Perception: hearing

Perception - Hearing (self-report)

LASA031 / LASA231
LASA604 / LASA704

Constructs: self-reported hearing ability with and without hearing aids, self-reported hearing ability in noise, self-reported hearing aid use, tinnitus, hearing aid use according to proxy, (change) in hearing ability with and without hearing aid according to proxy.

Contact: Marieke Pronk

Background

Age-related hearing loss
The bulk of the hearing loss cases in adults (i.e., 80%) can be classified as age-related hearing loss (ARHL).1,2,3 The traditional audiological hallmark of ARHL is a pronounced sensitivity loss in the high frequencies of the hearing spectrum. It generally kicks in around the age of 50 and has an insidious and progressive nature.3 ARHL is of sensorineural origin (i.e., the cochlea and/or associated tissues in the nervous system are affected). Further, ARHL is characterized by reduced speech understanding in noisy or reverberant environments, slowed central auditory processing of sound, and impaired sound localization3. Problems with understanding speech-in-noise is the most prominent and prevalent hearing complaint in hearing-impaired persons4, and in the case of ARHL, is often the first complaint. In general, men show an overall greater drop in sensitivity loss , and have a more pronounced loss in the high-frequency range.5

Prevalence of hearing loss
Hearing loss is one of the most prevalent chronic conditions in old age.1,2 Several studies described prevalence rates up to 40% in adults 50 years and older6 and up to 90% in persons more than 80 years of age7 and frail older persons living in residential care facilities8. In 2001, over 1.2 million Dutch older persons (aged 60 years and over) had an insufficient or poor ability to recognize speech in noise.9 This represented 43% of the total Dutch older population at that time. Based on a Dutch survey conducted in 2007, it was estimated that of all persons aged 75 years and over at that time, over 440.000 (41%) reported significant problems in group conversations and over 106.000 (10%) reported problems in one-on-one conversations. 10 Worldwide, adult-onset hearing loss is the second leading cause of years lived in disability.11,12

Self-reported vs. functional hearing ability
Contrary to functional measures (e.g., pure tone audiometry, speech-based performance tests), self-report measures reflect subjective hearing experience and implies that a person is aware that (s)he has hearing problems. In addition, non-auditory factors such as coping strategies (e.g., lipreading, positioning) generally applied in life can be considered by the individual, thus implying to better reflect daily life hearing. These elements are mostly not integrated in functional tests. Some argue that subjective factors decrease the validity of hearing measurement. Age and personality factors are mentioned in this respect.13 A number of studies show that older persons report lower levels of disability than younger persons with similar levels of objectively determined hearing impairment (e.g., 9,13,14). Suggested explanations include the insidious decline (may go unnoticed), older persons’ comparing behaviors (comparing oneself with peers who also deteriorate in hearing may mask own deficits), older persons’ lesser involvement in complex, demanding communication situations than younger-old, and geriapathy (older persons may view their hearing impairment as inherent to aging and thus do not consider it a serious problem). Besides increased underestimation of hearing problems by advancing age, there is also evidence that there is increased overestimation of hearing problems occurring simultaneously in relatively older-old versus younger-old persons.9 Further, it is known that men deny their hearing loss and underestimate their hearing problems somewhat more often than women do.15,16,17 Men may try to maintain their desired self-image which includes good hearing.18,19

Whether subjective report of hearing is ‘inappropriate’ or ‘undesirable’ depends on the goal of the study. With regard to psychosocial outcomes (see below), it is sometimes argued that self-reported hearing measures should be preferred as they reflect real experienced disability and thus are most sensitive to predicting psychosocial health. Although there is evidence for this (e.g., 18,20;21), other studies show inconclusive findings22 or some even show contradicting findings23. With regard to predicting hearing help-seeking and hearing aid uptake, self-reported hearing loss generally appears as a stronger predictor than objective hearing loss.24 When the goals is to unravel causal links between hearing and cognition (see below), objective measures may be preferred.

Hearing loss and psychosocial health
Hearing loss can undermine communication and enjoyment of sound to a great extent. Various studies found significant relationships with poor psychosocial health resulting from these restrictions, such as anxiety, depression and loneliness.22,25 -29 However, evidence is mixed as others found no significant relationships with psychosocial outcomes. 22,30-34 Further, there is evidence that only specific subgroups of older persons experience increasing loneliness due to hearing loss (e.g., men, non-hearing aid users, those living with a partner, those who recently lost their partner, those whose hearing deteriorated from an already impaired hearing).22,34 These effects may be explained by differences in social activities, social relationships, and coping mechanisms. Hearing loss is also associated with lower self-efficacy and mastery25 and with a smaller social network.25,35 Hearing ability does not appear to be important for the continuation of existing relationships, but impaired hearing does appear to inhibit starting new (replacement) relationships.35 Replacement of relationships is important in old age because of the high prevalence of contact loss following peer death or physical constraints limiting mobility to visit contacts.

Hearing loss and cognition
Central auditory processing of sound includes functions required to distinguish pitch, loudness and duration of acoustical signals36, but also cover more global cognitive functions such as information processing speed and working memory36-41. It is generally assumed that the involvement of these neurocognitive functions becomes more pronounced in challenging listening situations such as in noisy backgrounds (e.g.,36;41). Decline in information processing speed appears to explain a reasonable proportion of the decline in speech-in-noise recognition over time.42

In the literature on cognitive aging, a strong connection has been found  both in cross-sectional and longitudinal studies between sensory functioning and cognition (including incident cognitive impairment) (e.g., 43). The exact nature of the relationship in terms of causality is still unclear: does hearing loss cause cognitive decline, is it the other way around, do both apply, or is there no actual causal relationship between the two at all? Various hypotheses exist: 1) cognitive load on perception hypothesis: cognitive decline causes perceptual decline. This theory postulates that when cognitive processes exerting top-down control over perceptual systems are compromised, then perception of sensory inputs becomes less sensitive; 2) sensory deprivation hypothesis: perceptual decline causes permanent cognitive decline because prolonged and sustained limited sensory input will cause neuronal atrophy subsequently negatively affect cognitive functions; 3) resource allocation hypothesis: perceptual decline leads to impaired cognitive performance as sensory-impaired persons have to allocate more attentional resources to perceive and process sensory information leaving less resources for other cognitively demanding tasks; 4) information degradation hypothesis: impoverished perceptual input results in compromised cognitive performance, 5) common cause hypothesis: perceptual and cognitive declines are symptomatic of widespread neural degeneration.43Cognitive hearing researchers showed support for several hypotheses (e.g., 42-49).

Hearing aids
Hearing aid use is associated with reduction in hearing disability, improvement in disease-specific quality of life, and, to a lesser extent, with improvement in generic quality of life.50-54 Despite these favorable effects, various studies indicate that only a minority of the patients with potentially aidable hearing loss owns a hearing aid, fewer actually use it, and yet fewer are satisfied with it. About one third of the older adults with hearing impairment owns a hearing aid. 5,55 Others found that around 15% of the older hearing-impaired adults use a hearing aid.56 Even in a group of older persons with poor speech-in-noise recognition, only 42% owned a hearing aid.9 In the US, 17% of the hearing aid owners appears dissatisfied with its overall benefit, 9% is neutral, and 74% is satisfied about it.57 It is estimated that 12%-22% of the hearing aids are ‘in the drawer’.5,57

Obviously, there are barriers to uptake and use. These are partly known, and include amongst others: hearing loss/hearing aid stigma, wrong expectations of hearing aid benefits, low self-reported hearing disability, and low wearing comfort.24,58-60 Further complicating factors are that hearing aids provide amplification but do not fully restore normal hearing, and hearing aids need a long learning and adjustment period allowing the brain to adapt to new sound quality.3,60

Besides hearing aids, there is a range of non-instrumental interventions available. Examples include TV or telephone amplifiers, adjustment of the acoustics in the house, and communication programs including training in speechreading, communication strategies, and personal adjustment.61 These alternatives do not seem to be considered often.

Tinnitus
Tinnitus is the perception of sound or noise that can only be perceived by the person itself, i.e., it is perceived as originating from within the ears or somewhere else within the head. Different sounds can be perceived, such as buzzing, ringing, beeping, etc., and the sound can be perceived continuously or intermittently. An important proportion of the cases can be attributed to ear damage (e.g. caused by trauma or noise exposure). The experience of tinnitus can vary widely from mildly irritating to being very disturbing. 62

Prevalence rates originating from population-based older samples are scare. The few that have been performed show prevalence rates of 8-30%.63,64 The 5-year incidence is estimated to be 6-18%.63,64

Various studies showed significant relationships between tinnitus and psychosocial measures such as anxiety and depression, but other studies also show relationships with sleep and concentration problems.62,65-68 Hearing impairment is correlated with tinnitus.

Measurement instruments in LASA - Self-reported hearing ability (LASA*031)
A number of self-reported hearing ability questions are administered in LASA. The questions originate from the OECD long-term disability indicator69, and in LASA also include questions on vision (see Documentation on Vision), stuttering/lisping, and dyslexia. The OECD questions are also used in other large surveys focusing on public health problems (e.g.,70).

As an introduction to the Senses-section, the interviewer reads out loud the following instructions to the respondent:  ‘Now I would like to ask you something about hearing and vision. We would like to know how much difficulty you have with hearing and seeing. It concerns what you can normally do, with aids if necessary, such as glasses if you normally use these. It does not concern temporary/passing problems.’

Below are the questions about self-reported hearing ability that the interviewer asks the respondent:

*sense08: Can you hear well enough?
No I cannot; Yes, without difficulty; Yes, but with some difficulty ; Yes, but with much difficulty

*sense09 Can you follow a conversation in a group of three or four persons without a hearing aid?
No I cannot; Yes, without difficulty; Yes, but with some difficulty ; Yes, but with much difficulty

*sense10 Can you do this with a hearing aid?
No I cannot; Yes, without difficulty; Yes, but with some difficulty; Yes, but with much difficulty; Respondent does not have hearing aid

*sense11 Can you follow a conversation with one person?
No I cannot; Yes, without difficulty; Yes, but with some difficulty ; Yes, but with much difficulty

*sense12 Can you do this with a hearing aid?
No I cannot; Yes, without difficulty; Yes, but with some difficulty; Yes, but with much difficulty; Respondent does not have hearing aid

*sense13 Can you use a normal telephone?
No I cannot; Yes, without difficulty; Yes, but with some difficulty ; Yes, but with much difficulty

Note: Waves B, C: For sense09 and sense11 applies that when the respondent answers with ‘No I cannot’, only then questions sense10 and sense12 were administered.

Waves E, F, G, H, 2B, 3B: For sense09 and sense11 applies that when the respondent answers with ‘No I cannot’, ‘Yes, with some difficulty’, or ‘Yes, with much difficulty’, only then questions sense10 and sense12 were administered.

Scoring
The following scores are applied for the answer categories (so higher scores indicate worse hearing):

Yes, without difficulty –› 1 point; Yes, but with some difficulty –› 2; Yes, but with much difficulty –› 3; No I cannot –› 4

Slight variations of the self-reported hearing ability questions applied across LASA waves/cohorts

In the migrant (i.e., MB) cohort, questions sense09&10 and sense11&12 were merged into one question each:

*hoor3 Can you follow a conversation in a group of three or four persons (if necessary with (a) hearing aid(s))?
(No I cannot; Yes, without difficulty; Yes, but with some difficulty; Yes, but with much difficulty

*hoor1 Can you follow a conversation with one person (if necessary with (a) hearing aid(s))?
No I cannot; Yes, without difficulty; Yes, but with some difficulty; Yes, but with much difficulty

In the 2B cohort, sense08 was not asked at all.

On the H-wave, an additional self-reported hearing ability question was asked in the Senses section. (mhearup Can you understand someone who speaks to you during a birthday party or reception?). See below under heading ‘Measurement instruments in LASA - Self-reported hearing ability in noise’, and see Documentation on Speech-in-Noise Test.

Constructed variable: self-reported hearing ability with and without hearing aid (LASA*231)
Two dichotomous variables are available of which one includes hearing ability without hearing aid(s) (senseh) and another includes hearing ability while wearing hearing aid(s) (senseha). The senseh and senseha variables concern hearing ability in the two hearing situations: conversation with 3 or 4 persons (sense09&10) and conversation with 1 person (sense11&12). The score of senseha only differs from senseh if the respondent indicated to have hearing aids in the follow-up question, AND the hearing aid caused less difficulty hearing in this situation. In all other cases (i.e., when the respondent did not have a hearing aid or the respondent hearing was similar while wearing the hearing aid), the same score as in variable senseh was  adopted in senseha. The following scores are possible in senseh and senseha: 0: without or with some difficulty 1: > 1 item with some difficulty

The syntax according to which senseh and senseha were constructed from the variables from LASA*031 is available here.

Constructed variable: self-reported hearing ability; summed score (3 hearing situations) (LASA*031)
A score can be computed by summing the scores of questions on: following a conversation with 3 or 4 persons (sense09&10), following a conversation with one persons (sense11&12), and using a normal telephone (sense13). These three communication situations occur often in daily life and a assumed to thus have high face validity, i.e., reflecting relevant daily life hearing situations. A reduced ability to communicate in noise (associated with sense09&10) and in quiet (sense11&12) are important indicators of age-related hearing loss.3 Applying a summation yields scores ranging from 3-12 points (higher scores indicate more difficulty).

The summed score has been used in various articles (see under Previous use in LASA). Two versions can be computed: one that accounts for hearing aid use (incorporating sense10 and sense12), and one that does not. The SPSS syntax for making this variable can be accessed here.

Measurement instruments in LASA - Self-reported hearing ability in noise (LASAH031)
(See also Documentation Speech-in-Noise Test and associated files LASAE194, LASAF194, LASAG194)

In wave E, F, and G, an extra self-reported hearing ability question was administered preceding the Speech-in-noise test, in the Medical interview. See also documentation on Speech-in-noise Test. In wave H, this question was part of the Senses-section of the Medical Interview (see above under ‘Slight variations of the self-reported hearing ability questions applied across LASA waves/cohorts’).

The item originates from the Amsterdam Inventory for Auditory Disability and Handicap (AIADH).72

*hearup Can you understand someone who speaks to you during a birthday party or reception?
Almost never (1), Sometimes (2), Often (3), Almost always (4)

Measurement instruments in LASA – Hearing aid use (LASA*031)
(See also Documentation Speech-in-Noise Test)

In all waves and cohorts but the Migrant cohort (MB), hearing aid use can be indirectly deduced from the four OECD questions mentioned above (sense09&10 and sense11&12).

In wave D to G, additionally, hearing aid use is asked directly in sense07:

*sense07 Do you usually use a hearing aid? (Yes/No)

The interpretation of ‘ usually’ was left to the respondent. This may be complicated in situations when someone only uses hearing aids in particular situations or a few hours per day.

Hearing aid ownership/use may be deduced using both sense09&10, sense11&12, and sense07. A syntax describing this for the LASA E-wave can be accessed here.

In wave B and C, sense07 (Do you usually use a hearing aid?) was not asked. Instead, the interviewer was instructed to observe whether or not the respondent wore hearing aid(s) at the moment of interviewing.

*sense07 Respondent wears hearing aid (HA): observation (Yes/ No)

In wave H, and in the 3B cohort, instead of sense07, the following questions were asked, distinguishing better between hearing aid ownership and use:

*hoortst Do you own a hearing aid?
No, I have never had a hearing aid –› (skip hoort_upd)
Yes, I own one hearing aid, but I do not use it (any more)  –› (skip hoort_upd)
Yes, I own two hearing aids, but I do not use them (any more) –› (skip hoort_upd)
Yes, I own one hearing aid which I use
Yes, I own two hearing aids but I use one
Yes, I own two hearing aids which I use

*hoort_upd How many hours per day do you wear your hearing aids on average?
Less than 1 hour a day; 1-4 hours a day; 4-8 hours a day; The whole day

In the Migrant cohort (wave MB), similar questions were asked, just differing in response categories in the variable hoortst somewhat:

*hoortst Do you own a hearing aid?
I do not own hearing aid(s) –› (skip hoort_upd)
I do own hearing aid(s), but I but I do not use it/them any more –› (skip hoort_upd)
I own one or two hearing aids

Additional data on hearing aid use as part of Speech-in-noise test

In wave E, F, and G, additional information on hearing aid use was asked as part of a set of questions preceeding the Speech-in-noise test (see also Documentation ‘Speech-in-noise Test).

*hearwa Do you wear hearing aids? (none, 1, 2)

On G, an additional question was asked preceeding the Speech-in-noise test:

*gmhearwh How many hours per day do you wear your hearing aids on average?
I do not have hearing aids; I do not wear my hearing aids; Less than 1 hour; 1-4 hours; 4-8 hours; The whole day

Measurement instruments in LASA - Self-reported hearing ability and hearing aid use as indicated in telephone interview by the Respondent or its Proxy (LASA*604, LASA*704)
Some of the respondents could not participate in the main / medical interview and thus could not provide data on their hearing. Additional data was asked via the telephone (as part of the more comprehensive telephone interview), to the respondent itself, or to his/her proxy.

The type of hearing (aid) data differed across the waves:

B, 2B, 3B, and MB: No telephone interview administered.

Wave C: LASAC604: data from proxy AND respondent

*ctrespt Data from proxy or respondent? (Proxy; Respondent)

As an introduction to the Senses-section, the interviewer reads out loud the following instructions to the proxy/respondent: ‘I would like to ask you how … ‘s hearing and vision is. We would like to know how much difficulty … has. It concerns what he/she is normally able to, with aids if necessary, such as glasses.’

*cthear Did the hearing of … change the last three years? (Much better, Better, The same, Worse, Much worse)

Wave D and E: LASA*604: data from Proxy; LASA*704: data from Respondent

*604: data from Proxy: As an introduction to the Senses-section, the interviewer reads out loud the following instructions to the proxy/respondent: ‘I would like to ask you how … ‘s hearing and vision is. We would like to know how much difficulty … has. It concerns what he/she is normally able to, with aids if necessary, such as glasses.’

*tphear Did the hearing of … change the last 3 years? (Much better, Better; The same; Worse; Much worse)

*704: data from Respondent:

N.B. The questions asked here are exactly similar to *sense07, *sense09, and *sense10 from the main/medical interview.

Wave F, G, and H: LASA*604: data from Proxy; LASA*704: data from Respondent

See Wave D and E. The only difference is that tphear (change last 3 year) was not asked.

Measurement instruments in LASA – Tinnitus (LASA*031)
In wave H, 3B and the Migrant cohort (MB), three questions about tinnitus were asked.

These questions are based on questions used in a British questionnaire, described in an HTA report on hearing screening in adults.71

In the Migrant (MB) cohort, the following instructions were read out loud by the interviewer (this was not done in the H wave and in the 3B cohort): ‘Now I would like to hear something about tinnitus. This is also called ringing in the ears [Dutch: oorsuizen]. This is sound that is heard within the head, such as beeping, ringing, whizzing, or buzzing, without the sound being really present outside the head.’

* hoor_piep/tinnint01 Nowadays, do you ever get noises such as beeping, ringing, whizzing, or buzzing, in your head or ears which last longer than five minutes? (yes/no)

* hoor_ppfr/tinnint02 Do you hear these sounds sometimes, most of the times, or all the time? (Sometimes; Most of the times; All the time)

*hoor_irri/tinnint03 To what extend do these sounds annoy or upset you when they are at their worst? (Not at all annoying/upsetting; Slightly annoying/upsetting; Moderately annoying/upsetting; Severely annoying/upsetting)

Questionnaires
LASAB031 / LASAC031 / LASAD031 / LASAE031 / LAS2B031 / LASAF031 / LASAG031 / LASAH031 / LAS3B031 (B/C/D/E/2B/3B/MB: main interview, F/G/H/I: medical interview, in Dutch);

LASAC604 / LASAD604 / LASAE604 / LASAF604 / LASAG604 / LASAH604 (telephone interview with proxy, in Dutch)
LASAD704 / LASAE704 / LASAF704 / LASAG704 / LASAH704 (telephone interview with respondent, in Dutch)

in C also with respondent

Variable information
LASAB031 / LASAC031 / LASAD031 / LASAE031 / LAS2B031 / LASAF031 / LASAG031 / LASAH031 / LAS3B031 / LASMB031 / LASAI031;
LASAB231 / LASAC231 / LASAD231 / LASAE231 / LAS2B231 / LASAF231 / LASAG231 / LASAH231 / LAS3B231 / LASMB031 / LASAI031
(pdf)

LASAC604/ LASAD604 / LASAE604 / LASAF604 / LASAG604 / LASAH604 / LASAI604
(pdf);
LASAD704 / LASAE704 / LASAF704 / LASAG704 / LASAH704 / LASAI704
(pdf)

Availability of information per wave 1

 

B

C

D

E


2B*

F

G

H



3B*

MB*

I

Self-reported hearing ability

Ma

Ma

Tel_r
Tel_p

Ma

Tel_r
Tel_p

Ma

Tel_r
Tel_p

Ma

Me

Tel_r
Tel_p

Me

Tel_r
Tel_p

Me

Tel_r
Tel_p

Ma

 

Ma

 

Me

Tel_r
Tel_p

Self-reported hearing ability with and without hearing aid

Ma

Ma

Ma

Ma

Ma

Me

Me

Me

Ma

Ma

Me

Hearing aid use (as part of LASA031 or LASA604/704)

Ma

Ma

Tel_r
Tel_p

Ma

Tel_r
Tel_p

Ma

Tel_r
Tel_p

Ma

Me

Tel_r
Tel_p

Me

Tel_r
Tel_p

Me

Tel_r
Tel_p

Ma

Ma

Me

Tel_r
Tel_p

Tinnitus

 

 

 

 

 

 

 

Me

Ma

Ma

Me

1 More information about the LASA data collection waves is available here.

* 2B=baseline second cohort;
   3B=baseline third cohort;
   MB=migrants: baseline first cohort

Ma=data collected in main interview;
Me=data collected in medical interview;
Tel_r=data collected in telephone interview with respondent;
Tel_p=data collected in telephone interview with proxy

Please see documentation on Speech-in-noise Test for additional available data on hearing aid use.

Previous use in LASA
Self-reported hearing ability was used as a determinant of psychosocial health by Kramer et al. (2002) 25 (depression, self-efficacy, mastery, loneliness, social network; categorical version of self-reported hearing ability) and by Pronk et al. (201122) (depression, social loneliness, emotional loneliness, continuous version of self-reported hearing ability). Kramer et al. (2002)25 and Pronk et al. (2011)22 both used hearing data of the E wave. Pronk et al. (2011)22 compared, using longitudinal data (wave E&F) the predictive ability of the self-report measure (wave E) for follow-up psychosocial health (wave F) to that of the objective hearing measure of LASA (wave E) : the Speech-in-noise test (see that Documentation).

  • Kramer, S. E., Kapteyn, T. S., Kuik, D. J., & Deeg, D. J. (2002). The association of hearing impairment and chronic diseases with psychosocial health status in older age. J Aging Health, 14, 122-137.
  • Pronk, M., Deeg, D. J. H., Smits, C., Van Tilburg, T. G., Kuik, D. J., Festen, J.M., & Kramer, S.E. (2011). Prospective effects of hearing status on loneliness and depression in older adults - Identification of subgroups. Int J Audiol, 50, 887-896. doi:10.3109/14992027.2011.599871.

The relationship between self-reported hearing ability and Speech-in-noise test hearing ability was investigated by Smits et al. (2006).9 Data of the E wave were used. In the same study by Smits et al. (2006),9 self-reported hearing loss was used to derive age-specific prevalence rates of hearing loss (in addition to rates based on the objective Speech-in-noise test). Hearing aid use prevalence was also determined.

  • Smits, C., Kramer, S. E., & Houtgast, T. (2006). Speech reception thresholds in noise and selfreported hearing disability in a general adult population. Ear Hear, 27, 538-549.
Self-reported hearing loss was investigated as a determinant of change in social network size by Broese van Groenou et al. (2013). Data of wave B to G were used.
  • Broese van Groenou, M., Hoogendijk, E. O., & Van Tilburg, T. G. (2013). Continued and new personal relationships in later life: differential effects of health. J Aging Health, 25, 274-295.

References

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  2. Ries, P. W. (1994). Prevalence and characteristics of persons with hearing trouble: United States, 1990-91. Vital & Health Statistics-Series 10: Data from the National Health Survey, 188, 1-75.
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  7. Cruickshanks, K. J., Wiley, T. L., Tweed, T. S., Klein, B. E., Klein, R., Mares-Perlman, J. A., & Nondahl, D. M. (1998a). Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin. The Epidemiology of Hearing Loss Study. Am J Epidemiol, 148, 879-886.
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  10. Gommer, A. & Poos, M. (2010). Hoe vaak komen gehoorstoornissen voor? Volksgezondheid Toekomst Verkenning, Nationaal Kompas Volksgezondheid. Bilthoven: RIVM. http://www.nationaalkompas.nl/gezondheid-en-ziekte/ziekten-en-aandoeningen/zenuwstelsel-en-zintuigen/gehoorstoornissen/hoe-vaak-komen-gehoorstoornissen-voor/. Accessed 3 December 2013.
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  13. Gatehouse S. (1990). Determinants of self-reported disability in older subjects. Ear Hear, 11(5 Suppl), 57S-65S.
  14. Wiley, T.L., Cruickshanks, K.J., Nondahl, D.M., et al. (2000). Self-reported hearing handicap and audiometric measures in older adults. J Am Acad Audiol, 11(2), 67-75.
  15. Erdman, S. A. & Demorest, M. E. (1998a). Adjustment to hearing impairment I: description of aheterogeneous clinical population. J Speech Lang Hear Res, 41, 107-122.
  16. Erdman, S. A. & Demorest, M. E. (1998b). Adjustment to hearing impairment II: description of aheterogeneous clinical population. J Speech Lang Hear Res, 41, 123-136.
  17. Garstecki, D. C. & Erler, S. F. (1999). Older adult performance on the communication profile for the hearing impaired: gender difference. J Speech Lang Hear Res, 42, 785-796.
  18. Hallberg LR, Barrenäs ML (1993). Living with a male with noise-induced hearing loss: experiences from the perspective of spouses. Br J Audiol, 27, 255-61.
  19. Hallberg LR, Barrenäs ML (1995). Coping with noise-induced hearing loss: experiences from the perspective of middle-aged male victims. Br J Audiol, 29, 219-30.
  20. Dalton, D. S., Cruickshanks, K. J., Klein, B. E., Klein, R., Wiley, T. L., & Nondahl, D. M. (2003). The impact of hearing loss on quality of life in older adults. Gerontologist, 43, 661-668.
  21. Gopinath, B., Schneider, J., Hickson, L., McMahon, C. M., Burlutsky, G., Leeder, S. R., & Mitchell, P. (2012). Hearing handicap, rather than measured hearing impairment, predicts poorer quality of life over 10 years in older adults. Maturitas, 72, 146-151.
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