How do you manage presbycusis (age-related hearing loss) in a family medicine setting?

Management of Presbycusis in Family Medicine

Screen all adults ≥50 years old for hearing loss, obtain audiometry when suspected, and refer to audiology for hearing aids—this is the cornerstone of family medicine management for presbycusis. 1, 2

Initial Screening and Detection

• Screen patients starting at age 50 using simple office-based methods (whispered voice test) or validated questionnaires to identify hearing difficulty 1, 2
• Look for behavioral clues: patients asking for repetition, increasing TV volume, difficulty with phone conversations, or withdrawal from social situations 3, 4
• Family members often notice the problem before the patient does—actively ask family about communication difficulties 2, 3

Diagnostic Confirmation

• Order comprehensive audiometry (pure-tone audiometry with speech testing) as soon as hearing loss is suspected—this is the gold standard and should be obtained within 14 days 5, 4
• The audiogram will show bilateral, symmetric, high-frequency sensorineural hearing loss that is gradually progressive—this is the classic pattern of presbycusis 1, 3
• Perform otoscopic examination to rule out cerumen impaction (potentially curative if present) and examine the tympanic membrane 3, 4

Red Flags Requiring Urgent Specialist Referral

• Asymmetric hearing loss (>15 dB difference between ears): requires MRI to exclude vestibular schwannoma or other retrocochlear pathology 6, 2, 5
• Sudden sensorineural hearing loss (≥30 dB loss within 72 hours): requires immediate otolaryngology referral and high-dose corticosteroids 2, 5, 3
• Conductive or mixed hearing loss on audiometry: needs otolaryngology evaluation for potentially reversible causes 6, 2, 5
• Poor word recognition scores disproportionate to pure-tone thresholds: warrants specialist evaluation 2, 5

Patient Education (Critical Component)

Counsel every patient with presbycusis about the serious consequences of untreated hearing loss—this education is as important as the hearing aid referral itself: 2, 5

• Cognitive decline and dementia risk: hearing loss accelerates cognitive decline, but hearing aids may slow or prevent this progression 2, 7
• Falls and safety risks: untreated hearing loss increases fall risk and compromises situational awareness 2
• Social isolation and depression: communication difficulties lead to withdrawal from social activities 2, 8
• Quality of life impact: affects relationships, independence, and daily functioning 2, 8

Communication Strategies (Implement at Every Visit)

Teach and model these strategies during clinical encounters: 2, 5

• Face the patient at eye level when speaking 2
• Speak clearly and slowly without shouting 2
• Get the patient's attention before speaking 2
• Minimize background noise in the exam room 2
• Rephrase rather than simply repeating 2
• Provide written instructions for all medical advice 2
• Involve family members in education sessions 2

Amplification and Hearing Aids

• Refer all patients with confirmed presbycusis to audiology for hearing aid evaluation—even mild hearing loss benefits from amplification 2, 7, 3
• Do not wait for hearing loss to become severe—earlier intervention improves outcomes and may prevent cognitive decline 2, 7
• Address cost barriers proactively: discuss over-the-counter hearing aids for mild-to-moderate loss, Medicare Advantage coverage options, and state assistance programs 2, 4
• Emphasize that hearing aids improve safety, function, and quality of life while potentially delaying cognitive decline 2, 7

Cochlear Implant Consideration

• Refer for cochlear implant evaluation when patients have appropriately fitted hearing aids but continue to have poor speech understanding and significant hearing difficulty 2, 5
• Do not wait until hearing loss is profound—candidacy criteria have expanded and earlier referral improves outcomes 2

Follow-Up and Monitoring

• Reassess hearing at least every 3 years in patients with known presbycusis, as progression is common 6, 2, 5
• Monitor hearing aid adherence at each visit and troubleshoot barriers to consistent use (discomfort, cost of batteries, difficulty with insertion, stigma) 2, 7
• Annual evaluation of hearing aid function and benefit is recommended 5

Common Pitfalls to Avoid

• Do not order CT scans for hearing loss evaluation—MRI is the appropriate imaging modality when retrocochlear pathology is suspected 2, 5
• Do not order routine laboratory tests (thyroid, B12, syphilis serology) in patients with typical bilateral symmetric presbycusis unless systemic illness is suspected 5, 3
• Do not dismiss mild hearing loss as "normal aging"—even mild loss benefits from amplification and affects cognitive function 2, 7
• Do not rely on patient self-report alone—many patients underestimate their hearing loss 5, 4
• Do not prescribe antivirals, vasodilators, or thrombolytics for gradual presbycusis (these are only for sudden sensorineural hearing loss) 5

When Genetic Testing May Be Appropriate

• Consider genetic evaluation if presbycusis presents in a younger patient (<50 years) with multiple affected family members, as this may represent hereditary hearing loss rather than typical age-related presbycusis 1, 7