The Circle of Care For Older Adults With Hearing Loss and Comorbidities: A Case Study of A Geriatric Audiology Clinic
The Circle of Care For Older Adults With Hearing Loss and Comorbidities: A Case Study of A Geriatric Audiology Clinic
The Circle of Care For Older Adults With Hearing Loss and Comorbidities: A Case Study of A Geriatric Audiology Clinic
Research Article
Purpose: Older adults seeking audiologic rehabilitation often 84% had more than one comorbidity. Also noted were
present with medical comorbidities, yet these realities of hypertension (43%), falls (33%), diabetes (13%), and
practice are poorly understood. Study aims were to examine depression (16%). Integrating information from the
(a) the frequency of identification of selected comorbidities audiology chart and EHR provided a more complete
in clients of a geriatric audiology clinic, (b) the influence of understanding of comorbidities. Information about hearing
comorbidities on audiology practice, and (c) the effect of in the EHR included logs of outpatient audiology visits (75%
comorbidities on rehabilitation outcomes. of 135 cases), audiologists’ care notes for inpatients and
Method: The records of 135 clients (Mage = 86 years) long-term care residents (25%), and entries by other health
were examined. Information about comorbidities came professionals (60%). Modifications to audiology practice
from audiology charts (physical paper files) and hospital were common and varied depending on comorbidity. High
electronic health records (EHRs). Data about rates of success were achieved regardless of comorbidities.
rehabilitation recommendations and outcomes came from Conclusions: In this clinic, successful outcomes were
the charts. Focus groups with audiologists probed their achieved by modifying audiology practice for clients with
views of how comorbidities influenced their practice. comorbidities. Increased interprofessional communication
Results: The frequency of identification was 68% for visual, among clinicians in the circle of care could improve care
50% for cognitive, and 42% for manual dexterity issues; planning and outcomes for older adults with hearing loss.
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Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019 • Copyright © 2019 American Speech-Language-Hearing Association
Care of Older Adults With Multimorbidity, 2012). A survey one chronic health condition (other than hearing loss) was
of almost 2,000 adults (18 to 70 years old) found that at least reported by 79% of those who self-reported hearing loss
compared with only 68% of those with good hearing (Stam et depression, and/or diabetes. Cognitive loss could affect up to
al., 2014). Furthermore, research has linked hearing loss to 30%, falls could be an issue for almost half, and hyper-tension
numerous health conditions, with implications for could be a factor in more than half. It is difficult to estimate
rehabilitative audiology (Besser et al., 2018). how many may present with combinations of these
Among the relevant comorbidities for audiologists to comorbidities. Furthermore, comorbidities will affect a
consider are other sensorimotor declines (e.g., vision, man-ual growing percentage of people above 75 years of age.
dexterity) that may affect communication and device usage. Increasing awareness of these links has put a spotlight on the
Between 10% and 15% of individuals aged 75 years and older need for audiologists to understand more about the complex
report experiencing vision loss even when using glasses or medical history of older adults presenting for hear-ing help
contact lenses (e.g., Bizier, Contreras, & Walpole, 2016), and (Abrams, 2017). Research and guidelines for prac-tice are
dual (vision and hearing) sensory loss affects about a fifth of needed because there is a lack of direction from professional
those 80 years of age and older (Heine & Browning, 2015). organizations and regulatory bodies regarding whether and
Approximately 9% of individuals aged 65 years and older how audiologists should identify clients with comorbidities,
report dexterity disability (Bizier, Fawcett, modify their practice to accommodate for comorbidities, and
& Gilbert, 2016), and prevalence rates for difficulties with engage in interprofessional communica-tion in the circle of
upper extremity and hand function increase after age 65 years care.
(see Singh, 2009), with arthritis (other than osteoarthritis and
rheumatic arthritis) being associated with hearing loss (Stam et Circle of Care
al., 2014). Beyond audiology, geriatric health care could be
Audiologists should also be aware that hearing loss is a improved by promoting feelings of shared professional
risk factor for more rapid age-related declines in physical, responsibility (Stange, 2009) and increasing the effective-ness
cognitive, and mental health (e.g., falls, dementia, depres- of interprofessional communication among clinicians (e.g.,
sion). About 40% of those individuals 65 years of age and audiology, geriatric medicine, neuropsychology, optom-etry)
older who live in their own home will fall in any given year; in the circle of care for older adults who have hearing loss and
falls are even more common for those living in long-term care comorbidities (Pichora-Fuller, 2015). The term circle of care is
(LTC) facilities (Rubenstein, 2006), and hearing loss has been “…used to describe the ability of certain health information
associated with falls (e.g., F. R. Lin & Ferrucci, 2012). custodians to assume an individual’s implied consent to
Respectively, mild cognitive impairment and demen-tia affect collect, use or disclose personal health information for the
approximately 21% and 9% of individuals 65 years of age and purpose of providing health care…” (Information and Privacy
older (Knopman et al., 2016), and hearing loss has been Commissioner of Ontario, 2015, p. 1). In such an
associated with incident dementia (e.g., F. R. Lin, Metter, et interprofessional circle, clinicians with different speciali-
al., 2011). The prevalence of clinically significant symptoms zations work together and effectively communicate about and
of depression in the general population 65 years of age and manage their common client’s health conditions. How-ever, it
older is 15% (Blazer, 2003), and hearing loss has been is unclear whether, or how, information about hearing status
associated with depression (e.g., Huang, Dong, Lu, Yue, & and treatments is being exchanged in the cir-cle of care.
Liu, 2010). Medically complex older adults may be at risk for (a) not
In addition, audiologists should be aware of health being referred for hearing care, (b) not being appropriately
conditions such as hypertension and diabetes that may put treated by audiologists who are not informed about relevant
older adults at increased risk for hearing loss. The prevalence comorbidities, and/or (c) not fully benefiting from information
rate of high blood pressure is 71% for individuals 65 years of about their hearing being shared by audiologists with others in
age and older (McDonald, Hertz, Unger, & Lustik, 2009), and the circle of care. Care for older adults could potentially be
hypertension increases the risk of hearing loss (e.g., B. M. Lin improved by ensuring under-standing of and accommodation
et al., 2016). Diabetes affects 21.2% of those aged 65 years for hearing loss by allied health professionals and,
and older (McDonald et al., 2009) and has been associated reciprocally, understanding of and accommodation for medical
with hearing loss (e.g., Bainbridge, Hoffman, & Cowie, 2008). comorbidities by hearing health care professionals.
1204 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
health care may be the presence of medical comorbidities. Erber (2003) described how vision and motor skills could
Over a decade ago, Kricos (2000) reviewed evidence that influence everyday use and maintenance of hearing aids.
health status could influence rehabilitation outcomes, and
Nevertheless, little research has examined actual prevalence 39% male) seen at the Baycrest Hearing Services clinic for an
rates of comorbidities seen in audiology clinics offering ser- HAE appointment in 2015. Just over half of the participants,
vices to the oldest old and/or how comorbidities in older adults 76/135 (56%), were first-time hearing aid users, and the other
may influence their hearing health care–seeking and success. 59 (44%) were experienced users. The group pure-tone
average (0.5, 1.0, and 2.0 kHz) was 43.5 dB HL in the better
ear (SD = 14.4, range: 10–96.7) and 51.3 dB HL in the worse
ear (SD = 17.3, range: 13.3–113.3). Data on the living
Current Study arrangement of a client were available for just over half of the
The current case study of an example geriatric audi- cases (57%; 77/135). Of those for whom it was recorded,
ology clinic was conducted at the Hearing Services clinic at about half (52%; 40/77) received formal care, in-cluding care
Baycrest Health Sciences. The clinic is situated in a world- delivered at the client’s home (10%; 8/77), in a retirement
renowned, research-intensive geriatric teaching hospital with a home (25%; 19/77), or in LTC (17%;13/77). The other half
specialized focus on aging. Within this tertiary care setting, (48%; 37/77), who did not receive formal care, lived at home
the clinic provides a continuum of care to clients as they age, either alone (16%; 12/77) or with a family member who was
including services delivered to outpatients, inpatients, and almost always a spouse (32%; 25/77). Mar-ital status was
those living on site in the retirement home or LTC. On recorded for 60 clients; most were either mar-ried (48%) or
average, the clients are in their mid-80s, with ages ranging widowed (44%).
from 55 to over 100 years. These “oldest old”
(OO) individuals are rarely studied in the context of audio- Data Collection and Analyses
logic rehabilitation (Wattamwar et al., 2017). The caseload of Reviews of both the chart and EHR were conducted to
this clinic provides a rich opportunity for examining how quantitatively determine the frequency of the comor-bidities
hearing care may need to be tailored depending on the types of that were noted. The EHR was also reviewed to quantify
medical comorbidities experienced by older adults across an selected demographic information and to quantita-tively and
age range spanning several decades. The case study of this qualitatively examine sharing of information about hearing in
clinic is based on case records for all clients seen for hearing the circle of care. Quantitative and qual-itative data about
aid evaluation (HAE) in 2015 and focus groups with the rehabilitation recommendations and outcomes were gathered
audiologists who provided care for those clients. from the chart.
The goals of the study were to determine (a) the fre- Comorbidities. Visual, manual dexterity, cognitive
quency of identification of selected medical issues in the issues, depression, falls, hypertension, and diabetes were the
caseload, (b) the influence of comorbidities on audiology seven comorbidities examined in this study. They were chosen
practice, and (c) the effect of comorbidities on rehabilitation because of their associations with hearing loss and their
outcomes. potential relevance to audiologic rehabilitation. For each of
the chosen comorbidities, we coded three possible results:
“yes,” when it was noted that the client had the comorbidity;
Method “no,” when it was noted that the client did not have the
comorbidity; or “no response” (NR), when neither the presence
A mixed-methods design was used. Quantitative and
nor absence of the comorbidity was noted. Frequencies of
qualitative data were gathered using a chart review method.
“yes,” “no,” and “NR” responses were calculated for each
For each client, data were gathered by reviewing the physical
comorbidity noted in each source and all sources combined.
paper chart kept in the clinic (“the chart”) and the electronic
health record (“EHR”) stored online in the hospital infor-
A physical paper chart is maintained by the clinic staff
mation system and accessed by hospital staff through Medi-
for every client. It includes complete records of all client
tech software (Meditech). Additional qualitative data were
contacts (e.g., in-person appointments, phone calls), all
gathered from focus groups with all four clinical audiolo-gists
assessment and treatment forms (e.g., questionnaires, HAE
who work in the clinic. This study was conducted in
results), and financial records (e.g., purchase infor-mation
accordance with human ethics standards and received ap-
regarding hearing devices). Since 2004, visual, manual
proval from the institutional research ethics board.
dexterity, and cognitive issues have been screened routinely
at HAE appointments at this clinic, but no stan-dard
Chart Review procedures are used to collect information on the other four
comorbidities that were studied. Information about
Participants comorbidities was gathered in the chart based on responses to
Data were gathered from the records for all 135 clients selected questions about comorbidities on the standard HAE
(Mage = 86 years, SD = 7.4, range: 66–99; 61% female, history form and from notes about comor-bidities in
marginalia anywhere in the chart.
The EHR was examined as a supplementary source of
data about the frequencies of comorbidities. The EHR can
provide information regarding comorbidities and services
provided for those comorbidities. There are no standard
1206 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
used to elicit discussion around the topics described above.
With the audiologists’ consent, all focus group sessions were Analysis
audio-recorded to facilitate later analysis.
A qualitative content approach was used. This method
can be used to analyze text data, moving beyond counts of
Review of the Chart and EHR
occurrences of specific topics or words to create catego-ries Frequency of Identification of Comorbidities
that represent similar meanings or themes (Hsieh & Shannon, Table 1 shows the frequency of comorbidity identifica-
2005). It is one of the most common qualitative methods used tion based on the specific questions on the HAE history form,
in audiology research, and it allows for more interpretative marginalia in the chart, and notes in the EHR. Com-bining the
thematic analysis, in which questions of why and how are data from these sources, comorbidity identifica-tion rates were
answered (Knudsen et al., 2012). It can be used to describe a as follows: 68% (92/135 clients) had vision issues, 50%
phenomenon. In the current case, we investi-gated why and (68/135) had cognitive issues, 43% (58/135) had hypertension,
how comorbidities influence hearing care. Specifically, using 42% (57/135) had manual dexterity issues, 33% (45/135) had
this method, the audiologists were asked questions chosen to a history of falls, 16% (22/135) had depres-sion, and 13%
drive the data collection and to address the three research (18/135) had diabetes. Complete data on the three
aims. A sequence of steps were taken to transcribe the focus comorbidities were available for 119 cases, of which 20 (17%)
group audio recordings, check the tran-scription, and prepare had none of the three comorbidities. Figure 1 illus-trates the
manageable documents for analysis. All transcription, multiple comorbidities for the 99 clients who had complete
checking, and analysis were conducted using Microsoft Word data and at least one comorbidity in addition to hearing loss.
rather than a specific qualitative research software. Almost a third of these clients (31/99; 31%) had triple visual,
manual dexterity, and cognitive issues, and about a quarter
First, K. D. listened many times to the audio record-ings (26/99; 26%) had dual visual and cognitive issues.
of the focus groups, and then, she transcribed them,
identifying talkers by initials (recoded as A1, A2, A3, and Information added by reviewing chart marginalia and
A4). Based on these transcripts, the information pro-vided by EHR. For the three comorbidities (vision, manual dexterity,
the audiologists was extracted and entered in an analysis cognition) queried on the HAE history form, adding infor-
document organized according to the interview questions and mation from the chart marginalia resulted in the identifica-tion
themes discussed at each session. A second researcher (F. B.) of four more clients with visual issues, three more with
then listened to the audio recordings and read through K. D.’s manual dexterity issues, and four more with cognitive issues.
transcripts of the first two focus groups. F. B. made her own The EHR yielded sparser information, but it was still useful
notes related to the discus-sion of comorbidities in the focus for identifying 13 additional cases with vision issues, three
groups before reading through the analysis documents with manual dexterity issues, and five with cognitive issues.
prepared by K. D. A com-parison of the notes of the two There was more missing data for the other four co-
researchers revealed no instances of disagreement; however, morbidities that were not specifically queried on the HAE
there were 26 instances where F. B. suggested adding history form. The marginalia identified a few more clients
additional information to the analysis document. K. D. then with a history of falls (three cases), hypertension (seven
amalgamated F. B.’s com-ments into the final analysis cases), diabetes (two cases), and depression (one case), which
documents for the first two focus groups. There was no would otherwise not have been identified on the HAE form.
interrater reliability checking for the third focus group because The EHR provided much more information about these four
it was very short (15 min). For the fourth focus group, an RA comorbidities, resulting in the identification of an additional
listened to the recording and reviewed the transcript as F. B. 42, 51, 16, and 21 clients with a history of falls, hyper-tension,
had done for the ear-lier focus groups. A comparison of the diabetes, and depression, respectively.
notes of the two raters revealed no disagreements. The RA Effects of age on comorbidities. Given the wide age
suggested eight additions or wording changes, and all were range of the 135 clients, three subgroups of similar sizes were
accepted in the final document. created to investigate age-related differences in the frequency
of the comorbidities identified: young old (YO) aged 66–83
years, n = 45; middle old (MO) aged 84–90 years, n = 47; OO
aged 91–99 years, n = 43 (see Table 2). Not sur-prisingly, the
number of comorbidities increased with age. YO clients had
Results
an average of 1.9 (SD = 1.6; range: 0–5) comorbidities; MO
Results from the review of the chart and EHR will be clients had an average of 2.8 (SD = 1.9; range: 0–6)
described first, followed by the findings from the focus comorbidities, whereas OO clients had an aver-age of 3.3 (SD
groups. Results for each method will be organized accord-ing = 1.4; range: 0–6) comorbidities. A series of three
to the three aims of the study and related topics that emerged independent-samples t tests with Bonferroni correc-tions
when data were collected. revealed significant differences between the average number
of comorbidities experienced by the YO and OO groups, t(86)
= 4.15, p < .05, but no difference between the YO and MO
groups or between the MO and OO groups
(ps > .05). However, there was a significant positive corre-
lation between age and the number (0–7) of comorbidities (r
= 34, p < .01).
Note. Data represented as the number of participants (percentage of participants out of 135) for whom that comorbidity was identified. The
yes/no/unknown responses are defined as follows: “Yes” (explicit mention that the participant does have this comorbidity), “No” (explicit
mention that the participant does not have this comorbidity), and “NR” (no indication of the presence/absence of this comorbidity).
Association between comorbidities and living arrange- health professionals want to know whether a client has
ment. Furthermore, there was a connection between number of accessed services and/or obtained treatment for hearing loss at
comorbidities and living arrangement, with chi-square this clinic, it is possible that they would search the EHR for
analyses indicating that clients with a higher number of this information. For the majority of the 135 cli-ents in our
comorbidities were more likely to be receiving formal care sample (75%; 101/135), the clinic staff had noted in the
2
than those with fewer comorbidities, χ (30) = 93.21, p < .001. “history of visits” section of the EHR that the client had
Exchange of information about hearing loss. In a 2017 attended an appointment in the Hearing Services clinic. For
follow-up, 2 years after the HAE appointments of the clients one client, there was no information about a visit to the clinic.
had occurred, the EHR was searched for notes entered by For the other 33 cases (four from LTC), a member of the clinic
audiologists or other health care professionals about the staff had noted information in the EHR about the client’s
clients’ hearing loss, visits to the clinic, amplifi-cation status, treatment trajectory, including 73% (24/33) with notes that the
and/or audiologic rehabilitation. If allied client had hearing aids, 12% (4/33) that the client had attended
an HAE, 9% (3/33) that the client had an HT, and 6% (2/33)
that the client had ordered hearing aids.
Figure 1. Representation of the overlap of comorbid health issues
(vision, cognition, dexterity) for 99 of the 135 clients.This figure
does not include 16 individuals for whom there were missing data In addition to the notes about hearing made by staff of
for at least one of the three comorbidities, nor does it include the the Baycrest Hearing Services, it is possible that informa-tion
20 individuals for whom the “no” response was provided for all about a client’s hearing status and/or treatment options could
three issues.
have been noted in the EHR by other health profes-sionals.
Overall, the EHR contained information entered by other
health professionals about hearing loss or hearing care for
60% (80/135) of the cases in our sample. These 80 cases
included 24 of the 33 cases for which the audiol-
ogists had also provided information about hearing care
in the EHR. The majority (62%; 50/80) of the notes entered
in the EHR by other health professionals indicated only
that the client was wearing a hearing aid. For two clients
(3%), the notes suggested that the client would benefit from
referral to an audiologist and then later indicated that the
client was now wearing a hearing aid. Some notes only indi-
cated that the client had hearing loss (16%; 13/80), or only
noted referral to the clinic for a consultation (8%; 6/80).
The remainder indicated (mistakenly) that the client did not
have hearing loss (6%; 5/80), had completed an assessment
1208 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
Table 2. Number of comorbidities identified for all participants and for each of the three age subgroups
(percentage of participants indicated in parentheses).
Note. The seven comorbidities included in the count were visual issues, manual dexterity issues, cognitive
issues, history of falls, hypertension, diabetes, and depression. Young old participants are 66–83 years
old, middle old participants are 84–90 years old, and oldest old participants are 91–99 years old.
but without a treatment update (4%; 3/80), or that the client including 13 for whom exchanges were made before settling
would be scheduled for an annual checkup with the ear, nose, on the final device. Of the hearing aid purchasers, only 10
and throat doctor (1%; 1/80). clients (10/121; 8%) returned the aid; of those who returned
For a number of the clients, their physicians (mainly the aid, one had no comorbidities, but the other nine had two
from Neurology, Geriatric Assessment, and Memory Care or three comorbidities (four had vision and cognition issues,
clinics at Baycrest) had noted information in the EHR con- two had vision and dexterity issues, and three had vision,
cerning the potential interactions between comorbidities and dexterity, and cognitive issues).
hearing loss. These notes could be accessed by audiol-ogists Other treatments. For the majority of clients (71/111;
and might have informed hearing care. For example, one note 64%) who kept the hearing aid they purchased, the hearing aid
considered hearing loss and the risk of falls: “I told Mr. X that was the only technology they bought. However, con-sistent
1 with the audiologist’s remarks (see Table 3), and as shown in
hearing impairment is a risk factor for falls.” Potential issues
with manual dexterity and/or vision loss are implied in another Table 4, hearing aid accessories (remote controls, remote
note: “Hearing has declined, had a hearing aid trial but cannot microphones, devices to connect to phone, television, etc.)
put the batteries in herself so returned them.” Another note were recommended to 38 and provided to 27 clients. Notably,
considered the connection between hearing and cognition: “His 12 clients chose to use simple remote controls, and another six
bilateral hearing im-pairment may also contribute to poor chose a multipurpose remote control; all but one were clients
cognition.” Taken together, the notes about hearing made by with dexterity and/or vision comorbid-ities. More
other health professionals, along with these notes by conventional ALDs (personal amplifiers [two], specialized
physicians about the connections between hearing loss and clocks [three], and phone [five] or television devices [one])
comorbidities, provide evidence of interprofessional were recommended to 16 and bought by
awareness of hearing issues in the circle of care. Nevertheless, 11 clients; five clients already used conventional ALDs.
it seems that there could be potential benefit from richer Group rehabilitation was suggested to 32 and attended by
bidirectional inter-professional communication. eight clients. Overall, about a third of the clients took advan-
tage of rehabilitation options in addition to only hearing aids,
especially those with vision and dexterity issues.
Benefit from rehabilitation. The COSI overall improve-
Influence of Comorbidities on Practice and Outcomes ment score for the client’s self-identified most important
Hearing aids. Of the 135 clients who completed an listening goal was available for half of the clients (59/111;
HAE, a hearing aid was prescribed for 132 (98%), and the 53%) who kept their hearing aids. Considering only the COSI
three clients who did not receive a prescription were already overall improvement score, for the 59 clients who completed
experienced hearing aid users. Of the 132 clients who received the COSI, 21 reported much better performance, 36 reported
a hearing aid prescription, 11 clients were lost to follow-up, better performance, and only two reported no difference. As
including six who died, but follow-up information was shown in Table 4, half of the participants did not complete the
available for most clients (121/132; 92%). Of those for whom COSI (52/111; 47%), including roughly equal numbers of
follow-up information was available, almost all had purchased clients with cognitive, visual, and manual dexterity issues. The
a hearing aid at Baycrest (116/121; 96%; half new users and chart was examined for qualitative information regarding
half experienced users), and five clients bought a hearing aid outcomes noted at the HAC for clients who purchased and
elsewhere but were followed at Baycrest. Most (111/121; retained hearing aids but for whom no COSI data had been
92%) kept their hearing aids, collected. As described by the audiologists in the focus
groups, qualitative outcome information available in the charts
1
All emphasis our own. for these clients indicated
Table 3. Modifications to practice to accommodate for medical comorbidities for hearing test, hearing aid evaluation, hearing aid
fitting, and hearing aid check appointments.
Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
Table 3. (Continued).
i
n
f
o
r
m
a
t
i
o
n
a
b
o
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t
r
e
s
o
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r
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e
s
f
o
r
d
e
p
r
e
ssion and
Note. The table summarizes the results of qualitative data analysis of the considerations that the audiologists identified in the focus
discuss
groups as or
management being the most relevant and frequent in their practice. ALD = assistive listening device; SRT = speech reception
threshold; SAT
referral if = speech awareness threshold.
appropriate
1211 1212
Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
Table 4. Types of rehabilitation recommendations by comorbidity profile, with the number who received the recommendation
and the number who complied, and the evaluation method used by comorbidity profile.
Total number of
Types of recommendations
recommendations with selected outcomes No Cognition Dexterity Cogn
and the evaluation or total number receiving comorbidity Cognition Dexterity Vision and vision and vision and de
methods used an evaluation method (n = 20 + 1) (n = 6 + 1) (n = 8 + 1) (n = 14 + 4) (n = 26 + 2) (n = 13 + 2) (n = 1
Note. The 135 clients are categorized depending on their pattern of comorbidities. The first number in each cell indicates the number
of clients for whom “yes” or “no” was noted for all three comorbidities, and to it is added the number for whom the absence of a
response for a comorbidity is assumed to be a “no” even though there was no explicit response. For four clients, responses were
unknown for all three comorbidities. ALD = assistive listening device; HA = hearing aid; AR = audiologic rehabilitation; COSI =
Client-Oriented Scale of Improvement.
improvement reported either by the client or by a family responded by identifying the following health conditions
member and/or caregiver. Overall, almost all cases were (transcribed in the order that they were provided): cognitive
considered to be successes by their audiologist. impairment, anxiety and/or depression, visual impairment,
diabetes, heart conditions, macular degeneration, arthritis,
issues with mobility, neurodegenerative diseases (e.g., stroke,
Findings From the Focus Groups
Parkinson’s disease) that might affect manual dexterity and/or
The focus group data were analyzed to address the three ability to use a limb, speech issues, tremor, fine motor
research goals of this study concerning the frequency of problems (e.g., numbness in fingertips), neuropsychiatric
identification of comorbidities, modifications to practice symptoms of dementia, and “normal” age-related cognitive
made to accommodate comorbidities, and outcomes for changes (e.g., in memory). They unanimously agreed that the
clients with comorbidities. Themes from the focus groups are three most common comorbidities they typically see in their
summarized in Table 5. clients are cognitive, manual dexterity, and visual
impairments. Of note, although not indicated among the most
Frequency of Identification of Comorbidities frequently encountered, anxiety and depression were listed by
Common comorbidities. The audiologists were first A2 as “one of the most difficult” comorbidities to deal with,
asked to comment on the types of medical comorbidities due to the client’s increased need for counsel-ing and support.
with which their clients are most likely to present. They
Table 5. Identified themes from the focus groups with the four audiologists
Common comorbidities • The three most common are cognitive impairment (“first of all,” A3; “the biggest one,” A2),
manual dexterity, and visual impairment.
Identifying comorbidities in clients • Audiologists gather information about comorbidities in their clients from various sources,
including the EHR, the client’s referral form (“Always look at the physician’s referral.” A1),
client observation, the standardized case history form, and discussion with the significant
other accompanying the client.
Charting information about comorbidities • Clinicians agreed that it is important to document information about client’s comorbidities
in a consistent way in the audiology chart in order to facilitate information sharing and
ensure appropriate client care in cases where the treating audiologist is absent and another
audiologist fills in.
• The clinicians need a better way of indicating information about patients’ comorbidities.
(“I’ve been saying for ages that we need to put questions about stroke for example.” A1)
Assessment of client functioning • Clinicians look for evidence of the effects of comorbidities on a client’s function. Change
in function over time is charted. (“The comorbidities are always progressing, so you’re
constantly having to provide more and different support and adjustments.” A1)
Device selection • The presence of comorbidity(ies) will influence the device that is selected for the client. The
audiologists ask their clients if they will have support at home, for example, a significant
other who visits regularly or lives with them who could help with the hearing aid. (“I ask
much more: how often is your caregiver with you, is it part-time, is it full-time?” A2)
Treatment trajectory • Comorbidities affect follow-up; clients with more comorbidities typically return to the
clinic more often than those with fewer comorbidities. Support also affects follow-up;
clients with a supportive significant other or caregiver will likely need less follow-up. (“Another
big determinant of how often they come is if they have a good caregiver. If someone else is
managing it for them, they do a lot better.” A4)
Limitations to practice • Audiologists realize and acknowledge the limitations to their practice and knowledge and
to their ability to help clients. They indicate a willingness to learn more in order to provide
optimal care. (“Maybe I need to learn that [more about the comorbidity] in order to start
thinking about…my prescription.” A3)
Interprofessional communication • The audiologists currently only include information in the EHR for inpatients, but may
follow-up by e-mail with the referring physician and other clinicians (e.g., SLP) to share
results of hearing tests and notes on the client’s progress with hearing aid(s). (“Depends
who referred them. Some will have referrals from SLP, we’ll have referrals from the mild
cognitive impairment group, so whoever referred them would get a copy.” A1)
Gathering quantitative and qualitative data • Outcomes are always assessed and documented in the chart, even if a standardized
on treatment outcomes measure (e.g., the COSI) is not appropriate to use with a client. The key factor to assess
is how hearing loss affects quality of life and whether it has improved posttreatment. (“For
our population, changing the quality of their life is very important, that’s one of the things
that we need to measure that couldn’t be a number or anything.” A3)
Modifying the evaluation of outcomes • The audiologists speak with and observe the client and query an accompanying significant
because of comorbidities other about how the client is doing with their hearing instrument. (“If they have a family
member, a caregiver, we usually include them. They are often the ones who can answer
the question for you.” A4)
Note. EHR = electronic health record; SLP = speech-language pathologist; COSI = Client Oriented Scale of Improvement.
1214 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
of different types of accessories for use with an older Treatment trajectory. In light of the progressive nature
population. of most of the comorbidities considered in this study, the
audiologists indicated that their treatment plans must be In addition to information noted in the chart and EHR, a
updated on an ongoing basis. As stated by A1, “you’re copy of the HT form, including a description of the test results
constantly having to provide more and different support and and recommendations, is sent to the referring physician for
adjustments.” A2 expressed her opinion that some clients with each client. Typically, this form is sent out 2 to 3 weeks after
comorbidities are “never” discharged, and A4 noted that cases the HT, once it has been signed by a Baycrest
are only discharged if the client chooses to discontinue otolaryngologist. If the client completes an annual HT,
treatment. The audiologists unanimously reported that they information about current use of hearing aid(s) may be noted;
encourage clients to return for annual checkups to ensure that however, it is not routine to send follow-up infor-mation about
their equipment, including hearing aids and ALDs, is working treatment and outcomes to the referring physician. In addition,
properly. The progressive and challenging aspects of there is no systematic process for communicating information
comorbidities are such that the audiologists tend to see clients about a common client’s audiologic rehabilitation process to
with comorbidities more often than clients without nonphysician health care professionals.
comorbidities; for example, clients with comorbidities typi-
cally have a higher number of hearing aid checks. A3 noted
that an accelerated rate of functional change is often seen in
Outcomes
older clients who are more likely to have more comorbidities,
The audiologists unanimously felt that modifications to
saying that “Somebody who is 50 years old, in 5 or 6 years,
practice to accommodate for client comorbidities make a
how much change do you expect, compared to somebody who
“significant” (A3) and “huge” (A1) difference to treatment
is 90 years old…it is going to be [a] more sudden and
outcomes. Outcomes can be noted in the chart in various
significant and fast change for those who are much older.”
ways.
Limitations to practice. The ability of the audiologists to Quantitative data on treatment outcomes. The COSI is
help their clients may be limited by their knowledge about the intended to be used as a quantitative outcome measure. For
various comorbidities; for example, A3 explained that “I each of the self-identified listening goals, the form allows for
personally don’t know about any specific modifications for collection of an overall improvement score and a final ability
those kinds of patients [those admitted to the Baycrest score. The audiologists, however, reported that for most cases,
inpatient Behavioural Neurology Unit, many of whom exhibit they do not ask their clients about their final ability. In
hypersensitivity to noise and issues with mood] ‘cause I’m not particular, for clients with cognitive impairment, it may be
[a] psychologist.” They reported feeling that more knowledge difficult for them to recall or under-stand how to respond to a
could be helpful, and they were open to learning more in order question about the percentage of the time they achieve a
to improve how they adapt treatment to accom-modate for all listening goal. In addition, given that clients often have many
of their client’s needs; for example, A3 stated, “I need to learn follow-up appointments and may never be formally
more about depression, different types of de-pression, maybe I discharged, especially if they are experiencing ongoing
need to learn that in order to start thinking about that, [and changes in their health, it is difficult to ascertain when it
how it influences] my prescription.” would be appropriate to gather quanti-tative data on their
Interprofessional communication. The audiologists “final” ability. The audiologists felt that the “change” section of
reported that there is no formal interprofessional commu- the COSI more often yielded useful information, and they
nication protocol. Currently, they are required to add suggested that it is appropri-ate for some clients to use only
information to the EHR for inpatients (about 20% of the this section of the COSI. Even for clients for whom the COSI
audiology caseload) and Baycrest LTC residents (about 30% is too challenging to administer, the audiologists clarified that
of the caseload). For outpatient visits to Baycrest Hearing they do ask clients whether they are hearing better in the
Services, there is a record in the EHR that an appointment was specific situ-ations they had identified and less structured
attended in the clinic, but no additional information is qualitative responses are obtained.
provided routinely about what types of rec-ommendations or
services were provided. In cases where another health care
Qualitative data on treatment outcomes. The audiolo-
professional (e.g., a speech-language pathologist) has worked
gists unanimously agreed that they try to obtain qualitative
with the same client and the audi-ologist would like to follow-
more than quantitative outcome measures when evaluating the
up, the usual method for inter-professional communication is
client’s experience with hearing aids. They ask questions about
to send an e-mail to the specific clinician. The audiologists
how hearing loss affects the client’s quality of life and whether
noted that adding infor-mation about their service (i.e., about
quality of life has improved with amplification. As stated by
the client’s hearing status) to the EHR would take a lot of time,
A3, “That’s enough for me as an audiologist to know,
but they indi-cated that it could be worthwhile to do so; for
especially if you have a long process with the patient. To me,
example, A3 remarked that “It’s good to have. It’s going to be
having the number 90 or 90% or 85 is not [as important].”
extra work, because there’s a lot of patients.”
Modifying the evaluation of outcomes because of
comorbidities. The audiologists were asked whether the three
comorbidities queried in their HAE history form affect how
they evaluate outcomes for a client. They responded that
cognitive status has the biggest influence on whether
1216 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
dexterity, and cognitive issues because they recognized that tion trajectory and outcomes; however, information about
these comorbidities may have direct relevance to rehabilita- other comorbidities was noted in marginalia rather than on the
history form. The EHR offers an additional source of For the current sample, the majority of referrals (65%)
information about comorbidities; however, the audiologists were made by family physicians. Even in specialty clinics
did not routinely access information about comorbidities or such as memory care clinics, older adults are not always
enter information about hearing care in the EHR. Current routinely asked about their hearing or referred for hearing care
practice guidelines do not specify how audiologists should (e.g., Jorgensen, Palmer, & Fischer, 2014). Physicians may
gather or share information about comorbidities. Next best fail to refer medically complex clients for hearing care because
practice would be to develop protocols for gathering infor- they are focused on other health issues that they consider to be
mation about additional comorbidities on the audiology more important, or they may simply fail or forget to ask clients
history form and to establish more effective communication about their hearing or they may believe that the client or
among health professionals in the circle of care by using the caregiver will not want hearing care. Poten-tial bias against
EHR to exchange information to optimize care for clients who referring medically complex older adults for audiologic
have hearing loss. rehabilitation may help to explain, at least partially, why so
few older individuals who could benefit from hearing aids
Interprofessional Communication About Comorbidities purchase them. Having family physicians as a major referral
Failing to take hearing loss into account may jeopardize source introduces a potential opportunity for bidirectional
care on the part of other health professionals; for example, it interprofessional outreach and education. On the one hand,
could lead to miscommunication during the delivery of many audiologists have started to work more closely with family
types of health care and result in preventable errors (Bartlett, physicians to increase their knowledge regarding treatment
Blais, Tamblyn, Clermont, & MacGibbon, 2008). A special options and to reinforce the importance of hearing care as a
concern in this population is the possible over-estimation of key component of healthy aging, possi-bly even encouraging
their level of cognitive decline (e.g., Dupuis et al., 2015; referrals for all older clients as part of a holistic health
Guerreiro & Van Gerven, 2017). Given the duration and promotion approach. On the other hand, audiologists could
frequency of audiology appointments and the multiyear learn more about relevant comorbidities from other
follow-up provided to clients receiving audiologic professionals in the circle of care; for example, referral forms
rehabilitation, audiologists may be uniquely positioned (as an could query relevant comorbidities. Enhanced bidirectional
“alert provider”; Souza, 2014) to detect cognitive decline in communication would represent an extension of the
their clients (Shen, Anderson, Arehart, & Souza, 2016). In increasingly popular person-centered care framework, which
addition to considering comorbidities during the provi-sion of takes a client’s needs, abilities, and preferences into account
hearing health care, the audiologist could assist cli-ents to when planning and delivering audiologic rehabili-tation (e.g.,
seek and benefit from appropriate help from other health Grenness, Hickson, Laplante-Lévesque, & Davidson, 2014;
professionals. Singh et al., 2016), by ensuring that all members of a health
Opportunities to reduce barriers and promote earlier care team are cognizant of key infor-mation about the client’s
access to hearing care may arise from enhanced communica- hearing needs and that hearing care is modified to
tion with health professionals who treat the comorbidities that accommodate comorbidities.
may affect older adults with hearing loss. Hearing loss can
have significant negative effects on everyday functioning and
overall well-being (e.g., Ciorba, Bianchini, Pelucchi, & Modifications to Practice to
Pastore, 2012; Dalton et al., 2003). Thus, consistently captur- Accommodate Comorbidities
ing information about hearing loss and hearing care will The current study demonstrates how clinicians from one
contribute to a more holistic and comprehensive approach to specialized geriatric audiology clinic successfully modi-fied
caring for older adults (e.g., Bień, 2005) that considers the practice to accommodate comorbid health conditions.
reality of addressing multiple complex health conditions Such modifications to practice influenced routines for his-tory
simultaneously (e.g., Boyd & Fortin, 2010). It behooves taking, recommendations of technology options, topics in
audiologists to provide communication so as to ensure that counseling, the frequency of follow-up, and the involve-ment
appropriate information about a client’s hearing loss and of SOs.
audiologic rehabilitation is available to others in the circle of
care (for example, information about how to optimize
SOs
communication for a client with hearing loss, including advice
The audiologists emphasized the importance of involv-
regarding the use of personal technology and/or group ALDs).
ing SOs in the rehabilitation process, especially for those older
In reflecting on the study, the audiologists indicated that,
individuals experiencing cognitive loss. A family-centered
although it would require a significant time investment, it
approach has become internationally recognized as a key
could be worthwhile to provide a more detailed and system-
component of high-quality hearing health care provision for all
atic feedback to referral sources and others in the circle of
age groups, including older adults (Singh et al., 2016). For
care.
older individuals with physical and cogni-tive limitations, it
can be especially important to include family and/or formal
caregivers in the rehabilitation planning. Hearing loss can have
collateral effects on the communication partners of the
individuals experiencing the loss, particularly
1218 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
treatment process. This issue was addressed, at least partially, Given that many of the clients were OO adults, we
through the focus groups. expected the selected comorbidities, which are known to be
associated with hearing loss, to have higher prevalence than in Wright-Whyte for their assistance with the chart reviews and data
the general older adult population. This was the case for entry and the Baycrest audiologists, Heather Finkelstein, Akram
vision, dexterity, and cognition issues that were routinely Keymanesh, Debbie Ostroff, and Marilyn Reed, for their participa-
reported on the HAE form, but the rate of identi-fication of the tion in the focus groups.
other comorbidities was less than expected. Because
information about comorbidities may not have been gathered
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1220 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
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Copyright of Journal of Speech, Language & Hearing Research is the property of American
Speech-Language-Hearing Association and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.