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.