Age-Related Hearing Loss (Presbycusis): What’s Happening and What to Do About It

How common is age-related hearing loss?

According to the National Institute on Deafness and Other Communication Disorders (NIDCD), approximately one in three adults ages 65 to 74 has hearing loss. Among adults 75 and older, nearly one in two is affected.

More recent research suggests the true burden may be even greater in older age groups. A JAMA study found that 65.3% of U.S. adults age 71 and older had hearing loss and by age 90, that figure climbs to 96.2%. Despite this, less than 30% of older adults with hearing loss reported using hearing aids.

This could be partially attributed to the fact that the average person waits seven to ten years after first noticing symptoms before seeking help — a delay that carries real consequences, as we’ll explore below.

What causes hearing loss as we age?

Age-related hearing loss isn’t caused by a single thing. It’s the cumulative result of several biological processes that unfold over decades.

Changes in the inner ear

The cochlea — the fluid-filled, spiral structure that converts sound into electrical signals — contains thousands of microscopic sensory hair cells. These cells do not naturally regenerate in humans, so hearing loss caused by hair-cell damage is typically permanent.

Over time, the hair cells responsible for processing high-frequency sounds tend to degrade first. This is why age-related hearing loss almost always begins with difficulty hearing higher-pitched sounds and understanding speech clearly, particularly in noisy environments.

Additionally, the stria vascularis, a structure that helps maintain the inner ear’s chemical balance, becomes less efficient with age. Changes in the auditory nerve and other hearing pathways may further reduce the brain’s ability to process sound accurately.

Cumulative noise exposure

A lifetime of sound exposure takes a toll. The National Institute on Occupational Safety and Health (NIOSH) has established that repeated exposure to sounds above 85 decibels can cause permanent hearing damage over time.

Many adults with age-related hearing loss also have some degree of underlying noise-induced hearing loss layered on top of age-related changes, making the two difficult to fully disentangle.

Vascular and metabolic factors

Blood flow to the inner ear diminishes with age. Conditions associated with poor vascular health — including high blood pressure, diabetes, and smoking — are recognized risk factors for accelerated hearing decline because the cochlea is highly metabolically demanding and sensitive to changes in its blood supply.

Research has found a strong association between cardiovascular risk factors and hearing loss. One large study reported that adults with two or more cardiovascular disease risk factors had 92% higher odds of hearing loss compared with those without these risk factors. Maintaining cardiovascular health may therefore play an important role in preserving hearing as we age.

Additionally, emerging research suggests that fluctuations and declines in estrogen during perimenopause and menopause may contribute to hearing changes in some women, potentially through effects on cochlear function, blood flow, and auditory processing.

Genetic predisposition

Genetics may help explain why some people develop significant age-related hearing loss in their 60s while others retain relatively good hearing well into their 80s. A family history of early-onset hearing loss is a recognized risk factor, and researchers continue to study the genes that may influence how hearing changes with age.

Ototoxic medications

Some medications can damage the inner ear and contribute to hearing loss. These are known as ototoxic medications and include certain chemotherapy drugs (particularly cisplatin), some loop diuretics, and high doses of aspirin. In older adults who take multiple medications, ototoxicity may accelerate age-related hearing changes or worsen existing hearing loss.

The early signs: what presbycusis sounds like

Age-related hearing loss is typically bilateral (affecting both ears) and gradual — which is part of why it’s so easy to miss in its early stages. The brain often compensates for mild hearing loss remarkedly well, making it easy to overlook until communication becomes noticeably more difficult.

Common early signs include:

• Difficulty hearing certain speech sounds  — High-frequency consonants such as”s,” “f,” “th,” “sh,” and “v” are often the first sounds to become unclear. You may hear someone speaking but struggle to understand exactly what was said.
• Trouble hearing in background noise — Conversations in restaurants, family gatherings, and other noisy environments become increasingly difficult, even when one-on-one conversations in quiet settings remain manageable.
• Frequently asking people to repeat themselves — This is especially common when listening to women and children, whose voices typically contain more high-frequency sound information.
• Tinnitus — Ringing, buzzing, or hissing in the ears commonly occurs alongside age-related hearing loss.
• Turning up the volume — The television, phone, or other devices may gradually need to be set louder than others prefer.
• Listening fatigue — Concentrating on conversations can become exhausting because the brain is working harder to fill in missing information.

If these experiences sound familiar, a comprehensive hearing evaluation can help determine whether hearing loss is present and identify the most appropriate next steps.

Diagnosing age-related hearing loss

Age-related hearing loss is diagnosed through a comprehensive hearing evaluation performed by an audiologist. The cornerstone of that evaluation is pure-tone audiometry — a hearing test that measures the softest sounds you can detect across a range of frequencies. The result is plotted on a graph called an audiogram.

In age-related hearing loss, the audiogram typically shows a sloping pattern: hearing is relatively preserved in the low frequencies (lower-pitched sounds) but gradually worsens in the high frequencies, where many important speech sounds occur.

Speech audiometry is another important part of the evaluation. This testing measures how accurately you can understand words when they are amplified to your threshold, and helps distinguish between difficulty hearing (a sensitivity issue) and difficulty understanding (which may involve central auditory processing as well). Your audiologist will use both sets of results to guide recommendations.

The link between hearing loss and cognitive decline

A growing body of research has found that untreated hearing loss is associated with accelerated cognitive decline, social isolation, and depression in older adults. One of the most influential recent studies is the ACHIEVE study, a major 2023 clinical trial published in The Lancet, which found that hearing intervention significantly reduced cognitive decline in a subset of older adults at elevated risk.

The relationship between hearing and cognitive health is complex and still being studied. It does not mean hearing aids prevent dementia, but it does suggest that treating hearing loss has benefits that extend well beyond hearing itself.

From an audiologist: what patients often misunderstand about age-related hearing loss

Jessica Hinson, Au.D., working audiologist and a member of our medical review board, shares her perspective:

“One of the biggest misconceptions about age-related hearing loss is that people will immediately notice when it begins. In reality, hearing loss usually develops so gradually that many people adapt to it without realizing it. 

By the time many people seek help, symptoms are so severe they can’t be ignored.

This is why regular hearing evaluations become increasingly important as we age, particularly for adults with risk factors such as a family history of hearing loss, cardiovascular disease, diabetes, significant noise exposure, use of ototoxic medications, or conditions such as Ménière’s disease, otosclerosis, or meningitis. 

Another commonly overlooked symptom is listening fatigue. 

Many people assume they are simply getting older, becoming more introverted, or feeling more tired than they used to. In reality, untreated hearing loss forces the brain to work harder to fill in missing sounds, use context clues, and separate speech from background noise. That extra effort can be exhausting. 

In my experience, one of the first benefits many patients notice after treating their hearing loss is reduced listening fatigue and increased energy throughout the day.

Those in their 50’s should start scheduling annual hearing exams and being mindful of early signs of hearing loss, so that they can seek treatment sooner. 

Early identification and treatment often lead to better long-term outcomes and an easier adjustment to hearing aids if they become necessary.”

Treatment: what helps with age-related hearing loss

While age-related hearing loss cannot currently be reversed, effective treatments can improve communication, reduce listening effort, and enhance quality of life. Treatment typically focuses on amplification, communication strategies, and hearing rehabilitation.

Hearing aids

Hearing aids are the primary treatment for age-related hearing loss and one of the most effective tools available for improving communication. Modern devices do not simply make everything louder. Instead, they provide targeted amplification to the frequencies where hearing has declined (typically the high frequencies) while leaving sounds you hear well relatively unaffected.

Features such as directional microphones, noise reduction technology, rechargeable batteries, Bluetooth streaming, and smartphone connectivity can help users navigate the everyday situations where age-related hearing loss is most noticeable, including conversations, phone calls, and noisy environments.

Many adults with perceived mild-to-moderate hearing loss may also be candidates for over-the-counter (OTC) hearing aids, which became available following FDA rulemaking in 2022. However, prescription hearing aids fitted and verified by an audiologist using real-ear measurement remain the standard of care, particularly for moderate or greater hearing loss and for patients with more complex listening needs.

Cochlear implants

For adults with severe-to-profound hearing loss who do not receive adequate benefit from hearing aids, cochlear implants may be an option. Unlike hearing aids, which amplify sound, cochlear implants bypass damaged parts of the inner ear and directly stimulate the auditory nerve.

Cochlear implant candidacy has expanded significantly in recent years, allowing more adults with age-related hearing loss to qualify. An audiologist can determine whether a cochlear implant evaluation is appropriate.

Auditory rehabilitation and communication strategies

Hearing aids are often most effective when combined with auditory rehabilitation and communication strategies. These approaches help individuals maximize their hearing, improve communication confidence, and reduce listening fatigue.

Examples include speechreading (lipreading), choosing optimal seating and room positioning, reducing background noise when possible, and making direct communication requests such as, “Please face me when you speak.” Small adjustments like these can make conversations easier and improve day-to-day communication success.

When to seek an evaluation

Adults should consider a baseline hearing evaluation by age 50 and follow-up testing periodically thereafter, particularly if they have risk factors for hearing loss. Anyone who notices a change in hearing, tinnitus, or balance should schedule an evaluation promptly.

If you are over 60 and have not had your hearing assessed recently, a hearing evaluation is a simple step that can provide valuable information about your hearing health. Early identification and treatment are associated with better communication outcomes, easier hearing aid adaptation, and reduced listening effort.