Speak up! I can't hear you!”

Speak up! I can't hear you!”

Sometimes it does seem as if older people are all hard of hearing. When people can't hear, they may ask to have things repeated a lot or they may tune out and become uninvolved in conversation. Younger relatives end up shouting to try to make themselves heard, and they can lose patience when the older people won't try hearing aids. Younger people may overreact to the stereotype of the hard-of-hearing older person by “talking down” to all older people. In one survey of 84 people over age 60, 39% reported that they had been patronized or talked down to at least once (Palmore, 2001).

It is true that certain types of hearing loss are typically part of the “normal” aging process, but shouting is not usually the solution. It is also true that there are barriers for some people to getting hearing aids, but stubbornness is rarely one of them. Yet the myth persists. For example, a press release about a University of Florida study on the effects of hearing loss in older adults explicitly mentions the stereotype of older adults as being stubborn about admitting hearing loss. In this section we discuss the effects of the type of hearing loss that is typical of aging, and the best way to speak to someone who has this problem. We also evaluate the most likely reasons people might have for not purchasing hearing aids.

Myth #1 It is best to speak to an older person as you would to a small child – loudly, slowly, and with exaggerated emphasis

There is little doubt that changes in hearing trouble a large proportion of older adults. Hearing loss is among the most common conditions associated with aging. It affects approximately 18% of adults aged 45 to 64, 30% of adults aged 65 to 74, and 47% of adults 75 years and older (National Institute on Deafness and Other Communication Disorders, National Institutes of Health, 2010).

The type of age-related hearing loss characteristic of most individuals as they grow older is called presbycusis. It can come on so gradually that older adults do not necessarily notice any decline in their hearing. Perhaps for that reason, they are not always ready to admit they have a hearing loss, blaming any difficulty they experience on the acoustics of the room or the fact that the speaker is whispering.

When people, especially younger adults, assume that older adults cannot hear very well, they do what comes naturally: they speak louder, and when that doesn't work, they shout. Increasing the volume of speech may be helpful up to a point. Unfortunately, if the volume is too high, there is generally little gain. In fact, increasing the volume of speech beyond a reasonable level often backfires because it can actually distort the spoken message. Older adults may say, “I hear it but I cannot understand it,” which illustrates a phenomenon called phonemic regression.

With presbycusis, there is typically greater difficulty associated with high-frequency than with low-frequency tones. Women's voices usually have higher frequencies than men's voices. For this reason, older adults typically hear men better than they hear women. Also, within the range of human speech, consonants such as f, t, th, s, and z are characterized by high frequency, so it is not surprising that older adults have difficulty discriminating among words with high-frequency consonants (e.g., “fit” and “sit”). If frequency rather than volume is the problem, increasing the volume will not be as effective as lowering the frequency. One way to do that would be to reword the message, substituting key words that minimize high-frequency consonants. Also, women can make an effort to drop their voices to a lower pitch rather than increase the volume.

Here is another issue related to hearing loss in older adults: processing language takes time on a central (brain) level, and there is slowing with age in cognitive processing. To some extent, slowing down the pace of speech can be beneficial. But if the pace is so slow that it does not conform to the natural flow of language, slowing down is not usually helpful (Kemper, 1994; Wingfield & Stine-Morrow, 2000).

Prosody is an aspect of speech that refers to emphasis. People are known to use what has been termed motherese when speaking to small children. Motherese is characterized by exaggerated prosody, as well as by an unnaturally high-pitched tone often coupled with terms of endearment (e.g., honey, sweetie, dear). When directed toward older adults, this type of speech has been termed elderspeak. Elderspeak is characterized not only by shortened sentences, simplified grammar, and slower speech, but also by exaggerated pitch and intonation (exaggerated prosody).

Kemper and Harden (1999) set out to determine which characteristics of elderspeak are beneficial for older adult listeners and which may not be. They had older adults watch and listen to a videotape of a speaker who was describing a route while also tracing it on a map. The older adults reported that instructions were easier to follow when the speaker reduced the grammatical complexity of the instructions (that is, minimized the number of subordinated and embedded clauses) and when the speaker used semantic elaboration (that is, repeated and expanded upon what was said). (Note that the sentence you just read is pretty complex in that way.) If the speaker used simpler grammar and semantic elaboration, older adults improved their accuracy when they had to reproduce the same route on a map of their own. In contrast, cutting the length of the speaker's sentences did not improve their comprehension of the instructions, nor did it improve their performance when they traced a map of their own. Also, older listeners did not find it helpful when the speaker spoke at an unnaturally slow rate with many pauses or with exaggerated prosody. In short, being spoken to at a slower than normal speed and in atypically short phrases, as well as with exaggerated pitch and intonation, does little to enhance older adults' ability to comprehend speech.

Furthermore, even though typically well-intentioned, using elderspeak may not be a nice thing to do. Ryan and her colleagues (Ryan, Anas, & Gruneir, 2006; Ryan, Hummert, & Boich, 1995) contend that exaggerated prosody and terms of endearment are patronizing and often lead to a “communication predicament” situation: older adults feel uncomfortable when speakers use this manner of speech, so they prefer to withdraw altogether from any communicative interaction.

In sum, communication with older adults who have typical age-related hearing loss is most satisfactory when the language used by the speaker has reasonable volume but is not too loud. Speech should not be overly fast, but it should be no slower than the natural flow of the language and should minimize the use of high-frequency key words. It is also helpful if the speakers' sentences are not too grammatically complex and if the speaker states the message in several different ways (elaborates). Finally, it is important for speakers to face older adult listeners, who can then take advantage of visual cues such as reading the speaker's lips and seeing the speaker's body language. If it becomes clear that an older listener does not understand a message, changing the wording will probably be more effective than increasing the volume, slowing down speech to a snail's pace, or using exaggerated prosody. And elderspeak is related to baby talk, so it can be offensive.

Myth #2 Hearing aids are beneficial for older adults in just about any situation, but many are just too stubborn to use them

There is little question that as people grow older, they experience changes in both vision and hearing. People do not seem to be ambivalent about wearing eyeglasses to correct their vision, nor do they hesitate to visit an eye-care specialist for a change in prescription that will improve their visual acuity. Yet as many as 22.9 million older Americans have a hearing loss but do not own or use a hearing aid (Chien & Lin, 2012). Lin, Thorpe, Gordon-Salant, and Ferrucci (2011) estimate that only approximately one-fifth of older adults with hearing loss use a hearing aid. Popelka et al. (1998) conducted a study on 1,629 Wisconsin residents ranging in age from 48 to 92, all of whom had a hearing loss, to determine the extent to which they made use of hearing aids. Only 14.6% used hearing aids. Furthermore, among a subset of the study participants with severe hearing loss, the prevalence of hearing-aid use was only 55%. A number of participants reported that they owned a hearing aid but no longer used it. This problem is not confined to the U.S. A large-scale study was conducted in Australia on hearing-aid use among 3,000 individuals aged 49 to 99, with an average age of 67 (Hartley, Rochtchina, Newall, Golding, & Mitchell, 2010). Although 33% of the participants had a hearing loss, only 11% owned a hearing aid. Of those who did own a hearing aid, 24% reported that they never used it.

Given that hearing loss is a frequent occurrence among the older population, why are older adults not lining up to get hearing aids? The myth is that they are just too stubborn to do so. But according to Lin et al. (2011), older adults, and indeed people in general, tend to undervalue the negative impact of hearing loss not only on the ability to communicate but also potentially on health and general well-being. In fact, in a survey of 240 people who had no sight or hearing deficits, approximately three-quarters would prefer to lose hearing rather than sight (Kim, Goldman, & Biederman, 2008).

Age-related hearing difficulties usually come on gradually and insidiously, so many people do not realize that their hearing has declined until the loss is significant. Older adults may complain that other people are mumbling, that there is something wrong with the acoustics (sound system) in a movie theater or playhouse, and so on. They often deny that the problem lies with their own hearing capability, which could well be a reason for their low rate of hearing-aid use.

At some point, however, hearing loss can become sufficiently severe that older adults are no longer able to deny it and are forced to recognize that their hearing difficulties are not solely attributable to other people's mumbling or poor environmental acoustics. Also, other people (often family members) start to broach the subject of hearing impairment with the older adults. Then why do many older adults who could benefit from a hearing aid not get one?

Before assuming it is just stubbornness that prevents older adults from obtaining and/or using a hearing aid, it is important to recognize that there are a number of other reasons. First, getting and/or wearing a hearing aid is likely to signify to people that they are growing older, certainly more so than is the case with eyeglasses, which are worn by people of all ages. This means that failure to get a hearing aid could stem from denial about aging. In addition, some older adults may feel that wearing a hearing aid would make them look “stupid,” and would signify that they are incompetent. In short, wearing a hearing aid is a threat to their self-image (Ryan, Hummert, & Anas, 1997, November). This fear is not completely unfounded, given the existence of ageism in the U.S. as well as other countries (e.g., Belgium, Costa Rica, Hong Kong, Japan, Israel, and South Korea), wherein older adults are considered to be sweet and warm, but feeble (Cuddy, Norton, & Fiske, 2005).

Failure to get or use a hearing aid for fear of being considered incompetent could well be a reason for the low rate of hearing-aid use among older adults. But nowadays, many people wear an earpiece to talk on the phone or listen to music. Also, many modern hearing aids are very small and can be reasonably well hidden. Even so, small hearing aids can be extremely costly for older adults living on limited budgets and may also be difficult to manipulate. Larger, less expensive ones may not look so “hip.”

Another reason for older adults' low rate of hearing-aid use could be that it takes careful evaluation by ear, nose, and throat specialists and/or audiologists to determine whether a person with a specific type of hearing loss will benefit from a hearing aid. And when a hearing aid could help, it must be carefully tailored to a person's hearing loss. A hearing aid that amplifies all frequencies (even ones for which the wearer has relatively normal hearing) will be uncomfortable and probably not very useful. Many people try several hearing aids before they find one that works well for them (National Institute on Deafness and Other Communication Disorders, National Institutes of Health, 2001). Once again, there is the expense – hearing aids custom-made for an individual's specific hearing loss are costly and not covered by health insurance. Furthermore, hearing-aid owners do not just walk out the door after purchasing a hearing aid. Rather, they must be counseled on how to operate a hearing aid to achieve the maximum benefit. Popelka et al. (1998) suggest that to best deal with barriers to hearing-aid use, it may be necessary for hearing-aid professionals to offer users a long-term program of ongoing support and counseling.

Unlike eyeglasses, which can be prescribed to correct vision across a variety of situations, hearing aids may not be beneficial in every situation. Older hearing aids had limited usefulness in environments with background noise, such as restaurants with clattering dishes and multiple conversations going on (Schneider & Pichora-Fuller, 2000). Some older adults may have tried those in the past and become too frustrated to try the newer generation of hearing aids, which are better at reducing background noise. Also, expense is an issue: modern digital hearing aids with circuitry that selectively reduces the amplification of noise are costly, though still not perfect (Hamilton, 2013). Even so, many older adults could benefit from a hearing aid even if their difficulties are not completely resolved. But successful hearing aid users need training in how to adjust the hearing aid, and professionals who fit older adults with hearing aids should be ready to provide support until older adults are confident that their use is worthwhile. One further consideration is that even though modern hearing aids may modify the intensity of sound, they do not address difficulties with auditory processing at the central (brain) level (Wingfield, Tun, & McCoy, 2005). The impact of hearing loss on cognitive functioning remains to be more fully determined (Chien & Lin, 2012).

In sum, hearing loss remains largely untreated in the older adult population. Hearing aids can assist with communication if they are properly fitted and if older adults learn how to make the best use of them. But based on the statistics mentioned earlier, older adults do not seem eager to purchase them, and even when they do, they do not always use them. Even so, to assume that older adults are just stubborn is shortsighted and overly simplistic. The reasons older adults do not use hearing aids include denial of aging, the desire not to seem old and stupid, the expense, the difficulty of getting the devices to work just right, and negative experiences with older and less precise models. It is important to fully understand the reason(s) many older adults elect to miss out on the conversation rather than wear a hearing aid if we want to be effective educators regarding the potential value of these devices.