Contents Preface ix Contributors xi PART I: The Nature of Aural Rehabilitation 1 1 The Nature of Aural Rehabilitation 3 Raymond H. Hull 2 Introduction to the Handicap of Hearing Impairment: 23 Auditory Impairment versus Hearing Handicap Jack Katz and Thomas P. White 3 The Psychosocial, Educational, and Occupational Impact of Impaired 45 Hearing and the Vocational Rehabilitation Counseling Process R. Steven Ackley and Karen Dilka 4 Introduction to Hearing Aids and Amplification Systems 69 Joseph J. Smaldino PART II: Introduction to Aural Rehabilitation: Children With Impaired Hearing 87 5 Family Involvement and Counseling in Serving Children Who Possess 89 Impaired Hearing Dale V. Atkins 6 Considerations and Strategies for Amplification for Children Who Are 111 Hearing Impaired William R. Hodgson 7 Development of Listening and Language Skills in Children Who Are 137 Deaf or Hard of Hearing Arlene Stredler-Brown 8 Speech Development for Children Who Are Hearing Impaired 163 Daniel Ling 9 Cochlear Implantation in Children 189 Thomas C. Kryzer 10 Educational Management of Children with Impaired Hearing 207 Molly Pottorf-Lyon vi INTRODUCTION TO AURAL REHABILITATION PART III: Introduction to Aural Rehabilitation: Adults Who Are Hearing Impaired 223 11 Aural Rehabilitation for Adults: Theory and Application 225 Raymond H. Hull 12 Counseling Adults Who Possess Impaired Hearing 247 R. Steven Ackley 13 Hearing Aid Orientation for Adults Who Possess Impaired Hearing 269 Raymond H. Hull 14 Non-Hearing Aid Assistive Hearing Technology for Adults with 289 Impaired Hearing Joseph J. Smaldino PART IV: Considerations for Older Adults with Impaired Hearing 309 15 Influences of Aging on Older Adults 311 Judah L. Ronch and Michael Novotny 16 Auditory and Nonauditory Barriers to Communication in Older Adults 329 Dawn Konrad-Martin and Gabrielle Saunders 17 The Impact of Hearing Loss on Older Adults 347 Raymond H. Hull 18 Special Considerations for the Use of and Orientation to Hearing Aids 363 for Older Adults Raymond H. Hull 19 Techniques of Aural Rehabilitation for Older Adults with Impaired 377 Hearing Raymond H. Hull 20 Special Considerations in Aural Rehabilitation for Older Adults in 411 Health Care Facilities Raymond H. Hull APPENDICES: Materials and Scales for Assessment of Communication for 435 the Hearing Impaired Appendix A: CID Everyday Sentences 437 Appendix B: The Denver Scale Quick Test 441 Appendix C: The WSU Sentence Test of Speechreading Ability 443 Appendix D: Hearing-Handicap Scale 445 Appendix E: The Denver Scale of Communication Function 449 Appendix F: Test of Actual Performance 455 Appendix G: The Hearing Measurement Scale 457 CONTENTS vii Appendix H: Profile Questionnaire for Rating Communicative Performance 461 in a Home and Social Environment Appendix I: The Denver Scale of Communication Function for Senior 467 Citizens Living in Retirement Centers Appendix J: Wichita State University (WSU) Communication Appraisal and 471 Priorities Profile (CAPP) Appendix K: The Hearing Handicap Inventory for the Elderly 475 Appendix L: The Communication Profile for the Hearing Impaired 479 Appendix M: Communication Skill Scale 487 Appendix N: The Shortened Hearing Aid Performance Inventory 503 Appendix O: Communication Scale for Older Adults (3-Point Response Format) 505 Index 515 Preface The book that you have just purchased is an dents to determine on their own whether introductory book on the nature and pro- they understood important points within cess of aural rehabilitation. As an introduc- each chapter. tory look at the processes involved in this This book is divided into four parts: exciting aspect of our field, it covers a broad range of topics considered to be the most Part I: The Nature of Aural Rehabilitation important in preparing future professionals presents information that is fundamental to to serve children and adults with impaired the provision of services on behalf of all per- hearing. It is a natural outgrowth of what sons who possess impaired hearing, includ- previously became a popular text entitled ing an introduction to aural rehabilitation; Aural Rehabilitation, written and edited an introduction to the nature and potential by this author, that resulted in four success- impact of hearing impairment and related ful editions over a span of over 20 years. terminology; an introduction to hearing aids One of the reasons that those previous books and their components; and a psychosocial, were so popular among professors and stu- educational, and vocational profile of per- dents was not only the logical sequence in sons with impaired hearing. which the information was presented, but also the ease with which the book could be Part II: Introduction to Aural Rehabilitation: read. In other words, the book that you have Children with Impaired Hearing concen- purchased entitled, Introduction To Aural trates on habilitative/rehabilitative services Rehabilitation, retains the readability and on behalf of children who possess impaired ease of understanding that the previous hearing. The information centers on the im- books by this author have maintained over portance of family and its involvement in the years, but also provides comprehensive serving children who are hearing impaired; information on the nature and process of considerations regarding amplification for aural habilitation and rehabilitation on behalf children; the development of auditory skills of children and younger and older adults in children who are hearing impaired; lan- who possess impaired hearing. Therefore, guage and speech development for children the information is presented in a readable with impaired hearing; their educational fashion that has immediate theoretical and management; and the issue of cochlear practical application. implantation on behalf of children. The first page of each chapter provides a brief outline of the chapter for a quick Part III: Introduction to Aural Rehabilitation: content overview. Further, the examinations Adults Who Are Hearing Impaired concen- and answer sheets found at the conclusion trates on matters that affect services on behalf of each chapter provide a ready-made oppor- of adults with impaired hearing. Chapters tunity for professors to quiz their students in this section address the impact of hear- on a periodic basis, or to simply allow stu- ing impairment on adults, and procedures x INTRODUCTION TO AURAL REHABILITATION for counseling; hearing aid orientation; countries were consulted about the topics assistive listening devices for adults who they felt were important in preparing audi- are hearing impaired; and the history, the- ologists and speech-language pathologists ory, and application of aural rehabilitation to work with children and adults who pos- for adults. sess impaired hearing, and further, if they would prefer a term other than aural reha- Part IV: Considerations for Older Adults bilitation in this book. When a general con- with Impaired Hearing addresses special con- sensus was reached, this book was designed, siderations for services on behalf of older written, and prepared for you. adults who possess impaired hearing. The As an introductory look at the processes chapters in this section present information involved in aural rehabilitation, it covers a on psychosocial and physical factors of broad range of topics considered to be the aging; the special nature of hearing loss in most important in preparing future profes- older adulthood; the impact of hearing loss sionals to serve children and adults with on older adults; counseling the older adult impaired hearing. Therefore, a basic but who is hearing impaired; considerations for diverse range of vocabulary and sophisti- hearing aid use for older adults; techniques cation is acknowledged in regard to both of aural rehabilitation for all adults who are the content of the chapters and the book’s hearing impaired; and programs for the intended readership as an introductory book hearing impaired elderly in health care facil- in this area of study. The book has been ity environments. designed for use by a broad range of readers, primarily upper-level undergraduate students Appendices: The Appendices of this book and early graduate students in audiology and contain the most comprehensive compilation speech-language pathology, and as a refer- of assessments of communicative function in ence for professionals in audiology, speech- adults who possess impaired hearing found language pathology, deaf education, and other in any text on the topic of aural rehabilitation. fields that serve children and adults with impaired hearing. Other interested readers The topics for this book were by no include physicians, nurses, gerontologists, means arbitrary. University professors and vocational rehabilitation counselors, teach- practitioners of audiology, speech-language ers, psychologists, and sociologists. pathologists, deaf educators, rehabilitation Preparing this text has been an enjoy- counselors, psychologists, otologists and oto- able and rewarding experience. It will prove laryngologists, along with upper-level under- to be a valuable source of information for graduate and graduate students across the serving children and adults who possess United States, Canada, Europe, and other impaired hearing. Enjoy! Contributors R. Steven Ackley, PhD Touro Institute of Neurobehavioral Studies Professor and Chair Prairie Village, Kansas Hearing, Speech and Language Sciences Chapter 2 Gallaudet University Washington, DC Thomas C. Kryzer, MD Chapters 3 and 12 Wichita Ear Clinic Assistant Professor of Surgery and Family Dale V. Atkins, MA, PhD Medicine Psychologist, Author, Media Commentator University of Kansas School of Medicine Greenwich, Connecticut Wichita, Kansas Chapter 5 Chapter 9 William R. Hodgson, PhD Dawn Konrad-Martin, PhD Professor Emeritus Research Investigator Department of Speech, Language, and VA RR&D National Center for Hearing Sciences Rehabilitative Auditory Research University of Arizona (NCRAR) Tucson, Arizona Portland VA Medical Center Chapter 6 Assistant Professor Department of Otolaryngology, Head and Raymond H. Hull, PhD Neck Surgery Professor of Communicative Disorders and Oregon Health and Science University Sciences, Audiology/Neurosciences Portland, Oregon Coordinator—Doctor of Audiology Chapter 16 ProgramDepartment of Communication Sciences and Disorders Daniel Ling, PhD (Deceased) College of Health Professions Professor Emeritus Wichita State University Faculty of Applied Health Sciences Wichita, Kansas The University of Western Ontario Chapters 1, 11, 13, 17, 18, 19, 20 London, Ontario, Canada Chapter 8 Jack Katz, PhD Director Michael R. Novotny, BA Auditory Processing Service The Ericksson School Research Professor University of Maryland Baltimore County University of Kansas Medical Center Baltimore, Maryland Clinical Professor Chapter 15 xii INTRODUCTION TO AURAL REHABILITATION Molly Pottorf-Lyon, AuD, CCCA/SP Joseph J. Smaldino, PhD Adjunct Lecturer Professor and Chair Department of Communicative Sciences Department of Communication Sciences and Disorders and Disorders Wichita State University Illinois State University Wichita, Kansas Normal, Illinois Chapter 10 Chapters 4 and 14 Judah L. Ronch, PhD Arlene Stredler-Brown, MA, CCC-SLP Professor and Undergraduate Academic Adjunct Faculty Program Chair University of Colorado The Erickson School Adjunct Faculty University of Maryland Baltimore County University of British Columbia Baltimore, Maryland Boulder, Colorado Chapter 15 Chapter 7 Gabrielle H. Saunders, PhD Thomas P. White, MA, MBA Investigator and NCRAR Deputy Director Professor Emeritus of Education Outreach and State University of New York at Buffalo Dissemination Director Emeritus National Center for Rehabilitative Auditory Hearing Evaluation Services Research Buffalo, New York and Chapter 2 Assistant Professor Department of Otolaryngology Oregon Health and Science University Portland, Oregon Chapter 16 19 Techniques of Aural Rehabilitation for Older Adults with Impaired Hearing RAYMOND H. HULL Chapter Outline Introduction The Process of Aural Rehabilitation Individual versus Group Treatment The Ongoing Aural Rehabilitation Program: Reasons for Successful and Individual Treatment Unsuccessful Treatment Programs Group Treatment Use of Residual Hearing with Components of Aural Rehabilitation Supplemental Visual Clues Services for Older Patients Linguistic, Content, and Counseling Environmental Redundancies Hearing Aid Orientation Reducing Auditory or Visual Confusions Adjusting or Manipulating the Communicating under Adverse Listening Environment Conditions Creating Positive Assertiveness Other Approaches to Aural Rehabilitation Treatment Involvement of Family and Significant Others Summary 378 INTRODUCTION TO AURAL REHABILITATION Introduction found in a probable combination of both peripheral and central involvement.The audi- ologist is, indeed, serving complex people The process of aural rehabilitation on behalf who possess complex auditory disorders. of older patients is as exciting as it is rewarding. To be involved in the recovery of communication skills that may have pre- Individual versus viously caused an adult to withdraw from his communicating world is, indeed, gratify- Group Treatment ing. Both the patient and the audiologist can rejoice in the recovery of those skills. Individual Treatment Some older patients recover skills that allow them to participate on a social basis once Some individuals will require individual again, at least with a greater degree of effi- aural rehabilitation treatment. In instances ciency. Others may simply regain the ability in which patients are experiencing commu- to communicate with their family with nicative difficulties that are not conducive greater ease. In light of those gains and, per- to a group therapy environment because of haps, a step toward a reinstatement of com- their individual or personal nature, individ- municative independence, a patient and his ual sessions are warranted. audiologist have reason to rejoice. For example, a semiretired physician Clinicians cannot, under any circum- came to this author with a desire for more stances, hope to benefit every older hearing efficient communication within his office impaired person. But, in attempting to do and examination room. The sessions cen- so, if some are helped who had previously tered on the specific difficulties he was submitted to a self-imposed withdrawal experiencing in that environment, and he from family and friends because of the did not desire to open them up to group embarrassment from responding inappro- aural rehabilitation sessions. priately to misunderstood messages, then Another patient’s concern was that her professionals can be satisfied that our work granddaughter’s wedding was forthcoming, is worthwhile. and she felt that she was not going to be able Because most older adults who have to hear and understand what people were hearing impairment have experienced nor- saying while she stood in the reception line. mal to near-normal auditory function during Her request was to receive some hints on their younger years, and because they are how to “not embarrass herself and her fam- generally fully aware of the communicative ily” by responding inappropriately to what difficulties they face, it is important that our people were saying to her in the reverber- services address their specific communicative ant environment of their church fellowship needs. In light of the fact that it is being con- hall. Her aural rehabilitation program was firmed that auditory disorders found in older based on two sessions of problem solving adults are quite complex (see Chapter 16 and supportive and informational counsel- and Chapter 17), approaches to aural reha- ing. After successfully working through the bilitation must accommodate the communi- potential pitfalls of the communicative cation difficulties experienced as a result of demands of her granddaughter’s wedding, compounding problems; many of these are the woman returned to enter group therapy. TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 379 The sessions held for this woman were rather personal in regard to the difficulties she was Group Treatment anticipating and, in that instance and at that time, she felt that they were not conducive Group aural rehabilitative treatment, as dis- to a group therapy environment. So her cussed later in this chapter, can be extremely desire for individual sessions was fulfilled. motivating for many older adults who are Other circumstances in which individ- experiencing impaired hearing. Once the ual treatment sessions would be appropri- problems and difficulties that are specific to ate include: individual patients have been resolved to the degree possible through work on an indi- 1. The patient’s hearing impairment and vidual basis, patients can move into group concomitant communicative difficulties treatment, if group services are warranted are so severe that the patient requires (Figure 19–1). concentrated effort to resolve them to Individuals in group treatment find the greatest degree possible before strength in hearing of others’ successes and entering a group environment. failures in their own communicative envi- 2. The patient’s emotional response to the ronments. They gain insights through group auditory impairment and the resulting discussions and problem solving into how communicative difficulties are such that to best cope in spite of their hearing impair- group involvement, at that particular ment. The camaraderie that develops can time, is contraindicated. be rewarding to group members as their Figure 19–1. Group aural rehabilitation treatment works to allow patients to share frustrations and triumphs. 380 INTRODUCTION TO AURAL REHABILITATION confidence grows in their ability to take intolerant family member or roommate. charge of the difficulties that they have been And it is trust that must develop between having in their own communicative worlds. audiologist and patient. Counseling is the discussion that develops when a patient desires to talk about an incident in which he Components of Aural had particular difficulty understanding what Rehabilitation Services another person was saying, and also includes the problem solving that can unravel the for Older Patients possible reasons for the difficulty. This aspect of the process of aural reha- The following are important elements in bilitation is, again for lack of a better term, aural rehabilitation service programs for called counseling. But, whatever it is called, older adults that are applicable for either it involves listening, talking, problem solv- the well adult in the community or those ing, facilitating adjustment to a frustrating who are confined to a health care facility. disability, and the development of trust They include: between patient and audiologist. When an audiologist encounters an 1. Counseling older adult who has impaired hearing who 2. Hearing aid orientation says, “I do not desire to be helped. I am old 3. Adjusting the listening environment and I do not know how much longer I will 4. Development of positive assertiveness live,” the attitude of the person certainly 5. Developing compensatory skills in the will influence how much potential progress use of residual hearing and supplemen- that he will make. This is particularly true if tal visual cues the person has isolated himself from the 6. Involvement of family and significant outside world and is resigned to not seek others help because of advanced age. The Audiologist as Counselor Counseling If there are no other significant contraindi- As this author teaches his students about cating factors that would hinder respon- aural rehabilitation services for older adults, siveness to aural rehabilitation services, the it is emphasized that counseling, for lack of audiologist is in a position to serve in a coun- a better term, is one of the most important seling role. It is possible that this patient aspects and is intertwined throughout the has said what was said because he has been process of aural rehabilitation. It is not some- told by others that “you are too old.” A well- thing that occurs alone or out of context. It meaning physician may have said, “You is an integral part of everything an audiolo- know you’re no spring chicken any more.” gist does when working with his patients. Or a child may have said unthinkingly, It is talking. It is instilling confidence in a “Mom, you know you can’t care for yourself patient who has become discouraged when as well as you used to, so we should start he did not do as well as expected in a given thinking about moving you to a care facil- communicative environment. It is listening ity,” not realizing that the older adult is con- to the feelings a patient reveals about him- vinced that placement in a “care facility” self, or that person’s relationship with an will be terminal. Such statements, even said TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 381 in a well-meaning way, are understandably aural rehabilitative services or the progress unsettling to an older adult. they may be capable of. They are, further, One of this author’s patients, a woman those to which the audiologist must respond. of 89 years, told me that her 50-year-old The following are a few of those statements, daughter told her they should sell her house out of context, recorded by this author: and she should then move into an efficiency apartment. She was so hurt and angry that ■ “I feel that I’m on trial, becoming she could not think of anything to say. She incompetent.” felt convinced that if her mature daughter ■ “My son is right behind me. He comes felt that she could not care for her house, down to see me as often as he can, but then she must be doing a worse job than he has a lot of business to handle there. she thought. I asked her what she would I don’t see him very often anymore.” have said if her daughter had suggested that ■ “I can’t hear and my eyes bother me. to her when she was 45 years old and her Surgery won’t help my ears or my eyes. daughter was 15. She said she would have I’m told that I’m too old.” asked her why she would say such a thing, ■ “My arthritis bothers me all over, but she said, “But when you are 89 years especially with the weather. I used to old, perhaps it is not worth it.” walk a lot. I can’t hear now. I’m too If the medical records of an individual old.” indicate satisfactory health, and there appears ■ “I fear being alone—being melancholy to be nothing that would contraindicate the —with no future to look forward to. provision of aural rehabilitative services, I need to find some way to be useful. then the self-defeating attitude of the poten- But I can stand a lot. I’m still sturdy.” tial patient may be the only thing that stands ■ “I would like, more than anything, to be between the provision of services and rea- able to get out, to socialize, but I can’t sonable progress in aural rehabilitation treat- hear very well. I would like to go to ment. Although the person’s realistic view church, but the children don’t come on of becoming older may be a healthy one, Sundays and there is no one to take me.” long-term mourning because of age and the possibility of death is not. The audiologist One statement stands out from all of can be a positive catalyst in moving beyond the rest. It is a statement by a physically aging, particularly for those who are barred strong and mentally alert 82-year-old man from social interaction as a result of their who possesses impaired hearing and who auditory deficit. is torn between giving up and submitting to the opportunity to improve his ability to Feelings to Which the Audiologist function communicatively through an audi- Must Respond ologist’s services. The statement is, “I’d like to put a younger person on my shoulders to Phrases exemplifying attitudes typical of function intellectually on my behalf and many older adults who have hearing impair- hear for me, and to go on from there. I sup- ment have been recorded by this author pose I need to learn to rely on myself . . . during initial aural rehabilitation interviews relationships with people are important, with hundreds of older patients. The feelings but do I have the potential?” that prompted these revealing statements The above statements are representative are those that can and do stifle the desire for of those heard by audiologists who accept 382 INTRODUCTION TO AURAL REHABILITATION the opportunity to provide a significant rehabilitative service on behalf of adults who have impaired hearing. These people, in many ways, wish to be recognized not simply as older persons, but as adults who have grown older, who have something to offer, and who do not want to be left alone. Their resolution to “not be a bother” and their resignation to “being old” is, in some cases, the most logical choice in their minds for lack of alternatives. The audiologist can be a catalyst in developing a desire for self- enhancement. The audiologist must not be afraid to work with these patients in a close profes- sional manner. He must not be hesitant to intervene in a counseling role, but must be cognizant of those instances when a patient’s Figure 19–2. Assertiveness training brings emotional problems are beyond the scope out strengths patients may not realize they of the audiologist’s service. For those per- possess. sons, it is the responsibility of the audiolo- gist to refer the individual to other appro- priate counseling professionals. Above all, the patient must be confident in the audiol- —counsel—listen—ask questions—expect ogist who is providing the aural rehabilita- answers—listen—provide guidance. Then, tion service. The patient must be aware that add an appropriate amount of inspiration the audiologist understands the commu- for what may be the key to successful moti- nicative impact of presbycusis through his vational counseling. Counseling as a part of experience in working with other patients. the aural rehabilitation process is presented The patient must know that the audiologist later in this chapter under The Process of feels that he can, indeed, be helped to com- Aural Rehabilitation. municate more efficiently through aural rehabilitative services, and that feeling has justification on the basis of evaluation, not Hearing Aid Orientation sympathy. A feeling of justified trust is the true key to motivational counseling. The Information in Chapter 18 deals with con- patient pictured in Figure 19–2 trusts that siderations for hearing aid orientation on the audiologist understands the frustrations behalf of older adults. As stated in that chap- that he has experienced, and that what the ter, the process of adjustment to the use of audiologist is saying will assist him in learn- hearing aids and orientation to their efficient ing to cope in his otherwise difficult com- use can be facilitated with greater ease for municative environments. some older patients than others; this depends Listen-talk-empathize-listen—encour- on prior exposure to and knowledge of the age where appropriate—remember the sta- use of hearing aids and factors of memory, tus and age of the patient—provide support manual dexterity, and others. The process of TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 383 adjustment to hearing aids and orientation situations in which they desire to function to their use can be logically carried into more efficiently. After this is completed, they daily or weekly aural rehabilitation treat- are asked to choose one or two in which ment sessions, as can the trial use of various they most desire to learn to communicate assisting listening devices. more efficiently. They are, of course, re- Through carryover of hearing aid orien- quested to be reasonable in their selections. tation into the aural rehabilitation treatment In this way, the aural rehabilitation treat- program, slight adjustments to the hearing ment program can be designed to meet their aids can, for example, be made to alleviate specific communication needs. In instances communicative problems encountered dur- in which a patient’s auditory difficulties are ing the previous week. Questions can be so severe that group sessions are not prac- answered regarding their use, and discus- tical or cannot be tolerated by the patient, sions regarding certain difficult listening individual treatment is scheduled. environments can be entertained that may The goal, however, is to integrate the benefit not only that individual patient, but patient into a group situation as soon as others in a group session. More experienced possible, if at all possible. Another situation hearing aid users can be an important cata- in which it is desirable that individual treat- lyst in a new user’s successful adjustment to ment be instituted is in the case of a patient amplification. Further, experimental adjust- whose priority communication environment ments in hearing aid gain and frequency is so different as to warrant individual work. response can be made in accordance with A situation in point is a patient who was the activities in various treatment sessions. provided services individually by this author. Carryover of the hearing aid orienta- His most difficult communication environ- tion process into aural rehabilitation treat- ment as a teacher in a middle school was his ment sessions can be as important as the classroom. His treatment sessions, therefore, orientation process itself, and is a logical centered on physical/environmental adjust- extension. The consistency of patient con- ments in that specific room. The author tact is a valuable asset in facilitating adjust- worked with him individually on redesign- ment to amplification. In group treatment ing his classroom, which was specific to his sessions, the catharsis and camaraderie that difficulties and strategies for communication arise as various patients describe their own in that environment. He had little difficulty difficulties experienced during the initial in other more social environments. adjustment period is a healthy environment for efficient adjustment to hearing aid use. Patient Discussions of Problem Procedures for hearing aid orientation appli- Environments cable for older adults are outlined in Chap- ters 13 and 18 in this text. Problem solving of difficult listening envi- ronments can be extremely productive. Those sessions center on discussions of the Adjusting or Manipulating the patients’ chosen prioritized communication Listening Environment environments. Priority environments most frequently center on church (understand- As is noted in The Process of Aural Rehabil- ing the minister or Sunday school teacher, itation section of this chapter, elderly patients or participating in church committee meet- are initially asked to establish priorities for ings), other social environments in which 384 INTRODUCTION TO AURAL REHABILITATION groups of people meet, understanding what patient joins the group discussion by ex- women or children are saying, or under- panding on the explanation of the difficult standing what people are saying in environ- environment and as questions or possible mentally distracting environments such as solutions are made, ways in which he may on the street corner, in a restaurant, or at have been able to change the listening envi- the theater. The inevitable commonality of ronment or those within it to his benefit their choices allows for group sessions that become clearer. Others in the group also are beneficial for everyone, as the majority benefit because they may have found them- of patients can enter into the discussions as selves in a similar environment or may in they relate to them. the future. A problem specific to a certain envi- ronment, for example, is brought before the group by one of the therapy group mem- Creating Positive Assertiveness bers. The patient who presented the com- munication problem is asked to describe A trait that appears to become more typical it in detail by giving examples of instances as some people grow older is to become less when it has occurred and the physical envi- assertive. This is particularly true of older ronment of each. As the physical environ- adults who have been placed in a health ment is described, the audiologist or the care facility, or who have moved from their patient diagrams it on the chalkboard as home to a retirement complex not of their accurately as possible. The room or other own will, or who are trying to maintain physical environment is drawn on the chalk- their independence by remaining at home. board or flip chart (including windows, Some may seem “stubborn,” but those re- doors, partitions, furniture, and so on). The sponses may be out of self-defense, perhaps remainder of the group is then asked to because they may not have heard or under- give suggestions, as they see it, about how stood what was expected of them, or they the patient may have adjusted to that com- may suspect that they are being imposed munication environment by changing it, upon rather than being allowed to make making physical adjustments, or their opin- independent decisions about their life. ion of making requests of the speaker to Then, in all too many instances, older resolve the patient’s difficulty understand- persons in health care facilities are not told ing what was being said. what is going to be done to them, and they As those suggestions are made, the find that things are being done to them rather audiologist lists suggestions and makes the than for them. Rather than continuing to suggested adjustments on the diagram, for react against the health care facility person- example, (a) moving the patient’s chair into nel and, thus, being listed as “uncooperative,” a better situation for listening, (b) changing such patients may become more passive. position away from a window, (c) moving Whether an older person is residing in closer to a public address system speaker, a health care facility or in the community, it (d) asking the person being conversed with regrettably becomes more common for dra- to move closer, (e) walking out into a hall- matic and sometimes unpleasant things to way where it is quieter, (f) asking the speaker occur in that person’s life. In light of the to move closer to the microphone, and so on. unexpected occurrences that may occur, it Participation in this type of treatment becomes easier to remain passive and wait activity can be extremely motivating. As the rather than to become assertive and say TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 385 “No,” as one may feel forced to do some- The patient said that she hardly under- thing anyway. “Dad is getting stubborn in stood a word the speaker said throughout his old age,” may be the label placed on the the next hour, but she was too embarrassed older person. Many older persons feel pow- to leave the auditorium. When I asked her erless because of a lack of independence. It why she did not say, “Please use the micro- is difficult to respond to a rapidly changing phone; we are having difficulties hearing world when one does not possess the you,” when the speaker moved away from it, finances, transportation, physical mobility, her reply was that she just could not bring quickness of analytical thought, or strength herself to do it. She wanted to, but was too to manipulate one’s environment. embarrassed. “Besides,” she said, “maybe I was the only person there who couldn’t Examples of Passive Behavior hear her.” When I asked her if she was important enough to warrant that speaker’s One of this author’s patients, a 78-year-old consideration, this patient’s response was man, was asked to chair a committee in his simply, “I hope so.” I said, “Don’t you think church because of his knowledge of reli- that the microphone was placed there for a gion. He was flattered to be asked to accept purpose? A public address system generally that position, but then shortly resigned helps everyone to hear more comfortably. because he could not understand what his If you would have said something, I am sure committee members were saying. When that others in the audience would have been I asked him why he did not ask the mem- pleased that the presenter had returned to bers to speak up, he said that he did once. the podium and used the microphone.” Her He further stated that it worked for a short reply was that she had not thought of that. time, but then they returned to their previ- “But still,” she said, “I didn’t want to make ous manner of speaking. When I asked him a nuisance of myself. I’m just an old woman why he did not change the room arrange- who can’t hear very well.” One of the audi- ments so he could place himself in a more ologist’s challenges is to change that atti- advantageous position for communication, tude of self-depreciation. he said that the room had been in that same arrangement for years, and he did not want Learning to Help Themselves to disrupt it. Those attitudes can defeat an otherwise potentially productive person. The attitude just described is one that must Another example that illustrates the be altered, if possible, if persons who pos- feelings of older adults who have hearing sess impaired hearing are to learn to cope impairment is one that involved a 72-year- and function more efficiently in their com- old female patient who had just returned municative worlds. In light of the fact that from a lecture on Southeast Asia that she had some people are simply not willing to ac- been looking forward to attending for some commodate older adults who have hearing time. She explained that the lecturer, a impairment or, perhaps, are not aware of woman who had a rather soft voice, began what accommodations can be made to facil- talking to the audience, and then walked itate communication, older persons must away from the public address system micro- be taught ways to become assertive enough phone and sat down in front of the podium to manipulate their communication envi- with the statement, “I’m sure that you can ronments and those with whom they desire all hear me without the microphone.” to communicate. 386 INTRODUCTION TO AURAL REHABILITATION Altering Passive Behaviors these treatment sessions are, “If those with whom we desire to or must communicate As stated earlier, one way to alter passivity do not seem to be accommodating, then is by asking individual patients to describe we must assert ourselves by showing them difficult communication situations in which how they can best communicate with us!” they have found themselves during the past Suggestions or adjustments must be made week or month. The situation in which the without hesitation. To do otherwise is to 72-year-old woman found herself, as described “place ourselves back where we started.” above, is a prime example of the problems These are powerful treatment sessions that that are brought to the treatment sessions. instill confidence in patients who may not Suggestions by group members are brought have had confidence for some time. forth after individual questions by the group members and the audiologist have been satisfied. When other group members Involvement of Family and courageously state what they would have Significant Others done in that situation (e.g., told the woman speaker, “I would appreciate it if you would The patient’s family and significant others use the microphone.”) in front of the audi- in the patient’s life are critical elements for ence, they are asked if they really would a successful aural rehabilitation treatment have done it. If they hold fast to their com- program.This is particularly true if a patient’s mitment, they are challenged to do it at the significant other is willing to become in- next lecture they attend when the speaker volved in the aural rehabilitation process. hesitates to use the microphone. Occasion- This includes attending individual or group ally, a group member returns after such treatment sessions and participating in an experience and triumphantly proclaims, follow-up assignments. “I did it!” On occasion, another member of A significant other’s involvement in the aural rehabilitation treatment group who the aural rehabilitation treatment process may have been in attendance at that meet- provides that person with a better under- ing will confirm that the individual did a standing of the difficulties and frustrations very nice job in changing a poor listening with which the friend, spouse, or family situation to a more pleasant one. Also, others member undergoing treatment is faced, par- at the meeting may have thanked our patient ticularly if he can attend the first sessions for asking the speaker to use the micro- when discussions of hearing loss and difficult phone by saying, “We just did not have the communication situations are emphasized. courage to speak up like that!” The triumph It further aids the patient’s significant other is great and does much toward encouraging to understand the commonality of commu- the other group members to also become nication difficulties when other patients more assertive. discuss similar problems. The involvement Other difficult situations brought before prompts a realization that the communica- the groups may include family dinners, tion difficulties that have arisen because of going to a noisy restaurant, talking to timid the auditory deficit are not limited only to grandchildren, talking to one’s attorney with his spouse, family member, or friend, but other members of the family in attendance, are found in others as well. That enhanced following more than one request in a understanding hopefully can be passed on sequence, and many others. The bywords in to others who are close to the patient. TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 387 This author frequently requests that can be stressful even with normal hearing. those who attend the treatment sessions Even if grown children live in the same com- with individual patients be fit with earplugs munity, their desire for involvement with to at least experience to some degree what their parent on a social basis may be lacking, depressed hearing “sounds like.” Some of let alone a desire to become an important the communicative frustrations revealed by part of their mother’s or father’s rehabilita- the patients are often felt by the significant tion program. The excuse is generally, “We others at least during that brief period of just don’t have time.” In this remarkably time. It is explained to them, however, that advanced society, it is sad that we lose sight earplugs do not replicate the speech recog- of the needs of our family. But it seems to nition problems being encountered by the be the case, and alternative means for car- person with whom they are attending the ryover support for older patients must, in sessions, but simply demonstrate a moder- many cases, be sought. ate loss of hearing acuity. Still, their use may As stated earlier, a patient’s spouse can enhance a feeling of empathy for the frus- be the most effective significant other, if the trations the hearing impaired person must spouse is emotionally supportive of his or feel. One important byproduct of encourag- her husband or wife. If the spouse is not ing the involvement of a significant other in willing or capable of aiding in the support the aural rehabilitation treatment program or carryover process, then a friend is appro- is that carryover of the treatment process priate and can be a most effective partner into the everyday life of a patient can be in the aural rehabilitation process. In fact, at greatly enhanced. If, for example, an older times it is common for people to discuss patient asserts himself before the remainder feelings with supportive friends prior to of the family by suggesting certain adjust- bringing them before a spouse or other ments regarding seating arrangements for family members. In any event, a close friend Thanksgiving dinner so that he can become can be a very significant other. involved in the conversation with greater A case to illustrate this point is that of efficiency, the significant other can reinforce a 70-year-old male patient who was pro- and strengthen that positive step. vided aural rehabilitation services by this It is, further, not as much fun to go to author. He had been a widower for 4 years. a restaurant or the movie by oneself. The On the first day of his group aural rehabili- significant other will not only strengthen and tation program, he brought a female com- encourage carryover, but also make some panion. Both loved to fish and were almost potentially apprehensive situations more inseparable. They both enjoyed attending enjoyable. It helps to have someone there social gatherings together, but the patient to back you up when the going gets rough! was experiencing great difficulty hearing One of the most discouraging aspects and, in particular, understanding what was of the provision of any rehabilitative service being said in those environments. His to elderly patients is the lack of family female companion was willing to explain involvement. In many instances, if a spouse what was being said, but was becoming has passed away, the remainder of the family frustrated at the consistency with which may live quite a distance from the patient. she had to function in the capacity of inter- Children may visit only once a year if the preter. In this instance, she attended all treat- distance is great, and that may be for only a ment sessions with the patient, she wearing few days around a principal holiday, which her earplugs and he his hearing aids. A great 388 INTRODUCTION TO AURAL REHABILITATION deal of warmth and understanding devel- 5. Learning to become positively assertive; oped between them. And his ability to func- 6. Throughout everything listed, learning tion communicatively increased, as did her to use one’s residual hearing and sup- willingness to aid in the treatment process plemental visual cues to enhance com- through carryover. The assignments, which prehension of verbal messages. included experimentation at social gather- ings, were carried out in an excellent man- To put all of this together into a mean- ner. Problem situations that were to be dis- ingful aural rehabilitation treatment program cussed during treatment sessions lessened for an older adult is not really difficult. As a and, likewise, his dependence on his female matter of fact, the process becomes quite companion for communicative support logical once a number of older patients became less frequent. have critiqued your approach in relation to The support and carryover by this signif- its meaningfulness and benefit to them. icant other was instrumental in the patient’s The following is an example of an ap- achievements in learning to use his residual proach to aural rehabilitation treatment for hearing with greater efficiency, to use sup- elderly adult patients, employing and inter- plemental visual clues, and to change his most mingling the six listed areas. This process difficult listening environments in construc- has been found effective for use with both tive ways. Without such support and assis- confined and community-based older adults. tance, an audiologist will have great difficulty facilitating such improvements. In the end, he may never be able to assist the patient in making such significant and positive strides The Ongoing Aural as will the significant other. Rehabilitation Program: Reasons for Successful and Unsuccessful Treatment The Process of Aural Programs Rehabilitation Some structure in the treatment process is desired by the majority of older patients. But, The aural rehabilitation program for an on the other hand, overly structured sessions older adult patient can include: can be counterproductive. For example, it is sadly not uncommon for audiologists who 1. Knowledge of the patient’s desires and utilize traditional speechreading (lipreading) needs for communication through set- approaches that emphasize a progression ting priorities that are those of the from phoneme analysis to syllables, words, patient, not the audiologist; phrases, sentences, and stories (which, for 2. Ongoing motivational counseling as an example, stress several like phonemes) to integral part of the process; begin to realize in a fairly short time that 3. Carryover of hearing aid orientation, the patients who seemed motivated initially at least for those who seem to benefit are attending speechreading sessions with from amplification; less regularity. Soon they may cease attend- 4. Learning how to manipulate one’s envi- ing altogether. Excuses generally range from ronment and the speakers in those envi- “My family is coming to visit and I will be ronments to enhance communication; spending time with them,” to “We have sev- TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 389 eral church suppers coming up, and I have based on a treatment plan designed around to help with them.” It is embarrassing to see the assessed needs of each patient. Why, such persons downtown later with appar- then, are some audiologists still opening ently nothing to do. They may further call their lipreading lesson book and beginning to tell your secretary that they really do not at page 1 to provide services to patients who feel the need to come to “class” anymore, have varied and individual communication even though the audiologist knows that they deficits and needs? Those speechreading have made little or no progress in treatment. books too often are used as “hymnals,” and Those patients are telling us something the session begins with the audiologist say- that we should receive loudly and clearly. ing, “And for the next session we will turn That is, if they felt that aural rehabilitation to page 15.” That is not treatment. services were benefitting them, they proba- bly would still be attending, as they evidently Individualizing the Approach were motivated when they began. If the aural rehabilitation treatment How does one develop a meaningful ap- program had been geared to the specific proach to aural rehabilitation treatment for needs of those patients, they would proba- the older patient? More than 30 years ago bly be taking advantage of the audiologist’s Hardick (1977) described the basic charac- services. But, for those reasons, and because teristics of a successful aural rehabilitation the audiologist may have begun the first program for older adults. They are well session from a predetermined approach to defined and provide comprehensive guid- speechreading, the patients were not inter- ance for those who intend to provide serv- ested in receiving those services any more. ices for older patients and in many ways are A few faithful patients might continue to still current. Those characteristics are: attend, but they probably will leave the final session as able or unable to communicate 1. The program must be patient centered. with others they were in the beginning. 2. The program must revolve around ampli- The audiologist may wonder why these oth- fication and/or modifying a patient’s erwise apparently alert older adults have communication environment. not improved, even though they may say, 3. All programs consist of individual ther- “I enjoyed your class,” and pat the audiolo- apy, with some group sessions when gist on the shoulder. Further, why does this necessary. audiologist have to coerce patients in health 4. The session must contain normally hear- care facilities to attend aural rehabilitation ing friends or relatives of the person treatment sessions or have to depend on a who has hearing impairment. gracious activity director to bring them from 5. Aural rehabilitation programs are short- their rooms to attend sessions that should term. be helping them cope in the everyday world 6. The program is consumer oriented. more efficiently? Again, it may be because 7. Aural rehabilitation programs and their the audiologist has lost sight of the fact that potential benefits need to be promoted the treatment must be designed with the to colleagues and other professionals. needs of the patients in mind. Other treat- 8. “Successful graduates” should be used ment procedures used by speech-language as resource people in therapy activities pathologists, occupational therapists, phys- whenever possible (Hardick, 1977, pp. ical therapists, physicians, and others are 60–62). 390 INTRODUCTION TO AURAL REHABILITATION These characteristics are extremely otherwise distracting environments. The important for consideration prior to the ini- level of terminology is determined by the tiation of aural rehabilitation programs for individual or group in question. The audiol- older adults. They go far beyond the more ogist is cautioned never to speak down to traditional lipreading procedures that con- patients. It is important to use the correct tinue to be employed by some. Even though technical terminology, but immediately ex- Hardick (1977) and others recommended plain it at the level of the persons involved. group treatment for older patients, some Clinicians must always remember that the will require individual services. However, as audience is adult, no matter what their edu- has been noted by this author, there is a ten- cational level or age. They deserve to be dency among some to hesitate or refuse to treated as such. participate in individual treatment unless Charts need to be used in such discus- they themselves have requested it. sions, perhaps along with a 35-mm slide Other early patient-centered approaches or PowerPoint presentation on the ear. If to aural rehabilitation are discussed by Al- individuals in the group are severely hard piner (1963), Alpiner and McCarthy (1987), of hearing, projected slides should be used Colton (1977), Colton and O’Neill (1976), only if enough light can remain in the room Giolas (1994), Hull (1982, 1992, 1997, 2001, to facilitate the use of visual clues. Charts, 2007), McCarthy and Alpiner (1978), M. diagrams, slides, and chalkboard drawings Miller and Ort (1965), O’Neill and Oyer are used for these discussions, including (1981), Sanders (1982, 1993), and others. presentations on (a) the aging ear, (b) uses, The aspect stressed by these authors is that benefits, and limitations of hearing aids, older adult patients possess needs that are (c) environmental factors that affect com- specific to them and each patient’s aural munication, (d) poor speakers versus good rehabilitation program must be centered speakers and their makeup, and (e) a gen- on his needs and priorities. eral discussion of the aging process. If the ingredients presented on the pre- The basis for the first session (or ses- vious pages are combined properly, a possible sions) is to facilitate a basis of understand- sequence of services emerges. An example ing for the remainder of the treatment pro- of such a sequence is provided below. gram, to develop a better understanding among the patients of what has occurred to Awareness of Reasons for them, and to assure them that in all proba- Auditory Dysfunction bility they can improve, at least to some degree. Most persons leave such session or Understanding Hearing Loss. Facilitat- sessions with a better understanding and ing an awareness of the reason for auditory greater acceptance of what is occurring to communication difficulties through an un- them and a desire to participate in the aural derstanding of the process of aging and its rehabilitation treatment program. effect on the auditory mechanism is an It cannot be emphasized enough that important part of the aural rehabilitation a significant other in each patient’s life process. Included is a discussion of the cen- should be encouraged to attend these ses- tral processing of auditory-linguistic infor- sions (Figure 19–3). Whether it is a spouse mation and the effect of aging on the speed or a family member such as a child or a and precision of that important component friend, he will gain much greater insight in communication, particularly in noisy or into the auditory or communication prob- TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 391 Figure 19–3. A spouse, family member, or significant other can reinforce the aural rehabilitation process. lems with which the person is attempting asked, of course, to be realistic in their final to cope. choices. For some, the choice is a simple one. For others, it is more difficult. It is Prioritized Communicative Needs. The important to note, however, that if gains are second step in the aural rehabilitation treat- made in one category, there is the probabil- ment programs is, as stated earlier, to ask ity that patients will observe improvement each patient to list those difficulties in com- in others. munication that most affect him.The Wichita They are asked to discuss their choices, State University Communication Appraisal present a situation in which they had diffi- and Priorities Profile (CAPP), as presented culty, and explain what prompted them to in Figure 19–4, can be used in this process. make those choices. Particularly in a group They may include specific communication situation, it is interesting to note the general environments, such as a meeting room, consistency of priority areas that emerge. church, certain restaurant, table arrangement The patients generally appreciate the cama- at their child’s home, and so on. They also raderie that develops out of this discussion. may list certain individuals who they have For the first time, many of them realize that difficulty understanding. they are not the only ones who have diffi- The next step is for patients to set pri- culty in certain environments. orities for these situations or persons, from In many instances, patients put part of most important to least important and, if the blame for their auditory/communica- they had their choice, in which of those tive difficulties on others who display poor would they most like to improve. They are speech habits. That is acknowledged and 392 INTRODUCTION TO AURAL REHABILITATION Figure 19–4. The WSU Communication Appraisal and Priorities Pro- file (CAPP). discussed. The discussion centers on the fact the habits that interfere with efficient com- that there are, indeed, many poor speakers munication is appropriate. Patients generally in this world. A demonstration of some of immediately recognize poor speaking habits. TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 393 Even though there are many poor speakers, and the accompanying significant other, if persons with impaired hearing must develop he was involved). Suggestions regarding pos- ways to cope in those communication envi- sible ways the patient might have manipu- ronments. The encouraging acknowledg- lated the communication environment to ment that they can, in many instances, his best advantage, including the physical manipulate such difficult situations to func- environment or the speaker, are made by the tion more efficiently in them, and that they group under the guidance of the audiolo- will be working on those situations, ends gist and are accepted as viable or discarded. the discussion on a positive note. As stated by this author previously (Hull, These items generally do not consume 2007), insights into ways of manipulating more than 1 or 2 full-hour sessions. The the communication environment to the best discussions of priority difficulties and cir- advantage, along with methods of coping cumstances that interfere with efficient with and adjusting to frustrating situations, communication should not be curtailed, are in turn developed among patients under however, because the airing of frustrations the guidance of the audiologist. This form and concerns will greatly facilitate future of self- and group analysis is an extremely progress. For many, this may be the first important part of the aural rehabilitation time those concerns have been discussed. program. Patients, then, are helped to develop To prematurely conclude such a discussion their own insights into methods of adjust- simply on the basis of a rigid schedule can ing to situations where communication is stifle the airing of emotions and adjustment difficult. If, for some reason, they find that that may otherwise not be made. it is impossible for them to make the neces- sary adjustments, perhaps they can, in a On Becoming Assertive. Weekly assign- positive, supportive, and assertive manner, ments for each patient are made and include ease their difficulty by requesting that oth- noting a communication situation in which ers make certain adjustments. Perhaps they they had particular difficulty that, in the could request that the physical environ- end, interfered with communication. As dis- ment be adjusted so that they can function cussed earlier, they write about situations more efficiently in it or they can make and diagram the physical environment if adjustments on their own. necessary (or simply recall it as accurately It becomes difficult for some older as possible). In any event, patients are to patients to develop even mildly assertive bring the specifics of the situation to the behaviors. They do not want to be noticed next treatment session for presentation and as a demanding older person. Many do feel discussion. Each patient (or in the case of rather vulnerable, perhaps feeling that the individual treatment, the patient) presents people who invited them to a party did so his difficult situation, if one has been noted. more out of obligation than desire. They It is imperative that the patient who was may feel that if they request those seeking involved in the situation be the one who conversation change positions by moving presents it and not the significant other to a quieter place to talk, or request that who may accompany the patient. someone change the position of his chair to After a thorough presentation, with dia- be in a better position to talk then, perhaps, grams if desired, the situation is discussed the hosts will feel that it is more trouble by the group (or in the event of individual than it is worth to invite them again. In light treatment, by the patient, the audiologist, of such fears, it becomes quite logical to 394 INTRODUCTION TO AURAL REHABILITATION avoid that possibility by simply remaining that if she wants to talk to you, to take her quiet and being fearful that if asked a ques- gum out of her mouth!” to a timid, “If you tion, he might be embarrassed by answering value your friendship, maybe it is best to say inappropriately. Those fears are occasion- nothing and simply tolerate the situation.” ally brought forth by patients and should be The latter suggestion was discarded. The ulti- discussed as they arise. mate conclusion was to simply tell the truth. Examples of those discussions include It was the consensus of the group that one that was initiated by one of this author’s they would respect their own friend more patients who was being seen on a group if he would say something like, “You know, basis.The woman in question was discussing we’ve been friends for a long time. You real- a situation involving another woman with ize, as I do, that I have some difficulty hear- whom she had morning coffee on almost ing what people say to me. I have particular a daily basis for a number of years. The difficulty with men who wear mustaches or patient’s complaint was that her friend was beards, people who do not move their lips an incessant gum chewer, and as she chewed enough, or people who talk with their hand as she talked, it interfered with precise artic- near their mouth, as I depend upon seeing ulation and two-way conversation. Her friend the face of persons with whom I am talk- interpreted the patient’s inability to under- ing. You know, I have difficulty understand- stand what she was saying to be the result of ing what you say sometimes and I think that the hearing impairment, not her imprecise I may have discovered why. I know that you manner of speaking from her enthusiastic like to chew gum a great deal and, like me, gum chewing, compounded by the patient’s it helps my mouth not to become so dry. hearing loss. This apparent interpretation of I do think, however, that because you— the situation infuriated my patient. But she probably not realizing it—chew your gum continued the morning coffee time, because while we are talking, it doesn’t allow me to there were few other women her age in that see your lips move properly and, besides, geographic area and, besides, they had been you aren’t able to talk as plainly when you friends since childhood. chew it so hard. I just bet that if you don’t This woman’s major concern was how chew gum while we are having our coffee, to tell her friend that her manner of speak- I will be able to understand you better and ing and gum chewing had, for several years, we’ll have a nicer time talking. Do you want interfered with her ability to understand to give it a try?” Positive assertiveness are what she was saying and, in the end, made the two key words in this instance. For that what might have been a pleasant conversa- patient, the strategy she and the remainder tion a difficult one. She was particularly of the group determined as most effective afraid to say anything because of the embar- did prove to be successful. She maintained rassment her friend might feel because the the friendship. situation had been going on for so long and nothing had previously been said. “Almost Other Topics to Facilitate Communica- like,” as the patient said, “being associated tion. Other topics for discussion and for the with a person for a long time and never development of communicative strategies knowing her name. As time passes, you may include (a) weekly socials at private become increasingly embarrassed about ask- homes where the furniture arrangements in- ing her name, particularly when she knows terfere with efficient communication. Some, yours.” The suggestions that came from the as experienced through this author’s work group varied from an enthusiastic, “Tell her with older patients, involve (b) the table TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 395 arrangement at one patient’s son’s home aural rehabilitation program, sessions should where they usually had Thanksgiving din- also emphasize those aspects of commu- ner, (c) the television set at a male patient’s nication. Again, it is suggested that strict friend’s home, (d) the seating arrangement approaches to speechreading and auditory and acoustics at a church meeting room, training not be emphasized. Rather, the fact and others. Even though the discussions and that the majority of older patients possess thought-provoking suggestions generally normal to near-normal language function aid the individual whose situation is being should be capitalized on to encourage the discussed, they also provide insights for the use of innovative and useful approaches remainder of the group on how they, too, toward increased efficiency in the use of may be able to manipulate similar commu- a very natural complement to communica- nicative environments. tion, that is, the complement of vision to These assertiveness sessions can be ex- audition. tremely stimulating for the patients involved The premise on which these sessions are and for their significant others in attendance. based is that speech (including the phone- Patients have told this author that those ses- mic patterns of words in the English lan- sions are probably the most valuable for guage, the use of gestures, inflectional clues, them, particularly because we are working and the English language itself) is generally and sharing about their problems in com- quite predictable, although, understandably, munication. As patients identify with other there are differences among individual’s patients’ difficult communication situations speech patterns, use of gestures, words, and and relate to solutions as they see them, so on. A further premise is that the average insights into solutions for their own difficult listener has been taking advantage of the situations emerge and are strengthened. redundancies inherent in American English Self-confidence reawakens when pa- speech and language patterns to aid in verbal tients return to state that the solution con- comprehension for the majority of his life. trived during the last session did not work When hearing declines with age, along with as planned, but with a few adjustments devel- the precision and speed of the processing oped by him, it did. Most older patients, of phonemic verbal and linguistic elements of no matter the level of hearing impairment speech, it becomes more difficult to com- or how distraught they may be as a result of prehend what others are saying. This is par- their inability to communicate, can benefit ticularly true in environmentally distracting from these assertiveness sessions. The top- or otherwise difficult listening situations. ics of self-worth and “I’m important too” The purpose of these sessions, there- that become a part of the discussions are an fore, is to remind patients of what they have extremely important part of the total aural been doing for years at an almost subliminal rehabilitation program. level—that is, using important parts of audi- tory/verbal messages, when heard, and sup- plementing what was not heard with visual Use of Residual Hearing with clues. By visual clues, this author means the Supplemental Visual Clues face of the speaker, including lip, tongue, and mandibular movements, gestures, facial Even though the use of visual clues and expression, shoulder movements, and so every possible bit of residual hearing indi- on used to “fill in the gaps” between what vidual patients can muster is discussed and was heard, what was not heard, and what practiced throughout all aspects of the was observed visually. 396 INTRODUCTION TO AURAL REHABILITATION A further purpose of these sessions is surprised, in fact, to find that their “edu- to discuss the redundancies of the phone- cated” guesses are often extremely close, mic and linguistic aspects of spoken Amer- if not correct. Guesses in this instance may, ican English and to encourage patients to for example, range from “The man was walk- take advantage of them when they are com- ing down the street,” to “The stoplight fell municating with others. This aspect of the into the street.” They are, however, encour- aural rehabilitation treatment program is aged to be rational in their decisions. The called, for lack of a better descriptive title, question may appropriately be asked, “How “A Linguistic Approach to the Teaching of many times have you heard someone say, Speechreading” described by this author ‘The stoplight fell into the street?’ Probably over 30 years ago (Hull, 1976). It essentially not frequently. The word ‘street’ as the last depends on patients possessing normal word in a sentence tells you what? It tells language function. Further, a great deal you, generally, that something is happening. of time is spent using the chalkboard. If, If the word came as the second word in a however, a patient has visual impairment, sentence, maybe after the word ‘the,’ I may these sessions help to enhance auditory have been describing the street, such as, closure. The term closure is the byword ‘The street was very bumpy.’ But, because it during these sessions, as the reader soon is located at the end of the sentence, we will realize. know that something is probably happen- ing either on or to the street. Linguistic Closure “Now, let’s set the stage for an example of this activity. Let us say that your neigh- As the reader will observe in this section, bor’s child, Billy, has run away. You and other patients are asked to determine the correct people from around the neighborhood are information within sentences from the least searching for him. Suddenly, someone runs number of words provided. Patients are to you and says something about, “_____ asked to imagine that the word or words _____ _____ _____ _____ _____ street!” You written on the chalkboard are those that observed that the speaker had obviously were heard. Blanks are placed between been running, and was pointing up the street words, representing those not heard or not as he was talking. Now, what do you imag- heard well. Patients are, first of all, asked to ine the speaker was telling you?” Because tell the audiologist what the sentence is the audiologist has now set the stage for the about (out of context), when perhaps only patients, their guesses will probably be one word is provided out of a total of seven, quite close to what he had intended. with six blanks indicating those words that The audiologist’s next step is to say, were not heard. “Now I am going to allow you to fill in the Patients are encouraged to venture gaps by observing my face and gestures as guesses as to what the sentence might be. I take the place of the excited neighbor who Let us say, for example, that the word pre- is talking to you. I will be using the chalk- sented is street, located as the last word board (or flip chart) as you fill in the gaps.” in the sentence. The patients are asked to The audiologist then presents the sentence let their minds wander: “Take a guess.” As in a slightly audible manner and with full patients accept that encouragement and visible face and gestures. If patients are not begin to guess, the fear of being wrong able to “make closure,” then another word appears to decrease. Many are genuinely is added to the blanks on the chalkboard, TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 397 and the patients are allowed to try again. An example of the sequence of presentation, if Linguistic, Content, and additional words are required, is presented Environmental Redundancies below. Formal usage of American English is redun- 1. _____ _____ _____ _____ _____ _____ dant in the position of various parts of street! speech. In other words, the positions of prin- 2. I _____ _____ _____ _____ _____ street! cipal words, such as nouns, pronouns, and 3. I _____ _____ _____ _____ our street! direct objects, are generally constant, as are 4. I saw _____ _____ _____ our street! function words, descriptors such as adjec- 5. I saw _____ _____ down our street! tives and adverbs, and action words such as 6. I saw _____ running down our street! verbs. Some dialects within the United States 7. I saw Billy running down our street! do, however, deviate from those standard rules. During these sessions, although the As patients become aware of what the technical names of the parts of speech are message contains, the audiologist continues not stressed, the importance of those words by discussing (a) the importance of the that fall within various positions in verbal position of each word within the sentence messages are discussed as they relate to that was required before they were able to deriving the meaning of those messages. determine its content, (b) their linguistic This aspect of treatment capitalizes on value in terms of the probability of situations the fact that most older patients who have in the meaning of the sentence, (c) the hearing impairment will possess at least importance of the environmental clues that near-normal language function. It stresses were available to them, and (d) the supple- that as people listen to others, they zero in mental use of visual clues. on words within conversations that permit An important element involved in any them to at least derive the thought of what of these sessions is the audiologist’s enthu- is being said, so that the conversation can siasm for the fact that, perhaps, the patients be followed. In some distracting environ- needed only to “hear” one or two words out ments, less of the message may actually be of the sentence to make closure and grasp heard, but most persons can still maintain the meaning of the sentence. It is encour- the content or intent of what is being said. aging for older patients to understand that, It is normal in those circumstances to ask a with their knowledge of the English lan- speaker to repeat a word, if one was missed, guage and their successful use of visual and because it appeared to be an important one auditory clues, they were able to determine regarding the content of the statement. what a message was. The point that is stressed to the patients On more difficult sentences and more is that the reason a listener was able to complex contrived situations, patients may determine that the word was an important require more heard words to be provided one in following the conversation is that via the chalkboard. Nevertheless, they are most listeners have an almost innate knowl- being reminded that with a relatively small edge of the structure of the American English amount of visual, auditory, and environmen- language that has progressively expanded tal information, they are generally able to since early childhood. This provides the lis- determine at least the thought of what is tener with a distinct advantage even in light being said. of a loss of hearing. 398 INTRODUCTION TO AURAL REHABILITATION The treatment sessions that stress this An awareness of the predictability, or important aspect of efficient listening revolve redundancy, of people and what they will around bringing that functional language say within known environments is some- capability to a more conscious level. Occa- times surprising to older adults who have sionally, patients have become so despon- hearing impairment. If it is surprising, it is dent over an inability to communicate with generally because they had not really thought others that such otherwise natural compen- about it prior to that time. If nurtured, how- satory skills have become repressed. ever, this awareness can facilitate increased efficiency in communication. Content and Environmental Redundancies Reducing Auditory or These discussions stress that, as we observe Visual Confusions human behavior, it is discovered that not only do the same people generally say similar Other activities that, by necessity, are impor- things on similar occasions, but they also tant for adults may include sharing infor- say them in similar places. In other words, mation on why certain confusions of words in a given environment, depending on who occur in conversations. This particularly con- the person is with whom one will be speak- cerns older adults, because word confusions ing, what the listener knows about him, and may occur with some frequency. These dis- if the listener is aware of those influences, cussions not only mention the fact that the the general content of some conversations nature of the majority of auditory disorders can be predicted with reasonable accuracy. that older adults face enhances the proba- Patients are asked to describe the envi- bility of auditory confusions, but also that ronments they frequent. In all probability the nature of certain sound and visual ele- they will be those that were set as priorities ments within many words enhances the earlier. They are also asked to describe those probability of confusions because they either persons who are generally there, including sound like or look like other words. When their speaking habits, their facial character- words are confused with others, the meaning istics, and their known interests. During of a sentence or conversation may appear these treatment sessions, the patients also to be different than what was intended. are asked to write down the most frequent Words used as examples of homophenous topics of conversations that are observed (visually similar) and potentially confusing among those whom they have described. words include, for example: These not only include frequent topics, but also words and phrases that those people 1. found-vowed may use habitually. They are asked to keep 2. purred-bird those lists and add to them as they remem- 3. head-hen ber additional items or as they find out more 4. vine-fried about the person after speaking with him. 5. geese-keys Patients also are asked to begin new lists as 6. neck-deck they meet new people. The more one knows and remembers about a person, the more An example of an activity that can communication is enhanced. bring about an awareness of how these TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 399 confusions can occur is based on typed lists been to complete the thought of the conver- of sentences or sentences written on the sation, then they again are asked to attempt chalkboard. It is generally best to use those to determine what the confusion was. sentences that contain visually or auditorily An example of the type of brief con- confusing words within mock conversations versation and stimulus sentence used in to exemplify most accurately the patients’ this exercise is: real-world difficulties. In this instance, the first sentence on the patients’ list may be 1. Stimulus sentence: “She bought a new presented by the audiologist within a short coat.” “conversation.” The conversation is presented 2. Stimulus conversation: “Alice came over with voice, but as close to the patients’ yesterday to see me, and had some news auditory thresholds as possible. Full-face to share. She said that she now has a new observations and gestures are used. friend who is soft, black and white, and When the sentence within the conver- weighs about 1 pound. Well, she bought sation is presented, the patients are asked a new coat. She named him Mike.” to determine if the sentence the audiologist said was the same as or different from the In this stimulus conversation, the pos- one on their list. If they determine that there sible visual confusion occurs with the word was, indeed, a word that was different than coat, which was given to the patients within observed in the sentence on their list, then the stimulus sentence they were expecting they are asked to explain why they felt that from their list of sentences. Again, if patients there were differences. On the other hand, in this instance determine that the word in if they felt that the sentence presented by the sentence they were expecting did not the audiologist was the same as the one on make sense within the context of the con- their sheet or on the chalkboard, they also versation, they are asked to explain why that are asked to explain why. word seemed to be misplaced, and what the If in the context of the short conver- word should have been. Further, the visual sation the patients determine what word and auditory similarities and differences be- or words in that sentence “threw them off tween the word they were expecting and course,” they are asked not only to analyze the one they saw and heard are discussed. those confusing words, but attempt to deter- These exercises should progress toward mine why they were confusing.They also are truly homophenous (visually similar) and asked, in light of what they derived from the homophonous (acoustically similar) words remainder of the conversation, to determine within sentences. The “mental gymnastics” the words (or the thought) that the sentence required during these sessions allows for should have contained so that it makes sense. practice in making on-the-spot decisions When that analysis is completed, the patients regarding misunderstood messages by deter- again are asked to listen to and observe the mining why a sentence within a conversa- conversation and the possibly confusing tion was visually or auditorily confusing, or sentence to determine if it then appears to otherwise did not make sense. The process be what they thought it should have been generally involves: within the context of the intended message. If the word or words within the sentence still 1. Analyzing the information derived from do not appear to be what they should have the previous portions of a conversation; 400 INTRODUCTION TO AURAL REHABILITATION 2. Determining that a confusing word has Because situations include social events, been received that may change the con- meetings, the theater, church, and other de- tent of what is being said; sirable environments, the decision to avoid 3. Sifting mentally through other words them can be self-defeating. The torment of that look or sound like one that would those with hearing impairment may con- make more sense in light of the previ- tinue, as they still want to function commu- ous portions of the conversations; nicatively in those environments and are 4. Simultaneously projecting what that torn between making another attempt at word should have been from the ongo- coping and giving up altogether. ing conversation. In an attempt to ease such communica- tion problems, treatment sessions need not only be designed to aid patients in the Communicating under Adverse development of skills for communicating in Conditions those distracting environments, but also to develop coping strategies. The terms desen- One of the most frequent communication sitization, reciprocal inhibition, and others problems that older adult patients view may be appropriate to use here, but coping as their most difficult is communication in behaviors stands as the most meaningful noisy environments, including social events for this discussion. and meetings. Many patients’ primary com- Within this framework, patients again plaint, after finding themselves in an adverse choose as priorities those environments in listening environment, is that the noise and which they have most difficulty or those the resulting difficulties they experience in within which they most desire to function attempting to sort out the primary message with greater efficiently. Those situations are from the chatter of other voices makes recreated within the treatment room as them tense and nervous. They describe the accurately as possible, based on individual nervousness as perhaps the greatest detri- patients’ description of their chosen difficult ment to their ability to manage a conversa- environments. It is stressed that in the treat- tion successfully in those environments. ment environment, no one can fail but can They tell this author that as they begin to feel free to discuss his concerns or frustra- experience difficulty within a noisy com- tions as they arise. Use of the language-based municative environment, they begin to feel speechreading instruction previously dis- nervous. The nervousness, as they describe cussed is further emphasized during these it, results in a further deterioration of their sessions.The areas stressed in the discussions ability to cope in that environment and, during these noise exercises are outlined in thus, their ability to sort the primary mes- Table 19–1, but not in order of importance. sage from the noise. These sessions are used as the culmi- For many, the only alternative that ap- nating treatment experience. Patients are pears to be available is to excuse themselves asked to take everything that they have from the situation by ceasing the con- gained from the previous sessions and put versation. By submitting to that less-than- it to use here. Some may never learn to satisfactory option, however, they generally cope in environmentally distracting situa- feel some embarrassment. Unless they are tions. Others develop such self-confidence quite resilient, many will simply avoid those that they feel more comfortable in the most situations in which they consistently fail. adverse environments. TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 401 TABLE 19–1. Topics for Discussion Stressed during Treatment Sessions • Relaxation under stressful conditions. • Confidence that clients can piece together the thought of the verbal message, even though not all of it was heard. • Remembering that, because of their normal language function and their knowledge of the predictability of American English, they can determine what is being said if supplemental visual cues are used along with as much auditory information as is possible under the environmental circumstance. • Knowledge that other people in the same environment may also be having difficulty understanding what others are saying and that they also may or may not be coping successfully with the stress. • Freedom to manipulate the communication environment as much as possible by, for example, asking the person with whom they are speaking to move with them to a slightly quieter corner where they can talk with greater ease or move his chair to a more advantageous position so the speaker can be seen and heard more clearly, or other positive steps to enhance communication. • Remembering that if difficulty in a communication environment seems to be increasing, and feelings of concern or nervousness begin to become evident, they should feel free to interrupt the conversation and talk about the noise or the activity around them that seems to be causing the difficulties. The other person will probably agree with that observation and, in talking about it, feelings of stress may be reduced and communication may be enhanced. • Remembering that the amount of recorded noise used in treatment sessions is probably greater than will be found in other environmentally stressful situations. If success was noted in their treatment sessions, then similar success may be carried over into other stressful listening environments. One aspect of coping is stressed. That the environment the patient(s) described is is that few persons, whether they possess introduced into the room. It is best to use a normally functioning auditory mechanisms tape or CD with multiple speakers system or have hearing impairment, can tolerate to recreate the noise environment most every noise environment. They must learn accurately. The noise is introduced gradu- to recognize their limits in attempting to ally at the beginning of these sessions and develop coping behaviors. increased as tolerance and coping behavior likewise increase, until the noise is presented Introducing Noise into the at such a level as to become difficult to tol- Treatment Environment erate. If patients wear hearing aids, they also are asked to experiment with them as As each patient’s difficult communication they participate in the mock noisy commu- environment is recreated by the audiologist nication environments. and other members of the treatment group, The patients are told that the situation taped noise that is the same as or similar to during treatment is going to be made more 402 INTRODUCTION TO AURAL REHABILITATION difficult in regard to noise levels and/or of frustration and even anger are expressed visual distractions than they will probably freely among patients, the reality that those experience in the real world. Patients inev- feelings are not uncommon among others itably desire such an approach, as they would occasionally brings relief to those who per- rather practice in such difficult situations in haps thought that they were among only the friendly environment of the treatment a few who had such difficult time. These room than among less tolerant people. persons are thus learning to cope with their feelings and realize that they are normal Discussions of Adverse reactions to adverse and frustrating com- Listening Environments munication environments. Discussing those feelings freely, with- Discussions of noise itself and its natural out fear of negative responses from others, effect on speech perception are introduced is an important part of the aural rehabilita- before the actual recreations begin. An aware- tion process. As frustrations and anger are ness of different types of noise, the general expressed regarding their difficulties toler- acoustical characteristics, emotional impact, ating and communicating in a noisy world and other factors give patients a better under- —and occasionally at the whole process of standing of the situation as they see it. When growing older—the way opens for the aural one begins to gain an understanding of rehabilitation program to move forward feared elements, the fear generally subsides. toward the development of coping behaviors Almost without fail, some persons begin and techniques for manipulating their own to become nervous and frustrated during the communication environments as positive, noise sessions. The susceptibility of certain assertive attributes. As one of this author’s patients to intolerance for noise can be ob- patients so aptly stated, “In a noisy world served by an alert audiologist, even when of generally poor speakers, we usually have low levels of noise are introduced. to fend for ourselves. But we are looking to If the group (or individuals) begins to you to teach us how, and to give inspiration become obviously frustrated, the audiologist, to use what we learn.” rather than ceasing the activity immedi- ately, terminates it momentarily at a logical point and begins to discuss general feelings Other Approaches to Aural about the noise rather than attempting to Rehabilitation Treatment pinpoint individual personal feelings about it. The audiologist might appropriately say, Other components of effective aural reha- “Noise makes me feel nervous. How about bilitation sessions as utilized by this author you? Sometimes during these sessions I want (Hull, 2001) involve the following elements. to turn it off. When I’m in a situation where I can’t turn it off, it even makes me upset The Use of Time-Compressed sometimes. Is that a little like the feelings Speech you have when you find yourself in a situa- tion like that?” Generally, the response will In light of the probability of a slowing of the be affirmative and patients will agree that speed of central nervous system processing those feelings are real for them, also. of auditory-linguistic information with ad- The time-out periods are used to talk vancing age (Humes, 2008; Madden, 1985; about feelings about noise. When feelings Marshall, 1981; Schmitt & McCroskey, 1981; TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 403 Stach, 1990;Welsh,Welsh, & Healy, 1985; and particularly as it relates to speed, accuracy, others), the use of time compression of and visual vigilance (Hull, 1989). speech has been found by this author to be a method through which patients can learn Environmental Design to compensate to some degree for that decline. Some older patients can increase Hull (1989, 2001) has described avenues for their ability to comprehend speech with educating older patients who have hearing speed and precision that is greater than impairment regarding techniques and strate- they had before the training. gies of environmental design. This involves Patients practice by listening to progres- modifying the acoustical or environmental sively time-compressed sentences and para- design of their homes, offices, and other graphs, attempting over an 8- to 10-week communicative environments to their listen- sequence of sessions to increase the speed ing and communicative advantage. Training with which they are able to synthesize also involves how to make modifications in and make auditory-linguistic closure. Some those and other situations in which they patients have increased their accuracy of find themselves, including social environ- speech comprehension for sentences and ments, meetings, and business environments paragraphs up to 40% at time-compression that otherwise may have placed them at a levels of 35% (65% of the message received communicative disadvantage. These can be over time). These same older patients have very powerful aural rehabilitation sessions been found to correspondingly increase their that provide patients with tangible methods accuracy of auditory-only speech recogni- for modifying their most difficult communi- tion by as much as 24% (Hull, 1988). cation situations. This is a very exciting and tangible method for enhancing the speed and accuracy of speech comprehension among individual Summary patients who can tolerate the demands of the process. Usable aided or unaided hear- It is important for older patients to be given ing is a prerequisite, however, because this the opportunity to make decisions regard- is an auditory-only task. ing areas of communication in which they desire to improve. Even though many may Interactive Laser Video Training in feel discouraged because of the embarrass- Speed and Accuracy of Visual ing difficulties they experience in their Synthesis and Closure attempts at understanding what others are saying, they have communicative priorities Interactive laser video technology recently that must be addressed through their aural has evolved for use in training Olympic ath- rehabilitation programs. letes, Air Force fighter pilots, and air traffic As adults who probably possessed nor- controllers to increase their speed and accu- mal hearing during the majority of their life racy in making visual closure, visual track- and whose case histories may reveal noth- ing, and visual synthesis. This technology ing more than that they have become older, also has been found by this author to be an they deserve to participate in the decisions effective and motivational way of training regarding their treatment program. How- adults who have hearing impairment to ever, guidance must be provided by the increase their visual compensatory skills, audiologist. TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 407 End of Chapter Examination Questions Chapter 19 1. The author describes two circumstances in which individual treatment ses- sions would be appropriate for adult patients. What are they? a. b. 2. Some older adults begin to exhibit passive behaviors in communication situations in which one would expect them to “take charge” of the environ- ment or person causing the problem. Why may passivity begin to take the place of positive assertiveness among older persons who are hearing impaired? 3. Describe the role of a significant other in the aural rehabilitation process. 4. List and describe the six components of aural rehabilitation services for adult patients as described in this chapter. a. b. c. d. e. f. 5. Briefly explain the process that seeks to help a patient be less passive and more assertive in making positive change in difficult listening environments. 6. The author describes reasons why some approaches to aural rehabilitation work and why others do not. Briefly describe those reasons. 7. To improve a patient’s communicative environment, the audiologist might suggest: a. that the patient move closer to the speaker. b. that the patient move away from a window that may be casting shadows on the speaker’s face. c. that the patient move to a quieter place, where communication can take place. d. all of the above. 408 INTRODUCTION TO AURAL REHABILITATION 8. Individualizing an aural rehabilitation treatment program for a patient involves: a. focusing on the family’s concerns. b. group therapy. c. a long-term aural rehabilitation program. d. focusing first on the patient’s communication concerns and priorities. 9. “Counseling” involves: a. listening. b. building the patient’s confidence in himself. c. all members of the family. d. giving the patient current information about hearing loss and hearing aids. e. all of the above. 10. What is the complement of vision to audition? TECHNIQUES OF AURAL REHABILITATION FOR OLDER ADULTS WITH IMPAIRED HEARING 409 End of Chapter Answer Sheet Name Date Chapter 19 1. a. b. 2. 3. 4. a. b. c. d. e. f. 5. 6. 410 INTRODUCTION TO AURAL REHABILITATION 7. Which one(s)? a b c d 8. Which one(s)? a b c d 9. Which one(s)? a b c d e 10.
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