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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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The prevalence of hearing loss increases with advancing age and is very common in older adults. Approximately one fourth of adults aged 65 to 74 years and half of adults aged 85 years and older report some degree of hearing loss. Hearing loss, particularly when it develops late in life and is progressive in nature, can compromise an individual's ability to perform many important activities, such as using the telephone, driving, and shopping. Hearing loss also may lead to social withdrawal, depression, and exacerbation of coexisting psychiatric problems. Some older people with hearing loss also have cognitive impairment, and evidence suggests that improvement of hearing may contribute to improvement in cognitive ability. Many types of hearing loss can be improved with the use of hearing aids; however, only 10% to 15% of patients who could benefit from a hearing aid actually use one.

See chapter 6 for information about hearing screening for children and adolescents.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Clinicians should question elderly adults about hearing impairment and counsel about the availability of treatment when appropriate.
  • American College of Obstetricians and Gynecologists --
  • Women 65 years and older should be evaluated for hearing loss.
  • American Speech-Language-Hearing Association --
  • Considerable debate concerning the efficacy of selected screening protocols for older adults has taken place in recent years. Whether the choice of protocol actually influences compliance with the follow-up recommendations remains unclear. The clinician may choose to use a hearing handicap questionnaire, pure-tone audiometry, or both. The rationale for using a questionnaire and pure-tone audiometry in combination is that compliance with audiologic recommendations is often greater when individuals perceive their hearing loss to be a handicap. Selection of the protocol should take into consideration cost, compliance data for the particular population, and the specificity, sensitivity, and predictive values of screening. Equipment used should be appropriately calibrated, and self-assessment scales must be reliable. Compliance-improving strategies (eg, educational materials) should be an integral part of any screening program and appropriate follow-up services should be available.
  • Canadian Task Force on the Periodic Health Examination --
  • There is fair justification for looking for hearing loss in adults seen for other reasons. Further study is warranted if adults report being hard of hearing or fail to respond to the normal spoken voice; have a medical or family history placing them at high risk for hearing loss (eg, family history of hearing loss, occupational history of exposure to noise, pursuit of noisy leisure activities, or history of recurring ear problems). Screening for hearing impairment using an audioscope, a single question about hearing difficulty, or whispered voice out of the patient's field of vision is recommended as part of the periodic health examination for persons 65 years of age and older.
  • US Preventive Services Task Force --
  • Screen older patients for hearing impairment by periodically questioning them about their hearing. Counseling should be provided about the availability of hearing aid devices and referrals made for abnormalities as appropriate. The optimal frequency of such screening is left to clinical discretion. An otoscopic examination and audiometric testing should be performed on all persons with evidence of impaired hearing by patient inquiry. There is insufficient evidence to recommend routinely screening adults with audiometric testing. Screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines.

Basics of Hearing Screening


Question all older adult patients about signs of hearing loss. Because patients may not be fully aware of impairment, also question their family members, if possible.


A screening questionnaire may be used to screen for communication problems and social and emotional handicaps stemming from hearing loss. Questionnaires may be filled out by the patient or administered by staff. One type of standardized questionnaire for this purpose is presented in Table 35.1. This instrument has been shown to have sensitivity and specificity values in the range of 60% to 80%; these values are almost as high as those attained by pure-tone audiometry screening. Some authorities recommend audiologic referral for patients who score 10 or higher on this questionnaire. Screening questionnaires have the advantage of identifying patients who perceive hearing loss to be a problem and who may be particularly motivated to use a hearing aid. Some authorities recommend using both a questionnaire and pure-tone testing for screening. This approach may modestly improve sensitivity and specificity.


Pure-tone screening can be administered using either a standard pure-tone audiometer or a hand-held audioscope (an otoscope that emits tones of calibrated frequencies and intensities). When using either method, keep the environment in which screening is administered as quiet as possible. Use frequencies that are within the speech range. Disagreement exists about the sound intensity that should be used for screening. Following are two examples of suggested screening protocols:

  • Present pure tones at 25 dB at 1000 Hz, 2000 Hz, and 4000 Hz. Failure to respond to any one frequency in either ear at 25 dB constitutes a "fail." For adults younger than age 65 years, this may be the preferred protocol, but the majority of persons aged 65 years and older who are screened with this protocol may fail. Because of this difference, some authorities recommend using a 40-dB tone at 4000 Hz.
  • Present pure tones at 25 dB at 1000 Hz, 2000 Hz and 4000 Hz (optional). Failure to respond to the 40-dB tone at any one frequency in either ear constitutes a "fail". Inability to hear any one frequency 25 dB places an individual "at risk" for hearing loss. A referral for audiologic assessment may be appropriate if the person reports being handicapped by hearing loss. Persons who fail the screening should be monitored annually to determine whether their hearing loss is progressive.


Simple physical examination procedures for hearing screening, such as the whispered voice and finger-rub tests, are not recommended by major authorities. Although these crude hearing tests are fairly accurate, they are insensitive to disorders of central auditory processing and the understanding of speech.


Patients with evidence of hearing loss should be considered for referral to a specialist for comprehensive audiologic evaluation, especially if they feel handicapped by hearing loss. Because approximately 10% of individuals with hearing loss are amenable to medical or surgical treatment, and some patients are incorrectly identified as having hearing loss by screening, do not refer patients directly to a hearing aid dealer.


Provide appropriate follow-up management for all patients who are referred for audiologic evaluation. Patients may need considerable support and training to use their hearing aids effectively.

Table 35.1. Hearing Handicap Inventory in the Elderly -- Screening Questionnaire.


Table 35.1. Hearing Handicap Inventory in the Elderly -- Screening Questionnaire.

Patient Resources

  • Answers to Questions About Noise and Hearing Loss; How to Buy a Hearing Aid. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; (800)638-TALK (voice or TTY); (301)897-8682 (in Maryland). To order, call (301)897-5700, ext. 218. Internet address:
  • Age Page: Hearing and the Elderly. National Institute on Aging. Bldg 31, Room 5C27, 31 Center Drive, MSC 2922 Bethesda, MD 20892-2922; (301)496-1752. Internet address:

Provider Resources

  • Older Voices. To order this trainer's manual and resource materials for communication problems of older persons, contact the American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; (301)897-5700, ext 218. For general information, call (800)638-8255;

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American Speech-Language-Hearing Association, Ad Hoc Committee on Hearing Screening in Adults. Considerations in screening adults/older persons for handicapping hearing impairments. ASHA . 1992; 34:81–85. [PubMed: 1472164]
  4. Bess FH, Lichtenstein MJ, Logan SA, et al. Hearing impairment as a determinant of function in the elderly. J Am Geriatr Soc . 1989; 37:123–128. [PubMed: 2910970]
  5. Canadian Task Force on the Periodic Health Examination. The periodic health examination: 2. 1984 update. Can Med Assoc J. 1984; 130:1278–1285. [PMC free article: PMC1483525] [PubMed: 6722691]
  6. Canadian Task Force on the Periodic Health Examination. Prevention of hearing impairment and disability in the elderly. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 80.
  7. Gennis V, Garry PJ, Haaland KY, Yeo RA, Goodwin JS. Hearing and cognition in the elderly; new findings and a review of the literature. Arch Intern Med. 1991; 151: 2259-2264.
  8. Havlik RJ. Aging in the eighties: impaired senses for sound and light in persons aged 65 years and over: preliminary data from the Supplement on Aging to the National Health Interview Survey: United States; January-June 1984. Vital and Health Statistics. Hyattsville, Md: National Center for Health Statistics; 1986;125. US Department of Health and Human Services publication PHS 86-1250.
  9. Lichtenstein ME, Bess FH, Logan SA. Screening for impaired hearing in the elderly. JAMA. . 1988; 260:3589–3590. [PubMed: 3193585]
  10. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Aging . 1988; 17:347–351. [PubMed: 3068972]
  11. Mulrow CD, Lichtenstien MJ. Screening for hearing impairment in the elderly: rationale and strategy. J Gen Intern Med. 1991;6:249-258.
  12. Pappas JJ, Graham SS. Hearing Aid Dispensing Within a Medical Setting . Alexandria, Va: American Academy of Otolaryngology — Head and Neck Surgery Foundation; 1990.
  13. Schow R, Nerbonne M. Communication screening profile uses with elderly clients. Ear Hearing . 1982; 3:133–147.
  14. Uhlmann RF, Larson EB, Rees TS, Koepsel TD, Duckert LG. Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA . 1989; 262:1916–1919. [PubMed: 2926927]
  15. Uhlmann RF, Rees TS, Psaty BM, Duckert LG. Validity and reliability of auditory screening tests in demented and non-demented older adults. J Gen Intern Med . 1989; 4:90–96. [PubMed: 2651606]
  16. US Preventive Services Task Force. Screening for hearing impairment.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 35.
  17. Ventry I, Weinstein B. Identification of elderly people with hearing problems. ASHA. . 1983; 25:37–42. [PubMed: 6626295]
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