Hearing Impairment Associated With Lower Vision Rehab Gains

Individuals who are both vision impaired and hearing impaired typically gain less from standard vision rehabilitation than individuals who are vision impaired. Recent multi-center research employing a commonly used functional vision questionnaire found that even when individuals with hearing loss initiated with similar levels of visual function, they were less likely to show clinically significant improvement following outpatient low vision rehabilitation. Many standard methods of vision rehab rely on spoken instructions, audio cues and group classes and may be masking the effect of hearing impairment on outcome of rehabilitation, everyday vision function, safety and vision-related quality of life.

Why It Matters

Even minor communication problems may interfere with the success of vision rehabilitation efforts to enable individuals with vision impairments to remain living independently. Instruction in low vision services may include learning strategies for reading, safe and efficient preparation of meals, and taking and managing medications in the dark. Use of community mobility strategies, and the selection, use and maintenance of vision aids and other assistive devices and technology also may be included. The person with visual impairment may not hear important instructions, miss out on crucial information, or have difficulty following a fast paced stream of information and direction. As a result, a large amount of time may be spent re-explaining the same information over weeks and months instead of acquiring new strategies and techniques. As a result, individuals with visual impairments may fail to master key skills, rely on vision aids less than needed, and fail to generalize vision strategies to tasks they need to do every day.

For individuals with dual sensory loss, the risk of safety hazards and injury during mobility training and at home is significantly increased. Current orientation and mobility methods rely heavily on auditory information. Students with some degree of hearing loss may not be able to hear the sound of approaching bicycles or vehicles or auditory cues such as red lights and safety reminders from the MO instructor. Students with dual sensory loss may not hear appliances activate, such as the oven turning on, or safety reminders from others such as “stop,” “up,” “handrail on your right.” At home, they may miss important safety alerts such as their smoke alarm going off, a timer coming on, doorbell ringing, or sounds from medical equipment they use. Even if the decibel level is sufficient to wake the individual, the person with hearing loss may have difficulty locating the source of the sound in cluttered or echoic spaces.

Less seeing and less hearing both place greater demands on the brain than typical vision and hearing do, and both use up a lot of energy and divert a lot of resources away from other things that you might be doing. People with visual loss rely more on vision to get through their day than those without loss of vision, and people with hearing loss rely more on hearing than those with normal hearing ability. However, when both senses are impaired, the brain has fewer straightforward pathways to access information, placing greater demands on higher level cognitive resources. These demands can result in slower information processing, greater mental fatigue, and less efficient learning in rehabilitation. Training methods used with persons who have both vision and hearing loss need to be evaluated for accessibility. We cannot assume that all patients will comply with recommended training methods, even if they appear motivated to learn and use new vision and hearing strategies after Vision and Hearing Rehabilitation. There may be a training method problem instead of a patient problem.

Similar to mental health and social participation, sensory function are important aspects of quality of life. Vision and hearing impacts not only quality of life but also social participation. Many individuals with significant vision impairment are unable to perform activities that they enjoy such as reading, or tasks that they need to do on a daily basis such as managing medication or using the phone. Even individuals with mild hearing impairment report that hearing and understanding conversation is physically exhausting or even embarrassing in social settings. The impact of vision and hearing loss on social participation and on an individual’s sense of confidence and competence in social situations can lead to social isolation. Conversely, social withdrawal is not a trivial matter for individuals with mental health and substance use disorders, or poor health behaviors including physical inactivity. It can impede adoption of healthy behaviors and exacerbate symptoms of mental health and substance use disorders. It also can lead to increased dependence on family members or paid staff for assistance with daily living tasks.

Far too many rehabilitation outcomes are less than they could be because good communication access was not included. Outcomes are typically measured by a list of tasks (like following instructions or repeating words) and a rating of the individual’s effort or ability. However, the sole reason a patient shows “no improvement” could be because access to instruction was inadequate. A more complete assessment of rehabilitation outcomes would report the mode of communication used to complete the tasks, the amount of captioning or interpreter services needed, and the individual’s ability to understand and follow instructions in noisy and unpredictable places.

Both vision services and hearing services are typically organized and provided separately within health systems. As a result, patients and family members must often navigate different clinics, with separate locations, referral processes, insurance coverages, documentation and payment systems. While separate organization of vision and hearing services can make sense from the perspective of different health care specialists, the needs of older adults and their family members are further complicated by difficulties with transportation and caregiver support. Thus, even very effective vision rehabilitation programs can appear ineffective due to impediments to accessing necessary audiology treatment. However, with cooperation among health care providers such as Otolaryngology, Audiology, and Visual Rehabilitation, a treatment approach can be individualized to maximize the rehabilitation of patients who have both vision and hearing loss.

Hearing loss and vision impairment are highly prevalent health conditions with significant public health impact. With billions of people worldwide having some vision impairment, or hearing difficulty, dual sensory loss is not uncommon in routine clinical practice. Thus, for program managers developing rehabilitation programs for individuals with sensory disabilities, ensuring accessibility is not an afterthought to developing a “great program,” but a basic requirement to ensure that the program is safe and effective for all clients.

Who It Affects

The majority of individuals with dual sensory loss due to medical eye disease are older adults. Many patients in low vision rehabilitation have age-related macular degeneration, glaucoma, diabetic retinopathy, cataracts or cataract-related vision problems, and high levels of refractive error. In fact, a large percentage of older adults have some degree of age-related hearing loss. Often, individuals with hearing loss are unaware of the extent of their impairment. Initial hearing loss is often detected as difficulty hearing speech in noisy environments as opposed to open-field conversation at normal talking levels. As a result, the patient may start vision rehabilitation with untreated hearing impairment.

People with diabetes and vascular disease are getting a double whammy. In addition to the risk of vision loss from diabetic retinopathy and macular edema, many people with diabetes experience some degree of hearing loss. The microvascular changes and neuropathy associated with diabetes can affect the nerves that allow us to hear, leading to hearing loss. Since the factors that contribute to high blood pressure and vascular disease that affect the eyes also can affect hearing, many of these patients are experiencing problems with their vision and hearing.

In addition to having hearing loss throughout their lives, some individuals with lifelong hearing loss or early hearing impairment may be affected by the progression of eye disease in older age. Some individuals who are sign-fluent may also use lip reading, hearing aids and/or wear radio aid transmitters in their eyeglasses and use television captioning. Others may be only be able to use lip reading and visual access to sign from time to time. This group of individuals and their vision impairment goals may need a different approach to vision rehabilitation from the beginning. The focus would include tactile signing, close vision signing, braille reading and writing and strong environmental adaptations.

Genetic and syndromic conditions that affect hearing also can affect vision. Individuals with these conditions such as Usher syndrome and other forms of inherited retinal dystrophies may experience vision loss, which can be progressive. As a result, these patients may require vision rehabilitation earlier in life and may benefit from long-term planning for vision and hearing restoration or management.

Design of services for individuals with combined blindness and hearing loss can greatly impact outcomes. All individuals and organizations providing service and support to individuals who are vision impaired, including clinicians and rehabilitation teams such as low-vision optometrists and ophthalmologists, orientation and mobility specialists, and rehabilitation counselors and social workers, must consider hearing in their service design and strategies. Those individuals and organizations providing services for individuals who are vision impaired, including low-vision optometrists and ophthalmologists, and those who provide services for individuals who are hearing impaired, including audiologists and hearing aid specialists, can work more efficiently and provide more effective training and strategies for individuals with combined blindness and hearing loss if they can facilitate access to hearing services for their patients. Primary care physicians can play an important role in impacting the sensory losses of their patients by identifying sensory loss early and making timely referrals for comprehensive vision and hearing assessments.

Family members and caregivers often wish to support their loved ones with brain injury. Because families typically don’t receive formal communication accommodations and supports, they may unwittingly become the unofficial interpreters for the individual with brain injury. This means they might be teaching patients the same lessons over and over, or translating from doctors and therapists all day long. While good intentions are behind this support, unofficial interpreters can undermine patients’ privacy, burden family members, and change the information and instructions that need to be shared with the individual with brain injury. Thus, it is very important to include formal communication supports and strategies within brain injury rehabilitation to ensure individuals with brain injury receive care and respect their privacy and autonomy.

What Changes

1) Incorporate hearing screenings into routine vision rehab intake process.

Identifying a hearing impairment early in your training program is key to delivering training in the most effective way for that dog, and to avoid wasted time and resources training a dog who may require adaptations. Hearing screening can occur through brief screening questions to owners who are currently in training, a hearing assessment in the clinic, or referral to audiology for a comprehensive hearing evaluation if required. It is also important to note that hearing can change over time for many reasons including earwax accumulation, infection, device malfunction and developmental changes.

While there are many methods that clinics can use to support effective communication with their patients, there are a number of simple steps that staff in many clinics can take. Recording patients’ preferences for the method they require for communication and environmental needs can save misunderstandings occurring at several points. For example: “quiet room needed”, “I prefer to have captioning”, “I require face-to-face communication only”, “speak slowly”, or “interpreter required”.

2) Rehabilitation methods become deliberately multimodal

For lessons to learning where audio cues for audio cues are unreliable: Large print written plans with high contrast; step by step pictorial plans of the procedure; tactile demonstration and hands-on practice using guidance with consent for touch as necessary. Checklists can be provided to the patient and explained to them. They can be taken home and used as a reminder. Speech can be slowed down and paused regularly. “Teach-back”, where the clinician asks the patient to repeat back in their own words what they have to do.

While group training is a cost effective option, it can be less accessible to people with hearing loss if there are too many speakers at the same time, or the environment is too noisy.

3) The training facility is designed to train in both the visual (simulation) and auditory (recorded) learning modes.

Even small changes can make large differences in the communication effort required. A quiet space with minimal echo, bright lighting focused on the speaker, and lower volume background music can all make it easier for people to understand speech. Clinics also provide a visual ‘agenda’ for the session to help reduce patients’ anxiety and to aid their memories of the key elements of the communication that took place during the session.

Invest in safety training that goes beyond just warnings. Many people don’t hear or see warning alarms and messages because they are presented in a single format. Consider using multiple forms of alerts and reminders for smoke alarms and carbon monoxide detectors, doorbells, timers, and reminders to take medication. For cooking safety, look into products that are easily visible, have tactile markers, and vibrate instead of beep.

4) hearing aids and other assistive listening devices are available and might do some good.

While amplification can be a powerful tool in the lives of individuals who are blind or have low vision, it is not a cure-all. Amplification devices, such as hearing aids, assistive listening devices, and cochlear implants, can enable individuals with visual disabilities to gain access to critical auditory information. However, some individuals do not wear their amplification (for reasons such as discomfort, aesthetics, or the financial constraint of purchasing additional accessories), while others cannot afford the device or lack the necessary skills to perform routine maintenance. Many individuals, regardless of amplification, have difficulty hearing in the presence of background noise. Thus, it is crucial that the vision rehabilitation staff have an understanding of how an individual really hears in order to make appropriate recommendations in training.

Technology Supports can also be used to facilitate in-person consultations that would otherwise require in-person fitting appointments. Even when the consultant is in the same room, spoken words can be captured and displayed on a phone or tablet held by the consultant or by the person with hearing loss and an assistant. There are many services that offer captioned phone and many devices can easily Bluetooth stream from a clinician’s microphone. Clinics can provide simple setup and a folded, large print handout to the patient to enable their use remotely.

5) Interdisciplinary care pathways replace siloed service delivery

An integrated approach can help to reduce the number of failed attempts at training and maximise outcomes. The team may include a low vision clinician, an occupational therapist, an orientation and mobility instructor, an audiologist and/or hearing aid specialist. Additionally, a method of communication support such as speech-language therapy or an interpreter may be required. In some cases, inclusion on the referral form and ability to view the treatment plan would be all that is required.

Having a clear referral checklist for audiologists can help healthcare providers at the front line make the right referral at the right time. For example, does the person have difficulty following instructions in a group situation? Does the person rely heavily on lip reading? Is the person hesitant to attend social functions where they may have to listen in a group situation or in a noisy environment? Has it been several years since the individual had their last hearing assessment? Including such a referral checklist in the flow of work of healthcare providers can help to avoid missed opportunities for referral.

6) Update hospital policy and reimbursement, and staff training on appropriate utilization of services as patient needs evolve.

Pay models should take into account the time and support needed to provide meaningful vision and hearing focused rehabilitation services. While there is an up-front cost for longer treatment sessions with captioning and interpreters, and for coordinating interdisciplinary care among OT, PT, and ST, there can be long-term cost savings from falls and injuries prevented, medications not taken in error, and avoidance of unnecessary dependence on family members or caregivers. Many programs now take an integrated approach and would advocate for a “bundle” for sensory impairment care delivered through a specific care pathway rather than as two separate vision and hearing problems.

Staff training of the rehabilitation workforce to serve individuals with hearing loss is a solvable problem. Staff receive brief training on communication strategies for individuals with hearing loss, effective team work with interpreters, use of captioning technologies, and use of tactile and visual aids in teaching. In addition, connections are made between staff and patients and their respective peer-support networks, as well as with community health workers to support generalization of learned skills to the home environment.

7) Outcomes are measured in ways that really matter to “real world” practice.

Success in the pediatrics rotation should include not only the concept of safety, but also actual participation in clinical patient care, and not just going through the clinic assignments.

References:

https://pubmed.ncbi.nlm.nih.gov/41817533/