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Presbycusis

Author SectionEditor DeputyEditor

NikolasHBlevins,MD DanielGDeschler,MD,FACS HowardLibman,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jan2017.|Thistopiclastupdated:Nov18,2015.
INTRODUCTIONPresbycusis,oragerelatedhearingloss,isacommoncauseofhearinglossinadultsworldwide
[1].Presbycusisisacomplexandmultifactorialdisorder,characterizedbysymmetricalprogressivelossofhearing
overmanyyears.Itusuallyaffectsthehighfrequenciesofhearing,althoughitspresentationandclinicalcoursecanbe
variable.Presbycusishasatremendousimpactonthequalityoflifeofmillionsofolderindividualsandisincreasingly
prevalentasthepopulationages[2].

Thistopicwillfocusonthepathophysiology,clinicalpresentation,evaluation,andmanagementofpresbycusis.The
etiologyandevaluationofotherspecificcausesforhearingloss,aswellashearingamplification,arediscussed
separately.(See"Etiologyofhearinglossinadults"and"Evaluationofhearinglossinadults"and"Hearing
amplificationinadults".)

EPIDEMIOLOGYTheprevalenceofhearinglossincreaseswithage,withupto80percentoffunctionally
significanthearinglossoccurringinolderadults[3].InonepopulationcohortintheUnitedStates,theprevalenceof
hearingloss(definedbyaudiometry)increasedsteadilywithage[4]:

11percentages44to54
25percentages55to64
43percentages65to84

Presbycusisaffectsmorethanhalfofalladultsbyage75yearswithunchangedprevalenceoverthelastseveral
decades[59].Presbycusisismorecommoninmenthanwomen,butthisfindingmayberelatedtohigherlevelsof
noiseexposureseeninmen.

TheWorldHealthOrganization(WHO)estimatesthatin2025,therewillbe1.2billionpeopleover60yearsofage
worldwide,withmorethan500millionindividualswhowillsuffersignificantimpairmentfrompresbycusis[10].

RiskfactorsMultiplefactorscaninfluencetheonsetandseverityofpresbycusis[11].Thesefactorsincludelow
socioeconomicstatus,noiseexposure,ototoxins(eg,aminoglycosides,chemotherapeuticagents,heavymetals),
infections,smoking,hypertension,diabetes,vasculardisease,immunologicdisorders,andhormonalfactors(eg,
estrogen)[1218].Ageneticcomponentalsopredisposesindividualstoagerelatedhearingloss[19,20].

ANATOMYThenormalearcanbedividedintothreeanatomicareas:theexternalear,middleear,andinnerear
(figure1).Disordersofanyoftheseareascancontributetohearingloss.Theexternalearincludesthepinnaandthe
externalauditorycanal,whichdirectssoundstothemiddleear.Themiddleearincludesthetympanicmembrane,
tympaniccavity,ossicles,andtheeustachiantube.Themiddleearfunctionstopasssoundvibrationsfromthe
externaleartotheinnerear.Theinnerearisageometricallycomplex,fluidfilledorganthatresideswithinthedense
oticcapsuleinthetemporalbone.Theinnerearistheorganofhearing(cochlea)andbalance(vestibularsystem),both
ofwhichtranslatemotionoffluidaroundhaircells(fromeithersoundorheadacceleration)intoneuralsignals(figure2).
Thestriavascularis,asystemofsmallbloodvessels,producesthefluid(orendolymph)forthescalamedia,oneof
threefluidfilledcompartmentsofthecochlea.Theneuralsignalsproducedbythehaircellsandsurroundingfluidenter
thespiralganglionandaresubsequentlycarriedtothebrainbythevestibulocochlear(eighth)cranialnerve.(See
"Etiologyofhearinglossinadults",sectionon'Anatomyandphysiology'.)

PATHOPHYSIOLOGYHearinglosscanbesubdividedintotwobroadcategories:conductiveandsensorineural.
Conductivehearinglossischaracterizedbytheinabilitytomechanicallytransmitsoundvibrationsfromthe
environmenttotheinnerear.Conductivelossisduetodisordersoftheexternalandmiddleears.Sensorineural

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hearinglossischaracterizedbytheinabilitytoeffectivelytransducesoundinformationintousableneuralsignals.The
majorityofsensorineurallossistheresultofdisordersoftheinnerearitselfandisnotdirectlyrelatedtodysfunctionof
thevestibulocochlearnerve.Thus,theterm"nervedeafness"isoftenamisnomergiventhattheprimarydysfunction
occursintheinnerear,notthenerve.Presbycusisisatruesensorineuralloss,inwhichbothcochlearhaircellsand,
toalesserextent,thespiralganglioncellsinthevestibulocochlearnervecanbeaffected[2,21,22].(See"Evaluation
ofhearinglossinadults"and"Evaluationofhearinglossinadults",sectionon'Classificationofhearingloss'.)

Temporalbonehistologyprovidessomeinsighttotheunderlyingpathophysiologyofpresbycusis.Inthehistopathology
classificationsystem,presbycusisissubdividedbasedontheassociatedaudiometricpatternofloss,with
abnormalitiesofinnerearvasculature,haircells,andmembranesallcontributingtoaudiometricfindings[21,23].The
threemaintypesofpresbycusisproposedbythissysteminclude:

"Sensory,"characterizedbylossofhaircellsandahighfrequencyhearingdeficit
"Metabolic,"characterizedbylossofstriavascularisandalowfrequencyhearingdeficit
"Neural,"characterizedbylossofganglioncellsandavariablepatternofhearingloss

Despiteitscontinuedusage,thevalidityofthishistopathologicclassificationsystemhasbeenquestioned,sinceit
appearsthatnosinglehistopathologicfindingcanreliablyaccountfortheclinicalvariabilityseeninpresbycusis[24
28].

Instudiesoftemporalbonesfrompatientswithtypicalpresbycusis,thedegreeofhearinglosswasassociatedwith
disordersofanumberofvitalcochlearanatomicstructures[1].Theseincludedegenerationofthestriavascularis,
spiralganglioncells,andhaircells.Consistentwithfindingsseeninothercausesofsensoryhearingloss,theouter
haircellswerethepredominantstructuresaffected.Thus,presbycusisappearstobemostrelatedtolossofinnerear
sensorystructures,althoughtheunderlyingincitingeventsforthisremainunclear.

CLINICALPRESENTATIONThehallmarkofpresbycusisistheprogressive,symmetriclossofhighfrequency
hearingovermanyyears[2].Hearinglosscanalsobeaccompaniedbytinnitus,vertigo,anddisequilibriumleadingto
falls.Presbycusiscangreatlyimpactqualityoflife,causinglowselfesteem,isolation,anddepression[29,30].
Presbycusismayalsobeassociatedwithdementia,whichisdiscussedseparately.(See"Riskfactorsforcognitive
declineanddementia",sectionon'Others'.)

HearinglossTheprogressionofhearinglossisvariable,butthetypicalcourseisaslow,persistentdeclinein
hearingwithage(figure3).Thehearinglossbeginsinthesixthdecadeandistypicallysymmetrical,beginninginthe
highfrequencyrange(figure3).

Thefrequenciesmostaffectedbypresbycusisarethoseabove2KHz.Overtime,thehighfrequencieswillcontinueto
drop,andthemidandlowfrequencies(0.5to2KHz),associatedwithhumanspeech,alsobecomeprogressively
involved.Thelowandmidfrequenciesofhumanspeechcarrythemajorityofenergyofthesoundwave.Thisincludes
mostofthevowelinformationofwords(figure4).Itisthehighfrequencies,however,thatcarrytheconsonantsounds,
andthereforethemajorityofspeechinformation.Theseconsonantsoundstendtobenotonlyhighpitched,butalso
soft,whichmakesthemparticularlydifficultforpatientswithpresbycusistohear.Asaresultoftheirhearingloss
pattern,patientswithhighfrequencyhearinglosswilloftenreportbeingabletohearwhensomeoneisspeaking(from
thelouder,lowfrequencyvowels),butnotbeingabletounderstandwhatisbeingsaid(duetothelossofconsonant
information).

Hearingdeficitsareexacerbatedinthepresenceofcompetingbackgroundnoise.Themissinghighfrequenciesare
essentialtoallowtheinnereartofocusonsoundsofparticularinterestandpickthosesoundsoutfromcompeting
ambientnoise.Patientswithpresbycusiswilloftenperformquitewellinoneononecommunicationinaquietroom,
buttheabilitytohearwilldeclinewhenthereisevenasmallamountofcompetingnoise.Thisexperienceisoften
referredtoasthe"cocktailpartyeffect,"whichemphasizesthedifficultythatpatientsexperiencewithcommunication
insocialsettings.Patientsalsowilloftencomplainthattheyhavemoredifficultyhearingwomenthanmen,whichis
theresultoftheinherentlyhigherpitchofwomen'svoices.

Manypatientswillwaitforseveralyearsbeforeseekinghelpforpresbycusisandareoftenbroughttomedicalattention
attheinsistenceoffamilymembers.Thisisinpartduetotheinsidiousonsetofthedisorder,aswellasthenegative
stigmaassociatedwithhearingaiduse.Olderindividualsmayacceptsomedegreeofhearinglossasinevitable,and
donotconsideritatreatabledisorder.Leftunrecognized,hearinglossinolderadultscanleadtoprogressivesocial
withdrawal,depression,isolation,andsignificantfamilialstress[30].Itcanalsohaveanegativeimpactonpatient
doctorinteractions[31].Hearinglossalsomayhaveasignificantdeleteriouseffectonthespousesofaffected

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individuals[32].Theimpactofhearinglosscanbefurthercompoundedbythehigherincidenceofhearinglossin
individualswithothercoexistingfunctionallimitations[33].

Acommonfindinginpatientswithinnerearhearinglossisaparadoxicalhypersensitivitytoloudsounds.Patientswill
oftencomplainthatsoundsbecometooloudatlevelsthatwouldeasilybetoleratedbypersonswithnormalhearing.
Thisistheresultof"recruitment,"adisorderedprocessingofsoundintheinnerear[34].Thesimultaneouselevationof
thethresholdneededtohearquietsounds,andthereductionoftolerableloudsounds,resultsinanarrowingofthe
individual'sdynamicrange.Thiscancomplicatefittinghearingaidsforaffectedindividuals,wherecarefulupperoutput
limitsmustbesettomaintaincomfortlevels.Recruitmentexplainswhyshoutingatpatientswithpresbycusisisoften
quitecounterproductive,sinceitisprimarilythelowvowelfrequenciesthatareamplifiedbyshouting,whichcarrylittle
ofthemissingspeechinformationandcanbequiteuncomfortabletothelistener.

TinnitusTinnituscanbeanimportantproblemashearinglossprogresses[35,36].Thetinnitusismostcommonlya
steadyringing,rushing,or"static"sound,butmaybedescribedasabroadrangeofsensations,includingmusical
tones,bells,or"chirping."Thesoundisusuallydescribedasaffectingbothearsorpresentsdiffusely"inthehead."
Tinnitusoccurringinonlyoneearshouldpromptthecliniciantoinitiatefurtherevaluationforotheretiologies.In
addition,thepresenceofapulsesynchronousrushingsoundmayrequireadditionalimagingtoexcludevascular
disorders.(See"Etiologyanddiagnosisoftinnitus"and'Diagnosticimaging'below.)

DizzinessAssociatedlossofvestibularendorganfunction,termed"presbyastasis,"cancontributetovertigo,
disequilibrium,andfalls[37].Theconsequencesofthelossofperipheralvestibularfunctionisexacerbatedbythe
presenceofcoexistingdisorders,suchasperipheralneuropathy,arthritis,peripheralvasculardisease,anddecreased
visualacuity.Suchconditionscanlimittheabilityofanolderindividualtocompensateforperipheralvestibular
dysfunction.Withtheearlyrecognitionofpresbycusisanddizziness,patientsandcaregiverscaninitiatemeasuresto
increasefunctionandmobilitywhilereducingtheriskoffallsandtheirpotentiallydevastatingcomplications.(See
"Approachtothepatientwithdizziness"and"Falls:Preventionincommunitydwellingolderpersons".)

EVALUATIONThediagnosisofpresbycusisshouldbesuspectedbaseduponahistoryofslowlyprogressive,
symmetricalhearinglossintheolderpatient.Thephysicalexaminationmaybehelpfulindeterminingthetypeof
hearingloss(conductiveversussensorineural),possiblecontributingfactorsforhearingloss(eg,cerumen),orother
causesofhearingimpairment(eg,tumorssuchasacousticneuroma).Patientswithhearinglossrequireformal
audiogramtestingtoconfirmthediagnosis,determineseverity,andtodirectmanagement.Othertestingsuchasblood
testing,specializedaudiologicassessment,anddiagnosticimagingshouldbeperformedonlyifindicatedbyspecific
symptomsorsignsofotherdisease.Thisisdiscussedindetailelsewhere.(See"Evaluationofhearinglossinadults".)

Thereisnoconsensusregardingpopulationscreeningforhearingloss.AnevidencebasedreviewfortheUnited
StatesPreventiveServicesTaskForce(USPSTF)determinedthatadditionalresearchisneededontheeffectiveness
ofscreeningforhearingloss,withaparticularfocusonhealthoutcomes[38].TheUSPSTFispreparinga
recommendationstatementonscreeningforhearinglossinolderadults,whichshouldbeavailablein2011[39].The
AmericanSpeechLanguageHearingAssociationhasadvisedthatindividualsover50yearsofageshouldhave
completeaudiometrictestingeverythreeyears[40].However,concernshavebeenraisedabouttheresource
implicationswithoutprovenbenefit[41].Takingacarefulhearinghistoryfromallpatientsover50yearsofage,and
furthertestingthosewhoreporthearingdifficultieswillidentifymostindividualswithsignificanthearingdeficitsfrom
presbycusis.

Cliniciansshouldpracticemethodstofacilitatecommunicationwithhearingimpairedpatients.Facingthepatientswill
allowthemtouselipreadingcues.Speakingslowly,andnotchangingtopicsabruptly,willallowthemtocontinueto
putnewinformationintocontext.Speakingclearly,withoutshoutingoroverarticulating(andusingalowerpitched
voice)canaidcomprehension.Patientswithhearinglossmaynodandappeartofollowaconversationevenwhen
theyarenot.Byengagingthemactivelyintheconversationthecliniciancanensurethattheyareindeedreceiving
information.

HistoryMultiplepotentialetiologiesofhearinglossshouldbeconsideredpriortomakingthediagnosisof
presbycusis(table1).Acarefulhistoryofassociatedfactors,suchasfamilyhistory,ototoxicmedications,trauma,and
concurrentotologicsymptomscanhelpelucidatepotentialetiologies.Thediagnosisofpresbycusisshouldbe
questionedifthehearinglossisasymmetric,whichshouldleadtoevaluationforotherconditions,suchasotitismedia,
tumors,trauma,orasymmetricnoiseexposure(asoftenoccursfromfirearmsexposureorthelongtermuseofpower
toolsononeside).(See"Etiologyofhearinglossinadults".)

Inadditiontoaskingabouthearingloss,aquestionnairecanbehelpfulinelicitingamoredetailedhearinghistory.The
HearingHandicapInventoryfortheElderlyScreening(HHIES)isasimplequestionnairethatcanhelpidentifyolder

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adultpatientswithsignificanthearingimpairment(table2)[33,42,43].

Presbycusisdevelopsovermanyyears,andtherateofhearinglossprogressioncanhelptoestablishadiagnosis.Itis
oftendifficultforapatientorfamilymembertogiveanaccuratehistoryoftheonsetandprogressionofhearingloss.
However,thehistoryofsuddendecreaseinhearing(noticedoverdaysorweeksratherthanyears)shouldraise
suspicionforotheretiologies.(See"Suddensensorineuralhearingloss".)

PhysicalexaminationThephysicalexaminationgenerallyincludesotoscopy,inadditiontothewhisperedeartest
andtuningforksfortheassessmentofhearingloss.Thefullearexaminationisdiscussedindetailelsewhere.(See
"Evaluationofhearinglossinadults",sectionon'Examination'.)

Thephysicalexaminationoftheouterearsshouldbenormalinpresbycusis.Theotoscopicexaminationmaybeuseful
forassessingotherpotentialcausesofhearinglosssuchascerumenimpaction,infection,tympanicmembrane
perforation,ortumors(eg,exostosis,osteoma,polyps).

Althoughaudiometryisthemostwidelyaccepteddiagnostictestforhearingloss,thewhisperedvoicetestisasimple
testthatcanbeperformedintheprimarycareclinician'sofficewithoutequipment[44].Toperformawhisperedvoice
test,standatarm'slengthbehindthepatient(topreventlipreading)andmaskhearinginoneearbyoccludingtheear
canalandrubbingthetraguswithacircularmotion.Whisperashortsequenceoflettersandnumbersandaskthe
patienttorepeatthem.Testtheotherearinasimilarmanner.Atoneemittingotoscopeisanotherreliablemethodfor
detectinghearingloss.(See"Evaluationofhearinglossinadults",sectionon'Officehearingevaluation'.)

TheWeberandRinnetests,usingtuningforks,canhelpdistinguishconductiveorsensorineuralhearingloss,and
identifyanasymmetricalhearingloss(figure5andtable3).(See"Evaluationofhearinglossinadults",sectionon
'WeberandRinnetests'.)

AudiogramHearingismeasuredbystandardizedaudiometrictestingwhichassessesboththeabilitytoheartones
andunderstandwords.Puretonethresholdsaredeterminedbypresentingthesubjectwithavarietyoftonesof
frequenciesvaryingbetween250Hzand8KHz.Inapatientwithpresbycusis,anaudiogramwillshowdownward
slopingpuretonethresholdswithrelativepreservationofwordrecognitionscores(figure3).Thethresholdsneededto
justperceivethesetonesarerecorded,withnormalvaluesfallingbelow25decibels(dB).Humanspeechismainly
comprisedofsoundsfallingbetween500Hzand4kHz,withaverageconversationallevelsfallingatabout50dBof
loudness.Vowelstendtobelowerandlouder,whiletheconsonants,whichcarrythemajorityofmeaningofwords,fall
inthehigherandsofterrange(figure4).

Inadditiontomeasuringpuretonethresholds,completeaudiometricanalysisincludesameasureoftheabilityto
understandastandardizedlistofwordspresentedatacomfortablelisteninglevel.Thisistermedthe"wordrecognition
score,"withnormalhearingindividualsbeingabletocorrectlyidentify90percentormoreofwordspresented.Thisisa
measureofthesubject'sabilitytoprocesssound,andoftendecreasesdisproportionatelyincasesofneuralorcentral
dysfunction.Goodwordrecognitionscorespredictfavorableresponsetoamplification,sincetheyindicatethatthe
patientcanunderstandwordsiftheyareamplifiedtocomfortablelevels.Furtheraspectsoftheaudiologicassessment
arediscussedelsewhere.(See"Evaluationofhearinglossinadults",sectionon'Formalaudiologicassessment'.)

Olderpatientswithsuspectedhearinglossrequireformalaudiogramtestingtoconfirmthediagnosis,determine
severity,andtodirectmanagement.Monitoringthepatientwithafollowupaudiogramisalsoadvisable[45].These
maybescheduledyearlyormorefrequentlyifdeteriorationofhearingisobservedornewotologicsymptomsdevelop.

DiagnosticimagingImagingstudies,includingMRIandCT,arenotindicatedforthediagnosisofpresbycusis.An
MRImaybeindicatedtoexcludeneuralorcentralpathologyincaseswherethereissignificantasymmetryofhearing
loss,orotherindicationsofpossibletumor,suchasvestibularschwannomaorotherskullbaselesions[46].This
shouldbeparticularlyconsideredifthereisassociatedunilateralorpulsatiletinnitus,vertigo,orothercranialnerve
deficits.

MANAGEMENTDespitethehighprevalenceandimpactofpresbycusis,adirectedtreatmenttopreventorreverse
itseffectsisnotavailable.However,multipleoptionscancompensateforhearinglossandimprovedailyfunctionand
wellbeing[10].Simplerecognitionoftheproblemcanbeamajorpositivestep,ashearinglossinolderadultsisoften
mistakenforcognitiveimpairment.Theidentificationofhearinglosscanbereassuringformanypatients[47].Ifthe
diagnosisofpresbycusisismade,onecanattempttoidentifyandavoidadditionalfactorsthatcancontributeto
hearingloss,suchasongoingnoiseexposureortheuseofpotentiallyototoxicmedications.

Mostpatientswithsignificantagerelatedhearinglosswillbenefitfromuseofahearingaid.Cochlearimplantationis
utilizedforhearinglossrefractorytohearingaids.Assistivelisteningdevicesandauditoryrehabilitationmayalsobe
helpfulinthemanagementofpresbycusis.Interventionstoimprovehearingareparticularlyimportantinolderpatients
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withdementiabecausehearingimpairmentfurtherexacerbatescognitiveimpairmentandfunctionaldeclineinthese
individuals.

HearingaidsHearingaidscanimprovehearingfunctionformostcasesofpresbycusis[48].Theprogressionof
hearinglossrarelybecomessoseverethathearingaidsarenoteffectiveinrestoringtheabilitytocommunicate.The
useofappropriatelyfithearingaidscanamelioratethewithdrawal,depression,andemotionalimpactthatare
commonlyassociatedwithpresbycusis[49]andcanleadtoimprovementinqualityoflife[50].Specificissuesrelated
tohearingamplificationarediscussedseparately,includingidentificationofappropriatecandidates,choosingthetype
ofhearingaid,andfitting.(See"Hearingamplificationinadults".)

Manypatientshavehadnegativeexperienceswithhearingaids,orhaveheardotherpatients'negativereactionsto
hearingaids.Attimes,hearingamplificationisnottoleratedeitherbecausepatientsproducetoomuchcerumen,which
plugsthedevice,themeatusistoosmall,orthedevicehasincreasedstaticornoise.Theaidmayalsocause
discomfort,anditisacosmeticconcerntomanypatients.Finally,itmaynotallowthepatienttounderstandspeech
anybetter,butratheronlyallowsthepatienttohearnoiseatalouderlevel[51].Unfavorableexperiencescanbe
avoidedthroughcarefultesting,counseling,deviceselection,andfittingbyanexperiencedaudiologist.Most
dispensingaudiologistswilloffertrialperiodstominimizethefinancialrisktothepatient.Technologicaladvancements
inhearingaids,suchasdirectionspecificmicrophones,improvedspeechprocessingstrategies,andadditional
customizationoptions,mayhaveimprovedperformancesignificantlyfromwhenpatientslasttriedamplification[51].

Therearenostrictcriteriawhenhearingamplificationshouldberecommended.Whenthehighfrequencythresholds
aregreaterthan40dBontheaudiogram,atrialofhearingamplificationisgenerallyindicated.Lesserdegreesof
hearinglossmaywarrantamplificationwhenemployment,educationalneeds,orsocialneedsrequirefinerhearing.

Wellfithearingaidswillalsohelpwiththetinnitusexperiencedbymanypatientswithpresbycusis[36].Thereisa
balancebetweensoundsheardexternallyandthosegeneratedinternally.Therestorationofmissingfrequencieswill
oftennoticeablyreducetheperceptionofbothersometinnitus.(See"Treatmentoftinnitus".)

Despitethefactthathearingaidsofferpotentialhelp,onlyasmallpercentageofpatientswithpresbycusisactually
receiveeffectivetreatmentwithamplification[52].StudiesinWesterncountriessuggestthatonly10to20percentof
adultswithsignificanthearinglossactuallyhaveahearingaid[2,33,52].Inaddition,asmanyas25to40percentof
adultswhohavehearingaidsunderutilizeorabandonhearingaiduse.Thisemphasizestheneedforwelltrained
hearingprofessionalstoprovidecounseling,fitting,assistivelisteningdevices,and/orrehabilitationservicesto
maximizethechanceofbenefit.(See'Assistivelisteningdevices'belowand'Auditoryrehabilitation'below.)

CochlearimplantationForpatientssoseverelyaffectedbypresbycusisthatconventionalamplificationstrategies
arenolongereffective,cochlearimplantationoffershopetorestorehearing.Cochlearimplantationinvolvesthe
placementofanelectrodearraywithintheinnereartobypassthedamagedcochlea,andstimulatetheremaining
cochlearneuronsdirectlywithelectricalstimulation(figure6).Thisprocedurecanbeperformedsafely,evenin
octogenarians[53].

Cochlearimplantoutcomesinpresbycusispatientsmaybelimitedbytheagerelatedreductioninabilitytoprocess
soundinformation,aswellasagerelatedcognitivedeficits.Hearingimpairmentcanalsoresultfromalossofcochlear
nervefibersthattheimplantstimulates[14,54].Despitetheseconsiderations,thegreatmajorityofpatientsundergoing
cochlearimplantationforpresbycusiscanbeexpectedtoachievesignificantfunctionalimprovement,similartothat
seeninyoungerpatients[51,5560].Cochlearimplantsareindicatedforpeoplewithbilateralseverehearinglossthatis
notsignificantlyimprovedwithhearingaids[2].(See"Hearingamplificationinadults",sectionon'Cochlearimplants'.)

AssistivelisteningdevicesAvarietyofassistivelisteningdevicescanreducetheimpactofpresbycusisondaily
life[61].Thesemaybelinkedwithhearingaids,suchastelecoilsfortelephoneuseorfrequencymodulationsystems
thattransmitsoundinformationdirectlytoanindividual'shearingaid.Assistivelisteningdevicesmayalsobe
independentofhearingaids,suchastactileorvisualalertsthatcancompensateforlackofauditoryinput(eg,flashing
lightsforadoorbell).

Patientsatisfactionwithassistivelisteningdevicesisgenerallygood,althoughthereissomevariabilitydependingon
thespecificlisteningenvironmentinwhichtheyareapplied[62].Highfidelityfrequencymodulationsystemsthat
transmitsounddirectlytoauser'searsareapopularoption,andcanbeofparticularbenefitintheatersandlecture
hallswithotherwiseadverseacoustics[63,64].Theycanbehelpfulforlisteningtotelevision,andcanreducethe
stressoftryingtofindtherightvolumeforanumberoftelevisionviewers.Theuseofcaptioningfortelevisionviewing
canalsosignificantlyimprovecomprehensionforpatientswithpresbycusis[10].Assistivelisteningdevicescanbe
usedinseveralsettings,includingathome,atwork,andintheclassroom[65,66].

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AuditoryrehabilitationAuditoryorauralrehabilitationisdefinedassensorymanagement,instruction,perceptual
training,andcounselingforhearingimpairment[67].Auditoryrehabilitationincludesinterventionssuchasactive
listeningtraining,speechreading,andcommunicationenhancement.Specificexamplesincludeeducationonreading
facialexpressionsorlipcontoursofspeakers,interpretingcontextualcuessuchasposturetoovercomefastspeech,
andmaximizingenvironmentalfactorssuchasensuringadequatelightingorphasingoutcompetingsoundsources
[15].Thesetreatmentsareusuallyadministeredthroughoneononetraining,aswellasinthegroupsetting.Auditory
rehabilitation,whenavailable,isusuallypracticedincombinationwithhearingdevices.

Patientscanusespecificstrategiestoimprovetheircommunicationabilities.Selectingrestaurantsandvenueswith
favorableacousticscansignificantlyimprovetheexperience,ascanpositioningcompanionsonthesideofamore
favorableear.Oneofthemostimportantstrategiesisforthosewithhearinglosstoactivelyinformcompanionsabout
hearingloss.Inthiswaytheircompanionscanmakeahabitofusingbeneficialcommunicationtechniques(eg,
speakingslowlyandclearlywhilefacingtheindividualwithhearingloss).

Asystematicreviewofauditoryrehabilitationfoundthatthereislittleevidencethatrehabilitationimproves
communicationduetohearingloss[68].Inaddition,itisnotknownwhichmethodsofrehabilitationaremostlikelyto
behelpfulinwhichpopulations,aloneorincombinationwithhearingdevices.Despitelackofefficacy,auditory
rehabilitationisstillroutinelyperformed,andnewerrehabilitationmethodsarebeingdevelopedsuchasspeech
trackingandanalyticauditorytrainingincomputerizedformsthatmayofferbenefit[69].

FutureinterventionsFuturetreatmentsforhearinglossmayincludegenetic,cellular,orpharmacotherapyto
inducetheregenerationofhaircellstorepopulatethedamagedregionsofthecochlea[70].Theidentificationof
endogenousstemcellswithintheinnerearoffershopeforstemcelltherapy[7173].Theabilitytounlockthe
regenerativepotentialofsuchcellscouldhelptoaddressthefundamentaldeficitsinpresbycusis.Further
understandingisneededoftheunderlyingcausesofagerelatedhearinglosssothatmoretargetedinterventionscan
bedeveloped.

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"
andthekeyword(s)ofinterest.)

Basicstopic(see"Patienteducation:Agerelatedhearingloss(presbycusis)(TheBasics)")

SUMMARYANDRECOMMENDATIONS

Presbycusis,oragerelatedhearingloss,isacommoncauseofhearinglossworldwide,affectingmorethanhalf
ofalladultsbyage75years.(See'Epidemiology'above.)

Multiplefactorsinfluencetheonsetandseverityofpresbycusis.Thesefactorsincludegeneticpredisposition,low
socioeconomicstatus,noiseexposure,ototoxins(eg,aminoglycosides,chemotherapeuticagents,heavy
metals),infections,smoking,hypertension,diabetes,vasculardisease,immunologicdisorders,andhormonal
factors.(See'Riskfactors'above.)

Thehallmarkofpresbycusisistheprogressive,symmetriclossofhighfrequencyhearing.Highfrequency
speechcarriestheconsonantsounds,andthereforethemajorityofspeechinformation.Hearinglosscanalsobe
accompaniedbytinnitus,vertigo,anddisequilibrium.Presbycusiscancauselowselfesteem,isolation,and
depression.(See'Clinicalpresentation'above.)

Thediagnosisofpresbycusisshouldbesuspectedbaseduponahistoryofsymmetricalhearinglossovermany
yearsinanolderindividual.Thephysicalexaminationmaybehelpfulindeterminingthetypeofhearingloss
(conductiveversussensorineural),possiblecontributingfactorsforhearingloss(eg,cerumen),orothercausesof
hearingimpairment(eg,tumorssuchasacousticneuroma).Patientswithhearinglossthatimpairssocial
functioningorqualityoflifewillrequireformalaudiogramtestingtoconfirmthediagnosis,determineseverity,and
directmanagement.(See'Evaluation'above.)

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Adirectedtreatmenttopreventorreversetheeffectsofpresbycusisisnotavailable.However,mostpatients
withsignificantagerelatedhearinglosswillbenefitfromuseofhearingaids.Therearenostrictcriteriawhen
hearingamplificationshouldberecommended.Hearingaidsaregenerallyindicatedwhenhighfrequencyhearing
thresholdsreach40dBonanaudiogram.(See'Hearingaids'aboveand"Hearingamplificationinadults".)

Cochlearimplantsareutilizedforpatientswithseverehearinglossthatisnotsignificantlyimprovedwithhearing
aids.Assistivelisteningdevicesandauditoryrehabilitationmaybehelpfulforpresbycusisandareusually
employedinadditiontohearingamplificationdevices.(See'Cochlearimplantation'aboveand'Assistivelistening
devices'aboveand'Auditoryrehabilitation'above.)

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Topic15359Version18.0

ContributorDisclosures
NikolasHBlevins,MDNothingtodisclose.DanielGDeschler,MD,FACSNothingtodisclose.HowardLibman,
MDConsultant/AdvisoryBoards:GileadSciences[HIV(emtricitabine,efavirenz,elvitegravir,rilpivirine,tenofovir,
cobicistat)].

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
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