Of the 28 million Americans (one in 10) who have a hearing loss, only 20% (approximately 6 million) seek help for their communication difficulties (Olive, 2002; Van Houten, 2002). The prevalence of hearing loss increases to 50% in people older than 75 years of age. These people represent an often underserved or unserved population regarding assessment for hearing loss and intervention through the use of hearing aids. It is unfortunate that while managed care has dictated that primary care physicians (PCPs) serve as gatekeepers or principal referral sources regulating patients' access to specialized treatment (Olive, 2002), the incidence of physicians performing hearing screenings or making appropriate referrals to audiologists has decreased in recent years (Kochkin and Rogin, 2000). Even more troublesome is that too often, when hearing loss is suspected and then found, PCPs may tell their patients that it is just a part of getting older and nothing can be done about it. This may help explain why hearing aid use among the elderly is declining despite a rapidly aging population and today's advanced hearing aid technology, which is more capable than ever before of helping those with hearing loss. Clearly, physicians and other health care professionals must do a better job of assessing these individuals.

Recently, the Better Hearing Institute Physician Referral Development Program was launched to pursue physician referrals for audiologic services (Van Houten, 2002). This program is based on a powerful study by the National Council on the Aging involving 2,069 people with hearing impairment and 1,710 of their family members (Kochkin and Rogin, 2000). This study revealed that hearing loss is a major health concern and demonstrated significant quality-of-life differences between users and nonusers of hearing aids. For example, the study found that hearing aid users were more likely to report improvements in their physical, emotional and social well-being and were overall more socially active and less likely to have extended periods of depression, worry, paranoia and insecurity than were nonusers. These results should cause the medical community to advocate hearing aids as a necessary, rather than elective, component of health care (Bridges and Bentler, 1998).

Modern hearing aids are technologically advanced and can help reduce the communication problems of individuals with hearing impairment. Matching appropriate high-technology hearing aid features to elderly patients requires a holistic approach integrated within a transdisciplinary hearing health care model that is consistent with current principles of managed care as shown in the Figure. The purpose of this article is to describe a model that incorporates both medical and allied health care professionals in identifying and managing the hearing health care needs of elderly patients.

A holistic approach is one that considers patients' physical, psychological, social and communication status in addressing health problems. A transdisciplinary model involves breaking down barriers that exist across professions (American Speech-Language-Hearing Association [ASHA], 1996). By integrating a holistic approach (Lesner and Kricos, 1995) and a transdisciplinary model, the unique characteristics of each patient are considered. This results in the efficient use of resources, communication among professionals and a case-management approach for situations requiring complex solutions (ASHA, 1996; Johnson and Danhauer, 1999). Patients and their families (or significant others) are at the center of the model ensuring that hearing health care is patient-focused; participants are the PCP, allied health care professionals and support service staff.

In 1997, the World Health Organization's International Classification of Impairments, Activities, and Participation provided a conceptual framework for understanding the impact of hearing loss on elderly patients, their families and their daily lives. Impairment, intrinsic to patients, involves a breakdown in basic organ structure and function. Extrinsic to the patient are activity limitation (i.e., disability) and participation restriction (i.e., handicap), which are transactions between patients and the environment. In the model under discussion, the environment is where patients live, which, for the elderly, varies based on level of independence and financial status.

The audiologist is often the team leader in the transdisciplinary hearing health care model. Primary care physicians share a close relationship with patients and their families, as well as with other allied health care professionals and support service staff. Levels of involvement of these individuals vary, depending on patients' independence, living arrangements and complicating medical conditions. For example, elderly individuals living independently in their own homes may only communicate with their PCPs, while peers residing in assisted-living facilities require an integrated team for daily functioning. Nevertheless, communication among patients, families, PCPs, allied health care professionals and support service staff is critical for appropriate health care including identification, diagnosis and management of hearing loss.

Patients consult with their PCPs for diagnosis and treatment of health problems, including hearing loss. In this model, PCPs refer patients to audiologists who have specialized expertise in the diagnosis and management of hearing loss. However, many elderly patients may be unaware or unwilling to admit that they have a hearing loss warranting attention by the hearing health care team. Ideally, allied health care professionals (e.g., speech-language pathologists, nurses, occupational therapists or physical therapists) or support personnel in long-term residential care facilities for the elderly should recognize signs of hearing loss in their elderly patients and refer them to their PCPs and/or audiologists.

Hearing loss may also be identified by members of the health care team during stays in acute care hospitals or rehabilitation hospitals. Johnson and Danhauer (1999) advocated that hearing screenings be a routine part of patients' intake physicals at these facilities and that all allied health care professionals be trained to recognize signs of hearing loss, to communicate with patients having communication problems, and to assist with patients' hearing aids within the context of a comprehensive hearing support program. Identification of hearing loss is crucial, because patients cannot benefit from rehabilitation unless they can communicate with their therapists.

Ideally, hearing aid selection, evaluation and fitting is a six-step process involving audiologists, patients and the patients' families (ASHA, 1998).

Step 1: Assessment. The type and extent of hearing loss and suitability for rehabilitative efforts are determined. Depending on the referral source, patients diagnosed with hearing loss should be examined by their PCPs and/or an otolaryngologist to determine possible etiologies and explore medical treatments prior to trying hearing aids. The U.S. Food and Drug Administration requires a medical clearance or patient-signed medical waiver prior to obtaining hearing aids.

The primary treatment for loss of auditory sensitivity caused by sensorineural hearing loss (most common in the elderly) is a hearing aid fitted within a total aural rehabilitation program. To specify patients' determination, motivation and/or candidacy for audiologic rehabilitation, audiologists should use "income measures" that can help identify patients with unrealistic expectations about hearing aids, determine if special advisement is needed regarding the benefits of amplification in noise or assist in selecting appropriate amplification features for patients. Candidacy and rehabilitation assessment involve determining the effects of hearing impairment in activity limitation and participation restriction domains by administering pre-intervention measures for baseline or before hearing aid fitting. These instruments are typically self-report questionnaires and include input from families (e.g., the Client Oriented Scale of Improvement [COSI] [Dillon et al., 1997] asks them to prioritize difficult listening situations pre-treatment).

Because there are so many advancements in styles and circuitry available today, audiologists must conduct holistic evaluations of patients' characteristics in multiple areas (i.e., physical, psychological, social and communication) by using checklists and flowcharts to match appropriate external (e.g., the style of hearing aid and user-control options accessed either on the hearing aid or by remote control) and internal (e.g., circuitry) high-technology features to hearing aid candidates (Johnson et al., 2000). For example, use of completely-in-the-canal (CIC) hearing aids, which are placed deep into the ear canal and are desired by many patients for cosmetic reasons, requires consideration of patients' abilities in all four domains. In the physical domain, patients must have appropriate ear canal characteristics (e.g., round, medium-to-firm texture, average-to-long, slightly curvy) to assure proper fit and comfort, as well as proximal and distal manual dexterity for inserting and removing the hearing aids. In the psychological domain, patients are often good candidates for CICs if they are sensitive to the "hearing aid effect" (the stigma attached to the visual presence of hearing aids), because they are motivated to do what it takes for these instruments to work. In the communication domain, candidates for CICs need to have an appropriate degree and configuration of loss (e.g., high-frequency loss no greater than severe). In the social domain, audiologists should ensure that patients have adequate support networks to help them take advantage of high-technology hearing solutions (e.g., people who can assist them with the insertion and removal of CICs, if needed).

Similarly, audiologists must consider these same domains when considering high-technology hearing aid circuitry for patients. Considering the social domain, elderly patients who find it difficult to communicate in the presence of excessive background noise may find that programmable or digital hearing aids with directional microphones may help them hear talkers directly in front of them while attenuating noise from behind. Results of holistic audiologic assessments provide audiologists with realistic amplification options to present to patients and their families in the next step.

Step 2: Treatment planning. Audiologists, patients and families/caregivers make preliminary decisions and ensure that all participants have a realistic understanding of the intervention process. Intervention goes beyond patients and their hearing losses to include their living environments. For example, audiologists, administrators and support personnel can conduct facility accessibility audits to see how simple modifications such as carpeting common areas to reduce reverberation, establishing quiet areas for visitation or procuring assistive listening devices for residents' use can improve communication for the patients and all residents.

Step 3: Hearing aid selection. At this point, audiologists match the appropriate devices and features to the specific needs of their patients.

Step 4: Hearing aid verification. Audiologists perform quality control (e.g., electroacoustic characteristics, visual/listening and ear mold/hearing aid feature checks), physical fit (e.g., check cosmetic appeal, absence of feedback and physical comfort), and performance (e.g., real-ear probe-tube microphone measurements, audibility, comfort and tolerance) assessments to ensure that hearing aid goals have been met.

Step 5: Hearing aid orientation. This step includes a trial period of at least 30 days during which audiologists instruct patients and their families about proper use, care, insertion/removal, battery changing, troubleshooting and wearing times of the hearing aids, as well as expectations for performance. Audiologists must conduct in-services to train allied health care professionals and support service staff in long-term residential care facilities about daily monitoring (e.g., visual and listening checks) (Johnson and Danhauer, 1999) and graduated levels of assistance in hearing aid care and use (e.g., independent, partial assistance, full assistance and supervised use) (ASHA, 1997) as part of a comprehensive hearing support program.

Step 6: Validation. Validation occurs one to three months (and at least annually) after the hearing aid fitting. The perception of hearing aid benefit is provided by patients and their families through the use of various outcome measures for activity limitation, participation restriction and satisfaction. Income measures (in addition to others) used in Step 1 are administered as outcome measures to assess changes in patients' behaviors due to intervention. For example, difficult listening situations prioritized on the COSI by patients and families prior to treatment are rated for degree of change and amount of improvement while wearing hearing instruments. New hearing aid users make comparisons to the unaided condition, while experienced users compare the performance of new devices to that of their old hearing aids. Validation of amplification benefit is also based on input from patients' PCPs, allied health care professionals and support service personnel, who can help determine if patients have a greater sense of well-being and participate in more social events as a result of hearing aid use. In the transdisciplinary model, feedback from participants is critical to determine the effectiveness of the intervention plan and any need to modify it over time. Use of this model should increase the numbers of elderly patients who are referred for audiologic services and whose communication difficulties can be helped through appropriate amplification.

We have presented a holistic approach within a transdisciplinary model for meeting the hearing health care needs of elderly patients. Our model is patient-centered and requires dynamic communication among the participants: patients, families, PCPs, allied health care professionals, support personnel and audiologists to enhance quality of life for elderly patients.

Dr. Johnson is professor in the department of communication disorders at Auburn University.

Dr. Danhauer is professor and chair in the department of speech and hearing sciences at University of California, Santa Barbara.

ASHA (1996), Curriculum Guide to Managed Care. Rockville, Md.: American Speech-Language-Hearing Association.

ASHA (1997), Guidelines for audiology service delivery in nursing homes. Ad Hoc Committee on Audiology Service Delivery in Home Care and Institutional Settings. ASHA 39(suppl 17):15-29.

ASHA (1998), Guidelines for hearing aid fitting for adults. Ad Hoc Committee on Hearing Aid Selection and Fitting. Am J Audiol 7(1):5-13.

Bridges JA, Bentler RA (1998), Relating hearing aid use to well-being among older adults. The Hearing Journal 51(7):39, 42-44.

Dillon H, James A, Ginis J (1997), Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. J Am Acad Audiol 8(1):27-43.

Johnson CE, Danhauer JL (1999), Guidebook for Support Programs in Aural Rehabilitation. San Diego: Singular Pub. Group.

Johnson CE, Danhauer JL, Krishnamurti S (2000), A holistic model for matching high-tech hearing aid features to elderly patients. Am J Audiol 9(2):112-123.

Kochkin S, CM Rogin (2000), Quantifying the obvious: the impact of hearing instruments on quality of life. The Hearing Review 7:1:6-34.

Lesner SA, Kricos, PB (1995), Audiologic rehabilitation assessment: a holistic approach. In: Hearing Care for the Older Adult: Audiologic Rehabilitation, Kricos PB, Lesner SA, eds. Boston: Butterworth-Heinemann, pp21-58.

Olive J (2002), Better Hearing Institute launches new physician referral development program. Audiology Today 14(2):23-24.

Van Houten B (2002), BHI pursues physician referrals with innovative new program. The Hearing Review 9(2):26, 28, 60.

World Health Organization (1997), ICIDH-2: International Classifications of Impairments, Activities and Participation. A Manual of Dimensions of Disablement and Functioning. Geneva: World Health Organization.

A Transdisciplinary Holistic Approach to Hearing Health Care