The Hearing-Dependent Daily Activities

Scale to Evaluate Impact of Hearing Loss

in Older People
Jesús López-Torres Hidalgo, MD1,2 ABSTRACT
Clotilde Boix Gras, MD3 PURPOSE We wanted to design and validate the Hearing-Dependent Daily Activi-
Juan Manuel Téllez Lapeira, MD3 ties (HDDA) Scale as a means of identifying the impact of hearing loss in older
persons by measuring capacity to carry out hearing-dependent activities.
Ignacio Párraga Martínez, MD3
METHODS We undertook a cross-sectional, observational study to validate a scale
Maria Ángeles López Verdejo, MD4 administered during a personal interview with 1,160 participants aged 65 years
Francisco Escobar Rabadán, MD1 and older. When using the instrument to identify patients with hearing impair-
ment, sensitivity and specificity were determined using an audiogram with Ven-
Ángel Otero Puime, MD5 try and Weinstein criteria as the criterion standard. Standardized audiometries
1
Family and Community Medicine, were performed blindly, without knowledge of results of the HDDA Scale.
Faculty of Medicine, University of Castilla-
La Mancha, Albacete, Spain RESULTS According to the criterion standard, 506 participants had hearing
2
impairment (43.6%; 95% confidence interval [CI], 40.8%-46.5%). The HDDA
Department of Research, Teaching and
scale showed high internal consistency (Cronbach’s α = 0.91). Regarding hearing
Training, Health Care Service of Castilla-
La Mancha (SESCAM), Albacete, Spain
impairment criteria, the HDDA scale obtained a sensitivity of 80.0% (95% CI,
76.3%-83.3%) and a specificity of 70.2% (95% CI, 66.5%-73.5%).
3
Family and Community Medicine, Geren-
cia de Atención Primaria, Albacete, Spain CONCLUSIONS The HDDA scale constitutes a clinically useful instrument for
4
identifying the impact of hearing loss on daily life in the elderly, a condition
Opthalmology and Occupational Medi-
cine, Faculty of Medicine, University of
frequently overlooked during routine medical check-ups. This tool has acceptable
Castilla-La Mancha, Albacete, Spain psychometric properties and high internal consistency.
5
Department of Preventive Medicine and Ann Fam Med 2008;6:441-447. DOI: 10.1370/afm.890.
Public Health, School of Medicine, Univer-
sidad Autónoma de Madrid, Madrid, Spain
INTRODUCTION

E
vidence exists that up to 25% of persons between the ages of 65
and 75 years have undiagnosed hearing loss that may be detectable
through screening questionnaires.1 Despite the high prevalence of
hearing impairment and the effectiveness of rehabilitation measures, fam-
ily physicians do not normally make systematic use of hearing impairment
screening tests or structured interviews for all older patients. Evaluation
scales can be a rapid and easy means of assessing the impact of hearing
loss on daily life if appropriately chosen for each situation and if previ-
ously validated in persons of comparable socioeconomic characteristics.
Hearing loss can be improved by means of the correct diagnosis and
treatment,2 thereby facilitating patients’ and family members’ understand-
ing of the problem and providing the means to increase quality of life.
Conflicts of interest: none reported Correctly fitted hearing aids frequently contribute to successful reha-
bilitation of the patient, resulting in a positive influence on the elderly
person’s self-perception of health and on their daily life functioning.3 In
CORRESPONDING AUTHOR
fact, one major standard-setting organization, the US Preventive Services
Jesús López-Torres Hidalgo, MD
Task Force, currently recommends (“B” recommendation) screening of
Gerencia de Atención Primaria
C/ Marqués de Villores no 6 older adults for hearing impairment by periodically questioning them
02001 – Albacete, Spain about their hearing, counseling them about the availability of hearing aid
jlopeztorresh@medynet.com devices, and making referrals for abnormalities when appropriate. The

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optimal frequency of such screening has not been to 1,387 participants. Participants were selected by
determined and is left to clinical discretion. simple random sampling from a list of persons aged 65
Some instruments most frequently used to identify years and older registered in the National Health Care
the functional impact of hearing loss are often reputed system. Our validation study corresponds to a simul-
to possess insufficient validity in the community- taneous design in which diagnosis (audiometry) and
dwelling elderly.4 These scales include the Hearing testing (HDDA Scale) are concurrently applied to a
Measurement Scale5 (25 items), the Social Hearing sample of the population. To maintain tester objectiv-
Handicap Index6 (20 items), the Hearing Performance ity, audiometries were performed without knowledge
Inventory7 (90 items), the Hearing Disability and of HDDA Scale results.
Handicap Scale8 (20 items), the Hearing Handicap
Inventory for the Elderly9 (25 items), the Hearing Study Instrument
Handicap Inventory for the Elderly Screening test10 To construct the questionnaire items, we took into
(HHIE-S) (10 items), or adaptations of the same in account the characteristics of the population (cultural
the Mexican population, such as the Spanish Hearing level, state of health, etc) and reviewed the instruments
Impairment Inventory for the Elderly.11 The above- available to date for the detection of hearing impair-
mentioned instruments often possess low sensitivity, ment.9,11,13,15-19 We then formulated questions concern-
not surpassing the 75% level4,12-14 in the case of the test ing the following aspects related to hearing loss in the
currently used most frequently (HHIE-S). Accordingly, elderly and its impact on daily life: self-perception of
there is a need for new instruments of detection that hypoacusis, perception of basic sounds, interference
are simple, rigorous, and adapted to the psychosocial with hearing-dependent daily life activities, and impact
characteristics of older persons, given that cultural pat- on social activities. Initially, we included a greater
terns, education, and linguistic differences can have a number of items in each domain than what remained
major impact on the functioning of these instruments. in the final version of the scale. All items were devised
The object of our study was to design and validate and selected by means of consensus among partici-
the Hearing-Dependent Daily Activities (HDDA) pating researchers, and questions were written in a
Scale as a means to identify the impact of hearing loss neutral, clear, and simple style, requiring a minimum
on daily life in older persons by measuring capacity to amount of time and concentration on the part of the
carry out hearing-dependent activities. We considered patients in their responses.
tonal audiometry as the reference comparison stan- Once the questionnaire was formulated, a first pilot
dard, because it is markedly reliable in evaluating the test was conducted on 7 subjects. The object was to
hearing capacity of the elderly, their therapeutic needs, establish the clarity of the 19 questions initially con-
and functional prognosis. stituting the scale (in terms of patient comprehension)
and the clarity of the instructions contained therein, as
well as to record the time required to complete the test
METHODS (average age = 74.1 ± 5.4 years, average time = 4.7 ± 1.0
Design and Study Population minutes). After observing difficulties in the compre-
This observational, cross-sectional study consisted hension of several questions, the questionnaire was
of 2 parts: (1) development of an instrument, and (2) reduced to 12 items. A second pilot test was carried
validation of that instrument, administered by means of out on 40 subjects to ascertain the reproducibility of
a personal interview. The study took place in the city the scale’s results. Twenty subjects were interviewed
of Albacete, Spain, which comprises 8 principal health on 2 different occasions within less than 1 week and
zones and a population of 159,518 inhabitants, 13.4% the other 20 were given consecutive evaluations by 2
of whom are aged 65 years or older. Study participants different interviewers to determine reliability between
were residents of Albacete and aged 65 years and observers. In Supplemental Appendix 1, the HDDA
older. Exclusion criteria included cognitive disorders Scale is shown in English, and in Supplemental Appen-
and immobilized elderly persons unable to reach the dix 2, it is shown in Spanish. Appendixes are online-
health center for audiometry testing. only and available at http://www.annfammed.
We needed an estimated a sample size of 971 org/cgi/content/full/6/5/441/DC1.
participants based upon an expected 35% of older
persons with hearing problems (95% confidence Data Collection
interval ± 3%). Allowing for a 30% nonresponse rate We contacted Albacete residents selected for the
calculated using the formula “adjusted number of study by mail and later by telephone to explain the
subjects = number of subjects [1/ (1 – expected propor- purpose of the trial. Next, they were given appoint-
tion of losses)],” the definitive sample size increased ments at Health Centre Zone VI in Albacete for

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evaluation by 3 nurses who were previously trained in using Cronbach’s α reliability coefficient (correlation
the Department of Otorrhinolaryngology of the Uni- between responses to the distinct questions of the
versity Hospital Complex of Albacete. scale to evaluate homogeneity of items).
With the purpose of reducing error during data To evaluate content validity of the HDDA Scale,
collection, conditions of the scale administration were we assessed questions for the information they con-
standardized for all interviewees. The population tained regarding different dimensions involved in iden-
sample was selected to represent the population under tifying hearing impairment. The results of qualitative
study, including the entire clinical spectrum or comor- analysis indicated adequate validity of construction,
bidity of hearing impairment. Because our research showing that the contents of the scale were concor-
involved older persons with high levels of illiteracy, dant with the theoretical concept of the disorder and
we preferred to conduct interviews in which relevant comparable to that of other instruments which measure
issues could be clarified rather than rely on self-admin- the same attribute. We explored the latent dimen-
istered questionnaires, even though the latter ensures sions of hearing loss using factor analysis, consisting
greater patient privacy and may be more effective for of the principle components analysis factor extraction
information gathering. method followed by orthogonal varimax rotation. We
The predictor variable was the score obtained used the Kaiser-Meyer-Olkin index and Bartlett’s test
on the HDDA Scale. Overall scores were calculated of sphericity for factor analysis evaluation.
by arithmetically summing points received for each To assess criterion validity, we determined sensitiv-
item, with higher scores indicating fewer difficulties ity and specificity of the scale with its corresponding
in carrying out hearing-dependent activities. There 95% confidence intervals. Using the receiver operating
were 3 response options for each question: “always” characteristic (ROC) curve, we established the most
or “no, I can’t” (0 points), “occasionally” or “with some appropriate cutoff point, which served as an index of
difficulty” (1 point), and “never” or “yes, without the exactitude with which the HDDA Scale identifies
difficulty” (2 points). Finally, results were classified hearing impairment in the elderly. Finally, to evaluate
dichotomously into impairment present/absent, with the clinical utility of the test, we calculated positive
established different cutoff points. and negative predictive values and the probability quo-
The criterion standard used in this study was tient (likelihood ratio).
measurement of hearing threshold using liminal tonal
audiometry. Diagnosis of hearing impairment was
determined according to the criteria recommended by RESULTS
Ventry and Weinstein,20 consisting of a hearing loss Of the 1,387 potential participants selected, we were
of 40 dB or more at 1 and 2 kHz in 1 ear, or at 1 or able to conduct audiometry testing on 1,160, for a
2 kHz in both ears. Standardized audiometries were response rate of 83.6%. The average age of interview-
performed blindly, without knowledge of results of the ees was 73.3 ± 5.9 years (range 65-96 years); 44.1% (512
HDDA Scale. Hearing function was also evaluated by cases) were men, and 55.9% (648 cases) were women.
means of The HHIE-S9,11,14,21,22 in its abbreviated ver- There was a predominance of married persons (77.2%),
sion of 10 questions (cutoff point between scores of 67.7% of participants did not complete primary school
8 and 10). (including illiterate and functional illiterate partici-
The study was approved by the Clinical Inves- pants), and 61.9% had chronic health problems (of
tigation Ethics Committee of the Health Region of more than 3 months´ duration) (Table 1).
Albacete. Throughout the course of the trial, the fol- The reproducibility of the results of the HDDA
lowing ethical principles were maintained: voluntary Scale was evaluated in a sample of 40 older persons not
participation, informed consent, guaranteed anonym- included in the previous study (average age 70.7 ± 5.3
ity, and protection of data privacy. years), of whom 20 were interviewed on 2 different
occasions less than 7 days apart to measure intraob-
Statistical Methods server reliability, while another 20 received 2 consecu-
Statistical analysis, performed using SPSS 14.0 (SPSS tive interviews by 2 different interviewers to determine
Inc, Chicago, Illinois), began with a description of interobserver reliability. Spearman’s correlation coeffi-
participants. We used the intraclass correlation coef- cients for intra- and interobserver reliability were 0.935
ficient, based on analysis of variance and suited to (P <.001) and 0.977 (P <.001), respectively; intraclass
reflect the changes in average values and the correla- correlation coefficients for the same reliability mea-
tion between the distinct measurements, to test the sures were 0.932 (95% confidence interval [CI], 0.832-
reliability of the scale (intra- and interobserver consis- 0.973) and 0.985 (95% CI, 0.963-0.994), respectively.
tency). We evaluated internal coherence of responses After determination of auditory thresholds using

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tonal audiometry in the 1,160 elderly participants, we ranged from 0 to 24, with an average score of 18.94
found a hearing impairment rate of 43.6% (506 cases) points ± 5.03 points. The percentage distribution of
(95% CI, 40.8%-46.5%) according to Ventry and participants according to sex and score obtained on the
Weinstein criteria. HDDA is displayed in Figure 1.
Table 2 displays the items of the HDDA Scale The internal coherence of responses to items on
and the distribution of responses. Participants´ scores the HDDA Scale was evaluated by means of Cron-
bach’s α (correlation between responses to the distinct
Table 1. Participant Characteristics (N = 1,160) questions to ascertain homogeneity of items); the
scale was found to have very high internal consistency
Characteristic No. (%) (Cronbach’s α = 0.91).
Age, years The latent dimensions of the scale were explored
65-74 754 (65.0) using factor analysis. Adequacy of the analysis was
75-96 406 (35.0) assessed by the Kaiser-Meyer-Olkin index (0.897) and
Sex Bartlett’s test of sphericity (9,690.36, 66 df; P <.001),
Male 512 (44.1) allowing us to conclude that there were significant cor-
Female 648 (55.9)
relations between attributes. The factor analysis found
Marital status
2 factors capable of explaining 65.5% of the total vari-
Married 896 (77.2)
Single, widowed, divorced 264 (22.8)
ance: (1) items related to degree of hearing loss and to
Level of education
its social impact for the patient, and (2) items indicat-
Illiterate 56 (4.8) ing ability to perceive basic sounds. For each factor,
Functionally illiterate 730 (62.9) items with highest saturation levels were included, and
Primary education 283 (24.4) item content was interpreted to construct each of the
Middle and higher education 91 (7.9) dimensions of the scale. The factor loadings obtained
Morbidity for the items in the factor analysis are displayed in
No chronic illnesses 442 (38.1) Table 3.
1 or more chronic illnesses 718 (61.9) In Table 4, we display the validity parameters of sen-
Medication
sitivity, specificity, and predictive values according to
No medication 114 (9.8)
chosen cutoff point. Figure 2 shows the ROC curve of
Daily use of 1 or more drugs 1,046 (90.2)
the HDDA Scale, with an area under the curve of 0.822

Table 2. Distribution of Responses to Questions Contained in the Hearing-Dependent Daily Activities

Scale (N = 1,160 Participants)

Always Occasionally Never No Response

No. Questions No. (%) No. (%) No. (%) No. (%)
1. Have you noticed that you don’t hear as well as you used to? 240 (20.7) 468 (40.3) 452 (39.0) 0 (0.0)
2. Has anybody told you that you don’t hear well? 153 (13.2) 480 (41.4) 526 (45.3) 1 (0.1)
3. Does your family tell you that you turn up the volume of 204 (17.6) 307 (26.5) 648 (55.9) 1 (0.1)
the television or radio very loudly?
4. When you’re talking to someone, do you have to ask the 67 (5.8) 357 (30.8) 734 (63.4) 2 (0.2)
person to speak louder?
5. When you’re talking to someone, do you have to ask the 64 (5.5) 417 (36.0) 677 (58.5) 2 (0.2)
person to repeat what they’re saying various times?
With Some Yes, Without
No, I Can’t Difficulty Difficulty No Response
No. (%) No. (%) No. (%) No. (%)
6. Can you understand when someone is speaking to you in 91 (7.8) 386 (33.3) 683 (58.9) 0 (0.0)
a low voice?
7. Can you understand when someone is speaking to you on 8 (0.7) 106 (9.1) 1045 (90.2) 1 (0.1)
the telephone?
8. Can you hear the sound of a coin dropping on the floor? 19 (1.6) 117 (10.1) 1024 (88.3) 0 (0.0)
9. Can you hear the sound of a door closing? 10 (0.9) 96 (8.3) 1054 (90.9) 0 (0.0)
10. Can you hear when someone approaches you from behind? 29 (2.5) 186 (16.0) 944 (81.4) 1 (0.1)
11. Can you hear when someone is speaking to you in a noisy 76 (6.6) 447 (38.6) 635 (54.7) 2 (0.2)
setting such as a pub or restaurant?
12. Can you hold a conversation in a group setting when 77 (6.6) 436 (37.7) 645 (5.7) 2 (0.2)
several people are speaking at the same time?

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(95% CI, 0.798-0.847). By means of this curve we cal- scored above 10 points, considered to be indicative of
culated the most appropriate cutoff point for identifyinga major hearing impairment (11.3% of those responding
hearing impairment, corresponding to a score of 20 or to the questionnaire; 95% CI, 9.5-13.1). On the other
less on the HDDA Scale and a sensitivity and specific- hand, 60.6% (702 cases) of interviewees did not mani-
ity of 80.0% (95% CI, 76.3%-83.3%) and 70.2% (95% fest any hearing limitations (0 points). In response to
CI, 66.5%-73.5%), respectively. Despite our use of a the question, “How do you think your hearing is?”, we
standardized, sufficiently proven hearing test to confirm found that the majority (63.0%) described their hearing
a diagnosis, an imperfect criterion standard bias may capacity as good or very good, 29.0% as “so-so” or not
have resulted in our potentially overestimating indices particularly good, and the remaining 8.0% as bad or
of sensitivity and specificity for the HDDA Scale. very bad. When asked about the use of hearing aids, 52
We administered the questionnaire HHIE-S to (4.5%) of the elderly answered affirmatively.
1,158 participants, yielding an average score of 2.9 ± 5.1 Regarding hearing impairment criteria, the HHIE-S
(range from 0-36). One hundred thirty-one participants questionnaire obtained a sensitivity of 23.3% (95% CI,
19.8%-27.2%) and a specificity of
Figure 1. Distribution of Hearing-Dependent Daily Activities Scale 98.0% (95% CI, 96.6%-98.8%).
scores by participant’s sex (N = 1,160 participants). The question pertaining to self-per-
ceived hearing capacity classified
60 as “so-so, bad, very bad” reached
Male Female 50.6 a sensitivity of 61.8% (95% CI,
50
45.4 57.5%-65.9%) and a specificity of
Percent of participants

40 82.1% (95% CI, 79.0%-84.9%).

Assessment of convergent validity
30 27.7 of the HDDA Scale with respect to
24.5
20
the HHIE-S questionnaire revealed
14.513.1 a moderate to high correlation
10 6.7 6.9 (r = 0.776; P <.001).
4.5 4.0
1.2 0.9
0
0-4 5-8 9-12 13-16 17-20 21-24 DISCUSSION
Score
Hearing impairment in the elderly
patient may be overlooked in clini-
cal practice, as patients and profes-
Table 3. Loadings Obtained for the Hearing-Dependent Daily sionals tend to consider hearing
Activities Scale Items in the Factor Analysis loss as an age-related physiologic
Percent change. Because of the belief
Dimensions (Factors) Load Variance among physicians that treatment
1. Questions objectifying hearing loss and social interaction 38.78 for hearing loss is ineffective, aid
Have you noticed that you don’t hear as well as you used to? 0.774 for this condition is frequently not
Has anybody told you that you don’t hear well? 0.741 given.15 Early detection is impor-
Does your family tell you that you turn up the volume of the 0.695 tant, however, to reduce its impact
television or radio very loudly?
on the functional state and social
When you’re talking to someone, do you have to ask the 0.771
person to speak louder? behavior of the older person.4,23-25
When you’re talking to someone, do you have to ask the 0.803 Moreover, it should not be forgot-
person to repeat what they’re saying various times?
ten that almost 90% of cases of
Can you understand when someone is speaking to you in a 0.689
low voice? hypoacusis are due to neurosen-
Can you hear when someone is speaking to you in a noisy 0.688 sory changes and are amenable to
setting such as a pub or restaurant? hearing aids.26
Can you hold a conversation in a group setting when several 0.682
people are speaking at the same time?
Studies have shown that in
2. Perception of basic sounds 26.68 primary care, identification rates
Can you understand when someone is speaking to you on 0.772 of hearing disorders are low; heavy
the telephone? patient load and lack of time dur-
Can you hear the sound of a coin dropping on the floor? 0.854
ing office visits are likely contribu-
Can you hear the sound of a door closing? 0.846
tors to this situation. Because only
Can you hear when someone approaches you from behind? 0.749
20% of primary care physicians use

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Table 4. Test Characteristics of the Hearing-Dependent Daily Activities Scale According to Cutoff Point
(N = 1,160 Patients)

Positive Negative Positive Negative

Cutoff Sensitivity Specificity Predictive Predictive Probability Probability
Point (95% CI) (95% CI) Value (95% CI) Value (95% CI) Quotient (95% CI) Quotient (95% CI)
18/19 64.9 81.4 72.9 75.0 3.48 0.43
(60.6-68.9) (78.2-84.2) (68.6-76.8) (71.7-78.1) (2.93-4.14) (0.38-0.49)
19/20 73.1 76.2 70.2 78.6 3.06 0.35
(69.0-76.8) (72.7-79.3) (66.2-74.0) (75.2-81.6) (2.64-3.55) (0.30-0.41
20/21 80.0 70.2 67.4 82.0 2.68 0.28
(76.3-83.3) (66.5-73.5) (63.5-71.0) (78.6-85.0) (2.36-3.04) (0.24-0.34)
21/22 85.8 60.8 62.8 84.8 2.19 0.23
(82.5-88.6) (57.0-64.4) (59.1-66.3) (81.2-87.7) (1.98-2.42) (0.19-0.29)
22/23 90.4 47.5 57.1 86.6 1.72 0.20
(87.5-92.7) (43.7-51.4) (53.6-60.5) (82.6-89.7) (1.59-1.86) (0.15-0.27)

some kind of screening method to identify hearing dis- est, allowing correct classification of 70.2% of elderly
orders,27,28 there appears to be a need for easy-to-use patients with no hearing impairment. Our results indi-
scales in clinical practice that aid not only the diagno- cate that the HDDA Scale may be more sensitive than
sis of this condition but also evaluation of rehabilitation other previously designed instruments in identifying
measures.29 To further these ends, the HDDA Scale older persons with hearing loss,13,18 and it may possess
shows adequate reliability indices and acceptable valid- a higher predictive value than most items dealing with
ity criteria. Most importantly, this instrument reaches a self-perceived hearing capacity.30 Because the positive
sensitivity as high as 80.0%, which is of interest when predictive value of the HDDA Scale is conditioned by
the primary aim is early detection of hearing loss in the increased prevalence of hearing impairment in the
primary care practice. Specificity of the scale is mod- elderly, however, probability quotients are a less biased
means of assessing the scale’s efficacy
Figure 2. ROC curve for HDDA Scale in detecting hearing loss as a diagnostic tool.
in older adults (N = 1,160 patients). For patients requiring special
attention, such as the elderly, scales
1.0
can be useful as aids to diagnosis and
for measuring severity of the hear-
ing condition, both during office
consultations and in clinical studies.
0.8
For maximum efficacy, it is essential
that these tools are correctly adapted
to the patient’s cultural environment
0.6
and that they are endowed with
robust psychometric properties. In
Sensitivity

this regard, the scale most utilized to

date, the HHIE-S, has only minimally
0.4
explored cultural differences in self-
perceived hearing loss.31 Moreover,
the instruments currently available for
assessing hearing capacity frequently
0.2 contain an excessive number of items,
often multiple choice, which impede
their successful completion and justify
the attempts to simplify these scales.
0.0 The HDDA Scale we propose offers
0.0 0.2 0.4 0.6 0.8 1.0 ease of use, not only because of its
1-Specificity simplicity, but also because of the
short time required to complete it.
ROC = receiver operating characteristic; HDDA = Hearing-Dependent Daily Activities.
In conclusion, the aim of our

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study was to develop a clinically useful instrument to 11. López-Vázquez M, Orozco JA, Jiménez G, Berruecos P. Span-
ish hearing impairment inventory for the elderly. Int J Audiol.
detect hearing loss in older patients, a condition that
2002;41(4):221-230.
frequently goes unnoticed during routine medical
12. Nondahl DM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein R,
check-ups. The HDDA Scale has been designed for Klein BE. Accuracy of self-reported hearing loss. Audiology.
use in primary care and may serve to easily identify 1998;37(5):295-301.
hypoacusis and evaluate its impact on hearing-depen- 13. Gates GA, Murphy M, Rees TS, Fraher A. Screening for handicap-
dent activities. This scale was validated in a target ping hearing loss in the elderly. J Fam Pract. 2003;52(1):56-62.
population that approximated real-life conditions for 14. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools
for identifying hearing impaired elderly in primary care. JAMA.
diagnostic testing. Moreover, the HDDA Scale has
1988;259(19):2875-2878.
good psychometric characteristics, which makes it an
15. Weinstein BE. Age-related hearing loss. How to screen for it, and
instrument that the family doctor can use to identify when to intervene. Geriatrics. 1994;49(8):40-45.
hearing impairment efficiently in clinical practice. 16. McBride WS, Mulrow CD, Aguilar C, Tuley MR. Methods
To read or post commentaries in response to this article, see it for screening for hearing loss in older adults. Am J Med Sci.
1994;307(1):40-42.
online at http://www.annfammed.org/cgi/content/full/6/5/441.
17. Mulrow CD. Screening for hearing impairment in the elderly. Hosp
Key words: Hearing loss; hearing impairment; disability evaluation; Pract (Off Ed). 1991;26(2A):79-86.
elderly 18. Lichtenstein MJ, Bess FH, Logan SA. Diagnostic performance
of the hearing handicap inventory for the elderly (screening
Submitted September 2, 2007; submitted, revised, February 28, 2008; version) against differing definitions of hearing loss. Ear Hear.
accepted March 13, 2008. 1988;9(4):208-211.
19. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and man-
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