Social Isolation, Loneliness, Auditory Deprivation, & The Ripple Effect)))

There is a reason why music creates a ripple effect that can be felt across all levels of care in senior living —freeing up staff members providing one on one care simply by exercising the physics of sound.

Like much of my research my greatest insights took place in the eldercare field. In 2015 four years before Covid-19 silenced many musicians from public performances, and social isolation became a household word, I saw an urgent need to provide music as an auditory stimulus to combat social isolation for those elders unable to ambulate to Community Activities due to physical and/or cognitive decline.  It was not just any auditory stimuli, it was the favorite music of the residents living across the continuum of care. 

As I walked the halls with my guitar strapped over my shoulder, singing their favorite songs, other residents would follow me into the rooms of those most isolated. A simple approach but one that had rarely been done. It was an ideal way to use sound organically to fill the hallways and rooms with an injection of joy and social connection, building community for elders and staff members .

Cognitive and physical decline pose additional risks of social isolation by reducing an elder’s ability to participate in group activities, often resulting in countless hours spent alone in their rooms. Television for a sedentary elder may seem like a harmless substitute to offset social isolation,  and provide stimuli when caregivers are unavailable, but recent studies suggest excessive television watching is linked to a greater risk of developing cognitive impairment. Maureen Salamom, Executive Editor of Harvard’s  Women's Health Watch explains; 

“Compared with people who watched TV for less than an hour each day, participants who reported watching four or more hours of TV daily had a 28% higher risk of dementia, a 35% greater risk of depression, and a 16% higher risk of Parkinson's disease.”

And it is loneliness and social isolation that pose the greatest threats to our elders' well being. Nancy J. Donovan, an associate psychiatrist at Brigham and Women’s Hospital and Harvard Medical School tells us;

“First, loneliness is a form of suffering in older people that is prevalent but undetected and untreated in medical practice,” she said. “Second, loneliness has consequences. Our work shows that loneliness, like depression, is associated with accelerated cognitive decline in older Americans. This finding is important because it opens up new approaches for preventing and treating Alzheimer’s disease.”

There is a slight difference in the definition of loneliness vs social isolation. Loneliness, according to NIH,  is the distressing feeling of being alone or separated, whereas social isolation is the lack of social contacts or having few people to interact with regularly.  Several recent studies show that older adults who are socially isolated or feel lonely are at higher risk for heart disease, depression, and cognitive decline.

During the filming of my documentary short at Dallastown Nursing Center, I was asked by one of the administrators to play music for a resident who was a Vietnam veteran and rarely left his room. Another resident a few doors down heard the music and pedaled his wheelchair over to join in. Afterward, in a very touching moment, the gentleman in the wheelchair turned to the other man, who was beaming from all of the positive stimulation, and said, “Do you know, I’ve lived here for six years and this is the first time we’ve spoken?” The gentleman who never left his room replied, “Come back anytime, neighbor.”  And that kind of says it all. 

*You can watch my documentary short on the Welcome page.

The Physics of Sound

There was still so much I didn’t understand about the physics of sound, the auditory system, and its link to cognition. I also had not learned how hearing loss has a direct impact on balance due to the inner ear being part of the vestibular system. This affects our elders' spatial awareness, and their orientation to sounds in their environment.

Ototoxins; medications that cause nerve damage in the inner ear are also to blame for poor balance. My observation then, that social isolation was contributing to cognitive decline couldn’t have been more accurate. But it took the next two years of studying anatomy and physiology of hearing, the physics of sound and the psychosocial consequences of hearing loss for me to understand its impact on our elderly population. I sat for my boards in April of 2024 and am now a PA licensed hearing instrument specialist.

The 2024 Lancet Commission on Dementia Prevention, Intervention, and Care, identified hearing loss as one of 14 modifiable risk factors for dementia. According to the commission, treating hearing loss could prevent up to 7% of dementia cases globally, making it one of the most impactful areas for potential prevention. This raises the question of whether use of hearing aids in people with hearing loss can reduce or mitigate this increased dementia risk.

There is no question that hearing intervention is a preventative in transmitting and amplifying sound to provide adequate stimuli to the auditory system, but there is still so much that we don’t understand as to whether or not it can slow down cognitive decline once it starts. THIS is why we need more musicians using live music as a stimulus—to actively engage in the everyday lives of our elders to prevent those most vulnerable to social isolation from falling between the cracks of care. Consider the ramifications of providing personalized music, a holistic, non pharmaceutical and cost effective alternative, to prevent the psychosocial consequences of hearing loss that can lead to social isolation, depression and cognitive decline. It’s a win-win.

Auditory Deprivation

In hearing healthcare this lack of stimuli to the auditory cortex is called “auditory deprivation.” Auditory deprivation occurs when the hair cells or the neural connections in the cochlea are understimulated. The cochlea is the part of the auditory system that transduces sound from an acoustic sound wave to an electrical impulse where it is then processed in the brain to understand speech, or in this case music. Understimulation can result in a weakening of the entire auditory system which can then lead to atrophy, (a wasting away or a progressive decline) in areas of the brain responsible for understanding speech.

According to the National Institute of Health “Presbycusis (prez-buh-KYOO-sis) is hearing loss that develops gradually as you get older. It’s the most common cause of hearing loss and affects 2 out of 3 people in the U.S. age 70 or older. The medical term comes from the Greek words for elderly (presby-) and hearing (akousis).”

Presbycusis is a general term. What I see most in the aging population is high frequency hearing loss or sensorineural hearing loss. The hair cells that are responsible for sending the electrical impulses to the brain to process speech are organized tonotopically in the cochlea. If you think about the keys on a piano, the treble keys or the higher frequencies are anatomically closest to where acoustic sound waves enter the inner ear. Unfortunately, it is the higher frequencies of speech that has the greatest impact on our ability to understand the subtle speech sounds known as phonemes. Over a lifetime, and depending on your exposure to loud noise, these hair cells become damaged and die. Unlike other species, like birds and other vertebrates that are able to regenerate these hair cells due to evolutionary factors, human beings can not. Once these hair cells die the only treatment is hearing interventions or hearing aids.

One of the most common things people with hearing loss complain about is that other people are mumbling. When your brain can no longer understand the consonants and double consonants of speech, you begin to only process parts of a sentence. This in turn affects the meaning of words and impairs communication. When this happens it requires more mental energy to decode sentences and extract meaning. The term for this is “cognitive load.”

Dr. Alison Huang, an epidemiologist and Senior Research Associate from the Johns Hopkins Cochlear Center for Hearing and Public Health, whose research studies the impact of sensory loss on cognitive and mental health in older adults, explains,

“For people with hearing loss, processing speech and sound is much more difficult because it requires more resources —attention, focus and memory. When the parts of the brain that are responsible for auditory processing are less stimulated, they're more prone to atrophy, which is also a factor in dementia. Think of this area of the brain like a muscle, you either use it or lose it, which affects other cognitive processes like memory and executive function that can lead to cognitive decline.”

Coping mechanisms and the psychosocial consequences of hearing loss

The most insidious part of hearing loss is that it’s a very gradual decline. If you don’t catch it yourself or if a loved one doesn’t bring it to your attention you may become embarrassed about asking people to repeat themselves. Many people with hearing loss are in denial and become very good at acting as if they can hear to avoid the social embarrassment of hearing loss. In the meantime, your brain is not getting the proper stimulation.

*This is where I had my first AHA moment, and have come full circle with my previous work using music as an auditory stimuli to combat social isolation.

Many people with hearing loss begin to avoid social situations altogether and this leads to social isolation, initiating a downward spiral from denial to embarrassment, avoidance of social situations to depression, and from social isolation to cognitive decline. Those in hearing health refer to this as the psychosocial consequences of hearing loss.

Researchers have determined that the decreased ability to hear in noise for those with hearing loss is most common as we get older. We lose the ability to distinguish between what is speech and what is noise. New technology in hearing science is replicating the part of the brain that is able to separate speech from noise and boost hearing acuity 4db over noise to increase clarity of understanding speech.

Nina Krause, author, auditory biologist, neuroscientist, professor at Northwestern University, head of the neurobiological lab, Brainvolts, and director of the Knowles Hearing Center explains,

“Even with normal hearing thresholds, some older people simply cannot understand the sounds they can hear. This failure to make sense of sound usually takes the form of difficulty understanding speech in noisy places. Figuring out why this is, and what we can do about it, has been a holy grail of hearing science.” (Nina Krause et al)

Hearing Loss in America

As a hearing care practitioner working in eldercare, environmental noise is a key factor influencing quality of life—just as noise induced hearing loss is one of the number one causes of hearing loss. If your profession was in a machine shop or a steel mill, you most likely have been impacted.

Ironically long term care facilities, which are designed to promote healing and comfort, rank among the worst offenders of noise. In fact, many of the common areas, dining rooms, and even resident’s private rooms are considered complex acoustic environments—the polar opposite of comfort care. And to make matters worse, there are no sound level standards that exist in medicalized spaces such as long term care facilities.

To better understand what is meant by a complex environment, especially for those with hearing loss, consider the typical restaurant with high ceilings and little to no carpet to absorb sound. The days of fine dining when rooms were wired for acoustics and ambiance appear to be behind us. The restaurants of today are designed for high turnover and a short stay much like long term care facilities. This is where the paradox lies.

Two-thirds of adults older than 70 have hearing loss. (Lin FR, Niparko JK,L), and According to NIH, 24 percent of the total elderly population are in long term care facilities designed to meet their health care needs.

Sound and Complex Environments

Sound is a disturbance in air that consists of longitudinal waves carrying energy that travels outward in all directions. A complex acoustic environment can be particularly uncomfortable for those with dementia. Studies show that for this group, “sound is often the pathway to making sense of the surrounding world. Providing conditions that not only “permit,” but rather “promote” supportive sonic environments could be beneficial for the well-being and quality of life of persons with dementia in care facilities.”

Research on what defines complex acoustic environments are in themselves, complex. The most simplified description states that the more acoustic sources that are present, the more independent streams of sound event information are competing for the listener’s attention” (e.g., Cherry, 1953; Hawley et al., 1999; Shinn-Cunningham & Best, 2008).

In long term care facilities there are few rooms where you can create anything remotely sound proof or impervious to ambient sound. On a daily basis residents and staff compete with the sound of med techs rolling carts down the hallways, staff members shouting to each other across the halls, the sound of intercoms and alarms coming from resident rooms, to the hissing of oxygen machines. Environmental cues do have their place in ensuring safe conditions, but the unpleasant sounds that contribute to the background noise for our senior population interfere with communication. Communication is central to connection and quality of life.

Music as sound

In music, all sounds whether high or low in pitch travel through the air at the same speed. When sound travels through air, it is linear. “The physical meaning of linearity is that many different sounds (say, from different instruments in an orchestra) can travel through the same space at the same time, and each will be unaffected by the other.” (Hall E. Donald, Musical Acoustics, Second Edition.)

Janalea Hoffman, music therapist and author of RHYTHMIC MEDICINE; Music With a Purpose, responds to the question many have asked; “If I mask an annoying rhythm with some other sound, such as a wave machine or music louder than the sound that needs to be eliminated, will this solve the problem?”

Her response is this—“Since our bodies are always trying to synchronize with external rhythms, simply covering an annoying sound with another sound does not eliminate the phenomenon of entrainment”.

Unfortunately, short of major changes in public policy or a shift in awareness, complex acoustic environments seem to be the norm in long term care.

Aural Rehabilitation as Cognitive Rehabilitation

For those who live independently or those aging in place, there are certain modifications that can be made within the environment to optimize hearing. This is where education and aural rehabilitation comes into play. I have spent many consultations counseling married couples— one has significant hearing loss and the other has normal hearing. Because hearing is subjective it can be frustrating for both parties to communicate. Sometimes the solution is as simple as making sure to speak to the person with hearing loss directly in front of them opposed to from either side. Hearing is naturally amplified when both ears are working together.

Because hearing loss or Presbycusis is so prevalent in the aging population, it’s important, if you are a musician, to never assume that the individual you are performing for can hear the subtle phonemes or speech sounds within the lyrics. This is another reason why playing a familiar song is so validating to your audience. When they recognize the melody and rhythm, they don’t have to anticipate where the song is going. When you have hearing loss, listening to anything familiar takes the guesswork out and, as we are learning, lessens the “cognitive load” of having to decode what the performer is singing. I once worked with a hearing aid fitter who would recommend a patient, brand new to hearing aids, to go home and watch an old movie that they’d seen umteen times before. The logic is as you watch, you are already anticipating the next word in the script, so it requires less energy to hear and process the speech.

Try it.