Delivering Comprehensive Care to the Geriatric Population Using the Functional Communication Assessment

Author: Lois M. Bennardo, M.S., CCC-A, F-AAA

In this age of direct-to-consumer health care, automated testing and the possible emergence of over-the-counter hearing aids, audiologists must identify tasks and procedures that cannot be duplicated by a computer algorithm or robotic equipment. A particular aspect of patient care that seems to require human interaction is the initial communication needs assessment—a procedure conducted with the individual who has been coping with the ill-effects of hearing loss of gradual and surreptitious onset. By going beyond the results of the audiogram and focusing on the needs of the person, audiologists can separate themselves as true caregivers. This process of delivering patient-centered care and focusing on the entire person, rather than the audiogram, is more complex than many realize. It requires time, a precious commodity. More importantly, perhaps, it requires an audiologist who is a keen observer of human behavior and a willing listener; a clinician who can take a wide array of information culled from objective and subjective tests, synthesize all of this information and work with the patient in setting long range treatment goals. This approach is especially needed with older adults. Older adults are more likely to be suffering from a multiple number of chronic medical conditions. Older adults are among the most vulnerable to social isolation and falling. By relying on tools that assess the entire person, and not just the auditory system in isolation, audiologists can set themselves apart as valuable members of the health care establishment that work to meet the needs of the most vulnerable members of the population.

The purpose of this article is two-fold. Part one is to construct a comprehensive Functional Communication Assessment (FCA), composed of specific, existing measures, deemed appropriate for the older adult population with hearing loss (in particular, those aged 65 years or older). The focus of part two will be on how the FCA would be different for those aged 90 years and older. The main objective of both parts of this article is to demonstrate how a comprehensive assessment process that focuses on the individual, not their audiogram or hearing aids, can be brought to life in a busy clinical practice.

The typical comprehensive audiologic evaluation, which is comprised of air, bone and speech testing, does not address how an individual is affected by hearing loss. In order to determine how hearing loss affects patients’ real-life communication, everyday functioning and their quality of life (QoL), additional objective tests and subjective self-report measures are required. A comprehensive, Functional Communication Assessment will guide the audiologist, together with the patient, toward the most effective and appropriate evidenced-based treatment plan.

A Functional Communication Assessment is important because it goes beyond the identification of a hearing loss, and seeks to answer how someone is functioning with a hearing loss in everyday situations. Further, it is important to include self-report outcome measures in the FCA because, according to Cox (2003), health care is more consumer driven now and laboratory tests, such as aided sound field audiometry, cannot measure the real-world experiences of the patient. Self-report outcome measures, also known as questionnaires, when properly implemented and interpreted, validly measure real-life experiences.

Sweetow (2007) states that a FCA should be process-oriented around enhancing communication, and enable patients to take responsibility for helping themselves. It should be a collaborative approach between the audiologist and the patient in the management of his hearing loss (Kricos, 2006). This is in keeping with a patient-centered approach to the management of hearing loss. “Patient-centered care suggests that patients be encouraged to be active participants in their health care through the creation of a power-balanced therapeutic relationship with their health care professionals” (Grenness, et al. 2014, p S60). According to Smith and Kricos (2003), the older adult often downplays the negative effects of the hearing loss. By including a comprehensive FCA, issues and questions can be explored in depth, so that an individualized treatment program can be developed for each patient.

There are an abundance of objective tests and subjective self-report outcome measures that could be included in the FCA. One must be judicious in the inclusion of the chosen measures, to ensure that they have high reliability and validity, have content appropriateness and purpose, and pertain to the population for whom you will utilize them (Bentler, et al. 2000). Most importantly, they must be evidenced based whenever possible (Taylor, 2007). In addition, the chosen assessment should not be unduly taxing to the patient or the significant other.

Prior to the FCA, a comprehensive audiological evaluation needs to be performed to rule out the possibility of ear disease. Most audiologists would agree this evaluation should include comprehensive case history, otoscopic examination, pure tone air and bone conduction thresholds, Speech Recognition Thresholds (SRT), Word Recognition Scores (WRS), tympanometry, acoustic reflex thresholds with acoustic reflex decay, and possibly otoacoustic emissions.

The proposed FCA is broad-based and patient-oriented, designed to identify the handicap/disability and limitations and restrictions caused by hearing and communication difficulties. Let’s examine the components of a FCA that could be implemented in a typical audiological practice.
Objective Measures
  1. Acceptable Noise Levels (ANL)
    This test compares unaided MCL to background noise level (BNL) when an individual is listening to speech. The difference between these two measures is referred to as the acceptable noise level (ANL) score. The ANL is a measure of the patient’s annoyance to sound. It can be administered in 2 to 3 minutes. The smaller the ANL score, the better prognosis for hearing aid use. It is thought that an ANL score above about 10 dB is an indication that the patient may have a problem with background noise being so annoying that he may remove his hearing aids in noisy listening conditions. Nabelek (2006) stated that a measure such as the ANL, is more important than speech-in-noise testing because it determines how much noise an individual is willing to accept. The addition of this test to the FCA is important because individuals with hearing loss may be the most susceptible to annoyance problems (Mendel, 2009).

    According to a series of studies, conducted more than a decade ago at the University of Tennessee, it was found that the ANL score is a good predictor of hearing aid use because it determined that successful hearing aid users could accept more background noise compared with those who wore their hearing aids occasionally or only in quiet environments. Therefore, “knowledge of ANLs can help to determine successful hearing aid users and assist in determining the best technology and features for the patient” (Nabelek, et al. 2006).

  2. QuickSin
    The Quick Speech in Noise Test (QuickSin) is the most commonly used speech-in-noise test for purposes of measuring speech intelligibility. It has high validity and reliability, and is quick and easy to score (Mendel, 2009). The QuickSin is not susceptible to ceiling or floor effects because the signal-to-noise ratio (SNR) varies; it is calibrated and prerecorded (Taylor and Mueller, 2011). The QuickSin measures what is referred to as SNR loss; the greater the SNR loss, the more likely the patient will have significant communication problems (Taylor and Mueller, 2011). According to the QuickSin normative data, unaided SNR losses above 7-8 dB necessitate the need for aggressive management of background noise. Technology such as remote microphones would be particularly effective for SNR losses 7-8 dB and higher.

    It is important to include this test, as it is well documented that individuals with hearing loss have more difficulty understanding speech when background noise is present. The typical word recognition tests, which are usually performed in quiet, are not sensitive in determining real-life speech perception abilities (Mendel, 2009). In 2007, Mendel stated that speech-in-noise testing is one of the most sensitive and robust objective outcome measures and provides realistic information about speech perception.

    Further, Weinstein (2013) stated that speech-in-noise testing should be performed on all patients, since it is the primary complaint of most hearing aid users. Benefits of including this test are that it can be used to aid in hearing aid selection, and pre and post hearing aid benefit, as well as a tool for counseling, if an individual should deny hearing difficulties.
Subjective Outcome Measures
  1. Hearing Handicap Inventory for the Elderly-screening version (HHIE-S)
    The HHIE-S has high validity and reliability (Weinstein & Ventry, 1982), and adequate test sensitivity and specificity (Lichtenstein et al., 1988). It is quick and easy to administer. The questionnaire is a measurement of the handicapping effects of hearing loss. The questions focus on the perceived effects of hearing loss, with questions oriented to emotional consequences or social and situational consequences. The higher the score, the greater the handicap. According to Taylor and Mueller (2011), “The questionnaire relates to real-world experience and quantifies the true impact that hearing loss has on a person’s life” (p 142).

    It should be noted that in a study by Wiley, et al. (2000), an unexpected finding was that after accounting for hearing loss, the older age groups had lower (better) scores on the HHIE-S than for younger ages. The researchers attributed this finding to a number of factors, such as having less demanding lifestyles, less bothered by disabilities, greater tolerance for trying to carry on conversations in noisy places, and better coping skills. The HHIE-S can also be used to assess the benefit of amplification by measuring a change in perceived handicap.

  2. Hearing Handicap Inventory for the Elderly-Significant Others-screening version (HHIE-SP)
    The HHIE-S was modified to be used by a spouse/significant other (Newman & Weinstein, 1986). The results of their study indicated a discrepancy between a patient perceived handicap and the perception of the significant other. Nevertheless, it is important to obtain input from family members and/or caregivers, especially when the patient may minimize the hearing disability and/or communication challenges. Scores from both measures can be compared and may facilitate counseling, treatment, and management of the communication problems.

    According to Armero (2001), patients in denial of their hearing loss may create conflicts among family members. Armero (2001) also suggests that personal interviewing may be more sensitive in uncovering emotional and psychosocial effects of hearing loss on the significant other. Thus, the process of uncovering these discrepancies between the patient and their significant other can be uncovered when a tool like the HHIE is administered to both parties as part of the FCA.
  3. Client Oriented Scale of Improvement (COSI)
    COSI is an open-ended communication-needs assessment tool. It is a valid measure with good test –retest reliability, relevance, and diagnostic utility (Dillon et al., 1997). It is quick and easy to administer, and is one of the most commonly used real-world measures.

    It is personalized, as the patient must identify and prioritize five specific difficult communication situations. It can also be used as a goal-setting tool in pre and post hearing aid use. According to Kemp (1990) it is an ideal tool to be used as part of the FCA because it helps define the patient’s goals with respect to improved communication.
  4. Characteristics of Amplification Tool (COAT)
    The COAT is a self-reporting tool composed of nine questions which is quick and easy to administer (Sandridge & Newman, 2006). It includes questions designed to determine the needs of the patient, hearing aid preferences, and attitudes toward hearing aid use, as well as questions about financial concerns. The COAT easily facilitates discussion and counseling about top-of-mind issues related to hearing aid use.

    The authors recommend that audiologists customize questions according to the needs of their patients. We should also probe the patient’s motivation and ability for assistive listening devices, and knowledge and use of other technology, such as smart phones, in light of wireless connectivity with hearing aids and assistive listening devices.

  5. The Tinnitus Handicap Inventory (THI)
    Given the high prevalence of bothersome tinnitus among the adult population with hearing loss, a tinnitus questionnaire can be included as part of the FCA. One possible choice is the Tinnitus Handicap Inventory (THI) (Newman, et al., 1996). The THI is a self-report questionnaire that examines tinnitus handicap severity. It is composed of 25 questions and is quick and easy to administer. It has high test-retest reliability and repeatability (Newman, et al., 1998) and high internal consistency and validity (Zeman, et al., 2012).

    Sogebi, et al. (2015) advises us that “distressing otologic symptoms, such as tinnitus, are associated with poor functional abilities and when combined with hearing loss can affect cognitive function in older individuals” (p. 18). This tells us that we cannot dismiss tinnitus as an incidental symptom, but one that has more devastating implications. Therefore, it is reasonable for audiologists to routinely assess the handicapping conditions of tinnitus and offer management solutions for those with bothersome or annoying tinnitus.

Part II
Special Considerations and Additional Assessments Recommended for the 90-Year and Older Adult Population
It is well known that hearing loss is a chronic condition in older adults and is more prevalent with increasing age (Lin, et al., 2011). Hearing loss is most prevalent in the oldest-old individuals, those aged 85 years or older. This group may require additional assessments because of their unique medical conditions and other associated psychosocial factors, such as social isolation. For these reasons, non-audiological tests and screenings should be part of the routine FCA.

Kricos (2006) stated that older adults, particularly those aged 85 years and older, have different needs compared to younger adults. They have co-morbidities, such as cognitive deficits, impaired sensory functions, vestibular problems, dexterity problems, and significant psychosocial-related consequences.

The inclusion of additional measures to explore the needs for this age group and/or those experiencing similar “symptoms” is specified below. It should be noted that chronological age should not be the sole criteria for administering these non-audiological questionnaires; any one of them can be performed if concerns are raised by the patient, significant other, caregiver or simply by observation from the audiologist. It is also noted that before conducting screenings for conditions such as depression and dementia, audiologists must have a referral network in place as these conditions can only be diagnosed by a physician or nurse practitioner.

  1. Auditory processing disorders (APD)
    Auditory processing disorders (APD) are prevalent in patients over the age of 70 to 80 years (Beck, 2013). According to Strecker and Dancer (2005), APD screening should be included as part of a routine audiological evaluation for older adults. Although the QuickSin might be sufficient for some adult patients, screening for APD in the older age group is more important, in view of the high prevalence of APD and the association with Alzheimer’s disease.

    Gates et al. (2002) found that poor performance on the Synthetic Sentence Identification with Ipsilateral Competing Message (SSI-ICM) was common in individuals with probable Alzheimer’s disease, and very poor performance on it may be a future indication of dementia. Therefore, it would be important to include this measurement or a similar screening tool.
  2. Cognition
    Hearing loss in the oldest-old population has been associated with an increased risk for cognitive problems (Lin, 2011). Aging brings with it an increased risk for dementia (Souza, 2014). Memory is adversely affected by hearing loss, due to the greater cognitive load needed to compensate for the hearing loss (Lin, 2011). Cognitive ability in older adults can be assessed on a continuum. On one end of the continuum is normal cognitive aging, followed by mild cognitive impairment, and finally, dementia. Patients suspected of dementia, either based on the results of a formal screening process or through observation by the audiologist, need to be referred to a physician who can conduct a formal work-up.

    Dementia can be screened with the Mini-Cog, (Borson et al., 2000). It is fast and accurate and does not require proficiency in English (Elsawy & Higgins, 2011). According to Remensnyder (2012), the audiologist should be sensitive to the effect this test may have on the patient, i.e., the patient may become defensive or feel insulted about these particular questions. Thus, before the implementation of a dementia screening, the audiologist must be comfortable sharing the results of the dementia screen with patients and their caregivers.

  3. Depression
    There is a high prevalence of depression in the elderly and oftentimes it is not recognized by the family physician (Thibault & Steiner, 2004).

    Depression can be screened quickly with use of the Patient Health Questionnaire-2 (PHQ-2) (Kroenke, et al., 2003). It consists of 2 questions and has construct and criterion validity. It is an excellent tool to use in a busy clinical setting. According to Ward, et al., (2016), these questions are sensitive to depression but not specific. Like screening for dementia, audiologists must be comfortable sharing the results of such screenings with patients, and, in addition, have a referral network in place for those that fail the screen.

  4. Listening Effort
    According to Hornsby (2013), hearing loss causes increased listening effort and is associated with self-reports of stress, tension, and fatigue. Additionally, it is more of a concern to the elderly who have cognitive and other sensory deficits. Fatigue and listening effort cannot be gleaned from the limited, typical audiogram.

    A dedicated short questionnaire on listening effort, the Effort Assessment Scale (EAC), (Alhanbali et al., 2016) is highly recommended. It is quick and easy to administer and score. It may also be used to assess pre and post hearing aid benefit, as the use of hearing aids may reduce listening effort (Hornsby, 2013). Dittner, et al., (2004), cautions us that the information, derived from the subjective self-report scales, depends on the questions being asked. There are many different scales and you must choose correctly.

  5. Fatigue
    Fatigue is a significant consequence of untreated hearing loss. Hornsby & Kipp, (2016) state that individuals with hearing loss have more negative psychosocial consequences than individuals without hearing loss. These very consequences of hearing loss render these individuals more susceptible to subjective fatigue in their daily lives. They found that psychosocial hearing difficulties as indicated on the HHIE-A, were strongly related to subjective fatigue. In addition, “fatigue is a core symptom in depression and can impact quality of life” (Hjollund, et al., 2007).

    The Fatigue Assessment Scale (FAS), (Michielsen, et al., 2003) should be included and is quick and easy to administer and score.

  6. Socialization
    Social isolation and loneliness are prevalent in the oldest old population and, in particular, those with hearing loss. Weinstein, (2015) stated that strong social relationships and an active life are linked to survival, morbidity and successful aging. An easy-to-administer screening tool for loneliness is the De Jong Gierveld Loneliness Scale. This tool has six questions, three for emotional loneliness and three for social loneliness (de Jong Gierveld, J & van Tilburg, T., 2006).

  7. Health Related Quality of Life (HRQOL)
    It is worthwhile to determine the patient’s level of activity and functioning because the oldest individuals with hearing loss “have associated functional limitations in daily living activities and this puts them at risk for compromised independence” (Sogebi et al., 2015). Further, decreased hearing for environmental sounds can manifest as limitations in activities of daily living. The Activities of Daily Living (ADL) and the Instrumental Activities of Daily Living (IADL) are screening tools that can be used to assess functioning (Katz, et al., 1970);(Lawton & Brody, 1969). Each is short, easy to administer, and provides quantitative information about the overall quality of life of the individual prior to intervention.

  8. Mobility and Balance
    Limitations in mobility and gait are common to this population as are increased falls. Osteoporosis can also lead to falls. (Elsawy & Higgins, 2011); (Weinstein, 2015). In turn, falls can lead to hospitalization and eventual loss of independent living.

    Weinstein (2015), citing other researchers, stated that improving communication ability of the oldest older adults could reduce their increased risk for falls. The Tinetti Balance and Gait Evaluation could be used to assess a patient’s risk for falls (Elsawy & Higgins, 2011).

In summary, it is obvious that a more comprehensive FCA is needed for the geriatric patient, especially for the oldest old, for the reasons outlined above. There are a number of self-reporting questionnaires that can be included in the FCA, but those outlined here were chosen because they target some of the most common and devastating consequences of hearing loss. Additionally, they are short, and easy to administer and score. One should keep in mind that more time might need to be allotted for the initial FAC appointment, and perhaps, to advise the patient of such, prior to the appointment. Also, it may not be necessary to administer every questionnaire to every patient; the assessment should be individualized and patient-centered. The particular needs of the patient, based on initial observation and dialogue, should guide the selection of specific tests and procedures to be conducted during the FAC.

By choosing to adopt such a comprehensive assessment, one that is evidenced-based and patient-oriented, the clinician can feel confident that she has investigated and identified the significant consequences of a hearing impairment to participation in daily activities, and that these consequences can be addressed with an equally comprehensive treatment and management program.    
Lois M. Bennardo, M.S., CCC-A, F-AAA is an Au.D candidate at A.T.Still University. She can be contacted at
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