Maintaining independence and control over one's life is an increasingly important issue as we age. Appropriate hearing aid and related amplification contributes to independence and control. Using a Likert-like pretest-posttest non-equivalent control study, we used a Hearing Aid Manipulation Training Protocol (HATP) to ascertain if elderly hearing aid users can improve their ability to use amplification when exposed to a new user training paradigm. Participants included 16 elderly hearing aid users who had their hearing aids for three to six months, and who had significant difficulty handling and adjusting them. Half of the participants were trained with the HATP and half were not. After two weeks of HATP training, an average of 41% improvement in over-all hearing aid manipulation occurred in the experimental group, versus 9.6% improvement in the control group. Therefore, a net improvement in performance of 30.4% was realized by participants exposed to the HATP.
Introduction:
Maintaining independence and control over one's life are of great concern to all of us, and in particular, to those over 80 years of age (Wilken, Walker, Sandberg, and Holcomb, 2002; Feinberg and Whitlatch, 2001; Anonymous 1989). One important tool in achieving independence and control is the realization of optimal benefits from hearing aid use, for individuals experiencing significant hearing impairment (Johnson and Danhauer, 2002). This can be particularly important when one considers many diagnostic indicators which threaten an elderly individual's independence—for example, an initial diagnosis of Alzheimer's Disease (AD)—are almost entirely based on auditory tasks.
Therefore, because the majority of elderly people with hearing impairment do not seek or acquire amplification, there is a risk of over-diagnosed dementia (Chartrand, 2001a). Ideally, elderly hearing impaired individuals should not only receive timely correction of their hearing impairment, but they must be able to use their amplification systems optimally.
Two major challenges to optimal utilization of hearing aids are; manual dexterity and controlling the loudness of the acoustic environment.
If the hearing aid user cannot properly insert, remove, and manipulate their hearing aids, they are unlikely to wear them. A survey compiled by this author in eleven hearing health practices during the late 1980s demonstrated that up to 93% of very elderly hearing aid patients can be trained to manipulate a user volume control. As a general rule, these same patients could write proficiently and utilize fine-motor skills tasks, such as knitting, sewing, crafts, artwork and piano playing (Chartrand, 1993). It was determined that self-confidence was the main issue relative to hearing aid use, not dexterity (Chartrand, 1993).
Regarding taking control of the loudness of the listening environment, this is largely determined by whether or not the patient can manipulate the hearing aid volume control. This is not so much a cognitive issue as an occupational one (Chartrand, 2000). Volume controls (VCs) are important to hearing impaired users of hearing aid technology. Unfortunately, secondary to technical advances, the hearing aid industry has facilitated elimination of user VCs. Nonetheless, many manufacturers offer VCs as an option on their order forms. One can argue that digital circuits do an excellent job maintaining MCL and UCL levels. However, other subjective loudness issues are apparent to patients wearing hearing aids. For example; auditory fatigue, Eustachian tube dysfunction, abnormal loudness growth, fluctuating cochlear chemistry, all these factors and more, may cause loudness perception to change, despite maintenance of programmed loudness parameters. VCs allow the hearing impaired to take better control of their listening environment and overcome occlusion and other "own-voice" complaints (Chartrand, 2003). Surr, Cord, and Walden (2001) found that 77% of hearing aid consumers prefer a user volume control, once they understand it is available. Moreover, experienced hearing aid users with severe losses especially demand the use of a user volume control (Ross, 2004; Chartrand, 2001b).
Purpose of this Study:
Past studies established a link between the sense of hearing ability and cognition (Chartrand, 2001a). Further, very elderly hearing aid users experience disproportionately greater challenges using hearing aids than younger populations. What has not been shown previously, is that a specific training approach can assure greater utilization of hearing aids and promote communicative independence and control over the listening environment. The purpose of this study was to learn if a systematic training protocol for inserting, removing, and adjusting one's hearing aid, along with conceptual instruction of principles relating to these tasks, would provide skills necessary to overcome these challenges.
Methods:
Participant Selection Procedure
Prospective participants were chosen based on a chart review of patients from July 15, 2004 to February 15, 2005. Each participant had two to six month's experience with their own hearing aids. Each reported difficulty inserting, removing and adjusting their hearing aids. Each complained of situational or general difficulties following standard post-fitting training.
Twenty-three prospective participants were contacted via preliminary phone interview to determine if their difficulties in hearing aid utilization were serious enough to warrant participation and to see if they would consent to participating in a "hearing aid problem-solving study". Subsequently, sixteen of the twenty-three patients were assigned a date and time for the first visit.
Participants:
The population sample consisted of two groups:
Group 1 (n = 8), the experimental study group, consisted of four males and four females.
Average age: 84.5 years. SD 3.9. Age range 80-92.
Group 2 (n = 8), the control group, consisted of three males and five females.
Average age 86.6 years. SD 3.7. Age range 81-90.
Pre-Test & Training
The pre-test was administered to each participant in the same room, with the same interviewer, staggered over a five-day period. To assure reliability and stability, each of nine questions was read aloud by the interviewer while the participant read along. The participant was asked to respond to each question using the response that best fit their current hearing aid experience.
After the pre-test was administered, participants in the control group were allowed to leave the test site. Participants in the study (experimental) group were given the first of two training sessions utilizing the Hearing Aid Manipulation Training Protocol (HATP).
Session I of the HATP was administered over a 30-45 minute period, including instructions for specific exercises to be practiced on a daily basis until the next training session. Training Session II of the HATP was conducted approximately one week later for participants in a similar manner. One week later, the post-test was administered to the control and study group participants. A visual illustration of this pre-test/post-test non-equivalent control design is shown in figure 1 (below).
Figure 1. Pretest-posttest non-equivalent control study design
Materials:
Materials used for this study consisted of six components:
- A pretest-posttest questionnaire (Exhibit A). The questionnaire consisted of nine questions, three questions for each of the three areas of focus:
- Handling the hearing aids.
- Adjusting the volume control.
- Taking control of one's listening environment.
- Handling the hearing aids.
- The Hearing Aid Manipulation Training Protocol (HATP). The HATP training occurred over two 30-45 minute visits. The HATP was designed and tested to expand a hearing aid user's understanding about psychoacoustics, own-voice dynamics, and utilization of hearing aids as a coping strategy to improve speech-in-noise. During each HATP session, participants were given practice on each exercise until showing improvement in skills. They practiced each exercise on their own for a minimum of 15 minutes per day or until they felt more confident in accomplishing the task.
- A silicone replica of the human ear, on which to practice inserting and removing a non-working hearing aid, made specifically for that replica.
- Two heavy-duty aluminum alloy tuning forks (512Hz, 1024Hz) which
were used to help participants find a mid-line in binaural cases. - Reprinted articles pertaining to use of the volume control (Chartrand, 2001b) for participant home-study.
- Earcharts, visual models and other items utilized for training.
To assure consistency and validity, each question in the pre-test/post-test questionnaire was evaluated to determine relevance to the study question. Scaling was spaced to avoid overlap or confusion between degrees of responses. During the design and preliminary testing of this questionnaire, it was found that the usual Likert five-degree scale rendered responses too close together. Therefore, four-levels were chosen to reflect a Likert-like scale. The response scale was designed to reflect four scoring levels to reflect easily identifiable degrees of difficulty. The response scale was; 1- "Not at all," 2 - "Once in a while," 3 - "Most of the time," and 4- "All the time."
Questions were grouped into groups of three, reflecting three specific areas of focus:
- Handling the hearing aids- Inserting and removing the hearing aids and opening and closing the battery door.
- Adjusting the volume controls- Ability to recognize when volume controls have been adjusted too high (echo of own voice) or two low (occlusion of own-voice) and recognition of auditory fatigue.
- Taking control of one's listening environment- The ability to adjust hearing aid volume in extreme environments (quiet to noisy) as needed, coping with difficult listening situations (a dimly lit room), and strategizing in large area listening as needed.
Overall pre-test performance for Group I
Mean = 2.51, SD= 0.32, range = 1.00.
Overall post-test performance (after HATP training) of:
Mean=1.47, SD= 0.35, range = 1.00.
Group 1 demonstrated an overall performance improvement of 41%.
Overall pre-test performance for Group 2
Mean = 2.49, SD= 0.27, range= 0.6
Overall post-test performance for Group 2
Mean = 2.25, SD= 0.41, range = 1.40.
Group 2 demonstrated an overall performance of 9.6% without taking the HATP training.
Taking the pretest-posttest effect of 9.6% from Group 1's 41% will result in a real improvement level of 31.4% for Group 1. (See Figure 3).
Figure 2. Group 1 Pre-test/Post-test Data & Scores
Figure 3. Group 2 Pre-test/Post-test Data & Scores
Results:
This study demonstrated a significant improvement (41%) in overall performance for participants of Group 1, the trained/experimental group. All participants in Group I received two weeks of structured training utilizing the Hearing Aid Manipulation Training Protocol (HATP).
Group 2 participants demonstrated a nominal 9.6% improvement in overall performance. Using an untrained/control group to help assess "maturation" or the "expected learning curve" provided greater internal validity while assessing subjects not participating in the HATP.
Therefore, if we subtract the improvement experienced by the control group (9.6%) from the improvement determined by the experimental group (41%) a net improvement, presumably attributable to the HTAP is demonstrated (30.4%).
Discussion:
Participants chosen for this study were having post-fitting difficulties after receiving traditional hearing aid training. This study focused on learning concepts attendant to developing additional skills to ease anxiety and frustration while handling and manipulating hearing aids.
Despite the quantification of subjective thoughts and abilities, the net result of this work is a quantification of subjective measures. As such, factors measured here are highly variable and subject to personal abilities, feelings and emotions. Hearing and hearing loss are complex and can be significantly impacted by physiological, psychosocial, emotional, cognitive, motor and other factors, which can change daily. It is noted, for instance, that two of the control participants reported doing better on the pre-test than the post-test. As would be anticipated, however, post-test scores were generally better than pre-test scores.
As stated earlier, HATP was designed to teach three main concepts, which at first glance, may appear more complex than typical elderly patients can grasp. However, this study demonstrated that participants exposed to complex concepts, when accompanied with visual models, and which relate to specific learned motor skills, do indeed understand and achieve more confidence in manipulating their hearing aids.
Conclusion:
Hearing loss is not a black and white condition; it is unreasonable to expect normal or even near-normal hearing correction no matter how sophisticated the technology. The goal is to improve hearing function without creating untenable artifacts, such as dexterity, own-voice, or noise management complaints. In turn, quality of life should improve.
It is believed that this study demonstrates conclusively that real quality of life improvements can be realized in those having greater levels of difficulty when using the HATP training. Possibly, its use in hearing health practice may be particularly targeted for those with demonstrated post-fitting difficulties. With more refinement, especially in simplifying some of its complex concepts for hearing aid patients, the HATP training method may be a valuable tool in resolving hearing aid problems in the very elderly population.
About the author
Max Stanley Chartrand serves as Director of Rehabilitation at DigiCare Hearing Research & Rehabilitation, is profoundly deaf and utilizes a cochlear implant and assistive devices. A prolific writer and lecturer in hearing healthcare, he is currently enrolled in a doctoral level Behavioral Medicine program at Northcentral University. Correspondence: www.digicare.org
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View Exhibit A and B
