About one in three adults between 65 and 74, and roughly half of those 75 and older, has hearing loss significant enough to affect daily life, according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Presbycusis – age-related sensorineural hearing loss – is the most common cause, and unlike many conditions of aging, it has long been undertreated: only a minority of older adults who could benefit from hearing aids actually use them. The 2022 arrival of FDA-regulated over-the-counter hearing aids has begun to change access dramatically.
What Presbycusis Is
Presbycusis is gradual, bilateral, sensorineural hearing loss that results from age-related changes in the inner ear (cochlear hair cells), the auditory nerve, and the central auditory pathways. The classic pattern is high-frequency hearing loss first – affecting consonant sounds like s, f, sh, th, and t – which makes speech sound muffled or as though others are mumbling, even when the person can tell that someone is talking.
The loss typically develops over years and is often noticed first by family members (“Why is the TV so loud?”) rather than by the person themselves. Background noise – restaurants, family gatherings – magnifies the difficulty disproportionately. Tinnitus (ringing or buzzing in the ears) accompanies hearing loss in many cases. Because the onset is slow, people frequently adapt without realizing how much they are missing, which is one reason routine screening matters.
Causes and Risk Factors
Age is the dominant factor, but several modifiable contributors accelerate the process. Lifetime noise exposure (occupational noise, recreational noise, firearms, loud music) damages cochlear hair cells cumulatively. Ototoxic medications include certain antibiotics (aminoglycosides), platinum-based chemotherapy agents, high-dose loop diuretics, high doses of NSAIDs, and aspirin in toxic amounts – never stop a prescribed medication over hearing concerns without talking to your clinician.
Cardiovascular risk factors – hypertension, diabetes, smoking, and high cholesterol – affect cochlear blood supply and may worsen hearing loss. Genetic predisposition plays a role. Less often, an evaluation uncovers a contributing cause such as cerumen (earwax) impaction (a treatable mimic), Meniere’s disease, otosclerosis, acoustic neuroma, or autoimmune inner ear disease. Identifying these matters because some are treatable or need specific management.
Why Untreated Hearing Loss Matters
Hearing loss is not just an inconvenience. Untreated hearing loss is associated with social isolation, depression, a higher risk of falls, and faster cognitive decline. The Lancet Commission on dementia prevention has identified hearing loss as one of the largest potentially modifiable risk factors for dementia across the life course; its estimates suggest addressing hearing loss could, in theory, reduce a meaningful share of dementia cases at the population level. These are associations and modeled estimates rather than proof that treating one person’s hearing will prevent dementia, so the finding should be read as encouraging but not a guarantee.
The 2023 ACHIEVE trial, published in The Lancet, found that a hearing intervention slowed cognitive decline in a subgroup of older adults at increased dementia risk over three years, though the effect was not significant across the whole study population. This has still shifted the framing among clinicians: addressing presbycusis is increasingly viewed as part of brain health, not only ear health.
How Presbycusis Is Diagnosed
Diagnosis begins with hearing screening – many primary care offices use a brief whisper test or screening audiometry. Formal evaluation by an audiologist includes pure-tone audiometry (the booth test that generates an audiogram), speech audiometry (word recognition in quiet and in noise), and tympanometry (middle ear function).
The audiogram plots hearing thresholds (in decibels) across frequencies. As a general reference, normal hearing is roughly 0-25 dB; mild loss about 26-40 dB; moderate 41-55 dB; moderately severe 56-70 dB; severe 71-90 dB; and profound above 90 dB. Presbycusis typically shows symmetric, sloping high-frequency loss. Asymmetric findings, sudden hearing loss, or pulsatile tinnitus warrant ENT evaluation and possibly imaging, because they can signal a different, sometimes serious, cause.
Hearing Aids: Over-the-Counter and Prescription
Modern hearing aids are sophisticated digital devices that amplify selectively across frequencies, suppress noise, and connect wirelessly to phones and TVs. Styles include behind-the-ear (BTE), receiver-in-canal (RIC), in-the-ear (ITE), and completely-in-canal (CIC). Bluetooth-enabled, rechargeable, and increasingly software-driven devices are now common.
The key access change: the FDA’s over-the-counter hearing aid category took effect on October 17, 2022. OTC hearing aids are intended for adults 18 and older with perceived mild-to-moderate hearing loss, and they can be bought directly – in stores or online – without a medical exam, prescription, or audiologist fitting. This has substantially lowered cost and access barriers: OTC devices commonly range from a few hundred to around a thousand-plus dollars, well below the several thousand dollars often charged for a professionally fitted prescription pair. Established OTC and direct-to-consumer brands include Lexie, Jabra Enhance, Sony, and Eargo, among others.
OTC devices are not appropriate for severe or profound hearing loss, for children, or when “red flag” signs are present (such as sudden hearing loss, ear pain, drainage, or one-sided loss) – FDA labeling directs people with those signs to seek medical care. For moderate-to-severe or complex losses, prescription hearing aids fitted by an audiologist remain the standard, because they can be programmed precisely to your audiogram and provide more power and support. Whichever path you consider, a hearing test is the sensible starting point.
Insurance and Cost Considerations
Original Medicare does not cover routine hearing aids or the exams for fitting them – a longstanding source of frustration for older adults – so you pay the full cost yourself under traditional Medicare. Many Medicare Advantage (Part C) plans include a hearing benefit, often with a per-device or per-pair allowance; check your specific plan. Some Medicaid programs cover hearing aids, with eligibility varying by state. The Department of Veterans Affairs covers hearing aids for eligible veterans, often at no cost. Costco’s hearing aid program is widely used and typically less expensive than traditional retail.
Out-of-pocket cost for prescription hearing aids commonly runs from about $1,000 to $3,500 per device, and two are usually needed; many providers bundle the device with fitting, follow-up, and adjustments. The 2022 OTC category and direct-to-consumer brands have changed the affordability calculus considerably. Prices vary widely by device and provider, so confirm current pricing before buying. For broader cost context, see our healthcare costs guide.
Beyond Hearing Aids: Cochlear Implants and Assistive Devices
For severe-to-profound hearing loss that hearing aids no longer help adequately, cochlear implants bypass damaged hair cells by directly stimulating the auditory nerve. Adult candidacy criteria have expanded, and many older adults with significant presbycusis qualify; Medicare covers cochlear implantation for candidates who meet its criteria (this is distinct from routine hearing aids, which Original Medicare does not cover).
Assistive listening devices include amplified telephones, captioned phones (free for qualifying users through state programs), TV listening systems, FM/remote-microphone systems for classrooms or theaters, and hearing loops in many public venues. Smartphone apps, live-captioning features, and visual alerting systems further support communication and can complement hearing aids.
Communication Strategies for Family
Communicating with someone who has hearing loss takes more than volume. Get the person’s attention before speaking, face them directly, speak clearly without exaggerating, reduce background noise (turn off the TV, choose quieter restaurants, sit away from windows and noisy kitchens), rephrase rather than simply repeat when you are not understood, and use written notes for complex information.
Avoid showing frustration – it shuts down communication. Be patient with what feels like repetition; missed speech is a hearing problem, not a memory problem. For an older adult who also has cognitive concerns, see our caring for someone with dementia guide – untreated hearing loss can compound dementia symptoms and make assessment harder.
When to See a Doctor
Talk to your primary care provider or an audiologist if you notice consistently turning the TV up, asking others to repeat themselves, struggling in restaurants, withdrawing from conversations, or family members commenting on your hearing. Periodic hearing screening – for example, as part of the Medicare Annual Wellness Visit – is reasonable for adults 65 and older. Pair hearing concerns with vision concerns – see our presbyopia guide – since both often develop together.
When to seek urgent or emergency care: Contact your clinician promptly, or go to urgent care or the ER, for sudden hearing loss (over hours to days), sudden severe vertigo, severe ear pain or drainage with fever, hearing loss with neurologic symptoms (facial weakness, severe headache, visual changes), or pulsatile tinnitus. Sudden sensorineural hearing loss is a medical emergency – prompt evaluation and, when appropriate, steroid treatment (often within about 72 hours) can improve the chance of recovery, so do not wait.
Frequently Asked Questions
Are over-the-counter hearing aids as good as prescription ones?
For perceived mild-to-moderate hearing loss in adults, modern OTC devices can be effective and are substantially less expensive. For moderate-to-severe loss, asymmetric loss, or complex hearing needs, professional audiologic evaluation and prescription devices typically perform better because they are custom-programmed. Either path benefits from starting with a hearing test.
When did OTC hearing aids become available?
The FDA’s OTC hearing aid category took effect on October 17, 2022. It allows adults 18 and older with perceived mild-to-moderate hearing loss to buy hearing aids directly, without a prescription, medical exam, or audiologist fitting.
Do hearing aids slow cognitive decline?
The evidence is promising but not definitive. The 2023 ACHIEVE trial found slower cognitive decline in a higher-risk subgroup using a hearing intervention, though not across the whole study population. Hearing loss is considered a major modifiable dementia risk factor, but treating hearing is not a guaranteed way to prevent dementia. It is still worthwhile for hearing, safety, and quality of life.
Why doesn’t Medicare cover hearing aids?
Original Medicare’s exclusions trace to its 1965 enabling legislation, which left out hearing aids, eyeglasses, and routine dental care; it also does not cover exams for fitting hearing aids. Some Medicare Advantage plans include a hearing benefit. Legislative efforts to add hearing aid coverage to Original Medicare have not yet become law.
How long do hearing aids last?
A typical hearing aid lasts about 5-7 years with good care. Daily cleaning, periodic professional service, battery or charging management, and protection from moisture all extend its life. Replacement cycles often align with insurance or benefit timelines.
The Bottom Line
Presbycusis is common, important, and increasingly treatable. Get a baseline hearing test in your 60s and repeat as needed; address hearing loss early rather than waiting until isolation or cognitive concerns develop; and consider OTC hearing aids – available since October 2022 for adults with perceived mild-to-moderate loss – if traditional cost barriers have kept you out of treatment. For more significant loss, an audiologist and prescription devices (and, in select cases, a cochlear implant) remain the right path. Hearing loss is a brain-health and quality-of-life issue, not just an ear issue – and the evidence supporting early intervention keeps growing.
Medical disclaimer: This article is for general education only and is not medical advice. It cannot diagnose your hearing loss or tell you which device is right for you. See an audiologist or physician for a hearing evaluation, and seek prompt medical care for sudden hearing loss, severe vertigo, ear pain or drainage with fever, one-sided or pulsatile tinnitus, or hearing loss with neurologic symptoms – sudden sensorineural hearing loss is a medical emergency. Do not stop or change any prescribed medication over hearing concerns without talking to your clinician. Verify current device options, coverage, and prices directly with the manufacturer, your audiologist, and your plan.
Sources
- National Institute on Deafness and Other Communication Disorders (NIDCD, NIH) – “Age-Related Hearing Loss (Presbycusis)” (nidcd.nih.gov)
- U.S. Food and Drug Administration – “OTC Hearing Aids: What You Should Know”; OTC hearing aid rule effective October 17, 2022, for adults 18+ with perceived mild-to-moderate hearing loss (fda.gov)
- Medicare.gov – Original Medicare does not cover hearing aids or exams for fitting hearing aids; cochlear implant coverage for qualifying candidates (medicare.gov)
- Lancet Commission on dementia prevention, intervention, and care (2020; 2024 update) and the ACHIEVE trial, The Lancet (2023)