Introduction to AR Flashcards
What are rehabilitative services?
People typically have a chronic health condition that is irreversible and requires lifestyle modifications
The condition affects non-body-related dimensions (psychological & social effects, economic levels, leisure activities, social integration of that person in society)
What is the most common rehabilitation model in audiology?
The technocentric rehabilitative model
Focuses on technology and treats them as the only solution for the problem
What is a multi-faceted rehab approach?
Approach in patient centered care
Focus of counseling should include expectations, rehabilitative process, habituation, and involving the whole family
Discuss objective and subjective factor contributing to poor communication
Explain habituation, and limitations due to auditory damage and sound deprivation (restoration to normal is not possible, satisfaction will not be immediate; amplification adjustments are expected)
Help patient recognize amplification is just one component of the rehabilitative process
Explain effective “treatment” involves the whole family
Should you use a decision aid to review all of the possible rehabilitative options at the time of diagnostic assessment?
Yes
Amplification (hearing aids and/or HAT)
Communication strategies training
Speech and/or visual perception training to improve activity limitations
Group support
OTCs
Was the technocentric rehab model updated?
Yes, it was updated by ASHA in 2022 and confirms that the technology piece is just one part of the rehab model
Patient story
Self-assessment of auditory wellness
Technology
Communication strategies
Speech/visual perception training
Peer support
Validation of services
What does AR address?
The challenges and needs of the individual with hearing loss
Helping them adapt to and manage their condition effectively
What are the goals for AR?
Personalized based on needs and preferences of the patient
Common goals:
Reduce deficits related to loss of function, activity limitations, participation restrictions, & quality of life
Enhance conversational fluency
Recognize hearing loss imposes a multi-dimensional loss of function
What is the first goal of AR?
Reduce hearing related limitations
Functional loss (loss of functional integrity of the sense organ)
Activity limitation (sensory loss limits to the ability to understand communications, especially in noise)
Participation restriction (limited understand may impact desires to participate in life)
Quality of life (lack of participation may lead to isolation and reduction of self worth)
Is threshold loss an accurate predictor of activity limitations, work performance, work potential, and likelihood of social integration?
No
Goal #1 recognizes the need to gather information on each of these areas to create an AR plan of care that focuses on ways to reduce the PHLs limitations to optimize their ability to participate in activities
Will amplification improve activity limitations to some degree?
Yes
However, restoration of audibility alone doesn’t guarantee hearing related limitations are resolved
Can activity limitations remain despite amplification?
Yes
Is the aided speech signal sufficient for fully engaging in spoken language communication?
Will warning sounds effectively alert the listener while wearing amplification? How about when it’s removed?
Can the listener monitor the environment, recognize, and localize to events and deduce their significance?
Can they monitor and control the volume of their own speech? (Too much compression in the low frequencies will result in the patient raising their voice because they cannot judge how loud their voice is)
Can they understand communications while driving?
Can they, understand communication at a distance?
Do post-fitting standardized questionnaires effectively analyze activity limitations and participation restrictions?
Yes
Responses are compared to average data from large samples
Scores serve as a pre-fitting baseline/post-fitting assessment to quantify benefit, improvement of activity limitations, and increased participation
What is the usefulness of screening tools with patients?
It encourages them to self-monitor auditory wellness and identify when they might need to re/access hearing healthcare services for support
Examples: Acceptance and Action Questionnaire-Adult Hearing Loss
Social Participation Restrictions Questionnaire (SPaRQ)
Hearing Handicap Inventory- 25 question
What is AR goal 2?
Achieve conversational fluency
Because communication is a complex, give-and-take process, breakdowns anywhere in
the cycle can block the transfer of understanding
Our patients often violate the maxims of conversational fluency
What is the maxim of quantity?
Where one tried to be as informative as one possibly can, and shares as much information as is needed, and no more
What is the maxim of quality?
Where one tries to be truthful and does not give information that is false or that is not supported by evidence
What is the maxim of relation?
Where one tries to be relevant and says things that are pertinent to the discussion
What is the maxim of manner?
When one tries to be as clear, as brief, and as orderly as one can in what one says, and where one avoids obscurity and ambiguity
What are things that people with hearing loss will do that violates one maxim or another?
Dominates conversation limiting time that others can speak
Replies during conversations are brief. Responds with limited superficial content
Responds with information that may be perceived as false
Responds with irrelevant information, which is off topic or perceived as false by the listener
Shifts the topic of a conversation; or mises the fact the topic changed
Interrupts or disrupts conversational turn-taking (conversational flow is disrupted due to need for clarification, interrupts without realizing someone’s speaking, allows longer pauses before replying because cues to speak were missed)
Mixes up the order of events or omit critical facts
What is conversational fluency in the context of hearing loss?
The ability to engage in smooth, effortless, and enjoyable communication with others
What is ease of understanding in conversational fluency?
Accurately & effortlessly understanding communication, especially in challenging listening environments (e.g., background noise, crowded rooms)
Minimizing listening effort and fatigue
What is active participation in conversational fluency?
Effectively participating in the flow of conversation
Taking turns smoothly, understanding and responding appropriately to others
Maintaining topic focus and contributing meaningfully (so you don’t provide misinformation or respond inappropriately)
What are communication strategies of conversational fluency?
Utilizing effective communication strategies to naturally
Ask clarifying questions
Use visual cues and gestures - improve auditory closure skills
Repair communication breakdowns smoothly (e.g., “I’m sorry, could you repeat that?”)
What are social and emotional factors of conversational fluency?
Feeling confident and comfortable in social situations
Minimizing anxiety and frustration related to communication
Maintaining a positive and enjoyable communication experience
What is AR goal 3?
The AR plan recognizes the multi-dimensional factors impacting a PHLs ability to participate & communicate and addresses them
What are some of the multi-dimensional factors that impact PHL?
Physical health, vision, & cognition impact communication abilities (AR addresses these factors by teaching communication strategies and through informational counseling)
Self-esteem, coping skills, social skills impact participation (AR addresses these factors through personal adjustment counseling)
Family circumstances, peer & family relationships (AR address this by including families and communication partners (CP) in the rehabilitation plan)
What are the components of AR?
Optimized use of technology: hearing aid, OTC, or HAT
Enhanced Listening Skill Training: Speech perception training, Auditory-visual perceptual training, Cognitive “brain” training
Communication Strategies Training: For both the PHL and CP
Environmental Adaptations.
Emotional and Psychological Well-Being Support: Personal adjustment counseling and behavioral management training
Advocacy and Access
*Uses these to minimize the consequences of hearing loss
What does top down processing rely on?
Clear amplified signal with low distortion
The role of amplification is to transmit the highest quality of bottom-up signal to the brain
The brain facilitates top-down information processing
Despite the incredible gains in HA, barriers to listening and understanding speech remain in noisy environments
Advanced clinical standards require audiologists to understand the impact various amplification features, circuits, programing, and DSP settings will have on the output delivered to the ear
What does the brain need to rapidly do to listen?
Compare/contrast sound arriving to each hemisphere
Analyze loudness, spectral shape, and temporal aspects
Process the signal
Interpret
Apply meaning
Do age related neural changes impact top-down processing in older populations?
Yes
Amplification alone does not assure the PHLs neurotransmitter function is optimized for improved communication
Is efficient cognition required to achieve fast top down processing?
Yes
Attention, memory, and the ability to reason impact listening
Higher order cognitive processing of acoustic signal relies on simultaneous processing in several different parts of our memory system
What is the first thing that happens when you hear a sound?
Echoic memory
It creates a perfect replica of the acoustic stimulus
This memory is briefly stored for 250 msec
as a synthesized auditory memory
In this split second, the listener will process spatial location, intonation, and intensity
If the listener doesn’t process that quickly the signal and its meaning is lost
What is the stage after echoic memory?
Pattern recognition
Those synthesized auditory memories are compared to stored patterns in your long-term memory
How quickly you process this information is based on familiarity, how frequently your exposed to the sound, and the emotional importance of the sound
What factors assist with pattern recognition?
Audibility
Situational context
Attention
Knowledge of language
Do we need to be able to store the pattern recognition information for about 2 seconds in short term memory?
Yes
You do this while you try to retrieve meaning from long term memory
To do this, you need attention to hold onto information and focus to select the signal of interest & ignore irrelevant stimuli
When more attention is needed, less information is processed
What other factors impact processing speed?
Suprasegmental information
Complexity of task
Allocation of attention
Capacity and load
What is suprasegmental information?
Superimposed on acoustic stimuli improving listener accuracy (right hemisphere) and helping the listener separate competing voices
Loudness variations (intensity, stress patterns)
Pitch variations
Duration variations
Does loudness variation within words change meaning?
Yes
Syllables don’t all have the same level of loudness
Some are loud, some are soft, some are in between
Loudness changes related to stressed and unstressed syllables changes a words meaning
An inability to hear loudness variations can result in misunderstanding
Does pitch variation also change meaning?
Yes
Got the keys.
Got the keys?
Does duration variation in the length of vowel, syllables, and sentences change meaning?
Yes
Is more mental effort needed to understand complex sentences?
Yes
This makes it more difficult to process the signal
Slowed processing speeds make it difficult to retain the acoustic stimuli long enough to understand its meaning
What is allocation of attention?
Allows us to selectively focus on a limited amount of information
To block irrelevant information
To ignore competing noise
What is capacity vs load?
Capacity - the total reservoir of energy available to spend on a task
Load - the total amount of energy that must be expended
What happens when the load is greater than your capacity?
Fatigue
Processing speed slows down
What age related biologic changes result in difficulty inhibiting irrelevant stimuli?
Neural timing slows with age (broader neural tuning curves diminish frequency resolution, neural recovery takes more time, diminished brain connectivity slows hemispheric transmission)
Cognition declines
*happens to everyone after they turn 50
What does longer recovery time result in?
Jittery, inconsistent transmission of the signal
Reduced synchrony
What happens as the corpus callosum atrophies during aging?
Dichotic performance asymmetry between ears increases
Therefore it takes longer to process information
Do age related deficits exist independently of the decline in hearing sensitivity?
Yes
Age related deficits reduce sensitivity to suprathreshold temporal cues
Phoneme recognition performance is poorer in older adults (50+) with normal hearing than in younger adults
Does auditory mismatch slow processing speech while increasing listening effort?
Yes, especially in noise
Degraded input doesn’t match long-term memory of signal
Efficiency of working memory processing declines
Cochlear damage causes further mismatch of incoming signals
Distorted amplified or unamplified signals do not match the phonological representations stored in long-term memory
According to research, what is understanding speech in noise later in life dependent on?
Cognitive abilities (memory and attention), neural encoding (pitch and fidelity), and life experiences (musical training and physical activity)
*hearing thresholds do not predict speech in noise intelligibility
Does perceptual training enhance listening skills?
Yes
Research shows perceptual training improves age-related functions and reduces activity limitations supporting positive communication outcomes
Each patient individualized perceptual training plan will differ based on their personal activity limitations
What are some examples of perceptual training?
Speech perception training
Auditory-visual perceptual training
Cognitive “brain” training
Is hearing loss associated with accelerated cognitive decline?
Yes
For every 25 dB loss, cognitive decline advances by 7 years
Is hearing loss considered the most important modifiable risk factors for dementia?
Yes
Protecting our hearing health throughout our lives can have an impact on our likelihood for dementia
Prevalence of “subjective cognitive decline” was highest among persons with depression, with hearing loss, and with four or more risk factors
How is hearing loss thought to be related to dementia?
It may contribute to social isolation and loneliness (which is associated with a 50% increased risk of dementia)
It shifts the cognitive load of the brain (the brain spends too much energy trying to process what it’s hearing, leaving it less energy to spend on thinking and memory)
Accelerated brain atrophy (more so than normal brain shrinkage)
What happens to attention and focus as we age?
Those abilities decline
Making it difficult to block irrelevant information and ignore competing noise
What happens as capacity reduces with age?
Load is not managed as efficiently in complex environments
Capacity reduction requires more time to process signals
Additional processing time leads to fatigue
What is fluid intelligence?
Think logically
Solve problems in novel situations
Does decline with age
What is crystalized intelligence?
Ability to use skills
Have had across lifetime, doesn’t go away
Experiential knowledge
What is affected by fluid intelligence?
General sequential reasoning (slower in doing this)
Working memory (lower capacity contributes to poor performance on reasoning and problem solving)
Processing speed (slower processing speed reduces the amount of information that can be stored in a limited time frame)
Inhibitory control (leads to more errors and slower responses on tasks that require filtering out distracting information)
What is mild cognitive impairment (MCI)?
More likely to impact our own day-to-day work with out patients (occurs 5 times more frequently than dementia in the older population)
Often undiagnosed
Increases with age
Poses a lot of challenges with success with AR
A lot of these individuals think they are doing just fine
At 65 years old prevalence is 20 to 40% worldwide
When should you be alert to early signs of MCI and do a cognitive screening?
Include questions in the audiologic history to ask about memory, depression, and history of head injury
Pay attention to memory difficulty and inappropriate affective reactions
Inability to learn and retain new information, confusion over simple instructions
Difficulty in finding words or making decisions
Frequently missed appointments
What are the most common paper-based cognitive screening tools?
Mini mental state exam (MMSE)
Montreal cognitive assessment (MoCA)*
Six item cognitive impairment test (6CIT)
St. Louis university mental state (SLUMS)*
*More specific to MCI
Can hearing loss cause false positive cognitive performance scores?
Yes
Implement procedures for reducing the influence of hearing loss (small room, minimal noise)
Present face-to-face in a quiet room
Personal amplification devices should be used for those who don’t use hearing aids (hearing aids, pocket talker, etc.)
If testing is done across multiple sessions, hearing devices should be documented across sessions (testing environment should be consistent if the testing takes multiple sessions)
Why is the cognivue different?
Offers a non-auditory assessment of cognition
What are some strategies to enhance retention and recall when MCI is present?
Clear, brief instructions
Reduce covered content (written materials from manufacturers may be overwhelming, employ teach-back methods)
Increase frequency of visits
Consider slow-release compression
Encourage auditory-cognitive rehabilitation (classroom or computer)
Does compression further contribute to the auditory mismatch?
Yes
Fast acting compression alters the speech envelope more than slow acting compression
Individuals with high working memory are better able to identify the altered speech signal
Individuals with low working memory perform better with slow acting compression
What are some general tips to improve retention and recal?
Your presentation should include concrete advice
Explain concepts using easy to understand terminology
Present the most important information first
Stress the importance of the information you wish the individual to recall
Don’t present too much information
Repeat the most important information
Be sure you have taken steps and understand what the individual wants
Supplement information with written, graphical, and pictorial materials
