This older patient should be evaluated for hearing loss with the whispered voice test. Hearing loss is common in older adults, and it results in significant impairment in quality of life and potentially leads to depression and social isolation. Because patients may experience difficulties in understanding and communication, hearing loss is frequently misdiagnosed as cognitive dysfunction. There is some evidence that hearing aids in older patients improve not only hearing but also quality of life; therefore, patients who have cognitive or affective concerns that may be related to hearing should be screened for hearing loss. No one screening test has been shown to be superior to another. Whispered voice test, finger rub test, hearing loss questionnaire, and hand-held audiometry are all reasonable screening tests. Many patients with significant hearing loss deny any hearing deficits and can compensate for their hearing loss in a quiet office environment; therefore, a patient's perception of his or her own hearing or the patient's ability to carry on a normal conversation in the office setting should not be considered as evidence of adequate hearing. Patients who test positive or who report hearing loss should be referred for formal audiologic testing and consideration of amplification with hearing aids.
This patient has stable mild cognitive dysfunction that is not interfering with his executive functioning. His social functioning is impaired, but hearing loss has not been ruled out as the cause of his social impairment. As such, medication for dementia, such as donepezil, is not currently indicated.
Social isolation is a symptom of depression; however, this patient was appropriately screened with the two-question method (“During the past month, have you been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you been bothered by little interest or pleasure in doing things?”), which has a 97% sensitivity for identifying depression in older adults. A more extensive screen for depression, such as the PHQ-9, is not likely to add helpful information in this patient.
A diagnosis of hearing loss and its correction would be missed with clinical observation alone.