Increasing Access to Hearing Rehabilitation for Older Adults

Abstract

Purpose of Review

To provide an update on the recent research and policy developments affecting the current and future care of the 23 million older Americans with untreated hearing loss.

Recent Findings

Increasing evidence supports the association of age-related hearing loss with significant negative outcomes that affect the ability of older adults to age well. Despite an evolving understanding of the role hearing loss plays in the well-being and vitality of older adults, the vast majority of older adults go untreated and hearing healthcare disparities exist. Recent work to understand the multitude of factors involved in hearing healthcare decisions, coupled with innovative approaches and technology to deliver hearing care, aim to provide more older adults with equal access to the tools needed to age well. Most importantly, significant national efforts and policy proposals substantiate these efforts, and will be reviewed.

Summary

Age-related hearing loss is a critical public health issue that affects almost all older adults. Through the application of novel approaches and perspectives, the delivery of hearing healthcare for older adults is evolving in order to provide more affordable and accessible care. Accompanying policy efforts provide the necessary support needed to increase access to care significantly.

INTRODUCTION

Age-related hearing loss is an almost universal phenomenon that increasingly affects a greater number of older adults in the aging American population. Although traditionally approached as a benign and inevitable process of aging, society has begun to view age-related hearing loss as an unaddressed public health challenge, one that has taken on greater importance in recent years given concerted national efforts.^1,2 The review will provide an update on the latest epidemiology on hearing healthcare for older adults, the multitude of factors to consider in expanding access to care, along with recent novel approaches to the provision of hearing healthcare and the legislative efforts to support the expansion of hearing healthcare for older adults.

EPIDEMIOLOGY OF AGE-RELATED HEARING LOSS

Almost 26 million older Americans have a clinically significant hearing loss.³ With an aging population, the number of older Americans with hearing loss is expected to increase to over 41 million by 2060.⁴ The prevalence of age-related hearing loss doubles with each decade of life, with 2/3rds of older adults 70 years old and older with a clinically significant hearing loss, increasing to almost 90% of adults older than 80 years.^5,6 Age is the primary risk factor for age-related hearing loss, but sex and race/ethnicity are also documented risk factors, with higher rates of hearing loss among males and White older adults.⁵

Although the prevalence of age-related hearing loss has been well-documented, recent emphasis on the potential downstream effects of hearing loss have brought renewed interest to what is traditionally considered a normal part of the aging process.^7,8 Multiple epidemiologic studies document that age-related hearing loss is independently associated with accelerated cognitive decline⁹, incident dementia¹⁰, social isolation^11,12, depression^13–15, hospitalization¹⁶, increased health care expenditures¹⁷, falls¹⁸, and mortality¹⁹. Given the prevalence of age-related hearing loss and the extent of associated outcomes, the ability to intervene in a low-risk fashion, during late-life, raises the importance of hearing healthcare and the importance of understanding and addressing potential disparities in hearing care.

EPIDEMIOLOGY OF HEARING HEALTHCARE FOR OLDER ADULTS

The traditional approach to hearing healthcare entails aural rehabilitation, including communication strategies and provision of amplification, typically in the form of hearing aids. Few nationally representative estimates exist on older adults’ access to hearing healthcare and generally document hearing aid use as the primary indicator of hearing healthcare. Prevalence of hearing aid use among older adults with hearing loss is low and estimates range from 14.6% to 33.1%.^5,20–22 Similar to disparities in healthcare based on race/ethnicity and socioeconomic status, hearing aid use is lower among minority older adults and those with lower socioeconomic status.^21,22 Based on nationally representative data, rates of hearing screening, a service typically covered by Medicare, are higher among minority older adults, but rates of hearing aid use, which is not covered by Medicare, are lower.²² Furthermore, the prevalence of untreated hearing loss is higher among low-income older adults than those in higher income brackets.²³ For example, 88% of low-income older adults aged 60–69 years with hearing loss go untreated compared to 66% of high-income adults 80 years and older.²³

HEARING HEALTHCARE AS A HEALTH BEHAVIOR

Age-related hearing loss is increasingly considered a public health priority and, along with growing recognition of the impact of age-related hearing loss, traditional public health approaches and frameworks have begun to be applied to hearing healthcare and aid in our understanding of how to increase care. The ability to understand and address hearing healthcare as a health behavior provides a systematic approach to the complex and multifactorial decision of whether or not to seek care and, most importantly, potential targets for intervention. A number of health behavior change models have been applied to hearing healthcare, primarily help seeking and hearing aid uptake.

The transtheoretical model or stages of change model and the health belief model have been the primary behavior change models used to understand behaviors related to hearing healthcare. Combining the two models, Saunders et al. found that increasing self-efficacy, conveying perceived benefit, and providing a cue to action were critical constructs and should be incorporated into interventions.²⁴ Self-efficacy is a commonly targeted component in improving the uptake of a given health behavior, particularly when the behavior includes use of technology by an older adult, such as hearing aids, and can be enhanced through training.^25,26 Beyond self-efficacy, social support is associated with increased help-seeking, where significant others can act as a cue to action, and has also been associated with greater hearing aid satisfaction.^27,28 Self-reported hearing disability is another consistently cited factor closely associated with help-seeking behavior, which questions the importance of objective versus subjective measures of hearing loss.^25,29

In addition to factors that promote hearing healthcare as a health behavior, barriers to hearing healthcare exist, particularly relevant are social and cultural factors that influence help-seeking and hearing aid uptake.²⁵ Stigma is a significant barrier and frequently manifests as a threat to one’s self-perception, ageism, and vanity.³⁰ However, the growing popularity of hearables and other ear-worn devices among young adults may decrease the traditional negative associations of ear-level devices like hearing aids.^31,32 Beyond the individual, health care providers’ own views regarding the benefit of hearing healthcare and lack of referrals represent additional barriers to care.^25,33 Last, the lack of affordability and accessibility of the current, predominantly clinic-based model of hearing healthcare function as an additional barrier to hearing care, which includes the high-cost of devices to the lack of readability and suitability of hearing aid manuals for older adults.^2,25,34

INNOVATIONS IN HEARING HEALTHCARE DELIVERY

With the spectrum of barriers and the disparities that exist based on race/ethnicity and socioeconomic status, hearing healthcare must meet the needs of a range of older adults with hearing loss, beyond the narrow spectrum of older adults served by the current model of care. The stagnant rate of hearing aid adoption over the past 35+ years further underlines the need for new technologies and approaches.³¹ Advances in over-the-counter, direct-to-consumer technology along with community-delivered programs and primary care-driven models of care represent some of the novel approaches to hearing healthcare that meet recent calls for more affordable, accessible hearing care.^1,2,35 These advances help address the five major obstacles to hearing healthcare, including awareness, access, treatment options, cost, and device effectiveness.³⁶

Although the category of personal sound amplification products (PSAPs) is not new, there has been a recent increase in the number and variety of amplification products sold that do not fit within the traditional definition of hearing aid.³¹ Initial studies demonstrate that the majority of older adults are able to fit self-programming devices on their own and that some of the direct-to-consumer devices provide appropriate amplification for mild-to-moderate hearing loss based on electroacoustic analysis and simulated real-ear measurements.^37,38 Through a randomized double-blind, placebo-controlled trial, Humes et al. found that an over-the-counter model, using self-selected, pre-programmed hearing aids was efficacious and achieved similar effect sizes to the traditional audiology best practices approach.³⁹ Considering a human factors approach to design, several of the direct-to-consumer products provide older adult-friendly features like rechargeable batteries and a larger earpiece with buttons that are large enough to press without difficulty.⁴⁰ An additional benefit of these devices is the lower average cost of the devices, which range from less than $50 to $400, a striking difference compared to the $2,000-4,000 of traditional hearing aids.^31,37

While amplification is an important component of sensory management in the treatment of age-related hearing loss, aural rehabilitation and the accompanying fitting and orientation to an amplification device are essential components of hearing healthcare for older adults.^2,25 Beyond the traditional model of clinic-based care, programs delivered in the community have been proposed as a way to deliver more affordable, accessible services to older adults, specifically through the incorporation of community health workers. Recent pilot studies demonstrate the feasibility and acceptability of a community-based approach to deliver hearing care in underserved areas and address hearing healthcare disparities. One pilot study has trained an initial cohort of Spanish-speaking community health workers or promotoras to deliver an aural rehabilitation program along the United States-Mexico border.⁴¹ Another pilot study demonstrated the preliminary efficacy, feasibility, and acceptability of a one-time training session that incorporates the fitting of a low-cost, over-the-counter amplification device and aural rehabilitation strategies delivered in the community.⁴² Results from the randomized controlled pilot study document improvements in hearing handicap similar to those found with traditional hearing aids along with significant reduction in depressive symptoms among an urban-dwelling, low-income cohort of older adults.⁴² Both of these programs incorporate a community-engaged approach to research and target populations that have traditionally been unserved by the existing clinic-based model of hearing healthcare.

Finally, innovations in the delivery of hearing healthcare have also been made through the engagement of primary care providers, who can serve as an important advocate for their patients and navigator in the current, complex system of hearing healthcare.² Simple, low-cost interventions, such as an educational brochure on hearing loss and hearing healthcare, increased follow-up rates after hearing screening and enhanced communication.⁴³ Another recent pilot study in a memory care clinic demonstrates the preliminary benefit of a one-time hearing care program that includes a low-cost, over-the-counter amplification device and an abbreviated aural rehabilitation session tailored for cognitively impair older adults with hearing loss and their caregivers.⁴⁴ Primary care-based models are another model that may bring hearing care to more older adults.

RECENT POLICY AND REGULATORY CHANGES IN HEARING HEALTHCARE

Several major developments in the national landscape of hearing healthcare have evolved over the past years. Three primary changes are: 1) an increase in the general awareness of the need for affordable, accessible hearing care and a commitment from key agencies to expand care, 2) limiting barriers to direct-to-consumer hearing care, and 3) movement to open a range of products and approaches to hearing care delivery. These developments are the product of the National Academies of Sciences, Engineering and Medicine (NASEM) committee report on affordable, accessible hearing care and the President’s Council of Advisors on Science and Technology (PCAST) report on improving hearing technologies.^1,2 The FDA announced in December 2016 that it will not enforce the requirement for medical evaluation prior to purchasing hearing aids and, even more importantly, the FDA announced its commitment to allowing for over-the-counter hearing aids. This announcement eliminates barriers to the expansion of direct-to-consumer approaches to hearing care.

Finally, critical bipartisan legislation was introduced that will create a category for over-the-counter hearing aids and allow for the regulation and encourage development of a range of products and approaches to expand hearing healthcare delivery. A bipartisan bill, the Over-the-Counter Hearing Aid Act of 2017 (S.670, H.R. 1652), from Senators Warren and Grassley and Representatives Blackburn and Kennedy was introduced in December 2016 in response to the NASEM and PCAST recommendations. This bill would mandate that the FDA create a separate regulatory classification for over-the-counter hearing aids, and as of June 2017 this bill was on track to be passed in this current session of Congress. This type of legislation has increased public awareness around alternatives to amplification, beyond the traditional hearing aid. Further, the legislation will ease the regulatory environment in ways that will nourish a growing market of over-the-counter amplification devices and hearing aids, improving the quality, reducing the cost, and expanding available choice of technology older adults and their families. These national efforts are quickly changing the landscape of hearing health care and will support the further disruption and expansion of hearing healthcare for older adults.

CONCLUSION

Age-related hearing loss is a significant, unaddressed public health concern with substantial disparities in access and use of hearing healthcare. Recent advances in our understanding of hearing healthcare as a health behavior along with disruptive approaches to care and associated policy developments support real reform necessary to broaden access and affordability of hearing healthcare for all older adults.

Key Points.

• A systematic approach to hearing healthcare as a health behavior provides important targets for the development of effective interventions to increase help-seeking and amplification use.

• Innovations in technology, community-delivered approaches, and primary care-based programs may expand access to hearing healthcare among older adults, particularly underserved and at-risk populations.

• Recent national initiatives, including PCAST, NASEM, and pending federal legislation, promise to disrupt the current hearing healthcare delivery system with the goal of providing more affordable, accessible hearing healthcare.