Age-Related Hearing Loss in Men

W. Steven Pray, PhD, DPh; Joshua J. PharmD, candidate


US Pharmacist. 2006;30(12):10-15. 

Pharmacists are occasionally consulted concerning hearing loss in male patients. Hearing loss can be caused by such patient self-care activities as attempting to clean the ears with cotton-tipped applicators—a common cause of hearing reduction, due to cerumen impaction. It may also be caused by ototoxic medications. However, some hearing loss occurs with aging. This column discusses presbycusis, an age-related hearing loss that is more common in males.

The prevalence of hearing loss is dependent on the instruments used to detect it and the instruments' sensitivity. However, perhaps 30% to 35% of persons ages 65 to 75 experience hearing loss.[1,2,3,4] The figure reaches 40% to 50% in those ages 75 and above.[2] Hearing loss is the third most common chronic health problem in older adults.[1] The gradual aging of the baby boomers will push this figure even higher. (The first wave of baby boomers is now approaching the sixth decade of life.)

Some authorities assert that presbycusis occurs with equal frequency in both genders.[5] However, the Merck Manual directly contradicts this observation, stating that presbycusis is more common in men and that men suffer more severely than women.[6] Age is a predictor for presbycusis. Most people experience a reduction in sensory cells that begins at age 18.3 Another factor common to many male patients with presbycusis is sustained exposure to loud noise. Thus, the pharmacist may discover that the male has a history indicating potential hearing compromise. Perhaps he was a member of the military (exposure to fire from heavy ordnance), engages in hobbies that produce or emit loud noise (e.g., hunting, target shooting), has a job that requires exposure to loud noise (e.g., use of power tools, working on various engines), or enjoys such recreational pursuits as shooting fireworks or cutting trees with chain saws.

The person bothered by presbycusis usually has a typical history of gradually accelerating hearing loss. During the early stages, the loss is imperceptible. However, as time passes, he may notice the following:[2,3,5]

  • Increasing difficulty in understanding words when the speaker is talking rapidly. He may ask people to speak more slowly in an attempt to understand the conversation. The patient may complain that others are intentionally mumbling or slurring their speech.

  • Inability to hear words correctly when they are unfamiliar or involve more complex ideas and thoughts.

  • Problems in hearing a specific speaker when the ambient environment is full of sounds and distractions.

  • Loss of the ability to hear high-pitched sounds and women's voices, while retaining the capacity to understand men's voices and to hear deep, rumbling sounds.

  • Loss of the ability to tolerate loud noises.

A prototypical situation is a full restaurant with people at adjoining tables engaging in noisy conversations, forcing the presbycusis sufferer to strain to hear the voice of a waitress as she recites the day's specials. Another troublesome situation could be a business meeting where several groups are holding side conversations, hampering the listener's ability to comprehend the points that the major speaker is making.

Relatives of the person affected with presbycusis may notice that he often cups a hand around his ear to increase the intensity of sound. He may voluntarily move a chair closer to the television or ask if he can sit toward the front of a movie theater or church. He may also move closer to the speaker when engaged in conversation. All of these are clues to age-related hearing loss.

To understand the genesis of presbycusis, it is helpful to first understand the mechanisms of hearing.[3] Sound waves pass into the outer ear, where they cause the tympanic membrane to vibrate. These vibrations are passed to the malleus, incus, and stapes of the middle ear, and ultimately to the inner ear (cochlea). The organ of Corti within the cochlea contains sensory hair cells with the capacity to move in response to the vibrations, converting them to electrical impulses for transmission to the brain. The brain assimilates this input, along with additional clues, to distinguish the meaning and interpretation to be assigned to the sound. Thus, a car horn is given a different urgency and immediacy than is a ringing cell phone or a smoke detector.

Presbycusis is multifactorial in etiology. The most common age-related type is caused by a gradual loss of the sensory hair cells, known as sensory presbycusis.[3,5,7] The hair cells do not have regenerative capability; thus, each hair cell lost represents a permanent, irreversible reduction in the capacity to hear sounds. Hair cells are lost through epithelial atrophy that is natural with advancing age but also in some health conditions and through the action of medications, such as aspirin and some antibiotics.[2,5] Patients may also experience neural presbycusis—a variety wherein cochlear nerve cells or central neural pathway nerve cells atrophy as the patient ages.[5,8]

The person affected with presbycusis does not have a visible infirmity, as do those with a broken limb. Therefore, those interacting with him may not take helpful measures (e.g., speaking more slowly and distinctly). This forces him to continually ask for help and to offer an explanation for his problem, fostering a sense of disability. Patients may forego the pleasures of conversation, voluntarily deciding to remain in isolation at parties or social gatherings. People with hearing loss often compensate by observing hand movement, facial expression, and lip movements. However, this is impossible when talking on the telephone. Some people suffering from presbycusis may then cease speaking on the phone. People may also elect to eventually withdraw from social situations.[1] As these problems escalate, those with hearing loss become more prone than others to experience cognitive loss, depression, psychosis, and dementia.[1]

Patients cannot prevent the inevitable age-related changes that result in presbycusis. However, since some presbycusis occurs through noise exposure, patients can at least take all possible measures to reduce this source of hearing damage.[9,10] The first step is to develop a keen sense of situations that could lead to hearing loss. The man must understand that activities long believed to be innocent, such as lawn mowing, can produce irreversible damage.[2] Working with lathes or grinders in a job or hobby can be dangerous. With regard to noise, a simple rule can be applied: When in doubt, shut it out! The man should begin to acquire a set of hearing-protective devices and keep them handy in the home, garage, workshop, and car.

The pharmacist counseling a patient with presbycusis can use several commonsense guidelines to help him understand instructions about medications.[2] First, it is important for the pharmacist to face the patient, to enable the patient to clearly see the pharmacist's face during the conversation. The pharmacist should also choose a position that allows light to fall on the face, which will facilitate clear observation of facial expressions, gestures, and lip movements. If possible, the counseling area should be distant from the rest of the pharmacy area, which can be distracting due to attendant noise of cash registers, babies crying, and so on. Speech should be a little louder than normal, but shouting must be avoided, as it distorts the speech and makes it less intelligible. The pharmacist should speak at the normal rate, and sounds should not be unduly exaggerated. Speaking with food in the mouth and covering the face with the hands should be avoided. If the patient appears to have trouble understanding, it is helpful to rephrase the counseling points in shorter, more simple sentences.

The pharmacist can also provide assistance to the presbycusis patient in choosing a practitioner for hearing amplification devices. It is critical to first visit a physician to rule out serious medical problems that can cause hearing loss.[3] Otolaryngologists hold MD or DO degrees and can treat hearing loss by virtue of their specialization in conditions of the ear, nose, and throat.[3] Otologists and neurotologists are otolaryngologists who have further training in hearing and are also fully qualified to treat hearing loss.[5] Audiologists must have a master's degree in audiology from a university and offer practices specializing in evaluating hearing.[3]

The federal government observes that the most poorly trained hearing health care professionals are known as hearing aid dispensers.[3] The FDA states that all they need to practice is a high school education with six months of training under another licensed hearing aid dispenser; they must pass written and practical state examinations.[3] They are not physicians and are thus not qualified to diagnose medically treatable causes of hearing loss, such as simple wax buildup or serious tumors. Patients should be urged to seek a physician's care before consulting hearing aid dispensers. In fact, federal guidelines require that a physician visit occur before hearing aid dispensers fit any hearing aid. The guidelines also allow patients to sign a waiver if they refuse to take this basic step. However, hearing aid dispensers must not encourage patients to waive this basic medical examination and must advise them that it is not in their best interest to sign the waiver. Furthermore, buying hearing aids through the mail is risky. Patients should be advised against these purchases.