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07.10.2015
The Joint Committee on Infant Hearing (JCIH) endorses early detection of and intervention for infants with hearing loss. For infants who do not pass automated ABR in the NICU, referral should be made directly to an audiologist for rescreening and, when indicated, comprehensive evaluation including ABR. For rescreening, a complete screening on both ears is recommended, even if only one ear failed the initial screening.
Audiologists with skills and expertise in evaluating newborn and young infants with hearing loss should provide audiology diagnostic and auditory habilitation services (selection and fitting of amplification device).
At least one ABR test is recommended as part of a complete audiology diagnostic evaluation for children younger than 3 years for confirmation of permanent hearing loss. The timing and number of hearing re-evaluations for children with risk factors should be customized and individualized depending on the relative likelihood of a subsequent delayed-onset hearing loss. For families who elect amplification, infants in whom permanent hearing loss is diagnosed should be fitted with an amplification device within 1 month of diagnosis.
For infants with confirmed hearing loss, a genetics consultation should be offered to their families.
Every infant with confirmed hearing loss should be evaluated by an otolaryngologist with knowledge of pediatric hearing loss and have at least one examination to assess visual acuity by an ophthalmologist experienced in evaluating infants. The risk factors for congenital and acquired hearing loss have been combined in a single list, rather than grouped by time of onset.
All families of infants with any degree of bilateral or unilateral permanent hearing loss should be considered eligible for early intervention services.
There should be recognized central referral points of entry that ensure specialty services for infants with confirmed hearing loss. Early intervention services for infants with confirmed hearing loss should be provided by professionals with expertise in hearing loss, including educators of the deaf, speech-language pathologists, and audiologists. In response to a previous emphasis on “natural environments,” the committee recommends that both home-based and center-based intervention options should be offered. For all infants, regular surveillance of developmental milestones, auditory skills, parental concerns, and middle ear status should be performed in the medical home, consistent with the AAP pediatric periodicity schedule.
Infants who do not pass the speech-language portion of a medical home global screening or for whom there is a concern regarding hearing or language should be referred for speech-language evaluation and audiology assessment. The birth hospital, in collaboration with the state EHDI coordinator, should ensure that the hearing screening results are conveyed to the parents and the medical home. Parents should be provided with appropriate follow-up and resource information, and hospitals should ensure that each infant is linked to a medical home. Information at all stages of the EHDI process is to be communicated to the family in a culturally sensitive and understandable format. Individual hearing screening information and audiology diagnostic and habilitation information should be promptly transmitted to the medical home and the state EHDI coordinator. Families should be made aware of all communication options and available hearing technologies (presented in an unbiased manner). States should implement data-management and tracking systems as part of an integrated child health information system to monitor the quality of EHDI services and provide recommendations for improving systems of care. An effective link between health and education professionals is needed to ensure successful transition and to determine outcomes of children with hearing loss for planning and establishing public health policy.
It has long been recognized that unidentified hearing loss at birth can adversely affect speech and language development as well as academic achievement and social-emotional development. EHDI programs throughout the nation have demonstrated not only the feasibility of universal newborn hearing screening (UNHS) but also the benefits of early identification and intervention. State EHDI coordinators report system-wide problems, including failure to communicate information to families in a culturally sensitive and understandable format at all stages of the EHDI process, lack of integrated state data-management and tracking systems, and a shortage of facilities and personnel with the experience and expertise needed to provide follow-up for infants referred from newborn screening programs (White, 2003). All children with hearing loss should have access to resources necessary to reach their maximum potential.
All infants should have access to hearing screening using a physiologic measure no later than 1 month of age. All infants who do not pass the initial hearing screening and the subsequent rescreening should have appropriate audiologic and medical evaluations to confirm the presence of hearing loss no later than 3 months of age. All infants with confirmed permanent hearing loss should receive early intervention services as soon as possible after diagnosis but no later than 6 months of age.
The EHDI system should be family centered with infant and family rights and privacy guaranteed through informed choice, shared decision making, and parental consent in accordance with state and federal guidelines. The child and family should have immediate access to high-quality technology, including hearing aids, cochlear implants, and other assistive devices when appropriate.
All infants and children should be monitored for hearing loss in the medical home (AAP Task Force, 2003).
Appropriate interdisciplinary intervention programs for infants with hearing loss and their families should be provided by professionals knowledgeable about childhood hearing loss. Information systems should be designed and implemented to interface with electronic health records and should be used to measure outcomes and report the effectiveness of EHDI services at the patient, practice, community, state, and federal levels. The 2007 guidelines were developed to update the 2000 JCIH position statement principles and to support the goals of universal access to hearing screening, evaluation, and intervention for newborn and young infants embodied in Healthy People 2010 (U.S. The JCIH, however, is committed to the goal of identifying all degrees and types of hearing loss in childhood and recognizes the developmental consequences of even mild degrees of permanent hearing loss.
All infants, regardless of newborn hearing screening outcome, should receive ongoing monitoring for development of age-appropriate auditory behaviors and communication skills. The success of EHDI programs depends on families working in partnership with professionals as a well-coordinated team. The most important role for the family of an infant who is deaf or hard of hearing is to love, nurture, and communicate with the baby. Pediatricians, family physicians, and other allied health care professionals, working in partnership with parents and other professionals such as audiologists, therapists, and educators, constitute the infant's medical home (AAP Medical Home Initiatives, 2002).
An audiologist is a person who, by virtue of academic degree, clinical training, and license to practice, is qualified to provide services related to the prevention of hearing loss and the audiologic diagnosis, identification, assessment, and nonmedical and nonsurgical treatment of persons with impairment of auditory and vestibular function, and to the prevention of impairments associated with them. Early intervention professionals are trained in a variety of academic disciplines, such as speech-language pathology, audiology, education of children who are deaf or hard of hearing, service coordination, or early childhood special education.
The care coordinator is an integral member of the EHDI team who facilitates the family's transition from screening to evaluation to early intervention (AAP Committee, 2005). The deaf and hard-of-hearing community includes members with direct experience with signed language, spoken language, hearing aid and cochlear implant use, and other communication strategies and technologies. Multidisciplinary teams of professionals, including audiologists, physicians, and nursing personnel, are needed to establish the UNHS component of EHDI programs.
Each team of professionals responsible for the hospital-based UNHS program should review the hospital infrastructure in relationship to the screening program.
Some infants who pass newborn hearing screening will later demonstrate permanent hearing loss (J. The JCIH recognizes that there are important issues differentiating screening performed in the well-baby nursery from that performed in the NICU. Many inpatient well-baby screening protocols provide one hearing screening and, when necessary, a repeat screening no later than the time of discharge from the hospital, using the same technology both times. A NICU is defined as a facility in which a neonatologist provides primary care for the infant. A total of 120 level-II NICUs and 760 level-III NICUs have been identified in the United States by survey, and infants who have spent time in the NICU represent 10% to 15% of the newborn population (Stark & AAP, 2004).
Screening results should be conveyed immediately to families so they understand the outcome and the importance of follow-up when indicated. Communications with parents are confidential and presented in a caring and sensitive manner, preferably face-to-face. Educational materials are developed and disseminated to families that provide accurate information at an appropriate reading level and in a language they are able to comprehend. Parents are informed in a culturally sensitive and understandable manner that their infant did not pass screening and informed about the importance of prompt follow-up. Medical professionals receive the results of the screening test (pass, did not pass, or missed) as documented in the hospital medical record. Medical professionals receive communication directly from the hospital screening program regarding each infant in their care who did not pass or is missed and recommendations for follow-up.
Many well-baby screening protocols will choose to incorporate an outpatient rescreening within 1 month of hospital discharge to minimize the number of infants referred for follow-up audiologic and medical evaluation. Outpatient screening no later than 1 month of age should also be available to infants who were discharged before receiving the birth admission screening or who were born outside a hospital or birthing center. Home births and other out-of-hospital births: States should develop a mechanism to systematically offer newborn hearing screening for all out-of-hospital births. Across state border births: States should develop written collaborative agreements among neighboring states for sharing hearing screening results and follow-up information.
Hospital missed screenings: When infants are discharged before the hearing screening is performed, a mechanism should be in place for the hospital to contact the family and arrange for an outpatient hearing screening. Transfers to in-state or out-of-state hospitals: Discharge and transfer forms should contain the information of whether a hearing screening was performed and the results of any screening.
Additional mechanisms for states to share hearing screening results and other medical information include (a) incorporating the hearing screening results in a statewide child health information system and (b) providing combined metabolic screening and hearing screening results to the primary care physician.
Infants who meet the defined criteria for referral should receive follow-up audiologic and medical evaluations with fitting of amplification devices, as appropriate, no later than 3 months of age. Comprehensive audiologic evaluation of newborn and young infants who fail newborn hearing screening should be performed by audiologists experienced in pediatric hearing assessment. For infants from birth to a developmental age of approximately 6 months, the test battery should include a child and family history, an evaluation of risk factors for congenital hearing loss, and a parental report of the infant's responses to sound. A frequency-specific assessment of the ABR using air-conducted tone bursts and bone-conducted tone bursts when indicated.
Clinician observation of the infant's auditory behavior as a cross-check, in conjunction with electrophysiologic measures. Behavioral audiometry (either visual reinforcement or conditioned-play audiometry, depending on the child's developmental level), including pure-tone audiometry across the frequency range for each ear and speech detection and recognition measures. ABR, if responses to behavioral audiometry are not reliable or if ABR has not been performed in the past. At this time, there is insufficient evidence for use of the auditory steady state response as the sole measure of auditory status in newborn and infant populations (Stapells, Gravel, & Martin, 1995). Similarly, there are insufficient data for routine use of acoustic middle ear muscle reflexes in the initial diagnostic assessment of infants younger than 4 months (Keefe, Gorga, Neely, Zhao, & Vohr, 2003). The infant's pediatrician or other primary health care professional is responsible for monitoring the general health, development, and well-being of the infant.
The pediatrician or primary care physician should review every infant's medical and family history for the presence of risk indicators that require monitoring for delayed-onset or progressive hearing loss and should ensure that an audiologic evaluation is completed for children at risk of hearing loss at least once by 24 to 30 months of age, regardless of their newborn screening results (J. Children with cochlear implants may be at increased risk of acquiring bacterial meningitis compared with children in the general U.S.
Recommendations for the timing and type of pneumococcal vaccine vary with age and immunization history and should be discussed with a health care professional (CDC, 2003). Otolaryngologists are physicians and surgeons who diagnose, treat, and manage a wide range of diseases of the head and neck, specializing in treating hearing and vestibular disorders. A complete head and neck examination for craniofacial anomalies should document defects of the auricles, patency of the external ear canals, and status of the eardrum and middle ear structures.
In the absence of a genetic or established medical cause, a computed tomography scan of the temporal bones may be performed to identify cochlear abnormalities, such as Mondini deformity or an enlarged vestibular aqueduct, which have been associated with progressive hearing loss. Historically, an extensive battery of laboratory and radiographic studies was routinely recommended for newborn infants and children with newly diagnosed sensorineural hearing loss. If, after an initial evaluation, the etiology remains uncertain, an expanded multidisciplinary evaluation protocol including electrocardiography, urinalysis, testing for CMV, and further radiographic studies is indicated. The medical geneticist is responsible for the interpretation of family history data, the clinical evaluation and diagnosis of inherited disorders, the performance and assessment of genetic tests, and the provision of genetic counseling. Before newborn hearing screening was instituted universally, children with severe to profound hearing loss, on average, completed the 12th grade with a 3rd- to 4th-grade reading level and language levels of a 9- to 10-year-old hearing child (Traxler, 2000). Therefore, according to federal guidelines, once any degree of hearing loss is diagnosed in a child, a referral should be initiated to an early intervention program within 2 days of confirmation of hearing loss (CFA 303.321d).
UNHS programs have been instituted throughout the United States for the purpose of preventing the significant and negative effects of hearing loss on the cognitive, language, speech, auditory, social-emotional, and academic development of infants and children. The term “intervention services” is used to describe any type of habilitative, rehabilitative, or educational program provided to individuals with hearing loss. To ensure informed decision making, parents of infants with newly diagnosed hearing loss should be offered opportunities to interact with other families who have infants or children with hearing loss as well as adults and children who are deaf or hard of hearing. States should develop a single point of entry into intervention specific for hearing impairment to ensure that, regardless of geographic location, all families who have infants or children with hearing loss receive information about a full range of options regarding amplification and technology, communication and intervention, and accessing appropriate counseling services. To ensure accountability, individual, community, and state health and educational programs should assume the responsibility for coordinated, ongoing measurement and improvement of EHDI process outcomes. The primary purpose of regular developmental monitoring is to provide valuable information to parents about the rate of their child's development as well as programmatic feedback concerning curriculum decisions. Intervention professionals should seek to involve parents at every level of the EHDI process and develop true and meaningful partnerships with parents.
Intervention programs should include opportunities for involvement of individuals who are deaf or hard of hearing in all aspects of EHDI programs. Children with confirmed hearing loss and their families have the right to prompt access to quality intervention services.
Most infants and children with bilateral hearing loss and many with unilateral hearing loss benefit from some form of personal amplification (Pediatric Working Group, 1996).
Hearing aid fitting proceeds optimally when the results of physiologic audiologic assessment including diagnostic ABR, OAE and tympanometry and medical examination are in accord.
The goal of amplification device fitting is to provide the infant with maximum access to all of the acoustic features of speech within an intensity range that is safe and comfortable.
The ASHA Action Center welcomes questions and requests for information from members and non-members. This document is a revision of the Guidelines for Fitting and Monitoring FM Systems published by the American Speech-Language-Hearing Association (ASHA) in 1994. The principal change is in the recommendation for relative adjustment of the strengths of the signals received via the local (hearing aid or “environmental”) microphone and the FM microphone.
The availability and use of FM systems have increased as a result of Public Law 101-336, the Americans with Disabilities Act, and PL 105-17, the Individual with Disabilities Education Act (IDEA) Amendments of 1997, and Section 504 of the Rehabilitation Act of 1973 (PL 93-112). The signal level and signal-to-noise benefits of the FM microphone are, typically, in the range of 15 to 20 dB ( Hawkins, 1984). Little regulatory consumer protection has been mandated because most states do not classify these devices as hearing aids.
FM systems are available commercially, and many are purchased without consultation with an audiologist. The American National Standards Institute has not yet issued a standard for performance measurements of FM systems.
No standards currently exist for the selection, evaluation, and fitting of FM systems for persons with hearing loss or for use by persons with normal hearing. Candidacy, effectiveness, cost, lifestyles, needs, and aesthetics are important concerns and must be considered on an individual basis.
By addressing these issues, as well as the benefits and limitations of FM systems, the audiologist facilitates the successful use of FM amplification. This document provides guidelines for fitting and monitoring of personal and self-contained FM systems for children and adults with hearing loss.
The audiologist is the professional who is uniquely qualified to select, evaluate, fit, and dispense FM systems. Other ASHA policies and reports have addressed the appropriateness of the audiologist as the professional qualified to select, evaluate, and fit amplification devices. Before selecting an FM system for personal use, it is necessary to assess auditory capacity and the current level of auditory and communication function and to identify other factors related to device use.
During the preselection process, assessments may include, but are not limited to, audiological evaluation, observation of auditory performance in representative settings, consultation with the user or others knowledgeable about the user's performance, questionnaires and scales, hands-on demonstration, and a trial period. The issue of potential damage to the auditory mechanism should be considered when fitting any assistive listening device. Hands-on demonstration provides the user and family an opportunity to assess the components of the FM system(s) as they relate to specific needs. The audiologist is responsible for the training of individual(s) responsible for the use and maintenance of the FM system ( Johnson, Bensen, & Seaton, 1997). Generally, a daily check consists of visual inspection of the device and its coupling, followed by listening to the sound quality. The user or other appropriate individuals should have accessory supplies available to remedy routine problems as they occur. Periodic comprehensive monitoring of the FM system by the audiologist may include electroacoustic analysis, probe microphone measurements, and other in-depth troubleshooting measures. Periodic evaluations of hearing, and of performance with the FM device, are necessary to monitor stability of hearing, appropriate device settings, function, and degree of benefit.
These assessments may include, but are not limited to, audiologic evaluations, real ear performance measurements, assessments of speech recognition, consultations, observations of performance in normal-use settings, questionnaires, and subjective scales of performance benefit. Although FM systems are amplification devices similar to hearing aids, there are some distinct differences that need to be taken into account in developing measurement strategies. A second issue relates to the increased complexity of the FM systems compared with hearing aids. Finally, modifications must be made in some testing procedures to account for the way certain systems are physically arranged on the user. Typical electroacoustic evaluation includes measurement of output when using an input of 90 dB SPL. Gain and frequency response should be such that speech of average effort, produced at a distance of between 3 and 6 feet from the local microphone, is brought to an optimal level of audibility, over as wide a frequency range as possible, consistent with comfort. Saturation sound pressure level should be high enough to provide an adequate dynamic range above the threshold of audibility but low enough to avoid discomfort or damage from unusually loud sounds.
Acoustic feedback should be low enough to permit the gains called for in 2 and 4 without causing instability (whistling). For purposes of these guidelines, it will be assumed that goals 1 through 5, relating to amplification via the user's personal hearing aid have already been met to the audiologist's satisfaction. Ensure that the Volume control, Tone control, Saturation Sound Pressure Level, and any compression characteristics of the hearing aid are adjusted as normally used and that the aid is functioning properly.
Measure output into a 2-cc coupler for an input to the hearing aid microphone of 65 dB SPL at a frequency of 1000 Hz—as illustrated in Figure 2(a).
Couple the FM receiver to the hearing aid in the appropriate manner that is to be used by the wearer.
Adjust the FM volume control of the FM receiver so that a 65-dB SPL, 1000-Hz input to the remote microphone generates the same output from the hearing aid as that measured with the local microphone; see Figure 2(b). If the increase was 15 dB, you may reduce the FM volume control of the FM receiver so that the output into the 2-cc coupler falls by 5 dB.
If there was no increase of output when the input changed from 65 to 80 dB SPL, you may assume that the FM transmitter has a very low compression threshold.
When dealing with a self-contained FM system, in which the FM receiver and amplifier are in a single unit, first adjust the characteristics of amplification via the local (environmental) microphone to match those of the user's personal hearing aid (which we assume to have been fitted properly). Depending on the nature of the audiologist's test equipment, it may be easier to carry out the above procedure with a swept tone or speech-weighted noise input so as to produce a complete curve showing output as a function of frequency. Even if a single frequency is used for initial adjustment, full response curves should be run to confirm that the desired FM advantage is maintained over the 500 to 2000 Hz range —and further adjustments made if necessary.
Some acoustic analysis systems offer 85 dB SPL as a signal representing input to the FM microphone. A 1000-Hz pure tone at 80 dB SPL was chosen for the present guidelines as representative of the frequency and amplitude peak for vowels, in speech produced at a distance of a few inches from the FM microphone. Some FM systems automatically reduce gain via the local microphone whenever the FM and local microphones are active at the same time. An FM advantage of 0 dB is also appropriate if the FM system incorporates an automatic FM precedence feature to reduce the sensitivity of the local microphone whenever close speech input is detected in the FM channel. At the other extreme, users with profound hearing loss may need an FM advantage in the region of 15 dB.
At the time of fitting and during routine follow-up, the audiologist should confirm that the electroacoustic fitting goals have been attained or maintained.
Using swept tones or a complex noise, measure output as a function of frequency following standard procedures. If neck loop coupling is being used, make sure that the configuration of the loop, and the position and orientation of the aid in relation to the loop, represent real conditions of use.
If electroacoustic confirmation is to be carried out using output measurements in the ear canal of the user, rather than in a 2-cc coupler, the audiologist should follow standard procedures for testing via the local or hearing aid microphone. At the time of fitting and during routine follow-up it is imperative that the fitting be validated behaviorally. At the time of fitting and during routine follow-up, the audiologist should confirm that speech at both a few feet and a few inches from the local microphone, and speech at a few inches from the FM microphone, are within a comfortable range and of acceptable quality. At the time of fitting and during routine follow-up, the audiologist should measure speech perception under a set of representative conditions. Some writers have recommended placing the FM microphone within a few inches of a loudspeaker in order to simulate placement on an actual talker. For the hearing aid condition, it is recommended that speech perception be assessed with a speech signal of 55 dB HL and a background noise of 50 dB HL.
Select an appropriate speech recognition test giving consideration to the user's developmental age, language skills, and primary language. Make sure that all controls on the FM system are set for customary use and that the system is working.
Place the user in the calibrated sound field and yourself at the audiometer controls—as shown in Figure 4. Set the speech level to 55 dB HL (68 dB SPL) and obtain a speech perception score through the loud speaker (FM microphone off). Without making any other changes, turn ON the FM microphone and obtain a third speech perception score via Aid plus FM in noise.
The score obtained in quiet by Aid alone should be commensurate with other speech perception scores for this client obtained either aided or under headphones. When the FM microphone is turned on, the score in noise should return to a value that is not significantly lower (and may be higher) than that obtained in quiet by aid alone.
Turning off the noise in the Aid plus FM condition should not produce a significant change of score. At all points in the test process, confirm with the client that the speech levels are within an acceptable range of loudness and perceived quality—making due allowance for the negative effects of the noise. FM amplification systems have much to offer the person with hearing loss in terms of improved signal level and improved signal-to-noise ratio for speech produced at a considerable distance. The decision to use FM amplification must be based on both audiological and non-audiological factors. Before fitting, the user and other affected persons should receive orientation and counseling. The fitting goals for amplification via the local microphone do not differ from those for personal amplification.
The additional goal for amplification via the FM microphone is that the signal level and signal-to-noise ratio advantage be preserved in the ear of the listener. At the time of fitting, and during subsequent monitoring, the audiologist should confirm that the electroacoustic goals of fitting have been attained or maintained.
At the time of fitting, and during subsequent monitoring, the audiologist should confirm the appropriateness of the fitting through behavioral validation. Functional gain measurement is not recommended as an appropriate technique for evaluating FM amplification systems.
These guidelines were developed to provide direction to audiologists in the selection and fitting of FM systems. The following reading list includes, but is not restricted to, some of the publications referred to in the guidelines. These guidelines were developed by the Ad Hoc Committee on Audiology Service Delivery in Home Care and Institutional Settings and approved by the ASHA Legislative Council in November 1996 (LC 27-96).
All persons living in nursing home settings should receive or have access to comprehensive and continuing integrated audiology services for the purpose of attaining and maintaining the highest practicable level of physical, mental, and psychosocial well-being (Omnibus Budget Reconciliation Act, 1987). With changes in demographics and in the structure of the total health care delivery system, long-term care services emerge as viable and vital to the safety, well-being, and quality of life of older adults. Formal long-term care refers to the organization, delivery, and financing of a broad range of services and assistance to people who are severely limited in their ability to function independently on a daily basis over a relatively long period of time.
Within nursing facilities, nursing home residents can be characterized broadly on the basis of their length of stay: “short,” 1–6 months, or “long,” more than 6 months. Hearing health care professionals must become familiar with the goals of nursing home care; these goals influence the purposes and approaches to audiologic evaluation and management. The nature of care delivered in nursing homes is dictated in large part by the Omnibus Budget Reconciliation Act (OBRA, 1987).
Under OBRA, all nursing home residents covered by federal funds must be assessed using a standardized form known as the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Problems identified on the MDS trigger more detailed assessments called Resident Assessment Protocols (RAPs).
It is estimated that 5% of elderly Americans reside in the 19,000 nursing homes across the United States.
Audiologists who work in nursing facilities often are asked to conduct diagnostic services and administer treatment plans in nontraditional test environments. The standard protocol for audiology evaluation and management traditionally requires an acoustically treated test environment in accordance with American National Standards Institute (ANSI) standards (ANSI, 1991) and the ASHA Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology (ASHA, 1993). The general purpose of providing hearing screenings is to distinguish apparently healthy individuals from those with a greater probability of having a disease or condition and to refer these individuals for appropriate diagnostic testing (ASHA, 1994). The MDS is administered routinely to all nursing home residents to obtain a comprehensive approach to assessment, problem identification, and individualized care planning. The components of the comprehensive audiological assessment should take into account the resident's functional and cognitive ability, cost and time effectiveness, and efficiency. Bone conduction should be tested from 250 to 4000 Hz or at those frequencies for which ambient noise levels are within ANSI standards (ANSI, 1991). Speech recognition or detection thresholds to determine a recognition level for speech information. Assessment of most comfortable and uncomfortable listening levels if the individual is considered a hearing aid candidate. A reliable and valid functional communication assessment scale standardized on institutionalized individuals should be administered to determine candidacy for and benefit from hearing aids. The audiologist should monitor functional status annually to determine whether any significant change in resident status has taken place. As a result of the audiological assessment, the audiologist has one of three referral options, as presented in Figure 1.
The caregiver should be included in the rehabilitation process and should be encouraged to attend the hearing aid orientation sessions.
As part of the prefitting and fitting, ongoing hearing aid orientation sessions should be scheduled to optimize the benefits of hearing aid use.
Hearing aid use is limited among residents of nursing homes: approximately 5–10% per facility at any one time. Assistive listening devices improve the signal-to-noise ratio of the primary message by transmitting speech directly to the listener's ears free of external distortion such as noise or reverberation. Sound enhancement devices are available as hardwire, wireless, FM, or audio-induction systems. Wireless devices such as infrared systems are ideal for residents who enjoy television viewing. A variety of telecommunication technologies that enhance speech understanding over the telephone are ideal for use in nursing facilities. Individuals with hearing loss, nursing facility staff, family members, and administrators should be informed of the availability and advantages of audiological rehabilitation technology. New hearing aid users should be given a set of large print instructions (if cognitive level and vision permit) describing the care, maintenance, use, and operation of the hearing aid.
Each nursing unit at the facility should receive a revised hearing aid master list whenever a resident is fitted with a new hearing aid.
When a resident is placed on a hearing aid maintenance program, the audiologist or designated staff member should conduct bimonthly checks to ensure that the aid remains clean and in good working order. The audiologist should provide regular and periodic in-service training for nursing home staff to support the rehabilitation program designed for the resident and to provide carryover of therapeutic aspects into their daily lives (Hull, 1995). In-service training programs should be as practical and relevant to the attendees as possible.
Lost hearing aids are a significant concern of audiologists working with nursing home populations.
It is critical that all contacts with residents be documented in the appropriate place in the resident's chart. As part of the multidisciplinary team caring for the resident, the audiologist should be involved in the assessment of the individual's continuing care needs after discharge, and should contribute to a written plan for meeting those needs. The delivery of audiology services in nursing home facilities is dependent on the availability of third party reimbursement. Medicare will reimburse audiologists working in independent practices directly for diagnostic tests rendered in any nursing facility. When an audiologist is reimbursed directly by Medicare, the amount of reimbursement is linked to Common Procedural Terminology (CPT) codes and determined by the Medicare Fee Schedule. As in non-nursing home settings, aural rehabilitation services are not covered for audiologists. Many private health plans provide coverage for communication disorders associated with illness or accident, but often exclude those disorders that have a developmental or congenital etiology. The increasing number of older adults in society as well as changing consumer preference and health care delivery systems have led to more frequent activity of audiologists in the delivery of services in nursing homes. Risk Indicators Associated With Permanent Congenital, Delayed-Onset, or Progressive Hearing Loss in Childhood.


The goal of early hearing detection and intervention (EHDI) is to maximize linguistic competence and literacy development for children who are deaf or hard of hearing.
NICU babies admitted for greater than 5 days are to have auditory brainstem response (ABR) included as part of their screening so that neural hearing loss will not be missed.
Infants who pass the neonatal screening but have a risk factor should have at least one diagnostic audiology assessment by 24 to 30 months of age.
All infants should have an objective standardized screening of global development with a validated assessment tool at 9, 18, and 24 to 30 months of age or at any time if the health care professional or family has concern.
Historically, moderate-to-severe hearing loss in young children was not detected until well beyond the newborn period, and it was not unusual for diagnosis of milder hearing loss and unilateral hearing loss to be delayed until school age. At the time of the NIH consensus statement, only 11 hospitals in the United States were screening more than 90% of their newborn infants.
Available data indicate that a significant number of children who need further assessment do not receive appropriate follow-up evaluations.
The following principles provide the foundation for effective EHDI systems and have been updated and expanded since the JCIH 2000 position statement. A simplified, single point of entry into an intervention system appropriate for children with hearing loss is optimal. Families should have access to information about all intervention and treatment options and counseling regarding hearing loss. Continued assessment of communication development should be provided by appropriate professionals to all children with or without risk indicators for hearing loss. Intervention programs should recognize and build on strengths, informed choices, traditions, and cultural beliefs of the families. Studies have demonstrated that current screening technologies are effective in identifying hearing loss of moderate and greater degree (Norton et al., 2000). The roles and responsibilities of each team member should be well defined and clearly understood.
The birth hospital, in collaboration with the state EHDI coordinator, should ensure that parents and primary health care professionals receive and understand the hearing screening results, that parents are provided with appropriate follow-up and resource information, and that each infant is linked to a medical home (AAP Medical Home Initiatives, 2002).
From this foundation, families usually develop an urgent desire to understand and meet the special needs of their infant.
A medical home is defined as an approach to providing health care services where care is accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. All individuals who provide services to infants with hearing loss should have specialized training and expertise in the development of audition, speech, and language. Optimally, adults who are deaf or hard-of-hearing should play an integral part in the EHDI program. All team members work together to ensure that screening programs are of high quality and are successful. Use of either technology in the well-baby nursery will detect peripheral (conductive and sensory) hearing loss of 40 dB or greater (Norton et al., 2000). Consequently, the JCIH recommends ABR technology as the only appropriate screening technique for use in the NICU. The outpatient rescreening should include the testing of both ears, even if only one ear failed the inpatient screening. The recipient hospital should complete a hearing screening if not previously performed or if there is a change in medical status or a prolonged hospitalization. Once hearing loss is confirmed, coordination of services should be expedited by the infant's medical home and Part C coordinating agencies for early intervention services, as authorized by the Individuals with Disabilities Education Act, following the EHDI algorithm developed by the AAP (Appendix 1; AAP Task Force, 2003). The initial audiologic test battery to confirm a hearing loss in infants must include physiologic measures and, when developmentally appropriate, behavioral methods.
When permanent hearing loss is detected, frequency-specific ABR is needed to determine the degree and configuration of hearing loss in each ear for fitting of amplification devices. Furthermore, because some infants with neural hearing loss have no risk indicators, any infant who demonstrates "no response" on ABR elicited by tone burst stimuli must be evaluated by a click-evoked ABR, as previously described.
Behavioral observation alone is not adequate for determining whether hearing loss is present in this age group, nor is it adequate for the fitting of amplification devices. Auditory steady state response is a new evoked potential test that can accurately measure auditory sensitivity beyond the limits of other test methods.
In addition, the primary care physician must assume responsibility to ensure that the audiologic assessment is conducted on infants who do not pass screening and must initiate referrals for medical specialty evaluations necessary to determine the etiology of the hearing loss.
They perform a full medical diagnostic evaluation of the head and neck, ears, and related structures, including a comprehensive history and physical examination, leading to a medical diagnosis and appropriate medical and surgical management.
Atypical findings on eye examination, including irises of two different colors or abnormal positioning of the eyes, may signal a syndrome that includes hearing loss. Temporal bone imaging studies may also be used to assess potential candidacy for surgical intervention, including reconstruction, bone-anchored hearing aid, and cochlear implantation. The etiology of neonatal hearing loss, however, may remain uncertain in as many as 30% to 40% of children.
Geneticists or genetic counselors are qualified to interpret the significance and limitations of new tests and to convey the current status of knowledge during genetic counseling. The initiation of early intervention services should begin as soon as possible after diagnosis of hearing loss, but no later than 6 months of age. To achieve this goal, hearing loss must be identified as quickly as possible after birth, and appropriate early intervention must be available to all families and infants with permanent hearing loss. In some cases with mild hearing losses, amplification technology may be the only service provided. In addition, parents should also be offered access to professional, educational, and consumer organizations and provided with general information on child development, language development, and hearing loss. This state system, if separate from the state's Part C system, should integrate and partner with the state's Part C program. Early-intervention programs must assess the language, cognitive skills, auditory skills, speech, vocabulary, and social-emotional development of all children with hearing loss at 6-month intervals during the first 3 years of life, using assessment tools standardized on children with normal hearing and norm-referenced assessment tools that are appropriate to measure progress in verbal and visual language. Families also become knowledgeable about expectations and milestones of typical development of hearing children. To reflect the value of the contributions that selected parents make to development and program components, these parents should be paid as contributing staff members. Because intervention programs serve children with mild to profound, unilateral or bilateral, permanent conductive, and sensory or neural hearing disorders, role models who are deaf or hard of hearing can be significant assets to an intervention program. Early intervention programs should develop mechanisms to ensure that early intervention professionals have special skills necessary for providing families with the highest quality of service specific to children with hearing loss. For newborn infants with confirmed hearing loss, enrollment into intervention services should begin as soon after hearing loss confirmation as possible, and no later than 6 months of age. Research findings indicate that approximately one third of children with permanent unilateral loss experience significant language and academic delays (Bess & Tharpe, 1984, 1986).
If the family chooses personal amplification for their infant, hearing aid selection and fitting should occur within 1 month of initial confirmation of hearing loss even when additional audiologic assessment is ongoing. For infants below a developmental age of six months, hearing aid selection will be based on physiologic measures alone. That is, amplified speech should be comfortably above the infant's sensory threshold, but below the level of discomfort across the speech frequency range for both ears. The ASHA Ad Hoc Committee on FM Systems developed the present revision that was approved by ASHA's Legislative Council in 1999 (LC 29-99). The earlier guidelines recommended that inputs of 65 dB into the local microphone (representing speech at conversational distances) and 80 dB into the FM microphone (representing speech at a few inches) generate equal outputs in the listener's ear. It should be noted, however, that the present guidelines only address applications to persons with hearing loss.
For the benefit of readers wishing to learn more about this topic, a bibliography is provided in Appendix A. Section IIA of the ASHA Code of Ethics ( ASHA, 1992) states that “Individuals shall engage in the provision of clinical services only when they hold the appropriate Certificate of Clinical Competence or when they are in the certification process and are supervised by an individual who holds the appropriate Certificate of Clinical Competence.” For purposes of the present document, the ASHA Certificate of Clinical Competence in Audiology is considered to be the appropriate certification. They include Amplification as a Remediation Technique for Children With Normal Peripheral Hearing ( ASHA, 1991a), The Use of FM Amplification Instruments for Infants and Preschool Children With Hearing loss ( ASHA, 1991c), Scope of Practice in Audiology ( ASHA, 1996a), Scope of Practice in Speech-Language Pathology ( ASHA, 1996b), Maximizing the Provision of Appropriate Technology Services and Devices for Students in Schools ( ASHA, 1998), Guidelines for Graduate Education in Amplification ( ASHA, 1991b), and Guidelines for Audiology Services in the Schools ( ASHA, 1993).
Implicit in the preliminary stages is determining whether to use a personal FM system (in which the output of the FM receiver is coupled to personal hearing aids) or a self-contained FM system (in which the output of the FM receiver is amplified for direct presentation to the ear). This is of special concern when considering the fitting of a self-contained FM system to a person with near-normal hearing, mild hearing loss, or fluctuating hearing loss. In a sense, the user monitors sound quality continuously and may well detect such problems as intermittent function or a condition that “doesn't sound normal.” Indeed, one of the goals of management should be to encourage self-monitoring.
These supplies typically include such items as spare microphones, receivers, boots, batteries, cords, and neck loops. These comprehensive procedures should also be performed whenever an unresolved problem is identified during the daily check. These evaluations should be performed at least annually for adults and children 5 years of age or older.
First, and perhaps most important, the input level of speech to the FM microphone is more intense than to the hearing aid microphone. For instance, if a personal FM system with a neck loop is to be evaluated in a 2-cc coupler, then the hearing aid and neck loop must be in the same relative positions and orientations as they would have on the listener. First is the amplification of sounds received via the local (environmental) microphone (which is sometimes the microphone of the personal hearing aid).
It will also be assumed that, for a self-contained FM system, the characteristics for amplification via the local (environmental) microphone have been matched as closely as possible to those of the user's personal hearing aid. The basic goal is that the FM system should increase the level of the perceived speech, in the listener's ear, by approximately 10 dB. If using a standard neck loop, make sure the shape and orientation of the loop, and the distance and orientation of the aid in relation to the loop, are the same as in actual use. You should find that the output from the hearing aid increases by at least 10 dB; see Figure 2(c). In this case, increase the FM volume control of the FM receiver to provide a 5 dB increase of output (giving a 5 dB FM advantage).
In this case, the focus should be on output in the 500 to 2000 Hz range rather than just at 1000 Hz. In addition, it is advisable to assess performance with a speech-weighted stimulus as input. A primary concern of these guidelines is the negative effect of compression in the FM transmitter on the speech level and signal-to-noise ratio in the user's ear. This feature helps to maintain the signal-to-noise ratio benefits for speech received via the FM microphone.
The reasoning is: First, the user's hearing is good enough that adequate audibility of speech can be maintained via the remote microphone in spite of the reduced FM gain. The reasoning is: When the hearing loss exceeds 90 dB it becomes difficult to provide optimal audibility for speech received via the local microphone. Note that if Direct Audio Input is being used, the sensitivity of the hearing aid microphone may change. Suggested arrangement for electroacoustic assessment of a personal FM system that uses neck loop coupling. If it is not possible, the measurements must be done in a quiet environment such as the audiometric test booth.
When testing via the FM microphone, this should be placed as close as possible to the location of the reference microphone. The major problem with the functional gain approach is that the input levels to the FM microphone at the aided threshold will typically be quite low during the measurement procedure. These conditions should represent typical speech produced at a few inches and a few feet from the microphone and at a few inches from the FM microphone.
It should be noted, however, that the pattern of radiation from a loudspeaker and a human talker are very different—especially when the loudspeaker assembly contains different elements for different parts of the acoustic spectrum. If the score remains below that obtained by Aid alone in quiet, the gain in the FM channel is probably too low. If there is a significant increase of score, the gain in the FM channel is probably too low. The committee recognizes the complexity of the technology (including microphone and coupling strategies and the use of FM with digital and advanced signal-processing hearing aids) and the many unresolved issues of measurement (including input stimulus type and level). Part II 34 CFR Parts 300 and 303 Assistance to states for the education of children with disabilities and the early intervention program for infants and toddlers with disabilities; Final regulations.
With the increasing number of older adults in our society and the high percentage of hearing loss documented in this population, there is a need for a well-defined hearing management protocol for nursing home facilities. Community-based long-term care in the United States typically is delivered informally by a host of individuals, including family, friends, and neighbors who provide health, social, and personal care services. Short-term stayers enter for short-term rehabilitation after an acute illness such as stroke or hip fracture or if they are medically unstable or terminally ill. Nursing facilities must comply with OBRA to qualify for Medicare and Medicaid reimbursement.
The MDS, designed as an interdisciplinary tool, summarizes the resident's behaviors, problems, and special care needs, including functional levels, psychosocial well-being, and nutritional status (Kane et al., 1994).
If the RAPs identify problems in communication, psychosocial well-being, and cognitive status, the next level of assessment begins. Bureau of the Census reports that one in eight Americans is elderly, which is defined for federal regulation purposes as 65 years of age and older.
The heterogeneity of the population and facilities must be taken into account when developing treatment plans. Alternative test environments and protocols are the rule rather than the exception when providing audiology services in nursing homes.
For residents of nursing facilities who may present with a hearing deficit, the audiologist's goal should be to identify those in need of audiological or medical services necessary to ensure their health, safety, and maximal functioning (Ammentorp, Gossett, & Poe, 1991). Identifying and managing hearing loss often can reverse the diagnosis or lessen the severity of a confusional state. A standard approach cannot be dictated, given the social, psychological, and physical diversity of older adults receiving long-term care services. At the time of the otoscopic examination, the audiologist should check carefully for collapsed ear canals; their prevalence increases with increasing age, especially when supra-aural earphones are used.
Following bone conduction testing, the audiologist again should check carefully for collapsed canals in the event that an unexplained high frequency air-bone gap presents. The primary purpose of word recognition testing for residents of nursing facilities is to identify persons who need assistive technology, which would promote communication among residents, residents and caregivers, and residents and family members. If the resident is too confused to provide valid self-report data, a simple questionnaire regarding communication abilities could be completed by a formal or informal caregiver. If medical clearance is necessary for a potential hearing aid fitting, the referral should take place prior to the hearing aid evaluation session. Restoration in long-term care settings implies assisting residents to do as much as they can, as well as they can, for as long as they can (Hegner & Caldwell, 1994). The prevailing FDA regulations, Professional and Patient Labeling and Conditions for Sale of Hearing Aid Devices (FDA, 1977) should be followed when dispensing amplification. Studies have indicated that hearing aid users over age 60 prefer less amplification than various fitting strategies recommend. A successful hearing aid fitting depends in large part on the resident's level of dependency and the availability of a caregiver to assist the resident in inserting and adjusting the hearing aid. A staff caregiver or family member should participate in the orientation and counseling sessions when feasible to ensure carryover of information into daily life. Hearing aids are underutilized because of a variety of nonaudiological and audiological factors. A broader, more descriptive, and inclusive term for these devices is “audiological rehabilitation technology.” Audiological rehabilitation technology can be classified operationally according to functional category (Leavitt, 1989). These listening devices are ideal for one-on-one, large or small group situations, and television or radio listening. These devices enable the signal from the television to be delivered directly to the listener's ear free of interference and distortion.
Given the high prevalence of hearing loss among residents of nursing facilities, it may be desirable to have in-line amplifiers installed in each resident's telephone. Personal rooms of residents with significant hearing loss should be equipped with telephone alerting devices and smoke detectors with strobe lights or vibrotactile stimulation. Audiologists need to inform administrative staff that these devices can and should be used to bring facilities into compliance with the ADA and create a barrier-free environment for individuals with hearing loss. A hearing aid list should be posted on each nursing unit to provide a quick and easy reference, particularly for new and “floater” nursing staff. Zinc air batteries are recommended because they are less toxic than mercury batteries and have a longer battery and shelf life. Handson experience, adult learning principles, and interactivity are the key to successful sessions.
Although there is no guaranteed method of prevention, resident orientation, staff education, quality improvement (QI), spot checks, and appropriate reporting to nursing supervisors and administrators can help keep the problem at a minimum. If the resident is not considered an appropriate candidate for intervention, an explanation should be provided. Audiological summaries, professional and self-help resource listings, educational literature, and instructions for families should be made part of the resident's discharge packet to ensure carryover of information and inclusion of recommendations into the resident's daily life and routines.
Medicare as well as private health plans have specific coverage and medical review guidelines for audiology services. For reimbursement to occur there must be a physician referral and the procedures performed by the audiologist must be within the Medicare scope of coverage.
If an audiologist works under the supervision of a speech-language pathologist (subject to limitations of state regulation), Medicare will pay for speechreading services. Reimbursement for audiologic services may be restricted to certain provider settings (hospitals or clinics) or to licensed practitioners. Hearing—Resident's ability to hear (with hearing appliance, if used) during the LAST 7 DAYS. Without appropriate opportunities to learn language, these children will fall behind their hearing peers in communication, cognition, reading, and social-emotional development. In 2000, through the support of Representative Jim Walsh (R-NY), Congress authorized HRSA to develop newborn hearing screening and follow-up services, the Centers for Disease Control and Prevention (CDC) to develop data and tracking systems, and NIDCD to support research in early hearing detection and intervention. However, the outlook is improving as EHDI programs focus on the importance of strengthening follow-up and intervention.
The guidelines provide current information on the development and implementation of successful EHDI systems.
In addition, studies of children with permanent hearing loss indicate that moderate or greater degrees of hearing loss can have significant effects on language, speech, academic, and social-emotional development (Carney & Moeller, 1998). The hospital ensures that hearing screening information is promptly transmitted to the medical home and appropriate data are submitted to the state EHDI coordinator. Families gain knowledge, insight, and experience by accessing resources and through participation in scheduled early intervention appointments including audiologic, medical, habilitative, and educational sessions.
The primary health care professional acts in partnership with parents in a medical home to identify and access appropriate audiology, intervention, and consultative services needed to develop a global plan of appropriate and necessary health and habilitative care for infants identified with hearing loss and infants with risk factors for hearing loss. They provide newborn hearing screening program development, management, quality assessment, service coordination and referral for audiologic diagnosis, and audiologic treatment and management. Speech-language pathologists provide both evaluation and intervention services for language, speech, and cognitive-communication development. The care coordinator incorporates the family's preferences for outcomes into an IFSP as required by federal legislation.
Both adults and children in the deaf and hard-of-hearing community can enrich the family's experience by serving as mentors and role models. An audiologist should be involved in each component of the hearing screening program, particularly at the level of statewide implementation and, whenever possible, at the individual hospital level. Reporting and communication protocols must be well defined and include the content of reports to physicians and parents, documentation of results in medical records, and methods for reporting to state registries and national data sets. Moreover, because OAEs are generated within the cochlea, OAE technology cannot be used to detect neural (eighth nerve or auditory brainstem pathway) dysfunction.
When automated ABR is used as the single screening technology, neural auditory disorders can also be detected (Sininger, Abdala, & Cone-Wesson, 1997). For infants who do not pass automated ABR testing in the NICU, referral should be made directly to an audiologist for rescreening and, when indicated, comprehensive evaluation, including diagnostic ABR, rather than for general outpatient rescreening.
Confirmation of an infant's hearing status requires a test battery of audiologic test procedures to assess the integrity of the auditory system in each ear, to estimate hearing sensitivity across the speech frequency range, to determine the type of hearing loss, to establish a baseline for further monitoring, and to provide information needed to initiate amplification device fitting. Emerging technologies, such as broad-band reflectance, may be used to supplement conventional measures of middle ear status (tympanometry and acoustic reflexes) as the technology becomes more widely available (Keefe et al., 2003). Essential components of the medical evaluation include clinical history, family history of childhood-onset permanent hearing loss, identification of syndromes associated with early- or late-onset permanent hearing loss, a physical examination, and indicated radiologic and laboratory studies (including genetic testing). Middle-ear status should be monitored, because the presence of middle-ear effusion can further compromise hearing.
The CDC recommends that all children with, and all potential recipients of, cochlear implants follow specific recommendations for pneumococcal immunization that apply to cochlear implant users and that they receive age-appropriate Haemophilus influenzae type b vaccines. Often, a hearing or balance disorder is an indicator of, or related to, a medically treatable condition or an underlying systemic disease.
Congenital permanent conductive hearing loss may be associated with craniofacial anomalies seen in disorders such as Crouzon disease, Klippel-Feil syndrome, and Goldenhar syndrome (Nance, 2003).
As the widespread use of newly developed conjugate vaccines decreases the prevalence of infectious etiologies such as measles, mumps, rubella, H. Once hearing loss is confirmed, medical clearance for hearing aids and initiation of early intervention should not be delayed while this diagnostic evaluation is in process. All families of children with confirmed hearing loss should be offered and may benefit from a genetics evaluation and counseling. Even when the hearing status is not determined to be the primary disability, the family and child should have access to intervention with a provider knowledgeable about hearing loss (Kennedy, McCann, Campbell, Kimm, & Thornton, 2005). Some parents choose only developmental assessment or occasional consultation, such as parents with infants who have unilateral hearing losses.
A number of principles and guidelines have been developed that offer a framework for quality early intervention service delivery systems for children who are deaf or hard of hearing and their families (Bodner-Johnson & Sass-Lehrer, 2003). Parental consent must be obtained, according to state and federal requirements, to share the IFSP information with providers and transmit data to the state EHDI coordinator. These individuals can serve on state EHDI advisory boards and can be trained as mentors for families and children with hearing loss who choose to seek their support. In addition, there are reports of children with successful outcomes for each of the different methods of communication. Professionals with a background in deaf education, audiology, and speech-language pathology will typically have the skills needed for providing intervention services.
Successful early intervention programs (a) are family centered, (b) provide families with unbiased information on all options regarding approaches to communication, (c) monitor development at 6-month intervals using norm-referenced instruments, (d) include individuals who are deaf or hard of hearing, (e) provide services in a natural environment in the home or in the center, (f) offer high-quality service regardless of where the family lives, (g) obtain informed consent, (h) are sensitive to cultural and language differences and provide accommodations as needed, and (i) conduct annual surveys of parent satisfaction.
Audiologic habilitation services should be provided by an audiologist experienced with these procedures. Behavioral threshold assessment using visual reinforcement audiometry should be obtained as soon as possible to cross-check and augment physiologic findings (American Academy of Audiology, 2003). Traditionally the term auditory trainer has been used to refer to hard-wired, FM, infrared, or any amplification system other than a personal hearing aid. Optimal benefits are to be expected when an FM system is considered early in the process of fitting amplification. Federal regulations Part II, 34 CFR Subpart A, d300.24(b)(1) (Federal Register 1999) and PL 105-17, Part A, Section 602(22) and Part C, Sections 632(4)(E), and 632(4)(F)(ii) (Public Law 105-17, 1997) further define and support the audiologist's role in the evaluation and habilitation of the population between birth and age 21.
If a personal FM system is being considered, the personal hearing aids must have appropriate coupling capabilities and flexibility.
Research on the trial use of FM systems in the home with parents and toddlers (Benoit, 1989) and with college students (Flexer, Wray, Black, & Millin, 1987) suggests that acceptance and compliance may depend on the user's knowledge of how the system works in relation to the hearing loss and the perception that the benefits outweigh the inconvenience. The daily check can be performed by the parent, teacher, speech-language pathologist, or any one who has received appropriate training by the audiologist.
If a malfunction persists or otherwise cannot be identified and remedied through the daily check procedure, the audiologist should be notified. In any event, they should be performed routinely at least once a year for adults and children 5 years of age or older.
They should be performed more frequently for children under 5 years of age and for individuals with fluctuating or conductive hearing loss. These include lapel, lavaliere, boom, and conference microphones for the transmitter and ear-level or body-worn microphones at the receiver.
On personal FM systems, there will be one VCW for the FM system and one for the personal hearing aid. For self-contained FM systems that use earbuds or Walkman-type headsets, probe microphone measures may be preferred because those receivers cannot be coupled adequately to the 2-cc coupler.
It is important to use the same type of signal (such as pure tones or speech-weighted noise) when making measurements on the hearing aid and FM system for comparison purposes.
As will be explained below, there are specific situations when a lower or higher value may be appropriate.
Unfortunately, it also reduces audibility of other talkers who are not wearing the FM microphone. Second, because the local microphone is turned off, the signal-to-noise benefit for speech into the FM microphone is not compromised by noise picked up at the local microphone.
Basically, the problem of acoustic feedback prevents the audiologist from providing enough gain.
The system should, therefore, be retested with input to the hearing aid microphone before assessing FM input. These lower input levels would not be representative of the talker's voice entering the FM microphone during actual use of the FM system.
As a result, both the speech spectrum and the input level may deviate considerably from what is intended. Assuming the sound field has been calibrated for a 45-degree azimuth, the intensity of the speech would be 68 dB SPL, a level that should be typical of the input to the hearing aid microphone. These guidelines should be viewed as a reflection of the current understanding of these issues.
The use of FM amplification instruments for infants and preschool children with hearing loss.
Maximizing the provision of appropriate technology services and devices for students in schools.
Identification, assessment and management of children with unilateral sensorineural hearing loss. Issues in fitting FM units to children with unilateral hearing losses: Two case studies [monograph]. Amplification devices: Evaluating classroom effectiveness for moderately hearing-impaired college students. Comparisons of speech recognition in noise by mildly to moderately hearing-impaired children using hearing aids and FM systems. Effect of using an auditory trainer on the attentional, language, and social behaviors of autistic children.
Effects of amplification, speech reading, and classroom environments on reception of speech. Comparison of the listening effectiveness of hard-of-hearing children using three types of amplification. Preliminary findings: Effect of FM auditory trainers on attending behaviors of learning disabled children. Young-adult students' ratings of the relative performance of hearing aids, FM and loop amplification systems. Room acoustics effects on monosyllabic word discrimination ability for normal and hearing-impaired children. Amplification devices: Evaluating effectiveness for moderately hearing-impaired college students. Preferential seating is not enough: Issues in classroom management of hearing impaired students.
Comparisons of speech recognition in noise by mildly-to-moderately hearing-impaired children using hearing aids and FM systems. Implementation of an amplification system to assist the hearing impaired in a university setting. The protocol should encompass identification, evaluation, management, and caregiver education.
Home health agencies provide for the health and daily living needs of homebound persons when they are too ill to be cared for by family members (Hegner & Caldwell, 1994).
The OBRA guidelines specify residents' rights within nursing facilities and dictate components of the resident assessment. The nationally mandated MDS must be completed within 14 days of admission and updated when a major change in status takes place. The number of nursing home residents is expected to double over the next 30 years, exceeding 5 million by the year 2040. Among nursing home populations, the incidence of hearing loss is over 80% (Schow & Nerbonne, 1980).
For example, the classification of residents of nursing facilities as “short stay” or “long stay” will influence the nature of services provided.
Restrictive reimbursement policies further dictate certain patterns of care in nursing homes. Hearing screening and referral for audiology services or medical management should occur within the first 2 weeks of entry into the long-term care system (OBRA, 1987). Decisions regarding the nature and severity of hearing loss generally can be reached using routine behavioral audiometry and immittance tests.
It is the responsibility of the audiologist to ensure that audiometers, audioscopes, and immittance instrumentation are calibrated biologically on a daily basis and electroacoustically on an annual basis.
The 250 and 500 Hz test tones may be omitted if ambient noise levels exceed the ANSI standard (ANSI, 1991) or if acoustic immittance testing is done (ASHA, 1994).
Functionally relevant test materials are recommended because the adequacy of the resident's functional communication capacity is of primary importance in the evaluation of hearing status.


For adults likely to return to or for adults living in less restrictive environments, the screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) or the Self-Assessment of Communication (SAC) may be considered (ASHA, 1992b). If an annual audiological reevaluation is indicated, it should be noted in the chart and a recall schedule should be established. Maintenance is aimed at preventing further loss and limitation and helping the resident achieve as high a level of wellness and independence as possible (Hegner & Caldwell, 1994), using a holistic approach that considers physical, sociological, psychological, cognitive, and communication capabilities.
Care should be taken to recommend an earmold or hearing aid that the resident or staff can easily maintain, insert, and remove. To establish realistic expectations, the limitations of hearing aid use should be explained to the user and caregiver. It is critical that the orientation sessions be client-centered, with particular attention to the resident's communication needs within the given facility or listening environment. Foremost among the audiological factors is the high incidence of central auditory processing disorders (CAPD) that, according to Stach, Spretnjak, & Jerger (1990), tend to increase in prevalence with age.
Hardwire systems, which couple directly to the sound source via a microphone, amplifier, and external receiver to the listener, are ideal for the nursing home setting. If the nursing facility's lounge area is equipped with a television, nursing facilities should make sure to include a transmitter along with several receivers to enable residents to enjoy television viewing. Staff members in regular contact with residents, family members, or potential residents also should have in-line amplifiers installed in their telephones. Some smoke alarms emit a pungent aerosol spray into the air when visible or audible alarms are not effective. It is our professional responsibility to insure that this law is implemented so that people who are hard of hearing and deaf have equal access to services in nursing facilities. Comprehensive care plans must be completed to reflect individualized management and interventions for the resident. If the resident's potential for rehabilitation is questionable, a trial period should be worked out with the resident and nursing staff. The physician referral should state “testing for the purpose of obtaining additional information necessary for evaluation of the need for or appropriate type of medical or surgical treatment for a hearing deficit or a related medical problem” ( Medicare Carriers Manual, 1975). In this situation, reimbursement is based on “reasonable costs,” not the Medicare Fee Schedule, and payment is made directly to the nursing facility. It is anticipated that this document will provide audiologists with a comprehensive hearing management protocol and facilitate audiologists to confront the numerous challenges of the nursing home setting and provide quality audiology services.
Current estimates from the National Health Interview Survey, National Center for Health Statistics.
Preferred practice patterns for the professions of speech-language pathology and audiology.
Prevalence and Characteristics of Persons with Hearing Trouble: United States, 1990–91 Series 10. Such delays may result in lower educational and employment levels in adulthood (Holden & Diaz, 1998). Surgeon General, on learning of new technology, encouraged that detection of hearing loss be included in the Healthy People 2000 goals for the nation (U.S. By 2005, every state had implemented a newborn hearing-screening program, and approximately 95% of newborn infants in the United States were screened for hearing loss before hospital discharge. Additional services including genetics, ophthalmology, developmental pediatrics, service coordination, supportive family education, and counseling should be available (Calderon, Bargones, & Sidman, 1998). For the follow-up component, audiologists provide comprehensive audiologic diagnostic assessment to confirm the existence of the hearing loss, ensure that parents understand the significance of the hearing loss, evaluate the infant for candidacy for amplification and other sensory devices and assistive technology, and ensure prompt referral to early intervention programs. The otolaryngologist provides information and participates in the assessment of candidacy for amplification, assistive devices, and surgical intervention, including reconstruction, bone-anchored hearing aids, and cochlear implantation. The care coordinator supports the family members in their choice of the infant's communicative development. Such mentors have experience in negotiating their way in a hearing world, raising infants or children who are deaf or hard of hearing, and providing families with a full range of information about communication options, assistive technology, and resources available in the community. The lead coordinating agency in each state should be responsible for identifying the public and private funding sources available to develop, implement, and coordinate EHDI systems.
Hospitals and agencies should also designate a physician to oversee the medical aspects of the EHDI program. In the absence of national standards, audiologists must obtain normative data for the instruments and protocols they use.
Comprehensive assessment should be performed on both ears even if only one ear failed the screening test.
Clinical research is investigating its potential use in the standard pediatric diagnostic test battery. The primary care physician must partner with other specialists, including the otolaryngologist, to facilitate coordinated care for the infant and family. Otolaryngologists work closely with other dedicated professionals, including physicians, audiologists, speech-language pathologists, educators, and others, in caring for patients with hearing, balance, voice, speech, developmental, and related disorders. The assessment of infants with these congenital anomalies should be coordinated with a clinical geneticist.
Careful longitudinal monitoring to detect and promptly treat coexisting middle ear effusions is an essential component of ongoing otologic management of these children.
Indicated referrals to other medical subspecialists, including developmental pediatricians, neurologists, cardiologists, and nephrologists, should be facilitated and coordinated by the primary health care professional.
Because these studies are descriptive and not causal studies, the efficacy of specific components of intervention cannot be separated from the total provision of comprehensive services. Children with high-frequency losses and normal hearing in the low frequencies may only be seen by a speech-language pathologist, and those with significant bilateral sensorineural hearing losses might be seen by an educator of the deaf and receive additional services.
Foundational characteristics of developing and implementing early intervention programs include a family-centered approach, culturally responsive practices, collaborative professional-family relationships and strong family involvement, developmentally appropriate practice, interdisciplinary assessment, and community-based provision of services. Documentation of developmental progress should be provided on a regular basis to parents and, with parental release of information, to the medical home and audiologist. In many states, parents have been integral and often have taken leadership roles in the development of policy, resource material, communication mechanisms, mentoring and advocacy opportunities, dissemination of information, and interaction with the deaf community and other individuals who are deaf or hard of hearing. Almost all families choose at some time during their early childhood programs to seek out both adults and child peers with hearing loss.
The choice is a dynamic process on a continuum, differs according to the individual needs of each family, and can be adjusted as necessary on the basis of a child's rate of progress in developing communication skills. Professionals should be highly qualified in their respective fields and should be skilled communicators who are knowledgeable and sensitive to the importance of enhancing families' strengths and supporting their priorities. Because of the ambiguous nature of the term, only FM systems will be used in these guidelines. For instance, the hearing aids should have provision for direct audio input, or, if neck loop coupling is to be used, they should have sensitive telecoils. They should be performed more frequently for children under 5 years of age—perhaps as often as every 3 to 6 months.
This is 15–20 dB more intense than the typically assumed 60–70 dB SPL input to the microphone of the personal hearing aid 1–2 meters from the talker. There may be one or two environmental microphones, and they and the FM microphone may be omnidirectional or directional. The best way to satisfy this criterion is to place the neck loop and hearing aid on a person—preferably the actual user.
A low SSPL90 when testing with FM microphone input alone should not, therefore, be interpreted as a low SSPL90 for the system as a whole. The remaining issue faced by the audiologist, therefore, is adjustment of gain in the FM channel so as to maintain an appropriate FM advantage. Then, if necessary, increase gain in the FM channel so that the output increases by around 10 dB when the input increases from 65 to 85 dB SPL.
If simultaneous use of the FM and local microphones is the rule rather than the exception for a given individual, then the adjustment of gain via the local microphone should be made with the FM channel turned on, but receiving no input. Under these circumstances, a primary benefit of FM amplification is that the increased input to the FM microphone can provide greater audibility of speech at a distance. With all three options, it may be necessary to support the weight of the coupler as it hangs in front of the ear. These input level differences, combined with the fact that most FM microphone-transmitters incorporate input compression, make the aided sound field threshold values difficult to interpret.
For very young children, the audiologist may be limited to confirming the absence of aversive reactions to loud speech at a few inches from the microphones. Instead of using the plus and minus 45-degree azimuth loudspeaker arrangement, the audiologist may prefer that speech originate from 0 degrees and noise from 180 degrees.
A public school audiology program: Amplification maintenance, auditory management, and in-service education. In Facilitating classroom listening: A handbook for teachers of normal and hard of hearing students (pp.
The effect of microphone recording position on the long-term average spectrum of speech [thesis]. These guidelines are an official statement of the American Speech-Language-Hearing Association. The challenge for audiologists is to provide quality audiology services given the changing health care climate, personnel shortages, public policy initiatives, economic considerations, and reductions in provider reimbursements. Third-party reimbursement for community-based long-term care services generally is fragmented and often difficult to coordinate (Ouslander, Osterweil, & Morley, 1991). Over 90% of nursing home care is paid either by out-of-pocket expenditures or by Medicaid, with Medicare supporting less than 3% of the cost (Ouslander et al., 1991).
Both categories of residents may require audiology services; health status, economics, and time constraints dictate the extent of service required.
With regard to resident assessment and quality of care, facilities must provide all services necessary to maintain the highest practicable physical, mental, and psychosocial well-being. By the year 2020 more than 50 million Americans will be over 65, and by the year 2040 that number will exceed 75 million. The majority of nursing home residents are over 85 years of age and have multiple chronic conditions.
Some investigators have reported that approximately 92% of persons who live in health care facilities have hearing impairment that interferes with the communication process (Chafee, 1967; Hull, 1995). Audiology assessment procedures and decisions to intervene must be moderated by the resident's length of stay, the overall goals of nursing home care, and OBRA requirements.
Because of the dearth of data validating evaluation and management protocols within nursing facilities, this document does not attempt to prescribe protocols. The referral can be made by hospital discharge planners, intake personnel, nurses, social workers, speech-language pathologists, audiologists, physicians, or home health care providers. OBRA requires a registered professional nurse to conduct or coordinate the assessment with the appropriate participation of health professionals, including audiologists and speech-language pathologists. Often, nursing facilities are not equipped to allow audiologists to administer electrophysiologic tests such as auditory brainstem evoked response testing or vestibular evaluations. Although cerumen management is within the audiologist's scope of practice, assuming appropriate knowledge and skills (ASHA, 1992a), caution should be exercised when removing cerumen—many nursing home residents are frail and have complex medical conditions.
The audiologist should take into account the need for calibration and maintenance of equipment.
These instruments have been standardized on noninstitutionalized older adults and therefore are ideal for those in less restrictive settings. When taking earmold impressions, universal precautions and sterilization procedures for objects, surfaces, and people should be in place. When the perceived benefit is at odds with real ear data, the audiologist must make a decision as to the adequacy of the response, paying attention to input from the resident and caregiver as well as the real ear data. Older adults with CAPD tend to derive minimal benefit from hearing aids partly because of the interference posed by external distortions such as noise.
They can facilitate resident-to-resident, resident-to-staff, or informal caregiver-to-resident interactions.
Infrared systems have been installed successfully in large listening areas such as auditoriums, activity rooms, and places for religious observance, enabling large numbers of residents to follow the speaker free of noise or the disadvantage posed by distance. Audiologists should consult with the administration to ensure that the facility is in compliance with the ADA.
Nursing home facilities and state medical programs have different arrangements for paying for lost or damaged hearing aids and assistive listening devices. Seeger and Holt (1996) found that trial periods facilitated decision making in questionable cases. When an audiologist is reimbursed directly, it typically results in a lower reimbursement rate; however, the audiologist retains the right to bill Medicare directly (and receive direct payment) for residents covered under Medicare Part A.
The majority of private health plans cover audiologic diagnostic services when they are required by a physician to establish a diagnosis. To maximize the outcome for infants who are deaf or hard of hearing, the hearing of all infants should be screened no later than 1 month of age. Congress recommended cooperation and collaboration among several federal agencies and advocacy organizations to facilitate and to support the development of state EHDI systems.
The infant's pediatrician, family physician, or other primary health care professional is in a position to advocate for the child and family (AAP Committee, 2000; AAP Medical Home Initiatives, 2002). For the treatment and management component, audiologists provide timely fitting and monitoring of amplification (Pediatric Working Group, 1996). Audiologists may provide diagnostic and habilitative services within the individualized family service plan (IFSP) or school-based individualized education plan. Through the IFSP review, the infant's progress in language, motor, cognitive, and social-emotional development is monitored.
OAE measurements are obtained from the ear canal using a sensitive microphone within a probe assembly that records cochlear responses to acoustic stimuli. Because 30% to 40% of children with confirmed hearing loss will demonstrate developmental delays or other disabilities, the primary care physician should closely monitor developmental milestones and initiate referrals related to suspected disabilities (Karchmer & Allen, 1999).
In addition, the primary care physician is responsible for ongoing surveillance of parent concerns about language and hearing, auditory skills, and developmental milestones of all infants and children regardless of risk status, as outlined in the pediatric periodicity schedule published by the AAP Committee on Practice and Ambulatory Medicine (2000). Approximately 30% to 40% of children with hearing loss have associated disabilities, which can be of importance in patient management. This information may influence parents' decision making regarding intervention options for their child. Thus, the family-centered philosophy, the intensity of services, the experience and training of the provider, the method of communication, the curricula, the counseling procedures, the parent support and advocacy, and the deaf and hard-of-hearing support and advocacy are all variables with unknown effects on the overall outcomes of any individual child. Although criterion-referenced checklists may provide valuable information for establishing intervention strategies and goals, these assessment tools alone are not sufficient for parents and intervention professionals to determine whether a child's developmental progress is comparable with his or her hearing peers. Parents, often in partnership with individuals who are deaf and hard of hearing, have also participated in the training of professionals.
Programs should ensure that these opportunities are available and can be delivered to families through a variety of communications means, such as Web sites, e-mail, newsletters, videos, retreats, picnics and other social events, and educational forums for parents. Programs need to provide families with access to skilled and experienced early intervention professionals to facilitate communication and language development in the communication option chosen by the family.
When early intervention professionals have knowledge of the principles of adult learning, it increases their success with parents and other professionals. These guidelines, an official statement of the American Speech-Language-Hearing Association, provide guidance on use of specific practice procedures but are not official standards of the Association.
The first is when conversational input to the local microphone does not generate a high enough output for optimal audibility.
Their merit lies in the fact that a microphone placed a few inches from the mouth of a talker receives speech at a much higher level than one placed several feet away. Included are preselection and management considerations, as well as recommended procedures for performance measurement.
If possible, the listening check should be performed in the room(s) where the FM system will be used so that any interference will be detected. At the time of writing, there is no standard electroacoustic measurement procedure for FM systems. If output measurements are being made to adjust FM systems, then typical input levels should be used. It is important that each input channel in the FM system be evaluated and that the microphones be positioned in the proper manner. The true estimate of SSPL90 for the system is that obtained with 90 dB SPL input to the local (hearing aid or environmental) microphone. Similarly, the local microphone must be turned on, but receiving no input, when adjusting the FM volume control.
This will only happen, however, if the gain in the FM channel is maintained at a high enough level ( Boothroyd & Iglehart, 1998). The sound-field threshold values do represent the lowest intensity signal that the user can detect with the FM system. If time constraints preclude such comprehensive testing, priority should be given to testing in noise under the Aid plus FM condition—this being the true validation of the FM adjustment. An alternative is to test with monitored live voice with the tester wearing the FM microphone in its appropriate position. This would eliminate the possibility of a head shadow effect for either the speech or noise in the case of monaural fitting.
Speech recognition ability in children with unilateral sensorineural hearing loss as a function of amplification, speech stimulus, and listening condition. They provide guidance on the use of specific practice procedures but are not official standards of the Association. Rehabilitation specialists in general and audiologists in particular have to provide appropriate care in a cost-restricted environment. The home health care programs that do list speech treatment services as a benefit also list audiology within the rubric “speech therapy.” When community-based long-term care alternatives fail, older adults and their families seek formal long-term care services through different types of facilities that provide such services.
Medicaid, the major source of nursing home payments, covers over 70% of residents (Kane, Ouslander, & Abrass, 1994). A variety of disciplines must take part in the assessment and care planning process; the extent of each discipline's involvement depends on the nature of the resident's problems.
The high prevalence of disabling hearing loss reflects the fact that the majority of residents are over 80 years of age.
Identification and treatment of chronic conditions such as hearing loss are important goals, with the focus of care at all times remaining on functional independence, autonomy, quality of life, comfort, and dignity of the residents (Kane et al., 1994). The guidelines below are outcome-oriented and the role of the audiologist, at every stage of intervention, is to gain an understanding of the patient's function and the patient's perceived needs, abilities, and limitations (Lesner & Kricos, 1995). The screening results and any referrals should be documented in the resident's medical record. If additional diagnostic evaluations are indicated, the resident is typically referred out for these services. In addition, nursing facilities may regulate which professionals are permitted to perform cerumen management. The decision regarding candidacy for rehabilitation should take into account the audiologist's data, input from the nursing staff, and input from the resident.
Safety and infection control procedures should be in effect before, during, and after the hearing aid fitting as well as between residents. Nonaudiological factors include lifestyle variables, financial considerations, manual dexterity, listening needs, and cognitive status, and also interfere with successful hearing aid use.
These systems, which are inexpensive, durable, and easy to use, make communication exchanges easier and more meaningful; it is difficult and tiresome to communicate with residents who need but do not use amplification or assistive listening devices.
All coin-operated telephones should be hearing aid-compatible and contain in-line amplifiers. When possible, the audiologist should investigate the purchase of loss and damage insurance and incorporate that coverage into the cost of the hearing aid. A total quality management approach to the provision of audiology services in a long-term facility.
Those not passing screening should have a comprehensive audiologic evaluation no later than 3 months of age. A vital function of the family's role is ensuring direct access to communication in the home and the daily provision of language learning opportunities. The care coordinator assists the family in advocating for the infant's unique developmental needs. Thus, OAEs reflect the status of the peripheral auditory system extending to the cochlear outer hair cells. The medical home algorithm for management of infants with either suspected or proven permanent hearing loss is provided in Appendix 2 (AAP Task Force, 2003). The decision to obtain genetic testing is dependent on informed family choice in conjunction with standard confidentiality guidelines (NIDCD, 1999).
The key component of providing quality services is the expertise of the provider specific to hearing loss. They should be participants in the regular assessment of program services to ensure ongoing improvement and quality assurance. These guidelines supersede the Guidelines for the Fitting and Monitoring of FM Systems ( ASHA, 1994). This condition often is in cases of profound hearing loss because of gain constraints imposed by acoustic feedback. However, many manufacturers make these measurements and provide the results with their devices. This is particularly important given that most FM microphone transmitters employ some type of input compression.
Flexer (Ed.), Current audiologic issues in educational management of children with hearing loss. Most states require assessment by dental, pharmacy, podiatry, audiology, ophthalmology, and nursing professionals.
A person's hearing loss may interfere with attaining or maintaining the highest practicable, physical, mental, and psychosocial well-being. It is anticipated that the experienced audiologist can apply standard procedures in nonstandard settings to attain a complete picture of the resident's current hearing status and audiological rehabilitation needs. Audiologists performing cerumen management should follow specific measures to prevent disease transmission. It is not within the scope of this document to prescribe specific audiological or nonaudiological criteria for candidacy for intervention. Audiologists are encouraged to wear latex gloves when handling hearing aids and earmolds, but glove use should be discouraged when taking silicone earmold impressions.
Cognitive impairment associated with dementia, delirium, depression, amnestic syndromes, or benign senescent forgetfulness may render residents dysfunctional and unable to use hearing aid devices. An additional advantage of hardwire systems is that they represent a visible symbol of hearing loss, signaling to other residents and staff that it is necessary to modify communication techniques to ensure understanding.
Infants with confirmed hearing loss should receive appropriate intervention no later than 6 months of age from health care and education professionals with expertise in hearing loss and deafness in infants and young children. Health Resources and Services Administration (HRSA), funded pilot projects in Rhode Island, Utah, and Hawaii to test the feasibility of a universal statewide screening program to screen newborn infants for hearing loss before hospital discharge.
Over time, the child benefits from the family's modeling of partnerships with professionals and advocating for their rights in all settings.
Audiologists also provide services as teachers, consultants, researchers, and administrators.
In contrast, ABR measurements are obtained from surface electrodes that record neural activity generated in the cochlea, auditory nerve, and brainstem in response to acoustic stimuli delivered via an earphone. These services may be provided in the home or in a center, or a combination of the two locations.
In such cases advantage should be taken of the opportunity for increased output in the FM channel. Therefore, until a measurement standard procedure is available, devices should be evaluated at least according to the measurement procedures used by the manufacturer, which are typically those of ANSI S3.22 (1987) Specifications of Hearing Aid Characteristics. The gain and output of the FM system may be quite different if lower-level signals, which are not representative of the speech input to the FM microphone, are used in the measurement procedure.
A measure of speech perception should then be obtained with an age- and language-appropriate test. Paper presented at the annual convention of the American Speech-Language-Hearing Association.
Medical evaluation and treatment must be complemented every step of the way by assessment and care planning processes that involve a number of disciplines including audiology (Kane et al., 1994).
At this time approximately 13% of the total population is over 65 years of age; by the year 2040 this group will make up 21% of the total population.
The Occupational Safety and Health Administration (OSHA) determined that a significant health risk is faced by employees exposed to blood and other infectious materials that may contain bloodborne pathogens. The audiologist should maintain a list of residents who obtain hearing aids (see Appendix B).
Older residents who are withdrawn, isolated, and rarely interact with others may be adverse to hearing aid use but may benefit from assistive listening devices. This minimizes misunderstandings and the tendency to ignore people who have significant hearing loss. According to the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, residents who do not have sufficient hearing to use a regular telephone with an amplifier or have a speech impairment that precludes use of standard telephones should have access to text telephones. Regardless of previous hearing-screening outcomes, all infants with or without risk factors should receive ongoing surveillance of communicative development beginning at 2 months of age during well-child visits in the medical home (American Academy of Pediatrics [AAP] Medical Home Initiatives, 2002).
The National Institutes of Health (NIH), through the National Institute on Deafness and Other Communication Disorders (NIDCD), issued in 1993 the “Consensus Statement on Early Identification of Hearing Impairment in Infants and Young Children” (NIH, 1993). The transfer of responsibilities from families to their child develops gradually and increases as their child matures, growing in independence and self-advocacy. Automated ABR measurements reflect the status of the peripheral auditory system, the eighth nerve, and the brainstem auditory pathway. The second condition applies when the local microphone and FM microphone are active at the same time (and the system has no provision for FM precedence). The resulting improvements of signal level and signal-to-noise ratio in the listener's ear are recognized as the primary benefits of FM use ( Ross, 1992). In that it is not possible to consider every configuration of design and implementation, these guidelines are intentionally limited in scope.
Measurements such as full-on gain, SSPL90, and harmonic distortion should be obtained and should be compared to the manufacturer's values. It is for this reason that the recommended input level in these fitting guidelines is 15 dB higher for the FM microphone than for the local microphone. Also, the older population is getting older: within the over-65 age group, approximately 10% are over 85 years and this proportion is expected to rise to 17% by 2040. A registered nurse must sign and certify completion of the entire assessment (Lubinski & Frattali, 1993).
The regulation Occupational Exposure to Bloodborne Pathogens (OSHA, 1991) should serve as the basis for infection control procedures. At a minimum, the list should include the resident's name, hearing aid make and model, battery type, serial number, and which ear(s). Personal amplifiers are less costly than hearing aids and may provide sufficient auditory benefit for individuals with limited financial resources or because of audiologic or non-audiologic considerations do not warrant full-time hearing aid use.
Telecommunication technology facilitates contact with loved ones and is critical to the quality of life of residents of nursing facilities. EHDI systems should guarantee seamless transitions for infants and their families through this process. The statement concluded that all infants admitted to the NICU should be screened for hearing loss before hospital discharge and that universal screening should be implemented for all infants within the first 3 months of life (U.S. In particular, the reader is reminded that the guidelines do not apply to the use of FM amplification with persons who have normal auditory thresholds but who might benefit from improved signal-to-noise ratio because of disorders in such areas as auditory processing or attention.
Both the FM and environmental microphone(s) should be evaluated separately, with care taken to properly position the FM microphone transmitter in relation to the test signal source.
It has been demonstrated that hearing aids are a successful treatment for reversing social, emotional, and communication dysfunction caused by hearing loss (Mulrow et al., 1990). The nursing unit at the facility should receive a revised hearing aid list each time a resident is fitted with a new hearing aid. Equating the two output levels, therefore, equates the two signal-to-noise ratios—thereby eliminating the signal-to-noise advantage that the FM microphone was designed to provide. Under the Aid plus FM condition, however, the signal-to-noise ratio in the user's ear is likely to be less than 20 dB. In addition, hearing aids may improve cognition and functional health status, and decrease depression. In its 1994 position statement, the JCIH endorsed the goal of universal detection of infants with hearing loss and encouraged continuing research and development to improve methods for identification of and intervention for hearing loss (JCIH, 1994a, 1994b). The writers of the 1994 guidelines emphasized the complexity of the topic and acknowledged that there would be conditions under which the “equal output” recommendation would be inappropriate.
The growth of the “oldest-old” population will have a marked impact on the health care system in general and on the population needing long-term care in particular. The volume control setting for each resident should be marked in red and the hearing aid(s) should be imprinted with the resident's name to help prevent loss.
The AAP released a statement recommending newborn hearing screening and intervention in 1999 (AAP Task Force, 1999).
In reviewing those guidelines, the present ad hoc committee felt that profound hearing loss and simultaneous use of local and FM microphones are common enough to warrant particular attention.
In 2000, citing advances in screening technology, the JCIH endorsed the universal screening of all infants through an integrated, interdisciplinary system of EHDI (JCIH, 2000a, 2000b). The committee is, therefore, recommending steps designed to conserve, in the listener's ear, the signal level and signal-to-noise benefits of the FM microphone.
The Healthy People 2010 goals included an objective to “increase the proportion of newborns who are screened for hearing loss by one month, have audiologic evaluation by 3 months, and are enrolled in appropriate intervention services by 6 months” (U.S.



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