Chronic Disease, Case History & Care Coordination

Author: Kathryn R. Dowd, Au.D.

Chronic Disease
As baby boomers age, the incidence of hearing loss is swelling the ranks of the hearing-impaired population. The profession of audiology is aware of the significant damage to hearing caused by chronic diseases and medication. However there appears to be a lack of awareness of the causal link between chronic diseases and hearing loss among other medical and allied health professionals.

In times past, hearing loss in the aging population was given the diagnosis of presbycusis: “Gradual bilateral hearing loss associated with aging that is due to progressive degeneration of cochlear structures and central auditory pathways. Hearing loss usually begins with the high frequencies then progresses to sounds of middle and low frequencies.” (CMS, 2011). The term presbycusis should be archived from the active audiological lexicon. Its use obfuscates the major reasons hearing decreases as one ages.

The essential questions should be: What is the medically significant reason the patient is having a hearing test? What caused the hearing loss to decline in the first place? Is it just the aging process? Have the physician and audiologist considered chronic diseases as the contributing factor to the hearing loss?

A Rand Health study found that chronic diseases are the most costly and common health problems in the United States (Wu SY, Green A, 2000). The five leading chronic diseases listed by the Centers for Disease Control (CDC) are heart disease, stroke, cancer, diabetes and arthritis. Chronic renal disease, vascular disease and thyroid disease can also be added to the list of the top chronic conditions. According to the CDC, in 2005 almost 1 out of every 2 adults in the US had at least one chronic illness. Research is available to link every one of these chronic illnesses to impairment of hearing. In addition to the chronic diseases and conditions, ototoxic medications used to treat some of these diseases add insult to injury. Here is a brief summary of common diseases that have a documented link to hearing loss in adults.

Heart disease: A study, based on 2,226 participants aged between 52 and 97, was carried out by the Population Health Program Faculty at the University of Wisconsin in 2001. Hearing loss appeared in almost 80% of the people who had suffered from a cardiovascular disease. The prevalence of hearing loss is 54% greater among those with a history of heart disease than in the general population (Hutchinson KM, Alessio H, Baiduc RR, 2010).

Stroke: A vascular trauma in the brain that affects the nervous system, motor and thought processes. A stroke in the brain affects many bodily functions and hearing is not exempt. In 2008, the American Heart Association published a recap of an extensive study by Herng-Ching,L et al, that establishes a relationship between sudden sensorineural hearing loss, more easily called SSNHL, and stroke. (Herng-Ching L, Pin-Zhir C, Hsin-Chien L, 2008). This condition is marked, obviously, with the sudden onset of hearing loss, as in one day you hear fine and a week later you can’t understand the TV anymore.

Cancer: Cancer may affect hearing if the lesion is located in the vicinity of the ear. And chemotherapeutic use of Cisplatin to treat cancer is known to affect hearing. A consumer site for side effects of the drug on reveals that ototoxicity has been observed in up to 31% of patients treated with a single dose of Cisplatin 50 mg/m2, and is manifested by tinnitus and/or hearing loss in the high frequency range (4000 to 8000 Hz). The prevalence of hearing loss in children undergoing chemotherapy is particularly high and is estimated to be 40 to 60%. Decreased ability to hear normal conversational tones may occur. Deafness after the initial dose of Cisplatin has been reported. Ototoxic effects may be more severe in children receiving Cisplatin.

Diabetes: Mechanisms related to neuropathic or micro vascular factors, inflammation, or hyperglycemia may be mediating the association of diabetes and hearing impairment (Bainbridge KE, Cheng YJ, Cowie CC, 2010). Micro vascular changes, which often lead to nephropathy and retinopathy, also affect the cochlear vasculature. According to Bainbridge et al, thickened basilar membranes and capillaries of the stria vascularis and atherosclerotic narrowing of the internal auditory artery were found among autopsied people who had diabetes but not in people without diabetes. Patients with diabetes are also at higher risk of infection from cuts, surgery, abrasions. Therapeutic treatment with aminoglycoside antibiotics potentiates hearing loss from ototoxicity.

Arthritis: Rheumatoid arthritis is not found to contribute to hearing loss, but the condition of psoriatic arthritis can be added to the pantheon of autoimmune diseases that can lead to sensorineural hearing loss (Srikumar S, Deepak MK, Basu S, Kumar BN, 2004).

Severe arthritis and joint pain may lead to hip and knee replacement. Antibiotic treatments during these surgeries can be a potential source affecting hearing levels. Aminoglycosides in the bone cements has been cited in studies by Balint et al (2006) and Sterling et al (2003) to be emitted from the surgical site in the period following the operation. More research to judge the effects on hearing is needed when aminoglycosides are involved in these surgeries to control infection.

Case History
The case history for new patients or when a patient is seen for monitoring of hearing loss over time will expose potential contributing medical factors to the hearing loss. New diagnoses, surgeries and accidents/traumas that have occurred in the previous 1-5 years helps the audiologist understand why the patient’s hearing is declining or why speech discrimination has deteriorated.

The referral to the audiologist from the Medical Doctor, nurse practitioner or Doctor of Osteopathy must state the medical need for the hearing evaluation and be placed in the doctor’s patient file as documentation of the referral. A sample referral form (see enclosed) can be copied on the physician letterhead and used by the referring doctor. The standardized physician order allows the doctor to check off known medical history factors, with an order at the bottom to test for medical management purposes. The referral form can be placed in the patient’s file for documentation after it is faxed to the audiologist. The audiologist uses the information provided in the referral form as a starting point to question the patient further about relevant case history facts.

A Focus On Diabetes
A patient was diagnosed about 2 years ago with diabetes. The patient already had diagnoses of heart failure, hypothyroidism and hearing loss. When it was mentioned to the patient’s adult child how this new diagnosis of diabetes was one more reason to keep a check on hearing levels, the individual remarked, “What are you talking about? I have never heard of the link between diabetes and hearing loss!” This person works in a health agency , that involves diabetes prevention and control y and was unaware of the link. The audiologist asked the individual where to start, who to get information to, as there seemed to be a pervasive lack of education nationwide. The suggestion was to contact the state agency and to present the information to the person in charge of the chronic disease program.

The author went to the NC Diabetes Prevention and Control department and spoke with April Reese, Branch Head. Ms. Reese acknowledged she never heard of the link between diabetes and hearing loss, but learning that hearing loss can cause depression was an immediate interest for her, as there was a national initiative to raise awareness of diabetes and depression. This year the North Carolina Strategic Plan for 2011-2015 for Diabetes Prevention and Control recommends hearing screening of all patients with diabetes. A small gain...

Care Coordination
Hearing loss is an invisible handicap. Many patients and healthcare providers are unaware of the link between chronic diseases and hearing loss. The doctor or family member sees the isolation, depression and confusion resulting from hearing difficulties. The task of making all healthcare providers alert to the need of a baseline and monitoring hearing tests when there is a diagnosis of one of the chronic diseases needs to be a primary task for the audiologist.

Steps for the Audiologist
Given the conditions as described above, there are action steps that the audiologist may take to raise the awareness of undiagnosed hearing loss and the link with chronic diseases, medical conditions and medications.

The physician order states medical necessity ffor the hearing test. An order stating ‘Hearing Evaluation’ or ‘test hearing’ does not say why the patient is being tested. Medicare has listed ‘illness, injury, trauma and complaint’ as contributing factors necessitating a procedure such as a hearing test. ASHA recommends a physician order state ‘audiological evaluation for medical management purposes’. The order sent to the audiologist must also note in the patient’s chart at the physician’s office, along with the medical reason the patient is being referred (i.e. diabetes, hypothyroidism, cardiovascular problems, complaint of not hearing).

A complete case history. Document all illnesses and medications the patient takes now or has taken in the past. Ask if they have been in the hospital in the past 5-10 years and the reason for the inpatient stay. Record everything in the chart and incorporate the patient case history into the summary report to the doctor.

Report to the referring medical professional. State the contributing factors to the hearing loss, uncovered during the case history, in the audiological report. Recommend hearing monitoring in the report, due to the illness/injury/trauma given during the case history (e.g. test hearing in one year for medical management of diabetes). The contributing medical condition warrants checking hearing on a regular basis to monitor the stability or progressive nature of the hearing loss. The recommendation to test hearing in a year is not an ‘annual audiogram’, which is not allowed by many insurances. Writing a recommendation to test at some future interval in the report validates the medical necessity for the next test. The medical doctor receiving the report will learn more about how the hearing loss began, as well as future audiological needs of the patient.

Referral to other medical professionals. Ask patients with diabetes if they are receiving diabetes education. This program is a covered service to educate patients on proper glucose control, activity and eating habits, vision health, and dental health that is necessary for a better quality of life. The audiologist can initiate the referral by putting the patient in contact with the local diabetes education program.

Activism and the Future
Dr. Victor Bray, dean of the Salus University’s Osborne College of Audiology, (V. Bray, personal communication, July 17, 2012) stated: “The future of our profession rests on audiologists recognizing the co-morbidity of diseases that impact hearing and balance with other body systems. If we can educate our audiologists to recognize this co-morbidity and appropriately refer to other doctoring professions, we will make our mark in the health care system as a profession that adds value to the holistic care of patients. This is one of the strategies optometry used to become the point-of-entry for vision care. There are many optometrists who now have more than 50% of their practice as medical care, not selling of eyeglasses…. We must come to recognize and act knowing it’s about the patient, not the sensory system! if we are going to achieve our professional goals.”

Audiologists can raise our professional profile with these actions: Contact the local diabetes education group to provide information on hearing loss, offer hearing screenings start a coalition to educate patients on the need for hearing testing.

Contact the state agency for chronic diseases. . Ask them to promote better hearing health in the state. Find ways to work with their agency to raise awareness of the link between diabetes and other chronic diseases, and hearing loss.

Other health care professions have submitted a list of medically significant conditions, illness, etc. (ICD10 codes) that substantiate the reason for a patient to be evaluated and treated. Audiology must do the same and send the list of codes to CMS for approval and publication.

When coding for a hearing evaluation the audiologist can elect bilateral sensorineural hearing loss, conductive hearing loss, mixed hearing loss as the diagnosis, among the numerous outcome possibilities of the test. In addition, insert the contributing disease/condition causing the hearing loss in the coding process. Insurances require that hearing testing be done when there is a medical reason to test a patient.

The future is now and we as audiologists would do well to heed the call of Dr. Bray.    

Addendum A: Referral Form

Kathryn R Dowd, Au.D. is in private practice at Hearing Solution Center. Her practice unbundles services. She can be reached at

Bainbridge KE, Cheng YJ, Cowie CC.(2010) Potential Mediators of Diabetes-Related Hearing Impairment in the U.S. Population. Diabetes Care 33: 811-816

Bálint L, Koós Z, Horváth G, Szabó G. (2006) Detection of gentamicin emission from bone cement in the early postoperative period following total hip arthroplasty. Orthopedics 29:432-6

CDC’s Chronic Diseases and Health Promotion. Retrieved from

Centers for Medicare and Medicaid Services (2011) International Classification of Diseases Clinical Modification Health and Human Services Dept., National Center for Health Statistics; National Centers for Disease Control and Prevention

Cisplatin Drug Effects, Drugs.Com. Retrieved from

Herng-Ching L,Pin-Zhir C,Hsin-Chien L.(2008) Sudden Sensorineural Hearing Loss Increases the Risk of Stroke. Stroke 39: 2744-2748

Hutchinson KM, Alessio H, Baiduc RR.(2010) Association between cardiovascular health and hearing function: pure-tone and distortion product otoacoustic emission measures. Am J Audiol 19:26-35

Srikumar S, Deepak MK, Basu S, Kumar BN.(2004) Sensorineural hearing loss associated with psoriatic arthritis. J Laryngol Otol 118:909-11

Sterling GJ, Crawford S, Potter JH, Koerbin G, Crawford R. (2003) The pharmacokinetics of Simplex-tobramycin bone cement. J Bone Joint Surg Br 85:646-9

Wu SY, Green A. (2000) Projection of chronic illness prevalence and cost inflation. Santa Monica, CA Rand Health