Citation
Hearing Disability and Socioemotional Isolation in an Aging Population a Revolutionary Concept Analysis Using the World Health Organization's International Classification of Functioning Disability and Health

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Title:
Hearing Disability and Socioemotional Isolation in an Aging Population a Revolutionary Concept Analysis Using the World Health Organization's International Classification of Functioning Disability and Health
Creator:
Fakir, Razan Al
Publisher:
University of Florida
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Communication Sciences and Disorders
Speech, Language and Hearing Sciences
Committee Chair:
HOLMES,ALICE E
Committee Co-Chair:
GRIFFITHS,SCOTT K
Committee Members:
ALTMANN,LORI J
MARSISKE,MICHAEL

Subjects

Subjects / Keywords:
hearing

Notes

General Note:
The purpose of this study was to validate the International Classification of Functioning (ICF) Brief Core Set for Hearing Loss (HL) and to explore possible mechanisms that alter listening ability and increases the likelihood of social isolation in older adults. One hundred and thirty one independent older adults participated in the study. All participants either assigned to complete the objective outcome measures first and then the subjective or to complete the subjective outcome measures first and then the objective measures. Both objective and subjective measures were randomized in order. All participants were asked to complete the both outcomes according to their daily functioning. Results of this study further support the findings from the pilot studies that support the structure provided by the Core Set and validate the ICF brief core set as a valuable tool for use in audiologic rehabilitation (AR) clinical practice. Additionally, the study results raised the role of psychological effect of the dizziness in increasing effortful listening that influences social isolation

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UFRGP
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All applicable rights reserved by the source institution and holding location.
Embargo Date:
5/31/2018

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1 HEARING DISABILITY AND SOCIO EMOTIONAL ISOLATION IN AN AGING POPULATION: A REVOLUTIONARY CONCEPT ANALYSIS USING THE WORLD DISABILITY, AND HEALTH By RAZAN AL FAKIR A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2016

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2 2016 Razan Al Fakir

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3

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4 ACKNOWLEDGMENTS Firstly, I would like to express my sincere gratitude to my advisor Dr Alice E. Holmes for the continuous support of my Ph.D s tudy and related research, for her patience, motivation, and immense knowledge. Her guidance helped me throughout the entirety of research ing and writing of this thesis. I could not have imagined having a better advisor and mentor for my Ph.D study. Besides my advisor, I would like to thank the rest of my t hesis committee: Dr. Lori J Altmann, Dr Scott K. Griffiths, Dr Patricia B. Kricos, and Dr Michael Marsiske for their insightful comments and encouragement, but also for the hard question wh ich incented me to widen my research from various perspectives. My sincere thanks also go to Dr Colleen Le Prell and the Institute Of Aging who provided with all the support I need ed to c omplete this study. Without their priceless support it would not hav e been possible to conduct this research. Additionally, I am very grateful to all of the wonderful participants for volunteering for this study. I am, also, grateful for the graduate and undergraduate students for caring and help ing all through t he process of this research. Last but not the least; I would like to thank my husband Medhat who is the rock of my life and my progress. Special t hanks go to my friends, especially Amira Sirag and Maha El badri, for supporting me spiritually throughout my Ph.D journey since I came to Gainesville in 2012.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 4 LIST OF TABLES ................................ ................................ ................................ ........................... 8 LIST OF FIGURES ................................ ................................ ................................ ....................... 10 LIST OF ABBREVIATIONS ................................ ................................ ................................ ........ 11 ABSTRACT ................................ ................................ ................................ ................................ ... 12 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................ .............................. 14 Current Disability Model ................................ ................................ ................................ ........ 14 Emergence of the ICF Disability Model in Audiologic Rehabilitation ................................ .. 16 Hearing Function and Hearing Disability in an Aging Population ................................ ......... 21 Hearing Disability ................................ ................................ ................................ ................... 23 Activit y Limitation ................................ ................................ ................................ .......... 23 Participation Restriction ................................ ................................ ................................ .. 25 Research Aims ................................ ................................ ................................ ........................ 27 2 METHODS ................................ ................................ ................................ ............................. 29 Setting ................................ ................................ ................................ ................................ ..... 29 Demographics ................................ ................................ ................................ ......................... 29 Objective Outcome Measures ................................ ................................ ................................ 31 Pure Tone Audiometry Test (PTA) ................................ ................................ ................. 31 Acceptable Noise Level (ANL) ................................ ................................ ....................... 31 Bamford Kowal Bench Speech in Noise Test (BKB SIN) ................................ ............. 31 Brief Test of Attention (BTA) ................................ ................................ ......................... 32 Digit Span Test Backward (DSB) ................................ ................................ ................... 32 Montral Cognitive Assessment (MoCA) ................................ ................................ ....... 33 Visual Acuity Test ................................ ................................ ................................ ........... 33 Su bjective Outcome Measures ................................ ................................ ............................... 33 Demographics information sheet ................................ ................................ ..................... 33 Self Report ICF brief core set scale for HL ................................ ................................ .... 33 Big Five Personality Inventory 44 item (BFPI) ................................ .............................. 34 Tinnitus functional index (TFI) ................................ ................................ ....................... 34 Dizziness Handicap Inventory (DHI) ................................ ................................ .............. 34 Speech, Spatial and Quality of Hearing (SSQ) ................................ ............................... 35 The Geriatric Depression Scale (GDS) ................................ ................................ ........... 35 Loneliness and Social Isolation Scale of De Jong Gierveld (LSIS DJG) ....................... 35 Lubben Social Network Scale Revised (LSNS R) ................................ .......................... 36 Relationship Assessment Scale (RAS) ................................ ................................ ............ 36

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6 Equipment ................................ ................................ ................................ ............................... 36 Procedures ................................ ................................ ................................ ............................... 37 3 RESULTS ................................ ................................ ................................ ............................... 38 Data Analysis ................................ ................................ ................................ .......................... 38 Descriptive statistics ................................ ................................ ................................ ............... 38 Descriptive S tatistics for the Self Reported ICF Brief Core Set Scale for HL ............... 38 For body functions domain ................................ ................................ ...................... 38 For activity limitation and participation restriction ................................ .................. 38 For environmental factors ................................ ................................ ........................ 39 Descriptive S tatistics for the proposed objective and subjective outcome measures ...... 43 Objectives O utcome M easures ................................ ................................ ........................ 43 For the hearing sensiti vity as measured by PTA ................................ ...................... 43 For visual acuity as measured by Snellen chart ................................ ....................... 43 For hearing function as measured by the BKB SIN ................................ ................. 43 For attention function as measured by BTA ................................ ............................ 43 For memory function as measured by DSB via listening only and visual only modalitie s ................................ ................................ ................................ .............. 44 For the global cognitive function as measured by MoCA ................................ ....... 44 For the noise background as measured by ANL ................................ ...................... 44 Subjective O utcome M easures ................................ ................................ ........................ 44 For the sensation of tinnitus as measured by TFI ................................ ..................... 44 For sensation of dizziness as measured by DHI ................................ ....................... 44 For the effortful listening construct as measured by SSQ ................................ ........ 44 For the depression function as measured by GDS ................................ ................... 44 For personality and temperament function as measured by BFPI ........................... 45 For family support as measured by LSNS R ................................ ........................... 45 For the family relationship as measured by RAS ................................ ..................... 45 For the social isolation as measured by LSIS DJG ................................ .................. 45 Correlation Coefficient Between Proposed Objective and Subjective Outcome Measures and Aligned Categories of Self Reported ICF Brief Core Set Scale for HL .......................... 50 Factor Analysis and Structure Equation Modeling ................................ ................................ 54 Exploratory Factor Analysis (EFA) for the Self Reported ICF Brief Core Set Scale for HL ................................ ................................ ................................ ........................... 54 Confirmatory Factor Analysis (CFA) for the Self Reported ICF Brief Core Set Scale for HL ................................ ................................ ................................ ................. 56 Exploratory Factor Analysis (EFA) for the standardized outcome measures ................. 60 Confirmatory Factor Analysis for the standardized outcome measures .......................... 63 Structure E quation M odeling (SEM) for the Self Reporte d ICF Brief Core Set Scale for HL ................................ ................................ ................................ ................. 67 Structure Equation Modeling (SEM) for the S tandardized O utcome M easures with Depression ................................ ................................ ................................ .................... 70 S tructure Equation Modeling (SEM) for the S tandardized O utcome M easures with Cognitive D ecline ................................ ................................ ................................ ........ 73 Structure Equation Modeling (SEM): The I ntegrated M odel ................................ .......... 76

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7 4 DISCUSSION ................................ ................................ ................................ ......................... 79 Validation ................................ ................................ ................................ ............................... 79 Comparison between methods applied to validate ICF Brief Core Set for HL ............... 79 The dimensions of the ICF Brief Core Set for HL (CFA Models) ................................ ......... 82 Implications ................................ ................................ ................................ .............. 86 Application ................................ ................................ ................................ ............................. 88 Hearing Disability and Socio Emotional Isolation in an Aging Population ................... 88 Implications ................................ ................................ ................................ .............. 92 Study Conclusions ................................ ................................ ................................ .................. 93 Limitations of the study and Future direction ................................ ................................ ......... 93 APPENDIX A ARTICLE 1 ................................ ................................ ................................ ............................ 95 B ARTICLE 2 ................................ ................................ ................................ ............................ 96 C ARTICLE 3 ................................ ................................ ................................ ............................ 97 D SAMPLE OF OUTCOME MEASURES ................................ ................................ ............... 98 Self Reported ICF Brief Core Set for HL ................................ ................................ 98 Brief Test of Attention (BTA) ................................ ................................ ................ 104 Lubbe n social network scale Revised ................................ ................................ .... 105 De Jong Gierveld Loneliness Scale ................................ ................................ ........ 108 Relationship Assessment Scale ................................ ................................ .............. 109 E RAW DATA OF THE OBJECTIVE AND SUBJECTIVE OUTCOME MEASURES ...... 110 LIST OF REFERENCES ................................ ................................ ................................ ............. 119 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ....... 129

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8 LIST OF TABLES Table page 1 1 The beta version ICF Brief Core Set ................................ ................................ ................. 20 2 1 Participants Characteristics (N =131) ................................ ................................ ................ 30 3 1 The frequency distribution for items of body function domain per scale (0=no impairment, 1=mild, 2=moderate, 3=severe, and 4=complet e) from the 131 participants ................................ ................................ ................................ ......................... 40 3 2 The frequency distribution for items of disability domain per scale ................................ 41 3 3 The frequency distr ibution for items of environmental domain per scale ......................... 42 3 4 Descriptive statistics of the objective and subjective outcome measures for the 131 participants ................................ ................................ ................................ ......................... 46 3 5 Descriptive statistics of the objective and subjective outcome measures for the 131 participants ................................ ................................ ................................ ......................... 47 3 6 Descriptive statistics of the objective and subjective o utcome measures for the 85 participants with HL above 25dB (the HL group) ................................ ............................. 48 3 7 Descriptive statistics of the objective and subjective outcome measures for the 85 participants with HL above 25 dB (the HL group) ................................ ............................. 49 3 8 Correlation coefficient between ICF items and objective outcome measures for the 131 participants versus the 85 participant who have HL > 25dB ................................ ...... 52 3 9 Correlation coefficient between ICF items and subjective outcome measures for the 131 participants versus the 85 participant who have HL > 25dB ................................ ...... 53 3 10 Pattern (unique contribution of a variable to a factor), structure (where shared variance not ignored), communalities ( loadings of items on factors) (h2), and percent of variance using the maximum likelihood method ................................ ........................... 55 3 11 The standardized and unstandardized regression weight, standard error, covariance, and correlation estimates for the CFA Model ................................ ................................ .... 59 3 12 Pattern (unique contribu tion of a variable to a factor), structure (where shared variance not ignored), communalities ( loadings of items on factors) (h2), and percent of variance using the maximum likelihood method ................................ ........................... 62 3 13 The standardized and unstandardized regression weight, standard error, covariance, and correlation estimates for the CFA Model ................................ ................................ .... 66

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9 3 14 The unstandardized regression and standardized weigh t, standard error estimates for the SEM Model of predicting social isolation from Self Reported ICF Brief Core Set Scale for HL ................................ ................................ ................................ ....................... 69 3 15 The unstandardized regression and standardized weight, st andard error estimates for the SEM Model of predicting social isolation from the standardized outcome measures with D epression (GDS) ................................ ................................ ...................... 72 3 16 The unstandardized regression and standardized weigh t, standard error estimates for the SEM Model of predicting social isolation from the standardized outcome measures with global cognitive functions (MoCA) ................................ ........................... 75 3 17 The unstandardized regression and standardized weight, standard error estimates for the integrated SEM Model ................................ ................................ ................................ 78

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10 LIST OF FIGURES Figure page 1 1 Illustration of WHO ICF (World Hea lth Organization, 2001) model ............................... 15 1 2 The process of developing ICF Core Sets based on Selb, et al., 2014 ............................... 16 1 3 The hypothesized ( A Priori ) model predicting social isolation in older adults ................. 28 3 1 The CFA model of the Self Reported ICF Brief Core Set Scale for HL ........................... 58 3 2 The scree plot supported the 4 factor solutions for the standardized outcome measures. ................................ ................................ ................................ ............................ 60 3 3 The CFA model of outcome measures repr esenting the 4 factors solution ....................... 65 3 4 The SEM model of predicting social isolation from Self Reported ICF Brief Co re Set Scale for HL ................................ ................................ ................................ ....................... 68 3 5 The SEM model of predicting social iso lation fro m standardized outcome measures ...... 71 3 6 The SEM model of predicting social isolation from standardized outcome measures ...... 74 3 7 The integrated SEM with listing of standardized coefficient () on the direct arrows between model members and the R 2 (on the top of each variable or factor) across the 131participants ................................ ................................ ................................ ................... 77

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11 LIST OF ABBREVIATIONS ALDs Assistive Listening Devices AR Audiologic Rehabilitation HAs Hearing Aids HATs Hearing Assistive Technologies HL Hearing Loss ICD International Statistical Classification of Diseases and Related Health Problems ICF International Classificatio n of Functioning, Disability, and Health ICIDH International Classification of Impairments, Disabilities and Handicaps WHO World Health Organization

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12 Abstract o f Dissertation Presented to the Graduate School of the University o f Flo rida in Partial Fulfillment of the Requirements for the Degree of Doctor o f Philosophy HEARING DISABILITY AND SOCIO EMOTIONAL ISOLATION IN AN AGING POPULATION: A REVOLUTIONARY CONCEPT ANALYSIS USING THE WORLD IONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH By Razan Al Fakir May 2016 C ha ir: Alice E. Holmes Major: Communication Sciences and Disorders In 2010, t he beta versio n of the International Classifi cation of Functioning, Disability, and Heal th ( ICF) Brief Core Set for Hearing L oss (HL) in adults was developed and recommended to be validated through audiologic rehabilitation programs (AR) The preliminary studies validate d 1 8 of 27 categories using a clinician/researcher perspective support ed the four factor solution provided by the ICF framework and raised the possibility of using the ICF Brief Core Set to predict poor social interaction among elderly people with HL. This doctoral thesi s had two aims. T he primary aim was to validate the ICF Brief Core Set for HL from an aging population perspective d irectly through the S elf R eport ICF Brief Core Set Scale for HL and indirectly through the proposed model of the objective and subjective outcome measures The secondary aim was to explore if soci al isolation can be predicted from the ICF B rief Core Set for HL. One hundred and thirty one independent older adults participated in the study. All participants were either assigned to complete the objective outcome measures first and then the subjective measures or to complete the subjective outcome measures first and then the objective

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13 measures accord ing to their daily functioning Both objective and subjective measures were presented in randomize order. Twenty two ICF Brief Core Set categories were val idated from the perspective of older adults with and without HL through the Self Reported ICF Brief Core Set Scale. Additionally, the proposed objective and subjective outcome measures validated and verified 17 20 categories and confirmed the four factor d imensions The overall results highlighted that life experience of older adults with hearing disability is best explained by sensor, cognitive, and psychological performances. Further results unexpectedly highlighted the impact of dizziness in increasing listening effort and the likelihood of social isolation. Social isolation is the product of several interactions and not a certain consequence of growing older, but it is mitigated by decline in cognitive functions and health disorders. The ICF Brief Core Set Scale for HL combined with Montreal Cognitive assessment are a usefulness screening tools to be used in audiology clinical practice to predict whom at risk for social isolation and dementia.

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14 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW Cur rent Disability Model Disability, and Health proposed a new model for disabilities. As opposed to the International Classification of Impairments, Disabilities and Hand icaps (ICIDH 1, 1980), the ICF is a iopsychosocial model, which aims to integrate different perspectives of health into a cohesive coherent view. The ICF was designed for optimal benefit to patients, leading to new trends in team care development and r esearch that looked to enhance the functional capacity of the individual and to improve performance by modifying features of social environment. The ICF has been established to complement the diagnostic information provided by the International Statistical Classification of Diseases and Related Health Problems (ICD 10); however, there is a slight difference in classification procedure. The ICD 10 classifies health conditions, while the ICF classifies functioning and disability associated with health conditi ons. The ICF aims to provide a unified reference framework for the description and classification of health conditions, using a sta ndard concepts and terminology (WHO ICF, 2001): Impairments: Problems in body function s and /or structure s Activity limitation s: Difficulties an individual may have in executing activities Participation restrictions: Problems an individual may experience in involvement in life s ituations. In the context of health, Functioning represents the positive aspects of the interaction be tween individuals (with a health condition) and their contextual factors which are either while Disability represents the negative aspects. Disability is an umbrella term for impairments, and Activi ty limitations and Participation restrictions as shown in Figure 1 1.

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15 Figure 1 1: Illustration of WHO ICF (World Health Organization, 2001) model The ICF domains of disability have more than 1400 categories that serve as the units of the classification used to describe the health. The extensive list of ICF components was the main challenge of the classification. To facilitate the use of ICF, the WHO proposed the s that are related to specific health conditions. The ICF provides textual definitions as well as inclusion and exclusion terms for each category. For example, Hearing functions (b230) defines Sensory functions relating to sensing the presence of soun ds and discriminating the location, pitch, Inclusions are : functions of hearing, auditory discrimination, localization of sound source, lateralization of sound, speech discrimination; impairments such as deafness, heari ng impairment and hearing loss While, Exclusions are : perceptual functions ( b156 ) and mental functions of language ( b167 )

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16 The development of the ICF Core Sets recommended to be conducted in three phases: preparatory phase, an agreement by consensus phase (Phase I), and validation in clinical practice phase (Phase II) as recomm end by Selb and c olleagues ( Selb et al., 2014). The scheme of the three phases is illustrated in Figure 1 2. Figure 1 2. The process of developing ICF Core Sets based on Selb, et al., 2014 Emergence of the ICF Disability Model in Audiologic Rehabilita tion The ICF Core Sets for Hearing Loss (HL) development was initiated in 2010 by identifying ICF categories of particular relevance for adults with HL for use in clinical practice and research (Danermark, et al., 2005, 2010). By 2013, two beta versions o f the ICF Core Sets for HL were completed. The Comprehensive Core Set consists of 117 ICF categories and serves as a guide for multi professional comprehensive assessment. The Brief Core Set consists of 27 categories (of the 117) and serves as a minimal st andard for the assessm ent and reporting of functional performance and health in clinical studies (Danermark, et al., 2013). Both Core Sets were recommended to be validated through Audiologic Rehabilitation (AR) programs Linking methodology and coding proc edure is the method that was established by the WHO to validate

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17 Core Sets Projects (Cieza, et al., 2005). Validation of the Core Sets can be carried out in different ways depending on their specific purposes (Selb et al. 2014). A Core Set can be applied as a clinical tool to support clinicians in areas such as assessment needs measuring outcomes, and r ehabilitation (Hickson & Scarinci 2007; Timmer et al. 2015) Recently, t hree studies were conducted for validating the Core Sets for HL. The first validat ion study was completed through a literature review of 122 published studies by linking the Comprehensive ICF Core Set to 537 AR outcomes measures (Granberg, et al., 2014). Results highlighted two important issues. The first issue was the complexity of tra nslating (link ing ) health and health related information to the ICF categories Hence, additional rules were developed to be applied in future studies aiming to val idate Core Sets in AR programs. The second issue was t he lack of research focusing on commun ication difficulties in relation with social environmental factors (e.g. social support and/or attitudes) The possible reasons for these findings may originate from the focus on assessing hearing performance apart from other body systems and environment al factors. Undeniably, several recommendations to modify the AR traditional test battery have been reported in the literature, yet have not been applied in AR clinical practice. For example, several studies demonstrated the value of the ICF approach over the traditional approach and suggested a significant need to use the ICF in an elderly hearing impaired population for identifying environmental and personal factors that restrict participations (Stephens, et al., 2001; Hickson & Scarinci, 2007; Scarinci, et al., 2009) and for validating subjective outcome measures used in AR programs according to the ICF standards (Abrams & Chisolm, 2013). With the emergence of cogni tive neuroscience in AR a number of studies suggested adding global or specific cognitive screening assessments

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18 especially to the geriatric AR test battery (e.g. Kricos, 2006; Pichora Fuller and Singh, 2006; Anderson, 2013; Anderson, et al., 2013 ). In 2015, two pilot studies were conducted to explore the content validity of the ICF Brief Core Set for HL in two different clinical setting using the linking methodology (Alfakir, et al., 2015 a, b ). The overall r esults s upported Granberg and colleagues findings regarding the complexity of linking the content of the AR outcome measures to the ICF ca tegories; a nd the lack of research focusing on communication difficulties in relation to social environmental factors. Further, it was aligned with a recommendatio n to modify the AR test battery and a need to validate subjective outcome measures used in AR programs according to the ICF standards. In the pilot studies we were able to 1) validate 18 of 27 categories 2) id entify the four factor solutions that support the structur e provided by the ICF framework and 3) d emonstrate the possibility of using the ICF Brief Core Set as a useful outcome measure to predict problems contributing to poor functional perform ance in elderly people with HL. In addition to the linking methodology and coding procedure, the ICF scale (qualifies ) was applied to classify the sev erity of impairments, activity limitations, and participation restrictions. The ICF qualifiers showed to be highly reliable and remarkable to identify factors that play a role in extraordinary performance of older adults with HL. The excellent reliability of the ICF scale raised the applicability of the ICF Brief Core Set for HL to be used as an outcome measure. However, the questions were : which measures are most appropriate for addressing the ICF categories? Does ICF use represent the best clinical practi ce within AR programs to understand hearing disa bility? Altogether these findings raise the idea for a further validation process by using different methods rather than the linking procedure. Therefore, in the current study t wo different methods were prop osed to validate the ICF Brief Core Set for HL which is listed in Table 1 1. The direct

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19 method was planned to test the content validity of the ICF Brief Core Set for HL categories by developing a simple questionnaires addressing the ICF categories. The di rect method was estimated from Coene (2008) The indirect method was anticipated to validate and verify the ICF categories using a proposed standardized model of outcome measurements align with the ICF Brief Core Set categories. The purpose was to develop an integrated protocol that can be used in clinical practice and future studies that helps clinicians to predic t factors that contribute to hearing disability becoming a handicap or restriction.

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20 Table 1 1. The beta version ICF Brief Core S et ICF Domains b.126 Body Functions Temperament & Personality function b.140 Attention function b.144 Memory function b.152 Emotional function b.210 Seeing function b.230 Hearing function b.240 Sensation associated with HL and vestibular functi on Body Structure s.110 Structure of brain s.240 Structure of external ear s.250 Structure of middle ear s.260 Structure of inner ear Activity Limitation & Participation Restriction d.115 Listening d.240 Handling stress and other psychological demands d.310 Communicating with receiving spoken message d.350 Conversation d.360 Using communication devices and techniques d.760 Family relationship d.820 School education d.850 Remunerative employment d.910 Community life Environmental Fact ors e.125 Products & technology for communication e.250 Sound e.310 Support from Immediate family e.355 Support from health professional e.410 Individual attitudes of immediate family e.460 Societal attitudes e.580 Health service system & policies

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21 Hearing Function and Hearing Disability in an Aging Population According to the American Speech Language Hearing Association, hearing is defined as the process of collecting, attending to, and understanding sound from the environment (American Speech La nguage Hearing Association, 2012). There is no doubt that our hearing system is a primary window to discover the world. Throughout our lives hearing input provides us with an incredible rich and nuanced source of information. The ability to hear and listen depends on the integration of the auditory neural system from the ascending auditory pathways to the higher order function s and verse versa. With aging, the auditory system undergoes indirect central changes as well as direct morphological and physiologi cal changes The indirect central changes are primarily due to peripheral lesion s (degeneration of spiral ganglion) leading to a reduced input in to the central auditory system. The direct changes are induced by the biological effects of aging leading to decline in central neural auditory processing ability. These changes lead to loss of speech understanding greater than would be expected from the audiometric thresholds and a decreased ability to localize sounds and detect signals in noise. Therefore, the effect of aging on the central the decline of peripheral cochlea (Howarth & Shone 20066). In reality, understanding the relationship between the two pathologies in the human auditory system is sophisticated and difficult to differentiate. Three hypotheses were developed to explain age related differences in speech recognition. First, t he peripheral hypothesis suggested that poor speech recognition could be explained by aging ch anges in the auditory periphery ( e.g. Shucknect, 1964; Humes, et al.,

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22 1996 ). Second, t he central auditory processing hypothesis as measured by depressed scores in speech audiometric suggested that poor speech recognition could be explained by structural and functional changes in the au ditory pathways of the brainstem and portions of auditory cortex (Humes, et al. 1992; Humes, et al., 2012) Third, t he cognitive processing hypothesis as measured by auditory cognitive tests, suggested that poor speech perception and overall communicatin g difficulties contributed to cognitive deficits in older adult s (Jerger, et al. 1990; Jerger, et al. 1991; Humes, et al., 2007). These findings highlighted that there is no distinction between the three suggested hypotheses. In research parallel to hea ring research neuroscientists and cognitive gerontologist s proposed fou r hypotheses as possible explanations for the powerful inter connection of systems between perception and cognition in aging (Lindenberger & Baltes, 1994; Baltes & Lindenberger, 1997). In brief, t he common cause hypothesis suggested that declines are symptomatic of widespread neural degeneration, while t he cognitive load on perception hypothesis suggested that cognitive decline results in perceptual decline. The deprivation and the info rmation degradation hypotheses, unlike the two previous hypotheses, suggested that either perceptual decline results in permanent cognitive decline or impoverished perceptual input results in com promised cognitive performance, respectively. The information degradation hypothesis has been tested in several studies to determine the effect of changes in audition and cognition on listening performance in noisy environments and when listening becomes effortful (Pichora Fuller, 2003). With the emergence of the de privation and the information degradation hypotheses there was a growing interest in AR to further investigate the interacting contributions of auditory processing and cognitive processing in and its role in complex human auditory performance and behavior.

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23 Hearing Disability In essence the ICF Brief Core Set for HL categories, which is listed in Table 1 1, hearing disability has two aspects: 1. Activity limitation (listening, understanding meaning of message, conversation, maintaining family relationship, and handling stress). 2. Participation restriction (employment, education, and social community life). According to the ICF concept, these activities are highly sensitive to influence by the existence of HL and interacted with functional impairments (person ality, attention, memory, emotion, hearing, vision, and other sensations associate d with hearing and vestibular function), as well as environmental factors (use of assistive devices, noise, attitude, and support). Activity Limitation Unquestionably, HL l eads to poorer perception of speech and social isolation in older adults (Pronk, et al., 2014). To compensate for the deterioration in hearing sensitivity and adju st to conversation difficulties older adults may use basic hearing aids (HAs) (Humes, 2001, 2 007), specific features of hearing aids (Christensen, 2000) or assistive listening devices (ALDs) (Noe, et al., 1997; Alfakir, et al., 2015 c ). Byond H As use, older adults may rely on further compensatory resources such as, cognitive working memory ( Humes, 2006; Rudner, et al., 2011; Ronnberg, et al., 2013; Mishra, et al., 2014) social intellige nce (Finken, 2015), and/or family/social support (Gomez & Madey, 200, Alfakir & Holmes, in progress). These findings raised three empirical questions: F irst, how old er adults can rely on limited social support, cognitive resources and social intelligence if as epidemiologic studies indicate the followings: The prevalence of mild cognitive impairment is 42% in persons 65 years old and older 40% to 50% of older adults rep ort subjective memory symptoms; t he prevalence of dementia is 5% in persons aged 71 to 79 years, increasing to 24% in those aged 80 to 89

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24 About 25% of adults aged 65 years or old er have som e type of mental health problem such as a mood disorder, anxiety or depression which considered a non natural part of aging (Centers for Disease Control and Prevention, 2008). The prevalence of social isolation in community dwelling older adults indicates that isolation is as high as 43% (Smith & Hirdes, 2009; Nicholson, 2009). social and emotional support they need (McGuire, et al., 2007). Second, how older adults with HL do function if as recent longitudinal studies report the following: HL has increased at an average rate of 0.91 dB/year over an 11 year follow up; this rate accelerated with age, cognitive decline and hypertension (Kiely, et al., 2012). A s ystematic review study of listening comprehension across the adult lifespan found that while auditory sensitivity declined from age 20 to age 90, listening comprehension remained relatively unchanged until approximately age 65 70, with declines evident onl y for the oldest participants (Sommers, et al., 2011). Older adults with HL are at increased risk experiencing emotional distress, such as depression and social engagement restriction within three to five years later as measured ( Saito, et al., 2010; Gopin at h, et al., 2012). Dementia was evident after a six year follow up (Lin, et al., 2011) and personality change during a six year follow up (Berg & Johansson, 2014). Third, why listening and communication difficulties and social isolation are still the most common complaints among older listeners in both treated and untreated HL (Humes, et al., 2006; Mick, et al., 2014; Dawes, et al., 2015) Indeed, a ll of these factors may contribute to limit ing activities, increasing the listening effort, and restrict ing p articipation in social interactions and/ or increasing the likelihood of social isolation I n other word s, all these factors may contribute to turn ing disability in to a handicap or restriction. Obviously, being able to answer those questions require s a n inn ovative concept analysis and integrative understanding of the comprehensive profile of an individual instead of

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25 focusing only on the auditory system. This doctoral study propose s that the use of the ICF Brief Core Set for HL helps in : I nvestigating the c omplex relationship between hearing disability and socia l isolation in the aging population Identifying factors that may be responsible in turn ing hearing disabilit y in to handicap or restriction. Participation Restriction In psychology, social i ntelligence is the ability to build personal connections w ith others, deal with conflict and be part of a positive social network. This indicates that social intelligence requires high cognitive and executive abilities to perform day to day activities suc h as listening handling breakdown s in communication and information processing, maintain ing relationships with family and friends including an adequate network of people and strong social ties, and regulating negative societal attitude s ( Hess & Blanchar d Fields 1999) Three major psychological theories have been proposed to explain how people develop in old age, the disengagement activity, and continuity theories. The disengagement theory states disengagement by the aging individual theory raised several controversial issues in the field of aging, because it ignores the impact of low social support on aging life experi ences with disabilities. In 1963, the activity theory rose in opposing successful aging occurs when older adults stay active and maintain social interactions (Havighurst, 1963). This theory emphasizes two important issues. The first issue is the importance of maintaining an active lifestyle. The second issue is the role of social structure including relationships with family and friends that help older people to stay active and contin ue to maintain their own integrity. With the emergence of behavior observational studies in a large proportion of older adults with

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26 changing physical, mental, and social status the continuity theory was originated in 1989. The continuity theory proposes th older adults will usually maintain the same activities, behaviors, relationships as they did in their earlier years of life two fundamental structures of continuity that help people maintain the ir social inter action situations, t he internal and external structure s. P ersonality, ideas, and beliefs of an individual are some examples of the internal structure while relationships and social roles are some examples of the external structure t h at support elderlies f or maintaining their lifestyle, regardless of their health problems. These theories highlighted multifaceted factors of social isolation. premature death, lower gen eral well being, more depression, and a higher level of disability from Social isolation refers to the objective physical separation from other people, such as living alone or having a small social network and/or inadequate s ocial support (Foundation of AARP, 2012). Emotional isolation or loneliness refers more to the subjective feeling of being alone, separated, or apart from others (Biordi & Nicholson, 2009) Social isolation lity to self regulate social measured by a cognitive test called dichotic listening (Cacioppo, et al., 2000, 2014). Hence, with health problems associated with H L in older adults, the probability of social isolation or poor social interaction, when auditory comprehension was limited is very high (Mick, et al., 2014). The in depth analysis of the qualitative data which was extracted from the two pilot studies u sing the framework of functional assessment of behavior approach found that older people strive to continue participating, completely or partially in social events regardless of the HL and perceived handicap However, t his ability improves in the presenc e of positive support

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27 and attitude while r estric tion in term of feeling loneliness and social isolation seems to increase with maladaptive coping strategies, inability to handle stress and/or lack of social support (Alfakir & Holmes, in progress). This a ltogether raises the interest in applying the ICF Brief Core Set for HL as a holistic approach to explore the factors behind this behavior Research Aims Primary Aim: The primary aim is to validate the ICF Brief Core Set for HL from the aging populat ion perspective in two ways: directly through the self report ed ICF Brief Core Set Scale for HL a nd indirectly through the proposed model of standardized objective and subjective outcome measures Validation will be achieved by: 1. Testing the correlation between the responses to the self reported ICF Brief Core Set Scale for HL and the proposed model of outcome measures to support validity of ICF items. These include: Body functions domain: 1) personality, 2) emotion, 3) attention, 4) m emory, 5) vision 6) hearing 7) sensation related hearing (tinnitus), and 8) sensation related vestibular (dizziness). Activities and participation: 1) listening, conversation, communication, and using communication techniques will be combined as communication difficulties, 2) fami ly relationships, and 3) community life. Environmental factors: 1) products and technology 2) sound, and 4) support from family. 2. Evaluating the content validity, factor structure, and reliability of the self reported ICF Brief Core Set Scale for HL. 3. Evalu ating the adequacy of the proposed model of the objective and subjective outcome measures as a supplemental procedure to validate the ICF Brief Core Set for HL. Secondary Aim: The secondary aim is to explore if social isolation can be predicted from the proposed model of the objective and subjective outcome measure aligned with the ICF Brief Core Set for HL Figure 1 3 illustrated t he hypothesized model used to predict social isolation. The hypothesized model was derived from the literature review, ICF fr amework, and

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28 the pilot studies to reflect the complex interactions of environmental factors, functional performance, and activities limitation on social isolation. Figure 1 3. The hypothesized ( A Priori ) model predict ing social isolation in older adults

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29 CHAPTER 2 METHODS Setting This study was completed at the University of Florida. Testing took place in the Audiologic Rehabilitation Laboratory in Dauer Hall. For participants, o ne visit was required to complete the study lasting for 3 hours including t he break. Demographics Participants wer e 131 independent older adults whom ages between 60 and 89 year (mean [ M ] = 72.32, standard deviation [SD] = 6.83). Fifty five of the 131 participants (58%) were male. Fifty four of 131 participants (40.5%) had compl eted 14 to 16 years of education were the rest more or less educated The majority of the participants were retired (71.8%), living with a spouse (65.6%), had multiple health conditions (76.3%), such as high blood pressure, diabetes, or arthritis, had non hearing assistive devices technology (68.7%), and a corrective seeing function (e.g. eye glasses or surgery) (76%). Eighty five of 131 participants had HL above 25dB (85%). Seventy seven had a normal cognitive function (MoCA >26), forty eight had a mild c ognitive decline (MCI) (MoCA < 26), and seven had a severe cognitive decline (MoCA < 21). Detailed participant characteristics are provided in (Table 2 1).

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30 Table 2 1. Partici pants Characteristics (N =131) Characteristics Number = 131 Mean(SD) Range Age 60 69 70 79 80 89 52 55 24 72.32 (6.83) 60 89 Gender Male 55 Female 76 Education Levels 12 years 26 14 16 years 53 >16 years 52 Work status Retired 94 Employed 28 Volunteers 9 Living arrangements Live with spouse 86 Live with other relatives Live alone 13 32 Health conditions No medical disorders 31 Chronic medical disorders 100 Use of HA Ts None 90 HAs only 29 HA s + ALD s 9 ALD s only Have c orrected vision Yes (distance) Yes (close) Intellectual function (MoCA) Normal cognition > 26 MCI < 26 Severe cognitive Decline < 21 3 100 115 77 48 6

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31 Objecti ve Outcome Measures Pure Tone Audiometry Test (PTA) Only air conduction testing was completed in both ears. The Hughson Westlake technique was used to evaluate thresholds for the 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz frequencies. The calcul ation of the average thresholds for each ear was based on the 500, 1000, 2000, and 4000Hz frequencies Acceptable Noise Level (ANL) The ANL is a test developed by Nabelek and colleagues to determine an willingness to accept noise when listen ing to sp eech (Nabelek, et al., 1991). The ANL requires listeners to report the most comfortable listening level (MCL) for ongoing speech (Arizona Travelogue) in an adaptive procedure. Then they continue listening to the speech at their MCL while backgroun comfortable level for the background noise while still listening to the speech is determined (BNL). The ANL calculation can then be made by subtracting the BNL from the MCL (ANL=M CL BCL). A lower score means a greater tolerance of background noise. Bamford Kowal Bench Speech in Noise Test (BKB SIN) The BKB SIN consists of 18 equivalent sentence pairs, each list containing 8 10 sentences presented in increas ing levels of backgrou nd noise or changing in Signal to Noise Ratio ( SNR) (Bench, et al., 1979). All sentences are produced by one talker and the background noise by four talker babble. The SNRs range from +21 to 6 in each list. The BKB SIN is score d in a dB SNR breakdown with lower scores indicating better speech understanding in noise. In this study only a two list pair (No. 3 and 4) was used for all participants. The SNR loss scores for the four lists were averaged to create a combined SNR loss score. The scores of 3 7 indic ates a

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32 mild SNR loss and scores of 7 15 indicates moderate SNR loss, while scores > 15 dB indicates severe SNR loss. Brief Test of Attention (BTA) The BTA is an auditory perception task that measures divided attention in the verbal linguistic system dev eloped by (Schretlen, 1996). It provides a rapid, b edside assessment of attention impairment among non aphasic hearing adults, including those with visual and motor impairments that preclude tests which require visual scanning or manual dexterity. It is st 89 years who can distinguish between spoken numbers and spoken letters of the alphabet. The BTA consists of two parallel forms presented via audio CD. On Form N (Numbers), a voice reads ten lists of letters and numbe rs that increase in length from 4 18 elements. The respondent's task is to disregard the letters presented and cognitively count how many numbers were read aloud. Form L (Letters) consists of the same ten lists, but the respondent must disregard the number s and cognitively count how many letters were read aloud. The number of correctly monitored lists is summed across both forms, with raw scores ranging from 0 20. Test materials include the Professional Manual, the Stimulus Audio CD, and the Scoring Form. I t takes 10 15 minutes to administer. Digit Span Test Backward (DSB) The DS B was initially designed to measure working attention and memory (Wechsler, 1997 ) DSB is used to measure working memory's number storage capacity. Participants repeated digit str ings of increasing length in reverse order. A list of random numbers was presented once by visual only (DSB V) modality via a computer screen at the rate of one digit per second and once by listening only (DSB L) modality via a voice recording by a native English speaker at a rate of one digit per second. The list consisted of 8 sets or 1 6 trials The score was the total number of correct trials prior to failing two

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33 consecutive trials at any one span size (Gregoire & Van der Linden, 1997). Higher scores in dicated better performance. Montral Cognitive Assessment (MoCA) MoCA (version 7.1) is a cognitive screening tool designed to assist health professionals in detection of mild cognitive impairment (MCI). It assesses different cognitive domains: visuo constr uctional skills/ executive functions, attention and concentration, memory, language, abstract, and orientation. The total possible score is 30 points; the suggested cutoff score for normal cognitive function was > 26 (29.6 25.2), < 26 (25.2 19.0) for MC I and any score range from (21.0 11.4) considered as a risk for Alzheimer disorder (Nasreddine, et al., 2005). Visual Acuity Test Visual acuity was assessed with standard optometric procedures for both close and distance vision. An Ultimate Eye Snell en chart was presented at about 14 inches (close visual tests were performed according to daily functioning. Subjective Outcome Measures Demographics informa tion sheet This sheet includes the general information about their age, gender, education, occupation, marital, medical history status, and HAs use. Self Rep ort ICF brief core set scale for HL This is a self reported questionnaire developed by the research er. The theme of the questionnaire was based on another doctoral thesis aimed to at validat ing the ICF Core Set for Arthritis (Coene, 2008). The questionnaire was designed based on the description of the ICF B rief C ore S et for HL categories ( ICF manual 20 01 or online ICF browser ) Also, the rating

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34 scale was designed based on the ICF qualifiers related to each domain (ICF manual, 2001). The ICF B rief C ore S et S cale for HL can be seen in the Appendices. Big Five Personality Inventory 44 item (BFPI) BFPI is an inventory that measures an individual on the Big Five Factors (dimensions) of personality (Goldberg, 1993). Each of the factors is then further divided into pers onality facets: Extraversion (8 items) Agreeableness (9items) Conscientiousness (9 items) Neuroticism (8 items) Openness (10 items) Each questionnaire item probed respondents for a rating on a scale of 1 =disagree strongly, 2= disagree a little, 3=neither agree nor disagree, 4= agree a little, 5=agrees strongly. Tinnitus functional index (TF I) to their tinnitus ( Meikle et al., 2011 ). TFI is a self reported outcome designed to assess the multiple domain s of tinnitus severity. Each domain had at least thr ee or four items. Each questionnaire item asked respondents for a rating on a scale of 0 to 10, based on how they past week, how easy was it for you to cope wi to Higher scores indicate a more severe handicap. Dizziness Handicap Inventory (DHI) The DHI has been developed by Jacobson and Newman (1990). The D HI consists of 25 questions grouped into three dimensions: functional, emotional, and physical aspects of dizziness and unsteadiness. The scores ranged from 0 100 points. There were nine questions within each of the functional and emotional dimensions; wit h a maximum score of 4 for each item. Within the

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35 physical dimension there were seven questions with a maximum score of 4 f or each. Higher scores indicate a more severe handicap. Speech, Spatial and Quality of Hearing (SSQ) SSQ is a self report test of aud itory disability developed by Gatehouse and Noble in 2004. The SSQ includes 49 items that ask how well a listener would do in many complex listening situations illustrative of real life that covers: 1) hearing speech in a variety of competing contexts; 2) the directional, distance and movement components of spatial hearing; 3) segregation of sounds and attending to simultaneous speech streams; 4) ease of listening; 5) the naturalness, clarity and identifiability of different speakers, different musical piec es and instruments, and different everyday sounds. Each item describes a unique listening situation, and the patient answers on a scale of 0 10 to indicate how much difficulty individuals would have. Higher scores indicate more effortful listening. The Ger iatric Depression Scale (G D S) G D S is a 30 item self report assessment used to identify depression in the elderly. The GDS questions are answered "yes" or "no", instead of a five category response set. This simplicity enables the scale to be used with ill or moderately cognitively impaired individuals. The scale is commonly used as a routine part of a comprehensive geriatric assessment. One point is assigned to each answer and the cumulative score is rated on a scoring grid. The grid sets a range of 0 9 as "normal", 10 19 as "mildly depressed" and 20 30 as "severely depre ssed" (Yesavage, et al., 1982). Loneliness and Social Isolation Scale of De Jong Gierveld (LSIS DJG ) LSIS DJG is a n 11 item scale. Each item represents a statement with a three point respons e scale (no, more or less, yes). It includes the objective measure (social isolation) that relates to deficits in social integration and embeddedness and the subjective (emotional

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36 loneliness) that relates to the absence of an intimate attachment figure suc h as a partner or best friends (De Jong Gierveld & Kamphuis, 1985). The loneliness subscale consisted of 6 items, while the social isolation subscale involved 5 items. Higher scores indicate severe social isolation. Lubben Social Network Scale Revised (LS NS R) LSNS R consists of an equally weighted sum of 6, 12, or 18 items designed to gauge social isolation in older adults by measuring perceived social support received from family (6 items), friends (6 items) and neighborhood (6 items) (Lubben & Gironda 2004). The items measure size, closeness and frequency of contacts of a resp It was originally developed in 1988 and was revised in 2002 (LSNS R) along with an abbreviated version (LSNS 6) and an expanded version (LSNS 18). High er scores indicate high level of social support. Relationship Assessment Scale (RAS) RAS is a short version 7 item scale designed to measure general relationship satisfaction. Respondents answer each item using a 5 point scale ranging from 1 (low satisfac tion) to 5 (high satisfaction) (Hendrick, 1988). Higher scores indicate high level of fa mily relationship satisfaction. Equipment Otoscopy was completed at the beginning of the session using a Welch Allyn otoscopy. All objective testing was completed in a walled sound treated booth. The baseline audiometric testing was performed using a GSI 650 audiometer and ER 2 insert phones calibrated prior to beginning the study. Additionally each test was calibrated prior to beginning the s tudy. All objective tastings were presented in a sound field. The BKB SIN, ANL, and the BTA were routed through the diagnostic audiometer to a wall mounted speaker in the sound field. These

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37 testing were conducted with sound presentation s from a speaker at 0 degree azimuth and the par ticipant sitting one meter from the speaker. The DSB measure was presented via a Dell computer. For the listening tasks the computer was attached to an external computer speaker and the participant sitting half meter from the external speaker. The loudnes s level for the BKB SIN, BTA, and listening DSB outcome were obtained at approximately 65 70 dB SPL. Procedures All participants were recruited from the community through flyers and post cards sent to the University of Florida Audiology clinics, the University Of Florida Institute Of Aging, the University of Florida Health Street, and local senior citizen centers, local audiology clinics and senior living housing development s First all participants consented to be part of the study which was ap proved by the UF Institutional Review Board on the use of human subjects and which conforms to the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects. Next, if the participants were a HAs users, the function of the HAs were checked either by Real Ear Measurement or a liste ning check. Third, participants were either assigned to complete the objective outcome measures first and then the subjective or to complete the subjective outcome measures first and then the object ive measures. Both objective and subjective measures were randomized in order. All participants were asked to complete both outcomes measures according to their daily functioning. For example, if participants were HAs user s the BKB SIN was completed while the participants use d the HAs.

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38 CHAPTER 3 RESULTS Data Analysis All statistics were completed using the IBM SPSS VERSION 21 and AMOS VERSION 22. The statistical analysis used in this study includes: descriptive statistics, bivariate co rrelation coefficient, factors analysis, and structure equation modeling. Descriptive S tatistics Descriptive S tatistics for the Self Reported ICF Brief Core Set Scale for HL Results showed that 100% of the ICF categories were reported by the 131 participa nts in response to the Self Reported ICF Brief Core Set Scale for HL in Table 3 1, 3 2, and 3 3. For B ody F unctions D omain The health problems that were most reported to mildly limit (1=mild ) and completely restrict participation (4= complete ) in social interaction were 81 % for memory loss and 75.6% for hearing dysfunction. While 48 % reported limitations and restrictions due to temperament and personality functions, 45% due to attention deficits, 42% due to mental illness, and 40% due to sensation of tin nitus. Whereas the health problems that were least reported to limit and restrict participation in social interaction were 28% for distance acuity vision and 20% for sensation of dizziness or fear of falling. The frequency distribution for each item per sc ale (0=no impairment, 1=mild, 2=moderate, 3=severe, and 4=complete) is presented in Table 3 1. For A ctivity L imitation and P articipation R estriction The activities that were most reported to mildly limit to completely restrict social interaction were 6 5% due to handling stress and other psychological demands 60% due to using communication techniques (communication repair strategies) 52% due to listening and communication with receiving spoken messages 46% due to conversation. While the activities

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39 t hat were least reported to limit and restrict social interaction were 28% due to family relationship and 26% for involvement in community life The frequency distribution for each item per scale (0=no difficulty 1=mild, 2 =moderate, 3=severe, and 4=comple te) is presented in Table 3 2. For E nvironmental F actors Among the HAs users, 28 out of 38 reported that in using HAs or HATs, clarity of sound, and the soundness level was a facilitator. Among all participants, 110 out of 131 reported that background no ise was a barrier ranging from the mild to substantial to complete 62 out of 131 reported that loud sound was a barrier 14 out of 131 reported that family support was a barrier, 19 out of 131 reported that family attitude was a barrier, and only 9 out of 131 reported that social attitude was a barrier. The frequency distribution for items of environmental domain per scale ( 1=mild barrier, 2= moderate barrier, 3=severe barrier, 4=complete barrier, 0=no barrier neither facilitator, +1=mild facilitator, +2= moderate facilitator, +3= Substantial facilitator, +4= complete facilitator) is presented in Table 3 3.

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40 Table 3 1. The frequency distribution for items of body function domain per scale (0=no impairment, 1=mild, 2=moderate, 3=severe, and 4= compl ete) from the 131 participants Body Functions Frequency distribution and percent age 0 1 2 3 4 Temperament & Personality function 67 (51.1%) 47 (35.9%) 11 (8.4%) 5 (3.8%) 1 (.8%) Attention f unction 71 (54.2%) 48 (36.6%) 6 (4.6%) 5 (3.8%) 1 (.8%) Memory function 25 (19.1%) 76 (58%) 22 (16.8%) 7 (5.3%) 1 (.8%) Emotional function 73 (55.7%) 40 (30.5%) 9 (6.9%) 6 (4.6%) 3 2.3%) Seeing function (Far distance) 94 (71.8%) 27 (20.6%) 6 (4.6%) 3 (2.3%) 1 (.8%) Hearing function 32 (24.4%) 49 (37.4%) 32 (24.4%) 14 (10.7%) 4 (3.1%) Sensation associated with HL (Tinnitus) 78 (59.5%) 22 (16.8%) 14 (10.7%) 7 (5.3%) 10 (7.6%) Sensation associated with HL (Vestibular) 107 (80.2%) 17 (13%) 5 (3.8 %) 3 (2.3%) 1 (.8%)

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41 Table 3 2. The frequency distribution for items of disability domain per scale (activity limitation and participation restrictions) per scale (0=no difficulty, 1=mild, 2=moderate, 3=severe, and 4=complete) from the 131 partic ipants Activity Limitations and participation restriction Frequency distribution and percent age 0 1 2 3 4 Listening 56 (42.7%) 46 (35.1%) 17 (13%) 8 (6.1%) 4 (3.1%) Handling stress and other psycho logical demands 50 (35.2%) 64 (48.9%) 9 (6.9%) 7 (5.3%) 1 (.8%) Communicating with receiving spoken message 62 (47.3%) 52 (39.7%) 12 (9.2%) 4 (3.1%) 1 (.8%) Conversation 71 (54.2%) 42 (32.1%) 8 (6.1%) 8 (6.1%) 2 (1.5%) Using communication techniques 52 (39.7%) 39 (29.8%) 15 (11.5%) 18 (13.7%) 7 (5.3%) Family relationship 94 (71.8%) 31 (23.7%) 5 (3.8%) 1 (.8%) 0 Remunerative employment 125 (95.4%) 5 (3.8%) 1 (.8%) 0 0 Community life 97 (74%) 25 (19.1%) 4 (3.1%) 5 (3.8%) 0

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42 Ta ble 3 3 The frequency distribution for items of environmental domain per scale ( 1=mild barrier, 2= moderate barrier, 3=severe barrier, 4=complete barrier, 0=no barrier neither facilitator, +1=mild facilitator, +2= moderate facilitator, +3= Substantia l facilitator, +4= complete facilita tor) from the 131 participants Environmental Factors Barrier Facilitator 4 3 2 1 0 +1 +2 +3 +4 Among 38 HAs users: Technology for communica tion Use of HAs Clarity of sound Loudness of sound 0 0 0 2 2 4 1 6 2 4 3 2 3 0 3 3 6 5 10 11 9 10 9 10 5 2 3 Among 131 participants Sound Noise background Loud sound of speech 4 1 18 32 46 20 42 9 21 24 0 2 6 0 10 0 8 0 1 Support from Immediate family 1 0 1 12 49 19 15 16 18 Support from health professional 0 0 0 4 72 16 7 16 16 Family attitudes 1 0 5 13 66 10 8 13 15 Societal attitudes 0 0 2 8 70 17 12 14 8 Health service system & policies 0 0 1 8 74 13 8 14 13

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43 Descriptive S tatistics for the P roposed O bjective and S ubjective O utcome M easures Descriptive statistics with directionality of the scores for objective and subjective outcome measures among the 131 participants and the 85 participants with HL above 25 dB (the HL group) can be seen in table 3 4 3 5 3 6, and 3 7. Objectives O utcome M easures For the h earing sensitivity as measured by PTA The mean hearing threshold for average HL in both ears among the 131 participants was 3 3 dB HL ( SD =16.3). The mean hearing threshold for average HL in both ears among the HL group was 41.5 dB HL ( SD = 14 ). Forty asymmetric audiograms were identified across the entire sample size. For visual acuity as measured by Snellen chart The mean score for the distance visual acuity for the 131 was 0.84 ( SD=0.2). The mean score for the close visual acuity for the 131 was 0.85 ( SD=0.16). The mean for both test s among the HL group were almost identical. For hearing function as measured by the BKB SIN The mean score for the BKB SIN or the Signal to N oise R atio loss among the 131 participants was 0.42 dB ( SD= 3.4 ). The mean hearing threshold BKB SIN among the HL group was 1.3 dB ( SD= 4.3 ). For attention function as measured by BTA The mean score for the BTA am ong the 131 participants was 15.2 ( SD=4.4). The mean score among the HL group was 14.3 ( SD= 5 ).

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44 For memory function as measured by DSB via listening only and visual only modalities The mean score for the DSB via listening only modality among the 131 particip ants was 7.5 ( SD= 2 ). The mean score for the DSB via visual only modality among the 131 participants was 7 ( SD =2). The mean for both test s among the HL group were almost identical. For the global cognitive function as measured by MoCA The mean score for the MoCA among the 131 participants was 26.5 ( SD = 3 ). The mean score for the MoCA among the HL group was 26 ( SD= 3 ) For the noise background as measured by ANL The mean score for the ANL among the 131 participants was 3.5 ( SD= 4 ). The mean score for the ANL among the HL group was 3.4 ( SD = 4 ). Subjective outcome measures For the sensation of tinnitus as measured by TFI The mean score for the TFI among the 131 participants was 7.3 ( SD= 13.4 ). The mean score for the TFI among the HL group was 10 ( SD= 15.4 ). For sensation of dizziness as measured by DHI The mean score for the DHI among the 131 participants was 8.0 ( SD = 12 ). The mean score for the DHI among the HL group was 9.3 ( SD= 13.3 ). For the effortful listening construct as measured by SSQ The mean score for the SSQ am ong the 131 participants was 7.4 ( SD= 1.6 ). The mean score for the SSQ among the HL group was 7 ( SD= 1.6 ). For the depression function as measured by G D S The mean score for the G D S among the 131 participants was 5.2 ( SD= 5.3 ). The mean score for the G D S among the HL group was 5.5 ( SD= 5.3 ).

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45 For personality and temperament function as measured by B FPI Among the 131 participants the mean score for the Extroversion personality type was 3.3 ( SD= 0.8), Agreeableness 4.0 ( SD=0. 5 ) Conscientiousness 4.0 ( SD= 0.6), Neuro ticism 2.4 ( SD= 0.8, and openness 3. 7 ( SD=0. 6 ) The mean for the BFPI among the HL group were almost identical. For family support as measured by LSNS R The mean score for the LSNS 12 among the 131 participants was 37.34 ( SD= 9 ) The mean for the LSNS 12 am ong the HL group were almost identical. For the family relationship as measured by RAS The mean score for the RAS among the 131 participants was 31 ( SD= 5 ). The mean for the LSNS 12 among the HL group were almost identical. For the social isolation as meas ured by LSIS DJG The mean score for the LSIS DJG among the 131 participants was 3.3 ( SD= 2.7 ). The mean for the LSIS DJG among the HL group were almost identical.

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46 Table 3 4 Descriptive statistics of the objective and subjective outcome mea sur es for the 131 participants Objective outcome measures Scale Mean SD Min Max PTA of Right Ear (average of 500, 1, 2, & 4KHz) 32.98 18.17 7 .50 120.0 PTA of Left Ear (average of 500, 1, 2, & 4KHz) 32.68 16.56 5.00 88.75 PTA of Both ears (average of 500, 1, 2, & 4KHz) 32.98 16.28 8.75 100.0 BKB SIN Test (lower score better) 0.42 3.67 3.0 23.50 Visual Acuity (distance) (Higher score bette r) 0.84 0.19 0.40 1.00 Visual Acuity (close) (Higher score better) 0.85 0.16 0.40 1.00 BTA (Higher score better) 15.16 4.39 2.00 20.00 DSB L (Higher score better) 7.50 2.03 4.00 14.00 DSB V (Higher score better) 6.92 2.06 3.00 13.00 MoCA (Higher score better) 26.46 2.62 18.00 30.00 ANL (lower score better) 3.46 4.06 2.00 12.00

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47 Table 3 5 Descriptive statistics of the objective and subjective outcome mea sures for the 131 participants Subjective outcome measures Scale M ean SD Min Max TFI (lower score better) 7.31 13.40 0.00 58.8 DHI (lower score better) 7.82 11.77 0.00 62.0 SSQ (Higher score better) 7.37 1.62 1.14 9.77 G D S (lower score better) 5.18 5.35 0.00 27.0 BFPI Extraversion Agreeableness Conscientiousness Neuroticism Openness 3.31 4.06 3.93 2.43 3.76 0.85 0.55 0.61 0.87 0.67 1.38 2.00 2.40 1.00 2.00 5.00 5.00 5.11 5.38 5.00 LSNS R (Higher score better) LSNS R 6 LSNS R 12 LSNS R 18 19.47 37.34 47.43 4.83 8.83 12.75 6.00 9.00 10.0 29.0 56.0 80.0 RAS (Higher score better) 30.91 4.83 17.0 35.0 LSIS DJG Total (lower score better) Loneliness sub scale Social isolation sub scale 3.27 1.48 1.81 2.77 1.68 1.68 0.00 0.00 0.00 11.0 6.00 5.00

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48 Table 3 6 Descriptive statistics of the objective and subjective outcome measures for the 85 parti cipants with HL above 25dB ( the HL group ) Objective outcome measures Scale Mean SD Min Max PTA of Right Ear (average of 500, 1, 2, & 4KHz) 41.80 16.49 17.5 120.0 PTA of Left Ear (average of 500, 1, 2, & 4KHz) 40.47 14.97 10.0 88.75 PTA of Both ears (average of 500, 1, 2, & 4KHz) 41.47 13.92 26.0 100.0 BKB SIN Test (lower score better) 1.28 4.28 3.00 23.5 Visual Acuity (distance) (Higher score better) 0.83 0.20 0.40 1.00 Visual Acuity (close) (Higher score better) 0.84 0.17 0.40 1.00 BTA (Higher score better) 14.28 4.75 2.00 20.0 DSB L (Higher score better) 7.51 1.95 4.00 12.0 DSB V (Higher score better) 6.86 2.20 3.00 13.0 MoCA (Higher score better) 26.31 2.78 18.0 30.0 ANL (lower score better) 3.89 4.08 2.00 12.0

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49 Table 3 7 Descrip tive statistics of the objective and subjective outcome measures for the 85 parti cipants with HL above 25dB ( the HL group ) Subjective outcome measures Scale Mean SD Mi n Max TFI (lower score better) 9.81 15.44 0.00 58.8 DHI (lower score better) 9.32 13.26 0.00 62.0 SSQ (Higher score better) 6.91 1.65 1.14 9.61 G D S (lower score better) 5.53 5.36 0.00 27.0 BFPI Extraversion Agreeableness Conscientiou sness Neuroticism Openness 3.27 4.04 3.91 2.42 3.79 0.84 0.53 0.63 0.90 0.68 1.50 2.00 2.40 1.00 2.00 5.00 5.00 5.11 5.38 4.80 LSNS R (Higher score better) LSNS R 6 LSNS R 12 LSNS R 18 19.36 37.33 47.93 5.04 8.78 12.39 6.0 9.0 10.0 28.0 56.0 80.0 RAS (Higher score better) 30.84 4.50 17.0 35.0 LSIS DJG Total (lower score better) Loneliness sub scale Social isolation sub scale 3.41 1.61 1.80 2.64 1.69 1.63 0.0 0.0 0.0 11.0 6.0 5.0

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50 Correlation C oefficient between P roposed O bjective and S ubje ctive O utcome M easures and A ligned C ategories of Self Reported ICF Brief Core Set Scale for HL The results of a bivariate correlation coefficient analysis of the objective and subjective outcome measures for the131 part icipants are shown in the f ollowing Table s: 3 6 a and 3 6b 1. There was a significant corr elation between the individuals responses to the BFPI outcome and the effect of four types of temperament and personality function from the Self Reported ICF Brief Core S et scale for HL: Extrovers ion (r = .17, p=.044 ) Agreeableness ( r = .30, p=.001) Conscientiousness ( r = .23, p=.007) and Neuroticism ( r = .32, p < 0.001) ; w hile there is a non significant correlation with Openness (r = .0 3; p=.73) 2. There was a significant correlation between and the attention function from the Self Reported ICF Brief Core Set scale for HL ( r = 0.30, p = 0.001) 3. There was a significant corr elation between the individuals responses to the listening and visual wor king memory outcome and the memory function from Self Reported ICF Brief Core Set scale for HL [( r (DSB L) = 0.27, p = 0.002; r (DSB V) = .24, P = .004]. 4. There was a significant corr elation between the individuals responses to the G DS outcome and the emotion function from the Self Reported ICF Brief Core Set scale for HL ( r = 0.50, p < 0.001 ) 5. There was a significant corr elation between the individuals responses to the BKB SIN outcome and the hearing function from the Self Reported ICF Brief Core Set scale for HL ( r = .57, p < 0.001) 6. There was a significant corr elation between the individuals responses to the Snellen chart outcome (distance) and the seeing function from the Self Reported ICF Brief Core Set scale for HL ( r = 0 .36, p < 0.001)

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51 7. There was a significant corr elation between the individuals responses to the TFI and the tinnitus sensation from the Self Reported ICF Brief Core Set scale for HL ( r = .80, p < 0.001) 8. There was a significant corr elation between the individuals responses to th e DHI and the vestibular function from the Self Reported ICF Brief Core Set scale for HL ( r = 0.50, p < 0.001) 9. There was a significant corr elation between individuals responses to the SSQ and the listening, communication with verbal spoken message, con versation and using communication techniques from the Self Reported ICF Brief Core Set scale for HL [r (listening ) = 0.62, p < 0.001; r (communication with verbal spoken message) = .65, p < 0.001; r (conversation) = .6, p < 0.001; r (using communicati on techniques) = .50, p < 0.001]. Also, there is a significant correlation with handling stress ( r = .41; p < 0.001). 10. There was a significant corr elation between the individuals responses to the RAS and the family relationships (activities and particip ation domain) from the Self Reported ICF Brief Core Set scale for HL ( r = 0.1 7, p = 0.042; r = .18, p = .032) 11. There was a significant corr elation between the individuals responses to the LSIS DJG and the community life (activities and participation dom ain) from the Self Reported ICF Brief Core Set scale for HL (r = 0.32, p < 0.001) 12. There was a significant corr elation between the individuals responses to the ANL (environment factors) and the sound from the Self Reported ICF Brief Core Set scale for H L (r = 0.26, p = 0.002)

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52 13. There was a significant corr elation between the individuals responses to the LSNS 12 and the family support (environment factors) from the Self Reported ICF Brief Core Set scale for HL ( r = 0.20, p = 0.020) Further bivariate co rrelation coefficient analysis completed for the 85 participant with HL > 25dB showed very slight dif ferences as shown in Table s 3 8 and 3 9 Table 3 8 Correlation coefficient between ICF items and objective outcome measures for the 131 participants vers us the 85 participant who have HL > 25dB Objective Outcome measure ICF Items Domain Outcome measure R (n=131) R(n=85) Hearing Function Body Function BKB SIN 0 .57*** 0 .57*** Seeing Function Body Function Snellen chart (distance) 0 .36*** 0 .45*** Attention function Body Function BTA 0 .30** 0 .30** Memory function Body Function DSB L (Tasks) DSB V (Tasks) DSB L (Cap) DSB V (Cap) 0 .23** 0 .21** 0 .27** 0 .24** 0 .27** 0 .24** 0 .31** 0 .30** Sound Environmental ANL 0 .26** 0 .38*** *** P < 0. 001 ** P <0.01, P < 0.05

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53 Table 3 9 Correlation coefficient between ICF items and subjective outcome measures for the 131 participants versus the 85 participant who have HL > 25dB Subjective Outcome measure ICF Items Domain Outcome measure R(n= 131) R(n=85) Temperament & Personality function Body Function BFPI Extroversion Agreeableness Conscientiousness Neuroticism Openness 0 .17* 0 .30** 0 .23** 0 .32** 0 .03 0 .16 0 .21* 0 .22* 0 .27* 0 .01 Emotional function Body Function G D S LSIS DJG (Emotional) 0 .50*** 0 .44*** 0 .47*** 0 .45*** Structure of Ear Body Structure PTA 0 .64*** 0 .76*** Sensation of Tinnitus Body Function TFI 0 .83*** 0 .84*** Sensation of Dizziness Body Function DHI 0 .50*** 0 .54*** Listening, Communicating, Conversat ion, Using communication technique Handling stress Activity and Participation SSQ 0 .62*** 0 .65*** 0 .63*** 0 .50*** 0 .41*** 0 .57*** 0 .62*** 0 .61*** 0 .45*** 0 .41*** Family relationship Activity and Participation RAS 0 .17* 0 .23** Commun ity life Activity and Participation LSIS DJG (Total scale) LSIS DJG (Social) 0 .32*** 0 .26** 0 .35*** 0 .23** Support from family Environmental LSNS 12 0 .20** 0 .21* Product &Technology Environmental HA & ALDS usage 0 .35*** 0 .27** *** P < 0.001 ** P <0.0 1 P < 0.0 5

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54 Factor A nalysis and S tructure E quation M odeling Exploratory F actor A nalysis (EFA) for the Self Reported ICF Brief Core Set Scale for HL The EFA was conducted to determine the relationships between the ICF items and to support the four dimens brief core set scale for HL in this sample. A maximum likelihood with orthogonal ob lique rotations (promax) methods for Likert/ordinal data (ICF qualifiers) was applied to the 22 items for the study sample of 131 participants. The Kaiser Meyer Olkin (KMO) measure verified the sampling adequacy for the analysis, KMO = .88. An initial analysis was run to obtain eigenvalue square [( X 2 (231) =1556.44, P < 0.001), indicated that the relation between items were sufficiently large for the analysis. The Goodness of fit Test s (GOF) indicated a good fit ( X 2 (149) = 169.995, P criterion of 1 suggested by scree plot and in combination explained 55.3 % of the variance. These were: F 1. Non Audito ry F unctions and P articipation F 2. Environmental R esources F 3. Auditory F unctio n s and L imitation F 4. F amily R elationship (Third Party Disability) The rotated str ucture showed that Factor 1 and 3 were highly correlated ( r = 0 .65), F actor 2 and 3 were fairly correlated ( r = 0 .2), while F actor 4 was shown to be independent. The loadings of items on factors communalities, percent of variance per factor after rotatio n, and correlation mat rix are presented in Table 3 10 The internal consistency, Cronb Report ICF Brief Core Set for HL including items from the body functions and activities and participation scales was .89, while Cronb 6 items including the environmental items was .83.

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55 Table 3 10 Pattern (unique contributio n of a variable to a factor), structure (where shared variance not ignored), communalities ( loadings of items on factors) (h2), and percent of variance using the maximum likelihood method ICF model with the 22 items Items Rotated pattern matrix F 1 F 2 F 3 F 4 Rotated structure matrix F 1 F 2 F 3 F 4 h 2 Hearing function .16 .00 .97 .15 .50 .17 .88 .25 .82 Seeing function (Far) .52 .05 .20 .20 .60 .11 .48 .05 .40 Tinnitus .10 .02 .45 .01 .20 .08 .39 .02 .16 Vestibular/balance function .51 .07 .16 .30 .57 .02 .45 .18 .41 Temperament and personality .77 .00 .20 .16 .68 .04 .35 .25 .51 Attention function .70 .00 .04 .31 .70 .08 .44 .40 .60 Memory function .43 .12 .22 .20 .60 .22 .54 .30 .50 Emotional function .70 .01 .04 .03 .67 .04 .41 .12 .50 Listening .01 .10 .82 .02 .54 .05 .81 .11 .70 Communication .10 .07 .77 .07. .60 .06 .82 .02 .70 Conversation .30 .03 .53 .16 .64 .16 .73 .30 .61 C ommunication techniques .04 .08 .76 .24 .42 .19 .72 .15 .60 Handling stress .70 .06 .01 .11 .70 .01 .45 .20 .50 Family relationship .40 .08 .07 .50 .46 .00 .35 .54 .45 Community life HA Use Background noise .72 .01 .01 .00 .54 .08 .07 .06 .60 .08 .02 .14 .66 .00 .43 .04 .54 .20 .40 .10 .64 .00 .06 .22 .44 .30 .44 Family support Family attitude Social attitude Health support Health servi ces .02 .05 .01 .03 .02 .82 .81 .80 .88 .83 .06 .00 .10 .06 .02 .08 .22 .06 .21 .02 .00 .09 .22 .03 .04 .80 .80 .82 .90 .83 .05 .20 .31 .10 .12 .02 .14 .03 .28 .10 .65 .70 .71 .84 .70 Total Variance explained = 55.3 % Percent of varian ce 28.5.0% 17.4% 6.4% 3.0% Correlations Matrix 1.00 0.08 0.65 0.13 0.08 1.00 0.20 0.09 0.65 0.20 1.00 0.11 0.13 0.09 0.11 1.00 Kaiser Meyer Olkin of s ampling adequacy = .88, P < 0.0 1 F1. Non Auditory Functions and Participation F2. Environmental Resources F3. Au ditory Functions and Limitation F4. Family Relationship (Third Party Disability)

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56 Confirmatory F actor A nalysis (CFA) for the Self Reported ICF Brief Core Set Scale for HL In this analysis the CFA using the IBM SPSS AMOS was applied to evaluate the adequacy of the Self Reported ICF Brief Core Set Scale for HL The Goodness Of F it (GOF) indices which were selected to test the CFA model that best represents the present dataset were: C hi S quare, R oot M ean S quared E rror of A pproximation (RMSEA), C omparative F it I ndex (CFI), and Tucker Lewis Index (TLI). A GOF has: A probability level greater than 0.05 when chi square is close to zero. RMSEA, which is related to residual in the model, value 0.06 or less. CFI and TLI values of 0.90 or greater. The CFA usin g the Maximum likelihood estimates method was performed. The CFA confirmed the four factor solution across the 131 participants. The GOF statistics of the CFA model indicated a marginal support [ X 2 ( 204) = 316.493 P < 0.10 ; TLI = 911; CFI = .921 ; RMSEA = .0 65 Pclose =0. 043 ]. However, Bollen Stine bootstrap was done to test the null hypothesis that the model is correct. Bollen Stine bootstrap supported the fit of the model ( P = 0. 208 ). All the 22 ICF items were significantly related to the proposed latent variable Using the modification indices, the GOF indices were improved by determining the correlation between (Vestibular (e1) and seeing functions (e8)). The GOF become [ X 2 (203) = 29 8 098 P = 0.000 ; TLI = .923 ; CFI = .9 33; RMSEA = .060 Pclose =0. 1 3 2 ] Bollen Stine bootstrap supported the fit of the model (P = 0.2 91 ). Further, the CFA model was tested by the Generalized Least Square method The GOF statistics of the CFA model significantly support the model fit [ X 2 (203) = 219.009 P = 0. 210 ; TLI = 829 ; CFI = 851 ; RMSEA = .0 25 Pclose = 0. 976 ]. Th e Model which is presented in Figure 3 1 illustrates the results of Maximum likelihood estimates method. Additional details about the standardized and unstandardized regression

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57 weight, standard error, co variance, and correlation estimates for the CFA Model are presented in Table 3 11

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58 Figure 3 1 The CFA model of the Self Reported ICF Brief Core Set Scale for HL; Circles represent latent variables Rectangles represent measured variables Re present the error/ uniquenesses, Arrows represents variance from observed to latent variables Correlation arrows represent correlation between factors or between error/ uniquenesses and decimal numbers represent correlation estimate

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59 Table 3 11 The st andardized and unstandardized regression weight, standard error, covariance, and correlation estimates for the CFA Model Regression Weights Estimates Outcome measures (Indicators) B SE P Value Vestibular < --F1_NonAuditory Handling Stress < --F1_N onAuditory Attention < --F1_NonAuditory Memory < --F1_NonAuditory Emotional < --F1_NonAuditory Community Life < --F1_NonAuditory Temperament < --F1_NonAuditory Seeing < --F1_NonAuditory HA_Use < --F2_Environment Family Support < --F2_Enviro nment Family Attitude < --F2_Environment Social Attitude < --F2_Environment Health Service < --F2_Environment Health Support < --F2_Environment Tinnitus < --F3_Auditory Hearing < --F3_Auditory Listening < --F3_Auditory Communication < --F3_ Auditory Conversation < --F3_Auditory Using_ Communication _Techniques < --F3_Auditory Background_ Noise < --F3_Auditory 1.000 1.650 1.685 1.454 1.788 1.221 1.607 1.177 1.000 1.906 1.925 1.653 1.802 1.892 1.000 1.860 1.747 1.368 1.4 54 1.712 1.346 .500 .709 .750 .658 .674 .607 .686 .565 .551 .793 .795 .829 .841 .870 .389 .869 .827 .820 .755 .680 .650 .315 .315 .287 .348 .251 .317 .199 .300 .301 .252 .273 .281 .415 .395 .311 .337 .410 .3 26 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001

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60 Exploratory Factor Analysis (EFA) for the S tandardized O utcome M easures A Maximum Likelihood with orthogonal ob lique rotations ( P romax) methods for the standardized outcome measures was applied to the 22 items for the study sample of 131 participants. The EFA model reveled on six factors on of 1 and in combination, explained 5 4 .3 % of the variance. However, the scree plot suggested the four factors as can be seen in Figure 3 2. Figure 3 2. The scree plot supported the 4 fact or solution s for the standardized outcome measures. The EFA wa s completed with the four factor solution. The Kaiser Meyer Olkin (KMO) measure verified the sampling adequacy for the analysis, KMO = 70 An initial analysis was run square [( 105 ) = 440.832 P < 0.0 1), indicated that the relation between items were sufficiently large for the

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61 analysis. The Goodness of fit Tests (GOF) indicated a good fit ( X 2 ( 51 ) = 50.738 ; P < 0.0 1 ). The four factor solution explained 40.8 % of the variance. T hese Factors named as: F1. Non Sensory Functions F2. Sensory Functions and Limitation F3. Psychosocial and Restriction. F4. Family Relationship (Third Party Disability) The rotated structure showed that Factor 1 3 and 4 were highly correlated ( r = 0. 43 r = 0.43 ) respectively Factor 2 and 3 were fairly correlated ( r = 0.2 6). Further details of the loadings of items on factors communalities, percent of variance per factor after rotation, and correlation matrix are presented in Table 3 12

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62 Table 3 12 Pattern (unique contribution of a variable to a factor), structure (where shared variance not ignored), communalities ( loadings of items on factors) (h2), and percent of variance using the maximum likelihood method ICF model with the 15 ou tcome measures Items Rotated pattern matrix F1 F2 F3 F4 Rotated structure matrix F1 F2 F3 F4 h 2 Memory (DSB L) .081 .76 .03 .04 .07 75 .14 .14 57 Memory (DSB V ) .044 .84 .02 .00 .12 83 .21 14 69 Global Cognitive (MoCA) .1 2 .43 .10 .09 .30 50 .3 0 .26 30 Hearing Function (BKB SIN) .51 .07 .02 .32 .65 .10 40 55 52 Tinnitus (TFI) 31 .04 .05 08 .30 .02 15 .0 6 09 Vestibular (DHI) 45 .05 .14 14 45 .04 30 09 23 Depression (GDS) 26 .0 2 .47 .12 42 .17 .5 5 .16 35 Attention (BTA) .02 .05 .04 .97 .44 .26 .4 0 99 99 SSQ Social Isolation (LSIS DJG) .94 .07 .10 .03 .11 .92 .05 .01 .88 .32 .24 .20 .30 .88 33 .30 80 .78 Family Relationship (RAS) F amily Support (LSNS 12) .08 .06 .05 .03 .30 .53 30 .11 .09 .21 .08 .18 .21 .54 .13 .30 10 .30 HAs Use 41 .0 7 07 .22 46 .02 .16 .36 25 Background noise ( ANL ) .22 .0 2 .03 01 20 .01 .05 .08 .04 Vision (Distance) .02 .10 .043 .1 2 05 .1 1 .03 15 .03 Total Variance explained = 40 8 % Percent of variance 23.3 % 12.10 % 9.6 % 7.9 % Correlations Matrix 1.00 0.20 0. 43 0.43 0.20 1.00 0.2 6 0. 20 0.43 0.2 6 1.00 0.35 0 .43 0. 20 0.35 1.00 Kaiser Meyer Olkin of sampling adequacy = 70 P < 0.0 1 F 1. Sensory Functions and Limitation F2. Non Sensory Functions F3. Psychosocial and Restriction F4. Family Relationship (Third Party Disability)

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63 Confirmatory F actor A nalysis for the S tandardized O utcome M easures In this analysis the CFA using the I BM SPSS AMOS was applied to evaluate the adequacy of the proposed model of the objective and subjective outcome measures as a supplemental procedure to validate the ICF Brief Core Set for HL T he C FA for the four factor solution was examined using the SPS S to obtain a rough estimate of the factor st ructure of the outcome measures. The outcome measures included in each factor were: Factor 1: DSB V, DSB L, and MoCA This factor named as: Non Sensory Functions Factor 2: Visual acuity (distance), BBK SIN, TFI DHI, SSQ, ANL, BTA, and HATs use This factor named as Sensory Function s and Limitation Factor 3: LSNS 12, LSIS DJG, G D S This factor named as Psychosocial and Restriction Factor 4: RAS. This factor named as Family Relationships ( Third Party Disabilit y ) The CFA using the IBM SPSS AMOS and the Maximum likelihood estimates method was performed. The CFA confirmed the four factor solution across the 131 participants. The GOF statistics of the CFA model indicated a marginal support [ X 2 (85) = 120.775 P = 0. 007 ; TLI = .88; CFI = .90; RMSEA = .05 7 Pclose =0. 300 ; AIC = 208.133; BIC = 314.515]. However, Bollen Stine bootstrap was done to test the null hypothesis that the model is correct. Bollen Stine bootstrap supported the fit of the model ( P = 0.0 54 ). The removal of the visual acuity test had not support the model fit. The normality assumption of the univariate distributions showed a reasonable range of skewness and kurtosis and an acceptable joint multivariate value ( 1. 41 ; c.r. 0.36 0 ). All the outcome mea sures were significantly related to the proposed latent variable except for the distance visual acuity test. To improve model, the modification indices were used T wo high correlations of error terms were identified within Factor 2 (DHI, SSQ, and ANL) and between Factor 2 and 3 (DHI

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64 and LSID DJG) By correlating the error term between the DHI, SSQ, and ANL outcome measures, within Factor 2, the model was significantly improved. The GOF statistics for the improved model was [ X 2 (83) = 103.207 P = .066 ; TLI = .93; CFI = .94; RMSEA = .0 43 Pclose = 0. 644 ]. This Model is presented in Figure 3 3 Additional details about the standardized and unstandardized regression weight, standard error, covariance, and correlation estimates for the CFA Model are presented in Table 3 13

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65 Figure 3 3 The CFA model of outcome measures representing the 4 factors solution Circles represent latent variables Rectangles represent measured variables Represent the error/ uniquenesses, Arrows represents variance from observed to latent variables Correlation arrows represent correlation between factors or between error/ uniquenesses and decimal numbers represent correlation estimate

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66 Table 3 13 The standardized and unstandardized regression weight, standard error, covariance, a nd correlation estimates for the CFA Model Regression Weights Estimates Outcome measures (Indicators) B SE P Value DHI < --F2_Sensory SSQ < --F2_Sensory BTA < --F2_Sensory DeJong Total < --F3_Psychosocial GDS < --F3_Psychosocial LSNS_12 < -F3_Psychosocial DSB_L < --F1_Cognitive DSB_V < --F1_Cognitive BKB_SIN < --F2_Sensory HAs U se < --F2_Sensory MoCA < --F1_Cognitive ANL < --F2_Sensory TFI < --F2_Sensory Vision Far < --F2_Sensory .325 1.304 .770 1.000 .253 2.243 1.000 1.014 1.000 .286 .837 1.076 .267 .013 .308 .648 .650 .806 .596 .567 .788 .788 .818 .507 .512 .214 .263 .056 .105 .200 .117 .050 .434 .167 .057 .168 .489 .100 .024 P = .002 P < .001 P < .001 P = .0 01 P = .001 P < .001 P = .008 P = .027 P < .001 P =.571 F1. Non Sensory Functions or Cognitive Functions F 2. Sensory Function s and L imitation F 3. Psychosocial and R estriction F 4. Family Relationship ( Third Party Disability )

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67 S tructure E quation M odeling (SEM) for the Self Reported ICF Brief Core Set Scale for HL A SEM with Maximum Likelihood method was applied to evaluate if social isolation can be predicted from the Self Reported ICF Brief Core Set Scale for HL according to the a priori model, which was presented in Figure 1 3 The model includes 18 ICF items: Body Functions: T emperament Attention, Memory, Seeing, Hearing, Vestibular, and Tinnitus. Activity Limitations: Listening, Communication, Conversation, Using com munication techniques, handling stress, Family relationship, and Community life. Moderator/Mediation: Emotion Function Environmental Factors: HAs Use, Background Noise, and Family Support Social Isolation: two subscales of LSIS DJG The GOF statistics were ( X 2 ( 161 ) = 347.130 P = 0.000 ; TLI = 78 ; CFI = 8 1 ; RMSEA=0. 0 91 Pclose = 0. 000 ) To improve the model: Temperament was excluded from the model. Correlations between covariates were added. The modification improves the model. The GOF statistics ( X 2 (140) = 208.493 P = 0.0 00 ; TLI = .90; CFI = .92; RMSEA=0.0 61 Pclose = 0. 143 ). However, Bollen Stine bootstrap was done to test the null hypothesis that the model is correct. Bollen Stine bootstrap supported the fit of the model ( P = 0. 203 ). The GOF stati stics using the Generalized Least Square ( X 2 (140) = 134.494 P < 0.01; TLI = 1.12 ; CFI = 1.00; RMSEA=0.000 Pclose = 0. 995 ). The SEM model with listing of standardized coefficient () is presented in Figure 3 4 Direct Effect Background noise item associ ated with a significant negative effect on body functions ( = 70 P < 0.001) and a positive effect on activity limitations ( = .18, P = 0.0 33 ) Body Functions associated with a significant positive effect on activity limitations ( = 1.1 P < 0.001) and with negative effect on social isolation ( = .45 P = 0.001). Emotion function item associated with a significant positive effect on social isolation ( = .49 P < 0.001). F urther de tails are presented in Table 3 14

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68 Figure 3 4. The SEM model o f predicting social isolation from Self Reported ICF Brief Core Set Scale for HL; The standardized coefficient () on the direct arrows between model members and the R 2 (on the top of each variable or factor) across the 131participants

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69 Table 3 14 The un standardized regression and standardized weight, standard error estimates for the SEM Model of predicting social isolation from Self Reported ICF Brief Core Set Scale for HL Regression Weights Estimates Outcome measures (Indicators) B SE P Value Body Functions < --HA Use Body Functions < --Family Support Body Functions < --Background Noise Activity Limitation < --HA Use Activity Limitation < --Family Support Activity Limitation < --Background Noise Activity Limitation < --Bod y Functions Emotional < --Body Functions Emotional < --Activity Limitation Social Isolation < --Body Functions Social Isolation < --Activity Limitation Social Isolation < --Emotional DeJong Loneliness < --Social Isolation DeJong Social < --So cial Isolation Family Relationship < --Activity Limitation Community Life < --Activity Limitation Communication Techniques < --Activity Limitation Memory < --Body Functions Seeing < --Body Functions Hearing < --Body Functions Vestibular < --Bo dy Functions Tinnitus < --Body Functions Attention < --Body Functions Communication < --Activity Limitation Conversation < --Activity Limitation Handling Stress < --Activity Limitation Listening < --Activity Limitation .002 .004 .310 .000 .043 .134 1.882 .893 1.208 1.289 1.000 .658 1.000 .623 .382 .472 1.063 1.103 .906 1.937 .788 1.038 1.000 .905 1.000 .650 1.104 .005 .016 .707 .000 .097 .182 1.124 .416 .943 .455 .591 .498 .752 .467 .48 3 .486 .641 .617 .538 .821 .487 .366 .550 .824 .789 .578 .794 .029 .022 .053 .034 .027 .063 .310 1.080 .652 .403 .159 .191 .070 .085 .139 .165 .179 .294 .168 .278 .088 .096 .112 .950 .845 *** .993 .108 .033 *** .408 .064 .001 *** .001 *** *** *** *** *** *** *** *** *** *** *** *** P < .001

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70 Structure E quation M odeling (SEM) for the S tandardized O utcome M easures with Depression A SEM with Maximum Likelihood method w as applied to evaluate if social isolation can be predicted from the standardized outcome measures according to the a priori model, which was presented in Figure 1 3 The model includes 1 5 outcome measures. Body Functions: Attention (BTA), Memory (DSB V, D SB L), Seeing (Snellen for distance), Hearing (BKB SIN), Vestibular, (DHI) and Tinnitus (TFI). Activity Limitations: SSQ for (Listening, Communication, Conversation, Using communication techniques, and handling stress), and Family relationship. Moderato r/Mediation: Emotion Function (GDS) Environmental Factors: HAs Use, Background Noise (ANL), and Family Support (LSNS 12). Personal Factors: Severity of HL (PTA) Social Isolation: two subscales of the LSIS DJG After modifying the model based on modificatio n indices, t he GOF statistics were ( X 2 ( 9 0 ) = 126.203 P = 0.0 5 ; TLI = 90 ; CFI = 9 2 ; RMSEA=0. 0 5 6 Pclose = 0. 30 9 ) However, Bollen Stine bootstrap was done to test the null hypothesis that the model is correct. Bollen Stine bootstrap supported the fit of the model ( P = 0. 06 8 ). The SEM model with listing of standardized coefficient () is presented in Figure 3 5 Direct Effect Severity of HL associated with a significant negative effect on body functions ( = 75 P < 0.001) and with a significant negat ive effect on activity limitations ( = .40, P = 0.00 3 ) Social support associated with a significant positive effect on body functions ( = .30 P < 0.00 1) and with a significant negative effect on activity limitations ( = 20 P = 0.00 7 ) Body Functio ns associated with a significant positive effect on activity limitations ( = 73 P < 0.001) negative effect on depression ( = 1. 1 P < 0.001 ), and negative effect on social isolation ( = 1.9, P < 0.001 ). A ctivity limitations associated with a signi ficant positive effect on depression ( = .72 P = 0.0 1 2 ). Depression associated with a significant positive effect on social isolation ( = 38 2 P < 0.001). F urther de tails are presented in Table 3 15

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71 Figure 3 5. The SEM model of predicting social i solation from standardized outcome measures; the standardized coefficient () on the direct arrows between model members and the R 2 (on the top of each variable or factor) across the 131participants

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72 Table 3 15 The unstandardized regression and standardiz ed weight, standard error estimates for the SEM Model of predicting social isolation from the standardized outcome measures with D epression (GDS) Regression Weights Estimates Outcome measures (Indicators) B SE P Value Body Functions < --L SNS_12 Body Functions < --PTA Both Body Functions < --ANL Body Functions < --HAs Use Activity Limitation < --LSNS_12 Activity Limitation < --ANL Activity Limitation < --body Functions Activity Limitation < --HAs Use Activity Limitation < --PTA Both GDS < --Body Functions GDS < --Activity Limitation Social Isolation < --Body Functions Social Isolation < --Activity Limitation Social Isolation < --GDS DSB_L < --Body Functions DSB_V < --Body Functions DeJo ng Loneliness < --Social Isolation DeJong Social < --Social Isolation Relationship < --Activity Limitation SSQ < --Activity Limitation BTA < --Body Functions BKB_SIN < --Body Functions TFI < --Body Functions DHI < --Body Functions Vision Far < --Body Functions .021 .028 .009 .029 .023 .006 1.327 .067 .027 1.700 .606 2.445 1.000 .317 .411 .633 1.000 1.181 .048 1.000 1.000 1.259 .394 .521 .021 .302 .748 .061 .021 .184 .020 .726 .027 .388 1.108 .721 1.949 1. 456 .388 .125 .190 .477 .544 .011 .677 .646 .788 .297 .379 .067 .005 .004 .010 .118 .009 .015 .331 .171 .009 .505 .242 .381 .119 .312 .322 .254 .390 .174 .128 .134 .030 *** *** .371 .809 .007 .707 ** .695 .003 *** .012 *** .007 .188 .050 *** .901 *** .002 *** .477 *** P < .001

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73 Structure Equation Modeling (SEM) for the S tandardized O utcome M easures with Cognitive D ecline A SEM with Maximum Likelihood method was appl ied to evaluate if social isolation can be predicted from the standardized outcome measures according to the a priori model, which was presented in Figure 1 3 The model includes 15 outcome measures. Body Functions: Attention (BTA), Memory (DSB V, DSB L), Seeing (Snellen for distance), Hearing (BKB SIN), Vestibular, (DHI) and Tinnitus (TFI). Activity Limitations: SSQ for (Listening, Communication, Conversation, Using communication techniques, and handling stress), and Family relationship. Moderator/Media tion: Cognitive Function (MoCA) Environmental Factors: HAs Use, Background Noise (ANL), and Family Support (LSNS 12). Personal Factors: Severity of HL (PTA) Social Isolation: two subscales of the LSIS DJG The GOF statistics were ( X 2 (88) = 140.462, P = 0. 000 ; TLI = .85 ; CFI = .90 ; RMSEA = 0. 068 Pclose = 0. 086) The SEM model with listing of standardized coefficient () is presented in Figure 3 6. Direct Effect Severity of HL associated with a significant negative effect on body functions ( = 75, P < 0.001) and with a significant negative effect on activity limitations ( = .40, P = 0.00 3 ) Social support associated with a significant positive effect on body functions ( = .30 P < 0.00 1) and with a significant negative effect on activity limitations ( = .20 P = 0.00 7 ) Body Functions associated with a significant positive effect on activity limitations ( = 73 P < 0.001) positive effect on cognitive ( = .88 P = 0.00 8 ), and no effect on social isolation ( = 1.9, P > 0.0 5). F urther de t ails are presented in Table 3 16

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74 Figure 3 6. The SEM model of predicting social isolation from standardized outcome measures; the standardized coefficient () on the direct arrows between model members and the R 2 (on the top of each variable or factor) across the 131participants

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75 Table 3 16 The unstandardized regression and standardized weight, standard error estimates for the SEM Model of predicting social isolation from the standardized outcome measures with global cognitive functions (MoCA) Regression Weig hts Estimates Outcome measures (Indicators) B SE P Value Body Functions < --LSNS_12 Body Functions < --PTA Both Body Functions < --ANL Body Functions < --HAs Use Activity Limitation < --LSNS_12 Activity Limitation < --ANL Activ ity Limitation < --Body Functions Activity Limitation < --HAs Use Activity Limitation < --PTA Both MoCA < --Activity Limitation MoCA < --Body Functions Social Isolation < --Body Functions Social Isolation < --Activity Limitation Social Isolat ion < --MoCA DSB_L < --Body Functions DSB_V < --Body Functions DeJong Loneliness < --Social Isolation DeJong Social < --Social Isolation Relationship < --Activity Limitation SSQ < --Activity Limitation BTA < --Body Functions BKB_SIN < --Bo dy Functions TFI < --Body Functions DHI < --Body Functions Vision Far < --Body Functions .022 .029 .008 .047 .022 .004 1.288 .031 .026 .976 3.314 2.328 1.000 .011 .507 .718 1.000 1.791 .045 1.000 1.000 1.226 .360 .488 .023 .303 .752 .051 .034 .172 .013 .713 .013 .375 .426 .800 2.188 1.697 .044 .158 .222 .415 .721 .011 .687 .662 .786 .277 .363 .073 .005 .005 .011 .121 .009 .014 .315 .163 .009 .642 1.255 .361 036 .305 .313 .457 .391 .165 .124 .129 .029 *** *** .450 .701 .011 .804 *** .847 .004 .129 .008 *** .749 .096 .022 *** .908 *** .004 *** .437 *** P < .001

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76 Structure E quation M odeling (SEM) : The integ rated model A SEM with Maximum Likelihood method was applied on the integrated model for social isolation prediction. T his model had three factors named as: Auditory, Memory, and Socio emotional I solation. The SEM model with listing of standardized coeffic ient () is presented in Figure 3 7. Auditory: PTA, BTA, BKN SIN, SSQ, DHI, ANL, and TFI Cognition: DSB V, DSB L, and MoCA Social Isolation: LSIS DJG and GDS Environmental Factors: HAs Use, and Family Support (LSNS 12) A Chi square test of independence su pported the hypothesized model ( X 2 ( 69 ) = 86.730 P = 0.0 73 ). The GOF statistics were ( TLI = .9 5 ; CFI = .9 6 ; RMSEA = 0. 0 44 Pclose = 0. 604 ) Direct effects on social isolation Social support and network size (LSNS 12) was significantly associated with a n egative effect on socioemotional factor ( = 0. 55 P < 0.001). Indirect effects on social isolation HAs use was significantly associated with negative effect on Auditory factor ( = 0. 66 P < 0.001 ). Auditory factor paly an intervening variable betwee n HAs use and Socioemotional Isolation factor. Auditory factor was significantly associated with a negative effect on socioemotional factor ( = 0.24, P = 0.021). Social support and network size (LSNS 12) was significantly associated with a positive eff ect on global cognitive skills (MoCA) ( = 0. 21 P = 0.00 9 ). Global cognitive skills (MoCA) paly an intervening variable between Social support and network size (LSNS 12) and Auditory factor ( = 0.2 5 P = 0.0 07). Also, g lobal cognitive skills (MoCA) paly a n intervening variable between Memory and Auditory factors ( = 0. 47 P < 0.001 ). Further details are presented in Table 3 17

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77 Figure 3 7. The integrated SEM with listing of standardized coefficient () on the direct arrows between model membe rs and the R 2 (on the top of each variable or factor) across the 131participants

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78 Table 3 17 The unstandardized regression and standardized weight, standard error estimates for the integrated SEM Model Regression Weights Estimates Outcome measures (Ind icators) B SE P Value MoCA < --LSNS_12 MoCA < --Cognition /Memory Auditory < --HAs Use Auditory < --Cognition /Memory Auditory < --MoCA Socioemotional Isolation < --Auditory Socioemotional Isolation < --LSNS_12 DeJong Total < --Socioemotio nal Isolation GDS < --Socioemotional Isolation DSB_V < --Cognition /Memory BKB_SIN < --Auditory DSB_L < --Cognition /Memory SSQ < --Auditory ANL < --Auditory DHI < --Auditory PTA Both < --Auditory BTA < --Auditory TFI < --Auditory 060 .780 .712 .047 .014 1.092 .137 1.000 .250 1.000 1.405 1.100 2.125 1.887 .604 30.330 1.000 .506 .205 .466 .663 .249 .045 .240 .546 .806 .589 .752 .701 .839 .643 .227 .347 .921 .520 .302 .023 167 .126 .017 .030 .475 .025 .057 .212 .222 .392 .790 .175 4.819 .166 .009 *** *** .007 .631 .021 *** *** *** *** *** .017 *** *** .002 *** P < .001

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79 CHAPTER4 DISCUSSION Validation In this study, twent y two ICF Brief Core Set categories were validated t h rough a direct method of using a Self Reported ICF Brief Core Set Scale for HL including: All the categories (seven categories) list ed in the body functions domain. E ight of nine categories listed in t he activity limitation and participation restriction domain All the categories listed in the environmental factors. The four categories of the body structure domain and the school education category from the activity limitation and participation restric tion domain were not part of the Self Report ICF Brief Core Set Scale for HL Additionally 1 7 20 categories of the 22 categories were validated and verified through the indirect method using standardized outcome measures Despite the difficulty in align ing the standardized outcome measures wit h ICF Brief Core Set categories, results obviously showed the Self Report I CF Brief Core Set Scale for HL and its related outcome measures. Comparison b etween methods applied to validate ICF Brief Core Set for HL A direct method of using a Self Reported ICF Brief Core Set Scale for HL and an indirect method using standardized outcome measures were used in this study as compared with a researcher/clinician linking methodology used in the pilot studies. All methods showed almost identical pa ttern s of four extracted factors. First, t he Self Reported ICF Brief Core Set Scale for HL in its simple and initial version reveals that memory loss, hearing dysfuncti on, and inability to listen and communicate effectively were the major problems that limit and restrict participation in social interaction s ; w hile attention deficits tempe rament and personality emotional problems and sensation of

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80 tinnitus had a moderat e contribution to restricting social interaction. In regards to environmental fact ors, the majority of the participants reported noisy background as a barrier and the family/social support as a facilitator to social interact ion; while the majority of HA us ers reported HAs use as a facilitator, some reported HAs use as a barrier. T he self reported findings were verified by the significant correlation between the rating of ICF categories and the standardized outcome measures but unexpectedly it highlighted the psychological and physical problems associated with dizziness sensation as measured by DHI. Second the Self Reported ICF Brief Core Set Scale for HL factor analysis replicated the four factor solution functional performance that was found in linking methodology and qualifier coding procedure ( Alfakir, et al., 2015a) T he overall variances explained by the application of the two method s were shown to be almost identical (55%, 60% respectively) ; however there was a slight difference in the variances explained by each factor. In the linking methodology, auditory function was the major f actor that explained variance in performance ( 32.3%) while in the direct method the n on auditory function was the major f actor that e xplained the variances in performance (28.5%) followed by environmental factors (17.4%) Probably and not surprisingly, the deviation in variances was due to the focus on assessing hearing performance apart from other body systems and the surrounding envir onment as highlighted in the introduction and pilot studies whereas in the current study a more general introduction was given Third the overall variances explained by the application of the standardized outcome measures were shown to be lower (<40%) than the two other methods ( Self Reported ICF Brief

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81 procedure ). This indicat es some difficulty in align ing the outcome measures with ICF Brief Core Set categories. Four th, the reliability of the ICF scale in the direct method ( Self Reported ICF Brief Core Set Scale for HL ) was shown to be more robust and strong er compared to the linking and qualifier coding methodology In the linking method, for the items from the body functions and activities and participation scales was .8 8 alpha coefficient for the 2 2 items including the environmental items was 72 In the direct method, the body functions and limitation/restriction 6 items including the environmental items was .83. T his difference could be due to the complexity of the environmental factors scale and/or the d ifficulty that face s researcher s in classifying barrier s versus facilitator s for a patient instead of having the patient identify those by themselves The excellent reliability result s of the ICF scale, which is presented in the current study, is consisten t with a study assessing validity of the ICF scale s across 1,092 patients with 12 other chronic health conditions (Almansa, et al., 2011). Finally, all methods supported the four factor dimension The theme of the four F actor s almost identical, but how in dicators clustered in each F actor slightly differs. For example, the CFA model for the Self Reported ICF Brief Core Set Scale for HL (Figure 3 1) showed that indicators of E nvironmental F actor was fairly correlated with Auditory Factor ( r =.2 ). While in t he CFA model for standardized outcome measure, indictors of E nvironmental Factor were impeded in Auditory and Psychosocial factor leading to a strong relationship between these two factors ( r =. 55 ) as shown in Figure 3 3. This could be explai ned by the fac t that most audiologic

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82 test battery considers background when measuring auditory function and hearing disability but none consider the effect of social structure and family support and other environmental factors. Further reason could be due to difference between scales a s t he ICF scale for environmental factors represents two aspects, facilitator and barrier, which are not common in standardized outcome measures. Another example, the CFA model for the Self Reported ICF Brief Core Set Scale for HL (Figure 3 1) showed that vestibular and seeing items were clustered with non auditory factor that includes cognition, emotional, and other activity limitations such as handling stress and participation in community life; while vestibular and seeing functions were clustered within other auditory indicators. This could be explained by the vague definition of dizziness sensation that may include psychological and physical effect of vestibular and postural deficits. The dimensions of the ICF Brief Core Set for HL (CFA Model s ) already using administrative data have at best a rough idea of how people, individually and collectively, are doing and at worst they are making erroneous as (National Committee on Vit al and Health Statistics, 2001) Interestingly, all methods supported the four dimensions that explain poor social interaction performance in older adults with hearing difficulties. Both CFA models (Figur e 3 1, 3 3) highlighted a need to evaluate the person as a whole and not just the auditory system in order to develop rehabilitation plans. The main recommendation of this study is that four dimensions of ICF Brief Core Set for HL are necessary to be measu red. The advantage of using the Self Reported ICF Brief Core Set Scale for HL has two implications. First, it allows the clinician or researcher to translate functional information into a universal language, no matter, the method used to obtain it. Second, it could be used as an outcome measure to better understand performance or behavior, monitor changes in performance, and integrate into AR plans.

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83 Outcome measures form a central component in AR programs. They are used to indicate the major problems chall enging individuals with HL, contribute to the process of setting goals, and monitoring treatment effectiveness. In audiology clinical setting s the use of multiple outcome measures could be impractical in terms of the assessment time especially in elderly populations in term of reliability For example, t he overestimate might affect the self reported outcome measures of perceived hearing disability ( e.g. Eriksson Mangold & Carlesson, 1991 ). While the underestimate tends to cause delay in their seeking help for a potential disorder until they cannot communicate even in the best listening communication ( e.g. Smith & Kricos, 2003 ). In this study, the high and significant correlation between the Self Reported ICF Brief Core Set for HL and the standardized outcom e measurements indicates that the use of multiple outcome measures is practical in term s of time and reliability This could be done by using the Self Reported ICF Brief Core Set for HL as a screening tool followed by the standardized outcome measures. How ever, further improvement is required for the some items in the current version of the Self Reported ICF Brief Core Set for HL and further studies are needed to explore the best standardized outcome measures that represent the ICF categories. For example, Big Five Personality Inventory (BFPI) found to be not highly correlated with Temperament and Personality category ; this indicating that either single question was not clear or the BFPI was not the best measure. According to the presented CFA models all c ategories and their related outcome measurers were significant indicator s except for the vision in the CFA model for the standardized outcome measures; however, it showed to be an important part of the model due to close relationship with vestibular functi on or dizziness sensation. Probably because, almost the majority of participants had have a corrected vision when they evaluated.

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84 One of the unexpected findings in the CFA model of the standardized outcome measure was the correlation between the dizziness (DHI), listening ability (SSQ), and noise background (ANL). Undoubtedly, e ffective listening tends to be fostered when people demonstrate a relaxed alertness with the body leaning slightly forward, facing the other speaker or communication partner, mainta ining postural balance, and situating themselves at an appropriate distance from speaker. Given the high probability of HL to be associated with dizziness or probability of age related impairment in physical movement, it is not surprisingly that vestibular category was clustered in non auditory functions factor (Figure 3 1) and DHI outcome measure was grouped within sensory factor (Figure 3 3). Vestibular sensation triggered by any action could be taken to improve speech recognition Ross (1992) found that any trivial change in distance can significantly reduce the received level of speech as sound energy spreads and dissipates throughout meeting areas. Modifying situations requires the integration of functional connectivity between auditory vestibular visu al systems and cognitive abilities. When the discrepancy in sensory information processing occurs, the internal representation becomes inaccurate and vague; hence, emotion, such as anxiety and cognitive performance, such as poor attention suggested to be h ighly influenced (Smith, et al., (1997). This findings was reflected on the strong relationship between sensory, cognitive, and socioemotional performances. The role of the auditory visual cognitive in managing challenging situation s was reported in sev eral studies. For example, the integration of auditory visual input with cognitive functions lessened the noise distraction in the elderly as reported by (Kricos & Holmes, 1996; Tye Murray, et al., 2008; Feld & Sommers, 2009). Several studies highlighted t he relationship between vestibular deficits, cognitive decline, and emotion functions. For example, the animal studies significantly showed that rats without vestibular lesions perform better in cognitive tasks

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85 than rats with vestibular lesions (Smith & Zh eng, 2013). Further studies, showed that vestibular information provided by vestibular system in the vistibulo ocular and vestibule spinal reflexes and in the ascending pathways to the limbic system and neocortex is required for an accurate internal repres entation of the relationship between the self and the spatial environment (Angelaki, et al., 2009). This may provide further support of the involvement of Dizziness in limiting effective listening and/or restricting older adults with and without HL to part icipate in social interaction and in community life Tinnitus is often related to hearing loss, but not all, hearing impaired people have tinnitus. It was suggested that for tinnitus to develop, one has to have one of two conditions or both: a HL or a ch ronic neuro psychological overloading (Wagenaar, et al., 2010). Tinnitus is another significant indicator may disrupt speech in noise perception, cognitive, and emotion. This result supported by the recent findings that tinnitus leads to poor speech unders tanding and communicational problems (Miller, 2009; Araujo, et al., 2015). Further studies supported that tinnitus directly impairs cognitive performance, namely working memory and attention (Hallam, et al., 2004; Stevens, et al., 2007) or indirectly alter emotional function (Holmes & Padgham, 2009). Dysfunctional cognitive performance was obvious in the presented data as measured by global cognitive (MoCA), attention (BTA), and working memory (DSB L, DSB V) tests. The CFA model demonstrated the tight relat ion between auditory divided attention and speech in noise perception and the tight relation between working memory via both modalities and cognitive skills. Considering that including attentional and working memory outcome measures could be considered out to be significantly helpful. MoCA was designed to assist in detection of mild cognitive

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86 impairment, which on one hand, may help to explain poor performance of speech in noise percep tion, and on the other hand, may help to plan for further assessments by referrals to other Kraus, 2013) and further supports the preliminary study results (Al fakir, et al, 2015b). The CFA models further highlighted the role of family relationships. Results of the cur rent study high lighted the effect of poor f amily relationship in decreasing participation restriction. O ur results supported a study which found positive marital or family relationships were negatively associated with loneliness ( Hawkley et al., 2008). Further, this result is consistent with our preliminary study (Alfakir, et al, 2015) and with Scarinci et al ., ( 2009 ) model Despite the moderate correlation between the family relationship category and Relationship Assessment Scale (RAS), our results extend the findi ngs of Scarinci and collegues. Both CFA models highlighted that cognitive, sensory and socioemotional performance may contribute to t he direct or indirect effect of family relationship. Also, these findings provide further direction for the appropriate outcome measure to replace the RAS such as Self Assessment of Communication and the Significant Other Assessment of Communication which were developed by Schow and Nerbonne in 1982. Implications In brief, the CFA models speak to the need to address the four dimensions (Sensory, Cognitive, Psychosocial, and Family relationships) provided by the ICF Brief Core Set for HL when developing tre atment plans for patients complaining of listening difficulties, including mild HL. Given the attention to all epidemiologic and longitudinal studies of age related changes in health, a tool like the ICF Core Sets for HL will assist professio nals implemen ting an integrated perspective in hearing health care. The ICF Core Set for HL defines, in theory, all categories that

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87 are relevant to the functioning of patients with HL and consequently what to address and assess among patients with and without HL. It provides a comprehensive, multidimensional perspective. Application of the Core Sets for HL can ensure consistency in terminology across disciplines, improve inter and intra professional communication, and facilitate multidisciplinary responsibility. There fore the ICF Core Set categories can be regarded as a common standard from which different professionals can start their assessments and interventions. The functioning profile of the patient that can be created can be used as a reference for monitoring th e patient during follow up visits. Considering the ICF as a screening outcome measure could be particularly important for establishing baseline information and systematically monitoring of functional performance in older adults with listening difficulties over time The CFA model s reported in this study provide further insight into the course of hearing disability, socio emotional health, and its related environmental factors in a representative cohort of one hundred and thirty one older adults. This sugges t the possibility of social isolation being predicted by the by ICF Brief Core Set using th e standardized outcome measures. More details will be discussed in in the section below.

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88 Application Hearing Disability and Socio Emotional Isolation in an Agi ng Population A barrier to communication is something that keeps meaning from meeting. Meaning barriers exist between all people, making communication much more difficult than most people seem to realize. It is false to assume that if one can tal k he/she can communicate. Because so much of our education misleads people into thinking that communication is easier than it is, they become discouraged and give up when they run into difficulty. Because they do not understand the nature of the problem, t hey do not know what to do. The wonder is not that communicating is as difficult as it is, but tha t it occurs as much as it does. Reuel Howe (1963) The prediction model s (SEM) which are illustrated in Figure 3 4, 3 5, and 3 6 supported the a priori mode l, and clearly highlighted the complexity of what is involved in causing social isolation in older adults with HL and/or listening difficulties. The prediction model ( Figure 3 4 ) which was created from the Self Reported ICF Brief Core Set Scale for HL sh owed to be useful in predicting social isolation. However, further improvement is required for the initial version. This model highlighted the effect of the noisy environment on poor functional performance including daily activity limitations and the moder ator effect of emotion function on social isolation. The prediction model (Figure 3 5 ), which was created from the standardized outcome measures highlighted the mediation effect of depression (GDS) on social isolation. While the prediction model (Figure 3 6 ), which was created from the standardized outcome measures highlighted the mediation effect of cognitive skills (MoCA) on social isolation. Via this information we were able to integrate the a priori model which was presented in Figure 3 7. The integra ted model showed that social isolation in older adults with and without HL could be a maladaptive strategy for dealing with effortful listening or a psychological reaction if it is combined with depression and associated with lack of support from family me mbers and friends. In other words, social isolation could be a meaningf ul psychological reaction when older adults become discouraged and give up when run ning into poor listening conditions that degrade

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89 speech understanding In contrast, social isolation c ould be a psychological disorder when functional connectivity decreases and interacts with environmental f actors and decline in cognitive skills and lower working memory capacity. The integrated model demonstrated that effortful listening is the prod uct of inability to process degraded speech (BKB SIN), which depends critically on the ability to divide attention (BTA), ease of listening (SSQ), physical attending (DHI), presence of tinnitus (TFI), and inability to tolerate background noise (ANL). T his assumption is valid among non HAs users and HAs users who reported that HAs functions (clarity and loudness) were a barrier Results showed that the interaction between poor functional performance and HAs use and few benefits can significantly lead to soci al isolation. The implication of these findings may explain why listening and communication difficulties and social isolation still are the most common complaints among older listeners with both treated and untreated HL (Humes, et al., 2006; Mick, et al., 2014; Dawes, et al., 2015). In contrast the integrated model highlights the dynamic relationship between functioning or effortful listening, working memory capacity (DSB V and DSB L), and global cognitive function (MoCA) and its contribution to turning l imitations into restriction or isolation. Further, it highlights the effect of global cognitive skills on functioning or effortful listening and a need to screen for cognitive decline as recommended by researchers. Our study supports a study found a signif icant correlation between working memory performance and s entence r epetition and p rocessing (Small, et al., 2000). Further, it supports the effect of cognitive decline as a psychological barrier that leads to social isolation ( Havens et al ., 2004) and alig ns with the working group researchers whom outlined the clinical criteria that must be used to differentiate between normal cognition and MCI and between dementia (Albert, et al., 2011). These criteria

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90 are: 1. Concern regarding a change in cognition. 2. Im pairment in one or more cognitive domain. 3. Preservation of independence in functional abilities. 4. No evidence of a significant impairment in social functioning. To conceptualize the overall findings and its relation with socioemotional isolation firs t we need to understand the nature of effortful listening and its relationship to mental illness. Although depression and loneliness are aversive behavior s or uncomfortable states ; they are in many way s opposites. Loneliness in its positive nature is a war ning to initiate change in an uncomfortable condition. On the other hand, d epression makes individuals apathetic (Cacioppo & Patrick, 2008) In other words, while loneliness urges individuals to move forward to adjust for communication breakdown, depressio n holds individuals back. But when both converge it can lead to passive coping. However, this does not always lead to effective action and it may instead lead to learned helplessness. Within the struggle to self regulate, according to Cacioppo & Patrick, loneliness and depression are at their core a closely linked push and pull. This facilitates a simple, two part decision approach or withdraw repeated endlessly as the individual confront s every stimulus. Approach or withdraw are the two common and sh ared behaviors in normal listeners and HL listeners that may r ise in noisy environments. Several studies conceptualized loneliness as perceived social isolation and refer to the negative emotions resulting from a discrepancy between individuals nd present quality and/or quantity of social relationships ( Cacioppo & Patrick 2008 ). In our preliminary studies we found that even with HL and perceived handicap individuals with HL can still strive to maintain the normal social interaction by using adap tive or maladaptive compensatory strategies (Alfakir & Holmes, in progress). Negative emotional reaction s such as feel ing lonely or depressed are maladaptive strategies reported by older adults with HL. Thus, it was suggested that the effect of

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91 maladaptiv e strategies may strongly contribute to social isolation more than the effect of the HL itself. Yet, reasons beyond this maladaptive reaction were not clear. A possible explanation for this reaction in older adults with HL, according to our model ning difficulties in older adults can induce stress, leading their subconscious in a fight or flight mode. The presence of depression may make fearful or anxious thoughts become louder (push and pull assumption). T he presence of dizziness and in ability to change body position may make them feel either threatened or unsafe in some way. At this time, performance of cognitive functions, family relationship /support and availability of environmental resources may enhance or reduce socio For example, the HAs use offers an opportunity to enhance audibility, while the appearance of dizziness demands caution and fear of falling or unsteadiness whereas presence of tinnitus demands caution of speech perception clarity. With HL and dizziness ta sks or tinnitus ignorance, mental attending and effective listening become more challenging and may be independent from working memory. The suggested mechanism to explain this relationship is that as the auditory system is important for auditory localiza tion, the vestibular system is essential for path navigation; and both play an important role in directing attention toward different sources. This information is used to make decision, compute and action plan, and finally execute a movement. With probabil ity of the sensory losses to be associated with cognitive decline and negatively interaction with surrounding environments, this does not allow one to stop and think or to collect iencies in the way the brain coordinates and synchronizes activity amongst different regions may account for the

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92 words, when individuals with HL and vestibular disor ders exhibit reduced functional, the spatial function brain regions could contribute to performance deficits that lead to The integrated model tells us that as the HAs use was obvious on decreasing/increasing effortful listening and enh ancing/reducing participation, the role of family and friends support was more obvious on cognitive and mental health. In part it has strong and direct effects on social isolation or indirect effect s through the moderator/mediation effect of cognition decl ine and depression. These findings are consistent with studies that linked social support with successful ageing For example, perceived social support found to be was a strongly correlated with psychological distress associated with HL (Turner, et al 19 83), with HAs satisfaction and participation in group AR classes (Preminger, 2003), with motivation to help seeking and conversation facilitation (L ockey, et al., 2010), and with later life cognition ( Gow, et al., 2007). H owever, addressing the social sup port and elderly social structure in AR is un common Thus, i n the meantime, it is highly recommended for hearing care providers to assess availability of social support in addition to HAs. In brief, while non HAs use, may turn auditory limitations into restriction, lower social support may turn hearing disability into restriction by mitigating emotional distress, cognitive function, and mental illness. In other words, as HAs facilitates bottom up processing, social support facilitates top down processing Implications The overall models highlighted the difficulties separating changes in sensory inputs and poor cognitive performance from socio emotional disorders. Obviously, defining predictors that may lead to social isolation seems difficult and co mplex Social isolation management requires an integrative approach including the accessibility to the HATs in surrounding environments occupational therapy and application of modern cognitive neuroscience to health related issues.

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93 It is important to hig hlight that treating any disorder should go further and beyond disorder itself. For older adults with hearing difficulties we need to target reduced functional performance in order to enhance social interaction which is the overall goal of AR services. St udy Conclusions A direct method of using a Self Reported ICF Brief Core Set Scale for HL and an indirect method using standardized outcome measures were used in this study as compared with a researcher/clinician linking methodology used in the pilot studie s. All methods were shown to b e useful and ready for use in clinical practice. The Self Reported ICF Brief Core Set Scale for HL combined with Montreal Cognitive assessment are a usefulness screening tools to be used in audiology clinical practice to pred ict whom at risk for social isolation and dementia. Social isolation is the product of several interactions and not a certain consequence of growing older, but it is mitigated by decline in cognitive functions and health disorders. It is not difficult to find evidence in the literature that socio emotional isolation is a risk factor for cognitive decline and Alzheimer but it is difficult to find evidence that shows the reverse direction. As hypothesized social isolation would be a consequen ce rather than cause of cognitive decline and HL Limitations of the study and Future direction This study is unique in its approach and results; however, the study has some limitations. First the Self Report ICF Brief Core Set Scale for HL in it is ini tial version, has shown to be useful and appropriate to be used as a screening tool Yet, some categories [ Temperament and Personality ( b.126 ) and Sensation associated with vestibular function (b.240) were found to be not clear ly defined in its written for m, needing further improvement for the Self Report ICF Brief Core Set Scale for HL

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94 Second, the current version of the ICF Brief Core Set has 27 categories; seven are part of the environmental factors. In this study, we were able to include and study the effect of support from immediate family and friends. Further studies are needed to include the effect family and social attitude and other environmental items. Third, the Self Report ICF Brief Core Set Scale for HL was shown to be useful in validating IC F Brief Core Set. The use of this method is recommended to validate the ICF Comprehensive Core Set in a large sample size. Being able to validate the Comprehensive Core Set for HL is suggested to optimize the Brief Core Set. Fourth the Dizziness Handic ap Inventory questionnaire highlighted a relationship between sensory motor and listening; however, the role of the audio vestibular complex and its contribution to listening difficulties w ere not clear and requires further investigations. Finally, o ur st udy was completed on a sample of nonclinical older adults fairly well educated and of a higher social economic status. Further studies should be done with clinical populations and different age group, communities and cultures

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95 APPEN DIX A ARTICLE 1 1 1 Alfakir, R ., Holmes, A. E ., Noreen, F (2015). Functional performance in older adults with hearing loss: Application of the International Classification of Functioning brief core set for hearing loss: A pilot study. Int J Audiol. 2015 Sep; 54(9):579 86. doi: 10.3109/1499202 7.2015.1023903. Epub 2015 Mar 30.

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96 APPENDIX B ARTICLE 2 2 2 Alfakir, R. Hall, M., Holmes, A. (2015) How can the Success Post Cochlear Implant be Measured or Defined in Older Adults? Implications of the International Classification of Functioning Brief Core Set for Hearing Loss. Int J Phys Med Rehabil 3:302. doi:10.4172/2329 9096.1000302

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97 APPENDIX C ARTICLE 3 3 3 Alfakir R., Holmes, A. E., Kricos, P. B., Gaeta, L., Martin, S. (2015). Evaluation of Speech Perception via the Use of Hearing Loops and Telecoils. Gerontology and Geriatric Medicine January D ecember 2015 1: 2333721415591935, first published on July 8, 2015 doi: 10.1177/2333721415591935

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98 APPENDIX D SAMPLE OF OUTCOME MEASURES Self Reported ICF Brief Core Set for HL Part 1: Body Fun ctions If you think about your body and mind: Extent to which you have problems in the following areas Severity: Restriction: 0 No problem means the person has no problem 0 No restriction able to participate fully 1 Mild problem (25% of the time ) 1 Mild restriction (25% of the time ) 2 Moderate problem (50% of the time) 2 Moderate restriction (50% of the time) 3 Severe problem (more than 50% of the time) 3 Severe restriction (more than 50% of the time) 4 Complete problem (more than 95% of the time) 4 Complete restriction (more than 95% of the time) These questions are based on your normal day to day situations. If you consistently use an assistive device (i.e. hearing aid, contact lenses, and eye glasses) please answer the questions as if you are using the device/s. F unctional problems Severity Restriction Temperament and Personality functi ons Extent to which your personality or mood affects your day to day functioning. Extent to which this problem restricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4 Focus/attention function Extent to which you can concentrate or shift your focus Extent to which this problem restricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4 Memory function Extent to which you can remember things and recall new information Extent to which this problem restricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4

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99 Emotion al function Extent to which you feel unhappy. Extent to which this problem restricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4 Hearing function Ext ent to which you can hear normal conversation with several other persons in noise. Extent to which this problem restricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4 Seeing function Extent to which you can see ordinary newsprint. Extent to which you can recognize a friend on the other side of the street Extent to which this problem restricts you to socialize with your family or friends at home or community li fe 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 S ensation associated with hearing and vestibular I Extent to which you have ringing in your ear s Extent to which this problem restricts you to socialize wi th your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4 Sensation associated with hearing and vestibular II Extent to which dizziness trigger sensation of falling Extent to which this problem res tricts you to socialize with your family or friends at home or community life 0 1 2 3 4 0 1 2 3 4

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100 Part 2: Activities limitations and participation restrictions 2.1. If you think about your daily life activities: Extent to which you have problems in the following areas: Difficulty: Participation Restriction: 0 No problem means the person has no problem 0 No restriction able to participate fully 1 Mild problem ( 25% of the time ) 1 Mild restriction (25% of the time ) 2 Moderate problem (50% of the time) 2 Moderate restriction (50% of the time) 3 Severe problem (more than 50% of the time) 3 Severe rest riction (more than 50% of the time) 4 Complete problem (more than 95% of the time) 4 Complete restriction (more than 95% of the time) These questions are based on your normal day to day situations. If you consistently use an assistive device (i.e. hearing aid, contact lenses, and eye glasses) please answer the questions as if you are using the device/s. difficulties (Activity limitation) Difficulty Particip ation restriction Listening How much difficulty do you have listening to the television radio or movies with other family or friends? Extent to which this difficulty restricts you to socialize with your family or friends at home. Extent to which this difficulty restricts you to socialize with your family or friends by going to movies, restaurants, or church. 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Communication with receiving spoken messag es How much difficulty do you have understanding a statement or question ? Extent to which this difficulty restricts you to socialize face to face with your family or friends at home. Extent to which this difficulty restricts your face to face social life with family or friends (i.e. Go out to me et your friends or new people). 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

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101 Conversation How much difficulty do you have starting, continuing, or ending a conversation, or conversing with several people in a group ? Extent to which t his difficulty restricts you to socialize face to face with your family or friends at home. Extent to which this difficulty restricts your face to face social life with family or friends (i.e. Go out to me et your friends or new people). 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Using communication techniques How much difficulty do you have reading lips, or using commun ication repair strategies (e.g. ? Extent to which this difficulty restricts you to socialize face to face with your family or friends at home. Extent to which this difficulty restricts your face to face social life with fami ly or friends (i.e. Go out to me et your friends or new people). 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Using communication devices How much difficulty do you have with telecommunication, such as calling a friend on the telephone, emailing, texting, or messaging? Extent to which this difficulty restrict s you to social ize by phone with family or friends Extent to which this difficulty restrict you to participate in online support group or online social media. 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Family relationship How much difficulty do you have maintain ing your family relationships ? Extent to which this difficulty restricts you to social ize with your family or friends. Extent to which this difficulty restricts your social life with family or friends (i.e. Go out to 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

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102 me et your friends or new people). Handling stress How much difficulty do you have managing and controlling any stressful situations? Extent to which this difficulty restricts you to socialize with your family or friends at home? Extent to which this difficulty restri cts your social life with family or friends (i.e. Go out to me et your friends or new people). 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Community life How much difficulty do you have volunteering (helping others) in charitable organizations, service clubs, professional organizations, or social organizations? Extent to which this difficulty restrict s your social productivity or belonging ? 0 1 2 3 4 0 1 2 3 4 Rem unerative employment How much difficulty do you have at your paid work place, if any? Extent to which this difficulty rest ricts you to socialize with other co workers at place work or to make social arrangement (i.e. parties)? 0 1 2 3 4 0 1 2 3 4

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103 Part 3: If you think about your environment, where you work and live, indicate to what extent the following factors generally help or hinder your performance in daily life activities an d social event participation? Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives. Qualifier in environment: Barrier Neutral Facilitator 4 3 2 1 0 +1 +2 +3 +4 Environmental factors Barrier (Hinder) Facil itator (Help) Products & technology for communication ( *hearing aids, cochlear implants, and/or assistive listening devices) 1. Use 2. Clarity of sound 3. Loudness *If you do not use any of the devices mentioned, please answer 0. 4 3 2 1 0 +1 +2 +3 +4 4 3 2 1 0 +1 +2 +3 +4 4 3 2 1 0 +1 +2 +3 +4 Sound 1. Loud sounds (Someone talk loudly; Turn the T.V volume control up). 2. Background noise. 4 3 2 1 0 +1 +2 +3 +4 4 3 2 1 0 +1 +2 +3 +4 Support from Immediate family ( i ndividuals related to you by birth, marriage or other relationship s) including: (P resence, physical assistance, household assistance, encouragement and ALL the above listed activities 4 3 2 1 0 +1 +2 +3 +4 S upport fr om health professional s ( Information Counselling ) Appointment 4 3 2 1 0 +1 +2 +3 +4 Attitudes of people ( friends, Neighbors, Service providers culture toward your disability 4 3 2 1 0 +1 +2 +3 +4 A ttitudes of immediate family toward your disability 4 3 2 1 0 +1 +2 +3 +4 Health service system & policies (Preventing and treating your health problems ) 4 3 2 1 0 +1 +2 +3 +4

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104 Brief Test of Attention (BTA) Part 1: Tell me how many numbers are on each list A voice on the tape recorder will read a list of letters and numbers. First, you will keep track only of how many numbers you hear. Then, tell me how many numbers were on the list. Please, while the list is being read, ma ke your hands into fists and put them on the table or somewhere I can see them we will being with two examples to make sure you have sure have an idea. Remember, tell me how may numbers. Part 2: Tell me how many letters on each list A voice on the tape re corder will read a list of letters and numbers. First, you will keep track only of how many letters you hear. Then, tell me how many letters were on the list. Please, while the list is being read, make your hands into fists and put them on the table or som ewhere I can see them we will being with two examples to make sure you have sure have an idea. Remember, tell me how may letters. This is an example of the score sheet Item Correct answer Response Item Score Examples 1. 7 B X Examples 1. F 3 6 Trail 1. 5 K 7 H

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105 Lubben social network scale Revised I. Family: Considering the people to whom you are related by birth, marriage, adoption 1. How many relatives do you see or hear from at least once a month? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 2. Tell me about the relative with whom you have the most contact: How often do you see or hear from the relative with whom you have the most cont act? 0 = less than monthly 1 = monthly 2 = few times a month 3 = weekly 4 = few times a week 5 = daily 3. How many relatives do you feel close to? That is how many of them do you feel at ease with can talk about private matters or can call for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 4. How many relatives do you feel close to such that you could call on them for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 5. When one of your relatives has an important decision to make, how often do they talk to you about it? 0 = never 1 = seldom 2 = sometim es 3 = often 4 = very often 5 = always 6. How often is one of your relatives available for you to talk to when you have an important decision to make? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always

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106 II. Friendships: Considering all of your friends including those who live in your neighborhood 7. How many of your friends do you see or hear from at least once a month? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 8. How often do you see or hear from the friend with whom you have the most contact? 0 = less than monthly 1 = monthly 2 = few times a month 3 = weekly 4 = few times a week 5 = daily 9. How many friends do you feel at ease with that you can talk about private matters? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 10. Ho w many friends do you feel close to such that you could call on them for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 11. When one of your friends has an important decis ion to make, how often do they talk to you about it? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always 12. How often is one of your friends available for you to talk to when you have an im portant decision to make? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always

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107 III. Neighbors: Considering those people who live in your neighborhood... 13. How many of your neighbors do y ou see or hear from at least once a month? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 14. How often do you see or hear from the neighbor with whom you have the most contact ? 0 = less than monthly 1 = monthly 2 = few times a month 3 = weekly 4 = few times a week 5 = dai ly 15. How many neighbors do you feel at ease with that you can talk about private matters? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 16. How many neighbors do you feel close to such that you could call on them for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 17. When one of your neighbors has an important decision to make, how often do they talk to you about it? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always 18. How often is one of your neighbors available for you to talk to when you have an important decision to make? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always

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108 De Jong Gierveld Loneliness Scale Please indicate for each of the statements, the extent to which they apply to your situation, the way you feel now. Please ci rcle the Questions Yes More or Less No 1. There is always someone I can talk t o about my day to day problems 2. I miss having a really close friend 3. I experience a general sense of emptiness 4. There are plenty of people I can rely on when I have problems 5. I miss the pleasure of the company of others 6. I find my circle of friends and acquaintances too limited 7. There are many people I can trust completely 8. There are enough people I feel close to 9. I miss having people around 10. I often feel rejected 11. I can call on my friends whenever I need them

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109 Relatio nship Assessment Scale A 7 item scale designed to measure general relationship satisfaction. Respondents answer each item using a 5 point scale ranging from 1 to 5 1. How well does your partner meet your needs? Poorly Average Extremely well 1 2 3 4 5 2. In general, how satisfied are you with your relationship? Unsatisfied Average Extremely satisfy 1 2 3 4 5 3. How good is your relationship compared to most? Poor Average Excellent 1 2 3 4 5 4. into this relationship? Never Average Very often 1 2 3 4 5 5. To what extent has your relationship met your original expectations? Hardly at all Average Completely 1 2 3 4 5 6. How much do you love your partner? Not much Average Very much 1 2 3 4 5 7. How many problems are there in your relat ionship? Very few Average Very many 1 2 3 4 5

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110 APPENDIX E RAW DATA OF THE OBJECTIVE AND SUBJECTIVE OUTCOME MEASURES ID # Vision PTA RT PTA LT ANL BKB SIN TFI DHI SSQ BTA DSB L DSB V MoC A DGS LSNS 12 RAS LSIS DJG 1 .8 63.75 62.50 12 2.00 .0 18 3.26 12 5 3 23 14 42 35 5 2 1.0 28.75 32.50 0 1.50 .0 10 4.81 19 6 5 24 6 35 32 4 3 .6 41.25 52.50 0 .00 5.2 6 6.48 14 6 4 2 4 0 43 33 4 4 .6 13.75 15.00 0 1.50 .0 0 7.20 18 4 6 28 4 54 35 2 5 .5 67.50 21.20 2 2.00 .0 6 8.57 9 8 6 27 0 34 35 0 6 1.0 18.75 16.25 4 2.25 .0 0 8.04 19 8 9 29 1 41 34 0 7 1.0 45.00 38.75 5 1.00 .8 0 7.24 12 7 7 25 3 44 35 3 8 1.0 15.00 18.75 5 1.75 .0 0 9.69 14 6 4 24 0 42 33 0 9 1.0 55.00 57.50 7 4.50 20.0 0 5.48 13 7 10 28 5 39 35 3 10 .6 35.00 33.75 4 1.75 .8 0 8.75 14 12 13 30 0 34 34 4 11 1.0 28.75 27.50 0 .75 1.6 6 8.24 20 9 6 28 5 26 32 6 12 1.0 73.75 65.00 6 4.50 6.4 50 3.83 7 6 6 21 27 22 31 11 13 1.0 21.25 18.75 2 .75 .0 16 6.48 15 5 6 23 5 43 31 1

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111 14 1.0 27.50 37.50 8 .50 .0 0 5.12 13 5 6 22 4 24 31 3 15 .8 42.50 42.50 4 .75 .0 8 7.09 9 7 5 26 4 24 35 9 16 1.0 35.00 30.00 4 1.00 38.4 26 7.71 15 9 6 29 7 40 34 7 17 1.0 5 6.25 77.50 2 3.50 .0 8 5.91 5 8 5 27 5 45 33 7 18 1.0 21.25 20.00 0 2.75 .0 0 8.32 19 6 6 28 0 37 35 0 19 .8 15.00 23.75 2 1.75 .0 0 9.77 15 6 8 27 0 44 35 0 20 1.0 35.00 30.00 2 3.00 .0 32 9.24 19 11 12 30 0 40 35 1 21 1.0 53.75 21.25 6 1.75 .0 10 6.55 16 7 5 27 5 51 33 7 22 .6 28.75 23.75 4 1.75 18.0 0 8.97 20 6 5 23 6 43 35 2 23 .8 25.00 32.50 4 .50 .0 0 8.16 18 9 8 23 12 31 32 2 24 1.0 28.75 27.50 6 1.25 .0 0 9.28 19 12 12 30 0 51 32 3 25 1.0 12.50 12.50 4 .75 .0 0 6.95 17 8 5 27 18 46 34 6 2 6 1.0 38.75 36.25 8 .75 11.2 6 7.38 15 6 5 24 2 39 25 2 27 .6 28.75 42.50 4 .25 .0 0 6.10 20 8 7 29 2 51 32 0 28 1.0 16.25 17.50 1 1.50 34.0 0 7.20 20 9 6 29 7 44 27 1 29 .5 33.25 22.50 0 1.25 .0 0 7.67 18 7 7 21 2 41 31 2

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112 30 .5 27.50 30.00 9 1.75 2.4 0 6.28 14 6 4 28 11 36 35 1 31 1.0 13.75 21.25 10 .50 14.8 4 7.25 16 6 6 25 13 44 34 1 32 1.0 47.50 56.25 4 1.25 15.2 2 7.02 10 9 8 28 11 33 29 2 33 1.0 15.00 16.25 8 2.00 .0 10 8.91 20 7 6 29 2 48 25 0 34 1.0 46.25 48.75 10 1.50 .0 0 8.36 11 7 7 28 4 41 33 2 35 1.0 25.00 22.50 0 .75 .0 14 9.30 19 8 8 27 0 40 35 3 36 1.0 32.50 22.50 6 .25 1.2 0 8.77 20 8 9 26 3 55 33 0 37 .8 27.50 25.00 8 1.25 12.0 0 7.16 19 6 4 26 2 44 35 1 38 .6 20.00 12.50 4 1.75 12.8 0 9.61 19 6 5 29 0 32 35 2 3 9 1.0 43.75 22.50 8 1.75 .0 0 6.06 18 6 6 23 4 39 28 5 40 1.0 66.25 16.25 4 2.50 42.4 16 4.39 16 7 6 27 10 32 25 5 41 .8 16.25 23.75 6 .00 1.2 0 7.28 12 5 7 27 1 44 31 0 42 .6 21.25 26.25 10 1.75 .0 0 8.36 19 11 8 28 1 40 23 0 43 1.0 18.75 18.75 6 25 .0 24 8.20 18 8 7 28 17 19 35 11 44 1.0 31.25 26.25 6 .00 .0 6 9.04 16 7 7 27 2 37 27 5 45 1.0 47.50 40.00 2 2.25 .0 26 6.78 17 5 6 25 6 36 24 0

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113 46 .8 41.25 10.00 8 .25 5.6 0 8.01 18 9 11 30 4 42 30 3 47 1.0 30.00 32.50 8 .50 .0 10 6.60 15 9 7 25 3 28 34 2 48 .6 43.75 46.25 4 2.50 .0 0 9.40 18 5 6 22 2 43 35 2 49 1.0 40.00 40.00 10 1.25 5.2 0 7.40 20 8 5 30 3 42 35 0 50 1.0 18.75 15.00 6 .75 .0 0 8.47 12 13 10 30 7 36 35 2 51 .8 38.75 45.00 8 2.00 16.0 0 7.12 19 11 11 30 0 38 35 0 52 1.0 35.00 37.50 12 1.25 13.2 0 6.83 18 8 7 30 5 46 33 4 53 1.0 50.00 48.75 4 2.50 28.4 0 8.75 14 10 12 30 5 35 29 7 54 .4 56.25 58.75 2 3.75 27.6 6 4.89 7 10 5 24 13 29 35 9 55 1.0 35.00 32.50 6 .25 .0 6 8.83 17 7 6 27 3 56 35 0 56 1.0 41.25 53.75 10 1.75 .0 0 5.51 11 6 5 24 4 33 31 4 57 .8 40.00 26.25 2 .50 12.8 30 4.46 20 8 8 25 1 37 35 5 58 .6 17.50 27.50 12 .00 6.0 0 9.22 7 7 6 22 13 21 35 9 59 1.0 36.25 40.00 2 .25 .0 8 8.79 17 11 8 28 6 33 30 3 60 .5 7.50 10.00 2 2.50 .0 0 9.49 19 11 8 29 13 42 25 1 61 .8 46.25 41.25 8 1.25 6.8 16 7.02 19 7 9 28 5 44 33 0

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114 62 1.0 68.75 68.75 8 .75 53.6 14 7.68 17 8 8 27 20 28 26 6 63 1.0 51.25 52.50 2 5.50 .0 12 5.16 15 7 6 18 3 38 20 4 64 .4 22.50 13.75 0 .25 .0 14 9.04 18 6 7 30 8 34 35 2 65 1.0 41.25 47.50 10 3.50 .0 0 9.30 4 4 6 21 2 41 35 4 66 .8 15.00 8.75 4 1.00 .0 0 9.34 18 10 8 27 5 30 22 7 67 .8 36.25 31.25 2 1.50 21.2 24 9.55 18 6 7 26 3 54 30 3 68 1.0 26.25 21.25 2 .75 6.4 16 7.28 13 9 8 29 4 46 35 1 69 .8 18.75 18.75 8 1.50 .0 0 9.00 17 8 8 27 0 37 35 1 70 1.0 28.75 30.00 0 .75 .0 20 7.87 18 7 9 23 2 34 21 4 71 .8 33.75 37.50 2 .50 3.6 0 8.72 14 6 7 29 0 40 31 1 72 1.0 15.00 15.00 2 .00 .0 24 7.93 19 14 12 26 3 37 28 6 73 .8 11.25 17.50 4 1.75 .0 6 8.97 14 6 4 26 7 29 21 5 74 .4 5 8.75 56.25 2 3.25 .0 12 7.38 8 9 7 28 4 36 34 1 75 1.0 7.50 10.00 2 .25 .0 0 9.31 19 8 10 26 3 37 21 5 76 1.0 28.75 28.75 4 .00 .0 36 6.97 18 6 6 27 0 50 31 1 77 1.0 28.75 28.75 2 .75 .0 0 6.81 15 7 7 28 5 37 34 3

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115 78 1.0 12.50 18.75 6 1.50 9.6 0 8.8 7 17 9 9 29 3 25 35 3 79 .5 38.75 41.25 12 1.25 .0 0 6.89 10 8 5 26 8 43 27 2 80 .8 7.50 11.25 2 1.50 .0 6 9.29 17 5 6 27 0 29 28 5 81 .6 23.75 42.50 0 2.50 .0 0 7.81 20 9 8 25 3 39 35 0 82 .5 17.50 17.50 0 1.25 .0 0 8.02 17 8 8 22 2 46 35 1 83 .8 16.25 12.50 2 1.50 6.0 0 8.44 19 8 8 26 0 44 35 1 84 .8 15.00 17.50 8 .50 .0 0 9.14 15 5 6 28 1 34 35 3 85 1.0 48.75 47.50 2 5.75 2.4 4 6.36 6 6 4 24 6 9 30 3 86 .6 13.75 13.75 2 1.50 .0 0 6.41 11 5 5 22 0 29 33 2 87 1.0 25.00 30.00 2 1.25 3.6 0 7.10 19 8 6 30 2 37 30 4 88 1.0 13.75 25.00 0 1.50 .0 0 8.36 20 9 6 27 2 46 35 0 89 1.0 30.00 17.50 2 1.00 .0 0 8.08 16 9 8 30 4 41 33 4 90 .8 31.25 42.50 2 1.00 42.8 0 7.93 14 6 8 25 19 22 35 8 91 1.0 22.50 20.00 0 1.00 .0 4 9.04 19 9 6 28 1 47 25 2 92 1.0 47.50 45.00 2 .75 .0 0 7.22 19 6 4 26 2 42 28 1 93 1.0 68.75 28.75 8 .25 51.2 30 5.53 20 9 10 27 2 47 22 0

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116 94 1.0 20.00 30.00 2 .25 .0 4 8.97 16 6 6 23 2 27 35 4 95 1.0 28.75 38.75 12 1.75 27.2 0 5.77 12 4 4 25 10 20 24 6 96 1.0 41.25 3 1.25 2 1.00 7.2 10 6.65 8 6 4 26 3 39 34 5 97 1.0 16.25 5.00 2 1.25 4.8 12 7.48 19 8 12 29 1 50 35 0 98 1.0 8.75 11.25 2 1.50 .0 0 9.24 16 8 8 27 6 36 35 6 99 .8 26.25 22.50 2 .25 18.0 28 5.00 20 7 6 24 12 14 17 1 100 1.0 27.50 25.00 0 .25 .0 6 7 .26 16 8 8 28 5 25 35 1 101 .8 32.50 35.00 2 1.75 5.2 0 9.08 15 5 6 29 1 40 32 2 102 .5 67.50 17.50 0 1.50 .0 32 4.12 13 10 6 28 4 31 35 5 103 .8 25.00 62.50 2 .25 .0 0 8.95 12 6 7 29 0 36 30 2 104 .5 35.00 33.75 0 .50 .0 58 7.63 18 5 5 26 23 47 35 7 105 1.0 47.50 58.75 0 6.50 4.4 4 5.44 9 8 8 28 4 42 26 5 106 .8 18.75 28.75 4 2.25 .0 0 8.04 18 11 6 25 0 31 35 1 107 .8 42.50 50.00 2 .25 51.6 8 7.02 12 8 6 25 2 26 33 2 108 .5 31.25 35.00 4 .75 12.0 6 6.12 16 10 7 27 10 13 24 8 109 .8 28.75 45 .00 2 .25 19.2 0 8.37 8 8 6 29 3 34 35 1

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117 110 .8 35.00 37.50 2 .25 58.8 0 7.24 17 4 3 27 4 34 23 5 111 1.0 10.00 38.75 2 1.75 .0 20 7.20 20 7 5 30 7 49 35 0 112 .5 17.50 30.00 2 1.25 6.8 4 7.40 14 6 6 25 1 35 23 3 113 1.0 17.50 40.00 0 1.25 .8 20 7.89 19 12 8 28 0 39 33 0 114 .5 27.50 33.75 4 2.50 15.2 0 7.57 18 9 8 25 1 50 22 0 115 .6 50.00 38.75 0 2.50 .0 0 6.36 19 12 11 28 9 39 34 1 116 1.0 8.75 10.00 12 1.75 .0 0 8.26 20 7 9 28 12 42 34 7 117 .8 28.75 33.75 6 2.50 17.2 10 6.10 10 11 11 2 9 5 49 30 2 118 1.0 12.50 12.50 2 2.25 .0 0 8.67 19 4 7 25 20 38 35 4 119 1.0 38.75 55.00 2 1.75 10.0 6 6.79 11 8 6 28 0 42 31 1 120 .6 11.25 8.75 2 .75 .0 6 7.67 15 6 5 27 3 41 23 9 121 1.0 93.75 88.75 10 17.25 .0 26 4.34 7 9 11 27 4 45 35 1 122 1.0 21.00 30.00 2 .25 .0 12 4.39 9 7 6 24 9 28 33 6 123 .6 75.00 76.25 12 23.50 16.8 10 1.14 4 8 8 24 11 37 28 5 124 .8 23.75 18.75 2 2.25 2.8 8 9.59 19 5 7 24 9 19 20 10 125 .5 32.50 30.00 4 2.75 .0 0 6.12 13 6 7 27 20 33 25 3

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118 126 .5 52.50 53.75 2 4.75 27.6 62 2.93 9 5 8 29 6 26 31 5 127 .8 33.75 38.75 0 .50 .0 8 9.61 12 7 7 30 9 36 24 4 128 .4 47.50 43.75 3 6.00 .0 10 5.43 2 6 4 20 10 30 35 8 129 .8 120.00 81.25 5 21.00 34.8 30 5.03 2 6 6 18 8 32 33 6 130 1.0 22.50 43.75 8 .00 .0 8 6.69 18 9 5 27 1 33 17 10 131 .8 35.00 38.75 2 .50 56.8 14 6.24 18 5 5 27 2 40 19 5

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119 LIST OF REFERENCES AARP (2012). Loneliness among Older Adults: A National Survey of Adults 45+. AARP. Abrams, H. B, Chisolm, T. H. (2013). Will My Patient Benefit from Audiologic Re habilitation? The Role of Individual Differences in Outcomes. Semin Hear 2013; 34(02): 128 140. DOI: 10.1055/s 0033 1341349. Albert M S DeKosky S T, Dickson D Dubois B Feldman H H et al. (2011). The diagnosis of mild cognitive impairm ent du e to Alzheimer's disease: recommendations from the National Institute on Aging Alzheimer's Association workgroups on diagnostic guid elines for Alzheimer's disease. Alzheimers Dement 7: 270 279. Alfakir, R., Holmes, A. E., Noreen, F. (2015a). Functional per formance in older adults with hearing loss: Application of the International Classification of Functioning brief core set for hearing loss: A pilot study. Int J Audiol 2015 Sep; 54(9):579 86. doi: 10.3109/14992027.2015.1023903. Epub 2015 Mar 30. Alfakir, R., Hall, M., Holmes, A. (2015b) How can the Success Post Cochlear Implant be Measured or Defined in Older Adults? Implications of the International Classification of Functioning Brief Core Set for Hearing Loss. Int J Phys Med Rehabil 3:302. doi:10.4172/23 29 9096.1000302 Alfakir, R., Holmes, A. E., Kricos, P. B., Gaeta, L., Martin, S. (2015). Evaluation of Speech Perception via the Use of Hearing Loops and Telecoils. Gerontology and Geriatric Medicine January December 2015 1: 2333721415591935, first publish ed on July 8, 2015 doi: 10.1177/2333721415591935 Alfakir, R., Holmes, A. E. (2016). Beyond Hearing Loss And Perceived Handicap, Contextual Factors Contribute To Turning Disability Into A Handicap? A Qualitative Data Analysis (In progress). Almansa J ., Ay uso Ferrer M. (2011). The International Classification of Functioning, Disability and Health: development of capacity and performance scales. J Clin Epidemiol. 2011 Dec; 64(12):1400 11 doi: 10.1016/j.jclinepi.2011.03.005. Epub 2011 Jun 12. Anderson, S. (2013). The auditory cognitive system: To screen or not to screen Hearing J ournal 66(7): 36. Anderson, S., White Schwoch, T., Parbery Clark, A., Kraus, N. (2013). A dynamic auditory cognitive system supports speech in noise perception in older adults. Hearing Research 300: 18 32. Angelaki, D. E., Klier, E. M., Snyder, L. H. (20 09). A vestibular sensation: probabilistic approaches to spatial perception Neuron 64 448 461 10.1016/j.neuron.2009.11.010

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120 Araujo, Tiago de Melo, & Irio, Maria Ceclia Martinelli. (2015). Effect of sound amplification in speech perception in elderly wit h and without tinnitus. CoDAS, 27(4), 319 325. https://dx.doi.org/10.1590/2317 1782/20152015032 Atchley, R. C. (1989). "A continuity theory of normal aging". The Gerontologist 29 (2): 183 190. doi:10.1093/geront/29.2.183. PMID 2519525 Baltes, P.B., & Lind enberger, U. (1997). Emergence of a powerful connection between sensory and cognitive functions across the adult life span: A new window to the study of cognitive aging? Psychology and Aging, 12, 12 21. Bench, J., Kowal, A., Bamford, J. (1979). The BKB (B ench Kowal Bamford) sentence lists for partially hearing children. British Journal of Audiology 13: 108 112. Berg, A. I., Johansson, B. (2014). Personality Change in the Oldest Old: Is It a Matter of Compromised Health and Functioning? Journal of Personal ity 82: 25 31. doi: 10.1111/jopy.12030. Biordi, D. L., Nicholson, N. R. (2009). Social isolation. Chronic Illness: Impact and Interventions. 7th ed. Sudbury, MA: Jones and Bartlett Publishers, 85 116. Cacioppo, J. T., Berntson, G. G, Sheridan, J. F, McCl intock, M. K.(2000) Multi level integrative analyses of human behavior: Social neuroscience and the complementing nature of social and biological approaches. Psychological Bulletin 2000; 126 :829 843. Cacioppo, J. T., Cacioppo, S. (2014). Social Relationshi ps and Health: The Toxic Effects of Perceived Social Isolation. Social and Personality Psychology Compass, 8(2), 58 72. doi:10.1111/spc3.12087 Berntson, G. G. (2000). Lonely traits and concomitant physiological processes: The MacArthur Social Neuroscience Studies. International Journal of Psychophysiology, 35, 143 154. Cacioppo J. T ., Patrick W. (2008). Loneliness: Human Nature and the Need for Social Connection. W. W. Norton & Company, Inc., 500 Fifth Avenue, NewYork, N.Y. 10110. (Pages 83 86). Carver, C. S., & Scheier, M. F. (2001). Optimism, pessimism, and self regulation. In E. C. Chang (Ed.), Optimism and pessimism: Implications for theory, research, and pract ice (pp. 31 51). Washington, DC: American Psychological Association. Centers for Disease Control and Prevention, National Association of Chronic Disease Directors. (2008). The State of Mental Health and Aging in America Issue Brief 1: What Do the Data T ell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.

PAGE 121

121 Christensen, L. A. (2000). Signal to noise ratio loss and directional microphone hearing aids. Seminars in Hearing 21, 179 200. Cieza, A., Gey, S., Chatterji, S., Kostanjsek N., Ustn, B., Stucki, G. (2005). ICF linking rules: an update based on lessons learned. J Rehabil Med 37, 212 218. Coenen, M. (2008). Developing a method to validate the WHO ICF core sets from the patient perspective: Rheumatoid arthritis as a case in p oint: A Dissertation. http://edoc.ub.uni muenchen.de/8038/1/Coenen_Michaela.pdf Cumming, E., Henry, W.E. (1961). Growing Old. New York: Basic. p. 227. Danermark, B. (2005). A revie w of the psychosocial effects of hearing impairment in the working age population. In: Stephens D, Jones L, editors. The Impact of Genetic Hearing Impairment. London: Whurr Publishers; 2005. pp. 107 36 Danermark, B., Cieza, A., Gang, J.P., Gimigliano, F. (2010). International classification of functioning, disability, and health core sets for hearing loss: A discussion paper and invitation. Int J Audiol 49, 256 262 Danermark, B ., Granberg, S ., Kramer, S. E ., Selb, M ., Mller, C ( 2013). The creation of a Comprehensive and a Brief Core Set for Hearing Loss using the International Classification of Functioning, Disability and Health (ICF). Am J Audiol 2013 Oct 4. Dawes, P., Emsley, R., Cruickshanks, K. J., Moore, D. R., Fortnum, H., Edmondson Jones, M., McCormack, A., Munro, K. J. (2015). Hearing Loss and Cogni tion: The Role of Hearing Aids, Social Isolation and Depression. PLoS ONE 10(3), e0119616. http://doi.org/10.1371/journal.pone.0119616 De Jong Gierveld, J., Kamphuis, F. H. (1985).The development of a Rasch type loneliness scale. Applied Psychological Mea surement Q, 289 299 Eriksson Mangold, M., Carlsson, S. G. (1991). Psychological and somatic distress in relation to perceived hearing disability, hearing handicap, and hearing measurements. Journal of Psychosomatic Research 35 (6):729 40. Feld, J. E., Somm ers, M. S. (2009). Lipreading, Processing Speed, and Working Memory in Younger and Older Adults Journal of Speech, Language, and Hearing Research : JSLHR, 52(6), 1555 1565. doi:10.1044/1092 4388(2009/08 0137). Finken, D. (2015). The Relationship Between So cial Intelligence and Hearing Loss. A doctoral thesis at Walden University. http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=1882&context=dissertati ons

PAGE 122

122 Franklin C., Johnson L.V., White L., Franklin C., Smith Olinde L. (2013). The relationship b etween personality type and acceptable noise levels: A pilot study. Otolaryngol 902532 doi: 10.1155/2013/902532 Gatehouse S, Noble W. (2004). The Speech, Spatial and Qualities of Hearing scale (SSQ). Int J Audiol 2004; 43:85 99 Goldberg, L. R. (1993) The structure of phenotypic personality traits. American Psychologist Vol 48(1), Jan 1993, 26 34. http://dx.doi.org/10.1037/0003 066X.48.1.26 Gomez, R. G., Madey, S. F. (2001). Coping with hearing loss model for older adults. J Gerontol B Psychol Sci S oc Sci 2001 Jul; 56(4):P223 5. Gopinath, B., Hickson, L., Schneider, J., Mcmahon, C. M., Burlutsky, G., Leeder, S. R., Mitchell, P. (2012). Hearing impaired adults are at increased risk of experiencing emotional distress and social engagement restrictions five years later. Age and Ageing 41(5):618 623. Gow A J Pattie A Whiteman M C Whalley L J Deary I J. (2007). Social support and successful aging. Journal of Individu al Differences. 2007;28:103 115 Granberg, S., Mller, K., Skagerstrand, A ., Mller, C., Danermark, B. (2014). The ICF Core Sets for hearing loss: researcher perspective, Part II: Linking outcome measures to the International Classification of Functioning, Disability and Health (ICF). Int J Audiol. 2014 Feb; 53(2):77 87. doi: 10 .3109/14992027.2013.858279. Hallam RS, McKenna L, Shurlock L. (2004). Tinnitus impairs cognitive efficiency. Int J Audiol. 2004 Apr;43(4):218 26. Havens B Hall M Sylvestre G Jivan T (2 004). Social isolation and loneliness: differences between o lder ru ral and urban Manitobans. Can J Aging 23: 129 140. Havighurst, R. J. (1961). "Successful aging". The Gerontologist 1: 8 13. doi:10.1093/geront/1.1.8 Hawkley L C Hughes M E Waite L J, Masi C M Thisted R A, Cacioppo J T. (2008). Fr om social structural factors to perceptions of relationship quality and loneliness: The chicago health, aging, and social relations study. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. 2008; 63:S375 S384. Hendrick, S. S (1988). A generic measure of relationship satisfaction. Journal of Marriage and the Family 50, 93 98. Hess T M Blanchard Fields F (1999) Social Cognition and Aging.

PAGE 123

123 Hickson, L., Scarinci, N. (2007). Older adults with acquired hearing impairment: applying the ICF in rehabilitation. Semin Speech Lang 2007 Nov; 28(4):283 90. 2937. Howar th, A., & Shone, G. R. (2006). Ageing and the auditory system. Postgraduate Medical Journal 82(965), 166 171. http://doi.org/10.1136/pgmj.2005.039388 Humes, L. E. (2001). Issues in evaluating the effectiveness of hearing aids in the elderly: What to measu re and when. Seminars in Hearing 22, 303 314. Humes, L E. (2007). Hearing aid outcome measures in older adults. In C. A. Palmer & R. C. Seewald (Eds.), Hearing care for adults 2006 (pp. 265 276) Stafa, Switzerland: Phonak AG Humes, L. E., Christopherson L.A., Cokely, C. G. (1992). Central auditory processing disorders in the elderly: Fact or fiction? In J. Katz, N. Stecker, & D. Henderson (Eds.), Central Auditory Processing: A Transdisciplinary View (pp. 141 149). Humes, L E., Dubno, J R., Gordon Sala nt, S., Lister, J J., Cacace, A T., Cruickshanks, K J., Gates, G A., Wilson, R H., Wingfield, A. (2012). Centeral presbycusis: a review and evaluation of the evidence. Journal of the American Academy of Audiology 23(8), 635 666 Humes, L. E., Lee, J. H., Coughlin, M. P. (2006). Auditory measures of selective and divided attention in young and older adults using single talker competition. J Acoust Soc Am 2006 Nov; 120(5 Pt 1):2926 37. Humes, LE, Coughlin M, Talley LL. (1996). Evaluation of the use of a new compact disc for auditory perceptual assessment in the elderly. Journal of the American Academy of Audiology 7, 419 427. Jacobson, G. P., Newman, C. W. (1990).The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg 1990 Apr; 116(4):424 7. Jerger J., Mahurint R., Pirozzolot F. ( 1990). The Separability of Central Auditory and Cognitive Deficits: Implications for the Elderly. J Am Acad Audiol 1 :116 119 (1990) Jerger, J., Jerger, S., Pirozzolo, F. (1991). Correlational ana lysis of speech audiometric scores, hearing loss, age, and cognitive abilities in the elderly. Ear and Hearing 12, 103 109 Kiely, K. M., Gopinath, B., Mitchell, P., Luszcz, M., Anstey, K. J. (2012). Cognitive, health, and sociodemographic predictors of lo ngitudinal decline in hearing acuity among older adults. J Gerontol A Biol Sci Med Sci 2012 Sep; 67(9):997 1003. doi: 10.1093/gerona/gls066. Epub 2012 Mar 13.

PAGE 124

124 Kricos, P. (2006). Audiologic management of older adults with hearing loss and compromised cogni tive/psychoacoustic auditory processing capabilities. Trends in Amplification 10(1), 1 28. Kricos, P. B., Holmes, A. E. (1996). Efficacy of audiologic rehabilitation for older adults. Journal of the American academy of audiology 7, 219 229. Lin, F. R ., Ferrucci, L ., Metter, E. J ., An, Y ., Zonderman, A. B ., Resnick, S. M (2011). Hearing l oss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology 2011 Nov; 25(6):763 70. doi: 10.1037/a0024238. Lin, J. S., O'Connor, E., Rossom, R. C., Perdu e, L. A., Burda, B. U., Thompson, M., Ecksrtom, E. (2013). Screening for Cognitive Impairment in Older MAdults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Nov. Lindenberger, U., & Baltes, P. B. (1994). Sensory functioning and intelligence in old age: A strong connection. Psychology and Aging, 9, 339 355. Lubben, J., Gironda, M. (2004). Measuring social networks and assessing their benefits. In C. Phillips on, G. Allan & D. Morgan (Eds.). Social networks and social exclusion: Sociological and policy perspectives England: Ashgate Publishing Limited. Luchetti, M., Terracciano, A., Stephan, Y., Sutin A. R. (2015). Personality and Cognitive Decline in Older A dults: Data From a Longitudinal Sample and Meta Analysis. J Gerontol B Psychol Sci Soc Sci 2015 Jan 12. pii: gbu184. McGuire, L. C., Strine, T. W., Okoro, C. A., Ahluwalia, I. B., Ford, E. S.(2007). Modifiable characteristics of a healthy lifestyle in U. S. older adults with or without frequent mental distress: 2003 Behavioral Risk Factor Surveillance System. The American Journal of Geriatric Psychiatry 2007; 15(9):754 761. Meikle, M. B., Henry, J. A., Griest, S. E., Stewart, B. J., Abrams, H. B., McArdle R., clinical measure for chronic, intrusive tinnitus. Ear Hear. 2012 Mar Apr; 33(2):153 76. doi: 10.1097/AUD.0b013e31822f67c0 Mick P Kawachi I Lin F R (2014). The Association between Hearing Loss and Social Isolation in Older Adults. Otolaryngol Head Neck Surg. 2014 Mar; 150(3):378 84. doi: 10.1177/0194599813518021. Epub 2014 Jan 2. Miller ET. (2009). Reversing patient inactivity and isolation. Rehabil Nurs 2 009 Sep Oct; 34(5):178, 208.

PAGE 125

125 Mishra, S., Stenfelt, S., Lunner, T., Rnnberg, J., & Rudner, M. (2014). Cognitive spare capacity in older adults with hearing loss. Frontiers in Aging Neuroscience 6, 96. http://doi.org/10.3389/fnagi.2014.00096 Muccia, S., Ge oczea, L., Abranchesa, D., et al., (2014).Systematic review of evidence on the association between personality and tinnitus. Brazilian Journal of Otorhinolaryngology Volume 80, Issue 5, September October 2014, Pages 441 447 Nabelek, A. K., Tucker, F. M., & Letowski, T. R. (1991). Toleration of background noises: Relationship with patterns of hearing aid use by elderly persons. Journal of Speech and Hearing Research, 34, 679 685. Nasreddine, Z. S., Phillips, N. A., Bdirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005 Apr; 53(4):695 9. Nicholson, N. (2009). Social isolation in older adults: An evolut ionary concept analysis. Journal of Advanced Nursing, 65 1342 1352. doi:10.1111/j.1365 2648.2008.04959.x. Noe, M. C, Davidson, A. S, Mishler, P. J. (1997).The use of Large Group Assistive Listening Devices with and Without Hearing Aids in an Adult Classro om Setting. American Journal of Audiology November 1997, Vol. 6, 48 63. doi:10.1044/1059 0889.0603.48. Pichora Fuller, M. K. (20 0 3). Cognitive aging and auditory information processing. Int J Audiol. 2003 Jul; 42 Suppl 2:2S26 32. Pichora Fuller, M.K., Sin gh, G. (2006). Effects of age on auditory and cognitive processing: Implications for hearing aid fitting and audiologic rehabilitation. Trends in Amplification 10(1) 29 59 Preminger, J. E. (2003). Should significant others be encouraged to join adult group audiologic rehabilitation classes? Journal of the American Academy of Audiology, 14 545 555. Pronk, M., Deeg, D. J., Smits S., Twisk J.W., Tilburg T.G., Festen J.M., Kramer, S. E. (2014). Hearing Loss in Older Persons: Does the Rate of Decline Affe ct Psychosocial Health? Journal of Aging and Health 2014, Vol. 26(5) 703 723. DOI: 10.1177/0898264314529329. (2013). The Ease of Language Understanding (ELU) mod el: theoretical, empirical, and clinical advances. Frontiers in Systems Neuroscience 7 31. http://doi.org/10.3389/fnsys.2013.00031

PAGE 126

126 Ross, M. (1992). Room acoustics and speech perception. In M. Ross (Ed.), FM auditory training systems (pp. 21 43).Timonium, MD: York Press. Rudner, M., Rnnberg, J., Lunner, T. (2011). Working memory supports listening in noise for persons with hearing impairment. Journal of the American Academy of Audiology 22(3), p. 156 167. Saito, H., Nishiwaki, Y., Michikawa, T., Kikuchi, Y., Mizutari, K., Takebayashi, T., Ogawa, K. (2010). Hearing handicap predicts the development of depressive symptoms after 3 years in older community dwelling Japanese. Journal of the American Geriatrics Society 58, 93 97. Scarinci, N., Worrall, L., Hic kson, L. (2009). The ICF and third party disability: its application to spouses of older people with hearing impairment. Disabil Rehabil 2009;31(25):2088 100. doi: 10.3109/09638280902927028. Schow, R. Nerbonne, M. (1982). Communication screening profile: Use with elderly clients. Ear and Hearing, 3, 135 147. Schretlena, D., Bobholzb, H. J., Brandta, J. (1996). Development and psychometric properties of the brief test of attention. The Clinical Neuropsychologist 10: 80 89. DOI: 10.1080/13854049608406666 Selb, M., Escorpizo, R., Kostanjsek, N., Stucki, G., stn, B., Cieza, A. (2014). A guide on how to develop an International Classification of Functioning, Disability and Health Core Set. Eur J Phys Rehabil Med 2015 Feb ; 51(1):105 17. Epub 2014 Apr 1. Shu cknect, H.F. (1964). Further observations on the pathology of presbycusis. Archives of Otolaryngology 80, 369 382. Small J A Kemper S Lyons K. (2000). Sentence repetition and processing resources in Alzheimer's disease. Brain Lang 2000 Nov;7 5(2): 232 58. Smith P.F., Zheng Y. (2013). From ear to uncertainty: vestibular contributions to cognitive function. Integrative neuroscience doi: 10.3389/fnint.2013.00084. Smith P. F. (1997). Vestibular hippocampal interactions. Hippocampus 7, 465 471 10.1002 /(SICI)1098 1063(199 7)7:5<465::AID HIPO3>3.0.CO;2 G. Smith, S., Kricos, P.B. (2003). Acknowledgement of hearing loss by older adults. Journal of the Academy of Rehabilitation Audiology 36, 19 28. Smith, T. F., Hirdes, J. P. (2009). Predicting social isol ation among geriatric psychiatry patients. International Psychogeriatrics, 21 50 59. doi:10.1017/S1041610208007850.

PAGE 127

127 Sommers, M. S., Hale, S., Myerson, J., Rose, N., Tye Murray, N., & Spehar, B. (2011). Listening comprehension across the adult lifespan. Ea r and Hearing 32(6), 775 781. http://doi.org/10.1097/AUD.0b013e3182234cf6 Staab, J. P., Rohe, D. E.,, Eggers, S. D., Shepard, N. T. (2013). Anxious, introverted personality traits in patients wi th chronic subjective dizziness. J Psychosom Res 2014 Jan;76(1):80 3. doi: 10.1016/j.jpsychores.2013.11.008. Epub 2013 Nov 16. Stephens, D., Gianopoulos, I., Kerr, P. (2001). Determination and classification of the problems experienced by hearing impaired elderly people. Audiology. (2001) Nov Dec; 40(6):294 300. Stevens C Walker G Boyer M Gallagher M. (2007). Severe tinnitus and its effect on selective and divided attention. Int J Audiol 2007 May;46(5):208 16. Timmer, B. H., Hickson, L., Launer, S. (2015). Adults with mild hearing impairment: Are we meeting the challenge? Int J Audiol 54, 786 785. Turner, R.J., Frankel, B., Levin, D. (1983). Social support: Conceptualization, measurement, and implications for mental health. In J.R. Greenley (Ed. ), Research in Community and Mental Health (pp. 67 111), vol. 3, Greenwich, CT: JAI Press. Tye Murray, N., Sommers, M., Spehar, B., Myerson, J., Hale, S., & Rose, N. S. (2008). Auditory Visual Discourse Comprehension by Older and Young Adults in Favorable and Unfavorable Conditions. International Journal of Audiology 47(Suppl 2), S31 S37. doi:10.1080/14992020802301662. Wagenaar O, Wieringa M, Verschuure H. (2010). A cognitive model of tinnitus and hyperacusis; a clinical tool for patient information, appea sement and assessment. Int Tinnitus J 2010;16(1):66 72. Wechsler, D. (1997). Technical manual for the Wechsler Adult Intelligence and Memory Scale Third Edition. New York: The Psychological Corporation. World Health Organization. (2003).The Social Determi nants of Health: The Solid Facts Second Edition, 2003. World Health Organization. (2010). International Statistical Classification of Diseases Revision 10. (2010) http://www.who.int/classifications/icd/en/ World Health Organization.(1980). International Cl assification of Impairments, Disabilities and Handicaps. (1980). http://apps.who.int/iris/bitstream/10665/41003/1/9241541261_eng.pdf Health. (2001). http://www.who.int/classifications/icf/en/

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128 Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., Leirer, V. O. (1983). Development and validation of a geriatric depression screening scale: a prel iminary report. J Psychiatr Res 1982 1983; 17(1):37 49

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129 BIOGRAPHICAL SKETCH Dr. Al Fakir has more than 15 years of clinical experience in Clinical Otolaryngology and Audiologic Rehabilitation. She received her Ph .D. from the Universi ty of Florida in the spring of 2016 Her research is geared toward exploring predictors of hearing disability from two aspects including activity limitation (e.g. listening) and social participation restriction (e.g. social isolation) by using the Intenti onal Classification of Functioning, Disability, and Health Brief Core Set for Hearing Loss in Elderly. Findings will make a potential contribution in audiologic rehab ilitation programs for elderly. Dr. Al Fakir received two awards for her Outstanding Achie vement in Academic, University and Community Service from the International Center UF Alec Courtelis Award in 2014 and the Graduate Students Council Award in 2015. She also, received the Virginia Association of Aging Award for this study in 2016. Dr. Al F akir was highly involved in teaching, mentoring and community education She developed the Listening and the Social Interaction Program for older adults using the approach of Cognitive Behavioral Therapy. Also, s he p ublished three papers in reput abl e journa ls and t he fourth paper is in progress.