Introduction to AR

Question 1

What are rehabilitative services?

Answer 1

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)

Question 2

What is the most common rehabilitation model in audiology?

Answer 2

The technocentric rehabilitative model
Focuses on technology and treats them as the only solution for the problem

Question 3

What is a multi-faceted rehab approach?

Answer 3

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

Question 4

Should you use a decision aid to review all of the possible rehabilitative options at the time of diagnostic assessment?

Answer 4

Yes
Amplification (hearing aids and/or HAT)
Communication strategies training
Speech and/or visual perception training to improve activity limitations
Group support
OTCs

Question 5

Was the technocentric rehab model updated?

Answer 5

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

Question 6

What does AR address?

Answer 6

The challenges and needs of the individual with hearing loss
Helping them adapt to and manage their condition effectively

Question 7

What are the goals for AR?

Answer 7

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

Question 8

What is the first goal of AR?

Answer 8

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)

Question 9

Is threshold loss an accurate predictor of activity limitations, work performance, work potential, and likelihood of social integration?

Answer 9

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

Question 10

Will amplification improve activity limitations to some degree?

Answer 10

Yes
However, restoration of audibility alone doesn’t guarantee hearing related limitations are resolved

Question 11

Can activity limitations remain despite amplification?

Answer 11

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?

Question 12

Do post-fitting standardized questionnaires effectively analyze activity limitations and participation restrictions?

Answer 12

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

Question 13

What is the usefulness of screening tools with patients?

Answer 13

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

Question 14

What is AR goal 2?

Answer 14

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

Question 15

What is the maxim of quantity?

Answer 15

Where one tried to be as informative as one possibly can, and shares as much information as is needed, and no more

Question 16

What is the maxim of quality?

Answer 16

Where one tries to be truthful and does not give information that is false or that is not supported by evidence

Question 17

What is the maxim of relation?

Answer 17

Where one tries to be relevant and says things that are pertinent to the discussion

Question 18

What is the maxim of manner?

Answer 18

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

Question 19

What are things that people with hearing loss will do that violates one maxim or another?

Answer 19

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

Question 20

What is conversational fluency in the context of hearing loss?

Answer 20

The ability to engage in smooth, effortless, and enjoyable communication with others

Question 21

What is ease of understanding in conversational fluency?

Answer 21

Accurately & effortlessly understanding communication, especially in challenging listening environments (e.g., background noise, crowded rooms)
Minimizing listening effort and fatigue

Question 22

What is active participation in conversational fluency?

Answer 22

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)

Question 23

What are communication strategies of conversational fluency?

Answer 23

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?”)

Question 24

What are social and emotional factors of conversational fluency?

Answer 24

Feeling confident and comfortable in social situations
Minimizing anxiety and frustration related to communication
Maintaining a positive and enjoyable communication experience

Question 25

What is AR goal 3?

Answer 25

The AR plan recognizes the multi-dimensional factors impacting a PHLs ability to participate & communicate and addresses them

Question 26

What are some of the multi-dimensional factors that impact PHL?

Answer 26

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)

Question 27

What are the components of AR?

Answer 27

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

Question 28

What does top down processing rely on?

Answer 28

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

Question 29

What does the brain need to rapidly do to listen?

Answer 29

Compare/contrast sound arriving to each hemisphere Analyze loudness, spectral shape, and temporal aspects Process the signal Interpret Apply meaning

Question 30

Do age related neural changes impact top-down processing in older populations?

Answer 30

Yes Amplification alone does not assure the PHLs neurotransmitter function is optimized for improved communication

Question 31

Is efficient cognition required to achieve fast top down processing?

Answer 31

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

Question 32

What is the first thing that happens when you hear a sound?

Answer 32

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

Question 33

What is the stage after echoic memory?

Answer 33

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

Question 34

What factors assist with pattern recognition?

Answer 34

Audibility Situational context Attention Knowledge of language

Question 35

Do we need to be able to store the pattern recognition information for about 2 seconds in short term memory?

Answer 35

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

Question 36

What other factors impact processing speed?

Answer 36

Suprasegmental information Complexity of task Allocation of attention Capacity and load

Question 37

What is suprasegmental information?

Answer 37

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

Question 38

Does loudness variation within words change meaning?

Answer 38

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

Question 39

Does pitch variation also change meaning?

Answer 39

Yes Got the keys. Got the keys?

Question 40

Does duration variation in the length of vowel, syllables, and sentences change meaning?

Answer 40

Yes

Question 41

Is more mental effort needed to understand complex sentences?

Answer 41

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

Question 42

What is allocation of attention?

Answer 42

Allows us to selectively focus on a limited amount of information To block irrelevant information To ignore competing noise

Question 43

What is capacity vs load?

Answer 43

Capacity - the total reservoir of energy available to spend on a task Load - the total amount of energy that must be expended

Question 44

What happens when the load is greater than your capacity?

Answer 44

Fatigue Processing speed slows down

Question 45

What age related biologic changes result in difficulty inhibiting irrelevant stimuli?

Answer 45

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

Question 46

What does longer recovery time result in?

Answer 46

Jittery, inconsistent transmission of the signal Reduced synchrony

Question 47

What happens as the corpus callosum atrophies during aging?

Answer 47

Dichotic performance asymmetry between ears increases Therefore it takes longer to process information

Question 48

Do age related deficits exist independently of the decline in hearing sensitivity?

Answer 48

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

Question 49

Does auditory mismatch slow processing speech while increasing listening effort?

Answer 49

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

Question 50

According to research, what is understanding speech in noise later in life dependent on?

Answer 50

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

Question 51

Does perceptual training enhance listening skills?

Answer 51

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

Question 52

What are some examples of perceptual training?

Answer 52

Speech perception training Auditory-visual perceptual training Cognitive "brain" training

Question 53

Is hearing loss associated with accelerated cognitive decline?

Answer 53

Yes For every 25 dB loss, cognitive decline advances by 7 years

Question 54

Is hearing loss considered the most important modifiable risk factors for dementia?

Answer 54

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

Question 55

How is hearing loss thought to be related to dementia?

Answer 55

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)

Question 56

What happens to attention and focus as we age?

Answer 56

Those abilities decline Making it difficult to block irrelevant information and ignore competing noise

Question 57

What happens as capacity reduces with age?

Answer 57

Load is not managed as efficiently in complex environments Capacity reduction requires more time to process signals Additional processing time leads to fatigue

Question 58

What is fluid intelligence?

Answer 58

Think logically Solve problems in novel situations Does decline with age

Question 59

What is crystalized intelligence?

Answer 59

Ability to use skills Have had across lifetime, doesn't go away Experiential knowledge

Question 60

What is affected by fluid intelligence?

Answer 60

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)

Question 61

What is mild cognitive impairment (MCI)?

Answer 61

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

Question 62

When should you be alert to early signs of MCI and do a cognitive screening?

Answer 62

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

Question 63

What are the most common paper-based cognitive screening tools?

Answer 63

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

Question 64

Can hearing loss cause false positive cognitive performance scores?

Answer 64

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)

Question 65

Why is the cognivue different?

Answer 65

Offers a non-auditory assessment of cognition

Question 66

What are some strategies to enhance retention and recall when MCI is present?

Answer 66

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)

Question 67

Does compression further contribute to the auditory mismatch?

Answer 67

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

Question 68

What are some general tips to improve retention and recal?

Answer 68

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