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I Hear You, I Hear You, or Maybe I Don't

The Clinical Scenario
It was one of those unusual clinics where I saw three similar cases in which the exact same issue surfaced and I was able to demonstrate in “real time” to residents in training with me in the care of the elderly. The first of the encounters was with a couple accompanied by two family members; the couple lived at home with some personal care help and each had some degree of cognitive impairment but not enough to completely interfere with reasonably safe functioning when under some supervision. I was interviewing and examining one member of the couple and my resident was doing the same to the other.

Denial or Hearing Impairment: A common scenario
As I embarked on my interview with the patient it became clear that as noted in previous visits, he was quite hard of hearing. According to the son who was with him, his father refused to wear his hearing aids because “they bothered him” and he often stated that he had, “no problem with hearing”. Each time I spoke to him, he leaned into me to hear my question or answer and turning to the son to repeat the question.  With his wife the resident also noted in addition to some degree of cognitive impairment a significant degree of hearing impairment.

Low cost, effective hearing enhancement: very dramatic at times
I retrieved my Pocket Talker® which I keep in the office for such cases. I put the simple earphones first on him and gradually turned the volume and suddenly his face lit up as I asked if he could hear me and he said, “very well”. We practiced a bit with the device until it was clear that he could engage in a three way conversation with his son and me.  The resident was now ready to review the wife’s issues with me and the son entered the room with us as did his father. They had already learned from me that during the discussion, while I asked questions they were to sit quietly despite a desire to “help with answers” unless I asked them specifically to comment on something said to me by the patient. The resident had reiterated the story to me of mild dementia he mentioned and emphasized that she was quite hard of hearing; she had refused hearing aids although the family was planning on acquiring them. I retrieved the Pocket Talker® that I had just used with her husband, put on the head phones and as I increased the volume, like her husband her face lit up when she heard my questions and I looked at the son and husband and said to them, “maybe you can get a deal if you get two of these”.

A hearing augmentation “Hat trick”
Later in the clinic, a different resident saw another patient. This resident had not been apprised of the experience that I and my other resident had with the couple. She recounted a history of progressive cognitive decline and also mentioned an issue with hearing that the accompanying daughter raised. Like the previous couple the daughter said her mother absolutely refused to go for a hearing assessment and said that she did not want “hearing aids” as she “did not need them” and they were in any event “a waste of money”.  I carried out the same manoeuvre that I had used with the previous couple. Although less dramatic than the previous cases, the way she responded to my repeated questions clearly indicated that she could hear better with the device.  In this particular case,  I was not convinced yet that some of the apparent cognitive impairment may have been perceived as such due to her hearing impairment or at least aggravated by it.  I explained to the daughter when I said I was not yet sure of the degree of cognitive impairment, “if you can’t hear it, you can’t remember it”.

Don’t overlook Hearing as part of the Cognitive Assessment
In these three situations during one clinic session the young residents who in their careers would see many elderly people with cognitive impairment or dementia, the message of the importance in hearing was clearly demonstrated.  It can be hard to convince older people to utilize hearing aids or pay for them. For many a simple and inexpensive Pocket Talker® may be a device that can be used  as an introduction to the benefits of hearing enhancement or may on its own solve the hearing deficiency problem for the purpose of social communication.

                 

Comments

Very interesting! A lesson worth learning!

Whilst running the Oakville Menopause Clinic,I have always insisted that all Post Menopausal Patients have a Hearing test done every ten years. However there is a strong resistance to having this done, the argument is usually "I can hear very well!!" We find at least five percent have issues which need further investigations annually.

I think that is a good strategy- so it is necessary to find methods to overcome the usual resistance with an explanation as noted in the above reply to the idea of "hearing just fine". Also emphasize the potential long-term effects of hearing impairment and the development of cognitive impairment- most people including doctors are not aware of that understanding of the relationship which is developing in the fields of audiology and cognitive research.

I would like add to the article that even mild loss of hearing uncorrected impairs the cognite aspect of mental capacity and delayes the dementia process.

I cannot agree more with this observation. The whole area of the relationship bewteen hearing and cognition is coming into its own and research exploring the interconnected relationship is ongoing- in the meanwhile, we as practitioners should always keep in mind the importance of hearing and be able to counter the usual response from people we see who declare that they "hear just fine" is to help them understand the importance of not just hearing the sound but being able to discriminate the meanings of the sound which is often lost. One strategy I use is to "try" an amplification system such as a pocketalker(R) for a few months before making a commitment to a much more expensive investment in in-ear amplification systems.

very true! also check the vision too!

How much does the pocket talker costs ? where to buy it ? thanks!

Apologies - comment posted twice -

I don't know about where to buy PocketTalkers in actual stores but you can order them online. The cost is from $146 to $210 on the Canadian Hearing Society website - https://chs.ca/index.php?option=com_virtuemart&view=category&virtuemart_category_id=7&Itemid=233&lang=en There are PocketTalkers for sale on other websites, too.

As a hearing impaired physician who also cares for the elderly I am only too aware of the excellent observations made by Dr. Gordon. May I add that meeting patients in an environment where extraneous noise is minimised as well as looking at the patient, are ways to improve communication with the hearing impaired. Gazing at the computer screen and talking to the patient at the same time simply doesn't work!

Thanks for everyone's comments- they all add to the robustness of the article and understanding- the cost quoted sounds about right- our audiology department lends them out (with a credit card back-up if not returned or lost) and then patients/families can buy they from our department- should check with the local hospital audiology departments if you have access to them- also check witht he private hearing aid dispensers- I suspect they might have them as well- but may be not worth it for them to carry- their use is limited but for what they can be used for- very effective- I keep one in my office to use with patients and then if it seems to be working suggest to them and their family that they should try it for a few weeks to see if worthwhile for them and their circumstance- I now have a few patients who when they come to my office with their family they bring their litte gizmo for the interview. All the best, Michael