Beyond audiometric findings and electro-acoustic parameters, there are numerous factors that may have pronounced effects on hearing aid outcomes. The focus of this article is on strategies for minimizing the effects of non-audiological variables on hearing aid outcomes. Non-audiological variables that may impact outcomes include age; psychological variables, such as motivation, personality, and self-efficacy for audiologic rehabilitation; age; gender; and sociological variables such as education, lifestyle, social support, and race/ethnicity. These variables may account in part for the tremendous variability in treatment outcomes that result from the provision of hearing aids and other forms of audiological rehabilitation to adults. Practical suggestions will be offered for managing these variables in the practice of audiology.
Just over ten years ago, Gatehouse (1994) provided research evidence of the powerful impact that psychological variables have on adjustment to hearing loss, as well as hearing aid benefit, use, and satisfaction. Using a regression model analysis, he found that none of the audiological variables that he considered actually entered into the equation for social and psychological effects of hearing disability, whereas over 20% of the variance was explained by age and aspects of personality, particularly anxiety, and to a lesser extent depression. Gatehouse found that four psychological variables accounted for over 30% of the variation of hearing aid satisfaction ratings: hysteria, depression, sickness, and anxiety. Perceived help from hearing aids was also strongly influenced by certain aspects of personality. Thus, it appeared from Gatehouse's analyses that psychological and social variables may be more closely linked to hearing aid success than audiological and electro-acoustic parameters. In this article, we will consider what else we have learned since the decade in which Gatehouse published his intriguing findings on the role of non-audiological variables. In our work with adult hearing aid patients, these variables may impact how we counsel patients regarding realistic expectations, what factors we consider in deciding whether to fit the patient with hearing aids, as well as specific fitting recommendations and considerations.
Non-Audiological Variables Affecting Outcomes Age
The proportion of older adults in American society is expected to increase in the coming years, with the fastest growing age group being individuals 85 years and older (U.S. Department of Health and Human Services, 2003). In the decade between 1990 and 2000, the number of Americans ages 85 years and older grew at a rate 20 times higher than that of individuals in the age range of 15 to 44 years old (Hooyman and Kiyak, 2005). The predicted increase in the number of older adults as well as the number of what gerontologists refer to as the "oldest-old" (85 years plus), will undoubtedly impact the profession of audiology and its service delivery models.
Possible effects:
Smith, Kricos, and Holmes (2001), as well as Smith and Kricos (2002) describe a number of ways that age may impact audiologic rehabilitation outcomes, including vision problems, reduced manual dexterity, and cognitive compromises. The latter, in particular, has been receiving substantial attention from hearing scientists and audiologists in recent years (Pichora-Fuller, 2003; Humes, 2005; Larsby et al, 2005). Although many aspects of cognition are unperturbed by aging, others may decline with age. These include information processing speed, divided attention skills, ability to switch rapidly between multiple auditory inputs, sustained attention, selective attention, and working memory (Hooyman and Kiyak, 2005).
Wingfield and Tun (2001) outlined a number of age-related changes in cognitive factors that may affect speech perception by older adults, including reduced processing speed, less efficiency for tasks involving divided attention, and limitations in working memory capacity. The latter involves processing of information as well as storing it. These cognitive factors, when compromised, may contribute substantially to discourse difficulties in everyday situations, in which information is often presented quickly and under adverse conditions (Tun et al, 2002; Larsby et al, 2005).
Suggestions for minimizing aging effects:
Is your patient over 70 years of age? Assess finger dexterity and the ability to raise his hand to his ears. If your patient has difficulty manipulating the hearing aid controls, consider fitting your patient with automatic hearing aids that minimize the need to change hearing aid controls. Can the person see the hearing aid, its components, the battery, and educational materials that you provide? If not, consider the use of magnifying devices and easily visible fonts. If your caseload consists primarily of individuals who are 80 year plus, it may be wise to have a cognitive screening tool available, such as the Mini Mental States Examination (MMSE; Folstein et al, 1975; www.minimental.com), or to secure a psychology referral source for older individuals whose listening problems may be exacerbated due to cognitive decline. A promising new tool recently adopted by the Veterans Administration as a cognitive screen is the Saint Louis University Mental Status Examination (SLUMS; Banks and Morley, 2003), an 11-item scale with good reliability and validity. (Paid access to the online article and scale can be accessed here: biomed.gerontologyjournals.org/cgi/content/citation/58/4/M314) The SLUMS was developed to identify mild cognitive impairment and to differentiate it from dementia. SLUMS scores may range from 0 to 30, with lower scores indicating increasing levels of cognitive impairments within the cognitive domains of orientation, memory, attention, and executive functions.
If you learn, through cognitive screening or referral, that your patient appears to have additional cognitive components to their listening difficulties, consider careful counseling of the patient and her family, as well using as a collaborative problem-solving approach, assistive technology beyond hearing aids, controlling the communication environment to reduce listening difficulties, formal listening training, attention to the patient's self-efficacy for managing communication challenges, and clear speech training for frequent communication partners. There is some evidence that older listeners with reduced cognitive abilities obtain greater benefits from hearing aids when slow-acting compression is used (Gatehouse et al., 2003). This concept is being explored by several hearing aid manufacturers, who are offering programming defaults for slower release times in their fitting software for older hearing aid candidates (Souza, 2004). Kricos (in press) outlines a number of recommendations for audiologic management of older adults with compromised cognitive abilities.
Finally, because of potential increased difficulties with speed of processing and decreased working memory capabilities in many older adults, audiologists should make an extra effort to slow down when talking with the patient about test results and recommendations. Research by Wingfield and his coauthors (1999) showed that short pauses at meaningful syntactic points give the older adult time to process information before more information is delivered. The inclusion of short rest breaks has been shown to be particularly useful for processing of syntactically complex utterances by older listeners (Wingfield, Peele, and Grossman, 2003).
Psychological Variables
Possible effects:
There are several psychological factors that potentially may impact hearing aid outcomes. One of the most important factors affecting whether an individual will take up and continue use of hearing aids, rather than returning them for credit, is their motivation at the time of the hearing aid fitting. From results of their research, Jacobson and his coauthors (2002) identified motivation as the key factor influencing hearing aid rejection. Kemp (1990) emphasized the complexity of motivation, expressing the following equation:
Motivation = Wants X Beliefs X RewardsIn terms of the motivation to use hearing aids, the prospective hearing aid user must want the hearing aids, believe that they will help him, understand the potential benefits of amplification, and view the costs (not just financial, but also burdens such as learning how to use and care for the hearing aids, vanity, and getting use to the sound of his voice) as less than the potential benefits. Given Kochkin's (1998) MarkeTrak IV results demonstrating that more than half of all new hearing aid users reported that family members had motivated them to obtain hearing aids, we need to attend carefully to the patient's motivation to pursue amplification.
Costs
Since Gatehouse (1994) published his findings regarding the effects of personality on adjustment to hearing loss and hearing aids, there have been a number of other studies showing similar findings. The following personality traits have been linked to successful hearing aid use: external locus of control (Cox et al., 1999; Cox et al., 2005; Garstecki & Erler, 1998); anxiety/neuroticism (Gatehouse, 1994; Saunders & Cienkowski, 1996); introversion/extroversion (Cox et al., 1999; Saunders & Cienkowski, 1996); self-esteem (Saunders & Cienkowski, 1996); and lethargy/depression (Garstecki & Erler, 1998). Clearly more research is needed to establish the relationship between personality and adjustment to hearing loss and hearing aids, as well as to determine how to apply research findings in audiologic management of adults with hearing loss.
A psychological dimension that has received little attention, to date, from the audiology community, is self-efficacy. Bandura (1986, 1989) defines self-efficacy as the domain-specific belief that one can successfully complete a task. Self-efficacy has been applied to treatment programs for a number of health conditions (e.g., diabetes, fall prevention, weight loss, arthritis), and numerous studies have shown that building the patient's self-efficacy is highly beneficial for improving treatment compliance, healthier behaviors, and improved quality of life. Adjustment to hearing aids and hearing loss requires learning new skills and adjusting to amplified sound. The audiology patient's low self-efficacy for hearing aid use can often be detected from comments such as "I can't get the hearing aid in right." or "I can't get used to the sound of my voice". Determination of the patient's degree of self-efficacy prior to the hearing aid fitting may alert the audiologist to the necessity of finding ways to bolster the patient's confidence for successful hearing aid use. Although several authors have alluded to self-efficacy as it relates to AR outcomes (e.g., Carson and Pichora-Fuller, 1997; Kricos, 2000; Noh, Gagné, & Kaspar, 1994; Tsuruoka, et al., 2001), research in this area has been sorely lacking.
Suggestions for minimizing effects of psychological variables:
Is your patient motivated to use hearing aids? If not, provide examples of how hearing aids can improve his quality of life. Try to increase the patient's awareness of how hearing loss is affecting him, and consider holding off the fitting of hearing aids until the patient understands that hearing loss not only affects communication but also has mental, physical, and psychological effects as well. When the patient appears to be motivated, consider use of open-ended instruments such as the Client-Oriented Scale of Improvement (COSI; Dillon et al., 1997) and the Glasgow Hearing Aid Benefit Profile (GHABP; Gatehouse, 1999). These measures are ideally suited for this sort of evaluation because they specify the patient's own unique goals for hearing aid use.
Does your patient seem introverted, anxious, neurotic, and eager to blame problems on others? Predict lower levels of hearing aid satisfaction. Are you an extrovert and your patient is an introvert? Try to see things from their perspectives and not be too forceful, loud, or out-going. Be sensitive to the fact that your personality may be at polar opposites from those of many of your patients. For an excellent discussion of how the audiologist's personality may interact with the patient's, see Traynor and Holmes (2002).
Is your patient confident about his ability to learn how to use "high-tech" hearing aids? If not, build up his self-efficacy before, during, and after the hearing aid fitting. One way to do this may be to put him in touch with successful hearing aid users who can assure him that they too were worried about adjusting to hearing aids but that it did not take long to learn how to use them successfully.
Gender
Possible Effects:
There are a number of ways that the patient's gender may affect adjustment to hearing loss and audiologic rehabilitation outcomes. First, there is a body of knowledge in the health literature regarding gender differences in sensitivity to health-related concerns, with women generally more likely to report physical symptoms and discomfort, as well as higher levels of psychological distress. Further, women in general are more likely to seek help for their physical and mental symptoms.
Several research reports in the audiology literature have shown similar results regarding symptom reporting and help-seeking behaviors for women as compared to men. Garstecki and Erler (1998) found that females reported less denial and greater problem awareness related to hearing loss. These researchers also found that women place greater importance on social communication than men, which might influence their decision to seek help for their hearing difficulties. As far as adjustment to hearing loss, several authors have found that females report greater use of nonverbal communication strategies, and are more likely to have poorer results in several of the Communication Profile for the Hearing Impaired scales (CPHI) personal adjustment scales (Erdman & Demorest, 1998; Garstecki & Erler, 1998, 1999). This corresponds to reports that females are more likely to admit to physical & mental disabilities (Padgett et al., 1998a, b).
Some interesting gender effects have also been reported as far as the impact of hearing loss on spouses. Wallhagen et al. (2004) found that the impact of the husband's hearing loss on his spouse is stronger than the reverse.
Several investigators have reported gender effects on hearing aid outcomes. Cox and her coauthors (1999) found that female hearing aid users in their study reported fewer difficulties in background noise than men. Research by Wilson & Stephens (2003) indicated that their female research participants were significantly less able to manipulate hearing aids than their male research participants and that their male research participants were significantly more satisfied with their hearing aids than their female research participants.
So what is the bottom line on gender effects? Based on research that is available to date, the female's greater likelihood of acknowledging hearing loss and taking an active part in reducing communication difficulties may enhance positive outcomes for seeking hearing healthcare and obtaining hearing aids. Additionally, one of the most frequently reported problems that dispensing audiologists hear from their patients is difficulty hearing in background noise. Thus, we may anticipate greater tolerance for adjusting to the use of hearing aids in noise from female hearing aid users. A caveat, however, is that the female's increased likelihood of difficulties in manipulating hearing aids and greater probability of reporting dissatisfaction must be considered in predicting and trying to ensure successful adjustment to hearing aids.
Suggestions for minimizing gender effects:
Is your patient male? Predict that he will be less concerned about the effects of hearing loss on social communication, and may need information that raises his awareness of the impact of his hearing loss on his physical, mental, behavioral, social, and cognitive well-being. Is your patient female? Predict that she will have more difficulties manipulating the hearing aids but be less troubled by background noise.
Sociological Variables
Possible effects:
There are a number of sociological variables that may influence audiologic treatment outcomes. Among others, these include education, lifestyle, social support, and race/ethnicity. Of five non-audiological variables evaluated by Erdman & Demorest (1998), education and age had the strongest association with adjustment to hearing loss. Research participants with higher levels of education placed greater importance on communication, and reported better communication performance, greater communication need, more demanding communication environments, less frequent use of maladaptive behavior strategies, and fewer problems in the areas of personal adjustment. Garstecki and Erler (1998) found that research participants who reported more formal education were significantly more likely to adhere to the audiologist's recommendation for hearing aids.
Lifestyle may also affect adjustment to hearing loss and hearing aids. An individual who is retired and does not socialize on a regular basis will probably have fewer communication needs and thus less perception of hearing handicap and less likelihood of pursuing hearing aids. However, the audiologist via an interview and/or questionnaire should identify their communication needs. A retired, non-social individual may enjoy watching television and visiting with family and close friends via telephone. Thus, assistive devices beyond hearing aids should be considered to improve her overall quality of life.
Social support exerts a strong influence on adjustment to hearing loss and hearing aids. Garstecki and Erler (1998), for example, found that individuals who adhered to their audiologist's recommendation to wear hearing aids were more likely to have greater social support, and similarly, Erber et al. (1996) found that hours of hearing aid use increase with level of social support.
In the next 30 years, it is predicted that the number of White older adults is expected to increase by 81 percent in the United States, while the population of older adults within minority groups is expected to increase by 219 percent (Hooyman & Kiyak, 2005). Given this increased ethnic/racial diversity in the older adult population, it is important for audiologists to possess cultural sensitivity to patients who may have customs, health beliefs, and coping strategies that are different from their own. Erdman and Demorest's research (1998) into demographic variables that affect adjustment to hearing loss suggests that White individuals tend to report better communication performance and greater problem awareness than Black individuals. However, they also point out that there is evidence of more social support in the Black community, and therefore there may be reason to expect better adjustment to hearing loss among older Black individuals.
Suggestions for minimizing effects of sociological variables:
Does your patient have a strong social support system? If yes, predict more successful hearing aid use. Is your patient highly educated? Predict greater success with hearing aids. Is your patient retired? Predict less interest in wearing hearing aids than for those who are still in the labor force.
Summary
Along with audiological and electro-acoustic parameters, the dispensing audiologist should consider non-audiological variables that may affect hearing loss adjustment and hearing aid outcomes. As Cox and her coauthors recently pointed out, "To increase hearing aid penetration and improve the effectiveness of services, it is important for audiologists to gain expertise in recognizing different ways of thinking, feeling, and behaving in hearing aid seekers and adjusting therapeutic procedures to maximize the effectiveness of communication with each individual patient" (Cox et al., 2005, p. 23).
About Patricia Kricos
Dr. Patricia Kricos is a Professor of Audiology and Director of the Center for Gerontological Studies at the University of Florida. She received her PhD from the Ohio State University in 1973. Dr. Kricos has taught in the audiology program at the University of Florida since 1981. Her major clinical and research interests are in audiologic habilitation/rehabilitation. Dr. Kricos has published a number of articles and chapters on audiologic rehabilitation of children and older adults. She is excited by the challenges of instilling in audiology students a healthy balance between the technical aspects of the field and the more humanistic concerns such as the psychosocial aspects of hearing impairment. Dr. Kricos is an Audiology Online Contributing Editor in the area of adult amplification.
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