EVOTION – Big Data Supporting Public Hearing Health Policies

The holistic management of hearing loss (HL) requires appropriate public health policies for HL prevention, early diagnosis, long-term treatment and rehabilitation; detection and prevention of cognitive decline; protection from noise; and socioeconomic inclusion of HL patients. However, currently the evidential basis for forming such policies is limited. Holistic HL management policies require the analysis of heterogeneous data, including Hearing Aid (HA) usage, noise episodes, audiological, physiological, cognitive, clinical and medication, personal, behavioural, life style, occupational and environmental data. To utilise these data in forming holistic HL management policies, EVOTION, a new European research and innovation project, aims to develop an integrated platform supporting: (a) the analysis of related datasets to enable the identification of causal and other effects amongst them using various forms of big data analytics, (b) policy decision making focusing on the selection of effective interventions related to the holistic management of HL, based on the outcomes of (a) and the formulation of related public health policies, and (c) the specification and monitoring of such policies in a sustainable manner. In this paper, we describe the EVOTION approach.

We’ve all had these conversations. A family member asks us, “What’s all this talk about hearing loss and dementia?” A patient comes to our clinic and says, “I heard if I get a hearing aid, I will not get dementia.” Perhaps they’ve seen a headline claiming that “hearing loss is a major risk factor for dementia” in The Washington Post1 or heard an interview on National Public Radio’s Weekend Edition Sunday explaining that hearing loss “actually affect(s) the brain’s structural integrity.” 2 Other major news outlets have run similar stories 3,4, leading many to wonder: has hearing loss already damaged my brain? Am I destined to develop dementia?www.shutterstock.com.We recently wrote an article that critiqued these media reports. Our article was published in a geriatrics journal. Given the favorable reader response we have chosen to share our thoughts with our community of hearing health care professionals. The primary point we wish to convey is that messages like “hearing loss is a risk factor for dementia” need to be changed. Not only is such messaging confusing, but such messages are also prone to stigmatize and worry people with hearing loss. We should add as well that most scientists agree that the evidence to date is unsettled. CONFUSION ABOUT RISK The message that hearing loss is “the largest potentially modifiable risk factor for dementia” comes from an epidemiologic analysis that appeared in The Lancet in 2017 and 2020. 5 The reports were primarily based on studies in which people with various degrees of hearing loss (but without cognitive impairment at the start of the study) were followed over several years. In each of the studies, people with greater hearing loss at the outset were more likely to perform poorly on cognitive tests over time. Their cognitive dysfunction was severe enough to be labeled “dementia” more often than the dysfunction found in people who did not have hearing loss at the outset. Based on the studies reviewed, a set of distinguished epidemiologists declared that hearing loss is a leading “risk factor” for dementia. But “risk” and “risk factor” have special meanings in epidemiology. Unlike in everyday English (where “risk” suggests a cause of something bad) epidemiologic risk is only about co-occurrence, or correlation. But as we all probably learned during our undergraduate or graduate studies, correlation is not causation. In other words, saying that hearing loss is a risk factor for dementia does not mean that hearing loss causes dementia. SCIENTIFIC UNCERTAINTY ABOUT THE UNDERLYING CAUSE It is important to realize that after many years of research there is very little known about the causes of Alzheimer’s disease (AD) and AD-related dementias (AD/ADRD). Given our general ignorance, it is not surprising that we lack a scientific understanding about whether and how hearing loss might be involved. Four possible explanations have been advanced. 6 The first points to the social isolation that accompanies hearing loss, because social isolation is also associated with dementia. The second emphasizes the excess cognitive load associated with poor hearing: the degraded speech signal requires greater listening effort, depleting the cognitive resources that would otherwise be used for other tasks. The third posits an unknown aging factor that damages both the brain and the peripheral ear. A final theory says that hearing loss directly triggers or somehow augments the brain degenerative changes that are seen in AD/ADRD, perhaps mediated by the temporal lobe atrophy that can accompany hearing loss. It is unknown whether one or more of these theories is correct, and this is likely to remain unclear for the foreseeable future. In other words, we don’t know what explains the hearing loss-dementia link. STIGMA The experience of stigma includes internalized shame and exclusion from the wider social world. 7 People with hearing loss face tremendous stigma 8: that is a key part of being reluctant to seek care or postponing care from a hearing health care professional. The fear of being “found out” also drives our patients’ preferences for “discreet” instruments. People with hearing loss are notably reluctant to seek assistance and accommodation (most people with hearing loss do not own hearing aids) and of course they are worried that people will treat them differently. Instead of seeking help, people feign understanding and choose to withdraw rather than struggle in social situations. People with dementia also face stigma, and the stereotypes are fierce. 9 People with dementia are often seen as incapable of making decisions, acting independently, or participating in community life. There is probably no more stigmatized common chronic condition. “Dementia worry” (fearful anticipation of a dementia diagnosis, whether that fear is warranted or not) is a source of anxiety among many adults. 10 Like hearing loss, dementia often goes undetected in primary care settings and undertreated. THE BIG MISUNDERSTANDING In our experience, when people are told that “hearing loss is the most common preventable risk factor for dementia,” they don’t understand “risk” in the epidemiologic sense. They jump to the natural, everyday language interpretation of risk that suggests that they have a high probability of developing dementia. And they are worried. Some are terrified. After reading our previously published piece, a friend with hearing loss wrote of her immense relief to learn that she was not doomed to develop dementia. She had understood the reports she’d seen in the press as saying that she would be “unlikely to be able to dodge the dementia bullet.” A shared public understanding that hearing loss foreshadows dementia would be devastating for people with hearing loss, who could be subject to greater discrimination in the workplace and social exclusion. For example, if you (mis)understood that hearing loss foreshadows dementia, would you hire an older person who wore hearing aids? Would you want your widowed mother to remarry someone who had difficulty hearing? WHY HEARING LOSS MIGHT BE ASSOCIATED WITH GREATER COGNITIVE DECLINE We know that better hearing can help people to think, remember, and learn. 11 But some people are unfortunately destined to develop dementia as they age. As that unfolds, those individuals will be more cognitively symptomatic if they also have difficulty hearing, because of the importance of hearing in thinking, remembering, and learning. The current randomized trials of hearing aids have been portrayed as tests of whether hearing loss causes dementia, or if hearing aids can prevent dementia. We think this is a mischaracterization. If those receiving hearing aids fare better cognitively in follow up, with more crossing the threshold that is labeled “dementia” over time, can we conclude that hearing loss causes dementia, or hearing aids prevent dementia? We don’t think so. An equally plausible explanation is that hearing aids can help manage cognitive disability for those who are destined to develop dementia for separate (neuropathologic) reasons. For people who are destined to develop dementia, hearing aids may improve audibility, may reduce listening effort and fatigue; and these are very important benefits, but benefits that are quite different from “preventing dementia.” LET’S CHOOSE A POSITIVE MESSAGE If members of the public understand that hearing loss or auditory processing difficulties are a prodrome for dementia, then several things could happen. Policymakers might work to improve access to hearing health care. Primary care clinicians might screen their patients for hearing loss. People might be more inclined to seek care. And that would be good! But we agree with one of our colleagues who wrote to us when he read our recent publication: “We became audiologists to help people with hearing loss find help. Not scare them into submission.” Better hearing offers tremendous benefits that we have all witnessed in our clinical work. But let’s not sell our devices as “dementia preventers,” in part because it’s not clear that’s what they actually are. In fact, they are much more: we’ve seen them help people to hear better, think better, and appreciate life more. When we talk about the cognitive benefits of hearing aids and cochlear implants, let’s give a positive message like, “Hearing better helps you to think better.” Let’s not be confusing, or stretch the facts. Let’s not stigmatize the hearing loss community. Better hearing is good for anyone, at any age. Let’s move toward a philosophy of positive messaging.

A likely consequence of sensorineural hearing loss is a diminished ability to understand speech in noisy backgrounds. Indeed, the inability to hear in noise is one of the main reasons for dissatisfaction with hearing aid use.1 Although hearing aids with a directional microphone provide substantial improvement in the ability of wearers to understand speech in noisy environments,2 space requirements and the uncertainty of directional characteristics when a directional hearing aid is inserted deeply into the ear canal prevent the implementation of such technology in the smallest completely-in-the-canal (CIC) hearing aids. A patient who insists on wearing CIC hearing aids will have to rely solely on the efficacy of single-mic noise-management strategies. Currently, most commercial “noise reduction” schemes use the modulation rates of the input signal as a basis for estimating the “speech” and “noise” nature of the input. “Speech” sounds are amplified with input-dependent gain, while “noise” sounds are typically amplified at a reduced gain level beyond input-dependent levels (see Chung, 20043). The exact amount of gain reduction and its time course vary greatly among manufacturers. Despite such differences, most studies have reported only an improvement in listening comfort by use of such a scheme.4 The improvement in listening comfort is noteworthy. It suggests that hearing-impaired persons whose hearing aids have noise reduction may be less affected by high-output sound pressure levels, less stressed, and less distracted in noisy situations, and may be more likely to attend to the sound sources and wear their hearing aids longer than if they lacked this feature. Wearers may also improve their participation in daily activities and their quality of life. It is possible that the reduction in stress level (or distractions) may improve the user’s speech understanding in some noisy environments.

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Lessons from LOCHI.

You have accessThe ASHA LeaderFeature1 Feb 2012The American Hearing Loss Epidemic: Few of 46 Million With Hearing Loss Seek Treatment Anne OylerAuD, CCC-A Anne Oyler Google Scholar , AuD, CCC-A https://doi.org/10.1044/leader.FTR4.17022012.5 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Hearing loss is the third most prevalent chronic health condition facing older adults (Collins, 1997). But the treatment gap is significant: Only 20% of people who might benefit from treatment actually seek help. Most tend to delay treatment until they cannot communicate in even the best of listening situations. On average, hearing aid users wait more than 10 years after their initial diagnosis to be fit with their first set of hearing aids (Davis, 2007). And the incidence of hearing loss only increases with age—approximately one-third of Americans between ages 65 and 74 and nearly half of those older than 75 have hearing loss (National Institute on Deafness and Other Communication Disorders, 2011). With the population of individuals older than 65 expected to double between 2008 and 2030 to a projected 72.1 million (U.S. Administration on Aging, 2011), audiologists are poised to close the treatment gap. Early and careful evaluation and treatment show great promise in lessening the negative impact of hearing loss on clients' long-term health and quality of life. A Slow Decline Audiologists typically aren't surprised to hear that a spouse or significant other has been frustrated by hearing loss long before the affected individual acknowledges it. The insidious nature of age-related hearing loss—or presbycusis—allows many adults to ignore their hearing loss for years or even decades. One of the first signs of hearing loss often is an inability to hear and understand speech in noisy environments, but communication in all situations is hindered as the condition progresses. Gagné (2011), in explaining why individuals delay seeking hearing health services, eloquently describes the phenomenon of stigma: "In order to live well with hearing loss, one must recognize and accept hearing loss. Specifically, many people must overcome the misplaced shame and poor self-esteem that they may experience." A number of factors contribute to hearing loss in adults, including age, genetics, noise exposure, and chronic disease (e.g., diabetes, chronic kidney disease, and heart disease). Presbycusis advances gradually over time, affects both ears equally, and begins in the high frequencies before spreading to the lower. Because of this slow progression, many adults with presbycusis don't readily acknowledge their hearing loss, instead considering it a normal sign of aging. Not Just Decibels The impact of hearing loss is measured not only in decibels. Hearing loss is an individual experience—how a person copes depends on a great many factors, including early vs. late onset, progressive or sudden loss, the severity of the loss, and communication demands and personality (Kaland & Salvator, 2002). Regardless of the combination of these presenting factors, hearing loss has been linked to feelings of depression, anxiety, frustration, social isolation, and fatigue. Several studies have documented the impact of untreated hearing loss. An oft-cited survey was commissioned by the National Council on Aging in 1999 (Kochkin & Rogin, 2000). This nationwide survey of nearly 4,000 adults with hearing loss and their significant others showed significantly higher rates of depression, anxiety, and other psychosocial disorders in individuals with hearing loss who did not wear hearing aids. The survey examined the positive benefits of amplification and showed that hearing aid use positively affected quality of life for both the hearing aid wearers and their significant others. These findings were consistent with those of a large, randomized control study that found hearing loss to be associated with increased depression and decreased social/emotional, communicative, and cognitive functions for participants who were unaided as compared to those who received hearing aids. These conditions improved after hearing aids were fit (Mulrow, 1990). More recently, Frank Lin and colleagues (2011)at Johns Hopkins found a strong link between degree of hearing loss and risk of developing dementia. Individuals with mild hearing loss were twice as likely to develop dementia as those with normal hearing, those with moderate hearing loss were three times more likely, and those with severe hearing loss had five times the risk. This study could not definitively conclude that early treatment with hearing aids would reduce the risk of dementia, but there was a positive correlation between degree of hearing loss and risk of dementia. Hearing loss is an invisible handicap. Despite its increasing prevalence with age, hearing loss is often ignored during the diagnosis and treatment of cognitive and memory disorders in elderly patients (Chartrand, 2005). The comorbidity of hearing loss and cognitive disorders makes it even more important to determine hearing status prior to any diagnostic protocol. This determination would undoubtedly lead to more appropriate diagnoses and treatment and thus likely to result in better outcomes for individuals with cognitive impairments. Closing the Treatment Gap The impact of untreated hearing loss cannot be ignored. Educating consumers about the importance of seeking early treatment for themselves and their loved ones should be part of the equation. But with the U.S. population aging so rapidly, a health care system that recognizes the importance of early identification and treatment is also critical. Healthy People 2020—a government-sponsored, 10-year agenda for improving the nation's health—outlines several goals related to improving hearing health outcomes for adults. Specifically, Healthy People 2020 calls for an increase in the number of adults older than 70 who use hearing aids and hearing assistive technology, as well as in the number of adults ages 20–70 who have had a hearing evaluation in the past five years (U.S. Department of Health and Human Services, 2010). The fitting of hearing aids should be part of a larger treatment program that includes the person with hearing loss and his or her significant others. Research has shown improved quality of life and overall satisfaction when significant others receive support and education on hearing loss and communication strategies (Kramer, 2005). Group and individual audiologic rehabilitation programs tailored to the individual's communication needs have been shown to encourage feelings of acceptance and confidence that lead to earlier acceptance and improved benefits from carefully fit technology (Chisolm et al., 2004). Holistic rehabilitation approaches that take into consideration other age-related changes such as vision impairment, cognitive decline, and manual dexterity are needed to meet the needs of our growing elder population (Saunders, 2011). Ongoing research and advocacy on the efficacy of early identification and management of hearing loss may encourage better funding for hearing aids, as well as for important audiologic rehabilitation services. Before that change takes place, audiologists can help close the treatment gap. To increase the number of individuals who ultimately benefit from early management, we need to change commonly held perceptions of hearing loss. Audiologists who fit hearing aids must implement audiologic rehabilitation as part of their patient's plan of care, and ensure that individuals who ultimately seek hearing services are treated in a holistic, evidence-based manner that takes their psychosocial, physical, and communication needs into consideration. This article was adapted from "Untreated Hearing Loss in Adults: A Growing National Epidemic," which appeared in the Feb. 2 issue of ASHA Access Audiology. Read the original essay at Access Audiology. Tips for Achieving Better Audiology Outcomes Three dispensing audiologists supplied their tips for achieving optimal relationships with clients and therefore better client outcomes. Although especially relevant for older clients, these suggestions work well with all clients. Frank "Mac" Butts, PhD, CCC-A Hearing Clinics of Virginia Richmond, Virginia Your evaluation should be sufficient to convince yourself of the correctness of your recommendation. Do not confuse empowerment with enabling. Empowering a client to take responsibility for his or her rehabilitation is not the same as giving a modest recommendation and then allowing the client to continue resisting change. The medical model—in which the client brings symptoms that you treat—will not succeed in a private audiology practice. Automation will replace your technical skills. The ability to inspire, motivate, and change people's lives will never be replaceable. Your value as a clinician can be improved exponentially by your understanding of auditory processing in adults and by your ability to evaluate and treat auditory processing disorders. Hearing aids are remarkably better than just a few years ago, but trying to impress the client with technical features undermines your real value to them. We miss the opportunity to help many more people with hearing loss by treating it as an acute condition corrected by a hearing aid instead of a chronic disease managed by amplification and aural rehabilitation. Validation will save you time and frustration when the client starts demanding changes in the search for an unrealistic result. I have never observed an audiologist who could not have improved his or her listening skills. An outcome measure that reveals the impact of the hearing loss is helpful to the clinician, client, and significant others in that person's life. Louis R. Sieminski, PhD, CCC-A The Hearing Center Kingston, Pennsylvania How an elderly client and his or her loved ones are greeted by office staff—and especially the audiologist—is critical. The first few minutes can set the stage for successful outcomes. Older adults—indeed, all clients—should be treated with kindness, respect, and competence. The older adult must immediately feel liked and respected. If clients like and trust you, you will be successful. Trust is vitally important when trying to help someone. Never underestimate the power of a smile and good manners, especially with older adults. Kent E. Weaver, AuD, CCC-A Woodard Hearing Centers Des Moines, Iowa Be genuinely curious about the client as a person. What is the client's perspective on good communication, interaction, and hearing? Find out what the client values. What does the person expect and want, and in what order? Help clients define their goals. Then ask yourself, "What do I have available to help meet their needs?" Get to the demonstration! Demonstrate the benefits of using hearing aids in varied listening situations, as opposed to having no hearing aids. Let clients know you will do everything you can to help them reach their goals through technology and your knowledge. But tell them that treatment is a two-way street, that they must also make an effort. Overcome fear. Defuse uncertainty. Erase doubt. Sources Administration on Aging (2011). Aging statistics. Retrieved from http://www.aoa.gov/aoaroot/aging_statistics/index.aspx. Google Scholar Chartrand M. S.Undiagnosed pre-existing hearing loss in Alzheimer's disease patients.Audiology Online. Retrieved from http://www.audiologyonline.com/articles/article_detail.asp?article_id=1444. Google Scholar Chisolm T. H., Abrams H. B., & McArdle R. (2004). Short- and long-term outcomes of adult audiological rehabilitation.Ear and Hearing, 25(5), 464–477. CrossrefMedlineGoogle Scholar Collins J. G. (1997). Prevalence of selected chronic conditions: United States 1990–1992. National Center for Health Statistics.Vital Health Statistics, 10, 194. Google Scholar Davis A., Smith P., Ferguson M., Stephens D., & Gianopoulos I. (2007). Acceptability, benefit, and costs of early screening for hearing disability: A study of potential screening tests and models.Health Technology Assessment, 11, 1–294. CrossrefGoogle Scholar Gagné J-P, Southall K., & Jennings M. B. (2011). Stigma and self-stigma associated with acquired hearing loss in adults.Hearing Review, 18(8), 16–22. Google Scholar Kaland M., & Salvatore K. (2002). The psychology of hearing loss.The ASHA Leader, 7(5), 4–5, 14–15. Google Scholar Kochkin S., & Rogin C. M. A. (2000). Quantifying the obvious: The impact of hearing instruments on quality of life.The Hearing Review, 7(1), 8–34. Google Scholar Kramer S. E., Allessie G. H., Dondorp A. W., Zekveld A. A., & Kapteyn T. S. (2005). A home education program for older adults with hearing impairment and their significant others: a randomized trial evaluating short- and long-term effects.International Journal of Audiology, 44(5), 255–264. CrossrefGoogle Scholar Lin F. R., Metter E. J., O'Brien R.J., Resnick S.M., Zonderman A.B., & Ferrucci L. (2011). Hearing loss and incident dementia.Archives of Neurology, 68, 214–220. CrossrefGoogle Scholar Mulrow C. D., Aguilar C., Endicott J. E., Tuley M. R., Velez R., Charlip W.S., Rhodes M. C., Hill J. A., & DeNino L. A. (1990). Quality-of-life changes and hearing impairment: A randomized trial.Annals of Internal Medicine, 113(3), 188–194. CrossrefGoogle Scholar National Institute on Deafness and Other Communication Disorders. (n.d.). Quick statistics. Retrieved from http://www.nidcd.nih.gov/health/statistics/Pages/quick.aspx. Google Scholar Saunders G. H., & Echt K. (2011). Dual sensory impairment in an aging population.The ASHA Leader, 16(3), 5–7. LinkGoogle Scholar U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020. Washington, DC: Author. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Google Scholar Author Notes Anne Oyler, AuD, CCC-A, associate director of audiology professional practices, can be reached at [email protected]. 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The implementation of universal newborn hearing screening programs has increased the number of infants diagnosed with hearing loss and referred for amplification in the first few weeks of life. There is compelling evidence that children born with hearing loss who have been identified and begun intervention by 6 months of age will have significantly better language development than their later-identified peers. 1-3 The challenges of fitting appropriate amplification on this population include limited behavioral response to sound, possible complicating middle ear fluid, parental uncertainties, possible existence of additional handicaps, and limited resources to support and pay for hearing aids. Despite these issues, there is consensus that the diagnosis of congenital hearing loss should be completed in the first 3 months of life and be followed immediately with the consideration of hearing aid use. 4 As access to follow-up from newborn hearing screening improves, pediatric audiologists are faced with recommending technology for infants during their early weeks of life. The options available to them are expanding rapidly as amplification technology grows and diversifies. Outcome studies of children fitted with advanced amplification features are not common and cannot keep up with the features being introduced to the market. Most infants are fitted with the goal of providing audibility for environmental speech to enhance speech and language development and with the expectation that patients will use their hearing aids daily. The pediatric audiologist’s role is to share information on hearing loss and available amplification technology with the parents and their medical and support team. Parents depend on various professionals to acquire the information and tools they need to become empowered, informed consumers. Reaching decisions about the choice of technology for an infant includes examining available features and selecting what might be the best fit for the infant given all the available information and circumstances.

Background: Patients with age-related sensorineural hearing loss (HL) may benefit from auditory input amplification by using hearing aids (HAs). However, the impact of both HL- and HA-based rehabilitation on central auditory functional connectivity (FC) is not clear. Methodology: Sixty-two HL (22 females, aged 64.4 ± 7.6 years, pure-tone average 50.9 ± 14.7 dB right ear, 50.7 ± 12.9 dB left ear) and 32 normal hearing (NH) subjects (22 females, aged 59.3 ± 7.3 years) were examined in a 3T magnetic resonance imaging (MRI) study. HL patients were analyzed cross-sectionally at baseline (vs. NH subjects) and longitudinally at 6-month follow-up. Between the 2 scans, 31/62 patients used the HA 9.5 ± 3.8 h a day. Arterial spin labeling and blood oxygen level-dependent resting-state functional MRI were performed to measure regional perfusion in the primary auditory cortex and, from here to the whole brain, seed-based FC was performed. Before each scan, HL patients underwent audiological and neurological assessments. Results: At baseline, the HL condition was associated with regional hypoperfusion in right Heschl's gyrus (seed) and negative seed-based FC (anticorrelation) in posterior brain regions. Long-range FC in the precuneus correlated negatively with pure-tone and speech reception average thresholds. At 6-month follow-up, HA usage was associated with seed-based FC increase in the right superior frontal gyrus (SFG) and seed-based FC reduction in the right middle temporal gyrus. Long-range FC changes in the SFG correlated positively with executive function improvements. Conclusions: These findings suggest that HA-based rehabilitation may not reverse HL-related neural effects and yet carry neurological benefits by retuning long-range FC of the auditory system. Impact statement Age-related sensorineural hearing loss (HL) affects 40% to 60% of the worldwide population and a common, viable rehabilitation strategy is to provide auditory input amplification through hearing aids (HAs). By targeting metabolically depressed, auditory cortical centers, our work reveals a possible neural link between peripheral and central vulnerability in HL patients in the form of aberrant, long-range, functional connectivity effects. Similarly, we unveil how wearing HAs for 6 months may induce neuroplastic changes that positively correlate with improved neuropsychological performances.

Hearing loss causes numerous functional deficits. However, few studies have been conducted to assess the association between hearing loss and physical inactivity. This study aimed to evaluate the physical activity and sedentary behavior of hearing loss patients and their relation with the use of hearing aids. We extracted participants over 60 years of age with information on hearing status and physical activities from the eighth Korea National Health and Nutritional Examination Survey conducted from 2019 to 2020. We classified them into four groups: a normal hearing group (≤25 dB), a mild hearing loss group (>25 dB and ≤40 dB), a moderate hearing loss group (>40 dB and ≤50 dB), and a non-serviceable hearing group (>50 dB). Additionally, we extracted hearing aid users with hearing levels exceeding 50 dB. After adjusting other factors, the non-serviceable hearing group walked less frequently than the moderate (p = 0.004) and mild hearing loss group (p < 0.001) and walked less and sat more than the normal hearing group (walking frequency: p < 0.001; walking time: p = 0.020; and sitting time: p = 0.034). Also, the hearing aid users walked more frequently (p = 0.003) and for longer (p = 0.045) than the non-serviceable hearing group. Hearing loss is associated with reduced walking and a sedentary lifestyle. The use of hearing aids is associated with improved physical activity. Appropriate interventions, including hearing aids, should be provided to hearing loss patients. 3 (individual cross-sectional study) Laryngoscope, 134:5109-5115, 2024.

BackgroundTo the best of our knowledge, no empirically based consensus has been reached as to if, and to what extent, persons with hearing loss (HL) have reduced generic Quality of life (QoL). There seems to be limited knowledge regarding to what extent a hearing aid (HA) would improve QoL. The main aim of the present study was to review studies about the relationship between HL and QoL. A supporting aim was to study the association between distress and HL.MethodsLiterature databases (Cinahl, Pub Med and Web of Science) were searched to identify relevant journal articles published in the period from January 2000 to March 17, 2016. We performed a primary search pertaining to the relationship between HL, HA and QoL (search number one) followed by a supporting search pertaining to the relationship between distress/mood/anxiety and HL (search number two). After checking for duplications and screening the titles of the papers, we read the abstracts of the remaining papers. The most relevant papers were read thoroughly, leaving us with the journal articles that met the inclusion criteria.ResultsTwenty journal articles were included in the present review: 13 were found in the primary search (HL and QoL), and seven in the supporting search (HL and distress). The literature yields equivocal findings regarding the association between generic QoL and HL. A strong association between distress and HL was shown, where distressed persons tend to have a lowered generic QoL. It is suggested that QoL is lowered among HL patients. Some studies suggest an increased generic QoL following the use of HA, especially during the first few months after initiation of treatment. Other studies suggest that HA use is one of several possible factors that contribute to improve generic QoL.ConclusionsThe majority of the studies suggest that HL is associated with reduced generic QoL. Using hearing aids seem to improve general QoL at follow-up within the first year. HL is a risk factor for distress. Further research is needed to explore the relationship between HL and generic QoL, in addition to the importance of influencing variables on this relationship.

You have accessThe ASHA LeaderFeature1 Mar 2005Aural Habilitation Update: The Role of Speech Production Skills of Infants and Children With Hearing Loss Sheila R. Pratt Sheila R. Pratt Google Scholar More articles by this author https://doi.org/10.1044/leader.FTR2.10042005.8 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In It is well known that the development of speech is extremely limited without adequate auditory input and feedback. An obvious example is that hearing loss in infancy and early childhood usually affects all as pects of speech production unless there is early and consistent use of sensory aids as well as substantive sensorimotor and linguistic training. The speech development of infants and children with hearing loss hinges on their abilities to use audition not only to learn the sounds of their language, but also to use their articulators to produce those sounds and make use of auditory feedback to refine their speech over time. As such, the speech of children with prelingual hearing loss is particularly susceptible to delay and disorder, es pecially if the severity of the hearing loss is substantial and intervention is delayed or inadequate. Speech Development During the first six months of life (and possibly in utero) auditory perceptual learning is vital for acquiring oral language and speech, although the maturation timeline for the speech production in normal-hearing children is relatively lengthy. This protracted timeline may account for the long-term training and treatment needs of many children with hearing loss, even those identified and fitted early with sensory aids (Yoshinaga-Itano & Sedey, 2000). Young children with normal hearing typically begin babbling around 5–6 months of age and start verbal expression around 12 months of age. However, their speech production skills continue to be refined through the school-age years and well beyond when their basic phonological inventories have been established. For example, vowel space, voice-onset times, and vocal control adjust throughout early childhood (Assmann & Katz, 2000; Koenig, 2001; Lee, Pontamianos, & Naray anan, 1999). Furthermore, substantial acoustic variability is a hallmark of children’s speech production until late childhood. Although the research is somewhat mixed on the development of coarticulation, children appear to be less able than adults to coarticulate their speech gestures in a consistent manner, and as a consequence, their speech is less intelligible than that of adults (Katz, Kripke, & Tallal, 1991; Nittrouer, 1993). The refinement of auditory processing of speech has a similar developmental timeline. Child ren may apply different rules or weights to speech cues than adults, and these weights change throughout childhood (Nittrouer, 2003; Nit trouer, Crowther, & Miller, 1998). Their auditory processing of speech also appears to be more susceptible to acoustic and linguistic perturbations than is observed with adults. Children are more adversely affected than adults by background noise, reverberation, talker variability, re ductions in signal bandwidth, and the number of signal channels (Eisenberg et al., 2000; Ryalls & Pisoni, 1997; Kortekaas & Stelmachowicz, 2000). The Role of Audition in Speech Development and Production For mature speakers, audition acts as an error detector and a means of monitoring speaking conditions. It is considered to be slower than other forms of sensory information (i.e., proprioception) generated during speech, and therefore is likely limited to a feedback role (Perkell et al., 1997). Speakers use audition to determine if their articulators have produced sounds that are acoustically off-target. Audition also provides information for corrective adjustments, and as a consequence, is a contributor to the maintenance of speech integrity. Studies of frequency and spectrally shifted speech feedback have shown that adults rapidly adjust to minor acoustic perturbations with compensatory and/or matching strategies (Bauer & Larson, 2003; Houde & Jordan, 2002; Jones & Munhall, 2002, 2003). They appear to adjust their articulators so that their speech productions match their internal representations. In addition to acting as an error detector, hearing is used by mature speakers to determine how they should adjust their speech in various acoustic, linguistic, and social environments. For example, adults know when to speak slower, louder, softer, or more precisely in order to accommodate their listener or the environmental conditions (Perkell et al., 1997). In contrast, many young children are unable to adjust the clarity of their speech, even when explicitly directed to do so (Ide-Helvie et al., 2004). Audition also allows the development of articulatory organization by providing information about how to position, move, and coordinate the articulators for speech, movements that can differ from those associated with vegetative functions of the mechanisms (Moore & Ruark, 1996). For ex ample, infants use audition to learn how to shift from a vegetative breathing pattern to a pattern that can support speech. They learn how to position and move their tongues and to judge the acoustic consequences of those gestures. Coord ination of the larynx with the vocal tract and upper airway articulators is refined over years but requires an intact auditory system (Koenig, 2001; Tye-Murray, 1992). The lip and jaw movements associated with speech in infants and young children are highly variable but distinct from sucking, chewing, and smiling (Green et al., 2000; Green, Moore, & Reilly, 2002; Moore & Ruark, 1996). The implication is that although the same peripheral mechanisms are used across oral and respiratory functions, the differing goals require substantially distinct coordination and feedback efforts. The coordination needed to chew and swallow efficiently develops over early childhood but is largely independent of hearing, whereas the coordination required to move between vowel and consonant gestures, particularly in a coordinated and coarticulated manner, is strongly influenced by hearing (Baum & Waldstein, 1991; Guenther, 1995; Tye-Murray, 1992; Waldstein & Baum, 1991). Audition has a primary sensorimotor role in the development of speech, but it also is fundamental to infants and young children learning the sounds of their language. Furthermore, it helps them learn how specific speech events relate to their phonology, so that with development, young children become more able to use their hearing to inform them about the sequencing of speech gestures and the correctness of subsequent productions. Over time children learn to use audition to monitor ongoing speech, detect errors, and make corrective adjustments. Hearing Loss and Speech Production Hearing loss is common in the general population but its effects on speech production are most pronounced with individuals whose hearing loss is congenital or acquired in early childhood. Most adults who acquire their hearing losses later in life suffer little or no deterioration in intelligibility, likely because their residual hearing provides sufficient feedback since their mature speech production systems rely more on orosensory than auditory information to maintain proper control (Guenther, 1995; Goehl & Kaufman, 1984; Perkell et al., 1997). The speech differences that they do exhibit are subtle and usually imperceptible, even in cases of complete or nearly complete adventitious hearing loss. Nonetheless, some adventitiously deafened adults exhibit reduced speaking rate, and compromised articulatory and phonatory precision (Kishon-Rabin et al., 1999; Lane & Webster, 1991; Lane et al., 1995; Leder et al., 1987; Waldstein, 1990; Perkell et al., 1992). These speech differences are similar in nature, but not in severity, to those observed with prelingually deafened speakers. Most infants and young children with hearing loss demonstrate disordered phonation and articulation, as well as delays in the acquisition of sound categories. The entire speech production system can be affected, from respiratory support to the coarticulation of ongoing speech (Pratt & Tye-Murray, 1997). This is especially true if the hearing loss is identified late or after a period of protracted hearing loss. Furthermore, the overlap and interaction of disordered sound production and linguistic delay contribute to poor speech integrity and restricted speech development. Babbling generally does not appear before 12 months of age (Oller & Eilers, 1988; Oller et al., 1985) and canonical babbling has been observed as late as 31 months in this population (Lynch, Oller, & Steffens, 1989). Infants also produce fewer instances of canonical babble and include a more limited range of consonants in their babble (Stoel-Gammon, 1988; Stoel-Gammon & Otomo, 1986; Wallace, Menn, & Yoshinaga-Itano, 2000). However, later speech intelligibility is better predicted by the consonant inventory used in emerging spoken language during the second year of life than during babble (Obenchain, Menn, & Yoshinaga-Itano, 2000). The phonetic repertoires of infants with severe-to-profound hearing loss often are restricted when compared to their normal-hearing peers, although there is abundant individual variability (Lach, Ling, Ling & Ship, 1970; Stoel-Gammon & Otomo, 1986; Wallace et al., 2000; Yoshinaga-Itano & Sedey, 2000). The early speech inventories of infants with severe-to-profound hearing loss predominately consist of motorically easy sounds such as vowels and bilabial consonants. The sounds of their inventories also contain more low frequency information, which is more audible. For example, the babbling of infants with hearing loss often has a high concentration of nasals and glides, which include low-frequency continuant cues (Stoel-Gammon & Otomo, 1986). Without early intervention and appropriate fitting of sensory aids the speech-sound inventories of many children with hearing loss usually do not attain full maturity. Yoshinaga-Itano and Sedey (2000) found that children with moderate-to-severe hearing losses did not reach an age-appropriate complement of vowel and consonant sounds until about 4 and 5 years respectively, and many children with profound hearing loss had restricted inventories even at 5 years of age. Children with profound hearing loss often reach an early plateau in their speech skill development. For instance, the speech characteristics of many children with severe-to-profound hearing loss demonstrate little improvement in sound inventory and intelligibility after 8 years of age, even with the initiation of extensive training (Hudgins & Number, 1942, McGarr, 1987; Smith, 1975). Such results imply that, like auditory and language interventions, speech production therapy should be an important component of early intervention, and that the common practice of delaying speech training in children with hearing loss until they have functional language is developmentally untenable if the goal is for them to be oral communicators. In addition to the relationship between age-of-onset and speech impairment severity, there also is a moderately positive relationship between the severity of hearing loss and the extent of the associated speech difficulties (Boothroyd, 1969; Levitt, 1987; Smith, 1975). For example, children with mild-to-moderate hearing loss, particularly if well aided, tend to exhibit speech differences that are mild (Elfenbein, Hardin-Jones, & Davis, 1994; Oller & Kelly, 1974; West & Weber, 1973). Elfenbein and colleagues found that children with mild-to-moderate hearing loss exhibit good intelligibility but had higher than normal rates of affricate and fricative substitutions. Mild hoarseness and resonance problems also are present in 20% to 30% of this group of children. Moreover, they tend to have increased rates of voicing irregularities, difficulties with /r/ production, and omissions of back and word-final consonants. Early studies of children with profound prelingual hearing loss showed that most rarely acquired speech skills sufficient to interact easily using spoken language. On average, less than 20% of their words were intelligible to listeners who were not familiar with their speech (Hidgins & Numbers 1942; Markides, 1970; Smith, 1975). Smith (1975) evaluated 40 children with varying levels of hearing loss and, on average, only 18.7% (0% to 76%) of their words could be identified by inexperienced listeners. As expected, overall intelligibility was inversely related to the frequency of segmental and suprasegmental errors. However, with early identification of hearing loss and early intervention (i.e., fitting of sensory devices, behavioral training, and parent counseling), the numbers of children with severe-to-profound hearing loss and intelligible speech has increased (Uchanski & Geers, 2003). Many more children are developing sufficient speech perception to support development of speech production and oral language, but these advances may have added to the overall heterogeneity of the population (Higgins et al., 2003). Other factors contribute to the diversity of speech production skills observed with these children. For instance, cognitive skill (particularly nonverbal intelligence) has been found to be an important predictor of functional speech and oral language in children with hearing loss (Geers et al., 2002; Tobey et al., 2003). Auditory experience in infancy and early childhood, even of limited duration, positively influences the speech production skills of children who have severe-to-profound hearing loss (Geers, 2004). The use of sensory aids has a substantial impact on speech outcomes, but somewhat surprisingly, the age at which infants and young children are fitted with cochlear implants has not surfaced in studies of speech production as a significant predictor of later speech intelligibility (Geers et al., 2002; Tobey et al., 2003). Early implantation (less than 2 years) is, however, related to more normal oral communication development as a whole (both speech and oral language) (Geers, 2004). It may be that the age of implantation is not easily separated from other influences of intervention, like the orientation of the habilitation program and parent involvement, which relate strongly to children being auditory perceptual learners and users of auditory feedback. Another consideration is that many early-implanted children may be implanted too late to observe a clear impact on speech production. The critical ages at which hearing aids should be fitted has not been investigated, but like cochlear implants, it is assumed that earlier is better. The oromotor integrity and language skills are additional factors that often are neglected in studies of speech development in children with hearing loss. A substantial number of infants and children with hearing loss present with secondary handicapping conditions, such as neurological disorders. When these neurological disorders include the speech mechanism, the development of functional speech is difficult even if audition is optimized. As such, is it not unusual for a child with hearing loss to have a coexisting dysarthria along with the speech impairment secondary to the hearing loss. A subset of children with hearing loss also may have an apraxia of speech, but separating the impact of hearing loss from an apraxia of speech is difficult because the associated speech characteristics overlap (McNeil, Robin & Schmidt, 1997). Language disorders also are commonly observed in children with hearing loss, and are frequently evidenced in phonological disorder and lexical delay. As a result, extricating the sensorimotor impact of hearing loss on speech production from the influences of language disorder in individual children is not always straightforward (Peng et al., 2004). Habilitation: Sensory Aids and Treatment Most speech training approaches are dependent on optimizing the use of residual hearing although some approaches use other modalities (Pratt, Heintzelman, & Deming, 1993; Pratt & Tye-Murray, 1997). Correspondingly, it is generally believed that speech is learned most easily if infants and children learn and monitor their speech through their auditory systems. Therefore, the proper and early fitting, and consistent use of sensory aids, along with auditory and language training are important components of speech production training. In support of this auditory-based approach is the relationship between the severity of prelingual hearing loss and the extent of speech delay/disorder found in children (Boothroyd, 1969; Levitt, 1987; Smith, 1975), as well as any history of previous hearing (Geers, 2004). The relationship between audiometric configuration and speech intelligibility also argues for the importance of audition if the goal for a child is oral communication (Levitt, 1987; Osberger, Maso, & Sam, 1993). There is a growing literature supporting the positive impact of cochlear implants on speech development, as well as the role that auditory-oral-based training programs play in communication outcomes of children fitted with cochlear implants (Geers et al., 2002; Tobey et al., 2003). There is, however, limited efficacy data for children with less severe hearing loss who are typically fitted with hearing aids. The lack of research in this area is glaring because wearable electroacoustic hearing aids have been available for more than 50 years (Lybarger, 1988) and are a fundamental component of treatment approaches for most children with hearing loss. Furthermore, more infants and children are fitted with hearing aids than cochlear implants. Preliminary data reported by Stemachowicz and her colleagues (2004) on three infants fitted early with hearing aids suggested delays in sound category acquisition consistent with patterns previously reported in the literature. Sound inventories were impoverished, consonants were more affected than vowels, and sound containing high-frequency cues were particularly limited. Additional data by Pittman and colleagues (2003) observed that the amplitude of high-frequency speech cues directed to and produced by children wearing hearing aids may not be sufficient, although they did not connect their results directly to speech production outcomes. Pratt, Grayhack, Palmer, and Sabo (2003) found that differences in hearing aid configuration could alter vowel spacing of children even though the children in their study had intelligible speech, and the speech tokens measured were limited to acceptable productions. Their data indicated that hearing aids could alter the speech of children, but provided little information about the impact that hearing aids may have on speech development. Given the paucity of data-as well as the expansion of universal infant hearing screening programs-it is critical that more research be done in this area. Increasing numbers of infants with hearing loss will be identified shortly after birth and, if we are to effectively treat them, more should be known about the impact that hearing aids and other sensory aids have on speech and auditory system development. Aural Habilitation References Assmann P. F., & Katz W. F. (2000). Time-varying spectral change in the vowels of children and adults.Journal of the Acoustic Society of America, 108, 1856–1866. CrossrefGoogle Scholar Baum S., & Waldstein R. (1991). Perseveratory coarticulation in the speech of profoundly hearing-impaired and normally hearing children.Journal of Speech and Hearing Research, 34, 1286–1292. LinkGoogle Scholar Bauer J. J., & Larson C. R. (2003). Audio-vocal responses to repetitive pitch-shift stimulation during a sustained vocalization: Improvements in methodology for the pitch-shifting technique.Journal of the Acoustical Society of America, 114, 1048–1054. CrossrefGoogle Scholar Boothroyd A. (1969). Distribution of hearing levels in the student population of the Clarke School for the Deaf. Northampton, MA: Clarke School for the Deaf. Google Scholar Elfenbein J., Hardin-Jones M., & Davis J. (1994). Oral communication skills of children who are hard of hearing.Journal of Speech and Hearing Research, 37, 216–226. LinkGoogle Scholar Eisenberg L., Shannon R., Martinez A. S., & Wygonski J. (2000). Speech recognition with reduced spectral cues as a function of age.Journal of the Acoustical Society of America, 107, 2704–2710. CrossrefGoogle Scholar Geers A., Brenner C., Nicholas J., Uchanski R., Tye-Murray N., & Tobey E. (2002). Rehabilitation factors contributing to implant benefit in children.Annals of Otology, Rhinology, and Laryngology—Supplement, 189, 127–130. CrossrefGoogle Scholar Goehl H., & Kaufman D. (1984). the effects of adventitious include disordered of Speech and Hearing LinkGoogle Scholar J. R., Moore C. A., M., & R. W. (2000). The development of speech and jaw of & Hearing Research, LinkGoogle Scholar J. R., Moore C. A., & J. (2002). The development of jaw and lip control for of and Hearing Research, LinkGoogle Scholar F. Speech sound coarticulation, and effects in a of speech CrossrefGoogle Scholar E. A., A. & (2003). in children’s speech and after cochlear and CrossrefGoogle Scholar Houde J. F., & of speech and of and Hearing Research, LinkGoogle Scholar C., & Numbers F. An of the intelligibility of speech of the Google Scholar D. L., W. A., C., A. J., & used to speech clarity by normal-hearing children.Journal of the Acoustical Society of America, CrossrefGoogle Scholar Jones J. A., & (2002). The role of auditory feedback during Studies of of CrossrefGoogle Scholar Jones J. A., & (2003). to produce speech with an vocal The role of auditory of the Acoustical Society of America, CrossrefGoogle Scholar Katz W. F., C., & P. (1991). coarticulation in the speech of adults and young perceptual and of Speech and Hearing Research, 34, LinkGoogle Scholar L., R., & The of hearing on speech production of deafened adults with cochlear of the Acoustical Society of America, CrossrefGoogle Scholar characteristics of in children’s and of developmental of Speech and Hearing Research, LinkGoogle Scholar Kortekaas R., & P. (2000). effects on children’s perception of the Acoustical auditory and clarity of and Hearing Research, LinkGoogle Scholar R., Ling Ling L., & Early speech development in of the Google Scholar Lane H., & J. W. (1991). Speech deterioration in deafened adults.Journal of the Acoustical Society of America, CrossrefGoogle Scholar Lane H., J., M., M., & Perkell J. in the speech of cochlear implant An of of the Acoustical Society of America, CrossrefGoogle Scholar Leder S., J., J. C., C., & F. of adventitiously cochlear implant of the Acoustical Society of CrossrefGoogle Scholar S., A., & Acoustic of children’s of and spectral of the Acoustical Society of America, CrossrefGoogle Scholar the speech and language H., N., & D. Development of language and communication skills of hearing-impaired children. ASHA Google Scholar A R. of hearing aid MA: Google Scholar M., Oller & Development of in a child with congenital of The of CrossrefGoogle Scholar skills of hearing-impaired children in for the H., N., & D. Development of language & communication in hearing children. ASHA Google Scholar R., Robin D. A., & R. A. of and of sensorimotor speech disorders Google Scholar A. The speech of and hearing children with to factors of of CrossrefGoogle Scholar Moore C. A., & J. speech from earlier oral of Speech and Hearing Research, LinkGoogle Scholar (2002). to fricative perception and how it the of the Acoustical Society of America, CrossrefGoogle Scholar S., C. S., & E. The of acoustic in the perception of by children and & CrossrefGoogle Scholar L., & Yoshinaga-Itano C. (2000). speech development at months in children with hearing loss be predicted from information available in the second year of Google Scholar Oller R., & A. of a A with normal of Speech and Hearing Research, LinkGoogle Scholar Oller & C. of a of Speech and Hearing LinkGoogle Scholar J., M., & Speech intelligibility of children with cochlear implants, aids, or hearing of Speech and Hearing Research, LinkGoogle Scholar S., A. L., H., & production and language skills in children with cochlear of and CrossrefGoogle Scholar Perkell J., Lane H., M., & J. Speech of cochlear implant A study of vowel of the Acoustical Society of America, CrossrefGoogle Scholar Perkell J. S., L., Lane H., F. H., R., J., & P. Speech Acoustic auditory feedback and internal CrossrefGoogle Scholar Pittman A. L., Stemachowicz P. D. & (2003). characteristics of speech at the for in children.Journal of and Hearing Research, LinkGoogle Scholar Pratt R., A. & E. The efficacy of using the to treat young children with hearing of Speech and Hearing Research, LinkGoogle Scholar Pratt R., & Tye-Murray A. Speech impairment secondary to hearing of sensorimotor speech disorders Google Scholar Smith C. hearing and speech production in the of Speech and Hearing Research, LinkGoogle Scholar P. Pittman A. L., M., D. & P. The importance of high-frequency in the speech and language development of children with hearing of and CrossrefGoogle Scholar Stoel-Gammon C. of hearing-impaired & normally hearing A of of Speech and Hearing LinkGoogle Scholar Stoel-Gammon C., & Babbling development of hearing-impaired and normally hearing of Speech and Hearing LinkGoogle Scholar Tobey E. A., Geers A. Brenner C., & (2003). associated with development of speech production skills in children implanted by age and CrossrefGoogle Scholar Uchanski R. M., & Geers A. E. (2003). Acoustic characteristics of the speech of young cochlear implant A with normal-hearing and CrossrefGoogle Scholar Waldstein R. of on speech for the role of auditory of the Acoustical Society of America, CrossrefGoogle Scholar Waldstein R., & Baum (1991). coarticulation in the speech of profoundly hearing-impaired and normally hearing children.Journal of Speech and Hearing Research, 34, LinkGoogle Scholar Wallace L., & Yoshinaga-Itano C. (2000). babble the to speech for all A study of children who are or hard of Google Scholar Sheila R. Pratt, is in the of & at the of her at With With Additional to in Mar &

Age-related hearing loss (HL) is a highly prevalent and undertreated disease that has long been considered an inconsequential result of aging, and at worst, a simple quality of life problem. Recent research suggests that HL may have significant implications for mental and neurocognitive health. Several studies have shown preliminary evidence associating HL and depression.1 Identifying modifiable risk factors for late-life depression is crucial because depression is relatively common and disabling in the elderly. Late-life depression is often resistant to medications such as antidepressants. Since HL is highly prevalent, severely undertreated, easily diagnosed, and treatable (by hearing aids or cochlear implants), establishing a link between HL and late-life depression may yield a strategy to prevent or treat depression in the sub-group of patients who also have HL.Latinos, depression, mental healthTable 1: Participant Demographics by Hearing Loss CategoryTable 2: Odds of Clinically Significant Depressive Symptoms by Category of Hearing Loss (adjusted model)A recent study2 by our team investigated whether an association between audiogram-measured HL and clinically significant depressive symptoms exists by using data from the Hispanic Community Health Study/Study of Latinos (HCHS). Determining whether this association exists in a racial/ethnic minority, such as the Hispanic population, was of specific interest for several reasons. Depression has been reported to be more common in the Hispanic population compared to other ethnic/racial groups.3 In addition, depression may be underdiagnosed in Hispanic individuals due to language, cultural, and literacy barriers to health care.4 Moreover, early studies evaluating this association have largely been limited to Caucasian cohorts.1 A finding in one race/ethnic group does not necessarily translate to another. STUDY METHOD The HCHS is a multicenter, prospective, community-based cohort study of Hispanic/Latino adults in the United States. This dataset includes information from audiograms, interviews, physical examinations, and tests, such as laboratory bloodwork and neuropsychological testing. This cohort also happens to have a large sample of Hispanic individuals with audiometric hearing data—in fact, the largest study to date (5,328 subjects compared with 1,332 in the previously largest study5). Importantly, this dataset included a measure of depressive symptoms known as the Center for Epidemiologic Studies Depression Scale, 10-item version (CESD-10, a 10-question yes/no survey). Data collected from a total of 5,328 individuals were included in the study after excluding data on those below 50 years old and those with early-onset hearing loss or missing key data, such as audiograms, CESD-10 scores, or demographics. In this cross-sectional study, hearing loss was assessed using pure-tone audiometry in soundproof booths. All individuals had pure-tone audiometry across frequencies 500 Hz to 8,000 Hz tested by trained technicians. The four-frequency pure-tone average (PTA) based on hearing thresholds at 500, 1,000, 2,000, and 4,000 Hz was calculated for each ear; HL was based on the PTA of the better ear, and unilateral HL was excluded. Severity of HL was categorized as follows: absent or normal, 0 to 25 dB; mild 26 to 40 dB; moderate, 41 to 55 dB; moderately severe, 56 to 70 dB; severe 71 to 90 dB; and profound, 91 dB or greater.2 Since few participants had severe or profound HL, individuals in these categories were combined with those in the moderately severe HL group to form a category of moderately severe or worse (56 dB or greater) HL. Depressive symptoms were measured using the CESD-10. Examples of questions include “I felt depressed” and “I felt that everything I did was an effort.” Clinically significant depressive symptoms were defined by a CESD-10 score of 10 or higher, a cutoff also used in prior research.6 The study also adjusted for other variables that may confound the association between HL and depression. By confound, we mean that these variables might create a seemingly false association between HL and depressive symptoms. For example, age can cause both HL and depression. By adjusting for age, we take this into account to reduce or eliminate the confounding effect of age. These other variables were adjusted for included use of hearing aids, demographics (age, sex, educational level, etc.), and cardiovascular disease. RESULTS Baseline participant characteristics listed by HL category are provided in Table 1. The median age of participants was 58 years old. Of the 5,328 participants, 62 percent were women. Most patients (82%) had no HL, 14 percent had mild HL, 2.7 percent had moderate HL, and 0.9 percent had moderately severe or worse HL. The mean CESD-10 score was 7.7. Clinically significant depressive symptoms (i.e., a CESD-10 score ≥10) were present in 32 percent of participants without HL, 34 percent with mild HL, 45 percent with moderate HL, and 57 percent with moderately severe or worse HL. When adjusting for other variables that might cause confounding, such as hearing aid use, demographic factors, cardiovascular disease, and antidepressants, the odds of clinically significant depressive symptoms (CESD-10 score ≥10) increased 1.44 times for every 20 dB increase in HL. This adjusted model was used to calculate the odds of clinically significant depressive symptoms in each category of HL compared to normal hearing (0 dB hearing loss; Table 2). The odds of clinically significant depressive symptoms were 1.81 times as high for mild HL, 2.38 times as high for moderate HL, 3.12 times as high for moderately severe HL, and 4.30 times as high for severe HL. DISCUSSION The association between HL and depression, both common conditions of older life, was not previously well established. This study shows a strong association between audiometric HL and clinically significant depressive symptoms using a large Hispanic study population. When accounting for hearing aid use, age, sex, educational level, study site, geographic background, cardiovascular disease, and antidepressant use, the odds of having clinically significant depressive symptoms increased nearly 1.5 times for every additional 20 dB of HL. This is clinically significant, as 20 dB is approximately the difference between each category of HL; for example, moderate (41-55 dB) vs. mild (26-40 dB) HL. An individual with mild HL had almost twice the odds of having clinically significant depressive symptoms compared with someone with normal hearing (0 dB HL). An individual with moderate HL had nearly 2.5 times the odds and an individual with severe HL had over four times the odds of having clinically significant depressive symptoms. It is intuitive to hypothesize that HL may increase the risk for depression via the development of social isolation and loneliness, which themselves are associated with a higher risk of depression. HL treatments have been shown to improve loneliness,7 as well as social function and depressive symptoms.8 However, a key limitation of the study is that it does not prove that HL causes depression. This study was a cross-sectional, observational study that shows an association between HL and depression. As we know, association is not the same as causation; only a randomized controlled trial could show causation. This study adds to the growing literature examining HL and depression. It provides a more robust statistical analysis, includes data from multiple sites across the country, and is the largest to date examining HL and depression. The study also extends earlier findings9 to a different ethnic group. Given that the Hispanic population is the fastest growing ethnicity in the United States and depression may be more prevalent in this population compared to other ethnic/racial groups,3 identifying modifiable risk factors for depression in Hispanic/Latino individuals is crucial. This is especially important because Latino individuals are less likely to start medical (antidepressant) therapy and more likely to discontinue such therapy within the first 30 days of treatment.10 Depression in later life is a heterogeneous disorder with many risk factors, and results from this study suggest that HL may be one important pathway to becoming depressed. The high prevalence (80% in individuals older than 80 years of age) and infrequent treatment (<20% use hearing aids or cochlear implants) of HL amongst the elderly implies that recognizing and treating HL may have the potential to significantly improve health outcomes for older adults. While we don't know whether HL causes depression, nor do we know whether treating HL will prevent depression, it seems very reasonable to recommend treatment for older adults with HL given the low risk of hearing aid use and broad potential benefit. Future longitudinal studies and randomized controlled trials examining whether treating HL reduces the risk of late-life depression can help elucidate the relationship between HL and depression. Establishing a causal link between HL and depression may eventually guide clinical practice guidelines and treatment recommendations regarding HL as a modifiable risk factor for depression. Thoughts on something you read here? Write to us at [email protected]

Effect of Age-Related Hearing Loss on Neuropsychological Test Performance

Eyes Open, Ears On: Supporting Hearing Technology Use in Children with Hearing Loss

You have accessThe ASHA LeaderFeature1 Mar 2002The Psychology of Hearing Loss Mary Kaland and Kate Salvatore Mary Kaland Google Scholar and Kate Salvatore Google Scholar https://doi.org/10.1044/leader.FTR1.07052002.4 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The experience of hearing loss is different for everyone. Speech-language pathologists and audiologists need to have a good grasp of both the physical—and psychological—realities of hearing loss. Hearing loss makes communication with the outside world difficult, and an individual's personality affects adaptation of hearing loss. A psychologist and psychiatrist, both hard-of-hearing themselves, bring an inside view to some of the potential psychological effects of hearing loss and the ways that clinicians can address them. No two people have the same reaction to life circumstances. Hearing loss can induce observable psychological effects at various points in development. The potential psychological effects of hearing loss are different for children and adults, and an individual's personality affects adaptation to hearing loss and cochlear implants. In general, hearing loss makes interaction with the outside world difficult. Having a hearing loss has been described as an invisible handicap, especially in the social realm. In fact, Helen Keller once said that deafness cuts one off from people, whereas blindness cuts one off from things. Hearing Loss in Children Hearing loss is challenging at any age, but it poses unique issues for the young child. Having a hearing loss does not mean a child will develop psychological problems, just as a child from a family of divorce may or may not have emotional difficulties. The stressor (hearing loss, divorce) is superimposed on pre-morbid personality (coping skills) as well as biological predispositions. It is a combination of psychological, biological, and social factors that make a child more at risk than the general population. Some of the more commonly noted secondary aspects of hearing loss include communication and behavioral problems, self-esteem and image problems, and depression and introversion. Undiagnosed or misdiagnosed hearing loss can result in problems as the child may know something is not quite right but is not getting the proper professional attention. When a hearing loss—even a mild one—is correctly diagnosed, the child knows the truth about what is wrong, as opposed to thinking she is "crazy" or "stupid." Though less common today, children may be misdiagnosed as attention- or emotionally disordered, which can lead to many secondary self-esteem issues. When misdiagnosis occurs, the problem becomes twofold—the child receives an inaccurate and usually negative label, and their actual problem goes untreated for a long period of time. To some extent, communication issues are universal among people with hearing loss. When a child has difficulty interacting in a spontaneous way, a whole host of secondary problems can arise, and any or all of these issues can develop into more serious problems. These include learning difficulties, social isolation, and depression. Normal interactions require tremendous attention for the child with hearing loss. Listening becomes a multi-sensory task, involving a much greater level of visual and general attention than it does for those with normal hearing. While the child may communicate effectively, it requires a great deal of energy to do so. One of the most typical symptoms that motivates individuals with hearing loss to begin psychotherapy is fatigue, which can exacerbate depression. Increased incidences of behavioral problems are often cited in the literature on children who are deaf or hard-of-hearing. Behavioral problems in children such as hyperactivity or aggression can be the outward expression of internal difficulties—such as depression, anxiety, and learning disorders— and should be investigated. Behavioral problems are often best dealt with by school or mental health professionals with experience in these areas. When treating children with behavioral problems, clinicians must set limits, speak simply and clearly, avoid overly stimulating or distracting environments, and involve parents more than usual. Scheduling appointments at optimum times of day (based on parental knowledge of when their child is usually at their best) is also useful. In addition, children rarely perceive being different as a virtue. Children with any unique qualities may develop a negative self-image as a result. This is often evident in children with a variety of traits that come to characterize them, such as being overweight and wearing glasses. One personality trait often associated with hearing loss is introversion—the terms shy, quiet, and sensitive often refer to this. The general theory is that the child with hearing loss is more inner-focused as a result of reduced stimulation from the outside world. They may withdraw from peer interactions due to this inner focus, the extra effort demanded in communicating, or simply due to the alienating feeling of "being different." As a result, parents must apply extra effort to helping their child with hearing loss participate with peers and in social groups. Self-expression is difficult for all children, and this is greatly compounded by hearing loss. Parents and professionals must be extra-sensitive to children with hearing loss, as they are not always able to articulate their needs and feelings. They must be aware of potential problems and assist the child with hearing loss in becoming more comfortable with self-expression. Children with hearing loss need to be in an environment that welcomes questions and feelings, and while parents may not always have the answers, they should be at ease and curious about the questions. Clinicians can ask children who have hearing loss questions in the course of their work ("How do you feel about your new hearing aid" or "What do you think about your new hearing aid?") in an unobtrusive and casual manner and watch the child's response. Be careful about leading questions. "How do you like your new hearing aid " may indicate to the child that he is supposed to like it, which does not promote honesty if the child actually does not like it. All children should be taught that they have strengths and weaknesses and be encouraged to explore who they are and pursue the things they like and do well. It is the difficult chore of the parents of children with hearing loss to continually explore and question whether behaviors observed are a normal manifestation of the child's personality or a response to some form of distress caused by the hearing loss. Parents must find the delicate balance between overanalyzing every behavior and not paying enough attention to their child's actions. Finally, parents need to develop their own support systems to help them deal with their feelings. Hearing Loss in Adults Hearing loss in adulthood is a somewhat different psychological picture. A distinction can be made between psychological symptoms of early- and late-onset hearing loss in adults, although individuals in both groups commonly report anger, denial, isolation, social withdrawal, fatigue, and depression. Adults with early-onset hearing loss may have grown up dealing with some of the above problems. Clinical psychological knowledge tells us that all children bring manifestations of their childhood difficulties into adulthood. Some of these difficulties will continue to be problematic, and some will not. For instance, the child with hearing loss who was isolated and had poor self-esteem may be an isolated adult who underachieves. Adults must be understood as the totality of their developmental experiences, and hearing loss and its consequences are a part of that whole. Clinicians need to be curious about how clients feel about their hearing loss, how it was managed and discussed in their family, and how they feel it affects their choices in adulthood. Adults who have early-onset hearing loss often report that, while there were negative aspects of their hearing loss, they have come to incorporate the hearing loss into their personalities—it is part of who they are and of their identity. As a result, they have developed ways to cope with and manage the hearing loss in their daily lives. The situation is very different for late-deafened adults. These individuals have developed a personality that does not incorporate hearing loss. They have jobs, families, and personalities and relate to those aspects of their lives as fixed. When hearing loss occurs, it is a very disorienting experience. Rapid losses are more disorienting than gradual losses. Late-deafened adults often report that their hearing loss robs them of an understanding of their identity and often initiates an identity crisis. They may manifest a "reactive" depression and/or anxiety in response to a typically external situation. Late-deafened adults will often mourn the loss of their hearing as they go through Kubler-Ross' five stages of grief—denial and isolation, anger, bargaining, depression, and acceptance (see references). Professionals interacting with late-deafened adults should try to get a general sense of which stages the client is in. Denial, isolation, and anger are readily observable by clinicians. A newly diagnosed adult may mourn the loss by becoming withdrawn and refusing amplification. Family members and audiologists are the greatest help in this early stage. Patients often need to be taught new ways to interact in the world to increase their involvement. Bargaining frequently takes the form of comparing ("I can't really hear anymore, but at least my health is good") or devaluing ("Who cares if I cannot hear—I never really liked music"). Depression can manifest itself as tearfulness, slowed responses, or even changes in weight or sleeping patterns. If previously dapper men begin showing up for appointments unshaven or women come without makeup and with sloppy hair, they may be depressed. Professionals can note such things in an unobtrusive way ("How are you feeling this week?") and even talk with family members if they come with the client. It is believed that depression precedes acceptance because it represents a healthy beginning in truly taking in the negative aspects of one's disability. Finally, acceptance takes many forms for different people, but it usually indicates some integration of the loss into one's life. In this circumstance, acceptance may mean having all the negative feelings about one's hearing loss while not letting those feelings interfere with relationships and daily life. When going through the stages of mourning, functioning may be affected over the short term, but the person usually will move toward some degree of acceptance. If they do not, they may need emotional support from either a therapist or a support group. The Psychology of Cochlear Implants Personality and psychological factors can affect the surgical outcome in cochlear implantation. Professionals working with cochlear implants acknowledge a great deal of variation in satisfaction and performance with implants. Some of the factors that affect outcome—which is traditionally measured by speech-recognition ability—include length of deafness, IQ, speechreading ability, and hearing ability before implant. Research also notes certain psychological factors that can affect outcome, such as an individual's point of view (pessimist/optimist), expectations (realistic/non-realistic), and type of support system. There is a dearth of literature on the relationship between personality and cochlear implant surgery outcome. Personality can be thought of as the complex total of who we are, how we think, how we perceive information, and how we interact with the world. Cochlear implant surgery is a life event that will interact with and be shaped by our personality. The way an individual responds to stressful situations, illness, and physical stress in general will predict, to a certain extent, how that individual responds to an implant. Thus, a person who is rigid and pessimistic may look for, and comment on, all of the bad things about an implant, regardless of how it functions. While it may be healthier for an individual to observe the implant as part of a long process and to feel positive, it is very difficult to change the way people evaluate the world. Most people adapt in their own way over time. If they do not, they may benefit from talking with a therapist. People with hearing loss also are affected by a society that values physical perfection and beauty. There is an often subtle and unconscious bias about people who wear hearing aids and cochlear implants. In general, these prejudices are not mean-spirited, but the expression of fear—a fear of facing some of the bad things that can happen to people in life. People tend to want to feel good all the time and do not welcome exposure to things like disability, illness, and death. People often want to avoid exposure to situations and individuals who remind them of these concepts. Try having a conversation about death and dying at your next family gathering and watch the room clear out. This is simply a psychological fact of life, and professionals need to be aware of it. Speech-language pathologists and audiologists can benefit from a collegial relationship with a therapist that works with patients with hearing loss. We often present small group lectures at clinicians' request to encourage clients to understand the emotional effects of hearing loss. One of the goals of good psychotherapy is to help individuals understand how their personality works so they can observe it in operation and see how it affects their point of view. Finally, professionals working with clients with hearing loss must always pay attention to the many variables of hearing loss. The important ones include when the individual became hearing impaired, the cause and degree of the loss, and the progressive nature of the loss (gradual or sudden). The more severe the loss, and the earlier the age at which it was acquired, the greater the impact can be on psychological development. When working with individuals with hearing loss, it is imperative to establish a dialogue that invites information about the history and nature of the loss. The onset and degree of hearing loss make for a diverse group. This diversity can create an identity crisis for individuals who are neither "hearing "nor "Deaf "as they find where they fit in society. Professionals must have a go od grasp of both the physical realities of the individuals' hearing loss (degree, cause, course) as well as where individuals feel they belong on the cultural continuum of hearing loss. Many of these issues are common and can be present in individuals with hearing loss without necessarily being problematic. Whether or not they rise to the level of being a problem is determined by a complex combination of personality and environment. Clinicians can become more empathic listeners and more effective providers when they are educated about these generalities and the specifics of their clients' hearing loss. This includes both physical and psychological information. In the end, the latter will often affect how the client uses the physical information and assistance offered to them. References Niparko J.K., et al. (2000). Cochlear implants: Principles & practices.: Philadelphia, PA: Lippincott Williams & Wilkins. Google Scholar Kubler-Ross E. (1997). On death and dying. Riverside, NJ: Simon & Schuster. Google Scholar Chartrand Max S. (1990). Hearing instrument counseling.: Livonia, MI: National Institute for Hearing Instruments Studies. Google Scholar Vernon M., &Andrews J. (1990). The psychology of deafness. New York, NY: Longman. Google Scholar Author Notes Mary Kaland, is a clinical psychologist in private practice in New York City. She was born with a moderate progressive sensorineural hearing loss that resulted in profound hearing loss in early adulthood. She received a cochlear implant in August 2000. Contact her by email at [email protected] Kate Salvatore, is a fourth-year psychiatry resident at the University of Pennsylvania in Philadelphia. She will graduate in June and will begin a two-year fellowship in child/adolescent psychiatry at Children's Hospital of Philadelphia. She was born with a combined severe-to-profound sensorineural hearing loss in both ears and received a cochlear implant in January 2002. Contact her by email at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 7Issue 5March 2002 Get Permissions Add to your Mendeley library History Published in print: Mar 1, 2002 Metrics Downloaded 25,383 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2002 American Speech-Language-Hearing AssociationLoading ...