The scope of this page includes hearing screening for adults aged 18 years and older.
See the Screening section of the Hearing Loss (Adults) Evidence Map for summaries of the available research on this topic.
Hearing-related terminology may vary depending upon context and a range of factors. See the American Speech-Language-Hearing Association (ASHA) resource on hearing-related topics: terminology guidance for more information.
Hearing screening is the systematic application of a test or inquiry completed to identify individuals who are at risk for a hearing disorder or disability and who may benefit from further assessment, direct preventive action, and/or appropriate intervention. See the ASHA Practice Portal page on Hearing Loss in Adults for more in-depth information on this topic.
Without intervention, hearing loss in adults may contribute to higher rates of unemployment (or lower levels of employment), social isolation, loneliness, and social stigma (Shan et al., 2020; Shukla et al., 2020; World Health Organization, 2021b). Age-related hearing loss is significantly associated with cognitive decline, and it increases the risk for cognitive difficulties and/or dementia (Lin et al., 2011; Liu & Lee, 2019; Loughrey et al., 2018). Adults with hearing loss also experience a greater incidence of annual hospitalizations (Genther, Betz, Pratt, Martin, et al., 2015), a greater risk for falls (Lin & Ferrucci, 2012), and increased mortality (Genther, Betz, Pratt, Kritchevsky, et al., 2015).
Despite the burdens associated with untreated hearing loss, the average adult waits 8.9 years before taking action to address their hearing (Simpson et al., 2019). Asking older patients about hearing difficulties during routine medical exams significantly increases the identification of (and subsequent audiological referral for) individuals at risk for hearing loss (Zazove et al., 2020). Implementing routine hearing screenings may increase identification, diagnosis, and treatment of hearing loss in adults (Bennett et al., 2020; Yueh et al., 2003). There is guidance for establishing measures to screen individuals with increased hearing loss risk due to factors such as noise exposure, ototoxic chemical exposure, and/or increasing age (World Health Organization, 2021a).
This page excludes screening protocols and standards for occupational hearing conservation programs. For more information on this topic, please see The National Institute for Occupational Safety and Health (NIOSH): Noise & Hearing Loss Prevention and Occupational Safety and Health Administration: Occupational Noise Exposure.
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. Professional roles and activities in audiology include clinical services (e.g., screening); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include the following:
As indicated in the ASHA 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. Professional roles and activities in speech-language pathology include clinical services; prevention and advocacy; and education, administration, and research. 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 ASHA 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
While there is no one agreed-upon hearing screening schedule for adults, there are various factors to consider when deciding when and how often to get screened. These factors include age, comorbidities, risk factors (e.g., history of noise exposure), and access to routine screening (e.g., as part of an annual health appointment). Hearing screenings for adults may take place at or during
A comprehensive protocol for adult hearing screening may include several components (Schow, 1991; Ventry & Weinstein, 1983; World Health Organization, 2021c):
Completing each step of this process allows for more targeted and appropriate referrals and recommendations as well as patient-centered counseling. See the ASHA resource on person-centered care in audiology.
A brief case history should include questions designed to identify individuals with possible hearing and/or related disorders. Participation of significant others in the case history process can be valuable. See the ASHA Practice Portal page on Cultural Competence for information on gathering a case history.
A case history may include, but not be limited to, 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 or obvious anatomic abnormalities. 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.
Pass/Refer Criteria: Screening for Health Condition
Pure-tone screening is a behavioral test of hearing sensitivity that is typically completed with the use of a pure-tone audiometer that enables results to be plotted on an audiogram. Pure-tone stimuli are routed through either supra-aural earphones or insert earphones. If a pure-tone audiometer is not available or convenient, other options (e.g., laptop-based audiometers) allow for increased portability. Handheld audioscopes allow for otoscopic visualization and pure-tone screening, and some devices will utilize tones at a variety of presentation levels (e.g., 20 dB HL, 25 dB HL, 40 dB HL).
There are also a growing number of online and smartphone applications for hearing screening. These tools may use tone frequency testing and/or other methods (e.g., digits in noise). Advancements in technology allow for self-testing as an alternative method of monitoring hearing status and may help address unmet needs in hearing health care for adults (Wasmann et al., 2022). Many professionals advocate for self-screening. However, caution is warranted when using these tools due to variability in the applications, requirement for device calibration (Masalski et al., 2018), method of test administration, and other factors that may impact the accuracy of the results obtained.
An otoacoustic emission (OAE) is a sound generated from the cochlea in response to auditory stimulation (e.g., from a handheld OAE screening device). OAE testing can be particularly useful in screening for hearing loss in individuals who are difficult to test and/or who cannot reliably perform behavioral hearing screenings, as OAE test results do not rely on behavioral responses to sound stimuli (Jupiter, 2009). OAEs may also be used for monitoring cochlear damage due to noise or ototoxicity (Shetty et al., 2020).
Pass/Refer Criteria: Screening for Body Structure and Function
The incidence of hearing loss increases with age, and some adults will not pass a pure-tone screening at 25 dB HL, particularly at 4000 Hz. Hearing loss in excess of 25 dB HL is clinically significant, as it can negatively affect communication. Some clinicians have advocated for the use of higher screening levels (i.e., 30 dB HL or 35 dB HL) when screening adults of increasing age. While higher screening levels may result in lower referral rates, milder degrees of hearing loss may be missed, along with opportunities for further assessment, counseling, and education.
Self-assessment tools (e.g., questionnaires/inventories) for disability screening can be used in conjunction with other screening components to help identify those who would benefit from more comprehensive audiologic evaluation, counseling, and management (Louw et al., 2018; Ventry & Weinstein, 1983; World Health Organization, 2021c). These tools may identify an individual’s perceived difficulties related to hearing as well as changes to participation in activities. Hearing disability screening measures can be administered in a verbal, written, or computerized format. Some 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 those who may require audiologic follow-up.
Examples of hearing screening self-assessment tools include the following:
Pass/Refer Criteria: Screening for Disability (Activities and Participation)
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 resulting from adult hearing screening may involve counseling and education, comprehensive audiologic assessment, and/or other examinations or services as indicated. Examples include the following:
There is limited information in the literature about how often adults follow recommendations after a hearing screening and on the long-term outcomes of those referrals (Meyer et al., 2011; Thodi et al., 2013; Zazove et al., 2020). Some adults may appreciate the hearing screening opportunity but may choose not to act on the referrals or recommendations. Hearing screenings offer the opportunity to educate adults about the full range of rehabilitative options available to those with hearing loss (e.g., environmental modifications, auditory training, amplification). Knowledge of a wide 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 S3.6-2018 (ANSI, 2018b, or current standard) 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, 2018b). All calibration activities should be conducted by a trained audiologist or an external company or individual properly trained in performing such tasks.
A clinical or natural environment that is conducive to obtaining reliable hearing screening results will be free from auditory and visual distractions and interruptions and will allow for privacy and confidentiality.
Performing daily listening checks can 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 S3.1-1999 (ANSI, 2018a, or current standard) 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, circumaural, or insert). There are some smartphone-based sound level meters available that can be used to measure ambient noise; however, these applications may require calibration, and results may vary. When a sound level meter is not available, a biologic check is typically suitable.
It is important to follow universal precautions and appropriate infection control procedures during screenings. See ASHA’s page on infection control resources for audiologists and speech-language pathologists for detailed information.
Audiologists overseeing screening personnel can ensure proper screening skills by providing both initial and refresher training and validating the initial results of new screeners.
The ASHA Assistants Program page provides details regarding the audiology assistant career path and certification.
Documentation typically includes the date of screening, patient demographics, positive concerns from the case history, screening results, and recommendations and referrals. Any educational resources should be provided in a health-literate and person-centered format. For an example of a hearing screening template for adults, see Hearing Screening (Adults) [PDF].
For information on audiology and speech-language pathology services as well as issues related to Medicare, Medicaid, private health plans, and billing codes, see the ASHA resource on billing and reimbursement.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
This list of resources is not exhaustive, and the inclusion of any specific tool does not imply endorsement from ASHA. These tools do not replace a diagnostic hearing evaluation completed by a licensed and certified audiologist.
American National Standards Institute. (2018a). Maximum permissible ambient noise levels for audiometric test rooms (Rev. ed.; ANSI S3.1-1999). Acoustical Society of America.
American National Standards Institute. (2018b). Specification for audiometers (Rev. ed.; ANSI S3.6-2018). Acoustical Society of America.
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. https://www.asha.org/policy/
Bennett, R. J., Conway, N., Fletcher, S., & Barr, C. (2020). The role of the general practitioner in managing age-related hearing loss: A scoping review. American Journal of Audiology, 29(2), 265–289. https://doi.org/10.1044/2020_AJA-19-00090
Centers for Medicare & Medicaid Services. (2019). Long-term care facility resident assessment instrument 3.0: User’s manual (Version 1.17.1).
Gatehouse, S., & Noble, W. (2004). The Speech, Spatial and Qualities of Hearing Scale (SSQ). International Journal of Audiology, 43(2), 85–99. https://doi.org/10.1080/14992020400050014
Genther, D. J., Betz, J., Pratt, S., Kritchevsky, S. B., Martin, K. R., Harris, T. B., Helzner, E., Satterfield, S., Xue, Q., Yaffe, K., Simonsick, E. M., Lin, F. R. (2015). Association of hearing impairment and mortality in older adults. The Journals of Gerontology: Series A, 70(1), 85–90. https://doi.org/10.1093/gerona/glu094
Genther, D. J., Betz, J., Pratt, S., Martin, K. R., Harris, T. B., Satterfield, S., Bauer, D. C., Newman, A. B., Simonsick, E. M., Lin, F. R. (2015). Association between hearing impairment and risk of hospitalization in older adults. Journal of the American Geriatrics Society, 63(6), 1146–1152. https://doi.org/10.1111/jgs.13456
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(2), 99–107. https://doi.org/10.1044/1059-0889(2009/08-0020)
Lichtenstein, M. J., Bess, F. H., & Logan, S. A. (1988). Diagnostic performance of the Hearing Handicap Inventory for the Elderly (Screening Version) against differing definitions of hearing loss. Ear and Hearing, 9(4), 208–211. https://doi.org/10.1097/00003446-198808000-00006
Lin, F. R., & Ferrucci, L. (2012). Hearing loss and falls among older adults in the United States. Archives of Internal Medicine, 172(4), 369–371. https://doi.org/10.1001/archinternmed.2011.728
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(2), 214–220. https://doi.org/10.1001/archneurol.2010.362
Liu, C. M., & Lee, C. T. (2019). Association of hearing loss with dementia. JAMA Network Open, 2(7), e198112. https://doi.org/10.1001/jamanetworkopen.2019.8112
Loughrey, D. G., Kelly, M. E., Kelley, G. A., Brennan, S., & Lawlor, B. A. (2018). Association of age-related hearing loss with cognitive function, cognitive impairment, and dementia: A systematic review and meta-analysis. JAMA Otolaryngology—Head & Neck Surgery, 144(2), 115–126. https://doi.org/10.1001/jamaoto.2017.2513
Louw, C., Swanepoel, D. W., & Eikelboom, R. H. (2018). Self-reported hearing loss and pure tone audiometry for screening in primary health care clinics. Journal of Primary Care & Community Health, 9, 2150132718803156. https://doi.org/10.1177/2150132718803156
Masalski, M., Grysiński, T., & Kręcicki, T. (2018). Hearing tests based on biologically calibrated mobile devices: Comparison with pure-tone audiometry. Journal of Medical Internet Research, 6(1), e10. https://doi.org/10.2196/mhealth.7800
McDonough, A., Dookhy, J., McHale, C., Sharkey, J., Fox, S., & Kennelly, S. P. (2021). Embedding audiological screening within memory clinic care pathway for individuals at risk of cognitive decline—patient perspectives. BMC Geriatrics, 21(1), 1–8. https://doi.org/10.1186/s12877-021-02701-0
Meyer, C., Hickson, L., Khan, A., Hartley, D., Dillon, H., & Seymour, J. (2011). Investigation of the actions taken by adults who failed a telephone-based hearing screen. Ear and Hearing, 32(6), 720–731. https://doi.org/10.1097/AUD.0b013e318220d973
Reed, M., Freedman, M., Mark Fraser, A. E., Bromwich, M., Santiago, A. T., Gallucci, C. E., & Frank, A. (2022). Enhancing clinical visibility of hearing loss in cognitive decline. Journal of Alzheimer’s Disease, 86(1), 413–424. https://doi.org/10.3233/JAD-215377
Schow, R. L. (1991). Considerations in selecting and validating an adult/elderly hearing screening protocol. Ear and Hearing, 12(5), 337–348. https://doi.org/10.1097/00003446-199110000-00006
Schow, R. L., & Nerbonne, M. A. (1982). Communication screening profile: Use with elderly clients. Ear and Hearing, 3(3), 135–147.
Shan, A., Ting, J. S., Price, C., Goman, A. M., Willink, A., Reed, N. S., & Nieman, C.L. (2020). Hearing loss and employment: A systematic review of the association between hearing loss and employment among adults. The Journal of Laryngology & Otology, 134(5), 387–397. https://doi.org/10.1017/S0022215120001012
Shetty, S., Bhandary, S. K., Bhat, V., Aroor, R., Shetty, J., & Dattatreya, T. (2020). Role of otoacoustic emission in early detection of cisplatin induced ototoxicity. Indian Journal of Otolaryngology and Head & Neck Surgery, 1 – 6. https://doi.org/10.1007/s12070-020-01933-7
Shukla, A., Harper, M., Pedersen, E., Goman, A., Suen, J. J., Price, C., Applebaum, J., Hoyer, M., Lin, F. R., & Reed, N. S. (2020). Hearing Loss, loneliness, and social isolation: A systematic review. Otolaryngology—Head and Neck Surgery, 162(5), 622–633. https://doi.org/10.1177%2F0194599820910377
Simpson, A. N., Matthews, L. J., Cassarly, C., & Dubno, J. R. (2019). Time from hearing-aid candidacy to hearing-aid adoption: A longitudinal cohort study. Ear and Hearing, 40(3), 468–476. https://doi.org/10.1097/AUD.0000000000000641
Thodi, C., Parazzini, M., Kramer, S. E., Davis, A., Stenfelt, S., Janssen, T., Smith, P., Stephens, D., Pronk, M., Anteunis, L. I., Schirkonyer, V., & Grandori, F. (2013). Adult hearing screening: Follow-up and outcomes1. American Journal of Audiology, 22(1), 183–185. https://doi.org/10.1044/1059-0889(2013/12-0060)
Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. Asha, 25(7), 37–42.
Wasmann, J. W., Pragt, L., Eikelboom, R., & Swanepoel, D. W. (2022). Digital approaches to automated and machine learning assessments of hearing: Scoping review. Journal of Medical Internet Research, 24(2), e32581. https://doi.org/10.2196/32581
World Health Organization. (2021a, March 3). World report on hearing [Global report]. https://www.who.int/publications/i/item/world-report-on-hearing
World Health Organization. (2021b, April 1). Deafness and hearing loss [Fact sheet]. https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss
World Health Organization. (2021c, September 3). Hearing screening: Considerations for implementation [Handbook]. https://www.who.int/publications/i/item/9789240032767
Yueh, B., Shapiro, N., MacLean, C. H., & Shekelle, P. G. (2003). Screening and management of adult hearing loss in primary care: Scientific review. JAMA, 289(15), 1976–1985. https://doi.org/10.1001/jama.289.15.1976
Zazove, P., Plegue, M. A., McKee, M. M., DeJonckheere, M., Kileny, P. R., Schleicher, L. S., Green, L. A., Sen, A., Rapai, M. E., & Mulhem, E. (2020). Effective hearing loss screening in primary care: The Early Auditory Referral–Primary Care study. Annals of Family Medicine, 18(6), 520–527. https://doi.org/10.1370/afm.2590
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/.