When a Hearing Aid Isn’t Enough

Kitty Grutzmacher had suffered from poor hearing for a decade, but the problem had gotten worse over the past year. Even with her hearing aids, “there was little to no sound,” she said.

“I avoided going out in groups. I stopped playing cards, going to Bible study and even going to church.”

Her audiologist was unable to offer a solution to Grutzmacher, a retired nurse from Elgin, Illinois. But she found her way to Northwestern University’s cochlear implant program.

Krystine Mullins, an audiologist who evaluates patients’ hearing and advises them on their options, explained that surgical implantation of this electronic device usually significantly improves the patient’s ability to understand speech.

“I never even thought about it,” Grutzmacher said.

The fact that she was 84 years old was of no importance in itself. “As long as you are healthy enough to have surgery, age is not an issue,” Mullins said. A recent Northwestern implant patient was 99 years old.

Some patients need to think about this decision, because after surgery, clearer hearing still requires months of practice and adaptation and the degree of improvement is difficult to predict. “You can’t try it in advance,” Mullins said.

But Grutzmacher did not hesitate. “I couldn’t continue the way I was,” she said during a post-implant phone interview — one that involved frustrating repetition, but would have been impossible just weeks earlier. “I was completely isolated.”

Hearing loss in older adults remains largely undertreated. Federal epidemiologists estimate that it affects about 1 in 5 people ages 65 to 74 and more than half of people over 75.

“The mechanisms of the inner ear were not designed to last,” said Cameron Wick, an ear, nose and throat specialist at University Hospitals in Cleveland.

Although hearing loss can contribute to depression, social disconnection and cognitive decline, less than a third of people over 70 who could benefit from hearing aids have worn them.

For those who do, “if your hearing aids are no longer providing you with clarity, you should seek a cochlear implant evaluation,” Wick said.

Twenty-five years ago, “it was a novelty to implant people over 80,” said Charles Della Santina, director of the Johns Hopkins Cochlear Implant Center. “Now it’s a pretty common practice.”

In fact, a study published in 2023 in the journal Otology & Neurotology reported that cochlear implantation was increasing at a higher rate in patients over 80 than in any other age group.

Until recently, Medicare covered the procedure only for people with extremely limited hearing who could correctly repeat fewer than 40 percent of words on a word recognition test. Without insurance – cochlear implantation can cost $100,000 or more for the device, surgery, counseling and follow-up – many seniors don’t have this option.

“It was incredibly frustrating because patients with Medicare were excluded,” Della Santina said. (Similarly, traditional Medicare doesn’t cover hearing aids, and Medicare Advantage plans with hearing benefits still leave patients footing most of the bill.)

Then, in 2022, Medicare expanded coverage for cochlear implants to include older adults who can identify up to 60% of words on a speech recognition test, increasing the pool of eligible patients.

Yet even though the American Cochlear Implant Alliance estimates that the number of implants is increasing at about 10 percent per year, public awareness and audiologist referrals remain low. Fewer than 10% of eligible adults with “moderate to profound” hearing loss benefit, according to the alliance.

Cochlear implantation requires commitment. After the patient has received tests and counseling, the surgery, which is an outpatient procedure, usually lasts two to three hours. Many adults have surgery on one ear and continue to use a hearing aid on the other; some later receive a second implant.

The surgeon implants an internal receiver under the patient’s scalp and inserts electrodes that stimulate the auditory nerve in the inner ear; patients also wear an external processor behind the ear. (Clinical trials of an entirely in-house device are underway.)

Two or three weeks later, after the swelling has subsided and the patient’s stitches have been removed, an audiologist activates the device.

“When we first turn it on, you won’t like what you hear,” Wick warns. The voices initially seem robotic, mechanical. It takes several weeks for the brain to adapt and for patients to reliably decipher words and sentences.

“A cochlear implant is not something you just turn on and it goes,” Mullins said. “It takes time and some training to get used to the new sound quality.” She assigns homework, such as reading aloud for 20 minutes a day and watching TV while reading the subtitles.

After one to three months, “boom, the brain starts to understand and the clarity of speech goes away,” Wick said. By six months, older adults will have achieved most of their increased clarity, although some improvements continue for a year or more.

What improvement? This is measured by two hearing tests: the CNC (consonant-nucleus-consonant) test, in which patients are asked to repeat individual words, and the AzBio sentence test, in which the words to be repeated are part of complete sentences.

At Northwestern, Mullins tells older potential patients that a year after activation, an AzBio score of 60 to 70 percent — correctly repeating 60 to 70 words out of 100 — is typical.

A Johns Hopkins study of about 1,100 adults, published in 2023, found that after implantation, patients 65 and older could correctly identify about 50 additional words (out of 100) on the AzBio test, an increase comparable to the results of the younger cohort.

Participants over 80 showed about as much improvement as those between 60 and 70.

“They go from having difficulty following a conversation to being able to participate,” said Della Santina, author of the study. “Decade after decade, the results of cochlear implants have improved more and more. »

Additionally, an analysis of the experiences of 70 elderly patients at 13 implant centers, of which Wick was lead author, found not only “clinically important” hearing improvements but also improved quality of life.

Scores on a standard cognitive test also increased: after six months of using a cochlear implant, 54% of participants achieved a passing grade, compared to 36% before surgery. Studies of people aged 80 to 90 have shown that people with mild cognitive impairment also benefit from implants.

Still, “we’re careful not to overpromise,” Wick said. Usually, the longer older patients have had significant hearing loss, the harder they have to work to regain their hearing and the less improvement they may see.

A minority of patients feel dizzy or nauseous after surgery, although most recover quickly. Some struggle with technology, especially phone apps that adjust sound. Implants are less effective in noisy environments like crowded restaurants, and because they are designed to clarify speech, music may not sound good.

For those at the high end of Medicare eligibility who already understand about half of the speech they hear, implementation may not be worth it. “Just because someone is eligible doesn’t mean it’s in their best interest,” Wick said.

But for Grutzmacher, the choice seemed clear. Her initial tests revealed that even with hearing aids, she only understood 4% of the words on AzBio. Two weeks after Mullins turned on the cochlear implant, Grutzmacher could understand 46 percent using a hearing aid in his other ear.

She reported that after a few difficult days, her ability to talk on the phone had improved and that instead of turning the television volume up to 80, “I can hear it at 20,” she said.

So she made plans. “This week I’m going out to lunch with a friend,” she said. “I’m going to play cards with a small group of women. I have a church luncheon on Saturday.”

The New Old Age is produced through a partnership with The New York Times.