“Can you repeat that?”: Hearing loss in the elderly
Myron Yaster MD and Lynne G. Maxwell MD
OK, I know today’s PAAD on hearing loss in the elderly may appear to be far afield from our regularly reviewed articles, but if you bear with me, you’ll see why this is important. First, a true story that I know sounds like I am telling a joke…but it really did happen. Last year, my primary care doctor as part of my wellness care, set up appointments for me to have my vision and hearing tested. And yes, my wife Pam who was with me, had concerns about my hearing. So, even though I didn’t think I needed it, I went to an audiologist. You know the drill: I went into the sound proof room, had full over the ear headphones, and had my hearing tested for probably the first time since elementary school. At the conclusion of the test, the audiologist came into the room and asked: “Do you want the good news or the bad news?” I said “of course, give me the good news first”. The audiologist said: ”the good news is that you have almost perfect hearing.” I’m thinking what could be the bad news? The audiologist then said: “the bad news is that your wife is right…you’re not listening!”
When I saw today’s PAAD by FR Lin1 in the New England J of Medicine on hearing loss in the elderly, I thought many of you of a certain age may be interested. And many of you who work with older anesthesiologists may be interested in this as well. Hearing is an important part of wellness. Indeed, as a good friend and former colleague, Dr. Jackie Martin, always liked to stress is that we call it health care but in reality it’s sickness care. We need to do more proactively to keep ourselves and our patients healthy with simple things like routine checkups, dental, vision, and hearing testing.
My (LGM) personal experience with this issue started around six years ago when I felt that I was having trouble hearing breath and heart sounds during auscultation of the patient in a noisy operating room environment: suction, bovie, surgeon’s head banger metal music, loud conversations, anesthesia machine and monitoring, etc. A friend with hearing loss recommended an audiology evaluation and I went through the process just described by Myron. The audiologist told me that I had some moderate hearing loss that would be exacerbated in noisy environments. While it is reasonable to ask for quiet during induction and emergence, asking for silence throughout the case is not practical (and the suction and bovie don’t care). The audiologist recommended that I get an amplified stethoscope. I was reminded of my time in medical school at Johns Hopkins where I learned that the legendary Helen Taussig accommodation to deafness. “At age thirty-one, she started to go deaf and by age thirty-five was using a hearing aid and an amplified stethoscope. She was able to compensate for the loss of her hearing through the use of her hands for palpation of patients’ chests” (unfortunately a lost art). Technology has improved since the era of Dr. Taussig (she retired in 1963, but continued seeing patients and teaching in the clinic until 1977) and I found that the use of an amplified stethoscope (there are many available but the one I have is made by Eko), greatly improved my ability to hear heart and breath sounds in a noisy OR. However, that improvement demonstrated to me that there were other sounds that I was missing, both in the OR environment (surgeon asking me a unexpected question in a conversational voice), and conversation around a table in a noisy restaurant. So back I went to the audiologist and my hearing in all settings has been greatly improved by my use of hearing aids.
In reviewing today’s article, I (MY) also found several papers on the effects of noise and efforts to reduce noise in the pediatric operating rooms.2,3 I’ve just finished reviewing these article and will post as a PAAD next week. Myron Yaster MD
Original article
Lin FR. Age-Related Hearing Loss. N Engl J Med. 2024 Apr 25;390(16):1505-1512. doi: 10.1056/NEJMcp2306778. PMID: 38657246.
“Age-related hearing loss is characterized by the progressive loss of the sensory hair cells of the inner ear, which are responsible for encoding sound into neural signals. Unlike other cells throughout the body, sensory hair cells in the inner ear cannot regenerate, and these cells are progressively lost over the course of life owing to the cumulative effects of multiple etiologic processes. The strongest risk factors for age-related hearing loss include older age, lighter skin color as an indicator of cochlear pigmentation (given that melanin is protective in the cochlea), male sex, and noise exposure. Other risk factors include cardiovascular disease risk factors such as diabetes, smoking, and hypertension, which can contribute to microvascular injury to cochlear blood vessels. Beginning in early adulthood, hearing begins to diminish gradually, particularly with regard to sounds at higher frequencies. The prevalence of clinically significant hearing loss increases across the life span, nearly doubling with every decade of life such that more than two thirds of all adults 60 years of age or older have some form of clinically significant hearing loss. ”1
Why should we care? Epidemiologic data have shown associations between hearing loss and impaired communication, cognitive decline and most ominously with dementia.4
“The primary clinical rationale for addressing age-related hearing loss is to enhance a person’s access to speech and other sounds in the auditory environment (e.g., music and audible alerts…think pulse oximetry and various other alarms) in order to promote effective communication, engagement with daily activities, and safety. At present, there are no restorative therapies for age-related hearing loss, and management of the condition is focused on hearing protection, adoption of communication strategies to optimize the quality of the incoming auditory signal (over competing background noise), and the use of hearing technologies such as hearing aids and cochlear implants.”1
Noise reduction in the OR, procedure, and diagnostic imaging suites is increasingly becoming important to all of us, not only the elderly, particularly on induction and emergence (takeoff and landing).2,3 “Noise levels found in the operating room (OR) can hinder staff communication, create distractions during critical periods, adversely affect complex tasks, cause adverse physiological changes, cause the masking phenomenon, and negatively affect anesthesiologist’s mental efficiency and capability to distinguish changes in the pitch of a pulse oximeter.”2 How much more of an issue is this if one’s hearing is already impaired?
Finally, hearing aids are the primary method of treating hearing loss in the elderly. “Beginning on October 17, 2022, the Food and Drug Administration enacted new regulations allowing for the sale of over-the-counter hearing aids that would be available to consumers, without a hearing professional as an intermediary.5 These over-the-counter hearing aids are intended for adults with perceived mild-to-moderate levels of hearing loss with PTA4 values generally less than 60 dB, which encompasses 90 to 95% of all persons with hearing loss. Indeed, ear bud and hearing aid technology are merging and may be indistinguishable in the next couple of years.
I (MY) am unsure of how I can improve my ability to listen to Pam, but actual hearing loss is an expected life event that although not curable is definitely fixable. I would urge all of you to get your hearing tested and for God’s sake, overcome vanity and wear a hearing aid if you need it.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Lin FR. Age-Related Hearing Loss. The New England journal of medicine 2024;390(16):1505-1512. (In eng). DOI: 10.1056/NEJMcp2306778.
2. Crockett CJ, Nylander VE, Wooten EJ, Menser CC. The emergence noise reduction quality improvement initiative to enhance patient safety and quality of care. Paediatric anaesthesia 2022;32(11):1262-1269. (In eng). DOI: 10.1111/pan.14553.
3. Drzymalski DM, Camann WR. Noise reduction in the operating room: another leadership opportunity for anesthesiologists? Int J Obstet Anesth 2022;49:103231. (In eng). DOI: 10.1016/j.ijoa.2021.103231.
4. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet (London, England) 2020;396(10248):413-446. (In eng). DOI: 10.1016/s0140-6736(20)30367-6.
5. Lin FR, Chadha S. Over-the-Counter Hearing Aids - Using Regulatory Policy to Improve Public Health. The New England journal of medicine 2023;388(23):2117-2119. (In eng). DOI: 10.1056/NEJMp2302355.