---
title: "Midlife Hearing Loss and Cognitive Performance: Evidence from Untreated Unilateral and Bilateral C"
id: "plos-one-3-cognitive-effects-of-untreated-unilateral-and-bilateral-hearing-loss-in-midlife"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-3-cognitive-effects-of-untreated-unilateral-and-bilateral-hearing-loss-in-midlife"
content_type: "clinical_feed_article"
specialty: "Neurology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204"
published_at: "2026-10-21T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Midlife Hearing Loss and Cognitive Performance: Evidence from Untreated Unilateral and Bilateral C
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-3-cognitive-effects-of-untreated-unilateral-and-bilateral-hearing-loss-in-midlife
- **Specialty:** [Neurology](https://medichelpline.com/clinical-feed/neurology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204)
- **Published At:** 2026-10-21T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The study compared **hearing loss** and normal-hearing middle-aged adults (age 40–65), matched 1:1 for age and socioeconomic status, using a cross-sectional group comparison design. - Forty-eight participants were enrolled: 24 with normal hearing and 24 with untreated hearing loss; among the latter, 9 had **unilateral** loss and 15 had **bilateral** loss. - Cognitive domains tested were memory (contextual memory test, forward and backward digit span), attention (Go/No-Go accuracy and reaction time), and executive function (letter and category verbal fluency). - Adults with untreated hearing loss performed significantly worse across all administered cognitive tasks compared with normal-hearing peers; effect sizes were large for memory tasks, category fluency and Go/No-Go accuracy, and moderate for letter fluency. - The investigators pooled NH and HL data for correlation analyses and found associations between better-ear **pure-tone thresholds** and cognitive measures; Spearman correlations were used with Bonferroni adjustment. - A PCA produced a single composite cognitive score (eigenvalue 3.18, explaining 40% variance), and multivariate linear regression showed that better-ear PTA independently predicted cognitive performance, while age and education did not. - All cognitive tests (except the contextual memory test presentation) were delivered visually via jsPsych; task order was randomized, practice trials given, and sessions split if participants fatigued. - Audiometry followed standard protocols (0.25–8 kHz, PTA computed as mean 0.5–4 kHz); degree of hearing loss used Goodman’s criteria; treatment status restricted to untreated, postlingual losses ≥6 months. - Statistical approach included Mann–Whitney U, Kruskal–Wallis with Dunn post hoc tests, Holm adjustment for multiple comparisons, and effect sizes reported; software used: JASP and R. - Investigators acknowledged limitations: modest sample size, cross-sectional design, convenience sampling, and that duration of hearing loss—though documented—was not included in primary analyses; they called for longitudinal studies to determine temporal relationships.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosone%2Farticle%3Fid%3D10.1371%2Fjournal.pone.0361204) * * About * Browse * Publish * [](https://journals.plos.org/plosone/ "PLOS One") * Search [advanced search](https://journals.plos.org/plosone/search) * [Browse Topics](https://journals.plos.org/plosone/subjectAreaBrowse) Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click [here](https://github.com/PLOS/plos-thesaurus/blob/master/README.md "Link opens in new window"). [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204) [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204) * 0 [Save](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#savedHeader) * 0 [Citation](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#citedHeader) * 28 [View](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#viewedHeader) * 0 [Share](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204#discussedHeader) Open Access Peer-reviewed Research Article # Cognitive effects of untreated unilateral and bilateral hearing loss in midlife: Preliminary evidence * Lakshmi Satheesan, Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing Affiliation Department of Audiology and Speech Language Pathology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India ⨯ * Usha Shastri , Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – review & editing * E-mail: usha.shastri@manipal.edu (US); gagan.bajaj@manipal.edu (GB) Affiliation Department of Audiology and Speech Language Pathology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-1172-3549 ](https://orcid.org/0000-0003-1172-3549 "ORCID Registry") ⨯ * Gagan Bajaj , Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing * E-mail: usha.shastri@manipal.edu (US); gagan.bajaj@manipal.edu (GB) Affiliation Department of Audiology and Speech Language Pathology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0001-7551-7889 ](https://orcid.org/0000-0001-7551-7889 "ORCID Registry") ⨯ * Mohan Kumar Kalaiah Roles Conceptualization, Supervision, Writing – review & editing Affiliation Department of Audiology and Speech Language Pathology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India ⨯ # Cognitive effects of untreated unilateral and bilateral hearing loss in midlife: Preliminary evidence * Lakshmi Satheesan, * Usha Shastri, * Gagan Bajaj, * Mohan Kumar Kalaiah ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: October 21, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0361204) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0361204) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0361204) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0361204) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec001) * [Method](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec002) * [Results](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec011) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec014) * [Conclusion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec016) * [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec017) * [Acknowledgments](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#ack) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0361204) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204) ## Abstract Hearing loss has been identified as a modifiable risk factor for cognitive decline and dementia, although most of the evidence is derived from studies in older adults. Identifying such cognitive impairment in midlife is crucial, as it serves as a baseline for understanding changes in cognitive abilities that occur later in life. The present study aimed to compare the cognitive performance of age- and socioeconomic status-matched middle-aged adults with normal hearing and those with untreated hearing loss. This study included 48 participants aged 40–65 years, comprising 24 adults with normal hearing and 24 with untreated hearing loss. Among the latter participants, 9 had unilateral loss and 15 had bilateral loss. The cognitive evaluation involved assessing memory (forward and backward digit span and contextual memory test), attention via the Go/No-Go task, and executive function via the letter and category fluency tasks. Results showed that adults with untreated hearing loss performed significantly poorer on all the cognitive tasks compared to their normal-hearing counterparts. Large effect sizes were observed for memory tasks, the category fluency task and Go/No-Go accuracy, and a moderate effect size for the letter fluency tasks. Furthermore, multivariate linear regression analysis demonstrated that better-ear pure-tone thresholds independently predicted cognitive performance, but not age or education. These findings provide preliminary evidence on the association between untreated hearing loss and cognitive performance in middle age. However, considering the modest sample size and cross-sectional study design, longitudinal studies are needed to determine the temporal relationship between hearing loss and cognitive changes. ## Figures ![Table 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t004) ![Table 5](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t005) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t002) ![Table 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t003) ![Table 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t004) ![Table 5](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t005) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t002) ![Table 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0361204.t003) **Citation:** Satheesan L, Shastri U, Bajaj G, Kalaiah MK (2026) Cognitive effects of untreated unilateral and bilateral hearing loss in midlife: Preliminary evidence. PLoS One 21(10): e0361204. https://doi.org/10.1371/journal.pone.0361204 **Editor:** Naveen Nagaraj, Cincinnati Children’s Hospital Medical Center, UNITED STATES OF AMERICA **Received:** September 18, 2025; **Accepted:** October 6, 2026; **Published:** October 21, 2026 **Copyright:** © 2026 Satheesan et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** All relevant data are within the paper and its [Supporting Information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#sec017) files. **Funding:** The author(s) received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Midlife, typically spanning 40–65 years, represents far more than the midpoint of the lifespan [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref001),[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref002)]. It is a transitional stage in which emerging physiological, psychological and social changes begin to shape future health trajectories [[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref003),[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref004)]. It serves as a baseline for understanding changes in cognitive abilities that occur later in life [[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref005)–[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref007)]. Given these multidimensional transitions, midlife represents a critical period during which emerging health conditions, particularly, sensory decline such as hearing loss may have disproportionate consequences for long-term cognitive and functional outcomes [[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref008)]. Acquired hearing loss in middle age can pose substantial challenges, particularly in complex listening environments encountered in occupational and social settings, such as workplace meetings, group discussions, and conversations involving multiple speakers [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref009),[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref010)]. Untreated hearing loss increases listening effort and fatigue, which can compromise occupational performance and contribute to psychosocial consequences, such as loneliness, social isolation, anxiety, and depression [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref011)–[14](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref014)]. In addition to psychosocial effects, Xu et al. [[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref015)] highlighted possible alterations in the nervous, respiratory, psychiatric, and cardiometabolic systems associated with hearing loss during midlife. Among the 14 potentially modifiable risk factors identified by the 2024 Lancet Commission, midlife hearing loss was identified as one of the leading contributors to dementia risk, accounting for an estimated 7% of potentially preventable dementia cases worldwide [[16](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref016)]. These findings highlight the importance of timely identification and management of hearing loss across adulthood. Epidemiological data from an Indian population-based study indicated that the prevalence of hearing loss increases with age, with an estimate of 4.1% among adults aged 40–49 years, 5.1% among those aged 50–59 years, and 21.8% among those aged 60–69 years [[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref017)]. Moreover, the ACHIEVE study reported that among older adults at increased risk for cognitive decline, hearing intervention slowed the loss of thinking and memory abilities by 48% over 3 years [[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref018)]. These findings highlight the potential importance of addressing hearing loss at an earlier age. This is particularly relevant to midlife, when cognitive decline may begin as young as 45–49 years of age [[19](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref019)]. As neuroplasticity and cognitive reserve remain relatively preserved during midlife, this stage represents an optimal window for interventions, where rehabilitation efforts may yield maximal benefit, by leveraging intact neural adaptability and compensatory mechanisms [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref002),[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref005),[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref007)]. A recent systematic review and meta-analysis [[20](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref020)] revealed impairments in overall cognitive performance (Cohen’s d = −0.43) [[21](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref021)–[26](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref026)], memory (Cohen’s d = −0.25) [[21](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref021)–[24](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref024)] and executive function (Cohen’s d = −0.42) [[21](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref021),[22](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref022),[24](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref024),[25](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref025)] in young and middle-aged adults with acquired hearing loss. Neuroimaging evidence has revealed greater volume declines in brain regions essential for cognition, such as the hippocampus and entorhinal cortex as a function of midlife hearing loss (45–65 years of age) [[27](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref027)]. These changes in brain structures closely mirror those observed in normal aging [[28](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref028)], suggesting a potential link between midlife hearing loss and adverse age-related changes in brain health. Hence, detecting those at risk of cognitive decline during middle age could be an important consideration in healthcare settings [[29](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref029)]. Hearing loss is a heterogeneous condition, and its cognitive consequences may vary according to characteristics of the impairment itself. In particular, laterality, duration of auditory deprivation, and treatment status may influence cognitive outcomes [[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref018),[23](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref023)–[25](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref025),[30](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref030)–[39](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref039)]. Existing studies have reported associations between both unilateral and bilateral hearing loss and poorer cognitive performance, although most have relied on global cognitive measures and have provided limited characterization of specific cognitive domains [[30](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref030),[31](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref031)]. Moreover, hearing loss characteristics such as duration and treatment status are often inadequately documented, complicating the interpretation of observed cognitive differences [[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref018),[23](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref023)–[26](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref026),[33](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref033)–[37](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref037),[40](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref040)]. Consequently, the cognitive effects of untreated hearing loss during midlife remain incompletely understood. In the present study, treatment status was restricted to untreated participants, laterality was examined by comparing unilateral and bilateral hearing loss, and the duration of hearing loss was documented but not included in the primary analyses. Recent perspectives in audiology have emphasized age-related hearing loss as a potentially modifiable risk factor associated with cognitive impairment and have highlighted the importance of early identification of cognitive changes in individuals with hearing loss [[41](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361204#pone.0361204.ref041)]. While the association between hearing loss and cognitive decline has been well-documented in older adults, limited evidence is available on whether middle-aged adults with untreated hearing loss demonstrate poorer performance across different cognitive domains than those with normal hearing, and whether cognitive performance differs between individuals with unilateral and bilateral hearing loss. Therefore, the present study adds to the literature by elucidating domain-specific cognitive performance in middle-aged adults with untreated hearing loss, while carefully matching participants for age and socioeconomic status. ## Method ### Participants Approval for the current study was obtained from the Institutional Ethics Committee (IEC No: IEC KMC MLR 07/2024/468) before the recruitment of participants for the study. This study followed a standard group comparison research design conducted at a single time point between two groups: individuals with normal hearing (NH) and individuals with untrea
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