9 - Pediatrics & Geriatrics Flashcards
(83 cards)
1
Q
What are 5 special considerations for fitting HAs on children?
A
1) Small ears and ear acoustics (Differences in RECD, REUR, ear canal resonances)
2) Physical fit of the hearing aids & earmolds (as ears grow will have to change earmolds to have a good acoustic coupling)
3) Fitting methods and recommended gain (DSL v5, children get more gain than adults)
4) Listening needs and listening environments
5) Hearing aid technology & features
2
Q
What are the 4 the purposes of providing amplification to children?
A
1) To give them access to the auditory environment
2) Access to speech
3) Improve functional auditory capacity and participation
4) Audibility across the LTASS
3
Q
What is an essential component of fitting HAs on children?
A
Regular, reliability and validity measures of a child’s progress in meeting intervention goals in amplification must be determined; needs can rapidly change over time
4
Q
What are the early intervention and guidelines by the AAA?
A
- Children are learning language, they do not have the capacity to “fill in the blanks” for sounds that are not audible in the way that adult listeners have (must make sure that information is accessible to them)
- Children who use hearing aids must develop the ability to use information acquired while hearing amplified, processed sounds.
- Children fit with hearing aids that fail to render audible the full set of speech cues are at risks of deficits in speech production and/or learning
- Enhanced audibility is required to support better speech understanding, either increased level, increased SNR, or improvement of the listening environment.
- Prescriptive targets for children may specify greater outputs in quiet environments than adults
- Children’s hearing aid use is typically meditated by a caregiver. Caregiver training may be a unique challenge of the pediatric population
5
Q
How do you obtain threshold information in children?
A
- Need estimated threshold for at least one low frequency (500 Hz) & one high frequency (~2000Hz, or 4000 Hz) in each ear
- Rely on frequency specific ABR, ASSR (if available), or VRA if old enough
- Amplification CANNOT be delayed in infants because you don’t “have enough” threshold information
6
Q
What can you use for threshold estimates for children?
A
Electrophysiologic estimates of hearing sensitivity can be used as part of the complete audiological test battery
7
Q
What is the best electrophysiologic threshold estimate to use?
A
- FS-ABR (frequency-specific auditory brainstem response)
- Threshold estimates can overestimate the behavioural audiogram by 5-30dB!
- Use of correction factors: Electrophysiologic threshold obtained in dB nHL can be used to predict behavioural thresholdin dB eHL
- dB nHL - correction = dB eHL (eHL = estimation)
8
Q
What is this audiogram showing?
A
Circles = nHL values (frequency specific ABR values that were obtained)
+ = the eHL
9
Q
How do you input the eHL and nHL into verefit?
A
- If eHL is selected (you have already provided the correction factor), the Verifit treats the value as a behavioral threshold (dB nHL - correction = dB eHL)
- If nHL is selected, the Verifit converts the value to eHL before the dB SPL transformation
10
Q
Compared to adults, the ears of infants and young children show differences in what 2 things?
A
RECD and REUG (because it has to do with physical volume and size of the ear canal)
11
Q
What changes as children grow?
A
RECD and REUG (the difference becomes less and less as they grow and become more adult like)
12
Q
What is a possible reason that high frequency roll-off (above 2KHz) is happening?
A
Shallow placement of probe tube
13
Q
What is a possible reason that LF values are negative
- from -1 to -9 dB SPL is happening?
A
Slit leak (e.g., foam tip is too small)
14
Q
What is a possible reason that LF values are negative
-more than -10 dB SPL is happening?
A
Perforated TM or PE tube
15
Q
What is a possible reason that Increased values in low and mid frequencies is happening?
A
Middle ear effusion
16
Q
What do the lines on this picture mean?
A
Green line: coupler response
Purple: individual measurement
Dashed black line: age normative RECD value
Turquoise: difference
17
Q
Explain the REUG in children?
A
- The resonance frequency is much higher in young children than it is for adults (about 2-3 times higher)
- As a child ages, the peak begins to decrease/ shift to a lower resonant frequency
- The most rapid changes occur in the first 20 months of life, stabilizing after 24 months
- This is due to the changes in the physical properties of a growing ear canal!
18
Q
How much gain do children need?
A
- Children with hearing loss need more audibility (i.e., more gain) than adults to learn speech and language
- We need to maximize audibility (they can’t fill in the blanks)
19
Q
Why do adults have less gain than children?
A
- Adults have less gain provided than children (across the board; mild, moderate, and sever HLs)
- That’s why we need to input age in the fitting software (to have accurate gain parameters)
- If we don’t input age, we could be under amplifying gain
20
Q
Should you use propieratary formulas or the DSL-v5 on children?
A
- If proprietary methods are used… Expect large variability in responses!
- It is recommended to use the DSL-v5 fitting formula
21
Q
Children require more ____ than adults when learning language
A
Audibility
22
Q
Children require better ____ for optimal performance
A
S/N
23
Q
Should children have advanced features on their HAs?
A
- Features that reduce gain or audibility may be problematic for children learning language (e.g., noise reduction system, DM)
- Advanced hearing aid features are primarily developed for adults and tested on adult (very few studies on advanced features for children under 5 years of age)
24
Q
What 5 factors do you have to take into account for managing noise in pediatric fittings?
A
1) Hearing aid program options (how is ANR activated, accessed, and monitored)
2) Hearing aid ANR options (how strong is ANR, does ANR impact speech)
3) Report of loudness discomfort (in what circumstances, is it situational)
4) Child factors (developmental status, dexterity)
5) Family factors (involving parents in decision and monitoring)
25
Should children use noise reduction?
- NR can reduce gain & audibility
- Consider activating NR with school age children, if speech audibility is not compromised
- Verify the performance of the noise reduction system by comparing the hearing aid response to speech and noise inputs
26
Why are omni mics better than DM mics for children?
Omni mic may be better than adaptive DM for young children. Why?
- Overhearing and incidental learning
Talker of interest is not always at the front
- Small children don't always orient their head towards the talker
- Classroom environments
- e.g., looking down when taking notes -- remote mic better than DM in class.
27
Frequent ____ due to feedback as the child outgrows the earmolds
Earmold remakes
28
____ must be addressed to best ensure that gain is adequate, and feedback annoyance is minimal
Feedback
29
What is the importance os s/z audibility for language development?
- To show plural (One cup. Two cups.)
- To show third person present tense (I eat. He eats.)
- To show present tenses on some verbs (He put it on. He puts in on).
- To show possession (John’s dog.)
- To show possessive pronouns (Is that her? Is that hers?)
- To contract “is” (That is mine. That’s mine.)
- To contract “us” (Let us go. Let’s go.)
- To contract “has” (What has happened? What’s happened?)
- To contact “does” (What does it mean? What’s it mean?)
- To change adjective to noun (I like short pants. I like shorts.)
- To change adverb to noun (He went in and out. The ins and outs are tricky.)
- To show female gender (The host was an actor. The hostess was an actress.)
30
The use of ____ HA is recommended for children who would otherwise not be able to hear high frequency speech cues
Frequency lowering
31
What 5 factors do you need to consider for frequency lowering in a child's HA?
1) Hearing instrument (is bandwidth restricted, does the aid offer FL)
2) Fit to target (does the child have access to female /s/ without frequency lowering)
3) Configuration & degree of loss (candidacy more likely is loss is high frequency or severe to profound)
4) Child factors (depending on developmental status; can they respond or discriminate)
5) Caregiver/intervention report (depending on developmental stats; can they respond or discriminate)
32
What is the MAOF?
Maximum audible output frequency
33
How is MAOF used for frequency lowering?
- Performing REMs to determine if high-frequency speech stimuli is audible without the use of frequency lowering strategies
- We can use the the MAOF as a guideline
34
Explain these pictures
Left
- with FL off, we see if /s/ is audible
- we want to see the upper shoulder of the /s/ to be within the MAOF range (at here is is just below, so we will want to try FL)
Right
- when we turn on FL, and remeasure /s/ we see the upper shoulder of the /s/ shifting over a little bit
- we know have audibility because the upper shoulder of /s/ is within the MAOF
35
What are the FL recommended guidelines for children?
- Verify the gain of the hearing aid without frequency lowering using validated prescriptive targets
- Determine the candidacy for frequency lowering. Using the calibrated /s/ through verification, determine if the “shoulder” is audible. Generally recommended to present at 65 dB SPL
- Enable frequeny lowering, and adjust to optimize
- Provide post-fitting supports. Explaining the “why”, and “how long” it may take to adjust (6-8 weeks*) . Have communication partners provide feedback on the functionality of this feature
- Optional measure: measure /s/, and compare to /sh/
36
Should manual programs be used for children?
- Think about who is managing those programs
- May need if child uses an FM system/remote microphone technology
- Audiologist may have designed a manual program for a specific environment
- Technology level prescribed may have other manual programs of interest
- May need for telephone use (e.g. manual telecoil program)
37
How can parents manually change programs on their child's HAs?
- For small children, parents can change programs via a remote.
- Deactivate program button on hearing aid so child doesn't "play with the button".
38
What 3 ways do you verify pediatric HA fittings?
1) Aided thresholds in soundfield (not generally recommended as a first option)
2) REM
3) Simulated-REM
39
How are REMs use to verify children's HAs?
- HA is adjusted to meet targets in a controlled acoustic environment (the test box)
- The aided eardrum SPL is predicted based on the 2-cc values
- Reduces testing time and degree of cooperation from child
- The child doesn't need to be present during HA fine tuning
40
What are the coupler and adapter options for S-REM with verefit 2?
41
What 3 ways do you validate pediatric HA fittings?
1) Observation of auditory behaviours
2) Questionnaires or checklists to record behaviours (completed by parents, teachers other professionals)
3) Speech perception measures with other professionals
42
What are the post-fitting folow-up guidelines for children?
- Several visits in audiology are usually required in the first few months post detection of loss/fitting
- When everything is going well, follow-ups are generally outlined as followed according to the PPA 2023 guidelines
- Child and family seen at least one follow-up within the hearing aid trial period (first 60 days)
- Every three months for the first year
- Every six months of the second year
- Minimally, on an annual basis until “discharged"
43
What are the 6 reasons for fitting children with standard BTEs?
1) Durability
2) Less chance of feedback
3) Earmolds may be made out of soft material
4) Only the mold needs to be replaced as child grows
5) Possibility of getting a loaner when HA needs repair
6) Better audio connection to remote microphone technologies (FM systems)*
44
What are 8 different styling and accessories for appeal and retention?
1) Bilateral BTE (as small as possible)
2) Pediatric earhook
3) “Huggies”/ retainers
4) "Ear Gear"
5) Deactivated VC
6) Tamper resistant battery door
7) Bright shell colors
8) Colored earmolds
45
What is in a pediatric care kit?
- drying capsules
- battery capsules
- stickers
- listening tubes
46
____ people per year (all ages) ingest button batteries, half of them being hearing aid batteries
3,500
47
what case by case issues should be considered with each child?
- Mild or minimal hearing loss?
- Unilateral hearing loss?
- Profound hearing loss?
- Auditory neuropathy spectrum disorder?
- OE malformation?
- Recurrent otitis media?
- Down syndrome with recurrent otitis media?
48
Should a child be given HA with mild/minimal losses?
Observing if the unaided SII value is greater than 80%, the child with MBHL is likely “to develop language skills on par with their normal hearing peers
49
What are 6 considerations for the geriatric population?
1) Audiological care in aging patients with hearing loss
2) Aging process affect the auditory system
3) Population considerations
4) Hearing aid uptake, pathways to care
5) Needs particular to aging adults
6) Counselling skills of the audiologists
50
What are some unique considerations that can change throughout the auditory system in each person?
- Outer Ear
- Middle Ear
- Inner Ear
- Centrally
- Changes in other health areas can further impact either ones ability to function communicatively, or be successful in audiological interventions
51
What are 5 outer ear differences each patient can have?
1) Cartilage of the pinna may harden
2) Awareness of lesions, carcinomas, epithelium matters
3) Loss of elasticity may lead to collapsing canal
4) Caution in testing and ear impressions
5) Cerumen management considerations
52
On soft ears, use ____ material
hard
53
On hard ears, use ____ material
soft
54
What can happen with the middle ear?
Sound conduction may be compromised by ossification or stiffening of the ossicular chain
55
What are 3 differences that can happen with the inner ear and auditory nerve?
1) Degeneration of hair cells along the basilar membrane
2) Changes to the stria vascularis
3) Changes to the neuron function along the auditory nerve can influence the transmission of information to the brain
56
What are 3 differences that can happen with the central structure?
1) Both functional and biological changes
2) Changes that occur in the periphery influence the incoming signal to the brain
3) Reduction in brain gray matter
57
For our aging patients, these changes, that may be part of a normal age- related process may mean that there is an increased difficulty in (4):
- Comprehension
- More difficulty in challenging listening situations
- Degradation in the speed in which speech information is processed
- Executive functioning, working memory challenges may be a compounding factor to “hearing well” outside of the amplification choices we provide
58
How does the aging process affect the auditory system?
- Aging adults with hearing loss are at risk for developing dementia
- Mild hearing loss doubled dementia risk
- Moderate loss tripled risk
- Severe hearing impairment were five times more likely to develop dementia
59
What does ACHIEVE stand for?
Aging and Cognitive Health Evaluation in Elders
60
Explain the ACHIEVE study
- Study released in July 2023, Alzheimer’s Association International Conference in Amsterdam and in the Lancet
- 3 year study, randomized control trial, with 977 participants that evaluated if hearing care modified dementia risk, using PICO framework (Population, Intervention, Comparison, and Outcome)
- Participants recruited from the ARIC study, and de nova volunteers
- Adult onset bilateral hearing loss, at least 60% WRS, PTAs from 30-70 dB HL
- All based the Mini-Mental State Examination
61
What were the results of the ACHIEVE study?
- Hearing intervention did not reduce global cognitive decline in all participants in the group that received hearing intervention compared to the control group
- BUT…results suggest that hearing intervention might reduce cognitive decline over 3 years in older adults who are already at higher risk for cognitive decline
- AND….Specifically, HHIE-S scores declined or the hearing intervention group, with this change representing a shift in the average score from the problem to the normal range. In contrast, HHIE-S scores increased those in the health education control group
62
What is the modifiable risk factor?
It is promising that modifying hearing loss (getting intervention) can be a great risk factor for other cognitive impairments down the road (dementia)
63
Hearing loss consistently ranks among the top ____ causes of years lived with a disability
Five
64
Hearing loss is the ____ most common disability in older adults following heart disease and arthritis
Third
65
In Canada, an estimated 19% of adults have a ____ hearing loss (average of 0.5, 1,2,4 KHz), and an even greater number have hearing loss to some degree in the high frequency range (3,4,6,8 KHz)— typically where presbycusis begins
Mild
66
The WHO estimates that 466 million people are living with hearing loss globally, and that number is expected to grow by ____ million by 2050
900
67
Of those Canadians with some degree of hearing loss in the high frequency range ____ of those did not perceive that they had any hearing loss
77%
68
Even once this is suspected, Canadian adults tend to wait ____ before seeking help
7 years
69
What factors lead to unperceived hearing loss?
- Unperceived hearing loss is more common in individuals with unilateral hearing loss
- Unperceived hearing loss correlates to degree of hearing loss (milder losses tend to be more unnoticed than greater losses)
70
What factors may lead to action or inaction?
Inaction
- Coping strategies/Adapting to Loss— treating the status quo as “normal”
- Denial
- Stigma
- Barriers/Access to Care
Action
- Triggers
- Tipping Points
71
What do these patients say when they eventually come to the clinic?
What do patients tell us (or what do they not tell us)
- “I can hear, I just can’t understand what people are saying”
- “Everyone is mumbling”
- Difficulty following conversations
- Frustration (may be from both patients or those close to them)
- Avoidance strategies
- The “smile and nod”
72
Audiologists working with this demographic need to...
positively support patients in the aging process, adapt delivery of our services as needed, prepare patients with communicative strategies beyond hearing aids alone, and tailor rehabilitative interventions
73
The older adults may exhibit (4):
- Decreased performance on tests reflecting executive functioning
- Efficiency and processing speed
- Difficulty in retrieving and generating words and performing semantic processing
- Lower cognitive performance in the course of normal aging
74
How do we support behavioural changes?
- Transtheoretical Model (TTM) of Health Behavioural Change
- Precontemplation, Contemplation/Preparation, Action, and Maintenance
75
Explain the process of the TTM
- Precontemplation (i.e. “NOT ready”)
- No intention of taking action unaware that hearing loss problematic
- Contemplation (i.e. “getting ready”)
- Recognition that hearing loss may be problematic, evaluate the pros and cons of seeking help
- Action (i.e. moving forward)
- modifying behaviour, using therapy, acquiring new “healthy” behaviours
76
How do we meet the patient where they are?
- Audiologists must consider “where” patients are emotionally
- This understanding may further be extended to the patient’s support circle:
- Partners, spouses, children, close friends
- If we can understand how a patient feels about their hearing loss, their communicative impairments, and the impacts of those impairments on self- identity, we can better understand the motivations (or lack of motivation) in taking action
77
We cannot predict outcomes based on age ____
Alone
78
What is the cost of hearing loss for our aging population?
- Reduced overall psychological health
- Fatigue
- Reduced alertness to environment (possible safety concerns)
- Increased anxiety
- Less adaptability to learning new tasks
- Impaired memory
- Depression
79
What is the monetary cost?
Research from Reed et al.(YEAR) suggested that patients with untreated hearing loss experienced
- 50% more hospital stays
- 44% higher risk for hospital readmission within 30 days
- 17% more likely to have an emergency department visit
- 52% more outpatient visits compared to those without hearing loss
- Older adults with untreated hearing loss incur substantially higher total health care costs compared to those who don’t have hearing loss
80
Untreated hearing loss in Canada costs ____ each year. This is around
$11,800 per person with an untreated disabling hearing loss.
$20 billion
81
Costs are related to ____ and ____
lower quality of life, higher unemployment
82
What are the benefits of treating hearing loss for our aging population?
- Have less difficulty communicating
- Have less generalized anxiety
- Greater confidence in social situations
- Participate in more social activities
- Have a greater sense of overall physical health
- Report better cognitive ability (from the Lin et al. study in 2011, found that psychological health and cognitive conditions of patients with hearing loss improved within 3 months of using amplification)
83
