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S. Boucher, G. Duval, C. Annweiler


CHU Anger, Centre Hospitalier Universitaire d’Angers, Angers, France

Corresponding Author: Sophie Boucher, CHU Angers, Centre Hospitalier Universitaire d’Angers, Angers; Mitolab unit, Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d’Angers, Angers, France sophie.boucher@chu-angers.fr

J Frailty Aging 2021;in press
Published online May 4, 2021, http://dx.doi.org/10.14283/jfa.2021.19


Dear Editor,

«Healthy aging», defined by the World Health Organization (WHO) as « the process of developing and maintaining the functional ability that enables well-being » (1), needs the involvement of various physicians. The WHO-ICOPE (Integrated Care for Older People) approach was developed to early identify, diagnose and treat older adults’ frailties defined as impairments of at least one of the six intrinsic capacities (i.e., hearing, vision, mood, cognition, mobility and nutrition), which could precipitate functional loss and alter the quality of life (2). Among these intrinsic abilities, hearing is the sense of communication and socialization, and may influence the quality and accuracy of the medical examination and interview. Hearing impairment usually develop insidiously and is unrecognized or insufficiently self-reported by older patients. However, by 2050, the number of people with hearing loss will increase to over 900 million worldwide, mainly due to aging population.
During lifespan, hearing is exposed to a variety of aggressions, including occupational and recreational noise, solvents, ototoxic drugs, not to mention the deleterious effects of the metabolic syndrome, leading to age-related hearing loss known as presbycusis. Presbycusis starts with difficulty following conversations in noisy environments that can now be unmasked by speech in noise recognition tests. Hearing impairment then forces people to mobilize working memory in a listening-related effort (corresponding to the mental effort needed to understand the partially percept auditory message), which leads to mental fatigue and increases cognitive load. Over time, people gradually reduce social interactions, with subsequent risks of depression and cognitive decline.
Considering that hearing impairment occurring in midlife is the main modifiable risk factor for dementia (3), and given the frequency of this intrinsic frailty and the adverse impact on quality of life and autonomy, its early detection is essential. WHO-ICOPE recommends using the whisper test (Figure 1). To confirm the possible deficiency detected with this test, suffering inter examiner variation, clinicians may further complete the screening addressing the ability to understand speech in noise at the lowest possible signal-to-noise ratio (4) using the 2-minutes digits-in-noise test, available on smartphones or tablets (hearWHO) in different languages. This test detects presbycusis at its very first stage within a strong correlation (R = 0.80, p < 0.001) between the speech reception threshold and the audiometric pure tone average (from 0,5kHz to 4kHz). Its main limitation is the need for a very calm environment. An alternative for clinical evaluation is the widely used Hearing Handicap Inventory for the Elderly Screening (HHIE-S) questionnaire. This 10-questions assessment is sensitive (73.2%) and very specific (73.8%) for detecting mild-to-severe hearing loss if the score is ≥6 (5).
To confirm the diagnosis, specify the etiology and propose compensating device, clinicians can then refer the patient to an ENT (ears, nose and throat) physician, who will quantify the degree of hearing impairment, eliminate any ear pathology and look for any vestibular dysfunction promoting falls. After an audiometric test determining the auditory pure tone threshold at each frequency from 0,125 to 8kHz, in bone and air conduction (with vibrator or headphones respectively), and also the speech reception threshold in silence and noise, the specialist will determine the pure tone average to classify the severity of hearing impairment and recommend the use (or not) of hearing aid(s), possibly with speech therapy. In severe-to-profound deafness without satisfactory benefit from hearing aids, the ENT physician may propose cochlear implantation (after a multidisciplinary assessment) allowing the implanted cochlear electrodes to directly stimulate the auditory nerve fibers.
The last key role is those of caregivers, essential to support the patient in accepting and getting used to their hearing aids as early as possible during the hearing impairment. Indeed, auditory rehabilitation promotes brain plasticity, which is easier to mobilize in the event of a short period of hearing deprivation. Further, hearing aids improve quality of life and preserve cognitive functions (3) as do cochlear implants. 80% of older people with severe hearing loss and mild cognitive impairment (MCI) improved their cognition one year after cochlear implantation and only 6% developed dementia at 7 years, while this proportion is usually rather 50% in the MCI population at 5 years. Technological advances and rehabilitation improvements strengthened these results. By implementing progressive hearing correction, the hearing care professionals help with the acceptance of hearing aids. The speech therapists offer auditory perceptual rehabilitation, auditory memory and lip reading trainings, which promote progressive habituation and brain plasticity improving speech understanding skills and communication appeal.
In conclusion, identifying and treating hearing decline in older adults within the WHO-ICOPE approach requires strong inter-professional collaboration between family physicians, geriatricians, ENT specialists, hearing professionals and speech therapists, without forgetting the active participation of the elderly themselves and the support of their relatives. These efforts will allow acting on this intrinsic auditory frailty in older adults and maintaining function late in life.

Figure 1. The process of hearing function screening (in orange and green) to hearing impairment confirmation (in blue) and rehabilitation accuracy control


Conflicts of Interest: None declared by the authors.




1. World Health Organization World report on ageing and health. 2015. Available from: https://apps.who.int/iris/handle/10665/186463 [accessed 2021 Feb 26]
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3. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet Lond Engl. 2020 Aug 8;396(10248):413–46.
4. World Health Organization. WHO launches the hearWHO app for mobile devices to help detect hearing loss. Available from: https://www.who.int/deafness/news/hearWHOApp-news/en/ [accessed 2021 Feb 26].
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