Associations of frailty, self-reported balance problems, hearing abilities, and posturography in a sample of older adults.

OBJECTIVE: The aim of this study was to identify risk factors for self-reported balance problems, and to analyse associations between hearing and balance. DESIGN: A battery of tests was administered to assess hearing and balance performance, as well as additional health-related factors indicative of frailty and fall risk. In a retrospective analysis, logistic regression was used to identify risk factors for self-reported balance problems and linear regression was used to identify associations between hearing ability and functional balance. STUDY SAMPLE: For the risk factor analysis, 199 volunteers aged 55-81 years (mean:67) were divided into two groups according to their self-reported balance problems. Only participants lacking self-reported balance problems (n = 157) were included in the second analysis. RESULTS: Female gender, frailty, and fine-motor skills were statistically significant predictors of self-reported balance problems. Functional balance performance was related to hearing impairment for dynamic, but not for static, balance tasks. CONCLUSION: For a holistic approach to healthcare and regardless of age, individuals with multiple comorbidities and/or phenotypic signs of frailty should be considered at risk for falls. For further research, it was shown that dynamic, rather than static, balance tasks may be needed to gain deeper insights into the relationship between hearing and balance.

Self-reported hearing handicap in adults aged 55 to 81 years is modulated by hearing abilities, frailty, mental health, and willingness to use hearing aids.

OBJECTIVE: The aim of this study was to predict outcomes of the HHI questionnaire (Hearing Handicap Inventory) using individual variables beyond pure-tone hearing thresholds. DESIGN: An extensive health-related test battery was applied including a general anamnesis, questionnaires, audiological measures, examination of visual acuity, balance, and cognition, as well as tactile- and motor skills. Based on the self-assessment of health variables and different sensory and cognitive performance measures, a frailty index was calculated to describe the health status of the participants. A stepwise linear regression analysis was conducted to predict HHI scores. STUDY SAMPLE: A mixed sample (N = 212) of 55- to 81-year-old, participants with different hearing and aiding status completed the test battery. RESULTS: The regression analysis showed statistically significant contributions of pure-tone hearing thresholds, speech recognition in noise, age, frailty, mental health, and the willingness to use hearing aids on HHIE outcomes. CONCLUSIONS: Self-reported hearing handicap assessed with the HHI questionnaire reflects various individual variables additionally to pure-tone hearing loss and speech recognition in noise. It is necessary to be aware of the influences of age and health-related variables on HHI scores when using it in research as well as in clinical settings.

Impact of Lexical Parameters and Audibility on the Recognition of the Freiburg Monosyllabic Speech Test.

OBJECTIVE: Correct word recognition is generally determined by audibility, but lexical parameters also play a role. The focus of this study was to examine both the impact of audibility and lexical parameters on speech recognition of test words of the clinical German Freiburg monosyllabic speech test, and subsequently on the perceptual imbalance of test lists observed in the literature. DESIGN: For 160 participants with normal hearing that were divided into three groups with different simulated hearing thresholds, monaural speech recognition for the Freiburg monosyllabic speech test was obtained via headphones in quiet at different presentation levels. A software manipulated the original speech material to simulate two different hearing thresholds. All monosyllables were classified according to their frequency of occurrence in contemporary language and the number of lexical neighbors using the Cross-Linguistic Easy-Access Resource for Phonological and Orthographic Neighborhood Density database. Generalized linear mixed-effects regression models were used to evaluate the influences of audibility in terms of the Speech Intelligibility Index and lexical properties of the monosyllables in terms of word frequency (WF) and neighborhood density (ND) on the observed speech recognition per word and per test list, respectively. RESULTS: Audibility and interactions of audibility with WF and ND correctly predicted identification of the individual monosyllables. Test list recognition was predicted by test list choice, audibility, and ND, as well as by interactions of WF and test list, audibility and ND, ND and test list, and audibility per test list. CONCLUSIONS: Observed differences in speech recognition of the Freiburg monosyllabic speech test, which are well reported in the literature, depend not only on audibility but also on WF, neighborhood density, and test list choice and their interactions. The authors conclude that future creations of speech test material should take these lexical parameters into account.

Ecological Momentary Assessment in Hearing Research: Current State, Challenges, and Future Directions.

Common methods to assess hearing deficits and the benefit of hearing devices include retrospective questionnaires and speech tests under controlled conditions. As typically applied, both approaches suffer from serious limitations regarding their ecological validity. An alternative approach rapidly gaining widespread use is ecological momentary assessment (EMA), which employs repeated assessments of individual everyday situations. Smartphones facilitate the implementation of questionnaires and rating schemes to be administered in the real life of study participants or customers, during or shortly after an experience. In addition, objective acoustical parameters extracted from head- or body-worn microphones and/or settings from the hearing aid's signal processing unit can be stored alongside the questionnaire data. The advantages of using EMA include participant-specific, context-sensitive information on activities, experienced challenges, and preferences. However, to preserve the privacy of all communication partners and bystanders, the law in many countries does not allow audio recordings, limiting the information about environmental acoustics to statistical data such as, for example, levels and averaged spectra. Other challenges for EMA are, for example, the unsupervised handling of the equipment, the trade-off between the accuracy of description and the number of similar listening situations when performing comparisons (e.g., with and without hearing aids), the trade-off between the duration of recording intervals and the amount of data collected and analyzed, the random or target-oriented reminder for subjective responses, as well as the willingness and ability of the participants to respond while doing specific tasks. This contribution reviews EMA in hearing research, its purpose, current applications, and possible future directions.

The Quest for Ecological Validity in Hearing Science: What It Is, Why It Matters, and How to Advance It.

Ecological validity is a relatively new concept in hearing science. It has been cited as relevant with increasing frequency in publications over the past 20 years, but without any formal conceptual basis or clear motive. The sixth Eriksholm Workshop was convened to develop a deeper understanding of the concept for the purpose of applying it in hearing research in a consistent and productive manner. Inspired by relevant debate within the field of psychology, and taking into account the World Health Organization's International Classification of Functioning, Disability, and Health framework, the attendees at the workshop reached a consensus on the following definition: "In hearing science, ecological validity refers to the degree to which research findings reflect real-life hearing-related function, activity, or participation." Four broad purposes for striving for greater ecological validity in hearing research were determined: A (Understanding) better understanding the role of hearing in everyday life; B (Development) supporting the development of improved procedures and interventions; C (Assessment) facilitating improved methods for assessing and predicting ability to accomplish real-world tasks; and D (Integration and Individualization) enabling more integrated and individualized care. Discussions considered the effects of variables and phenomena commonly present in hearing-related research on the level of ecological validity of outcomes, supported by examples from a few selected outcome domains and for different types of studies. Illustrated with examples, potential strategies were offered for promoting a high level of ecological validity in a study and for how to evaluate the level of ecological validity of a study. Areas in particular that could benefit from more research to advance ecological validity in hearing science include: (1) understanding the processes of hearing and communication in everyday listening situations, and specifically the factors that make listening difficult in everyday situations; (2) developing new test paradigms that include more than one person (e.g., to encompass the interactive nature of everyday communication) and that are integrative of other factors that interact with hearing in real-life function; (3) integrating new and emerging technologies (e.g., virtual reality) with established test methods; and (4) identifying the key variables and phenomena affecting the level of ecological validity to develop verifiable ways to increase ecological validity and derive a set of benchmarks to strive for.

[Hearing test results of 18- to 20-year old men preceding military conscription from 2008-2010]. / Hörtestergebnisse bei 18- bis 20-jährigen Männern aus Kreiswehrersatzämtern von 2008­2010.

OBJECTIVE: High-frequency hearing loss is known to increase with age, whereas the amount and rate of increase of hearing loss in younger people is still unclear. A large proportion of young age groups is expected to preserve normal hearing. Therefore, the requirements for screening methods are particularly high and the motivation to participate is low. The obligatory examinations preceding military conscription include a pure-tone audiogram and thus allow the analysis of the hearing status of young male adults. MATERIAL AND METHODS: The prevalence of hearing impairment was determined using air-conduction thresholds of 18- to 20-year old men, from 54 German registration offices (KWEA), measured in 2008 to 2010. The criterion was based on candidates exceeding a threshold of 20 dB HL for one of the frequencies 3, 4, or 6 kHz in at least one ear. This very strict criterion was compared to other definitions of hearing impairment. RESULTS: The prevalence of hearing impairment was, on average, 15.3 % and thus in the same range as in other studies. However, the results of single KWEA differed by up to a factor of 10. CONCLUSIONS: Due to high fluctuations in measurement quality in the KWEA, regional differences in hearing thresholds of young men are not resolvable and it remains unclear whether the hearing loss has increased in comparison to earlier studies. The high variability of measurements near thresholds requires permanent quality inspections. However, hearing thresholds derived from screening cannot be evaluated applying the same criteria as for hearing tests in audiological centers or studies.

Development of an adaptive scaling method for subjective listening effort.

An adaptive procedure for controlling the signal-to-noise ratio (SNR) when rating the subjectively perceived listening effort (Adaptive Categorical Listening Effort Scaling) is described. For this, the listening effort is rated on a categorical scale with 14 steps after the presentation of three sentences in a background masker. In a first phase of the procedure, the individual SNR range for ratings from "no effort" to "extreme effort" is estimated. In the following phases, stimuli with randomly selected SNRs within this range are presented. One or two linear regression lines are fitted to the data describing subjective listening effort as a function of SNR. The results of the adaptive procedure are independent of the initial SNR. Although a static procedure using fixed, predefined SNRs produced similar results, the adaptive procedure avoided lengthy pretests for suitable SNRs and limited possible bias in the rating procedures. The adaptive procedure resolves individual differences, as well as differences between maskers. Inter-individual standard deviations are about three times as large as intra-individual standard deviations and the intra-class correlation coefficient for test-retest reliability is, on average, 0.9.

Social inequalities in pure-tone hearing assessed using occupational stratification schemes.

OBJECTIVE: The objective of this study is to analyse the performance of two occupational stratification approaches and the impact of social position on adult hearing. DESIGN: The prevalence of hearing impairment, pure-tone averages (PTA) and prevalence ratios (PR) for relative hearing loss, which focuses on the position of one's PTA in the age- and gender-specific distribution, were compared in groups defined by ISCO Skill Level and the International Socio-Economic Index (ISEI). STUDY SAMPLE: About 1571 subjects aged 30-89, including 677 highly screened adults, from the cross-sectional study HÖRSTAT. RESULTS: ISCO Skill Level and ISEI yielded qualitatively the same results. The prevalence difference between the socially least and most advantaged group ranges between 10 and 16%, varying with the scheme applied. Low- and high-frequency PTA and PR for relative hearing loss confirm the gradient. Screening reduced, but did not negate the social differences. The prevalence difference dropped to 6-7% in the otologically normal subsample. CONCLUSIONS: Social groups defined by hierarchical, occupational measures differ in their pure-tone hearing, even if the main risk factors are controlled for. This underlines the need for population-based sampling, the relevance of reporting the study group's social composition and the importance of advancing the discussion on appropriate social measures in hearing research.

[Hearing Loss and Speech Recognition in the Elderly]. / Hörverlust und Sprachverstehen im Alter.

Elderly people often complain about poor speech understanding in noisy environments. In clinical practice, speech tests under noise conditions are used to examine hearing ability. The HÖRSTAT study, conducted on a population-based random sample consisting of 1903 adults, used the Goettingen Sentence Test (GÖSA) under noise conditions along with pure-tone audiometry. Hearing impairment was defined as pure-tone average at 0.5, 1, 2 and 4 kHz (PTA-4) greater than 25 dB HL in the better ear (WHO criterion). As expected, pure-tone thresholds and speech recognition thresholds (SRT) in GÖSA worsened steadily with age. For a comparison of PTA-4, SRTGÖSA and self-reported hearing, analysis was limited to 553 adults aged 60-85 years with PTA-4 below 50 dB HL and SRTs measured with a constant 65 dB SPL noise level. The percentage of hearing-impaired increased from 13 % in the 60-65 year-old people to 60 % in those aged 80-85 years. Overall, 68 % of the 60-85 years adults showed normal hearing in terms of unimpaired hearing according to the WHO criterion. The SRTGÖSA of 66 % of the elderly adults with normal hearing, however, did not lie within the reference range established with young normal hearing subjects in the HÖRSTAT study (4.8 ± 1.8 dB SNR, mean±2 * standard deviation). Among the 553 elderly, only 24 % reached this reference range. PTA-4 and SRTGÖSA results showed moderate to good correlations (Pearson r = 0.562, within 5-years bands: 0.372-0.514). From PTA-4 ≥ 30 dB HL and SRTGÖSA ≥- 2 dB SNR, respectively, more than half of the subjects reported hearing difficulties. Despite the continuous decline of PTA-4 and SRTGÖSA with age, the proportion of self-reported hearing difficulties as well as the self-rated hearing ability score stagnated. From the age of 70 years onwards, the elderly in the HÖRSTAT sample tend to overestimate their hearing abilities and to underestimate their difficulties.

Hearing threshold distribution and effect of screening in a population-based German sample.

OBJECTIVE: To establish the status of hearing in adults in Germany and the effects of screening for noise, tinnitus, ear diseases, and general health on the distribution of hearing threshold levels (HTL) DESIGN: A cross-sectional epidemiological study conducted between 2010 and 2012 in two middle-sized cities. STUDY SAMPLE: A total of 1903 adults aged 18 to 97 years from a randomized sample drawn from the local registration offices and stratified for age and gender. RESULTS: Dispersion and distribution of HTL data observed in the population-based sample are well in line with international results. However, median HTL tend to be better than in most recent international studies. Screening for "otological normality" improves the median HTL overall by 3 dB in males and 1 dB in females. This effect is strongly age-dependent in males and far less pronounced in females. While by and large HTL medians of females in the screened sample meet the values expected by ISO 7029:2000, HTL medians of males in middle and higher age cohorts are better than expected, especially in the frequencies above 2 kHz. CONCLUSIONS: This study supports international findings that in males, the age-related decrease in hearing sensitivity at high frequencies is smaller than described by ISO 7029:2000.

Perceived listening effort and speech intelligibility in reverberation and noise for hearing-impaired listeners.

OBJECTIVE: The purpose of this study was to assess perceived listening effort and speech intelligibility in reverberant and noisy conditions for hearing-impaired listeners for conditions that are similar according to the speech transmission index (STI). DESIGN: Scaled listening effort was measured in four different conditions at five different STI generated using various relative contributions of noise and reverberant interferences. Intelligibility was measured for a subset of conditions. STUDY SAMPLE: Twenty mildly to moderately hearing-impaired listeners. RESULTS: In general, listening effort decreased and speech intelligibility increased with increasing STI. For simulated impulse responses consisting of white Gaussian noise exponentially decaying in time, a good agreement between conditions of different relative contributions of noise and reverberation was found. For real impulse responses, the STI slightly overestimated the effect of reverberation on the perceived listening effort and underestimated its effect on speech intelligibility. Including the average hearing loss in the calculation of the STI led to a better agreement between STI predictions and subjective data. CONCLUSION: Speech intelligibility and listening effort provide complementary tools to evaluate speech perception over a broad range of acoustic scenarios. In addition, when incorporating hearing loss information the STI provides a rough prediction of listening effort in these acoustic scenarios.

Speech perception at positive signal-to-noise ratios using adaptive adjustment of time compression.

Positive signal-to-noise ratios (SNRs) characterize listening situations most relevant for hearing-impaired listeners in daily life and should therefore be considered when evaluating hearing aid algorithms. For this, a speech-in-noise test was developed and evaluated, in which the background noise is presented at fixed positive SNRs and the speech rate (i.e., the time compression of the speech material) is adaptively adjusted. In total, 29 younger and 12 older normal-hearing, as well as 24 older hearing-impaired listeners took part in repeated measurements. Younger normal-hearing and older hearing-impaired listeners conducted one of two adaptive methods which differed in adaptive procedure and step size. Analysis of the measurements with regard to list length and estimation strategy for thresholds resulted in a practical method measuring the time compression for 50% recognition. This method uses time-compression adjustment and step sizes according to Versfeld and Dreschler [(2002). J. Acoust. Soc. Am. 111, 401-408], with sentence scoring, lists of 30 sentences, and a maximum likelihood method for threshold estimation. Evaluation of the procedure showed that older participants obtained higher test-retest reliability compared to younger participants. Depending on the group of listeners, one or two lists are required for training prior to data collection.

Intelligibility of time-compressed speech: the effect of uniform versus non-uniform time-compression algorithms.

For assessing hearing aid algorithms, a method is sought to shift the threshold of a speech-in-noise test to (mostly positive) signal-to-noise ratios (SNRs) that allow discrimination across algorithmic settings and are most relevant for hearing-impaired listeners in daily life. Hence, time-compressed speech with higher speech rates was evaluated to parametrically increase the difficulty of the test while preserving most of the relevant acoustical speech cues. A uniform and a non-uniform algorithm were used to compress the sentences of the German Oldenburg Sentence Test at different speech rates. In comparison, the non-uniform algorithm exhibited greater deviations from the targeted time compression, as well as greater changes of the phoneme duration, spectra, and modulation spectra. Speech intelligibility for fast Oldenburg sentences in background noise at different SNRs was determined with 48 normal-hearing listeners. The results confirmed decreasing intelligibility with increasing speech rate. Speech had to be compressed to more than 30% of its original length to reach 50% intelligibility at positive SNRs. Characteristics influencing the discrimination ability of the test for assessing effective SNR changes were investigated. Subjective and objective measures indicated a clear advantage of the uniform algorithm in comparison to the non-uniform algorithm for the application in speech-in-noise tests.

Listening effort and speech intelligibility in listening situations affected by noise and reverberation.

This study compared the combined effect of noise and reverberation on listening effort and speech intelligibility to predictions of the speech transmission index (STI). Listening effort was measured in normal-hearing subjects using a scaling procedure. Speech intelligibility scores were measured in the same subjects and conditions: (a) Speech-shaped noise as the only interfering factor, (b) + (c) fixed signal-to-noise ratios (SNRs) of 0 or 7 dB and reverberation as detrimental factors, and (d) reverberation as the only detrimental factor. In each condition, SNR and reverberation were combined to produce STI values of 0.17, 0.30, 0.43, 0.57, and 0.70, respectively. Listening effort always decreased with increasing STI, thus enabling a rough prediction, but a significant bias was observed indicating that listening effort was lower in reverberation only than in noise only at the same STI for one type of impulse responses. Accordingly, speech intelligibility increased with increasing STI and was significantly better in reverberation only than in noise only at the same STI. Further analyses showed that the broadband reverberation time is not always a good estimate of speech degradation in reverberation and that different speech materials may differ in their robustness toward detrimental effects of reverberation.

Development of a Phrase-Based Speech-Recognition Test Using Synthetic Speech.

Speech-recognition tests are widely used in both clinical and research audiology. The purpose of this study was the development of a novel speech-recognition test that combines concepts of different speech-recognition tests to reduce training effects and allows for a large set of speech material. The new test consists of four different words per trial in a meaningful construct with a fixed structure, the so-called phrases. Various free databases were used to select the words and to determine their frequency. Highly frequent nouns were grouped into thematic categories and combined with related adjectives and infinitives. After discarding inappropriate and unnatural combinations, and eliminating duplications of (sub-)phrases, a total number of 772 phrases remained. Subsequently, the phrases were synthesized using a text-to-speech system. The synthesis significantly reduces the effort compared to recordings with a real speaker. After excluding outliers, measured speech-recognition scores for the phrases with 31 normal-hearing participants at fixed signal-to-noise ratios (SNR) revealed speech-recognition thresholds (SRT) for each phrase varying up to 4 dB. The median SRT was -9.1 dB SNR and thus comparable to existing sentence tests. The psychometric function's slope of 15 percentage points per dB is also comparable and enables efficient use in audiology. Summarizing, the principle of creating speech material in a modular system has many potential applications.

Automated Measurement of Speech Recognition, Reaction Time, and Speech Rate and Their Relation to Self-Reported Listening Effort for Normal-Hearing and Hearing-Impaired Listeners Using various Maskers.

In speech audiometry, the speech-recognition threshold (SRT) is usually established by adjusting the signal-to-noise ratio (SNR) until 50% of the words or sentences are repeated correctly. However, these conditions are rarely encountered in everyday situations. Therefore, for a group of 15 young participants with normal hearing and a group of 12 older participants with hearing impairment, speech-recognition scores were determined at SRT and at four higher SNRs using several stationary and fluctuating maskers. Participants' verbal responses were recorded, and participants were asked to self-report their listening effort on a categorical scale (self-reported listening effort, SR-LE). The responses were analyzed using an Automatic Speech Recognizer (ASR) and compared to the results of a human examiner. An intraclass correlation coefficient of r = .993 for the agreement between their corresponding speech-recognition scores was observed. As expected, speech-recognition scores increased with increasing SNR and decreased with increasing SR-LE. However, differences between speech-recognition scores for fluctuating and stationary maskers were observed as a function of SNR, but not as a function of SR-LE. The verbal response time (VRT) and the response speech rate (RSR) of the listeners' responses were measured using an ASR. The participants with hearing impairment showed significantly lower RSRs and higher VRTs compared to the participants with normal hearing. These differences may be attributed to differences in age, hearing, or both. With increasing SR-LE, VRT increased and RSR decreased. The results show the possibility of deriving a behavioral measure, VRT, measured directly from participants' verbal responses during speech audiometry, as a proxy for SR-LE.

Implementing Ecological Momentary Assessment in Audiological Research: Opportunities and Challenges.

Ecological momentary assessment (EMA) is a way to evaluate experiences in everyday life. It is a powerful research tool but can be complex and challenging for beginners. Application of EMA in audiological research brings with it opportunities and challenges that differ from other research disciplines. This tutorial discusses important considerations when conducting EMA studies in hearing care. While more research is needed to develop specific guidelines for the various potential applications of EMA in hearing research, we hope this article can alert hearing researchers new to EMA to pitfalls when using EMA and help strengthen their study design. The current article elaborates study design details, such as choice of participants, representativeness of the study period for participants' lives, and balancing participant burden with data requirements. Mobile devices and sensors to collect objective data on the acoustic situation are reviewed alongside different possibilities for EMA setups ranging from online questionnaires paired with a timer to proprietary apps that also have access to parameters of a hearing device. In addition to considerations for survey design, a list of questionnaire items from previous studies is provided. For each item, an example and a list of references are given. EMA typically provides data sets that are rich but also challenging in that they are noisy, and there is often unequal amount of data between participants. After recommendations on how to check the data for compliance, reactivity, and careless responses, methods for statistical analysis on the individual level and on the group level are discussed including special methods for direct comparison of hearing device programs.

A language-independent hearing screening self-test at school-entry.

The usage of a tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check, was investigated. The results of 692 children, aged between 5 and 9 years and 4 months, recruited in seven different countries, were used to analyze the validity and the cultural independence of test. Three different test procedures, namely a monaural adaptive procedure, a procedure presenting the sounds dichotically in diotic noise, and a procedure presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule were studied. Results showed high sensitivity and specificity of all three procedures to detect conductive, sensorineural and mixed hearing loss > 30 dB HL. Additionally, the data collected from different countries were consistent, and there were no clinically relevant differences observed between countries. Therefore, the Sound Ear Check can offer an international hearing screening test for young children at school entry, solving the current lack of hearing screening services on a global scale.

Bayesian analysis of Ecological Momentary Assessment (EMA) data collected in adults before and after hearing rehabilitation.

This paper presents a new Bayesian method for analyzing Ecological Momentary Assessment (EMA) data and applies this method in a re-analysis of data from a previous EMA study. The analysis method has been implemented as a freely available Python package EmaCalc, RRID:SCR 022943. The analysis model can use EMA input data including nominal categories in one or more situation dimensions, and ordinal ratings of several perceptual attributes. The analysis uses a variant of ordinal regression to estimate the statistical relation between these variables. The Bayesian method has no requirements related to the number of participants or the number of assessments by each participant. Instead, the method automatically includes measures of the statistical credibility of all analysis results, for the given amount of data. For the previously collected EMA data, the analysis results demonstrate how the new tool can handle heavily skewed, scarce, and clustered data that were collected on ordinal scales, and present results on interval scales. The new method revealed results for the population mean that were similar to those obtained in the previous analysis by an advanced regression model. The Bayesian approach automatically estimated the inter-individual variability in the population, based on the study sample, and could show some statistically credible intervention results also for an unseen random individual in the population. Such results may be interesting, for example, if the EMA methodology is used by a hearing-aid manufacturer in a study to predict the success of a new signal-processing method among future potential customers.