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The impact of hearing loss on the quality of life

of elderly adults

This article was published in the following Dove Press journal:

Clinical Interventions in Aging
14 June 2012
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Andrea Ciorba Abstract: Hearing loss is the most common sensory deficit in the elderly, and it is becoming
Chiara Bianchini a severe social and health problem. Especially in the elderly, hearing loss can impair the exchange
Stefano Pelucchi of information, thus significantly impacting everyday life, causing loneliness, isolation, depen-
Antonio Pastore dence, and frustration, as well as communication disorders. Due to the aging of the population in
the developed world, presbycusis is a growing problem that has been reported to reduce quality
ENT and Audiology Department,
University Hospital of Ferrara, of life (QoL). Progression of presbycusis cannot be remediated; therefore, optimal management
Ferrara, Italy of this condition not only requires early recognition and rehabilitation, but it also should include
an evaluation of QoL status and its assessment.
Keywords: hearing loss, presbycusis, quality of life, elderly

Introduction
The term “presbycusis” refers to hearing loss that is associated with the cochlear
degenerative process of aging. By definition, presbycusis is bilateral, symmetrical,
and slowly progressive.1–3
Hearing loss is a common problem associated with senescence, and it is likely to
become more of an issue with changing population demographics in the developed
world. The impact of hearing loss may be profound, with consequences for the social,
functional, and psychological well-being of the person.
On one side, our lack of understanding of this disease process and our inability to
remediate its progression are important parts of the problem. At present, clinicians can
only use family history, the history of onset and progression, and the results of audio-
metric testing to determine the degree of impairment, to estimate the potential for future
hearing loss, and to make recommendations for amplification with hearing aids.
On the other side, optimal management of this condition also should include an
evaluation of quality of life (QoL) status and its assessment. This is due to the fact that
several studies have already demonstrated that presbycusis may have a negative effect
on QoL and psychological well-being – social isolation, depression, anxiety, and even
cognitive decline have been reported in affected persons.1–3
Despite efforts to understand the disease processes, at present, clinicians are still
unable to remediate its progression.

Correspondence: Andrea Ciorba

ENT and Audiology Department,
Epidemiology and risk factors of presbycusis:
University Hospital of Ferrara, a challenging problem
C.so Giovecca 203, 44100 Ferrara, Italy
Tel +39 0532 237447
Presbycusis is the most common cause of adult hearing deficiency; it is considered the
Email andrea.ciorba@unife.it most prevalent sensory impairment in the elderly, affecting individuals aged 75 years

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Ciorba et al Dovepress

and older. As our society matures, there are more people living - behavioral reactions, such as bluffing, withdrawing,
into their 60s, 70s, 80s, and beyond, due to factors such as blaming, and demanding
improved nutrition and health care. It has been reported that, - cognitive reactions, such as confusion, difficulty ­focusing,
in the United States, presbycusis affects 40% of the popula- distracting thoughts, decreased self-esteem, and com-
tion older than 75 years of age, and, in our aging society, it munication disorders.8,9
is becoming more prevalent.1–5 The 1995 UK national study
of hearing disorders found that 20% of adults had some Instruments to evaluate the impact
degree of hearing impairment (audiometric threshold greater of hearing loss on QoL
than 25 dB) in the better hearing ear; 75% of those are over Assessment of QoL deterioration due to hearing loss can
60 years of age.1–5 Recent estimations suggest that the number be achieved through several instruments, as reported in dif-
of senior citizens in the US with significant hearing loss could ferent studies in the literature.8,9 These can be divided into
increase to 35–40 million by the year 2030.1–5 hearing-related QoL instruments (Table 1) and generic QoL
Aging is defined as the biological process of growing instruments.
old, and intrinsic and extrinsic factors, as well as their inter- An example of a hearing-related instrument that incor-
actions, influence the degree and rate at which our hearing porates a question specifically designed to assess QoL is the
ages. Thus, the occurrence of presbycusis is thought to be Hearing Handicap Inventory for the Elderly (HHIE).10  This
determined predominantly by genetic factors; however, it also is a self-assessment tool designed to measure the effects
can be influenced by environmental factors, such as noise, of hearing impairment on the emotional and social adjust-
ototoxic drugs, alcohol, and diabetes.4–7 ment of elderly people. This inventory is comprised of two
subscales: a 13-item subscale that explores the emotional
Methods consequences of hearing impairment, and a 12-item subscale
We performed a PubMed database systematic review for peer- that describes both social and situational effects. The HHIE
reviewed articles published between January 2000 and Decem- has been judged a reliable and valid tool, as well as an easy-
ber 2011, matching the terms “hearing loss,” “presbycusis,” to-use questionnaire.8,9
“cochlea,” “quality of life,” and “elderly.” The search retrieved The Hearing Handicap Inventory for Adults (HHIA)11 is a
about 50 articles, which we proceeded to investigate. 25-item survey derived from the original HHIE by Weinstein
et al.10 It also is composed of a 13-item emotional subscale
Quality of life and presbycusis: hearing and a 12-item socio-situational subscale.11
loss is also a social loss The International Outcomes Inventory – Hearing Aids
Understanding the impact of hearing loss on quality of life (IOI-HA) by Cox et al12 explores the perceived usefulness
is of great importance, as difficulties with communication of hearing aids.12 The IOI-HA is a relatively short test that
affect interactions with other people. This is an important is easy to administer. Each of its seven questions is designed
aspect of everyday life, which can be seriously impaired in to target a different outcome domain, which include: usage
individuals with hearing loss, leading to a perceived reduction of hearing aid (number of hours per day of hearing aid use);
of QoL.8,9 benefit in terms of improvement in hearing-related activities;
The term “QoL” is used to evaluate the general well-being
of individuals. Considerable agreement exists regarding the
Table 1 Main specific instruments to evaluate the impact of
idea that the evaluation of QoL is multidimensional: physi- hearing loss on QoL
cal well-being, material well-being, social well-being, and Instrument Goal Items Reference
emotional well-being.8 It has now been reported by several HHIE10 Measures the effects of hearing 25 8–10
authors that hearing loss is an increasingly important public impairment on the emotional and
health problem that has been linked to reduced QoL, as it can social adjustment of elderly people
HHIA11 Measures the effects of hearing 25 9
impair the exchange of information, significantly impacting
impairment on the emotional
daily life, especially for elderly people. Reported effects of and social adjustment of adults
presbycusis on QoL are: IOI-HA12 Explores the perceived usefulness 7 11
- emotional reactions, such as loneliness, isolation, depen- of hearing aids
Abbreviations: HHIE, Hearing Handicap Inventory for the Elderly; HHIA,
dence, frustration, depression, anxiety, anger, embarrass- Hearing Handicap Inventory for Adults; IOI-HA, International Outcomes Inventory –
ment, frustration, and guilt Hearing Aids; QoL, quality of life.

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Dovepress Hearing loss and quality of life in the elderly

residual activity limitations; satisfaction; residual participa- efficacy, reduce risks, decrease waste, improve patient satis-
tion restrictions; impact on others; and quality of life.12 faction, and help to elevate the awareness of the profession
Generic QoL measures do not focus on any particular of audiology among third-party payers, other health care
disorder or treatment, but rather on the self-perceived over- providers, and, most importantly, current and future patients.
all health status of the individual. Those most commonly As otolaryngologists and audiologists continue to compete
administered, together with hearing-related tools, in order to in the health care marketplace, they can demonstrate that
understand the overall QoL level of the subjects, are: hearing rehabilitation reduces activity limitations, decreases
- The MOS 36-Item Short Form Health Survey (SF-36). participation restrictions, and improves health-related quality
The SF-36 consists of 36 items that assesses eight health of life. Only by measuring outcomes can otolaryngologists
concepts: (1) limitations in physical activities because of and audiologists be assured that hearing rehabilitation makes a
health problems; (2) limitations in social activities because difference and that patients have benefited from their care.13
of physical or emotional problems; (3) limitations in Nonetheless, a major drawback of these tools, as for other
usual role activities because of physical health problems; QoL scales, is related to the fact that the importance of differ-
(4) bodily pain; (5) general mental health ­(psychological ent QoL dimensions can vary among individuals and within
distress and well-being); (6) limitations in usual role activi- individuals over time, which means that structured measures
ties because of emotional problems; (7) vitality (energy and may be inaccurate or insensitive.14
fatigue); and (8) general health perceptions. It has been
used by several authors to evaluate the level of mental and Quality of life and presbycusis:
physical activity in subjects affected by hearing loss.9,12 present data
- The Social Functioning Questionnaire. It has been pro- Interestingly, among the population with hearing loss, only
posed by several authors to investigate the social behavior 39% of the subjects perceive that they have an excellent
and dimension of those affected by presbycusis.9,12 This global QoL level or very good physical health, compared
is an eight-item, self-rating scale (score range 0–24) cov- to 68% of those without hearing loss. Nearly one-third of
ering the most important domains of social life, such as the population with hearing loss report being in fair or poor
work, home activities, finances, spare time activities, and health, compared to only 9% of the population without hear-
social, family, and sexual relationships. It has been used ing loss; people with hearing loss are less satisfied with their
in combination with the revised version of the Symptom “life as a whole” than people without hearing loss.15
Checklist-90, which is a valid and reliable psychiatric When investigating the effects of hearing loss on QoL,
multidimensional self-report inventory, used to screen presbycusis has been reported to be the cause of reduced
for psychopathological symptom patterns and levels of communicative relationships, as well as reduced social and
distress in community and medical responders (such as emotional interactions.16 In particular, it is reported to be a
somatization, obsessive–compulsive behaviors, depres- source of loneliness, isolation, and decline in social activi-
sion, anxiety, and hostility).9,12 ties, as well as communication disorders and dissatisfaction
Following the administration of the above-mentioned with family life.16
tools, a list of realistic patient goals can be identified and As a result of maladaptive communication strategies,
developed by otolaryngologists and audiologists. Those tools those with hearing loss are reported to perceive their social
have been crafted in order to investigate and meet patient skills as poor, and thus, they also may experience reduced
demands; expectations of prosthesization have increased due self-esteem if a combination of hearing impairment and a
to the commercial promotion of certain hearing aid features, poor coping strategy contributes to failure in their roles.
such as adaptive directional microphones and environmental Moreover, some authors have stated that some patients are
noise reduction. The determination of comprehensive patient- afraid to consider hearing loss a problem and subsequently
specific goals will assist otolaryngologists and audiologists are afraid to seek medical help for the hearing loss. This may
in the selection of specific features as they apply them to the potentially lead hearing impaired individuals to a further
needs of their patients. level of disability and handicap.9
Those instruments have been developed with the intent It would be helpful if primary care physicians would
of building a foundation for evidence-based clinical practice test routinely for hearing impairment in adults and regularly
guidelines in hearing rehabilitation; clinical practice guide- refer those with hearing impairment to audiological tertiary
lines can minimize variability in outcome, maximize treatment care centers.9

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Ciorba et al Dovepress

Quality of life after rehabilitation Different degrees of hearing loss, successful rates of hearing
with hearing aids aid use, and rates of satisfaction with hearing aid use are main
The benefits and satisfaction of using hearing aids among factors that affect this estimate.30,32
hearing-impaired elderly people have been explored in some
studies.17,18 Conclusion
Joore and colleagues19 demonstrated that new hearing Presbycusis is a complex disease, with a controversial phys-
aid users experienced less anxiety and depression following iopathology, which is influenced by genetic, environmental,
hearing aid use. Mulrow et al20 also reported a reduction in and medical factors. It is an increasingly important public
depression among hearing aid users, as measured by a geriat- health problem that can lead to reduced quality of life, isola-
ric depression scale.21 In addition, Joore et al22 and Stark and tion, dependence, and frustration.
Hickson23 reported improvements in selected domain scores In the near future, it will be necessary to improve our
on the SF-36 as a result of hearing aid use.22,23 knowledge of this condition and its physiopathology, in an
In a large, multi-site study, McArdle et  al24 adminis- attempt to remediate its progression. In addition, it will be
tered both generic and hearing-related QoL measures to of great importance to improve methods of identifying indi-
380 participants randomized into experimental (immediate viduals with presbycusis and deteriorating QoL, thus improv-
hearing aid treatment) and control (delayed hearing aid ing services for providing hearing aids, assistive listening
treatment) groups. Hearing aids were shown to improve devices, and auditory rehabilitation. Identifying individuals
both generic and hearing-related QoL domains, although with hearing loss, supplying appropriate hearing aids or other
the improvement in QoL was stronger as measured by the listening devices, and teaching coping strategies may have a
hearing-specific measures.24 positive impact on the quality of life of older people.
Reductions in both emotional and social consequences of
hearing loss after wearing hearing aids have been measured Disclosure
by the HHIE in some studies.23–27 Particularly in their meta- The authors report no conflicts of interest in this work.
analysis, Chisolm et al18 showed that hearing aids improved
adults’ HHIE scores by reducing the psychological, social, References
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