Case Scenario

One of my patients brought her father as a new patient to my office. The man had moved nearby after his wife's death a year ago. His daughter said she thought he was depressed, because he didn't talk as much as he used to, and he wasn't interested in “going out and doing things.” As I talked with the man alone, I found him to be sad about his wife's death, but he denied feelings of depression—he said he was sleeping well, eating well, and enjoying watercolor painting. He scored well on the Mini-Mental State Examination and had no important medical problems except mild hypertension.

I noticed that he asked me to repeat myself several times, so as part of his work-up, I ordered a routine hearing test. His audiogram suggested bilateral hearing loss. At the close of the visit, I spoke to both the patient and his daughter, suggesting that one of his problems could be a hearing loss, which might explain his reluctance to engage in social activities. They agreed to try hearing aids.

A few months later, the patient and his daughter returned to the office. His daughter stated that they had gotten hearing aids for him, but that he never wore them. “And I still can't get him to go out and have fun,” she complained. I looked over at the patient, who was smiling at me. I wasn't sure he'd heard.

Commentary

This brief vignette raises questions about the biopsychosocial aspects of presbycusis. The answers to these questions can help guide clinical strategies for patients with hearing loss and their family members.

Why did the doctor notice the hearing loss, but the daughter didn't?

When hearing loss is slowly progressive, the patient and family members may be unaware of the ways in which they have modified behaviors to accommodate the hearing loss. Over time, people develop strategies that help them to continue some of their usual activities (e.g., sending a family member to tell the relative with hearing loss that dinner is ready, rather than calling to him from another room). Perhaps it was simply easier for the patient to speechread his daughter than the physician.

In this case scenario, the patient's hearing loss is newly diagnosed but may not be of recent onset. It is possible that the man and his wife had developed accommodative behaviors that kept him more connected to the outside world. If it was relatively easy for him to speechread his wife, he could have watched her in social activities to help him follow conversations. Being able to focus mainly on his wife would have been particularly helpful in group conversations, where one of the challenges of speechreading is knowing who will speak next so as to not miss any lip movements. With the death of his wife, this patient may have also lost much of his connection to the outside world.

What should a physician know about speechreading?

Speechreading is difficult. Only 30 percent of English sounds are distinguishable on the lips. Speechreading is easier when the person knows the topic or the speaker, and when the speaker's face is easy to see. In this scenario, the doctor is unfamiliar to the patient, which can make speechreading more difficult. Or the doctor may have a mustache or beard, or may tend to look away from the patient when speaking (e.g., looking down at the chart). The topics and vocabulary may be unfamiliar to the patient, and the frequent topic changes during an initial medical visit may be difficult for someone with hearing loss to follow.

Clinicians who suspect hearing loss in a patient can maximize the person's ability to speechread in the following ways:

• Keep the clinician's face (and the faces of all present) fully visible.

• Avoid backlights.

• Minimize background noise.

• Enable the patient to look at the clinician.

• Do not exaggerate word sounds or lip movements.

• Be explicit about topic changes.

• Check comprehension.

• Try speaking in a lower pitch (acquired hearing loss in older adults commonly affects higher frequencies).

Why doesn't the patient talk much?

Acquired hearing loss and depression are underdiagnosed, particularly in older adults. Avoidance of conversations can be a sign of depression or hearing loss. Because hearing loss makes it difficult to participate in conversations, one way to deal with that is for the person to avoid conversations by simply not talking.

Because hearing loss affects only the listening aspect of conversation, another way to deal with hearing difficulties is to do all the talking. Talking without listening does not draw attention to a hearing loss and does not require the effort of speechreading. Whether a person avoids conversations by not talking or by not allowing others much chance to talk, the result can be relationship difficulties within families and at work.

Why doesn't the patient use his hearing aids?

Clinicians should ask why a patient is not using hearing aids and how they were obtained. This patient maybe in denial about his hearing loss, or he may, as his daughter suspects, be depressed and withdrawn. He has certainly had significant life changes to adjust to in the past year—his wife's death, a move, a new doctor, and possibly a new hearing loss. Depression can be difficult to diagnose in older adults, and depressed mood may be absent. Tools such as the Beck Depression

Inventory can help in the diagnosis. If mood or adjustment disorders are diagnosed and adequately treated, his social withdrawal may improve, and he may be more interested in using his hearing aids.

Denial by a person with hearing loss may be more frustrating for physicians and family members to address. Since hearing loss affects family communication, referral to a family therapist may help patients see how their denial and hearing loss are affecting family members.

Family therapy may also help families identify other psychologic, social, or cultural barriers to hearing-aid use. For example, in mainstream U.S. culture, hearing aids often carry a stigma associated with disability and aging. In this case, acknowledging age or disability through the use of hearing aids may be difficult for this patient so soon after the loss of his wife.

Another possibility is that the hearing aids do not help the patient. Just as it is possible to buy reading glasses without a prescription or professional guidance, it is possible to buy hearing aids that are not matched to the patient's needs. Audiography performed in the family physician's office can help to diagnose hearing loss, but referral to an audiologist may improve the chance of a successful treatment plan.

An audiologist can test the patient's ability to hear and understand speech, both with and without amplification. Hearing aids that only amplify selected frequencies or that allow the patient to adjust the amplification setting based on the situation may be better for this patient. Sometimes a hearing loss is so profound that hearing aids do not help at all. In these cases, the audiologist may suggest other devices, such as a cochlear implant.

It is also possible that the hearing aids are uncomfortable or difficult for the patient to use. Hearing aids that amplify all sound frequencies may be painful if the sound being amplified is at a frequency that the patient hears well. If the hearing aid is not well fitted to the patient's external auditory canal, it may be bothersome or difficult to keep in place.

Otitis externa is not uncommon in people who wear hearing aids, so an examination may be warranted if the person reports pain or drainage. Most hearing aids are small, and their batteries are smaller, which can make them difficult to operate, particularly for a person with large or arthritic fingers.

Why doesn't the patient want to go out and have fun?

Until a person has adjusted to an acquired hearing loss, the concept of “going out and having fun” often seems to involve being able to hear. Concerts, dances, movies and theater, and conversations at parties or sporting events require hearing for full participation. Background noise can make even one-on-one conversations difficult.

It would be helpful for the physician to explore how the daughter and the patient define “going out and having fun.” Some theaters, concert halls, and cinemas are equipped with personal amplification systems to help share the performing arts with people who have hearing loss. Open-captioned films and subtitled foreign films are sometimes accessible options for people with adequate vision and literacy. Local advocacy and support groups for persons with hearing loss can suggest accessible activities in the area. Family counseling might help the patient to appreciate that his daughter's motivation is based on her love for him and might help the daughter to appreciate the challenge of going out with a hearing loss, and the other implications “going out” might have for her widowed father.

Would modifications to the patient's home be beneficial to him?

Even when denial is present, the patient may be willing to try assistive devices at home. Smoke detectors with flashing lights and alarm clocks that vibrate the bed are two examples that can help persons with hearing loss maintain safe independence. Signal lights can also alert the patient to a ringing doorbell or telephone. Headphones can allow the volume of a television or radio to be adjusted without disturbing family members or neighbors; some headphones may even work in theaters and cinemas. Using the television's captioning option can keep news and entertainment accessible. Specially trained working dogs can let their owners know about important sounds. Experiencing and acknowledging the benefits of these interventions can help the patient work through his denial. More information on these interventions can be found in the resources listed at the end of this commentary. Insurance coverage for assistive devices varies.

Acquired hearing loss and depression can be debilitating without appropriate interventions and support. Following up on clinical suspicions and collaborating with family members are important steps toward helping patients with either condition.