Advances in life expectancy over the past century are in large part attributable to a new era of prevention and health promotion to extend the healthspan. In contrast to lifespan or the length of one's life, healthspan refers to the period in life when one is healthy. Social, environmental, and physical activities are significant determinants of healthspan, and health-promoting activities across the lifespan affect healthspan.1 According to Fried and Rowe, factors that create health disparities should be the prime targets of public health solutions to optimizing healthspan.1 Within hearing health care, research has shown evidence of health disparities. For example, hearing aid ownership is lowest among socioeconomically disadvantaged groups including minority older adults.2,3 In vulnerable populations, hearing loss compounds the difficulty of accessing and communicating information in an already complex health care delivery system. Hence, it seems logical that hearing screening should be a mandatory part of a wellness check in primary care settings, especially for more vulnerable populations.
This new era of health promotion and disease prevention dovetails with advances in geriatric medicine wherein care has been influenced by the new dogma that clinical conditions previously considered to be “normal” for one's age actually pose risks and must be considered for prevention and management activities.1 For example, previously left untreated, isolated systolic hypertension is now viewed as a treatable risk factor for stroke.1 Similarly, the updated Lancet life course model of potentially modifiable risk factors for dementia lists hearing loss among the highest modifiable risk factors, citing that the identification of hearing loss in midlife significantly reduces dementia prevalence.4 Livingston and colleagues posited that the long follow-up times in the prospective studies reviewed suggested that those who developed dementia were not less likely to use hearing aids; instead, hearing aid use appeared to be protective against cognitive decline possibly due to the cognitive stimulation they provide.4
It is notable that while the quality of the evidence was weak, the World Health Organization (WHO) document, “Integrated Care for Older People,” strongly recommended that “screening followed by the provision of hearing aids should be offered to older people for timely identification and management of hearing loss.”5 It further suggested that “health care professionals should be encouraged to screen older adults for hearing loss by periodically questioning them about their hearing. Audiological examination, otoscopic examination, and the whispered voice test are also recommended.”5
The WHO document offered compelling reasons for their recommendations, and considered the relevance of opportunity costs and societal implications associated with untreated and undiagnosed hearing loss. They concluded that the benefits of the intervention outweighed the disadvantages and costs associated with hearing aid use.
In light of the above considerations, how could the U.S. Preventive Services Task Force (USPSTF) draft recommendations6 remain consistent with its 2012 recommendations, specifically that while age-related hearing loss is common and often overlooked, the available evidence is insufficient to assess the balance of benefits and harms of hearing loss screening in asymptomatic adults aged 50 years or older? In contrast, the WHO document5 included language suggesting that hearing screening and hearing aid use do not seem to harm individuals, and posited that the acceptability and increasing affordability of hearing aids, along with its benefits in enabling communication and engagement, would have profound societal implications.
A PROACTIVE APPROACH
The 2020 USPSTF guidance should be seen as a call to action by hearing care professionals and organizations. We must acknowledge that multiple factors account for the limited availability of evidence on the benefits and harms of screening. For one, the low uptake of traditional hearing aids may be a poor barometer of the success of screening efforts. Next, we have been operating within a delivery system that has been contaminated by limited access to hearing health care and marred by cost constraints. Also, many health care professionals working with older adults do not recognize that the consequences of hearing loss go beyond mere sensory loss. Integral to effective communication and person-centered care, hearing is a complex sense critical to engagement, well-being, and healthspan. By continuing to rely on the audiogram as the holy grail of audiology, we are limiting our reach by relying on a one-size-fits-all approach to hearing care and compromising the success of health promotion activities. Finally, the numerous barriers to access, including several trips to the audiologist's office for a hearing aid fitting, may also pose a hindrance to the uptake of hearing assistance. As Humes6 suggested, repeat visits to an audiologist are likely one additional consideration in the cost-benefit analysis many patients calculate when deciding whether to proceed with a costly hearing solution.
SCREEN FOR AUDITORY WELLNESS, NOT IMPAIRED HEARING
As part of hearing health promotion activities, let us reframe our concept of hearing status and our professional image as hearing aid salespersons and acknowledge the importance of counseling and advocacy about the importance of hearing in one's overall well-being. Recently, Humes7 offered a new framework for how we conceptualize hearing loss, moving away from the medical model whereby hearing status is traditionally defined by the audiogram and turning to the severity of a patient's hearing difficulties that are not typically captured by the audiogram. Rather than using audiometry-based pass-fail screening criteria, let's transition to the use of auditory wellness categories. Auditory wellness acknowledges that environmental and personal factors modulate the impact of impairment such as hearing loss, and is therefore variable in degree.7 Humes proposed, for example, that excellent auditory wellness would be synonymous with excellent auditory function and the absence of an auditory disability. In contrast, very poor auditory wellness would be equivalent to very poor auditory function and severe auditory disability in terms of participation restrictions. Screening failures and targeted intervention recommendations could be based on the degree of auditory wellness as the categories do in fact relate to readiness and hearing aid uptake.
Perceived auditory wellness could be a screening target. Using such a model, perhaps the concept of “not hearing well enough” to seek a hearing health care solution would be reconstrued as seeking a hearing solution to improve or maintain “auditory wellness.” Associating hearing with wellness may in fact buttress the decision to seek hearing health care advice and treatment. Leveraging emotional science and incentivizing those with compromised hearing to overcome personal and societal barriers may drive the decision to seek a hearing solution that optimizes communication and auditory wellness. In short, placing a positive spin (increasing positive feelings) on a stigmatized condition (avoiding negative feelings) may be a potent driver of patient decision-making in hearing health care. A positive emotion, once activated, may trigger a predisposition to see through a lens that would help individuals better self-manage environmental and situational challenges.
Let us be proactive in regarding auditory function as a target of hearing health promotion activities. Our healthspan may depend on it.
Acknowledgment: Thank you to Dr. Larry Humes for sharing a preprint of the manuscript, “Aging and Self-Assessed Auditory Wellness,” which will appear in Ear and Hearing in 2020 or early 2021.8