How Hearing Aids Help Cognition and Relationships

I was starting to notice that at busy restaurants, I could not distinguish voices clearly from the background noise. At the same time my mate Jeremy had more trouble hearing me in our own quiet home, and I found myself getting irritated repeating myself over and over.

When I told my friend Elyce, her ears perked up. She was engaged in research into aging and hearing to earn a Ph.D. in Public Health; she urged us to see an audiologist immediately and get hearing aids. But a doctor in my network had tested my hearing not long before and said my hearing loss was slight, normal for my age, and I could wait a while before being fitted for hearing aids.

Elyce vehemently disagreed. "Yes, some degree of hearing loss is normal as we age, but it's usually so gradual you don't notice it and you lose a lot before it becomes hard to distinguish the pattern," she said. "Imagine people telling you not to bother with glasses, that your vision is normal for your age? Does 'normal for your age' mean not driving? No, you get glasses."

Persuaded, I sought out a new audiologist.

It turns out most people wait seven to nine years before seeking intervention even though it is now well established that hearing loss impairs how we think, and mounting evidence that it is accompanied by cognitive decline and even dementia. Yet people often resist being tested, buying hearing aids or wearing them after purchase.

I started noticing this reluctance in others: Not only Jeremy, but a friend who kept asking others to repeat themselves; she had hearing aids but did not like using them. The companion of a girlfriend often forgot his hearing aids when they left on vacation. A stranger at a party could not contain her resentment at her husband for not accompanying her to social events because he can't join in the conversation.

It seems obvious that given our ageist culture, many don't want to appear old or dependent. But we don't seem to stigmatize dependence on glasses in the same way. I wondered why.

Who better to ask than my new audiologist, Melissa Alexander? She confirms that "hearing aids have come a long way in terms of design, functionality and style" but public prejudice makes many people feel old or handicapped if they use them.

Some people have a misperception that wearing hearing aids may make one's brain or ears "lazy" and dependent. On the contrary, Alexander adds, studies have shown that not wearing hearing aids when they are necessary can degrade cognition because the brain requires a certain amount of aural stimulation to maintain neural connections and hearing aids provide that stimulation.

I have come to realize I am quite ignorant about hearing in general. In her book, "Of Sound Mind: How Our Brain Constructs a Meaningful Sonic World," Nina Krause, a professor of neurobiology and otolaryngology at Northwestern University, illustrates her theme that sound is underrecognized and hearing is underappreciated. She describes "sound as invisible and fleeting, but dense with meaning in ways most of us don't recognize."

Our sense of hearing is always on. The structures and physiology of hearing are incredibly complex. The outer, middle and inner ear, the hair cells, fluid and bones conduct sound but it's the auditory cortex in the brain that makes sense of and interprets the sound, or "hears" it.

Over time it's not just that hearing worsens, the ability to recognize words and understand speech also deteriorate. Losing our ability to translate sounds into words and combine them clearly, means hearing loss impairs how we think, as well as our memory and mood. The brain can forget how to hear something, forget how to listen.

Which brings us to why hearing aids are much more complex and expensive than glasses and why users shouldn't assume they will work instantaneously. They work by teaching the brain to hear again, which takes about a month or two of uninterrupted wear, and maybe some adjustment and coaching. Folks who expect immediate improvement in their hearing may conclude that their hearing aids are not working.

Alexander describes how audiologists program hearing aids to give each ear a certain volume at each frequency so wearers can determine how many people are talking within two meters of their head, identify who is speaking, how loud their voice is and amplify individual voices so that everybody is audible against background noise. They're effectively tiny computers powered by artificial intelligence, and not cheap to produce.

Most health insurance plans, including Medicare, do not cover the cost of hearing aids. Over-the-counter aids designed for use by people with mild to moderate hearing loss cost between $100 and $1,000 and can be purchased without a prescription.

Hearing aids tailored to an individual's auditory issues need a prescription and cost from $1,000 to $7,500 or more; the median cost is roughly $2,500—a price unaffordable to 77% of Americans with functional hearing loss, according to one recent study.

The cost of not being able to afford a hearing aid may be much higher than that because of the correlation between hearing loss and diminished cognition or even dementia — and the fact that dementia is very expensive to treat.

Researchers at the Icahn School of Medicine in New York City calculated total health care expenses — including insurance, hospitalization, medication, nursing home, hired helpers, and in-home medical care — over the last five years of life for 1,700 patients divided into four groups. One had dementia, another cancer, a third had heart disease and the remaining patients died of other causes.

Average total health care costs over the last five years of life for patients with dementia was $287,038, the research found. This was 64% more than the cost of care for those who died of heart disease ($175,136), 66% more than people who died of cancer ($173,383), and 45% more than the average amount spent on people who died of other causes ($197,286).

Another study, by scientists at Johns Hopkins University in Baltimore, found that hearing aids reduced the rate of cognitive decline in older adults at high risk of dementia by almost 50% over a three-year period. "Treating hearing loss may be a safe way to lower the risk of dementia in vulnerable populations," the researchers concluded.

An article published in the medical journal Frontiers in Neuroscience in 2022 said that giving older people hearing aids for just six months improved their cortical and cognitive function and offset physical changes in the brain. Even when the aids were removed, patients' brains showed signs of reorganizing.

Hearing loss has another important cost: the emotional strain it often puts on personal relationships. As my friend Elyce is exploring in her research, and Alexander confirms, hearing partners have to adapt, often by speaking louder and slower, experiencing irritation and accepting decreases in connection and spontaneity.

Often, hearing partners feel they need to be vigilant and try to hear for their partner, so they may become a translator in social situations. To the listening-impaired person this can feel patronizing. But with or without that, there is a real risk of increasing social isolation, as was clear from the woman at the party mentioned earlier. "If you don't hear well, you tend to withdraw, feel increasingly socially disconnected and lonely and lead a less enriching life," Kraus writes in her book.

In addition, there is also a disturbing erosion of the ability to distinguish emotions that exist in the fringes of vocal sounds. The tone and emotional qualities of the voice can tell us as much and sometimes more than the words. A hearing-impaired person may also lose the ability to hear themselves and start to talk louder or slur their speech.

Elyce has found anecdotally that couples in therapy for communication problems may work with a therapist ignorant of the fact that hearing loss can play a part in relationship problems and that some of the negative behaviors may be an attempt to compensation for that deficit.

Alexander cites the Achieve Study, a National Institute of Health-backed long-term study of a large sample population. Patients with progressive hearing loss that is left untreated will have cognitive decline irrespective of genetic predisposition. But a recent follow-up study found that when patients with physical evidence of dementia would consistently wear hearing aids, they do not show symptoms of cognitive decline. That is consistent with the hypothesis that wearing hearing aids stimulates the brain and slows the dementia.

We have evidence that when one or both partners in a relationship has trouble hearing, wearing a hearing aid improves communication and adds a lightness to the relationship. The hearing individual can feel heard and understood and that makes for a dramatically better quality of relationship, not just for married couples, but also in other family dynamics and at work.

The stigma against hearing aids may be fading. Alexander said patients do not wait as long as they used to before seeking help. "They may come in with a report of tinnitus," she said, using the clinical term for chronic ringing in the ears, "but it's usually a spouse, relative, daughter or close friend encouraging that person to come get tested and treated." When patients come back in for adjustment or coaching, many tell her how it's improved their relationships.

"I worked with a couple. The husband was a younger professional guy, married to a wonderful lady and their frustration in my office was palpable," Alexander recalled. "His hearing loss was tremendous and she finally said, 'You're going to wear these hearing aids or we're getting divorced.' She meant it.

"Now he's one of my biggest advocates" she added. "It totally changed his life and relationship. And I get to hear those stories every day, which is the blessing of my job."