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1.  The Need for Improved Detection and Management of Adult-Onset Hearing Loss in Australia 
Adult-onset hearing loss is insidious and typically diagnosed and managed several years after onset. Often, this is after the loss having led to multiple negative consequences including effects on employment, depressive symptoms, and increased risk of mortality. In contrast, the use of hearing aids is associated with reduced depression, longer life expectancy, and retention in the workplace. Despite this, several studies indicate high levels of unmet need for hearing health services in older adults and poor use of prescribed hearing aids, often leading to their abandonment. In Australia, the largest component of financial cost of hearing loss (excluding the loss of well-being) is due to lost workplace productivity. Nonetheless, the Australian public health system does not have an effective and sustainable hearing screening strategy to tackle the problem of poor detection of adult-onset hearing loss. Given the increasing prevalence and disease burden of hearing impairment in adults, two key areas are not adequately met in the Australian healthcare system: (1) early identification of persons with chronic hearing impairment; (2) appropriate and targeted referral of these patients to hearing health service providers. This paper reviews the current literature, including population-based data from the Blue Mountains Hearing Study, and suggests different models for early detection of adult-onset hearing loss.
doi:10.1155/2013/308509
PMCID: PMC3655600  PMID: 23710184
2.  The benefits of hearing aids and closed captioning for television viewing by older adults with hearing loss 
Ear and hearing  2009;30(4):458.
Objectives
Although watching television is a common leisure activity of older adults, the ability to understand televised speech may be compromised by age-related hearing loss. Two potential assistive devices for improving television viewing are hearing aids and closed captioning, but their use and benefit by older adults with hearing loss are unknown. The primary purpose of this initial investigation was to determine if older hearing-impaired adults show improvements in understanding televised speech with the use of these two assistive devices (hearing aids and closed captioning) compared to conditions without these devices. A secondary purpose was to examine the frequency of hearing aid use and closed captioning use among a sample of older hearing aid wearers.
Design
The investigation entailed a randomized, repeated-measures design of 15 older adults (59–82 years) with bilateral sensorineural hearing losses who wore hearing aids. Participants viewed three types of televised programs (news, drama, game show) that were each edited into lists of speech segments, and provided an identification response. Each participant was tested in four conditions: baseline (no hearing aids or closed captioning), hearing aids only, closed captioning only, and hearing aids + closed captioning. Pilot testing with young normal-hearing listeners was conducted also to establish list equivalence and stimulus intelligibility with a control group. All testing was conducted in a quiet room to simulate a living room, using a 19-in flat screen television. Questionnaires were also administered to participants to determine frequency of hearing aid use and closed captioning use while watching television.
Results
A significant effect of viewing condition was observed for all programs. Participants exhibited significantly better speech recognition scores in conditions with closed captioning than those without closed captioning (p<.01). Use of personal hearing aids did not significantly improve recognition of televised speech compared to the unaided condition. The condition effect was similar across the three different programs. Most of the participants (73%) regularly wore their hearing aids while watching television; very few of them (13%) had ever used closed captioning.
Conclusions
On average, use of closed captioning while watching television dramatically improved speech understanding by a sample of older hearing-impaired adults compared to conditions without closed captioning, including when hearing aids were worn.
doi:10.1097/AUD.0b013e3181a26ef4
PMCID: PMC2820302  PMID: 19444122
3.  Dual Sensory Impairment in Older Adults Increases the Risk of Mortality: A Population-Based Study 
PLoS ONE  2013;8(3):e55054.
Although concurrent vision and hearing loss are common in older adults, population-based data on their relationship with mortality is limited. This cohort study investigated the association between objectively measured dual sensory impairment (DSI) with mortality risk over 10 years. 2812 Blue Mountains Eye Study participants aged 55 years and older at baseline were included for analyses. Visual impairment was defined as visual acuity less than 20/40 (better eye), and hearing impairment as average pure-tone air conduction threshold greater than 25 dB HL (500–4000 Hz, better ear). Ten-year all-cause mortality was confirmed using the Australian National Death Index. After ten years, 64% and 11% of participants with DSI and no sensory loss, respectively, had died. After multivariable adjustment, participants with DSI (presenting visual impairment and hearing impairment) compared to those with no sensory impairment at baseline, had 62% increased risk of all-cause mortality, hazard ratio, HR, 1.62 (95% confidence intervals, CI, 1.16–2.26). This association was more marked in those with both moderate-severe hearing loss (>40 dB HL) and presenting visual impairment, HR 1.84 (95% CI 1.19–2.86). Participants with either presenting visual impairment only or hearing impairment only, did not have an increased risk of mortality, HR 1.05 (95% CI 0.61–1.80) and HR 1.24 (95% CI 0.99–1.54), respectively. Concurrent best-corrected visual impairment and moderate-severe hearing loss was more strongly associated with mortality 10 years later, HR 2.19 (95% CI 1.20–4.03). Objectively measured DSI was an independent predictor of total mortality in older adults. DSI was associated with a risk of death greater than that of either vision loss only or hearing loss alone.
doi:10.1371/journal.pone.0055054
PMCID: PMC3587637  PMID: 23469161
4.  A randomised controlled trial of screening for adult hearing loss during preventive health checks. 
BACKGROUND: Prophylactic strategies to counter acquired hearing impairment may involve routine audiometric screening of asymptomatic working-age adults attending general practice for regular health checks. AIM: To evaluate the effect of adult hearing screening on subsequent noise exposure and hearing. DESIGN OF STUDY: A randomised controlled population-based study of health checks and health discussions in general practice. SETTING: The project was initiated in the district of Ebeltoft, Aarhus county, Denmark. METHOD: Intervention group participants' hearing thresholds were determined audiometrically at 0.5, 1, 2, 3, and 4 kHz in each ear. Participants were advised to get their ears checked if the average hearing loss exceeded 20 dB hearing level (dBHL) in either ear. Noise avoidance was emphasised when thresholds exceeded 25 dBHL bilaterally at 4 kHz. Follow-up included questionnaires and audiometry. RESULTS: Hearing loss was observed among 18.9% of the study sample at baseline. At the five-year follow-up we recorded no significant differences between the control and the intervention groups regarding subjective or objective hearing, or exposure to occupational noise. However, there was a tendency towards reduction in exposure to leisure noise among intervention participants (P = 0.045). Approximately 20% reported hearing problems; 16.5% reported tinnitus-related complaints; 0.8% used hearing aids; 35.0% reported frequent noise exposure; and occluding wax was suspected in 2.1%. CONCLUSION: Preventive health checks with audiometry did not significantly affect hearing, but leisure noise exposure tended to become less frequent. The poor effect may be ascribed to inadequate audiological counselling or a higher priority to other advice, e.g. on cardiovascular risk or lifestyle.
PMCID: PMC1313997  PMID: 11360697
5.  Bone Anchored Hearing Aid 
Executive Summary
Objective
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of bone-anchored hearing aid (BAHA) in improving the hearing of people with conduction or mixed hearing loss.
The Technology
The (BAHA) is a bone conduction hearing device that includes a titanium fixture permanently implanted into the mastoid bone of the skull and an external percutaneous sound processor. The sound processor is attached to the fixture by means of a skin penetrating abutment. Because the device bypasses the middle ear and directly stimulates the cochlea, it has been recommended for individuals with conduction hearing loss or discharging middle ear infection.
The titanium implant is expected to last a lifetime while the external sound processor is expected to last 5 years. The total initial device cost is approximately $5,300 and the external sound processor costs approximately $3,500.
Review of BAHA by the Medical Advisory Secretariat
The Medical Advisory Secretariat’s review is a descriptive synthesis of findings from 36 research articles published between January 1990 and May 2002.
Summary of Findings
No randomized controlled studies were found. The evidence was derived from level 4 case series with relative small sample sizes (ranging from 30-188). The majority of the studies have follow-up periods of eight years or longer. All except one study were based on monaural BAHA implant on the side with the best bone conduction threshold.
Safety
Level 4 evidence showed that BAHA has been be implanted safely in adults and children with success rates of 90% or higher in most studies. No mortality or life threatening morbidity has been reported. Revision rates for tissue reduction or resiting were generally under 10% for adults but have been reported to be as high as 25% in pediatric studies.
Adverse skin reaction around the skin penetration site was the most common complication reported. Most of these conditions were successfully treated with antibiotics, and only 1% to 2% required surgical revision. Less than 1% required removal of the fixture.
Other complications included failure to osseointegrate and loss of fixture and/or abutment due to trauma or infection.
Effectiveness
Studies showed that BAHAs were implanted in people who have conduction or mixed hearing loss, congenital atresia or suppurative otitis media who were not candidates for surgical repair, and who cannot use conventional bone conduction hearing aids. The need for BAHA is not age- related. Objective audiometric measures and subjective patient satisfaction surveys showed that BAHA significantly improved the unaided and aided free field and sound field thresholds as well as speech discrimination in quiet and in noise for former users of conventional bone conduction hearing aids. The outcomes were ambiguous for former users of air conduction hearing aids.
BAHA has been shown to reduce the frequency of ear infection and reduce the discharge particularly among patients with suppurative otitis media.
Patients have reported that BAHA improved their quality of life. Reported benefits were improved speech intelligibility, better sound comfort, less pressure on the head, less skin irritation, greater cosmetic acceptance and increase in confidence. Main reported shortcomings were wind noise, feedback and difficulty in using the telephone.
Experts and the BAHA manufacturer recommended that recipients of a BAHA implant be at least 5 years old. Challenges associated with the implantation of BAHA in pediatric patients include thin bone, soft bone, higher rates of fixture loss due to trauma, psychological problems, and higher revision rates due to rapid bone growth. The overall outcomes are comparable to adult BAHA. The benefits of pediatric BAHA (e.g. on speech development) appear to outweigh the disadvantages.
Screening according to strict eligibility criteria, preoperative counselling, close monitoring by a physician with BAHA expertise and on-going follow-up were identified as critical factors for long-term implant survival. Examples of eligibility criteria were provided.
Cost-effectiveness
No literature on cost-effectiveness of BAHA was found.
PMCID: PMC3387772  PMID: 23074440
6.  Cochlear Implant Rehabilitation in Older Adults: Literature Review and Proposal of a Conceptual Framework 
Hearing loss is a prevalent consequence of aging and also poses special challenges for older adults. Particularly when superimposed on other age-related conditions, presbycusis (age-related hearing loss) places the older adult at risk for social isolation and associated psychological and general health sequelae. The increasing cognitive demand of verbal communication, as well as the diminished sense of social and physical connectedness, can furthermore contribute to a feeling of vulnerability and poor health that worsens with advancing presbycusis. This cascade of downstream effects of hearing loss has implications for the self-assessment of health related quality of life (HRQL) and resulting estimates of associated costs. There is accumulating evidence of a potential role for cochlear implants (CI) in older adults with poor word understanding despite conventional hearing aid (HA) usage. In our review of the literature we identify strong evidence for the restoration of communication capacity in the deaf and hard of hearing geriatric population, little published work on communication performance in the real world and HRQL, and significant gaps of knowledge regarding how CI rehabilitation interacts with changing psychosocial and functional status. We therefore propose a broader conceptual framework than is currently available for the role of CI rehabilitation in the management of severe-to-profound hearing loss in older adults. We posit that the use of such a model in future investigations is needed to guide multidisciplinary investigations into the unique challenges of hearing loss in older adults as well as open new opportunities for innovation.
doi:10.1111/j.1532-5415.2012.04150.x
PMCID: PMC3902638  PMID: 22974240
presbycusis; hearing loss; aging; older adults; cochlear implant; communication; conceptual framework; cascade
7.  Auditory Cortex Signs of Age-Related Hearing Loss 
Age-related hearing loss, or presbyacusis, is a major public health problem that causes communication difficulties and is associated with diminished quality of life. Limited satisfaction with hearing aids, particularly in noisy listening conditions, suggests that central nervous system declines occur with presbyacusis and may limit the efficacy of interventions focused solely on improving audibility. This study of 49 older adults (M = 69.58, SD = 8.22 years; 29 female) was designed to examine the extent to which low and/or high frequency hearing loss was related to auditory cortex morphology. Low and high frequency hearing constructs were obtained from a factor analysis of audiograms from these older adults and 1,704 audiograms from an independent sample of older adults. Significant region of interest and voxel-wise gray matter volume associations were observed for the high frequency hearing construct. These effects occurred most robustly in a primary auditory cortex region (Te1.0) where there was also elevated cerebrospinal fluid with high frequency hearing loss, suggesting that auditory cortex atrophies with high frequency hearing loss. These results indicate that Te1.0 is particularly affected by high frequency hearing loss and may be a target for evaluating the efficacy of interventions for hearing loss.
doi:10.1007/s10162-012-0332-5
PMCID: PMC3441956  PMID: 22618352
presbyacusis; age-related hearing loss; auditory cortex
8.  Tinnitus and Patterns of Hearing Loss 
Tinnitus is strongly linked with the presence of damaged hearing. However, it is not known why tinnitus afflicts only some, and not all, hearing-impaired listeners. One possibility is that tinnitus patients have specific inner ear damage that triggers tinnitus. In this study, differences in cochlear function inferred from psychophysical measures were measured between hearing-impaired listeners with tinnitus and hearing-impaired listeners without tinnitus. Despite having similar average hearing loss, tinnitus patients were observed to have better frequency selectivity and compression than those without tinnitus. The results suggest that the presence of subjective tinnitus may not be strongly associated to outer hair cell impairment, at least where hearing impairment is evident. The results also show a different average pattern of hearing impairment amongst the tinnitus patients, consistent with the suggestion that inner hair cell dysfunction with subsequent reduced auditory innervation is a possible trigger of tinnitus.
doi:10.1007/s10162-013-0371-6
PMCID: PMC3660910  PMID: 23328862
tinnitus; hearing loss; psychoacoustics; absolute thresholds; frequency selectivity; compression
9.  Hearing Loss Prevalence and Risk Factors Among Older Adults in the United States 
Background.
Hearing loss has been associated with cognitive and functional decline in older adults and may be amenable to rehabilitative interventions, but national estimates of hearing loss prevalence and hearing aid use in older adults are unavailable.
Methods.
We analyzed data from the 2005–2006 cycle of the National Health and Nutritional Examination Survey, which is the first cycle to ever incorporate hearing assessment in adults aged 70 years and older. Audiometry was performed in 717 older adults, and data on hearing aid use, noise exposure, medical history, and demographics were obtained from interviews. Analyses incorporated sampling weights to account for the complex sampling design and yield results that are generalizable to the U.S. population.
Results.
The prevalence of hearing loss defined as a speech frequency pure tone average of more than 25 dB in the better ear was 63.1% (95% confidence interval: 57.4–68.8). Age, sex, and race were the factors most strongly associated with hearing loss after multivariate adjustment, with black race being substantially protective against hearing loss (odds ratio 0.32 compared with white participants [95% confidence interval: 0.19–0.53]). Hearing aids were used in 40.0% (95% confidence interval: 35.1–44.8) of adults with moderate hearing loss, but in only 3.4% (95% confidence interval: 0.8–6.0) of those with a mild hearing loss.
Conclusion.
Hearing loss is prevalent in nearly two thirds of adults aged 70 years and older in the U.S. population. Additional research is needed to determine the epidemiological and physiological basis for the protective effect of black race against hearing loss and to determine the role of hearing aids in those with a mild hearing loss.
doi:10.1093/gerona/glr002
PMCID: PMC3074958  PMID: 21357188
Hearing loss; Epidemiology; Older adults; Risk factors; Race; Hearing aids
10.  Hearing Loss and Cognitive Decline Among Older Adults 
JAMA internal medicine  2013;173(4):10.1001/jamainternmed.2013.1868.
Background
Whether hearing loss is independently associated with accelerated cognitive decline in older adults is unknown.
Methods
We studied 1984 older adults (mean age 77.4 years) enrolled in the HealthABC study, a prospective observational study begun in 1997–98. Our baseline cohort consisted of participants without prevalent cognitive impairment (Modified Mini-Mental State [3MS] scores ≥ 80) who underwent audiometric testing in Year 5. Participants were followed for 6 years. Hearing was defined at baseline using a pure-tone average (PTA) of thresholds at 0.5 – 4 kHz in the better-hearing ear. Cognitive testing was performed in Years 5, 8, 10, and 11 and consisted of the 3MS (measuring global function) and the Digit Symbol Substitution test (DSS, measuring executive function). Incident cognitive impairment was defined as a 3MS score < 80 or a decline in 3MS > 5 points from baseline. Mixed-effects regression and Cox models were adjusted for demographic and cardiovascular risk factors.
Results
Individuals with baseline hearing loss (PTA > 25 dB, n = 1162) had rates of decline in 3MS and DSS scores that were 41% and 32% greater, respectively, than those in normal hearing individuals (3MS: −0.65 points/year [95% CI: −0.73 – −0.56] vs. −0.46 points/year [95% CI: −0.55 – −0.36], p=.004; DSS: −0.83 points/year [95% CI: −0.94 – −0.73] vs. −0.63 points/year [95% CI: −0.75 – −0.51], p=.015). Compared to those with normal hearing, individuals with hearing loss had a 24% (Hazard ratio: 1.24 [95% CI: 1.05 – 1.48]) increased risk of incident cognitive impairment. Rates of cognitive decline and the risk of incident cognitive impairment were linearly associated with the severity of an individual’s baseline hearing loss.
Conclusion
Hearing loss is independently associated with accelerated cognitive decline and incident cognitive impairment in community-dwelling older adults. Further studies investigating the mechanistic basis of this association and whether hearing rehabilitative interventions could affect cognitive decline are needed.
doi:10.1001/jamainternmed.2013.1868
PMCID: PMC3869227  PMID: 23337978
11.  A Pilot Study on Cortical Auditory Evoked Potentials in Children: Aided CAEPs Reflect Improved High-Frequency Audibility with Frequency Compression Hearing Aid Technology 
Background. This study investigated whether cortical auditory evoked potentials (CAEPs) could reliably be recorded and interpreted using clinical testing equipment, to assess the effects of hearing aid technology on the CAEP. Methods. Fifteen normal hearing (NH) and five hearing impaired (HI) children were included in the study. NH children were tested unaided; HI children were tested while wearing hearing aids. CAEPs were evoked with tone bursts presented at a suprathreshold level. Presence/absence of CAEPs was established based on agreement between two independent raters. Results. Present waveforms were interpreted for most NH listeners and all HI listeners, when stimuli were measured to be at an audible level. The younger NH children were found to have significantly different waveform morphology, compared to the older children, with grand averaged waveforms differing in the later part of the time window (the N2 response). Results suggest that in some children, frequency compression hearing aid processing improved audibility of specific frequencies, leading to increased rates of detectable cortical responses in HI children. Conclusions. These findings provide support for the use of CAEPs in measuring hearing aid benefit. Further research is needed to validate aided results across a larger group of HI participants and with speech-based stimuli.
doi:10.1155/2012/982894
PMCID: PMC3501956  PMID: 23197983
12.  Hearing impairment and cognitive function among a community-dwelling population in Japan 
Background
Hearing impairment is a prevalent and chronic condition in older people. This study investigated the relationship between cognitive function and hearing impairment in a Japanese population.
Methods
A pure-tone average (0.5-2.0 kHz) was used to evaluate hearing impairment in 846 participants of the Iwaki Health Promotion Project who were aged at least 50 years old (310 men and 536 women). We also administered the Mini-Mental State Examination (MMSE), the Center for Epidemiologic Studies for Depression (CES-D) scale, Starkstein's apathy scale (AS) and the Short Form Health Survey Version 2 (SF-36v2). A multiple linear regression analysis assessed the association between hearing impairment and mental correlates.
Results
The overall prevalence of hearing impairment in this study population was 37.7%. The participants with hearing impairment were older and less educated compared to those with no hearing problems. We observed significant differences in the MMSE and AS scores between the mild/moderate to severe groups versus the non-impaired group. After adjusting for age, gender and amount of education, hearing impairment was significantly associated with MMSE and AS scores, but not with CES-D scores. Hearing impairment was significantly related to the social functioning (SF) and role emotional (RE) scores of the SF-36v2.
Conclusions
Hearing impairment is common among older people and is associated with cognitive impairment, apathy and a poor health-related quality of life. Screening for and correcting hearing impairments might improve the quality of life and functional status of older patients.
doi:10.1186/1744-859X-10-27
PMCID: PMC3192687  PMID: 21961439
13.  Effects of Age and Hearing Impairment on the Ability to Benefit from Temporal and Spectral Modulation 
Ear and Hearing  2012;33(3):340-348.
Objectives
At poor signal-to-noise ratios, speech understanding may depend upon the ability to combine speech fragments that are distributed across time and frequency. The goal of this study was to determine the effects of development and hearing impairment on this ability.
Design
Listeners in the present study included adults and children with normal hearing and with hearing impairment. The children with normal hearing included a younger group (4.6 to 6.9 years of age, n=10) and an older group (7.3 to 11.1 years of age, n=11). The adults with normal hearing were 19–27 years of age (n=10). Adults (19–54 years of age, n=9) and children (7.2 to 10.7 years of age, n=8) with hearing impairment were also tested. The two groups with hearing impairment had comparable mild/moderate bilateral sensorineural hearing impairment. Masked speech reception thresholds for sentences were determined in a baseline condition of steady speech-shaped noise and in noise that was either temporally modulated, spectrally modulated, or both temporally and spectrally modulated.
Results
The results of normal-hearing listeners indicated higher masked speech reception thresholds for children than adults in steady noise. Adults and children showed the same magnitude of masking release for spectral modulation. Adults showed more masking release than the younger children for temporal modulation, and showed more masking release than both the younger and older children for combined temporal/spectral modulation. Comparing normal-hearing and hearing-impaired listeners, the hearing-impaired listeners had higher masked speech reception thresholds (SRTs) in the steady noise condition and reduced masking release in the modulated noise conditions. Neither the two-way interaction between age and hearing impairment nor the three-way interaction between age, hearing impairment, and masking configuration was significant.
Conclusions
Although the reduced masking release for temporal modulation shown by the younger children with normal hearing could be due to poor temporal resolution, it more likely reflects inefficient use of speech cues in temporal gaps or factors stemming from higher signal-to-noise ratios required by children in the baseline condition. The reduced masking release for combined temporal/spectral modulation demonstrated by both the younger and older children with normal hearing may indicate that children in the age range tested here have some difficulty in combining speech information that is distributed across temporal and spectral gaps. Hearing impairment was associated with higher thresholds and reduced masking release in all modulation conditions. Children with hearing impairment showed the poorest performance of any group, consistent with additive effects of hearing loss and development.
doi:10.1097/AUD.0b013e31823fa4c3
PMCID: PMC3330172  PMID: 22237164
Speech perception; children; cochlear hearing loss; modulation
14.  Music Training Program: A Method Based on Language Development and Principles of Neuroscience to Optimize Speech and Language Skills in Hearing-Impaired Children 
Introduction:
In recent years, music has been employed in many intervention and rehabilitation program to enhance cognitive abilities in patients. Numerous researches show that music therapy can help improving language skills in patients including hearing impaired. In this study, a new method of music training is introduced based on principles of neuroscience and capabilities of Persian language to optimize language development in deaf children after implantation.
Materials and Methods:
The candidate children are classified in three groups according to their hearing age and language development. The music training program is established and centered on four principles, as follows: hearing and listening to music (with special attention to boost hearing), singing, rhythmic movements with music and playing musical instruments.
Results:
Recently much research has demonstrated that even after cochlear implant operation, a child cannot acquire language to the same level of detail as a normal child. As a result of this study music could compensate this developmental delay .It is known that the greater the area of the brain that is activated, the more synaptic learning and plasticity changes occur in that specific area. According to the principles of neural plasticity, music could improve language skills by activating the same areas for language processing in the brain.
Conclusion:
In conclusion, the effects of music on the human brain seem to be very promising and therapeutic in various types of disorders and conditions, including cochlear implantation.
PMCID: PMC3846262  PMID: 24303426
Cochlear implantation; Hearing loss; Language development; Music therapy; Neuroscience
15.  Hear ye? Hear ye! Successful auditory aging. 
Western Journal of Medicine  1997;167(4):247-252.
Age-related hearing loss (presbycusis) is a multifactorial process that affects nearly all people in their senior years. Most cases are due to a loss of cochlear hair cell function and are well mediated by communication courtesy and modern amplification technology. Severe hearing loss is generally due to cochlear problems or age-related diseases and may require speech reading, assistive listening devices, and cochlear implants, depending on the degree of loss. Presbycusis may seriously impair communication and contribute to isolation, depression, and possibly dementia. Accurate diagnosis and prompt remediation are widely available but are frequently underused. Geriatric health care and well-being is enhanced by the detection and remediation of communication disorders.
PMCID: PMC1304539  PMID: 9348755
16.  Potential Mediators of Diabetes-Related Hearing Impairment in the U.S. Population 
Diabetes Care  2010;33(4):811-816.
OBJECTIVE
We examined potential mediators of the reported association between diabetes and hearing impairment.
RESEARCH DESIGN AND METHODS
Data come from 1,508 participants, aged 40–69 years, who completed audiometric testing during 1999–2004 in the National Health and Nutrition Examination Survey (NHANES). We defined hearing impairment as the pure-tone average >25 decibels hearing level of pure-tone thresholds at low/mid (500, 1,000, and 2,000 Hz) and high (3,000, 4,000, 6,000, and 8,000 Hz) frequencies. Using logistic regression, we examined whether controlling for vascular or neuropathic conditions, cardiovascular risk factors, glycemia, or inflammation diminished the association between diabetes and hearing impairment.
RESULTS
Diabetes was associated with a 100% increased odds of low/mid-frequency hearing impairment (odds ratio 2.03 [95% CI 1.32–3.10]) and a 67% increased odds of high-frequency hearing impairment (1.67 [1.14–2.44]) in preliminary models after controlling for age, sex, race/ethnicity, education, smoking, and occupational noise exposure. Adjusting for peripheral neuropathy attenuated the association with low/mid-frequency hearing impairment (1.70 [1.02–2.82]). Adjusting for albuminuria and C-reactive protein attenuated the association with high-frequency hearing impairment (1.54 [1.02–2.32] and 1.50 [1.01–2.23], respectively). Diabetes was not associated with high-frequency hearing impairment after controlling for A1C (1.09 [0.60–1.99]) but remained associated with low/mid-frequency impairment. We found no evidence suggesting that our observed relationship between diabetes and hearing impairment is due to hypertension or dyslipidemia.
CONCLUSIONS
Mechanisms related to neuropathic or microvascular factors, inflammation, or hyperglycemia may be mediating the association of diabetes and hearing impairment.
doi:10.2337/dc09-1193
PMCID: PMC2845032  PMID: 20097782
17.  A Systematic Review of Studies Measuring and Reporting Hearing Aid Usage in Older Adults since 1999: A Descriptive Summary of Measurement Tools 
PLoS ONE  2012;7(3):e31831.
Objective
A systematic review was conducted to identify and quality assess how studies published since 1999 have measured and reported the usage of hearing aids in older adults. The relationship between usage and other dimensions of hearing aid outcome, age and hearing loss are summarised.
Data sources
Articles were identified through systematic searches in PubMed/MEDLINE, The University of Nottingham Online Catalogue, Web of Science and through reference checking. Study eligibility criteria: (1) participants aged fifty years or over with sensori-neural hearing loss, (2) provision of an air conduction hearing aid, (3) inclusion of hearing aid usage measure(s) and (4) published between 1999 and 2011.
Results
Of the initial 1933 papers obtained from the searches, a total of 64 were found eligible for review and were quality assessed on six dimensions: study design, choice of outcome instruments, level of reporting (usage, age, and audiometry) and cross validation of usage measures. Five papers were rated as being of high quality (scoring 10–12), 35 papers were rated as being of moderate quality (scoring 7–9), 22 as low quality (scoring 4–6) and two as very low quality (scoring 0–2). Fifteen different methods were identified for assessing the usage of hearing aids.
Conclusions
Generally, the usage data reviewed was not well specified. There was a lack of consistency and robustness in the way that usage of hearing aids was assessed and categorised. There is a need for more standardised level of reporting of hearing aid usage data to further understand the relationship between usage and hearing aid outcomes.
doi:10.1371/journal.pone.0031831
PMCID: PMC3313982  PMID: 22479312
18.  Aided speech-identification performance in single-talker competition by older adults with impaired hearing 
This study examined the effects of increased processing load on the closed-set speech-identification performance of young and older adults in a one-talker background. Since the older adults had impaired hearing, speech-identification performance was measured for spectrally shaped stimuli comparable to those experienced when wearing well-fit hearing aids. There were three groups of listeners: (1) 19 older adults with high-frequency sensorineural hearing loss; (2) 10 young adults with normal hearing who were assessed with the same spectrally shaped stimuli as the older adults; (3) 9 young adults with normal hearing who were assessed without spectral shaping and at a poorer target-to-competition ratio in an effort to equate overall performance to that of the older adults. In addition to this group factor, there were three within-participant repeated-measures independent variables designed to increase the demands on processing for the target and competing speech stimuli. These were: (1) competition meaningfulness (played in forward or reverse direction); (2) gender match between target and competing talkers (same or different gender); and (3) talker uncertainty (either the same target/competition talker pair or one of many such pairs on each trial). These three repeated-measures independent variables were examined in a 2 × 2 × 2 factorial design. They showed roughly independent and additive effects on speech-identification such that combinations of these variables decreased performance cumulatively. Older adults performed worse than young adults across the board, but also showed diminished relative improvement as the processing load was decreased. Individual differences in performance among the older adults were also examined.
doi:10.1111/j.1467-9450.2009.00740.x
PMCID: PMC2820503  PMID: 19778396
Aging; speech perception; hearing loss
19.  Internet Access and Use in Adults With Hearing Loss 
Background
The future rehabilitation of adults with hearing loss is likely to involve online tools used by individuals at home. Online tools could also be useful for people who are not seeking professional help for their hearing problems. Hearing impairment is a disability that increases with age, and increased age is still associated with reduced use of the Internet. Therefore, to continue the research on online audiological rehabilitative tools for people with hearing loss, it is important to determine if and to what extent adults with hearing loss use the Internet.
Objective
To evaluate the use of the Internet and email in a group of adults with hearing loss and to investigate if their use of Internet and email differed between genders, among different age groups, and how it compared with the general population in Sweden.
Methods
Questionnaires containing multiple-choice questions about Internet access, email use, and educational level were mailed to individuals with hearing loss, who were registered as patients at a hearing aid clinic. Out of the 269 invited participants, 158 returned a completed questionnaire, which was a response rate of 58.7%.
Results
The results showed that 60% (94/158) of the participants with hearing loss used computers and the Internet. The degree of hearing loss in the group of participants did not explain the level of Internet usage, while factors of age, gender, and education did (P<.001). More men than women used the Internet (OR 2.54, 95% CI 1.32-4.91, P<.001). Use of the Internet was higher in the youngest age group (25-64 years) compared to the oldest age group (75-96 years, P=.001). A higher usage of the Internet was observed in the participants with hearing loss, especially the elderly, when compared with the general population of Sweden (OR 1.74, 95% CI 1.23-3.17, P=.04).
Conclusions
We conclude that the use of computers and the Internet overall is at least at the same level for people with hearing loss as for the general age-matched population in Sweden, but that this use is even higher in specific age groups. These results are important for the future work in developing and evaluating rehabilitative educational online tools for adults with hearing loss.
doi:10.2196/jmir.2221
PMCID: PMC3650922  PMID: 23659867
hearing loss; hearing rehabilitation; Internet; trends
20.  Comparison of health related quality of life of primary school deaf children with and without motor impairment 
Objective
To compare the health-related quality of life (HRQOL) of primary school-age deaf children with or without motor impairment to that of typically developing peers.
Methods
This study was a prospective, cross sectional study. With age-matched controls, 100 children were analyzed in each of the following three categories: normal hearing, hearing impaired without motor impairment, and hearing impairment with motor impairment. The Paediatric Quality of Life Inventory (PedsQL™) version 4.0 was used to assess the HRQOL.
Results
Hearing impairment along with motor impairment in children is associated with significantly increased proportions of suboptimal levels of function and significantly lower HRQOL. Children with hearing impairment and no motor impairment had significantly lower scores in the emotional health and school function domains of the PedsQL than children with normal hearing, but there was no significant difference in the physical and social health domain scores. Children with hearing impairment and motor impairment showed significantly lower scores in all domains of the PedsQL compared to children with normal hearing. Scores in all four domains of the PedsQL differed between children with hearing impairment and no motor impairment and children with hearing impairment and motor impairment.
Conclusion
These findings indicate that children with hearing impairment, both with and without motor impairment, have a diminished health-related quality of life.
doi:10.1186/1824-7288-36-75
PMCID: PMC2997090  PMID: 21070679
21.  Hearing Aids: A Review for the Family Physician 
Canadian Family Physician  1987;33:1509-1512.
Hearing impairment is a common disability which can often be minimized by the use of hearing aids. Various types of hearing aids have been developed which are appropriate for most hearing losses that are not medically or surgically treatable, and these devices have been variously applied. Potential benefits and limitations of amplification need to be considered for each patient. Changes in technology, assistive devices, and the development of the cochlear implant have improved the ability of the hearing impaired to compensate for their disability. The benefits of new technology should not overshadow the importance of simpler considerations such as how we can speak more effectively to those who have difficulty in hearing
Images
PMCID: PMC2218403  PMID: 21263887
hearing aids; hearing disability
22.  Older people's views on what they need to successfully adjust to life with a hearing aid 
This article reports a study exploring what older people believe would enable them to adjust to and gain maximum benefit from wearing a hearing aid. A mixed methods approach was employed during 2006 involving interviews with key stakeholders, a survey across three Scottish health board areas and focus groups. Nine key stakeholders from six national and local organisations were interviewed about the needs of older people being fitted with hearing aids. In total, 240 older people belonging to three different types of hearing impaired older people were surveyed: long-term users of hearing aids, new hearing aid users, and those on a waiting list from urban and rural areas (response rate = 24%). A series of eight follow-up focus groups with 31 audiology patients was held. Health professionals appeared to neglect appropriate provision of information and overly rely on technological interventions. Of 154 older people already fitted with hearing aids, only 52% of hearing aid users reported receiving enough practical help post fitting and only 41% reported receiving enough support. Approximately 40% reported not feeling confident in the use of their aids or their controls. Older people wanted more information than they received both before and after hearing aid fitting. Information provision and attention to the psychosocial aspects of care are key to enabling older people to adjust and optimise hearing aid benefit.
doi:10.1111/hsc.12016
PMCID: PMC3712468  PMID: 23373520
audiological rehabilitation; hearing aid adjustment; older people; service-user views
23.  The effect of hearing impairment on the identification of speech that is modulated synchronously or asynchronously across frequency 
This study investigated the effect of mild-to-moderate sensorineural hearing loss on the ability to identify speech in noise for vowel-consonant-vowel tokens that were either unprocessed, amplitude modulated synchronously across frequency, or amplitude modulated asynchronously across frequency. One goal of the study was to determine whether hearing-impaired listeners have a particular deficit in the ability to integrate asynchronous spectral information in the perception of speech. Speech tokens were presented at a high, fixed sound level and the level of a speech-shaped noise was changed adaptively to estimate the masked speech identification threshold. The performance of the hearing-impaired listeners was generally worse than that of the normal-hearing listeners, but the impaired listeners showed particularly poor performance in the synchronous modulation condition. This finding suggests that integration of asynchronous spectral information does not pose a particular difficulty for hearing-impaired listeners with mild/moderate hearing losses. Results are discussed in terms of common mechanisms that might account for poor speech identification performance of hearing-impaired listeners when either the masking noise or the speech is synchronously modulated.
doi:10.1121/1.2821967
PMCID: PMC2647850  PMID: 18247898
24.  Evaluating the benefit of hearing aids in solving the cocktail party problem 
Trends in amplification  2008;12(4):300-315.
The benefit of wearing hearing aids in multitalker, reverberant listening environments was evaluated in a study of speech-on-speech masking with two groups of listeners with hearing loss (younger/older). Listeners selectively attended a known spatial location in two room conditions (low/high reverberation) and identified target speech in the presence of two competing talkers that were either colocated or symmetrically spatially separated from the target. The amount of spatial release from masking (SRM) with bilateral aids was similar to that when listening unaided at or near an equivalent sensation level and was negatively correlated with the amount of hearing loss. When using a single aid, SRM was reduced and was related to the level of the stimulus in the unaided ear. Increased reverberation also reduced SRM in all listening conditions. Results suggest a complex interaction between hearing loss, hearing aid use, reverberation, and performance in auditory selective attention tasks.
doi:10.1177/1084713808325880
PMCID: PMC2836772  PMID: 19010794
Hearing aids; informational masking; reverberation; spatial benefit; selective attention
25.  Childhood infections, but not early life growth, influence hearing in the Newcastle thousand families birth cohort at age 14 years 
Background
While current research priorities include investigations of age-related hearing loss, there are concerns regarding effects on childhood hearing, for example through increased personal headphone use. By utilising historical data, it is possible to assess what factors may have increased hearing problems in children in the past, and this may be used to inform current public health policies to protect children against hearing loss and in turn reduce the long-term burden on individuals and services that may possible evolve. The aim of this study was to investigate which factors in early life significantly impacted on hearing level in childhood using existing data from the Newcastle Thousand Families Study, a 1947 birth cohort.
Methods
Data on early life factors, including growth, socio-economic status and illness, and hearing at age 14 years were collated for a representative subset of individuals from the cohort (n = 147). Factors were assessed using linear regression analysis to identify associations with hearing thresholds.
Results
Males were found to have lower hearing thresholds at 250 Hz, 500 Hz and 1 kHz. Main analyses showed no associations between hearing thresholds and early life growth or socio-economic indicators. An increasing number of ear infections from birth to age 13 years was associated with hearing thresholds at 250Hz (p = 0.04) and 500Hz (p = 0.03), which remained true for females (p = 0.050), but not males (p = 0.213) in sex-specific analysis. Scarlet fever and bronchitis were associated with hearing thresholds at 8 kHz. After adjustment for all significant predictors at each frequency, results remained unchanged.
Conclusions
We found no associations between childhood hearing thresholds and early life growth and socio-economic status. Consistent with other studies, we found associations between childhood infections and hearing thresholds. Current public health strategies aimed at reducing childhood infections may also have a beneficial effect upon childhood hearing.
doi:10.1186/1472-6815-13-9
PMCID: PMC3735408  PMID: 23895514
Childhood hearing; Fetal growth; Risk factors; Aetiology; Epidemiology

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