With accelerating global population aging, age-related hearing loss (ARHL) has become one of the most prevalent sensory impairments in older adults (Tsai Do et al., 2024). According to the World Health Organization (WHO), the prevalence of ARHL increases steeply with age, from 10.9–17.6% at 60–69 years to 23.4–31.3% at 70–79 years, 41.9–51.2% at 80–89 years, and 52.9–64.9% among adults aged ≥90 years (World report on hearing, 2021). ARHL is associated not only with difficulties in speech understanding and listening fatigue but also with restricted social participation, loneliness, social isolation, and depressive symptoms. Loneliness and social isolation themselves are recognized by the WHO as major risk factors for mental health problems in later life (Ying et al., 2023; Bai et al., 2025; Li et al., 2025). Thus, interventions for ARHL have value beyond restoring auditory function, with the potential to enhance overall quality of life (QoL) by improving communication and social participation.

For adults with moderate-to-profound ARHL, cochlear implantation (CI) is widely regarded as one of the most effective options for auditory rehabilitation. Accumulating evidence indicates that advanced age per se is not an absolute contraindication to CI, and that older adults with multiple chronic conditions can still achieve meaningful gains in speech recognition and self-reported benefit (Bocquillon et al., 2025; Zhan et al., 2025). Nevertheless, concerns about CI outcomes in older adults persist in clinical practice. Conventional audiologic metrics capture only part of the changes that matter to patients, including communication, social participation, and emotional well-being (Brumer et al., 2022; Rasmussen et al., 2022; Philpott et al., 2025). In addition, expectations about postoperative benefit, the process of adaptation, and the availability of rehabilitation support are likely to shape subjective QoL outcomes (McRackan et al., 2021b).

QoL is a multidimensional construct centered on individuals’ subjective experience, encompassing auditory experiences, social interactions, mental health, and overall perceived health (Skevington et al., 2004). In CI research, hearing/CI-focused condition- or intervention-specific questionnaires (hereafter “hearing/CI-specific instruments”), such as the Nijmegen Cochlear Implant Questionnaire (NCIQ) and the Glasgow Benefit Inventory (GBI), primarily target auditory and social functioning and are considered more sensitive to CI-related benefit (Robinson et al., 1996; Hinderink et al., 2000). By contrast, generic or health-related QoL questionnaires (hereafter “generic instruments”), such as the World Health Organization Quality of Life–OLD module (WHOQOL-OLD), the Health Utilities Index (HUI2/HUI3), and the Short Form Health Survey (SF-36), capture broader health status and functional independence, and their patterns and sensitivity of change do not fully align with hearing-specific measures (McHorney et al., 1994; Feeny et al., 2002; Power et al., 2005). Existing studies also vary widely in follow-up duration, ranging from several months to many years after surgery, and QoL improvements appear to be time dependent, complicating direct comparisons across studies.

Although prior reviews have examined overall outcomes of CI in older adults (Andries et al., 2021), they often pool heterogeneous etiologies of age-related hearing loss and devote limited attention specifically to ARHL. They also have not systematically contrasted the benefit patterns captured by hearing-specific versus generic QoL instruments across different follow-up time points. Against this background, we conducted a systematic review to synthesize evidence on QoL changes after CI in adults with ARHL, with three objectives: (1) to characterize overall QoL changes after CI in ARHL; (2) to describe the benefit profiles detected by hearing/CI-specific versus generic instruments at different follow-up time points; and (3) to explore potential differences in the magnitude of QoL improvement across older age strata. Our aim is to inform expectation management, the timing of follow-up assessments, and the selection of outcome measures for CI in ARHL.

Drawing on a body of evidence composed predominantly of observational cohort studies, this review indicates that CI is generally associated with improved QoL in patients with ARHL. The most consistent benefit signals were observed in hearing/CI-specific instruments such as the NCIQ and GBI, whereas generic instruments more often showed delayed improvements, predominantly in social function–related domains.

The QoL constructs examined here can broadly be grouped into two categories. The first is social functioning, referred to as “social participation/social interaction” and encompassing NCIQ social interaction, GBI social support, WHOQOL-OLD social participation, and SF-36 social functioning. The second is physical health, including GBI physical health and SF-36 physical functioning and bodily pain. Other domains are reported using their original labels as defined in each instrument. The coherent improvement patterns observed for NCIQ and GBI likely reflect the close alignment between what these instruments measure and the primary mechanisms of CI benefit. Hearing/CI-specific instruments focus on functions directly targeted by CI—such as sound perception and social functioning—and are therefore particularly sensitive to changes in auditory and communication outcomes. By contrast, generic instruments such as the SF-36 and WHOQOL-OLD include several physical health domains that are only indirectly related to hearing interventions and are strongly shaped by comorbidity and normal aging in older adults, contributing to more variable trajectories in these scores (Andries et al., 2021). Consistent with our findings, a prospective multicenter study reported that, within the same CI cohort, hearing/CI-specific instruments were more sensitive than generic measures during follow-up (Lassaletta et al., 2022). The GBI, which explicitly captures pre–post change, is well suited to detecting general benefit and social function–related improvement. While reliable and useful in CI populations, it may be best positioned as a complementary indicator of perceived benefit (Lui et al., 2021). More recently, CI-specific instruments such as the Cochlear Implant Quality of Life (CIQOL) suite have been developed to more precisely map key CI benefit domains—communication, emotion, entertainment, environment, listening effort, and social situations—onto patients’ lived experience (McRackan et al., 2019). In comparative studies, the CIQOL-35 and CIQOL-10 have shown stronger construct validity and more robust reliability than several legacy tools, highlighting limitations in NCIQ structural validity and weaker reliability of the HUI3 (McRackan et al., 2021a). Ongoing work is extending CIQOL through cross-cultural adaptation and localization (Laplante-Lévesque et al., 2021; Pützer et al., 2024). Overall, hearing/CI-specific instruments appear to capture early, direct gains in sound perception, whereas generic instruments are better suited to reflecting the downstream social and psychological benefits that accrue with device acclimatization, listening training, and changes in everyday communication behavior. Future CI studies in older adults should therefore prioritize hearing/CI-specific instruments and CIQOL as primary outcome measures, using generic QoL instruments mainly as complementary endpoints, particularly for long-term follow-up.

At the domain level, we found that NCIQ improvements were most pronounced and stable over time in the basic and advanced sound perception domains, consistent with the direct impact of CI on sound detection, sound localization, and listening in complex auditory environments. Prior work has shown that bilateral CI, compared with unilateral implantation, can further enhance sound localization and spatial hearing (Gaylor et al., 2013). Importantly, however, gains in speech recognition do not automatically translate into parallel improvements in QoL (McRackan et al., 2018). In studies using the WHOQOL-OLD, a characteristic pattern emerged in which no significant changes were seen shortly after surgery, whereas significant improvements were observed at 6 months, particularly in sensory abilities and social functioning (Issing et al., 2020, 2022, 2024). This pattern suggests that overall QoL gains detected by generic instruments typically consolidate only over time. They become more apparent after patients have undergone device adaptation, programming optimization, auditory training, and reorganization of daily communication patterns. By contrast, physical health domains in generic instruments primarily reflect cardiopulmonary fitness, musculoskeletal status, neurodegeneration, and chronic disease burden; from a mechanistic perspective, they are not expected to improve to the same extent or pace as hearing-related outcomes. Furthermore, prior reports indicate that postoperative complications after CI are most often mild, self-limited local or vestibular problems—such as incision or skin discomfort, postoperative vertigo, and imbalance—whereas serious complications requiring revision surgery or leading to marked deterioration in overall health are relatively uncommon (Kanai et al., 2021; Orlando and Cruz, 2024). In very old recipients with multiple chronic conditions, such transient vestibular and somatic discomfort is not uncommon in the early postoperative period and may restrict daily activities and participation outside the home during recovery, thereby temporarily lowering scores in physical health–related domains of generic instruments at short-term follow-up (Vaz et al., 2022; Kutlu et al., 2024). Previous studies have also reported that overall QoL in older CI users can approximate that of healthy age-matched controls, while domains such as social functioning are more sensitive to CI-related change (Tokat et al., 2021). In terms of trajectory, QoL tends to improve over 6–12 months postoperatively (Lassaletta et al., 2022), with delayed effects such as increased everyday independence and reduced loneliness emerging beyond 18 months (Cuda et al., 2024). This pattern supports the view that CI influences QoL through a stepwise process, in which early auditory gains gradually extend to social and emotional domains. Beyond QoL, improved hearing and communication after CI may also indirectly affect broader health-related outcomes, including healthcare utilization, work ability, and social functioning (Bekele Okuba et al., 2023). Rehabilitation interventions such as auditory training have been shown to further enhance auditory and functional performance (Dornhoffer et al., 2024), underscoring that CI care should extend beyond device programming to include structured auditory training and strategies to promote social engagement. Consequently, preoperative counseling and follow-up assessments should emphasize realistic expectation management, avoid attributing changes in physical function solely to CI efficacy, and prioritize social functioning and communication opportunities as key follow-up and intervention targets. Enhancing family support, creating social participation opportunities, and providing rehabilitation training may help amplify and stabilize QoL benefits.

In our synthesis, most studies reported similar QoL gains across age groups, and a few even suggested larger improvements among patients aged ≥70 years. This pattern may reflect lower baseline QoL and more restricted social functioning in the very old, creating greater room for improvement, while perceived benefit from restoring basic hearing and communication may be comparable between very old and “younger old” adults. Age therefore seems to shape the conditions under which benefit can be achieved and sustained rather than determining whether benefit is possible. Recent evidence shows that recipients aged ≥80 years can still achieve meaningful improvements in auditory outcomes, although sustained device use may decrease over time. Discontinuation is typically driven by declining independence, challenges in device handling, and limited support networks rather than by an absence of auditory benefit in very old age (Hallin et al., 2023; Bocquillon et al., 2025). Data from the German national CI registry also point to under-treatment or incomplete coverage among adults aged ≥85 years, suggesting a need to improve access for very old candidates when expected benefit is clear (Stöver et al., 2024). Furthermore, significant postoperative improvements in speech recognition have been documented in recipients aged 80–89 and ≥90 years, reinforcing that very old adults can obtain substantial auditory gains (Zhan et al., 2025). Collectively, these data suggest that advanced age per se should not be viewed as an absolute barrier to CI; instead, candidacy decisions should be guided by a holistic assessment of overall health status.

This review has several limitations. First, studies used a mix of hearing/CI-specific and generic instruments with different domain structures and follow-up durations ranging from 1 month to several years, limiting direct comparability of outcomes across studies. Second, all included studies were observational, and ROBINS-I ratings indicated moderate to serious risk of bias. Many studies did not systematically adjust for key confounders, such as educational attainment, comorbidities, and participation in rehabilitation; consequently, the overall certainty of the evidence is low. Finally, although all included studies targeted adults with ARHL, the operational definitions of ARHL and the level of detail with which key exclusion criteria were reported varied across studies. As a result, residual mixed etiologies cannot be entirely ruled out, which limits the interpretation and generalizability of QoL-related conclusions.

This systematic review suggests that CI is generally associated with improved QoL in patients with ARHL. However, this conclusion is supported primarily by observational studies that are at moderate to serious risk of bias, particularly with respect to confounding and participant selection, so the overall certainty of the evidence is low. Benefit signals were most sensitive and internally consistent in hearing/CI-specific instruments such as the NCIQ and GBI, particularly in core domains related to sound perception and social functioning. Generic instruments (e.g., WHOQOL-OLD, SF-36, HUI3) more often revealed delayed and domain-specific gains, mainly in sensory abilities, social functioning, and mental health, while physical-function domains showed only limited improvement, likely reflecting the influence of aging and multimorbidity. Overall, current evidence does not support chronological age per se as a major constraint on CI-related benefit. Future studies should adopt more rigorous prospective designs, harmonize follow-up schedules and outcome frameworks, and prioritize CI-specific standardized tools (such as CIQOL) to enhance consistency of outcome measurement and provide more robust data on CI benefit across ARHL populations of different ages.