Evidence-based referral criteria for cochlear implants in adults

The 60/60 guideline is a simple screening rule to help identify adults who may benefit from referral for a cochlear implant evaluation. In a study of 529 adults, the guideline identified the majority of individuals who were later confirmed as cochlear implant candidates through comprehensive assessment.

Consider referral for a cochlear implant evaluation when both of the following are present:

Pure-tone average (PTA3) of 60 dB HL or greater in the better ear
Word recognition score of 60% or less in the same ear.

Zwolan TA, Schvartz-Leyzac KC, Pleasant T. Development of a 60/60 Guideline for Referring Adults for a Traditional Cochlear Implant Candidacy Evaluation. Otol Neurotol. 2020 Aug;41(7):895-900.

Research summaries

Mental wellbeing

Shukla A, et al. 2020, Otolaryngology–head and neck surgery; 162(5):622-33.

Methodology

Systematic literature review to summarize the current state of the literature exploring the association between hearing loss and social isolation and/or loneliness.

Findings and Recommendations

Hearing loss may be a modifiable risk factor for loneliness and social isolation.
These psychosocial outcomes are linked to cognitive decline, mental health impact, and increased healthcare costs.
Future research should explore whether hearing interventions (e.g., hearing aids) can reduce these risks.

Bott A, et al. 2021, International Journal of Audiology; 60:30-46.

Methodology

Scoping review to map and evaluate the extent, range, and nature of research examining the relationship between hearing loss, social isolation, and loneliness in adults across the lifespan

Findings and recommendations

There is a link between hearing loss and social isolation
Hearing care professionals should be aware of the psychosocial impacts of hearing loss.
Screening for social isolation and loneliness may help identify at-risk individuals.
Collaboration with other healthcare providers is essential to address these issues holistically.

Golub, J. S. et.al.(2019). Association of Audiometric Age-Related Hearing Loss With Depressive Symptoms Among Hispanic Individuals. JAMA otolaryngology– head & neck surgery, 145(2), 132–139

Methodology

Cross-sectional study on 5,328 Hispanic adults to investigate whether objectively measured age-related hearing loss (HL) is associated with clinically significant depressive symptoms

Findings and recommendations

Hearing loss is a potentially modifiable risk factor for late-life mental health issues.
Early detection and treatment (e.g., hearing aids or cochlear implants) could help reduce mental health impact.
Particularly relevant for Hispanic populations, who may face barriers to mental health care and have higher prevalence.

Nachtegaal J, Smit JH, Smits C, et al. The association between hearing status and psychosocial health before the age of 70 years: results from an internet-based national survey on hearing. Ear Hear. 2009;30(3):302-312.

Methodology

Cross sectional cohort study of 1,511 patients

Findings and recommendations

Hearing loss is negatively associated with higher distress, mental health impact, somatization and loneliness in young and middle-aged adults.
The odds for developing moderate or severe mental health problems increases by 5% for everydB SNR reduction in hearing.
For each dB SNR reduction of hearing status both the distress and somatization scores increased by 2%.

Greenberg PE, et al. Pharmacoeconomics. 2021;39(6):653-665

Methodology
Combined original analyses and literature based estimates based on the national suvey of drug use and the Optum health administrative claim database to update costs of Major Depressive Disorder (MDD) for adults in USA for 2018

Findings and recommendations

Economic burden of MDD increased 37.9%, from $236.6 billion in 2010 to $326.2 billion in 2018.
Workplace costs were the largest component (61% of total), rising 73% to $198.6 billion.
Suicide-related costs increased by 22.8% to $13.4 billion.
Recommend to target workplace interventions to reduce absenteeism and presenteeism, as these drive most costs.
Improve access and quality of treatment, especially for younger adults and severely impaired individuals.

Bigelow RT, et al. JAMA Netw Open. 2020;3(7)e2010986.

Methodology
Cross sectional study on adults in USA using data from 2017 National Health Interview Survey, 25 665 adults included in analysis to investigate the association between HL, psychological distress, and mental health care utilization among adults in the United States.

Findings and recommendations

Hearing loss (HL) was significantly associated with psychological distress and the association between HL and psychological distress was stronger than that for many other health conditions (e.g., diabetes, hypertension).
Adults with moderate HL were 1.53 times more likely to seek mental health services compared to those without HL.
Consider hearing loss as a potential modifiable risk factor for psychological distress.
Hearing aids may reduce psychological distress in individuals with moderate HL.

Huber M, et al. Ear Hear. 2025; Published online September 15, 2025.

Methodology
Cohort study in two tertiary research centers of 61 adult patients indicated for CI in Austria and Germany to investigate whether an improvement in hearing after cochlear implantation (CI) was associated with changes in depression and cognitive performance

Findings and recommendations

Hearing ability (speech recognition and subjective hearing) improved significantly 12 months after CI.
Mental health scores decreased significantly; clinical depression cases reduced from 37% pre-CI to 17% post-CI.
CI effectively improves hearing and reduces mental health impact, regardless of age.

McIlhiney P, et al. Clin Otolaryngol. 2025;50(5):848-855.

Methodology

Controlled, observational study of 87 adults in three groups, 44 normal hearing, 26 fitted with CI and 17 with untreated hearing loss in Australia to examine how cochlear implantation affects depression, anxiety and stress levels.

Findings and recommendations

Cochlear implantation was associated with lower anxiety and stress scores at 12 months compared to untreated hearing loss.
Depression scores increased over time in both CI and HL groups, remaining higher than in the NH group.
Anxiety and stress scores in CI recipients were comparable to NH controls after 12 months, while HL group scores worsened.
Include mental health screening in cochlear implant candidacy and post-operative care to identify and address issues early.
Train audiologists in mental health literacy to improve counseling and referral practices for CI recipients.

Gerst-Emerson K, et al. Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. Am J Public Health. 2015;105(5):1013–1019.

Methodology

Health and Retirement Study (HRS) of 3,530 US community-dwelling adults aged 60+ to examine whether loneliness is associated with increased health care utilization

Findings and recommendations

Over 50% of older adults reported loneliness in both 2008 and 2012.
Chronic loneliness (lonely in both 2008 and 2012) was significantly associated with more physician visits
Loneliness is a significant and under-recognized public health issue.
Targeted interventions (e.g., social programs, community engagement, group therapy) could reduce loneliness and potentially lower health care costs.
Physicians and health care providers should be aware of loneliness as a factor influencing patient behavior and health care use.

Research summaries

Physical safety

Agmon M, Lavie L, Doumas M. The Association between Hearing Loss, Postural Control, and Mobility in Older Adults: A Systematic Review. Journal of the American Academy of Audiology. 2017;28(6):575-88.

Methodology

Systematic literature review to systematically review the evidence on the relationship between hearing loss (HL) and postural control/mobility in older adults

Findings and recommendations

Strong association between HL and impaired postural control and mobility across all seven reviewed studies.
Severity of HL correlated with greater mobility limitations and fall risk.
Hearing aid use improved balance in some cases (e.g., Romberg and tandem stance tests).
HL should be considered a risk factor for falls and mobility issues.
Early diagnosis and rehabilitation of both hearing and balance may improve quality of life and reduce fall risk.

Foster JL et al., Trends Hear. 2022;26:23312165221144155.

Methodology

Systematic review and meta-analysis on adults aged ≥60 years with hearing loss and objective measures of postural stability or gait. 27,847 across 25 studies in multiple countries

Findings and recommendations

Moderate-to-severe hearing impairment is significantly associated with poorer postural stability compared to normal hearing:
Mild hearing impairment showed minimal impact, with only slight reduction in gait speed.
Standing balance and gait variability worsen with increasing hearing impairment.
Screen older adults with moderate or greater hearing impairment for balance and falls risk.

Haddad YK, et al., Inj Prev. 2024; 30(4):272-276.

Methodology

Observational study using estimated health expenditures on 9,199 patients in USA

Findings and recommendations

Healthcare spending on non-fatal falls among older adults in 2020 was US$80 billion, significantly higher than previous estimates.
Falls were reported by 24.5% of older adults, with nearly half experiencing recurrent falls.
Expand fall prevention efforts in clinical and community settings to reduce healthcare costs and injuries.

Goman AM et al., Lancet Public Health. 2025;10(6):e492-e502

Methodology

Secondary analysis of the ACHIEVE randomized controlled trial on 977 adults aged 70-84 in USA

Findings and recommendations

Hearing intervention group had 27% fewer falls over 3 years
Reduction observed for injurious falls
Hearing interventions may help reduce fall risk among older adults with hearing loss.
Consider integrating hearing care into fall prevention strategies for older adults.

Louza J, et al. Audiol Neurotol. 2019;24(5):245-252

Methodology

Prospective clinical trial on 33 adults in Germany with CI assessing postural control.

Findings and recommendations

Activation of CI significantly reduced risk of falls
72% of patients showed improvement in fall risk with CI activation; 28% showed slight deterioration.
Effect was more pronounced in older patients (>60 years), with significant improvement across all sound conditions.
Music and speech input had the strongest positive influence on postural control.
Optimize hearing rehabilitation with cochlear implants to potentially reduce fall risk, especially in elderly patients with severe to profound hearing loss.

Research summaries

Cognitive decline

Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214-220. doi:10.1001/archneurol.2010.362

Methodology

Prospective cohort study of 639 dementia-free US participants aged 36–90 to investigate whether hearing loss is prospectively associated with the development of all-cause dementia and Alzheimer’s disease (AD) in older adults.

Findings and recommendations

Hearing loss is independently associated with increased risk of dementia.
Each 10 dB increase in hearing loss was associated with a 1.27-fold increased risk of dementia
Hearing loss may be a modifiable risk factor for dementia.
Early detection and rehabilitation (e.g., hearing aids, cochlear implants) could potentially delay or reduce dementia onset.
Further research is needed to confirm causality and evaluate the impact of hearing interventions.

Yu RC, Proctor D, Soni J, et al. Adult-onset hearing loss and incident cognitive impairment and dementia – A systematic review and meta-analysis of cohort studies. Ageing Res Rev. 2024;98:102346

Methodology

Systematic review and meta-analysis to comprehensively evaluate whether adult-onset hearing loss is associated with increased risk of cognitive impairment and dementia

Findings and recommendations

The findings support a consistent and robust association between adult-onset hearing loss and increased risk of cognitive impairment and dementia.
Evidence of a dose-response relationship strengthens the case for a potential causal link.
Hearing loss may be a modifiable risk factor for dementia.
Hearing interventions (e.g., hearing aids) could potentially reduce dementia risk, especially in high-risk populations.
The ACHIEVE trial showed a 48% reduction in cognitive decline in a high-risk subgroup receiving hearing aids.

Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024;404(10452):572-628.

Methodology

Synthesize findings from systematic reviews, meta-analyses, cohort studies, and RCT’s to update the 2020 report with new evidence on dementia prevention

Findings and recommendations

Key modifiable Risk Factors for dementia were identified
Early Life: Less education (PAF: 5%)
Midlife: Hearing loss (7%), High LDL cholesterol (7%), Depression (3%)
Late Life: Social isolation (5%), Air pollution (3%), Untreated vision loss (2%)
Hearing treatment reduce risk
Public health approach: address socioeconomic determinants.
Equity focus: prioritize interventions for underserved and high-risk groups.
Scalable interventions: education, air quality, smoking cessation, hearing and vision care.

Wimo A, Seeher K, Cataldi R, et al. The worldwide costs of dementia in 2019. Alzheimers Dement. 2023;19(7):2865-2873. doi:10.1002/alz.12901

Methodology

Leverage prevalence data from IHME and UN population datasets to estimate the global societal costs of dementia in 2019

Findings and recommendations

Total global cost: US $1313.4 billion for 55.2 million people with dementia.
Average cost per person: US $23,796.
Policy urgency: Need for national dementia plans, especially in LMICs.
Infrastructure challenge: LMICs must develop sustainable long-term care systems.
Gender dimension: ~70% of informal caregivers are women, with higher proportions in LMICs.
Future planning: Societies must prepare for rising dementia prevalence and associated costs.

Mukadam N, Anderson R, Knapp M, et al. Effective interventions for potentially modifiable risk factors for late-onset dementia: a costs and cost-effectiveness modelling study. Lancet Healthy Longev. 2020;1(1):e13-e20.

Methodology

Cost modelling study to evaluate the cost-effectiveness of interventions targeting nine modifiable risk factors for late-onset dementia

Findings and recommendations

Three interventions (hypertension, smoking, hearing loss) are cost-effective or cost-saving.
These interventions should be prioritized in public health strategies for dementia prevention.
Benefits extend beyond dementia to cardiovascular and general health.
Findings are generalizable to other countries, especially LMICs with higher prevalence of these risk factors.

Seo HW, Ryu S, Han SY, Lee SH, Chung JH. Cochlear Implantation Is Associated With Reduced Incidence of Dementia in Severe Hearing Loss. Ear Hear. 2025;46(5):1189-1196.

Methodology

Observational population study on 52,219 South Korean adults with severe hearing loss and 1,280,788 individuals with normal hearing to investigate whether auditory rehabilitation—specifically cochlear implants (CI) and hearing aids (HA)—reduces the long-term risk of dementia

Findings and recommendations

In adults with severe hearing loss, hearing aids reduced the risk for dementia by 27% while cochlear implants reduced the risk by 45% resulting in a similar risk as those with normal hearing.
Supports hypotheses that auditory rehabilitation reduces cognitive load and improves social interaction, potentially preventing cognitive decline.

Research summaries

Social isolation

Shukla A, et al. 2020, Otolaryngology–head and neck surgery; 162(5):622-33.

Methodology
Systematic literature review to summarize the current state of the literature exploring the association between hearing loss and social isolation and/or loneliness.

Findings and Recommendations

Hearing loss may be a modifiable risk factor for loneliness and social isolation.
These psychosocial outcomes are linked to cognitive decline, social isolation, and increased healthcare costs.
Future research should explore whether hearing interventions (e.g., hearing aids) can reduce these risks.

Bott A, et al. 2021, International Journal of Audiology; 60:30-46.

Methodology
Scoping review to map and evaluate the extent, range, and nature of research examining the relationship between hearing loss, social isolation, and loneliness in adults across the lifespan.

Findings and recommendations

There is a link between hearing loss and social isolation.
Hearing care professionals should be aware of the psychosocial impacts of hearing loss.
Screening for social isolation and loneliness may help identify at-risk individuals.
Collaboration with other healthcare providers is essential to address these issues holistically.

Golub, J. S. et.al.(2019). Association of Audiometric Age-Related Hearing Loss With Depressive Symptoms Among Hispanic Individuals. JAMA otolaryngology– head & neck surgery, 145(2), 132–139

Methodology
Cross-sectional study on 5,328 Hispanic adults to investigate whether objectively measured age-related hearing loss (HL) is associated with clinically significant social isolation symptoms in older Hispanic adults.

Findings and recommendations

Hearing loss is a potentially modifiable risk factor for late-life social isolation.
Early detection and treatment (e.g., hearing aids or cochlear implants) could help reduce social isolation symptoms.
Particularly relevant for Hispanic populations, who may face barriers to mental health care and have higher social isolation prevalence.

Methodology
Cross-sectional study on 925 working Dutch adults to investigate the relationship between hearing status and need for recovery after work and whether psychosocial work characteristics (job demands and job control) influence this relationship.

Findings and recommendations

Hearing-impaired employees experience a “double workload”: managing job tasks and compensating for hearing limitations leading to greater fatigue and higher recovery needs.
Audiological rehabilitation programs should address work-related fatigue.
Monitoring recovery needs could help prevent long-term health issues and sick leave.
Occupational health professionals should consider hearing loss as a factor when employees report high fatigue or recovery needs.

Ray J, et al. Association of cognition and age-related hearing impairment in the English Longitudinal Study of Ageing. JAMA Otolaryngol Head Neck Surg. 2018;144(10): 876–882.

Methodology
Cross-sectional analysis on 7,385 English adults to examine the link between age-related hearing impairment (ARHI) and cognitive decline in older adults in the UK

Findings and recommendations

Moderate to severe hearing loss was associated with a 1-point lower memory score and worse executive function in individuals who did not use hearing aids.
Among hearing aid users, no significant link was found between hearing loss and cognitive decline.
Hearing loss increased the odds of social isolation and increased further as the hearing loss was more severe.
Screening for hearing loss in adults over 50 is recommended.
Public health campaigns should promote hearing aid use and awareness.
Early intervention could reduce dementia risk.

Gerst-Emerson K, et al. Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. Am J Public Health. 2015;105(5):1013–1019.

Methodology
Health and Retirement Study (HRS) of 3,530 US community-dwelling adults aged 60+ to examine whether loneliness is associated with increased health care utilization

Findings and recommendations

Over 50% of older adults reported loneliness in both 2008 and 2012.
Chronic loneliness (lonely in both 2008 and 2012) was significantly associated with more physician visits
Loneliness is a significant and under-recognized public health issue.
Targeted interventions (e.g., social programs, community engagement, group therapy) could reduce loneliness and potentially lower health care costs.
Physicians and health care providers should be aware of loneliness as a factor influencing patient behavior and health care use.

Flowers L, Shaw J, Farid M. Medicare spends more on socially isolated older adults. Insight on the Issues. Nov 2017.

Methodology
Health and Retirement Study (HRS) of 5,270 US community-dwelling adults aged 65+ to investigate whether social isolation among older adults is associated with increased Medicare spending.

Findings and recommendations

Social isolation is a significant social determinant of health contributing to higher health care costs and poorer health outcomes.
Screening: Develop tools to identify socially isolated Medicare beneficiaries.
Interventions: Fund culturally competent programs to reduce isolation
Integration: Include social isolation in public health frameworks and Medicare wellness visits.
Awareness: Elevate social isolation as a public health priority.

Hori K, Shah R, Paladugu A, et al. Social Outcomes Among Adults With Hearing Aids and Cochlear Implants: A Systematic Review and Meta-Analysis. JAMA Otolaryngol Head Neck Surg. 2025;151(8):806-816. doi:10.1001/jamaoto.2025.1777

Methodology
Systematic literature review and meta-analysis to evaluate the impact of hearing rehabilitation devices

Findings and recommendations

Hearing aids and cochlear implants improve social engagement and reduce feelings of social handicap.
Cochlear implants showed greater benefits, possibly due to more severe baseline hearing loss and structured rehabilitation.
Longer duration of device use was linked to greater improvements in social outcomes.
Hearing rehabilitation should be encouraged to reduce social withdrawal and its downstream effects (e.g., social isolation, cognitive decline).
Improved social outcomes may contribute to better overall well-being and mental health.

Health conditions contributing to hearing loss

Potential health impact of untreated hearing loss

Evidence-based referral criteria for cochlear implants in adults

Health conditions contributing to hearing loss

Potential health impact of untreated hearing loss

Evidence-based referral criteria for cochlear implants in adults

Research summaries

Mental wellbeing

Research summaries

Heart failure

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Sleep apnea

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High cholesterol

Research summaries

High blood pressure

Research summaries

Physical safety

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Cognitive decline

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Employment

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Social isolation

Research summaries

Diabetes

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