Defining Hearing Impairment as a Chronic Condition


By Max Stanley Chartrand, BC-HIS

Introduction: Chronic conditions such as diabetes mellitus, hypertension, cardiovascular disease, asthma, obesity, insomnia, gastrointestinal disorders, and chronic pain are widely recognized by the health professions. Hearing impairment, a more common chronic condition, is not. It is rarely mentioned as a chronic problem in consumer literature, medical textbooks or even caregiver handbooks. It is the purpose of this paper1) to identify and define hearing impairment as a prominent chronic condition suffered (often needlessly) by an increasing number of individuals, 2) to explore some of the barriers to effective treatment, and 3) to suggest an allied professional approach that can help remove barriers for treatment of hearing disorders.

Description and Treatment of Hearing Impairment. Auditory disorders cover a wide gamut of symptoms, most of which are chronic. They effect an estimated 31 million Americans, about 90% of whom suffer from disorders that cannot be treated medically or surgically (Kochkin, 2005; Aural Rehab Concepts, 2000). The FDA Hearing Rule, and subsequent amendments, require eight specific red flag conditions to be assessed and referred for possible treatment where encountered in those who present for an evaluation for hearing aids.

For those that exhibit any of the eight red flag conditions, treatment for (about 10% of all hearing losses in adults) may involve treating underlying causes, such as infection, physical obstructions or degenerative conditions, and/or by surgery for congenital abnormalities and lesions from injury. The majority of auditory disorders (about 90%), however, are sensory and/or neural ("sensorineural"), and therefore are generally not responsive to medical or surgical treatment. Instead, treatment may consist of hearing aids, cochlear implants, assistive devices, and/or rehabilitative counseling and training.

Most children cases are conductive (i.e., infection, impaction, deformity, etc.), while most adult cases are sensorineural, including etiologies of cochleovestibular, central auditory, and cognitive overlay. These latter conditions are chronic and have long-term affects on the lives of sufferers and those around them. The comorbidity rates for hearing loss concomitant to other chronic conditions is very high, suggesting many common causal and underlying pathologies (Chartrand, 1999).

Figure 1. Prevalence of permanent, chronic hearing impairment as a percentage of each age-group within the general population in the United States (Aural Rehab Concepts, 2000).

Assessment of the Patient. Assessment for auditory disorders involves the audiologic/audiometric battery of: Case history, otoscopy (examination of external and middle ears), tympanometry (middle ear assessment), air- and bone-conduction pure-tone thresholds, speech-based tests, and other parameters, such as real ear canal resonance, in situ hearing aid response, loudness growth abnormalities, and tinnitus assessment.

The FDA red flags serve as clinical/medical referral guidelines, and also inform in auditory status and causal factors indicating possible medical attention. During the case history, psychosocial factors are also explored to help assess the impact of hearing impairment on quality of life, as well as interpersonal relationship factors. These issues are considered integral to the effects of auditory disorders, and sometimes present the biggest obstacles for effective treatment. Post-treatment evaluations often involve tests for efficacy and verification (Chartrand, 1999).

Barriers to Effective Management of Hearing Impairment. Barriers to effective management of hearing impairment are considerable. Since the vast majority of auditory disorders lack self-assessable symptoms, the natural inclination of the sufferer is to remain oblivious to the disorder, or, at the least, to be in denial of it after being made aware of its existence (Chartrand and Chartrand, 2004). Likewise, those who associate with the sufferer are more likely to attribute the symptoms of hearing loss to any number of personality trait idiosyncrasies or as inappropriate/incomplete social behaviors (Chartrand, 2001b).

What's worse, too often health care professionals are likely to mistaken the symptoms of unmitigated hearing impairment for cognitive disorders, such as mild or moderate Alzheimer's disease or attention deficit disorder (Chartrand, 2001a; Tyberghein,1996; Gimsing, 1990). In fact, the symptoms of hearing impairment and the symptoms of mild Alzheimer's are so closely manifested, that proper psychological diagnoses cannot be made using only the standard cognitive clinical methodologies without first ascertaining auditory status (Adviware, 2005; Kalayam et al, 1995; Ullman et al, 1989; Folstein, Folstein, McHugh, 1974).

Figure 2. Principal barriers to effective management of chronic hearing disorders

For the patient

Lack of internal reference or reliable self-assessment from which to judge degree or effects of impairment

For family members

Lack of recognition of the signs of hearing impairment, and a propensity for assessing symptoms as psychosocial deficiencies

For public entities

Marked under-recognition of the prevalence and detrimental implications of unmitigated impairment, coupled with a demand for consumer regulation that (often) works against the paradigm of auditory rehabilitation

For health professionals in general

Lack of referral for symptoms of hearing disorders. Misdiagnoses and attribution to cognitive issues, such as depression, anxiety, paranoia, attention deficit, and/or Alzheimer’s

For hearing healthcare professionals:

Lack of allied professional communication and consensus on best practice standards

Overcoming the barriers to effective treatment of those with chronic hearing disorders will require a major public and consumer education campaign about auditory disorders and concomitant consequences of not seeking or rendering care. Hearing disorders need more lucent clinical recognition as one of the major chronic conditions, and treated as an important reason for referral to appropriate hearing health professionals.

In addition, clinical, medical, education, and regulatory entities need a crash-program about the need to first assess auditory disorders before concluding any cognitive, psychological, or psychosocial diagnoses. Developmental and learning disability assessments should begin with a thorough assessment of hearing health status and ability.

Counseling and Auditory Retraining Interventions. The realm of counseling intervention in the field of auditory disorders generally consists of four activities:

  • Pre-counseling before the evaluation. Pre-counseling helps prepare the patient and family members to better recognize the very real and deleterious effects of hearing loss on quality of life, interpersonal relationships, and health and emotional well-being. Pre-counseling should occur before the audiometric test battery to help elicit a more accurate case history.
  • Formal case history, which explores specific effects of the impairment on the patient and immediate family members. This form of counseling should involve family members or significant others, and should help prepare them to play a supportive role in the rehabilitative process.
  • Remediation counseling, which focuses upon effective utilization of treatment (hearing aids, assistive devices, coping strategies) and auditory retraining in an attempt to overcome auditory sensory deprivation, and to achieve specific habilitative/rehabilitative objectives.
  • Ongoing care and support to assure positive long-term outcomes of treatment, and improved health, quality of life, and emotional and social well-being. Ongoing care should be sensitive to hearing loss changes and the need for new technologies and strategies to help the patient maintain optimal communicative ability.

    America's Hearing Healthcare Team. The foregoing is best accomplished within a community hearing healthcare team setting. The team can be made up of patient, primary care physicians, otolaryngologists, hearing instrument specialists, clinical audiologists, allied professionals, educators, and researchers.

    America's Hearing Healthcare Team (AHHT) is a collaborative effort founded by the American Academy of Otolaryngology—Head and Neck Surgeons and the International Hearing Society. It has been endorsed by the American College of Surgeons, American Neurotology Society, Cochlear Implant Association, and the Deafness Research Foundation (AHHT, 2005).

    The initiative encourages each member of the team—organizationally and at the community level—to develop a deeper understanding about the true effects of hearing impairment on the lives of those who suffer from it. It promotes better allied professional communication, team meetings, and working together for the benefit of hearing impaired individuals.

    AHHT encourages more effective continuing education about ongoing advancements in technology, procedures, diagnostics, and counseling that are being advanced by each member of the team. Moreover, it fosters a deeper appreciation for the unique and important contributions each team member makes in the effort.

    Each member of the team can then explore within their specific practice setting how best to unlock the mysteries of auditory disorders. Together they can develop consensus on best practice standards in counseling, treating and serving those who suffer from chronic hearing disorders.


    About the author...

    Max Stanley Chartrand serves as Managing Director of DigiCare Hearing Research and Rehabilitation, and lectures and publishes widely on topics of hearing impairment, auditory rehabilitation, and hearing health issues. He welcomes comments and suggestions for research and continuing education of hearing professionals. Correspondence: or (719)676-3277.



    Adviware, (2005). Misdiagnosis of Alzheimer’s Disease. Retrieved on May 28, 2005, from alzheimers_disease/misdiag.htm.
    AHHT, 2005. America’s Hearing Healthcare Team. Retrieved on September 3, 2005, from  
    Aural Rehab Concepts, (2000). Prevalence of hearing loss by age-group in the United States. Retrieved on May 27, 2005, from
    Chartrand, M.S., (2005, April 18). Identifying neuroreflexes of the external ear canal. Audiology Online, retrieved on May 29, 2005 from
    Chartrand, M.S., and Chartrand, G.A., (2004). If a Tree Fell in the Forest: What’s Really Holding Back the Market? The Hearing Review, January, pp. 44-47.    
    Chartrand, M.S., (2001a, November). Hearing Health Care and Alzheimer’s Disease: The role of hearing healthcare in treating patients with Alzheimer’s disease. The Hearing Review, pp.26-29.
    Chartrand, M.S., (2001b, January-February). Cognitive Manifestations in Unmitigated Hearing Loss. The Hearing Professional, pp. 11-13.
    Chartrand, M.S. (1999). Hearing Instrument Counseling: Practical approaches to counseling the hearing impaired. Livonia, MI: International Institute for Hearing Instrument Studies.

    Folstein, M.F., Folstein, S.E., McHugh, P.R., (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, pp. 189-198.
    Gimsing, S. (1990). Word recognition in presbyacusis. Scand Audiol, 19(4), 207-211.
    Kalayam, B., Meyers, B. S., Kakuma, T., Alexopoulos, G. S., Young, R. C., Solomon, S., et al. (1995). Age at onset of geriatric depression and sensorineural hearing deficits. Biol Psychiatry, 38(10), 649-658.
    Kochkin, S. (2005, July). MarkeTrak 2005. The Hearing Review, pp. 18-24.
    Tyberghein, J. (1996). Presbycusis and phonemic regression. Acta Otorhinolaryngol Belg, 50(2), 85-90.
    Ullman, R., Larson, E., Rees, T., Koepsell, T., Duckert, L., (1989). Relationship of hearing impairment to dementia and cognitive function in older adults. The Journal of the American Medical Association, 261: 1916-1919.


    CE Examination


    1. Some of the principal barriers to effective treatment of hearing disorders are:

    1. Lack of internal reference with which to judge severity of hearing loss
    2. Consumer regulation that may inhibit auditory rehabilitation
    3. Lack of understanding of the pervasiveness and detriment of hearing loss
    4. Lack of referral for symptoms of hearing disorders
    5. All of the above


    2.  Pre-counseling consists of:

    1. A formal case history
    2. Assistive device counseling
    3. Consumer education before assessment
    4. Referral for medical evaluation
    5. Remediation Counseling


    3.  Generally, permanent, chronic sensorineural loss cases comprise ______ of the hearing impaired population.

    1. 10%
    2. 25%
    3. 50%
    4. 75%
    5. 90%


    4. Remediation counseling focuses upon:

    1. Overcoming auditory sensory deprivation
    2. Use of hearing aids
    3. Coping strategies
    4. Assistive devices as needed
    5. All of the above


    5. The prevalence of permanent, chronic hearing impairment in the general population of the United States:

    1. Generally decreases with age
    2. Is about the same for working age adults as for children
    3. Increases dramatically with age
    4. Is slightly higher for older adults
    5. Is slightly lower in younger age groups

    6. America’s Hearing Healthcare Team (AHHT) consists of:

    1. Hearing healthcare professionals who work together
    2. Consumers who have an interest in hearing disorders
    3. Primary care physicians, deaf educators, and speech pathologists
    4. All of the above
    5. None of the above


    7. Reasons for referral between members of AHHT can be:

    1. Evidence of any of the eight red flag conditions
    2. Need for a hearing evaluation
    3. The fitting of a hearing aid
    4. Training in speech reading
    5. All of the above


    8. One of the most important goals of ongoing care and support is:

    1. To introduce new strategies and technologies as patient’s hearing declines
    2. To obtain an accurate case history
    3. To accommodate for recruitment in the initial fitting
    4. None of the above
    5. All of the above


    9. Unrecognized hearing impairment can cause mis/over-diagnosis of:

    1. Strep throat
    2. Meniere’s
    3. Alzheimer’s
    4. Otosclerosis
    5. None of the above


    10.  By working together, local healthcare professionals can:

    1. Identify and treat hearing disorders earlier
    2. Improve communication and interaction between referring professionals
    3. Learn about advancements in each team member’s treatment armamentarium
    4. Educate and motivate more hearing impaired people to seek help
    5. All of the above



    Answer Key: 1-A, 2-C, 3-E, 4-E, 5-C, 6-D, 7-E, 8-A, 9-C, 10-E.