Golden Years, Golden Ears?
Ah Gong was a hearing aid user for as long as I can remember. Hindered by profound hearing loss, he was a man of few words. Instead, he preferred to express his love by buying roast duck for us whenever we visited on Sundays. Without fail, he distributed weekly allowances to all his grandchildren, and we made sure to thank him as loudly as we could. While the rest of the family mingled, he could not.
When watching TV, Ah Gong sat closer than anyone else. We communicated through simple gestures and written words, but interactions were limited to simple and somewhat superficial conversations. He did own a pair of hearing aids which, I recall, were huge, bulky and excessively loud. Even then, they were only partially effective.
That was more than a decade ago. Now that I am a practising audiologist, I have experienced first-hand, in the course of my work, the challenges and frustrations faced by patients with hearing loss.I wonder if Ah Gong ever felt alone back then. Could we have forged a deeper relationship with him through better communication and support?
AGE-RELATED HEARING LOSS
Presbycusis refers to hearing loss that gradually affects most of us as an inevitable consequence of ageing. This sensory hearing loss arises from the degeneration of sensory hair cells (also known as cochlea) in our inner ear. Some elderly may suffer from a combination of presbycusis and noise-induced hearing loss – the result of exposure to loud sounds over a prolonged period of time. Elderly suffering from diabetes, heart diseases or hypertension may be predisposed to sensory hearing loss. Exposure to ototoxic medications is also known to cause irreversible damage to sensory hair cells.
Other less common types of hearing loss include reduced transmission of mechanical sound energy in the outer ear or middle ear structures (conductive hearing loss); and hearing loss at the level of the neural pathways, along the hearing nerve between the cochlea and the brain (neural hearing loss). The latter includes damage from viral or bacterial infection, stroke, brain injury, or even the presence of a tumour.
PREVALENCE IN SINGAPORE
A 2017 study conducted in Singapore estimated that 422,000 elderly have some degree of hearing loss (greater than 25dB HL), while over 100,000 elderly suffer from disabling hearing impairment (greater than 40dB HL). These numbers are projected to double by 2030.
Despite this, only 7.5% of elderly with disabling hearing impairment were reported to have obtained hearing aids. Even then, possession of hearing aids does not mean usage, as a portion of them may just be irregular or non-users.
POTENTIAL CONSEQUENCES
Unaddressed hearing loss can complicate many aspects of everyday life. Mental effects and emotional reactions to hearing loss include denial, depression, anxiety, anger, isolation and fatigue. This can result in poor self-esteem and social withdrawal which will adversely affect relationships with others. And surprisingly, even a mild degree of hearing loss can increase the risk of falling among the elderly. This risk increases 1.4 times for every additional 10dB of hearing loss.
Most importantly, hearing loss is known to be associated with accelerated cognitive decline due to reduced sensory stimulation. A report by the Lancet Commission on Dementia Prevention, Intervention and Care indicated that hearing loss is one of the most significant modifiable risk factors in the development of dementia. It was assessed that failure to address hearing loss accounted for the onset of up to 9% of dementia cases.
Other observational studies have also found evidence that the severity of hearing loss correlates to the risk of dementia. Individuals with mild, moderate, and severe hearing loss were reported to be at two-, three-, and five-times higher risk of getting dementia respectively as compared to those with normal hearing.
SYMPTOMS OF HEARING LOSS
As hearing loss is gradual, an individual may not realise that he/she have lost some of his/her ability to hear over the years. As a simple screening test of hearing, if an individual answers “yes” to three or more of the following 10 questions, it is recommended Golden Years, Golden Ears? that he/she proceed for a more formal test of hearing.
MEDICAL DIAGNOSIS AND INTERVENTION
For an early diagnosis, report any symptoms suspicious for hearing loss to a general physician (GP) or otorhinolaryngologist – a doctor who specialises in conditions of the ears, nose and throat.
After the doctor has excluded medical conditions with reversible hearing loss, an onward referral will be made to an audiologist, who is a healthcare professional specialising in the testing and management of patients with hearing, balance, and other related problems. Depending on the degree and type of hearing loss, the audiologist will advise on the suitable types of hearing aid. The selection process should consider the following factors: the elderly’s lifestyle, dexterity, vision, cognition, and the availability of a caregiver to help manage the hearing aids.
Modern hearing aids can include elderly-friendly features like rechargeability, Bluetooth connectivity, remote tuning through tele-audiology, “Find My Hearing Aid” location function as well as a fall detection and alert system, in case the elderly sustains a fall.
BARRIERS TO HEARING AID USAGE AND OTHER MISCONCEPTIONS
Individuals with hearing loss may delay – on average – 10 years before getting help for their hearing loss. From the remarks of my patients, I have gained the following insights into their reasoning behind this long delay.
“I CAN STILL HEAR WITHOUT HEARING AIDS.”
Just as how one can still partially see without glasses, one can also partially hear without hearing aids.Even though people with hearing loss may still detect the sound of speech, it often lacks clarity, and the ability to distinguish words decreases in noisy environments. Early intervention reduces the listening effort required, and trains the hearing pathway and brain to transmit and process sounds. A longer period of auditory deprivation may potentially result in poorer outcomes with hearing aids.
“HEARING AIDS ARE SO TROUBLESOME.”
Indeed, hearing aids must be kept dry, clean, powered and functioning. However, hearing aid care and maintenance has been much simplified over the years. For instance, disposable batteries have largely been replaced by convenient rechargeable inbuilt batteries, while disposable dry silica gels have been substituted with electronic dehumidifiers. The long-term benefits of hearing aids certainly outweigh the slight inconvenience of care and maintenance.
“I WON’T NEED HEARING AIDS AS I SPEND MOST OF MY TIME AT HOME.”
Users are advised to wear their hearing aids during waking hours for maximum auditory stimulation. Even at home, watching TV or listening across the dining table is a form of “hearing exercise”. For elderly who live alone, good hearing provides vital environmental cues and safety awareness.
“MY FRIEND ENDED UP NOT USING HIS HEARING AID.”
Misinformation and negative impressions are often hard to reverse. Complaints from other hearing aid users could stem from incorrect or over-optimistic expectations of hearing aid performance under challenging listening situations. Realistically, it takes time for a new user to acclimatise to amplified sounds. It could be a user problem (rather than a device problem), where improper insertion of a hearing aid causes feedback, or a lack of cleaning causes ear wax to block the passage of sound. Hearing aid sound processing technologies have improved in leaps and bounds. I would strongly recommend to elderly who are struggling to hear to try out hearing aids for themselves, rather than simply accept the accounts of well-meaning friends.
“HEARING AIDS ARE VERY EXPENSIVE.”
Hearing aid prices can vary widely, depending on the technology level and additional features. There are typically three tiers in technology level: basic, mid, and premium. In general, the higher the tier, the better the overall listening experience, but basic tier hearing aids are often sufficient. The Seniors’ Mobility Fund offers either 75% or 90% subsidy to eligible Singaporean seniors. This initiative has significantly improved affordability and accessibility for elderly with financial concerns.
HOW LOVED ONES CAN HELP
There are four main stages in a hearing aid journey where the family can be actively involved.
- Seeking Help
Early signs of hearing loss are often first noticed by people who communicate with the elderly. Using an encouraging and tactful approach, point out how hearing loss has impacted the elderly’s life as well as family members’ lives. This may help the elderly come to terms with his/her hearing loss and motivate him/her to consider hearing options. - Uptake
During evaluation, the audiologist may present what appears to be an overwhelming number of options on hearing aid styles and features. With a supportive family member, the elderly is accompanied through the decision-making process. - Usage
The immediate family plays a crucial role in helping with hearing aid maintenance, especially when the elderly is unable to do so independently. For example, family members can take on the
delicate or tricky task of checking for ear wax accumulation, changing certain spare parts, and simple troubleshooting. Keeping the elderly engaged in social interactions and activities also translates into more opportunities for hearing aid use. The initial period requires new users to adapt to the sound of their own voice, and sounds that were previously missed will now be heard again. New users might start to complain about food chewing, fridge humming, slippers squeaking, and cutlery clinking as “noise”. The family can reassure that these are sounds that everyone can hear as well. - Satisfaction
In the adaptation process, the family should remain patient and provide positive feedback when an improvement in hearing is identified. When the elderly’s satisfaction with his/her hearing aids is enhanced, he/she will more likely commit to continuous usage.
STRATEGIES FOR SUCCESSFUL COMMUNICATION
For an individual using hearing aids, it is extremely important that others involved in the conversation help by using these communication strategies:
Ideal Position
- Face the listener directly.
- Speak at a close distance.
- Avoid talking to the listener from another room or while passing by.
Speak Clearly
- Speak up but do not shout.
- Speak at a slower pace without exaggeration.
- Pause in between sentences to give the listener time to process.
Speak Simply
- Use simple words and shorter sentences.
- Rephrase if necessary.
Conducive Environment
- If background noise is present, relocate to a quieter environment or turn down the source of competing noise, if possible.
Draw Attention
- Grab the listener’s attention by calling out his/her name or by giving a light touch on the shoulder before speaking.
Enhance Communication via Non-Verbal Means
- Use hand gestures, facial expressions, and body language to provide the listener with visual clues.
- Consider writing, texting, or smartphone speech-to-text application to support communication.
SUMMARY
The ageing population in Singapore will result in an increasing number of people with age-related hearing loss. Hearing loss takes a toll on the social, functional and psychological wellbeing of all individuals, but more so the elderly.
Healthcare professionals involved in elderly care emphasise the early diagnosis of hearing loss and intervention with hearing aids. This helps to keep the elderly socially and cognitively engaged, improve their quality of life, and delay the onset of dementia.
Hearing aids are often met with resistance, suspicion or disdain. Family members’ active involvement and support must not be underestimated as they have a pivotal influence on the user’s acceptance and successful usage of hearing aids. PRIME
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