A new edition of the book that guides Australian GPs in preventive practise has scrapped a previous recommendation for hearing screening every 12 months in people aged over 65 in favour of opportunistic assessment in specific populations.
The 10th edition of the RACGP Red Book states “screening for hearing loss is generally not recommended in asymptomatic adults aged 50 or over,” based on the US Preventive Services Task Force recommendation statement.
Instead, its new recommendation, based on current evidence for those over 50, is for doctors to do opportunistic assessment of hearing in patients who present with conditions that may be associated with hearing loss.
These include children with speech or behavioural concerns, chronic ear infections or glue ear, and adults with perceived hearing loss or concerns. It states it is important to assess hearing in these individuals.
Other specific populations at greater risk of hearing loss, also appropriate for opportunistic screening, include older people, people who work in loud environments, those who listen to loud music and use headphones for music or gaming, First Nations children, Aboriginal and Torres Strait Islander people, patients with a family history of hearing loss and people from refugee-like backgrounds.
“In Australia, rates of chronic suppurative otitis media and cholesteatoma are much higher in the adult refugee population than in the broader Australian population,” the book states. “In addition, refugee children and adolescents may have missed screening for hearing problems.”
The Royal Australian College of GPs (RACGP) launched the 10th edition of its “Red Book” Guidelines for preventive activities in general practice for GPs on 28 June 2024.
It says audiometry is best practice for a thorough assessment in these groups but hearing loss can also be assessed through single-question screening, asking ‘Do you have difficulty with your hearing?’ or longer patient questionnaires such as the hearing handicap inventory screening HHIE questionnaire for the elderly.
“Hearing assessments such as whispered voice and finger rub are no longer recommended because results can be variable as they are user-dependent,” it says.
Dementia, hearing loss and hearing aids
The book broaches dementia, hearing loss and hearing aids in a section on risk reduction interventions for cognitive decline and dementia, stating, “there is insufficient evidence to recommend the use of hearing aids to reduce the risk of cognitive decline and/or dementia”.
But it adds: “It is important for dementia patients and their carers to understand that there is a problem with cognition that needs management, and the concept of secondary prevention (ie slowing the progression of the disease) can then be introduced (eg smoking cessation, correction of hearing impairment, optimal management of other cardiac risk factors, diet and exercise). “
A new addition to the book states general population screening for dementia is strongly not recommended. But it adds “hearing loss is a risk factor associated with dementia” and “screening followed by provision of hearing aids should be offered to older people for timely identification and management of hearing loss”.
Other recommendations re-stated from the 9th edition include that:
- all newborns should have universal hearing screening and GPs should ensure parents of newborn infants are aware of the universal neonatal hearing screening program in their relevant state and territory and have had their newborn screened for congenital hearing impairment.
- non-pharmacological approaches to the prevention of falls in older adults should include managing hearing impairment and referring for audiology assessment.
- additional time may be needed for Aboriginal and Torres Strait Islander women’s first antenatal visit if they have hearing impairment requiring the use of Auslan.
The book says although the prevalence of hearing loss tends to increase with age, it can affect people of all ages, with significant consequences on the physical, functional and mental health of the individual.
It says causes include age-related hearing loss; exposure to loud environments, including occupational environments (eg construction sites, concert venues, bars, nightclubs); congenital or early onset childhood hearing loss; complications from diseases such as measles, meningitis, rubella and mumps; genetics; ototoxic drugs that damage the inner ear and smoking.
“GPs are well placed to detect, diagnose and provide advice to help prevent hearing loss,” the book states.
It recommends that to help prevent hearing damage GPs advise patients to avoid loud or sustained excessive noise, use hearing protection in high-noise environments, use volume controls for personal devices as necessary and avoid children being exposed to cigarette smoke.
High rates of persistent otitis media in infancy and childhood are associated with hearing loss across the life course for Aboriginal and Torres Strait Islander people and it advises GPs to refer to specific recommendations in the RACGP’s National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.
It says vaccinations which may reduce incidence of acute otitis media and/or acquired hearing loss include annual influenza vaccination (inactivated virus) in anyone aged six months or over; rubella, measles, Haemophilus influenzae type b and meningococcus in children younger than 15 years; and pneumococcal conjugate vaccination (13vPCV) during infancy.
Preventive activities for pregnant women include offering testing for rubella immunity and syphilis serology to prevent infections that may lead to congenital hearing loss, it adds.
The new edition builds on its long history of guiding preventive activities in general practice and includes recommendations on evidence-based screening, prevention of chronic disease, early detection of disease and empowering patients through health education and promotion.
Professor Danielle Mazza AM, RACGP Red Book Chair and Head of the Department of General Practice at Monash University, said a new more rigorous approach was used in the development of the new edition and the format redesigned to make information more accessible.
“The Red Book is the key resource for preventive healthcare in general practice,” she said. “In developing this new edition, we have used a clearer more consistent format so GPs can quickly access and review best practice advice on a wider range of conditions.”
This included adopting the new internationally recognised GRADE framework and rigorously reviewing all topics to ensure they were consistent, concise, evidence-based and implementable. This involved adopting or adapting existing recommendations from high-quality guidelines where possible (a meta-guideline approach) rather than the previous version where a team of GPs and experts used the NHMRC FORM framework.
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