Editor’s note:  The article title was edited for clarity.

Hearing loss is one of the most common conditions affecting older adults. Approximately one-third of people between the ages of 65 and 74 and half of people over age 75 have some type of hearing impairment or loss.1 Despite its high prevalence, however, hearing loss frequently goes undetected and untreated in this population, possibly because only 9% of clinicians recommend that their older adult patients get hearing tests.2

Depression and hearing loss frequently coexist. A study conducted by the National Institute on Deafness and Other Communication Disorders (NIDCD) found that more than 11% of adults with hearing loss also experience depression, compared with only 5% of the general population.3 Hearing loss is also associated with higher levels of anxiety, interpersonal sensitivity, and hostility,4 as well as higher rates of dementia,5 especially in older adults who are also visually impaired.6 Hearing loss in older adults is also independently associated with poorer cognitive and physical functioning and higher healthcare utilization and costs.7

“Although the relationship between hearing loss and cognitive impairment has been researched, there has been relatively little work done on the relationship between hearing loss and anxiety and depression,” according to Dan Blazer, MD, PhD, MPH, Professor of Psychiatry Emeritus, Duke University, Durham, North Carolina.

“Hearing loss and depression are common partners but understudied and underrecognized in older adults,” he told Psychiatry Advisor.

Reactive Depression

People with hearing loss showed a higher prevalence of psychological distress (39.7% vs 19.3%, P  <0.001) and memory loss (37.7% vs 5.2%, P  <0.001) than those without, according to study results recently published in Geriatrics & Gerontology International.8

While there are both neural (central) and ear-related (peripheral) mechanisms involved in hearing loss,9 there has been virtually no research on neural pathways that hearing loss might share with mood disorders. “It is not clear if there are common neural mechanisms between hearing loss and dementia, depression, or anxiety and, if so, what those might be,” said Robert Frisina, PhD, Professor, Department of Chemical and Biomedical Engineering, University of South Florida.

Dr Frisina, who is also the Director of the Global Center for Hearing and Speech Research, told Psychiatry Advisor that the subjects studied at the center “have many psychological and psychiatric issues because they are losing something they once had, which is a critical component of human communication.”

He noted that remedying hearing loss with hearing aids has been shown to improve depression in hearing-impaired individuals,10 suggesting that the depression is secondary to the hearing impairment.

The Depressive Trajectory

Hearing loss is a problem that often goes unnoticed, according to Dr Blazer.

Initially, the person may not be aware of early hearing loss because of its “insidious onset and progression, or because it is not apparent in quiet environments.”11 Moreover, only about 20% of persons aged 65 years or older with moderate to profound hearing loss perceive themselves as hearing impaired11 and only about only 25% of those with treatable hearing loss take action to get hearing devices.3

Initially, family, friends, or coworkers may also not notice the person’s hearing impairment. “Most people recognize when someone has a problem with eyesight. But on the other hand, people with hearing impairments can sit there and not say anything when they are in company, hearing little of the conversation and feeling isolated,” Dr Blazer said.

Affected individuals are frequently embarrassed by their hearing loss, so they say nothing to friends or family and literally suffer in silence.

Dr Frisina agreed. “At the beginning, people with encroaching hearing impairments lose the subtleties, hidden meanings, and true meanings of words and sentences.”

Most of the losses are of sounds with high pitches and frequencies, so people start losing the ability to hear consonants, which are higher pitched than vowels.

“When this happens, people begin confusing words that seem to sound similar or they guess, based on what they think the word might be, and are often wrong. Sometimes, family or friends think that the affected person has dementia because their responses are not congruent with the other person’s statement, or because the information isn’t getting through the auditory system to the cognitive processing or memory centers,” he explained.

People who are unable to hear even though they know they are being spoken to or who confuse words become anxious and frustrated, Dr Frisina continued. In addition, many withdraw instead of asking others to repeat what they said or to speak louder, and the withdrawal contributes to depression.

“Some people who do not withdraw become disruptive because they feel others are impatient with them or do not like them because it takes too much effort and trouble to communicate,” he said. “Grandchildren and children and even caregivers sometimes lose patience.”

Rule Out Hearing Loss

Both experts emphasize that psychiatrists should be suspicious of potential hearing loss when treating an older adult who is showing signs of depression, anxiety, or cognitive impairment.

The quiet office room in which a psychiatrist typically sees patients will not yield the necessary information. “The worst place to test a person’s hearing is the office because this is usually not where the problem occurs. Rather, it takes place in groups of people or other settings where there is background noise,” Dr Blazer pointed out.

Patients who require hearing tests should be referred to audiologists, who are the “entry point for people with hearing impairments,” he said.

Nevertheless, a simple screening test administered in the office can provide useful information. The Hearing Handicap Inventory for the Elderly–Screening Version can be a helpful way to start.11

Patients who are already aware of a hearing impairment and even those already wearing hearing aids should still be referred for an evaluation of their hearing prior to determining whether they have a mood disorder or cognitive impairment because their hearing may not be sufficiently corrected by these devices, Dr. Frisina added.

Risk Factors for Hearing Loss

Becoming aware of risk factors for hearing loss may raise a clinician’s level of suspicion that the condition is affecting his or her patient.

Several classes of medications are implicated in hearing impairments or hearing loss. Ototoxic medications include aminoglycosides and macrolides, certain cancer chemotherapy drugs (eg, cisplatin), and loop diuretics.12 Long-term use of nonsteroidal anti-inflammatory drugs and acetaminophen is also associated with hearing loss.13 Some evidence suggests that salicylates, progestin, and sildenafil also increase the risk.11

Antiepileptic drugs (eg, carbamazepine, phenytoin, valproate, lamotrigine, gabapentin, vigabatrin, and oxcarbazepine) can cause auditory and vestibular toxicities, so monitoring of patients taking these agents who are at high risk for audio-vestibular manifestations is necessary for appropriate preventive and therapeutic measures.14

Additional risk factors include male sex, exposure to loud noises, medical conditions (eg, diabetes mellitus, renal failure, atherosclerosis, immunosuppression, and head injury), industrial chemicals (eg, toluene and styrene), and tobacco use.11

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Tips for Psychiatrists Treating Hearing-Impaired Older Patients

Provide education. An important role that a psychiatrist can play in working with hearing-impaired older patients is to educate their families, Dr Frisina said.

“Tell the family that granddad isn’t ignoring you and doesn’t have dementia, but rather has a hearing loss that should be treated with hearing aids,” he suggested.

Family members should be made aware that speaking louder does not help and, in fact, often creates auditory distortion. “It is better to speak more clearly and more slowly, and to allow the person to see the face, get facial cues, and read lips,” Dr Frisina advised.

Educating the patient about his or her condition and what can and cannot be realistically expected from hearing aids and other interventions is also key. The NIDCC provides helpful fact sheets that can be given to the patient.1

Refer patients to audiologists. “Audiologists do not just prescribe hearing aids,” Dr Blazer pointed out. “They offer many techniques to help people cope better with hearing loss.” They can also be active in helping patients deal with tinnitus, which is a common and extremely challenging problem.

He added that many hearing instrument specialists who fit people with hearing aids can also provide the patient with useful tips for adapting to hearing loss.

Refer patients to auditory training programs. “The literature underlying auditory plasticity following placement of sensory devices suggests that additional auditory training may be needed for reorganization of the brain to occur and optimal performance from devices to be obtained.”15 Certain programs can also be accessed using web-based formats and smartphone technology.15

Auditory training programs are often offered by audiology centers that specialize in the elderly. “A university or good hospital with an audiology department would be a good place to start if you want to refer patients for auditory training,” Dr Frisina said.

Dr Frisina warned that the long-term success of these programs in improving hearing is “controversial.”

“We know they can make improvements while the person is in the program, but it is unclear if there are lasting benefits after the training program ends.”

Still, he added, “It won’t hurt and it will help while the patient is in the program.”

Encourage patients to listen to music. Music has shown effectiveness in providing neuroprotection.16 Dr Frisina called music “a special stimulus,” noting that in people with dementia and even advanced Alzheimer’s disease, “the last meaningful auditory stimulus is music. Some patients who are unable to understand commands can still dance or sing with the music.” He cautioned that music should not be too loud, which could cause further hearing damage.

Conclusion

As the baby boomers continue to age, the prevalence of hearing impairments in older adults will continue to rise. It is essential for psychiatrists to be aware of the interplay between hearing loss and mood disorders and to address the hearing loss before reaching a diagnostic conclusion or treatment plan.

References

1. National Institute on Deafness and Other Communication Disorders (NIDCD). Hearing Loss and Older Adults. Available at: https://www.nidcd.nih.gov/health/hearing-loss-older-adults. Updated July 17, 2018. Accessed August 31, 2017.

2. Packer L. The complex link between depression and hearing loss. Healthy Hearing. Available at: http://www.healthyhearing.com/report/52437-The-complex-link-between-depression-and-hearing-loss. July 27, 2017. Accessed September 4, 2019.

3. Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in US adults, National Health and Nutrition Examination Survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4):293-302.

4. Monzani D, Galeazzi G, Genovese E, Marrara A, Martini A. Psychological profile and social behaviour of working adults with mild or moderate hearing loss. Acta Otorhinolaryngol Ital. 2008;28(2):61-66.

5. Lin VYW, Black SE. Linking deafness and dementia: challenges and opportunities. Otol Neurotol. 2017;38(8):e237-e239.

6. Davidson JGS, Guthrie DM. Older adults with a combination of vision and hearing impairment experience higher rates of cognitive impairment, functional dependence, and worse outcomes across a set of quality indicators. J Aging Health. 2019;31(1):85-108.

7. Genther DJ, Frick KD, Chen D, Betz J, Lin FR. Association of hearing loss with hospitalization and burden of disease in older adults. JAMA. 2013;309(22):2322-2324.

8. Iwagami M, Kobayashi Y, Tsukazaki E, et al. Associations between self-reported hearing loss and outdoor activity limitations, psychological distress and self-reported memory loss among older people: analysis of the 2016 Comprehensive Survey of Living Conditions in Japan. Geriatr Gerontol Int. 2019;19(8):747-754.

9. Frisina RD. Age-related hearing loss: ear and brain mechanisms. Ann N Y Acad Sci. 2009;1170:708-717.

10. Choi JS, Betz J, Li L, et al. Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults. JAMA Otolaryngol Head Neck Surg. 2016;142(7):652-657.

11. Walling AD, Dickson GM. Hearing loss in older adults. Am Fam Physician. 2012;85(12):1150-1156.

12. Landier W. Ototoxicity and cancer therapy. Cancer. 2016;122(11):1647-1658.

13. Lin BM, Curhan SG, Wang M, Eavey R, Stankovic KM, Curhan GC. Duration of analgesic use and risk of hearing loss in women. Am J Epidemiol. 2017;185(1):40-47.

14. Hamed SA. The auditory and vestibular toxicities induced by antiepileptic drugs. Expert Opin Drug Saf. 2017;16:1281-1294.

15. Olson AD. Options for auditory training for adults with hearing loss. Semin Hear. 2015;36(4):284-295.

16. Kraus N, Zatorre RJ, Strait DL. Editors’ introduction to Hearing Research special issue: music: a window into the hearing brain. Hear Res. 2014;308:1.