Episode 57 - Hearing Loss - a podcast by Rio Bravo Family Medicine Residency Program

Hearing loss in the elderly, Dr Yomi explained the fundamentals of hearing loss, we said good-bye to graduating residents and welcomed the class of 2024.

Introduction: New Academic Year
By Hector Arreaza, MD

Today is July 1, 2021.

It’s that time of the year again when we say good-bye to our dear graduating residents, and we welcome a new group of eager PGY1s. 

On June 27, 2021, we had a graduation ceremony filled with emotion, stories, yummy food, and lots of dancing. We gave a well-deserved tie-dye lab coat to Dr Stewart as a sign of our appreciation and love. We say congratulations to our graduates who received their diploma: Monica Kumar, Joseph Gomes, John Ihejirika, Fermin Garmendia, Roberto Velazquez, Terrance McGill, Yodaisy Rodriguez, and Claudia Carranza. They all participated in this podcast, even more than once. I want to especially thanks Claudia who brought so many good ideas and her enthusiasm to this podcast. She promised she will continue to participate in the near future. 

Lisa Manzanares and Amna Fareedy received their diplomas a few months ago, but they were also remembered during this ceremony. 

And now we welcome our new interns [Drum roll]: Cecilia Covenas, Su Hlaing, Amardeep Chetha, Licet Imbert, Timiiye Yomi, Funmilayo Idemudia, Na Sung, and Amelia Martinez. They are officially starting their residency this week as the Class of 2024. I hope you can enjoy your training with us. And these interns are starting on the right foot. You will hear Tiimy present our podcast discussion today.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

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Hearing loss in the elderly. 
By Timiiye Dawn Yomi, MD, and Hector Arreaza, MD

 

INTRODUCTION:

Hearing loss is the third most common health condition after hypertension and arthritis to affect the elderly population. According to the World Health Organization, about 538 million people are affected by hearing loss worldwide with people between ages 61 to 70 years accounting for about third of this number. 

80% of those older than 85 years have experienced some form of hearing loss and men tend to experience greater hearing loss with earlier onset compared to women. 

Normal conversation uses frequencies of 500 to 3000 Hz at 45 to 60 dB. After age 60 there is a steady decline by one dB annually. Genetic component plays a role in age related hearing loss.

DEFINITION:

A person who is not able to hear at hearing thresholds of 20dB or better in both ears is said to have hearing loss. Hearing loss can be mild moderate or severe and it can be uni- or bilateral. 

Mild: On the average, persons with mild hearing loss hear the most-quiet sounds between hearing thresholds of 25-34dB with their better ear.

Moderate: The most-quiet sounds heard by these persons are between hearing thresholds of 34-49dB with their better ear.

Moderately severe:    These persons hear the most quiet sounds between hearing thresholds of 50-64dB with their better ear.

Severe: The most quiet sounds heard by these persons are between hearing thresholds of 65-79dB with their better ear.

Profound: Persons with profound hearing loss hear the most quiet sounds at thresholds of 80 dB or more.

Some terms we may want to address here are “Hard of hearing” and Deafness. 

A person is said to be hard of hearing when they have hearing loss ranging from mild to severe, but they usually can communicate through spoken language. 

Deaf people on the other hand have profound hearing loss and often communicate with sign language.

TYPES OF HEARING LOSS:

Hearing loss can be broadly divided into 3 types: Conductive, Sensorineural hearing loss, Mixed.

Conductive hearing loss: This involves anything that would limit the amount of external sound entering the inner ear. Common causes include cerumen impaction, perforated tympanic membrane, otitis media effusion, tumors such as glomus tumors, and tympanosclerosis.

Sensorineural hearing loss: This is hearing loss that involves the inner ear, cochlear and or the auditory nerve. Common causes are age-related hearing loss (presbycusis, which is the most common hearing loss in the elderly population) ototoxic medications such as aminoglycosides, autoimmune diseases, trauma, infection, neoplasm, and Meniere’s disease. 

Mixed: A combination of conductive and sensorineural

RISK FACTORS: 

Aging

Race (Caucasians have the highest prevalence of age-related hearing loss)

Genetics

Socioeconomic status

Loud noise exposure

Ototoxins such as aminoglycosides

Vascular diseases

Hypertension

Diabetes

Immunologic disorders

Infections

Smoking

Hormones such as estrogen.

 

CLINICAL PRESENTATION:

Patients may present with sudden or gradual hearing loss depending on the etiology

Common symptoms: inability to hear or understand speech in a crowded or noisy environment, difficulty with understanding consonants, difficulty having a phone conversation, inability to hear high pitched voices or noises, mumbling or muffling of speech or other sounds, frequently asking others to repeat themselves, speak more slowly, clearly and loudly; needing to turn up the volume of the TV or radio, withdrawal from conversations, avoidance of social settings, tinnitus (TEEN-it-us), disequilibrium which can result in falls.

Sometimes you have to start the conversation when you notice the patient asks you to repeat frequently. Make sure you gently ask a question such as: “How is your hearing?” or “How would you rate your hearing? Excellent, good or bad?” Patients may be on denial, but spouses or family members can help identify the problem.

ASSESSMENT: 

History: The goal is to identify risk factors such as noise exposure and medication use. 

For example, age-related hearing loss in the elderly has a gradual onset as opposed to hearing loss from perforation of the tympanic membrane which is sudden. 

Due to the emotional and functional impact of hearing loss, it is important to ask about mental health issues such as depression, social isolation and poor self esteem when taking a history from patients. 

Hearing loss can also result in cognitive decline, increase hospitalizations and functional disabilities, especially in the elderly. 

An analysis of 605 elderly patients with a large cohort study who had hearing test and cognitive testing done showed an association between hearing loss and decreased executive function, which makes early identification and treatment important.

SCREENING:

The USPSTF found insufficient evidence to demonstrate the benefits and harms of hearing screening. This a Grade I recommendation.

On the other hand, the American Speech Language Hearing Association advises that individuals over 50 years should have complete audiometric testing done every 3 years. 

Experts also recommend asking older patients or their care givers about hearing problems, counselling on treatments available and referrals when appropriate.

TYPES OF SCREENING TESTS:

Whispered test

Single question

Screening version of the hearing handicap inventory for the elderly

Audioscopy

The whispered test and screening question can be easily done in the primary care physician’s office.

MANAGEMENT:

Hearing loss is a life-changing event. It requires adaptation and changes in family members and friends.

The goals of management are to address underlying and contributing causes as well as comorbid conditions. 

This could range from managing comorbidities like hypertension and diabetes to treating underlying causes such as otitis media with antibiotics and steroids, to the use of devices such as hearing aids. 

Proper and effective interventions can greatly improve functional and emotional functions of affected individuals. 

Despite these potential benefits, non-adherence is common. Commonly cited reasons are initial disappointing results with hearing aids, cost, design of devices, social norms, negative stereotypes associated with hearing loss and use of hearing aids, etc., 

The family medicine physician plays a key role in the identification of patient barriers to managing hearing loss, encouraging adherence and patient monitoring.

PREVENTION:

Avoiding risk factors such as loud noise and ototoxic medications can help prevent the onset of hearing loss. Emerging evidence suggests the use of folic acid 800mcg daily and high intake of omega 3 fatty acids to help slow age-related hearing decline, but additional research is needed to help identify potential strategies to prevent the onset and slow progression age related hearing loss. 

Conclusion: Use your clinical judgment in screening, diagnosing, and treating hearing loss.

Now we conclude our episode number 57 “Hearing loss”, Dr Yomi explained on her official first day of residency how to detect hearing loss in elderly patients and how to evaluate and manage this disabling and life-changing condition. We are excited for this new academic year, we foresee a bright future ahead of us. Just like Hans Rosling said, “I’m not an optimist… I’m a very serious possibilist.” Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Timiiye Yomi. Audio edition: Suraj Amrutia. See you next week!

 

REFERENCES:

World Health Organization. (2021, April 1). “Deafness and hearing loss.” Retrieved from                                                                           https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss        

 

Anne DW. Gretchen MD. Hearing loss in older adults. Am Fam Physician.2012 Jun 15;85(12):1150-6. PMID: 22962895. https://www.aafp.org/afp/2012/0615/p1150.html#afp20120615p1150-t4

 

Weber PC. Etiology of hearing loss in adults. In: Kunins L, Deschler DG, ed. UpToDate, Waltham, Mass.: UpToDate, 2021.  https://www.uptodate.com/contents/etiology-of-hearing-loss-in-adults#

 

Heflin MT. Geriatric health maintenance. In: Givens J, Schmader KE, ed. UpToDate, Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com/contents/geriatric-health-maintenance  

 

Blevins NH. Presbycusis. In: Kunins L, Deschler DG, ed. UpToDate  Waltham, Mass.: UpToDate, 2021.                                                                                https://www.uptodate.com/contents/presbycusis       

 

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