Articles

Association between hearing aid use and mortality in adults

with hearing loss in the USA: a mortality follow-up study of
a cross-sectional cohort
Janet S Choi, Meredith E Adams, Eileen M Crimmins, Frank R Lin, Jennifer A Ailshire

Summary
Background Hearing loss has been identified as an independent risk factor for negative health outcomes and mortality. Lancet Healthy Longev 2024;
However, whether rehabilitation with hearing aid use is associated with lower mortality is currently unknown. This 5: e66–75

study aimed to examine the associations of hearing loss, hearing aid use, and mortality in the USA. See Comment page e10
Caruso Department of
Methods In this cross-sectional, follow-up study, we assessed 9885 adults (age 20 years and older) who participated in Otolaryngology-Head & Neck
Surgery (J S Choi MD), Davis
the National Health and Nutrition Examination Survey between 1999 and 2012 and completed audiometry and hearing
School of Gerontology
aid use questionnaires (1863 adults with hearing loss). Main measures included hearing loss (speech-frequency pure- (E M Crimmins PhD,
tone average) and hearing aid use (never users, non-regular users, and regular users). Mortality status of the cohort was J A Ailshire PhD), University of
linked to the National Death Index up to Dec 31, 2019. Cox proportional regression models were used to examine the Southern California,
Los Angeles, CA, USA;
association between hearing loss, hearing aid use, and mortality while adjusting for demographics and medical history.
Department of
Otolaryngology-Head & Neck
Findings The cohort consisted of 9885 participants, of which 5037 (51·0%) were female and 4848 (49·0%) were male Surgery, University of
with a mean age of 48·6 years (SD 18·1) at baseline. The weighted prevalence of audiometry-measured hearing loss Minnesota, Minneapolis, MN,
USA (M E Adams MD);
was 14·7% (95% CI 13·3–16·3%) and the all-cause mortality rate was 13·2% (12·1–14·4) at a median 10·4 years of Department of
follow-up (range 0·1–20·8). The rate of regular hearing aid use among adults with hearing loss was 12·7% Otolaryngology-Head & Neck
(95% CI 10·6–15·1). Hearing loss was an independent risk factor associated with higher mortality (adjusted hazard Surgery, Johns Hopkins
ratio [HR] 1·40 [95% CI 1·21–1·62]). Among individuals with hearing loss, the adjusted mortality risk was lower University School of Medicine,
Baltimore, MD, USA
among regular hearing aid users in comparison with never users (adjusted HR 0·76 [0·60–0·95]) accounting for (F R Lin MD)
demographics, hearing levels, and medical history. There was no difference in adjusted mortality between non-regular
Correspondence to:
hearing aid users and never users (adjusted HR 0·93 [0·70–1·24]). Dr Janet S Choi, Caruso
Department of Otolaryngology-
Interpretation Regular hearing aid use was associated with lower risks of mortality than in never users in US adults Head & Neck Surgery, University
of Southern California,
with hearing loss when accounting for age, hearing loss, and other potential confounders. Future research is needed Los Angeles, CA 90033, USA
to investigate the potential protective role of hearing aid use against mortality for adults with hearing loss. janet.choi@med.usc.edu

Funding None

Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND
4.0 license.

Introduction Hearing aids are a first-line intervention for most

Hearing loss is highly prevalent, affecting an estimated
1·6 billion people globally, and its prevalence is projected
to increase to 2·5 billion by 2050.1 The burden of hearing
loss is substantial as it impedes interpersonal
communication in both social settings and the workplace.
Previous studies have identified hearing loss as a major
risk factor for adverse health outcomes including reduced
quality of life, depression, dementia, and mortality.2–6
Previous systematic reviews and meta-analyses
demonstrated that hearing loss is significantly associated
with excess all-cause mortality even after adjusting for
demographics and comorbidities, and there is a dose–
response relationship in which the risks in mortality
doubled per 30 dB increase in hearing loss.4,5 However,
whether treatment of hearing loss with hearing aid use is
associated with lower risks of mortality is currently
unknown.
individuals with hearing loss and their use has been
shown to improve perceived disability from hearing loss
and quality of life.6 A few previous epidemiological
studies have included hearing aid use as a covariate in
exploring the association between hearing loss and
mortality.7–11 Among these, two studies have reported
secondary results with regard to hearing aid use while
accounting for audiometry-measured hearing loss:7,8
one study, based on US community-dwelling adults aged
70 years and older, reported no significant association
between hearing aid use and mortality,8 while another
study, based on Icelandic adults aged 67 years and older,
reported an association between hearing aid use and
lower risks of mortality within a subgroup of a cohort
with hearing and visual impairments.7 These studies
reported effect measures of hearing aid use as secondary
outcomes within the models designed for the primary

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 Articles
Research in context
Evidence before this study
We searched PubMed from database inception to June 1, 2023,
for articles on the association between hearing aid use and
mortality using the search terms (“hearing aid”) AND
(“mortality” OR “death”) AND (“adults” OR “aged”) AND
(“cohort studies” OR “longitudinal studies” OR “prospective
studies”) with no date or language restrictions. The search
retrieved 54 results and we also reviewed the cited references of
retrieved publications. An additional search was done in
PubMed on June 1, 2023, to identify articles on the association
between hearing loss and mortality using the search terms
(“hearing loss” OR “hearing impairment”) AND (“mortality” OR
“death”) AND (“adults” OR “aged”) AND (“cohort studies” OR
“longitudinal studies” OR “prospective studies”) which retrieved
508 results. Previous work including two systematic reviews and
one meta-analysis showed significant association between
hearing loss and mortality and its dose–response relationship.
However, much of the previous work investigated the
association between hearing loss and mortality without
adjusting for hearing aid use. Among five studies that have
included hearing aid use as a covariate, two studies have
reported secondary effect measures of hearing aid use while
accounting for audiometry-measured hearing loss. Of these
two, one study based on older adults in Iceland (aged 67 years
and older, 934 hearing aid users) demonstrated a significantly
lower risk of mortality among hearing aid users than in non-
users in a subgroup of older adults with impairments in both
hearing and vision. Another study based on US community-
dwelling older adults (aged 70 years and older, 250 hearing aid
users) demonstrated no significant association between hearing
aid use and mortality. Only one study has primarily investigated
the association between hearing aid use and long-term health
outcomes including mortality. This study, which was based on a
purpose of examining the association between hearing
loss and mortality, limiting the interpretation of the
effect measures. Furthermore, these studies included
older adults only with shorter follow-up durations,
providing limited understanding on the long-term role
of hearing aid use. One previous epidemiological study
primarily investigated the association between hearing
aid use and adverse health outcomes including
mortality.12 That study, which included a small sample of
hearing aid users (n=69), found no significant
association between hearing aid use and mortality.
This study aims to examine the associations between
hearing loss, hearing aid use, and mortality, accounting
for demographics and medical history using a nationally
representative sample of US adults.
Methods
Study design and participants
Our cross-sectional study is based on a cohort of adults
who participated in the National Health and Nutrition
e67
population-based study including US community-dwelling
adults and a small number of hearing aid users (aged 48 years
and older, 69 hearing aid users), found no association between
hearing aid use and mortality. In our literature review, no
previous studies have examined the association between
hearing aid use and mortality using a nationally representative
sample of US adults.
Added value of this study
This study included a national sample of US adults who
participated in the cross-sectional study of the National Health
and Nutritional Examination Survey between 1999 and 2012.
In multivariable models that accounted for potential
confounders, we found that adjusted all-cause mortality risk
was lower among regular hearing aid users than among those
who never used hearing aids. To our knowledge, this study
represents the most comprehensive analysis to date regarding
the association between hearing aid use and mortality. Our
study findings provide a long-term assessment of the
association between hearing aid use and mortality, based on
robust data that can be generalisable to the US population.
Implications of all the available evidence
The current study shows the potential protective role of
hearing aid use against mortality for adults with hearing loss.
Baseline differences exist between hearing aid users and never
users, in addition to unmeasured mediators that might have
contributed to the observed mortality differences. Taken
together, existing evidence supports larger-scale longitudinal
studies and randomised controlled trials that incorporate
comprehensive hearing and hearing aid use data to elucidate
the effect of hearing health on healthy longevity. Clinicians
should continue to promote regular hearing aid use among
adults with hearing loss when indicated.
Examination Survey (NHANES) between 1999 and 2012,
with follow-up data on mortality available up to and
throughout 2019.
NHANES is a collection of ongoing studies collected by
the US Centers for Disease Control and Prevention
designed to assess the nutritional and health status of
the non-institutionalised, non-military population in
the USA. Each cross-sectional study cycle in NHANES
uses a stratified, multistage probability sampling design
with selective oversampling of individuals with a low
income and those of racial minority backgrounds.
Sampling weights allow for analyses to account for the
complex survey design, yielding results that are
generalisable to the US population.13 Hearing aid use was
assessed once at the time of NHANES participation and
categorised into regular and non-regular use based on the
reported usage frequency. Regular hearing aid use was
defined as a primary exposure to investigate the role of
consistent hearing aid usage on mortality, excluding those
who tried hearing aids but did not use them regularly.
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Our analytic cohort comprised participants aged
20 years or older in the NHANES in 1999–2012 and who
had complete data on audiometry-measured hearing,
hearing aid use, mortality, and included covariates.
NHANES 2007–08 was excluded as audiometry data was
collected among adolescents only. The contribution from
each NHANES cycle is summarised in the appendix (p 1).
We have conducted a review of our manuscript
according to the STROBE checklist, ensuring compliance
with its requirements for reporting our observational
study. The study underwent review by the University of
Southern California Institutional Review Board and was
approved as being exempt from review (UP-20–01447).
This study is based on data from a de-identified publicly
available database.
Procedures
Audiometry was performed by trained examiners based
on the established NHANES protocols.13 Briefly, an
examiner determined the air conduction hearing
threshold for each ear without a hearing aid in a sound-
isolated room of the mobile examination centre. Testing
was conducted using the automated testing mode of the
audiometer Interacoustics Model AD226 (Assens,
Denmark). Audiometric equipment and sound booths (of
the same brands and models) were used during the study
period. Daily equipment calibration and monitoring of
ambient noise levels using a sound level meter were
performed as part of the quality assurance protocols.
Speech-frequency pure-tone average was calculated for
each ear based on thresholds at 0·5 kHz, 1 kHz, 2 kHz,
and 4 kHz. Audiometry-measured hearing loss was
defined as speech-frequency pure-tone average at
25 dB HL (hearing level) or greater in the better hearing
ear, as defined by WHO.14 Hearing loss was further
categorised into mild, moderate, and severe to profound
hearing loss based on the WHO grading (mild,
25 to <40 dB HL; moderate, 40 to <60 dB HL; severe to
profound, ≥60 dB HL).14
Hearing aid use was categorised into three groups
(never, regular, and non-regular hearing aid users) based
on interview data. Participants who answered “no” to
a question “Have you ever worn a hearing aid?” were
categorised as never hearing aid users. Regular hearing
aid use was defined on the basis of questions on frequency
of hearing aid use in the past 12 months, which varied by
cycle. Participants were considered regular hearing aid
users when reporting: (1) at least once a week, once a day,
or almost always (vs at least once a month or less frequently
than once a month; NHANES 1999–2004); (2) wearing
a hearing aid for at least 5 h per week (NHANES
2005–06, 2009–10); or (3) at least half the time, usually, or
always (vs seldom or never; NHANES 2011–12).
Participants who reported ever hearing aid use but not
meeting criteria for regular hearing aid users were
considered as non-regular hearing aid users. Questions
on cochlear implant use were asked only in
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Articles
NHANES 2011–12. Two participants who reported
cochlear implant use were excluded from the study cohort.
Mortality status was determined by probabilistic
matching between NHANES data and death certificates
up to Dec 31, 2019.15 The National Center for Health
Statistics has linked data collected from the NHANES
surveys with death certificate records from the National See Online for appendix
Death Index.15 Follow-up time was assigned using
person-months from the date of interview to the date of
death or censoring on Dec 31, 2019.
Information on demographics and medical history
were obtained from interview data. Sex was categorised
into male or female and marital status was categorised
into married or living with partner, or widowed, divorced,
separated, or never married. Self-reported race and For NHANES data see https://
ethnicity were grouped as White, Black, Hispanic, or www.cdc.gov/nchs/nhanes/
index.htm
other participants. The poverty-to-income ratio was
divided into four categories and level of education was
divided into three categories. Insurance was categorised
into no insurance, private insurance, or Medicare or
Medicaid. Medical history variables included diabetes,
hypertension, stroke, cardiovascular disease, smoking
status (never, former, or current), and BMI (normal,
18·5–24·9 kg/m²; underweight, <18·5 kg/m²; overweight,
25–29·9 kg/m²; and obese, ≥30 kg/m²). Covariates were
determined based on previous literature.8,16–19 They were
tested for collinearity using variance inflation factor and
we did not find any evidence of collinearity.
Statistical analysis
Study data were analysed in August, 2023. We summarised
categorical data using counts and percentages, and
continuous data using mean and SD as appropriate.
Baseline characteristics of the study participants were
compared using the two-tailed t test and Pearson χ² test.
Kaplan-Meier analysis was employed to estimate the
survival probabilities and generate survival curves for our
study cohort. Survival probabilities were estimated as a
function of time from when participants completed
audiometric assessment and questionnaires and survival
curves were generated by severity of hearing loss. The
association between hearing loss and all-cause mortality
was examined using Cox proportional hazards regression
models considering hearing loss as a binary and
categorical variable. Results were presented as hazard
ratios (HRs) and their corresponding 95% CIs. Sample
weights were used in all Cox proportional hazard
regression models to account for the complex sampling
design based on the NHANES analytic guidelines.20 The
association between hearing aid use and all-cause
mortality was examined using Cox proportional hazards
regression models in a subgroup of the cohort with
audiometry-measured hearing loss. Multivariable models
were sequentially adjusted for age, hearing loss,
demographics, and medical history. In models examining
the association between hearing aid use and mortality,
hearing loss was considered a continuous variable along
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Overall Participants Hearing aid use†

(n=9885) with hearing
loss* (n=1863)
Never users Non-regular Regular users p value
(n=1483) users (n=143) (n=237)
Age, years 48·6 (18·1) 69·4 (12·0) 68·4 (12·1) 72·0 (11·2) 74·4 (9·7) <0·0001
Sex
Male 4848 (49·0%) 1118 (60·0%) 864 (58·3%) 98 (68·5%) 156 (65·8%) 0·0080
Female 5037 (51·0%) 745 (40·0%) 619 (41·7%) 45 (31·5%) 81 (34·2%) ··
Race or ethnicity
White 4670 (47·2%) 1212 (65·1%) 914 (61·6%) 96 (67·1%) 202 (85·2%) <0·0001
Black 2161 (21·9%) 236 (12·7%) 204 (13·8%) 15 (10·5%) 17 (7·2%) ··
Hispanic 2224 (22·5%) 332 (17·8%) 290 (19·6%) 26 (18·2%) 16 (6·8%) ··
Other 830 (8·4%) 83 (4·5%) 75 (5·0%) 6 (4·2%) 2 (0·8%) ··
Education
Less than high school 2594 (26·2%) 725 (38·9%) 598 (40·3%) 58 (40·6%) 69 (29·1%) 0·0010
High school graduate 2231 (22·6%) 469 (25·2%) 383 (25·8%) 26 (18·2%) 60 (25·3%) ··
Some college or more 5060 (51·2%) 669 (35·9%) 502 (33·9%) 59 (43·3%) 108 (45·6%) ··
Poverty-to-income ratio
<1 1783 (18·0%) 279 (15·0%) 242 (16·3%) 18 (12·6%) 19 (8·0%) 0·010
1 to <2 2356 (23·8%) 572 (30·7%) 458 (30·9%) 49 (34·3%) 65 (27·4%) ··
2 to <3 1407 (14·2%) 312 (16·7%) 247 (16·7%) 24 (16·8%) 41 (17·3%) ··
≥3 3625 (36·7%) 539 (28·9%) 410 (27·6%) 38 (26·6%) 91 (38·4%) ··
Refused or unsure 714 (7·2%) 161 (8·6%) 126 (8·5%) 14 (9·8%) 21 (8·9%) ··
Marital status
Married or living with partner 6006 (60·8%) 1123 (60·3%) 897 (60·5%) 85 (59·4%) 141 (59·5%) 0·94
Divorced, widowed, separated, or never married 3879 (39·2%) 740 (39·7%) 586 (39·5%) 58 (40·6%) 96 (40·5%) ··
Health insurance
No 2205 (22·3%) 194 (10·4%) 183 (12·3%) 8 (5·6%) 3 (1·3%) <0·0001
Private 4796 (48·5%) 370 (19·9%) 311 (21·0%) 21 (14·7%) 38 (16·0%) ··
Medicare or Medicaid 2884 (29·2%) 1299 (69·7%) 989 (66·7%) 114 (79·7%) 196 (82·7%) ··
Smoking
Never 5250 (53·1%) 787 (42·2%) 637 (43·0%) 55 (38·5%) 95 (40·1%) <0·0001
Former 2543 (25·7%) 780 (41·9%) 586 (39·5%) 68 (47·6%) 126 (53·2%) ··
Current 2092 (21·2%) 296 (15·9%) 260 (17·5%) 20 (14·0%) 16 (6·8%) ··
BMI
Normal 2968 (30·0%) 515 (27·6%) 414 (27·9%) 34 (23·8%) 67 (28·3%) 0·71
Underweight 166 (1·7%) 20 (1·1%) 16 (1·1%) 1 (0·7%) 3 (1·3%) ··
Overweight 3343 (33·8%) 701 (37·6%) 546 (36·8%) 58 (40·6%) 97 (40·9%) ··
Obese 3408 (34·5%) 627 (33·7%) 507 (34·2%) 50 (35·0%) 70 (29·5%) ··
Diabetes 1074 (10·9%) 385 (20·7%) 317 (21·4%) 26 (18·2%) 42 (17·7%) 0·33
Hypertension 3034 (30·7%) 992 (53·3%) 780 (52·6%) 81 (56·6%) 131 (55·3%) 0·52
Cardiovascular disease 822 (8·3%) 399 (21·4%) 302 (20·4%) 39 (27·3%) 58 (24·5%) 0·074
Stroke 322 (3·3%) 160 (8·6%) 122 (8·2%) 14 (9·8%) 24 (10·1%) 0·54
Data are n (%) or mean (SD), unless otherwise specified. *Hearing loss defined on the basis of audiometry-measured speech-frequency pure-tone average at 0·5 kHz, 1 kHz,
2 kHz, and 4 kHz (≥25 dB HL). †Hearing aid use among individuals who have audiometry-measured hearing loss (n=1863). p values represent differences in demographics or
medical comorbidities by hearing aid use category among participants with hearing loss (never vs non-regular vs regular hearing aid users). They were calculated for each
characteristic based on χ² tests. One p value is available for each characteristic (ie, one for sex, one for race, one for education, etc).

Table 1: Baseline characteristics

with age. Sex, race, education, poverty-to-income ratio,
marital status, insurance, smoking, BMI, diabetes,
hypertension, cardiovascular disease, and stroke were
considered categorical variables. Schoenfeld’s residuals
were used to verify the proportional hazard assumptions
for all independent variables. A sensitivity analysis was
performed by combining non-regular and regular hearing
aid users into a single group termed ever hearing aid
users, and their mortality risks were compared with those
who reported never use. An additional sensitivity analysis

e69 www.thelancet.com/healthy-longevity Vol 5 January 2024


was done by restricting the study cohort to
NHANES 2005–12, as this period had relatively consistent
terminology for defining regular hearing aid use and was
considered more recent, with a lower likelihood of
changes in hearing aid use status after NHANES study
participation. All analyses were done with
STATA (version 16.1).
Role of the funding source
There was no funding source for this study.
Results
The study cohort consisted of 9885 adults who
participated in the 1999–2012 NHANES survey (mean
age 48·6 years [SD 18·1]). Of the 9885 participants,
5037 (51·0%) were female and 4848 (49·0%) were male,
and 1863 participants were found to have audiometry-
measured hearing loss at the time of NHANES
participation (table 1). There was a 14·8% loss of data
from the original cohort due to missing information on
covariates (n=1723). Among the 1863 participants who
had audiometry-measured hearing loss, 8·0% of data
were missing (n=163). There were no differences in
missingness by hearing aid use. Incorporating the
sampling weights, the estimated prevalence of
audiometry-measured hearing loss in US adults aged
20 years and older was 14·7% (95% CI 13·3–16·3).
Among adults with hearing loss, the rate of regular
hearing aid use was 12·7% (95% CI 10·6–15·1) and the
rate of non-regular hearing aid use was 6·6% (5·4–8·0).
The all-cause mortality rate at a median of 10·4 years of
follow-up (range 0·1–20·8; mean 12·2 years [SD 5·3])
was 13·2% (95% CI 12·1–14·4).
Kaplan-Meier survival estimates by severity of hearing
loss are presented in the figure. Overall, poorer hearing
was associated with higher risks of mortality (figure).
The age-adjusted risk of mortality was significantly
higher among adults with any hearing loss (HR 1·68
[95% CI 1·47–1·92]; table 2). The adjusted risks of
mortality continued to be significantly higher among
adults with hearing loss in multivariable Cox
proportional hazard regression models accounting for
demographics (HR 1·40 [1·22–1·61]) and for
demographics and medical history (HR 1·40 [1·21–1·62];
table 2). There was a dose–response relationship, with
moderate or worse hearing loss generally being
associated with higher risks of mortality than mild
hearing loss.
The association between hearing aid use and risk of
mortality was examined among adults with audiometry-
measured hearing loss (table 3). The risk of mortality
was lower among adults who reported regular hearing
aid use than never hearing aid users when adjusting for
age and severity of hearing loss (HR 0·66 [95% CI
0·52–0·84]; table 3). In a multivariable model adjusting
for age, levels of hearing loss, and demographics, the
risk of mortality remained significantly lower among
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Articles
adults who reported regular hearing aid use than never
hearing aid users (HR 0·70 [0·55–0·89; table 3). In an
additional multivariable model adjusting for age, levels
of hearing loss, demographics, and medical history, the
risk of mortality was lower for regular hearing aid users
than never users (HR 0·76 [0·60–0·95]; table 3). When
comparing non-regular hearing aid users to never users,
there were no significant differences in mortality risks
between the non-regular hearing aid users and never
users across all multivariable models (table 3).
Sensitivity analyses were done considering hearing aid
use in two alternative ways. The first sensitivity analysis
compared ever hearing aid users (including both regular
and non-regular users) to never users. In this analysis,
ever hearing aid users were shown to have lower risk of
mortality than never users when accounting for age,
hearing loss, and demographics (HR 0·77 [95% CI
0·62–0·97]; appendix p 2). However, there was no
significant association between hearing aid use and
mortality when additionally accounting for medical
history (HR 0·83 [0·67–1·03]; appendix p 2). The second
sensitivity analysis restricted the cohort to participants
from NHANES 2005–12. In this analysis, regular hearing
aid use was associated with lower risks of mortality in all
three models (HR 0·59 [0·46–0·76]; HR 0·61
[0·47–0·78]; HR 0·64 [0·51–0·81]; appendix p 3).
Discussion
In this study based on a nationally representative sample
of US adults, audiometry-measured hearing loss was
associated with an increased risk of all-cause mortality.
A dose–response relationship was observed, with more
severe levels of hearing loss being associated with higher
risks of mortality. Among individuals with hearing loss,
the risk of mortality was lower among regular hearing
aid users than never users in multivariable models
accounting for levels of hearing loss, demographics, and
medical history.
1·00
0·75
Survival estimates (%)
0·50
Normal hearing
0·25 Mild hearing loss
Moderate hearing loss
Severe to profound hearing loss
0
0 5 10 15 20
Follow-up (years)
Number at risk
Normal hearing 8022 7806 4302 3888 520
Mild hearing loss 1187 1036 566 277 42
Moderate hearing loss 553 413 210 56 9
Severe to profound hearing loss 123 92 42 9 1
Figure: Kaplan-Meier survival estimates by severity of hearing loss
Estimates categorised according to speech-frequency pure-tone average in better hearing ear (normal: <25 dB HL;
mild: 25 to <40 dB HL; moderate: 40 to <60 dB HL; and severe to profound: ≥60 dB HL).
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Unadjusted Multivariable models

HR (95% CI) p value Model 1* HR p value Model 2† HR p value Model 3‡ HR p value
(95% CI) (95% CI) (95% CI)
Hearing loss
Normal hearing 1 (ref) ·· 1 (ref) ·· 1 (ref) ·· 1 (ref) ··
Any hearing loss 6·80 (6·09–7·63) <0·0001 1·68 (1·47–1·92) <0·0001 1·40 (1·22–1·61) <0·0001 1·40 (1·21–1·62) <0·0001
Mild hearing loss 5·30 (4·60–6·10) <0·0001 1·55 (1·35–1·79) <0·0001 1·34 (1·15–1·56) <0·0001 1·31 (1·12–1·52) 0·0010
Moderate hearing loss 11·50 (10·00–13·10) <0·0001 1·97 (1·67–2·33) <0·0001 1·58 (1·32–1·88) <0·0001 1·66 (1·39–2·00) <0·0001
Severe to profound 12·20 (9·00–16·40) <0·0001 2·17 (1·60–2·93) <0·0001 1·51 (1·11–2·04) 0·0090 1·61 (1·20–2·16) 0·0020
hearing loss
Age (per year) ·· ·· 1·08 (1·07–1·09) <0·001 1·08 (1·07–1·08) <0·0001 1·07 (1·06–1·08) <0·0001
Sex
Male ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Female ·· ·· ·· ·· 0·63 (0·55–0·71) <0·0001 0·67 (0·59–0·77) <0·0001
Race or ethnicity
White ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Black ·· ·· ·· ·· 1·11 (0·95–1·31) 0·19 1·01 (0·85–1·18) 0·94
Hispanic ·· ·· ·· ·· 0·60 (0·46–0·79) <0·0001 0·66 (0·52–0·85) 0·0010
Other ·· ·· ·· ·· 0·83 (0·62–1·10) 0·19 0·74 (0·54–0·99) 0·048
Education
Less than high school ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
High school graduate ·· ·· ·· ·· 0·85 (0·73–0·99) 0·048 0·88 (0·75–1·03) 0·11
Some college or more ·· ·· ·· ·· 0·75 (0·63–0·90) 0·0020 0·83 (0·71–0·97) 0·020
Poverty-to-income ratio
<1 ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
1 to <2 ·· ·· ·· ·· 0·77 (0·64–0·91) 0·030 0·84 (0·71–0·99) 0·041
2 to <3 ·· ·· ·· ·· 0·80 (0·66–0·96) 0·015 0·87 (0·73–1·04) 0·13
≥3 ·· ·· ·· ·· 0·63 (0·53–0·74) <0·0001 0·71 (0·60–0·85) <0·0001
Refused or unsure ·· ·· ·· ·· 0·81 (0·61–1·08) 0·16 0·93 (0·70–1·23) 0·59
Marital status
Married or living with ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
partner
Divorced, widowed, ·· ·· ·· ·· 1·51 (1·32–1·72) <0·0001 1·49 (1·30–1·71) <0·0001
separated, or never married
Health insurance
No ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Private ·· ·· ·· ·· 0·69 (0·54–0·88) 0·0030 0·75 (0·58–0·96) 0·023
Medicare or Medicaid ·· ·· ·· ·· 1·20 (0·92–1·55) 0·17 1·14 (0·87–1·50) 0·32
Smoking
Never ·· ·· ·· ·· ·· ·· 1 (ref) ··
Former ·· ·· ·· ·· ·· ·· 1·21 (1·04–1·40) 0·015
Current ·· ·· ·· ·· ·· ·· 2·06 (1·79–2·37) <0·0001
BMI
Normal ·· ·· ·· ·· ·· ·· 1 (ref) ··
Underweight ·· ·· ·· ·· ·· ·· 1·86 (1·14–3·05) 0·014
Overweight ·· ·· ·· ·· ·· ·· 0·83 (0·72–0·95) 0·0070
Obese ·· ·· ·· ·· ·· ·· 0·95 (0·83–1·09) 0·45
Diabetes ·· ·· ·· ·· ·· ·· 1·59 (1·38–1·84) <0·0001
Hypertension ·· ·· ·· ·· ·· ·· 1·25 (1·11–1·40) <0·0001
Cardiovascular disease ·· ·· ·· ·· ·· ·· 1·47 (1·31–1·66) <0·0001
Stroke ·· ·· ·· ·· ·· ·· 1·60 (1·30–1·97) <0·0001
HR=hazard ratio. *Model 1 adjusted for age. †Model 2 adjusted for age, sex, race or ethnicity, education, poverty-to-income ratio, marital status, and health insurance.
‡Model 3 adjusted for age, sex, race or ethnicity, education, poverty-to-income ratio, marital status, health insurance, smoking, BMI, diabetes, hypertension, cardiovascular
disease, and stroke.

Table 2: Cox proportional hazard regression analysis examining the association between hearing loss and mortality

e71 www.thelancet.com/healthy-longevity Vol 5 January 2024

 Articles

Unadjusted Multivariable models

HR (95% CI) p value Model 1* HR p value Model 2† HR p value Model 3‡ HR p value
(95% CI) (95% CI) (95% CI)
Hearing aid use
Never users 1 (ref) ·· 1 (ref) ·· 1 (ref) ·· 1 (ref) ··
Non-regular users 1·41 (1·06–1·87) 0·018 0·88 (0·66–1·17) 0·39 0·89 (0·67–1·19) 0·44 0·93 (0·70–1·24) 0·66
Regular users 1·34 (1·06–1·69) 0·013 0·66 (0·52–0·84) 0·0010 0·70 (0·55–0·89) 0·0040 0·76 (0·60–0·95) 0·021
Age (per year) ·· ·· 1·08 (1·07–1·09) <0·0001 1·07 (1·06–1·08) <0·0001 1·08 (1·06–1·09) <0·0001
Hearing loss (per dB HL)§ ·· ·· 1·02 (1·01–1·03) <0·0001 1·01 (1·00–1·02) 0·0070 1·01 (1·00–1·02) 0·0090
Sex
Male ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Female ·· ·· ·· ·· 0·65 (0·53–0·79) <0·0001 0·69 (0·57–0·85) 0·0010
Race or ethnicity
White ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Black ·· ·· ·· ·· 0·90 (0·67–1·20) 0·45 0·75 (0·55–1·02) 0·068
Hispanic ·· ·· ·· ·· 0·70 (0·52–0·95) 0·022 0·71 (0·52–0·96) 0·033
Other ·· ·· ·· ·· 0·72 (0·52–1·00) 0·028 0·68 (0·49–0·93) 0·015
Education
Less than high school ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
High school graduate ·· ·· ·· ·· 0·95 (0·78–1·16) 0·63 0·95 (0·77–1·17) 0·64
Some college or more ·· ·· ·· ·· 0·87 (0·71–1·08) 0·20 0·90 (0·73–1·10) 0·33
Poverty-to-income ratio
<1 ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
1 to <2 ·· ·· ·· ·· 0·75 (0·68–1·05) 0·13 0·86 (0·69–1·08) 0·20
2 to <3 ·· ·· ·· ·· 0·91 (0·70–1·19) 0·51 0·94 (0·73–1·23) 0·66
≥3 ·· ·· ·· ·· 0·66 (0·51–0·85) 0·0020 0·69 (0·54–0·89) 0·0040
Refused or unsure ·· ·· ·· ·· 0·98 (0·67–1·42) 0·90 0·96 (0·65–1·41) 0·87
Marital status
Married or living with partner ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Divorced, widowed, separated, ·· ·· ·· ·· 1·58 (1·33–1·89) <0·0001 1·56 (1·30–1·87) <0·0001
never married
Health insurance
No ·· ·· ·· ·· 1 (ref) ·· 1 (ref) ··
Private ·· ·· ·· ·· 0·65 (0·43–0·98) 0·039 0·69 (0·46–1·04) 0·075
Medicare or Medicaid ·· ·· ·· ·· 0·98 (0·66–1·45) 0·91 0·91 (0·61–1·35) 0·64
Smoking
Never ·· ·· ·· ·· ·· ·· 1 (ref) ··
Former ·· ·· ·· ·· ·· ·· 1·15 (0·97–1·37) 0·10
Current ·· ·· ·· ·· ·· ·· 1·73 (1·31–2·28) <0·0001
BMI
Normal ·· ·· ·· ·· ·· ·· 1 (ref) ··
Underweight ·· ·· ·· ·· ·· ·· 4·01 (2·11–7·97) <0·0001
Overweight ·· ·· ·· ·· ·· ·· 0·79 (0·66–0·93) 0·0060
Obese ·· ·· ·· ·· ·· ·· 0·91 (0·76–1·08) 0·24
Diabetes ·· ·· ·· ·· ·· ·· 1·68 (1·38–2·04) <0·0001
Hypertension ·· ·· ·· ·· ·· ·· 1·13 (0·96–1·32) 0·13
Cardiovascular disease ·· ·· ·· ·· ·· ·· 1·43 (1·23–1·68) <0·0001
Stroke ·· ·· ·· ·· ·· ·· 1·37 (0·33–2·09) <0·0001
HR=hazard ratio. *Model 1 adjusted for age and hearing loss. †Model 2 adjusted for age, hearing loss, sex, race or ethnicity, education, poverty-to-income ratio, marital
status, and health insurance. ‡Model 3 adjusted for age, hearing loss, sex, race or ethnicity, education, poverty-to-income ratio, marital status, health insurance, smoking,
BMI, diabetes, hypertension, cardiovascular disease, and stroke. §Hearing loss was defined according to audiometry-measured speech-frequency pure-tone average in better
hearing ear (continuous variable, in dB HL).

Table 3: Cox proportional hazard regression analysis examining the association between hearing aid use and mortality among adults with audiometry-
measured hearing loss

www.thelancet.com/healthy-longevity Vol 5 January 2024 e72

 Articles
The results from the present study are consistent with
findings from previous epidemiological studies, which
have found significant associations between hearing loss
and mortality, as well as a dose–response relationship.4,5
By contrast, studies examining the association between
hearing aid use and mortality reported inconsistent
results probably related to heterogeneity in the duration
of follow-up, measures of hearing loss (self-
reported vs audiometry-based), and low numbers of
hearing aid users.7,8,11,12 Adjustment for audiometry-
measured hearing is imp­ ortant in this analysis as
individuals with worse levels of hearing (who are more
likely to be older, have medical comorbidities, and have
higher mortality risks)4,21 are more likely to adopt hearing
aids. One study based on a cohort of older adults in
Iceland adjusting for audiometry-measured hearing
reported a significant association between hearing aid
use and lower risks of all-cause mortality at 5 years of
follow-up, consistent with findings from this study.7 Our
study, which included longer follow-up results, provides
mortality data over an extended period and identifies
a potential long-term benefit of hearing aid use.
Notably, baseline differences were present between the
two groups, with regular hearing aid users generally
having a higher socioeconomic status and fewer medical
comorbidities, as shown in previous literature.22,23
Additionally, regular hearing aid use might be
an indicator that an individual is more health conscious
and more likely to follow up with medical appointments.
In our cohort, the results remained significant after
adjusting for relevant factors including demographics,
income, education, insurance, and other medical
comorbidities. Although we are unable to account for
residual confounding effects, these findings warrant
future research to explore the potential protective effect
of hearing aids against mortality when used regularly
among adults with hearing loss. In this study, insurance
status was included as a covariate representing one
aspect of access to health care. However, this study could
not account for other dimensions of access to health care
(eg, acceptability, availability, and accommodation)24 due
to unavailable data. Notably, regular hearing aid users
are more likely to have better access to health care across
all dimensions, which are positively correlated with
mortality status. Additionally, potential mediators such
as levels of loneliness, social interaction, and social
engagement were not available in these data. Previous
studies have shown associations between hearing loss
and loneliness, as well as between loneliness and
mortality.25,26 Hearing aid use has been found to have a
positive effect on reducing feelings of loneliness, social
isolation, and depression, which could have contributed
to the lowered mortality risk.27,28 An alternative
perspective could suggest loneliness and social
engagement as confounders, as individuals who decide
to use hearing aids might have lower levels of loneliness
and higher levels of social engagement at baseline,
e73
which could confound the results.29 Even in this case, we
expect the positive effects of hearing aid use on mental
health measures to persist in adults with higher baseline
levels of social interaction.
Multiple mechanisms have been proposed to explain
the association between hearing loss and mortality.5,19
The first possible mechanism involves common
pathology that affects both hearing and comorbidities
leading to death, such as cardiovascular disease, diabetes,
and dementia. If the association is fully attributed to this
mechanism, hearing aid use would not modify the risk of
mortality. The second possible mechanism operates via
the effect of hearing loss on frailty, an ageing-related
syndrome of physiological decline, characterised by
marked vulnerability to adverse health outcomes and
a strong independent predictor of mortality.30 Auditory
deprivation resulting from hearing loss, with diminished
input itself, might negatively affect brain structure.31
Furthermore, the association between hearing loss and
frailty is mediated by deterioration in mental, physical,
and cognitive functioning (eg, social isolation, anxiety,
depression, decreased physical activity, and cognitive
impairment).32 The effects of hearing loss on poor
patient–clinician communication have also been
suggested to be a contributing factor to increased risks of
hospital admission and health-care costs among older
adults with untreated hearing loss.33 For individuals with
hearing loss who would benefit from hearing aids, their
use in medical settings might enhance effective patient–
clinician communication and further contribute to
improved health outcomes.
Collectively, these results suggest the need to
investigate the effect of hearing aid use in downstream
health outcomes and mortality in longitudinal and
randomised controlled studies. Longitudinal studies
with an enhanced design incorporating comprehensive
information on hearing loss, hearing aid use and
potential confounders, and mediators are necessary.
Although conducting a randomised controlled trial of
hearing aid use on mortality is probably not feasible,
future trials that examine the effect of hearing aid use on
intermediate health outcomes across social, mental,
physical, and cognitive domains would enhance our
understanding of the relationship between hearing aid
use and mortality. For example, the ACHIEVE study,
a randomised controlled trial involving older adults with
untreated hearing loss, investigated the effects of
hearing aid use on changes in cognitive functioning.34
Recently published 3-year follow-up results have shown
a 48% reduction in cognitive decline associated with
hearing aid use in a subgroup of older adults at
an increased risk for cognitive decline.34
The prevalence of regular hearing aid use among
adults with hearing loss was low at 12·7% in our study,
consistent with findings from the previous literature
ranging from 7% to 37%.22,35 Many factors account for the
low rates of hearing aid use including cost, complexity of
www.thelancet.com/healthy-longevity Vol 5 January 2024

the hearing health-care system, lack of awareness of
treatment options and consequences of long-standing
hearing loss, and stigma associated with hearing loss
and hearing aid use.18 Previous studies have
demonstrated disparities in hearing aid use especially
among racial or ethnic minorities and individuals with
low socioeconomic status.17,36 There should be additional
efforts to improve accessibility and affordability of
hearing aids and to address disparities in hearing health
care as evidence of the potential protective role of
hearing aid use against adverse health outcomes
emerges.
We identified various limitations in this study. First,
despite adjusting for multiple major confounders,
residual confounding effects from other factors that
were not included in the study cannot be excluded. Our
results accounted for all available potential confounders
including demographics and medical comorbidities.
However, potential confounders and mediators that have
implications in understanding the mechanism behind
the associations between hearing loss or hearing aid use
and mortality, such as depression, social engagement,
and cognition were not available in this study. Second,
detailed information on hearing loss (eg, type, duration,
cause of hearing loss, and speech understanding) and
hearing aid use (eg, change in hearing aid use status,
duration of hearing aid use, hearing aid type, level of
amplification, objective data on hearing aid use such as
daily logs, and perceived benefits) was unavailable in
this study. Regular hearing aid use was defined on the
basis of three different questions on frequency of
hearing aid use which changed over the NHANES
cycles. The results might vary by different definitions
that have been adapted for regular hearing aid use. We
conducted sensitivity analyses using different definitions
of hearing aid use. Finally, this is a mortality follow-up
study based on cohorts from NHANES, which is a cross-
sectional study. As such, changes in measures including
hearing aid use status after NHANES participation were
not available. If a substantial number of participants
who reported never using hearing aids have since
adopted regular use after participating in the study, the
association between regular hearing aid use and
mortality in this study might have been underestimated.
Hearing loss has been identified as a potentially
modifiable risk factor for adverse health outcomes and
mortality. This study, based on a nationally representative
sample of US adults, demonstrated that regular hearing
aid use was significantly associated with a lower risk of
mortality. The replication of our study’s findings in
future research with more enhanced study designs is
imperative. This should encompass randomised
controlled trials investigating the effect of hearing aid
use on a spectrum of health outcomes linked to mortality,
alongside large-scale longitudinal studies that
incorporate comprehensive data on hearing aid use and
pertinent confounding and mediating variables.
www.thelancet.com/healthy-longevity Vol 5 January 2024
Articles
Contributors
JSC was involved in study conception, literature search, study design,
data collection, data analysis, data interpretation, manuscript writing, and
approval of the final manuscript. MEA was involved in study conception,
study design, data interpretation, manuscript revision, and approval of
the final manuscript. EMC was involved in study design, data
interpretation, manuscript revision, and approval of the final manuscript.
FRL was involved in data interpretation, manuscript revision, and
approval of the final manuscript. JAA was involved in study design, data
verification, data interpretation, manuscript revision, and approval of the
final manuscript. JSC and JAA accessed and verified the underlying data.
All authors confirm they have full access to all the data in the study and
accept responsibility for the decision to submit for publication.
Declaration of interests
JSC received a grant from the Lions Hearing Foundation. MEA reports
serving on a medical advisory council to Advanced Bionics. FRL reports
being a consultant to Frequency Therapeutics and Apple and the
Director of a public health research centre funded in part by a
philanthropic donation from Cochlear to the Johns Hopkins Bloomberg
School of Public Health.
Data sharing
The data and codebooks for the NHANES and the corresponding
mortality follow-up are publicly available on the study’s website.
NHANES data are available at the following link: https://wwwn.cdc.
gov/nchs/nhanes/. Mortality data are accessible through the following
link: https://www.cdc.gov/nchs/data-linkage/mortality-public.htm.
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