JSLHR
Research Article
The Circle of Care for Older Adults With Hearing Loss
and Comorbidities: A Case Study of a Geriatric
Audiology Clinic
a,b,c
Kate Dupuis, Marilyn Reed, Florine Bachmann,
d b,e
Ulrike Lemke, and M. Kathleen Pichora-Fuller
Purpose: Older adults seeking audiologic rehabilitation often
present with medical comorbidities, yet these realities of
practice are poorly understood. Study aims were to examine
(a) the frequency of identification of selected comorbidities
in clients of a geriatric audiology clinic, (b) the influence of
comorbidities on audiology practice, and (c) the effect of
comorbidities on rehabilitation outcomes.
Method: The records of 135 clients (Mage = 86 years)
were examined. Information about comorbidities came
from audiology charts (physical paper files) and hospital
electronic health records (EHRs). Data about
rehabilitation recommendations and outcomes came from
the charts. Focus groups with audiologists probed their
views of how comorbidities influenced their practice.
Results: The frequency of identification was 68% for visual,
50% for cognitive, and 42% for manual dexterity issues;
H earing loss affects about two thirds of people aged 70
years and older (e.g., Bainbridge & Wallhagen, 2014).
Initial help-seeking for age-related hearing
problems occurs earlier now than it did a decade ago, such
that the average age of a first-time hearing aid user has shifted
from about age 70 to 63 years (Abrams & Kihm, 2015). The
degree of a person’s hearing loss and its effects on functioning
continue to progress with advancing age. Given the
unprecedented aging of the population,
a
Hearing Services, Baycrest Health Sciences, Toronto, Ontario, Canada
b
Department of Psychology, University of Toronto, Ontario, Canada
c
Sheridan Centre for Elder Research, Sheridan College, Oakville,
Ontario, Canada
d
Phonak AG, Stäfa, Switzerland
e
Rotman Research Institute, Toronto, ON, Canada Correspondence
to Kate Dupuis: kate.dupuis@sheridancollege.ca Editor-in-Chief:
Frederick (Erick) Gallun
Editor: David Eddins
Received April 16, 2018
Revision received August 11, 2018
Accepted August 29, 2018
https://doi.org/10.1044/2018_JSLHR-H-ASCC7-18-0140
Publisher Note: This article is part of the Special Issue: Select Papers
From the 7th Aging and Speech Communication Conference.
Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019 • Copyright © 2019 American Speech-Language-Hearing Association
Care of Older Adults With Multimorbidity, 2012). A survey
of almost 2,000 adults (18 to 70 years old) found that at least
a d
84% had more than one comorbidity. Also noted were
hypertension (43%), falls (33%), diabetes (13%), and
depression (16%). Integrating information from the
audiology chart and EHR provided a more complete
understanding of comorbidities. Information about hearing
in the EHR included logs of outpatient audiology visits (75%
of 135 cases), audiologists’ care notes for inpatients and
long-term care residents (25%), and entries by other health
professionals (60%). Modifications to audiology practice
were common and varied depending on comorbidity. High
rates of success were achieved regardless of comorbidities.
Conclusions: In this clinic, successful outcomes were
achieved by modifying audiology practice for clients with
comorbidities. Increased interprofessional communication
among clinicians in the circle of care could improve care
planning and outcomes for older adults with hearing loss.
rehabilitative audiologists are increasingly called upon to
adapt their practice to meet the changing needs of older
adults, including those with complex conditions who are seen
in geriatric settings (Weinstein, 2015a, 2015b). Indeed,
hearing disability is an important issue in the broader context
of geriatric medicine because it is associated with numerous
health issues and social consequences such as reduced
communication function, social isolation, loss of autonomy,
impaired driving ability, and financial disad-vantage (Davis et
al., 2016).
Comorbidities Associated With Hearing
Loss in Older Adults
As with hearing loss, the prevalence of other health
conditions increases with age. In general, over 75% of indi-
viduals aged 65 years and older report multiple chronic con-
ditions (e.g., Gerteis et al., 2014). Indeed, multimorbidity is
one of the greatest challenges in caring for an older popu-
lation (American Geriatrics Society Expert Panel on the
Disclosure: This study was funded by Phonak AG, and two of the co-authors (F. B. and
U. L.) work for Phonak at the time these data were collected. However, although hearing
aid use was studied, hearing aid brand was not restricted to Phonak, and specific brands are
not discussed in this article.
1203
one chronic health condition (other than hearing loss) was
reported by 79% of those who self-reported hearing loss
compared with only 68% of those with good hearing (Stam et
al., 2014). Furthermore, research has linked hearing loss to
numerous health conditions, with implications for
rehabilitative audiology (Besser et al., 2018).
Among the relevant comorbidities for audiologists to
consider are other sensorimotor declines (e.g., vision, man-ual
dexterity) that may affect communication and device usage.
Between 10% and 15% of individuals aged 75 years and older
report experiencing vision loss even when using glasses or
contact lenses (e.g., Bizier, Contreras, & Walpole, 2016), and
dual (vision and hearing) sensory loss affects about a fifth of
those 80 years of age and older (Heine & Browning, 2015).
Approximately 9% of individuals aged 65 years and older
report dexterity disability (Bizier, Fawcett,
& Gilbert, 2016), and prevalence rates for difficulties with
upper extremity and hand function increase after age 65 years
(see Singh, 2009), with arthritis (other than osteoarthritis and
rheumatic arthritis) being associated with hearing loss (Stam et
al., 2014).
Audiologists should also be aware that hearing loss is a
risk factor for more rapid age-related declines in physical,
cognitive, and mental health (e.g., falls, dementia, depres-
sion). About 40% of those individuals 65 years of age and
older who live in their own home will fall in any given year;
falls are even more common for those living in long-term care
(LTC) facilities (Rubenstein, 2006), and hearing loss has been
associated with falls (e.g., F. R. Lin & Ferrucci, 2012).
Respectively, mild cognitive impairment and demen-tia affect
approximately 21% and 9% of individuals 65 years of age and
older (Knopman et al., 2016), and hearing loss has been
associated with incident dementia (e.g., F. R. Lin, Metter, et
al., 2011). The prevalence of clinically significant symptoms
of depression in the general population 65 years of age and
older is 15% (Blazer, 2003), and hearing loss has been
associated with depression (e.g., Huang, Dong, Lu, Yue, &
Liu, 2010).
In addition, audiologists should be aware of health
conditions such as hypertension and diabetes that may put
older adults at increased risk for hearing loss. The prevalence
rate of high blood pressure is 71% for individuals 65 years of
age and older (McDonald, Hertz, Unger, & Lustik, 2009), and
hypertension increases the risk of hearing loss (e.g., B. M. Lin
et al., 2016). Diabetes affects 21.2% of those aged 65 years
and older (McDonald et al., 2009) and has been associated
with hearing loss (e.g., Bainbridge, Hoffman, & Cowie, 2008).
Implications of Comorbidities for the Circle
of Care and Audiology Practice
Overall, it is reasonable to expect that at least 10%–
20% of individuals between 65 and 75 years of age, many of
whom are first-time hearing aid users, could present at
audiology clinics with vision loss, manual dexterity issues,
1204 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
health care may be the presence of medical comorbidities.
Over a decade ago, Kricos (2000) reviewed evidence that
health status could influence rehabilitation outcomes, and
depression, and/or diabetes. Cognitive loss could affect up to
30%, falls could be an issue for almost half, and hyper-tension
could be a factor in more than half. It is difficult to estimate
how many may present with combinations of these
comorbidities. Furthermore, comorbidities will affect a
growing percentage of people above 75 years of age.
Increasing awareness of these links has put a spotlight on the
need for audiologists to understand more about the complex
medical history of older adults presenting for hear-ing help
(Abrams, 2017). Research and guidelines for prac-tice are
needed because there is a lack of direction from professional
organizations and regulatory bodies regarding whether and
how audiologists should identify clients with comorbidities,
modify their practice to accommodate for comorbidities, and
engage in interprofessional communica-tion in the circle of
care.
Circle of Care
Beyond audiology, geriatric health care could be
improved by promoting feelings of shared professional
responsibility (Stange, 2009) and increasing the effective-ness
of interprofessional communication among clinicians (e.g.,
audiology, geriatric medicine, neuropsychology, optom-etry)
in the circle of care for older adults who have hearing loss and
comorbidities (Pichora-Fuller, 2015). The term circle of care is
“…used to describe the ability of certain health information
custodians to assume an individual’s implied consent to
collect, use or disclose personal health information for the
purpose of providing health care…” (Information and Privacy
Commissioner of Ontario, 2015, p. 1). In such an
interprofessional circle, clinicians with different speciali-
zations work together and effectively communicate about and
manage their common client’s health conditions. How-ever, it
is unclear whether, or how, information about hearing status
and treatments is being exchanged in the cir-cle of care.
Medically complex older adults may be at risk for (a) not
being referred for hearing care, (b) not being appropriately
treated by audiologists who are not informed about relevant
comorbidities, and/or (c) not fully benefiting from information
about their hearing being shared by audiologists with others in
the circle of care. Care for older adults could potentially be
improved by ensuring under-standing of and accommodation
for hearing loss by allied health professionals and,
reciprocally, understanding of and accommodation for medical
comorbidities by hearing health care professionals.
Audiology Practice
Despite the high prevalence of hearing loss in the older
population, levels of access to hearing health care have been
low. Fewer than 20% of individuals who may benefit from
hearing aids based on their audiograms use a device (e.g.,
Chien & Lin, 2012). Potential explanations for this low uptake
rate include, but are not limited to, stigma, low access to
services, and not understanding how to seek help for hearing
loss (for a review, see Knudsen, Öberg, Nielsen, Naylor, &
Kramer, 2010). One major under-recognized and relatively
unexplored barrier to hearing
Erber (2003) described how vision and motor skills could
influence everyday use and maintenance of hearing aids.
Nevertheless, little research has examined actual prevalence
rates of comorbidities seen in audiology clinics offering ser-
vices to the oldest old and/or how comorbidities in older adults
may influence their hearing health care–seeking and success.
Current Study
The current case study of an example geriatric audi-
ology clinic was conducted at the Hearing Services clinic at
Baycrest Health Sciences. The clinic is situated in a world-
renowned, research-intensive geriatric teaching hospital with a
specialized focus on aging. Within this tertiary care setting,
the clinic provides a continuum of care to clients as they age,
including services delivered to outpatients, inpatients, and
those living on site in the retirement home or LTC. On
average, the clients are in their mid-80s, with ages ranging
from 55 to over 100 years. These “oldest old”
(OO) individuals are rarely studied in the context of audio-
logic rehabilitation (Wattamwar et al., 2017). The caseload of
this clinic provides a rich opportunity for examining how
hearing care may need to be tailored depending on the types of
medical comorbidities experienced by older adults across an
age range spanning several decades. The case study of this
clinic is based on case records for all clients seen for hearing
aid evaluation (HAE) in 2015 and focus groups with the
audiologists who provided care for those clients.
The goals of the study were to determine (a) the fre-
quency of identification of selected medical issues in the
caseload, (b) the influence of comorbidities on audiology
practice, and (c) the effect of comorbidities on rehabilitation
outcomes.
Method
A mixed-methods design was used. Quantitative and
qualitative data were gathered using a chart review method.
For each client, data were gathered by reviewing the physical
paper chart kept in the clinic (“the chart”) and the electronic
health record (“EHR”) stored online in the hospital infor-
mation system and accessed by hospital staff through Medi-
tech software (Meditech). Additional qualitative data were
gathered from focus groups with all four clinical audiolo-gists
who work in the clinic. This study was conducted in
accordance with human ethics standards and received ap-
proval from the institutional research ethics board.
Chart Review
Participants
Data were gathered from the records for all 135 clients
(Mage = 86 years, SD = 7.4, range: 66–99; 61% female,
entry ciphers for the comorbidities, but notes regarding the
presence of comorbidities were sometimes available. Some
clients may be seen in the clinic as inpatients on one occa-sion
39% male) seen at the Baycrest Hearing Services clinic for an
HAE appointment in 2015. Just over half of the participants,
76/135 (56%), were first-time hearing aid users, and the other
59 (44%) were experienced users. The group pure-tone
average (0.5, 1.0, and 2.0 kHz) was 43.5 dB HL in the better
ear (SD = 14.4, range: 10–96.7) and 51.3 dB HL in the worse
ear (SD = 17.3, range: 13.3–113.3). Data on the living
arrangement of a client were available for just over half of the
cases (57%; 77/135). Of those for whom it was recorded,
about half (52%; 40/77) received formal care, in-cluding care
delivered at the client’s home (10%; 8/77), in a retirement
home (25%; 19/77), or in LTC (17%;13/77). The other half
(48%; 37/77), who did not receive formal care, lived at home
either alone (16%; 12/77) or with a family member who was
almost always a spouse (32%; 25/77). Mar-ital status was
recorded for 60 clients; most were either mar-ried (48%) or
widowed (44%).
Data Collection and Analyses
Reviews of both the chart and EHR were conducted to
quantitatively determine the frequency of the comor-bidities
that were noted. The EHR was also reviewed to quantify
selected demographic information and to quantita-tively and
qualitatively examine sharing of information about hearing in
the circle of care. Quantitative and qual-itative data about
rehabilitation recommendations and outcomes were gathered
from the chart.
Comorbidities. Visual, manual dexterity, cognitive
issues, depression, falls, hypertension, and diabetes were the
seven comorbidities examined in this study. They were chosen
because of their associations with hearing loss and their
potential relevance to audiologic rehabilitation. For each of
the chosen comorbidities, we coded three possible results:
“yes,” when it was noted that the client had the comorbidity;
“no,” when it was noted that the client did not have the
comorbidity; or “no response” (NR), when neither the presence
nor absence of the comorbidity was noted. Frequencies of
“yes,” “no,” and “NR” responses were calculated for each
comorbidity noted in each source and all sources combined.
A physical paper chart is maintained by the clinic staff
for every client. It includes complete records of all client
contacts (e.g., in-person appointments, phone calls), all
assessment and treatment forms (e.g., questionnaires, HAE
results), and financial records (e.g., purchase infor-mation
regarding hearing devices). Since 2004, visual, manual
dexterity, and cognitive issues have been screened routinely
at HAE appointments at this clinic, but no stan-dard
procedures are used to collect information on the other four
comorbidities that were studied. Information about
comorbidities was gathered in the chart based on responses to
selected questions about comorbidities on the standard HAE
history form and from notes about comor-bidities in
marginalia anywhere in the chart.
The EHR was examined as a supplementary source of
data about the frequencies of comorbidities. The EHR can
provide information regarding comorbidities and services
provided for those comorbidities. There are no standard
Dupuis et al.: Comorbidities in Geriatric Audiology 1205
and as outpatients on other occasions. Inpatients who are
referred by other services may be seen in the clinic as
outpatients after they have been discharged from the hospi-tal.
Conversely, those seen as outpatients in the clinic may later
be admitted as inpatients to various other services at Baycrest.
Therefore, the EHR can yield data about comor-bidities that
would not typically be captured in the chart and vice versa.
Demographics. Additional quantitative data about
gender and date of birth as recorded in designated Meditech
data fields and other demographic information (e.g., living
arrangement and marital status) were gathered from the EHR.
Sharing information in the circle of care. EHR entries
about hearing were also captured because the EHR is a tool
for information sharing in the circle of care. Informa-tion
about hearing in the EHR includes logs of outpatient visits to
Baycrest Hearing Services, audiologists’ care notes for
inpatients and LTC residents, and possibly notes about
hearing entered by other health professionals. Quantitative
data about the occurrence of these entries and qualitative data
about their content and the professionals who made them were
examined.
Treatment recommendations and outcomes. Both quan-
titative and qualitative data about treatment recommenda-tions
and outcomes were gathered from documentation in the chart
based on the HAE form and in other notes and marginalia
related to any stage of the rehabilitation process. This clinic
uses a fairly typical audiologic rehabilitation delivery model.
Clients must be referred by a physician in order for audiology
services to be billed to the provincial health care system. Most
clients complete the following sequence of appointments: (a)
hearing test (HT); (b) HAE, including hearing aid
prescription, recommendations for accessories and/or assistive
listening devices (ALDs), and completion of a purchase
agreement if the client opts to purchase a device at the clinic;
(c) hearing aid fitting (HAF; typically 2–3 weeks following a
purchase); (d) first hearing aid check (HAC; typically 2–4
weeks post-HAF); and
(e) additional HAC (typically 4–6 weeks post-HAF). The HT
and HAE may be completed in one 2-hr appointment. Not all
clients opt for an additional HAC. Patient- and family-
centered counseling are incorporated into the sequence of
appointments, and group rehabilitation training sessions may
also be provided. Thus, the trajectory of clients through a
rehabilitation process spans several months.
The HAE form documented the number and types of
recommendations made for technologies (hearing aids, acces-
sories, ALDs) and/or group rehabilitation. Using the clinic
sales records, it was possible to determine the number and
types of technologies purchased at Baycrest. Purchases else-
where were sometimes noted at post-HAE appointments.
Qualitative data about outcomes included notes about group
rehabilitation and the client’s self-reported use of and benefit
from the technologies. The Client Oriented Scale
1206 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
used to elicit discussion around the topics described above.
With the audiologists’ consent, all focus group sessions were
audio-recorded to facilitate later analysis.
of Improvement (COSI; Dillon, James, & Ginis, 1997), a self-
report measure of hearing aid benefit, was used to assess
needs and evaluate the outcomes for about half of the cli-ents.
For the others, a less structured approach was used because
the audiologists felt the COSI was too difficult or not
appropriate.
Procedures for collecting and checking data. Relevant
sections of the chart and EHR were scanned, and any entries
about comorbidities were recorded. Chart entries about
treatment recommendations and outcomes and EHR entries
about hearing and demographics were also recorded. All data
gathered from the charts were entered manually using custom
Medialab v2014.1.107 (Empirisoft) programs and were then
exported to Excel. These data were abstracted by trained
research assistants (RAs), and interrater reliability with the
first author (K. D.) was nearly perfect based on the first 10
charts. The data from the EHR were abstracted and manually
entered into a custom Excel spreadsheet. To determine
interrater reliability for the EHR comorbidity data, a different
RA examined the EHRs for notes about vision, manual
dexterity, and cognitive issues for 10% (14/135) of the cases.
Interrater reliability for the EHR data was 86% for visual and
manual dexterity issues and 93% for cognitive issues. The few
interrater discrepancies were resolved and were not
attributable to systematic errors.
Focus Groups
Participants
All four audiologists employed at Baycrest Hearing
Services participated in four focus groups (Mage = 54.3 years,
SD = 11.6 years, all female). They had a range of 13–
39 years of experience working with a geriatric population,
including delivering services to outpatients, inpatients, and
residents in retirement and LTC facilities.
Focus Group Procedures
Focus groups with the audiologists were conducted by
K. D. on four occasions. The first two focus groups were held
1 week apart and lasted approximately 75 min each. The
discussion focused on common comorbidities observed in
clients seen at the clinic, how the audiologists learn about
comorbidities, modifications to practice they make to
accommodate for comorbidities, and how/whether significant
others (SOs) are involved in care. The third focus group took
place about 3 months later and lasted approximately 15 min.
The discussion focused on comor-bidities not currently listed
on the HAE history form (e.g., cardiovascular health) and
procedural issues such as how they complete the HAE history
form and when they ask about possible comorbidities. The
final focus group, held about a year after the first interview,
lasted approximately 60 min. The discussion focused on
whether the audiologists believed their accommodations for
comorbidities influence rehabilitation outcomes, when and
how they communicate with other health care professionals,
and procedural issues related to charting client information
and treatment out-comes. At each session, a series of guided
questions was
Analysis
 A qualitative content approach was used. This method
can be used to analyze text data, moving beyond counts of
occurrences of specific topics or words to create catego-ries
that represent similar meanings or themes (Hsieh & Shannon,
2005). It is one of the most common qualitative methods used
in audiology research, and it allows for more interpretative
thematic analysis, in which questions of why and how are
answered (Knudsen et al., 2012). It can be used to describe a
phenomenon. In the current case, we investi-gated why and
how comorbidities influence hearing care. Specifically, using
this method, the audiologists were asked questions chosen to
drive the data collection and to address the three research
aims. A sequence of steps were taken to transcribe the focus
group audio recordings, check the tran-scription, and prepare
manageable documents for analysis. All transcription,
checking, and analysis were conducted using Microsoft Word
rather than a specific qualitative research software.
First, K. D. listened many times to the audio record-ings
of the focus groups, and then, she transcribed them,
identifying talkers by initials (recoded as A1, A2, A3, and
A4). Based on these transcripts, the information pro-vided by
the audiologists was extracted and entered in an analysis
document organized according to the interview questions and
themes discussed at each session. A second researcher (F. B.)
then listened to the audio recordings and read through K. D.’s
transcripts of the first two focus groups. F. B. made her own
notes related to the discus-sion of comorbidities in the focus
groups before reading through the analysis documents
prepared by K. D. A com-parison of the notes of the two
researchers revealed no instances of disagreement; however,
there were 26 instances where F. B. suggested adding
additional information to the analysis document. K. D. then
amalgamated F. B.’s com-ments into the final analysis
documents for the first two focus groups. There was no
interrater reliability checking for the third focus group because
it was very short (15 min). For the fourth focus group, an RA
listened to the recording and reviewed the transcript as F. B.
had done for the ear-lier focus groups. A comparison of the
notes of the two raters revealed no disagreements. The RA
suggested eight additions or wording changes, and all were
accepted in the final document.
Results
Results from the review of the chart and EHR will be
described first, followed by the findings from the focus
groups. Results for each method will be organized accord-ing
to the three aims of the study and related topics that emerged
when data were collected.
Review of the Chart and EHR
Frequency of Identification of Comorbidities
Table 1 shows the frequency of comorbidity identifica-
tion based on the specific questions on the HAE history form,
marginalia in the chart, and notes in the EHR. Com-bining the
data from these sources, comorbidity identifica-tion rates were
as follows: 68% (92/135 clients) had vision issues, 50%
(68/135) had cognitive issues, 43% (58/135) had hypertension,
42% (57/135) had manual dexterity issues, 33% (45/135) had
a history of falls, 16% (22/135) had depres-sion, and 13%
(18/135) had diabetes. Complete data on the three
comorbidities were available for 119 cases, of which 20 (17%)
had none of the three comorbidities. Figure 1 illus-trates the
multiple comorbidities for the 99 clients who had complete
data and at least one comorbidity in addition to hearing loss.
Almost a third of these clients (31/99; 31%) had triple visual,
manual dexterity, and cognitive issues, and about a quarter
(26/99; 26%) had dual visual and cognitive issues.
Information added by reviewing chart marginalia and
EHR. For the three comorbidities (vision, manual dexterity,
cognition) queried on the HAE history form, adding infor-
mation from the chart marginalia resulted in the identifica-tion
of four more clients with visual issues, three more with
manual dexterity issues, and four more with cognitive issues.
The EHR yielded sparser information, but it was still useful
for identifying 13 additional cases with vision issues, three
with manual dexterity issues, and five with cognitive issues.
There was more missing data for the other four co-
morbidities that were not specifically queried on the HAE
history form. The marginalia identified a few more clients
with a history of falls (three cases), hypertension (seven
cases), diabetes (two cases), and depression (one case), which
would otherwise not have been identified on the HAE form.
The EHR provided much more information about these four
comorbidities, resulting in the identification of an additional
42, 51, 16, and 21 clients with a history of falls, hyper-tension,
diabetes, and depression, respectively.
Effects of age on comorbidities. Given the wide age
range of the 135 clients, three subgroups of similar sizes were
created to investigate age-related differences in the frequency
of the comorbidities identified: young old (YO) aged 66–83
years, n = 45; middle old (MO) aged 84–90 years, n = 47; OO
aged 91–99 years, n = 43 (see Table 2). Not sur-prisingly, the
number of comorbidities increased with age. YO clients had
an average of 1.9 (SD = 1.6; range: 0–5) comorbidities; MO
clients had an average of 2.8 (SD = 1.9; range: 0–6)
comorbidities, whereas OO clients had an aver-age of 3.3 (SD
= 1.4; range: 0–6) comorbidities. A series of three
independent-samples t tests with Bonferroni correc-tions
revealed significant differences between the average number
of comorbidities experienced by the YO and OO groups, t(86)
= 4.15, p < .05, but no difference between the YO and MO
groups or between the MO and OO groups
(ps > .05). However, there was a significant positive corre-
lation between age and the number (0–7) of comorbidities (r
= 34, p < .01).
Dupuis et al.: Comorbidities in Geriatric Audiology 1207
Table 1. Frequency of identification of comorbidities (visual issues, manual dexterity issues, cognitive issues, history of falls, hypertension,
diabetes, and depression) from various data sources (audiology chart hearing aid evaluation form, audiology chart marginalia, or electronic
health record).

Response Visual Manual Cognitive History

Data source type issues dexterity issues issues of falls Hypertension Diabetes Depression

Hearing aid evaluation form Yes 70 (50.9) 50 (37) 58 (43) 0 0 0 0

No 51 (37.8) 74 (54.8) 69 (51.1) 0 0 0 0
NR 14 (10.4) 11 (8.1) 8 (5.9) 135 (100) 135 (100 135 (100) 135 (100)
Audiology chart marginalia Yes 4 (3) 3 (2.2) 4 (3.0) 3 (2.2) 7 (5.2) 2 (1.5) 1 (0.7)
No 0 0 0 1 (0.7) 0 0 0
NR 131 (97) 132 (97.8) 131 (97) 131 (97) 128 (94.8) 133 (98.5) 134 (99.3)
Anywhere in audiology chart Yes 74 (54.8) 53 (39.3) 62 (45.9) 3 (2.2) 7 (5.2) 2 (1.5) 1 (0.7)
No 48 (35.6) 71 (52.6) 66 (48.9) 1 (0.7) 0 0 0
NR 13 (9.6) 11 (8.1) 7 (5.2) 131 (97) 128 (94.8) 133 (98.5) 134 (99.3)
Electronic health record Yes 50 (37) 6 (4.4) 50 (37) 44 (32.6) 55 (40.7) 17 (12.6) 22 (16.3)
No 5 (3.7) 1 (0.7) 4 (3.0) 9 (6.7) 1 (0.7) 1 (0.7) 2 (1.5)
NR 80 (59.3) 128 (94.8) 81 (60) 82 (60.7) 78 (57.8) 117 (86.7) 111 (82.2)
All sources Yes 92 (68.1) 57 (42.2) 68 (50.4) 45 (33.3) 58 (43) 18 (13.3) 22 (16.3)
No 35 (25.9) 68 (50.4) 61 (45.2) 9 (6.7) 1 (0.7) 1 (0.7) 2 (1.5)
NR 8 (5.9) 10 (7.4) 6 (4.4) 81 (60) 76 (56.3) 116 (85.9) 111 (82.2)

Note. Data represented as the number of participants (percentage of participants out of 135) for whom that comorbidity was identified. The
yes/no/unknown responses are defined as follows: “Yes” (explicit mention that the participant does have this comorbidity), “No” (explicit
mention that the participant does not have this comorbidity), and “NR” (no indication of the presence/absence of this comorbidity).

Association between comorbidities and living arrange-
ment. Furthermore, there was a connection between number of
comorbidities and living arrangement, with chi-square
analyses indicating that clients with a higher number of
comorbidities were more likely to be receiving formal care
2
than those with fewer comorbidities, χ (30) = 93.21, p < .001.
Exchange of information about hearing loss. In a 2017
follow-up, 2 years after the HAE appointments of the clients
had occurred, the EHR was searched for notes entered by
audiologists or other health care professionals about the
clients’ hearing loss, visits to the clinic, amplifi-cation status,
and/or audiologic rehabilitation. If allied
Figure 1. Representation of the overlap of comorbid health issues
(vision, cognition, dexterity) for 99 of the 135 clients.This figure
does not include 16 individuals for whom there were missing data
for at least one of the three comorbidities, nor does it include the
20 individuals for whom the “no” response was provided for all
three issues.
health professionals want to know whether a client has
accessed services and/or obtained treatment for hearing loss at
this clinic, it is possible that they would search the EHR for
this information. For the majority of the 135 cli-ents in our
sample (75%; 101/135), the clinic staff had noted in the
“history of visits” section of the EHR that the client had
attended an appointment in the Hearing Services clinic. For
one client, there was no information about a visit to the clinic.
For the other 33 cases (four from LTC), a member of the clinic
staff had noted information in the EHR about the client’s
treatment trajectory, including 73% (24/33) with notes that the
client had hearing aids, 12% (4/33) that the client had attended
an HAE, 9% (3/33) that the client had an HT, and 6% (2/33)
that the client had ordered hearing aids.
In addition to the notes about hearing made by staff of
the Baycrest Hearing Services, it is possible that informa-tion
about a client’s hearing status and/or treatment options could
have been noted in the EHR by other health profes-sionals.
Overall, the EHR contained information entered by other
health professionals about hearing loss or hearing care for
60% (80/135) of the cases in our sample. These 80 cases
included 24 of the 33 cases for which the audiol-
ogists had also provided information about hearing care
in the EHR. The majority (62%; 50/80) of the notes entered
in the EHR by other health professionals indicated only
that the client was wearing a hearing aid. For two clients
(3%), the notes suggested that the client would benefit from
referral to an audiologist and then later indicated that the
client was now wearing a hearing aid. Some notes only indi-
cated that the client had hearing loss (16%; 13/80), or only
noted referral to the clinic for a consultation (8%; 6/80).
The remainder indicated (mistakenly) that the client did not
have hearing loss (6%; 5/80), had completed an assessment

1208 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
 Table 2. Number of comorbidities identified for all participants and for each of the three age subgroups
(percentage of participants indicated in parentheses).

Number of All participants Young old Middle old Oldest old

comorbidities (N = 135) (n = 45) (n = 47) (n = 43)

0 22 (16.3) 13 (28.9) 6 (12.8) 3 (7.0)

1 16 (11.9) 6 (13.3) 9 (19.1) 1 (2.3)
2 24 (17.8) 10 (22.2) 7 (14.9) 7 (16.3)
3 24 (17.8) 6 (13.3) 7 (14.9) 11 (25.6)
4 24 (17.8) 7 (15.6) 5 (10.6) 12 (27.9)
5 22 (16.3) 3 (6.7) 11 (23.4) 8 (18.6)
6 3 (2.2) 0 2 (4.3) 1 (2.3)

Note. The seven comorbidities included in the count were visual issues, manual dexterity issues, cognitive
issues, history of falls, hypertension, diabetes, and depression. Young old participants are 66–83 years
old, middle old participants are 84–90 years old, and oldest old participants are 91–99 years old.

but without a treatment update (4%; 3/80), or that the client
would be scheduled for an annual checkup with the ear, nose,
and throat doctor (1%; 1/80).
For a number of the clients, their physicians (mainly
from Neurology, Geriatric Assessment, and Memory Care
clinics at Baycrest) had noted information in the EHR con-
cerning the potential interactions between comorbidities and
hearing loss. These notes could be accessed by audiol-ogists
and might have informed hearing care. For example, one note
considered hearing loss and the risk of falls: “I told Mr. X that
1 with the audiologist’s remarks (see Table 3), and as shown in
hearing impairment is a risk factor for falls.” Potential issues
with manual dexterity and/or vision loss are implied in another
note: “Hearing has declined, had a hearing aid trial but cannot
put the batteries in herself so returned them.” Another note
considered the connection between hearing and cognition: “His
bilateral hearing im-pairment may also contribute to poor
cognition.” Taken together, the notes about hearing made by
other health professionals, along with these notes by
physicians about the connections between hearing loss and
comorbidities, provide evidence of interprofessional
awareness of hearing issues in the circle of care. Nevertheless,
it seems that there could be potential benefit from richer
bidirectional inter-professional communication.
Influence of Comorbidities on Practice and Outcomes
Hearing aids. Of the 135 clients who completed an
HAE, a hearing aid was prescribed for 132 (98%), and the
three clients who did not receive a prescription were already
experienced hearing aid users. Of the 132 clients who received
a hearing aid prescription, 11 clients were lost to follow-up,
including six who died, but follow-up information was
available for most clients (121/132; 92%). Of those for whom
follow-up information was available, almost all had purchased
a hearing aid at Baycrest (116/121; 96%; half new users and
half experienced users), and five clients bought a hearing aid
elsewhere but were followed at Baycrest. Most (111/121;
92%) kept their hearing aids,
1
All emphasis our own.
including 13 for whom exchanges were made before settling
on the final device. Of the hearing aid purchasers, only 10
clients (10/121; 8%) returned the aid; of those who returned
the aid, one had no comorbidities, but the other nine had two
or three comorbidities (four had vision and cognition issues,
two had vision and dexterity issues, and three had vision,
dexterity, and cognitive issues).
Other treatments. For the majority of clients (71/111;
64%) who kept the hearing aid they purchased, the hearing aid
was the only technology they bought. However, con-sistent
Table 4, hearing aid accessories (remote controls, remote
microphones, devices to connect to phone, television, etc.)
were recommended to 38 and provided to 27 clients. Notably,
12 clients chose to use simple remote controls, and another six
chose a multipurpose remote control; all but one were clients
with dexterity and/or vision comorbid-ities. More
conventional ALDs (personal amplifiers [two], specialized
clocks [three], and phone [five] or television devices [one])
were recommended to 16 and bought by
11 clients; five clients already used conventional ALDs.
Group rehabilitation was suggested to 32 and attended by
eight clients. Overall, about a third of the clients took advan-
tage of rehabilitation options in addition to only hearing aids,
especially those with vision and dexterity issues.
Benefit from rehabilitation. The COSI overall improve-
ment score for the client’s self-identified most important
listening goal was available for half of the clients (59/111;
53%) who kept their hearing aids. Considering only the COSI
overall improvement score, for the 59 clients who completed
the COSI, 21 reported much better performance, 36 reported
better performance, and only two reported no difference. As
shown in Table 4, half of the participants did not complete the
COSI (52/111; 47%), including roughly equal numbers of
clients with cognitive, visual, and manual dexterity issues. The
chart was examined for qualitative information regarding
outcomes noted at the HAC for clients who purchased and
retained hearing aids but for whom no COSI data had been
collected. As described by the audiologists in the focus
groups, qualitative outcome information available in the charts
for these clients indicated

Dupuis et al.: Comorbidities in Geriatric Audiology 1209

1210

Table 3. Modifications to practice to accommodate for medical comorbidities for hearing test, hearing aid evaluation, hearing aid
fitting, and hearing aid check appointments.
Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019

Comorbidity Hearing test Hearing aid evaluation Hearing

Vision • Severity of impairment may determine category of device • Ensure gla

(e.g., hearing aid or ALD) • Boldly iden
• Choice of manufacturer may be based on availability (e.g., red a
of specific options (e.g., need to change batteries or or mark wit
rechargeable aids) • Customize
• Choice of custom aid or ear tip for ease to orient and scale font
insert in the ear • Type of imp
• Choose features that are easy to see and handle (e.g., (e.g., tremo
simple remote control with large buttons, automatic
features, and program switching; easy-to-open battery
doors)
• Select easy-to-use accessories (e.g., big button remote
controls)
Manual dexterity • Severity of loss may determine category of device (e.g.,
hearing aid and/or ALD)
• Choice of manufacturer may be based on availability
of specific options (e.g., need to change batteries or
rechargeable aids)
• Severity of loss may determine choice of style (e.g.,
custom aid or ear tip depending on which is easier to
insert in the ear)
• Removal cord/handle to facilitate removal of custom
aids/molds
• Select device features for ease of manipulation (e.g.,
automatic program switching, easy-to-open battery
doors)
• Select easy-to-use accessories (e.g., big button remote
controls)
Cognition • Tailor instructions to individual’s ability • Simpler options and accessories (e.g., rechargeable • Tailor instru
(short, simple sentences) batteries and automated features) language c
• Practice/observe to confirm instructions • Prescribe devices with voice commands rather than • Repeat and
are understood beeps (e.g., prompt to change battery) instructions
• Use speech testing (SRTs, questions, • Add safety loops to tether aids to clothing for clients • Provide ins
SATs) if client is unresponsive to pure- if needed and picture
tone stimuli • Prescribe same style of aid for previous users • Determine
• Tailor response options to client’s ability • Ensure easy use with phone to avoid need to remove aid to the clien
(e.g., raise hand, say “yes,” observe facial • Since clients with dementia may be more sensitive when poss
expressions or eye movements) to noise, fit conservatively, ensuring output does not • Educate cli
• Minimize possible fatigue and agitation exceed comfort levels of improve
• Test at best time of day • Include significant others whenever possible communica
• Include significant other as needed • Establish ro
• Assess over multiple sessions as needed when they
• May need m
• May benefi
access to a
• Evaluate q
significant
Dupuis et al.: Comorbidities in Geriatric Audiology

Table 3. (Continued).

Comorbidity Hearing test Hearing aid evaluation Hearing

Mobility • Ensure sound booth and other clinic spaces • Ensure that hearing aid microphones pick up sounds • Counsel co
are safe and accessible (accommodate to the rear for clients in wheelchairs pushed by to-face (an
wheelchairs and other mobility devices, significant other attention a
elevators, handrails) • Angle up the directional microphone for sounds • Counsel on
• Assist to sit/stand as needed coming from above a wheelchair user balance pr
• Use clinic wheelchair if needed for transport • Remote microphone could be used by communication safety cons
in building or to parking partners to facilitate communication • Stress hyg
Hypertension or • If client uses blood thinners, exercise • For clients with a pacemaker, to avoid interference, comfort of
cardiovascular caution when taking earmold impressions, do not select wireless accessories worn on the chest given highe
disease or removing wax so as to minimize bleeding that pose a potential risk
Diabetes • Query vision (diabetic retinopathy,
hypertension)
• Counsel about possible connection between
hearing loss and diabetes and value of
monitoring hearing
Depression • Counsel about compounding effects of
unaddressed hearing loss on mood, social
isolation, and loneliness
• P
r
o
v
i
d
e

i
n
f
o
r
m
a
t
i
o
n

a
b
o
u
t

r
e
s
o
u
r
c
e
s

f
o
r

d
e
p
r
e
ssion and
Note. The table summarizes the results of qualitative data analysis of the considerations that the audiologists identified in the focus
discuss
groups as or
management being the most relevant and frequent in their practice. ALD = assistive listening device; SRT = speech reception
threshold; SAT
referral if = speech awareness threshold.
appropriate
1211 1212
Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019

Table 4. Types of rehabilitation recommendations by comorbidity profile, with the number who received the recommendation
and the number who complied, and the evaluation method used by comorbidity profile.

Total number of
Types of recommendations
recommendations with selected outcomes No Cognition Dexterity Cogn
and the evaluation or total number receiving comorbidity Cognition Dexterity Vision and vision and vision and de
methods used an evaluation method (n = 20 + 1) (n = 6 + 1) (n = 8 + 1) (n = 14 + 4) (n = 26 + 2) (n = 13 + 2) (n = 1

HA(s) Kept (111) 19+1 5+1 8+1 12+4 19 + 1 11+2 0+

Returned (10) 1 4 2
Not prescribed (3) 1 1
Lost (11) 1 2 2+1
ALDs Bought (11) 1+1 1 0+2 1 1 1
Recommended (16) 2 2 2 0+2 1 1 1
Prior ALD use (5) 1 1 1
Hearing aid accessories Bought (27) 5 3 6+2 4 3+1
Recommended (38) 7 4 7+2 6 3+1
Group rehabilitation Attended (8) 3 2 1
Recommended (32) 6 7 3+1 4 2+1
Combination of HA only (71) 11 4+1 3+1 6 15 + 1 7+1 0+
recommendations ALD only (1) 1
taken AR only (2) 2
HA and ALD (8) 1+1 1 0+2
HA and accessory (23) 4 3 5+2 3 2+1
HA and AR (4) 2 1
HA and ALD and accessory (2) 1 1
HA and AR and accessory (2) 1 1
Evaluation method COSI (59) 13 1 5 7+2 12 3+1 0+
Qualitative (52) 6+1 4+1 3+1 5+2 7+1 8+1

Note. The 135 clients are categorized depending on their pattern of comorbidities. The first number in each cell indicates the number
of clients for whom “yes” or “no” was noted for all three comorbidities, and to it is added the number for whom the absence of a
response for a comorbidity is assumed to be a “no” even though there was no explicit response. For four clients, responses were
unknown for all three comorbidities. ALD = assistive listening device; HA = hearing aid; AR = audiologic rehabilitation; COSI =
Client-Oriented Scale of Improvement.

improvement reported either by the client or by a family responded by identifying the following health conditions
member and/or caregiver. Overall, almost all cases were (transcribed in the order that they were provided): cognitive
considered to be successes by their audiologist. impairment, anxiety and/or depression, visual impairment,
diabetes, heart conditions, macular degeneration, arthritis,
issues with mobility, neurodegenerative diseases (e.g., stroke,
Findings From the Focus Groups
Parkinson’s disease) that might affect manual dexterity and/or
The focus group data were analyzed to address the three ability to use a limb, speech issues, tremor, fine motor
research goals of this study concerning the frequency of problems (e.g., numbness in fingertips), neuropsychiatric
identification of comorbidities, modifications to practice symptoms of dementia, and “normal” age-related cognitive
made to accommodate comorbidities, and outcomes for changes (e.g., in memory). They unanimously agreed that the
clients with comorbidities. Themes from the focus groups are three most common comorbidities they typically see in their
summarized in Table 5. clients are cognitive, manual dexterity, and visual
impairments. Of note, although not indicated among the most
Frequency of Identification of Comorbidities frequently encountered, anxiety and depression were listed by
Common comorbidities. The audiologists were first A2 as “one of the most difficult” comorbidities to deal with,
asked to comment on the types of medical comorbidities due to the client’s increased need for counsel-ing and support.
with which their clients are most likely to present. They

Table 5. Identified themes from the focus groups with the four audiologists

Theme Description of theme/outcome

Common comorbidities • The three most common are cognitive impairment (“first of all,” A3; “the biggest one,” A2),
manual dexterity, and visual impairment.
Identifying comorbidities in clients
Charting information about comorbidities
Assessment of client functioning
Device selection
Treatment trajectory
Limitations to practice
Interprofessional communication
Gathering quantitative and qualitative data
on treatment outcomes
Modifying the evaluation of outcomes
because of comorbidities
• Audiologists gather information about comorbidities in their clients from various sources,
including the EHR, the client’s referral form (“Always look at the physician’s referral.” A1),
client observation, the standardized case history form, and discussion with the significant
other accompanying the client.
• Clinicians agreed that it is important to document information about client’s comorbidities
in a consistent way in the audiology chart in order to facilitate information sharing and
ensure appropriate client care in cases where the treating audiologist is absent and another
audiologist fills in.
• The clinicians need a better way of indicating information about patients’ comorbidities.
(“I’ve been saying for ages that we need to put questions about stroke for example.” A1)
• Clinicians look for evidence of the effects of comorbidities on a client’s function. Change
in function over time is charted. (“The comorbidities are always progressing, so you’re
constantly having to provide more and different support and adjustments.” A1)
• The presence of comorbidity(ies) will influence the device that is selected for the client. The
audiologists ask their clients if they will have support at home, for example, a significant
other who visits regularly or lives with them who could help with the hearing aid. (“I ask
much more: how often is your caregiver with you, is it part-time, is it full-time?” A2)
• Comorbidities affect follow-up; clients with more comorbidities typically return to the
clinic more often than those with fewer comorbidities. Support also affects follow-up;
clients with a supportive significant other or caregiver will likely need less follow-up. (“Another
big determinant of how often they come is if they have a good caregiver. If someone else is
managing it for them, they do a lot better.” A4)
• Audiologists realize and acknowledge the limitations to their practice and knowledge and
to their ability to help clients. They indicate a willingness to learn more in order to provide
optimal care. (“Maybe I need to learn that [more about the comorbidity] in order to start
thinking about…my prescription.” A3)
• The audiologists currently only include information in the EHR for inpatients, but may
follow-up by e-mail with the referring physician and other clinicians (e.g., SLP) to share
results of hearing tests and notes on the client’s progress with hearing aid(s). (“Depends
who referred them. Some will have referrals from SLP, we’ll have referrals from the mild
cognitive impairment group, so whoever referred them would get a copy.” A1)
• Outcomes are always assessed and documented in the chart, even if a standardized
measure (e.g., the COSI) is not appropriate to use with a client. The key factor to assess
is how hearing loss affects quality of life and whether it has improved posttreatment. (“For
our population, changing the quality of their life is very important, that’s one of the things
that we need to measure that couldn’t be a number or anything.” A3)
• The audiologists speak with and observe the client and query an accompanying significant
other about how the client is doing with their hearing instrument. (“If they have a family
member, a caregiver, we usually include them. They are often the ones who can answer
the question for you.” A4)

Note. EHR = electronic health record; SLP = speech-language pathologist; COSI = Client Oriented Scale of Improvement.

Dupuis et al.: Comorbidities in Geriatric Audiology 1213

Identifying comorbidities in clients. The audiologists
identified specific sources from which they gather informa-
tion regarding clients’ comorbidities, including the following
(in the order described by the clinicians): the EHR, the client’s
referral form (sent to the clinic by the referring physician),
observation of the client by the audiologist, pre-viously
completed case history forms (see next theme), and discussion
with the SO accompanying the client. Both A3 and A4
indicated that they review the EHR on a regular basis,
whereas A1 stated that she does not because she pre-fers to
focus on the referral form. A4 cautioned that the referral form
can sometimes contain misleading information about the
client’s comorbidities, and she described a case where “the
physician’s referral was completely off the wall and led me
astray.” The audiologists agreed that it is com-mon for them to
assess potential problems in handling a hearing aid by
observing the client manipulate and insert
a “dummy” hearing aid. These observations can reveal obvious
issues that the client might have in seeing and handling the
device or difficulties in understanding how to perform tasks.
The audiologists agreed unanimously that this observational
approach is an effective way of uncovering visual, manual
dexterity, and cognitive comorbidities in a client that could be
directly relevant to the client’s ability to learn about and
maintain use of a hearing device. In addi-tion, the audiologists
stated that during intake, they ask questions that are geared
toward building rapport and finding out information about a
client’s comorbidities. A2 com-mented, “they don’t talk about
it very much, but I bring it up in a sensitive way…. I find that
it helps as part of how I counsel them.” All audiologists agreed
that the client’s SO is a key player in the conversation around
comorbidities such that, when an SO does accompany a client
to the appointment, information is “always” (A3) gathered
from both the client and their SO, consistent with family-
centered care. The audiologists expressed concern that some
audiolo-gists outside of their clinic may not realize that, with
the client’s permission, they are allowed to discuss comorbidi-
ties with the client’s SO. This point elicited further discussion
and clarification about the term circle of care and about what
information is permissible to share within a particular client’s
care team (i.e., other health professionals).
Charting information about comorbidities. The audiol-
ogists agreed unanimously that it is crucial to document
information about comorbidities in the chart. In particular,
such documentation ensures appropriate care when the client’s
usual audiologist is absent and another audiolo-gist fills in.
However, the audiologists were mixed in their descriptions of
how they used the HAE history form; A3 indicated that she
completes it for all new inpatients, whereas A4 indicated that
she completes it for outpatients but not for inpatients, and A1
stated that her case history is often not as detailed for an
inpatient. A2 explained that she tries to complete it with the
client if they are cognitively able to do so, or with an SO if
there is difficulty communicating with the client. In addition,
they discussed the importance of hav-ing dedicated sections of
the chart for inputting data about comorbidities. A4 stated, “I
just scribble it in somewhere;
1214 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
of different types of accessories for use with an older
population.
I think maybe we need a new form.” Currently, the audiol-
ogists do not screen systematically for any medical conditions
apart from visual, manual dexterity, and cognitive issues.
They agreed that Parkinson’s disease, diabetes, and neuro-
logical disorders are important conditions to add to the his-
tory form. Furthermore, they discussed adding a question
about current/past use of blood thinners. They felt that this
information was relevant with respect to wax removal and
taking earmold impressions because individuals using these
medications are more likely to bleed and the audiologists
“need to be very, very cautious and gentle” (A3).
Influence of Comorbidities on Practice
Specific modifications to practice made to accommo-
date for comorbidities are listed in Table 3.
Assessment of client functioning. When asked why they
screen for various medical comorbidities, one common theme
in the responses of the audiologists was that they were looking
for potential effects of these comorbidities on the client’s
functioning and rehabilitation needs; for example, A1 stated,
“we need to be very aware of what their func-tional needs are.”
Device selection. All four of the audiologists are very
experienced in working with an older, medically complex
population. Knowing about comorbidities influenced their
choice of hearing aids and/or ALDs and how they counsel
clients. For example, A4 indicated that she may choose an
ALD over a hearing aid depending on the client’s level of
impairment: “I try to convince them, I don’t think you’ll be
able to manage this, look at this [ALD], this will be much
easier for you.” Moreover, favoring rechargeable de-vices was
mentioned for cognitive, manual dexterity, and vision issues.
Comorbidities can also influence the types of counseling the
audiologists offer clients and/or SOs during the device
selection process. For example, as stated by A1, “when doing
motivational counselling, [I] will bring in what we’ve learned
about hearing and its importance to healthy aging.” In
particular, this audiologist discusses the link between hearing
loss and comorbidities, as well as social isolation, emphasizing
the importance of partici-pating socially for overall quality of
life.
Of note, the audiologists do not simply consider comor-
bidities while they are working with a specific client. The
potential for comorbidities in their caseload also influences
their more general business interactions with the representa-
tives of manufacturers. The audiologists share their knowl-
edge about how comorbidities can influence their clients’ use
of devices with the manufacturers’ representatives who come
to the clinic on a regular basis; for example, they reported
decisions to recommend specific products to accommodate for
comorbidities (e.g., hearing aids with rechargeable batte-ries).
A1 explained, “I do believe we have been able to have an
impact on some of the manufacturers when they come in to
give us their technology updates. One of the manufac-turers
said they had taken back what we are saying and trying to
make sure that they [the products] were designed with seniors
in mind.” A3 elaborated that a topic of discussion with
industry representatives had been the appropriateness
Treatment trajectory. In light of the progressive nature
of most of the comorbidities considered in this study, the
audiologists indicated that their treatment plans must be
updated on an ongoing basis. As stated by A1, “you’re
constantly having to provide more and different support and
adjustments.” A2 expressed her opinion that some clients with
comorbidities are “never” discharged, and A4 noted that cases
are only discharged if the client chooses to discontinue
treatment. The audiologists unanimously reported that they
encourage clients to return for annual checkups to ensure that
their equipment, including hearing aids and ALDs, is working
properly. The progressive and challenging aspects of
comorbidities are such that the audiologists tend to see clients
with comorbidities more often than clients without
comorbidities; for example, clients with comorbidities typi-
cally have a higher number of hearing aid checks. A3 noted
that an accelerated rate of functional change is often seen in
older clients who are more likely to have more comorbidities,
saying that “Somebody who is 50 years old, in 5 or 6 years,
how much change do you expect, compared to somebody who
is 90 years old…it is going to be [a] more sudden and
significant and fast change for those who are much older.”
Limitations to practice. The ability of the audiologists to
help their clients may be limited by their knowledge about the
various comorbidities; for example, A3 explained that “I
personally don’t know about any specific modifications for
those kinds of patients [those admitted to the Baycrest
inpatient Behavioural Neurology Unit, many of whom exhibit
hypersensitivity to noise and issues with mood] ‘cause I’m not
[a] psychologist.” They reported feeling that more knowledge
could be helpful, and they were open to learning more in order
to improve how they adapt treatment to accom-modate for all
of their client’s needs; for example, A3 stated, “I need to learn
more about depression, different types of de-pression, maybe I
need to learn that in order to start thinking about that, [and
how it influences] my prescription.”
Interprofessional communication. The audiologists
reported that there is no formal interprofessional commu-
nication protocol. Currently, they are required to add
information to the EHR for inpatients (about 20% of the
audiology caseload) and Baycrest LTC residents (about 30%
of the caseload). For outpatient visits to Baycrest Hearing
Services, there is a record in the EHR that an appointment was
attended in the clinic, but no additional information is
provided routinely about what types of rec-ommendations or
services were provided. In cases where another health care
professional (e.g., a speech-language pathologist) has worked
with the same client and the audi-ologist would like to follow-
up, the usual method for inter-professional communication is
to send an e-mail to the specific clinician. The audiologists
noted that adding infor-mation about their service (i.e., about
the client’s hearing status) to the EHR would take a lot of time,
but they indi-cated that it could be worthwhile to do so; for
example, A3 remarked that “It’s good to have. It’s going to be
extra work, because there’s a lot of patients.”
or not they assess final ability using the COSI. For clients
with cognitive issues, the evaluation of outcomes usually
In addition to information noted in the chart and EHR, a
copy of the HT form, including a description of the test results
and recommendations, is sent to the referring physician for
each client. Typically, this form is sent out 2 to 3 weeks after
the HT, once it has been signed by a Baycrest
otolaryngologist. If the client completes an annual HT,
information about current use of hearing aid(s) may be noted;
however, it is not routine to send follow-up infor-mation about
treatment and outcomes to the referring physician. In addition,
there is no systematic process for communicating information
about a common client’s audiologic rehabilitation process to
nonphysician health care professionals.
Outcomes
The audiologists unanimously felt that modifications to
practice to accommodate for client comorbidities make a
“significant” (A3) and “huge” (A1) difference to treatment
outcomes. Outcomes can be noted in the chart in various
ways.
Quantitative data on treatment outcomes. The COSI is
intended to be used as a quantitative outcome measure. For
each of the self-identified listening goals, the form allows for
collection of an overall improvement score and a final ability
score. The audiologists, however, reported that for most cases,
they do not ask their clients about their final ability. In
particular, for clients with cognitive impairment, it may be
difficult for them to recall or under-stand how to respond to a
question about the percentage of the time they achieve a
listening goal. In addition, given that clients often have many
follow-up appointments and may never be formally
discharged, especially if they are experiencing ongoing
changes in their health, it is difficult to ascertain when it
would be appropriate to gather quanti-tative data on their
“final” ability. The audiologists felt that the “change” section of
the COSI more often yielded useful information, and they
suggested that it is appropri-ate for some clients to use only
this section of the COSI. Even for clients for whom the COSI
is too challenging to administer, the audiologists clarified that
they do ask clients whether they are hearing better in the
specific situ-ations they had identified and less structured
qualitative responses are obtained.
Qualitative data on treatment outcomes. The audiolo-
gists unanimously agreed that they try to obtain qualitative
more than quantitative outcome measures when evaluating the
client’s experience with hearing aids. They ask questions about
how hearing loss affects the client’s quality of life and whether
quality of life has improved with amplification. As stated by
A3, “That’s enough for me as an audiologist to know,
especially if you have a long process with the patient. To me,
having the number 90 or 90% or 85 is not [as important].”
Modifying the evaluation of outcomes because of
comorbidities. The audiologists were asked whether the three
comorbidities queried in their HAE history form affect how
they evaluate outcomes for a client. They responded that
cognitive status has the biggest influence on whether
Dupuis et al.: Comorbidities in Geriatric Audiology 1215
relies on feedback from an SO about the client’s quality of life
and their everyday functioning with the device(s). The
audiologists did not feel that visual impairment necessi-tated
specific modifications to how outcomes are assessed.
Interestingly, the audiologists reported that manual dexter-ity
issues have less of an effect on outcomes now than in the past,
largely because rechargeable hearing instruments have
overcome barriers to successful use of devices. In the words
of A1, “rechargeables have been a lifesaver.”
Discussion
Most of the clients seen for HAE in this geriatric audi-
ology clinic had one or more (84%), or even two or more
(72%), medical comorbidities. The number of comorbidities
increased with age for this sample whose ages spanned
66 to 99 years (M = 86 years). Four audiologists with exten-
sive experience in geriatric audiology described how they
modify their practice to accommodate various comorbidities.
Importantly, outcomes suggest that benefit from hearing aids
and other technologies can be achieved by clients with
comorbidities in the context of comprehensive audiologic
rehabilitation including tailored counseling and ample follow-
up for clients and their SOs. Nevertheless, there could be
potential benefit from richer bidirectional interprofessional
communication in the circle of care for those with hearing
loss.
Frequency of Identification of Comorbidities
The seven comorbidities examined in the current study
were chosen because they have been linked to hearing loss and
could be relevant to hearing care. Vision or manual dex-terity
limitations may affect a client’s ability to handle and operate a
hearing aid. Cognitive declines may reduce the cli-ent’s ability
to recall information such as appointment times or understand
device handling instructions. Depression or other mood
disorders may diminish a client’s motivation to seek or adhere
to rehabilitation. Falls or mobility disability might restrict a
client’s opportunities for communication and social
participation and create barriers to attending appoint-ments
with their audiologist. Conditions such as hypertension treated
with blood thinning medications or diabetes may warrant
caution when a hearing health care practitioner removes
cerumen or takes an earmold impression. In general,
awareness of the interactions between these comorbidities and
hearing loss could enhance patient- and family-centered
rehabilitation. Furthermore, enriched interprofessional com-
munication in the circle of care could strengthen the position
of hearing care within the broader context of healthy aging.
Comparisons to Population Data
As expected based on population data, comorbidities
were highly prevalent, and prevalence increased with age in
our sample. Some comorbidities were identified at a higher
rate than would be estimated based on general population
1216 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
dexterity, and cognitive issues because they recognized that
these comorbidities may have direct relevance to rehabilita-
data: Dexterity disability was noted for 42%, over four times
the estimated 9% (Bizier, Fawcett, et al., 2016); vision loss
was noted for 68%, about four times the estimated 15%–20%
(Bizier, Contreras, et al., 2016; Heine & Browning, 2015);
cognitive loss was noted for 50%, almost twice the estimated
30% (Knopman et al., 2016); and depression was noted for
16%, slightly more than the estimated 15% (Blazer, 2003).
Other comorbidities were noted less than expected: Falls were
noted for 33%, about three quarters as often as the estimated
40% (Rubenstein, 2006); diabetes was noted for 13%, just
over half as often as the estimated 20% (McDonald et al.,
2009); and hypertension was noted for 43%, just over half as
often as the estimated 70% (McDonald et al., 2009).
These discrepancies in prevalence rates between the
sample in our case study and population-based statistics may
be attributable to multiple factors. It is possible that dexterity
disability, vision loss, cognitive loss, and depression are truly
more prevalent in the sample seen for HAE than in the general
population and that falls, diabetes, and hyper-tension are truly
less prevalent. It seems likely, however, that the information
on comorbidities noted by the audiol-ogists and others in the
circle of care was influenced by the apparent relevance of the
comorbidities to their practice; for example, audiologists may
attend more to dexterity, vision, and cognition because they
have recognized the importance of these comorbidities and
routinely gather and use this information for planning hearing
care, whereas they inquire about and/or attend less to
depression and falls, and even less to hypertension and
diabetes, because they consider these comorbidities to have
fewer direct impli-cations for hearing care. In addition,
audiologists may apply criteria for noting comorbidities that
are more specific to hearing care than the criteria used by
epidemiologists; for example, whether or not notes are made
about dexterity or vision issues could depend on the likely
effect of these issues on the ability to handle a hearing aid, and
notes about cognition may depend on concerns about a client’s
ability to understand and remember information during
audiologic rehabilitation. Whereas epidemiological studies
define prevalence using the results of recognized tests or self-
reports, audiologists rely more on clinical experience and
knowledge of individual clients. Over years of provid-ing care,
audiologists may become attuned to comorbidities because
they witness changes to physical and cognitive abilities that
affect their clients’ function and independence in managing
their hearing device care. Furthermore, the crude estimates of
prevalence in the general population we used could be refined
by more carefully examining stratifi-cation by age, gender,
and other factors to more closely match estimates to the
characteristics of our sample. Over-all, these discrepancies
highlight the need to understand more about how the
comorbidities that have been linked to hearing loss in the
general population manifest in clients receiving hearing care.
Strategies for Identifying Comorbidities
The audiologists in the current study had already de-
veloped standardized history questions about visual, manual
tion trajectory and outcomes; however, information about
other comorbidities was noted in marginalia rather than on the
history form. The EHR offers an additional source of
information about comorbidities; however, the audiologists
did not routinely access information about comorbidities or
enter information about hearing care in the EHR. Current
practice guidelines do not specify how audiologists should
gather or share information about comorbidities. Next best
practice would be to develop protocols for gathering infor-
mation about additional comorbidities on the audiology
history form and to establish more effective communication
among health professionals in the circle of care by using the
EHR to exchange information to optimize care for clients who
have hearing loss.
Interprofessional Communication About Comorbidities
Failing to take hearing loss into account may jeopardize
care on the part of other health professionals; for example, it
could lead to miscommunication during the delivery of many
types of health care and result in preventable errors (Bartlett,
Blais, Tamblyn, Clermont, & MacGibbon, 2008). A special
concern in this population is the possible over-estimation of
their level of cognitive decline (e.g., Dupuis et al., 2015;
Guerreiro & Van Gerven, 2017). Given the duration and
frequency of audiology appointments and the multiyear
follow-up provided to clients receiving audiologic
rehabilitation, audiologists may be uniquely positioned (as an
“alert provider”; Souza, 2014) to detect cognitive decline in
their clients (Shen, Anderson, Arehart, & Souza, 2016). In
addition to considering comorbidities during the provi-sion of
hearing health care, the audiologist could assist cli-ents to
seek and benefit from appropriate help from other health
professionals.
Opportunities to reduce barriers and promote earlier
access to hearing care may arise from enhanced communica-
tion with health professionals who treat the comorbidities that
may affect older adults with hearing loss. Hearing loss can
have significant negative effects on everyday functioning and
overall well-being (e.g., Ciorba, Bianchini, Pelucchi, &
Pastore, 2012; Dalton et al., 2003). Thus, consistently captur-
ing information about hearing loss and hearing care will
contribute to a more holistic and comprehensive approach to
caring for older adults (e.g., Bień, 2005) that considers the
reality of addressing multiple complex health conditions
simultaneously (e.g., Boyd & Fortin, 2010). It behooves
audiologists to provide communication so as to ensure that
appropriate information about a client’s hearing loss and
audiologic rehabilitation is available to others in the circle of
care (for example, information about how to optimize
communication for a client with hearing loss, including advice
regarding the use of personal technology and/or group ALDs).
In reflecting on the study, the audiologists indicated that,
although it would require a significant time investment, it
could be worthwhile to provide a more detailed and system-
atic feedback to referral sources and others in the circle of
care.
in the domains of quality of life and physical health (for a
review, see Kamil & Lin, 2015). Engagement and support
For the current sample, the majority of referrals (65%)
were made by family physicians. Even in specialty clinics
such as memory care clinics, older adults are not always
routinely asked about their hearing or referred for hearing care
(e.g., Jorgensen, Palmer, & Fischer, 2014). Physicians may
fail to refer medically complex clients for hearing care because
they are focused on other health issues that they consider to be
more important, or they may simply fail or forget to ask clients
about their hearing or they may believe that the client or
caregiver will not want hearing care. Poten-tial bias against
referring medically complex older adults for audiologic
rehabilitation may help to explain, at least partially, why so
few older individuals who could benefit from hearing aids
purchase them. Having family physicians as a major referral
source introduces a potential opportunity for bidirectional
interprofessional outreach and education. On the one hand,
audiologists have started to work more closely with family
physicians to increase their knowledge regarding treatment
options and to reinforce the importance of hearing care as a
key component of healthy aging, possi-bly even encouraging
referrals for all older clients as part of a holistic health
promotion approach. On the other hand, audiologists could
learn more about relevant comorbidities from other
professionals in the circle of care; for example, referral forms
could query relevant comorbidities. Enhanced bidirectional
communication would represent an extension of the
increasingly popular person-centered care framework, which
takes a client’s needs, abilities, and preferences into account
when planning and delivering audiologic rehabili-tation (e.g.,
Grenness, Hickson, Laplante-Lévesque, & Davidson, 2014;
Singh et al., 2016), by ensuring that all members of a health
care team are cognizant of key infor-mation about the client’s
hearing needs and that hearing care is modified to
accommodate comorbidities.
Modifications to Practice to
Accommodate Comorbidities
The current study demonstrates how clinicians from one
specialized geriatric audiology clinic successfully modi-fied
practice to accommodate comorbid health conditions.
Such modifications to practice influenced routines for his-tory
taking, recommendations of technology options, topics in
counseling, the frequency of follow-up, and the involve-ment
of SOs.
SOs
The audiologists emphasized the importance of involv-
ing SOs in the rehabilitation process, especially for those older
individuals experiencing cognitive loss. A family-centered
approach has become internationally recognized as a key
component of high-quality hearing health care provision for all
age groups, including older adults (Singh et al., 2016). For
older individuals with physical and cogni-tive limitations, it
can be especially important to include family and/or formal
caregivers in the rehabilitation planning. Hearing loss can have
collateral effects on the communication partners of the
individuals experiencing the loss, particularly
Dupuis et al.: Comorbidities in Geriatric Audiology 1217
from the SO can positively influence the older client’s suc-cess
in the rehabilitation process (Öberg, 2015). About half of our
sample received professional caregiving, in the home or in a
formal care facility such as LTC, and another third lived with
an SO. In the review of charts, there were notes about the
benefits of rehabilitation not only for clients but also for
family members and formal caregivers (e.g., “Sitter is very
pleased with improvements. Reports [that] client participates
much more now in conversations and especially in groups
where he never heard before.”; “Wife said he was hearing her
at every visit….”). Benefits realized by the SO and the SO’s
observations of benefits to the client make an important
contribution to the evaluation of rehabilitation outcomes,
particularly when clients are not capable of provid-ing their
own feedback.
Educating Clients
Even when an older adult with hearing loss does seek
audiologic rehabilitation, they may still not pursue treat-ment.
They may perceive hearing loss as simply one more medical
issue that must be dealt with and may delay or refuse
treatment in the face of other more pressing conditions such as
heart disease. Given the rapidly growing literature exploring
connections between hearing loss and comorbidi-ties,
audiologists may be in a unique position to counsel their
clients about the importance of seeking treatment for hearing
loss now and the potential benefits of treating hear-ing loss on
overall health and quality of life.
Influence of Comorbidities on Outcomes
In the current study, despite having one or more comor-
bidities, almost all clients achieved successful rehabilitation
outcomes. Overall, almost all clients (132/135; 98%) were
prescribed hearing aids; almost all (121/132; 92%) who were
prescribed aids purchased them, and almost all (111/121;
92%) retained them. About a third (40/111; 36%) of those who
retained hearing aids also bought an ALD or hearing aid
accessory, especially those with visual or dexterity issues.
About 6% of the sample also attended group rehabilitation.
High rates of success may be attributed to the skill of
the referring physicians and audiologists and/or to the
readiness of the clients and their SOs to take action. Clients
with comorbidities who make the decision to come to an HAE
may be more motivated to take action than others who never
come to an audiology clinic. Individuals may have decided to
seek help because they feel that hearing better is necessary
because of a comorbidity (e.g., those with vision loss) or that
hearing health is part of a broader plan to maintain health and
independence (e.g., those with cognitive loss). In the absence
of information about those with similar comorbidities who
never sought hearing care, it is not possible to determine what
factors underlie the success of the clients we studied. At any
rate, this case study of a clinic does demonstrate that hearing
care can be benefi-cial to those who seek help despite
comorbidities.
1218 Journal of Speech, Language, and Hearing Research • Vol. 62 • 1203–1220 • April 2019
treatment process. This issue was addressed, at least partially,
through the focus groups.
Outcome was evaluated for about half of the clients
using the COSI improvement measure, and the other half were
evaluated qualitatively. The audiologists described their
approach to evaluation as focusing on how the client is
functioning in his or her everyday life based on feedback from
the client and the SO to determine whether the client is
benefiting from treatment. This focus is consistent with an
approach to audiologic care recently described by Grenness et
al. (2014) that emphasizes the need for hearing health care
providers to consider factors beyond the audiogram in an
attempt to provide optimal hearing rehabilitation options.
Importantly, almost all clients were deemed to have achieved
successful outcomes insofar as they became regular users of
their devices and performed better on at least one of their
target goals for rehabilitation. These results demonstrate that
older individuals with various medical comorbidities, even
those in the OO group, are able to benefit from amplifi-cation
if their needs are accommodated within the context of
comprehensive rehabilitation. Thus, it seems that successful
audiologic rehab may not depend on the client’s age or medi-
cal complexity.
Limitations and Future Directions
Generalizability
The frequency of identification of comorbidities in the
current study was based on a sample of 135 clients seen in one
specific geriatric audiology clinic. The current study is a case
study of a clinic, and it is important to note that the results
may not be generalizable to other clinics. It could be that our
findings represent a gold standard for care inso-far as the
clinic is part of an internationally well-known, research-
intensive geriatric health care center and the audi-ologists may
have developed a high level of skill in iden-tifying and
accommodating comorbidities due to their extensive
experience working with this population. Audiolo-gists with
less experience and awareness of comorbidities might
recommend treatments that are less tailored to the needs of
clients, resulting in low adherence rates, or care that is less
effective in addressing the goals and needs of clients and their
family/caregivers who are contending with other health issues.
Comorbidities may influence how an individual uses his or her
devices, engages with his or her hearing health care provider,
sets goals in light of other health priorities, or approaches the
rehabilitation process. Not detecting or accommodating for
relevant comorbidities could compromise patient- and/or
family-centered hearing care. Given the paucity of literature
describing how comor-bidities influence practice in realistic
clinical conditions, it is not possible to compare the current
case study of this one clinic to other studies of geriatric
audiology practice. More case studies of clinics are needed.
Documentation
The data collected in the chart review were retrospec-
tive. As noted by Dullard and Saunders (2014), this method
may not provide a complete account of the assessment and
Given that many of the clients were OO adults, we
expected the selected comorbidities, which are known to be
associated with hearing loss, to have higher prevalence than in
the general older adult population. This was the case for
vision, dexterity, and cognition issues that were routinely
reported on the HAE form, but the rate of identi-fication of the
other comorbidities was less than expected. Because
information about comorbidities may not have been gathered
or recorded in a systematic way as is done in epidemiological
research, some comorbid conditions may have been
underestimated, especially for comorbidities that were not
included on the HAE history form. Large-scale studies should
investigate the prevalence of comorbidities more
systematically across larger groups of older adults seeking
audiologic rehabilitation. This would be facilitated by
standardized documentation to reduce variability in clinical
charting, likely taking advantage of advances in eHealth
documentation processes.
Sharing Information in the Circle of Care
Although sharing of information about hearing loss and
comorbidities in the circle of care was evident, there are clear
opportunities to improve interprofessional commu-nication
that could extend and enrich the circle of care. For hearing
care, it would be useful to develop processes for documenting
clients’ hearing status, recommended treatment options,
uptake of recommendations, and outcomes related to the
functioning of the client and SO(s). Future work by
professional associations or regulators could engage inter-
professional teams to collaboratively develop new best prac-
tices for exchanging information about comorbidities for
shared clients.
Conclusions
Most of the medically complex older adults in the
current case study were able to successfully acquire and use
hearing instruments in the context of comprehensive
audiologic rehabilitation. In particular, the audiologists from
this specialized geriatric clinic successfully modified hearing
aid recommendations and interactions with clients to
accommodate their health conditions using strategies that are
clinically feasible. Guidelines from professional organizations
and regulatory bodies that provide specific recommendations
for accommodating comorbidities in audiologic rehabilitation
could help advance practice with this population. An
interprofessional approach would promote the systematic and
bidirectional sharing of health information within a client’s
circle of care to better serve the needs of each client and
emphasize the key role of hear-ing health in the aging process.
Acknowledgments
This study was funded through a contract from Phonak AG to
Baycrest Health Sciences. We thank Zainab Anjum and Kay
quality of life in older adults. The Gerontologist, 43, 661–668.
https://doi.org/10.1093/geront/43.5.661
Wright-Whyte for their assistance with the chart reviews and data
entry and the Baycrest audiologists, Heather Finkelstein, Akram
Keymanesh, Debbie Ostroff, and Marilyn Reed, for their participa-
tion in the focus groups.
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