Hearing Loss Prevention Across the Lifespan
We have all seen statistics like this one from the Centers for Disease Control and Prevention (CDC): approximately 17% (36 million) of American adults report some degree of hearing loss. While not all hearing loss is preventable, the audiologist's role in promoting hearing health is as important to our profession and to our clients as habilitation and rehabilitation. ASHA Chief Staff Officer for Audiology Neil DiSarno has stressed the "long-term management of patients' hearing health" (DiSarno, 2013). All of us, whether in private practice, educational, medical, or other settings can enhance our profession by promoting healthy hearing behaviors across the lifespan. An up-front emphasis on hearing loss prevention supports the audiologist's role as a patient-centered professional—the person to be consulted whenever there is a question about hearing.
In this article, we will observe the National Institute for Occupational Safety and Health (NIOSH) recommendation to use the phrase "hearing loss prevention," rather than "hearing conservation," to convey the importance of preventing hearing loss, not simply conserving hearing. Moreover, hearing loss prevention should not be relegated to the occupational audiologist alone; given the changing landscape of health care and reimbursement in the United States, all audiology practices should be firmly rooted in prevention. This article will provide practical information and resources you can use to promote hearing health across the lifespan. Because noise exposure is such a pervasive issue at all ages, we will discuss that topic in a separate section.
Where do we start? In order to ground your practice in prevention, start by considering the clinic/business image reflected on your website and in your office and waiting room. What message do you project? If the focus is mainly on hearing aids and other hearing assistive technology, consider adding to your website healthy-hearing sections and links to resources. In the office, display hearing-health wall posters and printed material that patients can read there and/or take home. If you have a computer or TV in your waiting area, use it to show videos or PowerPoint slides or to present images and PDF files with prevention messages for individuals at different life stages. Even if the majority of your patients are elderly, they are likely to have children and grandchildren who could be at risk for hearing loss. Because older patients know firsthand the impact hearing loss can have on their lives, they will likely be motivated to help younger family members avoid experiencing communication difficulties.
Infant and child hearing. Patients and their families should understand that a healthy hearing lifestyle begins even before conception, and pregnant and nursing mothers should avoid alcohol and other drugs (Gerber, Epstein, & Mencher, 1995). Families with a history of hearing loss should be especially vigilant in monitoring their babies' hearing (Beswick, Driscoll, Kei, Khan, & Glennon, 2013). The CDC website provides straightforward tips for healthy pregnancy and a downloadable hearing loss fact sheet [PDF] for parents. The site includes a number of other free brochures and flyers in English and Spanish versions. Boys Town National Research Hospital has developed a website with information for new parents and parents-to-be who want to know about their babies' hearing; the site includes information about the newborn hearing screening process, so parents know what to expect in the hospital. The ASHA website is also a good resource for information, including free downloadable flyers and posters and for-sale brochures and posters.
Audiologists know that healthy hearing in the early childhood years is critically important in the development of speech and language and that even unilateral and minimal hearing loss can lead to learning problems (Kuppler, Lewis, & Evans, 2013; Yoshinaga-Itano, DeConde Johnson, Carpenter, & Stredler Brown, 2008). A healthy lifestyle and careful parental oversight can reduce or prevent illnesses associated with chronic middle ear conditions, and medical intervention should be sought when needed. Noise exposure is also an issue for babies and children. While parents may be under the impression that hearing screenings are part of well-baby and childhood check-ups, in reality few pediatricians have the equipment or personnel to conduct hearing testing. You can enhance your influence and reputation in the community by partnering with your local public health office, Head Start program, school district, or PTA to educate families and promote hearing screenings and positive hearing behaviors in childhood. Visit the Dangerous Decibels website for myriad ideas and fun activities to promote hearing health to school-age children. Even if your patient base does not include young children, perhaps you have time to train workers at Head Start and other preschool programs to perform OAEs in a screening protocol. For more information, see ASHA's otoacoustic emission (OAE) screening guidelines or watch a free 20-minute PowerPoint created by the National Center for Hearing Assessment and Management (NCHAM) at Utah State University.
Noise exposure and regulations. Noise induced hearing loss (NIHL) is the most common cause of hearing loss. Virtually every audiologist, regardless of his or her specialty area, will encounter patients with NIHL. Hearing loss due to excessive noise is preventable. So why—with all we've learned about hearing conservation/hearing loss prevention over the years—is this problem rampant? Our world has gotten noisier, and there persists a lack of awareness of the cumulative effects of noise on hearing. Many think of NIHL as a consequence of working in industry; however, we're also seeing the effects of noise from recreational exposures—in children as well as adults. Audiologists have a responsibility to educate and motivate our patients, friends, and families about the hazards of noise and how to prevent damage due to excessive noise.
The Occupational Safety and Health Act was passed in 1970 and with the promulgation of the 1983 amendment regarding noise and hearing conservation, many thought the problem would be solved. However, in the 30 years that industry has been required to comply with the amended standard, we have not seen a decline in occupationally related hearing loss. The standard is not considered protective or preventative, but merely a starting point; the rulemaking process is a series of compromises. In addition to the Occupational Safety and Health Administration mandates, hearing conservationists—including occupational audiologists—rely on NIOSH's Best Practice Guidelines. The approach recommended by NIOSH is more conservative and ultimately a more protective approach to hearing loss prevention than the OSHA regulations. For a detailed review and comparison of OSHA and NIOSH mandates, please consult the Hearing Conservation Manual, 4th Edition, by the Council for Accreditation in Occupational Hearing Conservation (CAOHC).
NIHL prevention and HPD. The first step in an effort to prevent injury from noise is and always should be noise control. OSHA and NIOSH, as well as the many Hearing Loss Prevention Programs intended for children, encourage individuals to "turn it down or walk away" (e.g., Dangerous Decibels, others). If you control noise to a safe level, workers and others should not sustain NIHL. Unfortunately, in the workplace, noise control is not a primary focus for most employers. Instead, hearing protective devices (HPDs) have moved to the front line of defense as an alternative approach to prevention. HPDs can do a fine job provided they are properly selected, fitted, and monitored. One size does not fit all, and there is no "best" protector. The selection of an appropriate HPD must take into account at least three factors: the individual's noise exposure, any existing hearing loss, and the need to communicate in the presence of excessive background noise. In the industrial setting, hearing protection must be adequate for the noise exposure and yet not overprotect the worker and possibly compromise his or her ability to work safely. If you do not do it already, consider adding HPDs to your practice. For example, custom-molded HPDs or "musicians'" earplugs, which have a linear filter, are not only for musicians. They can be a great option for individuals with or without hearing loss who need to communicate in noisy settings. The filtered/vented earplug can provide protection from noise while allowing speech sounds to be more easily heard.
There should never be an assumption that an individual knows how to fit a protector or that the protector is actually performing per the published noise reduction rating (NRR). Presently, several manufacturers offer fit testing for HPDs to determine a personal attenuation rating (PAR) as compared to the laboratory established NRR. These commercially available systems are revealing that worker's perceptions of a good fit/seal are not always reliable and that a visual inspection of the protector in the ear may not be indicative of proper fit. We now have tools available to help us ensure appropriate, adequate protection without risking over protection. For further information, the reader may want to contact any/all of the following manufacturers of HPD Fit Testing systems: 3M, Honeywell Safety Products, Kevin Michael & Associates, and Workplace Integra. The National Hearing Conservation Association is also a good resource for information on HPDs and other hearing loss prevention topics.
Hearing and aging. The link between reduced hearing and increased risk of dementia has been explored in recent scientific literature (e.g., Lin, 2012; Lin et al., 2011; Wingfield, Tun, & McCoy, 2005). Given our aging population and the impact of dementia on families, it is not surprising that this topic has caught the attention of the popular press as well. The case for hearing loss prevention across the lifespan has never been more urgent. Additionally, audiologists know that hearing aids can greatly improve interpersonal communication and relationships and reduce social isolation, which may in turn help stave off cognitive decline as well. Nevertheless, a recent study indicates that fewer than 15% of Americans age 50 and older who need hearing aids wear them (Chien & Lin, 2012). Selecting and fitting appropriate amplification remains an important tool in the overall picture of hearing health, and audiologists have a vital role to play in encouraging its acceptance and use.
In summary. NIHL and many other kinds of hearing loss are preventable. However, OSHA can't protect hearing, NIOSH can't protect hearing, and employers can't protect hearing! All can provide information, tools, and motivation to save hearing. As audiologists, we must help our patients understand that the preservation of hearing is a personal, life-long commitment. By working together and partnering with our colleagues in public health, medicine, and related fields, we must continue to educate ourselves and our patients, pass the word, and protect the precious sense of hearing.
Ann Dix, AuD, CCC-A
Clinical Assistant Professor
Affiliate of Special Interest Groups 6, 7, and 8
Mary M. McDaniel, AuD, CCC-A, CPS/A
Pacific Hearing Conservation, Inc.
Affiliate of Special Interest Group 8
About the Authors
Ann Dix is a clinical faculty member at Boston University, where she teaches aural rehabilitation at the undergraduate level and supervises MS-SLP students for their audiology and AR clinical experiences. Before joining the faculty at BU, Ann worked in an audiology private practice and in a hearing research laboratory at the Massachusetts Institute of Technology. Ann is a past member of the coordinating committee of ASHA SIG 8: Audiology and Public Health.
Mary M. McDaniel, AuD, is the owner of Pacific Hearing Conservation, Inc. in Seattle, Washington, and has worked exclusively in occupational audiology since 1984. She is a member of ASHA, past coordinator of ASHA's Special Interest Division on Hearing Conservation and Occupational Audiology, and recently completed a term on the Coordinating Committee of Special Interest Group 8, Audiology and Public Health. Dr. McDaniel is a past president of the National Hearing Conservation Association, the 2003 recipient of the NHCA's Michael Beall Threadgill Award for outstanding leadership and distinguished service, and past-chair of the Council for Accreditation in Occupational Hearing Conservation (CAOHC).
Beswick, R., Driscoll, C., Kei, J., Khan, A., & Glennon, S. (2013). Which risk factors predict postnatal hearing loss in children? Journal of the American Academy of Audiology 24(3), 205–213.
Chien, W., & Lin, F. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine 172(3), 292–293. doi:10.1001/archinternmed.2011.1408.
DiSarno, N. (2013). Data driven and determined. ASHA Access Audiology.
Gerber, S., Epstein, L., & Mencher, L. (1995). Recent changes in the etiology of hearing disorders: Perinatal drug exposure. Journal of the American Academy of Audiology 6(5), 371–377.
Kuppler, K., Lewis, M., & Evans, A. K. (2013). A review of unilateral hearing loss and academic performance: Is it time to reassess traditional dogmata? International Journal of Pediatric Otorhinolaryngology. doi: 10.1016/j.ijporl.2013.01.014. [Epub ahead of print]
Lin, F. (2012). Hearing loss in older adults: who's listening? Journal of the American Medical Association 307(11), 1147–1148. doi:10.1001/jama.2012.321.
Lin, F., Metter, J., O'Brien, R., Resnick, S., Zonderman, A., & Ferrucci, L. (2011). Archives of Neurology, 68(2), 214–220. doi:10.1001/archneurol.2010.362.
Wingfield, A., Tun, P. A., & McCoy, S. L. (2005). Hearing loss in older adulthood—What it is and how it interacts with cognitive performance. Current Directions in Psychological Science 14(3), 144–148.
Yoshinaga-Itano, C., DeConde Johnson, C., Carpenter, K., & Stredler Brown, A. (2008). Outcomes of children with mild bilateral hearing loss and unilateral hearing loss. Seminars in Hearing 29(2), 196–211.
Dangerous Decibels (Oregon Health and Science University)
Listen to Your Buds (ASHA)
May is Better Hearing and Speech Month
National Hearing Conservation Association
National Institute for Occupational Safety and Health
Patient Information Handouts
The Modern Evolution of Hearing Conservation Regulations
Wise Ears (NIDCD)