Editor's Note: This is the first installment of a two-part article. The conclusion will appear in the January 2017 issue.
Thanks to the career-long work of the late Marion Downs, early detection programs designed to identify infants who will benefit from early intervention are extraordinarily successful in the United States. The average age of identification has dropped to about 2 to 3 months, with remediation beginning as early as 6 months and notable improvements in language, social, and emotional development of children with an early diagnosis. Considering the prevalence and adverse health outcomes of age-related hearing loss, as well as the increasing availability of hearing health care solutions and interventions, it makes sense to learn from the success of our pediatric colleagues in revisiting the issue of screening older adults for age-related hearing loss.
From a public health perspective, clinical preventive services (CPS), which includes screening tests as well as health behavior counseling, is proven to save lives and promote well-being. Yet hearing and the ability to communicate are rarely considered contributing factors to well-being and, therefore, unworthy of screening efforts either inside or outside of a clinical setting. Because of the modest success of screening programs in primary care and the reality that clinicians don't have time to engage in CPS, there is a movement afoot by public health professionals for preventive services to take place in the community setting and be integrated into the work of clinicians (Milbank Q. 2001;79:579 http://bit.ly/2e8tCfJ;J Am Geriatr Soc. 2002;50:1886 http://bit.ly/2e8tZqE;Jt Comm J Qual Improv. 2001;27:63 http://bit.ly/2e8uUHO).
Audiologists should collectively advocate for behavioral counseling and screening of older adults regarding age-related hearing loss and consider other possible initiatives.
The evidence is clear, and so is the handwriting on the wall in terms of the positioning of hearing health care for older adults in the 21st century. Hearing loss is a major public health problem that poses various threats to communication, health, and well-being. Prevalence data from the 2001 to 2010 National Health and Nutrition Examination Surveys (NHANES) shows that while one in seven individuals 12 years of age and older have bilateral hearing loss, two thirds of adults 70 years of age and older have bilateral hearing loss (Am J Public Health. 2016;106:1820 http://bit.ly/2enGNoy). About 20 percent of people 60 to 69 years of age have mild bilateral hearing loss, and this number rises to nearly 40 percent among people 70 to 79 years of age (i.e., 6.8 million people). These numbers underscore the imperative of using creative initiatives to reach older adults with age-related hearing loss.
As a compelling intervention, CPS aims at reducing barriers to entry and promoting behavior change in healthy older adults. One of its underlying frameworks is meeting people where they are and engaging them in their community (e.g., workplace, independent living settings, etc.) and in the clinical setting through behavior change counseling and education (Ear Hear 2016;37:376 http://bit.ly/2e8ttc9;Am J Public Health. 2010;100:590 http://bit.ly/2e8wut4). Designed to help individuals rather than populations, interventions of this nature, when applied consistently and across settings, could have a large and sustained impact.
Evidence supporting my advocacy for hearing health screening across multiple community and clinical settings include:
(1) Age-related hearing loss is ubiquitous, with severity and risk increasing dramatically with age (Ann Intern Med. 2016;165:441 http://bit.ly/2e8vbdI;J Am Geriatr Soc. 2015;63:918 http://bit.ly/2e8vpBA).
(2) The adverse health outcomes are numerous, ranging from communication difficulties with physicians and increased odds of having a history of self-reported falls to increased risk for cognitive impairment and limitations in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Gerontologist. 2003;43:661 http://bit.ly/2fISIwI;Arch Intern Med. 2012;172:369 http://bit.ly/2e8wjy0).
(3) Men are at increased risk for all-cause and CVD-related mortality, even after controlling for such variables as smoking status, self-rated health, cognitive status, falls, walking disability, or hearing aid use (Age Ageing. 2014;43:69 http://bit.ly/2e8yDoE).
(4) People with moderate to severe hearing loss have an increased likelihood of requiring personal assistance from informal support systems, including family and friends (Age Ageing. 2010;39:458 http://bit.ly/2eFLH26).
(5) Hearing loss among community-based older adults is independently associated with higher incidence and rate of hospitalization (J Am Geriatr Soc. 2015;63:1146 http://bit.ly/2e8ACsU).
(6) Older adults (> 65 years) are predicted to live for more than half of their remaining years with at least mild levels of hearing loss and adults aged 75 years and older are predicted to live more than half of their remaining life with moderate hearing impairment (J Gerontol A Biol Sci Med Sci. 2016;71:637 http://bit.ly/2e8uYHp).
(7) Hearing loss in women correlates with walking difficulties and onset of new mobility limitations (J Am Geriatr Soc. 2009;57:2282 http://bit.ly/2e8wkSx).
(8) Decline in psychosocial health is closely linked to change in hearing status and partner death. Faster decline in hearing over time is associated with a greater increase in social and emotional loneliness; people with moderate hearing loss are at greatest risk (J Aging Health. 2014;26:703 http://bit.ly/2e8x5Lw).
(9) Hearing loss is independently associated with increased health care use and poorer self-rated health (JAMA. 2013;309:2322 http://bit.ly/2e8xmOq).
(10) Hearing loss at the end of life (last two years) is associated with lower ratings of subjective well-being (J Am Geriatr Soc. 2016;64:1486 http://bit.ly/2e8yPUP).
(11) Effective physician-patient communication is compromised by communication deficits, thereby affecting health outcomes negatively.
(12) Hearing aids are under-utilized by older adults even though they are the treatment of choice.
(13) There is significant co-morbidity associated with hearing loss, and hard-of-hearing persons experience more difficulties and delays in accessing health care as compared with persons not reporting hearing loss (J Community Health. 2011;36:748 http://bit.ly/2e8A3iK).
Let us start a dialogue and partnership with “hearing health first responders” to decide on the most appropriate settings for screening and hearing health behavior change counseling as a clinical preventive service. We must agree on best practices in terms of: (1) CPS protocols; (2) educational materials recognizing the existence of age-related hearing loss; (3) how to choose a qualified hearing health care professional, and; (4) effective and affordable tiered hearing health care interventions available to address age-related hearing loss.
Table 1 is a clinical decision support tool I have adapted to demonstrate the value of preventive screening of hearing loss. This also helps answer questions raised by many stakeholders who are not yet convinced that untreated age-related hearing loss is a serious public health challenge that poses a barrier to health care, longevity, and functional well-being (Ann Intern Med. 2011;154:174 http://bit.ly/2e8DRAG;J Community Health. 2011;36:748 http://bit.ly/2e8FrTm). The potential benefits of preventive hearing screening are likely to outweigh the harm, especially since hearing health is a modifiable risk factor through which behavior change may impact morbidity and mortality.
Part 2 in the January 2017 issue will discuss the innovative approaches to screening for age-related hearing loss (ARHL) and considerations in comparing the benefits and risks of screening older adults for ARHL.