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Recently, I've been trying to organize some of the columns and articles I've written over the past ten years. For audiologists, the audiogram is such a basic dimension and so self-evident that its explanation, after the thousandth time, is often unconsciously truncated and simplified.
Yet in spite of the recent advances made in diagnostic audiological evaluations, and they are truly impressive, the information and insights provided by the simple audiogram can still provide the most pertinent information to explain the behavioral implications of a hearing loss. This is a figure of an audiogram (with frequency in Hz along the top and Hearing Loss in decibels down the left side).
In addition to their energy locations on the frequency axis, speech sounds also vary in intensity.
Looking at the audiogram again, and relating it to the speech banana, it is apparent that a person with this hearing loss will hear more of the lower frequency speech sounds than the higher ones.
I don't want to give the impression that the perception of vowels is unimportant on the contrary, it is and can be very important -- only that by not actually hearing some of the consonants, hearing-impaired people have to struggle to fill in the acoustical gaps they produce in the stream of speech. This is a figure of an audiogram (with Frequency in Hz along the top and Hearing Loss in decibels down the left side). What I have often found useful in explaining the need to understand the audiogram is commenting that it is possible for someone to be completely deaf and have completely normal hearing in the same ear at the same time. There is another dimension of hearing loss that is sometimes also included on an audiogram and that is the discomfort threshold. The dilemma of the threshold of discomfort for hearing-impaired people is that it is often the same as that observed with normally hearing individuals (perhaps 90 dB or so across frequency). Finally, it is important for people to be familiar with the details of their audiogram so that they can track any changes with time. A weekly blog based on PodMed, Johns Hopkins podcast looking at the top medical stories of the week for people who want to become informed participants in their own health care. Screening tests are largely effective in identifying hearing loss in this population, the USPSTF found, and many of them can be easily administered in a primary care setting. Other topics this week include, also in Annals, factors related to the effectiveness of screening colonoscopy, lead and gout in the same issue, and a CDC warning on use of pain medications in kids after tonsillectomy.  Until next week, y'all live well.
Thanks for your comment; as you know, there are many issues with hearing aids, especially their cost and lack of standardization.
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If you think you might have a hearing loss, call Neurosensory on our toll free number 1300 965 513. Do you avoid certain social situations on the request of your loved one as a result of the hearing problem?
Do you think that your loved one is prioritising vanity over their capacity to hear properly?  Does this make you feel resentful?
If you have answered yes to the questions listed, it may indicate that you and your loved one are having some emotional challenges as a result of the hearing loss. As historically many people have associated adult onset hearing loss with aging, there can be reluctance for people to identify with having a hearing impairment. It is recommended that you discuss the negative impact of the untreated hearing loss with your loved one, to ensure that they really appreciate why there is a need to address the hearing loss. Charles Bonnet Syndrome, a common cause of hallucinations in the elderly, typically manifests in older patients with hearing loss. Many hallucinations that strike elderly people are caused by systemic changes in the brain. The most common causes of hallucinations in the elderly are dementia, Alzheimer's disease, side effects of medications, and psychosis. When an elderly person is exhibiting symptoms of dementia, he can sometimes experience paranoia along with delusions and hallucinations that are either auditory or visual. When people with dementia have hallucinations, it is typically due to systematic changes that occur within areas of the brain. Auditory or visual hallucinations in the elderly can occur with a condition known as Charles Bonnet Syndrome (CBS). Sometimes a particular sleep aid can trigger hallucinations, especially if an older person is not accustomed to periods of deep sleep. She thinks I am staying in the home and not going to see her and have left a recording of myself so she can speak to me when she rings. How can we (or can we) reassure her and should we be very sympathetic and listen attentively, matter of fact and say now Mum you know that's not true, don't really know how to handle it. As I was looking through them, it became apparent that I've neglected to discuss what is perhaps most important hearing dimension of all, the simple audiogram. Perhaps the most important insight of all is an appreciation of how specific audiograms impact upon the perception of certain speech sounds. Frequency (or pitch) is depicted on the horizontal axis, from low frequencies on the left (250 Hz) to high frequencies on the right (8000 Hz).
This is a general, but static, representation of the acoustical speech energy across frequency.
In reality, however, conversational speech is a dynamic and time-varying event, with one speech sound (phoneme) following another in a rapid succession. Those individuals with superior linguistic skills would perform this task better than those with lesser skills. Somebody with this type of hearing loss actually hears better at 250 Hz than the one whose audiogram is shown in figure 1, but much worse at 1000 Hz and higher. Without a hearing aid (and even with one) this person needs to depend upon visual cues (speechreading) to supplement the information received through hearing. Looking at this audiogram, we can state that this person has perfectly normal hearing in the left ear, but this is only true at 250 Hz and 500 Hz. In a room full of people with hearing loss, it is doubtful that any two would exhibit exactly the same audiogram for both their ears.
While an audiogram can help explain much of the auditory behavior of a person, it does not explain it all.
But because their threshold of hearing is elevated, but not their threshold of discomfort, this means that people with hearing loss generally have a reduced listening area (or narrow dynamic range). One issue remains a working definition of exactly what constitutes a hearing loss because of variability in frequency and intensity thresholds used for testing, but population-based estimates indicate that some 20-40% of adults older than 50 have some hearing impairment, and that percentage rises to 80% of those 80 years of age and older.  Another problem is that since hearing loss is usually subtle and incremental, the subject himself may fail to recognize or deny any hearing compromise.

Subsequently, assessing more hard outcomes with regard to managing hearing loss would be possible. Hearing aids can be easily carried by the patient and can be fitted over the top of the ear. However, Johns Hopkins Medicine reserves the right to remove any such postings that come to the attention of Johns Hopkins Medicine which are deemed to contain objectionable or inappropriate content. It looks at the top medical stories of the week for people who want to become informed participants in their own health care. A patient may believe that an object is in front of him, and so he believes he is "seeing" something that is non-existent, or hearing sounds and noises that do not exist. These changes that can contribute to delusions and hallucinations in the elderly patient generally occur within the frontal and temporal regions of the brain. This condition typically manifests in older patients with hearing loss or deafness, or who have limited sight or total blindness. You constantly have to repeat things you told her only 5 - 10 minutes prior, yet her long term memory is decent. She also has become quite irritable, particularly in the evenings and is eager to get even family members out of her house. Now he is seeing things that aren't there -- stuff like airplanes crashing into water, dark shadows with the figure of a human and sometimes he thinks he is in the hospital.
I've been around elderly people who have had bad reactions to Xanax or prescription sleeping pills like Ambien.
The nurse who comes in with their nighttime medications may be a trained assassin, or an image on the television could become a terrifying monster. The only advice I could give is to try to maintain that patience and keep visiting, even when she is increasingly hostile.
For people who may not even have heard of a pure-tone audiometer before they stepped into the audiologist's office, this is a quite understandable.
Without including speech in the equation, it is simply not possible to intelligibly discuss the audiogram. For some specific purposes, it may be useful to test 125 Hz as well as some frequencies higher than 8000 Hz (for example, a progressive hearing loss above 8000 Hz can occur with certain type of ototoxic medications). Some speech sounds, such as vowels are predominately composed of low frequency energy, with less of their power in the higher frequencies. The specific acoustical composition of speech sounds is partially shaped by the preceding and following sounds in an utterance. Looking at the speech banana, it is apparent that while a great deal of low frequency vowel energy will be perceived, practically no high frequency consonants would be. Some people, because of their superior ability to utilize some of the secondary cues in a speech signal referred to above, or their superior linguistic ability may do better than these comments would suggest.
Or one could assert that he is completely deaf in the left ear, as again indeed he is (but only at 4000 Hz and higher). There would be differences in degree of hearing loss at the different frequencies as well as divergences between the ears. We know that there are other dimensions to auditory experiences that cannot be explained by the audiogram. Elderly patients who have had or are recovering from a stroke have been known to experience hallucinations as well. Delusions differ from hallucinations, in that the patient doesn't necessarily see or hear things that aren't present, but he may have a distorted view of situations around him. When injury to the brain affects these significant areas, ability to reason, as well as visual disturbances can occur.
In addition to the patient having visions of things that do not exist, he may also become delusional and imagine a situation or event that has not actually occurred. Recently on occasion she has had hallucinations to the point she sees people outside her house skiing or ballroom dancing. They often get caught in a semi-awake situation and become convinced there are monsters in the room or visitors are really gangsters or plants have come to life.
When visiting elderly hospital patients, it might help to open the windows in order to provide light cues to their brains.
A simple urine test can confirm whether she does, and antibiotics usually clear them up fairly quickly. I know it’s difficult to maintain a positive relationship with an elderly person who is suffering from these kinds of hallucinations, but since dementia is so common in elderly people it is often ignored and that can make it a lot worse.
Even though just about everybody who receives a hearing aid has his or her hearing tested with a pure-tone audiometer, not everybody receives a comprehensive explanation of exactly what the results mean and what the implications are for them. To expect them to fully understand how the pattern of their hearing loss impacts upon their listening behavior is not very realistic.
This, after all, is the signal we are most interested in hearing (not to minimize the specific needs of certain groups of people for other types of sounds, such as musicians).
The amount of hearing loss is shown on the vertical axis with the higher numbers indicating a greater degree of hearing loss. The intensity of all other speech sounds in the English language fall within these bounds (note, however, that this does not take into consideration inflected speech, which will move the entire speech banana up and down).
These specific effects, such as the unique modifications in vowels made by different preceding and following consonants, are actually secondary cues that can be helpful for understanding speech.
Yes, but only with some difficulty and then only if the talker is close by and raises his or her voice slightly.
Looking at the audiogram, we can understand somewhat why this should occur: they are not hearing the full range of high frequencies where many of the consonants have their predominant energy. An individual with this audiogram would have even more difficulty in understanding speech than the one whose audiogram is shown in figure 1.
But there are limits to even the keenest brain and the most developed auditory integration ability; at some point, people do need to detect speech energy in order to understand a spoken message.
While there is merit and often necessity to this practice, there is also the danger of oversimplification. In the right ear, the hearing loss at each of the three frequencies is the same, also resulting in an average of 40 dB. People with bilaterally symmetrical hearing losses (that is, with similar hearing losses in both ears) may have quite different auditory experiences than people with bilaterally asymmetrical hearing losses. Still, the audiogram is a good place to begin when trying to understand someone's speech perception problems. Sounds delivered by the hearing aid below the threshold of hearing would not be audible; those exceeding the threshold of discomfort would not be tolerated (the hearing aid user would either turn the volume control down or simply remove the hearing aid).

It is a good idea for people to keep copies of all the audiometric tests administered to them so that comparisons can be made (and to be sure that they are dated correctly). Patients with CBS may also see visions of animals or other designs and sights that do not exist. She is absolutely adamant this is all true and cooked dinner for them all yesterday and was surprised that they all refused to eat anything.
If an elderly relative complains about a lack of sleep, my suggestion would be to have a doctor prescribe the lowest dose possible at first and sneak up on the problem. And even for those that do, at a time when prospective hearing aid purchasers are being inundated with new information, anxious about the test results, and worried about the cost involved, much of this explanation will be forgotten or misconstrued the time several weeks have passed. Indeed, the ability to take advantage of these cues may help explain why some people seem to understand speech much better than one would predict on the basis of their audiogram.
There are, unfortunately, many people with audiograms similar to this who do not, for one reason or another, wear hearing aids.
And we know from many years of research, that consonants contribute more to the understanding of speech than vowels.
In truth, they may be hanging on to speech comprehension with their finger tips; any further distortion in the speech signal, such as someone talking rapidly or in a foreign accent, or in the presence of noise and reverberation, and they lose it.
These people depend upon whatever low frequency energy they do receive for comprehending speech. And this person is missing just too much of the speech signal to expect easy communication in any oral exchange. Or perhaps someone's hearing loss is described by employing a single figure (derived usually from averaging the hearing losses at 500 Hz, 1000 Hz, and 2000 Hz). But it should be apparent, just from a visual inspection, that these two ears would perceive speech quite differently. All it would take would to resolve this verbal conundrum would be an understanding of what the audiogram actually signifies (degree of hearing loss across frequency). While most people exhibit a gradually sloping hearing loss across frequency (such as in figure 1), some people have audiograms that are very atypical.
Hearing losses greater than about 70 dB may produce qualitatively different effects than losses less than this. In brief, the audiogram is perhaps the most important indictor of one's hearing function, the particulars of which everybody who has a hearing loss should be aware of. These hallucinations typically happen to patients who, at some prior period in life, had been able to see or hear. Her hearing has diminished to the point where you have to yell for her to understand what you are saying. Medical support services , Surrey - UK, have been pretty useless, passing Mum's case between hospital, GP, health care professionals, private care companies etc.
She is pretty much blind now (she's 95) but she was seeing trees and talking strangely, like going in and out of hallucinations.
She is 101 years old, no history of CVA although she has high BP moderately controlled with meds.
It can be hard caring for an elderly person suffering from dementia, but maintaining a strong bond is always helpful. I know that I'm often bemused when I hear what some people recount to me what they think their audiologist told them about their audiogram and its implications. Only the shaded area of the speech banana above the threshold curve is audible; portions below will not be perceived.
Still, there are certain anchor locations for all speech sounds, as displayed on the speech banana, and these can offer valuable insights in understanding the effects of differing hearing losses.
And this audiogram depicts only a gradual high frequency hearing loss; were this person's audiogram something like the one shown in figure 2, problems with speech perception would be even more severe. The presence of noise and reverberation (not exactly an uncommon occurrence in our society!) would have a disproportionate effect on them, since it would mask the only speech energy they are able to receive. Quite clearly this example demonstrates that the shorthand description of a hearing loss with a number or a verbal label can be quite deceptive. This would include people with rising thresholds with frequency as well as those with perfectly normal hearing at the very low and high frequencies, but with moderately or severe hearing losses in the mid frequencies.
In this instance, it would be more of a challenge to package sound within this more restricted dynamic range (this is where advanced technology can be very helpful, as in hearing aids with fast acting automatic gain control circuits). She remembered what she had for dinner the night before, then she would say there's a nice cottage and that she's going to get her eyes fixed tomorrow. After that point, people will usually begin to display some communication difficulties because of the elevated hearing thresholds. In spite of portrayals to the contrary on some charts, no speech sound can be pinpointed to a speech point on the audiogram; all of them spread their energy somewhat along some segment of the frequency spectrum. For example people with an average 40 dB hearing loss are considered to have just a moderate hearing loss. The varieties are almost (but not quite) endless and many of these differences have behavioral implications.
A hearing loss may also involve central auditory pathways and these, too, may affect speech perception quite severely. I'm sure they will find brain atrophy at her age, but was wondering if she might benefit from dementia meds? The higher the number, the greater the impact of the hearing loss (referring only to the unaided condition). But such a shorthand label does not reflect the pattern of a hearing loss, a pattern, as we have seen, that may lead to more insights into the behavioral implications of a hearing loss. Nevertheless, in spite of all these caveats, the audiogram is still the most fundamental auditory dimension of all. The 100 dB point should not be confused with a 100% hearing loss, which is a total lack of hearing.
Hearing sensations do continue past this point, with some audiometers extending this vertical range to 120 dB.

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