Background: Hearing impairment (HI) is common and frequently under-recognized in patients who are seriously ill (1). During illness (especially acute illnesses), degraded auditory input can amplify delirium risk/severity, distort cognitive and neurologic assessments, and trigger iatrogenic cascades of harm (e.g., sedatives, restraints, missed therapy sessions, delayed goals of care conversations) (1-4). Experts recommend that access to hearing be restored as quickly as possible – “hearing access first” (1). This Fast Fact assimilates expert opinion and the best available evidence to guide clinicians on how to recognize HI, restore hearing access, and communicate when HI cannot be reversed.

Clinical impacts of hearing impairment (HI) in patients with serious illness:  

• Care satisfaction: Hearing loss can undermine the quality of clinical interactions, contributing to frustration, misunderstanding, and lower care satisfaction (4).
• Delirium: HI is associated with an elevated delirium risk in hospitalized patients (1,2). Multicomponent delirium prevention programs (e.g., HELP) include sensory optimization to reduce delirium incidence and duration (3). Hearing loss also can alter the presentation of delirium; patients may appear more inattentive, confused, withdrawn, or agitated (1,2). 
• Decision making capacity: Capacity assessments are communication dependent (4). In patients with serious illness, HI may prevent full access to information about prognosis, treatment options, and goals of care, limiting their ability to express their care values and preferences (4,5). HI may also adversely affect performance on cognitive tests (e.g., MOCA) raising the possibility that apparent cognitive deficits may partly reflect unaddressed communication barriers (4,5).

Identifying patients with HI: Although age (e.g., >65) is a major risk factor, it is not the only one (2,6). Younger adults may have HI, particularly after repeated occupational, military, or recreational noise exposure (6,7).  Other risk factors include diabetes, ototoxic cancer treatments like cisplatin or carboplatin, head injuries, genetic predisposition, and infections such as CMV or rubella. Clinicians should review the medical records and ask the patient, their surrogate, and/or their nurse if they have HI.  Even so, following these principles may not identify all with HI.  Suspect it when you encounter:  

• “Confusion” that is worse in noisy settings but improves in quiet 1:1 interaction (6,8-10). 
• “Pseudo-compliance” (nodding/smiling) without demonstrating understanding (6,8,9). 
• Marked improvement with written prompts/whiteboard or family at bedside (6,8). 

Rapid bedside checks for HI:  

• Whisper a series of 3 numbers and letters two feet behind a patient who blocks their opposite ear (11). Patients without HI, typically can repeat more than ½ the whispered items in each ear (11).
• To assess higher frequencies – rub your thumb and forefinger near the patient’s ear, patients without HI should be able to detect the sounds equally in both ears (11).
• Otoscopy to look for cerumen impaction/otologic pathology when feasible (11). 
• Examine any hearing aids/cochlear implants to ensure they are inserted correctly, charged, etc. (2).

Communication techniques: Consider all these strategies below before assessing decision-making capacity or conducting serious illness conversations (4-6). 

• Introduce yourself and your role.  Turn on a good light.
• Ask if they need or have hearing assistive devices, aids, or ear buds. Troubleshoot hearing aids (placement, battery/charging, cleaning) (3). Contact family/caregivers to bring in devices/batteries (3).
• Inquire if they can read lips.  If you are using a mask, make sure it is a clear one.
• Reduce competing noise in the room (e.g., mute the TV, close the door). Face the patient, make good eye contact, and speak clearly in low pitch tones (not necessarily louder), one idea at a time (8-10).
• Confirm comprehension with teach-back methods (e.g., “Can you tell me what you heard me just say to you now?” (7-9). Write keywords/instructions in large fonts. 
• For sign language users or patients who do not speak English as a primary language, arrange in-person interpreter services (7-9). 

Other management techniques: 

• Restore access: In patients with or at risk for delirium, restoring hearing access early may prevent the need for psychoactive medications, restraints, or labeling the delirium as refractory (1,2).
• Bridge with a personal hearing amplifier (e.g., pocket talker): When hearing aids are unavailable/ineffective or the care environment is noisy, hearing amplification devices like pocket-talkers can be effective tools while you wait for a functioning hearing device to become available (12). Place the microphone near the speaker and always start at a low volume (12). 
• Cerumen impaction: Treat when safe (cerumenolytic, irrigation or manual removal) using guideline-based approaches; refer to ENT if unsuccessful/complicating elements coexist (11).
• Speech/audiology consult: Consider for any complex phonatory-auditory pathology, augmentative communication coaching, or device troubleshooting (13). 
• Nighttime handoff: Devices can cause whistling noises or amplify pillow friction and disturb sleep. Remove devices at bedtime, store them safely, and reapply in the morning (3). Document what worked (amplifier device, written prompts, quiet room) for nursing/therapy/night teams (3).

When to involve ENT or neurology: Consult ENT for sudden or rapidly progressive asymmetric hearing loss, often with tinnitus and/or vertigo, otologic trauma, or concern for an active ear infection (14). Consider neurology when new focal neurologic deficits accompany hearing changes (14). 

References:   

1. Mormer E, Cipkala-Gaffin J, Bubb K, et al. Hearing and health outcomes: recognizing and addressing hearing loss in hospitalized older adults. Semin Hear. 2017;38(2):153-159. doi:10.1055/s-0037-1601570.
2. Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2017;377(15):1456-1466. doi:10.1056/NEJMcp1605501.
3. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676. doi:10.1056/NEJM199903043400901.
4. Hardin SR. Hearing loss in older critical care patients: participation in decision making. Crit Care Nurse. 2012;32(6):43-50. doi:10.4037/ccn2012225.
5. Sue K, Mazzotta P, Grier E. Palliative care for patients with communication and cognitive difficulties. Can Fam Physician. 2019;65(Suppl 1):S19-S24.
6. O’Leary DP, O’Leary TJ. Communicating with patients with hearing loss or deafness—can you hear me? JAMA Intern Med. 2024;184(4):345-346. doi:10.1001/jamainternmed.2023.8563.
7. World Health Organization. World report on hearing. Geneva, Switzerland: World Health Organization; 2021.
8. Shukla A, Nieman CL, Price C, et al. Impact of hearing loss on patient-provider communication among hospitalized patients: a systematic review. Am J Med Qual. 2019;34(3):284-292. doi:10.1177/1062860618798926.
9. Cudmore V, Henn P, O’Tuathaigh CMP, et al. Age-related hearing loss and communication breakdown in the clinical setting. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1054-1055. doi:10.1001/jamaoto.2017.1248.
10. Ghaeli P, Shahhatami F, Mojtahedzade M, et al. Preventive intervention to prevent delirium in patients hospitalized in intensive care unit. Iran J Psychiatry. 2018;13(2):142-147. 
11. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg. 2017;156(1):14-29. doi:10.1177/0194599816678832.
12. Koerber RM, et al. The clinical use of personal hearing amplifiers in facilitating accessible patient-provider communication: a scoping review. J Am Geriatr Soc. 2024;72(7):2195-2205. doi:10.1111/jgs.18784.
13. Beukelman DR, Light JC. Augmentative & Alternative Communication: Supporting Children and Adults With Complex Communication Needs. 5th ed. Brookes; 2020.
14. Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. Clinical practice guideline: sudden hearing loss (update). Otolaryngol Head Neck Surg. 2019;161(1_suppl):S1-S45. doi:10.1177/0194599819859885.

Authors’ Affiliations: Department of Geriatric Medicine, Yale University School of Medicine. 
Conflicts of Interest: None to report.
Version History: Originally edited by Sean Marks MD; first electronically published in April 2026.