Hearing loss is extremely common and associated with social isolation and poor mental and physical functioning, but it remains widely underdiagnosed and undertreated. Screening for hearing loss is a simple task, so why not screen everyone beginning at age 50? Early detection would lead to better health outcomes, right?
Not so fast. The US Preventive Services Task Force, an independent panel of primary care providers, recently concluded that the evidence was insufficient to weigh the value of screening in older adults unaware of their hearing impairment who did seek care for symptoms. The panel did not discourage doctors from conducting routine screenings of asymptomatic patients, but it did not recommend that they do so either.
Experts on hearing healthcare and aging concede that the task force got it right: little is known about the effects of screening on quality of life, cognitive function, and social interaction. “From a purely scientific standpoint, I have to agree with them,” said Frank R. Lin, PhD, an assistant professor of otolaryngology-head and neck surgery and epidemiology at Johns Hopkins School of Medicine and Bloomberg School of Public Health in Baltimore. “Those studies just have not been done,” he said.
Auditory research typically focuses narrowly on speech or hearing scores, not on quality of life or other big-picture outcomes, Dr. Lin said. Researchers often tackle larger public health questions related to aging, cognitive function, and healthcare costs, but “they don't really understand much about hearing,” he said.
Large trials are expensive and difficult to do, said James T. Pacala, MD, a professor and the associate head of family medicine and community health at the University of Minnesota Medical School in Minneapolis. The panel's new guidelines, published online this past August and later in the print edition of the Annals of Internal Medicine, replace 1996 recommendations favoring periodically questioning older adults about their hearing, counseling about hearing aids, and providing patient referrals when appropriate. (See FastLinks.)
Why the turnaround? “It wasn't so much a change in recommendation as much as a change in the overall process by which we evaluate evidence and make recommendations,” said Albert L. Siu, MD, the chair and a professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York City and a vice-chair of the US Preventive Services Task Force. Comparing the old guidance with the new advice would be like “comparing apples and oranges,” he said.
The task force raised the bar in recent years on the evidence required to recommend a preventive activity, and justifiably so, Dr. Pacala said. “I think they can make a pretty good argument that there should be a high burden of proof,” he said. Hearing screening, on the other hand, fundamentally differs from screening for some early-stage cancers, which can lead to unnecessary treatment, Dr. Pacala said, adding that the only potential harm with hearing screening is financial — the hit to a person's pocketbook because of inadequate insurance coverage of hearing aids.
Lack of Evidence
The task force reviewed studies published between 1950 and January 2010 on primary care screenings for age-related hearing loss in adults 50 and older. The review covered the association of screening with improved health outcomes, the benefit of early detection, treatment effectiveness, and the harm of screening and treatment.
The task force identified one “good quality” study showing that hearing aid use can improve hearing, communication, and social functioning in some adults with hearing loss. That study's findings, however, were limited to a population of white male veterans, many of whom had previously established, rather than screen-detected, hearing loss.
The only randomized controlled trial to examine the effect of hearing screening rather than treatment was designed primarily to measure hearing aid use rather than hearing-related function. The panel found no randomized trials or controlled observational studies on the potential adverse effects of screening or treating hearing loss with hearing aids.
The American Academy of Family Physicians updated its clinical guidelines to reflect the panel's advice. (See FastLinks.) It previously recommended that family doctors question older adults about hearing impairment and counsel them about treatment. Hearing screening, however, remains one required component of the Initial Preventive Physical Exam, also known as the “Welcome to Medicare” visit, which is offered to new Medicare beneficiaries, and the “Annual Wellness Visit,” which is available to established beneficiaries. A spokesman for the Centers for Medicare and Medicaid said it has no plans to amend these screenings.
The American Academy of Audiology, in comments on the panel's draft recommendation, noted that “a cost-effective screening program that helps to identify individuals with hearing loss (even a mild loss) and then provides education and information for the individual will help to identify hearing loss earlier for more effective treatment.” (See FastLinks.)
The American Speech-Language-Hearing Association said the task force's recommendation is a “call to action” for research examining whether screening this population would lead to improved outcomes. ASHA recommends that adults be screened at least every decade and at three-year intervals after age 50. (See FastLinks.)
Jaynee A. Handelsman, PhD, ASHA's vice president for audiology practice and the assistant director of the Vestibular Testing Center of otolaryngology-head and neck surgery at the University of Michigan Health System in Ann Arbor, said the association supports a three-pronged approach to screening. “In an ideal world, you would want to screen for disorder, impairment, and disability, so you're really getting a picture of not just whether somebody has a hearing loss, but how it's impacting their quality of life,” she said.
Where to Go from Here
Higher quality, larger scale screening trials, especially those testing new hearing-aid technology, would be beneficial, Dr. Pacala said. A potentially fertile area for research, he added, is the role of hearing loss in older adults becoming frail. Is hearing loss a contributor, a cause, or an effect? “If we were to take frail people and screen and treat them for hearing loss, would that be one of the pieces of the puzzle that could improve their health and functional status?” he asked.
Dr. Lin's research found that hearing loss is associated with poorer cognitive function and incident dementia, perhaps because the brain has to work harder to decode speech and that effort comes at a cost. Additional studies are needed to sort out these relationships. Is hearing loss a marker for dementia, for example, or could it be a modifiable risk factor?
Closing the data gap is part of the equation, but Dr. Lin said community-based models of service delivery, such as teleaudiology and self-fit hearing aids, must be developed as an alternative to audiology's clinic-based model of care. Such a system might appeal to adults with early hearing loss who would rather not make multiple clinic visits and spend thousands on hearing aids, he explained. “There's got to be something in between. The market has to be broad and diversified to account for the fact that two-thirds of all older adults have hearing loss,” Dr. Lin said.
* Read the US Preventive Services Task Force clinical guidelines at http://bit.ly/AnnalsIntMed.
* Learn more about the American Academy of Family Physicians' updated guidelines at http://bit.ly/AAFPguidelines2012.
* Read the American Academy of Audiology's response to the task force report at http://bit.ly/AAAresponse.
* See who should be screened for hearing loss at http://bit.ly/ASHAscreen.
* Learn more about Dr. Lin's research at http://bit.ly/LinResearch.
* Click and Connect! Access the links in The Hearing Journal by reading this issue on our website or in our new iPad app, both available at thehearingjournal.com.
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