Fatigue and Hearing Loss

What is fatigue?

Fatigue is a term used to describe tiredness, typically over a long period of time. It can be used to refer to physical or mental fatigue, a combination of both, or a symptom. Broadly, it can be used to refer to feelings, or behaviorally, as various measures of physical or mental performance [1].

How is hearing loss related to fatigue?

There is evidence to suggest that people with hearing loss are at a higher risk of experiencing fatigue than those who have normal hearing, due to increased listening effort [1, 2, 3]. A recent cross-sectional study examining the association between hearing loss and self-reported fatigue in 3,031 participants in the US (as part of the National Health and Nutrition Examination Survey) showed that those with hearing loss were more likely to report fatigue for more than half the days and nearly every day than not having fatigue even when other factors such as age, sex, race, ethnicity, education, smoking, drinking, noise exposure, and body mass index was accounted for [4]. The study reports the relative risk ratio (RRR), which is the probability of the event occurring in the group with exposure (in this case hearing loss) versus those without. A relative risk ratio of greater than 1 means that the event is more likely to occur if there was exposure. Every 10-dB HL–worse of audiometric hearing was associated with a higher likelihood of reporting fatigue for nearly every day (RRR = 1.24; 95% CI, 1.04-1.47) but not for more than half the days [4].

What implications does fatigue have for those with hearing loss?

Fatigue, particularly chronic fatigue can result in:

1. reduced quality of life
2. deficits in cognitive processing (maintaining attention, thinking quickly, clearly, or efficiently)
3. reduced workplace productivity and safety [1]

Do hearing aids help?

There is not definitive evidence yet. The quality of evidence available from a systematic review to answer the questions of whether hearing loss has an effect on fatigue and whether hearing device fitting has an effect on fatigue is “very low” [5]. Having said that the review did highlight support for these questions.

There is some support that hearing loss increases fatigue; the “very low” risk categorization is due to lack of homogeneity among studies, and that there haven’t been any randomized clinical trials conducted thus far. Evidence from self-report measures did not support the hypothesis that hearing aids reduced fatigue in full, although the evidence was more promising for cochlear implants than hearing aids. There was a positive result from one study that used behavioral measures, suggesting that more studies with validated and consistent fatigue measures are needed to examine this hypothesis cogently.

A longitudinal study by the same group looked at the effect of hearing aids before fitting, at 2 weeks, 3 months, and 6 months post-fitting and found that hearing aid fitting significantly reduced listening (-related) fatigue but not general fatigue. Social activity and participation levels also were shown to be increased in the hearing aid group relative to the control group [6].

Given the role of motivation in the framework of listening effort, it is possible that motivation may directly or indirectly contribute to listening fatigue [3]. The interplay between fatigue and motivation to wear hearing aids has yet to be examined.

What to do about fatigue?

The following practices help with general fatigue, and likely listening fatigue:

• healthy diet and exercise
• good and consistent sleep schedule
• lower stress
• socializing that gives enjoyment

If you have hearing loss and own hearing aids, wear that hearing aid you purchased…and do things you love.

References

1. Hornsby, Benjamin W. Y., Graham Naylor, and Fred H. Bess. “A Taxonomy of Fatigue Concepts and Their Relation to Hearing Loss.” Ear & Hearing 37, no. 1 (July 2016): 136S-144S. https://doi.org/10.1097/AUD.0000000000000289.
2. Hornsby, B. W. (2013). The effects of hearing aid use on listening effort and mental fatigue associated with sustained speech processing demands. Ear Hear, 34, 523–534.
3. Pichora-Fuller, Kathleen, M., Sophia E. Kramer, Mark A. Eckert, Brent Edwards, Benjamin W. Y. Hornsby, Larry E. Humes, and et al. (2016). “Hearing Impairment and Cognitive Energy: The Framework for Understanding Effortful Listening (FUEL).” Ear and Hearing 37, no. 1: 5S-27S.
4. Jiang, K., Spira, A.P., Lin, F.R., Deal, J. and Reed, N. S. (2023). Hearing Loss and Fatigue in Middle-Aged and Older Adults. JAMA, 149, 8, 758-760
5. Holman, J.A., Drummond, A., and Naylor, G. (2021). The Effect of Hearing Loss and Hearing Device Fitting on Fatigue in Adults: A Systematic Review. Ear andHearing, 42 (1), 1-11.
6. Holman, J. A., Drummond, A., and Naylor, G. (2021). Hearing aids reduce daily-life fatigue and increase social activity: a longitudinal study. Trends in Hearing, 25, 23312165211052786.

Copyright © 2023 Vidya Krull. All Rights Reserved.

How will we be when we are old?

Hiking in the Smokies, I was on the Chimney Tops Trail a few years ago. This is one of the more rugged trails that the majestic mountains have to offer, and if you make it to the top, you are rewarded with a panoramic view. It was a hot day, the rocky ledge at the end of the trail (picture attached) was pretty hot to grip, and there was no way I was getting to the top without gripping it. Long story short, I stopped just a few yards before I got to the top, where the view was brilliant as well. On the way back, I saw an old couple, likely in their 80’s, heading towards the top. I don’t know if they made it, but they sure looked determined. When I am that age, I would like to be like them – enjoying life and in good health.

What will we be like when we grow old? Will we have experienced all that life has to offer and look back upon it with satisfaction? Now I am beginning to get philosophical. In any case, researchers at the Center for Universal Design (CUD) at the North Carolina State University have come up with an ‘aging suit‘ that lets the wearer experience at least the physical challenges that are commonly associated with aging. The idea is to let users experience the difficulties older adults may have in performing a physical task, perhaps a task as simple as filling a jug of water. The ultimate goal is for the suit to aid in the design of products and workplaces that are more friendly to older adults. What a fantastic idea! Of course, the suit will not model the metabolic changes within the body itself, but even so, it offers a chance for young adults, or even caregivers, to experience the physical limitations faced by older adults: parents, relatives, or people living in assisted communities. That, in itself, is a valuable experience.

Several projects underway at the CUD are aimed at fulfilling their mission: improving environments and products through design innovation, research, education and design assistance. All projects seem to use the principles of Universal Design, which are listed on their website as:

1. Equitable Use: The design is useful and marketable to people with diverse abilities.
2. Flexibility in Use: The design accommodates a wide range of individual preferences and abilities.
3. Simple and Intuitive Use: Use of the design is easy to understand, regardless of the user’s experience, knowledge, language skills, or current concentration level.
4. Perceptible Information: The design communicates necessary information effectively to the user, regardless of ambient conditions or the user’s sensory abilities.
5. Tolerance for Error: The design minimizes hazards and the adverse consequences of accidental or unintended actions.
6. Low Physical Effort: The design can be used efficiently and comfortably and with a minimum of fatigue.
7. Size and Space for Approach and Use: Appropriate size and space is provided for approach, reach, manipulation, and use regardless of user’s body size, posture, or mobility.

Innovators, companies, and for that matter, any institution that sells a product or provides a service to the public would do well to follow these principles. Take a minute to look at your surroundings and think about whether the products you see are, indeed, compatible with universal design principles. I end this post with two questions for you:

What products or services can you think of that can be enhanced by universal design? And how would you like to be when you are old?

Copyright © 2023 Vidya Krull. All Rights Reserved.

Confessions of an audiologist: Listening in a noisy restaurant

It was a friend’s birthday party and the setting was a nice restaurant that we hadn’t been to before. I was excited to meet friends I hadn’t seen in a long time. When we arrived, there were only four people at the table. We inquired after each other and shared the latest happenings while taking in the ambience of the restaurant. The restaurant itself was quite small, but tastefully decorated. We easily had the largest table with 13 settings, located in the center of the restaurant, and there were several other smaller tables of threes and fours. As the food arrived and the conversation started to flow, I noticed that the restaurant had, by then, become full.

It was probably a half hour into the meal when I suddenly became aware that I was having difficulty following conversations.  There were just too many to keep track of and even though people were talking louder to make themselves heard, it wasn’t cutting it. Fortunately, I was sitting next to my spouse and could hear what he was saying. I tried to carry on a conversation with my friend sitting next to me, but found it difficult to do so while other pieces of conversations floated into my awareness: my spouse referring to me in some conversation, a friend talking about her last vacation, another talking about her pregnancy. The waitress sauntered in and asked cheerfully, “Is everything OK?”

Well, everything was not OK (“Yes, thank you!”). I only wish I could’ve heard the conversations that I participated in better. My thoughts turned to the difficulty people with hearing loss must have in noisy restaurants. Here I was, a “young, normal hearing” person (as a hearing scientist might describe me), having a tough time. As a student clinician, if a hearing-impaired client were to have mentioned difficulty understanding speech in a restaurant setting, I would have imparted the following advice:

1. Request a seat away from potential sources of noise – like the kitchen, stage, or the bar
2. If possible, request a table that has good lighting, so you can see the person you are talking to
3. Sit facing to the person you would most like to talk to, so you can see his/her lips (and lip-read)
4. Ask for clarification when you miss parts of the conversation
5. Avoid peak times when the restaurant is busiest and most noisy

My experience had just proved that these tips, although based in sound reasoning, do not always work. Our table was away from the kitchen and the restaurant did not have a bar or stage. It wasn’t cutlery clattering, or the sound of muted music that was bothering me. The noise was what hearing scientists would call ‘competing speech’, i.e., speech from other talkers that wasn’t part of the ‘target’ conversation (loosely defined here as the conversation I was most interested in).

Listening in noise of any kind is a difficult task because the energy in the noise tends to inundate (mask) the target speech (i.e., energetic masking). Listening in competing speech involves much more than energetic masking. This is because competing speech is, well, also speech. It is therefore difficult to separate speech that we are interested in (target) from speech we are not interested in (masker). This type of masking is referred to as ‘informational masking’. Understanding speech is made more difficult by the fact that the ‘target’ keeps moving (literally). In the mix of six talkers, you may be attending to one talker at some point and then switch to a different talker. Every time I heard my name, or heard a reference to me or my spouse, the conversation which until then had been the background suddenly became the target.

There was plenty of lighting in the restaurant, so that really wasn’t an issue. I had better luck hearing my spouse, who was sitting next to me, than the birthday girl, who sat right across from me. I should clarify here that I am really poor at lip-reading.

I would not have hesitated from asking for clarification if it had been a smaller group. As things were, with 13 people and at least six conversations at any given time, I did not even entertain the idea of asking for clarification. I would have loved to schedule the dinner for a time when the restaurant was less busy, but come on – who am I kidding? It is impossible for friends to find time to get together these days, given our busy schedules. It was actually quite a miracle that so many of us could get together at the same time. And what fun is a birthday dinner that is held at 4 in the afternoon anyway?

When I related my experience to my parents, they chuckled knowingly. We shared experiences about conversations where we had each misheard in noisy situations and laughed about it. Even though we didn’t express it, each of us knew that although we were able to laugh about it now, it wasn’t at all funny when it happened.

How might a hearing aid user fare in such a listening situation? If he were to switch to the program with the directional microphone, then the microphone would pick up conversations emanating from directly in front of the user and turn down ‘background’ noise. However, we are not always facing the talker in situations like these. Someone sitting next to us or two tables down might enter into the conversation and it may take a while for us to realize that, determine who it is, and turn to face the new talker. This is more difficult when the conversation is fast-paced and there are multiple participants. So directional microphones, although generally useful, would help only to the extent that the target conversation emanates directly in front of the user.

The goal of noise reduction algorithms, present in modern digital hearing aids, is to enhance the signal-to-noise ratio (i.e., level of the speech relative to the level of the noise) by reducing the background noise. However, despite many advances in noise reduction technology, it is least effective when the background is competing speech.

Digital hearing aids also use compression to turn down loud sounds and make sure that sounds remain comfortable to the hearing aid user. However, although this feature will make sounds comfortable to the wearer, it is unlikely to help with speech understanding in the sort of listening situation described here. The use of FM systems may also help in such a situation, but is more useful in a more structured listening environment (e.g., classroom or conference setting). For example, an FM system may work better in a conference setting, where the microphone can be placed in the center of the table and speakers can pass around the microphone to others as they speak.

This is not to say that hearing aids are not helpful. Quite the contrary; you are much better off with your hearing aid than without it. What I do want to emphasize here, though, is that there are limits to what current hearing aids can do and it is important to realize those limits and set realistic expectations. Listening in competing speech is difficult even for people with normal hearing.  The ability to separate target speech from competing speech involves focusing on the target speech and ignoring the competing speech. You have to do this while also trying to make use of all the contextual information available, and if you can the visual cues from lipreading as well. In other words, listening in noise involves a lot of ‘top-down processing’, where you are using cognitive resources to enhance your understanding of ‘bottom-up cues’ (i.e., signal processed by your hearing aid, and by the ear). So successful understanding of speech in such noisy backgrounds depends not only on one’s auditory status, but also on their cognitive abilities.  In older adults, cochlear hearing loss may be accompanied by deficits in the central auditory system and cognitive declines.  A hearing aid by itself cannot address central and cognitive deficits, although it is able to address audibility. I would likely give similar advice to a hearing-impaired client today, but with the caveats I just mentioned. Food for thought…

 Copyright © 2023 Vidya Krull. All Rights Reserved.

Executive function as a predictor of soccer success

Sorry for the brief hiatus from the blog, but I am glad to be back and blogging again. I have lots of thoughts to share, so without further ado, I’ll get right down to it.

I am not sure if you came across an article in the NY Times a few days ago that talked about the findings from a study (Vestberg et al., 2012) on brain function in soccer players. This study is interesting to me because it talks about executive function.

Executive function is a fairly heterogeneous construct that refers to “control processes responsible for planning, assembling, coordinating, sequencing, and monitoring other cognitive operations” (Salthouse, Atkinson, and Berish, 2003). The idea is that executive function is an orchestrator of many cognitive processes and helps co-ordinate their activity. Working memory, inhibition, attentional capacity, and inductive reasoning are a few of the cognitive processes controlled by executive function. Neuroimaging studies have shown the neural substrates of executive function to be fairly heterogeneous, but generally point to the frontal lobes of the brain, as well as the parietal areas as loci (see recent review by Collette, 2006).

The goal of the study was to see if executive function could predict success in soccer players. Executive function was a measure of choice because, as the authors point out, good soccer players have to use some of the many cognitive processes characterized by executive function a lot of the time. The player has to use “excellent spatial attention, divided attention,working memory and mentalizing capacity” and “quickly adapt, change strategy and inhibit responses” (Vestberg et al., 2012). First, researchers compared performance on tests of executive function (part of the D-KEFS or the Delis-Kaplan Executive Function System) across high and low division soccer players. They found that soccer players in the high division group had better scores on the tests than those in the low division group, even after controlling for age, position of play, and level of education. Both divisions performed better than standard (normative) performance on these tests. Two seasons later, they correlated the results from the tests of executive function to commonly used objective measures of soccer success – goals and assists made by these players during the interim. They found moderate significant correlations between the ‘points’ derived mathematically from the goals and assists and performance on measures of executive function, indicating that the tests of executive function they used could successfully predict success in soccer.

Notably, the moderate correlation they reported still only explains about 29% variance in objective measures of soccer success, suggesting that many other factors may also contribute to successful performance in soccer. I am not a soccer fan, but I am speculating that these could be factors like training and indicators of fitness and health.

Does this mean that soccer players are smarter? Or that soccer players who are better at the game are smarter? Not really. Generally, tests of executive function have not shown a relationship to general intelligence or IQ.  I don’t think that there is anything special about soccer, or soccer players, as distinctive from players of other sports as it relates to the ability to strategize, plan, update information in your memory throughout the game, or inhibit instinctive responses, use inductive reasoning, or any number of things commonly associated with executive function. If you did a study with chess players, or even with cricket players, you would likely find similar results. Then does this mean that playing sports can enhance your brainpower? I doubt it will enhance your brainpower any more than playing Sudoku or learning a new language – all activities that are mentally stimulating. It likely will make you more fit!

Does executive function change with age? Yes, executive function is one of the many cognitive processes that has been shown to decline with age. As I mentioned in an earlier post, there is sufficient evidence that there are interactions between sensory and cognitive processes in the aging human auditory system. Perhaps this will make an interesting topic for another post sometime. Enjoy reading and a penny for your thoughts!

 

REFERENCES:

1. Vestberg, T., Gustafson, R., Maurex, L. et al. (2012). Executive Functions Predict the Success of Top-Soccer Players. PLoS One, 7, 4, e34741.
2. Collette, F., Hogge, M., Salmon, E., and Van der Linden, M. (2006). Exploration of the neural substrates of executive functioning by functional neuroimaging. Neuroscience. 139, 209–221.
3. Salthouse, T.A., Atkinson, T.M., and Berish, D.E. (2003). Executive functioning as a potential mediator of age-related cognitive decline in normal adults. Journal of Experimental Psychology. 132, 4, 566-594.

 Copyright © 2023 Vidya Krull. All Rights Reserved.

Cigarette smoking and hearing loss

There are already several compelling reasons to quit smoking, but here is another one. Latest research provides compelling evidence that cigarette smoking is associated with hearing loss (Cruickshank et al., 1998; Cruickshank et al., 2012).

As part of an ongoing population study called the Beaver Dam Study, researchers are looking at the relationship between smoking and hearing loss. The study has a sample size of 4,926 individuals between the ages of 48 to 92 years so far (Cruickshank et al., 2012). Over a period of 15 years, researchers periodically examined hearing sensitivity (audiogram and other measures of hearing), habits related to smoking, and history of noise exposure, in addition to other measures. Cessation of smoking or reduction in consumption was also recorded.

Statistical analyses revealed that over 15 years, the hazard ratio (risk of developing a hearing loss for smokers, relative to non-smokers) increases significantly from 1.19 to 1.36. Cigarette smoking contributed as much as 5% to the risk of developing hearing loss in older adults.

To put things in perspective, a 60-year old person who smokes has a 65% probability of developing a hearing loss. For someone the same age who does not smoke, this risk is lower (56.1%). Researchers have suggested that the effect of smoking on hearing may directly or indirectly have to do with inflammation and constriction of blood vessels.

Research is underway to further examine the mechanisms by which smoking affects hearing. The silver-lining is that the risk of developing a hearing loss was found to decrease substantially when participants stopped smoking. Risk continued to decrease with increasing duration of smoking cessation. It is never too late to quit smoking.

REFERENCES:

1. Cruickshank, K., Nondahl, D., Dalton, D. et al. (March, 2012). Cigarette smoking increases the risk of hearing impairment. Podium presentation at the meeting of the American Auditory Society, Scottsdale, Arizona.
2. Cruickshank, K., Klein, R., Klein, B.E.K. et al. (1998). Cigarette Smoking and Hearing Loss: The Epidemiology of Hearing Loss Study. Journal of the American Medical Association. 279, 1715-1719.

Copyright © 2023 Vidya Krull. All Rights Reserved.

 

I don’t need hearing aids

Last year, AARP (formerly the American Association for Retired Persons) and ASHA (American Speech-Language-Hearing Association) administered an online/telephone based survey to 2,232 Americans who were older than 50 years of age. The survey had to do with key issues regarding their hearing health: attitudes, needs, knowledge regarding hearing help, and barriers to hearing health-care. It came up with some findings that affirmed what most audiologists already know:

Many older adults may suspect that they have a hearing problem and acknowledge that it is an important health concern, but do not seek help. Only 43% of the respondents had their hearing checked in the year preceding the survey. Where I am not aware of any specific guidelines for frequency of hearing testing in this age group, it is a good idea to get hearing tested annually, especially if there is a concern hearing is at risk. Free hearing screenings are periodically available through health networks and/or local universities with speech and hearing programs.

Among older adults who own hearing aids, many do not use them consistently (39%), even though they might feel that it improves their quality of life. One of the problems associated with inconsistent use of hearing aids is that it makes it difficult to get used to them. There is a period of adjustment associated with the use of hearing devices, just like with any other equipment. Inconsistent use is an issue because it eventually results in dissatisfaction with performance.

Hearing loss affects social relationships (44%). Maintaining conversations with family and friends becomes effortful and leads to a tendency for the person with hearing loss to: a) pretend that he/she has heard and understood what was said, b) change the topic of conversation or dominate conversation, and c) withdraw from such social interactions, or a combination of these reactions. Something the survey did not touch on is the effect of hearing loss on communication partners. Unless both parties understand the challenges they face and make an effort to increase the effectiveness of communication, hearing loss is stressful both to the person with hearing loss and their communication partner.

The most common issue with regards to hearing is being able to hear in background noise. 57% of the respondents identified this as a major issue with their hearing. Where the performance of current hearing aids in this environment needs improvement, there are a few simple things that the person with hearing loss can do to make their lives easier. Avoiding noise altogether is impossible, but when trying to have a conversation, you can control your immediate environment to a certain extent. For instance, turning down background noise such as the television or the radio may help. When in the car, rolling up the windows could cut down significantly on wind noise. Moving to a room that is quieter, choosing a seat in the restaurant that is away from potential sources of noise (kitchen, bar), and most importantly, facing the communication partner should help, although I realize that these tips may not help all the time.

The most important reason cited for not seeking help was that the perceived hearing loss was minor and ‘easy to live with’(58%). In the US, many older adults live by themselves or with their spouse and do not feel the need for a hearing aid since they ‘get by’ at home. However, the perceived severity of hearing loss may not necessarily be reflective of objective measures of hearing ability. Even when at home, people with hearing loss may miss out on sounds, which may affect safety. Regarding the occasions when one is not at home, the ability to communicate successfully perhaps becomes even more important and challenging, since these are conversations in unfamiliar surroundings and often with less familiar people. Other reasons for not seeking help includes cost, perceived benefit of hearing aids (family member/friend had poor experience) and other heath issues taking precedence.

This survey brings to light some pressing issues that affect hearing health-care in this age group. Clearly, hearing health-care needs to be more accessible to older adults, and this survey is a step in the right direction. If you are someone interested in learning more about hearing health in older adults, I would encourage you to read the summary of results from the survey here.

Copyright © 2023 Vidya Krull. All Rights Reserved.

I can hear but I can’t understand

This is the common complaint for most people with hearing loss. Often listeners are able to hear sounds when they are loud enough, but they have difficulty understanding speech, especially when there is background noise. For instance, when  chatting with a friend at the bar. Trying to attend to someone speaking when there are multiple speakers in the background is quite difficult for someone with hearing loss, an effect called the ‘cocktail party effect‘ (Cherry, 1953).

Why is this the case? Apart from the simple acoustics of how the sound we want to hear is affected by other unwanted sounds (background noise), other factors also affect our perception. As an esteemed colleague I know would point out, it is because ‘the ear is connected to the brain‘. From when a sound enters our ears to when we perceive it as something that is meaningful, it undergoes a multitude of physical, neural, and cognitive processing. There is increasing evidence that in addition to peripheral cues (i.e. acoustic cues from the auditory periphery), ‘top-down processes’ (such as attention, working memory, and contextual knowledge) play a role in speech understanding, especially in background noise (Pichora-Fuller, Daneman, and Schneider, 1995; Shinn-Cunningham and Best, 2008). One theory is that there are limited ‘cognitive resources’ or let’s say ‘currency’ available to us.  When we are listening in background noise, then we use more of this currency. As a result, less is available to us for other processes, such as recalling what was said before, or putting what we heard in context (Pichora-Fuller, Daneman, and Schneider, 1995). In addition to changes that take place in the auditory periphery (i.e. outer, middle, and inner ear/cochlea), central auditory changes (beyond the cochlea) as well as cognitive declines accompany aging (Committee on Hearing, Bioacoustics and Biomechanics (CHABA), 1988; Humes, 1996). As a result, older people may have greater difficulty understanding speech in noise than younger adults (Tun, McCoy and Wingfield., 2009). Researchers in our field are trying to further understand the role of the central auditory and cognitive factors that affect speech understanding. These factors may play a role in explaining individual differences in speech outcomes among hearing-impaired listeners. In other words, how people with the same audiogram may have very different speech understanding.

REFERENCES:

1. CHABA (1988). “Speech understanding and aging,” in Journal of the Acoustical Society of America, pp. 860-895.
2. Cherry, E. C. (1953). “Some experiments on the recognition of speech, with one or two ears,” Journal of the Acoustical Society of America 25, 975-979.
3. Humes, L. E. (1996). “Speech Understanding in the Elderly,” Journal of the American Academy of Audiology 7, 161-167.
4. Pichora-Fuller, K. M., Scheider, B.A., and Daneman, M. (1995). “How young and old adults listen to and remember speech in noise,” Journal of the Acoustical Society of America 97, 593-608.
5. Shin-Cunningham, B. G., and Best, V. (2008). “Selective Attention in Normal and Impaired Hearing ” Trends in Amplification 20, 1-17.
6. Tun, P. A., McCoy, S., and Wingfield, A. (2009). “Aging, hearing acuity, and the attentional costs of effortful listening,” Psychology and Aging 24, 761-766.

Copyright © 2023 Vidya Krull. All Rights Reserved.