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Now hear this: Paying attention to hearing loss

As the American population grays, age-related hearing problems will become more widespread. Doctors play a key role in helping patients realize it's a condition that can be addressed.

By Susan J. Landers, amednews staff. Nov. 4, 2002.

Recently retired couples soon may begin replaying the following scene in their physicians' offices. Wife to physician: "He's deaf as a post." Husband to physician: "No I'm not, she doesn't talk correctly."

They may both be right.

Hearing loss indicators
Toward better hearing
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But to get to the bottom of the problem, and to avoid conversing at top volume with aging baby boomers, primary care physicians should consider routinely screening patients for possible hearing loss. It's a step that can have a significant impact both on patients' quality of life and their health outcomes.

"We always get our vision tested, but not our hearing," said Lynn Luethke, PhD, the National Institutes of Health program director in hearing. Still, sensorineural hearing loss is one of the most prevalent disabling conditions in the United States, according to NIH findings. It affects some 20 million to 26 million people and is already present in 35% to 42% of individuals older than 65.

Unlike conductive hearing loss, which is correctable by removing an obstacle to sound waves, for instance a buildup of earwax, sensorineural hearing loss develops when the auditory nerve or hair cells in the inner ear are damaged. Noise, smoking, aging and certain medications are believed to be the cause.

"It's the No. 1 disability among the elderly," noted David Nielsen, MD, executive vice president of the American Academy of Otolaryngology.

Hearing loss is the No. 1 disability among the elderly.

"We call it the silent disability. There's no wheelchair or white cane, no cast on an arm or leg. People who have it just muddle through, struggling with communication," he said.

Muddling through is not the best option. Hearing loss can lead to a marked decline in quality of life, according to a large survey of older people published in 2000 by the National Council on the Aging and Market Strategies Inc., headquartered in Livonia, Mich.

Their survey of more than 2,000 people with hearing loss and an additional 2,000 of their family and friends revealed that people with untreated hearing loss reported more sadness, depression, worry, anxiety and paranoia.

Hearing loss as a disability is often underrated, Dr. Nielsen stressed. Even people with a mild to moderate loss may be unable to follow discussions in a large group. "There is a tendency to smile and nod and pretend that you are a part of society, but you're really not. And pretty soon these people become isolated," he said.

For many patients, help is available. Hearing aids have improved over the past several years and can improve the hearing of many people.

A study published in Journal of the American Medical Association two years ago concluded that wearing a hearing aid made a difference in the life of a person with hearing loss. This was true regardless of which of the three types of hearing aids used in the study was worn by a subject.

A third of people older than 65 have hearing loss.

"We were hoping that by publishing the study in JAMA we would get the word out that you need to get your patients tested," Dr. Luethke said.

Dr. Luethke has yet to see evidence that the message is out there in a big way, and most people continue to live with their hearing loss.

"About 80% of Americans who have significant hearing loss don't seek appropriate help," he said.

The stigma of wearing hearing aids is part of the reason, as is a patient's denial that a problem exists, Dr. Nielsen said. But statistics also indicate that appropriate referrals are not made often enough.

The problem may stem from society's view that hearing loss is a normal part of aging, so why bother with it, said Ken Brummel-Smith, MD, a geriatrician at the Providence Center on Aging in Milwaukie, Ore.

"Often older people will not complain of hearing loss even if it is happening. Or they don't recognize that it is occurring, and family members have to cajole them into having it checked out," he said.

80% of people with significant hearing loss don't seek help.

Primary care physicians can assess for hearing loss using such simple tools as the whisper test, Dr. Brummel-Smith said.

Standing behind a patient and whispering a series of numbers and letters for them to repeat is an easy assessment for hearing loss, Dr. Brummel-Smith said. In addition, most physicians have audiometers that can detect hearing loss quickly.

A series of questions that patients can answer for themselves, such as "Do people complain that I turn the television volume up too high?" or "Do I have trouble hearing when there is noise in the background?" can also be helpful in detecting hearing loss.

Once a hearing loss has been detected and that loss improved upon, patients also may gain a measure of safety by being better able to hear approaching traffic and sirens, Dr. Brummel-Smith said.

"And some data suggest that people with early dementia can also benefit from hearing aids," he said. "If they hear better and participate in conversations, there is some evidence that they function better."

Finding an audiologist who will take the time to work with a patient, especially one with dementia, is crucial to a successful outcome. Thorough evaluations of patients, accompanied by reports that are understandable to physician and patient alike, are prime considerations for judging audiologists, Dr. Brummel-Smith said. A report larded with the jargon of the profession would not be terribly helpful, he noted.

Physicians should develop a good working relationship with a reputable audiologist or hearing specialist, Dr. Brummel-Smith stressed. "There are a lot of shady operators out there who will sell low-quality units at high cost."

Reality checks

Patients also must have a realistic view of what hearing aids can and cannot do for them to be satisfied with the devices. Discontent with hearing aids is common, and part of that stems from inadequate preparation.

Patients who expect to hear like they did in their younger days are likely to be disappointed. Age-related hearing loss not only affects the volume of sound, Dr. Nielsen noted, it also affects distortion and clarity.

The 15 or 20 minutes a physician or audiologist spends explaining what a hearing aid will not do is very important to future satisfaction with an aid, he said. "I think it's critical to advise patients which of their expectations are reasonable and which are not," he said.

Hearing aids take some getting used to. "I ask patients, 'Can you imagine how long it would take you to learn to walk if you had to have a prosthetic leg following an amputation?' " Dr. Brummel-Smith said. "And they say, 'Oh yes, it would take months to get good at it.' Then I tell them the same thing is true of a hearing aid. It takes your brain months to get used to it."

"An audiologist is constantly talking about realistic expectations and counseling people that it takes six months to a year for the auditory system to accommodate itself to the sounds the hearing aids are sending up the auditory pathway," said Angela Loavenbruck, EdD, president of the American Academy of Audiology. Patience and realistic expectations are crucial to a patient being satisfied with hearing aids, she said.

Many physicians and audiologists also counsel family members to speak more distinctly when addressing a person with a hearing loss and to position themselves in areas that have the least amount of background noise at restaurants and parties.

When it comes to deciding on a specific type of hearing aid and whether it is worn behind the ear, inside the outer portion of the ear or in the ear canal, price and vanity play major roles.

The smallest and least obvious aids are costly -- up to $3,500 each for a tiny sophisticated digital device, Dr. Loavenbruck noted. In addition, such small hearing aids require a certain amount of dexterity to maintain. A patient with some dementia would not be a good candidate for a tiny hearing aid into which they must insert tiny batteries, she said.

"People come to us with very definite ideas about what they will or won't wear," she said. "We sometimes have to help them accept a device they thought they were unwilling to wear but which is going to be much more usable for them and more beneficial."

A patient's individual living circumstances often dictate which hearing aid will be most satisfactory, she said. An older person who is mainly at home listening to television and visiting with family and friends in quiet surroundings probably will not require a device with advanced programmable circuitry. But an older person who is actively attending meetings and doing volunteer work would be a good candidate for a programmable hearing aid.

The inside circuitry of hearing aids varies even if they are the same style. There are analog aids built by a laboratory to certain specifications established by the audiologist or other hearing specialist; computer programmable analog aids that are set by the hearing specialist to accommodate more than one program; or programmable digital devices that are equipped with microphone, receiver and computer chip and are the most flexible when it comes to adjustments.

The analog devices are the least costly, and the digital aids are the most expensive.

Patients do have between 30 and 60 days to try their hearing aids and, if they decide they don't like them, to have most of their money refunded. The Food and Drug Administration set the 30-day return policy. Individual states and practitioners may have established more liberal policies.

Also, there is no hard evidence that one type of hearing aid is better than another, Dr. Luethke noted, although for some people the newer technologies seem to make a difference. "But at this point the message is to get people to try hearing aids and to let them know that they don't have to go for the fancy ones," she said.

"Hearing aids come in all different shapes and sizes and prices," Dr. Luethke said. "My advice to people is to find a reputable person, either an audiologist or someone who is licensed as a distributor. Word of mouth from someone who is happy with their hearing aids is a good way to get referrals."

For patients who can't tolerate any object on or in the ear, perhaps those with psoriasis, implantable hearing aids may be an option. Approved two years ago by the FDA, the devices are surgically placed behind the eardrum or on the bones that conduct sound from the eardrum to the inner ear.

But while the implantable devices may signal what's to come, standard hearing aids are by far the more popular and probably will be for many years, Dr. Nielsen said.

"There have been some preliminary studies indicating that patients who use implantable aids hear better in noise, which is a big complaint of hearing aid users," Dr. Luethke said. "But that hasn't been validated yet.

"My advice would be for people to try conventional hearing aids before implantables," she said.

ADDITIONAL INFORMATION:

Hearing loss indicators

Ask your patients if they find themselves:

Asking people to repeat what they said.
Experiencing a ringing, buzzing, hissing or roaring in their ears.
Misunderstanding conversations.
Staying home to avoid social situations.
Complaining that people mumble.
Experiencing undue fatigue at the end of the day.
Turning up the volume on the TV, radio or stereo.
Having difficulty understanding speakers at public meetings or religious services.

Source: American Academy of Audiology

Toward better hearing

Some points to discuss when encouraging a patient to see a hearing specialist:

Hearing loss can cause withdrawal from social settings and events that were once enjoyed, and can cause misunderstandings that lead to strained relationships with family members and friends.
Hearing aids can help many people, and a comprehensive evaluation for a hearing device by a specialist is an excellent first step.
Hearing aids take time to get used to, often six months to a year, and likely will require additional visits to the specialist for fine-tuning after the first fitting.
Hearing aids are returnable for a refund of most of their cost after a trial period ranging from 30 to 60 days, depending on state or individual hearing specialist's policy.
Hearing aids are shrinking, and some tiny aids are worn unobtrusively deep inside the ear canal. But patients should remain open to the advice of the hearing professional as to whether behind-the-ear, in-the-ear, in-the-canal or completely-in-the-canal is the best type for them.
Advanced circuitry in some hearing aids can be programmed to greatly enhance sound. But these hearing aids are very expensive, and a less-expensive conventional hearing aid may be more suitable.
There is a lot that a hearing aid can't do. It can't return a patient's hearing to the way it was in their youth, and it may still be difficult to hear individual conversations in a noisy room.