Quality Indicators for the Care of Hearing Loss in Vulnerable Elders

Hearing loss is one of the most prevalent conditions in the older population, and its prevalence increases progressively with age. Thirty percent to 60% of the population aged 65 and older experiences some degree of hearing impairment. At least 13 million people in the United States suffer from hearing loss; more than half of them are aged 65 and older. As the older population grows, so will the prevalence of hearing impairment. The onset of hearing loss is most often insidious. Its gradual and progressive nature may delay or even eliminate appropriate diagnostic and therapeutic interventions, yet the effect of hearing loss on elderly people is significant. It has been found to be associated with depression, social isolation, poor self-esteem, and functional disability. Hearing impairment without intervention has been shown to have a negative effect on quality of life. Use of hearing aids or surgical intervention improves hearing and has a positive effect on quality of life. A number of screening tests have been developed for hearing loss and are the focus of two of the quality indicators (QIs) listed below. These tests will be described in more detail below. To confirm the presence of hearing loss, formal testing (audiogram) is necessary. Formal audiological testing is performed in a sound-protected setting and takes 30 to 60 minutes to complete. The patient's auditory threshold (pure-tone threshold) is assessed for frequencies from 500 to 8,000 Hz. The patient indicates the minimum decibel level at which a sound is perceived. Speech recognition is examined by having the patient listen to monosyllabic words at a comfortable listening level (usually 40 dB above speech threshold) and recording the percentage of correctly repeated words using a 50-word list. The two major forms of hearing loss are sensorineural and conductive hearing loss. Sensorineural hearing loss is more common and is associated with aging. Sensorineural hearing loss due to aging is termed presbycusis. This type of hearing loss typically occurs gradually over decades. Damage is at the neural level, including the hair cells in the inner ear. Because no treatment is available to reverse this damage, sensorineural hearing loss is usually treated with amplification. Alternatively, conductive loss results from mechanical abnormalities of the middle and external ear and may result from the presence of foreign bodies, fluid (otitis media), or ossicular discontinuities. In general, these losses respond best to surgical intervention. In summary, hearing impairment is not only prevalent but also burdensome in the older population. Early diagnosis and treatment of hearing impairment can improve quality of life and functional status in the aging population. METHODS: A total of 106 articles were considered in this review: 11 identified through a Web search, 69 through reference mining, and 26 from reference mining the Assessing Care of Vulnerable Elders (ACOVE)-1 monograph. RESULTS: Of the 10 potential QIs, the expert panel process judged seven to be valid, and three were rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.