Presbycusis (Age-Related Hearing Loss)

Definition and epidemiology

Presbycusis is a bilateral and symmetrical sensorineural hearing loss that develops from gradual degeneration of the hair cells, the stria vascularis and auditory-nerve structures in the inner ear with age.

It is among the most common causes of hearing loss worldwide. Prevalence rises markedly with age; relatively low in the 60s, it affects more than half of individuals at very old age (WHO, 2021).

The loss typically starts at high frequencies; this makes it hard to distinguish consonant sounds (s, sh, f, t) and leads to the complaint ‘I hear but I don’t understand.’

Symptoms and signs

The most common complaint is difficulty understanding speech, especially in noisy environments. The person hears that a sound is present but cannot pick out the words; they often ask for repetition or turn up the television.

Because of the loss of high-frequency consonants, speech is perceived as ‘not clear, muffled.’ Over time, phone calls and crowded settings become difficult, which can lead to social withdrawal.

Tinnitus often accompanies it. The onset is insidious and slow; that is why the person and their relatives usually notice the loss late.

Causes and risk factors

Presbycusis is multifactorial: genetic predisposition, lifelong noise exposure and metabolic-vascular factors act together.

Conditions affecting vascular health such as hypertension, diabetes, obesity and smoking increase the risk of hearing loss; they are thought to accelerate the process by impairing the inner ear’s microcirculation.

Managing these risk factors is important for protecting both hearing and general health (Gates & Mills, 2005).

Audiological and clinical assessment

Assessment starts with an examination that excludes outer/middle-ear causes. Presbycusis diagnosis rests largely on audiological tests and increasingly includes a ‘cognitive audiology’ perspective.

• Pure-tone audiometry: shows a bilateral, symmetrical sensorineural loss starting at high frequencies.
• Speech audiometry and speech-in-noise tests: reveal functional communication difficulty.
• Tympanometry and acoustic reflexes: exclude middle-ear causes.
• OAE: assesses cochlear outer hair-cell function.
• Cognitive-screening integration: may be recommended in older adults given the link between hearing and cognition.

Treatment and audiological rehabilitation

Presbycusis has no drug that reverses it; the mainstay of management is hearing aids and auditory rehabilitation. Modern digital devices, fitted to the person’s audiogram, make speech intelligible.

In individuals with severe-to-profound loss who do not benefit enough from a device, a cochlear implant is considered; successful results are obtained in suitable candidates even at advanced age.

Auditory rehabilitation is a multi-component process including device training, communication strategies, lip-reading and family involvement. A large-scale study, ACHIEVE, showed that hearing intervention can slow cognitive decline in older adults at cognitive risk (Lin et al., 2023).

Impact on quality of life and advice

Untreated hearing loss is associated with social isolation, depression, fall risk and cognitive decline. The 2024 Lancet Commission identified hearing loss as one of the most important modifiable risk factors for dementia (Livingston et al., 2024).

Not delaying device use, reducing noise, speaking face to face and clearly, and involving family members in communication are recommended. Early intervention protects both communication and general quality of life.