For Better Care for Older Adults, Think Hearing Loss.

Two scholarly papers published this month discussed the impact of hearing loss on patient communication in older adults. Both found that unrecognized hearing loss may have a serious negative impact on health care in the elderly.

In the first, published in the British Medical Journal (BMJ) on January 18, researchers Jan Blustein, a professor of health policy and medicine at NYU, Barbara E. Weinstein professor of audiology at the CUNY Graduate Center, and Joshua Chodosh, a geriatrician at NYU, found that the rate of hearing loss is underestimated in medical settings, and analyzed the effect of undetected hearing loss on doctor-patient communication.


In the second, published in the Journal of the American Medical Directors Association (JAMDA)  on January 30, the same authors as well as Ellen M. McCreedy, at the Center for Gerontology and Health at Brown University, discussed why hearing loss may be especially disabling in nursing home settings, and provided an estimate of the prevalence of hearing loss in those settings.

Hearing loss in older adults is measured in various ways. One is a catchall number that includes everyone over a certain age:  two-thirds of those over 70 have hearing loss, four-fifths of those over 80 have hearing loss. Sometimes it’s measured by decades: half of those 70-79 have hearing loss; 80 percent of those over 80 do. These figures include everything from mild to profound loss.

Whatever way you count it, however, the elderly experience hearing loss in large numbers. So when the researchers found that federal data indicated that 68 percent of long-term nursing home residents over the age of 70 had “adequate” hearing, it seemed worth investigating.  Was hearing loss just not being recognized in nursing homes? And if so, was it affecting care?

The Federal Data was compiled from the Minimum Data Set (MDS) that all nursing homes are required to report to the federal government. In 2016, nursing homes reported that 68 percent of their residents had “no difficulty in normal conversation, social interaction, or listening to TV.”

That number seemed “implausibly low” to Dr. Blustein and her colleagues. The National Health and Nutrition Survey (NHANES), which is the authoritative source about the rate of hearing loss among adults who live outside of institutional settings, found that only 44% of those 80 and older said that they had “excellent or good” hearing. As the JAMDA paper notes, these two figures are at “striking odds” with each other.

It stands to reason that the rate of hearing loss in nursing home residents should be about the same as that of adults living outside of institutional settings, which would mean that many people in nursing homes and other health care settings are having trouble hearing. They may not be having trouble hearing all the time, but crucial hearing situations are often the noisiest.

Many of those who say they hear adequately probably have mild to moderate age-related hearing loss. Their speech comprehension may be fine in quiet conversation. But nursing homes are far from quiet – studies show that social settings are often very noisy, with televisions blaring, dishes clattering in cafeterias, and residents crying out. Moreover, “high stakes” medical-care situations – emergency rooms, intensive care units, ambulances — tend to be the noisiest. These are also stressful situations, and stress also impacts comprehension.

Hearing aids are one solution, but hearing aid use remains low even in this population. Even if they do have hearing aids, people may leave them at home or in a safe place, to prevent loss or damage.

In both articles, the authors propose easy low-tech solutions for making sure hearing loss doesn’t get in the way of good patient care.

The first is for clinicians to be aware that their elderly patients may have hearing loss, even if they don’t know it. They should also check for impacted cerumen, or ear wax, which can affect hearing.

Every facility should have on hand personal amplifiers that can be shared with patients. The PocketTalker is perhaps the best known. The researchers also mention the Mino and the Sonido Listener. These devices cost about $150.

Health care workers also need to be mindful of communication strategies: they should make sure they have the listener’s attention, face the listener, speak clearly but not too slowly, rephrase rather than repeat words the listener has not understood.

Dr. Blustein (who has hearing loss herself and who serves on the Board of Trustees of the Hearing Loss Association of America, as do I) believes that hearing loss profoundly affects communication with patients. “Those of us with hearing loss often smile and nod so that the world thinks that we understand. It’s much more convenient. It’s easier. A patient may nod and smile, but not really understand what she is being told,” she said in an interview with the BMJ. Busy clinicians, too, may just want to move on, get their work done. So both the patient and the clinician may be contributing to the detriment of good patient care.

Unrecognized hearing loss can also sometimes be misdiagnosed as a cognitive impairment. “I think… my intuition… is that this is one of the great issues,” Dr. Blustein told the BMJ. “It’s sort of low-hanging fruit in clinical medicine, the assumption that someone has cognitive impairment when they don’t respond appropriately.”

Asked why the effect of hearing loss on good communication has remained unrecognized by many doctors, Dr. Blustein replied: “I think disability, generally, is not something that medicine is attracted to. We tend to be attracted to really dramatic, acute illness. Disability is complicated, it takes time.” And, she added, it occurs primarily in older people. “This is dismissed as ‘normal aging’. It’s ageism.”

People with hearing loss share some of the responsibility. Both patients and providers will benefit from the Guide for Effective Communication in Health Care, created by Jody Prysock and Toni Iacolucci. It includes information specifically for patients and their families (including a form that can be filled out in advance of medical interactions and should be entered into patient charts) and for providers. It can be found on the New York City Chapter’s website under Resources, with a link to the national website.

For people with hearing loss, it’s important to be honest, to disclose our disability. For providers, it’s important to recognize that hearing loss may be a factor. It’s a two-way street.


For more information about living with hearing loss, read my book “Shouting Won’t Help: Why I and 50 Million Other Americans Can’t Hear You. 

Considering a Cochlear Implant? You’re Never Too Old.

Is there  an age limit for cochlear implant recipients? I asked this question of several cochlear implant surgeons around the country. Their answer? Never.

All have implanted patients in their 90s and, as Anil Lalwani, of New York-Presbyterian/Columbia University Irving Medical Center said, he “routinely” operates on patients over 80. His oldest patient is 93.

Surgeon Jay Rubinstein, at the University of Washington Medical Center, has performed cochlear implant surgery on a 96-year-old. Like the others, he thinks chronological age is -not the issue, it’s a person’s overall health.

In other words, it’s not so much how many years you’ve lived as how well your body has held up. In April 2014, Mollie Smith, 99, became the oldest cochlear implant recipient in Europe.

Cochlear implant surgery takes about two to three hours and requires general anesthesia or heavy sedation, so the ability to tolerate anesthesia is essential. Even so, a 2009 study by Dr. Lalwani and others, found that cochlear implantation in the elderly carries minimal risk from anesthesia.

One of the important preexisting conditions that may preclude surgery is moderate or severe heart and/or lung disease, which could make anesthesia potentially dangerous, said Rick Hodgson, a surgeon with Head and Neck Surgical Associates in Portland, Ore. The oldest patient he has implanted was 92 and he’s doing well, Dr. Hodgson said, noting that as a surgeon he looks more at “biologic age than chronological age.”

Darius Kohan, an otologist-otolaryngologist in New York (who was my cochlear implant surgeon at New York Eye and Ear Infirmary), told me he implanted a patient who was 95 years 6 months old. The patient is still using the implant 21/2 years after surgery.

Even dementia may not be a disqualifier, the surgeons said, assuming that the patient is not violent or likely to destroy the external parts of the implant. A study published last summer on implantees with dementia found a significant cognitive improvement a year later. The patients also received regular auditory rehabilitation. It was not clear from the study whether it was the implant itself or the aural rehab that made the difference in improved cognitive abilities.

Jack Wazen, a surgeon and  partner at the Silverstein Institute and director of research at the Ear Research Foundation in Sarasota, Fla. (and a fellow board of trustees member with me for the Hearing Loss Association of America), was the most conservative of those interviewed on the question of dementia, saying he routinely implants those with mild to moderate cognitive decline, but not those with severe decline.

All agree on the importance of auditory rehab for older patients. As Dr. Hodgson put it, “Auditory rehab helps get the most out of the process. This is amazing and life-changing technology, so why wouldn’t we want to maximize the impact on someone’s life?” He added that younger implant recipients might still be in the workforce and get stimulation from their everyday environment. The older recipients are less likely to get that stimulation. Also important, as all the surgeons agreed, is a social support system. This doesn’t necessarily mean a companion in the home, but a regular conversation partner is essential. Social interaction is important in general for quality of life.

The one issue on which the surgeons differed was which ear to implant: the worse or the better one. With younger implantees, the decision is usually to implant the worse ear, to preserve the natural hearing in the good ear, often using a hearing aid in the good ear. But an elderly person may have been deaf for some time in the bad ear, and thus less likely to benefit from the implant.

Although most said that they would consider implanting the deaf ear, they might not if the ear had been deaf for a long period of time. Dr. Wazen specified five years or more. Dr. Hodgson pointed out that “the longer the duration of hearing loss, the higher the chance of diminished benefit due to deterioration of sensory elements in the inner ear.”

Both Dr. Lalwani and Dr.  Kohan said they would implant the worse ear. Dr. Kohan’s reasoning is that if the patient is still able to hear with the hearing aid ear, there may still be enough plasticity in the brain, with crossover from the nonhearing ear, to make an implant in the deaf ear function. Dr. Lalwani went further: “I would always implant the deaf ear. One does not lose anything from doing so. If the outcome is less than satisfactory, the other ear could always be implanted down the road.”

As for outcomes, all the physicians agreed that older recipients do well with cochlear implants. Dr. Kohan mentioned benefits like delayed mental deterioration, better quality of life and more independence.

Dr. Wazen is completing a study comparing the results among patients over 80 with those under 80. The study found no differences in healing or complication rates. All patients did better with the cochlear implant than they had with a hearing aid. The study did find that speech recognition scores with implants were better in the younger group. This may be due to a number of factors, Dr. Wazen said, “including length of deafness, poorer cognitive function [in the older group] and aging changes in the brain.”

So if your doctor recommends an implant, go for it, no matter what your age. “When elderly patients tell me they are too old for a CI,” Dr. Rubinstein said, “I tell them age is not important unless they are a cheese.”

This post first appeared on AARP Health on February 22, 2016.

Hearing Loss? Don’t Neglect Your Eyes

Take care of your eyes and ears
For people with hearing loss, even a small decrease in vision can affect the ability to lip-read and understand better what they hear. — Getty Images/Hero Images


Those of us with more than just moderate hearing loss tend to take care of our hearing.

We make sure our hearing aids are in good working order, and any new symptoms — dizziness, ringing in the ear, a drop in hearing — result in a prompt visit to the ear doctor.

Unfortunately, the eyes, like much of the rest of the body, become more susceptible to disease and other issues as we get older. Some problems are serious and can lead to blindness, if left untreated. But for people with hearing loss, even a small decrease in vision can affect the ability to lip-read and thus understand better what they hear.

The combination of vision and hearing problems can also decrease the ability to socialize, which has been linked to a greater risk of dementia.

A 2014 study of nearly 900 European adults age 75-plus with hearing problems and more than 27,000 Europeans age 50-plus with vision problems found that people with vision or hearing problems were less socially active than those without sensory problems, and those with both vision and hearing problems were the least socially active.

  • Age-related macular degeneration, a deterioration of the portion of the retina responsible for central vision, is the leading cause of vision loss in the U.S. According to the American Academy of Opthalmology, the risk of getting macular degeneration jumps from about 2 percent of people in their 50s to nearly 30 percent in people over age 75.
  • Cataracts, a clouding of the eye’s lens, can affect one or both eyes and are very common — by age 80, more than half of Americans either have it or have had cataract surgery, according to the National Eye Institute.
  • Retinal problems affect people with diabetes disproportionately, but can occur in anyone and can cause blindness if not treated.
  • Glaucoma, the leading cause of blindness, can develop without symptoms, so regular eye checkups are important.
  • Dry eyes may not sound like a problem, but million of Americans suffer from this painful, irritating condition that can affect vision. Some 20 million to 30 million older Americans have a mild condition, while 9 million suffer a moderate to severe case. “In patients over 50, dry eye is the most prevalent — and under-recognized and under-treated — condition out there,” Alan Carlson, M.D., professor of ophthalmology at Duke University School of Medicine, told AARP. “Virtually everyone over 55 has some degree of dryness.” There are treatments, generally over-the-counter eye drops, but don’t ignore the problem. It can result in a deterioration of vision.

Recently I started having painful itching in my right eye and the vision in that eye was blurry. I dismissed this as allergies, but a few weeks ago I began waking up in the middle of the night with stabbing headaches. I knew I should see my ophthalmologist — especially when I realized it had been almost two years since I’d had a checkup.

I regarded these new symptoms as bizarre, but not really worrisome. But when I mentioned them to a physician, she said I should go straight to the eye doctor.

I got some eye drops and made an appointment. In the meantime, I wanted to share the lesson learned. My physician friend put the fear of blindness in me, and I’ll never be so casual about my vision again.

This post first appeared on AARP Health on 10/25/2016.

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Katherine Bouton is the author of “Living Better With Hearing Loss: A Guide to Health, Happiness, Love, Sex, Work, Friends … and Hearing Aids,” and a memoir, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You”. Both available on

Yes, I Have Hearing Loss, Talk to Me Anyway

This bears repeating: It’s important to be included in the conversation.

True friends and understanding family will do that. They’ll repeat, they’ll rephrase, they might even spell it out. One friend pulls out a notebook and jots down the key words. It helps if I parrot back the parts of the sentence I did hear, so they understand what I missed.

But not everyone is as patient. How many times have I heard, “Never mind, it isn’t important”? Mimages-1aybe it isn’t, but I still want to hear it.

Nevertheless, constant repetition of something trivial does get tedious for the speaker — and for me! —  and so, sometimes in a social situation, I just let it go. I’d rather the person keep talking to me than understand every word.

(This is not something I’d do in a business meeting or in any important discussion, by the way. It’s just for social chitchat. And before you start lecturing me, I do use assistive devices, like an FM system or a Roger Pen. Sometimes I still just can’t hear.)

Is this wise? Do I really want to hear only part of a conversation? Maybe, depending on who the speaker is. What I do want is to be included in conversation. I want to be invited places. I want to be seen as someone fun and interesting, rather than as a constant drag on conversation. I know readers will criticize me for saying this. We people with hearing loss, especially advocates like me, are supposed to demand our rights, not lie down and surrender.

So why do I do just that — lie down and surrender? Why do I accept only part of the conversation? I think I have a good reason. A huge danger for people with hearing loss is isolation. Isolation is not good for your mental health. It can lead to depression and cognitive decline.

If I asked for clarification of every word, social chitchat would quickly bog down. As a result, I might not try again next time. That’s how isolation occurs.

For now, I listen closely, I try to gauge what I really want to hear and selectively ask the speaker for clarification. The rest of the time I smile and nod, or frown and sigh, or raise my eyebrows, or laugh appreciatively. How do I know to do this without knowing what was said? I follow the speaker’s face. The clues are all there. Of course I run the risk of a grossly inappropriate misreading of the speaker’s face. But that’s a risk I’ll take to keep people talking to me.


For more about living with hearing loss, read my books “Shouting Wont’ Help “and “Living Better With Hearing Loss,” both available at


This article first appeared in a slightly different form on AARP Health. 

New Study Suggests Hearing Aids May Help Protect Brain Health

For several years, studies have linked hearing loss and dementia, but no major study has addressed the big question: Could using hearing aids reduce the risk of cognitive decline? Now an important new French study finds that older adults who use hearing aids experience the same rate of cognitive decline as their peers with normal hearing. In other words, while hearing loss is associated with accelerated cognitive decline, hearing aids can slow that from happening, researchers say. The study, published …Click here to read about the surprisingly nuanced finds of this study.