The Laryngoscope

V
C 2011 The American Laryngological,
Rhinological and Otological Society, Inc.

Elderly Patients Benefit From Cochlear Implantation Regarding

Auditory Rehabilitation, Quality of Life, Tinnitus, and Stress

Heidi Olze, MD, PhD; Stefan Gräbel, Dr rer medic; Ulrike Förster, MD; Nina Zirke, Dipl Psych;
Laura E. Huhnd, cand. med.; Heidemarie Haupt, Dipl Eng (FH); Birgit Mazurek, MD, PhD

Objectives/Hypothesis: To determine the effect of cochlear implantation on quality of life, speech performance, tinnitus,
perceived stress, and coping strategy in patients aged
70 years in comparison with younger patients.
Study Design: Retrospective study.
Methods: A total of 55 postlingually deafened adults who were unilaterally implanted with a multichannel cochlear
implant for at least 6 months were included in the study. Twenty patients were aged
70 years (70–84 years), and
35 patients were <70 years (19–67 years). Speech perception was measured using the Freiburg monosyllable test in quiet
and the Hochmair-Schulz-Moser sentence test. In addition, the patients filled in six validated questionnaires.
Results: Speech perception and subjectively assessed auditory ability were similar in the two age groups after implanta-
tion. Disease-specific quality of life was improved in patients aged
70 years and even to a higher extent as compared to
younger patients. Tinnitus annoyance and perceived stress were reduced in elderly patients to the same extent as in younger
patients in the case of high initial severity level. The scores for the coping subdomain ‘‘seeking support’’ were reduced in
elderly patients.
Conclusions: The present study provides evidence that cochlear implantation constitutes a very successful procedure of
auditory rehabilitation, even for patients aged
70 years. In addition, elderly patients benefit from implantation, with
increased quality of life and reduced tinnitus and stress.
Key Words: Cochlear implantation, age, health-related quality of life, tinnitus, stress.
Level of Evidence: 2b.
Laryngoscope, 122:196–203, 2012

INTRODUCTION although primarily CI users aged more than 60 or 65

The question of the effectiveness of cochlear implan-
tation (CI) in elderly patients has become more
important with demographic changes. The social isola-
tion associated with acquired hearing loss in elderly
patients is accompanied by a decline in quality of life
and an increase in emotional handicap.1 Physical and
psychosocial changes, a long duration of deafness, and
reduced cognitive and learning abilities are believed to
influence the outcome in elderly patients.2–5 In addition
to age-related degeneration of the spiral ganglion cells
in the peripheral auditory system,6 there is also evi-
dence for possible deficits in the central auditory and
integration pathways in the elderly.7
In many studies, however, a comparable benefit
could be observed in elderly patients and in younger
patients regarding speech understanding after CI,2,3,8
From the Department of Otorhinolaryngology, Charité-
Universitätsmedizin Berlin, Berlin, Germany.
Editor’s Note: This Manuscript was accepted for publication Au-
gust 8, 2011.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Heidi Olze, MD, PhD, Charité-Universi-
tätsmedizin Berlin, Campus Virchow Klinikum, Department of Otorhino-
laryngology, Augustenburger Platz 1, 13353 Berlin, Germany.
E-mail: heidi.olze@charite.de
DOI: 10.1002/lary.22356
years were examined in this case. However, we now
increasingly have to deal with older patients, yet studies
with patients aged more than 70 years are uncommon.
Moreover, in both studies comparing patients aged more
than 70 years with younger patients and despite signifi-
cant improvements in speech understanding, worse
speech test results were obtained in the older age
group.4,9 However, the authors highlighted the positive
effects on quality of life of patients aged more than 70
years. Increased well-being, better self-esteem, and
enhanced activity were reported in elderly patients after
CI in other studies as well.3,10,11 Although previous stud-
ies have mainly examined changes in hearing and
speech understanding in elderly patients after CI, the
effect of the CI on health-related quality of life (HRQoL)
and its evaluation by using validated questionnaires has
strongly come to the fore.9,11
The correlation between hearing loss and tinnitus,
especially in elderly patients, has been observed in
many studies; after age 60 years, more than twice as
many persons experience tinnitus compared with per-
sons between the ages of 20 and 30 years.12 Tinnitus is
a further stress and handicap for deaf patients, in addi-
tion to their hearing disability. Interestingly, there are
many studies reporting reduction of tinnitus in addition
to improvement of hearing and speech discrimination af-
ter CI (for review, see Baguley and Atlas13 and

Laryngoscope 122: January 2012 Olze et al.: Cochlear Implantation in the Elderly
196
Quaranta et al.14). However, the impact of CI on tinnitus
in elderly patients has not undergone much study. Shin
et al.3 has shown improvement regarding tinnitus in
implant users aged more than 60 years, similar to
younger patients. To the best of our knowledge, tinnitus,
perceived stress, and coping strategies of elderly
patients using validated questionnaires before and after
CI have not yet been studied.
Therefore, we evaluated the effect of the CI on
HRQoL, speech understanding, tinnitus impairment,
perceived stress, and coping strategies in postlingually
deafened patients who were aged 70 years or more and
compared the results with a younger age group (<70
years). In addition, we characterized the association
between speech understanding and duration of deafness,
HRQoL, and psychometric parameters in both patient
groups after CI.
MATERIALS AND METHODS
Seventy-eight postlingually deafened adults were recruited
who were implanted unilaterally with a multichannel CI for at
least 6 months. The study was performed at the Ear, Nose, and
Throat Department of the Charité-Universitätsmedizin Berlin,
Germany, between 2006 and 2010 and approved by the local
ethics committee. Criterion for inclusion was speech perception
of 40% using the Freiburg monosyllable test in quiet (65 dB
SPL) with fitted hearing aid.
Preimplantation data were collected retrospectively. The
questionnaires, aimed at the evaluation of pre- and postimplan-
tation data, were sent and filled out separately. A total of 55
patients (74%; 20 males and 35 females) completed the ques-
tionnaires and participated in the speech performance test
before and after CI.
The mean patient age at the time of implantation was
58.4 6 17.0 years (range, 19–84 years), with 36.4% (n ¼ 20) of
the patients aged
70 years (74.4 6 4.6; range, 70–84 years)
and 63.6% (n ¼ 35) <70 years (74.4 6 4.6; range, 19–67 years).
In the older age group, there were 50% women and men (n ¼
10 each). The <70 years-old group consisted of 71.4% women (n
¼ 25) and 28.6% men (n ¼ 10).
The duration of deafness before CI was 13.3 6 14.9 years
(range, 0.4–70). In the elderly patients, the duration of deafness
was 13.1 6 16.1 years (range, 1–70) and did not differ from that
of the younger patients (13.4 6 14.5 years; range, 0.4–41).
The period of time after CI at the moment of completing
the questionnaires was 20.7 6 15.7 months (range, 6–63) in all
patients. The time did not differ between the elderly (21.2 6
19.0 months; range, 6–63) and younger (20.5 6 13.9 months;
range, 6.5–48.4) patient groups.
Before CI, the mean speech perception was 2.5% (range,
0–40) in the elderly patients and 5.5% (range, 0–40) in the
younger patients as indicated by the Freiburg monosyllable test
in quiet with fitted hearing aid (65 dB HL). The values did not
differ significantly.
All patients received a multichannel implant. The most
commonly used type was the Nucleus Freedom (n ¼ 29),
followed by Sonata (n ¼ 20), C40þ (n ¼ 3), CI24M (n ¼ 2), and
Pulsar (n ¼ 1). The following questionnaires were used to ob-
tain information on HRQoL, tinnitus severity, perceived stress,
coping strategies, and speech understanding.
HRQoL Instruments
The Nijmegen Cochlear Implant Questionnaire (NCIQ) is
a disease-specific questionnaire that measures HRQoL.15 The
NCIQ was translated into a German version by native German
Laryngoscope 122: January 2012
and English speakers using forward-backward translation. The
NCIQ consists of three general domains that are specified by
six subdomains: physical domain (NCIQ1, basic sound percep-
tion; NCIQ2, advanced sound perception; NCIQ3, speech
production), psychological domain (NCIQ4, self-esteem), and
social domain (NCIQ5, activity; NCIQ6, social interactions).
Every subdomain comprises 10 items, each being formulated as
a statement with a five-point response scale that varies from
‘‘never’’ to ‘‘always’’ (55 statements) or from ‘‘no’’ to ‘‘good’’ (five
statements). If a statement does not apply to a patient, a sixth
answer can be given: ‘‘not applicable.’’ Scores range from 0
(very poor) to 100 (optimal). Since its validation, NCIQ has
been used as a standard test to evaluate the HRQoL in patients
with CIs or hearing aids.
The Medical Outcome Study 36 Short Form healthy
survey (SF36) is a non–disease-specific, generic HRQoL instru-
ment.16 It contains 36 items that measure eight domains:
physical functioning, role functioning due to physical health
problems, role functioning due to emotional problems, bodily
pain, vitality, social functioning, mental health, and general
health perceptions. The number of response choices per item
range from two to six. Item scores on each dimension are coded,
totaled, and transformed into a scale from 0 to 100, in which
higher scores indicate better self-perceived health. A physical
component summary score and a mental component summary
score can be computed using the standardized scoring system.
Our survey had three additional questions: 1) For how long had
you been deaf when you received your CI? 2) How many hours
per day do you use the CI? and 3) Are you satisfied with the
changes in the quality of life after CI (never, sometimes, regu-
larly, usually, and always)?
Auditory Performance
The speech perception of all 55 patients who had com-
pleted the questionnaires was measured using the Freiburg
monosyllable test in quiet (65 dB SPL) with hearing aid before
CI. After CI, the Freiburg monosyllable test in quiet (70 dB
SPL) and the Hochmair-Schulz-Moser (HSM) sentence test in
noise (70 dB SPL, signal-to-noise ratio ¼ 15 dB) were used.
The Oldenburger Inventar (OI) was used to quantitatively
evaluate the subjective hearing situation after CI.17 The OI
that was used here contains 12 closed questions on different
standard hearing situations. The response choices (always,
often, rare, sometimes, and never) are evaluated with scores
from 1 to 5. The test result is obtained from the total of the
scores in each domain (hearing in quiet, hearing with back-
ground noise, and localization) and the total score, which can
be converted into a percentage. The higher the percentage, the
better is the hearing in this domain.
Psychometric Questionnaires
The Tinnitus Questionnaire (TQ) comprises 52 items and
evaluates the tinnitus-related distress on four severity levels
according to the TQ total score: low (1–30), moderate (31–46),
severe (47–59), and very severe (60–84).18 Tinnitus is consid-
ered to be ‘‘compensated’’ at a TQ level of 46 (annoyance in
quiet and under stress) and ‘‘decompensated’’ at a TQ level of

47 (permanent annoyance and psychological strain; accompa-
nied by complaints like depression, anxiety, impaired sleep, and
concentration). The TQ has been sufficiently evaluated and is
considered in Germany to be the method of choice to determine
the severity level of tinnitus. The split-half reliability is 0.94.
The Perceived Stress Questionnaire (PSQ) was used to
register the stress perceived by the patients. It comprises 30
items. The cutoff score for low level of perceived stress is 0.45
using the PSQ-30.19 The split-half reliability is in the range of
0.80 to 0.88.
Olze et al.: Cochlear Implantation in the Elderly
197
Fig. 1. Disease-specific health-related quality of life of the patients who were
70 and <70 years old as measured by the Nijmegen Coch-
lear Implant Questionnaire (NCIQ) subscales before and after cochlear implantation (CI). *P < .0001 versus before CI.
The German version of the Brief COPE, which is an
abbreviated form of the COPE inventory,20,21 was used to mea-
sure the coping behavior of the patients in the preceding
difficult or unpleasant situations. The COPE consists of 14
scales, each being represented by two items. The 28 items are
summarized into four scales: focus on positive coping (positive
reframing, humor, acceptance), active coping (active coping and
planning), seeking support (instrumental and emotional sup-
port, religion), and evasive coping (denial, self-blame, venting).
The values range from 1 (not at all) to 4 (very much). Internal
consistencies were within acceptable range (Cronbach a ¼ 0.61–
0.81).
Statistical Analysis
Changes in age and severity level groups were compared
by two-way analysis of variance (ANOVA). The Bonferroni post
hoc test was applied to compare individual scores. Speech per-
ception and time of implant use were compared between the
age groups using the Mann-Whitney U test. Correlations were
calculated by the Spearman rank correlation test. Significance
was set at P < .05. The results were shown as mean 6 standard
deviation in the text. The graphics show the mean 6 standard
error of the mean. Statistical analysis and graphics were made
using Statistica 7.1 (StatSoft, Tulsa, OK).
RESULTS
Disease-Specific HRQoL: Elderly Patients
Benefit to a Higher Extent
The CI resulted in a statistically significant
increase in the disease-specific HRQoL in both age
groups, as measured by the NCIQ and its six subscales.
Although the initial and final values did not differ sig-
Laryngoscope 122: January 2012
198
nificantly, the patients aged
70 years benefited from
the CI to a higher extent than the younger patients
(ANOVA interaction effect, P < .05). The NCIQ scores
increased from 31.3 6 16.6 to 68.0 6 12.4 in the older
group and from 39.7 6 14.8 to 61.1 6 14.3 in the
younger group (P < .0001). The NCIQ subscales mea-
suring speech production (NCIQ3), self-esteem (NCIQ4),
activity (NCIQ5), and social contacts (NCIQ6) also
revealed a higher improvement in the older than in the
younger group, as shown by statistically significant
interaction effects, whereas the basic (NCIQ1) and
advanced (NCIQ2) sound perception equally improved in
both groups (Fig. 1).
Generic HRQoL: Social Functioning and
Mental Health Also Improved in
Elderly Patients
The initial scores of the SF36 did not differ between
the two age groups. After CI, the subscales of the SF36
‘‘social functioning’’ and ‘‘mental health’’ had increased
in the patients aged
70 years as much as in the
younger patient group, but the increase of the mental
component summary score was only marginal in elderly
patients (P ¼ .059) and significant in younger patients
following the CI (Fig. 2). However, the scores of the
domains ‘‘physical functioning,’’ ‘‘bodily pain,’’ and ‘‘phys-
ical component summary’’ decreased in the older age
group (decrease of the score means worsening), whereas
the scores remained unchanged in the younger group
after the CI (Fig. 2). The different reactions are verified
by the statistically significant interactions.
Olze et al.: Cochlear Implantation in the Elderly
Fig. 2. Generic health-related quality of life of the patients who were
70 and <70 years old as measured by the Medical Outcome Study
36 Short Form healthy survey before and after cochlear implantation (CI). *P < .05, **P < .01, ***P < .001 versus before CI.
Auditory Performance: Both Patient Groups
Improved to a Similar Extent
The speech perception was 56.0 6 29.0% in the
patients aged
70 years after CI and did not differ from
that of the younger patients who achieved 59.5 6 29.1%,
as is indicated by the Freiburg monosyllable test in quiet
(70 dB SPL). No differences between the patient groups
were found either in the HSM sentence test after CI.
The mean scores were 55.8 6 28.1% in the elderly
patients and 48.4 6 32.5% in the younger patients.
The subjective assessment of auditory abilities
measured by the OI also revealed similar improvements
in the two age groups (Fig. 3). Both the total score and
the scores of the three subdomains ‘‘hearing in quiet,’’
‘‘hearing with background noise,’’ and ‘‘localization’’
increased significantly as compared with before CI.
Tinnitus Severity Did Not Differ Between the
Age Groups Either Before or After CI
Of the 55 patients who completed the question-
naires, 48 (87%) patients reported having chronic
tinnitus before CI. Sixteen patients with tinnitus were
aged
70 years, and 32 patients were aged <70 years.
The TQ score of the older patients decreased from
26.3 6 23.1 before CI to 22.3 6 17.7 after CI, but this
difference did not reach statistical significance. In the
younger age group, the TQ score decreased from 29.1 6
18.4 to 21.0 6 15.3 (P < .01). However, the scores did
not differ between the groups either before or after CI.
In addition, we analyzed the changes of the TQ
scores in patients with compensated and decompensated
Laryngoscope 122: January 2012
tinnitus, although there were only three and six
patients, respectively, with decompensated tinnitus in
the older and younger group before CI. In both age
groups, patients with low severity level did not show
any significant changes in the mean TQ score, whereas
in patients with high severity level, the TQ score
decreased significantly, both in the older (from 64.7 6
12.7 to 46.0 6 7.0, P < .05) and younger age group (from
58.3 6 8.8 to 36.5 6 19.4, P < .05). The different reac-
tions between the severity groups are verified by
statistically significant interaction effects (P < .01). In
one patient of the group aged
70 years, tinnitus had
worsened from compensated to decompensated status
after CI.
Low Level of Perceived Stress in Both Age
Groups After CI, Coping Strategy Improved
in Elderly Patients
In the elderly patients, the PSQ score was 0.32 6
0.18 before and 0.28 6 0.16 after CI (not significant). In
the younger patients, the initial score was 0.47 6 0.20
and decreased to 0.31 6 0.15 after CI (P < .0001). The
ANOVA revealed a significant interaction between the
two groups over time (P < .05), indicating that the
younger patients benefited from CI to a higher extent.
However, the scores did not differ between the age
groups before and after CI.
Moreover, we tested the changes in patients with
different severity level of perceived stress (0.45 and
>0.45) in both age groups. The PSQ scores did not
change in the groups with initial low severity level but
Olze et al.: Cochlear Implantation in the Elderly
199

decreased in both age groups with higher severity level. In
the elderly patients (n ¼ 6), the PSQ decreased from 0.52
6 0.16 to 0.32 6 0.11 (P < .05) and in the younger patients
(n ¼ 19) from 0.61 6 0.14 to 0.37 6 0.15 (P < .0001).
Regarding coping strategy, the elderly patients had
lower scores in the subscale ‘‘seeking support’’ after CI
(12.4 6 4.2) as compared to their initial scores (14.8 6
4.4; P < .05). We did not find any changes or differences
in the scores of the coping strategies ‘‘focus on positive,’’
‘‘evasive coping,’’ and ‘‘active coping.’’
CI Use and Satisfaction Are Similar
in Both Age Groups
The daily use of the CI was 13.1 6 3.2 hours in the
patients aged
70 years and 15.1 6 3.3 hours in the
younger patients (not significant). In the older group,
84.2% of the patients were often or always satisfied with
the CI-induced changes of their life. This number was
82.8% in the younger age group.
Duration of Deafness Significantly Influences
Speech Performance Using the Implant
We found a weak negative correlation between
duration of deafness and speech performance as indi-
cated by the Freiburg monosyllable test (r ¼ 0.34, P <
.05) and the HSM sentence test (r ¼ 0.27, P < .05).
However, the duration of deafness did not influence the
CI use and satisfaction of the patients.
In addition, we calculated the ratio of duration of
deafness to age and found a weak negative correlation
Laryngoscope 122: January 2012
200
Fig. 3. Auditory abilities of the patients who
were
70 and <70 years old as measured by
the Oldenburger Inventar (OI) and its sub-
scales before and after cochlear implantation
(CI). *P < .0001 versus before CI.
between the ratio and the speech performance as indi-
cated by the Freiburg monosyllable test (r ¼ 0.32, P <
.05). The ratio did not correlate either with the CI use
and satisfaction of the patients.
The patients’ age at the time of implantation did
not influence speech performance.
Correlations Between Speech Performance
and HRQoL and Psychometric Scores
We did not find any correlations between the
results of the monosyllable test and the scores of the OI
and NCIQ in the elderly patients after CI, but the
results of the HSM sentence test correlated with the
scores of the NCIQ1, which measures the basic sound
perception, (r ¼ 0.49; P < .05) and the mental component
summary score of the SF36 (r ¼ 0.64; P ¼ .01).
In the younger patients, the results of the monosyl-
lable test weakly correlated with the OI subdomain
‘‘hearing in quiet’’ (r ¼ 0.37; P < .05) and the scores of
the NCIQ2, which measures the advanced sound percep-
tion (r ¼ 0.40; P < .05) and the NCIQ3, which measures
the speech production, (r ¼ 0.36; P < .05).
Neither in the older group nor in the younger group
did speech performance correlate with the scores of the
psychometric questionnaires (TQ, PSQ, and Brief COPE).
DISCUSSION
Changes in the Quality of Life
The NCIQ showed significant improvements regard-
ing HRQoL for both age groups in the total score as well
Olze et al.: Cochlear Implantation in the Elderly
as in all subdomains. It was observed that the benefit
was even higher in elderly patients than in younger
patients. Both age groups reached a comparable level
regarding HRQoL after CI. This fact correlates with the
observations of other authors, who have described simi-
lar results in younger and elderly patients by means of
various disease-specific measurement instruments.9,10
Elderly patients appear to particularly benefit from CI
as, regardless of etiology, hearing loss in people aged
more than 60 years can have devastating effects on the
quality of life and overall functioning.1 When the hear-
ing loss is left untreated, these effects become an
ongoing contributor to the decline of health with age.
When the World Health Organization terminology is
used, hearing loss ranks third after depression and other
unintentional injuries as a leading cause of years lived
with disability in adults.22 In the case of hearing loss,
many of these years lived with disability presumably
occur during the elderly years.
Moreover, the level of expectations of elderly
patients seems to be realistic, which is reflected in the
fact that 84.2% of the elderly patients in our study were
often or even always satisfied with the CI-induced qual-
ity of life.
The age groups before CI were not different in the
analysis of the SF36. After CI, the domains of ‘‘physical
functioning,’’ ‘‘bodily pain,’’ and thus ‘‘physical compo-
nent summary’’ of patients aged
70 years were
assessed as worse. Age-related body changes in the
course of the study can probably explain this. Other
studies make similar observations as well, in which the
patients were partly observed over a longer period and a
worsening was shown in the previously mentioned
dimensions.23,24
A significant increase of ‘‘social functioning’’ and
‘‘mental health’’ was observed in the patients aged more
than 70 years. In general, a lack of sensitivity of the
SF36 in detecting changes in HRQoL after CI was also
seen in earlier studies.23,24 Therefore, on the basis of the
previous studies and our observations of low sensitivity,
we agree with Damen et al.23 that the SF36 should not
constitute the first choice to evaluate the generic HRQoL
of hearing-impaired patients.
Auditory Performance
Regarding auditory perception, elderly and younger
patients similarly benefited from CI. None of the two
speech tests showed any difference between both age
groups after CI. Our results therefore confirm those of
some previous studies in which no difference was observed
regarding speech understandability between elderly and
younger patients.2,3,5,10 However, the age limit for the
group classification in these studies was 60 or 65 years.
In contrast, other studies have produced worse
speech test results in elderly patients, despite significant
improvements in both age groups.4,9 It is remarkable
that the elderly patients in these two studies were aged

70 years, as in our study.
On principle, numerous factors may contribute to
the discrepancies between observed results after CI. Fac-
Laryngoscope 122: January 2012
tors that are difficult to quantify such as cognitive
ability and engagement with the rehabilitation program
as well as some degree of variability in duration of deaf-
ness and residual hearing may account for the observed
differences.5 Another explanation could be the follow-up
period after CI. Herzog et al.8 concluded that their group
of elderly patients gained a speech-perception level simi-
lar to younger patients, although the elderly patients
needed more time to reach the same scores after CI. In
our study, the mean time after CI was 21 months in
both age groups, whereas in the study of Vermeire
et al.,9 the mean post-CI time was 16 months in the
older group and 23 and 27 months in younger age
groups.
No significant difference between patients aged 70
and >70 years could be found in the subjective evalua-
tion of auditory performance with the OI in our study. A
similar improvement could be observed in both groups in
the total score, as well as in the three domains ‘‘hearing
in quiet,’’ ‘‘hearing with background noise,’’ and
‘‘localization.’’
Changes in the Tinnitus-Related Distress
The high prevalence of tinnitus in connection with
sensorineural hearing loss could be confirmed in this
study. In our study, the prevalence of tinnitus among CI
patients was 87%, which corresponded to the approxi-
mately 80% reported in a review of 18 studies.13
When considering both study groups separately, a
significant reduction in tinnitus impairment could only
be found in the younger patient group. However, the
number of patients with tinnitus in the younger patient
group was twice as high as in the older one. Tinnitus
impairment before CI was not particularly high in older
and younger patients with 26 or 29 scores, respectively,
and improved only by 4 or 8 scores, respectively.
In a previous study, it was shown that patients
with decompensated tinnitus profited from a tinnitus
therapy to a considerably higher extent than patients
with compensated tinnitus.25 This was also true for our
CI patients experiencing tinnitus. At a stronger tinnitus
severity level, the decrease in TQ score of older and
younger patients was similarly pronounced and
amounted to 19 or 22 scores, respectively. This way,
patients aged more than 70 years were also able to show
a comparably clear reduction in the tinnitus severity
level.
Perceived Stress and Coping Strategies
A clear age effect regarding perceived stress was
shown when comparing both age groups. According to
this, the younger patients, with a mean initial score of
0.47, that is, above the cutoff score for low level of per-
ceived stress (0.45), benefited more than the elderly
patients, whose initial score only amounted to 0.32 and
therefore corresponded to the initial score of normal pop-
ulation already before CI. The postoperative PSQ scores
had significantly decreased by 0.16 in the younger
patients and thus also reached the impairment percep-
tion of healthy adults.
Olze et al.: Cochlear Implantation in the Elderly
201
 A stronger subjective stress at the age of 30 to 54
years was also shown in other studies. It can presum-
ably be accounted for higher professional and family
exigencies in this period of life19,26 and further aggra-
vated by a severe hearing loss.
Similar to tinnitus impairment, a comparable
reduction of stress by 0.20 or 0.24 scores respectively
was observed in patients with a higher stress level
(>0.45) before CI in the older and in the younger age
group. In a tinnitus-only study, it was also shown that
only patients with initially higher perceived stress
showed a reduction in the PSQ scores after therapy.26
In addition, CI went along with a different coping
strategy in the group of patients aged more than 70
years, which appeared in a significantly less frequent
application of the strategy ‘‘seeking support’’ compared
with the initial score, possibly indicating a more autono-
mous lifestyle. Although information on an overall more
restricted coping repertoire in elderly patients, which is
characterized by a more passive and less flexible behavior,
is available in literature,19 our study showed no difference
when directly comparing both age groups before and after
CI, so that no age-related difference between coping strat-
egies can be generally assumed here.
Correlations Between Speech Performance
and Quality of Life
Previous studies have found positive correlations
between quality-of-life improvement and speech recogni-
tion performance after CI.10,11 These are interesting
findings, because other authors reported a lack of signifi-
cant correlation between user satisfaction and audiologic
test results.15,24 Although we only found significant cor-
relations between speech recognition performance and
the NCIQ1 in elderly patients and the NCIQ2 and
NCIQ3 in younger patients after CI, significant improve-
ments of the HRQoL were measured in all subdomains
of the NCIQ.
The additional correlation we found between the
mental component summary score of the SF36 and the
results of the HSM sentence test in the patients aged

70 years can be assessed as a positive impact of CI on
the mental condition in this group.
It can therefore be argued that the patients’ subjec-
tive perception of benefits due to CI is not directly
linked to the performance level. This is true for both age
groups. Our results indicate that the effect of CI on
HRQoL might even outweigh improvements in hearing
ability measured by speech perception tests.
The significant correlations between the results of
the Freiburg monosyllable test and the responses to
‘‘hearing in quiet’’ of the OI let us draw conclusions on
the efficiency of this test procedure for measuring the
subjectively assessed hearing loss in quiet.
Influence of Age, Duration of Deafness, and the
Ratio of Duration of Deafness to Age
Our study showed no difference regarding speech
understanding and HRQoL between elderly and younger
Laryngoscope 122: January 2012
202
patients after CI. Furthermore, our study supported the
finding of other studies in which age at implantation is
not directly linked to HRQoL or speech test results.9,10
On the other hand, duration of deafness and the ra-
tio of duration of deafness to age negatively influenced
the speech performance in our patients after CI. The
longer duration of deafness before CI was found to corre-
late with lower postoperative speech test results by
other authors.24,27 Leung et al.5 investigated the rela-
tionship between CI outcome and the ratio of duration of
deafness to age at implantation. This factor was first an-
alyzed in detail by Tyler and Summerfield.28 The
authors found that a greater ratio had a negative impact
on the performance with an implant. This corresponds
to our results. Thus, early identification of deaf adults
may further enhance the CI-induced benefit. This factor
may also come into consideration as a cause of different
speech test results of elderly and younger patients com-
pared with other studies. Owing to the fact that the
duration of deafness did not differ between the elderly
and younger patients in our study, we analyzed the age
effect on rehabilitation, HRQoL, tinnitus, and stress.
Our data on the pre-CI state were collected retro-
spectively, possibly leading to a recall bias. To minimize
this drawback, the questionnaires were sent to the
patients separately. Nonetheless, data on HRQoL retro-
spectively collected from implant users were shown to be
comparable to the prospective scores collected from
patients on a CI waiting list.15 In addition, the extent of
recall bias in these patients may be minimal, given that
the patients are not cured of their deafness and re-expe-
rience their impairment each time they remove their
speech processor.
CONCLUSION
The present study provides evidence that CI consti-
tutes a very successful procedure of auditory
rehabilitation even for postlingually deafened patients
aged
70 years. Elderly patients benefited from a simi-
lar improvement in hearing and speech understanding
compared with younger patients; also, the benefit of CI
further ranged over social and psychological areas and is
reflected by a significant improvement of HRQoL. In the
case of higher initial severity level, the patients aged

70 years were able to show clear reductions of the tin-
nitus annoyance and perceived stress after CI as well.
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