Scope and Purpose

Hearing loss is common in older adults, increases in prevalence and severity with age, and can affect quality of life and ability to function.^1-5 The U.S. Preventive Services Task Force (USPSTF) issued a recommendation on screening for hearing loss in adults ages 50 years and older in 1996.⁶ In 2009, the USPSTF commissioned a new evidence review in order to update its recommendation. The purpose of this report is to systematically evaluate the current evidence on screening for hearing loss in adults ages 50 years and older in primary care settings.

Condition Definition

A person with normal hearing perceives sounds at frequencies between 20 and 20,000 Hz.⁷ Frequencies between 500 and 4000 Hz are most important for speech processing. There is often discordance between objectively measured deficits in tonal perception at specific frequencies and intensity levels (measured as decibels) and subjective perceptions of hearing problems.^{8, 9} One study found that 20 percent of persons reporting hearing difficulty had normal hearing tests, while 6.2 percent of those not reporting difficulty had significant hearing loss.³ Hearing problems despite normal hearing tests could be caused by abnormal signal processing or sound discrimination. Because treatments for hearing loss are targeted at improving tonal perception by signal amplification, we use the term “hearing loss” in this review to refer specifically to deficits found on objective testing.

The standard objective test for hearing loss is the pure-tone audiogram, in which a patient is placed in a soundproof booth and tested on ability to hear tones at a series of discrete frequencies, typically in the range of 125 to 8000 Hz, at various decibels. There is no universally accepted definition for hearing loss. Reference criteria vary with regard to the frequencies and intensity thresholds used to determine hearing loss, and whether one or both ears are affected. Many studies define mild hearing loss as inability to hear frequencies associated with speech processing <25 dB and moderate hearing loss as inability to hear those frequencies <40 dB. Commonly used reference criteria include the Ventry and Weinstein criteria (>40 dB hearing loss at either 1000 or 2000 Hz in both ears, or >40 dB hearing loss at 1000 and 2000 Hz in one ear),⁹ the speech frequency pure-tone average (SFPTA) criteria (≥25 dB average hearing loss at 500, 1000, and 2000 Hz in the better ear),¹⁰ and the high-frequency pure-tone average (HFPTA) criteria (≥25 dB average hearing loss at 1000, 2000, and 4000 Hz in the better ear).¹¹

Prevalence and Burden of Disease/Illness

In population-based studies of community-dwelling older adults (ages 50 years and older), the prevalence of hearing loss ranges from 20 to 40 percent depending on the population evaluated and the criteria used to define hearing loss.^{1, 3-5} In adults ages 80 years and older, the prevalence increases to over 80 percent.¹ In a prospective study of 1636 adults ages 48 to 92 years without hearing loss at baseline, the 5-year incidence of hearing loss was 21 percent.¹ In one population-based study, about one third of older adults with hearing loss reported that they never had a hearing test.¹

Hearing loss can impact both quality of life and ability to function in older adults. Individuals with hearing loss may have difficulty with speech discrimination, participation in social activities, ability to enjoy music, and localization of sounds.¹² Hearing loss is associated with increased emotional dysfunction, depression, and social isolation.^13-15 Older adults with moderate to severe hearing loss are more likely to experience impaired activities of daily living and instrumental activities of daily living compared with those with mild or no hearing loss.²

Etiology and Natural History

Age-related hearing loss (presbycusis) is the most common cause of hearing loss in older adults. It refers to a type of sensorineural hearing loss involving degeneration of the cells of the organ of Corti. The hearing loss associated with presbycusis is typically gradual, progressive, and bilateral.^{1, 16} The disease initially affects the higher frequencies before progressing to the lower frequencies.¹² Hearing loss in older adults is multifactorial. In addition to age-related degeneration, other contributing factors include genetic factors, exposure to loud noises, exposure to ototoxic agents, history of inner ear infections, and presence of systemic diseases such as diabetes mellitus.^{8, 12, 17} Conductive hearing loss accounts for about 8 percent of cases of hearing loss in older adults.¹

Risk Factors

In addition to advanced age, a number of other risk factors are associated with hearing loss in older adults, including male sex, white race, family history, service/blue-collar occupation, exposure to loud noises, lower education level, smoking, hypertension, and diabetes.^{5, 17-21}

Rationale for Screening/Screening Strategies

While hearing loss is common in older adults, individuals may not realize that they have hearing loss because symptoms are relatively mild or slowly progressive, they may perceive hearing loss but not seek evaluation for it, or they may have difficulty recognizing or reporting hearing loss due to comorbid conditions, such as cognitive impairment. Screening could identify individuals with hearing loss who could benefit from the use of hearing aids or other therapies to address hearing loss.

Although formal audiometric testing is required to diagnose hearing loss, the equipment is expensive and testing is time intensive and requires specially trained staff.⁸ Screening in primary care settings is therefore typically based on the use of more readily performed tests that can identify those who should undergo a full audiometric evaluation. Clinical tests used to screen for hearing impairment include testing whether a patient can hear a whispered voice, a finger rub, or a watch tick at a specific distance. Perceived hearing loss or hearing-associated problems can be assessed by asking a single question (e.g., “Do you have difficulty with your hearing?”) or with a more detailed questionnaire. The Hearing Handicap Inventory for the Elderly-Screening (HHIE-S), the most commonly used screening questionnaire, is a 10-item self-administered questionnaire that assesses social and emotional factors associated with hearing loss and requires about 2 minutes to complete.^{9, 22} The AudioScope (Welch Allyn, Inc., Skaneateles Falls, NY) is a handheld screening instrument consisting of an otoscope with a built-in audiometer. It assesses the ability of patients to hear tones of 20, 25, and 40 dB at frequencies of 500, 1000, 2000, and 4000 Hz and requires approximately 90 seconds to administer.²²

Interventions/Treatment

Signal amplification is the primary treatment for hearing loss. Hearing aids vary widely in style, technology, features, and cost.^{12, 23} Hearing aid styles include behind-the-ear, in-the-ear, in-the-canal, and completely-in-the-canal designs. Digital signal processing has become the standard technology for hearing aids. Despite the high prevalence of hearing loss and many options for amplification, only 10 to 20 percent of those with hearing loss have ever used hearing aids, and 20 to 29 percent of patients who have used hearing aids at some point stop using them.^{3, 24, 25} Patients often experience dissatisfaction with hearing aids due to their appearance, background noise, discomfort, difficulty handling, and unmet expectations regarding effects on hearing impairment.^{12, 26} Other options for treatment of hearing loss include assistive listening devices (off-the-ear devices that amplify directional noise using a microphone or similar instrument), hearing rehabilitation, and cochlear implants for those with profound hearing loss who do not improve with hearing aids.^{12, 23}

Current Clinical Practice

Surveys indicate that although physicians overwhelmingly (92 to 98 percent) believe that hearing loss negatively affects quality of life in older adults, many do not routinely screen patients (40 to 86 percent).^27-29 Barriers to screening include lack of time, perception that there are more pressing clinical issues, and lack of reimbursement.^27-29

Recommendations of Other Groups

The American Speech-Language-Hearing Association recommends that adults be screened at least every decade through age 50 and at 3-year intervals thereafter.³⁰ Recommendations from the American Academy of Family Physicians³¹ and the American Academy of Audiology³² refer to prior USPSTF recommendations. In 1994, the Canadian Task Force on Preventive Health Care found fair evidence to screen the elderly for hearing impairment (B recommendation).³³ The American Geriatrics Society and the American Academy of Otolaryngology Head and Neck Surgery do not have recommendations.

Previous USPSTF Recommendation

In 1996, the USPSTF recommended “screening older adults for hearing impairment by periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making referrals for abnormalities when appropriate (B recommendation).”⁶