Older adults hearing screening strategies: a bibliometric review

ABSTRACT Purpose: to analyze the profile of publications on methods and instruments used to screen older adults hearing. Methods: the scientific production on older adults hearing screening methods, searching for articles published between 2016 and 2022. Data were collected from PubMed, Scopus, LILACS, Web of Science, and Google Scholar databases and the articles were categorized according to their year, study type, authors, and screening instrument. Data were also analyzed to suggest potential aspects to be addressed in future research in the area. Literature Review: altogether, 26 articles were found based on the eligibility criteria. Publications peaked in 2016, followed by 2020. Articles published in the United States predominated (18%), and HHIE-S (hearing handicap inventory for the elderly screening version) was the most used instrument; 90% of the publications were in English, and the most recurrent study type was cross-sectional, followed by instrument validation studies. Conclusion: the review points out the scarcity of scientific production on older adults hearing screening in both national and international research. The studies approached different populations, screening methods, hearing loss definitions, health systems, and public policies in the countries where they were conducted. Better methodologies must be implemented for future research in the area.


INTRODUCTION
In most countries, the number of older adults is growing, which points to an aging society.Pathologies whose frequencies increase with aging include those related to the inner ears.
Age-related hearing loss results from pathological changes in the auditory pathway and is associated with advancing age 1 .Hearing loss is the third most common chronic disease among older patients, after arterial hypertension and arthritis.According to statistics, about 30% of the world population above 60 years old have hearing loss, whose prevalence may reach 40% in those 70 years old 2 .Most such cases of hearing loss are related to age 3 .Studies have shown that untreated auditory sensory loss is associated with older adults´ decreased quality of life, physical [4][5][6][7][8][9] and emotional diseases [9][10][11] , and impaired social relations 12,13 .
According to the more recent results published in the World Report on Hearing, about 1.5 billion people worldwide have some degree of hearing loss.Approximately 466 million of these -equivalent to 6% of the world population -had a disabling loss ranging from moderate to total loss.Disabling losses occur mainly in older adults, as an estimated one third of those older than 65 years have some type of hearing loss that limits them 2 .
Age-related hearing losses reflect changes in the peripheral and central auditory systems.They initially have a greater impact at higher frequencies, which are more important to understand oral language 1 .In general, the first signs of age-related hearing loss are perceived by 60 years old, affecting the conversation frequency range, and subtly progressing to lower tones.Human hearing encompasses frequencies ranging from 20 Hz to 20000 Hz, and speech frequencies range from 400 Hz to 5000 Hz.Most losses occur in frequencies equal to or higher than 2000 Hz 1 .Thus, it becomes challenging to understand the interlocutor's speech, which gets degraded, particularly in the presence of background noise, increasing the cognitive effort.Difficulties to hear speech negatively affect social interactions and family relations.
Given the consequences, the ideal is to reach an early diagnosis.Screening can help identify hearing loss faster in these individuals, favoring precise diagnoses and assertive interventions.
Hearing screening is specifically defined by the American Speech-Language-Hearing Association (ASHA) as a quick pass/fail test, in which "pass" indicates the absence of hearing loss, and "fail" means

LITERATURE REVIEW
Initially, 377 articles were found in the first search, while the second one resulted in 425 articles on the topic.There were 137 duplicates between databases, leaving 288 for the title and abstract reading -after which, 159 articles were excluded for not meeting the inclusion criteria, leaving 129 potentially eligible articles.
In the following stage, four articles were excluded because they were not available in full text, and another 99 were not related to the use of hearing screening instruments, totaling 103 excluded articles.Lastly, 26 articles were selected for the study and analysis (Figure 1) and are described in detail in Chart 1.
read the articles in full texts, likewise classifying them as "included" or "excluded".When their opinions conflicted, the third reviewer analyzed the article in question and decided on the issue.Figure 1 presents the selection flowchart.

Eligibility criteria
The review included observational, experimental, and cohort studies, published in Portuguese or English after 2016: (a) whose participants were older adults; (b) which used some hearing screening method for this population; (c) whose full text was available in open-access databases or through the CAFe at UFPB (Federated Academic Community at the Federal University of Paraíba).Opinion articles, dissertations, theses, reviews, case series, case studies, and communications were excluded.

Data extraction
In the last stage, the data were extracted into a table with their author, title, year, country, findings, Caption: n = number of articles  The application had a 100% sensitivity and 60% specificity in screening, as compared with an audiometer.The questionnaire was significantly less precise, ascribing approval scores to three participants who failed both the application and the audiometry.

2016
Perception of hearing loss: use of the subjective faces scale to screen hearing among the elderly 17 Costa-Guarisco et al.

Subjective faces scale and whispered voice test 164 ≥ 60
There was a correspondence between the faces and the degree of hearing loss.Faces 2 and 3 had good sensitivity and specificity indices, with an area under the ROC curve of 0.81.The subjective faces scale seems to be a good, easy-toapply, low-cost instrument to complement hearing screening in gerontology services.

2016
The development and standardization of Selfassessment for Hearing Screening of the Elderly The prevalence of hearing loss according to the questionnaire was 76.1%, while the audiometry indicated 79.7%.The diagnostic accuracy of the instrument was 86.2%, with 89.1% sensitivity and 75.0%specificity, regardless of sex.Thus, HHIE-S is adequate to screen hearing loss in older adults, given its high accuracy and ease of use.

2018
Hearing screening and perceived participation restriction in the elderly 29

2019
A parsimonious approach for screening moderate-toprofound hearing loss in a community-dwelling geriatric population based on a decision tree analysis 30 Zhang et al.
Pure-tone audiometry and decision tree, using machine learning to optimize audiometry frequency and intensity

1,793 ≥ 60
A simple two-stage screening procedure using two tones (2 kHz and 0.5 kHz) selected through decision tree analysis (machine learning algorithm) can be applied to screen moderate to profound hearing loss in a community-dwelling older population in Shanghai.

2019
Screening for hearing loss in the Hong Kong Cantonesespeaking elderly using tabletbased pure-tone and word-innoise test 31 Kam et al.
Tablet The electronic alarm to remind physicians to ask their patients older than ≥ 55 years regarding hearing loss significantly increased audiological referrals of at-risk patients.

2020
Sensitivity and specificity of the Hearing handicap inventory for elderly-screening Thai version 36 Judee et al.

HHIE-S 222 ≥ 60
The Thai version of HHIE-S had good sensitivity and specificity boa to screen hearing loss (at 40 dB or more) in Thai older adults.HHIE-S can be used to identify patients with hearing loss and raise awareness of health in Thai older adults.2020 Score of hearing handicap inventory for the Elderly (HHIE) compared to whisper Test on presbycusis 37 Purnami et al.

HHIE-S and whispered voice test 60 ≥ 65
The whispered voice test is more sensitive than HHIE-S to detect hearing loss in patients with age-related hearing loss.

2021
The effective screening tools for detecting hearing loss in elderly population: HHIE-ST versus TSQ 38  MoBASA proved to be an accurate hearing screening method for older adults with disabling hearing loss.
publications, followed by 2020 (Figure 2).It must be highlighted that, as the search was conducted in May 2022, the number of articles by the end of that year may be greater.

Number of publications over the years
The number of studies published over the years varies considerably -2016 stands out with seven

Studies per country
After the analysis, the countries with the most publications were made evident by the articles selected for this study, with an emphasis on Brazil, China, and the United States (Figure 3).One study used the Digits-In-Noise test (DIN) in 3,327 participants and demonstrated that this test has excellent screening characteristics for moderate hearing loss, though inadequate to detect mild hearing loss 19 .Another study from 2020, with 9,666 participants, demonstrated that self-reported hearing measures had limited accuracy and were not sensitive enough to detect hearing loss.The self-reported measure in that study was no more than a questionnaire administered to the participants, asking whether they had difficulties following a conversation with background noise; it was answered on a 5-point Likert scale, in which 1 was excellent; 2, very good; 3, good; 4, average; and 5, poor 33 .No structured questionnaires, interviews, or validated instruments were used.

Hearing screening instruments
The review verified which hearing screening instruments are cited in the articles and how many times they were used in the 26 studies -which reported various instruments capable of screening older adults hearing (Figure 4).They included iPhone operating system (iOS) and Android applications, self-perception questionnaires (Hearing Handicap Inventory for the Elderly

Types of study and levels of evidence
The study types among the articles analyzed were mainly cross-sectional and validation studies.Most of them were cross-sectional, totaling 16 articles, followed by six validation studies.The other ones were cohort and exploratory studies, as shown in Figure 5.It was found that 50% of the selected publications are in the lower levels of the pyramid of scientific evidence.The cross-sectional studies were greatly exposed to methodological confounding variables, also known as biases.The search did not identify any randomized clinical trials.
Attention must be called to the lack of validation studies addressing low-cost self-assessment instruments to be used either by patients or hearing health prevention and promotion programs, as well as cohort studies demonstrating the effectiveness of these screening instruments.

Figure 1 . 1 .
Figure 1.Flowchart of article search and selection

Figure 2 .
Figure 2. Chart of the number of publications per year (2016-2020) Brazilian studies were conducted by the Federal University of São Carlos, Federal University of Minas Gerais, Marília Medical School, Federal University of Rio Grande do Sul, Federal University of Rio Grande do Norte, and the Santa Casa School of Medical Sciences of São Paulo.

Figure 3 .
Figure 3. World map highlighting the main countries of origin of the journals

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Brandão ER, Guimarães RDA, Soares MJG, Cavalcanti H Captions: HHIE -Hearing Handicap Inventory for the Elderly; HHIE-S -Hearing Handicap Inventory for the Elderly -screening version; SHSE -Self-assessment for Hearing Screening of the Elderly; SHSE-R -Self-assessment for Hearing Screening of the Elderly -revised.

Figure 4 .
Figure 4. Chart with the hearing screening instruments, presenting the quantitative data and main assessment instruments used in the selected studies

Figure 5 .
Figure 5. Quantitative data on the study types selected for the review the articles regarding their title, author, screening instrument, number and age of participants, and main findings