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Hearing Loss or DementiaHow hearing impacts patient outcomes

Steve Huart, AuDAudiology SupervisorRocky Mountain Regional VAMC(formerly Denver VAMC)

Presenter

Presentation Notes

3rd year audiology participating in GRECC If you don’t mind, enter job in the chat box so I know who’s out there. Nurse, MD, psychologist, social work, etc…

VETERANS HEALTH ADMINISTRATION

Financial DisclosuresThe author of this continuing education activity has no relevant financial relationships with commercial interests.

Hearing Loss or DementiaSteve Huart, AuD


OUTCOME/OBJECTIVES

• Define hearing loss as a modifiable risk factor for dementia– Literature review

• Describe why/when/how to refer to audiology vs. ENT– Medical vs. non-medical– Hearing loss vs. understanding

• Identify one change you can make to mitigate the negative impact of hearing loss in your practice

– Look• Do an otoscopic• Look for hearing aids

– Ask• Do you have any trouble hearing• Do you have hearing aids? Where are they?

– Refer to audiology

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Common abbreviations

• ARHL – Age Related Hearing Loss• HA – Hearing Aids• HL – Hearing Loss• PTA – Pure Tone Average• SNHL – Sensorineural Hearing Loss

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Case 1 ‘Mr. B’ 88y.o. HBPC patient

• Lives at home with his wife– Can’t hear phone ring– Can’t hear doorbell– Can’t hear the TV– Can’t understand people

• Got hearing aids “a while ago”– “They never worked!”

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Word recognition score:Right ear 40%Left ear 32%


Case 2 ‘Mrs. S’ 86 y.o. Assisted Living Ctr.

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Word recognition score:Right ear 92%Left ear 96%

• State Vet’s Home– 3 kids, 2 local, 1 in IL

• Local kids visit frequently• Weekly calls from kid in IL

– Hears “pretty well, I think”• Wearing hearing aids for years• “I’d be lost without them!”

HL risk factor for dementia

Define hearing loss as a modifiable risk factor for dementia


Seems like everything causes/contributes to dementiaAARP Bulletin June 2019

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Literature review – keeping it objective

• Untreated HL associated w/ 46% higher total health care costs over 10 years compared w/ costs for those w/o HL

– JAMA OTLARYNG bit.ly/hcare-costs

• ARHL significantly associated w/ decline in all main cognitive domains and with increased risk for cognitive impairment and incident dementia

• Meta analysis of 36 studies, 20,264 unique participants

– Loughrey, BA et. al. Association of ARHL with Cognitive Function, Cognitive Impairment, an Dementia. A systematic Review and Meta-Analysis JAMA OTOLARYNG HNS, 2018; 144(2): 115-126

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• Literature search of 488 articles selected 17 for inclusion

• All studies indicate HL is associated with dementia or cognitive decline

• Most only consider HL by PTA• 2 included central testing

– Dichotic signals – different info going to each ear

– SSI-ICM (synthetic sentence identification with ipsilateral competing message)

– SSW (Staggered spondaic word tests)– Thompson, R. HL as a Risk Factor For Dementia. A

Systematic Review. Laryngoscope InvestgOtolaryng. 2017 Apr; 2(2):69-79

• HL is associated w/ incident dementia• Prospective study of 639 patients

– Lin, F. et al. Arch Neurol 8(2) Feb 2011, 214-220

• Hearing loss is associated with accelerated cognitive decline and incident dementia

• N = 1,984 older adults– Lin, F. et al. JAMA Int Med 173(4) Feb 2013, 293-

299

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Presenter

Presentation Notes

Frank R. Lin, MD, PhD is the Director of the Cochlear Center for Hearing and Public Health and a Professor of Otolaryngology, Medicine, Mental Health, and Epidemiology at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health. Dr. Lin completed his undergraduate degree in biochemistry at Brown University and his medical education, residency in otolaryngology, and Ph.D. at Johns Hopkins. He completed further otologic fellowship training in Switzerland. Dr. Lin joined the faculty at Johns Hopkins in 2010 and is a practicing otologist with expertise in the medical and surgical management of hearing loss. His epidemiologic research established the impact of hearing loss on the risk of cognitive decline, dementia, and brain aging in older adults and served as the basis of the 2017 Lancet Commission on dementia conclusion that hearing loss was the single largest potentially modifiable risk factor for dementia. He now currently leads the ACHIEVE study which is a $20M NIH-funded randomized trial investigating if treating hearing loss can reduce the risk of cognitive decline in older adults. As the founder and inaugural director of the Cochlear Center for Hearing and Public Health, Dr. Lin leads a first-in-kind research center resulting from an academic-industry collaboration that is dedicated to training a generation of clinicians and researchers to understand and address the impact of hearing loss on older adults and public health



• Elderly individuals w/ HL have increased rate of developing dementia

• HL may be a marker for cognitive decline in adults 65 and older

• 4,463 patients > 65 y.o.– Gurgel, R et al. Otol Neurotol 35(5) June 2014

775-781

• In 1989 JAMA article Hearing Loss – Who’s Listening reported “HL strongly and independently associated w/ likelihood of having dementia”

• Since 2011 “…growing epidemiological and clinical research studies…have demonstrated that hearing impairment is associated w/ accelerated cognitive decline.”

• The greater the HL the greater the risk– Lin, F and Albert M. Aging Ment Helath 18(6) 2014

Aug. 671-673

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• ARHL is a possible biomarker and modifiable risk factor for cognitive decline, cognitive impairment and dementia

• Systematic review and meta-analysis• 36 studies• 12 countries• 20,264 patients

– Loughrey DG et al. JAMA Oto HNS doi:10.1000/mamaoto.20172513 Association of ARHL with Cognitive Function, Cognitive Impairment, and Dementia. A Systematic Review and Meta-analysis.

• HOH show increased risk of disability, dementia, and depression

• Associations were NOT found in those with HA

• Prospective study N=3,777• 1,289 reported hearing problems

– Amiera H et al. 2018 Sept 73(10) 1383-89 Death, Depressions, Disability and Dementia Associated with Self-reported Heairng Problems: A 25-year Study.

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• Depressive symptoms and HL are associated w/ increased risk of disability regardless of severity of HL

• 2196 patients in Health Aging and Body Composition Study

– Armstrong N et al. J of Geron Biol Sci Med Sci 2018 20(20) 1-6. Associations of HL and Depressive Symptoms w/ Incident Disability in Older Adults: Health, Aging, and Body Composition Study

• Men with hearing loss are more likely to develop dementia

• International Study• 37,898 men mean age 72.5• Followed for 11 years

– Food AH et al. Maturitas 2018 June 112:1-11

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• Greater HL is associated w/ poorer physical function

– Chen, D et al. J of Gerontology: Med Sci 2015: 654-661

• HL increases the risk of difficulty performing instrumental activities of daily living

– Lilijas, AE et al. Age Ageing. 2016 Sep 45(5) 662-667. Hearing Impairment and Incident Disability and All-cause Mortality in Older British Community Dwelling Men

• Interventions for cognitive training require adequate hearing and speech processing

• Restoring hearing and optimizing communication can increase social engagement and decrease the probablility of HL cascading into cognitive decline

– Weinstein, B. The Hearing J. 2017 Sept 18-20. Preventive Care for Dementia and HL

• ARHL adds to cognitive load of already vulnerable aging brain. May result in social disengagement accelerating cognitive decline

• There is no robust evidence that HA protect against cognitive decline but HA can reduce isolation, loneliness and depression improving mood, social interaction and participation in cognitively stimulating activity

– Weinstein, B. The Hng J 2017 Nov 26-30. Dementia and ARHL – Part II

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Potentially Modifiable risk factors for dementia:

• Low level of education• Hearing Loss • Hypertension• Obesity• Smoking • Depression• Physical inactivity• Social isolation• Diabetes

Livingston, G. et.al.Lancet 2017 Dec. 16; 360Dementia prevention, intervention and care


Literature review – keeping it really objective

• Prevention of 9 population attributable risk factors may be over optimistic• No evidence of increased dementia in the deaf community• Unlikely that treating HL will reduce dementia rates

– Kivimaki, M Prevention of Dementia by Targeting Risk Factors. Lancet 391:1574-1575. 2018 April 21.

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Literature review – Summary

• We do NOT know that HL causes dementia • We DO know that it is correlated• We DO know that is modifiable• We DO know that is treatable• We DO know that undiagnosed and untreated HL can make you look cognitively

impaired• We DO know that we are all going to be aware of HL and address it in older adults• We DO know that it is a good idea to refer older adults for evaluation • We DO know how important it is to look in ears when we can

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Hearing Loss

Describe why/when/how to refer to audiology vs. ENT

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ADLs

Hearing loss causes, contributes to, or exaccerbates:Communication handicap, social isolation, anger, frustration, fatigue, cognitive decline…

Presenter

Presentation Notes

Add hearing loss on top of all the other problems associated with aging and it’s a big problem 7 comorbidities associated w/ HL: 1. Social isolation and loneliness, 2. Depression, 3. Falls, 4. Cardiovascular disease, 5. Diabetes, 6. Cognitive impairment and dementia, 7. Mortality


• Encountered in all medical setting• Frequently influences medical encounters• 50% of those 60-69• 80% of those over 85!!• Primary effect – impaired communication• Contributes to social isolation• Reduced quality of life• Compared to age matched normal hearing peers hearing impaired show higher

rates of hospitalization, death, falls, frailty, higher rates of dementia, and depression

19Cunningham and Tucci, NEJM Dec. 21, 2017

How big a deal is hearing loss really?


Why refer?

• Cognitive Load “bandwidth”• HA may mitigate the effect of cognitive decline later in life.

– Hearing J

• HA early in course of HL may stem the worldwide rise of dementia.– J Am Geri Soc 2018

• HA use positively associated with memory scores. Scores decline slower after HA use.– Health and Retirement Study, N=2040, measured cognitive performance every 2 years over

18 years (1996-2014)

• HA use appears to be a buffer against the experience of loneliness.– Am J Audio 2016

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Causes of hearing loss

• Aging – Presbycusis

• Noise– Head trauma

• Cerumen– Ear wax

• Family history

• Ototoxic medications– Aminoglycoside antibiotics

• Gentamycin, Neomycin– Antineoplastics

• Cisplatin– Aspirin

• In large doses• Usually temporary• Tinnitus

• Syndromes– Usher’s

• Autoimmune– Meniere’s

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Presenter

Presentation Notes

Vast majority of what you will deal with are in the left column. Be aware of the others.


Types of hearing loss

• Peripheral– Conductive

• Wax• Ear infections• TM perforations• Cholesteatoma• Otosclerosis• Treatable (mostly)

– Sensorineural• Cochlear• Permanent (mostly)

– “Easy” to diagnose and treat

• Central– Medial to the cochlea

• Lesions– Acousitc schwannoma

• Brainstem injury• Brain injury• Auditory processing

disorders– Auditory synaptopathy

• Permanent (mostly)– Difficult to diagnose

and treat– Audiogram can be

normal

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Presenter

Presentation Notes

Conductive HL usually treatable. Chronic ears requiring multiple surgeries often end up wtih permanent HL. SNHL usually permanent. Some, like aspirin ototoxicity or SSHL, can return after treatment Central HL usually permanent, some schwannoma surgeries can restore hearing – sometimes hearing is sacrificed


Hearing Loss – can you fix it?

“Curable “• Cerumen• Ear wax• Plugged up ears• PLEASE DO OTOSCOPIC EXAM IF YOU CAN

– Incidence of cerumen at SVH ~30%• Other conductive hearing loss

– Rare in older adults• TM perforation

– Traumatic – Q-tip– Chronic

• Otitis– Externa/Media

• Otosclerosis

“Incurable”• Sensorineural hearing loss • Most common – usually cochlear in origin

– Permanent– Painless – Invisible– Insidious

• NOT curable but it IS TREATABLE

• Central hearing loss– Somewhere after the cochlea

• Auditory nerve• Brainstem• Cortex

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COMORBIDITIES Linked to Hearing Loss

• Social Isolation• Depression• Falls• Cardiovascular disease• Diabetes• Cognitive decline• Mortality

- American Academy of Audiology

Untreated hearing loss increases health care costs and hospitalization rates- AARP Bulletin Jan/Feb 2019 in collaboration with Johns Hopkins

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Hearing vs. Understanding – a BIG difference

2 basic truths:1. You can’t understand it if you don’t hear it.

Take care of the basics first. Ears clear? Hearing aids on?

2. Just because you hear it does not mean you understand it. Maximize the signal. Minimize the cognitive load.

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The audiogram• Pure tone thresholds measure

sensitivity by frequency• How loud each pitch has to be to

be audible, the “prescription”• Measured by air conduction and

bone conduction• Results are used to prescribe the

amplification characteristics when prescribing hearing aids: gain by frequency

Mr. B and Mrs. S audiometric results

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WRS:Right ear 40%Left ear 32%

WRS:Right ear 92%Left ear 96%

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Presenter

Presentation Notes

Left ear is a typical age related configuration Right ear could be a lot of things

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A lot (most?) HL occurs in the cochlea as a result of hair cell damage.

Presenter

Presentation Notes

12,000 OHC, 3,500 IHC Mammalian hair cells do not regenerate More hair cells you lose the greater the hearing loss Guy on left might do great with HA, guy on right – not so much Damaged cochlea still needs a HA and will benefit but this is the guy who will report hearing aids ‘don’t help’ In the human cochlea, there are 3,500 IHCs and about 12,000 OHCs. This number is ridiculously low, when compared to the millions of photo-receptors in the retina or chemo-receptors in the nose! In addition, hair cells share with neurons an inability to proliferate they are differentiated - this means that the final number of hair cells is reached very early in development (around 10 weeks of fetal gestation); from this stage on our cochlea can only lose hair cells. http://www.cochlea.eu/en/hair-cells

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In the aging auditory system there is potential for damage at any point.

Presenter

Presentation Notes

Human primary auditory cortex is in Heschel’s gyrus in the temporal lobe Signal has to travel from cochlea to cortex – takes longer as we age We hear slower, takes longer to process


What can you expect from hearing aids?

BIG oversimplification but hope it helps….

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Presenter

Presentation Notes

What did you see? “15”Those with normal color vision see a 15. “17”Those with red green color blindness see a 17. Nothing Those with total color blindness see nothing.

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What can you expect from hearing aids?

Presenter

Presentation Notes

If I can’t see a color, putting it under a magnifying glass does not help.


“My hearing aids are great!”

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Presenter

Presentation Notes

If I just have trouble hearing because things are not loud enough, lots of healthy hair cells and intact auditory pathway, hearing aids are great


“My hearing aids stink!”

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Presenter

Presentation Notes

If I have lost the ability to understand speech, very few functional hair cells and/or insult to the auditory pathway or auditory cortex, hearing aids will help me hear the speech but I’ll still have trouble understanding. Typical of presbycusis.


When/where to refer - depends on practice setting and resources available

Audiology• All geriatric patients• Non-specific hearing loss• Presbycusis• Sudden hearing loss• Tinnitus

PCP• Cerumen• Otalgia• Otorrhea• Vertigo/dizzy/balance

ENT (will probably want an audiogram)• Is it a ‘medical’ issue?• Has past medical Rx failed?• Can PCP treat? • HL chronic or sudden?

– Chronic rarely needs ENT unless there is relative comorbidity

• 21 CFR 801.420(c)(2), (Hearing Aids)– (i) Visible congenital or traumatic deformity of the ear.– (ii) History of active drainage from the ear within the

previous 90 days.– (iii) History of sudden or rapidly progressive hearing

loss within the previous 90 days. EMERGENCY– (iv) Acute or chronic dizziness.– (v) Unilateral hearing loss of sudden or recent onset

within the previous 90 days.– (vi) Audiometric air-bone gap equal to or greater than

15 decibels at 500 hertz (Hz), 1,000 Hz, and 2,000 Hz.– (vii) Visible evidence of significant cerumen

accumulation or a foreign body in the ear canal.– (viii) Pain or discomfort in the ear.

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What can you do?

Hearing loss takeaways

• Expect your patient has some degree of hearing loss• If possible, do an otoscopic exam – please!• Ask about hearing• Ask if they have hearing aids and if they use them• Refer to audiology when in doubt • Remember:• Most hearing loss in older adults is not curable• Most hearing loss in older adults IS TREATABLE

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Hearing Loss

Identify one change you can make to mitigate the negative impact of hearing loss in your practice


Identifying your patient with hearing lossIt’s not brain surgery

• Age– Remember 80% over 85 y.o.

• Chart review – Use it but don’t count on it

• Ask!– Beware of denial

• “What?”– Asking for repetition

• “Yes”• Inappropriate answers

– Maybe it’s NOT dementia

• Looking to others to answer• Puzzled look, Fatigue, Anger, Frustration• Withdrawal

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Presenter

Presentation Notes

Age – 80% of those over 85 y.o. Chart review – often NOT documented, or patient asked do you have trouble hearing and they deny it or don’t know it Ask! Do you have any trouble hearing? Can you hear me OK? Beware of denial. If every question is a “Yes” or “OK” maybe an attempt to disguise HL or not be a burden Wrong answer – if you say “How are you today?” and they say “Wednesday.” it might mean they didn’t hear you, not they are disoriented


“Best hearing aid?”

Depends!

Hearing lossLifestyleManual dexterityVisual acuityCognitive abilityConnectivity

Hearing aids style, shape, size

A = completely in canal, B = in the canal, C = in the ear, D = behind the ear, E = receiver in canal (RIC), F = slim tube


What’s in a hearing aid?

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optional

Disposable vs. Rechargeable


How do HAs work?


Domes, Wax traps, and Batteries

If you care for Vets who use hearing aids this is for you!


Connectivity

“streamer” may/may not be required


Other HAs/amplification options

• CROS• BiCROS• CI• Baha®


What can you do?

• Do an otoscopic exam• Look at the ear for hearing aids• Ask if they have hearing aids• Ask how they work• Ask when the last time they were seen by audiology• Do a quick check of battery and for wax• Refer to audiology

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Case 1 ‘Mr. B’ 88y.o. HBPC patient

• HBPC– Can’t hear phone ring– Can’t understand on the phone– Can’t hear doorbell– Can’t hear the TV– Can’t understand people

• Got hearing aids “a while ago”• “They never worked!”

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Tools for Mr. B

Amplified/captionedphone

Flashing doorbell

Hearing aids

Hearing aid accessories: TV streamer

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Case 2 ‘Mrs. S’ 86 y.o. Assisted Living Ctr.

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• State Vet’s Home– 3 kids, 2 local, 1 in IL

• Local kids visit frequently• Weekly calls from kid in IL

– Hears “pretty well, I think”• Wearing hearing aids for years• “I’d be lost without them!”

What is this caregiver doing right? Everything!Engaged, look at body language. Down at Vet’s level. Eye contact. Probably asked her if her hearing aids were working OK.Probably speaking slowly, articulating clearly, and raising voice just enough to be heard over hallway noise.


Tools for Mrs. B

Hearing aids Hearing aid accessory: remote mic

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For your office/travel kit

Comfort Duett

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What can you do beside refer to audiology? Remember this slide!Communicating effectivley with someone with hearing loss

• Remember what your mom taught you!– Look at me when you’re talking to me– Don’t mumble– Slow down– Don’t shout– Don’t talk with your mouth full

• Avoid distractions– Noise, Glaring light

• Provide printed material

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Further reading

• The Common Sense of Considering the Senses in Patient Communication– Frank R. Lin, MD, PhD and Heather E. Whitson, MD, MHS– J of AM Geri Society; 2017 Apri 24; https://doi.org/10.1111/jgs.14926

• Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting– Vikki Cudmore, MB, BCh, BAO; et al– JAMA Otolaryngol Head Neck Surg. 2017 Oct 1;143(10):1054-1055. doi:

10.1001/jamaoto.2017.1248.

• Hearing Loss in Adults – Lisa L. Cunningham, Ph.D., and Debara L. Tucci, M.D., M.B.A.– NEJM 2017; 377;2465-2473

• Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia A Systematic Review and Meta-analysis

– David G Loughrey, BA(Hons), et al.– JAMA Otolaryngology Head Neck Surg– https://www.ncbi.nlm.nih.gov/pubmed/29222544

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https://doi.org/10.1111/jgs.14926

https://www.ncbi.nlm.nih.gov/pubmed/29222544

Thanks!Please email with any feedback or questions. [email protected]

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