Age-Related Hearing Loss (Presbycusis)

Because they can hear low‐frequency sounds, they do not experience problems in locating the source of a sound, identifying it, or analyzing its rhythm and emotion. However, difficulties in discriminating what is said persist, and they spontaneously learn lip reading. For this reason, they are very comfortable in face‐to‐face conversations. This comfort may prevent individuals with hearing loss from recognizing their hearing loss.

Therefore, they generally do not require a hearing examination. Usually, the close ones of individuals with hearing loss, such as family members, observe signs like turning the TV volume up too high or frequent misunderstandings.

Doctor Audiologist Emel Uğur

Dr. Audiologist Emel Uğur was born in 1982 in Çanakkale. During her 15-year tenure at Istanbul Training and Research Hospital, she primarily worked on Pediatric Audiology (Hearing Loss in Infants and Children), Otological Diseases (Ear Diseases and Hearing Health), and Vestibular System Disorders (Vertigo and Imbalance). In 2015, she joined the Acıbadem Healthcare Group.

About Me

What are the Details of Age‐Related Hearing Loss?

Presbycusis is a hearing loss problem that occurs with advanced age. This condition typically becomes noticeable around the age of sixty and progresses over time. Factors such as stress, lifestyle habits, exposure to occupational noise, and various medical treatments can accelerate the progression of hearing loss.

The diagnosis of hearing loss should always be confirmed with audiometric measurements conducted in hospital settings following an examination by an ENT specialist. The best testing conditions are provided by audiology laboratories in hospitals.

The characteristic feature of age‐related hearing loss is that it manifests as a bilateral, symmetric reduction in the ability to perceive high‐frequency sounds. High‐frequency sounds are generally quiet and have low energy. However, they carry the distinctive features of speech. Therefore, they are very important for the intelligibility of speech.

Presbycusis is not a condition that can be treated with medical or surgical methods. Thus, the life handicap resulting from hearing loss can only be compensated for with hearing aids and implants.

Detecting and managing hearing loss is critically important for preserving quality of life. The use of hearing aids can reduce the difficulties faced by affected individuals in daily life and can prevent social isolation and depression.

What are the Causes of Age‐Related Hearing Loss?

Presbycusis is a complex health issue associated with the aging process, and many different factors can contribute to this condition. With age, structural and functional changes in the inner ear are among the primary causes of hearing loss. In addition, genetic predisposition, environmental factors, and hormonal changes also play an important role.

Genetic Factors:

In some individuals, changes in mitochondrial DNA have been observed to accelerate hearing loss by increasing the effects of oxidative stress.

Ototoxic Factors:

Certain medications that are necessary in some medical treatments can lead to a decrease in hearing sensitivity. Chemicals and drugs that can cause hearing loss include:

• Salicylates
• Loop diuretics
• Aminoglycosides
• Some chemotherapeutic (anti-cancer drug) agents

In addition, exposure to certain chemicals, particularly toxic chemicals such as toluene, styrene, and mercury, can have ototoxic effects and lead to hearing loss.

Noise Exposure Factors:

It is known that prolonged exposure to noise, especially in younger ages, can cause cochlear damage and consequently lead to more severe hearing loss in later years. Occupational noises (in factories, workshops, among armed forces personnel, municipal and construction workers, etc.) are also factors that accelerate hearing loss.

Hormonal Factors:

It is believed that sex hormones and glucocorticoids play a role in the reduction of hearing ability. Post‐menopausal hormone replacement therapies may also increase the risk of hearing loss.

Presbycusis is an age‐related hearing loss. However, factors that accelerate or predispose to it should not be overlooked. This diversity of causes leads to hearing loss manifesting in various forms.

Thus, presbycusis is classified within itself as sensor (sensory), neural, strial (metabolic), mechanical, mixed, and idiopathic (of unknown cause).

• Sensor (Sensory) Presbycusis:

It is associated with the loss of the receptor hair cells located at the basal turn of the cochlea. It leads to a hearing loss that is particularly noticeable at high frequencies.

• Neural Presbycusis:

It is characterized by a reduction in cochlear nerve fibers and spiral ganglion neurons. Significant impairments are observed in the ability to distinguish speech rather than in the configuration of the hearing loss. Hearing aids should be initiated without delay.

• Strial (Metabolic) Presbycusis:

It results from the degeneration of the stria vascularis cells. It is particularly affected by disorders in glucose metabolism. Noticeable hearing loss occurs in the low and mid frequencies.

• Mechanical Presbycusis:

It develops due to physical changes in the cochlea and is diagnosed by the audiogram pattern. High‐frequency loss is generally prominent. The ability to discriminate speech is proportional to the degree of hearing loss.

• Mixed Presbycusis:

It is the coexistence of multiple types of presbycusis.

• Idiopathic (Unknown Cause) Presbycusis:

It is a term used when no specific characteristics are present. Impaired cellular metabolism, reduced synaptic function, changes in endolymph chemistry, and central auditory processing disorders.

How Prevalent is Age‐Related Hearing Loss?

Presbycusis is a common condition among the elderly. There is a dramatic increase in the incidence of hearing loss with advancing age. While the incidence of hearing loss is between 15-20% in individuals aged 50-65, this rate rises to 30-40% in those over 65.

The increasing elderly population makes hearing loss one of the most significant problems in this group. According to the World Hearing Health Report published by the World Health Organization in 2021, as life expectancy increases, hearing loss becomes an even more important public health issue. Therefore, early resolution of presbycusis is one of the primary factors affecting the quality of life of the elderly population.

Also, according to the World Health Organization’s estimates, more than 500 million individuals aged 60 and over worldwide will experience significant hearing loss by 2025. These estimates indicate that hearing loss will become even more widespread with the increasing elderly population. More than half of older adults up to the age of 75 and almost all individuals over the age of 90 are affected by hearing loss.

What are the Processes Behind Age‐Related Hearing Loss?

Presbycusis is considered a natural consequence of aging and generally arises from a combination of internal and external factors. Significant changes are observed in the inner ear structure as age progresses. These changes include:

• Reduction in hair cells
• Structural deterioration in the stria vascularis region
• Degeneration of afferent spiral ganglion neurons

They can be listed as such. Additionally, environmental effects can also increase the severity of hearing loss. Exposure to noise, smoking, and the use of certain medications can damage the cells in the inner ear and accelerate hearing loss.

Disruptions in signal transmission to the auditory cortex are also part of this process. Damage to neurological pathways reduces the ability to process sounds, thereby decreasing the capacity to accurately perceive sounds.

What Symptoms are Observed in Age‐Related Hearing Loss and Which Examinations/Tests Should be Performed?

Presbycusis, which emerges as age progresses, generally presents with distinct symptoms. Among the most common issues is the difficulty in hearing high‐frequency sounds. It becomes particularly difficult to distinguish speech in crowded environments or situations with background noise.

The patient is often unaware of this condition, but those around them may observe this change. Hearing loss may have an insidious onset and gradually progress.

Physical examinations conducted to detect hearing loss are generally simple and straightforward. Common issues such as the accumulation of cerumen (earwax) can lead to misdiagnosis of hearing loss. Therefore, the ear should be examined first, and if necessary, cleaned by a physician.

Subsequently, various tests are performed to determine the type of hearing loss. Among these tests, pure-tone audiometry and speech audiometry are the most well-known. Pure-tone audiometry determines the type (conductive or sensorineural, etc.) and degree of the patient’s hearing loss. Additionally, speech audiometry examines the individual’s basic auditory processing skills, such as speech reception and discrimination.

What is an Audiogram?

An audiogram is the graph on which the hearing threshold levels detected by the pure-tone audiometry test are recorded. When well-interpreted, audiograms provide a good projection of the communication difficulties experienced due to hearing loss.

What are the Treatment and Management Methods for Age‐Related Hearing Loss?

There is no established treatment method for presbycusis. Hearing aids are used to improve the quality of life for individuals experiencing hearing loss.

Hearing aids amplify sounds, allowing the user to hear better. These devices can offer excellent solutions for individuals with hearing loss. Although hearing aids have various limitations, a well‐adjusted hearing aid results in an excellent user experience.

The effective use of hearing aids requires a learning and adaptation process. During this process, the patient must adapt to both the physical discomfort of the device and the cognitive adjustment. The maintenance and management of hearing aids continue after the device is fitted. This management requires auditory rehabilitation and is usually supported by audiologists.

Patients should be encouraged to adapt to hearing aids. Because many patients may perceive hearing aids as uncomfortable, unattractive, cosmetically unsuitable, or as a sign of aging.

In fact, healthy hearing enables the establishment and maintenance of healthy communication. Therefore, opinions should be obtained from experts, and various trial sessions should be conducted to determine the most appropriate device and settings.

Some Preventive Tips:

• Using earplugs or headphones to avoid prolonged exposure to high volumes helps reduce the acoustic trauma that exacerbates hearing loss.
• A healthy diet and an active lifestyle can help slow the progression of hearing loss.
• Quitting smoking may delay age‐related hearing loss.

Researchers are investigating the genetic and metabolic components of age‐related hearing loss:

• Antioxidants may slow hearing loss by considering the potential role of oxidative damage; however, studies in humans have found the effect of an antioxidant‐rich diet in preventing hearing loss to be limited.
• Agents such as Coenzyme Q-10 and Ginkgo biloba have been studied, despite insufficient evidence.
• Research into potential gene and hormone therapies for hearing loss is ongoing. These studies may offer new approaches to the treatment of hearing loss.

What Additional Considerations Should Be Taken into Account in Age‐Related Hearing Loss?

Presbycusis is diagnosed by exclusion and generally exhibits the characteristics of sensorineural hearing loss. Pure-tone audiometry and speech audiometry are essential tests. However, a broader test battery, known as immittance measurements—which evaluate the reflex arcs of the middle ear and auditory nerve—can increase the benefit that the patient derives from hearing aids.

If the hearing loss does not conform to the characteristics of presbycusis, advanced imaging and metabolic tests may be recommended. Conditions associated with hearing loss include genetic factors and various health problems. The underlying causes of hearing loss can be listed as follows:

• Exposure to noise
• Infections
• Ménière’s disease
• Trauma
• Autoimmune diseases
• Perilymph fistula
• Genetic predisposition
• Otosclerosis
• Tumors
• Exposure to ototoxic substances
• Metabolic dysfunctions

In elderly individuals, hearing loss may be accompanied by changes in mood and cognition. These conditions generally develop as a result of hearing loss. Particular attention should be paid to social isolation, depression, and cognitive changes. Therefore, the overall evaluation of elderly patients should include these changes.

What are the Effects of Age‐Related Hearing Loss?

The hearing loss that naturally comes with aging can significantly affect an individual’s daily life. Although presbycusis does not lead to complete deafness, if neglected or not treated appropriately, it can have profound effects on mental and cognitive health.

Hearing aids are a great aid in alleviating the problems that may arise from this condition. With regular use, these devices help reduce the effects of hearing loss:

• They prevent the social isolation caused by hearing loss
• They strengthen communication skills
• They delay cognitive decline

To ensure the effective use of hearing aids, individuals should be encouraged to participate in auditory rehabilitation programs. Such programs play an important role in coping with hearing loss.

In our country, the applications made for this purpose are very limited. Therefore, it is most constructive for individuals with hearing loss and those using hearing aids to gather in environments with low background noise to socialize, as a rehabilitation method.

Although hearing aids do not fully reverse hearing loss, the correct selection of a hearing aid, proper adjustment, and regular use can significantly improve quality of life. In cases where hearing aids are insufficient, surgical treatment methods may also be offered as an alternative.

What are the Complications of Age‐Related Hearing Loss?

Hearing loss in older adults can lead to various complications and affect many aspects of daily life. Firstly, this condition generally adversely affects individuals’ social interactions.

Increased social isolation can lower a person’s quality of life and lead to psychological disorders. In particular, individuals with hearing loss more frequently experience mood disorders such as anxiety, depression, and apathy.

In addition, hearing loss can pose a threat to safety during daily activities. For example:

• Individuals with hearing difficulties may have trouble hearing doorbells or phone rings.
• They may have difficulty detecting vital warnings such as smoke alarms and backup signals.

This situation particularly limits the ability to respond in emergencies and can create serious safety risks. Furthermore, hearing loss may reduce individuals’ autonomy and restrict their ability to move independently. Incomplete perception of auditory information limits a person’s interaction with their environment and, consequently, their environmental awareness.

Scientific research has revealed a strong connection between hearing loss and cognitive dysfunction. As the severity of hearing loss increases, the risk of developing cognitive disorders such as dementia also increases.

The mental burden caused by hearing loss leads to a greater consumption of brain resources. This results in a reduction in the resources available for memory and other cognitive functions.

Finally, there is a relationship between hearing loss and postural control. Hearing difficulties, especially in the elderly, can increase the risk of imbalance and falls. Falls can lead to serious injuries and even fatalities in older adults.

What Should Be Done to Prevent Hearing Loss in the Elderly?

Hearing loss inevitably increases with the aging process. This condition is frequently seen in adults, and early intervention can significantly improve quality of life.

Elderly individuals should be regularly tested for early detection of hearing impairments. Effective strategies can be implemented to combat hearing loss. These methods slow the progression of hearing loss and positively affect individuals’ social lives.

• Adopting a healthy lifestyle and avoiding smoking can delay hearing loss.
• Physical and cognitive activities are effective in preserving hearing ability.
• Regular cleaning of earwax is necessary to delay the onset of hearing loss.
• Using ear protection is essential to avoid prolonged exposure to high noise levels.

These measures also support overall health. Since hearing loss may be associated with cardiovascular risks, adopting healthy habits provides dual benefits.

Protecting the ears in noisy environments can prevent further deterioration of hearing loss. Elderly individuals should heed these recommendations to minimize the impact of hearing loss on social interactions.

Frequently Asked Questions

What is Metabolic Presbycusis?

Metabolic presbycusis is a distinct type of age‐related hearing loss. It develops in humans as a result of functional impairments in the auditory pathways with advancing age. This condition arises particularly as a result of the atrophy of the structure known as the stria vascularis due to aging. The stria vascularis supports metabolic health by maintaining the chemical and bioelectrical balance of the inner ear. Atrophy affects the cochlear hearing curve, leading to hearing loss. It is usually accompanied by symptoms such as tinnitus. Since metabolic presbycusis affects all frequencies, not only is hearing sensitivity reduced, but the ability to distinguish speech is equally impaired. The ability to understand speech, especially in noisy environments, is notably diminished.

At what age does presbycusis occur?

Presbycusis typically begins in middle age and becomes more prevalent as one gets older. It tends to manifest in the 40-45 age range. However, it is observed that by the age of 65-70, the condition reaches a very high prevalence of around 70-80% in the population. Thus, while the onset of presbycusis typically varies between 40 and 45 years of age, it is understood that this condition is much more common in advanced age. This age range is considered the most characteristic time period for presbycusis.

What is Neural Presbycusis?

Neural presbycusis is a type of hearing loss more commonly observed in older individuals. It is related to the degeneration of spiral ganglion cells in the inner ear and the atrophy of nerve cells in the central auditory pathways.

Every 10 years, between 2100 to 3500 hair cells in the inner ear degenerate, losing their function. This condition generally affects high-frequency sounds more. Thus, it leads to a marked reduction in the ability to distinguish speech. Neural presbycusis is associated with genetic predisposition. It becomes even more pronounced as age advances.