Hearing loss is a common problem caused by noise, aging, disease, and heredity. People with hearing loss may find it hard to have conversations with friends and family. They may also have trouble understanding a doctor’s advice, responding to warnings, and hearing doorbells and alarms.

Approximately one in three people between the ages of 65 and 74 has hearing loss, and nearly half of those older than 75 has difficulty hearing. But, some people may not want to admit they have trouble hearing.

Older people who can’t hear well may become depressed, or they may withdraw from others because they feel frustrated or embarrassed about not understanding what is being said. Sometimes, older people are mistakenly thought to be confused, unresponsive, or uncooperative because they don’t hear well.

Hearing problems that are ignored or untreated can get worse. If you have a hearing problem, see your doctor. Hearing aids, special training, certain medicines, and surgery are some of the treatments that can help.

Hearing depends on a series of complex steps that change sound waves in the air into electrical signals. Our auditory nerve then carries these signals to the brain.

1. Sound waves enter the outer ear and travel through a narrow passageway called the ear canal, which leads to the eardrum.
2. The eardrum vibrates from the incoming sound waves and sends these vibrations to three tiny bones in the middle ear. These bones are called the malleus, incus, and stapes.
3. The bones in the middle ear amplify, or increase, the sound vibrations and send them to the cochlea, a snail-shaped structure filled with fluid, in the inner ear. An elastic partition runs from the beginning to the end of the cochlea, splitting it into an upper and lower part. This partition is called the basilar membrane because it serves as the base, or ground floor, on which key hearing structures sit.
4. Once the vibrations cause the fluid inside the cochlea to ripple, a traveling wave forms along the basilar membrane. Hair cells—sensory cells sitting on top of the basilar membrane—ride the wave. Hair cells near the wide end of the snail-shaped cochlea detect higher-pitched sounds, such as an infant crying. Those closer to the center detect lower-pitched sounds, such as a large dog barking.
5. As the hair cells move up and down, microscopic hair-like projections (known as stereocilia) that perch on top of the hair cells bump against an overlying structure and bend. Bending causes pore-like channels, which are at the tips of the stereocilia, to open up. When that happens, chemicals rush into the cells, creating an electrical signal.
6. The auditory nerve carries this electrical signal to the brain, which turns it into a sound that we recognize and understand.

Hearing loss is a sudden or gradual decrease in how well you can hear. It is one of the most common conditions affecting older and elderly adults. Approximately one in three people between the ages of 65 and 74 has hearing loss and nearly half of those older than 75 have difficulty hearing. Having trouble hearing can make it hard to understand and follow a doctor's advice, to respond to warnings, and to hear doorbells and alarms. It can also make it hard to enjoy talking with friends and family. All of this can be frustrating, embarrassing, and even dangerous.

Age-related hearing loss (also called presbycusis, pronounced prez-buh-KYOO-sis) is hearing loss that occurs gradually for many of us as we grow older. It is one of the most common conditions affecting adults as we age. Approximately 15% of American adults (37.5 million) ages 18 and over report some trouble hearing, and about one in three people in the U.S. between the ages of 65 and 74 has hearing loss. Nearly half of those older than 75 have difficulty hearing.

Having trouble hearing can make it hard to understand and follow a doctor's advice, respond to warnings, and hear phones, doorbells, and smoke alarms. Hearing loss can also make it hard to enjoy talking with family and friends, leading to feelings of isolation.

Hearing loss typically occurs in both ears as we age. Because the loss is gradual, you may not realize that you've lost some of your ability to hear.

Hearing loss is a common problem caused by noise, aging, disease, and heredity. Hearing is a complex sense involving both the ear's ability to detect sounds in the environment and the brain's ability to interpret the sounds of speech. Major determinants of the impact of hearing loss on members of a population include:

• Degree of the hearing loss
• Configuration or pattern of hearing loss across frequencies
• Laterality/bilaterality of hearing loss (one or both ears affected)
• The area(s) of abnormality in the auditory system—such as the middle ear, inner ear, auditory neural pathways, or brain
• Speech recognition ability
• History of exposures to loud noise and environmental or pharmacologic toxicants to hearing
• Age

Measuring Hearing Loss

Mild losses may not be noticed and even moderate losses may not cause a problem for people with excellent perceptual abilities and good coping skills. Hearing loss may be identified by the person involved (called"self-report"), by friends and family, and by hearing testing. Formal audiometric testing is the gold standard for diagnosing hearing loss and monitoring treatment. Testing may be done at any age.

For estimates of the prevalence of hearing loss, all of these measures are of value and each provides insight into the burden of hearing loss on society. Self-report of hearing loss and the report of friends and family are important because they are relatively simple to determine and they provide a global assessment of the impact of the problem on the individual.

Formal Audiometric (Hearing) Tests

Formal audiometric testing, on the other hand, provides precise information displayed by frequency and hearing level. A convenient summary of the audiogram for each ear is the pure-tone average (PTA) of thresholds measured at specific frequencies. Thresholds are measured on a decibel (dB) hearing loss (HL) scale referenced to audiometric"zero" (the average hearing level at each frequency for normal young adults). One traditional PTA measure is the speech frequency average of thresholds at 500, 1000, and 2000 hertz (Hz). However, the frequencies to include in the PTA vary; for example, a high frequency such as 3000 Hz is included with the low frequency (500 Hz) and middle frequencies (1000 and 2000 Hz) in some formulations of the PTA. The most common PTA definition found in epidemiological, or population-based, studies is the four-frequency average of 500, 1000, 2000, and 4000 Hz.

As the PTA increases, the hearing ability decreases. Normal hearing for speech is observed in adults with PTAs of 25 dB HL or less. At a PTA of around 40 dB HL in both ears, most people are considered functionally impaired and could benefit from amplification. Severe to profound losses are present when PTAs are greater than 70 dB HL. At this level, hearing aids provide limited benefit and cochlear implants may be considered.

An accurate assessment of hearing includes:

• Laterality (one or both ears affected)
• Degree and pattern of threshold loss across frequencies
• Best ability to understand speech—either with hearing aids or loud speaking levels

Other factors to determine include:

• The rapidity of the onset or progression of hearing loss (people often adapt better to slowly progressive losses than to sudden losses)
• Associated symptoms such as tinnitus (ringing, roaring, or buzzing in the ears or head), hyperacusis (intolerance to normal environmental sounds), and recruitment (when loud sounds are suddenly uncomfortable)
• Treatment options, such as surgery, hearing aids, cochlear implants, aural rehabilitation, speech reading, or assistive listening devices

Implications of Hearing Loss

Hearing loss implications may be estimated in terms of societal burden, effect on the person, and treatment needs. To estimate the societal burden of hearing loss, age-specific rates of self (or family) report are appropriate. For estimating the impact of hearing loss on the person, a PTA more than 25 dB HL generally requires adaptive listening strategies, such as sitting closer to the source of sound. Active treatment, such as hearing aids, is frequently recommended at PTAs greater than 40 dB HL in both ears. The term "deaf" is generally applied to people with profound bilateral loss (PTAs greater than 90 dB HL). Modern cochlear implants are often helpful to children and adults with severe to profound losses (PTAs greater than 70 dB HL) of relatively short duration (less than 10 years). As a result, duration of hearing loss has become another important factor in describing hearing loss.

Hearing loss comes in many forms. It can range from a mild loss, in which a person misses certain high-pitched sounds, such as the voices of women and children, to a total loss of hearing.

There are two general categories of hearing loss:

• Sensorineural hearing loss occurs when there is damage to the inner ear or the auditory nerve. This type of hearing loss is usually permanent.
• Conductive hearing loss occurs when sound waves cannot reach the inner ear. The cause may be earwax buildup, fluid, or a punctured eardrum. Medical treatment or surgery can usually restore conductive hearing loss.

Sudden Hearing Loss

Sudden sensorineural hearing loss, or sudden deafness, is a rapid loss of hearing. It can happen to a person all at once or over a period of up to 3 days. It should be considered a medical emergency. If you or someone you know experiences sudden sensorineural hearing loss, visit a doctor immediately.

Age-Related Hearing Loss (Presbycusis)

Presbycusis, or age-related hearing loss, comes on gradually as a person gets older. It seems to run in families and may occur because of changes in the inner ear and auditory nerve. Presbycusis may make it hard for a person to tolerate loud sounds or to hear what others are saying.

Age-related hearing loss usually occurs in both ears, affecting them equally. The loss is gradual, so someone with presbycusis may not realize that he or she has lost some of his or her ability to hear.

Ringing in the Ears (Tinnitus)

Tinnitus is also common in older people. It is typically described as ringing in the ears, but it also can sound like roaring, clicking, hissing, or buzzing. It can come and go. It might be heard in one or both ears, and it may be loud or soft. Tinnitus is sometimes the first sign of hearing loss in older adults. Tinnitus can accompany any type of hearing loss and can be a sign of other health problems, such as high blood pressure, allergies, or as a side effect of medications.

Tinnitus is a symptom, not a disease. Something as simple as a piece of earwax blocking the ear canal can cause tinnitus, but it can also be the result of a number of health conditions.

Some people have a hearing problem and don’t realize it. You should see your doctor if you:

• Have trouble hearing over the telephone
• Find it hard to follow conversations when two or more people are talking
• Often ask people to repeat what they are saying
• Need to turn up the TV volume so loud that others complain
• Have a problem hearing because of background noise
• Think that others seem to mumble
• Can’t understand when women and children speak to you

Ask yourself the following questions. If you answer "yes" to three or more of these questions, you could have a hearing problem and may need to have your hearing checked by a doctor.

• Do you sometimes feel embarrassed when you meet new people because you struggle to hear? YES / NO

• Do you feel frustrated when talking to members of your family because you have difficulty hearing them? YES / NO

• Do you have difficulty hearing when someone speaks in a whisper? YES / NO

• Do you feel restricted or limited by a hearing problem? YES / NO

• Do you have difficulty hearing when visiting friends, relatives, or neighbors? YES / NO

• Does a hearing problem cause you to attend religious services less often than you would like? YES / NO

• Does a hearing problem cause you to argue with family members? YES / NO

• Do you have trouble hearing the TV or radio at levels that are loud enough for others? YES / NO

• Do you feel that any difficulty with your hearing limits your personal or social life? YES / NO

• Do you have trouble hearing family or friends when you are together in a restaurant? YES / NO

Adapted from Ventry I.M. & Weinstein, B.E. (1982). The hearing handicap inventory for the elderly: A new tool. Ear Hear 3(3),128–134.

Loud noise is one of the most common causes of hearing loss. Noise from lawn mowers, snow blowers, or loud music can damage the inner ear, resulting in permanent hearing loss. Loud noise also contributes to tinnitus. You can prevent most noise-related hearing loss. Protect yourself by turning down the sound on your stereo, television, or headphones; moving away from loud noise; or using earplugs or other ear protection.

Earwax or fluid buildup can block sounds that are carried from the eardrum to the inner ear. If wax blockage is a problem, talk with your doctor. He or she may suggest mild treatments to soften earwax.

A punctured ear drum can also cause hearing loss. The eardrum can be damaged by infection, pressure, or putting objects in the ear, including cotton-tipped swabs. See your doctor if you have pain or fluid draining from the ear.

Health conditions common in older people, such as diabetes or high blood pressure, can contribute to hearing loss. Viruses and bacteria (including the ear infection otitis media), a heart condition, stroke, brain injury, or a tumor may also affect your hearing.

Hearing loss can also result from taking certain medications. “Ototoxic” medications damage the inner ear, sometimes permanently. Some ototoxic drugs include medicines used to treat serious infections, cancer, and heart disease. Some antibiotics are ototoxic. Even aspirin at some dosages can cause problems. Check with your doctor if you notice a problem while taking a medication.

Heredity can cause hearing loss, as well. But not all inherited forms of hearing loss take place at birth. Some forms can show up later in life. For example, in otosclerosis, which is thought to be a hereditary disease, an abnormal growth of bone prevents structures within the ear from working properly.

People with hearing loss may find it hard to have conversations with friends and family, which can lead to less interaction with people, social isolation, and higher rates of loneliness. Learn about risk factors for social isolation and loneliness and ways to stay connected as you age.

Your doctor or specialist may suggest you get a hearing aid. Hearing aids are electronic, battery-run devices that make sounds louder. There are many types of hearing aids. Before buying a hearing aid, find out if your health insurance will cover the cost. Also, ask if you can have a trial period so you can make sure the device is right for you. An audiologist or hearing aid specialist will show you how to use your hearing aid.

Assistive-listening devices, mobile apps, alerting devices, and cochlear implants can help some people with hearing loss. Cochlear implants are electronic devices for people with severe hearing loss. They don’t work for all types of hearing loss. Alert systems can work with doorbells, smoke detectors, and alarm clocks to send you visual signals or vibrations. For example, a flashing light can let you know someone is at the door or the phone is ringing. Some people rely on the vibration setting on their cell phones to alert them to calls.

Over-the-counter (OTC) hearing aids are a new category of regulated hearing devices that adults with mild-to-moderate hearing loss will be able to buy without a prescription. OTC hearing aids will make certain sounds louder to help people with hearing loss listen, communicate, and take part more fully in daily activities. OTC hearing aids are expected to become available in stores and online in the next few years.

Talk with your doctor about what’s right for you. Learn more about hearing loss from the National Institute on Deafness and Other Communication Disorders.

Your treatment will depend on your hearing loss, so some treatments will work better for you than others. There are a number of devices and aids that can improve hearing loss. Here are the most common ones:

• Hearing aids are electronic instruments you wear in or behind your ear. They make sounds louder. Things sound different when you wear a hearing aid, but an audiologist or hearing aid specialist can help you get used to it. To find the hearing aid that works best for you, you may have to try more than one. Ask your audiologist or hearing specialist whether you can have a trial period with a few different hearing aids. Both of you can work together until you are comfortable. (Read the NIDCD fact sheet Hearing Aids for more information.)
• Cochlear (COKE-lee-ur) implants are small electronic devices surgically implanted in the inner ear that help provide a sense of sound to people who are profoundly deaf or hard-of-hearing. If your hearing loss is severe, your doctor may recommend a cochlear implant in one ear or both. (Read the NIDCD fact sheet Cochlear Implants for more information.)
• Assistive listening devices include telephone and cell phone amplifying devices, smart phone or tablet "apps," and closed circuit systems (induction coil loops) in places of worship, theaters, and auditoriums. (Read the NIDCD fact sheet Assistive Devices for People with Hearing, Voice, Speech, or Language Disorders for more information.)
• Lip reading or speech reading is another option that helps people with hearing problems follow conversational speech. People who use this method pay close attention to others when they talk, by watching how the speaker's mouth and body move.

There are three basic styles of hearing aids. The styles differ by size, their placement on or inside the ear, and the degree to which they amplify sound.

Behind-the-ear (BTE) hearing aids consist of a hard plastic case worn behind the ear and connected to a plastic earmold that fits inside the outer ear. The electronic parts are held in the case behind the ear. Sound travels from the hearing aid through the earmold and into the ear. BTE aids are used by people of all ages for mild to profound hearing loss. A new kind of BTE aid is an open-fit hearing aid. Small, open-fit aids fit behind the ear completely, with only a narrow tube inserted into the ear canal, enabling the canal to remain open. For this reason, open-fit hearing aids may be a good choice for people who experience a buildup of earwax, since this type of aid is less likely to be damaged by such substances. In addition, some people may prefer the open-fit hearing aid because their perception of their voice does not sound “plugged up.”

In-the-ear (ITE) hearing aids fit completely inside the outer ear and are used for mild to severe hearing loss. The case holding the electronic components is made of hard plastic. Some ITE aids may have certain added features installed, such as a telecoil. A telecoil is a small magnetic coil that allows users to receive sound through the circuitry of the hearing aid, rather than through its microphone. This makes it easier to hear conversations over the telephone. A telecoil also helps people hear in public facilities that have installed special sound systems, called induction loop systems. Induction loop systems can be found in many churches, schools, airports, and auditoriums. ITE aids usually are not worn by young children because the casings need to be replaced often as the ear grows.

Canal aids fit into the ear canal and are available in two styles. The in-the-canal (ITC) hearing aid is made to fit the size and shape of a person’s ear canal. A completely-in-canal (CIC) hearing aid is nearly hidden in the ear canal. Both types are used for mild to moderately severe hearing loss.

Because they are small, canal aids may be difficult for a person to adjust and remove. In addition, canal aids have less space available for batteries and additional devices, such as a telecoil. They usually are not recommended for young children or for people with severe to profound hearing loss because their reduced size limits their power and volume.

Although they work differently than the hearing aids described above, implantable hearing aids are designed to help increase the transmission of sound vibrations entering the inner ear. A middle ear implant (MEI) is a small device attached to one of the bones of the middle ear. Rather than amplifying the sound traveling to the eardrum, an MEI moves these bones directly. Both techniques have the net result of strengthening sound vibrations entering the inner ear so that they can be detected by individuals with sensorineural hearing loss. A bone-anchored hearing aid (BAHA) is a small device that attaches to the bone behind the ear. The device transmits sound vibrations directly to the inner ear through the skull, bypassing the middle ear. BAHAs are generally used by individuals with middle ear problems or deafness in one ear. Because surgery is required to implant either of these devices, many hearing specialists feel that the benefits may not outweigh the risks.

If you notice signs of hearing loss, talk to your doctor. If you have trouble hearing, you should:

• Let people know you have a hearing problem.
• Ask people to face you and to speak more slowly and clearly. Also, ask them to speak louder without shouting.
• Pay attention to what is being said and to facial expressions or gestures.
• Let the person talking know if you do not understand what he or she said.
• Ask the person speaking to reword a sentence and try again.
• Find a good location to listen. Place yourself between the speaker and sources of noise and look for quieter places to talk.

The most important thing you can do if you think you have a hearing problem is to seek professional advice. Your family doctor may be able to diagnose and treat your hearing problem. Or, your doctor may refer you to other experts, like an otolaryngologist (ear, nose, and throat doctor) or an audiologist (health professional who can identify and measure hearing loss).

Hearing problems can be serious. The most important thing you can do if you think you have a hearing problem is to seek professional advice. There are several ways to do this. You can start with your primary care physician, an otolaryngologist, an audiologist, or a hearing aid specialist. Each has a different type of training and expertise. Each can be an important part of your hearing health care.

An otolaryngologist (oh-toe-lair-in-GAH-luhjist), is a doctor who specializes in diagnosing and treating diseases of the ear, nose, and throat. An otolaryngologist will try to find out why you're having trouble hearing and offer treatment options. He or she may also refer you to another hearing professional, an audiologist (aw-dee-AH-luh-jist). An audiologist has specialized training in identifying and measuring the type and degree of hearing loss and recommending treatment options. Audiologists also may be licensed to fit hearing aids. Another source of hearing aids is a hearing aid specialist, who is licensed by a state to conduct and evaluate basic hearing tests, offer counseling, and fit and test hearing aids. 

If you or a family member might have hearing loss, consult a qualified health professional for early and appropriate care. Several types of professionals can help. Each has a different type of training and expertise, and each can be an important part of your hearing health care.

You may want to start by talking with your primary care provider. He or she will likely give you a medical exam to see if an infection, injury, or other condition (such as a buildup of ear wax) might be causing your hearing loss. Your primary care provider might then refer you to an otolaryngologist or other hearing health provider for more specific tests and treatment.

Listed below are the types of professionals who can help you with hearing loss.

A primary care provider is a physician, nurse practitioner, or physician assistant who provides general health care to patients by identifying and treating common medical conditions. Primary care providers often refer patients to medical specialists when necessary. Types of primary care providers include family practitioners or general practitioners, pediatricians, geriatricians, and internists.

An otolaryngologist (oh-toe-lair-in-GAH-luh-jist) is a physician who provides medical and surgical care, diagnosis, and treatment of the ear, nose, throat, and neck. Sometimes called an ENT, an otolaryngologist will work with you to find out why you’re having trouble hearing and offer specific treatment options. He or she might also refer you to another hearing professional, such as an audiologist or hearing instrument specialist, to receive a hearing test and be fitted for a hearing aid.

An audiologist (aw-dee-AH-luh-jist) has specialized training to test your hearing and identify the type and degree of hearing loss. Audiologists are not physicians, but they have a doctor of audiology graduate degree (Au.D.), which typically requires four years to complete after earning a bachelor’s degree. They must also pass an exam and complete a clinical fellowship. Audiologists are licensed to fit and dispense hearing aids; they can also work with you and your family to adapt to hearing loss and determine which devices, including hearing aids, would be most helpful.

A hearing instrument specialist, also known as a hearing aid specialist, is a state-licensed professional who conducts basic hearing tests, fits and dispenses hearing aids, and educates individuals and their family members about their hearing loss. The licensure requirement varies among states; most states require completing a 2-year apprenticeship.

Yes. You and your family can work together to make hearing easier. Here are some things you can do:

• Tell your friends and family about your hearing loss. They need to know that hearing is hard for you. The more you tell the people you spend time with, the more they can help you.
• Ask your friends and family to face you when they talk so that you can see their faces. If you watch their faces move and see their expressions, it may help you to understand them better.
• Ask people to speak louder, but not shout. Tell them they do not have to talk slowly, just more clearly.
• Turn off the TV or the radio if you aren't actively listening to it.
• Be aware of noise around you that can make hearing more difficult. When you go to a restaurant, do not sit near the kitchen or near a band playing music. Background noise makes it hard to hear people talk.

Working together to hear better may be tough on everyone for a while. It will take time for you to get used to watching people as they talk and for people to get used to speaking louder and more clearly. Be patient and continue to work together. Hearing better is worth the effort.

Styles of hearing aids

Source: NIH/NIDCD