Practice recommendations
- Simply asking elderly patients whether they have trouble hearing is an effective start to screening for hearing loss (SOR: B).
- Refer elderly patients with suspected hearing impairment for audiologic diagnosis and nonmedical rehabilitation treatment, including hearing aids (SOR: B).
- To assess a patient’s risk of falling, review gait, balance disorders, weakness, environmental hazards, and medications (SOR: A).
Strength of recommendation (SOR)
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
“Do you have a hearing problem now? Have you fallen recently?” These 2 simple questions are the first step in assessing a patient’s hearing status and risk of falls—a screening opportunity too often overlooked. Although family physicians are well qualified to address hearing loss and the risk of falls, screening elderly patients for these problems often seems like a lower priority than evaluating for serious, or potentially life-threatening, conditions. In a recent national survey of primary care physicians, most said they had little time to screen for hearing loss or vestibular or balance disorders and did so only if patients broached the subject or showed clear evidence of risk.1
Screening for hearing impairment in patients 65 years of age and older, with referral to appropriate specialists, ranked 15th among services deemed effective by the US Preventive Services Task Force and the Advisory Committee on Immunization Practices2,3—outranking screening for osteoporosis, cholesterol, and diabetes.
There is no evidence favoring any particular screening procedure. As a result, physicians have considerable leeway in assessing elderly patients’ functional ability and safety, including the risk of falls that may be precipitated by an impaired vestibular system and balance disorders.4
Screening for these problems need not be onerous. It can be accomplished as part of your continuity of care with longstanding patients or during the preventive care examination that Medicare offers newly enrolled patients. This review, and the screening tools and strategies that accompany it, will help you get started.
Hearing loss screening: Make it easier to do
Bilateral hearing impairment affects 1 in 3 adults over 65 years of age5 and is the third most common chronic condition among the elderly,6 trailing only arthritis and hypertension. Documented problems associated with hearing loss include social isolation, depression and anxiety, loneliness, diminished self-efficacy, and stressful relationships with family, friends, and coworkers who may experience frustration, impatience, anger, pity, or guilt in trying to communicate with a person who has a hearing loss.7-9
The mental, emotional, and social consequences of untreated hearing loss negatively affect patients’ health-related quality of life (HRQoL).8,10-15 Hearing loss also compromises patients’ ability to interact with you and to understand—and follow—your recommendations.
Simplify screening. A recent study assessed 2 hearing screening methods used with older adults who also underwent audiologic evaluation as part of the biennial examination for the Framingham Heart Study.16 It found that simply asking, “Do you have a hearing problem now?” effectively identified potential deficits. If you use the American Academy of Family Physicians’ (AAFP) Medicare Initial Preventive Physical Examination Encounter Form,17 consider replacing its entry for hearing loss with this simple question (See “Medicare preventive exam: Where the AAFP encounter form falls short”).
We recommend that you pose the question to elderly patients or their family members during regular office visits. If the answer is Yes, immediately assess the patient’s ability to understand conversational speech. If necessary, use an inexpensive amplification device to make it easier for you and your patient to communicate. Referral to an audiologist for a comprehensive evaluation may be indicated, as well.
Medicare preventive exam: Where the AAFP encounter form falls short
The American Academy of Family Physicians’ (AAFP) Medicare Initial Preventive Physical Examination Encounter Form17 does not fully address hearing screening. Unlike the Depression Screen and Functional Ability/Safety Screen sections, which require Yes or No responses to questions, the section covering hearing merely presents the term “Hearing Evaluation,” followed by a space for recording information.
Although the form clearly states that a Yes response to any question about depression or function/safety should trigger further evaluation, there is no such recommendation for further evaluation of hearing. Thus, some practitioners short on time may overlook hearing screening entirely, and some elderly patients with sensorineural hearing loss may not receive appropriate education, counseling, or referral.
Furthermore, the second page of the AAFP form that is given to patients and makes recommendations for scheduled follow-up does not even mention hearing or the risk of falling. That’s why it’s important to remember to cover these areas with your elderly patients—and why you may want to ask the questions, “Do you have a hearing problem now?” and “Have you fallen recently?”