Tech Topic | June 2019 Hearing Review

A large portion of individuals with dementia also have hearing loss.  When these patients are fitted with hearing aids for the first time, the use and operation of the instruments can be a struggle, and the struggle often carries over to their caregivers.  This research found that the use of teleaudiology via Signia TeleCare for these new hearing aid users increased awareness, improved benefit for several different communication settings, and reduced associated stress for the caregivers.

Within the United States, approximately 5.7 million people are living with dementia.Alzheimer’s disease accounts for approximately 60%-70% of these cases, followed by vascular dementias. These numbers are expected to rise in the next few decades, as life expectancy increases. The older the individual, the more likely he or she will be affected by dementia. It is rare for someone under the age of 65 to have dementia, but approximately 1 in 70 people aged 65-69 have this disorder, and nearly 1 in 4 people aged 85-89 have dementia. Given the aging demographic of Americans, the number of patients with cognitive concerns will only grow.2

We also know that approximately 1 in 3 people between the ages of 65 and 74 has hearing loss, and nearly half of those older than age 75 have difficulty hearing. When comparing these hearing loss data to the dementia prevalence findings, we see that for older individuals, there is a relatively high probability of having both dementia and hearing loss. There is also a growing body of literature suggesting some interaction between a person having hearing loss and the likelihood of them also presenting with dementia.3

The detrimental effects of hearing loss and dementia can extend to other people in the elderly patient’s life, especially significant others and care givers. Interaction between the hearing-impaired patient and their significant other or caregiver may be hindered due to the resulting communication deficits and breakdown. This can lead to frustration and a lesser desire to communicate for both parties. It is possible that the patient’s caregiver may actually benefit from the patient using hearing aids more than the patient, as communication will be more effective, less stressful and anxious, and make it a more enjoyable experience.

People with cognitive impairment may not need continual care, but family members or friends often take over the more complex instrumental activities of daily living, and provide regular support for the person. This causes an increase in caregiver burden. This is not only associated with an adverse emotional state and psychiatric morbidity, but can have a negative impact on the physical, financial, and social aspects of the caregiver’s life as well.

One area where the caregiver burden can exist is related to the recipient’s use of hearing aids, especially for a new hearing aid user. On average, new hearing aid users require 3-4 office visits—and maybe more if considerable fine-tuning is needed or if physical fit issues exist—to achieve an optimal fitting. When cognitive problems are present, extra time may also be needed for training regarding the use and care of the hearing aids. In many cases, the caregiver is not only responsible for assisting in the day-to-day use and adjustment of hearing aids, but also must assist the patient in getting to and from the necessary appointments.

Today, many of these issues can be handled through hearing aid telecare software, such as Signia TeleCare. TeleCare is an umbrella term to describe the provision of hearing healthcare services from a distance by using modern telecommunication systems including wireless communication. Through TeleCare, hearing care providers (HCPs) can reach out to the patients, reduce barriers, make programming changes to the hearing aids, improve user satisfaction, and help avoid patients having to travel or be transported to receive high quality hearing-related care. TeleCare can benefit the patient by allowing problems to be solved in a timely matter. And, related to our discussion here, TeleCare also can be very useful for the caregiver of a hearing aid user with dementia.

Previous studies with Signia TeleCare have been encouraging. In independent research conducted at the University of Western Ontario, participants using hearing aids rated their communication ability for several self-selected communication settings.The ratings were conducted both before and after a home trial. During the home trial, the participants used Telecare, and completed satisfaction ratings for each listening condition. One aspect of the research centered on the number of situations where the participant was Very Satisfied or Extremely Satisfied. Prior to the home trial, 13% of the situations received a rating of Very Satisfied, and only 3% a rating of Extremely Satisfied. Following the home trial with TeleCare intervention, 32% and 38% of situations received a rating of Very Satisfied and Extremely Satisfied respectively. That is, 70% of the combined 60 situations received a highly satisfied rating; importantly, 23 (38%) of these 60 situations involved speech understanding in background noise.4

Given the known advantages of TeleCare for patients using hearing aids, we questioned if caregivers also would embrace the use of this feature, and if it might reduce the stress and burden for caregivers who are attending to patients with dementia who have been fitted with hearing aids for the first time. Additionally, we questioned if the use of TeleCare resulted in improved communication for the patient, as reported by the caregiver.

Clinical Study 

Research was conducted at the University of South Dakota Speech, Language, and Hearing Department. Participants were recruited through clinical records and notices at various local facilities. Primary inclusion requirements were a bilateral hearing loss severe enough to warrant amplification, a desire to use hearing aids but not a previous consistent user, a score of 28 or lower on the education-corrected Mini-Mental State Examination (MMSE) but still had their own power of attorney, and a caregiver willing to participate in the study who was skilled in using a compatible smartphone to operate the Signia TeleCare.

The resulting participants were 19 males and one female (20 total) age 62-84 (mean 72 years). The caregivers were 19 females and one male ranging in age from 54-77 (mean 65 years). All participants had bilateral downward sloping hearing losses, with the mean audiogram showing hearing loss ranging from 20-25 dB in the low frequencies (250 and 500 Hz) dropping to 60-65 dB in the high frequencies (6000 and 8000 Hz). Their mean education-corrected MMSE ranged from 23 to 27 with a mean of 25.

All participants were new hearing aid users and were fitted bilaterally with the Signia Pure 7Nx using click sleeve coupling appropriate for their hearing loss. The hearing aids were programmed using the Signia Connexx 8.4 software to NAL-NL2 adult prescriptive targets, verified with probe-microphone measures for soft, moderate, and loud inputs to ensure comfort and audibility.  All directional and noise reduction features were activated. The client was enabled in Signia TeleCare via the Connexx software. The myHearing app was downloaded from Google Play or the Apple App Store and paired to the hearing aids prior to leaving the fitting appointment. Research staff had access to TeleCare at the Signia Internet portal (https://telecare.signiausa.com/#/login). The portal was checked throughout the work week for messages from the caregiver. Counseling through “Messages” was conducted, and remote fine-tuning adjustments through “Remote Tuning” were completed when needed.

The specific features of Signia TeleCare included:

  • The ability to remotely monitor indicators, such as wearing time, program use, and situation classification to determine when intervention might be necessary.
  • Ability to track the patient’s satisfaction for different real-world listening conditions to determine if programming changes or additional counseling were warranted.
  • The option to deliver at-home patient care by solving issues after the initial fitting through remote programming changes to the gain, output, frequency response, noise reduction, and other algorithms.
  • Real-time video calls, as well as text and voice CareChat capabilities, for easy and direct communication between the HCP and the patient/caregiver.

A crossover design was used, with individuals randomly assigned to one of two equal groups, which included a total of 6 weeks of hearing aid use. Group 1 received TeleCare for the first 3 weeks, but not the last 3 weeks. Group 2 was not informed of TeleCare for the first 3 weeks, and then used TeleCare for the final 3 weeks of their trial. During the 3-week period when the participants were not using TeleCare, they were scheduled for an in-person follow-up clinic visit, along with their caregiver, mid-way through the 3-week trial. All participants and caregivers returned to the clinic at the end of the 6-week home trial. In total, all participants and caregivers made at least 3 visits to the University Clinic.

As mentioned earlier, the task of bringing patients with dementia to medical appointments can be a burden for caregivers. The University of South Dakota is located in a small university town, with minimal traffic and parking issues. However, because of the rural nature of the location, it was necessary for many of the participants to travel a considerable distance for their clinic visit. On average, this distance was 37 miles, with some traveling from a distance of 100 miles or more.

At the time of the initial fitting, using a COSI format,each caregiver was asked to nominate three listening situations that they believed were important for the participant, and where they would want to see improvement using hearing aids. At the end of the first 3 weeks of hearing aid use (ie, the cross-over point), all participants and caregivers returned to the clinic, and the caregivers completed three scales:

1) The COSI scale of the three nominated communication items, rated in the conventional 5-point COSI format: 1 = Worse to 5 = Much Better.

2) A behavioral change scale, scored in the same manner as the COSI. This scale was based on the findings of Palmer et alin their research involving the use of hearing aids with patients with dementia. Five behavioral characteristic were assessed: Engage in conversations; Engage in interactions; More aware of environmental sounds; Paying attention to TV, and General alertness.

3) An 11-question 5-point burden scale (1 = minimal burden to 5 = significant burden). Some of the items of this scale were adapted from the Burden Scale for Family Caregivers (BSFC).7

At the end of the study (6-weeks of hearing aid use) the caregivers returned to the clinic and again completed the three scales above, and also a fourth scale consisting of three questions related to their use of TeleCare (7-point scale; 1 = Significantly Disagree, 4 = Neutral, 7 = Significantly Agree).

Study Findings

To review, this study featured a 6-week cross-over design in which both study groups used TeleCare for 3 weeks, and were without it for 3 weeks. Caregivers completed three different scales that examined: 1) The benefit obtained by the participants for the three COSI communication items selected by the caregivers; 2) Behavioral changes of the participants while using hearing aids, and 3) Ratings of burden by the caregiver relative to their care of the participant adjusting to hearing aid use.

COSI ratings.To facilitate the analysis of the nominated COSI items (total items = 60; three from the caregiver of each participant), the items were grouped into 6 different categories: Speech understanding in background noise, in the car, listening to television, on the phone, with significant others, and a general category including goals related to overall comprehension (eg, not asking “What?” all the time). Figure 1 shows the mean COSI ratings (by the caregiver) for the period of TeleCare use versus non-use.

As shown in Figure 1, the overall ratings for the COSI items revealed a general trend toward improvement when using hearing aids. Regardless if TeleCare was used, most all categorical mean ratings were at 3.0 or higher (#3 rating = Somewhat Better). What stands out, however, is the difference when TeleCare was part of the post-fitting treatment plan. The benefit derived from TeleCare was present for all categories, and significant for 4 of the 6 categories (p<.05). The difference in mean performance was quite substantial in many of the categories, with the greatest difference for “general comprehension,” where the average rating was 4.5 when TeleCare was applied versus only 2.7 when it was not.

Figure 1. Mean COSI ratings (completed by the caregiver) regarding the participants’ performance for a given 3-week period. Mean values for TeleCare use versus when TeleCare was not used are shown.  Ratings conducted using a 5-point scale (1 = Worse to 5 = Much Better).  The 60 COSI items provided by the caregivers were categorized into six areas: speech understanding in background noise, in the car, listening to television, on the phone, with significant others, and a general category related to overall comprehension.  The error bars represent 95th confidence intervals, and significant differences (p<.05) between the TeleCare condition are denoted by an asterisk.

Figure 1. Mean COSI ratings (completed by the caregiver) regarding the participants’ performance for a given 3-week period. Mean values for TeleCare use versus when TeleCare was not used are shown. Ratings conducted using a 5-point scale (1 = Worse to 5 = Much Better). The 60 COSI items provided by the caregivers were categorized into six areas: speech understanding in background noise, in the car, listening to television, on the phone, with significant others, and a general category related to overall comprehension. The error bars represent 95th confidence intervals, and significant differences (p<.05) between the TeleCare condition are denoted by an asterisk.

Changes in general behavior. In a 1999 publication related to hearing aid use with patients with dementia, Palmer and colleaguesreported that caregivers cited many positive changes that occurred when patients with dementia began using hearing aids. We used these comments to formulate a questionnaire focused on the behaviors reported. The mean findings (as reported by the caregivers) are shown in Figure 2. Regarding benefit from hearing aid use in general, improvement was noted for all areas (eg, a mean rating of 3.0 or better). Interestingly, for two areas—awareness and alertness—the ratings were significantly higher (p<.05) when TeleCare was used. This certainly could be partially related to the remote programming of the hearing aids when the need was present. It’s also possible that a contributing factor was the increased communication regarding the hearing aids via TeleCare, which might have simply made the caregiver more aware of the benefits of amplification for the participant.

Figure 2. Mean ratings (completed by the caregiver) for the five different general areas of behavior potentially related to hearing aid use. Mean values for TeleCare use versus when TeleCare was not used are shown.  Ratings conducted using a 5-point scale (1 = Worse to 5 = Much Better). The error bars represent 95th confidence intervals, and significant differences (p<.05) between the TeleCare condition are denoted by an asterisk.

Figure 2. Mean ratings (completed by the caregiver) for the five different general areas of behavior potentially related to hearing aid use. Mean values for TeleCare use versus when TeleCare was not used are shown. Ratings conducted using a 5-point scale (1 = Worse to 5 = Much Better). The error bars represent 95th confidence intervals, and significant differences (p<.05) between the TeleCare condition are denoted by an asterisk.

Caregiver burden. The caregiver completed an 11-question burden scale following each 3-week segment. We need to point out that most burden scales are designed for caregivers who are dealing with issues much more severe than someone using hearing aids for the first time (ie, caring for a bedridden significant other is much more burdensome than helping someone change the battery of their hearing aid). Additionally, the participants in our study only had mild cognitive decline, which again reduced the burden. For these reasons, the mean ratings for nearly all items on the 1 to 5 burden scale (5 = Extreme Burden) were below 2.0, with many near 1.0 (no burden). There was one exception, however, which was for the item: “How much stress do you feel between taking care of the care receiver and trying to meet other responsibilities of work and family?” This item had a mean 3.0 rating when TeleCare was not used, but importantly, it was lowered to 2.1 during the period of TeleCare use, a significant difference (p<.05).

TeleCare acceptability.The specific use of TeleCare by the caregiver was rated on a 7-point scale (1 = Significantly Disagree, 4 = Neutral, 7 = Significantly Agree). Positive group findings were obtained for all three of the questions asked:

  •  “Using telecare helped take care of hearing aid concerns and needs of the care-receiver”: Mean = 4.7 (1 to 7 scale).
  • “TeleCare was easy to use and understand”: Mean = 5.9 (1 to 7 scale).
  • “The use of telecare helped reduce my stress of taking care of the hearing aid needs of the care-receiver”: Mean = 5.4 (1 to 7 scale).

For all three of these questions, only 15% of the responses fell in the “Neutral” category, and no responses were below Neutral.

Summary and Conclusions

Changes in communication functioning due to cognitive decline, together with behavioral changes, can have a significant impact on day-to-day interactions and can result in considerable frustration. Family members and those who care for individuals with dementia are faced with challenges that can affect their own health and well-being. One of these challenges occurs when the dementia patient is fitted with hearing aids. Working with caregivers to use effective strategies that enhance communication and maximize the benefits offered by hearing aid use, may help them engage in conversation more successfully, and improve quality of life for the individual with dementia.

Our findings show that at least through the eyes of the caregiver, using TeleCare significantly enhances specific listing goals for the dementia patient. Not only are communication goals improved, but the patient’s awareness and alertness also are significantly impacted. Moreover, the caregiver reports less stress when TeleCare is used.

These findings suggest that involving caregivers in the fitting process, facilitated through TeleCare, will help maximize hearing aid benefit and satisfaction for the patient with dementia.

Lindsay Jorgensen, PhD, Taylor VanGerpen, Thomas A. Powers, PhD, and Dirk Apel bio.

Lindsey Jorgensen, PhD, is an associate professor at the University of South Dakota and is a Research Audiologist for the Department of Veterans Affairs in Sioux Falls, SD, as well as in Pittsburgh, Pa; Taylor Van Gerpen, BS, is in her fourth year of the Doctorate of Audiology at the University of South Dakota; Thomas A. Powers, PhD, is Managing Member of Powers Consulting; and Dirk Apel, BS, is the Head of Enhanced Consumer Experience, a team within the Sivantos Group based in Erlangen, Germany.

Correspondence can be addressed to Dr Jorgensen at: Lindsey.jorgensen@usd.edu

Citation for this article: Jorgensen L, Van Gerpen T, Powers TA, Apel D. Benefit of using telecare for dementia patients with hearing loss and their caregivers. Hearing Review. 2019;26(6):22-25.

References

  1. Dementia: Overview. American Speech-Language-Hearing Association (ASHA). https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289&section=Overview.

  2. Hearing loss and older adults. National Institute on Deafness and Other Communication Disorders (NIDCD). https://www.nidcd.nih.gov/health/hearing-loss-older-adults. Updated July 17, 2018.

  3. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. JAMA Neurology.2011;68(2):214-220.

  4. Froehlich M, Branda E, Apel D. Signia TeleCare facilitates improvements in hearing aid fitting outcomes. https://www.audiologyonline.com/articles/signia-telecare-facilitates-improvements-in-24096. Published January 4, 2019.

  5. Dillon H, James A, Ginis J. Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. J Am Acad Audiol.1997;8:27-43.

  6. Palmer CV, Adams SW, Bourgeois M, Durrant J, Rossi M. Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting. J Sp Lang Hear Res.1999;42(2):312-328.

  7. Blieszner R, Roberto KA. Care partner responses to the onset of mild cognitive impairment. Gerontologist. 2010;50(1):11-22.