Standard of Care for Adults With Hearing Loss and the Role of Cochlear Implantation: Living Guidelines.

CI Task Force, Cochlear Implant International Community of Action, et al. (2024).

Australia: HTANALYSTS; Cochlear Implant International Community of Action, 1-82.

<div>This living clinical practice guideline provides recommendations designed to optimize the care for adults with hearing loss, with a focus on the role of cochlear implants (CIs).&nbsp;</div>

CI Task Force; Cochlear Implant International Community of Action; Hearing Intervention Working Group; HTANALYSTS (Australia); Cochlear Limited (Australia)

<div>The following recommendations were made regarding hearing loss screening:</div> <div> <ul> <li>Hearing loss screening should be offered to adults aged 50 years or older, or earlier if the patient expressed concerns about hearing loss.</li> <li>Screening should use the single question: "Do you feel you have hearing loss?"</li> <li>If the person answers "yes," then the hearing loss referral process should be started.</li> <li>Hearing screening should be administered every one to three years (Weak Recommendation).&nbsp;</li> </ul> </div>

<div>Primary healthcare providers should arrange a referral to a hearing healthcare specialist for a full audiological assessment in adults presenting with new or suspected hearing loss (Consensus Recommendation).&nbsp;</div>

<div>Adults with any degree of hearing loss should be referred to a cochlear implant specialist for to determine CI candidacy if they meet the following criteria:</div> <div> <ul> <li>at least 60 decibel (dB) hearing loss in one or both ears at three frequency or four frequency unaided pure-tone average; and</li> <li>patient-reported difficulties with speech understanding in their everyday environment (Strong Recommendation).&nbsp;</li> </ul> </div>

<div>CI referral criteria should be evaluated at least every one to three years by an audiologist (or equivalent if not available in your country) for adults with any degree of hearing loss who do not meet the CI referral criteria upon initial assessment.&nbsp;</div> <div> <ul> <li>If the CI referral criteria is met, patients should be referred to a CI specialist for determination of CI candidacy.</li> <li>If the patient has sensorineural hearing loss (50&ndash;64 dB hearing loss) or the displays a significant change in their hearing ability, then this reassessment should occur at least every 6&ndash;12 months (Consensus Recommendation).</li> </ul> </div>

<div>Initial activation and programming of CIs should occur within 28 days after surgery for adults with severe, profound, or moderate sloping to profound sensorineural hearing loss based on patient recovery and approval from the CI surgical team. Post-activation, a CI users should have 4&ndash;6 appointments within the first&nbsp; year of their CI use. Two or three of these appointments should be mapping appointments within the first 3 months post-activation. All other appointments should be scheduled at the discretion of the CI surgical team (Consensus Recommendation).</div>

<div>CI rehabilitation for adults with severe, profound, or moderate sloping to profound sensorineural hearing loss should receive care multidisciplinary and person-centered care.</div> <div> <ul> <li>Essential members of this team include otolaryngologists specialized in CI, audiologists, and speech language pathologists or equivalents in these professionals are not available in your country.</li> <li>This team may involve other specialties including, but not limited to, psychologists, neurologists, geriatricians, social workers, radiologists, and individual and/or group peer supports.</li> <li>This team should consider initial and lifelong rehabilitation, and the CI user and their family, care partners, and/or friends should collaboratively contribute to the overall plan of care, as applicable (Consensus Recommendation).&nbsp;</li> </ul> </div>

<div>The following components of initial CI rehabilitation should be considered by audiologists:</div> <div> <ul> <li>initial CI programming to optimize access to sound, patient comfort, and performance;</li> <li>duration of daily processor use;</li> <li>checking magnet strength at implant site;</li> <li>counseling and education including information and in-depth instruction in handling (e.g., care, maintenance, fault and error detection, troubleshooting) of the CI system, the use of additional CI system devices (e.g., telephone adapter, induction or T-coil), and the pairing, fitting, and usage of mobile media devices and assistive listening devices;</li> <li>monitoring aided listening performance over time through the use of sound field hearing tests and standards;</li> <li>speech perception testing in silence and in background noise; and</li> <li>reviewing bimodal and electroacoustic adjustment in instances of bimodal hearing (Consensus Recommendation).&nbsp;</li> </ul> </div>

<div>The following components of initial CI rehabilitation should be considered by speech-language pathologists:</div> <div> <ul> <li>auditory rehabilitation including analytic and synthetic auditory training with phonemes, words, sentences, and text at the level of detection;</li> <li>discrimination, identification, and comprehension in different listening conditions including in quiet, noise, with and without visual support (e.g., lip reading), and using different listening devices (e.g., live voice, radio, laptop);</li> <li>training and education regarding the appropriate use and management of the sound processor and any assistive listening devices;</li> <li>training regarding the improvement of communication skills in daily life and how to identify when and why communication has failed; and</li> <li>tasks incorporating listening in 1-to-1 and in small groups, music training, and telephone training (Consensus Recommendation).</li> </ul> </div>

<div>The following components of lifelong CI rehabilitation should be considered by audiologists:</div> <div> <ul> <li>ongoing programming of the CI to optimize access to sound, patient comfort, and performance;</li> <li>technical advice/evaluation of the functionality of the CI system;</li> <li>fitting of mobile media devices and other assistive listening devices and counseling/training about them;</li> <li>speech perception testing in silence and in background noise via remote testing if available;</li> <li>monitoring of aided listening performance over time via remote testing, if available;</li> <li>periodical adjustment and fine-tuning of CI processors including control of stimulation parameters;</li> <li>training regarding basic device troubleshooting; and</li> <li>reviewing need for bimodal and electroacoustic adjustment in instances of bimodal hearing (Consensus Recommendation).</li> </ul> </div>

<div>The following components of lifelong CI rehabilitation should be considered by speech-language pathologists:</div> <div> <ul> <li>monitoring progress on all rehabilitation targets;</li> <li>training regarding the appropriate use and management of the CI sound processor and assistive listening devices;</li> <li>ongoing auditory therapy to train speech perception in difficult listening situations (e.g., listening in groups, at a distance, in noise, on the telephone); and</li> <li>training on how to improve communication skills in daily life and to identify when/why communication has failed (Consensus Recommendation).&nbsp;</li> </ul> </div>

<div>Audiologists, or equivalent if not available in your country, should evaluate hearing-related quality of life and speech perception, particularly in noise, for adult CI users with severe, profound or moderate sloping to profound sensorineural hearing loss.</div> <div> <ul> <li>For QoL, audiologists should use the Nijmegen Cochlear Implant Questionnaire or the Cochlear Implant Quality of Life if validated in the CI user's dominant language.</li> <li>For speech perception, audiologists should use validated communication measures in the CI user's dominant language using words and/or sentences in quiet and noise.</li> <li>These measures should be administered before implantation to establish a baseline and at least one 6 to twelve months after the CI is activated (Consensus Recommendation).</li> </ul> </div>

<div>The individual needs of every person receiving hearing interventions should be prioritized. Appropriate support and guidance should be provided accordingly. Audiologists, or equivalent if audiologists are not available in your country, should aim to facilitate personalized patient goal setting and achievement, which may consider family and care partner perspectives. This should include, at a minimum:&nbsp;</div> <div> <ul> <li>efforts to evaluate and regularly assess the patient's motivations and perceived self-efficacy of hearing health;</li> <li>lifelong and ongoing education, support, and guidance regarding the importance of communication training;</li> <li>lifelong and ongoing assistance with connecting to suitable providers of communication training opportunities, including individual and group peer support services, if available; and</li> <li>the provision or consideration of alternative interventions if the patient expresses dissatisfaction of no therapeutic benefit of selected interventions are not observed (Good Practice Statement).</li> </ul> </div>

<div>People receiving hearing interventions should be regularly assessment using validated objective (e.g., real ear measurements, aided and non-aided speech tests) and subjective performance measures in the dominant language of the patient. Assessment should consider from the subjective perspective of the patient alongside the objective verification and validation by an audiologist, if available in your country. The perspective of family members and care partners may also be considered in the assessment process. At a minimum, assessment should include an evaluation of:&nbsp;</div> <div> <ul> <li>communication ability (e.g., listening and hearing, ease and satisfaction in various listening circumstances);</li> <li>benefit and satisfaction of hearing interventions in various listening circumstances;</li> <li>the patient's ability to maintain personal and professional relationships in various listening circumstances; and</li> <li>satisfaction with listening and hearing of environmental sounds in various listening circumstances.</li> </ul> <div>Objective and subjective performance, including cochlear implant referral eligibility, should be assessed at baseline, upon the provision of the hearing intervention,&nbsp; one to three months after a person receives a hearing intervention, and annually thereafter. Reassessment should occur if the patient expresses dissatisfaction or no therapeutic benefit is observed, with consideration of medical or other audiological treatment alternatives (Good Practice Statement).&nbsp;</div> </div>

<div>Hearing-related QoL (HRQoL) should be regularly assessed by an audiologist, if available in your country, in people using hearing interventions.&nbsp;</div> <div> <ul> <li>The HRQoL measure should be validated and administered in the dominant language of the patient.</li> <li>HRQoL should be assessed, at a minimum, prior to the establishment of the hearing intervention to establish a person&rsquo;s baseline and 1-3 months after initiation of the hearing intervention.</li> <li>HRQoL should be reassessed annually after that to measure personal progress.&nbsp;</li> <li>HRQoL data should be gathered to inform counselling and rehabilitation efforts, including monitoring outcomes and eligibility for CI referral criteria (Good Practice Statement).&nbsp;</li> <li>Family members and care partner perspectives may also be considered when considering HRQoL (Good Practice Statement).&nbsp;</li> </ul> </div>

<div>People using hearing interventions, should have ongoing, life-long access to hearing health rehabilitation, with a preference for multidisciplinary, person-centric approach. At a minimum, hearing health rehabilitation should include:</div> <div> <ul> <li>personal adjustment counselling (e.g., support during the acclimatization period, establishment of hearing and listening expectations);</li> <li>informational counselling regarding device handling (e.g., care, maintenance, fault/error detection, troubleshooting);</li> <li>hearing/auditory rehabilitation (i.e., supportive strategies and tactics to aid listening and hearing in various listening circumstances);</li> <li>social support (e.g., individual or group peer support services, encouragement of family/care-partner support; Good Practice Statement).&nbsp;</li> </ul> </div>

<div>Cognitive functioning of individuals with hearing loss should be considered throughout the hearing health continuum, including in individuals with cognitive decline and those at increased risk of cognitive decline (e.g., those with advancing age).</div> <div> <ul> <li>If there is concern about the cognitive functioning individuals using hearing intervention, screening for cognitive function using a validates tool in the dominant language of the patient should be conducted by clinicians with adequate training.</li> <li>If indicated, the person should be referred to an appropriate specialist.</li> <li>If clinicians are not adequately trained to screen for cognitive functioning, the patient should be referred to an appropriate specialist</li> <li>The perspective of family members and care partners may also be considered when considering the cognitive functioning of the person using the hearing intervention.</li> <li>In people living with cognitive decline, care should be adapted accordingly and in consultation with an appropriate specialist (Good Practice Statement).</li> </ul> </div>

<div>People receiving hearing interventions should be informed of the ongoing role of technology throughout the hearing&nbsp;health continuum.<br>At a minimum, audiologists, or an equivalent if not available in your country, should discuss the following at the earliest opportunity with patients, families, and care partners:</div> <div> <ul> <li>hearing aids;</li> <li>implantable devices (e.g., acoustic, bone conduction, middle ear, CI);</li> <li>other assisted listening devices including new developments in technology;</li> <li>assistive technology supporting communication, listening, and hearing (e.g., text-to-speech applications, Bluetooth, alert systems); and</li> <li>limitations of technology (Good Practice Statement).</li> </ul> </div>