Scoping question: Does case finding and provision of hearing aids or assistive listening devices produce any benefit or harm for older people 60 years of age and over with hearing loss? The full ICOPE guidelines and complete set of evidence profiles are available at: who.int/publications/i/item/9789241550109# ICOPE guidelines -World Health Organization
With increasing age, deterioration in hearing sensitivity rises sharply. About one third of people 65 years of age and over live with some degree of hearing loss (1) and between 50% and 80% of older people over 80 years of age experience significant hearing loss. Hearing loss in older people is strongly associated with reduced functional ability, social isolation, depression, cognitive decline, poor quality of life, and need for care (2)(3)(4)(5). In most countries, particularly in low-and middle-income countries, hearing loss in older people is largely undetected and undertreated. This is mainly due to the lack of community outreach and lack of systematic screening for hearing loss in older people.
The most common form of treatment for hearing loss in older people is the provision of a hearing aid. Effective management strategies for hearing loss includes use of technologies such as hearing aids, assistive listening devices or cochlear implants, health education, environmental modifications (reducing interfering background noise, for example) and behavioural adaptations for the person and for their communication partners (simple communication techniques such as speaking clearly, for example) (6). Research evidence suggests that hearing aid use is strongly associated with improved communication in relationships, emotional stability, perception of mental functioning and physical health, and improved quality of life (8). Despite the increased availability of technology, however, the proportion of older people with hearing loss who use hearing aids is low (9). Moreover, evidence on effective case-finding and provision of care is mostly from high-income countries. The extent to which this evidence is generalizable to poorly resourced settings is unclear. This review has thus set out to answer two key questions: first, whether screening and provision of hearing aids are effective in improving hearing-related outcomes; and, second, whether education and educational interventions improve the uptake or adherence of hearing aid use among older people.
There is very limited, low quality evidence that suggests that case-finding for hearing loss improves the use of hearing aids among older people with hearing loss. One randomized controlled trial that enrolled 2 305 participants found that screening was associated with a significant increase in hearing aid use at one year compared with no screening.
There is limited low quality evidence on the effectiveness of case-finding through targeted screening and provision of hearing aids for older adults with hearing loss. Two trials that investigated the immediate provision of hearing aids, after screening for hearing loss, found significant and considerable improvements in hearing-related outcomes. However, these findings came from studies that recruited mostly Caucasian male veterans. Participants in the intervention groups qualified to receive free hearing aids.
There is limited low quality evidence to suggest that a self-management support intervention is effective in improving uptake or use of hearing aids in older adults with hearing loss. However, the effect sizes were small and not clinically significant, and the overall sample size was small.
We identified no studies on the harms associated with the screening or provision of hearing aids for hearing loss in older people. Harms are unlikely to be greater than minimal because screening and confirmatory testing are non-invasive and treatment with hearing aids is not associated with significant harms.

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ICOPE guidelines -World Health Organization

# Guideline development group recommendation and remarks Recommendation
Screening followed by provision of hearing aids should be offered to older people for timely identification and management of hearing loss.

# Strength of the recommendation: Strong
Quality of evidence: Low
- Due to the paucity of the evidence, the direct benefit of community case finding through targeted screening for hearing loss among older people is unclear. - Hearing aids should only be fitted after an audiometric assessment.
- Treatable ear conditions/medical pathologies should be ruled out before amplification devices are offered.
- A thorough ear examination is essential before undertaking hearing-aid fitting, including ear wax removal.
- The hearing aid should be appropriate for the person with hearing loss and should be properly fitted.
- The hearing aids recommended should be in line with the WHO's rehabilitation guidelines and preferred assistive product profile. - Close attention should ensure that instrument cases do not cause skin abrasion or irritation with long-term usage. - A referral should be made if the prospective user has aural discharge, pain or discomfort in the ear, acute or chronic dizziness, unilateral hearing loss, or sudden onset of severe tinnitus. - Hearing-aid provision should be accompanied by follow-up services and easy access to services for replacement of batteries, ear moulds, and maintenance and repair of hearing aids. - Self-support educational intervention should be considered when administering hearing aids to older people with hearing loss.
Hearing loss has a dramatic impact on both the quality of life and ability to function in older adults. Case-finding and provision of care, and supportive education interventions to promote the use of hearing aids may have a positive impact on older people who adhere to the use of hearing aids. Therefore, the GDG believes that this recommendation is likely to be valued by older people with hearing loss and stakeholders.

# Feasibility / resource use Explanation
How large are the resource requirements?
Major Minor Uncertain  Is the option feasible to implement?

# Yes No Uncertain
Most of the interventions evaluated in the trials were resource intensive. Screening and provision of hearing aid technology require economic and human resources (training) that might not readily available in all countries. No data were obtained on the rates of hearing aid use in low-and middle-income countries where access to hearing aid technology presents more of a challenge. The GDG believes that it is feasible to implement community case-finding and provision of hearing aids at primary care or community level.
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# Equity Explanation
Would the option improve equity in health?
The provision of, or prescription for, hearing aids already exists in clinical practice in most countries. However, in low-and middle-income countries there is a large service gap among older people because many of them have difficulties in accessing the hearing health services.
The GDG firmly believe that promoting community case-finding and immediate provision of hearing aids is likely to reduce inequality in care services.