Hearing Loss and Aging
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  • Hearing Impairment and Elderly PeopleMay 1986NTIS order #PB86-218559
  • Recommended Citation:U.S. Congress, Office of Technology Assessment, Hearing Impairment and Elderly People–ABackground Paper, OTA-BP-BA-30 (Washington, DC: U.S. Government Printing Office, May1986).Library of Congress Catalog Card Number 86-600511For sale by the Superintendent of DocumentsUS. Government Printing Office, Washington, DC 20402
  • PrefaceHearing impairment is very common among elderly people and can seriously affecttheir quality of life, personal safety, and ability to function independently. This OTAbackground paper discusses the prevalence of hearing impairment and its impact onelderly people; hearing devices and services that may benefit them; and problems inthe service delivery system that limit access to these devices and services.This background paper is part of the OTA assessment of Technology and Agingin America that was requested by the Senate Special Committee on Aging and the HouseSelect Committee on Aging, and endorsed by the House Committee on Education andLabor. For that assessment OTA selected five chronic conditions for in-depth analysisbecause of their prevalence and severe impact on elderly people and because of thepotential role of technology in their treatment. Hearing impairment is one of these con-ditions; the others are dementia, urinary incontinence, osteoarthritis, and osteoporosis.Many of the chronic conditions that affect elderly people, including the types ofhearing impairment that are most common, cannot be cured with available medicaland surgical treatments, As a result, some elderly people, their families, and othersassume that these conditions are not treatable. Yet assistive technologies can often helpto maintain functioning even when the underlying disease or condition cannot be cured.In the case of hearing impairment, these technologies include hearing aids, infraredand FM assistive listening devices, telephone amplification devices and other telecom-munication systems, signaling and alarm devices, and environmental design and auralrehabilitation techniques. Used singly or in combination, these technologies can facili-tate communication and help to maintain an independent lifestyle for many hearingimpaired people.As more and more Americans live to older ages, the prevalence of chronic condi-tions that cause functional impairment is expected to increase. Along with biomedicalresearch on the causes and possible cures for these conditions, the development andincreased use of technologies that compensate for functional impairment are amongthe most hopeful approaches to improving the quality of life of elderly people.OTA was assisted in the preparation of this background paper by many outsideadvisors and reviewers, including biomedical and social science researchers, physicians,audiologists, and representatives of the hearing aid dealers and hearing aid manufac-turers associations. We express sincere appreciation to each of these individuals andorganizations. As with all OTA reports, the content of this background paper is theresponsibility of the Office and does not necessarily represent the views of outside advi-sors or reviewers.
  • Technology and Aging in America Advisory Panel*Robert Binstock, Panel ChairDirector, Policy Center for Aging, Brandeis UniversityRaymond BartusGroup Leader of GeriatricsMedical Research DivisionLederle LaboratoriesRobert BerlinerDeanSchool of MedicineYale UniversityRobert N. ButlerChairmanDepartment of Geriatrics and Adult EducationMt. Sinai Medical CenterRobert ClarkAssociate ProfessorDepartment of Economics and BusinessNorth Carolina State UniversityLee L. DavenportSenior Vice President—Chief Scientist,emeritusGTE Corp.Ken DychtwaldpresidentDychtwald & AssociatesCaleb FinchProfessor of Biological Sciences andGerontologyUniversity of Southern CaliforniaVelma Murphy HillDirectorCivil and Human Rights DivisionService Employees International UnionRobert L. KaneSenior ResearcherThe Rand Corp.Paul A. KerschnerAssociate Director for Programs,Legislation and DevelopmentAmerican Association of Retired PersonsMaggie KuhnFounder and National ConvenerThe Gray PanthersMatt LindVice PresidentCorporate Planning and ResearchThe Travelers Insurance Co.Robert G. LynchVice PresidentMarketing PlanningGTE Corp.Mathy D. MezeyDirectorTeaching Nursing Home ProgramUniversity of PennsylvaniaHamish MunroProfessor of Medicine and NutritionTufts UniversityBernice NeugartenProfessor of Education and SociologyNorthwestern UniversitySara RixDirector of ResearchThe Women’s Research and EducationInstitutePauline RobinsonResearch Professor of GerontologyUniversity of Southern CaliforniaJohn W. RoweChief of GeriatricsBeth Israel HospitalBert SeidmanDirectorDepartment of Occupational Safety, Healthand Social SecurityAFL-CIOJacob SiegelSenior ResearcherCenter for Population ResearchGeorgetown Universityq Panel members’ affiliations are listed at the time the assessment began.NoTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members Theviews expressed in this OTA report, however, are the sole responsibility of the Office of “technology Assessment.iv
  • OTA Project Staff—Hearing Impairment and Elderly PeopleRoger C. Herdman, Assistant Director, OTAHealth and Life Sciences DivisionGretchen S. Kolsrud, Biological Applications Program ManagerRobert A Harootyan, Project DirectorDavid McCallum, * Project DirectorClaire W. Maklan, AnalystKatie Maslow, AnalystChris Elfring, EditorSupport StaffSharon Smith, Administrative AssistantLinda Ray ford, Secretary, Word Processing SpecialistBarbara Ketchum, Clerical AssistantRelated ProductsTechnology and Aging in America, OTA AssessmentImpacts of Neuroscience, OTA Background PaperTechnologies for Managing Urinary Incontinence, OTA Case StudyPrqf>rt Director until September 1983v
  • AcknowledgmentsThis project has benefited from the advice of many experts in the field of hearing impairmentand hearing services. OTA especially would like to thank the following advisors, reviewers, and con-tractors for their assistance and support.Gay BeckerAging Health Policy CenterUniversity of CaliforniaSan Francisco, CADerald BrackmannOtologic Medical GroupLos Angeles, CAScott C. BrownGallaudet Research InstituteWashington, DCAnthony DiRoccoNational Hearing Aid SocietyLivonia, MIDennis DreschlerWayne State UniversityDetroit, MIGeorge W. FellendorfFellendorf AssociatesWashington, DCRaymond M. FleetwoodHarry Diamond LaboratoryAdelphi, MDRichard M. FlowerDepartment of OtolaryngologyDivision of Audiology and SpeechUniversity of CaliforniaSan Francisco, CALaurel E. GlassCenter of Deafness: Research, Training, andMental Health ServicesUniversity of CaliforniaSan Francisco, CAJerome C. GoldsteinAmerican Academy of Otolaryngology-Headand Neck SurgeryWashington, DCSandra Gordon-SalantHearing and Speech Sciences DepartmentUniversity of MarylandCollege Park, MDElise HallMontgomery County Department of Housingand Community DevelopmentRockville, MDAnnette G. van HilstMontgomery County Department of Housingand Community DevelopmentRockville, MDLeonard JakubczakNational Institute on AgingBethesda, MDSam KinneyThe Cleveland ClinicCleveland, OHBarry LeshowitzDepartment of PsychologyArizona State UniversityTempe, AZThomas J. MaronickFederal Trade CommissionWashington, DCRalph F. NauntonCommunicative Disorders ProgramNational Institute of Neurological andCommunicative Disorders and StrokeBethesda, MDRobert J. NewcomerAging Health Policy CenterUniversity of CaliforniaSan Francisco, CASuzanne M. PathyThe Suzanne Pathy Speak-Up InstituteNew York, NYCarol M. RodinHearing Industries AssociationWashington, DCDavid SaksOrganization for the Use of the TelephoneOwings Mills, MDvi
  • Virginia W. SternProject on the Handicapped in ScienceAmerican Association for the Advancement ofScienceWashington, DCRocky StoneSelf Help for Hard of Hearing PeopleBethesda, MDJerry TobiasAuditory DepartmentNaval Submarine Medical Research LaboratoryGroton, CTGwenyth R. VaughnAudiology-Speech Pathology ServiceBirmingham Veterans Administration MedicalCenterBirmingham, ALTimothy J. WatersMcDermott, Will, and EmeryWashington, DCBarbara WilliamsOffice of Cued Speech ProgramsGallaudet CollegeWashington, DCPeggy WilliamsAmerican Speech-Language-Hearing Assoc.Rockville, MDHoward ZubickBrigham and Womens HospitalBoston, MAvii
  • ContentsPageCHAPTER 1: Overview . . . . . . . . . . . . . . . . . . . . . 3The Scope and Impacts of HearingImpairment in Elderly People . . . . . . . . . . 3Summary of Major Findings and Issues. . . . . . 4CHAPTER 2: The Epidemiology of HearingImpairment in Elderly People . . . . . . . . . . 11Types and Causes of Hearing Loss AmongElderly People . . . . . . . . . . . . . . . . . . . . .Measuring Hearing Impairment . . . . . . . .Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . .Age , . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Gender . . . . . . . . . . . . . . . . . . . . ... , . . .Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Income . . . . . . . . . . . . . . . . . . . . . . . . . . .Institutionalization . . . . . . . . . . . . . . . . . .Prevalence of Tinnitus . . . . . . . . . . . . . .The Impact of Hearing Impairment , . . . .Clinical Impact . . . . . . . . . . . . . . . . . . . . .Psychosocial Impact . . . . . . . . . . . . . . . .Denial of Hearing Impairment. . . . . . . .Deafness . . . . . . . . . . . . . . . . . . . . . . . . . . .CHAPTER 3: Treatment of HearingImpairment. . . . . . . . . . . . . . . . . . . . . . .Prevention . . . . . . . . . . . . . . . . . . . . . . . . . .Medical and Surgical Treatment. . . . . . . .Treatment of Conductive HearingImpairments . . . . . . . . . . . . . . . . . . . .Treatment of Sensorineural HearingImpairments . . . . . . . . . . . . . . . . . . . .Hearing Aids . . . . . . . . . . . . . . . . . . . . . . . .Problems in Hearing Aid Design andPerformance . . . ..., , , ..., ., , , ., ,Problems in Selecting the AppropriateHearing Aid.. . . . . . . . . . . . . . . . . . . .Problems in Adjusting to a Hearing AidAssistive Listening Devices . . . . . . . . . . . .Telecommunication Devices . . . . . . . . . . .Signaling and Alarm Devices. . . . . . . . . . .Assistive Device Development. . . . . . . . . .Environmental Design ., . . . . . . . . . . . . . .Aural Rehabilitation . . . . . . . . . . . . . . . . . .Hearing Aid Orientation . . . . . . . . . . . . .Auditory Training . . . . . . . . . . . . . . . . . .Speechreading . . . . . . . . . . . . . . . . . . . . .Counseling . . . . . . . . . . . . . . . . . . . . . . . .CHAPTER 4: The Service Delivery System .Service Providers and Referral Patterns .Physicians. . . . . . . . . . . . . . . . . . . . . . . . .Audiologists . . . . . . . . . . . . . . . . . . . . . . .Hearing Aid Dealers . . . . . . . . . . . . . . . .. . . . 11. . . . 13. . . . 14. . . . 14. . . . 15. . . . 15. . . . 16. . . . 16. . . . 16. . . . 17. . . . 17. . . . 18. . . . 19. . . . 20. . . . 25. . . . 25. . . . 27. . . . 27. . . . 27. . . . 2831. . . . 32. . . . 32. . . . 33. . . . 36. . . . 39. . . . 40. . . . 41. . . . 41. . . . 41. . . . 42. . . . 42. . . . 43. . . . 47. . . . 48. . . . 48. . . . 49. . . . 50PageReferral Patterns , . . . . . . . . . . . . . . . . . . . . . . 51The Role of Other Health Care and SocialService Providers . . . . . . . . . . . . . . . . . . . . 52Settings for Service Delivery. . . . . . . . . . . . . . . 54Health Care Settings . . . . . . . . . . . . . . . . . . . . 54Educational Settings . . . . . . . . . . . . . . . . . . . . 54Community Agencies . . . . . . . . . . . . . . . . . . . 55Alternate Approaches to Service Delivery. . . . 55Veterans Administration Hearing Services. . 55Elderhostel Program for the HearingImpaired . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Assistive Device Centers. . . . . . . . . . . . . . . . . 56Self-Help Groups for Hearing ImpairedPeople , . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Nursing Home Initiatives . . . . . . . . . . . . . . . . 57Screening Programs . . . . . . . . . . . . . . . . . . . . . . 58Regulation of the Delivery System . . . . . . . . . . 58CHAPTER 5: Funding for Treatment ofHearing Impairments . . . . . . . . . . . . . . . . . 63Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Other Government Funding Programs. . . . . . . 65Private Insurance . . . . . . . . . . . . . . .Where Services Are Provided andBy Whom. . . . . . . . . . . . . . . . . . .Type and Purpose of Services . . . .Role of the Physician . . . . . . . . . . .CHAPTER 6: Conclusion . . . . . . . . . . . .APPENDIX A:APPENDIX B:REFERENCESTablesTable No. Sources . . .Assistive Device Centers. . . . . . . . . . . . . . . . . . . . .. . . . . . . . 66. . . . . . . . 66. . . . . . . . 67. . . . . . . . 67. . . . . . . . 71. . . . . . . . 75. . . . . . . . 77. . . . . . . . 83PageCauses of Conductive and SensorineuralHearing Impairments. . . . . . . . . . . . . . . . . . . . . 11Hearing Loss in Decibels Related toApproximate Degree of Impairment . . . . . . . . 13Prevalence of Hearing Impairment, IncludingTinnitus, in the Civilian, NoninstitutionalizedPopulation, by Race and Selected AgeGroups, United States, 1977 . . . . . . . . . . . . . . . 16Types of Hearing Aids Sold in the UnitedStates, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Proportion of Hearing Aid purchasersby Age, 1983-85 . . . . . . . . . . . . . . . . . . . . . . . . . 30Persons Age 65 and Over Who Use aHearing Aid, United States, 1977. . . . . . . . . . . 31...Vlll
  • Table No.7. Satisfaction With Hearing Ability Using aHearing Aid . . . . . . . . . . . . . . . . . . . . . . . . . .FiguresFigure No.1. Structure of the Ear . . . . . . . . . . . . . . . . . .2. Prevalence of Hearing Impairment,Including Tinnitus, in the Civilian,Noninstitutionalized Population,United States, 1977 . . . . . . . . . . . . . . . . . . .3. Prevalence of Hearing Impairment AmongAdults by Frequency of Tone, UnitedPage Figure No. Page5. Cochlear Implant in Place. . . . . . . . . . . . . . . . 2831 6. Hearing Aid Types . . . . . . . . . . . . . . . . . . . . . . 297. Hardwire Device forOne-to-One Consultation . . . . . . . . . . . . . . . . . 34Page 8. Audio Loop Wand Receiver . . . . . . . . . . . . . 3411 9. FM Persona] Amplification Device:10.14 11.12.States, 1971-75 . . . . . . . . . . . . . . . . . . . . . . . . . 154. Prevalence of Tinnitus, by Severity and 13.Selected Age Groups, United States, 14.1960-62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Transmitter and Receiver . . . . . . . . . . . . . . . . 34Infrared Amplification Device:Transmitter and Receiver . . . . . . . . . . . . . . . . 35Three Types of Telephone AmplificationDevices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Sonic Alert Signaling System, Including aPaging Device and Door Bell Signaler . . . . . . 39Lip Reading Glasses . . . . . . . . . . . . . . . . . . . . . 43Materials Supplied to Participating Hospitalsby the Suzanne Pathy Speak-Up Institute. . . 53ix
  • Chapter 1Overview
  • Chapter 1OverviewTHE SCOPE AND IMPACTS OF HEARING IMPAIRMENTIN ELDERLY PEOPLEHearing impairment is a serious problem amongelderly people in the United States. It is the thirdmost prevalent chronic condition among the non-institutionalized elderly population, exceeded onlyby arthritis and hypertensive disease (118, 120,122).Elderly people are much more likely to have ahearing impairment than younger people. Slightlymore than 1 percent of all people under 17 yearsof age suffer some hearing impairment. But prev-alence rises to about 12 percent of all people be-tween 45 and 64, about 24 percent of those 65 to74, and about 39 percent of those 75 and over(121).1The prevalence of hearing impairmentamong elderly people in nursing homes is evengreater (98).While only 11 percent of the Nation’s popula-tion is over 65, about half of all hearing impairedpeople are over 65 (41). As this older segment ofthe population grows, the number of hearing im-paired individuals will rise dramatically. The over-75 population, which has the highest prevalenceof hearing impairment, is growing at a faster ratethan the elderly population as a whole, thus in-creasing the number and proportion of hearingimpaired people in the population. At present,about 7 million elderly persons have significanthearing loss. If current rates persist, by the year2000 more than 11 million elderly persons will besignificantly affected.Hearingimpaired individuals include those whoare deaf_ and those who are hard-of-hearing. Hard-of-hearing refers to a partial hearing loss that re-sults in difficulty with speech comprehension, al-though some auditory function remains. Deafrefers to a degree of impairment that renders hear-1’1 hese figures are hased on the results of interfiew sur~qvs. Fkti -matw of prekalenc(’ basfxi on audiometric testing art’ ronsiderahl)higher. (;h. 2 disrusses the differences hett$reen thr prclakmrc esti-m a t e s deternlined I)j these tt~o mf~thrds ot’ m e a s u r i n g h e a r i n gat)ilitting nonfunctional for ordinary purposes of life(117). Most people with hearing impairments arenot deaf, but even the partial hearing loss that iscommon among elderly people can limit their in-dependence and reduce the quality of their lives,Although hearing impairment is not life-threat-ening and does not directly restrict physical activ -ity, it can cause severe disability. Hearing loss limitsa person’s ability to interact socially with familyand friends and to receive and interpret informa-tion (10). Many warning devices such as fire alarmsrely on sound signals. Furthermore, hearing is animportant method of identifying dangers in theenvironment, such as approaching vehicles. Thus,hearing impairment can affect personal safety. Itcan also interfere with important activities of dailyliving, including shopping; using public transpor-tation; and communicating with health care pro-fessionals, tradespeople, and community serviceproviders. When hearing impairment limits a per-son’s ability to function independently, it can re-sult in a need for formal and informal long-termcare services.The importance of hearing and the problemsposed by hearing loss in elderly people have longbeen recognized. In 1968, the Senate Special Com-mittee on Aging noted the high prevalence of hear-ing loss among elderly people and directed its at-tention to three problem areas: 1) delivery ofservices to older people with hearing loss; 2) hear-ing aid sales; and 3) the effects of increasing noiseon future generations of Americans (127). Duringthe past 18 years we have made some progresscombatting these problems, but much remains tobe done.This background paper examines the kinds ofhearing impairments that are most common amongelderly people and the technologies that are avail -able to compensate for them. Chapter 2 reviewsthe types, causes, and prevalence of hearing im-pairment and its impact on elderly people. Chap-3
  • 4ter 3 discusses treatment methods, including pre-vention, medical and surgical treatments, anddevices and procedures to compensate for hear-ing loss. These include hearing aids, assistive listen-ing devices,2telecommunication devices, and auralrehabilitation techniques. The chapter also dis -2Assistiw listening devices are devices that transmit amplifiedsound more directly from its source to the listener; examples areaudio loops, infrared, and radio frequencj’ (Ahl and F%f) devices (74).SUMMARY OF MAJORThe Federal Government is concerned abouthearing impairment among elderly people becauseof its impact on their safety, quality of life, andability to live independently. Federal initiatives thathave addressed the problems of hearing impair-ment include funding for research, legislation toguarantee access to public facilities for hearingimpaired people, and regulation of hearing aidsales. These efforts have benefited hearing im-paired individuals of all ages. In addition, somefunding is available to treat hearing disordersthrough Medicare, Medicaid, the Veterans Admin-istration (VA), and other Federal programs.Despite these Federal programs, many elderlypeople with hearing impairments are not receiv-ing appropriate treatment or using potentially ben-eficial devices. Some do not seek treatment becausethey are not aware of their hearing loss or becausethey believe that nothing can be done to treat orcompensate for it. Negative social attitudes aboutgrowing old and becoming hard-of-hearing causesome elderly people to deny their hearing impair-ments. Others are aware of their hearing loss butavoid the use of hearing aids and assistive listen-ing devices because they do not want to call atten-tion to their loss.Public education is needed to increase aware-ness about the extent and types of hearing im-pairment among the elderly. Elderly people, theirfamilies, and health care professionals also needinformation about treatments, devices, and serv-ices that can compensate for hearing impairment.Federal, State, and local governments, private in-dustry, and organizations representing elderly andcusses obstacles to the use of these technologiesand looks briefly at problems of device develop-ment. Chapter 4 describes the existing systems thatprovide treatment for hearing impaired people,including the service providers, settings, and pat -terns of service delivery. The chapter emphasizesthe need for improved delivery systems that areadapted to the needs of elderly people. Chapter5 discusses funding for hearing devices andservices.FINDINGS AND ISSUEShearing impaired people must share responsibil-ity for public education programs that promoteawareness of the problem and encourage the useof appropriate treatments, devices, and services.Self -help groups are an increasingly strong andeffective force in promoting awareness of hear-ing impairment and the needs of hearing impairedpeople. While self-help groups for deaf people haveexisted for some time, groups for people with par-tial hearing loss have developed more recently.Some of these groups are organized on a nationallevel, sometimes with local chapters, while othersfunction only on a local level. One example of anational group is Self Help for Hard of HearingPeople, an organization with more than 15)000members and 170 local chapters and affiliates in41 States.While self-help groups differ in their primaryfocus and mode of operation, they tend to empha-size several important points:qqqthe severe impact of hearing loss on many in-dividuals;the need for hearing impaired individuals toadmit their hearing impairments, to overcomethe sense of shame that many hearing im-paired people feel, and to be more assertiveabout their communication needs; andthe need for families, friends, and others whointeract with hearing impaired people to beaware of and use devices and communicationtechniques that promote effective communi-cation.Self-help groups also stress the heterogeneityof hearing impaired people, both in terms of the
  • 5oto credit. Pete Souza, The White HousePresident Reagan has acknowledged his hearing loss and is using a small, canal-style hearing aid to compensate forit. By his example, the President has encouraged other hearing impaired people to acknowledge their impairments andconsider the use of a hearing aid or other hearing assistive device for themselves., :t t.,. ~ :I~ tSouza. The White
  • 6type and severity of each individual’s hearing lossand other physical, emotional, and social charac-teristics of the person and his environment thataffect his communication needs. This hetero-geneity creates a need for a variety of hearing de-vices and services and a process for determiningthe needs of each individual. Self-help groups pointout that the hearing impaired individual is usu-ally the best source of information about his hear-ing loss and that too little attention has been paidto what hearing impaired people, especially thosewith partial hearing loss, say about their needs.In addition to increased awareness of hearingloss in elderly people, there is a need for increasedresearch. Although the prevalence of hearing im-pairment far exceeds most diseases and disabili-ties of later life, the magnitude of this problem hasnot been reflected in the amount of research thathas been conducted on underlying pathologies,prevention, treatment, and rehabilitation. As a re-sult, the state of the art in this field has progressedmore slowly than in many other fields (10).Most hearing research has been focused on verysevere impairments, and particularly the problemsof deaf children. While the results of this researchare sometimes applicable to elderly people, thecharacteristics of hearing impairments that arecommon in elderly people often differ from thoseof severely hearing impaired younger people. Hear-ing impairment in the elderly is often mild or mod-erate, but it is widespread. It is often progressive,with a gradual onset, and may not be recognizedfor some time. In addition, a significant but as yetundefined number of elderly people have decreasedability to tune out background noise and thus havemore difficulty hearing in noisy settings than youn-ger people with comparable hearing ability (31,44). Finally, hearing impairment in elderly peopleoften coexists with other health problems that cancomplicate treatment and limit the effectivenessof hearing devices. Research focused on the mech-anisms of hearing impairment in elderly peopleand appropriate treatment approaches is needed.Few of the hearing impairments common amongelderly people respond to medical or surgical treat-ment. However, a variety of approaches, such asthe use of hearing aids, other assistive listeningdevices, and aural rehabilitation techniques, canbe used to compensate for hearing impairment.These approaches can improve communicationability even when the underlying problem cannotbe cured.Hearing aids are the most widely used devices,but most people with hearing impairments do notuse hearing aids. Estimates from various studiesindicate that between 8 and 25 percent of hearingimpaired people use a hearing aid3(41, 49,94,119),Some of those who do not use hearing aids havebeen told that a hearing aid will not help them;others deny that they need a hearing aid or resistusing a hearing aid for cosmetic reasons. Still othersbuy hearing aids but never learn to use them andeventually stop trying.Hearing aids function well for many elderly peo-ple but do not compensate for hearing loss in othersforqqqqseveral reasons:Some people buy hearing aids that are not wellmatched to their needs. Sometimes this oc-curs because they purchase an aid withouthaving a complete hearing evaluation to iden-tify their specific hearing deficits. Lack ofMedicare reimbursement for a hearing evalu-ation to select a hearing aid exacerbates thisproblem.Even when a person’s specific hearing defi-cits have been identified, lack of informationcomparing different types of hearing aids canmake it difficult to identify the most appro-priate aid.Hearing aids generally amplify all environ-mental sound, including background noise.Although design modifications can improvethe speech-to-noise ratio, some hearing aidusers continue to have problems tuning outbackground noise.Current hearing aid technology does not al-low custom design of a hearing aid in the waythat eyeglasses can be prescribed and groundspecifically for an individual. Within five years,microprocessor technologies may make “pre-scription hearing aids” available.In addition to hearing aids, assistive listening de-vices such as infrared and FM devices can benefitmany hearing impaired people. These devices can3Estimates of the percentage of hearing impaired people who usehearing aids vary depending on the source of the data and the fig-ure that is used for overall prevalence of hearing impairment,
  • 7be particularly effective for those with mild or mod-erate hearing loss and in situations where back-ground noise is a problem. Some profoundly im-paired persons can also benefit from them. Yetmost elderly individuals do not know about assis-tive listening devices and the existing service de-livery system does not promote their use. Rela-tively few hearing specialists offer a full range ofthe assistive devices. The VA Medical Center inBirmingham, Alabama, has developed a programto distribute these devices, and hearing specialistsat the center receive inquiries about the devicesfrom hearing impaired people all over the coun-try. They refer many people to hearing specialistsin their local areas, but in some areas there areno specialists trained in the use of these devices(129).Medicare, Medicaid, and private insurance donot reimburse for assistive listening devices or forprofessional adivce to determine which devicesare appropriate. (See ch. 5 for a discussion of fund-ing for hearing devices and services. ) Legislationto provide Medicare and Medicaid reimbursementfor these devices was introduced in Congress in1984 and again in 1985. Many observers doubt thatthis legislation will pass because of current budgetlimitations, but supporters argue that reimburse-ment for these devices would encourage their use,thus increasing the independence of hearing im-paired people and ultimately reducing Federalspending for other services.Aural rehabilitation services, including counsel-ing, training in speechreading,4and hearing aidorientation can help hearing impaired elderly peo-ple by reducing anxiety, facilitating better use ofresidual hearing, and achieving more realistic ex-pectations regarding remediation of hearing loss.Yet few hearing impaired elderly people receiveaural rehabilitation services. Public education andeducation of health care and social service pro-viders is needed to encourage the use of these es-sential services.Hearing impaired people who cannot hear overthe telephone face serious problems. They are notable to talk with family and friends, arrange nec-essary services, and obtain assistance in an emer-gency. Some people with mild or moderate hear-ing loss can manage well with a telephone that hasan amplifier in the handset. Others have hearingaids designed with a “telephone switch”5and theycan use compatible telephones. But not all tele-phones are compatible with hearing aids, and mosttelephones do not have amplifiers. In addition,many hearing aids are manufactured without atelephone switch. Some hearing impaired peopleand hearing professionals advocate Federal legis-lation to require that all new telephones be com-patible with hearing aids. Some also advocatestrengthening the Federal and State regulationsthat require telephone companies to make special-ized equipment available to hearing impaired peo-ple for use at home.Adapting public facilities so they are accessibleto the hearing impaired is an area where progresshas been very slow. Section 504 of the Rehabilita-tion Act of 1973 prohibits discrimination againstdisabled individuals by any program or activityreceiving Federal assistance. The law requires thatall facilities receiving any form of Federal supportmust provide access for people with all kinds ofhandicaps, including hearing impairment (80). Sofar, however, efforts have emphasized adaptingfacilities for people with problems in mobility. Thishas occurred even though the costs of installingan audio loop, infrared, or radio frequency (AMor FM) amplification system is usually minimal.compared to the costs of the major architecturalchanges needed to accommodate people with mo-bility impairments. Although it seems incongru-ous, public funding has been available for architec-tural modifications while the cost of amplificationsystems has been paid primarily by the private sec-tor (10).The needs of older people with hearing impair-ments should be considered in any plans to adaptfacilities for the handicapped. In addition, envi-ronmental design technologies to compensate forhearing impairment could be applied in public fa-cilities. These technologies are discussed in chap-ter 3.4S~)t~(!(’hr-(~acii~~g is another term for lipread ing, The term spcerh -read ing emphasizes that the hearing impaired person l~atrhm+ fa -rial, t h ro;it, ;iml hodk nlmrments of the spwiker in [id{] it ion t{) hisIll) n]otfmlf]nts in o;der to undf:rstand m hat he is s~ijing.5A telephone smitrh, nr ‘“ r st~ritrh ,“ is a feature hui]t into sorllphearing aids that allm~s the aid to pick up electronic signals direct 1)from compatihlp t(>lephon(j re(’ei~er-s, t h u s hypssing thf’ h e a r i n g;i id microphone’ and f’lim in:iting unlid nt ml sound.
  • 8A final concern is the apparentrivalry among the three groups oftension andhearing spe-cialists: physicians who specialize in hearing dis-orders, audiologists, and hearing aid dealers. Phy-sicians who specialize in hearing disorders aremedical doctors with training in diseases of theear. Audiologists are nonmedical hearing special-ists who have a master’s or doctoral degree in au-diology, the science of hearing, Hearing aid dealersare individuals who sell hearing aids who are nei-ther physicians nor audiologists. This report refersto individuals in each of these groups as “hearingspecialists .“ The training and unique skills of eachof these groups are discussed in chapter 4,Each group plays an important role in provid-ing hearing services for elderly people, The con-tinuing rivalry among them interferes with the de-velopment of service delivery systems that makethe full range of devices and services available tohearing impaired elderly people. Any Federal leg-islation or regulations related to hearing servicesshould discourage this rivalry and encourage thedevelopment of coordinated service delivery sys-tems that use the expertise of each type of hear-ing specialist.
  • Chapter 2The Epidemiology ofHearing Impairment inElderly People
  • Chapter 2The Epidemiology of HearingImpairment in Elderly PeopleTYPES AND CAUSES OF HEARING LOSS AMONG ELDERLY PEOPLEHearing impairment can be partial or complete.It can be unilateral (one ear) or bilateral (both ears),temporary or permanent, stable or progressive.Types of hearing impairment include conductive,sensorineural, mixed, and central processing dis-orders. These types are based on the site of struc-tural damage or blockage (see figure 1). Conduc-tive hearing impairment involves the outer and/ormiddle ear. Sensorineural impairment involvesdamage to the inner ear, the cochlea, and/or thefibers of the eighth cranial nerve. A mixed hear-ing impairment includes both conductive and sen-sorineural components. Causes of conductive andFigure 1 .—Structure of the EarMalleusItubeMiddle IOuter Ear Ear Inner EarIn the healthy ear, sound waves gathered by the outer ear are trans-mitted through the eardrum and three small bones in the middle ear—the malleus, incus, and stapes—and into the inner ear. There soundis converted from vibrations into electrical impulses by tiny sensoryreceptors, called hair cells, in the cochlea. The electrical impulsespass through the eighth cranial nerve Into the auditory centers of thebrain.SOURCE Vlckl Friedman, Washington University Medical Center at St. Louissensorineural hearing impairment are listed intable 1.A central processing disorder is a hearing im-pairment that influences complex aspects of hear-ing, such as understanding speech. The hearingTable 1 .—Causes of Conductive and SensorineuralHearing ImpairmentsCauses of conductive hearing impairments:External blockage: buildup of wax or presence of a foreignobject in the ear.Perforated eardrum.’ a hole or tear in the eardrum that canoccur as a result of injury, sudden pressure change, or in-fection.Genetic and congenital abnormalities.’ malfunction and/ormalformation of the outer and/or middle ear that can oc-cur in connection with hereditary disease or as a result ofillness or injury before or at the time of birth.Otitis media.’ middle ear infection with fluid accumulation.Otosclerosis: hereditary disease process resulting in over-growth of a small bone in the middle ear which interfereswith sound conduction.Causes of sensorineural hearing impairment:Prenatal and birth-related causes: infections such as rubel-la contracted by expectant mothers, drugs taken duringpregnancy, or difficult labor and delivery.Hereditary causes: a variety of disorders that damage thecochlea or higher nerve centers and are usually presentat birth; the gradual loss of hair cells in the cochlea thatbegins as young as the twenties and thirties in some in-dividuals and may be caused by heredity.Viral and bacteria/ infections: infections such as mumps, spi-nal meningitis, and encephalitis.Trauma: a severe blow to the head, an accident, or a strokeor brain hemorrhage that affect the ear, nerve pathways,and auditory brain centers.Tumors: tumors called acoustic neuromas that invade theeighth nerve.Noise: exposure to loud sounds that irreparably damage thehair cells.Cardiovascular conditions: hypertension, heart disease, orother vascular problems that alter blood flow to the innerear.Ototoxic drugs: aspirin, some antibiotics, diuretics, and cer-tain powerful anticancer drugs that damage the hair cellsor other vital parts of the inner ear.Meniere’s disease: a disorder characterized by fluctuatinghearing loss, dizziness, and tinnitus; possible causes in-clude aIlergy, hypothyroidism, diabetes, and syphilis.SOURCE: NINCDS, 1982 (124),11
  • 12impaired person may hear the words but not makeany sense out of them. Some words are difficultto interpret, almost as if the person were listen-ing to a foreign language. This kind of hearing im-pairment can be caused by disorders of the audi-tory pathways in the brain. With aging, the speedof nerve impulses may slow or the brain may losethe ability to interpret words that come at a rapidpace.Tinnitus is a condition that often accompanieshearing loss. It is a ringing, buzzing, or hissing inthe ears or head that can be continuous or inter-mittent. The causes of tinnitus are not well un-derstood but can include obstructions in the outerear, perforation of the eardrum, middle ear infec-tion, repeated exposure to loud noise, trauma, andsome medications,Presbycusis is the term most often used to de-scribe hearing impairment in elderly people. Theword presbycusis means “old hearing. ” It is usu-ally defined as a sensorineural loss caused bychanges in the inner ear, but some experts includemiddle ear changes associated with aging in thedefinition (124) and others emphasize the impactof changes in the eighth cranial nerve and audi-tory brain center (54).The diagnosis of presbycusis is used for hear-ing impairment associated with a variety of sen-sory, neural, metabolic, mechanical, and vascu-lar changes seen in elderly people. Yet little isknown about the underlying causes of presbycu-sis and the term is sometimes used when no spe-cific cause of the condition can be identified.Conditions that are frequently diagnosed as pres-bycusis include gradual loss of hair cells in the coch-lea and fibrous changes in the small blood vesselsthat supply the cochlea.1Some researchers believethat these changes are caused primarily by envi-ronmental factors and disease while others believethey are primarily a result of normal aging (125).However, not all elderly individuals are affectedby presbycusis, and some people over 90 retainacute hearing.The diagnosis of presbycusis is sometimes givenmistakenly when a specific cause of the hearingIThe cochlea is dependent on a single artery for blood supply,making hearing very susceptible to damage as a result of cardiovas-cular disease [73),impairment could be identified and possiblytreated (73). For example, wax buildup in the outerear frequently causes hearing impairment inelderly people. If presbycusis is diagnosed, the realproblem—ear wax—might be missed and go un-treated.The term presbycusis can be confusing becauseit is used to describe three situations: 1) treatableconditions caused by disease, 2) conditions causedby disease for which no treatment is known, and3) conditions believed to result from normal aging,For health care professionals, elderly people, andtheir families, a diagnosis of presbycusis may mis-takenly imply that nothing can be done for thepatient. Greater attention to isolating the cause ofa person’s hearing loss can help ensure promptand effective treatment in some cases. In general,however, more research is needed to describe theunderlying pathologies that cause presbycusis andto differentiate between treatable and untreatablecauses of these conditions.To develop a more complete understanding ofhearing loss associated with aging, we must im-prove our knowledge about the basic mechanismsof hearing in the normal ear. While the normalfunctioning of the outer and middle ear is rela-tively well understood, the structural and biochem-ical mechanisms of the inner ear and auditory braincenters are less well understood. The cochlea, apea-sized organ with more than a million movingparts, is one of the most complex mechanical struc-tures in the human body. Only within the past dec-ade have methods been developed to study thistiny structure. Research on the molecular struc-ture and mechanical properties of hair cells in thecochlea and the biochemical processes by whichsound vibrations are converted to neural impulseshas significantly increased our understanding ofthe basic mechanisms of hearing (53). But little isknown about how the damaged ear processessound (88).Lack of communication among researchers inthis field has been a problem but recent researchdevelopments have stimulated increased inter-action. A national conference on auditory bio-chemistry held in 1984 brought many prominentresearchers together for the first time and par-ticipants hope that this process will be repeatedregularly (30).
  • 13MEASURING HEARING IMPAIRMENTHearing impairment is measured by two meth-ods: interviews and audiometric tests. Definitionsof the levels of impairment reflect these two meth-ods. The interviewrmethod relies on self -reportedhearing loss and the resulting statistics are pre-sented in categories such as: “no trouble hearing, ”‘(can hear words spoken in a normal voice, ” ‘(canhear words shouted across a room,” and “at bestcan hear words shouted in ear” (119). Audiomet-ric tests measure an individual’s response to soundsof varying intensity or loudness, and level of im-pairment is reported in terms of the weakest soundthe individual can hear. Intensity of sound is meas-ured in decibels; zone scale used to define levelof impairment is illustrated in table 2.The level of hearing impairment that is consid-ered significant varies for different surveys, re-search projects, and clinical applications. Hearingspecialists and researchers continue to debate themost appropriate level to call significant for spe-cific applications.3Different surveys show different prevalencefigures in part because they select different levels‘The dccihel scale is a logarithmic Sral(> (hased on poh~rers of 1())that nleasLlrPs intensit~ of sound or loudness. A sm~ll inf’r~ase indecilwls ((IB) represents a large increase in loudness. For example,a s o u n d at 40 dB is 1() t imf?s as bLld as a S{)und at 30 dB and 100times as loud as a sound at 20 dkt3’I’h is drhate is N31(’t’illlt to scrfwning pro~r:irns and iclent ifirationof patients liho need tre:itment as discussed in rh. 4.Table 2.— Hearing Loss in Decibels Related toApproximate Degree of ImpairmentHearing loss in decibels (dB) Degree of impairmento to 20 dB . . . . . . . . . . . . . . . . . . . . . . Normal20 to 40 dB . . . . . . . . . . . . . . . . . . . . . Mild40 to 55 dB . . . . . . . . . . . . . . . . . . . . . Moderate55 to 70 dB . . . . . . . . . . . . . . . . . . . . . Moderately severe70 to 90 dB . . . . . . . . . . . . . . . . . . . . . Severe>90 dB . . . . . . . . . . . . . . . . . . . . . . . . Profound deafnessSOURCE Knauf, 1978 (64).of impairment as significant. Reported prevalencealso varies depending on whether the interviewor audiometric testing method is used. Prevalencefigures based on interviews tend to underestimatethe frequency of hearing impairment becausemany people, particularly elderly people, are notaware of their hearing loss or may deny or mini-mize its severity in an interview. Some experts be-lieve that audiometric testing provides more ac-curate measurement but prevalence figures basedon both methods are widely cited in the literature(10).Four types of audiometric tests are commonlyused to measure hearing loss: 1) pure tone air con-duction, 2) bone conduction, 3) speech reception,and 4) speech discrimination. Pure tone air andbone conduction tests measure hearing loss at spe-cific frequency levels. Hearing loss varies greatlyaccording to frequency, especially in elderly peo-ple, and information about hearing deficits at spe-cific frequencies is important for diagnosis, treat-ment, and research. The prevalence of hearing lossbased on audiometric tests varies according to: 1)the sound frequency used; 2) the decibel level atwhich hearing impairment is recognized for thatparticular survey, called the fence; 3) whether oneor both ears are tested; and 4) whether data arereported for the right or left ear, the better ear,the worse ear, or an average.Some individuals are able to hear the pure tonesused in air and bone conduction tests but havedifficulty understanding speech because of prob-lems in auditory discrimination. This condition,called dysacusis, is widespread among hearing im-paired elderly people. Pure tone air and bone con-duction tests underestimate the extent of dysacu-sis (69) and, as a result, prevalence estimates basedon pure tone air and bone conduction tests areusually lower than those based on speech recep-tion and speech discrimination tests (41).
  • 14PREVALENCEThe prevalence of hearing impairment varies byage, sex, race, income, and institutional status.prevalence estimates also vary depending onwhether they are based on interview or audiomet-ric testing.4There is ongoing debate about the ac-curacy of interview and audiometric tests for meas-uring hearing impairment and about the level ofhearing loss that constitutes significant disability.These debates are relevant to understandingwhether prevalence estimates are valid.The data in the following discussions reflect ourbest understanding of the nationwide prevalenceof hearing impairment. However, the generaliza-tions may not apply in certain geographic areas.For example, chronic ear infections are commonamong certain ethnic groups in Alaska and Indiansin some Southwestern States and this increasesthe prevalence of hearing impairment in thoseareas. Similarly, in areas where high-noise indus-tries are concentrated, hearing loss is more com-mon among persons of working age and older (10).AgeAccording to the 1977 National Health InterviewSurvey (NHIS), about 8 percent of the civilian,noninstitutionalized population experienced somedegree of chronic hearing impairment. Prevalencerises from about 1 percent of those under age 17to more than 38 percent of those over 75 (see fig-ure 2).4Prevalence figures based on interviews come from the 1977 Na-tional Health Interview Survey (NHIS), conducted by the NationalCenter for Health Statistics (NCHS). NHIS is an annual nationwidesurvey. Respondents are asked about acute and chronic health con-ditions of all members of the household. In 1977, a special supple-ment to the NHIS focused on hearing impairment. NHIS data are be-lieved to underestimate prevalence because some people deny orare unaware of their hearing impairments or may not consider theirhearing loss a problem and because NHIS interviews are usually con-ducted with only one member of the household, who may not beaware of or report hearing impairments of other household members.Prevalence figures based on audiometric testing come from theHealth and Nutrition Examination Surveys (HANES), conducted from1971 to 1975 by NCHS. A random sample of aduhs aged 25 to 74in the civilian, noninstitutionalized population was tested using puretone air and bone conduction tests at 4 frequency levels (500, 1,000,2,000, and 4,oOO Hertz) and a speech reception test. Air and boneconduction tests were reported for the right ear only; this lowersprevalence estimates because those with unilateral hearing loss inthe left ear are not included.Both NHIS and HANES underestimate overall prevalence in theelderly population because the institutionalized elderly, who havevery high prevalence, are not included.Figure 2.—Prevalence of Hearing Impairment,Including Tinnitus, in the Civilian,Noninstitutionalized Population, United States,197712 ”/0?— 80/04 %1 %I240/,All ages Under 17 17-44 45-64 65-7439%Iand overA g eSOURCE: NCHS, 1981 (120).Audiometric surveys also show significant in-creases in hearing impairment with age and theyindicate a higher overall prevalence than interviewsurveys (41, 51). For example, one national audio-metric survey showed that almost 30 percent ofindividuals between 65 and 74 and 48 percent ofthose between 75 and 79 had impaired hearingfor understanding speech (69).Audiometric data show that hearing loss isgreater for high frequency than for low frequencysounds for all age groups. As figure 3 indicates,hearing impairment at high frequencies is verycommon among elderly people.While most speech is in the range of 500 to 2,000H Z )5sounds such as S, th, k, and f are heard athigher frequencies. Elderly individuals with hear-ing impairments at 4,000 Hz (i.e., almost 60 per-cent of all elderly people) are often unable to hearthese sounds and this interferes with their under-standing of normal speech.‘Frequency is measured in vibrations or cycles per second, calledHertz (Hz).
  • 15Figure 3.— Prevalence of Hearing Impairment Among Adults by Frequency of Tone, United States, 1971-75°I500 Hz25-341 , 0 0 0 H z1 ~ 1 2 , 0 0 0 H z4 , 0 0 0 H z1 7 %0 10 20 30 40 50 60 70Percent hearing impairedaThese data are based on air condition tests, Figures include individuals who were able to hear the tones at 31 decibels or more at least 50 percent Of the time.SOURCE: NCHS, 1960 (1 16).GenderInterview surveys indicate that elderly men havea higher prevalence of hearing impairment thanelderly women. The 1977 NHIS found that amongpeople 65 to 74, about 29 percent of men reportedhearing impairments compared to only 20 percentof women. Among those 75 and over, 44 percentof men but only 35 percent of women reportedhearing impairments (121). Some experts suggestthat these different rates are the result of lifelongexposure to loud noise while hunting, serving inthe military, or working in farm and factory oc-cupations (10, 129).Longitudinal studies indicate that men andwomen aged 50 to 80 experience hearing loss inthe same frequency range, but hearing loss in-creases more rapidly in men than in women. Af-ter age 80, these differences in hearing impairmentbetween men and women become indistinguish-able (54, 123).Audiometric data show much higher prevalenceof high frequency hearing impairment for elderlymen than for elderly women, but elderly womenhave similar or slightly higher prevalence at lowfrequencies (54). For example, air conduction testsused in the Health and Nutrition Examination Sur-vey (HANES) showed that 78 percent of the menfrom age 65 to 74 had hearing loss at 4,000 Hz,compared to only 46 percent of the women in thatage group. In contrast, at 500 Hz about 12 percentof elderly men and 18 percent of elderly womenhad hearing loss, while at 1)000 Hz about 18 per-cent of elderly men and 21 percent of elderlywomen had hearing loss.6Bone conduction testsproduced similar findings (116). The reason forthis variation in prevalence for men and womenat different frequencies is not known.RaceThe 1977 NHIS indicated a substantially lowerprevalence of hearing impairment among non-whites of all ages than among their white coun-terparts (see table 3).Audiometric data show a more complex rela-tionship between race and hearing impairment,HANES data indicate that elderly nonwhites have6Figures include individuals who were able to hear the tones at31 dB or more at least 50 percent of the time,
  • 16Table 3.—Prevalence of Hearing Impairment,Including Tinnitus, in the Civilian, NoninstitutionalizedPopulation, by Race and Selected Age Groups,United States, 1977RaceAge White All otherUnder 17 years . . . . . . . . . . . . . . . . . . . . . . . 1 % 1 %17 to 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 345 to 64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 865 to 74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1875 and over . . . . . . . . . . . . . . . . . . . . . . . . . . 39 31SOURCE:NCHS, 1981 (120)a lower prevalence of severe hearing impairmentsthan elderly whites, but a higher prevalence ofmoderate hearing impairments.7This distinctionis true for pure tone air conduction measures at500, 1,000,2,000, and 4,000 Hz. On speech recep-tion tests elderly nonwhites had a higher preva-lence of hearing impairment at all levels of sever-ity except profound deafness (116). The differencebetween these results and data from interview sur-veys suggest that elderly nonwhites may be lesslikely than elderly whites to report hearing im-pairment in an interview.IncomeIn general, persons with low family income havea higher rate of hearing impairment at all ages thantheir wealthier counterparts. For example, the1977 NHIS found that the rate of impairment forpersons aged 65 to 74 with annual family incomesbelow $3,000 was about 30 percent. For the sameage group with incomes in excess of $15)000, therate was about 20 percent (121). With only minorvariation, this inverse relationship between incomeand hearing loss is sustained for all age catego-ries. Although the reasons for this relationship arenot known, it may be because low income peoplehave poorer general health, poor primary healthcare, and greater exposure to environmental noise7For this comparison, hearing impairment above 50 dB is consid-ered severe, while impairment from 31 dB to 50 dB is consideredmoderate.and this results in higher prevalence of hearingimpairment (10, 42).InstitutionalizationThe prevalence of hearing loss among institu-tionalized elderly people is greater than amongnoninstitutionalized elderly people. One surveyin a Veterans Administration nursing home foundthat 90 percent of the residents had hearing im-pairments (132). A review of research on hearingloss among nursing home residents found preva-lence estimates ranging from 48 to 82 percent (98).The variation among these findings is attributedto: different methods of measuring hearing loss,the types of nursing homes studied, characteris-tics of the selected population, lack of uniforminterpretation of “hearing loss)” and lack of infor-mation about threshold sensitivity at individual fre-quencies.A study of hearing impairment in a nursing homein Canada pointed out the inadequacy of selfreports for assessing hearing impairment in thistype of setting (22). Residents were interviewedabout their hearing ability and given audiometrictests. Fifty percent of the residents acknowledgeda hearing loss in interviews, but audiometric test-ing showed that 75 percent actually had hearingimpairments. Eight percent of the residents re-ported hearing loss when there was no audiomet-ric evidence of impairment, while 33 percent re-ported normal hearing but actually had clinicallysignificant loss. Audiometric testing should be aroutine procedure for elderly people admitted tonursing homes since hearing loss, including un-recognized loss, can affect a person’s ability to func-tion normally.Prevalence of TinnitusThe prevalence of tinnitus increases with age(see figure 4) and more women than men reporttinnitus (69).
  • 17Figure 4.— Prevalence of Tinnitus, by Severity andSelected Age Groups, United States, 1960-62a50 I40 severe0 L33—38———4118-24 25-34 35-44 45-54 55-64 65-74 75-79AgeaPercentage figures rounded to nearest whole number.SOURCE: Leske, 1981 (69).THE IMPACT OF HEARING IMPAIRMENTClinical ImpactHearing impairment lessens a person’s ability tohear environmental sound without amplification.In some cases it also diminishes the ability to dis-criminate between sounds even with amplifica-tion. This condition is common among hearing im-paired elderly people and results in the complaint,“I can hear you, but I can’t understand you” (54,89). Some research indicates that auditory discrimi-nation is a problem even for some elderly peoplewith normal hearing as measured by pure toneaudiometric tests. This is less often true of young-er people with normal hearing measured in thesame way (63).Loss of the ability to hear high-frequency soundsis characteristic of hearing impairment in manyelderly people. At birth the human being is ableto hear sounds as high as 30,000 Hz, but each yearof life results in some loss. By the teens, many in-dividuals can hear only up to 20,000 Hz, and byold age many people cannot hear sounds at 4,000Hz or even 2,000 Hz, the level of some speechsounds (32).Elderly people with hearing impairment usuallyhave diminished ability to hear low-intensitysounds, but their ability to hear very loud or high-intensity sounds can remain unchanged. This canmake it uncomfortable to use hearing devices thatamplify all sounds uniformly because relativelyloud sounds that are amplified then become in-tolerably loud (89).Another common characteristic of hearing im-pairment in elderly people is an inability to tuneout background noise. Many elderly people experi-ence difficulty hearing in a noisy environment be-cause they cannot separate speech from back-ground noise (54, 82). Although available data arenot conclusive, studies suggest that elderly peo-ple have more difficulty hearing in a noisy envi-ronment than younger people with comparablehearing ability. Furthermore, even elderly indi-viduals with normal hearing ability, measured byaudiometric tests, can experience problems withbackground noise (31,44). Sound reverberationsin large rooms such as auditoriums and churchesalso interfere with speech perception among manyelderly people.aIn the normal ear, the efferent system is a sys-tem of complex neural mechanisms that act to con-%h. 3 discusses the implications of these findings for hearing aiddesign, the use of assistitw listening de~’ices, and eniironmentaf de-sign technologies. Implications for screening programs and iden-tification of people ~tho need treatment are discussed in ch. 4,
  • 18trol discrimination of sound, detection of soundsignals in noise, and localization of sound. Littleis known about how this system inhibits responseto some auditory signals and tunes out unwantedsound. Further, it is not known how the efferentsystem changes with age and whether suchchanges are part of why elderly people have diffi-culty understanding speech in noisy environments.Continued research on the mechanisms of selec-tive inhibition could help increase our understand-ing of hearing impairment in the elderly (30).psychosocial ImpactHearing impairment causes psychological andsocial difficulties because it interferes with a per-son’s ability to communicate effectively. Commu-nication plays an essential role in maintaining rela-tionships and the quality of life, and hearing lossdeprives not only the individual, but also familyand friends, of easy communication. Repeated in-stances of unheard or incorrectly heard commu-nication are frustrating for the individual andeveryone he converses with and may cause allthose involved to initiate conversation less fre-quently. When these frustrating situations occurover prolonged periods, family relationships canbe severely strained. Hearing loss also can affecta person ability to speak clearly because his ownvoice sounds distorted, and this can add anotherimpediment to communication.Hearing loss limits a person’s ability to enjoymany forms of entertainment, such as television,radio, music and theater, and as a result he maywithdraw from them. Similarly, some hearing im-paired people stop going to church and socialgatherings because they cannot hear well enoughto enjoy these activities (32, 54). Hearing impair-ment also limits access to information that is nor-mally available through personal communication,television, radio, and telephone. Elderly peoplewho have both hearing and visual impairmentsare even more severely limited in their access toinformation.Aging can bring many kinds of losses: loss of in-come and decreased sense of usefulness associ-ated with retirement; loss of relationships due tothe death of spouse, siblings, and friends or dueto a physical move from a familiar home or com -munity; and diminished health, energy, and mo-bility. While most elderly people cope well withthese losses, hearing impairment can hinder thecoping process by interfering with the person’sability to become involved in new activities, formnew relationships, and arrange for needed serv-ices (10).For some people, hearing impairment can leadto withdrawal, social isolation, and depressioncaused by lack of interpersonal communicationand contact. One British study found a significantrelationship between depression and hearing im-pairment among community dwelling elderly peo-ple (51). Another study, however, found no corre-lation between hearing impairment and eitherdepression or social interaction (112). The re-searchers suggest that the subjects in the latterstudy may not be typical of the elderly populationbecause of their general good health, economicsecurity, and high level of education. Further re-search is needed to clarify the relationship betweenthese variables.Clinical observation suggests that there is a rela-tionship between hearing impairment and psy-chopathology in some individuals. Particularlywhen hearing impairment occurs gradually, as itoften does in later life, deaf and hard-of-hearingindividuals sometimes develop delusions of perse-cution and other paranoid reactions. These symp-toms may occur because the older person is notaware of his hearing impairment—he notices thatothers seem to be talking in his presence but tooquietly for him to hear or that they are laughingabout something he cannot hear. He becomes sus-picious and may accuse them of excluding him de-liberately. When they deny these accusations, hemay become more suspicious.Research has demonstrated this relationship be-tween hearing impairment and paranoid symp-toms (139). College students were hypnotized toinduce temporary hearing impairment and thenasked to work with others on a joint project. Thesesubjects tended to develop symptoms of paranoia,including suspiciousness, grandiosity, irritability,and judgmental attitudes.Some clinicians and long-term care providershave suggested that hearing impairment can causeor exacerbate mental deterioration in old age (10).
  • 19One study found a significant relationship betweenhearing impairment and dementia (51). The rela-tionship did not hold up, however, when age wascontrolled, indicating that while both hearing im-pairment and dementia are associated with advanc-ing age, they are not otherwise correlated. Anotherstudy showed that hearing impaired individualsdo as well as individuals with no hearing problemson nonverbal tests of cognition but less well onverbal tests (112). It is not known whether theseresults occur because the hearing impaired indi-viduals do not hear the questions on verbal testsclearly or whether some types of hearing impair-ment interfere with cognitive processes for en-coding and recalling verbal messages.Changes in brain function associated with agingcan affect hearing, according to a report preparedby the Working Group on Speech Understandingand Aging of the National Academy of Sciences.The report, to be published in 1986, indicates thatphysiological changes in the brain that affect over-all brain function (not only the auditory braincenters) can result in slowed response to auditorystimuli (113). Continued research on the relation-ship between cognitive change and hearing lossis needed.Perhaps more important than any actual rela-tionship between hearing impairment and men-tal deterioration is a widespread assumption insociety that elderly persons who are hearing im-paired are also confused (30, 112, 124). A strongtendency exists to stereotype elderly people assenile (95) and the additional factor of a hearingloss increases stereotyping. In a study conductedin an acute care hospital, health care professionalsdescribed their impatience with elderly personswith hearing losses (9). Several respondents saidthe method they used in interactions was to“scream at them. ” This behavior was consideredacceptable since the patients were old “and prob-ably senile, too. ”Other negative attitudes about individuals withhearing impairments are also widely held. Peopleseem to be more sympathetic to visible impair-ments and may be more sympathetic to blind peo-ple than to those with hearing impairments. More-over, there is an unfortunate tendency to blamethe hearing impaired person for his or her disabil-ity, especially if the person is also old. This ten-dency may partially explain the sense of shamethat many hearing impaired people feel (82). Fi-nally there is a common belief among health careproviders, as well as among the general public,that hearing loss in elderly people is not treatable(lo).A study comparing hearing impaired elderly peo-ple who did not seek treatment with those whodid seek treatment identified two factors that af-fected whether people sought help: 1) the sever-ity of the impairment, and 2) the onset of hearingimpairment before retirement age. Both elderlyindividuals and their physicians can have nega-tive attitudes about hearing loss that begins in oldage. This can play an important role in determin-ing which individuals seek treatment (55).Nursing home residents are very likely to havehearing impairments that can be particularlydevastating for several reasons. The move to anursing home requires adjustment to a new envi-ronment, new people, and new daily routines.Hearing impairment interferes with the individ-ual’s ability to develop relationships with staff andother patients and to fully understand the dailyschedule. One regular visitor to a nursing homereports a comment that is heard all too often withregard to hearing impaired residents, “Don’t bothertalking to her, she can’t hear you” (14).Some hearing impaired nursing home residentshave mobility impairments that interfere with theirability to interact with others and other sensoryimpairments, such as vision and speech deficits,that further reduce their ability to socialize. Thesemultiple impairments compound the isolation oftenassociated with severe hearing loss. Finally, manynursing home residents have irreversible mentalimpairments caused by strokes, primary degener-ative dementias such as Alzheimer’s disease, orother disease conditions. In this context, it is easyfor nursing home employees to assume that hear-ing impaired residents who do not answer ques-tions correctly and do not seem to understand thedaily routine are also mentally impaired. The im-pact of this assumption on the hearing impairedresident’s quality of life can be very severe.Denial of Hearing ImpairmentMany elderly people deny they have a hearingproblem despite substantial evidence to the con-
  • 20trary. Many authors have discussed the problemsof denial and refusal to seek treatment (76), butlittle attention has been given to the underlyingreasons for it. Elderly people who deny or avoidconfronting a hearing loss are not doing so in avacuum. Negative social attitudes about hearingimpairment and growing old encourage denial.Hearing impairment is not visible, and invisibilityfacilitates denial. In addition, hearing impairmentin elderly people often has a very gradual onsetthat can make it difficult to recognize.For elderly persons with one or more life-threat-ening illness, hearing impairment may seem in-significant in comparison. The onset of depression,withdrawal, paranoia, and other mental healthproblems associated with hearing impairment isslow and insidious and may seem unrelated to thehearing loss. An elderly person’s inability to re-ceive aural cues can lead to accidents, though thecauses may seem ambiguous. Likewise, difficul-ties in communication and social relationships maynot be attributed to hearing loss, even when theloss is acknowledged. As a result, hearing impair-ment often is mistakenly seen as unimportant byelderly people, their families, and health careproviders (10). This denial of the importance ofhearing impairment and our failure to recognizeits full impact on independent functioning are clearobstacles to effective treatment.DEAFNESSOnly a small percentage of elderly people aredeaf. There is no consensus about the exact prev-alence of deafness, in part because of variationin the method used to measure hearing impair-ment and the level of impairment that is definedas deafness. However, estimates using audiometrictests indicate that about 2 to 4 percent of all el-derly people are deaf (116, 119). Among peopleover 75, prevalence increases somewhat, and ifpeople with severe hearing impairments are in-cluded, prevalence increases significantly.For practical purposes elderly deaf people canbe divided into three groups: 1) those who becamedeaf very early in life before language was ac-quired, 2) those who became deaf during early ormiddle life after language was acquired, and 3)those who became deaf during later life. Peoplewho have been deaf since childhood have usuallylearned to use sign language and have deaf andnondeaf friends and associates with whom theycan communicate using sign language.gSince theirmethod of communication is manual, their abilityto communicate usually does not diminish withage. Some people who became deaf in early or mid-dle life use speechreading as their preferred modeof communication. Visual impairments acquired‘1’his network of informal relationships is often wfcwcxi to asthr “deaf communit~’.”late in life can interfere wispeechreading techniques.th their ability to useIndividuals who become deaf late in life facedifferent problems. Sign language is an entirelynew and complex system of communication thatthey must learn if they are to interact with otherdeaf people who use sign language. Yet their rela-tives and lifelong friends seldom know sign lan-guage. The result can be extreme social isolation.People who are deaf and people with partial hear-ing loss are similar in some ways and very differ-ent in others. Both groups can benefit from in-creased awareness of their communicationproblems among their families, friends, health careand social service providers, and others who in-teract with them. Yet the devices and hearing serv-ices that are most effective for each group aredifferent. For example, sign language and telecom-munication devices that rely on visual messages,such as the telecommunication devices for the deaf(TDDs) described in chapter 3, are most effectivefor deaf people. In contrast, hearing aids, assis-tive listening devices, and telephone amplifiers aremore appropriate for those with partial hearingloss.In the past, hearing research and many hearingservices have focused on deaf and very seriouslyhearing impaired people, and less emphasis has
  • been placed on partial hearing loss (10). When deafpeople and those with partial hearing loss are com-bined into a single category-’’the hearing im-paired’’ -at least 16 million people are included.Yet this large number is sometimes used to justifyfunding for research programs and hearing serv-ices focused primarily on the deaf—a group of21about 2 million people. Self-help groups for hard-of-hearing people have pointed out this discrep-ancy (109) and funding agencies and hearing re-search centers are slowly readjusting their re-search and service priorities to encompass the verylarge proportion of hearing impaired people whoare not deaf.
  • Treatment of Hearing ImpairmentChapter 3
  • Chapter 3Treatment of Hearing ImpairmentThe options available for treating hearing im-pairment in elderly people are generally the sameas for younger people. However, the suitability andeffectiveness of various treatments differ consider-ably among age groups because of the type of hear-ing loss most frequently encountered and becauseof other physical, psychological, and social char-acteristics of each group (10).Preventing hearing impairment is an obviousfirst approach. Even if hearing impairment can-not be completely avoided, preventive measurescan slow the rate of deterioration or reduce theultimate severity of the impairment. A second ap-proach is medical and surgical treatment. Whilethese treatments are effective for some types ofhearing impairment, the types of hearing prob-lems that are most common in elderly people arenot presently treatable with medical or surgicalmethods. Thus alternatives are needed. These gen-erally do not change the underlying hearing lossbut instead help compensate for hearing loss andmaintain adequate communication. They includethe use of hearing aids, assistive listening devices,telecommunication devices, signaling and alarmdevices, and environmental design technologies.In addition, aural rehabilitation services can helphearing impaired people communicate more suc-cessfully with or without the use of amplificationdevices.PREVENTIONSome causespeople are notof hearing impairment in elderlywell enough understood to alloweffective preventive measures. For example, die-tary factors and circulatory changes have beenimplicated as accelerators of deterioration in theauditory system. Yet the specific relationship ofthese factors to hearing loss is not known, and fur-ther research is needed before preventive strate-gies can be developed (10).other causes of hearing impairment are well un-derstood and often preventable; these include un-treated ear infections, exposure to loud noise, andsome medications. Untreated or inadequatelytreated ear infections at any time in life can causeconductive hearing loss, though it may not be im-mediately disabling. In old age, however, as sensori-neural loss further reduces hearing acuity, seri-ous disability may develop. Thus better health carethroughout life could prevent some hearing im-pairments in old age (10).Exposure to loud noise at any age can cause ir-reversible sensorineural damage and significanthearing loss. Airplanes, motorcycles, heavy traf-fic, farm and industrial machinery, gunfire, andloud music are sources of noise that can perma-nently damage hearing. Other sources of loud noisehave also been identified. For example, the Amer-ican Academy of Otolaryngology-Head and NeckSurgery has recently warned that some types ofcordless telephones can cause hearing loss becausethe phones continue to ring at a high decibel levelafter being answered until a switch is flipped tothe ‘(talk” position. Seven million of these cordlessphones were estimated to have been sold in 1984(2).The popularity of loud rock music, along witha rise in other environmental noise, creates a se-vere threat to the auditory acuity of young peo-ple. A 1968 study of hearing impairment amongstudents in Knoxville, Tennessee, showed that 4percent of sixth graders had hearing loss at highfrequencies. This proportion increased to 11 per-cent of ninth graders and 33 percent of freshmenat the University of Tennessee. A year later, a sim-ilar study showed that more than 60 percent ofthe next freshman class had some hearing loss (70).As these individuals grow older, their noise-in-duced hearing loss may be exacerbated by the au-ditory changes associated with aging.Self Help for Hard of Hearing People, one of theself -help groups for hearing impaired people, has25
  • 26developed a “Quiet School Program” to provideinformation and educational materials to schooladministrators, teachers, students, and parentsabout the relationship between loud noise andhearing loss. The materials include colorful postersand a device that flashes a warning light when noisein the school cafeteria reaches a dangerous level(101).The increased use of portable radios and tapeplayers with earphones may cause a greater prev-alence of noise-induced hearing loss. A study inNew York City found many listeners playing theirportable radios at 100 decibels, the equivalent ofa car horn 3 feet away (65). A recent British re-port concluded, however, that portable radios andtapeplayers are a less serious threat to hearing thanare other sources of loud noise such as industrialmachinery and gunfire (38).Federal legislation to control noise includes theOccupational Safety and Health Act of 1970 andthe Noise Control Act of 1972. Federal regulationsdefine the amount of time that workers may beexposed to noise of a given intensity. Noise con-trol procedures have been implemented in someindustries. In addition, some local governmentshave enacted noise control legislation and viola-tors are being prosecuted (111). These efforts even-tually may reduce the prevalence and severity ofnoise-induced hearing loss. Many incidents of ex-posure to loud noise, however, are not within gov-ernment regulatory control. Increased public edu-cation is needed to alert people of all ages to theimpact of loud noise on hearing and the long-termdamage that can result.Some drugs also damage auditory mechanisms.Although not a major cause of hearing impairment,these “ototoxic” drugs must be considered in anydiscussion of prevention. The best known of thesedrugs are the aminoglycosides, a class of antibi-otics that includes streptomycin. These drugs canbe life-saving; unfortunately, they also sometimesdamage hearing (10). Even commonly used, over-the-counter drugs such as aspirin can be ototoxic,although probably only in the high dosages some-times used to treat arthritis. Fortunately, aspirin-induced hearing loss is usually reversible if it isrecognized early and aspirin dosage is reduced (10).ototoxic drugs can create problems in peopleof any age. Nevertheless, diseases that require theiruse are more prevalent in later life. Too little re-search has been done to provide a full understand-ing of the mechanisms of ototoxicity and of theessential chemistry of the agents that may be oto-toxic. Educational efforts have been effective ininforming most physicians of the potential haz-ards of streptomycin, but the ototoxic effects ofother drugs have been less well publicized (10).Hearing loss is a symptom with many possiblecauses and accurate diagnosis can sometimes helpprevent permanent hearing impairment. Yet someelderly people do not receive thorough diagnos-tic evaluation. Symptoms such as sudden onset ofhearing impairment and unilateral deafness sug-gest a diagnosis other than presbycusis, and med-ical evaluation of patients with these symptomscan sometimes lead to effective treatment (73).
  • 27MEDICAL AND SURGICAL TREATMENTMedical and surgical treatment can resolve con-ductive hearing losses that originate in the outeror middle ear, but the sensorineural losses thatare most common among the elderly generally can-not be treated with available medical and surgicalmethods. Cochlear implants can alleviate profoundsensorineural hearing loss in some individuals andresearch continues to improve these devices.Treatment of ConductiveHearing ImpairmentsWax buildup in the outer ear is common amongthe elderly and interferes with the passage of soundto the middle ear. Recognizing this problem andremoving the impacted ear wax can improve hear-ing even if there are other auditory deficits.1.Middle ear disease is most common in childhoodbut it also occurs in adulthood and old age. Otitismedia (infection of the middle ear) can be causedby allergies or upper respiratory infection and ef-fective treatment may require medication. Perfo-ration of the eardrum can occur at any age as theresult of middle ear infection or direct trauma.Repair occurs without treatment in some cases,while surgical repair is needed in other cases.Otosclerosis impairs movement of the stapes, asmall bone in the middle ear. The impaired move-ment causes progressive hearing loss. While themost common age of onset is in the third or fourthdecade of life, surgery can be beneficial at any ageand carries only a small risk of complication (27).Treatment of SensorineuralHearing ImpairmentsAlthough most sensorineural losses cannot becorrected through medical or surgical interven-tion, some losses due to tumors, sudden vascularchanges, or fluid pressure changes affecting theinner ear or auditory nerve can be treated. Thesedisorders, however, are relatively infrequent inelderly people (12).IRemOl:Il of impacted ear ~~a.x can tw diffiruit and painful andshould tw (lone L]ndPr ttlc supf’rl is ion 0[ a ph:’s irian.Acoustic TumorsAcoustic tumors can cause sensorineural hear-ing loss, vertigo (dizziness), tinnitus, facial paraly-sis, or numbness. These tumors generally occurduring the third or fourth decade of life but mayalso occur in the sixth and seventh decade (13.5).These tumors can be fatal and surgical removalis a life-saving measure, but it does not usually re-sult in improved hearing.Meniere’s DiseaseSensorineural hearing loss can also result fromMeniere’s disease, the symptoms of which includefluctuating hearing loss, tinnitus, pressure in theears, and vertigo (93). The cause of Meniere’s dis-ease is not known. Treatment with medication isthe first choice, and surgery is used only whenhearing loss or disabling vertigo persists despitedrug therapy. Rates of success with surgery varyfrom 62 to 95 percent, depending on the type ofsurgery performed (92).Cochlear ImplantsThe cochlear implant is an electronic device de-signed to give persons with profound bilateral sen-sorineural hearing loss an improved sense ofsound. Part of the device is surgically implantedin the inner ear and part of it is worn externally(see figure 5). The cochlear implant is intendedto neuroelectrically simulate natural hearing, butfull attainment appears far in the future (10). Thesound produced by these devices has been de-scribed as fluctuating, grating noises and buzzes(88), and users need extensive training to learn tointerpret the sound. Yet implants have improvedspeechreading ability—at least in isolated experi-ments—by giving rudimentary clues to a speakerwords (25). These devices also provide a sense ofthe duration, rhythm, and loudness of sound thatcan be helpful in understanding speech and iden-tifying environmental sounds (8, 71).Cochlear implants hold most promise for deafpeople whose transducing organ in the cochleais ineffective but whose auditory nerve endingsare still responsive to direct stimulation (88). Inthe past 20 years, hundreds of people worldwide
  • 28Figure 5.—Cochlear Implant in Place$The cochlear implant translates sound into electrical signals, bypass-ing damaged tissues in the inner ear and allowing the brain to receiveauditory information. It works as follows: An external microphone de-tects sound which is translated into electrical impulses by a signalprocessor and then transmitted to an external coil positioned behindthe ear. This coil induces a like signal in another coil implanted in-side the skull. From the internal coil, the signal is carried to an elec-trode in or on the cochlea, stimulating nearby auditory nerve fibersto transmit messages to the brain. This diagram shows the parts ofthe implant designed by William House and his colleagues. Other sys-tems are similar, except that the external coil and microphone maybe worn on a headset and multichannel devices have more electrodes.SOURCE: D. Grady, “Sounds Instead of Silence,” Discover, 1983.have received experimental cochlear implants, andmany of them have been enthusiastic about theresults (71). No statistics are available on the num-ber of elderly persons who have received implantsor their response to them. In 1984, the Food andDrug Administration (FDA) approved one type ofcochlear implant for clinical use in the UnitedStates, a device developed by William House and3M Corp. In 1985, FDA approved a more sophisti-cated implant developed in Australia.Research on cochlear implants continues at theHouse Ear Institute of Los Angeles; the KresgeHearing Research Institute at the University ofMichigan; Stanford University Medical School;University of California, San Francisco; Johns Hop-kins University School of Medicine; and other hear-ing research centers. One focus of research is im-proving the sound processing capabilities of thedevices. Another focus is the development of mul-tichannel devices that are expected to allow morerealistic sound perception for the individual (71).The House implant illustrated in figure 5 is a sin-gle-channel device with a single stimulating elec-trode, and the Australian device mentioned aboveis a single-channel device with 22 stimulating elec-trodes. Four- and eight-channel devices are nowbeing tested and some people report significantimprovement in speech recognition with these de-vices. Researchers believe that with enough chan-nels, the cochlear implant could restore normalhearing. However, the difficulties involved in de-signing a multichannel device and successfullyplacing and maintaining it in the tiny, spiral-shapedcochlea are formidable (71).Cochlear implants can damage remaining nervefibers and other delicate tissues in the patient’sear. As a result, researchers in England, Austria,and Switzerland are working on ‘(extra cochlear ”devices, where the electrode is implanted outsidethe cochlea (45).In its present form the cochlear implant is notappropriate for most elderly people because theyhave partial hearing loss rather than the profounddeafness for which the device is now used. Anec-dotal evidence indicates that some people who havehad implants have been severely disappointed bylimitations on the sounds they are able to hear (128).Cochlear implants are expensive, ranging from$12,000 to $15,000 for preoperative evaluation,surgery, the device, and postoperative auditorytraining (8). In the future, however, as cochlearimplants are improved through research and test -ing they may become an important treatment op-tion for elderly people.HEARING AIDSSince only a small portion of elderly people with the problem are essential. For many years, hear-hearing impairments can benefit from medical or ing aids were the only available option. Recentlysurgical treatment, other approaches to mitigate there has been increased interest in other devices
  • 29that can help individuals with hearing impairmentsand these devices are discussed later in thischapter.Hearing aids are amplification devices that com-pensate for partial hearing loss. The individualmust have some residual hearing to benefit froma hearing aid. The earliest hearing aids were me-chanical “ear trumpets” that gradually evolved intothe small, more effective, battery-powered tech-nology that is available today.Hearing aids are available in five basic styles: on-the-body, over-the-ear, eyeglass, and two in-the-ear styles (see figure 6). On-the-body aids have areceiver that is attached to clothing or carried ina pocket, Ear-level aids are worn over the ear orfitted into the temple bar of eyeglasses. In-the-earaids include one style that fits into the auricle orouter area of the ear and a smaller device, the ca-nal style aid, that fits almost completely into theear canal.Until recently, the most frequently sold hear-ing aids were over-the-ear aids, but beginning in1983 in-the-ear styles have outsold the other types.In-the-ear aids are popular because of their smallsize, and the canal style aid, which first appearedon the market in 1982, is extremely popular forIOn-the-body typethis reason. Table 4 shows the types of hearingaids sold in 1984. Canal style aids are included inthe “in-the-ear” category. Sales of canal style aidsincreased from less than 1 percent of total hear-ing aids sold in 1982 to 9 percent in 1983, and 22percent in 1984 (23). About 65 percent of peoplewho bought hearing aids in 1984 were fitted forone aid, while about 35 percent were fitted fortwo aids, one for each ear (23).In the past, on-the-body aids could provide moreamplification than other types of aids and weretherefore recommended for people with severehearing impairments. Recent technological ad-vances in the miniaturization of hearing aid com-ponents now make it possible for individuals withsevere hearing impairments to use ear-level aids.Increased miniaturization, however, has raisedconcern about the quality of sound provided, par-Table 4.—Types of Hearing Aids Sold in theUnited States, 1984Type of aid Percent of total salesIn-the-ear . . . . . . . . . . . . . . . . . . . . . . . 60.00/0Over-the-ear . . . . . . . . . . . . . . . . . . . . . 37.0On-the-body . . . . . . . . . . . . . . . . . . . . . 1.5Eyeglass . . . . . . . . . . . . . . . . . . . . . . . . 1.5. -SOURCE: Cranmer, 1965 (23).Figure 6.—Hearing Aid TypesOver-the-ear typeEyeglass typeIn-the-ear typeCopyright 1976 by Consumers Union of United States, Inc., Mount Vernon, N.Y. 10553. Reprinted by permission from CONSUMER REPORTS, June 1976.
  • 30ticularly with devices as small as canal style aids.Miniaturization of the microphone and speakerelements of hearing aids has been less effectivethan miniaturization of the electronic circuitry,and this can result in sound distortion—a seriousdrawback for elderly people who have difficultywith auditory discrimination (54, 60). While re-search continues to improve the miniaturized com-ponents of hearing aids, some hearing specialistsworry that people may select a small hearing aidthat is not well suited to their needs because ofits cosmetic appeal.Over the years, hearing aids have helped mil-lions of people by maximizing their residual hear-ing and allowing them to function in communica-tion situations that otherwise would have beenimpossible. Yet most people with hearing impair-ments do not use hearing aids. Estimates of thepercentage of hearing impaired people who usehearing aids vary depending on the source of thedata and the figure that is used for overall preva-lence of hearing impairment. A recent analysisusing three different prevalence rates estimatesthat between 8 and 17 percent of all hearing im-paired people use hearing aids (41). A 1984 indus-try survey indicated that of the 16 million peopleof all ages with hearing impairments in the UnitedStates, about 4 million (25 percent) own hearingaids. About 2 million others (12.5 percent of hear-ing impaired people) do not admit to having a hear-ing impairment, and the remaining 10 million (62.5percent) admit to having a hearing impairment butdo not have a hearing aid. Of those who own hear-ing aids, about 14 percent do not use them (49).The majority of hearing aid users are elderly.Table 5 gives the age breakdown of individualswho bought hearing aids between 1983 and 1985.Table 5.—Proportion of Hearing Aid Purchasersby Age, 1983-85Proportion of allAge hearing aid purchasers2 to 39 . . . . . . . . . . . . . . . . . . . . . . . . 8%40 to 49 . . . . . . . . . . . . . . . . . . . . . . . 350 to 59 . . . . . . . . . . . . . . . . . . . . . . . 1160 to 69 . . . . . . . . . . . . . . . . . . . . . . . 3170 to 79 . . . . . . . . . . . . . . . . . . . . . . . 3080 to 89 . . . . . . . . . . . . . . . . . . . . . . .14} 78%90 to 99 . . . . . . . . . . . . . . . . . . . . . . . 3SOURCE: Market Facts, 1985 (75).Elderly people with hearing impairments aremore likely to use hearing aids than younger peo-ple with comparable hearing loss. Data from the1977 National Health Information Survey show thatabout 20 percent of all hearing impaired personsover 65 used a hearing aid, compared to 4 percentof hearing impaired persons age 3 to 44 and 10percent of hearing impaired persons age 45 to 64(118). Among elderly people, hearing aid use in-creased with increasing severity of hearing impair-ment (see table 6).Even though elderly people with hearing impair-ments are more likely to use hearing aids thanyounger people with similar impairments, mosthearing impaired elderly people do not use hear-ing aids. Many reasons for this have been sug-gested. Some elderly people are unaware of theirhearing impairments and therefore do not buy anaid, others reject the use of a hearing aid becausethey associate it with getting old or becoming hand-icapped. Still others believe that their hearing lossis not severe enough to require the use of a hear-ing aid or that hearing aids are not effective forthe kinds of impairments they have. Cost is an ad-ditional deterrent for some people (49).Among those who do buy hearing aids, some arevery satisfied; others are less satisfied; and someare disappointed with the aid. A nationwide sur-vey of people of all ages who purchased hearingaids between 1983 and ,19852asked respondentshow satisfied they were with their hearing abilitywith the current hearing aid. Responses are shownin table 7.Those who answered that they were somewhatdissatisfied (6 percent) or very dissatisfied (4 per-cent) were asked about specific problems they ex-perienced in using the aid. These people identi-fied the following problems (75):q amplification of unwanted noise,‘This survey, commissioned by the Federal Trade Commission(FTC), was designed to produce a representative sample of all U.S.households and to reflect the experiences of all hearing aid pur-chasers nationwide (86). The FTC requested public comment on themethodology of the survey, and no serious problems in survey meth-ods were identified by the time the public record was closed (87).Since then, analysts have pointed out that the survey might be bi-ased because it was a mail survey and because the respondents weremembers of a panel of consumers who had agreed to participatein Market Facts surveys ( 107).
  • 31Table 6.—Persons Age 65 and Over Who Use a Hearing Aid, United States, 1977Can hear words Can hear words At best canAll levels of Unilateral hearing spoken in a shouted across hear wordsKnown hearing aid use hearing trouble trouble normal voice a room shouted in earUse a hearing aid . . . . . . . . . . . . . . 19.9°/0 10.80/0 12.70/o 27.50/o 58.40/oDo not use an aid . .............80.1 89.2 87.3 72.5 41.6SOURCE” NCHS, 1982 (1 18)Table 7.—Satisfaction With Hearing AbilityUsing a Hearing AidPercent of allDegree of satisfaction hearing aid purchasersVery satisfied. . . . . . . . . . . . . . . . . . . 47%Somewhat satisfied . . . . . . . . . . . . . 37Neither satisfied nor dissatisfied. . 6Somewhat dissatisfied. . . . . . . . . . . 6Very dissatisfied . . . . . . . . . . . . . . . . 4SOURCE: Market Facts, 1985 (75).qqqqqinability to hear in crowds,having to ask people to repeat themselves,feedback from the hearing aid,difficulty hearing phone conversations,friends/relatives complaining about theirhearing.Those who said they were somewhat satisfiedor neither satisfied nor dissatisfied (43 percent ofthe total sample) were not asked about problemsthey experienced in using the aid. If they had beenasked, they might have identified similar problems.Dissatisfaction with a hearing aid can result fromseveral problems: 1) deficiencies in the designand/or performance of the aid itself, 2) selectionof an aid that is not well matched to the person’sneeds, 3) inability to adjust to the aid, or 4) a com-bination of all three. In many cases, it can be diffi-cult to determine the cause of dissatisfaction.problems in Hearing Aid Designand PerformanceThe sound produced by hearing aids is some-times described as mechanical. one reason for thisis that most hearing aids amplify sound in the fre-quency range of 500 to 4,000 Hz, although a fullfrequency range from about 50 to 10,000 Hz isneeded to provide reasonably accurate timbre (thequality given to sound by its overtones). In addi-tion, hearing aids do not handle all tones evenly,resulting in further sound distortion (21).Another problem with hearing aids is that theyamplify background noise as well as speech, andusers of all ages have difficulty learning to tuneout distracting background noise. As a result, somehearing aid users turn off their aids in noisy envi-ronments (67). Recent changes in transducer de-sign can intensify the speech signal in contrast tobackground noise and thus improve the speech-to-noise ratio (89). However, amplification of un-wanted background noise remains a problem formany hearing aid wearers. For elderly people whohave diminished ability to tune out backgroundnoise, this problem is particularly severe.Since many elderly people have more severehearing loss at high frequencies than low frequen-cies, uniform amplification of all frequencies isoften ineffective. One approach to this problemis a high -frequency emphasis hearing aid that am -plifies only high-frequency sounds, allowing low-frequency sounds to enter the ear without am-plification (115). Another approach is frequencylowering, an electronic sound processing tech-nique that lowers the frequency of received sound.This technique is in the developmental stage andsound distortions produced by the frequencylowering systems limit their effectiveness (88).Difficulty with sound discrimination is a com-mon element of hearing impairment in elderly peo-ple. Thus technical limitations in hearing aids thatdistort sound can actually worsen the hearing abil-ity of some individuals (54). Sophisticated soundprocessing techniques that have been developedfor military and space applications may somedaybe used to overcome the problems of sound dis-tortion, background noise, and high-frequencyhearing loss. Using these advanced techniques:. . . minute signals are successfully pried out ofa profusion of far stronger noises that have oftenbeen accumulated over great distances in space.Communication in present day air battles dependsupon stunning solutions to the problem of signal(and speech) selectivity for multicommunication
  • 32among pilots and between pilots and ground con-trol. Such solutions employ sophisticated logicsoftware in which the distinguishing physicalcharacteristics of the desired signals are recog-nized while those of the undesired competing sig-nals are rejected (11).Adaptation of these techniques to hearing aiddesign is a high priority at the National Instituteof Neurological and Communicative Disorders andStroke and other hearing research centers acrossthe country (81). Obstacles include miniaturiza-tion of the necessary equipment and the final costof the device.Several other problems can also interfere withhearing aid performance. Hearing aids need fre-quent cleaning and if the user does not clean theaid it will not work properly. Hearing aids can bedamaged by heat and moisture, causing a need foradjustments or repair. The batteries can die, andalthough checking the batteries is an obvious firststep for most hearing aid users, hearing specialistsencounter people who complain that their hear-ing aids do not work, only to find that the batter-ies are dead. Portable battery testers are availableand can help solve this problem. In the future, hear-ing aids could be designed with a detector circuitto sense low battery voltage and alert the user bya visual, auditory, or tactile signal. Obviously, newusers need a thorough hearing aid orientation toforewarn them about these potential problems.Problems in Selecting theAppropriate Hearing AidAt present, there is no technique to make a hear-ing aid that exactly matches an individual’s hear-ing deficits, the way eyeglass lenses are groundto match a prescription. Instead, hearing aiddealers and dispensers attempt to custom fit theaid to the individual’s hearing deficit by combin-ing and adjusting available components.One problem faced when selecting an appropri-ate hearing aid is identifying the individual’s pre-cise hearing deficits, Hearing specialists disagreeabout what tests are needed to select a hearingaid and who is qualified to perform the tests. Au-diologists are trained to evaluate hearing deficits,and some hearing specialists believe that a com-prehensive audiologic evaluation is necessary toselect a hearing aid. Yet many elderly individualsbuy hearing aids without seeing an audiologist (10).other hearing specialists argue that while a com-prehensive audiologic evaluation is essential fordiagnosing some ear diseases, only certain hear-ing tests are relevant to the selection of a hearingaid and these tests can be performed effectivelyby hearing aid dealers (62, 90, 133).Another problem that arises when selecting anappropriate hearing aid is that little informationis available comparing different brands and typesof hearing aids. Hearing aid manufacturers pro-vide technical performance data on their devices,but information about the relative merits of vari-ous brands and models is scarce.The National Technical Institute for the Deaf andthe Massachusetts Institute of Technology havedesigned a device to simulate the characteristicsof a variety of hearing aids. This “Master HearingAid” provides information about the most appro-priate hearing aid for the individual (19). Computerprograms also have been developed to analyze au-diometric data and select specific models of hear-ing aids that most closely match the individual’shearing deficits. Eventually, it is hoped that a com-puter chip programmed by a “Master Hearing Aid”could be installed in the individual’s hearing aidto provide an exact match between the individ-ual’s hearing deficits and the signal processingcharacteristics of the aid (19). This would consti-tute a “prescription hearing aid.” Research on vari-ous aspects of the prescription hearing aid is inprogress at the Central Institute for the Deaf inSt. Louis, the Lexington School for the Deaf in NewYork City, and other hearing research centers.Problems in Adjustingto a Hearing AidEmotional and psychological factors can inter-fere with a person’s adjustment to hearing aid use.For example, some people fail to adjust to theirhearing aids because they are embarrassed by theappearance of the aid. Small, “invisible” aids arepopular for this reason. Larger aids that providebetter sound fidelity and are more easily manipu-lated by arthritic hands are sometimes rejectedin favor of smaller, more expensive, and less ef -
  • fective instruments (10). The use of two aids, onefor each ear, may also be rejected for this reasoneven though two aids can provide better hearingacuity for many people (134).Unrealistic expectations can also interfere witha person’s adjustment to the hearing aid. Some in-dividuals buy a hearing aid expecting it to restorenormal hearing and are disappointed with the re-sults. This disappointment can cause significantacceptance problems (10). Research indicates that30 percent of those who purchased hearing aidsfrom 1983 to 1985 expected that their aids wouldrestore normal hearing. of these people, one-thirdsaid their hearing aids did restore normal hear-ing, about one-half said it somewhat restored nor-mal hearing, and the remaining 12 percent wereunsure or said it did not restore normal hearing(75).Some people believe that elderly people havemore difficulty adjusting to hearing aids thanyounger people because of an assumed age-relatedinability to adjust to anything new; however, no.research justifies this conclusion. In fact, little con-33elusive information is available about the precisereasons why individuals of any age fail to adjustto hearing aids, and more research is needed inthis area.Anecdotal evidence suggests that some elderlypeople who are severely confused and hearing im-paired may be unable to learn to use a hearingaid or even to understand its purpose. For thesepeople, environmental design technologies andassistive listening devices that require less adjust-ment could be more appropriate. These ap-proaches are described later in this chapter.All people fitted with hearing aids need assis-tance adjusting to the aid. Someone must answerquestions, reassure the person during discourag-ing periods, make needed adjustments to the hear-ing aid and attachments, counsel the individualand the family regarding expectations, and assistin the adaptation to environmental sounds. Other-wise, the aid will remain unused. These factorspoint to a strong need for competent professionalinvolvement in the evaluation, selection and fit-ting, and adjustment of hearing aids (10).ASSISTIVE LISTENING DEVICESIn addition to hearing aids, four types of assis-tive listening devices can be used to increase audi-tory effectiveness: hardwire devices, audio loopsystems, radio frequency devices (AM and FM),and infrared amplification devices. These devicestransmit sound directly from the speaker or othersource to the listener, thus reducing interferencecaused by background noise. They have been usedprimarily in classrooms and public meeting roomsand are often referred to as “large room systems. ”They are now being used by some people for one-to-one or small group listening as well as TV andradio listening.Assistive listening devices can be used by elderlypeople who have hearing aids and have difficultytuning out background noise. In addition, thesedevices can give some elderly persons with mildto moderate hearing loss enough amplification toallow them to hear effectively without a hearingaid in some situations.Hardwire devices provide a direct wire linkbetween the listener and the source of sound. Ex-amples are the earphones used with portable ra-dios, tape players, TV, and stereos. Hearing im-paired people can obtain earphones with adjustablevolume. Some hardwire devices have a micro-phone that can be placed on a table or held by thespeaker (see figure 7). Some can be used with ahearing aid. The simplicity of these devices makesthem useful for radio and television listening andsome one-to-one conversation, but the wire con-nection to the source of sound is too restrictivefor many purposes.An audio loop system is composed of a micro-phone that is worn or held by the speaker anda length of wire called an induction loop that canbe installed or simply placed in a room. Sound fromthe microphone is converted into an electromag-netic signal that is transmitted by the loop andpicked up by any hearing aid with a telephone
  • 34Figure 7.— Hardware Device forOne-to-One ConsultationSOURCE’ Williams Sound Corpswitch. Loop systems can also be used by peoplewho do not have hearing aids but wear or carrya receiver that can pick up the electromagneticsigna13(see figure 8). Loop systems have been usedextensively in schools for the deaf and are nowbeing used in churches, theaters, and other meet-ing rooms.Hearing impaired people who want to use theloop system must sit within the area of the loop,but people with no hearing problems can sit inthe same area. Sound quality is not always uni-form throughout the area and the devices some-times pick up interference from fluorescent light-ing (103).An FM amplification device is composed of asmall, wireless, battery-operated FM microphonethat can be placed near the source of sound (a per-son, television, radio, etc.) and a tiny portable ste-reo radio equipped with earphones that are wornby the hearing impaired person (see figure 9).Sound is transmitted from the microphone to thereceiver by radio wave. The transmission rangeis 100 feet or more, which allows the person tomove about while listening to radio, television, orconversation. Individuals with hearing aids can useFM amplification devices if their hearing aids havea telephone switch and they use a neckloop or ifStn some museums, audio loop systems are used for self-guidedtours for nonhearing impaired persons. The indi~’idual carries awand recei~er that is actit’ated as he approaches an exhibit.Figure 8.—Audio Loop Wand ReceiverSOURCE: VA Medical Center, Birmingham, AlabamaFigure 9.—FM Personal Amplification Device:Transmitter and ReceiverSOURCE. Williams Sound Corptheir hearing aids are designed for direct audioinput.4Until a few years ago, the Federal Communica-tions Commission (FCC) limited the use of radiosignals for amplification devices to educational set-tings. This restricted the development of FM am-plification devices for personal use. Since 1982,however, changes in Federal regulations have al-lowed increased public access to radio frequen-cies. This has stimulated the development and mar-4Over-the-ear, eyeglass, and on-the-body aids that are designedfor direct audio input use an adapter cord that can be plugged intothe hearing aid at one end and into the FM receiver at the otherend. In-the-ear aids can use a button receiver that is snapped ontothe hearing aid for direct audio input.
  • 35keting of FM amplification devices for use in thehome and in public facilities such as theaters,churches, and large meeting rooms. These devicesare also being used in automobiles.An AM amplification device transmits soundusing AM radio wave lengths, and the sound ispicked up by a special AM receiver worn by thelistener or by a portable pocket radio. The soundquality provided by AM amplification devices isusually not as good as that provided by FM devices.AM amplification devices are subject to the samesources of interference as AM radios (e.g., thun-derstorms and lamp dimmers). In addition, AN I de-vices can only be used within an area enclosed byfour walls, while FM amplification devices can beused indoors and outdoors. As a result, FM am-plification devies are used more frequently (103).An infrared amplification device is composed ofa battery-operated transmitter and a receiver (seefigure 10). The transmitter transforms sound intoan electrical signal that modulates an infrared lightbeam. This invisible light beam is picked up by areceiver worn by the listener (67). Infrared hear-ing devices are used primarily in theaters and someinstitutional settings, but they can also be used inthe home (68).one advantage the infrared device has over t heAll and FM amplification devices is that the in-frared light signal is absorbed by any opaque sur-face. Thus a person in one room can use an in-frared amplification device to hear a speaker inthat room while people in other rooms can useinfrared devices to hear other speakers. There isno spillover of the infrared signal and privacy ofcommunication is maintained. In contrast, AM andFM radio signals can radiate from one room toanother. In an institutional setting or any privatesituation, the spillover of AM and FM signals is un-acceptable (67).one disadvantage of infrared devices is that theycannot be used in direct sunlight, and thus can-not be used outdoors like FM amplification devices.Large amounts of incandescent light in a room canalso cause interference (103).Although assistive listening devices have beenused primarily to amplify sound in large roomsand public settings, they are now being used morefrequent}’ by individuals for interpersonal com-Figure 10.—lnfrared Amplification Device:Transmitter and ReceiverSOURCE: VA Medical Center, Birmingham, Alabamamunication and TV and radio listening. Many ap-plications that are especially relevant for elderlypeople have been suggested. For example, physi-cians and other professionals who talk with elderlypeople could have these devices available in theiroffices. In hospitals and nursing homes, the de-vices could be used by staff to communicate withhearing impaired patients, and patients could usethem to listen to radio or TV without botheringother patients. Assistive listening devices could beespecially helpful in banks and other offices where
  • 36people communicate through glass barriers. Un-like hearing aids, no training is required to usethem so they can be immediately helpful in manylistening situations.Assistive listening devices are particularly ap-propriate for many elderly people with mild ormoderate hearing loss because these devices canprovide satisfactory auditory function in somelistening situations even without the use of a hear-ing aid. When a hearing aid is needed, assistivelistening devices can help tune out bothersomebackground noise.one obstacle limiting the use of assistive listen-ing devices is the resistance many hearing impairedpeople feel to using devices that are visible (140).Another obstacle is lack of awareness among thehearing impaired elderly of the kinds of devicesthat are available. Many hearing specialists—including physicians, audiologists, and hearing aiddealers—know very little about these devices anddo not encourage their use (74). Some of thesespecialists believe that a correctly fitted and func-tioning hearing aid is a better treatment optionthan an assistive listening device because the hear-ing aid does not require microphones, transmit-ters, or induction wires, and thus appears more“natural .“ Advocates of assistive listening devicespoint out, however, that hearing aids can be in-effective in some listening situations (102). Theseexperts believe that until hearing aids can be de-signed to effectively filter out background noise,other devices are also needed.TELECOMMUNICATION DEVICESOne of the most handicapping aspects of hear-ing loss for hearing impaired people of all ages isthe inability to use the telephone. For the elderly,particularly those who live alone, the telephoneis a link to the outside world and inability to useit can compromise safety, interfere with independ-ent functioning, and deprive the individual of so-cial interaction with family and friends. Anecdotalevidence indicates that when family members andfriends are not able to contact the elderly hearingimpaired person regularly by telephone, they be-come increasingly anxious about his or her wel-fare. In some cases, this results in suggestions thatlive-in help or nursing home placement is needed.Hearing over the telephone is difficult even forthose elderly people who have very mild hearingloss and are able to hear well in person. This isbecause telephone signals are transmitted in alimited frequency range, and very low and highfrequency sounds that can be important for un-derstanding speech are omitted in transmission.Line noises and other sound distortions also in-terfere with the quality of sound transmission. Inthe future, as the need grows to transmit moreconversations over a limited number of telephonelines, this problem may become worse. Some meth-ods for increasing line capacity involve removingparts of the speech message that are consideredunimportant; 5however, the standards for whatis unimportant are based on the hearing abilityof younger people with normal hearing. Researchis needed to document the effect of removing partsof the speech message on the hearing ability ofelderly and other hearing impaired individuals.This could be a first step toward public policy re-quiring transmission of telephone signals that canbe heard by hearing impaired people up to a cer-tain level of hearing loss (11).A variety of devices are available to help hear-ing impaired people use the telephone. The sim-plest of these, which is most effective for individ-uals with mild to moderate hearing loss, is a volumecontrol device that can be built into the telephonehandset or attached to the side of the telephone.Portable telephone amplifiers are also available,although many elderly individuals do not knowabout them (see figure 11). Some research indi-cates that telephone amplifiers are more effectivefor individuals with relatively constant hearing lossacross all frequencies and less effective for thosewith marked loss at only the high frequencies (58).‘These telephone engineering procedures, called “time process-ing, ” include ~’oice sltritching, time di~’ision multiph~x, and pulse rodemodulation ( 11).
  • 37Figure 11 .—Three Types of Telephone Amplification Devices-..SOURCE Courtesy of Radio Shack, A Dlvlslon of Tandy CorpSOURCE VA Medical Center, Birmingham, AlabamaBefore the breakup of AT&T, telephone hand-sets with amplifiers and other specialized equip-ment for hearing impaired people were availablethrough the telephone company and the cost ofthese devices was regulated by State public utilitycommissions. Following the breakup of AT&T, Fed-eral legislation and FCC regulations allowed Statepublic utility commissions to choose whether toregulate or deregulate this equipment (84). GSomeStates no longer regulate the cost of these devices,while others regulate all devices, or only neworders. This has created confusion for hearing im-paired customers because now prices of equip-ment vary from State to State, the availability of6.AT&.’I’ has created a National Special ?ieeds Center in JNet Jer -sej’ and nlan) tek; phone rustorners continue to rent or t]u}’ telc -p h o n e h:indsf~ts with amplifiers f r o m ,ArI’&’I’.
  • 38equipment is uncertain, and it is often difficult tofind repair service. Legislation to require State reg-ulation of these devices was introduced in Con-gress in 1985 (S. 402) (91) and hearings probablywill be scheduled in 1986.7Another device to help hearing impaired peo-ple use the telephone is the telephone switch or“T switch” on a hearing aid. The telephone switchallows the hearing aid to pick up electronic leak-age from compatible telephone receivers and by-pass the hearing aid microphone. Unfortunately,many hearing aids do not have telephone switches.8In addition, anecdotal evidence indicates that somepeople do not know whether their hearing aidshave telephone switches, or if they do, how to usethem (106). Furthermore, not all telephones arecompatible with these hearing aids. The Telecom-munications for the Disabled Act of 1982, whichbecame law in 1983, requires that all telephonesinstalled in ‘(essential places” be compatible withhearing aids by January 1, 1985. Included as es-sential are public pay telephones; telephones foremergency use (e.g., on bridges, in tunnels, andalong highways); and telephones in hospitals, con-valescent homes, homes for the aged, and otherpublic facilities (97). S.402, as proposed by Sena-tor Pressler, would require that all new telephonesbe compatible with hearing aids.Other telecommunication devices are availableor being developed for people with severe hear-ing impairments. Some devices are used primar-ily by younger people with severe hearing impair-ments and may be inappropriate for many elderlypersons. Telecommunication devices for the deaf(TDDs) were first developed in 1965. These devicesallow users to type a message that is convertedto tones and carried over a phone line, At the otherend of the line, another TDD converts the mes-sage back to typewritten copy. In the past 10 years,small, portable TDDs have become available andmany deaf individuals have these devices at home,Public agencies, such as fire departments, police7A .A. Gilro-v, “Telecommunications Specialized Customer Prenl -ises Equipment for the Disabled Federal Actions Affecting Its Pro-~rision ,“ Congressional Research Service report, kliir. 22, 1985, pro-’ides more information on the current status Federal regulationsin this area,Telephone switches work best in o~’er-the-ear and on-the-bodyhearing aids. It is more difficult to incorporate a telephone switchin an in-the+ar aid (97).departments, and hospitals, are being equippedwith TDDs. Some communities have TDD switch-boards to relay communication from people whorely on these devices to people and institutions thatdo not have the required equipment (10).9other devices are in the development stage, in-cluding Teletex and Viewdata. These are informa-tion retrieval systems that transmit text and sim-ple graphics to a television receiver. Viewdata hasa message service so subscribers can communi-cate with one another. Viewdata, if and when ex-tensively accepted throughout the country, willprovide electronic mailbox capability to both deafand hearing people (35).Picturephone and Vistaphone are devices de-signed to transmit a visual image of the speakerover an ordinary telephone line, thus allowingsome hearing impaired individuals to communi-cate by speechreading or sign language. Commer-cial production of these devices was expected toincrease use and reduce cost, but neither hascaught on and there has been no support for pro-duction (35).No data exist to show how many elderly peopleuse or could use these telecommunication devices.Elderly individuals who have had hearing impair-ments since childhood or early adulthood can beexpected to continue using the devices they haveused throughout life. For those who become hear-ing impaired in old age, however, use of these de-vices requires both the hearing impaired personand those who communicate with him to acquirenew skills. TDDs and Viewdata require users toknow how to type and have the necessary equip-ment. The hearing impaired person must be ableto see well enough to read typed messages. Pic-turephone and Vistaphone are only helpful to thosewho communicate by speechreading or sign lan-guage. Since few elderly people use these meth-ods of communication, the usefulness of these de-vices is limited for them.Computerized speech recognition systems arebeing developed that could greatly simplify tele-communications for hearing impaired people.“Selected Telecommunications Devices for Hearing-Impaired Per-sons, ” OTA background paper, 1982, reviews the history of TDDs,current problems in accessibility, and legislation affecting use ( 1 14)
  • 39These systems convert spoken words into printedoutput that could be displayed on a screen attachedto the telephone. Since messages do not have tobe typed, this system could allow much faster com-munication between hearing impaired individualsand between hearing and nonhearing persons.The speech recognition systems available nowhave major limitations. They recognize only a fewwords and sometimes confuse words. Most arespeaker dependent, which means that the systemmust be adapted to the idiosyncrasies of the speechof a particular individual. Some very expensive sys-tems (up to $35,000) offer vocabularies of 500words, good background noise tolerance, and abil-ity to respond to speech variations (57).Most research on speech recognition systemsis not being conducted for the benefit of hearingimpaired people. It is being pursued primarily toencourage the broader use of computers by allpeople. However, the results of this work are likelyto benefit hearing impaired people. As researchcontinues and prices fall, these systems could pro-vide an easier way for individuals without a hear-ing problem to communicate by telephone withthe hearing impaired.Closed caption television is a technology that isincreasingly available to deaf and hard-of-hearingpeople. Captions transmitted with the televisionsignal appear on the screen when decoded witha special device. These captions can be difficultfor some elderly people to see if they also havevisual impairments, but they can make televisionnews and entertainment available to many hear-ing impaired elderly people. As of November 1985,94 hours of closed caption programming wereavailable each week. ABC provides closed captionsfor all its prime time programming, and NBC, CBS,and PBS each provide some closed captioned pro-grams (79). However, the cost of a decoder ($200to $500) prevents some elderly people from usingclosed caption television (10).SIGNALING AND ALARM DEVICESSignaling and alarm devices that convert soundto visual or tactile signals are important for thesafety and independence of hearing impaired per-sons. Flashing lights or vibrating devices can sub-stitute for the sounds of a fire alarm, smoke alarm,telephone, doorbell, or alarm clock (see figure 12).The Rehabilitation Comprehensive Services andDevelopmental Disabilities Amendments of 1978requires adaptation of warning systems in publicfacilities, housing units, and health care facilitiesserving older people. Federal regulations set forthstandards for audible and visual alarm systems inthese facilities (10).Tactile Paging Devices use radio signals to gen-erate vibrations in a portable receiver carried bythe hearing impaired individual. The person feelsthe vibrations and can respond to the signal. Thedevices can be used to contact the individual withina one-quarter mile radius of the transmitter.These devices can be used alone or combinedwith a hearing aid or other assistive listening de-vices and telecommunication devices. A combina-tion of devices can compensate effectively for mostFigure 12.—Sonic Alert Signaling System,Including a Paging Device and Door Bell SignalerSOURCE: VA Medical Center, Birmingham, Alabamahearing impairment in elderly people. But thesedevices cannot be useful to hearing impairedelderly people unless they know such options ex-ist. While information generally is available in thedeaf community, elderly people are seldom partof this group. Since elderly people seldom receivecomprehensive aural rehabilitation services, theydo not learn about devices from hearing specialists
  • 40Public information about available devices andtreatment options almost always focuses on “new”and dramatic approaches. For example, cochlearimplants are now receiving considerable cover-age although very few patients have received them.The emphasis on revolutionary breakthroughs inmedical and surgical treatment distracts attentionfrom the far less dramatic rehabilitative proce-dures and devices that could benefit the majorityof hearing impaired elderly people (10).ASSISTIVE DEVICEIn the United States today, assistive devices forhearing impaired people are developed by:qqqqqqquniversities and colleges for the deaf;universities and colleges with rehabilitationtraining programs and/or speech and hear-ing clinics;Rehabilitation Engineering Centers for theHearing Impaired, funded by the National In-stitute for Handicapped Research;the Veterans Administration,10Departmentof Defense, and other agencies of the FederalGovernment that offer rehabilitative servicesand are also engaged in the development ofassistive devices;laboratories of commercial firms;independent inventors and entrepreneurs;andthe Small Business Innovative Research Ini-tiative of the National Institutes of Health.With few exceptions, the major financial respon-sibility for research and development of hearingaids and innovative devices for hearing impairedpeople has been borne by commercial manufac-turers. Although competition among manufac-turers has brought some achievements, there havealso been problems. For example, miniaturizationof hearing aids has improved their marketabilitybut it also sometimes reduces performance (54,‘The VA program of medical device development and testing isthe topic of a 1985 OTA report, Medicaf Devices and the VeteransAdministration. This report discusses VA policies for research anddevice development for all kinds of medical conditions, includinghearing impairment.Advertising by hearing aid manufacturers anddistributors has been an important source of publicinformation about hearing loss and hearing aids.While it undoubtedly contributes to public aware-ness and greater acceptance of hearing aids, ad-vertising is selective and does not give equal weightto all treatment options (10). Chapter 4 discussessome alternate methods for increasing people’sawareness of the many devices available.DEVELOPMENT60). Furthermore, relatively little effort has beenmade to develop highly specialized devices thatbenefit only a small number of people because thepotential market is limited (10).Problems in developing and disseminating allkinds of assistive devices for handicapped peopleare discussed in a 1982 OTA report, Technologyand Handicapped People. Problems that limit de-velopment and dissemination of devices for elderlypeople are discussed in a 1985 OTA report, Tech-nology and Aging in America. Many of the prob-lems discussed in these reports affect the devel-opment of devices for hearing impaired elderlypeople. For example, it is often difficult to identifypotential users, and small companies—frequentlythe source of innovative products—lack financialand staff resources to launch a marketing cam-paign to reach these people. Without an identifia-ble market, companies are reluctant to invest inresearch, development, and manufacture of newdevices. Lack of third-party reimbursement fordevices and erratic funding guidelines by publicprograms that pay for these devices also limit themarket.In some industrial countries, such as Sweden,the development of assistive devices is considereda government responsibility. Public funding is pro-vided not only to develop and manufacture devices,but also for distribution and repair. In the UnitedStates, where distribution of assistive devices hasbeen left primarily to the private sector, lack ofan identifiable market discourages developmentof these devices (10).
  • 41ENVIRONMENTAL DESIGNBuilding design characteristics affect the be-havior of sound and the relative ease or difficultyof hearing. For example, hard-surfaced walls andfloors reflect sound, creating reverberations thatinterfere with hearing, while sound absorbentwall-covering materials decrease reverberations(66). Attention to the acoustic characteristics ofbuildings could decrease the impact of hearing im-pairment for people of all ages.Background noise is a major impediment forhearing impaired individuals, regardless ofwhether they use hearing aids. Proper planningand building design can help limit unnecessarybackground noise. For example, in a nursing homeor congregate housing facility the dining roomshould not be located between a noisy kitchen anda noisy laundry room or mealtime conversationwill be difficult for hearing impaired residents.Daily events should be scheduled to account forthe problem of background noise. Thus, vacuum-ing and other noisy activities should not be sched-uled when residents are involved in a discussiongroup.Room arrangement and lighting can also affecthearing. In a large room where several conversa-tions may occur at once, space dividers that ab-sorb sound can create a sense of privacy and de-crease ambient noise levels that interfere withhearing (52). Similarly, good lighting and an unob-structed view of a speaker can facilitate use ofspeechreading techniques (73). While much isknown about design characteristics that affecthearing, this knowledge has not been widely ap-plied. Relatively inexpensive measures that reducereverberations and background noise in buildingsused by elderly people could benefit many peoplewith hearing loss.AURAL REHABILITATIONFew hearing impaired elderly people receiveaural rehabilitation services. Yet these services canbean important part of treatment. Some aural re-habilitation services, such as auditory training andspeechreading, are primarily provided by audiol-ogists, if at all. other services, such as hearing aidorientation, can be provided by both audiologistsand hearing aid dealers.S@ language is taught to many younger per-sons with severe hearing impairments, but it isnot widely used by the elderly for several reasons.First, it is difficult for elderly people who develophearing loss late in life to learn a completely newlanguage. In contrast, many younger people withsevere hearing impairments have used sign lan-guage since childhood,11Young people with severehearing impairments often attend school and in-teract with other severely hearing impaired peo-1 IHearing specialists who treat young persons with severe hear-ing impairment disagree about whether sign language or an alterna-tive procedure for understanding normal speech, such as speechread -ing and Cued Speech, is the best method of communication (37). Thiscontroversy applies primarily to young people and is not discussedin this report,ple who use sign language. Thus, they develop anetwork of friends and associates who communi-cate by sign language. In contrast, the friends andassociates of elderly people who become hearingimpaired late in life seldom know sign language.Finally, hearing impaired elderly people usuallyretain some residual hearing and other methodsto maximize residual hearing can be more effec-tive and more acceptable than sign language (136).Hearing Aid OrientationHearing aid orientation can help people over-come problems that interfere with the successfuluse of the aid. The user needs instruction in thecare and maintenance of the aid and earmold, anopportunity to practice inserting the earmold andbatteries and changing volume controls, and ad-vice and encouragement about gradually increas-ing the use of the hearing aid in a variety of listen-ing situations (10).Unrealistic expectations about the ability of ahearing aid to restore normal hearing can inter-fere with adjustment to the aid for some people.
  • 42Hearing aid orientation should begin before theaid is purchased and provide information aboutproblems that can be expected and the need fortraining. It should also continue after the aid ispurchased. All users should return to the hearingaid dealer or audiologist for a followup check onthe functioning of the aid and the individual’s ad-justment to it.12Auditory TrainingIntonational patterns created by variation in thepitch, intensity, and duration of sound give cluesabout the content and meaning of speech. Audi-tory training teaches the individual to use theseclues to supplement his residual hearing. The per-son learns to recognize and differentiate soundsby practicing with live or recorded sounds (136).Auditory training now is used almost exclusivelywith hearing impaired children. But the elderly,who usually have some residual hearing, can alsobenefit and some auditory training programs in-clude elderly people.SpeechreadingSpeechreading is the use of visual cues to facili-tate the understanding of speech. The hearing im-paired person is taught to recognize lip, facial,throat, and body positions and movements in-volved in speech production (26, 96). Few elderlyindividuals are taught speechreading techniques,although these techniques can be particularly ef-fective for people who have only partial hearingloss, including those who use a hearing aid.Negative attitudes about the rehabilitation po-tential of elderly people among elderly individualsthemselves, their families, and health and socialservice professionals contribute to the failure tooffer training in speechreading. It is often assumedthat most elderly people are not willing or ableto learn speechreading. Clearly this assumptionshould not go unchallenged when training has notbeen offered to many of those who might benefitfrom it.Cued Speech is a system of communication thatsupplements speechreading and is being used with12Some dealers and audiologists include the cost of a followup checkin their initial price, while others charge extra for it (104).elderly people in a few places in the United States.Developed by R. Orin Cornett, Cued Speech in-volves the use of eight hand shapes that clarifyconsonant sounds and four hand positions thatclarify vowel sounds. For example, the words “mit,”“bit)” and “pit” are virtually indistinguishable withonly speechreading techniques. Cued Speech usesa hand signal to designate which consonant is be-ing spoken (136). Cued Speech differs from signlanguage in that it clarifies spoken language ratherthan replacing it with manual communication (36).To use Cued Speech, the hearing impaired indi-vidual and others who want to communicate withhim must learn the hand signals and positions. Thistakes up to 20 hours for most adults, plus exten-sive practice. Learning requires motivation andCued Speech trainers have noted that some fam-ily members are reluctant to learn this new com-munication technique, While very few elderly peo-ple have been taught Cued Speech thus far, thosewho do master it report great satisfaction withtheir renewed ability to communicate clearly usingnormal spoken language (136).Microelectronic aids to speech comprehensionsuch as visual and tactile devices may soon be avail-able. For example, the Upton eyeglass speechreader projects voice-spectrum information ontothe wearer’s eyeglasses to augment speechread-ing. Although the display of speech-sound catego-ries are far from error free, some information ofmodest consistency is better than no informationat all. Some design improvements are necessarybefore the Upton system is ready to be field tested(88).An automatic cuer has been developed by R. OrinCornett and Robert Beadles as an aid to CuedSpeech. This device, the “Autocuer,” uses a micro-processor to classify speech into cue groups andactivate 56 tiny light-emitting diodes on the user’seyeglasses (39) (see figure 13). A l-year trial of theAutocuer using children and adults was scheduledto begin in 1985 (99).Vibrating devices that give cues to facilitatespeechreading are also being developed. One ex-ample is the “Teletactor belt, ” which is wornaround the abdomen and produces vibrations thatare felt as a tickling sensation by the user. Differ-ent sounds cause distinctive patterns of vibrationsthat the individual must learn to recognize (15).
  • 43Figure 13.—Lip Reading GlassesThe “Autocuer” is designed to helpAs Illustrated in these photographs, different sounds are difficult to distinguish using only visual cues.speech readers distinguish sounds that appear similar. A microphone on the glasses frame picks up the voice as much as 12 feet away andtransmits it to a microprocessor that analyzes the sound and relays signals back to light-emitting diodes on the glasses lens The diodes producean Image that represents the sound. The series above shows the images that represent the sentence He can go.SOURCE Research Triangle Institute, RTI Park, North Carolina.The inventor of this device, Frank Saunders, hasreceived a Small Business Innovative Research Ini-tiative award from the National Institutes of Healthto develop it; it is being tested for efficacy in mid-dle aged and elderly people (59).Some hearing researchers believe that tactilestimulators will be most useful for people withsome residual hearing who use the sensations toenhance speechreading (60). Others believe thatpeople who have lost their hearing after learningto speak will probably never be able to learn touse the vibratory cues effectively and that the de-vices will be most useful to the prelingually deaf(25).These electronic speechreading aids are in thedevelopment stage. Furthermore, each will requireusers to undergo substantial training. when theybecome available, their advantage over currentspeechreading techniques will be that they pro-vide cues to differentiate sounds that are visuallyidentical. Their advantage over Cued Speech willbe that the hearing impaired individual will be ableto communicate with anyone in any setting, with -out depending on the speaker’s ability to cue.CounselingCounseling can help hearing impaired peopleovercome negative attitudes that interfere with
  • 44rehabilitation and develop strategies to managelistening situations in ways that lessen their dis-ability (26). Problems that interfere with the reha-bilitation of hearing impaired elderly people in-clude: 1) physical conditions such as poor vision,arthritis, limited manual dexterity, and limited mo-bility; 2) lack of motivation and a sense of hope-lessness; and 3) cost factors. Counseling can be ef-fective in addressing each of these problems.Physical impairments that are common amongelderly people can interfere with aural rehabilita-tion, For example, the elderly person with reducedvisual acuity may be unable to see well enoughto use speechreading techniques. Individuals witharthritis may be unable to insert a hearing aid ear-mold properly due to reduced mobility of the shoul-der or manual dexterity (10). Similarly, those withdiabetes or other conditions that decrease sensi-tivity in their fingers may have trouble insertingthe earmold and adjusting the aid. The total phys-ical condition of the individual should be evalu-ated before an appropriate treatment is recom-mended. Counseling can help develop methods forovercoming the obstacles that hinder treatment.Lack of motivation and a related sense of hope-lessness also interfere with aural rehabilitation.Elderly people are particularly likely to believe thatnothing can be done to correct their hearing prob-lems. This belief is exacerbated by society’s nega-tive attitudes about the rehabilitation potential ofelderly people, Some elderly individuals have beenknown to suggest that services be directed towarda younger person who could derive greater bene-fit. Denial of hearing impairment also limits moti-vation (l).A first step in dealing with lack of motivationis to understand the meaning of the hearing lossto the individual, the situations in which he/shehas difficulty hearing, and how important thesesituations are to him/her (96). Second, the reha-bilitation process should be adapted to the needsand abilities of the individual. Healthy, activeelderly people may be capable of obtaining serv-ices provided in the community. However, otherswith financial or health-related problems are oftenunable or unwilling to seek out such services andan outreach program may be needed (26). Diag-nostic and rehabilitative services could be providedin the person’s home, a senior center, or a nurs-ing home. Hearing specialists also could providein-service education to the individual’s caregivers(family, day program counselors, nursing homestaff, etc.). Including “significant others” in the re-habilitative process enhances the hearing impairedindividual’s chances of success,Obstacles to the increased use of aural rehabili-tation services, hearing aids, assistive listening de-vices, and telecommunication, signaling and alarmdevices include problems in the service deliverysystem (ch. 4) and lack of funding (ch. 5). Whether.an elderly person elects to seek aural rehabilita-tion or fitting for amplification devices often de-pends on financial status and the relative valuehe places on communication compared to otherproducts and services he needs.
  • Chapter 4The Service Delivery System
  • Chapter 4The Service Delivery SystemThe existing service delivery system1does notprovide access to optimal treatment, devices, andservices for many hearing impaired elderly peo-ple. Listed below are some of the most commonproblems that need to be addressed:qqqqqqSome hearing impaired elderly people arenever evaluated by a hearing specialist. Datafrom the Health and Nutrition ExaminationSurvey, collected from 1971 to 1975, showedthat 61 percent of elderly people with signifi-cant hearing impairments had never had anyaudiometric testing. Low-income elderly peo-ple were particularly unlikely to have beentested (50).A 1984 survey showed considerable improve-ment in this problem over the past decade.However, of the 16 million people with hear-ing impairments in the United States, about3.7 million (23 percent) have not seen a hear-ing specialist even though they are aware oftheir hearing impairment. Another 2 million(12.5 percent) are unaware of or deny thatthey have a hearing impairment (49). No agebreakdown is available for these data.At least 75 percent of all hearing impaired peo-ple do not own a hearing aid, and some peo-ple buy hearing aids that are not well matchedto their needs.Some elderly people who have had a hearingaid and/or a hearing evaluation in the past re-fuse further evaluation and treatment becausethey were disappointed with the previous ex-perience (73).Many elderly people are not aware of avail-able assistive listening devices, telecommu-nication devices, and signaling and alarmsystems.Few elderly people receive aural rehabilita-tion services despite the potential benefit ofthese services.I As used in this report, the term “ser~’ice deli~erj’ sj’stem ” refersto ser~ice prmiders, referral patterns, and the settings in ~thichhearing sertices are delii’ered.The service delivery system involves three typesof hearing specialists-physicians, audiologists, andhearing aid dealers-each with a substantiallydifferent orientation to hearing impairment. Al-though there are always exceptions to any gener-alization, it can be said that physicians generallyapproach hearing impairment from a medical pointof view and their primary objective is curing orameliorating disease in their patients. Audiologistsgenerally approach hearing impairment from aservice point of view and their primary objectiveis assessing the individual’s communication defi-cits and recommending or providing services anddevices to improve communication ability. Hear-ing aid dealers generally begin from a businesspoint of view and their primary objective is pro-viding an effective and satisfactory product fortheir customers. An increasing number of audiol-ogists are now selling hearing aids, and these “dis-pensing audiologists ’’can be expected to share atti-tudes and objectives with both hearing aid dealersand audiologists.These differences in points of view and objec-tives among the three types of hearing specialistscan lead to disagreement. What is the best formof treatment for hearing impaired people? Whichhearing specialist should a person see first? Shouldone type of specialist coordinate or supervise hear-ing services provided by other specialists? Changesin patterns of patient referral and treatment haveboth theoretical significance and financial impli-cations for each type of hearing specialist. As aresult, rivalry among them has been intense attimes. This rivalry has been and will continue tobe exacerbated whenever proposed Federal leg-islation and regulations appear to designate onetype of specialist as the primary provider of hear-ing services.The rivalry among hearing specialists contrib-utes to fragmentation of delivery system and re-sults in a lack of continuity of care. A client whois unaware of the differences between the threetypes of hearing specialists must often seek outservices on his own. Frequently, each type of hear-ing specialist works in a different setting and clients47
  • 48must make numerous trips to obtain all the neces-sary services. This is particularly difficult for manyelderly people.These problems have been solved in some hos-pital- and university-based speech and hearingclinics that combine medical and audiological serv-ices and the capacity to dispense hearing aids andother devices. The Veterans Administration (VA)also has a comprehensive delivery system. In addi-setting up private practice groups that provide afull range of hearing services in one setting. Fi-nally, the professional societies that represent eachtype of hearing specialist have sponsored programsat the national, State, and local level to increasecommunication and cooperation among the pro-viders of hearing services. Continued efforts tocoordinate the delivery of hearing services wouldbenefit hearing impaired people of all ages.tion, a growing number of hearing specialists areSERVICE PROVIDERS AND REFERRAL PATTERNSPhysicians, audiologists, and hearing aid dealersare the principal providers of hearing services.Speech therapists, social workers, psychologists,nurses, and other health care and social serviceproviders are sometimes involved in referring theelderly for hearing evaluation and treatment.PhysiciansMany elderly persons enter the service deliverysystem via a primary care physician, such as a gen-eral practitioner, family practitioner, or internist.2Some individuals are referred by the primary carephysician to another physician who specializes indiseases of the ear–usually an otolaryngologistor otologist.Otolaryngology is a medical/surgical specialty,requiring 5 years of specialty training in the diag-nosis and medical/surgical treatment of conditionsaffecting the ear, nose, throat, head and neck, andfacial, cosmetic, and reconstructive plastic surgery.Otolaryngologists also receive some training inhearing measurement and aural rehabilitation. Anotologist is a board certified otolaryngologist whochooses to limit his practice to medical/ surgicaltreatment of diseases of the ear.Some hearing specialists believe that the first stepin the delivery of hearing services should be anevaluation by a physician, specifically an otolaryn -‘Although no data are available, anecdotal evidence indicates thatonly a small proportion of primary care physicians include a hear-ing test as part of a regular physical examination (106). Thus, it islikely that most of the elderly people who discuss their hearing witha primary care physician initiate the discussion themselves, or itmay be brought up by a family member.gologist or otologist, and that the physician shouldsupervise treatment. Physician involvement is seenas essential because the physician is the only hear-ing specialist who can diagnose diseases that causehearing loss (62, 42). Even though few of the hear-ing impairments common among elderly peopleare medically treatable, prompt identification ofthose few is clearly important. In addition, hear-ing impairment is sometimes the earliest symptomof serious pathology, such as an acoustic tumor,that requires immediate medical attention (10).Physicians, including otolaryngologists, otolo-gists, general practitioners, internists, and others,often play a key role in determining which hear-ing services are provided for elderly people. Pri-vate insurance and government funding programsoften require that a physician approve hearingservices as a condition of payment. Yet physicianswho do not specialize in diseases of the ear gener-ally receive very little training about auditory prob-lems and almost no training in the managementof auditory impairments that are not medicallytreatable. As a result. many of these doctors lackthe expertise necessary to identify the hearing serv-ices needed by most elderly people (10).Some hearing specialists express similar reser-vations about the role of otolaryngologists and otol-ogists in determining what hearing services areprovided for elderly people. These people arguethat although otolaryngologists and orologists arethe acknowledged experts in diagnosis of ear dis-eases, they are primarily trained in medical andsurgical treatment and therefore are not well-qualified to advise hearing impaired adults about
  • 49hearing aids and alternative approaches to com-pensate for hearing loss (33). It is said that theyare particularly unlikely to know about assistivedevices, telecommunication devices, and signal-ing and alarm systems (108).In contrast, others argue that otolaryngologistsreceive substantial training in amplification andmanagement of hearing impairment. The Amer-ican Academy of Otolaryngology-Head and NeckSurgery also provides postgraduate education pro-grams and self-instructional courses for physicianson the rehabilitation of hearing impaired people(43). It is interesting to note that a Federal TradeCommission survey of people who purchased hear-ing aids from 1983 to 1985 found that 6 percentpurchased their aids from a physician (75). Someobservers believe that the number of physicianswho dispense hearing aids is increasing and thatthis trend will continue (106).AudiologistsAudiologists are nonmedical hearing specialiststrained in the identification, measurement, andrehabilitation of hearing impairment. Audiologiststake courses in speech, hearing, and languagemechanisms, culminating with a master’s or doc-toral degree in audiology. Many also hold a Cer-tificate of Clinical Competence from the AmericanSpeech-Language-Hearing Association (ASHA). Thepractice of audiology is currently licensed in 35States, and State licensing requirements are gen-erally as rigorous as those for the Certificate ofClinical Competence (10).Evaluation by an audiologist includes an assess-ment of hearing threshold sensitivity, speech dis-crimination ability, and residual peripheral andcentral auditory function. While audiological test-ing often reveals information that is useful to phy-sicians in establishing a medical diagnosis, the pri-mary purpose of the audiologic assessment is todetermine the impact of impaired hearing on a per-son total communication ability. The assessmentusually includes a comprehensive history covering:qqqthe onset and development of the hearing im-pairment;its relationship to physical, social, and emo-tional well-being;previous treatment;q the relationship of the hearing impairment toother sensory or perceptual dysfunctions; andq the effect of the hearing impairment on theperson’s speech (10).Some hearing specialists argue that a compre-hensive audiologic assessment is needed to deter-mine the potential benefit of a hearing aid, the typeof hearing aid that is needed, whether the fittingshould be monaural or binaural, and which earshould be fitted (10). Others argue that parts ofthe audiologic assessment are not relevant to de-termining the potential benefit or selection of ahearing aid and that these tests can be unneces-sary, time-consuming, and expensive for somehearing impaired people (62, 90, 133).Until recently, audiologists did not sell hearingaids. There was a commitment to establish audi-ology as a profession that would provide hearingservices, not products, and as a scientific disciplinethat would not be involved in commercial activi-ties (41). The practice of audiology has changedconsiderably in recent years, however, and 35 to40 percent of audiologists now sell hearing aids(18).3Some analysts believe that the traditionalcommitment of audiologists to remain uninvolvedin commercial aspects of hearing aid sales has re-sulted in skeptical or negative attitudes about hear-ing aids among some audiologists and that theymay, therefore, fail to recommend a hearing aideven when the aid might benefit the patient (41).Some audiologists sell assistive listening devicesand telecommunication, signaling, and alarm de-vices. Survey data indicate that these devices ac-count for about 2 percent of the gross profits ofdispensing audiologists (23). other audiologists pro-vide clients with information about these devices,but do not sell them. Still others neither sell norprovide information about them, and some are notknowledgeable about them. Few professional train-ing programs for audiologists include courses on3Audiologists who dispense hearing aids are suh ject to an}’ rele -frant State regulations. In some States, lirensed audiologists are re -quired to take a hearing aid dealer’s exam to dispense hearing aids,while in other States they are exempt from this requirement, SomeStates require that audiologists rornplete an apprenticeship underthe supervision of a licensed hearing aid dealer, while others donot. 1 hese ’ariat ions in regulations can cause Confusion and ten-sion bettteen audiologists and hearing a ici dealers tind impedereciprocit~, agreements hetltfwn States ( 10).
  • 50assistive devices and the certification program foraudiologists administered by ASHA does not re-quire comprehensive training about these devices(33). Training programs such as those developedby Vaughn and Lightfoot of the VA Medical Cen-ter in Birmingham, Alabama, described later in thischapter, are designed to inform audiologists andother hearing specialists about these devices. Inaddition, ASHA has sponsored training workshopsfor audiologists on assistive listening devices.Most audiology training programs have not em-phasized the special problems of hearing impair-ment in elderly people. However, ASHA has re-cently developed a model curriculum for thispurpose.Hearing Aid DealersHearing aid dealers sell hearing aids and hear-ing aid accessories, such as batteries, tubing, andearmolds. Hearing aid dealers do not have lengthyformal education in hearing impairment like oto-laryngologists, orologists, and audiologists. Yetmany have considerable experience and expertisein the remediation of hearing loss. They are gen-erally well qualified to select and fit hearing aids,make earmold impressions, and instruct peoplein the use and care of hearing aids. Many dealersalso repair hearing aids. Both hearing aid dealersand audiologists provide hearing aid orientation.All three types of hearing specialists provide coun-seling for hearing impaired people, although thefocus and content of counseling may differ sub-stantially depending on who provides it.Hearing aid dealers have been harshly criticizedin the past. Other hearing specialists and some con-sumer advocates have charged that hearing aiddealers focus too much on sales, that their salestactics are too aggressive, and that they are notadequately trained to evaluate hearing impairment.The National Hearing Aid Society (NHAS) offersa 20-week home-study course for hearing aiddealers, but the course has been criticized as in-adequate, incorrect, and outdated (10, 126).Despite these criticisms, a recent nationwide sur-vey showed that 72 percent of the people whobought hearing aids from hearing aid dealers weresatisfied and would return to the same dealer. Only16 percent would not return to the same dealer,and 12 percent were undecided. Consumer satis-faction with hearing aid dealers was lower thansatisfaction with dispensing physicians and audi-ologists, however; 78 percent of those who boughta hearing aid from a physician and 81 percent ofthose who bought an aid from an audiologist saidthey would return to the same seller (75). Whilethe validity of the sampling procedure for this sur-vey has been questioned (107), and consumer satis-faction was greater among those who purchasedaids from physicians and audiologists, these datado indicate considerable satisfaction with the per-formance of hearing aid dealers.Hearing aid dealers are the only hearing spe-cialists available in some geographic areas, and assuch they provide hearing services to people whowould otherwise have no access to services. In addi-tion, it is likely that over the years hearing aiddealers as a group have had more experience withelderly hearing impaired people than other hear-ing specialists. Their understanding of the practi-cal realities of providing amplification for elderlycustomers—problems of acceptance and adjust-ment and the kinds of listening situations that areparticularly difficult for elderly people even witha hearing aid-could be a valuable source of in-formation about the physical and psychologicalaspects of hearing loss in elderly people.Hearing aid dealers are licensed in 45 States. Asubstantial number of dealers are also accreditedby NHAS and/or the National Board for Certifica-tion in Hearing Instrument Sciences. NHAS has con-ferred the title “certified hearing aid audiologist”on dealers who pass the NHAS home-study course.Audiologists object to the use of this title by hear-ing aid dealers, saying that it can be confusing toconsumers because it implies that the dealer pos-sesses expertise which he does not have (10). ASHAhas recently won a U.S. Patent Office ruling thatonly audiologists can use the word “audiologist”in their title. NHAS has appealed this ruling (133).Most hearing aid dealers do not sell assistivelistening devices or telecommunication, signaling,and alarm devices. These devices account for lessthan 1 percent of the gross sales of hearing aiddealers (23). Some hearing aid dealers do not sellthese devices because they believe that assistive
  • 51listening devices are a low-cost alternative to hear-ing aids and could therefore reduce hearing aidsales. The profit to the dealer on assistive devicesis generally less than on hearing aids. Some dealersalso complain that they do not have enough spaceto display the devices. Others may not know aboutavailable devices (33, 68, 74). yet interest in thesedevices is increasing and some observers believethat more hearing aid dealers and dispensing au-diologists will begin to offer them in the near fu-ture (29, 74).Referral PatternsElderly people with hearing impairments can en-ter the service delivery system through a primarycare physician, a physician specialist, an audiolo-gist, or a hearing aid dealer. Each hearing special-ist can provide services himself and/or refer theperson to one or more other specialists. In one pat-tern of service delivery, the point of entry is a pri-mary care physician, who may treat the individ-ual, refer him directly to an audiologist or hearingaid dealer, or refer him to an otolaryngologist orotologist. The otolaryngologist may conduct hear-ing tests in his office or refer the patient to an au-diologist for testing. When testing indicates sen-sorineural or other irreversible hearing loss, theotolaryngologist may refer the patient directly toa hearing aid dealer or he may refer the personto an audiologist for assessment of the potentialbenefit of hearing aid use, selection of the appro-p r i a t e i n s t r u m e n t , a n d o t h e r r e h a b i l i t a t i v e m e a s -ures. The audiologist may supply the hearing aidor refer the patient to a hearing aid dealer (10).A second pattern of service delivery involves en-try through the audiologist or audiology clinic. Ifthe initial audiologic evaluation suggests the pos-sibility of medically significant pathology, the in-dividual is referred to a physician, usually an oto-laryngologist. When no such pathology is apparent,the audiologist proceeds with hearing aid evalua-tion and aural rehabilitation services. If a hearingaid is recommended, it may be dispensed by theaudiologist or the individual may be referred toa hearing aid dealer (10).In a third pattern of service delivery, the hear-ing aid dealer is the point of entry, with contactinitiated by the consumer or as a result of solicita-tion by the dealer. The dealer may refer the con-sumer to a physician or an audiologist for medicalor audiologic evaluation, or he may dispense thehearing aid on the basis of his own evaluation (10).Federal Food and Drug Administration (FDA) reg-ulations require that hearing aid purchasers mustpresent a written statement from a licensed phy-sician to the dealer or dispenser, dated within theprevious 6 months, certifying that their hearingloss has been evaluated by the physician and thatthe individual is a candidate for a hearing aid. How-ever, people over 18 years of age can sign a formwaiving the requirement for a physician’s evalua-tion (10). No information is available about howmany hearing aids are sold on the basis of thesewaivers. However, only 42 percent of those whobought hearing aids from 1983 to 1985 recalledbeing told about the requirement of a physician ‘Sevaluation or a signed waiver, 46 percent said theyhad not been told about the requirement, and 12percent could not remember (75).Many physicians and audiologists are concernedthat people who see a hearing aid dealer first fre-quently are not referred to a physician for medi-cal evaluation or to an audiologist for compre-hensive audiologic evaluation. Although data onreferral patterns are not conclusive, a nationwidesurvey of people who purchased hearing aids from1983 to 1985 indicates that 64 percent of respond-ents saw a physician about their hearing problemsbefore purchasing a hearing aid. Of these individ-uals, 92 percent saw an ear specialist and 15 per-cent saw a general practitioner or internist. Clearly,some individuals saw both (75).Survey data also show that about 45 percent ofrespondents received information about hearingaids from an audiologist prior to purchasing anaid and 53 percent said that an audiologist recom-mended the performance characteristics for theiraid (75). Thus at least half of those who purchaseda hearing aid had seen an audiologist before buy-ing the aid.Anecdotal evidence suggests that some peoplewho are referred by a hearing aid dealer to a phy-sician or audiologist for evaluation prior to pur-chasing a hearing aid are not referred back to thedealer to buy the aid (133). In some cases, the phy-sician or audiologist may recommend against pur -
  • 52chasing an aid, while in other cases the person maypurchase the aid from the audiologist or a differ-ent dealer recommended by the physician or audi-ologist. Obviously, alleged instances of the lattertype are troublesome to hearing aid dealers.Also troublesome to dealers is the finding thatphysicians and audiologists often recommendagainst hearing aids for people who, in the opin-ion of the dealer, would benefit from using an aid.One national survey showed that among hearingimpaired people who do not own hearing aids, 63percent have discussed their hearing problemswith a hearing specialist. Of those who saw anotolaryngologist or otologist, 34 percent receiveda recommendation against buying a hearing aid.Of those who saw an audiologist, 27 percent re-ceived a recommendation against buying an aid(49). While no information is available aboutwhether hearing aid dealers would recommendhearing aids for all of these people, it is clear thatthere is disagreement among hearing specialistsabout who can benefit from a hearing aid.This information about hearing specialists, refer-ral patterns, and recommendations about hear-ing aid use raises many questions about the mostappropriate hearing services for hearing impairedelderly people. For example:qqqqqIs physician evaluation essential for all elderlyhearing impaired people?Should a physician, or a physician who spe-cializes in ear diseases, supervise all hearingservices?Isa comprehensive audiologic evaluation nec-essary for all elderly hearing impaired people?Which hearing tests are necessary to deter-mine the potential benefit of a hearing aidand/or to select the appropriate aid?Are there categories of individuals with par-tial hearing loss who cannot benefit fro-m ahearing aid? If so, can these categories beagreed on by the three types of hearing spe-cialists?These questions relate both to the quality of hear-ing services and to their cost, and hearing spe-cialists disagree strongly about the relative meritsof different patterns of service delivery.This OTA report reaches no conclusions aboutthese important questions or the relative advan-tages of different patterns of service delivery. Thetwo nationwide surveys of the service delivery sys-tem that have been cited throughout this report(49, 75) provide valuable information about theexisting service delivery system. Further researchis needed to determine the costs and benefits ofalternate patterns of service delivery. Such re-search would require a prior determination ofwhich hearing services are essential and/or desira-ble for elderly people—a determination that canbest be made by drawing on the expertise and ex-perience of all three types of service providers.It is possible that the Federal Government couldinitiate or support a joint effort of this kind.The Role of Other Health Care andSocial Service ProvidersSpeech therapists, social workers, psychologists,nurses, and other health care and social serviceprofessionals also provide advice, referrals, andemotional support to hearing impaired elderly peo-ple. Unfortunately, many of these professionalsknow very little about hearing impairment or avail-able treatments, devices, and hearing services. Allhealth care and social services professionals shouldbe educated about hearing impairment and appro-priate procedures for referring people to hearingspecialists (10). Training materials are also neededfor health care and social service providers whohave completed their professional education.ASHA received a grant from the Administrationon Aging to develop training materials for hear-ing specialists and other health and social serviceproviders who work with elderly people. One ex-ample of such materials is the recent ASHA andthe National Information Center on Deafness pub-1ication Hearing Loss: lnformation for Professionalsin the Aging Network (137).The Suzanne Pathy Speak-Up Institute, basedin New York City, has developed a program to trainhospital personnel to recognize and respond ef-fectively to hearing impaired patients. Hospitali-zation is an anxiety-producing experience for mostpeople. For hearing impaired elderly people, hos-pitalization can be especially frightening becausethey are often unable to hear instructions and ex-planations given by nurses, physicians, and otherhospital personnel, The National Center for Law
  • 53Figure 14.— Materials Supplied to ParticipatingHospitals by the Suzanne Pathy Speak.Up InstituteSPEAK UP!RULES TO REMEMBER WHEN SPEAKING TO SOMEONE WITH AHEARING LOSS:q DO NOT SHOUT.q SPEAK CLEARLY AND SLOWLY.q REPHRASE A MISUNDERSTOOD SENTENCE.q MOVE AWAY FROM BACKGROUND NOISE. aq STAND N CLEAR LIGHT FACING THE PERSON YM~L F HEWITH WHOM YOU ARE SPEAKING. SPEAK. UP INSTITUTEq DO NOT OBSCURE YOUR MOUTH WITH A CIGARETTE OR HANDSAND DO NOT CHEW FOOD WHILE SPEAKING.q ASK THE PERSON WHAT YOU MIGHT DO TO MAKECONVERSATION EASIER.and the Deaf points out that when patients can-not hear explanations of their condition and pro-posed treatment, their “informed consent” couldbe considered legally invalid. In addition, there isa risk of wrong diagnosis for patients who cannotcompletely understand questions about theirsymptoms and consequently provide inaccurateinformation to the physician (80).The Suzanne athy Speak-up program providesstickers to mark patient charts and instructioncards to remind staff how to communicate withhearing-impaired patients (see figure 14). As of July1984 the program was in effect in more than 50hospitals across the country (110) and is being ex-tended to home health care agencies (85).To increase awareness of hearing impairment, the Suzanne athySpeak-Up Institute has developed this large sign to place above thebed of the hearing impaired patient. Smaller gummed stickers are alsoavailable to mark the medicai chart of each hearing impaired patient.They also supply a gummed card for the medical chart of each pa-tient to remind hospital staff of rules for communicating with the hear-ing impaired,SOURCE: Suzanne Pathy Speak-Up Institute
  • 54SETTINGS FOR SERVICE DELIVERYMost hearing services for elderly people are pro-vided in the offices of physicians, audiologists, andhearing aid dealers. To a lesser extent, hearing serv-ices are also provided in health care and educa-tional settings and in multi-service communityagencies. Although certain services, such as med-ical and surgical treatment, can only be providedin health care settings, others such as aural reha-bilitation can be provided in a variety of settings.In some instances, the character of apparently sim-ilar services may differ when they are deliveredin different settings. In other instances they maybe virtually identical. Reimbursement for services,however, depends heavily on the setting wherethey are provided (10).Health Care SettingsExcept for surgery, few hearing services are de-livered in hospitals on an inpatient basis. This maybecome even more rare because of restrictionson admission and length of stay resulting from theMedicare prospective payment system. Diagnos-tic services are sometimes provided in hospitals,but aural rehabilitation services are seldom avail-able (10).Most hearing services provided by health careinstitutions are delivered on an outpatient basis,in either hospital-based or independent speech andhearing clinics, Diagnostic and rehabilitative serv-ices are usually provided, but the emphasis is onshort -term care. Because of the relatively high over-head costs in most medically based outpatient fa-cilities, long-term rehabilitative services in thesesettings are often prohibitively expensive. Occa-sionally, hearing services for older people are pro-vided by local health departments and even mo-bile medical clinics.Extended care facilities, such as nursing homes,would seem to be an optimal setting for the deliv-ery of hearing services. Speech pathology serv-ices often are required as a condition of licensurefor extended care facilities and speech patholo-gists sometimes refer elderly residents for hear-ing evaluations. However, comprehensive hear-ing services are seldom available in these facilitiesand it is often difficult for nursing home residentsto go out to the offices of hearing specialists be-cause of their other physical impairments. Somehearing aid dealers do visit nursing homes to evalu-ate patients and fit hearing aids, but few otolaryn-gologists and audiologists are available to treat resi-dents in nursing homes.Home health programs also offer an optimal set-ting to deliver hearing services, but unfortunatelythese services are rarely provided. In a study of206 home health agencies, only 5 percent providedhearing services (72). Adult day care centers thatserve people who require long-term care but canbe maintained at home at night and on weekendsare another possible setting for the delivery of hear-ing services to some older people (10). It is notknown how many adult day care centers now pro-vide hearing services.Educational SettingsHearing services are provided by some adult edu-cation agencies, community colleges, and univer-sity speech and hearing clinics. Adult educationagencies first offered lipreading instruction forhearing impaired people during the 1920s and1930s. Some of these programs have been ex-panded and now offer a comprehensive range ofaural rehabilitation services (10).During the past decade, several States have en-couraged community colleges to initiate programsfor disabled students. While some of these pro-grams offer primarily vocation-oriented instruc-tion to students, others offer comprehensive hear-ing services to adults of all ages (10).University speech and hearing clinics are anothersource of hearing services and in some communi-ties they are the major provider of services. Theseclinics are usually affiliated with the speech andhearing or audiology department of a university.This makes low-cost hearing services availablesince virtually all services are provided by studentsunder careful supervision. However, this use ofstudents gives an unrealistic impression about thetrue cost of hearing services (10). University speechand hearing clinics often provide a wider rangeof hearing services than other settings (115), in-
  • 55eluding comprehensive evaluation, aural rehabili-tation, and fitting for hearing aids. Some also sup-ply assistive listening devices (140).Community AgenciesMany communities offer hearing services inmulti -service agencies. For example, senior centersgenerally provide recreation, education, counsel-ing, and other social services for elderly people;some also offer hearing screening and other hear-ing services.4 Some communities also have speechand hearing centers that offer a wide array of serv-ices including hearing aid dispensing. They mayalso sponsor satellite programs in other commu-nity agencies where older people are likely to beserved (10).4A recent studv of hearing services in senior centm’s, S[ud} ofPrograms and Sertzices for the Hearing Impaired Eki@Lr in S&iorCenters and C/ubs in the United States, will be puhlished I)j (;ai -laudet Research Institute in 1986 [100).ALTERNATE APPROACHES TO SERVICE DELIVERYAlternate approaches exist that can help improvethe delivery of hearing services. These include pro-grams of the Veterans Administration, the elder-hostel program of Gallaudet College, and assistivedevice centers. Self-help groups for hearing im-paired people are also effective in educating peopleabout hearing impairment, appropriate treatment,and methods for dealing with the fragmented de-livery system. Two projects to provide hearingservices for nursing home residents also have beendeveloped and are described below,Veterans Administration HearingServicesThe VA program of hearing services is one modelof comprehensive service delivery. The VA pro-gram is an outgrowth of military aural rehabilita-tion centers established during World War II. AtVA medical centers across the country, hearingservices include: 1) evaluation by an audiologist;2) evaluation by an otologist or otolaryngologist;3) hearing aid dispensing; and 4) rehabilitation serv-ices such as speechreading, auditory training, andspeech training to correct speech or voice prob-lems associated with a hearing impairment (83).Veterans with service-connected hearing impair-ments are eligible to receive all hearing servicesat no cost. Veterans who do not have service-connected hearing impairments but are over 65or cannot afford hearing services are eligible fora free hearing test. Certain categories of veteransare also eligible for free hearing aids. These in-clude veterans with service-connected hearing im-pairments, those who have 50 percent or moreservice connected disability, those who are receiv-ing home care benefits from the VA, prisoners ofwar, and World War I veterans. Other veteransare referred to hearing aid dealers or speech andhearing clinics to purchase a hearing aid. In fiscalyear 1984, the VA distributed more than 36,000hearing aids to eligible veterans (47). Large vol-ume purchasing arrangements lower the cost ofeach aid, but it is difficult to compare the cost ofaids distributed by the VA with the cost of aidsdistributed by other dispensers because the profes-sional costs associated with testing hearing andselecting an aid are sometimes not included in theVA figures.The VA model of service delivery has beenadopted in other institutional settings where med-ical, audiologic, and hearing aid dispensing serv-ices are offered “under one roof .“ One such pro-gram is at the Albany Medical Center, where overthe past 7 years more than 1,900 hearing impairedpeople of all ages have been treated. The programprovides otolaryngologic, audiologic, and rehabili-tative services, including evaluation for hearingaids, hearing aid dispensing, hearing aid orienta-tion and counseling, speechreading, auditory train-ing, and hearing aid repair (134). Similar programshave been developed by health maintenance orga-nizations, particularly those that operate compre-hensive medical centers (10).The VA Medical Center in Birmingham, Alabama,has a program of service delivery that goes beyondwhat is provided in other VA medical centers. Oneof its primary objectives is the provision of com-
  • 56prehensive services and followup for veterans whohave difficulty coming to the medical centers VAstaff point out that many people, not only veterans,live far from centers where comprehensive hear-ing services are provided and are unlikely to re-turn for regular reevaluation, aural rehabilitation,and counseling. Even when long distances are notinvolved, lack of transportation and physical im-pairments that interfere with travel cause manypeople to drop out of treatment. Consequently,the Birmingham VA program provides many serv-ices by telephone.In this program, the initial evaluation and treat-ment are done in the hospital or the clinic, but af-ter the initial treatment the clinic staff regularlyinitiate telephone contact with clients to reviewtheir progress, provide auditory training exercisesand supplemental drills, and answer questionsfrom the client or his family. Conference calls areused to conduct “group meetings” among individ-uals with similar impairments so they can give eachother moral support and helpful hints about cop-ing with mutual problems (130). This use of thetelephone spares clients from repeated trips to themedical center. The alternative-sending staffmembers out to provide services away from themedical center—is prohibitively expensive.The Birmingham VA program also emphasizesthe use of assistive devices, both for telephone com-munication and for one-to-one and group listen-ing, Many kinds of devices are given or loaned toclients. They encourage clients who wear hear-ing aids and those who do not to use assistivedevices and have created a videotape explainingthe kinds of assistive listening devices that areavailable.6The Birmingham VA program also stresses train-ing for hearing specialists and other health careand social service providers. VA staff have beeninvolved in many conferences and training work-shops across the country where they explain theirmethod of telephone contacts for client education,reevaluation, and treatment, and educate pro-These services are supported by the L’A Exchange of Medical In-formation and Rehabilitation, Research, and Development Programs.bThe videotape was prepared by Gwenyth i’aughn and RobertLightfoot for the Sertoma Foundation, ith partial funding fromSiemens Hearing Instruments, Inc.viders about assistive listening devices, telecom-munication devices, and signaling and alarm sys-tems. They also provide telephone consultationto clinicians in VA and non-VA facilities.A final component of the Birmingham VA pro-gram is REMATE, Remote Machine-Assisted Treat-ment and Evaluation. REM ATE is a computer-baseddelivery system. The computer is programmed bythe clinician to provide drill sessions by telephonefor veterans nationwide and to store client re-sponses for later review by the clinician. This sys-tem can also be used to gather and store data forlong-term evaluation of treatment procedures(130).Elderhostel Program for theHearing ImpairedAnother innovative approach to the delivery ofhearing services is the elderhostel program con-ducted at Gallaudet College since 1981. Hearingimpaired persons over 60 and their spouses or “sig-nificant others” are invited to the college in Wash-ington, DC, for a week in the summer. They at-tend presentations about the nature of hearingloss and its impact on relationships, strategies forcoping with hearing loss, and the roles of varioushearing specialists. Lists of hearing specialists inthe participants’ home States are provided and as-sistive devices are on display. Participants also at-tend sessions on nonverbal communication anddeaf culture. Participants have particularly ap-preciated the information on assistive devices andself-help techniques. Small group activities are alsoimportant; they allow hearing impaired elderlypeople to interact with others and realize they arenot alone in coping with hearing loss. The origi-nators of this elderhostel program believe it couldbe repeated at colleges and community agenciesthroughout the country (61).Assistive Device CentersAssistive device centers for the hearing impairedare locations where a variety of devices used tocompensate for hearing loss are displayed anddemonstrated. Hearing impaired people, their fam-ilies, and health care and social service providerscan visit these centers to learn about available de-vices. One assistive device center at the Fort Lauder-
  • 57dale oral School is manned by volunteers from theTelephone Pioneers of America. Demonstrationdevices have been contributed by the manufac-turers (34). Appendix B contains a list of assistivedevice centers in the United States. Centers areneeded in other locations throughout the country,Self-Help Groups for HearingImpaired PeopleSelf-help groups for hearing impaired people pro-vide information for their members about devicesand techniques that help compensate for hearingloss and about the role and expertise of differenttypes of hearing specialists. The names of someof these groups are listed in appendix A. Some ofthem have assistive listening devices and telecom-munication, signaling, and alarm devices availableat their meetings so that attendees can try them.One self-help group, Self Help for Hard of Hear-ing People (SHHH), in cooperation with the Birming-ham VA, has produced a series of six pamphletson assistive listening devices and their uses.Some self -help groups are primarily for deaf peo-ple, while others are primarily for hard-of-hearingpeople. Membership is open to people of all ages,but many members are elderly, particularly in thegroups oriented to people with partial hearing loss.While younger people with hearing impairmentsand other handicaps have become increasingly as-sertive about the rights of the handicapped, manyelderly people are still reluctant to call attentionto their handicaps and to demand appropriate serv-ices. Self-help groups emphasize the rights of hear-ing impaired people and the rights of the consumer,an approach that may be particularly appropri-ate for elderly people (105).The Suzanne Pathy Speak-Up Institute is a self-help group that focuses on improving communi-cation between hearing impaired and normal hear-ing people. Members are encouraged to disclosetheir hearing loss and wear a symbol to indicateit. The organization provides information to com-munity groups about how to communicate effec-tively with hearing impaired people.Nursing Home InitiativesDespite the high prevalence of hearing impair-ment in nursing homes and its often severe effectson residents’ ability to interact with others, giveand receive information, and adjust to the facil-ity, little attention has been given to this problem.As one nursing home administrator pointed out:“To be perfectly frank, communication is at thebottom of my priorities. We care about nutrition,hygiene, medication; that’s it” (14). Even when nurs-ing home staff attempt to address the problemsof hearing impairment among residents, few areknowledgeable about the devices and treatmentsavailable. Access to hearing services is often limitedbecause some residents cannot pay for them andbecause it is difficult to take residents out to aspecialist office or get the specialist, particularlyan otolaryngologist or audiologist, to come to thenursing home. As a result, many people who mightbenefit from hearing services and devices do notreceive them.The Nursing Home Ombudsman Program ofMonroe County, New York, is an example of oneapproach developed to help solve this problem. TBeginning in 1981, as a result of the effort of oneombudsman volunteer, the program has providedsensitivity training for all ombudsman volunteersto increase their understanding of the impact ofhearing impairment on residents. The volunteersare taught how to communicate with hard-of-hearing and deaf people. They are trained to beaware of residents whose hearing aids are notworking properly or who may need new batter-ies. The ombudsman Program has also providedworkshops for nursing home staff to increase theirunderstanding of hearing impairment, hearingaids, and other devices that can benefit residents.The success of these approaches in nursing homeshas prompted a recent expansion of the programinto local hospitals (14).A second program initiative for nursing homeresidents is being developed by SHHH and theAmerican College of Health Care Administrators(ACHCA). In the first stage of this program, SHHHwill train volunteers to help residents better usetheir hearing aids by teaching them to insert andremove the aids, encouraging regular use, and as-sisting with cleaning and battery replacement.ACHCA will notify nursing home administratorsof the availability of the program and provide SHHHwith the names of interested administrators (4).The I-”f?dera] (;ok’ernrnent pro~rides funds to each State to cir’ekIpand run a nursing home omhudsman [)ro~riinl Oesign of’ t hr pro-griim is up to the State and some stiit~s hii~ wntractrd i~ith 1()(’iilii~(’n[’i(>s t o ln~l]len~ent the progriim,
  • 58SCREENINGScreening programs are an important methodof identifying people who have hearing impair-ments and need treatment. The goal of these pro-grams is to identify all those who need furtherevaluation, but hearing specialists continue to de-bate the best methods for doing this. As discussedin chapter 2, interview methods fail to identifysome people with hearing impairments becausethe people are unaware of their hearing loss ordeny it to the interviewer. This may be particu-larly true in some minority groups. Pure tone airand bone conduction tests miss individuals whocan hear pure tones but have difficulty with audi-tory discrimination. Since this is frequently a prob-lem among elderly people, speech reception andspeech discrimination tests are an important ele-ment of an effective screening program for them.In addition, elderly people often have particulardifficulty with background noise and some meas-ure of hearing in a noisy environment is needed(54).Ventry and Weinstein (131) have developed ascreening program for elderly people that includesboth audiometric tests and a self-assessment in-strument to identify the social and emotional ef-PROGRAMSfects of hearing loss. The self-assessment instru-ment is the first designed for and standardizedon elderly people. Further testing of this screen-ing program is being funded by the National Insti-tute on Aging (59).Some elderly people who are very withdrawnand apparently cognitively impaired do not re-spond to the usual audiometric tests and self-assessment instruments. A technique that has beenused with very young children can also be usedto measure the hearing of these people. This tech-nique measures brain wave response to sound,or auditory evoked potential, and does not requireactive cooperation from the person being tested.A hearing aid can be put on the person to deter-mine whether amplification increases the brainwave response. Finding hearing loss in a very with-drawn person does not necessarily mean that ahearing aid or other treatment will be effectivebecause the patient may be too cognitively im-paired to benefit from the device (140). Never-theless, the availability of a technique to measurehearing in these patients is important for diagnosticpurposes.REGULATION OF THE DELIVERY SYSTEMFederal legislation and regulations affect the de-livery of hearing services both directly, throughFDA regulations on hearing aids, and indirectly,through Medicare and Medicaid regulations onreimbursement for hearing services. Medicare andMedicaid are discussed in chapter 5. This sectionreviews FDA regulations. The Federal Trade Com-mission (FTC) recently decided against indus-trywide regulation of various aspects of hearingaid sales, and the history of this decision is alsodiscussed briefly.Federal investigation of hearing aid sales prac-tices began in the 1960s. Early efforts led by Sen-ators Kefauver and Church resulted in news re-leases and other reports that alerted the publicto widespread problems but did little to preventor control them. During the mid-1970s, the FTCinitiated a major effort to develop regulations forhearing aid sales, The results of their investiga-tions and recommended regulations were pub-lished in 1978. The recommended regulationswould have restricted advertising, in-home sales,marketing of used hearing aids, and the use ofscreening programs to identify potential custom-ers. The most important and most vigorously con-tested recommendation was a provision to allowa hearing aid purchaser or renter to cancel thesale or rental within 30 days and receive a refund(10, 77).Hearings were held in 1978 and FTC staff rec-ommended issuance of the regulations after re-viewing the “compelling testimony (about) the nu-merous experiences reported of unusable hearingaids, purchased at great financial sacrifice, and
  • 59of a multitude of abusive sales transactions andsales tactics” (48). However, the Commission didnot rule on the staff recommendations at that time.In 1985, with the regulatory procedure still pend-ing, the FTC contracted for a survey of hearingaid users to determine whether regulation of hear-ing aid sales was needed. The results of the sur-vey many of which have been reported in thisOTA background paper, convinced FTC staff andcommissioners that no industrywide regulationis needed (86). The regulatory procedure subse-quently has been dropped.Regarding the 30-day trial period, the survey in-dicated that 64 percent of the respondents pur-chased hearing aids with a trial period, 16 percentcould not remember whether a trial period wasavailable, and 20 percent purchased aids for whicha trial period was not available. Some States re-quire a trial period, while others do not.8How-ever, the survey showed that people who pur-chased hearing aids in States that require a trialperiod were no more likely to be offered a trialperiod than people who purchased aids in Statesthat do not require a trial period (75).The FTC concluded from these data that trialperiods are widely available and that State lawsrequiring trial periods may not increase their avail-ability (86). A staff memo to the FTC Commissionersconcluded: “Market forces appear to have beenas effective as legal requirements in promoting theproliferation of trial periods” (86).The FTC reliance on these survey findings hasbeen criticized because the sampling proceduresused produced very few respondents in the Statesthat require a trial period. Thus, the differencein availability of trial periods in States that requirea trial period and those that do not could haveoccurred by chance (107). In addition, althoughthe survey indicates that almost two-thirds of thosewho purchased hearing aids were offered trialperiods, at least 20 percent purchased aids forwhich a trial period was not available, To hearingspecialists and consumer advocates who believeKknnecticut, klaine, Nmi ltampshire, NmI }’ork, (Wgon, “1’exas,trermont, and thr District of (’olumhia require ii trial period. (:ali.f’ornia, Kentuck}, North (:arolin:i, ‘1’t’nnessetI, and tl’ashington halela~ts or rx’gulations that require a trial period under some rirrum -stan(w. other- States ha~[~ no r’t>(~l]ir’~>rl~(]rlt for :1 trial period [7.51.that the availability of a trial period is important,these figures are not reassuring.ASHA and the American Association of RetiredPersons (AARP) submitted testimony opposing theFTC decision to drop the regulatory procedure.They cited experiences of their members that sup-port continuing need for regulation of the hear-ing aid industry. AARP testimony emphasized t heneed for an FTC-sponsored consumer educationprogram to inform the public about hearing im-pairment, hearing specialists, and devices to com-pensate for hearing loss (3).In the mid- 1970s, almost simultaneously with theinitial FTC efforts, FDA began to develop regula-tions for hearing aids under its mandate to regu-late medical devices. The purpose of the FDA ef-fort was quite different from that of FTC. FDA wasconcerned about the “safety and effectiveness” ofhearing aids as medical devices, not with sales prac-tices per se. The proposed FDA regulations weremuch less restrictive than the FTC regulations, metwith less opposition, and were adopted in 1977.The FDA regulations were at odds with the lawsand regulations of several States, and those Statesapplied for exemption from the new Federal rules.In virtually all instances the State regulations weremore restrictive than the new FDA regulations.FDA reviewed these applications and granted someexemptions but most were denied (10).The FDA hearing aid regulations relate primar-ily to labeling and conditions of sale. Labeling re-quirements specify that the hearing aid must showthe name of the manufacturer or distributor, themodel name or number, serial number, year ofmanufacture, and an indication of the correct bat-tery position. The requirements also specify es-sential information that must be contained in aninstructional brochure to illustrate and describethe operation, use, and care of the aid; sourcesof repair and maintenance; and a statement to theeffect that the use of a hearing aid may be onlypart of a rehabilitative program that may also in-volve speechreading or auditory training. Thisbrochure must be provided with the aid. The reg-ulations also require a warning to dispensers andpurchasers that certain conditions make medicalconsultation advisable prior to purchase of an aid.The warning to dispensers also advises cautionwhen fitting the more powerful hearing aids.
  • 60As discussed earlier, FDA requires that the con-sumer provide the hearing aid dealer or dispenserevidence of a physician’s evaluation or sign a waiverof this requirement before purchasing a hearingaid. Although there is no information about thenumber of aids that are sold on the basis of waivers,some hearing specialists believe that the numberis high and that the use of waivers underminesthe basic purpose of the FDA regulations. In 1980,ASHA testified to this effect before the Senate Sub-committee on the Handicapped:Under the FDA’s regulation, hearing aids can andare being sold to persons without either a medicalexamination or a test of their hearing. This is leav-ing the hard-of -hearing, especially the elderly, vul-nerable to the pressures of hearing aid salesmen.Without testing, it is impossible to know the type,nature, and degree of loss or even whether a hear-ing aid is necessary or will be beneficial. withoutrequiring a hearing test, State consumer protec-tion officials or private parties lack the fundamen-tal evidence to prove whether or not a hearing aidwas appropriately sold . . . The FDA’s regulation,its preemption of State laws providing greater pro-tection to consumers and its pressure on otheragencies to follow its suit has been a major set-back in providing quality care to the hearing im-paired, especially the elderly (6).Other hearing specialists disagree and argue thatthe FDA regulations are fulfilling their intent (133).Assistive listening devices are generally not reg-ulated by FDA. Hearing specialists are concernedabout the need to protect consumers from devicesthat may be useless or harmful. At the same time,many hearing specialists do not favor FDA regu-lation of these devices because FDA rules aboutthe distribution of medical devices affect how de-vices can be marketed and could ultimately raisecosts and limit use (33).In addition to FTC and FDA regulations, the de-livery of hearing services to elderly people is af-fected by Medicare and Medicaid regulations thatcontrol reimbursement. In many instances, theseregulations determine point of entry, who mayprovide services, the services that may be deliv-ered, the setting in which the services are provided,and the way in which the services are offered.These programs are discussed in the next chapter.
  • —.ChapterFunding for TreatmentHearingofImpairments
  • Chapter 5Funding for Treatment ofHearing ImpairmentsHearing services and devices are paid for directlyby hearing impaired people or by private insur-ance and government programs such as Medicare,Medicaid, and the Veterans Administration (VA). ’In general, medical and surgical hearing servicesprovided by physicians are covered by Medicare,Medicaid, and private insurance. Some servicesprovided by audiologists are also covered, espe-cially when authorized by a physician, but evalu-ations for hearing aids are usually not covered.Hearing aids and assistive listening devices are notcovered by Medicare and are rarely covered byprivate insurance. Medicaid pays for hearing aidsin about half the States, but only a small percent-age of the elderly population is eligible for theseservices. only about 15 percent of hearing aidsare paid for wholly or in part by any third-partypayer, including Medicaid, the VA, and private in-surance (75).The pattern of funding for hearing services re-flects an underlying philosophy of government andprivate insurance programs that emphasizes theimportance of physician care and medical and sur-gical treatment, while deemphasizing rehabilita-tive approaches such as providing assistive devicesto help people function despite impairments. Thisphilosophy is also evident in Medicare and Medic-aid regulations and private insurance policies thatlimit reimbursement for devices and rehabilita-tion services related to impairments in vision andspeech.Hearing aids are the most common form of treat-ment for hearing impairment in elderly people,and it is often alleged that the cost of hearing aidsseverely restricts their use. one report points out,however, that the cost of hearing aids has risenvery little in the past 25 years (41). From 1960 to1980, while the Consumer Price Index increasedmore than 300 percent, the average cost of a hear-ing aid increased from about $350 to $450, or lessa r i n g ser’ices prwidwl and paid for I)yf t hf~ L’eterans .Adnlin-istration ere discussed in rh. 4.than 25 percent. Sales expansion, improved man-ufacturing techniques, and changes in marketinghave led to this relative price stability despite in-flation in the economy as a whole, While the costof a hearing aid is still too high for some low-in-come people, many people can afford them. In fact,the number of individuals buying hearing aids in-creased significantly between 1980 and 1983 de-spite a 25 percent decrease in third-party reim-bursement (24).Since government programs and private insur-ance usually do not pay for hearing aids, hearingimpaired people often have to pay for these de-vices themselves. While many elderly people dopurchase hearing aids, few are also willing andable to pay for a comprehensive audiological evalu-ation to help them select the hearing aid or auralrehabilitation services to help them adjust to it(138).Assistive listening devices are not covered byMedicare, Medicaid, or private insurance. Legis-lation has been introduced in Congress to allowreimbursement for these devices under Medicareand Medicaid. The Handicapped Assistance Act of1985 (H.R. 1432) would amend the Social SecurityAct to allow payment for sensory and communi-cation aids for persons with visual, speech, andhearing impairments. Reimbursement would belimited to $5,000 a year and no more than $15,000in any 5-year period (17).Allowing tax credits for the purchase of assis-tive listening devices is another approach to en-courage their use. This idea is not now politicallyviable because Congress and the Administrationoppose creating new tax deductions and tax credits(56).Aural rehabilitation services are covered byMedicare, Medicaid, and some private insurancein certain circumstances, but these services areseldom received by elderly people, as discussedin chapter 3. Government initiatives to increasethe use of these services could include increased63
  • 64funding and/or simplification of the complex re- education about the potential benefit of aural re-quirements for reimbursement for these services habilitation for elderly people could encourage in-under Medicare and Medicaid. Increased public dividuals to pay for these services themselves,MEDICAREAlmost all Americans over 65 are covered byMedicare, the health insurance program author-ized by Title XVIII of the Social Security Act to pro-vide payment for specified health services. UnderPart A Hospital Insurance, Medicare pays for hos-pital care, some posthospital extended care, andhome health services. Under Part B SupplementalMedical Insurance Benefits, Medicare pays for phy-sicians services, hospital outpatient services, diag-nostic laboratory tests, some durable medical sup-plies, and services such as physical therapy andspeech therapy when authorized by a physician(lo).Most physician services related to the diagnosisand treatment of hearing impairment are coveredby Medicare. Some hearing services provided byan audiologist are reimbursable under certain cir-cumstances. For example, an audiological evalua-tion requested by a physician to help diagnosehearing disorders is reimbursable. Rehabilitativeservices provided by an audiologist are coveredfor some patients, but complex regulations, sum-marized below, govern which audiology servicesare covered, and in which settings (10).Under Medicare Part A, rehabilitative audiologyservices requested by a physician and directly re-lated to the condition for which a patient is hospi-talized can be provided for hospital inpatients andresidents of skilled nursing facilities (SNF). Diag-nostic and therapeutic audiology services re-quested by a physician can be covered for hospi-tal inpatients when provided by an audiologist whois either an employee of the hospital or who hasmade a contractual arrangement with the hospi-tal. An audiologist who is employed by the hospi-tal can also provide audiology services for patientstransferred to a SNF if the SNF and the hospitalhave a transfer agreement (10).Under Medicare Part B, an audiological evalua-tion requested by a physician for diagnostic pur-poses is reimbursable. Other hearing services pro-vided by an audiologist also can be reimbursedunder Part B: 1) if the audiologist is employed bya physician or in a physician-directed clinic, 2) ifthe physician is on the premises and supervisesthe services, and 3) if the audiological services arean integral part of the physician’s professional serv-ices. Diagnostic and therapeutic services providedby audiologists also can be reimbursed as a PartB benefit for audiologists employed in a rehabili-tation agency, skilled nursing facility, hospital out -patient clinic, or home health agency (10).Hearing services provided by hearing aid dealersare not reimbursed by Medicare. Medicare doesnot pay for hearing evaluations performed to helpselect a hearing aid and it does not pay for hear-ing aids or other assistive listening devices.MEDICAIDMedicaid is a joint Federal/State program, au- The Federal Government requires that Statethorized by Title XIX of the Social Security Act to Medicaid programs cover certain health care serv-provide funding for health care services for the ices, while other services are optional. States arepoor. Elderly individuals with income and assets required to cover:below established levels are eligible for Medicaid.People with income above these levels but with q Hearing services provided by hospitals to in-high medical expenses are also eligible in some patients or outpatients. These services can in-States. elude audiology services prescribed by a phy-
  • 65qqqsician with a physician’s recertification of theneed for continuing treatment every 30 days.Hearing services provided in SNFs by a physi-cian or an audiologist working under the direc-tion of a physician.Hearing services provided by physicians in thecommunity.Some hearing services provided by audiolo-gists in the community. These services mustbe provided under the personal supervisionof a physician. States are free to define thedegree of personal supervision required, butmany adopt the definition used by the Medi-care program—that the audiologist must beemployed by a physician (or group of physi-cians) and practice in the same office or clinicas the physician (10).States are not required to reimburse any otherhearing services under Medicaid, but Federalmatching funds are available to States for a widevariety of optional services including diagnosis,screening, rehabilitative services, and hearing aids.Most States limit the optional Medicaid servicesthey provide in order to control overall costs ofthe Medicaid program:. A 1979 survey of Medic-aid programs in 49 States2and the District ofColumbia conducted by the American Speech-Language-Hearing Association (ASHA) revealed thefollowing about States’ coverage of hearing serv-ices beyond the mandatory benefits:q Twenty-nine States covered evaluative anddiagnostic services provided by ASHA-cer-Z,.rizon;i did not participate in the k!edirtiid program at the timeof the sur~e}!.qqtified or licensed audiologists regardless of thesetting, but in seven of these States coveragewas limited to children. Only 7 of the 29 Statescovered aural rehabilitation services foradults. Fifteen additional States covered au-diology services only when provided in spe-cific facilities or agencies, such as rehabilita-tion centers and home health agencies. Theremaining States only covered hearing serv-ices provided by physicians.Prior authorization by the State Medicaidagency was required for aural rehabilitationservices in all cases, but was seldom requiredfor diagnostic services. Referral from a phy-sician was generally required for all services.Twenty-eight States provided reimbursementfor hearing aids for eligible adults. Prior au-thorization was required in nearly all States.Other requirements for reimbursement ofaids varied: evaluations by audiologists orthrough speech and hearing centers approvedby the State were mandatory in 36 States; 10of these permitted evaluation by an otolaryn-gologist in lieu of an audiologist, while 14 re-quired a physician’s examination in additionto the audiologist’s evaluation (7).As a result of Medicaid cutbacks since 1979,fewer States probably pay for hearing servicesnow. Moreover, even in those States that pay foraural rehabilitation services and hearing aidsthrough Medicaid, the reimbursement rates areoften so low that providers refuse to serve Medic-aid patients.OTHER GOVERNMENT FUNDING PROGRAMSFunding for hearing services is available to some other devices, and aural rehabilitation. However,elderly veterans and retired military personnel only about 2 percent of all people receiving anythrough VA and military hospitals. Some elderly services from State Vocational Rehabilitation Agen-individuals are also served in programs sponsored cies are over 65 (13). No figures are available onby the Bureau of Indian Affairs and the Federal the number of elderly individuals who receiveBureau for Community Health Services. hearing services.State Vocational Rehabilitation Agencies provide Federal funds for the elderly are available toa wide range of services to handicapped individ- States through the Title XX Block Grant, the Com-uals, including hearing impaired people. These munity Development Block Grant, and Title III ofservices can include counseling, hearing aids and the Older Americans Act. Some States use some
  • 66of these funds to provide hearing services, butthese programs are very limited and the demandfor services always exceeds available funds. Forexample, in 1984 Montgomery County, Marylandinitiated a program to buy or lend assistive devicesPRIVATEThe private health insurance industry consistsof three major components: 1) the nonprofit BlueCross and Blue Shield plans that enroll 38 percentof the privately insured population; 2) commer-cial insurance companies that provide coverageto 54 percent of the privately insured population;and 3) independent prepaid and self-insured healthplans including large prepaid group practice planssuch as the Kaiser Foundation plans and healthplans operated jointly by union and managementin some industries. These prepaid plans cover onlyabout 7 percent of the insured population, but theyare more likely than other insurers to offer a com-prehensive array of outpatient and preventiveservices (10).Private insurance coverage of hearing servicesis important for elderly people because Medicarecovers only part of the health care expenses ofelderly people, currently less than 50 percent.Many older people purchase supplemental insur-ance from private insurers. In addition, a smallsegment of the elderly population is not eligiblefor or not enrolled in Medicare and many of thesepeople have private insurance (10).Determining whether an insurer will reimbursefor hearing services is not simple. Each insurancepolicy is independently negotiated, so that a sin-gle company may issue policies with many varia-tions in the provisions affecting hearing services.In fact, few policies directly address hearing serv-ices; instead, coverage is determined by the pro-visions for broad categories of services such as‘(miscellaneous medical,” “physiotherapy)” or“other medically necessary services. ” Whetherhearing services are reimbursable depends on ifa given service meets the general conditions inthese broad categories (10).of all kinds using Community Development BlockGrant funds. About 90 percent of the funds werespent for hearing aids for people of all ages andthe demand for hearing aids was so great that theprogram ran out of money in 3 months (46).INSURANCEThe principal variables that affect coverage are:In what setting is the service provided? (Hos-pital inpatient unit, hospital outpatient depart-ment, physician’s office, audiologist’s office,hearing aid dealer’s office, speech and hear-ing clinic?)Who is providing the service? (A physician,a licensed or ASHA certified audiologist, ahearing aid dealer?)What kind of service is provided? (Diagnosis,evaluation for a hearing aid, aural rehabili-tation?)Why is the service needed? (Injury, illness, con-genital or acquired disease, organic or non-organic disorder?)What is the role of the beneficiary’s physician?(Prescription, supervision, referral?)Because conditions in the policies of private in-surers vary so greatly, it is not possible to docu-ment exactly which hearing services are coveredby which insurers for which groups of benefici-aries. However, some general statements can bemade about predominant patterns and limitationsof coverage.3Where Services Are Providedand By WhomHealth insurance primarily covers the cost ofhospitalization and physicians’ services and most3This information is deri~red from three sources: 1) collection ofarious existing surveys undertaken by ASHA members and othersof major insurers doing business in their areas (.5, 16, 20, 40); 2)a sur~rey conducted by ASHA’S Task Force on Prik’ate Insurance of15 major national insurers (7); and 3) a study conducted by the BlueCross Association of Blue Shield plan reimbursement of nonphysi-cian prok’iders (78).
  • 67policies reimburse for hearing services providedby physicians in hospitals and in the community.In addition, certain hearing services are coveredwhen provided by a qualified practitioner. In onesurvey, a licensed audiologist was deemed qual-ified by nine companies and six companies ac-cepted ASHA certification in lieu of licensure (7).Four insurers left the choice of a qualified practi-tioner up to the physician prescribing and super-vising the services. Blue Cross/Blue Shield planstend to be less flexible about whom they will re-imburse. A study of all 70 Blue Shield plans na-tionally reported that only 9 would reimburse forcovered services provided by audiologists (78).Type and Purpose of ServicesNearly all policies specify that they cover only“medically necessary” services, but none definesthe term. In effect, a service is medically neces-sary when a physician says it is and the insureragrees. This requirement mandates the involve-ment of physicians for all reimbursable services(lo).Coverage of specific hearing services by the com-panies surveyed was virtually uniform. Audiologictesting needed by a physician to establish a diag-nosis was covered in all cases. Routine evaluationsto detect hearing loss and services related to de-generative hearing loss were never covered. Sev-eral companies would cover audiologic servicesand hearing aids when a hearing loss resulted froman accident or injury, but most policies specificallyexclude hearing aid evaluations and hearing aids.A survey by Hewitt Associates, a nationwide con-sulting firm specializing in employee benefits andcompensation, found that only 6 percent of U.S.firms offer hearing-care plans (28). The United Au-tomobile Workers Union has recently negotiatedthe first major labor contract to include coverageof hearing aids (104).Hearing services provided to maintain ratherthan improve hearing are generally excluded. Ifa beneficiary had a communicative handicap be-fore an injury or illness that is covered by a pol-icy, then hearing services would be covered onlyto the extent that they were needed to restore thebeneficiary to his or her previous level of func-tioning.Role of the PhysicianPhysicians must be involved in health insuranceclaims for hearing services at least enough to doc-ument “medical necessity” to the insurer. Physi-cian referral and supervision is the most commonrequirement. Supervision generally means that thephysician must cosign claims and accept respon-sibility for the services (10).Among the insurers surveyed by ASHA, six re-quired only physician referral for hearing serv-ices. Two required physician approval of such serv-ices, while three required physician supervision(7). TWO companies did not specify the role of thephysician, while one required physician directionof diagnostic audiologic services, The distinctionsbetween “approval, ““recommendation ,“ and “su-pervision” are fuzzy, but the insurers’ intent inall cases is to ensure that a physician’s statementof the initial and continuing need for services issubmitted before claims will be paid.Thus private insurance coverage of hearing serv-ices appears to mirror Medicare and Medicaid cov-erage, allowing reimbursement for medical andsurgical services and for services provided by phy-sicians for medical problems. In contrast, reha-bilitative services, and particularly the cost of hear-ing aids and assistive listening devices, are notcovered. Thus elderly people must pay for theseservices and devices themselves or do without.
  • Chapter 6~C()Dt:lusion
  • Chapter 6ConclusionThis background paper has discussed the typesof hearing impairment that are most commonamong elderly people, hearing devices and serv-ices that may benefit them, and aspects of the de-livery system and third-party reimbursement thatlimit use of these devices and services. Federal pol-icy options have not been analyzed. However, someof the findings of this paper are relevant to thedevelopment and analysis of Federal legislative andregulatory policies. These are listed below:qqqqHearing impairment is very common amongelderly people and can seriously affect theirsafety, quality of life, and ability to live inde-pendently.Most research on hearing impairment hasfocused on very severe impairments, deafness,and the hearing impairments of young peo-ple, rather than the moderate or partial hear-ing impairments that are common amongelderly people. As a result, many questionsabout the pathology of hearing loss in elderlypeople remain unanswered. The term pres-bycusis is used to refer to hearing loss associ-ated with aging, but there is disagreementabout the term’s meaning. In addition, thecauses of presbycusis are not well understood.Most research on treatment for hearing im-pairment has focused on medical and surgi-cal treatments rather than rehabilitative ap-proaches. Yet the latter are generally moreeffective for the types of hearing impairmentcommon among elderly people. Rehabilitativeapproaches such as the use of hearing aids,assistive listening devices, and aural rehabili-tation services can improve a person’s abilityto communicate even when the underlyingcause of the hearing impairment cannot becured,Third-party reimbursement, including Medi-care and Medicaid, is available for medical andsurgical treatment but usually is not availablefor hearing aids, assistive listening devices, andsome aural rehabilitation services, Thus, thesereimbursement programs fail to fund thetreatments that are most effective for elderlypeople.qqqqMany people, including the elderly, their fam-ilies, health care and social service profes-sionals, and others, are not aware of the prev-alence of hearing impairment among elderlypeople; its physical, emotional, and social im-pact; and the hearing devices and services thatcan compensate for it. Public education to in-crease awareness of this problem and train-ing for health care and social service profes-sionals are needed.Negative attitudes about aging and the re-habilitation potential of elderly people dis-courage the use of potentially effective treat-ments. Public education programs could bedesigned to counteract these negative atti-tudes. In addition, they could emphasize thatcommunication is a two-way process, involv-ing both the speaker and the listener. Someof the simplest methods for facilitating hear-ing, such as the rules for speaking to some-one with a hearing loss, require active coop-eration by the speaker. Public educationprograms could emphasize the role of thespeaker in facilitating effective communica-tion with hearing impaired people.Hearing aids have been helpful for many hear-ing impaired people, but most hearing im-paired people do not buy a hearing aid andsome who buy an aid do not use it. Factorsthat interfere with increased use of hearingaids include problems in the design or func-tion of the aid; problems in selecting an appro-priate aid for the individual; inability of theindividual to adjust to the aid; and disagree-ment among hearing specialists about who canbenefit from a hearing aid. The frequency withwhich each of these problems occurs is notknown. Developing solutions for them is a po-tential area for cooperative research by thehearing aid industry and hearing specialists(physicians, audiologists, and hearing aiddealers).Assistive listening devices can be particularlybeneficial for hearing impaired elderly peo-ple because they lessen the impact of back-ground noise, a major problem for many el-71
  • 72derly people, These devices can be used inpublic meeting rooms and for interpersonalcommunication in doctors’ offices, hospitals,and nursing homes, and in a variety of socialand recreational listening situations. Yet thesedevices are not widely used. Increasing theiruse will require recognition of their potentialvalue by hearing specialists (physicians, au-diologists, and hearing aid dealers) and effortsby these specialists to promote them.Use of the telephone is particularly importantfor elderly people who live alone and thosewho have difficulty getting out because ofphysical impairments. Federal legislation andregulations that affect the availability of tele-phones compatible with hearing aids and tele-phone amplification devices for home useshould acknowledge the important role thetelephone plays in maintaining the safety, in-dependence, and quality of life of hearing im-paired elderly people.Much is known about environmental designtechniques that can reduce reverberationsand background noise and thus facilitate hear-ing. However, this knowledge has not beenwidely applied. Building design regulations forlong-term care facilities and housing for theelderly could incorporate these design tech-niques.Aural rehabilitation services such as hearingaid orientation, auditory training, speechread-ing, and counseling are frequently not avail-able to elderly people with hearing impair-ments despite their potential benefit.The existing service delivery system is frag-mented and does not provide optimal hear-ing services for elderly people. Rivalry amongthe three types of hearing specialists —physi-cians who specialize in hearing disorders, au-diologists, and hearing aid dealers-contrib-utes to the fragmentation of the deliverysystem. Any Federal legislation or regulationsrelated to hearing services could be designedto encourage the development of coordinatedservice delivery systems.In some instances, an educated consumer isthe best protection against deficiencies in theservice delivery system. Self-help groups maybe the most effective method for educatingconsumers,Although almost half of all hearing impairedpeople are over 65, the training of hearingspecialists generally has not emphasized thetypes of hearing impairments that are com-mon among elderly people and the mostappropriate treatments for them. Each typeof hearing specialist needs training in theseareas.The impact of hearing impairment on elderlypeople in hospitals and nursing homes can beparticularly severe, limiting their ability tocommunicate with doctors, nurses, and otherpersonnel, understand their medical treat-ment, and understand and adjust to facilityroutines. Federal and State regulations gov-ern many aspects of patient care in hospitalsand nursing homes, but few regulations ap-ply to the provision of hearing devices andservices for hearing impaired patients.While hearing impairment is a serious problemamong elderly people in this country, partial solu-tions are available. We now have an increased un-derstanding of the problem and various devicesand services are available. Federal initiatives in theareas of research, public education, and improve-ments in the service delivery system could helpsolve the problems faced by hearing impairedelderly people and could significantly improve thequality of their lives.
  • Appendixes
  • Appendix AInformation SourcesAlexander Graham Bell Association for theDeaf3417 Volta Place, N.W.Washington, DC 20007(202) 337-5220American Academy of Otolaryngology—Headand Neck Surgery1101 Vermont Avenue, N. W., Suite 302Washington, DC 20005(202) 289-4607American Speech-Language-HearingAssociation10801 Rockville PikeRockville, MD 20852(202) 897-5700American Tinnitus AssociationP.O. Box 5Portland, OR 97207(503) 666-2625AT&T National Special Needs Center2001 Route 46Parsippany, NJ 070541-800-233-1222Audiology—Speech Pathology ServiceBirmingham VA Medical Center700 South 19th StreetBirmingham, AL 35233(205) 933-8101, ext. 6702Better Hearing Institute1430 K Street, N.W.Suite 600Washington, DC 20005(202) 638-7577Consumers Organization for the HearingImpaired, Inc. (COHI)P.O. Box 8188Silver Spring, MD 20910(301) 587-2514Hear-Say2525 Murworth, Suite 207Houston, TX 77054(713) 666-2625International Federation of the Hard ofHearingPirol Kamp D-2000Hamberg 65, German Federal RepublicNational Association for Hearing and SpeechAction10801 Rockville PikeRockville, MD 208521-800-638-8255National Association of the Deaf814 Thayer AvenueSilver Spring, MD 20910(301) 587-1788National Captioning Institute5203 Leesburg PikeFalls Church, VA 22041(703) 998-2400National Center for Law and the DeafGallaudet College800 Florida Avenue, N.E.Washington, DC 20002(202) 651-5454National Hearing Aid Society20361 Middlebelt RoadLivonia, MI 48152(313) 478-2610National Information Center on DeafnessGallaudet College800 Florida Avenue, N.E.Washington, DC 20002(202) 651-5109National Technical Institute for the Deaf(NTID)One Lomb Memorial DriveP.O. BOX 9887Rochester, NY 14623(716) 475-6400Office of Cued Speech ProgramsGallaudet College800 Florida Avenue, N.E.Washington, DC 20002(202) 651-552775
  • 76Organization for the Use of the Telephone(OUT)P.O. Box 175Owings Mills, MD 21117(301) 655-1827Self Help for Hard of Hearing People, Inc.(SHHH)7800 Wisconsin AvenueBethesda, MD 20814(301) 657-2248Suzanne Pathy Speak-Up Institute, Inc.525 Park AvenueNew York, NY 10021(212) 832-8286Telecommunications for the Deaf, Inc.814 Thayer AvenueSilver Spring, MD 20910(301) 587-1788
  • Appendix BAssistive Device CentersAssistive device centers are locations where a variety of devices to compensate for hearing im-pairment are displayed and demonstrated. The centers are open to the public, and some centers sellas well as demonstrate devices. This list of assistive device centers was adapted from information pro-vided to OTA by George W. Fellendorf, Fellendorf Associates, Inc. In addition to the centers listedhere, many hearing specialists display and sell some devices.ARIZONAHeidico, Inc.444 South Montezuma StreetPrescott, AZ 86301(602) 445-9554 (V) (TDD)Contact: Remi SaffranTucson Hearing Societyc/o University of ArizonaDepartment of Speech and HearingTucson, AZ 85721(602) 621-7070Contact: Anne Lanshe or William HodgsonCALIFORNIAHearing Society for the Bay Area1428 Bush StreetSan Francisco, CA 94109(415) 775-5700 (V); (415) 776-3323 (TDD)Contact: John L. Darby or Michael V. SiskH.E.A.R. CenterProvidence Speech and Hearing1301 Providence AvenueOrange, CA 92668(714) 639-4990 (V); (714) 639-1393 (TDD)Contact: Donna GreenfieldHouse Ear Institute256 South Lake StreetLos Angeles, CA 90057(213) 483-4431 (V); (213) 484-4642 (TDD)Contact: Linda K. DyeCOLORADOHarvard Park Hearing Center950 East Harvard AvenueSuite 500Denver, CO 80210(303) 777-4327 (V and TDD)Contact: Bruce D. SchachterleThe Hearing Store2308 South Colorado BoulevardDenver, CO 80222(303) 757-4327 (V); (303) 757-4715 (TDD)Contact: Bruce D. SchachterleDISTRICT OF COLUMBIAGallaudet CollegeAssistive Devices CenterDepartment of Audiology800 Florida Avenue, NEWashington, DC 20002(202) 651-5328 (V and TDD)Contact: Cynthia Compton FernandesFLORIDAFort Lauderdale Oral School of NovaUniversity3375 W. 75th AvenueFort Lauderdale, FL 33314(305) 475-7324Contact: Joan Rollins-Bellows or Jack MillsILLINOISChicago Hearing SocietyCharles Silberman Center for AssistiveDevices10 West Jackson BoulevardChicago, IL 60604(312) 939-6888 (V); (312) 427-2166 (TDD)Contact: Daria PopowychSound Resources, Inc.201 East OgdenHinsdale, IL 60521(312) 323-7970 (V and TDD)Contact: Barbara Carlson77
  • 78INDIANAPurdue Audiology ClinicHeavilon Hall, Purdue UniversityWest Lafayette, IN 47907(317) 494-3789Contact.’ Carl A. BinnieKANSASInstitute of Logopedics2400 Jardine DriveWichita, KS 67219(316) 262-8271 (V and TDD)Contact: Karen Black KramerMARYLANDAssistive Devices CenterConsumers Organization for the HearingImpaired, Inc. and The National Associationof the Deaf814 Thayer AvenueSilver Spring, MD 20910(301) 587-2514 (V); (301) 946-0037 (TDD)Contact.’ Gary Olson or Will Gross (V) BillPaschell (TDD)Hearing and Speech Agency of MetroBaltimore, Inc.2220 St. Paul StreetBaltimore, MD 21218(301) 243-3800 (V); (301) 243-1274 (TDD)Contact: Clifford LullSelf Help for Hard of Hearing People7800 Wisconsin AvenueBethesda, MD 20814(301) 657-2248 (V); (301) 657-2249 (TDD)Contact: Howard (Rocky) Stone or CharlesMizellNEW YORKBurke Rehabilitation CenterDepartment of Speech, Language andAudiology785 Mamaroneck AvenueWhite Plains, NY 10605(914) 948-0050, extension 2306Contact: Rochelle ShotlandHearing Rehabilitation CenterAlbany Medical Center HospitalNew Scotland AvenueAlbany, NY 12208(518) 445-4535 (V and TDD)Contact: Donna S. WaynerMill Neck FoundationP.O. Box 100Mill Neck, Long Island, NY 11765(516) 922-3880 (V and TDD)Contact: Louis FrillmanNational Technical Institute for the DeafOne Lomb Memorial DriveRochester, NY 14623(716) 475-6473 Kathy Tyson(716) 475-6476 Diane CastleNew York League for the Hard of Hearing71 West 23d StreetNew York, NY 10010(212) 741-7650 (V); (212) 255-1932 (TDD)Contact: Joshua M. GendelPark East Hearing Center1641 East AvenueRochester, NY 14610(716) 461-9192 (V); (716) 461-0357 (TDD)Contact: Sheila DalzellOKLAHOMAHearCareMedical Park CenterSuite 601Bartlesville, OK 74006(918) 333-8910 (V and TDD)Contact: Carolyn KislerOREGONEugene Hearing and Speech Center1202 Almaden StreetP.O. BOX 2087Eugene, OR 97402(503) 485-8521 (V and TDD)Contact: R. Craig Ford
  • 79TENNESSEE TEXASBill Wilkerson Hearing and Speech Center Callier Center for Communication Disorders1114 19th Avenue South University of Texas at DallasNashville, 37212 1966 Inwood Road(615)320-5353 (V) Dallas, TX 72535Contact: Judy Ventress (214) 783-3000 (V and TDD)Contact: Carolyn R. Musket
  • References
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