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Editors Note: Part 1 of this article (May 2000 HR, pgs. 34-41) detailed the Survey for Client Acceptance of Hearing Loss and Aids (SCAHLA), an 18-question survey designed to provide information on a clients perceptions of hearing loss while initiating serious thinking about issues like the implications of a hearing loss and the value of treating hearing problems via amplification. Part 2 of a two-part article on facilitating the acceptance of hearing loss and hearing instruments discusses common objections to the purchase and use of hearing aids. Several client objections are posed, along with suggestions on how to discuss the objections in a positive manner with the goal of empowering the client to take action on his/her hearing problem. According to the U.S. Census Bureau1, approximately 4.3 million individuals are currently 85 years old and 429,000 Americans are age 95 or older. The rate of hearing impairment among adults living in nursing homes is approximately 54-77%.2-4 It is known that the presence of a hearing loss can have an effect on mental wellness5,6 and social interactions.7 Murlow et al.8 demonstrated that the presence of a hearing loss is associated with significant emotional, social and communication dysfunction. Thus, helping older adults to purchase and use hearing instruments can improve the quality of their lives and will be beneficial to society in general. Typically, there are two major issues related to the purchase of hearing instruments by older individuals: the denial of the existence of hearing loss and/or the minimization of the severity of the hearing loss. The administration of a survey like the SCAHLA prior to the initial evaluation is helpful in dealing with some of the denial.9 Even after accepting the presence of hearing loss, older adults may not purchase the hearing instruments. Some of the rationales used for not buying hearing aids and the strategies for addressing these rationales are discussed below: I only have a mild hearing loss. In many such cases, the client may be minimizing the hearing loss, and the loss may actually be moderate or severe. In these cases, counseling should include a detailed explanation of the audiogram. Before beginning counseling, two high-performance BTE hearing instruments should be programmed with the clients hearing thresholds and fitted to the client with trial earmolds, allowing the client to experience the benefits of quality amplification. Let the client know that wearing the trial hearing instruments will: 1) Allow them to experience how speech sounds through the hearing instruments; 2) Allow them to hear the explanation of the audiometric results more clearly. The clients are often more willing to wear trial hearing instruments during counseling if they have completed the SCAHLA9 prior to the evaluation. During counseling, comparison of the clients results with the results of people who have normal hearing is essential. Repetition and reinforcement of the information, in some cases, can help accommodate the memory problems and slower rates of processing experienced by some older individuals. Following the explanation of the audiogram, the clinician can counsel the client and significant others further to ensure comprehension of the test results. Additionally, addressing the following questions can be useful: What was the softest sound heard at 4 kHz by the client during testing? (Point to the frequency.) What is the softest sound that a normal person can hear at the same frequency? (The use of 4 kHz is useful since, for most clients, the severity of the hearing loss at this frequency is moderate or worse.) What were the softest levels at which half of the words were heard correctly (i.e., Speech Reception Thresholds)? What are the softest levels at which individuals with normal hearing can repeat half of the words correctly? At what level were the words presented to arrive at the Most Comfortable Level? (For example, the words may have been presented at 75 dB HL.) What level do normal-hearing people prefer (45-50 dB)? How loudly will a person have to speak to hear the client clearly (e.g., if the most comfortable level was 75 dB HL, the person will have to shout at the top of his voice)? What are normal conversation levels (45 dB HL)? In some cases, the hearing loss may actually be mild; however, the client should understand that research suggests that even a mild hearing loss can result in significant communication handicaps. The earlier one begins to use the hearing instruments to help remediate a hearing loss, the easier his/her auditory system will adapt to listening to the amplified sounds. Still another reason is that the auditory nerve fibers will receive adequate stimulation, possibly minimizing auditory nerve degeneration.10 There is some evidence that even mild hearing loss may negatively impact memory. Rabbitt10 showed that older individuals with slight hearing loss could recall visually presented words at the same performance levels as younger individuals, but had difficulty in recalling words presented via audition only. There are some cases where a person with mild hearing loss may not benefit from a hearing instrument or the benefit may be minimal and should be carefully evaluated. In these cases, the need for speech recognition in noise and the environments in which the client functions should be considered. For example, a client who spends most of his/her time at home or in quiet may not derive as much benefit from a hearing instrument if the mild hearing loss is restricted only to higher frequencies. In these situations, the client may wish to consider a hearing instrument with an extended frequency range or certain assistive devices (e.g., pocket talker, TV listening devices, etc.) to meet their individual listening requirements. I don't talk with many people anyway. The client should be encouraged to think more about this situation by asking the following questions: How many people do you talk to? Do people have to make some adjustments to talk to you? Do they have to repeat? If yes, how do they feel about it? Do they avoid talking to you? Would you like to talk to more people? Inform the client that research has shown that the use of hearing instruments can improve social interactions, which relates to better quality of life and health. Some people with hearing impairment have been known to withdraw from others or reduce their social interactions. Others have found, upon purchasing hearing instruments, that the quality of their social lives and interactions increase and they are more willing to participate in a variety of activities like church functions, special events, volunteer work, clubs, etc. I can turn up the TV loud, which is the only thing I listen to anyway. This rationale involves two parts: Enjoyment in watching TV and limited social interactions. The issue about limited social interactions should be addressed as described above. To address the issue of enjoyment in watching TV, ask if he/she enjoys listening to the TV as much as in days past? Inform the client that turning up the TV increases the loudness of all sounds equally. Referring again to the audiogram, explain that the hearing instrument will increase loudness according to the hearing loss at various frequencies. For example, minimal hearing loss at lower frequencies means less amplification for low frequency sounds. In some settings (e.g., apartment complex, townhouse or condo), asking about how their neighbors feel about the loudness of the TV is helpful. Similarly, the spouse and/or other family members may have objections to the volume of the TV. Hearing aids will make me look too old. Ask about the clients perception of someone who does not seem to understand what is being said. Clients should consider how others perceive them when their hearing is inadequate (i.e., without hearing instruments). Is the client perceived as being someone with normal hearing? In fact, most people are probably aware of the hearing loss. The client might also be made aware of some impressions formed by individuals with normal hearing when they encounter people who are hard of hearing but refuse to address their hearing problems. In some cases, people can form false impressions, such as the individual who is hard of hearing is frustrating to converse with, not interested in listening to others, bored (or boring!), crotchetyor even senile! Ask the client to compare these impressions with the impression of being old. The option of CIC hearing instruments is valuable for clients who are highly concerned about appearance. Such individuals may include those who go through surgical procedures to remove wrinkles or excessive fat. Some clinicians are hesitant in recommending CIC instruments for older clients. However, with proper instruction, expectations and expressed confidence in the client's ability, most older clients can use CIC aids successfully. Some older clients actually have an easier time inserting and removing these hearing instruments than larger aids. It should also be noted that research has shown greater cosmetic acceptability/use with smaller aids.11 Plath12, in a survey of experienced dispensing professionals, noted that the elderly may worry greatly about cosmetic issues and about being identified as being hard of hearing due to a visible hearing instrument. He suggested that the fear of suffering social disadvantages as a person with a recognizable problem might be more important than cosmetic concerns. Thus, any concerns about cosmetic appearance need to be explored in detail and should be addressed appropriately. Some clients may benefit from relevant research findings. Iler et al.13 conducted a study to see if older individuals negatively perceive peers who use hearing instruments with reference to achievement, personality or appearance. Older observers were shown photographic slides of different individuals wearing a body-type hearing aid, a BTE instrument or no aid. The results suggested that older individuals with hearing instruments were not perceived as lower in achievement, personality or appearance. Other clients may benefit from being aware of hearing instrument use by well-known individuals (e.g., presidents, celebrities, sports stars) so that they can associate hearing instrument use with high achievements. Hearing aids don't work or Hearing instruments arent worth it. Ask how the client has reached this conclusion. All the issues raised by the client should then be discussed. For example, the client may say that her late husband had a hearing aid and he never used it. She should be informed that the hearing instrument works only if you use it and that, the longer one uses it, the more effective it will be. Ask the client if she knows why her husband did not use his aid. Was it because he did not benefit from it? Was it because he did not like the way it looked? Was he given proper instruction on its use and was it fitted properly? The hearing care professional should address each of these issues as best as possible. If necessary, she should be informed that it is in her best interest to experience a hearing instrument herself with a 30 day trial or acclimatization period. (While there is currently debate in the aural rehab field on selling a trial period, advocating a trial period is effective as long as appropriate expectations and objectives are established.) Another client may have purchased a hearing instrument and says it does not work. Under these circumstances, the dispensing professional can examine the characteristics of the hearing instrument with reference to the audiometric results. The reasons for why the hearing instrument is not performing well should be explored and explained to the client. For example, the client may say that the sounds are too loud (e.g., due to linear amplification). In other cases, the vent-size may be too large causing excessive feedback. Any possible modifications should be made in the current instrument. Limitations of monaural hearing instrument use relative to binaural amplification should be explained. Over time, the client may be willing to replace the current linear hearing instrument and/or buy another instrument for his/her unaided ear. I don't expect to live much longer or I cant see how hearing instruments will help me. This year, approximately 429,000 individuals are expected to be older than age 95.1 Thus, when a 80-year-old says that she is too old and may not live much longer, it is quite possible she may outlive many much younger, currently healthy people. Clients should also recognize the continuous advancements in medical treatments. Remedies for many diseases and disabilities are becoming available in rapid succession. The client should also be made aware thatregardless of life expectancythe focus should remain on ones current quality of life. Hearing instruments have been shown to improve the quality of life for people with hearing loss. Inform clients of the recent Hearing Industries Association and the National Council on the Aging study14 which suggest that use of hearing instruments may be related to: Improved interpersonal relationships; Reduction in anger and frustration; Reduction in depression; Improved emotional stability; Reduced paranoid feelings; Enhanced group social activity. Use of other research findings to motivate the older client to purchase hearing instruments: Bridges & Bentler15 similarly showed that clients who are successful in using their hearing instruments exhibit significantly higher life satisfaction than those who do not use hearing instruments. Murlow et al.16 showed that the use of hearing instruments can lead to the improvement of social, emotional and communication function in older individuals. Many clients consider the maintenance of cognitive function important and thus may be motivated to seek hearing aids and rehabilitation. Research findings like those of Naramura et al.17 showed a correlation between auditory and cognitive function. They suggested that early detection of the hearing impairment could contribute to the maintenance of the quality of life in the elderly. Our ability to hear provides us with cognitive stimulation in a variety of ways. Sekuler & Blake18 suggested that a decrease in hearing ability over several years could lead to cognitive dysfunction due to lack of sensory stimulation. Many older individuals are aware of their memory impairments, and relevant research may help motivate them to purchase hearing instruments. Dye and Peak19 evaluated 58 male veterans before and following hearing instrument fitting. They noted significant improvements on memory tests following amplification use. Since depression among older individuals is relatively high, another finding that may motivate clients to use hearing instruments is the association of hearing loss with depression.6 Apollonio et al.7 demonstrated that sensory deprivation due to uncorrected sensory impairment (visual and auditory) is associated with a significant impairment of mood, self-sufficiency in instrumental activities of daily living and social relationships. These impairments were not apparent in subjects with sensory impairments who were using sensory aids. A review of a variety of research findings since the late-70s has been presented in the November 1998 issue of The Hearing Review.20 Can Someone with a Mild Hearing Loss Benefit from Hearing Aids?Yes! Use of a hearing aid can make listening less strenuous. Research has shown that even a mild hearing loss can result in significant communication handicaps.1 Research has shown that older persons with mild hearing loss benefit from hearing aid use.2 Research has also shown that older individuals with slight hearing loss have difficulty recalling (remembering) words presented without visual cues.3 If the same words are presented with visual cues, they do not have difficulty with the words. A plausible explanation is that individuals with impaired hearing must invest more mental energy (resources) in identifying words than individuals with normal hearing. Thus, less mental resources are available to memorize the words at the time of presentation of the words. The requirement of higher mental energy for recognizing words also makes it difficult to understand speakers who talk at a somewhat faster rate (e.g., children). The earlier you start wearing hearing aids, the easier it will be for you to get accustomed to amplified sounds. If you have tinnitus (ringing/noises in ears), the use of hearing aids can reduce the perception of that tinnitus. References 1. Hearing Industries Assn: Impact of Hearing on physical and psychosocial health. Hearing Review 1998; 5 (11): 26-29. 2. Rabbitt P: Mild hearing loss can cause apparent memory failures which increase with age and reduce with I.Q. Acta Otolaryngol (Stockh) 1991; Suppl 476: 167-176. 3. Tesch-Romer C: Psychological effects of hearing aid use in older adults. Journal of Gerontology: Psychological Sciences 52B (3):P127-P138. Handouts (like the example in Fig. 1) geared towards addressing specific health issues, including relevant research findings, are useful. The handouts should not include technical jargon and complicated research design and analysis details. However, a list of relevant references should be included for those clients who are interested in obtaining further details. Many clients have access to the Internet and can obtain additional information about each reference provided in the handout. References 1. U.S. Census Bureau: Washington, D.C. . 2. Garahan MB, Waller JA, Houghton M, Tisdale W & Runge CF: Hearing loss prevalence and management in nursing home residents. J Am Geriatr Soc 1992; 40(2): 130-134. 3. Voeks SK, Gallagher CM, Langer EH & Drinka PJ: Hearing loss in the nursing home: An institutional issue. J Am Geriatr Soc 1990;38 (2): 141-145. 4. Voeks SK, Gallagher CM, Langer EH & Drinka PJ: Self-reported hearing difficulty and audiometric thresholds in nursing home residents. Jour Fam Pract 1993; 36(1): 54-8. 5. Bridges JA & Bentler RA: Relating hearing aid use to well-being among older adults. Hear Jour 1998; 51 (7): 39-44. 6. Herbst KR & Humprey C: Hearing impairment and mental state in the elderly living at home. Brit Med Jour 1980; 281 (6245): 903-5. 7. Appollonio I, Carabellese C, Frattola L & Trabucchi M: Effects of sensory aids on the quality of life and mortality of elderly people: A multivariate analysis. Age and Aging 1996; 25 (2): 89-96. 8. Murlow CD, Aguilar C, Endicott JE, Velez R, Tuley MR, Charlip WS & Hill JA: Association between hearing impairment and the quality of life of elderly individuals. Jour Am Geriatr Soc 1990;38 (1): 45-50. 9. Rawool VW: A survey to help older clients accept hearing loss and hearing aids. Hearing Review 2000; 7 (5): 34-41. 10. Rabbitt P: Mild hearing loss can cause apparent memory failures which increase with age and reduce with I.Q. Acta Otolaryngol (Stockh) 1991; Suppl 476: 167-176. 11. Brooks DN: Some factors influencing choice of type of hearing aids in the UK: behind-the-ear of in-the-ear. Brit Jour Audiol 1994; 28:91-98. 12. Plath P: Problems in fitting hearing aids in the elderly. Acta Otolaryngol (Stockh) 1991;Suppl 476: 278-280. 13. Iler KL, Danhauer JL & Mulac A: Peer perceptions of geriatrics wearing hearing aids. Jour Speech Hear Disord 1982; 47(4):433-8. 14. Kochkin S & Rogin CM: Quantifying the obvious: The impact of hearing instruments on quality of life. Hearing Review 2000; 7 (1): 6-34. 15. Bridges JA & Bentler RA: Relating hearing aid use to well-being among older adults. Hear Jour 1998; 51 (7):39-44. 16. Murlow CD, Tuley MR & Aguilar C: Sustained benefits of hearing aids. Jour Speech Hear Res 1992; 35 (6): 1402-1405. 17. Naramura H, Nakanishi N, Tatara K, Ishiyama M, Shiraishi H, & Yamamoto A: Physical and mental correlates of hearing impairment in the elderly in Japan Audiology 1999; 38: 24-9. 18. Sekuler R & Blake R: Sensory underload. Psychology Today 1987; 21:48-53. 19. Dye CJ & Peak MP: Influence of amplification on the psychological functioning of older adults with neurosensory hearing loss. J Acad Rehab Aud 1983; 16: 210-220. Correspondence can be addressed to Vishakha Rawool, PhD, Dept. of Audiology & Speech Pathology, Navy Hall 1, Bloomsburg Univ., Bloomsburg, PA 17815; e-mail: rawool@bloomu.edu.

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