Heightening our vigilance towards patient well-being

Abstract

Objective

Audiology patients frequently experience psychosocial difficulties created by their hearing loss or exacerbated by the loss. Clinicians are not always attuned to the unstated emotional undercurrents which may signal a need for further discussion or referral. This article aims to heighten audiologists’ vigilance towards patient well-being.

Design

A series of case vignettes with sample dialogue demonstrate the need for heightened clinical awareness of confounding consequences patients may grapple with and possible responses to these issues.

Conclusions

Beyond hearing loss, contributing detractors to patient well-being can be difficult to recognise for clinicians, and exploration and discussions may feel challenging to broach. A heightened vigilance within patient care calls upon audiologists to be alert for concerns or conditions beyond hearing loss that may be threatening our patients or further decreasing the quality of their lives and that of their families.

Keywords:

• Patient-care vigilance
• suicidal ideation
• dementia
• marital strife
• self-concept
• elder abuse
• risk assessment

Introduction

It was just over 40 years ago that George Engel, an American internist and psychiatrist, developed the biopsychosocial model of illness and healing (Engel 1980; Engel 1977). In contrast to the traditional biomedical approach to healthcare, this more holistic or humanistic view fully encompasses the thoughts, feelings and personal stories of patients along with their familial, vocational and societal interactions. The biopsychosocial model is the foundation of person-centred care that clinicians strive to practice today.

As Donne (1624) so eloquently noted in his Devotions in 1624, “no man is an island entire of itself”. The broader view of one’s interdependency with others that this statement reflects is at the root of the biopsychosocial model: a model which more fully embraces the family unit through the more inclusive term of family-centred care. Simultaneously, we are charged to treat each patient’s personhood. As Sir Osler (1899) reminds us: “Care more particularly for the individual patient than for the special features of the disease” (p. 308), a quote usually paraphrased as “Care for the patient, not the disease”. Both person-centred care and family-centred care focus on the patient as a whole person integral to the various spheres of life – family often being the greatest of these spheres. In keeping with precedent, in this article, we will use the term person-centred care, with full acknowledgement that the term encompasses both patients, their families and the larger milieu of society (Registered Nurses’ Association of Ontario [RNAO] 2015).

Our purview of vigilance

Patient counselling has long been recognised as a major component to audiologic care (American Academy of Audiology 2004). Such counselling frequently extends beyond the typical content transfer of hearing information, into the realms of personal support, self-advocacy development and motivational engagement (Clark and English 2019a). Beyond these, audiologists, like all healthcare professionals, must maintain a heightened awareness of the whole patient, poised to make referrals when the need arises (Clark and English 2019a, 2019b).

Professional audiology organisations around the globe outline a behavioural guide for clinicians through promulgated codes of ethics. In the United States, the American Academy of Audiology Code of Ethics (American Academy of Audiology 2018) clearly states that practitioners are ethically bound to “…use available resources, including referrals to other specialists…” While a screening vigilance may appear to be restricted by statements such as, “Audiologists may perform speech or language screening, or other screening measures, for the purpose of initial identification and referral of persons with other communication disorders”, the purview of vigilance requires each of us to hold forth a wider outlook towards screening. In reality, we already do maintain a wider screening outlook. In many countries, legislation exists to promote the welfare of the populace in such instances as child or elder abuse. And, indeed many clinicians enhance their value as members of a broader health-care team when they remain vigilant for signs of patient abuse, patient depression, or caregiver stress.

Person-centred care can be broken into seven components (see Table 1) which together promote patient engagement to bring patient psycho-emotional concerns front and centre into the biophysical aspects of clinical diagnoses and treatments. Within the context of maintaining a heightened vigilance towards patient well-being, component 6 of person-centred care calls for “a continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context” (Clark and English 2019a).

Table 1. Components of person-centered care in audiologic practice from a bio-psych-social perspective (From Clark and English 2019b).

Diversity recognition	A respect for differences in cultural background, beliefs, values and opinions aimed towards a recognised common ground
Therapeutic listening	A demonstrated attempt towards empathic understanding of the patient/family perspective of hearing loss impact underpinned by an unconditional positive regard and non-judgmental relationship
Information sharing	Discussion of findings in the context of expressed concerns seeking to match provided details to patient readiness
Shared decision making	Recommendations based upon research, expert opinion and the expressed experiences, needs and concerns of the patient and family; shared goal rendering encourages active participation from all parties and, as needed, negotiated compromise.
Assessed outcomes	Functional capabilities and satisfaction of delivered care assessed through measured outcomes
Holistic outlook	A continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context
Follow through	Timely and accessible service provision in an established on-going framework to ensure continued satisfaction and success

Vigilance may include what some clinicians view as difficult conversations with patients and families. The following case examples demonstrate increased awareness of concerns beyond the hearing loss and resultant communication disruptions that may have brought a patient into the audiology office and means in which these concerns can be broached.

Case illustration 1: vigilance to self-concept

Each patient presents with a unique self-concept, defined as an individual’s belief about oneself, including one’s attributes and a sense of “who I am” (Baumeister 1999). Although audiologists prefer facts to beliefs, self-concept beliefs should not be overlooked because they can have a direct impact on patient outcomes. For example, if a patient’s “belief about self” adamantly rejects the self-concept of a person who uses hearing devices; our efforts to help will be stymied.

When we heighten our vigilance to self-concept, we recognise it from the moment a patient begins to explain the reason for an appointment: family is concerned, friends are noticing problems, or the patient is personally aware of changes. From the patient’s story, we learn the extent and quality of family/social connections as well as personal reactions to circumstances, and most importantly the position of “self” within the narrative (Charon et al. 2017).

By midlife, adults have usually developed a relatively fixed self-concept. Sustaining one’s self-concept is of high importance; it is no surprise, then, to learn that changes in self-concept are not easy. According to Amesberger et al. (2019), applying the “continuity theory” explains how adults strongly desire to maintain their self-concept, and will resist change if it represents a threat to their status quo. At the same time, self-concept is not immutable, and can be influenced by life experiences.

One of the most frequently observed threats to self-concept in audiology is related to patient age. Individuals (at least in Western cultures) tend to struggle with the aging process, frequently documented in comparisons between subjective age (how old do I feel?) and chronological age. Researchers report a remarkably consistent finding in Western culture: when adults are asked how old they feel, most perceive themselves as younger than their chronological age, by as much as 20 years. For example, Bergland, Nicolaisen, and Thorsen (2014) asked 2471 participants to answer the question, “How old do you feel?” at two different points, 5 years apart. Not only did most participants report a subjective age perception lower than their chronological age at the beginning of the study, but 5 years later, the differences increased. In other words, although chronological age increased by 5 years, participants’ subjective ages stayed relatively stable. Additionally, a younger subjective age has been shown to be a predictor of aspects of successful aging such as well-being, health and longevity (Kotter-Grühn, Kornadt, and Stephan 2015), a correlation we could mention to help patients consider change.

The audiologist, Dr. Mosley, found meeting with her new patient to be very informative. Ms. Apple conveyed an appreciation for efficiency, and did not hesitate to provide her history: she had had more than her share of health problems but these days were full of energy, to the point of making a career change. Her family supported the challenge but encouraged her to find out more about her hearing, as it seemed to concern them. Personally, she didn’t see it their way but she valued their concern.

 Test results indicated a loss that would benefit from amplification. When Dr. Mosley summarised her findings, Ms. Apple tensed up: “I’m turning 58 next month. That’s too young to be wearing hearing aids”. Pointing out the flaw in this assumption would be counterproductive, so Dr. Mosley nodded and said, “An early Happy Birthday to you! Age is a funny thing, isn’t it? I wonder … do you feel 58”?

 Ms. Apple laughed. “I was just talking about this with my husband. I still feel 35! It’s always been that way for me. He said he also feels much younger than his age. Strange, isn’t it”?

 Dr. Mosley hoped her next comment would make sense: “As I understand it, it’s actually a common perception, and also an encouraging one. Apparently, people who feel younger, like you do, experience a greater sense of ‘successful aging’ as the years go by. So that’s good news, yes”? Ms. Apple agreed, seeming to relax, perhaps because she felt understood.

 Dr. Mosley asked how she would like to proceed, and Ms. Apple sighed but said, “Tell me more about hearing aids”.

Patient-centred care requires us to stay vigilant to all relevant aspects of our patients’ lives. A key focus of our attention, because it is so integral to patient outcomes, is the patient’s self-concept. We do not have specific tools, or the qualifications, to measure self-concept, and yet we can learn a great deal during our encounters, including the perception of subjective age.

Case illustration 2: marital strife and family strife

Ideally, an audiology clinical appointment includes the patient and some significant other or primary communication partner; and most often this is a spouse. While the interactions between a husband and wife during a clinical visit are most often unremarkable, clinicians are sometimes fortunate enough to witness clear demonstrations of love and support that can be an inspiration to their own domestic relationships. In contrast, we sometimes witness an emotional distance between partners in which attitudes are displayed and words exchanged that causes one to wonder what home life is like if this is the couple’s more public behaviour.

No couple begins life together in anticipation that the love felt and bond experienced will not endure a lifetime. While most marriages experience the sometimes tsunamic ups and downs of life, the vast majority of couples seem to weather their storms emerging stronger and more committed on the other side. For others, the views and responses to life’s storms differ significantly between partners creating misunderstandings, resentment and anger.

Hearing loss can have its own detrimental impact on relationships. Once enjoyed early morning banter, end of the day small talk, conversational asides, inside jokes and pillow talk, often become increasingly less frequent or may disappear altogether. Misheard requests, frequent repetitions and repeatedly forgotten communication assistance behaviours can all heighten tensions and exacerbate any of the normal strife a couple may encounter.

Audiologists are not marriage counsellors; nor should they attempt to act as such. But what do we do, if we witness clear, possibly long-endured animosity between partners? Do we pretend we do not notice and sit in an embarrassed silence? Perhaps we should say something.

When Dr. Spence asked her patient what concerns brought him in to see her, he was quick to point out that the appointment was all his wife’s idea. “You’ve been stubborn about this for years just like everything else. It’s high time we got here”, his wife was quick to counter. As conversations continued before the hearing test, and subsequently when discussing the test findings, a number of pointed and annoyed exchanges passed between Mr. and Mrs. Lynch.

 Dr. Spence wondered what life was like at home if this was how this couple treated each other in front of someone they had just met. She finally said, “I have worked with others where hearing loss has been present for a long time. Hearing loss can sometimes be like a wedge in a relationship and time can drive that wedge deep enough that it can be difficult to remember what life as a couple was like before the hearing loss. Can you see yourselves in that description”?

 Mrs. Lynch, who had looked down shortly after Dr. Spence had begun, now continued to look at her hands folded in her lap. Mr. Lynch said looking at his wife, “We’re just here for the hearing test”.

 Well, let’s concentrate on that, then. We can revisit the impact of hearing loss another time if you would like. I know someone who I have found very helpful in helping couples regain their lives after hearing loss has taken its toll.

From Clark and English (2019b), with permission

It can feel uncomfortable commenting on the impact of lost hearing on a couple’s relationship, especially for younger clinicians. But when the erosive impact of hearing loss on a relationship is clearly visible, it can be transformative to at least mention that life does not have to continue as it is. Some may show interest in exploring further what has been broached. Some, like Mr. Lynch, may shut the idea down almost immediately. But at that point it has been broached. Mr. Lynch’s wife may contact the audiologist at a future time for more information. Or perhaps she will not. But their audiologist has demonstrated her vigilance for impactful concerns and offered outside assistance if desired.

Of course, relationship turmoil can go far beyond the boundaries of the involved couple to extend to others in their lives; children, grandchildren, friends and colleagues. Sometimes, the involvement of “family” in the hearing rehabilitation process can highlight and contribute to positive directions for improving self-concept. There has been a great deal of interest in welcoming family into the audiologic process (Singh et al. 2016). Buy-in from the audiologist and staff can contribute to family participation. This can include encouraging others to attend the person’s hearing assessment and treatment and, should occur from the start of the relationship when scheduling the first appointment and subsequent meetings. In addition, accommodations can be made using tele-audiology to perhaps allow children who are working or live out of state to attend sessions.

When Mrs. Diaz called the audiologist’s office to schedule an appointment for her husband, she informed the scheduling clerk that her husband’s hearing loss was destroying her marriage and his relationship with their children. The scheduler made an appointment for a hearing test and time for counselling afterward. She encouraged Mrs. Diaz to see if her children could also attend.

 Dr. James, the audiologist, was careful to allow all parties to express their feelings about the hearing loss and made sure that Mr. Diaz was allowed to express his point of view. The session allowed the family to have a glimpse into the issues Mr. Diaz was dealing with regarding his hearing loss; they never realised how troubling it was for him not to hear, despite his refusal to seek help. The family agreed to work together and attempt some resolution combining amplification and communication strategies.

 At the time of his hearing aid fitting, Lucy, Mr. Diaz’ daughter, had broken her ankle and was unable to attend the appointment. In order to allow her to continue to participate in his care, a video conference was arranged and Lucy was part of the hearing aid fitting.

This illustration highlights the impact hearing loss can have, not only on the immediate couple but also the extended family. While it may not be feasible to have family attend all sessions, the availability of video visits can certainly increase the potential of including others. The hearing loss had a shared impact and the inclusion of family allowed for shared decision making and mutual understanding, an important tenant of person-centred care.

Case illustration 3: suicidal ideation

The World Health Organisation (WHO) has reported a global suicide rate of 10.5 per 1,000,000 people per year (nearly 800,000) occurring at the alarming frequency of one suicide every 40 s (World Health Organization 2020). The WHO further notes that evidence suggests that for each adult who dies of suicide, there may be more than 20 others who attempt suicide. The true number of suicides and suicide attempts may actually be considerably higher than reports suggest. Given that attempted or successful suicide frequently meets strong religious or cultural condemnation and is deemed a criminal offence in some countries, death by suicide may be underreported, misclassified or deliberately hidden in public death records (Mishara and Weisstub 2016; Noyes 1968; Schmalz 2018).

Nearly 80% of suicides occur in low- and middle-income countries. Worldwide, in 2016, it was ranked as the 18th leading cause of death averaged across all age groups and the second leading cause among those 15–29 years of age (World Health Organization 2020). While suicide attempts are more common among adolescents and younger adults, older adults have the highest rate of completed suicides in almost all countries (Conejero et al. 2018). In the United States, the Centre for Disease Control ranks suicide as the 10th leading cause of death further reporting that males over 85 years of age most frequently have the highest rate of death by suicide of any age subgroup (American Foundation for Suicide Prevention n.d.). While women more often speak of suicide, in actuality, it is shockingly more frequent among men being described as a “silent epidemic” (Bilsker and White 2011). The higher rate of completed male suicides may in part be attributed to the fact that men commonly select more lethal means of suicide than do women. As a result, elderly adult suicide attempts in general, are more likely to result in death often due to the use of more lethal means of suicide, are less likely to be discovered and rescued and, when found, their greater physical frailty frequently compromises recovery (Conwell, Van Orden, and Caine 2011).

Social isolation appears to be directly related to suicidal behaviours (Suicide.org. n.d.), and hearing loss is known to significantly increase social isolation, especially among the elderly. When compounded by additional negative life events, the combined impact can be devastating. Suicide statistics around the globe suggest that many experience intense feelings of hopelessness and loss of purpose in their lives.

Too often, non-mental health professionals operate under the influence of two prevalent suicide myths that suggest that (1) asking someone about suicide will put the thought in that person’s mind and that (2) someone who talks about suicide is not really serious. In direct opposition to these myths, it is imperative that all healthcare professionals, including audiologists, be prepared to open discussions with patients in pain and offer direction to trained professionals who can assist. While the lack of familiarity of such discussions may cause those outside of the mental health professions to feel uncomfortable, they can be a critical life-line for our patients who may be silently suffering severe emotional pain.

Dr. Sikes noticed Mr. Williams’ change in demeanour quite early in the appointment. She had been his audiologist for years and today he seemed despondent, his head was lower than usual and his eye contact was less. She had not seen him in over a year, but remembered shortly before his last appointment his wife had died. They had been very close and he had taken it hard. She decided to be direct with him and asked, “Mr. Williams, you don’t seem to be yourself today. What’s changed in your life since I last saw you”?

 Mr. Williams looked up briefly before returning his gaze to a spot on the carpet a few feet in front of his feet. “My daughter moved in with me shortly after Ruth died. She’s single again and she thought I could use the company. She was right, as she always is. Her presence in that quiet old house was a Godsend. Then a few months later she was diagnosed with stage four pancreatic cancer and passed away a few months after that. Parents shouldn’t outlive their children. It’s not right. Sorta makes ya wonder if life’s even worth living”.

 Dr. Sikes gently placed her hand on her patient’s arm and said compassionately, “I can’t even imagine the type of grief you have been going through. I suspect your daughter was as wonderful a woman as your wife was. But I’m concerned, what do you mean when you say life’s not worth living anymore”?

 “I don’t know. I’m just in a lot of pain, ya, know? But, I’m not going to end it all, if that’s what you’re worried about.

 Dr. Sikes continued, “Well, I do know that sometimes grief can be so great that we feel it will never go away. I have the number of a grief-support group I would like to give you.”

While reviewing his patient’s case history with Mrs. Jensen, the audiologist, Dr. Goldberg, says, “I see that you answered yes to the question, ‘Do you or your family have any concerns about memory challenges that you appear to have”? Can you tell me about your concerns?

 Looking over at her mother, Mrs. Jensen’s daughter begins, “Well, we have noticed some changes, but we haven’t mentioned them to anyone yet. Mom seems to forget a lot of what she has been told and the other day she couldn’t remember her neighbour’s dog’s name. That doesn’t sound like much, but she has been dog-sitting that dog for nearly 12 years when its family travels and often the dog stays at Mom’s house, even when her neighbours are in town. Should we be concerned”?

 Dr. Goldberg responds, “Well, we do have these moments. But what you are saying does make one think.” Turning to her patient, she continues, “Would you be willing to have me give you a brief screening to see if we should be concerned? If the results suggest further exploration would be good, I know a wonderful doctor I could recommend for you”.

Most who may contemplate suicide do not want to kill themselves. They simply want their pain to go away, and sometimes they cannot envision any other way. Dr. Sikes knows this, and she has demonstrated her recognition of and appreciation for the pain her patient is experiencing. Mr. Williams may be sincere that he has no intention of harming himself, but he may also be responding as he knows societal norms expect him to respond. Dr. Sikes has no way of knowing if Mr. Williams will follow through and call the support group of which she has made him aware. For this reason, she would call this patient the following day to see how he is faring.

For those like Mr. Williams, who state their intent is not truly self-harm, the follow up check-in call from Dr. Sikes and encouragement to join a support group or to reach out to friends or family may be enough. If, however, Mr. Williams continues to allude to suicidal ideation, any healthcare professionals in the United States, like Dr. Sikes, can call 911 to request a safety check when concern dictates. Privacy legislation permits one to reveal a patient’s name and address and reason for concern with no more self-identification than stating that one is a healthcare professional.

In this case example, Dr. Sikes has judged her patient’s suicide risk to be low based on his response. Certainly, there are times in many people’s lives when they may mention suicide with no serious contemplation of action. However, when one accompanies mention of suicide with a clear statement of intent with a plan of action in mind and a means to follow through, risk is much higher and more direct action is required. If this had been true with Mr. Williams, Dr. Sikes might have responded, “Based on what you are saying it sounds like you are not safe right now. I want you to talk with someone before you leave today. I’m concerned and want to ensure you are safe”.

Potential suicide must be taken seriously. Patients who state a serious intent of self-harm should not be allowed to leave without contacting family or some form of outside support. Most countries have established suicide hotlines (Trout 1980). If concern is high, and a mental health professional is on site at Dr. Sikes place of employment, she could accompany her patient to her colleague’s office. If there is no onsite assistance available, she could call a suicide hotline with Mr. Williams for immediate assistance.

An audiologist may practice for years and never see evidence of a patient’s clear distress and potential self-harm. But the vigilant audiologist will be alert for this, and be prepared to respond as needed should the occasion arise.

Case illustration 4: cognitive decline

The prevalence of both hearing loss and dementia increases with age, a coexistence that leads to significant challenges for patients, families and audiologists (Cacace 2007). Dementia is one of the major causes of disability and dependency with over 50 million cases of dementia worldwide increasing by nearly 10 million new cases each year (World Health Organization 2019). The decreased cognitive functioning of dementia is often accompanied by deterioration in emotional control, social behaviour or motivation (World Health Organization 2019). Affecting cognitive brain functions of language, memory, perception and thought to an extent that it adversely impacts activities of daily living (see Table 2), dementia is misunderstood by many, frequently consciously hidden from others, and often underreported (World Health Organization 2015). To facilitate open discussion of concerns of dementia onset, audiologists should consider including a dementia screening question within their case history (Armero et al. 2017).

Table 2. Characteristics of the three stages of dementia.

Early stage: gradual onset and often not recognised

• Forgetfulness

• Losing track of time

• Becoming lost in familiar places

Middle stage: signs and symptoms are more clear and more restricting

• Forgetful of recent events and familiar people’s names

• Becoming lost at home

• Increased difficulty with communication

• Increased personal care needs

• Frequent wandering and repeated questioning

Late stage: a near total dependence and inactivity

• Unaware of time and place

• Difficulty recognising relatives and friends

• Greater need for assisted self-care

• Difficulty walking

• Behaviour changes that may escalate and include aggression

From Dementia Key Facts World Health Organisation (2019)

Mrs. Richman was in for a 6-month clean and check of her hearing aids. While the hearing aids were out of her ears, her daughter-in-law said in a quiet voice, half to herself, “I don’t think anyone knows what we go through with Mom”. The audiologist paused as she attached one of Mrs. Richman’s hearing aids to the analyser and responded, “I would imagine the day to day responsibilities in caring for your mother-in-law must be quite stressful. How do you cope”?

From Clark and English (2019b) with permission.

If trained in cognitive screening, an audiologist might present such screening to patients as a means to help ensure patients remain as socially active as possible. Alternatively, a case history question, as presented in the vignette, can suffice to raise the issue and guide conversation to discuss concerns more fully with the patient’s physician. If an audiologist provides a formal cognitive screen, a useful screening measure for dementia used by a variety of health professionals is the Mini-Cog (Borson et al. 2003). As noted by Beck, Weinstein, and Harvey (2018), the very act of screening for dementia can serve as a trigger for the memories of the many unwanted life changes that may accompany aging. This may be true as well for some patients during informal discussions when a direct screening has not been performed. To offset this possibility, Beck and colleagues recommend empowering patients after screening by allowing them to guide the next step by asking if they would like information on how the results of the screening might be beneficial.

Conversations following a cognitive screening should include discussions of the nature of screenings, and that results (without labelling them as failing) can be related to a variety of factors including medications, vitamin deficiencies or depression. Similarly, when a patient performs well on a cognitive screening, discussions should include the imperfect nature of screening measures. Certainly, if patient or family concerns persist or increase, they should be encouraged to talk further with their family physician.

The WHO has promulgated guidelines addressing interventions and lifestyle behaviour modifications for the reduction of cognitive decline and dementia including improved control of linked medical conditions such as hypertension and diabetes as well as reduction of modifiable risk factors like unhealthy diets and physical inactivity (World Health Organization 2019). Hearing loss is certainly one of the identifiable risk factors for dementia (Lin et al. 2011; Lin et al. 2013; Livingston et al. 2017; Nirmalasari et al. 2017). While treating hearing loss can lessen the impact of co-existing dementia (Beck, Weinstein, and Harvey 2018), the early identification of dementia can also assist with hearing-care planning. Audiologists clearly can serve a role in enhanced early recognition of the warning signs of dementia to facilitate appropriate care.

Case illustration 5: elder abuse

Elder abuse is recognised internationally as pervasive and growing (Pillemer et al. 2016). The WHO defines elder abuse as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (World Health Organization n.d.). Such abuse can be physical, sexual, emotional/psychological or financial in nature or may manifest as either intentional or unintentional neglect of need. While noting that estimates of elder abuse are likely low due to underreporting, the WHO suggests that nearly 16% of those over 60 years of age are subjected to abuse of one form or another with the prevalence expected to increase with the rapidly aging global population (World Health Organization n.d.). Others report that as many as 25% of vulnerable adults and one-third of family caregivers have been involved in significant abuse (Cooper, Selwood, and Livingston 2008). The problem may even be more significant than thought as barriers exist for both detection and reporting of elder abuse (Schmeidel et al. 2012).

Elder abuse is especially high in such institutions as nursing homes and long-term care facilities with as many as two in every three staff reporting they have perpetrated abuse (World Health Organization 2018). However, elder abuse most frequently takes place where older adults live with their abusers. These are often adult children, or family members such as spouses or grandchildren (Help Guide 2019). Those individuals with cognitive impairment are potentially the most vulnerable to abuse (Pillemer et al. 2016).

An audiologist’s vigilance for caregiver stress and ensuing discussions of various means to reduce life stressors can serve as a possible prevention of potential elder abuse. When parents move in with their adult children, strain may be added to currently experienced stressors related to worries of the adult child’s own grown children, ending careers, downsizing, financial changes and the adult child’s personal evolving health concerns. Others who take care of an older family member also frequently have unique stress factors that can be exacerbated by the sense of a loss of personal space and privacy, decreased social opportunities, and a growing sense of isolation. The new responsibilities of caregiving, including providing for transportation needs for a growing number of medical appointments and assistance with routine daily care, further add to perceived stress. Certainly, this growing toll on the caregiver’s life, emotion and personal freedom can lead to heightened caregiver stress (Hudson 2013).

Despite the sudden drop in fall temperatures, Dr. Alverez’s 10:00 patient, Mr. Abrams, arrived with his granddaughter in a light sweater. As he shuffled in with his walker and oxygen tank, Dr. Alverez noticed he was in sandals and that his long yellowing toenails were beginning to curl from lack of trimming. Mr. Abrams appeared to have lost considerable weight over the past 6 months since his last visit. Mr. Abram’s granddaughter offered minimal assistance as he got seated in the exam room chair and said in a loud and somewhat stern tone, “Just let me do the talking. I don’t have all day and I want to get back home”. Mr. Abrams made no eye contact.

While most find the caregiving experience to be personally enriching, for some, the protracted burden and responsibilities seem only to relentlessly expand as health conditions deteriorate. A direct inquiry into how another is doing in life demonstrates an empathic perception of that person’s condition and allows for an opening to a dialogue. A heightened vigilance towards patient well-being requires that practitioners be prepared to provide assistance beyond the direct communication needs of patients.

There are a variety of social services available in most developed countries to aid the elderly and thereby reduce some of the responsibilities of caregivers and decrease their stress. Recommendations of housekeeping and meal preparation services for the older adult striving to maintain independence yet leaning heavily on family members, or adult day care for elderly patients who have moved in with one of their children, can provide needed respite for caregivers. Community resource brochures on stress management classes can also be invaluable for some families.

From a hearing loss management standpoint, audiologists should be cognisant of the stress a caregiver may feel with the added responsibility for maintaining expensive hearing aids. Patients with dementia may be prone to lose things, or even hide hearing aids. Audiologists should ensure that caregivers are aware of programmes to insure hearing aids against loss or damage (Clark and English 2019b).

There are considerable variations in both legal and legislative approaches to address elder abuse among different countries with the greatest resources available in higher-income nations (Pillemer et al. 2016). While there is no federal mandate to report suspected elder abuse in the United States, most states have passed legislation that requires that healthcare providers report abuse when suspected (Daly et al. 2003). This is true in many other countries as well.

Healthcare workers are frequently in a position to identify signs of elder abuse (see Table 3), and the ethical responsibility to report these observations should not be taken lightly. Certainly, it is not the role of an audiologist to directly confront a situation as described with Mr. Abrams. However, in many localities, suspected abuse can be reported anonymously to the police or social agencies such as Senior Protective Services. In some countries, reporting is legislatively mandated whether the observer of abuse is a friend, healthcare professional, lawyer or neighbour (Elder Abuse Prevention n.d.). When mandated, reporters are protected from both criminal and civil liabilities, while failure to report is a criminal offence. In other localities, reporting is voluntary with no penalty for failure to report and with protection from civil liability.

Table 3. Possible signs of elder abuse.

• Unexplained signs of injury such as bruises, welts or scars, especially if they appear symmetrically on two sides of the body

• Broken bones, sprains or dislocations

• Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should)

• Broken eyeglasses or frames

• Signs of being restrained, such as rope marks on wrists

• Threatening, belittling or controlling caregiver behaviour exhibited in the clinic

• Behaviour from the elder that mimics dementia, such as rocking, sucking or mumbling to oneself

• Unusual weight loss, malnutrition and dehydration

• Untreated physical problems

• Unsuitable clothing or covering for the weather

Source: Helpguide.org

Seniors themselves are frequently reluctant to report abuse due to uncertainty of where or how to seek assistance, fear of retaliation, dependence on the abuser, personal pride or embarrassment, belief that the police or social agencies cannot help, or an inability to communicate due to dementia or expressive language difficulties (Elder Abuse Prevention n.d.). When elder abuse does exist, it most likely will continue and may escalate. Clearly, vigilance towards patient well-being dictates that audiologists watch for signs that may suggest an older patient is suffering from abuse and report concerns.

Remaining within our boundaries

Audiologists are not mental health professionals. But audiologists, like those in other “helping professions”, can serve as non-mental health counsellors (Kennedy and Charles 2017) when helping patients who are psychologically normal but who may be understandably distraught, confused, angry or upset with factors that can arise from hearing, tinnitus or balance disorders (Clark and English 2019b).

Audiologists are not educationally prepared nor licenced to provide the types of counselling that may be beneficial to those in any of the five cases presented. We are, however, the very type of front-line healthcare provider who should be watching for situations or conditions that would benefit from consult with a psychologist, psychiatrist or social worker. When these situations or conditions arise in an audiology clinical encounter, audiologists are ethically bound to be prepared to broach these topics directly with their patients and patients’ families and to ensure referral for needed care.

Needed referral to a mental-health professional is not the abandonment of one’s patients. The referring audiologist maintains the patient for current and future audiological needs while ensuring the greater mental health of the patient. Discussions of concerns and recommendations for greater assistance should be made with confidence with an open willingness to address all questions regarding the referral. When addressing patient or family questions it is important to emphasise that the patient’s need for greater help is the same as that for any person in their position when encountering stressful and/or disturbing life experiences.

We should remain cognisant of the potential stigma a patient may feel when referred for professional counselling. Professional labels such as psychiatrist or psychologist can conjure thoughts of mental illness for some patients. For others, social workers may bring to mind child protection services causing parents to think the clinician believes they are unfit as parents. The more generic term counsellor is often heard as less threatening than these other professional titles and even more comfortable than the term therapist.

Every audiologist should maintain a list of mental-health professionals who are taking new patients in their area. Ideally, referrals should be made to mental health professionals who are familiar with hearing impairment. Counsellors in school programmes for children with hearing loss or schools for the deaf may be able to provide needed services or may be aware of colleagues in the community who can. When counsellors familiar with hearing impairment are not available in the local community, it would behove any clinician to develop a relationship with local mental health professionals and provide training in effective communication strategies when speaking to those with hearing loss. Not only then, are audiologists an important source for mental health referrals, but, they are frequently the advocates for clients with hearing loss and their families.

Conclusion

Clinicians in most all professions can lose themselves within the technical aspects of the services they provide resulting in a failure to fully engage in person-centred care. Rather than attending to the wider concerns and needs of the whole patient, they may fail to recognise the sometimes hidden requests for assistance beyond the information typically provided. In keeping with component six of person-centred care (Table 1), audiologists have a role in improving the greater well-being of their patients. As such, hearing-care may go beyond solely improving the state of one’s audition. While hearing concerns may have been the impetus to make an appointment, our offices should serve as an entry to any other health services a patient may need. Audiologists must watch attentively for concerns and situations, both stated and unstated, that may necessitate further activity for mental health exploration and the need for professional outside referral. When these are recognised, we must be comfortable addressing them directly and confidently to ensure that appropriate assistance is forthcoming.

Disclosure statement

The authors have no financial or non-financial conflicts relevant to this article.