Original Article

Self-perceived hearing handicap and hearing

sensitivity in nursing home elderlies
Autopercepção e sensibilidade auditiva em idosos institucionalizados
Maria Beatriz Baruzzi1, Alda Christina Lopes de Carvalho Borges2, Miriam Ikeda Ribeiro3, Fabio Nasri4

ABSTRACT autoavaliação (HHIE-S). Resultados: A escolaridade mostrou uma média

Objectives: To identify hearing sensitivity and self-perceived handicap
and their relation. Methods: Schooling, dependence for daily activities
and auditory complaints were investigated in 79 nursing home elderly
subjects, male and female, aged from 66 to 100 years. All underwent
basic hearing evaluation and answered a self-assessment scale
(HHIE-S). Results: Mean schooling was of 8.3 years. Thirty-one
subjects (39.3%) were classified as independent, 43 (54.4%) as semi-
dependent and 5 (6.3%) as dependent. Fifty-eight (73.4%) subjects
had complaints concerning their hearing. Only 25.3% demonstrated
normal hearing for low and medium frequencies, and 8.9% and 7.6%
for high frequencies on the right and left ears, respectively. Hearing
loss for low and medium frequencies was mild, while that for high
frequencies was moderate. The great majority of subjects (64.6%)
did not demonstrate hearing handicap as evaluated by the HHIE-S.
Conclusions: Hearing loss without self-perceived hearing handicap
was prevalent in the group and these aspects were highly associated,
that is, the worse the hearing sensitivity, more evident the handicap.
The development of hearing loss is usually slow and only perceived
when affecting the entire frequency range, leading to difficulties in
social integration and lack of motivation in maintaining interpersonal
relations, strengthening the social barriers and demonstrating the
importance of the audiologist in these institutions.
Keywords: Hearing; Hearing loss; Auditory perception; Questionnaires;
Aging; Health of institutionalized elderly
RESUMO
Objetivos: Identificar o grau de sensibilidade auditiva e a autopercepção
do handicap em idosos e verificar a relação entre ambos. Métodos:
Realizou-se o levantamento da escolaridade, grau de dependência para
as atividades de vida diária e das queixas relacionadas à audição de
79 indivíduos, de ambos os gêneros, na faixa etária de 66 a 100 anos,
residentes em uma instituição de longa permanência. Submetidos
à avaliação audiológica básica e à aplicação de um questionário de
Study carried out at Residencial Israelita Albert Einstein – RIAE, São Paulo (SP), Brazil; and Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil.
Master’s degree; Speech therapist at Residencial Israelita Albert Einstein – RIAE, São Paulo (SP), Brazil.
1
de 8,63 anos cursados; 31 indivíduos (39,3%) foram classificados como
independentes, 43 (54,4%) semidependentes e 5 (6,3%) dependentes;
58 (73,4%) indivíduos apresentaram alguma queixa relacionada à
audição. Apenas 25,3% da amostra apresentou grau de sensibilidade
auditiva normal para as frequências baixas e médias e 8,9% à direita e
7,6% à esquerda para as altas, sendo o grau leve o mais frequente para
as baixas e médias, e o moderado para as altas, para ambos os lados.
A maioria dos idosos não apresentou percepção do handicap auditivo
(64,6%). Conclusões: Houve alta prevalência de deficiência auditiva,
porém sem percepção do handicap na maioria dos indivíduos avaliados,
estando estes dois aspectos amplamente relacionados. O caráter lento
e progressivo da deficiência auditiva, que só passa a ser notado quando
se atinge altos graus de comprometimento, soma-se à dificuldade de
integração social deste grupo e o desinteresse em manter as relações
interpessoais, intensificando as barreiras e apontando para a grande
necessidade da atuação fonoaudiológica dentro destas instituições.
Descritores: Audição; Deficiência auditiva; Percepção auditiva;
Questionários; Idoso; Saúde do idoso institucionalizado
INTRODUCTION
Brazil, as several other countries, is going through a
process of population aging. Demographic data (IBGE,
2004) point to the social impact of the increased
concentration of the population older than 60 years
and the influence of the aging process in biological,
psychological and social-cultural aspects(1).
Biologic aging may cause the loss of autonomy
(partial or total) to perform daily activities, becoming
one of the main risk factors for institutionalization(2-3).
Entering a lengthy stay institution has a major
impact on social relations and these individuals face
isolation. When there is hearing deprivation, isolation

PhD; Lecturer of Human Communication Disorders from Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil.
2

Nurse specialized in Public Health; Manager of Residencial Israelita Albert Einstein –RIAE, São Paulo (SP), Brazil.
3

MD; Master’s degree from Academia Europeia de Medicina do Envelhecimento, São Paulo (SP), Brazil.
4

Corresponding author: Maria Beatriz Baruzzi – Rua Galofre, 35 – apto. 71 – Chácara Klabin – CEP 04116-240 – São Paulo (SP), Brasil – Tel.: 11 5083-8051 – e-mail: mbeatrizb@einstein.br
Received on Aug 21, 2008 – Accepted on Feb 5, 2009

einstein. 2009;7(2 Pt 1):176-81


is enhanced, and the progression of functional changes,
of cognitive decline and of depression symptoms may
be accelerated.
The reasons for non-compliance of the elderly
population on the auditive rehabilitation programs have
been widely investigated. Such programs attempt to
improve hearing of different sounds and helping these
individuals to cope with limitations (hearing disability) in
their daily activities, and to minimize the disadvantages
(handicap) due to hearing impairment(4). More
investigation on the aspects related to auditory dysfunction
in institutionalized elderly subjects is needed(5-6).
In Brazil, there are few professionals interested
in caring for this specific population(7). The process of
auditory rehabilitation must meet the needs of these
individuals and according to the institution, adapting the
environment and training the team, family and friends,
in order to provide as many subsidies as possible to
improve communication.
OBJECTIVE
To identify the hearing behavior: hearing sensitivity and
self-perceived handicap in a group of institutionalized
elderly subjects and to verify the relation between
both.
METHODS
The project for this study was analyzed by the Ethics
Committee of Universidade Federal de São Paulo
and of Instituto de Ensino e Pesquisa da Sociedade
Beneficente Israelita Brasileira Hospital Albert
Einstein and approved under process number 0054/06
and 05/371, respectively.
Residencial Israelita Albert Einstein is a lengthy stay
institution for the elderly cared by a multiprofessional
team. Periodically, as from admission, the elderly
subjects undergo thorough gerontologic assessment and
are classified according to the degree of independence
to perform activities of daily life into three different
groups: independent, semi-dependent and dependent.
Seventy-nine institutionalized subjects took part
in the present study, with the following inclusion
criteria: minimum age of 60 years, absence of cognitive
impairment that could limit the performance of the
proposed tasks; voluntary agreement to participate in
this study and signing the informed consent form.
The sample was composed by individuals aged from
66 to 100 years, 62 females with a mean age of 85.13
years (± 6.28) and 17 males with mean age of 82.76
(± 6.69) years.
Data about age, schooling and degree of independence
to perform daily life activities were obtained from the
Self-perceived hearing handicap and hearing sensitivity in nursing home elderlies 177
medical charts available at the institution. Complaints
about hearing of each individual were also studied and
all data were recorded in an investigation protocol.
First, a self-assessment questionnaire was applied,
The Hearing Handicap Inventory for the Elderly
– Screening Version (HHIE-S)(8), adapted for the
Portuguese language(9). There are three possible
answers to the questionnaire: yes (corresponds to four
points), sometimes (two points) and no (no point);
with the following categorization: severe or significant
perceived handicap – above 24 points; mild to moderate
handicap – 10 to 24 points; no perceived handicap – 0
to 8 points.
Next, they underwent laminar tonal audiometry,
air audibility thresholds with headphones, in the 250 to
8,000 Hz frequencies, and bone with 500 to 4,000 Hz
bone vibrator when necessary(10). An acoustic booth, a
MA41 MAICO audiometer with TDH-39 headphones,
properly verified, were used(11).
The degree of hearing sensitivity based on the mean
hearing thresholds at 500, 1,000 and 2,000 Hz frequencies
and the magnitude of hearing impairment based on the
3,000 and 4,000 Hz frequencies were categorized as(12):
• normal: below 25 dBNA;
• mild: 26 to 40 dBNA;
• moderate: 41 to 55 dBNA;
• moderately severe: 56 to 70 dBNA;
• severe: 71 to 90 dBNA;
• profound: above 90 dBNA.
The statistical analysis of the present study involved
descriptive statistics of the categorical variables with
absolute frequency (n) and proportion (%), and of
continuous variables with means, standard deviations,
minimum and maximum values, medians and quartiles.
In order to compare the degree of hearing sensitivity
and self-perceived hearing, the Fischer exact test
was used (expected values lower than five), and the
comparison of different degrees of hearing sensitivity
between the right and left ears was done with the
Bowker symmetry test, for related samples for variables
with three or more categories, and the McNemar test
for related samples for variables with two categories.
The statistical analysis of the present study was
descriptive and analytical and used non-parametric
tests. The significance level adopted was 5% and the
confidence intervals applied during the study were
determined with 95% statistic confidence.
RESULTS
There was a high incidence of females in the population
studied (78.48%) and the age ranged from 66 to 100
years. Comparison between ages, according to gender,
einstein. 2009;7(2 Pt 1):176-81
178 Baruzzi MB, Borges ACLC, Ribeiro MI, Nasri F

demonstrated that females had a mean age of 85.13 35

(± 6.28) years higher than males, of 82.78 (± 6.69) years. 30

The degree of dependence for daily life activities 25

most frequent was semi-dependent, encompassing 20

43 (54.43%) of the individuals studied, 31 (39.24%) 15

independent and 5 (6.33%) dependent elderly 10

individuals. Mean schooling was of 8.63 (± 4.31) 5

years, ranging from 0 to 18 years. 0

Normal Mild Moderate Mod. Severe Severe Profound
The most frequent hearing complaint was difficulty in
hearing, present in 43 (54.4%) individuals, significantly RE (Low and medium frequencies)
LE (Low and medium frequencies)
different from other complaints (p < 0.001): dizziness RE (High frequencies)
LE (High frequencies)
(30.4%), tinnitus (22.8%), auditory discomfort (6.3%)
Figure 1. Comparing hearing sensitivity degree between the left and right ears at
and history of ear problems (5.1%). Only 21 (26.6%) low, medium and high frequencies
individuals had no complaints regarding hearing.
Table 1 shows a significant predominance of mild
involvement in both sides (36.71%), compared to the 1 and 2 show the comparison between both ears, with no
remaining hearing sensitivity degrees, and only 20 significant difference between them. There was a close
(25.30%) individuals had a normal hearing sensitivity in relation between increased hearing sensitivity and aging.
both sides at low and medium frequencies (Figure 1). Regarding self-perceived hearing handicap, 64.6% (51
Regarding high frequencies, 8.9% and 7.6% of the individuals) had no perception, 20.3% had mild to moderate
subjects had normal sensitivity at the right and left ears, perception and 15.2% had severe or significant perception
respectively; there was a predominance of moderate of the handicap (Figure 2). The HHIE-S results were related
degree (35.4% at the right and 32.9% at the left). Tables to the age group, presence of hearing complaints and degree

Table 1. Comparing hearing sensitivity degree between the left and right ears at low and medium frequencies

Moderately
Hearing sensivity degree Normal n(%) Mild n(%) Moderate n(%) Severe n(%) Profound n(%) Total n(%)
severe n(%)

Normal 19 (24.05) 1 (1.27) 0 (0.00) 0 (0.00) 0 (0.000 0 (0.00) 20 (25.32)

Mild 1 (1.270 23 (29.11) 5 (6.330 0 (0.00) 0 (0.00) 0 (0.00) 29 (36.71)

Moderate 0 (0.00) 4 (5.06) 7 (8.86) 1(1.27) 0 (0.00) 2 (2.53) 14 (17.72)

Moderately severe 0 (0.00) 1 (1.27) 3 (3.80) 5 (6.33) 2 (2.53) 0 (0.00) 11 (13.92)

Severe 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 2 (2.53) 0 (0.00) 2 (2.53)

Profound 0 (0.00) 0 (0.00) 0 (0.00) 1 (1.27) 0 (0.00) 2 (2.53) 3 (3.80)

Total n(%) 20 (25.32) 29 (36.71) 15 (18.99) 7 (8.86) 4 (5.06) 4 (5.06) 79 (100.00)

Bowker test for symmetry: S = 7.11; FD = 15; p = 0.955

Table 2. Comparing hearing sensitivity degree between the left and right ears at high frequencies

Moderately
Hearing sensivity degree Normal n(%) Mild n(%) Moderate n(%) Severe n(%) Profound n(%) Total n(%)
severe n(%)

Normal 5 (6.33) 2 (2.53) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 7 (8.86)

Mild 1 (1.27) 10 (12.66) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 11 (13.92)

Moderate 0 (0.00) 0 (0.00) 21 (26,58) 6 (7.59) 0 (0.00) 1 (1.27) 28 (35.44)

Moderately severe 0 (0.00) 0 (0.00) 4 (5.06) 13 (16.46) 2 (2.53) 0 (0.00) 19 (25.05)

Severe 0 (0.00) 0 (0.00) 1 (1.27) 2 (2.53) 6 (7.59) 0 (0.00) 9 (11.39)

Profound 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 3 (3.80) 2 (2.53) 5 (6.33)

Total n(%) 6 (7.59) 12 (15.19) 26 (32.91) 21 (26.58) 11 (13.92) 3 (3.80) 79 (100.00)

Bowker test for symmetry: S = 5.73; FD = 15; p = 0.984

einstein. 2009;7(2 Pt 1):176-81

 Self-perceived hearing handicap and hearing sensitivity in nursing home elderlies 179

of hearing sensitivity. Older age was associated with a higher Mean schooling years found point to low level
degree of hearing loss and a significant perception of age for of schooling, considered a risk factor for cognitive
low, medium and high frequencies. decline and for a lower degree of independence for
daily life activities, because the individuals with higher
schooling show a greater interest in keeping general
15%
health and have more access to specialized care(14).
No perception of handicap The need for care and help to perform daily
20%
Mild to moderate perception
Significant perception
life activities associated to poor family support are
65% determining factors for institutionalization(15), and
thus may justify the predominance of semi-dependent
Figure 2. Distribution of the population studied per perception of handicap
elderly individuals.
The relation between schooling and the degree of
Although the analyses performed point toward a independence found in the literature was not observed,
close relation between the degree of hearing sensitivity probably due to the fact that this group is made up
and self-perceived hearing handicap, it can be observed of individuals of high cultural level, demonstrated by
that even individuals with severe and profound hearing knowledge of two or more languages, great interest in
loss did not show self-perceived hearing handicap for music, painting and, especially, reading; such findings
low, medium, and high frequencies (Tables 3 and 4). may have influenced positively the preservation of
functional capacity.
Hearing disability affects not only sound audibility,
DISCUSSION speech recognition, but also integration between
The predominance of females in the population studied, hearing and other sensory modalities. Sensory losses
although higher than what is found in the Brazilian in the elderly are often accompanied by difficulty
population, in which women represent 55.1%(1), is probably in performing daily life activities, and may exert a
due to the increased longevity of this sex worldwide and damaging influence in the self-perceived general health
in Brazil, and to the fact that older age is considered one status, in quality of life and maintenance of social
of the risk factors for institutionalization(13). relations(16-17). The prevalence of hearing impairment in

Table 3. Comparing hearing sensitivity degree and self-perception (left and right ears) at low and medium frequencies*
Hearing sensivity degree
Moderately Total
HHIE-S Normal Mild Moderate Severe Profound
severe
OD OE OD OE OD OE OD OE OD OE OD OE OD OE
16 16 24 25 6 7 4 2 0 1 1 0
No perception 51 51
80.00 80.00 82.76 86.21 42.86 46.67 36.36 28.57 0.00 25.00 33.33 0.00
4 4 4 4 5 4 2 2 1 1 0 1
Mild to moderate 16 16
20.00 20.00 13.79 13.79 35.71 26.67 18.18 28.57 50.00 25.00 0.00 25.00
0 0 1 0 3 4 5 3 1 2 2 3
Significant 12 12
0.00 0.00 3.45 0.00 21.43 24,1 45.45 42.86 50.00 50,0 66.67 75.00
Total 20 20 29 29 14 15 11 7 2 4 3 4 79 79
Fisher’s exact test: p<0.001
*The sample number corresponds to the number of ears according to the different degrees of hearing sensitivity.

Table 4. Comparing hearing sensitivity degree and self-perception (left and right ears) at high frequencies*
Hearing sensivity degree
Moderately Total
HHIE-S Normal Mild Moderate Severe Profound
severe
OD OE OD OE OD OE OD OE OD OE OD OE OD OE
7 6 8 9 18 17 15 15 2 4 1 0
No perception 51 51
100.00 100.00 72.73 75.00 64.29 65.38 78.95 71.43 22.22 36.36 20.00 0.00
0 0 3 3 7 6 2 4 2 3 2 0
Mild to moderate 16 16
0.00 0.00 27.27 25.00 25.00 23.08 10.53 19.05 22.22 27.27 40.00 0.00
0 0 0 0 3 3 2 2 5 4 2 3
Significant 12 12
0.00 0.00 0.00 0.00 10.71 11.54 10.53 9.52 55.56 36.36 40.00 100.00
Total 7 6 11 12 28 26 19 21 9 11 5 3 79 79
Fisher’s exact test: p=0.006
*The sample number corresponds to the number of ears according to the different degrees of hearing sensitivity.

einstein. 2009;7(2 Pt 1):176-81

180 Baruzzi MB, Borges ACLC, Ribeiro MI, Nasri F
the institutionalized population is even greater than in
the remaining one, probably because it is made up of
older individuals(5,16).
Presbycusis is slow and progressive, and often causes
hearing impairment to be perceived only at higher
degrees of involvement(18).
Inquiring about complaints regarding hearing allows
identifying some individuals who do not have hearing
difficulty, but other symptoms which accompany or
precede hearing impairment, such as: tinnitus, dizziness,
hearing discomfort, among others.
Hearing assessment performed in lengthy stay
institutions is not a frequent practice and the lack of
resources and professionals interested in working in these
institutions are some of the obstacles found(6-7,19). The mere
investigation about the presence of hearing difficulty has
been shown as an efficacious tool for screening elderly
people with hearing deficit, which represents the most
frequent complaint of the population studied(20).
By analyzing the degree of hearing sensitivity for
low, medium and high frequencies, a low incidence of
individuals with normal hearing was observed, as well
as greater severity of involvement of high frequency
in both sides, with no significant difference between
them, in accordance with some studies(16,20). The loss
of hearing sensitivity was mild for low frequencies and
moderate for medium and high frequencies(17). A close
relation between worsening of hearing sensitivity and
increasing age was also observed(14,21-22).
The variability found in literature about the incidence
of hearing impairment in the elderly population is
justified by different classifications employed. The
difference between hearing sensitivity in the low and
medium frequencies, when compared to the high
ones, demonstrate the importance of using broader
classifications, which take into account the levels of
hearing sensitivity at high frequencies.
The higher involvement of high frequencies (decreasing
audiometric configuration) impair the perception of
consonant sounds, hindering speech understanding in
noisy environments, which often causes decontextualized
responses and injures social relationships(23).
Adjusting to hearing impairment is a unique process,
since individuals with the same type and degree of
hearing impairment may show different communication
performance, in which behavioral and cognitive changes
are made in order to minimize the resulting problems.
Hearing assessment, therefore, should encompass the
different relations between hearing impairment and
disability, by means of self-assessment questionnaires.
Institutionalization has been an option considered
for the elderly with functional disabilities, however,
this is an excluding model that has deep impact in the
quality of life of the individual(24).
einstein. 2009;7(2 Pt 1):176-81
Isolation and loss of interest in interpersonal
relationships observed in the group of institutionalized
elderly may, on the other hand, interfere in the self-
assessment of hearing handicap, in addition to, of
course, the stigma of old age, which causes these
individuals in tending to deny the presence of hearing
impairment and even at an early phase, to refuse
undergoing an assessment and the process of hearing
rehabilitation(25).
The self-assessment questionnaires are very useful
to design the rehabilitation program, because sound
amplification, besides reducing the loss of hearing
sensitivity, would restore and expand social integration
of the individual, by reducing psychosocial and
emotional disadvantage, intervening in the hearing
handicap and providing facilitating strategies in different
communication situations(26-27).
The HHIE-S was chosen because it is an instrument
of quick and easy application, well-accepted by the
elderly. When investigating the self-perceived hearing
handicap, it was observed that most of the individuals
studied did not perceive the handicap, which was
significantly different from other results.
An alarming finding in the present study was the
high rate of hearing involvement of individuals with no
perception of hearing handicap; this may be associated
with the lack of interest in social relations that occur
in institutions and that should be taken into account in
their process of rehabilitation.
There was a close relation between the degree of
hearing impairment and the perception of hearing
handicap, which agrees with the literature reviewed(5,8).
For high frequencies, this relation is stronger than
for normal and mild degree. The high proportion of
individuals with no perception of handicap can be
explained, when only the high frequencies are affected
with less impact in handicap.
The highly variable responses, when comparing
these two assessments; for instance, individuals with
severe loss of hearing sensitivity and no perception of
handicap and those individuals with different degrees of
sensitivity and different levels of perception of handicap,
justify the need for studying all sorts of hearing behavior
in this group.
Considering all specific characteristics of this group of
individuals, speech therapy and audiology care, inserted
within a specialized team in gerontology in lengthy stay
institutions for the elderly becomes essential for social
integration and maintenance of quality of life.
CONCLUSIONS
The most frequent degree of loss of hearing sensitivity
was mild for low and medium frequencies and moderate

for high frequency. There was a high incidence of hearing
impairment in this population for low, medium and high
frequencies and the complaints regarding hearing occur
in 73.4% of subjects studied, with hearing difficulty
being the most frequent. Self-perceived handicap was
significantly associated with the presence of complaint,
especially with difficulty hearing and worsening of
hearing sensitivity, but not to the remaining variables;
most of the individuals assessed did not have self-
perceived handicap. There was a significant association
between self-perceived handicap, worsening of hearing
sensitivity, and to age.
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