For many older adults (≥ 60 years old), aging is associated with an increased risk of hearing loss1 and may also be associated with an increased risk of depression.2 Over the past 40 years, many studies have examined hearing loss and depression in older adults, with some reporting a positive association and others reporting no association. Several reasons contribute to these conflicting findings. First, the association between hearing loss and depression has been most frequently reported in epidemiological studies (cross-sectional and cohort studies) that often introduce bias to the study design, invariably affecting outcome results and reducing confidence in study findings.3 Second, some studies measure hearing loss using pure tone audiometry,4 whereas others measure hearing loss with self-reported outcomes,5 which may produce differing estimates of hearing loss and therefore biased results. Third, many studies do not control for the influence of cognitive impairment/decline on the association between hearing loss and depression in older adults despite substantial evidence showing the positive association between hearing loss and cognitive decline as people age.6 Fourth, most studies do not accurately report or control for the influence of hearing aid use in older adults with hearing loss and depression. As such, the influence of hearing aid use on the relationship between hearing loss and depression is unclear. Lastly, many studies investigating the potential association between hearing loss and depression have not reported results adjusted by participant health/psychosocial characteristics, which undermines the validity of their findings.7,8 With these caveats in mind, it was therefore important to conduct an extensive systematic review and meta-analysis of all published studies examining hearing loss and depression in older adults to synthesize the available evidence and provide a rigorous estimate of the association between hearing loss and depression in older adults.9
A systematic review and meta-analysis were conducted10 to identify all studies examining hearing loss and depression in older adults published from the first date of publication to July 17, 2018. Participants, study characteristics, and hearing loss and depression outcomes were extracted from each study, and most recent studies were included in this meta-analysis where data were reported from the same cohort but in separate studies. Odds ratio (OR) was used to represent the effect size in this meta-analysis. ORs equal to or greater than 1.68, 3.47, and 6.71 represent small, medium, and large effects, respectively.11
In total, 1,435 titles and abstracts were systematically screened in online databases. Thirty-five studies, including 147,148 participants from 18 countries and all seven continents, met the inclusion criteria of this meta-analysis. Twenty-four studies had cross-sectional and 11 had cohort designs. In the studies that reported sample demographics, participants were older adults (age Myears = 73.43, SD = 4.40) and more frequently female (58.69%). Overall, hearing loss was associated with a small but statistically significant greater odds of depression in older adults (OR = 1.47, 95% CI = 1.31 – 1.65; Fig. 1). Within this overall effect, no significant differences were observed when studies were grouped and compared by type of hearing measure, use of hearing aids by a proportion of participants, presence of cognitive impairment among a proportion of participants, or inclusion of covariates in outcome results (Table 1).
HEARING LOSS-DEPRESSION CONNECTION
The first main finding of this review and meta-analysis indicates that hearing loss is associated with 1.47 greater odds of depression in older adults, which is a small effect. Although this association was statistically significant, a small increase in the odds of depression indicates that a small proportion of older adults may experience depressive symptoms associated with their hearing loss, but most may not. Within the broader population, depression is frequently associated with negative life events (e.g., death of a loved one, loss of income), long-term stress, personality disorders, substance abuse, and poor diet,12 and these factors may be worsened in older adults who experience a general decline in their health and/or hold negative perceptions of aging.2 Health practitioners (specifically audiologists) working with older adults with hearing loss must therefore be aware of the heterogeneous etiology of depression and understand that a proportion, not the majority, of older patients will experience depressive symptoms associated with their hearing loss.
The second main finding indicates that the association between hearing loss and depression may not be influenced by the type of hearing loss measure, demographic or health characteristics, or aural rehabilitation in the form of hearing aids. Recent evidence shows that social support may moderate the relationship between hearing loss and depression in later life,13 suggesting that older adults may benefit from educational training14 and psychosocial counseling15 to help them navigate their changing health and its associated impact on their quality of life. Adults with severe to profound hearing loss also report not receiving but wanting referrals to psychosocial counseling as part of their aural rehabilitation.16 It is important to note, however, that many older adults associate stigma with depression and mental health disorders,17 which often inhibits their intentions to seek help and makes it increasingly difficult for audiologists and geriatricians to identify when older adults may be in need of, and will benefit from, intervention. For example, the U.K. Royal College of Psychiatrists reported that upon hospital admission, almost half of all older adults with a diagnosis of depression did not have that diagnosis included in their patient notes or reported in their discharge correspondence with their general practitioner.18 Audiologists may benefit from training to increase their understanding of psychosocial difficulties experienced by older adults with hearing loss19 and increase their confidence in identifying and discussing mental health concerns with older patients. Increased use of depression screening tools (e.g., Geriatric Depression Scale) by health professionals working with older adults with hearing loss may also increase awareness of depression in this population and the proportion of individuals benefiting from psychologists and psychiatrists specializing in the treatment of depression.20
In summary, a small proportion of older adults may experience depression associated with their hearing loss, and hearing aids may not alleviate depressive symptoms associated with hearing loss. It is important to note, however, that there was significant variability between the methods used within studies included in this meta-analysis. We therefore recommend future researchers conduct high-quality randomized controlled trials to increase our understanding of the potential beneficial effects of hearing aids on mental health in older adults with hearing loss. Nonetheless, the current study is the most extensive systematic review and meta-analysis of hearing loss and depression published to date, and these findings are strengthened by a large (N > 145,000) globally representative sample of older adults.
1. Goman AM, Lin FR Prevalence of hearing loss by severity in the United States. Am J Public Health.
2. Freeman AT, Santini ZI, Tyrovolas S, Rummel-Kluge C, Haro JM, Koyanagi A Negative perceptions of ageing predict the onset and persistence of depression and anxiety: Findings from a prospective analysis of the Irish longitudinal study on ageing (TILDA). J Affect Disord.
3. Ioannidis JP Exposure-wide epidemiology: Revisiting Bradford Hill. Stat Med.
4. Hidalgo JLT, Gras CB, Lapeira JT, Verdejo MÁL, del Campo JMDC, Rabadán FE Functional status of elderly people with hearing loss. Arch Gerontol Geriatr.
2009;49: 88-92. doi:10.1016/j.archger.2008.05.006.
5. Saito H, Nishiwaki Y, Michikawa T, Kikuchi Y, Mizutari K, Takebayashi T, Ogawa K Hearing handicap predicts the development of depressive symptoms after 3 years in older community-dwelling Japanese. J Am Geriatr Soc.
6. Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA Association of age-related hearing loss with cognitive function, cognitive impairment, and dementia: A systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg.
7. Al Sabahi S, Al Sinawi H, Al Hinai S, Youssef R Rate and correlates of depression among elderly people attending primary health care centres in Al Dakhiliyah governorate, Oman. Eastern Mediterr Health J. 2014 20 181–189
8. Chou KL, Chi I Prevalence and correlates of depression in Chinese oldest-old. Int J Geriatr Psychiatry. 2005;20:41-50. doi:10.1002/gps.1246.
9. Lawrence BJ, Jayakody DMP, Bennett RJ, Eikelboom RH, Gasson N, Friedland PL Hearing loss and depression in older adults: A systematic review and meta-analysis. Gerontologist.
10. Stroup DF, Berlin JA Morton SC … Thacker SB. Meta-analysis of observational studies in epidemiology: A proposal for reporting. JAMA.
11. Chen H, Cohen P, Chen S How big is a big odds ratio? Interpreting the magnitudes of odds ratios in epidemiological studies. Commun Stat Simul Comput.
12. Beck AT, Alford BA Depression: Causes and treatment. 2009; USA: University of Pennsylvania Press.
13. West JS Hearing impairment, social support, and depressive symptoms among US adults: A test of the stress process paradigm. Soc Sci Med.
14. Preminger JE, Meeks S Evaluation of an audiological rehabilitation program for spouses of people with hearing loss. J Am Acad Audiol.
15. Lindsey H Mental well-being tightly linked to hearing health. Hear J.
16. Hallam R, Ashton P, Sherbourne K, Gailey L Acquired profound hearing loss: Mental health and other characteristics of a large sample. Int J Audiol.
17. Conner KO, Copeland VC, Grote NK, Koeske G, Rosen D, Reynolds CF, Brown C Mental health treatment seeking among older adults with depression: The impact of stigma and race. Am J GeriatrPsychiatry.
18. Hood C, Plummer K, Quirk A Survey of depression reporting in older adults admitted to acute hospitals. 2018; Royal College of Psychiatrists: UK.
19. Ekberg K, Grenness C, Hickson L Addressing patients' psychosocial concerns regarding hearing aids within audiology appointments for older adults. Am J Audiol.
20. Smarr K L, Keefer AL Measures of depression and depressive symptoms: Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Arthritis Care Res.