Half of Older Adults With Hearing Loss Never Reach an Audiologist

A national analysis of more than 1.4 million Americans aged 65 and older finds that the steepest losses in hearing care happen at the very first steps of the journey, not at the operating room door.

Hearing loss is one of the most common chronic conditions of later life, and one of the most undertreated. Researchers have long known that only a minority of older adults who could benefit from hearing devices actually use them, but pinning down exactly where people drop out of the care system has been difficult.

A new study published in Otology & Neurotology Open takes on that question at unusual scale. Drawing on the records of nearly one and a half million older Americans with hearing loss in both ears, the research team traced each stage of the pathway, from a basic hearing evaluation all the way to cochlear implant surgery, and measured who moved forward and who did not.

Background: Why the Researchers Looked at This

Sensorineural hearing loss is the most common form of hearing loss in older adults. It arises when the delicate sensory cells of the inner ear, or the nerve that carries sound to the brain, become damaged, most often through aging and long-term noise exposure. When it affects both ears, everyday communication can become a daily struggle.

Treatment follows a stepped pathway. Most people start with an audiology evaluation, a professional hearing assessment. Those with mild to moderately severe loss are typically candidates for hearing aids. For people whose loss becomes severe to profound, a cochlear implant, a surgically placed device that stimulates the hearing nerve directly, can restore access to sound that hearing aids no longer provide.

Previous research has documented that cochlear implants are used by only a small fraction of the people who qualify for them. What has been less clear is where along the pathway people are lost. Is the problem getting in the door at all, being referred onward for specialist evaluation, or deciding against surgery at the end? The answer matters, because each bottleneck calls for a different fix.

How the Study Was Done

The researchers used Epic Cosmos, a de-identified database that pools electronic health records from health systems across the United States. They identified adults aged 65 and older who had diagnosis codes for sensorineural hearing loss in both ears between January 2021 and December 2024.

For each person, they checked whether the record showed three key milestones: an audiology evaluation, a cochlear implant candidacy evaluation, and cochlear implant surgery itself. They then calculated, stage by stage, the odds that different groups moved forward, comparing patients by age band, sex, race, rurality, and distance from a cochlear implant center.

Because the sample was so large, the team treated only very strong statistical signals as meaningful, flagging results below a probability threshold of one in a thousand as the most reliable findings.

What the Researchers Found

Of 1,461,489 older adults with hearing loss in both ears, 746,118, or 51.1 percent, had an audiology evaluation on record. In other words, nearly half never received even a baseline professional hearing assessment during the four-year study window.

The narrowing continued from there. Fewer than 2 percent of those evaluated went on to a cochlear implant candidacy assessment. Yet among people who did reach that assessment, roughly 64 percent proceeded to surgery. The pathway, in short, loses most people early; those who make it to the specialist stage usually follow through.

The pattern was not the same for everyone. Adults aged 85 and older were less likely to get an audiology evaluation and, even when evaluated for candidacy, less likely to receive an implant. Black and Asian patients had lower odds of reaching candidacy evaluation. Women were less likely to be evaluated for candidacy, but once evaluated, they were more likely than men to go on to implantation.

One result ran against expectations: patients living farther from an implant center, and those in rural areas, showed higher odds of candidacy evaluation and surgery. The authors caution that this likely reflects a selection effect. People willing to travel long distances for care are an unusually motivated group, so the finding says more about who overcomes barriers than about geography making access easier.

What It Means for People with Hearing Loss

The study reframes the access problem. The biggest losses do not happen when people weigh the decision about surgery; they happen much earlier, when hearing loss goes unevaluated and when candidates are never referred onward. The authors describe candidacy referral and evaluation as a critical and potentially fixable bottleneck for making hearing care more equitable.

For families, the practical message is that the first step counts the most. An older adult who mentions difficulty following conversation has, statistically, only an even chance of ever getting a formal hearing evaluation. Asking a primary care doctor directly about a hearing assessment, and about referral options if loss is significant, can move someone past the stage where most people stall.

Lowering the First Barrier to Better Hearing

Because this study highlights how many older adults never clear the first hurdle of a formal evaluation, it strengthens the case for lowering the entry cost of hearing help. That is exactly what FDA-OTC hearing aids were created to do for adults with mild to moderate loss: no referral chain, no appointment backlog, and a far lower price than traditional channels.

Panda Air is one example of this newer generation of self-fitting OTC hearing aids. It is an earbud-style device with 16-channel sound processing and adaptive noise reduction, and it works straight out of the box. An optional companion app can run a frequency-specific hearing check through the aid itself and tune the sound to your hearing profile, though the app is never required. As rechargeable hearing aids with a charging case go, it is built for low upkeep, with fast charging and 60 hours of total listening time per charged case, plus Bluetooth for calls, TV, and music, a 5-year warranty, and a 45-day trial that starts when the product arrives.

One caveat belongs alongside this study: OTC devices are approved for mild to moderate hearing loss. People with severe or profound loss, including the cochlear implant candidates this research followed, still benefit most from clinical evaluation and professionally fitted care. Details on the Air are at pandahearing.com/products/panda-air.

Limitations of This Research

The study relied on diagnosis and procedure codes in electronic health records, which can miss care delivered outside the participating health systems and cannot capture hearing aid use purchased privately or over the counter. The odds ratios were unadjusted, meaning the group comparisons were not corrected for other differences between patients, and a cross-sectional design cannot prove what caused the drop-offs it describes.

The authors declared no conflicts of interest.

Where This Leaves Us

A picture of hearing care in America emerges from this research in which the system loses half its patients before it has properly met them. Fixing referral bottlenecks will take changes inside clinics, but individuals do not have to wait for that: getting a hearing evaluation on the calendar, and asking directly about next steps, remains the single most effective move an older adult with hearing difficulty can make.

Patel PV, Gopal V, Patel D, Porter RG. Access and Attrition Across Audiology and Cochlear Implant Care Among Older Adults with Bilateral Sensorineural Hearing Loss. Otology & Neurotology Open. 2026;6(3):e096. Retrieved from PubMed. https://doi.org/10.1097/ONO.0000000000000096