Hearing Impairment and Elderly People

May 1986

NTIS order #PB86-218559
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Hearing Impairment and Elderly People–A

Background Paper, OTA-BP-BA-30 (Washington, DC: U.S. Government Printing Office, May

1986).

Library of Congress Catalog Card Number 86-600511

For sale by the Superintendent of Documents

US. Government Printing Office, Washington, DC 20402
Preface

Hearing impairment is very common among elderly people and can seriously affect

their quality of life, personal safety, and ability to function independently. This OTA

background paper discusses the prevalence of hearing impairment and its impact on

elderly people; hearing devices and services that may benefit them; and problems in

the service delivery system that limit access to these devices and services.

This background paper is part of the OTA assessment of Technology and Aging

in America that was requested by the Senate Special Committee on Aging and the House

Select Committee on Aging, and endorsed by the House Committee on Education and

Labor. For that assessment OTA selected five chronic conditions for in-depth analysis

because of their prevalence and severe impact on elderly people and because of the

potential role of technology in their treatment. Hearing impairment is one of these conditions; the others are dementia, urinary incontinence, osteoarthritis, and osteoporosis.

Many of the chronic conditions that affect elderly people, including the types of

hearing impairment that are most common, cannot be cured with available medical

and surgical treatments, As a result, some elderly people, their families, and others

assume that these conditions are not treatable. Yet assistive technologies can often help

to maintain functioning even when the underlying disease or condition cannot be cured.

In the case of hearing impairment, these technologies include hearing aids, infrared

and FM assistive listening devices, telephone amplification devices and other telecommunication systems, signaling and alarm devices, and environmental design and aural

rehabilitation techniques. Used singly or in combination, these technologies can facilitate communication and help to maintain an independent lifestyle for many hearing

impaired people.

As more and more Americans live to older ages, the prevalence of chronic conditions that cause functional impairment is expected to increase. Along with biomedical

research on the causes and possible cures for these conditions, the development and

increased use of technologies that compensate for functional impairment are among

the most hopeful approaches to improving the quality of life of elderly people.

OTA was assisted in the preparation of this background paper by many outside

advisors and reviewers, including biomedical and social science researchers, physicians,

audiologists, and representatives of the hearing aid dealers and hearing aid manufacturers associations. We express sincere appreciation to each of these individuals and

organizations. As with all OTA reports, the content of this background paper is the

responsibility of the Office and does not necessarily represent the views of outside advisors or reviewers.
Technology and Aging in America Advisory Panel*

Robert Binstock, Panel Chair

Director, Policy Center for Aging, Brandeis University

Raymond Bartus

Group Leader of Geriatrics

Medical Research Division

Lederle Laboratories

Robert Berliner

Dean

School of Medicine

Yale University

Robert N. Butler

Chairman

Department of Geriatrics and Adult Education

Mt. Sinai Medical Center

Robert Clark

Associate Professor

Department of Economics and Business

North Carolina State University

Lee L. Davenport

Senior Vice President—Chief Scientist,

emeritus

GTE Corp.

Ken Dychtwald

president

Dychtwald & Associates

Caleb Finch

Professor of Biological Sciences and

Gerontology

University of Southern California

Velma Murphy Hill

Director

Civil and Human Rights Division

Service Employees International Union

Robert L. Kane

Senior Researcher

The Rand Corp.

Paul A. Kerschner

Associate Director for Programs,

Legislation and Development

American Association of Retired Persons

Maggie Kuhn

Founder and National Convener

The Gray Panthers

Matt Lind

Vice President

Corporate Planning and Research

The Travelers Insurance Co.

Robert G. Lynch

Vice President

Marketing Planning

GTE Corp.

Mathy D. Mezey

Director

Teaching Nursing Home Program

University of Pennsylvania

Hamish Munro

Professor of Medicine and Nutrition

Tufts University

Bernice Neugarten

Professor of Education and Sociology

Northwestern University

Sara Rix

Director of Research

The Women’s Research and Education

Institute

Pauline Robinson

Research Professor of Gerontology

University of Southern California

John W. Rowe

Chief of Geriatrics

Beth Israel Hospital

Bert Seidman

Director

Department of Occupational Safety, Health

and Social Security

AFL-CIO

Jacob Siegel

Senior Researcher

Center for Population Research

Georgetown University

● Panel members’ affiliations are listed at the time the assessment began.

NoTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members The

views expressed in this OTA report, however, are the sole responsibility of the Office of “technology Assessment.

iv
OTA Project Staff—Hearing Impairment and Elderly People

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Gretchen S. Kolsrud, Biological Applications Program Manager

Robert A Harootyan, Project Director

David McCallum, * Project Director

Claire W. Maklan, Analyst

Katie Maslow, Analyst

Chris Elfring, Editor

Support Staff

Sharon Smith, Administrative Assistant

Linda Ray ford, Secretary, Word Processing Specialist

Barbara Ketchum, Clerical Assistant

Related Products

Technology and Aging in America, OTA Assessment

Impacts of Neuroscience, OTA Background Paper

Technologies for Managing Urinary Incontinence, OTA Case Study

Prqf>rt Director until September 1983

v
Acknowledgments

This project has benefited from the advice of many experts in the field of hearing impairment

and hearing services. OTA especially would like to thank the following advisors, reviewers, and contractors for their assistance and support.

Gay Becker

Aging Health Policy Center

University of California

San Francisco, CA

Derald Brackmann

Otologic Medical Group

Los Angeles, CA

Scott C. Brown

Gallaudet Research Institute

Washington, DC

Anthony DiRocco

National Hearing Aid Society

Livonia, MI

Dennis Dreschler

Wayne State University

Detroit, MI

George W. Fellendorf

Fellendorf Associates

Washington, DC

Raymond M. Fleetwood

Harry Diamond Laboratory

Adelphi, MD

Richard M. Flower

Department of Otolaryngology

Division of Audiology and Speech

University of California

San Francisco, CA

Laurel E. Glass

Center of Deafness: Research, Training, and

Mental Health Services

University of California

San Francisco, CA

Jerome C. Goldstein

American Academy of Otolaryngology-Head

and Neck Surgery

Washington, DC

Sandra Gordon-Salant

Hearing and Speech Sciences Department

University of Maryland

College Park, MD

Elise Hall

Montgomery County Department of Housing

and Community Development

Rockville, MD

Annette G. van Hilst

Montgomery County Department of Housing

and Community Development

Rockville, MD

Leonard Jakubczak

National Institute on Aging

Bethesda, MD

Sam Kinney

The Cleveland Clinic

Cleveland, OH

Barry Leshowitz

Department of Psychology

Arizona State University

Tempe, AZ

Thomas J. Maronick

Federal Trade Commission

Washington, DC

Ralph F. Naunton

Communicative Disorders Program

National Institute of Neurological and

Communicative Disorders and Stroke

Bethesda, MD

Robert J. Newcomer

Aging Health Policy Center

University of California

San Francisco, CA

Suzanne M. Pathy

The Suzanne Pathy Speak-Up Institute

New York, NY

Carol M. Rodin

Hearing Industries Association

Washington, DC

David Saks

Organization for the Use of the Telephone

Owings Mills, MD

vi
Virginia W. Stern

Project on the Handicapped in Science

American Association for the Advancement of

Science

Washington, DC

Rocky Stone

Self Help for Hard of Hearing People

Bethesda, MD

Jerry Tobias

Auditory Department

Naval Submarine Medical Research Laboratory

Groton, CT

Gwenyth R. Vaughn

Audiology-Speech Pathology Service

Birmingham Veterans Administration Medical

Center

Birmingham, AL

Timothy J. Waters

McDermott, Will, and Emery

Washington, DC

Barbara Williams

Office of Cued Speech Programs

Gallaudet College

Washington, DC

Peggy Williams

American Speech-Language-Hearing Assoc.

Rockville, MD

Howard Zubick

Brigham and Womens Hospital

Boston, MA

vii
Contents

Page

CHAPTER 1: Overview . . . . . . . . . . . . . . . . . . . . . 3

The Scope and Impacts of Hearing

Impairment in Elderly People . . . . . . . . . . 3

Summary of Major Findings and Issues. . . . . . 4

CHAPTER 2: The Epidemiology of Hearing

Impairment in Elderly People . . . . . . . . . . 11

Types and Causes of Hearing Loss Among

Elderly People . . . . . . . . . . . . . . . . . . . . .

Measuring Hearing Impairment . . . . . . . .

Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . .

Age , . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gender . . . . . . . . . . . . . . . . . . . . ... , . . .

Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Income . . . . . . . . . . . . . . . . . . . . . . . . . . .

Institutionalization . . . . . . . . . . . . . . . . . .

Prevalence of Tinnitus . . . . . . . . . . . . . .

The Impact of Hearing Impairment , . . . .

Clinical Impact . . . . . . . . . . . . . . . . . . . . .

Psychosocial Impact . . . . . . . . . . . . . . . .

Denial of Hearing Impairment. . . . . . . .

Deafness . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 3: Treatment of Hearing

Impairment. . . . . . . . . . . . . . . . . . . . . . .

Prevention . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical and Surgical Treatment. . . . . . . .

Treatment of Conductive Hearing

Impairments . . . . . . . . . . . . . . . . . . . .

Treatment of Sensorineural Hearing

Impairments . . . . . . . . . . . . . . . . . . . .

Hearing Aids . . . . . . . . . . . . . . . . . . . . . . . .

Problems in Hearing Aid Design and

Performance . . . ..., , , ..., ., , , ., ,

Problems in Selecting the Appropriate

Hearing Aid.. . . . . . . . . . . . . . . . . . . .

Problems in Adjusting to a Hearing Aid

Assistive Listening Devices . . . . . . . . . . . .

Telecommunication Devices . . . . . . . . . . .

Signaling and Alarm Devices. . . . . . . . . . .

Assistive Device Development. . . . . . . . . .

Environmental Design ., . . . . . . . . . . . . . .

Aural Rehabilitation . . . . . . . . . . . . . . . . . .

Hearing Aid Orientation . . . . . . . . . . . . .

Auditory Training . . . . . . . . . . . . . . . . . .

Speechreading . . . . . . . . . . . . . . . . . . . . .

Counseling . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 4: The Service Delivery System .

Service Providers and Referral Patterns .

Physicians. . . . . . . . . . . . . . . . . . . . . . . . .

Audiologists . . . . . . . . . . . . . . . . . . . . . . .

Hearing Aid Dealers . . . . . . . . . . . . . . . .

. . . . 11

. . . . 13

. . . . 14

. . . . 14

. . . . 15

. . . . 15

. . . . 16

. . . . 16

. . . . 16

. . . . 17

. . . . 17

. . . . 18

. . . . 19

. . . . 20

. . . . 25

. . . . 25

. . . . 27

. . . . 27

. . . . 27

. . . . 28

31

. . . . 32

. . . . 32

. . . . 33

. . . . 36

. . . . 39

. . . . 40

. . . . 41

. . . . 41

. . . . 41

. . . . 42

. . . . 42

. . . . 43

. . . . 47

. . . . 48

. . . . 48

. . . . 49

. . . . 50

Page

Referral Patterns , . . . . . . . . . . . . . . . . . . . . . . 51

The Role of Other Health Care and Social

Service Providers . . . . . . . . . . . . . . . . . . . . 52

Settings for Service Delivery. . . . . . . . . . . . . . . 54

Health Care Settings . . . . . . . . . . . . . . . . . . . . 54

Educational Settings . . . . . . . . . . . . . . . . . . . . 54

Community Agencies . . . . . . . . . . . . . . . . . . . 55

Alternate Approaches to Service Delivery. . . . 55

Veterans Administration Hearing Services. . 55

Elderhostel Program for the Hearing

Impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Assistive Device Centers. . . . . . . . . . . . . . . . . 56

Self-Help Groups for Hearing Impaired

People , . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Nursing Home Initiatives . . . . . . . . . . . . . . . . 57

Screening Programs . . . . . . . . . . . . . . . . . . . . . . 58

Regulation of the Delivery System . . . . . . . . . . 58

CHAPTER 5: Funding for Treatment of

Hearing Impairments . . . . . . . . . . . . . . . . . 63

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Other Government Funding Programs. . . . . . . 65

Private Insurance . . . . . . . . . . . . . . .

Where Services Are Provided and

By Whom. . . . . . . . . . . . . . . . . . .

Type and Purpose of Services . . . .

Role of the Physician . . . . . . . . . . .

CHAPTER 6: Conclusion . . . . . . . . . . . .

APPENDIX A:

APPENDIX B:

REFERENCES

Tables

Table No.

1.

2.

3.

4.

5.

6.

Information Sources . . .

Assistive Device Centers

. . . . . . . . . . . . . . . . . . . . .

. . . . . . . . 66

. . . . . . . . 66

. . . . . . . . 67

. . . . . . . . 67

. . . . . . . . 71

. . . . . . . . 75

. . . . . . . . 77

. . . . . . . . 83

Page

Causes of Conductive and Sensorineural

Hearing Impairments. . . . . . . . . . . . . . . . . . . . . 11

Hearing Loss in Decibels Related to

Approximate Degree of Impairment . . . . . . . . 13

Prevalence of Hearing Impairment, Including

Tinnitus, in the Civilian, Noninstitutionalized

Population, by Race and Selected Age

Groups, United States, 1977 . . . . . . . . . . . . . . . 16

Types of Hearing Aids Sold in the United

States, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Proportion of Hearing Aid purchasers

by Age, 1983-85 . . . . . . . . . . . . . . . . . . . . . . . . . 30

Persons Age 65 and Over Who Use a

Hearing Aid, United States, 1977. . . . . . . . . . . 31

. . . Vlll
Table No.

7. Satisfaction With Hearing Ability Using a

Hearing Aid . . . . . . . . . . . . . . . . . . . . . . . . . .

Figures

Figure No.

1. Structure of the Ear . . . . . . . . . . . . . . . . . .

2. Prevalence of Hearing Impairment,

Including Tinnitus, in the Civilian,

Noninstitutionalized Population,

United States, 1977 . . . . . . . . . . . . . . . . . . .

3. Prevalence of Hearing Impairment Among

Adults by Frequency of Tone, United

Page Figure No. Page

5. Cochlear Implant in Place. . . . . . . . . . . . . . . . 28

31 6. Hearing Aid Types . . . . . . . . . . . . . . . . . . . . . . 29

7. Hardwire Device for

One-to-One Consultation . . . . . . . . . . . . . . . . . 34

Page 8. Audio Loop Wand Receiver . . . . . . . . . . . . . 34

11 9. FM Persona] Amplification Device:

10.

14 11.

12.

States, 1971-75 . . . . . . . . . . . . . . . . . . . . . . . . . 15

4. Prevalence of Tinnitus, by Severity and 13.

Selected Age Groups, United States, 14.

1960-62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Transmitter and Receiver . . . . . . . . . . . . . . . . 34

Infrared Amplification Device:

Transmitter and Receiver . . . . . . . . . . . . . . . . 35

Three Types of Telephone Amplification

Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Sonic Alert Signaling System, Including a

Paging Device and Door Bell Signaler . . . . . . 39

Lip Reading Glasses . . . . . . . . . . . . . . . . . . . . . 43

Materials Supplied to Participating Hospitals

by the Suzanne Pathy Speak-Up Institute. . . 53

ix
Chapter 1

Overview
Chapter 1

Overview

THE SCOPE AND IMPACTS OF HEARING IMPAIRMENT

IN ELDERLY PEOPLE

Hearing impairment is a serious problem among

elderly people in the United States. It is the third

most prevalent chronic condition among the noninstitutionalized elderly population, exceeded only

by arthritis and hypertensive disease (118, 120,

122).

Elderly people are much more likely to have a

hearing impairment than younger people. Slightly

more than 1 percent of all people under 17 years

of age suffer some hearing impairment. But prevalence rises to about 12 percent of all people between 45 and 64, about 24 percent of those 65 to

74, and about 39 percent of those 75 and over

(121). 1 The prevalence of hearing impairment

among elderly people in nursing homes is even

greater (98).

While only 11 percent of the Nation’s population is over 65, about half of all hearing impaired

people are over 65 (41). As this older segment of

the population grows, the number of hearing impaired individuals will rise dramatically. The over75 population, which has the highest prevalence

of hearing impairment, is growing at a faster rate

than the elderly population as a whole, thus increasing the number and proportion of hearing

impaired people in the population. At present,

about 7 million elderly persons have significant

hearing loss. If current rates persist, by the year

2000 more than 11 million elderly persons will be

significantly affected.

Hearingimpaired individuals include those who

are deaf_ and those who are hard-of-hearing. Hardof-hearing refers to a partial hearing loss that results in difficulty with speech comprehension, although some auditory function remains. Deaf

refers to a degree of impairment that renders hear1

’1 hese figures are hased on the results of inter\fiew sur~qvs. Fkti -

matw of prekalenc(’ basfxi on audiometric testing art’ ronsiderahl)

higher. (;h. 2 disrusses the differences hett$reen thr prclakmrc estimates deternlined I)j these tt~o mf~thrds ot’ measuring hearin g

at)ilitt

ing nonfunctional for ordinary purposes of life

(117). Most people with hearing impairments are

not deaf, but even the partial hearing loss that is

common among elderly people can limit their independence and reduce the quality of their lives,

Although hearing impairment is not life-threatening and does not directly restrict physical activ -

ity, it can cause severe disability. Hearing loss limits

a person’s ability to interact socially with family

and friends and to receive and interpret information (10). Many warning devices such as fire alarms

rely on sound signals. Furthermore, hearing is an

important method of identifying dangers in the

environment, such as approaching vehicles. Thus,

hearing impairment can affect personal safety. It

can also interfere with important activities of daily

living, including shopping; using public transportation; and communicating with health care professionals, tradespeople, and community service

providers. When hearing impairment limits a person’s ability to function independently, it can result in a need for formal and informal long-term

care services.

The importance of hearing and the problems

posed by hearing loss in elderly people have long

been recognized. In 1968, the Senate Special Committee on Aging noted the high prevalence of hearing loss among elderly people and directed its attention to three problem areas: 1) delivery of

services to older people with hearing loss; 2) hearing aid sales; and 3) the effects of increasing noise

on future generations of Americans (127). During

the past 18 years we have made some progress

combatting these problems, but much remains to

be done.

This background paper examines the kinds of

hearing impairments that are most common among

elderly people and the technologies that are avail -

able to compensate for them. Chapter 2 reviews

the types, causes, and prevalence of hearing impairment and its impact on elderly people. Chap3
4

ter 3 discusses treatment methods, including prevention, medical and surgical treatments, and

devices and procedures to compensate for hearing loss. These include hearing aids, assistive listening devices,2 telecommunication devices, and aural

rehabilitation techniques. The chapter also dis -

2Assistiw listening devices are devices that transmit amplified

sound more directly from its source to the listener; examples are

audio loops, infrared, and radio frequencj’ (Ahl and F%f) devices (74).

SUMMARY OF MAJOR

The Federal Government is concerned about

hearing impairment among elderly people because

of its impact on their safety, quality of life, and

ability to live independently. Federal initiatives that

have addressed the problems of hearing impairment include funding for research, legislation to

guarantee access to public facilities for hearing

impaired people, and regulation of hearing aid

sales. These efforts have benefited hearing impaired individuals of all ages. In addition, some

funding is available to treat hearing disorders

through Medicare, Medicaid, the Veterans Administration (VA), and other Federal programs.

Despite these Federal programs, many elderly

people with hearing impairments are not receiving appropriate treatment or using potentially beneficial devices. Some do not seek treatment because

they are not aware of their hearing loss or because

they believe that nothing can be done to treat or

compensate for it. Negative social attitudes about

growing old and becoming hard-of-hearing cause

some elderly people to deny their hearing impairments. Others are aware of their hearing loss but

avoid the use of hearing aids and assistive listening devices because they do not want to call attention to their loss.

Public education is needed to increase awareness about the extent and types of hearing impairment among the elderly. Elderly people, their

families, and health care professionals also need

information about treatments, devices, and services that can compensate for hearing impairment.

Federal, State, and local governments, private industry, and organizations representing elderly and

cusses obstacles to the use of these technologies

and looks briefly at problems of device development. Chapter 4 describes the existing systems that

provide treatment for hearing impaired people,

including the service providers, settings, and pat -

terns of service delivery. The chapter emphasizes

the need for improved delivery systems that are

adapted to the needs of elderly people. Chapter

5 discusses funding for hearing devices and

services.

FINDINGS AND ISSUES

hearing impaired people must share responsibility for public education programs that promote

awareness of the problem and encourage the use

of appropriate treatments, devices, and services.

Self -help groups are an increasingly strong and

effective force in promoting awareness of hearing impairment and the needs of hearing impaired

people. While self-help groups for deaf people have

existed for some time, groups for people with partial hearing loss have developed more recently.

Some of these groups are organized on a national

level, sometimes with local chapters, while others

function only on a local level. One example of a

national group is Self Help for Hard of Hearing

People, an organization with more than 15)

00 0

members and 170 local chapters and affiliates in

41 States.

While self-help groups differ in their primary

focus and mode of operation, they tend to emphasize several important points:

●

●

●

the severe impact of hearing loss on many individuals;

the need for hearing impaired individuals to

admit their hearing impairments, to overcome

the sense of shame that many hearing impaired people feel, and to be more assertive

about their communication needs; and

the need for families, friends, and others who

interact with hearing impaired people to be

aware of and use devices and communication

techniques that promote effective communication.

Self-help groups also stress the heterogeneity

of hearing impaired people, both in terms of the
5

oto credit. Pete Souza, The White House

President Reagan has acknowledged his hearing loss and is using a small, canal-style hearing aid to compensate for

it. By his example, the President has encouraged other hearing impaired people to acknowledge their impairments and

consider the use of a hearing aid or other hearing assistive device for themselves.
6

type and severity of each individual’s hearing loss

and other physical, emotional, and social characteristics of the person and his environment that

affect his communication needs. This heterogeneity creates a need for a variety of hearing devices and services and a process for determining

the needs of each individual. Self-help groups point

out that the hearing impaired individual is usually the best source of information about his hearing loss and that too little attention has been paid

to what hearing impaired people, especially those

with partial hearing loss, say about their needs.

In addition to increased awareness of hearing

loss in elderly people, there is a need for increased

research. Although the prevalence of hearing impairment far exceeds most diseases and disabilities of later life, the magnitude of this problem has

not been reflected in the amount of research that

has been conducted on underlying pathologies,

prevention, treatment, and rehabilitation. As a result, the state of the art in this field has progressed

more slowly than in many other fields (10).

Most hearing research has been focused on very

severe impairments, and particularly the problems

of deaf children. While the results of this research

are sometimes applicable to elderly people, the

characteristics of hearing impairments that are

common in elderly people often differ from those

of severely hearing impaired younger people. Hearing impairment in the elderly is often mild or moderate, but it is widespread. It is often progressive,

with a gradual onset, and may not be recognized

for some time. In addition, a significant but as yet

undefined number of elderly people have decreased

ability to tune out background noise and thus have

more difficulty hearing in noisy settings than younger people with comparable hearing ability (31,

44). Finally, hearing impairment in elderly people

often coexists with other health problems that can

complicate treatment and limit the effectiveness

of hearing devices. Research focused on the mechanisms of hearing impairment in elderly people

and appropriate treatment approaches is needed.

Few of the hearing impairments common among

elderly people respond to medical or surgical treatment. However, a variety of approaches, such as

the use of hearing aids, other assistive listening

devices, and aural rehabilitation techniques, can

be used to compensate for hearing impairment.

These approaches can improve communication

ability even when the underlying problem cannot

be cured.

Hearing aids are the most widely used devices,

but most people with hearing impairments do not

use hearing aids. Estimates from various studies

indicate that between 8 and 25 percent of hearing

impaired people use a hearing aid3 (41, 49,94,119),

Some of those who do not use hearing aids have

been told that a hearing aid will not help them;

others deny that they need a hearing aid or resist

using a hearing aid for cosmetic reasons. Still others

buy hearing aids but never learn to use them and

eventually stop trying.

Hearing aids function well for many elderly people but do not compensate for hearing loss in others

for

●

●

●

●

several reasons:

Some people buy hearing aids that are not well

matched to their needs. Sometimes this occurs because they purchase an aid without

having a complete hearing evaluation to identify their specific hearing deficits. Lack of

Medicare reimbursement for a hearing evaluation to select a hearing aid exacerbates this

problem.

Even when a person’s specific hearing deficits have been identified, lack of information

comparing different types of hearing aids can

make it difficult to identify the most appropriate aid.

Hearing aids generally amplify all environmental sound, including background noise.

Although design modifications can improve

the speech-to-noise ratio, some hearing aid

users continue to have problems tuning out

background noise.

Current hearing aid technology does not allow custom design of a hearing aid in the way

that eyeglasses can be prescribed and ground

specifically for an individual. Within five years,

microprocessor technologies may make “prescription hearing aids” available.

In addition to hearing aids, assistive listening devices such as infrared and FM devices can benefit

many hearing impaired people. These devices can

3

Estimates of the percentage of hearing impaired people who use

hearing aids vary depending on the source of the data and the figure that is used for overall prevalence of hearing impairment,
7

be particularly effective for those with mild or moderate hearing loss and in situations where background noise is a problem. Some profoundly impaired persons can also benefit from them. Yet

most elderly individuals do not know about assistive listening devices and the existing service delivery system does not promote their use. Relatively few hearing specialists offer a full range of

the assistive devices. The VA Medical Center in

Birmingham, Alabama, has developed a program

to distribute these devices, and hearing specialists

at the center receive inquiries about the devices

from hearing impaired people all over the country. They refer many people to hearing specialists

in their local areas, but in some areas there are

no specialists trained in the use of these devices

(129).

Medicare, Medicaid, and private insurance do

not reimburse for assistive listening devices or for

professional adivce to determine which devices

are appropriate. (See ch. 5 for a discussion of funding for hearing devices and services. ) Legislation

to provide Medicare and Medicaid reimbursement

for these devices was introduced in Congress in

1984 and again in 1985. Many observers doubt that

this legislation will pass because of current budget

limitations, but supporters argue that reimbursement for these devices would encourage their use,

thus increasing the independence of hearing impaired people and ultimately reducing Federal

spending for other services.

Aural rehabilitation services, including counseling, training in speechreading,4 and hearing aid

orientation can help hearing impaired elderly people by reducing anxiety, facilitating better use of

residual hearing, and achieving more realistic expectations regarding remediation of hearing loss.

Yet few hearing impaired elderly people receive

aural rehabilitation services. Public education and

education of health care and social service providers is needed to encourage the use of these essential services.

Hearing impaired people who cannot hear over

the telephone face serious problems. They are not

able to talk with family and friends, arrange necessary services, and obtain assistance in an emergency. Some people with mild or moderate hearing loss can manage well with a telephone that has

an amplifier in the handset. Others have hearing

aids designed with a “telephone switch”5 and they

can use compatible telephones. But not all telephones are compatible with hearing aids, and most

telephones do not have amplifiers. In addition,

many hearing aids are manufactured without a

telephone switch. Some hearing impaired people

and hearing professionals advocate Federal legislation to require that all new telephones be compatible with hearing aids. Some also advocate

strengthening the Federal and State regulations

that require telephone companies to make specialized equipment available to hearing impaired people for use at home.

Adapting public facilities so they are accessible

to the hearing impaired is an area where progress

has been very slow. Section 504 of the Rehabilitation Act of 1973 prohibits discrimination against

disabled individuals by any program or activity

receiving Federal assistance. The law requires that

all facilities receiving any form of Federal support

must provide access for people with all kinds of

handicaps, including hearing impairment (80). So

far, however, efforts have emphasized adapting

facilities for people with problems in mobility. This

has occurred even though the costs of installing

an audio loop, infrared, or radio frequency (AM

or FM) amplification system is usually minimal

.

compared to the costs of the major architectural

changes needed to accommodate people with mobility impairments. Although it seems incongruous, public funding has been available for architectural modifications while the cost of amplification

systems has been paid primarily by the private sector (10).

The needs of older people with hearing impairments should be considered in any plans to adapt

facilities for the handicapped. In addition, environmental design technologies to compensate for

hearing impairment could be applied in public facilities. These technologies are discussed in chapter 3.

4S~)t~(!(’hr-(~acii~~g is another term for lipread ing, The term spcerh -

read ing emphasizes that the hearing impaired person l~atrhm+ fa -

rial, t h ro;it, ;iml hodk nlmrments of the spwiker in [id{] it ion t{) his

Ill) n]otfmlf]nts in o;der to undf:rstand m hat he is s~ijing.

5A telephone smitrh, nr ‘“ r st~ritrh ,“ is a feature hui]t into sorllp

hearing aids that allm~s the aid to pick up electronic signals direct 1)

from compatihlp t(>lephon(j re(’ei~er-s, thus hypssing thf’ hearin g

;i id microphone’ and f’lim in:iting unlid nt ml sound.
8

A final concern is the apparent

rivalry among the three groups of

tension and

hearing specialists: physicians who specialize in hearing disorders, audiologists, and hearing aid dealers. Physicians who specialize in hearing disorders are

medical doctors with training in diseases of the

ear. Audiologists are nonmedical hearing specialists who have a master’s or doctoral degree in audiology, the science of hearing, Hearing aid dealers

are individuals who sell hearing aids who are neither physicians nor audiologists. This report refers

to individuals in each of these groups as “hearing

specialists .“ The training and unique skills of each

of these groups are discussed in chapter 4,

Each group plays an important role in providing hearing services for elderly people, The continuing rivalry among them interferes with the development of service delivery systems that make

the full range of devices and services available to

hearing impaired elderly people. Any Federal legislation or regulations related to hearing services

should discourage this rivalry and encourage the

development of coordinated service delivery systems that use the expertise of each type of hearing specialist.
Chapter 2

The Epidemiology of

Hearing Impairment in

Elderly People
Chapter 2

The Epidemiology of Hearing

Impairment in Elderly People

TYPES AND CAUSES OF HEARING LOSS AMONG ELDERLY PEOPLE

Hearing impairment can be partial or complete.

It can be unilateral (one ear) or bilateral (both ears),

temporary or permanent, stable or progressive.

Types of hearing impairment include conductive,

sensorineural, mixed, and central processing disorders. These types are based on the site of structural damage or blockage (see figure 1). Conductive hearing impairment involves the outer and/or

middle ear. Sensorineural impairment involves

damage to the inner ear, the cochlea, and/or the

fibers of the eighth cranial nerve. A mixed hearing impairment includes both conductive and sensorineural components. Causes of conductive and

Figure 1 .—Structure of the Ear

Malleus

I

tube

 Middle I

Outer Ear Ear Inner Ear

In the healthy ear, sound waves gathered by the outer ear are transmitted through the eardrum and three small bones in the middle ear—

the malleus, incus, and stapes—and into the inner ear. There sound

is converted from vibrations into electrical impulses by tiny sensory

receptors, called hair cells, in the cochlea. The electrical impulses

pass through the eighth cranial nerve Into the auditory centers of the

brain.

SOURCE Vlckl Friedman, Washington University Medical Center at St. Louis

sensorineural hearing impairment are listed in

table 1.

A central processing disorder is a hearing impairment that influences complex aspects of hearing, such as understanding speech. The hearing

Table 1 .—Causes of Conductive and Sensorineural

Hearing Impairments

Causes of conductive hearing impairments:

External blockage: buildup of wax or presence of a foreign

object in the ear.

Perforated eardrum.’ a hole or tear in the eardrum that can

occur as a result of injury, sudden pressure change, or infection.

Genetic and congenital abnormalities.’ malfunction and/or

malformation of the outer and/or middle ear that can occur in connection with hereditary disease or as a result of

illness or injury before or at the time of birth.

Otitis media.’ middle ear infection with fluid accumulation.

Otosclerosis: hereditary disease process resulting in overgrowth of a small bone in the middle ear which interferes

with sound conduction.

Causes of sensorineural hearing impairment:

Prenatal and birth-related causes: infections such as rubella contracted by expectant mothers, drugs taken during

pregnancy, or difficult labor and delivery.

Hereditary causes: a variety of disorders that damage the

cochlea or higher nerve centers and are usually present

at birth; the gradual loss of hair cells in the cochlea that

begins as young as the twenties and thirties in some individuals and may be caused by heredity.

Viral and bacteria/ infections: infections such as mumps, spinal meningitis, and encephalitis.

Trauma: a severe blow to the head, an accident, or a stroke

or brain hemorrhage that affect the ear, nerve pathways,

and auditory brain centers.

Tumors: tumors called acoustic neuromas that invade the

eighth nerve.

Noise: exposure to loud sounds that irreparably damage the

hair cells.

Cardiovascular conditions: hypertension, heart disease, or

other vascular problems that alter blood flow to the inner

ear.

Ototoxic drugs: aspirin, some antibiotics, diuretics, and certain powerful anticancer drugs that damage the hair cells

or other vital parts of the inner ear.

Meniere’s disease: a disorder characterized by fluctuating

hearing loss, dizziness, and tinnitus; possible causes include aIlergy, hypothyroidism, diabetes, and syphilis.

SOURCE: NINCDS, 1982 (124),

11
12

impaired person may hear the words but not make

any sense out of them. Some words are difficult

to interpret, almost as if the person were listening to a foreign language. This kind of hearing impairment can be caused by disorders of the auditory pathways in the brain. With aging, the speed

of nerve impulses may slow or the brain may lose

the ability to interpret words that come at a rapid

pace.

Tinnitus is a condition that often accompanies

hearing loss. It is a ringing, buzzing, or hissing in

the ears or head that can be continuous or intermittent. The causes of tinnitus are not well understood but can include obstructions in the outer

ear, perforation of the eardrum, middle ear infection, repeated exposure to loud noise, trauma, and

some medications,

Presbycusis is the term most often used to describe hearing impairment in elderly people. The

word presbycusis means “old hearing. ” It is usually defined as a sensorineural loss caused by

changes in the inner ear, but some experts include

middle ear changes associated with aging in the

definition (124) and others emphasize the impact

of changes in the eighth cranial nerve and auditory brain center (54).

The diagnosis of presbycusis is used for hearing impairment associated with a variety of sensory, neural, metabolic, mechanical, and vascular changes seen in elderly people. Yet little is

known about the underlying causes of presbycusis and the term is sometimes used when no specific cause of the condition can be identified.

Conditions that are frequently diagnosed as presbycusis include gradual loss of hair cells in the cochlea and fibrous changes in the small blood vessels

that supply the cochlea.1 Some researchers believe

that these changes are caused primarily by environmental factors and disease while others believe

they are primarily a result of normal aging (125).

However, not all elderly individuals are affected

by presbycusis, and some people over 90 retain

acute hearing.

The diagnosis of presbycusis is sometimes given

mistakenly when a specific cause of the hearing

IThe cochlea is dependent on a single artery for blood supply,

making hearing very susceptible to damage as a result of cardiovascular disease [73),

impairment could be identified and possibly

treated (73). For example, wax buildup in the outer

ear frequently causes hearing impairment in

elderly people. If presbycusis is diagnosed, the real

problem—ear wax—might be missed and go untreated.

The term presbycusis can be confusing because

it is used to describe three situations: 1) treatable

conditions caused by disease, 2) conditions caused

by disease for which no treatment is known, and

3) conditions believed to result from normal aging,

For health care professionals, elderly people, and

their families, a diagnosis of presbycusis may mistakenly imply that nothing can be done for the

patient. Greater attention to isolating the cause of

a person’s hearing loss can help ensure prompt

and effective treatment in some cases. In general,

however, more research is needed to describe the

underlying pathologies that cause presbycusis and

to differentiate between treatable and untreatable

causes of these conditions.

To develop a more complete understanding of

hearing loss associated with aging, we must improve our knowledge about the basic mechanisms

of hearing in the normal ear. While the normal

functioning of the outer and middle ear is relatively well understood, the structural and biochemical mechanisms of the inner ear and auditory brain

centers are less well understood. The cochlea, a

pea-sized organ with more than a million moving

parts, is one of the most complex mechanical structures in the human body. Only within the past decade have methods been developed to study this

tiny structure. Research on the molecular structure and mechanical properties of hair cells in the

cochlea and the biochemical processes by which

sound vibrations are converted to neural impulses

has significantly increased our understanding of

the basic mechanisms of hearing (53). But little is

known about how the damaged ear processes

sound (88).

Lack of communication among researchers in

this field has been a problem but recent research

developments have stimulated increased interaction. A national conference on auditory biochemistry held in 1984 brought many prominent

researchers together for the first time and participants hope that this process will be repeated

regularly (30).
13

MEASURING HEARING IMPAIRMENT

Hearing impairment is measured by two methods: interviews and audiometric tests. Definitions

of the levels of impairment reflect these two methods. The interviewr method relies on self -reported

hearing loss and the resulting statistics are presented in categories such as: “no trouble hearing, ”

‘(can hear words spoken in a normal voice, ” ‘(can

hear words shouted across a room,” and “at best

can hear words shouted in ear” (119). Audiometric tests measure an individual’s response to sounds

of varying intensity or loudness, and level of impairment is reported in terms of the weakest sound

the individual can hear. Intensity of sound is measured in decibels; z one scale used to define level

of impairment is illustrated in table 2.

The level of hearing impairment that is considered significant varies for different surveys, research projects, and clinical applications. Hearing

specialists and researchers continue to debate the

most appropriate level to call significant for specific applications.3

Different surveys show different prevalence

figures in part because they select different levels

‘The dccihel scale is a logarithmic Sral(> (hased on poh~rers of 1())

that nleasLlrPs intensit~ of sound or loudness. A sm~ll inf’r~ase in

decilwls ((IB) represents a large increase in loudness. For example,

a sound at 40 dB is 1() t imf?s as bLld as a S{)und at 30 dB and 100

times as loud as a sound at 20 dkt

3’I’h is drhate is N31(’t’illlt to scrfwning pro~r:irns and iclent ifiration

of patients liho need tre:itment as discussed in rh. 4.

Table 2.— Hearing Loss in Decibels Related to

Approximate Degree of Impairment

Hearing loss in decibels (dB) Degree of impairment

o to 20 dB . . . . . . . . . . . . . . . . . . . . . . Normal

20 to 40 dB . . . . . . . . . . . . . . . . . . . . . Mild

40 to 55 dB . . . . . . . . . . . . . . . . . . . . . Moderate

55 to 70 dB . . . . . . . . . . . . . . . . . . . . . Moderately severe

70 to 90 dB . . . . . . . . . . . . . . . . . . . . . Severe

>90 dB . . . . . . . . . . . . . . . . . . . . . . . . Profound deafness

SOURCE Knauf, 1978 (64).

of impairment as significant. Reported prevalence

also varies depending on whether the interview

or audiometric testing method is used. Prevalence

figures based on interviews tend to underestimate

the frequency of hearing impairment because

many people, particularly elderly people, are not

aware of their hearing loss or may deny or minimize its severity in an interview. Some experts believe that audiometric testing provides more accurate measurement but prevalence figures based

on both methods are widely cited in the literature

(10).

Four types of audiometric tests are commonly

used to measure hearing loss: 1) pure tone air conduction, 2) bone conduction, 3) speech reception,

and 4) speech discrimination. Pure tone air and

bone conduction tests measure hearing loss at specific frequency levels. Hearing loss varies greatly

according to frequency, especially in elderly people, and information about hearing deficits at specific frequencies is important for diagnosis, treatment, and research. The prevalence of hearing loss

based on audiometric tests varies according to: 1)

the sound frequency used; 2) the decibel level at

which hearing impairment is recognized for that

particular survey, called the fence; 3) whether one

or both ears are tested; and 4) whether data are

reported for the right or left ear, the better ear,

the worse ear, or an average.

Some individuals are able to hear the pure tones

used in air and bone conduction tests but have

difficulty understanding speech because of problems in auditory discrimination. This condition,

called dysacusis, is widespread among hearing impaired elderly people. Pure tone air and bone conduction tests underestimate the extent of dysacusis (69) and, as a result, prevalence estimates based

on pure tone air and bone conduction tests are

usually lower than those based on speech reception and speech discrimination tests (41).
14

PREVALENCE

The prevalence of hearing impairment varies by

age, sex, race, income, and institutional status.

prevalence estimates also vary depending on

whether they are based on interview or audiometric testing.4 There is ongoing debate about the accuracy of interview and audiometric tests for measuring hearing impairment and about the level of

hearing loss that constitutes significant disability.

These debates are relevant to understanding

whether prevalence estimates are valid.

The data in the following discussions reflect our

best understanding of the nationwide prevalence

of hearing impairment. However, the generalizations may not apply in certain geographic areas.

For example, chronic ear infections are common

among certain ethnic groups in Alaska and Indians

in some Southwestern States and this increases

the prevalence of hearing impairment in those

areas. Similarly, in areas where high-noise industries are concentrated, hearing loss is more common among persons of working age and older (10).

Age

According to the 1977 National Health Interview

Survey (NHIS), about 8 percent of the civilian,

noninstitutionalized population experienced some

degree of chronic hearing impairment. Prevalence

rises from about 1 percent of those under age 17

to more than 38 percent of those over 75 (see figure 2).

4Prevalence figures based on interviews come from the 1977 National Health Interview Survey (NHIS), conducted by the National

Center for Health Statistics (NCHS). NHIS is an annual nationwide

survey. Respondents are asked about acute and chronic health conditions of all members of the household. In 1977, a special supplement to the NHIS focused on hearing impairment. NHIS data are believed to underestimate prevalence because some people deny or

are unaware of their hearing impairments or may not consider their

hearing loss a problem and because NHIS interviews are usually conducted with only one member of the household, who may not be

aware of or report hearing impairments of other household members.

Prevalence figures based on audiometric testing come from the

Health and Nutrition Examination Surveys (HANES), conducted from

1971 to 1975 by NCHS. A random sample of aduhs aged 25 to 74

in the civilian, noninstitutionalized population was tested using pure

tone air and bone conduction tests at 4 frequency levels (500, 1,000,

2,000, and 4,oOO Hertz) and a speech reception test. Air and bone

conduction tests were reported for the right ear only; this lowers

prevalence estimates because those with unilateral hearing loss in

the left ear are not included.

Both NHIS and HANES underestimate overall prevalence in the

elderly population because the institutionalized elderly, who have

very high prevalence, are not included.

Figure 2.—Prevalence of Hearing Impairment,

Including Tinnitus, in the Civilian,

Noninstitutionalized Population, United States,

1977

12 ”/0

?

— 80/0 \

4 %

1 %

I

240/,

All ages Under 17 17-44 45-64 65-74

39%

I

and over

A g e

SOURCE: NCHS, 1981 (120).

Audiometric surveys also show significant increases in hearing impairment with age and they

indicate a higher overall prevalence than interview

surveys (41, 51). For example, one national audiometric survey showed that almost 30 percent of

individuals between 65 and 74 and 48 percent of

those between 75 and 79 had impaired hearing

for understanding speech (69).

Audiometric data show that hearing loss is

greater for high frequency than for low frequency

sounds for all age groups. As figure 3 indicates,

hearing impairment at high frequencies is very

common among elderly people.

While most speech is in the range of 500 to 2,000

H Z)

5 sounds such as S , th, k, and f are heard at

higher frequencies. Elderly individuals with hearing impairments at 4,000 Hz (i.e., almost 60 percent of all elderly people) are often unable to hear

these sounds and this interferes with their understanding of normal speech.

‘Frequency is measured in vibrations or cycles per second, called

Hertz (Hz).
15

Figure 3.— Prevalence of Hearing Impairment Among Adults by Frequency of Tone, United States, 1971-75°

I

 500 Hz

25-34

 1,000H z

1~12,000H z

 4,000H z

1 7 %

0 10 20 30 40 50 60 70

Percent hearing impaired

a

These data are based on air condition tests, Figures include individuals who were able to hear the tones at 31 decibels or more at least 50 percent Of the time.

SOURCE: NCHS, 1960 (1 16).

Gender

Interview surveys indicate that elderly men have

a higher prevalence of hearing impairment than

elderly women. The 1977 NHIS found that among

people 65 to 74, about 29 percent of men reported

hearing impairments compared to only 20 percent

of women. Among those 75 and over, 44 percent

of men but only 35 percent of women reported

hearing impairments (121). Some experts suggest

that these different rates are the result of lifelong

exposure to loud noise while hunting, serving in

the military, or working in farm and factory occupations (10, 129).

Longitudinal studies indicate that men and

women aged 50 to 80 experience hearing loss in

the same frequency range, but hearing loss increases more rapidly in men than in women. After age 80, these differences in hearing impairment

between men and women become indistinguishable (54, 123).

Audiometric data show much higher prevalence

of high frequency hearing impairment for elderly

men than for elderly women, but elderly women

have similar or slightly higher prevalence at low

frequencies (54). For example, air conduction tests

used in the Health and Nutrition Examination Survey (HANES) showed that 78 percent of the men

from age 65 to 74 had hearing loss at 4,000 Hz,

compared to only 46 percent of the women in that

age group. In contrast, at 500 Hz about 12 percent

of elderly men and 18 percent of elderly women

had hearing loss, while at 1)000 Hz about 18 percent of elderly men and 21 percent of elderly

women had hearing loss.6 Bone conduction tests

produced similar findings (116). The reason for

this variation in prevalence for men and women

at different frequencies is not known.

Race

The 1977 NHIS indicated a substantially lower

prevalence of hearing impairment among nonwhites of all ages than among their white counterparts (see table 3).

Audiometric data show a more complex relationship between race and hearing impairment,

HANES data indicate that elderly nonwhites have

6

Figures include individuals who were able to hear the tones at

31 dB or more at least 50 percent of the time,
16

Table 3.—Prevalence of Hearing Impairment,

Including Tinnitus, in the Civilian, Noninstitutionalized

Population, by Race and Selected Age Groups,

United States, 1977

Race

Age White All other

Under 17 years . . . . . . . . . . . . . . . . . . . . . . . 1 % 1 %

17 to 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3

45 to 64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 8

65 to 74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 18

75 and over . . . . . . . . . . . . . . . . . . . . . . . . . . 39 31

SOURCE:NCHS, 1981 (120)

a lower prevalence of severe hearing impairments

than elderly whites, but a higher prevalence of

moderate hearing impairments.7 This distinction

is true for pure tone air conduction measures at

500, 1,000,2,000, and 4,000 Hz. On speech reception tests elderly nonwhites had a higher prevalence of hearing impairment at all levels of severity except profound deafness (116). The difference

between these results and data from interview surveys suggest that elderly nonwhites may be less

likely than elderly whites to report hearing impairment in an interview.

Income

In general, persons with low family income have

a higher rate of hearing impairment at all ages than

their wealthier counterparts. For example, the

1977 NHIS found that the rate of impairment for

persons aged 65 to 74 with annual family incomes

below $3,000 was about 30 percent. For the same

age group with incomes in excess of $15)

000, the

rate was about 20 percent (121). With only minor

variation, this inverse relationship between income

and hearing loss is sustained for all age categories. Although the reasons for this relationship are

not known, it may be because low income people

have poorer general health, poor primary health

care, and greater exposure to environmental noise

7

For this comparison, hearing impairment above 50 dB is considered severe, while impairment from 31 dB to 50 dB is considered

moderate.

and this results in higher prevalence of hearing

impairment (10, 42).

Institutionalization

The prevalence of hearing loss among institutionalized elderly people is greater than among

noninstitutionalized elderly people. One survey

in a Veterans Administration nursing home found

that 90 percent of the residents had hearing impairments (132). A review of research on hearing

loss among nursing home residents found prevalence estimates ranging from 48 to 82 percent (98).

The variation among these findings is attributed

to: different methods of measuring hearing loss,

the types of nursing homes studied, characteristics of the selected population, lack of uniform

interpretation of “hearing loss)” and lack of information about threshold sensitivity at individual frequencies.

A study of hearing impairment in a nursing home

in Canada pointed out the inadequacy of self

reports for assessing hearing impairment in this

type of setting (22). Residents were interviewed

about their hearing ability and given audiometric

tests. Fifty percent of the residents acknowledged

a hearing loss in interviews, but audiometric testing showed that 75 percent actually had hearing

impairments. Eight percent of the residents reported hearing loss when there was no audiometric evidence of impairment, while 33 percent reported normal hearing but actually had clinically

significant loss. Audiometric testing should be a

routine procedure for elderly people admitted to

nursing homes since hearing loss, including unrecognized loss, can affect a person’s ability to function normally.

Prevalence of Tinnitus

The prevalence of tinnitus increases with age

(see figure 4) and more women than men report

tinnitus (69).
17

Figure 4.— Prevalence of Tinnitus, by Severity and

Selected Age Groups, United States, 1960-62a

50 I

40 severe

0 L

33 —

38 —

—

—

41

18-24 25-34 35-44 45-54 55-64 65-74 75-79

Age

a

Percentage figures rounded to nearest whole number.

SOURCE: Leske, 1981 (69).

THE IMPACT OF HEARING IMPAIRMENT

Clinical Impact

Hearing impairment lessens a person’s ability to

hear environmental sound without amplification.

In some cases it also diminishes the ability to discriminate between sounds even with amplification. This condition is common among hearing impaired elderly people and results in the complaint,

“I can hear you, but I can’t understand you” (54,

89). Some research indicates that auditory discrimination is a problem even for some elderly people

with normal hearing as measured by pure tone

audiometric tests. This is less often true of younger people with normal hearing measured in the

same way (63).

Loss of the ability to hear high-frequency sounds

is characteristic of hearing impairment in many

elderly people. At birth the human being is able

to hear sounds as high as 30,000 Hz, but each year

of life results in some loss. By the teens, many individuals can hear only up to 20,000 Hz, and by

old age many people cannot hear sounds at 4,000

Hz or even 2,000 Hz, the level of some speech

sounds (32).

Elderly people with hearing impairment usually

have diminished ability to hear low-intensity

sounds, but their ability to hear very loud or highintensity sounds can remain unchanged. This can

make it uncomfortable to use hearing devices that

amplify all sounds uniformly because relatively

loud sounds that are amplified then become intolerably loud (89).

Another common characteristic of hearing impairment in elderly people is an inability to tune

out background noise. Many elderly people experience difficulty hearing in a noisy environment because they cannot separate speech from background noise (54, 82). Although available data are

not conclusive, studies suggest that elderly people have more difficulty hearing in a noisy environment than younger people with comparable

hearing ability. Furthermore, even elderly individuals with normal hearing ability, measured by

audiometric tests, can experience problems with

background noise (31,44). Sound reverberations

in large rooms such as auditoriums and churches

also interfere with speech perception among many

elderly people.a

In the normal ear, the efferent system is a system of complex neural mechanisms that act to con-

%h. 3 discusses the implications of these findings for hearing aid

design, the use of assistitw listening de~’ices, and eniironmentaf design technologies. Implications for screening programs and identification of people ~tho need treatment are discussed in ch. 4,
18

trol discrimination of sound, detection of sound

signals in noise, and localization of sound. Little

is known about how this system inhibits response

to some auditory signals and tunes out unwanted

sound. Further, it is not known how the efferent

system changes with age and whether such

changes are part of why elderly people have difficulty understanding speech in noisy environments.

Continued research on the mechanisms of selective inhibition could help increase our understanding of hearing impairment in the elderly (30).

psychosocial Impact

Hearing impairment causes psychological and

social difficulties because it interferes with a person’s ability to communicate effectively. Communication plays an essential role in maintaining relationships and the quality of life, and hearing loss

deprives not only the individual, but also family

and friends, of easy communication. Repeated instances of unheard or incorrectly heard communication are frustrating for the individual and

everyone he converses with and may cause all

those involved to initiate conversation less frequently. When these frustrating situations occur

over prolonged periods, family relationships can

be severely strained. Hearing loss also can affect

a person ability to speak clearly because his own

voice sounds distorted, and this can add another

impediment to communication.

Hearing loss limits a person’s ability to enjoy

many forms of entertainment, such as television,

radio, music and theater, and as a result he may

withdraw from them. Similarly, some hearing impaired people stop going to church and social

gatherings because they cannot hear well enough

to enjoy these activities (32, 54). Hearing impairment also limits access to information that is normally available through personal communication,

television, radio, and telephone. Elderly people

who have both hearing and visual impairments

are even more severely limited in their access to

information.

Aging can bring many kinds of losses: loss of income and decreased sense of usefulness associated with retirement; loss of relationships due to

the death of spouse, siblings, and friends or due

to a physical move from a familiar home or com -

munity; and diminished health, energy, and mobility. While most elderly people cope well with

these losses, hearing impairment can hinder the

coping process by interfering with the person’s

ability to become involved in new activities, form

new relationships, and arrange for needed services (10).

For some people, hearing impairment can lead

to withdrawal, social isolation, and depression

caused by lack of interpersonal communication

and contact. One British study found a significant

relationship between depression and hearing impairment among community dwelling elderly people (51). Another study, however, found no correlation between hearing impairment and either

depression or social interaction (112). The researchers suggest that the subjects in the latter

study may not be typical of the elderly population

because of their general good health, economic

security, and high level of education. Further research is needed to clarify the relationship between

these variables.

Clinical observation suggests that there is a relationship between hearing impairment and psychopathology in some individuals. Particularly

when hearing impairment occurs gradually, as it

often does in later life, deaf and hard-of-hearing

individuals sometimes develop delusions of persecution and other paranoid reactions. These symptoms may occur because the older person is not

aware of his hearing impairment—he notices that

others seem to be talking in his presence but too

quietly for him to hear or that they are laughing

about something he cannot hear. He becomes suspicious and may accuse them of excluding him deliberately. When they deny these accusations, he

may become more suspicious.

Research has demonstrated this relationship between hearing impairment and paranoid symptoms (139). College students were hypnotized to

induce temporary hearing impairment and then

asked to work with others on a joint project. These

subjects tended to develop symptoms of paranoia,

including suspiciousness, grandiosity, irritability,

and judgmental attitudes.

Some clinicians and long-term care providers

have suggested that hearing impairment can cause

or exacerbate mental deterioration in old age (10).
19

One study found a significant relationship between

hearing impairment and dementia (51). The relationship did not hold up, however, when age was

controlled, indicating that while both hearing impairment and dementia are associated with advancing age, they are not otherwise correlated. Another

study showed that hearing impaired individuals

do as well as individuals with no hearing problems

on nonverbal tests of cognition but less well on

verbal tests (112). It is not known whether these

results occur because the hearing impaired individuals do not hear the questions on verbal tests

clearly or whether some types of hearing impairment interfere with cognitive processes for encoding and recalling verbal messages.

Changes in brain function associated with aging

can affect hearing, according to a report prepared

by the Working Group on Speech Understanding

and Aging of the National Academy of Sciences.

The report, to be published in 1986, indicates that

physiological changes in the brain that affect overall brain function (not only the auditory brain

centers) can result in slowed response to auditory

stimuli (113). Continued research on the relationship between cognitive change and hearing loss

is needed.

Perhaps more important than any actual relationship between hearing impairment and mental deterioration is a widespread assumption in

society that elderly persons who are hearing impaired are also confused (30, 112, 124). A strong

tendency exists to stereotype elderly people as

senile (95) and the additional factor of a hearing

loss increases stereotyping. In a study conducted

in an acute care hospital, health care professionals

described their impatience with elderly persons

with hearing losses (9). Several respondents said

the method they used in interactions was to

“scream at them. ” This behavior was considered

acceptable since the patients were old “and probably senile, too. ”

Other negative attitudes about individuals with

hearing impairments are also widely held. People

seem to be more sympathetic to visible impairments and may be more sympathetic to blind people than to those with hearing impairments. Moreover, there is an unfortunate tendency to blame

the hearing impaired person for his or her disability, especially if the person is also old. This tendency may partially explain the sense of shame

that many hearing impaired people feel (82). Finally there is a common belief among health care

providers, as well as among the general public,

that hearing loss in elderly people is not treatable

(lo).

A study comparing hearing impaired elderly people who did not seek treatment with those who

did seek treatment identified two factors that affected whether people sought help: 1) the severity of the impairment, and 2) the onset of hearing

impairment before retirement age. Both elderly

individuals and their physicians can have negative attitudes about hearing loss that begins in old

age. This can play an important role in determining which individuals seek treatment (55).

Nursing home residents are very likely to have

hearing impairments that can be particularly

devastating for several reasons. The move to a

nursing home requires adjustment to a new environment, new people, and new daily routines.

Hearing impairment interferes with the individual’s ability to develop relationships with staff and

other patients and to fully understand the daily

schedule. One regular visitor to a nursing home

reports a comment that is heard all too often with

regard to hearing impaired residents, “Don’t bother

talking to her, she can’t hear you” (14).

Some hearing impaired nursing home residents

have mobility impairments that interfere with their

ability to interact with others and other sensory

impairments, such as vision and speech deficits,

that further reduce their ability to socialize. These

multiple impairments compound the isolation often

associated with severe hearing loss. Finally, many

nursing home residents have irreversible mental

impairments caused by strokes, primary degenerative dementias such as Alzheimer’s disease, or

other disease conditions. In this context, it is easy

for nursing home employees to assume that hearing impaired residents who do not answer questions correctly and do not seem to understand the

daily routine are also mentally impaired. The impact of this assumption on the hearing impaired

resident’s quality of life can be very severe.

Denial of Hearing Impairment

Many elderly people deny they have a hearing

problem despite substantial evidence to the con-
20

trary. Many authors have discussed the problems

of denial and refusal to seek treatment (76), but

little attention has been given to the underlying

reasons for it. Elderly people who deny or avoid

confronting a hearing loss are not doing so in a

vacuum. Negative social attitudes about hearing

impairment and growing old encourage denial.

Hearing impairment is not visible, and invisibility

facilitates denial. In addition, hearing impairment

in elderly people often has a very gradual onset

that can make it difficult to recognize.

For elderly persons with one or more life-threatening illness, hearing impairment may seem insignificant in comparison. The onset of depression,

withdrawal, paranoia, and other mental health

problems associated with hearing impairment is

slow and insidious and may seem unrelated to the

hearing loss. An elderly person’s inability to receive aural cues can lead to accidents, though the

causes may seem ambiguous. Likewise, difficulties in communication and social relationships may

not be attributed to hearing loss, even when the

loss is acknowledged. As a result, hearing impairment often is mistakenly seen as unimportant by

elderly people, their families, and health care

providers (10). This denial of the importance of

hearing impairment and our failure to recognize

its full impact on independent functioning are clear

obstacles to effective treatment.

DEAFNESS

Only a small percentage of elderly people are

deaf. There is no consensus about the exact prevalence of deafness, in part because of variation

in the method used to measure hearing impairment and the level of impairment that is defined

as deafness. However, estimates using audiometric

tests indicate that about 2 to 4 percent of all elderly people are deaf (116, 119). Among people

over 75, prevalence increases somewhat, and if

people with severe hearing impairments are included, prevalence increases significantly.

For practical purposes elderly deaf people can

be divided into three groups: 1) those who became

deaf very early in life before language was acquired, 2) those who became deaf during early or

middle life after language was acquired, and 3)

those who became deaf during later life. People

who have been deaf since childhood have usually

learned to use sign language and have deaf and

nondeaf friends and associates with whom they

can communicate using sign language.g Since their

method of communication is manual, their ability

to communicate usually does not diminish with

age. Some people who became deaf in early or middle life use speechreading as their preferred mode

of communication. Visual impairments acquired

‘1’his network of informal relationships is often wfcwcxi to as

thr “deaf communit~’.”

late in life can interfere wi

speechreading techniques.

th their ability to use

Individuals who become deaf late in life face

different problems. Sign language is an entirely

new and complex system of communication that

they must learn if they are to interact with other

deaf people who use sign language. Yet their relatives and lifelong friends seldom know sign language. The result can be extreme social isolation.

People who are deaf and people with partial hearing loss are similar in some ways and very different in others. Both groups can benefit from increased awareness of their communication

problems among their families, friends, health care

and social service providers, and others who interact with them. Yet the devices and hearing services that are most effective for each group are

different. For example, sign language and telecommunication devices that rely on visual messages,

such as the telecommunication devices for the deaf

(TDDs) described in chapter 3, are most effective

for deaf people. In contrast, hearing aids, assistive listening devices, and telephone amplifiers are

more appropriate for those with partial hearing

loss.

In the past, hearing research and many hearing

services have focused on deaf and very seriously

hearing impaired people, and less emphasis has
been placed on partial hearing loss (10). When deaf

people and those with partial hearing loss are combined into a single category-’’the hearing impaired’’ -at least 16 million people are included.

Yet this large number is sometimes used to justify

funding for research programs and hearing services focused primarily on the deaf—a group of

21

about 2 million people. Self-help groups for hardof-hearing people have pointed out this discrepancy (109) and funding agencies and hearing research centers are slowly readjusting their research and service priorities to encompass the very

large proportion of hearing impaired people who

are not deaf.
Treatment of Hearing Impairment

Chapter 3
Chapter 3

Treatment of Hearing Impairment

The options available for treating hearing impairment in elderly people are generally the same

as for younger people. However, the suitability and

effectiveness of various treatments differ considerably among age groups because of the type of hearing loss most frequently encountered and because

of other physical, psychological, and social characteristics of each group (10).

Preventing hearing impairment is an obvious

first approach. Even if hearing impairment cannot be completely avoided, preventive measures

can slow the rate of deterioration or reduce the

ultimate severity of the impairment. A second approach is medical and surgical treatment. While

these treatments are effective for some types of

hearing impairment, the types of hearing problems that are most common in elderly people are

not presently treatable with medical or surgical

methods. Thus alternatives are needed. These generally do not change the underlying hearing loss

but instead help compensate for hearing loss and

maintain adequate communication. They include

the use of hearing aids, assistive listening devices,

telecommunication devices, signaling and alarm

devices, and environmental design technologies.

In addition, aural rehabilitation services can help

hearing impaired people communicate more successfully with or without the use of amplification

devices.

PREVENTION

Some causes

people are not

of hearing impairment in elderly

well enough understood to allow

effective preventive measures. For example, dietary factors and circulatory changes have been

implicated as accelerators of deterioration in the

auditory system. Yet the specific relationship of

these factors to hearing loss is not known, and further research is needed before preventive strategies can be developed (10).

other causes of hearing impairment are well understood and often preventable; these include untreated ear infections, exposure to loud noise, and

some medications. Untreated or inadequately

treated ear infections at any time in life can cause

conductive hearing loss, though it may not be immediately disabling. In old age, however, as sensorineural loss further reduces hearing acuity, serious disability may develop. Thus better health care

throughout life could prevent some hearing impairments in old age (10).

Exposure to loud noise at any age can cause irreversible sensorineural damage and significant

hearing loss. Airplanes, motorcycles, heavy traffic, farm and industrial machinery, gunfire, and

loud music are sources of noise that can permanently damage hearing. Other sources of loud noise

have also been identified. For example, the American Academy of Otolaryngology-Head and Neck

Surgery has recently warned that some types of

cordless telephones can cause hearing loss because

the phones continue to ring at a high decibel level

after being answered until a switch is flipped to

the ‘(talk” position. Seven million of these cordless

phones were estimated to have been sold in 1984

(2).

The popularity of loud rock music, along with

a rise in other environmental noise, creates a severe threat to the auditory acuity of young people. A 1968 study of hearing impairment among

students in Knoxville, Tennessee, showed that 4

percent of sixth graders had hearing loss at high

frequencies. This proportion increased to 11 percent of ninth graders and 33 percent of freshmen

at the University of Tennessee. A year later, a similar study showed that more than 60 percent of

the next freshman class had some hearing loss (70).

As these individuals grow older, their noise-induced hearing loss may be exacerbated by the auditory changes associated with aging.

Self Help for Hard of Hearing People, one of the

self -help groups for hearing impaired people, has

25
26

developed a “Quiet School Program” to provide

information and educational materials to school

administrators, teachers, students, and parents

about the relationship between loud noise and

hearing loss. The materials include colorful posters

and a device that flashes a warning light when noise

in the school cafeteria reaches a dangerous level

(101).

The increased use of portable radios and tape

players with earphones may cause a greater prevalence of noise-induced hearing loss. A study in

New York City found many listeners playing their

portable radios at 100 decibels, the equivalent of

a car horn 3 feet away (65). A recent British report concluded, however, that portable radios and

tapeplayers are a less serious threat to hearing than

are other sources of loud noise such as industrial

machinery and gunfire (38).

Federal legislation to control noise includes the

Occupational Safety and Health Act of 1970 and

the Noise Control Act of 1972. Federal regulations

define the amount of time that workers may be

exposed to noise of a given intensity. Noise control procedures have been implemented in some

industries. In addition, some local governments

have enacted noise control legislation and violators are being prosecuted (111). These efforts eventually may reduce the prevalence and severity of

noise-induced hearing loss. Many incidents of exposure to loud noise, however, are not within government regulatory control. Increased public education is needed to alert people of all ages to the

impact of loud noise on hearing and the long-term

damage that can result.

Some drugs also damage auditory mechanisms.

Although not a major cause of hearing impairment,

these “ototoxic” drugs must be considered in any

discussion of prevention. The best known of these

drugs are the aminoglycosides, a class of antibiotics that includes streptomycin. These drugs can

be life-saving; unfortunately, they also sometimes

damage hearing (10). Even commonly used, overthe-counter drugs such as aspirin can be ototoxic,

although probably only in the high dosages sometimes used to treat arthritis. Fortunately, aspirininduced hearing loss is usually reversible if it is

recognized early and aspirin dosage is reduced (10).

ototoxic drugs can create problems in people

of any age. Nevertheless, diseases that require their

use are more prevalent in later life. Too little research has been done to provide a full understanding of the mechanisms of ototoxicity and of the

essential chemistry of the agents that may be ototoxic. Educational efforts have been effective in

informing most physicians of the potential hazards of streptomycin, but the ototoxic effects of

other drugs have been less well publicized (10).

Hearing loss is a symptom with many possible

causes and accurate diagnosis can sometimes help

prevent permanent hearing impairment. Yet some

elderly people do not receive thorough diagnostic evaluation. Symptoms such as sudden onset of

hearing impairment and unilateral deafness suggest a diagnosis other than presbycusis, and medical evaluation of patients with these symptoms

can sometimes lead to effective treatment (73).
27

MEDICAL AND SURGICAL TREATMENT

Medical and surgical treatment can resolve conductive hearing losses that originate in the outer

or middle ear, but the sensorineural losses that

are most common among the elderly generally cannot be treated with available medical and surgical

methods. Cochlear implants can alleviate profound

sensorineural hearing loss in some individuals and

research continues to improve these devices.

Treatment of Conductive

Hearing Impairments

Wax buildup in the outer ear is common among

the elderly and interferes with the passage of sound

to the middle ear. Recognizing this problem and

removing the impacted ear wax can improve hearing even if there are other auditory deficits.1

.

Middle ear disease is most common in childhood

but it also occurs in adulthood and old age. Otitis

media (infection of the middle ear) can be caused

by allergies or upper respiratory infection and effective treatment may require medication. Perforation of the eardrum can occur at any age as the

result of middle ear infection or direct trauma.

Repair occurs without treatment in some cases,

while surgical repair is needed in other cases.

Otosclerosis impairs movement of the stapes, a

small bone in the middle ear. The impaired movement causes progressive hearing loss. While the

most common age of onset is in the third or fourth

decade of life, surgery can be beneficial at any age

and carries only a small risk of complication (27).

Treatment of Sensorineural

Hearing Impairments

Although most sensorineural losses cannot be

corrected through medical or surgical intervention, some losses due to tumors, sudden vascular

changes, or fluid pressure changes affecting the

inner ear or auditory nerve can be treated. These

disorders, however, are relatively infrequent in

elderly people (12).

IRemOl:Il of impacted ear ~~a.x can tw diffiruit and painful and

should tw (lone L]ndPr ttlc supf’rl is ion 0[ a ph:’s irian.

Acoustic Tumors

Acoustic tumors can cause sensorineural hearing loss, vertigo (dizziness), tinnitus, facial paralysis, or numbness. These tumors generally occur

during the third or fourth decade of life but may

also occur in the sixth and seventh decade (13.5).

These tumors can be fatal and surgical removal

is a life-saving measure, but it does not usually result in improved hearing.

Meniere’s Disease

Sensorineural hearing loss can also result from

Meniere’s disease, the symptoms of which include

fluctuating hearing loss, tinnitus, pressure in the

ears, and vertigo (93). The cause of Meniere’s disease is not known. Treatment with medication is

the first choice, and surgery is used only when

hearing loss or disabling vertigo persists despite

drug therapy. Rates of success with surgery vary

from 62 to 95 percent, depending on the type of

surgery performed (92).

Cochlear Implants

The cochlear implant is an electronic device designed to give persons with profound bilateral sensorineural hearing loss an improved sense of

sound. Part of the device is surgically implanted

in the inner ear and part of it is worn externally

(see figure 5). The cochlear implant is intended

to neuroelectrically simulate natural hearing, but

full attainment appears far in the future (10). The

sound produced by these devices has been described as fluctuating, grating noises and buzzes

(88), and users need extensive training to learn to

interpret the sound. Yet implants have improved

speechreading ability—at least in isolated experiments—by giving rudimentary clues to a speaker

words (25). These devices also provide a sense of

the duration, rhythm, and loudness of sound that

can be helpful in understanding speech and identifying environmental sounds (8, 71).

Cochlear implants hold most promise for deaf

people whose transducing organ in the cochlea

is ineffective but whose auditory nerve endings

are still responsive to direct stimulation (88). In

the past 20 years, hundreds of people worldwide
28

Figure 5.—Cochlear Implant in Place

$

The cochlear implant translates sound into electrical signals, bypassing damaged tissues in the inner ear and allowing the brain to receive

auditory information. It works as follows: An external microphone detects sound which is translated into electrical impulses by a signal

processor and then transmitted to an external coil positioned behind

the ear. This coil induces a like signal in another coil implanted inside the skull. From the internal coil, the signal is carried to an electrode in or on the cochlea, stimulating nearby auditory nerve fibers

to transmit messages to the brain. This diagram shows the parts of

the implant designed by William House and his colleagues. Other systems are similar, except that the external coil and microphone may

be worn on a headset and multichannel devices have more electrodes.

SOURCE: D. Grady, “Sounds Instead of Silence,” Discover, 1983.

have received experimental cochlear implants, and

many of them have been enthusiastic about the

results (71). No statistics are available on the number of elderly persons who have received implants

or their response to them. In 1984, the Food and

Drug Administration (FDA) approved one type of

cochlear implant for clinical use in the United

States, a device developed by William House and

3M Corp. In 1985, FDA approved a more sophisticated implant developed in Australia.

Research on cochlear implants continues at the

House Ear Institute of Los Angeles; the Kresge

Hearing Research Institute at the University of

Michigan; Stanford University Medical School;

University of California, San Francisco; Johns Hopkins University School of Medicine; and other hearing research centers. One focus of research is improving the sound processing capabilities of the

devices. Another focus is the development of multichannel devices that are expected to allow more

realistic sound perception for the individual (71).

The House implant illustrated in figure 5 is a single-channel device with a single stimulating electrode, and the Australian device mentioned above

is a single-channel device with 22 stimulating electrodes. Four- and eight-channel devices are now

being tested and some people report significant

improvement in speech recognition with these devices. Researchers believe that with enough channels, the cochlear implant could restore normal

hearing. However, the difficulties involved in designing a multichannel device and successfully

placing and maintaining it in the tiny, spiral-shaped

cochlea are formidable (71).

Cochlear implants can damage remaining nerve

fibers and other delicate tissues in the patient’s

ear. As a result, researchers in England, Austria,

and Switzerland are working on ‘(extra cochlear ”

devices, where the electrode is implanted outside

the cochlea (45).

In its present form the cochlear implant is not

appropriate for most elderly people because they

have partial hearing loss rather than the profound

deafness for which the device is now used. Anecdotal evidence indicates that some people who have

had implants have been severely disappointed by

limitations on the sounds they are able to hear (128).

Cochlear implants are expensive, ranging from

$12,000 to $15,000 for preoperative evaluation,

surgery, the device, and postoperative auditory

training (8). In the future, however, as cochlear

implants are improved through research and test -

ing they may become an important treatment option for elderly people.

HEARING AIDS

Since only a small portion of elderly people with the problem are essential. For many years, hearhearing impairments can benefit from medical or ing aids were the only available option. Recently

surgical treatment, other approaches to mitigate there has been increased interest in other devices
29

that can help individuals with hearing impairments

and these devices are discussed later in this

chapter.

Hearing aids are amplification devices that compensate for partial hearing loss. The individual

must have some residual hearing to benefit from

a hearing aid. The earliest hearing aids were mechanical “ear trumpets” that gradually evolved into

the small, more effective, battery-powered technology that is available today.

Hearing aids are available in five basic styles: onthe-body, over-the-ear, eyeglass, and two in-theear styles (see figure 6). On-the-body aids have a

receiver that is attached to clothing or carried in

a pocket, Ear-level aids are worn over the ear or

fitted into the temple bar of eyeglasses. In-the-ear

aids include one style that fits into the auricle or

outer area of the ear and a smaller device, the canal style aid, that fits almost completely into the

ear canal.

Until recently, the most frequently sold hearing aids were over-the-ear aids, but beginning in

1983 in-the-ear styles have outsold the other types.

In-the-ear aids are popular because of their small

size, and the canal style aid, which first appeared

on the market in 1982, is extremely popular for

I

On-the-body type

this reason. Table 4 shows the types of hearing

aids sold in 1984. Canal style aids are included in

the “in-the-ear” category. Sales of canal style aids

increased from less than 1 percent of total hearing aids sold in 1982 to 9 percent in 1983, and 22

percent in 1984 (23). About 65 percent of people

who bought hearing aids in 1984 were fitted for

one aid, while about 35 percent were fitted for

two aids, one for each ear (23).

In the past, on-the-body aids could provide more

amplification than other types of aids and were

therefore recommended for people with severe

hearing impairments. Recent technological advances in the miniaturization of hearing aid components now make it possible for individuals with

severe hearing impairments to use ear-level aids.

Increased miniaturization, however, has raised

concern about the quality of sound provided, parTable 4.—Types of Hearing Aids Sold in the

United States, 1984

Type of aid Percent of total sales

In-the-ear . . . . . . . . . . . . . . . . . . . . . . . 60.00/0

Over-the-ear . . . . . . . . . . . . . . . . . . . . . 37.0

On-the-body . . . . . . . . . . . . . . . . . . . . . 1.5

Eyeglass . . . . . . . . . . . . . . . . . . . . . . . . 1.5 . -

SOURCE: Cranmer, 1965 (23).

Figure 6.—Hearing Aid Types

Over-the-ear type

Eyeglass type

In-the-ear type

Copyright 1976 by Consumers Union of United States, Inc., Mount Vernon, N.Y. 10553. Reprinted by permission from CONSUMER REPORTS, June 1976.
30

ticularly with devices as small as canal style aids.

Miniaturization of the microphone and speaker

elements of hearing aids has been less effective

than miniaturization of the electronic circuitry,

and this can result in sound distortion—a serious

drawback for elderly people who have difficulty

with auditory discrimination (54, 60). While research continues to improve the miniaturized components of hearing aids, some hearing specialists

worry that people may select a small hearing aid

that is not well suited to their needs because of

its cosmetic appeal.

Over the years, hearing aids have helped millions of people by maximizing their residual hearing and allowing them to function in communication situations that otherwise would have been

impossible. Yet most people with hearing impairments do not use hearing aids. Estimates of the

percentage of hearing impaired people who use

hearing aids vary depending on the source of the

data and the figure that is used for overall prevalence of hearing impairment. A recent analysis

using three different prevalence rates estimates

that between 8 and 17 percent of all hearing impaired people use hearing aids (41). A 1984 industry survey indicated that of the 16 million people

of all ages with hearing impairments in the United

States, about 4 million (25 percent) own hearing

aids. About 2 million others (12.5 percent of hearing impaired people) do not admit to having a hearing impairment, and the remaining 10 million (62.5

percent) admit to having a hearing impairment but

do not have a hearing aid. Of those who own hearing aids, about 14 percent do not use them (49).

The majority of hearing aid users are elderly.

Table 5 gives the age breakdown of individuals

who bought hearing aids between 1983 and 1985.

Table 5.—Proportion of Hearing Aid Purchasers

by Age, 1983-85

Proportion of all

Age hearing aid purchasers

2 to 39 . . . . . . . . . . . . . . . . . . . . . . . . 8%

40 to 49 . . . . . . . . . . . . . . . . . . . . . . . 3

50 to 59 . . . . . . . . . . . . . . . . . . . . . . . 11

60 to 69 . . . . . . . . . . . . . . . . . . . . . . . 31

70 to 79 . . . . . . . . . . . . . . . . . . . . . . . 30

80 to 89 . . . . . . . . . . . . . . . . . . . . . . . 14} 78%

90 to 99 . . . . . . . . . . . . . . . . . . . . . . . 3

SOURCE: Market Facts, 1985 (75).

Elderly people with hearing impairments are

more likely to use hearing aids than younger people with comparable hearing loss. Data from the

1977 National Health Information Survey show that

about 20 percent of all hearing impaired persons

over 65 used a hearing aid, compared to 4 percent

of hearing impaired persons age 3 to 44 and 10

percent of hearing impaired persons age 45 to 64

(118). Among elderly people, hearing aid use increased with increasing severity of hearing impairment (see table 6).

Even though elderly people with hearing impairments are more likely to use hearing aids than

younger people with similar impairments, most

hearing impaired elderly people do not use hearing aids. Many reasons for this have been suggested. Some elderly people are unaware of their

hearing impairments and therefore do not buy an

aid, others reject the use of a hearing aid because

they associate it with getting old or becoming handicapped. Still others believe that their hearing loss

is not severe enough to require the use of a hearing aid or that hearing aids are not effective for

the kinds of impairments they have. Cost is an additional deterrent for some people (49).

Among those who do buy hearing aids, some are

very satisfied; others are less satisfied; and some

are disappointed with the aid. A nationwide survey of people of all ages who purchased hearing

aids between 1983 and ,19852 asked respondents

how satisfied they were with their hearing ability

with the current hearing aid. Responses are shown

in table 7.

Those who answered that they were somewhat

dissatisfied (6 percent) or very dissatisfied (4 percent) were asked about specific problems they experienced in using the aid. These people identified the following problems (75):

● amplification of unwanted noise,

‘This survey, commissioned by the Federal Trade Commission

(FTC), was designed to produce a representative sample of all U.S.

households and to reflect the experiences of all hearing aid purchasers nationwide (86). The FTC requested public comment on the

methodology of the survey, and no serious problems in survey methods were identified by the time the public record was closed (87).

Since then, analysts have pointed out that the survey might be biased because it was a mail survey and because the respondents were

members of a panel of consumers who had agreed to participate

in Market Facts surveys ( 107).
31

Table 6.—Persons Age 65 and Over Who Use a Hearing Aid, United States, 1977

Can hear words Can hear words At best can

All levels of Unilateral hearing spoken in a shouted across hear words

Known hearing aid use hearing trouble trouble normal voice a room shouted in ear

Use a hearing aid . . . . . . . . . . . . . . 19.9°/0 10.80/0 12.70/o 27.50/o 58.40/o

Do not use an aid . .............80.1 89.2 87.3 72.5 41.6

SOURCE” NCHS, 1982 (1 18)

Table 7.—Satisfaction With Hearing Ability

Using a Hearing Aid

Percent of all

Degree of satisfaction hearing aid purchasers

Very satisfied. . . . . . . . . . . . . . . . . . . 47%

Somewhat satisfied . . . . . . . . . . . . . 37

Neither satisfied nor dissatisfied. . 6

Somewhat dissatisfied. . . . . . . . . . . 6

Very dissatisfied . . . . . . . . . . . . . . . . 4

SOURCE: Market Facts, 1985 (75).

●

●

●

●

●

inability to hear in crowds ,

having to ask people to repeat themselves,

feedback from the hearing aid,

difficulty hearing phone conversations,

friends/relatives complaining about their

hearing.

Those who said they were somewhat satisfied

or neither satisfied nor dissatisfied (43 percent of

the total sample) were not asked about problems

they experienced in using the aid. If they had been

asked, they might have identified similar problems.

Dissatisfaction with a hearing aid can result from

several problems: 1) deficiencies in the design

and/or performance of the aid itself, 2) selection

of an aid that is not well matched to the person’s

needs, 3) inability to adjust to the aid, or 4) a combination of all three. In many cases, it can be difficult to determine the cause of dissatisfaction.

problems in Hearing Aid Design

and Performance

The sound produced by hearing aids is sometimes described as mechanical. one reason for this

is that most hearing aids amplify sound in the frequency range of 500 to 4,000 Hz, although a full

frequency range from about 50 to 10,000 Hz is

needed to provide reasonably accurate timbre (the

quality given to sound by its overtones). In addition, hearing aids do not handle all tones evenly,

resulting in further sound distortion (21).

Another problem with hearing aids is that they

amplify background noise as well as speech, and

users of all ages have difficulty learning to tune

out distracting background noise. As a result, some

hearing aid users turn off their aids in noisy environments (67). Recent changes in transducer design can intensify the speech signal in contrast to

background noise and thus improve the speechto-noise ratio (89). However, amplification of unwanted background noise remains a problem for

many hearing aid wearers. For elderly people who

have diminished ability to tune out background

noise, this problem is particularly severe.

Since many elderly people have more severe

hearing loss at high frequencies than low frequencies, uniform amplification of all frequencies is

often ineffective. One approach to this problem

is a high -frequency emphasis hearing aid that am -

plifies only high-frequency sounds, allowing lowfrequency sounds to enter the ear without amplification (115). Another approach is frequency

lowering, an electronic sound processing technique that lowers the frequency of received sound.

This technique is in the developmental stage and

sound distortions produced by the frequency

lowering systems limit their effectiveness (88).

Difficulty with sound discrimination is a common element of hearing impairment in elderly people. Thus technical limitations in hearing aids that

distort sound can actually worsen the hearing ability of some individuals (54). Sophisticated sound

processing techniques that have been developed

for military and space applications may someday

be used to overcome the problems of sound distortion, background noise, and high-frequency

hearing loss. Using these advanced techniques:

. . . minute signals are successfully pried out of

a profusion of far stronger noises that have often

been accumulated over great distances in space.

Communication in present day air battles depends

upon stunning solutions to the problem of signal

(and speech) selectivity for multicommunication
32

among pilots and between pilots and ground control. Such solutions employ sophisticated logic

software in which the distinguishing physical

characteristics of the desired signals are recognized while those of the undesired competing signals are rejected (11).

Adaptation of these techniques to hearing aid

design is a high priority at the National Institute

of Neurological and Communicative Disorders and

Stroke and other hearing research centers across

the country (81). Obstacles include miniaturization of the necessary equipment and the final cost

of the device.

Several other problems can also interfere with

hearing aid performance. Hearing aids need frequent cleaning and if the user does not clean the

aid it will not work properly. Hearing aids can be

damaged by heat and moisture, causing a need for

adjustments or repair. The batteries can die, and

although checking the batteries is an obvious first

step for most hearing aid users, hearing specialists

encounter people who complain that their hearing aids do not work, only to find that the batteries are dead. Portable battery testers are available

and can help solve this problem. In the future, hearing aids could be designed with a detector circuit

to sense low battery voltage and alert the user by

a visual, auditory, or tactile signal. Obviously, new

users need a thorough hearing aid orientation to

forewarn them about these potential problems.

Problems in Selecting the

Appropriate Hearing Aid

At present, there is no technique to make a hearing aid that exactly matches an individual’s hearing deficits, the way eyeglass lenses are ground

to match a prescription. Instead, hearing aid

dealers and dispensers attempt to custom fit the

aid to the individual’s hearing deficit by combining and adjusting available components.

One problem faced when selecting an appropriate hearing aid is identifying the individual’s precise hearing deficits, Hearing specialists disagree

about what tests are needed to select a hearing

aid and who is qualified to perform the tests. Audiologists are trained to evaluate hearing deficits,

and some hearing specialists believe that a comprehensive audiologic evaluation is necessary to

select a hearing aid. Yet many elderly individuals

buy hearing aids without seeing an audiologist (10).

other hearing specialists argue that while a comprehensive audiologic evaluation is essential for

diagnosing some ear diseases, only certain hearing tests are relevant to the selection of a hearing

aid and these tests can be performed effectively

by hearing aid dealers (62, 90, 133).

Another problem that arises when selecting an

appropriate hearing aid is that little information

is available comparing different brands and types

of hearing aids. Hearing aid manufacturers provide technical performance data on their devices,

but information about the relative merits of various brands and models is scarce.

The National Technical Institute for the Deaf and

the Massachusetts Institute of Technology have

designed a device to simulate the characteristics

of a variety of hearing aids. This “Master Hearing

Aid” provides information about the most appropriate hearing aid for the individual (19). Computer

programs also have been developed to analyze audiometric data and select specific models of hearing aids that most closely match the individual’s

hearing deficits. Eventually, it is hoped that a computer chip programmed by a “Master Hearing Aid”

could be installed in the individual’s hearing aid

to provide an exact match between the individual’s hearing deficits and the signal processing

characteristics of the aid (19). This would constitute a “prescription hearing aid.” Research on various aspects of the prescription hearing aid is in

progress at the Central Institute for the Deaf in

St. Louis, the Lexington School for the Deaf in New

York City, and other hearing research centers.

Problems in Adjusting

to a Hearing Aid

Emotional and psychological factors can interfere with a person’s adjustment to hearing aid use.

For example, some people fail to adjust to their

hearing aids because they are embarrassed by the

appearance of the aid. Small, “invisible” aids are

popular for this reason. Larger aids that provide

better sound fidelity and are more easily manipulated by arthritic hands are sometimes rejected

in favor of smaller, more expensive, and less ef -
fective instruments (10). The use of two aids, one

for each ear, may also be rejected for this reason

even though two aids can provide better hearing

acuity for many people (134).

Unrealistic expectations can also interfere with

a person’s adjustment to the hearing aid. Some individuals buy a hearing aid expecting it to restore

normal hearing and are disappointed with the results. This disappointment can cause significant

acceptance problems (10). Research indicates that

30 percent of those who purchased hearing aids

from 1983 to 1985 expected that their aids would

restore normal hearing. of these people, one-third

said their hearing aids did restore normal hearing, about one-half said it somewhat restored normal hearing, and the remaining 12 percent were

unsure or said it did not restore normal hearing

(75).

Some people believe that elderly people have

more difficulty adjusting to hearing aids than

younger people because of an assumed age-related

inability to adjust to anything new; however, no .

research justifies this conclusion. In fact, little con33

elusive information is available about the precise

reasons why individuals of any age fail to adjust

to hearing aids, and more research is needed in

this area.

Anecdotal evidence suggests that some elderly

people who are severely confused and hearing impaired may be unable to learn to use a hearing

aid or even to understand its purpose. For these

people, environmental design technologies and

assistive listening devices that require less adjustment could be more appropriate. These approaches are described later in this chapter.

All people fitted with hearing aids need assistance adjusting to the aid. Someone must answer

questions, reassure the person during discouraging periods, make needed adjustments to the hearing aid and attachments, counsel the individual

and the family regarding expectations, and assist

in the adaptation to environmental sounds. Otherwise, the aid will remain unused. These factors

point to a strong need for competent professional

involvement in the evaluation, selection and fitting, and adjustment of hearing aids (10).

ASSISTIVE LISTENING DEVICES

In addition to hearing aids, four types of assistive listening devices can be used to increase auditory effectiveness: hardwire devices, audio loop

systems, radio frequency devices (AM and FM),

and infrared amplification devices. These devices

transmit sound directly from the speaker or other

source to the listener, thus reducing interference

caused by background noise. They have been used

primarily in classrooms and public meeting rooms

and are often referred to as “large room systems. ”

They are now being used by some people for oneto-one or small group listening as well as TV and

radio listening.

Assistive listening devices can be used by elderly

people who have hearing aids and have difficulty

tuning out background noise. In addition, these

devices can give some elderly persons with mild

to moderate hearing loss enough amplification to

allow them to hear effectively without a hearing

aid in some situations.

Hardwire devices provide a direct wire link

between the listener and the source of sound. Examples are the earphones used with portable radios, tape players, TV, and stereos. Hearing impaired people can obtain earphones with adjustable

volume. Some hardwire devices have a microphone that can be placed on a table or held by the

speaker (see figure 7). Some can be used with a

hearing aid. The simplicity of these devices makes

them useful for radio and television listening and

some one-to-one conversation, but the wire connection to the source of sound is too restrictive

for many purposes.

An audio loop system is composed of a microphone that is worn or held by the speaker and

a length of wire called an induction loop that can

be installed or simply placed in a room. Sound from

the microphone is converted into an electromagnetic signal that is transmitted by the loop and

picked up by any hearing aid with a telephone
34

Figure 7.— Hardware Device for

One-to-One Consultation

SOURCE’ Williams Sound Corp

switch. Loop systems can also be used by people

who do not have hearing aids but wear or carry

a receiver that can pick up the electromagnetic

signa13 (see figure 8). Loop systems have been used

extensively in schools for the deaf and are now

being used in churches, theaters, and other meeting rooms.

Hearing impaired people who want to use the

loop system must sit within the area of the loop,

but people with no hearing problems can sit in

the same area. Sound quality is not always uniform throughout the area and the devices sometimes pick up interference from fluorescent lighting (103).

An FM amplification device is composed of a

small, wireless, battery-operated FM microphone

that can be placed near the source of sound (a person, television, radio, etc.) and a tiny portable stereo radio equipped with earphones that are worn

by the hearing impaired person (see figure 9).

Sound is transmitted from the microphone to the

receiver by radio wave. The transmission range

is 100 feet or more, which allows the person to

move about while listening to radio, television, or

conversation. Individuals with hearing aids can use

FM amplification devices if their hearing aids have

a telephone switch and they use a neckloop or if

Stn some museums, audio loop systems are used for self-guided

tours for nonhearing impaired persons. The indi~’idual carries a

wand recei~er that is actit’ated as he approaches an exhibit.

Figure 8.—Audio Loop Wand Receiver

SOURCE: VA Medical Center, Birmingham, Alabama

Figure 9.—FM Personal Amplification Device:

Transmitter and Receiver

SOURCE. Williams Sound Corp

their hearing aids are designed for direct audio

input.4

Until a few years ago, the Federal Communications Commission (FCC) limited the use of radio

signals for amplification devices to educational settings. This restricted the development of FM amplification devices for personal use. Since 1982,

however, changes in Federal regulations have allowed increased public access to radio frequencies. This has stimulated the development and mar4Over-the-ear, eyeglass, and on-the-body aids that are designed

for direct audio input use an adapter cord that can be plugged into

the hearing aid at one end and into the FM receiver at the other

end. In-the-ear aids can use a button receiver that is snapped onto

the hearing aid for direct audio input.
35

keting of FM amplification devices for use in the

home and in public facilities such as theaters,

churches, and large meeting rooms. These devices

are also being used in automobiles.

An AM amplification device transmits sound

using AM radio wave lengths, and the sound is

picked up by a special AM receiver worn by the

listener or by a portable pocket radio. The sound

quality provided by AM amplification devices is

usually not as good as that provided by FM devices.

AM amplification devices are subject to the same

sources of interference as AM radios (e.g., thunderstorms and lamp dimmers). In addition, AN I devices can only be used within an area enclosed by

four walls, while FM amplification devices can be

used indoors and outdoors. As a result, FM amplification devies are used more frequently (103).

An infrared amplification device is composed of

a battery-operated transmitter and a receiver (see

figure 10). The transmitter transforms sound into

an electrical signal that modulates an infrared light

beam. This invisible light beam is picked up by a

receiver worn by the listener (67). Infrared hearing devices are used primarily in theaters and some

institutional settings, but they can also be used in

the home (68).

one advantage the infrared device has over t he

All and FM amplification devices is that the infrared light signal is absorbed by any opaque surface. Thus a person in one room can use an infrared amplification device to hear a speaker in

that room while people in other rooms can use

infrared devices to hear other speakers. There is

no spillover of the infrared signal and privacy of

communication is maintained. In contrast, AM and

FM radio signals can radiate from one room to

another. In an institutional setting or any private

situation, the spillover of AM and FM signals is unacceptable (67).

one disadvantage of infrared devices is that they

cannot be used in direct sunlight, and thus cannot be used outdoors like FM amplification devices.

Large amounts of incandescent light in a room can

also cause interference (103).

Although assistive listening devices have been

used primarily to amplify sound in large rooms

and public settings, they are now being used more

frequent}’ by individuals for interpersonal comFigure 10.—lnfrared Amplification Device:

Transmitter and Receiver

SOURCE: VA Medical Center, Birmingham, Alabama

munication and TV and radio listening. Many applications that are especially relevant for elderly

people have been suggested. For example, physicians and other professionals who talk with elderly

people could have these devices available in their

offices. In hospitals and nursing homes, the devices could be used by staff to communicate with

hearing impaired patients, and patients could use

them to listen to radio or TV without bothering

other patients. Assistive listening devices could be

especially helpful in banks and other offices where
36

people communicate through glass barriers. Unlike hearing aids, no training is required to use

them so they can be immediately helpful in many

listening situations.

Assistive listening devices are particularly appropriate for many elderly people with mild or

moderate hearing loss because these devices can

provide satisfactory auditory function in some

listening situations even without the use of a hearing aid. When a hearing aid is needed, assistive

listening devices can help tune out bothersome

background noise.

one obstacle limiting the use of assistive listening devices is the resistance many hearing impaired

people feel to using devices that are visible (140).

Another obstacle is lack of awareness among the

hearing impaired elderly of the kinds of devices

that are available. Many hearing specialists—

including physicians, audiologists, and hearing aid

dealers—know very little about these devices and

do not encourage their use (74). Some of these

specialists believe that a correctly fitted and functioning hearing aid is a better treatment option

than an assistive listening device because the hearing aid does not require microphones, transmitters, or induction wires, and thus appears more

“natural .“ Advocates of assistive listening devices

point out, however, that hearing aids can be ineffective in some listening situations (102). These

experts believe that until hearing aids can be designed to effectively filter out background noise,

other devices are also needed.

TELECOMMUNICATION DEVICES

One of the most handicapping aspects of hearing loss for hearing impaired people of all ages is

the inability to use the telephone. For the elderly,

particularly those who live alone, the telephone

is a link to the outside world and inability to use

it can compromise safety, interfere with independent functioning, and deprive the individual of social interaction with family and friends. Anecdotal

evidence indicates that when family members and

friends are not able to contact the elderly hearing

impaired person regularly by telephone, they become increasingly anxious about his or her welfare. In some cases, this results in suggestions that

live-in help or nursing home placement is needed.

Hearing over the telephone is difficult even for

those elderly people who have very mild hearing

loss and are able to hear well in person. This is

because telephone signals are transmitted in a

limited frequency range, and very low and high

frequency sounds that can be important for understanding speech are omitted in transmission.

Line noises and other sound distortions also interfere with the quality of sound transmission. In

the future, as the need grows to transmit more

conversations over a limited number of telephone

lines, this problem may become worse. Some methods for increasing line capacity involve removing

parts of the speech message that are considered

unimportant; 5 however, the standards for what

is unimportant are based on the hearing ability

of younger people with normal hearing. Research

is needed to document the effect of removing parts

of the speech message on the hearing ability of

elderly and other hearing impaired individuals.

This could be a first step toward public policy requiring transmission of telephone signals that can

be heard by hearing impaired people up to a certain level of hearing loss (11).

A variety of devices are available to help hearing impaired people use the telephone. The simplest of these, which is most effective for individuals with mild to moderate hearing loss, is a volume

control device that can be built into the telephone

handset or attached to the side of the telephone.

Portable telephone amplifiers are also available,

although many elderly individuals do not know

about them (see figure 11). Some research indicates that telephone amplifiers are more effective

for individuals with relatively constant hearing loss

across all frequencies and less effective for those

with marked loss at only the high frequencies (58).

‘These telephone engineering procedures, called “time processing, ” include ~’oice sltritching, time di~’ision multiph~x, and pulse rode

modulation ( 11).
37

Figure 11 .—Three Types of Telephone Amplification Devices

-..

SOURCE Courtesy of Radio Shack, A Dlvlslon of Tandy Corp

SOURCE VA Medical Center, Birmingham, Alabama

Before the breakup of AT&T, telephone handsets with amplifiers and other specialized equipment for hearing impaired people were available

through the telephone company and the cost of

these devices was regulated by State public utility

commissions. Following the breakup of AT&T, Federal legislation and FCC regulations allowed State

public utility commissions to choose whether to

regulate or deregulate this equipment (84). G Some

States no longer regulate the cost of these devices,

while others regulate all devices, or only new

orders. This has created confusion for hearing impaired customers because now prices of equipment vary from State to State, the availability of

6.AT&.’I’ has created a National Special ?ieeds Center in JNe\t Jer -

sej’ and nlan) tek; phone rustorners continue to rent or t]u}’ telc -

phone h:indsf~ts with amplifiers from ,ArI’&’I’.
38

equipment is uncertain, and it is often difficult to

find repair service. Legislation to require State regulation of these devices was introduced in Congress in 1985 (S. 402) (91) and hearings probably

will be scheduled in 1986.7

Another device to help hearing impaired people use the telephone is the telephone switch or

“T switch” on a hearing aid. The telephone switch

allows the hearing aid to pick up electronic leakage from compatible telephone receivers and bypass the hearing aid microphone. Unfortunately,

many hearing aids do not have telephone switches.8

In addition, anecdotal evidence indicates that some

people do not know whether their hearing aids

have telephone switches, or if they do, how to use

them (106). Furthermore, not all telephones are

compatible with these hearing aids. The Telecommunications for the Disabled Act of 1982, which

became law in 1983, requires that all telephones

installed in ‘(essential places” be compatible with

hearing aids by January 1, 1985. Included as essential are public pay telephones; telephones for

emergency use (e.g., on bridges, in tunnels, and

along highways); and telephones in hospitals, convalescent homes, homes for the aged, and other

public facilities (97). S.402, as proposed by Senator Pressler, would require that all new telephones

be compatible with hearing aids.

Other telecommunication devices are available

or being developed for people with severe hearing impairments. Some devices are used primarily by younger people with severe hearing impairments and may be inappropriate for many elderly

persons. Telecommunication devices for the deaf

(TDDs) were first developed in 1965. These devices

allow users to type a message that is converted

to tones and carried over a phone line, At the other

end of the line, another TDD converts the message back to typewritten copy. In the past 10 years,

small, portable TDDs have become available and

many deaf individuals have these devices at home,

Public agencies, such as fire departments, police

7A .A. Gilro-v, “Telecommunications Specialized Customer Prenl -

ises Equipment for the Disabled Federal Actions Affecting Its Pro-

~rision ,“ Congressional Research Service report, kliir. 22, 1985, pro-

\’ides more information on the current status Federal regulations

in this area,

Telephone switches work best in o~’er-the-ear and on-the-body

hearing aids. It is more difficult to incorporate a telephone switch

in an in-the+ar aid (97).

departments, and hospitals, are being equipped

with TDDs. Some communities have TDD switchboards to relay communication from people who

rely on these devices to people and institutions that

do not have the required equipment (10).9

other devices are in the development stage, including Teletex and Viewdata. These are information retrieval systems that transmit text and simple graphics to a television receiver. Viewdata has

a message service so subscribers can communicate with one another. Viewdata, if and when extensively accepted throughout the country, will

provide electronic mailbox capability to both deaf

and hearing people (35).

Picturephone and Vistaphone are devices designed to transmit a visual image of the speaker

over an ordinary telephone line, thus allowing

some hearing impaired individuals to communicate by speechreading or sign language. Commercial production of these devices was expected to

increase use and reduce cost, but neither has

caught on and there has been no support for production (35).

No data exist to show how many elderly people

use or could use these telecommunication devices.

Elderly individuals who have had hearing impairments since childhood or early adulthood can be

expected to continue using the devices they have

used throughout life. For those who become hearing impaired in old age, however, use of these devices requires both the hearing impaired person

and those who communicate with him to acquire

new skills. TDDs and Viewdata require users to

know how to type and have the necessary equipment. The hearing impaired person must be able

to see well enough to read typed messages. Picturephone and Vistaphone are only helpful to those

who communicate by speechreading or sign language. Since few elderly people use these methods of communication, the usefulness of these devices is limited for them.

Computerized speech recognition systems are

being developed that could greatly simplify telecommunications for hearing impaired people.

“Selected Telecommunications Devices for Hearing-Impaired Persons, ” OTA background paper, 1982, reviews the history of TDDs,

current problems in accessibility, and legislation affecting use ( 1 14)
39

These systems convert spoken words into printed

output that could be displayed on a screen attached

to the telephone. Since messages do not have to

be typed, this system could allow much faster communication between hearing impaired individuals

and between hearing and nonhearing persons.

The speech recognition systems available now

have major limitations. They recognize only a few

words and sometimes confuse words. Most are

speaker dependent, which means that the system

must be adapted to the idiosyncrasies of the speech

of a particular individual. Some very expensive systems (up to $35,000) offer vocabularies of 500

words, good background noise tolerance, and ability to respond to speech variations (57).

Most research on speech recognition systems

is not being conducted for the benefit of hearing

impaired people. It is being pursued primarily to

encourage the broader use of computers by all

people. However, the results of this work are likely

to benefit hearing impaired people. As research

continues and prices fall, these systems could provide an easier way for individuals without a hearing problem to communicate by telephone with

the hearing impaired.

Closed caption television is a technology that is

increasingly available to deaf and hard-of-hearing

people. Captions transmitted with the television

signal appear on the screen when decoded with

a special device. These captions can be difficult

for some elderly people to see if they also have

visual impairments, but they can make television

news and entertainment available to many hearing impaired elderly people. As of November 1985,

94 hours of closed caption programming were

available each week. ABC provides closed captions

for all its prime time programming, and NBC, CBS,

and PBS each provide some closed captioned programs (79). However, the cost of a decoder ($200

to $500) prevents some elderly people from using

closed caption television (10).

SIGNALING AND ALARM DEVICES

Signaling and alarm devices that convert sound

to visual or tactile signals are important for the

safety and independence of hearing impaired persons. Flashing lights or vibrating devices can substitute for the sounds of a fire alarm, smoke alarm,

telephone, doorbell, or alarm clock (see figure 12).

The Rehabilitation Comprehensive Services and

Developmental Disabilities Amendments of 1978

requires adaptation of warning systems in public

facilities, housing units, and health care facilities

serving older people. Federal regulations set forth

standards for audible and visual alarm systems in

these facilities (10).

Tactile Paging Devices use radio signals to generate vibrations in a portable receiver carried by

the hearing impaired individual. The person feels

the vibrations and can respond to the signal. The

devices can be used to contact the individual within

a one-quarter mile radius of the transmitter.

These devices can be used alone or combined

with a hearing aid or other assistive listening devices and telecommunication devices. A combination of devices can compensate effectively for most

Figure 12.—Sonic Alert Signaling System,

Including a Paging Device and Door Bell Signaler

SOURCE: VA Medical Center, Birmingham, Alabama

hearing impairment in elderly people. But these

devices cannot be useful to hearing impaired

elderly people unless they know such options exist. While information generally is available in the

deaf community, elderly people are seldom part

of this group. Since elderly people seldom receive

comprehensive aural rehabilitation services, they

do not learn about devices from hearing specialists
40

Public information about available devices and

treatment options almost always focuses on “new”

and dramatic approaches. For example, cochlear

implants are now receiving considerable coverage although very few patients have received them.

The emphasis on revolutionary breakthroughs in

medical and surgical treatment distracts attention

from the far less dramatic rehabilitative procedures and devices that could benefit the majority

of hearing impaired elderly people (10).

ASSISTIVE DEVICE

In the United States today, assistive devices for

hearing impaired people are developed by:

●

●

●

●

●

●

●

universities and colleges for the deaf;

universities and colleges with rehabilitation

training programs and/or speech and hearing clinics;

Rehabilitation Engineering Centers for the

Hearing Impaired, funded by the National Institute for Handicapped Research;

the Veterans Administration,10 Department

of Defense, and other agencies of the Federal

Government that offer rehabilitative services

and are also engaged in the development of

assistive devices;

laboratories of commercial firms;

independent inventors and entrepreneurs;

and

the Small Business Innovative Research Initiative of the National Institutes of Health.

With few exceptions, the major financial responsibility for research and development of hearing

aids and innovative devices for hearing impaired

people has been borne by commercial manufacturers. Although competition among manufacturers has brought some achievements, there have

also been problems. For example, miniaturization

of hearing aids has improved their marketability

but it also sometimes reduces performance (54,

‘The VA program of medical device development and testing is

the topic of a 1985 OTA report, Medicaf Devices and the Veterans

Administration. This report discusses VA policies for research and

device development for all kinds of medical conditions, including

hearing impairment.

Advertising by hearing aid manufacturers and

distributors has been an important source of public

information about hearing loss and hearing aids.

While it undoubtedly contributes to public awareness and greater acceptance of hearing aids, advertising is selective and does not give equal weight

to all treatment options (10). Chapter 4 discusses

some alternate methods for increasing people’s

awareness of the many devices available.

DEVELOPMENT

60). Furthermore, relatively little effort has been

made to develop highly specialized devices that

benefit only a small number of people because the

potential market is limited (10).

Problems in developing and disseminating all

kinds of assistive devices for handicapped people

are discussed in a 1982 OTA report, Technology

and Handicapped People. Problems that limit development and dissemination of devices for elderly

people are discussed in a 1985 OTA report, Technology and Aging in America. Many of the problems discussed in these reports affect the development of devices for hearing impaired elderly

people. For example, it is often difficult to identify

potential users, and small companies—frequently

the source of innovative products—lack financial

and staff resources to launch a marketing campaign to reach these people. Without an identifiable market, companies are reluctant to invest in

research, development, and manufacture of new

devices. Lack of third-party reimbursement for

devices and erratic funding guidelines by public

programs that pay for these devices also limit the

market.

In some industrial countries, such as Sweden,

the development of assistive devices is considered

a government responsibility. Public funding is provided not only to develop and manufacture devices,

but also for distribution and repair. In the United

States, where distribution of assistive devices has

been left primarily to the private sector, lack of

an identifiable market discourages development

of these devices (10).
41

ENVIRONMENTAL DESIGN

Building design characteristics affect the behavior of sound and the relative ease or difficulty

of hearing. For example, hard-surfaced walls and

floors reflect sound, creating reverberations that

interfere with hearing, while sound absorbent

wall-covering materials decrease reverberations

(66). Attention to the acoustic characteristics of

buildings could decrease the impact of hearing impairment for people of all ages.

Background noise is a major impediment for

hearing impaired individuals, regardless of

whether they use hearing aids. Proper planning

and building design can help limit unnecessary

background noise. For example, in a nursing home

or congregate housing facility the dining room

should not be located between a noisy kitchen and

a noisy laundry room or mealtime conversation

will be difficult for hearing impaired residents.

Daily events should be scheduled to account for

the problem of background noise. Thus, vacuuming and other noisy activities should not be scheduled when residents are involved in a discussion

group.

Room arrangement and lighting can also affect

hearing. In a large room where several conversations may occur at once, space dividers that absorb sound can create a sense of privacy and decrease ambient noise levels that interfere with

hearing (52). Similarly, good lighting and an unobstructed view of a speaker can facilitate use of

speechreading techniques (73). While much is

known about design characteristics that affect

hearing, this knowledge has not been widely applied. Relatively inexpensive measures that reduce

reverberations and background noise in buildings

used by elderly people could benefit many people

with hearing loss.

AURAL REHABILITATION

Few hearing impaired elderly people receive

aural rehabilitation services. Yet these services can

bean important part of treatment. Some aural rehabilitation services, such as auditory training and

speechreading, are primarily provided by audiologists, if at all. other services, such as hearing aid

orientation, can be provided by both audiologists

and hearing aid dealers.

S@ language is taught to many younger persons with severe hearing impairments, but it is

not widely used by the elderly for several reasons.

First, it is difficult for elderly people who develop

hearing loss late in life to learn a completely new

language. In contrast, many younger people with

severe hearing impairments have used sign language since childhood,11 Young people with severe

hearing impairments often attend school and interact with other severely hearing impaired peo1 IHearing specialists who treat young persons with severe hearing impairment disagree about whether sign language or an alternative procedure for understanding normal speech, such as speechread -

ing and Cued Speech, is the best method of communication (37). This

controversy applies primarily to young people and is not discussed

in this report,

ple who use sign language. Thus, they develop a

network of friends and associates who communicate by sign language. In contrast, the friends and

associates of elderly people who become hearing

impaired late in life seldom know sign language.

Finally, hearing impaired elderly people usually

retain some residual hearing and other methods

to maximize residual hearing can be more effective and more acceptable than sign language (136).

Hearing Aid Orientation

Hearing aid orientation can help people overcome problems that interfere with the successful

use of the aid. The user needs instruction in the

care and maintenance of the aid and earmold, an

opportunity to practice inserting the earmold and

batteries and changing volume controls, and advice and encouragement about gradually increasing the use of the hearing aid in a variety of listening situations (10).

Unrealistic expectations about the ability of a

hearing aid to restore normal hearing can interfere with adjustment to the aid for some people.
42

Hearing aid orientation should begin before the

aid is purchased and provide information about

problems that can be expected and the need for

training. It should also continue after the aid is

purchased. All users should return to the hearing

aid dealer or audiologist for a followup check on

the functioning of the aid and the individual’s adjustment to it.12

Auditory Training

Intonational patterns created by variation in the

pitch, intensity, and duration of sound give clues

about the content and meaning of speech. Auditory training teaches the individual to use these

clues to supplement his residual hearing. The person learns to recognize and differentiate sounds

by practicing with live or recorded sounds (136).

Auditory training now is used almost exclusively

with hearing impaired children. But the elderly,

who usually have some residual hearing, can also

benefit and some auditory training programs include elderly people.

Speechreading

Speechreading is the use of visual cues to facilitate the understanding of speech. The hearing impaired person is taught to recognize lip, facial,

throat, and body positions and movements involved in speech production (26, 96). Few elderly

individuals are taught speechreading techniques,

although these techniques can be particularly effective for people who have only partial hearing

loss, including those who use a hearing aid.

Negative attitudes about the rehabilitation potential of elderly people among elderly individuals

themselves, their families, and health and social

service professionals contribute to the failure to

offer training in speechreading. It is often assumed

that most elderly people are not willing or able

to learn speechreading. Clearly this assumption

should not go unchallenged when training has not

been offered to many of those who might benefit

from it.

Cued Speech is a system of communication that

supplements speechreading and is being used with

12Some dealers and audiologists include the cost of a followup check

in their initial price, while others charge extra for it (104).

elderly people in a few places in the United States.

Developed by R. Orin Cornett, Cued Speech involves the use of eight hand shapes that clarify

consonant sounds and four hand positions that

clarify vowel sounds. For example, the words “mit,”

“bit)” and “pit” are virtually indistinguishable with

only speechreading techniques. Cued Speech uses

a hand signal to designate which consonant is being spoken (136). Cued Speech differs from sign

language in that it clarifies spoken language rather

than replacing it with manual communication (36).

To use Cued Speech, the hearing impaired individual and others who want to communicate with

him must learn the hand signals and positions. This

takes up to 20 hours for most adults, plus extensive practice. Learning requires motivation and

Cued Speech trainers have noted that some family members are reluctant to learn this new communication technique, While very few elderly people have been taught Cued Speech thus far, those

who do master it report great satisfaction with

their renewed ability to communicate clearly using

normal spoken language (136).

Microelectronic aids to speech comprehension

such as visual and tactile devices may soon be available. For example, the Upton eyeglass speech

reader projects voice-spectrum information onto

the wearer’s eyeglasses to augment speechreading. Although the display of speech-sound categories are far from error free, some information of

modest consistency is better than no information

at all. Some design improvements are necessary

before the Upton system is ready to be field tested

(88).

An automatic cuer has been developed by R. Orin

Cornett and Robert Beadles as an aid to Cued

Speech. This device, the “Autocuer,” uses a microprocessor to classify speech into cue groups and

activate 56 tiny light-emitting diodes on the user’s

eyeglasses (39) (see figure 13). A l-year trial of the

Autocuer using children and adults was scheduled

to begin in 1985 (99).

Vibrating devices that give cues to facilitate

speechreading are also being developed. One example is the “Teletactor belt, ” which is worn

around the abdomen and produces vibrations that

are felt as a tickling sensation by the user. Different sounds cause distinctive patterns of vibrations

that the individual must learn to recognize (15).
43

Figure 13.—Lip Reading Glasses

As Illustrated in these photographs, different sounds are difficult to distinguish using only visual cues. The “Autocuer” is designed to help

speech readers distinguish sounds that appear similar. A microphone on the glasses frame picks up the voice as much as 12 feet away and

transmits it to a microprocessor that analyzes the sound and relays signals back to light-emitting diodes on the glasses lens The diodes produce

an Image that represents the sound. The series above shows the images that represent the sentence He can go.

SOURCE Research Triangle Institute, RTI Park, North Carolina.

The inventor of this device, Frank Saunders, has

received a Small Business Innovative Research Initiative award from the National Institutes of Health

to develop it; it is being tested for efficacy in middle aged and elderly people (59).

Some hearing researchers believe that tactile

stimulators will be most useful for people with

some residual hearing who use the sensations to

enhance speechreading (60). Others believe that

people who have lost their hearing after learning

to speak will probably never be able to learn to

use the vibratory cues effectively and that the devices will be most useful to the prelingually deaf

(25).

These electronic speechreading aids are in the

development stage. Furthermore, each will require

users to undergo substantial training. when they

become available, their advantage over current

speechreading techniques will be that they provide cues to differentiate sounds that are visually

identical. Their advantage over Cued Speech will

be that the hearing impaired individual will be able

to communicate with anyone in any setting, with -

out depending on the speaker’s ability to cue.

Counseling

Counseling can help hearing impaired people

overcome negative attitudes that interfere with
44

rehabilitation and develop strategies to manage

listening situations in ways that lessen their disability (26). Problems that interfere with the rehabilitation of hearing impaired elderly people include: 1) physical conditions such as poor vision,

arthritis, limited manual dexterity, and limited mobility; 2) lack of motivation and a sense of hopelessness; and 3) cost factors. Counseling can be effective in addressing each of these problems.

Physical impairments that are common among

elderly people can interfere with aural rehabilitation, For example, the elderly person with reduced

visual acuity may be unable to see well enough

to use speechreading techniques. Individuals with

arthritis may be unable to insert a hearing aid earmold properly due to reduced mobility of the shoulder or manual dexterity (10). Similarly, those with

diabetes or other conditions that decrease sensitivity in their fingers may have trouble inserting

the earmold and adjusting the aid. The total physical condition of the individual should be evaluated before an appropriate treatment is recommended. Counseling can help develop methods for

overcoming the obstacles that hinder treatment.

Lack of motivation and a related sense of hopelessness also interfere with aural rehabilitation.

Elderly people are particularly likely to believe that

nothing can be done to correct their hearing problems. This belief is exacerbated by society’s negative attitudes about the rehabilitation potential of

elderly people, Some elderly individuals have been

known to suggest that services be directed toward

a younger person who could derive greater benefit. Denial of hearing impairment also limits motivation (l).

A first step in dealing with lack of motivation

is to understand the meaning of the hearing loss

to the individual, the situations in which he/she

has difficulty hearing, and how important these

situations are to him/her (96). Second, the rehabilitation process should be adapted to the needs

and abilities of the individual. Healthy, active

elderly people may be capable of obtaining services provided in the community. However, others

with financial or health-related problems are often

unable or unwilling to seek out such services and

an outreach program may be needed (26). Diagnostic and rehabilitative services could be provided

in the person’s home, a senior center, or a nursing home. Hearing specialists also could provide

in-service education to the individual’s caregivers

(family, day program counselors, nursing home

staff, etc.). Including “significant others” in the rehabilitative process enhances the hearing impaired

individual’s chances of success,

Obstacles to the increased use of aural rehabilitation services, hearing aids, assistive listening devices, and telecommunication, signaling and alarm

devices include problems in the service delivery

system (ch. 4) and lack of funding (ch. 5). Whether

.

an elderly person elects to seek aural rehabilitation or fitting for amplification devices often depends on financial status and the relative value

he places on communication compared to other

products and services he needs.
Chapter 4

The Service Delivery System
Chapter 4

The Service Delivery System

The existing service delivery system1 does not

provide access to optimal treatment, devices, and

services for many hearing impaired elderly people. Listed below are some of the most common

problems that need to be addressed:

●

●

●

●

●

●

Some hearing impaired elderly people are

never evaluated by a hearing specialist. Data

from the Health and Nutrition Examination

Survey, collected from 1971 to 1975, showed

that 61 percent of elderly people with significant hearing impairments had never had any

audiometric testing. Low-income elderly people were particularly unlikely to have been

tested (50).

A 1984 survey showed considerable improvement in this problem over the past decade.

However, of the 16 million people with hearing impairments in the United States, about

3.7 million (23 percent) have not seen a hearing specialist even though they are aware of

their hearing impairment. Another 2 million

(12.5 percent) are unaware of or deny that

they have a hearing impairment (49). No age

breakdown is available for these data.

At least 75 percent of all hearing impaired people do not own a hearing aid, and some people buy hearing aids that are not well matched

to their needs.

Some elderly people who have had a hearing

aid and/or a hearing evaluation in the past refuse further evaluation and treatment because

they were disappointed with the previous experience (73).

Many elderly people are not aware of available assistive listening devices, telecommunication devices, and signaling and alarm

systems.

Few elderly people receive aural rehabilitation services despite the potential benefit of

these services.

I As used in this report, the term “ser~’ice deli~erj’ sj’stem ” refers

to ser~ice prmiders, referral patterns, and the settings in ~thich

hearing sertices are delii’ered.

The service delivery system involves three types

of hearing specialists-physicians, audiologists, and

hearing aid dealers-each with a substantially

different orientation to hearing impairment. Although there are always exceptions to any generalization, it can be said that physicians generally

approach hearing impairment from a medical point

of view and their primary objective is curing or

ameliorating disease in their patients. Audiologists

generally approach hearing impairment from a

service point of view and their primary objective

is assessing the individual’s communication deficits and recommending or providing services and

devices to improve communication ability. Hearing aid dealers generally begin from a business

point of view and their primary objective is providing an effective and satisfactory product for

their customers. An increasing number of audiologists are now selling hearing aids, and these “dispensing audiologists ’’can be expected to share attitudes and objectives with both hearing aid dealers

and audiologists.

These differences in points of view and objectives among the three types of hearing specialists

can lead to disagreement. What is the best form

of treatment for hearing impaired people? Which

hearing specialist should a person see first? Should

one type of specialist coordinate or supervise hearing services provided by other specialists? Changes

in patterns of patient referral and treatment have

both theoretical significance and financial implications for each type of hearing specialist. As a

result, rivalry among them has been intense at

times. This rivalry has been and will continue to

be exacerbated whenever proposed Federal legislation and regulations appear to designate one

type of specialist as the primary provider of hearing services.

The rivalry among hearing specialists contributes to fragmentation of delivery system and results in a lack of continuity of care. A client who

is unaware of the differences between the three

types of hearing specialists must often seek out

services on his own. Frequently, each type of hearing specialist works in a different setting and clients

47
48

must make numerous trips to obtain all the necessary services. This is particularly difficult for many

elderly people.

These problems have been solved in some hospital- and university-based speech and hearing

clinics that combine medical and audiological services and the capacity to dispense hearing aids and

other devices. The Veterans Administration (VA)

also has a comprehensive delivery system. In addisetting up private practice groups that provide a

full range of hearing services in one setting. Finally, the professional societies that represent each

type of hearing specialist have sponsored programs

at the national, State, and local level to increase

communication and cooperation among the providers of hearing services. Continued efforts to

coordinate the delivery of hearing services would

benefit hearing impaired people of all ages.

tion, a growing number of hearing specialists are

SERVICE PROVIDERS AND REFERRAL PATTERNS

Physicians, audiologists, and hearing aid dealers

are the principal providers of hearing services.

Speech therapists, social workers, psychologists,

nurses, and other health care and social service

providers are sometimes involved in referring the

elderly for hearing evaluation and treatment.

Physicians

Many elderly persons enter the service delivery

system via a primary care physician, such as a general practitioner, family practitioner, or internist.2

Some individuals are referred by the primary care

physician to another physician who specializes in

diseases of the ear–usually an otolaryngologist

or otologist.

Otolaryngology is a medical/surgical specialty,

requiring 5 years of specialty training in the diagnosis and medical/surgical treatment of conditions

affecting the ear, nose, throat, head and neck, and

facial, cosmetic, and reconstructive plastic surgery.

Otolaryngologists also receive some training in

hearing measurement and aural rehabilitation. An

otologist is a board certified otolaryngologist who

chooses to limit his practice to medical/ surgical

treatment of diseases of the ear.

Some hearing specialists believe that the first step

in the delivery of hearing services should be an

evaluation by a physician, specifically an otolaryn -

‘Although no data are available, anecdotal evidence indicates that

only a small proportion of primary care physicians include a hearing test as part of a regular physical examination (106). Thus, it is

likely that most of the elderly people who discuss their hearing with

a primary care physician initiate the discussion themselves, or it

may be brought up by a family member.

gologist or otologist, and that the physician should

supervise treatment. Physician involvement is seen

as essential because the physician is the only hearing specialist who can diagnose diseases that cause

hearing loss (62, 42). Even though few of the hearing impairments common among elderly people

are medically treatable, prompt identification of

those few is clearly important. In addition, hearing impairment is sometimes the earliest symptom

of serious pathology, such as an acoustic tumor,

that requires immediate medical attention (10).

Physicians, including otolaryngologists, otologists, general practitioners, internists, and others,

often play a key role in determining which hearing services are provided for elderly people. Private insurance and government funding programs

often require that a physician approve hearing

services as a condition of payment. Yet physicians

who do not specialize in diseases of the ear generally receive very little training about auditory problems and almost no training in the management

of auditory impairments that are not medically

treatable. As a result. many of these doctors lack

the expertise necessary to identify the hearing services needed by most elderly people (10).

Some hearing specialists express similar reservations about the role of otolaryngologists and otologists in determining what hearing services are

provided for elderly people. These people argue

that although otolaryngologists and orologists are

the acknowledged experts in diagnosis of ear diseases, they are primarily trained in medical and

surgical treatment and therefore are not wellqualified to advise hearing impaired adults about
49

hearing aids and alternative approaches to compensate for hearing loss (33). It is said that they

are particularly unlikely to know about assistive

devices, telecommunication devices, and signaling and alarm systems (108).

In contrast, others argue that otolaryngologists

receive substantial training in amplification and

management of hearing impairment. The American Academy of Otolaryngology-Head and Neck

Surgery also provides postgraduate education programs and self-instructional courses for physicians

on the rehabilitation of hearing impaired people

(43). It is interesting to note that a Federal Trade

Commission survey of people who purchased hearing aids from 1983 to 1985 found that 6 percent

purchased their aids from a physician (75). Some

observers believe that the number of physicians

who dispense hearing aids is increasing and that

this trend will continue (106).

Audiologists

Audiologists are nonmedical hearing specialists

trained in the identification, measurement, and

rehabilitation of hearing impairment. Audiologists

take courses in speech, hearing, and language

mechanisms, culminating with a master’s or doctoral degree in audiology. Many also hold a Certificate of Clinical Competence from the American

Speech-Language-Hearing Association (ASHA). The

practice of audiology is currently licensed in 35

States, and State licensing requirements are generally as rigorous as those for the Certificate of

Clinical Competence (10).

Evaluation by an audiologist includes an assessment of hearing threshold sensitivity, speech discrimination ability, and residual peripheral and

central auditory function. While audiological testing often reveals information that is useful to physicians in establishing a medical diagnosis, the primary purpose of the audiologic assessment is to

determine the impact of impaired hearing on a person total communication ability. The assessment

usually includes a comprehensive history covering:

●

●

●

the onset and development of the hearing impairment;

its relationship to physical, social, and emotional well-being;

previous treatment;

● the relationship of the hearing impairment to

other sensory or perceptual dysfunctions; and

● the effect of the hearing impairment on the

person’s speech (10).

Some hearing specialists argue that a comprehensive audiologic assessment is needed to determine the potential benefit of a hearing aid, the type

of hearing aid that is needed, whether the fitting

should be monaural or binaural, and which ear

should be fitted (10). Others argue that parts of

the audiologic assessment are not relevant to determining the potential benefit or selection of a

hearing aid and that these tests can be unnecessary, time-consuming, and expensive for some

hearing impaired people (62, 90, 133).

Until recently, audiologists did not sell hearing

aids. There was a commitment to establish audiology as a profession that would provide hearing

services, not products, and as a scientific discipline

that would not be involved in commercial activities (41). The practice of audiology has changed

considerably in recent years, however, and 35 to

40 percent of audiologists now sell hearing aids

(18). 3 Some analysts believe that the traditional

commitment of audiologists to remain uninvolved

in commercial aspects of hearing aid sales has resulted in skeptical or negative attitudes about hearing aids among some audiologists and that they

may, therefore, fail to recommend a hearing aid

even when the aid might benefit the patient (41).

Some audiologists sell assistive listening devices

and telecommunication, signaling, and alarm devices. Survey data indicate that these devices account for about 2 percent of the gross profits of

dispensing audiologists (23). other audiologists provide clients with information about these devices,

but do not sell them. Still others neither sell nor

provide information about them, and some are not

knowledgeable about them. Few professional training programs for audiologists include courses on

3Audiologists who dispense hearing aids are suh ject to an}’ rele -

frant State regulations. In some States, lirensed audiologists are re -

quired to take a hearing aid dealer’s exam to dispense hearing aids,

while in other States they are exempt from this requirement, Some

States require that audiologists rornplete an apprenticeship under

the supervision of a licensed hearing aid dealer, while others do

not. 1 hese \’ariat ions in regulations can cause Confusion and tension bettteen audiologists and hearing a ici dealers tind impede

reciprocit~, agreements hetltfwn States ( 10).
50

assistive devices and the certification program for

audiologists administered by ASHA does not require comprehensive training about these devices

(33). Training programs such as those developed

by Vaughn and Lightfoot of the VA Medical Center in Birmingham, Alabama, described later in this

chapter, are designed to inform audiologists and

other hearing specialists about these devices. In

addition, ASHA has sponsored training workshops

for audiologists on assistive listening devices.

Most audiology training programs have not emphasized the special problems of hearing impairment in elderly people. However, ASHA has recently developed a model curriculum for this

purpose.

Hearing Aid Dealers

Hearing aid dealers sell hearing aids and hearing aid accessories, such as batteries, tubing, and

earmolds. Hearing aid dealers do not have lengthy

formal education in hearing impairment like otolaryngologists, orologists, and audiologists. Yet

many have considerable experience and expertise

in the remediation of hearing loss. They are generally well qualified to select and fit hearing aids,

make earmold impressions, and instruct people

in the use and care of hearing aids. Many dealers

also repair hearing aids. Both hearing aid dealers

and audiologists provide hearing aid orientation.

All three types of hearing specialists provide counseling for hearing impaired people, although the

focus and content of counseling may differ substantially depending on who provides it.

Hearing aid dealers have been harshly criticized

in the past. Other hearing specialists and some consumer advocates have charged that hearing aid

dealers focus too much on sales, that their sales

tactics are too aggressive, and that they are not

adequately trained to evaluate hearing impairment.

The National Hearing Aid Society (NHAS) offers

a 20-week home-study course for hearing aid

dealers, but the course has been criticized as inadequate, incorrect, and outdated (10, 126).

Despite these criticisms, a recent nationwide survey showed that 72 percent of the people who

bought hearing aids from hearing aid dealers were

satisfied and would return to the same dealer. Only

16 percent would not return to the same dealer,

and 12 percent were undecided. Consumer satisfaction with hearing aid dealers was lower than

satisfaction with dispensing physicians and audiologists, however; 78 percent of those who bought

a hearing aid from a physician and 81 percent of

those who bought an aid from an audiologist said

they would return to the same seller (75). While

the validity of the sampling procedure for this survey has been questioned (107), and consumer satisfaction was greater among those who purchased

aids from physicians and audiologists, these data

do indicate considerable satisfaction with the performance of hearing aid dealers.

Hearing aid dealers are the only hearing specialists available in some geographic areas, and as

such they provide hearing services to people who

would otherwise have no access to services. In addition, it is likely that over the years hearing aid

dealers as a group have had more experience with

elderly hearing impaired people than other hearing specialists. Their understanding of the practical realities of providing amplification for elderly

customers—problems of acceptance and adjustment and the kinds of listening situations that are

particularly difficult for elderly people even with

a hearing aid-could be a valuable source of information about the physical and psychological

aspects of hearing loss in elderly people.

Hearing aid dealers are licensed in 45 States. A

substantial number of dealers are also accredited

by NHAS and/or the National Board for Certification in Hearing Instrument Sciences. NHAS has conferred the title “certified hearing aid audiologist”

on dealers who pass the NHAS home-study course.

Audiologists object to the use of this title by hearing aid dealers, saying that it can be confusing to

consumers because it implies that the dealer possesses expertise which he does not have (10). ASHA

has recently won a U.S. Patent Office ruling that

only audiologists can use the word “audiologist”

in their title. NHAS has appealed this ruling (133).

Most hearing aid dealers do not sell assistive

listening devices or telecommunication, signaling,

and alarm devices. These devices account for less

than 1 percent of the gross sales of hearing aid

dealers (23). Some hearing aid dealers do not sell

these devices because they believe that assistive
51

listening devices are a low-cost alternative to hearing aids and could therefore reduce hearing aid

sales. The profit to the dealer on assistive devices

is generally less than on hearing aids. Some dealers

also complain that they do not have enough space

to display the devices. Others may not know about

available devices (33, 68, 74). yet interest in these

devices is increasing and some observers believe

that more hearing aid dealers and dispensing audiologists will begin to offer them in the near future (29, 74).

Referral Patterns

Elderly people with hearing impairments can enter the service delivery system through a primary

care physician, a physician specialist, an audiologist, or a hearing aid dealer. Each hearing specialist can provide services himself and/or refer the

person to one or more other specialists. In one pattern of service delivery, the point of entry is a primary care physician, who may treat the individual, refer him directly to an audiologist or hearing

aid dealer, or refer him to an otolaryngologist or

otologist. The otolaryngologist may conduct hearing tests in his office or refer the patient to an audiologist for testing. When testing indicates sensorineural or other irreversible hearing loss, the

otolaryngologist may refer the patient directly to

a hearing aid dealer or he may refer the person

to an audiologist for assessment of the potential

benefit of hearing aid use, selection of the appro -

priate instrument, and other rehabilitative measures. The audiologist may supply the hearing aid

or refer the patient to a hearing aid dealer (10).

A second pattern of service delivery involves entry through the audiologist or audiology clinic. If

the initial audiologic evaluation suggests the possibility of medically significant pathology, the individual is referred to a physician, usually an otolaryngologist. When no such pathology is apparent,

the audiologist proceeds with hearing aid evaluation and aural rehabilitation services. If a hearing

aid is recommended, it may be dispensed by the

audiologist or the individual may be referred to

a hearing aid dealer (10).

In a third pattern of service delivery, the hearing aid dealer is the point of entry, with contact

initiated by the consumer or as a result of solicitation by the dealer. The dealer may refer the consumer to a physician or an audiologist for medical

or audiologic evaluation, or he may dispense the

hearing aid on the basis of his own evaluation (10).

Federal Food and Drug Administration (FDA) regulations require that hearing aid purchasers must

present a written statement from a licensed physician to the dealer or dispenser, dated within the

previous 6 months, certifying that their hearing

loss has been evaluated by the physician and that

the individual is a candidate for a hearing aid. However, people over 18 years of age can sign a form

waiving the requirement for a physician’s evaluation (10). No information is available about how

many hearing aids are sold on the basis of these

waivers. However, only 42 percent of those who

bought hearing aids from 1983 to 1985 recalled

being told about the requirement of a physician ‘S

evaluation or a signed waiver, 46 percent said they

had not been told about the requirement, and 12

percent could not remember (75).

Many physicians and audiologists are concerned

that people who see a hearing aid dealer first frequently are not referred to a physician for medical evaluation or to an audiologist for comprehensive audiologic evaluation. Although data on

referral patterns are not conclusive, a nationwide

survey of people who purchased hearing aids from

1983 to 1985 indicates that 64 percent of respondents saw a physician about their hearing problems

before purchasing a hearing aid. Of these individuals, 92 percent saw an ear specialist and 15 percent saw a general practitioner or internist. Clearly,

some individuals saw both (75).

Survey data also show that about 45 percent of

respondents received information about hearing

aids from an audiologist prior to purchasing an

aid and 53 percent said that an audiologist recommended the performance characteristics for their

aid (75). Thus at least half of those who purchased

a hearing aid had seen an audiologist before buying the aid.

Anecdotal evidence suggests that some people

who are referred by a hearing aid dealer to a physician or audiologist for evaluation prior to purchasing a hearing aid are not referred back to the

dealer to buy the aid (133). In some cases, the physician or audiologist may recommend against pur -
52

chasing an aid, while in other cases the person may

purchase the aid from the audiologist or a different dealer recommended by the physician or audiologist. Obviously, alleged instances of the latter

type are troublesome to hearing aid dealers.

Also troublesome to dealers is the finding that

physicians and audiologists often recommend

against hearing aids for people who, in the opinion of the dealer, would benefit from using an aid.

One national survey showed that among hearing

impaired people who do not own hearing aids, 63

percent have discussed their hearing problems

with a hearing specialist. Of those who saw an

otolaryngologist or otologist, 34 percent received

a recommendation against buying a hearing aid.

Of those who saw an audiologist, 27 percent received a recommendation against buying an aid

(49). While no information is available about

whether hearing aid dealers would recommend

hearing aids for all of these people, it is clear that

there is disagreement among hearing specialists

about who can benefit from a hearing aid.

This information about hearing specialists, referral patterns, and recommendations about hearing aid use raises many questions about the most

appropriate hearing services for hearing impaired

elderly people. For example:

●

●

●

●

●

Is physician evaluation essential for all elderly

hearing impaired people?

Should a physician, or a physician who specializes in ear diseases, supervise all hearing

services?

Isa comprehensive audiologic evaluation necessary for all elderly hearing impaired people?

Which hearing tests are necessary to determine the potential benefit of a hearing aid

and/or to select the appropriate aid?

Are there categories of individuals with partial hearing loss who cannot benefit fro-m a

hearing aid? If so, can these categories be

agreed on by the three types of hearing specialists?

These questions relate both to the quality of hearing services and to their cost, and hearing specialists disagree strongly about the relative merits

of different patterns of service delivery.

This OTA report reaches no conclusions about

these important questions or the relative advantages of different patterns of service delivery. The

two nationwide surveys of the service delivery system that have been cited throughout this report

(49, 75) provide valuable information about the

existing service delivery system. Further research

is needed to determine the costs and benefits of

alternate patterns of service delivery. Such research would require a prior determination of

which hearing services are essential and/or desirable for elderly people—a determination that can

best be made by drawing on the expertise and experience of all three types of service providers.

It is possible that the Federal Government could

initiate or support a joint effort of this kind.

The Role of Other Health Care and

Social Service Providers

Speech therapists, social workers, psychologists,

nurses, and other health care and social service

professionals also provide advice, referrals, and

emotional support to hearing impaired elderly people. Unfortunately, many of these professionals

know very little about hearing impairment or available treatments, devices, and hearing services. All

health care and social services professionals should

be educated about hearing impairment and appropriate procedures for referring people to hearing

specialists (10). Training materials are also needed

for health care and social service providers who

have completed their professional education.

ASHA received a grant from the Administration

on Aging to develop training materials for hearing specialists and other health and social service

providers who work with elderly people. One example of such materials is the recent ASHA and

the National Information Center on Deafness pub1ication Hearing Loss: lnformation for Professionals

in the Aging Network (137).

The Suzanne Pathy Speak-Up Institute, based

in New York City, has developed a program to train

hospital personnel to recognize and respond effectively to hearing impaired patients. Hospitalization is an anxiety-producing experience for most

people. For hearing impaired elderly people, hospitalization can be especially frightening because

they are often unable to hear instructions and explanations given by nurses, physicians, and other

hospital personnel, The National Center for Law
53

Figure 14.— Materials Supplied to Participating

Hospitals by the Suzanne Pathy Speak.Up Institute

SPEAK UP!

RULES TO REMEMBER WHEN SPEAKING TO SOMEONE WITH A

HEARING LOSS:

● DO NOT SHOUT.

● SPEAK CLEARLY AND SLOWLY.

● REPHRASE A MISUNDERSTOOD SENTENCE.

● MOVE AWAY FROM BACKGROUND NOISE. a ● STAND N CLEAR LIGHT FACING THE PERSON YM~L F HE

WITH WHOM YOU ARE SPEAKING. SPEAK. UP INSTITUTE

● DO NOT OBSCURE YOUR MOUTH WITH A CIGARETTE OR HANDS

AND DO NOT CHEW FOOD WHILE SPEAKING.

● ASK THE PERSON WHAT YOU MIGHT DO TO MAKE

CONVERSATION EASIER.

and the Deaf points out that when patients cannot hear explanations of their condition and proposed treatment, their “informed consent” could

be considered legally invalid. In addition, there is

a risk of wrong diagnosis for patients who cannot

completely understand questions about their

symptoms and consequently provide inaccurate

information to the physician (80).

The Suzanne athy Speak-up program provides

stickers to mark patient charts and instruction

cards to remind staff how to communicate with

hearing-impaired patients (see figure 14). As of July

1984 the program was in effect in more than 50

hospitals across the country (110) and is being extended to home health care agencies (85).

To increase awareness of hearing impairment, the Suzanne athy

Speak-Up Institute has developed this large sign to place above the

bed of the hearing impaired patient. Smaller gummed stickers are also

available to mark the medicai chart of each hearing impaired patient.

They also supply a gummed card for the medical chart of each patient to remind hospital staff of rules for communicating with the hearing impaired,

SOURCE: Suzanne Pathy Speak-Up Institute
54

SETTINGS FOR SERVICE DELIVERY

Most hearing services for elderly people are provided in the offices of physicians, audiologists, and

hearing aid dealers. To a lesser extent, hearing services are also provided in health care and educational settings and in multi-service community

agencies. Although certain services, such as medical and surgical treatment, can only be provided

in health care settings, others such as aural rehabilitation can be provided in a variety of settings.

In some instances, the character of apparently similar services may differ when they are delivered

in different settings. In other instances they may

be virtually identical. Reimbursement for services,

however, depends heavily on the setting where

they are provided (10).

Health Care Settings

Except for surgery, few hearing services are delivered in hospitals on an inpatient basis. This may

become even more rare because of restrictions

on admission and length of stay resulting from the

Medicare prospective payment system. Diagnostic services are sometimes provided in hospitals,

but aural rehabilitation services are seldom available (10).

Most hearing services provided by health care

institutions are delivered on an outpatient basis,

in either hospital-based or independent speech and

hearing clinics, Diagnostic and rehabilitative services are usually provided, but the emphasis is on

short -term care. Because of the relatively high overhead costs in most medically based outpatient facilities, long-term rehabilitative services in these

settings are often prohibitively expensive. Occasionally, hearing services for older people are provided by local health departments and even mobile medical clinics.

Extended care facilities, such as nursing homes,

would seem to be an optimal setting for the delivery of hearing services. Speech pathology services often are required as a condition of licensure

for extended care facilities and speech pathologists sometimes refer elderly residents for hearing evaluations. However, comprehensive hearing services are seldom available in these facilities

and it is often difficult for nursing home residents

to go out to the offices of hearing specialists because of their other physical impairments. Some

hearing aid dealers do visit nursing homes to evaluate patients and fit hearing aids, but few otolaryngologists and audiologists are available to treat residents in nursing homes.

Home health programs also offer an optimal setting to deliver hearing services, but unfortunately

these services are rarely provided. In a study of

206 home health agencies, only 5 percent provided

hearing services (72). Adult day care centers that

serve people who require long-term care but can

be maintained at home at night and on weekends

are another possible setting for the delivery of hearing services to some older people (10). It is not

known how many adult day care centers now provide hearing services.

Educational Settings

Hearing services are provided by some adult education agencies, community colleges, and university speech and hearing clinics. Adult education

agencies first offered lipreading instruction for

hearing impaired people during the 1920s and

1930s. Some of these programs have been expanded and now offer a comprehensive range of

aural rehabilitation services (10).

During the past decade, several States have encouraged community colleges to initiate programs

for disabled students. While some of these programs offer primarily vocation-oriented instruction to students, others offer comprehensive hearing services to adults of all ages (10).

University speech and hearing clinics are another

source of hearing services and in some communities they are the major provider of services. These

clinics are usually affiliated with the speech and

hearing or audiology department of a university.

This makes low-cost hearing services available

since virtually all services are provided by students

under careful supervision. However, this use of

students gives an unrealistic impression about the

true cost of hearing services (10). University speech

and hearing clinics often provide a wider range

of hearing services than other settings (115), in-
55

eluding comprehensive evaluation, aural rehabilitation, and fitting for hearing aids. Some also supply assistive listening devices (140).

Community Agencies

Many communities offer hearing services in

multi -service agencies. For example, senior centers

generally provide recreation, education, counseling, and other social services for elderly people;

some also offer hearing screening and other hearing services.4 Some communities also have speech

and hearing centers that offer a wide array of services including hearing aid dispensing. They may

also sponsor satellite programs in other community agencies where older people are likely to be

served (10).

4A recent studv of hearing services in senior centm’s, S[ud} of

Programs and Sertzices for the Hearing Impaired Eki@Lr in S&ior

Centers and C/ubs in the United States, will be puhlished I)j (;ai -

laudet Research Institute in 1986 [100).

ALTERNATE APPROACHES TO SERVICE DELIVERY

Alternate approaches exist that can help improve

the delivery of hearing services. These include programs of the Veterans Administration, the elderhostel program of Gallaudet College, and assistive

device centers. Self-help groups for hearing impaired people are also effective in educating people

about hearing impairment, appropriate treatment,

and methods for dealing with the fragmented delivery system. Two projects to provide hearing

services for nursing home residents also have been

developed and are described below,

Veterans Administration Hearing

Services

The VA program of hearing services is one model

of comprehensive service delivery. The VA program is an outgrowth of military aural rehabilitation centers established during World War II. At

VA medical centers across the country, hearing

services include: 1) evaluation by an audiologist;

2) evaluation by an otologist or otolaryngologist;

3) hearing aid dispensing; and 4) rehabilitation services such as speechreading, auditory training, and

speech training to correct speech or voice problems associated with a hearing impairment (83).

Veterans with service-connected hearing impairments are eligible to receive all hearing services

at no cost. Veterans who do not have serviceconnected hearing impairments but are over 65

or cannot afford hearing services are eligible for

a free hearing test. Certain categories of veterans

are also eligible for free hearing aids. These include veterans with service-connected hearing impairments, those who have 50 percent or more

service connected disability, those who are receiving home care benefits from the VA, prisoners of

war, and World War I veterans. Other veterans

are referred to hearing aid dealers or speech and

hearing clinics to purchase a hearing aid. In fiscal

year 1984, the VA distributed more than 36,000

hearing aids to eligible veterans (47). Large volume purchasing arrangements lower the cost of

each aid, but it is difficult to compare the cost of

aids distributed by the VA with the cost of aids

distributed by other dispensers because the professional costs associated with testing hearing and

selecting an aid are sometimes not included in the

VA figures.

The VA model of service delivery has been

adopted in other institutional settings where medical, audiologic, and hearing aid dispensing services are offered “under one roof .“ One such program is at the Albany Medical Center, where over

the past 7 years more than 1,900 hearing impaired

people of all ages have been treated. The program

provides otolaryngologic, audiologic, and rehabilitative services, including evaluation for hearing

aids, hearing aid dispensing, hearing aid orientation and counseling, speechreading, auditory training, and hearing aid repair (134). Similar programs

have been developed by health maintenance organizations, particularly those that operate comprehensive medical centers (10).

The VA Medical Center in Birmingham, Alabama,

has a program of service delivery that goes beyond

what is provided in other VA medical centers. One

of its primary objectives is the provision of com-
56

prehensive services and followup for veterans who

have difficulty coming to the medical centers VA

staff point out that many people, not only veterans,

live far from centers where comprehensive hearing services are provided and are unlikely to return for regular reevaluation, aural rehabilitation,

and counseling. Even when long distances are not

involved, lack of transportation and physical impairments that interfere with travel cause many

people to drop out of treatment. Consequently,

the Birmingham VA program provides many services by telephone.

In this program, the initial evaluation and treatment are done in the hospital or the clinic, but after the initial treatment the clinic staff regularly

initiate telephone contact with clients to review

their progress, provide auditory training exercises

and supplemental drills, and answer questions

from the client or his family. Conference calls are

used to conduct “group meetings” among individuals with similar impairments so they can give each

other moral support and helpful hints about coping with mutual problems (130). This use of the

telephone spares clients from repeated trips to the

medical center. The alternative-sending staff

members out to provide services away from the

medical center—is prohibitively expensive.

The Birmingham VA program also emphasizes

the use of assistive devices, both for telephone communication and for one-to-one and group listening, Many kinds of devices are given or loaned to

clients. They encourage clients who wear hearing aids and those who do not to use assistive

devices and have created a videotape explaining

the kinds of assistive listening devices that are

available. 6

The Birmingham VA program also stresses training for hearing specialists and other health care

and social service providers. VA staff have been

involved in many conferences and training workshops across the country where they explain their

method of telephone contacts for client education,

reevaluation, and treatment, and educate proThese services are supported by the L’A Exchange of Medical Information and Rehabilitation, Research, and Development Programs.

bThe videotape was prepared by Gwenyth i’aughn and Robert

Lightfoot for the Sertoma Foundation, \\ith partial funding from

Siemens Hearing Instruments, Inc.

viders about assistive listening devices, telecommunication devices, and signaling and alarm systems. They also provide telephone consultation

to clinicians in VA and non-VA facilities.

A final component of the Birmingham VA program is REMATE, Remote Machine-Assisted Treatment and Evaluation. REM ATE is a computer-based

delivery system. The computer is programmed by

the clinician to provide drill sessions by telephone

for veterans nationwide and to store client responses for later review by the clinician. This system can also be used to gather and store data for

long-term evaluation of treatment procedures

(130).

Elderhostel Program for the

Hearing Impaired

Another innovative approach to the delivery of

hearing services is the elderhostel program conducted at Gallaudet College since 1981. Hearing

impaired persons over 60 and their spouses or “significant others” are invited to the college in Washington, DC, for a week in the summer. They attend presentations about the nature of hearing

loss and its impact on relationships, strategies for

coping with hearing loss, and the roles of various

hearing specialists. Lists of hearing specialists in

the participants’ home States are provided and assistive devices are on display. Participants also attend sessions on nonverbal communication and

deaf culture. Participants have particularly appreciated the information on assistive devices and

self-help techniques. Small group activities are also

important; they allow hearing impaired elderly

people to interact with others and realize they are

not alone in coping with hearing loss. The originators of this elderhostel program believe it could

be repeated at colleges and community agencies

throughout the country (61).

Assistive Device Centers

Assistive device centers for the hearing impaired

are locations where a variety of devices used to

compensate for hearing loss are displayed and

demonstrated. Hearing impaired people, their families, and health care and social service providers

can visit these centers to learn about available devices. One assistive device center at the Fort Lauder-
57

dale oral School is manned by volunteers from the

Telephone Pioneers of America. Demonstration

devices have been contributed by the manufacturers (34). Appendix B contains a list of assistive

device centers in the United States. Centers are

needed in other locations throughout the country,

Self-Help Groups for Hearing

Impaired People

Self-help groups for hearing impaired people provide information for their members about devices

and techniques that help compensate for hearing

loss and about the role and expertise of different

types of hearing specialists. The names of some

of these groups are listed in appendix A. Some of

them have assistive listening devices and telecommunication, signaling, and alarm devices available

at their meetings so that attendees can try them.

One self-help group, Self Help for Hard of Hearing People (SHHH), in cooperation with the Birmingham VA, has produced a series of six pamphlets

on assistive listening devices and their uses.

Some self -help groups are primarily for deaf people, while others are primarily for hard-of-hearing

people. Membership is open to people of all ages,

but many members are elderly, particularly in the

groups oriented to people with partial hearing loss.

While younger people with hearing impairments

and other handicaps have become increasingly assertive about the rights of the handicapped, many

elderly people are still reluctant to call attention

to their handicaps and to demand appropriate services. Self-help groups emphasize the rights of hearing impaired people and the rights of the consumer,

an approach that may be particularly appropriate for elderly people (105).

The Suzanne Pathy Speak-Up Institute is a selfhelp group that focuses on improving communication between hearing impaired and normal hearing people. Members are encouraged to disclose

their hearing loss and wear a symbol to indicate

it. The organization provides information to community groups about how to communicate effectively with hearing impaired people.

Nursing Home Initiatives

Despite the high prevalence of hearing impairment in nursing homes and its often severe effects

on residents’ ability to interact with others, give

and receive information, and adjust to the facility, little attention has been given to this problem.

As one nursing home administrator pointed out:

“To be perfectly frank, communication is at the

bottom of my priorities. We care about nutrition,

hygiene, medication; that’s it” (14). Even when nursing home staff attempt to address the problems

of hearing impairment among residents, few are

knowledgeable about the devices and treatments

available. Access to hearing services is often limited

because some residents cannot pay for them and

because it is difficult to take residents out to a

specialist office or get the specialist, particularly

an otolaryngologist or audiologist, to come to the

nursing home. As a result, many people who might

benefit from hearing services and devices do not

receive them.

The Nursing Home Ombudsman Program of

Monroe County, New York, is an example of one

approach developed to help solve this problem. T

Beginning in 1981, as a result of the effort of one

ombudsman volunteer, the program has provided

sensitivity training for all ombudsman volunteers

to increase their understanding of the impact of

hearing impairment on residents. The volunteers

are taught how to communicate with hard-ofhearing and deaf people. They are trained to be

aware of residents whose hearing aids are not

working properly or who may need new batteries. The ombudsman Program has also provided

workshops for nursing home staff to increase their

understanding of hearing impairment, hearing

aids, and other devices that can benefit residents.

The success of these approaches in nursing homes

has prompted a recent expansion of the program

into local hospitals (14).

A second program initiative for nursing home

residents is being developed by SHHH and the

American College of Health Care Administrators

(ACHCA). In the first stage of this program, SHHH

will train volunteers to help residents better use

their hearing aids by teaching them to insert and

remove the aids, encouraging regular use, and assisting with cleaning and battery replacement.

ACHCA will notify nursing home administrators

of the availability of the program and provide SHHH

with the names of interested administrators (4).

The I-”f?dera] (;ok’ernrnent pro~rides funds to each State to cir\’ekIp

and run a nursing home omhudsman [)ro~riinl Oesign of’ t hr progriim is up to the State and some stiit~s hii\~ wntractrd i~ith 1()(’iil

ii~(’n[’i(>s to ln~l]len~ent the progriim,
58

SCREENING

Screening programs are an important method

of identifying people who have hearing impairments and need treatment. The goal of these programs is to identify all those who need further

evaluation, but hearing specialists continue to debate the best methods for doing this. As discussed

in chapter 2, interview methods fail to identify

some people with hearing impairments because

the people are unaware of their hearing loss or

deny it to the interviewer. This may be particularly true in some minority groups. Pure tone air

and bone conduction tests miss individuals who

can hear pure tones but have difficulty with auditory discrimination. Since this is frequently a problem among elderly people, speech reception and

speech discrimination tests are an important element of an effective screening program for them.

In addition, elderly people often have particular

difficulty with background noise and some measure of hearing in a noisy environment is needed

(54).

Ventry and Weinstein (131) have developed a

screening program for elderly people that includes

both audiometric tests and a self-assessment instrument to identify the social and emotional efPROGRAMS

fects of hearing loss. The self-assessment instrument is the first designed for and standardized

on elderly people. Further testing of this screening program is being funded by the National Institute on Aging (59).

Some elderly people who are very withdrawn

and apparently cognitively impaired do not respond to the usual audiometric tests and selfassessment instruments. A technique that has been

used with very young children can also be used

to measure the hearing of these people. This technique measures brain wave response to sound,

or auditory evoked potential, and does not require

active cooperation from the person being tested.

A hearing aid can be put on the person to determine whether amplification increases the brain

wave response. Finding hearing loss in a very withdrawn person does not necessarily mean that a

hearing aid or other treatment will be effective

because the patient may be too cognitively impaired to benefit from the device (140). Nevertheless, the availability of a technique to measure

hearing in these patients is important for diagnostic

purposes.

REGULATION OF THE DELIVERY SYSTEM

Federal legislation and regulations affect the delivery of hearing services both directly, through

FDA regulations on hearing aids, and indirectly,

through Medicare and Medicaid regulations on

reimbursement for hearing services. Medicare and

Medicaid are discussed in chapter 5. This section

reviews FDA regulations. The Federal Trade Commission (FTC) recently decided against industrywide regulation of various aspects of hearing

aid sales, and the history of this decision is also

discussed briefly.

Federal investigation of hearing aid sales practices began in the 1960s. Early efforts led by Senators Kefauver and Church resulted in news releases and other reports that alerted the public

to widespread problems but did little to prevent

or control them. During the mid-1970s, the FTC

initiated a major effort to develop regulations for

hearing aid sales, The results of their investigations and recommended regulations were published in 1978. The recommended regulations

would have restricted advertising, in-home sales,

marketing of used hearing aids, and the use of

screening programs to identify potential customers. The most important and most vigorously contested recommendation was a provision to allow

a hearing aid purchaser or renter to cancel the

sale or rental within 30 days and receive a refund

(10, 77).

Hearings were held in 1978 and FTC staff recommended issuance of the regulations after reviewing the “compelling testimony (about) the numerous experiences reported of unusable hearing

aids, purchased at great financial sacrifice, and
59

of a multitude of abusive sales transactions and

sales tactics” (48). However, the Commission did

not rule on the staff recommendations at that time.

In 1985, with the regulatory procedure still pending, the FTC contracted for a survey of hearing

aid users to determine whether regulation of hearing aid sales was needed. The results of the survey many of which have been reported in this

OTA background paper, convinced FTC staff and

commissioners that no industrywide regulation

is needed (86). The regulatory procedure subsequently has been dropped.

Regarding the 30-day trial period, the survey indicated that 64 percent of the respondents purchased hearing aids with a trial period, 16 percent

could not remember whether a trial period was

available, and 20 percent purchased aids for which

a trial period was not available. Some States require a trial period, while others do not.8 However, the survey showed that people who purchased hearing aids in States that require a trial

period were no more likely to be offered a trial

period than people who purchased aids in States

that do not require a trial period (75).

The FTC concluded from these data that trial

periods are widely available and that State laws

requiring trial periods may not increase their availability (86). A staff memo to the FTC Commissioners

concluded: “Market forces appear to have been

as effective as legal requirements in promoting the

proliferation of trial periods” (86).

The FTC reliance on these survey findings has

been criticized because the sampling procedures

used produced very few respondents in the States

that require a trial period. Thus, the difference

in availability of trial periods in States that require

a trial period and those that do not could have

occurred by chance (107). In addition, although

the survey indicates that almost two-thirds of those

who purchased hearing aids were offered trial

periods, at least 20 percent purchased aids for

which a trial period was not available, To hearing

specialists and consumer advocates who believe

Kknnecticut, klaine, Nmi ltampshire, NmI }’ork, (Wgon, “1’exas,

trermont, and thr District of (’olumhia require ii trial period. (:ali.

f’ornia, Kentuck}, North (:arolin:i, ‘1’t’nnessetI, and tl’ashington hale

la~ts or rx’gulations that require a trial period under some rirrum -

stan(w. other- States ha~[~ no r’t>(~l]ir’~>rl~(]rlt for :1 trial period [7.51.

that the availability of a trial period is important,

these figures are not reassuring.

ASHA and the American Association of Retired

Persons (AARP) submitted testimony opposing the

FTC decision to drop the regulatory procedure.

They cited experiences of their members that support continuing need for regulation of the hearing aid industry. AARP testimony emphasized t he

need for an FTC-sponsored consumer education

program to inform the public about hearing impairment, hearing specialists, and devices to compensate for hearing loss (3).

In the mid- 1970s, almost simultaneously with the

initial FTC efforts, FDA began to develop regulations for hearing aids under its mandate to regulate medical devices. The purpose of the FDA effort was quite different from that of FTC. FDA was

concerned about the “safety and effectiveness” of

hearing aids as medical devices, not with sales practices per se. The proposed FDA regulations were

much less restrictive than the FTC regulations, met

with less opposition, and were adopted in 1977.

The FDA regulations were at odds with the laws

and regulations of several States, and those States

applied for exemption from the new Federal rules.

In virtually all instances the State regulations were

more restrictive than the new FDA regulations.

FDA reviewed these applications and granted some

exemptions but most were denied (10).

The FDA hearing aid regulations relate primarily to labeling and conditions of sale. Labeling requirements specify that the hearing aid must show

the name of the manufacturer or distributor, the

model name or number, serial number, year of

manufacture, and an indication of the correct battery position. The requirements also specify essential information that must be contained in an

instructional brochure to illustrate and describe

the operation, use, and care of the aid; sources

of repair and maintenance; and a statement to the

effect that the use of a hearing aid may be only

part of a rehabilitative program that may also involve speechreading or auditory training. This

brochure must be provided with the aid. The regulations also require a warning to dispensers and

purchasers that certain conditions make medical

consultation advisable prior to purchase of an aid.

The warning to dispensers also advises caution

when fitting the more powerful hearing aids.
60

As discussed earlier, FDA requires that the consumer provide the hearing aid dealer or dispenser

evidence of a physician’s evaluation or sign a waiver

of this requirement before purchasing a hearing

aid. Although there is no information about the

number of aids that are sold on the basis of waivers,

some hearing specialists believe that the number

is high and that the use of waivers undermines

the basic purpose of the FDA regulations. In 1980,

ASHA testified to this effect before the Senate Subcommittee on the Handicapped:

Under the FDA’s regulation, hearing aids can and

are being sold to persons without either a medical

examination or a test of their hearing. This is leaving the hard-of -hearing, especially the elderly, vulnerable to the pressures of hearing aid salesmen.

Without testing, it is impossible to know the type,

nature, and degree of loss or even whether a hearing aid is necessary or will be beneficial. without

requiring a hearing test, State consumer protection officials or private parties lack the fundamental evidence to prove whether or not a hearing aid

was appropriately sold . . . The FDA’s regulation,

its preemption of State laws providing greater protection to consumers and its pressure on other

agencies to follow its suit has been a major setback in providing quality care to the hearing impaired, especially the elderly (6).

Other hearing specialists disagree and argue that

the FDA regulations are fulfilling their intent (133).

Assistive listening devices are generally not regulated by FDA. Hearing specialists are concerned

about the need to protect consumers from devices

that may be useless or harmful. At the same time,

many hearing specialists do not favor FDA regulation of these devices because FDA rules about

the distribution of medical devices affect how devices can be marketed and could ultimately raise

costs and limit use (33).

In addition to FTC and FDA regulations, the delivery of hearing services to elderly people is affected by Medicare and Medicaid regulations that

control reimbursement. In many instances, these

regulations determine point of entry, who may

provide services, the services that may be delivered, the setting in which the services are provided,

and the way in which the services are offered.

These programs are discussed in the next chapter.
—.

Chapter

Funding for Treatment

Hearing

of

Impairments
Chapter 5

Funding for Treatment of

Hearing Impairments

Hearing services and devices are paid for directly

by hearing impaired people or by private insurance and government programs such as Medicare,

Medicaid, and the Veterans Administration (VA). ’

In general, medical and surgical hearing services

provided by physicians are covered by Medicare,

Medicaid, and private insurance. Some services

provided by audiologists are also covered, especially when authorized by a physician, but evaluations for hearing aids are usually not covered.

Hearing aids and assistive listening devices are not

covered by Medicare and are rarely covered by

private insurance. Medicaid pays for hearing aids

in about half the States, but only a small percentage of the elderly population is eligible for these

services. only about 15 percent of hearing aids

are paid for wholly or in part by any third-party

payer, including Medicaid, the VA, and private insurance (75).

The pattern of funding for hearing services reflects an underlying philosophy of government and

private insurance programs that emphasizes the

importance of physician care and medical and surgical treatment, while deemphasizing rehabilitative approaches such as providing assistive devices

to help people function despite impairments. This

philosophy is also evident in Medicare and Medicaid regulations and private insurance policies that

limit reimbursement for devices and rehabilitation services related to impairments in vision and

speech.

Hearing aids are the most common form of treatment for hearing impairment in elderly people,

and it is often alleged that the cost of hearing aids

severely restricts their use. one report points out,

however, that the cost of hearing aids has risen

very little in the past 25 years (41). From 1960 to

1980, while the Consumer Price Index increased

more than 300 percent, the average cost of a hearing aid increased from about $350 to $450, or less

aring ser\’ices prwidwl and paid for I)yf t hf~ L’eterans .Adnlinistration \\ere discussed in rh. 4.

than 25 percent. Sales expansion, improved manufacturing techniques, and changes in marketing

have led to this relative price stability despite inflation in the economy as a whole, While the cost

of a hearing aid is still too high for some low-income people, many people can afford them. In fact,

the number of individuals buying hearing aids increased significantly between 1980 and 1983 despite a 25 percent decrease in third-party reimbursement (24).

Since government programs and private insurance usually do not pay for hearing aids, hearing

impaired people often have to pay for these devices themselves. While many elderly people do

purchase hearing aids, few are also willing and

able to pay for a comprehensive audiological evaluation to help them select the hearing aid or aural

rehabilitation services to help them adjust to it

(138).

Assistive listening devices are not covered by

Medicare, Medicaid, or private insurance. Legislation has been introduced in Congress to allow

reimbursement for these devices under Medicare

and Medicaid. The Handicapped Assistance Act of

1985 (H.R. 1432) would amend the Social Security

Act to allow payment for sensory and communication aids for persons with visual, speech, and

hearing impairments. Reimbursement would be

limited to $5,000 a year and no more than $15,000

in any 5-year period (17).

Allowing tax credits for the purchase of assistive listening devices is another approach to encourage their use. This idea is not now politically

viable because Congress and the Administration

oppose creating new tax deductions and tax credits

(56).

Aural rehabilitation services are covered by

Medicare, Medicaid, and some private insurance

in certain circumstances, but these services are

seldom received by elderly people, as discussed

in chapter 3. Government initiatives to increase

the use of these services could include increased

63
64

funding and/or simplification of the complex re- education about the potential benefit of aural requirements for reimbursement for these services habilitation for elderly people could encourage inunder Medicare and Medicaid. Increased public dividuals to pay for these services themselves,

MEDICARE

Almost all Americans over 65 are covered by

Medicare, the health insurance program authorized by Title XVIII of the Social Security Act to provide payment for specified health services. Under

Part A Hospital Insurance, Medicare pays for hospital care, some posthospital extended care, and

home health services. Under Part B Supplemental

Medical Insurance Benefits, Medicare pays for physicians services, hospital outpatient services, diagnostic laboratory tests, some durable medical supplies, and services such as physical therapy and

speech therapy when authorized by a physician

(lo).

Most physician services related to the diagnosis

and treatment of hearing impairment are covered

by Medicare. Some hearing services provided by

an audiologist are reimbursable under certain circumstances. For example, an audiological evaluation requested by a physician to help diagnose

hearing disorders is reimbursable. Rehabilitative

services provided by an audiologist are covered

for some patients, but complex regulations, summarized below, govern which audiology services

are covered, and in which settings (10).

Under Medicare Part A, rehabilitative audiology

services requested by a physician and directly related to the condition for which a patient is hospitalized can be provided for hospital inpatients and

residents of skilled nursing facilities (SNF). Diagnostic and therapeutic audiology services requested by a physician can be covered for hospital inpatients when provided by an audiologist who

is either an employee of the hospital or who has

made a contractual arrangement with the hospital. An audiologist who is employed by the hospital can also provide audiology services for patients

transferred to a SNF if the SNF and the hospital

have a transfer agreement (10).

Under Medicare Part B, an audiological evaluation requested by a physician for diagnostic purposes is reimbursable. Other hearing services provided by an audiologist also can be reimbursed

under Part B: 1) if the audiologist is employed by

a physician or in a physician-directed clinic, 2) if

the physician is on the premises and supervises

the services, and 3) if the audiological services are

an integral part of the physician’s professional services. Diagnostic and therapeutic services provided

by audiologists also can be reimbursed as a Part

B benefit for audiologists employed in a rehabilitation agency, skilled nursing facility, hospital out -

patient clinic, or home health agency (10).

Hearing services provided by hearing aid dealers

are not reimbursed by Medicare. Medicare does

not pay for hearing evaluations performed to help

select a hearing aid and it does not pay for hearing aids or other assistive listening devices.

MEDICAID

Medicaid is a joint Federal/State program, au- The Federal Government requires that State

thorized by Title XIX of the Social Security Act to Medicaid programs cover certain health care servprovide funding for health care services for the ices, while other services are optional. States are

poor. Elderly individuals with income and assets required to cover:

below established levels are eligible for Medicaid.

People with income above these levels but with ● Hearing services provided by hospitals to inhigh medical expenses are also eligible in some patients or outpatients. These services can inStates. elude audiology services prescribed by a phy-
65

●

●

●

sician with a physician’s recertification of the

need for continuing treatment every 30 days.

Hearing services provided in SNFs by a physician or an audiologist working under the direction of a physician.

Hearing services provided by physicians in the

community.

Some hearing services provided by audiologists in the community. These services must

be provided under the personal supervision

of a physician. States are free to define the

degree of personal supervision required, but

many adopt the definition used by the Medicare program—that the audiologist must be

employed by a physician (or group of physicians) and practice in the same office or clinic

as the physician (10).

States are not required to reimburse any other

hearing services under Medicaid, but Federal

matching funds are available to States for a wide

variety of optional services including diagnosis,

screening, rehabilitative services, and hearing aids.

Most States limit the optional Medicaid services

they provide in order to control overall costs of

the Medicaid program:. A 1979 survey of Medicaid programs in 49 States2 and the District of

Columbia conducted by the American SpeechLanguage-Hearing Association (ASHA) revealed the

following about States’ coverage of hearing services beyond the mandatory benefits:

● Twenty-nine States covered evaluative and

diagnostic services provided by ASHA-cerZ,.\rizon;i did not participate in the k!edirtiid program at the time

of the sur~e}!.

●

●

tified or licensed audiologists regardless of the

setting, but in seven of these States coverage

was limited to children. Only 7 of the 29 States

covered aural rehabilitation services for

adults. Fifteen additional States covered audiology services only when provided in specific facilities or agencies, such as rehabilitation centers and home health agencies. The

remaining States only covered hearing services provided by physicians.

Prior authorization by the State Medicaid

agency was required for aural rehabilitation

services in all cases, but was seldom required

for diagnostic services. Referral from a physician was generally required for all services.

Twenty-eight States provided reimbursement

for hearing aids for eligible adults. Prior authorization was required in nearly all States.

Other requirements for reimbursement of

aids varied: evaluations by audiologists or

through speech and hearing centers approved

by the State were mandatory in 36 States; 10

of these permitted evaluation by an otolaryngologist in lieu of an audiologist, while 14 required a physician’s examination in addition

to the audiologist’s evaluation (7).

As a result of Medicaid cutbacks since 1979,

fewer States probably pay for hearing services

now. Moreover, even in those States that pay for

aural rehabilitation services and hearing aids

through Medicaid, the reimbursement rates are

often so low that providers refuse to serve Medicaid patients.

OTHER GOVERNMENT FUNDING PROGRAMS

Funding for hearing services is available to some other devices, and aural rehabilitation. However,

elderly veterans and retired military personnel only about 2 percent of all people receiving any

through VA and military hospitals. Some elderly services from State Vocational Rehabilitation Agenindividuals are also served in programs sponsored cies are over 65 (13). No figures are available on

by the Bureau of Indian Affairs and the Federal the number of elderly individuals who receive

Bureau for Community Health Services. hearing services.

State Vocational Rehabilitation Agencies provide Federal funds for the elderly are available to

a wide range of services to handicapped individ- States through the Title XX Block Grant, the Comuals, including hearing impaired people. These munity Development Block Grant, and Title III of

services can include counseling, hearing aids and the Older Americans Act. Some States use some
66

of these funds to provide hearing services, but

these programs are very limited and the demand

for services always exceeds available funds. For

example, in 1984 Montgomery County, Maryland

initiated a program to buy or lend assistive devices

PRIVATE

The private health insurance industry consists

of three major components: 1) the nonprofit Blue

Cross and Blue Shield plans that enroll 38 percent

of the privately insured population; 2) commercial insurance companies that provide coverage

to 54 percent of the privately insured population;

and 3) independent prepaid and self-insured health

plans including large prepaid group practice plans

such as the Kaiser Foundation plans and health

plans operated jointly by union and management

in some industries. These prepaid plans cover only

about 7 percent of the insured population, but they

are more likely than other insurers to offer a comprehensive array of outpatient and preventive

services (10).

Private insurance coverage of hearing services

is important for elderly people because Medicare

covers only part of the health care expenses of

elderly people, currently less than 50 percent.

Many older people purchase supplemental insurance from private insurers. In addition, a small

segment of the elderly population is not eligible

for or not enrolled in Medicare and many of these

people have private insurance (10).

Determining whether an insurer will reimburse

for hearing services is not simple. Each insurance

policy is independently negotiated, so that a single company may issue policies with many variations in the provisions affecting hearing services.

In fact, few policies directly address hearing services; instead, coverage is determined by the provisions for broad categories of services such as

‘(miscellaneous medical,” “physiotherapy)” or

“other medically necessary services. ” Whether

hearing services are reimbursable depends on if

a given service meets the general conditions in

these broad categories (10).

of all kinds using Community Development Block

Grant funds. About 90 percent of the funds were

spent for hearing aids for people of all ages and

the demand for hearing aids was so great that the

program ran out of money in 3 months (46).

INSURANCE

The principal variables that affect coverage are:

In what setting is the service provided? (Hospital inpatient unit, hospital outpatient department, physician’s office, audiologist’s office,

hearing aid dealer’s office, speech and hearing clinic?)

Who is providing the service? (A physician,

a licensed or ASHA certified audiologist, a

hearing aid dealer?)

What kind of service is provided? (Diagnosis,

evaluation for a hearing aid, aural rehabilitation?)

Why is the service needed? (Injury, illness, congenital or acquired disease, organic or nonorganic disorder?)

What is the role of the beneficiary’s physician?

(Prescription, supervision, referral?)

Because conditions in the policies of private insurers vary so greatly, it is not possible to document exactly which hearing services are covered

by which insurers for which groups of beneficiaries. However, some general statements can be

made about predominant patterns and limitations

of coverage.3

Where Services Are Provided

and By Whom

Health insurance primarily covers the cost of

hospitalization and physicians’ services and most

3This information is deri~red from three sources: 1) collection of

\arious existing surveys undertaken by ASHA members and others

of major insurers doing business in their areas (.5, 16, 20, 40); 2)

a sur~rey conducted by ASHA’S Task Force on Prik’ate Insurance of

15 major national insurers (7); and 3) a study conducted by the Blue

Cross Association of Blue Shield plan reimbursement of nonphysician prok’iders (78).
67

policies reimburse for hearing services provided

by physicians in hospitals and in the community.

In addition, certain hearing services are covered

when provided by a qualified practitioner. In one

survey, a licensed audiologist was deemed qualified by nine companies and six companies accepted ASHA certification in lieu of licensure (7).

Four insurers left the choice of a qualified practitioner up to the physician prescribing and supervising the services. Blue Cross/Blue Shield plans

tend to be less flexible about whom they will reimburse. A study of all 70 Blue Shield plans nationally reported that only 9 would reimburse for

covered services provided by audiologists (78).

Type and Purpose of Services

Nearly all policies specify that they cover only

“medically necessary” services, but none defines

the term. In effect, a service is medically necessary when a physician says it is and the insurer

agrees. This requirement mandates the involvement of physicians for all reimbursable services

(lo).

Coverage of specific hearing services by the companies surveyed was virtually uniform. Audiologic

testing needed by a physician to establish a diagnosis was covered in all cases. Routine evaluations

to detect hearing loss and services related to degenerative hearing loss were never covered. Several companies would cover audiologic services

and hearing aids when a hearing loss resulted from

an accident or injury, but most policies specifically

exclude hearing aid evaluations and hearing aids.

A survey by Hewitt Associates, a nationwide consulting firm specializing in employee benefits and

compensation, found that only 6 percent of U.S.

firms offer hearing-care plans (28). The United Automobile Workers Union has recently negotiated

the first major labor contract to include coverage

of hearing aids (104).

Hearing services provided to maintain rather

than improve hearing are generally excluded. If

a beneficiary had a communicative handicap before an injury or illness that is covered by a policy, then hearing services would be covered only

to the extent that they were needed to restore the

beneficiary to his or her previous level of functioning.

Role of the Physician

Physicians must be involved in health insurance

claims for hearing services at least enough to document “medical necessity” to the insurer. Physician referral and supervision is the most common

requirement. Supervision generally means that the

physician must cosign claims and accept responsibility for the services (10).

Among the insurers surveyed by ASHA, six required only physician referral for hearing services. Two required physician approval of such services, while three required physician supervision

(7). TWO companies did not specify the role of the

physician, while one required physician direction

of diagnostic audiologic services, The distinctions

between “approval, ““recommendation ,“ and “supervision” are fuzzy, but the insurers’ intent in

all cases is to ensure that a physician’s statement

of the initial and continuing need for services is

submitted before claims will be paid.

Thus private insurance coverage of hearing services appears to mirror Medicare and Medicaid coverage, allowing reimbursement for medical and

surgical services and for services provided by physicians for medical problems. In contrast, rehabilitative services, and particularly the cost of hearing aids and assistive listening devices, are not

covered. Thus elderly people must pay for these

services and devices themselves or do without.

Chapter 6

Conclusion

This background paper has discussed the types

of hearing impairment that are most common

among elderly people, hearing devices and services that may benefit them, and aspects of the delivery system and third-party reimbursement that

limit use of these devices and services. Federal policy options have not been analyzed. However, some

of the findings of this paper are relevant to the

development and analysis of Federal legislative and

regulatory policies. These are listed below:

●

●

●

●

Hearing impairment is very common among

elderly people and can seriously affect their

safety, quality of life, and ability to live independently.

Most research on hearing impairment has

focused on very severe impairments, deafness,

and the hearing impairments of young people, rather than the moderate or partial hearing impairments that are common among

elderly people. As a result, many questions

about the pathology of hearing loss in elderly

people remain unanswered. The term presbycusis is used to refer to hearing loss associated with aging, but there is disagreement

about the term’s meaning. In addition, the

causes of presbycusis are not well understood.

Most research on treatment for hearing impairment has focused on medical and surgical treatments rather than rehabilitative approaches. Yet the latter are generally more

effective for the types of hearing impairment

common among elderly people. Rehabilitative

approaches such as the use of hearing aids,

assistive listening devices, and aural rehabilitation services can improve a person’s ability

to communicate even when the underlying

cause of the hearing impairment cannot be

cured,

Third-party reimbursement, including Medicare and Medicaid, is available for medical and

surgical treatment but usually is not available

for hearing aids, assistive listening devices, and

some aural rehabilitation services, Thus, these

reimbursement programs fail to fund the

treatments that are most effective for elderly

people.

●

●

●

●

Many people, including the elderly, their families, health care and social service professionals, and others, are not aware of the prevalence of hearing impairment among elderly

people; its physical, emotional, and social impact; and the hearing devices and services that

can compensate for it. Public education to increase awareness of this problem and training for health care and social service professionals are needed.

Negative attitudes about aging and the rehabilitation potential of elderly people discourage the use of potentially effective treatments. Public education programs could be

designed to counteract these negative attitudes. In addition, they could emphasize that

communication is a two-way process, involving both the speaker and the listener. Some

of the simplest methods for facilitating hearing, such as the rules for speaking to someone with a hearing loss, require active cooperation by the speaker. Public education

programs could emphasize the role of the

speaker in facilitating effective communication with hearing impaired people.

Hearing aids have been helpful for many hearing impaired people, but most hearing impaired people do not buy a hearing aid and

some who buy an aid do not use it. Factors

that interfere with increased use of hearing

aids include problems in the design or function of the aid; problems in selecting an appropriate aid for the individual; inability of the

individual to adjust to the aid; and disagreement among hearing specialists about who can

benefit from a hearing aid. The frequency with

which each of these problems occurs is not

known. Developing solutions for them is a potential area for cooperative research by the

hearing aid industry and hearing specialists

(physicians, audiologists, and hearing aid

dealers).

Assistive listening devices can be particularly

beneficial for hearing impaired elderly people because they lessen the impact of background noise, a major problem for many el71
72

derly people, These devices can be used in

public meeting rooms and for interpersonal

communication in doctors’ offices, hospitals,

and nursing homes, and in a variety of social

and recreational listening situations. Yet these

devices are not widely used. Increasing their

use will require recognition of their potential

value by hearing specialists (physicians, audiologists, and hearing aid dealers) and efforts

by these specialists to promote them.

Use of the telephone is particularly important

for elderly people who live alone and those

who have difficulty getting out because of

physical impairments. Federal legislation and

regulations that affect the availability of telephones compatible with hearing aids and telephone amplification devices for home use

should acknowledge the important role the

telephone plays in maintaining the safety, independence, and quality of life of hearing impaired elderly people.

Much is known about environmental design

techniques that can reduce reverberations

and background noise and thus facilitate hearing. However, this knowledge has not been

widely applied. Building design regulations for

long-term care facilities and housing for the

elderly could incorporate these design techniques.

Aural rehabilitation services such as hearing

aid orientation, auditory training, speechreading, and counseling are frequently not available to elderly people with hearing impairments despite their potential benefit.

The existing service delivery system is fragmented and does not provide optimal hearing services for elderly people. Rivalry among

the three types of hearing specialists —physicians who specialize in hearing disorders, audiologists, and hearing aid dealers-contributes to the fragmentation of the delivery

system. Any Federal legislation or regulations

related to hearing services could be designed

to encourage the development of coordinated

service delivery systems.

In some instances, an educated consumer is

the best protection against deficiencies in the

service delivery system. Self-help groups may

be the most effective method for educating

consumers,

Although almost half of all hearing impaired

people are over 65, the training of hearing

specialists generally has not emphasized the

types of hearing impairments that are common among elderly people and the most

appropriate treatments for them. Each type

of hearing specialist needs training in these

areas.

The impact of hearing impairment on elderly

people in hospitals and nursing homes can be

particularly severe, limiting their ability to

communicate with doctors, nurses, and other

personnel, understand their medical treatment, and understand and adjust to facility

routines. Federal and State regulations govern many aspects of patient care in hospitals

and nursing homes, but few regulations apply to the provision of hearing devices and

services for hearing impaired patients.

While hearing impairment is a serious problem

among elderly people in this country, partial solutions are available. We now have an increased understanding of the problem and various devices

and services are available. Federal initiatives in the

areas of research, public education, and improvements in the service delivery system could help

solve the problems faced by hearing impaired

elderly people and could significantly improve the

quality of their lives.
Appendixes
Appendix A

Information Sources

Alexander Graham Bell Association for the

Deaf

3417 Volta Place, N.W.

Washington, DC 20007

(202) 337-5220

American Academy of Otolaryngology—Head

and Neck Surgery

1101 Vermont Avenue, N. W., Suite 302

Washington, DC 20005

(202) 289-4607

American Speech-Language-Hearing

Association

10801 Rockville Pike

Rockville, MD 20852

(202) 897-5700

American Tinnitus Association

P.O. Box 5

Portland, OR 97207

(503) 666-2625

AT&T National Special Needs Center

2001 Route 46

Parsippany, NJ 07054

1-800-233-1222

Audiology—Speech Pathology Service

Birmingham VA Medical Center

700 South 19th Street

Birmingham, AL 35233

(205) 933-8101, ext. 6702

Better Hearing Institute

1430 K Street, N.W.

Suite 600

Washington, DC 20005

(202) 638-7577

Consumers Organization for the Hearing

Impaired, Inc. (COHI)

P.O. Box 8188

Silver Spring, MD 20910

(301) 587-2514

Hear-Say

2525 Murworth, Suite 207

Houston, TX 77054

(713) 666-2625

International Federation of the Hard of

Hearing

Pirol Kamp D-2000

Hamberg 65, German Federal Republic

National Association for Hearing and Speech

Action

10801 Rockville Pike

Rockville, MD 20852

1-800-638-8255

National Association of the Deaf

814 Thayer Avenue

Silver Spring, MD 20910

(301) 587-1788

National Captioning Institute

5203 Leesburg Pike

Falls Church, VA 22041

(703) 998-2400

National Center for Law and the Deaf

Gallaudet College

800 Florida Avenue, N.E.

Washington, DC 20002

(202) 651-5454

National Hearing Aid Society

20361 Middlebelt Road

Livonia, MI 48152

(313) 478-2610

National Information Center on Deafness

Gallaudet College

800 Florida Avenue, N.E.

Washington, DC 20002

(202) 651-5109

National Technical Institute for the Deaf

(NTID)

One Lomb Memorial Drive

P.O. BOX 9887

Rochester, NY 14623

(716) 475-6400

Office of Cued Speech Programs

Gallaudet College

800 Florida Avenue, N.E.

Washington, DC 20002

(202) 651-5527

75
76

Organization for the Use of the Telephone

(OUT)

P.O. Box 175

Owings Mills, MD 21117

(301) 655-1827

Self Help for Hard of Hearing People, Inc.

(SHHH)

7800 Wisconsin Avenue

Bethesda, MD 20814

(301) 657-2248

Suzanne Pathy Speak-Up Institute, Inc.

525 Park Avenue

New York, NY 10021

(212) 832-8286

Telecommunications for the Deaf, Inc.

814 Thayer Avenue

Silver Spring, MD 20910

(301) 587-1788
Appendix B

Assistive Device Centers

Assistive device centers are locations where a variety of devices to compensate for hearing impairment are displayed and demonstrated. The centers are open to the public, and some centers sell

as well as demonstrate devices. This list of assistive device centers was adapted from information provided to OTA by George W. Fellendorf, Fellendorf Associates, Inc. In addition to the centers listed

here, many hearing specialists display and sell some devices.

ARIZONA

Heidico, Inc.

444 South Montezuma Street

Prescott, AZ 86301

(602) 445-9554 (V) (TDD)

Contact: Remi Saffran

Tucson Hearing Society

c/o University of Arizona

Department of Speech and Hearing

Tucson, AZ 85721

(602) 621-7070

Contact: Anne Lanshe or William Hodgson

CALIFORNIA

Hearing Society for the Bay Area

1428 Bush Street

San Francisco, CA 94109

(415) 775-5700 (V); (415) 776-3323 (TDD)

Contact: John L. Darby or Michael V. Sisk

H.E.A.R. Center

Providence Speech and Hearing

1

3

01 Providence Avenue

Orange, CA 92668

(714) 639-4990 (V); (714) 639-1393 (TDD)

Contact: Donna Greenfield

House Ear Institute

256 South Lake Street

Los Angeles, CA 90057

(213) 483-4431 (V); (213) 484-4642 (TDD)

Contact: Linda K. Dye

COLORADO

Harvard Park Hearing Center

950 East Harvard Avenue

Suite 500

Denver, CO 80210

(303) 777-4327 (V and TDD)

Contact: Bruce D. Schachterle

The Hearing Store

2308 South Colorado Boulevard

Denver, CO 80222

(303) 757-4327 (V); (303) 757-4715 (TDD)

Contact: Bruce D. Schachterle

DISTRICT OF COLUMBIA

Gallaudet College

Assistive Devices Center

Department of Audiology

800 Florida Avenue, NE

Washington, DC 20002

(202) 651-5328 (V and TDD)

Contact: Cynthia Compton Fernandes

FLORIDA

Fort Lauderdale Oral School of Nova

University

3375 W. 75th Avenue

Fort Lauderdale, FL 33314

(305) 475-7324

Contact: Joan Rollins-Bellows or Jack Mills

ILLINOIS

Chicago Hearing Society

Charles Silberman Center for Assistive

Devices

10 West Jackson Boulevard

Chicago, IL 60604

(312) 939-6888 (V); (312) 427-2166 (TDD)

Contact: Daria Popowych

Sound Resources, Inc.

201 East Ogden

Hinsdale, IL 60521

(312) 323-7970 (V and TDD)

Contact: Barbara Carlson

77
78

INDIANA

Purdue Audiology Clinic

Heavilon Hall, Purdue University

West Lafayette, IN 47907

(317) 494-3789

Contact.’ Carl A. Binnie

KANSAS

Institute of Logopedics

2400 Jardine Drive

Wichita, KS 67219

(316) 262-8271 (V and TDD)

Contact: Karen Black Kramer

MARYLAND

Assistive Devices Center

Consumers Organization for the Hearing

Impaired, Inc. and The National Association

of the Deaf

814 Thayer Avenue

Silver Spring, MD 20910

(301) 587-2514 (V); (301) 946-0037 (TDD)

Contact.’ Gary Olson or Will Gross (V) Bill

Paschell (TDD)

Hearing and Speech Agency of Metro

Baltimore, Inc.

2220 St. Paul Street

Baltimore, MD 21218

(301) 243-3800 (V); (301) 243-1274 (TDD)

Contact: Clifford Lull

Self Help for Hard of Hearing People

7800 Wisconsin Avenue

Bethesda, MD 20814

(301) 657-2248 (V); (301) 657-2249 (TDD)

Contact: Howard (Rocky) Stone or Charles

Mizell

NEW YORK

Burke Rehabilitation Center

Department of Speech, Language and

Audiology

785 Mamaroneck Avenue

White Plains, NY 10605

(914) 948-0050, extension 2306

Contact: Rochelle Shotland

Hearing Rehabilitation Center

Albany Medical Center Hospital

New Scotland Avenue

Albany, NY 12208

(518) 445-4535 (V and TDD)

Contact: Donna S. Wayner

Mill Neck Foundation

P.O. Box 100

Mill Neck, Long Island, NY 11765

(516) 922-3880 (V and TDD)

Contact: Louis Frillman

National Technical Institute for the Deaf

One Lomb Memorial Drive

Rochester, NY 14623

(716) 475-6473 Kathy Tyson

(716) 475-6476 Diane Castle

New York League for the Hard of Hearing

71 West 23d Street

New York, NY 10010

(212) 741-7650 (V); (212) 255-1932 (TDD)

Contact: Joshua M. Gendel

Park East Hearing Center

1641 East Avenue

Rochester, NY 14610

(716) 461-9192 (V); (716) 461-0357 (TDD)

Contact: Sheila Dalzell

OKLAHOMA

HearCare

Medical Park Center

Suite 601

Bartlesville, OK 74006

(918) 333-8910 (V and TDD)

Contact: Carolyn Kisler

OREGON

Eugene Hearing and Speech Center

1202 Almaden Street

P.O. BOX 2087

Eugene, OR 97402

(503) 485-8521 (V and TDD)

Contact: R. Craig Ford
79

TENNESSEE TEXAS

Bill Wilkerson Hearing and Speech Center Callier Center for Communication Disorders

1114 19th Avenue South University of Texas at Dallas

Nashville, 37212 1966 Inwood Road

(615)320-5353 (V) Dallas, TX 72535

Contact: Judy Ventress (214) 783-3000 (V and TDD)

Contact: Carolyn R. Musket

References

1.

2.

3,

4.

. . 5

6.

7.

8.

9.

10.

11.

12,

13.

14.

15.

Alpiner, J. G., “Aural Rehabilitation and the Aged

Client, ” Audecibel 22:102-104, 1973.

American Academy of Otolaryngology-Head and

Neck Surgery, “Cordless Telephones Can Cause

Permanent Hearing Loss,” News, Washington, DC,

Apr. 26, 1984.

American Association of Retired Persons and

American Speech-Language-Hearing Association,

Testimony to the Federal Trade Commission, Sept.

9, 1985.

American College of Health Care Administrators

and Self Help for Hearing Impaired People, Inc.,

“The Administrator/Audiologist/Volunteer Team

Approach to Helping the Hard-of-Hearing Nursing Home Resident, ” concept paper, 1985.

American Speech-Language-Hearing Association

(ASHA), Kansas City Area Directors of Speech

Pathology Departments, “Blue Cross/Blue Shield

Coverage for Speech Pathology Services, ” ASHA

Directors Conference, 1978.

American Speech-Language-Hearing Association

(ASHA), Testimony before the Senate Subcommittee on the Handicapped, 1980.

American Speech-Language-Hearing Association

(ASHA), Task Force on Private Health Insurance

and Gokrernmental Affairs Department, “A Report

on Third-Party Reimbursement of Speech-Language Patholo~v and Audiology Services, ” May

1980.

Bailey, B. J., “Cochlear Prosthesis Implantation: Review of the Issues, ” Journal of the American Medica] Association 251(24):3282, 1984.

Becker, G., The Disabilit&v Experience: Educating

Health Professionals About Disabling Conditions

(Berkeley, CA: University of California Press, 1981).

Becker, G., Flower, R. M., Glass, L. E., and Newcomer, R. J., The A4anagement of Hearing Impairment in Older Adults, OTA contract No. 333-

8970.0, 1984.

Bergman, iM., “Assistive Listening Devices, Part I:

LNew’ Responsibilities, ” Asha 25(3):19-23, 1983.

Berkowitz, A., “Audiological Rehabilitation of the

Geriatric Patient,” Hearing Aid Journal 8:30-34,

1975.

Blake, R., “Disabled older Persons: A Demographic

Analysis,” Journal of Rehabilitation 47(4):19-27,

1981.

Boyd, S., and Adams, H., “Ombudsman Program

for Nursing Homes)” Shhh 6(1):11-15, 1985. I

Braeges, J., “The Use of Speech Displays With the

Hearing Impaired,” in M.R. Redden and v.W.

Stern, Technology for Independent Living II

16

(Washington, DC: American Association for the

Advancement of Science, 1983).

Brantman, M., “The Status and Outlook for Com -

mercial Health Insurance Coverage of Speech and

Hearing Services,” ASHA Journal 15(4):183-187,

1973.

17. Brown, G. E., “The Handicapped Independence

Assistance Act,” The Congressional Record, Mar.

6, 1985.

18. Cherow, E., American Speech-Language-Hearing

19

Association, personal communication, Dec. 9,

1985.

Clarcq, J.R., “Employment for Disabled Individuals:

Skills Needed To Meet the Needs of Employ ers, ”

in M.R. Redden and V.W. Stern, Technology for

Independent LivingII (Washington, DC: American

Association for the Advancement of Science, 1983).

20. Colorado Speech-Language-Hearing Association

(CSHA), “The State-~f-th~-Art: Speech Pathology/Audiology Health Insurance Claims, ” 1979.

21. Consumer Reports—’’How To Buy a Hearing Aid:

What Consumers Should Know,” 41(6):346-352,

22.

23.

24,

25,

26,

27.

28.

29.

30.

31.

32,

1976.

Corbin, S., Reed, M., Nobbs, H., et al., “Hearing

Assessment in Homes for the Aged, ” Journal of

the American Geriatrics Societ~~ 32(5):396-400,

1984.

Cranmer, K., “Hearing Aid Dispensing–1985,”

Hearing Instruments 36(5):6-12, 1985.

Cranmer, K., “Hearing Aid Dispensing–1983, ”

Hearing Instruments 34(5):9-12, 1983.

Cross, M., “Bionic Claims Fall on Deaf Ears ,“ A’e\~r

Scientist 102(1412):10, 1984.

Davis, J. M., and Hardick, E.J., Rehabilitative Audiology for Children and Adults (Ne\$r York, NY:

John Wiley & Sons, 1981).

Derlacki, E. L., “Otosclerosis, ” Hearing Disorders,

J.L. Northern (cd. ) (Boston, MA: Little, Brown &

Co., 1976).

Dessler, G., “A Survey of Fringe Benefits, ” San Francisco Examiner, Mar. 26, 1984, sec. D, p. 9.

DiRocco, A., Executive Vice President, National

Hearing Aid Society, personal communication,

May 1985.

Dreschler, D,, Auditory Biochemist, 11’ayne State

University, Detroit, MI, personal communication,

November 1984.

Dubno, J. R., Dirks, D. D., and Morgan, D. E., ‘(Effects of Age and Mild Hearing Loss on Speech Recognition in Noise, ” Journal of the Acoustical Society of America 76(1):87-96, 1984.

Elwell, L., “Hearing: Safeguarding an Endangered

83
84

33<

34<

35<

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

Resource,” speech delivered to the Oklahoma Alliance on Aging, Oklahoma City, OK, July 2, 1984.

Fellendorf, G. W., Develop and Deliver: Proceedings of the First International Conference on Assistitfe Devices for Hearing Impaired Persons

(Washington, DC: Fellendorf Associates, Inc.,

1984).

Fellendorf, G. W., “A Model Demonstration Center of Assistive Devices for Hearing Impaired People,” .l.A.l?.A. XV:70-82, 1982.

Fellendorf, G. W., Current Developments in Assis -

tive Dew”ces for Hearing-Impaired Persons in the

United States (Washington, DC: Gallaudet Research Institute, Gallaudet College, 1982).

Fleetwood, R., Harry Diamond Laboratory, letter

to OTA, Aug. 10, 1985.

Fleetwood, R., Harry Diamond Laboratory, personal communication, June 1984.

Fox, B., “Ear Splitting for Pleasure, ” IVew Scientist

107(1468):21, 1985.

Gallaudet College, “The Autocuer, ” 1983.

Goates, W .A., and Goates, J. S., “Data Fmm National

Study of Private Practice in Speech Pathology and

Audiology, ” presented at ASHA Directors Conference, 1975.

Goldstein, D. P., “Hearing Impairment, Hearing

Aids, and Audiolo~V,” Asha 26(9):24-35,38, 1984.

Goldstein, J. C., MD., Executive Vice President, The

American Academy of Otolaryngolo~-Head and

Neck Surgery, letter to OTA, May 16, 1985.

Goldstein, J .C., MD., Executive Vice President, The

American Academy of Otolaryngolog, Head and

Neck Surgery, personal communication, May 15,

1985.

Gordon-Salant, S., University of Maryland, Department of Hearing and Speech Sciences, personal

communication, Nov. 28, 1984,

Grady, D., “Sounds Instead of Silence)” Discover

4(10):54-57, 1983.

Hal], E., Department of Social Services, Montgomery County, MD, personal communication,

1984.

Hauck & Associates, Hearing Industries Statistical Report, May 15, 1985.

Hearing Aid Industry Staff Report, Final Report

to the FTC and Proposed Trade Regulation Rule

(16 CFR Part 440) (Washington, DC: Bureau of Consumer Protection, September 1978).

Hearing Industries Association (HIA), “HIA Survey

of the Hearing Impaired Population: Executive

Summary, ” 1985.

Heller, T. A., Larson, E. B., and LoGerfo, J. P., “Quality of Ambulatory Care of the Elderly: An Analysis of Five Conditions, ” Jourmd of the American

Geriatrics Societ&v 32(11):782-88, 1984.

51. Herbst, K. G., and Humphrey, C., “Hearing Impairment and Mental State in the Elderly Living at

Home,” British Medical Journal 281(6245), 1980.

52. Hiatt, L. G., “Technology and Chronically Impaired

53

Elderly: Interpretations Leading to Performance

Demands and Products in Institutions and in Community Care Systems, ” Conference Papers, National Research Conference on Technology and

Aging, The Gerontological Association of America and The Western Gerontological Society, 1982,

AOA Grant #90 AR 0025.

Hudspeth, A.J., “The Cellular Basis of Hearing: The

Biophysics of Hair Ce]]s, ” Science 230(4727):745-

752, 1985.

54. Hull, R. H., HearingLmpairment AmongAgingPersons (Lincoln, NE: Cliff Notes, 1977).

55. Humphrey, C., Herbst, K. G., and Faurgi, S., “Some

56

57.

Characteristics of the Hearing Impaired Elderly

Who Do Not Present Themselves for Rehabilitation)” British Journal of Audiolo~ 51(1):25-30,

1981.

Humphreys, R. R., “Legislation and Regulation: Do

They Support or Impede Assistive Device Development and Distribution?” in Fellendorf, G.W., De-

~lelop and Deliver: Proceedings of the First International Conference on Assistive Devices for

Hearing Impaired Persons (Washington, DC:

Fellendorf Associates, Inc., 1984).

Hunt, J .A., and Handa, M .K., “Speech Recognition

Struggles to Life, ” High Technolo@ 4(6)30-32,

1984.

58. Hutchinson, K. “An Evaluation of Telephone Amplification Devices,” paper presented to the ASHA

conference, Cincinnati, OH, Nov. 19, 1983.

59. Jacubczak, L., National Institute on Aging, personal

communication, Nov. 21, 1984.

60. Jamison, S. L., “The Role of Technolo~ in the Em61

62.

ployment of Hearing-Impaired Perso;s,” Technology for Independent Living, V.W. Stern and M .R,

Redden (eds.) (Washington, DC: American Association for the Advancement of Science, 1982).

Kaplan, H., “Elderhostel for the Hearing Impaired,”

Asha 25(7):46-49, 1983.

Kinney, S., Head, Section of otology and NeuroOtolo~, Otolaryngology and Communicative Disorders Division, The Cleveland Clinic, letter to

OTA, May 3, 1985.

63. Kirikae, I., Sate, T., and Shiraro, T., “Study of Hearing in Advanced Age)” Larymgoscope 74:205-21,

1964.

64. Knauf, V. H., “Communication Training, ” Handbook of C]inica]Aud”o]o~, 2d cd., J. Katz (cd.) (Baltimore, MD: Williams & Wilkins Co., 1978).

65. Kornblum, A., “Sound Off!” US May 23, 1983.

66. Leib, R.K., “The Chronically Impaired Elderly in
67,

68,

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

Institutions and in the Community Care System:

Technological Applications Leading to Ne}tr and

Impro\ed Products, ” Conference Papers, National

Research Conference on Technology and Aging,

The Gerontological Association of America and

The Western Gerontological Society, 1982, AOA

Grant #90-AR-0025.

Lesho\vit z, B., “De\~e]opment of an Infrared Hearing Aid, ” h~edical Instrumentation 16(1):15-16,

1982.

Leshowitz, B., Department of psycholo~v, Arizona

State Uni\ersitJ~, personal communication, Oct. 4,

1984.

Leske, NI.C., “Prevalence Estimates of Communicati~’e Disorders in the [1. S.: Language Hearing,

and J’estibular Disorders ,“ Asha 23(3):229-237,

1981.

Lipscomb, D. ItI., “En\rironmental Noise is

Grow~ing-Is It Damaging Our Hearing?” Clinical

Pediatrics 11(7):374-375, 1972.

Loeb, G. E., “The Functional Replacement of the

Ear,” Scientific American 252(4 ):104-1 11, 1985.

Lubinski, R. B., and Chapey, R., ‘(Communication

Ser\~ices in Home Health Agencies: Availability and

Scope,” itsha 22(1 1):929-934, 1980.

Mader, S., “Hearing Impairment in Elderly Persons, ” Journal of the American Geriatrics SocietL\r

32(7):548-553, 1984.

Nlahon, l\r.J,, “Assisti\e Dmrices and Systems: The

hlarket Lifts Off, ” The HearingJournal 38(4): 7-13,

1985.

Alarket Facts, “A Description of the F~periences

of Recent Hearing Aid Purchasers, ” sur~rey for the

Federal Trade Commission, 1985.

itlaurer, J .F., and Rupp, R. R., Hearing and Aging:

Tactics for lntertention (Ne\\’ York: NY: Grune &

Stratton, 1979).

hlcLauchlin, R.hl., “The Impact of Laws and Regulations on Devices for the Hearing Impaired, ”

Hearing and Hearing Impairment, L.J. Bradford

and W .G. Hardy (eds. ) (Ne;v York, NY: Grune &,

Stratton, 1979).

NlcNerney, W .J., “Skyrocketing Health Care Costs:

The Role of Blue Shield,” Hearings before the Subcommittee on Oversight and Investigations of the

Committee on Interstate and Foreign Commerce,

House of Representatives, 95th Cong., 2d sess.,

1978, 604-650.

National Captioning Institute, “For Your Information, ” Nov. 1, 1985.

Naunton, R. F., Director of the Communicative Disorders Program, National Institute of Neurological and Communicative Disorders and Stroke, persona] communication, Nokrember 1984.

National Center for Law and the Deaf, Le&?l Rights

82

83

84.

85

of HearingImpaired Peo@e (Washington, DC: Gal -

laudet College Press, 1984).

Naunton, R. F., “Hearing Loss—The Inkrisible Handicap, ” Medicine for the Layman lecture, National

Institutes of Health, Bethesda, MD, Oct. 12, 1984.

Newby, H .A., “Veterans Administration, ” Hearing

and Hearing Impairment, L. J. Bradford ancl 11’ .(;.

Hardy (eds.) (New York, NY: Grune & Stratton,

1979).

Organization for the Use of the Telephone, ’’The

OUT]ine,” X1(26):2, Feb. 14, 1985.

85. Pathy, S. M., letter to OTA, Mar. 19, 1985.

86. Pederson, A., Deputy Director, Federal Trade

Commission, memorandum to the Commission,

July 12, 1985.

87. Pederson, A., Deputy Director, Federal Trade

Commission, memorandum to the Conlmission,

Sept. 12, 1985.

88. Pickett, J. M., “Hearing Through Sight and Feeling,”

IEEE Spectrum 19(4):37-41, 1982.

89. Popelka, G. R., “Improving the Hearing of the

E!derly,~~ Communications Technolo@r and the

Elder@, R.E. Dunkle, M.R. Haug, anci Itl. Rosenberg (eds.) (New York, NY: Springer Publishing Co.,

1984).

90. Pratt, L. L., Department of Otolaryngology, Cooper

Medical Center, letter to Timothj~ J. IVaters, for

the National Hearing Aid SocietJ’, Nov. 23, 1977.

91. Pressler, L., “Telephone Equipment for Ser\~ice to

Certain Disabled Persons, ” The Congressional Record 131(12), Feb. 6, 1985.

92. Pulec, JL., ‘( Meniere’s Disease, ’’Hearing Disorders,

J.L. Northern (cd.) (Boston, lt!A: Little, Brot\m, &

Co., 1976).

93. Pulec, J. L., “Meniere’s Disease: Etiologies, Natural History, and Results of Treat merit,” Otolaq’ngologic Clinics of North America 6:25, 1973.

94. Punch, J., “The Prevalence of Hearing Impairmerit, ” Asha 25(4):27, April 1983.

95. Rodin, J., and Langer, E., “Aging Labels: The Decline of Control and the Fall of Self -Esteem,” Journal of Sociai Issues 36(2):13-29, 1980,

96. Ross, M., Principles of Aural Rehabilitation (Ne\\

York, NY: The Bobbs-Merrill Co., 1972).

97. Saks, D., “Telephone Hearing Aid Compatibility, ”

Shhh 5(5):6-8, 1984.

98. Schow, R. L., and Nerbonne, MA., “Hearing Le~els

Among Elderly Nursing Home Residents, ” Journal of Speech and Heari~ Disorders 45, 1980.

99. Science 85, “Lip Reading Glasses, ” 6(2):6, 1985.

100. Sela, 1., Gallaudet Research Institute, personal communication, December 1985.

101, Shhh, “The Quiet School Program, ” Special Report

on Noise, 1984.

102, SHHH, “ALDS and You, ” 1984.
86

103. SHHH, “Communications Access Systems for

Groups and Large Rooms,” 1983.

104. Stern, V., Project on the Handicapped in Science,

American Association for the Advancement of Science, Washington, DC, letter to OTA, June 26,

1985.

105. Stern, V., Project on the Handicapped in Science,

American Association for the Advancement of Science, Washington, DC, personal communication,

June 7, 1984.

106. Stone, H. E., Executive Director, SHHH, personal

communication, Nov. 14, 1985.

107. Stone, H. E., “The FTC and the Hearing Aid industry, ” 1985.

108. Stone, H. E., “Statement of Self Help for Hard of

Hearing People, Inc., to the Subcommittee on

Health, Committee on Ways and Means, U.S. House

of Representatives, ” Mar. 12, 1984.

109. Stone, H. E., letter to Hon. Frank U. Guarini, Aug.

25, 1983.

110. Suzanne Pathy Speak-Up Institute, Inc., iVewsletter 6(2):5, New York, NY, July 1984.

111. Taylor, R. A.,“What All That Noise Is Doing to Our

Lives,” U.S. News and World Report 97(50), 1984.

112. Thomas, P. D., Hunt, W .C., Garry, P.J., et al., “Hearing Acuity in a Health Elderly Population: Effects

on Emotional, Cognitive, and Social Status, ” Journal of Gerontology 38(3):321-325, 1983.

113. Tobias, J,, Chairman, Committee on Hearing, Bioaccoustics, and Biomechanics, National Research

Counci], persona] communication, Dec. 10, 1984.

114. U.S. Congress, Office of Technology Assessment,

“Selected Telecommunications Devices for Hearing-Impaired Persons, ” Washington, DC, 1982.

115. U.S. Department of Commerce, National Bureau

of Standards, E. Corliss, “Facts About Hearing and

Hearing Aids, ’’HEW Pub. No. (FDA) 79-4016, 1979.

116. U.S. Department of Health, Education and Welfare, National Center for Health Statistics, M.

Rowland, “Basic Data on Hearing Levels of Adults

25-74, U.S. 1971 -75,” USDHEW Pub. No. (PHS)

80-1663, Office of Health Research, Statistics, and

Technolo@, Series 11, No. 215, Hyattsville, MD,

1980.

117. U.S. Department of Health, Education, and Welfare, National Institute of Neurological Disease and

Stroke (NINDS), Human Communication and Its

Disorders: An Overview, Bethesda, MD., NINDS

Monograph, Nov. 10, 1969.U.S. Department of

Health and Human Services, National Center for

Health Statistics, Current Estimates From the National Health Interview Survey, U.S. 1982, Series

10, #150, DHHS Pub. No. (PHS) 85-1578, 1985.

118. U.S. Department of Health and Human Services,

National Center for Health Statistics, P.W. Ries,

“Hearing Ability of Persons by Sociodemographic

and Health Characteristics: U .S .,” Vital and Health

Statistics, DHHS Pub. No. (PHS) 82-1568, Series 10,

No. 140 (Washington, DC, 1982).

119. U.S. Department of Health and Human Services,

National Center for Health Statistics, S.S. Jack, Current Estimates from the National Health Interview

Survey, U. S., 1979, Series 10, #136, DHHS Pub. No.

(PHS) 81-1564, 1981.

120. U.S. Department of Health and Human Services,

National Center for Health Statistics, B.A. Feller,

“Prevalence of Selected Impairments, U. S., 1977, ”

Vital and Health Statistics, DHHS Pub. No. (PHS)

81-1562, Series 10, No. 134 (Washington, DC: U.S.

Government Printing Office, 1981).

121. U.S. Department of Health and Human Services,

National Center for Health Statistics, unpublished

data from the 1981 Health Interview Survey, 1981.

122. U.S. Department of Health and Human Services,

National Institute of Neurological and Communicative Disorders and Stroke, National Institutes of

Health, “Research on Presbycusis Supported by

NIH-NINCDS-CDP,” letter to OTA, Nov. 11, 1984.

124. U.S. Department of Health and Human Services,

National Institute of Neurological and Communicative Disordem and Stroke, National Institutes of

Health, “Hearing Loss, Hope Through Research, ”

NIH Pub. No. 82-157, 1982.

125. U.S. Department of Health and Human Services,

National Institute on Aging, “Age Page: Hearing

and the Elderly,” 1983.

126. U.S. Senate Report of Review of NHAS Home-Study

Course, U.S. Senate Permanent Subcommittee on

Investigations of the Committee on Government

Operations, 1975.

127. U.S. Senate, “Hearing Loss, Hearing Aids and the

Elderly,” report 98-912 (Washington, DC: U.S. Government Printing Office, July 18-19, 1968).

128. Vaughn, G. R., Chief of Audiology and Speech

Pathology, VA Medical Center, Birmingham, AL,

personal communication, May 1985.

129. Vaughn, G. R,, Chief of Audiology and Speech

Pathology, VA Medical Center, Birmingham, AL,

personal communication, November 1984.

130. Vaughn, G. R., Faucett, R. A., and Lightfoot, R. K.,

“Communication Outreach: Delivery Systems and

Devices, ” in R.E. Dunkle, M.E. Haug, and M. Rosenberg, Communications Technology and the

Elderly: Issues and Forecasts (New York, NY:

Springer Publishing Co., 1984).

131. Ventry, I., and Weinstein, B. E., ‘(Identification of

the Elderly With Hearing Problems, ’’Asha 27(7):37-

42, 1983.
.

87

132. J’eterans Administration, “REMATE: Communication Out reach,” Audiolo~v-Speech Patholog-- Service, Medical Center, Birmingham, AL, 1983.

133. k$’aters, T., McDermott, Will, and Emory, Washington, DC, personal communications, June 1985.

134. lh’ayner, D. S., and Goldstein, J. C., “Sensorineural

Hearing Loss: hledical Rehabilitation, ’’Shhh 6(2):6-

9, 1985.

135. Wea\er, M., and Northern, J. L., “The Acoustic

Nerve Tumor, ” Hearing Disorders, J.L. Northern

(cd.) (Boston, MA: Little, Browrn & CO., 1976).

136. LITilliams, B., Gallaudet College, personal communication, July 1984.

137. Williams, P. S., “Hearing Loss: Information for

Professionals in the Aging Network,” Gallaudet College, Washington, DC, 1984.

138. Williams, P. S., Professional Practices Division,

American Speech-Language-Hearing Association,

personal communication, July 10, 1984.

139. Zimbardo, P.G, and Anderson, S. M., “Induced

Hearing Deficit Generates Experimental Paranoia, ”

Science 212:(4509):1529-1531, 1981.

140. Zubick, H., Instructor in Surgery, Harvard University, personal communication, Oct. 4, 1984.