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This article originally appeared in The Hearing Professional May—June 2005
By Patricia E. Connelly, PhD, CCCA
Mo B, Lindbaek M, Harris S. Cochlear implants and quality of life: A prospective study. Ear and Hearing 2005;
26:186–194.
Vermeire K, Brokx JP, Wuyts FL, Cochet E, Hofkens A, Van de Heyning PH. Quality of life benefit from cochlear implantation in the elderly. Otology and Neurotology 2005; 26:188–195.
LEARNING OUTCOMES
As a result of reading this article, you are expected to:
Every once in a while coincidences occur in articles that are published by two different peer reviewed journals. In the examples of contemporary research presented in this Research Review, two articles that focus on the same topic appeared during the same month and year (April 2005). One journal (Ear and Hearing) is a periodical used mainly by audiologists and hearing scientists to disseminate timely information on different aspects of audition. The other (Otology and Neurotology) is a primary platform for otolaryngologists, typically otologists/neurotologists. Another interesting coincidence is that the research efforts of each came out of Europe; the Mo, et al. team is from Norway, and Vermeire, et al. from Belgium. This Research Review will include both articles because of the coincidental simultaneity of their publication and because each reinforces the other’s conclusions.
The Mo, et al. study set out to detail the aspects of a patient’s life that were most influenced by cochlear implantation. They were particularly interested in the correlation between quality of life (QoL) and psychological state as a result of the implant. Although there are studies that indicate improvements in QoL from cochlear implantation, Mo, et al. determined that those reports were not strong enough in their study designs and the instruments used to measure QoL.
Twenty-seven subjects participated who were post-lingually deafened adults with various etiologies for their deafness. The subject pool had a mean age of 57.6 years (6 14.5 years; range 28–82 years). The 15 women and 12 men had an average duration of deafness of eight and half years (6 10.3 years).
Three instruments were used to evaluate QoL issues. The House Ear Institute developed the Patient Quality of Life Form (PQLF) and the Index Relative Questionnaire Form (IRQF). These are hearing loss–specific questionnaires for patients (PQLF) and for their significant others (IRQF) that inquire about coping, adaptation and emotional alterations resulting from the implant. In addition, a general QoL tool was used called the Short-Form 36 (SF-36). Psychological issues were surveyed using the shortened version of the Hopkins Symptom Check List (HSCL), the HSCL-25 that has 25 self-assessment questions concerning the presence of depression and anxiety over the past week. All instruments were given both pre- and post-implantation.
The results of this study are comprehensively presented and discussed in the Mo, et al. article. In summary, this team found “that the cochlear implant recipients after surgery received statistically significant improvements in the ability to communicate, were less isolated, had less feeling of being a burden and had better relations with their nearest and dearest friends compared with before surgery” (page 191). They found that QoL improvements as a result of the cochlear implant were evident in both the person implanted as well as in their index relative. They also found a significant reduction in the psychological aspects of anxiety and depression one year after implantation. Further, a statistically significant association between reduced anxiety and depression and improved QoL was revealed in this study.
Vermeire, et al. set out to compare pre- and post-implant audiologic and QoL results between a younger and an older group of cochlear implant recipients. Although other studies making similar comparisons have been published, Vermeire, et al. indicted that the self-assessment questionnaires used were constructed specifically for the groups studied rather than a standardized and validated assessment instrument that could be broadly applied in many clinics. So, Vermeire, et al. used the Glasgow Benefit Inventory (GBI); the Hearing Handicap Inventory for Adults (HHIA) and the scale for the prediction of hearing disability in sensorineural hearing loss (SNHL).
There were 89 post-lingually deafened adults participating in this study. They were divided into three age groups with mean ages as follows: young—42 years; middle-aged—62 years and geriatric—74 years. The average age at implantation was 58 years for the entire group.
Audiometric data analyses revealed that the two younger groups of subjects had significantly better post-implant hearing thresholds than the geriatric group as measured by a comparison of pure-tone thresholds. Significant speech perception improvements were also noted for all three age groups, with the young and middle-aged groups performing equivalently and the geriatric group showing the poorest speech perception as measured by an open-set word recognition task. By the way, dementia was ruled out in all subjects during the preoperative qualification phase for implant candidacy.
As for QoL results, all three instruments used showed improvements post-implantation. The HHIA revealed statistically significant improvements in the emotional and situational subscales. The GBI showed significant benefits post-implantation on the total score and the general and social subscales. The SNHL indicated a mean for the total group of subjects to be 59.22% as compared to the normal hearing ability of a young adult being 100%. When results were analyzed by age groups, the total HHIA indicated statistically significant improvements in QoL for the middle-aged and the geriatric groups, but not for the younger group of subjects. The GBI demonstrated significant benefit for each age group. As for the SNHL, the younger subjects’ mean for hearing disability was 60.74%, for the middle-aged the mean was 59.53%, and it was 56.39% for the geriatric group. The differences among the groups were not statistically significant.
In toto these results indicate that two measurable outcomes of cochlear implantation are improvements in a patient’s QoL and improved speech perception for younger adults as well as geriatric patients who are post-lingually deaf. Although older subjects tended to get less measurable audiometric benefit, they nonetheless demonstrated that the better hearing did indeed lead to a better QoL equivalent to that of younger subjects.
These two articles represent a way of looking at outcomes that has not been emphasized previously in auditory rehabilitation. We’re all familiar with hearing aid fitting “tools of the trade.” We verify a fitting using functional gain, real ear or speech mapping, for example, to ensure that our goals have been met for each patient. We confirm that our efforts at reducing the hearing impairment through amplification have resulted in soft speech that is audible, conversational speech that’s comfortable and loud sounds that are endurable. The fitting should also be validated in that the patient’s perceptions of benefit and those of a relative/friend are surveyed using pre- and post-fitting measures of disability and handicap. We typically use self-assessment instruments such as the APHAB, COSI and HHI to validate a fitting and assess benefit. Verification and validation measures focus on treatment effects—apply a treatment (hearing aids or a cochlear implant) and measure the effect of the treatment.
The unique aspect of the two articles reviewed here is that changes in QoL have been emphasized, that is how the treatment impacts on the patient’s daily life. Health-related quality of life (HRQL) is a term that accentuates “a more comprehensive outcome of medical interventions, with physical, social, and psychosocial domains” (p. 186, Mo et al.). The concept of HRQL focuses on how people live with their health conditions and how these can be improved to achieve a productive, fulfilling life. It has implications for medical practice for law and social policy to improve access and treatment and for the protection of the rights of individuals and groups.1
HRQL is built on a hierarchical framework that includes impairment, disability and handicap. Impairment implicates the organ structure and function (hearing loss). In the next higher level, a medical abnormality integrates into whole-body functions, and this is more commonly termed disability. Disability is a limitation in activity imposed by an impairment. In the highest levels a medical abnormality impacts a person’s social fulfillment, and this is known as handicap, a restriction of participation imposed by an impairment.
HRQL is a generic concept built on the perspectives of impairment, disability and handicap. We have tools to measure each—the impairment domain, the activity limitations highlighted in the disability domain and the handicap domain with its focus on the participation domain. By securing assessments in each domain we are able to make statements about a patient’s QoL imposed by hearing loss and specific to how the hearing loss affects personal activity and social participation. For an excellent chapter on this topic I strongly recommend “Outcome Measures in Aural Rehabilitation” in the Handbook of Outcome Measurements in Audiology.2
Mo et al. and Vermeire et al. have used common hearing-related outcome measures to assess QoL changes as a result of cochlear implantation and have measured associations of those QoL measures with audiometric data, age and psychological factors. Their results are identical in that they both show QoL improvements from an otoprosthesis. They both appeared during the same month. They both used the terminology “quality of life.” Coincidence? Yes, of course. But we need to respond to the secondary message sent by these articles. That is, read more about QoL measurements and adopt the term in your practice. It’s a term that’s understood by every patient and his or her family/significant other. They can easily relate to it. It should be adopted in every dispensing office. THP
For a copy of these articles, contact Pat Connelly, PhD, CCCA, at connelpe@umdnj.edu.
Dr. Connelly is an assistant professor of surgery at the New Jersey Medical School and director of audiology service at the UMDNJ–University Hospital in Newark, New Jersey.
1. World Health Organization. International classification of impairments, activities and functioning. http://www3.who.int/icf/icftemplate. cfm? myurl=homepage.html&mytitle=Home%20Page Accessed April 22, 2005.
2. Johnson CE, Danhauer JL. Handbook of outcome measurements in audiology. Clifton Park, NY: Thomson, 2002.
