Key learning points:
- Hearing loss is a very common feature of ageing
- Primary care nurses are well placed to support people with hearing loss
- Simple changes in communication, such as always facing someone and slowing speech slightly, can make a big difference
Hearing loss is one of the most common experiences of ageing and yet it remains misunderstood in many ways. There are 10 million adults with hearing loss in the UK and this number will increase to more than 14.5 million by 2031.1 It is possible to develop hearing problems at any age but the overwhelming majority occur in later years. It is estimated that around one in 10 people aged 55-74 have hearing loss and this rises to five in 10 of those over 75, and to eight in 10 of those over 80.2 Individuals may not realise they have hearing problems because of the gradual nature of the changes, and it is often not until they get feedback from others that they seek help. Hearing loss impacts the experience of older people either directly or indirectly through communication with partners, friends and family.3 The consequences of having hearing loss can be severe, with significantly increased risks of social isolation and depression.3,4,5,6,7
There is a relatively low uptake of adult hearing services and those who do present for help typically wait 10 to 15 years before doing so.3 Hearing loss is experienced gradually in many cases and coping can take the form of normalising the experience as part of ageing, rather than interpreting it as a health problem that requires treatment.3,4
Which patients are affected?
Any older person is likely to have some changes to their hearing and for a large proportion these changes will be undetected.3 It is common for hearing to deteriorate gradually over time and for people to seek help only once the problem has become acute.
Hearing loss as we age is contributed to by loss of the fine nerve endings or hair cells in the cochlea and also by central auditory processing changes. The longer a person manages with reduced hearing, the greater they will find the challenges of using hearing aids in terms of physical dexterity, learning and central auditory changes.6
This creates a vicious circle, where an individual waits to seek help and try a hearing aid, only to discover they find the hearing aid harder to use and adjust to because they have lived without sound for an extended period of time.3,4,5,6
How to recognise hearing problems
Hearing problems become part of daily life and people often adapt to them without particularly noticing. Key signs are: the volume of their television, difficulty following a conversation and inability to hear alerting sounds.
As the type of hearing loss that is most common involves deterioration of nerves in the inner ear, the symptoms are often partial mis-hearing and are therefore harder to spot.
The person may pick up part of what is said, perhaps hearing louder vowel sounds or intonation patterns, but not hearing clearly. Therefore, there can be an apparent inconsistency in performance, depending how much noise is around them.
Relatives sometimes refer to people ‘hearing when they want to’. This is usually a symptom of nerve damage rather than intention.
As so many people are affected by hearing loss it is an important feature to consider for anyone over the age of 70 (although hearing loss itself may start in their 50s).
The experience of hearing loss may be so common that it is not recognised as a problem by the affected individuals. It can be helpful to let people know there are services to help and that a lack of hearing does not need to be a problematic feature of ageing.
Hearing loss can be caused by a number of different factors. In older people, arteriosclerosis, cardiovascular disease, genetic factors and long-term noise exposure may all play a part in presbyacusis.8 Bacterial and viral infections affect people of all ages, and hereditary and birth injuries can cause hearing loss from birth.8
Sensorineural hearing loss creates damage in the peripheral and central nerve fibres of the ear, leading to reduced perception at some, but not usually all, frequencies of sound.8
Conductive hearing problems occur when the mechanical movements of the outer or middle ear are restricted.8 Wax causes blockage to the sound waves entering the ear and reduces hearing. Infections in the middle ear cavity can restrict movement of the middle ear bones and prevent sound travelling through the ear.
The important distinction between these types of hearing loss is in the effect on sound perception.
Conductive problems lead to sounds seeming quieter. Sensorineural loss leads to sounds becoming distorted and partially heard.8 This can make the hearing behaviour appear variable depending on circumstances such as the level of background noise.
What should the primary care nurse do?
You are well placed to help people identify when their hearing is changing and direct them to help. Where there are additional symptoms, people need to be referred by their GP to ear, nose and throat (ENT) specialists to assess the individual’s medical or surgical needs, for example, if a person has recurrent ear infections or additional symptoms such as persistent noises in the head or ears (tinnitus) or unexplained dizziness. If a person reports hearing problems in one ear only, they should also be directed to ENT in the first instance.
For cases where the hearing problem is consistent in both ears, without other symptoms, the patient should be referred by the GP to the audiology service. Adult audiology services are available in many centres including on some high streets and patients may well have a choice of provider. The audiologist will take a full case history, assess the degree and nature of the hearing problem and recommend further treatment, usually in the form of a hearing aid.
A common problem that holds up audiological assessment and treatment is wax. If wax occludes the tympanic membrane, it is best to remove it before referral.15
There is limited evidence on the best way to remove wax but there is some indication that using drops to soften wax can help.15 Water and saline appear to be as effective as over-the-counter remedies.15
Alongside these practical ways of intervening with a patient who has hearing loss, it is also important to provide emotional support in broaching the subject. Hearing loss is a sensitive and challenging thing for some people to discuss.9 It can be helpful to frame discussions in a way that raises the possibility that there is help available.
Facing the problem
It can be helpful to normalise not only the hearing loss but also the help sought for hearing loss. Most of us will develop hearing loss, so it makes sense to frame the discussion making clear that it is usual and expected, and can be improved.
Listening to patient experience is important,10 as is recognising that people may be at a stage of change where it is more important to provide information on choices or options to be referred rather than advising.10,11
There is an option grid decision aid to help present options to people with hearing problems (see resources).
There are medical and surgical interventions that can apply to conductive hearing loss, but the most usual treatments for sensorineural hearing loss are hearing aids. Hearing aids are digital amplifiers that are fitted to target the frequencies of sound that each individual cannot hear and to amplify those frequencies. As most everyday sounds are complex, this means hearing aids will appear to make a wide range of sounds louder, but not necessarily immediately clearer.
Most audiologists consider that hearing aids require a period of adjustment and re-learning of sound in order to help. The NHS provides behind-the-ear hearing aids with ear moulds or slim tube fittings into the ear.
Generally, the more a person practises using the hearing aids, the better they become at making sense of the sounds they hear through them. Many people find hearing aids very difficult to manage and rejection rates for hearing aids remain high.3,4
If people are supported when adjusting to their hearing aids, outcomes are better.3,4,5 In particular, patients may need support in learning the practicalities of fitting hearing aids, changing batteries and aftercare. There are services available to help this through audiology but practising fitting and changing batteries is an area where primary care nurses can be a great help.
Hearing aids are not the only options for hearing loss. Assistive listening devices are able to amplify specific problematic sounds such as the phone, doorbell or television without requiring the user to wear a device at all times. These devices are available to buy and, in some circumstances, may be funded by local authorities. Organisations such as Action on Hearing Loss provide information and materials on assistive listening devices.12
Lip-reading classes and communication groups may be available in the local area and provide a valuable social support to people with hearing loss. Such groups may be available through the local NHS hearing therapy service or through local education services. These services aim to improve confidence in communication and may develop cognitive and listening skills.13,14
Hearing therapists who specialise in hearing rehabilitation can enable people to use devices that will help them, including hearing aids and assistive listening devices. They are trained to provide counselling and support to people facing hearing loss and their families.
Dealing with hearing problems
A hearing problem tends to mean that people have difficulty telling sounds apart as well as hearing them. It is sensible to modify communication behaviours with this in mind.
Speaking slightly more slowly and clearly tends to be more helpful than speaking louder. Enabling the patient to see your face clearly (including making sure your face is in the light) as you speak is also very important and the visual cues in speech become more crucial when hearing is reduced. It can help a great deal to reduce background noise by turning off background sounds where possible and choosing quieter locations to communicate in. It is also helpful to rephrase as well as repeat a message if someone is struggling to hear it, as some patterns of sound may simply be harder for them to access.
1 International Longevity centre press release: Statement from the Commission on Hearing Loss in response to Monitor’s report on the use of choice in commissioning adult hearing services. ilcuk.org.uk/index.php/news/news_posts/press_release_press_statement_from_the_commission_on_hearing_loss_in_respon.
2 Mulrow C, Aguilar C, Endicott J et al. Association between hearing impairment and the quality of life of elderly individuals. Journal of the America Geriatrics Society 1990;38:45-50.
3 Gianopoulos I, Stephens D, Davis A. Follow-up of people fitted with hearing aids after adult hearing screening: the need for support after fitting. BMJ 2002;31:471.
4 Dalton D, Cruickshanks K, Klein B et al. The impact of hearing loss on quality of life in older adults. Journal of Gerontology 2003;43:661-8.
5 Arlinger S. Negative consequences of uncorrected hearing loss – a review. International Journal of Audiology 2003;42 Suppl 2:2S17-20.
6 Lin F, Ferrucci L, Metter E et al. Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology 2011;25:763-70.
7 Brooks D. Factors relating to the under-use of postaural hearing aids. British Journal of Audiology 1985;19:211-17.
8 Davis H, Silverman S. Hearing and deafness. Holt, Rinehart & Winston of Canada; 1970.
9 Wallhagen M. The stigma of hearing loss. Journal of Gerontology 2010;50:66-75.
10 Gidman J. Listening to stories: Valuing knowledge from patient experience. Nurse Education in Practice 2013;13:192-6.
11 Pryce H, Wainwright D. Help-seeking for medically unexplained hearing difficulties: A qualitative study. International Journal of Therapy and Rehabilitation 2008;15:343-9.
12 Action on hearing loss. Products for people with hearing loss and tinnitus. actiononhearingloss.org.uk/supporting-you/products-and-equipment.aspx.
13 British Academy of Audiology. Access to lip-reading classes. baaudiology.org/indexphpnews/news-home/access-lip-reading-classes/.
14 Hickson L, Worrall L, Scarinci N. A randomized controlled trial evaluating the active communication education program for older people with hearing impairment. Ear and hearing 2007;28:212-30.
15 Burton M, Doree C. Ear drops for the removal of ear wax. The Cochrane Library; 2003.
Option grid decision aid. Available at: optiongrid.org/option-grids/grid-landing/27.