Key points
- We recommend asking the question, “Do you have a hearing problem now?” to identify people with unrecognized hearing loss.
- Presbycusis contributes to depression and dysfunctional interpersonal relationships.
- Asking older patients (and their family members) whether they have a hearing problem is an effective screening method for new patients and periodic health assessments.
- Referral for hearing testing and hearing rehabilitation should be done for those with a suspected hearing problem.
ABSTRACT
Objective To compare 2 screening methods for unrecognized handicapping hearing loss in the elderly.
Study Design Cross-sectional study.
Population Five hundred forty-six older individuals who underwent audiometry at biennial examination 22 of the Framingham Heart Study and who took the Hearing Handicap Inventory for the Elderly–Screening (HHIE-S) questionnaire.
Outcomes Measured The 2 screening methods were the 10-item HHIE-S and 1 global question: “Do you have a hearing problem now?” The gold standard was an audiogram showing a pure tone threshold of 40 dB HL or higher at 1 and 2 kHz in one ear or at 1 or 2 kHz in both ears. Both screening methods were compared with the gold standard in terms of sensitivity, specificity, and predictive values. The 10-item screening version of the HHIE-S (cutoff score between 8 and 10) had a sensitivity of 35% and a specificity of 94% for detecting the criterion hearing loss. The global subjective measure had greater sensitivity (71%) but lower specificity (71%) than the HHIE-S. Combining the global question and the HHIE-S items failed to improve the specificity of the global question or the sensitivity of the HHIE-S.
Conclusions The global measure of hearing loss was more effective than the detailed questionnaire in identifying older individuals with unrecognized handicapping hearing loss. Primary care physicians are encouraged to ask their patients whether they have a hearing problem and refer patients who do for formal hearing testing.
Handicapping hearing loss is one of the most common health problems of older people. Because hearing loss leads to social isolation, depression, and withdrawal from life activities,1 screening for hearing loss should be included in the health assessment of older people. Although primary care physicians endorse the desirability of screening for hearing loss, screening methods vary widely in strategy, technique, application, and effectiveness.2 Since improved methods for remediation of hearing loss have evolved over the past decade, renewed efforts for detecting and referring people with possible handicapping hearing loss are appropriate.
The gold standard for the clinical evaluation of people reporting hearing loss is a formal audiogram. However, obtaining audiometry is difficult in many locales because of problems with access, referral, and reimbursement. Therefore, many practices rely on self-administered questionnaires to screen for hearing loss.
In 1982, Ventry and Weinstein3 introduced the 25-item Hearing Handicap Inventory for the Elderly (HHIE), which was designed to assess the self-perceived psychosocial handicap of hearing impairment in the elderly as a supplement to pure tone audiometry in the evaluation of hearing aid effectiveness (Appendix.) A shorter 10-item version of the HHIE, the Hearing Handicap Inventory for the Elderly–Screening (HHIE-S), was introduced in 1986 as a screening instrument for handicapping hearing loss and is widely used.2
The reliability and validity of the HHIE-S has been established.4,5 However, the HHIE was not developed as a screening instrument but as a method to assess the effectiveness of amplification; the subset of 10 HHIE items was extracted later for use as a screening instrument. Even shorter questionnaires and questions6,7 have been shown to be valid and effective in hearing screening.
The purpose of this report was to determine whether the single question might be as effective and efficient a method as the formal questionnaire to screen for handicapping hearing loss. We describe the associations among the global hearing history question, the HHIE-S results, and formal hearing testing in 546 people (mean age ± SD, 78.3 ± 4.1 years) from a population-based cohort of elderly subjects (Framingham Heart Study Cohort).
Methods
The data for this report were derived from our ongoing hearing study of the Framingham Heart Study cohort. The Framingham Heart Study members comprise a population-based cohort that has been studied biennially since the first cycle from 1948 to 1950.8 The cohort has a substantial history of environmental noise exposure and noise-induced hearing loss.9 Hearing tests were offered to all members of the cohort at biennial examinations (E) E15,9 E18,10 and E22 (from 1983 to 1985).
Subjects in this study had a hearing test at E22 and completed the HHIE. Of the 927 people who were willing and able to take part in the E22 health examination, 723 volunteered to have a pure tone audiogram and all were asked to take the 25-item HHIE. The HHIE was completed by 672 subjects before the hearing testing, and the answers were reviewed by the audiologist for completeness. The global question was asked separately on an otologic history intake form, which also inquired about hearing aid use at the time of hearing testing. There was no provision for family members’ opinions about the subject’s hearing status. Of the 723 participants, 51 did not take the questionnaire. Reasons for noncompliance varied and included time constraints, fatigue, and malaise.