Karen Van Doorne with Dr. Barb
Karen Van Doorne earned her doctorate in audiology from the Arizona School of Health Sciences, a division of A.T. Still University in Mesa. She's licensed by the State of Michigan and is Board Certified by the American Academy of Audiology; she's been honored as an Academic Scholar through the American Board of Audiology. She's a member of the American Academy of Audiology, the Academy of Doctors of Audiology, the American Tinnitus Association, the Educational Audiology Association, the Academy of Rehabilitative Audiology, and the American Auditory Society. Through these memberships, Karen maintains a high level of understanding of hearing loss, emerging hearing technologies, and best practices for providing hearing care. She's spoken extensively on hearing healthcare and treatment of hearing disorders.
Dr. Barb: Today we’re speaking with Karen Van Doorne, who has more than four decades as a hearing health care provider. We’re going to learn from her experience in understanding hearing loss, its effects on us and on our relationships. We’ll also hear how we can effectively counter its effects. Welcome, Karen!
Karen: Thank you, Barb.
Dr. Barb: Yes, I’m glad you could join me today. I find this an area of interest, and probably more so as I get older and find others around me who are experiencing some of the changes of hearing that occur.
So we are both women who have found our way into the medical field. Can you just share what led you to choose a field of medicine?
Karen: I had a really really cute professor! No [laughs], I joke about that. At the University of Wisconsin-Eau Claire, we had visiting professors coming from the University of Wisconsin-Madison that talked about the complexity of the auditory system. I got exposed to a lot of that as an undergraduate and fell in love with it. That’s a crazy thing to fall in love with, but that was me. I’ve loved audiology and practiced audiology now for about 44 years, and I’ve never been bored, because everybody is different. The combination of anatomy and physiology, physics and psychology, and how that applies to a human being when you are fitting to treat hearing loss has never been kind of boring. So I still love it.
Dr. Barb: Yeah, that’s fascinating because when you think about fields of healthcare, health care-related things, audiology doesn’t really bubble up to the top. I think most of us can only name one or two audiologists. So it is a fascinating field. Is it an area that needs more practitioners, or is it somewhat saturated with practitioners?
Karen: No, it is definitely not saturated. We’ve gone to a clinical doctorate program – there’s research doctorate of PhD and clinical doctorate with AUD doctor of audiology – for several years now. But there could be more audiologists. At the time I got involved in it, it was mostly men; now it’s mostly women. But it is a very necessary part of the complexity of – aging well is hearing well. Healthy hearing is healthy aging, but also communication with physicians, I think, is really important. So we really need a lot more audiologists.
Dr. Barb: That’s a good plug for those who might know someone interested in entering the sciences. So our readers at MiddlesexMD and the listeners at The Fullness of Midlife are generally midlife or beyond. Generally I think about hearing loss is associated with aging, but I think you consider that a “myth.”
Karen: I do, I do.
Dr. Barb: So can you review with me and listeners really what are some of the risk factors or causes of hearing loss?
Karen: I’d be happy to do that. Back when I studied four decades ago or first got into the field, we used to say, “Hearing loss is perspicuous.” And there is a factor to that, but my interest has always been why. Why is hearing loss changing? Why does your hearing change? As we have been developing more scientific studies, we are able to look a correlations – the co-morbidities with hearing loss – and you’ll find increased hearing loss with diabetes, with cardiovascular disease, with noise exposure, of course – that’s the leading one – there’s a genetic component to hearing, ototoxic drugs, and smoking. There are some additional studies now that are showing some co-morbidities, which means there are two-disease processes in one person, linking it to fibromyalgia, rheumatoid arthritis, kidney disease, and sleep apnea. So when we look at hearing loss, we think about aging; but that’s an old theory. And we obviously didn’t have the data and the connections to the other disease processes. A lot of people will often not seek treatment because of this information because they don’t want to address the hearing loss because they think it’s related to aging. If they ignore their hearing loss, in effect they can postpone aging. [laughs]
Dr. Barb: Interesting. Is there any common path of physiologic process that happens in those diseases that you mentioned – without getting too deep into the weeds of the science behind it – I’m just curious; things like heart disease and smoking and diabetes? Is there some common process or pathway that’s influencing hearing?
Karen: You wonder about information, don’t you, in the big picture of everything. What’s good for the heart is good for your hearing. The inner ear is bathed in tiny little capillaries, so oxygen, you know, inflow into those areas is influenced by all kinds of things. Noise exposure will damage the inner hair cells and when you continue to repeat a loud sound – like listening to concerts – as Baby Boomers, we were all exposed to a lot of noise. When we go to a lot of them, those hair cells just kind of lie down. And that’s called temporary threshold shift. Eventually, in the morning you hear better; they are restored. But there can be a lot of damage over time to the stria vascularis, which is the little leg that they sit on, and that can cause issues. So I think it’s vascular in nature, a lot of it, and related to inflammation.
Dr. Barb: Well, that makes sense. Among my own friends and family I’ve observed that hearing loss typically seems quite gradual, so probably contributing to a delay in diagnosis, I would imagine. Is there a time or a sign or an indication as to when you might seek evaluation or further understanding of hearing?
Karen: You bet. I think, though, it starts happening – sometimes it will happen when a family member will let you know. When it happens so gradually, you’re not aware of it. You’re just not aware there’s a mild hearing loss there, but other people are going to be noticing that. So that’s a cue. If someone’s telling you and your family, “Hey, you know, you’re not paying attention to me.” Or, “You’re not hearing.” It’s real. That’s the first thing you should do is go and get tested at that time.
The other thing you’ll notice if you have a hearing loss is people are starting to mumble. It’s just not clear. Or the TV might be up a little louder than your friends or your family might want it to be. And you know, there’s issues with that. You might ask for repetitions. You’ll say, “What?” And a lot of times what happens is you blame other people for not speaking up. Or, “I can hear him, but I can’t hear this person and this person and this person.” So it’s very confusing.
What happens when you have a hearing loss – even a mild one – is you lose the high frequencies. When you lose the high frequencies, you lose clarity. So the word “cats” for instance, the vowel sound of a is in the low pitches [Karen enunciates the a in cat]. You aren’t losing that. You’re losing the high, so the [Karen enunciates each letter of the word ‘cat’ phonetically] c, the t, and the s are now not audible. So you heard; you just didn’t understand what it was that you heard. And then what happens is, the conversation continues and you finally put it together in your brain that that was the word “cats.” But everybody’s moved on, and now they’re laughing, and you don’t understand what the joke was. That’s kind of a key indicator. You get words mixed up like peach and teach, or dime and time, and you get confused. Or you might be at a Bible study with a bunch of women and you can’t hear what they are saying, but yet you go home and you hear your husband. Well, he has a low-frequency voice. Women and children are in a high frequency range – right in the area that you have a hearing loss.
The other indicator is you might hear fine in a one-to-one, but you have problems in a background of noise, and of course you just blame the noise. But that’s because you are losing the clarity of sound because the high frequencies are not present for you.
Another classic one – and this is my pet peeve for typically men – they get accused of “selective attention” or “You hear what you want to hear.” You know there’s a reason for that and it is all some level of hearing loss.
Dr. Barb: Interesting, yes. And I find it fascinating that, you know it is women’s voices for instance. [laughs] Maybe that’s why we go to the selective hearing is because we think we are being tuned out intentionally.
Karen: I have had a family that came in – a couple – who are very much in love, older couple, and he came in because his wife was saying, “You know, you’re just not paying any attention to me. You are just not paying attention to me.” And it was an issue. We also get referrals sometimes right before the neurologist. When we’re worried about memory, and we get somebody, and it’s either about his hearing or his memory. And in our experience, when men come here, the situation has been resolved because they get to get hearing instruments, and they are hearing better and interacting better and remembering better. So those are interesting stories.
Barb: So that leads me to kind of expand on that. What really is at risk if we don’t address hearing loss, both for the individual and for their relationships?
Karen: That’s kind of why I’m still an audiologist after 44 years, and enjoy it, because there’s so much to do in this area. You find if you have a hearing loss, you stop attending group functions as much, restaurants, you don’t want to go to plays. You kind of lose your sharpness, your vibrant self. You may argue more with family members. You can become more withdrawn, isolated, and then also, because you can’t hear, you think other people are talking about you. It can also lead to depression. Hearing loss can lead to depression because it leads to isolation, and isolation leads to depression. Other people may feel you are stuck up because you didn’t respond to them, say coming out of church, and somebody is saying something softly and you just ignore them. Or even worse, they can think that something is wrong with you because you are not responding.
The risk factor also increases with falls. The more hearing loss you have, the more it’s related to a fall risk, which, of course, we know is a very bad thing when you get older. It can increase the rate of depression, it decreases the quality of life, and we do know that untreated hearing loss is related with a decrease in short-term memory.
The other things that will happen is relationships will suffer. Those that have to repeat get tired of repeating and they just stop talking. Those with hearing loss stop asking “what” because of the response it gets. And then the relationship shows signs of strain. This can happen with friends, but also family as well.
Dr. Barb: Wow. It is sort of a fascinating thing to think about. And I think it makes sense in hearing you list all of those things that that might be the direction that interactions go for something that is largely treatable.
I have recently read about – you talked about short-term memory loss – so can you talk a little bit more about the connection between hearing and memory and maybe even dementia?
Karen: You bet. We know, like I said, that untreated hearing loss is linked to short-term memory, but at this time we cannot make inferences that treating hearing loss with amplification will reduce the risk. Remember, association does not imply causation. This is where the study is ongoing, supported by NAH research grants through Johns Hopkins [University], and it will be completed in about 2020. We can say, however, that studies have shown that – one study says that if you take three groups of people, and they are all headed toward dementia – one is a normal hearing group; one is a group that has untreated hearing loss; and one is a group that has treated hearing loss with appropriately fitted real ear-tested amplification. That group with untreated hearing loss got there faster – got to dementia faster.
We know that treating hearing loss with hearing devices allows a person to interact more with others, increase socialization and interaction, and all of those are important components to aging and engaging well. There’s also a study that I found was really interesting that lack of stimulation – this was down a couple of years ago – lack of stimulation to the auditory cortex, which is the part of the brain that receives and interprets sound, that in the presence of hearing loss the auditory cortex on a PET scan in untreated hearing loss shows less activity in the presence of speech; however, the occipital lobe – the vision center of the brain – was more active, which is very interesting from a standpoint of, you know it means, therefore, losing auditory recognition with hearing loss and depending more in vision for communication. That can’t be good. So that makes it difficult sometimes when we put hearing instruments on for the first time, those receptive centers in the brain haven’t heard for a while.
So the dementia issue is an ongoing one. There are studies that are supporting the links, but we don’t know what the causation is yet. So I think the jury is still out on that. And I think it’s important to understand that it’s a scare tactic sometimes that people use, and I think we need to approach that very cautiously and wait for the data.
Dr. Barb: Sure. I’ve known people who could benefit from hearing assistance, but are resistant to that. That seems to be a common response. I’m just curious what your understanding of that is, and why it is we seem to not welcome the ability to improve our quality of life through something that is so readily available to us. Can you speak to that a bit?
Karen: That’s been interesting to me. The study of this has been fascinating for me. I think a lot of it comes from, Barb, with education. The perception that hearing loss is normal part of aging, or can’t be treated, is one of the main causes for not doing anything. The lack of recognition of hearing changes, not knowing that your hearing is changing, or not believing the people around you. Often people think it’s everybody else’s inability to speak up.
Another issue is stigma, again due to misinformation. “You know my great grandfather had a hearing aid and, oh my gosh, he had so much trouble with it.” Or, “My mom had a hearing aid.” And when I say, “How long ago was your mom using that hearing aid?” “Oh, 20 years ago.” Think about computers and how they have changed in 20 years.
Cost – people still consider that as an issue. But the data suggests that even in socialized countries, the utilization rate is the same. When socialized countries are paying for hearing aids, the utilization rate is the same as it is in the US. So I’ve never really figured that out. Um, yeah.
Dr. Barb: Yeah, interesting. We’ve got a ways to go, it sounds like, in educating the population.
Karen: That’s what we keep trying to do. And I think when people understand that you have to look at the body as an aging process we have to look at it holistically. Hearing is important in social function, in navigating aging well, keeping your brain sharp, understanding and hearing and getting information. So to me, that’s just being the best part of who you want to be is treating your hearing loss.
Dr. Barb: Certainly. And in some of women’s health conditions we know that the sooner women address a problem and initiate treatment, maybe the more successful it’s going to be, rather than postponing and waiting and hoping to get full function back. Is there something true about that in hearing or is that not necessarily the case?
Karen: I have learned over 44 years of doing this, and then looked at the research. Yes. The answer is yes, the longer you wait the worse it is and if you don’t use it, you lose it. Just like in any other area. If you wait seven years to get treatment for hearing, the brain has kind of forgotten how to hear. It has to relearn that process. When you are fitted with hearing devices, the first thing you are going to notice is an awareness of soft sounds. It’s distracting at first, because the brain has to relearn what those sounds are. After it gets use to it – it like stops bringing it to your attention – it adapts. And you hear it now, but it’s in the background. It’s not terribly hard to adapt to those anymore because the way hearing instruments function now – they adjust about a 100 times a second to your environment – it makes it much easier to adapt to new hearing.
The one concern that I have had, and I haven’t been able to solve this problem yet in terms of education or reaching to people. And it bothers me because single women, older single women who live alone that have hearing loss – and sometimes very significant hearing loss – don’t have the sense of urgency to treat it because there’s no one there to really interact with, and they can turn the TV up as loud as they want, and they can hear. They can turn the radio up or the phone up as loud as they want and they can hear. But then they go to Bible study or a group or a play and they struggle.
If you wait too long, like when that threshold, which in my personal experience hits around 60 decibels which is a significant hearing loss, they are walking around with, their prognosis for using hearing instruments becomes less and less because any sound is an intrusion to them. They’ve waited too long. The hearing loss is too great and it makes it much more difficult. You have to be very motivated at that point to be able to use amplification.
Dr. Barb: Is there any short summary of the changes in hearing assistance that happened over time that you can bring listeners up to date on? I think, as you mentioned, what we remember of our grandparents or parents probably is not the current technology available. Is there some way to summarize where it’s come?
Karen: Yes. I will be happy to do that. I can tell you that I started out in 1975 as a young audiologist of just 25 years of age, and people would undress for me when I would ask to see their hearing aid because they kept their hearing aid, which was a box, in their slip – in a pocket in their slip.
Karen and Dr. Barb: [laugh]
Karen: It was very disturbing as a young 25-year-old when a woman would start undressing when I would ask to look for her hearing aid, but she had kept it there, and there were wires going up to her ear. Now when somebody comes into the office, I sometimes laugh because I say, “Well, you’re not wearing your hearing instruments.” And they say, “Yes, I am.” Because I can’t even see them.
The visibility issue is one thing to address, and I think that hearing loss is much more visible than any hearing instrument could ever be. You know, it’s much more noticeable. So for 20 years now, we’ve been fitting digital amplification. People still come in thinking that hearing instruments are analog, so when you rotate a wheel, everything goes up, including loud sounds and soft sounds. Now digital amplification is adjusting 100 times a second. It can be iPhone compatible. It’s completely automatic so the algorithms are always reading your environment and assessing the complexity, the environment, allowing speech to be increased so that you can hear better in a background of noise. They are small. They are Bluetooth compatible. They are hearing-loop compatible for churches. All of those things have changed, so it’s very easy to get used to using hearing instruments. You can even now stream music through your instruments using them as receivers.
Dr. Barb: Wow. Is there some limitation in availability because of cost? My understanding is that insurance doesn’t uniformly cover that as a medical device. What’s your understanding of individuals proceeding with treating this condition, or maybe the limitation of treating it because of cost?
Karen: And again, I go back to that study for utilization rates, but I will address the cost issue. There’s a lot of options that are available in an audiologists’ office. For 20 years – at least in our office – for 20 years we had been fitting what we call “starter” hearing aids. A woman will come in and notice just a subtle change in her hearing. It’s not a $6,000 problem, or a $4,000 problem. It’s maybe a $1,500 problem. So we have found companies to work with us that we can provide wonderful starter hearing instruments that are durable, that work really well, that are cute, that we can use when there’s just an early bit of hearing loss because that hearing loss doesn’t need to be addressed like a more severe hearing loss is. So we can do that.
The other options available now are unbundling prices so you take the unit, the instruments themselves, we program them, do real ear testing, educate you, follow to make sure you are okay, and then you pay as you go. So we can unbundle the services, separate the costs from the service component of it. That’s been very very helpful for people who travel and that sort of thing.
You also have hearing foundations that are available. If somebody is financially eligible – and we can get the paperwork for you – you would pay $250 an ear. Or if you only wanted one, heaven forbid, you could pay $250 and they would provide you a new pair of hearing instruments. Priority Medicaid has coverage for hearing instruments. Holland Free Clinic in Holland works with providing local audiologists and centers to get hearing instruments. My philosophy is if somebody walks through my door and needs amplification, we’re going to find a way to have that happen, and that’s been the case for many years.
Dr. Barb: That’s encouraging to hear that that shouldn’t be an obstacle to seeking care and receiving care. For those individuals who feel like they could benefit from having assessments, what kind of characteristics or qualifications should they look at in finding a provider?
Karen: I think that you should look for, first of all, a board-certified hearing instrument specialist or a doctor of audiology. You want to have an audiology-based practice where evidence-based protocol is in place. That means the clients’ needs are paramount before anything else. You need to have consideration of your lifestyle, your financial needs, and good follow-up care. You need annual screenings to make sure your hearing is stable. And real ear testing periodically to make sure the devices continue to provide good benefit.
Many people don’t know that you can have those hearing instruments adjusted to meet the change of your hearing, and I think that’s a very important point to make. The lifespan of a hearing instrument, in my professional opinion, should be about five years. Sometimes people are told three, but that is not true. You can reprogram that guy and make them sing and have a great other two years using those hearing instruments. You could ask your friends who delivers on superior customer service; who is going to be around if something happens. You should be able to call somebody and get good information over the phone.
Because hearing devices can be sold on a retail model, and sales are their number one motive, make sure you slow down and get all your questions answered, like warranties and service and hearing loop compatibility. And maybe get a second opinion. This is going to be a provider that you will get to know, but also depend on for years to come.
Dr. Barb: Yeah, that’s a good point. So thank you for all the good information you’ve provided today. In conclusion, I’d like to ask, if you are willing to share, where you find richness at this stage of your life, Karen?
Karen: You have asked me many questions that I was easily able to answer, and this one made me think. After 44 years, I still love audiology. But after a cancer diagnosis last year, I’m finding the gift of grabbing those grandkids more often, engaging with friends on a deeper level, and shifting my attention to healing. I’ve also embraced the wise woman in me – the one who appreciates what I’ve learned in life, and I have no problems any more asking for that senior discount at the health food store.
Dr. Barb and Karen: [laugh]
Karen: Yeah, that’s a big step for me. I’ve learned a lot both professionally and personally, and want to continue to navigate with love and kindness in my life in spite of what has happened. I’m different than I was before and I’m going to embrace all the stages of life with joy and acceptance, hopefully, and I want to be the best version of me that I can be. And that’s my take on that.
Dr. Barb: What a very thoughtful response to that question. I’m sorry that it’s maybe taken a difficult turn in your health journey to bring you to this place, but it seems like the outcome has had some benefits to you in this journey now that you are looking forward to.
Karen: When you have adversity, you just have to find the pony!
Dr. Barb: Aww [laughs]. Well, thanks again, Karen, for taking the time and sharing with us and educating listeners on the importance of good hearing.
Karen: Great! Thanks for having me, Barb.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.