Listen up! - Specsavers · per cent today who are cigarette smokers.1 Women took up the habit later than men with prevalence peaking at 44 per cent before falling to 17 per cent and

1Listen up! Hearing loss in an ageing society

Listen up! Hearing loss in an ageing society Professor Les Mayhew

2 Listen up! Hearing loss in an ageing society 3Listen up! Hearing loss in an ageing society

Overview

This independent report, commissioned by Specsavers Audiologists, examines the latest research on hearing loss in an ageing society, with particular focus on the impact the potential rising pension age and increased longevity will have on the economy and those who experience hearing loss.

Data from the following sources has been used to present the findings:

• English Longitudinal Study of Ageing (ELSA)

• Charitable bodies

• Government statistics

• Academic journals

• Specsavers Audiologists

Further information on the sources of evidence is given in each section and information presented is for England (and Wales where stated).

Les Mayhew is a professor of statistics at Cass Business School, in the Faculty of Actuarial Science and Insurance, and is the managing director of Mayhew Harper Associates Ltd. He is a former senior civil servant with almost 20 years of experience in the Department of Health and Social Security, Department of Social Security, HM Treasury and Office for National Statistics where he was also a director. He is an associate research scholar at the International Institute for Applied Systems Analysis in Vienna, an honorary fellow of the Institute of Actuaries and a member of the Royal Economic Society. He is widely published and specialises in demographic ageing, health and social care and pensions.


Contents

Overview 3

Contents 5

Summary 7

1 A look at the ageing population 8

2 Hearing loss in old age 11

2.1 Addressing hearing loss 11

2.2 The current state of hearing loss in the UK 11

3 Trends in life expectancy in England and Wales 14

3.1 The gender life expectancy gap and hearing loss 14

3.2 Increased life expectancy and future trends 14

4 Increased longevity and its impact on hearing loss prevalence 16

4.1 What does increased life expectancy mean for those with hearing difficulties? 16

4.2 Reported hearing loss versus uptake of hearing aids 16

4.3 Projections for workplace hearing loss 17

4.4 Regional patterns 18

4.5 Severity of hearing loss 19

5 Typical hearing loss demographics 22

5.1 An analysis of hearing loss sufferers 22

5.1.1 Hearing loss risk factors 23

5.1.2 Using risk factors to predict hearing aid uptake 25

5.1.3 Employment rates for those with hearing loss 26

5.1.4 Hearing loss as a contributing factor to loneliness and social isolation 27

6 Concluding reflections 29

7 Recommendation for action 31

8 References 32


then the current figure of 2.5 million will grow to 3.9 million, a 56 per cent increase compared with now. Coupling the prevalence of hearing loss with demographic forecasts, we expect it to increase by around 1.6 per cent per year to 2030. This scale of growth is bound to impact on the workplace and is clearly a trend that businesses and health services should prepare for. Currently, the direct cost to the taxpayer of hearing loss is at least £1 billion a year, and that figure becomes much greater once wider, indirect social and economic factors are taken into account.

Key findings:

• If pension age is to raise to 70, the number of people of working age with hearing loss will increase by 56 per cent by 2030

• Hearing loss currently costs the tax payer at least £1 billion a year

• Based on Specsavers Audiologists data we found that hearing loss was profound or unaidable in only around 1.7 per cent of the population taking hearing tests

Summary

The good news is that we are all living much longer. As a result the UK population is ageing rapidly. In England and Wales the population aged 50+ is set to increase by 18 per cent from 21.3 million in 2016 to 25.2 million by 2030. The population aged 75+ will increase by almost 50 per cent from 4.8 million to 7.1 million. Age-related hearing loss, the subject of this research, is one of the hurdles people will increasingly face both while in work and after. Because there will be more people to support, government will also be forced to raise pension age potentially to as high as 70 years by 2030 as compared with 65 today. However, the projected increase in state retirement age will also mean that more people of working age will experience hearing difficulties than previously. There is now recognition that staying healthier for longer will help individuals remain productive for longer but also enjoy their retirement. The role played by age-related hearing loss is pivotal to this and how to recognise and manage its effects is part of the solution.

Using newly available data based on the English Longitudinal Study of Ageing (ELSA), we find that 32.9 per cent of the 50+ population living in England, or 6.6 million, report hearing difficulties, which is made up from 37.7 per cent men and 29 per cent women. Of these, we estimate there are 2.5 million people aged between 50 and 65 of working age with hearing difficulties. Without any rise in state pension age, by 2030 this will increase to 2.7 million people – an increase of 6.4 per cent. However, if state pension age were to increase to 70 by 2030, which is quite likely,


faster through wealthier educated networks: for example, the educated better off were the first to quit smoking. Better educated people can process information relevant to their health better than less educated people. Remaining smokers tend to be in less educated lower income groups who live in more deprived areas of the country or towns.

Key among the societal changes that have occurred which have benefited men has been the reduction in smoking prevalence. Smoking habits developed from the 1920s onwards, reaching a peak in 1948 when 82 per cent of adult men in Great Britain smoked some form of tobacco. This compares with only 20 per cent today who are cigarette smokers.1 Women took up the habit later than men with prevalence peaking at 44 per cent before falling to 17 per cent and so this trend has benefited men proportionately more. Interestingly, despite their increasing popularity most e-smokers are cigarette smokers who want to give up cigarettes.

An important contributory factor has been the massive changes that have taken place in occupational structures since the 1970s. The UK has undergone a significant industrial transformation with the numbers employed in more hazardous occupations in manufacturing, fishing and mining falling substantially. For example, employment in the coal mining industry, which is strongly associated with lung disease, has fallen from a peak of 1.2 million in 1920, to 0.3 million in 1970 and finally to only a few thousand today.

The economic and practical ramifications of the postponement of death over a long period are considerable. Not only will people need to work until they are older before they receive their state pension they will also need to keep themselves healthier. The reason for this is that a balance needs to be struck between the number of state pensioners and adult workers for pensions to be affordable otherwise taxes would need to increase and/or pensions be reduced and/or immigration

Most people regard ageing as a problem. After each significant birthday we count down the clock. We think to ourselves ‘not long to go’ and pause to consider our situation. We wonder how we will spend our time and what lies in store especially once our children have flown the nest. But is that really how we feel? As remarked by John Lennon, ‘life is what happens while you are busy making other plans’. The problem is that plan fulfilment is dependent on many factors including how long we expect to live and also our state of health.

Demographic statistics can be helpful in this regard. When we reach 50 years old most of us are already past the half-way mark but in the past it used to be much earlier. Since 1950 alone, life expectancy at age 50 has increased by eight years for women and even more for men who are steadily catching up. This should be celebrated as the benefits of living longer lives are being increasingly shared by more of the population especially if we remain in good health. Taking good care of your health not only enables you to live longer but helps you to enjoy your latter years and to fulfil those plans.

It has also been a long accepted demographic maxim that females outlive males. However, when we examine the historical record for the last century, the gap in life expectancy tends to vary as part of a long-term trend. For years at a time the gap appears to close, while other times it widens or remains the same. Sometimes the reasons are obvious and coincide with either wars or epidemics, but at other times life expectancy drifts apart or narrows due to no obvious event. We are now in a phase in which the gap between men and women is closing quite rapidly – a wake-up call to men, you might say, to think through how they wish to spend their extra years.

Becoming better off has helped incalculably in the life expectancy race. The wealthier you are the more likely you are to adopt healthy behaviours and hence are better placed to avoid or defer health problems to later in life. We know that healthy behaviours spread much

1. A look at the ageing population

This compares with a combined caseload of those specifically with hearing loss or related ear conditions of 24,000 in total.5 This figure translates into direct benefit costs of at least £100 million a year6 and crudely equates to approximately £1 billion in lost output (i.e. if they had been in work) plus the cost of health care.7

The higher the state pension age rises, the more likely failing health will cause people to exit the workforce before reaching it. Such considerations could act as a break on further advances in life expectancy itself and therefore the trends currently underway.8 Having to make plans, in John Lennon’s words, therefore seems both poignant and resonant because plans help to avert a crisis during our later years. Taking a more positive view, men will be enabled to work for longer in reasonable health and be expected to live for almost as long as their partners (after taking account of the typical age difference upon union), whilst cohabitation itself is a factor in reducing mortality.9

would need to increase.2 Currently, it is being equalised for men and women to 66 by 2018 but the government is reviewing whether it should be higher. Our calculations show that in order to maintain the same ratio as today between workers and retirees it needs to be 67 in 2025 and 70 by 2030.

More people now work beyond state pension age following the abolition of the default retirement age (DRA)3, but we should not underestimate the number of people that leave the workforce before they reach state pension age. The percentage of people who become economically inactive due to illness or disability increases from 10 per cent at age 50 to 25 per cent by 65. Not only does this result in lost economic output but also smaller occupational pensions for the individuals affected. Rising state pension age will cause this to increase so we can therefore see why remaining healthier for longer becomes increasingly important. The focus of this paper is on hearing loss but how many people are economically inactive due to this condition is unclear.

Hearing loss is certainly a contributory factor especially where it is related to other health problems.4 Statistics from the Department for Work and Pensions on working age benefits show that of the 2.4 million people claiming Employment Support Allowance – the main working age benefit for those with long-term health conditions – the most common reasons are mental illness and musculoskeletal problems.


2. Hearing loss in old age

Although there is no medical cure for age-related hearing loss, hearing tests can detect an underlying medical condition and identify the benefits of hearing devices. Specsavers Audiologists, which commissioned this research, recommend hearing tests once a year from the age of 55 but because of its slow onset people do not tend to get their ears tested until they are older. Hearing test data shows that most hearing loss is aidable except in about 1.7 per cent of cases and that early testing can slow the rate of deterioration of hearing loss. Market data shows 1.6 million hearing aid transactions a year in which the NHS remains the biggest provider with 83 per cent of the UK market. The market is growing at between 2 to 4 per cent per year which is roughly the range we would expect based on demographic ageing. However, due to lags in take-up, the gap between hearing loss and the wearing of hearing aids is set to widen. Since hearing tests and appliances are free under the NHS, the research argues that cost should not be a barrier to seeking help, but that failure to recognise hearing loss or take timely action is more important.

2.2 The current state of hearing loss in the UK

In this research, we are concerned with the impacts of increasing life expectancy and the expected growth of the older population on hearing abilities and what this might mean in terms of the impact on individuals, society and business. Questions we seek to address include how prevalent hearing loss is in the older population, whether there are differences between men and women in age-related hearing loss, and also the take-up of hearing appliances as a function of hearing loss. We are especially concerned with the socio-economic dimension: e.g. whether hearing difficulties affect employment prospects, whether living alone coupled with hearing difficulties, ill health or disabilities exacerbates an individual’s feelings of loneliness or isolation, and to what extent men or women are more disadvantaged in this respect.

2.1 Addressing hearing loss

Safeguarding our health is no guarantee of immortality and our quality of life will change as we get older. One of the things we notice is that our sight and hearing will deteriorate and typically we make adjustments to accommodate such changes but at some point we decide to seek professional help. Clearly as the population ages this will impact on providers and services such as sight and hearing tests, which will be in greater demand. For example, forecasts presented here indicate an 18.3 per cent growth in the population aged 50+ to 25 million by 2030, but a 48.7 per cent rise in the number aged 75+ to 7.1 million.

However, there is a problem with hearing loss which sets it apart from other disabilities. When we have an issue with our eyesight we don’t think twice about visiting the optician, but hearing loss is different. Problems with eyesight are perceived to directly impact on one’s life and need urgent attention whereas the evidence is that people needlessly live with moderate hearing loss for years. The great majority of hearing loss is age-related and something all over 50s should recognise and address. Tell-tale signs of hearing loss include having the TV volume up too loud, finding conversations in noisy places hard work, asking people to repeat themselves on the phone, and friends and family make comments about your hearing.

There are two main types of hearing loss. One is sensorineural hearing loss which is caused by damage to the sensitive hair cells inside the inner ear or damage to the auditory nerve. This occurs naturally with age or as a result of injury. Conductive hearing loss arises when sounds are unable to pass from your outer ear to your inner ear, often because of a blockage such as earwax, a build-up of fluid from an ear infection, or because of a perforated ear drum. Of these sensorineural is by far the most common and is diagnosed in nearly 90 per cent of all hearing tests.


We tested this assertion using new data and found that the socio-economic context, as well as other age-related disabilities and long-term illnesses combine to negatively affect the quality of life in old age.

One of the problems when discussing issues relating to hearing loss is to appreciate that many terms relating to hearing impairment, for example ‘deaf’, ‘deafened’, ‘hard of hearing’, ‘hearing impaired’, ‘hearing disabled’ and so on, are used in the literature. These terms can be used to refer to different conditions in different contexts and in different cultures. A further inconsistency is that hearing level is defined differently by different organisations. In some cases it refers to the hearing level in the better ear, and in others to the average hearing level of the two ears. Consistently defined data on hearing loss is hard to come by partly for these reasons. 16 It is quite telling, for example, that estimates for the number of people with hearing loss published for the UK two years ago relied on prevalence rates that had not been updated since the 1980s. 17

For help with disentangling some of these issues we turn to the English Longitudinal Study of Ageing, or ELSA as it is known. 18 ELSA is a unique and rich resource of information on the health, social wellbeing and economic circumstances of the English population aged 50 and older, which started in 2002. Its primary objective is to collect longitudinal multidisciplinary data from a representative sample of the English population aged 50 and older. The current sample combines data from previous waves of data collection covering over 9,500 participants. Over the period of its existence ELSA has built up a data resource that is widely used by social scientists and others including government.

Each participant in the survey, whose sample members are drawn from respondents to the Health Survey for England, has a face-to-face interview followed by a self-completion questionnaire every two years and covers a nurse assessment every four years. The information contained in ELSA is extremely rich. It covers living arrangements, health, income,

Why should we be so concerned? The Health Survey for England (2014)10 found that hearing loss is significantly under reported in the adult population and that often people do not realise their hearing has deteriorated. For example, the report ‘Hearing Matters’ 11 found that 75 per cent of people with moderate or worse hearing had not had their hearing tested in the last 12 months and that people wait on average 10 years before seeking help. Age UK, for example, argues that many more could benefit from wearing hearing aids but would prefer to ‘get by’ because of the ungainly appearance of devices and ‘poor aftercare’.12 However, both technology and the appearance of hearing aids are improving all the time, but more importantly hearing aids can slow the decline in hearing loss and keep people socially engaged.

The NHS is the first port of call for most people with hearing loss. It currently spends about £450 million annually on hearing services but there is intense debate on whether more should be done, e.g. in terms of population screening.13 NHS England published an action plan which sets out a case to tackle what it calls the ‘rising social and economic costs of uncorrected hearing loss’ including the variations in access and quality of services.14 It plans to address this by improving both the commissioning and integration of services to ensure that ‘people of all ages with hearing loss are actively supported’. Although short on detail, plans include new clinical guidelines developed by the National Institute for Health and Care Excellence (NICE) for ‘Adult Onset Hearing Loss’ to be published in 2018 which should provide the NHS with a new advice and treatment ‘template’ for years to come.

Perhaps the most devastating claim is that hearing loss can lead to social isolation, depression and is associated with poor physical health and premature death, and that access to services is more difficult in such cases. According to the Global Burden of Disease study age-related hearing loss is the eighth most important contribution to years of life lived with disability (YLD), behind musculoskeletal conditions, falls, Alzheimer’s disease and Chronic Obstructive Pulmonary Disease (COPD). 15

or disabilities exacerbates one’s feelings of loneliness or isolation.

The research also benefits from new hearing data collected by Specsavers Audiologists, one of the leading high street providers of hearing care in the UK. This data is based on people that seek hearing tests and so in the vast majority of cases they are already experiencing some hearing difficulties which is usually why they present for tests in the first place. However, the degree of hearing loss experienced in these tests is very helpful for disaggregating those that do not need hearing aids from those that do and for identifying the numbers who are beyond help in this regard.

First however, we need to consider how the population is changing as life expectancy increases. Specifically we consider how this is likely to change the landscape in terms of hearing loss and its associated consequences relating to the social effects, how it affects the market for hearing appliances as well as on the impact on the workforce in general. As might be expected a growing elderly population will increase the prevalence of hearing loss in the adult population with commensurate consequences for assistive aids to help with hearing, visits to doctors and audiologists for hearing tests and also to manufacturers of these devices. Notably, it will also increase in the working age population because of planned and expected further rises in state pension age.

personal social circumstances and attitudes as well as many other domains including paid work. In wave 7, it published data on self-reported hearing loss for the first time in the early part of 2016, which we analyse here.19 As a result it opens up a new and previously unseen window on the social and economic implications of adult hearing loss.

Some headline statistics from ELSA on hearing loss are instructive. According to ELSA, 32.9 per cent of the 50+ population living in England, or 6.6 million people, report hearing difficulties which is made up from 37.7 per cent among men and 29 per cent among women.19 Mainly for reasons of greater exposure to noise in their working lives, men tend to experience hearing loss slightly before women, which helps to explain these differences. Age-related hearing loss is a progressive condition so that by age 79 about 35 per cent of men are affected. Not everyone wears a hearing aid even if they suffer from hearing difficulties. ELSA shows that 11.9 per cent of the 50+ population or 2.3 million people use hearing aids which equates to only 36 per cent of the population with hearing difficulties.20

In this report, we consider the effects of an ageing population on hearing loss from a social and economic standpoint. Using ELSA we drill down into the prevalence of hearing loss at different ages. We examine the personal characteristics of people that wear hearing aids including their economic circumstances. We do this by creating ‘risk’ profiles to understand which risk factors to be most predictive of hearing aid usage in different subgroups. Examples of questions we seek to answer include whether hearing difficulties affect one’s employment prospects and whether living alone coupled with hearing difficulties or ill health


eight years since 1950. Most notably the gap has been reducing since the 1980s as men catch up with women. It now stands at around 3.1 years and is projected to converge by 2030 or shortly after.

3.2 Increased life expectancy and future trends

Gender convergence and rising life expectancy has important consequences for the age structure, pensions and services commonly used by older people including health and social services. It will mean, for example, that cohabiting couples will stay together for longer and so slightly reduce the risk of isolation in later life. Because hearing tends to deteriorate with age it also means that the prevalence of hearing difficulties in the working age population will also increase, and that age-related prevalence of hearing difficulties will increase slightly faster assuming current age-related prevalence trends are maintained.

Using information from the Office for National Statistics 2014, Table 1 shows that the 50+ population of England and Wales is set to increase from 21.3 million in 2016 to 25.2 million by 2030 (+18.3 per cent). It further shows that, although women will still outnumber men, the

3.1 The gender life expectancy gap and hearing loss

Looking backwards to when records began is helpful because this shows not only how life expectancy has grown but also the stark differences in longevity between men and women as it evolved. Figure 1 charts the progress of life expectancy over the period from 1841 onward. The data shows that life expectancy in England and Wales in 1841 for women aged 50 was 21.2 years and for men 19.9 years, a gap of only 1.3 years. It is especially noteworthy that the ages to which men and women could expect to live then, roughly 70 years21, could be the new state pension age by 2030! We could also surmise that because life was shorter, hearing loss was less prevalent but it was also unaidable since the necessary technologies were not available.

Because hearing deterioration is slightly more pronounced for men than for women the life expectancy gap between men and women assumes greater significance. In the early part of the 20th century it widened considerably before plateauing at 5.3 years during the 1970s. By 2011 life expectancy for men at age 50 stood at 31.2 years having increased by 8.6 years since 1950. For women it is 34.3 years having increased by

3. Trends in life expectancy in England and Wales

Figure 1: Trends in life expectancy at age 50 in England and Wales (Source: Human Mortality Database)

Table 1: Projected changes to the 50+ population in England and Wales: 2016 to 2030 (Source: ONS 2014 principal projections)

the conversion rate. This can been seen in the second part of Table 1, which shows that the 75+ population is set to grow to 7.1 million by 2030, up from 4.8 million in 2016. This is a 47.8 per cent increase from levels in 2016.

growth rate for men is higher over the period, which is of course the demographic dividend resulting from their increasing longevity. Since hearing difficulties are more common in the oldest age bracket this will increase the take-up of hearing tests and aids depending on

Aged 50+

Gender 2016 2020 2030 Growth per cent

Men 10.1 10.8 12.0 18.9

Women 11.2 11.9 13.2 17.9

Total 21.3 22.7 25.2 18.3

Aged 75+

Gender 2016 2020 2030 Growth per cent

Men 2.0 2.3 3.2 60.0

Women 2.8 3.0 3.9 39.3

Total 4.8 5.3 7.1 47.8

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y=1.024x - 1.0517

R2 = 0.94611


if we compare the heights of the columns at each age, only about 12 per cent of people with self-reported hearing difficulties at age 50 to 54 uses a hearing aid but this rises to 72 per cent by age 85 to 89. We can note in passing that cost is an unlikely explanation for difference since the NHS provides free hearing tests and also hearing aids. Failure to recognise hearing loss or to take timely action is more important.

4.2 Reported hearing loss versus uptake of hearing aids

If we assume that the current age-related prevalence of hearing difficulties and the wearing of hearing aids will continue into the foreseeable future it is possible to provide estimates of future hearing loss based on demographic trends in the population. This is done simply by multiplying prevalence rates by the expected numbers of the population in each age group. For England and Wales we found that the number of people with hearing difficulties and the number using hearing aids will both grow roughly linearly as is shown in Figure 3, although the take up of hearing aids will rise more slowly.

The growth shown equates to a rise in the number of people with hearing difficulties of

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4.1 What does increased life expectancy mean for those with hearing difficulties?

To understand the implications of longevity on hearing loss we can illustrate this point using ELSA data. Figure 2 shows the prevalence of hearing loss by age and also of wearing hearing aids. As is seen, hearing loss rises linearly from around 20 per cent in the 50 to 54 age group to a peak of just over 54 per cent by age 85 to 89. In the 90+ age group, people who survive to this age report slightly reduced hearing difficulties, although this might be a sampling issue. However, ELSA data also shows that hearing difficulties do not translate directly into the wearing of hearing aids whose usage increases from 2.7 per cent at age 50-54 to a peak of 38.9 per cent by age 85-89 with an average of 11.9 per cent. This is because there is a lag between experiencing hearing loss and taking corrective action by wearing a hearing aid.

The conversion rate will depend on the severity of hearing loss and whether a person decides to seek timely help for their hearing difficulties. The implication of this chart is that there is a lag of well over a decade, so that for example a person initially experiencing hearing difficulties at age 60 to 64 may not start wearing a hearing aid until well into their 70s. Put another way,

If state pension age were to increase to age 70 by 2030, which is quite likely, then the current figure will increase by 56 per cent to 3.9 million or one in 3.8 of the working age population age 50+. This scale of growth is bound to impact on the workplace and is clearly a trend that businesses and health services should prepare for.

The actual growth in annual sales of hearing aids is not the same as the number of people wearing hearing aids. Market data shows 1.6 million hearing aids are transacted each year in which the NHS remains the biggest provider with 83 per cent of the UK market which is growing at 4 per cent per year – roughly what we would expect based on demographic ageing. The private sector, which includes well-known brands such as Specsavers Audiologists, is growing much faster but from a smaller base. When translating from sales of hearing aids to the wearing of hearing aids several factors need to be taken into account such as the average replacement time between hearing aids which we estimate to be between two and four years, people switching from old to new models, repairs to existing aids, the number of aids sold per person, and so on.

about 1.6 per cent a year in the 50+ age bracket from around 6.6 million in 2016 to 8.3 million in 2030. The number wearing hearing aids will rise at a slower rate of 1.4 per cent a year from 2.5 million to 3 million on the same basis. This will open up the gap between the number with hearing loss and hearing aid usage by a further 1.2 million. These figures are of course subject to challenge since they assume no improvement in age-related hearing loss resulting from say healthier lifestyles or changing occupations. Conversely, they contain no judgement about whether hearing aid technology will improve and so make hearing devices more cost effective or if the wearing of hearing aids will itself become more widely accepted.

4.3 Projections for workplace hearing loss

The conjectured increases in state retirement from age 65 to 70 by 2030 will also mean that more people of working age will experience hearing difficulties than previously. Extending the analysis of this age group we estimate there are currently 2.5 million people aged between 50 and 65 with hearing difficulties. Without any rise in state pension age this would increase to 2.7 million by 2030, an increase of 6.4 per cent.

4. Increased longevity and its impact on hearing loss prevalence

Figure 3: Projected growth in the prevalence of hearing difficulties and the wearing of hearing aids in England and Wales

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R2 = 0.94611

Figure 2: Prevalence of hearing difficulties and wearing hearing aids in the 50+ population (source: ELSA)


If the age-specific prevalence of hearing difficulties in each government region is multiplied by the age-specific population of people aged 50+ and totalled, we obtain an estimate of the number of people in each region with hearing difficulties. The national pattern is seen clearly in Figure 4 which is a map of England showing the dominance of the North West (cell G14 to 17) and South East (cell H21 to M22). Across the whole of England we arrive at a figure of 6.1 million varying from 320,000 in the North East (cell J13 and 14) to over one million in the South East. Although, as we saw above, prevalence is greater in the North East, it is the sheer weight of the population in the South East that makes it the region with the highest absolute level of hearing loss.

The equivalent variation in the use of hearing aids follows a more variable pattern. We found that the rate of usage of hearing aids was highest in the North East at 14.6 per cent as compared with an average of 11.9 per cent across the country and only 8.2 per cent in London. If usage is compared with the prevalence of hearing loss then regional differences in uptake are even greater with London the lowest at 31.2 per cent and the North East the highest at 40.1 per cent (England average 36 per cent). Such differences may be cultural in origin as well as socio-economic, but due to small sample sizes it is not possible to be more specific about the age groups affected.

While we do not expect everyone with hearing difficulties to wear a hearing aid we might reasonably expect a proportionate relationship and indeed this is what we find, i.e. more hearing aids are worn the higher the prevalence of hearing difficulties. However, we generally find there is a lag of roughly 20 per cent in the prevalence of hearing aid usage versus the prevalence of hearing loss. For example, if hearing loss in an age group is 30 per cent, hearing aid usage is only 10 per cent in the same age group; if it is say 60 per cent in an older age group then only 40 per cent of people would use hearing aids and so on. This suggests there is a threshold before people take action, i.e. 20 per cent of those with hearing loss in each group ought to be seeking regular hearing checks but are not.

4.4 Regional patterns

The pattern of hearing difficulties at sub-national level will differ slightly from the national picture for local reasons. One of these could be due to differences in current and former employment- based exposure to noise in areas noted for heavy industry or former employment in the military, which is also noted for hearing problems in later life. ELSA shows that the prevalence of hearing difficulties in the 50+ age group is 32.9 per cent on average but this varies from as high as 36.5 per cent in the North East to 30.8 per cent in the South East and 26 per cent in London. In the case of the North East, for example, prevalence from age 70 onwards is generally higher which lends some support to this theory.

term these as: 1. ‘No loss’, 2. ‘Mild loss’, 3. ’Moderate loss’, 4. ‘Severe loss ’ and 5. ‘Profound/Unaidable’.22

Over the page, Figure 6 shows the results of these breakdowns by age group and severity measured in percentage terms from age 50. Of those aged 50-59, test results show that 78.8 per cent has Mild to Moderate hearing loss, although this is not representative of the whole population. Hearing loss increases with age so that by the mid-90s tests show that just over 12 per cent has No loss or only Mild loss. No loss and Mild loss are then replaced by Moderate loss which increases its share throughout the

4.5 Severity of hearing loss

We have seen that ‘hearing difficulties’ is a rather general term which gives no indication of the severity of hearing loss in each age group. ELSA does not categorise information on the degree of hearing loss which is easy to convert into the type of scale which is favoured by audiologists and especially providers of hearing tests. Specsavers Audiologists have been providing hearing tests and hearing aids since 2002. We used Specsavers data to investigate levels of hearing loss experienced by around 137,000 people undergoing hearing tests on either ear between 2010 and 2016 (65,000 men and 72,000 adult women). The map in Figure 5 showing 613 of their England-based outlets shows that the test data are representative of the whole country and not just certain regions.

Most people taking tests will generally have concerns about their hearing already whether it is only mild hearing loss or something worse. Some, for example, will have been advised to take a hearing test by their family members or GPs. Others may not recognise that they have progressive hearing loss and so a few may be in ‘self-denial’. Based on the test data analysed, around 90 per cent are diagnosed with sensorineural hearing loss which occurs naturally with age or as a result of injury. Of those tested, 5 per cent were aged under 60, 84.4 per cent were between 60 and 89 and 10.7 per cent were 90 or over. Audiologists recommend regular hearing tests once a year from 55 and so it seems that younger age groups are not taking action earlier enough based on this data.

Tests themselves are carried out on both ears since hearing loss can be confined to just one ear or both. In our analysis we found that either ear is equally susceptible to hearing loss and so in what follows we combine the data from both ears to increase the sample size to around 274,000 test results altogether. The results of hearing tests are usually banded into nine categories ranging from ‘No loss’ to ‘Profound’ and ‘Unaidable’. To simplify the presentation of our findings we cut these nine categories down into five larger, mutually exclusive groups. We

Figure 4: A map of England shows the estimated number of people aged 50+ with hearing difficulties in each Government region

Figure 5: Hearing tests undertaken by Specsavers Audiologists at store locations in England between 2013 and 2015 broken down by government region

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Legend Estimated number of people with self-assessed hearing difficulties in England aged 50+:

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Legend • Specsavers stores

Specsavers hearing tests carried out in england 2013 to 2015

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and 1.7 per cent in the Severe or Profound category. No loss is the second smallest category with only 2.9 per cent of all tests falling into this group. As previously stated, however, this is not a measure of prevalence but a measure of people seeking hearing tests who will, in most cases, report a hearing problem. Most people wearing hearing aids will tend to fall into the Moderate or Severe categories based on our previous analysis of the take-up of hearing devices using ELSA data.

age range. Severe and Profound loss is small relatively, but increases in size from about age 75 onwards.

In categories from age 90+, Profound and Severe account for 20 per cent or more of all hearing loss tests.

A percentage breakdown in the reduced categories of hearing loss across all ages is given in Table 2. This shows that 87.1 per cent of all test results fall into Mild or Moderate loss categories

Age group 1 2 3 4 5 Total per cent

50-59 0.8 2.7 1.2 0.2 0.1 5.0

60-69 1.3 11.3 6.0 1.0 0.2 19.8

70-79 0.7 15.9 13.4 2.1 0.4 32.5

80-89 0.2 10.8 17.2 3.2 0.7 32.1

90+ 0.0 1.9 6.7 1.7 0.3 10.7

Total by category per cent

2.9 42.6 44.5 8.2 1.7 100.0

Table 2: Test results by category, 1 to 5, and age groups as an absolute percentage of all hearing tests

Figure 6: Percentage breakdown of hearing test outcomes based on tests on either ear with men and women combined

Ag

e 50

+ (m

illio

ns)

Year

Life

exp

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ncy

at a

ge

50

Year

40

35

30

25

20

151840 1860 1880 1900 1920 1940 1960 1980 2000 2020

MenWomen

Per

cen

t o

f p

op

ulat

ion

Age Group

60.0

50.0

40.0

30.0

20.0

10.0

0.0



50-54 55-59 60-64 65-69 75-7970-74 80-84 85-89 90 orOver

Per

cen

t o

f te

sts

Age Group

10.0

9.0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.02016 2018 2020 2022 2024 2026 2028 2030



100

90

80

70

60

50

40

30

20

10

0


Severe

Moderate

Mild

No loss

50-54

55-59

60

-64

65-6

9

70-74

75-79

80

-84

85-8

9

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95-9

9

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+

Pre

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cen

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Observed per cent

45.0

40.0

35.0

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20.0

15.0

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0.00.0 10.0 20.0 30.0 40.0 50.0

y=1.024x - 1.0517

R2 = 0.94611


it perceived to be more or less important than other physical disabilities or health conditions?

In this section we undertake a more in-depth use of ELSA data in order to seek answers to these questions as they apply to the 50+ population of England. In particular, we investigate risk factors which are predictive of three important outcome measures – wearing hearing aids, being in paid work, or experiencing social isolation. Of course other outcomes could also be defined, so these choices must be viewed in terms of their social significance and the relative role of hearing loss in their occurrence and are considered illustrative. This is important since there is a

5.1 An analysis of hearing loss sufferers

So far we have not distinguished between what kinds of people experience hearing loss and the corollary of whether they wear hearing aids or not. This is important because it can identify people that could be helped by targeted campaigns and public health initiatives for people whose lives and wellbeing could, in principle, be greatly enhanced. In this respect there are many factors to consider: does choosing to wear a hearing aid differ between socio-economic groups by age, gender, living arrangements wealth and income? Second, how does hearing loss affect economic aspects such as being in paid employment, and third, is

5. Typical hearing loss demographics

category e.g. experiences hearing difficulties and has a long-term limiting illness. This is discussed and analysed in the next section.

5.1.1 Hearing loss risk factors

A risk ladder is a table that enumerates all possible combinations of binary risk factors, and quantifies the number of people exposed to each risk factor combination. It is a powerful segmentation tool because it can pinpoint which risk groups are at greater or lesser risk and also the contribution of each risk factor to any given outcome. In general, we find that risk factors are more predictive of a particular outcome depending on whether they occur together or not (e.g. a man with hearing difficulties is more likely to be in work if he only experienced hearing difficulties and not a long-term limiting illness).

How predictive these risk factors are differs according to outcome. The following worked example demonstrates this. It concerns the population that uses hearing aids, i.e. the ‘outcome’, according to the first four risk factors listed in Table 3 covering personal health and includes the presence of any limiting illness, any disabilities and hearing loss and sight impairment. We then follow this with two further examples which consider the impact of the same risk factors on two socio-economic outcomes – paid employment and social isolation.

We are interested in what percentages of different subgroups in the population are using hearing aids based on the given risk factors. Table 4 lists all 16 possible combinations of four different risk factors applying to individuals in the sample: These are ‘has a long-term limiting illness’, ‘self-reported hearing is only fair or worse,’ ‘eyesight is fair or worse’, ‘is eligible for disability benefit(s)’. A ‘Y’ in each column indicates that a member of that sub-group is exposed to that particular risk factor so that for example if there are, say, three ‘Y’s in a row, three of the four risk factors will apply.

balance to be struck between the level of detail possible and the danger of very small sample sizes in highly segmented subgroups.

Our choice of risk factors is based on materiality and relevance by which we mean they are common among the population and there is a direct or indirect statistical association with the outcome measure(s) of choice such as wearing a hearing aid. We already know that hearing difficulties are correlated with growing old, so that for example a person aged 75+ is 3.8 times more likely to wear a hearing aid than someone under 75 based on ELSA, but we also know that health and wellbeing is highly variable in older populations and so age is only a proxy for a range of conditions and circumstances that are broadly age-related but not mechanistically so.

Table 3 provides a list of the variables tested in this analysis and their relative frequency in the sample ELSA population of 9,666 persons aged 50+. They are in two sections: ‘outcomes’ and ‘risk factors’. The risk factors are sub-divided into two groups: factors relating to each individual’s health and wellbeing such as health status and hearing loss and those relating to a person’s socio-economic background such as wealth, income, age and gender. For the purposes of our analysis it is assumed that each outcome and risk factor can take only one of two values, one or zero – for example, either a person is employed or not, lonely or not or lives alone or not etc.

The percentage column in Table 3 provides an indication of how often an outcome or risk factor occurs in the sample. For example, it shows that 32.9 per cent are in paid employment, 3.5 per cent report that they are lonely, and 54.5 per cent have a long-term limiting illness. The prevalence of each varies, so for example self-reported loneliness or isolation occurs in only 3.5 per cent of cases which compares for example with self-reported hearing difficulties which applies to 21.6 per cent of cases. However, these percentages do not tell us what proportion falls into more than one risk

Outcomes Identified in data by: per cent of all respondents

Uses hearing appliances Uses hearing aid 11.9

Employment In paid work 32.9

Isolation Self-reported loneliness and sense of isolation

3.5

Risk factors Identified in data by: per cent of all respondents

Personal health Presence of a limiting long-term illness

54.5

Disabilities Eligible for one or more disability benefits

11.6

Hearing loss Self-reported hearing is only fair or worse

21.6

Sight impairment Eyesight only fair or worse 13.2

Other (socio-economic)

Gender differences Male 44.5

Household type Lives alone 22.6

Wealth Owns own home outright 65.9

Low income household Receives a means tested benefit 6.7

Age (a) Aged under 65 42.0

Age (b) Aged under 69 60.9

Table 3: List of outcomes and risk factor selection with their definition and relative occurrence in the ELSA population


Ag

e 50

+ (m

illio

ns)

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exp

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50.0

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20.0

10.0

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Moderate

Mild

No loss

50-54

55-59

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-64

65-6

9

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75-79

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-84

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95-9

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cen

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Observed per cent

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35.0

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5.0

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y=1.024x - 1.0517

R2 = 0.94611

the sample population – which agrees with the percentage shown in Table 3 next to ‘Hearing loss’. The results show that people with fair to poor hearing loss are much more likely to wear hearing aids and is a key risk factor occupying the first eight rows. But it also shows that hearing aids may be worn by people whose hearing is not perfect but better than ‘fair’. To summarise, the table shows that there is a very wide range of usage of hearing aids in the 50+ population from 38.4 per cent in the top risk group to less than 5 per cent in the bottom risk group. Further analysis enables us to quantify the individual influence of each risk factor to see how each compares.

This influence is determined using logistic regression, the results of which are expressed in odds: e.g. a person exposed to risk factor X is Y times more likely to wear a hearing aid than not. A risk factor with odds of less than one means

Subgroups are ranked from high to low based on the percentage of each subgroup predicted to use a hearing aid. For example in row one there are 198 respondents (2.1 per cent of the sample) among whom the predicted use of hearing aids is 38.4 per cent. These are people with a long-term limiting illness with fair or worse hearing who are eligible for disability benefits. This finding contrasts with the much larger subgroup of 3,397 people in row 15 (35 per cent of the sample) to which none of these risk factors applies and among whom the predicted use of hearing aids is 5.2 per cent. The average for the sample population using hearing aids is 11.9 per cent which is shown in the bottom right hand corner.

The numbers at the foot of each column relate to the occurrences of each risk factor. For example 2,086 respondents report hearing difficulties which equates to 21.6 per cent of

5.1.2 Using risk factors to predict hearing aid uptake

How useful are these factors for predicting hearing aid usage? Figure 7 plots the predicted use of hearing aids against the observed use of hearing aids found in ELSA based on the logistic regression results. As is seen the data points lie very close to a straight line indicating a strong correspondence between the predicted and observed usage with a coefficient of explanation, R-Squared of 95 per cent. Such segmentations of the population wearing hearing aids can be useful for targeting purposes – e.g. where the aim might be to encourage the use of hearing aids or for other purposes such as identifying whether there is a causal link between a risk factor and any given outcome.

Alternative segmentations of the population based on socio-economic factors are also informative. For example we may find that people in certain socio-economic groups experiencing hearing loss are less likely to wear a hearing aid and so on. This may be important for targeting public health campaigns in areas where exposed risk groups concentrate. If the same analysis as above is performed using

that its influence has the opposite effect – in this case hearing aids would be worn by a smaller percentage of the sub-group if it applied. Our analysis shows that the odds or likelihood of using a hearing aid increase:

• 1.6 times if a person has a long-term limiting illness

• 5.3 times if a person is experiencing hearing difficulties

• 0.9 times if a person has fair or worse eyesight

• 1.3 times if eligible for disability benefits

Of these, hearing difficulties is unsurprisingly the most predictive of these followed by long-term limiting illness. As can be seen, fair or worse eyesight falls into this category but with a value that is close to one it means that its effect of whether hearing aids are used or not is essentially neutral. These odds are multiplicative so that for example a person exposed to all four risk factors is 1.6 x 5.3 x 0.9 x 1.3 = 9.9 times more likely to use a hearing aid than a person with none of these risk factors.

Category Number in category

Has long-term limiting illness

Self-reported hearing is fair or worse

Eyesight is fair or worse

Eligible for disability benefit(s)

Predicted use of hearing aids per cent

1 198 Y Y 38.4

2 143 Y Y Y Y 35.7

3 772 Y Y 32.1

4 279 Y Y Y 29.6

5 16 Y Y 27.5

6 8 Y Y Y 25.2

7 575 Y 22.3

8 95 Y Y 20.3

9 479 Y Y 10.6

10 164 Y Y Y 9.5

11 2,865 Y 8.2

12 371 Y Y 7.4

13 91 Y 6.7

14 20 Y Y 6.0

15 3,397 5.2

16 193 Y 4.6

total 9,666 5,271 2,086 1,273 1,119 11.9

Table 4: Risk Ladder showing the use of hearing aids in 16 sub-groups based on different risk factor combinations (Note; Y = risk factor applies)

Figure 7: Predicted versus observed percentage of adults aged 50+ using hearing aids


inactive population across the ages. Clearly, the significance of these results from the standpoint of hearing loss is mainly indirect, except as we have seen hearing loss tends to reduce employment prospects especially in combination with other risk factors.

5.1.4 Hearing loss as a contributing factor to loneliness and social isolation

Only 3.5 per cent of the sample reported feelings of loneliness and isolation which increases with age. The most interesting finding here is the influence of long-term limiting illness, poor eyesight and being disabled. Each increased the chances of loneliness or isolation twofold. Hearing loss is less predictive of loneliness and isolation but it can be considered as an important exacerbating factor which could accelerate the onset of other diseases of old age such as dementia. This makes sense because ill health and disability make it more difficult to leave the home, unlike hearing loss which does not place the same constraints on mobility. Together these four risk factors accounted for 61 per cent in the variation in loneliness and isolation and so not as high as in the previous examples.

With regard to socio-economic risk factors it was found, unsurprisingly, that a person is 2.5 times more likely to experience loneliness and isolation if they live alone. However, this was 2.5 times more likely if they lived on low income but 1.2 times less likely if they were male and 1.6 times less likely if they owned their own home. This finding shows that income and wealth tend to counteract isolation tendencies by helping people to live a more fulfilling life with greater choice. These four risk factors accounted for 68 per cent of the variation in self-perceived loneliness and isolation. To put a scale on the problem, of the 3.5 per cent in the ELSA sample expressing feelings of isolation or loneliness, 25 per cent of these also report ‘fair to poor’ hearing. In population equivalent terms, loneliness therefore affects 700,000 adults aged 50+ in England of whom around 175,000 also self-reports hearing loss.

pension age, then this falls to 50 per cent. Below current state pension age, 35 per cent are inactive or unemployed and 65 per cent are in paid employment. There is, as might be expected, a rising gradient of economic inactivity with age which is bound to change as pension age increases. For example, the data also show that those with hearing loss have inactivity rates that are 6.3 per cent higher in the 64 or under population than those without hearing loss as compared with 9.3 per cent in the 69 or under age group with obvious implications for future employment rates as pension age increases.

The segmentation of the population into personal risk factors shown in Table 3 finds that the importance of each changes only slightly within each age group – for example eligibility for disability benefits, which has the largest effect of all the risk factors, increases the chances of being economically inactive by four to five times. Poor eyesight and long-term limiting illness are also predictive and statistically significant but their influence is less important than disability. Although it is the least influential of the risk factors, hearing loss differs because it rises with age as we showed above, i.e. you are more likely to be inactive if you suffer hearing loss aged 65+ than if you are under 65.

The influence of socio-economic factors on working patterns also shows a strong differentiation between subgroups. For example, a man is between 1.2 and 1.4 times less likely to be economically inactive than a woman, although this may be partly related to different retirement ages and other factors such as caring responsibilities e.g. a woman looking after an elderly relative. A person is also more likely to be inactive if they own their own home, probably because wealthier people are less likely to need the income. People on means tested benefits are income poor by definition and are therefore also much more likely to be inactive.

We also find that cohabitation tends to lengthen working life. Living alone reduces the chances of paid employment between 2.2 and 3.6 times depending on age group. For a person aged under 65, living alone has a lesser effect than if somebody is aged 69 or less. Taken together these factors generally accounted for over 90 per cent in the variations in economically

People that live alone are also more likely to use hearing aids – which might suggest the need to be able to communicate effectively, but it is also a possible sign of poor health given the previous analysis. The implication is that should all four factors apply then hearing aids would be 6.6 times more likely to be used than in a group where none of these risk factors applied. Again such information might be helpful in targeting campaigns to encourage regular hearing checks.

We also analysed two other outcomes: whether being economically inactive is affected by or associated with hearing loss and if hearing loss can lead to loneliness or social isolation. These were analysed on the same basis as hearing aid usage using exactly the same sets of risk factors but it is not necessary for the results to be spelled out in the same detail. Some of the key findings are as follows.

5.1.3 Employment rates for those with hearing loss

Of the total sample of adults aged 50+, 67.1 per cent are retired, economically inactive or unemployed. If we restrict our age group to those below age 70, the possible future state

the second group of risk factors in Table 3, we obtain the following findings:

The use of hearing aids increases:

• 1.7 times if it is man rather than a woman

• 1.9 times if a person lives alone

• 1.7 times if a person owns their own home outright

• 1.2 times if a person receives financial support with Council Tax

The significance of this is that it shows some social stratification in the use of hearing aids. Men are more likely to wear them because hearing loss is higher than in women or perhaps women find there is a stigma attached to wearing them. But it also shows that better off people owning their own home rather than renting or paying off the mortgage are more likely to use a hearing aid, as are people on low income and receiving help with paying Council Tax (hearing aids are free under the NHS and low income groups also receive other benefits like free prescriptions).


years by 2030 will inevitably lead to a greater focus in the workplace.

We already know that one of the main causes of hearing loss is exposure to noise which commonly affects men more than women because of differences in their occupational histories. However, since traditional male occupations in heavy industry such as coal mining have long been in decline, it is possible that reduced noise exposure in subsequent male cohorts will lead to reduced hearing loss unless they are being replaced by equally noisy new industries. Data on industrial Injuries Benefit, for example, for occupational hearing loss sustained in work show a drop of 35 per cent in caseload to 9,500 since 2000 so it shows that progress in limiting noise exposure, at least in the workplace, is working.

Male exposure to noise is also very high among the military and the levels experienced by military personnel can exceed that of the maximum protection achievable. Because military personnel are usually fairly young when they are exposed to noise the effects can last a lifetime thereby increasing the burden of hearing loss at a population level. However, because the size of the military has reduced substantially in recent decades, we would expect this source of hearing loss to reduce in tandem in coming decades. Similar points could be made about other activities but these are not necessarily occupationally related such as listening to exceptionally loud amplified music through headphones or at concerts (e.g. the current popularity of MP3 players).

As we saw from our research, hearing loss is not always recognised or acted upon by individuals themselves and so may need prompting from friends and family or employers. It was shown that people experience hearing difficulties long before they decide to use a hearing device. There are various reasons for this: a person may not be aware of the problem and so may not take any action, or there may be a stigma attached to hearing loss leading to self-denial. Finally, a person may not be aware of the help

Hearing loss is a significant public health problem which ranks highly among all the causes of years lived with disability. It is also one which is partly treatable and manageable but also substantially preventable if people take the right precautions. Some degree of hearing loss is inevitable during a person’s life especially in old age. How much loss is experienced is partly determined by genetics and birth related conditions or illness, but mainly by ones’ exposure to noise during the life course. Regular testing can help by highlighting changes to a person’s hearing over time, detecting other medical conditions or simply by improving quality of life by prescribing the wearing of a hearing aid.

We are now in a period of rapid population ageing and increasing longevity which will inevitably result in an increased prevalence of hearing loss in the general population. Because this can be predicted with reasonable certainty, it should be relatively easy to raise awareness of this condition among the medical profession and providers of hearing test and hearing aids so that they can plan and commission services accordingly. Partly in response to the ageing population, NHS England has published an action plan on hearing loss which includes the development of new NICE guidelines for treating hearing loss and a new commissioning framework which will provide a more evidence-based approach to interventions.

Our research has identified one possible trajectory this might take in terms of the prevalence of hearing difficulties and the subsequent usage of hearing aids based on demographic projections of the population. However, these forecasts do not take into account longer term changes in the causes of hearing loss and exposure to noise, individual behaviours, or technology. Together these may reduce prevalence to a degree by delaying the onset of hearing loss and also the severity but equally this may lead to an increase in the take-up of hearing aid devices. Although employers already have certain duties towards the hard of hearing under the Equality Act (2010), the conjectured rises in state pension age to 70

6. Concluding reflections


happen especially, as we saw, it is aidable in most cases.

Although increases in state pension age will result in more people of working age experiencing hearing loss, it is arguable that hearing loss need not become a serious hindrance if regular tests are carried out and help is sought. At age 70, 34.4 per cent of the population will experience some hearing difficulties. While more than half of all people tested by Specsavers Audiologists in this age group had hearing loss rated as moderate or worse, the good news is that most of these cases were aidable. On issues such as whether a person aged under 70 was in paid employment, hearing loss was slightly less predictive than vision impairment. The main risk factors were long-term limiting illness and physical disability such as musculo-skeletal problems.

Nevertheless, hearing loss is an important part of this mix especially if it is coupled with economic inactivity, sight impairment, and generally poor health at older ages. In these cases it can lead to accelerated cognitive decline, depression, increased risk of dementia, poorer balance, falls, hospitalisations, and early mortality23 (Davis et al, 2016). Especially where hearing loss is treatable our results suggest that wearing a hearing aid can improve a person’s quality of life24 (Weinstein et al, 2016). There are also social implications, such as reduced communicative function, social isolation, loss of independence and mobility and financial decline. Being active and in reasonable health can obviously alleviate these risks as our analysis of ELSA data has shown.

A person suffering hearing loss may not experience the same feelings of loneliness once social and other factors are taken into account. For example, sharing a home is a significant factor in reducing feelings of loneliness and isolation. Additionally, while men are more likely to experience hearing loss than women they are also more likely to be in paid employment. These circumstances overlap and are largely shared with different social outcomes and are interconnected. These findings may seem self-evident but putting a scale on the problem is important from a public policy standpoint e.g. how many people live alone on low income with hearing loss and what difference would it make to their lives and prospects if they wore a hearing aid and found a job?

available or may be wrongly concerned about the cost. In a few cases, the reverse is true, namely that there may be a financial motive for seeking damages resulting from hearing loss in say the work place or military.

Medical technology for treating hearing loss is improving but there is a long way to go – for example, discovering the means to identify what is required to regenerate hair cells in humans which are crucial for hearing. Gene therapy, the development of new drugs and surgery and implants are the main directions of travel in research terms. From a preventive stand point, testing can determine if hearing loss exists, even for the youngest populations, and the nature of the hearing loss including the possible benefits through available treatments. Based on Specsavers Audiologists data we found, for example, that hearing loss was profound or unaidable in only about 1.7 per cent of the population taking hearing tests.

Auditory rehabilitation is now available for individuals of all ages who have hearing loss. Modernised techniques include individually tailored and computerised training in speech reading (lip reading), auditory training, and assistance in everyday listening through custom-designed personal hearing aids, both of the analogue and more modern digital kind. Software to screen out extraneous noise in future hearing appliances is also in prospect. The design and miniaturisation of hearing aids has also made their use more socially acceptable so reducing the stigma aspects to a degree. Testing and treatment for hearing loss is also free under the NHS which removes an important cost barrier so that those on low income or means need not be disadvantaged. However, more bespoke and miniaturised hearing aids can be tailored to individual needs.

Using ELSA we were able to assess age-related hearing loss within a wider context including the co-prevalence of ill health and disability and also the socio-economic circumstances of the older adult population. This is an especially important area of policy as the population ages. Older people need to rely on different sources of help to maintain their quality of life from social and primary care services to optometrists, dentistry and audiology services, in some cases supplied direct to their home. Among all the problems of growing old, we found that hearing loss is important but it is not the worst thing that can

7. Recommendation for action

offering free hearing tests at work as well as encouraging their employees to attend regular hearing checks once a year for anyone over 55.

The contribution of this research is that it draws attention to the impact of hearing loss in an ageing population and allows us to unpick different dimensions of hearing loss in different age groups and social strata. By extending this process and investigating further risk factors, it should be possible to design more bespoke approaches and solutions such as early detection by targeting people among the more vulnerable categories and those less likely to seek help. Increasing longevity, raised pension age and the need to work for longer will encourage the search to find solutions, but it is also important that we, as individuals, do not become complacent and that we guard our most precious asset – namely our health.

More research is needed to tease out these issues but we believe that this analysis has begun the process of putting a scale on the problem and the interactions between risk factors and social conditions. The headline finding that the conjectured rise in state pension age from age 65 to 70 by 2030 will result in the number of people of working age with hearing loss will rise from 2.5 million to 3.9 million (+ 56 percent) should be a wake-up call to businesses.

In the UK there are currently no guidelines for managing hearing loss in the workspace beyond the Equality Act 2010. Under the Equality Act 2010 employers have a duty to make ‘reasonable adjustments’ for people who are hard of hearing, so as to avoid a ‘substantial disadvantage’ in work. Only those with hearing loss that has a substantial effect on their day-to-day capabilities are likely to be protected. It is vital that structures are in place for those that are needlessly trying to manage mild/moderate hearing loss in the work place, especially at a time when workforce populations living with hearing loss is increasing more than twofold. Employers should be taking action to increase awareness of hearing loss in the work place by


which attempts the quantification of the benefits as well as costs of screening.

8 Thatcher, A. R., S. L. K. Cheung, S. Horiuchi, and J.-M. Robine, J-M. (2008) The compression of deaths above the mode. Population Association of America.

9 Cheung, Y.B. (2000) Marital Status and Mortality in British Women: A Longitudinal Study, International Journal of Epidemiology, 29, 93-99. Karlsson, M., L. Mayhew, and B. Rickayzen (2009) Individualised Life Tables: Investigating Dynamics of Health, Work and Cohabitation in the UK , Journal of Population Ageing, 1(2-4), p.153-191

10 The Health Survey for England (HSE) is a series of annual surveys about the health of people living in England commissioned by the Health and Social Care Information Centre: https://www.ucl.ac.uk/hssrg/studies/hse

11 Hearing Matters (2015) Action on Hearing Loss, a national charity

12 Later Life in the United Kingdom June 2016: http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true

13 The ‘Commission on Hearing Loss: Final Report’ (ILC-UK, 2014)

1 Source: Cancer UK: http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/smoking/lung-cancer-and-smoking-statistics#history

2 Blake, D. and L. Mayhew (2010) ‘On The Sustainability of the UK State Pension System in the Light of Population Ageing and Declining Fertility’. The Economic Journal, 512;116, F286–F305

3 DRA enabled employers to retire people at age 65 but this requirement was abolished in 2011

4 Emond, A., M. Ridd, H. Sutherland, L. Allsop, A. Alexander, J. Kyle. The current health of the signing Deaf community in the UK compared with the general population: a cross-sectional study. BMJ Open 2015:5.

5 Includes Employment Support Allowance, Incapacity Benefit and Severe Disablement Allowance and Industrial Injuries Benefit.

6 It does not include tested benefits paid to household s such as Housing Benefit and Income Support and ignores people in work with hearing loss who are paid less on average the those without hearing loss

7 The ‘Commission on Hearing Loss: Final Report’ (ILC-UK, 2014) puts the figure much higher by noting that people with hearing problems have lower rates of employment than those with no disabilities. See also ‘Cost benefit analysis of hearing screening for older people’ (2010) London Economics

Specsavers Audiologists: 1. No loss; 2. Mild; 3. Mild/Moderate; 4. Moderate; 5. Moderate/ Severe; 6. Severe; 7. Severe/Profound; 8. Profound ; 9. Unaidable . The five reduced categories used in this paper combine the original nine Specsavers categories as follows: ‘No loss’, category 1; ‘Mild loss’, categories 2 and 3; ‘Moderate loss’, categories 4 and 5; ‘Severe loss’, categories 6 and 7; ‘Profound loss’, categories 8 and 9.

23 Davis, A., C. M. McMahon, K. M. Pitchora-Fuller, S. Russ, F. Lin, B. O. Olusanya, S. Chadha, and K. L. Tremblay (2016) Aging and Hearing Health: The Life-course Approach. The Gerontologist, 56, S256-S267.

24 Weinstein, B. E., L. W. Sirow, S. Moser (2016) Relating Hearing Aid Use to Social and Emotional Loneliness in Older Adults. American Journal of Audiology, Vol. 25, 54-61

14 NHS England (2015), ‘Action Plan on Hearing Loss’: http://www.bcig.org.uk/wp-content/uploads/2015/03/Action-Plan-on-Hearing-Loss-Final-23.3.15.pdf

15 Murray, C. et al (2013) Global Burden of Disease Study 2010. Lancet, vol. 380, no. 9859.

16 Evaluation Of The Social And Economic Costs Of Hearing Impairment: B. Shield (2006), http://www.hear-it.org/sites/default/files/multimedia/documents/Hear_It_Report_October_2006.pdf

17 See ‘Estimates of the number of adults in England, Wales, and Scotland with a hearing loss’ (2014) Akeroyd, M. A., K. Foreman, and J. A. Holman

18 English Longitudinal Study of Ageing: http://www.elsa-project.ac.uk/

19 Based on question: ‘Whether experiences hearing difficulties?’

20 Based on question: ‘Ever wears a hearing aid?’

21 Biblically speaking: ‘Three score years and 10’.

22 There are nine levels of hearing loss used by

Acknowledgement The author would like to thank Gillian Harper of MHA Ltd. for her contributions to this research and also Specsavers Audiologists for providing data.

8. References

34 Listen up! Hearing loss in an ageing society

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