Age and Ageing 2023; 52: 1–8 © The Author(s) 2023.

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NEW HORIZONS

New horizons in holistic, person-centred health

promotion for hearing healthcare
David W. Maidment1 , Margaret I. Wallhagen2 , Kathryn Dowd3 , Paul Mick4 , Erin Piker5 ,
Christopher Spankovich6 , Emily Urry7

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1
School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
2
School of Nursing, University of California, San Francisco, CA, USA
3
The Audiology Project, Charlotte, NC, USA
4
Department of Surgery, College of Medicine, University of Saskatchewan, Saskatoon, Canada
5
Department of Communication Sciences and Disorders, College of Health and Behavioral Studies, James Madison University,
Harrisonburg, VA, USA
6
Department of Otolaryngology - Head and Neck Surgery, University of Mississippi Medical Center, Jackson, MI, USA
7
Research and Development, Sonova AG, Staefa, Switzerland
Address correspondence to: David Maidment, School of Sport, Exercise and Health Sciences, Loughborough University,
Loughborough LE11 3TU, UK; Tel: +44(0) 1509 225439. Email: d.w.maidment@lboro.ac.uk

Abstract
Over the course of a lifetime, the risk of experiencing multiple chronic conditions (multimorbidity) increases, necessitating
complex healthcare regimens. Healthcare that manages these requirements in an integrated way has been shown to be more
effective than services that address specific diseases individually. One such chronic condition that often accompanies ageing
is hearing loss and related symptoms, such as tinnitus. Hearing loss is not only highly prevalent in older adults but is
also a leading cause of disability. Accumulating evidence demonstrates an interplay between auditory function and other
aspects of health. For example, poorer cardiometabolic health profiles have been shown to increase the risk of hearing loss,
which has been attributed to microvascular disruptions and neural degeneration. Additionally, hearing loss itself is associated
with significantly increased odds of falling and is a potentially modifiable risk factor for cognitive decline and dementia.
Such evidence warrants consideration of new possibilities—a new horizon—for hearing care to develop a holistic, person-
centred approach that promotes the overall health and wellbeing of the individual, as well as for audiology to be part of an
interdisciplinary healthcare service. To achieve this holistic goal, audiologists and other hearing healthcare professionals should
be aware of the range of conditions associated with hearing loss and be ready to make health promoting recommendations
and referrals to the appropriate health practitioners. Likewise, healthcare professionals not trained in audiology should be
mindful of their patients’ hearing status, screening for hearing loss or referring them to a hearing specialist as required.
Keywords: cardiovascular disease, dementia, falls, hearing loss, interprofessional care, older people
Key Points
• Hearing loss is associated with a range of negative health conditions, including poorer cardiometabolic health profiles,
increased odds of falling, and is a potentially modifiable risk factor for dementia.
• Health promoting activities, such as individuals adopting healthier behaviours or societies developing public health
interventions, may help promote positive hearing health and minimise the negative health impact of hearing loss and
related co-morbidities.
• Healthcare professionals need to be aware of the range of negative conditions associated with hearing loss.
• Hearing healthcare professionals need to be part of an integrated, interprofessional team, ensuring that holistic and person-
centred care is delivered to older adults.

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D. W. Maidment et al.

Longer lives are one of society’s most remarkable col- function and other aspects of health. For example, epidemi-
lective achievements; they reflect advances in social and ological evidence demonstrates that hearing loss in older
economic development, as well as in health [1]. However, adults is independently associated with declines in physical
with the passage of time, numerous underlying physiological functioning [11–13]. Maintaining optimal physical func-
changes occur and the incidence of major burdens of dis- tioning is essential to healthy ageing, with declines leading
ability from losses in hearing, vision and mobility increases. to poorer quality of life and greater dependence, as well
There is also an increased risk of developing chronic (or as increasing the risk of morbidity and mortality [14]. In
non-communicable) diseases, including cardiovascular dis- addition to general declines in physical functioning, hearing
eases, chronic respiratory disorders, cancers and demen- loss in older adults is also a specific risk factor for falls [15].
tia [2]. Older age is associated with an increased risk of Several mechanistic pathways underpinning the association
experiencing several chronic conditions simultaneously (so between hearing loss and physical functioning have been
called ‘multimorbidity’), as well as the emergence of complex postulated (Figure 2) and are discussed in detail elsewhere
health states known as geriatric syndromes, which include [16, 17]. Briefly, the cognitive reserve hypothesis suggests that,

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conditions such as frailty, delirium and falls [2]. Thus, it due to the requirement to process degraded sound signals,
is perhaps unsurprising that healthcare that considers and hearing loss results in an increased load on cognitive and
manages the complex needs of older age in an integrated way attentional resources, which are also necessary for physical
has been shown to be more effective than services that simply functions such as postural control and balance. Alternatively,
address specific diseases individually [3]. it has been suggested that psychosocial difficulties, namely,
Globally, over 65% of people aged over 60 years expe- social isolation, loneliness and depression, commonly experi-
rience some degree of hearing loss, with the prevalence of enced by older adults with hearing loss, mediate associations
hearing loss increasing dramatically with age; hearing loss between hearing loss and physical functioning, termed the
rises from 15% among people aged in their 60s, to >80% social cascade hypothesis. A further mechanism involves the
among those aged ≥80 years [4]. Hearing loss is a leading vestibular system, whereby measures of hearing loss may act
cause of disability; in 2019, the global number of years lived as a proxy for a concomitant vestibular loss, which leads to
with disability attributable to hearing loss was 43.5 million greater imbalance and falls.
[5]. Hearing loss impairs communication and social inter-
actions [5], is associated with loneliness and social isolation Hearing loss, cognitive decline and dementia
[6], anxiety [7] and depression [8], as well as reduced quality
In addition to physical function, it is becoming increas-
of life [9]. However, the decline in hearing experienced
ingly recognised that hearing loss is associated with cogni-
in older age is not necessarily an inevitable degenerative
tive decline and dementia. Evidence from several systematic
process associated with growing old. Though some level
reviews has shown that adults with hearing loss have a greater
of hearing change is inevitable with age (in particular, at
risk of developing dementia than those without hearing loss
high frequencies ≥8 kHz), the degree of loss is dependent
[18–22]. Additionally, in a global review of modifiable risk
on numerous modifiable and non-modifiable risk factors.
factors for dementia, it was found that hearing loss was
Although not inclusive, the illustration in Figure 1 (source:
the greatest potentially modifiable risk factor for dementia
[5]) highlights how both causative and preventive factors
in mid-life [23]. The proposed mechanisms of association
interact across a person’s lifespan to determine the occur-
between hearing loss and dementia are similar to those
rence, nature, severity, and progression of hearing loss [10].
already discussed in relation to hearing loss and physical
As such, there are opportunities for intervention, in the form
functioning, namely, cognitive reserve and social cascade. A
of prevention, identification, treatment and rehabilitation,
further explanation is common cause, whereby hearing loss
across an individual’s life that could and should be addressed
and cognitive decline share a common underlying pathology,
by healthcare practitioners. Subsequently, this publication
such as oxidative stress or chronic inflammation, but are not
will highlight our growing understanding of the range of
causally related [24–26].
health conditions that are associated with hearing loss and
discuss potential health promoting activities that may help
minimise the negative health impact of hearing loss and Hearing loss and cardiovascular health
related co-morbidities. In addition, it will discuss how this Hearing loss is also associated with various chronic con-
evidence presents a new horizon for interprofessional teams ditions, including cardiovascular diseases and their risk
to provide holistic and patient-centred hearing healthcare. factors (e.g. diabetes, hypertension, smoking) [27, 28].
These associations can likely be explained by pathological
changes within the vasculature of the inner ear, given that
Associations between hearing and health the cochlea is very metabolically active and relies on robust
circulation for optimal functioning. Indeed, hypertension,
Hearing loss and physical function smoking, diabetes and dyslipidemia are all associated with
Decreased hearing acuity, like declines in other sensory lower capillary density, reduced angiogenesis, increased
systems, is multifactorial in nature. An accumulating body capillary basement membrane thickness, changes in capillary
of evidence demonstrates the interplay between auditory supporting cell (pericyte) concentrations, inflammation,

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 Holistic, person-centred hearing health promotion

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Figure 1. Risk and protective factors influencing hearing capacity across the life span. Source: World Report on Hearing; © World
Health Organization 2021; Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0
IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Figure 2. Schematic of possible mechanisms underlying the association between hearing loss and physical functioning. The model
posits that the association may be explained by the cognitive reserve hypothesis, psychosocial difficulties experienced by older adults
with hearing loss (social cascade hypothesis) and/or vestibular dysfunction occurring concomitantly with hearing loss.

accumulation of reactive oxygen molecules and/or down- Given that metabolic risk factors for cardiovascular dis-
regulation of vasodilators such as nitrous oxide [29]. eases are modifiable, and because they are highly prevalent,
Such structural changes can impair molecular transport public health or clinical interventions to better address them
(e.g. of oxygen, ions, glucose, metabolites or proteins) could potentially result in significant improvements in hear-
across capillary walls. Inflammation and oxidative stress ing health. One of the most strongly supported interven-
caused by cardiovascular risk factors may also directly tions is physical activity; it is well established that regular
damage cochlear cells or extracellular proteins [30]. The physical activity in older adults can benefit multiple physical
pathological changes caused by poor cardiometabolic and mental health outcomes, including improved all-cause
health accumulate with age, may accelerate age-related mortality and reducing the incidence of noncommunicable
hearing loss and cause comorbid disease in multiple organ diseases [31]. Therefore, according to the World Health
systems. Organization’s (WHO) [31] evidence-based guidelines, for

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D. W. Maidment et al.

older adults to achieve optimal health benefits, the mini- interventions to manage conditions associated with losses i
mal recommendation is 150 to 300 minutes of moderate n intrinsic capacity; and (iii) the engagement and coordi-
intensity aerobic physical activity, or at least 75–150 minutes nation of multiple healthcare services that are all driven to
of vigorous intensity aerobic physical activity per week. a single goal of maintaining intrinsic capacity and can be
Nevertheless, older adults with hearing loss do not meet these delivered through primary- and community-based care.
guidelines, with a recent analysis of data from the English Unfortunately, however, Wallhagen, Strawbridge and
Longitudinal Study of Ageing (ELSA) showing that physical Tremblay [36] have highlighted that there are few examples
activity declines more rapidly in older adults who report of holistic and interprofessional care described in the
hearing loss compared to those that do not [32]. Hearing literature, especially as related to hearing healthcare. This
loss specific barriers to physical activity have also been iden- is because there are several barriers to implementing
tified, including mental fatigue, as well as fear of alienation interprofessional care in this context, including the structure
and stigma [33]. Environmental modifications and social of healthcare services that can make interdisciplinary
support may nevertheless facilitate physical activity in this communication difficult, as well as financial, regulatory

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population [33]. On this basis, there is a need to mitigate and legal constraints [36]. Yet, to address the range of
the decline in physical activity and ensure physical activity is health conditions associated with hearing loss, and to
accessible in older adults with hearing loss to support healthy minimise its negative impact on health, hearing healthcare
ageing [32]. must be integrated into the larger healthcare system.
Although it should be recognised that the reported asso- Further, to provide truly holistic and patient-centred care,
ciations between cardiovascular risk factors and hearing loss providers across the spectrum of healthcare settings must
are inconsistent in the literature, and may only account for incorporate hearing healthcare into their practices and
a small amount of variance, improved cardiovascular health become aware of the importance of hearing to health.
has the potential to improve overall well-being and possibly Although a model of patient-centred care is yet to be
reduce the risk for further hearing loss progression [34]. developed specifically for hearing healthcare, Grenness
Even if the effects of better cardiovascular health on hearing and colleagues [40] investigated the views of older adults
are small for an individual, the societal benefits could be with hearing loss in relation to their preferences during
large, as poor cardiovascular health is widely prevalent [35]. audiological rehabilitation. Critically, these authors found
Moreover, there is little risk that interventions targeting car- that patients expressed a preference for individualised care in
diovascular disease would exacerbate hearing problems. As relation to the patient-practitioner relationship, information
such, there have been increasing calls for hearing healthcare provision, and decision making. More recently, it has
to take a more interdisciplinary and holistic approach, as been suggested that a patient-centred approach to hearing
well as to address the broader health needs of individuals healthcare should also incorporate evaluations of patients’
with hearing loss to promote overall health and well-being general health and lifestyle so that more targeted support
[36, 37]. can be provided to reduce the potential burden of multiple
chronic diseases that frequently co-occur with hearing loss
[41]. Subsequently, novel strategies and examples that aim
A new horizon: interprofessional, holistic and to promote interprofessional, holistic and patient-centred
patient-centred hearing healthcare practices that incorporate hearing healthcare are described.
In 2001, the USA-based Institute of Medicine (now the
National Academies of Science, Engineering and Medicine)
emphasised that, to address the gaps in care, healthcare The integration of hearing loss in diabetes services
practitioners and organisations should no longer operate in Some recommendations are beginning to incorporate
silos, which results in a lack of complete information about consideration of the value of including hearing healthcare
an individual’s complex health needs [38]. To bridge this providers within interdisciplinary healthcare teams. For
disparity, it was deemed essential for clinicians and insti- example, persons with diabetes require many different
tutions to collaborate to ensure that care was coordinated. specialists to address the problems they experience, including
This type of coordination and sharing of information is the endocrinology, podiatry, optometry, dentistry, and pharma-
core of interprofessional practice, which aims to provide cists. Based on this, the USA’s Centers for Disease Control
integrated and patient-centred care to older people. This (CDC) has highlighted the need to address hearing loss in
practice has been further outlined by the WHO’s recent their ‘Diabetes and Hearing Loss’ online resources [42]. These
2019 guidance for integrated care for older people (ICOPE) materials (e.g. TakeChargeofYourDiabetes:HealthyEars [43])
[39]. The ICOPE approach proposes that care for older support the ways in which the incorporation of hearing
people should be based on a multi-step process that involves healthcare should be considered by other professionals to
the following: (i) an assessment of an individual’s needs, pref- prevent the negative sequalae associated with diabetes. The
erences, and goals, including the identification of declines in CDC, for instance, recommends a baseline hearing test
key intrinsic capacities (e.g. vision, hearing, cognition, psy- and balance screening at the time of diabetes diagnosis,
chological health, physical health); (ii) the development of followed by annual hearing loss testing. Current efforts to
personalised, patient-centred care plans that involve multiple raise awareness of the effects of diabetes on hearing and

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 Holistic, person-centred hearing health promotion

balance in the USA are focused on involving physicians part of their memory assessment. On this basis, the inte-
and diabetes education specialists. One recommendation gration of audiology assessments into memory services may
is to assign the task of taking an online hearing screening be worthwhile, especially given the amount of hearing loss
and completing a brief balance survey as one component of detected and the potential impact of hearing loss on future
diabetes education classes. The diabetes education specialist cognitive decline [45].
can then discuss this information with the patient or as
part of a group session, along with recommendations for
an appropriate follow-up. Another effort in the USA is Practical considerations for increasing awareness of
to include hearing and balance recommendations in the hearing loss in healthcare professionals
discharge recommendations of hospital’s electronic medical A further consideration is that healthcare practitioners in
records to ensure that this is considered if patients are seen general need to be aware of hearing ability when providing
at subsequent medical emergencies, such as stroke, heart counselling and discussing plans of care because miscom-
attack, out of control diabetes or trauma. Automating the munication can occur and impact safe and effective care

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medical necessity of a referral for each patient takes away the [46, 47]. In this regard, there is a need to educate multidisci-
issues of not seeing the invisible handicaps of hearing loss plinary, primary healthcare teams (e.g. general practitioners,
and associated risk of falls or other comorbidities. practice nurses, etc.) and other healthcare professionals about
Although such holistic recommendations are currently the importance of hearing to health, as well as about the need
uncommon, the focus on diabetes by the CDC provides to implement valid screening tests for hearing capacity. This
an example of the way in which audiologists and other is essential because hearing loss is not easily recognised in
hearing healthcare providers might use such data in their a one-on-one, face-to-face meeting in a quiet examination
practices. Thus, for instance, when a person is identified room. Hearing loss is invisible and may not be identified if
with hearing loss, questions about vision and a vision exam the person is only asked if they have a hearing loss. The issue
can suggest the need for modifications in an individual’s of anosognosia, the inability of the patient to know they have
dependence on speechreading and the need to incorporate a sensory impairment, as well as the stigma often associated
other cues for communication. Alternatively, if a person with hearing loss and hearing aids, often limits the subjective
with diabetes is having balance problems and is at risk recognition of hearing loss. Primary healthcare teams should
of falls, referral to audiology, physical therapy or podiatry, also be mindful of other sensory losses, including visual
as well as to persons with expertise in balance exercises, acuity, given the prevalence of vision loss similarly increases
and the evaluation of potential vestibular problems, may be with age. Moreover, while the prevalence of dual sensory (i.e.
necessary. Vision is also integrally connected to the risk of hearing and vision) loss in the USA may be less than 1%
falls and may need further evaluation. Furthermore, given among persons under that age of 70, it rises to 11.3% among
the potential for peripheral neuropathy secondary to diabetes individuals 80 years and older [48]. Thus, the occurrence of
or chemotherapy, evaluation by neurology might be helpful. visual impairment must also be considered when screening
and testing hearing.
There is now a range of possible hearing screening tools
The integration of hearing loss in dementia services available that could be easily incorporated into various
Given that hearing loss is associated with cognitive decline primary healthcare settings. Commercially available and
and dementia, it may be increasingly important for hearing calibrated screening equipment (e.g. screening audiometer
healthcare professionals to communicate with other prac- and otoacoustic emissions) that do not require a hearing
titioners who work with persons with dementia and other specialist are an option. Alternatively, where screening
cognitive impairments to assure a person’s hearing acuity is or diagnostic audiometry is not available or would be
considered in advance of doing any cognitive assessments. inappropriate, screening applications (or apps) for smart-
Currently, there is very little hearing screening, nor diag- phones or tablet computers may be a suitable alternative
nosis and treatment of hearing loss in advance of cognitive (e.g. ‘hearWHO’ [49]). Although these tests already exist
services [44]. However, the incorporation of routine audi- and are available, they are not currently implemented
ology screening in memory services may be beneficial. In in routine clinical practice [36]. Therefore, there is a
support, in a tertiary referral memory service in Ireland, potentially unexploited, yet viable, opportunity for primary
McDonough and colleagues [45] explored the experiences, healthcare teams to incorporate low-cost hearing tools into
tolerability and understanding of having a hearing assess- their practices. In doing so, this could facilitate a more
ment in patients with mild cognitive impairment as part patient-centred approach, whereby patient–practitioner
of their memory assessment pathway. In this study, hearing interactions, information provision, and decisions about
assessment involved a full audiological history, otoscopy, management and treatment options are tailored to the
tympanometry, and both pure tone and speech audiometry individual, empowering them to be a more active participant
completed by a hearing specialist (i.e. audiologist). Overall, in their healthcare.
the majority (90%) of participants were found to have at least In addition to hearing tests, including questions about
a mild hearing loss, were satisfied with their experience of understanding speech in noise may help to uncover hear-
having a hearing evaluation and felt that it was an important ing difficulty [50]. Spankovich and Yerraguntal [51], for

5
D. W. Maidment et al.

instance, recommended a series of questions for screening for other negative health effects, such as falls, dementia and
patients with diabetes for hearing loss, which can also be eas- poor cardiovascular health, as well as misunderstandings in
ily translated to other patients without diabetes by removing the healthcare setting. These understandings, emphasised in
question 4: the current publication, can also broaden holistic, patient-
centred care provided in all hearing and general healthcare
1. Do you or your family perceive any change in your
settings to support healthy ageing.
hearing?
2. Do you have hearing difficulty in quiet places or noisy
places? Declaration of Conflicts of Interest: Dr Emily Urry is a
3. Have you had your hearing tested in the past 2 years? Senior Expert in Digital Health Innovation at Sonova AG,
4. Do you know how diabetes can affect your hearing? Staefa, Switzerland.
5. Do you know what to do if you perceive a change in Declaration of Sources of Funding: This work was sup-
hearing? ported by the brand Phonak, which is part of the Sonova
6. Do you know how to reduce your risk for hearing loss? AG Group. Neither Phonak or Sonova played a role in the

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writing of this paper.
If the patient answers ‘Yes’ to questions 1 or 2 or ‘No’
to questions 3–6, it is recommended they be referred for References
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specificity of the Speech, Spatial and Qualities of Hearing
Scale (SSQ5) for screening hearing in adults. CoDAS 2022; Received 10 October 2022; editorial decision 9 January
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