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. 

How I Learned to Love My Cochlear Implant.

In 2013 in my first book, “Shouting Won’t Help,” I wrote about the difficult experience I had adjusting to a cochlear implant I received in 2009. That section was excerpted in Bloomberg View and it is still easily available online.shoutingwonthelp

I often get letters from people who have seen the article and are worried by the information in it. They write to ask if they should get a cochlear implant. (Needless to say, this is a question only they and their medical professionals can answer.) Part of the concern stems from the Bloomberg title, “Cochlear Implants Are Miraculous and Maddening.” If you read the article carefully, as I just did, you won’t see me damning cochlear implants. But you will see me raising some caveats.

I am 100 percent in favor of getting a cochlear implant if you qualify for one, and if your hearing aid no longer works for you. I am also 100 percent in favor of aural rehabilitation after the implant. If your implant center doesn’t offer aural training, look for it elsewhere. A speech language-pathologist is one possible provider. There are many online training programs, the best known of which is L.A.C.E. This is a graduated program that starts with speech at a decibel level you can hear (this is determined before you start the program) and gradually increases the noise level in the background. I have written about aural rehabilitation previously on this blog, and you can find other suggestions there.

So how did I come to love my cochlear implant after my initial tepid embrace?

The first answer is practice. I have taken formal and online aural rehabilitation courses. I’ve worked one on one with a speech language pathologist. I listen to recorded books and then read the text to make sure I’ve gotten it right.

The second answer is consistent use. I wear the implant all day every day.

The third answer is technology. The cochlear implant I got in 2009 was not nearly as sophisticated as the replacement implant I got in 2014. (Most implant companies upgrade the external processor every five years.)

The fourth answer is support. I am active member of the Hearing Loss Association of America. We meet regularly and we share tips and experiences. I am always learning new things about hearing.

The fifth is to have reasonable expectations. Is my hearing perfect? Far from it. I need assistive listening devices and captions to hear in a group. I use captions to watch TV. I use captions at movie theaters. I say “What?” a lot. But I live an active daily life in the hearing world, and rarely feel disabled.

But without my cochlear implant I would hear almost nothing. My hearing loss is progressive and the hearing in my hearing-aid ear continues to drop. I am already planning for a second cochlear implant. I qualify now (many times over) but my hearing aid is adequate and this is one area where I follow my own advice: If you can still hear with a hearing aid, hold off on a cochlear implant.

If your hearing aid is no longer adequate, start your research. I have written a great deal about cochlear implants and with every writing my optimism grows. The paperback version of “Shouting Won’t Help” is more upbeat on cochlear implants than the hardcover was. My 2015 book “Living Better with Hearing Loss” offers more updated information than the earlier books, and also reflects my comfort and satisfaction – and gratitude! – for having a cochlear implant.


For more information on living with hearing loss, see my books on

Study Finds that Hearing Aids Work, but So Do Over-the-Counter-Type Hearing Devices. Both Work Better When an Audiologist Is Involved

Are OTC Devices Better?
Photo: ALAMY

A new study definitively found that hearing aids can help older adults with hearing loss. We’ve known this intuitively, of course, but this well-designed study provided the kind of proof that has not existed before.

The study team at the University of Indiana, Bloomington, was led by Larry E. Humes. “The research findings provide firm evidence that hearing aids do, in fact, provide significant benefit to older adults,” Dr. Humes said. “This is important because, even though millions of Americans have hearing loss, there has been an absence of rigorous clinical research that has demonstrated clear benefits provided by hearing aids to older adults.”

The study also found that an over-the-counter model of hearing aid (OTC hearing aids are not yet available) performed almost as well as an expensive hearing aid.

Those fitted with the real hearing aid, as well as a placebo group,  also received professional help with fit and instruction. The presence of best-practice audiology services greatly influenced the outcome, even in those receiving the placebo.

The six-week Indiana University study, published in the March issue of American Journal of Audiology, compared outcomes among three groups of patients: One that got a hearing aid that included the services of an audiologist. One that followed an over-the-counter process,  with the consumer choosing from among three pre-programmed devices — in actuality, the same high-end digital pair as the first group — but without a fitting. And a control group that got a professional fitting for a placebo hearing aid that had no amplification.

The subjects were 154 adults, ages 55 to 79, with mild to moderate hearing loss. The researchers compared benefits, including user satisfaction and usage of hearing aids after six weeks.

The researchers found that hearing devices helped both the audiologist group and the OTC group., although the OTC group was less satisfied with the hearing aids and less likely to purchase them after the trial. About 55 percent of the OTC participants said they were likely to purchase their hearing aids after the trial vs. 81 percent for the audiologist group.

Satisfaction significantly increased for patients in the OTC group who opted after the formal trial period to continue with an audiologist for a four-week follow-up. More of them also opted to purchase their hearing aids after receiving these audiology services.

Making OTC hearing aids available is the goal of a bill recently introduced by Sens. Elizabeth Warren (D-Mass.) and Chuck Grassley (R-Iowa) authorizing the sale of OTC hearing aids for mild to moderate loss. In an article in JAMA, they wrote: “Increasing access to innovative, low-cost hearing technologies must be part of the policy response to the untreated hearing loss now experienced by millions of Americans.”

The Hearing Loss Association of America (HLAA) also supports the Warren-Grassley bill and issued a call to action to its members to support it. Many members of HLAA have severe to profound hearing loss and would not be candidates for an OTC aid, but as the HLAA statement put it, improving service at the basic end encourages innovative technologies for all types of hearing loss. In addition, the introduction of lower-cost hearing aids and competitive pricing may help bring the cost of all hearing aids down.

Audiologists who are concerned that OTC hearing aids will put them out of business should take comfort in the study’s findings about the benefits of best practices in audiology. If audiologists get behind OTC hearing aids, it could mean hundreds of thousands more patients needing their services.

This would be good for people with hearing loss, and good for audiologists. And if hearing-aid manufactures get into the low-cost hearing business, it will be good for them as well. The study by Humes and colleagues shows that nobody really has anything to lose by encouraging innovation and competition in hearing aids.

For those who would like to read the study, here’s a link to the open-access publication:

For more information about living with hearing loss, my books  “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You” and “Living Better With Hearing Loss” are available at


This post was first published in a slightly different form on AARP Health on April 7, 2017.

How’s Your Hearing? Maybe Not as Good as You Think.

Undetected Hearing Loss
Getty  Images/Canopy

If you think your hearing is fine, a new report from the Centers for Disease Control and Prevention (CDC) should make you think again. One in 4 people ages 20 to 69 who reported that their hearing was good to excellent were found to have hearing damage.

This kind of “hidden hearing loss” doesn’t show up on standard hearing tests but can make it difficult to impossible to hear conversation in a noisy setting.

The CDC analyzed more than 3,500 hearing tests conducted by the National Health and Nutrition Examination Survey (NNANES) in 2011 and 2012. It found that 20 percent of people who thought they could hear well and who said they didn’t work in a noisy environment nevertheless had hearing loss — some of them in their 20s. The type of loss they had, including a drop in the ability to hear high-pitched noise, indicated that noise damage may be to blame.

Even more surprising, more than half of the 40 million adults who have noise-related hearing damage developed it away from the workplace, from exposure to noisy rock concerts, sporting events, leaf blowers, traffic and other sources, the CDC reported.

Adding to the problem, 70 percent of people exposed to loud noise never or seldom wear hearing protection.

Although noise exposure in the workplace is well documented as a cause of hearing loss (the danger level is set at eight hours at more at 85 decibels, equivalent to the sound of heavy city traffic), the proportion of people with this kind of loss who don’t have a noisy workplace is an indication of how loud our everyday world is.

The understanding that some hearing loss is hidden and  doesn’t show up on standard hearing tests is relatively recent, the Associated Press recently reported. The loss, Harvard otolaryngology researcher M. Charles Liberman explained, may be caused by loud noise that damages the connections between hair cells in the inner ear and the nerves that carry the hearing signal to the brain.

You can test how well you understand speech in a noisy environment using a special online exercise prepared for the Associated Press in conjunction with the Mailman Center for Child Development at the University of Miami.

To take the test, click here. You will be asked to repeat a series of sentences. The exercise begins in quiet, but then slowly introduces background noise. The noise comes in six levels, faint at first but eventually louder than the words. People with hearing loss will start to have some trouble understanding the words at the second or third level, the AP reported.

What both the CDC report and the recent research into hidden hearing loss indicate is that people need to be aware of the noise they are exposing themselves to, and wear earplugs or noise-canceling headphones to protect their hearing. Keep the volume down, whether it’s while watching TV or listening to music or other programs through earbuds. The Hearing Loss Association of America offers more information on the CDC report, on its website. You can also go to the CDC website.

Hearing loss is no mere nuisance. As the CDC report noted, “Continual exposure to noise can cause stress, anxiety, depression, high blood pressure, heart disease, and many other health problems.”

Update (May 9, 2017): For more on this, read the May issue of Hearing Journal: Noise-Induced Hearing Loss: What Your Patients Don’t Know Can Hurt Them. 


This post first appeared on AARP Health on March 22, 2017.

Consumer Reports Rates PSAP’s

Bouton Blog - Consumer Reports
CR looked at hearing devices called PSAP’s – Istock

The February issue of Consumer Reports  magazine took an in-depth look at hearing loss and the hearing aid industry, as well as at the newest “hearing helpers” — less expensive, over-the-counter devices that may help some people with mild to moderate hearing problems.

Titled “No More Suffering in Silence?,” the report included the results of a fall 2015 survey of more than 131,000 of CR‘s subscribers. Nearly half reported they had trouble hearing in noisy environments, yet only 25 percent had had their hearing checked in the past year.

This isn’t surprising, as anyone who follows the hearing-healthcare business knows. The National Institute on Deafness and Other Communication Disorders (NIDCD) reports that among adults 20 to 69, only 16 percent of those who could benefit from a hearing aid has one.

Consumer Reports, however, with a subscription base of 7 million, reaches far more people than an NIDCD statistic does. When CR tells its readers about the dangers of untreated hearing loss, it is sending a message to millions who might not otherwise hear it.

The Consumer Reports article begins with an overview of hearing loss, noting the recent changes in understanding of the consequences of hearing loss. Once dismissed as “part of getting older” or a “nuisance,” we now know that untreated hearing loss is a “significant national health concern, one that’s associated with other serious health problems, including depression and a decline in memory and concentration. Several studies even suggest a link between hearing loss and dementia,” the article says.

Cost could be a big reason for this, the magazine notes. The National Academy of Sciences reports that hearing aids cost an average $4,700 per pair in 2013 and can climb to almost twice that price. Plus, hearing aids are usually not covered by health insurance or Medicare.

This is where OTC hearing helpers — also called PSAP’s, for personal sound amplification products — come in. They cost a fraction of the price of an average hearing aid. But do they really work?

The magazine had three of its employees with mild to moderate hearing loss try four devices priced from $20 to $350, wearing them for three to seven days to see how well they could help with hearing in a noisy environment. CR‘s audio labs also tested the devices for amplification, batteries, microphone function and sound distortion.

The most important finding: Pinching pennies can hurt you. The two lowest-priced devices — the Bell & Howell Silver Sonic XL ($20) and the MSA 30X ($30) – were found not only inadequate, but also potentially dangerous. Both overamplified sharp noises, like a siren, to the point where hearing damage could occur.

A hearing-aid researcher who assessed the devices recommended avoiding those under $50. “They don’t seem to help much, if at all, and could actually further diminish your ability to hear,” the magazine reported.

The two PSAPs that fared better were the SoundWorld Solutions C550+ ($350) and the Etymotic Bean ($214 each, $399 for a pair). CR reported on the pros and cons of each device, offering overall “device advice” for each one.

In general, The C55+ and the Bean seem useful for people with mild to moderate loss. The Bean was found to be especially helpful for those with hearing loss in the higher frequencies rather than the lower. For complete details, click here.

If your hearing loss is serious enough to warrant a hearing aid (and much hearing loss is, so have your hearing checked by an audiologist first), the article offered some suggestions for ways to pay less. I’ll write about these in my next post.


A version of this post first appeared on AARP Health on March 6, 2017.

Good News About Hearing Loss, With Qualifications

Hearing loss is declining, according to a study published on December 15 by researchers at Johns Hopkins School of Medicine.

At the top of Mt. Etna, April 2016, with Damian Croft of What does this have to do with hearing loss? Nothing! It’s a New Year’s treat.

This is good news.

But before you put back in those earbuds and conclude that all those reports of an “epidemic” of hearing loss were wildly exaggerated, read a little closer.

The study of almost 4000 adults 20 to 69 years old found that the overall prevalence of hearing loss (as measured in the speech frequencies) dropped from 16 to 14 percent in the years between 1999-2004 and 2011-12.  (Among adults 60 to 69, however, a whopping 39.3 percent still had hearing loss.)

The decline among working age adults was slight but statistically significant. Despite the fact that there was a greater number of older adults, “the estimated number of adults aged 20 to 69 years with hearing loss declined absolutely, from an estimate of 28.0 million in the 1999-2004 cycles to 27.7 million in the 2011-2012 cycle.”

“Our findings show a promising trend of better hearing among adults that spans more than half a century,” said Howard J. Hoffman, M.A., first author on the paper and director of the NIDCD’s Epidemiology and Statistics Program. “The decline in hearing loss rates among adults under age 70 suggests that age-related hearing loss may be delayed until later in life.”

The researchers attributed the decline to a decrease in noisy manufacturing jobs, to increased use of hearing protection (OSHA requirements for hearing protection have helped), to a drop in smoking and to better medical care.

A greater awareness of the dangers of noise may also have helped. It’s no longer unusual to see someone at a sporting event or loud concert wearing protective headphones. It’s the norm for people with ride-on lawn mowers or those doing other kinds of noisy yard work to wear headphones.

But before we celebrate and abandon advocacy for equal access for people with hearing loss, remember that the age group studied is getting older every day. In the coming years we can expect that normal age-related hearing loss will have its usual effects. “Despite the benefit of delayed onset of HI,” the paper concluded, “hearing health care needs will increase as the US population grows and ages.”

We’re still going to need cheaper and more accessible hearing aids. We’re still going to have to defeat the stigma of hearing loss so that people will wear those hearing aids – and help offset or prevent the negative health effects of untreated hearing loss.

We’re making progress against hearing loss, and that’s cause for celebration. But don’t give up the good habits that have allowed us to get to this point. The world is still noisy. We still need to protect our ears. There is still a lot of hearing loss. We need to treat it.


This post appeared in a slightly different form on AARP Health on Dec. 22, 2016.

What Do Consumers Want? Try Asking a Consumer.

If you asked consumers what is most important when buying a hearing aid, would they say price or sound quality?

Hearing Tracker, a respected independent online resource for consumers, and USB Evidence Labs recently surveyed more than 360 audiologists about what brands and features consumers ask for most when buying a hearing aid.

Not surprisingly, sound quality came in first by a long shot (56 percent), with reliability a distant second (17 percent) and value for money in third place (12 percent).

I don’t doubt that is exactly what the audiologists’ customers said they wanted. But I also wonder if the answers would have been different if consumers, especially those who never go to an audiologist, had been asked directly. I expect those consumers would say an affordable price was their top priority.

Currently, only 1 in 7 U.S. adults who can benefit from a hearing aid have one. Why don’t the other six?

The answer is cost. “Hearing aids are expensive,” Jan Blustein and Barbara Weinstein wrote in a June 2016 article in the American Journal of Public Health. Medicare and most insurance plans don’t cover them, and so consumers typically pay for aids and fittings out of pocket. And that can get costly. The average cost of a single hearing aid is $2,300, but because age-related hearing loss typically affects both ears, that’s a tidy $4,600 — a sum beyond the reach of many older people. Blustein and Weinstein note that “in a recent population-based prospective study, a majority of participants cited cost as a major deterrent to buying a hearing aid.”

Kim Cavitt, a past president of the Academy of Doctors of Audiology, says audiologists have turned a blind eye to consumer wants. In a recent article headlined “Have We Missed the Signs?” in Hearing Health and Technology Matters, she wrote that consumers “for the past decade have been clamoring for lower-cost amplification solutions,” meaning more affordable hearing aids or hearing aid–like devices.

The devices she refers to are lower-cost products that can effectively help with mild to moderate hearing loss. These won’t replace traditional hearing aids, she wrote but will expand the market by providing a gateway to more advanced traditional hearing aids.

She also noted that consumers want transparent pricing from audiologists — including detailed pricing of various goods and services — and access to assistive listening devices and aural rehabilitation. But mostly, consumers want hearing amplification they can afford.

This month, responding to that consumer demand, Senators Elizabeth Warren (D-Mass.) and Chuck Grassley (R-Iowa) introduced a bill to ease restrictions for getting hearing aids, including eliminating a required medical exam for many devices. The bill was supported by a number of organizations, including AARP and the Hearing Loss Association of America (HLAA), the nation’s largest consumer group representing people with hearing loss.

The legislation preceded an announcement from the Food and Drug Administration that it will no longer require adults to get a medical exam before purchasing certain hearing aids, clearing the way for a new category of over-the-counter devices.

Barbara Kelley, the executive director of the HLAA, endorses both developments.

“Each and every day,” she wrote, “our office receives letters, phone calls and emails from people with hearing loss inquiring about financial assistance to purchase hearing aids (up to 10 requests a day). The financial help page on is the number one visited page on HLAA’s website. Sadly, there are few financial aid resources. Creating a category of over-the-counter hearing aids will go a long way toward making these essential devices affordable for the millions of Americans who need them.”

Cavitt agrees, although she isn’t by any means discounting the need for audiologists. People with serious hearing loss will always need audiologists and the services that only they can offer, she says.

For now, though, the goal should be finding an easier, financially feasible way to get the remaining 6 out of 7 Americans with hearing loss the devices they need.


This post was first published on AARP Heath on December 19, 2016.

For more on hearing loss and hearing health:

shoutingwonthelpLiving Better jpegKatherine 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