Hearing screening is the systematic application of a test or inquiry completed to identify individuals who are at risk for a hearing disorder, impairment, or disability and who may benefit from further assessment, direct preventive action, and/or appropriate intervention.
It is estimated that 15% of the adult population in the United States has hearing loss (Blackwell, Lucas, & Clarke, 2014). The incidence of hearing loss increases with age, with 5.5% of adults ages 18–39, 19% of adults ages 40–69, and 43% of adults over age 70 with self-reported difficulty hearing without a hearing aid (Centers for Disease Control and Prevention [CDC], 2015).
Without intervention, hearing loss in adults contributes to higher rates of depression, anxiety, and other cognitive disorders (Kochkin & Rogin, 2000). A strong correlation has been found between hearing loss and the risk for developing dementia ( Lin et al., 2011). In 2012, the U.S. Preventive Service Task Force (USPSTF) acknowledged that hearing loss is a common consequence of aging and that many older adults may not recognize the early stages of hearing loss. The USPSTF called for additional research to better understand the health benefits that might result from the hearing screening of adults in primary care settings (USPSTF, 2012). Routine hearing screenings may reduce the prevalence of underdiagnosed and undertreated hearing loss in adults ( Yueh, Shapiro, MacLean, & Shekelle, 2003).
This page excludes screening protocols and standards for occupational hearing conservation programs. For more information on this topic, please see Occupational Safety and Health Administration (OSHA): Hearing Conservation.
Audiologists, by virtue of academic degree, clinical training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of hearing screening programs. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include the following:
As indicated in the Code of Ethics (ASHA, 2016a), audiologists who work in this capacity should be specifically educated and appropriately trained.
Speech-language pathologists (SLPs) play a role in the hearing screening process. They also offer speech, language, and communication assessment, as well as (re)habilitation services to individuals with hearing loss. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles and responsibilities for SLPs include the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who work in this capacity should be specifically educated and appropriately trained.
Hearing loss risk factors and associated conditions include
Adult hearing screenings may take place in a variety of settings and situations, including the following examples:
A comprehensive protocol for adult hearing screening uses a three-pronged approach with the following components ( Schow, 1991; Ventry & Weinstein, 1983):
Completing each step of this process allows for more targeted, appropriate referrals/recommendations and for more patient-appropriate counseling.
A brief case history should include questions designed to identify individuals with possible hearing or related disorders. Participation of significant others in the case history process can be valuable. A case history may include the following questions:
Otoscopy completed by a trained examiner (e.g., audiologist, audiology assistant) allows for visualization of the tympanic membrane and inspection of the external ear canal for drainage, foreign bodies, impacted cerumen, infection, fluid, or structural abnormalities. A screener who is not trained in otoscopy can perform a general visual inspection of the outer portion of the ear and make note of any anomalies. The information obtained during visual inspection or otoscopy may have an important impact on screening results and/or referral to medical personnel for further evaluation.
Pure-tone screening is typically accomplished with the use of a pure-tone audiometer. Pure-tone stimuli are usually routed through either TDH supra-aural earphones or insert earphones.
Handheld audioscopes allow for otoscopic visualization and pure-tone screening. Some of these devices will utilize tones at a variety of presentation levels (e.g., 20 dB HL, 25 dB HL, 40 dB HL).
There are a growing number of online and smartphone applications for hearing screening; however, caution is warranted when using these applications due to variability in the results obtained.
Otoacoustic emissions (OAEs) can be used to screen for hearing loss, particularly for populations who may be difficult to test, and for monitoring cochlear damage due to noise or ototoxicity ( Engdahl, Tambs, Borchgrevink, & Hoffman, 2005; Jupiter, 2009).
Because the incidence of hearing loss increases with age, many older adults will likely fail a pure-tone screening at 25 dB HL, particularly at 4000 Hz. Hearing loss in excess of 25 dB HL can negatively affect communication and, therefore, reflects a clinically significant hearing impairment. Some clinicians have advocated for use of higher screening levels (i.e., 30, 35, or 40 dB HL) when screening older adults. These higher screening levels will result in lower fail rates but may miss milder degrees of hearing loss and opportunities for further assessment, counseling, and education. Further studies are needed to determine whether different screening levels might be more appropriate for different age ranges.
Self-assessment tools (questionnaires/inventories) for disability screening can be used in conjunction with screenings for impairment and disorder to help identify those who would benefit from more comprehensive audiologic evaluation, counseling, and management (Ventry & Weinstein, 1983). Hearing disability screening measures can be administered in a verbal, written, or computerized format. Some patient report measures can be completed by family members or significant others. In the absence of an audiometer or other screening technology, these questionnaires can be useful in the identification of individuals at risk for hearing loss and requiring audiologic follow-up.
Examples of hearing screening self-assessment questionnaires include the following:
Before using a self-assessment questionnaire, it is important to review the background publications related to the administration, scoring, and interpretation associated with that specific tool.
Referrals and recommendations may involve counseling and education, comprehensive audiologic assessment, and/or other examinations or services as indicated. For example:
There is limited information in the literature as to how often adults follow referral recommendations after hearing screening or the long-term outcomes of those referrals (e.g., auditory rehabilitation, hearing aids). Some adults may appreciate the hearing screening opportunity but may choose not to take action on the referrals or recommendations. Hearing screenings offer the opportunity to educate older adults about the full range of rehabilitative options available to those with hearing loss (e.g., environmental modifications, auditory training, amplification, counseling). A wider range of options may increase the chance that an individual will pursue some follow-up services.
Audiometric equipment must meet applicable specifications of the American National Standards Institute (ANSI)/Acoustical Society of America (ASA) S3.6-2010 (ANSI, 2010) and/or manufacturer recommendations to ensure accurate results. Calibration should be performed annually using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and biologic listening checks should be conducted to verify equipment performance prior to each use (ANSI, 2010). Visual inspection should be completed to check for any obvious equipment damage. All calibration activities should be conducted by a trained audiologist or an external company/individual properly trained in performing such tasks.
Hearing screening should be conducted in a clinical or natural environment that is conducive to obtaining reliable screening results and that is free from auditory and visual distractions and interruptions. In addition, the location should allow for privacy and confidentiality.
Perform daily listening checks to rule out defects in major pure-tone screening components. Ambient noise levels may exceed ANSI standards for pure-tone threshold testing in audiometric test rooms (ANSI, 2013) but must be sufficiently low to allow accurate screening. A sound level meter, if available, may be used to establish maximum permissible noise levels at 25 dB HL for the earphone to be used during screening (i.e., supra-aural or insert earphones). However, when a sound level meter is not available, a biologic check is suitable.
It is important to ensure that adherence to universal precautions and appropriate infection control procedures are in place during screenings. Instrumentation that comes into physical contact with the patient must be cleaned and disinfected after each patient use (and per manufacturer's instructions), and clinician hand washing or use of sanitizing gel between patients should be routine ( Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007). Disposable equipment, such as insert eartips, should be discarded after each patient use. See OSHA standards relating to occupational exposure to bloodborne pathogens and the CDC's Universal Precautions for Preventing Transmission of Bloodborne Infections.
When audiologists oversee other screening personnel, initial training and refresher training is provided to ensure proper screening skills and knowledge. It is beneficial for the results of new screeners to be validated by an audiologist.
See ASHA Practice Portal page on Audiology Assistants for information on the training, educational standards, and roles/responsibilities of these paraprofessionals.
Documentation typically includes the date of screening, patient demographics, medical and medication history, positive concerns from the case history, screening results, and recommendations and referrals. Any educational resources should be written in plain language (see ASHA's Health Literacy web page) and with culturally and linguistically appropriate translations provided as needed. For a hearing screening template for adults, see Hearing Screening (Adults) [PDF].
Although screenings are important to maintain the hearing health of adults, they are not a covered Medicare audiology benefit. The "Welcome to Medicare" preventive visit, Medicare Advantage plans, private plans, and Affordable Care Act–compliant plans may include screening as part of well visits, but these screenings may not be separately billable.
A failed hearing screening, a positive history of chronic diseases, ototoxic/vestibulotoxic medication use, or a genetic illness with comorbid hearing loss may support medical necessity for a referral to an audiologist. When referred by a physician, most plans will cover diagnostic exams for hearing and balance that are performed by an audiologist.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American National Standards Institute. (2013). Maximum permissible ambient noise levels for audiometric test rooms. (Rev. ed.; ANSI S3.1-1999). New York, NY: Author.
American National Standards Institute. (2010). Specification for audiometers (ANSI S3.6-2010). New York, NY: Author.
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/
Blackwell, D. L., Lucas, J. W., & Clarke, T. C. (2014). Summary health statistics for U.S. adults: National Health interview survey, 2012. National Center for Health Statistics Vital Health Statistics, 10, 1-161.
Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/databriefs/db214.htm NCHS Data Brief, 2015.
Centers for Medicare and Medicaid Services. (2015). Long-term care facility resident assessment instrument 3.0 user's manual, version 1.13. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-V113.pdf
Engdahl, B., Tambs, K., Borchgrevink, H. M., & Hoffman, H. J. (2005). Otoacoustic emissions in the general adult population of Nord-Trondelag, Norway: III. Relationships with pure-tone hearing thresholds. International Journal of Audiology, 44, 15–23.
Gatehouse, S., & Noble, W. (2004). The Speech, Spatial and Qualities of Hearing Scale (SSQ). International Journal of Audiology, 43, 85–89.
Jupiter, T. (2009). Screening for hearing loss in the elderly using distortion product otoacoustic emissions, pure tones, and a self-assessment tool. American Journal of Audiology, 18, 99–107.
Kochkin, S., & Rogin, C. M. (2000). Quantifying the obvious: The impact of hearing instruments on quality of life. Hearing Review, 7, 6–34 .
Lin, F. R., Metter, J., O'Brien, R. J., Resnick, S. M., Zonderman, A. B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68, 214–220.
Newman, C. W., Jacobson, G. P., Hug, G. A., Weinstein, B. E., & Malinoff, R. L. (1991). Practical method for quantifying hearing aid benefit in older adults. Journal of the American Academy of Audiology, 2, 70–75.
Schow, R.L. (1991). Considerations in selecting and validating an adult/elderly hearing screening protocol. Ear and Hearing, 12, 337–348.
Schow, R. L., & Nerbonne, M. A. (1982). Communication screening profile: Use with elderly clients. Ear and Hearing, 3, 135–147.
Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee. (2007).Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
U.S. Preventive Services Task Force. (2012). Final Recommendation Statement, Hearing Loss in Older Adults: Screening, August 2012. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/hearing-loss-in-older-adults-screening
Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. Asha, 25, 37-42.
Yueh, B., Shapiro, N., MacLean, C. H., & Shekelle, P. G. (2003). Screening and management of adult hearing loss in primary care: Scientific review. The Journal of the American Medical Association, 289, 1976–1985.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Adult Hearing Screening page:
In addition, ASHA thanks the members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders (Technical Report on Audiologic Screening) and the members of the Panel on Audiologic Assessment (Guidelines for Audiologic Screening) whose work was foundational to the development of this content.
Members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders were Robert Nozza (chair), Judith Gravel, Joan Martilla, Michael Nerbonne, Diane Scott, Thayne Smedley, and Jo Williams (ex officio). Guidance on the report was provided by Jean Lovrinic, vice president for governmental and social policies (1991-1993).
The Panel on Audiologic Assessment was led by Chie Craig (chair). The adult working group included Sabina Schwan (coordinator), Gary Jacobson, and Wayne Olson. Evelyn Cherow served as ex officio. Larry Higdon served as the monitoring Executive Board Officer.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Adult Hearing Screening (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Adult-Hearing-Screening/.