Hearing and Balance Disorders from Diabeteschoosehealth.utah.gov/healthcare/continuing...Audiology evaluation & management of hearing. Balance screening and evaluation. Treatment of

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DisclosuresHearing and Balance Disorders from DiabetesJanuary 16th, 2019

• The Western Multi-State Division is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

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Dr. Kathryn Dowd, AuDExecutive DirectorThe Audiology Project, Incwww.theaudiologyproject.com

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Why Diabetes and Hearing Loss? (2011 Survey)

• Unknown complication (49% aware of the relationship between diabetes and hearing loss)

• 95% rarely or never refer patients for hearing screening• 98% do not use any hearing screening tools• Referral networks: 28% indicated good network; 10%

indicated excellent

Why Diabetes and Hearing Loss? (2017 Survey)

• Known complication: 95% are aware• 76% rarely or never refer patients for hearing screening• 96% do not use any hearing screening tools• Referral networks are improving: 35% indicated good

network; 7% indicated excellent

Weakened immunity with advancing age…

Increased prevalence of chronic disease

Ototoxic medications more common

Increased prevalence of hearing loss?


Hearing Loss: A Silent Epidemic

• Average time to diagnose and treat

7 years

• Only 20% identified and treated

Unmet medical need

• MDs and health organizations not informed about links between chronic and infectious disease

The Invisible Handicap


A Confounding Factor• Anosognosia: inability to know you

are sick or have a sensory impairment

• Patient “denies” illness

• Lack of self-awareness– Spouse and family notice first

• Not denial but true neurological deficit


Diseases Affecting Hearing & Balance

Diabetes

Chronic renal disease

Cardiovascular disease

•Hypothyroidism

Alzheimer’s disease

Paget’s disease

Chron’s disease


Diabetes Ear Disease

• Micro vascular effects of diabetes may damage stria vascularis and cochlear blood supply

Cochlear Microangiopathy

• Affects 8th nerve and spiral ganglion

Neural Degeneration


Vasculature of the Ear



L65% of individuals with Vision Impairment could achieve normal vision with an eye exam and new glasses, reducing falls leading to fractures. 20

Reduced corneal sensitivity, dry eye, and ocular muscle palsies are early indicators of diabetes and associated neuropathies. 21

Diabetic retinopathy is associated with periodontal disease. 18

Worsening diabetic retinopathy is associated with elevated diastolic blood pressure. 19

Vision loss due to diabetes is associated with major depression. 17

Signs of diabetes detected in the eye are associated with peripheral neuropathies of the foot and foot ulcers. 22

Diabetic retinopathy is associated with early kidney disease-Albuminuria. 23

Retinal plaque signals obstructive vascular disease of the heart or carotid artery. 24

Hearing loss is higher among those with

diabetic retinopathy

Comprehensive Eye Exam

References available by request: Michael R. Dueñas OD, FNAP,

AOA Chief Public Health Officer, [email protected]

www.theaudiology

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Audiological Concerns: Diabetes

Hearing Loss• Cochlear microangiopathy• Neural degeneration

Balance & Fall Risk • Foot neuropathy and vision effects• Vestibular effects of diabetes

Diabetic Pain & Infection Control• Ototoxicity• Vestibulotoxicity


Audiological Concerns: Cardiovascular Disease

Hearing Loss• Strokes: CVA• DVT, PE, HBP

Balance & Fall Risk• Fluid build up in extremities: loss of feeling• Hypertension related (44% in NHANES)

Medication• Loop inhibiting diuretics• Pain Rx


Diabetes Ear Disease

Impact

Audibility

Clarity

Communication

Employment

Social life

Medical management


Consequences of Hearing Loss

Symptoms

Misses verbal instructions

Noncompliance

Worse patient outcomes

Medical Management

• Asks for repetition

• Brings 3rd-party interpreter

• Associated with cognitive decline and depression– Social isolation– Stress– Confusion



Diabetes & Vestibular Disorders

Causes & Treatment

• Problems in inner ear and central vestibular system → vestibular impairment

• Pathophysiology linked to diabetes

• May be resolved with physical therapy or symptoms treated with medication

Symptoms

• Reduced mobility and need of assistance

• Worsened by vision and proprioceptive deficits linked to diabetes

• Increased fall risk can lead to serious injuries


Vestibular Symptoms • Diabetic retinopathy

and vision

• Diabetic ear disease and vestibular input

• Neuropathy and proprioception

• Refer patients with diabetes who cannot stand or walk unsupported with eyes open or eyes closed

Balance

Vision

Proprioception

Vestibular


Vestibular Symptoms • Nystagmus -

involuntary, rapid and repetitive eye movements

• Usually side-to-side but can be vertical or circular

• Reason to refer patients with diabetes

Balance

Vision

Proprioception

Vestibular


Vestibular Symptoms Vestibulo-Ocular Reflex (VOR)

• Nystagmus -involuntary, rapid and repetitive eye movements

• Usually side-to-side but can be vertical or circular

• Reason to refer patients with diabetes

Ears and eyes are connected!www.theaudiologyproject.com 22

Auditory

30% hearing loss prevalence

(NHANES)

80% among skilled nursing

facility residents

Vestibular

39% have balance

disorders

Fall risk higher with retinopathy and neuropathy

Cognitive

Comorbid with auditory and

vestibular disorders

Complications of Diabetes


https://www.ncbi.nlm.nih.gov/pubmed/18559825

https://www.asha.org/policy/GL1997-00004/


https://www.ncbi.nlm.nih.gov/pubmed/?term=Falls+and+Balance+Impairments+in+Older+Adults+with+Type+2+Diabetes:+Thinking+Beyond+Diabetic+Peripheral+Neuropathy


Auditory

27% have risk

of hearing

loss

Vestibular

81% show vestibular

risk

Cognitive

61% list potential cognitive

risk

Complications of Diabetes Insulin Medications


http://www.theaudiologyproject.com/apps/blog/categories/show/2123899-medications-that-will-make-you-dizzy

Who Evaluates Hearing Loss and Balance?

• Audiologists are the experts – Perform audiological & vestibular evaluations– Refer when medical or surgical need

• Masters, AuD, PhD

Degrees

• ABA, CCC-A

Certifications


Audiology Scope of Practice

Audiology evaluation & management of hearing

Balance screening and evaluation

Treatment of hearing loss and balance problems

Counseling for social, job and personal

Tinnitus, cochlear implants, pediatric specialties


Vestibular: Falls Risk Management

Screening Protocols

• Interview: fall history or increased fear of falling

• Timed up-and-go test

• Functional reach test

• Dynamic gain index

• Clinical test of sensory integration of balance

• Modified Hallpike (BPPV)

Advanced Assessments

• Computerized dynamic posturography (CDP)

• Videonystagmography (VNG)

• Cervical vestibular evoked myogenic potential (cVEMP)

• Rotary chair


Auditory: Hearing Management

Screening Protocols

• Interview: Patient & Family Members

• Standardized Questionnaires (HHIE)

• Otoscopy

• Pure-tone screening

• Otoacoustic Emissions (OAE) screen

Advanced Assessments

• Audiometry

• Tympanometry

• Acoustic Reflexes

• OAE (full battery)

• Speech Intelligibility

• Auditory Brainstem Response (ABR)


Insurance Coverage • Adult Medicaid hearing aid coverage varies by state

– Find yours at www.hearingloss.org/content/medicaid-regulations– Children always covered by Medicaid/insurance

Mos

t

Insurances cover audiological & vestibular diagnostic testing. So

me

Employer insurance plans have hearing aid coverage.

Non

e

Medicare has no hearing aid coverage. Advantage plans may have some coverage.


http://www.hearingloss.org/content/medicaid-regulations

Cost for Uninsured • Children always covered for services and devices

• Vocational Rehabilitation option for adults without coverage

• Adult out-of-pocket

Hearing AidsRehabilitationVestibular

EvaluationAudiological Evaluation


Summary of Presentation

31

Diabetic Patient

Pathophysiology

Ototoxic &VestibulotoxicMedications

Hearing,Vestibular,Cognitive,

SocialConsequences

YOURObservation

& Referral

AudiologicalManagement

ImprovedPatient

Compliance

www.theaudiologyproject.com

2018 Annual Meeting & Forum

Align with Pharmacy for otovestibulotoxicmonitoring

Collaborate with Podiatry for better balance and foot care

Ensure Optometry Evaluation to help lower risk of falls

Counsel patients to see Dentist several times a year

Audiology and PPOD Professions

Ongoing IPE and IPC/IPP with the other professions


Kathy Dowd, AuD, Executive Director

The Audiology Project

[email protected]

704-502-5016www.theaudiologyproject.com 34

mailto:[email protected]

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Hearing and Balance Disorders from Diabeteschoosehealth.utah.gov/healthcare/continuing...Audiology evaluation & management of hearing. Balance screening and evaluation. Treatment of