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Hearing Loss: Perceptions and Solutions

October 1, 2006
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A decrease in auditory function can send out contradictory signals by Amanda D. Nichols
BY AMANDA D. NICHOLS Hearing Loss: Perceptions and Solutions
Hearing loss can be dealt with effectively to improve a resident's quality of life Hearing loss is the third most common chronic condition found in the elderly population, following hypertension and arthritis.1 According to a 1999 Centers for Disease Control and Prevention study, 21% of nursing home residents have some degree of hearing loss.2 This figure, however, is probably an underestimate because hearing impairment tends to be overlooked or underdiagnosed in the long-term care setting.

Communication difficulties are not the only problems associated with hearing impairment. Hearing loss can lead to depression, social isolation, stress, and functional problems, such as impaired balance. Hearing loss and dementia have several symptoms in common, such as confusion, withdrawal, irritability, disorientation, and inappropriate responses, that can lead to a diagnosis of a more severe cognitive impairment than is truly the case. When furnished with hearing amplification, residents with dementia score better on cognitive screening tests than those without amplification.3 When a proper screening program is in place and assistive listening devices are used, continuing decreases in quality of life and functional abilities can be stabilized.

Although there is no universal protocol for screening hearing in nursing home residents, helpful assessment tools do exist. The Hearing Handicap Inventory for the Elderly is a widely used screening questionnaire. This 10-item questionnaire assesses the emotional and social impacts of hearing loss on residents. Answers are given in a "Yes," "No," or "Sometimes" format and then scored accordingly. Scoring and interpretation instructions are provided (see table).

If a resident fails the screening, a full audiologic evaluation performed by a state-licensed, American Speech-Language-Hearing Association (ASHA)'certified audiologist is recommended. A comprehensive audiologic exam is considered the standard method for determining the type and severity of hearing loss and to rule out middle-ear pathology. In addition, it provides essential information in determining candidacy for hearing aids, assistive listening devices (ALDs), and aural rehabilitation. Medicare Part B covers hearing evaluations (CPT code 92557) when they are deemed medically necessary, such as to rule out a middle-ear pathology as a cause for a de-crease in hearing.

Otoscopic ear examination should be performed in conjunction with an audiologic evaluation to exclude other treatable causes of hearing loss, including cerumen (earwax) impaction, ear infections, and tympanic membrane perforations. In fact, cerumen impaction is one of the most common causes of hearing loss in the elderly and can be attributed to a hearing loss of up to 40 decibels.4 Aural rehabilitation and amplification should be offered to residents once they have been qualified as candidates for these services. Helpful Resources

American Speech-Language-Hearing Association, www.asha.org

Better Hearing Institute, www.betterhearing.org

Centers for Medicare & Medicaid Services, www.cms.hhs.gov

HITEC Group, Ltd., www.hitec.com

Williams Sound Corp., www.williamssound.com Aural Rehabilitation
Aural rehabilitation must be deemed medically necessary to be a covered service under Medicare. Medical necessity is determined by the recommendations of an audiologist and speech-language pathologist, and depends on determination that a hearing aid or an ALD in itself would not "sufficiently meet the patient's functional communication needs."5 This type of speech-language therapy is reimbursable under CPT code 92507 which, under Medicare, is described as the "treatment of speech, language, voice communication, and/or auditory processing disorder."

Hearing aids are the most commonly used amplification for the hearing-impaired. It has been reported, however, that only one-fifth of all residents who could benefit from hearing aids actually own them.6 The most common reasons cited for this are residents' anxiety about hearing aid maintenance and care, and cost. Other issues with hearing aids, such as problems with insertion, cleaning, changing batteries, using volume controls accurately, and turning hearing aids on and off, can indeed be overwhelming, and residents may decide that their hearing "isn't that bad" after all.

According to ConsumerAffairs.com, the average cost of a pair of hearing aids in 2004 was $2,300.7 Cost can be prohibitive for the elderly, who might rely strictly on Medicare and Medigap to meet their healthcare needs. In fact, of the 10 standard Medigap plans available, not one covers the cost of hearing aids. A few commercial insurance companies reimburse for hearing aids, but coverage varies greatly. Medicaid coverage for hearing aids also varies greatly, depending on the state.

Other Amplification Options
Assistive technology can play an important role in the hearing healthcare of residents who are unable to handle or afford hearing aids. Assistive technology falls into two main categories: alerting devices and ALDs.