Elder Care Interprofessional Provider Sheets

Communication: Improving Communication with People Who Have Hearing Loss

Fadyeh Barakat, AuD, Department of Speech, Language, and Hearing Sciences, University of Arizona 

October 2018


  • When speaking to older adults who have hearing loss, do so in a quiet place with good lighting, be sure they can see your face, and speak slowly and clearly. If you determine that they didn't understand what you have said, rephrase your statement with different wording, rather than simply repeating it.
  • Many older adults with hearing impairment wait years before seeking evaluation or obtaining a hearing aid. If you detect hearing loss in one of your patients, refer to an audiologist.
  • Provide written information to supplement what you have told the patient. This will allow the patient to fill in any information missed during conversation, and help them remember and share that information with family/friends.

Age-related hearing loss, also known as presbycusis, is one of the most common chronic conditions faced by older adults. It affects 1 in 3 adults between the ages of 65-74 years and half of those over age of 75, with white individuals affected at triple the rate of blacks. Presbycusis is associated with cognitive decline and higher rates of dementia, and also with increased fall rates. The rate of progression and severity of hearing loss depends on many factors including genetics, history of noise exposure, use of ototoxic medications, and presence of other coexisting ear disease.

Presbycusis is sensorineural in nature, meaning that the primary damage to the auditory system is in the auditory nerve or inner ear (cochlea). Hearing loss is typically bilateral and characterized not just by a loss of auditory volume, but also by decreased ability to discern high-frequency (high-pitched) sounds. This, in turn, affects the ability to hear "soft consonants" in speech, such as s, sh th, and f. This results in a loss of clarity of speech sounds. Increasing the overall volume of the sound (i.e., talking louder) may or may not improve clarity.

As a result, those with presbycusis typically report that they can hear a speaker's voice but cannot understand it. The speech is unclear, and people talking sound like they are mumbling or muffled. The struggle to hear is further exacerbated by background noise or when multiple speakers are present, and understanding can be more difficult for non-native speakers of the language being spoken. This all can result in miscommunication, confusion, and frustration for everyone involved.

It is thus no surprise that hearing loss impairs ease of communication not only for the person with hearing loss (PHL), but also for communication partners such as family and friends. It may become difficult for a PHL to understand spoken medical advice, respond to warnings or alerting sounds, and participate in everyday conversations. Many difficulties involved in communicating with a PHL can be resolved by following ten simple communication tips.

TIP 1: Get the PHL's Attention.

If conversation is initiated suddenly or there are many conversations happening at once, PHLs may not realize someone is talking to them. Getting a PHL's attention before addressing them can be as simple as tapping them on the shoulder or saying their name before you begin speaking. For example, "Mr. Smith (pause), when was the last time you fell?"

TIP 2: Be Sure that the PHL Can See Your Face.

A PHL's ability to understand you can often be improved by using visual cues. Seeing the speaker's face provides important information for speech interpretation, such as the shape and movement of the lips and mouth, facial expressions, and gestures (pointing to an object or providing direction). These visual hints can be hidden if a speaker tries to communicate while taking notes on a clipboard or computer, or addresses the PHL from a distance or while performing another task, like hand-washing.  

TIP 3: Find a Quiet Place with Good Lighting to Create a Conducive Environment for Good Communication.

To take advantage of visual cues, it is helpful to communicate in an environment with adequate lighting and limited background noise. If lighting is inadequate (backlighting or low-lighting), a PHL may not be able to see the speaker's face. Background noise like fans can make it difficult for PHLs to use what little auditory information they do get to understand speech.

TIP 4: Speak Slowly, Clearly, and Simply.

Often when people encounter a PHL, their first instinct is to talk louder. Remember, volume isn't the only issue with presbycusis. Louder isn't always better; sometimes louder is just louder. It is more beneficial to slow down the rate of speech, not unnaturally slow, but enough for the PHL to be able to keep up and ask for clarification. By simply slowing down the rate of speech, articulation improves, thereby improving clarity. Try to use simple terms and phrases, as convoluted or medically-heavy terminology may be too difficult for a PHL to process.

TIP 5: Confirm Understanding with Clarifying Questions. 

Encourage PHLs to repeat what they heard and understood. Specific responses and explanations of what was just said help to confirm understanding versus simply asking "Do you understand?"

TIP 6: Rephrase Rather Than Repeat. 

Often a PHL's first response when they do not understand is to say "What?" or "Huh?"  It may be tempting to simply repeat exactly what you said, but this is often unhelpful. Instead, rephrase what you just said and provide the information in another way. See example in the box below. 

TIP 7: Pause at Meaningful Places in the Conversation. 

PHLs are trying to process spoken information as fast as they can, and they can fall behind. Pausing in between phrases can help PHLs catch up and give them time to ask for clarification.

TIP 8: Provide Context and Avoid Changing Subjects Without Warning.

Providing PHLs with context gives them one more tool to compensate for their hearing loss. Context makes it easier to fill in auditory gaps. If you must switch topics, provide a statement to prepare the PHL for the change. For example, "About your medication (pause), how long have you been taking metformin?"

TIP 9: Use Assistive Technology. 

Often hearing loss can be so significant that providing additional volume in addition to the tips already discussed, can provide a significant benefit to PHLs. Assistive technology like Pocket Talkers or FM systems (see figure) are portable, easy to use, and relatively inexpensive. These devices improve access to speech by amplifying a speaker's voice directly into the PHL's ears. This can help reduce the effect of background noise and reverberation. The picture below shows a pocket-talker.

TIP 10: Refer to an Audiologist. 

On average, people struggle with hearing loss for 5-7 years before seeking assistance, and they often wait over 10 years after diagnosis before being fit with hearing aids. Those from minority groups and those with less education have lower rates of hearing aid use. These delays can impair quality of life, with PHLs often experiencing depression, anxiety, and social withdrawal. Appropriate management of hearing loss can allow PHLs to participate more fully in life. Note, however, that while hearing aids can help amplify missing speech sounds and improve communication, PHLs may still struggle to understand speech in noisy environments and will benefit from the communication strategies outlined in this edition of Elder Care.


"Pocket Talker"

Table 1: Rephrase Rather Than Repeat

Initial Question and Patient's Response

Clinician:  When you fell, which side did you land on?
PHL: What?

Example of Repeating:

Clinician: When you fell, which side did you land on?
PHL: I still didn't get it.

Example of Rephrasing:

Clinician: Did you fall on your left or your right side?
PHL: Oh, my right side.


Table 2: Other Recommendations for Improving Communication with Individuals Who Have Hearing Impairment
What to Do   How to Do It
Provide Accurate Visual Information Excessive facial hair can make it difficult to for patients to see important visual cues. Avoid chewing gum or eating while speaking, as this can provide inaccurate cues.
Face the Person Be at the same level, facing the person, to provide more visual cues.  
Use Paper and Pencil If you are unsuccessful with spoken communication, write the information.
Provide Printed Materials Whenever possible, provide printed materials supporting the information you just provided the PHL. This will not only fill in any information missed during conversation, but will also help them remember and share that information with family/friends.

References and Resources