Old Age Hearing Loss

Why and when do people get age-related hearing loss?

There is a wide spectrum of ages at which people may start developing age related hearing loss. Initially, the hearing loss is very mild and not perceptible. It affects both ears and progresses gradually with age till it finally becomes noticeable to both the patient as well as his family and friends. Typically the hearing loss may start from 50 years of age onwards, but may start even earlier in certain individuals from as early as 30 years of age. Different studies quote different statistics. However, it is indisputable that the prevalence of hearing loss increases with age, with more than half of people aged 75 years old having age related hearing loss. Those who have an early onset of age related hearing loss probably have a genetic predisposition. 

Age related hearing loss is known medically as Presbyacusis. It arises because of damage to the hearing sense organ called the cochlea. Within the cochlea many different types of cells are responsible for different functions in the sensation of hearing. One of these classes of cells is called the outer hair cells. These outer hair cells help to amplify the perception of sounds received by the cochlea and are essential for hearing. These outer hair cells are very sensitive to internal and extrinsic factors which can easily damage them. The outer hair cells supplying the higher frequency areas of hearing in the cochlea are much more vulnerable than those supplying the lower frequencies and are the ones usually damaged in age related hearing loss (presbyacusis). This explains why age related hearing loss mainly involves the high frequencies. 

Sometimes, there is also damage to the nerve cells that transmit the hearing from the cochlea to the brain, otherwise known as the spiral ganglion cells. As both these types of cells do not have the capacity to regenerate, once damaged, the age related hearing loss is permanent and irreversible. This is unlike in certain animals such as in birds and fish where they have the capacity to regenerate their damaged cells and therefore do not develop similar age related hearing loss.

What are the types of hearing issues seniors commonly face?

Seniors face a variety of hearing issues. The most common is an overall impairment in their hearing ability. They compensate by coming closer towards the speaker, raise the volumes of their entertainment devices like their television sets, or ask the speaker to speak louder. These seniors need the overall louder volumes to overcome their underlying poorer hearing ability. 

Another very common issue in age related hearing loss pertains to the fact that it affects the higher frequencies more than lower frequencies. A common refrain is that they find it harder to listen and understand women 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 the seniors can hear that there is speech being spoken, they are unable to decipher the words. The low and mid frequencies of speech carry most of the energy of the sound wave. However, it is the high frequency consonant sounds that carry the majority of speech information. These consonant sounds tend to be both high frequency as well as softly spoken, making it especially difficult to hear for seniors with age related hearing loss. As a result, although the seniors are able to report hearing that something is being spoken but they are not able to understand what is being said. 

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

Seniors may also face another concomitant hearing issue of 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 the underlying damage to the outer hair cells and sensory or neural cells results in instability of these cells and may account for generation of unwanted internal perception of noise as well. Often described as a chirping or cricket sound, they may sometimes be also of lower pitch like a humming noise. Thankfully, the tinnitus is often mild and seldom disabling. Most times, the brain is also able to habituate and get used to the tinnitus such that it is no longer distracting or frustrating for the person. 

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

This has 2 implications: Firstly, it may be difficult to accurately fit and tune a set of hearing aids for affected seniors, as careful upper output limits must be set to maintain comfortable hearing. Secondly, it also explains why shouting at affected individuals is often counter productive, since it its primarily the low frequency sounds that are amplified by shouting, rather than the high frequency sounds which is what the listener misses. Such loud volumes can be uncomfortable for the senior listener.

What are the signs that a senior’s hearing ability is declining?

The early signs would include increasing the volume of entertainment devices such as televisions and radios/ music players when listening. Family members usually complain that the seniors have turned up the volumes 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 in fact common to see and hear family members shouting in order to get themselves heard. Oftentimes affected seniors may also lean closer to the speaker to hear them better. At other times, family members will report that the seniors just don’t seem to have heard what was spoken. 

Poor speech discrimination also leads to problems such as misunderstanding what has been spoken and responding inappropriately. Otherwise, seniors may also report that many people they speak with seem to be mumbling or not speaking 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 leads to an inability to follow the progress of the meeting. 

Age related hearing loss affects men more than women. And as the hearing loss affects the high frequencies more than the low frequencies, they may find listening to women and children’s voices more difficult. 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 that hearing in crowded and noisy environments is particularly difficult. They may be able to hear in quiet rooms but not in noisy bars. They may also have difficulty using the telephone.

How can we find out if our senior family members are having hearing problems if they don't tell us?

The above answer to question 3 should provide clues that the senior is having hearing difficulties. It is evident in the fact that the senior doesn’t follow conversations, or is “living in their own world” that he may be having difficulty listening and so either doesn’t actually hear what is spoken or chooses not to try. 

The best way is to convince the senior to go for a proper hearing evaluation to determine his level of hearing loss. This can be done at a community based audiology clinic or in an ENT specialist centre.

Nowadays, there are also a variety of smartphone based apps that perform hearing screening assessments using simple paired ear phones or headphones. Many of these have not been extensively validated but can act as a simple screening tool to determine if senior family members have hearing problems since they are easy to download and perform. Once suggested as having hearing impairment, it would be good 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 utilize 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.

Why is it important to go for functional screening? How often should it be done?

Functional screening allows us to detect age related hearing loss and take the necessary steps to implement hearing interventions that can significantly aid the hearing of affected seniors and improve their quality of life.

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

Functional screening is available for seniors from the age of 60 years 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 oftentimes do not see any benefits in hearing intervention to enable them to 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 that they have good function of all their senses. 

The sense of hearing is not the only sense to deteriorate with age. Oftentimes, vision is also 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 home bound. This leads to a vicious cycle of little physical activity to keep them healthy as well.

How are the hearing checks conducted at the functional screening?

There are a variety of checks performed at the functional screening. These include answering certain hearing screening questionnaires, with or without tinnitus screening questionnaires.  Examples of such questionnaires include the Hearing Handicap Inventory for the Elderly- Screening (HHIE-S). 

There will also be a direct examination of the external ear canal and ear drums using a special illumination device (otoscope) by trained personnel in an examination called otoscopy. 

At the simplest level of functional screening, the formal hearing tests are performed using simple equipment including ear muffs which are able to test the person’s hearing ability at certain sound intensities (25 and 40dB). These can be performed by trained lay personnel rather than actual audiologists or audiology technicians.  

At the next level of functional screening, more advanced equipment is available to perform a frequency specific hearing screening test called the 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 the pressure of the middle ear using special techniques that measures the movements of the ear drum when presented with certain air pressures delivered to the ear canal. 

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

If the results show that the person has hearing issues, what should he/she do?

The first thing the person should do should be to consult a trained individual, either an an ENT surgeon or audiologist. When the hearing loss is of a sufficient degree, a conventional hearing aid can be prescribed to enable better hearing. Milder degrees of hearing loss may just warrant serial hearing test surveillance and fitting of the hearing aids only when the hearing loss severity progresses. 

The senior may wish to involve his family in the care of his hearing issues as oftentimes, the hearing issues lead to communication issues and disorders in the family. The family can then help the senior take responsibility in completing the evaluation and also in taking care of the various hearing devices that may be prescribed for their use. This is important as seniors may also have problems with forgetfulness leading to lost devices as well as problems with fine motor movements leading to problems with handling small hearing devices. 

There will be certain patterns and types of hearing loss that will warrant an ENT surgeon to attend to. These include other types of hearing loss such as conductive hearing loss, single sided hearing loss, sudden loss of hearing as well as very severe to profound hearing loss. 

The ENT Surgeon will be able to elucidate the actual cause of the hearing loss and whether other types of hearing devices will be useful for these patients. There are a variety of specialized hearing aids that can be prescribed for these special cases of hearing loss. 

Furthermore, there are a number of specialized surgical hearing implants that may be needed to help the hearing of certain patients. These include the use of cochlear implants, active middle ear implants and Bone Conduction Hearing implants.

What are the consequences if the hearing issue is not followed up or treated?

There are many consequences. 

The common consequences would be problems with communication. This arises because the senior either does not hear what is spoken and is therefore not aware of certain instructions or things spoken. Otherwise, frequently what is spoken is often misunderstood. This leads to much tension and stress between the senior and the family members. Even the compensatory mechanisms to cope with the hearing loss leads to added stress and misunderstanding amongst 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, and this usually implies an angry tone and they recoil or shout back and are hurt emotionally by this perceived rudeness by their family members. Family also get frustrated when they have to repeat the same sentence several times in order to be understood properly. As such, they sometimes prefer not to speak at all to the senior leading to a reduction in interactions and sometimes a breakdown in familial relationships. 

Difficulties hearing in crowded and noisy environments leads to affected seniors preferring to stay home rather than attending social functions. This leads to a reduction of social activities that otherwise would keep them engaged mentally and emotionally. 

Oftentimes the frustration over communication and hearing issues leads to the affected senior choosing not to bother at all and withdrawing socially entirely. He retreats literally into a “silent world” and doesn’t participate in conversations so as to avoid the problems of communicating entirely. 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, a set of hearing aids can significantly help to overcome any concomitant tinnitus that may accompany the hearing loss. Firstly, the hearing aids amplify the environmental sounds and this acts as a mask over the internally generated tinnitus noise, making it much less perceptible. Secondly the restoration of the missing frequencies will often reduce the perception of bothersome tinnitus as well. Tinnitus that is not well tolerated or controlled, can also lead to significant emotional health issues, stress and depression. 

The sense of hearing is not the only sense to deteriorate with age. Oftentimes, vision is also 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 home bound. This also leads to a vicious cycle of little physical activity which would otherwise have helped to keep them healthy.

Some old folks with mild hearing loss said they don't like to use a hearing aid because it's too sensitive, eg. picks up a lot of background noises. What's your advice?

Oftentimes, the reason why many seniors do not like their hearing aids is because they have not been properly tuned. Today’s modern digital hearing aids have very advanced features which are able to 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. 

Certain seniors may complain that the hearing aids are too loud sometimes. As mentioned, in age related hearing loss, there is also less tolerance to loud noises. The upper limits of the hearing aids must therefore be properly tuned to ensure it does 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 of hearing aids include the sound of an loud acoustic feedback loop whenever the hearing aid is being physically adjusted in the ear canal or removed. This is peculiar usually to the smaller hearing aids such as in-the-canal (ITC) hearing aids where the speaker is located very close to the microphone which then sets into motion an acoustic feedback cycle than gets progressively and quickly louder. The solution would be to consider other designs such as behind-the-ear (BTE) hearing aids where the speaker is physically far away from the microphone and will not lead to such an acoustic feedback loop occurring. 

In all, there is a suitable hearing aid 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.

What are the dos and don'ts to maintain healthy ears?

Avoid excessive loud noise exposure as this leads to noise induced damage to the inner ear hearing. This means not playing music on the headphones at extremely loud volumes. If working in loud and noisy environments, please remember to wear hearing protection devices such as ear plugs and ear muffs or both. For those occupationally exposed to loud noises, it is also important to go for your yearly Audiometric evaluation to check on the status of your hearing. 

Do not use cotton buds to clean your ear canals. While it is a common practice, this is actually dangerous as it is performed in a blind manner. There is the potential for the cotton bud to be pushed too deep and injure the ear drum and middle ear structures. There is also potential to scratch and damage the skin of the ear canal, exposing the ear to an increased risk of infections. Furthermore, as it is blind, you may actually be pushing the ear wax deeper into the ear canal and impacting it with the cotton bud. This will then require formal wax removal by a trained ENT surgeon, besides causing a drop in your hearing due to a plug of wax in the ear canal. It’s best to leave the ear canal alone as it is designed to be self cleaning, with the ear wax emptying itself out at the ear canal opening. As the saying goes, “Put Nothing smaller than your elbow in your ear”