Hearing Loss

Basic Facts & Information

What is Hearing Loss?
About a third of adults older than 65and half of those older than 85have some
hearing problem. It is the fourth most common chronic disease among older
adults.
Hearing loss is more than an inconvenience; it can lead to depression, withdrawal,
anger, loss of self esteem, and overall unhappiness with life. Theres even some
evidence it can affect your memory and other cognitive processes, as well your
mobility. Because it can make communicating with your healthcare professional
difficult, hearing loss can even jeopardize your overall health.
Age related hearing loss (ARHL) happens gradually over time, so that although
those around you may notice problems, you may think youre fine. Interestingly,
once people are diagnosed and begin using hearing aids or other forms of hearing
assistance technologies, do people realize how much hearing they have lost.
The bottom line is that treating hearing loss can significantly improve the quality
of your life and interactions with others, including relieving the depression often
associated with hearing loss.
Sound and the Ear
We define sound in two ways:

Frequency (pitch), which is measured in cycles per second. Normal

speech falls in a frequency range of 250 to 8,000 cycles per second with
most of the range important for speech understanding lying in the higher
frequencies (for example, 1500 to 4000 Hz).

Intensity (loudness), which is measured in decibels. The lowest intensity

at which a sound must be generated to be heard is called the threshold for
hearing. The higher your individual threshold, the louder the sound has to
be made to be heard and the worse your hearing.

Normal hearing depends on three components: your ear, the nerves leading from
the ear to the brain, and the brain. The ear modifies the sounds coming from the
outside and the brain processes and helps us understand and interpret sound.

Hearing starts with a sound wave, or vibration. The sound wave travels through
the outer part of your ear (ear canal) and travels to the eardrum which is a thin
membrane that separates the outer parts of the ear from the inner parts. When the
ear drum vibrates, three bones (auditory ossicles) send the vibration to the cochlea
(tiny spiral cavity with sensory cells), and the signals are carried by nerve fibers to
the brain where speech understanding takes place.
Hearing Loss Defined
Hearing loss is formally defined as the loss of the ability to hear pure tones across
the range of audio frequencies required to understand speech. The hearing loss
contributes in large part to difficulty understanding what others say especially in
noisy conditions. ARHL usually occurs in both ears.
There are three main types of hearing loss which include: conductive,
sensorineural, and mixed. ARHL is sensorineural in nature.

Updated: March 2012

Posted: March 2012

Hearing Loss
Causes & Symptoms
Hearing loss can be caused by physical changes in the ear, the auditory nerve, or
in the ability of your brain to process sound. Sometimes, all three might be
involved.
Age-Related Changes in the Ear
When you age, the outer part of the ear canal thins while earwax gets drier and
stickier. This increases the risk of impacted wax. In addition, the ear drum may
thickens, but the most significant changes are those that take place in the cochlear
with the loss of sensory cells and degenerative changes in the nerve fibers
carrying information from the sensory cells to the brain.

Conductive hearing loss. With this type of hearing loss, your hearing is
muffled. It is typically caused by a build up of ear wax, which clogs the
ear canal and prevents sound from entering. Your primary healthcare
professional can diagnose and remove the wax if there is an excessive

build-up. It is normal for all ears to have some was as this helps to protect
the outer ear.

Other causes of conductive hearing loss include infections in the skin

lining the ear canal, fluid in the middle ear, arthritis that affects the bones
of the ear, or a hole in the ear drum, none of which are very common in
older people. One condition that affects older individuals and cause
conductive hearing loss is Pagets disease of bone.

Sensorineural hearing loss. This is the most common type of hearing loss
in older adults. It is typically caused by degenerative changes or damage to
the hair cells and/or nerves in the cochlea,. The main cause is age but
excessive noise exposure and ototoxicity (see list below) are contributory.

Other causes of sensorineural hearing loss include genetics and blood

vessel problems (including those related to diabetes). More rarely, it may
be related to occupational and environmental chemical exposures and
certain autoimmune diseases or nerve tumors. Infections such as herpes
and influenza may cause sensorineural hearing loss, as can cigarette
smoking. People with diabetes and cerebrovascular disease are more prone
to hearing loss. Dual sensory impairment (for example, vision and hearing
loss) is a significant problem for at least 30% of older adults.

One type of sensorineural hearing loss, called central hearing loss,

occurs when you lose the ability to understand speech in adverse listening
situation such as in the presence of competing noise, competing
conversation, or in reverberant environments. People with dementia are
more likely than those without to have hearing loss. The hearing loss in
persons with dementia is often times more severe than in those without
dementia.
Signs and Symptoms of Hearing Loss
Typical signs of a hearing problem include:

Playing the radio or TV too loudly

Saying what? a lot during conversations

Having problems communicating during parties or in restaurants

Not hearing something if the person is out of your range of vision.

Sometimes you are so unaware of your hearing loss that it is up to a family

member to tell you and your healthcare professional that youre having problems
hearing.
A simple way to tell if youre having problems is with the whisper test. Have
someone stand about two feet away and whisper a letter or number combination
like ADE. If you cant hear the combination, you have some hearing loss and
should undergo formal testing. Ringing in the ear or tinnitus often accompanies
ARHL but it could be a symptom of a condition requiring medical attention so if
you experience this see your doctor or an otolaryngologist (ENT) doctor for an
evaluation.
Medications that May Affect Hearing
There are more than 200 ototoxic drugs, meaning they affect hearing. Often,
simply stopping the drug will restore the hearing, but sometimes the damage is
permanent. The first sign of hearing problems related to a medication is usually
tinnitus, or ringing in your ears. You may also experience some balance problems
or dizziness. Ototoxic medications include:

Certain antibiotics

Certain chemotherapy drugs

High doses of aspirin, acetaminophen and non-steroidal antiinflammatories

Loop diuretics

Antimalarial drugs.

Updated: March 2012

Posted: March 2012
Diagnosis & Tests
The first step in having your hearing evaluated is telling your healthcare
professional that you have a hearing problem. Dont be embarrassed as it is a
condition which is increasing in prevalence and for which effective treatments are
available.

The important thing is getting it diagnosed as soon as possible. This helps prevent
other physical and emotional effects such as depression and social isolation. In
fact, older adults should have their hearing assessed every year, just like vision
testing.
Physical Examination
Your healthcare professional will examine your ear canal for wax, foreign
material, inflammation, or other causes of conductive hearing loss and remove any
wax or other debris. If you feel you have a hearing loss or if it has gotten worse,
you may be referred to an otolaryngologist (ear, nose, throat doctor) for further
evaluation, and/or to an audiologist for a hearing testing and possible non-medical
treatment.
Audiometric Testing
Most hearing problems are diagnosed by audiologists, healthcare professionals
trained in hearing and balance issues. Most can also help select and fit hearing
aids and hearing assistance technologies. They can also determine if you are a
candidate for a cochlear implant (CI), which is surgically implanted by a
physician. Individuals with severe to profound hearing loss are considered
possible candidates for CI. Audiologists conduct audiometric testing to determine
how much hearing youve lost. Such testing can also provide clues about the
causes of your hearing loss.
The gold standard test is pure-tone audiometry. The test is simple and painless:
you wear earphones and listen to pure tones at different pitches and volumes sent
to one or both ears, letting the audiologist know when you no can no longer hear
the tone.
The audiologist will also test your ability to understand speech in quiet and in
adverse listening situations, and will assess your middle ear to determine if there
are any abnormalities including excessive fluid build-up or negative pressure.
Your primary healthcare professional or audiologist may also ask you to complete
a questionnaire designed to assess communication function in various settings.
These sets of questions can help quantify your perception of the impact that
hearing loss has on your daily activities and responses are often predictive of
candidacy for some form of non-medical intervention to promote hearing and
understanding.

Care & Treatment

Some causes of hearing loss can be treated medically or surgically. However, most
hearing loss in older adults is treated with strategies to improve communication,
amplify the sound (such as hearing aids), or both.
Hearing Assistance Technologies
These devices include:

Microphones and transmitter that you put close to the sound source (like
your TV) to transmit the sound to a receiver and headphones or earpieces,
usually wirelessly.

Personal pocket devices that amplify sounds closest to you, such as

conversation, while reducing background noise. The devices are about the
size of a business card, with about 100 hours of battery life. You clip it
onto your belt, slip it into a pocket, or wear it around your neck, where it
transmits the sound to headphones or ear buds. These devices are
hardwired.

Telephone ringers, which increase the volume of telephone rings, or make

the phone vibrate or flash a light. Text telephones are also available. Most
are free to people who are deaf or have severe hearing loss.

Other hearing assistance devices include closed-caption televisions, and vibrating

and flashing devices such as alarm clocks and timers, smoke alarms, doorbell
alerts, and motion sensors. You can find many of these items through state
agencies for people with hearing loss, or online.
Hearing Aids
Hearing aids are the most common amplification devices. They can improve your
ability to understand speech, particularly soft speech and conversational loud
speech. Its best to get hearing aids in both ears because that helps you identify the
direction of the sound and most important improves understanding in noisy
situations. If you have only lost the hearing in one ear, you may only be eligible
for one hearing aid, but there are now a variety of options for persons with singlesided deafness.
Although you can buy hearing aids from many sources, including online, you
should work with an audiologist or other healthcare professional trained in
audiology. This way, you can make sure you get the right hearing aid for your
needs that is fitted and adjusted correctly.

Not everyone benefits from hearing aids and they do require gradual adjustment.
Some people cant tolerate the feeling of having something in their ear but the
open-fit hearing aids which are now very common for those with mild to
moderate hearing loss do reduce this sensation. Others may have so much damage
that they still cant understand speech. However, counseling that teaches
communication strategies and aural rehabilitation in addition to hearing aids can
optimize chances of success. So make sure you can return your hearing aid at no
cost after a trial period. At the same time, dont give up too soon! Your audiologist
can often adjust the fit and settings to improve the comfort and sound quality.
A hearing aid is just part of the equation for improved hearing; the other half is a
hearing rehabilitation program. This includes counseling regarding the benefits
and limitations of hearing aids and suggestions for communicating with others. It
is typically included in the cost of the hearing aid.
Of course, hearing aids cant help if you dont use them. Many older adults
purchase hearing aids but then dont use them or only them occasionally. Among
the reasons:

Problems manipulating the tiny devices with their hands.

Amplification of background noise.

Thinking the aid is not needed.

Cost concerns:
o

Medicare does not cover hearing aids or other listening devices,

although some Medicare Advantage plans may offer them as an
added benefit.

Most private insurers also dont cover hearing aids or other

listening devices.

Some state Medicaid programs may cover hearing aids, but the
reimbursement usually does not cover the whole cost.

Federal programs such as the Department of Veterans Affairs may

pay for hearing aids, depending on your eligibility.

Background noise is another problem. Traditional hearing aids increase all sound,
so noises like rattling papers, running water, or other conversations can be very
distracting. Newer technologies use multiple microphones and digital signal
processing to decrease background noise, which can significantly improve your
ability to understand speech in noise and increase your satisfaction with the

hearing aid. The majority of hearing aids today are digital and most include
features to promote understanding in difficulty listening situations.
Choosing the Right Hearing Aid
There are numerous styles of hearing aids. The best style for you depends on:
o

the amount of your hearing loss

your desire for available features

your motivation and ability to properly insert and use the hearing
aid

The most popular hearing aids are the behind-the-ear followed by in-the-ear
models. Hearing aids are customized to your particular hearing loss and lifestyle
needs. You can also often get two or more programs within a single hearing aid.
For instance, you could use one program when youre in an environment with
background noise; another when youre in a quieter environment. The audiologist
uses a computer to adjust ranges and balance for each program. Some of the
newer hearing aids automatically adjust the volume to increase amplification of
soft sounds without becoming too loud.
Some hearing aids include a telecoil, which detects the magnetic field produced
by telephones that are compatible with hearing aids. The telecoil lets you listen on
the telephone with less distraction from background noise. It can also be used with
many assistive-listening devices and in public spaces which have hearing loops
which are increasingly gaining in popularity. The downside is that strong
magnetic devices such as computer monitors can produce interference. Still, a
telecoil is a useful feature that you can add to your hearing aids without much
additional cost.
Behind-the-ear hearing aids hang behind the ear and are connected directly to an
earmold ( customized to fit your ear), or a dome which varies in terms of the
amount of outer ear occlusion. These aids are more visible than in-the-ear models,
but they are durable, easily adjusted, and easily repaired. Some behind-the-ear
aids can also be connected to other assistive-listening devices such as telephone or
television amplifiers.
In-the-ear hearing aids are smaller devices that are custom fit to your ear. For
some, they are very difficult to adjust and maintain because tiny particles of skin
or wax get into them and damage them. However, most behind-the-ear hearing
aids and in-the-ear hearing aids now come with wax guards which minimizes the
chances of blockage from wax.
Cochlear Implants

A cochlear implant is an electronic device surgically implanted in your ear. It

bypasses the damaged cochlear hair cells and transmits sensory impulses directly
to the cochlear nerves. Cochlear implants are only used only in people with
severe to profound hearing loss whose hearing doesnt improve with hearing aids.
They dont restore normal hearing, but will help you hear environmental sounds
and understand speech better, use a telephone and, they restore the enjoyment of
music for many.
Having a cochlear implant surgery requires extensive testing before surgery and
training after surgery. Most Medicare program and insurance companies cover the
procedure.

Lifestyle & Management

Strategies to Improve Communication
Let others know that you have some hearing loss and tell them what they can do
to improve communication. You might also be able to use lip reading to help you
communicate. Just make sure you face the person directly and ask them to speak
slowly and clearly, enunciating each word.
You can pick up cues from the context of a conversation to identify the meaning.
Also watch any gestures the person makes; this can also help with interpreting
what theyre saying.
Sometimes, you need the person to write or type the information. You might carry
a pad and pen with you, or even use a touch screen phone or tablet computer for
this purpose.
Communicating with a Hearing-Impaired Person
Even if your hearing is fine, your friends or family members may not be. Here
are some tips for improving communication:

Ask the person about the best way to communicate with him or her

Obtain the persons attention before speaking

Eliminate background noise and distractions as much as possible

Ensure your listener can see your lips:

o

Speak face-to-face in the same room

Dont hide your lips with your hands or other objects

Have the light shine directly on the your face, not behind you

Speak slowly and clearly, but dont shout

Speak towards the ear that has better hearing (if hearing loss is different in
each ear)

Rephrase your comment if the listener doesnt understand the first time, or
if a reply doesnt make sense

Spell words out, use gestures, or write or type the information

Have the listener repeat back what he or she heard to avoid

misunderstandings

Tell your communication partner that you have difficulty hearing

Make sure that room in which you are communicating are well-lit, free of
noise, and that you sit within close range to the speaker

Make sure your communication partner is in the same room when

speaking with you.

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