Hearing Screening for Older Adults Using Hearing Questionnaires
Under Medicare Part B of an Initial Preventive Physical Examination (IPPE), physicians or other qualified nonphysician practitioners (NPPs) are encouraged to utilize hearing screening questionnaires in order to assist in a review of an elderly individual’s functional ability and level of safety, and to provide the appropriate counseling and referral as part of the screening.1
Elderly persons rely on auditory input to maintain safety, social contact, awareness of their environment, and overall functional ability. Hearing function declines with age, yet relatively few elderly people undergo audiological evaluation/rehabilitation. Hearing aids (HAs) are the treatment of choice for the elderly, and modern HAs are effective in minimizing the negative consequences of hearing loss in the daily functioning of elderly individuals.
Demographics of Hearing Loss and Hearing Aid Use
In 2002, the number of older Americans was 35.6 million, representing 12.3% of the total U.S. population. The older population is expected to double to more than 70 million by the year 2030. Most alarming is the fact that the number of individuals age 85 years and older is expected to rise from 4.6 million in 2002 to 9.6 million in 2030. These older adults will live longer with numerous chronic conditions, including hearing impairment.2
Loss of hearing associated with aging, referred to as presbycusis, affects approximately 30% of adults age 65 years and older, and approximately half of the population over age 75. Recognizing the profound effect of hearing impairment, the Healthy People 2000 and 2010 health initiatives from the U.S. Department of Health and Human Services encouraged screening and counseling for this chronic condition.3,4 Hearing loss is a disorder amenable to early intervention and rehabilitation, yet approximately one-fourth of those who could benefit from HAs actually use them.4 Further, technological assistance available for hearing impairment has been demonstrated to improve quality of life of older adults.5 Despite recommendations for periodic hearing screening,3,4,6 there is a dearth of preventive hearing healthcare services available to older adults. In turn, audiologic diagnostic and rehabilitative services are underutilized.7
Functions of Audition
Hearing is a distance sense that subserves three unique functions: The primitive/awareness level is the basic ability to hear background sounds in the environment (eg, birds singing). Hearing at this level allows individuals to psychologically feel a part of the living world. The signal/warning level helps warn individuals of dangers in the environment (eg, fire, oncoming cars). The symbolic level, the highest function of hearing, enables interpersonal communication.8
According to Maslow’s Hierarchy of Human Needs theory, older adults are very motivated to seek professional assistance when a chronic condition is a threat to safety, self-esteem, and the need to belong.9 As amplification technologies can help preserve functional abilities, older adults should be encouraged to take advantage of preventive hearing healthcare services.
Consequences of Hearing Loss
Sensorineural hearing loss of a mild-to-moderate degree (Figure) is a hallmark of presbycusis, and can threaten safety and security. The speech understanding difficulties associated with presbycusis lead to feelings of frustration and discouragement, limit previously enjoyed activities, strain family relations, interfere with interactions with service providers, and compromise safety and independence. Moderate sensorineural hearing loss can interfere with telephone use, further putting individuals at risk.10 In addition to possible isolation and depression, current evidence suggests that hearing loss is associated with cardiovascular disease, and it may be an early sign and a contributor to dementia.11,12 Given the high prevalence of senile dementia among adults, especially those residing in institutions, and the high prevalence of hearing loss, it is likely that the two disorders will co-occur in a large proportion of elderly individuals. Therefore, unrecognized or untreated hearing loss can confound the diagnosis of dementia and exacerbate the behavioral manifestations of individuals with senile dementia.
Results of a survey by the National Council on Aging confirmed that untreated hearing loss has serious emotional and social consequences. Its survey of 2300 hearing-impaired adults age 50 and older revealed that individuals with untreated hearing loss were more likely to report depression, anxiety, and paranoia and were less likely to participate in organized social activities than individuals who wear HAs.5,13 In light of research findings stating that negative effects of hearing loss are mostly reversible with rehabilitative treatment, early intervention is key, especially given the increasingly large number of older adults in the workforce and the number of older adults returning to work from retirement.12 The latter is significant in light of a report that adults with untreated hearing loss can expect to suffer economic losses, including higher rates of unemployment.14
Efficacy of Ampliciation Technologies
Amplification technologies including hearing assistive technologies (HATs) and HAs help to minimize the negative consequences of hearing loss in daily function.
HATs, commercially available and inexpensive devices, are ideal for selected listening conditions in lieu of or as a supplement to HAs. Alerting devices, a category of assistive technology (eg, flashing lights), can help promote safety and independence as well.
HAs of the digital and analog variety are of proven efficacy in improving speech intelligibility, social, emotional, psychological, and physical functioning of individuals with hearing loss.5,15,16 Health-related quality of life as measured using hearing-specific and generic measures improves dramatically with HA use.17 Digital hearing instruments, a choice of 90% of new HA users, are associated with significantly higher ratings on overall benefit and satisfaction, decrease in feedback noise, better sound quality, greater helpfulness in several important listening situations, and improved performance in noisy situations.15
Implications for Physicians
Effective January 1, 2005, Medicare provides additional coverage for preventive benefits under Medicare Part B Preventive Services.1 When services are “furnished to an individual by a physician or other qualified NPP with the goal of health promotion and disease detection” under Part B of the IPPE, the following is recommended:
1. “Review of the individual’s functional ability and handicap and level of safety, as described below, based on the use of appropriate screening questions or a screening questionnaire, which the physician or other qualified NPP may select from various available screening questions or standardized questionnaires designed for this purpose and recognized bynational professional medical organizations.” (Page 4, under General Information)1
2. “Review of the individual’s functional ability and level of safety, as defined in 42 CFR 410.16 (a), must include, at a minimum, a review of the following areas: a. Hearing impairment.” (Page 5, under General Information)1
3. “Education, counseling, and referral…provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B benefits.” (Page 15, under Chapter 18-Preventive and Screening Services)1
A number of brief questionnaires have been useful in identifying older adults with hearing loss that is associated with the World Health Organization nomenclature defining activity limitations and participation restrictions.18 Healthcare professionals including physicians, nurses, and audiologists have demonstrated that data from self-report instruments are better than pure tone measures in predicting follow-up with recommendation for rehabilitation.19-21 The Hearing Handicap Inventory for the Elderly-Screening version (HHIE-S), widely used by a variety of healthcare professionals, is quick and easy to administer, is of known validity and reliability, and is predictive of need for HAs and HA success.10,22,23 The HHIE-S, standardized on noninstitutionalized older adults age 65 years and older, includes 5 questions to evaluate the emotional (E) aspect of the hearing handicap and 5 questions to evaluate the social/ situational (S) difficulties caused by the hearing loss. Patients are simply asked to answer “yes,” “sometimes,” or “no” for each question, and not to skip a question if they avoid a situation due to a hearing problem.10,24 An answer of “no” scores 0, “sometimes” scores 2, and “yes” scores 4. Total scores range from 0 to 40. Scores of 0-8 suggest no hearing handicap, scores of 10-24 suggest mild-moderate hearing handicap, and scores of 26-40 suggest significant hearing handicap. A referral for follow-up should be made for scores greater than or equal to 1010,24 (Table24).
Milstein and Weinstein25 designed a screening protocol for use with the elderly that combines pure tone screening, the HHIE-S, a hearing status/stages of readiness questionnaire, and counseling. One hundred forty-seven elderly subjects participated in the study. Of 134 who failed the pure tone screen, only 49 (37%) reported a handicap (failed the HHIE-S). However, all but one of 49 subjects (98%) who perceived a handicap (failed the HHIE-S) also failed pure tone screening, supporting the sensitivity of self-report data for identifying social and emotional consequences of impaired hearing.25
Utilizing Prochaska et al's26 Stages of Readiness concept, Milstein and Weinstein25 also investigated subjects’ view of their hearing status and their stages of readiness for audiological rehabilitation, if needed, using a hearing status/stages of readiness questionnaire established for the study. As stages of readiness increased, subjects were more likely to fail the HHIE-S. These data suggest that the HHIE-S better represents stages of readiness and desire to purchase rehabilitation services. The National Institutes of Health endorsed the use of the HHIE-S by physicians or other qualified NPPs27 as an initial yet crucial step to review the elderly individual’s functional ability and level of safety. Using the HHIE-S, elderly individuals can be provided with rehabilitation as early as possible in order to prevent hearing-related activity limitations and social participation restrictions.
The Medicare guideline specifically states that counseling should be an integral part of preventive health protocols. Information on: (1) the nature of hearing loss; (2) the effects of the hearing loss on communication/daily functioning; and (3) the remedial procedures (HAs and HATs) should be shared with older adults undergoing screening. Incorporating brief counseling regarding the nature of hearing loss, its consequences, and the advantages of HA/rehabilitation might positively affect the elderly individual's decision regarding follow-up. If the individual perceived that the reduction in handicap (benefits) outweighed the inconveniences (barriers) associated with HAs, then the outcome would be a higher likelihood of compliance with the rehabilitation recommendation.
Recommended Screening Protocol
The current hearing healthcare system can cope with an increased caseload of elderly individuals with handicapping hearing impairments.10,12,28 The HHIE-S is ideal for use by physicians or other qualified NPPs. The questionnaire, available in many languages including Spanish and Mandarin, can be completed in a little more than two minutes.
To promote compliance with the recommendations of healthcare professionals, informative written pamphlets should be distributed to individuals undergoing the screen, irrespective of whether they pass or fail. The provision of brief verbal and written tips may be helpful in moving elderly individuals from one stage of readiness (eg, denial) to another (eg, acceptance). The recommendation from an audiologist or a physician might be the single most powerful predictor of whether hearing-impaired individuals will pursue rehabilitation29 underlining the import of screening by physicians or other qualified NPPs as prescribed in Medicare Part B.
Patients often prefer that a physician rather than an audiologist perform the initial hearing screen, as they regard the recommendation of a physician as important.30 However, unfortunately, physician screening for hearing loss during physical examination has declined and is currently only 12.9%.27
The long-term goal of hearing screening is providing early assessment and intervention to forestall the onset of preventable consequences. Hearing screening questionnaires are valid and reliable tools that physicians or qualified NPPs can use to review functional ability and level of safety, as recommended by Medicare Part B. This will allow elderly individuals with hearing loss to obtain rehabilitation services as early as possible to prevent disability/handicap and improve quality of life, two important goals of professionals providing services to the growing elderly population.
The authors report no relevant financial relationships.
Dr. Milstein is Assistant Professor, Department of Speech-Language-Hearing Sciences, Hofstra University, Hempstead, NY. Dr. Weinstein is Executive Officer, Clinical Doctoral Programs/Audiology, Nursing Science and Physical Therapy, The Graduate Center, The City University of New York, Manhattan.
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2. U.S. Department of Health and Human Services. A profile of older Americans. Available at: www.aoa.gov/prof/statistics/ profile/2003/profiles2003.asp. Accessed March 15, 2007.
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27. Kochkin S. MarkeTrak VII: Hearing loss population tops 31 million people. The Hearing Review 2005;12(7):16-29.
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