Hearing Loss in Older Adults: A Public Health Perspective Frank R. Lin, M.D. Ph.D.

Transcription

1 Hearing Loss in Older Adults: A Public Health Perspective Frank R. Lin, M.D. Ph.D. Assistant Professor of Otolaryngology, Geriatric Medicine, Mental Health, and Epidemiology Johns Hopkins University Baltimore, Maryland

2 Prevalence of Hearing Loss in the United States, Hearing loss defined as a better-ear PTA of 0.5-4kHz tones > 25 db Lin et al., Arch Int Med. 2011

3 Hearing Loss & Hearing Aid Use Prevalence in the U.S., Chien & Lin, Arch Int Med, 2012

4 Age-Related Hearing Loss (ARHL) Basic Questions What are the consequences of ARHL for older adults? What is the impact of treating ARHL on older adults? How can ARHL be effectively addressed in the community?

5 Healthy Aging

6 Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Physical Mobility & Activity Healthy Aging Keeping Socially Engaged & Active Health Resource Utilization Hearing Loss

7 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Hearing Loss? Cognitive & Physical Functioning Common pathological process

8 Intensity Sunday Principles of Auditory Physiology #1 Hearing depends on peripheral transduction & central processing of sound

9 Principles of Auditory Physiology #2 Audiometry measures the cochlea s ability to detect & encode sound PTA = Pure tone average of 0.5, 1, 2, & 4 KHz tones in the betterhearing ear

10 Intensity Hearing Loss & Cochlear impairment Sunday Decreased hearing sensitivity & poor frequency resolution Effortful listening

11 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Hearing Loss Cognitive & Physical Functioning Common pathological process

12 Hearing Loss & Cognitive Load Kahneman model of shared attention and resource capacity (D. Kahneman, Attention & Effort,1973) Cognitive Resource Capacity Auditory Perceptual Processing Requirements Available Cognitive Resources For Performance of Tasks Age-Related Decline

13 Hearing Loss & Cognitive Load Poorer hearing is associated with: A. Reduced language-driven activity in primary auditory pathways B. Increased compensatory language-driven activity in pre-frontal cortical areas B Peelle et al, J. Neurosci, 2011 Grossman et al, Brain Lang, 2002

14 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Hearing Loss Brain structure/function Cognitive & Physical Functioning Common pathological process

15 Does Peripheral Hearing Loss Affect Brain Structure/Function? In humans, hearing loss associated in cross-sectional studies with: Reduced cortical volumes in primary auditory cortex Husain et al Brain Research Peelle et al, 2011 J. Neuroscience Eckert et al JARO Variation in central auditory white matter tract integrity on DTI Chang et al Neuroreport Lin et al J. Magn Reson Imaging In animals, cochlear impairments associated in longitudinal studies with: Tonotopic reorganization of auditory cortex Kakigi et al 2000 Audiology Cheung et al 2009 J. Neurosci Morphologic changes in central neuronal structures Groschel et al 2010 Neurotrauma

16 Double Hit Theoretical Model Hearing Loss & Brain Structure/Function Microvascular Disease Cognitive Alzheimer s Neuropathology Function Hearing Impairment F. Lin & M. Albert, Aging & Mental Health, In press 2014

17 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Hearing Loss Brain structure/function Cognitive & Physical Functioning Social Isolation Common pathological process

18 Social Isolation Cognitive & Physical Functioning Health Behavioral Pathways Smoking Adherence to medical tx Diet Exercise Psychological Pathways Self-esteem Self-efficacy Coping Sense of well-being Physiologic Pathways HPA axis response Immune system fxn Cardiovascular reactivity Cole & Cacioppo, Genome Biology, 2007 Cole & Cacioppo, PNAS, 2011 Social isolation is associated with upregulation of proinflammatory genes & increased inflammation

19 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Hearing Loss Brain structure/function Cognitive & Physical Functioning Social Isolation Common pathological process

20 Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Physical Mobility & Activity Healthy Aging Keeping Socially Engaged & Active Health Resource Utilization Hearing Loss

21 Projected Worldwide Prevalence of Dementia Alzheimer s Disease International, 2009

22 Memory Hearing Loss & Cognition Background Free and cued selective reminding test (FCSRT) Executive Function Trail Making B Stroop Mixed Digit symbol substitution Psychomotor/processing speed Verbal function & language These tests are not dependent on hearing.

23 Hearing Loss & Cognition Executive Function: Trail Making B 1 7 C E 5 B Trail Making B H 8 F 1 G 3 D A 6 4 2

24 Hearing Loss & Cognition Executive Function: Stroop Mixed 1 Stroop Mixed GREEN RED RED GREEN BLUE BLUE GREEN RED YELLOW BLUE BLUE GREEN YELLOW BLACK

25 Hearing Loss & Cognition Executive Function: Digit Symbol Substitution Test (DSS) DSS: Digit Symbol Substitution Test

26 Hearing Loss & Cognition/Dementia Datasets for Epidemiologic Analyses NHANES: National Health and Nutritional Examination Surveys Cross-sectional, representative sample of U.S. population BLSA: Baltimore Longitudinal Study of Aging Ongoing prospective study of older adults since 1958 HealthABC: Health, Aging, & Body Composition Study Prospective, population-based study of ~3000 adults 70 years and older

27 Hearing Loss and Cognition Cross-Sectional Studies NHANES N = 605 adults years Lin, J. Geront. Med. Sci., 2011 BLSA N = 347 adults >60 years Lin et al., Neuropsych., 2011 Models adjusted for age, sex, race, education, diabetes, smoking, hypertension

28 Hearing Loss & Cognitive Decline Adjusted 3MS & DSS scores by years of follow-up and hearing loss status in 1,966 adults > 70 years followed for 6 years 41% 32% faster rate of cognitive decline in 3MS DSS scores in HL vs. NH Adjusted for age, sex, race, education, study site, smoking status, hypertension, diabetes, and stroke history Lin et al. JAMA Int Med. 2013

29 Hearing Loss & Incident Dementia Dementia incidence in 639 adults followed for >10 years in the BLSA Risk of incident allcause dementia (compared to normal hearing) a HR 95% CI p Mild Moderate Severe a Adjusted for age, sex, race, education, DM, smoking, & hypertension Lin et al., Arch Neuro., 2011

30 Does Peripheral Hearing Loss Affect Brain Structure/Function? Microvascular Disease Cognitive Function Alzheimer s Neuropathology Hearing Impairment

31 Hearing Loss & Accelerated Brain Volume Decline BLSA Hypothesis: Hearing loss is associated with accelerated atrophy in the superior, middle, and inferior temporal gyri 126 participants (56-86 years) in the neuroimaging substudy of the BLSA Mean follow-up duration of 6.4 years

32 Estimated Annual Rates of Change in Brain Volume (cm 3 /year) + <.05; * <.01; ** <.001 Lin et al., Neuroimage 2014

33 Voxel-Based Analyses Difference in mean gray matter volume change in those with HL vs. NH L Faster decline in brain volume in HL vs. NH Lin et al., Neuroimage 2014

34 Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Physical Mobility & Activity Avoiding injury Healthy Aging Keeping Socially Engaged & Active Increased falls (Viljanen et al, JGMS 2009; Lin et al. Arch Int Med 2012) Physical mobility/functioning Reduced walking speed (Viljanen et al. JAGS 2009; Li et al., Gait & Posture 2012) Accelerated decline in physical functioning (Chen et. al. Under review 2013) Driving ability (Hickson et al. JAGS 2009; Picard et al 2008) Health resource utilization/mortality Increased odds of hospitalization (Genther et al, JAMA, 2013) Health Resource Utilization/Mortality Increased mortality (Karpa et al Ann Epi 2010; Fisher et al. 2013; Genther et al, Under review)

35 Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Hearing Loss Brain structure/function Cognitive & Physical Functioning Social Isolation Common pathological process

36 Age-Related Hearing Loss (ARHL) Basic Questions What are the consequences of ARHL for older adults? What is the impact of treating ARHL on older adults? How can ARHL be effectively addressed in the community?

37 The question of whether treating hearing loss could delay cognitive/physical decline or dementia remains unknown There has never been a randomized clinical trial of treating hearing loss to explore effects on reducing the risk of cognitive decline/dementia

38 Conceptual Model for HL-Cognition RCT In collaboration with Marilyn Albert, Joe Coresh, Richey Sharrett, ARIC Study Team (T. Mosley, D. Knopman, C. Jack), and U. South Florida (T. Chisolm, A. Eddins) Intervention Proximal/Mediating Outcomes Primary Outcome Secondary Outcomes HRQL Best-Practices Hearing Rehabilitative Treatment Audibility of speech & environmental sounds Enhanced Verbal Communication & Social Engagement Cognitive Functioning Social/Leisure Activities Daily Functioning Mobility Brain structure (MRI)

39 Age-Related Hearing Loss (ARHL) Basic Questions What are the consequences of ARHL for older adults? What is the impact of treating ARHL on older adults? How can ARHL be effectively addressed in the community?

40 How can ARHL be effectively addressed in the community? Future Trends Understanding & approaching hearing loss in the context of healthy aging/public health Institute of Medicine Workshop in the U.S.

41 IOM Workshop on Hearing Loss & Healthy Aging January 13-14, 2014 Washington, D.C. Two-day workshop addressing: Implications of HL for healthy aging/public health & needed areas of research Developing innovative models of care & technologies to address HL Short & long-term collaborative strategies to approach HL as a public health priority in the U.S.

42 How can ARHL be effectively addressed in the community? Future Trends Understanding & approaching hearing loss in the context of healthy aging Jan 2014 Institute of Medicine Workshop in the U.S. Innovations in hearing health care/technology Accessible & affordable services/technology

43 Innovations in Hearing Health Care Limitations of Current Model Current (only) gold-standard model of hearing healthcare: Repeat visits with audiologist for evaluation, counseling, sensory management, fitting

44 Current Model of Hearing Health Care Gold Standard Audiology Care $$$$ 3-6 months

45 Innovations in Hearing Health Care Affordable & Accessible Stepping Stones are Needed for Hearing Health Care Technology - Self-fit hearing aids Over-the-counter hearing aids Incorporation of Bluetooth allowing for integration with smart phones & wireless sound transmission Cost USD $ Services - Community health care workers Community-based hearing screening Counseling, education, & provision of self-fit hearing aids & other assistive technologies Referral as needed

46 Additional Models of Hearing Health Care are Needed Self-Fit Hearing Aid $ 3 hours Community Health Worker $$ 1 day Hearing Aid Dispenser $$$ 1-2 months Gold Standard Audiology Care $$$$ 3-6 months

47 Are you telling What are me the that consequences I m of hearing going loss to develop for older adults? dementia? What is the impact of treating hearing loss on older adults? How can hearing loss be effectively addressed in the community? Hypertension Heart attack & stroke Intervention: Medication, Lifestyle modification Hearing loss Cognitive decline, dementia, poorer physical functioning Intervention: Comprehensive hearing tx?

48 Acknowledgments Johns Hopkins Dane Genther David Chen Joe Coresh Carrie Nieman Richey Sharrett Marilyn Albert Josh Betz Rebecca Kamil BLSA Luigi Ferrucci Susan Resnick Jeff Metter Yang An Josh Goh HealthABC Tamara Harris Eleanor Simonsick Kristine Yaffe NIDCD K23DC Triological Society & American College of Surgeons Clinician Scientist Award Eleanor Schwartz Charitable Foundation NIA Pepper OAIC Career Development Award NIA Intramural Research Program