Optimising hearing services for adults living with dementia and hearing impairment in residential aged care facilities

Abstract

Over 90% of adults living with dementia in residential aged care facilities (RACFs) will have a concomitant hearing impairment, resulting in a dual sensory-cognitive communication impairment. Identifying and appropriately managing hearing impairment may lead to improved hearing-related communication, caregiving and quality of life. However, within RACFs, hearing impairment is under-identified and sub-optimally managed. Therefore, the overarching aim of this thesis was to explore ways to optimise the delivery of hearing services to adults living with dementia and hearing impairment in RACFs.This thesis is comprised of a systematic review (chapter 2) and three original studies, advancing knowledge in diagnostic audiology (chapter 3), and rehabilitative audiology (chapters 4 and 5), and developing an intervention that could be used to promote shared decision-making (chapter 6).In chapter 2, a systematic review explored the proportion of adults living with dementia who could complete the gold standard hearing test, pure-tone audiometry (PTA), and contained two key findings. First, from 1,237 eligible studies only three met all inclusion criteria, highlighting the dearth of research in this area. Second, the proportion of adults completing PTA was identified as 56% to 59%. The facts that approximately 40% of adults living with dementia could not complete PTA indicated that there was a need to explore the feasibility of alternative non-behavioural hearing tests.In chapter 3, a prospective cross-sectional feasibility study, examined whether Cortical Automatic Threshold Estimation (CATE) – an automated late auditory- evoked potential (AEP) test – was a suitable alternative to PTA for estimating hearing threshold for adults living with dementia in RACFs. Sixteen participants completed this study and results demonstrated that CATE was a feasible alternative to PTA, particularly for adults with severe dementia. Using both PTA and CATE also resulted in 87.5% of participants having their hearing thresholds estimated. However, a limitation of estimating hearing thresholds using CATE was the time taken to conduct assessments (approximately 50 minutes).In chapter 4, a qualitative study consisting of semi-structured interviews with 23 participants from four stakeholder groups (audiologists, RACF staff, family caregivers and individuals living with dementia and hearing impairment) explored (1) the impact of hearing impairment, and (2) current management practices for adults with dementia and hearing impairment living in RACFs. Thematic analysis revealed three key themes: the far-reaching consequences of hearing impairment; hearing impairment should be appropriately managed; and different stakeholder priorities for managing hearing impairment. Importantly, because audiologists and RACF staff prioritised different approaches for managing hearing impairment – audiologists prioritising hearing aids and RACF staff prioritising communication strategies – hearing impairment remained largely sub-optimally managed and thus, the far-reaching consequences remained.In chapter 5, the interviews reported on in chapter 4, were further analysed to identify the barriers and facilitators underlying five central behaviours that influenced hearing impairment management: (1) recognition of hearing impairment, (2) assessment of hearing impairment, (3) referral to and provision of hearing services, (4) management of hearing aids, and (5) shared decision-making. A framework analysis that applied the Capability, Opportunity, Motivation, and Behaviour model (COM-B) identified inter-related barriers to all behaviours, in terms of caregivers’ capability, opportunity and motivation. Two prominent barriers impacting many behaviours was that hearing impairment management was not prioritised by the staff in RACFs (motivation) and caregivers (family and RACF staff) lacked knowledge on hearing services (capability).Taken together, the qualitative findings in chapters 4 and 5, demonstrated that there are contrasting practices for managing hearing impairment for adults living with dementia and hearing impairment in RACFs. Audiologists focused on the provision of hearing aids whereas RACF staff focussed on communication strategies. Caregivers (family and RACF staff) also lacked knowledge but wanted information on all options available for treating hearing impairment.A decision aid, HEARMyChoice®, was developed in chapter 6 as a result, and then piloted using a mixed-methods, pre-exposure post-exposure design. Three dyads, consisting of an adult living with dementia and hearing impairment in an RACF and a family caregiver, took part in the study. The pilot study showed that the decision aid helped to improve participants’ knowledge of treatment options and assisted dyads to reach agreement in choosing options for treating hearing impairment, suggesting utility of the decision aid in this context.Findings in this thesis indicated that hearing services for adults living with dementia and hearing impairment in RACFs could be optimised by: (1) audiologists’ using CATE to assess hearing for those people unable to complete PTA; (2) audiologists using a decision aid to present a range of hearing intervention options to residents and caregivers; and (3) RACF staff prioritising the management of hearing impairment.