IS COCHLEAR IMPLANTATION THE NEW TREATMENT FOR DEMENTIA?

Transcription

1 Cochlear Nordic Symposium, Malmo 2019 IS COCHLEAR IMPLANTATION THE NEW TREATMENT FOR DEMENTIA? Charlie Huins Louise Craddock Alex Bishop Max Roderick Midlands Cochlear Implant Programme Queen Elizabeth Hospital Birmingham UK

2 background population predictions; deaf population association hearing loss & cognitive decline impact of cochlear implantation additional benefits - health & QoL impacts birmingham study conclusion

3 ELDERLY

4 WHAT IS ELDERLY? 10th C - Elder : in a wider sense, a predecessor, one who lived in former days Oxford English Dictionary (of a person) old or ageing OED rather old; especially: being past middle age Merriam-Webster United Nations: >60 WHO: >65 most papers: >65

5 POPULATION AGED 60-79Y & 80Y OR OVER BY DEVELOPMENT GROUP, 2000, 2015, 2030 & Population (millions) or over World More developed regions Less developed regions Least developed countries Source: United Nations (2015): World Population Prospects: The 2015 Revision

6 ELDERLY POPULATION Worldwide: 1 in 8 were Africa >60y (901 million) Population aged 60 years or over (millions) Asia Latin America and the Caribbean Oceania Europe Northern America by 2030: 1in 6 (1.4 billion) - outnumber children aged 0-9y by 2030, elderly = >25% of population in Europe & USA >80yr: fastest growing group - triple by 2050 to 434 million Population aged 80 years or over (millions) >60yrs >80yrs Source: United Nations (2015): World Population Prospects: The 2015 Revision

7 2000 PERCENTAGE OF POPULATION > 60 YEARS Source: United Nations (2015): World Population Prospects: The 2015 Revision

8 UK POPULATION AGE STRUCTURE IN 2016, AND PERCENTAGE CHANGE BETWEEN 2002 AND 2016 Source: UK Office for National Statistics

9 PEOPLE AGED 90 AND OVER IN THE UK, 1986 TO 2016 Source: UK Office for National Statistics

10 HEARING LOSS

11 ) n o i l l i m ( n o i t a l u p o p l a b s o l s g o l % g 5 n i r > a e h g n i l b ] a n s i e d r d l e i h c hav n o i l l i m 2 3 ; s t l u d a n o i l l i [328 m 10 million adults in UK have hearing loss (45,000 children) 1:6 of UK population Action on Hearing Loss, DoH aring e h d n a s s Deafne ar y 20 u r b e F, O loss, WH Of Global Population, 0.9% are profoundly deaf 65 milli o By 2030, adult onset hearing loss = one of top 10 disease burdens Limingi et al n WHO 2006 By 2031, 14.5 million (20%) in UK will have hearing loss Hearing Matters, Action on Hearing Lo ss, DoH 2011 s s lo g in r a e h e v a 71% of >70y h D oh Action on Hearing Loss, ,500 se vere-profo u ss lo g in ar he l fu ng ni ea m ly al ic in cl ve ha 2/3 of >70y 1 Lin FR et al. Hearing loss prevalence in the United States. Arch Int Med 201 Action on Hearing Lo nd adults in ss, DoH UK

12 PREVALENCE OF SEVERE AND PROFOUND DEAFNESS SHI / PHI prevalence [% of population in age segment] 3% 3% 2% 2% 1% 1% 0% severe hearing impairment profound hearing impairment x 2 x % 0.04% 0.05% 0.10% 2.60% 0.40% [ 0; 16] [16; 60] [61; 80] x 5 age segment x 65 Paediatric Data: Fortnum, H. M., Summerfield, A. Q., Marshall, D. H., Davis, A. C., Bamford, J. M.: Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study. BMJ 2001;323;7312: Adult data: Davis, Hearing in Adults, 1995, ISBN

13 DEMENTIA

14 DEMENTIA prevalence projected to double every 20 years 2050: 100 million 1:85 worldwide 1,2 interventions delaying onset by 1 year 10% decrease in global prevalence in Ferri CP et al. Lancet Prince M et al. World Alzheimer Report Brookmeyer R et al. Alzheimers Dement 2007

15 HEARING LOSS & COGNITIVE DECLINE

16 HEARING LOSS & COGNITIVE DECLINE hearing loss independently associated with poorer cognitive functioning 1 and dementia 2,3 Cognitive scores 24% lower in individuals with HL 4 HL associated with 41% greater rate of cognitive decline cf. normal hearing every 10dB HL at baseline associated with incremental additional rate of decline 1. Lin FR et al. J Gerontol A Biol Sci Med Sci Lin FR et al. Arch Neurol Deal JA et al. J Gerontol A Biol Med Sci Lin FR et al. JAMA Intern Med 2013

17 HEARING LOSS & COGNITIVE DECLINE mechanisms poor verbal communication increased isolation increased cognitive load environmental deafferentiation

18 HEARING LOSS & OTHER FACTORS

19 ECONOMICS HL associated with higher total medical expenditures - $3.1 billion extra (US, 2010) 1 NHS costs per year: Depression - 520m pa Dementia - 16,700-37,500 per person affected 2 1. Foley D et al. J Am Geriatr Soc Lamb B et al. Improving access to cochlear implantation: Change lives and save society money. The Ear Foundation 2016.

20 HL vs COSTS & UTILISATION untreated HL (>50yrs) higher healthcare costs (46.5% vs no HL) increased readmission (44%) more patient stays & ED visits longer hospital stay average $22,434 more over 10-year period than patients without HL Reed NS, Altan A, Deal JA et al. Trends in Health Care Costs and Utilization Associated With Untreated Hearing Loss Over 10 Years. JAMA Otolaryngol Head Neck Surg. 2019;145(1):27-34.

21 QUALITY OF LIFE excellent QoL : 39% with HL cf 68% normal hearing 1 fair or poor health : 33% with HL cf 9% no HL HL: source of loneliness, isolation, and decline in social activities, as well as communication disorders and dissatisfaction with family life 2 HAs: HHIE: reduced psychological, social & emotional consequences 3 1. The National Council on the Aging. The Consequences of Untreated Hearing Loss in Older Persons. Washington, DC: The National Council on the Aging Lotfi Y et al. Arch Iran Med Chisholm TH et al. J Am Acad Audiol. 2007

22 COCHLEAR IMPLANTATION

23 ACCESS & BENEFITS Only 6.7% of UK adults with profound HL are implanted 1 perceived improvements in communication, confidence, education and employment, independence and family life after implantation 2,3 1. Raine et al Athalye et al Ng et al 2016

24 COCHLEAR IMPLANTATION AND COGNITIVE FUNCTION

25 COGNITIVE FUNCTION AFTER CI 6 cognitive tests (MMSE, FWT, clock-drawing test, verbal fluency test, d2 test of attention, TMT- A&B) pre-ci: 25% = normal in all 6 post-ci: 40% = normal in all 6 Mosnier I, Bebear JP, Marx M et al. Improvement of cognitive function after cochlear implantation in elderly patients. JAMA Otolaryngol Head Neck Surg May 1;141(5):

26 normal cognitive tests Pre-CI % Post-CI % abnormal tests Mosnier I, Bebear JP, Marx M et al. Improvement of cognitive function after cochlear implantation in elderly patients. JAMA Otolaryngol Head Neck Surg May 1;141(5):

27 CI & NEUROCOGNITION M3: attention Recall: short-term memory n-back: working memory Flanker: inhibitory abilities for stimuli OPSAN: working memory Trail A&B: processing speed & executive function Verbal fluency: long-term memory Völter C, Götze L, Dauert S et al. Can cochlear implantation improve neurocognition in the ageing population? Clin Interv Aging Apr 20;13:

28 COCHLEAR IMPLANTATION AND DEPRESSION

29 CI & DEPRESSION QoL - NCIQ significant improvements in all 6 domains Depressive symptoms - Geriatric Depression Scale no depression: 59% pre-ci 76% post-ci Mosnier I, Bebear JP, Marx M et al. Improvement of cognitive function after cochlear implantation in elderly patients. JAMA Otolaryngol Head Neck Surg May 1;141(5):

30 CI & QoL significant improvements post CI: improved speech understanding significant improvement 0-6 months post CI no significant improvement 6-12 months sensory abilities QoL significant increase improved autonomy, executive planning & working memory Sonnet M-H, Montaut-Verient B, Niemier J-Y et al. Cognitive Abilities & Quality of Life After Cochlear Implantation in the Elderly. Otol Neurotol. 2017;38:e

31 CI & QoL Völter C, Götze L, Dauert S et al. Can cochlear implantation improve neurocognition in the ageing population? Clin Interv Aging Apr 20;13:

32 MIDLANDS HEARING IMPLANT PROGRAMME (ADULTS), BIRMINGHAM, UK Rupan Banga Will Brassington Stuart Burrell Stacey Cooper Chris Coulson Louise Craddock Gill Currier Charlie Huins Richard Irving Gemma Mole Peter Monksfield Patrick Richmond-Ward Alison Riley Tracy Wright Surgeon Head of Service Audiologist Audiologist Surgeon Clinical Scientist & Manager Nurse Surgeon Surgeon Hearing Therapist Surgeon Hearing Therapist Audiologist Hearing Therapist

33

34 MIDLANDS HEARING IMPLANT PROGRAMME ACTIVITY (ADULTS) Surgery Referrals Maintained

35 n =102 AGE AT IMPLANTATION ( )

36 AGE AT IMPLANTATION < >85 n =102

37 UK NICE COCHLEAR IMPLANT CRITERIA National Institute for Health and Care Excellence >90dB HL at 2 & 4 khz (unaided) <50% score of Bamford-Kowal-Bench (BKB) sentence 70dB SPL children: speech, language & listening skills appropriate to age, developmental stage & cognitive ability >80 db HL at two or more frequencies (500Hz, 1, 2 & 4kHz) <50% AB word score

38 PATIENTS EXCLUDED FROM BKB ANALYSIS (N=32) Pre-lingually deaf Medically Complex Revision Non-English Speaker Non-user Ossification / Incomplete Insertion CI for SSD Deceased 70 patients

39 BKB SCORES BY AGE Average age <65 = 49.25y Average age >65 = 75.65y Significant improvement: Pre-op Week 1 Week 1 3 months No significant difference between age groups at any test interval [Also: Sonnet M-H, Montaut-Verient B, Niemier J-Y et al. Cognitive Abilities & Quality of Life After Cochlear Implantation in the Elderly. Otol Neurotol. 2017;38:e ]

40 SERVICE EVALUATION questionnaire to 102 patients ( ) Likert scale design 63 responses

41 SINCE I HAD MY COCHLEAR IMPLANT 1. my hearing has improved 2. my confidence has improved 3. my social life has improved 4. my general health has improved 5. my memory has improved 6. my concentration has improved 7. I have more energy 8. listening is easier 9. I feel mentally sharper 10. my overall quality of life has improved

42 strongly disagree strongly agree n=63

43 Not at all Moderately Significantly SUBJECTIVE RATING OF BENEFIT

44 SUBJECTIVE RESULTS BY AGE <65y >65y

45 CO-MORBIDITIES Co-morbidities No co-morbidities n=54 n=48

46 BALANCE DISTURBANCE Yes No <65y >65y n=54 n=48

47 TINNITUS Yes No <65y >65y n=54 n=48

48 CONCLUSIONS Between groups: No significant difference in performance No difference in subjective scores No significant difference in comorbidities or complications Improvement in subjective benefits in CI, including QoL Confidence Social Mental sharpness General health Concentration Elderly patients gain equivalent benefit from CIs as younger patients

49 CONCLUSION 0.9% global population are profoundly deaf by 2050, 1:85 of world population will have dementia HL associated with 41% greater rate of cognitive decline cf. normal hearing individuals CI decreases cognitive load, improved attention, concentration & executive function, leading to improved cognitive function CI improves communicative capacity & performance and autonomy CI reduces depressive symptoms & significantly improves QoL

50 THANKS Co-authors Louise Craddock Clinical Scientist & Implant Programme Manager Alex Bishop Medical Student, University of Birmingham Max Roderick Medical Student, University of Birmingham Peter Nightingale Statistician, Institute of Translational Medicine, Birmingham

51 thank you