Hearing Loss in Older Adults

Hearing Impairment
Hearing loss is the third most prevalent chronic condition and
the foremost communicative disorder of older adults in the
United States. Hearing loss is an underrecognized public health
issue. Among adults between the ages of 60 and 69 years of age,
31% have bilateral hearing loss of at least mild severity. In
those older than 70 years of age, the prevalence is 63%, and in
those older than age 85, the prevalence is 80%. In all age
groups, men are more likely than women to be hearing impaired,
and black Americans have a lower prevalence of hearing
impairment than either white or Hispanic Americans
(Bainbridge & Wallhagen, 2014).
Age-related hearing impairment is a complex disease caused by
interactions between age-related changes (see Chapter 3),
genetics, lifestyle, and environmental factors.
Factors associated with hearing loss include noise exposure, ear
infections, smoking, and chronic disease (e.g., diabetes, chronic
kidney disease, heart disease) (Bainbridge & Wallhagen, 2014).
Hearing loss may not be an inevitable part of aging, and
increased attention is being given to the links between lifestyle
factors (e.g., smoking, poor nutrition, hypertension) and hearing
impairment (Heine et al., 2013) (Box 19.5).
Box 19.5. Promoting Healthy Hearing
• Avoid exposure to excessively loud noises.
• Avoid cigarette smoking.
• Maintain blood pressure/cholesterol levels within normal
limits.

• Eat a healthy diet.
• Have hearing evaluated if any changes are noticed.
• Avoid injury with cotton-tipped applicators and other cleaning
materials.
Consequences of Hearing Impairment
The broad consequences of hearing loss have functional and
clinical significance and should not be viewed as something a
person accepts as part of aging. Hearing loss diminishes quality
of life and is associated with multiple negative outcomes,
including decreased function, increased likelihood of
hospitalizations, miscommunication, depression, falls, loss of
self-esteem, safety risks, and cognitive decline (Bainbridge &
Wallhagen, 2014; Lin et al., 2013). Growing evidence supports
an association between age-related hearing loss and cognitive
decline and dementia (Bainbridge & Wallhagen, 2014; Lin,
2012; Lin et al., 2013).
Hearing impairment increases feelings of isolation and may
cause older adults to become suspicious or distrustful or to
display feelings of paranoia. Because older persons with hearing
loss may not understand or respond appropriately to
conversation, they may be inappropriately diagnosed with
dementia. All of these consequences of hearing impairment
further increase social isolation and decrease opportunities for
meaningful interaction and stimulation.
Types of Hearing Loss
The two major forms of hearing loss are conductive and
sensorineural.

1. Sensorineural hearing loss results from damage to any part of
the inner ear or the neural pathways to the brain. Presbycusis
(also called age-related hearing impairment or ARHI) is a form
of sensorineural hearing loss that is related to aging and is the
most common form of hearing loss. Presbycusis progressively
worsens with age and is usually permanent. The cochlea appears
to be the site of pathogenesis, but the precise cause of
presbycusis is uncertain (Lewis, 2014).
Noise-induced hearing loss (NIHL) is the second most common
cause of sensorineural hearing loss among older adults. Direct
mechanical injury to the sensory hair cells of the cochlea causes
NIHL, and continuous noise exposure contributes to damage
more than intermittent exposure (Lewis, 2014). NIHL is
permanent but considered largely preventable.
The rate of hearing impairment is expected to rise because of
the growing number of older adults and also because of the
increased number of military personnel who have been exposed
to blast exposure in combat situations. Noise-induced hearing
loss may be reduced through the development of better ear-
protection devices, education about exposure to loud noise, and
emerging research into interventions that may protect or repair
hair cells in the ear, which are essential to the 259body's ability
to hear (National Institute on Deafness and Other
Communication Disorders [NIDCD], 2014).
2. Conductive hearing loss usually involves abnormalities of the
external and middle ear that reduce the ability of sound to be
transmitted to the middle ear.
Otosclerosis, infection, perforated eardrum, fluid in the middle
ear, tumors, or cerumen accumulations cause conductive hearing
loss.
Cerumen impaction is the most common and easily corrected of
all interferences in the hearing of older people (Fig. 19.4).
Individuals at particular risk of impaction are African

Americans, individuals who wear hearing aids, and older men
with large amounts of ear canal tragi (hairs in the ear) that tend
to become entangled with the cerumen. When hearing loss is
suspected, or a person with existing hearing loss experiences
increasing difficulty, it is important first to check for cerumen
impaction as a possible cause. After accurate assessment, if
cerumen removal is indicated, it may be removed through
irrigation, cerumenolytic products, or manual extraction.
Interventions to Enhance Hearing
Hearing Aids
A hearing aid is a personal amplifying system that includes a
microphone, an amplifier, and a loudspeaker. There are
numerous types of hearing aids with either analog or digital
circuitry. The size, appearance, and effectiveness of hearing
aids have greatly improved (decreasing stigma), and many can
be programmed to meet specific needs. Digital hearing aids are
smaller and have better sound quality and noise reduction, as
well as less acoustic feedback; however, they are expensive.
The behind-the-ear hearing aid looks like a shrimp and fits
around and behind the ear; a small tube sits in the canal to
direct the amplified sound. It is less commonly used now than
the small, in-the-ear aid, which fits in the concha of the ear.
Completely-in-the-canal (CIC) hearing aids fit entirely in the
ear canal. These types of devices are among the most expensive
and require good dexterity. Some models are invisible and
placed deep in the ear canal and replaced every 4 months. New
hearing aids can be adjusted precisely for noisy environments
and telephone usage through software built into smartphones.

Most individuals can obtain some hearing enhancement with a
hearing aid. The kind of device chosen depends on the type of
hearing impairment and the cost, but most users will experience
hearing improvement with a basic to midlevel hearing aid. The
investment in a good hearing aid is considerable, and a good fit
is critical. Hearing aids can range in price from about $500 to
several thousand dollars per aid, depending on the technology.
The cost of hearing aids is usually not covered by health
insurance or Medicare, which can be a barrier to purchase.
Adjustment to Hearing Aids
Nearly 50% of people who purchased hearing aids either never
wore them or stopped wearing them after a short period. Factors
contributing to low hearing aid use after purchase include
difficulty manipulating the device, annoying loud noises, being
exposed to sensory overload, developing headaches, and
perceiving stigma. Hearing aids amplify all sounds, making
things sound different. People often delay acquiring hearing
aids because the loss occurs gradually and they often ignore or
deny the loss. Individuals wait on average 7 to 10 years between
signs of hearing loss and audiological consultation (Lewis,
2014). This delay makes adjustment to the device even more
challenging (Lane & Conn, 2013).
Age-related hearing loss (ARHL) is like any other physical
impairment and requires counseling, rehabilitative training,
environmental accommodations, and patience. Audiology
centers, often attached to hospitals, medical centers, and
universities, are excellent places for aural rehabilitation
programs but costs are usually not covered by Medicare. The
Internet may be a valuable tool for aural rehabilitation, as well
as for improving adjustment to hearing aids and communication
(Lewis, 2014).
It is important for nurses who work with individuals wearing

hearing aids to be knowledgeable about the care and
maintenance. They can teach the individual, family, or formal
caregiver proper use and care of hearing aids (Box 19.6). Many
older people experience unnecessary 260communication
problems when in the hospital or nursing home because their
hearing aids are not inserted and working properly, or they are
lost.
Box 19.6 Tips for Best Practice
Hearing Aid Care and Use
• When a hearing aid is first purchased: Initially it is advisable
to wear for 15 to 20 minutes per day until the person is adjusted
to the new sounds.
• Gradually increase the wearing time to 10 to 12 hours.
• Be patient and realize that the process of adaptation is
difficult but ultimately will be rewarding.
• Make sure your fingers are dry and clean before handling
hearing aids. Use a soft dry cloth to wipe your hearing aids.
• Each day remove any earwax that has accumulated on the
hearing aids. Use the brush that is included with the aid to clean
difficult-to-reach areas.
• You will be instructed how to best insert the model you
purchase.
• If it is not pre-programmed, adjust the volume to a level that
is comfortable for you. You may be able to adjust the volume
for different environments, depending on the model.
• Use great caution to avoid getting the aid wet; do not wear

when swimming or taking a shower or bath.
• Also avoid use when around fine particles that can clog the
microphone such as hair spray, make-up, or blowing sand and
dirt.
• Many aids will slowly decrease in volume and may make a
“peep” when it is time to change the battery. Check the battery
by turning the hearing aid on, turning up the volume, cupping
your hand over the ear mold, and listening. A constant whistling
sound indicates that the battery is functioning. A weak sound
indicates that the battery is losing power and needs
replacement.
• Be sure to remove the battery and return the aid to its case
when not in use. This will extend the life of the battery and
protect the aid.
Cochlear Implants
Cochlear implants are increasingly being used for older adults
with sensorineural loss who are not able to gain effective
speech recognition with hearing aids. Cochlear implants are safe
and well tolerated and improve communication. The surgery is
now commonly done bilaterally (Lewis, 2014). A cochlear
implant is a small, complex electronic device that consists of an
external portion that sits behind the ear and a second portion
that is surgically placed under the skin. Unlike hearing aids that
magnify sounds, the cochlear implant bypasses damaged
portions of the ear and directly stimulates the auditory nerve.
Hearing through a cochlear implant is different from normal
hearing and takes time to learn or relearn. Most insurance plans
cover the cochlear implant procedure. The transplant carries
some risk because the surgery destroys any residual hearing.
Therefore, cochlear implant users can never revert to using a
hearing aid. Individuals with cochlear implants need to be

advised to never have a magnetic resonance imaging (MRI) scan
because it may dislodge the implant or demagnetize its internal
magnet.
Assistive Listening and Adaptive Devices
Assistive listening devices (also called personal listening
systems) should be considered as an adjunct to hearing aids or
used in place of hearing aids for people with hearing
impairment. These devices are available commercially and can
be used to enhance face-to-face communication and to better
understand speech in large rooms such as theaters, to use the
telephone, and to listen to television. Many movie theaters have
both sound amplifiers and personal subtitle devices available.
Other examples of assistive listening and adaptive devices
include text messaging devices for telephones and closed-
caption television. Alerting devices, such as vibrating alarm
clocks that shake the bed or activate a flashing light, and sound
lamps that respond with lights to sounds, such as doorbells and
telephones, are also available. Special service dogs (“hearing
dogs”) are trained to alert people with a hearing impairment
about sounds and intruders. Dogs are trained to respond to
different sounds, such as the telephone, smoke alarms, alarm
clock, doorbell/door knock, and name call, and lead the
individual to the sound.
The use of computers and email also assists individuals with
hearing impairment to communicate more easily. Programs such
as Skype and FaceTime are also beneficial because they may
allow the person to lip read and to adjust volume. Pocket-sized
amplifiers (available at retail stores) are especially helpful in
improving communication in health care settings, and nurses
should be able to obtain appropriate devices for use with
hearing-impaired individuals.

Implications for Gerontological Nursing and Healthy Aging
1. Assessment
2.
Hearing impairment is underdiagnosed and undertreated in older
people (Bainbridge & Wallhagen, 2014). Older people may be
initially unaware of hearing loss because of the gradual manner
in which it develops and, therefore, not report any problems.
Screening for hearing impairment and appropriate treatment are
considered an essential part of primary care for older adults.
Assessment of hearing includes a focused history and physical
examination and also screening assessment for hearing
impairment. Ask the person if he or she has any difficulty
understanding speech in noisy situations, during telephone use,
or in daily conversation. Obtaining information from the
significant other about hearing problems can also be useful.
Self-assessment instruments (Box 19.7) and the Hearing
Handicap Inventory for the Elderly (HHIE-S) can also be
included (Box 19.8). Question the patient about prolonged noise
exposure, past ear injuries, and use of potentially ototoxic
medications as well.
Box 19.7. Do I Have a Hearing Problem?
• Do I have a problem hearing on the telephone?
• Do I have trouble hearing when there is noise in the
background?
• Is it hard for me to follow a conversation when two or more
people talk at once?
• Do I have to strain to understand a conversation?
• Do many people I talk to seem to mumble (or not speak
clearly)?

• Do I misunderstand what others are saying and respond
inappropriately?
• Do I have trouble understanding the speech of women and
children?
• Do people complain that I turn the TV volume up too high?
• Do I hear a ringing, roaring, or hissing sound a lot?
• Do some sounds seem too loud?
From National Institute on Deafness and Other Communication
Disorders: Hearing loss and older adults, 2014. Available at
http://www.nidcd.nih.gov/health/hearing/pages/older.aspx#2.
Accessed October 31, 2014.
Box 19.8. Resources for Best Practice
Hearing Impairment
American Tinnitus Association: Sounds of tinnitus
Hartford Institute for Geriatric Nursing (Try This: General
Assessment Series): Hearing handicap for the elderly: Screening
version (HHIT-S)
NIDCD (National Institute on Deafness and Other
Communication Disorders): Hearing loss and older adults;
Interactive sound ruler: how loud is too loud (experience noise
levels)
NIH Senior Health: Hearing loss (patient information)
Sight and Hearing Association: Unfair hearing test/filtered

speech (experience presbycusis)
Physical examination includes assessing the external ear to
determine any evidence of infection and using an otoscope to
visualize the inner ear, looking for any possible causes of
conductive hearing loss such as cerumen impaction or the
presence of foreign objects.
Inspect the tympanic membrane (TM) for integrity. Depending
on findings, the patient may need to be referred for follow-up
by a specialist. If no problems are identified, perform a few
basic screening tests.
These may include the Rinne and Weber tests to differentiate
between conductive and sensorineural hearing loss. Other tests
include the whisper and finger rub test.
3. Interventions
Nursing actions are based on assessment findings and may
include referral to an audiologist, education on hearing loss
(including prevention and consequences), and provision of
information about hearing aids, assistive listening devices, and
communication techniques. If cerumen impaction is found,
cerumen removal may be indicated.
There are many evidence-based resources available that can be
used to educate the patient and family and assist the nurse in
designing educational materials (Box 19.8). Using the
information presented in this chapter, nurses can play an
important role in providing older adults the information they
need to improve their hearing and avoid the negative
consequences of untreated hearing loss.
Effective communication strategies when working with
individuals who are hearing-impaired are presented in Box 19.9.
Box 19.9. Tips for Best Practice
Communicating with Elders Who Have Hearing Impairment

• Never assume hearing loss is from age until other causes are
ruled out (infection, cerumen buildup).
• Inappropriate responses, inattentiveness, and apathy may be
symptoms of a hearing loss.
• Face the individual and stand or sit on the same level; do not
turn away while speaking.
• Gain the individual's attention before beginning to speak.
Look directly at the person at eye level before starting to speak.
• Determine if hearing is better in one ear than another and
position yourself appropriately.
• If hearing aid is used, make sure it is in place and batteries are
functioning.
• Keep hands away from your mouth and project voice by
controlled diaphragmatic breathing.
• Avoid conversations in which the speaker's face is in glare or
darkness; orient the light on the speaker's face.
• Careful articulation and moderate speed of speech are helpful.
• Lower your tone of voice and articulate clearly.
• Label the chart, note on the intercom button, and inform all
caregivers that the patient has a hearing impairment.
• Use nonverbal approaches: gestures, demonstrations, visual
aids, and written materials.
• Pause between sentences or phrases to confirm understanding.

• When changing topics, preface the change by stating the topic.
• Reduce background noise (e.g., turn off television, close
door).
• Utilize assistive listening devices such as pocket talker.
• Verify that the information being given has been clearly
understood. Be aware that the person may agree to everything
and appear to understand what you have said even when he or
she did not hear you (listener bluffing).
• Share resources for the hearing-impaired and refer as
appropriate.
Tinnitus
Tinnitus is defined as the perception of sound in one or both
ears or in the head when no external sound is present. It is often
referred to as “ringing in the ears” but may also manifest as
buzzing, hissing, whistling, cricket chirping, bells, roaring,
clicking, pulsating, humming, or swishing sounds. The sounds
may be constant or intermittent and are more acute at night or in
quiet surroundings. The most common type is high-pitched
tinnitus with sensorineural loss; less common is low-pitched
tinnitus with conduction loss such as is seen in Meniere's
disease.
Tinnitus generally increases over time. It is a condition that
afflicts many older people and can interfere with hearing, as
well as become extremely irritating. It is estimated to occur in
nearly 11% of elders with 263presbycusis. Tinnitus is a growing
problem for America's military personnel and is the leading
cause of service-connected disability of veterans returning from

Iraq or Afghanistan (American Tinnitus Association, 2016).
The exact physiological cause or causes of tinnitus are not
known, but there are several likely factors that are known to
trigger or worsen tinnitus. Exposure to loud noises is the
leading cause of tinnitus, and the exposure can damage and
destroy cilia in the inner ear. Once damaged, the cilia cannot be
renewed or replaced. Other possible causes of tinnitus include
head and neck trauma, certain types of tumors, cerumen
accumulation, jaw misalignment, cardiovascular disease, and
ototoxicity from medications. More than 200 prescription and
nonprescription medications list tinnitus as a potential side
effect, aspirin being the most common. There is some evidence
that caffeine, alcohol, cigarettes, stress, and fatigue may
exacerbate the problem.
Interventions
Some persons with tinnitus will never find the cause; for others
the problem may arbitrarily disappear. Hearing aids can be
prescribed to amplify environmental sounds to obscure tinnitus,
and there is a device that combines the features of a masker and
a hearing aid, which emits a competitive but pleasant sound that
distracts from head noise. Therapeutic modes of treating
tinnitus include transtympanal electrostimulation, iontophoresis,
biofeedback, tinnitus masking with alternative sound production
(white noise), cochlear implants, and hearing aids. Some have
found hypnosis, cognitive behavioral therapy, acupuncture, and
chiropractic, naturopathic, allergy, or drug treatment to be
effective.
Nursing actions include discussing with the client about times
when the noises are most irritating and having the person keep a
diary to identify patterns. Assess medications for possibly
contributing to the problem. Discuss lifestyle changes and
alternative methods that some have found effective. Also, refer

clients to the American Tinnitus Association for research
updates, education, and support groups (Box 19.8).
Key Concepts
• Vision loss is a leading cause of age-related disability.
• The leading causes of visual impairment in the United States
are diseases that are common in older adults: age-related
macular degeneration (AMD), cataracts, glaucoma, and diabetic
retinopathy.
• Many causes of visual impairment are preventable, so
attention to keeping eyes healthy throughout life and early
detection and treatment of eye disease are essential.
• Nurses who care for visually impaired elders in all settings
can improve outcomes by assessing for vision changes, adapting
the environment to enhance vision and safety, communicating
appropriately, and providing appropriate health teaching and
referrals for prevention, treatment, and assistive devices.
• Age-related hearing impairment is a complex disease caused
by interactions among age-related changes, genetics, lifestyle,
and environment.
• Presbycusis (also called age-related hearing impairment or
ARHI) is a form of sensorineural hearing loss that is related to
aging and is the most common form of hearing loss.
• Hearing loss diminishes quality of life and is associated with
multiple negative outcomes including decreased function,
increased likelihood of hospitalizations, miscommunication,
depression, falls, reduced self-esteem, safety risks, and
cognitive decline.

• Screening for hearing loss is an essential component of
assessment in older adults.
• Nurses need to know how to operate hearing aids and assist
individuals with hearing impairment to access assistive listening
Hearing loss is a common problem caused by noise, aging,
disease, and heredity. People with hearing loss may find it hard
to have conversations with friends and family. They may also
have trouble understanding a doctor’s advice, responding to
warnings, and hearing doorbells and alarms.
Approximately one in three people between the ages of 65 and
74 has hearing loss, and nearly half of those older than 75 has
difficulty hearing. But, some people may not want to admit they
have trouble hearing.
Older people who can’t hear well may become depressed, or
they may withdraw from others because they feel frustrated or
embarrassed about not understanding what is being said.
Sometimes, older people are mistakenly thought to be confused,
unresponsive, or uncooperative because they don’t hear well.
Hearing problems that are ignored or untreated can get worse. If
you have a hearing problem, see your doctor. Hearing aids,
special training, certain medicines, and surgery are some of the
treatments that can help.
Studies have shown that older adults with hearing loss have a
greater risk of developing dementia than older adults with
normal hearing. Cognitive abilities (including memory and
concentration) decline faster in older adults with hearing loss
than in older adults with normal hearing. Treating hearing
problems may be important for cognitive health.
Hearing loss occurs in approximately one in three people age 65

to 74 and nearly one in two people age 75 and older in the
United States, making it one of the most common conditions
affecting older adults. Last year, the National Academies of
Sciences, Engineering, and Medicine released Hearing Health
Care for Adults: Priorities for Improving Access and
Affordability, a report that highlights the importance of hearing
health to communication and overall quality of life, and
proposes recommendations to increase the availability and
affordability of hearing health care.
NIA-funded research has indicated that hearing loss may impact
cognition and dementia risk in older adults. A 2011 study found
that older adults with hearing loss were more likely to develop
dementia than older adults with normal hearing. In fact, there
was a relationship between level of uncorrected hearing loss and
level of dementia risk: mild hearing loss was associated with a
two-fold increase in risk; moderate hearing loss with a three-
fold increase in risk, and severe hearing loss with a five-fold
increase in risk. (Lin et al., 2011).
Furthermore, a more recent study found that cognitive abilities
(including memory and concentration) declined faster in older
adults with hearing loss, as compared to older adults with
normal hearing (Lin et al., 2013). These observations by
scientists raise the question: can cognitive decline and/or
dementia onset be slowed or stopped by correcting hearing loss?
Signs of Hearing Loss
Some people have a hearing problem and don’t realize it. You
should see your doctor if you:
· Have trouble hearing over the telephone

· Find it hard to follow conversations when two or more people
are talking
· Often ask people to repeat what they are saying
· Need to turn up the TV volume so loud that others complain
· Have a problem hearing because of background noise
· Think that others seem to mumble
· Can’t understand when women and children speak to you
· Types of Hearing Loss
· Hearing loss comes in many forms. It can range from a mild
loss, in which a person misses certain high-pitched sounds, such
as the voices of women and children, to a total loss of hearing.
There are two general categories of hearing loss:
Sensorineural hearing loss occurs when there is damage to the
inner ear or the auditory nerve. This type of hearing loss is
usually permanent.
Conductive hearing loss occurs when sound waves cannot reach
the inner ear. The cause may be earwax buildup, fluid, or a
punctured eardrum. Medical treatment or surgery can usually
restore conductive hearing loss.
Sudden Hearing Loss
Sudden sensorineural hearing loss, or sudden deafness, is a
rapid loss of hearing. It can happen to a person all at once or
over a period of up to 3 days. It should be considered a medical
emergency. If you or someone you know experiences sudden
sensorineural hearing loss, visit a doctor immediately.
Age-Related Hearing Loss (Presbycusis)
Presbycusis, or age-related hearing loss, comes on gradually as
a person gets older. It seems to run in families and may occur
because of changes in the inner ear and auditory nerve.
Presbycusis may make it hard for a person to tolerate loud

sounds or to hear what others are saying.
Age-related hearing loss usually occurs in both ears, affecting
them equally. The loss is gradual, so someone with presbycusis
may not realize that he or she has lost some of his or her ability
to hear.
Ringing in the Ears (Tinnitus)
Tinnitus is also common in older people. It is typically
described as ringing in the ears, but it also can sound like
roaring, clicking, hissing, or buzzing. It can come and go. It
might be heard in one or both ears, and it may be loud or soft.
Tinnitus is sometimes the first sign of hearing loss in older
adults. Tinnitus can accompany any type of hearing loss and can
be a sign of other health problems, such as high blood pressure,
allergies, or as a side effect of medications.
Tinnitus is a symptom, not a disease. Something as simple as a
piece of earwax blocking the ear canal can cause tinnitus, but it
can also be the result of a number of health conditions.
Causes of Hearing Loss
Loud noise is one of the most common causes of hearing loss.
Noise from lawn mowers, snow blowers, or loud music can
damage the inner ear, resulting in permanent hearing loss. Loud
noise also contributes to tinnitus. You can prevent most noise-
related hearing loss. Protect yourself by turning down the sound
on your stereo, television, or headphones; moving away from
loud noise; or using earplugs or other ear protection.
Earwax or fluid buildup can block sounds that are carried from
the eardrum to the inner ear. If wax blockage is a problem, talk
with your doctor. He or she may suggest mild treatments to
soften earwax.

A punctured ear drum can also cause hearing loss. The eardrum
can be damaged by infection, pressure, or putting objects in the
ear, including cotton-tipped swabs. See your doctor if you have
pain or fluid draining from the ear.
Health conditions common in older people, such as diabetes or
high blood pressure, can contribute to hearing loss. Viruses and
bacteria (including the ear infection otitis media), a heart
condition, stroke, brain injury, or a tumor may also affect your
hearing.
Hearing loss can also result from taking certain medications.
“Ototoxic” medications damage the inner ear, sometimes
permanently. Some ototoxic drugs include medicines used to
treat serious infections, cancer, and heart disease. Some
antibiotics are ototoxic. Even aspirin at some dosages can cause
problems. Check with your doctor if you notice a problem while
taking a medication.
Heredity can cause hearing loss, as well. But not all inherited
forms of hearing loss take place at birth. Some forms can show
up later in life. For example, in otosclerosis, which is thought to
be a hereditary disease, an abnormal growth of bone prevents
structures within the ear from working properly.
How to Cope with Hearing Loss
If you notice signs of hearing loss, talk to your doctor. If you
have trouble hearing, you should:
· Let people know you have a hearing problem.
· Ask people to face you and to speak more slowly and clearly.
Also, ask them to speak louder without shouting.
· Pay attention to what is being said and to facial expressions or
gestures.
· Let the person talking know if you do not understand what he

or she said.
· Ask the person speaking to reword a sentence and try again.
· Find a good location to listen. Place yourself between the
speaker and sources of noise and look for quieter places to talk.
· The most important thing you can do if you think you have a
hearing problem is to seek professional advice. Your family
doctor may be able to diagnose and treat your hearing problem.
Or, your doctor may refer you to other experts, like an
otolaryngologist (ear, nose, and throat doctor) or an audiologist
(health professional who can identify and measure hearing loss).
Devices to Help with Hearing Loss
Your doctor or specialist may suggest you get a hearing aid.
Hearing aids are electronic, battery-run devices that make
sounds louder. There are many types of hearing aids. Before
buying a hearing aid, find out if your health insurance will
cover the cost. Also, ask if you can have a trial period so you
can make sure the device is right for you. An audiologist or
hearing aid specialist will show you how to use your hearing
aid.
Assistive-listening devices, mobile apps, alerting devices, and
cochlear implants can help some people with hearing loss.
Cochlear implants are electronic devices for people with severe
hearing loss. They don’t work for all types of hearing loss.
Alert systems can work with doorbells, smoke detectors, and
alarm clocks to send you visual signals or vibrations. For
example, a flashing light can let you know someone is at the
door or the phone is ringing. Some people rely on the vibration
setting on their cell phones to alert them to calls.
Over-the-counter (OTC) hearing aids are a new category of
regulated hearing devices that adults with mild-to-moderate
hearing loss will be able to buy without a prescription. OTC
hearing aids will make certain sounds louder to help people

with hearing loss listen, communicate, and take part more fully
in daily activities.
Promoting Hearing Health Across the Lifespan
Globally, one in three adults has some level of measurable
hearing loss, and 1.1 billion young persons are at risk for
hearing loss attributable to noise exposure. Although noisy
occupations such as construction, mining, and manufacturing
are primary causes of hearing loss in adults, nonoccupational
noise also can damage hearing. Loud noises can cause
permanent hearing loss through metabolic exhaustion or
mechanical destruction of the sensory cells within the cochlea.
Some of the sounds of daily life, including those made by lawn
mowers, recreational vehicles, power tools, and music, might
play a role in the decline in hearing health. Hearing loss as a
disability largely depends on a person’s communication needs
and how hearing loss affects the ability to function in a job. The
loss of critical middle and high frequencies can significantly
impair communication in hearing-critical jobs (e.g., law
enforcement and air traffic control).
Occupational Noise-Induced Hearing Loss
A recent analysis of 2011–2012 National Health and Nutrition
Examination Survey (NHANES) data estimates that
approximately 14% of U.S. adults aged 20–69 years (27.7
million persons) have hearing loss. After adjustments for age
and sex, hearing impairment was nearly twice as prevalent in
men as in women; age, sex, ethnicity, and firearm use were all
important risk factors for hearing loss.

CDC’s National Institute for Occupational Safety and Health
(NIOSH) estimates that 22 million workers are exposed to
hazardous levels of noise in their workplaces (2). The estimated
prevalence of hearing loss among noise-exposed workers is
12%–25%, depending on type of industry. Reductions in
workplace noise and increased use of hearing protection might
have contributed to a decreased prevalence of hearing loss over
time in some sectors, including agriculture, forestry, fishing,
and hunting and transportation, warehousing, and utilities (3).
The risk for incident hearing loss (i.e., the likelihood of
observing a new case of hearing loss in a worker’s longitudinal
audiometric data) decreased by 46% from the periods 1986–
1990 to 2006–2010 .
For high exposure levels such as firearm or aircraft noise above
140 decibels sound pressure level (dB SPL), engineering and
administrative controls might not reduce noise exposures
adequately. Such situations require hearing protection devices
(HPDs) providing upwards of 30–40 dB of noise reduction when
worn properly. Despite the existence of occupational
regulations for hearing protection, many workers fail to achieve
adequate protection because their earplugs or earmuffs do not
fit properly. Hearing protector fit testing provides an
opportunity to train workers to properly fit hearing protectors
and to encourage effective use. The NIOSH HPD Well-Fit
hearing protector fit-test system is a simple, portable solution
for testing in quiet office spaces. Other fit-testing systems are
commercially available.
Nonoccupational Noise-Induced Hearing Loss
Primary sources of nonoccupational hearing loss in the United

States include noise exposure from recreational hunting or
shooting, use of personal music players, overexposure at
concerts and clubs, and certain hobbies (e.g., motorsports and
woodworking with power tools). In 2016, CDC began initiatives
to raise awareness about the risk for permanent hearing damage
attributable to nonoccupational noise exposures, including the
development of new communication tools about noise-induced
hearing loss.
Persons with normal hearing can detect sounds equally soft at
all frequencies. When hearing is damaged by noise, the hearing
test will show a loss of acuity in a narrow range of middle to
high frequencies (3–6 kHz) with better hearing at both lower
and higher frequencies.
The weighted prevalence of an audiometric notch was 24%,
extrapolated to represent nearly 40 million U.S. adults.
Unilateral audiometric notches were three times more prevalent
than were bilateral audiometric notches and were more
prevalent in men than in women. Participants who reported
having exposure to loud noise at work were twice as likely to
have evidence of hearing damage as were those who did not.
However, 20% of persons with no occupational exposure to loud
noise had an audiometric notch, suggesting that 21 million U.S.
adults likely have hearing damage from noise at home or in
their communities.
The presence of an audiometric notch increased with age,
ranging from 19% of participants aged 20–29 years to 29% of
those aged 40–49 years. The prevalence of notches decreased
among persons aged 50–59 years, as high-frequency hearing
loss associated with aging increasingly masks the notch
associated with noise-induced hearing loss.
Regardless of whether participants’ exposure was to work or
recreational noise, 24% of those with such damage reported that
their hearing was excellent or good, suggesting that many
persons might be either unaware of or ignoring noise-induced

hearing damage. Although most noise-induced hearing loss is
preventable, the NHANES analysis found that 70% of persons
exposed to loud noise in the past 12 months had seldom or never
worn hearing protection (5).
Noise-induced hearing loss in youths is not a new problem. An
analysis of 1988–1994 NHANES data identified audiometric
notches in 20% of males and 12% of females aged 12–19 years
among a population of 5,249 U.S. children and young adults
aged 6–19 years (6). An analysis of 2005 and 2006 NHANES
data found that 17% of both males and females had notched
audiograms (7).
Hearing Loss Worldwide
Hearing loss affects tens of millions of persons in the United
States and hundreds of millions of persons worldwide, and
during the past few decades, the estimated number of persons
with hearing loss has steadily increased. The World Health
Organization (WHO) estimates that approximately 360 million
persons live with disabling hearing loss, including
approximately 328 million (91%) adults (56% males and 44%
females) and 32 million (9%) children. As the population ages,
it is estimated that approximately 320 million persons aged >65
years will have hearing loss by 2030 and approximately 500
million by 2050.
National Prevention Efforts
To ensure that all persons can benefit from efforts to prevent
noise-induced hearing loss, a coordinated public health hearing
loss reduction and mitigation approach should focus on
effective population-based preventive interventions that go
beyond clinical service and traditional areas of diagnosis,
treatment, and research and focus on epidemiologic

surveillance, health promotion, and disease prevention. Such an
approach can help determine the needs of the population and the
barriers to care, leading to policies for prevention and
management of hearing loss. Health communication science
provides a theoretical framework to study, develop, and
evaluate interventions designed to change individual behavior.
Some of these theories have been applied in the promotion of
hearing health.
Dangerous Decibels (http://dangerousdecibels.org/external icon)
is an evidence-based intervention program that has changed
knowledge, attitudes, beliefs, and behaviors of both youths and
adults for the prevention of noise-induced hearing loss and
tinnitus.
The messaging incorporates three strategies for hearing loss
prevention:
1) turn it down
2) walk away
3) protect your ears.
Originally developed for youths, Dangerous Decibels has been
successfully adapted for civilian adults and the military, and its
effectiveness was demonstrated in randomized trials among
children in the United States and in studies in New Zealand and
Brazil. Comparison of responses to predelivery and two
postdelivery questionnaires found that participants in the
Dangerous Decibels presentation exhibited substantial
improvements in knowledge, attitudes, and intended behaviors
related to hearing and hearing loss prevention that were
partially maintained 3 months after the presentation. Most
recently, Dangerous Decibels expanded into a community-based
intervention and is self-sustaining in U.S. Native American
communities. The materials are in use in all 50 states, four U.S.
territories, and 41 countries. Online games and activities are
available, including Jolene, a system that measures music-

listening sound levels and aids in educational outreach for
hearing health.
CDC has developed tools and communication products to
promote best practices for hearing loss prevention. In addition
to practical engineering controls, administrative controls, and
using hearing protectors, NIOSH promotes the Buy Quiet and
Quiet-by-Design programs, designed for employers to take an
inventory of their potentially harmful loud tools and replace
them with quieter ones. Approximately 20 companies and
individuals have been recognized for successful efforts by the
Safe-in-Sound Excellence in Hearing Loss Prevention and
Innovation Award (http://www.safeinsound.us/external icon)
developed by NIOSH and the National Hearing Conservation
Association.
In 2015, United Technologies, a corporation that serves
customers in the commercial aerospace, defense, and building
industries, received the award for promoting a hearing-loss
prevention culture throughout the corporation. United
Technologies reduced the number of persons exposed to
hazardous noise by approximately 80%, thereby eliminating the
need for a hearing conservation program for approximately
10,000 workers.
Other efforts include the promotion of recommended noise
exposure standards for the workplace. NIOSH recommends an
85-dB limit for an average daily 8-hour exposure and a 3-dB
exchange rate, which means that each increase of 3 dB in
exposure level reduces the recommended exposure time by half
(13). Thus, an 88-dB exposure limit is recommended for up to 4
hours and a 91-dB exposure limit for 2 hours. The National
Hearing Conservation Association 85-3 Coalition, an
organization of worker, professional, and industrial hygiene
associations, promotes the use of an 85-dB limit and 3-dB
exchange rate to protect the hearing of workers.

WHO focuses on undertaking evidence-based advocacy to raise
awareness of deafness, hearing loss, and hearing care within all
levels of society. WHO develops policy that advocates for
hearing care provisions in its 194 member countries and
develops standardized technical tools, recommendations,
guidelines, and training resources to support policy
development and implementation. It also engages directly with
national ministries of health and other stakeholders to develop,
implement, and monitor strategies for ear and hearing care.
Two principal advocacy initiatives promoted by WHO include
World Hearing Day (http://www.who.int/pbd/deafness/world-
hearing-day/en/external icon) and the Make Listening Safe
initiative
(http://www.who.int/pbd/deafness/activities/MLS/en/external
icon) (15). The Make Listening Safe initiative was launched in
2015 to reduce the growing risk for hearing loss posed by
unsafe listening practices in recreational settings. As part of
this initiative, WHO is working with partners to develop
technical standards and applications for personal audio systems
and to promote safe listening practices among application (app)
users. World Hearing Day, observed each year on March 3, aims
to increase hearing loss awareness among policymakers,
professionals, and communities. The 2018 theme is “Hear the
future,” drawing attention to the globally increasing number of
persons with hearing loss, focusing on preventive strategies,
and outlining steps to ensure access to necessary rehabilitation
services and communication tools and products.
Noise reduction and avoidance can prevent hearing loss or slow
its progression. Persons can protect themselves by moving away
or taking breaks from loud sounds, using quieter consumer
products, lowering volumes on personal listening devices,
reducing time listening to loud levels of music, and using
hearing protectors. Hearing protectors need to fit well to reduce
noise exposures effectively. Health care providers can inform

patients about hearing loss symptoms, early diagnosis of
hearing loss, and prevention strategies.
Policymakers, governments, and manufacturers of equipment
can develop policies to reduce noise levels and limit noise
exposures of the public. In parts of Europe, community noise
and the effect of urban soundscapes on public health have
received considerable attention. In the United States, national,
state, and local community noise-control efforts are largely
uncoordinated, potentially resulting in higher levels of
community noise. Increasing awareness and reducing needless
exposures to loud noise might help the public take appropriate
steps to protect their hearing.
References
Hearing Loss: A Common Problem for Older Adults. (2018,
November 20). Retrieved November 4, 2019, from
https://www.nia.nih.gov/health/hearing-loss-common-problem-
older-adults.
Murphy, W. J., Meinke, J. E., undefined, D. K., undefined, S.
C., & undefined, J. I. (2018, March 1). CDC Grand Rounds:
Promoting Hearing Health Across the Lifespan. Retrieved
November 4, 2019, from
https://www.cdc.gov/mmwr/volumes/67/wr/mm6708a2.htm.
What's the connection between hearing and cognitive health?
(2017, October 19). Retrieved November 4, 2019, from
https://www.nia.nih.gov/news/whats-connection-between-
hearing-and-cognitive-health.

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