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Good morning. I'm Alan Jenny. On behalf of Dr. Franklin, my cochair of this workshop
planning committee, I'd like to welcome everyone to the workshop on hearing loss and healthy
aging. This workshop is being hosted by the IOM forum on aging, disability and independence,
which I also cochair with my colleague Dr. Jack row. This forum cope -- focuses on problems
at the intersection of aging and disability. Our forum offers an ongoing neutral venue
where stakeholders and government, academia, industry, foundations and consumer groups
can come together to discuss issues of mutual interest and concern such as age-related hearing
loss. We have many sponsors of our workshop today. I want to take a moment to thank each
of them in addition to the forum. We have Academy of doctors of audiology, the American
Academy of audiology, the American speech language hearing Association, the cochlear
Americas, the European hearing instrument Manufacturers Association, the hearing industries
Association, the Hearing Loss Association of America, high health innovations, the national
Institute on aging, the national Institute on deafness, and other communication disorders,
and the sound world solutions. We're delighted and appreciate the support of each of these
organizations. In particular, I also want to thank Contacta, Inc. This two-day workshop
-- in addition, I also want to thank the planning committee whose names are listed on the back
of your agenda who put together this two-day workshop.Now, in terms of our objectives for
today and tomorrow, first, our intent is to try to describe and characterize the public
health significance of hearing loss and the relationship between hearing loss and healthy
aging. In addition, one of our goals is to discuss the range of hearing needs and rehabilitation
strategies that are available. We want to explore innovative technologies and look at
barriers to their development and their use. We also want to identify areas of the research
going forward both short and long-term and consider collaborative strategies that can
be adopted for improving awareness of age-related hearing loss and intervention strategies.
Now, in general over the next two days if you've looked at the workshop schedule, you
will see that the workshop is comprised of a series of panels that we've put together.
After all of the speakers and each panel have given their formal presentations, there will
be a joint question and answer session during which time members of the audience may pose
questions for the panel to consider and discuss. When you have questions to ask, we would ask
that you use one of the microphones around the room. Now, I've been asked to give an
important announcement so you understand the role of IOM and national Academy workshops.
Unlike other IOM panels, this is a standalone workshop. It's not part of an ongoing study
by the IOM. A summary of the presentations and discussions made over the next two days
will be prepared. And it is will be done in accordance with the institutional policies
and procedures that will be published by the national Academy's press. The summary will
be broadly distributed, and will be made available to the public. We should note that all the
views presented over the next two days and the report that will be published represent
the views of the presenters, not any particular agencies or organizations. The report will
not contain findings or recommendations, unlike other IOM study panels. So workshops are different
than some of the more traditional IOM study panels. I've also been asked to highlight
a couple of housekeeping announcements, which I will now do. First, I want to mention that
we are webcasting the workshop. In addition, we're now on Twitter. Our hash tag is #IOMHearingLoss.
The webcast will be posted onto the website. The website is listed at the back of the agenda.
I've already mentioned if you have questions or comments that you want to make, please
approach one of the microphones. Slides are being presented today and tomorrow. They will
also be posted on the websites for people to review. We've put together a detailed speaker
biography -- they are available as handouts. Because of that, we will not be giving lengthy
introductions. So that we can't really reserved the time for presentation and discussion.
I will now turn it over to my cochair, Dr. Franklin from Johns Hopkins University, who
will provide some framing remarks for this workshop. Thank you and welcome.
[Applause]
Good morning, everyone. Alan, thank you very much. I want to echo his comments and thank
you again for being here at this incredibly multidisciplinary meeting. Over the next 15
minutes, I'm going to give a brief overview, what we will cover as well as because of the
range of different vectors, a brief primer about hearing and healthy aging from this
context. If we look across the lifespan based on data from the United States, and we use
a definition defined by the world -- world health organization. When hearing impairment
becomes -- significant. This is remarkable. By time, we get to be about 70 and above,
nearly two out of every three Americans has a clinically meaningful hearing impairment.
At the same time if we look at one of the most basic steppingstones of hearing loss,
based on the same national data sets, we see the rate of hearing aid use is phenomenally
low. This rate of hearing use -- hearing aid use has not changed in decades. Broadly, what
we see is that the rate of actual hearing aid use among people with a hearing impairment
is about 15%. I think this is a natural reason to think, it's so low in the states because
hearing aids are barely covered by insurance or Medicare. Because of that, it is so low.
That's not quite true. We go to other countries, Western Europe and United Kingdom wear hearing
aids are fully covered by national health insurance, rates of hearing aid use are just
a little bit higher but not substantially higher. What this gets at, while cost is critically
important, cost is not the only issue. If you look at some of the most basic public
health questions pertaining to hearing loss, these questions are unanswered or just beginning
to be answered now. These are the questions that are going to drive this workshop over
the next couple days. What's been done for each of these and what we need to do going
forward. First question, pretty basic. What are the consequences of hearing loss for older
adults? Is it issues of quality of life or possibly domains beyond quality-of-life? Second
question, given this possible impacts, what are the options for addressing and treating
hearing loss in an individual? What is the impact of those treatments? On the third question,
probably the most important. Two out of three adults over 70 has a meaningful hearing impairment,
how do we go about addressing that as a society? You realize now that because these questions
are just beginning to be answered and have not been focused on from this context before,
there's amazing paradox in society with me -- many of you are familiar with. This shows
mild hearing loss. This belongs to John, a 12-year-old boy. I can guarantee you across
insurance companies, physicians, patients, providers, they will all agree this hearing
impairment has to be addressed. It can impact how well this child can communicate with friends
and family members. The amazing thing about this is while this hearing impairment is critically
important, if we said John is now 72 years old, the same hearing impairment, the same
functional impact on communication, all of a sudden, usually this hearing impairment
is met with a shrug. So does everyone else your age. So there's a fundamental paradox
there. The same functional impact on communication, same hearing loss, critically important for
one member but not so important for another. What this gets at his these questions have
never really been approached conceptually from a multidisciplinary point of view. One
of the first questions I will be addressing early is the consequence of hearing loss.
What we're going to start with is from this perspective. Concept of healthy aging which
I think is one of those things all of us in this room are implicitly familiar with. We
know what it is and a lot of times healthy aging is one of those things you know it when
you see it. So the top right, this is Gladys Burrow. She was 92 years old when she finished
a marathon. A very vibrant, dynamic picture of healthy aging. In contrast, an older man
with mobility impairments in a wheelchair. Probably not the ideal picture of healthy
aging. Top left, a grandmother interacting with her grand dollar on a daily basis -- with
her granddaughter on a daily basis. In contrast, an older woman with early dementia. Not what
we would expect of healthy aging. What's going to be reviewed to the first of this workshop
is this link between hearing and these domains with characterizing healthy aging, cognitive
and physical functioning. To provide background, intuitively, a lot of us when we think about
this issue want to say of course they are related but common pathologic process. Clearly,
from a public health standpoint, that links these two, who cares. No matter what we do
from a public health standpoint to address and prevent hearing impairment, we're not
going to get a difference on these downstream outcomes. What I'm going to go over now is
thinking about how could hearing impairment contribute in some way shape or form to cognitive
functioning? I need to give some basic -- three basic slides about basic hearing and auditory
physiology to make sure we are on the same page as we begin this workshop. First principle
is that when we talk about hearing, it depends on two basic processes. Peripheral transduction
of sound and central processing or decoding of sound in the brain. What I mean by that
if you look at the top left, this is a speech spectrogram. All speech is complex. Composed
of different frequencies. It's all progressing in real time. The whole job of a cochlea in
the middle is to take in that incredibly complex set of sound vibrations and transduce it with
accurate fidelity into a signal that goes to the brain for d ecoding. If an engineer
is in the room, this is a process of encoding and decoding centrally. When we talk about
hearing, we can measure hearing at multiple different levels. We have more peripheral
measures that characterize how the cochlea does things like -- hearing tests that I will
show you a bit as well as central measures, someone's overall communication abilities
and even speech and noise tests. Central measures depend on bottom-up processing. They automatically
depend on top-down cognitive processing of that signal. You can measure at multiple different
levels. Importantly, when we think about basic bread-and-butter age-related hearing loss,
a lot of times what we are talking about is peripheral impairments in the cochlea. Comprised
of many cells, they cannot regenerate. Over time there's a damage from gazing, noise,
medicines, et c etera. When we talk about measuring hearing loss, measuring the peripheral
cochlear function. How well can the cochlea encode a sound and sent to the brain? The
way we do this is through clinical work as well, through different frequencies of different
sounds, 250 is a low pitched s ounds, 8000 is high-pitched. Each of these sounds will
measure how loud it has to be for the individual to hear it. 0 decibels is very soft. 40 is
about a whisper. 60 is conversational voice. Typically first to simplify things, we say
we can hear sounds less than 25, normal hearing. 25 to 40 is mild, then moderate, et cetera.
Classic simplifies more, what's often done clinically is people just summarize someone's
pure tone average. Hearing ability specifically in this range of frequencies critical for
speech. The higher the number, the worse your hearing loss, the lower the number, the better
the hearing. Very soft sounds. With those basic principles out of the way, I think we
can start exploring how hearing impairment can contribute to these domains of healthy
aging. Remember what I said before, when you have hearing loss it implies there are impairments
in the cochlea over time. What this leads to is not only issues of decreased hearing
sensitivity, you cannot hear soft sound.
Primarily, poor frequency and temporal resolution. The cochlea being able to crisply encode this
complicated sound, sends a very garbled signal to the brain. Classically for any of us who
have friends, parents who have hearing impairment, the state -- they say that it is not that
I can't hear you, it's that I can't understand you. Sounds like you're mumbling. That's what
hearing loss does. This is the described as a process of effortful listening. You can
still hear, make it out but you've got to concentrate that much harder to make out what's
being said. So one way that has been hypothesized in which hearing impairment is this idea of
cognitive load. Is the brain constantly have to rededicate resources, decoding a very garbled
signal and expensive systems? That's one idea. Another idea is that hearing impairment can
lead to direct changes in brain structure that can lead to cascading consequences on
function. If you have a very impaired garbled auditory signal from the ear, does that precipitate
functional changes in the brain? One of the most intuitive ideas for which hearing impairment
could contribute to cognitive problems is that some way, shape, or form can contribute
to social isolation. For many decades, we've -- one of the main drivers of morbidity and
mortality in older adults. With that in mind, one of the questions which will be addressed
in this workshop is given this possible impact, how do we even go about addressing hearing
impairment at an individual level? What are the impacts of those treatments? I specifically
we'll cover several topics. We will look at how is hearing impairment assessed in terms
of hearing needs assessment? The rehabilitative strategies for addressing hearing impairment.
We will talk about the healthcare workforce. Who is out there to address hearing impairment
for the individuals? We will have extended discussions about technologies. Hearing aids
versus personal sound amplification products? As well as the role of devices. Hearing loop
systems are -- there's one in this room right now, if you're in the back of the room and
the acoustics are pretty good but if you have bad acoustics and you had a hearing age -- a
hearing aid, anything I'm saying goes straight to your hearing aid which can make all the
difference in these settings. We will discuss these technologies as well. The third most
important question, the last question of how can age-related hearing loss be effectively
addressed in the community? If two thirds of older adults have a meaningful hearing
impairment, how do we even begin confronting that as a society assuming we want to address
it? There will be several topics we are going to discuss. One of the most important ones
is this thought process of how to be begin understanding and approaching hearing loss
in the context of healthy aging? For many of us, hearing is one of those processes that's
very much the usual process of aging. If we begin viewing it from the context of healthy
aging, it becomes that much more important. Otherwise we're seeing this as a relatively
-- what we will talk about is collaborative strategies for research, education and awareness
that need to go forward, bringing all the different stakeholders in this room. Second
big thing is delivery models of hearing healthcare. Also insurance coverage. How do we go about
delivering more accessible models of care? Third-party reimbursement for these services?
Third question we will discuss is actual innovations in hearing technologies. What can be done
going forward to develop more affordable accessible innovative technologies? Also the role of
open wireless standards. Why can't a simple iPhone -- go straight to a hearing aid? We
will discuss those issues as well. This is a summary slide. As we begin this workshop,
many of us would agree I think that overall if we look generally at the status of hearing
loss, in Society right now, for a lot of people, it's relatively inconsequential. Just relatively
inconsequential. It's fairly -- very poorly understood among the research community and
providers and it's incredibly stigmatized. Also, many of us would agree that many of
the current technologies and natural models of care are not meeting the needs of many
individuals in society. This overall perception has not changed in 50, 60, 70 years. More
so than ever, a lot of us recognize there are certain trends in society that are going
to force a change over the next five, 15, 25 years. One big factor is this one. Increasing
insight into the fact that optimal hearing is likely critical for many aspects of functioning
and healthy aging. Along the same lines is that right now we are clearly facing the tip
of the iceberg in terms of aging with baby boomers, fundamentally different from previous
generations. Demanding a different level of what they expect from later life in the third
age. Where the idea of hearing impairment important -- not compatible with the idea
that hearing loss should be ignored. Many of us would know this already but there's
been incredibly rapid progress in the last five, six, seven years with the pace of technology
in terms of actual technology out there for hearing and other types of systems. All of
us recognize going forward we had a crystal ball of the next 20, 30, 40 years what many
of us would expect -- with these trends that sounds almost self-evident that we will approach
hearing loss, understand the concepts of healthy airing -- healthy aging. It will sound self-evident.
There will be more expanded, transparent options for hearing healthcare. There will be some
degree of third-party reimbursement. Regardless of this workshop, this would go ahead eventually.
I would argue it would take 10, 20, 30, 40 years. What all this hope as we begin this
workshop is this workshop will begin catalyzing this change quite simply. Rather than taking
20, 30, 40 y ears, whether we can accelerate this process. So I will finish up there. And
I want to introduce our first speaker. Kathrine is a close friend of mine, a former editor
of the New York Times who has dealt with age-related hearing loss over the last 20, 30 years of
her life. She wrote a memoir with her life in the journalism industry. She will present
her experiences. I will ask Catherine to come up n ow.
[Applause]
Thanks. Thank you. I'm really pleased to be here in this very distinguished group of speakers
and audience. And thank you, Frank, for those nice words. I'm here representing the consumer.
I have been a hearing aid consumers since 2002. I wear hearing aids in my right ear
and a cochlear implant in my left ear. I wear them all day every day. I wouldn't have life
without them. But we have a -- we have come a long way since the first days of hearing
correction. But we still have a long way to go. That guy on the right looks food -- looks
very familiar to many of you. As Frank has said and studied, only one in seven people
who benefit from a hearing aid wearers one. And we all have a pretty good idea of why
this is. Costs, the perception that they don't work very well, and the stigma of aging. I
agree with the first two. Hearing aids are incredibly expensive and not reimbursed by
insurance most of the time and they don't work well for many, especially in noise, but
I disagree about age. This is a graph which shows you that about two thirds of people
with hearing loss begin to lose their hearing before the age of 60. Mostly in the decades
of 20 to 59. I lost my hearing when I was 30 originally. And then Frank just showed
this graph which is why I think we think that hearing loss is for the elderly. All those
people who get hearing loss in the earlier decades add up to about 80% of people over
80 having hearing loss. So it's very easy to understand why we equate the two. But I
think as a consumer, this is important because I think this reinforces the stigma of age.
If we could realize that hearing loss affects people of all ages, I think we would all be
much more likely to wear hearing aids. People often ask me what hearing loss sounds like.
I can't say generically what hearing loss sounds like. I can only say what my experience
sounds like. I think we all experience hearing loss in different ways depending on the degree
and the nature of the loss, the kind of correction we have, the kind of person we are. And the
relative difficulty of the challenges in our daily hearing environment. Uncorrected, my
hearing loss sounds like this. Actually peaceful. It is lonely but peaceful. But when I put
in my hearing aid, and people start talking and cars start going by, it sounds a lot like
this. It gets louder and louder and louder. Still, I wear it anyway because when it's
quiet, I can hear birds chirping, I can hear a stream gurgling, I can hear so many things.
But I can't hear anything without my devices. So they are essential to me. Even though we
all hear d ifferently, there are common elements in the way we experience the onset and progression
of hearing loss. I want to talk about two of these here today. The first is that all
but the most resilient people, when they experience hearing loss especially sudden hearing loss
or serious hearing loss over a period of time, can find it really emotionally devastating.
We grieve the loss not only of hearing but also of our way of l ife. Hearing loss affects
how we work, it in -- affect our enjoyment of music and movies and lectures, our relationships
with family and friends, and for many, including m e, that emotional reaction begins with denial.
My hearing isn't that bad. I don't need a hearing aid. I'm sure you've all heard that.
I did that for two decades. More than two decades actually. In 2002, after more than
20 years after I was given a diagnosis of fairly severe loss, I got a hearing aid. I
got two because by that I could not hear in my right ear anymore. I did not give up denial
at that point. I -- my ENT would find the cause, managed to reverse the progression.
Because my hearing loss is undiagnosed. I began researching hearing loss myself. Delving
into my health history, hoping for a clue. And instead, my hearing continued to drop
inexplicably and infuriatingly. And so did my spirits. I sank deeper and deeper into
depression. In 2008 I lost the minimal remaining hearing in my left ear. Most of hearing in
my right ear as well. I isolated myself increasingly at work. I worked at the New York Times. And
with friends. I avoided the cafeteria. I avoided meetings I should go to. I never went out
for drinks afterwards with people. The low point for me came a little bit later. I -- it
was during that period in 2008. The night of Obama's first e lection. I watched the
election returns alone at home on my couch. I told my friends I couldn't come watch with
them. I drank too much. And I fell asleep before I even knew that Obama had won. Always
accompanying this d epression, there was anger at my hearing, anger at my colleagues, anger
at my husband. I was short with my kids, I was estranged from my friends. I was angry
with the hearing aid industry for not coming up with better products. I was angry at my
audiologist for not being able to make me here again. I was angry at science, angry
at the world. Following year, I got a cochlear implant but mine was not a joyful Eureka experience
as other people have described unfortunately. All that negative stress made it very hard
for me to adjust to my cochlear implant. And so did years of neglect. I could not get an
implant in this new jik until almost the time I did because FDA regulations prohibited it
because I could hear in my right ear. Left ear was basically death for 30 years because
-- before I got my cochlear implant. -- it was deaf. By the end of the year, I left my
job. Despite the cochlear implant and the hearing it, I couldn't do the work. And I
wasn't interested in doing the work that was offered as a substitute. So by now it was
January of 2010. I was out of work, I was deaf, I really was that rock-bottom. The only
way to go up -- the only way to go was up. Anger actually helped, surprisingly enough.
Anger was Mike originally incentive for writing my book. I'll show them. I'll show them what
I've been through. I'll show them all how badly they treated me and how unsympathetic
they were. Fortunately, I moved on. That's not a good premise for a book.
[Laughter]
And as I researched hearing loss and as I got to know a lot more people with hearing
loss, I gradually was able to put it into perspective. And eventually, I reached in
this familiar graph which I'm sure you know about, that elusive stage of acceptance. I
was able to accept that hearing loss is part of who I am. Because I write and speak about
hearing loss, it's a big part of who I am. But it's by choice. I own my hearing loss.
Hearing loss does not own me. That doesn't mean that I don't have occasional fits of
what the blogger calls your jik rage. Hearing loss is always there. And always ready to
trip you up. The second thing I want to talk about is hearing aid marketplace. I think
most consumers find it incredibly frustrating -- one people don't get hearing aids is because
they don't know where to begin. They don't know what kind of hearing aid to get, wish
they buy it? How can they afford it? Do they need an audiologist? People ask me these questions
all the time and I say, I don't know. I'm a writer, not in audiologist. No to your doctor.
Go to an ENT. -- go to your doctor. I had a very good audiologist recommended by my
ENT who guided me through the maze. Even now I'm not sure where I've been or how I got
here. My first pair of hearing aids back in 2000 to costs $6000 which was a major buyout
of my salary. When I applied for insurance, I actually did get something, $500 for two
hearing aids. With subsequent hearing aids I was turned down flat. And I did get three
more pairs after that. It's really to me, no wonder that so many people turn to the
big-box stores or the Internet for the hearing aid purchases. We are a do-it-yourself country
when it comes to consumerism. And we shop where we can get best bargains. So I think
we have to acknowledge that the Internet and the big-box stores are a part of hearing aid
community. I think that what we can do is to make sure that the pardon -- that the bargain
comes with a good audiologist. For those of you -- -- my audiologist spent hours and hours
with me. The acoustically ideal environment of her office seemed fine. That I would be
assaulted by street noise. Speech would sound imprecise or be fuzzy in the real world. I
would go back, she would fix it, I'd go back. And still I was hurt too much of what I didn't
want to hear and not enough of what I did want to hear. Sometimes my hearing aid inched.
Sometimes it was too tight. I don't know how it would get tight and not tied in, but it
did. I would take it back, I would shave it off or adjust something or send it back to
the manufacturer. Each time I got a new hearing aid through her, she did what I think all
audiologist would do, she immediately scheduled three follow-up appointments in that first
30-day period. And to readjust and preprogrammed hearing aid. Often that was not enough and
I still had to try a different brand because my hearing is complicated and not very good.
Above all, she stuck with me cheerfully through these many, many years of hearing it. I'm
sure that I was far from her least cost effective patient. Even this paragon of audiology had
lapses. She did not explain that getting the most from a hearing aid takes practice and
patience. She did refer me to a hearing loss support group -- didn't refer me. She didn't
tell me about rehab programs available. None of my hearing aids had a coil until two years
ago when I specifically asked for one. This is not unusual. 40% still do not have tell
coils. -- telecoils. Finally, I bought the Bluetooth for use with the telephone. And
it works as long as I was in a quiet place. As I quickly realized, I was now at the mercy
of my cell phone p rovider. You cannot make a call unless you have cell phone service.
Even when you do, there's a natural lag of the sell phone but also additional lag from
the Bluetooth. People say they cannot hear you. Which I always found very ironic since
most of the time I can't hear them. Generally though, the phone continues to elude me even
with all the devices I have. A year ago my son called -- my son is an adult -- I had
no idea who it was. He said he kept saying it is Will. I was saying, you want to talk
to Will? He's not here. Now at least I think I would finally recognize that it was Will
even though I might not hear what he was saying. And I like many people rely on captions, which
are fine. I won't say more about that. Two years ago, I got an FM system. Also from the
same audiologist. It's much more versatile than the i, -- ICOM. You can put it on the
podium. The first time I used it for any sustained period was on a trip to China. It was fabulous.
I heard everything he said in a crowded marketplace and Museum. I was absolutely thrilled with
it. But the controls -- I don't know how to use -- the one on the left is what I wear.
That's the receiver picked the one on the right is the transmitter.The controls are
all on the device that does up here with the speaker. And that doesn't make any sense.
It's me who needs to be able to change those controls. There was a small volume control
but not a way to change the p rogram, not a way if I'm somehow on the wrong channel
to change it. I'm not about to walk up to the podium and start fooling around with it
in the middle of somebody's speech. Also, this device has many moving parts. Four obvious
ones. Two devices and two charges but also also to things inside. One of them always
seems to be broken. It connects to the phone but there's no sound. Someone talks into it
but I don't hear it. I plug it into the TV and that mute the TV so my husband cannot
hear i t. Finding out why it doesn't work involves visiting the audiologist again. And
generally weeks and weeks of waiting while one part after another is sent pack to the
manufacturer. My hearing aid is sent back to seven -- to see whether it is the quiet.
A few days after I get back, it stops working. I've been going through this for almost the
entire time I've had my device. But I went through it especially this past fall. And
over the Christmas break, I spent a lot of time fooling around with it myself and I discovered
that the one part that hadn't been checked was the charger for the transmitter. So the
transmitter was charged when I was in the audiologist's office because she plugged it
in but -- no wonder I wasn't hearing. Quickly by now, I have come to know the rep and she
agreed to send me a new charger. At the moment I have a working FM system. And that model
is not one that is used in the hearing aid industry. That direct-to-consumer model. But
it is what the implant companies to routinely. I know my rep at advanced bionics. And now
I know my rep -- thank you for providing this quick fix, Natalie, to my FM system. It's
far more efficient. I don't understand why it isn't done in hearing aid business. Meanwhile,
I want to say that I have Bluetooth in my car. It connects to my phone. Automatically
and effortlessly every single time. So there's something there with room for improvement.
In the past couple years, -- I'm not going to talk about this. I want to show you this
picture. This is a photo of my bedside table on the trip to China. With my chargers and
my equipment, which as you can see probably needed their own suitcase. I do wonder why
it's not possible to make something more like a universal charger. Every charger is different.
In the past couple years, I have experienced looping, which is another hearing assistive
device. It's amazing. I hear better with looming -- with looping then I having years. I don't
have to carry around any charges. I don't have to put anything around my neck or on
my head. It's great but it can't solve all of our problems. I think we really -- looping
advocates need to remember this. You cannot use it if you are profoundly deaf. If you
don't wear a hearing aid -- or an implant, you can't use it if you don't have hearing
aids except by putting something around your neck. You can't use it if you don't have a
telecoil. As I said before, 40% of hearing aids don't have telecoils. You can't use it
mostly if you don't know the loop is there. This loop -- these are two variations of it.
It should be displayed like that, both inside and outside the venue. The Gershwin theater
in New York where wicked is playing is looped, which is great but you cannot find out that
information anywhere on their website, in their ads, even in the fine print of their
website where the talk about devices, systems. Looping is not mentioned anywhere. I think
the biggest problem for now is that in this country, very few venues have installed looping.
Consumers don't know what looping is. They don't ask for it. If they don't ask for it,
they don't get it. Juliann sturgeons from Wisconsin has personally been responsible
for installing a lot of loop systems in Wisconsin. And she has a mission to have a loop system
installed in every audiologist's office. I didn't know about looping because my audiologist
didn't know about looping. If she didn't know about it, she had not experienced it. And
didn't realize how useful it would be for me. If she had had a looping system, she could
have demonstrated it for me, I might have gone to my favorite lecture Hall and said
there's this great system, it's going to cost you a few thousand dollars but many people
will benefit. More people will show up. You want more gray hair in your audience, get
that looping system in there. And I think we would begin to see a lot more movement
on this. There's one more thing is that I personally can't use looping without the backup
of CART over there. In a looped environment. And I had to turn around to look at the CART
to see what was said. Somebody had introduced me as a celebrity. That's the other reason
I like t hat. So --
[Laughter]
We would all like to be happy consumers. But we're not there yet. And I want to say a few
other things. I think we need -- first, we need standardized, best practice protocols
at every level. The marketplace is truly a chaotic mess. Consumers are overwhelmed by
the choices and the cost. Audiologists, social workers, nursing home employees, need to understand
the emotional toll that hearing loss takes. They need to understand when they are confronted
with denial or a nger, where that's coming from. And they need to encourage that person
to find a sport like HLAA or ALDA. Turn that negative into a positive. Every audiologist
should offer the same minimum checklist of services. Ideally audiologists should also
be able to test hearing aids in a real world environment. I know that's possible. Downtown
Manhattan has one. It is amazing to walk into a room that sounds like the Street. And see
how well your hearing aids work or don't work. All of this would benefit the industry as
well, as it would undoubtedly reduce the rate of returns from consumers who have not been
educated about the hearing loss, have not been counseled about the need to practice
and come back in for reprogramming. Who have hearing aids that don't fit properly. Hearing
aid companies need to get their act together and give us hearing aids that work even in
noise. They need to bring their prices in line with other consumer electronics. I think
we are all baffled by why this is not possible. They also need to make assistive devices that
work and that are simple to use. Government needs to mandate coverage for hearing aids,
cost of not providing hearing aids is far higher in terms of unemployment and cognitive
kind and dementia than the cost of providing them. You're going to hear a lot about this
over the next few days as Frank said a minute ago. And finally, hearing aids should be as
common and effective and affordable as unremarkable -- as unremarkable as glasses. Thank you.
[Applause]
Katherine, thank you so much. We're going to open our first session which is on the
topic of aging and hearing loss, I'll ask our panelists to come up to the table in the
front. This panel will serve as a segue into the workshop, what healthy aging is, and the
first group will be epidemiologist and scientific director of the national Institute on aging.
We have Jim Furman, and we have Kathy pitcher-Fuller, a professor of psychology, one of the audiologists.
We will start -- start with Dr. Fujii.
Thank you to the organizers of this meeting. This really is an honor to be speaking at
this audience. And I also want to thank Frank. Three years ago he came in my office and opened
my eyes on this very important problem that is related to aging. I have the very challenging
task of introducing you to the aging field and to what is healthy aging in 10 minutes.
10 minutes is really a very short time if you are a human being. I'm going to try to
do my best. And I will say that I could summarize all my talk in this s lide. This is really
the cycle of a lifetime. And start with crawling on the ground, but very soon and fast, start
walking and running. And then there is a period where very little seems to me -- in terms
of the aging process. In fact, aging is hiding in the body. A lot more is occurring in this
stage that allows us to maintain good physical and cognitive function because there is continuous
adjustment and utilization and strategies that allowed you to maintain these activities
and this cognitive function in spite of changes and loss that occur during the aging process.
And then this idea of reserve, it's important because when functional reserves become to
be discarded and composition doesn't work anymore, there is a moment of decline and
the decline accelerates. Most of individuals -- I think in the lucky individual, it is
very, very short and in the less lucky individual, much longer. There's a period of disease and
disability. This is a summarization of the concept we have in mind about aging process.
But there is incredible variability here. Some individuals, this trajectory is maintaining
high up to the last day of your life. There individuals that start showing functional
decline because of the disease or other causes, much earlier in life. And when I give a talk,
usually people tell me that -- how do you explain this variability? I think there's
an incredible opportunity in fact because if aging can be in some individual, be a square
trajectory where we are happy and enjoying every moment and every occasion in life up
to the last year about life, means that maybe we can find the secret to extend this experience
to many more individuals. Then if we want to start measuring aging, then we need to
have some solid parameter that we are dealing with. So in the last few years, we have been
talking about, what are the domains that are important for the quality of aging? And to
make a very long story short, we are trying to summarize four domains -- variables that
can be measured in an individual and give us some idea, measurable idea of how good
is aging and what is the quality of aging? That is extremely important, because we cannot
change what we cannot measure. We cannot demonstrate that something is effective and we can make
aging better if we cannot measure aging. And they're mostly four domains. There are change
in body composition, change in energy imbalance, and these occur in every living individual,
not only human beings but also in every animal model that we have studied before. So that
they occur unavoidably with aging. They may be incredibly well compensated, so they have
very little effect on the experience of life in that individual, but they occur in everybody.
So I'm going to start by talking about energy imbalance because it gives me an example that
I can use to then shift to what could be the reason why in fact, hearing loss can have
an effect across the four domains. It doesn't really have an effect on social isolation,
but it can actually have potential impact on the physiology of aging, impact every domain
that occurs in the aging process. So let's say, what is energy? In order to work in the
e nvironment, in order to do everything we like to do, dancing, reading books, talking
to a friend, we need energy. Energy is the amount of energy that you can stand in a day,
usually expressed as fitness. The amount of energy that you can generate in 24 hours.
I'm simplifying a lot here because I'm using this as an example. Then you have this amount
of energy that you can use it one day. And then if you don't use it, if you use it too
quickly during the day, you don't get enough for the entire 24 hours, at some point you're
going to die. And you're going to die because a large part of this energy is used. Just
to maintain the function, the vitality of your body. 50 to 70% of your energy your body
produces is just to stay alive and doing nothing else. If you wake up in the morning, and you
are not eating, doing nothing, that is the 60% of energy that you need to use. Then there's
another amount of energy that is used for other purposes. Now, that is in a healthy
individual, but in an individual that is a little bit less healthy, for example fighting
with disease of disability, part of the extra energy maintained is used to maintain this
homeostatic equilibrium. I we use a very simple example. If you have the flu, you're generating
antibodies. Protein synthesis, highly isotherm it. Use enormous amount of energy. If you
use that energy to create antibodies, there's a lot of excess energy you have to read books,
to dance, to talk to your friends, to go out for dinner. All the things that we like to
do in life. So in aging, what's happening is that the amount of energy you are given
to use every day, the box of energy you received everyone is becoming a little bit smaller.
The amount of energy you need to just stay alive and fight the disease of disability
is a little bit larger. So these shrink, shrink, so in fact, disease impact on your energy
availability -- by that mechanism, also impacts your functional s tatus. You can think less,
you can walk less, you can do a lot less activity. Not directly related to the disease because
the disease is eating up the energy. You have less energy to do those activities. Now, if
we use the same analogy -- I'm going to skip this slide so that -- in the area of neurodegeneration,
we think about hearing loss, the first thing that comes to mind is that there is a nice
American saying that you can -- walking and chewing gum -- the people that are able to
walking and chewing gum -- I think is such an incredible intuition. We have two activities
that need to be done at the same time. In an individual that is healthy and has absolutely
no problems, it can be done without even thinking. Without -- in a natural way. You can walk
in a natural way without thinking that you are walking. Without thinking about it but
if for example you start having problems in your mouth and chewing gum requires some attention,
then I can tell you that you're walking is going to slowdown. It is a principle where
we know that if you have a cognitive and physical activity -- of their ongoing in your brain,
unless you are very, very young and very, very fit, you're going to slowdown and the
experience you have, probably every day is that you see people that slowdown on the street
as they are using the telephone and in f act, there are signs that show that -- there is
a car in front of you, it's going slower because somebody is talking on the telephone. And
you cannot -- you want to scream because you want to tell them, you cannot really talk
on the telephone while you are driving. And there are other issues for example that people
that play the organ that know that when you are using the pedals, it's really, really
difficult to do something really fast in your upper extremities. So there's interference
in the brain. So I apologize with the neurologists here because I'm slicing the brain in a very,
very agnostic way -- and there are parts of the brain that are functional reserves in
yellow. Some of the brains that are important for cognitive motor function. There's certainly
a part of the brain that deals with hearing. And when you have problems with hearing, when
you have to spend more energy in your brain to understand what is coming from your ears,
what's happening is that this area -- this energy expands. Because of with aging, the
functional reserve is reduced, this is going to have an impact on the ability to do -- in
practice, you're doing the tasks. You are doing a cognitive task constantly. That cognitive
task is going to interfere with any other function that you are dealing with in that
moment. Your balance, walking, your ability to deal with sudden obstacles. So that the
entire range of your functional status is going to be affected. Older age is often associated
with a state of brain susceptibility, reduced acidity and functional reserve. Additional
requests to the brain compete with finite resources, may have functional consequences
and increased fragility. Because of the reduced assistant, effective adaptation is less likely
to occur. Hearing loss may have a negative impact on expected functional domains. Thank
you very much for your attention.
[ Applause]
I'm not sure -- I just hit the red button and it moves? Okay. Good. Make sure it is
pointed over there.
Okay.
My name is Jim Furman. And I'm thrilled to be here today. For really three reasons. I've
had a hearing loss all of my life. I've experienced the consequences of a mild loss, moderate
loss, severe loss over my lifespan. I understand at a personal level the benefits and limitations
of treatment, not only hearing aids but speech reading education. 30 years ago, when I had
a full head of hair, I was at the Robert Wood Johnson foundation and work with Barbara Weinstein
and tried to convince my colleagues that aging and age-related hearing loss was a serious
problem and something should be done about it. I did not succeed. We did not succeed.
But I have a feeling that we are at a different moment in history. And this -- these two days
might mark a historic turning point on this issue. Third, as the CEO of the national Council
on aging, one organization whose mission is to improve the lives of millions of older
adult, I'm alarmed by the prevalence and consequences of untreated hearing loss. So what I'd like
to do in the time allotted to me his address what I see as some of the key issues affecting
-- related to age-related hearing loss in this country. First of all, as we've heard,
it's a prevalent condition where two out of every 100 children has hearing loss and one
out of 14 people under the age of 65 has hearing loss, 40% of people between the age of 65
and 84 have hearing loss is and two out of three people over the age of 85 have hearing
loss. So clearly, we're talking about something that's prevalent. The prevalence alone isn't
enough to make a compelling case. Diabetes is prevalent and clearly we have a crisis
there. But sinusitis is prevalent too and we don't worry too much about that. So prevalence
matters, but it isn't sufficient. The most -- another really critical and unusual characteristic
of hearing loss is that it is invisible. You can't tell who has a hearing loss by looking
at them. You can't tell the severity of the loss -- and you have no idea what it means
to them. So look around this room. Raise your hand if you have normal hearing. Put them
down. Thank you. Raise your hand if you have some level of hearing loss. Okay. Keep your
hand up if you have a mild to moderate loss. If you have a moderate to severe loss. If
you have a severe to profound loss. So we would not have known that about these people
in this room. We just know there's a group of people. We know some of them have hearing
loss is. We don't know how much hearing loss they have. And we don't know what it means.
But here's the real issue. A critical issue in understanding this issue. Hearing loss
is not only invisible to you, hearing loss is visible to those of us who have hearing
loss. We are aware that we are missing things, but we have no clear idea about how much we
miss or what we have missed. And we have to understand this if we are going to solve the
fact of bridging the gap before us. And now with the help of my colleague, I want to hopefully
demonstrate for you what I'm talking about. We're going to -- I'm going to tell you -- starting
at the beginning. The first one is just a level set to see what normal hearing is. Okay?
I'm going to stop after this one.
Please adjust the volume so that this is the level of normal speech. One, two, three, four,
five --
That was my son. My college son who helped me put this together. So now, one of the most
common questions that I get is I will be at a concert and my wife and other people will
say, do you hear the music? Honestly, I don't know what that means. So we're going to pay
for -- place of three segments of music in a r ow. If you have a severe to profound loss,
we're not going to bother playing it because wouldn't hear anything. What you're going
to hear in sequence is what the music sounds like, to a person with a moderate to severe
loss, then with a mild to moderate loss, then with normal hearing. Play the next three please.
[Music]
That was moderate to severe. This is mild to moderate.
[Music: Dancing Queen]
Now moderate.
Thank you.
So now raise your hand if you could hear the difference between those three. Raise your
hand if you couldn't really hear the difference between those three. So what you've heard
there is something that people don't hear -- when you say, did you hear the music? I
heard the music. People with mild to moderate heard the music. People with normal hearing
heard the music. But what effect does that have? What's the effect of not hearing music?
Quality-of-life may be. What's the effect of going to a movie and missing the dialogue?
Quality-of-life. But there's something more important. What about communication? If you
can't understand what your boss, coworker is saying to you, what your spouse is saying
to you, what your child or grandchild is saying to you, what's the effect of that on hearing?
Now we're going to go through the same sequence for a conversation in a restaurant. Severe
to profound, not going to demonstrate because you can't hear it. First, let's have three.
Let's listen to these. Moderate to severe.
[Indiscernible] [Indiscernible -- low volume]
Mild to moderate.
Menu -- certain terms -- the way to go --
Normal.
So I'm looking at this menu, was jumping out at me is surf and turf.
Definitely the way to go. That's great here.
Thank you. Thank you very much. The key to this is that none of us can understand the
problem or empathize if we don't have a sense of the degree to which it is affecting us.
The other thing that's really important is what you've just heard is a dramatic loss
of function. But in fact, what happens in a gradual age-related way, you don't hear
those dramatic differences. The core issue here is most people with hearing loss do not
understand what they are missing and therefore they are not motivated to take action. Took
a long time, but thank you. The next thing that's really important is that it is insidious.
The consequences are not obvious, and they're first -- pervasive. We're going to hear from
experts on this subject about the psychosocial impacts, but the most important one as far
as I'm concerned is the inability to hear well, inability to communicate well, makes
it much harder to continue to be an active, engaged and contributing member of society.
After looking at this model of people, not participating, not staying at work, not staying
involved, it's really hard if you have a significant hearing loss that's untreated. The next thing
about this is a treatable condition. Even people with severe hearing loss can function
at a much higher level with proper hearing aids and treatment. We know they are not pervert
-- perfect. We know you can't restore 2020 hearing like we do 2020 vision but it can
be significantly improved. But one of the concepts that I've learned is not just about
good hearing aids. It also requires really good speech reading skills. When I was seven
years old, because of PL 504, I was pulled out of second grade and given speech lessons
twice a week. It is the amplification, plus the ability to read lips that enables me to
function. When Frank -- Frank Lin was t alking, I could hear him when I could see him. I closed
my eyes, and I missed 50% of what he said right now. We have to recognize that if we
want to correct this problem among older adults, it's not just about amplification, it's about
auditory training and speech reading as w ell. When you do the research as people are
doing now, on the comorbidity of vision problems and hearing l oss, you find those people can't
function in part because they can't speech read. If you don't believe me, throughout
this conference, close your eyes for a couple minutes when somebody is talking. And you'll
start to see how important speech reading is as part of the problem. We also know as
we've heard, it is often untreated. Six out of 10 with moderate to severe application
-- don't have hearing aids. 70% of people between 65 and 74 don't use hearing aids and
half the people of other ages are not using hearing aids. We did a study 14 years ago
on the consequences of hearing loss on older adults. The reasons that older adults gave
us for not using hearing aids blew my mind. 69% of all the people with untreated hearing
loss said that, my hearing isn't bad enough. I can't get along fine without a hearing aid.
I can guarantee you as a person with a moderate to severe loss, there's no way that you are
doing fine and getting along fine without it if that hearing loss is not treated. Consumer
concerns about expense are very significant, but I don't think those of the real reasons
people don't get hearing aids. The one that blow -- the one most mind blowing for me is
vanity and statement. 20% of people say it would make me feel old. I don't like the way
I would look. I'm too embarrassed to wear one. They are not too embarrassed to respond
inappropriately, to pull out of situations, to be viewed as senile, but they are viewed
-- too embarrassed to be seen wearing a hearing aid. This is astounding for me. And finally,
because my time is up, this is not a priority for policymakers. Nobody is seriously talking
about expanding coverage for hearing a ids. We cannot yet make a case to Medicare that
it is cost-effective and we could do this. Medicaid, which has covered hearing aids may
be cutting back because of cost pressure. The VA is a deacon of all of this and hallelujah
to the VA. The fundamental issue is the policymakers and general public are unsure whether this
is a lifestyle issue, healthcare cost issue, or a public health concern. This conference
should help move awareness on that issue. Finally, this is a solvable public health
challenge. We know what's happening. We understand the interventions. It's not like we have to
create some new solutions that don't exist. What we have to do is create the awareness
of the problem and move together with collective action to make a difference. In summary, this
is a prevalent condition, an invisible condition, insidious, treatable, often untreated, not
yet a priority for policymakers, and a solvable public health challenge. Thank you.
[Applause]
All right. I'm an audiologist. Also an experimental psychologist. I'm going to share with you
my perspectives on why it matters. More importantly, I'm going to share with you the perspectives
of a particular older adult who lives with hearing loss. This was a woman who attended
a talk I gave on hearing and aging at a meeting of the Canadian hard of hearing Association.
She says when you are hard of hearing, you struggle to hear. When you struggle to hear,
you get tired. When you get tired, you get frustrated. When you get frustrated, you get
bored. When you get bored, you quit. She was feeling very victorious, because she said,
I didn't quit today. And I think what we would like for all healthy older adults is for them
not to quit. But unfortunately, many of them avoid this cascade of problems from hearing
issues, cognitive issues, emotional issues, social issues by simply withdrawing from social
interaction. That is absolutely not where we want people to go. Now, many of these speakers
already this morning talked about how aging is a gradual process. We heard about the 20
years that Kathryn took before she sought help for her hearing loss.We have before us
here something you're going to see over and over again. We pretty about -- heard about
audio grams. This is the ISO medium thresholds for men and women across the decades of life.
I've drawn that redline because all of the lines, all of the marks above are in the normal
range, clinically speaking in terms of this average Frank spoke about. Below the line,
you are in the abnormal range. What we see here is that in fact, for women at the age
of 70 and men at the age of 60, half of the population actually is not in the zone that
would be considered to be clinically significant hearing l oss. Half of them are not yet candidates
for hearing aids, but they have problems. Some of these problems are accumulation of
lifelong problems, some of them are specific age-related problems that manifest in those
high-frequency losses in the audiogram. Some of their hearing deficits are not seeing the
in the audiogram. There also invisible to the clinician because we're not measuring
them. And so my point is there are many types of age-related hearing loss. This heterogeneity.
And we really have to think about what happens in the early stages. That's what I'm going
to draw your attention to now. So people have understood that people who still have pretty
good audio grams, who can have quite an easy time and -- in a quiet, ideal situation, even
more than for younger people, older people have difficulties in what I would call challenging
listening conditions. These are conditions where there might be noise like traffic noise.
There could be multiple talkers, you could be unfamiliar with the talkers, what they
are talking about. You could be multitasking as Dr. Carucci mentioned, while we are listening
and doing something else. The pace could be fast. It could be challenge because you are
trying to get to you -- used to a new technology or you have a serious health issue, heaven
forbid in a healthcare encounter you're trying to understand what your doctor is trying to
tell you. So healthcare situations have to be right up there in the top list of challenging
listening conditions. So how do people deal with healthcare in general when they have
a hearing loss? Again, what we don't want is for these every day realistic, challenging
conditions to be the kinds of situations where you stay home as Katherine told us that she
did. All right. So what we could do is ask people, how do you do out there in everyday
life? Which is a questionnaire like the speech, spatial and qualities of hearing aid scale.
We would find big age differences on the items that had to do with conversing in an adverse
environment and where we have to use that cognitive energy to focus and switch attention
like you would have to do in any kind of social interaction in a group. And the poor scores
that we see circled in red for many of the older adults on that scale, we would not know
from their audiogram and not know from simple words and noise measures that clinicians might
do in the clinic. So the plot thickens. What is it about everyday life? Let's move to more
competent speech materials. Going to like a full sentence. This isn't a lecture. Just
a sentence. And we have the speech perception and noise test list where in illest there
are 50 sentences. The person has to repeat the sentence's final word. Half of the sentences
give a clue to what is the word, no? Was a context. Store your coffee with a spoon. A
zebra has black-and-white -- o kay. You knew what I was going to say. You've got ahead
jumped on me because you could deploy context. The rest of the sentences do not have helpful
context. John did not talk about the spoon. So we get this test in a range of signal to
noise conditions. I hope you are going to hear more about signal to noise ratios today.
Roughly speaking, we are going to going from a quiet living room to the minus five being
in a noisy aircraft. The kind of conditions you are in every day. Without context, 50%
of the words are correct for young person, just below zero. 50% are correct for an old
person above zero. So we can quantify the challenge of noise to an older person with
a pretty good audiogram, not even talked about hearing a lot yes as being about three DB.
We can look at the difference between performance for high versus low context sentences. Horizontal
lines. And nicely, the older people get more benefit from that context than the gun. Also
to the magnitude of about three dB. The young and old are doing the job of listening, they
are arriving at a performance level but doing it in different ways. Young people are using
the signal, old people who have had gradual changes in their hearing for a long time are
using more of their brain to get the job done. Could we simulate this? We heard a nice simulation
from James. In our experiments, we simulated the temporal aspect of auditory aging. And
we can make the performance of the young people drop down to the level of the old people.
So we can simulate the signal-to-noise challenge. But then what happens? Once you get that signal,
what do you do with it? Part of development in general is that there are gains and losses.
So in cognitive development, there are gains and losses. What happens? We saw that old
people use context more. When we put the young people in the simulation, they also use context,
but putting them in that -- somebody used the word garbled I think -- Frank did -- the
garbled experience of listening, old people are much more proficient at using context.
They've developed a way of doing this over time. Young people do not get instantly better
at using context when faced with a garbled input. On the loss side, we can also make
young people remember like old people when they have that little distortion in the signal.
Okay? So we see the consequences, the declines in processing that might be secondary to poor
signal input. We can simulate that in young people. What we can simulate are the longest
-- long-term compensation processes, to use semantic knowledge. We have these old people,
over 20 years, listening, using their brain to do the work that they're ears can't do
so efficiently.-- their is jik. What happens when we have them in a clinic and we're giving
them the Montreal cognitive assessment? Well, if you can't hear the word, that's kind of
a no-brainer. No pun intended. But let's just take the words which in the learning trials,
people did repeat correctly. And how well do they remember them? So the older adults
have much higher blue bars, they are recalling the items at a delay, which they could successfully
repeat in the learning trials. The people with hearing loss have more equal blue and
red bars. So they repeated those words. Does that prove they heard it? At some level, they
did, but they can't remember it a few minutes later. If we look at the difference over the
five words in the delayed recall portion of the MoCA, there's no difference. Where the
groups are different are on the first words of the list. So you hear it with difficulty,
you can succeed in repeating it, but you can't hold onto it. You can't do things with it.
Like remember it. You can't do all of the cognitive things that you would like to do.
Let's just push this a little further to some social and emotional connections which we
heard in that initial quote. We have been playing around with some data. This is some
Swedish data from the Betula study and also the same people that did the MoCA test in
Toronto. In this model, we see that age contributes to the changes in hearing and memory. Hearing
contributes to changes in memory. And that through cognition, hearing results in reduced
social participation. So we have that cascade. And I think somehow, part of what you're going
to hear in these two days is that we really have to unpack that cascade. Using various
research approaches and to use those to inform p ractice. So I would say to you, hearing
loss is that you -- diagnosed medically but it is experienced socially. There are year-brain
networks which are plastic in the short run -- ear-brain networks and ultimately in the
long run, there is deterioration in processing and understanding information as it goes down
in time. There are interactions with social situations. The physical environments are
enormously challenging and accessibility is a problem. People with hearing loss -- there
are health implications in terms of, how do we promote healthy and active aging? How do
we even save them from adverse events that they are going to encounter because of communication
problems? How do we facilitate their ability to self manage health issues? How do we get
them to adhere and benefit for all kinds of health issues that rely on communication?
So I disagree with Jim that the solutions are not all there. We have some auditory solutions,
but we need to put it together with a broader perspective that includes the cognitive, social
and environmental approaches.
[Applause]
I want to thank all our s peakers. We are going to take a break after this session,
so we're going to finish up at 10:35. So we probably have about seven or eight minutes
for questions from the audience now. We will ask if you do ask a question, please do come
up and use one of the microphones if possible.
So do we have --
A number of the speakers -- I'm John from hearing foundation in Canada -- a number of
the speakers have referred to a stigma. That's something that we've been doing or trying
to do some work on in Canada as well. I'm just wondering if you know or if people can
talk to the work that's being done on stigma affecting the use of hearing aids or even
the acknowledgment of hearing impairments here in the states?
Okay. That was the slide I took out in the interest of time. So my colleague, Allison
Chastain is a social psychologist. And of course, is it Sigma to a ging, he hearing
loss, are these two different things? We are a bit unclear on that. So these same 300 people,
that we've had in this big study, we measured their stigma to aging. And in a nutshell,
what we found -- we are writing this up now -- is that people -- these are 50-year-old
and plus -- some of them have a little bit of hearing loss, but if we just look at people
who have no more than a mild hearing loss, we measured their hearing, measured their
cognition, they have self-report measures, they have the stigma measures. Stigma to age
is related to actual performance on both memory and hearing. And it is mediated through self-report.
And the contribution of stigma to age is independent of actual age. So now, what we don't know,
because it's not longitudinal, are the people who are performing poorly developing negative
attitudes towards aging? Or are the people who have negative attitudes toward aging declining
faster? And we really need this answer to know how our interventions might need to address
stigma to age and self efficacy before we even begin to deal with hearing. So it is
a hot topic.
[Captioners transitioning] They are probably not aware of how they are
being perceived. Because they don't hear. And I think that is a construct we have to
change in people's minds.
Next question?
One of your slides mentioned airplane noise. For situations an airplane during an accident
during a terrorist event there has been somewhat concerned about national national security
and emergency response, either programs going on now to take into account people with hearing
loss who are in those situations and cannot understand the emergency instructions.
I don't know about airplane specifically, I doubted. Some people, there is very clear
concerned about even people in their own homes hearing fire alarms. And help people with
hearing loss are not going to have a fast response they need in order to survive. I
think even in hospitals, noise and hospitals, we have in our national media recently had
an example of a hospital on the prairies were people are supposed to be quiet and resting
and getting better in hospitals but hospitals are tremendously noisy. They redesigned the
hospitals so people could actually sleep and recover after their surgeries. We have standards
for classroom design. But why don't we have standards for healthcare environments? Why
don't we have standards for long-term care facilities? We do need to move on accessibility,
vastly beyond justice.
Just a nonscientific answer, there may very will be a safety issue but it seems to me
the much more prevalent consequences are not hearing what your doctor tell us you to do,
not hearing what your spouse tell us you to do. My son, from college when out the door
and waved goodbye and my other son said did you hear what he said? He said I am going
to the diner, do you want to come with me? I did not here, my son thought he I didn't
care enough. I think it is insidious subtle consequences in everyday situations where
we really need to focus the most attention. I think that affects everybody. If I am in
an airplane and I have to evacuate and I do not here it I will hold be person next to
me and they will take me out. It is insidious and affects every situation but to me the
most fundamental situation are the inability to communicate and therefore the impact in
terms of a contributing active member of society.
There is literature that shows there are more adverse events in healthcare. With communication
disorders. I've been trying to talk the -- we does hospital management and the geriatric
hospital where I do some research because they're looking at patient flow. How long
does it take to get a patient through the admissions process and on through different
stages in a hospital event. And I would love that to be broken down according to people
with hearing loss or not and I bet you there's a lot of inefficiencies in the processes that
go on in the hospital because you have to repeat things because people don't understand.
I personally have been in the number of emergency situations I slept through a fire in a hotel
because I did not hear the fire alarm. My husband had surgery and the surgeon came up
to tell me the results and zero so anxious that my hearing was worse, and I did not hear
a word he said. Even though I asked him to repeat it about five times. The EMTs come
to my mother, the doors open, the alarms are still going, trucks are coming, they are saying
I don't know what they're saying. They're asking me about my mother's condition. I cannot
explain it. I think these emergency situations are really important and there is by the way
a fire system you can hook up with your own fire alarm that is a light operated system.
I have never been able to make it work but it does exist. If that technology could be
simplified, that would make a huge difference at least a home or if they were installed
in hotel rooms. Fire is a really important issue. I agree with that speaker, we need
to think about these.
We will take one more question and then we will break for a few minutes before the next
session.
You mentioned the invisible nature of hearing loss. I'm curious from a public health standpoint
how or where does that start to become visible for the patient? Besides the wife. More from
a public health standpoint. From a society public health standpoint to make it visible?
If a people have a vision loss you put the glasses on and it's obvious to everybody.
You don't have the equivalent of anything that simple and elegant in that situation.
Part of the problem is the fact that hearing loss is supposed to be so much correlated
to aging. Even in primary care. You could capture hearing loss in the early stage and
try to correct it whenever possible, it does not occur because it is just one of the many
things of aging. I remember talking to -- the prevalence of hearing loss is enormous. 60%
of the centenarians have significant hearing loss. And if you talk to them, hearing loss
for them is -- they are afraid that something is going to happen to them and they will not
be able to react. They're happy about everything else but they are constantly complaining.
I think that sensitizing be society is an important problem and including and including
one of the issues is important.
I want to thank all of our speakers from our first session. [ Applause ] And we will come
back here at 10:45. [ The event is on a break and will resume at 10:45am EST. Captioner
standing by. ]
Everyone please take their seats, we are going to get started.
For the sake of saving time, please be seated and we can start and allow the speaker as
much time as possible. And we are going to hear something that really follows back to
the hopes that we heard this morning. About the connection between hearing loss and healthy
aging. We have three really outstanding speakers. [ Indiscernible ] from Johns Hopkins University
who is also one of our collaborators. Alan [ Indiscernible ] is one of the world experts
on disability from Boston University school of Public health and Barbara Winston will
talk about the psychological aspect. She is from the University of New York. I think we
will just start and allow you as much time as possible.
It's a great pleasure to be here this morning and I also would like to thank the organizers
for preparing this really important meeting which I think is going to have very long-term
consequences. Just because I am always in the habit of presenting disclosures, I have
here a list of the organizations with which I am a consultant and have grants that might
be relevant but in point of that -- fact I think there are no disclosures for my presentation.
I have been asked to speak this morning about the impact of hearing loss on cognition. And
what I'm going to be talking about -- I will focus on the longitudinal studies that show
an association and hearing loss an incident dementia. An association between hearing loss
and changes in brain atrophy. And a number of other people about why there might be these
links. And cognitive decline it's a few words about potential future directions. You saw
this slide from Frank talking about things that might be associated with cognitive decline.
That might be relevant. I will be talking about the first two. And function and how
they might lead to cognitive decline over time. A relatively few in number. Cross-sectional
study that showed hearing loss longitudinal studies and declines in cognitive performance
over time. People who are not demented at one point in time and followed longitudinally.
Longitudinal imaging studies because I have a relatively finite amount of time to talk
to this morning what I wanted to do was to focus on two different types of studies. One
of the studies that have been done that use pure tone on the almond tree to assess hearing.
There are two studies on two studies on incident dementia that I'm going to talk about two
of them changes in brain volume I will present one and that I will talk to a recent study
is impressed looking at declines and whole brain volume and volumes. So they two studies
on commit cognition and one is called health ABC stands for health aging and body composition
study. 3000 individual 70 years and older. The longitudinal study I will be talking about
comes from the Baltimore longitudinal study on aging. Diagnoses of clinical groups of
individuals. Were part of what's called the autopsy study. The major outcome which looked
at declines with the digit symbol substitution test. The one I'm going to show you this morning
is the substitution test. I will show it to you, I wanted to emphasize that this is a
pretty multifactorial test. So you will see when you look at it. It is a test that is
given to people that they have to do within a defined amount of time. So speed is relevant.
Such that, you have to compare one item with another. Or start shifting is also relevant
and attention and I will show you what I mean so this is the task. It consists of people
seeing a series of digits. A series of symbols. And their task is to copy that this symbol
to go with the digit. If you understand the instructions to the task, your hearing ability
is irrelevant. As long as you understand what you have to do. Copy these symbols as quickly
as they can. And obviously then and you have to be able to pay attention. And you are shifting
back and forth between and the symbols incidental memory is important because if you begin to
learn these digit symbol pairs it is a test that is not of a particular multifactorial
and it is sensitive from the health ABC study these data show us that these individuals
who were followed up to six years individuals who had normal hearing performed much better
over time and a 32% greater rate of cognitive decline. Among the people with hearing loss
and another of confounders so that was pretty striking data that individuals over time are
performing more poorly on this test that does not require that you actually here and everything
else is incidental to that. The other piece of relevant data has to do with incident dementia.
Most of you know what we mean by dementia it was a syndrome, a particular diagnosis
of a particular disease. In order to be diagnosed with dementia you have to have progressive
declines in mental ability to the point where you are no longer able to function independently.
The way we define this is you have to have impairments in two or more domains of cognition
and of course the important thing is you have to have at one point in time have been performing
better and this represents a decline. We're not talking about lifelong disabilities. So
when you think about progressive incident dementia of course dementia just does not
happen overnight, it happens very gradually. The question is how long it takes people to
being normal to being mildly impaired -- impaired, reaching me sort of boundaries where we say
they reach a diagnosis of dementia. The best data related to the relationship with hearing
loss an incident dementia comes from the Baltimore longitudinal study on aging and this is what
the data look like. Over here you see the proportion of people who are dementia free.
So everybody starts out being dimensioned free. The question is what is the relationship
between hearing loss and time to develop to be given a diagnosis and you can see right
away that there is a very striking relationship between hearing loss and time to develop dementia.
You look over here these are the hazard ratios, the strength with the relationship and the
significance and -- a number of other covariates that might be relevant to the outcome. In
this study were 639 people were evaluated following is -- followed for over 10 years
there is a really convincing and striking relationship between hearing loss and time
to develop cognitive impairment. This is just -- in case there are questions about the analyses
I should say there were a lot of other ways in which the data were looked at. These findings
seem to be -- hearing loss and brain structure. A number of studies and this is one of them
individuals with poor hearing and reduced gray matter. Brain volume in the part of the
brain that has to do with hearing. The auditory cortices. This is the left auditory cortex,
this is the right. At this is demonstrating declines in the volume of brain matter in
both of those regions. This is the control area looking at motor -- the motor cortices
showing no relationship. Again cross-sectional he a very strong finding but you wonder whether
or not this is true at one point in time and does not get gradually worse. These are data
from Frank and his colleagues related to the Baltimore longitudinal study on aging and
they were fortunate sense this is a longitudinal study, they were able to ask the question
not only is there an association between hearing loss and atrophy in the parts of the brain
I have to do with hearing because you can imagine that the connections between those
parts of the brain are getting worse and so that might be the reason for some change in
brain volume but whether or not in fact there are changes for globally in the brain. This
is a much smaller study because this is a sub study of individuals who had not only
analyses of hearing but who had imaging as well. There were 126 participants overall,
75 with normal hearing and 50 with hearing loss. And a mean follow-up was about six years.
These are the findings.
It is really quite striking. If you look here in this last column, you will see not surprisingly
that in the brain regions related to hearing, there are significant changes over time. The
temporal lobe, which is where these regions are located also has a significant change
over time. But more importantly, there are global changes, for global changes in brain
matter, global changes in white matter suggesting that perhaps there is a cascading effect,
a broader effect in brain volume among individuals with progressive hearing loss. This is just
a very -- for those of us used to looking at brain images, this looks all right but
I know to you it is very confusing. The main reason I wanted to put it up is that the interesting
thing that nobody really understands is that more of these changes are in the right hemisphere
then in the left hemisphere. I would love to know people's thoughts about why that might
be the case. This is the bulk of the literature we have to think about and respect to this
question. I think the conclusions you come to from the literature so far are pretty clear.
With respect to the longitudinal studies of cognition, hearing loss is clearly associated
with declines in cognition overtime and with incident dementia. With respect to the longitudinal
imaging studies, it is clear that hearing loss is associated with an increased rate
of brain atrophy overtime, whole brain atrophy as well as brain atrophy in the focal regions
that are related to hearing. What could explain this association and why am I presenting both
the imaging data and the cognitive data to you this morning? The hypothesis that I have
come up with is that hearing loss is associated with increased brain atrophy and the evidence
would suggest that it is just in the areas that have something to do with hearing. But
in those individuals who have accumulations of other types of brain pathology, Alzheimer's,
microvascular disease, what ever it might be, you have in essence a double hit. A particular
will level of pathology and over that you add pathology related to hearing loss and
that is why overall, you have these two processes that contribute to declines in cognition and
that enable people to cross this arbitrary threshold. I have here a slide that is trying
to present this hypothesis. If you imagine that this is -- these are people who have
pathologies of various kinds, Alzheimer's pathology, microvascular, whatever it might
be, if you add to it the pathology related to hearing loss, brain atrophy, and you know
that a total amount of brain damage is required to reach this threshold, that might explain
the reason that hearing loss is associated with incident dementia.
Obviously, if this is a modifiable problem, what might we do about it? In order to know
if it is modifiable, in order to know whether these relationships really are true and can
be impacted, one possibility would be to conduct a randomized clinical trial. For you to people,
you gave some individuals with hearing loss a hearing aid, treatments of various kinds,
you waited to give the other group hearing aids, and you followed them over time. You
looked at their cognition, you looked at diagnoses related to dementia, you looked at MRI volumes,
and perhaps you looked at other things that we are going to be hearing about on this panel
this morning, things like social engagement and quality of life and if you saw that there
is a strong relationship in randomized clinical trial between hearing loss an incident dementia
and cognitive decline than that would be the time to say there is something that we can
do about it. I think that that will -- I hope this will be a topic that will be discussed
further this morning and I am really pleased to have been able to talk to you. Thank you.
[ Applause ]
Thank you. I have the privilege of looking at the topic of functional consequences of
hearing loss. That you and there are some interesting parallels in the literature that
Marilyn reviewed on the cognitive consequences. As others have mentioned this morning, hearing
loss is seen by many to be a communication disorder but hearing loss may have much more
wide-ranging consequences such as those that Marilyn talked about in the cognitive area.
In the functional area, it has been hypothesized by various people that hearing loss can increase
the risk of falls and injuries, it could lead to increased limitation in an individual's
function as well as subsequent disability. And it can reduce one's activity in participation
which can lead to decreased quality of life. These are very broad topics and I certainly
cannot cover the full range in a 15 minute presentation, but I will try to touch on some
of the highlights in the research that has been done. In terms of the functional consequences
of hearing loss, I am going to highlight some of the most recent longitudinal studies and
the potential functional consequences and I'm going to try to draw some conclusions
and make some recommendations for future research in this area. The first question is the one
of whether or not age-related hearing loss may be related to falls. Here I'm going to
focus on some studies that have been done in Finland, the Finnish twin study that looks
at false risk. These investigators hypothesized that hearing loss would lead to increased
risk of falls that postural balance would act as an important mediator between hearing
loss and subsequent false. They studied 423 women, mean age was 68 years. A clinical audiology
or and postural balance was measured on a spectrum. Falls were tracked on 12 monthly
calendars. You the findings from these studies said falls rate were the best in quartiles
-- per 100 person months. Two or more falls, 30% in the poorest hearing group reported
30%, two or more falls versus two or more in the best 200. Higher false risk was partially
explained what may look at and controlled for postural control. However, even after
controlling for posture, those with poor hearing still had a twofold increased risk of false.
The second question I wanted to touch dog is hearing loss related to limitations in
one -- once function. Here again I will turn to Finland and the Finnish twins study where
they looked at the impact of hearing loss on walking ability. Again, this was focused
on women only age 63 to 76. They had follow-up measures over a three-year period. They used
a clinical audiology are and for walking speed they looked at 10-meter maximum walking speed
measured in a court or using photocells for timing. They also looked at the six minute
walk test to look at endurance of walking and they used patient reported outcome measure
of one's perceived difficulty in walking 2 kilometers without resting. The findings from
the study with respect to hearing loss and walking are as follows.
First of all, 41.2% of the participants in this study had impaired hearing correlated
cross-sectional it with poor mobility. In age-adjusted logistic regression, the women
with hearing loss had twice the risk, and odds ratio of just over 24 new major difficulties
in walking 2 kilometers as those without hearing loss. For another study that looked at this
issue, looking at both function and disability, I will go to the study of Janet Altman which
is the group of Franklin where they used the health ABC cohort study and the impact of
hearing loss of function and disability. As Marilyn said it is a prospective cohort study
with annual visits and for this study they looked at years one, four, six, 10, and 11.
They had over 2200 adults from two states and they ranged in age from 70 to 79. They
looked at uncorrected hearing loss measured by pure tone audiology. Lower extremity function
was measured by the FPP be index which is an index that includes measures of gait speed,
standing balance and one's ability to rise repeated Lee out of a chair. They also looked
at incident disability assessed using a patient reported outcome instrument that was not specified
in the publication. They observed a small dose-dependent effect with greater levels
of hearing loss associated with poor function over time and among women interestingly, greater
risk for incident disability. Results were robust to adjustment for multiple potential
confounders in their analyses. This shows you some of the data. They looked at visits
one, five, 11, normal mild and moderate hearing loss and you can see the magnitude of the
differences.
Women with moderate or greater hearing loss had a 31% greater increased risk of disability
compared with those with normal hearing. This association was not seen for men in this cohort
study. Fully adjusted analyses restricted to individuals with mild or greater hearing
loss found that individuals who used hearing aids had function scores at visits one, five,
and 11 that were not significantly different than individuals not using hearing aids. No
significant attenuation in the risk of incident disability associated with hearing aid use.
Interestingly, this goes back to one of the priorities that Marilyn talked about in the
cognitive area which I think is also extremely important in the physical function area is
to really investigate carefully whether or not hearing aid and other forms of adaptation
to age-related hearing loss, will they have a moderating effect of these kinds of relationships?
In this study, that was not observed. However, as the authors rightly point out, measures
of hearing loss are very crude in this cohort study. Data on hours of hearing and hearing
use and hours of data that they where the hearing aid, the number of years they use
the hearing aid, the adequacy of auditory rehabilitation, none of those were available
in this study. They had a crude measure of whether or not someone used a hearing aid
or not. It did not have an attenuating effect on the relationship they saw. Going on to
the Alameda County study where again they looked at a variety of measures of function
and disability, this was published a bit longer ago. This is a one year prospective cohort
study with just over 2500 subjects. They used a patient reported outcome measure of hearing
loss and they measured it even with the use of a hearing aid. They were looking at not
pure tone, and that hearing loss, but hearing loss with using a hearing aid. 48.5% reported
some hearing loss, 17.1% reported moderate to severe hearing loss. They looked at the
Association of hearing loss with the ability to perform ADLS, I ADL, physical performance
measure, measures of depression and social participation. They had a wide range of punctual
outcome measures to look at over a relatively short period of time. In terms of their findings
interestingly, they found no consistent association with hearing loss and performance of ADL,
I ADL, or physical performance. They did however see a very clear association with social functioning.
You and these are the measures that they used. Measures of social functioning that included
a question about feeling left out, feeling lonely or remote, hard to feel close and cannot
pay attention. These are odds ratios for those with mild loss and those with moderate or
greater loss. And so they did see a consistent association with social functioning but not
with any of the measures of physical functioning that were available in this study. Finally,
the question of going beyond physical function and looking at more disability behaviors such
as driving, the question of his hearing loss related to driving behaviors? When you look
at this research, past research has shown that people with hearing impairments do appear
to be more likely to have stopped driving. I referenced this particular article that
reviewed some of the literature. And then in a Québec study, they looked at daily noise
exposure and measured hearing loss and they saw that it was associated with greater risk
of traffic accidents as recorded in a database collected from driving records in Québec.
They saw a very clear association with those exposed to daily noise with measurable hearing
loss and traffic accidents. And then I want to call your attention to a study in Australia,
Queensland University of technology published in 2010 where they studied 107 men and women
with a mean age of 73.5. They measured hearing with pure tone audiology but in addition they
used a patient reported measures of the hearing handicap inventory for the elderly scale.
They reported that 26% of the subjects had mild hearing loss and 19% had moderate to
severe hearing loss. They drove a 5-kilometer closed course wearing glasses and/or hearing
aids. They allowed them to adapt to the hearing loss if they usually wore it. They drove with
and without auditory and visual distractors. They had both herbal and visual requests to
report sums of numbers presented while driving. As the distractions. I can't imagine doing
that. But they did it. I would love to get that part of the IRB. Interestingly, they
found no individual hearing measure, whether it was pure tone audiology or the patient
reported measures associated with overall driving performance on the closed course track.
No Association. They controlled primarily for age in their analyses. Interestingly enough,
they did see a significant interaction between hearing impairment in the presence of the
distractors. People with moderate to severe hearing impairment had significantly poor
driving performance in the presence of distractors as compared to those with normal or mild hearing
impairment. To summarize, in terms of the state of the science on the functional consequences
of hearing loss, existing studies on the Association of hearing loss with incident functional decline
are really inconsistent. Some studies demonstrate a positive association and others find weaker
no significant association but it depends on a lot of factors, primarily having to do
with specific functions one is looking up and how one measures the hearing loss. Hearing
loss when you look across the literature from my reading of it, it appears clearly to have
some real a relatively modest functional and disability consequences based on the literature
available today, which clearly could affect one's quality of life. However, the heterogeneity
in the study results is likely explained by many differences across the studies. The state
of the science is far from mature in this area. Many differences in how hearing is measured.
Some use subjective self-report, some use an object of clinical audiology. Whether a
hearing aid was used, many times is not taken into consideration and in some of the studies
it is not even reported. What disablement distant -- dimensions are being assessed very
widely all the way from falls to walking to performance of ADL, I ADL and driving behavior.
Futurist search for my perspective we need to clarify what is the right exposure variable
for the specific question that we are interested in. Uncorrected hearing loss is most commonly
assessed as was in the cognitive study. I find fascinating the question of whether or
not hearing aids and other forms of other correction is going to have a modifying effect
of these kinds of Association. That work is really not been done, much like what Marilyn
pointed out in the cognitive area. It has not been done in the physical function area
as well. For my perspective prior to jumping into controlled trials, I would love to see
some really careful observational studies with and without correction over long periods
of time. Before we really commit to doing trials in this area. At least in the physical
functionary.
When the focus is on disability behaviors such as driving, from my perspective as well
as things like social participation, hearing loss with correction may be a more meaningful
exposure variable then pure hearing loss without correction. If you want to know whether or
not it will have an effect on what people do in their realize it seems to me with vision
loss, you would never study the effect of vision loss on driving without correction.
It seems to me with hearing loss the same approach should be taken when the interest
is disability type behaviors, such as driving as an example. Finally from my perspective,
the functional outcomes on the surface seems very simple but in fact, this is a very complex
area. We really need to clarify those most important functions that may or may not be
related to hearing loss and not just pick those that are available in the existing cohort
studies which tends to be what we do and understandably so. I understand all the time. Once the capacity
-- such as walking, and prevents event such as false are critical for further exploration
as well looking at disability behaviors such as driving, social function, ADLS and quality
of life. Thank you very much. [ Applause ]
Thank you very much. I think we have had the appetizer. And I hopefully will be presenting
significant information convincing you that the science is further than some literature
would suggest. And I have spent the past couple of weeks combing through the literature, doing
my own systematic review. And I was very convinced that when I started looking at the psychosocial
effects of hearing loss in the elderly in 1979, there was nothing on this area. Having
done this systematic review now, there's a lot. When I started in 1979, Jim Firman had
hair, I had no gray hair. And we looked like Frank Lynn. We have come a long way. Unfortunately,
hopefully, you'll see the compelling evidence that we are in the rates space. Right space.
The first issue is hearing loss as a chronic condition. A number of different tests we
have to identify whether or not -- for when a condition is a chronic condition and I think
the most interesting ones which are not as obvious, substantial economic burden in society.
Not a lot of literature that. There is a large gap between evidence -based treatment and
practicing hearing. There was a huge gap over an extended period of time. A number of health
professionals, definitely hearing loss. And hearing loss frequently goes untreated until
more accurate -- and as you will see moderate to severe hearing loss. Biggest issues. Hearing
loss definitely meets the test of chronic conditions. Also chronic conditions are associated
with -- when we are looking at what is clear is that the goal in healthy aging is that
independent is -- psychological well-being. For chronic conditions you have what I have
done is gone through I have been to Japan. I've been to Australia, Italy. It's remarkable
what I come up with. It was emphasized that I must cover -- in the 15 minutes I have allotted
and hopefully will be commenced the evidence. BlueMountain hearing study in Australia. The
blue Mountains I study, the -- very low study, Medicare beneficiary studies have looked at
hearing loss and its consequences all the different core let's and by the time you are
finished you will be convinced that we have we had to treat an address hearing loss. Interestingly,
I was most impressed by the homogeneity in the outcome measures that people using I was
touched to learn that the questionnaire I developed in 1982, after eight -- widely used
questionnaire so this studies throughout the world, and disease specific measure of hearing
loss, hearing handicap inventory translated in every single language you can consider.
Generic measures, the studies I will be talking about use the best health outcomes study as
of 36. Most of the studies that we will be talking about use the -- ideals and ADLs functional
status measure. The first question that I will start with and following up is in the
area of functional disability functional disability in terms of cost and the issue of whether
or not relates to it and the research on that I have reviewed this is one study and I will
not be able to talk about this the study had over 600,000 that were surveyed in Australia.
Hearing loss, self-reported hearing loss. 40% had a self-reported then there are these
were asked to rate the order of the that they felt were limiting their lives. And the third
one that came up was self-reported hearing disability. And that's the only that didn't
measure hearing loss. However you measure it and it is really important. And here we
have a study by [ Indiscernible ] McMahan. They have done a lot of work and they have
have a large sample a number of different longitudinal studies. Measured hearing loss
is associate with ADLs and I ADLs.
Moderate to severe hearing loss has the greatest relationship to ADL and IADL. But hearing
loss of any severity is related to reduction in the ability to perform ADLs and IADL. Hearing
aid users were more likely to have impaired ADL. Hospitalization risk, health burden.
Burden of disease, another study with Franklin and his colleagues. And they used the database
and they looked at burden of disease. Burden of disease number of self-reported physical
and mental -- hospitalization. They did find that hearing impaired participants, hospitalizations
in the past year. Hearing loss was significantly and independently associated with increased
healthcare use and with burden of disease if you talk about self-reported hearing problems
over the past 30 days. And then in another study, they found that self-reported -- self-reported
hearing handicapped was independently associated with low self regulated health. Self rated
health is very important. It is related to mortality and a number of significant endpoints.
Self rated health is a very important outcome measure that we should be focusing on. Next
to social isolation. Social isolation is an important area. Lack of social contact or
more self perceived subjective experience of lack of social connections. I became interested
in social isolation in 1978 when I found that you can measure social isolation. My dissertation
was on hearing loss and social isolation in the elderly. I was discouraged from doing
it because nobody else had looked at it. From that point. Most people were not really that
interested in the psychosocial effects of hearing loss. Most of the literature was on
profound hearing loss. I persevered because my mentor -- at the time I wanted to measure
the relationship between -- and how information is encoded. Description of hearing losses.
I also wanted to have an estimate of how information is decoded. There were not that many test
available so I looked at how hearing lost and I looked at auditorium processing was
related for those of you ideologists, and for hearing handicap I use the -- that was
the best one available at the time and he used the monosyllabic words. Important to
look at the different ways -- but eight did not know what the right way is. I used subject
and what's interesting is that each measure of hearing was related to isolation. The strongest
relationship was the subject of -- the object of experience and the strongest relationship
was was self-reported hearing handicap. The next strongest was in terms of auditory processing
measure that cognitive load involved in understanding speech. The weakest -- the weaker correlation
was with pure tone and monosyllabic word recognition. Interestingly I broke my sample groups. The
people who are most subjectively and objectively isolated were the ones who had the worst measured
hearing, had the poorest in terms -- the poorest in terms of self perceived hearing handicap
and he had the most challenging auditory processing. Interesting that I did all those measures
and interesting what you will see later in terms of what we know now in terms of what
hearing measures relate to for outcomes. Recently in 2008 another study on -- from out of Australia,
3000 participants , Hawthorne found that the likelihood of self perceived social isolation
increased with the number of chronic conditions and notably, depression had the strongest
association with subjective social isolation followed by self-reported hearing difficulties.
Hearing difficulties came up before this as a correlate of social isolation. Depression
. Depression as we know is prevalent in the elderly. 15% to 20% of older adults do have
a report of that have been diagnosed with depression. Like hearing loss, depression
goes undetected and untreated. It is one of those invisible chronic conditions.
McDonald did her dissertation in Canada on risk of developing depression and on hearing
loss and hearing handicap and depression and she used the CST and to look appeared on hearing.
Self-reported hearing problems using the hearing handicap inventory accounted for more of the
variance depression than hearing impairment. And there is a strong relationship and in
these recent study in Japan -- and colleagues, a large sample longitudinal, what they found
is that you odds of depressive symptoms were high in people with hearing handicap as compared
to those without hearing handicap. Hearing handicap, self-reported -- was an independent
predictor of depressive symptoms. Hearing impairment was not. It does matter how we
measure it and it's very important to look at hearing to make sure we have all the measures
available. They did conclude that self-reported -- handicap does predict depressive symptoms
in the Japanese. [ Indiscernible ] and the blue Mountains hearing study found that depressive
symptoms were significantly higher in those with hearing loss and there was an independent
association between hearing handicap and the presence of depressive symptoms. I think I
will not go into falls because -- I will mention you do that a study that was not mentioned
was by Stevens, they looked at a large sample of Medicare beneficiaries, over 12,000. They
identified state -- this statistically significant risk factors for falls and people who had
a high number of -- inability to perform ADLs, functional limitations and individuals with
depression were at risk for falls. In their sample interestingly 30% of their people in
their sample who were at risk for falls did have hearing loss. Hearing loss is quite prevalent
among individuals who have reported falling and in this slide you can see 45% of the sample
with poor self rated health reported falls, 32% of the individuals had difficulty hearing.
It is prevalent, falls are prevalent among people who cannot hear, and most likely it
is -- hearing loss is a risk factor for falls and that would be reason enough to screen
everybody with falls for hearing loss. You we spoke about the Finnish twin study. The
possible -- is hard to walk and talk, top-down and bottom-up challenges. The hearing and
vestibular mechanisms share some structures. Those could be mediating variables for the
falls when they have hearing loss.
This hearing loss impact independence by increasing reliance on support systems? That would be
a question about independence. And the reliance on support systems would mean if you need
to use more family support, if you need to use more formal support systems theoretically
that would suggest that you would be less independent. This was an interesting study.
This was again a blue Mountain hearing study. 2800 people, about 33% of the individuals
had hearing loss. Most of the studies I will talk about, the prevalence of hearing loss
in the sample, 33%, hearing aid use about 14%. There is a theme in there in terms of
the prevalence of hearing loss and utilization of hearing aids. It was interesting, hearing
loss was associated with increased use of community support and informal support systems.
Hearing loss was a predictor of community use of community support after five years.
And severity of hearing loss mattered. Again, here we have people with moderate to severe
hearing loss were at increased risk and needed to use community support services. Interesting,
people with moderate to severe loss had a higher risk of developing reliance on community
support as compared to the hearing impaired. What was interesting is that the people who
used -- the individuals who use the support systems were more likely to be hearing aid
users. You can interpret that one way or the other. The use of hearing aids for their sample,
the people who had hearing aids were at increased risk for the need to use community support
services.
Mortality. This is an interesting area, and I think it is a valuable area to explore as
well. This was [ Indiscernible ] and collects. The blue Mountain hearing study. And what
they found is that in their sample, 33% hearing loss. The individuals with hearing loss had
greater difficulty walking than the individuals without hearing loss, greater cognitive impairment,
poor self rated health and higher probability of having diabetes. What they found is that
hearing loss severity was connected to mortality, but it was through mediating variables. For
walking difficulty, through cognitive impairment and related hearing loss. It was an indirect
relationship and they used structural equation modeling. Which in order to be able to highlight
the relationship between hearing loss, mortality and variability, and what you can see here
is that there is not a direct pathway between hearing loss and mortality, but hearing loss
is related to cognitive impairment, disability and walking, these are all related to self
rated health so there is an indirect correlation with mortality so this is why these are some
of the functions that we have to look at when we look at the effectiveness causality, not
implicated here. It does not mean causality but this is an important Association. Quality-of-life.
When we think about quality of life, persons perception of health, social interactions,
physical function, psychological function are important when we think about quality
of life. There are a number of studies, the Dalton study was -- out of the epidemiology
of hearing study. Collaborating with the people in Australia. Dalton found that self-reported
hearing handicap, severity of hearing loss was associated with reduced scores on the
several domains of the SF 36 hearing handicap correlated with more of the hearing impairment
but both correlated very significantly in a convincing relationship. Also, hearing loss
-- severity of hearing loss -- severity of communication difficulties as Jim mentioned,
communication is key and hearing loss communication are interrelated. Severity of hearing handicap
associated with lower summer scores on the PCS and MCS scales of the SF 36. Jia and his
colleagues and that was part of the Baltimore -- the Blue Mountain hearing study. Relationship
between quality-of-life and hearing loss people with moderate to severe hearing loss. Associated
with poor scores on the PCS, MCS scales of the SF 36 and five of the eight dimensions.
Moderate to severe hearing loss -- when you get to that point, that is really when you
begin to measure and see the devastating and disruptive effects of hearing loss. But we
know both high and low frequency had poor scores than people without hearing loss. People
with both high and low frequency loss scores on -- people with only high-frequency hearing
loss and only people of high-frequency hearing loss had comparable scores so it matters the
severity matters, the frequencies that are involved matter. And there is a trajectory
in terms of hearing loss in quality of life. Over a ten-year period. The people who developed
incident hearing loss were much more likely to have reduced quality of life. The value
of hearing aids is -- I want to end on a possibly slightly potentially up note. That we have
work to do. Hearing aid use correlates with perceived need for improved hearing. Hearing
aid use correlates with feeling disabled by hearing loss and hearing aid use relates to
a feeling of being limited in terms of the ability to participate in society, which Jim
mentioned. Hearing aid users, the value of hearing aids in these different studies that
I talked about, many of the people that have hearing aids and what they found is that hearing
aid users utilize and needed more support services. Overtime, hearing aids had been
quality-of-life on the physical scale of the SF-36. And less of a decline in mortality
than non- hearing aid users. I want to leave on a good note. In that hearing aids do have
some sort of an effect. What we know from Hogan, his 600,000 individuals hearing aid
users had better quality-of-life than non- hearing non- hearing aid users. But they had
a poorer quality of life relative to the general population. What I would like to conclude
with is proposing the fit model. Might explain and many of these different functional and
psychosocial effects. And we have work to do in terms of future research. Just a few
suggestions. What are the absolute and relative risk reduction, is important public health.
Reduced with what is the time to create clinic full desk clinically meaningful reduction
of the concern about rising to benefit. And conclude the ability to hear communicate and
understand really matters. [ Applause ]
Thank you very much. Three outstanding speakers. We have time for questions. Please come to
the microphone so everybody can hear your question.
I am Paul [ Indiscernible ], public health researcher from the University of British
Columbia. To everybody, it seems clear that there is Association between hearing loss
and physical psychosocial and functional outcomes. Can we predict the people who are going to
be most at risk for these negative outcomes property beyond the severity of their hearing
loss. Which factors predict good outcomes and which factors predict bad outcomes property?
In the literature I reviewed my answer would be the research is not sufficiently mature
to answer those questions yet.
I am Donna Sorkin, the director of the American cochlear implant alliance. What I heard all
of you say is the little bit of work that we have done on the effect of hearing aid
use typically did not get at a fine-grained look how people were fit, whether they had
received rehabilitation, etc.. And I would like to make a pitch for ensuring that when
we're looking at hearing aid usage particularly in the severe to profound range and we know
from the data that most people who use hearing aids have a severe to profound loss. And many
of them should be using cochlear implants because they are not getting sufficient benefit
so we really need to distinguish between those people who are fit appropriately and who are
getting appropriate benefit from them. My 89 -year-old mom has a moderate loss and does
dramatically better with her hearing aids on. It is astounding how much better she does.
Clearly, if she were in the severe to profound range, maybe not that same kind of benefit.
When we design those studies, we have to make sure that we are looking at how people are
doing with their implementation, and take a look at those elderly cochlear implant users
who have had moved up to that level. And how that is affecting vote -- both the dementia
scores and the functional physical scores as well.
We know that cochlear implants are effective in improving quality of life and elderly individuals.
And yes, there is a huge need for randomized control trials on the efficacy of hearing
aids in terms of the importance -- the outcomes that are important in terms of public health
outcomes and we have to of course have good measures of the hearing aids, we have to -- the
studies and most of the studies looking at the psychosocial consequences hearing loss
includes large groups of hearing aid users, the hearing aid use is and after question.
The issue is that people with hearing aids are doing better without hearing aids but
they still have significant problems because they have other issues as well. It is a very
packed question.
I would just add obviously rhetoric randomize controlled trial is what is needed next. And
I would argue that it is in the part of the thing you would want to do is see how will
hearing aid is improved by people wearing hearing aids. Using one or not would not address
the question you raised.
Two comments. One complementary, one provocative. I do think that intervention studies with
the proper intervention are essential. I would caution it is not just hearing aids. And it
is speech reading otherwise. we're not really looking at and that is true cross all three
domains. I put myself -- I blame myself for this as well. I am struck by how ageless all
of this research is. I am stating this little strongly. It starts with an assumption that
all people are keeping them -- avoiding more -- [ Indiscernible ] like dementia. Keeping
them functioning or improving their psychosocial functions. The real question we're not asking
is there and ability to work and are they continuing to work they don't have the financial
research otherwise. Contribute work, how much do they volunteer and to what extent extent
do they participate in the family, taking care of grandchildren and other people. If
we start with this view that this is just about nonfunctioning people who are not expected
to contribute to society, that is a [ Indiscernible ] point of view. We have to turn this around
and say we have a tremendous resource of 70 million people, baby boomers growing older,
and the most important imperative is to keep them working and contributing and what is
the effect of hearing loss untreated and treated on those outcomes?
My questions have had preempted by the previous two speakers. I do think that the end point
of this is how will hearing aids work in the individuals who you are looking at for continuity.
I am assuming probably that you are going to find out good hearing aids and good hearing
correction to reduce belly solve the people who are wearing hearing aids that don't work
very well for them and part of it has to do with rehabilitation and other kinds of -- learning
to where you're hearing aids all the time even if they are properly fitted. But the
endpoint is that we need I am not sure hearing aids are not very effective. Including people
in the workplace, here dementia is terrifying we have to measure and we have to put a lot
of pressure to make the hearing aids work for everybody.
[ Captioners transitioning; please stand by. ]
A.
Mentoring Barbara Weinstein SF 36 S F-36 CEASD CSD
CSD CSD S-D CES-D.
Is.
I think we as -- we talk about hearing loss. Is it a medical crisis as we develop? I think
it is. Yet, we don't treat it that way. You're sick, you get an MRI, you break, you are this,
but I love the idea of why the medical model does not fall and hearing loss as it does
for cancer or anything else. Why aren't we doing MRIs and doing functional MRIs to look
at how a patient is responding and after treatment, what do we see plasticity improve? Are we
looking at -- is our outcomes with treatment better? We're all heading this direction to
where pretty soon we're going to be paid based on outcomes and best practices and how well
your clinic is doing. So that's one question about looking at post treatment. Do we see
patients getting better? Regarding the hearing aids, as an audiologist, that's what I do.
I try to help patients. But I think that the industry has faulted and created more of the
mess that we're into. I just googled living well with. And I can tell you that hearing
loss never comes up. It's living well with arthritis, diabetes, alcoholism. This is stuff
that we put on ourselves, right? Alcohol, drugs? We do this. As is part of life. So
living -- living well with everything -- what I here is that hearing loss affects us in
so many ways. And it's disconcerting that the industry is pushing out all these hearing
aids at 142-decibel output to do what, to loosen your molars? I think it comes to a
point, hearing aids work but you have to have a mechanism -- because this is an external
device. What happened to the implant that basically then goes back and sends -- that
stimulate the dendrites on the nervous system for you to hear again? I have patients with
implants that I don't know -- that they don't here. So this is an industry issue. I wish
that this Council would be more proactive with the hearing industry to get them to really
fine tune what their missions are and make dispensing and the rehabilitation more direct
at a patient outcomes to prove that what we do does the right thing. For them to stay
active. Just a comment, but thanks.
I will also add as long as I am appear -- you can't throw anything at me -- the hearing
aid manufacturers -- when you get a hearing aid, -- the biggest problem people have is
-- difficulty understanding speech and noise. We understand that the way in which you can
overcome that problem is ensuring the speech must be lower than the noise. Got to get the
microphone close to the speaker. Why is it now people have to pay an extra $500 for a
remote microphone and then extra $500 for the streaming to enable you to use the remote
microphone when in fact the whole reason why they are coming to you is for that device
that's going to help you understand better in noise? I think it's important that we don't
keep adding on to the cost of a product that is so, so expensive. And with those products
of course, there's problems in terms of figuring out how to use them. So I will underscore
what you suggested. I'm sure we have an audience with an open mind here. And hopefully we will
take it back with them.
Okay. I have been fascinated by this for a long time. And I was sitting listening to
you and I thought, if I were a clinician, I would be really confused right now. And
I think we need a few more dimensions to our thinking. So we are talking at one extreme
about the kind of people I saw in the clinic that made me want to go and do a PhD in cognitive
type -- psychology. These were the 40, 50-year-olds, preretirement adults, who had problems but
they did not yet enough -- having of hearing loss that they were really obvious candidates
for hearing aid. On the other extreme, we have people that are wearing cochlear implants.
We have an enormous range of hearing problems. And then we also have an enormous range going
from the 40-year-olds to the centenarians. And I think we are never going to have a one-size-fits-all.
And wrapped in that huge space of age and hearing loss are the questions, how early
is early enough? To do something? And we think we should start earlier, but how early is
early enough? Then the other question is when is it too late? I think maybe those are ways
of taking this enormous territory that would help the clinician to figure out, when should
I do something? When should I stop doing something? The other thing that runs through my mind
is we've got this small percentage of people using hearing aids and we wring our hands
about that. But maybe it's because the rest of the people with hearing problems need other
solutions. And one of the pieces of advice that I was given when I was interested in
developing the concept of hearing accessibility was given to me by a person who had -- was
in a wheelchair and he had been a leader in the anti-landmines movement. His advice was
that we were never going to get anywhere as hearing professionals if we continue to talk
about hearing loss, because it was a minority issue. But if we talk about hearing accessibility
and communication accessibility in the spirit of universal design, and that everybody should
have a conducive environment for communicating, then we can actually go to the population
level and we can actually make a difference. So just some ideas about the new territory
that we were trying to understand.
Kathy, can I quote one of your colleagues from one of the early studies that came out
of your facility? On hearing loss -- went to intervene and the quote is that we must
intervene before hearing loss becomes an intolerable burden. And that's early. But the Mercedes
$6000 hearing aid -- we need to intervene early with targeted interventions.
Maybe Frank at some point will get us to an analogy -- to another chronic health issue
like diabetes. You don't wait for somebody -- or hypertension don't wait for somebody
to be having a heart attack or collapsing before you start giving them education about
lifestyle, before you have these softer interventions that predispose people for readiness, for
self-management, and those are just not things we do. And why not?
I would make a comment that in this room, we have people who are concerned about hypertension.
We have people who are concerned about treating dementia. And the way that we learn about
when to treat people on how ill they need to be before they treatment is by having randomized
trials and looking at the outcome. That's how we learn the answer .
I think the speaker --
Dr. Luigi Ferrucci, can I say something? My name is Valerie Fletcher. I run the Institute
for human centered design in dealing with the role of design in minimizing limitations.
My question is actually about the characteristics of all of these studies samples. I've heard
only gender and age noted. We've talked a lot this morning about the cost of hearing
aids and cochlear implants and the lack of coverage for that. I'm really curious about
the demographics of culture as it relates to hearing loss and economic status. Because
with our nation moving in the direction it is inexorably moving, we better be thinking
about those things too.
I think you make a really good point. A lot of the literature did not dig deeply into
some of those other demographic factors. So it's a really good point. I think literature
has really scratched the surface in terms of really understanding the potential modifying
effect of various types of hearing assistive devices.
It's Chris Roberts. I enjoyed the review of literature. You've clearly read a lot and
prepared a lot. But overwhelmingly, it was about correlation and satiation but the thing
that matters is causation in this area, won't move forward without causation. Over after
causation data. And my interest in listening to your reviews was to try to tease out from
what you were saying which did relate to causation because there were elements of it and what
you said. I just wondered if the speakers could go through their respective areas and
make some comments on what they thought the literature said in their areas relating to
causation.
Who has the comments to address that question?
Very little. I tried to focus on longitudinal studies primarily. So that we could have a
clear time order. So I focused on mostly cohort studies. I did not focus on a lot of experimental
studies. The closest would be the driving work that I reviewed. And so I would say that
comes closest.
And I would say the same. The reason I emphasized longitudinal studies is that that seems to
get closer to a real causative relationship. But it still correlational level. We have
a lot more to learn.
In terms of cause and effect, there were a couple more slides I wanted to show in terms
of hearing aid interventions and the effect on caregiver burden and the effect on depression
and quality of life. I guess those are not very strong studies. But the earlier studies,
Cynthia and her group of physicians in Texas in the '80s did their study and they looked
at people -- they gave individuals hearing aids, they measured over time quality-of-life,
not hearing aid users, and they did find for example people who used hearing aids over
time, there was a reduction in depression. Whether or not there's a causality thing but
they did suggest that -- perhaps if we -- that's why we have to do these studies because there
are no good randomized control trials on the effective outcomes with hearing aids that
would even get us even closer to the causality issue. But at least these correlational studies,
these longitudinal studies give us a feel for what we now have to go after.
Very quick follow-up, perhaps a rhetorical question, but are we at risk of overblowing
the public health problem without causative data if we only rely on associative or collective
data -- correlative data?
The US preventive services task force did not endorse screening for hearing loss, nor
did they endorse screening for cognitive decline. Because we do not have the outcome studies
that show that if we do intervene, we're going to -- our interventions are going to have
to have beneficial effect.
I just wanted to bring up a comment -- something that struck me at the end of last session
as well. Somebody said, how can we make hearing loss more visible? Will -- likewise when we
talk about treating hearing loss, it strikes me what the problem is nobody thinks about
hearing loss until people are reaching middle-age. And then it is all of a sudden, hearing loss
is important. But with very few exceptions people are not talking about hearing loss
to younger generations. We talk about prevention of hearing loss and not going to noisy discos
or whatever they're called these days but I think the point is that the awareness that
we need to hear, we need to communicate throughout life is something we need to start getting
to the younger generation as a way of thinking. And then people as they get older will be
aware that the hearing may deteriorate and they do need to keep putting the emphasis
on being able to hear and communicate.
I just want to echo that. I think we need to look at design of public health issues
especially when -- we are trying to -- Arenas trying to compete to be the l oudest. I want
to raise the issue around doing studies because being engaged in a lot of studies related
to older adults, I get concerned sometimes about maybe coming up with some very creative
designs. I worry about the ethics of randomized control trials in certain situations where
not providing someone with an intervention raises multiple kinds of issues. We know that
-- if you look at the smoking literature, that was a very strong relationship. That's
observational but it was over time and they were so strong that they were able to finally
say, this is really negative. So I think it's not that we don't need the causative information
and randomization is usually the gold standard, but I do think we need to think of maybe other
creative research designs to look at some of these issues so that we don't run into
the ethical issues of treating versus not treating people who we really feel probably
need the treatment .
I'm Becky, a geriatrician from Pittsburgh. I was wondering in the aging field, we tend
to have a lot of difficulty getting the primary care physicians and the general medical community
to accept some of the outcomes we're talking about like cognition, functional decline and
I'm wondering if maybe we should be targeting some other outcomes that are already focused
on in the primary care arena, outcomes with disease specific for diabetes or hospitalization,
reimbursement, other topics that are hot topics when -- in the general medical field as well
and seeing if we can impact outcomes in that area.
[Indiscernible -- low volume] this has been a really, really interesting morning. And
the number of questions that have formed in my mind -- one of them is, what is the state
of the search? Or risk factors -- who is going to do well? Or is not going to do well? I
think that's a critical question because it is really decoding -- cognitive component
that may predict who is going to do well and to is not. The second question which is related
to the previous question, if we really think that the load is important, the brain does
a lot of things. And the mind does things also to regulate metabolism. And somebody
looks at whether hearing loss is associated with the chronic disease. I mean diabetes.
Talking about diabetes prospectively. The cross-sectional association doesn't count
here, but maybe that would be a vehicle by which we could talk to the primary care physicians
and say, it's not just communication. This has got to have an effect on something you
know very well and you recognize very well and you are already trying to prevent. Maybe
a backdoor to make people do that.
Obviously there are lots of large longitudinal studies that could be analyzed to address
some of the questions that you raised, for sure. Diabetes is a risk factor for hearing
loss. I was telling Frank the other day, I personally know of somebody who had a very
dramatic loss of hearing, partly because of underlying diabetes. So I agree, that would
be a very good avenue to pursue.
I would also add, I thought Jim Firman made a very convincing argument that we need to
go in both directions. His argument that we need to look at community levels of participation,
work, driving, Independents, engagement as a parent, grandparent, caregiver, these are
important social roles that could be severely compromised by hearing loss. They have not
been well studied. Somewhere, but I think both directions -- those are profoundly important
societal roles that deserve investigation as well as the more medically oriented issues
as well.
I love that you mentioned volunteerism.
I would say that I have a patient -- the reason why he was able to increase volunteerism is
because he got hearing aids. And that helped him. But who will do well and who needs hearing
aids? How do you define who do well? But in terms of fulfilling societal roles, it's obviously
very important.
If there are no other questions, thank you very much. We will reconvene this meeting
in an hour, at 1:15.
Just for some housekeeping for people that don't know the b uilding, the cafeteria is
on the third floor. You are on your own for lunch. In the spirit of healthy aging, if
you take the staircase right outside, it is two floors. They will put you right in the
cafeteria. Otherwise there is the elevator. We will start as Luigi Ferrucci said at 1:
15.
[Event is on break and will resume at 1:15.]
Hi. We're going to get started, if everyone can get seated. Okay. Good afternoon, everyone.
Welcome back from lunch. My name is Lou back. -- Beck. I have the privilege of moderating
the session on current approaches to hearing healthcare delivery. I'm going to introduce
our panelists. Our first presentation is the spectrum of hearing impairment. Our speaker
is Therese Chisolm from the University of South Florida. Our second presenter is Margaret
Hagan, a nurse and profession or of gerentological nursing at the University of California San
Francisco. Our third speaker is Nikoli B iscard. Terry, I guess he will be our first speaker.
Thank you. Thanks, Lou. I'd like to begin by thanking the conference organizers for
inviting me here today. It is a little chilly in Florida, but it's always fun to come to
DC. I was given the title and asked to talk about the spectrum of hearing impairment in
older adults. As we heard this morning, age-related hearing loss, which is sometimes also turned
-- the slow loss of hearing that people get as they get older. Age-related hearing loss
is associated with elevated hearing thresholds, meaning that we cannot hear soft sounds, it
is also reducing speech understanding in noisy and echoing environments. So it interferes
with the perception of rapid changes in speech. Leading to the common complaints that we hear
from our older patients in the audiological setting such as those shown here. Age-related
hearing loss not only leads to problems with communication that leads to frustration, but
as we heard earlier today, it's been associated with sadness and depression, worry, anxiety,
paranoia, and emotional turmoil and insecurity. Thus impacting on a person's quality of life.
Age-related hearing loss has also been associated in some studies with an increased likelihood
of depression and also decreased self-sufficiency in activities of daily living. And as we heard
earlier today, there is a relationship between hearing loss and incident dementia with Dr.
Lynn's group being leaders in examining those relationships onships today. And interestingly,
if we compare the symptoms of Al's hammers disease that are commonly given to those of
untreated hearing loss, we see that there is a remarkable similarity in complaints.
Age-related hearing loss does not have a cure. However, we can utilize many treatments to
improve everyday function. And hearing loss can be effectively managed so that as we age,
we can continue to live a full and active life. Managing for hearing loss, healthy hearing
for aging of course begins with identification. And that topic is not one that I have time
to address today, but it's a critical one. And also its associated with having individuals
believe that hearing is important and that we can treat hearing loss effectively. Again,
this is a topic I believe is critically important, but one that I won't have time to address
today. In talking about a way to manage hearing loss, the healthy aging, it is important that
we have evidence-based protocols. And the most recent one was developed in 2006 by the
American Academy of audiology. And it is called the guidelines for the audiological management
of adult hearing impairment. Of course 2006 is quite a while a go, so we do have subsequent
relevant research that impacts on the development of evidence-based protocols. In evidence-based
protocol a pproach, we begin by managing hearing loss for healthy aging by completing a comprehensive
assessment of the hearing impairment, functional hearing related difficulties, and the identification
of other individual factors which preachers shows us impact upon intervention. -- reach
-- research shows us. We can develop an integrated treatment plan. It involves both technical
aspects and nontechnological aspects. And of course, it's important to continually measure
the outcomes of our interventions and use the information from our outcomes assessment
to modify our treatment plan. Let's begin by thinking a minute about comprehensive assessment.
We get information about the hearing impairment from the audiological examination leading
to a graph such as this, which is called the audiogram. The audiogram tells us how sensitive
an individual's hearing is to different sounds that range from low pitch to very high pitch.
On the degree of hearing loss as Frank mentioned this morning, can range from mild to profound
and is typically described in terms of the pure tone average or PTA, which is calculated
by averaging sensitivity thresholds for specific frequencies. Unfortunately, age-related hearing
loss is just not that simple. We have known for over 60 years that there are two components
to the type of hearing loss that exhibited by individuals as a result of aging. There
is of course the audibility component, but there's also a a component that is referred
to as distortion. We can deal with the audibility component simply by making sounds louder through
hearing aids or other types of listening devices. However, no matter how loud we make the sounds,
the distortion component results in problems with the clarity or the cleanness of the signals.
Making sounds louder is critically important but as shown in this visual representation,
making a noisy signal bigger does not necessarily increase its clarity. And of course, there
are external factors that impact on how well hearing aids and other devices work in the
environment. For example, we constantly are listening to speech in a background of noise,
which obscures the importance each sounds -- of each sound and distract the listener.
Of course there's a special type of noise that impacts on speech understanding called
reverberation. And that's what makes all of you sound so great when you are singing in
the shower. However, when you're trying to communicate in many other situations, and
the reflected sound energy is nothing cadence with the original source, it creates a great
deal of difficulty as shown in this visual analogy here. The additional adding a more
visual information does not help with the clarity of this sentence. Can anybody read
the sentence? All right. So you guys are all good. You don't suffer from reverberation,
Bob.And then of course there's the known relationship between the intensity of sounds and distance,
such that for every doubling of distance -- the signal loses six dB in intensity. This -- [Indiscernible
-- multiple speakers] and communicating difficult for all of us. And these difficulties are
exacerbated by the effects of hearing loss and aging. And also the age-related processing
declines that are associated cognitively. So in terms of managing hearing loss for healthy
aging, in addition to developing an audiogram, we also need to measure a person's ability
to understand speech and noise as Kathleen Pichora-Fuller told us earlier this morning.
And clinically, we do have many objective measures of speech understanding and noise
that we can use. But I have to admit, it's not always done in the clinic.
[Captioners transitioning]
In these sealed a signal to noise ratio that a person needs, how much does the signal have
to be in order to understand 50% of what is being said? 2 decibels 450% recognition, yielding
SNR 50 of plus two DB. Might not need the speech to be 12 DB or greater for 50% correct
recognition. Unfortunately we cannot predict a person's SNR 50 simply by looking at the
auto -- audiogram from these who recently participated in a study. In addition to getting
audiogram's and measuring the signal-to-noise ratio for 50% correct recognition we also
need to assess functional hearing related difficulties. This can be done of course through
eight he tailed case history but that case history should not necessarily focus on the
medical aspects related to the person's hearing loss but what it is like for that person to
live with the hearing loss daily and the social and emotional impact of that hearing loss.
We have many cycle metrically valid self-support measures that provide useful information for
documenting and identifying -- the client oriented skill of improvement which was developed
at the national acoustics laboratories in Australia to develop three 25 realistic and
achievable goals for intervention for my clients. And a nice thing about the procedure is that
we can utilize it to measure outcomes at different points after intervention has been initiated
and then modify our intervention plan based on the results at that point in time. What
about the interventions? We have both technical interventions and non-technical interventions.
In terms of technical interventions, the majority people with mild to moderate hearing losses
can be effectively helped through the use of hearing aids. Simply put what a hearing
aid does. Acoustical information for speech which is obscured by of a hearing loss and
increases the level of that speech access the important optimal hearing aid fitting
numerous evidence -based decisions must be made once those decisions were made and an
individual is fitted with a hearing aid. In terms of both the physical fit and the comfort
to the individual and more important is the signal processing for a test called really
year measures. Intervention for adults with hearing loss has been established was conducted
by [ Indiscernible ] in and we mentioned this Duddy before. Documented improvement and communication
function. And these positive outcomes up to one year of hearing aid use. Which looks at
the quality-of-life assessments as a degree of hearing loss. With the health utilities
Index. Higher numbers indicating increased quality-of-life. Prior to hearing aid intervention
as shown in the blue line significantly decreased with hearing loss. in this generic quality-of-life
measure.
For individuals with more severe to profound hearing impairment cannot adequately be provided
it is not possible currently to increase the intensity of the speech signal through acoustic
amplification to make the important speech zones accessible to individuals with the most
severe hearing loss is. Cochlear implants or cochlea of the stimulate the acoustic
nerve provide a very efficacious -- you might ask my friend Donna Sorkin later today. Of
a cochlear implant user. Regarding management with cochlear implants show significant improvement
in terms of understanding speech but even with the best hearing aids or cochlear -- combined
effects of noise, distance and reverberation. Continue to present challenges for listening
and communicating for individuals with hearing loss particularly for individuals who are
aging and when you put the two together there really are issues. In terms of our integrated
treatment plan, our technical interventions must also include consideration of a category
of devices which we refer to as hearing assistive technologies. Dr. Compton calmly well provide
a great deal of information about this to you tomorrow and she truly is the expert.
One type of hearing assistive technologies, assistive listening devices, the loop in this
room is an example of, they can be used alone or combined to supplement performance and
a variety of difficult listening conditions. In general and assistive listening device
works with Dr. Compton collies three principles. We have to catch him hardware a wireless link
and couple that sound to the persons here. Importance of access to warning sounds of
other environments as flooring prices so eight person can have
access to those of Porton sounds. I cannot emphasize enough. Device orientation and instruction
regarding use and care. This can be done individually. I think that is the more common approach.
We have you have to have at least one of these I truly need several
that or orientation to use any of these other devices. Systematic approach to device orientation.
Non-technical interventions. Oral or audiological rehabilitation approaches. Along with my colleague
Michelle Arnold. Evidence -based practice and audiology. Our review looked at what we
referred to his group approaches systematic review can be done by Dave Hawkins in 2005
which indicated that these were helpful for addressing the communication needs and psychosocial
aspects of hearing loss individuals. A prime example of a group oral rehabilitation program
can be found in the develop by Louise Hickson and -- and the active and in this program
get to know about communication strategies, problem solving approaches, assistive listening
devices, information and advice to give their significant communication -- the may also
practice relaxation techniques. After a week of getting to know about these each week,
then they get to try these various approaches out and report back to the clinician about
what was successful and what was difficult. In our review of current approaches to audiological
rehabilitation for older adults, we also looked at the class of information -- which are auditory
training or listening training, and as Jim pointed out earlier, we might want to combine
that listening training with speech reading training because we typically do communicate
by looking and listening in most situations.
Good evidence that some of these approaches could improve outcomes for individuals with
hearing loss and since that time, that led to the development of many commercially available
computer-based programs such as the lace program which someone mentioned earlier this morning.
The lace training involves looking at modules related to the comprehension of degraded speech,
designed to enhance positive skills. Helpful hints about communication strategies. The
latest systematic review and computer-based for adults with hearing was not as robust
as we would like auditory training combined Dr. Arnold and I found it was fitting did
improve outcomes both in terms of communication and quality-of-life. Price-performance as
well as improvement in many quality-of-life measures. In addition, I worked -- the work
I did years ago we could incorporate a group or rehabilitation program post hearing aid
fitting. And those benefits would be realized much quicker than if an individual was given
hearing aid without the provision if they participate in the programs because they truly
get to understand sitting in the living room watching television while they in are in the
kitchen watching dishes. We should should consider. About communication strategies.
Even when they have mild hearing losses of my it be ready to engage in using a hearing
aid or other forms of personal forms of amplification. But we do need further research.
I would like to give you my final thoughts. Re: hearing loss and healthy aging from a
public health perception -- perspective. It should be treated and that we have effective
treatments that could be readily accessible. Age-related hearing loss is not understood
to be important public health issue or we would not be here today. We need to continue
to engage in those studies that we described this morning. Where we look at the cognitive
functional and social emotional effects of untreated and treated hearing loss. About
hearing loss and develop strategies designed to address those issues. Even though we have
evidence -based interventions available. We need to continue to improve those interventions
particularly based on our increased understanding of the effects of cognitive aging. And we
need to look at examining the potential for how systematic hearing intervention might
influence cognitive functional and social emotional status. We do have the lack of insurance
coverage for hearing rehabilitative devices. What is the role of PSP we need to be able
to continue -- through cost effectiveness and cost utility analysis. For we currently
have an over emphasis integrated for older individuals. They can help us landscape. Associating
with aging. We can provide the appropriate interventions that can mitigate the negative
effects live with hearing loss is a part of healthy aging. Thank you. [ Applause ]
Good afternoon it is and honor to be here today to our discussion before to increase
access and my task is to try and synthesize reverting heard of impact of hearing loss
and many things that impact daily lives. Seeking healthcare who have hearing loss one of the
questions that keeps coming up is why is there. Explain issue they have care system and so.
We'll become a little more able to see some of the ways in which we might be able to make
some changes I think I will hit on areas that have not been addressed so far. In my assessment
of the system it is framed both but my clinical experience, I've been very interested and
I am a nurse but I work with older adults and very interested in the interface between
policy and practice and struggling with the issue is how policy influences how I as a
clinician can provide an offer to the people I work with to make their lives better. It's
also influenced by my exploration and my interest is a health and aging policy fellow to look
at Medicare payment systems and issues around how one might influence that. Given that,
but me CM make sure I know which button -- the objectives over these next few minutes is
to describe the various stakeholders that are involved in the hearing healthcare system.
These are the individuals that are impacted by changes in policy we might make or interventions
at multiple levels. Or financial coverage if you will. I want to provide a schematic
of a flow. You've heard the others today. I want to discuss the key issues raised at
these various intersections or phases if you will. And then summarize and talk a little
bit about the gaps in our knowledge and where we need to go from here. I will have to acknowledge
given the timeframe it is relatively simplified. For the stakeholders? There are a lot of them.
The first three consumers and healthcare providers and hearing healthcare providers themselves.
Are ones that I will focus on terms of essential parts of hearing healthcare system. It is
important to think of this as significant others advocate for the needs and healthcare
providers and we have not address those individuals. But we really need to think about them as
well. In the hearing healthcare providers also that are -- the services they should
be offering. Very important in terms of contextualizing this and impacting -- what goes on in the
care model. Medicare and Medicaid services. Medicare is under the offices of them for
sure. Other healthcare companies that follow the dictates or models some of the programs
around the things that Medicare offers. And policymakers and legislators, they are interested
in and concerned about the cost of healthcare and family I do want to emphasize public health
professionals. But we tend to overlook them and we actually do when you look at it have
national public health policy related to hearing healthcare. Healthcare 2020,
-- and protection devices subcategories unfortunately
these goals healthcare providers. Webinars, not a good reason reason as a researcher.
The other thing that needs to frame this is the payment system. Hearing healthcare model
and as all of you know, Medicare is primary payer for older adults. Medicare that thinks
about covering a service. But it has to be and risible and necessary for and treatment.
If it falls within these parameters. However, when you look at the original Medicare bill.
The legislation that set up Medicare, the exclusionary clause related to healthcare.
Covers vision dental and hearing. What Medicare should be covering and we will give you a
new heart but we will not be able to give you classes, dentures, or hearing aids. And
the healthcare system in three areas who has to go through the primary care setting. As
I mentioned with Medicare one of the issues is the coverage for appropriate diagnosis
and treatment the most of the time you want to be referred -- that implies you are being
diagnosed with a condition or something that fits -- we will get into the variance a little
but more. One of the things that we look at the consumer, we have already addressed a
lot of issues. They attributed to aging and they think that it's normal. It comes on slowly
and subtly and so they are not aware, and they're very concerned about the cost. They
often don't think that the hearing aids work. They have old perceptions of what is going
on. I hope some of that is changing but it's very true. And I do think that the stigma
related to aging comes out a lot in my own research. Sometimes the hearing industry itself
does not help that much because every time we look at the media in terms of what it advertises
to person to think about getting a hearing loss you see the same sort of thing. Almost
invisible. So small, no one well know. And what that does is I think is set up the perception
issue don't want anyone to know that you have hearing loss. A badge of honor. A negative
perception that we can make changes pretty easily about. Wouldn't necessarily be and
that's where we have to take turn to the healthcare providers numbers are terribly well-documented.
That services an independent organization. That reviews screening processes like mammograms
based on the evidence is it appropriate to screen. Who should be screened.
Don't scream but what they found was that between 40 and 86% admitted not screening
routinely even though they said that they felt hearing loss was important issue for
older adults. And they said reasons were a lack of time, perceptions that there are more
per pressing issues lack of reimbursement at their level. Doing an exam they think more
about audio grams and things like that. It is not routinely screened and in my own work,
we interviewed 91 -- and of the 82 that I could recall, 85% said that their practitioners
never screened unless it was -- I have a problem and I want to be referred in which case the
person might refer them. With one woman who kept talking about she went to see here practitioner
and knew she had hearing loss. Nice and clean. And another who mentioned that -- collaborated,
to ask the practitioner about it and my wife has a hearing loss. Why say that? The list
to say, the wife was not very happy. Is a major problem. But unfortunately it was reinforced
and this was brought up by Barbara by the fact that preventative services task force
also said and they concluded from the review is that the evidence is not sufficient to
assess the benefits or harms of screening for asymptomatic adults aged 50 and older.
Unless you going complain there was no data. Technically it is a neutral statement. So
good data one way or the other but from the standpoint of the practitioner who is busy,
it became a -- I shouldn't screen. It is not needed for me to screen. Tema directly after
that and said they would no longer recommended. So they said that additional research is needed
to understand the effects of screening compared with no screening on health outcomes to confirm
benefits of treatments and so forth which is one of the areas that we need to look at.
If however the person is referred they actually enter a very confusing system in many ways
themselves. Far from a unified --. We have audiologists, and often have PhD's or now
they may have a Dr. of audiology because that is the entry into practice. But there are
also practitioners, speech language pathologist, otolaryngologist, ENT physicians, with special
training, head back and audiology and so forth. And they are the hearing interest -- instrument
specialist. Trained or to just dispense hearing aids although a broader training, but they
are state regulated and state defined in many ways. A lot of overlap in terms of individuals
seeking treatment my end up seeing or not saying. They might offer very different services
to the person to come to see them. Because these professionals, they don't agree with
each other in many cases about the types of things that would be helpful to have their
practices continue to function, not in favor of Medicare. They're quite concerned that
the payment reimbursements will not keep them in practice. Most of the audiologists would
like direct access so people could come directly to them. But not the otolaryngologist do not
think that's a good idea. They don't agree with each other in which policies should change.
Needless to say the each have their own Association that then argues for at their particular viewpoint
at various levels in terms of Congress and so forth. So they speak again, a lot of tension
across this and the tension now is getting larger in many ways because of the new models
that are coming out and the various challenges in terms of their own practices. So the tension
is growing. The other thing that is related to this is the way in which the services are
charged within the system itself. In general, most audiologists, and this is changing and
unbundling of cost. Not really what the person is this sincerely paying for. But it is bundled
into -- with the person might be offering. The consumer always really appreciate that.
So that they need to -- that is into the return and all those kinds of things as well. And
that -- if you unbundle it, it makes it more transparent, the cost of the hearing aid,
the cost of the services are. That is an area that I think people are looking at in terms
of potentially changing. I will note that Medicaid which is the low-income individuals
and high healthcare cost, older adults or adults were eligible, it is very state specific.
In most states it will cover things for children but there are a lot of states that don't do
anything for older adults and if they do what they cover varies greatly. And a can change.
Somebody else mentioned that earlier, the unfortunate part about Medicare -- Medicaid
-- is that given the state's financial condition it may change fairly back-and-forth kind of
way. In summary, I think what I would like to emphasize is that the hearing healthcare
system is really not coordinated in terms of offering services at most level and right
now in terms of almost the offerings with access restricted by the lack of coverage
by Medicare and other insurance companies. I am ignoring the VA because the VA does cover
hearing services consumer beliefs about hearing loss and also the services because sometimes
they do feel like they're just being sold hearing aids. The cost of hearing aids is
currently sold, the way they are available, I think a big area is the primary care practitioners
screening and referral is really very little education around here hearing loss in the
primary care or health care field. They get a smattering related to that and geriatricians
often don't get as much training. In hearing loss as those of us who are interested -- really
think they need. When I talk to people I really find out they don't know. The range of practitioners
and so forth all interrupt a make things a lot harder. What we need in terms of -- as
I am summarizing here, certain more when we need to generate data on the benefits of primary
care screening and the effectiveness of hearing aids. That is something that is been echoed
I think across today. We need to evaluate models of care that may be targeted to individuals
in varying levels of hearing loss. We need programs to inform older adults but hearing
loss, the ability of options and how to be educated when seeking treatment. Educate healthcare
practitioners about hearing loss and resources and public health issue, and I want to step
back and also say one of the things about screening that was brought up a little bit
earlier that is a concern and it's got to do with conforming older adults about available
options is that when I talk to low-income clinics about screening, what I get from practitioners
is why should I screen property I cannot offer them services. They cannot pay for the hearing
devices. It is a big limit for low income centers that don't have access to the services,
and they will raise expectations by screening. I think making more the screening easy in
the settings, inexpensive and considering the fact that the person who doesn't have
the resources for some of the things we would like to give them at least understand many
of the communication issues and other kinds of devices that will help them stay engaged.
And long-term I'm hoping that we will move toward common ground and come to some understanding
. [ Applause ]
Good afternoon. I will chime in with the rest of the groups. Amazing that this has been
possible to get going. Great job. Getting organized and proud of being the only -- to
speak today. I will give you a perspective from outside of this country. Primarily from
Europe but also some other observations. A brief introduction about myself. And the Association
that I represent. Market for hearing aids. Analyses and coverage. And some information
about the European situation, delivery models we have and some analysis of how works. And
then some of the future perspectives that we are saying. This is myself. At a much younger
stage. I am sitting in front of the first so-called minicomputer that the company acquires
to explore into digital signal processing. Since then I served multiple your says head
of R&D for the company. And then since 99 when -- was merged with the Corporation I've
been doing a lot of stuff. Falsely within IPR but also maintaining my large network
of acquaintances throughout the international hearing industry. Is an Association. That
unites the six leading hearing aid manufacturers. We believe we provide the world consumption.
And as you can see they're located across the world. In Minneapolis. Siemens in Singapore.
Still in Germany. And then in Denmark, three of the other manufacturers -- are located.
It is called the European -- Manufacturers Association because most of them are European.
It is the group of the six hearing aid companies. It could be called international for that
matter. Registered in Brussels and the CEOs meet twice here and all decisions and eat
good the nurse. And then tease each other about current events. The real work the technical
committee for him and the market: Where we try to do sponsor this website. A website
with neutral noncommercial information about hearing issues and products. Translated into
six major languages. Operating for 10 years now. The world market for hearing aids. 2012
it was almost 11 million units. Total revenue around $5 billion. It's not a huge industry
is such. The growth is steady around 2% per year and has been like that for a long time.
We'll probably continue we believe. Different panels you can see how it is distributed across
the world. European the major orchids. North America second. Asia-Pacific driven by Japan
Australia China Korea. And then the rest of the world accounting for 800,000 units.
One of the questions we have in looking at throughout the day and we take some looks
-- how do we figure out how many people in a given country is actually using. I listen
to Frank saying some numbers about this early on and I am happy that line number seem to
coincide with those. There are very little -- and therefore we have developed a model
that can be used to at least estimate and the only thing we objectively know is how
many hearing aid units were sold in a given year in a given country. Let's take a look
at some of these major market areas. We see Europe, USA Japan Russia China India -- really
large population groups. And you can see the millions of people living there, all of that
is pretty objective. And yellow headline means that this is an estimate, we can estimate
pretty accurately is what is the percentage of the population over 18 and why do we need
over 18. We have a number saying that. Certain percentage of the population over 18 suffers
from hearing loss. And the percentage is 60%. You can debate whether that is the right number
or another number, and therefore this -- and so by using those numbers, we can estimate
the impact population of these countries. And now we need to take a look at the hearing
aids. We can find that out. We do a consensus estimate among the members every year. How
many hearing aids could be recently re- were sold in different countries. Those numbers
are shown there as well. So in your we sold USA 2.8, the next important part is to understand
how many people got to hearing aids the not one. Because you can't say that just because
we sold 2.8 million hearing aids. 2.8 million people got hearing aids. If some of them got
to hearing aids, it is still less people. We have to estimate that percentage, no accurate
figures for but we have some pretty good data points there as well. And now we can figure
out how many people were -- that we get over here where we can say how many people were
fitted in a given year. And on the magic comes because we save the typical --
him Russia, China and India very tight. And I don't think this is surprising. It is clear
that if you live in the development country. And you do get some money hearing aids are
not the first things we think about. Rather have cell phones, refrigerators, TV sets and
the like. So that thing about hearing aids was down the list of things that you actually
would your money on. We try to do it this way. You put on the X axis the domestic product
per capita. Big masses of people. Tied to correlate that with the we now see a pretty
good correlation here as you grow in welfare you get to higher percentages. Japan seems
surprisingly low. And Europe seems surprisingly high. Around that --. And that is -- EU partly,
because EU is not one country. For the 28 different countries are very different sizes
and shapes and populations in languages and what have you. Not one country. And here have
done exactly the same calculation and now we see the pattern here. We have Denmark with
55% a bit of a jump down Lithuania, Slovakia Romania Cyprus. Around 20%. In a map of Europe
into the green countries are those with more than 30%. Him 15% to 20% is the middle centrally
or European countries. Is running 10%. The differences there are many different explanations.
The standard of living or GDP. Or insurances are offering, makes a big difference. The
accessibility, the visibility, how parent is it that you can get here once. And historical
dimension, some countries have had free hearing aids for ages. Other countries used recently
in some of them don't have anything. These four different things are what we think defines
the difference. It coincides with the fact that there are four different delivery models
or one strongly different and some more northwest in the countries United Kingdom, Norway Sweden
and Finland, characteristic for certain things. And sore the other ones. It's let's try to
take a look at them. Northwestern model is characterized by public hospitals with audiology
departments and a fair number of them to. Offering free hearing aids with good quality
for also the sins. You simply just have to show up and ask for an appointment. Most of
the countries there is a private dispensing channel. Alongside. Sometimes the waiting
line can be rather long. And turn into a private opportunity and the way that private opportunity
works is really different from country to country and it covers 10% to 50% of the total
number of hearing aids sold. In the UK, it is a completely private market. You have to
pay everything. No substitute from the government.
In Denmark you can get a voucher from the government they you can take to a private
dispenser and it will cover the cost of decent hearing aids. You get 75% refunds, if you
go to a private dispenser. And the typical pattern here is that if you do not go to a
government clinic you have to see an ENT who will see you have hearing loss, we will be
referred to a private dispenser or public dispensaries according to your wish the central
European model or insurance -based. Importantly it is an insurance that you must have. Not
like you can say I don't want to have insurance. And the insurance will cover some part of
it but not the last part of it. 10% to 20% of the hearing aids. The government system
is the same, you need to see, refer you to a hearing aid dispenser and he will 50 hearing
it and you'll come back to the dispenser and he will verify that and you can get your insurance
policy. This European model is pretty much the same except there's not much supportive
of. And you still need to -- if you want to have subsidy and there are certain groups,
we will get some money. If you turn to the East European model there is not much to run
for. The governance varies from nothing to -- interaction. Private dispensing. So these
are the four different ways acting out in your. And Lisa early on that there is some
sort of procedure issue here about how to do things. When you fit hearing aids, we have
a similar thing in Europe where in 2007 some French guy said we need to have a European
standards for hearing aids. It was adopted in 2010 that sets of standards much of the
way we heard early on education, facilities, equipment, the fitting process, and the quality
management system you should maintain subsequently. It is not intended to cover children, cochlear
implants and other comforted him but that's. It is not mandatory in the sense that it is
being implemented or must implemented but if you do pass legislation about these matters
you should comply with the standards for the soft recommendation or a recommendation that
you must -- see Mike Europe is a lot of different countries with a lot of different history
and traditions. If we do that GDP plot over Europe, we see again a pretty good correlation
between GDP per capita and the hearing aids. Except that up here, we have some countries
that fall completely off the line and we have finished on here that are strange. Fluid goes
over the top. They would have been done here.
That is not so interesting. The interesting bit is this one up here. The green area where
it is -- clearly shows that if you offer people free hearing aids in a reasonable way, they
will pick it up and they know from other investigations that they do use them just as much as they
do in other countries. The element here is another -- United States here. The purple
one here. If it's there with the German French Belgian level. And if you try to estimate
the subsidy level in each of these countries which is not -- always easy to do but I've
done it and given it a try you see again unsurprising that there is the lower the subsidy is the
-- the higher the subsidy is generally the higher the coverages. Except that some countries
-- fall short. What happened in Finland, the introduce free hearing aids for the population
rather recently. The other countries they have had it for ages. That is the only real
explanation. People are simply not educated to pick up --
I don't think that is necessarily true. But I think also the fact that Finland is a rather
large country with a very dispersed population in some of them are living far away from me
so it might be a complication.
Weiss Denmark such a wonderful example of the Denmark was a company that introduced
free hearing is for everyone in 1959. We have been working at this for quite some time.
The clinics have a choice of products. Not just one product. A choice of products and
generally good quality and even in 2000 it was still the leading country in the world
about 25%. But it was considered to be unsatisfactory that people should wait somewhere between
three to eight and sometimes even more months to get an appointment. And to get a refit
would take another couple of months to get into the clinic again that was seen as an
attractive. To establish his voucher system where you could get that she could also take
a voucher an upgrade to a more sophisticated product if you wanted to -- so this caused
a lot of private people to establish dispensing offices everywhere. And that caused a considerable
drain of staff so their ability to lower the waiting list was not very easy. It created
a large media exposure. People advertise for. Commercials, newspapers, there was a lot of
talk about it. And that might have been part of the explanation. It became something that
was apparent to people that you could get a hearing aid.
What happened was that the total market grew by 80% over 11 years. Public which is the
-- went down by 20,000 units and the private went up. And a recent survey has shown that
people on average are more happy with the service they get in the private -- and public
-- and here the purple circles and only -- are all the private shops and as you can see there,
all over the country, in cities where the clinic might have been several hours by bus
or something. A lot of retired people are not getting around that easily. That hold
visibility -- you will find here. Also mean something to the proliferation so I think
we can conclude here. We think we can conclude that hearing aid coverages basically a function
of standard of living. But a certain level of subsidy clearly increases the coverage
and particular when the subsidy covers it -- basic hearing aid. I'm also tempted to
say that the fact that a government or some other body decides to support hearing aids
financially is also an endorsement of the idea of getting -- that should not be underestimated.
Than the accessibility and the visibility is clear that it increases the coverage the
it is seen as common to do these things. You see people going in there, -- I have one slide
that was missed. You can us a question if you believe me when I say that in most countries
people with severe and profound hearing loss is have a relatively high percentage coverage
for that group of people because they have a serious problem. And where the growth is
then going to come from is from moderate and mild hearing loss us. Which means that some
people will buy hearing it's a more moderate losses. And not to discriminate against anybody,
they will appear as pretty ordinary people and make other people think that -- and therefore
they will reduce the stigma to have more people use them and you will not get that feeling
that it is something special. This is not evidence or size. My personal reflections
on what we have seen. I think it has accelerated -- guessing more people with hearing aids
and you think they look okay with that. They have become much nicer visually. They're much
nicer today. That's another factor. All that sounds really nice but unfortunately it doesn't
appear to be quite that nice in the future because the cost of this is not to be underestimated.
Some of the countries we're seeing this pushback from insurance companies and public systems
that were was expensive and the -- version of the aging population is going to be very
costly. At the same time the hearing aids are getting better every year and more more
attractive. For people want to have them. This is not a creation that is easy to solve.
We will see reductions in the subsidies and some increased -- with thing. We will also
-- that was what we just heard recently. The prize package, the price of the package would
be differentiated. It is clear that somebody who things in a five -year-old child with
serious hearing loss is requiring a lot more attention and service on some middle-aged
man who went hunting too much and the need for hearing aid, he will pick that up pretty
quickly I think. Why should that cost the same property as it was said the fact that
the whole service charge is transported into that little piece of plastic is in some ways
unfair. This is a delicate matter and I know that most communities are shaky about this
whole discussion and that is fair enough. They think it is inevitable that it is going
to come up someday. And the last part is that people have somehow to figure out if they
take care of dental work and they are spectacles, they will have to pay some sort of the hearing
stuff as well. Some degree of subsidy will clearly improve to go forth. Those are my
words. Thank you. Plus back
Thank you to the panelists. Very excellent presentations, and now we are going to open
the discussion to the audience for questions. We would like to remind you please to come
to the microphone, identify yourself and tell us who you are directing the question two.
Questions please what the
Matt Quinn from the FCC. Of the things that we have seen in the Affordable Care Act is
a focus on accountable care organizations and patient centered medical homes. And that
patient centered medical homes, a couple of the key tenants are that it's primary care
led. Answer on the patients needs rather than the needs of the healthcare system. And third
it's connected to community models. Not just physicians but others outside of the healthcare
system. One of the other pieces is that mental health is incorporated in this. How much have
we seen that -- hearing health envision how the numbers have been Incorporated in the.
I think it is not -- we have pushed for -- one of the essential services. And it didn't make
that package, although you can work with it at a state-level. One of the models that might
be helpful in terms of thinking about it is the pace for all inclusive care of the elderly,
that has been started with -- in the San Francisco but at risk program. It has always been based
on getting a lump sum to take care of older adults. These are for out older adults as
will Navajos come at it from a patient oriented perspective which means that they can use
those funds whenever they want in terms of meeting the needs of the patient. They're
much more likely in some ways to provide hearing aids if they feel that it is a patient need.
Rather than some of the other organizations. I do think that it does matter. I do think
that the education of the practitioners to really understand the needs. I think it would
make a difference for the person to get screened because if a practitioner earlier I think
was mentioned like hypertension for instance, if someone comes in and has their blood pressure
taken and they have high blood pressure, the practitioner pays attention to that. They
say looks like you have high blood pressure and you should be on a special diet or medications,
they know it is a healthy. I think that again, if we somehow build it in, it becomes something
that is much more acceptable and then begin to monitor outcomes. But it I have not seen
it as a focus unfortunately.
Any of the recognized CMS a CEOs have Incorporated hearing loss management and prevention.
Medicare advantage, some of them do cover hearing or have. With the change in -- and
we have talked -- trying to think about never fell into the welcome to Medicare exam. Which
or the risk factor that is supposed to be done every year. Unfortunately because right
now in Medicare it is a statutory exclusionary cause there has to be change in the legislation
to make a difference, change Medicare legislation. Although it has been tried, many people have
-- with Claude Pepper he introduced a bill to change Medicare to cover the services.
It never goes anywhere. Because there is the push.
Thank you.
To follow-up, this question related to the Affordable Care Act. Because coverage under
the act is really designed to mimic the commercial healthcare system. We are not seen much coverage
hearing aids. And if the state has a statute that requires coverage for children, then
it is being covered. We are nothing adult coverage and hearing aids. Cochlear implants
because typically covered by commercial plans and being covered under the Affordable Care
Act. To answer your question.
One topic I want to raise, relatively provocative, is -- people of different levels and needs
of care. Very mild hearing impairment, very quick, about 10 years ago. Hearing aids are
regulated by the FDA. By virtue of that cover typically by an audiologist and 10 years ago
FDA to develop a new class of hearing aids, over the counter hearing aid be opened immediately
to consumers. I think that is -- personal amplification process. I want to get from
a policy perspective thoughts on the role of a separate class or over-the-counter hearing
aid, maximum prescribed double. Hopefully that will be alleviated. Overall thoughts
of re- entertain this issue, [ Indiscernible ]
Who would like to answer that?
Maybe all three actually.
I don't have a problem talking to this. I think we have heard over and over today, there's
clear evidence that you need to have some sort of assessment made. And the fact that
you know that you have a hearing impairment, most people can figure that out. Do from there,
to know what to do about it, and merits a bit more investigation than just buying a
product. And see if it works. And the other part about that is that those who do not have
hearing aids, as I also said, typically also people with a small problem. People with a
small problem or not the least difficult customers to deal with. They only need the product in
certain proportions of their life. And the rest of the time they're not really happy
with it. The last accurate fittings you do for their group. The higher the likelihood,
they will not be happy with it. In general. And therefore I am not so convinced that it's
-- one class and then another high-priced class. I would like to see a continuum between
the two. For you get a smaller service package for a need that is not so complicated doesn't
really assist in never really flies. And you can't get a decent another was that most people
are happy with. Personally not so convinced of the benefit of it and it has existed for
ages. It has never gone anywhere. I am not paranoid about this because it has been there
all along and the explanation is an understanding wondered connected.
Hearing loss was only due to the ability issues. You have the distortion on it and then with
aging and cognitive resource issue and cognitive factors. Utilizing a device that provides
amplification without understanding limitations learning about strategies appropriate use
-- I don't think going to resolve the problems and I think you do run into the issue of someone
trying something and not satisfying them for having their needs and giving up on the whole
process. I don't think everyone who comes into CS -- I had a classic story that I tell
my students, her only communication it. Showed a mild hearing loss and her need was one she
was riding in the car with her sister because she depended a lot on visual cues. That was
fine for here for year two. She was ready to years later to come back and have them.
If you don't consider all your options. On the person comes in then I think we are doing
it a disservice. So much misinformation out there and misunderstanding of what he hearing
loss really is like. What it does to the signal. Not a simple answer and not a simple solution.
The engineers would have solved years ago. That is my $0.02.
We're pretty much on the same page. Had to get the right people if it was -- with the
personal amplifying sound system are not regulated. Them and some of them are getting better.
And there are some new products that can be self regulating. It's possible dumb line that
if you have online self hearing assessments if you will with people who are really savvy
who can see with the audiogram might look like or get at least an idea, and a really
technologically adept at doing that, I think for a lot of -- really elderly individuals,
some of those processes would be difficult. Unless they have the classes and the other
programs and they try something when you mentioned just echo we don't have good data but that
is an issue.
Purely from the perspective of public health. Hearing is important. But if two thirds of
every older adult has hearing impairment, the current models of care will not be able
to sustain it. What I actively think about is what do we do if we think hearing accessibility
is a good thing. What can we do to achieve that? I am not quite sure at this point.
If it was embedded in a really good consumer education program, where they understood the
limitations and knew that they had problems, and this was a first step, it was a lot of
work that needs to surround us somehow.
I will let Kathy Coke but that's that issue of bundling and unbundling so people understand
the device versus the other services. And that perhaps if you work with people in the
hearing loss Association of America, not all of the non-technical intervention has to be
done by an audiologist. You can train community work, other people that could provide some
of those options. If you think about the model of how you're doing things -- and communities
and people with hearing loss themselves, I think we can have some solutions. To be cost
effective.
I will make a small footnote that Canada is a different country. We are a little different
sometimes. In the spirit of being a little different. I would really like this just a
-- of the marketing view versus the healthcare policy view. And I think we need to have more
discussions like that. And I have questions that I would like to explore. I don't think
you have the answers, but it comes to my mind that maybe some of those differences in countries
have to do now with aging. But say with industrial noise exposures and people who have gotten
their hearing aids because they were programs and industry. Hearing aids were provided to
Worker's Compensation. For occupational hearing loss. Including the us, large numbers of people
who have entered the hearing care system because they have military exposures. We kind of have
to separate the population according to the etiology and we might have a little different
picture. If we focus strictly on the -- population. I also -- GDP is interesting. But there's
a large literature on the social determinants of health more broadly. Which would say that
its distribution of wealth in the country which is predictive of health outcomes. As
opposed to the average. And that is another interesting thing we could explore. And gets
to this matter of the privileged and underprivileged. My real burning question for you is what is
industry's commitment to helping with this agenda. We put a lot of emphasis, we tried
to be beautiful in terms of using evidence -based to guide practice and policy. I know
there's a lot of differences amongst health practitioners and amongst our industry partners.
But I will share a story which I find rather horrifying. A few months ago I was in the
audiology clinic at Baycrest, big geriatric hospital. Patient comes into the audiologist
to get a hearing aid. In which there is a full-page ad. With very tiny print that says
that it is a -- article. Looks like a news item. Have proven that if you get a hearing
aid you'll not get dementia. What are your ethics to make sure that people don't go crazy
without evidence. Trying to create sales out of our good intentions. Very provocative question.
Here are the person who can make it right.
He is leaving tomorrow.
I will change my flight.
The ad was by one of your related companies.
There is no don't there are inappropriate advertising -- and I don't think it is fair
-- one of the few things that has persuaded people to get hearing aids is this correct
but dementia and we have tried with grandchildren on your lab, four or five years with relatively
-- results. And there was a Danish have not. That was maybe -- slightly more ethical. I
am not defending the way it was done, I think the idea of telling people that it may have
consequences [ Indiscernible ] is an interesting thing. The idea of making people aware of
this I don't think is appropriate.
I had a quick comment. And also a question. The majority of hearing loss the world is
not in our country but developing countries. Populations are aging to. They been at the
forefront of innovations in terms of delivery of healthcare. The use of cell phones. And
tracking disease. Perhaps because they are not burdened -- burdened I'm just wondering
to know of any innovations it would be interesting to if they occur over the few years which
might be helpful in terms of lowering cost.
There are individuals who have designed hearing aids which I think is solar powered. And other
ones were self -- programmed. And that are much more low-cost. There are individuals
if they and low income countries and wanted to -- I think they will begin to -- we're
beginning to see those coming back here. Thing promoted for use in this country.
My name is Alicia, I am here with the Academy of doctors of audiology. Knowing that Dr.
Irvin and myself are of the younger generation and we may not see Social Security and Medicare.
As it getting revamped. I'm curious as to the cost of when all of these devices might
be -- I'm curious if you can comment and the European models. How much does the society
end up paying into the healthcare system or they then get free or reduced cost devices.
If they are fortunate to benefit from.
Not sure I have any data. I can remember what the costs -- the private part of the Danish
system was. Estimated at 270 million Danish [ Indiscernible ]. For a population of 5 million
people. [ Indiscernible - low volume ] in Denmark it is seen as the hospital procedure.
Pay high taxes, generally speaking major hospitalization and surgery. And came home there pretty happy
paying and that is been like that and they should be giving the understanding that is
worthwhile to pay for. There might still be some opportunities to roll the cost. But we
don't generally advise our customers him advice about how to run their businesses. It is costly,
yes, no doubt about it.
Listening to this panel, I could ask a question of the earlier panel. I wonder if we do -- cause
a disservice by lumping together mild hearing loss with moderate and severe. If we had had
a an entire conference on moderate and severe loss and implications and a supper one on
my loss, would we have come to different conclusions or as we are describing the dimensions of
the problem any intervention, the necessity of treatment does it help or hurt for us to
be clearer in distinguishing. There is a prevalence of 70% people over 85 have hearing loss but
how much of that is mild? Mild hypertension or borderline hypertension versus severe.
I would be interested in any thoughts on whether it helps or hurts to more clearly distinguish
between mild and moderate to severe.
Not only based on the audiogram, you need to look at understanding abilities. You cannot
just say every mild hearing loss is the same. Cognitive factors. All -- to determine the
impact. It is hard to separate. Severe to profound, and the more profound and cannot
person benefit from acoustic amplification you might be talking about different things.
That was a good point. We have to think about different needs at different levels of handicap.
Coming at it for more of a health perspective I think one of the things -- I don't think
we have good enough data at this point to show this but there are some data about auditory
plasticity in terms of thinking about the fact that it's like a muscle, if you don't
use it it decides to do something else. And so I think that the changes that occur when
you're not getting acoustic stimulation in the brain itself raises issues about whether
early intervention is positive in terms of minimizing problems later. From that standpoint,
if we do early intervention, are we making it easier for individuals to adapt long-term
to admittedly -- hearing loss may continue to decline. Maybe it will not be as bad but
speech understanding may stay better and their ability to use various devices may be better.
I think from that standpoint even -- if you have hypertension, the goal is to treated
early so you minimize the side effects of it long-term. From a health standpoint I think
that it is good to think of it as a continuum.
The animal research supports having be augmented acoustic environment in the animal data to
support that.
We will take a question here and then there.
Noreen Gibbons, clinical audiologist with [ Indiscernible ] innovations. I am wondering
if there is a -- an age of intervention lower in Europe than we see in the US. A lot of
third-party coverage and I'm convinced people started sooner. And as a clinician, there
is nothing more challenging than a 90 -year-old coming in for the first time to learn how
to use hearing aids. Intervention -- mild or loss is great but also dexterity is better,
vision is better. Does Europe have any better rates?
I think so, I don't have any evidence to support it but it is clear that the success rate for
very old people coming and finally to get a hearing aid after 16 years of denial, the
success rate is clearly much less. And if you take the majority decision when you start
to have -- for other people, that you are not hearing probably, you have it assessed
that there is a problem you get some remedy for. Ability to do stuff much more easily
throat age. I will answer the question about the cost. There is another element to it.
The ability to keep your job goes up tremendously if you take care of your hearing. We did a
big study some years ago called on heard but -- we interviewed 3000 people between 55 and
70. Randomly picked, full interview, and full audio metric test or threshold test. The interesting
part there was that when you asked people, do you think that you have hearing loss and
they said yes, I recognize, to think that your hearing loss is impacting your conditions
at work? Most of them and I don't think it matters at work. A later section a dozen questions
about how do you feel work? Do think your boss is always on your back? And other questions
like that. In that category, they came out clearly different. Much more paranoid about
everything with better hearing capacity. There is evidence that you should do these things
for your own sake and because it improves you, where I come from you go on welfare and
become a burden to society rather than an asset. I think most have this understanding
that if you do work and you pay taxes -- taxes and you are an asset. The ability to keep
that ability as long as possible is tightly related to your -- it is for many types of
work, they are quite abundant I would say. It is difficult to quantify exactly what those
would be in terms of money. You can do some calculations, we have done them and came out
with astronomical numbers. Not very inclined to show them because I think they're ridiculous.
There is another part of the equation, what you get for the money you spend in terms of
keeping people in their private homes longer instead of taking them to nursing homes and
all these things that are -- and that is the other side of the equation. Not so easy to
quantify but I believe that
[ Captioners transitioning; please stand by. ]
There is another part of the equation in terms of people in their private homes longer instead
of taking them to nursing homes and other things that are costing society and that is
on the other side of the equation so not just to quantify but I truly believe that [Indiscernible].
Okay. Is that it? Other questions? One more question? Two more questions? >>
I am [Indiscernible] and I am going to take a second input all my clinical audiology hat
and kudos to Kathy for throwing the flag on the advertisement but I am probably going
to deflect that a little bit. I don't know how much of that is the role and responsibility
of the manufacturing community as much as we need to start bringing in some self-regulation
of their own professions and we have ethics boards we have self-regulatory boards we have
state licensing boards and what we need to do is throw the flag on each other when that
occurs because I don't know but it may not have--there is probably a clinic tied to that
and we would like to see a little bit of improvement in self-regulatory behavior. A question for
Teresa in terms of tying things back to the AAA guidelines with a set of standards and
this morning, I apologize, I think it was Jim said he cannot fix what you cannot measure
and I am wondering where we are with progress. We have been writing a one trick pony on audiogram
for a long time in determining candidacy and it is not the candidacy we tented treated
as the main gatekeeper for permission to treat so I'm just wondering if there are any new
things on the horizon as far as better diagnostic test to explore this amazing nonlinear processing
cochlea that has damaging and dysfunction that go along with the tide to the central
nervous system and we will stop relying as much on that audiogram which is not telling
us a lot. >> That would be nice. I think even just give us more information about the system
I think it is critical to do speech and noise testing. I think that is something that should
be routine in every clinic and it is not. We started out --you have to do the whole
battery of tests and I think you can measure cognition bound did to publish something recently
about cognitive measures we can include?
[Indiscernible] Was it you? >> Doing the mocha .
That is a whole other discussion but I am scared to death because cardiologists have
gotten that it is important to understand cognition and there are cognitive but -tests.
But we don't know what to do with them and audiology practice I don't think it is ready
for prime time and that is another practice implementation that we need to have.
I want to add to that. What we want to know from the literature is --take and so you look
at all of the predictors of hearing aid update and the audiogram is the least significant
cell at the input level you have to use the measures that are predictive of uptake and
successful outcomes so I think I cannot talk about that but there is plenty of information
and just use the audiogram, that was 40 years ago when Jim had hair and I had no gray hairs.
I want to comment if you don't have access to the acoustic speeches signal you don't
have anything to start with so you need to know what your accesses because that is one
step at least in my humble opinion. Bob may have comments on the diagnostics. Tomorrow?
>> I have seen some research as you age you decreased linearly and if you look at the
signal-to-noise ratio you need to understand speech. It has a different curve which is
exponentially at a later stage so I think it is highly relevant and so that should be
used a lot more and show people what to expect and if you have a --to noise ratio now hearing
aid is going to make you here well , it will not happen because you cannot pick it up whereas
microphone systems you can trace where the sound is coming from will help you and you
have to confront people with that fact early on and have them be severely disappointed
and come back and I think what to recommend people would be much more easy to deal with
if you had some of that evidence.
So the take away might be the audiogram is not the only thing we're going to measure
and maybe we are on our way to a clinical practice guideline and I want to know any
more question or another comment from anyone. Okay. I would like to thank the panelists
for a very great set of presentations I would also like to announce to you that we are going
to have a break but we need you in your seats at 3:30 PM. Okay? We will start at 3:30 PM
because we are giving you 5 min. extra on the break. Thank you. >> If everyone can get
seated, we will get started. >> We are back in session. Now we are doing session number
four on innovative models and the program says Nicole will do a presentation on community
health workers and unfortunately she had to leave with a family emergency situation. So
one of our former speakers is going to take care of that as well as she can and the presentation
will be posted afterwards.
I have not had a chance to look at these slides so I apologize ahead of time. The reason she
asked me to try to step in today when her family emergency made her leave very quickly
and go back to Arizona. Everything is going to be okay. Her dad was in a car accident
and possibly had a stroke and shoe- he was on his way to take care of her *** because
her husband was on the way to the North Pole to do some research on her suitcase never
got here on top of everything else I need to get her credit for wanting to get a talk
in today given all of that. Dr. Maroney is at the University of Arizona and I was very
privileged to get to know her as a consultant for when she prepared a grand presentation
and these are her collaboratives with the Arizona research Center, the Department of
Spanish and Portuguese and the Mariposa County health Center. She-her program and her research
looks at community healthcare workers and sober she wanted to talk to you about who
they are and why they are so poor gent and have community healthcare workers can improve
health and access to care. So community healthcare workers , the front-line public health workers,
they are considered trusted members that have served the community. They serve as a liaison
between health and social services and various communities. And the facilitators for individuals
access to services and they improve quality and cultural competence of service delivery.
They have many titles as shown here and one in Arizona is the one highlighted here. I
have no good Spanish. Does anybody speak Spanish? The community healthcare workers have core
competencies. They have to know to have good communication skills, interpersonal skills
etc. but the important one for us today is to know they have to have a good knowledge
base which they can share with the individuals about whatever health condition they are providing
information about. So the most important aspect of what community health workers to this provide
the cultural mediation between communities and Health and Human Services does. They also
advocate for individual and community needs and make sure that there is culturally appropriate
health education and support available to the individuals. So what is distinctive about
community healthcare workers? They don't provide clinical care. They generally do not hold
one another --they do not hold special licenses and Dr. Maroney has highlighted a critic of
part of what they do is have expertise about the community because they share the culture
and life experience with the population they are serving so that they can contribute certain
results that other professionals cannot. For example patients might not fill comfortable
describing issues with medication and they just want take it and --and they can communicate
back to the physicians and interventions can be done appropriately and another important
part and peers rather than-- God--patient relationships. Previous research has shown
that having community healthcare workers improves access to care she has been used successfully
for chronic disease prevention and management and it has resulted in improved utilization
of services and it ends up reducing inappropriate use of emergency rooms is also controlled
cost and there is a good return on investment by having community healthcare workers. The
research has shown community healthcare workers have a proven effectiveness in addressing
health disparities for minority populations. Increasing health care utilization provided
culturally competent health education and advocating for patients needs.
Dr. Maroney said was she first learned about the Kennedy health worker model she had a
life moment with high impact thinking this could work to address a problem we have reaching
people in the community who are otherwise not seeking ideological services. To address
this from an audio logical standpoint she had at the University of Arizona, many years,
been doing a community-based rehabilitation program called he living well with hearing
loss and so to combine that program the computer to health worker intervention to prove access
care, imagine the potential for improved outcomes in a different population. She included the
slide to show as much as we have a general population, not accessing healthcare a percentage
of Hispanic and Latino accessing hearing healthcare is much less estimated to be at about 4% in
this country. So she developed a community-based ideological rehabilitation model to identify
untreated hearing loss in the Hispanic population so far 84 adults have been tested in the community
and 76% had hearing loss but had never had access to care. They placed these people into
Spanish community-based groups. She also has a group of equal in less community-based participants
and both groups showed improved outcomes in terms of enjoyment of life and daily use of
communication strategies even without the use of hearing aids. So she wanted to highlight
that the rationale for us seeking ways to reach underserved populations has to do with
the diversity of the aging population in the United States and growing prevalence of chronic
health conditions among all aging populations including hearing loss. We have an increased
focus on prevention and wellness and healthcare and we have a growing , Lux healthcare system.
Although we know that social and behavioral determinants of health are important to examine
there is a lot of cross pressure on the system. So that is another goal of healthy people
2020 is a commitment to reduce health inequities across populations. In collaboration with
community providers and community health workers she is seeking to identify barriers and resources
in the community and collaboratively develop an efficacious community health worker intervention
in a community that is generally underserved and facing great health disparities. Assuming
the local context for her researches that it has to do with the fact that the University
of Arizona has established a relationship with the Mariposa community healthcare Center
may looked at effectiveness of healthcare worker intervention and show that it has been
very effective in diabetes and cardiovascular health. So we know that hearing loss and audiology
has connections to diabetes and cardiovascular health so why not have the community health
workers address hearing loss education and intervention as well as diabetes and cardiovascular
health. The social and economic demographics of the community in which the project will
occur suggest that there are many utilizing the community healthcare workers is very cost
effective.
So, through her research which is funded by NIH, and ID CD, she is doing a project. The
first part of the project she is identifying barriers and facilitators of access to hearing
healthcare and the underserved population. After she identifies these barriers and facilitators
they're going to develop culturally linguistic a relevant materials and then in the second
phase of the research project test the effectiveness of the community health worker model of intervention
for hearing loss. So terms of her future direction she hopes to test the effectiveness and other
geographic regions with underserved populations and further integrate other aspects of audiological
services. And establish cost effectiveness of early intervention and develop new models
of care that integrate community health workers. This is a group at the University of Arizona
with whom she works and she had a slide here and I think --there is someone awesomely --tell
me your name because --tell the group your name. [Indiscernible] Massachusetts with a
community health worker project and she did mention that you were here and doing very
similar work so hopefully if there are questions later on you may be able to address them.
Thank you very much. [Laughter] [Applause].
Good job.
Now for something different. [Indiscernible] who is working at the VA research Center as
well as something with IT over distance or something.
Thank you. I don't know how I can live up to you doing a talk spontaneously like that.
But anyway I will be talking about the future of audiology. So what I want to do is give
an overview of where we are and I am going to integrate questions and implications and
research needs. A lot of what I am presenting today comes from a conference that we held
in Portland last summer so I should think the presenters most of them are not here for
helping with this presentation. So to make sure we're on the same page I want to begin
briefly with a definition. It is the delivery of audiology services and information via
telecommunication technologies and I want to provide that definition because Teleaudiology
is not a separate subspecialty. Audiology that uses technology to facilitate what we're
trying to accomplish and that puts it into a different framework when one is thinking
about it. There are four typical methodologies used and I'm going to describe each one so
we can see how they apply to interventions. One methodology is where data is collected
at a remote site for the patient and they are transmitted at a later date for healthcare
professional to review. Then there is real-time Teleaudiology through videoconferencing simultaneously
communicating and remote monitoring for a patient will be wearing some kind of device
for data that is being sent and mobile health which is a patient driven independent of the
practitioner use. And these are all applicable for various practices. But I'm going to focus
on today, mobile health. And the reason I'm going to focus on that, because that opens
up the biggest unknown for the field. When something audiologists are running for themselves,
we know where we're going we have control whereas mobile health, there is a lot of stuff
out there that we really don't know what is going to do. I will briefly describe a couple
of successful programs that are going right now in the US. First one is the Alaska federal
access you are across Alaska and in terms of audiology it is used for a variety of things.
And just to sell you some outcomes one aspect is huge and expensive to travel most are located
in Anchorage and most [Indiscernible] are not [Laughter] this is the travel savings
and miles that has been noted since Teleaudiology came in to practice and apparently they estimate
they have saved millions of miles of [Indiscernible].
There is an associative travel dollar savings and here they are the graph looks similar
and may have saved lands of dollars as well and maybe more importantly the wait time is
to be greater than five months and 47% of the cases. Now they're down to single digits
and this is not audiology specifically general medicine in Alaska. And to provide satisfaction
it is very high with more than 60% and 90% of people agree with these statements and
likewise just-this is from a few individuals in patients are very satisfied with. The VA
has a very well-established active tele-health program and out of necessity as many patients
live in rural areas with a long travel time to a hospital. So with audiology there were
over 1.6 million veterans who need audio logical services. They have ongoing research projects
right now and I'm going to focus on one which is a pilot program looking at remote hearing
aid programming in which there is a technician and there is not geologist who does remote
programming so the question is on the outcomes equivalent for face-to-face and remote programs
so on this next slide with ratio is out, using the established outcome measure and all of
these the green --are higher even higher than the [Indiscernible] and there is a lot a lot
of data. The point being that it seems like remote programming is as successful as face-to-face.
So now I want to move on to mobile health of patient driven stuff and what is it doing
for us at the moment terms of audiology? Well Teleaudiology made it easier to access a hearing
test. There are lots of online hearing test out there and there are telephone screenings
to test your hearing. These of course raise issues that we need to think about the first
one is the data accurate and valid question work we don't know. Clearly some of these
measures are well-designed and they have been proven to be valid. Of course pollinated -false
negatives would be a problem if we told patients they had bad hearing and they don't, and the
other thing is do people understand the results that these online tests are providing to them
? There is definitely an issue with communication and whether or not patients understand what
they're being told. Now, it is no different than many patient clinician interactions because
it is well-known that they talk at a higher level than their patients but in a face to
face interaction the patient can ask a question. Whereas with these remote testing things they
cannot ask follow-up questions what is important we make sure the information is understandable.
And then of course, to the self conducted tests at home motivate behavior change? Do
they go get a hearing test if they were told Le Monde that they failed a screening? There
is some data to look at that. This is a study from Australia with delicate actions taken
by individuals who found a telephone hearing screening test and if they failed to test,
it was recommend they go and get a hearing test.
Out of 193 that failed the test, only poorly percent went and followed the advice they
had been given and of those only half of them got a hearing aid. On the other hand this
is not that different than face-to-face screening. This is another study, this is a face-to-face
screening study that was done in the VA and did not study of 650 individuals who screened
positive for hearing loss that was recommend that they go get a hearing test less than
one third of those individuals did and less than half [Indiscernible] got hearing aids
so the issue isn't Teleaudiology per se. It does not seem to me. So what can we do about
it? What we need to understand is more about the attitudes and beliefs underlying behaviors.
What motivates someone to engage in those behaviors and that is somewhere that we really
need to go. Public health messages are a good start. We need to be telling different messages
for different age groups where sending a different message about what people should be doing.
Okay technology has also made it easier to access assistive technology. At the end of
the last session people alluded to the alternative distribution systems so in a traditional setting
that we are used to a patient obtains a hearing aid through an audiologists, private crack
this or a big store and they both definitely [Indiscernible] with online retail there are
conditions in which -- so we have various online ways of returning hearing aids. Two
of these would involve some level of hearing involvement that one of these does not. And
so I think that is possibly a concern, certainly something we need to be thinking about. So
these new models are controversial but there are inevitable especially with the increased
availability of [Indiscernible] systems. So what role were they play? Something again
that we have to think about what the implications are. And we don't know yet so need to be conducting
the research to find out how these are going to impact outcomes. Otherwise you can access
technology is using high-tech things. You can turn a smartphone into a hearing aid.
Lots of apps out there to do that. Basically we don't know what these apps are doing. We
don't know if they have any value. Maybe they are a -form of hearing aid. So there are a
lot of strong opinions about it and again we need to do that research to find out what
the implications are.
Technology and tinnitus management. So there is an ongoing study looking at tele-plus tinnitus
management. Split is not only high-tech but it would be considered all of-audiology how
does that telephone counseling help? We don't know yet. There is a lot of home-based online
computerized training but to which -accuse someone of that this morning. Is it effective?
There are findings and next week is a controlled study of [Indiscernible] and we found no positive
benefits of place on a group level when it was compared with a auditory tuning condition
and the standard of care and education but within each group there were people the benefit
of seller doing a randomized control trial we have not lost the ability to look at some
of those individual differences so we need to do is we need to better identify who will
and will not benefit from things like this and only other hand there are a few downsides
to conducting auditory training solicited problem of people do it? Probably not a big
problem. There are also a lot of online hearing related counseling projects and chat rooms
etc.
There is very little worked up to look at the effectiveness. This study did a RCT comparing
online education by professional with a online discussion forum with peers. And they found
that both groups actually did decrease in the hearing handicap although there were different
psychosocial benefits among the groups so it is a positive sign that these on-time counseling
and groups are helpful at some point once again, we don't know. Select it also seems
important putting patients and clinicians think about Teleaudiology? They could potentially
be a barrier to video it opinions are so they did a couple of surveys and clinicians must
first one was looking at [Indiscernible] and they surveyed 202 clinicians and --what we
have here superb worship of respondents amazing the different seizures, a tester who has worn
hearing aids previously and what did they find pushed her anything in the grain is a
pretty positive willingness. And why it is neutral and red is not willing at all. So
we see these kind of interactive counseling and asking questions they are willing to use
Teleaudiology. When it comes to these little procedures, around 50% were more willing and
he didn't even --and when it comes to new patients they were not able to use Teleaudiology
at all. Similar data from 224 patients. There is a broad range of responses. On average
more than 50% are moderately willing to try Teleaudiology. What is really important, this
is conducted in Germany. Can you change people's attitudes and opinions? What do they think
after they have been engaged? So they looked at attitudes and what they found among a small
number of subjects, patients who often had remote hearing aid programming, two sets of
them had a more positive opinion about doing the adjustments are not. Likewise clinicians,
was the same proportion that found it more favorable after they have used it. >> We do
need to approach the education of clinician and could be a barrier where he flew to do
is to make sure we do that well. There are host of other things I can possibly talk about
today. I have underlined some of them they're the things that researchers and clinicians
have a possibility to control and access these of the things. So, to summarize Teleaudiology
provides easy access to health care many levels. There's a great diversity of options for rehabilitation
and it is generally acceptable to patients and clinicians. It could and should open a
hearing health care to a broader use of individuals. We need to validate the data we are collecting.
We need to validate and collect what is coming out of it, we need to optimize usability and
effectiveness of any to understand outcomes and there remains a need to change during
health behaviors some people access the options that are available having. So you hear the
people access what they should. So my final slide, the question isn't [Indiscernible]
how will it happen? And what we can do to ensure the most positive outcomes . Thank
you. [Applause] >> Thank you. Now account of the last speech and that is by [Indiscernible]
was a family doctor in Arizona who was also about his experiences on hearing loss of primary
care. Select a good afternoon I am Thomas Powers the doctor, not one that is associated
with this organization so that is what I look different. Anyway. I would like to thank the
Institute for inviting me here. And I will like to think the steering committee and the
organizing committee as well. I'm not usually a presenter so I am out of my covers home
but we're excited to sure what we're doing with you. My apologize for the medical session
not adequately addressing her hearing issues and I compliment you for sharing your hearing
loss with us and [Indiscernible]. Anyway, the Institute requests -if your researchers
and academics and I am a hands-on faculty person that the Institute one of these based
on numbers. So what am I going to do for numbers? So we went out and did a survey of patients
we have been working with with hearing loss. In this screen gives you an overview. We screen
767 patients over six months. Of the 767 we tested one good seven and of those we fitted
with a hearing aid. 79% of those patients were native to hearing aids. And 86% reported
they would not have purchased or delayed giving those dates the cost so that is a big-after
that has been discussed and certainly the cost is the big issue for these patients.
I have come from [Indiscernible] Arizona is a small town in western zone, population of
52,000. This time of year is 12 to 70,000 of the snowbirds. Have a self practice is
just me. I have seller. I have my wife that helps me. She does the Office of Management
and Budget to receptionist and one medical assistant. Airplane name is that we are the
Americans home for London Bridge or extreme summer temperatures. We get 200 senators and
average and you are going to have temperatures that are even higher and we have temperatures
than 120 set times. Practice of 7600 active patients in 40% of those are between 45 and
64 and 47% and as I age, the age of my patients get older and pediatric patients and my tolerance
for those snotty ready noses hasn't gone down. [Laughter]. Anyway that is where we come from.
And basically we're in the center of our triangle for Los Angeles, Las Vegas and Phoenix. So
we are out of the little of nowhere with no other surrounding communities.
We incorporated hearing testing into our practice because it would. It allowed for more comprehensive
care of the patient. I was trained and residents say, we had exposure to a audio mature, bulky
and complicated and you needed a soundproof booth of there was no as going to incorporate
that into private practice. It was a practical space wiser cost wise so hearing testing was
neglected and we did the whisper test for commercial drivers license but how accurate
is a whisper test? It is something that has been neglected it was mentioned earlier, if
we can't test for it, we can't treat it and unfortunately that is what is happening across
the board with most of my colleagues. However, because of the system that we came across
it makes sense to do it and adds more comprehensive care to our patients. Our patients are not
getting the help of the talked about earlier today, is expensive and they are afraid of
the cost and there is denial and they certainly don't come to you and say I have a hearing
loss, can you check me. They are not satisfied with solutions, I had a patient that went
to a big store for a hearing aid. They did their research. They found out that they could
negotiate the price a little bit. They negotiated the price will they got home they realized
it wasn't the same model so she was very bitter about that situation. So if she lost trust
and ability . The program that we started was in this past April and if you would've
told me in March I was testing and dispensing hearing aids and speaking at Washington DC
about it I would have said you're nuts. [Laughter]. Here I am and it has been very interesting
what we are doing is we are screening every patient over the age of 40 that comes in the
office. I have a sump will hearing screening with four request season 40 dB and she tests
every patient that comes OSHA does vital signs. There is a form that she fills out with the
results. There is a subjective part where the patient from a scale of 1 to 10, how bad
their hearing is a metaphor was given to me and when I was a patient I go over the format
if they have missed two frequencies and have eight or less than I recommend testing for
them. We are able to do testing in the office we have an automated ideology machine. It
is software that is applied to a laptop that has a high quality headphone and we do it
in a quiet room it takes us--we have a pre-question before 7 to 10 questions that helps us rule
out other reasons for hearing other than age related and we are only interested in age-related
hearing loss. If it is something more involved than we want to referrer that out and we also
--in Los Angeles we are designed to treat 80% and 20% are going to get referred out
once they hear the audiogram is printed out I go over with the patient and it shows it
is significant loss the computer program will suggest a hearing aid they have a hearing
aid there is one model with four versions to it each one is preprogrammed with four
programs it is behind the ear model and we are able to set the patient up with a demo
and my assistant will set the hearing aid up and I will fit it into the year and once
it is in the ear we assess how the comfort is we assess what the perception of the hearing
is and we give them time with it and we invite them to go to the lobby to see what the TV
sounds likely invite them to go outside to see with the traffic sounds like in the wind.
If they have an appointment they will keep it on during the appointment in they can get
used to that if they decide to purchase it, my wife will help them with the maintenance
and care for it and she will go over the financial part of their out the door within an hour
and a half of their hearing is fixed. So it is a very innovative system, it is very simplified
. We will not treat everybody but we are getting a lot of hearing loss and we do refer some
as noted. The security screenings were not expected by the patient. We're certainly not
going to ask them if we can test their hearing because there are patients that would say
no, they don't want to know if they have a hearing loss and final exams. 89% did not
expect to have hearing checked by the primary care physician office so that is a huge number
20% have had their hearing checked in the last two years. So, you talked about this
task force that could have come up with a decision on this hearing screenings should
be done. For us guys in the trenches doing day-to-day work we look at that in say, are
you nuts? Why would you not test for hearing? It only takes a second what is the big deal?
So those studies are disturbing like the one that came out about vitamins they said they
could not come out within the concise statement on vitamins. Have you seen anyone with low
vitamin C? It is curvy. What about low vitamins B12? There is a guy that walked in the office
and I thought he had a stroke. The labs came back he had a B12 level of less than 10. Three
days later he was walking clinically perfect. So some of these studies to get very frustrated.
Do it. There is no argument. Just do it. So that is what we are trying to do.
These screenings were appreciated by the patients by these numbers. This lower part is interesting.
This shows that 94% of the people perceive that they had a hearing problem and of those
94%, 80% needed hearing aids. So if they proceeded there is a good chance they had a hearing
problem so we have to go after it. This slide shows 138 had failed those hearing screenings
and we tested 107 and we weren't able to fit all of those for various reasons hearing aids
we are showing can be dispensed by the primary care physician at 44% the other big numbers
are 24% but couldn't afford it if we can get those people fitted either a lot of denial
especially with older men without a spouse that is there during the exam it is called
go mad, it is the old man disease, grumpy old man disease and it doesn't matter how
bad the losses they could have eight and it doesn't matter how bad the losses they could
have 890 dB loss of Mayor adamant that their hearing assigns what is huge denial if the
spouses there she talks him into it but if that spouse is not there there is nothing
you can do to get that guy a hearing aid. So it really helps to have the spouse there
you can see that we are being somewhat successful in providing hearing aids.
We applied the abbreviated profile on hearing aid benefits and apparently it is an industrywide
standard and you can seek 79% of patients were new to hearing aids and 21% had previous
hearing aids and when I was evaluating the system and I do not know if there were any
good or not, are just a $15 Walmart model I did not have any great way of knowing if
these were decent hearing aids that I asked some of my patients to come in and try these
and they said they were as good as the ones of they had a one they were in the market
for a new one they would come by and probably purchase these hearing aids. 72% were wearing
them from 8 to 16 hours and that is pretty successful at their wearing them and they're
not throwing them in a sock drawer. We're making sure they're comfortable and working
my wife helps with any calls that comes in and we are able to do home visits if they
are older and cannot come to the office. We will go to the house and help them and refresh
them on how to do things and they are very satisfied and they're using them. Here is
another part of the APHAB you can see how we are transforming the lives we're making
conversation with family easier, they're going to movie theaters grocery stores, so we're
really making improvement in their lifestyle it is dramatic. And it doesn't take long for
us to do that. The impact on the practice. It doesn't really affect my receptionist others
only take the appointments. The MAA is not involved in this they get involved just because
they are trying to guess who is going to buy who is not going to buy so it is a game for
them. And my wife is the assistant and between the two of us we end up doing most of it and
it doesn't direct my schedule because I am seeing these patients on top of my regular
schedule so it does back and once in a while but we're still working on the scheduling
and it has had a little bit of impact but not much. The patients are very surprised
they are very grateful and happy and I think it is one of the best things that could have
happened . Many people cannot afford them I think you are better off with your physician
who is interested in fixing the problem so patients really trust me I have been taking
care of them for 25 years so there is a lot of trust and has been successful for that
reason. It is very rewarding and gratifying and life-changing to the patients and he put
a hearing aid hand they wake up in the dislike Christmas morning
We had one lady walk out and hearing a flapping sound that was her flip-flops so it is amazing
. It is a great service to provide good the technology is great. We have been able to
simplify it it is cost effective he can bring the office and do it right away . These are
only $1500 a pair. So they are substantially less. Most are between five and $7000 at the
big stores. So opening the door. Some patients have a hard time affording the cost we have
a care credit program if they qualify for that and still there are some that cannot
afford 1500 and it is hard to see those people walk out because you know they would benefit
from the use of it. So, from a personal standpoint it is very gratifying I get a lot of pleasure.
If I treat someone with high blood pressure and put them on medication that is going to
cost them --a month and I tell them to eat certain foods and I tell them to lose weight.
To think they're going to thank me for that? [Laughter] they don't understand the importance
of it but I sure don't get a thanks. But you improve someone's hearing and is it transforming.
It is very gratifying. So we need to keep pushing this. You're doing great research
. And things will advance. We get cognition assessments and this has no place to go but
up. We need to get this into family practice residencies primary care and hope I am [Indiscernible].
So thank you for your time. [Applause] we are ready for questions and as usual, you
can come up to the microphone .
I would like to ask you a question about your private this because an issue I've run into
all the time [Indiscernible] whenever I try to integrate the idea of a screening protocol
for anything into primary care they worry about patient flow. Have you tried to cost
this out in terms of the MA doing whatever and your time to take That peace let alone
the interruption because in big practices, do you get reimbursed for the testing? >> First
of all no I do not charge for the testing or the fitting. It is complementary. We do
ultrasound screening in our office which is complementary that usually goes between 50
and $500 around town but we found a few offer these screenings because insurance companies
are not going to pay [Indiscernible] and patients are not going to pay for. Anything above their
vegetable, they're not interested. But by offering these services we're finding pathology
from the ultrasounds is incredible. The thyroid cancer, aortic aneurysms, it is incredible
that have followed you that we find if you don't look for it so the same thing they could
charge and Medicare will pay $25 and all of a sudden they will see a big spike in my audiogram
reimbursement and they will pay for that six months later they will say there must be some
kind of pride and you have had 70 and they will request that so we're going to do it
free and the patients love it. He said you will never get a hearing aid. You can test
me but you will never get a hearing aid. Cranky old guy. We tested him and he was surprised
at his Los Angeles said go ahead but I'm not going to keep it. You could not take that
out. He wanted to walk home with it and to this day he is extremely satisfied so we don't
charge for that. The cost for me it doesn't cost anything because it is not doing anything
more. If we had to replace -- you have PAs because science and the states control the
licensing and it allows me to dispense and so larger clinic it would work even better
because you have more people in the world not be as much of an effect that will fit
in easier. >> David from Massachusetts. I think a way to scale up what you are doing
were talking about tens of 50,000 and we're talking about practice in Massachusetts that
once the clinician is to have 50,000 patients and even the PAs are busy so I think if you
bring in a community health worker who is part of the community there hard of hearing
and they share an emotional experience, they connect. At that level. Earlier [Indiscernible]
and I was cofounder because we are talking about the health care system I was cofounder
of the demonstration for healthcare reform in Massachusetts. We talk about the demonstration
projects and the insurance but we don't talk about the CH W but we have not engage those
at the very beginning we would never have been able to demonstrate it. We needed to
do research. One thing I might add to Dr. Baroni's list, CHW can promote participation
and research for going to understand it so CHW can help with that research. A nice
example, I know and I will adjust on the North Shore of Boston they were for them in the
office she reports a lot of the patients are still refusing and she hesitates to call the
patients and follow-up her fear is there going to see me --they are going to see me as a
[Indiscernible] person trying to encourage them to buy a hearing aid. But if you could
have has an intermediate step, halfhearted hearing patient who has been successful in
integrating technology and learning whatever strategies they can use socially to improve
their success talk to the patient before they see the cardiologist of the hearing instrument
specialist that can provide education and counseling and our experience was with the
health care reform we would have gotten nowhere without it so it is a very important opportunity
I was a little concerned about how our your nose and throat specialist, we are a small
town and everybody knows that everybody is doing was a little concerned about how [Indiscernible]
would react because they dispense hearing aids that I was concerned about the audiologist
in town but a lot better in the big stores, are not there full-time that come in from
Palm Springs a couple of days a week that they're not there full-time so those kind
of concerned about them wondering if I was trying to steal their business that is not
the case. We need the audiologist and air nose and throat and when I look at this for
the last 25 years they let all of these people fall through the cracks so we're essentially
picking up those that they have missed. They are the easier one but they miss them read
your comment about the audiologist and office, that will work but there is a phenomenon that
being a physician pay hearing a physician, they hear it from a physician, they trust.
They don't always trust another person but for some reason physicians have whatever you
have most of them will trusted. If there is an audio just an office the doctor will introduce
some bed who really helps to have that physician interaction that is part of primary care family
Precht this and that is what we specialize in. I might spend 25 min. without patient
whatever it takes to get to the problem. That is part of the approach we are patient oriented
we take the time to explain things >> That is a pretty loaded talk but a question on
the Teleaudiology. So what do you think is happening with licensure laws as it relates
to where who, if I am in Florida and my patient is in Washington, where does the lost because
there is a licensure that you are treating the person in Washington at that time .
I simply don't know. [Laughter] It wasn't [Indiscernible] I don't know if anybody [Indiscernible]
That is a huge challenge. We see a lot of international patients and three Skype a lot
and we do some of this some of them have the option on their processors that you can do
through the phone. [Indiscernible]
That is my point. Who is stopping us from doing this because I think a lot of our patients
who would benefit greatly and any thought of what is happening state licensure, if I
can treat the patient across the board.
You have answers?
I do a dementia clinic can we serve people in West Virginia and Ohio and you can have
it good across the country but our colleagues can't treat people across the state border
because they are a nonfederal institutions of that is the basic answer and I have no
idea about cross-country .
I was going to say the same thing , in Florida in terms of training the students to eventually
be able to practice total health, we have been looking into it for speech language pathology
and I have one person doing it 10 --Florida license so imagine it is the same. >> I am
Tracy and to be self-promoting I ran a workshop on tell health and August 2012 and this was
a huge issue that was discussed at that workshop's other is a summary of that event. I can't
say there is an answer but it is a big problem.
I am in audiologist and it ties in a little bit but it is not perhaps the same but as
a physician, I don't know if you are aware of the law of the state of Arizona .
I am not specifically aware of that --and our small community that is not a strong issue
because we don't have any large performing arts centers or anything like that we do you
have on our bill of sale, it does say that it doesn't have--technology in that hearing
aid.
Part of the concept for the Arizona licenses that they are not getting a [Indiscernible]
course it is just for performing arts centers of this were on the phone it is for assistive
technology without that you cannot access a lot of those other technologies.
I think you are right and as you know technology has become more recognized and I think probably
in the future these will have that technology and stay up with the market and is to be advanced
and we are in patients who were present and we explain what it is so they are well-informed
there is not trickery are trying to be honest and straightforward
I can tell you are extremely passionate and that is why I became an audiologist. Thank
you.
My name is-- tran1 --and [Indiscernible] I want to ask for your feedback and maybe a
general assessment about feasibility of [Indiscernible] Africa do something similar to what people
are doing with blood pressure they're all sorts of monitors and tie have a blood pressure
and it is possible to do something similar for hearing in my hearing and a simple device
to quickly check a home and also with hearing aids they would get they could have something
more objective feedback this is not working very well suited there are ways you can monitor
your hearing --toxicity monitoring it is a way of doing a high-frequency [Indiscernible]
to monitor people who were in chemotherapy because if the doses to it could damage the
-and you'll lose your hearing and high-frequency and if you can change the regime before that
sets them and you can save somebody's hearing so those which have to integrate that into
the system as well and so yes you can and to be sent to the manufacturer for audiologists
You can adjust it remotely
She has done some work on hearing loss prevention where they have kiosks that you can go into
and get education and I can do that same a model looking at it for hearing and screening
so why don't you address that?
Sure. >> We developed, it is more of an education screening system so people will take notice
of the --to protect their hearing from high levels of noise we have these booths located
at the VA center and also in a couple of Army medical centers --description issues I would
suggest that probably rather than physical booths, we should be doing this online or
remotely because it is more accessible to people and I think it is a wonderful idea
and we want to do that we want to --so I agree I think the technology is probably coming
it has just come to the physicians level where they can afford at and we could afford it
you know eventually it will come to the home market and we go to the community healthcare
and you're going to get screened anyway to come to the office so we're going to have
it covered. >> Putting things online, one of the nice features as you can begin to tailor
the content to the individual that is using it because you can have different module so
someone who comes on so tailoring and targeting interventions and I think it is a great way
to go. >> This is a big topic one of the ways in which they can mature is to be more assertive
in terms of professional cooperation and especially will talk about older people and so many older
people have hearing problems I worry about so many people with hearing loss we have to
go to get the surgery and leave a hearing aid outside and all of these atrocities participating
and other health interventions that are not so I'm curious for Gabby and Dr. Powers now
you know is that change how you deliver healthcare we have other problems and go for surgeries
do you set it up so their experiences more communication accessible and there is so much
electronic health going on harder. People you go to any one of the tertiary clinics
and you want to come back for a follow-up, they will say will that be in person or e-mail
and so what they do if it is a hard of hearing person who what if there are accessibility
issues and is this opportunity to establish much better relationships in terms of getting
it right and
I am on board with you and I think the physician treating with back pain he have had back pain
yourself you have empathy for yourself and you can give them a lot of help and in town
the organization that has low cost mammograms they also offer a virtual dementia tour and
I took my staff over one day at lunch and they give you a visually impaired device,
they give you a lot of Tory impaired device they going to remedy the five tasks to do
in these writing three sentences to your family picking a sweater out of a pile of clothes
and to do these simple things were extremely difficult so it gave myself an idea of what
dementia is my staff and idea so when these older people come in so with them except their
appointments we need to be doing a better job about making sure people maintain their
hearing during certain procedures and things like that and it helps to experience these
things and make them more sympathetic with the patient.
Clearly it would seem that communication is conducted by e-mail and messaging systems
for the hearing impaired person does is a huge opportunity. I think the one thing that
is ironic is that has assisted living forward, sewer privacy issues that make it more difficult
legally to be communicating and it is kind of unfortunate that the opportunity is open
and disclosing and another way so we need to figure that out. And I heard an NPR article
on consumer electronics talking about monitoring devices but what the article focused on was
patient privacy and how nobody is developing these things and one developer said my philosophy
is let's develop the device and find out what we can do and then put in patient privacy
and kind of a pull and push. >> Good afternoon James Appleby thank you very much for all
of your presentations. I want to make a comment about what would happen to the community over
time around sticking it to [Indiscernible] if every patient is getting screened suddenly
it is not a big deal next year the year after. It is just what we do. We take blood pressure
and temperature and we screen for this as well so I applaud you for that and just encourage
as we are thinking about what additional steps we can do to start pushing towards primary
care to introduce this as part of the normal routine to eliminate the stigma that comes
with it and there is an analogy and you mentioned a few moments ago for the Medicare visits
in which we are to be detecting cognitive impairment and that we have not been able
to put in place in primary care except for cases of regular mechanisms to do it it doesn't
someone I create all sorts of fears and concerns etc. among patients and I urge you to think
about that and if every patient they are coming in for their annual wellness visit, take a
short assessment or detection of experience or whatever it is being detected would not
be such a terribly scary thing so there are a lot of analogies between what you're doing
to illuminate statement where doing for other areas. Thank you. >> Somebody asked about
screening. I think screening and physicians offices should be something that we should
not look lightly on. So I first started going on four years ago, one of my first goals was
to go to internal medicine and insist that everybody over the age of 45 was screened
and what we did was just use a handheld preset to 20 or 40 dB and you heard it or you didn't
and since December 2010 we have caught six acoustic neuromas and for NSF tumors. These
are people who just had no idea. But there was in a symmetry, there was a bilateral.
So they did identify this and now there is a hearing test in here and we actually have
all of the physicians to have the same happen they just do it. So it is part of the well-being
just like we talk about. This is part of societal problems that we're going to have to face
eventually and this is getting more and more. It is not the 80s and 90s. We are starting
to see hearing loss much earlier these --life is no longer linear and these people need
to be stimulated today and [Indiscernible] back in the 80s with the most phenomenal $300
hearing aids to help a lot of these physicians with people with these very mild high frequency
and then Songbird came out. We buy cheaters because we can't say so I commend you for
what you are doing and I think a lot of people are being missed and those folks who potentially
come back and have severe problems you're going to refer them on and screen them and
make sure they're medically and FDA guidelines but I think there are screening of medical
primary care situations, it needs to happen. This is part of our health.
I agree. What if I is a physician did not do blood pressure checks on everyone that
came in. The medical board would be all over me. And so hearing is the same. It is an important
vital sign that we should be taking and for whatever reason has gotten lost in the will
take reeducation and the American Academy of physicians need to reeducate the American
Academy of internist. They all need to--is a simple it is not a big costs do a screen
it is not time-consuming it is a simple device. To test is going to be more. But for screening,
it should be widespread and done every time a blood pressure or pulse is taken.
I would like to echo the comment about people being unaware. People deliberately are in
denial but I often think it is a lack of awareness and by screening somebody you will see that
change. It will be something that can be documented. And we can limit use of the word denial and
we think that is simply often a lack of awareness because it is so gradual over time. >> It
has been a really great day and when you think about graduated hearing loss, we have gone
through that it is a peripheral problem as well as a central problem in the central problem
is not just the auditory cortex processing but highs that could have order functioning
as well and we have it some technology and improving technology to help with proofreading
and I think there is also profound increases in our understanding about what we can do
and probably a huge opportunity we have is the understanding that the aging brain can't
remain as plastic as it ever was. And what we have to do is take advantage of that plasticity
and I think the discipline we need to embrace is that advances that are taking place there
am I question really is it doesn't surprise me if you do a population sort of auditory
training at a population level you don't show much because I still don't think we are embracing
the fundamental principles of neural plasticity that you need focused attention and it often
surprises me that you get fakes and some of those patients but my question is what was
your experience? Where were you thinking in terms of what we should be doing centrally
to be more active? >> [Indiscernible] was a co-conspirator so I came out of that thinking
we need to be able to predict who is going to benefit and who is not. We don't know how
to do it. Another thing about the study, are subject population is all that transit strikes
me that many of them have had hearing loss for 40 years. If they had lost some hearing
so why we would expect four weeks will affect --is beyond me I think that is not a real
estate expectation. We have talked about doing a study, let's involve the patient and the
decision if they believe they are motivated, maybe that is the way to go. That is going
to be the best predictable outcome that patient desire to participate >>
[Indiscernible] so one of the things we were interested in looking at involves the patients
because I think until we get the diagnostic tools to say you need to work on speech because
that might help you because you have some sort of problem following bad or you need
to have a detention issue we don't have the tool to quickly do that but I think there
are options that you can do to let the person self guide to a certain extent about what
they perceive they're getting benefit from. The interesting thing about the study with
the 279 patients if you talk to the patients, they still loved it. They're getting something
out of it. Maybe we are increasing their confidence.
Don't know what the role of increasing confidences so we don't know exactly we can measure the
group level what is changing. >> This thing [Indiscernible] what is happening
with neurotransmitters it is clear a lot of medication these people are on could have
profound effects I think we have to be thinking about how patient these people are and I'm
not sure what your thoughts are about that.
We did not look at that and I think we have comorbidities and we can go back and look
at that but whether or not there are medications that the good point they did not take into
account. There was some work done with cochlear implants looking at some medications that
enhanced training. To remember that was done in Miami.
Texas.
Texas. Dallas. Where they actually had medications enhanced [Indiscernible] [Indiscernible] [Indiscernible]
>> >> On the last point I want to thank all of our speakers after -- after eight hours
I'm happy to say that we are on time so I'm going to stay on time saying it has been a
wonderful day and I think it has been a true multidisciplinary to assemble and I think
we are doing a great job and three questions over the next couple of days consequences
of hearing loss how to address hearing loss and what do we need to do going forward given
that two older adults have it in the first couple of topics we have hearings tied to
healthy aging and how we can treat hearing loss and tomorrow we will begin tackling --about
the innovations that need to go forward if we want to address hearing loss from public
health standpoint so thank you very much. We will reconvene at nine in the morning.
[Applause] [Event concluded]