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Addressing Hearing Loss to Improve Communication During the COVID‐19 Pandemic

1. Annweiler CBA, Faucon E, et al. Neurological, cognitive and behavioral disorders during COVID-19: the nitric oxide track. J Am Geriatr Soc. 2020. https:// doi.org/10.1111/JAGS-1153-L-May-20. 2. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. 3. Girard TD, Thompson JL, Pandharipande PP, et al. Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med. 2018;6(3):213-222. 4. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. 5. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220. 6. Hughes CG, Pandharipande P, Ely EW. Delirium: Acute Brain Dysfunction in the Critically Ill. Cham: Springer; 2020. 7. Iroegbu JD, Ifenatuoha CW, Ijomone OM. Potential neurological impact of coronaviruses: implications for the novel SARS-CoV-2. Neurol Sci. 2020;41: 1329-1337. https://doi.org/10.1007/s10072-020-04469-4 [Epub ahead of print]. 8. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020; e201127. https://doi.org/10.1001/jamaneurol.2020.1127. 9. Pleasure SJ, Green AJ, Josephson SA. The spectrum of neurologic disease in the severe acute respiratory syndrome coronavirus 2 pandemic infection: neurologists move to the frontlines. JAMA Neurol. 2020. https://doi.org/10. 1001/jamaneurol.2020.1065. Online ahead of print. 10. Alkeridy WA, Almaghlouth I, Alrashed R, et al. A unique presentation of delirium in a patient with otherwise asymptomatic COVID-19. J Am Geriatr Soc. 2020. https://doi.org/10.1111/jgs.16536. Online ahead of print.

Hearing loss affects half of all adults older than 60 years. 3 However, little consideration is given to addressing hearing loss for effective communication. 4,5 Hearing loss limits communication via poor auditory encoding of speech signals, resulting in reduced clarity of speech. Cognitive processing, especially working memory, may also be impacted as adults with hearing loss attempt to make sense of poor signals. The stressful, busy, and noisy hospital 6 environment exacerbates problems, leading to limited treatment understanding and increased frustration.
Importantly, poor communication may mediate the association between hearing loss and health outcomes. Adults with hearing loss have increased risk of 30-day readmission, experience longer length of stay, and are less satisfied with care. 7,8 Moreover, hearing loss is associated with poor functional recovery following intensive care unit admissions. 9 Sensory deprivation may increase risk to experience delirium as older adults are cut off from communication and their environment.
The current extended use of PPE during the COVID-19 pandemic limits visualization of the mouth, preventing lipreading, and acts as a general sound barrier. Even when using videoconferencing equipment, lag and poor image quality may cause significant visual barriers. Coupled with noisy hospital environment (e.g., alarms and constant communication among staff), these visual barriers render the natural sensory substitution compensation methods used by adults with hearing loss as futile. Additionally, distancing may limit access to caregivers or interpreters (American Sign Language) to facilitate conversations during visits.
Thoughtful consideration of addressing barriers is needed ( Figure 1). In the outpatient and telehealth setting, Table 1 Possible mechanisms of COVID-19-related cognitive dysfunction Indirect CNS involvement through inflammatory or immune response Viral encephalitis due to direct CNS invasion COVID-19-related organ failure (lung, heart, kidney, or vasculature) and metabolic dysfunction COVID-19 ICU-related delirium Large-vessel stroke or lacunar stroke syndrome Exacerbation or unmasking of underlying cognitive impairment or neurodegenerative process Medication-related adverse reaction Other unknown mechanism Abbreviations: CNS, central nervous system; COVID-19, coronavirus disease 2019; ICU, intensive care unit.
This article was published online on 2 July 2020. An error was subsequently identified in the Acknowledgment section. This notice is included in the online and print versions to indicate that both have been corrected on 15 July 2020.

Handheld Amplification
Simple handheld devices, such as the Pocket Talker (Williams Sound, Eden Prarie, MN) or SuperEar (Sonic Technology Products, Nevada County, CA), allow users use standard headphones and easily amplify sound to their desire with the volume control to improve communication.

Amplified and Caption Telephones
These telephones are specially designed for persons with hearing loss and provide increased amplification and captioned conversation

In-Room Videoconferencing
Leveraging video technology to communicate with patients may seem like it would pose barriers; however, it allows for providers to speak clearly and show their mouth for lip-reading. In addition, technology companies can amplify frequencies important for speech and use speech to text to caption the video in real time.

Speech to Text
Speech to test applications, such as the software provided by Google (Mountain View, CA), are increasingly available. These applications can provide live transcription of conversation to assist those with hearing loss.

Smartphone Amplification
Applications, such as Google Sound Amplifier (Mountain View, CA), offer high quality noise reduction algorithms and amplification in personal smartphones. These may represent an option when handheld amplifiers are not available.

Remove Background Noise
Reducing background noise by turning down the television and closing the door to noisy areas can improve communication.

Improve Room Lighting
Proper lighting helps persons with hearing loss visualize the speaker to aid in lip-reading, but overwhelming lighting (such a window reflection) can be distracting.

Preprepared Placards
Preprinted placards of common phrases, questions, and comments used throughout the hospital stay or outpatient visit can be helpful. Using large font with high contrast color can further help older adults.

Whiteboards or Tablets
Although it can be cumbersome, using whiteboards to write out conversation or tablets to type out conversational items represents a last resort option.

Ensure Attention
Conversation and communication require both parties to be attentive and ready.

Face-to-Face Communication
Ensuring that the listener can see your face to leverage lip-reading skills is important. This also ensures sound is being directed at the listener rather than in another direction. This means looking up from charts and away from computers when possible to communicate.

Visualization of the Mouth When Possible
Covering the mouth area is a must to prevent spread of the COVID-19 virus. However, any opportunity possible to use clear masks or distance videoconferencing without masks can help people who consciously and subconsciously lip-read

Speak Slow and Low
Age-related hearing loss generally occurs in higher frequencies and limits the clarity of speech. Slowing down and using a slightly lower tone can help listeners with hearing loss follow the conversation.

Do Not Shout
Most age-related hearing loss is an issue of clarity rather than volume. Although some increased volume helps, shouting often further distorts information.

Give Context to Conversation
By placing the conversation in context, it helps the listener decipher and fill in the gaps of difficult to hear words. This means adding supporting information like common descriptions or actions associated with topics and adding redundancy to information presented.

Rephrase Rather than Repeat
Rephrasing can help the listener gain new context about the conversation and use words that are easier to hear. Repeating can create a frustrating negative feedback loop. Technology offers additional solutions. Handheld amplifiers can increase signal volume but require sterilization considerations (i.e., one device cannot be shared) and are not compatible with videoconferencing technology. More advanced solutions through smartphones, such as speech to text and amplifier applications with customization for user preferences, should be considered. Using smartphone applications eliminates the need for sharing products in some cases and may be integrated into videoconferencing technology. Moreover, simple methods, such as preparing common questions and statements on placards with large text and using whiteboard for written statements, can help facilitate communication.
Providers should adopt changes to communication beyond the environment and technology to accommodate the needs of adults with hearing loss across settings. The reductionist approach that increased volume from an amplifier is all that is needed oversimplifies hearing loss. Many adults with mild/moderate hearing losses (36 of the 38 million adults with hearing loss in the United States) benefit immensely from communication techniques, including ensuring attention, facing patients, speaking slowly rather than shouting, and choosing to rephrase rather than repeat information. These tactics also compliment and augment the technologic and environmental modifications noted above. Moreover, these techniques improve all communication regardless of hearing loss status and could go a long way in improving patient-provider communication in the United States.
Fundamental to addressing hearing loss is the need for better surveillance. Many with more mild losses do not recognize their hearing loss as it may pose few problems in everyday life. However, the demanding healthcare communication environment, especially during the pandemic, may pose significant barriers. At minimum, healthcare settings should ask about hearing loss and incorporate these methods to intervene with struggling adults.
Communication is vital to patient-centered care. 10 Although improvements have been made to empathetic communication training, little consideration has been given to the communication needs of the millions of Americans with hearing loss. Addressing hearing loss to improve communication and treatment understanding could improve rehabilitation following intensive care unit stay and reduce risk of a 30-day readmission. Moreover, improved sensory awareness may prevent delirium, whereas improved patient-provider rapport may improve satisfaction with care. Although immediate accommodations must be made during this crisis, long-term consideration of sustainable approaches to address hearing loss are equally important.