Association of Hearing Loss

With Hospitalization and

Burden of Disease in Older
Adults
Dane J. Genther, MD; Kevin D. Frick, PhD; David Chen, BS; Joshua Betz, MS; Frank R. Lin, MD, PhD

To the Editor: Hearing loss (HL) is a chronic condition that affects nearly 2 of every 3 adults
aged 70 years or older in the United States. 1 Hearing loss has broader implications for older adults,
being independently associated with poorer cognitive2 and physical functioning.3
The association of HL with other health economic outcomes, such as health care use, is unstudied.
We investigated the association of HL with hospitalization and burden of disease in a nationally
representative study of adults aged 70 years or older.

METHODS
We analyzed combined data from the 2005-2006 and 2009-2010 cycles of the National Health and
Nutrition Examination Survey (NHANES), an ongoing epidemiological study designed to assess the
health and functional status of the civilian, noninstitutionalized US population. 4 Air-conduction
pure-tone audiometry was administered to all individuals aged 70 years or older, according to
established NHANES protocols.
Hearing was defined per the World Health Organization 5 as the average of hearing thresholds (in
decibels) at speech frequencies (0.5-4 kHz) in the better-hearing ear (range: 0-100 dB). Data on
hospitalizations (during the previous 12 months) and on burden of disease (during the previous 30
days) were gathered through computer-assisted or interviewer-administered questionnaires.
Hospitalization was defined as any hospitalization (yes or no) and number of hospitalizations (0, 1,
or >1 times). Burden of disease was defined as self-reported number of days of poor physical health,
poor mental health, and inactivity due to health (0-10 or >10 days).4
Data were analyzed using stepwise multivariable logistic and ordinal logistic regression models to
investigate the association of HL as a continuous variable (per 25 dB) with hospitalization and
burden of disease, adjusting for demographic characteristics and cardiovascular risk factors. We
accounted for the complex sampling design using sample weights according to National Center for
Health Statistics guidelines.
Data were analyzed using Stata version 11 (StataCorp). A 2-sided threshold of P < .05 was used to
evaluate statistical significance. The NHANES protocol was reviewed and approved by the National
Center for Health Statistic's institutional review board and informed written consent was obtained
from all participants.

RESULTS
Compared with individuals with normal hearing (n = 529), individuals with HL (n = 1140) were
more likely to be older (mean age: 74.7 vs 77.0 years; P <.001), male, white, less educated, in lower
income households, have a positive history for cardiovascular risk factors, have a history of
hospitalization in the past year (18.7% vs 23.8%; P = .02), and have more hospitalizations (1.27
[95% CI, 1.13-1.41] vs 1.52 [95% CI, 1.40-1.64]; P = .03) (Table 1).

Table 1. Demographic Characteristics of Participants Aged 70 Years or Older With

Audiometric Testing From National Health and Nutrition Examination Surveys in 20052006 and 2009-2010a

Fully adjusted models accounting for demographic and cardiovascular risk factors demonstrated
that HL (per 25 dB) was significantly associated with any hospitalization (odds ratio [OR], 1.32
[95% CI, 1.07-1.63]), number of hospitalizations (OR, 1.35 [95% CI, 1.09-1.68]), more than 10 days
of self-reported poor physical health (OR, 1.36 [95% CI, 1.06-1.74]), and more than 10 days of selfreported poor mental health (OR, 1.57 [95% CI, 1.20-2.06]) (Table 2). Hearing loss was not
associated with days of self-reported inactivity due to health.

Table 2. Association of Hearing Loss With Any Hospitalization, Number of

Hospitalizations, and Burden of Disease in the Previous 12 Months From National Health
and Nutrition Examination Surveys in 2005-2006 and 2009-2010

DISCUSSION
For adults aged 70 years or older, HL was independently associated with hospitalization and poorer
self-reported health over the past 12 months. This is, to our knowledge, the first nationally
representative study to demonstrate that HL is independently associated with increased health care
use and burden of disease among older adults. Pathways through which HL would contribute to the
odds of hospitalization and poorer self-reported health include effects of HL on social
isolation,6health-related oral literacy, and cognitive decline. 2

Alternatively, residual confounding by unmeasured factors not accounted for in our analyses (eg,
subclinical microvascular disease) could also underlie the observed associations. A principal
limitation of this cross-sectional study is that we cannot determine the temporal course and
mechanisms through which hearing loss could be associated with hospitalization and burden of
disease.
Future economic analyses may need to take into account these potential broader implications of HL
on the health and functioning of older adults. Additional research is needed to investigate the basis
of these observed associations and whether hearing rehabilitative therapies could help reduce
hospitalizations and improve self-reported health in older adults with HL.

ARTICLE INFORMATION
Author Contributions: Drs Genther and Lin had full access to all of the data in the study and
take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Genther, Frick, Chen, Lin.
Acquisition of data: Genther, Chen.
Analysis and interpretation of data: Genther, Frick, Betz, Lin
Drafting of the manuscript: Genther, Lin.
Critical revision of the manuscript for important intellectual content: Genther, Frick, Chen,
Betz, Lin.
Statistical analysis: Genther, Frick, Chen, Betz, Lin.
Obtained funding: Lin.
Administrative, technical, or material support: Chen, Lin.
Study supervision: Lin.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE
Form for Disclosure of Potential Conflicts of Interest. Mr Chen reported receiving student tuition
support from the William Demant Foundation. Dr Lin reported serving as a consultant to Pfizer,
Autifony, and Cochlear Corp; and receiving speakers fees from Amplifon. No other author reported
any disclosures.
Funding/Support: This study was supported by grant T32DC000027-24 from the National
Institutes of Health and grant 1K23DC011279 from the National Institute on Deafness and Other
Communication Disorders, with further funding from the Triological Society and the American
College of Surgeons through a clinician scientist award, and funding from the Eleanor Schwartz

Charitable Foundation. Funding for National Health and Nutrition Examination Survey data
collection was provided by the Centers for Disease Control and Prevention, National Center for
Health Statistics, and the National Institute of Deafness and Other Communication Disorders (for
audiometric data).

Role of the Sponsor: The sponsors had no role in the design and conduct of the study;
collection, management, analysis, and interpretation of the data; and preparation, review, or
approval of the manuscript; and decision to submit the manuscript for publication.
Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

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