Geriatric Audiology: Interview with Barbara E. Weinstein, PhD
Douglas L. Beck, AuD, spoke with Dr. Weinstein about her new book, Geriatric Audiology, speech-in-noise, QuickSIN, HINT, CST, Mini Mental State Examination (MMSE), and more.
Academy: Good morning, Barbara. Thanks for your time!
Weinstein: Hi, Doug. My pleasure, good to speak with you.
Academy: Barbara, I know you're a professor and the executive officer at the AuD program at the Graduate Center, City University of New York (CUNY) in Manhattan. How long have you been at CUNY?
Weinstein: I've been here teaching audiology at CUNY since 1987, when I was at the Lehman Campus and I've been the executive officer at the Graduate Center since 2005, when I launched the AuD program.
Academy: Okay, well I know what an audiologist is, but please explain, what is an executive officer?
Weinstein: Good question! I started as the executive officer of the Health Sciences Program, which is very much the same thing as the chairperson. In fact, I was the founding chair of the doctor of audiology program, the doctor of nursing sciences, the doctor of physical therapy, and the doctor of public health program, which means I had my hands full! So as CUNY initiated these programs, I helped foster and develop them in the early days, and fortunately—after they were all launched and were thriving around 2010 to 2011, they each became independent programs with their own dedicated management teams. So I was replaced by four people. This gave me the freedom to focus on rewriting my text and getting back to audiology, which I love
Academy: Wow—those must've been remarkably busy times! And if I recall, while I was lecturing at CUNY two years ago, I recognized the building from growing up in New York, and was surprised to see The Graduate Center, CUNY housed in the wonderful old building previously owned by B. Altman and Company on 5th Avenue and 34th Street!
Weinstein: That's right. Altman's is a landmark building and fortunately, CUNY purchased the part of the building that is on Fifth Avenue across the street from the Empire State Building.
Academy: And The Graduate Center has had an incredible and distinguished faculty and has established itself as one of the premier audiology brain-trusts with previous and current faculty members such as Arthur Boothroyd, Harry Levitt, Stan Gelfand, Shlomo Silman, and so many others. The alumni base is quite impressive, as well.
Weinstein: Thanks, Doug. I agree—it's an amazing place with an extraordinary faculty, amazing students and resources.
Academy: Okay then, so let's spend a little time talking about your new book, it's the second edition titled Geriatric Audiology, and it's a brand new, 2013 text. The first edition was published in 2000, and things have changed quite a bit since then. So what was it that inspired you to spend thousands of hours writing, editing, re-writing and publishing the second edition?
Weinstein: Things really have changed! In fact, I was hoping to go through the book, update it a little bit here and there, and ship it off to the publisher. But the reality is, as you noted earlier, everything has changed and our knowledge has increased dramatically in the last 13 years—and so the second edition of Geriatric Audiology is actually an entirely re-written book! In fact, the cover captures the biggest change, which is the evidence documenting the integral role the brain plays in auditory processing and the impact of age related changes on processing and communication!
Academy: And your approach throughout the second edition is unique in that you go beyond diagnostic tests and aural rehabilitation.
Weinstein: Yes, that's right. To me, the book is all about interdisciplinary approaches to maximally manage and work with the geriatric audiology patient. That is, in order to serve the elderly patients as well as we can, we have to understand their sociology, their psychology, their needs and desires and all aspects of aging and geriatric medicine.
Academy: I should note the second half of the book includes topics such as "Communication Management—An Integrated Approach," and "Health Promotion and Disease Prevention for Older Adults," as well as "Long-Term Care Services" and "Financing Health Care." These are, of course, very important topics, and not common topics in the audiology literature. If you don't mind, I'd like to also get your thoughts on the relationship between cognition and audition with regard to aging?
Weinstein: The answer to that question could easily fill an entire book! Nonetheless, as we've moved forward in audiology over the last decade, we've recognized more and more the important relationship between, and the integration of, sensory and cognitive systems. The most important thing may be that it's incredibly difficult to separate cognitive from auditory processing, that is they each impact the final percept. Hence, when the stimulus itself includes words or sentences, attributing the listening difficulty to specific cognitive or auditory deficits becomes a difficult, and arguably impossible task. Therefore, we have to tap into specific processing problems our patients report, so as to evaluate these skills, and choose the appropriate intervention. An excellent approach is to assess speech-in-noise, using material that has excellent face validity and is appropriately challenging. In fact, I believe when we do not assess speech-in-noise, we are doing the patient a grave disservice.
Academy: I totally agree. In fact, as I speak to audiologists and dispensers across the country, I usually pose a three-pointed question: (1) What is the major problem for all children suspected of having auditory processing disorders, (2) What is the number-one problem of the patient we fit with hearing aids last week, and (3) What is the number-one reason new patients come to see us?
Of course, the answer is "speech in noise" (SIN). Unfortunately, very few clinicians ever test SIN, and to me, it's critically important. I believe we should test every patient for SIN ability—and then after they're appropriately fitted with amplification or have gone through auditory rehabilitation, we should re-test their SIN ability and there should be an improvement if our treatment was effective. And of note, one cannot predict (at all!) a SIN score (or ability) based on pure tone threshold tests. The only way to know how an individual performs in noise is to test them!
Weinstein: I agree. I should add that the number-one complaint of hearing aid users remains difficulty understanding speech in noise so we have to continue to strive to ensure that our auditory interventions are working. This could translate in to auditory-based cognitive training as a supplement to hearing aids and we must insure that we select feature settings that can assist with challenges posed by aging. The fact that few clinicians assess speech-in-noise, is, in my view, holding us back as a profession responsive to the needs of the 35 million persons with hearing difficulties.
I really believe we need to incorporate evidence-based practices and we need to re-assess our test batteries and screening protocols to determine if what we are doing reflects the most up-to-date professional knowledge and needs of our patients. And, Doug, as you know, many of our colleagues are not yet up-to-speed with regard to the issues and realities of cognitive changes that impact their patients. And so in the second edition of Geriatric Audiology, I urge audiologists to take a look at what we now know about aging, hearing loss, and cognitive engagement and cognitive changes (and more), and urge them to incorporate this new knowledge into their daily practice.
Of course, audiology started in the 1940s with auditory rehabilitation (AR) as the focus, but with the advent of technology our focus changed to an emphasis on diagnostics. Over the ensuing decades our focus on technology remains, even in the rehabilitative purview so we must now marry the technology, the patient, diagnostics and rehabilitation to insure that our measurements uncover patient problems which our technologies and rehabilitative acumen can address.
Academy: So then, with regard to SIN and cognition evaluations, which tests do you recommend for audiologists? Which tests serve perhaps as "the least common denominator," which they must really become familiar with?
Weinstein: There are many options, and some are better than others for various reasons and in certain situations. However, if you're going to pin me down to a few things each of us needs to familiar with, I would have to say we each should be very familiar and comfortable with the QuickSIN for SIN testing because it is very fast, very efficient, and within a few minutes it provides a quick estimate of a person's SIN ability and really it should be part of the standard test battery.
Academy: And what do you tell people when they say they don't want to purchase yet another test?
Weinstein: Two things. As a firm believer in evidence-based practice, the first thing I feel obliged to say is it's best to use a recorded, commercially available and proven test, like the QuickSIN—because it's already been verified and validated and really, it is not very expensive!
Having said that, and given the importance of assessing speech-in-noise pre- and post-intervention, the second thing is the audiologist can create his or her own SIN test. There's not much to it. Using an iPhone or iPad one can record different noise backgrounds such as traffic noise, cafeteria noise, or cocktail party noise, and then integrate this with sentence stimuli at multiple SIN levels.
One can establish norms in the office by testing 5 or 10 people using their own protocol. Alternatively, one can use the patient as his/her own control group and assess performance in noise over time using the same testing conditions. Every patient is a case study and I do whatever I can to improve their daily function with interventions vis-a-vis their hearing. Also, there are many commercially available tests that can be very useful including the Hearing-in-Noise Test (HINT), Connected Speech test (CST) and more, and these tests add very realistic and interesting information to the situation at hand. Of course, the patient's own report of continuing speech understanding and communicative challenges with hearing aids has merit and cannot be undervalued.
Academy: And, what about a single cognition test? Is there a quick and easy test of cognition the audiologist can use to determine the cognitive status of the patient?
Weinstein: Absolutely. I think we do need to screen our patients for cognitive or mental status and we should probably use the Mini Mental State Examination (MMSE). The MMSE takes about ten minutes or so, and it quickly screens their mental status based on knowledge of the correct time and place, recalling lists of words, simple arithmetic, as well as language and motor skills. I realize many audiologists don't feel comfortable using the MMSE, but the way I look at it is if we assess SIN or use the MMSE pre-treatment, and then we re-assess post treatment, we'll be able to find important and beneficial changes when we take care of patients. To me, this is in the patient's best interest, and it's in the profession's best interest to make sure we're facilitating improved auditory and cognitive processing.
Academy: And for the audiologists reluctant to use the MMSE because they're concerned about what to do when the patient fails – the answer is simple, refer! For example, we all examine ear canals and eardrums every day, and when you see an abnormality (like a glomus tympanicum) you must refer. It's the same thing. If the patient does poorly on the MMSE, refer them back to their primary care physician or the referring physician with an explanation of your findings and the reason for referral.
Weinstein: Sure, that's exactly right. So my concern is we need to work toward gathering improved and modern assessment and treatment protocols and we need to be mindful of trends in health care, namely patient-centered care with a focus on the whole person, not just the ears! The psychology literature is replete with examples of the benefits of cognitive retraining and we should be gathering data showing the added value of auditory based cognitive retraining.
Academy: Barbara, it's been a pleasure chatting with you and I really enjoyed the book and the conversation. Your approach to the geriatric patient is comprehensive, inclusive and will very likely provide the highest level of success.
Weinstein: Thanks, Doug. I appreciate your time and your interest in the book!
Barbara E. Weinstein, PhD, is a professor and the executive officer at the AuD program at the Graduate Center, City University of New York.
Douglas L. Beck, AuD, board certified in audiology, is the Web content editor for the American Academy of Audiology.