As hearing care is now
shifting from tertiary institutions into the community, read all about the GP’s
key role in identifying and referring patients to community audiology services
for timely management.
WHAT IS PRESBYCUSIS?
Presbycusis refers to age-related hearing loss and is an extremely common condition, affecting up to 88% of Singaporean patients over the age of 60. With Singapore having one of the highest life expectancies globally, this prevalence is expected to rise.
The hearing loss associated with presbycusis can be mild, moderate or severe-profound. It can also affect lower frequency or higher frequency hearing.
Early symptoms that patients experience include mishearing words and/or difficulty hearing in noise. Tinnitus is also not uncommon among this patient group.
IMPLICATIONS OF PRESBYCUSIS
The negative associations of presbycusis have long been demonstrated by various studies, but have received increased attention in recent years.
Individuals with hearing loss are at higher risk of:
Association with dementia
A study based in the United States found that the risk of incident dementia was 1.89 times higher in elderly with mild hearing loss, and 4.94 times higher in elderly with severe hearing loss.5
Locally, a longitudinal study involving 1,515 subjects found that among participants who were cognitively normal at baseline, those with hearing impairment were 2.3 times more likely to develop mild cognitive impairment or dementia.6
Although the mechanisms via which this occurs are not fully elucidated, there are several proposed theories:
Social isolation may result in reduced cognitive stimulation, predisposing one to decline.
It has also been proposed that hearing impairment requires the brain to recruit finite neurologic reserve to make up for the deficits in auditory perception, affecting other cognitive functions.
Association with depression
Studies have also found that up to 20% of patients with presbycusis also have symptoms of depression.7 Several mechanisms have been proposed for this.
Untreated hearing loss often results in communication difficulties, affecting social interactions with loved ones and friends. This can result in increased frustration when interacting with patients with presbycusis. Difficulties with communication may eventually reduce interactions and participation in enjoyable activities, resulting in increased loneliness and quality of life among these patients.
Depression and cognitive decline have an inherent two-way relationship, with one worsening the other.
MANAGEMENT OF PRESBYCUSIS
Increased awareness of the potential complications of hearing loss has placed increased importance on screening for hearing loss, as treatment with devices such as hearing aids has been shown to positively impact quality of life8.
Where indicated, patients with severe-profound hearing loss not adequately rehabilitated with hearing aids will also be recommended cochlear implantation by ENT.
Although research into the role of hearing rehabilitation in preventing and even reversing the above complications of presbycusis is preliminary, it is suggested that it does play an important part.
To address the needs of individuals with presbycusis, early detection, appropriate referrals and access to interventions are crucial to ensure hearing care can be received in a timely manner.
COMMUNITY AUDIOLOGY CLINICS: EMBRACING A NEW MODEL OF CARE
Traditional model of care
The traditional model of care for patients with hearing issues involves GP clinics and polyclinics referring patients to an ENT specialist within a tertiary hospital. These patients will subsequently visit an audiologist in the restructured hospital for hearing intervention and rehabilitation.
Shifting care into the community
However, patients with presbycusis can be effectively managed and supported in the community without requiring referrals to ENT doctors.
Our recent national initiative, Healthier SG, aims to shape the public's care-seeking behaviour by shifting tertiary care into the community. Individuals with hearing loss can promptly receive appropriate care at community audiology clinics.
Benefits of community audiology care
By bringing audiology services to the community, barriers such as long travel distances, long referrals from ENT to hospital audiologists and delayed help-seeking can be reduced.
This increased accessibility empowers patients and caregivers to support active aging and minimise impairments caused by age-related hearing issues.
Screening for hearing loss
A nationwide functional screening (FS) programme for seniors under Project Silver Screen was launched in 2018 to detect age-related health conditions including hearing loss. Singaporeans aged 60 and above are being screened, and those who fail the hearing screening are referred to community-based medical institutions.
The Tiong Bahru Community Health Centre (TBCHC) is one of the community clinics collaborating with the FS programme to conduct diagnostic hearing assessments, hearing interventions and rehabilitation as part of the continuum of care.
THE TIONG BAHRU COMMUNITY HEALTH CENTRE
Community audiology clinics have been established throughout the island, and one such clinic under Singapore General Hospital (SGH) is TBCHC which provides hearing care services. It is located near to Tiong Bahru MRT and accessible via public transport.
TBCHC also adopted the National University of Singapore boothless protocol ― an innovative diagnostic tool that allows hearing assessments without the need for a traditional sound booth.
Figure 1 Boothless hearing test in a consult room at TBCHC
TBCHC's role in care
TBCHC receives referrals from various sources including polyclinics, CHAS GP clinics and the FS programme. This enables patients who have age-related, stable hearing loss to receive early detection and interventions to promote healthy aging.
Should a patient require further medical attention or tertiary care, the patient will be referred from the community clinic to an ENT specialist. Furthermore, patients from SGH who have received medical clearance for hearing aid fittings are redirected to TBCHC for hearing aid evaluations and follow-ups.
Figure 2 Referral routes for senior citizens with hearing loss
Audiological services offered at TBCHC include:
- Pure-tone audiometry
- Immittance testing
- Hearing aid evaluations
- Hearing rehabilitation
Supporting patients requiring financial assistance
For patients who require financial assistance for hearing devices, audiologists at the clinic also provide guidance on the government subsidies available based on their eligibilities.
Singaporeans aged 60 and above with disabling hearing loss may be eligible for the Seniors' Mobility and Enabling Fund (SMF). Audiologists can assist patients in checking their household means-testing (HHMT) outcomes to determine eligibility and facilitate the application process for SMF in purchasing hearing devices.
The subsidy provided by SMF is capped at $3,000, with varying percentages of 0%, 75%, 90% and 100%, depending on the HHMT and any social service assistance the patient may be receiving. In cases where the cost of the hearing device(s) exceeds $3,000, the patient would pay the remaining balance after deducting the subsidy. The prices of hearing aids can range from $900 to $12,000 for a pair.
WHO GPs SHOULD REFER TO TBCHC
Primary care physicians play an important role in identifying patients who will benefit from referral to community audiology services for further management.
The inclusion criteria for referral to TBCHC are:
The exclusion criteria are:
Any cognitive challenges or dementia (as the patient is required to follow simple instructions)
Earwax or visible foreign body in the ear canal
Abnormalities of the outer ear (anotia, microtia, atresia or surgically enlarged ear canal)
Active ear infection, inflammation or discharge
Any persistent pain affecting either ear
Sudden hearing loss
Asymmetrical hearing loss
Pulsatile or severe tinnitus
In 2021, a pilot programme was launched for direct referrals from Bukit Merah Polyclinic and Outram Polyclinic to TBCHC.
For GP/CHAS clinics and other polyclinics, referral forms can be requested via email to firstname.lastname@example.org.
PATIENT RESPONSE TO COMMUNITY AUDIOLOGY CARE
According to a patient experience survey, 67% of patients who received hearing care services either from SGH or community clinics expressed a preference for the community clinics over the restructured hospital.
Reasons cited include:
- Proximity to their homes
- Convenience to access the clinic
- The ability for the patient to visit the clinic independently
As part of preventive care management and community-based hearing care, the goal is to expand this model of care and establish more audiology clinics in the community. This expansion will help facilitate patient journeys, and reduce unnecessary referrals to ENT specialists for patients with stable hearing loss such as presbycusis.
By optimising the referral pathways, specialised care in tertiary hospitals can be prioritised for patients who truly require it while timely care in the community can be provided for those who would benefit from it.
Lin, F. R., Yaffe, K., Xia, J., Xue, Q. L., Harris, T. B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H.N., Ferrucci, L., Simonsick, E.M. and Health ABC Study Group, F. T. (2013). Hearing loss and cognitive decline in older adults. JAMA internal medicine, 173(4), 293-299.
Lawrence, B. J., Jayakody, D. M., Bennett, R. J., Eikelboom, R. H., Gasson, N., & Friedland, P. L. (2020). Hearing loss and depression in older adults: a systematic review and meta-analysis. The Gerontologist, 60(3), e137-e154.
Xu, D., Newell, M., & Francis, A. (2021). Fall-related Injuries Mediate the Relationship between Self-Reported Hearing Loss and Mortality in Middle-Aged and Older Adults. The journals of gerontology. Series A, Biological sciences and medical sciences, 76(9), e213-e220.
Shukla, A., Harper, M., Pedersen, E., Goman, A., Suen, J. J., Price, C., Applebaum, J., Hoyer, M., Lin, F.R. and Reed, N.S. (2020). Hearing loss, loneliness, and social isolation: a systematic review. Otolaryngology–Head and Neck Surgery, 162(5), 622-633.
Lin FR, Metter EJ, O'Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214-220.
Heywood R, Gao Q, Nyunt MSZ. Hearing loss and risk of mild cognitive impairment and dementia: findings from the Singapore Longitudinal Ageing Study. Dement Feriatr Cogn Disord. 2017;43(5-6):259-268.
Cosh S, Helmer C, Delcourt C, Robins TG, Tully PJ. Depression in elderly patients with hearing loss: current perspectives. Clin Interv Aging. 2019;14:1471-1480. Published 2019 Aug 14.
Gates GA, Mills JH. Presbycusis. Lancet. 2005 Sep 24-30;366(9491):1111-20.
Dr Ng Jia Hui is a Consultant Otolaryngologist at Singapore General Hospital. She has subspecialty interests in otology and neurotology, and regularly treats patients with hearing loss and chronic ear disease in her practice. She hopes to raise awareness of the importance of good hearing in healthy aging, and the usage of hearing devices and implants in hearing rehabilitation.
Ms Chew Yong Yee is a clinical audiologist based in the community clinics under Singapore General Hospital. Ms Chew was involved in establishing and setting up audiology clinics at the Tiong Bahru Community Health Centre and the Sleep Centre at SingHealth Tower. Additionally, Ms Chew was a member of the research team at the National University of Singapore, where she contributed to the development of the boothless protocol and its successful implementation in the community setting.
With eight years of clinical experience, she is dedicated to delivering comprehensive and patient-centred care. She is passionate about enhancing healthcare practices and exploring new avenues for improving patient outcomes, constantly striving to contribute to the continuous improvement of patient care.
Acknowledgements: Mr Gopal Krishnan Sarepaka and Ms Leem Pei Shan for giving guidance in this article.
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