Current issues of ACP Journal Club are published in Annals of Internal Medicine


Diagnosis

Review: Screening for hearing impairment in elderly patients is useful

ACP J Club. 1991 Sept-Oct;115:55. doi:10.7326/ACPJC-1991-115-2-055

Related Content in the Archives
Audioscope was more accurate than questionnaire for screening for hearing loss in older adults


Source Citation

Mulrow CD, Lichtenstein MJ. Screening for hearing impairment in the elderly. Rationale and strategy. J Gen Intern Med. 1991 May/Jun;6:249-58. [PubMed ID: 2066832]


Abstract

Objective

To evaluate the rationale and strategies for screening for hearing impairment in elderly patients.

Data sources

Published studies were identified with MEDLINE (1966 to May 1990) using search terms adult, elderly, hearing impairment, hearing loss, and presbycusis; bibliographies of relevent articles, audiology journals, and abstract publications were searched by hand.

Study selection

Articles containing original data addressing any of 7 clinical epidemiologic questions for evaluating a screening program. Physical diagnosis screening tests that were considered were whispered voice, tuning fork, finger rub, and Welch-Allyn audioscope. 3 short self-administered questionaires considered were the Hearing Handicapped Inventory for the Elderly-Screening Version (HHIE-S), Self Assessment of Communication, and the Revised Denver Scale of Communication-Short Version.

Data extraction

Results were categorized by the 7 screening criteria; information about study populations, designs, and analyses was systematically appraised.

Results

More than 100 original articles were identified that found that the burden of illness associated with hearing impairment is considerable; difficulty with social and emotional functioning is common; and it is unclear whether clinically significant depression or impaired cognition can be caused by hearing impairment. Simple accurate tests that identify patients with and without hearing loss are available. The best screening methods include the portable Audioscope (with sensitivity of 87% to 96% and specificity of 70% to 90% likelihood ratio of a positive test ranges from 3.1 to 9.4), and the HHIE-S questionnaire (overall accuracy about 75% and the likelihood ratio of a positive test is up to 12.0) or both. Effective treatment with hearing rehabilitation devices is available. In a randomized controlled trial it was found that a group of veterans with hearing-impairment who received hearing aids improved in social, emotional, communicative, and cognitive functioning compared with veterans waiting to receive amplification. As many as 50% of screened persons are likely to comply with advice regarding further formal audiologic testing and hearing aid use. A reliable way to identify people who will comply has not been established, and high costs are cited frequently as important reasons for noncompliance. Most affected persons would be appropriately reached with annual screening examinations in the primary care setting. The overall effectiveness of a widespread population screening program is unknown, and it is unclear whether benefits would be of sufficient magnitude to justify the costs of screening the nearly 30 million Americans who are over 65 years of age.

Conclusions

Screening elderly adults for hearing impairment in the primary care setting is a rational practice and is best done with the portable Audioscope or a screening questionnaire, the Hearing Handicap Inventory in the Elderly-Screening Version, or both.

Source of funding: Not stated.

Address for article reprint: Dr. C.D. Mulrow, Audie Murphy Veterans Affairs Hospital (11C), 7400 Merton Minter Boulevard, San Antonio, TX 7828, USA.


Commentary

A variety of quick tests added to the traditional physical examination have been suggested as screening tools to detect common and potentially treatable disease states in elderly persons. Because of the time pressures of primary care geriatrics, it is difficult to persuade the practitioner to add a particular screening test. 7 crucial factors have been proposed to support the use of a test in mass screening (1).

The strength of this review is that it uses an extensive critical analysis of the literature to scrutinize each of these 7 criteria. Inevitably, there are criteria that studies do not address or for which there is a lack of high-quality studies. The authors point out such deficiencies, for example, the lack of randomized trials showing efficacy of screening for hearing impairment in a physician's office.

Unfortunately, none of the studies compare cases of hearing impairment detected by the screening instruments with those that would be detected as part of a routine comprehensive physical examination and history. The benefit of screening would only apply to those hearing-impaired patients that an astute physician would otherwise miss. It would be valuable to investigate whether using a screening test on a patient with a glaringly obvious communication deficit because of hearing loss would improve compliance with physician recommendations for further audiologic evaluation and appropriate interventions.

The authors use the existing data to make a good case for screening for hearing impairment by primary physicians. This study can serve as a model for rigorous analysis of the utility of proposed screening tests.

Jay S. Luxenberg, MD
San Francisco Institute on AgingSan Francisco, California, USA


Reference

1. Cadman D, Chambers L, Feldman W, et al. Assessing the effectiveness of community screening programs. JAMA. 1984;251:1580-5.