Hearing loss often an unnoticed disability

Observations on the state of medical practice and medical life

By Eric Anderson, MDis a semiretired family physician in San Diego. His commentaries from 2000-05 are available on amednews.com. Posted June 20, 2005.

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Art Linkletter, the author and TV personality who entertained America for 60 years, once lectured on the concept "Old Age is Not for Sissies." He remarked, "When you lose your vision you notice your arms getting too short, but when you lose your hearing it's so gradual you miss the problem."

Ken Patterson, an audiologist in Escondido, Calif., understands that. A friend of Linkletter's, he was introduced by him to actor Roy Rogers and fitted the cowboy celebrity with his first hearing aids.

Patterson today is not so concerned with public figures. He is more troubled by the fact that a considerable number of Americans -- 28 million to 38 million depending on the report cited -- are hearing impaired (one of them, me). Many of the hearing impaired are in physicians' offices for other reasons, and doctors having to repeat their instructions don't realize they're seeing the tip of the iceberg and a hearing evaluation is called for.

Indeed, a colleague once criticized one of my patients who was not following his suggestions. "What I told him must have gone in one ear and out the other," he said.

"No," I said, "It's not even going in one ear. Didn't you notice he's deaf?"

Of course we don't notice. We are so busy attending to other concerns patients -- especially the elderly -- bring we don't have time (or make time) to carry out simple audiometry tests that might have taken an extra minute. So we don't realize our patients have a disability.

The Americans with Disabilities Act has surely assisted our patients. And, to a degree, the ADA has helped the hearing impaired. They can get special telephones and request hearing aids in movie theaters that work, somewhat, if the wearer can sit in a central position. But in general the hearing impaired are ignored by our nation, even though studies of those entering college show that, due to the noise bombardment in today's society, these students have the hearing loss of a 40-year-old person.

Furthermore, the hard of hearing don't get the sympathy we accord those moving in wheelchairs or walking with white canes. It's sad, because although the hearing impaired may see the messenger, they don't get the message. They -- like all of us -- live in a culture where communication is king. They lean forward in their chairs, study the persons talking, cup hands behind their ears, frown and even fiddle with their hearing aids -- while speakers prattle on, often turning away from listeners and seldom slowing down, or speaking more clearly or making an effort to help those persons listening.

Ever strained to catch a telephone number that was slurred fast into your voice mail? That's what regular conversation is often like for the hearing impaired. It's a scourge for doctors, too. Today's medical care sometimes requires complicated instructions. If they are not heard, we all have problems.

So what can we do?

For starters, we can ask the patient, or more likely the spouse, penetrating questions: Does he say you mumble? Does he have the TV on too loud for your comfort? Do you repeat yourself a lot? Does he answer the phone, look confused then hand it to you? Or, do family members avoid sitting with her in the movies because she keeps asking, "What did he say?" Does she tend to order the same as you in restaurants because she never catches what the waitperson said the specials were? Does she respond readily and appropriately to her grandchildren? (Children's voices can be especially hard to hear.)

Then, questions answered, we can screen. Simple inexpensive audiometers are readily available. We can refer patients who don't do well for more sophisticated testing. It's worth doing, because if the hearing loss isn't addressed, the patient can often become socially withdrawn and a less-productive member of society.

Who is at risk of losing some hearing?

Not everyone. There are primitive tribes with what audiologists call "virgin ears" who live in quiet environments and don't get presbycusis, the gradual hearing loss that starts for most of us in our mid-30s. And there are those who appear genetically protected from loud noise damage. Audiologists call those lucky persons "iron ears."

The unlucky ones are those who work in our constantly changing cities assailed as they are on every corner by jackhammers; those who play in the outdoors, hunting, shooting, working with boat engines or riding motorcycles. Those who attend rock concerts or listen with stereo headphones for more than two hours a day to loud music cranked up, commonly, to 115 decibels. Those who work with noisy farm or industrial equipment, unfortunates who have had recurrent ear infections or head trauma, those who had to take ototoxic drugs or those born to a mother who had rubella. And those who have just gotten old.

Says David K. Woodruff, AuD, a clinical audiologist in San Diego, "Approximately 25% of persons age 65 and older have some hearing loss. [Yet] a study reported in the Annals of Internal Medicine revealed that 80% of primary care physicians don't screen their older patients for hearing loss."

How physicians can help

Well, we can face patients when we talk, speak more slowly and clearly but not more loudly, repeat what we've just said and use more visual aids. But that goes only so far.

Invariably, thoughts turn to the question of hearing aids. It's an expensive question. Hearing aids usually aren't covered by health insurance, and they don't suit everyone.

Mine have not worked particularly well and I've gone through the three common types.

I found the completely-in-the-ear type uncomfortable, like a finger sticking in my ear, but they were certainly unobtrusive. The shell type is more obvious, can carry a larger unit, but if the wind is blowing or the car window is open extraneous noise is a problem. The kind where the unit sits above the ear and the receiver (at the end of a narrow tube) goes into the ear canal is much more comfortable, but since the ear canal is not blocked, ambient sound easily enters, and the aids become omnidirectional.

I am not impressed by manufacturers' claims that today's digital computerized hearing aids are unidirectional. I've been able to hear the people behind me in restaurants as well or as badly as those sitting opposite me. My hearing loss, however, is not the typical one of older persons and my abrupt drop-off in hearing at certain frequencies does not lend itself to much electronic improvement. And to be fair, I should say every person I've noticed wearing hearing aids has made glowing tribute to them, despite their cost.

Prices are high for several reasons, Dr. Woodruff says. It's costly to develop such miniaturized electronics. Only a fraction of people with partial hearing loss ever chooses to try them, and of those who do, 20% return them for a refund, so there isn't the volume business that keeps prices down, such as is seen with eyeglasses.

Furthermore, he says, hearing aids don't improve hearing the way glasses help vision. Patients need to be told that, even with aids, they will remain somewhat hearing impaired.

Yet even that limited gain can significantly improve the quality of a patient's life (and that of those around them), not to mention give a fair chance of boosting that individual's treatment compliance. Given an aging population -- one brought up on rock music, to boot -- it's a message that should be delivered to doctors more often. The question is, are they willing to listen?

Eric Anderson, MD is a semiretired family physician in San Diego. His commentaries from 2000-05 are available on amednews.com.

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