Article Archive
May/June 2014

Hearing Loss — Undiagnosed and Undertreated

By Renee A. Monahan, AuD, CCC-A, and Louis R. Sieminski, PhD, CCC-A
Today’s Geriatric Medicine
Vol. 7 No. 3 P. 14

Despite dramatic strides in correcting older adults’ hearing loss, the pervasive impairment often goes untreated.

Advancing age is by far the most common cause of hearing loss. The aging process affects the entire human ear but largely results in damage to the inner ear (cochlea).

Presbycusis, or age-related hearing loss, occurs slowly and progressively, affecting mainly the higher frequencies or pitch ranges of speech. This type of hearing impairment causes great difficulty in understanding normal speech, especially in the presence of background noises. Neither medical nor surgical interventions can improve this type of hearing loss. However, a conductive component (a problem with or defect of the outer and/or middle ear mechanism) often is present as well and can be corrected with medical intervention.

Although hearing loss can occur at any age, conservative estimates of its pervasive nature indicate that between 25% and 40% of individuals over the age of 65 will experience some hearing loss. The prevalence increases to between 40% and 66% in patients over the age of 75, and more than 80% of individuals over the age of 85 will experience significant hearing loss.1 However, primary care physicians routinely screen only about 12.9% of the total US population for hearing loss.2

The prevalence and significant disabling effects of hearing loss should make proper diagnosis and treatment a standard of care in all patients, especially in the elderly.

When hearing loss is suspected, it’s important to enlist the expertise of a qualified audiologist who can perform a hearing evaluation. Audiologists can determine the presence of hearing loss, its degree, and the type of loss, whether sensorineural or cochlear, conductive, or a combination of both, known as mixed hearing loss.

Audiologists also provide recommendations to help rehabilitate patients with hearing loss. They can recommend hearing devices, correctly fit and program these devices, and provide proper wearing instructions. Measured outcomes can ensure success. Primary care physicians and audiologists should work closely together to effectively manage patients with hearing loss.

Hearing Loss and Cognitive Decline
Dementia, cognitive impairment, and hearing loss often affect the same aging population. Because many tests for dementia are verbal, untreated hearing loss can adversely affect test results. In 2010, researchers estimated that approximately 4.7 million Americans over the age of 65 were diagnosed with Alzheimer’s dementia.3

A recent study completed at Johns Hopkins Medical Center found that people with untreated hearing loss have a greater risk of developing dementia than do individuals who have no hearing loss.4 This longitudinal study showed participants with hearing loss have a 40% greater chance of cognitive decline compared with those who had normal hearing at the beginning of the study. Dementia and hearing impairment share several overlapping symptoms, including social isolation, decreased comprehension, discrimination, inappropriate word use, and difficulty following conversation.

Most audiologists who see patients with a decreased level of cognitive function or in various stages of dementia will attest to the dramatic improvements that occur when properly fitted devices improve patients’ hearing; patients’ family members and caretakers also confirm marked improvements. One study confirmed that fitting hearing aids to patients diagnosed with Alzheimer’s dementia was effective in helping with their communication skills and significantly decreased patient behavioral problems and caregiver stress.5

Long Term Care Facilities
An estimated 3.3 million people live in the nation’s nearly 16,000 nursing homes, and an additional 750,000 reside in assisted-living facilities.6 Increasing longevity suggests those numbers will increase. Many facilities report that the average age of residents is 90. Statistically, hearing difficulties will negatively impact them socially and mentally and affect their quality of life.

Hearing loss also affects the physicians, nurses, social workers, aides, and other staff members who care for residents; it can create barriers to interacting or following directions. It’s imperative that long term care facilities have a certified audiologist on staff who can act as a consultant to provide hearing evaluations. He or she also can ensure the proper functioning of residents’ hearing devices.

An audiologist also can provide in-service training to staff members who care for residents, working closely with physicians and the entire staff to ensure proper hearing care for all residents.

Hearing loss is twice as prevalent in adults with diabetes as it is in those who do not have diabetes. About 21% of people with diabetes will experience hearing loss compared with 9% of those who do not have diabetes.7 A recent study also found that women between the ages of 60 and 75 with poorly controlled diabetes had significantly worse hearing than those whose diabetes was controlled.8

A degree of hearing loss occurs during the natural aging process but is accelerated dramatically in patients with diabetes. This is true especially if blood glucose levels aren’t controlled with medication, diet, or exercise.

Given these statistics, patients with diabetes should undergo annual hearing screenings. The American Diabetes Association recommends that patients with diabetes who suspect hearing loss should contact their primary care physician for possible referral to an audiologist.

Another cause of hearing loss is smoking. According to the Centers for Disease Control and Prevention (CDC), approximately 42.1 million people in the United States smoke, and far more are exposed to secondhand smoke. Additionally, the CDC estimates that 53.6% of the children in the United States were exposed to secondhand smoke in 2007 to 2008.

Research indicates smokers are nearly two times more likely to experience hearing loss than nonsmokers, and people who are exposed to secondhand smoke have a 1.94 times greater risk of developing hearing loss.9 There also is a correlation between hearing loss and the number of cigarettes and frequency of smoking. According to a longitudinal study of Japanese male office workers, the longer people smoked and the more cigarettes they smoked each day, the greater the hearing damage.10

In addition, patients’ past noise exposure from high–noise-level occupations or activities dramatically increases presbycusis. The correlation between high noise levels and permanent hearing loss is well documented in the literature. The intensity and frequency of the sound and the period of time over which an individual experiences high noise levels influences the extent of damage that occurs in the inner ear. Primary care physicians should routinely screen for hearing loss in patients who report past noise exposure. These patients often will also complain of tinnitus.

Additional Contributing Factors
Idiopathic sudden sensorineural hearing loss (SSNHL), defined as the onset of an unexplained one-sided hearing loss or sudden deafness, affects an estimated five to 20 people per 100,000,11 which likely is a low estimate, as many such patients never seek medical attention. Sudden hearing loss occurs over the course of a few hours and often is accompanied by dizziness, vertigo, and/or tinnitus.

Often people who have SSNHL believe it has resulted from impacted earwax and often fail to seek immediate attention. Many physicians’ offices delay seeing patients who call to complain of a sudden hearing loss; however, it’s important to see and diagnose such patients within 72 hours of the time patients first notice the hearing loss. Physicians’ office staffs should be made aware of the importance of this timeline when patients call the office.

It’s likely a physician who sees a patient with this complaint will observe nothing on physical examination of the ear. An audiologist can determine whether the loss has resulted from inner ear or sensorineural involvement and differentiate the origin from other causes.

Not all cases of SSNHL are idiopathic. When no clear cause is determined, it’s described as SSNHL. The most popular theories to explain these cases include viral infection, immune system inflammation, and impaired circulation where blood supply is cut off for a period of time. Whatever the cause, it’s important to reach a timely diagnosis and immediately initiate an aggressive treatment program.

The standard treatment for SSNHL is a tapering course of oral corticosteroids (prednisone or methylprednisolone). In some cases, the steroids are injected directly into the inner ear through the tympanic membrane.12 Serial audiograms help document the degree of improvement, if any.

If the hearing loss is permanent, caution should be taken to protect the hearing in the good ear. Lifelong avoidance of scuba diving and exposure to loud, hazardous noise levels (eg, recreational shooting, loud music) should be strongly considered. In rare cases, the hearing loss can be bilateral. If hearing doesn’t return, hearing devices often can be effective.11

Earwax routinely is produced by the glands located in the ear canal and helps protect the ears from dirt and insects. However, the sticky, odorless substance can become impacted and cause hearing loss. In advanced age, the glands often produce an overabundance of wax. Bits and pieces of wax naturally fall out as we chew or converse, but earwax often becomes impacted by the overuse of Q-tips that push wax deeper into the ear canal. If impacted wax is suspected, proper diagnosis and removal are important. The symptoms of impacted wax are a feeling of blockage in the ear, diminished hearing and, at times, tinnitus.

An otoscope enables physicians to visualize wax impaction. An audiologist can use instruments to measure whether the ear is impacted, for example, an acoustic impedance bridge, which also can measure any perforation of the tympanic membrane.

If a perforation in the eardrum is detected, extreme caution must be used when removal of earwax is warranted. The wax is softened with an over-the-counter softening product, and a water syringe can gently wash it out. Physicians often also use a specialized spoonlike instrument to remove wax. Its removal provides improved hearing, and the physician can clearly observe the tympanic membrane clearly.13

It’s important that a hearing test be performed prior to and following earwax removal to measure the differences, with the percentage of improvement documented in an audiogram.

Ototoxic Drugs
Certain medications can damage the ear, resulting in hearing loss, tinnitus, and balance disorders. There are roughly 300 over-the-counter and prescription drugs currently available that have been shown to be potentially ototoxic.14 Hearing loss caused by an ototoxic medicine usually develops quickly, with ringing in the ears presenting as the first manifestation. Hearing can sometimes return to normal after discontinuing the medication; however, some medications can cause permanent hearing damage.

It remains unknown how common ototoxic side effects are. With extremely ototoxic drugs such as cisplatin, used in cancer treatment, virtually every patient who takes the drug suffers hearing loss.15 And with aminoglycoside antibiotics, one study found that of the 53 study participants who took these drugs, 47% developed hearing loss.16 Researchers estimate that each year approximately 4 million Americans receive aminoglycoside antibiotics such as gentamicin, neomycin, vancomycin, and tobramycin.17

Some common over-the-counter medications are potentially more ototoxic when recommended doses are exceeded, but the effects can be reversed once the medications are discontinued. These medications include aspirin and NSAIDs such as ibuprofen and naproxen. Websites such as those for The Center for Hearing and Communication, the American Speech-Language-Hearing Association, the Hearing Loss Association of America, and the American Tinnitus Association provide lists of potentially ototoxic medications.

Physicians, pharmacists, and caregivers must become familiar with prescription and over-the-counter drugs that can be ototoxic and recognize the early symptoms and signs of ototoxicity. If a known ototoxic drug is prescribed, an audiologist should complete a baseline hearing evaluation and perform serial hearing tests while patients remain on the drugs. If hearing loss is detected, changing the dosage or prescribing a different drug often can prevent permanent hearing loss.

Assistive Hearing Technology
Although hearing aids have existed for more than 100 years, the use of digital technology and programming computers over the past two decades has advanced the capabilities of hearing devices to an extraordinary level. Hearing aids are no longer simply amplifiers but are small computers making thousands of adjustments to maximize hearing enhancement. Newer devices can reduce background noise and enhance human speech frequencies while providing more amplification at certain pitch levels where deficits exist.

Hearing aids and related devices are individually programmed based on many factors, including a patient’s age and processing capabilities and the degree and type of hearing loss. As hearing loss progresses, the devices can be reprogrammed to accommodate changes in hearing function. Additionally, some hearing devices have connectivity capabilities and can be used with televisions, cell phones, landline phones, and music listening devices.

Patients should learn proper maintenance of hearing aids and devices, including how often the batteries should be changed and how to properly clean them because they are mechanical devices that can break or malfunction. Patients should know that expert evaluation and correction may be needed if whistling or feedback occurs, since this should not continue.

Hearing aids, which come in various shapes, sizes, and price ranges, should be acquired through an audiologist or a dispenser experienced in proper fitting. Each state has licensing bodies that oversee the fitting of hearing aids, which are considered medical devices. Most insurance plans, including Medicare, don’t pay for hearing aids although the cost of a hearing evaluation by a credentialed audiologist usually is reimbursed.

However, four out of five Americans with hearing loss don’t wear hearing devices,18 and many people don’t realize that such devices can treat the majority of hearing losses. Untreated hearing loss can cause embarrassment, social stress, tension, and fatigue not only for the sufferer but also for family members, friends, and colleagues.

One of the primary reasons people choose not to wear hearing devices is denial of the hearing disability itself. Other factors include cost (roughly $800 to $3,500 each), vanity, inconvenience, and misunderstanding about hearing aids. Many people think of hearing aids as the large banana-shaped devices their grandparents wore.

Family members and caregivers can play an important role in encouraging people with hearing loss to try wearing hearing devices and accept them as a way to improve quality of life. For many, physicians’ and family members’ and friends’ encouragement create the deciding factor in a patient’s acceptance.

Final Thoughts
Pervasive among the geriatric population, hearing loss can significantly affect older adults’ cognitive function and social well-being as well as adversely affecting family members and caregivers. But an audiologist’s evaluation and professional recommendations can help correct hearing loss with the use of modern hearing devices that can effectively improve hearing capabilities when expertly fitted and adjusted.

Physicians and family members/caregivers should encourage patients with suspected hearing loss to seek specialized care and reap the benefits of correctly and consistently worn hearing devices.

— Renee A. Monahan, AuD, CCC-A , and Louis R. Sieminski, PhD, CCC-A, are audiologists in private practice at The Hearing Center of NEPA in Kingston, Pennsylvania.

Identifying Hearing Loss
If patients answer yes to some of the following questions, they may have a hearing loss:

1. Do you have trouble hearing in groups?

2. Do you ask people to repeat what they say?

3. Do you think people tend to mumble?

4. Do you turn up the volume on the television?

5. Do you have difficulty hearing some people on the phone?

6. Do you have difficulty hearing at the movies?

7. Do you have difficulty hearing in noisy restaurants or at parties?

8. Do you have trouble hearing at work?

9. Do you have difficulty hearing in a car or bus?

10. Do family members think you have a hearing loss?

1. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA. 2003;289(15):1976-1985.

2. Kochkin S. MarkeTrak VII: hearing loss population tops 31 million people. Hear Rev. 2005;12(7):16-29.

3. Hebert LE, Weuve J, Scherr PA, Evans DA. Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology. 2013;80(19):1778-1783.

4. Hearing loss and dementia linked in study. Johns Hopkins Medicine website. February 14, 2011.

5. Palmer CV, Adams SW, Bourgeois M, Durrant J, Rossi M. Reduction in caregiver-identified problem behaviors in patients with Alzheimer’s disease post-hearing-aid fitting. J Speech Lang Hear Res. 1999;42(2):312-328.

6. Comarow A, US News staff. US News’ best nursing homes—2013. MSN Healthy Living website.

7. Bainbridge KE, Hoffman HJ, Cowie CC. Diabetes and hearing impairment in the United States: audiometric evidence from the National Health and Nutrition Examination Survey, 1999 to 2004. Ann Intern Med. 2008;149(1):1-10.

8. Study: Diabetes affects hearing loss, especially in women. Henry Ford Health System website.

9. Cruickshanks KJ, Klein R, Klein BE, Wiley TL, Nondahl DM, Tweed TS. Cigarette smoking and hearing loss: the epidemiology of hearing loss study. JAMA. 1998;279(21):1715-1719.

10. Nakanishi N, Okamoto M, Nakamura K, Suzuki K, Tatara K. Cigarette smoking and risk for hearing impairment: a longitudinal study in Japanese male office workers. J Occup Environ Med. 2000;42(11):1045-1049.

11. Sudden deafness. Massachusetts Eye and Ear Infirmary website. Updated March 21, 2011.

12. The buzz on ... sudden hearing loss. Rush University Medical Center website.

13. Diseases & conditions: cerumin impaction. Cleveland Clinic website. Last reviewed December 20, 2013.

14. Bauman N. Drugs and tinnitus: put yourself in the driver’s seat. Tinnitus Today. 2009;34(1):21-23.

15. Fausti SA, Henry JA, Schaffer HI, Olson DJ, Frey RH, Bagby GC Jr. High-frequency monitoring for early detection of cisplatin ototoxicity. Arch Otolarygol Head Neck Surg. 1993;119(6):661-666.

16. Fausti SA, Henry JA, Schaffer HI, Olson DJ, Frey RH, McDonald WJ. High-frequency audiometric monitoring for early detection of aminoglycoside ototoxicity. J Infect Dis. 1992;165(6):1026-1032.

17. Fausti SA, Wilmington DJ, Helt PV, Helt WJ, Konrad-Martin D. Hearing health and care: the need for improved hearing loss prevention and hearing conservation practices. J Rehabil Res Dev. 2005;42(4 Suppl 2):45-62.

18. Kochkin S. MarkeTrek VII: obstacles to adult non-user adoption of hearing aids. Hear J. 2007;60(4):27-43.