Hearing Loss in Older Adults: Screening -- Asymptomatic Adults Aged 50 Years or Older


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older.

Frequency of Service

No information available.

Risk Factor Information

Aging is the most important risk factor for hearing loss. Presbycusis, a gradual, progressive decline in the ability to perceive high-frequency tones due to degeneration of hair cells in the ear, is the most common cause of hearing loss in older adults. However, hearing loss may result from several contributing factors. Other risk factors include a history of exposure to loud noises or ototoxic agents, including occupational exposures; previous recurring inner ear infections; genetic factors; and certain systemic diseases, such as diabetes.


Clinical

Clinical Considerations

Patient Population

This recommendation applies to asymptomatic adults aged 50 years or older. It does not apply to persons seeking evaluation for perceived hearing problems or for cognitive or affective symptoms that may be related to hearing loss. These persons should be assessed for objective hearing impairment and treated when indicated.

Risk Assessment

Aging is the most important risk factor for hearing loss. Presbycusis, a gradual, progressive decline in the ability to perceive high-frequency tones due to degeneration of hair cells in the ear, is the most common cause of hearing loss in older adults. However, hearing loss may result from several contributing factors. Other risk factors include a history of exposure to loud noises or ototoxic agents, including occupational exposures; previous recurring inner ear infections; genetic factors; and certain systemic diseases, such as diabetes.

Screening Tests

Available screening tests include physical diagnostic tests, such as the whispered voice, finger rub, and watch tick tests (bearing in mind that many modern watches no longer audibly tick); single-question screening or longer patient questionnaires; and handheld audiometers. All are relatively accurate and reliable screening tools for identifying adults with objective hearing loss. In addition, self-administered questionnaires, such as HHIE-S, can identify adults with perceived (or subjective) hearing difficulty. Not all adults with perceived hearing difficulty have objective hearing loss.

Treatment

Before a person receives a hearing aid, diagnosis of objective hearing loss should be confirmed with a pure-tone audiogram. Fair evidence from studies in highly selected populations shows that hearing aids can improve self-reported hearing, communication, and social functioning for some adults with age-related hearing loss.

Suggestions for Practice Regarding I Statement

Potential preventable burden. Finding objective hearing loss indicates eligibility for a hearing aid but does not convincingly identify persons who will find the devices helpful and wearable and will use them. One subgroup analysis of a randomized, controlled trial found that in older adults who did not have self-perceived hearing loss at study entry, screening and receipt of a free hearing aid did not increase use after 1 year compared with an unscreened control group (and overall use was low, at 0% to 1.6%) 1. However, health-related quality of life is improved for some adults with moderate to severe hearing loss who use hearing aids compared with those who do not 2.

Cost. The cost of screening varies according to the test. The cost of a questionnaire consists of the time required of both the patient and clinician. In-office clinical techniques (whispered voice, finger rub, or watch tick tests) and audiometry are quick to perform; however, handheld audiometers have up-front equipment costs. Diagnostic confirmation of a positive screen is typically done with a pure-tone audiogram, which requires a soundproof booth and trained personnel to administer the test and takes approximately 1 hour to complete. The cost of a hearing aid is a barrier to use for many older adults because it is not covered by Medicare and many private insurance companies.

Other Considerations

Research Needs and Gaps

Future studies should concentrate on patients older than 70 years and examine whether there are differential effects of treatment on outcomes at different ages (for example, older than 70 or 80 years). Adequately powered studies are needed to better evaluate the effect of screening for hearing loss on health outcomes, such as emotional and social functioning, communication ability, and cognitive function, rather than intermediate measures, such as hearing aid use or satisfaction, particularly among adults without self-perceived or established hearing loss at baseline.

The incremental benefits and costs of screening asymptomatic adults compared with only testing and treating those who seek treatment of perceived hearing impairment are unknown. Knowledge of specific factors or patient characteristics associated with increased and sustained use of hearing aids, once prescribed, could permit testing and treatment targeted to those most likely to benefit.

Update of Previous USPSTF Recommendation

This recommendation replaces the 1996 recommendation, in which the USPSTF recommended periodically questioning older adults about their hearing, counseling them about the availability of hearing aids, and making referrals when appropriate 15. This conclusion was based on the best available evidence at that time, which was indirect in nature and largely limited to studies of diagnostic accuracy and treatment of persons with established or perceived hearing loss. The previous USPSTF noted that no controlled trials could prove the effectiveness of screening asymptomatic older adults for hearing impairment. Screening and diagnostic evaluation are 2 distinct activities, and treatments may vary in effectiveness depending on how the condition is identified. There may be important differences between a person who has subjective hearing symptoms and is diagnosed with objective impairment as a result of symptoms and a person without self-perceived hearing difficulties who has a routine and automatic screening examination that detects a personally inapparent but objectively identifiable decline in hearing function.

Since the 1996 recommendation was published, direct evidence from a randomized, controlled trial evaluating the effect of screening itself, rather than treatment alone, has become available 1. Although this trial found that screening was associated with an increase in hearing aid use, the benefit seemed to be limited to persons who had self-perceived loss of hearing at baselineno difference in use was seen for asymptomatic persons with objective hearing loss detected with screening. Of note, screening was not found to have a discernible effect on hearing-related quality of life; however, the trial was not primarily designed nor did it have sufficient statistical power to detect health or functional outcomes, so additional research would be helpful to draw more definitive conclusions. Therefore, the USPSTF now concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older (I Statement).


Rationale

Rationale

Importance

Age-related sensorineural hearing loss is a common health problem among adults aged 50 years or older. Hearing loss can affect social functioning and quality of life.

Detection

Convincing evidence shows that screening tools can reliably and accurately identify adults with objective hearing loss. Clinical tests used to screen for hearing impairment include testing whether a person can hear a whispered voice, a finger rub, or a watch tick at a specific distance. Perceived hearing loss can be assessed by asking a single question (for example, “Do you have difficulty with your hearing?”) or with a more detailed questionnaire, such as the Hearing Handicap Inventory for the Elderly–Screening Version (HHIE-S). A handheld screening instrument consisting of an otoscope with a built-in audiometer can also be used.

Benefits of Detection and Early Treatment

Because of a paucity of directly applicable trials, evidence is inadequate to determine whether screening for hearing loss improves health outcomes in persons who are unaware of hearing loss or have perceived hearing loss but have not sought care. One good-quality study showed that hearing aids can improve self-reported hearing, communication, and social functioning for some adults with age-related hearing loss. This study nearly exclusively evaluated white male veterans with moderate hearing loss and moderate to severe perceived hearing impairment, more than one third of whom had been referred for evaluation of hearing problems; as such, these findings were of limited applicability to a hypothetical asymptomatic, screened population. The only randomized trial that directly evaluated the effect of screening for hearing impairment—rather than the effect of treatment alone—was not primarily designed nor had sufficient statistical power to detect differences in hearing-related function. The USPSTF concludes that the evidence is inadequate to assess the benefit of screening and early treatment in an unselected screening population.

Harms of Detection and Early Treatment

Because of a lack of studies, evidence to determine the magnitude of harms of screening for hearing loss in older adults is inadequate; however, given the noninvasive nature of both screening and associated diagnostic evaluation, these harms are probably small to none. Adequate evidence shows that the harms of treatment of hearing loss in older adults are small to none.

USPSTF Assessment

The USPSTF concludes that evidence is lacking, and the balance of benefits and harms of screening for hearing loss in adults aged 50 years or older cannot be determined.


Others

Recommendations of OthersThe American Speech-Language-Hearing Association recommends that adults be screened once per decade and every 3 years after age 50 years 16. The American College of Obstetricians and Gynecologists recommends that female patients aged 13 years or older be evaluated and counseled on hearing as part of the periodic health assessment 17. The American Academy of Family Physicians is in the process of updating its recommendation.


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