Putting it all together

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Putting it all together

• Robert W. Sweetow, Ph.D.
• University of California, San Francisco

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• Per popular request..

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Agenda

• Why we need to do something different?
• Do our current practices predict success with
  amplification?
• Why do we need EBP and how would it help?
• Establishing an overall rehab plan

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Why we need to do something different?

• Expectations
• Unnecessary follow up visits
• Less than desired satisfaction
• RFC

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Expectations vs. Goals

• Expectations have a product orientation
• Patient assumes passive role
• Whatever goes wrong is the professionals fault
• Goals have a rehabilitation orientation
• Patient assumes active role
• Patient shares in the process

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Blessed is he who expects nothing, for he will
not be disappointed

• Ambrose Bierce

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• Why do patients seek our help?

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Elements of Communication (Kiessling, et al,
2003 Sweetow and Henderson-Sabes, 2004)
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Goal is to relieve HANDICAPPING effects (WHO,
1997)

• Audiogram doesnt show these effects
• This information is obtained through counseling
• These effects are constantly changing

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What constitutes a typical evaluation?

• Pure tone audiogram
• Middle ear assessment - sometimes
• OAEs - sometimes
• Monosyllabic speech testing in quiet
• LDLs, MCLs, and RECDs sometimes
• Sentence recognition in noise - sometimes
• Informational counseling

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Coxs 2005 Evidence Based Practice Review of

• pre-fitting speech audiometry
• aided assessment during the fitting
• post-fitting

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Pre-Fitting Speech Audiometry

• 11 studies
• 10 used some type of speech-in-noise testing
  (including CST and NST) in their design the
  other used speech testing in quiet conditions
  only.
• Four studies indicated a statistically
  significant, but weak correlation between
  pre-fitting test scores and hearing aid outcome.
• None of the 11 studies showed a strong predictive
  relationship between pre-fitting speech test
  scores and self-reports of hearing aid outcome.

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Post-Fitting Speech Audiometry

• 8 studies5 of which were also reviewed in the
  unaided review
• The predictive nature of these studies was
  consistent for both unaided and aided comparisons
  to hearing aid outcome If the unaided test
  showed no relationship to hearing aid outcome,
  the aided version of the test was not different.
• As with the unaided QuickSIN, Walden and Walden
  (2004) showed a predictive relationship between
  the aided QuickSIN results and self-report
  measures of hearing aid outcome. However, this
  predictive relationship is dependant upon age..
• With the effects of age removed, the correlation
  between the U-QSIN and the IOI-HA dropped to r
  -.14 and was not statistically significant, as
  was the partial correlation between the A-QSIN
  and IOI-HA scores (r -.23).

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Post-Fitting Speech Audiometry (cont.)

• meta-analysis of three large studies
• Four unaided and four aided measures of speech
  intelligibility were correlated with each other.
• Additionally, five measures of subjective
  benefit, two measures of satisfaction and three
  measures of usage, were all correlated with each
  other.
• However, no predictive relationship across these
  measures was found.
• Conclusion - there are three separate and
  distinct measures of hearing aid outcome
• Usage
• Subjective satisfaction and benefit
• Speech intelligibility performance

Humes (2003)
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Speech intelligibility, satisfaction, and RFC

• No evidence of relationship between unaided
  speech intelligibility scores and self-reports of
  satisfaction and benefit
• No evidence of correlation between RFC and
  unaided speech Taylor, 2007

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Are we really testing communication?
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Current speech perception tests.

• Dont take the contextual nature of conversation
  into account
• Dont take the interactive nature of conversation
  into account
• Dont allow access to conversational repair
  strategies that occur in real life

Flynn, 2003
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Hearing aid patients by age

Age (years)
From Strom, Hearing Review, 2001
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Perceptual and cognitive declines (resource
limitations) in elderly

• Speed of processing
• Working memory
• Attention difficulties (noise, distraction and
  executive control)

Wingfield and Tun, 2001- Seminars in Hearing
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Say the colors of the dots as quickly as you can
from left to right
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Say the colors in which the words are printed as
quickly as you can from left to right
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• OVER

• WHEN

• HARD

• AND

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Say the colors in which the words are printed as
quickly as you can from left to right
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• YELLOW

• BLUE

• GREEN

• RED

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Working Memory

• Short-term memory depicted in terms of storage
  capacity.
• Working memory capacity-limited, stores recent
  info, provides computational mental workspace to
  manipulate and integrate with long-term memory.
• Limited capacity that is shared between
  processing and storage
• Limits exceeded if processing too effortful or if
  more time is needed.

Pichora-Fuller 2003
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Knowledge is preserved in long-term memory

• Crystallized intelligence
• Semantic memory worldly knowledge
• Episodic memory personal history
• Procedural memory experience
• Fluid intelligence - problem solving
• processing is slowed, thus fluid intelligence may
  be compromised

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Threshold elevation can account for nearly all of
the changes in speech perception with age. (in
quiet or in less demanding listening
environments.)

• Humes 1996

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In complex perceptual tasks, older listeners are
more likely to demonstrate supra-threshold
deficits in addition to the effects of reduced
audibility. It is less certain exactly what
factors contribute to these deficits.

• Pichora-Fuller Souza 2003

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Impact of aging on speech perception

• Even in the absence of hearing loss, older
  subjects require 3-5 dB higher SNR than young
  listeners (Schneider, Daneman and Murphy, 2005).
• Older subjects with normal hearing perform
  approximately the same as young hearing impaired
  subjects (Wingfield and Tun, 2001)

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Pichora-Fuller, 2006

• Perhaps the problem isnt that older people
  have true cognitive differences than young.
  Rather, the need for greater SNR places a greater
  strain on the cognitive resources. This creates
  more effortful listening.

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Potential impediments to achieving mastery of
these elements

• Hearing loss
• Although it is true that mere detection of a
  sound does not ensure its recognition, it is even
  more true that without detection the probability
  of correct identification is greatly diminished.
  (Pascoe, 1980)
• Global cognitive decline
• Maladaptive compensatory behaviors
• Neural plasticity and progressive
  neurodegeneration
• Morest, 2004
• Loss of confidence
• Saunders and Cienkowski (2002)

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The biggest mistake we currently make may be

• Making hearing aids the focus of our attention,
  when the focus should be
• Enhancing communication

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How to do it?

• All patients should be told at the outset of the
  appointment (even during the scheduling) that
  they will be receiving
• a CNA (Communication Needs Assessment) and
• an overall (ICEP) Individualized Communication
  Enhancement Plan that will consist of
• education and counseling
• communication strategies
• individualized auditory training
• hearing aids and / or ALDs
• group therapy

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History
Basic audiologic evaluation
Communication Needs Assessment (CNA)
Results
Individual Communication Enhancement Plan
(ICEP)
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Relevant Domains for CNA

• Communication expectations and needs
• Sentence recognition in noise
• Tolerance of noise
• Ability to handle rapid speech
• Binaural integration (interference)
• Cognitive skills (working memory, speed of
  processing, executive function)
• Auditory scene analysis
• Perceived handicap
• Confidence / self-efficacy

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Communication Needs Assessment

• Measures beyond the audiogram that can be used to
  define residual auditory function.
• Objective procedures
• QuickSIN
• BKB-SIN
• Hearing in Noise Test (HINT)
• Words in Noise (WIN)
• Acceptable Noise Levels (ANL)
• Binaural interference
• Dichotic testing
• Listening span
• TEN
• Rapid (compressed) speech test
• Speechreading
• Dual-tasking

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Communication Needs Assessment

• Measures beyond the audiogram that can be used to
  define residual auditory function.
• Subjective measures
• Hearing Handicap Inventory for the Elderly
  Screening HHIE-S
• The Hearing Handicap Inventory for Adults (HHIA)
• Communication Scale for Older Adults (CSOA)
• Communication Confidence Test
• Communication partner subjective scales (SAC and
  SOAC)
• Combined (objective and subjective) methods
• Performance Perceptual Test (PPT)

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The Individual Communication Enhancement Plan

• may include any or all of the following
• A plan for learning about their particular
  hearing loss
• A training program that may be completed at home
  or in the clinic
• Hearing aids fitted to their specific hearing
  loss and communication needs and/or other hearing
  assistive devices, including alerting and
  listening devices, and subsequent detailed
  instruction and demonstration regarding the use
  and care of these devices
• Workshops to learn more about living effectively
  with hearing loss
• Counseling for the patients and members of their
  support system to enhance participation and
  address emotional and practical limitations
• Return visit(s) to assess the effectiveness of
  the communication program.
• Referral to other professionals i.e. memory and
  aging center and/or psychologist
• Referral to social agencies for support

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Is this practical?????
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Aural (auditory, audiologic) rehab

• Should NOT be considered an add-on!
• Incorporate it at the very beginning

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Training is not a new concept.

• But now we have the means to do it
  effectivelyvia computer aided auditory
  rehabilitation.so that..
• It can be performed in a private, non-threatening
  environment
• It can proceed at the individuals optimal pace
• Progress assessment can be done automatically

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What factors should be considered to create a
comprehensive program?

• Should be cost effective
• Home training
• Must be practical and easily accessible
• Proceed at the patients optimal pace
• Interactive
• Maintain interest and attention while minimizing
  fatigue
• Train near threshold
• Should integrate listening training with repair
  strategies (i.e. bottom up and top down)
• Measurement and feedback (to patient) regarding
  progress or lack of progress
• Verifiable via remote or datalogging
• Should give patient responsibility
• Reinforcement may be lower cost, better results

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What do we do for a patient receiving an
artificial limb?

• What do we do for a cochlear implant patient?
• What do we do for a patient with a balance
  disorder?
• What do we do for a hearing impaired patient?

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• Top-down influences of cognition on perception
• Bottom-up influences of perception on cognition

Bates et al 1994, 1997
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Aural rehab

• (of which hearing aids are but a part),
• is
• EBP and it does separate you from your competitors

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LACE (Listening and Communication Enhancement)

• Cognitive
• Auditory Working Memory
• Speed of Processing
• Degraded and competing speech
• Background noise
• Compressed speech
• Competing speaker
• Context / Linguistics
• Interactive communication
• All of the above are designed to enhance
  listening and communication skills and improve
  confidence levels

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Return for Credit study

• Martin M, August 2007, The Hearing Journal
• N625
• RFC for 452 patients not doing LACE 13.1
• RFC for 173 patients doing LACE 3.5

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Sederholm, S., LACE Up Profit and Productivity.
Advance. 9,3,44, 2007

• my patients began to focus not on the
  performance of their hearing aids, but rather
  their performance with their hearing aids!
• they no longer have to fully rely on their
  hearing aids in order to effectively communicate
  
• RFC has gone from 10 (pre-LACE) to 0 for LACE
  users

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RFC Hearing Planet study

• Group Not Receiving LACE
• 12 RFC
• (48 of 400)
• Group receiving LACE
• 40 completed at least 3 sessions of LACE
• 5 RFC
• (8 of 160)
• Significant reduction (Fishers Exact Test plt0.05)
• 8.5 RFC overall for those receiving LACE
• (34 of 400)

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Free download of program orientation

• www.lacecentral.com
• or
• www.neurotone.com

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Evidence-based Practice

• Based on systematic and rigorous reviews of the
  scientific literature
• Promotes data-driven decision making
• As opposed to
• opinion
• conjecture
• routine

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Evidence-based Practice

• Establishes the efficacy of treatments and
  indications for use based on evidence
• Reduces unnecessary or inappropriate care
• Identifies best clinical practices
• Promotes the development of clinical practice
  guidelines

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Benefits of Clinical Practice Guidelines

• Translate research into evidence-based patient
  care
• Promote best practices
• Foster the appropriate use of knowledge
• Reduce variation in clinical practice
• Optimize outcomes

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Levels of Evidence

• Level 1 Large randomized trials with clear-cut
  results (low risk of error)
• Level 2 Small, randomized trials with uncertain
  results (moderate to high risk of error)
• Level 3 Nonrandomized, contemporaneous controls
• Level 4 Nonrandomized, historical controls and
  expert opinion
• Level 5 Uncontrolled studies, case series, and
  expert opinion

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Strength of Recommendations

• Level I - Usually indicated, always acceptable
  and considered useful and effective
• Requires Grade A evidence
• Level IIa - Acceptable, of uncertain efficacy and
  may be controversial. Weight of evidence in favor
  of usefulness/efficacy.
• Requires Grade B evidence

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Strength of Recommendation (cont.)

• Level IIb - Acceptable, of uncertain efficacy and
  may be controversial. May be helpful, not likely
  to be harmful.
• Requires Grade C evidence
• Level III - Not acceptable, of uncertain efficacy
  and may be harmful.

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Defining the Quality of Individual Studies (AHRQ)

• Good quality studies ...
• are descriptive rather than definitional
• refer to efficacy trials more than to other type
  of studies
• relate more to therapies than to other processes
  (e.g. diagnostic results)

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Defining the Quality of Individual Studies (cont.)

• Good quality studies ...
• focus heavily on study design elements
  characteristic of randomized controlled trials
• emphasize scientific methods and variables
  related to internal validity
• Lohr, K.N. Carey, T.S. (1999). Assessing Best
  Evidence Issues in Grading the Quality of
  Studies for Systematic Reviews. Journal on
  Quality Improvement, 259, 471-479

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Self-Perception of
Communication Needs, Performance, and Selection
of Goals for Treatment

• 1. Each patient should receive formal
  self-assessment instrument(s)/inventory(s) prior
  to
• fitting to establish communication needs,
  function, and goals.
• 2. Goals should be patient specific and composed
  of both cognitive and affective
• characteristics.
• 3. Post-fitting administration of these
  instrument(s) is necessary to validate
• benefits/satisfaction from amplification.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006 Non-Auditory
Needs Assessment

• 1. be aware of the non-auditory factors that may
  impact successful prognosis.
• 2. query or screen for issues related to general
  health, manual dexterity (finger sensitivity),
  near vision, support systems, motivation, and
  prior experience with amplification.
• 3. use self-assessment scales to assess hearing
  aid readiness.
• 4. consider cognitive abilities and personality
  assessment
• 5. maintain a list of professionals trained to
  deal with the above mentioned issues to whom
  patients might be referred.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006 Gain processing

• Initial selection of target gain for average
  speech input levels should be based on a
  validated prescriptive procedure.
• Validated prescriptive methods appear to be a
  reasonable
• starting point and are time efficient.
• Hearing aids with a low compression threshold
  (CT) are recommended for patients with reduced
  dynamic range (DR) of hearing to improve
  audibility for low-intensity sounds while
  avoiding discomfort for high-intensity sounds
• Evidence relative to the number of compression
  channels is mixed.
• More than three to five channels of compression
  is not
• considered necessary unless data can support
  that the specific
• implementation can result in at least equivalent
  performance and sound quality when compared to
  lower numbers of channels.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006 Gain processing
(cont.)

• Use of compression for patients with severe to
  profound hearing loss should be limited to
  compression that minimizes the alteration of
  speech cues, particularly in the temporal domain
  (i.e., CL or low CT with few compression
  channels, low compression ratios (CR), and long
  time constants)
• b. Fast-acting compression may not be suitable
  for patients with limited cognitive abilities
  (more prevalent in the elderly population). Fast
  compression time constants may be slightly
  beneficial for patients with normal and high
  levels of cognitive functioning.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Output and OSPL90

• Measurement of Threshold of Discomfort (TD) on
  individual patients and the setting of OSPL90 so
  that it does not exceed TD is recommended.
• Minimally, the output sound pressure level with a
  90 dB input (OSPL90) of a hearing aid should not
  exceed the patients TD in order to ensure
  comfort and to reduce exposure to potentially
  damaging input levels.
• CL is recommended over peak clipping (PC) for
  output limitation. PC may be preferred by some
  patients with profound hearing loss having prior
  experience with PC hearing aids.

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The Evidence Output Limiting

• There does not appear to be any compelling
  evidence suggesting superior performance or
  preference among the commonly used output
  limiting strategies.
• Humes et al. (1997)
• Surr et al. (1997)
• Larson et al. (2000)

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006 Frequency shaping

• At least four to eight frequency handles (bands)
  for gain shaping are recommended to optimize
  audibility.
• Greater numbers of handles (bands) may be
  desirable to increase the precision with which
  the frequency response of the hearing aid follows
  the slope of the audiogram, but evidence does not
  support improved audibility.

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The Evidence Digital Signal Processing

• Some studies have demonstrated subjective
  benefits such as listening comfort, quality of
  sound and quieter circuitry.
• No compelling evidence of the superiority of DSP
  in objective or subjective outcome measures
  (Newman and Sandridge, 2001)

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Digital noise
reduction (DNR)

• DNR processing may be helpful for enhancement of
  sound quality and patient comfort. Not all
  implementations of DNR are equivalent, and data
  specific to individual implementations should be
  evaluated prior to selection.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Digital feedback
suppression/cancellation (DFS)

• DFS processing may be helpful for reduction of
  feedback and allow for a wider vent that may be
  beneficial to reduce the occlusion effect. Not
  all implementations of DFS are equivalent, and
  data specific to individual implementations
  should be evaluated prior to selection

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Multiple memories

• Multiple memories are useful when specific signal
  processing is beneficial in some environments,
  but not others.
• The most obvious case is that of directional
  versus omnidirectional microphone modes.

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The Evidence Directional Microphones

• There is compelling evidence that DMHAs are
  effective, at least in low reverberant
  environments and coupled with non-DSP
  instruments, at certain critical distances.
• Amlani (2001)

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Switchable
directional/omnidirectional microphone

• Recommended for patients with complaints of
  speech understanding in noise. Common listening
  situations exist in which directional technology
  is not desirable (e.g., wind noise), therefore
  fixed (nonswitchable) directional technology is
  not recommended in the majority of cases.
• Patients with extremely poor speech understanding
  in noise may not receive enough signal-to-noise
  ratio (SNR) advantage from this technology when
  listening at poor SNRs to reveal benefit, and
  other technologies such as FM systems may be
  warranted.
• Adaptive directional microphone technology is
  recommended for patients who experience difficult
  listening situations with relatively discrete
  noise source location.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Monaural versus
binaural

• Binaural amplification is recommended for most
  patients.
• However, monaural fittings may be warranted based
  on specific patient needs and in particular cases
  of asymmetry, binaural interference, and
  financial and/or cosmetic concerns.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Quality Control

• Electroacoustic verification of all hearing aids
  (new and repaired) is recommended. This
  verification should be completed prior to fitting
  to ensure the hearing aid is in working order and
  to provide a benchmark for future quality control
  measures.
• Verification of features and physical parameters
  is also recommended prior to the hearing aid
  fitting. Such verification may include
  confirmation of earmold/shell style, ordered vent
  size, color, type, as well as a number of hearing
  aid processing (memories, automatic switches,
  etc.) and mechanical (directional microphones,
  t-coil, integrated FM, etc.) features.
• 3. Those features which cannot be verified
  through physical examination or standard
  electroacoustic verification methods should be
  verified through a listening check. These may
  include operation of the VC, directional
  microphones, FM, t-coil, and so on.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Fitting and
Verification of Hearing Aids

• Choice of assessment signal
• Actual speech or a speech-like signal should be
  used
• when attempting verification of prescriptive
  methods for
• which the targets are based on speech inputs.
  That is, the
• preferred hearing aid verification method should
  include a
• test signal that produces an output similar to
  the output for
• a speech signal of the same input level. This
  would require
• that the test signal adequately represent the
  frequency,
• intensity, and temporal aspects of speech.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Fitting and
Verification of Hearing Aids

• Gain verification
• Prescribed gain from a validated prescriptive
  method should be verified using a probe
  microphone approach that is referenced to ear
  canal SPL. Although deviation from target gain in
  some instances is tolerable, or even desirable,
  some evidence suggests that reliability of the
  gain verification method is important due to a
  decrease in perceived hearing aid benefit with
  increasing deviation from target gain values.
• One common desirable deviation from target
  relates to bilateral fitting. The majority of
  prescriptive formulas for gain and output targets
  are based on monaural amplification. For those
  methods that do not account for binaural
  summation, gain verification targets should be
  reduced by approximately 5-6 dB, while the
  maximum output may or may not be reduced. Also,
  some prescriptive formulas for open fittings may
  be inappropriate as there is no need to correct
  for the insertion loss created by including an
  earmold or hearing aid shell in the fitting
  process.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Fitting and
Verification of Hearing Aids

• Output verification
• Given the importance of avoiding excessive
  hearing aid output (as
• described in the hearing aid selection section),
  maximum hearing aid
• output (OSPL90) verification is recommended to
  ensure that it does not
• exceed the patients threshold of discomfort
  (TD). Simulated real-ear
• techniques are recommended for accomplishing this
  goal as accurately
• as possible, while limiting exposure level.
• Alternatively, aided loudness measures may be
  obtained however,
• data supporting the efficacy of these procedures
  is still lacking.
• Aided loudness measures may be preferred for
  timesaving purposes,
• especially if TD is estimated, rather than
  directly measured.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Hearing Assistive
Technology

• 1. The use of HAT should be considered in the
  management of each patient as personal hearing
  aids may not address all of the patients
  communication and safety needs.
• 2. Counseling, instruction, and coaching should
  be included to ensure optimal use of FM systems.
• 3. Careful individualized adjustment of relative
  gains via FM and hearing aid microphones is
  needed for successful use of the FM system.
• 4. The establishment of goals and the provision
  of systematic instruction and counseling
  regarding FM use over several weeks are critical
  to success with FM systems.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Hearing Aid
Orientation

• The following device-related information should
  be provided to each
• patient, and ideally to at least one family
  member or caregiver, as part
• of the hearing aid fitting process
• Hearing aid features (multiple programs,
  telephone coil, directional microphone settings,
  direct audio input, and other special features)
• Insertion/removal
• Battery use (size, how to change, disposal,
  purchase options)
• Care and cleaning
• Comfort
• Feedback
• Telephone use
• Warranty protection

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Hearing Aid
Orientation (cont.)

• The following information should be reviewed
  with each patient, and ideally at least one
  family member or caregiver, as part of the
  hearing aid fitting process
• Wearing schedule
• Goals and expectations
• Adjusting to amplification family, social,
  school, and work settings
• Environment issues restaurants, groups,
  movies, television
• Improved hearing and listening strategies
• Speechreading
• Monaural/binaural hearing aid use
• Post-fitting care

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Counseling and
Follow-Up

• 1. Post-fitting counseling and follow-up should
  be (a) provided to new hearing aid users
• and (b) offered to experienced users who have
  not received these services or who may want a
  refresher course.
• 2. The patients primary communication partner(s)
  should be included.
• 3. Counseling and follow-up can be provided in a
  group or individual format.
• 4. Patients should be informed that the full
  benefits from amplification may not be
  immediately apparent.

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Guidelines for the Audiologic Management of Adult
Hearing Impairment, AAA, 2006Assessing Outcomes

• Subjective
• Objective

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Are we properly instructing our patients to
assess outcome?

• Hearing soft sounds
• Louder perception
• Understanding speech in noise
• but what about..
• Hafters comment that elevators dont make
  climbing better, but they do make it easier!!!!!
• Listening effort
• End of day fatigue
• Strategies
• Quality of life
• Benefit or satisfaction
• RFC

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A word about new technology

• InSound Lyric

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• Radical changes in technology have immediate
  impact
• Changes in practice or procedures must overcome
  the hurdle of inertia

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• robert.sweetow_at_ucsfmedctr.org

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Applause
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Communication Needs Assessment

• OBJECTIVE MEASURES

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QuickSIN

• Assesses ability to understand speech in
  background babble
• Female speaker
• 5 key words/sentence
• 6 sentences/list
• Takes about 5 minutes with interpretation
• Cost of test 160

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Effect of memory on QuickSIN?
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SPIN sentence Listening Span

• Assesses auditory (working) memory and speech
  understanding in quiet
• Uses r-SPIN sentences
• Present 2 sentences, listen to SPIN sentence and
  patient answers whether last word was predictable
  or not (I heard the dog bark vs I bought a new
  couch). Then, patient is asked what the two
  words were at the end of each sentence.
• Takes about 5-10 minutes with interpretation
• Cost of test very little
• (Daneman and Carpenter, Pichora-Fuller)

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Binaural interference

• Difficulty with bilateral amplification
• in some elderly patients might be attributable
• to age-related progressive atrophy and/or
• demyelination of corpus callosal fibers,
• resulting in delay or other loss of the
  efficiency
• of interhemispheric transfer of auditory
• information.

Chmiel et al (1997)
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Binaural interference

• Dichotic listening
• Jerger 1996, HJ 2001, AO
• Percentage of elderly patients could be high
• Walden and Walden, 2005
• Dichotic Digit Test (DDT)
• Musiek,1983 Strouse and Wilson,1999
• MLDs?
• Speech MLD Bentler, unpublished
• Not just lack of binaural integration

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DDT

• 2 domains
• Auditory memory
• Binaural interference
• 2 response paradigms
• Free Recall
• Repeat all digits regardless of ear.
• This task indicates general cognitive factors
  such as speed of processing and memory
• Directed Recall
• Listener is instructed to attend to one or the
  other ear and to repeat the digits heard in that
  ear.
• This paradigm reflects auditory processing the
  extent to which conflicting auditory information
  presented to the contralateral ear interferes
  with correct speech recognition in the
  ipsilateral ear (binaural interference).
• Strouse A, Wilson RH. (1999) Recognition of
  one-,two- and three-pair dichotic digits under
  free and directed recall. J Am Acad Audiol
  10557571.

102
Acceptable Noise Level TestANL

• ANL measures patients willingness to accept
  background noise when listening to speech
• Assesses MCL for speech in quiet and the highest
  noise level tolerated with speech at MCL
• Takes about 5-10 minutes with interpretation
• Cost of test 70
• Nabelek et al

103
Communication Needs Assessment

• SUBJECTIVE MEASURES

104
Hearing Handicap Inventories HHIE/HHIA (or
screening versions)

• 25-item (10-item screener) measure of lifestyle
  and emotional effects of hearing loss.
• Takes less than 5 minutes of patient time, 1
  minute professional time for interpretation

105
Client Oriented Scale of Improvement COSI

• Self-report questionnaire requiring patient to
  list 5 listening situations in which help with
  hearing is required.
• Post-rehab, the reduction in disability and the
  resulting ability to communicate in these
  situations is quantified.
• Takes less than 5 minutes of patient time, 2
  minutes professional time for interpretation

106
Self Assessment of Communication Significant
Other Assessment of CommunicationSAC / SOAC

• 10-item measure of communication performance and
  problems for the patient and the significant
  other.
• Takes 3 minutes of patient time, 2 minutes
  professional time for interpretation

107
Communication Confidence Test
108
Communication Confidence TestPlease circle the
number that corresponds most closely with your
response for each answer. If you wear
hearing aids, please answer the way that you hear
WITH your hearing aids.
109

• 1. Are you confident when you are conversing with
  one or two people in your own home?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 2. Are you confident when you are conversing
  with friends in a noisy environment, like a
  restaurant?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 3. Are you confident about your ability to
  improve your acoustic environment in
• order to hear better for example moving closer
  to the person speaking to you?
• Extremely Very Moderately
  Slightly Not at All
• 5 4 3
  2 1
• 4. Are you confident about your use of
  communication strategies to improve your ability
  to understand speech for example asking the
  speaker to talk slower, asking the speaker to
  rephrase, etc.?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1

110

• 5. Are you confident that you are able to tell
  where sounds are coming from (for example if more
  than one person is talking can you identify the
  location of the speaker?)
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 6. Are you confident that you are able to follow
  quickly-paced conversational material?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 7. Are you confident that you are able to focus
  on conversation when other distractions are
  present?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 8. Are you confident that you can understand the
  speaker in large rooms like an auditorium or
  house of worship?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1

111

• 9. Are you confident in your ability to
  understand unfamiliar speakers in a quiet room?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 10. Are you confident in your ability to
  understand unfamiliar speakers in a noisy
  environment?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 11. Are you confident that you can switch your
  attention back and forth between different
  speakers or sounds?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1
• 12. Are you confident that when communication
  breaks down (i.e. you are unable to follow the
  conversation), you would try to continue the
  interaction?
• Extremely Very Moderately Slightly
  Not at All
• 5 4 3
  2 1

112
CCT interpretation

• 50 Confident
• 40-50 Cautiously certain
• 30-39 Tentative
• Below 29 Insecure

113
Communication Needs Assessment

• COMBINED MEASURES

114
Performance Perceptual TestPPT

• Assesses the objective and subjective ability to
  understand speech in noise, permitting a direct
  comparison between measured and perceived ability
  to understand speech.
• Uses HINT, male speaker
• Takes about 10-12 minutes with interpretation
• Cost of test inexpensive if you have the HINT
  CD, expensive otherwise

115
Digital Signal Processing How good is the
evidence?

• Example 1
• Valente, Fabry, Potss, and Sandlin (1998).
  Comparing the performance of the Widex Senso
  digital hearing aid with analog hearing aids. J
  Am Acad Audiol 9 342-360

116
Valente, et al. (1998)

• 50 subjects at 2 sites
• previous non-digital users
• subjects/experimenters unblinded
• nonrandomized/uncontrolled
• objective (R-SPIN, HINT) and subjective (APHAB,
  preference questionnaire) outcome measures
• statistics well-described

117
Valente, et al. (1998)

• Results
• mean LP item score on the R-SPIN at 50 dB level
  was significantly better for Senso than subjects
  current instrument. Otherwise there was no
  difference
• no difference between instruments on HINT
• Senso scored better on EC and RV subscales of
  APHAB but not on BN or AV
• Ss preferred Senso on only 3 of 24 questions on
  preference questionnaire

118
Digital Signal Processing How good is the
evidence?

• Example 2
• Valente, Sweetow, Potts, and Bingea (1999).
  Digital versus analog signal processing Effect
  of directional microphone. J Am Acad Audiol 10
  133-150
• comparison of digital omni-directional vs.
  digital directional vs. analog omni-directional

119
Valente et al. (1999)

• 40 subjects at 2 sites
• previous hearing aid users
• subject/experimenters unblinded
• non-randomized/uncontrolled
• objective (R-SPIN) and subjective (preference
  questionnaire) outcome measures
• statistics well described

120
Valente et al. (1999)

• Results (objective outcome measures)
• digital directional performed better on R-SPIN
  than digital omni or analog instruments at -7 and
  0 dB SNR otherwise there was no significant
  differences among instruments
• there were no significant differences on R-SPIN
  between digital omni- and patients analog
  instrument

121
Valente, et al. (1999)

• Results (subjective outcome measure)
• Subjects preferred digital directional to digital
  omni or own hearing aid.
• There was no significant difference in preference
  between digital omni and subjects own hearing
  aid.

122
Digital Signal ProcessingHow good is the
evidence?

• Example 3
• Walden, Surr, Cord, Edwards, and Olson (2000).
  Comparison of benefits provided by different
  hearing aid technologies. J Am Acad Audiol 11
  540-560
• comparison of digital BTE instrument
  (omni-directional/directional/noise reduction)
  with linear instrument with input compression or
  2-channel WDRC

123
Walden et al. (2000)

• 40 subjects at one site
• experienced analog users with input compression
  or WDRC circuitry
• Subjects were partially blinded (did not know the
  differences among the 3 program settings on the
  digital instrument)
• test conditions were well described

124
Walden et al. (2000)

• Laboratory dependent measures (CST) and
  subjective field ratings (PHAB semantic
  differential scale at 3 programming
  configurations of digital instrument only) well
  described
• Procedures very well described as were the
  statistical analyses
• Confounding variables addressed

125
Walden et al. (2000)

• Results
• There was a small advantage for WDRC over input
  compression (WDRC did not need to be implemented
  digitally).
• Substantial performance advantage observed for
  directional microphones in noise but this
  advantage was reduced in everyday listening
  environments.

126
Walden et al. (2000)

• Result (cont.)
• In general, performance with the digital hearing
  aid was not significantly better than that of the
  subjects own aid, particularly those
  incorporating WDRC technology.

127
Efficacy of Digital Hearing Aids Proof or
Placebo

• With thanks to Ruth Bentler

128
Experiment I

• 20 subjects, two 4-week trial periods with
  DigiFocus Senso
• 10 Ss fit with DigiFocus first 10 with Senso
• Subjects given manufacturers promotional
  information

129
Experiment I

• Promotional information - both instruments
• like a personal computer on your ear
• high fidelity clean clear like the difference
  between an audio tape and CD
• extremely flexible can be adjusted to fit the
  individual
• provides comfortable listening/loudness

130
Experiment I

• Promotional information - DigiFocus
• makes 1 million calculations/decisions per second
• Promotional information - Senso
• samples 1 million times per second
• 100 parameters to adjust
• 40 million calculations per second

131
Experiment I

• Results
• some preferred the DigiFocus others the Senso
• slightly more than half preferred the Senso
• no statistically significant difference
• everyone liked Digital

132
Experiment II

• New cohort of 20 subjects
• same methodology as Experiment I except what
  subjects were told
• 10 subjects told they were receiving digital
  technology for the 1st 4-week trial 10 subjects
  were told they were receiving conventional
  technology
• for half of the subjects DigiFocus was labeled as
  digital and Senso was labeled as conventional
  - reversed for other half

133
Experiment II

• Subjects who received digital instrument were
  given manufacturers promotional information
• Subjects who received conventional instrument
  were only told it was conventional technology

134
Experiment II

• Results
• 18 of 18 subjects who completed experiment
  preferred the digital instrument regardless of
  whether it was the Senso or DigiFocus
• Subject comments
• everything is better! with the digital

135
Experiment III

• New cohort of 20 subjects
• subjects wore the identical instruments for both
  trial periods but the instruments were described
  differently for each
• during one trial period Ss were told the
  instruments contained the latest digital
  technology and provided with the manufacturers
  promotional material
• during the other trial period Ss were told the
  instruments contained conventional circuitry

136
Experiment III

• Results
• 17 of 20 subjects preferred digital
• 3 subjects could not detect difference
• Subject comments
• I could hear much better with the second
  digital set under a whole range of situations
• Youd have to go a long way to do better than
  the digitals

137
Experiment III

• Subject comments (cont.)
• and the clinician was just excellent and so
  believable
• Those non-digitals sounded like a low-budget
  movie (full professor/researcher in College of
  Dentistry)

138
Prefitting (cont.)

• Non-randomized study (N50)
• Unaided NU-6 in quiet No predictive relationship
  between the NU-6 and hearing aid outcome
• Unaided QuickSIN scores were compared to scores
  obtained on the International Outcome Inventory
  for Hearing Aids (IOI-HA), Satisfaction with
  Amplification in Daily Life (SADL), and Hearing
  Aid Usefulness Scale (HAUS).
• Unaided QuickSIN score and all measures of
  outcome were correlated.
• However, once the effects of aging are taken into
  consideration, there is no predictive
  relationship between unaided QuickSIN scores and
  hearing aid outcome. Walden and
  Walden (2004)

139

• Hearing
• Temporal processing
• Listening
• Segregation of multiple streams in auditory
  scenes
• Informational vs energetic masking
• Inhibition of irrelevant stimuli
• Comprehending
• listening ease/effort
• working memory measures
• Role of contextual support
• Communicating
• Social interaction vs information exchange goals
• Inter-dependencies with communication partners
• Non-stereotyping reinforcement of successful
  communication

Kiessling, et al, 2003
140
The problem is. hearing aids dont ..

• resolve impaired frequency resolution
• rectify impaired temporal processing
• undo maladaptive listening strategies
• properly reverse neural plastic effects
• correct for changes in cognitive function
• meet unrealistic expectations

141
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142
BKB-SIN and QuickSIN

• Instructions are similar
• Sentences are more predictive and less key words
• Patients typically have scores 5-7 dB better on
  the BKB-SIN

143
The ANL.

• Shown to be a strong predictor of hearing aid
  use, when unaided ANL scores are collected during
  the pre-fitting appointment (Nabelek, Tampas,
  Burchfeld, 2004).
• Unaided ANL scores predicted a patients success
  with hearing aids with 85 accuracy
• (Nabelek et al., 2006).

144
6 dB or less implies good candidate 10 dB or
worse implies poorer candidate. Success defined
as using hearing aids when needed. Regression
curve showing the predicted probability of
success with hearing aids as a function of
unaided ANL score (Adapted from Nabelek et al.,
2006).
145
Paired t test P value 0.1709 P
value 0.3389 P value summary ns
P value lt0.001 R squared 0.54 HHIE scores are
negatively correlated with CCT scores
146
Performance Perceptual Test

• Saunders and Cienkowski
• Saunders and Forsline

147
PPT

• Performance SRTN similar to HINT determines
  SNR at which listener understands 50 of material
• Perceptual SRTN tester alters SNR until subject
  reports that s/he can just understand everything
  that was said
• Performance-Perceptual Discrepancy (PPDIS)
  difference between the Performance SRTN and the
  Perceptual SRTN
• If Performance SRTN is better (more adverse SNR)
  than Perceptual SRTN, listeners are
  underestimating ability
• If Performance SRTN is poorer (less adverse SNR)
  than Perceptual, listeners are overestimating
  ability

148
Case Studies
149
Case 1

• Test results from standard battery
• Air conduction thresholds and speech testing
  results are unchanged from the last audiogram
• WHAT NEXT?

150
Case 1

• Additional tests for CNA
• HHIE
• CCT
• Results
• HHIE-S 22 (mild-moderate handicap)
• CCT 36 (slightly pessimistic)

151
Case 1

• Additional tests for CNA
• HHIE
• CCT
• QuickSIN (each ear)
• Results
• HHIE-S 22 (mild-moderate handicap)
• CCT 36 (tentative)
• QuickSIN 12 dB SNR loss (AD) 10 dB SNR loss
  (AS)

152
Case 1

• Additional tests for CNA
• HHIE
• CCT
• QuickSIN (each ear)
• Listening Span screener
• Results
• HHIE-S 22 (mild-moderate handicap)
• CCT 36 (tentative)
• QuickSIN 12 dB SNR loss (AD) 10 dB SNR loss
  (AS)
• Listening span screener normal
• 7 extra minutes

153
Case 1

• Interpretation
• Sentence recognition in noise not predicted by
  audiogram or WRS in quiet
• Individual Communication Enhancement Plan
• AT
• AR
• directional microphones
• ALD workshop

154
Case 2

• History
• 78 year old patient returns to clinic reporting
  that hearing aid is not working
• Daughter reports more difficulty communicating
  with patient
• Electroacoustic check reveals that hearing aid is
  functional
• Last hearing test 15 months ago
• No other significant history

155
Case 2

• Test results from standard battery
• Unchanged since last hearing test

WHAT NEXT?
156
Case 2

• Additional tests for CNA
• HHIE-S
• CCT
• Results
• HHIE-S 30 (severe handicap)
• CCT 24 (insecure)

157
Case 2

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear)
• Results
• HHIE-S 30 (severe handicap)
• CCT 24 (insecure)
• QuickSIN 15.5 dB SNR loss (each ears)

158
Case 2

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear)
• Listening Span
• Results
• HHIE-S 30 (severe handicap)
• CCT 24 (insecure)
• QuickSIN 15.5 dB SNR loss (each ears)
• Listening Span 2 (auditory memory affected)

159
Case 2

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear)
• Listening Span
• BKB-SIN
• Results
• HHIE-S 30 (severe handicap)
• CCT 24 (insecure)
• QuickSIN 15.5 dB SNR loss (each ears)
• Listening Span 2 (auditory memory affected)
• BKB SIN 6 dB SNR loss
• 15 extra minutes

160
Case 2

• Interpretation
• Sentence recognition in noise biased by memory
  issues
• Individual Communication Enhancement Plan
• Discuss findings with patient
• Counseling with patient and family
• Referral to memory and aging specialist
• Cognitive training
• AT/ AR
• Consider memory when fitting amplification
• (i.e. slow compression, written instructions)

161
Case 3

• History
• 82 year old patient seen in clinic for audiogram.
• First fit with high-end hearing aids 3 years ago,
  but returned the hearing aids reporting they
  made things worse.
• Spouse is frustrated and wants patient to try
  hearing aids again.
• Patient would like to communicate better, but
  disliked listening through hearing aids.
• No other significant history

162
Case 3

• Test results from standard battery
• Thresholds decreased slightly since last test AU
• Speech testing results essentially unchanged

WHAT NEXT?
163
Case 3

• Additional tests for CNA
• HHIE-S
• CCT
• Results
• HHIE-S 12 (mild handicap)
• CCT 46 (cautiously certain)

164
Case 3

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear, inserts)
• Results
• HHIE-S 12 (mild handicap)
• CCT 46 (cautiously certain)
• QuickSIN 3.5 dB SNR loss (AS) 9.5 dB SNR loss
  (AD)

165
Case 3

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear, inserts)
• DDT (performed after results of QuickSIN)
• Results
• HHIE-S 12 (mild handicap)
• CCT 46 (cautiously certain)
• QuickSIN 3.5 dB SNR loss (AS) 9.5 dB SNR loss
  (AD)
• DDT reveals binaural interference

166
Case 3

• Additional tests for CNA
• HHIE-S
• CCT
• QuickSIN (each ear, inserts)
• DDT (performed after results of QuickSIN)
• SAC and SOAC (spouse very involved)
• Results
• HHIE-S 12 (mild handicap)
• CCT 46 (cautiously certain)
• QuickSIN 3.5 dB SNR loss (AS) 9.5 dB SNR loss
  (AD)
• DDT reveals binaural interference
• SAC 20
• SOAC 39, severe
• 15 extra minutes

167
Case 3

• Interpretation
• Binaural interference not predicted by WRS in
  quiet or audiogram
• Patient somewhat in denial
• Individual Communication Enhancement Plan
• Counseling discuss ramifications modifying
  acoustic environment
• Recommend one hearing aid in noisy
  environment difficult listening situations
• Recommend AR class for patient spouse

168
Case 4

• History
• 48 year old patient reporting gradual change in
  hearing over last 4 years
• Positive history of noise exposure