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Geriatr Gerontol Int 2014
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Self-perception of the hearing-impaired elderly before and after hearing-aid fittings Mirna Rossi Barbosa, Daniel de Sousa Medeiros, Luiza Augusta Rosa Rossi-Barbosa, Marise Fagundes Silveira, Andrea Maria Eleutério de Barros Lima Martins and Antônio Prates Caldeira Postgraduate Program in Health Sciences, State University of Montes Claros, Montes Claros, Brazil
Aim: To evaluate the impact of hearing aid (HA) fittings among elderly patients through the Hearing Handicap Inventory for the Elderly (HHIE). Methods: The present study was carried out with 125 hearing-impaired individuals over aged 65 years in the northern region of Minas Gerais, Brazil. The instrument used was the HHIE self-assessment questionnaire. HHIE were completed before and after HA fittings. Data were analyzed using the non-parametric Wilcoxon test and the McNemar χ2-test. Results: There were significant decreases in general, social and emotional handicap after HA use (P < 0.001). The percentage of patients with severe hearing handicap decreased from 45.6% to 8.8% with HA use. The greatest difficulty reported by respondents, both before and after HA use, was “hearing when someone whispers”. Conclusions: Although HA use significantly improves the hearing handicap, some older adults still maintain social and emotional limitations. The HHIE instrument can be a great ally in helping professionals understand and rehabilitate the difficulties that remain after amplification. Geriatr Gerontol Int 2014; ••: ••–••. Keywords: elderly, hearing aid, hearing loss, self-assessment.
Introduction Brazil has undergone a demographic transition resulting from a mortality rate reduction among the young and an increase in life expectancy. In 2008, for every 100 children (aged 0–14 years), there were 24.7 older adults (aged ≥65 years). It is estimated that in 2050, there will be more than 172 older adults for every 100 children.1 With an aging population, there is an increase in chronic health problems, resulting in an increased demand for health services.2 Among the chronic health problems, hearing loss, or presbycusis, stands out because it has a prevalence of 25.6% among Brazilian older adults.3 Presbycusis is a major sensory change associated with aging. Because it is detrimental to communication and, thus, to interpersonal relationships, presbycusis can
lead to depression.4 It also negatively affects daily activities.5 These disadvantages highlight the need for the systematic evaluation of how older adults perceive these difficulties. Assessment, screening and follow up of hearing-impaired patients can prevent serious complications. The Hearing Handicap Inventory for the Elderly (HHIE) is an instrument that assesses the consequences of hearing loss in older adults.6 Many elderly people with presbycusis require hearing aids (HA) to re-establish their communicative function.7 HA fittings are complex, and require time for amplification adjustments.8 Adaptation to HA use requires regular monitoring to assess the effectiveness of the HA and patient satisfaction.9,10 This monitoring can include evaluating the impact(s) of hearing amplification on the social life of the HA user. In the present study, we assessed the impacts of HA fittings using the HHIE questionnaire.
Accepted for publication 25 July 2014.
Methods
Correspondence: Miss Mirna Rossi Barbosa MS, Office 4, Avenida Cula Mangabeira, 562 – Santo Expedito, CEP 39401-001 – Montes Claros (MG), Brazil. Email:
[email protected]
The present study was carried out from January 2010 through August 2011, with patients attending the only public hearing healthcare service in the northern region
© 2014 Japan Geriatrics Society
doi: 10.1111/ggi.12376
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of Minas Gerais, Brazil. This region, which covers 86 municipalities and an estimated population of 1.5 million inhabitants, is poor and includes many cities that have the lowest Human Development Index of the country. The participants were selected at random, from the official database, if they were aged 65 years older and had used HA for at least 4 months. People who could not complete the questionnaire were excluded. Data were collected during home visits. Interviewers did not receive any technical information about patients and their rehabilitation, besides name and address. Three attempts were made to visit each patient, and after three failed attempts, a patient was considered lost to the study. Therefore, 191 older adults were interviewed in their homes, and all of them had already been fitted more than 4 months earlier. Out of the 191 older adults, 13 were considered lost to the study and 53 were not able to evaluate their handicap perception with the hearing aid because they abandoned the use of it. To determine the sample size required to compare handicap levels before and after HA use, the following formula was used:11
2σ 2d ( zα 2 + z1−β )
2
n=
Δ2
where σd = Standard deviation of the difference = 28.6 Δ = Estimated difference = 27.5 zα/2 = Normal distribution score for the significance level = 0.05 z1−β = Normal distribution score for the power = 0.90 Using the Dimam program, we determined that we required a sample size of at least 86 individuals.11 The evaluation instrument used was the HHIE selfassessment questionnaire translated into Portuguese.12 The instrument consists of 25 questions that purport to identify the social (12 questions) and emotional (13 questions) impacts of presbycusis. Each question has three possible answers (yes, no or sometimes), with point values ranging from 0 to 4 points; total scores range from 0 to 100. Scores were classified as follows: no hearing handicap (total score ≤16), mild/moderate hearing handicap (total score from 18 to 42) and severe/ significant hearing handicap (total score >42).12 HHIE were completed before and after unrestricted HA use. The HHIE survey before hearing aid fitting was carried out in all patients by one of the authors, who was working at the service at that time, as a research of local interest, whose data were not published. Results were analyzed both descriptively and analytically. We used the non-parametric Wilcoxon and McNemar–Bowker 2
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tests with a significance level of 5% to compare results analytically. Statistical data analysis was carried out using the SPSS program 19.0 (SPSS, Chicago, IL, USA). This project was approved by the research ethics committee of the State University of Montes Claros.
Results The mean age of the 125 people interviewed was 77.65 years (SD = 7.6 years). Patient data are shown in Table 1. Most of the participants were women (51.2%), and information about hearing loss was not available for all patients. Among those who had this information, the most common type of hearing loss was sensorineural (24.8% for the left ear and 27.2% for the right ear), and the most common degree of hearing loss was moderate (33.6% for the left ear and 36.0% for the right ear). Considering the hearing loss in the better ear, the most common degree was also moderate (38.4%). Almost all older adults received two devices (96.0%). Most of the HA devices were: behind the ear type (87.2%), category digital programmable, non-linear and WDRC multichannel compression (52.0%). Table 2 shows the means and SD of the hearing handicaps before and after HA fittings. Decreases in handicap after HA fittings were observed in general, and in the social and emotional scales (P < 0.001). The degrees of hearing handicaps before and after HA fittings are reported in Table 3. Before HA fitting, 45.6% of the older adults reported a severe/significant handicap perception. After at least 4 months of HA rehabilitation, this grade of handicap perception was reported by 8.8% of the older adults, a statistically significant difference (McNemar–Bowker test). Difficulties reported by the respondents before and after HA fittings are shown in Tables 4 and 5. The two most common problems reported before were: to hear when someone speaks in a whisper and to hear when attending a party. After HA fittings, the main problem remained to hear when someone speaks in a whisper, but the second was to hear using the telephone.
Discussion The present study identified perceived limitations, before and after HA fittings, among older adults suffering from hearing loss. HA use was found to reduce the limitations caused by hearing loss. This result is similar to another study that also used the HHIE questionnaire before and after HA use, and observed a significant reduction in hearing handicap after HA use.13 Research carried out in Italy showed a significant reduction in depressive symptoms and an improvement in the quality of life for the hearing impaired after HA use.14 HA fittings increase patient well-being and quality of life by © 2014 Japan Geriatrics Society
Self-perception of the hearing-impaired
Table 1 Participant characteristics Characteristic
Sex Female Male Education (years of study completed) ≥8 1–7 Illiterate Type of left ear hearing loss Conductive Sensorineural Mixed No hearing loss No information Degree of left ear hearing loss Mild Moderate Moderately severe Severe Profound No hearing loss No information Type of right ear loss Conductive Sensorineural Mixed No hearing loss No information Degree of right ear hearing loss Mild Moderate Moderately severe Severe Profound No hearing loss No information Degree of hearing loss in better ear Mild Moderate Moderately severe Severe No hearing loss No information Hearing aid type BTE ITE/ITC/CIC Hearing aid category C B A Not informed Hearing aid fitting Binaural Monaural
No. participants
Percentage of participants (n = 125)
64 61
51.2 48.8
21 62 42
16.8 49.6 33.6
4 31 30 2 58
3.2 24.8 24.0 1.6 46.4
4 42 8 9 4 2 56
3.2 33.6 6.4 7.2 3.2 1.6 44.8
4 34 28 1 58
3.2 27.2 22.4 0.8 46.4
6 45 6 10 1 1 56
4.8 36.0 4.8 8.0 0.8 0,8 44.8
8 48 6 4 3 56
6.4 38.4 4.8 3.2 2.4 44.8
109 16
87.2 12.8
65 16 22 22
52.0 12.8 17.6 17.6
120 5
96.0 4.0
A, non-programmable, linear, single-channel compression; B, digital programmable or non-programmable, WDRC mono- or multichannel compression; BTE, behind the ear; C, digital programmable, non-linear, WDRC multichannel compression; CIC, completely in the ear canal; ITC, in the ear canal; ITE, in the ear.
© 2014 Japan Geriatrics Society
improving communication and social inclusion.15,16 This result is important, because older adults who selfreport hearing handicaps constitute a group at risk for a poor quality of life.15 We observed that, before receiving HA, most older adults reported handicaps ranging from mild to severe. This finding shows that presbycusis negatively affects the social performance of individuals.17 Although social and emotional impacts are specific to individuals, it is interesting to note that, for some respondents, hearing loss did not cause any limitations. Other studies also observed that not all older adults with hearing loss perceived social or emotional handicaps.18 Older adults can adapt to their impaired hearing; for example, by avoiding communication-demanding situations. Additionally, because the presbycusis develops slowly, older adults often think it is normal to hear less as they age.19 Most respondents reported a moderate degree of hearing loss. Although it was not possible to correlate handicap scores with the degrees of hearing loss (because information was not available for all patients), we found that the number of people reporting severe/ significant handicaps was much higher than the number of people reporting severe or profound hearing loss. Thus, perceived hearing handicaps vary among people reporting the same degree of hearing loss. It is as common to find patients with hearing loss who complain little about loss of function as it is to find patients with mild hearing loss who perceive themselves to have a high handicap level.20 The major difficulties perceived by older adults relate to social aspects, as shown in another study.21 Substantial differences between social and emotional aspects have not been found. Before HA fittings, most respondents reported difficulty hearing when someone whispers. This hearing loss is a major contributor to difficulties in speech comprehension.22 Presbycusis is more often associated with the inability to hear highfrequency sounds that are important for speech discrimination.23 Difficulty hearing in noisy environments, such as parties, restaurants and meetings, and difficulty watching television or listening to the radio are also common among people with hearing disabilities. In a Swedish study, the major difficulties reported by older adults were “talking to several people” and “hearing sounds from another room”.19 In the present study, after HA fittings, many difficulties were eased, but some older adults still reported handicaps, such as listening to someone whispering. The second greatest difficulty presented by the older adults after HA fitting referred to telephone use. Although the HA provided have a coil to improve telephone communication, study participants did not use it, perhaps because they were not instructed on the use of this feature. This difficulty was observed regardless of the type of HA used. Such difficulties were noted in |
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Table 2 Hearing handicaps before and after hearing aid fittings Handicap General handicap Before After Social scale Before After Emotional scale Before After
Mean score (n = 125)
Standard deviation
40.83 14.02
26.00 17.25
20.91 8.08
12.39 9.38
19.92 5.94
15.26 9.01
P-value*
