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Unrecognized Hearing Loss

Identifying Unrecognized Hearing Loss

De Iorio, Monica L. MS; Rapport, Lisa J. PhD; Wong, Christina G. PhD; Stach, Brad A. PhD

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doi: 10.1097/01.HJ.0000612592.19609.31
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Age-related hearing loss (presbycusis) is one of the most common health conditions in adults over 50 years old. It is important to recognize and treat acquired hearing loss because it is linked to many adverse consequences, such as communication difficulties, social isolation, depression, and diminished quality of life.1,2 Despite the high prevalence of age-related hearing loss, many adults have hearing loss that goes unrecognized. People may miss identifying their age-related hearing loss because the onset is typically slow and gradual. They may not notice subtle changes in their hearing-related behaviors that attempt to compensate for the loss, such as increasing the volume on audio devices. Of course, someone who is not aware of their hearing loss is not likely to report the problem to health care providers, and he or she is subsequently less likely to receive screenings or referrals to audiology. This is a problem because early identification of age-related hearing loss allows for timely intervention and improved outcomes.3 In fact, adults who delay treatment until their hearing loss is severe do not respond to interventions as well as those who initiate interventions early in the course of their hearing loss.3 A good deal of research has focused on adults with diagnosed hearing loss that goes untreated (e.g., the problem of low uptake and use of hearing aids).4 Unfortunately, little is known about people who are unaware of their hearing loss.

iStock/Manuel-F-O, internet, telehealth, hearing loss.

Our research aimed to explore characteristics that differentiate adults with unrecognized hearing loss from those with recognized hearing loss and adults with normal hearing.5 By definition, it is difficult to conduct systematic research on a population of individuals who are unaware of their impairment and not seeking evaluation or treatment for it. We had a serendipitous opportunity to do so in the process of completing a study on assessment of verbal memory among adults with diagnosed hearing loss. In our initial study, we sought a comparison group of older adults with hearing in the normal range. We then worked with older adults who presented themselves as healthy volunteers for a study that specifically required participants with normal hearing.6 Each participant completed a hearing screen as part of a larger assessment. The screening paradigm identified a surprisingly large subgroup of people who had substantial hearing loss but self-reported that their hearing was normal. Although this unique group was excluded from the original study, we understood that their data presented a rare opportunity to learn more about the characteristics of people with unrecognized hearing loss, which might eventually improve efforts in identifying individuals who are least likely to seek out services independently.


Our study recruited older adults with and without hearing loss from the Henry Ford Health System (HFHS), Wayne State University (WSU), and the greater Metropolitan Detroit community. Thus, there was an opportunity for participation regardless of hearing status, and no requirement was placed that might motivate potential volunteers to misreport their self-perceived hearing abilities. The total sample comprised 130 adults aged 55 to 85 years old. Of these, 61 were diagnosed with age-related sensorineural hearing loss; they were largely recruited from the audiology services at HFHS and WSU. These volunteers were documented to have speech-frequency pure-tone average (PTA) of air-conduction thresholds of > 25 decibels hearing level (dB HL) at 0.5, 1, 2, and 4 kHz in the better ear. Participants who volunteered for the normal hearing group underwent hearing screens using a portable audiometer as part of the research study. Of the 69 adults who volunteered for that group, our hearing screens indicated that only 39 had hearing in the normal range. Unrecognized hearing loss was identified in 30 volunteers who had described themselves as having no hearing difficulty, but whose hearing thresholds were >25 dB at 0.5, 1, 2, or 4 kHz. As part of the original study, participants completed a subjective and objective assessment of their physical health, various measures of cognition, and personality assessment of their traits for positive and negative affectivity (emotionality).

The groups were equivalent in general physical health status, education, estimated IQ, and various cognitive abilities. Marital status and likelihood of living alone also did not differ among the groups. However, consistent with the known risk factors for hearing loss, individuals with unrecognized hearing loss were more likely to be men (60%) and tended to be older (average age of 70 years old) compared with participants with normal hearing (31% men, average age of 65 years old). Importantly, participants with hearing loss were similar in age and proportion of men regardless of whether the hearing loss was recognized or not. Thus, age and gender alone cannot be used to identify individuals particularly at risk for unrecognized hearing loss.

Interestingly, individuals in the unrecognized hearing loss group could be differentiated from the groups with hearing in the normal range and recognized hearing loss by their higher levels of positive affectivity. In fact, positive affectivity predicted group membership in the unrecognized hearing loss group even after accounting for age, gender, physical health, and cognitive health. In contrast, negative affectivity did not differ meaningfully among the groups. These results suggest that high positive affectivity may be related to discounting health declines and subsequently delaying intervention.


It is widely accepted that hearing screening is an important component of health care for older adults. However, the method used to identify hearing loss and the effectiveness of screening are quite variable. Frequently used techniques include self-report questionnaires or even simply asking if a person has noticed any difficulty hearing.7 However, as highlighted in our study, there is a sizeable subset of people who are likely to deny hearing difficulty upon questioning but have meaningful hearing loss. Individuals who report high positive affectivity are particularly at risk for biased responding on self-reported hearing measures. Typically, positive affectivity is associated with physical health, self-esteem, and subjective well-being;8 yet, it may also be associated with an overly rosy outlook that downplays negative things such as age-related decline, including hearing loss. Some studies have linked optimism and positive affectivity to denial and avoidance. For example, research indicates that people who engage in optimistic denial also tend to underrate their level of health risk.9

Providing educational materials on hearing screening and support for interdisciplinary referrals of patients to audiology services can help promote early identification of and intervention for individuals with age-related hearing loss.10,11 In light of the findings from our study, it is important to keep in mind that a patient's denial of hearing difficulty does not preclude the need for a referral for a hearing screening or assessment.

Further research should explore the best practices in psychoeducation about hearing screening that targets patients who do not endorse hearing loss. This may help optimize the likelihood of patient follow-up with assessment and intervention. Previous research has shown that self-perceived hearing problems and hearing-related functional impairment are positively related to help-seeking, hearing aid use, and hearing aid satisfaction across the spectrum of mild-to-severe hearing loss.12,13 Broadly targeted screening programs that specifically comment on the high prevalence (and associated risks) of unrecognized hearing loss may help increase the identification of hearing loss through heightened self-awareness and/or awareness within the person's family and social network. Subsequently, highlighting the importance of early intervention and prevention may enhance motivation and adherence with follow-up treatment among people with unrecognized hearing loss who are identified via screening. Including psychological assessment of readiness for change may also help in understanding a patient's level of awareness of hearing loss and motivation for intervention compliance.14 It may also be useful in engaging family members in discussions about hearing interventions for patients with poor awareness of their hearing impairment.


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