John Greer Clark, PhD
Professor, University of Cincinnati, OH
Audiologists must always be prepared to view their patients in a context wider than the immediate condition for which they may be seen. One of the seven primary components of person-centered care in audiologic practice is that of a holistic outlook for patients which dictates “a continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context” (Clark & English, 2019, p. 5). Both hearing loss and dementia can have negative impacts on patients’ emotional well-being, psychological status, and societal and family interactions. The incidence of dementia increases with advancing age, as does presbycusis, presenting significant challenges to the audiologist when these conditions coexist (Cacace, 2007).
Hearing loss is one of the noted modifiable risk factors for dementia (Livingston et al., 2017), and if identified and treated early, its impact on dementia may be lessened (Beck et al., 2018). Similarly, early detection of dementia has the potential to lessen the negative impact of hearing loss on one’s quality of life.
Broaching the Subject
One means of broaching the subject of possible cognitive decline with patients is to include inquiry of concern within the case history (Amero et al., 2017). The following scenario depicts how to segue into a discussion about screening.
While reviewing case history information with Mr. Baxter and his wife, Dr. Collier says, “I see that you answered ‘Yes’ to the question ‘Do you or any members of your family have any concerns about memory challenges or confusion that you appear to have?’ Can you tell me a bit about your concerns?”
Mr. Baxter looks over at his wife hoping that she might respond to this topic that he tries his best not to think about. After a brief pause, Mrs. Baxter responds, “Well we aren’t sure if it is anything really, but we have noticed that Jim seems to lose things a lot. His glasses… keys… his watch the other day. We all lose things, but this just seems to be so much more frequent than before. And last week he called me from the grocery parking lot. He said he wasn’t sure if home was to the left or the right from the store. We downsized four years ago and it used to be a right turn out of the lot, but now it’s a left turn. We haven’t really talked to anyone about this. Not yet, anyway.”
“Well, you are correct,”Dr. Collier says. “We all do forget things and lose things, even lose our direction sometimes. But what you are saying does seem to make one pause.” Turning to Mr. Baxter, she continues,“Would you be willing to have me give you a brief screening to see if we should be concerned? If the results of the screening suggest that further exploration on this would be in order, I know a wonderful doctor I could recommend for you.”
(From: Clark & English, 2019, with permission)
And Then What?
As noted by Beck and colleagues, the very act of completing a cognitive screening, or even suggesting such, can serve as a post-traumatic trigger for the memories, sometimes all too recent, of the many unwanted changes (of all kinds) that frequently accompany aging. As such, these authors suggest empowering patients at this juncture by relinquishing the lead and asking if they would like information on how the results of the screening may be beneficial.
Subsequent conversation should emphasize that no screening is definitive and that poor performance (that is, not failure) can be related to prescription medications, vitamin deficiencies, or depression. It should be stated that the audiologist’s goal is to ensure that patients remain as socially active as possible and that further evaluation is recommended to help achieve that goal. At this juncture, and in keeping with the audiologists’ code of ethics, audiologists should have well established referral networks. Conversely, when the patient performs well on a cognitive screening, discussion should include mention of the fact that screenings are imperfect, and if the family’s present concerns continue or increase they should discuss them with the patient’s physician.
And What If?
Patient-centered ethics dictates that a patient’s desire to decline professional recommendations take precedence over the professional’s desire to provide treatment (Clark, 2007). Even so, when a patient initially selects to decline recommendations, explorations of underlying reasons through practices of motivational engagement are often successful in helping a patient find the internal motivation and resources to engage with recommendations (Clark & English, 2019). But in the end, accepting the supremacy of patients’ decisions on the direction of their care should never be viewed as a case of failed intervention.
And Now What?
Each of us must examine our comfort level in discussing issues of cognitive decline with our patients and providing screenings when indicated. When we feel uncomfortable with providing services our patients may need, we are ethically bound to research the area of discomfort, discuss it with colleagues and prepare ourselves to provide the best care possible. When screening patients for dementia, two useful cognitive screening tools are the Mini-Cog Screener (Borson et al., 2003) and the Saint Louis University Mental Status Examination (see video for more info: http://bit.ly/2ofDNBf).
Cacace AT. (2007). Aging, Alzheimer’s disease, and hearing impairment: Highlighting relevant issues of additional research, Editorial. American Journal of Audiology, 16, 2-3.
Clark JG. (2007). Patient-centered practice: Aligning professional ethics with patient goals. Seminars in Hearing, 28(3), 163-170.
Livingston G, Sommerlad A, Orgeta V, et al. (2017). Dementia prevention, intervention, and care. The Lancet, 39, 2673-2734.