Anne L. Oyler, AuD, CCC-A
The statistics are alarming. According to the National Institute on Deafness and Other Communication Disorders (NIDCD), 36 million Americans have a hearing loss—this includes 17% of our adult population. The incidence of hearing loss increases with age. Approximately one third of Americans between ages 65 and 74 and nearly half of those over age 75 have hearing loss (NIDCD, 2010). Hearing loss is the third most prevalent chronic health condition facing older adults (Collins, 1997). Unfortunately, only 20% of those individuals who might benefit from treatment actually seek help. Most tend to delay treatment until they cannot communicate even in the best of listening situations. On average, hearing aid users wait over 10 years after their initial diagnosis to be fit with their first set of hearing aids (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007).
Our population is aging. According to the Administration on Aging (2011, para. 1), "the older population will burgeon between the years 2010 and 2030 when the 'baby boom' generation reaches age 65." In 2009, people over 65 represented 12.9% of the population; by 2030, they will represent 19.3%. The population of individuals over 65 is expected to double between 2008 and 2030 to a projected 72.1 million (Administration on Aging, 2011, para. 2).
Hearing loss in adults has a number of contributing factors, including age, genetics, noise exposure, and chronic disease (e.g., diabetes, chronic kidney disease, and heart disease). Age-related hearing loss or presbycusis is generally a slow, progressive hearing loss that affects both ears equally. Presbycusis begins in the high frequencies and later affects the lower frequencies. One of the first signs of hearing loss is often an inability to hear and understand speech in noisy environments. Because of this slow progression, adults with presbycusis do not readily acknowledge their hearing loss, considering it a normal sign of aging. As audiologists, we are not surprised to hear that the spouse or significant other has been frustrated by the hearing loss long before the individual with the hearing loss even acknowledges it. It is this insidious nature of presbycusis that allows many adults to ignore their hearing loss for years or decades.
The impact of hearing loss is not simply measured in decibels. Hearing loss is an individual experience, and how the individual copes will depend on a great many factors, including early versus late onset, the progressive nature of the loss (gradual vs. sudden), the severity of the loss, communication demands, and personality (Kaland & Salvatore, 2002). Regardless of the combination of these presenting factors, hearing loss has been linked to feelings of depression, anxiety, frustration, social isolation, and fatigue.
Several studies have documented the impact of untreated hearing loss. An often cited survey was commissioned by the National Council on Aging in 1999 (Kochkin & Rogin, 2000). This nationwide survey of nearly 4,000 adults with hearing loss and their significant others showed significantly higher rates of depression, anxiety, and other psychosocial disorders in individuals with hearing loss who were not wearing hearing aids. This survey looked at the positive benefits of amplification and showed that hearing aid use positively affected quality of life for both the hearing aid wearer and his or her significant other. These findings were consistent with the findings of a large randomized controlled study which found that hearing loss was associated with decreased social/emotional, communication, and cognitive function in addition to increased depression for subjects who were unaided as compared to those who received hearing aids. These conditions were improved after hearing aids were fit (Mulrow et al., 1990).
More recently, Dr. Frank Lin and his colleagues at Johns Hopkins University found a strong link between degree of hearing loss and risk of developing dementia. Individuals with mild hearing loss were twice as likely to develop dementia as those with normal hearing, those with moderate hearing loss were three times more likely, and those with severe hearing loss had five times the risk. While this study could not definitively conclude that early treatment with hearing aids would reduce the risk of dementia, there was a positive correlation between degree of hearing loss and risk of dementia (Lin et al., 2011).
Hearing loss is an invisible handicap. Although it is increasingly prevalent with age, hearing loss is often ignored during the diagnosis and treatment of cognitive and memory disorders in elderly patients (Chartrand, 2005). The comorbidity of hearing loss and cognitive disorders makes it even more important to determine hearing status prior to any diagnostic protocol. This would undoubtedly lead to more appropriate diagnosis and treatment as well as significantly better outcomes for individuals with cognitive impairments. Vision impairment is another common comorbidity affecting between 9% and 22% of adults over 70 (Saunders & Echt, 2011). Researchers using longitudinal data from the National Center for Health Statistics and the National Institute on Aging analyzed the relationship between vision impairment and hearing loss on quality of life in older adults, and they concluded that both hearing loss and vision impairment have a negative impact on health, social participation, and daily activities, and those individuals with a combination of both hearing loss and vision impairment (i.e., dual sensory impairment) experience the greatest difficulty (Crews & Campbell, 2004). The implication is that when both sensory systems are impaired, the individual is less able to compensate.
As Gagné, Southall, and Jennings (2011) pointed out, in their study of why individuals delay in seeking hearing health services because of stigma, "In order to live well with hearing loss, one must recognizeand accepthearing loss. Specifically, many people must overcome the misplaced shame and poor self-esteem that they may experience" (para. 2). The fitting of hearing aids needs to be part of a larger treatment program that includes the individual and his or her significant other(s). Research has shown improved quality of life and overall satisfaction when significant others receive support and education regarding hearing loss and communication strategies (Kramer, Allessie, Dondorp, Zekveld, & Kapteyn, 2005). Group and individual audiologic rehabilitation programs that are tailored to the individual’s communication needs have been shown to help create feelings of acceptance and confidence that lead to earlier acceptance and improved benefits from carefully fit technology (Chisolm, Abrams, & McArdle, 2004). Rehabilitation approaches that provide holistic treatment and take into consideration other age-related changes such as vision impairment, cognitive decline, and manual dexterity are needed to meet the needs of our expanding older population (Saunders & Echt, 2011).
Healthy People 2020 has outlined several goals that relate to improving hearing health outcomes for adults. Specifically, the initiative calls for an increase in the number of adults over 70 who use hearing aids and hearing assistive technology as well as the number of adults ages 20–70 who have had a hearing evaluation in the past 5 years (U.S. Department of Health and Human Services, 2011). The impact of untreated hearing loss cannot be ignored. Early and careful evaluation and treatment show great promise in mitigating the consequences of hearing loss on long-term health and quality of life. With the U.S. population rapidly aging, a health care system that recognizes the importance of early identification and treatment is critical. Educating consumers regarding the importance of seeking treatment early for themselves and their loved ones will have to be part of the equation. Indeed, changing perceptions regarding hearing loss is critical to increasing the number of individuals who ultimately benefit from early management. Audiologists who fit hearing aids must implement aural rehabilitation as part of their patients’ plan of care to help ensure that individuals who ultimately seek hearing services are treated in a holistic, evidence-based manner that takes their psychosocial, physical, and communication needs into consideration. Additionally, ongoing research and advocacy regarding the efficacy of early identification and management of hearing loss may help encourage better funding for hearing aids as well as important aural rehabilitation services.
Anne L. Oyler, AuD, CCC-A, is associate director of audiology professional practices at ASHA.
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Chartrand, M. S. (2005). Undiagnosed pre-existing hearing loss in Alzheimer's disease patients. Audiology Online.
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