Recognizing and treating age-related hearing loss

Hearing loss in the high frequency range occurs with increasing age. Due to its gradual progression, hearing loss often goes unnoticed for a long time. There is evidence that untreated hearing loss can have far-reaching social, emotional and health consequences for those affected. Early detection is possible using simple diagnostic test procedures. These include questionnaires – according to a recent study, the HHIE and the SSQ-12, for example, are suitable test instruments.

From the age of 50, the probability of developing hearing loss increases as a function of age [1]. The ICD diagnosis “presbycusis” or age-related hearing loss (ICD-10 code: H91. 1) refers to a slowly progressive, chronic, mostly symmetrical hearing impairment with an emphasis on high frequencies (Fig. 1) [1–3].
Initially, so-called discrimination disorders occur as an early symptom; this leads to an impairment of the overtone spectra of sounds in conversations [4]. At a hearing threshold of ≤20 dB in the better-hearing ear, one speaks of regular hearing, at 95 dB or higher of complete hearing loss [5]. The intermediate levels of hearing loss (mild, moderate, profound hearing loss) are not categorized uniformly internationally. In addition to the severity of hearing loss, a distinction is also made between unilateral and bilateral hearing loss. According to a study commissioned by the Swiss Health Observatory (Obsan) and published in 2022, hearing impairment is particularly widespread in old age: Around one sixth of 65–74-year-olds and around one third of 75-year-olds living in Switzerland have a hearing impairment [5].

The causes of age-related hearing loss are varied and complex; it is generally assumed that there is an interplay between physiological aging processes, genetic factors, environmental influences (noise, ototoxic substances) and other characteristics of health status and health behavior [5].

Prevention and screening in the context of primary care

Presbycusis is thought to be a neurosensory disorder that originates from functional changes in the hair cells in the cochlea, neuronal loss in the spiral ganglia and associated nerve fibers as well as metabolic-atrophic changes in the striatum. Today, the smallest and in some cases technologically advanced hearing aids are available as therapeutic approaches. In its resolution of May 30, 2017, the World Health Assembly, a body of the WHO, called on governments to introduce strategies for otological and audiological care within primary healthcare systems and to implement prevention and screening programs for the most vulnerable population groups [6].

According to epidemiological data, around 30% of men and 20% of women in Europe up to the age of 70 are affected by a hearing loss of ≥30 dB; among 80-year-olds, the corresponding prevalence is estimated at 55% of men and 45% of women [7,8]. In a publication published in 2024, Ferrán et al. point out that some older people affected by age-related hearing loss (ARHL ) have a tendency to passively endure this condition [9]. However, delaying treatment can be detrimental to health. On the one hand, communication problems and misunderstandings can lead to loneliness and loss of independence. Secondly, ARHL is associated with an increased risk of balance problems, falls, social isolation, depression and cognitive impairment, which can severely affect the quality of life of older people [10,11].

Observational study provides interesting findings

For their study, Ferrán et al. at the Department of Otorhinolaryngology of the Clínica Universidad de Navarra (Spain) and through an advertisement in a local newspaper until August 2023 recruited a total of 710 patients who were assigned to three groups [9]:

• Group A (n=210): Individuals aged ≥55 years with normal hearing and balance abilities, characterized by a pure-tone average of 0 to 20 dB at frequencies of 500, 1000, 2000 and 4000 Hz, and exhibiting good static and dynamic balance control.
• Group B (n=302): Individuals aged ≥55 years who were diagnosed with a hearing and/or balance disorder but were not undergoing treatment.
• Group C (n=198): Individuals aged ≥55 years who were diagnosed with a hearing and/or balance disorder and received treatment: with hearing aids (HA), active middle ear implants (AMEI), bone conduction implants (BCI), cochlear implants (CI) or vestibular rehabilitation.

The average duration of hearing loss in group B was 11.8 years and in group C 21.0 years. A total of 60% of the 500 patients with hearing loss received no treatment at all. In group C, the average time to treatment of hearing loss was 14.1 years. The researchers wanted to examine the effects of delayed treatment on audiometric tests and various questionnaires. There were no statistically significant correlations between time to treatment and speech audiometry (p=0.471), the HINT test (p=0.784) or the SSQ12 (p=0.637). However, there was a significant association with Digit Symbol Substitution Test (DSST) scores (p=0.003), suggesting that the longer a patient’s treatment is delayed, the worse their cognitive performance. In Group B, the average length of untreated hearing loss was 11.8 years.

Conclusion: HHIE-S and SSQ12 as practicable screening tools

Ferrán et al. recommend increased screening for hearing loss in primary care, particularly in the over-60 age group [9]. In their study, they achieved a sensitivity of at least 77% with the “Hearing Handicap Inventory for the Elderly” (HHIE), the “Speech, Spatial and Qualities of Hearing Scale” (SSQ12) and pure-tone audiometry at 4 kHz, with the SSQ12 questionnaire having the lowest sensitivity of these three tests and the HHIE questionnaire the highest. In combination, the three tests achieved a sensitivity of 90.2% and a specificity of 86.4%.

• “Hearing Handicap Inventory for the Elderly” (HHIE): This is an easy-to-complete questionnaire for patients [32]. Among other things, it determines the social-emotional impairment caused by the hearing loss. The screening version (HHIE-S) consists of 10 items, half of which relate to emotional and/or social or situational aspects [32]. The total score of the HHIE-S ranges from 0 (minimum) to 100 (maximum). Scores below 16 in each subsection indicate no significant disability, while scores between 17 and 42 indicate a mild to moderate degree of disability and scores above 43 indicate severe disability. A higher HHIE-S score correlates with a higher degree of disability due to hearing impairment. Generally, applicants or recipients can complete this assessment in about 5 minutes. The completed questionnaire was also reviewed by an audiologist.
• “Speech, Spatial and Qualities of Hearing Scale (SSQ-12): This is a questionnaire in which a patient indicates how well they can hear and understand in various situations [33]. The test contains a total of 12 questions, which are divided into three sections: Speech comprehension, spatial hearing (perception of sound in space) and quality (clarity of speech and other sounds), suitable for adults of all ages and children aged nine and over. A rating scale from 0 to 10 is used for each question, with higher scores indicating better performance. Results are usually presented as mean scores for each section, but they can also be analyzed individually or in different groups, allowing comparison between two time points. Clinically relevant differences can be recognized by the fact that the score for each section shifts by 1.0 between test sessions. This questionnaire usually takes about 10 minutes to complete.

Ferrán et al. conclude that early detection of hearing loss in older people enables early intervention, which can help to better preserve the cognitive and mental abilities as well as the autonomy of this population group with positive effects on the quality of life of those affected and their environment [9,12].
The HHIE, the SSQ12 and pure-tone audiometry at 4 kHz are inexpensive, simple and quick tests that can be used in a program for the early detection of hearing loss in primary care centers. Depending on the results of the questionnaire, the attending physician could initiate treatment by an ENT specialist if necessary.

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HAUSARZT PRAXIS 2024; 19(9): 30-31 (published on 18.9.24, ahead of print)