Hearing Loss and Dementia

Transcription

1 Hearing Loss and Dementia Sergi Costafreda Senior Lecturer Mental Health of Older Adults Division of Psychiatry, UCL

2 Dementia age-specific incidence has dropped 20 years Matthews FE, et al. The Lancet (2013)

3 Risk of incident dementia Dose response N=639 Median follow up 11.9 years No base cognitive impairment (Blessed>26) Adjusted for age, sex, race, education, diabetes, smoking, hypertension (FR Lin et al, 2011, Arch Neurol)

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5 Age-related Hearing Loss

6 Hearing loss and incident cognitive impairment - Normal cognition at baseline (no dementia or cognitive impairment) - Hearing loss assessed at baseline (PTA or clinical diagnosis) - Follow-up >4 years and include assessment of cognition - Outcome of incident cognitive impairment or dementia based on operationalised criteria - Adjusted by age and sex

7 Hearing loss is very prevalent Moderate to severe HL Mild Depression Dementia

8 High Pv ARHL X Risk Dem Attributable risk 36% (Lin 11) When adjusted by correlation of HL with other RF: ~9% (Lancet Dementia Commission Livingston et al, 2017)

9 age-related HL and risk of dementia: recap Age-related Peripheral HL (cochlea) a. Main issue: amplification b. It s an independent RF for i. accelerated cognitive decline ii. incident cognitive impairment iii. incident dementia (up to 20 years afterwards)

10 age-related HL and risk of dementia: recap Age-related Peripheral HL (cochlea) a. Main issue: amplification b. It s an independent RF for i. accelerated cognitive decline ii. incident cognitive impairment iii. incident dementia (up to 20 years afterwards) Central HL (brain) a. Main issue: understanding speech in noise b. Possible association to prodromal AD.

11 age-related HL and risk of dementia: recap Age-related Peripheral HL (cochlea) a. Main issue: amplification b. It s an independent RF for i. accelerated cognitive decline ii. incident cognitive impairment iii. incident dementia (up to 20 years afterwards) Central HL (brain) a. Main issue: understanding speech in noise b. Possible association to prodromal AD.

12 age-related HL and risk of dementia: recap Age-related Peripheral HL (cochlea) a. Main issue: amplification b. It s an independent RF for i. accelerated cognitive decline ii. incident cognitive impairment iii. incident dementia (up to 20 years afterwards) Central HL (brain) a. Main issue: understanding speech in noise b. Possible association to prodromal AD. Why?

13 Bias of cognitive tests in HL Standard cognitive tests assume NH No ifs, ands or buts? overdiagnosis of dementia in HL However HL is linked to lower performance even w/ visual st HL: poor performance in delayed recall >> WM (with visual stimuli) (Ronnberg et al, 2014, Frontiers Aging Neuroscience)

14 Depression and isolation in HL Depression and social isolation - HL linked to depression (Chang-Quan, 2010) - HL linked to social isolation (Pronk et al, 2013) And Dep and SI are RF for Dem But, so far it is (almost) all observational Bennett et al, 2006

15 HL affects memory even if person can decode what is said

16 HL increases cognitive load HL produces shift of brain activity Reduction in dedicated auditory regions Peele et al, 2011 Increase in flexible frontal (language and executive control - left DLPFC) thus unavailable for other processing Grossman et al, 2002

17 HL and brain atrophy Long suspected that HL results in atrophy of auditory cortex Demonstrated in cross-sectional studies (Whole brain and particularly white matter Rigters, 2017) (Auditory cortex, Peelle, 2011)

18 Hearing loss and subsequent brain atrophy n = 126 with HL, age years, 6 years follow-up (Lin et al, 2014)

19 Effects of ARHL on path to dementia Can hearing aid treatment delay or prevent dementia?

20 Effects of hearing loss on path to dementia? Can hearing aid treatment delay or prevent dementia? Correlational evidence, prone to biases. is it enough to aggressively treat? we need an experiment

21 Obstacles to a naïve trial of hearing aids Ethical issues: withholding effective treatment Bleeding between arms - non-compliance ~40%. - non-intervention arm might get HA =>Trial would not be conclusive Endpoints: there are no hearing free cognitive tests - outcomes confounded by HL and HA Need for a Pragmatic trial, need to demonstrate Feasibility

22 P-ACHIEVE (Deal et al, 2017): Treating HL in healthy elders - Inclusion/exclusion - Adult onset bilateral HL (better-hearing ear.5-2khz 30<PTA<70 db) - cognitively intact (MMSE>23 if high school, >25 if some college), no dementia - Results: - Main trial feasible (N=850, 3 years follow-up) - intervention reduced hearing handicap, there were some cognitive effects on memory in both intervention groups (possible practice effects)

23 Diagnosing HL in MCI feasibility study Inclusion: MCI Decline from a previous level of cognitive functioning Not sufficiently severe to significantly interfere with independence ~50% will develop dementia within 3 yrs Intervention: home-based hearing assessment, sending results to GPs results - in our sample, 12/17 (70%) with newly diagnosed MCI had untreated HL - We advised their GPs to send them to audiology for HA treatment - After 3 months 2 people had HAs, both reported difficulties adhering

24 TACT intervention prototype Gold standard hearing assessment and treatment Home-based Delivered by audiologist + assistant psychologist Emphasis on integration routine

25 TACT pilot trial Participants: MCI Intervention Home-based programme of hearing assessment, treatment and support for HA use vs healthy ageing educational intervention Outcomes Primary: feasibility (76 patients randomised, 80% of which complete 6 month trial) Secondary Acceptability of TACT intervention >70% participants Estimate proportion of daily use in TACT and TAU (expected 50% increase)

26 Inclusion criteria Clinical diagnosis of MCI(ICD-10) in the past 12 months. 55 years of age or older (as MCI under 55 is rarely linked to neurodegeneration and future dementia) Living in the community (not in hospital or residential care). Mental capacity to provide informed consent to trial procedures. Audiometric hearing impairment. Participants must have adult-onset hearing impairment with a four-frequency pure tone average (0.5, 1, 2, 4 khz) in the better-hearing ear of 30 decibels Hearing Level (db HL) and <70 db HL. This level of hearing impairment is the level at which individuals would be most likely to benefit from the use of conventional amplification devices such as hearing aids. Phoneme Recognition in Quiet score 60% in better ear. A phoneme recognition in quiet score <60% suggests hearing impairment that may be too severe to benefit from conventional amplification devices such as hearing aids. Exclusion (None to be satisfied) Any self-reported hearing aid use in the past year.. Spoken or written English is not sufficient for trial procedures, Diagnosis of hearing loss with onset in childhood (<18 years of age) ICD-10 criteria for current substance use disorder (abuse or dependence) or alcohol-related brain damage.

27 Inclusion criteria MCI(ICD-10) diagnosed in last 12 months 55 y/o Hearing loss it s our job to check that. Exclusion (None to be satisfied) Using hearing aids. Insufficient English Hearing loss with onset in childhood (<18 years of age) ICD-10 criteria for current substance use disorder including alcohol

28 Inclusion criteria MCI(ICD-10) diagnosed in last 12 months 55 y/o Hearing loss it s our job to check that. Exclusion (None to be satisfied) Using hearing aids. Insufficient English Hearing loss with onset in childhood (<18 years of age) ICD-10 criteria for current substance use disorder including alcohol We will be recruiting in October 2018 you ll hear from us very soon!

29 JAMA. 2017;317(19):2028. doi: /jama

30 Thank you TACT trial team CI: Sergi Costafreda, Field team: Kingsley Powell, Madison Tutton Co-investigators and collaborators UCL Ear Institute: Anne Schilder, Doris Bamiou, Maria Chait, Rishi Mandavia, Debi Vickers UCL Department of Statistical Science: Rumana Omar, Menelaos Pavlou UCL Division of Psychiatry: Gill Livingston, Glyn Lewis Johns Hopkins: Frank Lin, Adele Goman