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Addressing Disparities in Senior Hearing Health Care

by Carrie Nieman
An elderly woman with hearing aid

In an online chat, Johns Hopkins Hospital instructor Carrie Nieman recommends strategies to reach more older adults with hearing loss from underserved communities.

Participant: Could you provide some suggestions on approaches to providing hearing care to older adults?

Carrie Nieman: A lot of work recently has focused on getting outside of the clinic and working to address the barriers that older adults may encounter, particularly vulnerable older adults. We have started working with mobile technologies and over-the-counter (OTC) devices as well as with community health workers partnered with audiologists.

Participant: Do you find that disparities, primarily of a socio-economic nature, are related to cognition?

Nieman: There are significant disparities in the prevalence of cognitive impairment by race/ethnicity, but we also know that disparities in hearing care exist by race/ethnicity and socio-economic status. We don’t know a lot about minority older adults in terms of hearing care (from a population standpoint), but differences in cognition may play a role.

Participant: What are some strategies to improve health care service delivery to racial/ethnic minorities?

Nieman: Most of what we know from a population standpoint regarding age-related hearing loss comes from studies done with primarily white older adults, so that limits our current understanding. Rates of age-related hearing loss differ by race/ethnicity, or more precisely, hearing loss varies by skin color. It is believed to relate to differences in the amount of melanin in the cochlea. Melanin—or specifically melanocytic functioning—has a protective effect, which translates to older adults with darker skin color typically having lower rates of hearing loss. Regardless, rates of hearing loss among minorities are still high (50–60 percent), just not as high as white older adults.

We know from NHANES (National Health and Nutrition Examination Survey, 2005–2006 and 2009–2010), a nationally representative sample of older adults, that minority older adults report using hearing aids at a rate of around 10 percent, versus white older adults who report hearing aid use at around 20–30 percent. In terms of strategies, I think there is a lot to be done. Based on focus groups we have done in the community, a lot of older adults complain that hearing loss is not on their radar, either because of so many competing medical concerns or because their primary care doctors do not talk to them about it, or they did not know who to see, or there were no payment plan options available. I think it’s about getting into the community. That means partnering with patients and organizations to help get services out to those who may not traditionally seek care.

Participant: Do you find literacy level to be a barrier to care?

Nieman: Literacy is not something many of us think about regularly. In our pilot study in Baltimore, we delivered hearing care in affordable-living senior apartments. Many of our participants had a sixth-grade reading level or lower. There are many structural barriers, including literacy and health literacy, to all of health care, but we don’t always think about those that apply to hearing care.

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Participant: Has there been any research that points to a decline in cognition changing the way the auditory system functions?

Nieman: I think that reflects on the limitations of our traditional audiograms and reliance on pure-tone audiometry. We know that individuals with dementia and Alzheimer’s are able to complete pure-tone audiometry, but higher-order processing that may be required for something like speech-in-noise testing may change for someone with cognitive impairment. Fitting hearing aids or devices for older adults with cognitive impairment highlights a lot of the same lessons from human factors that we should be considering for all older adults: their dexterity matters, their vision, their ability to change batteries or charge the device.

Participant: What are your thoughts on the role new legislation on OTC hearing aids will have in reaching older adults?

Nieman: There are a lot of devices already on the market as PSAPs [personal sound amplification products], and have been for years. However, recently there have been some great advances in products. The legislation will help standardize the quality of devices and hopefully get rid of a lot of the poor-quality products out there. In terms of improving access, the legislation is a start, but there are a lot of barriers that may impact an older adult’s ability or willingness to seek hearing care. Many are still going to need a navigator or someone to teach them about their devices and their hearing loss, manage expectations, etc. The last mile of connecting an older adult to a piece of technology is still going to be there.

Participant: In your experience, do most physicians understand hearing impairment to be a serious public health concern?

Nieman: I must say the new Lancet report on dementia was a really big step in highlighting the role of hearing loss in the aging process. For the first time, I have had my geriatric and gerontology colleagues asking how they can include hearing screening in their studies and incorporate it in their care. The big thing will be the results of the ACHIEVE trial.

Participant: What are some tangible ways to enhance older patients’ self-efficacy around hearing care?

Nieman: There are a lot of things we can do, and a lot of us probably already include these things in our practice. One basic method is to incorporate teach-backs into device training, which means having an older adult observe a step (for example, turning the device on), do the step themselves, and then teach you or his/her loved one how to do that step. Also, drawing upon a patient’s past experiences can be important if they have used a cellphone or a hearing aid, or worked with a bluetooth headset or something they have already mastered.

Also, provide the training in the context of something that is relevant to them. Provide the device orientation in the context of the patient’s day: Here is what you do with the device when you get up, go about your day, at the end of the day, etc. You cannot forget about praise and reassurance. Many older adults have a fear of breaking a device or destroying it in some way. Recognizing that may be a fear your patient has, and going out of your way to reassure them, can make a difference.

Participant: Any suggestions on how to re-establish trust between audiologists and older adults in underserved communities?

Nieman: Another important point! There is a lot of mistrust, and rightfully so, in a lot of underserved communities. Recognize this outright and ask the older adult about their concerns and expectations. Having an open conversation can build trust. If someone is unhappy or defensive from the start, sometimes calling attention to that can open the door for them to share what they did not like or what they fear. Reassure them you are committed to their satisfaction and then deliver on that.

Participant: In closing, if a participant were to remember or put into practice only one idea from your session, what would that one key takeaway be?

Nieman: Push yourself to think about the patient—the older adult—as a whole person as much as possible. Recognize that our goal is to build on their ability to communicate and engage. Keeping the user, the older adult, at the center of care at all times can help us do that.

Carrie Nieman, MD, MPH, is an instructor in the Division of Otology of Johns Hopkins Hospital’s Department of Otolaryngology–Head and Neck Surgery. cnieman1@jhmi.edu. 

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