See also: Articles on Music, Hearing Loss, and Hearing Devices 

 

As you read this website, keep in mind the following:

• People with hearing loss can differ in many ways.  

• ​Some information may be more similar to your situation. 

• Pick and choose the information most useful for you.

 

Music Therapy for Older Adults with Hearing Loss:

Considerations for Music Therapy Practice

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Introduction

Music may not sound 'normal' to individuals with hearing loss who use hearing devices like hearing aids (HAs) or cochlear implants (CIs). This page provides information for music therapists to help understand the impact of a hearing loss on music appreciation and music therapy.   

 

Topics covered on this page include:

• Prevalence of hearing loss in older adults

• Causes of presbycusis

• Common symptoms of presbycusis

• Common treatments for presbycusis

• Considerations for music therapists when working with older adults with presbycusis

• Differences in music perception between HAs and CIs

• Can older adults with hearing loss still enjoy music?

 

Presbycusis

Presbycusis or age-related hearing loss (ARHL) is gradual hearing loss in both ears due to aging; it is common among older adults. As people get older, the hair cells of the cochlea in the inner ear get damaged and gradually die, leading to presbycusis. This is a permanent change because the damaged hair cells do not grow back. Music therapists working with older adults are likely to encounter individuals with hearing loss. 

 

           

Q. How prevalent is presbycusis in older adults? 

A. The prevalence and degree of presbycusis increase with age, making it more common among older adults. 

• Nearly one-third of adults aged 65-74 and half of those aged 75+ have some degree of hearing loss. 

• Prevalence increases for older adults living in community nursing or assisted living facilities.

  • ​ 70-90% are estimated to have hearing loss.  

(Cohen-Mansfield & Taylor, 2004; U.S. Census Bureau, 2018)

The prevalence of hearing loss with age makes it likely that older adults served by music therapists may have hearing loss and use hearing devices. Therefore, music therapists can learn to provide effective strategies and accommodations for hearing loss to enhance older adults' therapeutic experiences.        

 

Q. What causes presbycusis?

A. There are many causes for presbycusis; most often it occurs due to changes in the following parts of the auditory pathway:

• Within the inner ear (most common) and along the nerve pathways to the brain (see Figure 1).

​​​

Figure 1. Anatomy of the Human Ear

 

Q. What are some symptoms of presbycusis? 

A. While each person's symptoms may vary, here are the most common symptoms: 

• Have difficulty hearing conversations in a quiet environment.

  • Experience difficulty hearing high-pitched sounds (e.g., women's or children's voices, "s" or "th" sound). The ability to hear low-pitched noises is usually affected to a lesser degree.

• Have even more trouble understanding conversations in noisy or reverberant places. 

  • ​Background noise may include background music. 

• Have trouble understanding conversations over the telephone. 

• Perceive certain sounds such as loud sounds or background sounds as overly loud and annoying.

• May develop tinnitus (a ringing, buzzing, or hissing sound) in one or both ears.

• Tend to rely on lip leading. 

• May practice 'social bluffing,' or pretending to hear or understand something that is being said (e.g., nodding, smiling, saying “ok”).

 

Q. What hearing devices are common among older adults with hearing loss?

A. Hearing devices do not cure hearing loss. They provide greater access to sound. 

• Hearing aids (HAs) are the primary intervention for presbycusis. 

  • A hearing aid is an externally worn device that amplifies acoustic sounds through the ear canal to the brain.

  • For more information on hearing aids, click here.

• Cochlear implants (CIs) can be an option for adults with more severe hearing loss who do not obtain significant benefits from hearing aids.

  • A cochlear implant has a surgically implanted electrode array, plus an externally worn sound processor, and a microphone. It is digitally transmitted via electrical stimulation to the auditory nerve. The electrical stimulation is not a replica of musical pitch or timbre.

  • For more information about cochlear implants, click here. 

Depending on the severity and type of loss, an older adult with presbycusis may be:

• Unilateral (one HA or CI) user

• Bilateral (two CIs or HAs) user

• Bimodal (one HA and one CI) user (most common)

 

Q. What are some important considerations when music therapy clients have hearing loss? 

A. Take into account 1) the individual (patients/clients), 2) hearing profiles, 3) sensory input, and 4) listening environment (See figure 2). 

Figure 2. Factors that affect music appreciation and therapeutic interactions

• Individual:​

  • People differ in how well they cope with hearing loss.

    • People who normally cope well may have more difficulty if they are tired or frustrated.

  • People differ in experiences with music prior to hearing loss. 

• Hearing Profiles: 

  • People vary greatly in how severe their hearing loss is, and how it affects music AND speech.

    • Most people have some degree of residual hearing or remaining natural hearing. 

    • Greater remaining natural hearing (residual hearing) helps with music perception and sound quality. 

  • Some people who have mild to moderate hearing losses have more residual hearing and get more benefits from wearing HAs. 

    • Many persons with hearing loss do not use HAs or do so inconsistently. Research shows the best outcomes from consistent, daily use of hearing devices. 

  • Some with more severe or profound hearing losses rely on CIs.

  • HAs and CIs do not convey sound the same way.

  • HAs and CIs do not “cure” hearing loss or restore hearing. 

  • Most CI users use a hearing aid in the opposite ear; this is called bimodal hearing. 

• Sensory Input: 

  • Hearing devices convey some parts of music or types of music better than others.

  • Music that has more complex parts tends to be less enjoyable.

  • Music in the background can interfere with spoken communication. 

  • For more information about how different musical sounds affect listening enjoyment, click here.

• Listening Environment:

  • Music sounds better in a quiet listening environment than in noise.

    • Music is likely to sound better in a non-reverberant space. 

  • For more information about how the listening environment impacts music perception, click here.

(Gfeller, Darrow, & Wilhelm, 2018)

 

 

The table below shows the basic differences between hearing aids and cochlear implants.

Table 1. Comparison of Hearing Aids and Cochlear Implants

	Hearing Aid	Cochlear Implant
Candidates/Population	Effective for those with mild-to-profound hearing losses who understand speech if presented loud enough.	Effective for those with severe-to-profound hearing losses and who cannot understand speech even when presented loudly.
Function	Amplifies the sound that is delivered to the ear. Receives sound through a microphone, which converts the soundwaves to an electrical signal and sends them to an amplifier. The amplifier increases the power of the signals and then sends them to the ear through a speaker.	Does not amplify sound. Bypasses the damaged hair cells in the cochlea and directly stimulate the auditory nerve using electrical current.
Battery	Battery required. Battery types can be disposable or rechargeable. A battery serves as the power source for a hearing aid.	Most CIs are powered by either disposable or rechargeable batteries. A battery serves as the power source for the external processor.
Benefits	May improve speech understanding in quiet environments. Provides better access to low-frequency sounds.	Provides good speech understanding in quiet listening conditions. Can hear higher frequency sounds.
Limitations	Does not cure hearing loss or restore hearing.  Amplifies some frequencies more than others, especially those beneficial to speech recognition.  Can make all sounds, including background noise and undesired sounds, louder; cause difficulty understanding speech in noise. Can produce a whistling sound (feedback). Can cause sounds, including own voice, to sound too louder at first. Necessitates greater reliance on lip-reading.	Does not cure hearing loss or restore hearing.  Performs poorly in recognizing speech in background noise or competing talkers. Access to the lower frequencies below 250 Hz is limited. Many CI users report that the perception of sounds becomes “mechanical” or “raspy” and less aesthetic. Necessitates lesser reliance on lipreading.
Outcome	Success with a HA is individual and unpredictable.	Success with a CI is individual and unpredictable.
Timing	Generally, it takes approximately two weeks or less for the user to adapt to hearing aids.	Generally, it takes approximately 6 to 12+ months for the recipient to adapt to cochlear implants.

(Gfeller et al., 2000; 2010; Leek et al., 2008; Turner et al., 2004; Uys & Van Dijk,  2011; Wilson, 2000)

 

Q. What does music sound like with hearing assistance? 

A. Both HAs and CIs are designed primarily for the transmission of sounds related to speech, not for the sounds of music, although hearing programs for music do exist.

• Click here to learn more about how signal processing used in HAs plays a role in music perception for HA users.

• Click here to learn more about the complexities of musical elements with CI technology, on CI and music processing. 

 

The table below shows some differences in music perception in those with HAs and compared to those with CIs.  

Table 2. Comparing Music Perception between HA and CI Users

	Hearing Aid	Cochlear Implant
Overall Music Sound Quality	Music sounds more natural through a HA than a CI when there is some residual (preserved) hearing. Music tends to sound fuller and more natural to HA users with more residual hearing. HA provides a reasonable replica of structural features of music, though the sound quality is likely to suffer or be distorted. Musical beauty varies considerably depending on the listening environment, the HA user's level of residual hearing, and the sound characteristics of the performance or recording.	Music tends to sound better for hybrid CI users who have more preserved low-frequency residual hearing. Compared to reports from people with normal hearing, the overall quality of musical sound through CIs is reported as less pleasant or even unpleasant. Music may sound like noise or buzzing, but some aspects of music may sound more enjoyable. Music tends to sound more full and more natural for CI users with good residual hearing in the non-implanted ear.
Duration (Rhythm, Tempo, Meter, Beat)	Rhythm or beat is the aspect of music most effectively conveyed through a HA.	Rhythm or beat is the aspect of music most effectively conveyed through a CI. CI users typically perceive rhythm as accurately as people with normal hearing when those patterns are simple and at moderate rates.
Pitch Elements (Pitch, Melody, Range, Direction, Harmony)	Conveys pitch, but some sounds may be distorted or unnatural.  Is less effective at amplifying the wider range of frequencies that music produces, compared to the narrower range of frequencies in speech.  Is least effective in conveying melody. HA users report difficulty perceiving small pitch changes. Tend to perform much better than CI users on melody recognition and pitch discrimination.	Has poor conveyance of a wide range of pitches (high and low frequencies).  Individual notes and melodies may sound unclear. Harmonic structures, melodies, and chords may sound distorted. CI users report difficulty discerning distinct pitch and melodic contour (the sound of notes going higher and lower).
Timbre (Tone Quality)	Can discriminate musical instrument timbres, though less effectively than people with normal hearing; difficulty processing rapid changes and subtleties in timbre. Tend to perform much better than CI users on instrument identification.	Limits discriminating different musical instrument timbres. Shows greater ability to identify percussive instruments (e.g., piano) than woodwind or brass instruments. Conveys subtle and distinct timbre of instruments or singing voices poorly.
Dynamics	Provides limited dynamic range.  Loud music may cause distortion.  Conveys rapid changes in dynamics poorly.	Provides limited dynamic range which can reduce the effectiveness of music. Loud music may cause distortion.
Lyrics	Lyrics can be difficult to understand, especially against background accompaniment. HA users may understand the lyrics better with decreased intensity of the accompanying musical instrument.	Lyrics can be difficult to understand against background accompaniment. CI users may understand the lyrics of a song better with familiar songs and with relatively soft accompaniment.
Musical Form (Complexity, Texture)	Has difficulty processing rapidly changing, complex, or very loud musical sounds (e.g., music by large ensembles, music with many competing rhythms or melodies). Music may sound distorted, or some parts being left out, which in turn causes a lack of clarity.	Has difficulty processing rapidly changing, complex, or very loud musical sounds (e.g., music by large ensembles, music with many competing rhythms or melodies).
Instrumentation	Some instruments sound noisier or more unnatural than others.	Some voices or instruments sound very distorted or harsh. Some sound less or more pleasant than others.
Outcome	Music perception and music enjoyment vary significantly among CI users.	CI recipients using the same type of CI vary considerably on how well they perceive or enjoy music.

(Fletcher, 2021; Gfeller et al., 1998; 2001; Gfeller & Lansing, 1991; 1992; Madsen & Moore, 2014; McDermott, 2004)

 

For me, music is pleasant when I know the song and lyrics and only when one or two instruments are playing. (A CI user).

My CI tends to distort higher pitched instruments and I find that violins, oboe, piccolo and higher pitched instruments very difficult to listen to. (A CI user).

 

Q. Can older adults with hearing loss still enjoy music?

A. Yes. Despite these difficulties, older adults still report that music is an important part of their lives (Creech et al., 2013). Depending on the degree and type of hearing loss, certain elements of music may still be pleasant (e.g. rhythm), although this varies from person to person. Thus, music can still be a powerful and meaningful therapeutic medium for older adults, including those with hearing loss.

 

Click the link below for clinical suggestions for optimizing the effectiveness of music and communication during music therapy:

• Strategies and accommodations to enhance musical and verbal communication

 

 

References

Cohen-Mansfield, J., & Taylor, J. W. (2004). Hearing aid use in nursing homes. Part 1: Prevalence rates of hearing impairment and hearing aid use. The Journal of Post-Acute and Long-Term Care Medicine, 5(5), 283–288.

Gfeller, K., & Lansing, C. R. (1991). Melodic, rhythmic, and timbral perception of adult cochlear implant users. Journal of Speech & Hearing Research, 34(4), 916–920. https://doi.org/10.1044/jshr.3404.916

Gfeller, K., & Lansing, C. (1992). Musical perception of cochlear implant users as measured by the Primary Measures of Music Audiation: an item analysis. Journal of Music Therapy, 29(1), 18-39.

Gfeller, K., Knutson, J. F., Woodworth, G., Witt, S., & DeBus, B. (1998). Timbral recognition and appraisal by adult cochlear implant users and by normal-hearing adults. Journal of the American Academy of Audiology, 9(1), 1–19.

Gfeller, K., Christ, A., Knutson, J. F., Witt, S., Murray, K.T., & Tyler, R. S. (2000). Musical backgrounds, listening habits, and aesthetic enjoyment of adult cochlear implant recipients. Journal of the American Academy of Audiology, 11, 390-406.

Gfeller, K., Mehr, M., & Witt, S. (2001). Aural rehabilitation of music perception and enjoyment of adult cochlear implant users. Journal of the Academy for Rehabilitative Audiology, 34(17), 27.

Gfeller, K., Jiang, D., Oleson, J. J., Driscoll, V., & Knutson, J. F. (2010). Temporal stability of music perception and appraisal scores of adult cochlear implant recipients. Journal of the American Academy of Audiology, 21(01), 028-034.

Gfeller, K. E., Darrow, A. A., & Wilhelm, L. A. (2018). Music therapy for persons with sensory loss. In A. Knight, B. LaGasse, and A. Clair (Eds.), Music therapy: An introduction to the profession (pp.217–245). Silver Spring, MD: American Music Therapy Association.

Hearing Loss Association of America. (n.d.). Hearing Loss Facts and Statistics. https://www.hearingloss.org/wp-content/uploads/HLAA_HearingLoss_Facts_Statistics.pdf?pdf=FactStats

Leek, M. R., Molis, M. R., Kubli, L. R., & Tufts, J. B. (2008). Enjoyment of music by elderly hearing-impaired listeners. Journal of the American Academy of Audiology, 19(6), 519-526.

Madsen, S. M., & Moore, B. C. (2014). Music and hearing aids. Trends in Hearing, 18, 2331216514558271.

McDermott, H. J. (2004). Music perception with cochlear implants: a review. Trends in amplification, 8(2), 49-82.

National Institute on Deafness and Other Communication Disorders. (2021). Quick Statistics About Hearing. https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing

U.S. Census Bureau. (2018). Summary health statistics: national health interview survey, 2018. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_A...

Uys, M., & Van Dijk, C. A. (2011). Development of a music perception test for adult hearing-aid users.

Wilson, B. S. (2000). Cochlear implant technology. Cochlear implants: Principles and practices, 109-118.

 

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