Hearing and Balance in Healthy Aging Project: Characterization of Hearing, Balance, and Other Associated Disorders in Three Population Groups Aged 55 and Over

Abstract

Introduction

Active aging emphasizes optimizing health and participation for a better quality of life as people age. This paper explores the significant impact of hearing loss and balance disorders on the elderly. Age-related hearing loss is thought to contribute to communication breakdown and cognitive dysfunctions. The “hearing and balance in healthy aging” project focuses on early detection, mitigation, and advocacy. Objectives include exploring epidemiological traits, evaluating overall well-being impact, proving positive intervention effects, and advocating societal care for the elderly with hearing loss and balance disorders, aiming to reduce their broader impact on cognition, independence, and sociability.

Methods

This study is observational, prospective study. Subjects over 55 years old with a follow-up every year or every 2 years were divided into three groups, according to their hearing and balance: within the normal range (group A), detected and not treated (group B), and detected and treated (group C). At each visit, they underwent a series of tests or questionnaires, evaluating different areas: hearing, balance, cognition, depression, dependence, tinnitus, loneliness, health.

Results

A total of 710 patients were included in the study. The distribution of patients was as follows: group A – 210 patients, group B – 302 patients, and group C – 198 patients. Significant differences were found between the three groups related to age, sex, educational level, bilingualism, and work activity. In group C, there was a higher percentage of males, older than in groups A and B, and the percentage of individuals with a university education was lower (28%), as was the rate of bilingualism (23%). In terms of hearing, significant differences were found in the three groups in the mean PTA, speech discrimination in quiet, and the HINT test, with worse results for group C. Only patients in group C presented a perception of hearing impairment, and the handicap caused by hearing impairment worsened from group A to C. Concerning balance, both tests performed (TuGT and DHI) revealed increased difficulty in maintaining autonomous walking from group A to C, which, again, exhibited the worst results, with statistically significant differences across the group. Analysis about cognition revealed significant differences in DSST questionnaires and in TMT scores, where group C had the worst scores. In HUI3 questionnaire scores, the differences between each and every group were statistically significant, with group C showing moderate disability.

Conclusion

This extensive analysis, encompassing a considerable number of subjects, reveals significant findings that have important implications for the early prevention of hearing loss and its consequent consequences. At the same time, these data represent an initial exploration, which raises the need for in-depth examinations of additional factors and longer follow-up to continue contributing insights and knowledge for a healthy aging.

Plain Language Summary

This study investigates the substantial impact of hearing loss and balance disorders in older people in the context of active aging, with the aim of improving health, participation, and overall well-being. The “hearing and balance in healthy aging” project, a prospective, observational study, includes 710 participants over 55 years of age, classified into groups according to their hearing and balance status. Significant differences between groups reveal disparities in age, gender, education, and occupation. The group with detected and treated cases has the most adverse outcomes in hearing, balance, cognition, and quality of life. These findings underscore the importance of early detection and intervention and present a global view of the consequences of hearing loss and balance disorders on cognitive function, autonomy, and general health in the aging population. However, additional factors should be further explored and follow-up should be expanded as this project has the potential to further contribute to the promotion of healthy aging.

Introduction

The World Health Organization (WHO) defines active aging as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age [1], allowing people to ‘realize their potential for physical, social and mental well-being throughout the life course.’” The list of contributors to healthy aging is long and varied with most items independent of hearing loss (HL) and balance disorders (BDs). Nevertheless, treating deafness and/or dizziness has proven positive effects on several health-related quality of life domains, which in turn benefits health status overall.

HL and/or BDs are frequently linked to pathologies of the auditory or vestibular systems. These pathologies might appear in isolation or together [2]. HL and/or BD represent a greater risk of cognitive impairment, frailty, and social exclusion with considerable negative consequences for their quality of life, that of those who care for them, and for the sustainability of health and care systems [3, 4]. The early detection of risks associated with aging (like HL and/or BD) using common telecommunications infrastructure approaches will enable an earlier intervention preventing their negative consequences.

Age-related hearing loss (ARHL) is the loss of hearing that gradually occurs in most people as they grow older. It is one of the most common conditions affecting older and elderly adults. According to Roth et al. [5], roughly 30% of men and 20% of women in Europe suffer from a hearing loss of 30 dB HL or more at age 70 and 55% of men and 45% of women at 80. About one-third of those who are affected at the European level have disabling hearing loss and it is estimated that around 900,000 [6] have hearing loss severe enough to be candidates for a cochlear implant (CI). ARHL is a key communication disorder, which is characterized not only by a peripheral (cochlear) component but also by a central component. Severe hearing loss patients can barely understand spoken language. Even if they have an adequate tonal hearing sensation, they cannot understand complex acoustic stimuli, such as language or music, particularly in a noisy environment [7]. The central neuronal processing speed and the timing of afferent integration is altered. Furthermore, a loss of inhibitory control and spatial memory has been observed [8] as the result of the sensory (hair) cell loss and progressive deafferentation. Central ARHL must be regarded as an underrated factor, responsible for the break-down of interhuman communication in the elderly. This often leads to social isolation, abandonment of working life, and sub-depression. The lack of auditory information is also associated with cognitive dysfunctions and in extreme cases to age-related dementia [9, 10]. However, epidemiological studies show that the risk of developing a central ARHL is increased by 4–9% per year of age (beginning around 55) with increased prevalence in men [11]. Taken together, this explains how hearing impairment negatively affects the quality of life of the elderly [12]. Recent studies suggest that individuals with hearing loss are more likely to develop Alzheimer’s disease or other forms of dementia over time [13], and age-related hearing impairment is potentially a reversible risk factor for dementia and Alzheimer disease [14].

The cause of BD in the elderly is usually related to multiple factors. Vestibular pathology is a common etiology, but their type varies: positional vertigo is very common, while Meniere’s disease or vestibular migraine have rarer presentation at that age but may already be present but undiagnosed in several subjects, which increases its prevalence [15].

ARHL is usually the result of degenerative processes affecting the inner ear. However, there may be accompanying changes in the labyrinth at the cellular, microvascular, and metabolic levels, generating symptomatically permanent sensorineural hearing loss and/or vestibular disorders, leading to impaired balance. Hearing and balance impairments as well as falls are common among older people. Identifying modifiable risk factors for falls in older adults is of significant public health importance [16, 17]. While hearing is not typically considered a risk factor for falls, recent reports [18–20] demonstrated a strong association between audiometric hearing loss and incident falls. Lin and Ferrucci [21] report that hearing loss was significantly associated with the odds of reported falls. For every 10 dB increase in hearing loss, there was a 1.4-fold (95% CI, 1.3–1.5) increased odds of an individual reporting a fall over the preceding 12 months. Several mechanisms could explain the observed association between hearing loss and falls. There may be a concomitant dysfunction of both the cochlea and the vestibular organs given their shared location within the bony labyrinth of the inner ear. Decreased hearing sensitivity may also directly limit access to auditory cues that are needed for environmental awareness. Finally, the association of hearing loss with falls may be mediated through cognitive load and reduced attentional resources. Attentional resources are critical for maintaining postural control, and decrements in attentional and cognitive resources due to hearing loss may impair the maintenance of postural balance in real-world situations and increase the risk of falling [22]. The latter two pathways, that suggest a possible causal pathway between hearing loss and falling, are intriguing because hearing loss is highly prevalent but remains vastly undertreated in older adults [23, 24].

The project “hearing and balance in healthy aging” is focused on the development of solutions that support active and healthy aging by enabling early detection and mitigation of risks associated with aging. Although the auditory thresholds of patients affected by ARHL have been studied, there are not enough data about the impact of HL on the quality of life of the elderly. There are few epidemiological data that research the link between ARHL and BD, diet, habits and physical exercise. Such information might be extremely useful to provide comprehensive, early care to elderly people affected by a HL linked or not to BDs, thereby contributing to existing prevention and treatment measures that reduce the impact of HL and/or BDs beyond the sensory field, on cognition, independence, and sociability. In addition, the information obtained might provide insights into the economic impact on society of HL and BDs in this population. The objectives of the project “H&B in healthy aging” are:

• 1.To detect and typify hearing loss and BD among people older than 55 years of age and the epidemiological traits that might be linked to such disorders (primary prevention)
• 2.To evaluate the impact of HL and/or BD on the domains that have impact on overall well-being and healthy aging in the elderly such as hearing ability, dependency, cognition, falls, and depression (in short: to evaluate the general status of quality of life in elderly individuals)
• 3.To prove the positive impact of early intervention in HL and BDs among the elderly (secondary prevention) on quality of life, especially regarding their communication, cognitive, mental, and autonomy-related abilities
• 4.To advocate for the care of hearing and balance disorders of elderly patients at a societal level among the general population

In this article, the specific objective is the characterization of hearing, balance, and other associated disorders, in three population groups of individuals aged 55 and older. These groups are described below in the Population section.

Materials and Methods

Study Design

The study design of this project is an observational study, including prospective and progressive measures taken repeatedly over time. In this article, we will focus on the evaluation of the subjects of all groups at the time they were included during visit 1 (shown in Fig. 1).

Fig. 1.

The 3 study groups and the follow-up design of each of them are explained over time. It is shown that some of the subjects can pass from one to another group (dashed lines) when acquiring a loss of hearing or balance or by being treated. The evaluation was carried out every 2 years up to the age of 65 years and thereafter every year. The results of visit 1 are presented in this article. H, hearing; B, balance; y, years.

This study is observational as no additional intervention is applied to the treated subjects. Outcomes from routine practice are recorded through observational measures using standard scales used widely in geriatrics and audiology.

Population

The three subgroups of the total population were divided according to the following criteria:

• Group A: subjects ≥55 years whose hearing and balance is within the normal range (hearing: 0–20 dB pure-tone average at 500, 1,000, 2,000, and 4,000 Hz in the better ear balance: good static and dynamic balance control);

• Group B: subjects ≥55 years, in whom a hearing and/or balance disorder has been detected and has not been treated, for whatever reason;

• Group C: subjects ≥55 years, in whom a hearing and/or balance disorder has been detected and has been treated (hearing aids, active middle ear implants, bone conduction implants, CIs, vestibular rehabilitation).

In-/Exclusion Criteria

Inclusion Criteria of Group A

Inclusion criteria of group A include ≥55 years of age; normal hearing, both ears; normal balance; fluency in Spanish language used to assess clinical performance; willingness to participate in and to comply with all study procedures; able to decide on study participation personally and independently sign their consent.

Inclusion Criteria of Group B

Inclusion criteria of group B include ≥55 years of age; abnormal hearing, any ear and/or abnormal balance, without appropriate treatment; fluency in Spanish language used to assess clinical performance; willingness to participate in and to comply with all study procedures; able to decide on study participation personally and independently sign their consent.

Inclusion Criteria of Group C

Inclusion criteria of group C include unilateral or bilateral HA-BCI-AMEI-CI users with bilateral hearing loss; ≥55 years of age when they received the treatment; hearing aid ear: meets the criteria for HA treatment; implant ear: meets the criteria for BCI-AMEI-CI treatment; willingness to participate in and to comply with all study procedures; fluency in Spanish language used to asses clinical performance; able to decide on study participation personally and independently sign their consent.

Exclusion Criteria

Exclusion criteria include significantly/severely dependent or fragile; unable to provide consent personally; unable to complete questionnaires for self-assessment independently; ossification or other cochlear anomalies preventing full electrode insertion in case of CI; retro cochlear or central origins of hearing impairment; significant comorbidities preventing study participation (e.g., blindness, immobility, severe aphasia, etc.); clinical failure for treatment in regard to chronic depression, dementia, and cognitive disorders.

Study Measures

The following observational clinical assessment tools were selected for repeated assessment and to measure changes in the overall health status of the elderly individual. These are commonly used in audiology and/or geriatric practices. Figure 2 summarizes the assessment tools.

Fig. 2.

Selection of observational clinical assessment tools that have been selected for assessment in the overall health status of the elderly individual.

Assessment Tools

Anamnesis

Patients were asked about anamnesis and clinical history such as rural versus urban environment, level of education, neurological, cardiovascular, psychiatric, neurological, endocrinological history, presence of diabetes, exposure to noise, and tobacco use.

Health-Related Quality of Life

Health Utility Mark III (HUI3). The HUI3 is a generic tool to assess health-related quality of life completed by the patient [24, 25]. HUI3 described by Horsman et al. [26] was validated for Spanish by Ruiz et al. [27]. The “4-week recall” version of the self-assessed HUI3 with 15 questions is included as the main outcome for repeated assessment at each time interval. The HUI3 is a sensitive measure that assesses the impact of medical treatments including CI, over time, across eight health domains: vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. The 15 questions provide a descriptive response system enabling classification of the respondents into predefined HUI3 health states. The focus of the questionnaire is the health state of the individual, assessing the degree of their perceived impairment for each domain. The scoring function was derived from Standard Gamble and Visual Analog Scale methods employed for assessment of a random sample of Canadians (n = 504), resulting in utility scores from – 0.36 to 1.00, where a negative score is a state worse than death [25]. A clinically significant change is set at 0.03 or more between time points. This form can be completed in approximately 10–15 min by the candidate/recipient.

Hearing

Speech Spatial Qualities (SSQ12). The SSQ12 is a self-assessment scale of hearing ability and communication in daily environments, completed by the patient [28]. Twelve questions are divided into three subcategories: speech (comprehension), spatial (hearing in space), and quality (speech and sounds) and are appropriate for use in adults of all ages and children from 9 years [29]. Each question is scored on a 0–10 point rating scale, with higher numeric values reflecting greater ability for the responder. The resulting scores are generally reported as mean ratings for each category but may also be regrouped or assessed individually and the ratings over two time points compared. Clinically significant differences were set at a rating change of 1.0 for each subcategory score between test intervals, as a typically observed difference rating reported in the literature for assessment of unaided and aided hearing aid or implant users [30]. This form can be completed in approximately 10 min by the candidate/recipient.

Hearing Handicap Inventory in the Elderly Screening Test (HHIE-S). The HHIE-S is a short form self-assessment scale designed to assess the effects of hearing impairment on the emotional and social adjustment in everyday life of the elderly individual before and after hearing treatment. The HHIE-S comprises ten questions (5 emotional and 5 social/situational) [31].

HHIE-S total varies from 0 (minimum) to 100 (maximum). A score lower than 16 points in each subscale indicates no handicap; a score between 17 and 42 indicates a mild to moderate handicap; and a score above 43 indicates severe handicap. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment. This form can be completed in approximately 5 min by the candidate/recipient.

Unaided Pure Tone Air-Conduction Audiometry (PTA). Unaided hearing thresholds, dBHL, for pure-tone stimuli via air conduction are presented under headphones, following routine clinical practices. Frequencies for measurement include 250, 500, 1,000, 2,000, and 4,000 Hz. Pure-tone average was calculated. This routine test is completed in approximately 5 min by the clinician and the candidate/recipient.

Speech Discrimination Assessment in Quiet. The assessment of speech recognition in quiet was performed in the subject’s daily listening condition; that is as follows:

• Aided binaurally or

• Aided monaurally, one ear unaided, or

• Bilaterally unaided (i.e., no hearing aid or CI available)

As per local routine practice, standardly used speech materials are presented in sound field at various presentation levels, to determine the score-intensity function curve per individual, which includes 65 dB SPL. Recorded speech stimuli are presented from a loudspeaker at 0° azimuth, 1 m away at head level. The speech test materials consisted of disyllabic word lists in Spanish.

Recorded outcomes included the percentage of items correctly identified compared to the total number of speech items presented at 65 dB SPL and the speech reception threshold level, dBSPL, at which 50% of speech items are correctly recognized, i.e., SRT50%. This routine test is completed in approximately 10–15 min by the clinician and the candidate/recipient.

Speech Discrimination Assessment in Noise. The assessment of speech recognition in noise was performed in the subject’s daily listening condition, i.e.:

• Tests in noise are typically done for patients who can correctly understand a minimum of 50% of speech items in quiet. Speech tests are performed in the free field sound booth with competing background noise. According to local routine practices, standardly used speech materials are presented adaptively to obtain the SRT50% in noise, or speech stimuli may be presented fixed at 65 dBSPL and the competing background noise (i.e., pink noise) varied for each presentation list to obtain the SRT50%. Recorded speech stimuli and the competing background noise are presented from a loudspeaker at 0° azimuth, 1 m away at head level. Test materials included sentences or words

• Aided monaurally, one ear unaided, or

• Bilaterally unaided (i.e., no hearing aid or CI available)

This routine test is completed in approximately 10–15 min by the clinician and the candidate/recipient.

Falls

The Time Up and Go (TUG) Test. The TUG test measures the time a person takes to stand up from a standard armchair, walk 3 m (10 feet), turn around, walk back to the chair, and then sit down again. The test is performed by the patient wearing regular footwear, using customary assistive devices, if any, and walks at a comfortable and safe pace. The clinician uses a stopwatch to measure the required timing accurately for the complete physical maneuver and the seconds taken to perform it recorded. The test is performed at follow-up assessment intervals [32]. The score was interpreted as follows: <10 s, independent mobility; <20 s, mostly independent; >20 s, reduced mobility. This test can be completed in approximately 3 min by the clinician with the candidate/recipient.

Dizziness Handicap Inventory (DHI). DHI is a 25-item inventory designed to evaluate the self-perceived handicapping effects caused by dizziness [33]. DHI has 3 domains: functional (9 questions, 36 points), emotional (9 questions, 36 points), and physical (7 questions, 28 points). Scores greater than 10 points indicate a BD. 16 to 34 points corresponds to a mild handicap, 36 to 52, a moderate handicap, and +54 points, a severe handicap.

Depression

Geriatric Depression Scale-15 (GDS-15). The GDS-15 is a self-report measure of depression in older adults completed by the patient. The 15-item version was developed as a time-efficient and easy-to-complete version with responses in a yes/no format. The items included have demonstrated a high correlation with depressive symptoms in previous validation studies [34]. This questionnaire was validated in Spanish by Martínez de la Iglesia et al. [35].

The scale consists of easy questions and yes/no answers. Each answer is scored 0 or 1. A total score above 5 points for the 15-item question must be studied as a potential case of depression. The final classification will consist of patients without depression when they score between 0 and 5; patients with likely depression when they score between 6 and 9; and patients with depression when they score between 10 and 15. This form can be completed in approximately 5–7 min by the candidate/recipient.

Cognition

Mini Mental State Examination (MMSE). The “Mini-Examen Cognoscitive” (MEC) questionnaire by Lobo is used [36]. This is the version of Folstein’s “Mini Mental State Examination” (MMSE) questionnaire adapted and validated for Spain. The MMSE is a 30-point screening test used extensively in clinical and research settings to measure potential cognitive impairment. It is often used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual’s response to treatment.

The MEC examines functions including registration, attention and calculation, recall, language, ability to follow simple commands and orientation. Administration of the test requires no special training or equipment and takes between 5 and 10 min. Scores indicate the following cognitive functionality: ≥24/30 is normal; 19–23, mildly impaired; 10–18, moderately impaired; ≤9, severe impairment.

Digit Symbol Substitution Test (DSST). The Digit Symbol Substitution Test [37] is a neurophysiological test sensitive to brain damage, dementia age, and depression assessing working memory. It consists of (e.g., nine) digit-symbol pairs (e.g., 1/−, 2/┴ ... 7/Λ, 8/X, 9/=) followed by a list of digits. Under each digit, the subject should write down the corresponding symbol as fast as possible. The number of correct symbols within the allowed time (i.e., 120 s) is measured. Symbol copy decline has a strong correlation with age.

This form can be completed in approximately 2 min by the candidate/recipient with the clinician. The DSST contained in the Wechsler Adult Intelligence Scale is called “Digit Symbol” (WAIS-R), “Digit Symbol Coding” (WAIS-IV).

Trail B Test. The trail B [38] is a neurophysiological test assessing executive function requiring skills of visual search, scanning, speed processing, and mental flexibility. Trail B is a Trail Making Test that consists of 25 circles distributed over a sheet of paper. The circles include both numbers (1–13) and letters (A – L); the patient draws lines to connect the circles in an ascending pattern, with the task of alternating between the numbers and letters (i.e., 1-A-2-B-3-C, etc.). The patient should be instructed to connect the circles as quickly as possible, without lifting the pen or pencil from the paper. The time the patient takes to connect the “trail” is scored. If the patient makes an error, it is pointed out immediately and the patient is allowed to correct it. Errors affect the patient’s score only in that.

The correction of errors is included in the completion time for the task. The test is stopped after 5 min. This form can be completed in maximum 5 min by the candidate/recipient together with the clinician.

Dependency

Lawton Instrumental Activities of Daily Living Scale (L-IADL). The L-IADL was described by Lawton and Brody [39] and then validated in Spanish by Vergara et al. [40]. Performance of IADLs requires mental as well as physical capacity. The IADL scale measures the functional impact of emotional, cognitive, and physical impairments and their need for personal care services. IADLs are scored based on what an individual can do rather than what he/she is doing. IADLs are scored based on how an individual usually performs each of the eight tasks. The tasks assessed include telephone use; food preparation; shopping; housekeeping; laundry, transportation mode; responsibility for own medication; and ability to handle finances. The patient receives a score of 1 for each category item if his or her competence is rated at some minimal level or higher, or a score of zero if below minimum capacity. The total sum of scores may range from 0 to 8. A lower score indicates a higher level of dependence. This form can be completed in approximately 5 min by interviewing the patient and reviewing the medical history.

De Jong Loneliness. The development and testing of an explanatory loneliness model were described in Gierveld and Tilburg [41]. A 6-item validated version of the loneliness scale was developed by Gierveld and Tilburg [41], three questions assessing social isolation and 3 on emotional loneliness. The scale was used in face-to-face interviews. This form can be completed in approximately 1 min by the clinician by interviewing the patient.

Statistical Analysis

A comparative study was conducted for non-paired samples (hearing results and quality-of-life questionnaires) between the three study groups. Differences between groups were tested using ANOVA and Tukey’s post hoc tests for quantitative data and χ² test for qualitative data. Distributional assumptions were checked using box plots and quantile quantile plots. The IBM SPSS Statistics 20.0 program was used for data analysis. A p value less than 0.050 is considered as statistically significant.

Results

At the time of the last review, August 2023, 710 patients were included in the study. The distribution of patients was as follows: group A – 210 patients (128 women), group B – 302 patients (166 women), and group C – 198 patients (88 women). The demographics and medical history of each group are listed in Table 1.

Table 1.

Demographics and medical history of each group

Characteristics	Group A (n = 302)	Group B (n = 211)	Group C (n = 198)	p value
Gender (male/female)	61% F	55% F	44% F	p < 0.010
Age	61 y	66 y	68 y	p < 0.001
Habitat (rural/urban)	83% U	78% U	73% U	NSD
Assistance (none/family)	99% none	97% none	98% none	NSD
Education level	50% university	38% university	28% university	p < 0.001
Languages (mono/plurilingual)	66% monolingual	70% monolingual	77% monolingual	p < 0.050
Work activity	53% yes	34% yes	29% yes	p < 0.001
Tobacco	55% no	47% no	45% no	NSD
Cardiovascular disease	28% yes	31% yes	31% yes	NSD
Psychiatric disease	18% yes	21% yes	18% yes	NSD
Neurological disease	4% yes	8% yes	9% yes	NSD
Endocrine disease	31% yes	31% yes	32% yes	NSD
Mobility (normal/assisted)	1% assisted	2% assisted	5% assisted	NSD

The only significant differences observed among the three groups were related to age, gender, educational level, bilingualism, and occupational activity. Group C showed a higher percentage of males, with a mean age of 68 years compared to 66 and 61 years for groups B and A, respectively. In group C, the percentage of individuals with a university education was lower (28%), as well as bilingualism rates (23%). As expected, the active workforce index was lower in group C (29%) due to their retirement age.

Hearing

Table 2 displays the results of hearing tests for each of the three study groups. The upper part of Figure 3 gives PTAs for right and left ears separately, at frequencies of 500–4,000 Hz, and for each population group (the mean PTA was: group A 12.6 dB; group B: 34.1 dB; group C: 69.8 dB) and the auditory threshold differences at each frequency across each of the groups were statistically significant (p < 0.001). The lower part of Figure 3 gives speech discrimination scores in quiet. This test was performed binaurally or monaurally aided, with one ear unaided (hearing aid or CI) for group C. As for groups A and B, it was conducted bilaterally unaided. The differences were (include numeric differences with confidence intervals) statistically significant between each of the groups (p < 0.001). Figure 3 also presents the results of speech discrimination in noise (HINT test), in the same conditions of aided or unaided as in quiet. Likewise, the differences were significant between each group (p < 0.001); the great impact on listening in noisy environments was relevant for group C (2.9 dB), as it was for group B (−0.8 dB), which, in turn, revealed differences compared to group A (−2.5 dB). Groups B and C had a predominance of bilateral hearing loss (group B: 74.42%; group C: 90.40%), progressive implementation (group B: 92.80%; group C: 88.26%), and sensorineural type (group B: 91.69%; group C: 92.43%).

Table 2.

Results of the hearing tests for each of the study groups

PTA	500 Hz	1,000 Hz	2,000 Hz	4,000 Hz	Total
Group A	9.7 dB (6.6) (0; 90)	9.3 dB (6.2) (0; 85)	10.3 dB (8.0) (0; 85)	21.2 dB (12.3) (0; 90)	12.6 dB (5.9) (2.5; 87.5)
Group B	24.2 dB (18.9) (0; 120)	28.0 dB (19.1) (0; 120)	35.9 dB (19.8) (0; 125)	48.4 dB (20.5) (0; 120)	34.1 dB (16.9) (1.2; 120)
Group C	61.4 dB (38.2) (0; 120)	66.4 dB dB (36.9) (5; 120)	70.9 dB (33.8) (0; 125)	80.8 dB (31.6) (0; 120)	69.8 dB (33.5) (3.7; 120)
Speech audiometry in quiet			Speech audiometry in noise (HINT test)
Group A	99.8% (1.1) (88; 100)		Group A	−2.5 dB (1.0) (−4.4; 3.2)
Group B	94.2% (10.6) (24; 100)		Group B	−0.8 dB (3.6) (−4.2; 34.0)
Group C	89.2% (14.1) (0; 100)		Group C	2.9 dB (5.5) (−3.5; 45.0)
HHIE-S total	Total (range 0–120) 7.1 (5.7) (0; 20)		SSQ12	Total (range 0–120) 78.9 (25.0) (0; 120)
Group A	2.9 (3.8) (0; 18)		Group A	94.8 (19.7) (35; 120)
Group B	7.3 (4.9) (0; 20)		Group B	78.3 (23.4) (0; 120)
Group C	11.5 (5.7) (0; 20)		Group C	63.1 (22.1) (7; 120)

Fig. 3.

The unaided pure tone audiometry results are presented in the upper part of the figure. Lower left illustrates the results. Lower right displays the speech discrimination in noise results (HINT test).

Figure 4 depicts the analysis of the mean tonal audiometry thresholds (0.5–4 kHz) in groups A and B considering age and gender. The mean age of the individuals comprising group A was 62.1 (SD 5.3) and 61.7 (SD 6.3) years, for males and females, respectively, whereas in group B, they were 66.1 (SD 7.3) and 67.1 (SD 8.7) years, respectively. Significant decline was noted with age and significant differences (p < 0.001) were likewise observed by gender, with males revealing greater hearing impairment.

Fig. 4.

In groups A and B, the correlation between tonal audiometry thresholds (mean value of 0.5–4 kHz), age, and gender were analyzed.

Figure 5 presents the total score on the HHIE-S questionnaire. Groups B (11.1) and C (18.7) show values of significant differences with respect to normality in group A (4.1). But only patients from group C show, clearly, a subjective perception of HL. By category, the degree of handicap severity increased from group A to C. The lower portion of the same figure illustrates the results of the SSQ12 questionnaire, where statistically significant differences (p < 0.001) were also observed, and group C had the worst perception of handicap (63.1).

Fig. 5.

In the upper part of the figure, the HHI-E questionnaire results are presented: absolute values on the right and by category on the left. A score lower than 16 points in each subscale indicates no handicap; a score between 17 and 42 indicates a mild to moderate handicap; and a score above 43 indicates severe handicap. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment. The scores on the SSQ12 can be seen on the left. It is a self-assessment scale of hearing ability and communication in daily environments.

Falls

Figure 6 displays the results of TuGT and DHI. Both tests revealed increased difficulty in maintaining autonomous walking from group A to C, which, again, exhibited the worst results, with statistically significant differences across the groups. In TuGT, abnormal values were found in 13%, 17%, and 31% for groups A, B, and C, respectively. In the DHI questionnaire, abnormal values were found in 14%, 22%, and 25% for groups A, B, and C, respectively.

Fig. 6.

On the left are the results of the TuGT and on the right, those of the Dizziness Handicap Inventory questionnaire.

Cognition

Table 3 illustrates the scores on the various questionnaires to assess cognitive status, for each of the three study groups. No intergroup differences were detected on the Mini Mental State Examination (MMSE), nor relevant degrees of impairment were evidenced in any of the three groups.

Table 3.

Cognitive test results for each group

MMSE	No DET	Mild DET	Moderate DET	Severe DET	Punctuation MMSE
Group A	69	5	0	0	27.4 (2.4) (22; 30)
Group B	91	18	1	0	26.4 (2.9) (16; 30)
Group C	84	11	0	0	26.6 (2.5) (19;30)
DSST	Correct symbols (n)		TMT	Time (s)	Errors (n)
Group A	49.2 (12.7) (17; 79)		Group A	77.1 (33.1) (33; 300)	1.9 (2.5) (0; 12)
Group B	42.9 (14.6) (0; 78)		Group B	92.4 (57.1) (34; 599)	2.2 (2.7) (0; 17)
Group C	38.7 (14.9) (9; 77)		Group C	105.8 (66.6) (33; 419)	2.6 (3.6) (0; 23)

MMSE, Mini Mental State Examination; DET, deterioration; DSST, Digit Symbol Substitution Test; TMT, Trail Making Test.

In contrast, in the DSST questionnaire significant differences (p < 0.001) were detected between groups B (42.9) and C (38.7) compared to group A (49.2) (shown in Fig. 7a). On the other hand, the TMT scores did exhibit significant differences on both execution time (group A: 77.1 s; group B: 91.2 s, 105.8 s) as well as the number of mistakes made (group A: 1.9; group B: 2.2), and group C (2.6) had the worst scores (shown in Fig. 7b, c).

Fig. 7.

a shows the results of the DSST for each of the three groups. b, c display the results of the TMT on both time and errors, respectively. The p values for the statistical comparison across groups are expressed as ***p < 0.001 and **p < 0.01.

Depression

Table 4 illustrates the scores on the different questionnaires, among them, the depression scores for each of the three study groups. No significant differences were detected on the GDS-15 questionnaire across the three population groups. The mean score was 1.3, 1.7, and 1.6 for groups A, B, and C, respectively. This questionnaire revealed signs of depression in 5.2%, 5.2%, and 7.0% for groups A, B, and C, respectively.

Table 4.

Results of questionnaires for assessment of depression, isolation, autonomy, and tinnitus

Depression GDS15	No depression	Possible depression	Depression	Punctuation GDS15
Group A	193	6	11 (5.2%)	1.4 (2.3) (0; 12)
Group B	279	7	16 (5.2%)	1.7 (2.6) (0; 14)
Group C	177	7	14 (7.0%)	1.9 (2.5) (0; 13)
De Jong Loneliness			L-IADL
Group A	1.2 (1.5) (0; 6)		Group A	7.9 (0.4) (5; 8)
Group B	1.3 (1.5) (0; 6)		Group B	7.7 (0.9) (1; 8)
Group C	1.4 (1.6) (0; 8)		Group C	7.6 (1.1) (2; 8)
THI	No DIS	Mild DIS	Moderate DIS	Severe DIS	Punctuation THI
Group A	197	9	4	0	3.4 (8.9) (0; 60)
Group B	269	20	8	5	6.0 (13.3) (0; 82)
Group C	145	32	13	8	11.5 (18.1) (0; 84)

DEP, depression; L-IADL, Lawton Instrumental Activities of Daily Living Scale; THI, Tinnitus Handicap Inventory; DIS, disability.

Dependency and Loneliness

Likewise, Table 4 displays the results of the questionnaires that evaluate dependence and isolation, for each of the three study groups. The results of the Lawton Instrumental Activities of Daily Living Scale (L-IADL) and the De Jong Loneliness scale were within normal limits for all three groups. Nevertheless, groups B and C presented significantly worse results versus group A. In the L-IADL questionnaire, the values were 7.9, 7.7, and 7.6 for groups A, B, and C, respectively. In the De Jong Loneliness questionnaire, the values were 1.2, 1.3, and 1.4 for groups A, B, and C, respectively.

Tinnitus

Table 4 summarizes the THI scale scores obtained by the three population groups. No significant differences were observed across groups (mean values of 3.4, 6.0, and 11.5 for groups A, B, and C, respectively). Overall, the values identified were within the range of mild disability.

Health-Related Quality of Life

Figure 8 displays the HUI3 questionnaire scores. The values for group A were within the normal range; the ones for group B indicated mild disability, and those for group C, pointed to moderate disability. The differences between each and every group were statistically significant.

Fig. 8.

The HUI3 quality of life for each of the groups is displayed. The p values for the statistical intergroup comparison are represented by ***p < 0.001 and **p < 0.01.

Discussion

Although the auditory thresholds of aging individuals or BDs, which are more prevalent among the elderly, have already been studied, there are still insufficient data on the impact of these entities on the quality of life of this population. There are also sparse epidemiological data allowing for analyzing the relationship between HL and/or BD, clinical antecedents, and medical history. This information can be very useful to provide comprehensive and early care to elderly individuals with HL associated or not with BDs, thus contributing to optimize the currently available prevention and treatment means and to reduce the impact that HL and/or BD can have on the person affected by these conditions beyond the sensory aspect, including on areas such as cognition, autonomy, and sociability. Likewise, the information obtained may be of great interest for evaluating the economic impact of HL and BDs among this population group on society. Thus, our aim is to advance the concept of “active or healthy aging,” defined by the WHO as “the process of optimizing opportunities for health, participation, and safety with a view to enhance the quality of life of ageing people.”

Hence, this project “hearing and balance for healthy aging” represents an innovative and original model by proposing an inclusion of a broad number of subjects who will be followed over a long period, implementing a global vision of the human being and its quality of life, and integrating numerous data obtained from the study of multiple variables potentially linked to hearing and balance. Performing this research with a study population comprised by Spanish-speaking subjects is also a novel aspect of this study. With the presentation of the results in this article, the authors attempt to characterize the hearing, balance, and other associated disorders in three population groups over 55 years, at the first visit of the patients included in the project.

As regards hearing, the differences are significant across the three groups on each and every one of the evaluations performed, whether audiometric tests in quiet or in noise, or on questionnaires. The results corresponding to group C, consisting of individuals treated with hearing aids, do not reach the levels of speech discrimination in group A, particularly in those situations of listening in noise. Nevertheless, the results with hearing devices in quiet are good, reaching 89.2% on disyllabic recognition, but worse performance in adverse hearing conditions as revealed by the HINT test and the HHIE and SSQ12 questionnaires. This shows that one of the main challenges when developing hearing devices continues to be that of improving language perception in noisy situations [42].

By means of the PTA hearing thresholds of groups A and B, hearing in adults over the age of 55 can be characterized according to age and gender. As in other studies [43, 44], greater auditory decline was seen in males and in older subjects, whether male or female.

Groups B and C performed worse on the TuGT and on the DHI-T questionnaire than group A, indicating reduced balance ability. Severity was greater in group C for balance and for hearing. These results are consistent with those referenced by other authors [19, 23] that associate greater susceptibility to falling among people with greater hearing loss. Hearing is important in maintaining balance. Traditionally, the maintenance of postural balance is described as a process where the correct output of the musculoskeletal system relies on the interaction of the somatosensory, vestibular, and visual systems with probability of balance impairment increasing with increasing number of underlying systems affected. It is possible that, at least to some extent, deterioration in one sensory subsystem can be compensated by information through other subsystems, including hearing. People with poorer hearing were at three- to fourfold higher risk for falls compared with people with good hearing [45]. Adjustment for postural balance decreased the risk markedly, but still, people with poorer hearing were at twofold risk for falls. Auditory rehabilitation should be a priority when aiming to prevent falls and to promote health and well-being among older people.

Tinnitus was not a serious problem for the study subjects, who had mean scores of less than 16 on the THI, the value below which tinnitus is deemed to be mild. Although there were no significant differences between the three groups, as the levels of hearing loss were higher, so were the scores on the THI questionnaire. This is also reflected by other authors who relate hearing loss, tinnitus, and age [46].

One of the main study objectives was to analyze the relationship between hearing and balance and other areas, such as cognition, isolation, autonomy, and depression and quality of life in general. We did not find any data that made it possible to correlate hearing loss with loss of autonomy, isolation, or depression in any of the three groups assessed in this study. Mention must be made of the fact that group C filled in the questionnaires considering their status with the use of the hearing devices. We understand that the decreased impact hearing loss would have had on these areas in group C had they received treatment. Nonetheless, significant intergroup differences were observed on cognition and quality of life. We believe it to be particularly relevant to point out that differences were seen between groups A and B. Despite displaying mild hearing loss, group B exhibited worse results on the DSST and TMT time than group A, which reveals that, even in the early phases of hearing loss, changes in cognition are already associated with such hearing loss. This finding poses a working hypothesis according to which early treatment for hearing loss could decrease cognitive decline to some degree. Recent studies show that early detection of auditory and vestibular impairments in the elderly and their early treatment will enhance the resulting treatment of their hearing loss and the risk to suffer falls, and it will also contribute to reducing cognitive disorders – and the subsequent loss of self-sufficiency among those who suffer these impairments and the negative socio-economic impact entailed. Increasing prevalence of central auditory processing disorders in the 70+ population has been observed. This impairment of communication can only partially be overcome by auditory rehabilitation programs. Different authors [47, 48] pointed out that auditory rehabilitation and/or home training are efficient tools to reduce communication disability and improved cognitive function in hearing-aid users without cognitive impairment, or with dementia, suggesting that interventions that restore hearing might be effective for the alleviation of late life cognitive disorders.

Significant impairment of quality in life as per the HUI3 questionnaire was detected in groups B and C, compared to group A. ARHL and BDs generate a series of effects that undermine quality of life in seniors by hindering communication and walking and fostering isolation and cognitive impairment. Different authors point out one of the consequences of which is a negative financial impact on those who suffer from such issues, in addition to society in general [4, 49]. The positive impact of hearing aids and CIs on QoL and financial situation in the elderly is well documented [49, 50] and justifies adopting extensive programs to detect hearing and balance loss in older people and to facilitate access to those treatment measures that foster active aging as expressed by the WHO.

Conclusion

In this comprehensive study, we analyzed the characterization of hearing, balance, and other associated disorders in three population groups of individuals aged 55 and older.

• In the study groups with abnormal hearing (groups B and C), a predominant pattern of bilateral, progressive, and mild to moderate neurosensory hearing loss was identified. Despite group B showing abnormal hearing levels in these tests and in the HHIES and SSQ12 questionnaires, individuals in this group rejected the use of hearing aids.

• Age and gender significantly influenced the hearing levels in all groups, including group A (reference group), especially when considering auditory thresholds at 4,000 Hz.

• A relationship was established between hearing levels and results in balance tests (TuGT and DHI), indicating that scores on these tests worsened with increasing hearing impairment.

• Significant differences were observed among the three groups in the DSST and TMT cognitive questionnaires, indicating that greater hearing impairment is associated with cognitive decline.

• Hearing loss significantly impacted overall quality of life, as evidenced by the HUI3 questionnaire, where groups B and C exhibited the lowest scores.

Statement of Ethics

The project was approved by the Clinical Research Ethics Committee of the University Clinic of Navarre with file number 2017.174. A written informed consent was obtained from participants in the study.

Conflict of Interest Statement

No conflict of interest was declared by the authors.

Funding Sources

This study was supported by Cochlear Limited.

Author Contributions

All authors contributed to this work as follows: concept: J.P. de Lima, R. Manrique-Huarte, S. Ferran, A. Huarte, and M. Manrique. Supervision: R. Manrique-Huarte and M. Manrique. Materials: J.P. de Lima, R. Manrique-Huarte, S. Ferran, F. Mallmann, D. Calavia, B. Andueza, A. Huarte, M.A. Gallego, and M. Manrique. Analysis and/or interpretation: J.P. de Lima, R. Manrique-Huarte, S. Ferran, D. Calavia, A. Huarte, and M. Manrique. Literature search: J.P. de Lima, R. Manrique-Huarte, S. Ferran, F. Mallmann, and M. Manrique. Writing: J.P. de Lima, S. Ferran, and M. Manrique. All authors discussed the results and implications and commented on the manuscript at all stages.

Funding Statement

This study was supported by Cochlear Limited.

Data Availability Statement

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to J.P.L.