Associate Professor Louise Hickson

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Overview of Research Older People with Hearing
Impairment

• Associate Professor Louise Hickson
• Communication Disability in Ageing Research
  Centre
• Division of Audiology

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Communication Disability in Ageing Research Centre

• Category 1 Research Centre
• Room 825 Therapies Building
• Directors - Louise Hickson and Linda Worrall
• Other Staff Dr Bronwyn Davidson 2 RAs
• 10 postgraduate students
• www.shrs.uq.edu.au/cdaru
• Current grants 1 NHMRC, 2 ARC Linkage, Hon

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Collaborators

• Social Work and Applied Human Sciences
• Australasian Centre on Ageing
• Optometry
• Occupational Therapy
• Psychology

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ICF Framework
Health condition (disorder or disease)
Body structure and function
Activity
Participation
Environmental factors
Personal factors
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Case Examples (Worrall Hickson, 2003)

• Mrs A (aged 67 years)
• Moderate bilateral SNHI
• ALs problems understanding speech in noisy
  situations, cant hear phone ring, cant hear TV
  at normal volume
• PRs withdraws from social situations, has
  resigned as secretary of the local card club

• Mrs B (aged 63 years)
• Severe bilateral SNHI
• ALs minimal problems in noise (uses FM,
  conference mic), no problems with phone (uses
  flashing light), some problems with conversation
  on the phone even with telecoil
• PRs busy social life, works full-time for a
  disability support agency giving advice
• on ALDs

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Some project examples.

• Communication impairments in older people
• Effects of hearing impairment on everyday lives
  of older people (what AL and PR do they
  experience?)
• Relationships between hearing impairment, AL and
  PR and quality of life
• Measuring outcomes of interventions using
  measures of AL and PR
• Third party disability in spouses

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Other projects

• Factors associated with quality of life change
  after hearing aid fitting
• Consumer satisfaction with hearing aids model
  from marketing literature
• Intervention for older people with hearing
  impairment living in residential care
• The efficacy of the Active Communication
  Education (ACE) program for older people with
  hearing impairment

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What is current practice?

• Fitting of hearing aids an impairment-focused
  treatment, may also reduce ALs and PRs of the
  individual
• If hearing aids are worn the evidence is that
  they reduce the ALs and PRs experienced in
  everyday life and improve quality of life (e.g.,
  Newman et al., 1991 Mulrow et al., 1990)

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However...

• Many older people will not wear hearing aids
• gt50 of older people (e.g., Hogan et al., 2001
  Stephens et al., 2001 van den Brink et al.,
  1996 Wilson et al., 1998)
• Many who are fitted with hearing aids are not
  successful users in the longterm
• 10 to 36 using aids lt 1 hour/day 3 months
  post-fitting (e.g., Dillon et al., 1999 Hickson
  et al., 1999 Mulrow et al., 1992)
• many continue to wear aids but continue to
  report difficulties in everyday life (e.g.,
  Newman et al., 1991 Primeau, 1997).

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• Q Are we currently meeting the communication
  needs of older people with hearing impairment?

A Not always and different approaches are
needed for different client groups
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Interventions for Older People in Residential Care
Health condition (disorder or disease)
Body structure and function
Activity
Participation
Personal factors
Environmental factors
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Residential Care Population

• Residents are generally frail and have a number
  of chronic illnesses.
• High prevalence of communication impairments
  (e.g., Worrall, Hickson Dodd, 1994)
• 77 to 95 have hearing impairment (e.g., Worrall
  et al., 1994 Garahan et al., 1992)
• Many residents have dual sensory loss (e.g.,
  Erber Scherer, 1999)
• Use of hearing aids is very limited (e.g.,
  Bradley Molloy, 1991) and audiological services
  are fragmented (e.g., Lubinski et al., 1993)

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Residential Care Environment

• The physical environment is problematic - lack of
  privacy, high reverberation levels, high levels
  of glare (e.g., Lubinski, 1995 Jones et al.,
  1992)
• The social environment is restricted - few
  opportunities to talk, communication partners,
  topics of conversation, reasons to talk (e.g.,
  Kaakinen, 1995 Lubinski, 1995)
• Staff have limited knowledge about hearing and
  focus on physical care with little time to talk
  to residents (e.g., Kato et al., 1996 Garahan et
  al., 1992)

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• Programs for older people living in residential
  care need to focus on the broader communication
  environment of the facility as well as the
  individuals within it.

staff
family
residents
visitors
volunteers
administrators
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Participation Enablement Program (PEP) (Looi,
Hickson et al., 2004)

• a holistic, communication-focused approach to the
  rehabilitation of residents
• developed by a multidisciplinary team audiology,
  speech pathology, social work, nursing,
  residential care providers.

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The Facility

• 60 bed facility in suburban Brisbane
• Each resident had a single room with shared
  bathroom
• Central dining and lounge areas
• 84 (part-time and full-time) staff - 61 nursing
  personnel, 2 physiotherapists, 1 aromatherapist,
  1 administrative officer and 19
  domestic/maintenance staff.

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Assessment Phase

• Individual (n 15)
• Impairment PTA, otoscopy
• Activity and Participation Nursing Home Hearing
  Handicap Inventory (Schow Nerbonne, 1977)
  Questionnaire of Communication

• Environmental
• Communication Environment Assessment and Planning
  Guide (Lubinski, 1995)
• Staff survey (n 27)
• Family members survey (n 15)

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Results Assessment of Residents

• Wax occlusion was a major problem (5 needed
  treatment).
• 14 residents had HI, 5 had been fitted with a
  hearing aid, 2 wore aids
• 5 reported ALs and PRs
• All said that they enjoyed talking to others, but
  seven of the participants felt that there were
  insufficient opportunities for doing so

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Results Assessment of Environment

• Communication environment could be improved in
  many respects staff communication with
  residents, staff-staff communication, the
  acoustic environment, the physical arrangements
  for communication, the visual environment
• Staff placed a priority on physical care of
  residents
• Family members thought communication environment
  could be improved

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Intervention Phase

• Individual
• Medical treatment
• Discussion of need for individual rehabilitation
  with resident and family members
• Checking of current amplification devices

• Environmental
• Communication groups for residents
• Training sessions for staff on hearing and
  communication, hearing aids and ALDs
• Suggestions to Director for systems changes
  checking for wax, loop system, improving
  environment

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Results Intervention Phase

• Individual Level
• 5 residents with aids used them more consistently
• 3 residents applied for hearing aids/ALDs
• Environmental Level
• staff agreed on the need for an individualised
  information sheet system for each resident with a
  hearing aid
• residents reported that the program had given
  them more opportunities for communication
• a system for regular checking for wax was
  implemented
• changes made to the environment to improve
  communication

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Summary

• Project highlights the importance of
  environmental factors for successful
  rehabilitation of older people with hearing
  impairment living in residential care
• Interventions need to be multi-professional

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Interventions for Older People Living in the
Community
Health condition (disorder or disease)
Body structure and function
Activity
Participation
Personal factors
Environmental factors
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Evidence about Communication Programs

• What doesnt work?
• Didactic programs
• Lectures on hearing loss and hearing aids (Norman
  et al., 1994, 1995)
• Distribution of lists of hearing tactics (Wilson,
  Hickson Worrall, 1998)

• What works?
• Interactive group programs (Abrams et al., 1992
  Beynon et al., 1997 Worrall et al., 1998)
• Active problem solving approach (Kricos Holmes,
  1996)
• Focus on communication, not impairment

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Why group programs?

• Support from peers
• Opportunity for socialisation
• Opportunity for conversational practice in group
  situations
• Cost-effectiveness

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What is Active Communication Education (ACE)?

• Group program for 5 weeks (2 hours/week)
• 6 to 8 participants significant others (no more
  than 10 per group)
• For older people who identify themselves as
  having hearing problems, with or without hearing
  aids
• Facilitated by an audiologist
• or speech pathologist

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• Program is run in community locations
• Uses a problem-solving interactive approach
• Each group begins with a communication needs
  analysis in week 1

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Communication Needs Analysis
communicating across rooms
people who talk fast
people who put their hand over their mouth
family gatherings
TV
priest at church
soft voices
jokes/humour
conversations in the car
meetings
smoke alarm
TV documentaries with music background
socialising with people who dont understand the
problem
the theatre
people with accents
hearing instructions of the band master
people who gesture
French teacher
timer on stove
understanding other bids at bridge
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• Participants then prioritise what they want to
  work on for the next 4 weeks
• Program consists of a series of modules about
  different issues based on needs e.g.,
  communicating with family/spouse around the
  house, understanding people who don't speak
  clearly, group communication
• Each module discussion of the communication
  situation, sources of difficulty, possible
  solutions, practical exercises, take-away
  exercises and written information

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Objectives of the ACE

• to learn individual problem-solving skills that
  can by applied in a range of situations
• to know about
• communication strategies
• lipreading
• how to request clarification
• assistive technology

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How is ACE being evaluated?
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Who were the participants?

• 96 people aged 58 to 94 years (M 77, SD 8)
• Recruited mainly via talks to seniors groups
  (46) and retirement villages (30)
• better ear PTA average at .5, 1, 2, and 4 kHz
  from 26.5 to 87.5 dB HTL (M 42.63 SD 11.67)
• 51 had hearing aids fitted
• 39 reported actually wearing aids gt1 hour/ day.
  
• 17 used an ALD
• 35 had SO who attended at least 1 session

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How were outcomes measured?
comparing pre and post self-reports of
participation restrictions, communicative
function, and quality of life
examining outcomes questionnaires post-ACE
listening to the qualitative responses of the
participants
Post assessments by a researcher blind to
pre-intervention results.
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Pre-post intervention measures

• Hearing Handicap Questionnaire (HHQ Gatehouse
  Noble, 2004)
• How often does your hearing difficulty restrict
  the things you do? (never.almost always)
• Self-Assessment of Communication (SAC Schow
  Nerbonne, 1982)
• Do you experience communication difficulties in
  situations when speaking with one other person?
  (almost never..always)
• Quantified Denver Scale of Communicative Function
  (QDSCF Alpiner et al., 1974 Tuley et al.,
  1990)
• The members of my family are annoyed
  with
  my loss of hearing. (SD..SA)

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Pre-post intervention measures

• Ryff Psychological Well-Being Scale (Ryff, 1989)
• I have confidence in my own opinions, even if
  they are contrary to the general consensus.
• The demands of everyday life often get me down.
  (SD.SA)
• Short-Form 36 (SF-36 Ware Sherbourne, 1992)
• In general, would you say your health is
  (Excellent..poor)
• During the past 4 weeks, how much of the time has
  your physical health or emotional problems
  interfered with your social activities? (all of
  the time.none of the time)

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Outcomes questionnaires

• Modified version of the Client Oriented Scale of
  Improvement (COSI Dillon et al., 1997)
• International Outcome Inventory Alternative
  Interventions (IOI AI Noble, 2002)

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Qualitative questions

• What did you like about the ACE program?
• How can the program be improved?
• What action have you taken as a result of
  attending the ACE?

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Results Pre-post intervention differences

• Reduction in participation restrictions on HHQ (p
  .001)
• Reduction in communication difficulties on the
  SAC (p .009)
• Improvements in well-being on the Ryff (p
  .038)
• Improvements on physical functioning subscale of
  the SF-36 (p .008)

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Results COSI goal examples

• Improved communication with spouse
• Be able to hear clearly when in a crowd or
  talking to a single person in the crowd
• Ways to help me to handle my deafness better
• To find out how others have dealt with and are
  dealing with hearing loss
• Develop a way of saying "speak up you mumbler"
  but in an acceptable way that would bring results

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Results COSI goal 1 (n 72)
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Results IOI-AI items
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Comparison of IOI-AI and IOI-HA
Different from the present study p lt .05
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Results Qualitative Responses

• The program was constructed in a friendly manner.
  It was very informative but had the attendees
  thinking i.e. working out better strategies than
  they had previously used.

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• It's hard to break old habits but I now know I
  have to concentrate harder which I am trying to
  do. I'm also aware of other strategies to employ
  when the occasion arises.
• As a result of attending the program I have
  spoken out more about my hearing difficulties and
  encouraged other hearing impaired people to do
  the same.

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Summary of ACE findings so far

• Significant reduction in participation
  restrictions and communication difficulties
• Significant improvements in well-being and
  health-related quality of life
• 74 reported improvement for at least one
  communication goal
• 65 using strategies more than 1 hour/day
• High levels of satisfaction reported

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Where to from here?

• investigate factors associated with change
• compare findings with ACE to those of a control
  group who attended a social program
• determine if positive improvements are
  maintained in the longterm

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Other research interests..

• Collaborating with psychology
• Research about reasons for outcomes of
  interventions for older people with hearing
  impairment what theories apply here?

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Thank you!

• My contact details l.hickson_at_uq.edu.au