目的 台灣已如其他開發國家一樣邁向高齡化社會，而與老年人相關的各項議題，必然越來越需重視。根據內政部調查65歲以上老人對未來生活最擔心的問題，以自己的健康占最多(約24%)，可見老人的健康問題值得關注。聽力退化是老人常見的健康問題，據臨床觀察，自50歲起就開始有聽力退化的現象，65歲以上老年人約1/3有聽障的現象。而聽力退化可能會影響年長者之社會功能及情緒，特別是在高齡化社會，非常值得重視。美國、英國、北歐、甚至鄰近之韓國皆有大型社區型研究探討相關議題，反觀臺灣雖然也已進入高齡化社會，搜索文獻臺灣本土之老人聽障相關社區型流行病學研究，如盛行率、嚴重度，卻相當缺乏。本研究即嘗試利用現有資源，自參與臺北市老人健康檢查的民眾，取得社區65歲以上老人聽力相關的流行病學資料，以了解 (1)在台北市社區老人中，老人聽障的盛行率及嚴重度，以及助聽器使用狀況； (2)在社區老人中，聽力損失(hearing impairment)和自覺聽力障礙(self-perceived hearing handicap)的關係； 以及本土老人「會造成障礙的聽力損失(handicapped hearing impairment)」的建議值； (3)在社區老人中，除了聽力損失外，是否還可以找到自覺聽力障礙(self-perceived hearing handicap)的非聽覺(non-audiologic)相關因子

方法 對至臺北市立聯合醫院陽明院區接受94年度臺北市老人健康檢查的所有民眾，邀請其自願參加額外的純音聽力檢查(雙耳氣導0.5,1,2,4,6,8 kHz)，及問卷訪談--包含HHIE-S(hearing handicap inventory for elderly-screening version)、聽力相關病史、基本資料及自述健康狀況。並經其同意取得老人健檢身體檢查及血液生化檢查的資料。

結果 共1232位65歲(含)以上長者參與研究，排除掉11位有雙側耳部問題(如耳膜穿孔或自年輕時聽力就不好)的長者後，最後有1221人(男:女=682:539)納入分析。這群受檢長者在65-69歲及70-74歲這兩個年齡層的性別組成與母群體並無差異，而其他年齡層則男性受檢者比例略高。分年齡層純音聽力平均閾值圖顯示典型老人重聽型態：呈現越高頻聽力減退越嚴重之趨勢，而且年齡層越老聽力越差。女性在＜2kHz聽力閾值比同年齡層的男性差，＞2kHz則比同年齡層的男性好(至少在80歲以前是如此)，在2kHz則無差異。年齡層65至69歲的M3(優耳0.5, 1, 2 kHz聽力閾值之平均值)為34.9±7.3 dBHL、70-74歲M3為36.6±7.7dB HL、75-79歲M3為40.1±9.5dB HL、80-84歲M3為42.9±9.7dB HL、≧85歲M3為46.4±9.2dBHL，M4(優耳0.5, 1, 2, 4 kHz聽力閾值平均值)則各增加3至4 dB HL。65-69, 70-74, 75-79, 及≧80歲之年齡別(age-specific)聽障盛行率分別為：以M4＞25dB HL為標準97.5%, 99.5%, 99.4%, 100%；以M4≧40dB HL為標準分別為36.8%, 45.9%, 63.6%, 77.7%；以M4≧55dB HL為標準分別為3.2%, 5.6%,11.3%, 25.1%。本研究族群中老人聽障之總盛行率以M3＞25dB HL為標準是96.5%，M3≧40dB HL 為38.7%，M3≧55dB HL為5.6%；M4＞25dB HL為99.0%，M4≧40dB HL 為 52.7%，M4≧55dB HL為9.3%。本研究族群中13.9%有持續耳鳴，與老人聽障嚴重程度相關，但與年齡及性別無關；18.8%曾有眩暈病史，與較嚴重的老人聽障、較老的年齡層、及女性相關。無論是男性或女性長者，聽障對長者最常造成不便的情況是：「聽電視或收音機有困難」以及「在外面餐廳和朋友或家人一起時有困難」。本研究對象符合內政部定義”輕度以上聽障”( M4≧55dB HL)的長者中(n=120)，只有10.8%正在使用助聽器，而其中從未使用助聽器者(占78.3%)其實有28.7%覺得自己需要助聽器，卻因「聽說戴起來不舒服」(72.4%)或「不知道去哪裡配」(22.2%)而沒有去配。而對已有世界衛生組織定義中度以上聽障(M4≥41 dB HL)的555位長者，其中HHIE-S≥10的人45.4%使用或自覺需要使用助聽器，而HHIE-S<10的人只有5.0%使用或自覺需要使用助聽器，這個現象暗示”自覺聽力障礙”與”使用或自覺需要使用助聽器”很具關聯，似乎比實際的聽覺能力適於用來篩檢比較會去使用助聽器改善聽力的長者，至少在提供長者聽能復健服務時應列入考量。本研究這羣台北市社區65歲以上老人，有世界衛生組織定義「中度以上聽力損失(hearing impairment, M4≥41 dB HL) 」和「自覺聽力障礙(self-perceived hearing handicap, HHIE-S≥10)」只有中度相關(correlation coefficient rs=0.521) 。而自覺聽力障礙(HHIE-S總分)與中低頻聽力較相關，與高頻聽力(6和8 kHz)較不相關，且與雙耳M4(0.5-4kHz)最相關。在已知有世界衛生組織定義中度以上聽力損失(M4≥41 dB HL)的長者中：單變項分析時，70歲以上的年齡層，越老有自覺聽力障礙的比例也增加，這可能是越老聽力損失會越厲害，使得自覺聽力障礙比例增加；但65-69歲的族群有自覺聽力障礙的比例卻比70-74歲的族群還高，這似乎支持年紀較輕的老人比年紀大的容易覺得有聽力障礙，可是在校正其他因素後，年齡並非自覺聽力障礙的顯著相關因子。本研究有世界衛生組織定義中度以上聽損(M4≧41dB HL)的社區老人中，除了聽覺能力外，有喪偶、以及自覺整體健康狀況不好或普通，在校正其他因素後，仍是自覺聽力障礙的顯著相關因子(associated factors)。

結論 過去臺灣對老人聽障之相關研究相當缺乏，此橫斷式研究提供老人聽障及聽能復健狀況之資料，希望可以在相關議題上提供參考。因為自覺聽力障礙是會去尋求改善聽力的重要驅動力，加上聽力損失在老人中非常普遍，這些研究發現指出在社區老人中比較需要去進行聽力關懷的次族群--也就是較易自覺聽力障礙的那些老人。

OBJECTIVES: Presbycusis(age-related hearing impairment) is a common degenerative disorder among the geriatric population that warrants attention in a society with an aging population. Taiwan meets the World Health Organization’s criteria for a society with an aging population, with more than 9% of its population older than 65. The health-related issues of older persons, which include presbycusis, are of growing concern in Taiwan. A literature review of epidemiologic studies indicates that the prevalence of presbycusis differs among different groups of people. Prevalence data of presbycusis in older persons in Taiwan, however, is scarce. The objective of the present study was to report our analysis of a community-recruited cohort of elderly subjects aged 65 and older in Taipei, Taiwan, on (1) the prevalence and severity of presbycusis(age-related hearing impairment) in this cohort; (2) the use and need for hearing aids among the hearing-impaired, and also among the self-perceived hearing-handicapped; (3) the relationship between a hearing impairment and a self-perceived hearing handicap among this group of elderly persons, and (4) the various characteristics, besides hearing ability, associated with a self-perception of a hearing handicap among those subjects with a moderate -to-profound hearing impairment.

METHODS: A cross-sectional survey of community-dwelling elderly persons age 65 and older participating in an annual general purpose geriatric health examination in 2005 in Taipei. Pure-tone audiometry and a questionnaire including the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S) were administered, after obtaining the subject’s consent to participate in the study. Demographic information, lifestyle, self-report health status, and biochemical data were also collected.

RESULTS: A total of 1232 people aged 65 or older were recruited, among them 11 subjects with a history of bilateral ear disorder (ear drum perforation, hearing impairment since youth) were excluded. Thus, 1221 subjects (682 men and 539 women) were used for the final analysis. The main study findings are (1) The study cohort showed pure-tone thresholds worsening, especially at frequencies >2 kHz with increasing age. The mean pure-tone average at speech frequencies (0.5, 1, and 2 kHz) of the better ear of subjects stratified by 5-year age groups ranged from 34.9 dB hearing level (HL) to 46.4 dB HL. The pure-tone average at speech frequency in women was slightly higher than that in men in all age groups. When comparing the mean pure-tone thresholds of men and women at different audiometric frequencies within each age group, a “gender-reversal” phenomenon similar to that reported by Jerger et al was noted. That is, above 2 kHz men showed greater average loss than women, but below 2 kHz women showed greater average loss than men. At 2 kHz, there was no gender difference. The prevalence of presbycusis (defined by M3≥55dBHL) was 1.6% (65-69 years), 3.2% (70-74 years), 7.5% (75-79 years), and 14.9% (≥80 years); (2) Only 10.8% of who might be benefited by hearing aids(with M4≧55dB HL) were present-user of them. For study subjects with moderate-to-profound hearing impairment (M4≥41 dB HL), 5.0% of those with HHIE-S<10 and 45.4% of those with HHIE-S≥10 used or required hearing aids (χ2 test, p<0.001). The data suggested that a self-perceived hearing handicap (HHIE-S≥10) might be a better indicator than hearing impairment for referral for hearing aid fitting among elderly persons; (3) There was a moderate association (γs=0.521) between hearing impairment and self-perceived handicap. Only 21.4% of the study subjects with moderate-to-profound hearing impairment (M4≥41 dB HL, n=555) perceived themselves as hearing-handicapped (HHIE-S total score≥10). Besides hearing level, marital status (widowed) and self-perceived general health (bad or neutral) were all factors significantly associated with a self-perceived hearing handicap among elderly subjects with moderate-to-profound hearing impairment
CONCLUSIONS: These data provide primary quantitative information about estimates of prevalence and severity of presbycusis(age-related hearing impairment) among Taiwanese people. Since presbycusis is quite a common phenomenon among the older people, the findings of this study implied the high-risk subgroups with a self-perceived hearing handicap who would more likely to need the hearing rehabilitation services.

中文摘要 …………………………………………… 7
英文摘要 …………………………………………… 9
圖目錄 ……………………………………………… 11
表目錄 ……………………………………………… 12

第一章 緒論
第一節 研究緣起 …………………………………… 14
第二節 研究目的 ……………………… 16

第二章 文獻探討
第一節 本研究所使用重要名詞的定義 ……………………… 17
第二節 老人聽障的盛行率及嚴重度 ………………………… 20
第三節 老人聽障者使用助聽器的狀況 ………………………… 22
第四節 在老年族群中，聽力損失(hearing impairment)和自覺聽力
障礙(self-perceived hearing handicap)的關係 ………… 23
第五節 在老年族群中，自覺聽力障礙(self-perceived hearing
handicap)的非聽覺相關因子 ………………………… 25

第三章 材料與方法
第一節 研究取材背景 ………………………………………… 27
第二節 研究對象 ……………………………………………… 27
第三節 研究方法 ……………………………………………… 27
第四節 資料分析及統計方法 ………………………………… 29

第四章 結果與討論
第一部分 老人聽障的盛行率及嚴重度 …………………… 31
1.1 研究樣本(Study population)的年齡層和性別分布，
以及與母群體(target population)之比較 …… 31
1.2 純音聽力檢查結果 ………………………………… 33
1.3 同年齡層老人聽障「性別差異」的探討 ………… 35
1.4 臺北市老人聽障盛行率之估計值 …………………… 38
1.5 本研究老人中有耳鳴及眩暈的比例，及其相關因子… 39
1.6 第一部分〈討論〉 …………………………………… 39
第二部分 老人聽障者使用助聽器的狀況 …………………… 42
2.1 本研究所有受檢者中，使用助聽器的狀況 ………… 42
2.2 符合內政部定義「輕度以上聽障(M4≧55dB HL)」
的受檢者中，配戴助聽器的情形及經驗 …………… 42
2.3 符合內政部定義「輕度以上聽障(M4 ≧55dB HL)」
長者中，政府補助對配助聽器的影響 ……………… 43
2.4 自覺聽力障礙(self-perceived hearing handicap)或有聽力
損失(hearing impairment)的老人使用助聽器的狀況 … 44
2.5 第二部分〈討論〉 …………………………………… 45
第三部分 本研究的老人，對老人聽力障礙量表—篩檢版(HHIE-S)
各題回答之情況 ……………………………………… 46
第四部分 在社區老人中，聽力損失(hearing impairment)和
自覺聽力障礙(self-perceived hearing handicap)的關係…48
4.1 自覺聽力障礙(HHIE-S總分)與各種純音聽力閾值平均值
(pure-tone threshold average)的相關性(correlation)的探討48
4.2 聽力損失(以binaural M4代表)和自覺聽力障礙(以HHIE-S
總分代表)嚴重程度的不一致 ………………………… 49
4.3 臺灣老人的「會造成障礙的聽力損失(handicapped hearing
impairment)」的建議值 ……………………………… 51
4.4 第四部分〈討論〉 …………………………………… 52
第五部分 在社區老人中，自覺聽力障礙(self-perceived
hearing handicap)的非聽覺相關因子 ………………… 54
5.1 單變項分析(univariate analysis) ……………………… 55
5.2 多變項Logistic迴歸分析(Logistic regression analysis)57
5.3 第五部分〈討論〉 …………………………………… 58

第五章 研究限制與未來展望 ………………………… 61

第六章 結論 …………………………………………………… 63

結語 ………………………………………………………… 67

參考文獻 ……………………………………………………… 68

附錄一 本研究所使用問卷 ………………………………… 73

附錄二 本研究發表之期刊論文

1. Chang HP, Chou P. Presbycusis among older Chinese people in Taipei, Taiwan: a community-based study. International Journal of Audiology. 2007; 46(12):738-745 ………… 77

2. Chang HP, Ho CY, Chou P. The factors associated with a self-perceived hearing handicap in elderly people with hearing impairment —results from a community-
based study. Ear and Hearing. (under revision) ……… 86


張欣平醫師簡歷 …………………………………………… 124

誌謝 ………………………………………………………… 129

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