Should audiologists measure cognition: How and why?

Transcription

1 Should audiologists measure cognition: How and why? Kathy Pichora-Fuller Professor, Psychology, University of Toronto Adjunct Scientist, Toronto Rehabilitation Institute, University Health Network Adjunct Scientist, Rotman Research Institute, Baycrest Hospital, Toronto Guest Professor, Linneaus Centre HEAD, Linköping University, Sweden Funded by CIHR, NSERC, & Hearing Foundation of Canada

2 Outline (Part I Healthy Adults ) Relevance of cognition for listening Gains and losses in health cognitive aging Cognitive processing declines and listening Use of context and compensation Brain plasticity and training New ideas for listening training

3 Prevalence of Hearing Loss in Older Adults Audiometry (e.g., Plomp, 1978; Moscicki et al., 1985; Willott, 1991) 65 years 24% 70 years 30% 75 years 50% years 83% 75% of people with hearing loss are > 75 years old Average first time hearing aid user ~ 70 years

4 Audiograms and Age (ISO 7029) Women Men 3kHz 3kHz HF audiometric threshold elevation OHC (also noise-induced hearing loss) Endocochlear potentials ~ stria vascularis Neural loss of synchrony (Mills, Schmeidt, Schulte, & Dubno, 2006)

5 Speech Understanding in Noise Little problem in ideal listening conditions Quiet One talker Familiar person, topic, situation Simple task, focused activity Difficulty in challenging listening conditions Noise Multiple talkers Strangers, accents, new topic, novel situation Complex task, many concurrent activities Fast pace Hearing aid Avoid by withdrawal from social interaction!

6 Speech Perception in Noise (Pichora-Fuller, Schneider, Daneman, JASA, 1995) 8 lists of 50 sentences Half low-context John did not talk about the spoon. Half high-context Stir your coffee with a spoon. Repeat last word of sentence Vary S:N (Sometimes also recall) Old need 3 db better S:N Context helps 3 db YOUNG OLD OLD HL

7 Speech, Spatial & Qualities of Hearing Scale (SSQ; Noble & Gatehouse, 2004; Bahn, Singh, Pichora-Fuller, JAAA, 2012) Older normal vs HL Older vs Younger Adults Older normal hearing for age with clinically normal audiograms up to 4 khz

8 SSQ and Behavioural Hearing Tests: Not Significantly Correlated Pure-tone Average (db HL) Words-in-Noise (WIN) 50% threshold (db SNR)

9 SSQ Items with Largest Age-related Differences Speech Conversing in adverse environment Young - Old score (10-point scale) Conversation in reverberant environment 1.7 Talking with a person in continuous noise 1.6 Focusing, switching attention Ignore interfering voice of different pitch 1.9 Following conversation switching in a group 1.6

10 Speech Understanding in Noise CHABA Report (1988). J Acoust Soc Am, 83, Peripheral auditory Central auditory Cognitive Interactions of sensory and cognitive aging Schneider BA, Pichora-Fuller MK, Daneman M. The effects of senescent changes in audition and cognition on spoken language comprehension. In: Gordon-Salant S, Frisina RD, Popper A, Fay D, eds. The Aging Auditory System: Perceptual Characterization and Neural Bases of Presbycusis. Berlin: Springer; 2010:

11 Outline (Part 1) Relevance of cognition for listening Gains and losses in health cognitive aging Cognitive processing declines and listening Use of context and compensation Brain plasticity and training New ideas for listening training

12 What Changes in Cognitive Development over the Lifespan? (Craik & Bialystock, Handbook of Cognitive Aging, 2008) Younger Control (PROCESSING) -working memory -processing speed -divided attention Older Representation (KNOWLEDGE) -vocabulary - world knowledge - expertise -sensory Context (reliance, benefit from SUPPORTIVE ENVIRONMENT)

13 Bottom up Bottom-Up &Top Down Processing Effortful listening Bottom-up processing less efficient Top-down processing more necessary Bottom-up (ear to brain) Analysis of acoustic signal Better signal (faster) Poorer signal amount & type of distortion Meaning Knowledge Top Down Top-down (brain to ear) Priming (pre-signal) expectations facilitate recognition (faster) Disambiguation (post-signal) knowledge constrains alternatives (slower) Repair (post-signal) Fill in gaps or correct errors (slower) Sound

14 As Processing Effort Increases Extreme demand: Accuracy drops But if accuracy remains high, increased processing (cognitive effort/load) is manifested by Reduced working memory span Slower speed Problems dividing attention (dual task)

15 Working memory System responsible for the PROCESSING and temporary STORAGE of information during the performance of all complex cognitive tasks, including comprehension assumed to have a limited capacity that must be shared between processing and storage (Baddeley, 1976; Daneman & Carpenter, 1980) Attentional control and speed of processing

16 Spectrograms for Jittered and Intact Sentence in Babble

17 Effect of Simulated Auditory Aging on Working Memory Span

18 Measuring Working Memory: Why and How. Fred Mary INTER- Off-line WM = 5 WM = 7 Fred in Quiet Fred in Noise Fred in More Noise Processing Storage INTRA- On-line WM = 5 WM = 3 WM = 1 If task demand does not exceed capacity, would recognition accuracy be reduced? If task demand does exceed capacity, would recognition accuracy be reduced? If WM measured on-line, would it correlate with performance (accuracy, speed, effort)?

19 Are Older Adults Special? Audibility (audiogram) is primary but not a special aging factor (Humes, 2003, JAAA 2007) If audibility factor is minimized Age-related auditory temporal processing issues emerge Especially in challenging listening conditions Complex speech (e.g., sentences) Complex backgrounds (e.g., competing talkers) Critical age differences when conditions become challenging Older listeners need 2-3 db better S:N than younger listeners Cognitive factors important in challenging conditions!!! Regardless of age Regardless of audiogram

20 Word Span with NU6s (Smith, Pichora-Fuller, Alexander, Wilson, & Anderson, in prep) Word Recognition Judgment Recall RICE Rice, FIST X, Fish Fish, RISK GRACE Risk, Grace, BAR SHOVE X, Car X X Card, X Shove, X WHAT MOON What, Moon, CALF THAT Rice, That,

21 6 RECOGNITION 5 MEAN NUMBER OF WORDS PER SET SIZE RECALL NONE OBJECT ALPHA YOUNGER OLDER SET SIZE

22 OHL Recognition Recall

23 Benefit from Context (db SNR) 7.0 Cognitive Aging db Gains: Knowledge is preserved and context is helpful Younger Intact Younger Jitter Older Intact Losses: Processing Working memory Slowing Attention/Inhibition HIGH LOW

24 Cognitive Neuroscience of Aging Same performance achieved with different processing More widespread activation ~ brain reorganization Young brain activity more lateralized Old brain activity more distributed Deterioration or compensation? HAROLD: Hemispheric asymmetry reduction in older adults (Cabeza, 2002) PASA: Posterior-anterior shift in aging (Davis, Dennis, Daselaar, Fleck & Cabeza, 2008)

25 Context, Intelligibility & Brain Activation (Obleser, Wise, Dresner & Scott, 2006) High vs. low predictability at intermediate signal quality for younger adults listening to distorted (noise-vocoded) SPIN sentences Activation to HIGH-CONTEXT > LOW-CONTEXT speech Various areas activated including the left dorsolateral prefrontal cortex (working memory & semantic processing)

26 Compensation (Grady, 2012, Nature Reviews Neuroscience, 13, ) low high

27 Cognitive Capacity Low High Task Demands (Pichora-Fuller & Jamieson, 2012) Low P2 Task 3 Task 2 Task 1 Auditory Capacity P1 High Task 1 depends mostly on auditory capacity (e.g., detecting a sound). Task 2 depends more on cognitive capacity (comprehending a lecture). Task 3 depends even more on cognitive capacity (dividing attention during group conversation). P1 is a person with normal hearing and slightly below average cognitive capacity who has sufficient combined capacities to succeed on all 3 tasks. P2 is a person with hearing loss and high cognitive capacity who is able to succeed on all 3 tasks by using cognitive capacity (world and linguistic knowledge) to help compensate for deficits in auditory processing.

28 Cognition & HA Benefit Correlated Landmark 2003 studies (Gatehouse et al.; Humes; Lunner) Those with higher cognitive function do better with complex, fast-acting signal processing Those with lower cognitive function do less well with such complex devices Cognition matters in challenging conditions Why? How measure cognitive status? To predict or guide treatment (HA fitting, training) As a new outcome measure

29 Explained variance Lunner & Sundewall-Thorén, JAAA 2007 N = 32 experienced HA users Replicates earlier studies (Gatehouse et al. 2003, 2006) with sentence tests Explained SNR variance from hearing loss and cognitive performance 45% 40% 35% 30% 25% 20% PTA(6) VLM 15% 10% 5% 0% Slow&Unmod. Slow&Mod. Fast&Unmod. Fast&Mod. Test condition

30 Cognitive Hypotheses & Training Cognitive Compensation Hypothesis (Li, Krampe, & Bondar, 2005; Li & Lindenberger, 2002) declining sensory (and motor) functions are compensated by higher-level cognitive and attentional processes CRUNCH - Compensation-Related Utilization of Neural Circuits Hypothesis (Reuter-Lorenz & Cappell, 2008) additional brain regions are recruited by older adults when capacity limits are reached in a given task or combined tasks. STAC - Scaffolding Theory of Aging and Cognition (Park & Reuter-Lorenz, 2009) there is the potential to enhance such compensation by training.

31 Outline (Part IB) Relevance of cognition for listening Gains and losses in health cognitive aging Cognitive processing declines and listening Use of context and compensation Brain plasticity and training New ideas for listening training

32 New Rehab Approaches Pichora-Fuller, M.K. (2013). Auditory and cognitive processing in audiologic rehabilitation (pp ). In J. Spitzer & J. Montano (Eds.), Adult audiologic rehabilitation: Advanced practices (2 nd edition). Plural Publishing, San Diego, CA. Ease of Listening 1. Semantic priming 2. Stream segregation 3. Spatial expectation 4. Emotional consistency

33 Speed and Ease of Processing As adults age: Auditory temporal processing declines Cognitive information processing slows Auditory and cognitive aging can combine to make listening sluggish Easier listening is reflected in faster listening Reaction time or online measures could reveal differences in speed/ease when accuracy measures are near ceiling and insensitive

34 Lexical decision reaction time in younger and older listeners: The effects of semantic context and the type and amount of acoustical distortion Huiwen Goy - Preceding context distorted or intact Target intact Congruent Stir your coffee with a spoon. (yes) Neutral Its name is grock. (no) Incongruent Stir your coffee with a risk. (yes) - Measure RT when lexical decision correct - Facilitation (RT neutral context RT congruent context) Goy, H., Pelletier, M., Coletta, M., & Pichora-Fuller, M.K. (in press). Journal of Speech, Language and Hearing Research.

35 Increasing Distortion of Context Only Slows Lexical Decision for Intact Items More Some None

36 Effects of Distorting Context on Speed of Lexical Decision Older listeners RTs are more facilitated by context. Signal distortion reduces facilitation.

37 Speed (and Ease) of Listening Signal quality affects listening: Faster if signal is intact Slower if signal is distorted or degraded or noisy Could be influenced by hearing aid processing Context affects listening: Faster if context is semantically congruent Slower if context is semantically incongruent Could be influenced by AR training

38 New Rehab Approaches Ease of Listening 1. Semantic priming 2. Stream segregation 3. Spatial expectation 4. Emotional consistency

39 Speech-on-Speech Listening Ezzatian, Li, Schneider & Pichora-Fuller, submitted Payam Ezzatian Circles : intact two-talker speech masker condition. Diamond : time-reversed two-talker speech masker. Triangles pointing up : 3-band noise-vocoded speech masker condition. Triangles pointing down: 16-band noise-vocoded speech masker condition. Squares: precedence-effect speech masker condition. Dotted lines word position effect; solid lines no word position effect

40 New Rehab Approaches Ease of Listening 1. Semantic priming 2. Stream segregation 3. Spatial expectation 4. Emotional consistency

41 Spatial Attention (based on Kidd et al., 2005) Unlikely 80% Likely Ready Hopper, Unlikely 10% go to white 2 now 10% Gurjit Singh Ready Charlie, go to blue 1 now Ready Baron, go to green 8 now Ready Charlie, go to [colour] [number] now. Task: Identify colour and number with target callsign Callsigns = Charlie, Hopper, Baron, etc. Probability of target at the centre location (1.0, 0.8, ) Simple vs Complex instruction

42 Task Complexity Hurts Older Adults if Target at Unlikely Location Singh, Pichora-Fuller, Schneider, JASA 2008; in press, Ear & Hearing

43 New Rehab Approaches. Ease of Listening 1. Semantic priming 2. Stream segregation 3. Spatial expectation 4. Emotional consistency

44 Emotion & Word Recognition (Dupuis & Pichora-Fuller, in prep; Dupuis PhD) Mixed vs. Blocked; Young > Old ~ 11% vs. 6% Kate Dupuis FEAR SAD

45 Listening in Noise ~ Driving Uphill in Snow Low gear (effort) Slow down (speed) Keep moving (continuity) Monitor space (expectations) Stay calm (emotion) Expertise (training) Snow tires (technology) Get where you want to go Stay safe

46 Outline ( Part 2 Dual Hearing and Cognitive Loss) 1. Links between hearing loss and dementia 2. Diagnosing MCI and dementia 3. Hearing and cognitive assessment 4. Rehabilitation Pichora-Fuller, K., Dupuis, K. Reed, M. & Lemke (in press). Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach. Seminars in Hearing.

47 Cognitive Impairment Canadian Study of Health and Aging (Ebly et al., 1994) Dementia years: 15% years: 23% years: 40% > 95 years: 58% Of adults years old living in community 15% have dementia

48 Hearing Loss Associated with Dementia Gold, Lightfoot & Hnath-Chisolm (1996) 27 of 30 (90%) patients with Alzheimer s had hearing impairment (pure-tone screen & HHIE) Uhlmann et al. (1989) Case-control study with 100 pairs Prevalence of hearing loss significantly higher in those with Alzheimer s-type dementia Hearing loss significantly correlated with MMSE Lin et al. (2004) Dual sensory loss associated with greatest odds for cognitive decline and for functional decline on five everyday activities over a period of four years

49 Dual Sensory (Hearing & Vision) Loss Self-reported DSI (Caban et al., 2005) 3% in general population 17% in adults > 80 years Clinical measures in 400 veterans (Smith et al., 2008) 42-75% depending on criteria for HL 100 in each of 4 age groups (<65, 65-74, 75-84, 85+ yrs) Unaided > 40 db HL pure-tone average threshold in better ear Regular PTA (.5, 1 & 2 khz) vs high-frequency PTA (1,2 & 4 khz) 7.4% vision impairment overall Best corrected acuity less than 20/40 (legal blindness) > 20% dual loss in veterans > 85 years

50 Central Auditory (Speech in Noise) Problems May PRECEDE Dementia Longitudinal epidemiological studies Gates et al. (1996) N >700, speech in competing speech test (SSI-ICM) in those without stroke, dementia, or HL (PTA 40 db HL) MMSE administered 2, 4, 6 years later Those with low scores on SSI-ICM were 6-12 times more likely to develop clinical dementia Gates et al. (2002, 2008) Similar results for longer follow-up period (3-12years)

51 Pure-tone HL related to incident dementia Lin, F. R., Metter, E. J., O Brien, R. J., Resnick, S. M., Zonderman, A. B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives Neurology, 68(2), Lin FR, Ferrucci L, Metter EJ, et al. (2011). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology, 25, Lin FR. (2012). Hearing loss in older adults. Who s listening? JAMA, 307, Lin FR, Yaffe K, Xia J, et al. (2013). Hearing loss and cognitive decline in older adults. JAMA Intern Med, 173,

52 Central Auditory Tests (DDT) Idrizbegovic E, Hederstierna C, Dahlquist M, Nordström CK, Jelic V, Rosenhall U. (2011). Central auditory function in early Alzheimer's disease and in mild cognitive impairment. Age Ageing, 40,

53 Outline ( Part 2) 1. Links between hearing loss and dementia 2. Diagnosing MCI and dementia 3. Hearing and cognitive assessment 4. Rehabilitation

54 When does cognitive aging start? 1.5 Z-Score Synonym Vocabulary Pattern Comparison (Speed) Raven's (Reasoning) Recall (Memory) Percentile of Population Chronological Age Salthouse (2004) Current Directions in Psychological Science

55 New View Cognitive decline as a continuum Healthy aging MCI Dementia

56 Figure 1. Estimates of age-specific prevalences of Alzheimer s disease (AD), Mild Cognitive Impairment (MCI), and Non-Affected (NAs), aged 60 85, assuming 1.0% rate for conversion from NA to MCI at age 60. (Adapted with permission from Yesavage JA, O Hara R, Kraemer H, et al. Modeling the prevalence and incidence of Alzheimer s disease and mild cognitive impairment. J Psychiat Res 2002;36: )

57 Symptoms and Diagnosis Changes in cognitive functioning Declines in memory, learning, attention, and judgment Disorientation in time and space Difficulties in word finding, communication Declines in personal hygiene Inappropriate social behaviour Personality changes

58 Most common form of progressive, degenerative, and fatal dementia accounting for up to 60% of all cases of dementia Alzheimer s Disease Neurological changes in Alzheimer s disease Microscopic Rapid cell death in hippocampus, cortex, basal forebrain Neurofibrillary tangles (beta-amyloid protein) Neuritic plaques Neurotransmitters altered

59 Other Forms of Dementia Vascular Dementia CVA (stroke) Parkinson s Disease Associated with dopamine deficiency 14% to 40% will develop dementia Huntington s Disease Associated with GABA deficiency Alcohol Dementia Complex Wernicke-Korzakoff s Disease AIDS Dementia Complex (ADC)

60 Symptoms and Diagnosis Sundowning symptoms worse in the evening Wide variation in the rate of deterioration Wandering Incontinence Loss of personhood Past: definitive diagnosis depends on autopsy Now: possible to measure in brain (plagues/tangles) Comprehensive and broad diagnosis can be reasonably accurate pre-mortem Treatable causes of Alzheimer s-like dementia must be ruled out

61 7 (2011)

62

63 Outline ( Part 2) 1. Links between hearing loss and dementia 2. Diagnosing MCI and dementia 3. Hearing and cognitive assessment 4. Rehabilitation

64 Hearing Loss Can Impair Performance on Any Task Using Auditory Stimuli Weinstein & Amsel (1986) N=30 institutionalized elders with senile dementia 10 of 30 reclassified to less severe category of dementia when retested with amplification (83% had hearing loss > 25 db HL, significantly higher than comparison sample w/o dementia)

65 MoCA N=301 N=122

66 Effect of Background Noise on MoCA Scores Dupuis, Marchuk, Pichora-Fuller, Chasteen, Singh, & Smith, submitted (Aging, Neuropsychology and Cognition) 20 per group Veronica Marchuk Speech 50 dbhl Babble 30 dbhl Babble 62 dbhl

67 Assessing Person with Dementia Marilyn Reed, Canadian Hearing Report, in press Give short, simple instructions Practice, to ensure instructions are understood Provide prompting and encouragement Accept a variety of responses Get most valuable information first (i.e., minimize fatigue, agitation) Speech testing (meaningful stimuli) more successful that PTs; SRTs more reliable than PTTs Obtain SATs where SRTs unobtainable Use any speech material that is effective; meaningful/familiar speech (simple questions or digits more successful than PBs or spondees) Test at time of day when most alert (usually morning) Presence of caregiver/family member may reduce agitation or anxiety Assess over multiple sessions if needed Include speech in noise and CAP test (s) appropriate to capability Objective assessment; acoustic reflexes, ABR (OAEs unlikely)

68 Outline ( Part 2) 1. Links between hearing loss and dementia 2. Diagnosing MCI and dementia 3. Hearing and cognitive assessment 4. Rehabilitation

69 Aging & Communication Cognitive Loss Mobility Loss Clinically Normal Hearing Loss Vision Loss

70 Doing the math in the clinic? in life? NORMAL NORMAL NORMAL Auditory Visual Cognitive DEAFNESS BLINDNESS DEMENTIA Degree of Impairment

71 Stave off and Slow Decline

72 Possible Protective Factors Physical Being male Genetics Cardiovascular health Diet Exercise Occupational Education Bilingualism Employment Social Activity Cognitive Activity Volunteering

73 Interactive Effects of Physical Activity and Diet Scarmeas et al. (2009) JAMA, 302,

74 Mild Cognitive Impairment (e.g, Troyer & Murphy, 2007) Active lifestyle ~ risk of future dementia Cognitive engagement Tasks involving problem-solving, decision-making, learning, remembering new information Social interaction Rich social stimulation and active social network Participating in group activities and interactions Physical activity Some activities are done in groups, with music Enriched environments Group interventions Communication-related disorders??? Kelly Murphy

75 MCI Memory Intervention Program Goals Increase knowledge about practical and effective memory strategies Increase use of targeted strategies in everyday memory situations Change beliefs about memory function and factors influencing memory function Improve memory performance on objective memory tasks Troyer, Murphy, Anderson et al., (2008). Neuropsych. Rehab, 18, 65-88

76 MCI Memory Intervention Program Group intervention Detailed handouts At-home assignments Concurrent sessions for families Memory Strategies Knowledge (Know) Use in everyday life (Use out) Use in laboratory (Use in) Memory Beliefs Memory Performance Troyer, Murphy, Anderson et al., (2008). Neuropsych. Rehab, 18, 65-88

77 MCI Memory Intervention Program Week 1 st hour 2 nd hour - MCI 2 nd hour - family 1 What is MCI? Overview of Strategies Memory book MCI and dementia risk 2 Stress and Relaxation Memory book Safety 3 Stress & Relaxation follow-up Spaced Retrieval 4 Nutrition Semantic Association Behavioural Coping Nutrition 5 Community Resources Intentions Cognitive Coping 6 Recreation Strategy Application Planning ahead Troyer, Murphy, Anderson et al., (2008). Neuropsych. Rehab, 18, 65-88

78 Cognitive Benefits of Better Hearing Arlinger, Lunner, Lyxell, & Pichora-Fuller, SJP, 2009 Older adults using hearing aids have better emotional and social wellbeing and greater longevity (Appolonio et al., 1996; Cacciatore et al., 1999; Naramura et al., 1999; Seniors Research Group, 1999) Reduced rate of decline in scores on a cognitive screening test over a six-month period following intervention with hearing aids (Allen et al., 2003) Slower cognitive decline in Alzheimer s cases with better hearing (Peters, Potter, & Scholer, 1988; Wahl & Heyl, 2003) Hearing aid use reduced problem behaviours judged by caregivers of adults with dementia (Palmer et al., 1998)

79 Hearing Aid Fitting & Dementia Handling and Care: Automated features, minimal manual controls Remote controls intuitive/user friendly Verbal prompts Manageable battery doors (marked if low vision) Removal cords Safety loops for attachment to clothing for advanced CI Facilitate phone use with hearing aid, so not removed Establish routine for storage once removed For previous users: do not change style (or manufacturer) of aid do not change battery size or style of door Accessories to improve SNR (remote microphone, FM compatible) Training: Longer acclimatization period (6-12 months) Written instructions (large print, pictures, supported communication) Schedule prompt and more frequent return visits Counseling and AR; group/social model Involve/instruct caregivers in management and AR

80 Good Hearing Health Could Promote Good Cognitive Health PRESERVE communication and social interaction stave off social isolation slow cognitive decline Kate Dupuis Marilyn Reed Ulrike Lemke-Kalis

81 Vancouver, British Columbia World Congress of Audiology September 18-22, 2016