hearing aid use in nursing homes, part 2: barriers to effective utilization of hearing aids

Hearing Aid Use in Nursing Homes,Part 2: Barriers to Effective Utilizationof Hearing Aids

Jiska Cohen-Mansfield, PhD, ABPP, and Judith W. Taylor, PhD

Objective: This study examined barriers to hearing aiduse among persons who were reported to have a hear-ing aid and among those reported to have hearingdifficulties but no hearing aids.

Setting: Interviews were conducted at a large, mid-Atlantic nonprofit nursing home.

Participants: Both nursing home residents (279) andnursing staff members (51) were interviewed.

Design and Measurements: In a cross-sectional surveyof nursing home residents, brief structured interviewswere performed by trained research assistants withboth residents and caregivers to obtain informationregarding residents’ hearing ability, hearing aid useand daily maintenance, and potential barriers to suchuse.

Results: Among residents reported to have hearingproblems but who did not use a hearing aid, the majorproblem was neglect of the issue; participants did notknow why residents did not have a hearing aid, resi-dents had not had hearing evaluations, and staffmembers were not aware of hearing problems in res-idents. Among residents who did use a hearing aid,the majority (69%) of those for whom informationwas available had problems with the devices. The most

common problems reported were that the device washard or inconvenient to use, it did not fit well or hurt,and the device was not functioning well. The vast ma-jority (86%) needed help taking care of the hearingaids. Close to half of the staff members had not re-ceived any training in the use or maintenance of thedevices. Lack of delegation of responsibility for themanagement of hearing was identified for 29%, andrelatives were used for maintenance of hearing aids in14% of residents with hearing aids.

Conclusions: Barriers to hearing aid use are thereforecomplex and multifactorial, involving lack of systemcommitment to utilization of hearing aids, lack ofknowledge by staff members, inappropriate delega-tion and care procedures, hearing aid design and fitissues, and difficulties for residents in handling thehearing aids. Addressing these issues requires changeon multiple levels, including change at the institu-tional level, concerning policy and training; change atthe unit level, regarding care procedures and followup; change at the individual level, providing betterchecks of fit and function of the hearing aids; andfinally, change at the societal level, addressing designand cost issues for hearing aids in this population.(J Am Med Dir Assoc 2004; 5: 289–296)

Keywords: Hearing aid; hearing impairment; barriers

The prevalence of hearing impairment among residents inlong-term care facilities is estimated to be as high as 70%1 to90%,2 and in part 1 of this article, we found estimates of grosshearing impairment rates (ie, detected in regular speechrather than in audiologic examination) ranging from 53% to63%. Despite these high rates, the underdetection of hearingloss3 and the underuse of hearing aids and other assistive

devices among this population is of significant concern (seepart 1 of this article for further discussion).

The adverse effects of uncorrected hearing impairment onquality of life have been well documented and include increaseddepression, social dysfunction, decreased cognitive function, andimpairment in the performance of activities of daily living (seecompanion paper). Other sensory deficits such as visual impair-ment further compound the negative effects of hearing impair-ment by limiting environmental cues and the ability to usecompensatory strategies such as lip reading.4 Furthermore, as aresult of the isolation and/or sound distortions that occur withhearing impairment, dementia-related symptoms become ampli-fied, causing further distress and frustration not only to thepatients, but to caregivers as well.5

Several studies have documented the potential benefits ofhearing aids for persons with dementia. When monaural hear-

The Research Institute on Aging (J.C.-M.), Hebrew Home of Greater Washing-ton, Rockville, Maryland; and The George Washington University (J.C.-M.,J.W.T.), Washington, DC.

Address correspondence to: Jiska Cohen-Mansfield, PhD ABPP, Research Insti-tute on Aging, Hebrew Home of Greater Washington, 6121 Montrose Road,Rockville, MD 20852. E-mail: [email protected]

Copyright ©2004 American Medical Directors Association

DOI: 10.1097/01.JAM.0000136961.08158.09

ORIGINAL STUDY Cohen-Mansfield and Taylor 289

ing aids were given to patients with Alzheimer’s disease withmoderate to severe sensorineural hearing loss, a significantdecrease in several communication-related problem behaviorswas found (eg, making negative statements, forgetting, repeat-ing questions, saying “I can’t hear you”).6 In the same study,family caregivers reported that patients became more alertand interactive, engaged more in conversation, and paid moreattention to environmental stimuli. Similarly, persons withdementia showed increased cognitive functioning, with par-ticular improvement in orientation within 3 months of beinggiven hearing aids.7 Durrant et al.5 reported dramatic im-provement with amplification for one patient with Alzhei-mer’s disease previously described as belligerent, shoutingconstantly, and difficult to manage.

Although this evidence supports the use of hearing aidsamong persons with dementia, utilization rates of hearing aidsare substantially less in this population than are reportedamong the general population. Little research has examinedthe potential barriers to effective hearing aid use amongindividuals in long-term care facilities, many of whom havedementia.

Thibodeau and Schmitt8 performed visual and auditoryinspections of 36 hearing aids belonging to residents in nurs-ing homes and retirement centers. Results revealed that 64%of the hearing aids belonging to nursing home residents wereclassified as malfunctioning, which included dead or weakbatteries, clogged vents or sound openings, and malfunctionswith volume control, auditory quality, and tubing.

Most studies on barriers have been conducted among cog-nitively intact, community-dwelling elderly persons. Com-mon reasons for nonuse of hearing aids include cost,9,10 dif-ficulty manipulating and handling,4,9,11,13 cosmetics/vanity/stigma10,11,15 (the “stigma” reason is more specifically reportedas calling attention to the handicap9), lack of awareness ofhearing loss,10 comfort,9,10 performance,10 irritation in theear,11 acoustic feedback problems11,12 and amplified noise,9,10

difficulties with volume controls,12 problems inserting theaids,12 difficulty with changing batteries,12 poor understand-ing of how to use devices4 (eg, setting it improperly, like fortelephone use instead of normal speech), and dissatisfactionwith the use of aids.4 Elderly users of hearing aids, eyeglasses,and dentures reported having the least satisfaction with theirhearing aids as compared with the other devices, with only14% reporting being “highly satisfied” with their hearing aidsversus glasses (37%) and dentures (60%).14

In summary, despite available data regarding barriers tohearing aid use among elderly persons in the community,there is a limited amount of research investigating factors thatinhibit the effective use of hearing aids among the elderly innursing homes. However, the literature does demonstrateclear benefits of hearing aid use in this population. Giventhese issues, the current project assessed potential barriers toeffective hearing aid use among nursing home residents. Theobjectives of the study were thus to assess and compare resi-dents’, staff’s, and interviewers’ perceptions of barriers thatimpede effective hearing aid use. Factors associated with theunderuse of hearing aids in this population are expected to bemultifactorial, operating at individual (eg, loss, intolerance, or

inconvenience of devices; hearing aid malfunctioning, or theneed for new batteries; limited ability to use and maintainhearing aids without assistance), institutional (eg, lack ofrecognition among staff of residents’ hearing impairments;staff members’ lack of knowledge or understanding of hearingaid use and maintenance; lack of procedures for maintenanceof hearing aids), and societal levels (eg, prohibitively highcost of hearing aids).

METHODS

For a complete description of the participants, measures,and procedures, refer to part 1 of this article. A brief summaryfollows.

Participants included 279 resident–caregiver dyads (279residents, 51 caregivers) and 16 nurse managers and chargenurses at a large mid-Atlantic non-for-profit nursing home.Resident information regarding demographics, cognitive sta-tus, hearing ability, and hearing aid use was obtained from theMinimum Data Set (MDS).16 Brief structured interviews wereperformed by trained research assistants with both residentsand caregivers to obtain information regarding residents’ hear-ing ability, hearing aid use and daily maintenance, and po-tential barriers to such use. Nurse managers and charge nurseswere interviewed to assess whether there were otoscopes andassistive listening devices on their units.

Of these participants, 33 residents who were reported tohave hearing aids answered at least a portion of the question-naire concerning barriers to hearing aid use. An additional 28residents reported to have hearing problems but no hearingaid were able to respond to at least a portion of the question-naire. Another 11 residents did not provide answers to thisinterview because of communicative, cognitive, or hearingdifficulties, or because of lack of awareness of hearingproblems.

RESULTS

Individual-Level Barriers

Of the 33 residents who used hearing aids and responded tothe questionnaire, 23 (70%) reported having one or moreproblems with the devices. Primary problems reported in-cluded the following: hearing aids do not work properly or arebroken (12), the devices do not fit well or are not tolerated(7), and the devices are either too hard to put in or areinconvenient to use (14). Additional problems included de-vices requiring service, or being too expensive to fix or replace(see Table 1, column 1).

Primary problems reported by the 28 nonusers include thefollowing: not feeling a hearing aid was needed (15), financialcost of purchasing or replacing a hearing aid was prohibitive(3), and residents had not been evaluated (4) (see Table 1,column 3). Other responses from nonusers included the fol-lowing: a hearing aid would not be helpful for one resident’sspecific impairment; one resident said that she would like tohave a hearing aid and has told her doctor she wants one butdoes not know why she has not gotten one; and one reportedthat she used to have one but does not any longer. Thisresident said she used to have hearing aids before entering the

290 Cohen-Mansfield and Taylor JAMDA – September/October 2004

nursing home. She also said they had been uncomfortable towear (see Table 1 for reported barriers).

The nursing staff was also interviewed regarding any po-tential barriers to hearing aid use, both for hearing impairednonusers as well as for hearing aid users (see Table 1). Staffreported 42 residents as using hearing aids and 31 to behearing impaired nonusers. Most often, the nursing assistantdid not know why the resident did not have a hearing aid(55%). Intolerance of the devices was the greatest problemreported for nonusers of hearing aids, with 10% of residentsreported to have taken off or not tolerated their hearing aids.Other reported problems included the devices being broken,residents not being evaluated for a device, and resident refusalto use a device. Of the 42 hearing aid users, staff reported 12to have problems with their hearing aids. The most commonproblem reported was losing the devices or being scared to losethe devices (12%). Other problems included intolerance(5%), broken (5%) and poorly functioning (2%) devices.

Several questions addressed residents’ ability to maintaintheir hearing aids. More than half of those who responded tothese questions reported problems in such tasks, with only35% not requiring any assistance with putting on or taking offhearing aids or with changing batteries. As can be seen inTable 1, 43.3% of the residents required help putting hearingaids on, and 12.9% needed help taking them off. The greatestdifficulty was reported for changing batteries, with 62.1% ofresidents reporting being unable to manage this task on theirown. One resident had a new hearing aid and had not yetneeded to change batteries.

Nursing staff also reported whether residents were able touse and maintain their hearing aids by themselves (see Table1). Consistent with the findings from the residents’ reports,changing batteries was the task for which most residents(86.5%) were reported to require assistance. More than half of

the residents (62.5%) were aided in putting hearing aids in,and 54.0% received assistance taking them off.

In comparing staff members’ ratings with those by residentsin Table 1, two trends are evident: residents were much moreaware of barriers to hearing aid use, whereas staff often saidthey did not know the reasons for nonuse. In contrast, resi-dents estimated their ability to care for the hearing aids ashigher than did staff members.

Institutional-Level Barriers

There were 175 residents who were identified as havingprobable hearing impairment by at least one of the sources(MDS, certified nursing assistant [CNA], research assistant, orresident). Staff’s underrecognition of hearing impairmentsamong residents is demonstrated by the fact that CNAs wereunaware of the presence of a hearing impairment for 102(58.3%) of the residents reported to have impaired hearing byat least one of the other three sources.

Regarding staff’s knowledge of the use and maintenance ofhearing aids (see Table 2), 45.8% of CNAs reported that theyhad not received any training in the use or maintenance ofthe devices, and two noted that they would need retraining atthis point. One third (31.3%) of the staff reported a lack ofknowledge regarding at least one aspect of the use and main-tenance of hearing aids, potentially affecting at least 24.4% ofthe residents in their care. Despite the lack of formal training,most of the staff reported knowing how to turn hearing aidson and off (93.7%), how to check to see if they are working(87.5%), and how to change batteries (87.5%). Fewer re-ported knowing how to check and clean the hearing aids ofwax (68.7%).

To assess unclear unit-level policies, the lack of delegationof responsibility for the management of hearing aids wasdefined as instances in which there was no clear person

Table 1. Reported Problems With Hearing Aid Use

UsersSelf-report(N � 33)

UsersStaffReport(N � 42)

NonusersSelf-report(N � 28)

NonusersStaffReport(N � 31)

Any problem 70% 29% 46% 84%No need/no problem 31% 71% 54% 16%Service needed (cleaning, batteries) 6% — — —Not functioning well/broken 36% 7% 4% 3%Not fitting well, hurts, not tolerated 21% 5% 7% 10%Hard to use/inconvenient 42% — 7% —Too expensive 3% — 11% —Lost, afraid of losing — 12% 4% —No evaluation — — 14% 10%Do not know — 5% — 55%Physician did not recommend/will not help — — 7% 3%Refuse anything — — — 3%Resident needs help putting devices on (n � 30 resident,

40 staff)43% 62.5%

Resident needs help taking devices off (n � 30 resident,37 staff)

13% 54%

Resident needs help changing batteries (n � 29 resident,37 staff)

62% 86.5%


designated with the task of managing a resident’s hearing aid.In these cases, multiple people (eg, nursing assistant andcharge nurse) were listed as responsible, or the resident’sfamily was indicated as responsible for putting the hearing aidin, taking it off, or for changing the batteries.

Nursing staff and residents provided use and maintenanceinformation for residents who currently use hearing aids.Nursing assistants were most often described as providing helpin putting hearing aids on, taking them off, and changingbatteries, although others (eg, charge nurse or medicine aide)were also performing these duties for some residents. Lack ofclarity regarding delegation of some of these duties was re-ported for 10 of 36 residents who reported or were reported inneed of help in any of the three tasks. Additionally, fiveresidents were reported to depend on relatives for help insome of these activities. It should be noted, however, thatthere was considerable discrepancy between staff and residentreports on the need and identity of help with hearing aids.

Another issue concerning unit-level systems of auditorycare emerged involving unit policies concerning such care.Two of the 12 units have policies in which the medicine aidewas specifically designated as the staff member in charge ofhearing aid management. The medicine aide was responsiblefor putting hearing aids on for residents in the mornings,taking them off in the evenings, and storing them in adesignated place in the nursing office when not in use. Incontrast, in all other units, the resident’s caregivers, mostoften the nursing assistants, performed these activities andstored the hearing aid in the resident’s bedside cabinet.

Additionally, it was determined that of the 16 units ques-tioned, only one had an otoscope on the unit for general use.None of the others owned either an otoscope or an assistivelistening device. Two of the nurse managers mentioned thatphysicians on their units bring their own otoscopes to theunit.

Societal-Level Barriers

With respect to cost being a prohibitive factor for thepurchase or replacement of hearing aids, four residents re-ported cost to be the primary factor for not having a hearingaid. There were additional residents who reported lost orbroken devices to be the primary factor related to nonuse, and

the reason for nonreplacement could be related to cost. Care-givers reported lost or broken devices to be the primary factorrelated to nonuse for eight residents.

DISCUSSION

As demonstrated in part 1, the most common barrier in-volving the largest number of residents is inadequate screen-ing, resulting in a lack of recognition of hearing impairmentsand the need for hearing aids. Current findings add to theissue of underdetection and suggest that inadequate treatmentof hearing loss in the nursing home also stems from a combi-nation of factors involving design characteristics of hearingaids, resident limitations, and nursing home systems of care.

Design characteristics of the hearing aids were identified asproblems limiting effective use of the devices. Residents com-plained that the devices either did not fit well, hurt, were hardto use, or did not work properly. Such complaints correspondto complaints regarding hearing aids by other users4,8,9,11–13

and underscore the need to improve the quality of hearingaids. Additionally, for this frail population, the frequent needto change batteries poses a significant burden. Current find-ings showed that 62% (self-report) to 86% (CNA report) ofresidents required assistance performing this function. Thesefindings suggest that an improved design of hearing aids thatallows for longer-lasting batteries, a more comfortable fit,easier adjustment (eg, remote ability to locate the hearingaid), and overall better functioning (eg, fewer rates of mal-function, more durable material that would decrease breakrates) could increase the use of hearing aids in this population.Given the level of cognitive deterioration in this population,the ease of use and comfort should be considered the mostimportant aspects of a hearing aid device. These needs couldbe slightly different than those of community-dwelling el-derly, who are often concerned with vanity issues and socialimpact of their hearing aids.

An additional factor that has been identified regarding thehearing aids and reported problems with design characteris-tics, however, is the critical need for sufficient follow up withelderly recipients to ensure not only proper fit and venting,but also that the individual understands how to use thedevices.17 Dissatisfaction and rejection of the devices is more

Table 2. Staff’s Lack of Knowledge of the Use and Maintenance of Hearing Aids

No. of Residentsto Whom IssuesApply (n � 242)

No. of NursingAssistants ReportingThese Issues (n � 48)

Lack of training on use/maintenance 41.3% 45.8%Lack of knowledge regarding

Turning hearing aid on/off 3.3% 6.3%Checking to see if working 9.5% 12.5%Changing batteries 6.2% 12.5%Checking/cleaning for wax 27.7% 31.3%

Any of the above four tasks 28.1% 31.3%

Note: These data refer to staff members’ responses regarding their knowledge and training. The 48 staff members who responded to thesequestions were responsible for 242 residents in the sample. The percentages are therefore presented as proportions pertaining to staffmembers or to the residents they work with.


likely without this attention, thus suggesting that these prob-lems could be a function not only of the design characteristicsof the devices, but also of insufficient training and follow upand individual limitations of the users.

With respect to individual factors, reported problems in-cluded intolerance of the devices and a limited ability to useand maintain hearing aids without assistance. Although thiscould in part be remedied with improved follow up for recip-ients, it is also likely to reflect limitations caused by cognitiveand physical impairments, thus shifting the responsibility ofeffective use to caregivers. Also, the use of hearing aids withthis population is frequently dismissed because of the claimthat these residents constantly lose the devices. In contrast,our results found low levels of reports of lost hearing aids. It ispossible, however, that some lost hearing aids are indeed thereason for lack of use in residents for whom the nursingassistant was not aware of the reason for nonuse.

The rates of individual-level barriers to hearing aid usediffered from those previously reported for cognitively intactelderly. The rates of difficulties related to quality such asbackground noise, comfort, or performance were much higherthan the 4% reported in a survey of hearing aid dispensers.10

Similarly, the rates related to handling the device (difficultieswith volume controls, inserting the aids, or with changingbatteries) found in this study were also considerably higherthan those reported in community-dwelling elderly.12

At the institutional level, the most prevalent barrier tohearing aid use is the lack of recognition among staff of theresidents’ hearing impairments. Current findings showed thatnursing staff providing daily care to residents identified hear-ing loss in only 42% of the residents identified by othersources as having impaired hearing (see part 1 of this article).Additionally, close to half (46%) of the nursing staff lackedtraining in the use and maintenance of hearing aids. Nearlyone third (31%) did not know how to check and cleanhearing aids for wax, potentially contributing to the limitedeffectiveness of the devices even when worn. With the ex-ception of two units that had designated persons responsiblefor hearing aid management, unclear delegation of responsi-bility was reported in all other units. Although not all resi-dents required assistance with hearing aid care, the lack ofdelegation likely contributes to underuse of the devices as wellas to the loss of hearing aids among the cognitively impaired.Finally, of 16 unit managers interviewed, only one reportedthat the unit owned an otoscope, and none possessed assistivedevices that could help those residents with hearing problemsbut who do not use hearing aids for whatever reason.

It was expected that cost would be a significant societal-level factor in the underuse of hearing aids. However, thehigh cost of hearing aids was rarely mentioned as a barrier.Only 11% of residents with hearing problems who do not usehearing aids cited financial reasons for not having the devices,and it was not cited by any of the nursing staff interviewed asa possible barrier. It is possible that this is an underestimate ofthe actual problem, because lost or broken devices might notbe replaced because of the cost. Additionally, in this study, wewere unable to ask the family members or the charge nursesfor the reasons, and they could have provided additional

insight. Costs would probably be mentioned much more oftenby the person who actually makes the decision whether topurchase a hearing aid.

The high cost and lack of coverage of hearing aids is likelyto prevent not only the purchase of hearing aids for someresidents, but also sufficient screening with thorough audio-logic evaluation. It is possible that without resources to pur-chase hearing aids, evaluations might not be considered use-ful. To clarify the magnitude of costs, reports from three localagencies were obtained indicating that the cost of an audio-logic evaluation is approximately $140 in the nursing home.There is a wide range in the cost of hearing aids, with mostcosting over $1500, but prices range from $500 to over $2000.Cost could be partially covered by private insurance. Medic-aid pays for hearing aids in some states, usually providing onlypartial coverage.

To assess the relative importance of the different barrierswithin this sample, we combined the responses from allsources and analyzed some of the barriers in Figures 1–3.Figure 1 represents barriers among the 53 individuals claimedto have a hearing aid by the MDS, the nurse, or the researchassistant. Of these individuals, 28% were reported to have noproblems with the hearing aid by either the nursing staff orthe resident (this corresponds to 31% of persons for whominformation about problems was available). Sixty-four percent(or 69% of those for whom information about problems wasavailable) were reported to have a problem by at least one ofthe sources; problems with fit and difficulties using the aidwere most common, whereas others complained that thedevices did not work well or were broken.

Among the same 53 residents (Fig. 2) identified as possiblyhaving a hearing aid, only 11% (14% of those for whominformation was available) did not require help putting hear-ing aids on, taking them off, or replacing batteries. Sixty-eightpercent (86% of those for whom information was available)needed help; most of whom needed help with all three func-tions. This demonstrates the high level of dependence of theresidents on staff members for use and maintenance of hearingaids. Information could not be obtained from either residentor nurse for 21% of the 53 residents using the hearing aids.

Figure 3 depicts reasons for nonuse of hearing aids amongthose reported to have hearing problems. Only 16% weredescribed by at least one source as not needing a hearing aid.The most common problem was lack of information (71%).Either the respondent reported not knowing why the persondid not have a hearing aid or the resident could not bequestioned and the nursing staff was not aware of the hearingproblems or of whether the person had a hearing aid. Whena problem was identified, the most often mentioned problemwas lack of an evaluation. Problems with hearing aid functionand use were also mentioned as barriers.

These results highlight the complexity of barriers to hear-ing aid use in the nursing home. A general neglect of the issueis the most important barrier to effective use. However, issuesin optimizing the fit of devices, the follow up on broken andlost hearing aids, the clear and consistent assistance withmaintenance of hearing aids, and the resources to allow forappropriate hearing aid care all need to be addressed. Many


problems can be attributed to more than one level. For ex-ample, a resident report of an ill-fitting hearing aid couldreflect the high costs of replacement, lack of follow up by staffmembers, or lack of resident ability to put it in properly.

Because this study was a low-cost clinical investigation, welacked the resources to perform audiologic tests on all resi-dents. As discussed in part 1, evaluations would help toestablish the correct baseline of the prevalence of underde-tection of hearing dysfunction and a more precise estimate ofunderuse of hearing aids. Similarly, it would be preferable tointerview the complete care team, including charge nurse andfamily members, concerning the reasons for nonuse of hearingaids, but that was beyond the resources of this study. Indeed,the high level of the staff’s reports of ignorance as to thereason of nonuse of hearing aids could possibly obscure amyriad of unknown reasons. An additional limitation to gen-eralization lies in the fact that the nursing home is relativelyhighly staffed with both medical and nursing staff, has aconsultant audiologist, and had a fund that contributed tohearing aids so that hearing aid use reported here couldactually be higher than that in the industry.

Future research needs to examine how many people willactually benefit if proper screening and follow-up processes areput in place. The number could range from the majority ofnursing home residents, given the prevalence of hearing prob-lems in this population and given the prevalence of problemshandling hearing aids, or it could be a relatively small minor-ity who can actually use a hearing aid sufficiently to improvecommunication and to be able to access auditory stimuli inactivities. Regardless of the percentage, the impact of im-proved hearing on cognitive ability, functional status, inap-propriate behavior, and overall quality of life is such that we

Fig. 1. Problems with hearing aids among hearing aid users—combined staff and resident responses (n � 53).

Fig. 2. Hearing aid users: Rates of help needed for use andmaintenance of hearing aids with the three tasks of putting thehearing aids on, taking them off, and changing batteries (n � 53).


believe it is mandatory that nursing homes work toward improv-ing it. Furthermore, when hearing aids are not feasible forreasons of cost, or difficulties in residents keeping them in placeor adjusting them, alternative devices should be used routinely.Such devices include amplifiers, telephones with switches forvolume control, microphones for groups activities in whichresidents can be hooked into a line feed or wireless connectionthat provides amplification (http://www.soundinstitute.com/article_detail.cfm/ID/73), or a pocketalker, an amplifierthat can be used in combination with a variety of head-phones and with a variety of distances between talker andlistener (http://www.wasa-shhh.org/Amplification.pdf).

CONCLUSION

As a result of this project, a quality improvement processwas initiated. It resulted in several policy changes and reso-lutions, including hearing evaluations on admission; im-proved delegation of responsibility for those identified as notable to manage their hearing aids; provision of amplifiers,otoscopes, and specific tools for hearing aid maintenance (eg,battery testers and cleaning kits) to all units; and continuedin-service training in hearing aid maintenance and care fornursing staff. Specific changes in policies and procedures areavailable on request (JCM).

Barriers to hearing aid use emerge as complex and mul-tifactorial, involving lack of a system commitment to use ofhearing aids, lack of knowledge by staff members, inappro-priate delegation and care procedures, hearing aid designand fit issues, as well as difficulties of residents in handlingthe hearing aids. Addressing these issues requires changeon multiple levels, including change at the institutionallevel, concerning policy and training; change at the unitlevel, regarding care procedures and follow up; change atthe individual level, providing better checks of fit andfunction of the hearing aids; and finally, change at thesocietal level, addressing design and cost issues for hearingaids in this population.

Medical directors are in a position to effect institutional-level change regarding many of these identified issues such asimproving the frequency of audiologic care, including hearingexaminations and wax removal. Medical directors could alsoattempt to work with the nursing department on improvednursing-level hearing testing and improved follow-up proce-dures for those residents who receive hearing aids. Such followup includes consistent hearing aid care and frequent assess-ment of hearing aid function. Training and monitoring ofnursing staff performing these procedures has to be included inthis operation.

Fig. 3. Reasons for nonuse of hearing aids among hearing impaired nonusers (n � 22).


ACKNOWLEDGMENTS

This study was supported by grants from the AMDA Foun-dation/Pfizer Quality Improvement Award, the GoldmanFund, and the Rothstein Family. The authors thank LindaHarris, RN, for her contribution to the policy examples.

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New concepts. J Am Geriatr Soc 1995;43:928–935.2. Palumbo MV. Hearing Access 2000: Increasing awareness of the hearing

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home: An institutional issue. J Am Geriatr Soc 1990;38:141–145.4. Schluter LA. Careprovider guidelines for adapting hearing aids and

instructing the elderly in their use. Phys Occup Ther Geriatr 1989;7:71–81.

5. Durrant J, Gilmartin K, Holland A, et al. Hearing disorders managementin Alzheimer’s disease patients. Hear Instrum 1991;42:32–35.

6. Palmer CV, Adams SW, Bourgeois M, et al. Reduction in caregiver-identified problem behaviors in patients with Alzheimer’s disease post-hearing-aid fitting. J Speech Lang Hear Res 1999;42:312–328.

7. Weinstein BE, Amsel L. Hearing loss and senile dementia in the insti-tutionalized elderly. Clin Gerontol 1986;4:3–15.

8. Thibodeau LM, Schmitt L. A report on the condition of hearing aids innursing homes and retirement centers. J Acad Rehab Audiol 1988;21:113–119.

9. Franks JR, Beckmann NJ. Rejection of hearing aids: Attitudes of ageriatric sample. Ear Hear 1985;6:161–166.

10. Kochkin S. Hearing professionals’ views on market expansion, part 1:Why don’t people buy hearing instruments? Hear Instrum 1991;42:6–8.

11. Gianopoulos I, Stephens D, Davis A. Follow-up of people fitted withhearing aids after adult hearing screening: The need for support afterfitting. BMJ 2002;325:471.

12. Henrichsen J, Noring E, Christensen B, et al. In-the-ear hearing aids:The use and benefit in the elderly hearing-impaired. Scand Audiol1988;17:209–212.

13. Parving A, Sibelle P. Clinical study of hearing instruments: A cross-sectional longitudinal audit based on consumer experiences. Audiology2001;40:43–53.

14. Smedley T. Self-assessed satisfaction levels in elderly hearing aid, eye-glass, and denture wearers. Ear Hear 1990;11(suppl):41S–47S.

15. Brooks D. Some factors influencing choice of type of hearing aid in theUK: Behind-the-ear or in-the-ear. Br J Audiol 1994;28:91–98.

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Tips for Clinicians

Digital Noise Reduction: How it works in hearing aids

In noisy situations, understanding speech in relation to loudness comfort has traditionally been among the topcomplaints of hearing instrument wearers. The noise reduction systems in analog or first generation instrumentstypically reduce loudness in large “chunks” of the instruments’ frequency response. Unfortunately, these large chunksof reduced frequency response also include many needed speech frequencies, and cause speech perception to besignificantly corrupted.

Today, many digital hearing aids use a variety of multi-band noise reduction systems which discretely andcontinuously monitor the speech-to-noise ratios of up to twenty frequency bands.

The incredibly rapid sound modulation analysis capability of these instruments detects and reduces overalldominant and peak areas of unwanted noise. However, they do this in very small frequency areas instead of largechunks of the combined speech and noise signal, thus preserving speech intelligibility even in the presence of noise.This feature, when used in combination with a directional microphone system, provides patients with speech clarityunequaled in the history of hearing aid usage.

Leonard Reid, PhDClinical Audiologist


hearing aid use in nursing homes, part 2: barriers to effective utilization of hearing aids

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