20Q: Hearing Loss and Listening-related Fatigue

From the Desk of Gus Mueller

I’m betting that at one time or another, many of you, when watching a movie on TV, became frustrated when you couldn’t follow the dialog—usually due to foreign/regional accents, or unusually loud background music. In fact, the listening demands often make it difficult to follow the story—cognitive overload maybe. And what did you do? Turn on closed captioning, right? Did you know that a recent survey found that ~70% of Gen Z respondents stated that they use this feature “often.” Millennials were at around 53%. And we assume that nearly all of these respondents had normal hearing. Do they know something that older folks don’t?

It's well known that individuals with hearing loss have to exert greater listening effort, which often involves higher levels of mental processing and cognitive resources. Listening effort often leads to listening-related mental fatigue. Your Monday Morning hearing aid patient is going to tell you all about the problems he is having understanding in background noise, and hearing the voices of his young grandchildren.  But will he talk about fatigue? Will you ask him? How often will “reduce listening effort and fatigue” be an item on the COSI?

Back in 2013 there was an article published in Ear and Hearing titled: The effects of hearing aid use on listening effort and mental fatigue associated with sustained speech processing demands. It was written by Benjamin Hornsby, PhD, from Vanderbilt. So, what has Dr. Hornsby been up to the past 13 years? You guessed it, he and his Vandy colleagues have been busy conducting additional research related to listening-related fatigue for both adults and children, and have developed several clinically-friendly self-assessment scales to address this issue. He is here this month to tell us all about it.

Ben Hornsby, PhD, is an Associate Professor in the Department of Hearing and Speech Sciences at the Vanderbilt Bill Wilkerson Center, Vanderbilt University School of Medicine—a member of the Vandy faculty as teacher-scholar-researcher for the past ~25 years. Dr. Hornsby also directs the Hearing and Communication Research Laboratory at Vanderbilt.

Most of you know Dr. Hornsby from his 100 or more presentations and peer-reviewed journal articles, and his presentations at national and international scientific meetings. His research has been funded by private industry and federal agencies, including the National Institutes of Health (NIH) and the Institute of Education Sciences (IES).

Dr. Hornsby holds membership in several professional organizations and has served as a Section Editor, Guest Editor, and reviewer for multiple scholarly journals. He is a Fellow of the American Speech-Language-Hearing Association and the International Collegium of Rehabilitative Audiology (ICRA).

As you’ll notice as you get to the end of Ben’s 20Q, our Mystery Question Woman reached her 20th question before Ben ever had the chance to describe the fatigue scales that he has developed. The good news is that the two of them have agreed to come back to these pages to continue their discussion in a month or two.  Stay tuned.

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Hearing Loss and Listening-related fatigue—Understanding the Problem

Learning Outcomes 

After reading this article, professionals will be able to:

• Describe the differences between mild, transient fatigue and the severe, recurrent listening-related fatigue experienced by individuals with hearing loss.
• Explain the relationship between mental effort, goal achievement, and the development of fatigue as described by Hockey’s motivational control theory.
• Identify the clinical importance of using disease-specific assessment tools, such as the Vanderbilt Fatigue Scales, over generic fatigue measures.

1. I have to admit, when someone comes to see me about problems with their hearing, fatigue isn’t typically the first thing I think of asking about. Doesn’t everyone get fatigued?

Well, you’re probably not alone in your thinking. And yes, depending on how you define it, fatigue is a universal issue. When I give a presentation on this topic, I’ll often start by asking the audience to raise their hand if they’ve ever been fatigued—and, unless they are already asleep, most everyone raises their hand. Fatigue is a ubiquitous experience, but that doesn’t mean it is something that is easily understood. Even though fatigue is something we are all “familiar” with, for over 100 years researchers have had difficulty finding a consensus definition (Ackerman, 2011). This difficulty occurs, in part, because we tend to define fatigue based on our backgrounds and interests.

Benjamin Hornsby, PhD

2. Backgrounds and interests? You’re starting to lose me already.

Well, if you ask most people about their fatigue, they’ll probably talk about their subjective experiences (e.g., feeling tired or exhausted), but not everyone thinks about fatigue this way. For example, a physiologist with an interest in muscle fatigue might measure and define fatigue in terms of metabolic or cellular changes in muscle tissues. Or a neurologist or psychologist interested in cognitive fatigue associated with multiple sclerosis might measure and define fatigue using performance on cognitive tests (For an overview of fatigue constructs see Hornsby, Naylor, & Bess, 2016). 

3. I see, that makes sense. I’m curious, are there associations between fatigue-related physiological, cognitive, and subjective effects?

Sorry, there isn’t a quick answer to that question! To keep this as a 20Q rather than a book or review article, suffice it to say that the research is mixed. Some studies show associations between measures, but the associations are not universal nor are the measures related in a one-to-one fashion (Hockey, 2013). While the cognitive and physical manifestations of fatigue are clearly important, the subjective experience of fatigue is likely to be most relevant for our clinical patients, so I’m thinking that this is what is of the most interest to you. 

4. Right, let’s focus on subjective fatigue. You already told me that everyone gets fatigued from time to time. If so, why are we even talking about fatigue?

Yes, of course, everyone has felt (or will feel) fatigued at some point. But in healthy populations, most often the fatigue we experience is mild and transient in nature. That is, we put a lot of effort (mental or physical) into something (e.g., yard work, a work project, studying for an exam) and over time, we might start to feel a little fatigued (or fatigued a lot, if we worked really hard). But if we take a break or work on something else for a bit, the fatigue generally resolves and has no lingering after-effects on our quality of life (Hockey, 2013).

5. Understand completely. But that really doesn’t sound like a big deal, and as I asked before, if this happens to everybody, why do we care? 

You’re right, that kind of mild and transient fatigue is common, and normal, but it’s not the kind of fatigue I’m talking about— and this gets to your question—"Why do we care?”. For some people, their fatigue can be much more severe, recurrent, and it can develop in response to situations that don’t usually lead to fatigue in a typical healthy population. For example, some people with hearing loss can become severely fatigued just from trying to listen and understand someone. When fatigue develops in response to listening demands, it is often referred to as “listening fatigue” or “listening-related fatigue” (e.g., McGarrigle et al., 2014). Such severe and recurrent fatigue can have significant negative effects on quality of life. Fatigue of this magnitude is very uncommon in healthy populations but is a primary complaint for many individuals with chronic health conditions- such as cancer, multiple sclerosis, and hearing loss (Hornsby, Naylor & Bess, 2016). 

6. Severe fatigue that occurs frequently. OK, that does sound like a real problem. What sort of negative effects are you talking about?

To be clear, fatigue effects are diffuse, diverse, and are expressed differently across individuals. That is, some people are affected a lot while others are not affected at all. For those who are impacted, fatigue can have physical, cognitive, social, and emotional manifestations. For example, related to cognitive effects, in a fatigued state, we are more likely to be easily distracted, have difficulty maintaining attention on a task, and our ability to process information quickly may be degraded. Together, these issues can impair decision-making. As a result, working adults with severe fatigue tend to be less productive and more prone to accidents than non-fatigued peers (Ricci et al. 2007). Older adults are also negatively affected. Compared to non-fatigued peers, older adults experiencing high levels of fatigue tend to be less active physically and socially, more likely to be depressed, and less able to manage their own self-care (Amato et al., 2001; Johnson, 2005; Eddy & Cruz, 2007).

7. Ok, that definitely sounds like something to avoid! What causes some people to develop such severe fatigue, but not others? 

Well, fatigue is a complex construct, and many factors can influence fatigue development and its magnitude. However, one factor that almost universally plays a role is how much effort is applied towards a task. Clearly, you are less likely to develop fatigue if you aren’t applying effort towards something! But as you might expect, the relationship between effort and fatigue isn’t that simple. For example, we can apply a lot of effort towards something and do so for a long period of time, without developing fatigue. Think of the video-gamer who is totally engrossed in a complex game for multiple hours but feels excited, not fatigued, when they win their game. Or the marathon runner who crosses the finish line, setting a personal best record; despite the hours of effort they just put into the race, they may be excited and energized at the end (although fatigue may set in later). 

8. So, fatigue isn’t just a result of applying effort? 

No, it’s not. As I said above, lots of factors play a role in whether fatigue will develop and, if so, its magnitude. One general model of fatigue, that’s relevant for people with hearing loss, suggests feelings of fatigue are influenced not only by the effort being applied towards some goal/task (e.g., goal of understanding someone in a conversation), but by the reward obtained if we achieve (or don’t) the desired goal/task (Hockey, 2013). Hockey’s model argues that we are continuously, and unconsciously, allocating a certain amount of effort towards a goal (e.g., reading a book, making dinner, understanding a conversation). At the same time, we are monitoring the relationship between how much effort we are applying and the expected reward we’ll get for achieving that goal (i.e., the effort/reward relationship). The amount of effort we allocate will depend on how hard it is to achieve the goal (e.g., run a marathon vs. walk the dog around the block; or, listen to a commercial on TV in a quiet room vs. understand your doctor explain a medical diagnosis over a bad telephone connection). If we are putting a lot of effort towards some goal we don’t (or can’t) achieve, Hockey’s model suggests that fatigue will develop. In a sense, fatigue serves as a mechanism our body uses to make sure we aren’t applying high levels of effort towards tasks that don’t provide much reward. That is, when you are starting to feel fatigue, your body is giving you a “wake-up call”. The feelings of discomfort are designed to make you think about the effort you’re exerting; and make sure that any potential reward you might get will be worth that effort. If you continue to apply high levels of effort without getting adequate reward (e.g., the marathon runner trying hard to catch the person in front of them but are unable to do so) fatigue is likely to continue to increase—and become increasingly uncomfortable—until at some point you reduce or stop applying effort towards that task and shift to something else (e.g., slow down).

9. But what makes you think this is a problem for people with hearing loss?

Good question! Although systematic research in this area is limited, anecdotal reports and qualitative research have long suggested that fatigue is a significant issue for some people with hearing loss. If we think about this in terms of Hockey’s model, hearing loss can cause people to struggle to hear and understand family and friends. As a result, compared to normal hearing peers, they may need to allocate higher levels of mental effort (e.g., attention, cognitive resources) towards listening/communication tasks. 

10. But I’m thinking that for many patients, more effort might not solve the problem?

Exactly, and unfortunately many people with hearing loss continue to struggle despite applying high levels of effort towards listening. Let’s think about this in terms of Hockey’s model. A person with hearing loss has to apply high levels of effort when trying to hear and understand their family/friends in a noisy setting towards (i.e., an important/rewarding task). However, despite their efforts, they are unsuccessful (i.e., the person with hearing loss continues to struggle to communicate). Hockey’s model suggests this combination would increase the risk for developing high levels of fatigue (see Figure 1; note the red arrow). So, qualitative reports of high levels of fatigue for some people with hearing loss makes sense. 

Figure 1. A block diagram, based on Hockey’s (2013) motivation control theory of fatigue, highlighting conditions which may increase or minimize the development and magnitude of listening-related fatigue in a communication setting. Adapted from Davis et al., 2021. 

11. Okay, all that makes sense, but is this really something that many people with hearing loss complain about? 

Well, like you said at the start, fatigue may not be the first topic that patients bring up with you, but if you ask them about fatigue associated with listening challenges, you’ll find that it is a significant problem for a substantial portion of them (e.g., Davis et al., 2021; HLAA, 2021; Hughes et al., 2018). 

For example, in a survey of adults with hearing loss, over 60% of respondents reported fatigue was a hearing loss-related health concern that they have, or had, experienced. In fact, a third (33%) of the respondents said hearing loss-related fatigue was one of their top 3 most troublesome issues (HLAA, 2021). 

12. Wow. Top three? I wouldn’t have guessed it would be that important.

For some people, it absolutely can be very important. Here are a few quotes I pulled from various sources that highlight this issue: 

“I go to bed most nights with nothing left. It takes so much energy to participate in conversations all day that I’m often asleep within minutes.”

-adult with longstanding hearing loss (Portis, 2008). 

“…a consistent problem [for me]… is listening fatigue and just always being really, really tired… fatigue affects my work, it affects my relationships. It affects basically everything I do in my life.” 

-adult with late-onset hearing loss (HLAA, 2021).

So, some people with hearing loss tell us directly that listening-related fatigue is a significant issue that negatively affects their quality of life. And, the evidence that fatigue can be a big problem for people with hearing loss isn’t just anecdotal. There’s a growing body of empirical research that supports what people with hearing loss have been telling us for a long time. 

13. What does the research tell us about fatigue associated with hearing loss? 

As I mentioned earlier, research in this area is limited (but growing), and the results vary somewhat depending on which fatigue measure was used in the study, but the general conclusion is that fatigue in people with hearing loss is similar to, or more commonly, greater than the fatigue experienced by age-matched peers without hearing loss. For example, we published a study back in 2016 that was the first to use standardized fatigue measures to assess fatigue in adults with hearing difficulties (Hornsby and Kipp, 2016). One of the measures we used was the fatigue and vigor subscales from the Profile of Mood States (POMS; McNair, Lorr, and Droppleman, 1971).

14. Before you go on, I’ve never heard of the POMS.  

That’s not surprising—most audiologists haven’t. The POMS is a reliable and valid measure that has been used extensively to assess multiple moods, including fatigue and vigor deficits, in a wide range of populations. However, it hasn’t been used much in people with hearing loss and was not developed to specifically assess fatigue associated with listening difficulties. 

We typically use subjective measures/scales to quantify the magnitude or frequency of an individual’s fatigue-related complaints. “Generic” scales (like the POMS) are useful for assessing fatigue across a wide range of populations (e.g., healthy athletes, general population, those with various chronic diseases). However, “disease-specific” measures are generally more sensitive for assessing fatigue associated with a specific health condition (e.g., cancer-related fatigue). However, until recently, there were no disease-specific measures for assessing fatigue associated with listening difficulties. Most work in this area has used “generic” scales or “disease-specific” measures that were not developed to target listening-related fatigue.

15. Got it. Let’s get back to your findings.

We compared our POMS results to an age-matched normative sample. As expected, we found that adults with hearing problems reported significantly less vigor (lower vigor scores reflect more problems), but surprisingly, we found no difference in mean fatigue ratings between the groups. Given anecdotal reports suggesting hearing problems can lead to significant fatigue, we weren’t sure what to make of this null finding. 

16. So how did you handle that?

We did a follow-up analysis looking at the prevalence of “severe” fatigue and vigor deficits in our sample. “Severe” problems were defined as scores that exceeded the 1.5 standard deviation cut points based on normative means. The results were compelling. Compared to normative data, adults with hearing difficulties were more than twice as likely to report severe fatigue and more than four times as likely to report severe vigor deficits (Figure 2). This finding was consistent with the anecdotal reports I mentioned above.

Figure 2. Percentage of adults with hearing problems who experience “severe” fatigue or vigor deficits compared to POMS normative data. Severe = scores that are 1.5 standard deviations above (fatigue) or below (vigor) POMS normative mean values (from Hornsby & Kipp, 2016).

17. Have other studies supported these findings?

Yes, additional results from our group, and other researchers, were consistent with these initial findings (e.g., Alhanbali et al., 2017; Jiang et al., 2023; Hornsby et al., 2023). For example, using a different fatigue measure (Fatigue Assessment Scale; Michielsen et al., 2003 and Alhanbali et al., 2017) found mean fatigue ratings of adult hearing aid users, adult cochlear implant users, and adults with single-sided deafness were all significantly greater than fatigue ratings of an age-matched control group with normal hearing.

18. OK. You’ve convinced me—it sounds like fatigue can be a significant problem for at least some people with hearing loss. So, . . . what do we do about it?

Great question! That leads me to a primary point: Given that some people with hearing loss experience fatigue that is so significant it negatively affects their quality of life, I believe we should 1) identify these individuals 2) once identified, we should suggest evidence-based interventions to help reduce their fatigue-related issues, and 3) use reliable and validated measures to assess the effectiveness of the interventions.

19. I’m game, let’s start with your first point. You mentioned the POMS and FAS earlier. Are these the measures you suggest using to identify people with significant problems?

The POMS and the FAS are reliable and valid fatigue measures, and they have been used with a wide range of populations, including people with hearing loss. However, neither instrument is “disease-specific”. That is, neither was developed specifically to assess fatigue associated with listening difficulties. Research suggests that disease-specific instruments tend to be more sensitive to, and provide the most precise estimate of, the construct being measured (Ware et al., 2016)—i.e., listening-related fatigue in our case. This was a primary reason for the development of the Vanderbilt Fatigue Scales (VFS; Hornsby et al., 2021, 2022, 2023). The VFSs were the first tools specifically developed to measure listening-related fatigue.

20. So tell me a little bit about the scale.

Well, it’s not one scale. There are five versions of the VFS: two versions for use with adults (VFS-A) and three versions for use with children (VFS-Peds).  But guess what... that was your 20th question, and I have a lot to tell you about these scales. Let's plan on meeting again in a month or two!

References

Ackerman, P. L. (2011). 100 years without resting. In P. L. Ackerman (Ed.), Cognitive fatigue: Multidisciplinary perspectives on current research and future applications (pp. 11–37). American Psychological Association.

Alhanbali, S., Dawes, P., Lloyd, S., & Munro, K. J. (2017). Self-reported listening-related effort and fatigue in hearing-impaired adults. Ear and Hearing, 38(1), e39–e48.

Amato, M. P., Ponziani, G., & Rossi, F. (2001). Quality of life in multiple sclerosis: The impact of depression, fatigue and disability. Multiple Sclerosis Journal, 7(5), 340–344.

Davis, H., Schlundt, D., Bonnet, K., Camarata, S., Bess, F. H., & Hornsby, B. W. (2021). Understanding listening-related fatigue: Perspectives of adults with hearing loss. International Journal of Audiology, 60(6), 458–468.

Eddy, L., & Cruz, M. (2007). The relationship between fatigue and quality of life in children with chronic health problems: A systematic review. Journal for Specialists in Pediatric Nursing, 12(2), 105–114.

Hearing Loss Association of America. (2021). Voice of the patient report: HLAA’s externally led patient-focused drug development (PFDD) meeting for people and families living with sensorineural hearing loss.

Hockey, G. R. (2013). A motivational control theory of fatigue. In G. R. Hockey (Ed.), The psychology of fatigue: Work, effort and control (pp. 132–154). Cambridge University Press.

Hornsby, B. W., Camarata, S., Cho, S. J., Davis, H., McGarrigle, R., & Bess, F. H. (2021). Development and validation of the Vanderbilt Fatigue Scale for Adults (VFS-A). Psychological Assessment, 33(8), 777–788.

Hornsby, B. W., Camarata, S., Cho, S. J., Davis, H., McGarrigle, R., & Bess, F. H. (2022). Development and evaluation of pediatric versions of the Vanderbilt Fatigue Scale for children with hearing loss. Journal of Speech, Language, and Hearing Research, 65(6), 2343–2363.

Hornsby, B. W., Camarata, S., Cho, S. J., Davis, H., McGarrigle, R., & Bess, F. H. (2023). Development and validation of a brief version of the Vanderbilt Fatigue Scale for Adults: The VFS-A-10. Ear and Hearing, 44(5), 1251–1261.

Hornsby, B. W., & Kipp, A. M. (2016). Subjective ratings of fatigue and vigor in adults with hearing loss are driven by perceived hearing difficulties not degree of hearing loss. Ear and Hearing, 37(1), e1–e10.

Hornsby, B. W., Naylor, G., & Bess, F. H. (2016). A taxonomy of fatigue concepts and their relation to hearing loss. Ear and Hearing, 37, 136S–144S.

Hughes, S. E., Hutchings, H. A., Rapport, F. L., McMahon, C. M., & Boisvert, I. (2018). Social connectedness and perceived listening effort in adult cochlear implant users: A grounded theory to establish content validity for a new patient-reported outcome measure. Ear and Hearing, 39(5), 922–934.

Jiang, K., Spira, A. P., Lin, F. R., Deal, J. A., & Reed, N. S. (2023). Hearing loss and fatigue in middle-aged and older adults. JAMA Otolaryngology–Head & Neck Surgery, 149(8), 758–760. https://www.google.com/search?q=https://doi.org/10.1001/jamaoto.2023.1328

Johnson, S. (2005). Depression and fatigue. In J. DeLuca (Ed.), Fatigue as a window to the brain (pp. 157–172). MIT Press.

McGarrigle, R., Munro, K. J., Dawes, P., Stewart, A. J., Moore, D. R., Barry, J. G., & Amitay, S. (2014). Listening effort and fatigue: What exactly are we measuring? A British Society of Audiology cognition in hearing special interest group ‘white paper’. International Journal of Audiology, 53(7), 433–445.

McNair, D., Lorr, M., & Droppleman, L. (1971). Profile of mood states. Educational and Industrial Testing Service.

Michielsen, H. J., De Vries, J., & Van Heck, G. L. (2003). Psychometric qualities of a brief self-rated fatigue measure: The Fatigue Assessment Scale. Journal of Psychosomatic Research, 54(4), 345–352.

Portis, L. D. (2008, June 17). Fatigue, fear and coping! Hearing Elmo. https://hearingelmo.care/2008/06/17/fatigue-fear-and-coping/

Ricci, J. A., Chee, E., Lorandeau, A. L., & Berger, J. (2007). Fatigue in the US workforce: Prevalence and implications for lost productive work time. Journal of Occupational and Environmental Medicine, 49(1), 1–10.

Ware, J. E., Gandek, B., Guyer, R., & Misajon, R. (2016). Standardizing disease-specific quality of life measures across multiple chronic conditions: Development and initial evaluation of the QOL Disease Impact Scale (QDIS®). Health and Quality of Life Outcomes, 14(1), Article 84. https://doi.org/10.1186/s12955-016-0483-x