Article

The impact of hearing loss on the quality of life of elderly adults

ENT and Audiology Department, University Hospital of Ferrara, Ferrara, Italy.
Clinical Interventions in Aging (Impact Factor: 2.08). 06/2012; 7:159-63. DOI: 10.2147/CIA.S26059
Source: PubMed

ABSTRACT

Hearing loss is the most common sensory deficit in the elderly, and it is becoming a severe social and health problem. Especially in the elderly, hearing loss can impair the exchange of information, thus significantly impacting everyday life, causing loneliness, isolation, dependence, and frustration, as well as communication disorders. Due to the aging of the population in the developed world, presbycusis is a growing problem that has been reported to reduce quality of life (QoL). Progression of presbycusis cannot be remediated; therefore, optimal management of this condition not only requires early recognition and rehabilitation, but it also should include an evaluation of QoL status and its assessment.

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Clinical Interventions in Aging 2012:7 159–163
Clinical Interventions in Aging
The impact of hearing loss on the quality of life
of elderly adults
Andrea Ciorba
Chiara Bianchini
Stefano Pelucchi
Antonio Pastore
ENT and Audiology Department,
University Hospital of Ferrara,
Ferrara, Italy
Correspondence: Andrea Ciorba
ENT and Audiology Department,
University Hospital of Ferrara,
C.so Giovecca 203, 44100 Ferrara, Italy
Tel +39 0532 237447
Email andrea.ciorba@unife.it
Abstract: Hearing loss is the most common sensory deficit in the elderly, and it is becoming
a severe social and health problem. Especially in the elderly, hearing loss can impair the exchange
of information, thus significantly impacting everyday life, causing loneliness, isolation, depen-
dence, and frustration, as well as communication disorders. Due to the aging of the population in
the developed world, presbycusis is a growing problem that has been reported to reduce quality
of life (QoL). Progression of presbycusis cannot be remediated; therefore, optimal management
of this condition not only requires early recognition and rehabilitation, but it also should include
an evaluation of QoL status and its assessment.
Keywords: hearing loss, presbycusis, quality of life, elderly
Introduction
The term “presbycusis” refers to hearing loss that is associated with the cochlear
degenerative process of aging. By definition, presbycusis is bilateral, symmetrical,
and slowly progressive.
1–3
Hearing loss is a common problem associated with senescence, and it is likely to
become more of an issue with changing population demographics in the developed
world. The impact of hearing loss may be profound, with consequences for the social,
functional, and psychological well-being of the person.
On one side, our lack of understanding of this disease process and our inability to
remediate its progression are important parts of the problem. At present, clinicians can
only use family history, the history of onset and progression, and the results of audio-
metric testing to determine the degree of impairment, to estimate the potential for future
hearing loss, and to make recommendations for amplification with hearing aids.
On the other side, optimal management of this condition also should include an
evaluation of quality of life (QoL) status and its assessment. This is due to the fact that
several studies have already demonstrated that presbycusis may have a negative effect
on QoL and psychological well-being social isolation, depression, anxiety, and even
cognitive decline have been reported in affected persons.
1–3
Despite efforts to understand the disease processes, at present, clinicians are still
unable to remediate its progression.
Epidemiology and risk factors of presbycusis:
a challenging problem
Presbycusis is the most common cause of adult hearing deficiency; it is considered the
most prevalent sensory impairment in the elderly, affecting individuals aged 75 years
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Clinical Interventions in Aging 2012:7
and older. As our society matures, there are more people living
into their 60s, 70s, 80s, and beyond, due to factors such as
improved nutrition and health care. It has been reported that,
in the United States, presbycusis affects 40% of the popula-
tion older than 75 years of age, and, in our aging society, it
is becoming more prevalent.
1–5
The 1995 UK national study
of hearing disorders found that 20% of adults had some
degree of hearing impairment (audiometric threshold greater
than 25 dB) in the better hearing ear; 75% of those are over
60 years of age.
1–5
Recent estimations suggest that the number
of senior citizens in the US with significant hearing loss could
increase to 35–40 million by the year 2030.
1–5
Aging is defined as the biological process of growing
old, and intrinsic and extrinsic factors, as well as their inter-
actions, influence the degree and rate at which our hearing
ages. Thus, the occurrence of presbycusis is thought to be
determined predominantly by genetic factors; however, it also
can be influenced by environmental factors, such as noise,
ototoxic drugs, alcohol, and diabetes.
4–7
Methods
We performed a PubMed database systematic review for peer-
reviewed articles published between January 2000 and Decem-
ber 2011, matching the terms “hearing loss,“presbycusis,
“cochlea,“quality of life,and “elderly.The search retrieved
about 50 articles, which we proceeded to investigate.
Quality of life and presbycusis: hearing
loss is also a social loss
Understanding the impact of hearing loss on quality of life
is of great importance, as difficulties with communication
affect interactions with other people. This is an important
aspect of everyday life, which can be seriously impaired in
individuals with hearing loss, leading to a perceived reduction
of QoL.
8,9
The term “QoLis used to evaluate the general well-being
of individuals. Considerable agreement exists regarding the
idea that the evaluation of QoL is multidimensional: physi-
cal well-being, material well-being, social well-being, and
emotional well-being.
8
It has now been reported by several
authors that hearing loss is an increasingly important public
health problem that has been linked to reduced QoL, as it can
impair the exchange of information, significantly impacting
daily life, especially for elderly people. Reported effects of
presbycusis on QoL are:
- emotional reactions, such as loneliness, isolation, depen-
dence, frustration, depression, anxiety, anger, embarrass-
ment, frustration, and guilt
- behavioral reactions, such as bluffing, withdrawing,
blaming, and demanding
- cognitive reactions, such as confusion, difficulty focusing,
distracting thoughts, decreased self-esteem, and com-
munication disorders.
8,9
Instruments to evaluate the impact
of hearing loss on QoL
Assessment of QoL deterioration due to hearing loss can
be achieved through several instruments, as reported in dif-
ferent studies in the literature.
8,9
These can be divided into
hearing-related QoL instruments (Table 1) and generic QoL
instruments.
An example of a hearing-related instrument that incor-
porates a question specifically designed to assess QoL is the
Hearing Handicap Inventory for the Elderly (HHIE).
10
This
is a self-assessment tool designed to measure the effects
of hearing impairment on the emotional and social adjust-
ment of elderly people. This inventory is comprised of two
subscales: a 13-item subscale that explores the emotional
consequences of hearing impairment, and a 12-item subscale
that describes both social and situational effects. The HHIE
has been judged a reliable and valid tool, as well as an easy-
to-use questionnaire.
8,9
The Hearing Handicap Inventory for Adults (HHIA)
11
is a
25-item survey derived from the original HHIE by Weinstein
et al.
10
It also is composed of a 13-item emotional subscale
and a 12-item socio-situational subscale.
11
The International Outcomes Inventory Hearing Aids
(IOI-HA) by Cox et al
12
explores the perceived usefulness
of hearing aids.
12
The IOI-HA is a relatively short test that
is easy to administer. Each of its seven questions is designed
to target a different outcome domain, which include: usage
of hearing aid (number of hours per day of hearing aid use);
benefit in terms of improvement in hearing-related activities;
Table 1 Main specic instruments to evaluate the impact of
hearing loss on QoL
Instrument Goal Items Reference
HHIE
10
Measures the effects of hearing
impairment on the emotional and
social adjustment of elderly people
25 8–10
HHIA
11
Measures the effects of hearing
impairment on the emotional
and social adjustment of adults
25 9
IOI-HA
12
Explores the perceived usefulness
of hearing aids
7 11
Abbreviations: HHIE, Hearing Handicap Inventory for the Elderly; HHIA,
Hearing Handicap Inventory for Adults; IOI-HA, International Outcomes Inventory –
Hearing Aids; QoL, quality of life.
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residual activity limitations; satisfaction; residual participa-
tion restrictions; impact on others; and quality of life.
12
Generic QoL measures do not focus on any particular
disorder or treatment, but rather on the self-perceived over-
all health status of the individual. Those most commonly
administered, together with hearing-related tools, in order to
understand the overall QoL level of the subjects, are:
- The MOS 36-Item Short Form Health Survey (SF-36).
The SF-36 consists of 36 items that assesses eight health
concepts: (1) limitations in physical activities because of
health problems; (2) limitations in social activities because
of physical or emotional problems; (3) limitations in
usual role activities because of physical health problems;
(4) bodily pain; (5) general mental health (psychological
distress and well-being); (6) limitations in usual role activi-
ties because of emotional problems; (7) vitality (energy and
fatigue); and (8) general health perceptions. It has been
used by several authors to evaluate the level of mental and
physical activity in subjects affected by hearing loss.
9,12
- The Social Functioning Questionnaire. It has been pro-
posed by several authors to investigate the social behavior
and dimension of those affected by presbycusis.
9,12
This
is an eight-item, self-rating scale (score range 0–24) cov-
ering the most important domains of social life, such as
work, home activities, finances, spare time activities, and
social, family, and sexual relationships. It has been used
in combination with the revised version of the Symptom
Checklist-90, which is a valid and reliable psychiatric
multidimensional self-report inventory, used to screen
for psychopathological symptom patterns and levels of
distress in community and medical responders (such as
somatization, obsessive–compulsive behaviors, depres-
sion, anxiety, and hostility).
9,12
Following the administration of the above-mentioned
tools, a list of realistic patient goals can be identified and
developed by otolaryngologists and audiologists. Those tools
have been crafted in order to investigate and meet patient
demands; expectations of prosthesization have increased due
to the commercial promotion of certain hearing aid features,
such as adaptive directional microphones and environmental
noise reduction. The determination of comprehensive patient-
specific goals will assist otolaryngologists and audiologists
in the selection of specific features as they apply them to the
needs of their patients.
Those instruments have been developed with the intent
of building a foundation for evidence-based clinical practice
guidelines in hearing rehabilitation; clinical practice guide-
lines can minimize variability in outcome, maximize treatment
efficacy, reduce risks, decrease waste, improve patient satis-
faction, and help to elevate the awareness of the profession
of audiology among third-party payers, other health care
providers, and, most importantly, current and future patients.
As otolaryngologists and audiologists continue to compete
in the health care marketplace, they can demonstrate that
hearing rehabilitation reduces activity limitations, decreases
participation restrictions, and improves health-related quality
of life. Only by measuring outcomes can otolaryngologists
and audiologists be assured that hearing rehabilitation makes a
difference and that patients have benefited from their care.
13
Nonetheless, a major drawback of these tools, as for other
QoL scales, is related to the fact that the importance of differ-
ent QoL dimensions can vary among individuals and within
individuals over time, which means that structured measures
may be inaccurate or insensitive.
14
Quality of life and presbycusis:
present data
Interestingly, among the population with hearing loss, only
39% of the subjects perceive that they have an excellent
global QoL level or very good physical health, compared
to 68% of those without hearing loss. Nearly one-third of
the population with hearing loss report being in fair or poor
health, compared to only 9% of the population without hear-
ing loss; people with hearing loss are less satisfied with their
“life as a whole” than people without hearing loss.
15
When investigating the effects of hearing loss on QoL,
presbycusis has been reported to be the cause of reduced
communicative relationships, as well as reduced social and
emotional interactions.
16
In particular, it is reported to be a
source of loneliness, isolation, and decline in social activi-
ties, as well as communication disorders and dissatisfaction
with family life.
16
As a result of maladaptive communication strategies,
those with hearing loss are reported to perceive their social
skills as poor, and thus, they also may experience reduced
self-esteem if a combination of hearing impairment and a
poor coping strategy contributes to failure in their roles.
Moreover, some authors have stated that some patients are
afraid to consider hearing loss a problem and subsequently
are afraid to seek medical help for the hearing loss. This may
potentially lead hearing impaired individuals to a further
level of disability and handicap.
9
It would be helpful if primary care physicians would
test routinely for hearing impairment in adults and regularly
refer those with hearing impairment to audiological tertiary
care centers.
9
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Quality of life after rehabilitation
with hearing aids
The benefits and satisfaction of using hearing aids among
hearing-impaired elderly people have been explored in some
studies.
17,18
Joore and colleagues
19
demonstrated that new hearing
aid users experienced less anxiety and depression following
hearing aid use. Mulrow et al
20
also reported a reduction in
depression among hearing aid users, as measured by a geriat-
ric depression scale.
21
In addition, Joore et al
22
and Stark and
Hickson
23
reported improvements in selected domain scores
on the SF-36 as a result of hearing aid use.
22,23
In a large, multi-site study, McArdle et al
24
adminis-
tered both generic and hearing-related QoL measures to
380 participants randomized into experimental (immediate
hearing aid treatment) and control (delayed hearing aid
treatment) groups. Hearing aids were shown to improve
both generic and hearing-related QoL domains, although
the improvement in QoL was stronger as measured by the
hearing-specific measures.
24
Reductions in both emotional and social consequences of
hearing loss after wearing hearing aids have been measured
by the HHIE in some studies.
23–27
Particularly in their meta-
analysis, Chisolm et al
18
showed that hearing aids improved
adults’ HHIE scores by reducing the psychological, social,
and emotional effects of hearing loss.
18,28
Cox et al
29
also
investigated different types of hearing aids and their impact
on QoL, concluding that programmable hearing aids provide
the most efficient effects.
18,29
Only a few studies have focused on the effects of restor-
ing binaural hearing and consequences for QoL. It has been
demonstrated that binaural hearing aid wearers may benefit
from the ability of the central auditory system to integrate
binaural information and enjoy benefits such as binaural loud-
ness summation, difference in masking level, localization,
and elimination of head-shadow.
17,30,31
It has been reported
that, globally, about 80% of patients with severe, bilateral
hearing loss wear hearing aids binaurally; therefore, patients
with symmetric hearing loss should be more comfortable
with binaural hearing aids.
17,30,31
Finally, looking at cost-effectiveness analysis, Joore et al
reported that using a hearing aid and returning hearing-
impaired people to an ordinary lifestyle is cost effective.
32
In
addition, Chao and Chen
30
stated that, for hearing-impaired
elderly people, the use of hearing aids can be considered a
cost-effective strategy for rehabilitation.
17,30,31
Based on the
average gain in hearing-related QoL, the outcome per year
after the intervention could range from 1333 to 3889.
30,32
Different degrees of hearing loss, successful rates of hearing
aid use, and rates of satisfaction with hearing aid use are main
factors that affect this estimate.
30,32
Conclusion
Presbycusis is a complex disease, with a controversial phys-
iopathology, which is influenced by genetic, environmental,
and medical factors. It is an increasingly important public
health problem that can lead to reduced quality of life, isola-
tion, dependence, and frustration.
In the near future, it will be necessary to improve our
knowledge of this condition and its physiopathology, in an
attempt to remediate its progression. In addition, it will be
of great importance to improve methods of identifying indi-
viduals with presbycusis and deteriorating QoL, thus improv-
ing services for providing hearing aids, assistive listening
devices, and auditory rehabilitation. Identifying individuals
with hearing loss, supplying appropriate hearing aids or other
listening devices, and teaching coping strategies may have a
positive impact on the quality of life of older people.
Disclosure
The authors report no conflicts of interest in this work.
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