As an audiologist who carries out home visits, I occasionally have patients who are in care homes and nursing homes. It can be difficult to be sure that my patient will be making best use of their hearing aids when factors such as dementia and physical disabilities mean they are not always capable of managing their own hearing aids.
I have met some fabulous staff members in homes, and without a doubt they care for their residents and want the best for them. However if you haven’t had a hearing loss yourself, it’s difficult to understand the effects it has on you and your life.
Your world becomes smaller and duller as you are not connected to it. TV and radio can’t be enjoyed so you receive less stimulation when in your room. Conversation becomes difficult, and you are aware that you are a burden to the staff (no matter how friendly) because they need to repeat themselves or shout. Conversation can also be misheard, and the embarrassment of misunderstandings can make it seem easier to just not converse at all sometimes. When several residents are sat together with multiple different levels of hearing loss, it creates a huge barrier to interaction. Add to this the fact that even with hearing aids, it’s not always possible for those with cognitive problems to know if the battery has died or they are in need of maintenance, and you have residents who are heavily reliant on staff to manage their hearing care day to day. Quality of life is impacted immediately when hearing aids stop working
With falls, cognitive decline and dementia both being caused/worsened by untreated hearing loss, it should be obvious that care homes need to support their residents in obtaining and maintaining hearing aids or other methods of communication as a key priority for their mental health and physical well-being.
So how can care homes and audiologists help residents to hear better?
Hearing Loss or Dementia?
Hearing loss can make a resident’s dementia seem worse than it is. Hearing loss and dementia signs can be mixed up, such as not following the thread of conversation, talking about a different topic, being unresponsive to your name or other familiar words, and generally taking a lot of processing time to receive the words being spoken. I have had multiple mild dementia patients ‘improve’ drastically upon getting hearing aids, as social interactions with the condition was being made that much harder by hearing loss. If a hearing loss is suspected, the GP should be contacted to arrange a hearing assessment. If family wish to pursue private hearing aid options, an independent audiologist who conducts home visits is the best choice, as they can observe their patient in their home surroundings and work fully informed of the home’s specific characteristics (e.g. common areas, dining facilities, TV volume etc). I recommend a hearing test as soon as a patient has the onset of dementia as it can be difficult to test hearing accurately in the later stages. I recommend a hearing test on entry to the care home if the resident has never had one previously, and regular tests throughout the stay (18 monthly is adequate). It may be possible to work with an independent audiologist to test all residents, maintaining records on hearing ability and contributing to your care plans for the patients’ individual needs.
Hearing Aids
The majority of hard of hearing residents will benefit from conventional hearing aids. Obtaining the aids is the first hurdle, maintaining them is the next, which I’ll come to. The GP refers the patient to Audiology, at the local hospital or health centre. Home visits are not always easily available but should be possible if the resident can’t be transported. If the resident has additional problems such as blindness or dementia, you can ask for a spare pair of aids/earmoulds for them, so they are never without them. If the funds are there for private aids, it can help to know a local, trusted independent audiologist who can come to the home, so that you have a ready recommendation for family who may not be from the local area.
Helping the Audiologist
If you feed back to the audiologist on behalf of the resident, you will get the best outcome for them. The audiologist may not know that their patient is struggling with hearing discomfort in the dining room - as the patient may forget their issues. Keeping notes on hearing ability/problems and feeding them back is valuable to the audiologist and resident.
Communication Tactics
Hearing aids or not, patients with cognitive challenges and hearing loss need clear, concise communication. Keeping sentences short, speaking at a regular pace, pronouncing words fully, facing the resident when you speak and making sure your face is not in shadow will help enormously. To bring another resident into a conversation you need to first announce the topic, as this will help them to then identify spoken words correctly (by as much as 80% more, versus not knowing the topic).
Environment
The communal areas should be well lit so residents can see faces and lips clearly. There should be space for others to sit with the patient rather than 'looming' over them. Hard surfaces reflect sound, creating an echo that impedes speech processing. Clattering plates, cutlery and vocalisation from other residents can make hearing speech impossible and the sound can be uncomfortable with basic (NHS) hearing aid technology. Soft furnishings and sound absorbing wall panels/room dividers (which could double as display areas) can really help speech recognition and comfort levels/agitation. Televisions should have subtitles displayed at all times and should be of a size large enough for the viewer to read (there will be settings for this too)
Lipreading
Although your patient may not know it, chance are they are lipreading you without knowing. Always have your face fully in the light, at a comfortable seeing distance and be at the patient's level. You will find engagement rockets up when the patient doesn't have to put too much effort into conversing. Televisions on talk programs where the face is clearly seen also aid in hearing the TV.
Hearing Aid Maintenance
All residents with hearing aids should have a battery changing schedule as they will not necessarily notice if one or both aids fails. Batteries last a predictable length of time, so if the average battery life is 5 days, they should be changed every 4 days to ensure residents are getting full hearing. Before putting the aids on the resident, turn on the aid, hold it in a closed fist and listen for feedback (whistling or squealing). If the aids do not squeal, the battery is dead or there is a blockage that needs clearing (either in the tube or the wax guard depending on model). The standard tubing on behind-the-ear (BTE) devices should be flexible. If it has become discoloured or is stiffening your resident will not be hearing very well. Several staff members should be trained on how to replace standard tubing or thin tube assemblies (every four months), and correctly sized spare tubes/domes should be requested from the NHS Audiology department and kept labelled for each resident. This means they do not have to wait for days until their aids are fixed, and saves multiple visits to Audiology.
If the resident is not hearing you very well, ask them to tell you what they can hear when you gently rub a finger over the microphone ports (small holes in the top/back of the aid). They should hear a loud rustling sound which indicates the aid is putting out sound. If the sound is muffled or they hear nothing, there is a blockage or dead battery. Above all, do not assume a patient has a working hearing aid, just because they are wearing a hearing aid.
Hygiene
Hearing aids are essential, but they should be regularly sanitised to prevent ear infection. This can be done via a UV drying box for RIC aids, or for BTE aids by removing the tubing/earmould and soaking in detergent. Shake the tube/earmould vigorously and dry with a paper towel. Check the tube is free of liquid before reattaching it to the aid body. Residents should not be wearing their hearing aids at bedtime, and staff need to enforce this and keep a log of sanitisation and the serial numbers (or a photo) of each resident's aid in case of loss.
Communication devices
If the resident cannot wear hearing aids for whatever reason, communication devices (“Communicator”) with headphones and a neck worn microphone are available for around £100 from disability suppliers such as Connevans. These devices are not custom made so can be used for any resident who needs them. A spare Communicator is a low cost/easy way to ensure no resident needs to lose hearing ability during times of aid loss/misplacement/repair, ear infections or other disruption to their hearing aid wear.
Wax Removal & Feedback
Aids will create feedback noise if the ear is blocked with wax or if they are not inserted properly. Persistent feedback not improved by reinserting the aids should flag up to staff members that the resident needs to be checked for wax buildup.
Management and Culture
The culture of the care home should make residents’ hearing needs as much a priority as physical care. Hearing impairments are as individual as the people who have them, but the above advice is common to all and should form part of the training for all staff who are new to elder care. A hearing aid is a link to the world and a link to people, and quality of life/satisfaction of residents will be improved if the care home management take it seriously. Remember, your residents may not be able to communicate their needs to you so staff need to proactively manage their needs.
From clinical and personal experience, I can tell you that it is depressing and isolating to be without your hearing aids. You feel out of the loop, and miserable. Communication is difficult and you can feel like not bothering at all. You can be misconstrued as you are trying to concentrate so hard that your face looks upset (furrowed brow etc). Alternatively a hearing aid/environment that is too loud (and amplified in an unnatural way) can make you feel frustrated and even angry, along with a severe headache. These are normal human responses that may be magnified by dementia or loss of personal agency.
Finally, the audiologist who prescribes the hearing aids needs to take responsibility for training on their correct usage, setting volume/comfort levels and any repairs of broken aids (subject to funding arrangements/contract, if private). In a care home setting it is often the staff members or family members, rather than the patient, who will make the difference to quality of life, so the audiologist must be prepared to explain and train them. Care home management should request training from the audiologist at the outset. Request their help in preparing a Care Plan and seek their advice immediately if there are any issues.
I am passionate about improving lives through effective communication and engagement. Although I cannot answer everyone personally, please feel free to reach out if you want to share this article or need clarification.