Healthy Aging 11/10/2011. Frank R. Lin, M.D. Ph.D. Maintaining Physical Mobility & Activity. Keeping Socially Engaged & Active.

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1 & Frank R. Lin, M.D. Ph.D. Assistant Professor Johns Hopkins Department of Otolaryngology-HNS Core Faculty Johns Hopkins Center on Aging & Health 27 October 2011 & Overview Why study hearing loss? physiology & measurement Epidemiologic research on hearing loss & aging Treatment options for hearing loss Future research directions Fountain of Youth Lucas Kranach 1546 Maintaining Physical Mobility & Activity Keeping Socially Engaged & Active Avoiding Injury Cognitive Vitality & Avoiding Dementia Preventing Illness and Disease 1

2 Decades later, I can see many of the central themes of my thinking about judgment in that old experience. One of these themes is that people who face a difficult question often answer an easier one instead -Daniel Kahneman, NYTimes Magazine, 10/23/11 Epidemiologic Associations? Clinical & Public Health Impact What does this mean for me? Keeping Socially Engaged & Active Maintaining Physical Mobility & Activity Cognitive Vitality & Avoiding Dementia Avoiding Injury Preventing Illness and Disease Prevalence of in the United States,, Prevalence of & Aid Use in the U.S., loss defined as a bilateral PTA of 0.5-4kHz tones > 25 db loss defined as a bilateral PTA of 0.5-4kHz tones > 25 db Lin et al., Arch Int Med Chien and Lin, 2011 & Strikes against as a Research Focus Ubiquitous = Inconsequential Silent disability of very gradual onset Historical evolution of otology as a field Paradigm for Research Causes Cochlear/Hair cell physiology Auditory Processing Epidemiologic risk factors Genetic causes NIDCD Research NIA Aging Research Effects Communication Quality of life Dementia & Cognition? Physical functioning? Social Isolation? Morbidity & Mortality? Health care costs? 2

3 & Overview Why study hearing loss? physiology & measurement Epidemiologic research on hearing loss & aging Treatment options for hearing loss Future research directions Principles of Auditory Physiology #1 depends on peripheral transduction & central processing Intensity Sunday Principles of Auditory Physiology Hair Cells Stria vascularis #2 Multiple different factors can progressively damage the cochlear hair cells and stria vascularis, leading to age-related hearing loss that is characterized by increased hearing thresholds and poor frequency resolution. Congenital Anomalies Aging & Presbycusis Intrinsic Inner Ear Diseases Genetics Infection Systemic Factors Medications Noise Epidemiologic Factors & Strength of Association Strong Age & Family History Sex Race Noise Exposure Intermediate Hypertension Stroke Ototoxic drugs High cholesterol Ryan A F PNAS 2000;97: Hair cell Injury Gates 2005 Vascular damage to stria vascularis Weak Bone mineral density Smoking Diabetes 3

4 Speech sounds are complex! Principles of Auditory Physiology #3 Audiometry is the gold-standard method for assessing the cochlea s ability to detect & encode sound Int ensity Increased hearing thresholds and poor frequency resolution. Principles of Auditory Physiology & Overview Why study hearing loss? PTA = Pure tone average of 0.5, 1, 2, & 4 KHz tones in the better- hearing ear physiology & measurement Epidemiologic research on hearing loss & aging Treatment options for hearing loss Future research directions Keeping Socially Engaged & Active Maintaining Physical Mobility & Activity Cognitive Vitality & Avoiding Dementia Avoiding Injury Preventing Illness and Disease Alzheimer s Disease Projected U.S. Prevalence from 2000 to 2050 Alzheimer s Association,

5 & Dementia Common Cause or Modifiable Risk Factor? Cognitive Decline & Dementia Intensity Sunday Presbycusis & Cochlear impairment Increased hearing thresholds & poor frequency resolution Effortful listening Common pathological process & Dementia Common Cause or Modifiable Risk Factor Cognitive Load & Cognitive Load Kahneman model of shared attention and resource capacity Cognitive Resource Capacity Cognitive Decline & Dementia Auditory Perceptual Processing Requirements Available Cognitive Resources For Performance of Tasks Age-Related Decline Common pathological process & Cognitive Load Poorer hearing is associated with reduced gray matter in the auditory cortices. Peele et al, J. Neurosci, 2011 & 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 Peele et al, J. Neurosci, 2011 Grossman et al, Brain Lang,

6 & Dementia Common Cause or Modifiable Risk Factor & Cognition/Dementia Recent Epidemiologic Studies Cognitive Load Social Isolation Cognitive Decline & Dementia # 1 loss and cognition Baltimore Longitudinal Study of Aging (BLSA) National Health and Nutritional Examination Surveys (NHANES) Common pathological process # 2 loss and incident dementia BLSA & Cognition Background Memory Free and cued selective reminding test (FCSRT) Executive Function Trail Making B Stroop Mixed These tests are not strongly Digit symbol substitution dependent on Psychomotor/processing speed receptive verbal Trail Making A communication Stroop colors and words Verbal function & language Category/Letter Fluency & Cognition Memory: Free and Cued Selective Reminding Test (FCSRT) Subjects are presented with 16 items over 4 cards. Subjects are then asked to recall the 16 items over 3 trials, with category cueing as needed & Cognition Executive Function: Trail Making B & Cognition Executive Function: Stroop Mixed C Trail Making B H 8 1 G 6 A E F D B Stroop Mixed GREEN RED RED GREEN BLUE BLUE GREEN RED YELLOW GREEN BLUE RED YELLOW BLACK 6

7 & Cognition Executive Function: Digit Symbol Substitution Test (DSST) Association of age and hearing loss with cognition in 347 adults >60 years in the Baltimore Longitudinal Study of Aging DSST: Digit Symbol Substitution Test Models adjusted for age, sex, race, education, diabetes, smoking, hypertension Lin et al., Neuropsych., 2011 Association of hearing loss and DSST scores in 605 adults years in NHANES Association of age and hearing loss with cognition in 605 adults years in NHANES Digit Symbol Test g y (speech-frequency PTA) Lin, J. Geront. Med. Sci., 2011 Lin, J. Geront. Med. Sci., 2011 & Cognition Conclusions loss is independently associated with lower scores on tests of memory and executive function in both BLSA and NHANES The magnitude of the reduction in cognitive performance associated with hearing loss is clinically significant: 25 db hearing loss 7 years of age on tests of executive function & Incident Dementia Background If hearing loss is associated with poorer cognitive performance, is it also associated with the risk of developing dementia? FCSRT Memory Score Memory begins to decline 7 years before dementia diagnosis Years before dementia diagnosis Grober et al., J. Int Neuropsych.,

8 & Incident Dementia BLSA Cohort & Incident Dementia in the BLSA BLSA participants with audiometry and cognitive testing 1990 to 1994 N = 749 Excluded subjects: 58 subjects with prevalent dementia 39 with > 3 errors on Blessed 13 with MCI Baseline study cohort 1990 to 1994 N = subjects with incident all cause dementia 37 with Alzheimer s disease 1991 to 2008 Lin et al., Arch Neuro., 2011 & Incident Dementia & Incident Dementia Risk of Incident All-Cause Dementia by HL Hazard ratio of incident all-cause dementia (compared to normal hearing) a HR 95% CI p Mild Moderate Severe a Adjusted for age, sex, race, education, DM, smoking, & hypertension Hazard Adjusted for sex, age, race, education, diabetes, smoking, and hypertension Lin et al., Arch Neuro., 2011 (PTA db) Lin et al., Arch Neuro., 2011 & Incident Dementia Conclusions loss is independently associated with all-cause dementia & the risk of all-cause dementia increases linearly with HL severity after 25dB If HL is causally-associated associated with dementia, we estimate that the dementia risk attributable to HL in our cohort > 60 y is 36.4% (95% CI: ) Keeping Socially Engaged & Active Maintaining Physical Mobility & Activity Cognitive Vitality & Avoiding Dementia Avoiding Injury Preventing Illness and Disease 8

9 Conceptual Model of Consequences of HL in Aging Physical Functioning Gait Speed as a Predictor of Survival Cognitive Load Mobility & Functional Decline Social Isolation Common pathological process Physical Functioning Gait Speed as a Predictor Survival Cross-sectional association of age and hearing loss with gait speed in participants aged years, NHANES (n = 1138) Gait Speed (m/.5 1 /s) Age ( years ) ( db HL ) Studenski et al, JAMA, 2011 Li and Lin, 2011 Association of gait speed per year of age or 25 db of hearing loss in participants aged years Keeping Socially Engaged & Active Cognitive Vitality & Avoiding Dementia Maintaining Physical Mobility & Activity Avoiding Injury Preventing Illness and Disease Li and Lin,

10 Falls as a Public Health Problem 1/3 of older adults >65 y has a fall every year resulting in: 2.2 M non-fatal injuries 20,000 deaths from fall-related injuries Approximately $28.2 billion in direct medical costs Association of with Reporting Falls over the Previous Year in Adults years, NHANES Cognitive Load Poor Awareness of Environment Poor Balance & Falls Common pathological process Lin & Ferrucci, Arch Int Med 2011 Keeping Socially Engaged & Active Maintaining Physical Mobility & Activity Cognitive Vitality & Avoiding Dementia Avoiding Injury Preventing Illness and Disease & Common Cause or Modifiable Risk Factor Cognitive Load Social Isolation Healthy Aging Common pathological process Can treating hearing loss delay cognitive decline & dementia? The Billion Dollar Question Only one 1 randomized study of hearing aids ever performed that explores outcomes beyond communication and HRQL No other studies have ever been performed to examine the possible impact of hearing rehabilitative treatment on older adults & Overview Why study hearing loss? physiology & measurement Epidemiologic research on hearing loss & aging Treatment options for hearing loss Future research directions 10

11 Prevalence of & Aid Use in the U.S., Why are hearing aids so seldom used? Lack of health insurance reimbursement for aural rehabilitative services and devices A general perception that hearing loss is an inconsequential part of the aging process Lack of evidence that therapies for hearing loss can impact critical downstream outcomes (e.g. social isolation, cognition) loss defined as a bilateral PTA of 0.5-4kHz tones > 25 db Chien and Lin, 2011 A current model of hearing health care that focuses on simply dispensing a hearing aid rather than on comprehensive aural rehabilitation. Comprehensive Rehabilitation Properly fitted hearing aids/cochlear implants Assistive Listening Devices (ALDs) Amplified telephones loop systems Aural rehabilitative counseling Gain processing & Digital compression Feedback reduction Noise reduction algorithms Speech enhancement algorithms A Aid That Cuts Out All the Clatter Telecoils & Loops By JOHN TIERNEY After he lost much of his hearing last year at age 57, the composer Richard Einhorn despaired of ever really enjoying a concert or musical again. Even using special headsets supplied by the Metropolitan Opera and Broadway theaters, he found himself frustrated by the sound quality, static and interference. Then, in June, he went to the Kennedy Center in Washington, where his Voices of Light oratorio had once been performed with the National Symphony Orchestra, for a performance of the musical Wicked. 11

12 Cochlear Implants & Overview Why study hearing loss? physiology & measurement Epidemiologic research on hearing loss & aging Treatment options for hearing loss Future research directions Future Research Directions SMART I Study at Johns Hopkins Studying Multiple Outcomes after Aural Rehabilitative Treatment Study SMART 2: currently in the planning stages of a large randomized controlled trial of comprehensive hearing rehab to examine effects on cognition and other functional outcomes Pharmacologic therapies for hearing loss Melanocyte-stimulating hormone for hearing preservation? Drugs to boost hearing function on a transient basis? For more information: flin1@jhmi.edu 12

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