Hearing Loss Determining Eligibility for Social Security Benefits (2005) / Chapter Skim
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4 Testing Adult Hearing: Conclusions and Recommendations
4 Testing Adult Hearing: Conclusions and Recommendations
Pages 101-139
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From page 101... ...
. In contrast, the ability to detect nonspeech sounds such as warning signals can be predicted using procedures that take into account the intensity and frequency content of the signal and background noise, as well as the puretone thresholds (the audiogram)
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From page 102... ...
Recommended guidelines for speech testing used by SSA in Step 3 should control each of these variables to improve the reliability of speech testing. Predictive Validity The committee's key task, a very difficult one, is to recommend standardized hearing tests that optimally predict the inability to work, taking into account issues of hearing aids, cochlear implants, non-English-speaking claimants, nonauditory deficits, and the hearing demands of different workplaces.
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From page 103... ...
. For any given test and cutoff (such as 40 percent correct on a test of word recognition, as in the current medical listings)
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From page 104... ...
. Job types 2, 3, and 4 all require hearing ability, but many people who could perform job type 2 would be unable, because of hearing loss or nonauditory problems, to meet the communication demands of job types 3 and 4.
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From page 105... ...
Expert testimony presented in the public forum held by the committee indicates that these criteria often fail to identify individuals who may be at risk in the workplace because of hearing loss, particularly those in hearing-critical jobs. There are several reasons for such failures: · The existing formula for disability determination for adults doesn't take into account speech recognition performance at average conversational speech levels, which are likely to be encountered in everyday communication situations.
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From page 106... ...
Finally, Food and Drug Administration regulations state that adults with hearing losses exceeding 70 dB HL may be candidates for cochlear implants, in recognition of the limited benefit that these individuals may receive from amplification. Thus, claimants with severe hearing losses who do not wear hearing aids or cochlear implants have essentially no ability to hear or understand conversational speech in the workplace and may be placed at a significant disadvantage as a result.
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From page 107... ...
If the claimant does not use a hearing aid or cochlear implant, then the speech recognition tests (quiet and noise) are presented to the listener in the sound field in the unaided mode (ears uncovered)
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From page 108... ...
Under the current medical listings, many persons with severe hearing loss who are not cochlear implant users are denied eligibility because their PTA 512 is better than 90 dB HL and their speech recognition score, measured at unrealistically high presentation levels, is higher than 40 percent correct. Many of these individuals are false negatives.
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From page 109... ...
We also sought tests that could be performed in unaided and aided listening conditions to indicate the benefit that a claimant receives from a hearing aid, cochlear implant, or other assistive listening device in real-world situations. Tests that could be performed by claimants who are nonnative speakers of English were also preferred.
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From page 110... ...
The measures to be assessed in the test battery for adults are: · pure-tone thresholds in each ear presented via air and bone conduction transducers, · speech thresholds using earphones in each ear, · speech recognition performance for signals presented in the sound field at average conversational levels in quiet and in noise, · tympanometry, and · acoustic reflex thresholds. The latter two tests are included to rule out conductive pathology, because a conductive component to the hearing loss often can be managed medically with improvement in hearing sensitivity.
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From page 111... ...
. A professional audiologist is deemed necessary because the recommended procedures include performing tests with the claimant's own hearing aid(s)
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From page 112... ...
The committee recommends that SSA require a checklist to accompany all hearing test results obtained for adults who are filing a claim for hearing disability. The checklist should be completed by the clinical audiologist at the time of the test and submitted with other data as part of the claim for disability.
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From page 113... ...
It is recommended that an individual not be tested if there is a history of recent noise exposure (within 72 hours) or if hearing sensitivity is noticeably poorer on the exam day, in cases of fluctuating hearing loss.
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From page 114... ...
Yes No 10. Has the claimant been using a hearing aid or cochlear implant for a sufficient duration to derive maximum benefit from it?
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From page 115... ...
The pure-tone test must be conducted without the use of a hearing aid or cochlear implant (unaided)
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From page 116... ...
. The Step 3 medical listings currently are applied at the boundary between severe and profound hearing loss.
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From page 117... ...
. A checklist item should be completed to indicate that standard test stimuli were used for assessing the speech threshold.
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From page 118... ...
For SSA disability determination, it is important to assess speech recognition performance in quiet to predict the extent to which an individual can receive instructions and communicate orally with coworkers, clients, patients, supervisors, and students in quiet listening environments. Because many work environments have noise backgrounds, assessment of speech understanding performance in simulated noise conditions is also important to predict the communication function of workers in these typical situations.
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From page 119... ...
To that end, the committee developed a set of specific criteria to use in selecting clinical speech recognition tests for disability determination at the present time. These specific criteria are in addition to those described above in the section on criteria for selecting tests for disability determination.
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From page 120... ...
, which is within the range of everyday conversational speech levels. A third criterion for the speech recognition test is that normative data must be available for background noise presented at typical S/N ratios encountered in daily communication.
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From page 121... ...
The "competition" or "noise" in this test consists of sentences spoken by a single talker. The single-talker competition was chosen rather than a broadband noise competition because for this version of the VA-NU6 test, the mean speech recognition performance levels of listeners with normal hearing are within the range 50-90 percent correct, over the S/N ratios of interest.
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From page 122... ...
The long-term RMS level is closer to 65 dB SPL, comparable to the long-term RMS level of conversational speech. All speech recognition testing is conducted in the sound field with speech and competition presented through a single loudspeaker located at 0° azimuth at a distance of 1 meter from the listener.
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From page 123... ...
These characteristics include stimuli that reflect everyday speech, recorded versions that are standardized on listeners with normal hearing and with hearing loss, recordings in the most common non-English languages spoken in the United States that are standardized on native speakers of those languages, evidence of reliable scores, availability of numerous equivalent lists, procedures that minimize the influence of cognitive factors, a reasonable administration time, and known psychometric properties (i.e., performance-intensity functions)
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From page 124... ...
The methods used to accomplish this include evaluating claimants on speech recognition tests presented in the sound field at conversational speech levels and retaining the 40 percent cutoff for speech recognition performance in this condition for the Step 3 medical listing. The testing of claimants with their own hearing aids or cochlear implants in this condition is expected to reduce the likelihood of identifying people as disabled who are able to function well in the workplace with their own devices.
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From page 125... ...
NU6 speech 0-40 percent Very poor word recognition performance in test in sound correct moderate noise levels. field at 70 dB SPL with Severely limited ability to follow individual spoken noise (+10 dB words while using the telephone in a typical office S/N ratio)
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From page 126... ...
. Claimants who wear hearing aids or cochlear implants are tested only in the aided condition, using their own hearing aids or cochlear implants set to the usual settings.
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From page 127... ...
As in the quiet situation, claimants should be tested with their own hearing aids or cochlear implants, adjusted to the usual settings, or unaided if the claimant does not use a hearing aid or cochlear implant. The recommended test is the VA-NU6 test presented at a speech level of 70 dB SPL with a single competing talker at two S/N ratios: +10 and 0 dB.
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From page 128... ...
The committee sought to include a speech recognition test in noise in the SSA disability determination process that conformed to the criteria stipulated above. As noted, there was only one recorded, standardized speech recognition test at the time of this writing that satisfied these criteria: VA-NU6.
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From page 129... ...
If an adult claimant wears a hearing aid or a cochlear implant, this must be noted on the checklist. Any claimant who wears a hearing aid must be evaluated in the unaided mode on the pure-tone threshold test and speech threshold test (described above)
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From page 130... ...
consists of measures of signal detection in the sound field. Detection thresholds in the sound field are assessed differently with the two types of devices (hearing aids and cochlear implants)
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From page 131... ...
We recommend that the claimant be fully eligible to receive disability support on the basis of unaided testing until they receive and adjust to their hearing aid or cochlear implant. CHECKLIST ITEM 10: Has the claimant been using a hearing aid or cochlear implant for a sufficient duration to derive maximum benefit from it (3 months for a hearing aid and 6 months for a cochlear implant)
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From page 132... ...
The hearing-related tasks in the workplace that have not been addressed are those that should be evaluated in future research aimed at identifying the importance of these tasks in the workplace, as well as developing tests to measure performance on these tasks. TABLE 4-3 Dimensions and Difficulty of Auditory Tasks in the Workplace in Relation to Clinical Tests Measured in the Standard Audiometric Protocol Dimension Easy Addressed?
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From page 133... ...
No Signal quality Excellent Yes Distorted (public No address systems) Language Native English Yes Nonnative Yes familiarity English Use of Test with Yes Test without Yes hearing aid hearing aid hearing aid Use of cochlear Test with Yes Test without No (no implant cochlear implant cochlear implant measurable performance)
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From page 134... ...
2. Assess speech recognition performance for two full 50-item lists of monosyllabic words presented at 70 dB SPL in the sound field at 0º azimuth in quiet (speech recognition test: VA-NU6 recording or other equivalent tests approved by SSA subsequent to this report)
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From page 135... ...
presented in the sound field in quiet at 0º azimuth, while claimant wears the hearing aid or cochlear implant, with the device adjusted to the user's normal settings. Testing is binaural with unaided ear uncovered.
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From page 136... ...
The current protocol includes evaluation of speech recognition performance in noise, in addition to the existing tests of speech recognition performance in quiet and pure-tone hearing sensitivity, with the goal of assisting SSA officers in evaluating claims in Steps 4 and 5. The committee recommends that SSA should examine the claimant's speech communication tasks on the job, in relation to performance on these audiological measures.
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From page 137... ...
Evaluate recognition performance for speech materials presented at conversational speech levels in the sound field by a wide range of listeners, including those with varying degrees of hearing loss and those who use hearing aids and cochlear implants. These must also be known to quantify the effects of hearing loss and the use of assistive devices on speech understanding in conditions that simulate everyday listening.
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From page 138... ...
sentence tests presented in unisensory and bisensory modalities. These would be particularly valuable to assess the extent to which the availability of visual cues aids speech reception in everyday listening situations by individuals with significant hearing loss.
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From page 139... ...
Develop and validate clinical tests of localization for purposes of estimating everyday performance in realworld environments while listeners are unaided or use hearing aids or cochlear implants. Research Recommendation 4-10.
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