The Role of Hearing in Aging and Hearing Rehabilitation Technology

with an Outlook on Future Applications

Lukas H. B. Tietz and Gabrielle H. Saunders

Eriksholm Research Centre, Rørtangvej 20, 3070 Snekkersten, Denmark

Keywords: Hearing, Hearing Loss, Ehealth, Tele-health, Hearing Aids, Rehabilitation.

Abstract: The purpose of this position paper is to raise awareness about the negative impacts of age-related hearing loss

and the importance of providing good hearing healthcare. We also provide an overview of state-of-the-art

hearing aids - the standard rehabilitative technology for hearing loss – along with some thoughts about the

future of hearing healthcare. Provision of hearing intervention is critical because untreated age-related hearing

loss is associated with numerous negative impacts on the health and well-being, such as increased odds of

falling, social isolation and cognitive decline. We suggest that, hearing technologies that combine intelligent

computer systems with user centred approaches to hearing healthcare provision will ensure that hearing aids

result in improved quality of life for those with hearing loss.

1 INTRODUCTION

Age-related hearing loss (ARHL) is one of the top 5

contributors to years lived with disability. ARHL has

broad negative psychosocial impacts and, perhaps

more alarmingly, untreated ARHL is known to be

associated to cognitive decline and dementia (GBD

2015 Disease and Injury Incidence and Prevalence

Collaborators, 2016) Gerontologists and others with

an aging clientele therefore need to be aware of

options for audiological rehabilitation of their aging

patients.

The purpose of this position is to describe the

impacts of untreated hearing loss on the individuals

and their family, to discuss the role of audiological

care, and to make the case that gerontologists need to

adjust their practice if a client has untreated hearing

loss. Additionally, this work provides an overview of

state-of-the-art hearing aids (HAs) - the standard

rehabilitative technology for hearing loss – along with

some thoughts about the future of hearing healthcare,

so that the reader knows the options available to those

with ARHL.

2 IMPACTS OF ARHL

Hearing loss is a chronic condition, the prevalence of

which is strongly associated with age.

Epidemiological studies indicate that approximately

25-50% of people have a bilateral hearing loss of 30

dB or more by age 70 years, which increases to

between 40% and 75% by age 80 years, (Roth et al.,

2011, Feder et al., 2015; Goman and Lin, 2016). The

rate of onset of hearing loss increases at faster pace

yet in those aged 80 years and older (Wattamwar et

al., 2017).

Untreated hearing loss has many negative impacts

– it limits the ability to conduct activities of daily

living (Gopinath et al., 2012) and increases the odds

of falling (Jiam et al., 2016), as well as increasing

utilization of healthcare services and hospitalization

rates (Green and Pope, 2001; Genther et al, 2013). At

a psychosocial level, hearing loss is associated with

social isolation, loneliness, and depression (Sung et

al., 2016; Mick et al., 2014; Hay-McCatcheon et al.,

2018). Further, data are rapidly accumulating that

show a robust link between hearing loss and cognitive

decline (Dawes et al., 2015; Amieva et al., 2015, Lin

et al., 2013).

The mechanisms of the above associations are not

always clear, although hearing loss as a mediator

between use of healthcare services and other

conditions has certainly been demonstrated. For

example, in a study by Crealey and O’Neill (2018),

hearing loss was found to consistently predict aspects

of cognition, autonomy, mobility and memory, which

in turn, predicted frequency of GP visits. On a

positive note, whether directly or indirectly, use of

Tietz, L. and Saunders, G.

The Role of Hearing in Aging and Hearing Rehabilitation Technology with an Outlook on Future Applications.

DOI: 10.5220/0007760603050310

In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 305-310

ISBN: 978-989-758-368-1

305

hearing aids seems to moderate some of these

negative effects (Amieva et al., 2015; Crealey and

O’Neill, 2018; Hay-McCutcheon et al., 2018; Ray et

al., 2018; Weinstein et al., 2016).

Unfortunately, the use and uptake of hearing aids

among individuals with ARHL is low. Data suggest

that people wait on average 7-10 years after noticing

hearing problems before seeking help (Davis et al.,

2007), and that just 15-30% of people who would

benefit from hearing aids obtain and use them (Chien

and Lin, 2012; NIDCD, 2016). Explanations for low

help seeking and uptake of hearing healthcare include

a lack of awareness of hearing loss because of its very

gradual onset, stigma associated with hearing loss and

hearing aids, the cost of hearing aids and a lack of

access and/or knowledge of how to access services

(Wallhagen and Reed, 2018; Wallhagen, 2010;

Saunders et al., 2018).

Primary care is an important entry way to almost

all health care services. Unfortunately, screening for

ARHL in primary care is uncommon with overall

rates found to be about 23% (Abrams and Kihm,

2015). Of even greater concern are reports from older

patients that their primary care practitioners (PCPs)

do not view ARHL as a health-related issue, or as a

priority during office visits (Chou et al., 2011). More

alarmingly yet, is the finding that even when issues

related to ARHL are raised by individuals seeking

care, practitioners often negate the concern, and/or

view hearing aids as stigmatizing or ineffective

(Wallhagen, 2010). It is thus important bring

awareness of the impacts of untreated hearing loss to

practitioners who provide services to the elderly, and

to educate them as to how hearing loss can be

managed.

3 TECHNOLOGY FOR HEARING

REHABILITATION

This section describes state-of-the-art hearing aid

technology and provides some ideas about the future

of hearing healthcare which will allow for novel

functionalities and possibilities in rehabilitation,

service delivery, and research.

3.1 Current Technologies

A traditional hearing aid consists of a microphone to

pick up external sounds, an amplifier to increase the

incoming signal gain and some form of transducer to

transfer sound from the amplifier to the ear canal.

However, today’s devices incorporate many

additional features that provide signal enhancement

via digital signal processing. These features include

the following:

 Multiple channels

 Directional microphone systems

 Noise reduction

 Feedback management

 Wireless connectivity

 Data logging

 Learning features

 Binaural processing

 Multiple programs

Current developments are also focussing on

increasing the processing power of the built-in

computing units, while reducing the power

consumption overall. It is important that the audio

processing happens as fast as possible to reduce the

time delay between the picked-up signal at the

microphones and the transmitted signal at the

speaker.

3.1.1 Multiple Channels

A channel is essentially a filter that breaks out a broad

band signal into discrete bands of frequencies.

Signals within a frequency band or channel are

analysed and processed independently from signals in

other bands. Parameters that are typically analysed

and processed within a band are gain (for overall

amplification, feedback and output control), noise

reduction processing and directional microphone

polar patterns. Broadly, the advantage of multiple

channels is customization of the hearing aid output to

a specific configuration of hearing loss.

3.1.2 Directional Microphone Systems

Almost all of today’s hearing aids are equipped with

multiple microphones, that enable incoming signals

to be differentially amplified depending on their

source relative to the microphone ports. Directional

microphones aim to provide greater amplification for

signals arriving from the front than for signals

arriving from the left, right or behind, thus improving

the signal-to-noise ratio of signal from the front that

are delivered to the ear of the hearing aid user. Most

hearing aids today automatically adjust the

directionality of the microphones in response to the

environmental input. This is generally beneficial for

the user, but it has its limitations if the hearing aid

software misclassifies an incoming signal or if the

user wants to listen to a sound source that is not

located in front of them.

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3.1.3 Noise Reduction

The most common complaint of hearing aid users is

difficulty hearing in a noisy environment. Noise

reduction algorithms were thus implemented into

hearing aids to decrease the annoyance caused by

noise, and to improve speech understanding. Noise

reduction algorithms have generally been shown to be

effective at the former, but not the latter (Brons et al.,

2015). Digital noise reduction algorithms vary greatly

across hearing aids and new signal processing

approaches are continually being developed.

Wind noise, caused by the vibration of the

microphone membranes due to wind turbulence

around the microphone inlets is another problem for

hearing aid user, so noise reduction algorithms

targeting wind noise have been developed with some

success.

3.1.4 Feedback Management

Acoustic feedback occurs when the sound that has

been amplified by the hearing aid re-enters the

microphone and is amplified again, causing a high

pitch whistle or ringing. Feedback can be a problem

in hearing aids because the receiver and microphone

are physically close together and thus acoustic

leakage can easily occur. Leakage can also occur

when the speaker is not properly inserted into the ear.

Signal processing algorithms to combat feedback

have been successfully developed. Typically, these

systems work by limiting the output from a hearing

aid channel when feedback is detected in that channel

or in newer hearing aids, by introducing an oscillating

signal that cancels out the feedback signal

3.1.5 Wireless Connectivity

Telecoil systems allow the hearing aid to pick up

signals from compatible electromagnetically looped

systems. These systems are typically found in

auditoriums, churches or larger meeting rooms where

external microphones are utilised by a speaker. The

telecoil system transmits the recorded voice signal via

an induction loop directly to the hearing aid. The

principle is shown in figure 1.

The signal then is processed by the digital sound

processor and fed to the speakers of the HA. This way

the microphones of the HA are bypassed, which

increases the signal-to-noise ratio and should enhance

speech understanding. This system allows a large

group of hearing aid users to receive the same signal.

A different wireless solution is a FM based system,

where an external audio signal is picked up by an

amplifier and transmitter device – called streamer –

Figure 1: A telecoil system consists of an external

microphone, an amplifier and an induction coil that is

placed in the room around the HA users.

and then transmitted via radio frequency to an

antenna in the HA. Thereby the signal is bypassing

the integrated microphone and is processed directly

by the sound processor. The principle for streamer

functionality can be seen in figure 2.

Figure 2: The FM system consists of an external signal

source like TV or radio and an amplifier and transmission

device that directly couples to the patients HAs.

The difference to the telecoil system is that here

the signal is transmitted to one single pair of hearing

aids. This connectivity method can also be used to

utilize a portable external microphone that can be

handed to a conversation partner.

Bluetooth connectivity gains more popularity

these days as it allows for direct connection with

smartphones and other certified Bluetooth audio

devices. Sound can be streamed directly to the

processor of the hearing aid. This functionality also

allows the patient to handle steering inputs for the

HAs, like adjusting the volume or program. This

technology enables two-way data communication,

which is important for some of the future

technologies, that will be described further on. Newer

Bluetooth standards are allowing for less energy

consumption, while the connection is active.

3.1.6 Datalogging

The internal digital memory space on the hearing aids

is used for data logging. When visiting the

audiologist, the data log can give insights into the

usage pattern of the devices. The internal memory can

include data on the total usage of the device, daily

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average, average of sound pressure levels, classified

environments or program usage. The environment

classification usually differentiates between: quiet,

speech, speech in noise and noise.

3.1.7 Learning Features

Some hearing aids now offer a learning functionality,

a logic software saves the user interactions on the

hearing aid in correlation with other logged data.

Over time this can lead to less need to interact with

the HA, as the devices could automatically adjust

volume or program when detecting a known

environment. This feature is very new and holds a lot

of potential for the future, especially to increase

device usability.

3.1.8 Binaural Processing

With binaural processing capabilities, a pair of

hearing aids is communicating wirelessly with each

other. This feature is used to make program or volume

changes on both hearing aids by just using the button

on one of them. In recent years, the protocol also

allows for sound source location detection, meaning

the side from which the sound is represented can be

detected and amplified accordingly, also allowing for

a better directional effect.

3.1.9 Multiple Programs

Hearing aids provide the possibility for the

audiologist to create different programs, that suit

different auditory environments and personal

preferences. Optimised settings e.g. a high level of

directionality and high level of noise reduction can be

saved as settings in a ‘conversation program’. The

different programs can be accessed by the patient

easily and quickly on the hearing aids or through the

connected smartphone application, to suit the

patients' needs in different environments.

3.2 Future Technologies

With the implementation of smart connectivity new

opportunities present themselves as hearing aids are

now opening to be used as Internet-of-Things

activated devices. Remote monitoring as well as

changes to the personalization of the devices have

been introduced very recently. Self-monitoring

features have also gained increasing recognition.

Over-the-air firmware updates for hearing aids start

to be available from this point forward (Hoppe and

Hesse, 2017). Thanks to the low energy and high

bandwidth wireless connection, more complex signal

processing could be handled by a smartphone, as that

offers more processing power. Rechargeable batteries

have recently been introduced but they have yet to be

implemented widely in more HA models.

Applications that include data transfer could

incorporate artificial intelligence – supported

optimisations. Continuous monitoring of HA usage

via data collection in a cloud service enable usage

pattern recognition and, through machine learning,

better automated setting prediction of the device for

certain situations (Zhang et al., 2016). These could

enhance the user experience through an ‘always right’

option based on the learned preferences of the user in

certain situations.

Research in auditory fields is also transformed

through the availability of remote data collection. The

EU-project ‘EVOTION’ is utilizing the collection of

different variables from the hearing aids as well as

smartphones, health sensors and clinical repositories.

These data should then be used to find possible

success factors for hearing loss treatment and support

the formulation of hearing healthcare policies based

on real world evidence (Dritsakis et al., 2018). This

concept of evidence collection through connected

devices could also be applied to other fields of policy

making.

Additional, to the objective data collection, new

possibilities for subjective feedback would improve

the labelling of data. Giving the user the possibility to

report on the quality and functionality of hearing aids

in a current situation would provide personal labels,

which in turn could be used at later points to intervene

in challenging situations. These personal labels and

notes can also be used for improved counselling.

4 CONCLUSIONS

In conclusion, ARHL has numerous negative impacts

on life, thus limiting the ability to conduct activities

of daily living. Furthermore, increased odds of

falling, social isolation as well as a strong connection

with cognitive decline are significant indicators that

an ARHL should be treated. A hearing loss, that is

recognised and treated, is battling these and other

negative impacts. Hearing health as a part of general

health is an important factor for aging well and should

be recognized by the science of gerontology and

research into this area is worthwhile as well as

important.

Hearing aids are the standard rehabilitative

technology for hearing loss and modern HAs offer a

large number of features that should help increase

speech intelligibility and usability. Wireless

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connectivity and software enhancements have a great

impact on the usability and versatility of the devices

and can lead to better rehabilitation in the future. In

combination with artificial intelligence, data

collection and powerful computer systems as well as

user centred approaches, the rehabilitation with these

devices can have a positive impact on the quality of

life of those living with ARHL.

REFERENCES

Abrams H.B. and Kihm J. An introduction to MarkeTrak

IX: A new baseline for the hearing aid market. Hearing

Review. 2015;22(6):16.

Amieva H., Ouvrard C., Giulioli C., Meillon C., Rullier L.

and Dartigues J.F. (2015). Self-Reported Hearing Loss,

Hearing Aids, and Cognitive Decline in Elderly Adults:

A 25-Year Study. J Am Geriatr Soc., 10):2099-2104

Brons I., Houben R. and Dreschler W.A. (2015) Acoustical

and perceptual comparison of noise reduction and

compression in hearing aids. Journal of Speech,

Language, and Hearing Research 58: 1363–1376.

Chou R., Dana T., Bougatsos C., Fleming C. and Beil T.

Screening adults aged 50 years or older for hearing loss:

a review of the evidence for the U.S. preventive

services task force. Ann Intern Med. 2011;154(5):347-

355.

Chien, W., and Lin, F.R. (2012). Prevalence of hearing aid

use among older adults in the United States. Archives

of Internal Medicine, 172(3), 292–293.

https://doi.org/10.1001/archinternmed.2011.1408

Crealey G.E. and O'Neill C. (2018). Hearing loss, mental

well-being and healthcare use: results from the Health

Survey for England (HSE). J Public Health (Oxf), Nov

Dawes P., Emsley R., Cruickshanks K.J., Moore D.R.,

Fortnum H., Edmondson-Jones M., McCormack A. and

Munro K.J. (2015). Hearing loss and cognition: the role

of hearing AIDS, social isolation and depression. PLoS

One, 10(3):e0119616.

Davis, A., Smith, P., Ferguson, M., Stephens, D. and

Gianopoulos, I. (2007). Acceptability, benefit and costs

of early screening for hearing disability: a study of

potential screening tests and models. Health

Technology Assessment, 11(42).

https://doi.org/10.3310/hta11420

Dritsakis, G., Kikidis, D., Koloutsou, N., Murdin, L., Bibas,

A., Ploumidou, K., Laplante-Lévesque, A.,

Pontoppidan, N.H. and Bamiou, D. (2018). Clinical

validation of a public health policy-making platform for

hearing loss (EVOTION): protocol for a big data study,

1–9. https://doi.org/10.1136/bmjopen-2017-020978

GBD 2015 Disease and Injury Incidence and Prevalence

Collaborators. (2016). Global, regional, and national

incidence, prevalence, and years lived with disability

for 310 diseases and injuries, 1990-2015: a systematic

analysis for the Global Burden of Disease Study 2015.

Lancet (London, England), 388(10053), 1545–1602.

https://doi.org/10.1016/S0140-6736(16)31678-6

Genther, D.J., Frick, K.D., Chen, D., Betz, J., and Lin, F.R.

(2013). Association of hearing loss with hospitalization

and burden of disease in older adults. JAMA - Journal

of the American Medical Association. American

Medical Association.

https://doi.org/10.1001/jama.2013.5912

Goman, A.M., and Lin, F.R. (2016). Prevalence of Hearing

Loss by Severity in the United States. Am J Public

Health, 27(4), 1812–1818.

https://doi.org/10.1353/hpu.2016.0164

Gopinath B., Schneider J., McMahon C.M., Teber E.,

Leeder S.R. and Mitchell P. (2012). Severity of age-

related hearing loss is associated with impaired

activities of daily living. Age Ageing. 2012

Mar;41(2):195-200.

Green, C. A., and Pope, C. R. (2001). Effects of Hearing

Impairment on Use of Health Services Among the

Elderly. Journal of Aging and Health, 13(3), 315–328.

https://doi.org/10.1177/089826430101300301

Hay-McCutcheon M.J., Reed P.E. and Cheimariou S.

(2018). Positive Social Interaction and Hearing Loss in

Older Adults Living in Rural and Urban Communities.

J Speech Lang Hear Res. 61(8):2138-2145

Hoppe, U. and Hesse, G. (2017). Hearing aids: indications

, technology , adaptation , and quality control. GMS

Current Topics in Otorhinolaryngology - Head and

Neck Surgery, 16, 1–24.

Jiam N.T., Li C. and Agrawal Y. (2016). Hearing loss and

falls: A systematic review and meta-analysis.

Laryngoscope. 2016 Nov;126(11):2587-2596.

Lin F.R., Yaffe K., Xia J., Xue Q.L., Harris T.B., Purchase-

Helzner E., Satterfield S., Ayonayon H.N., Ferrucci L.

and Simonsick E.M.; Health ABC Study Group. (2013).

Hearing loss and cognitive decline in older adults.

JAMA Intern Med. 173(4):293-9

Mick P., Kawachi I. and Lin F.R. (2014). Otolaryngol Head

Neck Surg. The association between hearing loss and

social isolation in older adults. 150(3):378-84

Mroz, M. (2018). Hearing aid technology. Retrieved from

https://www.healthyhearing.com/help/hearing-

aids/technology

NIDCD (2016) Quick Statistics About Hearing. Accessed

from

https://www.nidcd.nih.gov/health/statistics/quick-

statistics-hearing#9

Ray J., Popli G. and Fell G. (2018). Association of

Cognition and Age-Related Hearing Impairment in the

English Longitudinal Study of Ageing. JAMA

Otolaryngol Head Neck Surg. 144(10):876-882.

Roth T.N., Hanebuth D. and Probst R. (2011). Prevalence

of age-related hearing loss in Europe: a review. Eur

Arch Otorhinolaryngol. 268(8):1101-1107.

Saunders G.H., Frederick M.T., Silverman S.C., Penman

T., Gardner A., Chisolm T.H., Escabi C.D., Oree P.H.,

Westermann L.C., Sanchez V.A. and Arnold M.L.

(2018). Hearing Screening in the Community. J Am

Acad Audiol. Jan 25 [Epub ahead of print].

The Role of Hearing in Aging and Hearing Rehabilitation Technology with an Outlook on Future Applications

309

Sung Y.K., Li L., Blake C., Betz J. and Lin F.R. (2016).

Association of Hearing Loss and Loneliness in Older

Adults. J Aging Health, 28(6):979-94

Wallhagen M.I. (2010). The stigma of hearing loss.

Gerontologist. 50(1):66-75

Wallhagen M.I. and Reed NS. (2018). Implications of

Hearing Care Policy for Nurses. J Gerontol Nurs.

44(9):9-14.

Wattamwar K., Qian Z.J., Otter J., Leskowitz M.J., Caruana

F.F., Siedlecki B., Spitzer J.B. and Lalwani A.K.

(2017). Increases in the Rate of Age-Related Hearing

Loss in the Older Old. JAMA Otolaryngol Head Neck

Surg. 2017 Jan 1;143(1):41-45.

Weinstein B.E., Sirow L.W. and Moser S. (2016). Relating

Hearing Aid Use to Social and Emotional Loneliness in

Older Adults. Am J Audiol., 25(1):54-61

Zhang, T., Mustiere, F., and Micheyl, C. (2016). Intelligent

Hearing Aids : The Next Revolution. 2016 38th Annual

International Conference of the IEEE Engineering in

Medicine and Biology Society (EMBC), 72–76.

https://doi.org/10.1109/EMBC.2016.7590643

ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health

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