Title: Optimising hearing-Related Communication for care Home Residents with Dementia (ORCHARD): a realist synthesis
Funder: Department of Health and Social Care

Abstract: Both hearing impairment and dementia are common in care homes. Hearing impairment occurs in 70-90% of residents, and dementia in about 75%. Together, the two can be formidable barriers to communication. Managing hearing loss in care homes is complex. Testing hearing in dementia is difficult. Other problems contribute to poor communication: care homes are often noisy, making communication harder for people with poor hearing; aphasia in dementia exacerbates the impact of deafness; residents and care staff often have different backgrounds and some don t speak English as their first language. Hearing aids are often supplied, but problems can arise, e.g. the resident doesn t tolerate the aid or understand what it s for, may be unable to operate it, or may simply destroy it. Care staff may lack knowledge and skills to support hearing aid use, or may not value the effort required to encourage the resident to wear the aid. Hearing aids are frequently mislaid, lost or broken. Families of residents are frequently upset if an aid is not worn, or if it is missing or broken. Residents not using aids cannot readily access auditory stimuli required to communicate. Evidence regarding effective strategies to improve hearing-related communication in care homes is limited. Managing hearing loss in care homes is complex and often co-exists with other problems, e.g. dementia, which can affect staff attitudes and their approach to its management. Realist synthesis (see Figure 1 in appended supplementary file) is a theory-driven explanatory approach for evaluating health and social complex interventions. It utilises a range of different sources of data, thereby maximising the use of all available literature and resources. It is designed to address the questions of what works, how, why, to what extent, for whom and in what circumstances. Therefore it uses a pragmatic approach to assess evidence, and seeks to explain why different outcomes can occur in different contexts. It has not previously been used in hearing loss research. This team, comprising experts in hearing science, dementia care and realist synthesis, will review all forms of relevant information, including grey literature and relevant websites. We will recruit a context expert group of practitioners, care home staff and the public. This group will meet seven times during the project. These facilitated half day meetings will help us develop and refine our explanations about how best practice in hearing management can occur in care homes. We will also interview a small number (3-5) individual care home residents with both hearing and cognitive problems. From the literature, the group will explore how and why the reported outcomes have occurred. An explanation of the interplay between context, mechanisms and outcomes will be sought. From this, we will develop and refine an initial rough realist programme theory to be tested against the data (from the literature and the experience of our context experts) to see how well it can explain the pattern of findings. The realist programme theory will drive further literature searching; thus moving iteratively between the analysis of particular examples, the emerging rough realist programme theory and further exploratory searching. This requires a flexible and evolving search strategy. Both our methods and our reporting will adhere to the RAMESES guidance on realist synthesis. We will test the ideas arising from the evidence and the emerging realist programme theory with the context expert group at subsequent meetings as the research progresses. This will enable us to understand what best practice looks like and what makes it effective. Finally, this study will i) develop national guidelines to ensure best practice, and ii) suggest future research topics to support care homes in managing hearing-related communication.

Lay abstract: Hearing impairment affects 2 million people aged 80+in the UK and 70-90% of older people in care homes. Over 300,000 people have dementia and significant hearing loss, exacerbating communication difficulties, likely to double within 20 years. Managing dementia with hearing loss in care homes is complex. Hearing tests can be difficult to perform. Care homes are often noisy, making communication harder for someone with poor hearing. Residents and care staff often have different backgrounds: sometimes neither speaks English as their first language. Hearing aids are often supplied, but problems can arise, e.g. the resident doesn t tolerate the aid or understand what it s for, may be unable to operate it, or may destroy it. Staff may lack skills and knowledge about hearing, and therefore feel that it is unimportant whether the aid is being worn or not. Hearing aids go missing, which can upset relatives. This topic is neglected by research and we don t know the best ways to improve hearing-related communication in this population. We will use a realist synthesis technique to address the questions of what works, how, why, to what extent, for whom and in what circumstances, to manage hearing loss in people with dementia in care homes. Realist synthesis is a flexible approach to reviewing the literature and using expert opinion and experience, designed to understand and evaluate complex health situations. Our team includes experts in audiology, dementia care and realist synthesis. We will review all relevant literature, not just scientific papers. We will recruit a group of practitioners, care staff and the public, who have professional or personal experience in this area ( context experts ) to help us (i) develop and refine recommendations about best practice in hearing management in care homes, and (ii) propose future research into interventions to support care homes in hearing-related communication.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: NEUROLOGICAL;EAR