Draft Recommendation Statement
Hearing Loss in Older Adults: Screening
September 08, 2020
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
- Update in Progress for Hearing Loss in Older Adults: Screening
|Older adults||The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults. See the "Practice Considerations" section for additional information regarding the I statement.||I|
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Age-related sensorineural hearing loss is a common health problem among adults. Nearly 16% of U.S. adults age 18 years or older report difficulty hearing.1 The prevalence of perceived hearing loss increases with age, with 43% of adults age 70 years or older reporting hearing loss compared with 19% and 5.5% of adults ages 40 to 69 years and 18 to 39 years, respectively.2
Hearing loss can negatively affect an individual’s quality of life and ability to function independently. Persons with hearing loss may have difficulty with speech discrimination and localization of sounds. It has been shown to be associated with increased social isolation, which can increase the risk of cognitive decline.3
Because of a lack of evidence, the USPSTF concludes that the benefits and harms of screening for hearing loss in asymptomatic older adults are uncertain and that the balance of benefits and harms cannot be determined (Table). More research is needed.
For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4
Patient Population Under Consideration
This recommendation applies to asymptomatic adults age 50 years or older with age-related hearing loss. It does not apply to adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.
Definition of Hearing Loss
The normal human ear can process sound frequencies from 20 to 20,000 Hz, with 500 to 4,000 Hz being the most important range for speech processing.5 There is no universally accepted definition for hearing loss as frequency and intensity (as measured in decibels) thresholds vary depending on the reference criteria used. However, many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB.6
Pure-tone audiogram is the most standard method for quantitative measurements of hearing; however, it is not always correlated with reported symptoms of hearing loss. There is often discordance between objectively measured deficits in hearing on pure-tone audiogram and subjective perceptions of hearing problems.7 In one study, 1 in 5 persons who report hearing loss had a normal hearing test, while 6% of those with severe hearing loss detected on audiogram did not report feeling that they had hearing loss.8
Assessment of Risk
Increasing age 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.
Clinical tests to assess for potential hearing loss include the whispered voice, finger rub, and watch tick tests. Perceived hearing loss can also be assessed by single-question screening (asking “Do you have difficulty with your hearing?”) or longer patient questionnaires such as the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) questionnaire.9 Technology such as the AudioScope® (Welch Allyn, Skaneateles Falls, NY), a handheld otoscope with a built-in screening audiometer, or tablet-based audiogram apps can also be used.10 Diagnostic confirmation of a positive screen is typically performed with pure-tone audiogram. The finding of objective hearing loss indicates eligibility for an assistive hearing device but may not identify persons who will find the devices helpful and use them.
Treatment or Interventions
Persons with mild or moderate sensorineural hearing loss are primarily managed with hearing aids. For persons with severe or profound hearing loss, cochlear implants and alternative communication techniques (i.e., active listening training, speech reading) are potential treatment options.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
If left uncorrected, hearing loss can lead to significant burden for patients, family members, and society. As persons age, moderate to severe hearing loss is associated with significantly higher impairment in instrumental activities of daily living (IADLs), such as driving and managing medications or finances, as well as impairment in basic activities of daily living (ADLs) such as ambulation, bathing, and toileting.11
Hearing loss is also associated with other adverse social and health outcomes, including social isolation, depression, and dementia.3 Some evidence suggests that hearing loss is also associated with increased hospitalizations and higher rates of mortality.12-14
As screening and confirmatory testing for hearing impairment are noninvasive and serious harms of treatment are rare, there are likely little to no adverse effects of screening for hearing loss. Potential harms include anxiety, labeling, and stigma as well as middle and outer ear conditions (i.e., otitis externa, cerumen impaction) associated with hearing aid use.
Accurate estimates of screening rates for hearing loss in adult primary care are not available. Older surveys indicate that primary care clinicians generally agreed that hearing loss negatively affects their patients, but reported low screening rates.15 Clinicians have reported barriers to screening and treatment of hearing loss, including issues such as lack of knowledge, poor perception of audiology services, lack of time, and lack of reimbursement.15-17 Among persons seeking treatment for hearing loss, barriers to receiving care include a lack of awareness of hearing loss; confusion about options for accessing hearing-related care (e.g., primary care assessment, audiology evaluation, or over-the-counter device); and decision making related to treatment options, preferences, and cost.18 Additionally, dissatisfaction or difficulties with using hearing aids may factor into the perceived effectiveness of these devices.18 In one large study of veterans eligible to receive free hearing aids, only 10% of all participants reported using devices after one year. In the same study, among those without self-perceived hearing loss but with hearing loss diagnosed by audiogram, hearing aid use was 0% to 1.6%.19,20 These factors may limit the effectiveness of screening and treatment for hearing loss.18
The benefit of earlier hearing aid use among persons with screen-detected mild hearing loss (with no or little perceived hearing-related functional impairment) is not clear. There is no standard of care or guideline consensus on when hearing aids are recommended, and early use of hearing aids does not prevent or delay further decline in age-related hearing loss.21,22
Scope of Review
The USPSTF commissioned a systematic review6 to update its 2012 recommendation on screening for hearing loss in adults age 50 years or older. The scope of this review is similar to that of the prior systematic review.24
Accuracy of Screening Tests and Risk Assessment
Thirty-three studies (six good-quality and 27 fair-quality) evaluated the diagnostic accuracy of various screening modalities compared with pure-tone audiogram for the detection of hearing impairment in older adults.6 Nine studies evaluated a clinical test (e.g., whispered voice, finger rub), 13 studies evaluated asking a single question, 11 studies evaluated a hearing questionnaire (e.g., HHIE-S), and 10 studies evaluated a handheld or mobile-based audiometric device. Many studies assessed multiple screening tools.6 Most studies included community-dwelling older adults enrolled from outpatient clinical or community settings, although four studies included adults in chronic care/rehabilitation facilities. Among the studies that reported age, the median age of study participants was 69 years.6 Few studies provided racial, ethnic, or socioeconomic data on participants.
Many studies reported on the accuracy of screening tests to detect hearing loss defined by multiple thresholds (e.g., >25 dB, >40 dB) averaged over different frequencies; however, studies used slightly different thresholds and criteria (e.g., whether one or both ears were affected) to define hearing impairment.6 In general, studies considered hearing loss of 25 to 30 dB as mild hearing loss and loss of 35 to 40 dB as moderate hearing loss.
Thirteen studies assessed the accuracy of single-question screening for detecting hearing loss.6 For detecting mild hearing loss, the pooled sensitivity and specificity was 66% and 76%, respectively (k=10; n=12,637).6 For moderate hearing loss, the pooled sensitivity and specificity was 80% and 74% (k=6; n=8,774) respectively.
Eleven studies assessed the accuracy of screening questionnaires, eight of which assessed the accuracy of the HHIE-S.6 Too few studies reported data to pool accuracy of the HHIE-S for detecting mild hearing loss. Across four studies (n=7,194), sensitivity of HHIE-S ranged from 34% to 58%, and specificity ranged from 76% to 95%.6 For detecting moderate hearing loss, the pooled sensitivity of HHIE-S (k=5; n= 2820) was 68% and pooled specificity was 78%.6 The Hearing Self-Assessment Questionnaire (HSAQ) and the Revised Five-Minute Hearing Test (RFMHT) were evaluated in one study each. For detecting mild hearing loss, the HSAQ had a sensitivity of 89% to 76% and specificity of 84% to 96%, based on two standard cut-offs. The sensitivity and specificity of the RFMHT for detecting mild hearing loss was 80% and 55%, respectively.6
The diagnostic accuracy of clinical tests (i.e. whispered voice, watch tick, or finger rub) were evaluated in nine studies.6 Six of these assessed the accuracy of the whispered voice test at 6 inches, 2 feet, or both. For detecting mild hearing loss, the pooled sensitivity and specificity of the whispered voice test was 94% and 87%, respectively. Sensitivity for detecting at least moderate hearing loss, defined as more than 40 dB, ranged from 30% to 60%, and specificity ranged from 80% to 98%.6 One study of whispered voice test accuracy found difference based on practitioner experience.6 Other clinical tests, such as the finger rub and watch tick tests, were evaluated in few studies. In general, for both mild and moderate hearing loss, these tests had low sensitivity and high specificity.6
Ten studies evaluated the accuracy of various handheld audiometric screening devices.6 Two studies assessed the accuracy of the AudioScope to detect mild (>25 to >30 dB) hearing loss and four studies assessed the accuracy for detecting moderate (>40 dB) hearing loss. For mild hearing loss, sensitivity ranged from 64% to 93% and specificity ranged from 70% to 91%. There was relatively high sensitivity (range, 94% to 100%) for detecting moderate hearing loss, although variable specificity (range, 24% to 80%). Four studies assessed tablet-based audiogram apps designed for screening, although only one, the uHear™ app, was reviewed in more than one study. It reported sensitivity between 68% and 100% and specificity between 87% and 89% for detecting moderate hearing loss (>40 dB).6
Benefits of Early Detection and Treatment
Direct evidence of the effect of screening for hearing loss on clinical outcomes is limited. Only one fair-quality randomized, controlled trial examined the effect of screening on health outcomes. The Screening for Auditory Impairment–Which Hearing Assessment Test (SAI-WHAT) trial (n=2,305) randomly assigned predominately male veterans age 50 years or older to hearing loss screening with the AudioScope, HHIE-S questionnaire, or combined screening vs. a control group of no screening.19,20 The primary outcome was hearing aid use 1 year after screening. Included participants were predominantly male (94%), age 50 years or older (mean, 61 years), and recruited from a Veterans Affairs medical center. Three-fourths reported self-perceived hearing loss at baseline. Overall, hearing aid use across all arms was low (<10%), but significantly higher for those screened with the AudioScope or combined screening vs. controls. Hearing aid use was very low among participants without baseline perceived hearing impairment (0% to 1.6%).19,20 A secondary outcome of the trial was the effect of hearing aid use on quality of life. No statistically significant differences in quality of life scores were observed across the study arms after 1 year; however, the trial was not powered to detect differences in hearing-related function.6 The generalizability of these results is limited, as this study was composed of relatively younger (mean age, 61 years) male veterans with a high prevalence of perceived hearing loss and who were eligible for free treatment services.
Several trials reported on hearing aid use and changes in hearing-related function measured by the HHIE-S; however, clinically meaningful improvements in the HHIE-S associated with hearing aid use were limited to studies enrolling veterans who generally had greater baseline hearing impairment.6 Four studies reported on general quality of life or function and other non-hearing–related health outcomes; of these, only one study found significant benefit in favor of the intervention on the Short Portable Mental Status Questionnaire and the Geriatric Depression Scale. No study examined the effect of interventions on the incidence of dementia or neurocognitive impairment.6 Overall, the population of white male veterans and higher prevalence of moderate hearing loss at study entry limits the generalizability of these findings.
Harms of Screening and Treatment
No randomized trials or controlled observational studies evaluated potential adverse effects associated with screening or treatment of hearing impairment using hearing aids.6 Potential harms include false-positive results that lead to unnecessary testing, treatment, or both; labeling; and anxiety. Harms related to treatment are thought to be minimal; however, potential harms of treatment include further hearing loss related to amplification or over amplification.25 Some persons with quantitative hearing loss may not have perceived hearing loss or experience negative effects on their quality of life and may not benefit from screening or treatment. Such overdiagnosis and overtreatment could be considered a potential harm.
How Does Evidence Fit With Biological Understanding?
Although sensorineural hearing loss is a relatively common consequence of aging, it has a gradual onset, so many older adults may not recognize that they have an impairment or may not perceive their sensory deficits to be a problem. Some individuals may alter their daily activities to adapt to the loss. Additionally, some older adults may resist seeking treatment for hearing impairment or adhering to use of a hearing aid because of fear of social stigma or a feeling of loss of independence, or discomfort associated with hearing aid use.
More studies are needed that address the following areas.
- The benefit of screening and treatment of asymptomatic adults on health outcomes, such as quality of life and function, not just on hearing aid use or quality of hearing.
- The potential harms of screening and treatment, such as false-positive results and overtreatment.
- Consistent use of definitions of hearing loss to improve certainty about the accuracy of screening tests.
- The general adult population, as well as diverse subpopulations.
- The role of over-the-counter assistive hearing devices compared to prescription amplification devices.
- Screening tools that identify not just adults with hearing loss by audiogram definition criteria, but adults with unrecognized hearing loss that would benefit (the most) from amplification.
Several organizations have issued statements about screening for hearing loss in older adults. The American Academy of Family Physicians references the current (2012) USPSTF I statement for hearing loss screening in asymptomatic adults age 50 years or older.26 The U.K. National Screening Committee does not recommend a national screening program for hearing loss in adults age 50 years or older.27 The American Speech-Language-Hearing Association recommends that adults be screened by an audiologist once per decade and every 3 years after age 50 years or more frequently in those with known exposures or risk factors associated with hearing loss.28 The American Geriatrics Society recommends annual screening for hearing loss for all adults age 65 years or older.29
1. QuickStats: percentage of adults aged ≥18 years with any hearing loss, by state - National Health Interview Survey, 2014-2016. MMWR Morb Mortal Wkly Rep. 2017;66(50):1389.
2. Zelaya CE, Lucas JW, Hoffman HJ. Self-reported hearing trouble in adults aged 18 and over: United States, 2014. NCHS Data Brief. 2015(214):1-8.
3. Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA. Association of age-related hearing loss with cognitive function, cognitive impairment, and dementia: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;144(2):115-126.
4. U.S. Preventive Services Task Force. Procedure manual. 2018. https://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Accessed August 19, 2020.
5. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA. 2003;289(15):1976-1985.
6. Feltner CW, Wallace I, Kistler C, Coker-Schwimmer M, Jonas DE, Middleton JC. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 200. AHRQ Publication No. 20-05269-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2020.
7. Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. 1983;25(7):37-42.
8. Gates GA, Cooper JC Jr., Kannel WB, Miller NJ. Hearing in the elderly: the Framingham cohort, 1983-1985. Part I. Basic audiometric test results. Ear Hear. 1990;11(4):247-256.
9. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA. 1988;259(19):2875-2878.
10. Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA. 2006;295(4):416-428.
11. Chen DS, Betz J, Yaffe K, et al. Association of hearing impairment with declines in physical functioning and the risk of disability in older adults. J Gerontol A Biol Sci Med Sci. 2015;70(5):654-661.
12. Genther DJ, Frick KD, Chen D, Betz J, Lin FR. Association of hearing loss with hospitalization and burden of disease in older adults. JAMA. 2013;309(22):2322-2324.
13. Genther DJ, Betz J, Pratt S, et al. Association between hearing impairment and risk of hospitalization in older adults. J Am Geriatr Soc. 2015;63(6):1146-1152.
14. Genther DJ, Betz J, Pratt S, et al. Association of hearing impairment and mortality in older adults. J Gerontol A Biol Sci Med Sci. 2015;70(1):85-90.
15. Johnson CE, Danhauer JL, Koch LL, Celani KE, Lopez IP, Williams VA. Hearing and balance screening and referrals for Medicare patients: a national survey of primary care physicians. J Am Acad Audiol. 2008;19(2):171-190.
16. Danhauer JL, Celani KE, Johnson CE. Use of a hearing and balance screening survey with local primary care physicians. Am J Audiol. 2008;17(1):3-13.
17. Cohen SM, Labadie RF, Haynes DS. Primary care approach to hearing loss: the hidden disability. Ear Nose Throat J. 2005;84(1):26, 29-31, 44.
18. Contrera KJ, Wallhagen MI, Mamo SK, Oh ES, Lin FR. Hearing loss health care for older adults. J Am Board Fam Med. 2016;29(3):394-403.
19. Yueh B, Collins MP, Souza PE, et al. Long-term effectiveness of screening for hearing loss: the Screening for Auditory Impairment--Which Hearing Assessment Test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2010;58(3):427-434.
20. Yueh B, Collins MP, Souza PE, et al. Screening for Auditory Impairment-Which Hearing Assessment Test (SAI-WHAT): RCT design and baseline characteristics. Contemp Clin Trials. 2007;28(3):303-315.
21. U.S. Department of Veterans Affairs. Prescribing hearing aids and eyeglasses. VHA Directive 2008-070. Washington, DC: U.S. Department of Veterans Affairs; October 28, 2008.
22. National Institute for Health and Care Excellence (NICE). Hearing loss in adults: assessment and management. 2018. https://www.nice.org.uk/guidance/ng98/chapter/Recommendations. Assessed August 19, 2020.
23. Moyer VA. Screening for hearing loss in older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(9):655-661.
24. Chou R, Dana T, Bougatsos C, Fleming C, Beil T. Screening adults aged 50 years or older for hearing loss: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;154(5):347-355.
25. American Academy of Audiology; Academy of Doctors of Audiology; American Speech-Language-Hearing Association; International Hearing Society. Regulatory Recommendations for OTC Hearing Aids: Safety and Effectiveness. 2018. https://www.asha.org/uploadedFiles/Consensus-Paper-From-Hearing-Care-Associations.pdf. Assessed August 19, 2020.
26. American Academy of Family Physicians. Clinical preventive service recommendation: hearing. 2012. https://www.aafp.org/patient-care/clinical-recommendations/all/hearing.html. Accessed August 19, 2020.
27. UK National Screening Committee. UK NSC hearing loss in adults recommendation. 2016. https://legacyscreening.phe.org.uk/policydb_download.php?doc=587. Accessed August 19, 2020.
28. American Speech-Language-Hearing Association. Preferred practice patterns for the profession of audiology. 2006. https://www.asha.org/policy/PP2006-00274/. Accessed August 19, 2020.
29. Yueh B, Shekelle P. Quality indicators for the care of hearing loss in vulnerable elders. J Am Geriatr Soc. 2007;55(Suppl 2):S335-339.
|Detection||Adequate evidence that screening instruments can detect hearing loss.|
|Benefits of Screening and Intervention and Treatment||
|Harms of Early Detection and Intervention and Treatment||Inadequate evidence to determine the harms of screening and treatment for hearing loss.|
|USPSTF Assessment||The evidence on screening for hearing loss is lacking and the balance of benefits and harms cannot be determined.|