Old age and hearing loss: lack of screening ends up being costly

THE ESSENTIALS

Long relegated to the status of a “minor ailment” of aging, hearing loss is still too often perceived as an unavoidable inconvenience. Yet, in older people, its effects go far beyond mere difficulty hearing: it can compromise independence, undermine daily safety, and impair the quality of care.

And, as is often the case in public health, the solutions exist, whether they are technical, clinical, or organizational. It is their integration into care pathways that is lacking, particularly in long-term care facilities.

A health and economic burden…

The prevalence of hearing loss increases sharply with age. It is around one-third in people aged 65-75 and affects approximately one in two people in the most advanced ages (80 years and over), according to European data . This increase is also observed in France in the CONSTANCES cohort, where the prevalence of hearing loss exceeds 60% in the 71-75 age group .

The consequences are not only individual, but also collective: untreated hearing loss can lead to communication difficulties, misunderstandings in care instructions, social withdrawal, depression, faster cognitive decline, balance problems and an increased risk of accidents.

This generates direct costs for the healthcare system, requires significant time and energy from family members, and, most importantly, leads to a loss of quality of life that is often invisible in public accounts. The World Health Organization ( WHO ) estimates that untreated hearing loss represents nearly one trillion dollars annually worldwide ; this figure, which covers all age groups, should be interpreted less as a precise measurement than as a sign of the scale of the problem.

In recent literature, the link between hearing loss and cognitive decline and dementia is gaining increasing attention. The Lancet 2024 Commission , a leading authority on dementia prevention, has identified 14 modifiable risk factors that could theoretically prevent or delay nearly 45% of dementia cases.

Among them, hearing loss stands out as the leading modifiable risk factor in adulthood, with an attributable fraction of 7%, as much as high LDL cholesterol ( nicknamed “bad cholesterol” because, in excess, it builds up on the artery walls ), and more than diabetes , smoking , or high blood pressure . The dose-response effect is well-documented: each 10-decibel increase in hearing loss is associated with a 16% rise in the risk of dementia.

Most importantly, interventional data now support these observational associations. The ACHIEVE randomized clinical trial showed, in older adults at high risk of cognitive decline, a 48% reduction in overall cognitive decline at three years in the assistive device group compared to the control group.

In parallel, a meta-analysis of eight observational studies involving more than 127,000 participants, followed from two years to twenty-five years, showed that the use of hearing aids was associated with a 19% reduction in the risk of long-term cognitive decline, compared to uncorrected hearing loss.

These results suggest a potential cognitive benefit of hearing aids. From an economic perspective, a British model estimates that the provision of hearing aids could also generate net savings, particularly due to its potential effect on the incidence of dementia.

With 57 million people suffering from dementia worldwide in 2019 and projections of 153 million by 2050, any preventive measure that can even modestly alter this trajectory represents a considerable human and economic challenge.

International scientific literature links hearing loss to frailty , defined as a state of increased vulnerability to health events resulting in particular from a decrease in physiological reserves. This association is strongly found in several studies combining cross-sectional and longitudinal data, even if the exact degree of causality remains debated.

Frailty, hearing loss and… falls

Falls clearly illustrate this link between hearing and frailty. A recent result from the ACHIEVE trial reinforces this observation : participants who received hearing intervention experienced, over three years, an average of 27% fewer falls than the control group.

In France, falls are one of the most visible markers of loss of autonomy. The three-year national fall prevention plan for the elderly , launched in 2022, already identified it as a major public health issue and estimated its cost at 2 billion euros per year, of which 1.5 billion is borne by the Health Insurance.

According to recent data from Public Health France , in 2024, nearly 175,000 hospitalizations and more than 20,000 deaths related to falls were recorded among people aged 65 and over. Between 2019 and 2024, the standardized hospitalization and mortality rates associated with falls increased by 20.5% and 18%, respectively. These trends raise even more questions given that the plan aimed for a 20% reduction in fatal or disabling falls by 2024.

The question is therefore no longer whether hearing deserves a place in the care pathways of the elderly, but how to give it a concrete place.

Sensory impairments are common in nursing homes.

In nursing homes (referred to as “Ehpad ” in the international literature), hearing loss is far from marginal. It is often part of a cluster of sensory, cognitive, and functional vulnerabilities.

In France, the 2014 Disability-Health survey already showed that in institutions , 42% of residents suffered from functional hearing limitations, including 15% with severe or very severe forms, representing a prevalence almost two and a half times higher than that observed at home.

The European SHELTER study , conducted in eight countries, reached a similar conclusion at the time: nearly two out of three residents had at least one visual or hearing impairment, and almost a third had both. In other words, in care facilities, sensory impairments are not the exception, but the norm. Yet, detection remains uneven, and this is where one of the blind spots in care lies.

This problem is not new. As early as the 2000s, studies in nursing homes showed that significant hearing loss remained undetected in more than half of the residents, and argued for regular assessments as well as genuine institutional screening policies.

Twenty years later, the issue is clearly identified in France, but is not systematically integrated into healthcare organizations. In 2021, the joint report by the General Inspectorate of Social Affairs (IGAS) and the General Inspectorate of Education, Sport and Research (IGESR) on the hearing care sector nevertheless recommends the appointment of a “hearing liaison” for a nursing home or group of nursing homes and the testing of a protocol adapted to the screening, fitting of hearing aids and follow-up of elderly people unable to move around.

In other words, the need has been identified for a long time; what is still lacking is its systematic translation into ordinary practices.

Proven solutions, an organization to be built

The obstacles are well known: trivialization of the disorder, particularly among the elderly – especially when they have multiple pathologies or cognitive disorders – unequal access to audiological pathways, patient fatigue, difficulty in the actual use of hearing aids and, above all, lack of institutional routine.

As an illustration, a pragmatic trial in primary care shows how much the concrete organization of screening conditions its effectiveness: when it was offered and carried out on site, adherence was almost four times higher than that observed when it had to be carried out at home.

In individuals with cognitive impairments, recent literature reviews further highlight the limitations of self-administered questionnaires alone and the value of assessment methods adapted to this population.

A major lever is therefore organizational: integrating the screening for hearing impairments upon admission to nursing homes and their follow-up, training designated contacts, facilitating access to audiology services, and supporting the effective daily use of hearing aids. These are all avenues already identified, notably by the IGAS and the IGESR, but they still need to be more systematically incorporated into practice.

At a time when France is seeking to structure its policy for the elderly, making hearing an integral part of the care pathway in institutions is not a luxury: it is a dimension of the quality of care.

Source – Laurence Hartmann, Senior Lecturer in Health Economist, LIRSA EA4603 Laboratory, National Conservatory of Arts and Crafts (CNAM)