Age-Related Hearing Loss Dr mohammad hossein baradaranfar MD Associated professor of Otolaryngology head & neck surgery.

Age-Related Hearing Loss

Dr mohammad hossein baradaranfar MD

Associated professor of

Otolaryngology head & neck surgery

How Are We Doing?

•Prevalence of ARHL far exceeds the number who seek audiologic diagnosis and treatment

•Attempts to reach more▫Screening▫Education

Physician Consumer

I Propose--A New Perspective

•“Hearing loss is a significant, looming, c ostly PUBLIC HEALTH ISSUE”

•Left unaddressed/untreated▫Continued growth in number of, not just

hearing-, but psychosocially and cognitively-impaired older adults with diminished quality of life, requiring costly care

This New Perspective Recognizes…•Treating hearing loss is more than

dispensing hearing aids•Audiologists’ focus on the hearing aid as

the sole solution is counter-productive▫To the patient/family▫To the profession

•New perspective acknowledges and respects the broad scope of practice of Audiology as fundamental in the treatment of hearing loss

New Marketing Approach•(Not small/invisible/discreet/hidden)•But--•Hearing aids are the devices that will

▫Improve memory▫Enable continued active social life▫Prevent mental slowing▫Make it possible to continue living an

independent, active, mentally-healthy life•Wearing hearing aids is a “Brain

training” exercise that has immediate positive impact

What is the Prevalence of ARHL in US?•Under-estimated!

▫Too much reliance on self-report▫Statistic varies with definition of “hearing

loss”•Varies by sex at all ages M>F•At age 48-59

▫Men: 35%; Women 12%•At age 80-92

▫Men: 95%; Women 85%•It’s universal, inevitable, and grossly

undertreated

Prevalence of ARHL in Europe?

•30% of men & 20% of women by the age of 70 ,have at least 30dB SNHL

•55% of men & 45% of women by the age of 80

What Auditory Functions are Impaired in Aging?

o sensory presbycosis : Loss of hair cells at base of cochlea

o Neural presbycosis Low SDS

o Strial presbycosis Flat audiometry

o Cochlear conductive Stifness of basilar membrane

Etiologic Factors in the Development of Age-Related Hearing Loss•Noise

▫Cumulative over the lifetime

▫Even at “non-hazardous” levels

•Genetics•Heart Disease

▫Vascular impairment•Diabetes

▫Vascular impairment

• Socio-Economic Status▫ Possibly a causative

factor of other factors that cause hearing loss

• Alcohol• Exercise (lack thereof)• Hypertension• Smoking• Inflammation

▫ Related to dental disease

World Health Organization: Hearing Loss Is…•The most common causes of disability

globally are adult-onsethearing loss…

•Hearing loss is the third leading cause of years lived with disability▫After depression and unintentional injuries

•The MOST prevalent cause of moderate-severe disability worldwide▫All ages, particularly age 60+

World Health Organization

•Hearing impairment can impose a heavy social and economic burden on individuals, families, communities and countries.

•In adults, hearing impairment often makes it difficult to obtain, perform, and keep jobs.

•Properly fitted hearing aids can improve communication in at least 90% of people with hearing impairment

What are the “Costs” of Ignoring Hearing Loss?• Missed opportunities for communication,

information exchange, humor, emotion• Reduced income/productivity• Social ineptness• Social isolation• Patient/Family/significant other stress• Reduction in Quality of Life (QOL)• Depression• Dementia—causative, shared origin/result of

aging, or exacerbative? ▫Perhaps all 3?

Does Hearing Loss Cause Dementia? Perhaps…•JAMA,2008 Uhlmann, et al. •Relationship of hearing impairment to

dementia and cognitive dysfunction in older adults.• 100 cases with Alzheimer's-type dementia (AD)

and 100 age-, sex-, and education-matched, nondemented controls.

•Greater hearing loss is associated with a higher odds of having dementia.

•Hearing loss is significantly correlated with the severity of cognitive dysfunction.

Relationship of Hearing Impairment and Cognitive Decline

• Hearing impairment exaggerates the effects of cognitive deficit• Audiological evaluation must be a part of the

differential diagnosis of dementia• ARHL or other untreated hearing loss is a

causative factor in development of dementia• May be either comorbidity or causative

relationship of hearing loss and depression/dementia

• Hearing loss requires diagnosis and treatment to attain/maintain optimal cognitive function

Audiometrically-matched older vs younger listeners•Older listeners have more difficulty

understanding speech in noise•Older listeners have more difficulty

understanding speech in speech•Older listeners have poorer performance

on tests of auditory processing (e.g., time-compressed speech, gap detection)

•Older listeners have greater difficulty with rapid speech

This is not new information• National Council on Aging - 1999• 4000 older hearing impaired persons• Hearing aids result in

▫ better relationships▫ better feelings about self▫ improved mental health ▫ greater independence, security

• Non-use results in ▫ Depression▫ Sadness▫ Worry and anxiety▫ Emotional turmoil▫ Insecurity▫ Reduced social activity▫ Paranoia

Treatments• Treatment decisions should be made in partnership with

patient/significant other/family• Use a patient-centered approach

▫ define all options, including doing nothing▫ Define the cost of doing nothing

• Realistic pros and cons of each option▫ E.g., waiting vs moving ahead now with hearing aids▫ E.g., individual vs group rehabilitation vs peer support

group▫ E.g., TV and telephone amplifiers in lieu of hearing aids

• In an environment acknowledging▫ Hearing aids are necessary▫ Hearing aids are not sufficient (limitations)▫ Costs of neglecting treatment

Auditory Rehabilitation— Integral Part of the Treatment Picture•Patient•Family/significant others•Hearing Assistance Technologies•Communication Strategies•Communication Styles

Auditory Rehabilitation—What Is It?•Predicated on identifying and diagnosing

individual with hearing loss•Predicated on willingness of

patient/family/significant other(s) to participate in rehabilitation

•Can AR be efficacious if hearing loss is not treated with hearing aid(s), cochlear implant(s), other amplification system(s)?▫Maybe not

Active Listening

•Trains listeners to listen for meaning of whole sentence rather than individual words/speech sounds

•Goals include▫Increased confidence▫Concentration ▫Use of non-verbal and situation cues▫Modification of environment to facilitate

listening•Use of reflective listening

Reflective Listening•Listen intently•Show interest and understanding via eye

contact and body language•Use closure and guessing skills to fill in

blanks•Disregard noise•Don’t give up•Use coping strategies such as repeat,

rephrease

MarkeTrak VII (2005) – Survey of 6,000 people•93% stated QOL improvement, at least

“some of the time” as a result of hearing aids ▫70% cite more effective communication▫50% report improved social life, self-

confidence and sense of safety▫40% report improved sense of independence

and emotional health▫33% improved mental and cognitive function▫25% report improved physical health

Not Just Hearing Aids!

•Cochlear implants shown to improve QOL in older adults (Wanscher, 2006)

•Significant improvement in social functioning▫Increased socialization known to be related

to decreased depression

Summary of Adverse Psychosocial Effects of Untreated Hearing Loss•Decreased QOL and well-being•Poorer mood and depression•Social isolation•Poorer physical functioning and self-

sufficiency•Impaired inter-personal relationships•Amenable to change when amplification is

initiated

What We ARE Doing

• Diagnosing hearing loss–For the primary purpose of fitting hearing

aids• Encouraging people to have their hearing

screened• Promoting the profession of Audiology• Advocating for public policies that

favorably impact our profession and the patients we serve

What We AREN’T Doing• Putting hearing loss in the larger picture of–Negative impact on QOL–Negative impact on psycho-social and

emotional health• Promoting counseling– To patient, family, significant others

• Promote use of all assistive technologies, but not as “the” solution

• Recognizing and promoting that hearing aids aren’t aren’t the sole solution to ARHL communication impairment• Necessary, but insufficient

New preventive clues ?• a diet high in cholesterol could have adverse

influences on hearing• monounsaturated fat & Cholesterol-Lowering

Medication are beneficial• anticonvulsant drugs from a family of T-type

calcium channel blockers can significantly preserve spiral ganglion neurons during aging

• Serum folate was significantly lower among elderly with ARHL

• Combination antioxidant therapy effectively decreased threshold shifts on ABR within an animal model of ARHL

SSNHLSudden Sensory Neural Hearing Loss

SSNHL

•Progressive sensory neural HL over 12 hr or less

•Incidence: 5-20 in 100,000•2-3% of outpatient visits•Any age ; most: 6th decade•M=F

Presentation?

•Unilateral HL on awakening•Rarely bilateral •Sometimes fluctuating•Aural fullness•Tinitus•Vertigo (40%)

What is the ethiology?

•Infection•Neoplasms•Trauma &TM perforation•Drug•Immunologic•Vascular•Developmental• idiopathic

Any chance for cure?

•Poor prognosis:

More severe HLDownsloping or flat HLVertigo low SDSChildren & >40 years old

Treatment modalities?

Steroid:

•Most widely accepted treatment•Prednisolone 1mg/kg/day for 10 days•Repeat these course until no improvement

be noted•Intratympanic :Better resultsLower side effects

Treatment

Improve cochlear blood flow:

•Mostly used vasodilators: histamine IV,oral papaverine,oral nicotinic acid

•Carbogen (O2 + Co2)•No controled study has shown benefit of

papaverine ,nicotinic acid or pentoxyphiline

•Dextrean ,manitol,pentoxyphiline,heparin

Treatment •Low salt diet :2 gr is recommended

•Dioretics

•Antiviral

•MRI

•Treat any known ethiology

Noise induced hearing loss

NIHL

What is NIHL?

•Bilateral symetric SNHL •Almost never profound losses•First TTS (transient threshold shift)

•Then PTS (permanent threshold shift )

•Early : in 3 kHz , 4kHz(greatest) , 6kHz•With progression : low frequencies also •Rapid progression in 10 – 15 years then

slower

No way to cure!

•The most important points :

1.Prevention

1.Early detection

Thanks for your Attention