Old Age Hearing Loss

Seniors face a variety of hearing issues. The most common is an overall impairment in their hearing ability. They compensate by moving closer to the speaker, turning up the volume on entertainment devices like their television sets, or asking the speaker to speak louder. These seniors often need louder volumes to overcome their underlying hearing loss.

Another common issue in age-related hearing loss is that it affects higher frequencies more than lower frequencies. A common refrain is that they find it harder to listen to and understand women’s and children’s speech, as they tend to have higher-pitched voices.

There is also significantly poorer overall speech discrimination due to this high-frequency hearing loss. This means that although seniors can hear that speech is being spoken, they cannot decipher the words. Low and mid frequencies carry most of the energy of the sound wave.

However, high-frequency consonant sounds carry most speech information. These consonant sounds tend to be both high-frequency and softly spoken, making them especially difficult for seniors with age-related hearing loss to hear.

As a result, although seniors can report hearing that something is being spoken, they cannot understand what is being said.

All types of hearing loss are accentuated by competing background noise. As a result, seniors may report that they can hear in quiet rooms and when facing the speaker; however, in a noisy, crowded environment, they lose the ability to hear clearly. This is also known as the “cocktail party effect”.

Seniors may also experience another common hearing issue: tinnitus. Tinnitus is the perception of internal noise from one’s own hearing system that is not generated from the external environment. This frequently accompanies age-related hearing loss, as underlying damage to the outer hair cells and sensory or neural cells can destabilise these cells and may also contribute to unwanted internal noise.

Often described as a chirping or cricket sound, it may also be lower-pitched, like a humming noise. Thankfully, the tinnitus is often mild and seldom disabling. Most of the time, the brain can habituate to the tinnitus, so it is no longer distracting or frustrating.

Lastly, although it seems counterintuitive, age-related hearing loss may affect seniors and cause a narrowing of their dynamic range of hearing. This occurs because they need louder sounds to perceive them. At the same time, their ears are also more sensitive to loud sounds that otherwise normal-hearing people find tolerable. This is due to disordered sound processing in the inner ear, a phenomenon known as “recruitment”.

This has 2 implications: First, it may be difficult to accurately fit and tune hearing aids for affected seniors, as careful upper output limits must be set to maintain comfortable hearing. Second, it also explains why shouting at affected individuals is often counterproductive, since shouting primarily amplifies low-frequency sounds rather than the high-frequency sounds the listener misses. Such loud volumes can be uncomfortable for the senior listener.

Early signs include increasing the volume of entertainment devices such as televisions and radios/music players when listening. Family members often complain that seniors have turned the volume up too loud and are disturbing them.

Other signs include asking communication partners to repeat sentences they have just spoken, or to speak louder. It is common to see and hear family members shouting to get heard. Oftentimes, affected seniors may also lean closer to the speaker to hear them better. At other times, family members report that seniors just don’t seem to have heard what was said.

Poor speech discrimination can also lead to problems such as misunderstanding what was said and responding inappropriately. Otherwise, seniors may also report that many people they speak with seem to mumble or not speak clearly.

Those who are still working actively and attending meetings in conference or large rooms will have difficulty hearing speakers at the far ends of the room. This can make it hard to follow the progress of the meeting.

Age-related hearing loss affects men more than women. Because hearing loss affects high frequencies more than low frequencies, they may find it harder to hear women’s and children’s voices. Husbands often joke that they can’t hear their wives properly, when in fact there is a physical condition accounting for that! Alternatively, they may report not being able to hear the high-pitched beeping of certain alarms like the fridge door ajar alarm, or the microwave bell tinkling.

They will find hearing in crowded, noisy environments particularly difficult. They may be able to hear in quiet rooms but not in noisy bars. They may also have difficulty using the telephone.

The above answer to question 3 should provide clues that the senior is having hearing difficulties. It is evident that the senior doesn’t follow conversations or is “living in their own world,” which may mean they have difficulty listening and either don’t hear what is being said or choose not to try.

The best approach is to encourage the senior to have a proper hearing evaluation to determine the level of hearing loss. This can be done at a community-based audiology clinic or in an ENT specialist centre.

Nowadays, a variety of smartphone-based apps perform hearing screening assessments using simple paired earphones or headphones. Many of these have not been extensively validated but can serve as a simple screening tool to determine whether senior family members have hearing problems, since they are easy to download and use. If you suspect a hearing impairment, it would be helpful to have them undergo a formal hearing test/audiometry to evaluate the level and pattern of hearing loss.

There are also a variety of hearing screening questionnaires that are available online, and you can utilise these to ask the senior these questions directly so that you can ascertain whether they are actually noticing clues that point towards them having a hearing loss.

Functional screening helps detect age-related hearing loss and take the steps needed to implement hearing interventions that can significantly improve affected seniors’ hearing and quality of life.

Functional screening can detect hearing loss at an earlier, milder stage. With appropriate education and intervention, seniors can enjoy good hearing throughout their golden years.

Functional screening is available for seniors aged 60 and older. It should be performed yearly.

Oftentimes I find in my clinical practice that the Asian philosophy towards age-related hearing loss has been one of indifference and placid acceptance. Patients often tell me that hearing loss is “part and parcel of growing old”. They often do not see any benefit in hearing intervention to help them hear better and improve their social communication.

They do not realise that social communication is even more vital in those senior years to keep them active and mentally alert. Dementia has now been suggested in many studies to be aggravated by hearing loss. Keeping our seniors actively engaged in activities and physically independent requires good function of all their senses.

Hearing is not the only sense to deteriorate with age. Vision is also often impaired with age. To couple vision loss with hearing loss would be to allow an individual to be bereft of the ability to interact and appreciate the environment around them, leading them to become socially reclusive and many times homebound. This can lead to a vicious cycle of reduced physical activity, which can also affect their health.

Functional screening includes a variety of checks. These include answering certain hearing screening questionnaires, with or without tinnitus screening questionnaires. Examples include the Hearing Handicap Inventory for the Elderly Screening (HHIE-S).

Trained personnel will also directly examine the external ear canal and eardrums using a special illumination device (otoscope) in an examination called otoscopy. At the simplest level of functional screening, formal hearing tests are performed using simple equipment, including ear muffs that test the person’s hearing ability at certain sound intensities (25 and 40dB). Trained lay personnel, rather than audiologists or audiology technicians, can perform these.

At the next level of functional screening, more advanced equipment can perform a frequency-specific hearing screening test called Pure Tone Audiometry to determine the pattern and severity of hearing loss. This requires an audiologist or audiology technician to perform these tests. At the same time, another hearing test known as Tympanometry is performed, which measures middle-ear pressure using special techniques that measure eardrum movement when certain air pressures are delivered to the ear canal.

All these tests are simple and easy to perform and do not cause physical discomfort to the person being tested.

First, the person should consult a trained professional, either an ENT surgeon or an audiologist. If the hearing loss is severe enough, a conventional hearing aid can be prescribed to improve hearing. Milder hearing loss may warrant serial hearing tests and hearing aid fitting only if the severity progresses.

The senior may want to involve his family in managing his hearing, as hearing issues often lead to communication problems and family conflict. The family can then help the senior take responsibility for completing the evaluation and caring for the various hearing devices that may be prescribed for their use. This matters because seniors may also have forgetfulness that leads to lost devices, as well as fine motor issues that make it harder to handle small hearing devices.

Certain patterns and types of hearing loss will warrant an ENT surgeon’s attention. These include other types of hearing loss such as conductive hearing loss, single-sided hearing loss, sudden hearing loss, and very severe to profound hearing loss.

The ENT surgeon can identify the cause of the hearing loss and determine whether other types of hearing devices will be useful for these patients. A variety of specialised hearing aids can be prescribed for these cases of hearing loss.

Furthermore, some patients may need specialised surgical hearing implants to improve hearing. These include cochlear implants, active middle ear implants, and Bone Conduction Hearing implants.

There are many consequences.

Common consequences include communication problems. This happens because the senior may not hear what is being said and therefore may not be aware of certain instructions or information. Otherwise, what is spoken is often misunderstood. This leads to much tension and stress between the senior and the family members. Even compensatory mechanisms to cope with hearing loss can add stress and misunderstanding within the family.

For example, in order to be heard, family members often raise their voices. The affected senior perceives that their family is shouting at them, which usually implies an angry tone; they recoil or shout back and are emotionally hurt by this perceived rudeness.

Family members also get frustrated when they have to repeat the same sentence several times to be understood. As a result, they sometimes prefer not to speak at all to the senior, reducing interactions and sometimes straining family relationships.

Difficulty hearing in crowded, noisy environments can lead affected seniors to prefer staying home rather than attending social functions. This reduces social activities that would otherwise keep them mentally and emotionally engaged.

Often, frustration with communication and hearing issues leads the affected senior to stop trying altogether and withdraw socially. He retreats into a “silent world” and doesn’t participate in conversations to avoid the problems of communicating. This oftentimes leads to social isolation and depression.

As mentioned earlier, the lack of communication and hearing/ social interaction is being suggested as one of the contributing factors to the progression of dementia in a significant proportion of elderly seniors as well.

Furthermore, hearing aids can significantly help overcome any concomitant tinnitus that may accompany hearing loss. First, hearing aids amplify environmental sounds, which can mask internally generated tinnitus, making it much less noticeable. Second, restoring missing frequencies often reduces the perception of bothersome tinnitus. Tinnitus that is not well tolerated or controlled can also lead to significant emotional health issues, stress and depression.

Often, the reason many seniors don’t like their hearing aids is that they haven’t been properly tuned. Today’s modern digital hearing aids have advanced features that can automatically detect certain unwanted background noises and digitally reduce them rather than amplify them. This requires proper programming, which may entail more than a single visit to the audiologist.

Some seniors may complain that the hearing aids are too loud at times. As mentioned, age-related hearing loss also reduces tolerance for loud noises. The upper limits of the hearing aids must therefore be properly tuned to ensure they do not cross this comfortable threshold. This again requires more visits to the audiologists to properly program the hearing aids to the patient’s hearing profile for easy, comfortable listening,

Other complaints about hearing aids include a loud acoustic feedback loop whenever the hearing aid is physically adjusted in the ear canal or removed. This is usually more common with smaller hearing aids, such as in-the-canal (ITC) hearing aids, where the speaker is very close to the microphone, which can trigger an acoustic feedback cycle that quickly and progressively gets louder.

The solution is to consider other designs, such as behind-the-ear (BTE) hearing aids, where the speaker is physically far from the microphone and will not trigger such an acoustic feedback loop.

Overall, a suitable hearing aid exists for the vast majority of patients with age-related hearing loss. It simply requires a trained audiologist to recommend a suitable hearing aid based on the person’s hearing and functional needs, as well as a commitment by both the wearer and the audiologist to program and tune the device properly to maximise its performance.

Avoid excessive loud noise exposure, as this can cause noise-induced damage to the inner ear. This means not playing music on the headphones at extremely loud volumes. If you work in loud, noisy environments, remember to wear hearing protection devices such as earplugs, earmuffs, or both. If you are occupationally exposed to loud noise, it is also important to attend your yearly Audiometric evaluation to check your hearing status.

Do not use cotton buds to clean your ear canals. While it is a common practice, it is actually dangerous because it is done blindly. The cotton bud can be pushed too deep and injure the eardrum and middle ear structures. It can also scratch and damage the skin of the ear canal, increasing the risk of infection.

Furthermore, because you can’t see inside, you may push earwax deeper into the ear canal and pack it in with the cotton bud. This can then require formal wax removal by a trained ENT surgeon and can also cause a drop in hearing due to a wax plug in the ear canal. It’s best to leave the ear canal alone, as it is designed to be self-cleaning, with the earwax emptying itself out at the ear canal opening. As the saying goes, “Put nothing smaller than your elbow in your ear”.