PRACTICE RECOMMENDATIONS
•Ensure that all the infants you care for underwent hearing screening shortly after birth and that those who tested positive are retested in ≤3 months. B
•Evaluate elderly patients for hearing loss during their initial visit and annually thereafter. A
•Speak clearly, maintain eye contact, and use nonverbal gestures when communicating with patients with hearing loss. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Hearing impairment is a widespread problem, affecting approximately 36 million US adults1 and an increasing number of children.2 Yet it often goes undetected. The consequences of untreated or undertreated hearing loss can be severe.
Adverse effects are often age-dependent: In children, hearing loss is associated with a broad range of complications, including delays in language development, decreased reading comprehension, and poor academic performance, as well as social and emotional problems.2,3 In adults—particularly the elderly—hearing impairment can lead to social isolation, depression, and a diminished quality of life.4,5
Early detection and treatment can do much to alleviate these adverse effects. But many physicians received little training in the identification and treatment of hearing loss in medical school. What’s more, people with significant hearing loss tend to have fewer interactions with health care providers than their counterparts with no hearing impairment6—a finding that some attribute to fear, mistrust, and frustration.7
Physician awareness of the problems facing people with hearing loss, the importance of screening, and the need to improve communication with hearing-impaired patients (TABLE 1)8 can help change that. The strategies presented here were developed with this in mind.
TABLE 1
How to better communicate with patients who have hearing loss8
| Maintain eye contact and avoid covering your lips while speaking; avoid shouting |
| Use gestures and other nonverbal cues |
| Draw diagrams or use pictures to make a point |
| Reduce background noise (eg, by closing a door or finding a quiet corner) |
| Use the “teach-back” method to ensure understanding |
| Use sign language or provide a sign language interpreter or an oral transliterator* |
| *Ask whether the patient is comfortable with sign language or oral transliteration, which is sometimes used to facilitate oral communication with people who have hearing loss. |
The scope of hearing loss across the lifespan
Hearing loss affects 1 to 3 in every 1000 newborns.9 The prevalence increases to 2% among 5-year-olds, and to 10% to 20% by age 18.10,11 The risk accelerates in “early older life” (defined as ages 50-69 years), with men affected more often than women.12 Hearing loss is the fourth most common chronic condition among older adults, and it is estimated that ≥70% of nursing home residents have some degree of impairment.13
Hearing loss can be categorized as mild (a loss of 20-40 decibels [dB]), moderate (41-55 dB loss), moderate to severe (56-70 dB loss), severe (71-90 dB loss), or profound (>91 dB loss), but any degree of hearing loss should be considered noteworthy.
In children, the impact of mild impairment is often minimized by both professionals and parents, especially among those whose speech developed normally. Unfortunately, the failure to respond appropriately in such cases often increases the adverse effects of the hearing loss.14
In adults, even mild to moderate impairment can lead to significant functional impairment and, therefore, a decreased quality of life.5 And in elderly patients, any undetected hearing loss can adversely affect their performance on cognitive tests, leading to an incorrect diagnosis of cognitive impairment. Elderly patients often minimize hearing deficits, and many believe—incorrectly—that hearing loss due to aging is not amenable to treatment.15
Hearing loss in children may be congenital or acquired
In children, hearing loss can be divided into 2 main categories: congenital and acquired. Congenital etiologies include genetic diseases such as Down syndrome, Usher syndrome, and Alport syndrome—thought to account for 50% of pediatric hearing loss—and intrauterine infections. Causes of acquired hearing loss include recurrent otitis media—most common among infants and young children—and environmental noise (TABLE 2).16-18
TABLE 2
Common causes of hearing loss16-18
| Newborns, children, and adolescents |
|---|
| Childhood infection (eg, measles, mumps, meningitis) |
| Genetic syndrome (eg, Down syndrome, Usher syndrome, Alport syndrome) |
| Head trauma |
| In utero infection (eg, toxoplasmosis, rubella, HSV, CMV, syphilis) |
| Noise exposure |
| Otitis media (recurrent) |
| Ototoxic medication* |
| Premature delivery |
| Adults and the elderly |
| Acoustic neuroma |
| Head trauma |
| Impacted cerumen |
| Noise exposure |
| Otitis media (recurrent) |
| Otosclerosis |
| Ototoxic medication* |
| Presbycusis |
| *Includes aminoglycosides, cisplatin, and loop diuretics, among others. CMV, cytomegalovirus; HSV, herpes simplex virus. |
Adolescents and young adults often expose themselves to loud noises from personal electronic devices, and the use of hearing protection in this population is low.19 The results of one small study suggest that almost a third of adolescents regularly use the highest volume on their iPods or MP3 players, which can cause hearing damage over time.20 Noise levels at which hearing loss occurs can be found at http://www.cdc.gov/niosh/topics/noise/noisemeter.html.21 It is important for adolescents as well as adults to be aware of the risk of hearing loss from repeated exposure to loud noise, but evidence suggests that education about this danger is more likely to lead to behavior change in working-age adults than in teens.22