When a Hearing Aid Isn’t Enough

By Paula Span, KFF Health News

Kitty Grutzmacher had contended with poor hearing for a decade, but the problem had worsened over the past year. Even with her hearing aids, “there was little or no sound,” she said.

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

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

Introduction to Cochlear Implants

There, Krystine Mullins, an audiologist who assesses patients’ hearing and counsels them about their options, explained that surgically implanting this electronic device usually substantially improved a patient’s ability to understand speech.

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

That she was 84 was, in itself, immaterial. “As long as you’re healthy enough to undergo surgery, age is not a concern,” Mullins said. One recent Northwestern implant patient had been 99.

The Decision-Making Process

Some patients need to ponder this decision, given that after the operation, clearer hearing still requires months of practice and adaptation, and the degree of improvement is hard to predict. “You can’t try it out in advance,” Mullins said.

But Grutzmacher didn’t hesitate. “I couldn’t go on the way I was,” she said in a postimplant phone interview — one that involved frustrating repetition, but would have been impossible a few weeks earlier. “I was completely isolated.”

Prevalence of Hearing Loss

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

“The inner ear mechanisms weren’t built for longevity,” said Cameron Wick, an ear, nose, and throat specialist at University Hospitals in Cleveland.

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

Cochlear Implantation as an Option

For those who do, “if your hearing aids no longer give you clarity, you should ask for a cochlear implant assessment,” Wick said.

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

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

Medicare Coverage and Accessibility

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

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

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

The Procedure and Recovery

Cochlear implantation requires commitment. After the patient receives testing and counseling, the surgery, which is an outpatient procedure, typically takes two to three hours. Many adults undergo surgery on one ear and continue using a hearing aid in the other; some later go on to get a second implant.

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

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

Adjusting to the Implant

“When we first turn it on, you won’t like what you hear,” Wick cautioned. Voices initially sound robotic, mechanical. It takes several weeks for the brain to adjust and for patients to reliably decipher words and sentences.

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

Expected Outcomes

Within one to three months, “boom, the brain starts getting it, and speech clarity takes off,” Wick said. By six months, older adults will have reached most of their enhanced clarity, though some improvement continues for a year or longer.

How much improvement? That’s measured by two hearing tests: The CNC (consonant-nucleus-consonant) test, in which patients are asked to repeat individual words, and the AzBio Sentence Test, in which the words to be repeated are part of full sentences.

Success Stories and Studies

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

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

Participants over 80 showed roughly as much improvement as those in their late 60s and 70s.

Conclusion

For Grutzmacher, though, the choice seemed clear. Her initial testing found that even with hearing aids, she understood only 4% of words on the AzBio. Two weeks after Mullins turned on the cochlear implant, Grutzmacher could understand 46% using a hearing aid in her other ear.

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

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

FAQs

What is a cochlear implant?

A cochlear implant is a medical device that is surgically implanted to improve hearing in individuals with severe to profound sensorineural hearing loss.

Who is eligible for a cochlear implant?

Eligibility for a cochlear implant varies, but generally includes individuals with severe to profound sensorineural hearing loss who receive little to no benefit from traditional hearing aids.

How long does the surgery take?

The surgery typically takes two to three hours and is an outpatient procedure.

How long does it take to recover from the surgery?

Recovery from the surgery usually takes a few weeks, after which the device is activated and the patient begins the process of adjusting to the new sound quality.

How effective are cochlear implants?

Cochlear implants can significantly improve speech recognition and quality of life for individuals with severe to profound sensorineural hearing loss, but the degree of improvement can vary from person to person.