SMART TALK TO SHARE WITH PATIENTSAge-related hearing loss
Age-related hearing loss By Kourosh Parham, MD, PhD, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Connecticut Health, Farmington, CT/AAO-HNS Geriatric Otolaryngology Committee Part of an occasional patient-focused series on geriatric otolaryngological care May is Better Hearing and Speech Month, a time to raise public awareness about hearing and speech issues as well as available treatment options. This year we are focusing on the impact of hearing loss as related to age, from infants and children to working-age adults to the elderly. Otolaryngologists treat hearing loss in patients of all ages, helping to mitigate the impact hearing loss can have on one’s quality of life. You can learn more about Better Hearing and Speech Month online at www.entnet.org/BetterHearingSpeechMonth. Hearing loss is the most common sensory problem among older adults. Studies show that by 2060, 22 percent (92 million) of the population will be 85 or older, while 4 percent (18 million) of the population will be around 65 years old. Age-related hearing loss (ARHL, also known as presbycusis) is, by far, the leading cause of hearing loss in developed countries. Currently it affects 50 percent of 65-year-olds and more than 80 percent of those 85 years old and older. Evaluation The diagnosis of ARHL is based on patient history, physical examination, and a battery of audiologic tests, including an audiogram. ARHL is a progressive condition arising from changes in the inner ear (the cochlea) and the brain. Because of its deceptive nature, people frequently are less aware of their communication difficulties than the people around them and often discuss the hearing problem reluctantly with a physician at the insistence of family members. Hearing loss specifics over time Although early hearing loss is different for all and dependent on a number of factors, often the earliest sign of ARHL appears late in middle age. By this time, cochlear changes are advanced enough to affect hearing within the sound range that makes up our daily lives. Often the experience of loss causes a person to misidentify words that sound the same and then make up for this problem by using the situation to understand the meaning. Age-related high-pitched hearing loss results in difficulty hearing consonants and makes hearing in noisy places more difficult. Often these high-pitched sounds work to separate syllables and words from one another. Without them, words tend to run together and sound “mumbled.” As voices of children and women tend to have a higher pitch, the person with hearing loss may complain that women speak too softly or that “my grandchildren mumble.” Over the years, as a person’s hearing loss increases to include lower-pitched sounds, the loss is a bigger problem. This may result in a person’s lessening ability to understand difficult issues and to think and reason as quickly as would be normal. This means that hearing in noisy places and hearing accented or fast speech becomes more challenging. A common complaint from the person may be, “I can hear the words, but I can’t understand them.” People find what work-arounds as they can to cope. Some ask others to speak louder or more slowly, while others avoid conversation and social activity. There are also social ramifications to this attribute of age-related hearing loss. Difficulties hearing on the telephone, particularly cell phones in which quality of sound may fluctuate with the strength of the network signal, serve as a barrier to their effective use as an alternative to face-to-face communication. Related problems with hearing loss Besides speech sounds, other important high-frequency warning sounds (alarms, ringing tones, turn signals, etc.) also become more difficult to hear. Reduced ability to hear alarms raises concern about safety. For example, older individuals with hearing loss have been shown to be at increased risk of motor vehicle accidents while driving. Besides difficulty in hearing communication sounds and alarms, other auditory functions are also impaired such as the accuracy of detecting sound sources. As hearing loss severity increases, overall function diminishes among older individuals. It has long been speculated that inability to communicate effectively, and potential decreased overall functional status, will lead to social isolation. This association was not affected by use of hearing aids. Social isolation has significant implications for the well-being of geriatric patients: lonely or isolated older adults are at greater risk for development and progression of cardiovascular disease and are more than twice as likely to develop Alzheimer’s disease. Thus besides the insidious nature of the disorder, the isolation associated with hearing loss may be another factor that leads to delayed presentation and diagnosis, primarily because there is little pressure to seek care for communication difficulties. Inherent difficulties in communication, which result in compounding psychosocial effects such as isolation, may precipitate psychiatric disorders such as depression, but whether hearing loss can contribute to depression remains a subject of debate. Tinnitus Another symptom that affects the well-being of patients with sensorineural hearing loss is tinnitus (intrinsic noises not heard by others). The incidence of tinnitus increases with age: Tinnitus affects 15 percent of the general population and 33 percent of geriatric persons. Presence of tinnitus by itself is not an independent risk factor for depression, but older individuals who perceive their tinnitus to be a problem or have problems with tinnitus when going to bed often display depression symptoms. In patients who also have ARHL, tinnitus can be a source of emotional and sleep disorders, difficulties in concentration, and social problems. In geriatric patients, it has been shown that tinnitus is associated with worse control of congestive heart failure in geriatric patients and may have important clinical implications for the early identification of patients who need more aggressive management of heart failure. Managing hearing loss Based on the results of medical evaluation, candidacy for different rehabilitation strategies is considered. Depending on the severity of hearing loss, interventions could include improved communication strategies and modification of listening environment, to personal assistive devices and hearing aids, to cochlear implantation. While these strategies are principally directed at compensating for peripheral hearing loss, our understanding of age-related changes in the brain, including cognitive changes, have significant impact on rehabilitation strategies. Prevention A number of factors have been recognized as contributing to the development of ARHL. These might be broadly classified into two categories: intrinsic and extrinsic. Intrinsic factors are host factors and are primarily genetic (including gender and race). There are family genetics that we are born with and those we can help—health issues such as diabetes, hypertension, diabetes, and stroke. Managing these factors can have a critical role in prevention of ARHL. Because ARHL is a progressive condition, awareness of these factors is important not just to the older population, but also the young since their impact is not appreciated until decades later. Individuals with ARHL often report a family history of hearing loss among parents, siblings, and close relatives. Therefore, it has been presumed that ARHL has a genetic component that influences the age of onset and severity of the loss. Challenges in separation of environmental from genetic factors have made it difficult to assess the contribution of genetics to ARHL. Overall, the heritability estimates suggest that up to 55 percent of the variance ARHL is attributable to genes. This means in a large group of biologically related people, hearing sensitivity is more similar than in a group in the same general environment, but who are unrelated. Modifiable risk factors The influence of genetics is likely to be modulated by a set of non-genetic factors. Cardiovascular disease, high blood pressure, and diabetes are well recognized as risk factors. Older persons with moderate-to-severe hearing loss have a significantly higher likelihood of reporting previous stroke, but it should be emphasized that ARHL is not predictive of increased risk of stroke. Chronic kidney disease and systemic inflammation may contribute to progression of ARHL. A common thread among these disorders is vascular disease/arteriosclerosis. Environmental factors There is also a set of modifiable environmental factors that have been identified. Noise exposure and cigarette smoking are the best established risk factors. Among older adults, history of exposure to workplace noise raises the risk of cardiovascular disease and angina, and severe exposure was associated with risk of stroke. There is much concern about recreational noise exposure, particularly given prevalence of personal listening devices among the younger population. Smoking-related worsening of hearing loss with age is likely mediated by vascular disease. Long-time smokers with occupational noise exposure tend to have higher risk of permanent sensorineural hearing loss. Oxidative stress is one possible mechanism for the aging process, and cochlear oxidative stress has been implicated in ARHL. Diets rich in antioxidants have been suggested to reduce ARHL and there is some evidence that healthy diets tend to be associated with better high frequency thresholds in adults.
Age-related hearing loss
By Kourosh Parham, MD, PhD, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Connecticut Health, Farmington, CT/AAO-HNS Geriatric Otolaryngology Committee
Part of an occasional patient-focused series on geriatric otolaryngological care
Evaluation
The diagnosis of ARHL is based on patient history, physical examination, and a battery of audiologic tests, including an audiogram. ARHL is a progressive condition arising from changes in the inner ear (the cochlea) and the brain. Because of its deceptive nature, people frequently are less aware of their communication difficulties than the people around them and often discuss the hearing problem reluctantly with a physician at the insistence of family members.
Hearing loss specifics over time
Although early hearing loss is different for all and dependent on a number of factors, often the earliest sign of ARHL appears late in middle age. By this time, cochlear changes are advanced enough to affect hearing within the sound range that makes up our daily lives. Often the experience of loss causes a person to misidentify words that sound the same and then make up for this problem by using the situation to understand the meaning.
Age-related high-pitched hearing loss results in difficulty hearing consonants and makes hearing in noisy places more difficult. Often these high-pitched sounds work to separate syllables and words from one another. Without them, words tend to run together and sound “mumbled.” As voices of children and women tend to have a higher pitch, the person with hearing loss may complain that women speak too softly or that “my grandchildren mumble.”
Over the years, as a person’s hearing loss increases to include lower-pitched sounds, the loss is a bigger problem. This may result in a person’s lessening ability to understand difficult issues and to think and reason as quickly as would be normal. This means that hearing in noisy places and hearing accented or fast speech becomes more challenging. A common complaint from the person may be, “I can hear the words, but I can’t understand them.”
People find what work-arounds as they can to cope. Some ask others to speak louder or more slowly, while others avoid conversation and social activity. There are also social ramifications to this attribute of age-related hearing loss. Difficulties hearing on the telephone, particularly cell phones in which quality of sound may fluctuate with the strength of the network signal, serve as a barrier to their effective use as an alternative to face-to-face communication.
Related problems with hearing loss
Besides speech sounds, other important high-frequency warning sounds (alarms, ringing tones, turn signals, etc.) also become more difficult to hear. Reduced ability to hear alarms raises concern about safety. For example, older individuals with hearing loss have been shown to be at increased risk of motor vehicle accidents while driving. Besides difficulty in hearing communication sounds and alarms, other auditory functions are also impaired such as the accuracy of detecting sound sources.
As hearing loss severity increases, overall function diminishes among older individuals. It has long been speculated that inability to communicate effectively, and potential decreased overall functional status, will lead to social isolation. This association was not affected by use of hearing aids. Social isolation has significant implications for the well-being of geriatric patients: lonely or isolated older adults are at greater risk for development and progression of cardiovascular disease and are more than twice as likely to develop Alzheimer’s disease. Thus besides the insidious nature of the disorder, the isolation associated with hearing loss may be another factor that leads to delayed presentation and diagnosis, primarily because there is little pressure to seek care for communication difficulties.
Inherent difficulties in communication, which result in compounding psychosocial effects such as isolation, may precipitate psychiatric disorders such as depression, but whether hearing loss can contribute to depression remains a subject of debate.
Tinnitus
Another symptom that affects the well-being of patients with sensorineural hearing loss is tinnitus (intrinsic noises not heard by others). The incidence of tinnitus increases with age: Tinnitus affects 15 percent of the general population and 33 percent of geriatric persons. Presence of tinnitus by itself is not an independent risk factor for depression, but older individuals who perceive their tinnitus to be a problem or have problems with tinnitus when going to bed often display depression symptoms. In patients who also have ARHL, tinnitus can be a source of emotional and sleep disorders, difficulties in concentration, and social problems. In geriatric patients, it has been shown that tinnitus is associated with worse control of congestive heart failure in geriatric patients and may have important clinical implications for the early identification of patients who need more aggressive management of heart failure.
Managing hearing loss
Based on the results of medical evaluation, candidacy for different rehabilitation strategies is considered. Depending on the severity of hearing loss, interventions could include improved communication strategies and modification of listening environment, to personal assistive devices and hearing aids, to cochlear implantation. While these strategies are principally directed at compensating for peripheral hearing loss, our understanding of age-related changes in the brain, including cognitive changes, have significant impact on rehabilitation strategies.
Prevention
A number of factors have been recognized as contributing to the development of ARHL. These might be broadly classified into two categories: intrinsic and extrinsic. Intrinsic factors are host factors and are primarily genetic (including gender and race).
There are family genetics that we are born with and those we can help—health issues such as diabetes, hypertension, diabetes, and stroke. Managing these factors can have a critical role in prevention of ARHL. Because ARHL is a progressive condition, awareness of these factors is important not just to the older population, but also the young since their impact is not appreciated until decades later. Individuals with ARHL often report a family history of hearing loss among parents, siblings, and close relatives. Therefore, it has been presumed that ARHL has a genetic component that influences the age of onset and severity of the loss.
Challenges in separation of environmental from genetic factors have made it difficult to assess the contribution of genetics to ARHL. Overall, the heritability estimates suggest that up to 55 percent of the variance ARHL is attributable to genes. This means in a large group of biologically related people, hearing sensitivity is more similar than in a group in the same general environment, but who are unrelated.
Modifiable risk factors
The influence of genetics is likely to be modulated by a set of non-genetic factors. Cardiovascular disease, high blood pressure, and diabetes are well recognized as risk factors. Older persons with moderate-to-severe hearing loss have a significantly higher likelihood of reporting previous stroke, but it should be emphasized that ARHL is not predictive of increased risk of stroke. Chronic kidney disease and systemic inflammation may contribute to progression of ARHL. A common thread among these disorders is vascular disease/arteriosclerosis.
Environmental factors
There is also a set of modifiable environmental factors that have been identified. Noise exposure and cigarette smoking are the best established risk factors. Among older adults, history of exposure to workplace noise raises the risk of cardiovascular disease and angina, and severe exposure was associated with risk of stroke. There is much concern about recreational noise exposure, particularly given prevalence of personal listening devices among the younger population. Smoking-related worsening of hearing loss with age is likely mediated by vascular disease. Long-time smokers with occupational noise exposure tend to have higher risk of permanent sensorineural hearing loss.
Oxidative stress is one possible mechanism for the aging process, and cochlear oxidative stress has been implicated in ARHL. Diets rich in antioxidants have been suggested to reduce ARHL and there is some evidence that healthy diets tend to be associated with better high frequency thresholds in adults.