Hearing loss in old age, which often goes untreated, has far-reaching consequences. Furthermore, reduction of cognitive abilities and dementia can also occur, which also affects quality of life. The aim of this study was to investigate the hearing performance of seniors without hearing complaints with respect to speech perception in noise and the ability to localize sounds. Results were tested for correlations with age and cognitive performance. The study included 40 subjects aged between 60 and 90 years (mean age: 69.3 years) with not self-reported hearing problems. The subjects were screened for dementia. Audiological tests included pure-tone audiometry and speech perception in two types of background noise (continuous and amplitude-modulated noise) which was either co-located or spatially separated  from the target speech. Sound localization ability was assessed and hearing performance was self-evaluated by a questionnaire. Speech in noise and sound localization was compared with young normal hearing adults. Although considering themselves as hearing normal, 17 subjects had at least a mild hearing loss. There was a significant negative correlation between hearing loss and dementia screening (DemTect) score. Speech perception in noise decreased significantly with age. There were significant negative correlations between speech perception in noise and DemTect score for both spatial configurations. Mean SRTs obtained in the co-located noise condition with amplitude-modulated noise were on average 3.1 dB better than with continuous noise. This gap-listening effect was severely diminished compared to a younger normal hearing subject group. In continuous noise, spatial separation of speech and noise led to better SRTs compared to the co-located masker condition. SRTs in MSNF deteriorated in modulated noise compared to continuous noise by 2.6 dB. Highest impact of age was found for speech perception scores using noise stimuli with temporal modulation in binaural test conditions. Mean localization error was in the range of young adults. Mean amount of front/back confusions was 11.5% higher than for young adults. Speech perception tests in the presence of temporally modulated noise can serve as a screening method for early detection of hearing disorders in older adults. This allows for early prescription of hearing aids. The World Health Organization (WHO) estimates that approximately one third of all people over the age of 65 suffer from a hearing loss, although the number of unreported cases is likely to be even higher, as it usually takes time before a progressive hearing loss is diagnosed . From 20Although hearing impairment has a major impact on the quality of life of the elderly. hearing loss in elderly subjects is frequently undetected and untreated . In a stIt is known that speech perception in noise is impaired even in the presence of a mild hearing loss compared to age-matched normal-hearing individuals . In the Likewise, In Summary, increasing age adversely affects the processing of both TFS and slowly varying envelope (ENV), whereby a stronger correlation with speech perception in noise was found for TFS. Therefore, spatial release from masking (SRM) is reduced for speech stimuli in older subjects with or without hearing loss. This implies that aged subjects will have difficulties relative to young normal-hearing subjects when trying to understand speech in the presence of interfering sounds coming from different directions in space, as is common in everyday life .Therefore, the aim of the present study was to investigate speech perception under complex noise conditions with multiple noise sources in a cohort of older persons. Speech reception thresholds (SRTs) were assessed in two types of background noise (continuous and amplitude-modulated noise) which was either co-located or spatially separated  from the target speech .It was expected that impaired TFS and ENV processing as well as a potentially reduced SRM effect would show an impact on SRTs as a function of age. In addition, spatial hearing ability was evaluated based on the accuracy of sound localization obtained for broadband noise stimuli. Screening of cognitive performance was assessed to identify potentially deteriorated results that might correlate with the hearing test battery outcomes. Finally, results from a cohort of seniors with no self-reported hearing loss  were compared with data obtained in previous studies using the same test setup in young adults with normal hearing .The study comprised a total of 40 subjects . The subjects were aged between 60.1 and 89.7 years .Subjects were recruited for participation via flyers and an advertisement at the grounds of the University Hospital Frankfurt. The three inclusion criteria mentioned in that advertisement were (1) aged 60 or higher, (2) no subjective awareness of any hearing problems, and (3) no use of hearing aids. Each of the subjects was a native German speaker, as the speech perception tests were conducted in German. The study was approved by the Ethics Committee of the Department of Medicine of the Goethe University in Frankfurt am Main, Germany (No. 164/13).Before performing the tests, an ear inspection was performed and a tympanogram was obtained for each ear to exclude study candidates with eventual conductive hearing loss. The study tests required ~3 h per subject and were each conducted on 1 day. The order of study tests was randomized.The DemTect  was usedThe results of the individual subtests are converted into age-corrected test scores, then summed up and expressed as a DemTect score (max. 18 points). The resulting test scores are independent of age and educational level and thus provide information on whether cognitive performance is age-appropriate (DemTect score: 13–18 points), slightly impaired (DemTect score: 9–12 points) or whether dementia is suspected (DemTect score: ≤8 points) . The durPure-tone audiometry was performed in a sound-attenuated room to determine the subjects’ individual hearing thresholds. Air conduction hearing thresholds were determined for pure-tones from 125 to 8,000 Hz for each ear of each subject using calibrated headphones. Bone conduction hearing thresholds were not determined because middle ear pathologies were excluded in advance both by patient history and by tympanometry. The pure-tone average (PTA) hearing loss was determined from the frequencies 500 Hz, 1, 2, and 4 kHz (PTA_4). Furthermore, a pure-tone average hearing loss for high frequencies was calculated as mean hearing loss of the frequencies 4, 6, and 8 kHz (PTA_high).Speech tests were conducted for different types of background noise in two spatial loudspeaker configurations to simulate everyday listening situations. The measurements were conducted in an anechoic chamber with dimensions 4.1 m × 2.6 m × 2.1 m (length × width × height). The system for sound playback consisted of 128 loudspeakers arranged in a rectangular array in the horizontal plane at a height of 1.20 m, which corresponded approximately to the ear height of the seated subjects. Further detailed information on the playback system is given in Speech reception thresholds (SRTs) in noise were determined with the German matrix test [Oldenburg Sentence Test, OLSA, The test was conducted in a closed set mode, i.e., the subject had to select the perceived words of the sentence on a matrix presented on a touchscreen. In order to become familiar with the task, a training trial with 30 test sentences was performed with each subject before the study test began. Subsequently, four test runs of the OLSA were performed with each subject in random order, differing in noise type and spatial noise configuration.Two types of noise were used. The speech-shaped “OlNoise” is a temporally continuous noise whose long-term spectrum matches that of the word material of the matrix test . This coTwo spatial noise configurations were tested. In the first condition, noise was presented from the same direction as speech signal .In the second condition, a diffuse noise  was created by means of wave field synthesis . Four vin = 14, mean age: 26.4 ± 5.4 years, range: 22–37.3 years) using the identical test setup was shown. The criterion for normal hearing was a pure-tone hearing loss lower than 25 dB HL between 0.25 and 8 kHz. The results obtained in the cohort of older subjects in the present work were compared with the data from In the study of The test for sound localization took place in the same anechoic room with the same loudspeaker arrangement. LED chains with a total of 704 individual LEDs were mounted above the loudspeakers to indicate the direction of sound incidence.via the toggle switch and mirrored to the front. Prior to the start of the test, a detailed introduction to the LED display system took place, as well as a training run in which each test loudspeaker was tested once. A total of seven test loudspeakers were tested between −60 and +60°  in front and back. Each of the 14 test loudspeakers was randomly selected five times  in order to measure the localization accuracy  and uncertainty (dispersion of mean error) of localization. The test was performed in complete darkness. The duration of a whole test run was about 15 min.The test stimulus was a white noise (high-pass filtered at 150 Hz) consisting of five pulses. Each pulse had a duration of 30 ms with a rise time of 3 ms followed by a pause of 70 ms [according to n = 9, mean age: 30.3 ± 6.1 years, pure-tone hearing loss lower than 25 dB HL for all test frequencies between 0.25 and 8 kHz) using the identical test setup (data unpublished so far).The relative localization error was calculated for each subject by averaging the relative localization errors of each angle (both front and back). Furthermore, the percentage front-back confusions were calculated. Results were compared with data obtained in young adults with normal hearing  questionnaire  to assesp-values were adjusted using the Bonferroni-Holm method. Adjusted p-values < 0.05 were considered as statistically significant. Only adjusted p-values were given in the manuscript if not stated otherwise.The collected data was processed and analyzed using the statistical program SPSS Statistics 27 . The target variables of the various tests were checked for normal distribution. Since none of the target variables showed a normal distribution, further evaluation was carried out with non-parametric methods. The Spearman Rho test was used to examine the correlation between the test variables. For multiple comparisons Individual results of the DemTect are shown in Pure-tone thresholds of the 40 subjects  are shown in Median PTA_4 was 18.75 dB HL (IQR: 12.5-27.5 dB HL), median PTA_high was 35 dB HL (IQR: 20-56.7 dB HL).p < 0.001; S0N0 modulated noise: Z = −3.515, p < 0.001; MSNF continuous noise: Z = −2.642, p = 0.016; MSNF modulated noise: Z = −2.236, p = 0.025).The SRT results divided in two age groups 60–74 years and 75–90 years for the different test conditions are shown in p < 0.001). The IQR of the SRTs obtained in modulated noise (−6.2 to −10.6 dB SNR) was 3.1 dB larger than the IQR for continuous noise.Boxplots of SRT results averaged over all older study participants were shown in p < 0.001). The IQR of the SRTs obtained in MSNF with modulated noise (−3.0 to −7.4 dB SNR) was 2.8 dB larger than the IQR for continuous noise.The SRT in MSNF using continuous noise was −8.8 dB SNR (IQR: −8.1 to −9.7 dB SNR), 3.7 dB significantly lower than the SRT for the modulated noise . In the modulated noise condition, a significantly lower SRT was obtained in S0N0 condition compared with MSNF .Speech reception thresholds with continuous noise were significantly higher in the S0N0 condition than in the MSNF condition . Mean difference was lowest for test conditions using continuous noise . More important, in conditions with modulated noise large differences between younger and older subjects were found .Speech reception thresholds results obtained in young adults with normal hearing using the identical test setup  are illuThe median relative localization error was 5.8° (interquartile range: 4.5–8.1°) and the median amount of front-back confusions was 12.9% (interquartile range: 5.0–31.1%).n = 9, mean age: 30.3 ± 6.1 years).Results of mean localization error and front-back confusions divided in two age groups 60–74 years and 75–90 years are provided as p < 0.001) compared with young adults.The results of front/back confusions are shown in Correlations in the senior group between age and DemTect scores, pure-tone hearing thresholds, and speech in noise scores and were shown in p = 0.04). There was significant correlation between age and PTA_4  as well as between age and PTA_high . There was a significant correlation between age and S0N0 SRT for both types of noise . There was a significant correlation between age and MSNF SRT for continuous noise  and modulated noise .A significant negative correlation between age and DemTect score was found  was found.After partialling out high-frequency hearing loss, only a significant correlation between age and S0N0 SRT in continuous noise  and between the DemTect score and the MSNF SRT in modulated noise . A scatterplot showing individual DemTect scores and MSNF SRTs in modulated noise is provided as p = 0.017) and between S0N0 SRT in modulated noise and DemTect score  was found which failed to reach significance after Bonferroni-Holm correction (p = 0.06 for both correlation coefficients).There was a significant negative correlation between the DemTect and the S0N0 SRT in continuous noise  and the total SSQ scores  failed to reach significance after Bonferroni-Holm correction (p = 0.084 and p = 0.117). After partialling out high-frequency hearing loss, no significant correlations between age and SSQ scores were found.Correlations between age and SSQ scores are shown in Spearman rank correlations were calculated between SSQ speech scores of the senior subject group and high-frequency hearing loss and SRTs in noise. SSQ spatial scores were analyzed for potential correlations with high-frequency hearing loss, SRTs in spatially separated noise and localization scores. Furthermore, correlations between mean total SSQ score and all hearing performance measures were calculated. The correlation coefficients are shown in p = 0.025). Negative correlations between SSQ score of speech and PTA_high  and SRTs in modulated noise  failed to reach significance after applying a Bonferroni-Holm correction .A significant negative correlation (after applying a Bonferroni-Holm correction) was found between the SSQ score of speech perception and the SRT in configuration S0N0 for continuous noise  failed to reach significance after applying a Bonferroni-Holm correction (p = 0.22).A negative correlation between the SSQ score for spatial hearing and localization error . Negative correlations between total SSQ score and PTA_high , SRTs in modulated noise  and localization error  became non-significant (p = 0.12/0.06/0.12/0.141) after correction for multiple comparisons.There was a significant negative correlation between the mean total SSQ score and the SRT in the configuration S0N0 in continuous noise  could be substantially degraded as reflected in the speech in noise tests using MSNF. The slope of the speech discrimination function for modulated noise in S0N0 and MSNF is ~6%/dB. Therefore, mean deterioration of speech perception in modulated noise in compared with young adults was 58.8% (S0N0) and more than 37 percent (MSNF). In conditions using continuous noise differences of about 18% (MSNF) and 31% (S0N0) were found. Since speech perception in clinical routine is mainly assessed in quiet or in continuous noise, it could be expected that deficits in speech perception in the elderly in everyday conditions are oftentimes underestimated.In the co-located target and masker condition S0N0, mean SRTs in modulated noise were significantly lower than in continuous noise. The amplitude-modulated noise contains temporal gaps, which enables for release from masking (RM). Furthermore, In our study RM was found to be 3.1 dB and, thus, 7.9 dB poorer than in a normal hearing adult group. A possible explanation for the reduced RM in seniors in the present study could be that these seniors had age-related hearing loss. As one result, audibility for sibilants is reduced. There are also deficits in frequency selection resulting in poorer separation of speech and noise and making temporal gaps more difficult or impossible to detect . DuquesnThe role of binaural processing is evident in the tested MSNF condition where speech and noise were spatially separated. Spatial release from masking (SRM) leads to improved SRTs compared to a co-located masker and target position due to the head shadow and binaural squelch effect. In the study by In the present study, DemTect scores correlated significantly with two out of four OLSA SRTs. During the OLSA task the subject has to remember five words before recalling them on a touch screen display. Working memory stores verbal information while processing that information . If the The mean localization error in our study population was only slightly but not significantly increased compared with normal hearing young adults. This is in line with results reported by This is supported by the result of a significantly higher amount of front-back confusions compared with young adults which was confirmed in two other studies . The occIn the present study no significant correlation between the results of cognitive performance and the localization ability of sounds was found. Likewise, Sixty-five percent of the subjects showed age-appropriate cognitive performance in the DemTect test, and 35% of the subjects showed a mild cognitive impairment. None of the subjects were suspected of having dementia. Since study subjects were recruited for participation via flyers and an advertisement at the grounds of the University Hospital Frankfurt, it is also conceivable that seniors with reduced cognitive performance who were already being cared for by nursing at home or in a retirement home may not have been reached at all. Therefore, our study group cannot be considered as representative.Memory span of the working memory decreases with age . This war = 0.5). In a study by On the other hand, the correlation between age and DemTect score vanished after partialling out high-frequency hearing loss and applying Bonferroni-Holm correction for multiple comparisons. It was also shown that subjects with higher age and more severe hearing loss  and/or with higher SRTs in noise (three out of four tests) tended to have lower DemTect scores. The Berlin Aging Study also reported that individuals with poorer hearing also had poorer cognitive performance  there was at least some awareness of the subjects for an own auditory deficit. Nevertheless, all of them described themselves as having no hearing problems. This suggests that not only the own perception of hearing loss is a problem for seniors, but also to accept hearing disabilities and deciding to seek help is a challenge. All subjects without self-reported hearing complaints were included. Since subjects suffering from so far unnoticed hearing loss were not excluded the study population is partly inhomogeneous. Another drawback is potentially that subjects with asymmetric hearing loss were included. A higher amount of subjects aged 80 and older would be desirable to extent the quality of correlation analysis. Furthermore, additional tests on temporal processing  are in need to interpret deficits in speech perception in modulated noise or spatial noise conditions and its relation to cognitive performance.Although no complaints about hearing ability were reported in the present study group of seniors, the results of the study support the hypotheses that hearing performance decreases with increasing age together with declining cognitive abilities even if not detected by the subject itself. This holds especially for speech perception in noise in complex conditions where intact binaural hearing is a mandatory requirement. Therefore, special attention should be given to hearing screening programs to improve the quality of life of older people. Speech perception tests using temporally modulated noise can serve as a screening method for early detection of hearing disorders in older adults. Hearing screening should also be mandatory for dementia patients, just as dementia screening is mandatory for seniors with known hearing loss. Further research is needed to investigate on the causality between dementia and hearing loss.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Department of Medicine of the Goethe-University Frankfurt am Main, Germany (No. 164/13). The patients/participants provided their written informed consent to participate in this study.TW and UB contributed to the conception and design of the study. CM and TW organized and conducted the experiments, performed the statistical analysis, and wrote the first draft of the manuscript. All authors contributed to the interpretation of the data, manuscript revision, and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


CDH23 gene are known to be responsible for both syndromic hearing loss (Usher syndrome type ID: USH1D) and non-syndromic hearing loss (DFNB12). Our series of studies demonstrated that CDH23 variants cause a broad range of phenotypes of non-syndromic hearing loss (DFNB12); from congenital profound hearing loss to late-onset high-frequency-involved progressive hearing loss. In this study, based on the genetic and clinical data from more than 10,000 patients, the mutational spectrum, clinical characteristics and genotype/phenotype correlations were evaluated. The present results reconfirmed that the variants in CDH23 are an important cause of non-syndromic sensorineural hearing loss. In addition, we showed that the mutational spectrum in the Japanese population, which is probably representative of the East Asian population in general, as well as frequent CDH23 variants that might be due to some founder effects. The present study demonstrated CDH23 variants cause a broad range of phenotypes, from non-syndromic to syndromic hearing loss as well as from congenital to age-related hearing loss. Genotype (variant combinations) and phenotype  are shown to be well correlated and are thought to be related to the residual function defined by the CDH23 variants.Variants in the The online version contains supplementary material available at 10.1007/s00439-022-02431-2. CDH23 gene, a member of the cadherin superfamily, encodes calcium-dependent cell–cell adhesion glycoproteins and is known to be expressed in both the inner and outer hair cells in the cochlea. Encoded protein cadherin 23 comprises the “Tip Link” structure of the stereocilia important for hair cell function  and non-syndromic hearing loss (DFNB12) , from congenital profound hearing loss to high-frequency-involved progressive hearing loss   were recruited from 102 otolaryngology departments nationwide. Among these subjects, we selected patients with CDH23 variants based on MPS for 63 target genes. Prior to participation in this study, which was approved by the Shinshu University Ethical Committee and the ethical committee within each participating institution, written informed consent was obtained from all patients . Clinical information and peripheral blood samples were obtained from each subject and from all their consenting relatives. This study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Shinshu University School of Medicine (No. 387-4 September 2012 and No. 576-2 May 2017).http://hereditaryhearingloss.org/) were analyzed in this study. The detailed protocols for targeted enrichment and DNA sequencing have been described elsewhere , the 6,500 exome variants (http://evs.gs.washington.edu/EVS/), The Genome Aggregation Database (https://gnomad.broadinstitute.org), the human genetic variation database (dataset for 1208 Japanese exome variants) (http://www.genome.med.kyoti-u.ac.jp/SnpDB/index.html), the 8300 Japanese genome variation database (https://jmorp.megabank.tohoku.ac.jp/202102/) and the 333 in-house Japanese normal hearing controls. The filtering procedures were performed using our original database software as described previously (Nishio and Usami http://www.bioinformatics.nl/cgi-bin/primer3plus/primer3plus.cgi).Sixty-three genes . The variants consisted of 90 missense variants, 9 nonsense variants, 11 splicing variants and 16 frameshift deletion variants. Variants were defined as likely causative variants if the following criteria were fulfilled: (1) pathogenic or likely pathogenic based on the ACMG criteria, or (2) in the case of variants of uncertain significance (VUS) based on the ACMG criteria, where significant CADD scores (> 20) were observed, (3) biallelic variants found in recessive inheritance cases, (4) no other candidate variants were found and (5) there was no contradiction with the family analysis (if samples from family member were available). Based on the ACMG guidelines, the variants were categorized into 24 pathogenic, 40 likely pathogenic and 62 VUS. Among the mutations, p.P240L was the most common , followed by p.R1588W , p.R2029W  and p.E956K  . Among them, six patients had associated visual impairment (Supplementary Table 3).Various combinations of biallelic variants were detected and a total of 307 subjects were diagnosed as suffering hearing loss caused by As shown in Fig. With regard to genotype/phenotype correlations, in contrast to the patients with p.[P240L];[P240L], p.[P240L];[E956K] p.[P240L];D1347N] and p.[P240L];[Q1716P] who exhibited more severe hearing loss with limited residual hearing in the lower frequencies, the majority of patients with p.[P240L];[R1588W], p.[P240L];[R2029W], p.[R1588W];[R1588W] and p.[R2029W];[R2029W] showed high-frequency-involved hearing loss  and 120 used cochlear implants or electric acoustic stimulation (CI/EAS), with 13 cases not wearing any aids and 6 unknown cases (Supplementary Table 2).With regard to the effects of hearing aids and cochlear implantation, hearing threshold (dB) and monosyllable perception score (%) were found to be significantly improved after these interventions Fig. .Fig. 5BeCDH23 variants. No other candidate variants were found in these patients. The present large-cohort study revealed that the prevalence of CDH23-associated hearing loss was 2.64%  among bilateral SNHL probands and 3.95% (273/6912) among ARSNHL/sporadic probands in this Japanese population. Some patients (n = 29) were found in ADSNHL families, which is probably due to a pseudo-dominant inheritance pattern. These frequencies are slightly higher than those in our previous report  . As in our previous reports on DFNB12 , p.R2029W (10.3%) and p.E956K (4.7%). These four common variants account for 62.4% of all variants. For such recurrent variants, founder effects have been demonstrated in many deafness genes: for example, with regard to GJB2, it is reported that c.35delG, which is predominant throughout Europe, the Middle East, North Africa, North and South America and Australia; and c.235delC, which is commonly found in East Asians, are due to founder effects  of the patients. According to the age at which clinical information was collected (see Supplementary Table 2) and the age range of patients with each combination of biallelic variants, visual symptoms were not observed, despite the inclusion of a large number of patients aged 10 years and older. Phenotype classification (DFNB12 or Usher phenotype) is shown in Supplementary Table 2. It is necessary to take into consideration that patients with “non-syndromic (NS)” hearing loss up to the second decade may experience visual symptoms in the future. However, some cases with the same variant do not present with visual symptoms even in the third decade. For example, in terms of p. [P240L]; [P240L], 22 patients were within the second decade, so the term NVS  is used; however, as no visual symptoms were observed in two patients over the third decade, it was speculated that this variant shows a non-syndromic phenotype. The same results can be observed for many variants. The majority of patients (192/198) were found to not have any associated visual symptoms; therefore, most patients with the trans configuration show a non-syndromic phenotype  identified in this study (Supplementary Table 1) were missense mutations, which are supposed to have a residual function. With regard to genotype/phenotype correlations, the DFNB12 phenotype is reported to be associated with biallelic missense mutations, whereas the USH1D phenotype is associated with presumably functional null alleles, including nonsense, splice-site, frameshift or some missense mutations  had undergone vestibular function testing. The patient had no bilateral response on the caloric test. In this study, instead, we collected clinical information, thinking that “the month at which the head is supported when sitting” and “the month at which walking started” could be indirect evidence of a developmental delay and vestibular dysfunction. As a result, it was clarified that five out of six patients with Usher syndrome had a delayed start to walking, which could be indirect proof of vestibular dysfunction (Supplementary Table 2). This was also supported by the fact that most of the patients had no delay in starting to walk; that is, there were not many cases of CDH23 variants cause a wide range of hearing loss from non-syndromic hearing loss (DFNB12) to syndromic hearing loss and Usher syndrome type ID (USH1D). Also, the present results showed that most cases of CDH23-associated hearing loss are congenital/early onset. Nonetheless, a certain number of cases of late-onset (up to the 60 s) progressive hearing loss were also identified. As shown in Fig. CDH23-related hearing loss to be high-frequency-involved progressive hearing loss  of variants in the Japanese and other ethnic groups are shown.Supplementary file1 (XLSX 25 KB) Table 1 CDH23 variants detected and the hearing devices applied in this studySupplementary file2 (XLSX 21 KB) Table 2 Combinations of biallelic CDH23 variants showing associated visual impairmentSupplementary file3 (XLSX 12 KB) Table 3 Combinations of biallelic CDH23 (PDB accession number 3q2w) as a structural template. The results of the 3-dimensional analysis were visualized by MacPyMOL version 0.99rc.6 (http://www.pymol.org)Supplementary file4 (EPS 4897 KB) Figure 1: Three-dimensional modeling of WT cadherin 23 and the p.E956K variant. A 3-dimensional model was built by comparative modeling using the SWISS-MODEL workspace and with the coordinates of human Below is the link to the electronic supplementary material.


We hereby report on the audiological and genetic findings in individuals from a Brazilian family, with the following mitochondrial mutation A1555G in the 12SrRNA gene (MT-RNR-1). Nine individuals underwent speech, audiologic  and genetic evaluations. Eight individuals among the A1555G carriers were affected by hearing impairment and one person had normal hearing thresholds till the end of the present study. The audiologic evaluation results indicated normal hearing thresholds all the way to bilateral profound hearing loss with post-lingual onset and variable configuration. Two affected siblings presented progressive hearing loss. It was impossible to precise the time of hearing loss onset; however, the impairment was present in both children and adults. The genetic study revealed the A1555G mitochondrial mutation It is estimated that 16% of the hearing loss cases in Brazil have confirmed genetic origins, while 70% of the patients have non-syndromic hearing loss. Recessive autosomal inheritance accounts for 80% of the non-syndromic inherited hearing loss cases; dominant autosomal patterns are seen in 10% to 20% of the cases; 2–3% of the cases are connected to chromosome X; and mitochondrial inheritance occurs in only 1% of the patientsMitochondrial DNA mutations and deletions have been identified in non-syndromic sensorineural hearing loss patients. The mutation most commonly associated with maternal inheritance is A1555G on gene 12S rRNA, a relatively frequent finding among Asians. This mutation is found in approximately 3% of the Japanese, 5.3% of Indonesian and 0.5–2.4% of the European patients with sensorineural hearing loss The pathogenesis of this mutation is still largely unknown, despite the various papers in the literature published on the matterMutation A1555G has been described as the main cause of aminoglycoside-induced hearing lossA study on the audiological traits connected to mitochondrial DNA mutation in a Chinese family with 41 hearing loss patients found that the condition was associated with mitochondrial mutation A1555G on gene 12S rRNA. The patients had symmetric bilateral sensorineural hearing loss - often progressive - with wide variation on the time of onset. The authors also mentioned that environmental factors may have had a determining role in the clinical manifestation of the mutationThe same audiological aspects were verified in another study that enrolled 21 Japanese families with this mutation. The authors also found that there were individual variations in the characteristics of the hearing loss, correlation with permanent tinnitus, with and without history of taking aminoglycosides, and more severe hearing loss among patients who took the antibiotic drugA similar study done in Calabria enrolled 55 members of 6 families with the mutation. They were affected by non-syndromic, generally symmetric hearing loss involving mainly high frequencies. The disease varied from mild to moderate, and progressed slowly. Subjects previously treated with ototoxic drugs had severe hearing loss, and one of them was a deaf-muteIn a Danish population, the prevalence of sensorineural dysacusis related to alterations in mitochondrial DNA and the identified clinical signs indicated that hearing loss caused by this mutation has a wide range of phenotypes in audiological traits such as hearing loss grade, manifestation, and time of onsetA study done in Brazil on the prevalence of A1555G mitochondrial mutation and other mutations on mitochondrial gene RNAtSer(UCN)(MT-RNR-1) enrolled 203 individuals with hearing loss and found mutation A1555G in 2% (4 families) of the patients. Other mutations were not found in this studyFrom the above mentioned studies, the ones that looked into audiological tests shed light on information and issues yet unaddressed by Brazilian studies. They indicate, for instance, that by analyzing affected families we can gather a broader perspective on the audiological characteristics and their evolution, as well as possible environmental factors. This study aimed to describe the audiological and genetic findings pertaining to a Brazilian family with mutation A1555G on mitochondrial gene 12SrRNA.This study describes a family of subjects affected by non-syndromic hearing loss characterized by patterns of mitochondrial inheritance. One of the patients (III-8) was seen by a speech therapist and was suspected to have inherited hearing loss. His family members were then invited to be clinically assessed. Nine individuals were examined by ENT, speech therapy, and audiology experts  and underwent genetic testing. Other family members came only to perform genetic studies or for the described clinical exams. This study describes and analyzes the audiological findings of only the nine individuals that underwent the tests mentioned above, i.e., genetic tests and ENT, speech therapy, and audiological examination. This study was approved by the Ethics Committee for Research with Human Beings at the Institute of Biomedical Sciences under permit 023/CEP.Genetic studies included the analysis of DNA extracted from lymphocytes. PCR followed by DNA digestion with restriction enzyme Hae III were used to search for mitochondrial mutation A1555G, as described by Estivill et al. (1998)The speech therapy and audiological exams were done at the ENT outpatient ward at Universidade de São Paulo (USP) and at the clinic under the Division for Education and Rehabilitation of Communication Disorders at Pontifícia Universidade Católica de São Paulo (DERDIC/PUC-SP). Genetic tests were conducted at the Center for Human Genome Studies of the Department of Genetics and Evolutional Biology at IBUSP.All family members who underwent DNA analysis were found to have mutation A1555G on mitochondrial DNA gene RNAr 12S .Figure 1One of the subjects III-9) had no audiological symptoms, i.e., had normal hearing by the time of the tests. The other eight family members had different grades of bilateral, moderate to severe sensorineural hearing loss . The dat had no aAudiological monitoring was done only for subjects III-8 and III-10 - two affected siblings - and their hearing loss was found to be worsening progressively. They had fluctuating, progressive hearing loss in both right and left ears . HearingAudiometric findings, considering the degree of hearing loss, indicated that clinical phenotypes varied quite substantially among the members of the studied family. The cases of hearing loss ranged from moderate to severe and were all bilateral and post-lingual. As mentioned above, there was no prevalent time of onset. Many of the subjects affected at adult age had tinnitus, and those treated for it had unsatisfactory outcomesWe could not connect the onset or worsening of hearing loss symptoms to the administration of aminoglycosides, as the subjects were unable to accurately report on the use of antibiotics.Only one subject (II-3) with hearing loss had been previously exposed to occupational noise, one of the possible environmental factors leading to gene mutation expressionSubjects were informed of the importance of having their hearing status monitored and of the risks associated with taking aminoglycosides. Some started using hearing aids and greatly improved their oral communication skills and quality of life. The significant improvement in hearing tone and vocal thresholds confirmed the presence of cochlear involvement and stressed the absence of central hearing pathway involvement among patients with mitochondrial DNA mutation hearing loss.Many studies have been produced to enhance the etiologic diagnosis of hearing loss. Technologic developments, new examination techniques, and genetic tests have allowed earlier and more accurate diagnosis, providing further clarification on the etiology of the condition.Mitochondrial DNA mutations are an important cause of hearing loss. General practitioners should therefore be very careful when diagnosing the etiology of the condition, and use the valuable aid of genetic tests with that purpose. Clinical teams may thus assist in preventing the early onset and worsening of hearing loss cases, mitigating tinnitus prevalence, and advise patients on the risk of taking aminoglycosides and being exposed to noise for prolonged period of time.


Cochlear implant (CI) overall provides a very good outcome, but speech comprehension outcome in the elderly is more variable. Several clinical factors play an important role. The management of residual hearing, the presence of comorbidities, and especially the progression of cognitive decline seem to be the clinical parameters that strongly determine the outcome of cochlear implantation and need to be discussed prospectively in the consultation process with the elderly hearing impaired. In the context of this review article, strategies for dealing with these will be discussed. Timely cochlear implantation should already be considered by hearing aid acousticians or practicing otolaryngologists and communicated or initiated with the patient. This requires intensive cooperation between hearing aid acousticians and experts in the clinic. In addition, residual hearing and comorbidities in the elderly need to be considered to make realistic predictions about speech comprehension with CI. Long-term aftercare and its different implementations should be discussed preoperatively, so that the elderly person with hearing impairments feels well taken care of together with his or her relatives. Elderly patients with hearing impairments benefit most from a CI in terms of speech comprehension if there is a large cochlear coverage  and the therapy is not hampered by comorbidities, especially cognitive decline. The World Report on Hearing determines in the foreword: “Over 1.5 billion people currently experience some degree of hearing loss, which could grow to 2.5 billion by 2050” . European epidemiological studies have shown that approximately 30% of men and 20% of women have a hearing loss (HL) of at least 30 dB at the age of 70 years. At the age of 80 years, the number of persons with HL further increases to about 55% of men and 45% of women . It has Most cases of HL are sensorineural in origin. For those affected, there is the option of amplifying sound using hearing aids and delivering it to the dysfunctional hair cells or replacing it electrically through direct stimulation using a cochlear implant (CI).Even at the age over 65 years, which the United Nations defines as the age of onset for elders , CI is sThe variability of patients’ postoperative speech understanding outcomes demonstrates that individual factors determine the degree of benefit from CIs. In this regard, duration of hearing loss, extent of residual hearing, age at onset of deafness, etiology of hearing loss, cognitive decline or other additional disabilities, anatomic cochlear conditions, insertion of electrode array, and number of active electrodes, among others, play a critical role in postoperative speech comprehension with CI .Therefore, it is necessary to address CI and its associated follow-up in the elderly based on the current state of the art. This review article describes the challenges and opportunities in individualized hearing rehabilitation in the elderly with hearing impairment, especially with the clinical perspective of dealing with residual cochlear hearing, the presence of comorbidities, and cognitive decline, as dealing with these factors in the elderly with hearing impairment differs in part from dealing with younger hearing impaired, obviously strongly influencing reintegration into social life.In the following paragraphs, the scientific status of residual hearing, comorbidities, and cognitive decline will be presented, and then, strategies for individual rehabilitation are derived in the discussion.The typical audiological picture of a presbyacusis is the loss of hearing in the high frequencies. A progressing presbyacusis commonly goes along with an increasing high-frequency loss. Patients with high-frequency deafness and residual hearing in the low frequencies under 500 Hz also benefit from CI . Specifin = 50) with CI compared to younger patients . They listed comorbidities by frequency: hypertension, coronary artery disease, diabetes mellitus type 2, atrial fibrillation, chronic obstructive pulmonary disease, aortic valve stenosis, pulmonary fibrosis, and aortic and cerebral aneurysm each. A correlation of speech comprehension has not been described by the authors, but to the complication rate, which does not differ significantly between younger and older patients even with comorbidities.Numerous previous studies have investigated the hearing outcome of elderly with CI without residual hearing . Howeverz = −16.41, p < 0.001) with a large effect size (r = 0.59) of Group 1. The data show that higher age is associated with lower speech comprehension scores. In contrast, there is minimal to no correlation between age and speech perception scores in Group 2 after 1 year of CI experience. The statistical test yielded a difference in the speech comprehension across Groups 1 and 2 for the FMT (p = 0.001) but surprisingly, no significant difference for sentences in the noise test (p = 0.222). Comorbidities were documented in more than one-third of the patients in Group 1 (37.9%). Multimorbidities have also been documented in several patients . The comorbidities were categorized, with cognitive and/or neurological diagnoses forming a separate category. Speech comprehension is most influenced by neurological comorbidities , followed by multimorbidity.In recent years, several prospective studies addressed the effects of CI fitting on cognitive function in elderly persons with hearing impairment e.g., . The maiThe success of cochlear implantation is determined by various influencing factors. In the context of this article, the presence of residual hearing and the presence of comorbidities with a special case of cognitive decline are described as influencing obvious clinical factors for elderly patients with hearing impairment with CI to derive strategies for individual decision-making process, hearing rehabilitation, and reintegration into social life. These strategies are necessary for the common decision-making process for CI in the elderly. In elderly with hearing aids, it is known that patients who participate intensively in diagnostic, therapeutic, and counseling appointments are more satisfied with the sound quality and performance of their hearing aids . The eldUp to a moderate hearing loss, a hearing aid fitting provides sufficient amplification of acoustic signals and satisfaction in speech comprehension, which are affected by age, type of hearing impairment, time of daily hearing aid usage, and the threshold of hearing and education . Regularvia EAS.In the case of high-frequency hearing loss, a decreasing benefit of purely acoustic amplification can generally be expected . Above tThe concept of partial surgical insertion  allows gThe steady increase in auditory skills during the 1st year of CI use is evident in all elderly patients. However, if the elderly suffer from comorbidities, an influence on postoperative speech comprehension can be suspected, especially if multimorbidities or neurological comorbidities are present. Comorbidities without cognitive or neurological involvement  also lead to less speech comprehension postoperatively. The more comorbidities an elderly person has, the less the postoperative speech comprehension develops with CI . KnowledCognitive decline is a special case of comorbidity and represents the greatest obstacle to the development of adequate speech comprehension. Cognitive decline manifests itself insidiously and presents a wide variation. Although the patients were not aware of any cognitive impairment, screening results in the routine study of the elderly  are neveThe “2020 Lancet Commission on dementia prevention, intervention, and care” developed a risk reduction model. In this model, hearing impairment is the main contributor to the development of dementia. It represents 20.5% (8.2 points) of the modifiable factors . SensoryThe qualified selection of a CI for elderly patients with hearing impairment provides the basis for high-standard CI care and requires special knowledge and handling of this group of persons. A timely CI fitting should be taken into account whenever conventional hearing aids do not show the benefit they should. This requires intensive cooperation between hearing aid acousticians and CI specialists in the clinics. Patient groups can also be an important link in parallel and should offer additional advice and share their personal experiences. Furthermore, the diagnosis and handling of residual hearing and comorbidities, especially cognitive decline in the elderly, is necessary to make realistic predictions about speech comprehension with CI. Long-term aftercare and its different possibilities should be discussed already preoperatively, so that the elderly person with hearing impairment, together with his or her relatives, feels that he or she is in good hands. Elderly patients with hearing impairment benefit most in speech comprehension from a CI when large cochlear coverage  is provided and therapy is not hindered by comorbidities, especially cognitive decline. Further research needs to address borderline outcomes in the elderly with CI to identify additional predictors of success and learning curves in the elderly with and without cognitive decline.AI wrote the manuscript. TL corrected and completed the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Korean government started to cover part of the price of hearing aids ($200) for individuals with hearing disabilities in 1997, and the reimbursement for a hearing aid increased in 2005 ($300) and again in 2015 ($1000). The aim of this study was to evaluate the annual trend of newly-registered individuals with hearing disability according to the changes of the hearing aid provision scheme. Subjects with newly-registered hearing disabilities were assessed using Korean National Health Insurance Service (KNHIS) data from January 1, 2004, to December 31, 2018. A total of 271,742 individuals were newly registered during the index period. Records of hearing aid prescriptions and hearing aid subsidies were used to assess the adoption of hearing aids. This study also assessed the intervals between registration of hearing disability and the adoption of hearing aids, as well as the number of hearing aid subsidies provided. From 2004 to 2009 there was a slight increase in the number of individuals newly registered with hearing disabilities, and from 2011 to 2015, the number showed a tendency to decrease. Then, from 2015, the number of individuals with hearing disabilities increased abruptly, and the proportion of subjects receiving hearing aid subsidies also increased. Between 2004 and 2018, the time interval from hearing disability registration to hearing aid adoption showed a decreasing trend. We conclude that the annual number of individuals with newly-registered hearing disabilities is affected by the level of the hearing aid subsidy, and there is much unregistered or unaddressed hearing loss prior to the introduction of realistic hearing aid provision. Auditory deprivation can impair quality of life throughout life. Hearing loss impedes language development in childhood and contributes to dementia risk and cognitive decline in old age5. For these reasons, early diagnosis and proper hearing rehabilitation are important, and the role of hearing aids has been emphasized7.Hearing loss is one of the most common disabilities, and negatively affects multiple aspects of individuals’ lives due to problems with speech recognition and communication8. A recent US community survey demonstrated that the average bundled cost of a hearing aid was $2500, and three-quarters of Americans with hearing loss could not afford a hearing aid8. The widespread lack of insurance cover for hearing aids could be one of the reasons for the poor uptake of hearing aids9.However, the substantial out-of-pocket costs for hearing aids can be a major barrier to hearing rehabilitationAll Koreans have been covered by medical insurance since 1989 with a single insurer named the National Health Insurance System (NHIS) of Korea, which provides partial subsidies for hearing aids to individuals registered as “hearing disabled” after comprehensive hearing evaluation. The hearing aid subsidy program started in 1997, with partial reimbursement (about $200) of the cost of a hearing aid, and this increased to $300 in 2005. In 2015, the hearing aid subsidy was increased to about $1,000, which is the price of a single entry-level hearing aid.The present study aimed to identify trends in the annual number of newly-registered individuals with hearing disability, and of hearing aid use, according to changes in hearing aid provision.National claims data related to insurance reimbursement provide information on medical institutions; personal information including hearing disability; disease classification according to the10th version of the International Classification of Diseases and Related Health Problems (ICD-10); medical history ; and medical costs. We examined National Health Information Database data (NHIS-2022-1-269) from January 2004 to 2018. Individuals who have hearing loss can be registered as hearing disabled for social and financial assistance including subsidies for hearing aids and discounts or exemptions from telecommunication and public transport charges, as well as for tax reductions. The present study assessed individuals with hearing disabilities and a history of hearing aid subsidies based on the NHIS database.Medical claims data regarding hearing disability from January 2004 to December 2018 were analyzed retrospectively. Adult individuals 30–80 years old who were newly-registered with hearing disability during the index period were identified and evaluated. Recipients of the medical aid program for the extremely-low income group, individuals with multiple disabilities, and individuals with missing data were excluded from the analysis /6. Based on these audiometric tests, an otolaryngology specialist would issue a medical certificate for hearing loss. The test results and medical certificates were reviewed by two otology specialists affiliated with the Korean government who would confirm the disability registration based on the audiometric threshold.10.Hearing disability was classified into 5 levels: Grade 2 (better ear ≥ 90 dB HL), Grade 3 (better ear ≥ 80 dB HL), Grade 4 (better ear ≥ 70 dB HL), Grade 5 (better ear ≥ 60 dB HL), and Grade 6 (worse ear ≥ 80 dB HL and better ear HL ≥ 40 dB HL). In the current study, subjects with Grades 2 and 3 were classified as ‘profound hearing loss’ and those with grades 4, 5, and 6 as ‘moderate to severe hearing impairment’—terms closely resembling the World Health Organization grades of hearing impairmentThe Korean government has been providing hearing aid payments to individuals with hearing disability once every 5 years since 1997; the amount was changed from about $200 per device to about $300 in 2005, and to $1000 per device in 2015. With a hearing aid prescription issued by otolaryngologists, individuals with hearing disability could purchase their hearing aids from distributors of their choice. Claims for hearing aids are paid to the sellers after an otolaryngologist checks the adopted device by direct inspection and aided audiometry, and issues a confirmation document.Demographic information on age, gender, household income and dwelling place was assessed. Use of a hearing aid was defined as individuals with a hearing aid prescription and history of hearing aid subsidy during the index period. Time intervals between hearing disability registration and hearing aid subsidy were also assessed.Data were analyzed using SAS Enterprise Guide software version 7.1 . The demographic characteristics of the study population were summarized as percentages for categorical variables, and means and standard deviations for continuous variables. The chi-square test was used to compare categorical variables between hearing aid users and non-users. The Exact Poisson Method was used to compare frequencies of newly- registered hearing disabled and hearing aid adoption rates. The annual trend of hearing aid subsidy during the index period was examined using data for the entire population of South Korea.This investigation was approved by the local ethics review board  and performed in accordance with the Declaration of Helsinki and good clinical practice guidelines. The Institutional Review Board waived written informed consent for this study as the KNHIS dataset consists of de-identified secondary data available for research purposes.From 2004 to 2018, the total number of newly-registered adults with hearing disability was 271,741, of which 52.9% were males and 78.8% were over 65 years of age. Of these individuals 84.9% had moderate to severe hearing loss and only 15.1% had profound hearing loss.During the index period, 190,401 (70.1%) individuals received one or more hearing aid payments while the other 81,341 (20.9%) had not purchased a hearing aid by the end of the index period in 2018  and rose dramatically in response to a substantial increase in the hearing aid subsidy (from 2015). In addition, the proportion of individuals with newly- registered hearing disabilities who received hearing aid subsidies increased to 85.3% in response to the large increase in hearing aid subsidy in 2015.To our knowledge, this is the first official study to assess behavior regarding hearing aid adoption using a nationwide population database. The results indicate that a realistic hearing aid provision policy can facilitate rehabilitation behavior in individuals with hearing disability.11. Unaddressed hearing loss and inadequate hearing rehabilitation reduce quality of life in multiple ways, especially in terms of cognitive function11, and recognition of the social burden of hearing loss has grown. To alleviate the ill effects associated with hearing loss and its sequalae, hearing aid provision in an audiology clinic is the customary management procedure12. Despite the high prevalence of hearing impairment in old age, only a limited proportion of the hearing loss population who could potentially benefit from a hearing aid report current use of a hearing aid14. In the United States, approximately three-quarters of individuals with hearing loss cannot afford a hearing aid8. A Korean population study showed that only 17.4% of individuals with bilateral moderate to profound hearing loss purchased a hearing aid, and only about 73% of those individuals used the hearing aid regularly14. The importance of the diagnosis and management of hearing loss tends to be underestimated, especially in developing countries11.Hearing loss is the most common chronic condition in older individuals. The number of individuals worldwide with hearing loss is projected to reach 2.45 billion by 2050, a 56.1% increase from 201916. The hearing aid market is controlled by a limited number of companies, and the price of hearing aids is rather high and considered a first barrier to hearing aid adoption17. In other words, insurance coverage is a significant driver of hearing aid adoption18. According to data on welfare provisions for persons with disabilities, the South Korean government has been subsidizing a portion of the cost of 5-yearly purchase of hearing aids since 1997. The amount of the hearing aid subsidy increased from 250,000 won (about $200) to 340,000 won (about $300) in 2005 and was then tripled to 1,130,000 won  at the end of 2015.The mean cost of a pair of fitted hearing aids ranged from $2,200 to $7,000 in 2014, and consumer reports show that the average price for a pair of hearing aids was $4,860 in 202119. It demonstrated that the trend of hearing loss showed a gradual decrease from 2010 to 201519. In the present study, consonant with that report, the number of newly-registered individuals with hearing disability decreased from 2009 to 2013  increased Fig. , which s20. In Iceland, the national health insurance scheme fully covers hearing aid purchase every 4 years, but only 11% of those with hearing loss use hearing aids21. This low hearing aid adoption rate can be explained by the complexity of the factors underlying hearing aid use. Hearing aid adoption is influenced by an intricate interaction between personality, perceived social value, and social stigma22.This study demonstrated that reducing the cost to consumers/patients for hearing aids by expanding the hearing aid subsidy increased uptake in individuals with hearing loss who could benefit from a hearing aid. We identified an immediate increase in uptake of hearing aids following the expansion of hearing aid subsidies Fig. . However23. A retrospective cohort study in the United States found that the benefit of hearing aid adoption in individuals self-reporting hearing loss was identified as reducing the probability of emergency room visits and hospitalizations, and decreased Medicare spending17. However, use of a hearing aid led to increased office visits, and more total health care spending and out-of-pocket costs17. Another study proposed that the provision of hearing aids eventually adds value to the health care system and provides net savings to the Medicare program24. After 2015, individuals with severe to profound hearing loss could receive a hearing aid subsidy covering the cost of a single hearing aid under the South Korean national insurance system. It will be important to monitor whether expansion of the hearing aid provision scheme reduces the loss of quality of life associated with hearing disability in terms of access to the medical system and leads to a reduction of overall medical expenses, and this information should be reflected in any future changes to hearing aid provision. Lastly, hearing aid adoption does not necessarily imply regular use of the hearing aid25. Proper hearing aid fitting and checking, as well as counseling are important in establishing an appropriate and effective hearing rehabilitation environment26.Several studies have attempted to quantify the financial results of hearing lossThis study has the strength of using nationwide population data to investigate annual trends in numbers of newly-registered hearing disabled in response to changes in hearing aid provision. It successfully identified changes in hearing aid adoption according to the level of financial support. The study also has limitations, mostly related to the characteristics of the claims data, since they do not include physical examination data such as tympanic membrane status and exact hearing level. Also, since the national hearing disability registration scheme only includes individuals with severe to profound hearing loss, the present study could not assess the use of hearing aids by individuals with mild to moderate hearing loss. These limitations could be overcome in future by including additional large sources of medical data.In conclusion, expansion of the Korean hearing aid provision scheme resulted in a dramatic increase in hearing disability registration and hearing aid adoption, indicating that there was much unregistered or unaddressed hearing loss prior to the introduction of realistic hearing aid provision.


Aim: Assess the efficacy of the central auditory function in elderly patients who do not complain of hearing. Materials and Methods: Case study involving 40 individuals within the age range of 60 to 75 years. The patients underwent auditory processing evaluation based on anamnesis, otorhinolaryngological exam, threshold tonal audiometry, speech recognition threshold, speech recognition index, immittance measures, stapes reflex study, synthetic phrases identification test with ipsilateral competitive message, frequency pattern test and alternate twin-syllable test through dichotic task; age range and hearing loss influenced results from the phrases identification with ipsilateral competitive message. Percentages of right answers below normal standards were seen in the three tests that assessed the central auditory functions. Conclusion: Elderly individuals who did not complain of hearing presented relevant prevalence of signs of central auditory function inefficiencies.In the elderly, the results of central auditory pathways behavioral assessments are considered to be difficult to read because of the possible interference of peripheral auditory pathway involvement.  Some elderly have difficulties to understand speech, that do not match the peripheral auditory disorder they have11Auditory processing assessment information is important to identify functional deficits that could be associated to difficulties in speech understandingIpsilateral synthetic phrases identification test with competitive message (SSI/MCI), frequency patterns test (PPS) and the alternate dissyllable by dichotic task test (SSW) are behavioral sensitive tests, with specificity, reliability and facility to use in certain lesions or dysfunctions of the different areas of the auditory central nervous system (ACNS).1)ipsilateral deficit when there is lesion in the lower portion of the pons;2)contralateral deficit when there is a lesion in the upper portion of the pons; and3)bilateral deficit when the lesion is large and invasiveThe ipsilateral synthetic phrases identification test with competitive message (SSI/MCI) proposes a monoaural task that reduces speech redundancy signal by means of speech competition, identifying brain stem involvement1)deficit in both ears in the murmuring and naming response modes, when there is RH involvement;2)results within normal ranges in both ears of the murmuring type of response, associated with a deficit in both ears in the naming response mode, when there is LH involvement; and3)results within normal ranges in both ears in the murmuring response mode, associated with deficits in both ears in the naming response mode, when there is involvement of the corpus callosum.23The frequency pattern test (PPS) assesses the temporal processing of auditory information, identifying the involvement of the right hemisphere (RH), left hemisphere (LH) and the inter-hemispheric conections1)deficit in the competitive right or bilateral, when there is LH involvement;2)deficit on the competitive left, when there is RH involvement; and3)deficit on the competitive left, when there is involvement of the corpus callosum.25The alternate dissyllable test by means of dichotic tasks (SSW), which is based on the simultaneous presentation of different sounds to the right ear (RE) and the left ear (LE), identifies involvement of the brain stem, RH, LH and inter-hemisphere connectionsThe goal of the present investigation is to assess the efficiency of central auditory function of elderly patients who report good hearing.This study, approved by the Ethics Committee of the Hospital São Paulo/ Universidade Federal de São Paulo - Escola Paulista de Medicina, was carried out by the Neurotology Course, at the Department of Otorhinolaryngology-Head and Neck Surgery of this University, and approved under protocol # 258/00. The participants signed a Free and Informed Consent Form before being submitted to the proposed evaluation.We assessed 40 patients in the age range of 60 to 75 years of age, without history of neurological disorders, right-handed, who reported good hearing. The patients were submitted to auditory processing evaluation by means of an interview; otorhinolaryngological exam; threshold tonal audiometry; speech recognition threshold (SRT); speech recognition index (SRI); immittance test; stapes reflex test; SSI/MCI, PPS and SSW, considering the response in the conditions of the competitive right (CR) and competitive left (CL), to evaluate their performance in dichotic speech tasks.The reference used for the analyses of results was the normality pattern of adult individuals. The expected percentage of correct answers in both ears at SSI/MCI in the competition/stimulus ratio 0dB is of 80.0%, in the competition/stimulus ratio -10dB is 70%, and in the competition/stimulus ratio -15dB is 60.0%27; at SSW in the CR and CL is 90.0% of correct answersWe used the t-paired and the variance analysis for the statistical study. In order to analyze the influence of gender, the individuals were broken down in two groups, one of females and one of males; regarding the age variable, the individuals were broken down into three groups, one of people between 60 and 65 years of age, another between 66 and 70 years of age and a last one, of people between 71 and 75 years of age; and the hearing loss variable, where the individuals were distributed in two groups, one with threshold averages in the frequencies of 500; 1,000; 2,000 and 3,000 Hz up to 25dB HL and in the frequencies of 4,000; 6,000 and 8,000 Hz lower than 30dB HL and another with average threshold averages in the frequencies of 4,000; 6,000 and 8,000 Hz higher than 30dB HL.Of the 40 elderly examined, 29 were women and 11 were men; 15 were between 60 and 65 years, 12 were between 66 and 70 years and 13 had between 71 and 75 years; mean age was 68.2 years, with a standard deviation of 4.4.The descriptive values regarding tonal thresholds, speech recognition thresholds in dB HLNA, and speech recognition index are shown on Audiometry led to the identification of thresholds within normal ranges in all frequencies tested in eight cases (20.0%); symmetrical sensorineural hearing loss with descending shape in 24 (60.0%); and hearing loss in isolated frequencies in 8 (20.0%). Speech recognition thresholds (SRT) below or equal 25dB were found in 32 cases (80.0%) in the right ear and in 34 (85.0%) in the left ear. Percentage speech recognition indices with correct answer percentages higher than or equal to 88% were found in 35 cases (87.5%) in the right ear and in 33 (82.5%) in the left ear.Regarding immittance testing, all the individuals presented type A curves, with contra and ipsilateral stapes reflex thresholds matching their auditory thresholds.In the SSI/MCI we found the following results in comparison with normal values for adults: 21 individuals (52.5%) had values considered within normal ranges; ten (25.0%) had results below those of normal ranges, bilaterally; and nine (22.5%) had values which were unilaterally below normal values.The statistical analysis regarding the comparison among genders, age ranges, hearing loss and right ear performance in comparison with the left ear indicated: 1) no gender influence on the results; 2) significant influence of the age range (p=0.043) on SSI/MCI results regarding the stimulus/competition ratio -15dB, with individuals between 70 and 75 years of age presenting the worse results when compared to individuals in the age range of 60 to 65 years of age; 3) significant influence of the hearing loss in the ratio -15dB (p=0.012 in the RE and p=0.004 in the LE), in the -10dB (p=0.042 in the LE) ratio, and in the 0dB (p = 0.042 in the RE and p=0.017 in the LE) ratio; and 4) significant difference between the ears (p=0.002) in the -15 dB stimulus/competition ratio, with better results associated with the LE.In the frequency patterns test - PPS we found the following results in comparison with normal values for adults: 29 individuals (72.5%) had values within normal levels of normality in the murmuring response mode; and 20 (50.0%) presented values that were within normal ranges for the naming response mode.1)significant difference between the percentage of correct answers in the murmuring response mode and the percentage of correct answers in the naming response mode, bilaterally, (p<0.001), with a higher percentage of correct answers in the murmuring response mode;2)bilateral significant difference between the percentage of inversions in the murmuring response mode and the percentage of inversions in the naming response mode, (p<0.001), with a lower percentage of inversions in the murmuring response mode;3)significant gender influence in both ears on the naming response mode (p=0.018), with women having more difficulties;4)no hearing loss and age influence on the results; and5)no significant difference between the ears.The statistical analysis considering the naming/murmuring response mode, gender, age range, hearing loss and right ear performance in relation to the left ear indicated that:In the alternate disyllables test - SSW we found the following results in comparison with normal values for adults: 20 individuals (50.0%) had values within normal ranges in the competition condition, bilaterally; three (7.5%) had values below normal patterns, bilaterally; 14 (35.5%) had values below normal patters in the left competitive condition; and three (7.5%) had results below normal standards in the competitive condition.1)hearing loss, gender and age range did not influence the results in the competitive right and left conditions; and2)there was a significant difference between the percentage of correct answers in the right and left competitive conditions (p=0.002), and the highest average of correct answers percentage was presented in the right competitive condition.The statistical analysis in relation to the comparison of gender, age, hearing loss and right ear performance in relation to the left ear showed that:In the joint analysis of SSI/MCI, PPS and SSW we found the following results in comparison with normal values for adults: eight (20.0%) individuals presented normal results in all the tests; six (15.0%) presented low results in all the tests; 13 (32.5%) presented low results in two tests; and 13 (32.5%) presented low results in one test only.Obtaining information on auditory processing depends on tests which are sensitive enough to detect the involvement of different regions of the auditory system.The patients presented hearing thresholds within normal ranges in all the frequencies tested; symmetrical and descending sensorineural hearing loss curves, and hearing loss in isolated frequencies. Most patients had SRI values within normal ranges, and this justified why these patients reported good hearing.In the SSI/MCI test, the average correct answers percentage, in the three competition conditions  was below the results considered normal for adult individuals1)bilateral deficit in the murmuring and naming response modes when there is RH involvement;2)normal results bilaterally in the murmuring response mode, associated with a bilateral deficit in the naming response mode when there is LH involvement; and3)normal results bilaterally in the murmuring response mode, associated with a bilateral deficit in the naming response mode when there is involvement of the inter-hemisphere conectionsIn the frequency patterns test - PPS there are response patterns which are characteristic according to the lesion location in the central auditory system:In the PPS test, the prevalence of results below normal ranges for adults in the naming response mode suggests that the elderly we evaluated would have impairments in the auditory pathways associated with this task, without, however, having involvement of the auditory pathways associated with the murmuring response modeWe have seen that the average of correct answers in the naming response mode for males is within normal values, and this was not seen for women. These PPS results suggest that in elderly women there is impairment of the auditory pathways responsible for naming frequency patternsIn the SSW test, the percentages of correct answers in the CR and CL conditions show results below normal standards for adultsBased on the findings of these three tests and considering normality patterns for adult individuals, 20.0% of the elderly individuals had ACNS involvement stemming from aging. The fall in binaural processing is frequently associated with aging; however, it does not manifest itself in all casesAltered results in all three tests, present in 15.0% of the cases, would indicate auditory pathway involvement that go from the brain stem to the cortex, including inter-hemisphere pathways. In this group, the brain stem impairment was not confirmed in three individuals, because they had hearing loss. Aging-related alterations along the entire ACNS can be associated with a widespread loss of neuronsAlterations in two tests were seen in 32.5% of the patients. Eight patients had results that suggest the involvement of cortical areas, associated with brain stem impairment; in four of these cases the brain stem involvement was not confirmed because of the hearing loss. One case had signs suggesting brain stem impairment; one case had corpus callosum impairment; one case had corpus callosum impairment and LH impairment; one case had RH impairment; one case had RH and LH impairment.Altered results in one test only were seen in 32.5% of the elderly evaluated. In SSI, four cases were altered, and in three of them the findings suggest brain stem involvement, and in one case with hearing loss, the result was not conclusive. In the PPS we had four cases with alterations - the findings point towards a possible involvement of cortical areas, but one was not confirmed by the SSW. As far as SSW is concerned, five cases had alterations, four had a right ear advantage and one had left ear advantage, suggesting a possible brain stem involvement or that of cortical and/or corpus callosum; these possibilities were not corroborated by the SSI/MCI, as to brain stem involvement, or PPS application as far as cortical and/or corpus callosum involvement is concerned.1)ACNS structures would be affected at different times, in stages, and the individuals who did not have alterations in all the tests could present an involvement of the most external ACNS structures in future evaluations;2)aging would affect certain ACNS structures, depending on the susceptibility of each individual;3)the involvement observed would not happen because of aging only, it could stem from health problems along the person”s life; and4)the group of tests chosen could not be sensitive enough to detect mild dysfunctions, despite being proven sensitive to detect ACNS lesions. Nonetheless, we did not see a relationship between general physiological factors, life style and a greater incidence of central auditory function involvement in the elderlyWe have raised some hypothesis that could explain our findings:In our study, the analysis of the three tests together suggest that there are no response patterns that happen only with the elderly, and this has also been seen in other studies carried out with individuals of this age rangeThe majority (80.0%) of the elderly individuals we examined, despite having reported good hearing, presented altered results in their central auditory functions, suggesting that this is a study field that needs to be explored in future studies, with the goal of establishing the ACNS”s role in the auditory behavior of the elderly and their diagnostic and therapeutic implications.The prevalence of abnormalities, alone or combined, in the identification of synthetic phrases with ipsilateral competitive message, in the naming of frequency patterns and in dichotic hearing tasks is relevant and characterize impairment of the central auditory function in elderly people who report good hearing.


More importantly, the “end‐capped” ternary strategy enables efficient and facile improvement of all‐PSCs performance without additional selection and complicated synthesis for the third component.Recently, all‐polymer solar cells  have received increasing attention and made tremendous progress. However, the power conversion efficiency (PCE) of all‐PSCs still lags behind the polymer‐donor‐small‐molecule‐acceptor based organic solar cells, owing to the excessive phase separation with poor miscibility between polymer donor and acceptor. In this research, an “end‐capped” ternary strategy is proposed by introducing PM6TPO as a third component to fabricate highly efficient all‐PSCs. The PM6:PM6TPO:PY‐IT based ternary devices exhibit impressive PCE of 17.0% with enhanced light absorption and optimal morphology, and the introduction of PM6TPO significantly reduces the phase separation. The ternary devices also exhibit improved stability, outstanding tolerance of active layer thickness, and high performance of 1 cm A ternary strategy is proposed toward highly efficient all‐polymer solar cells  by introducing end‐capped PM6TPO. The champion device based on PM6:PM6TPO:PY‐IT exhibits an impressive power conversion efficiency (PCE) of 17.0%, which is attributable to the optimal morphology with improved miscibility and reduced phase separation. It is worth mentioning this is one of the highest PCEs known to the authors for all‐PSCs. In recent years, thanks to the innovation of the photovoltaic materials, interface engineering, and deeper understanding of device physics, the power conversion efficiencies (PCEs) of polymer‐donor‐small‐molecule‐acceptor‐based OSCs have made an impressive progress of 19%. Among various systems of OSCs, the all‐polymer solar cells  are considered as one of the most promising techniques for approaching application due to their improved devices stability and film ductility. Recent research efforts, especially the strategy of polymerized small molecular nonfullerene acceptors as polymer acceptor materials, have driven the PCEs of the all‐PSCs to exceed 16%. Nonetheless, the reported PCEs of all‐PSCs still lag behind polymer‐donor‐norfullerene‐acceptor based OSCs, largely due to the lack of further understanding and optimization of active layer morphology. Typically, poor miscibility between polymer donor and acceptor leads to excessive phase separation, promoting the recombination of charge carrier and depressing the parameters of all‐PSCs performance.Solution‐processed organic solar cells (OSCs) have received widespread attention, on the basis of their outstanding advantages in flexibility,1, 2 Reviewing recent research on ternary all‐PSCs, Liu and co‐workers have introduced BN‐T into the host binary system to fabricate the more crystalline active layer with improved exciton harvesting and charge transfer; Ma et al. used J71 as the third component, and obtained a PCE of 16.52% without damaging the initial film ductility; Li and co‐workers have introduced low‐cost PTQ10 as the second donor and obtained a higher efficiency with improved tolerance of active layer thickness. However, all the above third component need to be additionally synthesized, which undoubtedly increases the cost and complexity of further production. Moreover, achieving proper all‐polymer morphology with suitable phase separation is still a challenge.Ternary strategy is considered as one of the most efficient and facile approaches for the improvement of the OSCs performance by directly blending another donor/acceptor. In the classical ternary systems, these third components play a number of important roles, such as enhancement of light absorption, facilitation of charge transfer, and optimization of nanoscale morphology.36 Rev is introduced into previous proposed binary system PM6:PY‐IT as the third component. PM6TPO can be referred as “twins” polymer with PM6. Specially, the end‐capped ternary strategy avoids the complicated selection and additional synthesis for the third component. More importantly, the PM6TPO exhibits moderate aggregation and superior miscibility with the end‐capped group with steric effect, which shows excellent potential for achieving more suitable phase separation and optimal morphology. Through this strategy, an impressive 17.0% PCE of PM6:PM6TPO:PY‐IT based optimal ternary all‐PSCs is achieved (with the weight ratio of 0.5:0.5:1), which is higher than 15.49% and 15.26% for PM6 and PM6TPO based binary devices, respectively. The optimal ternary devices present a boosted short‐circuit current density (JSC) of 24.80 mA cm−2 (within 1% mismatch) and a higher fill factor (FF) of 72.52% without reduction of open‐circuit voltage (VOC) of 0.945 V, on the basis of highly efficient charge transport and enhanced light harvesting. The PM6:PM6TPO:PY‐IT based devices exhibit excellent storage stability and a decent tolerance in film thickness.In this research, we propose a novel ternary strategy based on the introduction of “end‐capped” polymer donor and achieve a high efficiency of 17.0%. The “end‐capped” strategy can also achieve the regulation of the aggregated state and miscibility, which are rarely reported in recent years. The PM6TPO, possessing additional end‐capped group with PM6,40 is Then, further characterization demonstrates the ternary devices possess more efficient exciton dissociation, charge transfer, and more balanced charge transport. Furthermore, the morphology studies reveal that the introduction of PM6TPO can finely tune the molecular packing and induce more suitable phase separation length scale. This successful case not only gives a facile approach for highly‐efficiency all‐PSCs with one of the best performances among the all‐PSCs without additional selection of the third component, but also provides an effective solution for low‐cost morphology optimization.2Figure The chemical structures of polymer donor PM6, polymer acceptor PY‐IT, and end‐capped polymer donor PM6TPO are shown in λonset. The PM6: PM6TPO binary blend film exhibits similar spectrum, with λonset between the PM6 and the PM6TPO based films (the detailed information collected in Table V and −5.51 (−3.62) eV, respectively, which are comparable with previous literatures. The HOMO and LUMO levels are −5.60 and −3.97 eV for acceptor PY‐IT, which are well matched with these polymer donors.The normalized UV–vis absorption spectra of the materials in solid film (solution) are shown in Figure J–V) curves are exhibited in Figure Table JSC of 22.96 mA cm−2, a VOC of 0.940 V and an FF of 71.77%. In comparison, the PM6TPO:PY‐IT based all‐PSCs achieve similar photovoltaic parameters with a PCE of 15.26%, a JSC of 23.43 mA cm−2, a VOC of 0.937 V, and an FF of 69.50%. Due to the similar properties of PM6 and PM6TPO, these binary systems possess similar photovoltaic performance, and the PM6TPO:PY‐IT based all‐PSCs exhibit a relatively lower FF and higher JSC due to subtle differences in the aggregation state of these two “twins” polymers.To further investigate the photovoltaic performance of the binary and ternary devices, all‐PSCs were fabricated on the basis of a conventional device structure of ITO/PEDOT:PSS/active layer/PNDIT‐F3N/Ag. For all the devices, the donor: acceptor (D:A) weight ratio is 1:1, and the detailed fabrication processes are summarized in the Supporting Information. The current density–voltage . The spectra are obviously enhanced from 400 to 850 nm by the introduction of PM6TPO, which is consistent with the above UV–vis absorption spectra and leads to the increased JSCs. Moreover, the storage stability of binary and ternary devices was investigated under the dark condition in nitrogen atmosphere. The PM6:PM6TPO:PY‐IT based all‐PSCs present the best performance in this research, the ternary devices maintain more than 90% of the initial performance over 1200 h, and more than 85% over 1600 h. The photo stability of all the devices was measured, and the ternary devices also exhibited the best performance, which maintains an initial efficiency of 85% after more than 400 h. Additionally, we have measured the thermal stability for ternary and binary devices, which were heated at 100 °C in the nitrogen atmosphere. The PM6:PM6TPO:PY‐IT based ternary devices exhibited the best performance, which still remains an initial efficiency of 85% after 96 h of heating  of the binary and ternary blends by the space charge limits current (SCLC) method  versus effective voltage (Veff) was measured  and charge collection (ηcoll) can be calculated by the formulas of Jph/Jsat and Jmax/Jsat, the ternary all‐PSCs present the maximal ηdiss and ηcoll of 97.58% and 85.58%, respectively. The above results indicate that the introduction of the end‐capped PM6TPO facilitates the exciton dissociation and charge collection.To reveal the origin of the improved performance of the ternary all‐PSCs, the dependency of photocurrent  versus log (Plight intensity) are 0.990, 0.966, and 0.960 for ternary devices, PM6 and PM6TPO based binary systems, respectively. These results indicate that the PM6:PM6TPO:PY‐IT based devices possess less charge recombination. Furthermore, the relationship of Voc versus In (Plight intensity) is defined as Voc∝n×(KTq)/InPlightintensity in Figure K is Boltzmann's constant, T is temperature, and q is the elementary charge. The n values are 1.16, 1.24, and 1.25 for ternary devices, PM6 and PM6TPO based binary devices, respectively. The ternary devices exhibit the least trap‐assisted recombination and monomolecular recombination. The above results indicate that PM6:PM6TPO:PY‐IT based all‐PSCs possess the more efficient charge transport and higher FF.To further investigate the charge recombination kinetics of the binary and ternary all‐PSCs, the dependency of Figure To further study the effect of the end‐capped PM6TPO as the third component on all‐PSCs performance, the steady‐state photoluminescence (PL) spectra and time‐resolved photoluminescence (TRPL) spectra were conducted to analyze charge generation and transport dynamic. The PL spectrum of PY‐IT neat film is collected in Figure τ = 172 ps. As shown in Figure Next, the TRPL spectra were used to further study the charge transfer with the introduction of end‐capped PM6TPO. The TRPL spectra of donor‐only films are shown in Figure  The pump laser was set at 820 nm for selectively exciting acceptor, and spectra recorded at different decay time are shown in Figure The femtoseconds‐transient absorption spectra (fs‐TA) were selected to gain deep insight of the excitons generation and dissociation dynamics for the PM6:PM6TPO:PY‐IT ternary films and these two binary films.44 TheFigure The active layer morphology plays an important role in the understanding of the photovoltaic performance and working mechanism, the atomic force microscopy (AFM) was used to confirm the binary and ternary film morphology. The AFM height and phased images are collected in  As illustrated in Figure π–π stacking diffraction peaks at ≈1.66 Å−1 from the line‐cuts of OOP direction, and the diffraction peaks located at 0.293 Å−1 in the IP orientation are also observed. Moreover, the crystalline coherence length (CCL) can be calculated according to the Scherrer equation, and CCLs of the PM6, PM6TPO, and their binary films are 21.26, 19.98, and 18.84 Å, respectively. The above results indicated that the introduction of end‐capped group could appropriately decrease aggregation of PM6, and the blending of these “twins” polymer can effectively achieve fine control of crystallinity. The PY‐IT neat film exhibit pronounced scattering peaks (010) in the OOP direction with a CCL of 22 .50 Å , which can be seen in Figure The molecular packing and crystalline ordering of neat and blend film were characterized by grazing incident wide angle X‐ray scattering (GIWAXS).45 As χΑ‐Β, which is inferred from the surface tension (γ) of the materials via the equation of χ∝(γA−γB)2, and the γ of neat films were measured from the contact angle with water and glycerol by the Wu's model. All the contact angles are shown in Figure γ and χΑ‐Β are summarized in Tables γ of 19.82, 20.25, and 23.11 mN m−1, respectively. These results indicated that PM6TPO has excellent miscibility with PM6 , and PM6TPO shows better miscible with PY‐IT than PM6, which demonstrated PM6TPO can improve the miscibility between donor and acceptor phase.The miscibility between the materials can be speculated by the Flory–Huggins interaction parameter Figure The working principle of ternary OSCs is closely dependent on morphology of blend film. Therefore, the transmission electron microscope (TEM) and dark‐field transmission electron microscope (DF‐STEM) were used for visual characterization of the phase separation and morphology. The DF‐STEM are imaged by scattered electrons, and the bright area represents crystalline domains. As shown in VOC of devices decreases slightly from 0.950 to 0.934 V with the increasing of active layer thickness, and the values of FF possess a similar decreasing trend, which mightily can be ascribed to the increased charge recombination and film resistance. The values of JSC continuously increased with active layer thickness increasing from 80 to160 nm, and then decreased with further increasing of the thickness, the increasing of JSC probably is due to the enhancement of light absorption. The highest PCE of 17.0% is achieved with the active layer thickness of ≈140 nm. Moreover, the PM6:PM6TPO:PY‐IT based ternary all‐PSCs exhibited excellent tolerance of the active layer thickness, the devices possess decent efficiencies >16% with thickness ranging from 80 to 160 nm. A high PCE of 14.62% is obtained for the all‐PSCs with the thickness of 200 nm. Meanwhile, 1 cm2 all‐PSCs are considered as the important unit cell for large‐area photovoltaic module. Hence, 1 cm2 all‐PSCs are fabricated based on the PM6:PM6TPO:PY‐IT, which possess a high PCE of 13.90% with a JSC of 24.17 mA cm−2, an FF of 60.52%, and a VOC of 0.950 V , which are shown in the Figure E1 is the inevitable radiative loss of the BHJ devices, which can be calculated by the Shcoley–Queisser theory. The ΔE1 possess same value of 0.257 eV for all the binary and ternary devices. ΔE2 is the inevitable radiative loss below the bandgap due to the nonstep‐function‐like absorptance, exhibiting the values of 0.066, 0.065, and 0.064 eV for PM6, PM6TPO based binary devices and ternary all‐PSCs, respectively.First, E3 is the nonradiative energy loss, which can be calculated according to Equation , which are shown in Figure E3 for these two binary devices based on PM6:PY‐IT and PM6TPO:PY‐IT are 0.196 and 0.200 eV, respectively. The PM6:PM6TPO:PY‐IT based ternary devices show relatively lower ΔE3 of 0.193 eV. Therefore, the total energy loss for all‐PSCs based on PM6:PY‐IT, PM6:PM6TPO:PY‐IT, and PM6TPO:PY‐IT are 0.519, 0.514, and 0.522 eV, respectively. All the detailed parameters are summarized in Table For the last part, ΔEquation (2)ΔE33JSC of 24.80 mA cm−2, a higher FF of 72.52%, and resulting in an impressive PCE of 17.0%, which is one of the best performances among the all‐PSCs. This research demonstrates the importance of “end‐capped” ternary strategy for improving the photovoltaic performance and indicated the potential for further industrial application.In conclusion, we propose a novel “end‐capped” ternary strategy for highly efficient and stable all‐PSCs, on the basis of a set of “twins” polymer donor PM6TPO and PM6. This “end‐capped” assisted strategy can effectively improve device performance without additional selection and synthesis of the third component, which avoids complex third‐component selection and reduces costs of materials. The optimal ternary blends possess enhanced light harvesting and fine‐tuned morphology, the morphology study revealed the ternary blends exhibit the more suitable phase separation. Therefore, the all‐PSCs based on PM6:PM6TPO:PY‐IT achieves significantly enhanced The authors declare no conflict of interest.Supporting InformationClick here for additional data file.