts, referral to an ENT specialist is recommended. The use of cotton buds to clean the external canal is strongly discouraged because this often pushes the cerumen deeper into the canal, as well as poses a risk for injury to the canal walls and tympanic membrane (Schwartz et al., 2017).
Care and Maintenance of Hearing Devices. All nursing personnel (i.e., RNs, LPNs, CNAs) are responsible for the care and management of hearing devices, yet many nursing home staff have not received formal training in this area and report not having the knowledge and skills to best assist residents (Azmak, 2018; Solheim et al., 2016). Training nursing personnel on the use, care, and maintenance of hearing aids and ALDs is vital to providing quality nursing care to residents with hearing impairment (Pryce & Gooberman-Hill, 2013).
Hearing Aids: Use, Care, and Maintenance. A hearing aid is a battery-powered, sound-amplifying device that consists of a microphone to pick up sound and convert it to electric energy, an amplifier to magnify the electric energy, a receiver to convert the electric energy back into sound, and an ear piece that directs the sound into the ear.
There are several different types of hearing aids. The most common type is the behind-the-ear aid. This type fits snugly behind the ear and the hearing aid case holds elements of the aid that amplify the sound. The sound is then delivered from the aid to the ear via a piece of plastic tubing connected to an ear piece, which can be custom made for the individual (usually called an ear mold) or be a stock ear tip (usually called a dome). Another widely used type of hearing aid is the in-the-ear aid. This device is a one-piece aid and has all the components within the earmold. Manufacturers' specific guidelines should be followed for proper hearing aid use, care, and maintenance.
Strategies for hearing aid use for residents with dual sensory loss. A high proportion of residents with hearing impairment will also have vision impairment. It is recommended that residents' audiologists consider each person's vision impairment when discussing device options, battery type, and need for other ALDs (Saunders & Echt, 2007). Kricos (2007) points out that the fundamental consideration in such cases is to increase the visibility of devices and components and, if possible, to make functions automatic rather than requiring residents to make changes. For example, the volume and settings of hearing aids could be set automatically by the audiologist. It will also be important for hearing aid instruction manuals to be provided in large print, or electronically, so that they can be used with screen readers.
Strategies for hearing aid use for residents with cognitive impairment or dementia. Given that a high proportion of residents with hearing impairment will also have cognitive impairment/dementia, the following strategies may help residents remember to use and care for their hearing aids (Meyer et al., 2019). These strategies have been developed in the context of evidence-based memory support strategies (Smith et al., 2011) and include:
Use of reminders, including spoken prompts, visual reminders, written reminders, and picture reminders, to help residents remember to wear their hearing aids.
Deciding on a place for devices and their accessories and storing these in the same place each day when not in use. Labels can be helpful.
Establishment of consistent routines for daily hearing aid use.
Practice and allowance of extra time to perform tasks.
Breaking hearing aid use into simple steps.
If any problems persist or if difficulties with hearing aid management cannot be corrected by the above, the resident's audiologist should be contacted. Pertinent data should be documented, including any problems the resident has with the hearing aid. In addition, daily care, maintenance, and insertion and removal times can be recorded on a flowsheet.
Assistive Listening Devices: Use, Care, and Maintenance. ALDs are any type of device (other than hearing aids and cochlear implants) that assist someone with hearing impairment to hear better and function better in day to day communication. They can be devices for listening to specific signals, such as the television, radio, or alarms, or for listening to general signals individually or in a group. They can be used in conjunction with a hearing aid or cochlear implant or on their own. ALDs are also referred to as hearing assistance technology (Southall et al., 2006).
The following are examples of the more common types of ALDs that have been used in nursing facilities (Aberdeen & Fereiro, 2014; Palmer et al., 2017):
Personal amplifiers. These devices comprise a microphone that the speaker talks into, an amplifier to make the sounds louder, and a wire leading to the headphones/earphones worn by the resident. The volume is adjustable. These types of ALDs are simple to use, and appropriate for one-on-one conversation, watching television, and listening to the radio. However, due to the wire connection, this type of ALD may be too restrictive for large group conversations. They are considerably less expensive than conventional hearing aids and can be purchased over the counter. New smaller versions of such amplifiers are also increasingly becoming available and are referred to as personal sound amplification products (PSAPs) in the United States. Reed et al. (2017) compared a sample of PSAPs with conventional hearing aids and found that some of them improved speech understanding to the same extent as hearing aids.
Television devices. These devices typically consist of a set top box that picks up the signal and transfers amplified sound directly to the listener who is wearing headphones/earphones. The connection might be hard wired with a plug into the television; however, wireless infrared transmission has been reported to be more suitable for aged care (Palmer et al., 2017). In the infrared system, a microphone picks up the energy from the speaker, converts it, and transmits it to an infrared converter. The converter transmits the signal on an infrared carrier beam. The listener wears a receiver, which looks like lightweight earphones. This type of system allows residents to be involved in group activities or to watch television in a lounge area. This type of system cannot be used in direct sunlight.
Amplified telephones. Telephones with large buttons and amplification should be available to residents in nursing facilities. These can be used with or without hearing aids.
Alerting devices. There are many other ALDs that could be provided depending on the individual resident's needs. For example, residents who cannot hear a knock on their door may wish to have a visual signal that someone is entering their room.
Frequency modulation (FM) systems. Such systems are used with hearing aids or cochlear implants and are fitted by an audiologist. The speaker wears a small microphone (usually hung around the neck) and signals are transmitted via radio frequency carrier waves directly to the resident's hearing aids or cochlear implants. The FM system is particularly useful in group situations where the resident wants to listen to a single speaker in the group.
Induction loop systems. Some nursing facilities may have an induction loop system to help residents who wear hearing aids or cochlear implants to hear in group situations. The system consists of a microphone, an amplifier, and a wire that surrounds a designated area of space. It may be that a whole room in a facility is looped and the wire that allows this will not be visible (e.g., could be laid in the flooring). A microphone is placed near the speaker and the signal is directly picked up by those wearing suitable hearing aids or cochlear implants. It would be important for nursing staff to discuss the use of the loop system with an audiologist. These systems can be remarkably effective for residents with hearing impairment, but training is necessary.
Contextual Factors: Environmental-Level Support
If impairment level support is provided, the evidence is that it will improve a person's activity limitations and participation restrictions; however, further improvement will be gained if the environment can be optimized for the person with hearing impairment. Key environmental factors that can impact how residents experience illness relate to the health care professional themselves (i.e., knowledge, attitudes), as well as the presence of family, the physical environment, and hospital procedures and policies (O'Halloran et al., 2011).
Communication Strategies for Health Care Professionals. Hearing impairment has a profound effect on nursing facility residents' communication abilities. Nursing staff can contribute to the physical and emotional well-being of residents with hearing impairments by becoming sensitive to their needs. Table C (available in the online version of this article) provides a synthesis of recommendations found in the literature related to key communication strategies.
Strategies to Communicate with Nursing Facility Residents with Hearing Impairment
Evaluation of Process and Outcomes
Several indicators should be monitored over time to evaluate the process and outcomes of implementing this evidence-based guideline. Process indicators are those interpersonal and environmental factors that can facilitate the use of a guideline and may be evaluated by administering a test before and after implementation. The guideline has an example of a pretest–posttest entitled The Hearing Impairment Knowledge Assessment Test. In addition, the Process Evaluation Monitor and the Outcome Evaluation Monitor (both included in the full guideline) should be administered following implementation of the guideline.
Outcome indicators are outcomes expected to change or improve with consistent use of the guideline. The major outcome indicators that should be monitored over time include (Jennings & Head, 1997; Shapiro & Shekelle, 2004):
Ensuring residents are screened for hearing impairment on admission and an ongoing basis.
Residents with hearing impairment are treated and referred to an ENT physician and/or audiologist.
Residents with hearing impairment receive appropriate nursing interventions.
The current article describes the key points in the evidence-based practice guideline entitled Nursing Management of Hearing Impairment in Nursing Facility Residents (Meyer & Hickson, 2020). The full guideline includes the significance of hearing impairment, key definitions, individuals at risk, assessment criteria and tools, management of hearing impairment, and steps for evaluation and outcomes. We believe the implementation of this evidence-based practice guideline will improve the quality of life and quality of care of nursing facility residents with hearing impairment.
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Examples of Commonly Used Categories of Degree of Hearing Impairment
|World Health Organization (2012) Degree of Impairment||Hearing Threshold Average at 500, 1,000, 2,000, and 4,000 Hz||American Speech-Language-Hearing Association (ASHA) (based on Clark, 1981)||Hearing Threshold Average at 500, 1,000, and 2,000 Hz|
|No impairment||25 dB or less||Normal||−10 to 15 dB|
|Slight/mild||26–40 dB||Slight||16–25 dB|
|Moderate||41–60 dB||Mild||26–40 dB|
|Severe||61–80 dB||Moderate||41–55 dB|
|Profound||81 dB or greater||Moderately severe||56–70 dB|
|Profound||91 dB or greater|
Bedside Hearing Impairment Assessment/Screening Instruments
|Tool||Abnormal Findings||Kind of Hearing Impairment||Key Procedure Steps||Selected References|
|Otoscope||Obstruction or damage to external or middle ear||Conductive hearing loss||Insert and inspect ear canal and tympanic membrane.||Dillon (2003); Jarvis (2004)|
|Hand-held screening audiometer (25 or 40 dB tone at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz)||Hearing impairment is indicated if the resident does not respond at 40 dB at any frequency in either ear.||Conductive, sensorineural, or mixed hearing loss||In a quiet environment, ask the patient to make a fist with one hand. Instruct the patient to identify when they hear a sound by raising a finger or saying yes. Present pure tones of random loudness (in dB).||American Speech-Language-Hearing Association (1997, 2002); Bagai et al. (2006); Bienvenue et al. (1985); Gates et al. (2003); Wallhagen et al. (2006); Yueh et al. (2003)|
|Minimum Data Set (MDS)||0 = normal
1, 2, or 3 = abnormal||Conductive, sensorineural, or mixed hearing loss||Administer in a quiet setting at admission, quarterly, annually, and with a significant change.||Centers for Medicare & Medicaid Services (2019); Sindhusake et al. (2001)|
|Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) (Ventry & Weinstein, 1983)||0 to 8 = no hearing handicap
9 to 24 = mild to moderate hearing handicap
25 to 40 = severe hearing handicap||Conductive, sensorineural, or mixed hearing loss||Administer in a quiet setting to cognitively intact residents at admission, quarterly, annually, and with a significant change.||Scudder et al. (2003); Sindhusake et al. (2001); Wiley et al. (2000); Ventry & Weinstein (1983)|
|Nursing Home Hearing Handicap Index (NHHI) (Schow & Nerbonne, 1980)||0 to 20 = no hearing handicap 21 to 40 = slight hearing handicap
41 to 70 = mild to moderate hearing handicap
>71 = severe hearing handicap||Conductive, sensorineural, or mixed hearing loss||Administer in a quiet setting to cognitively intact residents at admission, quarterly, annually, and with a significant change.||Scudder et al. (2003); Schow & Nerbonne (1977); Sindhusake et al. (2001); Wiley et al. (2000)|
|Severe Dual Sensory Loss (SDSL) Screening Tool||Individuals who score ≥ 1 on both subscales may have clinically significant dual sensory impairment.||Conductive, sensorineural, or mixed hearing loss||Administer in a quietsetting by a nurse who has cared for the patient for one shift.||Roets-Merken et al., (2014); Svingen & Lyng (2006)|
|Inpatient Functional Communication Interview–Staff Questionnaire (IFCI-SQ)||“Always” = no communication difficulty “Sometimes” or “Never” = communication difficulty||Conductive, sensorineural, or mixed hearing loss||Administer in a quietsetting by a nurse who has cared for the patient for one shift.||O'Halloran et al. (2017)|
Strategies to Communicate with Nursing Facility Residents with Hearing Impairment
|Gain attention||Residents with hearing impairment may not be aware that you are talking to them.
Begin a conversation by using the resident's name.
If the resident is not facing you, consider alerting them by gently touching their hand, arm or shoulder.
|Face the resident and spotlight your face||People with hearing impairment often lip read and therefore need to see you to hear you.
Position yourself so that you can look directly at the resident at eye level before speaking. Do not speak directly into the resident's ear.
Do not chew gum or cover your mouth when speaking.
Face a window or a lamp so that the light is on your face, not the resident's, when you speak.
If the room is dark, move to another area with more lighting.
|Reduce background noise||Speech can be difficult to understand when there is any background noise.
Minimize noise where possible (e.g., turn off the television, turn down the radio, close a window)
Move to a quieter area to communicate.
|Speak clearly at a moderate pace - do not shout||Shouting distorts the sound of speech making it more difficult to understand. It also distorts the face of the speaker, making lip-reading difficult, and may frighten and upset the resident.
Speak clearly and slowly, pausing occasionally to help the resident keep up with the word flow.
Articulate carefully and avoid mumbling.
Do not exaggerate expressions as this makes lip reading difficult.
Do not use a high pitch tone. A lower, deeper voice is often easier to understand.
If the resident has better hearing in one ear, try to position yourself so that you speak closest to that ear.
Do not use “elder speak” (e.g., use of diminutives [honey, sweetie], inappropriate plural pronouns [“we” instead of “you”], tag questions that imply an answer, and baby talk).
|Use simple language and allow time for the resident to respond||Residents with hearing impairment will need extra time to understand what is said especially if the language is complex and/or there is background noise. When it is too difficult to listen, some residents may agree with everything, even when they do not understand what is being said.
Use simple language and emphasize key words.
Use gestures if you need to clarify a statement or question.
Avoid changing the topic of conversation without warning.
Allow time for the resident to listen and respond.
If the resident does not understand a particular phrase or word, try rephrasing instead of repeating.
Use written communication if needed.