• Prerequisites and learning objectives
• Lesson
  • Content
    • 1 - Hearing loss in the elderly
      • 1.1 - Presbycusis
        • 1 . 1 . 1 - Pathophysiology
        • 1 . 1 . 2 - Clinical signs
        • 1 . 1 . 3 - Diagnosis
        • 1 . 1 . 4 - Treatment
          • 1 . 1 . 4 . 1 - Hearing aid
          • 1 . 1 . 4 . 2 - Speech and language therapy
      • 1.2 - Other types of hearing loss in the elderly
        • 1 . 2 . 1 - Chronic otitis
        • 1 . 2 . 2 - Otospongiosis
        • 1 . 2 . 3 - Other types of perception hearing loss in the elderly
    • 2 - Vertigo andequilibrium problems in the elderly
      • 2.1 - Vertiginous pathology in the aged subject
        • 2 . 1 . 1 - Benign positional paroxysmal vertigo
        • 2 . 1 . 2 - Menière’s disease
        • 2 . 1 . 3 - Vestibular neuritis
        • 2 . 1 . 4 - Cochleovestibular ischemia
      • 2.2 - Central nervous system impairment leading to equilibrium problems
        • 2 . 2 . 1 - Vascular etiology
        • 2 . 2 . 2 - Parkinson’s disease
        • 2 . 2 . 3 - Causes due to medication
      • 2.3 - Equilibrium problems in the elderly without a particular pathology
        • 2 . 3 . 1 - Physiological reminder
        • 2 . 3 . 2 - Aggravating factors to consider
        • 2 . 3 . 3 - Recommended strategies
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1  -  Hearing loss in the elderly

1 . 1  -  Presbycusis

Presbycusis is defined as an alteration of audition related to age, but it should not be forgotten that an aged subject may present with all the types of hearing loss observed in younger patients.

Antecedents of otitis, otospongiosis, trauma of any nature, toxic agents, and certain infections can provoke hearing loss to which is added the effect of aging.

Sensory aging begins very early for the auditive organ (from the age of 25 years). It affects the auditory field at the high-pitched level and remains infra-clinical for a long time. The average hearing loss (conversational frequencies) is estimated to be 0.5 dB per year for 65 years of age, 1 dB for 75 years, and 2 dB for 85 years (Fig.1).

Fig.1 : Graph showing the progression of average auditory thresholds in tonal audiometry as a function of the patient’s age

Deafness is predominantly at the high-pitched frequencies and becomes socially perturbing when the audiometric threshold is superior to 30 dB HL at the 2 000 Hz frequency.

Aging of the internal ear is variable among subjects. This variability is related to genetic factors, local aggravation factors (chronic otitis…), general factors (metabolic, vascular…), or environmental factors (acoustic trauma…).

1 . 1 . 1  -  Pathophysiology

Presbycusis affects the sensory cells of the organ of Corti, which undergo a larger degeneration at the base of the cochlea (high-pitched sounds) than at the summit (low-pitched sounds). It is the external auditory hair cells that are the most affected. These contractile cells adapt the deformation of the basilar membrane to the stimulus via the selective amelioration of the frequency perception.

In the presbycusic subject, there is :

• an elevation of the auditory thresholds due to the degeneration of the internal auditory hair cells (the intensity of the sound needs to be increased in order to be heard);
• a decrease in frequency discrimination due to the degeneration of the external auditory hair cells leading to an alteration of speech comprehension even if amplified: “I hear but I do not understand”.

1 . 1 . 2  -  Clinical signs

It is a perception deafness that is bilateral and symmetric, which predominantly involves the high-pitched frequencies. The hearing loss is usually isolated but can be accompanied by tinnitus and balance disorders.

The appearance of the first symptoms is generally between 60 and 65 years of age. When the symptoms begin earlier, one speaks of a precocious or aggravated presbycusis.

Generally, the presbycusis is defined by three stages :

• Infra-clinical stage :
  • The symptom consists of a loss of intelligibility in a noisy background. The patient is hampered during conversations with several participants (family meals, restaurant, etc.), in meetings, in the presence of background music…;
  • The audiogram shows normal thresholds for low-pitched sounds up to the frequency of 2000 Hz, with an inconsistent loss for high-pitched frequencies at less than 30 dB (fig.2);

• Stage with social impact :
  • The auditive disturbance is frank, and the patient needs to request repetition and an elevation of the voice. This occurs when the loss attains 30 dB at the frequency of 2000 Hz.
  • Support becomes imperative;

• Isolation stage :
  • The untreated patient stops communicating;
  • At times leading to depressive syndrome.

Fig.2 : Tonal audiometry showing perception deafness beginning at the high-pitched frequencies  

Early presbycusis; CO: bone conduction; CA: air conduction.