Improving the Accessibility and Quality of Hearing Health Services for Seniors with a Hearing Loss

By Mathieu Hotton, PhD Audiologist

Introduction

Hearing loss affects approximately one in three people aged 65 and older worldwide [1]. In Canada, 38.7% of individuals aged 65-85 have a hearing loss measured by audiometry; this proportion increases with age, reaching 51.4% among those aged 75-79 and 69.8% among those aged 80-84 [2]. Thus, more than 2.75 million Canadian seniors live with hearing loss [2, 3]. Hearing loss can lead to communication difficulties, fatigue, anxiety, social isolation, distress, and depression [4-6]. It is associated with cognitive decline and a higher risk of falls among older adults [7]. It can also affect significant others, who may experience frustration related to communication difficulties and an increased sense of burden associated with their caregiving role [8-10]. The impacts of untreated hearing loss are estimated to cost $261.8 billion annually in the Americas, including $88.6 billion in healthcare costs and $44.1 billion in lost productivity [1].

Hearing healthcare services are nonetheless available and include audiologic rehabilitation, which aims to reduce activity limitations and participation restrictions by supporting adaptation to hearing loss [11, 12]. These services are based on a person- and family-centered approach and may include hearing aids, communication strategies, auditory training, and counseling. However, relatively few seniors with hearing loss receive hearing healthcare services [1]. The situation appears particularly concerning among seniors living in residential care settings, where it is estimated that 60-80% of residents have hearing loss, often without it even being identified [13-15]. In addition, the adoption and use of hearing aids remain suboptimal. Indeed, between 25% and 32% of these individuals own hearing aids in Canada [2]. Among them, 5% to 40% use them rarely or not at all [16].

Several factors contribute to this situation. Limited access to hearing healthcare services may result from a shortage of specialized resources, a lack of awareness of available services, and the absence of government policies on hearing health [1]. Furthermore, low rates of hearing aid adoption and use are related, among other things, to technology (effectiveness, appearance), individuals’ perceptions of their difficulties, their attitudes and those of their relatives toward hearing loss and amplification (e.g., self-stigma), as well as the support provided by significant others. The services also influence intervention approaches and the attitudes of hearing healthcare professionals [17-25]. Available evidence on clinical services suggests that they are often suboptimal [26-33]. As a result, many seniors with hearing loss and their families may not receive adequate support, particularly during the hearing aid fitting process. Additionally, the cost of hearing aids is an important factor limiting access to this technology for many seniors with hearing loss [34].

In the context of rapid population aging and considering that hearing loss is an important and potentially modifiable risk factor for dementia [35], it is essential to improve the accessibility and quality of hearing healthcare services. The work conducted in our laboratory is part of this effort and is structured around four main areas:

1. Audiological needs assessment
2. Peri-fitting intervention
3. Alternative hearing amplification technologies
4. Hearing healthcare services in residential care and home support contexts

Audiological needs assessment

Audiological needs assessment involves identifying a person’s rehabilitation needs while considering the impacts of hearing loss on the individual and their significant others, as well as the personal and environmental factors influencing their functioning [36]. This assessment is necessary to determine whether the individual should use hearing aids. Until recently, no specific guidelines existed to guide audiologists in conducting this assessment. Practice guidelines addressing needs assessment are available [37-39], but their recommendations remain general and not very operational. This has resulted in considerable variability in how audiologists assess needs [40]. 

To address this gap, we developed the Quebec Audiological Assessment Protocol for Younger and Older Adults (QAAP-YOA) [41]. This protocol provides audiologists with clear guidance on the elements to include in a rigorous needs assessment. The data collected to date suggest that the QAAP-YOA is relevant and valid, and that it helps improve the quality of evaluations and recommendations [42, 43]. However, its use requires time and extends consultation duration. Work is underway to migrate the QAAP-YOA to a web-based platform to improve efficiency, enable remote administration, and facilitate the involvement of significant others.

Peri-fitting intervention

Peri-fitting intervention encompasses all information, education, and counseling activities carried out before, during, and after the acquisition of hearing aids. Its goal is to prepare users and their significant others to adopt and use this technology. It plays a central role in hearing aid adoption, use, and outcomes. Indeed, an adequate intervention—particularly in the preparation phase—can: 1) Promote better alignment between expectations and the reality of hearing aid use, 2) Strengthen intrinsic motivation and self-efficacy, and 3) Support the development of the skills required to use hearing aids effectively [44-51]. These intermediate factors are themselves associated with more regular and effective hearing aid use, greater benefits, and ultimately improved social participation and quality of life [52-54]. Conversely, when preparation is insufficient, individuals may experience disappointment with hearing aids, feel a lack of control or competence, and reduce their use of the devices despite their technological potential [24, 55]. Significant others who are insufficiently involved or informed may also feel unprepared to support the adaptation process, which can exacerbate communication difficulties and relational burden [56, 57]. Thus, the quality of peri-fitting intervention is critical to maximizing outcomes.

However, the available evidence indicates that peri-fitting interventions are often suboptimal. Consultations are frequently focused on technical aspects and primarily led by professionals, with limited user participation [26, 28, 29, 31, 32]. A large amount of information is delivered in a short time, leaving little room to express concerns or engage in shared decision-making. Furthermore, the preparation phase is often reduced to a minimum, despite being essential for informed consent. Several hypotheses have been proposed to explain this situation, including time constraints during appointments, financial and billing considerations (often tied to hearing aid sales), and clinicians’ communication skills and training in person- and family-centred care [27, 30, 33].

In a recent project [58], we conducted interviews with new hearing aid users, significant others, and professionals to better understand the challenges encountered during the fitting process. Although satisfaction rates were generally high, the results indicate that several aspects of the peri-fitting intervention are insufficiently addressed, including links between hearing and cognitive health, adaptation to hearing aids, available alternatives, and follow-up services. Significant others expressed a desire to be more involved in their partner's appointments to better support them. Additionally, some users reported feeling pressured by professionals to purchase hearing aids, which negatively affected trust. Finally, many users and their relatives expressed a desire for greater professional involvement in public education on hearing health and hearing aids to reduce stigma and barriers to use, and to alleviate the daily burden experienced by individuals with hearing loss and their families.

In this context, we are working in partnership with users to co-develop a new peri-fitting intervention program. This program aims to support preparation for hearing aid use, facilitate post-fitting adaptation, and promote a person- and family-centred approach that integrates shared decision-making and informed consent.

Alternative hearing amplification technologies

Direct-to-consumer (DTC) hearing devices represent a promising avenue for improving accessibility and acceptability of hearing amplification. These include personal sound amplification products, smart earbuds, over-the-counter (OTC) hearing aids, and certain active hearing protection devices [59, 60]. Their main advantage lies in their accessibility and lower cost, making them attractive for individuals with mild to moderate hearing loss or those hesitant to adopt conventional hearing aids. However, these devices show considerable variability in performance, raising concerns about their effectiveness and safety [59-65]. In this context, our work, conducted in collaboration with researchers at the École de Technologie Supérieure (ÉTS), aims to evaluate the electroacoustic performance of DTC hearing devices, their effects on auditory perception, and their impact on variables such as listening effort [66-69]. We are also developing an online dissemination tool to inform both the public and professionals about these technologies and support informed decision-making [70].

In addition, hearing aid recycling programs represent another potential solution to improve access to amplification, particularly for individuals with low incomes. In recent years, we have collaborated with the Association des Personnes avec une Déficience de l’Audition (APDA), a community organization in the Québec City region that operates a hearing aid recycling program [71], to better understand the benefits and limitations of this approach. Our findings show that such programs can improve communication and social participation among users [72-74]. However, they also face challenges, including rapid device obsolescence and difficulties with repairs. The success of these initiatives largely depends on the involvement of hearing healthcare professionals in device collection, refurbishment, and follow-up. Technical and organizational constraints, however, may limit their participation, highlighting the need for adapted collaboration models. We continue to work with the APDA to support ongoing improvements to its program.

Hearing healthcare services in residential care and home support contexts

Access to hearing healthcare services remains particularly limited for seniors living in residential care settings or receiving home support services. These individuals often have significant needs but face major barriers, including long wait times, mobility constraints, and service costs. Hearing healthcare services are generally not systematically integrated into these environments. As a result, individuals must follow the same care pathways as the general population, often requiring them to leave their homes to access services. This situation represents a significant barrier for those with reduced mobility or cognitive impairment. Moreover, staff working in these settings are often not adequately trained in hearing health, limiting their ability to recognize signs of hearing loss and intervene appropriately [75-78]. As a result, many cases of hearing loss remain unidentified or insufficiently managed.

In this context, we have established a collaboration with the CIUSSS de la Capitale‑Nationale, a local public health facility, to support the integration of hearing health into services offered in residential care and home support settings. In collaboration with colleagues from University of Montreal, we have developed training programs in hearing health for care staff, and their implementation and effectiveness have been assessed [79, 80].These initiatives represent an important step toward better integration of hearing health into services for older adults and pave the way for the development of innovative service delivery models better adapted to their needs.

Conclusion

Hearing loss in older adults represents a major public health issue due to its significant impact on communication, social participation, mental and cognitive health, and the well-being of affected individuals and their families. In the context of rapid population aging in Canada, it is imperative to act now to improve the accessibility, quality, and relevance of hearing healthcare services.

Audiologists play a central role in this transformation. This includes improving assessment practices, strengthening peri-fitting interventions through a person- and family-centred approach, and contributing to the development and integration of more accessible technological solutions. Special attention must be given to the most vulnerable populations, especially seniors living in residential care settings or receiving home support services, for whom access to services remains largely insufficient. The development of innovative service delivery models, combined with training for non-specialized staff, represents a promising avenue for reducing inequities in access. Beyond clinical services, promoting hearing health and raising public awareness are also crucial to encouraging earlier consultation, reducing stigma associated with hearing loss, and improving the uptake of available solutions.

The work carried out in our laboratory is part of this ongoing effort to advance hearing healthcare through the development of tools, knowledge, and interventions that support clinical practice and facilitate system-level improvements. We hope to contribute, alongside the broader audiology community, to building more accessible, equitable, and effective services for Canadian seniors.

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