American Academy of Audiology Task Force

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Washington University School of MedicineDigital Commons@BeckerStaff Publications2006Audiologic management of adult hearingimpairmentAmerican Academy of Audiology Task ForceFollow this and additional works at: http://digitalcommons.wustl.edu/audio_fapubsPart of the Medicine and Health Sciences CommonsThis Article is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Staff Publications by anauthorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationAmerican Academy of Audiology Task Force, "Audiologic management of adult hearing impairment" (2006). Staff Publications. Paper2.http://digitalcommons.wustl.edu/audio_fapubs/2SEPTEMBER/OCTOBER   200632 AUDIOLOGY TODAYAUDIOLOGIC MANAGEMENT OF ADULT HEARING IMPAIRMENTAn executive summary of the AmericanAcademy of Audiology’s Task Force onAudiologic Management of the Adult Patientand Adult Hearing Impairment is presentedon the following pages.  Michael Valenteserved as chair of the Task Force and pre-pared this summary on behalf of the TaskForce.  The Task Force members were HarveyAbrams, Darcy Benson, Theresa Chisolm,David Citron, Dennis Hampton, AngelaLoavenbruck, Todd Ricketts, Helenda Solodarand Robert Sweetow.  The entire final reportis available for review and downloads on theAcademy web site at www.audiology.org/ publications/documents/positions/adultrehab/. SUMMARY GUIDELINES AMERICAN ACADEMY OF AUDIOLOGYAUDIOLOGY TODAY 33VOLUME 18, NUMBER 5WHY A NEW GUIDELINE?The most recent guidelines for hearing aid fittings in adultswere published in 1998 (Valente, et al., 1998) and, obviouslysince that time, there have been significant advances in hearingaid technology and methods to verify and validate fittings.There was concern that current clinical practices may do little todifferentiate how hearing aids are dispensed by audiologists.The current Task Force felt that this important topic deservedanalysis using evidence-based principles (EBP) in developingnew guidelines, and that the guidelines must be patient-centeredby incorporating a section on auditory and non-auditory needs-assessment. Finally, it was felt that if the “spirit” of the guide-lines were followed then implementation by audiologists would:• Promote uniformity of care, • Decrease variability of outcomes, • Promote better fitting practices, • Elevate the clinical care to our patients as well as elevateour profession,• Provide greater patient satisfaction, and,• Reduce the hearing aid return rate.The Task Force divided the guidelines into five majordivisions: (1) Introduction; (2) Assessment; (3) TechnicalAspects of Intervention; (4) Audiologic Rehabilitation includingInstruction, Orientation, Counseling and Follow-Up; (5)Assessing Outcomes. These divisions follow the sequencepatients typically follow when pursuing amplification. The fivedivisions were divided into the nine sections and the numbersappearing below in parenthesis indicate the number of keyrecommendations developed for each section.  The specificrecommendations for each section ranged between none and 13.Overall, the guideline contains 43 specific recommendations.• Assessment: auditory assessment (0), auditory needsassessment (3), and non-auditory needs assessment (6).• Technical Aspects of Intervention: hearing aid evalua-tion (13), quality control (2), fitting and verification (7),and hearing assistive technology (4).• Instruction, Orientation, Counseling and Follow-UpAudiologic Rehabilitation: hearing aid orientation (2),and counseling and follow-up audiologic rehabilitation (6).• Assessing Outcomes (0)A systematic search of the literature was conducted usingEBP for each of the 43 recommendations. The search focusedon the best available evidence to address each recommendationand ensured maximum coverage of studies at the top of thehierarchy of study types (Levels 1-2).  The search extended tostudies or reports of lower quality (Levels 3-6) only if higherquality studies could not be found.  However, for most recom-mendations within the guidelines, less than 1/3 were judged asLevel 1-2. This finding should be of concern as it points to theneed for research to justify how audiologists provide servicesrelative to the sections covered in these guidelines.  ORGANIZATION OF THE GUIDELINESEach section of the guidelines begins with an objectivestating the purpose for the section, followed by a backgrounddetailing how the section fits within the guideline. SpecificRecommendations then follow and each section ends with theTable of Evidence and References.INTRODUCTION TO THE GUIDELINESWithin the Introduction section, the guidelines provideseveral statements outlining some of the essential compo-nents. First, a licensed audiologist must provide services.Second, the combined efforts of the audiologist, patient, sig-nificant others, and/or caregivers are essential. Third, assess-ment must be viewed as a multi-faceted process that includesassessment of auditory function to determine the extent ofimpairment and assessment of activity limitations and partici-pation restrictions through self-report of communication needand performance. Fourth, consideration should be given toassess the typical listening environments using such tools asdata logging. Also, there should be consideration of howthese levels of assessment interact and reinforce each other toimprove quality of life (QOL). It was felt that as a result ofthe multi-faceted assessment, clear and realistic individual-ized goals for intervention could be set.ASSESSMENTAuditory Assessment.  This section details the variouscomponents of the auditory assessment of the patient. Someof the specific components may include: • Comprehensive case history, • Identifying type and magnitude of hearing loss via pure-tone and  speech audiometry as well as immittance,• Measuring loudness discomfort levels (LDLs) • Otoscopic inspection and cerumen management,• Determine need for treatment/referral to physician or needfor further  tests (ABR; vestibular, etc),• Counsel patient, family, caregiver on the results andrecommendations,• Assess candidacy and motivation toward amplification, • Determine medical clearance as determined by FDA (1977).Audiologic Management of Adult Hearing ImpairmentSUMMARY GUIDELINES AMERICAN ACADEMY OF AUDIOLOGY34 AUDIOLOGY TODAY SEPTEMBER/OCTOBER   2006Auditory Needs Assessment. This section details proce-dures to develop patient-specific communication needs. Thisincludes providing realistic expectations and creating patient-specific fitting goals as the initial stage of the “validation”process. Also involved in this process is determining whichhearing aid “features” may be appropriate for the patient.These features may include:• Directional microphones• Direct auditory input (DAI)• Noise management• Frequency Modulation (FM) devicesAs part of the Auditory Needs Assessment, the patient mayrespond to a variety of questionnaires which might includeany of the following:• Abbreviated Profile of Hearing Aid Benefit (APHAB)(Cox and Alexander, 1995).• Client Oriented Scale of Improvement (COSI) (Dillonet al., 1997).• Hearing Handicap Inventory for the Elderly (HHIE)(Ventry and  Weinstein, 1982).• Expected Consequence of Hearing Aid Ownership(ECHO) (Cox and  Alexander, 2000)• Glasgow Hearing Aid Benefit Profile (GHABP)(Gatehouse, 2000)• International Outcome Inventory-Hearing (Cox et al.,2003)Non-Auditory Needs Assessment.  This section deals with thenon-auditory needs of the patient and recognizes that theseneeds may interact with auditory needs to determine successwith amplification. These non-auditory needs  may includecognition, patient expectations, motivation, willingness totake risks, assertiveness, manual dexterity, visual acuity, priorexperience with amplification, general health, tinnitus, occu-pational demands, and the presence of support systems.TECHNICAL ASPECTS OF INTERVENTIONHearing Aid Selection.  This section relates to the decisionsneeded to select the appropriate hearing aid(s) and hearingassistive technology (HAT) based on the results of the hear-ing, auditory and non-auditory needs assessment. The out-come of this process is an attempt to match the appropriatestyle and features to the patient. These decisions may include:• Style (CIC, ITE, ITC, BTE)• Occlusion management• Volume control• Bilateral versus monaural• Direct auditory input (DAI); telecoil (programmable)• Type of signal processing• Capacity for frequency shaping (number of bands)• Selection of output and SSPL90• Number of memories• Number of channels of compression and feedbackmanagement • Digital noise reduction• Switchable or adaptive directional/omnidirectionalmicrophones• Frequency compression or transposition• Bone anchored devices• CROS/BICROS/Transcranial CROSQuality Control.  The objective of this section is to ensurehearing aids meet reasonable and expected quality standardsprior to scheduling for hearing aid fitting and verification. Asmall percentage of instruments and earmolds may be defec-tive on receipt. In addition, hearing aids and earmolds mayarrive in good working order, but with the incorrect configu-ration/features. Quality control (QC) measures are necessaryto limit patient and clinician frustration and inconvenience.Examples of QC may be:• Verify directional microphones performance,• Electroacoustic analysis of new and repaired aids to assurecompliance to standards and repairs are completed to cli-nician satisfaction, • Electroacoustic analysis at final fit to provide base formeasures at semi- annual or annual checks, • Verify features to include confirmation of earmold/shellstyle, vent, color, type,  processing (memories, automaticswitches, etc.) and mechanical (directional microphones, t-coil, integrated FM, etc) features, • Features not verifiable through physical examination orelectroacoustic  verification should be verified through alistening check. These may include operation of the VC,directional microphones, FM, t-coil, etc.Fitting and Verification.  The objective of this section is toassure the fitting and verification procedure is viewed as aprocess that culminates in the optimal fitting. Verificationprocedures also serve as a benchmark against which futurehearing aid changes can be compared. Verification proceduresshould be based on validated hearing aid fitting rationales andare expected to yield a comfortable fit of hearing aids includ-ing all desired features. In the fitting and verification processa signal must be presented to the hearing aid whether in thetest chamber or with a probe microphone in the real ear. TheAudiologic Management of Adult Hearing ImpairmentSUMMARY GUIDELINES AMERICAN ACADEMY OF AUDIOLOGYAUDIOLOGY TODAY 35VOLUME 18, NUMBER 5SUMMARY GUIDELINES AMERICAN ACADEMY OF AUDIOLOGYAudiologic Management of Adult Hearing Impairment36 AUDIOLOGY TODAY SEPTEMBER/OCTOBER   2006Hearing Aid Orientation. The objective of this section is toensure patients obtain the desired benefits from amplificationas easily and efficiently as possible. The hearing aid orienta-tion process begins with the initial hearing aid fitting and maycontinue over several visits. Hearing aid orientation is com-plete only when all appropriate information has been providedand the patient (or family member/caregiver) is competent tohandle the instruments or declines further post-fitting care. Orientation information can be device- or patient-related.Device-related is specifically about the care and use of hear-ing instruments. Patient-related includes helping the patientunderstand the nature of hearing loss, adjust to amplification,have realistic expectations of the benefits and limitations ofamplification, and take advantage of other sources of help(such as better communication strategies, HATs andspeechreading). Topics included in orientation may include: • Use and care of aids such as instrument features; inser-tion/removal; battery use; care and cleaning; comfort;feedback, use with telephone; warranty.• Wearing schedule; goals and expectations; adjustment toamplification; speechreading; post-fitting. CaCounseling and Follow Up Audiologic Rehabilitation.The objective of this section is to provide patients who havereceived hearing aids a comprehensive understanding con-cerning the effects of hearing impairment and the implemen-tation of strategies to mitigate those effects. The membersview the fitting of hearing aids as the beginning of the treat-ment process. Successful management requires comprehen-sive counseling to help the patient adjust to his/her hearingaids and instruct the patient and his/her primary communica-tion partners, to develop appropriate communication strate-gies to maximize and augment the assistance he/she receivesfrom the hearing aids. Counseling is often required to helpthe patient learn new strategies to help ensure success. Inaddition, emotional factors concerning hearing loss must beaddressed in a comprehensive audiologic rehabilitation pro-gram. Counseling can be provided on an individual basis, butis often delivered in small group settings. Topics addressed in these sessions should include:• Anatomy and physiology of hearing process• Understanding the audiogram• Problems associated with understanding speech in noise• Appropriate/inappropriate communication behaviors• Communication strategies• Listening and repair strategies• Ways in which to control the environment• Assertiveness training • Realistic expectations from amplification• Stress management• Speechreading skills• HATs• Community resourcesAssessing Outcomes.   This part of the patient manage-ment process assesses how well intervention reduced activitylimitations, decreased participation restrictions, and improvedquality of life and is referred to as validation. Validating thechoices made as part of the assessment, selection, and fittingprocesses, to the extent that the patient’s needs have beenmet, is accomplished through the administration of outcomemeasures. Many outcome measures, described in the auditoryand non-auditory needs assessment section, have been devel-oped to assess the impact of a hearing impairment on theindividual in the areas of communication functioning, activitylimitation and participation restrictions.As critical as it is to measure the benefits of hearing aidintervention at the level of the patient, the measurement oftreatment outcomes is assuming greater importance on thenational health care stage. Through the routine use of clinical-ly applied outcome measures and carefully controlled clinicaltrials, audiologists can build a foundation for evidence-basedclinical practice guidelines. Clinical practice guidelines, inturn, minimize variability in outcome, maximize treatmentefficacy, reduce risks, decrease waste, improve patient satis-faction, and should elevate the profession of Audiologyamong third party payers, other health care providers, and,most importantly, current and future patients. As audiologistscontinue to compete in the health care marketplace, they mustdemonstrate that treatments reduce activity limitations,decrease participation restrictions, and improve health-relatedquality of life. Only by measuring the outcomes of treatmentcan audiologists be assured that interventions make a differ-ence and patients have benefited from their care.REFERENCESAmerican Academy of Audiology (2004). Pediatric amplification guideline. AudiolToday, 16(2):46-53.American Speech-Language-Hearing Association (1997) Preferred practice patterns for the professionof audiology. Rockville, MD.Cox R. (2004) Waiting for evidence-based practice for your hearing aid fittings? It’s here! Hear J57(8):10,12,14,16-17.Cox R, Alexander G. (1995) The abbreviated profile of hearing aid benefit. Ear Hear 16:176-186.Cox RM, Alexander GC. (2000) Expectations about hearing aids and their relationship to fitting out-come. J Am Acad Audiol 11:368-382.Cox R, Alexander G, Beyer C. (2003). Norms for the international inventory for hearing aids. J AmAcad Audiol 14(8):403-413.Dillon H, James A, Ginis J. (1997) The client oriented scale of improvement (COSI) and its relation-ship to several other measures of benefit and satisfaction provided by hearing aids. J Am Acad Audiol8:27-43.Gatehouse S. (2000). Page 10: The Glasgow hearing aid benefit profile. Hear J 53(3):10,12,14,16,18.Hearing Aid Devices: Professional and client labeling and conditions for sale. (1977). FederalRegister 42(31):9286-9297. Valente M, Bentler R, Seewald R, Trine T, Van Vliet D. (1998) Guidelines for hearing aid fitting foradults. Am J Audiol 7:5-13.Ventry I, Weinstein B. (1982) The hearing handicap inventory for the elderly: A new tool. Ear Hear3:128-134. AUDIOLOGIC REHABILTATION:Instruction, Orientation, Counseling and Follow Up

Audiologic management of adult hearing impairment

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Audiologic management of adult hearing impairment

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