The positive impact for the elderly of early intervention in hearing loss and balance disorders. Clinical and socio-economic aspects.
Hearing Loss Is Often a Silent Problem
In most cases, family and friends are more aware of the problem than the patient. It would seem cautious for healthcare professionals to screen for one of the most prevalent chronic diseases affecting older people, but unfortunately, this is not done. It is most unfortunate that the penetration rate of hearing aids and cochlear implants is between 10%-15% among users since they have proven to be effective means to treat hearing loss. These numbers show that we need to take on a holistic approach to this problem, raising awareness among healthcare professionals and society as a whole, and implementing early detection, diagnosis and intervention programs, with optimal monitoring, to ensure that the desired benefits are achieved.
The causes for this low penetration rate may be:
- The person affected denies the problem.
- The hearing aid fitting/cochlear implant programming is delayed, the hearing system is not stimulated for an excessive period of time.
- Mismatch of expectations and results obtained.
- Social stigma linked to agerelated hearing loss. The patient opposes wearing a hearing aid visibly.
- Partial approach to the issue, exclusively focused on treating the hearing loss, leaving aside the fact that this impairment is associated with multiple conditions that must be considered.
- Improper control of the hearing aid used.
The Consequences of Presbycusis and Balance Disorders. Their Economic Impact
The impact of presbycusis and balance disorders on an aging population, as in Europe, is high. If hearing loss and balance disorders are not accurately diagnosed and treated, the population of Europe and the world have a smaller chance of active and healthy aging. As mentioned in this document, presbycusis and balance disorders will bring about several effects that undermine the quality of life of the elderly:
- Functional Impact. Hearing loss and decreased autonomy reduce the quality of life in several ways: communication difficulties, increased social isolation, reduced capacity to participate in all areas of social life and contribution to other health issues.
- Social/Emotional Impact and Health. Hearing loss can increase the risk of mental health issues: anxiety, paranoia and depression are some risks one must consider. People with hearing loss are over-represented in the sample of patients with late-life paranoid psychosis. Older individuals with hearing loss are more likely to develop depression compared to normal-hearing individuals.
- Cognitive Impact. A considerable number of publications1,2 show that hearing loss among the elderly is associated with dementia independently. This sheds light on the factors that contribute to reducing cognitive function in the elderly.
- Economic Impact. Hearing loss leads to the loss of income and employment (Kochkin 2015) (unemployment rates are higher), more sick leaves, less opportunities to advance their professional career, and difficulties to recover a job. The cost of untreated hearing loss in Europe is estimated at €213 billion for 2050. Besides, it is estimated that some 900 million people around the world—out of which 90 million are in Europe—suffer from hearing loss3,4. The annual indirect and direct costs of untreated hearing loss in various European countries range from €32,000 million in Germany, €23,400 million in France, €22,000 million in the United Kingdom, €21,300 million in Italy, to €16,300 million in Spain or €14,000 million in Poland5.
“The Real Cost of Hearing Loss”, a report by The Ear Foundation (2014)6 shows the actual cost of hearing loss for adults, and how to reduce its impact with the latest technology available to treat hearing loss and balance disorders. O’Neil7 has proven that the economic cost of NOT offering technological solutions to treat hearing loss is greater than the cost of providing these technologies. European healthcare systems need to calculate the actual cost of hearing loss. There is considerable risk in not providing hearing aids, bone-conduction implants, cochlear implants and other hearing solutions. Today, this opens the door to costly demands on healthcare systems and it will generate significant costs in social care going forward. Giving aid to treat hearing loss today changes that individual’s life—and saves society some money. A US study8 compared hearing aid users with non-users. People with severe hearing loss who did not use hearing aids were subject to unemployment rates (15.6%) double those observed among individuals who used their hearing aids (8.3%). The result obtained with cochlear implants can create opportunities in the job market as well. Monteiro9 described that patients with cochlear implants saw their income increase significantly versus what they earned before the implant. In a study, Clinkard10 found that 60% of patients were unemployed before getting their cochlear implant. Their unemployment rate was cut down to 49% after the implantation. In a study using a questionnaire to assess the job satisfaction of patients treated with a cochlear implant, Huarte11 found that 93.05% of the group felt more motivated to go to work, 79.31% saw themselves as more competent and 67.23% improved their interpersonal relations at work a year after activating their cochlear implant. The study concludes that the cochlear implant has positive impact at work and on social skills, as it benefits the communication skills of implanted patients.
Falls are the most frequent cause of fatal and non-fatal traumatism. Their economic cost is estimated at $67.7 billion in the USA. Among the modifiable risk factors described, drugs, visual impairment, weak lower limbs and vitamin D deficiency have been mentioned. Surprisingly, hearing loss is not mentioned as a predisposing factor, despite the scientific evidence that shows a relation between falls and hearing loss, as pointed out in this document.
Cognitive impairment is a consequence of hearing loss among the elderly, as described in this document as well. In 2010, the prevalence of dementia above 70 years of age in the USA was estimated at 14.7%12. There are 6 to 9 million people with dementia in Europe annually. The annual economic cost per person attributable to dementia in the USA was USD$56,290 in 201312. The direct and indirect cost of all brain diseases exceeds €790 billion in Europe, compared with €200 billions of cardiovascular diseases and €150 billions of cancer13. The cost of dementia in people above 60 years of age amounted to 0.79% and 0.77% of the gross domestic product of France and Italy respectively in 200914. Managing hearing loss improperly can increase the cost. According to some estimations, Social Services in the United Kingdom could save £28 million if the hearing loss of patients with severe dementia were properly treated, as this would have delayed the need for institutionalized care, and the corresponding economic cost15.
The Positive Impact of Treating Presbycusis and Balance Disorders
There has been a revolution in the efficacy and power of communication technologies over the last few decades, including hearing aids, bone-conduction implants, cochlear implants and other aids. Healthcare systems are in a better position to face the health disorders and social consequences stemming from hearing loss and balance disorders.
Hearing aids are an effective, well-accepted solution to treat hearing loss. According to several studies, their utilization reaches 80-90%. Some systematic reviews have reported that hearing aids are a cost-effective intervention16,17,18. The employment rate of hearing aid users is almost double that of non-users8.
The “American Association of Audiology Task Force” carried out a systematic review of the medical literature and concluded that hearing aids improve the quality of life of its users and reduce the negative effects of hearing loss on psychological, social and emotional aspects19. More recent studies about quality of life have revealed the beneficial effect of hearing aids20,21,22. Hearing aid users have reported positive results compared with non-users, and described improved socialization, mental and physical health23. The use of hearing aids mitigates the risk of social dependence and premature death24,25, and they have a positive effect on depression26.
There are increasingly more studies proving that cognitive impairment can be reduced by using hearing aids. An extensive French randomized study with a cohort of 3,670 patients over age 65, proves that stimulating the auditory pathway with hearing aids is beneficial. This study started in 1989-1990, and the participants have been regularly evaluated for 25 years. The study concludes that hearing loss is associated with faster cognitive impairment in older adults, and that older adults who use hearing aids go through a significantly milder process27.
In general, people with severe to profound hearing loss use cochlear implants. Ever since cochlear implants made their appearance in the 1980s, many studies have evidenced that patients with severe to profound hearing loss, regardless of the age at implantation, can access the spoken language enabled by their implants28.
Cochlear implants restore auditory perception. In doing so, they reduce the prevalence of tinnitus, improve the quality of life, reduce the symptoms of depression and improve overall cognitive skills29,30,31.
The cost-benefit advantages of cochlear implantation have been well established in a series of systematic reviews and research32. A review in 2011 concluded that unilateral implantation yields a positive cost-benefit balance, including older adults in this assumption33. Using bilateral cochlear implants (simultaneous and sequential) has become a staple of clinical practice in the last few years34,35. Bilateral cochlear implants offer a superior ability to locate sound and discriminate speech in noisy environments, compared with unilateral implantation in adults36,37. A recent economic evaluation in adults with sequential, bilateral cochlear implants in Canada proved a positive cost-benefit ratio38. Another multi-center randomized study in Europe compared the use of unilateral vs. bilateral cochlear implants in a post-lingual adult population. It concluded a positive cost-benefit balance for patients with life expectancies equal or greater than 5-10 years39.
Hearing is important to maintain balance. Postural balance is a process in which the correct functioning of the muscular-skeletal system depended on the correct interaction between the vestibular, visual and somatic sensory subsystems. If one of these subsystems fails, it has impact on keeping balance. This failure may be offset by another subsystem, such as hearing. As correctly mentioned and pointed out by Lin40, people with hearing loss are twice and three times more likely to suffer falls than a normal-hearing person. Adopting therapeutic measures to repair or rehabilitate injuries affecting balance are key to reduce the risk of falls and can also help treat the hearing problem. One may reasonably argue that treating hearing loss must be a priority when preventing falls and promoting quality of life among older adults.
Finally, early detection and a comprehensive management of presbycusis and/or balance disorders and their etiopathogenic factors are key. This will enable prevention by early intervention, allowing the elderly to maintain their communication, cognitive, mental skills and autonomy. In sum the quality of life of the elderly will improve and the negative impact their dependance has on caregivers and the economic sustainability of healthcare systems will be mitigated as well.
- Lin FR, Yaffe K, Xia J, Xue QL, Harris TB, Purchase-Helzner E, et al. Health ABC study group: Hearing loss and cognitive decline in older adults. JAMA Intern Med 2013;173:293-299.
- Lin FR, Ferrucci L, An Y, Gho JO, Doshi J, et al. Association of hearing impairment with brain volumen changes in older adults. Neuroimagine 2014;90:84-92.
- Shield B. Evaluation of the social and economic costs of hearing impairment. Hear it. 2006. http.//www.hear-it-org.
- Roth TN, Hanebuth D, Probst R. Prevalence of age-related hearing loss in Europe: a review. Arch Otorhinolaryngol 2011;268:1101-1107.
- Evaluation of the social and economic costs of hearing impairment. October 2006. Hear-it AISBL.
- Brian Lamb OBE, Sue Archbold, Ciaran O’Neill. Spend to save: Investing in hearing technology improves lives and saves society money. Ear Foundation, 2014.
- O’Neill, C., Lamb, B., Archbold, S. (2016) Cost implications for changing candidacy or access to service within a publicly funded healthcare system? Cochlear Implants International, 17:sup1, 31-35.
- Kochkin S. (2010). The efficacy of hearing aids in achieving compensation equity in the workplace. The Hearing Journal, 63(10): 19–28. Medicine;172:369-71.
- Monteiro E, Shipp D, Chen J, Nedzelski J, Lin V.J Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income. Otolaryngol Head Neck Surg. 2012 Apr;41 Suppl 1:S43-8.
- Clinkard D, Barbic S, Amoodi H, Shipp D, Lin V. (2015) The economic and societal benefits of adult cochlear implant implantation: A pilot exploratory study.
- Huarte A, Martínez – López M, Manrique R, Erviti S, Calavia D, Alonso C, Manrique M. Work activity in patients treated with cochlear implants (Actividad Laboral en pacientes tratados con Implantes Cocleares). Acta Otorrinolaringológica Española 2017;68 (2):92-97.
- Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary cost of dementia in the United States. N Engl Med 2013;368:1326-1334.
- Olesen J, Gustavsson A, Svensson M. European brain council: The economic cost of brain disorders in Europe. Eur J Neurol 2012;19:155-162.
- Wimo A, Winblad B, Jönsson L. The worldwide societal costs of dementia: Estimates for 2009. Alzheimers dement 2010;6:98-103.
- Action for Hearing Loss (2013) Hearing Screening for Life. RNID/London Economics ‘Cost benefit analysis of hearing screening for older people’
- Chao & Chen (2008) Cost-effectiveness of hearing aids in the hearing-impaired elderly: a probabilistic approach. Otology and Neurotology 29(6): 776-83.
- Morris, A.E. Lutman, M.E. Cook, A.J. Turner, D. An economic evaluation of screening 60- to 70-year-old adults for hearing loss. Journal of Public Health 2012.
- Joore et al., (2003) The cost-effectiveness of hearing-aid fitting in the Netherlands. Archives of Otolaryngology - Head and Neck Surgery 129(3).
- Chisholm et al., (2007) A systematic review of health-related quality of life and hearing aids: Final report of the American Academy of Audiology task force on the health-related quality of life benefits of amplification in adults. Journal of American Academy of Audiology 18: 151-183.
- Ciorba, A., Bianchini, C., Pelucchi, S., & Pastore, A. (2012).The impact of hearing loss on the quality of life of elderly adults. Clinical Interventions in Aging, 7, 159–163.
- Swan et al (2012) Health-related quality of life before and after management in adults referred to otolaryngology: a prospective national study. Clinical Otolaryngology 37(1): 35-43.
- Barton et al (2004) Comparing utility scores before and after hearing aid provision: results according to the EQ-5D, HUI3 and SF-6D. Applied Health Economics and Health Policy 3(2):103-5.
- Kochkin, K., and Rogin (2000) Quantifying the obvious: The impact of hearing instruments on quality of life. Hearing Review 7(1).
- Fisher, D. et al., (2014) Impairments in Hearing and Vision Impact on Mortality in Older People. The AGES-Reykjavik Study, Age Ageing. 43(1):69-76.
- Contrera K J, Betz J, Genther, D J. Lin, F R. (2015) Association of Hearing Impairment and Mortality in the National Health and Nutrition Examination Survey. JAMA Otolaryngol Head Neck. Surg. Pub online Sep 2015.
- Saito et al., (2010) Hearing handicap predicts the development of depressive symptoms after three years in older community-dwelling Japanese. Journal of the American Geriatrics Society 58(1), 93-7.
- Amieva, H. Ouvrard, C. Giulioli, C. Meillon, C. Rullie,R. L. Dartigues, JF. Self-Reported Hearing Loss, Hearing Aids, and Cognitive Decline in Elderly Adults: A 25-Year Study. J Am Geriatr Soc. 2015 Oct;63(10):2099-104.
- Manrique M, Ramos A, Morera C, Cenjor C, Lavilla MJ, S.Boleas M, Cervera-Paz FJ. Evaluación del implante coclear como técnica de tratamiento de la hipoacusia profunda en pacientes pre y post locutivos. Acta Otorrinolaringológica Española 2006;57 (1): 2-23.
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- Manrique R, Calavia D, Huarte A, Girón L, Manrique M.Treatment for hearing loss among the elderly: auditory outcomes and Impact on quality of life. Audiology & Neurotology 2016;21(Suppl 1):26-35 .
- Huarte A, Lezaun R, Manrique M. Quality of life outcomes for cochlear implantation in the elderly. Audiology and Neurotology 2014;19 sup 1(1):36-39.
- Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, Hoyle M, Liu Z, Price A, Stein. (2009) The effectiveness and cost effectiveness of cochlear implants for severe and profound deafness in children and adults: a systematic review and economic model. K Health Technol Assess 2009. Sep: 13 (44).
- Turchetti G, Bellelli S, Palla I, Berrettin S, (2011) Systematic review of the scientific literature on the economic evaluation of cochlear implants in adult patients. ACTA otorhinolaryngologica ita lica;31:319-327.
- Hayes Inc. Cochlear Implants: Bilateral Versus Unilateral-A Health Technology Assessment Prepared for Washington State Health Care Authority. April 17, 2013.
- Peters B, Wyss J, Manrique M. Worldwide Trends in Bilateral Cochlear Implantation. Laryngoscope 2010;120 (Nº 5 Supl 2):17-44.
- Van Schoonhoven J, Sparreboom M, van Zanten BG, et al., (2013) The effectiveness of bilateral cochlear implants for severe-to-profound deafness in adults: A systematic review. Otol Neurotol 2013; 34: 190–8.
- Gifford RH, Driscoll CL, Davis TJ, Fiebig P, Micco A, Dorman MF. (2015) A Within-Subject Comparison of Bimodal Hearing, Bilateral Cochlear Implantation, and Bilateral Cochlear Implantation With Bilateral Hearing Preservation: HighPerforming Patients. Otol Neurotol. 2015 Sep; 36(8):1331-7.
- Chen JM, Amoodi H, Mittmann N. (2014) Cost utility analysis of bilateral cochlear implantation in adults:A health economic assessment from the perspective of a publicly funded program. Laryngoscope 2014;124:1452–8.
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- Lin FR, Ferrucci L. Hearing loss and falls among older adults in the United Sates. Arch Intern Med 2012;172:369-371.