Hearing Screening in the Community : What is the future? Krishan Ramdoo Clinical ENT Research Registrar, Dept of Ear Nose & Throat – Head & Neck Surgery Northwick Park Hospital, London, England Audiology and Hearing Devices 2015

Northwick Park Hospital Audiology and Hearing Devices 2015

One of the largest integrated care trusts in the country, bringing together hospital & community services across Brent, Ealing & Harrow. Established on 1 October 2014, employing more than 8,000 staff & serve a diverse population of approximately 850,000. Our Trust looks after: Central Middlesex Hospital Community services across Brent, Ealing and Harrow, including Clayponds Rehabilitation Hospital, Meadow House Hospice, Denham Unit and Willesden Centre Ealing Hospital Northwick Park Hospital St Mark’s Hospital Audiology and Hearing Devices 2015

Contents Case Study Background Aim Methods and Materials Results Discussion Reducing costs Audiology and Hearing Devices 2015

Case Study 72 year old lady, admitted to hospital with worsening confusion over the last 6 months. Lives in Nursing home, staff have noticed decreased interaction with others Treated for Urinary Tract Infection Audiogram performed– found to have presbycusis Fitted with aid and followed up Marked improvement noticed with interaction between family and staff. Audiology and Hearing Devices 2015

Background : Global problem World Health Organisation: proportion of people aged over 60 is growing faster than any other age group. 360 million persons in the world with disabling hearing loss (5.3% of the world’s population). Of this 360 million, 91 % are adults. The Global Burden of Disease study (WHO 2008) ranked hearing loss as the 8 th most important contributor to years lost through disability Audiology and Hearing Devices 2015

Background: National problem In the UK the government has highlighted that with an ageing population, hearing loss is something that needs to be addressed. UK figures suggest 10.3 million people aged over 65 years. Health economist calculations have published that the Cost per annum for hearing loss and deafness is estimated to be £30billion Related to direct costs and also larger costs of dealing with heath and social impact of hearing loss This has prompted the calls for a National Hearing Screening Program for the over 65s. Audiology and Hearing Devices 2015

Background Throughout the UK the pathway to access ear care services is extremely disjointed and we have had first- hand experience of this in our local clinical environment. Presbycusis is common Linked with social isolation and depression Elderly patients have complex medical and social needs. Hearing loss often overlooked Opportunistic screening advocated by British Geriatric Society Audiology and Hearing Devices 2015

Background 75% of individuals who live in care homes could have a hearing loss. Extrapolate to 2032, 620,000 older people will be living in care homes and of these, almost 500,000 will have hearing loss. 1/3 of older patients with hearing loss have never had a hearing test. Audiology and Hearing Devices 2015

Aim Determine the prevalence of undiagnosed hearing loss in the North London Care Home Environment. Look at the feasibility of portable hearing screening utilising smartphone technology. Establish the need for development of a Community- based hearing loss screening programme. Audiology and Hearing Devices 2015

Which Screening tool? Audiology and Hearing Devices 2015

Bagai A, et al. Does this patient have hearing impairment? JAMA 2006 Question: Do you suffer from hearing loss? Yes No Whisper Test Pass Fail Referred for Pure Tone Audiometry and GHABP No further input Audiology and Hearing Devices 2015

Bagai A, et al. Does this patient have hearing impairment? JAMA 2006 Referred to Audiology if: Answer ‘Yes’ to screening question (71% chance HL over 25dB) Failed whisper test (86% chance HL over 25dB) ‘No’ on screening question + ‘Pass’ on Whisper test: 3% chance of hearing loss over 25dB Audiology and Hearing Devices 2015

Ramdoo K et al. Opportunistic Screening in Elderly inpatients. SAGE 2014 Use of method in Hospital Inpatients on medical / care- of-the-elderly wards, admitted for other medical problems. Results: 33% of patients suffering with undiagnosed hearing loss. Audiology and Hearing Devices 2015

Methods & Materials Hearing screening using Bagai model Agreement with Local Nursing Homes to carry out screening Inclusion criteria: Patients > 65 yrs Residents at Nursing Homes in the North London area Verbal consent to screening Exclusion criteria Active ear disease Lack capacity Audiology and Hearing Devices 2015

Materials and Methods II Whisper test All tests performed by same individual in designated quiet room Whisper at 30dB or 30dB above background Pure Tone Audiometry Performed by a Community Audiologist Outcome measures Prevalence of undiagnosed hearing loss Screen:aid ratio Evaluation of community based screening Audiology and Hearing Devices 2015

Results I 56 patients screened Age years (mean 84.5) Audiology and Hearing Devices 2015

Results II Question: Do you suffer from hearing loss? (56) Yes: 20 (36%)No: 36 (64%) Whisper Test Pass: 6 (11%) Fail: 22 (39%) Referred for Pure Tone Audiometry and GHABP: 42 (75%) No further input Audiology and Hearing Devices 2015 Unsuitable: 8 (14%)

Results III Referred for Pure Tone Audiometry and GHABP: 42 (75%) Suitable for Hearing aid: 26 (62%) Declined: 5 (12%) Unsuitable: 11 (26%)Tested: 26 (62%) Mild: 27%, Moderate:42%, Severe: 31% Reported HL: 12 Failed whisper: 14 Audiology and Hearing Devices 2015

Discussion I 62% suitable for hearing aids Significant unmet need in vulnerable patients 62% referred for hearing aids Screen:Aid ratio = 2:1 Likely to have effect of Quality of Life, communication, social interaction, +/- care needs 2 part hearing screen: Simple, reproducible, effective Audiology and Hearing Devices 2015

Discussion II Limitations: Background noise Audiometry difficult in infirm May also have difficulty with hearing aids Audiology and Hearing Devices 2015

Portable Screening The use of smartphones and tablets in healthcare are rising continually. Their portability and accessibility provide novel solutions to a number of medical problems. Audiology and Hearing Devices 2015

Portable screening – how good is it? A prospective study assessing the feasibility for the use of a tablet application, to perform opportunistic screening for hearing loss in the over 60s, in an outpatient setting. Audiology and Hearing Devices 2015

Methods and Materials 50 participants were recruited over the age of 60, who were visiting our outpatient department for non ear-related complaints Exclusion criteria: Patients with previously diagnosed hearing loss or significant otological history. A hearing test was performed with the “EarTrumpet” iPad app and validated against Pure Tone Audiometry. Otoscopy and whisper test were also carried out. Audiology and Hearing Devices 2015

Results The tablet application correctly diagnosed the presence of moderate to severe hearing loss (>40dB threshold) On average, the application overestimated the hearing loss by 9.5 dB compared to PTA. Audiology and Hearing Devices 2015

Results II Sensitivity of 95% and a specificity of 77% 30% suitable for hearing aids. PORTABLE HEARING SCREENING IS SENSITIVE AND FEASIBLE Audiology and Hearing Devices 2015

Reducing costs Changing our referral pathway will significantly reduce costs Development of new technology to bring services to patients Audiology and Hearing Devices 2015

Current Pathway Audiology and Hearing Devices 2015

Proposed new pathway Audiology and Hearing Devices 2015

Reducing costs Referral costs to Primary care are expensive A full Audiometric examination including follow up is £524 Some patients have simple wax: 64% in the Nursing home had simple wax Ear irrigation is regarded as unsafe as not under direct vision Cost of referral is £128 In our hospital alone we had 266 new patients in one month for audiological assessment. Patient costs. Audiology and Hearing Devices 2015

What’s the solution? Bringing services to the patient, which environment New studies…..benefits patients Having an all in one kit Enables hearing screening Ear examination Intervention (wax removal) if required We have developed a patented kit to provide this. Prototype phase Cheap and disposable Audiology and Hearing Devices 2015

Conclusion High prevalence of undiagnosed hearing loss in elderly residents in the North London Care home environment. High prevalence of hearing loss with opportunistic screening using a portable device There is the need to change pathways and integrate technology in to this. Saving on referral costs and better care for patients. Audiology and Hearing Devices 2015

Questions? Audiology and Hearing Devices 2015

References 1. WHO Ageing figures Population ageing statistics – House of Commons Ageing statistics – February Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin. The Epidemiology of Hearing Loss Study. Am J Epidemiol. 1998;148(9): JAMA Jan 25;295(4): Does this patient have hearing impairment?Bagai A, Thavendiranathan P, Detsky ASBagai A Thavendiranathan PDetsky AS 5. Relationship between sensory hearing loss and depression in elderly people: a literature review. Millán-Calenti JC, Maseda A, Rochette S, García-Monasterio I. Rev Esp Geriatr Gerontol Jan- Feb;46(1):30-5. Millán-Calenti JCMaseda ARochette SGarcía-Monasterio IRev Esp Geriatr Gerontol. 6. NICE guidelines: Dementia Issue date NOV 2006, revised JAN A world of silence: a case for tackling hearing loss in care homes. October 2012, Action for Hearing loss (formerly RNID). 8. Commission on Hearing loss – The real cost of Hearing Loss – September 2014 Adult Deafness 2014