Abstract

Given the high prevalence of presbycusis and its detrimental effect on quality of life, screening tests can be useful tools for detecting hearing loss in primary care settings. This study therefore aimed to determine the accuracy and reproducibility of the whispered voice test as a screening method for detecting hearing impairment in older people. This cross-sectional study was carried out with 210 older adults aged between 60 and 97 years who underwent the whispered voice test employing ten different phrases and using audiometry as a reference test. Sensitivity, specificity and positive and negative predictive values were calculated and accuracy was measured by calculating the area under the ROC curve. The test was repeated on 20% of the ears by a second examiner to assess inter-examiner reproducibility (IER). The words and phrases that showed the highest area under the curve (AUC) and IER values were: “shoe” (AUC = 0.918; IER = 0.877), “window” (AUC = 0.917; IER = 0.869), “it looks like it's going to rain” (AUC = 0.911; IER = 0.810), and “the bus is late” (AUC = 0.900; IER = 0.810), demonstrating that the whispered voice test is a useful screening tool for detecting hearing loss among older people. It is proposed that these words and phrases should be incorporated into the whispered voice test protocol.

Key words
Older persons; Screening; Hearing loss; Senior health care services; Primary health care

Introduction

Population ageing due to rising life expectancy is a global phenomenon. Brazil is no exception to this trend and, according to current projections, the total number of people aged 60 years or over is expected to reach 32 million by 2020¹1. Instituto Brasileiro de Geografia e Estatística (IBGE) [Internet]. Projeção da população do Brasil por sexo e idade: 2000-2060 [acessado 22 fev 2015]. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2013/default_tab.shtm
http://www.ibge.gov.br/home/estatistica/... . Aging is a natural process of human development whereby individuals undergo gradual physiological changes²2. Veras RP, Mattos LC. Audiologia do envelhecimento: revisão da literatura e perspectivas atuais. Rev Bras Otorrinolaringol 2007; 73(1):128-1234.^,33. Veras R. Em busca de uma assistência adequada à saúde do idoso: revisão da literatura e aplicação de um instrumento de detecção precoce e de previsibilidade de agravos. Cad Saude Publica 2003; 19(3):705-715..

Presbycusis is an age-related change in auditory acuity characterized by symmetrical, downward sloping high-frequency, bilateral, sensorineural hearing loss²2. Veras RP, Mattos LC. Audiologia do envelhecimento: revisão da literatura e perspectivas atuais. Rev Bras Otorrinolaringol 2007; 73(1):128-1234.^,44. Baraldi GS, Almeida LC, Borges ACC. Evolução da perda auditiva no decorrer do envelhecimento. Rev Bras Otorrinolaringol 2007; 73(1):64-70.^,55. Anjos WT, Labanca L, Resende LM, Costa GLP. Correlação entre as classificações de perdas auditivas e o reconhecimento de fala. Rev CEFAC 2014; 16(4):1109-1116.. The prevalence of age-related hearing loss ranges between 30% and 90%²2. Veras RP, Mattos LC. Audiologia do envelhecimento: revisão da literatura e perspectivas atuais. Rev Bras Otorrinolaringol 2007; 73(1):128-1234.^,44. Baraldi GS, Almeida LC, Borges ACC. Evolução da perda auditiva no decorrer do envelhecimento. Rev Bras Otorrinolaringol 2007; 73(1):64-70.^,66. Ramdoo K, Bowen J, Dale OT, Corbridge R, Chatterjee A, Gosney MA. Opportunistic hearing screening in elderly inpatients. SAGE Open Medicine 2015; 2:1-5.. Presbycusis causes major communication difficulties, particularly in understanding speech and conservations in noisy environments⁷7. Tenorio JP, Guimarães JA, Tenório L, Flores NGC, Iorio MC. Comparação entre critérios de classificação dos achados audiométricos em idosos. J Soc Bras Fonoaudiol 2011; 23(2):114-118.

8. Calais LL, Borges ACLC, Baraldi GS, Almeida LC. Queixas e preocupações otológicas e as dificuldades de comunicação de indivíduos idosos. Rev soc bras fonoaudiol 2008; 13(1):12-19.^-99. Ribas A, Kozlowski L, Almeida G, Marques JM, Silvestre RAA, Mottec CM. Qualidade de vida: comparando resultados em idosos com e sem presbiacusia. Rev bras geriatr gerontol 2014; 17(2):353-362.. The diagnosis of hearing loss is made through pure-tone audiometry and vocal audiometry to determine auditory sensitivity and the quality of peripheral auditory information based on sound frequency hearing and speech recognition index²2. Veras RP, Mattos LC. Audiologia do envelhecimento: revisão da literatura e perspectivas atuais. Rev Bras Otorrinolaringol 2007; 73(1):128-1234.^,55. Anjos WT, Labanca L, Resende LM, Costa GLP. Correlação entre as classificações de perdas auditivas e o reconhecimento de fala. Rev CEFAC 2014; 16(4):1109-1116.. These tests, together with acoustic immittance testing, are used to determine the type and degree of hearing loss and help doctors to diagnose presbycusis. Pure-tone audiometry is the gold-standard for hearing evaluation and requires an acoustically treated environment and equipment¹⁰10. Marini ALS, Halpern R, Aerts D. Sensibilidade, especificidade e valor preditivo da queixa auditiva. Rev Saude Publica 2005; 39(6):982-984.. Given the operational complexities involved in performing pure-tone audiometry, this test has limited use as a method for the universal hearing screening of older people. As a result, other hearing screening methods that can be easily used and applied by trained practitioners are emerging as an alternative in the public health arena¹¹11. Caldas CP, Veras RP, Motta LB, Lima CK, Kisse CBS, Trocado CVM, Guerra ACLC. Rastreamento do risco de perda funcional: uma estratégia fundamental para a organização da Rede de Atenção ao Idoso. Ciên Saúde Colet 2013; 18(12):3495-3506..

The whispered voice test has been recommended as a screening test for detecting hearing impairment among elderly persons suspected of having presbycusis⁶6. Ramdoo K, Bowen J, Dale OT, Corbridge R, Chatterjee A, Gosney MA. Opportunistic hearing screening in elderly inpatients. SAGE Open Medicine 2015; 2:1-5.^,1212. Schneider RH, Marcolin D, Dalacorte RR. Avaliação funcional de idosos. Scientia Medica 2008; 18:4-9.

13. Lachs MS, Feinstein AR, Cooney LM Jr, Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A Simple Procedure for General Screening for Functional Disability in Elderly Patients. Ann Intern Med 1990; 112:699-706.^-1414. McShefferty D, Whitmer WMW, Swan IRC, Akeroyd MA. The effect of experience on the sensitivity and specificity of the whispered voice test: a diagnostic accuracy study. BMJ Open 2013; 3(4):e002394.. It is considered a low-cost, simple-to-use and fast test for detecting moderate hearing loss among adults who do not need to use hearing aids¹⁴14. McShefferty D, Whitmer WMW, Swan IRC, Akeroyd MA. The effect of experience on the sensitivity and specificity of the whispered voice test: a diagnostic accuracy study. BMJ Open 2013; 3(4):e002394.

The health care guidance note produced by the Ministry of Health, Aging and the Health and Care of Older People (Envelhecimento e saúde da pessoa idosa)¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... recommends the whispered voice test as a screening instrument for testing auditory acuity among older people. According to the recommendations, the examiner should stand outside the patient's field of vision at a distance of 33 cm from each ear and whisper at each side a simple brief question such as “what is your name?”. If the patient does not respond, the external auditory canal should be inspected for any obstruction that may cause a reduction in auditory acuity. In the absence of obstruction, the patient should be referred to specialized health center for audiometric testing¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... .

The whispered voice test has been used in senior health care centers and in the Unified Health System by geriatric health practitioners and a range of other health professinoals¹⁶16. Centro de referência à saúde do idoso de Belo Horizonte [Internet]. Protocolo de avaliação multidimensional do idoso [acessado 2015 jul 14]. Disponível em: http://www.hc.ufmg.br/geriatria/img/galeria_fotos/Protocolo.pdf
http://www.hc.ufmg.br/geriatria/img/gale... ^,1717. Centro de referência à saúde do idoso de Campinas [Internet]. Avaliação breve do idoso [acessado 2015 jul. 8]. Disponível em: http://www.campinas.sp.gov.br/sa/impressos/adm/FO811.pdf
http://www.campinas.sp.gov.br/sa/impress... . However, everyday questions such as “what is your name?” may contain cognitive clues, whereby hearing only the word “what” or “name”, for example, may lead to the correct answer even though the patient has hearing loss and needs intervention. In Brazil, the current lack of research on the sensitivity, specificity, inter-examiner reproducibility and positive and negative predictive values of the whispered voice test raises difficulties to the standardization and validation of this technique as a screening tool for detecting hearing loss among the aged population.

In Brazil, until now there is no standardization and validation of this technique, due to there are not studies in which sensitivity, specificity, inter-examiner reproducibility and positive and negative predictive values of the whispered voice test are stablish as a screening tool for detecting hearing loss among aged Brazilian population.

The present study therefore aims to determine the reproducibility and accuracy of the whispered voice test as a screening tool for detecting hearing loss among older people by employing different phrases and using pure-tone threshold audiometry as the reference test. Based on the findings of this study, we propose a set of different speech stimuli as part of the whispered voice test protocol.

Methodology

A cross-sectional accuracy study was undertaken whereby hearing evaluations were performed with a group of older people attending a senior health care center at a public university hospital in Brazil.

The study sample comprised all patients aged 60 years or over referred by the geriatric services who underwent an audiological evaluation in the center between February and November 2013 and who agreed to take part in the study by signing an informed consent form. Those patients who did not complete the proposed evaluation were excluded from the study, resulting in 210 patients with an average age of 76 years (standard deviation: 8, minimum of 60 years and maximum of 97 years) and 420 tested ears.

The data collection process involved the following steps: inspection of the external auditory canal; the whispered voice test; and pure-tone and vocal audiometry.

The inspection of the external auditory canal was undertaken using a Omni 3000 otoscope to determine whether there was total or partial obstruction of the external acoustic meatus. Patients with an obstruction that was likely to impede the detection of hearing thresholds were informed and referred for assessment and otorhinolaryngological procedures and subsequent evaluation¹⁸18. Sistema de Conselhos Federal e Regionais de Fonoaudiologia [Internet]. Manual de procedimentos em audiometria tonal limiar, logo audiometria e medidas de imitância acústica [acesso 2015 Ago 15]. Disponível em: http://www.fonoaudiologia.org.br/publicacoes/Manual%20de%20Audiologia%20.pdf
http://www.fonoaudiologia.org.br/publica... ^,1919. Redondo MC, Lopes Filho O. Avaliação auditiva básica: acumetria e audiometria. In: Lopes Filho O. Tratado de fonoaudiologia. 3a ed. Barueri: Editora Manole; 2013. p.53-69..

The whispered voice test was conducted by specialized professionals in a silent room with minimal internal and external noise and with the patient sitting in a chair in the presence only of the examiner. Despite the fact that the room had an acoustic booth, we opted to carry out the test in an untreated environment so that the findings would reflect the reliability of the tool for use in typical medical consulting rooms, including those found in primary health care facilities. The stimuli were presented via the whispered speech of the examiner, who was careful to speak at a uniform level of loudness throughout the tests. The examiner stood behind each ear at arm's length (measured as the distance between the elbow and clenched fist and equivalent to a distance of approximately 33 centimeters from the tested ear) at an angle of zero and outside the patient's field of vision¹⁴14. McShefferty D, Whitmer WMW, Swan IRC, Akeroyd MA. The effect of experience on the sensitivity and specificity of the whispered voice test: a diagnostic accuracy study. BMJ Open 2013; 3(4):e002394.^,1515. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... .

Verbal stimuli were previously selected considering the following linguistic aspects: word size, commonly used phrases and words in Portuguese, and the presence of common speech sounds in Portuguese. To cater for the audiometric characteristics of presbycusis⁵5. Anjos WT, Labanca L, Resende LM, Costa GLP. Correlação entre as classificações de perdas auditivas e o reconhecimento de fala. Rev CEFAC 2014; 16(4):1109-1116., we were careful to ensure that the speech material contained a phonemic repertoire that included different points of articulation, emphasizing fricatives, which have lower peak acoustic energy and a wider frequency spectrum²⁰20. Russo I, Behlau M. Percepção da fala: análise acústica do português brasileiro. São Paulo: Lovise; 1993.. All words and phrases were selected from speech lists used in audiological evaluation²¹21. Costa MJ, Iório MCM, Mangabeira-Albernaz PL. Reconhecimento de fala: desenvolvimento de uma lista de sentenças em português. Acta AWHO 1997; 16(4):164-173.^,2222. Pereira LD, Schochat E. Manual de Avaliação do processamento auditivo central. São Paulo: Lovise; 1997., considering size, ease of reproduction, and suitable content for older people.

A set of different whispered phrases and words was presented to both ears. The nontest ear was occluded by the examiner by rubbing the tragus in a circular motion to minimize the participation of the opposite auditory canal. For the right ear, the patient was requested to answer the question “what is your name?” and repeat the phrase “it looks like it's going to rain”, the word “shoe”, the word “Key”, and the word “does”. For the left ear, the patient was requested to answer the question “how old are you?” and repeat the phrase “the bus is late”, the word “window”, the word “rain”, and the word “chalk”. For each whispered stimulus, the result was expressed as a fail, where the patient was unable to correctly repeat the phrase or word (tested positive for possible hearing loss), or a pass (tested negative for hearing loss).

To test inter-examiner reproducibility, 42 participants were randomly selected and underwent the test again. This time, the test was conducted by a less experienced examiner who was a multiprofessional resident in the field of geriatric medicine and trained to conduct the test. The test was conducted in a room with similar features to the one used in the first test and appropriate care was taken to control internal and external noise. Reproducibility was tested by comparing the level of agreement between the results obtained by the first and second examiners for each stimulus. The level of agreement was determined using the Kappa coefficient (k) using the following categories²³23. Siqueira AL, Tibúrcio JD. Estatística na área da Saúde: conceitos, metodologia, aplicações e prática computacional. Belo Horizonte: COOPMED, UFMG; 2011.: 0 – 0.2: very poor; 0.21–0.4: poor; 0.41 – 0.6: moderate; 0.61 – 0.8: good; 0.81 – 100: very good.

The intrinsic quality of the whispered voice test was assessed by calculating sensitivity, specificity, and positive and negative predictive values, using audiometry as a reference test. Receiver operating characteristic (ROC) analysis was performed using the sensitivity and specificity values. The area under the curve (AUC) was calculated to assess the accuracy of the whispered voice test for each of the phrases used²³23. Siqueira AL, Tibúrcio JD. Estatística na área da Saúde: conceitos, metodologia, aplicações e prática computacional. Belo Horizonte: COOPMED, UFMG; 2011..

Pure-tone audiometry was performed after the whispered voice test to determine bone-conduction and air-conduction thresholds. This was done using an appropriately calibrated AVS-500 audiometer and acoustic booth, both manufactured by Vibrasom. Initially, air-conducted hearing thresholds were determined at 250Hz, 500Hz, 1000Hz, 2000Hz, 3000Hz, 4000Hz, 6000Hz, and 8000Hz. When these thresholds exceeded 20dB HL, bone-conducted thresholds were determined at 500Hz, 1000Hz, 2000Hz, 3000Hz, and 4000Hz¹⁹19. Redondo MC, Lopes Filho O. Avaliação auditiva básica: acumetria e audiometria. In: Lopes Filho O. Tratado de fonoaudiologia. 3a ed. Barueri: Editora Manole; 2013. p.53-69.. In accordance with the BIAP classification, hearing loss was confirmed when hearing thresholds were higher than 20dB HL at the following frequencies: 500Hz, 1000Hz, 2000Hz, and 4000Hz¹⁸18. Sistema de Conselhos Federal e Regionais de Fonoaudiologia [Internet]. Manual de procedimentos em audiometria tonal limiar, logo audiometria e medidas de imitância acústica [acesso 2015 Ago 15]. Disponível em: http://www.fonoaudiologia.org.br/publicacoes/Manual%20de%20Audiologia%20.pdf
http://www.fonoaudiologia.org.br/publica... ^,2424. Bureau International d’ Audiophonologie (BIAP) Classification audiométrique des deficiencies auditives [Internet].[acessado 2011 Maio 15]. Disponível em: http://www.biap.org/fr/recommandation/archives/65-ct-2-classification-des-surdites/5-recommandation-biap-021-bis
http://www.biap.org/fr/recommandation/ar... .

The data was analyzed using the software program OpenEpi version 3.03²⁵25. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 3.01 [Internet]. 2013 [cited 2015 jun 23]. Disponível em: http://www.OpenEpi.com
http://www.OpenEpi.com... .

The study was approved by the Ethics Committee at the Federal University of Minas Gerais and was conducted in accordance with National Health Council guidelines.

Results

General characteristics of the study participants

The general characteristics of the study participants are presented in Table 1. A total of 420 individual ears were tested. Based on the results of pure-tone audiometry as a reference test, the prevalence of hearing loss was 68.8% (Table 1).

Sensitivity, specificity, and negative and positive predictive values of the whispered voice test

Table 2 shows the comparison between the results of the whispered voice test and tone audiometry and the sensitivity, specificity and negative and positive predictive values for each stimulus presented.

Accuracy of the whispered voice test

Figure 1 shows the ROC curves produced using the sensitivity and specificity values from the whispered voice test for each stimulus. A visual analysis of the curves shows that the AUC of the stimulus “shoe” was 0.918, followed by “window” (AUC = 0.917), “it looks like it's going to rain” (AUC = 0.911), “the bus is late” (AUC = 0.900), “what is your name?” (AUC = 0.886), “key” (AUC = 0.886), “how old are you?” (AUC = 0,837), “rain” (AUC = 0.880), “does” (AUC = 0.696), and “chalk” (AUC = 0.687) (Figure 1).

Reproducibility of the whispered voice test

The reproducibility of the whispered voice test varied according to the stimulus. Table 3 shows the level of agreement between the answers obtained by the first examiner and those obtained by the second examiner.

Proposed application of the whispered voice test

Based on the results of the tests of accuracy and reproducibility, Figure 2 shows the proposed application of the whispered voice test as a screening tool for detecting hearing loss among older people.

Discussion

The search for an efficient and effective screening test for detecting hearing loss among the geriatric population is important, particularly given the prevalence of hearing impairment among older people and the detrimental effect it can have on quality of life if left undetected and untreated⁶6. Ramdoo K, Bowen J, Dale OT, Corbridge R, Chatterjee A, Gosney MA. Opportunistic hearing screening in elderly inpatients. SAGE Open Medicine 2015; 2:1-5.. In view of the important contribution of hearing to communication among older people and the limited access to audiological services, primary care services are expected to provide auditory acuity screening of the geriatric population and refer patients to secondary care services as and when necessary²⁶26. Aguilera SLVU, Franca BHS, Moyses ST, Moyses SJ. Intermunicipal inequities in access and use of secondary health services in the metropolitan area of Curitiba. Rev bras epidemiol 2014; 17(3):654-667.. Hearing screening should be simple enough to be conducted in primary care settings and sensitive enough to identify patients with possible risk of hearing loss³3. Veras R. Em busca de uma assistência adequada à saúde do idoso: revisão da literatura e aplicação de um instrumento de detecção precoce e de previsibilidade de agravos. Cad Saude Publica 2003; 19(3):705-715..

Hearing screening to detect hearing impairment is currently recommended as a fundamental component of any general evaluation of an older individual in national health care guidelines not only in Brazil, but also in other countries such as the United Kingdom and Austrelia²⁷27. Pirozzo S, Papinczak T, Glasziou P. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ 2003; 327:967.

28. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197.

29. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.^-3030. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing 1988;7(5):347-351.. The present study tested the whispered voice test, recommended by the Ministry of Health for screening older people in primary health care settings¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... , standardized the questions using phonetically balanced words and phrases, and suggested a new test protocol (Chart 1).

The technique used for the whispered voice test varies between studies²⁷27. Pirozzo S, Papinczak T, Glasziou P. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ 2003; 327:967.

28. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197.^-2929. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.^,3131. Uhlmann RF, Rees TS, Psaty BM, Duckert LG. Validity and reliability of auditory screening tests in demented and non-demented older adults. J Gen Intern Med 1989; 4:90-96.. For example, the appropriate distance between the examiner's mouth and tested ear ranges between 33¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco...

16. Centro de referência à saúde do idoso de Belo Horizonte [Internet]. Protocolo de avaliação multidimensional do idoso [acessado 2015 jul 14]. Disponível em: http://www.hc.ufmg.br/geriatria/img/galeria_fotos/Protocolo.pdf
http://www.hc.ufmg.br/geriatria/img/gale... ^-1717. Centro de referência à saúde do idoso de Campinas [Internet]. Avaliação breve do idoso [acessado 2015 jul. 8]. Disponível em: http://www.campinas.sp.gov.br/sa/impressos/adm/FO811.pdf
http://www.campinas.sp.gov.br/sa/impress... ^,2828. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197. and 60 centimeters ⁶6. Ramdoo K, Bowen J, Dale OT, Corbridge R, Chatterjee A, Gosney MA. Opportunistic hearing screening in elderly inpatients. SAGE Open Medicine 2015; 2:1-5.^,2828. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197.

29. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.^-3030. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing 1988;7(5):347-351., while other studies use digits, letters and words as stimuli⁶6. Ramdoo K, Bowen J, Dale OT, Corbridge R, Chatterjee A, Gosney MA. Opportunistic hearing screening in elderly inpatients. SAGE Open Medicine 2015; 2:1-5.^,2828. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197.

29. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.

30. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing 1988;7(5):347-351.^-3131. Uhlmann RF, Rees TS, Psaty BM, Duckert LG. Validity and reliability of auditory screening tests in demented and non-demented older adults. J Gen Intern Med 1989; 4:90-96.. In the present study, the examiner stood 33 cm to the side of the tested ear¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... ^,2828. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197. and whispered phrases and different sized words in an attempt to identify the most sensitive types of verbal stimuli specifically capable of determining possible hearing loss, using audiometry as a reference test. The phrases and words were chosen bearing in mind that presbycusis is characterized by hearing loss at high frequencies⁵5. Anjos WT, Labanca L, Resende LM, Costa GLP. Correlação entre as classificações de perdas auditivas e o reconhecimento de fala. Rev CEFAC 2014; 16(4):1109-1116. and therefore the test should contain words and phrases with sounds in this frequency band, such as fricatives.

The findings showed varying sensitivity and specificity values according to the verbal stimulus used (Table 2): the larger the phrase or word, the higher the specificity of the test, while the smaller the word size the higher the sensitivity. For the phrase “what is your name?” sensitivity and specificity were 82.9% and 94.3%, respectively. This question is predictable and commonly used on a day-to-day basis, thus increasing redundancy and the likelihood of guessing the correct answer. This in turn means that the number of false negatives was higher than that found for words such as “shoe” or “window”. The same occurs with the phrase “how old are you?”, suggesting that both phrases should not be used for hearing screening. Previous studies that determined the sensitivity and specificity of the whispered voice test conducted in other countries found that sensitivity and specificity values ranged between 80% and 100% and 80% and 90%, respectively²⁷27. Pirozzo S, Papinczak T, Glasziou P. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ 2003; 327:967.

28. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract 1985; 35(273):197.

29. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.

30. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing 1988;7(5):347-351.^-3131. Uhlmann RF, Rees TS, Psaty BM, Duckert LG. Validity and reliability of auditory screening tests in demented and non-demented older adults. J Gen Intern Med 1989; 4:90-96..

To demonstrate the relationship between sensitivity and specificity, ROC analysis was performed to reveal phrases for which there was greater optimization of sensitivity as a function of specificity (Figure 1). The results showed that the AUC value was greatest for the words “shoe” (AUC = 0.918) and “window” (AUC = 0.917), followed by “it looks like it's going to rain” (AUC = 0.911), “the bus is late” (AUC = 0.900), “what is your name?” (AUC = 0.886), “key” (AUC = 0.886), “how old are you?” (AUC = 0.837), “rain” (AUC = 0.880), “does” (0.696), and “chalk” (0.687) (Figure 1). Thus, the words that showed highest accuracy were “shoe” and “window”. These words begin with fricatives within the frequency band 3000Hz to 8000Hz, showing that speech discrimination is influenced by high frequencies and that the whispered voice test should therefore include words with speech sounds in this frequency band in order to make it more sensitive to sloping hearing loss, which is a major characteristic of presbycusis⁵5. Anjos WT, Labanca L, Resende LM, Costa GLP. Correlação entre as classificações de perdas auditivas e o reconhecimento de fala. Rev CEFAC 2014; 16(4):1109-1116..

Some studies report that the whispered voice test may be influenced by variables related to the presentation of stimuli by the examiner, such as voice intensity and experience¹⁴14. McShefferty D, Whitmer WMW, Swan IRC, Akeroyd MA. The effect of experience on the sensitivity and specificity of the whispered voice test: a diagnostic accuracy study. BMJ Open 2013; 3(4):e002394.^,2929. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: The best test for screening for hearing impairment in general practice? Br J Gen Pract 1996; 46(409):473-474.. In the present study, the whispered voice test was initially conducted by an experienced examiner who was careful to speak at a uniform level of loudness throughout the tests. To test inter-examiner variability, the same procedure was repeated by a second examiner with 20% of the individual ears. The results show that the level of agreement between the examiners varied according to the stimulus presented. The phrases that showed best inter-examiner reproducibility where the trisyllabic words “shoe” (k = 0.877) and “window” (k = 0.869), followed by the phrases “the bus is late” (k = 0.810) and “it looks like it's going to rain” (k = 0.810). For the phrase “what is your name?” inter-examiner reproducibility was 75%.

The reproducibility values of the whispered voice test described in the literature vary. A study carried out in Washington that compared the results of the whispered voice test conducted by an otolaryngologist with those obtained by a speech therapist found that level of agreement was 67%³¹31. Uhlmann RF, Rees TS, Psaty BM, Duckert LG. Validity and reliability of auditory screening tests in demented and non-demented older adults. J Gen Intern Med 1989; 4:90-96., while a study that compared the results of the test performed by a geriatrician and otolaryngologist showed a rate of 88%³⁰30. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing 1988;7(5):347-351.. Despite the variability among reproducibility values, our findings show that the whispered voice test is reproducible, since, depending on the stimulus presented, the level of agreement remained between good and very good even after changing the examiner. This shows that a properly trained practitioner is capable of conducting the test in a primary health care setting. The most important benefit of this test is that it offers greater efficiency without reducing screening quality, meaning that only patients who really need specialized hearing evaluations will be referred to secondary care services.

Despite being a simple test of hearing ability, the whispered voice test does have some limitations, since it should be conducted carefully by an experienced examiner in a quite setting. Furthermore, mild degrees of hearing loss (up to 40 dB) may go undetected by the test. However, from a public health perspective, this type of hearing loss has little detrimental impact on the quality of life and independence of older patients¹⁸18. Sistema de Conselhos Federal e Regionais de Fonoaudiologia [Internet]. Manual de procedimentos em audiometria tonal limiar, logo audiometria e medidas de imitância acústica [acesso 2015 Ago 15]. Disponível em: http://www.fonoaudiologia.org.br/publicacoes/Manual%20de%20Audiologia%20.pdf
http://www.fonoaudiologia.org.br/publica... ^,2424. Bureau International d’ Audiophonologie (BIAP) Classification audiométrique des deficiencies auditives [Internet].[acessado 2011 Maio 15]. Disponível em: http://www.biap.org/fr/recommandation/archives/65-ct-2-classification-des-surdites/5-recommandation-biap-021-bis
http://www.biap.org/fr/recommandation/ar... . On the other hand, moderate hearing loss may go unnoticed by older people, which can have a detrimental effect on cognition, independence and quality of life⁹9. Ribas A, Kozlowski L, Almeida G, Marques JM, Silvestre RAA, Mottec CM. Qualidade de vida: comparando resultados em idosos com e sem presbiacusia. Rev bras geriatr gerontol 2014; 17(2):353-362.^,1818. Sistema de Conselhos Federal e Regionais de Fonoaudiologia [Internet]. Manual de procedimentos em audiometria tonal limiar, logo audiometria e medidas de imitância acústica [acesso 2015 Ago 15]. Disponível em: http://www.fonoaudiologia.org.br/publicacoes/Manual%20de%20Audiologia%20.pdf
http://www.fonoaudiologia.org.br/publica... ^,2424. Bureau International d’ Audiophonologie (BIAP) Classification audiométrique des deficiencies auditives [Internet].[acessado 2011 Maio 15]. Disponível em: http://www.biap.org/fr/recommandation/archives/65-ct-2-classification-des-surdites/5-recommandation-biap-021-bis
http://www.biap.org/fr/recommandation/ar... .

Presbycusis is progressive and can be treated and rehabilitated using electronic sound amplification devices available through the auditory health care services provided under Brazil's public health care system³²32. Brasil. Ministério da Saúde (MS). Portaria n° 587, de 07 de outubro de 2004. Determina que as Secretarias de Estado da Saúde dos estados adotem as providências necessárias à organização e implantação das Redes Estaduais de Atenção à Saúde Auditiva. Diário Oficial da União 2004; 11 out.^,3333. Buriti AKL, Oliveira SHS. Adaptação à prótese auditiva em usuários assistidos pelo SUS. Rev soc bras fonoaudiol 2012; 17(1):41-46.. It is important to highlight that early diagnosis and intervention is crucial to ensure successful rehabilitation and use of these devices among the geriatric population, since the longer the period of auditory deprivation, the more difficult it is for an older individual to become readapted to the world of sound⁹9. Ribas A, Kozlowski L, Almeida G, Marques JM, Silvestre RAA, Mottec CM. Qualidade de vida: comparando resultados em idosos com e sem presbiacusia. Rev bras geriatr gerontol 2014; 17(2):353-362.^,3333. Buriti AKL, Oliveira SHS. Adaptação à prótese auditiva em usuários assistidos pelo SUS. Rev soc bras fonoaudiol 2012; 17(1):41-46..

In light of the above, the whispered voice test is an important screening tool for detecting hearing loss among the geriatric population.

The findings of the present study reveal that, for the phrase “what is your name?”, suggested by the guidance note Aging and the Health and Care of Older People¹⁵15. Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde [Internet]. Envelhecimento e saúde da pessoa idosa [acessado 2015 set 20]. Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... , inter-examiner reproducibility, sensitivity, specificity, and positive and negative predictive values were 75%, 83%, 94%, 97%, and 73%, respectively, while accuracy, expressed by area under the ROC curve, was 89%, using audiometry as a reference test. The words “shoe” and “window” showed the highest accuracy. For the word “shoe”, AUC, inter-examiner reproducibility, sensitivity, specificity, positive and negative predictive values were 92%, 88%, 94%, 90%, 95%, and 87%, respectively, whereas for the word “window” AUC, sensitivity, specificity, positive and negative predictive values were 92%, 93%, 90%, 96%, and 85%, respectively. Thus, although the use of the phrase “what is your name?” is suggested for screening, the present study reveals that other words and phrases showed higher sensitivity and reproducibility. In light of this, it is suggested that the whispered voice test should be conducted as outlined in Chart 1.

Conclusion

The findings suggest that the whispered voice test is an acceptable screening test to detect hearing loss in the geriatric population. The speech stimuli that showed greatest accuracy and reproducibility were the words “shoe” and “window” and the phrases “the bus is late” and “it looks like it's going to rain”. It is therefore suggested that these stimuli should be included in the whispered voice test protocol. The suggested expressions are phonetically balanced and highly used in the speeches. They also include high frequency sounds, which are the most affected by presbycusis.

Acknowledgments

We would like to thank the staff at the senior health care center in Belo Horizonte. We are also grateful to the students from the speech therapy course at UFMG and multiprofessional resident at the Hospital das Clínicas who took part in data collection.

References

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