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Cudmore V, Henn P, O’Tuathaigh CMP, Smith S. Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1054–1055. doi:10.1001/jamaoto.2017.1248
Recent analyses have highlighted a significant increase in the rate of hearing loss in patients 60 years and older.1 The estimated prevalence of bilateral hearing loss greater than 25 dB is 27% among patients age 60 to 69 years; 55%, 70 to 79 years; and 79%, 80 years and older.1 The prevalence of medical errors is higher among older patients, and they are also among the most dependent users of the health care system.2 Failures in clinical communication are considered to be the leading cause of medical errors.2 Walsh and colleagues3 reported that improved communication between the medical teams and families could have prevented 36% of medical errors. However, the contribution of hearing loss to medical errors among older patients is nascent. While audiometry is an effective method of diagnosis of hearing impairment, not all impaired listeners will have the same speech comprehension, despite having similar pure-tone thresholds and configurations.4 In the present study, qualitative analysis was applied to semistructured interview data collected in 100 older adults 60 years and older. Baseline prevalence was calculated for communication breakdown in hospital and primary care settings among adults reporting hearing loss. We also identified common, discrete aspects of a clinical consultation that older adults with hearing loss may find difficult and which may be contributing toward medical error.
A convenience sample of participants were enrolled from the outpatients department at Cork University Hospital. Informed consent (oral) was obtained, exclusion criteria included cognitive impairment and lack of spoken English. Two authors independently reviewed the responses, coding all comments and developing an initial thematic framework. This study was approved by the Cork Clinical Research Ethics Committee.
Of 100 older adults interviewed, 57 reported some degree of hearing loss, with higher rates of unilateral and bilateral loss reported by adults 80 years or older relative to all other groups (Table 1); 50% of the study population had previously undergone audiometric testing, and 26% used a hearing aid device. Forty-three adults reported having misheard a physician and/or nurse in a primary care or hospital setting, and frequency of reported mishearing did not vary according to age group. When asked to elaborate on context of mishearing in a clinical setting, emergent themes consisted of (in descending order of citation frequency): general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, and use of language (Table 2).
The prevalence of reported hearing loss our sample population is comparable with expected estimates from similar age cohorts. This qualitative analysis confirms that age-related hearing loss has a negative effect on clinical communication across both hospital and primary care clinical settings. A recent report of the National Academies of Sciences, Engineering, and Medicine, acknowledged that hearing aids improve hearing acuity but are limited in their capacity to “...restore normal hearing or fully improve communication abilities especially in noise.”5 The latter point was highlighted in the present study, as well as a recent report6 that demonstrated that both phonemic contrast and contextual factors can contribute to miscommunication in clinical settings in adults with moderate and severe hearing impairment. Otolaryngologists are in a strong position to understand and address the needs of older patients with hearing impairments, recognizing that the circumstances of medical conversations vary widely not only in relation to environmental background noise but also the attendant pain and fear and distress of illness or injury, lack of familiarity with medication names, diagnoses, and the other essential components of medical discourse. Few of these elements are part of routine audiometric assessment. We recommend that content-related and setting-related factors identified as barriers to communication in adults with hearing impairment be incorporated within a patient-centered approach to clinical communication with this patient population.
Corresponding Author: Colm M. P. O’Tuathaigh, BA, PhD, School of Medicine, University College Cork, Brookfield Health Sciences Complex, College Road, Cork T12 AK54, Ireland (firstname.lastname@example.org).
Accepted for Publication: May 21, 2017.
Published Online: August 24, 2017. doi:10.1001/jamaoto.2017.1248
Author Contributions: Dr O'Tuathaigh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cudmore, Henn, O'Tuathaigh.
Obtained funding: O'Tuathaigh.
Administrative, technical, or material support: Cudmore, O'Tuathaigh, Smith.
Study supervision: Cudmore, O'Tuathaigh.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
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