Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting

Abstract

This cohort study calculates baseline prevalence of communication breakdown in hospital and primary care settings among older adult patients reporting hearing loss.

Recent analyses have highlighted a significant increase in the rate of hearing loss in patients 60 years and older. The estimated prevalence of bilateral hearing loss greater than 25 dB is 27% among patients age 60 to 69 years; 55%, 70 to 79 years; and 79%, 80 years and older. The prevalence of medical errors is higher among older patients, and they are also among the most dependent users of the health care system. Failures in clinical communication are considered to be the leading cause of medical errors. Walsh and colleagues reported that improved communication between the medical teams and families could have prevented 36% of medical errors. However, the contribution of hearing loss to medical errors among older patients is nascent. While audiometry is an effective method of diagnosis of hearing impairment, not all impaired listeners will have the same speech comprehension, despite having similar pure-tone thresholds and configurations. In the present study, qualitative analysis was applied to semistructured interview data collected in 100 older adults 60 years and older. Baseline prevalence was calculated for communication breakdown in hospital and primary care settings among adults reporting hearing loss. We also identified common, discrete aspects of a clinical consultation that older adults with hearing loss may find difficult and which may be contributing toward medical error.

Methods

A convenience sample of participants were enrolled from the outpatients department at Cork University Hospital. Informed consent (oral) was obtained, exclusion criteria included cognitive impairment and lack of spoken English. Two authors independently reviewed the responses, coding all comments and developing an initial thematic framework. This study was approved by the Cork Clinical Research Ethics Committee.

Results

Of 100 older adults interviewed, 57 reported some degree of hearing loss, with higher rates of unilateral and bilateral loss reported by adults 80 years or older relative to all other groups (Table 1); 50% of the study population had previously undergone audiometric testing, and 26% used a hearing aid device. Forty-three adults reported having misheard a physician and/or nurse in a primary care or hospital setting, and frequency of reported mishearing did not vary according to age group. When asked to elaborate on context of mishearing in a clinical setting, emergent themes consisted of (in descending order of citation frequency): general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, and use of language (Table 2).

Table 1. Overview of the Study Population.

Characteristic	Age Groups, y
	Total	60-69	70-79	≥80
Total, No. (% female)	100 (39)	35 (34)	38 (37)	27 (48)
Age, mean (SEM), y	73 (0.9)	64 (0.5)	75 (0.4)	84 (0.7)
Hearing loss type, No.
Unilateral	21	6	8	7
Bilateral	36	9	15	12
No hearing loss	43	20	15	8
Previous noisy work environment, No.	43	17	17	9

Abbreviation: SEM, standard error of mean.

Table 2. Response Theme, Example, and Frequency of Common Words 59 Patients With Hearing Loss Misheard.

Theme	Example of Patient Comment	No. (%)
Consultation content
Occasions when problems of mishearing and/or misinterpretation are focused on illness-related or treatment-related information (eg, diagnosis, prognosis, medication dose/regimen)	“I suppose when the doctors are speaking, you know, they have their own words and you’d have to ask.” “I think definitions of illness…” “Instructions they’re giving me…” “Just explaining your condition or even medication…”	21 (36)
Nonspecific and/or unlimited
Occasions when problems of mishearing are not limited to a discrete aspect of the consultation	“…you can’t bring it down to one word at all, like, you know, like, it’s general.” “I wouldn’t hear a whole sentence sometimes maybe.” “I probably miss half of what he says to me.”	17 (29)
Doctor-patient or nurse-patient communication breakdown
Occasions when problems of mishearing and/or misinterpretation are attributed to difficulties in verbal or non-verbal communication between the physician/nurse and the patient	“Some people talk so fast you’d miss what they’re saying…” “…if there’s 2 or 3 people talking together…” “…it depends on how loud or how low he talks to you.” “If you’re talking to me, look at me.”	16 (27)
Use of language
Occasions when problems of mishearing are language-dependent	“It depends on how one pronounces things.” “Similar sounding words would be the ones that would catch you.”	6 (10)
Selective deafness
Occasions when problems of mishearing are deliberate or intentional	“You’re not listening to what you don’t want to hear.”	4 (7)
Occasions of hospital setting–specific mishearing	“…if there’s a bit of noise around I can’t hear.” “…if there’s a bit of noise around, you know?”	2 (3.5)

Discussion

The prevalence of reported hearing loss our sample population is comparable with expected estimates from similar age cohorts. This qualitative analysis confirms that age-related hearing loss has a negative effect on clinical communication across both hospital and primary care clinical settings. A recent report of the National Academies of Sciences, Engineering, and Medicine, acknowledged that hearing aids improve hearing acuity but are limited in their capacity to “...restore normal hearing or fully improve communication abilities especially in noise.” The latter point was highlighted in the present study, as well as a recent report that demonstrated that both phonemic contrast and contextual factors can contribute to miscommunication in clinical settings in adults with moderate and severe hearing impairment. Otolaryngologists are in a strong position to understand and address the needs of older patients with hearing impairments, recognizing that the circumstances of medical conversations vary widely not only in relation to environmental background noise but also the attendant pain and fear and distress of illness or injury, lack of familiarity with medication names, diagnoses, and the other essential components of medical discourse. Few of these elements are part of routine audiometric assessment. We recommend that content-related and setting-related factors identified as barriers to communication in adults with hearing impairment be incorporated within a patient-centered approach to clinical communication with this patient population.