Age-Related Hearing Loss

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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. What Auditory Functions are Impaired in Aging? • sensory presbycosis : Loss of hair cells at base of cochlea • Neural presbycosis Low SDS • Strial presbycosis Flat audiometry • Cochlear conductive Stifness of basilar membrane

9. 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

10. 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+

11. 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

12. 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?

13. 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.

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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 the sole solution to ARHL communication impairment • Necessary, but insufficient

27. 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

28. SSNHLSudden Sensory Neural Hearing Loss

29. 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

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

31. What is the ethiology? • Infection • Neoplasms • Trauma &TM perforation • Drug • Immunologic • Vascular • Developmental • idiopathic

32. Any chance for cure? • Poor prognosis: • More severe HL • Downsloping or flat HL • Vertigo • low SDS • Children & >40 years old

33. Treatment modalities? Steroid: • Most widely accepted treatment • Prednisolone 1mg/kg/day for 10 days • Repeat these course until no improvement be noted • Intratympanic : • Better results • Lower side effects

34. Treatment Improve cochlear blood flow: • Mostly used vasodilators: histamine IV,oralpapaverine,oral nicotinic acid • Carbogen (O2 + Co2) • No controled study has shown benefit of papaverine ,nicotinic acid or pentoxyphiline • Dextrean ,manitol,pentoxyphiline,heparin

35. Treatment • Low salt diet : • 2 gr is recommended • Dioretics • Antiviral • MRI • Treat any known ethiology

36. Noise induced hearing lossNIHL

37. 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

38. No way to cure! • The most important points : • Prevention • Early detection

39. Thanks for your Attention