Hearing Loss in Older Adults: A Public Health Perspective

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1 in Older Adults: A Public Health Perspective Frank R. Lin, M.D. Ph.D. Associate Professor of Otolaryngology, Geriatric Medicine, Mental Health, & Epidemiology Johns Hopkins University Baltimore, Maryland Age-Related (ARHL) Basic Questions What are the consequences of ARHL for older What is the impact of treating ARHL on older How can ARHL be effectively addressed in the community? Prevalence of in the United States, John Smith, y.o. loss defined as a better-ear PTA of 0.5-4kHz tones > 25 db Lin et al., Arch Int Med & Aid Use Prevalence in the U.S., Age-Related (ARHL) Basic Questions What are the consequences of ARHL for older What is the impact of treating ARHL on older How can ARHL be effectively addressed in the community? Chien & Lin, Arch Int Med,

2 Intensity & Cochlear impairment Healthy Aging Sunday Decreased sensitivity & distortion in sound encoding Effortful listening Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Mobility & Activity Healthy Aging Keeping Socially Engaged & Active Health Resource Utilization & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Common pathological process & Healthy Aging Common Cause or Modifiable Risk Factor? Common pathological process & Cognitive Load Kahneman model of shared attention and resource capacity (D. Kahneman, Attention & Effort,1973) Auditory Perceptual Processing Requirements Cognitive Resource Capacity Available Cognitive Resources For Performance of Tasks Age-Related Decline 2

3 & 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 & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Brain structure/function Social Isolation Common pathological process & Healthy Aging Common Cause or Modifiable Risk Factor Social Isolation Cognitive Load Brain structure/function Common pathological process Health Behavioral Pathways Smoking Adherence to medical tx Diet Exercise Cole & Cacioppo, Genome Biology, 2007 Cole & Cacioppo, PNAS, 2011 Psychological Pathways Self-esteem Self-efficacy Coping Sense of well-being Physiologic Pathways HPA axis response Immune system fxn Cardiovascular reactivity Social isolation is associated with upregulation of proinflammatory genes & increased inflammation Double Hit Theoretical Model & Brain Structure/Function & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Microvascular Disease Structure/ Function Alzheimer s Neuropathology Brain structure/function Impairment F. Lin & M. Albert, Aging & Mental Health, 2014 Social Isolation Common pathological process 3

4 & Healthy Aging 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 & Cognition Background Memory Free and cued selective reminding test (FCSRT) Executive Function These tests are Trail Making B not dependent Stroop Mixed on hearing. Digit symbol substitution Psychomotor/processing speed Verbal function & language Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Mobility & Activity Healthy Aging Keeping Socially Engaged & Active Health Resource Utilization Trail Making B & Cognition Executive Function: Trail Making B 7 1 A H 6 C G 8 1 E D 4 F B Projected Worldwide Prevalence of Dementia & Cognition Executive Function: Stroop Mixed 1 Stroop Mixed GREEN RED RED GREEN BLUE BLUE GREEN RED YELLOW BLUE BLUE GREEN YELLOW BLACK Alzheimer s Disease International,

5 & Cognition Executive Function: Digit Symbol Substitution Test (DSS) DSS: Digit Symbol Substitution Test & 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 and Cognition Cross-Sectional Studies NHANES N = 605 adults years Lin, J. Geront. Med. Sci., 2011 & Accelerated Brain Volume Decline BLSA Hypothesis: loss is associated with accelerated atrophy in the superior, middle, and inferior temporal gyri BLSA N = 347 adults >60 years Lin et al., Neuropsych., participants (56-86 yrs) in the neuroimaging substudy of the BLSA Mean follow-up duration of 6.4 years 1.5T MRI performed annually Models adjusted for age, sex, race, education, diabetes, smoking, hypertension & Cognitive Decline HealthABC 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 DSS 3MS scores in HL vs. NH L Voxel-Based Analyses Difference in mean gray matter volume change in those with HL vs. NH Faster decline in brain volume 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 Lin et al., Neuroimage

6 Double Hit Theoretical Model & Brain Structure/Function Age-Related (ARHL) Basic Questions Microvascular Disease Structure/ Function Impairment Alzheimer s Neuropathology What are the consequences of ARHL for older What is the impact of treating ARHL on older How can ARHL be effectively addressed in the community? F. Lin & M. Albert, Aging & Mental Health, 2014 Cognitive Vitality & Avoiding Dementia Avoiding Injury Maintaining Mobility & Activity Healthy Aging Keeping Socially Engaged & Active Health Resource Utilization/Mortality Avoiding injury Increased falls (Viljanen et al, JGMS 2009; Lin et al. Arch Int Med 2012) mobility/functioning Reduced walking speed (Viljanen et al. JAGS 2009; Li et al., Gait & Posture 2012) Accelerated decline in physical functioning (Chen et. al. JAGS, 2015) Driving ability (Hickson et al. JAGS 2009; Picard et al 2008) Health resource utilization/mortality Increased odds of hospitalization (Genther et al, JAMA, 2013; JGMS 2015) Increased mortality (Karpa et al Ann Epi 2010; Fisher et al. 2013; Genther et al, JGMS 2014) 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 & Healthy Aging Common Cause or Modifiable Risk Factor Cognitive Load Brain structure/function Social Isolation Common pathological process & Cognition Mechanistic Pathways Intervention Cognitive Load Changes in brain structure Cognitive Reduced Social Engagement loss intervention could: Reduce the cognitive load of processing degraded sound Provide increased brain stimulation Improve social engagement Role of HL as a potentially modifiable, late-life risk factor for cognitive decline & dementia 6

7 Conceptual Model for the Aging, Cognition, and Evaluation in Elders (ACHIEVE Healthy Aging) 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 Best Practices Rehabilitative Treatment Vs. Successful Aging Control Proximal/Mediating Outcomes Audibility of speech & environmental sounds Enhanced Verbal Communication & Social Engagement Primary Outcome Cognitive Secondary Outcomes HRQL Social/Leisure Activities Daily Mobility Brain structure (MRI) Age-Related (ARHL) Basic Questions What are the consequences of ARHL for older What is the impact of treating ARHL on older How can ARHL be effectively addressed in the community? NIA R34AG Atherosclerosis Risk in Communities (ARIC) & Aid Use Prevalence in the U.S., ARIC Cohort : 1987-present; n=15,792 Supported by National Institutes of Health NHLBI with ancillary studies by NCI, NEI, NIA, NIAAA, NIDCD, NIDDK, NIEHS, NINDS, NCRR & NIH Roadmap Arch Int Med, 2012 ACHIEVE Trial Design Timeline & Overview of RCT Timeline: RCT planning process (R34AG046548) - Pilot study, development of protocol/operations manual, etc Trial grant submission Recruitment at ARIC field sites Follow-up Participants: ~ y.o., healthy, cognitively normal communitydwelling adults with untreated mild-moderate HL recruited Intervention: Randomization to best-practices hearing rehabilitative treatment vs. successful aging intervention control Outcome: Study powered to detect 0.25 effect-size difference in rates of cognitive decline between the two groups at 3 years post-randomization NIA R34AG Prevalence of Aid Use United States (Arch Int Med, 2012) 26.7M adults 50 years with hearing loss 3.8M use hearing aids Overall rate of HA use: 14.2% England and Wales (NICE Report, 2000) 8.1M with hearing loss 1.4M use hearing aids Overall rate of HA use: 17.3% 7

8 Barriers to Health Care (HHC) Cost/Affordability Awareness & Understanding Awareness of impact/public health importance Intervention Cognitive Load Access to Services &Technology Changes in brain structure Reduced Social Engagement Understanding of treatment options Intervention aids? Sound amplifiers? Audiologists? ENTs? aid dispensers? Mail order hearing aids? Costco? Access to Services &Technology Barriers to Health Care (HHC) Current (only) gold-standard model of HHC: Repeat clinic-based visits with audiologist/dispenser for evaluation, counseling, sensory management, fitting FDA/state regulations restrict direct access to hearing aids Awareness & Understanding Cost/Affordability Access to Services &Technology Technology Design & Utility Barriers to Health Care (HHC) Technology Design & Utility when it really matters Cost/Affordability Proprietary 2.4GHz or 900MHz Awareness & Understanding Access to Services &Technology FM Receiver with loop Streamer Remote Mic 8

9 Barriers to Health Care (HHC) IOM Consensus Study in Progress Cost/Affordability Awareness & Understanding Access to Services &Technology Technology Design & Utility 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 Report due 2016 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 Report due 2016 White House Conference on Aging & President s Council of Advisors on Science & Technology Report due Fall 2015 IOM Workshop on & 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. PCAST is an advisory group of the nation s leading scientists and engineers who directly advise the President and the Executive Office of the President. PCAST makes policy recommendations in the many areas where understanding of science, technology, and innovation is key to strengthening our economy and forming policy that works for the American people. 9

10 How can ARHL be effectively addressed in the community? Future Trends Understanding & approaching hearing loss in the context of healthy aging Institute of Medicine Report due 2016 White House PCAST Report due Fall 2015 Convergence of medical devices (hearing aids) & consumer electronics ( PSAPs, hearables ) Innovations in hearing health care/technology Accessible services & affordable technology Innovations in Health Care Affordable & Accessible Options are Needed Technology Personal sound amplifiers (PSAP) Over-the-counter hearing aids with in-situ testing & verification Cost < $ Nick Reed Electroacoustic Analysis of PSAPs Innovations in Health Care Affordable & Accessible Stepping Stones are Needed for Health Care Technology Personal sound amplifiers (PSAP) Over-the-counter hearing aids with in-situ testing & verification Cost < $ Services - Community health care workers Community-based hearing screening Counseling, education, & provision of sound amplifiers & other assistive technologies Referral as needed 10

11 Listen by Mister Pixel from The Noun Project Brain by Marek Polakovic from The Noun Project Listen by Mister Pixel from The Noun Project Brain by Marek Polakovic from The Noun Project Person by Wilson Joseph from The Noun Project People by irene hoffman from The Noun Project Snail by alf from The Noun Project Speech Bubble by Thomas Le Bas from The Noun Project Talking by Lucian Dinu from The Noun Project Head by Jens Tärning from The Noun Project 10/14/2015 Access earing care quality through ccessible esearch & olutions HEARS Intervention 1) Screening 2) Device Orientation: - Self-fit amplification device - Individual programming 3) Counseling: - Expectation management - Communication Strategies Carrie Nieman Pilot Studies in Multiple Populations Carrie Nieman Sara Mamo Janet Choi Older Adults in Assisted Living Facilities or with Cognitive Impairment Korean-American Older Adults Korean Martyrs Catholic Church How are you? How are you? How are you? Licensing & Dissemination Pilot Studies Non-profits Local government Multiple Intervention Communities Development Outcomes in participant & communication partner Social Engagement Communication Activities HRQL of How are you? 54 Text Contrast Communication Tips and Tricks 1. Attention First 2. Get Face to Face Icons Reading Level 3. Speak Slowly 4. Big Ideas and Key Words 5. Repeat then Reword BIG KEY IDEA 6. Summarize 83 How We Hear There are 3 main steps in how we hear. Hello Communication Tip #2: Repeat then Reword If someone did not understand you, repeat it once. If that does not work, reword it. Hello What did you think of the meal? What did you think of the meal? Tell me about the food. Sound enters ear Signal goes to brain Brain interprets signal Repetition only works once. Checklist Explain the 3 steps of hearing

12 Turn ON the Pocket Talker Microphone ON Checklist ON Additional Models of Health Care are Needed Audiologist as the Leader Aid Dispenser of a Team $$$ Community 1-2 months Health Worker $$ Personal Sound 1/2 day Amplifier $ 1-2 hours Gold Standard Audiology Sara Mamo Care $$$$ 3-6 months Nick Reed Time/ Expense/ Expertise Turn ON Pocket Talker Note red ON light 17 Battery Place the Battery, Turn on CS-50 Earpiece 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. Checklist Connect battery to earpiece Indicate when CS-50 is ON ON Ready to use 14 Innovations in hearing health care/technology Accessible services & affordable technology Open wireless standards Memory Clinic HEARS Project Feedback Son-in-law of a 91 yo woman with MMSE of 17 Open Wireless Standards Fundamental limitation of all hearing aids? How to increase signal-to-noise ratio? Options: Post-microphone Algorithmic processing of sound Pre-microphone loop systems Proprietary wireless systems (2.4Ghz, 900Mhz) 12

13 when it really matters Proprietary 2.4GHz or 900MHz Are you telling What are me the that consequences I m of hearing going loss to develop for older dementia? What is the impact of treating hearing loss on older How can hearing loss be effectively addressed in the community? FM Receiver with loop Streamer Hypertension Heart attack & stroke Intervention: Medication, Lifestyle modification Remote Mic loss Cognitive decline, dementia, poorer physical functioning Intervention: Comprehensive hearing tx? Convergence of medical devices with consumer electronics Johns Hopkins Carrie Nieman Sara Mamo Nick Reed Joe Coresh Richey Sharrett Josh Betz Esther Oh NIA Luigi Ferrucci Susan Resnick Yang An Eleanor Simonsick Nicole Marrone Terry Chisolm Acknowledgments K23DC R34AG Triological Society & American College of Surgeons Clinician Scientist Award Eleanor Schwartz Charitable Foundation NIA Intramural Research Program Johns Hopkins ADRC Johns Hopkins ATIP How can ARHL be effectively addressed in the community? Future Trends Understanding & approaching hearing loss in the context of healthy aging Institute of Medicine Workshop Report due 2016 White House PCAST Report due Fall 2015 Innovations in hearing health care/technology Accessible services & affordable technology Open wireless standards Third-party reimbursement of hearing health care Unbundling of hearing health care Coverage for audiologic rehabilitative services (not devices) 13