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Meeting the Hearing Health Care Needs of the Oldest Older Adult Barbara E. Weinsteina

Purpose: The purpose of this article is to provide an overview of the auditory needs of and approaches to management of the oldest older adult. Method: This article is an overview of principles of geriatric care and implications of untreated hearing loss for function, management, and care of the oldest older adult. Conclusions: Person-centered care is at the heart of health care delivery to the oldest older adult, who typically suffers

from multimorbidity. Given the high prevalence of moderate to severe hearing loss in this cohort and the functional limitations of untreated hearing loss, audiologists must become proactive in educating stakeholders on the importance of identifying and referring the oldest older adult for management of hearing health care needs. Audiologists have an integral role to play in collaborating with health care professionals in optimizing health care for the oldest older adult.

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especially advanced care planning and end-of-life care (Graham, 2014). Considering caregiver needs, understanding the value of the service, embracing a biopsychosocial model of care, and giving attention to psychosocial factors are increasingly emphasized as part of geriatric care (Pacala, 2014). In medicine, the term high value implies that a test or treatment has benefits and minimal associated risk, harm, and burden (Owens, Qaseem, Chou, & Shekelle, 2011). Promotion of better health care with an eye toward improved quality of life is at the heart of geriatrics, with its multidisciplinary focus. To this end, person-centered, holistic, humane care is recognized as integral to optimizing patient encounters and health outcomes (Pacala, 2014). In the face of the persistent and recurring health crises that beset the oldest older adults, social contacts—namely, friends and family—are a very important part of the social reality of the oldest older adult. In fact, strong social relationships and active engagement with life are linked to survival, morbidity, mortality, and successful aging (HoltLunstad, Smith, & Layton, 2010; Rowe & Kahn, 1977). As a result of their meta-analysis, Holt-Lunstad et al. (2010) concluded that because social relationships influence health outcomes, the maintenance of these relationships should be a priority. Health professionals should underscore the importance of meaningful social engagement and promote interventions that could help preserve social function. Social support in the form of engaging in activities, friendships, and intimacy can benefit an individual’s functioning and help form a protective barrier against the disability process (Femia, Zarit, & Johansson, 2001).

he population aged 65 years and over is projected to increase from 43.1 million in 2012 to 83.7 million in 2050. The baby boomers, who began turning 65 years old in 2011 and who will be aged 85+ years in 2050, are largely responsible for this growth. The number of people in the oldest older adult age cohort (i.e., those aged 85 years and over) is projected to grow from 5.9 million in 2012 to 18 million in 2050, accounting for 4.5% of the U.S. population (National Institute on Aging [NIA], 2007). The oldest older adults constitute 7% of the world’s population of those aged 65 years and over, with more than one half living in China, the United States, India, Japan, Germany, and Russia (NIA, 2007). Age-related hearing loss in this population is becoming more widespread, and its effect on other health problems is daunting. Unique to the oldest older adult is an increase in the duration and prevalence of chronic-disease morbidity. Management of this cohort involves treating the primary disease process, managing geriatric syndromes (e.g., cognitive impairment), and treating concomitant psychosocial symptoms (Pacala, 2014). The expansion of morbidity gives rise to an increased reliance on personal care assistance at home and in long-term care settings. Good physician–patient communication is a core skill set for health care delivery in multiple care settings and across the continuum of care,

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Graduate Center, City University of New York

Correspondence to Barbara Weinstein: [email protected] Editor and Associate Editor: Larry Humes Received December 1, 2014 Revision received February 16, 2015 Accepted February 16, 2015 DOI: 10.1044/2015_AJA-14-0078

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Disclosure: The author has declared that no competing interests existed at the time of publication.

American Journal of Audiology • Vol. 24 • 100–103 • June 2015 • Copyright © 2015 American Speech-Language-Hearing Association Research Forum: Hearing Health Care for the Oldest Older Adults

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Minimal disability in performing functional tasks such as activities of daily living (ADL; i.e., tasks that involve caring for or moving the body, such as walking) or instrumental ADL (i.e., tasks that support an independent lifestyle, such as using the telephone or shopping) and normal cognitive status are integral to healthy and successful aging as well (Cosco, Stephan, & Brayne, 2014). Life satisfaction experienced by the oldest older adults is poorest among those with depressive symptoms, low self-rated health, and poor perceived quality of social networks (Berg, Hassing, McClearn, & Johansson, 2006). The oldest older adults still want to engage with life and people. The six senses considered to be most important include security, significance, belonging, achievement, purpose, and continuity (Nolan, 2012; Rea, 2012). It is incumbent on stakeholders to create an environment in which the oldest older adults can experience these senses. It is through person-centered care that these senses are fostered, and the oldest older adults can continue to thrive and enjoy an improved quality of life. Patient-centered communication skills are fundamental to ensuring that patient values and preferences are respected (Levinson, Lesser, & Epstein, 2010). The ability to communicate, to be understood, and to understand others is an important driver of social interactions and enjoyment of life and is at the heart of personcentered care. Although the majority of persons aged 85 years and older have significant hearing impairment, only a small proportion (26.5%) use hearing aids (Kiely, Gopinath, Mitchell, Luszcz, & Anstey, 2012; Lin, Thorpe, Gordon-Salant, & Ferrucci, 2011). The breakdown in communication for those with moderate to severe hearing loss, especially in the presence of environmental distractors, interferes with patientcentered communication and can be the beginning of a downward spiral. The “person–environment fit” model of stress and well-being (Lawton & Nahemow, 1973) may help explain the array of findings linking hearing loss to selected health outcomes. The model posits that a key determinant of stress is the fit between the individual’s adaptive resources (e.g., hearing ability) and the demands of the environment (e.g., noise). An imbalance between environmental demands and ability to respond to those demands generates deleterious health outcomes. In short, when the stress is higher and wellbeing is lower, the fit between coping capacity and environmental demands is weak. Hence, interacting with others in circumstances that are less than optimal can be a trigger for stress among those with significant untreated hearing loss. There is a strong temporal (i.e., over time) relationship and gradient effect between severity of hearing difficulties and quality of life. Compared with persons with normal hearing, persons with severe hearing loss were more likely to have poorer scores on the mental composite scores of the Short Form 36 Health Survey (SF-36; McHorney, Ware, & Raczek, 1993); the greater the self-reported hearing handicap, the more diminished were functional status and the ability to carry out daily functions over time (Gopinath, Hickson, et al., 2012; Gopinath, Schneider, Hickson, et al., 2012; Gopinath, Schneider, McMahon, et al., 2012). Also

compared with persons without hearing loss, persons with moderate to severe hearing loss were three times more likely to report difficulty with instrumental ADL requiring communication (Gopinath, Schneider, McMahon, et al., 2012; Strawbridge, Wallhagen, Shema, & Kaplan, 2000). Significant hearing loss, which is more typical of the oldest older adult cohort, is also related to depression, poor selfrated health, increased likelihood of falls, frailty, and cognitive impairment (Gopinath, Hickson, et al., 2012; Lin, 2014; Lin, Metter, et al., 2011). Hogan, O’Loughlin, Miller, and Kendig (2009) confirmed that hearing loss is an underestimated health problem: Persons with hearing disability, including hearing aid users, have lower perceived physical and mental health status. The effect is more pronounced in the physical domain and among those with more significant self-reported hearing problems. At each stage of advancing age, respondents to Hogan et al.’s survey experienced a change in health status such that the decline in health status was most pronounced at the point of severe and profound hearing disability. Individuals with moderate to severe hearing loss have greater odds of having lower physical activity levels compared with those with normal hearing. Compared with older adults with normal hearing, older adults with moderate to profound hearing difficulties had 59% greater odds of having lower levels of self-reported physical activity and 70% greater odds of having lower levels of accelerometermeasured physical activity (Gispen, Chen, Genther, & Lin, 2014). Regarding the latter, the association with activity level was robust and sensitivity analyses confirmed that even after controlling for demographic factors, cardiovascular factors, and body mass index, a 25 dB shift in hearing, for example, was associated with increased odds of having lower physical activity levels. The relation remained even when restricting the sample to the young old. Further analysis revealed that neither sex nor age moderated the relationship between hearing and physical activity levels (Gispen et al., 2014). The association between hearing impairment and physical activity levels is consistent with recent evidence linking hearing impairment to disability in walking and lower gait speed, the latter being a robust predictor of mortality and morbidity (Li, Simonsick, Ferrucci, & Lin, 2013). Physical activity is essential to healthy aging, and, given its connection to hearing loss, it is not surprising that respondents to a large health impact study rated self-reported hearing loss to be the third most problematic condition after chronic pain and restrictions in physical activity (Hogan et al., 2009). The finding that self-rated health, cognitive status, and disability in walking mediate the relationship between hearing impairment and all-cause mortality (i.e., annual number of deaths in a given age group per the population in that age group) underscores the need for aggressive preventive programs designed to identify modifiable conditions such as hearing loss that threaten health outcomes (Karpa et al., 2010). Given the unprecedented increases in life expectancy and gains in longevity, this is of critical importance as people continue to age in place.

Weinstein: Hearing Health Care for the Oldest Older Adults

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There is some recent evidence that hearing aids can serve as a buffer against subjective social isolation and loneliness, even among the oldest older adults (Pronk, Deeg, & Kramer, 2013). In a preliminary report, Weinstein and Sirow (2014) found that scores on the DeJong Gierveld Loneliness Scale (DeJong Gierveld & Kamphuis, 1985), which quantifies social and emotional loneliness, were reduced significantly after 3 to 6 weeks of hearing aid use. In their sample of older adults with essentially moderate to severe hearing loss, a significant proportion of hearing aid users were categorized as not isolated following hearing aid use and a smaller proportion were categorized as isolated. This pattern held for the oldest older adult participants as well. Hearing aid use is also associated with reduced caregiver burden, improved physical functional status, and reduction in depressive symptoms. Highlighting these outcomes to stakeholders should help bolster efforts to identify and treat hearing loss, perhaps forestalling the onset of the negative outcomes associated with significant untreated hearing loss (Boi et al., 2012). The growth in the oldest older adult population has dramatic implications and poses significant challenges to society in general and opportunities for audiologists in particular. Regarding everyday function, effective communication, which is central to delivery of person-centered care, remains a core skill as people age. Yet physician–patient communication and the quality of the health care experience are compromised by hearing loss (Mick, Foley, & Lin, 2014). In turn, poor physician–patient communication hinders treatment adherence, patient activation, and selfmanagement (Levinson et al., 2010). Optimizing the communication ability of the oldest older adults with significant hearing loss through hearing health care interventions could potentially reduce their increased odds of falls, reduced capacity for independent living, lower physical activity levels, and poor self-rated health (Gopinath, Schneider, McMahon, et al., 2012; Karpa et al., 2010). Communication breakdowns with care providers are likely throughout the health care continuum, especially during transitions in care, which will place the oldest older adult population at increased risk for adverse outcomes. Audiologists working in acute, chronic, and long-term care settings should advocate for use of hearing health care technologies by stakeholders throughout the continuum of care. Use of formal and informal support networks is greatest among the oldest older adults, and the likelihood of using community or family support increases with increasing severity of hearing loss. It is not surprising that persons with hearing loss who have never used a hearing aid are twice as likely to use community support services compared with those without hearing loss (Schneider et al., 2010). Because severely diminished hearing is associated with decline in functional status based on ADL measures, the oldest older adults are at increased risk for compromised independence (Gopinath, Schneider, McMahon, et al., 2012). Audiologists must work with primary care providers and demonstrate how improved hearing health can optimize delivery of effective and compassionate care and

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reduce some of the burden of disease, especially among the more vulnerable. We should advocate for the installation of assistive technology in the settings in which the oldest older adults are most likely to congregate or frequent to ensure the social engagement necessary for quality of life and quality of care. In sum, hearing loss is more than a nuisance condition, especially among the oldest older adults (Whitson & Lin, 2014). The cascading consequences for patients and caregivers, and the economic implications for society that are attributable to risk for costly health outcomes, are increasingly being realized. The oldest older adult who presents with multiple complex comorbidities, including moderate to moderately severe hearing loss, will become a mainstay of the caseload of audiologists. Interprofessional collaboration is critical throughout the continuum of care, be it with the robust elderly in ambulatory care settings, during transitions in care, or with the very ill facing end-of-life and palliative care decisions. Good communication is at the core of health care delivery because it is essential to adherence with treatment regimens, trust, satisfaction with the provider, and improved health status. Audiologists should leverage their expertise in preventive hearing health care and educate stakeholders about how to recognize when a hearing impairment exists, propose strategies for communicating with individuals with impaired hearing, and intervention options that have the potential to help the oldest older adults remain socially integrated and empowered. Given the centrality of communication to advanced care planning and to successful and active aging, audiologists must assume a proactive role in helping to optimize the overall health care of the oldest older adult (Institute of Medicine, 2014). In this way, the profession of audiology—of which a core mission is promoting quality hearing care and enhancing communication —will remain sustainable.

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Weinstein: Hearing Health Care for the Oldest Older Adults

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Meeting the Hearing Health Care Needs of the Oldest Older Adult.

The purpose of this article is to provide an overview of the auditory needs of and approaches to management of the oldest older adult...
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