My Four Most-Used Fall Prevention Approaches

Have you noticed that an older relative seems to be having trouble hearing you at times?

Or perhaps you’ve realized that sometimes YOU are the one saying “What?”

These situations are extremely common. Sometimes the issue is that one is trying to communicate in a noisy place and there is no need for concern.

But in many cases, these kinds of issues can indicate that an older person (or even a middle-aged person) is being affected by age-related hearing loss. (The medical term is “presbycusis”)

You probably already know this: chronic hearing impairment becomes very common as one gets older. The National Institute on Aging reports that one in three adults aged 65-74 has hearing loss, and nearly half of those aged 75+ have difficulty with hearing.

Hearing loss also affects a significant number of people earlier in life. A 2011 study on the epidemiology of hearing loss documented hearing loss in 11% of participants aged 45-54, and 25% of those aged 55-64.

In short, research confirms that quite a lot of people experience hearing loss. But sadly, research also confirms that hearing loss is often under-recognized and inadequately addressed.

This is a major public health issue, for older adults and also for the many middle-aged adults experiencing hearing loss. At this point, we know quite a lot about:

• The many ways hearing loss negatively impacts the person affected by it (and their family),
• The many ways we can help correct hearing loss, through hearing aids, other amplification options, and better communication techniques.

Since this is such an important issue, in this article, I’ll share the following:

• 4 key things to know about hearing loss in aging
• What to do if you’re concerned about hearing loss
• A brochure you can use to persuade a reluctant older adult to address hearing loss
• The simple device many geriatricians use for hearing loss

4 Key Things to Know about Hearing Loss in Aging

A while back, I interviewed my UCSF colleague, Professor Meg Wallhagen, PhD, to join me on my podcast to talk about hearing loss and what can and should be done about it. She is a nationally recognized expert on hearing loss and spent years on the board of the Hearing Loss Association of America.

You can listen to these podcast episodes here:

094 – Interview: Hearing Loss in Aging: Why It Matters & Getting Evaluated

095 – Interview: Hearing Aids & Other Hearing Loss Treatment Options

Here are my four top takeaways from the interviews with Professor Meg Wallhagen:

1. It’s not good to put off addressing hearing loss.

Why this is important:

• Your brain’s auditory cortex needs the hearing input to remain in good shape!
  • Hearing involves getting the input through your ears and the related nerves, AND then your brain must process this sensory input in what’s known as the “auditory cortex.”
  • “Use it or lose it” applies here. Your brain’s auditory cortex will get worse at processing sound, if you don’t give it enough good quality input to work with.

• Hearing loss is associated with negative impacts on cognitive function.
  • Cognitive abilities (e.g. memory and thinking) may decline faster in people with hearing loss.
  • Studies have linked hearing loss to a higher risk of dementia. For more on this, see: What’s the connection between hearing and cognitive health?

• It is easier and better for the brain if you try to correct hearing loss sooner rather than later.
  • The sooner you improve the hearing input coming into the brain, the better it is for the brain. This is also much better for social relationships, work relationships, safety, and more.
  • Hearing aids also require a period of adaptation and learning. This becomes harder as brains get older. It also becomes harder as hearing loss becomes more severe with time.

• Hearing loss has a significant impact on social relationships.
  • Friends and families become tired of all the extra effort required to communicate when there is hearing loss, and may engage less with a person. Spouses, in particular, can become very frustrated.
  • Workplace performance and relationships can be affected, and this can negatively impact an older person’s job and ability to maintain their job.
  • People with unaddressed hearing loss are more likely to become socially isolated.

2. Don’t assume that your primary care doctor will notice hearing loss or initiate a suitable evaluation.

Why this is important:

• Research shows that hearing loss is commonly overlooked in primary care.
  • Patients and families should be proactive in bringing up hearing loss and in asking their health providers to address it.
  • If your older parents or another relative is experiencing hearing loss, encourage them to talk to their health provider about it.
    • Try printing out and reviewing Professor Wallhagen’s brochure, as it explains why addressing hearing loss is important and what can be done.

• Traditional Medicare, unfortunately, does not cover routine audiology testing.
  • It may cover this type of testing when it is ordered by a medical professional “for the purpose of informing the physician’s diagnostic medical evaluation or determining appropriate medical or surgical treatment of a hearing deficit or related medical problem.”
  • Some Medicare Advantage plans may cover audiology.
  • The best is to ask your health provider and see if you can get this testing covered.

Provided there are no medical red flags noted, evaluation of most age-related hearing loss requires removing earwax and then a referral to audiology, for in-depth testing of hearing. For more on what is covered in the audiology evaluation, see here and here.

3. Consider options other than hearing aids, especially for people who aren’t good candidates for hearing aids.

Why this is important:

• Hearing aids can be very effective, but they aren’t right for everyone. That’s because:
  • For them to help with hearing, a person must put in some time and effort in getting them properly adjusted, and in letting the brain learn to work with them. They require much more work than glasses!
  • People who are cognitively impaired, or have very severe hearing loss, may not be able to handle the work of adapting to hearing aids.
  • Hearing aids also require maintenance. Some older adults will not able to manage changing batteries, keep track of these devices, or making necessary adjustments.

• Not everyone is a good candidate for hearing aids.
  • People with dementia often have difficulty cooperating with the fitting and adjustment period. Plus, the dementia process affecting their brain may also make it harder for their auditory cortex to learn to adapt to the hearing aid.
  • People with very severe or long-standing hearing loss may be less likely to benefit from hearing aids. This is in part because more amplification and correction is needed, and also because the brain needs to do more work to compensate for all that time during which it wasn’t getting the right input.

• Other approaches to amplification and communication can be effective to help with hearing loss. These include:
  • Assistive devices for phones
  • Assistive devices for TVs and other devices
  • Better communication strategies, such as seeking quieter places to talk when possible and directly facing the person with hearing loss, so they can see the face and lips of a speaker.
  • “Pocketalkers“*, which are a simple and inexpensive hearing amplification device used by geriatricians and others. They can also usually be used with people who have dementia.

Note: as of October 2022, over-the-counter (OTC) hearing aids have finally become available. The National Council on Aging has a list of best OTC hearing aids here. As far as I can tell, the main advantage of OTC devices is that they are less expensive than conventional hearing aids. If a person is not a good candidate for a hearing aid, an OTC hearing aid is not going to fix that problem.

4. Age-related hearing loss affects higher frequency sounds in particular, and causes distortion (not muffling) of sounds. 

Why this is important:

• This is why older people with hearing loss will say they can hear.
  • They are right, they CAN hear! But their hearing loss makes it harder for them to hear certain speech frequencies, which leads to distortion of sound.
  • It’s important to realize that age-related hearing loss causes distortion, not muffling.

• This is why it’s usually not helpful to shout at someone with age-related hearing loss.
  • You will just be making a distorted sound louder.
  • Instead, use the communication strategies recommended in Professor Wallhagen’s brochure (see below).

• This is why deciphering speech becomes difficult for someone with age-related hearing loss.
  • Many consonants are spoken at a relatively high frequency.
  • When age-related hearing loss affects the ability to hear different consonants, human speech becomes harder to decipher.

• This is why older adults with hearing loss may have difficulty understanding children, and other high-pitched voices.
  • Young children often have higher-pitched voices. These can be hard for older adults with hearing loss to decipher, unless the hearing loss is addressed.

What to do if you’ve been concerned about hearing loss

Talking to Professor Wallhagen really brought this home for me: hearing loss is important and it’s much better to address it sooner rather than later!

In particular, addressing hearing loss earlier is better for the brain, better for relationships, and may even help a person perform better at work.

If you’ve had any concerns about hearing loss for yourself or for another older adult, here are the basic next steps:

1.Bring it to the attention of your primary care provider (PCP). 

Start by letting your PCP know of any potential hearing loss. The PCP should do a related “history and physical examination”, meaning they will ask questions about related symptoms and medical conditions that can affect hearing. They will also do a physical examination related to auditory issues.

Most hearing loss in older adults is garden-variety age-related hearing loss (which is technically called “presbycusis“). It usually happens due to a combination of age-related changes and noise-related damage to the inner ear, and it slowly gets worse over time.

It’s also extremely common for hearing loss to be caused by — or usually worsened by — ear wax (technically called “cerumen”) plugging up the ear canal.

For this reason, it’s essential that the PCP look in both ear canals, to make sure there aren’t any blockages.

If there is any ear wax accumulation, the ear wax should be removed. This is sometimes done in the doctor’s office, but it’s also common (and probably safer) to do this at home, using some ear wax softening drops and a bulb syringe to gently rinse the ear canal.  AARP has a good article on this topic here: The Ins and Outs of Safe Earwax Removal.

There are also many other medical conditions that can cause hearing loss. Among other reasons, hearing loss can be related to a viral infection, to brain changes, or even to certain medications.

A medical exam related to hearing can help check for these less common causes of hearing loss, before you proceed with further audiology evaluation. In some cases, the PCP might refer you to an ears-nose-throat specialist (an otolaryngologist). But in many cases, the initial medical examination can be done in primary care.

2. Get an audiology evaluation.

An audiology evaluation is a special detailed test of a person’s hearing.

During the evaluation, the audiologist will vary the pitch and loudness of sounds, to determine what is the quietest sound each ear can hear at different frequencies. Audiology evaluations also usually include speech recognition tests.

You can learn more about audiology evaluations here: Hearing Tests for Adults.

The audiology evaluation helps pinpoint the specific types of sounds that a person is having difficulty hearing, and also helps classify the hearing loss as mild, moderate, or severe.

These results can then be used to determine what type of hearing aids might be suitable, or whether other types of hearing assistive technology should be considered.

3. Seek out suitable hearing assistive technology.

If the older person is a good candidate for hearing aids (remember, not everyone is!), then you should look into getting suitable hearing aids.

Until recently, this required being fitted for hearing aids by an audiologist. However, as of October 2022, over-the-counter (OTC) hearing aids have become available. A small randomized trial published in April 2023 found that “self-reported and speech-in-noise benefit was equivalent between the self-fitting OTC and audiologist-fitted hearing aid conditions at the end of 6 weeks.”

In other words, preliminary research suggests that OTC hearing aids, which are generally more affordable than audiologist-fitted hearing aids, are a good option for people with mild to moderate hearing loss. (Note: the average age of participants in this trial was 64.)

There are also other hearing assistive technologies to consider. The Hearing Loss Association of America provides a nice overview here: Hearing Assistive Technology.

4. Learn and use hearing loss communication strategies.

Whether or not an older person is using hearing aids or other hearing assistive technology, it’s worth learning and using certain strategies that make communication easier when someone has hearing loss.

These include:

• Face the hearing-impaired person directly, with the speaker’s face in good lighting. Avoid being backlit when you are speaking.
• Avoid shouting, which distorts speech. Instead, speak clearly, distinctly, and not too fast.
• Try to minimize background noise.
• Say the person’s name when you start speaking, or otherwise get their attention before you continue speaking.
• Don’t cover your mouth or chew food while speaking to someone with hearing loss.

There is a good list of communication tips available here: Communicating with People with Hearing Loss.

What to do if an older person won’t address their hearing loss

There are, of course, common obstacles that come up to addressing hearing loss.

A major one is that affected person often either doesn’t notice their hearing loss or avoids addressing it. They don’t want to feel old. They may have heard “hearing aids don’t work,” or that they’re expensive. Or they may just be waiting for their doctor to bring it up.

If this has come up for you, I highly recommend you try using Professor Wallhagen’s specially designed brochure. It’s been clinically tested in research, which has confirmed that it helps older adults address hearing loss.

Click here for the brochure: Hearing Helps Us Stay Connected to Others.

Use the brochure to help an older adult address their hearing loss. You can print it out, discuss it with family, and then use it to spark a conversation with your health providers. Here it is again: Hearing Helps Us Stay Connected to Others.

The simple device many geriatricians use for hearing loss

The best approach to hearing loss is the one I described above: get evaluated by the PCP, get an audiology evaluation, and then get suitable hearing assistive technology.

But what if you’re trying to communicate with an older adult who hasn’t yet gotten evaluated for hearing loss? Or maybe isn’t a good candidate for hearing aids?

In this case, a short-term solution to consider is a Pocketalker * type of device. These are especially helpful when it comes to people with dementia, who often are not good candidates for hearing aids.

Many geriatricians carry pocket talkers with them, since they are so handy for communicating with those “hard-of-hearing” patients. In fact, I’ve had a Pocketalker in my doctor’s bag since geriatrics fellowship, and always take it with me on housecalls.

To help you address hearing loss 

Again, I highly recommend UCSF Professor Meg Wallhagen’s wonderful informative brochure, which has been clinically proven to help older adults address hearing loss:

Click here for the brochure: Hearing Helps Us Stay Connected to Others.

Good luck addressing hearing loss! It’s really worthwhile, even if it can be an effort to get the process started.