Hearing Loss in Nursing Home Residents

Hearing loss in nursing home residents may have a critical impact on quality of life. As such, facility staff should be encouraged to embarrass more comprehensive hearing assessments. On this week’s episode, we welcome Dr. Kathy Dowd, AuD to talk about hearing assessments, care plans, and the “hearing standard of care” for nursing home residents.

Schenk: Hello out there. Welcome back to the podcast. My name is Rob and I will be your host for this episode. Today we’re talking about an issue that I think is often overlooked and that is how hearing loss in nursing home residents is affected by chronic illnesses, medications and other factors. And as a result of hearing loss, how quality of life can suffer. So this is a systematic problem in many nursing homes because assessment tools maybe aren’t the best and staff that does the assessments that review a resident’s ability to hear perhaps aren’t trained in a way that would bring about the type of care that would allow the resident to attain the highest practicable health.

So we are having on today an expert in this area, Dr. Kathy Dowd. She is an audiologist to talk about all those things, hearing, chronic illnesses, balance disorder assessments and changes to nursing home ways that would help quality of life of residents. So before I get her on, let’s learn a little bit about her.

Dr. Kathy Dowd received her undergraduate degree in French education from Spalding University, a master’s in audiology from the University of Louisville and a clinical doctorate from Salus University. Her background’s in audiology over the past 39 years is varied – educational audiology at local and state levels as well as a private practice and ENT and proprietary clinics. For the past five years, Dr. Dowd has worked to raise the awareness of chronic disease and autotoxic medications causing hearing loss by instructing diabetes educators, optometrists and audiologists nationally about the silent, unmet medical need. In April 2016, her advocacy efforts moved the Centers for Disease Control to consider a recommendation for hearing testing to the patient guide, “Take Charge of Your Diabetes.” Dr. Dowd is heading the advocacy and collaboration of audiology organizations and setting clinical guidelines for patient care in the area of chronic and infectious diseases, and we again are so happy to have Dr. Dowd on the show. Dr. Dowd, welcome to the program.

Dowd: Thank you Rob. I’m glad to be here.

Schenk: Excellent. So Dr. Dowd, we’re so happy to have you on the show to talk about the issues surrounding chronic illnesses, hearing loss and balance disorders and how those issues relate to one another and in turn relate to the quality of life and care that our seniors and specifically residents of nursing homes receive. So can you kind of – and you’re the expert on this, so can you kind of unpack how chronic diseases like diabetes affect an individual’s hearing kind of from a 40,000-foot view, kind of unpack that for us?

How does chronic disease affect hearing loss in nursing home residents?

Dowd: Certainly. The Audiology Project is focused on diabetes and the effects on hearing and balance, but we also know cardiovascular disease, chronic kidney disease, Alzheimer’s, Alport Syndrome, Crohn’s Disease, all of these chronic diseases will have a negative effect on hearing and sometimes also on balance. In addition to whatever the person has experienced during life with noise exposure or medications, strong medications to treat infection like sepsis or MRSA, those also have an effect on hearing. So for diabetes, what is happening is it’s a microvascular disruption in the body. And it’s been known for a long time that this affects your eyesight. It affects your foot neuropathy, the feeling in your feet. It affects even in your brain, you get this disruption in the microvascular system throughout the body and in your kidney. So diabetes doesn’t discriminate. It’s everywhere in the body, even in the ear. The issue with the ear is we can’t look into the cochlea, which is the inner ear, to see this disruption like you might see it in the back of the eye. So that’s a problem. And cardiovascular is really macrovascular issues – that means the large blood vessels. So if you have a tendency for blood clotting, pulmonary embolisms, strokes, even hypertension can cause your hearing to go down. Alzheimer’s again, if Alzheimer’s is related to changes in the brain, that’s where the receptor for the auditory signals is or the receptors for your balance and for your orientation and space. So anybody in nursing homes who have chronic diseases needs to be tested and the audiologist needs to find out all the different things that have happened to this person in their life that might have contributed to a hearing problem.

Schenk: So if I understand you correctly, Dr. Dowd, it seems to be at least kind of two drivers for how chronic illnesses can affect the hearing. One is, as you mentioned, the macrovascular, meaning the blood flow. The other is kind of an interference with the senses and the receptors of the brain due to something like Alzheimer’s. So you’ve got, on one hand, something like strokes, diabetes, peripheral artery disease on one end of the spectrum. And on the other end, you’ve got dementia, Alzheimer’s that can all have an effect on the hearing, which is interesting because growing up, at least all I remember learning is you’ve got little hairs in your ear, and if they fall flat, that’s the hearing loss. That’s how you get hearing loss as opposed to what you just mentioned. So that’s really interesting. That’s news probably to a lot of people. At least that’s news to me.

Dowd: Yes, I think many in the medical field are unaware of these causes and the need for evaluation.

Schenk: Exactly. So at the top of the show in your bio, we mentioned The Audiology Project. Can you talk about that a little bit?

What is the Audiology Project? 

Dowd: Well I started The Audiology Project probably about five or six years after my mother-in-law was diagnosed with diabetes. She was in an assisted-living center. She already had a cardiovascular disease. She already had hyperthyroidism, which contributed to hearing problems. And then she got this diagnosis of diabetes. When I reached out to CDC to get some material knowing that she already had a hearing problem, which she had hearing aids, but CDC was not aware of the relationship between diabetes and hearing loss. So over the course of the next five or six years, I was in communication with them. And then in 2016, I spoke with the Johnson & Johnson Diabetes Institute with the American Optometric Association about this issue for audiology, and they recommended we get all of our audiology associations together, bring them together for a stakeholders meeting – how are we going to move this issue forward and raise awareness of this new, emerging issue? So in September of 2016, we formed The Audiology Project, and just last year in November of 2019, we wrote a definitive publication and seminar in hearing that explains the pathophysiology, what is happening to the ears and the fibrillar system, and then also how does audiology need to identify and manage this from both a hearing standpoint and a balance standpoint, because your balance system and your hearing system are right next to each other and it’s one nerve, the eighth nerve comes off both of them sending the signal up to the brain. So the effects are for both systems.

Schenk: I see. So before we get into that, can you kind of – is there a difference between one person’s hearing loss versus another person’s hearing loss? Are there different types of hearing losses if that makes any sense? I don’t know – is that something? Are there different layers or different types that might work faster than the other in terms of loss of hearing?

Does hearing loss in nursing home residents occur at different times? 

Dowd: Well noise is probably the quickest damaging feature for your hearing because you can have one incident of extreme noise and lose your hearing totally. Certain medications depending on your susceptibility on those medications could totally wipe out your hearing. And it’s impossible for an audiologist to know until the person comes in, you take a really good case history and then you test. It’s impossible to know until you do the test – “Ah, this is what it is.” So yeah, there’s varying degrees of hearing problems. It could be a mild hearing problem where it just sounds like people are mumbling. When it gets into moderate or severe, you’re actually missing critical aspects of speech. You know you can hear somebody but you’re really having much more difficulty understanding. And so they’re profound – by that time, it’s usual that your hearing was not evaluated before that time although again, you could have a sudden hearing loss from some of the things I just mentioned and it could go overnight. But normally the progression could start with a mild hearing loss and then progress to severe or profound. About 10 to 15 percent of hearing problems can be medically or surgically corrected, so once the audiologist tests you, they’re going to know if there’s a chance you can have medical treatment or surgery that’s going to reverse the hearing problem and then a referral is made.

Schenk: So tell us about the test then. When should somebody be tested and what is involved in the test? Is it literally like your hand is on the patient, like you have to go inside the body? Can you kind of talk about that a little bit? What can we expect from that?

How should a nursing home resident be tested for hearing loss? 

Dowd: Well when you go to the audiologist, usually what they do again is take a case history so we know all the things that have happened to you. Is it in your family? Did you shoot guns as a youngster, go hunting? Did you work in a factory? Do you have high blood pressure? Are you on medication for anything? And then that starts turning up the chronic diseases. Then the audiologist looks in your ears to see if there’s anything blocking or anything abnormal in the ear canal. It could be something as easy as a wax blockage, so removing the wax then does away with the hearing problem because the wax was blocking the sound waves from going into your ear and then the eardrum. We examine the eardrum, make sure there was nothing that looks abnormal with that, no holes in the eardrum. We can’t look beyond that. So then again, we take the case history but then we put you in the booth and we put headphones on, and then we put a bone conduction oscillator behind one of your ears, on the bone right behind your ear. So we test air conduction with the headphones on and you’re given really tiny beeping sounds and you’re supposed to press the button as soon as you hear that. And it’ll be different pitches. And they’ll do one ear and they’ll do the other ear. And then they do bone conduction and that just sends the signal directly to the cochlea past the middle ear or the eardrum, and it finds out how well you can hear just in the cochlea. And we can chart that. And then there maybe are some other tests that are done too – for example, otoacoustic emissions. That is examining your inner ear hair cells and how well they’re functioning. Sometimes you can have normal hearing but you’re going to show up with a problem with OAEs, with otoacoustic emissions, which tells us there may be some damage occurring, so you need to keep a check on your hearing over time. We also do tympanometry, which moves the eardrum back and forth and makes sure that it is moving, because if it doesn’t move, then there’s some problem on the other side of the eardrum. Maybe the middle little ear bone has stiffened up. And that’s an issue that can be corrected usually by an ear, nose and throat, an otolaryngologist can do surgery to correct that. So once we’re all done, we have a picture of your hearing.

How is a nursing home resident’s quality of life affected by hearing loss? 

Schenk: Yeah, and I wish that every time – well let me back up. Federal and state law require that when a resident is admitted to a nursing home that an interdisciplinary team consisting of the doctor, nurse, people that have hands-on care going forward do a head to toe assessment of the resident, that’s everything from cognition to whether or not there are wounds on the person. And in the process of doing that, you get history, you get the family involved for all the reasons that you just stated. But I don’t, just offhand, it’s the Minimum Data Set is the federal assessment, and I don’t recall – I know there’s hearing on it but I don’t think it goes into the detail that you’ve described, although I wish it did. And the reason why I wish it did is I would love for you to explain this as we’ve talked about chronic illness. We’ve talked about how it has the potential to affect hearing. We talked about how medication might affect hearing and how to test for it, at least not now, but at the end of the day, there is at least in my experience the misconception that, “Well Grandma can’t hear very well, but all that means is we have to turn the TV up for her.” What does quality of life have to do – or what’s the correlation between quality of life, health and the loss of someone’s hearing?

Dowd: Well and that’s one of the focuses of the federal laws – the Omnibus Budget and Reconciliation Act of 1987, and it states there needs to be an assessment of hearing in order to ensure the best quality of life for the resident. However, when they wrote the CMS, the Medicare MDS Assessment for Hearing, I don’t think they consulted any audiologists because the intake nurse talks with the person, the new resident, face-to-face in a quiet room and then comes away with this subjective determination of, “Oh, I think you could hear me okay,” and so they mark that everything’s all right, when in fact what happens is one-on-one, face-to-face in a quiet exam room, even a physician won’t see a hearing problem that’s significant. And there’s a lot of research that has come out recently that says that this CMS, MDS hearing assessment severely under-identifies hearing loss. And I’m trying to raise this awareness with Medicare right now. I think they wrote this assessment probably back in 1987 when OBRA took effect. But it’s not – it’s a subjective view of somebody’s hearing and it’s not valid. It’s not an objective screening.

What is the current Federal requirement regarding hearing loss testing in nursing home residents? 

Schenk: Agreed. And it’s been a while since I’ve read the RAI manual, the manual that the MDS coordinator, whoever the nurse is conducting the hearing test for the MDS, what detail they go into, it’s definitely not as you describe it. You’re right, they notch off can the person be understood and is the person, can they understand from a hearing standpoint? It really doesn’t go very far as you mentioned to where you talk about…

Dowd: Well and if the intake person would even cover their mouth when they’re talking, that’s going to take away the 40 percent understanding from lip reading. So if they would even do that, they’d see a little bit more, but you can’t really know until you have a valid, objective hearing screening, not a discussion with the person. Or a hearing evaluation – that’s the only way to know these people are coming into the facility from the hospital after having a heart attack or a stroke or diabetes that’s out of control or kidney failure. All of these things that just happened very recently in the hospital have a very potential impact on hearing loss and it’s not being addressed right now in the MDS hearing assessment at all.

Schenk: Right.

Dowd: So it’s a problem.

How else does hearing loss affect quality of life for nursing home residents? 

Schenk: And like I said, so I understand from a quality of life standpoint, if somebody can’t hear, it might mean that they self-isolate because they can’t participate in things, but what else in your research have you seen? In other words, how does that affect balance, hearing with balance, these types of things going forward in terms of somebody losing their hearing and not wanting to walk anymore, things like that?

Dowd: Well and hopefully the physical therapist, when they come in to do their evaluation, takes into consideration any potential vestibular problems that may be happening. We do an assessment, the audiologist does the assessment stimulating the vestibular system and then watching eye movement, but there’s some things you can do statically too to assess the person’s balance. So at this point, what happens with hearing loss is it causes confusion, depression and isolation. So the person doesn’t want to come out to group activity like bingo because they’re not ever going to win. They can’t hear the person that’s calling the bingo. Or they’re going to be depressed because they hear everybody talking around them but they don’t understand. They feel like they’re talking about them. They’re mumbling about them. So they get very suspicious. One gentleman that I tested in a nursing home, the CNAs, the aides said, “After we identified his hearing problem and corrected his hearing,” they said, “Oh my God! It’s night and day!” And I said, “What do you mean?” They said, “Well we used to come in, give him a bath and he would physically fight us. And now when we come in, he can hear us explain what we’re going to do and how we’re going to do it, and so he’s fine with it.” And so obviously before he felt like he was being accosted and nobody’s explaining things to him, where once he understood what was going on, it was like, “Oh, okay. Yeah, I do need a bath,” and he was fine with it. It affects everything and my issue right now is that nursing homes are allowing cognitive evaluations of new residents and cognitive treatments, and there is no hearing screening first, which in my thought is should not be happening. You cannot assess somebody’s cognitive status without first making sure they can hear well or else correcting their hearing and then looking at cognitive.

Schenk: That makes a lot of sense and that example of the individual that was fighting the baths, that’s the perfect example of how hearing can do wonders for the person’s care. So how that would probably shake down without the issue with the hearing being resolved is they’re going to say he’s non-compliant. They’re going to call the family. He’s going to get ridiculed by the family possibly, “Dad, stop fighting them about baths,” that type of thing, but give him the hearing test and he can understand what’s going on, that’s a night and day difference in outcome.

Dowd: But hearing loss is invisible.

Schenk: Exactly.

Dowd: It’s an invisible handicap. So you can’t tell. You just think, “Oh, they’re not paying attention to me,” or “They’re ignoring me,” when in fact, they just don’t hear you.

What is the “hearing standard of care” for assessing hearing loss in nursing home residents? 

Schenk: Correct. You’ve mentioned more appropriate assessment techniques for hearing loss, doing this prior to any type of cognitive assessment. You’ve talked about testing at regular intervals for these purposes based on a holistic approach, medications, history of chronic illnesses, these types of things. What other types of what I think you have called them in your writings and presentations the hearing standard of care, what other examples of the hearing standard of care should nursing homes be doing for either prevention of hearing loss or caring for someone with hearing loss?

Dowd: Well when you can consider that 80 percent of the people in nursing homes have a hearing problem, everybody needs to have an evaluation when they first come in, at least then you set a baseline. And so there’s 20 percent of the people will have normal hearing, but they’re still being given medical care or medications. They may suddenly get an infection but at least you have a picture of where they’re starting. So I think a baseline hearing test is the first thing that needs to happen. And then if you find somebody that can benefit from amplification, from hearing aids, that needs to be the next step. The wonderful thing about hearing aid technology now is that you actually can get, when you go to the dining room in a skilled nursing facility, which is a little bit noisier, there’s technology that actually takes down some of the background noise and allows you to hear the people in front of you at your table. And it makes it easier to hear in that situation. There’s Bluetooth so that you can connect to an iPhone or a smartphone and have continual conversations with your family and it goes right into your hearing aid. You don’t have to put the phone up to your ear. The Bluetooth sends it into your hearing aids and makes sure you can hear it.

Schenk: Right, right.

Dowd: And then just ongoing evaluation, I mean we can’t stop with just the initial assessment, but depending on your history, it may be in three months or six months, but the audiologist needs to test you again. Has anything changed or is your hearing stable?

Schenk: Got you. Well Dr. Dowd, this has been a fantastic conversation, one that is not often held with individuals that have a loved one in a nursing home about how hearing, taking hearing loss seriously and understanding the appropriate ways to assess the loss and to take interventions and steps towards caring for somebody with hearing loss, so we really, really appreciate you coming on the show today.

Dowd: Oh certainly. Thanks so much for having me, Rob.

Schenk: Absolutely. It’s a reoccurring theme on this program that nursing home assessments, training and family participation sometimes are not what they need to be, which in turn leads to a decline in the quality of life of residents. So I hope that we’ve all learned something today about how hearing loss is more than just “tell Grandma to turn the TV up,” that it has other ramifications on quality of life and the care received. So these are all important things and we are very fortunate to have Dr. Dowd come on the show and talk to us about these things because she’s doing great work out there. All these things go towards quality of life and appropriate care in nursing homes.

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