Communication and Hearing Loss:

Tammy Fredrickson MA, CCC-A

Boulder Medical Center Audiology

2750 Broadway Boulder, CO 80304

Phone 303-440-3073

Fax: 303-440-3170

Tips for Effective Communication

Hearing Loss affects 31 million people in the United States. It can affect anyone - young or old, rich or poor. Although some people are born with hearing loss, many others develop it slowly as part of the aging  process.

Hearing loss impacts not only the individual who has it, but also those around him/her. Today's hearing aids have incorporated cutting edge digital technology. They can significantly improve one's ability to hear sounds, but unfortunately, they cannot return the hearing to normal - they can only help people to hear better.

Learning some basic communication techniques can help to facilitate communication between those with hearing loss and those without.

Tips for the person speaking:

• Get the person's attention prior to speaking to him.
• Move closer to the listener. This is especially important if there is background noise.
• Speak slowly and clearly - there's no need to shout!
• Face the listener - be sure she can see your face and lips; this can help to reinforce what you're saying.
• Be aware of the environment - loud noises and inadequate lighting can make communication difficult.
• Be patient! Difficulty communicating is frustrating for both the speaker and the listener. Ask what you can do to help the listener understand.

Be a Good Listener...

• Get Closer to the speaker - Distance can distort sounds. Even people with normal hearing have difficulty hearing someone who is down the hall, upstairs, or around the corner.
• Watch the person who is speaking - Your eyes and knowledge can help fill in what your ears miss.
• Reduce or eliminate background noise - Move away from noisy places when possible (i.e., the restaurant's kitchen). Turn off the TV or radio during conversations. Consider the building/room materials: draperies, carpeting, and upholstered furniture absorb sound (making speech easier to hear) while windows and hard floors do not.
• Be assertive! Tell people that you have hearing loss. Then, they may understand why you may not respond immediately or appropriately.

For more information on hearing loss and communication, check out these websites:

www.asha.org

www.audiology.org

3/18/2008

Periodic Health Examinations in Adults

Thomas Higgins, MD
3/28/00

The content of routine health examinations for asymptomatic adults varies widely. No two physicians are likely to agree on what screening should be done. The most obvious modifiers for examination content are age & sex, however, personal & family history play a large role. To make matters more difficult, there is often very little agreement on what is beneficial among different advisory committees. Of necessity, the final decision as to the content of the screening exam is up to the patient & physician.

The cost of health screening can be high. Since it has been difficult to show a reduction in the overall cost of health care due to screening, health insurance plans have been slow make screening a benefit. This means that you as a patient may be responsible for all or a large part of the cost of the screening exam and any associated testing.

Finally, some examinations & testing procedures can be both misleading and potentially harmful. False positive tests can lead to sleepless nights and more invasive testing. Physical complications of testing procedures can be more serious.

It is widely accepted that you should see your physician regularly for checkups. What is not so widely accepted is what should be checked & who should pay for it.

The following are general guidelines for screening of the asymptomatic adult. Recommendations are based on my own experience & bias. The recommendations do not include the evaluation of specific problems, findings or abnormalities detected during screening.

Prices listed are estimates as of the time of this writing. Probability of insurance coverage is also given where known.

In the final analysis, the buck literally stops with you. Your physician will recommend but you need to know what you want & are willing to pay for. I recommend strongly that you contact your insurance company and know what benefit they provide for screening before your clinic visit.

The Physical examination: The physician interview & exam is perhaps the most useful screening tool. The interview involves a review of personal, family & social history. The examination is age & sex dependent. Areas of particular interest for screening include:

• Height and weight checks with an assessment of nutritional status at all ages.
• Evaluation of blood pressure in persons over 21 years of age.
• Pelvic examination & pap smear in sexually active women.
• Clinical Breast examination in adult women.
• Digital rectal examination of the prostate. 
• Occult blood testing after the age of 40.
• Evaluation of vision & hearing.
• Inspection of the skin

After the examination, physician counseling may occur. Common topics discussed include:

• Smoking risks for both the smoker and exposed children
• Estrogen replacement therapy & calcium supplementation in women
• Obesity & eating disorders
• Physical activity recommendations
• Alcohol use & abuse
• Unsafe sexual practices & drug use
• Breast feeding recommendations
• The recommended use of 0.4 to 0.8 mg/day of folate for women of child bearing age
• Accident prevention including seat belts, child safety seats, motorcycle helmet use, smoke detectors, poison control.
• Self breast exams for women.
• Aspirin prophylaxis in individuals with risk factors for coronary artery disease.
• The A, B, C, D, Es of melanoma recognition:
  1. Asymmetry
  2. Border irregularities
  3. Color variation (ie, different colors within the same region)
  4. Diameter greater than 6 mm
  5. Enlargement

Frequency of the physician examination is age dependent.

• Young adults should be seen every 5 years.
• After the age of 50, exams are generally recommended every 1 to 2 years.

Immunization: Immunization is perhaps the single most beneficial preventative measure in use today. Further information as well as frequently asked questions can be found at www.cdc.gov/nip/Q&A

• Tetanus & diphtheria toxoid: every 10 years as a routine and as needed if a severe wound occurs more than 5 years after the last booster.
• Influenza vaccine: adults over 65 years of age, health care workers, individuals in contact with the chronically ill, women in the 2^nd or 3^rd trimester of pregnancy during flu season, persons traveling to foreign countries during flu season and persons with chronic illness.
• Pneumococcal vaccine: adults over 65, persons after splenectomy or with splenic dysfunction.
• Measles & mumps: Persons entering college, travelers to foreign countries and adults born after 1956 without documentation of immunization on or after their first birthday.
• Rubella: Persons without documentation of immunization on or after their first birthday or who are not seropositive on testing.
• Hepatitis B: Health care workers & persons with occupational exposure to blood products, institutionalized persons, persons with unsafe sexual practices or intravenous drug usage, patients on hemodialysis or receiving regular blood products.
• Hepatitis A: Persons traveling to high-risk areas, some food handlers, persons with unsafe sexual practices or IV drug usage.
• Varicella: persons without a history of varicella or vaccination or who are seronegative on testing.
• Poliovirus: unvaccinated adults whose children will be receiving polio vaccine.

Routine Laboratory Testing:

• Cholesterol Testing: recommended every 5 years for adults.
• Thyroid Function testing: recommended in neonates. Beneficial in those over 60 years of age & those with a family history (FHx) of thyroid disease.
• Blood Count: periodically in menstruating females.
• Liver function tests and serologic tests for syphilis & AIDS in individuals engaged in unsafe sexual practices or using IV drugs.
• Periodic Prostate antigen testing (PSA) in men over 50 years of age.

Testing of doubtful value in asymptomatic individuals:

• Routine Chest Xray
• Routine EKG
• Routine Blood chemistry profiling
• Routine Urine analysis
• Blood type & Rh
• Upper Endoscopy with one exception. First generation Japanese Americans should be screened for gastric cancer that is frequent in this group of individuals.
• Pap smears after a hysterectomy done for non-malignant disease & where the cervix has been removed.

Screening for specific diseases:

Ovarian Cancer: Routine pelvic examinations. A case is being made for a combination of Ca125 blood level & pelvic ultrasound examination in women with the rare disorder of familial ovarian cancer. Screening generally begins after the age of 50 with a frequency of every 2 years. This screening is not recommended for the general population.

Prostate cancer: The American Urological Association and the American Cancer Society recommend that men over the age of 50 years be screened for prostate cancer with both an annual digital rectal examination and serum PSA test. Screening at age 40 years is recommended in men who have a high risk for prostate cancer; these include black men and men who have a family history of prostate cancer, especially in the man's father, brother, or uncle.

Breast Cancer: Mammography is generally recommended yearly after the age of fifty. Some recommend every other year from 40 to 50 as about 10% of breast cancers occur in this age group. Strong FHx may warrant earlier testing.

Diabetes: Some experts recommend measurement of fasting plasma glucose in all persons at age 45 years and periodically thereafter. A value less than or equal to110 mg/dL is considered normal.

I prefer testing after a meal and accept values of less than or equal to 120 mg/dl as normal. In my opinion, testing should be done periodically in all persons who have a positive FHx of diabetes or who are obese.

A special situation occurs during pregnancy where screening for gestational diabetes is recommended at 24 to 28 weeks of gestation. Screening for gestational diabetes initially involves a 50-gram oral glucose challenge with the plasma glucose measured one hour later. A value of greater than or equal to140 mg/dL is considered abnormal.

Colon cancer screening: Screening generally begins in both men & women at age 50 & several tests are used in various combinations.

• Digital rectal examination.
• Fecal occult blood testing recommended yearly.
• Screening sigmoidoscopy recommended every 5 years.
• Double-contrast barium enema every 5 to 10 years.
• Colonoscopy every 10 years.

The pros & Cons of each approach include:

• Digital rectal exams will detect only 5% of tumors.
• Fecal occult blood testing rarely detects of premalignant polyps because they do not usually bleed.
• Flexible sigmoidoscopy detects ½ of the colonic lesions because it only visualizes the last ½ of the colon..
• Double contrast Barium Enema is capable of detecting most lesions greater than 1 cm but a second procedure is then necessary for removal of the polyp.
• Colonoscopy has the advantage of both finding most of the polyps & removing them at the time of the proceedure. Colonoscopy is the most expensive proceedure & requires sedation.
  

Because there is no single test, a combination of the above is often recommended. More aggressive screening is indicated in individuals with a positive FHx of colon cancer.

Glaucoma screening: The American Academy of Ophthalmology (AAO) recommends a comprehensive eye examination for every person over age 40 by an ophthalmologist or an optometrist. A typical frequency of examination is every 3 to 5 years for those without risk factors, and every 1 to 2 years for those with one or more risk factors such as borderline pressures, cupping of the optic disk, black race, diabetes mellitus, and family history. The AAO also suggests periodic examination for black men and women between ages 20 to 39 because of the higher incidence of glaucoma in this racial group.

Osteporosis Screening: Densitometry is of value in women unable or unwilling to take estrogens after menopause and in persons with a history of other conditions including eating disorders, hyperparathyroidism, kidney stones, amenorrhea, etc.

Cervical Cancer Screening: Annual pap smears in all sexually active women or after the age of 18 is generally accepted. Some physicians feel that pap smears may be discontinued after the age of 65 if the individual has had 3 negative pap smears previously.

Coronary artery disease: Routine exercise tolerance testing (ETT) is generally not recommended. In some situations screening of asymptomatic individuals may be appropriate.

The American Academy of Family Physicians recommends ETT for those people who have jobs linked to public safety (eg, pilots, air traffic controllers) or that requires high cardiovascular performance (eg, police officers, firefighters).

The American College of Sports Medicine recommends ETT for men over age 40, women over age 50, and other asymptomatic people with multiple cardiac risk factors prior to beginning a vigorous exercise program.

Individuals with three or more major coronary risk factors (eg, smoking, male sex, obesity, family history of heart disease, over 45 years of age, diabetes, hypertension, and hypercholesterolemia), have an incidence of significant coronary disease that may approach 10 percent. The relatively high prevalence of coronary disease in such patients suggests that screening may be effective.

In summary, there is no such thing as a single routine physical examination for asymptomatic individuals. Proper examination involves risk factor analysis that incorporates the individual’s personal & family history, age, sex and physical findings. Recommendations for screening must also take into account the cost to the patient & lengths to which the patient is willing to go to reasonably predict potential problems. As a patient you should become an active participant in your own health care & know your insurance benefits.