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The specter of diminished hearing ability is a real one to most of the elderly When an older client comes to the speech and hearing center or medical facility for assistance in resolving his hearing problem, the audiologist and otologist must understand the complexities and complications of the aging process itself, as well as the specific problems of presbycusis as they attempt to help the e’derly person.

Statistically it has been shown that for a broad population of elderly people, hearing loss associated with aging is approximately “a decibel a year" (Gaeth, 1948). This means that between the ages of 65 and 85, the average elderly person may anticipate a cumulative 20 dB loss of hearing. Not all elderly people will fit into this easy-to-compute pattern, but the older person will experience a gradual decline in hearing ability as age increases.

Beasley (1940) also observed this relationship in a national survey which attempted to determine the amount of hearing loss in our country. He found that at ages 35 to 44, 1.3% of men and 1% of women had a hearing loss of 47 dB or greater. In the age range 65 to 74, one out of every 14 men (7.1%) and one out of every 18 women (5.5%) was hearing impaired.

From an observation in the 1960's, and with the bias that the subjects were volunteers rather than random samples, the Detroit Hearing and Speech Center (Rupp, 1965) reported the following figures for its Michigan State Fair Project for the years 1960 to 1965 from 20,680 subjects:

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The criterion for pass-fail was a screening test at 15 dB (ASA). A "fail” classification was based on two or more failures at the set intensiity level, Age range efficiency for hearing according to pass-fail classifications showed the following results for the representative year of 1963 :

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The reduction in hearing efficiency with increasing age, again, is a dramatic


A Public Health Service publication, "Hearing Levels of Adults by Age and Sex: United States 1960-1962,” reviews hearing efficiency for adults. Using a probability sample of 7,710 citizens in the age range 18 to 79 years, inferences were made for the 111 million adults who were noninstitutionalized civilians. The findings show that 8.4% of the population had hearing efficiency that was less than 15 dB average (ASA) for the better ear for speech frequencies. Males tend to have about 50 per cent more hearing loss than do females. Again, the prevalence of hearing impairment is shown to progress with age. Those under age 25 years showed 0.8% with hearing loss; those individuals in the 65 to 74 year range showed 13% with loss; and those over 75 years showed 26% with deficient hearing.

In contrast to many studies, the work of Rosen and co-workers (1962, 1964) in the Sudan strongly indicates that it is the total environment in which an individual lives which may be responsible for either good or poor hearing. In this remote region in Africa, the Mabaan tribesmen in the age range 70 to 79 years showed only minimal loss of hearing at the high frequencies. For example, the mean hearing level at 6000 Hz was only 23 dB (ASA). We may conclude, therefore, that hearing efficiency appears to be culturally related.

As any worker in the field of audiology will agree, there are many causes for hearing loss. Hoople (1960) reports that it is difficult to accept the aging factor alone as the full culprit in this emerging problem. If no insults from infection had ever occurred, or if no exposure to noise had ever taken place, might there not be a difference in the loss of hearing, decade by decade, which so many surveys have demonstrated ?

Hoople is supported by Fowler (1959), who feels that a host of factors may be historically responsible for this condition. He enumerates a partial list as follows: "severe strains, fright, grief, frustration, poisonous drugs, antibiotics, overexertion, bacterial and virus infections, acoustic, psychic and other traumas, electric shock, metabolic disorders, pregnancy, vitamin deficiencies . . . exposure to cold, allergies and thromboses.” In the American culture, a lifetime of recurrent assaulting of the hearing apparatus may precede the actual hearing loss and may evidence itself as presbycusis in the middle or late 60's.

In a different type of culture where the stresses, noise bombardment and other potential traumas are less numerous, it is possible that hearing loss in the elderly will alo be less inarked. The Rosen studies (1962, 1964) cited earlier report that in the Mabaan civilization, hearing efficiency remains very good throughout life. This isolated tribe lives in an environment of very low noise; and perhaps as a result the incidence of high blood pressure, ulcers, asthma, and coronary thrombosis is also low.

Schuknecht is especially concerned about the function of the fixed postmitotic ce'ls which constitute the highest plane of differentiation. These are the cell structures that must stand up against the wear and tear of a human existence that is not particularly conducive to the careful preservation of these small cell structures.

From his research in the 1950's, Schuknecht reported on two types of presbycusis. Sensory presbycusis begins in middle age as a part of an aging process affecting all tissue, progresses very slowly for decades and manifests itself clinically by a preshycusis curve showing an abrupt hightone hearing loss.

Neural presbycusis starts late in life, progressing slowly for years, and it is characterized clinically by high tone deafness with disproportionately severe loss in auditory discrimination. It is the otological manifestation of an aging process affecting the central nervous system where an insufficient number of functional neurons are unable to effectively transmit and decode the neural patterns.

In 1964, Schuknecht added two more types of presbycusis to his original categories of sensory and neural presbycusis—metabolic and mechanical presbyeusis.

He suggests that the four types of functional deficit can be reflected in distinct patterns. Any individual, however, may be a victim of more than one type of presbycusis.

Metabolic presbycusis is described as a type of slowly progressive hearing loss "due to defects in the physical and chemical processes by which energy is produced and made available for use by the sense organs" (Schuknecht, 1964). Patients exhibiting a metabolic type of prebycusis show threshold elevations which are essentially flat across the frequency spectrum.

Mechanical presbycusis, on the other hand, is reflected audiometrically as slowly progressive hearing loss characterized by a gradually descending configuration into the higher frequencies. Schuknecht (1964) theorized that it is. caused by a disorder "in motion mechanics of the cochlear duct."

The important question, however, is the psychological effect that presbycusis has on the hearing and understanding ability of the affected person. In the early stages of presbycusis, and most likely at a period prior to the time of diagnosis, the individual may be unaware of any obvious hearing difficulty. The individual may think there is a temporary condition which is affecting his hearing. Gradually, as the hearing deficit increases and spreads in terms of frequency composition, the elderly client becomes truly aware of a developing impairment in hearing.

The basic problem in the phonemic-regression pattern in the elderly patient is that the individual has difficulty in understanding the speech which he does hear. This is brought out in an interesting manner in a report from the Moosehaven Research Laboratory in which the authors state, “More than two-thirds of the hearing-aid group indicate they have difficulty in understanding, rather than in hearing (with aids turned on). Surprisingly, about a quarter of the non-users report the same difficulty. It is interesting to note that the later group gives ample evidence of having some hearing difficulty, yet every person in this group refuses to attribute any of this difficulty to his own hearing inadequacy" (Kleemeier & Justiss, 1955).

Such findings may suggest that even when the amount of loss is not great enough to warrant the use of a hearing aid, the superimposed degenerative action in the spiral ganglion may be having an effect. It is possible for the elderly person

to demonstrate poor understanding of speech, even though his loss in hearing sensitivity is mild. However, among the elderly, understanding ability for speech may be independent of the configuration of the audiogram (Pestalozza and Shore, 1955). Clinicians should not make preliminary decisions concerning understanding ability of a specific individual based only on his puretone audiogram.

The first line of defense against presbycusis belongs to the family physician or medical specialist who performs the annual or biannual physical examination with the older individual.

Any responses on the part of his patient which may indicate some deterioration of hearing function should guide the physician to suggest monitoring of the hearing function by an otological specialist, as well as serial diagnostic audiological observations to most carefully assess the hearing performance over a time period of two or more years. An ideal audiological program will be that one which secures hearing aids for those clients who may benefit from their use. There are, however, many potential problems which may arise in the securing and subsequent maintenance of a hearing aid for the elderly client.

Pestalozza and Shore (1955) point out that a patient with a mild hearing loss and good discrimination might not be satisfied with a hearing aid, while on the other hand, a person with a more severe hearing loss might enjoy wearing an instrument even thought his discrimination is very poor. Each individual must be studied and evaluated in terms of his own needs and goals for hearing aid use; however, most specialists agree that the person with presbycusis should have a hearing aid before the time of intense need actually arrives.

How does the individual or his family go about obtaining a hearing aid or determining if, in actually, a hearing aid would be of value? Rupp and Koch (1969) outline a conservative approach to the acquisition of a hearing aid by a senior citizen. Their step-by-step approach follows:

1. Medical diagnosis by a medical ear-specialist.
2. Diagnostic hearing assessment by a qualified professional audiologist.

3. Decision reached to investigate the use of a hearing aid on the part of the patient.

4. Appointment with an audiologist for a hearing aid evaluation in which the following goals are considered :

A. Is hearing sensitivity improved with an aid?
B. Is the aided understanding ability maintained or improved ?
C. Is the quality of the sound pleasing or acceptable through the aid?

D. What effect does competing noise have on the listener's efficiency? 5. Training program with the recommended hearing aid (with possible trial wearing).

6. Making a final decision about purchasing the recommended hearing aid.

Unfortunately, there are many problems of adjustment for the elderly person using a hearing aid. An enumeration of them will realistically prepare the client and family for the multiplicity of potential problem areas. 1. Poor memory leads to many problems such as:

a. forgetting to turn aid off at night ;
b. forgetting when to change batteries ;

c. becoming confused between new and used batteries. 2. Poor vision and manual control lead to:

a. difficulty in changing batteries because of their inaccessability;
b. placing batteries in aids backwards ;
c. hurting fingers on sharp protuberances in and on aids ;
d. difficulty in inserting earmold in ear;
e difficulty in keeping battery contacts clean;

f. failure to turn aid completely off because of inability to see directions or feel click indicating "off" position. 3. Inability to learn to operate the instrument properly. Unquestionably, this is the greatest problem. (Kleemeier and Justiss, 1955.)

The authors of the above list make a plea for a hearing aid that is designed for the simplest operation possible while still consistent with the requirements of the instrument. In addition, someone else in the person's environment should make a daily check on the aid to insure that it is working correctly.

At Moosehaven, a guidance program was set up to assist the elderly residents in resolving their problems with their hearing aids. In addition to the audiometric examinations which were conducted, a great deal of the clinician's time was spent replacing batteries, training individuals in the use and care of their hearing aids, and especially in individual counseling. (Kleemeier and Justiss, 1955.)

Miller (1967) is more outspoken on the need for help in orienting the elderly client to his aid. “No presbycusic patient who has not used a hearing aid preri. ously should purchase one without an opportunity to use the aid first under supervision and with at least a short program of training in the essentials of auditory training and speech reading." His concern is that, without adequate training, the successful elderly hearing aid wearer rarely will be found.

As Miller insists, a program of auditory training (or "training in listening") must be a part of the orientation program in the use of the hearing aid. Even without the use of hearing aids, there are certain beneficial effects of a program of training in listening for this hearing-handicapped individual.

While it will be the audiologist and speech and hearing clinician who will carry the burden of therapy-management in their various clinical and educational programs, equally important, and even more long lasting in their impact, will be the individuals who are in daily association with elderly hearing-impaired persons. They have a major responsibility in promoting a satisfactory adjustment to the hearing handicap. Hoople (1960) reviews their responsibility as follows: "Members of the family, friends and the public should have a sympathetic approach to elderly people who have a hearing handicap. It is tiring to enunciate carefully, it is difficult to remember to speak slowly, and one becomes weary of talking slightly louder than usual, but these little courtesies can make all the difference in the world to those who are hard of hearing. These people can be excluded or included by the neglect or use of these simple measures."

Effective therapeutic follow-up for the elderly client with a hearing impairment is usually accomplished most easily under the guidance of a professional audiologist. He or she may work in a community hearing and speech center, in a hospital, in a rehabilitation agency, or in a university hearing and speech center.

In Michigan during the past two years, two group programs for the elderly have been developed. In Ann Arbor, the Audiology Division of the Speech Clinic of the Medical School of the University of Michigan has been offering a Hearing Information and Counseling Program to the community in cooperation with the Senior Citizens Guild (Harless and Rupp, 1971). The ten-week course has been offered repeatedly in two retirement residences and at the Senior Citizens Guild with enthusiastic enrollment each term. Six areas of hearing education and reabilitation are covered in the course and include:

1. group discussions about hearing loss in the elderly,
2. screening hearing tests,
3. group discussions about hearing aids,
4. speech reading practice,
5. review of tips on managing a hearing loss,

6. review of follow-up diagnostic and rehabilitative services available in the community.

In Detroit a similar project entitled Educational Rehabilitation Programs for the Elderly has been underway since early 1971 and is offered by the Department of Audiology of the Wayne State University School of Medicine in cooperation with the Department of Recreation of the City of Detroit (Hardick, 1971). Ten week group sessions are held at two Retiree Centers in the city and the areas covered in the course include:

1. information on hearing loss,
2. hearing tests to the participants,
3. discussions about hearing aids,
4. practice on speechreading and auditory training,
5. recommendations for follow-up and clinical appointments.

Both institutions report that while attendance was deliberately limited in order to allow optimal participation, the participants in the training sessions were enhusiastic in terms of information acquired and guidance given in terms of available follow-up.

Since each elderly individual has a unique and special challenge with regard to his own hearing loss, all rehabilitation programs should be customized to the individual client and his needs. The ultimate value of group classes is that the clients themselves are able to share both frustrations and successes as they work their way through their own rehabilitation program.

Clinical contact with elderly clients who evidence disabling hearing problems has shown that such patients usually need special and gentle handling. It is especially important that all discussions and recommendations made to the patient are clearly understood by him. Goals established with the client should be of a magnitude that can be achieved. Such patients will need large amounts of encour

agement and praise in order for them to continue their programs of rehabilitation. The family and friends must also be completely involved in the total program if it is to succeed. The rewards of such a project are sufficient to warrant the efforts expended by the client, his family and the professional worker.

Our senior citizens deserve the best rehabilitation programs that can be dereloped on their behalf. The differenec between success and failure of such programs is the emotional set of the senior citizen himself. If the program has succeeded, the individual will maintain interest in his world ; if the program has failed, then we may find a lonely and isolated non-communicator. It is vital that such programs succeed. It is our responsibility and our challenge as hearing and speech clinicians to make every effort to protect the aging person from dehumanizing isolation.

References Beasley, W. "Characteristics and Distribution of Impaired Hearing in the Population of the United States," Journal of the Acoustical Society of America, 12, 1940, 114-121.

Bloomer, H. “Communication Problems Among Aged County Hospital Patients," Geriatrics, 15 (14), 1960, 291–295.

Davis, H. (ed.). Hearing and Deafness. Murray Hill Books, New York, 1947.

Davis, H. and Usher, J. "What is Zero Hearing Loss?" Journal of Speech and Hearing Disorders, 22 (5), 1957, 662-690.

Dohahue, Wilma (quoted in) “500 to Attend University of Michigan Parley on Aging," The Ann Arbor News, July 10, 1968, 16.

Fowler, E. "Presbycusis—The Aging Ear," Annals of Otology, Rhinology, and Laryngology, 68 (3), 1959, 764–776.

Gaeth, J. "Study of Phonemic Regression in Relation to Hearing Loss." Unpublished doctoral dissertation, Northwestern University, 1948.

Hardick, E. "An Educational and Rehabilitational Program for the Elderly." Unpublished report, The Wayne State University, July, 1971.

Harless, E. and Rupp, R. "A Project Report: Aural Rehabilitation of the Elderly.” Unpublished report, The University of Michigan, June, 1971.

Hoople, G. "Care of Hearing in the Elderly," Geriatrics, 15 (2), 1960, 106-109. Kleemeier, R. and Justiss, W. “Adjustment to Hearing Loss and to Hearing Aids in Old Age." In Aging and Retirement, Editor I. Webber, University of Florida Press, Gainesville, 1955, 34–48.

Miller, M. "Audiologic Management of Presbycusic Patients,” Fenestra, 4 (4), 1967, special insert article.

Pestalozza, G. and Shore, I. “Clinical Evaluation of Presbycusis on the Basis of Different Tests of Auditory Function,” Laryngoscope, 55 (12), 1955, 1136–1163.

Rosen, S.; Bergman, M.; Plester, D. ; El-Mofty, A., and Satti, M. “Presbycusis Study of a Relatively Noise-free Population in the Sudan," Annals of Otology, Rhinology, and Laryngology, 71 (3), 1962, 727-743.

Rosen, S.; Plester, D.; El-Mofty, A.; and Rohen, H. "High Frequency Audiometry in Presbycusis: a Comparative Study of the Mabaan Tribe in the Sudan with Urban Populations,” Archives of Otolaryngology, 79 (1), 1964, 18–32.

Rupp, R. and Lindahl, R. "Hearing Screening Tests as a Method of Case-Finding," ASHA, 7 (10), 1965, 420.

Rupp, R. and Koch, L. "How to Choose a Hearing Aid,” Modern Maturity, April-May 1969, 65-66.

Schuknecht, H. “Presbycusis," Laryngoscope, 65 (6), 1955, 402-419.

Schuknecht, H. “Further Observations on the Pathology of Presbycusis," Archives of Otolaryngology, 80 (4), 1964, 369-382.

[Reprinted from the Journal of Speech and Hcaring Disorders, May 1972, Vol. 37, No. 2)


(By Edwin L. Harless and Ralph R. Rupp, University of Michigan,

Ann Arbor, Mich.) [To date, aural rehabilitation of the elderly has had limited success. In an attempt to improve this success factor, the audiology division of a university speech clinic provided a 10-week program of counseling and speech reading to elderly patients. One means of obtaining registrants for the course was a community hearing-screening project before the program began. The program itself included hearing screening, speech reading practice, a review of "helpful hints,"

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