The patient presented to the clinic as a blind 45-year-old male with bilateral, symmetric severe sensorineural hearing loss. He was currently wearing binaural full-shell, custom, in-the-ear (ITE) hearing aids that were approximately eight years old. Despite numerous attempts to discuss new devices, the patient had been resistant to consider new technology, despite the fact that third-party pay would offset the majority of the cost. In addition, the patient had suffered panic attacks during the previous two clinic visits when discussing the need for replacement.
The patient was already quite anxious and agitated by the time I saw him, as he had been waiting for some time to be seen. Further, his service dog was restless, lending to the sense of urgency. Audiometric findings revealed no change since his previous examination two years ago (FIGURE 1), but once again, the patient was extremely resistant to discussion of new devices, despite the fact that the current ones were in need of replacement. Monosyllabic word recognition was bilaterally symmetric, at approximately 50 percent for recorded stimuli. Immittance showed no evidence of middle-ear or retrocochlear pathology.
Electroacoustic evaluation and real-ear measurements revealed that the patient’s ITE aids were providing appropriate gain and output for his hearing loss, and the patient was generally satisfied with their performance. Physical inspection of the devices, however, revealed them to be in poor working order, with apparent visual wear-and-tear on the rotary volume controls, plus cerumen impaction in both receiver ports. Review of the patient’s insurance indicated that he was eligible for new hearing aids at no cost to him through state third-party insurance programs. When this was discussed, however, the patient immediately became quite agitated, instead insisting that we clean and repair these devices.
Pop Quiz: What Is/Are Your Clinical Impressions?
A. Patient is a “power junkie,” who is resistant to give up his linear, peak-clipping devices.
B. Due to his blindness, patient does not want behind-the-ear (BTE) or receiver-in-the-canal (RIC) devices, which would be more appropriate for his hearing loss. In addition, his comfort with existing controls (traditional volume control wheel) likely makes him reticent to switch products.
C. Patient has not been properly counseled regarding the significant advances that have taken place with hearing aid technology during the past decade.
D. All of the above.
E. None of the above.
The correct answer is “E,” although I will admit that my first impression was likely a combination of A, B, or C. For some reason, despite the fact that I was in the middle of a very busy clinical day, I (for once) resisted the temptation to begin solving the problem before I learned more about it.
I asked for his permission to ask a couple questions about why he was so attached to these particular devices. He granted permission, and said that he found custom devices easier to insert, remove, and operate than BTEs (which he had tried). I agreed, and informed him that we could find other custom devices that worked for his loss.
The second objection related to the fact that he preferred to use a traditional analog (hard “stop”) rotary volume control, rather than a button or remote control. While I concurred that it was increasingly challenging to find “non-digital” volume controls, I also discussed the advantages of modern wireless hearing aids that provided more control options (binaural controls, separate left/right controls) and the patient seemed intrigued about the new features.
So far, so good. We also addressed that although non-linear hearing aids may not initially sound as loud to him as his linear devices, we would work towards optimizing benefits with lower overall output levels, which would prevent over-amplification. Additionally, we discussed directional microphone devices not only to address communication in noisy listening environments, but also stressed the importance of preserving spatial awareness, given that his blindness prevented visual cues to assist him with localization.
Feeling victorious, I suggested that we proceed with ordering a new set of devices, but the barriers went up and the patient’s anxiety increased to full-blown panic attack levels.
Pop Quiz: At This Point, What Would You Do?
- Refer the patient to psychological counseling to address his panic attacks.
- Schedule an appointment in one week to continue discussion regarding options.
- Repair the patient’s eight-year-old hearing aids.
- Employ motivational engagement counseling strategies.
- Something else.
Any of the above options may be reasonable options, but my attitude was that simply repairing his current devices would ultimately be a disservice to the patient. I had recently been involved with the development of the Ida Institute’s second seminar series that focused on “motivational engagement” as a patient-centered approach to behavioral change.
Eager to use the tools that I had been teaching, I calmly proceeded with guiding the patient through a more comprehensive analysis of benefits/liabilities of the status quo versus seeking change to new devices. The central tenet of motivational counseling as a strategy is that it empowers the patient to come to the best decision by addressing their own fears regarding change.
In the process of employing the tools, we learned that the underlying issue was not fear of new technology, different form factors, or different gain/output settings. Rather, we learned that the fundamental issue was that every clinician he had seen in the past immediately started the process of otoscopy, inserting otoblocks, and making earmold impressions, without considering the resulting claustrophobia for a severely hard-of-hearing, blind person who was subject to panic attacks!
When I suggested that we do one ear at a time, with the hearing aid work in the other ear so that I could communicate throughout the process, the patient was agreeable, but apprehensive. After an agonizing five minutes (thankfully the first impression on that ear was a good one), we repeated the process for the other side. I ordered new hearing aids and two weeks later fitted the patient with new devices that he loved.
Moral of the Story
Until I learned to use my two ears and one mouth in direct proportion to listen more and talk less, I couldn’t really uncover the root cause of the patient’s anxiety. In fact, until he uncovered it for himself, he didn’t really realize it either, and we both learned a lesson that day.
In my 35 years in the profession, I have always been drawn to the more challenging cases. Despite the temptation to review the audiometrics and start “solving” problems, we cannot really understand and address individual patient issues until we learn more about the person. Counseling tools like motivational engagement are a great way to assist with the discovery process and sort out whether a patient really isn’t motivated to act versus struggling with the normal cognitive dissonance that grips many first-time hearing aid users.
The final lesson from this case related to the fact that although audiologists often become frustrated with the comparisons between hearing and vision, there are significant comorbidities in the aging population between hearing loss and visual impairment. The prevalence of myopia (nearsightedness) in persons aged 12–54 years old is approximately 42 percent, and has risen over the last 30 years (Vitale, Sperduto, Ferris, 2009).
Furthermore, the prevalence of cataract, age-related macular degeneration, and open-angle glaucoma increases with age, and affects nearly 8 percent of those over age 80 in the United States. Overall, the incidence of all conditions leading to “low vision” or “blindness” is 23.7 percent of the U.S. population older than 80.
Increasingly, the aging Baby Boomer population will present with both hearing and “non-correctable” visual impairments, and increasingly clinicians will need to address specific issues related to form factors, technology, user controls, and signal processing strategies for this population. In addition, be sensitive to the specific issues of vulnerability that may accompany the patient with hearing and vision loss as they navigate through the process of hearing aid diagnosis and treatment.
Vitale S, Sperduto RD, Ferris FL. (2009) Increased prevalence of myopia in the United States between 1971–1972 and 1999–2004. Arch Ophthalmol 127(12):1632–1639.