Hearing loss is one of the common manifestations of physical decline in the elderly, which not only leads to auditory-verbal communication disorders, but also causes mental and psychological problems such as weakness, loneliness, suspicion, anxiety, depression and social isolation. Recent studies have found that hearing loss is also closely related to cognitive decline in the elderly, which increases the burden on families and society. As the mainland enters an aging society, it has become an urgent task to pay attention to the impact of hearing loss on the quality of life of the elderly, and to achieve early detection, early diagnosis and early intervention.
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Basic concepts
Hearing loss in the elderly refers to the general term for the decline of hearing function in the elderly over 60 years old (the World Health Organization's definition of the age of the elderly population: 65 years old is recommended in developed countries, and 60 years old is recommended in developing countries) due to factors such as aging, ear diseases, genetic factors, noise damage, ototoxic drugs, metabolic diseases and poor lifestyle habits.
Hearing loss in old age can be caused by a single factor, or it can be the result of several deafness factors acting on top of each other. This consensus focuses on the most representative hearing loss caused by aging factors (presbycusis in the traditional sense, that is, hearing loss and speech recognition ability that appear symmetrical and slowly progress with age, and high-frequency hearing is the first to be affected).
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epidemiology
According to the World Health Organization in 2018, about one-third of people over the age of 65 have moderate or higher hearing loss. In 1997, a cross-sectional epidemiological survey of 8,252 elderly people in six cities showed that the overall prevalence of hearing loss among people over 60 years old was 33.7%. Based on the data of the Second National Sample Survey of Persons with Disabilities in mainland China, the proportion of people over 60 years old with hearing disabilities is as high as 11%, and the number of people exceeds 20 million. In 2016, a survey of four provinces in mainland China found that the prevalence of hearing loss increased significantly with age, and the elderly aged 60~74 accounted for 53.65%. At the end of 2018, there were about 249.49 million people aged 60 and above in mainland China, of which about 166.58 million were ≥ 65-year-old, accounting for 11.9% of the total population. It is estimated that by 2050, the number of elderly people in China will reach 487 million, accounting for 34.9% of the total population. Accordingly, the prevention and treatment of hearing loss in the elderly population is grim and urgent.
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Harmfulness
Hearing loss in the elderly can cause a series of serious problems such as the decline of auditory-verbal communication ability and the decline of quality of life, which requires sufficient attention from the whole society and active early intervention.
1. Decreased verbal communication skills
In the early stage of hearing loss in the elderly, high-frequency hearing loss is the main manifestation, which is mainly manifested in the decline of speech recognition rate, especially in the noisy environment, which is more difficult to communicate verbally. When hearing loss affects low to medium frequencies, verbal communication is difficult even in a quiet environment. As a result, older people actively reduce their social interactions.
2. Decreased emotional and social communication skills
Elderly people have hearing loss and reduced speech recognition ability, resulting in disinterest in the things around them, and over time, they become suspicious, suspicious and inferior, and even have psychological and spiritual problems such as anxiety and depression, as well as social isolation. Studies have found that 24% of elderly patients with hearing loss have varying degrees of psychological or psychiatric abnormalities, while about 40% have tinnitus and 20% have balance disorders. As hearing loss worsens, the elderly's ability to receive and process information from the outside world weakens, leading to accelerated aging and a sharp decline in quality of life.
3. Cognitive decline
Cognitive decline is common in older people with hearing loss. The study found that the incidence of Alzheimer's disease in older adults with mild, moderate and severe hearing loss was 2, 3 and 5 times higher than that of normal hearing older adults, respectively. However, the specific relationship and mechanism between the two are not yet very clear.
4. Decreased risk aversion
Elderly patients with hearing loss have a reduced ability to perceive dangerous warning sounds in daily life (such as traffic horns, fire alarms, reminders from people around them, etc.), and at the same time, the ability to locate sound sources decreases with age, and the orientation judgment of danger warning signals will also have problems. Therefore, the safety risks posed by hearing loss in the elderly cannot be ignored.
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Clinical presentation
1. Hearing loss
Due to the interaction of multiple pathogenic factors such as aging, ear disease, and systemic diseases, different forms of hearing loss can occur in the elderly. When accompanied by external and middle ear diseases, conductive and mixed hearing loss occurs; When inner ear disorders such as sudden hearing loss and Meniere's disease occur, vertigo and varying degrees of sensorineural hearing loss can occur. Hearing loss due to age usually presents with bilateral, symmetrical, progressive sensorineural hearing loss predominantly high-frequency hearing loss. Hearing loss caused by some systemic chronic diseases can also manifest itself as high-frequency hearing loss.
2. Decreased speech recognition
Elderly patients with hearing loss often have a significant decrease in speech recognition rate, which is manifested as hearing but not hearing clearly, soft voices cannot be heard clearly, loud and noisy; At the same time, due to the decrease in the time domain information processing ability of the auditory system, the speech recognition ability will be significantly reduced in the noisy environment and fast speech speed communication scenarios.
3. Tinnitus and other clinical manifestations
Elderly patients with hearing loss are usually accompanied by tinnitus, which is mostly manifested as persistent high-profile tinnitus, which can affect sleep quality in severe cases, and there is a vicious circle of mutual influence. In addition, hearing loss is associated with an increased probability of falls in older adults. As mentioned earlier, patients often have abnormal emotions such as loneliness, anxiety, depression, and cognitive decline.
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Early detection and diagnosis
1. Early detection of hearing loss in old age
Early detection of hearing loss in the elderly is extremely important, and patients or close people should have relevant common sense for early detection and early intervention.
(1) Self-observation in daily life or daily observation by caregivers such as family members.
(2) Physician simple assessment method and questionnaire screening method: the examinee answers the hearing-related questions raised by the physician according to the experience of daily life, and the physician evaluates it; The Simplified Screening Scale for Hearing Impairment in the Elderly (HHIE⁃S) can also be used, in which the participant is asked to answer hearing-related questions within 5 minutes and judged based on the score.
(3) Simple device screening method: refers to remote hearing screening based on communication tools and digital audiometry programs. Remote hearing screening based on landlines, web software, or mobile apps has been implemented, but it is important to note that there may be discrepancies between the above screening results and real hearing.
(4) Audiometer screening method: 500, 1000, 2000, 4000 and 8000 Hz pure tone air conduction audiometry is carried out by audiological trained personnel in an acoustic insulation room or in a quiet environment, and if each frequency meets the screening standard, it will pass the hearing screening. This screening method is highly specialized and sensitive.
2. Clinical diagnosis
(1) Medical history inquiry
In the diagnosis of hearing loss in older age, a history is important and should include the following.
1. Aspects of hearing loss, predisposing factors, time and degree of occurrence, aggravating or alleviating factors, etc.
2. The impact of hearing loss on daily life.
3. Whether it is accompanied by other ear symptoms, such as tinnitus, earache, ear discharge, dizziness, etc.
4. Past medical history includes traumatic history, noise exposure history, ototoxic drug use history, chronic disease history (hypertension, diabetes, hyperlipidemia, etc.).
5. History of smoking and drinking.
6. Family history.
(2) Recommended clinical examination
1) Otology examination.
2) Basic audiological examination: a Pure tone audiometry, including the measurement of the air conduction and bone conduction hearing threshold of the conventional test frequency, it is recommended to add 3 000 and 6 000 Hz tests; b Acoustic conductance test, including tympanogram and ipsilateral and contralateral stapes muscle acoustic reflex test; c Speech audiometry is very important for the evaluation of hearing loss in the elderly, including speech recognition threshold, speech recognition rate, and speech test under noise. In patients with cognitive impairment, behavioral audiometry may be inaccurate, and the addition of electrophysiology testing is recommended.
(3) Other clinical examinations
1) Auditory function test: including auditory brainstem response (ABR), otoacoustic emission, tinnitus matching, etc., if accompanied by vertigo, vestibular function and balance function can be tested.
2) Cognitive function assessment: Commonly used cognitive assessment tools can be divided into two categories: one reflects overall cognition, such as the Brief Mental State Scale (MMSE) and the Montreal Cognitive Assessment Scale (MoCA); The other category reflects a single cognitive domain, such as the Auditory Word Learning Test (AVLT) for memory function, the Verbal Fluency Test and Boston Naming Test (BNT) for language function, and the Connected Test A and B for attentional/executive function. The assessment of cognitive function should be done by relevant professionals, and some patients have severe hearing loss, which will affect the assessment operation, and the hearing can be corrected before the assessment or the assessment tool can be changed to mainly rely on visual completion.
3) Imaging examination: Cranial MRI and temporal bone CT examination are selected according to the needs of the condition, which are mainly used for differential diagnosis and exclusion of central lesions and pontine cerebellar angle mass lesions.
and (4) the degree of hearing loss in the elderly
In 1997, the World Health Organization classified hearing loss into four grades based on the average air-conduction hearing threshold of patients with better ears, as shown in Table 1. It is worth noting that since hearing loss in the elderly is mainly due to high-frequency hearing loss, the assessment of speech recognition ability is more important than the assessment of pure tone hearing threshold.
(5) Early detection and diagnosis of hearing loss in the elderly
It is of great significance to establish a graded and popularized hearing loss assessment system for the elderly that is suitable for the grassroots level and can be popularized for early detection and early intervention (Fig. 1). The detection and screening of hearing loss in the elderly in community hospitals, and timely referral to higher-level hospitals after the discovery of problems, will be conducive to the establishment of an intervention system for elderly hearing loss.
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Preventative care
1. Promote a healthy lifestyle
Eat a reasonable diet, exercise moderately, stay away from noise, and strengthen the management of systemic chronic diseases. With the increase of age, the probability of chronic diseases in the elderly increases, and it is necessary to pay enough attention to the risk factors that accelerate hearing loss, such as hypertension, diabetes, and hyperlipidemia, and intervene in time.
2. Reduce risk factors
(1) Avoid the use of ototoxic drugs: the incidence of adverse drug reactions in the elderly is significantly higher than that in the younger population, and the risk of drug interaction increases when taking multiple drugs at the same time. Therefore, it is recommended that the elderly should consult a doctor before taking the drug, and try to avoid ototoxic drugs such as aminoglycoside antibiotics.
(2) Avoid noise damage: high-intensity, continuous noise will cause damage to the human ear, resulting in deafness, tinnitus, etc. Noise protection should be strengthened at a young age, to prevent hearing damage caused by sudden knocking, to wear hygienic PPE as needed, and to avoid recreational noise damage.
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intervene
Treatment and intervention of hearing loss in the elderly are closely related to its etiology. The treatment of the underlying disease is emphasized, and the appropriate intervention is selected according to the degree of hearing loss. In the early stage, medication and listening training are the mainstay, and hearing aids or cochlear implants are prescribed as appropriate when the results are not effective.
1. Medications
For hearing loss caused by common inner ear diseases, such as sudden deafness and Meniere's disease, relevant clinical guidelines should be referred to for targeted treatment; For patients with tinnitus, drugs can be used to reduce symptoms and improve quality of life (such as ginkgo biloba extract, etc.); For patients with vertigo, the cause should be actively investigated, and the quality of life should be improved by reducing symptoms through drugs; For older patients with hearing loss with systemic chronic diseases, the primary disease should be treated aggressively and audioprotective follow-up should be carried out; For patients with mild cognitive impairment, early use of cognitive function-improving drugs is recommended.
2. Hearing aids
Hearing aids are an effective means to help elderly people with hearing loss improve their hearing and improve auditory-verbal communication, but inappropriate use of hearing aids should be avoided without adequate medical and audiological evaluation.
The key to fitting hearing aids for seniors is to enable them to easily understand speech in different listening contexts, regain their true sense of sound, and ultimately accept and benefit from hearing aids.
(1) Indications and general principles for hearing aid fitting
1) For patients with mild or moderate hearing loss, especially those with good speech recognition rate in quiet environments, it is recommended that hearing aids be the first choice as a means of hearing compensation.
2) People with severe or very severe hearing loss should consider cochlear implantation in time when they cannot meet their basic hearing needs after wearing hearing aids. If surgery is not available for the time being, high-power hearing aids are still recommended.
3) For people with hearing loss in both ears, hearing aids are recommended for both ears.
(2) Medical evaluation and audiology evaluation before fitting
Hearing aids should be evaluated by an otolaryngologist prior to medical evaluation. Audiologic evaluations include pure-tone audiometry, conduction impedance testing, and speech audiometry, as well as discomfort threshold testing. Comprehensive analysis of the test results to determine the nature and extent of hearing loss. Older patients with hearing loss who are suspected of having cognitive or central processing impairments should be asked by a neurologist or psychiatrist for cognitive and central function testing.
(3) Hearing aid fitting process
1) Hearing aid pre-selection: Hearing loss in the elderly may continue to worsen, and there should be a certain amount of spare gain space when choosing hearing aids; For older patients with poor finger dexterity, behind-the-ear hearing aids are recommended; For people with mild or moderate hearing loss, a more comfortable "open ear" hearing aid can be used, and hard earmolds can also be made. In conclusion, elderly patients with hearing loss should try to avoid the use of customized (in-ear, in-ear, deep-canal) hearing aids.
2) Hearing aid fitting: The fitting level of hearing aids directly affects its use effect. Therefore, it is recommended that elderly patients with hearing loss go to a professional medical institution or a qualified hearing aid fitting center for fitting. By simulating daily life scenarios, the hearing care professional can adjust the hearing aid parameters according to the patient's feelings and improve the patient's adaptation to the hearing aid.
3) Post-fitting evaluation and disposal: In order to achieve satisfactory results when wearing hearing aids, the elderly should make precise fine-tuning before and after fitting and avoid excessive use of the program selection function. For those who have good learning receptivity, suitable hearing aid assistive devices can be recommended according to their needs.
4) Use and maintenance of hearing aids: Elderly patients with hearing loss and/or guardians should be carefully explained the various precautions for the use of hearing aids.
5) Follow-up follow-up: Regular follow-up visits should be carried out after hearing aid fitting to understand the use of hearing aids and the changes in the patient's hearing loss, so as to optimize and adjust the hearing aid parameters or refer to a specialist clinic for further diagnosis and treatment.
(4) Precautions for hearing aid fitting
1) In the following cases, referral should be considered first, and hearing aids should not be prescribed for the time being: a conductive hearing loss; b Sudden onset of hearing loss within 3 months; c Progressive or fluctuating hearing loss; d Accompanied by earache, otorrhoea, tinnitus, dizziness or headache; e Cerumen embolization of the external auditory canal or stenosis/atresia of the external auditory canal.
2) For elderly patients with hearing loss who have low speech recognition rate and central lesions and/or cognitive impairment, the expected value of hearing aid effect should be patiently explained.
3) Tinnitus may affect the use of hearing aids, but some patients will have varying degrees of relief of tinnitus after wearing hearing aids, so they should patiently explain to patients and suggest them to try to wear hearing aids.
4) During the use of hearing aids, if there are uncomfortable symptoms such as hearing loss and dizziness, you should be referred to a specialist for evaluation in time.
(5) For details of rehabilitation guidance, please refer to the auditory rehabilitation training section below
3. Cochlear implants
Cochlear implantation is currently the most direct and effective rehabilitation method to solve severe or very severe sensorineural hearing loss, and has a good effect on improving the speech recognition rate and communication ability of the elderly. At present, the proportion of elderly people with hearing loss in mainland China receiving cochlear implants is low, which may be related to factors such as cognitive perception, economic income, insurance policies, and concerns about the risks of surgery.
(1) Suitable people for cochlear implantation in the elderly
Elderly patients with hearing loss have a good auditory speech foundation in the past, and the results of cochlear implantation are clear. Clinically, the life expectancy and hearing decline trend of elderly patients should be comprehensively considered, and cochlear implants should be implanted as soon as possible to improve the quality of life when the indications for cochlear implant surgery are met.
Indications include: 1) severe or profound sensorineural hearing loss in both ears, unable to communicate normally auditory speech with hearing aids; 2) Able to tolerate surgery under general anesthesia; 3) Have good psychological quality, and have reasonable expectations for the results of surgery for themselves and their families; 4) Able to adhere to auditory rehabilitation training and have good family support; 5) Pass the preoperative central function and cognitive function assessment.
(2) Safety of cochlear implantation in the elderly
Clinical studies have shown no statistically significant difference in the incidence of anesthesia and surgery-related complications in older people with cochlear implants compared with those with other age implants.
Because elderly patients often have other systemic diseases, and there are individual differences in the degree of physical function reduction caused by aging, and the probability of anesthesia and surgery-related complications is unequal, comprehensive evaluation before and during surgery is extremely important.
and (3) the effect of cochlear implantation in the elderly
After cochlear implantation in elderly patients with hearing loss, the hearing threshold of each frequency was significantly improved. The speech recognition rate after surgery was significantly higher than that before surgery, and there was no significant difference in the speech recognition rate in a quiet environment compared with that of adults under 60 years old who were deaf after speech. Compared with hearing aids, cochlear implants are better at improving speech recognition and comprehension in quiet and noisy environments in older people with hearing loss.
Due to the large individual differences in the effect of implantation in elderly patients with hearing loss, more attention should be paid to the improvement of patients' subjective satisfaction and quality of life, as well as the effective improvement of communication ability in family and social life.
(4) For details of rehabilitation guidance, please refer to the auditory rehabilitation training section below
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Auditory rehabilitation
Auditory rehabilitation training in older patients with hearing loss can accelerate the process of acceptance and adaptation of artificial hearing devices, and promote improved speech recognition and communication skills. At the same time, it can also stimulate cognitive abilities such as memory and concentration. In the whole auditory rehabilitation training, a rehabilitation model should be established that is family-centered, supplemented by rehabilitation institutions and multidisciplinary personnel (including doctors, audiologists and psychological counselors). With the rapid expansion of network functions and applications, distance education and smartphone software have gradually become a good helper for home rehabilitation training.
1. Basic Principles
Establish reasonable expectations.
Establish a good mental state and cultivate auditory and verbal communication habits.
Create a good rehabilitation adaptive training environment.
Establish an individualized program and actively carry out rehabilitation adaptation training.
2. Training content
(1) Unused assistant device holder
Elderly patients with hearing loss who have not been intervened with hearing aids for various reasons should actively use the following communication methods to improve their verbal communication skills.
Shorten the distance of conversation.
Speakers should speak clearly, speak slowly, and raise their voice moderately.
Get the most out of your vision, communicate face-to-face, and make the most of your lip reading and body language.
Using residual hearing, students are trained in auditory perception, recognition, discrimination, and comprehension, and master listening skills.
(2) Those who use hearing aids
For elderly patients with hearing loss who have received hearing aid intervention, rehabilitation training should be based on adaptation to wearing hearing aids, and the commissioning, verification and effect evaluation of the devices should run through the entire rehabilitation process. Auditory rehabilitation includes cognitive training and hearing training: commonly used cognitive training methods are memory training, processing speed training, etc.; Listening training is carried out gradually from four aspects: auditory perception, recognition, discrimination and comprehension. In most cases, especially in noisy environments, when older patients are unable to communicate effectively with hearing aids alone, they need to improve their communication strategies or use them in conjunction with other assistive technologies (e.g., FM systems).
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prospect
With the intensification of the aging process of the national population, it is expected that the number of senile hearing loss patients will increase significantly, which should arouse the common attention of the whole society, improve the awareness of prevention and control, and achieve early detection, early diagnosis and early intervention, so as to effectively improve the quality of life of the elderly and reduce the social burden. The following aspects are recommended to be considered for future priorities.
1. Etiology and epidemiological studies
The etiology and risk factors of hearing loss in the elderly are still unclear, and the interaction of multiple factors and the role of other factors in promoting hearing loss in the elderly need to be revealed. The mainland should organize a multi-center, large-sample epidemiological baseline survey to analyze relevant risk factors and promote etiological research. In addition, through health big data analysis and artificial intelligence technology, we will promote hearing screening for the elderly, establish scientific and accurate early warning methods, and realize early intervention for hearing loss in the elderly.
2. Research on pathogenesis and interventions
The focus of the work on hearing loss in the elderly should shift from treatment to prevention and control, in-depth research on the pathogenesis, active exploration of pathogenic factors, molecular genetics research, and acceleration of methodological research on diagnostic technology and intervention methods.
(1) Drug research: in-depth research on the etiology of hearing loss in the elderly, revealing its pathophysiological mechanism, and laying a theoretical foundation for the research and development of preventive and therapeutic drugs.
(2) Research on artificial hearing technologies such as hearing aids and cochlear implants: Carrying out the work of artificial hearing technology in sound processing strategies and wireless integration will help improve patients' compliance and enhance their ability to live independently. Further improving the AI processing strategy of acoustic signals and improving the speech recognition rate will be the focus areas of future research and development.
(3) Gene therapy: Some studies have reported that microRNA can regulate the aging process, and some studies have tried to introduce exogenous DNA into the inner ear to replace defective genes to induce hair cell and nerve fiber regeneration. Significant trials are still needed to determine the safety and efficacy of gene therapy.
3. Research on chronic diseases in the elderly
Hearing loss in the elderly is closely related to a variety of chronic diseases, cognitive and psychological disorders, etc. Therefore, basic and clinical research on the impact of chronic diseases in the elderly on hearing should be strengthened. Hearing loss in older age increases the incidence of cognitive dysfunction, and central auditory processing impairment may be an early manifestation of Alzheimer's disease. Therefore, exploring the correlation and influencing factors of hearing loss and cognitive dysfunction in the elderly will help to deepen the understanding of the decline of physical function in the elderly and optimize the intervention mode of hearing loss and cognitive dysfunction.
4. Hearing intervention and rehabilitation system construction for the elderly
According to the characteristics of the elderly population, a prevention-oriented and pass-forward socialized work model should be carried out, and big data analysis and artificial intelligence should be used to build an all-round, full-coverage and whole-process rehabilitation and intervention system for elderly hearing loss. With the acceleration of the aging process of the population in the mainland, it is incumbent upon us to strengthen the construction of a hearing loss prevention and treatment system for the elderly population that benefits urban and rural areas. Ensuring hearing health begins in the present generation.