Kitty Grutzmacher struggled with hearing problems for a decade, but the situation worsened in the last year. Even with her hearing aids, she “heard very little or nothing at all,” she said.
“I avoided going out in groups. I stopped playing cards, going to Bible studies, and even stopped going to church.”
Her audiologist couldn’t provide a solution for Grutzmacher, a retired nurse from Elgin, Illinois. But she found the cochlear implant program at Northwestern University on her own.
There, Krystine Mullins, an audiologist who evaluates patients’ hearing and advises them on their options, explained to her that surgically implanting this electronic device usually significantly improves the patient’s ability to understand words.
“I had never thought about it,” said Grutzmacher.
Her age of 84 was irrelevant. “As long as you are healthy enough to undergo surgery, age is not an issue,” said Mullins. Recently, a Northwestern patient had an implant at the age of 99.
Some patients need to think about this decision, as after the operation, clearer hearing still requires months of practice and adaptation, and the degree of improvement is difficult to predict. “You can’t test it in advance,” said Mullins.
But Grutzmacher didn’t hesitate. “I couldn’t continue as I was,” she said in a follow-up phone interview after the implant; an interview where they had to repeat questions to her, but it would have been impossible a few weeks earlier. “I was completely isolated.”
Hearing loss in older adults remains undertreated. Federal epidemiologists have estimated that it affects approximately 1 in 5 people aged 65-74, and more than half of those over 75.
“The mechanisms of the inner ear are not designed for longevity,” said Cameron Wick, an otolaryngologist at the Cleveland University Hospitals.
Although hearing loss can contribute to depression, social disconnection, and cognitive impairment, less than a third of people over 70 who could benefit from hearing aids have used them.
For those who do use them, “if their hearing aids no longer provide clarity, they should request an evaluation for a cochlear implant,” said Wick.
Twenty-five years ago, “implanting people over 80 was a novelty,” said Charles Della Santina, director of the Cochlear Implant Center at Johns Hopkins. “Now, it’s quite common.”
In fact, a study published in 2023 in the journal Otology & Neurotology reported that cochlear implantation was increasing at a faster rate in patients over 80 than in any other age group.
Until recently, Medicare covered the procedure only for people with extremely limited hearing who could correctly repeat less than 40% of words in a speech recognition test. Without insurance – the cochlear implant can cost $100,000 or more for the device, surgery, counseling, and follow-up – many older people do not have this option.
“It was incredibly frustrating because they were excluding Medicare patients,” said Della Santina. (Similarly, traditional Medicare does not cover hearing aids, and Medicare Advantage plans with hearing benefits still leave patients paying the bulk of the bill).
Then, in 2022, Medicare expanded cochlear implant coverage to include older adults who could identify up to 60% of words in a speech recognition test, increasing the number of eligible patients.
However, although the American Cochlear Implant Alliance estimates that implants are increasing by approximately 10% annually, public awareness and referrals from audiologists remain low.
Less than 10% of eligible adults with moderate to profound hearing loss receive them, according to the alliance.
Cochlear implantation requires commitment. After the patient receives tests and counseling, the surgery, which is an outpatient procedure, usually lasts two to three hours. Many adults undergo surgery on one ear and continue to use a hearing aid on the other; some later receive a second implant.
The surgeon implants an internal receiver under the patient’s scalp and inserts electrodes, which stimulate the auditory nerve, in the inner ear; patients also wear an external processor behind the ear. (Clinical trials are underway for a fully internal device).
Two to three weeks later, once the swelling subsides and the stitches are removed, an audiologist activates the device.
“When we first turn it on, you won’t like what you hear,” Wick warned. Voices initially sound robotic, mechanical. The brain takes several weeks to adapt, and patients begin to decipher words and sentences accurately.
“A cochlear implant is not something that just turns on and works,” said Mullins. “It takes time and some training to get used to the new sound quality.” She assigns tasks, such as reading aloud for 20 minutes a day and watching TV while reading subtitles.
Within one to three months, “boom! The brain starts to catch on, and speech clarity takes off,” said Wick. At six months, older adults will have achieved most of their improved clarity, although some improvements continue for a year or more.
How much improvement? It is measured through two hearing tests: the CNC test (consonant-nucleus-consonant), where patients are asked to repeat individual words, and the AzBio Sentence Test, where the words to be repeated are part of complete sentences.
At Northwestern, Mullins explains to older potential patients that, a year after activation, an AzBio score of 60% to 70% (correctly repeating 60 to 70 words out of 100) is typical.
A Johns Hopkins study with approximately 1,100 adults, published in 2023, revealed that, after the implant, patients aged 65 and older could correctly identify about 50 additional words (out of a total of 100) in the AzBio test, a comparable increase to the results of the younger cohort.
Participants over 80 showed a similar improvement to those between 60 and 70.
“They go from struggling to follow a conversation to being able to participate,” said Della Santina, the study’s author. “Decade after decade, cochlear implant results have been getting better.”
In addition, an analysis of the experiences of 70 older patients at 13 implant centers, of which Wick was the lead author, revealed not only clinically significant auditory improvements but also a better quality of life.
Scores on a standard cognitive test also increased: after six months of cochlear implant use, 54% of participants passed the test, compared to 36% before surgery. Studies focused on people aged 80-90 have shown that those with mild cognitive impairment also benefit from implants.
However, “we are cautious and do not promise too much,” Wick said. Generally, the longer older patients with significant hearing loss spend, the more effort they will have to put in to regain their hearing and the less improvement they may see.
A minority of patients experience dizziness or nausea after surgery, although most recover quickly. Some have difficulty with technology, including mobile apps that adjust sound. Implants are less effective in noisy environments, such as crowded restaurants, and since they are designed to clarify speech, music may not sound good.
For those at the upper end of Medicare eligibility and already understand about half of the speech they hear, the implant may not seem cost-effective. “Just because someone is eligible doesn’t mean it’s the best option for them,” Wick concluded.
For Grutzmacher, however, the decision seemed clear. Her initial tests revealed that, even with hearing aids, she only understood 4% of words in the AzBio test. Two weeks after Mullins placed the cochlear implant, Grutzmacher could understand 46% with a hearing aid in the other ear.
She reported that after a few difficult days, her ability to speak on the phone had improved, and instead of turning up the TV volume to 80, “I hear it at 20,” she said.
So she was making plans. “This week I’m going to have lunch with a friend,” she said. “I’m going to play cards with a small group of women. I have a church lunch on Saturday.”
The New Old Age is produced in collaboration with The New York Times.
