There's not enough evidence to recommend screening all older adults in the United States for hearing loss, the most recent recommendations to come from the US Preventive Services Task Force, or USPSTF, and published in Annals of Internal Medicine, state. Yet as Rick and I review in PodMed, abundant research, much of it from Johns Hopkins, does establish risks related to hearing loss in older people, especially social isolation, dementia, and falls. Just how much evidence is needed to make hearing loss screening routine? As we reveal in the podcast, evidence needs to accumulate that once hearing loss is identified, it can be effectively managed and that such managements lessens or averts adverse outcomes. Could be some time before that happens, so for now, what evidence did the task force use to make its recommendations?
The task force reviewed all the literature published between 1950 and January 2010 on sensorineural hearing impairment screening in adults 50 years of age and older, who did not already have a diagnosis of hearing loss in a primary care setting. This was limited to subjects who did not self-report a hearing problem. Evidence was examined on any association of screening with improved health outcomes, accuracy of screening methods, benefit of early detection rather than symptomatic detection of hearing loss, effectiveness of treatment, and harms and benefits associated with screening and treatment.
Screening tests are largely effective in identifying hearing loss in this population, the USPSTF found, and many of them can be easily administered in a primary care setting. One issue remains a working definition of exactly what constitutes a hearing loss because of variability in frequency and intensity thresholds used for testing, but population-based estimates indicate that some 20-40% of adults older than 50 have some hearing impairment, and that percentage rises to 80% of those 80 years of age and older. Another problem is that since hearing loss is usually subtle and incremental, the subject himself may fail to recognize or deny any hearing compromise.
Once a hearing problem is identified, studies reviewed for these recommendations underscored the sad fact that the vast majority of people aren't willing to use a hearing aid, in fact, in the few studies included for review that number was less than 10%. Clearly, attempting to determine whether hearing aid use ameliorated outcomes or improved quality of life was fruitless. As Rick and I opine in the podcast, we really need public education efforts to improve the image of hearing aids and teach people that there is a learning curve associated with their use so improvement is not immediate. In addition, manufacturing standards and insurance coverage would likely encourage more widespread employment of hearing aids. Subsequently, assessing more hard outcomes with regard to managing hearing loss would be possible.
So what about the potential harms of screening? Since testing is noninvasive, such harms are nonexistent. How about overdiagnosis and overtreatment? Hard to assess with current evidence, but seems less likely than say, harms relative to prostatectomy. In sum then, right now the evidence to clearly persuade anyone of the positive aspects of routine screening for hearing loss among older adults is lacking, but in my mind, it's a lot like that old adage about you can't get a job without experience but how do you get experience without a job?
Other topics this week include, also in Annals, factors related to the effectiveness of screening colonoscopy, lead and gout in the same issue, and a CDC warning on use of pain medications in kids after tonsillectomy. Until next week, y'all live well.