As many of us get older, we can expect to acquire hearing loss. Fortunately, this develops gradually and takes 10 years or more before it becomes noticeable and reaches mild to moderate impairment. In view of the slow nature of hearing loss, minor changes go unnoticed or ignored until they become an obvious communication problem. As hearing loss progresses, many seniors learn how to accommodate their needs by making the television louder, getting a telephone amplifier, using assistive listening devices and personal amplifiers, and by asking others to repeat or to speak louder. Eventually, most of these attempts fail to provide maximized hearing and properly fitted hearing aids are ultimately needed.
The prevalence of hearing loss is approximately 30% for those 65-75 years old (National Institute on Hearing and Other Communicative Disorders) accelerating to 80% by the age of 85. Age related hearing changes typically occur because of health conditions such as high blood pressure, diabetes, high cholesterol, medication reactions, genetics and syndromes, noise exposure, infections, and other diseases, but not necessarily aging per se. Historical studies from the 1960’s demonstrated that in tribal societies (Mobans) where there was no environmental pollution or disease from diet, there was also no appreciable hearing loss, regardless of age. This suggests that the occurrence of hearing loss, in our modern day, is tied to environmental, genetic, diet, cultural, and societal factors rather than age alone. In the United States, hearing loss up to the age of 60 is typically not significant enough to require hearing aids. As we age changes to both the ears and the brain can occur, making communication a primary issue along with vision.
In 2011, new research findings from the Johns Hopkins University School of Medicine, supported by a grant from the National Institute on Aging, have shown that even mild untreated hearing loss in seniors accelerates brain aging by 6-7 years with a 2 to 5 times increased risk of dementia and for some, even Alzheimer’s disease (Central Presbycusis). This is because, the electrical activity in the brain is reduced by hearing loss and the chronic effort and reasoning required trying to understand speech is a burden on the brain. The lack of maintaining the brain’s normal awareness to sound unwinds the connections. Furthermore, increased isolation, lack of motivation to engage others, and the loss of autonomy and purpose that signify a healthier life course is impaired.
In view of the dilemma of Central Presbycusis, hearing aids should be used on a regular basis to preserve the brain’s sound map, support memory and auditory processing, maintain awareness of the environment, and promote interpersonal communication. It is clear from years of research that a world of silence and the lack of good communication results in poorer health, more hospitalizations and early death, poorer balance, depression and loneliness, or better stated; using hearing aids improves quality of life. As in children, the early identification of hearing loss is important when considering the best short and long-term outcomes. A simple hearing screening in a doctor’s office or by an Audiologist will determine the degree of hearing loss and the need for further diagnostic testing.
In addition to hearing loss, many seniors will naturally develop hearing ability changes. Some of these are a result of slower processing, but a number of them can come from medical issues such as diabetes, high cholesterol, and high blood pressure. These changes result in miscommunication patterns called a central auditory processing disorder (CAPD). Similar to hearing loss, CAPDs cause difficulty identifying speech sounds and understanding words, especially between the ears and listening in background noise. Auditory processing difficulties can range from very mild to an inability to follow a one-on-one conversation in a quiet room. In an extreme case, it would appear to any observer that the individual has deafness, but in fact, the problem is much different.
Although changes in the brain from normal aging and disease cause CAPDs, they are not an indication of reduced cognitive ability or the onset of dementia, but they can exist in addition to these conditions. Seniors with hearing loss and a CAPD are treated with hearing aids and a number of assistive listening devices (ALD). They are also trained in listening skills and strategies to optimize their abilities. The most successful patients with training adjust to their limitations and learn to use their communication skills effectively. For example, if moderate background noise was disturbing or confusing, regardless of appropriately fitted hearing aids with noise reduction and other devices, then it would be obvious to plan lunch in a quiet restaurant before or after the rush. At large family events, the best strategy is to share your hearing limitations and find a quieter room away from noise to speak with a few family members at a time. When in social situations, watching the person speaking and paying attention to facial expressions and body language gives hints to the content of the conversation. Being current with local and worldly events will also aid in understanding and interacting in the conversation.
In some communities, lip reading classes are available and highly recommended as the added information to sound increases the discrimination appreciably. Although we all have natural abilities to speech read, multiple modality processing between hearing and vision can be heightened to include cues that allow the brain to process easier. These few strategies improve understanding and can lessen the impact of hearing loss on interpersonal relationships and that is what aging is all about.
Hearing Aid Use
Seniors should start using hearing aids when the degree of hearing loss is mild to moderate. This is because a minimal hearing loss produces consistent difficulty hearing softer sounds, while continuing to maintain near normal hearing for many moderate and loud sounds. The use of hearing aids early on restores the ability to hear the soft sounds before the lack of hearing has changed the brain’s normal sound map and wiring to something less than maximum. The decision to fit one or both ears is dependent upon the degree of hearing loss and the quality of information received from each ear. In some cases, the information from the ears may be conflicting; a single hearing aid (most typically the Right ear) in this case is the only solution, but this is rare and fitting both ears, whenever possible, is the best hearing solution for a variety of reasons.
The use of amplification, from the early stages of hearing loss, maintains audibility at the ear allowing the brain to decipher, maintain, and learn about sound. Age is not a significant factor in the “plasticity” (ability to change and learn) of the brain. This is why modern research has been able to demonstrate that hearing aids and auditory therapy, at all ages, advances hearing ability.
Fast Speech and Hearing in Noise Solutions
Frequently, seniors have difficulty understanding fast speech and/or conversations in background noise. Difficulty understanding fast speech comes from an inability of the brain to identify the gaps between the words or speech sounds. The evaluation to determine a gap problem is called the Random Gap Detection Test developed by Dr. Robert Keith at the University of Cincinnati. As the speed of the talker increases, the gaps are not detected and the sounds blend or smear together, making them impossible to discern. Auditory training can help improve hearing skills, but slower and clearer speech at a moderate loudness can be helpful. As previously described, difficulty hearing speech in background noise may take place in the ear, brain, or both.
For some with severe impairment, even the newest technology cannot cure the problem. Hearing in noise testing can determine the necessity and potential for benefit when using noise reduction hearing aid technology. An Audiologist, before any hearing aid purchase, should perform these tests. Regardless of the origin of the masking disorder (ear or brain), the only solution is to reduce the amount of noise and increase the perception of speech. Directional hearing aids and hand held remote microphones, coupled with digital noise reduction circuitry and patient training, provide the best solution. These special microphones filter out sounds primarily from the sides and behind, while passing those that are in the direct path of the listener. The information is then processed through the noise reduction circuit to soften noise and improve comfort. For these reasons, hearing aids with both fixed and adaptive directional microphones are a necessity.
Some seniors have difficulty adapting to the quality of their voice when first using hearing aids. Seniors, who start using hearing aids when they have a severe hearing loss and high tone hearing loss with normal bass, are more likely to have aided voice difficulty. Initially, the claims may be that the voice sounds raspy or harsh, tinny or hissing, nasal, dull or plugged, loud, or reverberates as if their head was in a barrel. In many cases, adjustment to the prescription, style, or ear mold can cure the situation. However, a person with a naturally raspy or nasal voice will hear that quality and must adapt to their own tones to some degree. To remove or reduce the mid and high tone power to accommodate the patient’s normal voice tones will reduce speech clarity in others, but these can gradually be reintroduced over a few months period.
The Aided Voice Evaluation is designed to save or prevent hearing aids from being rejected because a patient feels uncomfortable hearing their own voice. It is a quick evaluation, requiring nothing more than saying “Mary had a little lamb” and finding the voice location and quality. When speaking, speech should feel and sound as if it were coming out of the mouth and throat. A voice located primarily in the ears, head, nose, or chest is inappropriate and a signal of an improper fit. Clearly, if the aided voice prevents the user from speaking comfortably because the voice sounds are unnatural, then the hearing aids are not fitted correctly and will be rejected. Adjustments to the ear mold and prescription can dramatically improve aided voice and, in most cases, resolve the issue entirely.
Assistive Listening Devices (ALD)
In addition to hearing aids, varieties of amplifiers that make life easier are available through a number of manufacturers. On a daily basis, most seniors get the best benefit from using amplifiers for both the telephone and television. Telephone amplifiers should be t-coil and hearing aid compatible and have a speakerphone option and Bluetooth enabled if they are going to connect directly to hearing aid products. The important part to remember is that hearing aids alone or any one of these devices will not solve all listening situation difficulties. Therefore, combinations of devices that best match the listening situation should be selected, practiced with, and used on a regular basis. When communication difficulty increases, seniors derive extra benefit by using hearing aid accessories that connect directly to electronic devices such as wireless FM, Bluetooth, and T-Coils. As the senior population grows over the next 20 years to nearly 72 million in the United States, the need for public venues that accommodate those with hearing loss is going to be increasing. Some industries have already installed special ALD and T-Coil Loop equipment to improve sound quality for the hearing impaired in theaters and other public arenas. For example, in London, the taxi cabs and rail lines are outfitted with T-Coil devices.
Difficulty hearing presentations, sermons, or lectures in large rooms has always been an issue for the hearing-impaired. Hearing aids are typically less effective in large rooms because of the nature of room acoustics, microphone capabilities, and hearing loss. As sound from a public address system enters a room and bounces from surface to surface (reverberation), it is degraded. The bouncing waves interfere with the original sound wave and over-all clarity is diminished. Seniors often find themselves unable to hear in large rooms and frequently complain that their hearing aids are of no value and avoid these activities. In order to overcome this difficulty, special FM listening systems and T-Coil Loops have been installed in many movie theaters, playhouses, religious facilities, and concert halls throughout the country. In many instances, the use of these headsets is free of charge. These systems work on the principle of eliminating the acoustics of a room and reverberation by sending the signal from the public address system directly to a wireless headset. This results in the best word clarity and sound quality.
Are You Motivated and Ready?
Ultimately, hearing aid results are dependent upon the motivation and readiness of the patient. For men, the motivation is frequently the spouse who is constantly repeating words and dealing with a television that is too loud or difficulty on the job. For women, it is more a judgment of quality of life and the need to communicate rather than vanity, although both are available with modern technology. However, without being ready to take the time necessary to adapt to sound and the use of hearing aids, the adventure will be less than satisfactory. Although the type and degree of hearing loss and the knowledge of the Audiologist are important, the patient’s readiness to proceed and willingness to stick with the rehabilitation program is what makes users successful. After hearing aids are initially fitted, learning to use amplification and adjusting to a new sense of hearing takes time and patience. The hearing aid process is not a quick solution, but well worth the long-term benefits. Although most seniors will see immediate improvement, it will not be until three to six months or more before the brain’s hearing thumbprint is remapped.
Even though modern amplification can be very automatic, it requires constant use, proper adjustment, batteries, and cleaning. Some of the new sounds will be problematic and require adjustments to the prescription, while others will just take time to learn. Multiple visits to the Audiologist are typical. Ear mold modifications for comfort and sound quality may be needed to control sound waves in the ear canal. Appointments for fixing tone quality and loudness that is either too little or too much are commonplace. Taking time to work with the Audiologist to resolve common hearing aid problems will insure that the hearing aid settings and features are being maximized for each individual loss (Fitting Hearing Aids).