Increases in the Rate of Age-Related Hearing Loss in the Older Old

Key Points

Question  Is the rate of age-related hearing loss constant in the oldest old (≥80 years)?

Findings  This retrospective study demonstrated that the rate of age-related hearing loss is significantly greater in the 10th decade of life than in the 9th decade at all frequencies. Despite the universal presence of hearing loss in the study sample, only 59% used hearing aids.

Meaning  Hearing loss accelerates with age in the oldest old, a population in which hearing aids are vastly underused despite their great potential benefit.

Importance  There is a critical disparity in knowledge regarding the rate and nature of hearing loss in the older old (80 years and older).

Objective  To determine if the rate of age-related hearing loss is constant in the older old.

Design, Setting, and Participants  We performed a retrospective review that began on August 1, 2014, with audiometric evaluations at an academic medical center of 647 patients aged between 80 and 106 years, of whom 141 had multiple audiograms.

Main Outcomes and Measures  From a population perspective, the degree of hearing loss was compared across the following age brackets: 80 to 84 years, 85 to 89 years, 90 to 94 years, and 95 years and older. From an individual perspective, the rate of hearing decrease between 2 audiograms was compared with age.

Results  Changes in hearing among age brackets were higher during the 10th decade of life than the 9th decade at all frequencies (5.4-11.9 dB hearing level [dB HL]) for the 647 patients (mean [SD] age, 90 [5.5] years). Correspondingly, the annual rate of low-frequency hearing loss was faster during the 10th decade by the 3.8 dB HL per year at 0.25 kHz, 3.8 dB HL per year at 0.5 kHz, and 3.2 dB HL per year at 1 kHz. Despite the universal presence of hearing loss in our sample, 382 patients (59%) used hearing aids.

Conclusions and Relevance  There is a significant increase in the rate of hearing loss in patients during the 10th decade of life compared with the 9th decade that represents a fundamental change in the mechanistic process of presbycusis. Despite the potential benefit of hearing aids, they remain underused in the older old. Use may be improved by changing the method of hearing rehabilitation counseling from a patient-initiated model to a chronic disease example.

Presbycusis, or age-related hearing loss (ARHL), affects approximately two-thirds of adults older than 70 years and four-fifths of adults older than 85.¹ It is a major public health concern that is associated with numerous deleterious effects. Although ARHL increases social isolation because of impaired communication, it decreases one’s ability to perform activities of daily living and instrumental activities of daily life without assistance from others.² Poor hearing is also associated with an increased incidence of cognitive impairment and rate of cognitive decrease.^3,4 Finally, ARHL increases overall mortality in older adults because of injuries from falls and motor vehicle crashes and is notably associated with poor self-rated health.⁵ Despite the high prevalence and negative health consequences of ARHL, hearing aids are underused in the older adult population regardless of being shown to improve the social, functional, and emotional effects of hearing loss.^6-8

Currently, there is a global demographic change that has resulted in an increase in the number of older adults. In the United States, the population of individuals older than 80 years is expected to double in the next 40 years.⁹ To better serve this growing population, it is important to consider persons 60 years and older as a continuum of age rather than a single group. The majority of research in ARHL, however, groups participants older than 70 years into a single category, thus obscuring changes in the severity of hearing loss as individuals live to 80 years or older. Here, we characterize the hearing loss of individuals between the ages of 80 and 106 as it relates to age, sex, and hearing aid use.

The institutional review board of Columbia University approved a search based on the criteria of (1) having an audiogram on file in the Department of Otolaryngology–Head & Neck Surgery and (2) being older than 80 years at the most recent audiogram. Pure-tone air conduction thresholds at 0.25, 0.5, 1, 2, 4, and 8 kHz were recorded in decibel hearing level (dB HL). Speech-reception thresholds, word recognition scores (WRSs), and the audiologists’ classification of the type of hearing loss (sensorineural, conductive, mixed, other, or no hearing loss) were also recorded. Average thresholds between ears were compared for each individual; the side with the lower average threshold was designated the better hearing ear.

Participants were divided into 4 age brackets: 80 to 84 years, 85 to 89 years, 90 to 94 years, and 95 years and older. Average thresholds in the better hearing ears for each frequency were compared across all age brackets with analysis of variance, and those between pairs of consecutive age brackets were compared with t tests. Effect size was calculated among age brackets using Cohen d.

To measure the rate of hearing loss, participants with 2 audiograms were divided into 3 groups: (1) both audiograms taken during the 9th decade of life, (2) first audiogram taken in the 9th decade and second in the 10th decade, and (3) both audiograms taken during the 10th decade. Annual average threshold differences for better hearing ears at each frequency were compared across groups with analysis of variance, and those between 2 consecutive groups were compared with t tests.

Finally, average thresholds in the better hearing ears at each frequency were compared between men and women and between hearing aid users and nonusers with t tests. Average annual threshold differences were also compared between the same groups using t tests.

The search identified 647 individuals. The mean (SD) and median age of the study sample was 90 (5.5) years. The majority of the population had sensorineural hearing loss (Table). On average, participants had a 10 dB HL difference between the better hearing ear and worse hearing ear for each frequency (eFigure 1 in the Supplement). Of the 647 individuals, 141 had 2 audiograms performed after the age of 80 from which the rate of hearing loss could be calculated.

Thresholds worsened with each older age bracket; however, individuals in the 95 years and older group had significantly worse hearing than those in all the other age brackets (Figure 1). Quiz Ref IDThe difference between individuals in the 95 years and older and those in the 90 to 94 years bracket was highest at 0.5 kHz (11.9 dB HL) and was smallest at 8 kHz (5.4 dB HL). These differences were plotted to show the change in hearing among age brackets on a population level (Figure 2).

On an individual level, the annual rate of hearing loss in patients with 2 audiograms was significantly faster during the 10th decade at low frequencies (Figure 3). Specifically, the rates of decrease were 2.0 vs 3.9 dB HL per year at 0.25 kHz (95% CI, 1.1-2.9 and 3.2-4.6 kHz; Cohen d, 0.4), 2 vs 3.8 dB HL per year at 0.5 kHz (95% CI, 1.1-2.9 and 3.2-4.5 kHz; Cohen d, 0.3), and 1.9 vs 3.2 dB HL per year at 1 kHz (95% CI, 1.0-2.8 and 2.6-3.7 kHz; Cohen d, 0.3) for the 9th and 10th decades, respectively. Although the hearing loss at high frequencies was also faster during the 10th decade, the higher rate was not significant: 2.5 vs 2.7 dB HL per year at 2 kHz (95% CI, 1.4 to 3.7 and 2.1 to 3.2 kHz; Cohen d, 0.18); 2.1 vs 2.4 dB HL per year at 4 kHz (95% CI, 1.4 to 3.4 and 2.2 to 3.1 kHz; Cohen d, 0.20); and 0.8 vs 2.0 dB HL per year at 8 kHz (95% C1, −0.1 to 1.6 and 1.6 to 2.4 kHz; Cohen d, 0.1) for the 9th and 10th decades, respectively.

The ratio of women to men in each age bracket increased with age (Table). Quiz Ref IDWomen had better hearing at 4 kHz (eFigure 2 in the Supplement). Men had a faster rate of decrease at 0.25 kHz (eFigure 3 in the Supplement). Otherwise, there was no difference in hearing or the rate of hearing loss between sexes.

Hearing aid use or disuse was documented in 364 medical records, and 59% of patients (382 of 647) reported using hearing aids regularly. The percentage of patients who used hearing aids increased with age, and all participants 95 years and older reported regular use (Table). Quiz Ref IDOn average, hearing aid users had worse hearing at every threshold (eFigure 4 in the Supplement). The difference was highest at 0.25 kHz (20 dB HL) and least at 8 kHz (10 dB HL). There was no difference in the rate of hearing decrease regarding thresholds between hearing aid users and nonusers. The rate of WRS decrease in the general population was −1.06 WRS per year (eFigure 5 in the Supplement). Hearing aid users had a significantly faster annual WRS decrease (−2.20 WRS per year) than nonusers (−0.11 WRS per year).

To our knowledge, this study is one of few that examines hearing loss in a large sample of patients older than 80 years. Quiz Ref IDAll participants had hearing loss, defined as more than 25 dB HL at any frequency.¹⁰ The universal presence of hearing loss may represent an ascertainment bias because patients who received care from the Department of Otolaryngology–Head & Neck Surgery at Columbia University, New York, New York, were included in this study; however, patients may have presented to the department for nonhearing-related issues (such as with sinus or voice). The reason participants were referred for audiological evaluation could not be determined from the medical record in the majority of cases, and our results should therefore be applicable to the general population.

Analysis of hearing among groups was conducted using the better hearing ear, which prevents exaggerating the severity of hearing loss and underscores the universality of hearing damage in the older population. The 10 dB HL average difference between ears is expected because asymmetrical hearing loss is a common and benign occurrence in the older old.¹¹

Sehl and Yates¹² showed that most variables affected by senescence decrease at a constant percentage per year and therefore are linear (first-order) functions of age. This finding means that with each year, the absolute value lost is less than the prior year because the initial value is lower. We found that between ages 80 and 94, however, hearing is not a function of age (zero order). Instead, hearing is lost (dB HL increases) by the same absolute value each year. Hearing loss may avoid the type of decrease seen in other aging processes because it is protective against further acoustic trauma; thus, exposure decreases as hearing worsens.

In the 95 years and older bracket, however, the rate of decrease was significantly faster at low frequencies (0.25, 0.5, and 1 kHz) than in other age brackets. This result is probable because there is a biological change in the origin of ARHL that overcomes any otoprotective effects given by hearing loss in patients 80 years and older. Although ARHL is normally associated with high-frequency hearing loss, several previous investigations have shown that the rate of hearing damage increases for low frequencies and decreases with high frequencies throughout the progression of aging. To our knowledge, Glorig et al¹³ were the first to observe this phenomenon and proposed that a ceiling effect occurs for the rate of hearing loss, where diminished hearing reserve at higher frequencies results in slower rates of decrease.

Several prospective studies support the ceiling effect hypothesis. Using the Baltimore Longitudinal Study of Aging database, Brant and Fozard¹⁴ found that the rate of decrease increased at low frequencies (0.5-3 kHz) in patients between ages 60 and 79 years, whereas the rate of decrease for high frequencies remained unchanged for those between ages 40 and 89 years. Using the Framingham Heart Study database, Gates and Cooper¹⁵ found that the rate of low-frequency decrease (0.5-2 kHz) was faster for individuals between ages 60 and 69 years than for those older than 70. A later prospective study by Lee et al¹⁶ showed that worse baseline hearing at high frequencies (6-8 kHz) correlated with a slower rate of decrease at those frequencies. Finally, a cohort study by Wiley et al¹⁷ found that individuals in the age 50 to 69 group had its fastest rates of decrease at higher frequencies, whereas the age 70 to 89 group had its fastest rates of decrease at lower frequencies.

Our study adds to this work by examining an older age group. On a population level, we found that the difference in hearing among age brackets is significantly larger between the 90 to 94 and 95 years and older ranges (Figure 2). This finding was supported on an individual level: the rate of low-frequency hearing loss (0.25-1 kHz) for individuals in the 10th decade is significantly faster than in younger individuals (Figure 3). Furthermore, the rate of low-frequency decrease surpasses the rate of high-frequency decrease in the older old (eFigure 6 in the Supplement). This result is clinically significant because we have shown that low-frequency hearing not only continues to rapidly decrease with age but that the rate of decrease also increases into older age. Considering that elderly patients universally have high-frequency hearing loss, it becomes obvious that hearing aids should be implemented for all individuals in their 10th decade, if not sooner.

Prior work has consistently found that women 80 years and older have less severe hearing loss than men.¹⁸ We found that women had better hearing at 4 kHz, but this is of minor clinical relevance. Therefore, when a patient is 80 years or older, sex has a negligible role in hearing. It should be noted, however, that the proportion of women increased in each successive age bracket, which may have diminished any differences in hearing between sexes.

The existing literature is less unanimous when describing the effects of sex on the rate of decrease. Although Pearson et al¹⁸ concluded that hearing decreases twice as fast in males, Gates and Cooper¹⁵ found that hearing reduces slightly faster in females. Lee et al¹⁶ found that females from 50 to 69 years of age had faster rates of decrease at 4 and 6 kHz, but from 70 to 89 years of age, there was no difference between sexes at any frequency. We found that from 80 to 106 years of age, men had a faster rate of decrease at 0.25 kHz. Although these results are consistent with men being more affected by hearing loss, it is again of minor clinical relevance, and sex, therefore, should not affect clinical practice when evaluating hearing loss in the older old.

We found that hearing aids were underused in our study sample. Despite the universal presence of audiometric hearing loss, 59% of patients (382 of 647) reported using them regularly. This finding is consistent with other studies that report on the underuse of hearing aids.^6,19 The percentage we show is higher than prior studies reflecting the increased incidence of hearing loss in our older study sample.

Hearing aid users were older (all participants older than 95 years used hearing aids) and had poorer hearing; they had significantly worse hearing at each tested frequency (eFigure 1 in the Supplement) and a faster decrease in WRSs when compared with nonusers. The faster rate of WRS decrease probably represents inherently worse auditory function in hearing aid users rather than an effect of hearing aids. Quiz Ref IDThis is because when comparing rates of WRS decrease between the monaurally and binaurally hearing-aided groups, we found that the unaided ears in the monaurally aided group had a significantly faster decrease than the aided ears in both groups. This finding provides further support for the unaided ear effect first described by Silman et al²⁰ and later again by Hurley,²¹ where it is hypothesized that the unaided side will have a faster decrease in WRSs due to the relative deprivation of auditory stimulation.

Patients 80 years and older and those with the worst auditory function use hearing aids despite the entire sample standing to benefit from them, thus suggesting that hearing aids are viewed by the public as a last option. Impediments to comprehensive use include concerns about high cost, complex dispensing procedures, social stigma, and cosmesis. To overcome these limitations, in September 2015, the President’s Council of Advisors on Science and Technology recommended federal intervention to improve quality, increase competition, and reduce the cost of hearing aids.²² There is urgency to increase hearing aid use among the older population because untreated hearing loss is associated with higher risks for social isolation, depression, dementia, inability to work, reduced physical activity, and falls.

Currently, hearing aid candidates are usually referred to an otolaryngologist, who may make the recommendation based on the results of the patient’s audiogram. Because otolaryngologists rarely contribute to the longitudinal care of most patients, the recommendation alone probably provides insufficient motivation for patients to accept hearing aids. We therefore propose that hearing loss should be treated as a chronic disease and that the use of hearing aids be thought of as a lifestyle modification. Audiological evaluations should be a regular part of geriatric care owing to the incidence and subtle onset of hearing loss. Hearing aid use should be encouraged with hearing loss; and the recommendation, cost, cosmesis, and functional outcome should be discussed. To encourage the acceptance of hearing aids, we should work to change the negative perception of hearing aids by educating the patient about their positive effect on the quality of life, enhancing cognition, and decreasing the burden of disease.^2-8 If a recommendation of hearing aids is resisted, we should use our collective experience in counseling patients with other chronic diseases, such as diabetes and hypertension, and tobacco use about lifestyle modifications; counseling is ideally performed through a motivational interviewing approach in a longitudinal primary care setting.^23,24 Therefore, improving outcomes for elderly patients with hearing loss depends on increasing the collaboration between otolaryngologists and the primary health care professionals in counseling patients about understanding rehabilitative strategies and accepting hearing aids.

Hearing is rapidly lost in patients older than 80 years. The rate of low-frequency hearing loss increases during the patient’s 10th decade. The difference in auditory function between sexes is minimal in the older old. Finally, hearing aids are underused in this population despite a universal potential benefit that increases with age. To improve use, hearing aids should be thought of as a lifestyle modification. More attention should be on counseling patients on accepting hearing aids in a longitudinal primary care setting, especially in the population living to 80 years or older.

Corresponding Author: Anil K. Lalwani, MD, Department of Otolaryngology–Head & Neck Surgery, Columbia University College of Physicians and Surgeons, 168 Fort Washington Ave, Harkness Pavilion 8, New York, NY 10032 (anil.lalwani@columbia.edu).

Accepted for Publication: July 20, 2016.

Published Online: September 15, 2016. doi:10.1001/jamaoto.2016.2661

Author Contributions: Mr Wattamwar and Dr Qian had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Both authors contributed equally to this work.

Study concept and design: Wattamwar, Qian, Leskowitz, Spitzer, Lalwani.

Acquisition, analysis, or interpretation of data: Wattamwar, Qian, Otter, Leskowitz, Caruana, Siedlecki, Lalwani.

Drafting of the manuscript: Wattamwar, Qian, Otter, Caruana, Siedlecki, Lalwani.

Critical revision of the manuscript for important intellectual content: Wattamwar, Qian, Leskowitz, Caruana, Spitzer, Lalwani.

Statistical analysis: Wattamwar, Qian, Caruana.

Obtained funding: Leskowitz.

Administrative, technical, or material support: Leskowitz, Siedlecki, Spitzer, Lalwani.

Study supervision: Leskowitz, Lalwani.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Spitzer reported serving as an advisory board member for Med El Corp. Dr Lalwani reported serving on the medical advisory board for and receiving personal fees from Advanced Bionics Corp. No other disclosures were reported.