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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.
• Participants must complete the pre-test, attend the entire live event, and complete the post-test with a score of 80% or greater to earn one and a half contact hours.
• No conflicts of interest are involved in this series. This includes no content relevant to commercial interest and no presence of commercial support.
• Please note that due to reporting guidelines, you will have three weeks after the live webinar to complete your post-test and print your certificate. You will NOT be able to access or earn continuing education credits after the three week time frame.
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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?
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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
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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
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Diseases Affecting Hearing & Balance
Diabetes
Chronic renal disease
Cardiovascular disease
•Hypothyroidism
Alzheimer’s disease
Paget’s disease
Chron’s disease
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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
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Vasculature of the Ear
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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]
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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
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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
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Diabetes Ear Disease
Impact
Audibility
Clarity
Communication
Employment
Social life
Medical management
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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
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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
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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
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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
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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
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Auditory
27% have risk
of hearing
loss
Vestibular
81% show vestibular
risk
Cognitive
61% list potential cognitive
risk
Complications of Diabetes Insulin Medications
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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
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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
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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
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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)
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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.
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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
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Summary of Presentation
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Diabetic Patient
Pathophysiology
Ototoxic &VestibulotoxicMedications
Hearing,Vestibular,Cognitive,
SocialConsequences
YOURObservation
& Referral
AudiologicalManagement
ImprovedPatient
Compliance
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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
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Kathy Dowd, AuD, Executive Director
The Audiology Project
704-502-5016www.theaudiologyproject.com 34