Article Archive
January/February 2017

The Far-Reaching Consequences of Untreated Hearing Loss
By Renee A. Monahan, AuD, CCC-A; Louis R. Sieminski, PhD, CCC-A; and Joseph Motzko, AuD, CCC-A
Today's Geriatric Medicine
Vol. 10 No. 1 P. 18

Hearing loss in older adults negatively affects social, physical, and cognitive aspects of daily routines. Though hearing impairment can often be easily corrected, relatively few take advantage of available solutions.

There is widespread belief that hearing loss is a benign result of aging. However, the latest research reveals that untreated hearing loss can have significant negative consequences on an individual's physical, mental, and social health. According to a study conducted by The National Council on Aging, untreated hearing loss can result in significant emotional and social consequences. The study found that hearing-impaired adults with untreated hearing loss were more likely to report depression, anxiety, and paranoia and were less likely to participate in social activities compared with those who wore hearing aids. According to James Firman, EdD, president of The National Council on Aging, "This study debunks the myth that untreated hearing loss in older persons is a harmless condition."1

Hearing loss can occur at any age and for many reasons. Prolonged exposure to high-intensity noises such as machinery can lead to noise-induced hearing loss. Some medications are ototoxic and can cause or accelerate hearing loss. Impacted cerumen, otosclerosis, and perforated tympanic membranes can also cause hearing loss, but are largely correctable and reversible. However, the largest proportion of hearing loss in the geriatric population results from presbycusis.

Presbycusis is the decrease of hearing due to aging.2 A hearing loss arises due to naturally occurring degradation of the inner ear structures and is not medically correctable. Presbycusis is generally a slowly progressive hearing loss that affects both ears. Presbycusis begins in the higher frequencies, where it affects the proper understanding of the (soft) consonants of speech, such as the /s/, /sh/, /th/, or /f/ sounds. It is this loss of clarity that leads people to report perceiving others as mumbling or lacking proper enunciation. These problems are more evident when background noise is present and noise further masks speech sounds. The effects of presbycusis can be minimized with properly fitted hearing aids.

Adults with presbycusis often do not readily perceive their own hearing loss until it has advanced significantly. Presbycusis is a gradual loss occurring over many years. Typically, an individual's family, friends, or caregivers are the first to recognize a hearing problem. Common signs of hearing loss, as observed by others, include answering questions inappropriately or asking questions that seem unrelated to the conversation.

Presbycusis results from aging; therefore, it follows that as people age, the prevalence of hearing loss also increases. Research published in The Journals of Gerontology Series A: Biological Sciences and Medical Sciences finds that 45.6% of people between the ages of 70 and 74 have hearing loss, and the percentage grows to 80.6% for people over the age of 85. Generally, men of all ages have a higher incidence of hearing loss than females, and whites are twice as likely as blacks to have hearing loss. The prevalence of hearing loss increases as education and income decreases.3 The first baby boomers, those Americans born between 1946 and 1964, turned 70 years in 2016. This cohort's aging has created a rapidly growing segment of the population that has or will have hearing loss.

Baby boomers plan to work longer than other generations as they age and want to remain socially active. Those with hearing loss or suspected loss desire competent professionals who will expertly evaluate their hearing and provide solutions. However, most hearing-impaired elderly do not seek solutions despite the well-documented consequences of impaired hearing. Of the estimated 35 million Americans who are hearing impaired, only 28.5% wear hearing devices. A 2005 MarkeTrak VII report projected that the number of Americans with hearing loss will increase to 40 million by 2025.4 It is hoped that the percentage who will seek help and wear hearing devices will increase as the knowledge and recognition of the adverse consequences of untreated hearing loss are better understood.

Negative Results of Hearing Loss
Studies have shown that even a mild untreated hearing loss can have adverse effects on an individual's social, psychological, cognitive, and overall health.5 Studies have linked untreated hearing loss to the following effects:6

• irritability, negativism, and anger;
• fatigue, tension, stress, and depression;
• avoidance or withdrawal from social situations;
• social rejection and loneliness;
• reduced alertness and increased risk to personal safety;
• impaired memory and ability to learn new tasks;
• reduced job performance and earning power;
• diminished psychological and overall health;
• increased number of falls and accidents;
• potential decrease in cognitive skills;
• reduced short-term memory; and
• higher incidence of dementia.

As a result of some of these conditions, individuals with hearing loss struggle to perform many everyday tasks, such as understanding conversations with loved ones or friends and with hearing the TV, music, or telephone conversations. Frustration with the inability to hear and understand conversations frequently causes older adults with hearing loss to avoid restaurants or other noisy places. Likewise, these individuals experience difficulty in understanding cashiers, sales clerks, and their priests or ministers.

Relatives and friends of hearing-impaired individuals can also be adversely affected. Relationships with children, grandchildren, other relatives, and friends are adversely affected, sometimes to the extent that individuals experience a decrease in their willingness to socialize with or engage in a conversation when a loved one consistently fails to hear them properly. Friends and family members' frustration likewise increases when attempting to communicate with a person with untreated hearing loss.7

Hearing Loss and Cognitive Decline
Recent studies show untreated hearing loss leads to increased risk of cognitive decline and dementia. Frank Lin, MD, PhD, says, "The general perception is that hearing loss is a relatively inconsequential part of aging." However, recent findings suggest that it plays a much greater role in brain health. Lin has authored several studies pointing to a link between hearing loss and cognitive problems ranging from mild impairment to dementia. He further reports the more severe the loss, the greater the risk of developing dementia. Elderly individuals who had suffered a moderate hearing loss were at a three times greater risk of developing dementia than normal hearing subjects. Those with a more severe hearing loss were at a five times greater risk. The author states, however, that increased risk does not mean a person is certain to develop dementia.8

Some physicians now realize the significant link between hearing loss and cognitive decline. However, less than 25% of physicians screen for hearing loss even when dementia is suspected. According to P. Murali Doraiswamy, MBBS, a professor of psychiatry at Duke University and coauthor of The Alzheimer's Action Plan: What You Need to Know — And What You Can Do — About Memory Problems, From Prevention to Early Intervention and Care, "The benefits of correcting hearing loss on cognition are twice as large as the benefits of any cognitive enhancing drugs." Researchers believe that hearing loss causes "cognitive load"; the effect of constantly straining to understand stresses the brain. Lin and colleagues suggest hearing loss may affect brain structure in a way that contributes to cognitive problems. Brain imaging studies show that older adults with hearing loss have less gray matter in the brain that receives and processes sounds from the ears.9

Because most hearing losses cannot be corrected medically or surgically, the primary method for treating hearing loss is the use of hearing aids and, to a much lesser degree, cochlear implants. Despite the negative consequences of untreated hearing loss, only 20% of people with hearing loss have taken corrective action.3 Studies have shown there are many reasons adults fail to seek help in the form of hearing aids. Among the main reasons for not considering wearing hearing aids are denial, vanity, perceived stigma, and cost. There is also widespread belief that hearing aids cause people to appear weak or old.

Recent studies have shown that the great majority of people who wear hearing aids report positive results. The loved ones and caregivers of hearing-impaired hearing aid users report positive outcomes as well. A survey commissioned by the National Council on Aging showed that hearing aid use positively affected quality of life for both the hearing aid wearer and his or her relatives and friends. These findings were consistent with another randomized controlled study that found hearing loss was associated with decreased social interaction, communication, cognitive functioning, and an increase in depression. The study found these conditions were improved with hearing aid use.10

A 2015 scientific longitudinal study shows those who use hearing aids have the same cognitive level as those without hearing loss while also attenuating cognitive decline. The study also found that by helping to restore communication abilities, hearing aids can also help improve mood, increase social interactions, and enable participation in cognitively stimulating activities.11 Hearing aid use also helps to improve and maintain relationships with loved ones, friends, and caregivers.

21st Century Hearing Aids
Today's hearing aids are sophisticated digital, programmable, cosmetically appealing devices that have been proven to improve hearing even in noisy environments. It is imperative that the type and degree of hearing loss are diagnosed before a hearing aid is recommended or fitted. Once hearing devices are recommended, they should be fitted by a qualified and experienced audiologist.

The myth of benign hearing loss that "isn't that bad" has been shattered. Research has shown that hearing loss affects more than just hearing. Untreated hearing loss can affect people socially, mentally, and physically. The good news is that the use of properly fitted hearing aids has been shown to reduce or eliminate the challenges associated with hearing loss.

Hearing aids can help hearing-impaired individuals live better lives, participate in social activities, keep their jobs, and improve overall quality of life. It is strongly recommended that all individuals, especially those over the age of 60, have their hearing checked annually. If a hearing loss is suspected, a comprehensive audiologic evaluation by a board certified audiologist should be completed. The audiologist works hand in hand with an individual's physician to determine the best way to expertly treat the hearing loss. Through this comprehensive approach, patients can receive the hearing care and treatment they need.

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

1. Untreated hearing loss linked to depression, social isolation in seniors. Audiol Today. 1999;11:4.

2. Roland PS. Presbycusis. Medscape website. Updated November 24, 2015.

3. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011;66A(5):582-590.

4. MarkeTrak 9: a new baseline. Estimating hearing loss and adoption rates and exploring key aspects of the patient journey, Final Report, March 2014, Hearing Industries Association.

5. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment. A randomized trial. Ann Intern Med. 1990;113(3):188-194.

6. Arlinger S. Negative consequences of uncorrected hearing loss — a review. Int J Audiol. 2003;42(Suppl 2):2S17-2S20.

7. Lehane CM, Dammeyer J, Elsass P. Sensory loss and its consequences for couples' psychosocial and relational wellbeing: an integrative review. Aging Ment Health. 2016;7:1-11.

8. Lin FR, Metter EJ, O'Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214-220.

9. Hearing loss linked to accelerated brain tissue loss. ScienceDaily website. Published January 22, 2014.

10. Bentler RA, Niebuhr DP, Getta JP, Anderson CV. Longitudinal study of hearing aid effectiveness. I: Objective measures. J Speech Hear Res. 1993;36(4):808-819.

11. Amieva H, Ouvrard C, Giulioli C, Meillon C, Rullier L, Dartigues JF. Self-reported hearing loss, hearing aids, and cognitive decline in elderly adults: a 25-year study. J Am Geriatr Soc. 2015;63(10):2099-2104.

The correct fitting and wearing of hearing devices frequently goes unaccomplished. Often individuals, and especially the elderly, fail to be correctly fitted for hearing devices and fail to receive instructions on proper care of the devices. Individuals' brains process sounds differently, and peoples' homes as well as work and social environments are different. It is imperative that when hearing aids become necessary, they are fitted and programmed by a qualified and experienced audiologist.

A free or nominal-cost trial of the aids prior to purchase is highly recommended. The audiologist should explain the correct way to wear the aids, how to clean the devices, and how to properly change the batteries or troubleshoot the aids if they stop working. Hearing aids need periodic service and come with factory warranties. Payment can often be facilitated by companies that allow for monthly payments over extended periods.

Numerous studies have shown that the wearing of two hearing aids vs one is far more effective. Hearing devices must be worn all day every day, even when a hearing-impaired person is home alone. It takes the brain time to adapt to hearing more normally with the hearing aids. Often in the initial few days of use, an individual doesn't like or even recognize his or her own voice. Many hearing-impaired individuals tend to speak more loudly than necessary. Hearing loss interferes with the ability to properly monitor one's own voice.

Nobody prefers to wear hearing devices or spend money to purchase hearing aids. However, when they're necessary, it's imperative that professionals properly fit the appropriate hearing aids. Providers should refer hearing-impaired patients to a board-certified professional to properly evaluate hearing and then fit the correct hearing devices. Discourage patients from the inclination to purchase cheap hearing aids. Most professionals maintain websites listing their qualifications. Suggest to patients that they find a professional they trust and like, who will treat them with kindness, respect, and competence and provide great service.