1 563350CNRXXX / Clinical Nursing ResearchLane and Clark research-article2014 Article Assisting Older Persons With Adjusting to Hearing Aids Clinical Nursing Research 2016, Vol. 25(1) The Author(s) 2014 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / cnr.sagepub.com Kari R. Lane, PhD, RN, MOT 1,2 and M. Kathleen Clark, PhD, ARNP 2 Abstract This intervention study tested the feasibility and initial effect of Hearing Aid Reintroduction (HEAR) to assist persons aged 70 to 85 years adjust to hearing aids. Following this 30-day intervention, hearing aid use increased between 1 and 8 hr per day with 50% of participants able to wear them for at least 4 hr. Hearing aid satisfaction improved from not satisfied to satisfied overall. The study demonstrated that HEAR is feasible and could improve hearing aid use of a substantial number of older persons who had previously failed to adjust to their hearing aids and had given up. However, further testing among a larger and more diverse population is needed to better understand the effectiveness and sustainability of the intervention. Keywords hearing loss, presbycusis, hearing aid adjustment Hearing loss is the third most common chronic illness in older persons today, topped only by hypertension and arthritis (Hannula, 2011). Although hearing aids are the most effective treatment for hearing loss, many individuals who buy hearing aids cannot adjust to wearing them. Untreated hearing loss can 1 University of Missouri, Columbia, USA 2 University of Iowa College of Nursing, Iowa City, USA Corresponding Author: Kari R. Lane, S311 Sinclair College of Nursing, University of Missouri, Columbia, MO 65211, USA.
2 Lane and Clark 31 affect a person s health and safety, as well as interactions with family, community, and healthcare providers. Nurses are in a unique position to facilitate the adjustment to hearing aids, as nurses interact with older persons on a regular basis through multiple settings. Description of the Problem Approximately 38% of individuals between the ages of 65 and 75 currently experience hearing loss, and that number rises to 54% as people age past their 75th year (Oyler, 2012). Hearing aids are the most common treatment for hearing loss; however, 48.3% of elders who purchase hearing aids fail to adjust to them enough to wear them daily (Kochkin, 2010). Many researchers have found that hearing loss is associated with adverse psychosocial effects, including decreased quality of life and well-being, increased depression, delirium, dementia, social isolation, poorer physical functioning, and self-sufficiency (Gopinath et al., 2012; Lin et al., 2011; Schneider et al., 2010; Solheim, Kvaerner, & Falkenberg, 2011). Hearing impairment can restrict an individual s sense of safety contributing to a fear of being home alone, fear of social isolation, and fear of nursing home placement (Bance, 2007; Baumbusch & Shaw, 2011; Kochkin, 2005). The most common complaint, reported by those who failed to adjust to their hearing aids, was hearing aid induced sensory overload. Sensory overload is the discomfort with, and difficulty adjusting to, ambient noise (Kochkin, 2005). Ambient noise consists of extraneous sounds such as fans, furnaces, air conditioners, electronic appliances, wind noise, or other sounds in the environment, in addition to sounds of persons conversing in the background. Persons with a hearing loss have not heard these normal ambient noises for some time, perhaps for years, and this noise can be painful, irritating, and difficult to ignore (Helvik, Wennberg, Jacobsen, & Hallberg, 2008; Perez & Edmonds, 2012). While the amplification of ambient noise persists, it is possible that hearing aid adjustment can minimize the perception of these sounds, making the perception of ambient noises less noticeable, speech sounds more understandable, and hearing aid use more comfortable. Hearing aids are the most common treatment for hearing loss in older persons. Strong evidence exists that hearing aids improve the quality of life of those individuals who use them. However, adjustment to hearing aids can be difficult. In 2005, it was estimated that more than 325,000 hearing aids, less than 4 years old, sat in patient s dresser drawers, not used (Kochkin, 2005). Nurses can play a valuable role in both promoting hearing healthcare and hearing aid adjustment. Nurses develop relationships with clients in many healthcare settings, including primary care, home health care, and
3 32 Clinical Nursing Research 25(1) residential settings. Nurses, nurse practitioners, and nurse care managers who assist older adults in adjusting to hearing aids may be seen as positive listeners, encouragers, and communicators of healthcare needs (Matthias et al., 2010). In addition, active participation of the patient in the process in collaboration with audiology and nursing should strengthen adherence and uptake of hearing aids (Laplante-Levesque, Hickson, & Worrall, 2010). Current Strategies Used to Assist in Adjustment to Hearing Aids Audiologists and hearing aid dispensers typically use one of two strategies to assist in education and training of individuals adjusting to hearing aids: (a) wearing the hearing aids all day from Day 1 (Total Immersion) or (b) gradual self-paced adjustment. Total Immersion Approach This method requires new users to wear the hearing aids for 8 to 12 hr a day and not remove them unless sleeping or performing an activity where they may get wet (Dancer, 2009). Although commonly used, there is no empirical evidence to support this method. One suggested strength of the total immersion approach is that daily exposure of the auditory system to all sound frequencies may assist the brain in learning to hear better again. This is termed acclimatization. If this were true, it would work by increasing the transmission of sound to the brain. However, whether the brain can be retrained in this manner is controversial (Welsh Assembly Government, 2010). This approach poses problems for those who cannot tolerate the auditory or physical discomfort having the hearing aids in their ears for this extended time frame, and may lead to premature, unnecessary rejection of the devices. Gradual Adjustment A gradual adjustment approach entails slowly increasing the time the hearing aid is worn. However, the pace of the incremental increase in hearing aid use has not been clearly identified or tested. Most authors, who support a gradual approach, suggest an individualized self-paced gradual method, generally recommending that the patients wear their hearing aid as much as possible the first day, gradually increasing the wear time until a full day of wear time is achieved (Laplante-Levesque et al., 2010; Valente et al., 2008). Laplante- Levesque et al. (2010) indicated that older adults can gradually adapt to hearing aids and minimize the extent of its impact to themselves and others.
4 Lane and Clark 33 From a physiological standpoint, a gradual exposure to hearing aid use allows the individual to adjust to the physical presence of the device and to minimize the discomfort related to sensory overload (Dillon, 2012). However, the gradual approaches described in the literature have not been tested and are problematic. Failing to provide specific incremental use guidelines could lead increasing hearing aid use too rapidly causing sensory overload, or conversely, failure to progress. Adjustment to hearing aids may be complicated by the age of the typical hearing aid user. Therefore, it is important to consider the learning needs of older individuals when developing a hearing aid adjustment intervention. This is not addressed in typical graduated approaches. Hearing Aid Reintroduction (HEAR) Intervention The HEAR intervention is a systematic gradual method to support adjustment to hearing aids designed by one of the authors (K.R.L.; Lane, 2012). HEAR addresses the major barrier to hearing aid adjustment, the physiological discomfort accompanying sensory overload, and uses Critical Education Gerogogy (CEG) principles to address the learning and counseling needs that accompany advancing age (Findsen & Formosa, 2011; Formosa, 2011; Luppi, 2009). Briefly, the fundamental principles of CEG include pacing learning activities so not to overwhelm the participant, repeating critical information frequently, providing positive reinforcement, using terminology consistent with the participant s reading level, individualizing instruction, providing a clear structure to the learning of the material, ensuring that lessons are at a length within the participant s optimal concentration time frame, and providing hands-on learning (Findsen & Formosa, 2011; Formosa, 2011; Luppi, 2009). Specific components of the intervention are matched with the CEG model in Table 1. With the HEAR intervention, the duration of hearing aid usage increased slowly from 1 hr on Day 1 to 10 hours on Day 30. In addition, sound complexity is increased from listening to the sounds in your own home such as electrical appliances running, furnaces, fans, and so forth, to listening in loud, crowded areas. The intervention was specifically designed to be completed within 30 days as most states have laws mandating a 30-day (minimum) trial period for hearing aids ( Buying a Hearing Aid, 2010). The intervention is supported through the use of a workbook developed by the author (K.R.L.). Briefly, the workbook provides detailed daily hearing aid use instructions specifying the length of time the hearing aids are to be worn and the type of sound environment the hearing aids are to be worn in. It provides daily guidance, helpful tips, encouragement, and includes daily journaling pages to allow the elder to record their progress and concerns. The workbook was set up and structured using a simple framework with large font.
5 Table 1. HEAR Intervention Mapped to Critical Educational Gerogogy Model. CEG category Physiological comfort Pacing information Repeating vital information Positive reinforcement Appropriate terminology Individualized Intervention strategy Gradual increase in wear time allows for adjustment to ear mold itself, but also to the amplification of sound. Time increase only every 3 days. Information is clarified and repeated for emphasis in workbook. Face-to-face meetings review important concepts from the previous week. Encouragement provided at each face-toface meeting. Encouraging messages are included on individual workbook page. Workbook and faceto-face interactions presented at eighthgrade reading levels. Alternative practice scenarios are presented in workbook to allow for individual differences. Future applications may be more individualized to each patient. Note. HEAR = Hearing Aid Reintroduction. Clear structure Each day in workbook is specifically structured to provide clear guidelines. Appropriate time frame Keep faceto-face meetings short. Gradual increase in time allows for adjustment to sensory input. Hands-on learning Weekly face-to-face meetings allow practice on difficult concepts Practice scenarios presented for practice each day Physical environment Manipulate to suit needs Decrease distractions Decrease background noise Choose seating to promote hearing 34
6 Lane and Clark 35 The intervention also included weekly visits with a registered nurse. The registered nurse provided additional support, answered questions, and/or adjusted the plan according to each participant s individual needs, and collected information regarding the hearing aid user s progress and experiences. HEAR has several strengths: (a) It adjusts for the patient s individual physiological and psychological experience; (b) it allows the person to have more control over the process by offering alternatives and suggestions for continued use; (c) it manages expectations by promoting the concept that wearing hearing aids is not as easy as putting on a pair of eyeglasses; (d) it allows for time to reinforce concepts, provide feedback, support, and encouragement to the patient over several weeks and to make adjustments to the hearing aids as necessary; and (e) continued exposure to new sounds and experiences will promote eventual adjustment to hearing aids. Finally, the incorporation of Critical Educational Gerogogy principles enhances the ability of older persons to learn (Formosa, 2011; Glendenning & Battersby, 1990). The purpose of this study was to test the effect of the HEAR intervention on duration of daily hearing aid use and satisfaction with hearing aids among older persons who have previously experienced a failure to adjust to hearing aids. The research AIMS were (a) to describe the feasibility of a prototype hearing aid adjustment intervention among older persons who have previously experienced a failure to adjust to hearing aids and (b) to estimate the effect of the intervention on duration of daily hearing aid use and satisfaction with hearing aids among older persons who have previously experienced a failure to adjust to hearing aids. The long-term goal of this research is to develop a hearing aid adjustment protocol that can be used in collaboration with audiology by nurses in many settings to improve hearing ability and quality of life for elders. Method Study Design A single-group pretest posttest design was used to determine the effect of our prototype systematic graduated HEAR Intervention on duration and satisfaction with hearing aid use in 15 men and women aged 70 to 85 residing in Eastern Iowa. The study was approved by the University Institutional Board Review Committee, and all participants gave informed consent prior to being screened. Inclusion and exclusion criteria. In addition to age (70-85 years), to be included in the study individuals had to own functioning hearing aid(s) and be willing to try to adjust to the hearing aids again. Participants were excluded if they (a) exhibited a cognitive deficit as defined by a score of less than or equal
7 36 Clinical Nursing Research 25(1) to 4 by the Six-Item Screener (SIS; Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002), (b) lacked the fine motor skills to manipulate the hearing aids, or (c) were unable to speak or read English. Sample Recruitment took place at multiple local community organizations in Eastern Iowa. Recruitment was completed by the primary investigator of this study, who was not affiliated with the organizations in any way. A short 5-min presentation regarding the research study was presented to each group. Attendees were given 3 5 cards with a box to check indicating whether they wished to participate or not. All attendees were instructed to place their postcard in the box at the door regardless of their desire to participate. This method was used to limit potential peer pressure to participate. In addition, attendees were asked to notify any other persons in their acquaintance of the study. A total of 32 individuals were screened. Of these 32 individuals, 7 (11%) did not meet the inclusion criteria, due to lack of dexterity (n = 2, 28%), improperly functioning hearing aids (n = 3, 42.8%), or a score of 4 on the SIS (n = 2, 28%), indicating cognitive decline. Of the remaining 25 people, 10 (31%) declined participation due to time constraints (n = 2, 6.2%), lack of interest (n = 1, 3.1%), or failing health (n = 7, 21%). All 15 recruited participants completed the entire 30 days of the study. Instruments Demographic and hearing aid data were collected via a self-report questionnaire. This included the basic demographic characteristics of age, race, gender, education, marital status, and income, as well as the age, make, model, battery size, and type of the participant s hearing aid. In addition, questions were asked pertaining to the type of provider they sought care from (an audiologist or a hearing aid dispenser), the number of hearing aids, and instructions they were given at the time of receiving their hearing aids. The duration of hearing aid use was measured by the self-reported number of hours the hearing aids were worn and was recorded daily, for 30 days, in the participant s intervention workbook. Participants wrote down the total number of hours the hearing aids were worn at the time they removed their hearing aids. If they took their hearing aids in and out multiple times during the day participants were asked to record each start/stop time. The primary investigator then added up all total hours and minutes of hearing aid wear time. Satisfaction with hearing aids was measured using one item, from the Glasgow Hearing Aid Benefit Profile (GHABP). The GHABP was derived as
8 Lane and Clark 37 a follow-up and/or outcome measure for routine audiological service. In its entirety, the GHABP measures the domains of disability, handicap, hearing aid benefit, and satisfaction with hearing aids. Each domain is specific to the patients individual listening environments. The patient is able to identify up to eight listening situations in which they would like to hear better. For each specific listening situation, the individual rates the amount of difficulty, level of annoyance, proportion of time the hearing aid is worn, the amount of help the hearing aid provides, the level of difficulty the individual experiences, and the degree of satisfaction with the hearing aid. The satisfaction question from the GHABP was how satisfied are you with your hearing aids? Response choices were 0 not applicable, 1 not satisfied at all, 2 a little satisfied, 3 reasonably satisfied, 4 very satisfied, and 5 delighted with aid. This question was given in response to each of the eight listening situations the individuals identified (Gatehouse, 1998, 1999). The GHABP has been extensively tested for validity and reliability through a variety of means (Gatehouse, 1999). The criterion validity, responsiveness to change, test retest reliability, and internal reliability were examined. The internal reliability was deemed to be >.7 on all questions. The GHABP was reexamined with this group 3 weeks after the original data collection point, and a test retest reliability result of.86 was found. The validity and reliability of the GHABP were tested on participants of similar backgrounds, ages, and hearing difficulties as this study (Gatehouse, 1999). Permission to use the GHABP was granted by the Medical Research Council (MRC) Institute of Hearing Research Nottingham University Section (MRC, 2013). Treatment Fidelity In keeping with strategies for insuring fidelity described by Resnick et al. (2005), a fidelity plan was developed a priori to ensure treatment consistency in implementation of the HEAR intervention, which included four strategies. First, the workbook and the protocol for the face-to-face meeting with the nurse were standardized. Second, a sole intervener implemented the intervention with oversight from senior-level research faculty. Third, all data pages were reviewed for missing data and completeness at each weekly meeting. Finally, the intervener reviewed reenactments from participants of previous skills learned at each standardized face-to-face meeting. Data Analysis All data entry was completed by two different research assistants and then verified for accuracy. Participant s demographic characteristics and hearing
9 38 Clinical Nursing Research 25(1) aid history were described using means, for normally distributed variables, and medians and proportions for non-normally distributed or categorical variables. Differences in the pretest/posttest scores on the duration of hearing aid use and hearing aid satisfaction were described using means and medians and statistically tested using Wilcoxon signed-rank test, as the data did not meet assumptions for parametric tests. Consistent with the literature, successful use of hearing aids was then defined as wearing hearing aids for 4 or more hours per day (Kochkin, 2010). The previous analysis was repeated descriptively comparing the differences in hearing aid use time and satisfaction between successful versus non-successful users. The analysis was completed using SAS 9.8 statistical software. Results This study sample included 15 community dwelling persons, 11 (73%) female, 4 (27%) male, aged 70 to 85 years, with a mean age of 78 years. All participants were Caucasian, with the exception of one participant, who was African American and most had graduated from college (73.3%, n = 11). No participants withdrew from the study once it began. Most people (86.7%, n = 13) paid for their hearing aids without third-party assistance, for example, out of pocket. One participant had hearing aid third-party coverage from Veteran s Administration, and one participant had Medicaid coverage. Instructions given to each participant by the audiologist on how to wear the hearing aids differed. Five main categories of instructions were noted: (a) gradually increase the time wearing the hearing aids (26.7%, n = 4); (b) wear the hearing aids all of the time (20%, n = 3); (c) wear the hearing aids as much as you can, keep practicing (6.7%, n = 1); (d) no specific directions were given (13.3%, n = 2); and (e) participants did not recall the directions provided (33.3%, n = 5; Table 2). Change in Hearing Aid Use Figure 1 provides a visual depiction of the median hours of hearing aid use by day of intervention. Overall, participants increased their hearing aid use gradually over the course of the 4-week intervention from no use (0 hr) at pretest to a median hearing aid use time of 4.7 hr (range = 1-9), p =.0001 at posttest (Figure 1). Participants were classified as successful if they were able to wear their hearing aids at least 4 hr each day. Just more than half of the participants (n = 8, 53%) increased their hearing aid use by 4 or more hours and were successful users, whereas the remaining 46.7% of subjects (n = 7) reported an increase of 1 to 3 hr (indicating unsuccessful hearing aid use). In the successful
10 Lane and Clark 39 Table 2. Demographic and Hearing Aid Characteristics of Study Participants (N = 15). Characteristics Age Gender Male 4 Female 11 Educational level High school graduate 4 College graduate 11 Race Caucasian 14 African American 1 Age at the time of diagnosis Instruction from audiologist Gradual 5 All of the time 3 No directions provided 2 Do not recall 5 n hearing aid use group, median hearing aid use increased by 4.5 hr as compared with the median increase of 0.75 hr for those who were not successful. Satisfaction With Hearing Aids At baseline, all participants rated their satisfaction with their hearing aids as 1, indicating that they were not satisfied at all. Following the intervention, the median satisfaction score increased significantly to 2 (a little satisfied) with a range of 1 to 4 hr. (p =.0037). However, 40% (n = 6) still reported that they were not satisfied at all in the posttest, whereas 60% (n = 7) as reasonably satisfied or very satisfied. Not surprisingly, there was a greater increase in the overall satisfaction with hearing aids in the successful versus unsuccessful users. At pretest, 85% of those who were unsuccessful users still reported that they were not satisfied with 15% reporting that they were a little
11 40 Clinical Nursing Research 25(1) 9 8 Hours of Hearing Aid Use AllPar cipants Unsuccessful Successful Day of Intervention Figure 1. Median progression of hearing aid use for all participants (N = 15). satisfied. In contrast, 87.5% of those who were successful at posttest reported being reasonably satisfied or very satisfied. Discussion This research provides evidence that a systematic gradual approach to hearing aid adjustment that incorporates Critical Educational Gerogogy learning principles may be effective in increasing both the duration of hearing aid use and satisfaction with hearing aids among older persons who had previously failed to adjust. This is encouraging as approximately half of those who purchase hearing aids are unable to use them and suggests that our intervention could improve the communication ability of a substantial number of older persons who had previously failed to adjust to their hearing aids and had given up. We found very little published literature evaluating the effects of any intervention to facilitate hearing aid adjustment and no published literature specifically targeting older persons who owned hearing aids but previously failed to adapt. Our study, therefore, provides preliminary data that can be of use in developing evidence-based interventions directed toward improving
12 Lane and Clark 41 hearing aid adjustment. Further studies are needed to determine the sustainability of the intervention over time. Our observation that half of the participants did not successfully adjust to their hearing aids as defined by hearing aid use of at least 4 hr per day and remained largely unsatisfied with their hearing aid use is somewhat troubling and not explained by our current data. This group may differ in their physiological response, or specific personal demographic characteristics, social circumstances, or attitudes toward hearing aid use that could be used to tailor interventions to this group. For example, some individuals find that they begin to withdraw from social situations and no longer perceive a need to wear the aids. In addition, literature has shown that the longer the time frame is between the onset of hearing loss and initiation of hearing aid use, the more difficult adjustment becomes (Helvik et al., 2008). Future studies need to have a large and diverse population that will allow more detailed assessment of predictors of successful use that will assist us in identifying modifiable factors that predict successful hearing aid use. Limitations While this study provides some evidence supporting the effectiveness of a systematic gradual hearing aid intervention, it is limited by its small, non-random sample and lack of control group. We chose a single-group pretest posttest design for two reasons. First, as all of the participants had previously failed to adjust to hearing aids, they, in essence, served as their own controls, and second, consistent with Phase I trials, it is important first to determine the safety and efficacy of an intervention on a small sample of participants group before going to the expense and participant burden of including a control group. We recognize that the attention provided through the daily workbook and weekly meetings with the one RN could influence change regardless of the nature of the intervention. The fact that almost one half of the participants remained unsuccessful and unsatisfied with their hearing aids speaks against that influence. Nevertheless, studies providing equal attention control groups are needed to fully address attention in this intervention. The sample size was small but in keeping with recommendations for Phase I clinical trials. Our sample also lacked diversity with respect to race/ethnicity and education level. This could have important ramifications for the composition of the workbook. Conclusion Our study demonstrates that a 30-day systematic gradual approach to hearing aid adjustment appears to be beneficial in persons who own hearing aids but
13 42 Clinical Nursing Research 25(1) failed to adjust to them. This intervention could be important in improving communications in the 48% of people who purchase hearing aids, but never use them. Further research, using randomized controlled trials including a diverse sample, is needed to confirm the HEAR intervention s effectiveness. In addition, further exploration of factors that identify persistent unsuccessful users will be helpful to understand how to revise intervention to reach those people who did not respond to the HEAR intervention. Acknowledgment The authors would like to acknowledge the John A. Hartford Foundation Archbold Scholars and the Morris Seed Grant at the University of Iowa for their funding support of this project. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Bance, M. (2007). Hearing and aging. Canadian Medical Association Journal, 176, doi: /cmaj Baumbusch, J., & Shaw, M. (2011). Geriatric emergency nurses: Addressing the needs of an aging population. Journal of Emergency Nursing, 37, doi: /j.jen Buying a hearing aid. (2010). Retrieved from articles/0168-buying-hearing-aid Callahan, C. M., Unverzagt, F. W., Hui, S. L., Perkins, A. J., & Hendrie, H. C. (2002). Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care, 40, Dancer, J. (2009). Hearing aids the first 30 days. Sedona, AR: Auricle Ink Publishers. Dillon, H. (2012). Hearing aids (Vol. 2). New York, NY: Thieme. Findsen, B., & Formosa, M. (2011). Rationales for older adult learning. Lifelong Learning in Later Life, 7, doi: / _8 Formosa, M. (2011). Universities of the third age: A rationale for transformative education in later life. Journal of Transformative Education, 8, doi: / Gatehouse, S. (1998). Administration manual for the Glasgow Hearing Aid Benefit Profile. Available from
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15 44 Clinical Nursing Research 25(1) Schneider, J., Gopinath, B., Karpa, M. J., McMahon, C. M., Rochtchina, E., Leeder, S. R., & Mitchell, P. (2010). Hearing loss impacts on the use of community and informal supports. Age and Ageing, 39, doi: /ageing/afq051 Solheim, J., Kvaerner, K. J., & Falkenberg, E. S. (2011). Daily life consequences of hearing loss in the elderly. Disability and Rehabilitation, 33, doi: / Valente, M., Abrams, H., Benson, D., Chisolm, T., Citron, D., Hampton, D.,... Sweetow, R. (2008). Guidelines for the audiologic management of adult hearing impairment. Retrieved from compendium/guidelines/guidelines-for-the-audiologic-management-of-adult- Hearing-Impairment.htm Welsh Assembly Government. (2010). How to use your hearing aid. Cathays Park, Cardiff: Major Conditions and Clinical Support Branch, Welsh Assembly Government. Author Biographies Kari R. Lane, PhD, RN, MOT, is an assistant professor at University of Missouri. She received her doctorate from the University of Iowa. Her current research interests involve improving communication in elderly populations with hearing loss. M. Kathleen Clark, PhD, ARNP, is a Professor at University of Iowa College of Nursing with research interests related to behavioral, biologic, and hormonal determinants of bone density and body composition and patterns of change in weight, fat mass, lean mass, and fat distribution among young adult women.