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Challenges and Opportunities in Presbycusis

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 Otolaryngology http://oto.sagepub.com/
-- Head and Neck Surgery

Challenges and Opportunities in Presbycusis

Kourosh Parham, Brian J. McKinnon, David Eibling and George A. Gates
Otolaryngology -- Head and Neck Surgery 2011 144: 491 originally published online 10 February 2011
DOI: 10.1177/0194599810395079

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395079
am et alOtolaryngology–Head and Neck Surgery
© The Author(s) 2010
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OTOXXX10.1177/0194599810395079Parh
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Invited Article
Challenges and Opportunities in Presbycusis
Kourosh Parham, MD, PhD1, Brian J. McKinnon, MD, MBA2,
David Eibling, MD3, and George A. Gates, MD4
No sponsorships or competing interests have been disclosed for this article.
Abstract
The population aged 65 years and older is increasing at a
faster rate than the total population, with predictions that
by 2030, 20% of the population will be 65 years or older. In
2006, between 35% and 50% of those aged 65 years or older
reportedly had presbycusis, a sensory impairment that con-
tributes to social isolation and loss of autonomy and is associ-
ated with anxiety, depression, and cognitive decline.To address
these concerns, the Geriatric Committee of the American
Academy of Otolaryngology, in conjunction with the Hear-
ing Committee, focused on 3 challenges and opportunities
in the management of presbycusis: (1) the financial burden
of caring for patients with presbycusis in the face of increas-
ing costs and declining reimbursements; (2) future treatment
options arising from improved understanding of the molecu-
lar mechanisms underlying presbycusis, and (3) recognition of
central presbycusis as a condition commonly superimposed
on peripheral age-related hearing loss whose diagnosis and
management can improve outcomes.
Keywords
presbycusis, aging, cochlea, fiscal considerations, central audi-
tory dysfunction
Received September 10, 2010; revised November 23, 2010; accepted
December 1, 2010.
I
n 2008, the National Center for Health Statistics data
showed that between 1950 and 2006, the US population
doubled and that over this same time period, the popula-
tion of Americans older than 65 years tripled while those older
than 75 and 85 years grew 5- and 10-fold, respectively. The
report further predicted that by 2030, 20% of the population
will be 65 years or older. The Institute of Medicine, in the
same year, noted that the health care delivery system in the
United States is poorly prepared for the unique needs of older
adults and identified specific recommendations to mitigate the
impact of the impending onslaught.1 Nearly all otolaryngolo-
gists will be affected by these demographic realities. Optimal
evaluation and management of these older adult patients will
depend on otolaryngologists acquiring new knowledge and
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Otolaryngology–
Head and Neck Surgery
144(4) 491­–495
© American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2011
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599810395079
http://otojournal.org
skills. To help address this gap, the Geriatric Committee of the
American Academy of Otolaryngology, in cooperation with 4
other academy committees, sponsored a series of mini semi-
nars with the theme of “Challenges and Opportunities in Man-
aging Disorders of the Older Adult” at the 2010 AAO-HNSF
Annual Meeting & OTO EXPO in Boston, Massachusetts.
This article is 1 of the 4 in the series.
Hearing loss is one the most common of chronic conditions
affecting the older patient, with a prevalence of 77% in 60- to
69-year-olds2 and an even higher prevalence in those 80 to 96
years of age.3 Age-related hearing loss (presbycusis) can be
defined as the sum of all conditions that lead to decreased hearing
sensitivity with age. It is difficult to separate various host and
environmental factors that influence hearing from aging alone.
For example, noise exposure is a well-established risk factor for
hearing loss2; however, the effects of noise-induced hearing loss
may continue long after exposure has stopped.4 Furthermore,
conditions that affect cardiovascular health, such as smoking and
diabetes, also contribute to hearing loss over a lifetime.2-6 Family
history (ie, genetic susceptibility) of presbycusis is another key
risk factor for presbycusis, as about 30% to 50% of variance in
presbycusis is attributed to the effects of genes.7,8
As a leading cause of sensory impairment, presbycusis
affects familial and societal interactions by limiting the ability
to communicate. Presbycusis is believed to be associated with
social isolation and loss of autonomy among older adults and
contributes to development of anxiety, depression, and cogni-
tive decline.9-12 The high prevalence of presbycusis and its sig-
nificant impact on the health and well-being of older individuals
positions the otolaryngologist, the practitioner who diagnoses
1
Division of Otolaryngology, Department of Surgery, University of
Connecticut Health Center, Farmington, Connecticut, USA
2
Department of Otolaryngology–Head & Neck Surgery, Medical College of
Georgia,   Augusta, Georgia, USA
3
Department of Otolaryngology, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania, USA
4
Virginia Merrill Bloedel Hearing Research Center, University of Washington,
Seattle, Washington, USA
Miniseminar presented at American Academy of Otolaryngology—Head and
Neck Surgery, Annual Meeting & OTO EXPO 2010, Boston, Massachusetts.
Corresponding Author:
Kourosh Parham, MD, PhD, Division of Otolaryngology, Department of
Surgery, University of Connecticut Health Center, Farmington, CT 06030-
6228
Email: parham@neuron.uchc.edu
492 Otolaryngology–Head and Neck Surgery 144(4)
and treats presbycusis, to play a substantial role in improving
the quality of life for our aging population.13 Otolaryngologists
must face the challenge of managing the growing burden of
presbycusis in an environment where Medicare is expected to
have unfunded liabilities up to $100 trillion.14 Healthy People
2010 has objectives not only to reduce the risk of hearing loss
but also to increase access for hearing-impaired individuals to
hearing rehabilitation services, adaptive devices (including
hearing aids, cochlear implants), and other technology,15 whose
out-of-pocket costs are significant.16 However, fewer than 25%
of those who would benefit from hearing aids use them17; 76%
of nonusers indicate that the cost is a significant reason for this,
with 64% of nonusers simply stating that they cannot afford
them.18 Interestingly, in health systems where hearing aids are a
covered benefit, elder hearing-impaired hearing aid use is
greater than 60%.19
How is the otolaryngologist to respond? Here, we outline 3
key elements of this response: (1) fiscal considerations—
developing strategies to maintaining the economic viability of
the otolaryngologic practice through a thorough understanding
of what drives costs and reimbursements; (2) future treatments—
understanding mechanisms underlying medical treatment
strategies for management of presbycusis in the horizon; and
(3) central auditory testing—recognition that central auditory
diagnostic testing in addition to tests of peripheral function
may be required to specifically address the unique needs of
the geriatric population with hearing impairments.
Fiscal Considerations
A significant challenge facing the otolaryngologist is how to
provide care for patients with presbycusis in the face of
declining reimbursement and increasing costs. Some simple
actions can improve reimbursement and economic viability.
Many otolaryngologists spend the necessary time to fully
explain to the patient and family the issues surrounding the
patient’s hearing loss and management, then fail to bill for
that time. When counseling dominates (more than 50%) the
time a physician spends with the patient and/or family
encounter, that time is considered the key to a particular level
of service. Counseling must be consistent with the nature of
the problem and the patient’s and/or family’s needs and can
include review of diagnostic results, discussion of further
evaluation, risk reduction in the form of hearing protection,
and management options to include amplification and its
forms. Proper documentation and appropriate coding can
markedly improve reimbursement.
Some actions require a great deal more knowledge, and
work review of a practice’s financial performance should lead
to the development of business plans focusing on aggressive
cost and revenue management. For example, a geriatric
cochlear implant program can become economically viable by
using an implant system that includes just a single external
processor, combined with exclusive contracting and careful
management of surgical time. Some actions involve the inno-
vative application of technology. The decrementally cost-
effective medical innovation is one that saves money but is
less effective, trading on the cost-quality tradeoffs,20 a
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practice common in other commodities such as furniture, cell
phones, or even foodstuffs. With hearing aid prices up to
$6800, while their components (microphone and other ele-
ments) cost less than $100, the opportunity for a decremen-
tally cost-effective device is staggering.
It is now less an issue of what to do than how to pay for it.
The business methods and skills necessary are not typical for
an otolaryngologist but are not beyond their reach and are as
essential as their clinical acumen to lift the burden of presby-
cusis. The benefit from our services can be tremendous: in a
1998 study by the National Council on the Aging, successful
hearing device users were more likely to report better physi-
cal, emotional, mental, and social well-being than those who
did not use hearing aids and by extension reduce the utiliza-
tion of health resources.15,16
Future Treatments
A growing body of evidence suggests that aging, including in
the cochlea, is associated with increased oxidative damage to
mitochondria and molecular mediators of cell function.21
Seidman and colleagues22 proposed that aging is associated
with accumulation of reactive species in the cochlea and mito-
chondrial DNA damage, causing deletions in the mitochondrial
genome that render the mitochondria bioenergetically ineffi-
cient. Indeed, a 4977 base-pair deletion acts as an accurate
biomarker for age-related changes in a variety of tissues,
including the human cochlear spiral ganglion cells.23 There are
likely additional mtDNA deletions that contribute,24 and when
a critical level of the accumulated deletions is reached, cell
death is triggered.25 Several apoptotic pathways/genes linked to
oxidative stress are activated in the aging cochlea, including
caspase-related pathways and mitogen-activated protein
kinase.26,27 Induction of the mitochondrial proapoptotic gene,
Bak, by oxidative stress leads to loss of hair cells and spiral
ganglion cells and age-related hearing loss in an animal model
of presbycusis.28 Molecules associated with survival mecha-
nisms of the hair cells also appear to be affected by the aging
process. The phosphatidyl-inositol 3,4,5-triphosphate/Akt path-
way, involved in maintaining cell homeostasis, decreases in
aging cochlea due to elevation of lipid phosphatase PTEN.27
Because oxidative stress plays a major role in aging and
presbycusis, it follows that minimization of oxidative stress in
the cochlea may serve to ameliorate presbycusis. Such effort
has been directed primarily at 2 strategies: (1) decrease meta-
bolic activity and resultant oxidative stress through caloric
restriction and (2) increase antioxidants and free radical scav-
engers through dietary supplementation. Early work on caloric
restriction in presbycusis, which reduces the degree of oxida-
tive damage, showed a slowing of age-related hearing loss29
and preservation of hearing without cochlear degeneration.30,31
The beneficial effects of caloric restriction may be mediated
by the upregulated expression of genes involved in mitochon-
drial (ie, lower levels of mtDNA deletions) and downregu-
lated expression of apoptotic genes.30-32
Oral supplementation with antioxidants is likely more practi-
cal. Animal studies have demonstrated that oral supplementation
with mitochondrial antioxidants α-lipoic acid and coenzyme
Parham et al 493
Q(10) suppress Bak, a proapoptotic gene, expression and reduce
cochlear cell death and age-related hearing loss.33 Similarly, a
combination of 6 antioxidants targeting 4 sites within the oxida-
tive pathway all but eliminates age-related hearing loss.34
Resveratrol, an extract from grapes and red wine, which protects
against oxidative stress, attenuates age-related hearing loss, likely
through its anti-inflammatory effects.35 There is also emerging
evidence from clinical trials that dietary supplements of free radi-
cal scavengers and mitochondrial antioxidants may play a protec-
tive role in human presbycusis. Oral administration of rebamipide,
α-lipoic acid, and vitamin C for at least 8 weeks in 46 patients
with age-related hearing loss resulted in improved hearing lev-
els.36 Daily folate supplementation for 3 years slowed the decline
of low-frequency hearing thresholds in subjects with presbycu-
sis.37 At this time, the available clinical evidence is not strong
enough to support a recommendation of oral supplementation in
the treatment of presbycusis. Future clinical trials need to further
characterize which patients (eg, type of presbycusis) might ben-
efit and define specific supplements and duration of treatment.
As promising as the studies in molecular presbycusis have
been, the challenge of accounting for age-related hearing loss
through the study of macromolecules and genes is illustrated
by the finding that age-related hearing loss is associated with
changes in expression of 4000 cochlear genes.30 While even 1
gene can have a significant impact on presbycusis, likely mul-
tiple genes, or more importantly, interaction of genes with
other factors may be the main determinant of hearing loss in
most instances. For example, the age-related sensorineural
hearing loss expressed in C57BL/6J mice is the result of a
gene, named Ahl,38 located on chromosome 10,39 which codes
for a hair cell–specific cadherin and affects stereocilia.40
However, noise-induced hearing loss, hormonal influences,
augmented acoustic environments, and diet can modulate
hearing loss, even in the presence of the Ahl gene.41 Although
further studies are needed to shed light on the complex effects
of aging and its interaction with other factors in producing
presbycusis, there are new treatment strategies in ameliorating
presbycusis in the horizon.
Central Auditory Testing
The ultimate perception of speech is in the brain; therefore, it
is not unexpected that age-related brain dysfunction could
affect hearing. Central presbycusis (ie, age-related central
auditory processing dysfunction) is a common element of
presbycusis that is typified by difficulty understanding speech
in noise or other difficult listening situations. Central auditory
processing problems are usually superimposed on peripheral
cochlear dysfunction, and in late cases, central problems
dominate treatment challenges. Because speech understand-
ing may be affected at both the peripheral and central levels,
an adequate assessment protocol should evaluate both.
The importance of central auditory testing is further high-
lighted when the impact of age-related disorders is taken into
account. For example, prevalence of dementia increases with
age, rising from 3% among those aged 65 to 74 years to almost
50% among those aged 85 years or older and by 2050 will
increase to 13 million in the United States.42 Gates and
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colleagues43 have shown that poor performance on central
auditory tests is common in people with Alzheimer disease
(AD). The prevalence of a poor central auditory test perfor-
mance was 33% for the cognitively normal group, 80% for the
memory impaired group, and 90% for the AD group.44
Furthermore, poor performance in older people with other-
wise normal mental status is associated with increased odds of
later diagnosis of dementia.45
Central presbycusis limits rehabilitation, increasingly so
with advanced age, yet few centers include central testing in the
routine evaluation of people for amplification candidacy. A
large discrepancy between the history and the results of stan-
dard peripheral auditory tests may prompt an evaluation of cen-
tral auditory function. An example is when a patient has
reasonable speech understanding in quiet environments but has
severe speech problems in noisy or difficult listening environ-
ments. The most frequently used central tests evaluate speech
recognition in relation to noise or other speech sounds. Only a
subset of the available central auditory tests, which are resistant
to effects of peripheral hearing loss, can be used in the presby-
cusic patient. These include the Synthetic Sentence Identification
either with an Ipsilateral or Contralateral Competing Message46
and Dichotic Sentence Identification test.47
Auditory processing testing should be included in the eval-
uation of older people with hearing difficulty to tailor their
rehabilitation program. For example, degraded speech, such
as occurs in noise, reverberant halls, or with rapid speakers, is
more difficult to understand. Therefore, optimizing the listen-
ing environment (eg, turning off the television, speaking
slower) has positive effects on speech comprehension.
Enhancing the signal-to-noise ratio is an important consider-
ation. Patients with central processing disorders generally do
better with a single aid in the better ear.48,49
Aural communication is enhanced by viewing the speak-
er’s face. Facial expressions and lip contours provide assis-
tance in filling the gaps resulting from unheard speech sounds.
Unfortunately, formal speech reading classes are available at
few centers. Materials are now becoming available on the
World Wide Web.
For people with severe losses, auditory training is likely to
be of benefit. The hearing-impaired listener is trained to iden-
tify speech sounds and keywords with amplification in place.
Such training is seldom available outside of major centers, but
now, the widespread availability of personal computers and
Internet access has facilitated the development of automated
programs for training. While training has the promise of
improved speech comprehension for people with central pres-
bycusis, the use of training in this condition is in its early
stages.
Conclusions
Presbycusis is a common disorder affecting the health and quality
of life of our rapidly increasing number of geriatric patients. At
present, the out-of-pocket cost of hearing aids represents a major
barrier to increased utilization. The otolaryngologist’s apprecia-
tion of what drives costs may lead to creative opportunities to
overcome this obstacle. Better understanding of the molecular
494 Otolaryngology–Head and Neck Surgery 144(4)
mechanisms underlying presbycusis is opening the doors to
new treatment options aimed at reducing oxidative stress in the
auditory system. In addition to the standard approach to diag-
nosis and management of the peripheral component of age-
related hearing loss, addressing the central consequences of
peripheral losses as well as the direct, sometimes pathological
impact of aging on the central nervous system may lead to
improved rehabilitation outcomes.
Author Contributions
Kourosh Parham, drafting manuscript and final approval; Brian J.
McKinnon, drafting manuscript and final approval; David Eibling,
drafting manuscript and final approval; George A. Gates, contrib-
uted to drafting manuscript and final approval.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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