Eye & Ear Diseases

Amplification: The Treatment of Choice

for Presbycusis
Doron Milstein, PhD, Hofstra University, Long Island, NY, USA. relations. Difficulty interacting with fam-
ily and friends can lead to reduced
Barbara E. Weinstein, PhD, Graduate School and University Center, CUNY, involvement in leisure time activities and
New York, NY, USA. socialisation. Interference with solitary
activities, such as problems hearing tele-
Hearing loss diminishes quality of life.The elderly rely on auditory input to maintain social vision or radio, can jeopardise psycho-
contact and awareness of their environment, such that hearing loss in this age group can lead logical well-being, while problems using
to isolation and withdrawal from the community. Most elderly individuals do not take advan- the telephone may compromise security.
tage of available audiological services nor do they use hearing aids (HAs), the treatment of Undetected hearing loss also can
choice for their hearing loss. Modern HAs utilise digital technology and computer software to affect medical management. Hearing loss
improve speech intelligibility. Current research reveals that HAs are effective in minimising can prevent a physician from obtaining a
the negative consequences of hearing loss in the daily functioning of the elderly.The availability valid medical, psychiatric and social his-
of sophisticated technology allows for more efficient HA fitting, and allows the audiologist to tory, which increases the potential for a
spend more time counseling. misdiagnosis. Misunderstandings with
respect to important medication instruc-
Key words: presbycusis, hearing aid technologies, rehabilitation, assistive listening devices. tions can interfere with medical treat-
ment. Hearing loss also might be
Demographics with age, which are variable, have corre- misinterpreted as a cognitive, affective or
The fastest growing segment in the U.S. sponding effects on pure-tone hearing personality disorder. As such, it could
population is, and will continue to be, the sensitivity and speech understanding (see interfere with therapeutic interventions
elderly. In the U.S., hearing impairment article, page 40). Older adults suffer sig- across all disciplines (e.g., social work)
increases with age, such that its preva- nificant hearing loss in both the low and and could exacerbate medical conditions
lence ranges from 25% among persons high frequencies, but the loss is general- such as Alzheimer disease or depression.4
7074 years to more than 50% among ly greater in the high frequencies (which, A recent study by the National
persons 85 years of age and older.1 Simi- consequently, negatively affects speech Council on the Aging (NCOA) revealed
larly, hearing impairment increases with understanding). The hearing loss associ- that untreated hearing loss has serious
age among Canadians, as does preva- ated with aging, presbycusis, is gradual emotional and social consequences.7 This
lence. Patterson noted that at least 25% of in onset, bilateral, symmetrical and sen- survey of 2,300 hearing-impaired adults
Canadians older than 65 years reported sorineural. It tends to be mild to moder- 50 years and older revealed that indi-
hearing problems, with audiologically ate in degree, with speech understanding viduals with untreated hearing loss were
detectable hearing loss present in more difficulties most pronounced in noisy sit- more likely to report depression, anxiety
than one-third of all people in that age uations.4 Sensorineural hearing loss can and paranoia and less likely to participate
group.2 Prevalence of hearing loss is even arise from a variety of medical conditions, in organised social activities than indi-
greater among the elderly living in insti- including vascular and metabolic diseases viduals who wear HAs. They also con-
tutions. Despite the high prevalence of and ototoxicity. Moscicki, et al. noted that cluded that HAs help to reduce the
hearing loss, older adults represent a age, sex, family history, Menieres disease negative consequences of hearing loss.
small proportion (i.e., 30%) of the case- and noise exposure are significant risk fac-
load of U.S. audiologists.3 Furthermore, tors for hearing loss, but age is by far the Efficacy of Hearing Aids
estimates of hearing aid (HA) use range most critical risk factor.5 Amplification is the treatment of choice
from 1023%.4 Although hearing loss is a for presbycusis. Kochkin and Rogin stat-
disorder amenable to early intervention, Consequences ed that since modern hearing instruments
the elderly tend to wait about 10 years Weinstein suggested that persistent diffi- improve speech intelligibility, they should
before seeking assistance. culties in understanding may present ini- also improve the social, emotional, psy-
tially as feelings of frustration and chological and physical functioning of
Hearing Loss Characteristics discouragement.4,6 Hearing difficulties individuals with hearing loss.8 Indeed,
Hearing loss results from degenerative can severely limit engagement in activi- the NCOA study revealed that hearing
changes in the inner ear, the auditory ties and strain family relations. For exam- instruments were clearly associated with
nerve and structures within the central ple, difficulty understanding ones spouse impressive improvements in these areas
auditory nervous system. The changes or caregiver can interfere with ongoing for people with hearing loss. Specifically,

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Amplification for Presbycusis

Advances in HA technologies, espe-

Questions from the Hearing Handicap Inventory for the cially the movement away from analog
ElderlyScreening Version (HHIES) technology, can better address the needs
of the elderly. For example, directional
Does a hearing problem cause you to feel frustrated when talking to members of your family?
microphones suppress background noise
Does a hearing problem cause you difficulty when visiting friends, relatives or neighbours? and focus on and amplify speech coming
from the front. Compression/non-linear
Does a hearing problem cause you difficulty when listening to TV or radio? circuitry prevents loud sounds from being
Do you feel that any difficulty with your hearing limits or hampers your personal or uncomfortable or too loud, entering the
social life? HAoutput/intensity into the patients tol-
erable dynamic range and, consequently,
Does a hearing problem cause you to feel embarrassed when meeting new people? minimising or eliminating the need for
using volume control. Furthermore,
Do you have difficulty hearing when someone whispers?
removal cords or notches ease manipula-
Modified from Weinstein, 2000 and Ventry and Weinstein, 1983. tion, a cerumen guard minimises ceru-
men obstruction, and a high volume
along with improved hearing, rehabilita- Hearing Aids by Systems/ control knob can ease adjustment if need-
tion with HAs also improved interper- Technologies ed. Finally, feedback and occlusion con-
sonal relationships, reduced depression, HA technologies include: trols, as well as telephone compatibility,
reduced anger and frustration, improved (1) conventional/analog HA; are available. Thus, the advent of high-
emotional stability, reduced paranoid (2) digitally programmable analog HA end HAs should serve as an inducement
feeling and enhanced group activity.9 (uses conventional/analog technol- for the elderly to attempt their use.
Family members also noted significant ogy to process the sound, but digital
improvements in most areas measured as technology to modify the character- Disposable Hearing Aids
a result of HA use. istics of the analog circuit, utilising It is interesting to address the use of dis-
computer software); and posable HAs (conventional or digital),
Hearing Aid Technologies (3) fully digital HA (uses digital tech- whereby the HA is manufactured as a
Present day HAs, which are becoming nology to process the sound). standard package and can be disposed
increasingly effective at treating hearing Programmable HAs rely on computer after a certain time period; thus, it is a
loss, can assist elderly patients with software to adjust the electroacoustic fea- modular rather than custom HA and is
understanding speech in noisy situations tures of the HA to the patients needs. The not based on an individual patients ear-
and can help to overcome problems asso- audiologist can compare different pro- mold impression or HA prescription. If
ciated with hearing loss. grams, thereby enabling selection of the cir- the disposable HAs features fit the
cuitry most appropriate for the patients patients audiogram configuration and
Hearing Instrument Types by Size hearing loss, and better fine-tuning of the hearing loss needs, advantages would
Custom HAs range from the smallest, response. Programmable HAs allow for include the ability to be fitted by the
which fits all the way inside the ear use of remote control to enable the patient audiologist immediately post-audiologi-
canal (Completely-In-the-Canal, CIC), to alternate between programs or to adjust cal evaluation/medical clearance (no
to the Canal HA which fits mostly in the the volume control. They require less need to obtain earmold impression or
ear canal with a small part extending mechanical parts than conventional HAs, order the HA), lower cost and no need
into the concha, and the In-The-Ear resulting in fewer breakdowns and repairs for batteries and volume control. How-
(ITE) HA which basically fits entirely in and, consequently, lower costs.10 ever, possible disadvantages include the
the concha of the outer ear. Behind-The- Fully digital HAs have the advan- inability to make adjustments and to fine-
Ear (BTE) HAs attach to an earmold tages of programmable HAs, but manip- tune to the patients needs, and the HA
and are worn over the ear. Overall, it is ulation of sound can be performed even may not fit the patient properly, causing
important to note that the size of the more efficiently. Digital HAs can min- feedback problems. Thus, although dis-
HA does not correlate with quality. Size imise or prevent feedback noise, can posable HAs might increase the first-
is an issue that should be discussed process sound so that speech signal will hand experience of rehabilitation/
between the patient and audiologist, be enhanced/amplified more so than amplification among hearing-impaired
and for which various factors should be environmental noise, and can provide a patients, an unsuccessful experience due
considered, such as the nature and more natural signal, speech or voice qual- to their possible limitations might rein-
degree of the patients hearing loss and ity. Furthermore, digital technology force outdated beliefs regarding the lim-
the patients physiological needs (i.e., requires less power and circuit size, ited efficiency of HAs in general.10
dexterity, visual status). allowing the HA to be made smaller.10 Assistive listening devices are an

20 GERIATRICS & AGING May 2003 Vol 6, Num 5

 Amplification for Presbycusis

adjunct to HAs or can be used in lieu of References

HAs. These devices are commercially
1. NCHS (National Center for Health Statistics).
available, inexpensive and ideal for select
Health, United States, 1999, with health and
listening conditions. They help to better aging chartbook. Hyattsville, MD: NCHS, 1999.
understand television and speech in large 2. Patterson, C. Prevention of hearing impairment
rooms, such as in movies, churches or and disability in the elderly. In: Canadian Task
Force on the Periodic Health Examination.
synagogues. Telephone amplifiers are
Canadian guide to clinical preventive health
very useful for persons having difficulty care. Ottawa: Health Canada, 1994:954-63.
understanding speech over the tele- 3. American Speech-Language-Hearing Associ-
phone. Alerting devices, such as vibrat- ation. 2002 Omnibus Survey: Practice trends
in audiology. Rockville, MD: ASHA, 2002.
ing alarm clocks and flashing lights to
4. Weinstein, B. Geriatric audiology. New York:
alert individuals to a fire, are invaluable. Thieme Medical Publishers, Inc., 2000.
Persons with hearing impairment have at 5. Moscicki EK, Elkins EF, Baum HM, et al.
their disposal a variety of devices that can Hearing loss in the elderly: an epidemiologic
study of the Framingham Heart Study
help overcome their communication and
Cohort. Ear Hear 1985;6:184-90.
interpersonal difficulties. 6. Weinstein BE. Geriatric hearing loss: myths,
HAs may be rejected if the patient is realities, resources for physicians. Geriatrics
unprepared and not thoroughly coun- 1989;44:42-59.
7. NCOA (National Council on the Aging). The
seled regarding their use. Utilising com-
consequences of untreated hearing loss in older
puter software with both programmable persons: Summary, NCOA, 1999. www.ncoa.org
and digital HAs allows for a faster and 8. Kochkin S, Rogin CM. Quantifying the obvi-
more efficient fitting. The audiologist can ous: the impact of hearing instruments on
quality of life. Hearing Review 2000;7:6-34.
spend more time listening to the patients
9. Kirkwood DH. Major survey documents neg-
hearing needs, difficulties and expecta- ative impact of untreated hearing loss on
tions, and counseling them regarding the quality of life. Hearing Journal 1999;52:32-40.
latter. Counseling should address issues 10.Dillon H. Hearing aids. New York: Thieme
Medical Publishers, Inc., 2001.
ranging from HAmanipulation and main-
11. Lichtenstein MJ, Bess FH, Logan SA. Valida-
tenance to realistic expectations and moti- tion of screening tools for identifying hearing-
vation, thereby allowing for successful impaired elderly in primary care. JAMA
rehabilitation and improved quality of life. 1988;259:2875-8.
12.Ventry IM, Weinstein BE. Identification of eld-
Conclusion erly people with hearing problems. ASHA
1983;25:37-42.
Despite the high prevalence of hearing
loss and its negative consequences, most
elderly individuals do not receive audio-
logical services, nor do they use HAs.
Physicians are in the ideal position to
help audiologists reach elderly people
with hearing impairment. Simple screen-
ing techniques with an audioscope,
which combines an audiometer with an
otoscope, can be a practical tool for physi-
cians.11 Furthermore, administration of a
brief questionnaire, such as the Hearing
Handicap Inventory (Table),4 can help
identify older adults who are experienc-
ing activity limitations and participation
restrictions due to hearing loss. Given the
beneficial effects of available technology,
referral to an audiologist can help
improve quality of life of older persons
with hearing impairment.

No competing financial interests declared.

www.geriatricsandaging.ca 21