A 70-year-old man is brought to the office by his wife. She reports that he "no longer listens to me" when she speaks and that this has worsened over the past 2 years. The patient has moved his living room chair farther away from her and closer to the TV. He does not like to join her for their weekly dinners with friends anymore. The patient reports he has trouble understanding his wife, especially when the environment is noisy. He says he got tired of asking his friends to repeat themselves and so does not enjoy eating out with them. Medications include hydrochlorothiazide, lisinopril, and aspirin. The patient does not smoke or use alcohol. Which of the following is the most likely cause of his condition?

Question

A 70-year-old man is brought to the office by his wife.  She reports that he "no longer listens to me" when she speaks and that this has worsened over the past 2 years.  The patient has moved his living room chair farther away from her and closer to the TV.  He does not like to join her for their weekly dinners with friends anymore.  The patient reports he has trouble understanding his wife, especially when the environment is noisy.  He says he got tired of asking his friends to repeat themselves and so does not enjoy eating out with them.  Medications include hydrochlorothiazide, lisinopril, and aspirin.  The patient does not smoke or use alcohol.  Which of the following is the most likely cause of his condition?

Quizplus · Accepted Answer

This elderly patient brought in for evaluation of social withdrawal has trouble understanding speech when there is competing background noise. This is a common scenario for patients with presbycusis (age-related hearing loss), a bilateral, progressive, sensorineural hearing loss (SNHL). Presbycusis affects >50% of adults by age 75 and is likely related to cochlear hair cell loss and cochlear neuron degeneration. Age-related brain atrophy also likely contributes (likely due to increased information processing times) and may explain the disproportionate problems with speech discrimination in older compared with younger patients with SNHL. High frequencies are affected first, making it more difficult for patients to understand higher-pitched voices (eg, women, children). Tinnitus often develops and is typically described as continuous ringing, rushing, or buzzing. Patients with presbycusis often hear well in one-on-one conversations in a quiet room; however, even a small amount of competing noise impairs hearing (eg, speech discrimination). Therefore, education of the patient and family is imperative. In addition to limiting background noise, families should be counseled to look directly at patients when speaking to them. Amplification (eg, hearing aids) may be beneficial. (Choice B) Ototoxic medications (eg, aminoglycosides, loop diuretics) can also cause bilateral, symmetric SNHL and may compound age-related hearing loss. This patient's medications (at typical doses) are not normally implicated in hearing loss. (Choice C) Parkinson disease leads to loss of dopaminergic neurons in the substantia nigra. It may present with social isolation and withdrawal, but this patient's history of difficulty understanding speech is more consistent with hearing loss. (Choice D) Otosclerosis is caused by abnormal bone deposition, resulting in stiffening of the ossicular chain. It is usually found in younger patients and presents with conductive hearing loss. In contrast to this patient, those with conductive hearing loss may have paradoxically improved speech understanding in background noise (paracusis of Willis). (Choice E) Tympanosclerosis (scarring of the tympanic membrane) can cause stiffening that may lead to conductive hearing loss in severe cases. However, patients typically have a history of otitis media (typically chronic) or previous tympanostomy tubes. Chalky, white patches are often seen on the tympanic membrane. Educational objective: Sensorineural hearing loss that occurs with aging is called presbycusis. It presents with bilateral, high-frequency hearing loss and is related to damage to sensorineural structures in the inner ear.

A 70-Year-Old Man Is Brought to the Office by His