Marques 2021

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European Archives of Oto-Rhino-Laryngology

https://doi.org/10.1007/s00405-021-06805-6

OTOLOGY

Age‑related hearing loss, depression and auditory amplification:


a randomized clinical trial
Tatiana Marques1,2,3   · Filipa D. Marques4,5 · António Miguéis6

Received: 17 December 2020 / Accepted: 7 April 2021


© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Purpose  Our study investigates the effectiveness of aural rehabilitation to decrease depressive symptoms in older adults,
and the relationship between hearing loss and depression.
Methods  A randomized controlled study was conducted at a hearing rehabilitation center with people over 65 years old.
Participants were randomly allocated to the intervention group who received hearing aids, or to the control group. Data
collection included pure-tone audiometry and a Portuguese version of the Geriatric Depression Scale assessed at two time
points: baseline (P0) and after 4-week period (P1).
Results  The results show that the increase of hearing thresholds in pure-tone audiometry is associated with a significant
increase in depressive symptoms (p = 0.001). The effect of aural rehabilitation for improving depressive symptoms was
significant in intervention group (p = 0.000) and between groups (p = 0.003) in P1.
Conclusion  Age-related hearing loss has adverse effects on older adults’ mental health, due to reduced hearing inputs that may
increase levels of effort to communicate and affect social engagement, which lead to depression. Hearing aid use improves
levels of depression and can promote greater quality of life in older adults.

Keywords  Aging · Depression · Hearing aids · Hearing loss · Rehabilitation

Introduction sensorineural hearing loss, that has a profound impact on


older adult communication and daily functioning [2, 3].
A growing body of evidence has shown that aging is the It is known that hearing loss has negative consequences
most common cause of hearing impairment and is referred to on physical functioning, mental health, and social relations.
as age-related hearing loss (ARHL) [1]. ARHL results from Recent studies have suggested that ARHL is strongly associ-
pathologic processes associated with loss of hair cells at ated with depression in the geriatric population, revealing that
the basilar membrane, which leads to a progressive bilateral ARHL gives rise to poorer quality of life, leading to increased
prevalence of depression [4–8]. The mechanisms underlying
this association are still unclear. However, they are thought to
* Tatiana Marques be a result of impaired communication and of the decrease of
tatiana.marques@estescoimbra.pt social engagement, affecting their ability to perform activities
1 of daily life [9]. Kim et al. studied a group of subjects with
Department of Biomedicine, Faculty of Medicine, University
of Porto, Porto, Portugal hearing threshold ≥ 60 dB in both ears or ≥ 80 dB in one ear
2 and ≥ 40 dB in the other [10]. The hearing assessment was
Department of Audiology, Coimbra Health School, Coimbra,
Portugal performed with pure-tone audiometry (PTA) and auditory
3 brainstem response (ABR), while depression was diagnosed
Department of Audiology, OuviSonus, Estrada da Beira,
nº483, 3030‑173 Coimbra, Portugal using the International Classification of Disease. A strong
4 correlation was observed between hearing loss and depres-
Department of Education, Coimbra College of Education,
Coimbra, Portugal sion, independent of age and educational level. The conclusion
5 drawn by the authors was that the severity of hearing disorder
CINTESIS, Porto, Portugal
was associated with increased depressive symptoms in older
6
University Clinic of Otorhinolaryngology, Faculty people compared to other ages. Similar studies describe this
of Medicine, University of Coimbra, Coimbra, Portugal

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European Archives of Oto-Rhino-Laryngology

relationship and Mulrow et al. corroborated the ARHL-depres- prior to their participation, and the procedures applied
sion association and suggested aural rehabilitation to treat the were carried out in accordance with the Declaration of
patients. The study concerned 188 older adults with hearing Helsinki. A total of 79 patients over the age of 65 years old
loss, in which half of the subjects were hearing aid users, with with moderate sensorineural hearing loss were recruited at
the findings showing that aural rehabilitation promoted social a specialized hearing rehabilitation center from a tertiary
participation and decreased depressive symptoms in the hear- hospital after being referred to the ENT service. Study
ing aid group [11]. eligibility criteria specified moderate bilateral symmet-
These findings indicate the importance of early aural reha- ric sensorineural hearing loss, based on a PTA of hear-
bilitation and provide support for use hearing aids as an effec- ing thresholds at 0.5, 1, 2 and 4 kHz of 41 dB to 70 dB
tive treatment on older adults. Aural rehabilitation involves HL in better ear. Exclusion criteria included subjects with
restoring the audibility of sounds to improve speech perception dementia, as defined by a score of ≤ 27 if participants had
[9]. However, stigmatization and financial issues may contrib- high school degree or more and ≤ 22 if had college or less
ute to low adoption rates for hearing aids in older adults. on the Portuguese version of the Mini-Mental State Exam-
In this context, studies have shown that older adults with ination (MMSE). In addition, participants with prior use of
hearing impairment, a greater number of depressive symp- hearing aids or abnormal otoscopy findings were excluded
toms appear, which may be improved by hearing aids [10]. from the sample.
Possible mechanisms for improvement with the hearing Eleven had cognitive impairment and seven of them
aids have been proposed, suggesting that recovery of hear- use hearing aids, being excluded from the sample. As a
ing audibility facilitates communication and enhance social result, the date from 61 subjects provided information were
relations, which decrease anxiety and depressive symptoms, included in analysis. Informed consent was obtained prior
contributing to well-being and thereby improving the quality to measurements.
of life of the older people [2]. Conversely, Mener et al. found Participants completed a full audiometric battery, includ-
that there was no relationship between ARHL and depres- ing tympanometry, pure-tone audiometry, word recognition
sion, and Pronk et al. showed similar findings, although scores (WRS), performed with the Amplaid A756 model
revealed that ARHL was associated with increased loneli- equipment and Aurical. Pure-tone thresholds were assessed
ness in men after a 4-year follow-up [7, 12]. through air conduction audiometry at 0.25, 0.5, 1, 2, 4,
Such variations in findings produce limited evidence and 8 kHz and bone conduction pure-tone audiometry at
into this relationship, due to methodological differences 0.5, 1, 2, and 4 kHz. White noise was used for masking if
in assessment and classification of ARHL and depression. applicable.
Further, methodological assessment of hearing loss can be Word recognition score (WRS) for Portuguese monosyl-
limited by use of self-reported hearing loss, conducting to labic words was assessed using Portuguese phonetically bal-
contradictory results. Concomitantly, possible mechanisms anced words.
for depression in ARHL determine the necessity of ongo- Depression was examined using the GDS Portuguese ver-
ing research to clarify equivocal findings and contribute to sion. This is a self-reported scale containing 27 questions
better understanding the etiology beyond this association, to detect depressive symptoms in the last 2 weeks. Subjects
which could help to develop interventions that decrease the with a score of 11 or above are likely to be depressive [14].
impact of ARHL on mental health. In addition, few stud- Higher scores reflect more symptoms of depression.
ies have provided evidence that hearing aids improve health Enrolled participants completed a standardized evalu-
outcomes in older adults [13]. ation and according with simple randomization method,
Therefore, the present study aimed to examine the asso- participants were randomly allocated into two groups after
ciation between depressive symptoms and ARHL, assessed an independent audiologist generated the random alloca-
with a pure-tone average (PTA) and a validated Portuguese tion sequence using Qualtrics (Provo, UT, USA) software
version of the Geriatric Depression Scale (GDS) and verify program. The study participants were not feasibly masked
the effectiveness of aural rehabilitation through the assess- to randomization status. Thirty-two participants fitted with
ment of depression with GDS at baseline (P0) and after bilateral hearing aids of the same model (Receiver in the Ear
4-week period (P1). Hearing Aid) and brand were included in the intervention
group (IG), and 29 participants were assigned to control
group (CG). The hearing intervention included hearing aids
Materials and methods adjustment and control of the daily use through the process-
ing algorithm built in hearing aids memory (mean time of
The study was approved by the Ethical Committee of Pol- 6 h of daily use). To the control group, no treatment was
ytechnic Institute of Coimbra in March 2018 (Approval applied. The GDS was administered at two timepoints: base-
number 2/2018). All the participants gave written consent line (P0) and after 4-week period (P1) to compare depression

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European Archives of Oto-Rhino-Laryngology

symptoms between the groups and in pre- and post-treatment that the participants in CG had a significantly higher mean
in each group. age than those in IG (t = − 2.555; p = 0.013). Second, the
All the participants in the research completed the study study of the BPTA between the groups showed no significant
program. difference (t = 1.615; p = 0.112). The participants in control
Data management and analyses were performed using group had a BPTA of 53.34 dB HL and those in intervention
IBM SPSS Statistics 25. The results were analyzed with group of 56.95 dB HL.
Students’ test for paired and unpaired data and linear regres- Pearson’s correlation analysis was used for variables
sion for correlations among variables such as age, better BPTA and GDS scores. A moderate correlation was found
ear pure-tone average (BPTA), and educational level before with increase of hearing thresholds associated with higher
aural rehabilitation. Statistical difference results were con- levels of depression (R = 0.37, p = 0.03).
sidered significant value at alpha level < 0.05. The effect of hearing loss on depressive symptoms was
then evaluated with a linear regression model, including age,
marital status, education level, and BPTA. The regression
Results model was designed using the GDS scores as the dependent
variable and BPTA and other factors entered as covariates,
Demographic data such as age, marital status, and educational level. First, sim-
ple regression analysis was performed, with each of the inde-
The sample was characterized by age, gender, education, pendent covariates added separately. This univariable model
marital status, better ear pure-tone average (BPTA), and is represented by GDS score = β0 + β1x1 + ε, where β0 is the
depression symptoms (shown in Table 1). The mean age of intercept, β1 is the change in the score of GDS with each one
the participants in the CG was 82.38 years old (SD = 6.99) of the covariates, and ε is an error term. The results shows
and 77.47 in IG (SD = 7.93). that hearing loss has an independent association with depres-
sive symptoms (F(1.59) = 4.307, p = 0.08; R2 = 0.385), even
Data analysis after the effects of age (β = 0.153, t = 1.241; p = 0.220), mari-
tal status (β = 0.171; t = 1.399; p = 0.167), and educational
The two participants groups were compared in terms of sex, level (β = 0.196; t = 1.551; p = 0.126) have been accounted
age, marital status, educational level, BPTA and GDS scores, for. The main predictive factor of depression was BPTA
using the independent samples t test. First, it was observed (β = 0.289; t = 2.416; p = 0.019).
To the subsequent analysis were performed a multiple
regression with all covariables for the depression score in
Table 1  Participant descriptions the multiple regression equation. The multiple regression
Individuals N (%) or mean (SD) p equation was as follows: y = 3.101 + 0.348x1 + 0.105x2 + 0.
135x3 + 0.270x4 − 11.34, where y is the predicted value of
Intervention Control group Between
group groups GDS scores, x1 is the BPTA, x2 is the participants age, x3 is
the marital status, and x4 is the educational level. Adding all
Age 77.47 (7.93) 82.38 (6.99) 0.013* covariables together led to a significant improvement of the
Gender model (p = 0.021), and of the variance (R2 = 0.560) (shown
  Male 13 (40.60%) 14 (48.30%) 0.556 in Table 2).
 Female 19 (59.40%) 15 (51.70%) To determine whether the treatment of using a hearing
Marital status aid had any significant effect on depression, a Student’s test
 Married 20 (62.50%) 11 (37.90%) 0.321 for paired data analysis were performed (shown in Table 3).
 Not married 12 (37.50%) 18 (62.10%) The scores obtained in the GDS revealed that there were
Education significant differences between the evaluation and reassess-
 Nill 1 (3.10%) 9 (31.10%) 0.121 ment steps in IG (t = 4.093; p = 0.000). It could be observed
 Elementary 21 (65.60%) 14 (48.30%) that the older adults in IG showed fewer depressive symp-
school
toms after 1 month of use of hearing aids. In CG, no statis-
 Middle school 6 (18.80%) 5 (17.20%)
tic differences were found between P0 and P1 (t = 0.567;
 High school 4 (12.50%) 1 (3.4%)
p = 0.454). Analyzing the GDS results with Student’s test
GDS scores (P0) 10.63 (6.43) 11.69 (4.27) 0.296
for unpaired data, it was found that the mean of GDS scores
GDS scores (P1) 6.94 (5.71) 10.97 (5.29) 0.003*
in P0 was 11.69 in control group and 10.63 in intervention
BPTA 56.95 (9.58) 53.34 (8.47) 0.112
group. The average of GDS scores in P1 was 10.97 in con-
BPTA better ear pure-tone average, GDS geriatric depression scale trols and 6.94 in participants with hearing aids. The results
*p < 0.05 showed that the IG improves depressive symptoms relative

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European Archives of Oto-Rhino-Laryngology

Table 2  Results from the linear regression analysis reversed with the use of this devices. These results support the
Depression score covariates β coefficient (95% CI) R2 findings of Castiglione et al., who assessed 125 older adults
and compared the degree of hearing loss and the effectiveness
BPTA 0.289 (0.017; 0.317) 0.385* of hearing aid use to in depression. The results showed that
Age 0.153 (0,021; 0.361) 0.151 depressive symptoms occurred more often in participants with
Marital status 0.171 (0.004;0.357) 0.167 higher hearing thresholds. Reduction in depressive symptoms
Educational level 0.196 (0.005; 0.268) 0.126 was also observed after the use of hearing aids. The conclusion
BPTA + age + marital sta- 0.348 (0.097; 0.599) 0.560* drawn by the authors is that some factors influence this positive
tus + educational level
effect of aural rehabilitation, such as the of social isolation, the
β coefficient reflects the depression score change according with the positive effect on neuroplasticity that reflects auditory training
covariables. R2 is given as a measure of the goodness of fit of the in working memory and reading ability, as well as improve-
model ment in self-motivation, self-esteem and self-confidence [17].
BPTA better ear pure-tone average, GDS geriatric depression scale However, the study includes hearing-impaired with mild to
*p < 0.05 profound hearing loss and, consequently, the selection of hear-
ing aids was based on the degree of hearing loss, which can
lead to variations in findings and produce limited evidence into
Table 3  Student’s test for paired data analysis to determine whether this relationship. In our study, the inclusion criteria were spe-
the treatment of using a hearing aid had any significant effect on cific about the degree of hearing loss, which allows that the IG
depression, between the evaluation (P0) and reassessment (P1) steps
in IC and CG
received bilateral hearing aids of the same model and brand.
The CG has not received treatment, therefore, results obtained
GDS scores IG CG suggest that the lack of auditory stimulation may be associ-
P0 P1 P0 P1 ated to increased social isolation, which leads to the depres-
sion that was maintained after a 4-week period. Therefore, we
p 0.000* 0.454
hypothesize that loneliness and social isolation may be related
GDS geriatric depression scale to depression in older adults and future research should try to
*p < 0.05 address if there is a relationship between these variables.
Further, Boi et al. found that hearing aid has positive
results in depression after 1 month of use, nevertheless at
to the control group, showed by the decrease in GDS scores the end of 6 months, the level of depression was even lower,
that went from 10.63 in P0 to 6.94 in the final session of suggesting that these results can be maintained and even
IG, and from 11.69 to 10.97 in CG. There was a significant improved over time [18]. Our research corroborated that pro-
difference between the GDS scores obtained between the viding enhanced hearing inputs may lead to a decrease of
groups under P1 condition (t = − 3.049, p = 0.003). levels of depressive symptoms, which can be related to the
decrease of effort required to communication and facilitate
greater social engagement.
Discussion Therefore, the results of present study further support
the importance of early identification of age-related hearing
Our research has shown that ARHL influences the devel- loss and the effectiveness of aural rehabilitation as a treat-
opment of depressive symptoms even when other factors ment in the older population, to prevent mental health and
are considered. These results support the findings of West, improve quality of life. However, the mechanisms underlie
who found that older adults with ARHL have a significant this recovery are still unclear, our hypothesis suggests that
increase in depressive symptoms [15]. Previously, Caccia- improving hearing ability decreases loneliness and restores
tore et al. studied 1332 subjects older than 65 years and social participation, which in turn improves mental status.
found a strong correlation between hearing loss and depres- Hence, it is suggested that future research using loneli-
sion [16]. Our findings suggest that a highly significant ness and socioeconomic status datasets should address the
relation exists between hearing impairment and depressive limitations of our study, and therefore, confirm or dispute
symptoms, even after controlling sociodemographic factors our findings.
that could explain this association. In addition, these previ-
ous studies used a methodological assessment of hearing
loss that can be limited using self-reported hearing loss.
Furthermore, significant improvements have been found
in depressive symptoms following the use of hearing aids,
indicating that the effect of hearing loss on depression can be

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European Archives of Oto-Rhino-Laryngology

Conclusions from the Three-City prospective cohort study. Int J Geriatr Psy-
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Acknowledgements  The authors would like to gratefully acknowl- patients with hearing loss: current perspectives. Clin Interv Aging
edge participants for generously sharing their time in this research. 14:1471–1480. https://​doi.​org/​10.​2147/​CIA.​S1958​24
The authors woukd like to acknowledge Dr. Carolina Fernandes for 10. Kim SY, Kim H, Park E et  al (2017) Severe hearing impair-
useful discussions. ment and risk of depression: a national cohort study. PLoS ONE
12(6):1–11. https://​doi.​org/​10.​1371/​journ​al.​pone.​01799​73
Funding  This research received no specific grant from any funding 11. Mulrow CD, Aguilar C, Endicott JE et al (1990) Association
agency in the public, commercial, or not-for-profit sectors. between hearing impairment and the quality of life of elderly
individuals. J Am Geriatr Soc 38:45–50. https://d​ oi.o​ rg/1​ 0.1​ 111/j.​
1532-​5415.​1990.​tb015​95.x
Declarations  12. Pronk M, Deeg D, Kramer S (2014) Hearing status in older per-
sons: a significant determinant of depression and loneliness?
Conflict of interest  The authors declare that there is no conflict of in- Results from the longitudinal aging study Amsterdam. Am J
terest. Audiol 22(2):316–320. https://​doi.​org/​10.​1044/​1059-​0889
13. Bosdriesz J, Stam M, Smits C et al (2018) Psychosocial health
Ethical approval  The study was approved by the Ethical Committee of cochlear implant users compared with that of adults with and
of Polytechnic Institute of Coimbra in March 2018 (Approval number without hearing aids: results of a nationwide cohort study. Clin
2/2018). Otolaryngol 43:828–834. https://​doi.​org/​10.​1111/​coa.​13055
14. Pocinho M, Farate C, Dias C et al (2009) Clinical and psycho-
Consent to participate  All the participants gave written consent prior metric validation of the geriatric depression scale (GDS) for Por-
to their participation, and the procedures applied were carried out in tuguese elders. Clin Gerontol 32(2):223–236. https://​doi.​org/​10.​
accordance with the Declaration of Helsinki. 1080/​07317​11080​26786​80
15. West J (2017) Hearing impairment, social support and depressive
symptoms among U.S. adults: a test of the stress process para-
digm. Soc Sci Med 192:94–101. https://​doi.​org/​10.​1016/j.​socsc​
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