Differing
dmulvany@usa.net
(408) 379-6065

(Written for public guardians in California regarding hearing loss in elderly clients)

Introduction

Attended all national SHHH conventions since 1984 and received 12 days of training in the
ADA, sponsored by the US Department of Justice and the EEOC. Hard of hearing since early childhood. Most hard of hearing people do not appear to receive adequate aural rehabilitation or adequate information from hearing health care professionals, due in part to lack of funding from insurance or other sources. Hearing aids and most audiological examinations are excluded from coverage by Medicare. Hearing health care professionals tend to focus only on audiological examinations and hearing aids. Therefore, most hard of hearing people do not understand the characteristics of their own hearing loss or how to communicate their needs to others effectively unless they have utilized other resources such as SHHH or written materials. They also tend not to know about assistive technology available for their hearing loss.

Unaided hearing loss is prevalent among older adults and is associated with depression, cognitive decline, reduction in functional status, and emotional and social handicaps. This inservice aims to inform conservators of useful information pertaining to the detection and management of hearing loss. Much is available and can be done to improve the quality of life for people with hearing loss and to prevent or minimize the above negative effects.

Anticipate Hearing Loss

Studies show 54%, 69%, 82% of institutionalized elderly have hearing loss.
Medical records failed to identify 48% of residents with moderate to severe hearing losses.
60% of nursing home residents reported trouble hearing in different situations.
25-34% of nursing home residents had impacted ear wax affecting hearing (treatable by removal)
Self-report and nursing staff not reliable indicators of hearing loss; reports of hearing status were incongruent in 41% of the cases.

In one study, 50% of clients in an outpatient mental health clinic were found to have varying degrees of hearing loss, largely unknown to either the client or the therapist.

Hearing loss tends to be in the high frequencies (where many consonant and most electronic sounds congregate). High frequency hearing is relatively more important to speech comprehension than is low frequency hearing, but speechreading can help greatly with the detection of consonants. (Speechreading is lipreading plus attending to other visual cues.)

Encouragement, a supportive environment, and/or counseling

Many people with unaided, undiagnosed hearing loss deny or minimize their hearing loss. The reasons for this are many, but it appears important to realize that many do have negative attitudes about having such a hearing loss and will need some form of external assistance to accept their hearing loss and to utilize coping strategies and assistive technology. Others may accept that they have a hearing loss but be reluctant to request help with it for such reasons as fearing being a burden on others. Still others may simply not know there are different forms of help available.

Encouragement

The conservator can do much to convey a positive attitude about accepting and accommodating hearing loss. Facial expressions and other non-verbal behavior is all the more important to people who cannot hear well. Look for ways to improve communication with people who do not hear you well, and foster their participation--build upon their suggestions in some way instead of negating their efforts. Show that whether they understand you is important to you. Always face your client, make sure you get their attention before you speak to them, reduce background noise, stand with light in your face and not in their eyes, and generally speak reasonably clearly with adequate volume without yelling. Individuals' needs may differ; if they have trouble understanding you, ask what would help. Some deafened individuals may need words written down for them. Do not exaggerate what you are doing as that may cause embarrassment or self-consciousness for the individual; treat the hearing loss as a normal part of life to be dealt with. Bring an assistive listening device to all initial meetings.

A Supportive Environment

Persons living with and/or taking care of the person may be tempted to take shortcuts in their communication or to experience and express frustration with the hard of hearing person. Education about the nature of the hearing loss can help reduce frustration as expectations become more realistic. It is not only the hard of hearing person who needs to cope with the hearing loss; others in the environment also need to adjust their own behavior in order to communicate effectively with the hard of hearing person. Without an effort from others to accommodate the hearing loss, the hard of hearing person can feel and remain discouraged about becoming more assertive.

(In some cases, even a supportive environment may not be enough to override an individual's resistance to acknowledging and accommodating his/her hearing loss. (Many families experience frustration with a relative who refuses to do anything about the hearing loss.) Special interventions can be used in such situations but are beyond the scope of this inservice.)

Counseling

Counseling can be helpful simply as a preventive measure to help people improve the quality of their lives; it is not only for people with severe psychiatric disabilities . Counseling is more often considered to address or prevent/minimize the following, which can be both outcomes of unrecognized and unaided hearing loss and barriers to successful adaptation to hearing loss:

Denial/minimization of hearing loss
Bluffing (failure to communicate lack of understanding)
Reluctance to assert needs
Passivity and withdrawal
Relationships impaired by communication dysfunction
Depression
Hopelessness
Cognitive decline (a probably outcome of poor communication access, discouragement, withdrawing, shutting down, and inadequate intellectual stimulation)

Some hard of hearing people are of course able to reach a successful adaptation to their hearing loss without counseling. However, the average length of time to get a hearing aid after the onset of hearing loss is seven long years. Many people obviously find it very difficult to come to terms with their hearing loss on their own. Counseling can help them reduce negative attitudes, both internal and external, which impede their progress in acquiring more successful coping strategies. Also important is how significant others deal with the communication needs of the hard of hearing person; family attitudes can play a truly significant role in the person's own attitude. Other family dynamics invariably complicate the relationships and communication, leading to less than ideal functioning which may be improved with counseling.

The public guardian may wish to arrange for a knowledgeable counselor to make a home visit to meet with clients who appear to have a hearing loss but who feel reluctant to utilize or even resist the resources available to them; the counselor may be able to intervene more successfully with the client.

Strategies for Detecting Hearing Loss

Ask about trouble hearing in groups, watching television, or on the telephone (ask about all three)
Whisper two feet away (in quiet) without allowing lipreading---extremely high predictor of hearing loss.
Offer personal amplifier for client to try and observe whether client benefits. Ear buds (which fit entirely within the ear) provide closer and thus louder amplification but should be cleaned after each use.

If client does not understand words spoken in a whispered voice and has not been tested previously, obtain audiological examination. If personal amplifier provides more benefit than current hearing aids, seek further consultation (improved hearing aid or procurement of assistive listening device).

Obtain Medical Clearance and Audiological Examination

Ideally, medical causes for hearing loss should be ruled out before the client sees an audiologist.
Medi-Cal requires prior approval for audiological examination and purchase of hearing aid. Clients without SSI may qualify for medically-needy Medi-Cal if medical bills would otherwise bring a month's income below the cut-off point.
Medicare does not pay for hearing aids.

Vision Exam and Correction

Speechreading naturally requires vision. Poor eyesight will interfere with the acquisition and use of speechreading behavior and potentially with inserting hearing aids and changing batteries. It is helpful to understand the limitations of the client before selecting the hearing aids and/or remote control (optional) for the hearing aid.

Obtain Hearing Aids

Hearing aids have been shown to provide significant improvements in the quality of life for people with hearing loss.

Recommended (for significant loss): Behind-the-ear (BTE) hearing aids tend to be more powerful, more versatile, easier for the consumer to see and operate, and easier to repair. However, most people seem to choose ITE (in-the-ear) hearing aids. In my opinion, if the ear mold for a BTE is attractive, a BTE can be more attractive than the common in-the-ear (ITE) hearing aid. BTEs also usually provide a more effective telecoil than an ITE can.

Ear molds need to be replaced approximately once a year; an ITE would have to be sent back to the factory to improve the fit if the shape of the ear changes and produces feedback, leaving the user without a hearing aid. Ultimately, the consumer needs to feel free to make this choice and may feel the ITE is more desirable.

Remote Control---easier to see controls but may be susceptible to loss. Try to choose a hearing aid that can be operated both via the hearing aid itself and by the remote control, especially for the volume control and the telecoil.
Telecoil---This is a device inside the hearing aid that picks up the electromagnetic field from a hearing-aid compatible telephone and which prevents feedback on telephone and facilitates use of assistive listening devices. However, many elderly leave the hearing aid on the telecoil ("T") setting, which blocks out outside sound, and then think their hearing aid is broken or that the battery is dead. In my opinion, the benefits of a telecoil (for a telephone user) usually outweigh the disadvantages and the disadvantages can be countered by more thorough counseling and oversight from the staff of the residential care facility.
Counseling from the hearing aid dealer re: hearing aid and environmental complications is necessary. Generally, a new user of a hearing aid needs time to get adjusted and should be warned about wearing the hearing aid in noisy situations.
Trial period--request at least 60 or 90 days, not minimum 30.
Support and education from/of others (staff)
Theft protection in residential care facilities (insurance, lockable musical box?)

Hearing aids are often not enough, however; other factors and resources need to be considered as well. Hearing aids can do very well in some situation but not in all; assistive listening devices or captioning help speech comprehension in noise or when the sound is at a distance.

Appropriately fitted hearing aids set a cap on amplification according to the person's hearing loss and can prevent further hearing loss. Hearing aids should thus not be replaced with assistive listening technology unless the consumer refuses to or cannot use hearing aids.

Assistive listening devices with microphones that can be placed near the sound source do help the listener capture much more of the sound than he/she would otherwise, particularly high frequency sounds, which tend to be much weaker than low frequency sounds.

Evaluate Home Environment

Telephone (phone amplification and alerting system; both are available from many state programs)
Doorknock/doorbell alert
Fire alarm (vibrating attachment recommended for more severely HOH)
Television (closed caption decoder and/or assistive listening device)

Newer TVs, 13 inches or larger, will have captioning capability built-in; use Menu option or remote control to set Captions (CC) to CC1.

Alarm clocks (radio alarm clock or vibrating attachment)
Timers (vibrating, to manage cooking and other timed activities)
Reduction of background noise (RCFs, nursing homes)
Intelligibility of speech of others in home (some individuals may need more education about how to communicate more effectively with hard of hearing people if they have an accent or speak quickly or unclearly)

Consider Transportation-related Communication Needs

Assistive Listening Device to communicate with drivers of public transportation vehicles (useful in other environments as well)
Mirrors on windshield to aid lipreading (optional)
Placement in front seat to aid lipreading.
Reduction of background noise (roll up windows, turn off radio)

Placement Issues

All non-religious places of public accommodation, including RCFs, are required to provide auxiliary aids and services for communication access (Title III of ADA---Americans with Disabilities Act, California's Unruh Civil Rights Act) unless there would be an undue burden or hardship (Title III* or II). Prescription devices like hearing aids are not included in this requirement.

Staff need to be willing to learn how to communicate well with HOH clients
Accents, speech impairments, and poor command of English can be a significant hurdle to communication for HOH (staff and other clients)
During communication activities, background noise should be reduced
Acoustical factors such as carpet and ceiling can reduce reverberation greatly
Consider hearing factors in all aspect of life at the RCF/nursing home--dining, socializing, activities, bathroom, sleeping

____________________________________________________________________________________________

*California Civil Code 54.1.(a) (1) Individuals with disabilities shall be entitled to full and equal access, as other members of the general public, to accommodations, advantages, facilities, medical facilities, including hospitals, clinics, and physicians' offices, and privileges of all common carriers, airplanes, motor vehicles, railroad trains, motorbuses, streetcars, boats, or any other public conveyances or modes of transportation (whether private, public, franchised, licensed, contracted, or otherwise provided), telephone facilities, adoption agencies, private schools, hotels, lodging places, places of public accommodation, amusement, or resort, and other places to which the general public is invited, subject only to the conditions and limitations established by law, or state or federal regulation, and applicable alike to all persons.

Title III of the ADA can be found at http://www.usdoj.gov/crt/ada/reg3a.html. RCFs and nursing homes would be covered as social service establishments or places of lodging. Places of public accommodations are required to provide auxiliary aids and services (not prescription devices like eyeglasses or hearing aids) to facilitate communication access.

Tax credits up to $5000 have been and may be available to small businesses for costs complying with the ADA. Structural modifications may also qualify for a tax deduction (up to $15,000). More information is available from the IRS or the Disability and Business Technical Assistance Center at (800) 949-4232.