Hear and now

Better, less costly treatments for hearing loss coming soon

Here and now Spring18

As far as Amy Yotopoulos could tell, her father, Edwin Lutz, was changing with age, the way most people do. He had become more introverted and quiet, less engaged. But he was still the same. He was simply finding everything harder to hear.

As his six grandchildren were born and learned to talk, he had difficulty picking up what they were saying. Trying to keep up in any conversation wasn’t just difficult, it was sometimes impossible. “If I didn’t hear something right at the beginning, I just gave up. So I just kind of gave up on listening,” Lutz said.

Lutz, who is now 76, was frustrated with his first pair of hearing aids, which he received about 12 years ago. He would only put them in if his wife, Peggy, suggested it, and then they would squeal or he’d still struggle to hear, only to give up and toss them back in the drawer. Yotopoulos watched as her father grew tired of saying “I can’t hear you” to her and his grandkids. “And it was hard for the kids to take turns, speak clearly and slowly, face Grandpa, et cetera,” she says. “So we all just figured this was the new normal.”

For Yotopoulos, director of the Mind Division of the Stanford Center on Longevity, this new normal was unacceptable. How could a man whose daughter was an expert on healthy aging be unable to address his hearing loss? Yotopoulos was well aware how common it is for aging adults to be afflicted with hearing loss; how rarely they get adequate treatment; and how vast the impact of untreated hearing loss can be on their health, mobility, finances and relationships.

With access to the Stanford Medicine physician-scientists who are making advances in the diagnosis and treatment of hearing loss, Yotopoulos also knew that new solutions were within reach — not just for her dad, but for the millions of people who have hearing loss today or are projected to have it in the future.

According to the National Institutes of Health, “Approximately one in three people between the ages of 65 and 74 has hearing loss, and nearly half of those older than 75 have difficulty hearing.” A review of literature in the October 2017 JAMA Otolaryngology raised that estimate, stating that hearing impairment affects nearly two-thirds of Americans who are 70 and older. Simply put, adults older than 70 are more likely to have hearing loss than to have normal, healthy hearing.

Despite these statistics, fewer than 20 percent of people with hearing loss obtain treatment. The small percentage of people who address the issue, such as by getting hearing aids, don’t usually do so until eight to 10 years after their initial diagnosis — enough time for some of the conditions related to hearing loss to take hold.

Understanding hearing loss

The way we live with hearing loss, however, is in the midst of a revolution, with enormous changes ahead. New approaches to testing and more affordable and effective treatments are clearing the way for healthier hearing in aging adults. Those changes can’t come soon enough. Aging adults are less willing than ever to let hearing loss slow them down and are more open to wearing advanced, in-ear devices.

Yotopoulos says people might be more motivated to take action if they were fully aware of the health consequences of not being treated.

“We can’t say hearing loss causes these issues at this point, but it’s correlated with decreased mental health, such as depression, and increased risk of cognitive decline, dementia and death,” Yotopoulos says. “It’s correlated with your balance, risk of falls and sense of social engagement. And we now know that social isolation has the same mortality and risk factors as smoking a pack of cigarettes a day, or as being obese.”

Because her dad had surmounted other serious health issues, his hearing loss seemed a relatively manageable problem. Still, it was a continual source of frustration. The simple joy of watching British television mysteries with his wife became a complicated activity full of missed moments and him asking questions. Lutz could no longer hear the sounds of the outdoors that he loved. And there was no joy in going to restaurants, where background noise made it impossible to follow conversations.

“I thought he was just kind of calmer or just wanted to watch things,” says Yotopoulos. “And it was a little sad because he wasn’t this ‘Hey let’s play a card game together’ kind of grandpa anymore.”

“Hearing loss is a potent isolator,” says Robert Jackler, MD, the Edward C. and Amy S. Sewall Professor in Otorhinolaryngology, professor of neurosurgery and of surgery at Stanford. “Human communication is nourishing not only to the soul, but also to the mind and, ultimately, the body. People who become isolated and unable to interact with others withdraw into an ever-closing circle that leads to unhappiness and depression for many.”

Edwin Lutz and his wife, Peggy, don’t let his hearing problems slow them down. They hike, kayak, backpack, sail, golf and enjoy time with friends and family. ‘At our age, one can never stop because if you do, you will never get back,’ he says. (Photo courtesy of Edwin Lutz)

For older adults, that isolation has far-reaching consequences. “When you lose your hearing, you don’t just lose your ability to hear,” says Matthew Fitzgerald, PhD, assistant professor of otolaryngology-head and neck surgery at Stanford. “There’s evidence to suggest that the brain may reorganize, that the brain will change, when you have hearing loss and are deprived of sound.”

Losing our sense of sound as we age is, for most people, caused by the deterioration of cells deep in the inner ear known as hair cells. “It’s a popular misconception that hearing loss, when you grow older, is ‘nerve deafness.’ In fact, we know that the hearing part of the brain and the hearing nerve remain intact,” explains Jackler, who is chair of the Department of Otolaryngology-Head & Neck Surgery.

Instead, most adults experience a gradual breakdown of “a relatively small population of hair cells that take vibrations in the air and turn them into nerve impulses the brain understands as sound.” Repeated exposure to loud noise — at work sites or concerts, for example — can expedite that breakdown.

“It wasn’t a single event that caused my hearing loss. It was a gradual progression, part of it age, and part of it the environment I was in.”

As a boy growing up on a farm in South Dakota, Lutz was a hunter. “We shot rifles and shotguns,” he says. “And we didn’t wear any hearing protection.” In 1965, when Lutz was 23, he began his service as a helicopter pilot for the Army, serving in the Vietnam War. “Even though we had flight helmets and earplugs, the high frequency of the turbines caused complete high-frequency hearing loss,” says Lutz. In 1987, his military retirement physical showed that Lutz still had hearing in the lower ranges, but over time he began to lose that as well.

“It wasn’t a single event that caused my hearing loss,” says Lutz. “It was a gradual progression, part of it age, and part of it the environment I was in.”

The onset of hearing loss as we age may be gradual, but the accumulated effect on our population is developing into an epidemic of drastic proportions. This is especially true in the United States as the baby boom generation — the 75 million babies born from 1946 to 1964 — has reached or is about to reach senior citizenship. The number of individuals of all ages with mild to complete hearing loss will balloon from just under 44 million today to nearly 55 million in 2030.

With such vast demand for audiological health care services, coupled with recent advances in technology and treatments, the hearing care industry is ripe for transformation. Even as the industry is changing, so are the aging individuals it serves. “It used to be that grandmother sat upstairs and knitted and came down for dinners and was with the grandchildren,” says Jackler. “Now seniors want to live active, full and socially engaged lives. They want to go to seminars, enjoy restaurants and be out with friends until a much later age.”

That’s certainly true for Ed and Peggy Lutz. While most of their friends near their home in the state of Washington travel south for the winter, the Lutzes go north. Ed Lutz is the youngest male member of his ski club at Big White in Kelowna, British Columbia. The oldest member is 90. “I’ve had two strokes and lost a third of my peripheral vision on the left side, so I follow my wife down the slopes now,” he says.

Lutz has also had two heart attacks, remedied by a pacemaker and defibrillator. Yet he and his wife still enjoy hiking and backpacking, sea kayaking, sailing on the lake, playing bridge, golfing, and volunteering at the local community civic center and the annual chamber music festival. “At our age, one can never stop because if you do, you will never get back.”

That desire to stay active and engaged as an aging adult can accentuate the stigma of hearing loss and of using hearing aids. For many adults, losing hearing is a signal of increasing and inevitable physical fragility that can be profoundly difficult to accept. Wearing a hearing aid can feel like having that fragility openly on display. Many would rather live without it.

Couple this with the outrageous prices of hearing aids and the barriers to care feel insurmountable.

High demand for cutting costs of care

Hearing aids cost anywhere from $1,000 to $6,000, which includes the device — or devices, as two are often needed — and the professional services to fit and program them. Few insurance companies provide coverage for hearing aids, though the full coverage the Veterans Health Administration provides is a welcome exception.

Hearing aids are the third most expensive tangible investment most families make, after a house and car. Yet the investment is still a good choice because the use of hearing aids has been shown to mitigate income loss up to $22,000 annually for people with extreme hearing loss. Annual excess medical expenditures for U.S. adults with hearing loss who are 65 and older are estimated at $3.1 billion, according to a study in the Journal of the American Geriatrics Society published in June 2014.

“The profit margin for hearing aids approximates that for popcorn at the movie theater.”

“It’s horrendous how expensive hearing aids are. They are enormously overpriced,” says Jackler. “The profit margin for hearing aids approximates that for popcorn at the movie theater.”

That movie-popcornlike profit margin may soon be a thing of the past, as the new wave of hearing health takes hold. On Aug. 18, 2017, the Over-the-Counter Hearing Aid Act, designed to provide greater public accessibility and affordability for over-the-counter hearing aids, was signed into law. The law will make it easier for people with mild to moderate hearing loss to access hearing aids.

“The challenge,” explains Fitzgerald, “is getting people the right type of care they need for their level of hearing loss. Individuals who have more difficulty communicating will likely be best served by seeing an audiologist, while individuals who have less difficulty communicating should benefit from an over-the-counter device. What’s missing is a way to help triage or help guide patients as to what level of care they should be seeking.”

For family members like Yotopoulos and Peggy Lutz, having a way to help guide Ed Lutz to the right level of care would have simplified things. Recognizing that need — for people with hearing loss and their family members who notice it — Yona Vaisbuch, MD, clinical instructor of otolaryngology at Stanford, is developing an online tool for front-line assessment “to help bring people over the age of 55 to try solutions like hearing aids.”

First conceived in a six-month project with the Stanford Byers Center for Biodesign, the nonprofit website WeHearYou will offer a short video on awareness, a basic hearing screening, an explanation of treatments and an option to input your location to find a provider.

“Today we know that age-related hearing loss doesn’t start when you’re 60 or 70. That’s when it becomes really symptomatic,” says Vaisbuch. “We now know that people in their 30s are already beginning to experience subtle decline.” His hope is that the website will be a way to screen and inform as many people as possible.

“When you have hearing loss, you spend a lot of time just trying to compensate for that,” says Vaisbuch. “We call it the cognitive load. You’re putting all your cognitive effort into hearing, instead of into the other things you’re doing. With time, those brain changes will not be reversible. That’s why we need to treat hearing loss as soon as possible.”

Improving diagnostics

But to adequately treat hearing loss, patients must first have an accurate diagnosis — a key to revolutionized hearing care. Jackler and Fitzgerald are challenging the routine hearing tests of the past and are developing a new approach.

“The way hearing testing has been done for the past 60 years is threshold testing in a quiet room,” says Jackler. “Well, for most people, their problem is not how well they hear really soft whispers in a quiet room.”

“The reality is that when patients walk in the door, the No. 1 complaint they have is the difficulty of understanding speech in the presence of background noise,” says Fitzgerald, who is the chief of audiology at Stanford Health Care and Lucile Packard Children’s Hospital Stanford. “At Stanford, we’re taking the lead in trying to make speech in noise the default test of speech perception in the audiology test battery. This small, but fundamental shift would be one of the most significant changes in how hearing testing is done in this country in decades.”

The change would be particularly beneficial for older people with hearing loss, Fitzgerald says, because “when you get older, the ability to extract speech from background noise gets a little worse than when you’re younger, and the existing test battery doesn’t account for that possibility at all.” Testing a patient’s ability to communicate and understand speech may allow audiologists and physicians to parse the effects of aging from the effects of hearing loss.

While these new measures are part of the standard audiometric testing at Stanford, only some clinics nationally have incorporated them. “They are more often seen as something extra,” says Fitzgerald.

“When you have hearing loss, you spend a lot of time just trying to compensate for that.” 

Changing decades of clinical practice doesn’t happen overnight, Fitzgerald says, and some audiologists question what it adds to their practice. His research aims to show how these measures can be readily integrated and to emphasize the additional information that can be gained from their use. The next, ideal step after that research is published, he says, would be for the governing bodies for both audiology and otolaryngology to recommend guidelines for speech in noise testing as part of the baseline audiological evaluation. “I’m optimistic that high-quality published research, in conjunction with maintaining a presence at national meetings, will facilitate this transition that is long overdue,” Fitzgerald says.

The more accurate the measure of a patient’s hearing difficulty, the more accurate and personalized treatment can be. Because hearing difficulty is highly individualized, from the degree and type of hearing loss right down to the shape of the ear, there’s no one-size-fits-all solution. With a broad selection of fittings, features and styles, a variety of hearing aids can drastically improve hearing for people with mild to severe hearing loss right now.

“There’s been more development in hearing aids in the past seven years than in the past 70,” says Gerald Popelka, PhD, adjunct professor of neurosurgery, head of the Stanford Ear Institute Neuromodulation Research Lab and one of the inventors of the first digital hearing aid.

High-tech advancements in devices

Those advances include everything from digital Bluetooth-connected hearing aids that work with devices like televisions and other sound systems to stream audio to designs that fit invisibly in the ear canal or with a low-profile shape around the ear. Each can be programmed to the individual frequency needs of the listener.

Even as today’s technology can readily solve the hearing difficulties of many people, the pace of innovation is still gaining momentum. Solutions to hearing loss are being developed both within the ear and beyond the ear. By the time that Generation Y — the only generation to outnumber baby boomers, and one that’s already accustomed to the regular use of in-ear devices — begins to reach age 60 in 2041, these innovations, along with others we cannot yet imagine, will be available.

“Increasingly,” says Jackler, “wearing something on your ear will be a badge of technological prowess rather than a marker of age and infirmity.” Jackler and his associates in Stanford’s audiology division and the Byers Center for Biodesign envision devices that are capable of doing much more than enhancing hearing for users of any age.

“It turns out that having a telemetry system attached to the human body has very important implications, not the least of which are for hearing,” says Jackler. “If you have something clipped on your ear that communicates out to a computer system, you have the ability to monitor oxygen, glucose, blood pressure and, through little EKG-like sensors on your chest, the electrical activity of your heart.”

All of this health monitoring could be available in the same device — Vaisbuch calls such devices “earables” — that stores and plays your music or audiobooks and connects to your phone or to audio text messaging. Such a device could, for example, alert you if you’re starting to cross the street when a car is coming or discreetly remind you of the name of the host’s spouse when you arrive at a party. As voice-to-text technology improves, it could eliminate the need for a keyboard, reducing carpal tunnel syndrome. It could be programmed to lower background noise and amplify voices in spaces that are often especially challenging for people with hearing loss, such as restaurants or theaters. It could also use noise-cancelling technology to silence the environment when desired.

“The ear becomes an important part of this enriched linkage between the human body and machines,” says Jackler. “You’re looking at a coupling of man and electronic device that really changes our understanding of how diseases function.”

Another intervention that Jackler hopes will become a reality in the near future is a biological cure for hearing loss. Through the Stanford Initiative to Cure Hearing Loss, more than a hundred scientists and technicians are working to cure inner-ear hearing loss — the type that results from hair cell degeneration — which remains incurable today.

“We’re very hopeful that this will come to humans in the next decades and that what was heretofore incurable will become curable.”

Stefan Heller, PhD, the Edward C. and Amy H. Sewall Professor and professor and vice chair of research in otolaryngology, was the first to discover the stem cells within the inner ear of mammals that can be converted to hair cells. “We know that hair cells regenerate in birds, reptiles and amphibians,” says Jackler, “but not particularly in mammals such as humans.”

Under Heller’s leadership, the hearing loss initiative is exploring the manipulation of pluripotent stem cells — foundational stem cells that exist in the patient’s own body, in this case in the ear itself — to restore hair cells and allow patients to hear again. So far, the team has seen success only in mice.

“We’re very hopeful that this will come to humans in the next decades and that what was heretofore incurable will become curable,” says Jackler, “and that we’ll be able to rejuvenate hearing in the elderly, in the child born deaf and in someone who’s lost hearing from a variety of medical conditions.”

Until that cure is available, Jackler is still enthusiastic about the increasing options available to patients. “I have a huge optimism about the future of our ability to help people with hearing loss,” he says.

For two days in March 2017, the Stanford Center on Longevity gathered international experts in a broad range of fields including audiology, psychology, engineering, architecture and health advocacy to focus on improving communication for people with hearing loss. Yotopoulos and her colleagues had organized the conference to increase awareness of the prevalence and risks of untreated hearing loss, and of the need to think about hearing in the context of accessibility for all ages and in all settings. “It’s such an important piece of what Stanford University is doing with education and with creating community,” Yotopoulos says. “If we aren’t able to hear and listen to each other, we don’t have anything.”

Participants at the conference looked at many aspects of hearing, such as how acoustics in public spaces could be enhanced; how hearing tests could be improved; how hearing aid device technology, service, and cost could be transformed for the better; and how close scientists are to a cure. Even as they underscored the coming crisis of hearing loss in a ballooning population of aging adults, they envisioned a world designed to enhance listening and communication.

“Don’t give up if the first pair of hearing aids doesn’t feel right. Let your mind get accustomed to the new sounds.”

Yotopoulos had already seen, personally, the impact of some of these changes. In 2015, her father was fitted with two Bluetooth-enabled hearing aids at a Veterans Affairs clinic in Washington. “The audiologist was great,” says Lutz. “He said, ‘Now you’ve got hearing aids, Ed, but you know you’ve still got to learn how to listen.’ And my wife thought that was really great advice.”

Lutz has his own advice for people with hearing loss: “Don’t give up if the first pair of hearing aids doesn’t feel right. Let your mind get accustomed to the new sounds.”

He’s happy to hear the birds easily again. And he’s able to keep up with the clues when he and his wife watch their favorite mysteries.

“My wife can set the TV volume to what’s comfortable for her, and with the device I can set it for what’s comfortable for me,” says Lutz. “And I’m not afraid to go to a restaurant or a crowded place because I can adjust the ambient noise. I feel more comfortable around people in conversations, and I understand the kids better.”

Being able to communicate easily with his wife has been the most meaningful improvement. “Just being able to hear what she said, rather than having to have her repeat herself three times,” says Lutz. “Now I can hear her more often and I can answer her, so it’s clear, yeah, I’m paying attention to you. We have a pretty good life, but the hearing aids have enhanced it.”

Though they live far apart, Yotopoulos loves talking with her dad on the phone about everything from the activities of her now-teenage kids to the Lutzes’ latest adventures — such as learning to play the guitar and speak Spanish. It’s not only easier for her to communicate with him, but it’s also good to see him as the active, involved person he really is. “Having the hearing aids that actually work for him changed so much,” she says.

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Julie Greicius

Julie Greicius is the senior director of external communications in the Office of Communications.

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