aging causes a series of changes in the body . as in other organs , the first changes in the functioning of the auditory system can be observed around 30 to 40 years , and these changes intensify over time . hearing loss due to aging is called presbycusis 
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  the consequences of hearing loss may vary according to the type , degree , and age of onset . adults and older adult persons generally present with mild to moderate sensorineural hearing loss,2 
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 10 which can lead to isolation and restrict participation in social and family life , often as an effort to avoid becoming the subject of ridicule or contempt.11 hearing loss can also be associated with cognitive impairment , depression , and reduced functional status and quality of life.5 
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  the diagnosis and early intervention , as well as the implementation of a hearing reeducation program specific to the population of adults and older adults , are key issues to improve quality of life for this population and , consequently , enable them to enjoy a better family life and social integration.3 
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 19 in presbycusis , however , as the hearing loss occurs gradually and progresses slowly,4 
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 11 therefore , hearing screening should be a standard procedure in hospitals , health centers , and clinics , with the aim of quickly , easily , and inexpensively testing a large number of individuals , thus enabling early diagnosis and treatment and decreasing the consequences of hearing deprivation.5 
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 22 this procedure , however , is still not commonly used by professionals working with adults and older adults.23 in brazil , the most commonly used method to detect hearing loss is the complete audiometric evaluation , which requires a soundproof booth , and thus it is not accessible as a screening tool . currently , screening can be performed by means of standardized questionnaires10 or by undertaking simplified hearing tests , not intended to determine hearing thresholds but rather to identify the possibility of an individual presenting hearing loss.24 recently , a piece of portable equipment for hearing screening that can be used on individuals of different age groups has been launched in brazil . it is designed for use in quiet environments and does not require an audiometric booth . the operation of the device is extremely simple and does not cause any discomfort to the patient . subjects are instructed to pay attention and signal every sound they hear by raising their hand . a positive test indicates that the subject should undergo a complete audiological evaluation , according to the device 's user manual.25 
  given the nonexistence of similar devices in the brazilian market and the lack of a theoretical framework on the subject , this study aims to verify the device 's ability to discriminate between middle - aged and older adults with or without mild or moderate hearing loss , using two interpretation criteria : the one recommended by the manufacture 's manual ( criteria 1 ) and the one proposed by the authors of this study ( criteria 2 ) . this cross - sectional , observational , comparative study had a sample consisting of both men and women participating in university outreach projects , aged 45 years or older . the study was initiated after participants had signed the informed consent form . according to the norms established for human research , this study was reviewed and approved by the research ethics committee of the institute of psychology of the universidade federal do rio grande do sul ( under registration number 22229 ) . subjects included individuals who , at the time of data collection , presented with wax obstructing their ear canal , either unilaterally or bilaterally , identified by visual inspection of the ear canal ; outer ear pathologies ; cholesteatoma ; or chronic suppurative otitis media ( identified by a medical report or through information provided by the subject ) . after signing the informed consent form , the individuals answered a sociodemographic questionnaire consisting of questions related to hearing , tinnitus , and earache . after this , participants underwent a meatoscopy using a welchallyn ( new york , usa ) brand otoscope . the hearing screening was performed using the hearchek screener equipment from siemens ( munich , germany ) in a quiet environment , with noise levels under 50-db spl ( sound pressure level ) as per the guidelines in the device 's user manual.25 the environmental noise level was checked using the manaus dl-4020 sound pressure meter ( manaus , brazil ) . the machine produces a sequence of three sounds at the frequency of 1,000  hz ( 55- , 35- , and 20-db hearing level [ dbhl ] ) and three other sounds in the frequency of 3,000  hz ( 75 , 55 , and 35 dbhl ) . results were recorded in a specific form , indicating the number of times and the intensities at which the individual perceived the sound . according to the equipment 's user manual , individuals who perceived more than three sounds were considered to have the screening , whereas individuals who heard less than three sounds in each ear were considered to have  failed because two of proposed sounds ( 35 and 20 dbhl at 1,000 hz ) fall in the normal hearing threshold , the authors of this work decided to test also different criteria : the participant was considered to have failed the screening if they did not hear five of six sounds . therefore , individuals who perceived at least five of the sounds presented in each ear were considered to have  passed  ( criteria 2 ) . tone thresholds were tested by air conduction from 250 to 8,000  hz and by bone conduction from 500 to 4,000 hz . an ad 229e audiometer ( denmark ) was used , with tdh-39 ( usa ) headphones . the degree of hearing loss was classified by finding the mean of the thresholds obtained at the frequencies of 500 , 1,000 , 2,000 , and 4,000 hz . mean values equal to or under 25 dbhl indicated normal hearing ; mean values between 26 and 40 dbhl indicated mild hearing loss ; mean values between 41 and 60 dbhl indicated moderate hearing loss ; mean values between 61 and 80 dbhl indicated severe hearing loss ; and mean values over 81 dbhl indicated profound hearing loss.26 after the examinations had been performed , the sensibility ( percent of true - positive tests ) and specificity ( percent of true - negative test ) were calculated for both criteria . we chose to include only subjects with normal hearing thresholds and mild to moderate hearing loss in the study , because they represent more significantly the effects of aging on hearing . as described earlier , most of the individuals in the age group under study presented with these degrees of hearing loss.2 
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  the data analysis initially approached descriptive statistics , with the distribution of simple and relative frequencies , as well as mean , standard deviation , and range , and the symmetry was investigated using the kolmogorov wallis test was performed to check if the discriminatory accruals were significantly different , because this test does not require observing the assumptions of the previous tests . to evaluate the accuracy of the screening tests for the diagnosis of hearing loss , calculations of sensitivity , specificity , positive predictive value , and negative predictive value were performed using the result of the pure tone audiometry as the gold standard , through the mcnemar test . data were treated statistically using the statistical package for social sciences for windows 17.0 software ( usa ) and , for decision criteria , a significance level (  ) of 5% was adopted . the data analysis initially approached descriptive statistics , with the distribution of simple and relative frequencies , as well as mean , standard deviation , and range , and the symmetry was investigated using the kolmogorov wallis test was performed to check if the discriminatory accruals were significantly different , because this test does not require observing the assumptions of the previous tests . to evaluate the accuracy of the screening tests for the diagnosis of hearing loss , calculations of sensitivity , specificity , positive predictive value , and negative predictive value were performed using the result of the pure tone audiometry as the gold standard , through the mcnemar test . data were treated statistically using the statistical package for social sciences for windows 17.0 software ( usa ) and , for decision criteria , a significance level (  ) of 5% was adopted . the sample consisted of 55 subjects , with a mean age of 65.3    8.4 years , with ages ranging between 48 and 85 years . of the total of study participants , 20.0% ( n  =  11 ) were between 48 and 59 years , 52.7% ( n  =  29 ) were between 60 and 69 years , and 27.3% ( n  =  15 ) were between 70 and 85 years . the majority of the group under study were females , accounting for 83.6% ( n  =  46 ) of the sample . there was a predominance of normal hearing thresholds ( p  <  0.001 ) in both the right ear ( 64.8% ) and the left ear ( 74.5% ; table 1 ) . there was a loss by nonresponsiveness in the right ear evaluation . to analyze the use of the screening equipment regarding sensitivity and specificity in terms of detecting hearing loss , data were analyzed for each ear separately , so as to more accurately identify the probability of pass or fail . according to the results presented in table 2 , for the right ear , it was found that the screening had a very low sensitivity using criteria 1 , reaching a value of only 26.3% . specificity , in turn , was 100% ( i.e. , all ears classified as having normal hearing passed the screening ) . when using criteria 2 , there was an increase in sensitivity ( 94.7% ; i.e. , of the 19 ears with hearing loss , 18 failed the screening ) . of the 35 right ears with normal hearing , 26 passed the screening ( table 2 ) 
 table 3 presents the results of the hearing screening in the left ear . thereby , of the 14 ears with hearing loss , only three failed the screening . specificity was at 100% ( i.e. , all ears with normal hearing passed the screening ) . with the use of criteria 2 , sensitivity was at 100% ( i.e. , all the ears diagnosed with hearing loss failed the screening ) . thus , of 41 ears with normal hearing , only 27 passed the hearing screening ( table 3 ) . this study aimed to verify the sensitivity and specificity of hearing screening in middle - aged adults and older adults with or without mild to moderate hearing loss , when compared with a pure tone audiometry ( gold standard ) . studies have underscored the screening as an important hearing care activity , because it enables early diagnosis and intervention in adults and older adults.7 
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  this study showed a sample made up mostly of females ( 83.6% ) . this factor may be related to the greater number of women in the studied age group,9 
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 34 as well as to a more effective presence of the female gender in group activities and to a more active lifestyle,33 because the population under study attends university outreach activities . a significant number of individuals had hearing classified as normal ( 64.8% for right ear and 74.5% for left ear ) . mild ( 27.8% right ear and 12.7% left ear ) to moderate ( 7.4% right ear and 12.7% left ear ) cases of hearing loss were also observed in the sample . the literature shows similar results to those found in this work , because one of the characteristics of presbycusis is mild to moderate hearing loss.2 
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  mild hearing loss is not regarded as disabling , because it allows individuals to perceive most environmental sounds . moderate hearing loss , on the other hand , can incapacitate an individual for adequate social life.26 it should be noted , however , that even mild hearing loss hinders the perception of consonant sounds that are important to proper speech recognition and discrimination , thus causing communication disturbances that can lead to social isolation and alienation from the family . therefore , even mild hearing loss should be identified , and individuals suffering from it should be referred for rehabilitation . the screening is an examination aiming to determine whether or not a person is likely to have the investigated disorder . the usefulness of a screening should be evaluated against an independent standard ; in audiology , this standard is the pure tone audiometry.35 
  hearing screenings in older adults , however , have been the subject of few studies . previous studies have reported the use of various methods , such as self - assessment questionnaires,3 
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 28 tests using a tuning fork,5 
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 35 tests using a single generic question,3 
 27 and tests using a portable audioscope ( welch allyn inc . , skaneateles fall , new york , united states ) device.3 
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 28 among these methods , the most reliable for screening hearing impairment involve the use of the audioscope,5 
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 29 and the joint application of the hearing handicap inventory for the elderly instrument  reduced version  and the audioscope.22 
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  the audioscope is similar to the equipment used in our study . it is an otoscope that emits pure tones at the frequencies of 500 , 1,000 , 2,000 , and 4,000  hz , at intensities of 20 , 25 , and 40 dbhl . screening using this equipment does not require expertise in audiology and lasts approximately 3 minutes.36 
  the results obtained show that , by analyzing the responses of the hearing screening using criteria 1 , there was high specificity but low sensitivity ( i.e. , the equipment did not allow for the identification of individuals with mild to moderate hearing loss ) . considering this method of analyzing the results , sensitivity and specificity values were lower than with the audioscope . in a previous study,37 seniors had been screened in medical offices and at an audiological center . sensitivity was identical in both locations ( 94% ) and specificity was lower in medical offices ( 72% ) when compared with the audiological center ( 90% ) . when using the new evaluation method proposed by the researchers ( criteria 2 ) , however , there was a significant increase in sensitivity , but a decrease in specificity was observed . with this new way of interpretation , the sensitivity values reached 94.7% in the right ear and 100% in the left ear . the values proved similar to those obtained with the audioscope , thus extending the possibility of identifying individuals with mild and moderate hearing loss , which usually occurs in presbycusis . however , this interpretation decreased specificity values , which was 100% for both ears using the manufacturer 's criterion . with the new criterion , the specificity obtained was 74.3% for the right ear and 65.9% for the left ear , which means that the possibility of false - positives increased . in diseases of high prevalence in the population , such as hearing loss , screening tests must have a high sensitivity to be useful to clinicians , because , otherwise , negative results may be false - negatives.38 false - negatives should be the main concern for the screening . when hearing loss goes undetected , individuals are not referred for assessment and diagnosis , which consequently prevents treatment from being initiated . thus , the cutoff or criterion used must prioritize maximum sensitivity,24 
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  based on this premise , it is believed that the interpretation of results using the criterion set by the investigators is more effective and efficient for detecting hearing loss in adults and older adults . it is suggested , therefore , that professionals begin using this new criterion , thus reducing the possibility of false - negatives and ensuring that individuals with mild to moderate hearing loss are identified during hearing screening using portable equipment . it is important to reinforce that testing was performed considering individuals with normal hearing and with mild to moderate hearing loss . in these individuals , the method developed by the researchers was more appropriate , proving to have enough sensitivity to identify minimal hearing loss . therefore , it became clear that , provided the properly established criteria for analysis of the responses , this portable equipment possesses excellent usefulness in daily clinical practice , allowing middle - aged adults and older adult persons with hearing loss to be identified , referred for evaluation , and , if necessary , oriented on the use of hearing aids . this study showed that , in the hearing screening of middle - aged adults and older adults using portable equipment , the rules for interpreting results suggested by the manufacturer showed low sensitivity and high specificity in identifying mild to moderate hearing loss . however , the adoption of a new criterion developed by researchers increased the sensitivity , thus allowing individuals with such degrees of hearing loss to be identified . we concluded that , when using the proper methodology , hearing screening devices can be effective in screening for hearing loss in adults and older adult persons .
introduction  hearing screening allows the identification of individuals with hearing loss . 
 aim  to determine the sensitivity and specificity of a portable hearing screening device in middle - aged and older adults using the manufacturer scoring and a scoring system proposed by the researchers . 
 methods  in this transversal study , participants underwent anamnesis , otoscopy , and hearing screening using portable equipment . 
 after this , a pure tone audiometry was performed , with participants classified into two groups : with and without hearing loss . 
 the sensitivity and specificity of the hearing screening were calculated for the right and left ears using two methods of interpretation : the original method recommended by the manufacturer ( criteria 1 ) and the method proposed by researchers ( criteria 2 ) . 
 results  the sample consisted of 55 individuals , 83.6% ( n  =  46 ) of whom were women . 
 per criteria 1 , the sensitivities were 26.3 ( right ear ) and 21.4% ( left ear ) . 
 the specificity was 100% for both ears . 
 using criteria 2 , the sensitivity was 94.7 ( right ear ) and 100% ( left ear ) . 
 the specificity was 74.3 ( right ear ) and 65.9% ( left ear ) . 
 conclusion  this study showed that the criteria proposed by the manufacturer presented low sensitivity in the hearing screening . 
 the criteria proposed by the researchers to achieve a more efficient performance reached high and balanced values for sensitivity and specificity .