Columns

report by the President’s Council of Advisors on Science and Technology recommended federal actions to “simultaneously decrease the cost of hearing aids, spur technology innovation and increase consumer choice options.” The Council suggested, for example, that the Food and Drug Administration permit a “basic” hearing aid, for mild to moderate age-related hearing loss, to be sold over the counter… something that every state prohibits.  

In May 2016 the Department of Justice published a Federal Register Notice that it will submit an information collection request to the Office of Management and Budget (OMB) for review and approval. The proposed collection is titled Assessing the Potential Monetized Benefits of Captioning Web Content for Individuals Who are Deaf or Hard of Hearing. The intent is to solicit information from such persons about the perceived monetary value of captioning on Web sites. The Department is not suggesting that disabled people be asked to pay for captioning. It is merely soliciting information about the theoretical monetary value they place on captioning Web Content in order to help the Department quantify the benefits of captioning on Web sites. Written comments and suggestions from the public and affected agencies are encouraged. Comments will be accepted until July 11. 

Might this have something to do with senior citizens, hearing aids, and dementia and Alzheimer’s? You betcha. 

Closed captioning (CC) and subtitling are processes of displaying text on a TV, video screen, or other visual display to provide additional or interpretive information. Both are typically used as a transcription of the audio portion of a program as it occurs (either verbatim or in edited form), sometimes including descriptions of non-speech elements. Other uses have been to provide a textual alternative language translation of a presentation's primary audio language that is usually burned-in (or "open") to the video and unselectable.  

Subtitle is a transcription or translation of the dialogue when sound is available but not understood by the viewer (e.g., dialogue in a foreign language) or when sound is unavailable or not clearly audible (e.g., when audio is muted or the viewer is deaf or hard of hearing).  

The term "closed" (versus "open") indicates that the captions are not visible until activated by the viewer, usually via the remote control or menu option. On the other hand, "open” captions are visible to all viewers. 

Most of the world does not distinguish captions from subtitles. "Subtitles" assume the viewer can hear but cannot understand the language or accent, or the speech is not entirely clear, so they transcribe only dialogue and some on-screen text. "Captions" aim to describe to the deaf and hard of hearing all significant audio content -- spoken dialogue and non-speech information such as the identity of speakers and occasionally, their manner of speaking -- along with any significant music or sound effects using words or symbols.  

Closed captioning was first demonstrated in 1971 at a National Conference on Television for the Hearing Impaired. Regular open captioned broadcasts began on PBS's The French Chef in 1972.  

The National Captioning Institute was created in 1979 in order to get the cooperation of commercial television networks. 

The first use of regularly scheduled closed captioning on American television occurred in 1980. Sears had developed and sold the Telecaption adapter, a decoding unit that could be connected to a standard television set. Among the first programs seen with captioning was Masterpiece Theatre on PBS.  

In 1990, the Americans with Disabilities Act (ADA) ensured equal opportunity for persons with disabilities. The ADA prohibits discrimination against persons with disabilities in public accommodations or commercial facilities. Title III of the ADA requires that public facilities - such as hospitals, bars, shopping centers and museums (but not movie theaters) - provide access to verbal information on televisions, films or slide shows. Ask: What about senior community centers and housing? 

Under the Television Decoder Circuitry Act of 1990, television captioning was performed by a costly set-top box. Through discussions with the manufacturer it was established that the appropriate circuitry integrated into the television set would be less expensive than the stand-alone box. In January 1991, the Federal Communications Commission (FCC) enacted rules on implementation of Closed Captioning. It required all analog television receivers with screens of at least 13 inches or greater, either sold or manufactured, to have the ability to display closed captioning by July 1, 1993. 

The Telecommunications Act of 1996 expanded on the Decoder Circuity Act to place the same requirements on digital television receivers by July 1, 2002. All TV programming distributors in the U.S. are required to provide closed captions for Spanish language video programming as of January 1, 2010. 

H.R. 3101, the Twenty-First Century Communications and Video Accessibility Act of 2010, was passed by the United States House of Representatives in July 2010. A similar bill with the same name was passed by the Senate in August 2010 and signed by President Obama in October. The Act requires, in part, for ATSC-decoding set-top box remotes to have a button to turn on or off the closed captioning in the output signal. It also requires broadcasters to provide captioning for television programs redistributed on the Internet. 

On February 20, 2014, the FCC unanimously approved the implementation of quality standards for closed captioning, addressing accuracy, timing, completeness, and placement. This is the first time the FCC has addressed quality issues in captions. 

Closed captions were created for deaf or hard of hearing individuals to assist in comprehension. They can also be used as a tool by those learning to read, learning to speak a non-native language, or in an environment where the audio is difficult to hear or is intentionally muted. Captions can also be used by viewers who simply wish to read a transcript along with the program audio. 

In the United States, the National Captioning Institute noted that English as a foreign or second language (ESL) learners were the largest group buying decoders in the late 1980s and early 1990s, before built-in decoders became a standard feature of US television sets. This suggested that the largest audience of closed captioning was people whose native language was not English.  

For older televisions, a set-top box or other decoder is usually required. In the U.S., since the passage of the Television Decoder Circuitry Act, manufacturers of most television receivers sold have been required to include closed captioning display capability.  

The Food and Drug Administration, acting on recommendations by the President’s council, will host a public workshop next month to consider whether its hearing aid regulations “may hinder innovation, reduce competition and lead to increased cost and reduced use.” The agency has also reopened public comments on proposed regulation of so-called personal sound amplification products and their marketing. 

Hearing loss is a disability  

Dr. Christine Cassel, one of the authors of a recent JAMA editorial on hearing health policies, reports that Congress banned Medicare coverage of hearing aids 50 years ago because “people thought hearing loss was just a normal part of aging. … They didn’t see it as a disability or a medical problem.” But however normal, hearing loss can have significant consequences. A Finnish study reports older adults with poor hearing experiencing a greater number of falls than those with normal hearing. American researchers have demonstrated a similar association in those aged 40 to 69. And older adults with hearing loss are also more apt to report periods of poor physical and mental health and to be hospitalized. 

Studies also show a relationship between hearing loss — mild, moderate, or severe — and accelerated rates of cognitive decline.  

Aging ears affect many other aspects of our health. Otolaryngologist and epidemiologist Dr. Frank Lin points to several possible causes. With diminished hearing, “your brain is constantly having to work harder to process garbled sounds” — a concept called cognitive load — and may have less capacity for other mental tasks. 

In every other aspect of our lives, advances in electronic technology have made things cost much, much less. That has not happened with hearing aids. 

Hearing loss is a disability. Currently untreated in about 85% of those affected, it may be the nation's most damaging and costly sensory handicap. It is often not obvious to others or even to those who have it. Its onset is usually insidious, gradually worsening over years. 

Many of those affected can still hear sounds and think the real problem is that people are not speaking clearly. They often ask others to speak up, repeat what was said or speak slowly. Or they pretend they can hear, but their conversations may be filled with non sequiturs. When I can’t see a mouth, I respond with my address instead of my date of birth.  

Social isolation has been linked to depression and an increased risk of death from conditions like heart disease. Another major risk associated with hearing problems is dementia and Alzheimer's disease. Older people with hearing loss are more likely than those with normal hearing to develop dementia. 

This finding alone should prompt more people to get their hearing tested and, if found impaired, get properly fitted with aids that can help to keep them cognitively engaged. Perhaps it will also grab the attention of politicians who determine what is and what is not covered by Medicare and, in turn, by other health insurers. What have your candidates committed to? 

The hearing aid itself represents only about a third of what audiologists charge. (Medicare does cover testing with a physician’s referral.) Medicare does not pay for hearing aids, and many older people cannot afford thousands of dollars that quality aids and auditory training can cost. Last year, Representative Debbie Dingell (Democrat/ Michigan), with six Democratic co-sponsors, tried to pass legislation to remove Medicare’s hearing aid restriction. The bill stalled in committee.  

Furthermore, for the fewer than 15% of hearing-impaired people who have hearing aids, the devices themselves are not an adequate solution. Hearing aids work best when the distance between the sound and the listener is less than six feet and when background noise is minimal, which can preclude clear communication in theaters, airports, restaurants and many other social settingsPeople are most likely to notice communication problems when their hearing loss exceeds 25 decibels. It's not that they can't hear, but they can't understand. Hearing loss at this level affects the clarity of words. 

Although hearing impairment was first linked in major medical journals to dementia and cognitive dysfunction more than 20 years ago, not until last year did researchers demonstrate an independent association with dementia over time. By following 639 people ages 36 to 90 for nearly 12 years, Dr. Lin and his Johns Hopkins University and National Institute on Aging colleagues showed a direct relationship between the participants' degree of hearing loss and their risk of later developing dementia or Alzheimer's disease. 

xxx 

Go fish (but not in the Bay!) Eating a meal of seafood or other foods containing omega-3 fatty acids at least once a week may protect against age-related memory loss and thinking problems in older people, according to a team of researchers at Rush University Medical Center and Wageningen University in the Netherlands. Their research findings were published in the May 4 online issue of Neurology, the medical journal of the American Academy of Neurology. The age-related memory loss and thinking problems of participants in the study who reported eating seafood less than once a week declined more rapidly compared to those who ate at least one seafood meal per week. While cognitive abilities naturally decline as part of the normal aging process, there is something that we can do to mitigate this process," says Martha Clare Morris, ScD, a Rush nutritional epidemiologist and senior author of the paper. 

Seafood is the direct nutrient source of a type of omega-3 fatty acid (docosahexaenoic acid) that is the main structural component of the brain. While epidemiologic studies have shown the importance of seafood and omega-3 fatty acids in preventing dementia, few prior studies have examined their associations with specific types of cognitive ability. 

Further, the protective association of seafood was even stronger among individuals with a common genotype (APOE-ε4) that increases the risk of developing Alzheimer's disease. The APOE is a gene involved in cholesterol transport to neurons. About 20% of the population carries the APOE-ε4 gene, although not everyone who has the gene will develop Alzheimer's disease.  

xxx 

Recommended reading:

“Personal health: lifelines for people with hearing loss” by Jane E. Brody. January 17, 2012 New York Times.