We measure blood pressure before a patient has a stroke. We check cholesterol before a coronary event. We evaluate vision before impairment interferes with driving or reading.
So why is hearing treated differently? For many people, the last routine hearing test they remember was in elementary school. Decades pass before anyone checks again, often after the problem has become impossible to ignore. Conversations are frustrating, family members are repeating themselves, and social gatherings are exhausting. At this point, the change may have been developing gradually for years.
These days, a reactive approach to hearing care is increasingly difficult to justify. Hearing health belongs on the same spectrum as other routinely monitored aspects of adult health: establish a baseline, reduce avoidable risk, monitor for change, and intervene when a clinically meaningful shift emerges. In clinical practice, it is not uncommon for adults to report that they have never been asked about their hearing by their primary care provider, highlighting how often hearing health remains overlooked in routine care.
Now, I’m completely aware of what I’m asking. Primary care visits are already carrying depression screening, fall risk, medication reconciliation, immunizations, and whatever the patient actually came in for. Any proposal that begins “clinicians should also” deserves skepticism.
So let me be specific about the cost. What I’m describing is creating a baseline through one question, and it can be as small as asking whether a patient has noticed difficulty hearing conversation. It doesn’t require equipment, a booth, or a separate visit. It doesn’t require a normal-versus-abnormal determination. It requires asking, listening to the answer, and knowing what to do when the answer is yes.
The World Health Organization’s updated guidelines on reducing cognitive decline and dementia bring new urgency to this shift. The WHO estimates that up to 45 percent of dementia cases may be attributable to modifiable factors. The Lancet Commission estimates that hearing loss accounts for roughly 7 percent, making it the largest single modifiable risk factor in midlife. WHO guidelines also state that hearing aids may be offered to adults with hearing loss as part of dementia risk-reduction strategies. In a randomized controlled trial done by ACHIEVE, hearing aids and audiologic support slowed cognitive decline by 48 percent over three years among older adults at elevated risk. With these stats in mind, hearing can no longer be treated as an isolated sensory concern with no relevance to broader health.
Hearing loss rarely comes all at once. People typically accommodate it, gradually adjusting their behavior. They turn up the television. They choose quieter restaurants. They position themselves closer to the person speaking. They rely more heavily on facial expressions and context. Because these accommodations develop gradually, people may not recognize them as signs of hearing loss.
That distinction is where clinical judgment lives. A baseline does not require universal screening or an annual audiologic evaluation for every adult. It requires knowing which of our patients belong in the symptomatic group at all. Most of the time, we don’t ask.
Prevention begins before the test result changes
Hearing care is not limited to detecting loss. It also includes helping patients protect the hearing they have.
Noise-related hearing damage is largely preventable, yet many adults don’t understand that risk is determined by both volume and duration. A sound doesn’t have to be painful to be harmful. Repeated exposure to power tools, loud fitness classes, concerts, sporting events, firearms, machinery, and high-volume personal audio can gradually cause permanent damage.
Clinicians routinely counsel patients about sunscreen, seat belts, nutrition, and exercise. Safer listening deserves similar attention.
The advice can be as straightforward as lowering the volume, taking breaks from prolonged listening, and increasing distance from the sound source. If you have to raise your voice to be heard by someone standing an arm’s length away, consider the environment potentially hazardous to hearing. These recommendations require little time, but they give patients an opportunity to act before the damage appears on an audiogram.
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Monitoring should be based on risk, not crisis
Once a baseline exists, follow-up can be individualized. A patient with substantial occupational exposure, tinnitus, ototoxic treatment, or a documented change may need closer monitoring. A lower-risk adult with normal hearing may just need hearing revisited during routine preventive visits and reevaluated when symptoms, age, exposures, or family observations warrant it.
Primary care clinicians can begin with a question: “Have you or someone close to you noticed a change in your hearing?” If a patient says yes, there are two things they can immediately do:
- Complete a validated hearing screening questionnaire to better understand the impact of their hearing difficulties.
- Refer the patient for a comprehensive hearing evaluation with a hearing professional.
The answer may reveal much more than whether a patient can hear a tone. Difficulty following conversation in background noise, frequently asking others to repeat themselves, withdrawing from group settings, or misunderstanding instructions can affect safety, relationships, and the patient’s ability to participate in care. Certain symptoms should also trigger more urgent evaluation, like sudden hearing loss, unilateral or asymmetric symptoms, persistent ear pain or drainage, pulsatile tinnitus, or associated neurologic findings.
Earlier identification creates more options
When hearing loss is identified, intervention doesn’t always mean an automatic hearing aid prescription. It may include cerumen management, medical or surgical evaluation, communication strategies, assistive technology, auditory rehabilitation, counseling, or amplification. If hearing aids are appropriate, they should be selected through shared decision-making and supported with proper fitting, verification, education, and follow-up.
The goal is to identify hearing changes before they have significantly affected daily life, while patients still have a wider range of options.
Primary care clinicians don’t need to perform comprehensive audiology to make hearing part of preventive care. They need a reliable way to ask about changes, recognize risk, offer basic counseling, and refer when appropriate.
Preventive medicine works best when it identifies change early enough for patients to have choices. The right time to establish a hearing baseline is not when communication problems have become impossible to ignore, but when there is still something meaningful to protect.
Rachel Artsma is an audiologist.
