Hearing and Health Outcomes: Recognizing and Addressing Hearing Loss in Hospitalized Older Adults

Abstract

As age increases, the prevalence of hearing loss significantly increases, reaching up to 89% of those 80 years and older. Hearing loss in older patients is often unrecognized and its consequences are often underappreciated. Hearing loss can interfere with the ability to exchange important health information and to participate in health care decision-making. Hearing loss during hospitalization increases the risk of misdiagnosis. There is a lack of empirical data regarding prevalence and recognition of hearing loss in hospitalized older adults. In this article, we describe a variety of negative outcomes that may result when older inpatients are functioning with unrecognized hearing loss.

Learning Outcomes: As a result of this activity, the participant will be able to (1) list three negative outcomes associated with unrecognized hearing loss in older adults; (2) give examples of communication difficulties described by hospitalized adults who have hearing loss; (3) list negative outcomes associated with hearing loss in older hospitalized adults.

Hearing loss is the third most reported chronic condition in the United States.¹ In a study analyzing data from the 2005 to 2006 cycles of the National Health and Nutrition Examination Survey (NHANES), the prevalence of hearing loss in those ages 70 and over was 63.1%.² Lin et al reported the prevalence of hearing loss significantly increased with age and reached 80.6% in those age 85 years and above.² Likewise, Cruickshanks et al reported that hearing loss increased greatly with age and reached a prevalence of 89.5% in those aged 80 years and older.³ In general, these prevalence data have been collected on typically functioning, community-dwelling older adults, via participation in actual hearing tests or via responses to surveys. Despite the high prevalence of hearing loss in older adults, the condition remains largely unrecognized and underappreciated in older adults across community settings and potentially during hospital stays.^{4 5 6}

Along with prevalence data on this population, there is a growing literature describing the varied effects of untreated hearing loss on an individual's function and potential for successful aging. Hearing loss negatively impacts psychosocial health and cognitive functioning.^{7 8 9} Hearing loss can affect a person's quality of life and overall ability to function.¹⁰ Persons with hearing loss have more physician visits and may have more hospital visits.^{11 12 13} Genther et al analyzed two cycles of the NHANES data to examine the association between hearing loss and hospitalization in individuals age 70 and above.¹⁴ These results, published in 2013, showed that those with audiometrically confirmed hearing loss had more hospitalizations than those with normal hearing sensitivity. Later, Genther et al conducted a prospective study that examined audiometry results and quantification of documented hospitalization episodes.¹⁵ The results showed that hearing loss was associated with a higher incidence and annual rate of hospitalization in community-dwelling older adults. Additionally, older adults with hearing loss experience more difficulties and delays in accessing health care,¹⁶ compared with their normal-hearing peers. Delay in health care access could potentially contribute to a higher number of hospital admissions for older adults who have hearing loss.

Potential Impact of Hearing Loss in The Hospital Environment

Given the associations between hearing loss, health, and hospitalizations in older adults, it is reasonable to consider the impact of hearing loss on inpatient hospital experiences and outcomes. Aside from the goal of achieving the best possible outcomes from a hospital stay, hospital administrators have an array of associated risks of which they should be aware. These risks are listed in Table 1 and further explained here.

Table 1. Rationale for Hospital Administrators to Address Hearing Loss in Older Inpatients.

Risk	Potential Undesirable Outcome
Misdiagnosis17 19	Longer length of stay, higher cost
Increased falls19 20	Complication/extension of stay, higher cost
Lack of communication accessibility21	Americans with Disability Act violation
Risk to physician-patient communication23 24 25 26	Lower postdischarge adherence, readmission

First, hearing loss increases the risk of medical misdiagnosis,^{17 18} potentially resulting in longer and more expensive length of stay. For Medicare patients, where reimbursement is fixed based on diagnosis, hospitals must strive for the most efficient diagnosis and treatment, including the shortest possible length of stay. Second, hearing loss has been associated with an increase in the probability of falls.^{19 20} Fall prevention for inpatients is a high priority in hospital cost containment plans. By identifying patients with hearing loss, it may be possible to reduce associated fall risks in the hospital. A third reason for attention is that the Americans with Disability Act (ADA) mandates communication accessibility for hospitals and other medical facilities.²¹ Administrators aim to avoid violations of the ADA regulations, which can result in costly lawsuits and unsatisfactory public relations. Consideration of hearing accessibility beyond the use of a sign language interpreter is necessary, because the vast majority of inpatients with hearing loss are strictly aural/oral communicators. Finally, poor provider-patient communication has the potential for the misunderstanding of health choices, discharge instructions, and medication directions. These miscommunications have the potential to result in poorer adherence to discharge instructions and possible unplanned readmission. Unplanned readmission within 30 days is considered an adverse event representing poor quality and high hospital expense when Medicare patients are involved.

The capacity to receive verbal information is compromised in patients with hearing loss. Inpatients with hearing loss are at an increased risk for miscommunications because of adverse noise conditions in the typical hospital listening environment.^{4 22 23 24} Pope et al conducted a study on inpatients at a veterans hospital, examining patients' ability to identify and recall high-context and low-context speech against a background of simulated hospital noise.²⁵ Results showed that patients with hearing loss may have less success in hearing, understanding, and remembering new information in the hospital compared to those with normal hearing. These authors suggested that patients who do not hear and understand information exchanged during hospitalizations could potentially be at a higher risk for readmission.

Poor physician-patient communication is associated with a limited quality of health care decision-making.²⁶ Active patient participation in health care decision-making is essential to optimal patient outcomes and is a goal of the U.S. Department of Health and Human Services.²⁷ This is of particular importance in the hospital environment, where medical decisions need to be made quickly and family members are not always present to support communication interactions. Patients with hearing loss are at risk for communication breakdowns during the exchange of health information while hospitalized.^{5 24 28 29 30} Fook et al evaluated the impact of hearing loss on communication between older patients and medical staff (physicians and nurses).²⁸ Twenty-two percent of patients rated communication with their doctor as poor, very poor, or unsatisfactory. With the addition of voice amplifiers and acetate cards informing staff of patients' hearing loss, there was a significant improvement in the perception of communication, with only 6% of patients reporting poor or unsatisfactory communication with their doctor. Prior to the addition of voice amplifiers and informational cards, there was a significant difference between patients' perception of communication with nurses and that of doctors. Nurses scored significantly better than doctors. However, with the introduction of the voice amplifiers and cards, there was no significant difference in perception of communication with nurses versus doctors.

Mulley and Ng conducted a survey with 53 hearing aid users attending an audiology clinic to determine if hearing loss led to difficulties during recent hospitalizations.³¹ Sixty-two percent of the respondents described problems during hospital visits that included difficulty following directions and interference from background noise. Other complaints described physicians speaking at a rapid rate while not facing patients, shouting questions, and assuming that patients had comprehended their message. Given the communication barriers that arise for older inpatients, it is clear that hearing loss may contribute to reduced participation in the medical decision-making process.

Hearing Loss and Potential Hospital Complications

In hospitalized older adults, hearing loss has been identified as a significant risk factor for developing delirium.³² According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for delirium, the main features are: disturbance in attention and awareness, acute development and tendency to fluctuate, and additional disturbances in cognition.³³ In older adults, delirium is the most frequent complication of hospitalization,^{34 35} and it occurs in 11 to 42% of hospital admissions.³⁶ Incident delirium refers to delirium that occurs following hospital admission and can develop at any time during hospitalization. Incident delirium is certainly an undesirable hospital complication because it is associated with increased morbidity and mortality, increased length of stay, and increased institutionalization upon hospital discharge.^{37 38 39}

Another potential complication for older inpatients is an accidental fall. Evidence suggests an association between hearing loss and falls among older adults.²⁰ Lin et al examined the relationship between hearing loss and fall history from participants in the NHANES data set (2001 to 2004).²⁰ Similarly, Kamil et al studied a large cohort of older adults age 70 to 79.⁴⁰ Data from audiometry and self-reported number of falls were used in analyses to investigate whether hearing loss was associated with frailty and falls. Results indicated that those participants with moderate or greater hearing loss had greater odds of falling over time, compared to those with no hearing loss. These results showed that greater hearing loss was independently associated with self-reported falls in the preceding year. These findings were consistent with those of Lopez et al and Viljanen et al demonstrating that the consequences of hearing loss are not necessarily restricted to communication ability alone, but also to patient safety.^{41 42}

Hearing Loss: Largely Underrecognized and Underaddressed

Hospital staff often lack the formal training and skills needed to recognize and to communicate effectively with patients with hearing loss.²² Studies have addressed both the lack of hospital staff's awareness of hearing loss within the patient population and inadequate training in communication strategies.²⁹ The invisible nature of hearing loss is particularly challenging to hospital care providers.⁴³ Heron and Wharrad investigated nursing staff's ability to accurately identify the presence and degree of hearing loss in older patients.²² Nurses' judgments as to the presence of hearing loss were compared with the results of audiometric testing: 15 of 49 (30.6%) of the nurse responses correctly identified the presence of hearing loss, 30 of 49 (61.2%) failed to identify existing hearing loss, and 4 of 49 (8.2%) were unsure regarding the presence of hearing loss. With regard to the degree of hearing loss present, 14 (53.8%) responses matched the measured degree of hearing loss and 2 (7.7%) gave incorrect assessments of degree. Ten (38.5%) were unsure of the degree of hearing loss. The authors of the study concluded that medical and nursing staff need further resources and training to address the assessment of patients' hearing abilities. VanCott explored communication patterns between older patients (age 65 to 95 years) and nurses during admission assessment on general medical-surgical units in two acute care hospitals.²⁴ This author categorized miscommunications into six areas including: acoustics, phonology and syntax, lexicon, conceptions, intent, and credence. A breakdown in communication due to acoustics (message not reaching the hearer) occurred in 50% of admission interviews and was mainly due to noise in the environment. VanCott further reported that nurses failed to recognize when patients were experiencing hearing difficulties during the interview and that acoustical problems occasionally resulted in patients providing misleading information during the admission assessment.²⁴

There is currently no standard protocol guiding hearing screening or evaluation procedures in the inpatient hospital setting. Screening audiometry is not a routine component of hospital admissions or nursing assessment procedures. Therefore, the most likely scenario for identification of hearing loss on admission involves direct questioning or informal observation by nursing staff. When asked directly about hearing status, older individuals will typically underestimate their own degree of hearing impairment when compared to the gold standard of audiometry.^{43 44 45 46 47 48} In the absence of direct questioning regarding hearing loss, nursing staff may use informal observation to assess an older hospital patient's hearing and communication ability. Heron and Wharrad collected survey responses to describe the methods most often used by nurses to assess a patient's communication ability.²² The most frequently used method involved having a conversation with the patient, followed by observing if the patient wears a hearing aid. The next most common method was to ask the patient directly if they had a hearing problem. Another aim of that study was to examine the extent to which nurses were aware of patients' communication ability. Results suggested that nurses were largely unaware of patients' hearing ability, though they had demonstrated theoretical knowledge of hearing loss. Similarly, Hines investigated communication problems of patients with hearing loss in the hospital.²⁹ He administered surveys to patients with hearing loss who had been in the hospital in the prior 3 years. Respondents reported that their communication needs had not been adequately addressed by hospital staff. The author concluded that shortcomings seemed to result from inadequate training of nurses and doctors and from patients' reluctance to reveal their communication difficulties to the staff.

Quality Improvement Efforts Targeting Older Inpatients With Hearing Loss

As noted earlier, several studies have quantified the prevalence of hearing loss in community-dwelling older adults, but not in hospitalized patients. Similarly, it is unclear what the most feasible and effective method of identifying hearing loss might be in the hospital setting where immediate health needs are top priority. Given these challenges, the authors of this article have undertaken a quality improvement project to investigate related questions at a large urban hospital in Pittsburgh, Pennsylvania. This project grew out of an interprofessional collaboration between clinicians, students, and investigators from audiology, nursing, and geriatrics. Within the hospital, our group has become known as the Communication, Hearing, and Audiometry Team (CHAT), and we have reached out to patients, nurses, physicians, and other care providers throughout the hospital units. An overarching goal of this project had been to assess the visibility of hearing loss under standard hospital conditions. Preliminary results of this project support the challenging nature of recognizing existing hearing loss in older hospital patients. The results from this study will be disseminated in a future publication.

Conclusions and Discussion

Given the known prevalence of hearing loss in community-dwelling older adults, it is likely that at least two thirds of older hospitalized patients have some degree of hearing loss. For some of these patients, the hearing loss will not significantly impede the flow of health-related communication. For others, the ability to receive important health information may be seriously compromised. The latter group includes those inpatients we can describe as functioning with a high communication risk level. It appears that the invisibility of hearing loss remains a challenge in recognizing and addressing the associated communication risk. Furthermore, hearing may be a low priority for patients when they are worried about pressing health issues, potentially impacting the accuracy of self- report responses. Unfortunately, a hospital stay is precisely the time when critical health information is exchanged, often under adverse listening conditions.

Future Considerations

In keeping with Taylor's call for a model of interventional audiology, it seems that the inpatient hospital setting is a relevant environment for action.⁴³ Future data regarding the impact of hearing loss on hospital outcomes will further clarify the extent of this problem. One approach to improve identification of hearing loss could involve restructuring the questions or procedures included in the admission process. Given the high prevalence of hearing loss in the older hospitalized population, another approach might be to include a quick, objective measure of hearing thresholds on admission, for all older patients. This measure could lead to an assessment of communication risk and could trigger preventative interventions (e.g., personal amplifier, risk notice in the electronic medical record , wrist band notification). Any of these methods would necessitate buy-in from the entire health care team and hospital administrators. In all, it seems that the invisibility of hearing loss might best be remedied by audiologists reaching across health disciplines with an interventional approach.