Treatment for Hearing Loss among the Elderly: Auditory Outcomes and Impact on Quality of Life

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1 Audiology Neurotology Proceedings Audiol Neurotol 216;21(suppl 1):29 35 DOI: / Pulished online: Novemer 3, 216 Tretment for Hering Loss mong the Elderly: Auditory Outcomes nd Impct on Qulity of Life Rquel Mnrique-Hurte Diego Clvi Alici Hurte Irujo Lur Girón Mnuel Mnrique-Rodríguez Otorhinolryngology Deprtment, University of Nvrr Clinic, Pmplon, Spin Key Words Presycusis Age-relted hering loss Cochler implnt Hering id Elderly Auditory outcomes Qulity of life Astrct The study im ws to determine the enefit of cochler implnttion nd hering ids in older dults dignosed with hering loss nd to evlute the index of depression, nxiety nd qulity of life fter such tretments. A retrospective cohort comprised 117 ptients older thn 65 yers nd dignosed with moderte to profound hering loss who were included nd clssified into 2 groups (treted vs. non-treted). A ttery of tests including uditory (pure-tone verge, disyllic words in quiet t 65 db SPL) nd findings from series of questions relevnt to qulity of life were compred etween oth groups. Auditory outcomes for disyllic words were 58.21% for the cochler implnt-treted group nd 82.8% for the hering id-treted group. There ws positive effect on nxiety, depression, helth sttus nd qulity of life in the cochler implnt group versus the profound hering loss. We conclude tht older dults with moderte to profound hering loss gin enefit from hering ids or cochler implnts not only in terms of improved hering function, ut lso in terms of positive effects on nxiety, depression, helth sttus nd qulity of life. Introduction 216 The Author(s) Pulished y S. Krger AG, Bsel Hering loss is one of the most common complints of sensory dysfunction in older dults. It hs een estimted tht 25% of the popultion etween 65 nd 75 yers old hve hering loss, nd this percentge increses up to 7 8% in the ge group 75 yers of ge nd older [Sprinzl nd Riechelmnn, 21]. Demogrphic trends, including greter longevity nd growing numers of older dults, point to the relevnce of understnding nd mnging hering loss. Recent studies suggest tht mnging hering loss is prmount, not only to restore hering ility, ut lso to improve socil skills, cognitive ility nd qulity of life. This study ims to nlyze uditory outcomes following tretment with cochler implnt (CI) or hering id E-Mil krger@krger.com The Author(s) Pulished y S. Krger AG, Bsel /16/217 29$39.5/ This rticle is licensed under the Cretive Commons Attriution- NonCommercil-NoDerivtives 4. Interntionl License (CC BY- NC-ND) ( Usge nd distriution for commercil purposes s well s ny distriution of modified mteril requires written permission. Rquel Mnrique-Hurte Otorhinolryngology Deprtment, University of Nvrr Clinic Pio XII 36 ES 318 Pmplon (Spin) E-Mil unv.es

2 HA group (n = 46) Men PTA 58.8 db 79 yers (SD = 6.8) 26 F/2 M Fig. 1. Study cohort: 4 sugroup clssifictions, showing summry chrcteristics for hering loss, men pure-tone verge (PTA;.5 4 khz), men ge, nd gender. Sugroups included: untreted modertesevere SNHL (MS-SNHL), untreted profound SNHL (), nd treted groups, i.e. CI nd HA users. F = Femle; M = mle. Sujects >65 yers old with hering loss (n = 117) MS-SNHL (n = 62) (n = 55) Control MS-SNHL (n = 16) Men PTA 49.2 db CI group (n = 45) Men PTA 99.6 db Control (n = 1) Men PTA 99.2 db 76 yers (SD = 7.) 7 F/9 M 77 yers (SD = 6.2) 24 F/21 M 74 yers (SD = 5.) 8 F/2 M (HA) in ptients older thn 65 yers dignosed with hering loss, nd to evlute the index of depression, nxiety nd qulity of life compred to s with similr chrcteristics who received no tretment for their hering loss. Mterils nd Methods A retrospectively exmined hering-impired cohort of elderly ptients routinely seen in our clinic underwent ttery of prospective ssessments to mesure the impct of hering loss on their overll well-eing. All study sujects signed written informed consent form to confirm their voluntry prticiption in the study. Sujects A sugroup of 117 sujects from our routinely treted clinicl popultion of ptients 65 yers tht ttended our office from My 213 to July 214 with treted or untreted moderte-severe or profound sensorineurl hering loss (SNHL) were enrolled in the study nd underwent further ssessment. To eliminte severe cses of cognitive dysfunction, ll sujects met the criteri of fewer thn 3 fils on the Pfeiffer test [Pfeiffer, 1975]. Individul dt sets were ville for preimplnttion nd posttretment intervls t minimum of 2 yers fter device tretment (CI or HA) for udiometric threshold testing (pure tone efore tretment nd free-field using wrle tones fter tretment) nd speech recognition tests (Spnish disyllic words t 65 db SPL in quiet). The cse file reviews yielded 4 sugroups of sujects: CI group nd corresponding control group s well s n HA group nd their corresponding control group. Both s presented with similr ge, hering loss thresholds nd hering functionlity on disyllic word speech scores. The division of the clinicl cohort into ech of the 4 sugroups with summry chrcteristics is shown in figure 1. Evlution Bttery A ttery of tests ws dministered prospectively to evlute the overll well-eing of the ptients specificlly relted to nxiety, depression, helth sttus nd qulity of life nd their perceived hndicp using stndrdly ville clinicl evlution tools. All sujects included in the study completed the tests listed in tle 1. They consisted of the Geritric Depression Scle [Yesvge et l., 1983] where score higher thn 5 indictes suspicion of depression, the Generlized Anxiety Disorder 7 [Spitzer et l., 26] where score higher thn 5 indictes suspicion of n nxiety disorder, nd the Hering Hndicp Inventory for the Elderly (HHIE) [Ventry nd Weinstein, 1984] indicting effects of hering loss upon dily ctivities. For the HHIE, score lower thn 16 points in ech suscle indictes no hndicp, score from 17 to 42 mens mild to moderte hndicp nd score higher thn 43 mens severe hndicp. The Helth Utility Index mrk III (HUI- III) [Frncis et l., 22] mesures the multi-ttriute helth utility from to 1. with 1. representing norml helth. Contrry to the other questionnires, the closer to 1 the score is, the etter the result. Sttisticl Anlysis Sttisticl nlyses to compre score differences on ech test mesure etween the sugroups were performed using the Mnn- Whitney U test. Two-sided p vlues <.5 were considered sttisticlly significnt. All sttisticl nlyses were crried out with IBM SPSS Sttistics version 22. Results A descriptive view to the performnce of the treted groups is shown in figure 2. Men percent correct disyllic word scores, oth efore nd fter hering device tretment (HA/CI) re shown in figure 2. Significnt u- 3 Audiol Neurotol 216;21(suppl 1):29 35 DOI: / Mnrique-Hurte/Clvi/Hurte Irujo/ Girón/Mnrique-Rodríguez

3 12 HA CI 8 PTA thresholds (db) Disyllic words (%) Before 1 month 6 months 12 months 24 months Lst visit Before 1 month 6 months 12 months 24 months Lst visit Fig. 2. Unided nd ided uditory thresholds. Pure-tone verge (PTA) thresholds (.5, 1, 2, nd 4 khz) in oth CI nd HA groups, efore tretment nd during follow-up until the lst visit. Speech perception for disyllic words t 65 db SPL in quiet for CI nd HA groups efore nd during follow-up until the lst visit. Tle 1. The medin scores nd interqurtile rnges re shown for ech sujective questionnire in the untreted nd device-treted sugroups Untreted groups Treted groups MS-SNHL HA CI GAD (3) 5 (8) 3 (6) 2.5 (4) GDS 1.5 (3) 3.5 (3) 2 (6) 2 (2) HUI-III.67 (.422).45 (.11).61 (.39).57 (.33) Totl HHIE 2 (2.5) 65.2 (19.37) 34 (34) (21.41) Emotionl HHIE 6 (14) 33 (2) 14 (13) 22 (2) Situtionl HHIE (7.41) 32.8 (1.88) 2.87 (1.52) (1.27) MS-SNHL = Moderte-severe SNHL; = profound SNHL; GAD-7 = Generlized Anxiety Disorder 7; GDS = Geritric Depression Scle; HUI-III = Helth Utility Index mrk III; HHIE = Hering Hndicp Inventory for the Elderly. ditory function improvement is oserved fter tretment in oth device-treted sugroups compred to their pretretment performnce level on disyllic word tests in quiet (p <.1), which remins stle over time up to 2 yers nd more. In figure 2, the significnt functionl gin otined fter tretment in ech device sugroup is illustrted, compring ided nd unided wrle tone thresholds in the free field; the threshold lso remins stle over time (p <.1). The medin scores nd interqurtile rnges re shown for ech sujective questionnire used for treted nd untreted groups in tle 1. However, more detiled view to the distriution of scores for ech of the 4 sugroups for ll mesures is shown in figures 3 5. Figure 3 shows the results for Generlized Anxiety Disorder 7 nd Geritric Depression Scle scores suggesting no significnt differences etween the device tretment sugroups nd their untreted controls. Furthermore, no significnt differences re noted either etween the 2 device sugroups or etween the 2 non-tretment s on these mesures. The distriution of multi-ttriute helth utility index scores otined vi the HUI-III ( fig. 4 ) indictes significntly etter helth utility scores for CI users compred Hering Loss Tretment mong the Elderly: Outcomes Audiol Neurotol 216;21(suppl 1):29 35 DOI: /

4 2 15 p =.286 Color version ville online * Color version ville online GAD p =.247 p =.798 p = HUI-III p =.14 p =.62 p =.384 p = p =.69 1 p =.4 GDS * p =.178 p =.96 p = Totl HHIE p =.114 p <.1 p = CI HA MS-SNHL CI HA MS-SNHL Fig. 3. Medin scores for the Generlized Anxiety Disorder 7 (GAD-7) test for every sugroup. Medin scores for the Geritric Depression Scle (GDS) test for every sugroup. The p vlue corresponds to the comprison etween groups. Asterisk nd circles represent outliers of ech group. = Profound SNHL; MS- SNHL = moderte to severe SNHL. Fig. 4. Medin scores for the HUI-III test for every sugroup. Medin scores for totl HHIE test scores for every sugroup. The p vlue corresponds to the comprison etween the groups. Asterisk nd cirlces represent outliers of ech group. to their untreted (p =.14), while no significnt differences etween the HA user sugroup nd their control sugroup were found. The HHIE scores shown in figure 4 suggest the gretest hndicp due to hering loss is oserved for the untreted profound SNHL sugroup nd lest for the moderte-severe SNHL group. While no significnt differences were noted etween treted nd untreted s, CI users hd significntly higher hndicp thn the HA user group (p <.1). Closer exmintion of the HHIE scores, dividing the responses to questions descriing emotionl nd situtionl hndicp, ws performed for ech sugroup, nd the results re illustrted in figure 5. Results suggest trend towrds decresed situtionl nd emotionl hndicp for oth device user groups compred to the untreted s; however, the difference is only sttisticlly significnt for situtionl hndicp for the HA user group (p =.3). Furthermore, the differences for oth situtionl nd emotionl hndicps re sttisticlly significnt etween untreted groups nd etween device user groups. Not surprisingly, untreted profound SNHL nd CI users experience significntly greter hndicp thn the untreted moderte-severe SNHL group nd the HA users, respectively (p <.1). 32 Audiol Neurotol 216;21(suppl 1):29 35 DOI: / Mnrique-Hurte/Clvi/Hurte Irujo/ Girón/Mnrique-Rodríguez

5 Situtionl HHIE Emotionl HHIE Discussion 35 p =.658 p <.1 p =.3 33 This study confirms tht the ppliction of HA or CI is useful in reducing hering disility in ptients older thn 65 yers experiencing hering loss, depending on the degree of hering loss. This enefit is demonstrted y improvements in hering thresholds, disyllic word recognition scores, multi-ttriute HUI vlues nd hering hndicp emotionl nd situtionl scores. The use of conventionl mplifiction for moderte to severe SNHL cn improve speech recognition significntly s illustrted for our study cohort of HA users with scores incresing from 55% unided to 88% ided fter 6 32 p <.1 2 p =.147 p =.1 p =.112 CI p = MS-SNHL Fig. 5. Medin scores for situtionl HHIE for every sugroup. Medin scores for emotionl HHIE for every sugroup. The p vlue corresponds to the comprison etween groups. Circles represent outliers of ech group. HA Color version ville online months of follow-up. However, the proportion of hering-impired people who ctully wer n HA, even in developed countries, is still reltively low where more thn hlf do not use ny mplifiction [Popelk et l., 1998]. Some resons tht my explin the poor usge of HAs hve een descried y Gopinth et l. [211] nd include expensive costs of HA, socil stigm with ptients emrrssed to wer them, or the sence or lck of proper informtion or guidnce on HA use. The end result is tht the mjority of ptients older thn 65 yers with moderte to severe SNHL re not eing properly treted. As shown y our study results, the degree of hering loss lone (despite the ge nd potentil for other comoridities) crries n impct on dily life nd communiction. The more profound the degree of hering loss, the more limited the ptient ecomes. Surprisingly, fter fitting n HA, ptients my hve poorer perception of their hering ility nd its susequent limittions thn prior to the HA fitting. Possily fter the fitting of n HA, the individuls my ecome more wre of their hering impirment nd the socil nd communiction limittions nd consequences. In contrst, Vuorilho et l. [26] descried tht using HAs correctly hs een reported to led to decresed hering hndicp scores when questioned with the HHIE. Such chnges in their study re shown even when non-users (1%) re included. They conclude tht HA fitting, s process, hs strong positive impct on emotionl sttes. The moderte-severe SNHL groups (treted nd nontreted) show no differences in nxiety nd depression scores. Such findings contrst with previous reports tht stted tht high HHIE scores re risk fctor in the development of depression mongst elderly individuls [Sito et l., 21]. Our nlysis of HHIE scores ws derived from cohorts of treted nd untreted individuls within hering-impired popultion, wheres Sito et l. [21] compred norml-hering sujects to heringimpired ones. Thus, such differences in the incidence of depression etween oth groups my e relted to the popultion studied. Our recommendtion is to include n ssessment of the perceived hndicp vi the HHIE s useful screening tool for community-dwelling elderly people to identify those t risk. Our study clerly demonstrtes greter enefit from cochler implnttion for older dults with more significnt hering loss thn from conventionl mplifiction for the HA user group. Postimplnttion, udiometric tests suggest significnt improvements in uditory thresholds over the pre-opertive unided condition nd for men word recognition scores on disyllic words, which Hering Loss Tretment mong the Elderly: Outcomes Audiol Neurotol 216;21(suppl 1):29 35 DOI: /

6 reched 52% compred to % efore implnttion. As shown in figure 2, the lrgest nd most rpid improvement in hering performnce ws oserved within the first 6 months of tretment, remining stle therefter. Previous studies hve shown tht the lerning curve for elderly implntees is similr to tht oserved for the younger implnted popultion, while solute scores for the elderly mesured in noisy environments tend to e lower [Lenrz et l., 212]. Our cohort demonstrted tht once the rpid uditory improvement is seen, uditory outcomes increse slowly, reching plteu independent of ge nd is mintined during the follow-up. This my e due to the fct tht neurl degenertion might e prevented with uditory stimultion [Leke et l., 28]. Severl fctors my influence enefits from CI tretment in older dults tht include pre-opertive speech discrimintion [Lin et l., 212], overll sttus of helth [Clrk et l., 212], consistency of HA use within lifetime, eductionl level, residentil sttus nd level of depression [Frncis et l., 215]. Given it is common udiologicl prctice to demonstrte tht CI nd HA tretment cn provide dequte functionl gin for the respective groups of hering-impired elderly ptients, through improved speech recognition, we cn ssume logicl consequence is tht communiction is lso improved; however, the question rises: wht is the ultimte impct on their dily life? According to dt for our study cohort, nxiety nd depression levels show no correltion with treted or untreted conditions or the degree of hering loss, wheres trend for lower levels of nxiety nd depression re noted in the CI group compred to their. In study y Olze et l. [212], it ws demonstrted tht hering loss significntly influences isoltion, which explins the influence in the socil domin. Bsed on our findings from the HUI-III test, the degree of hering loss cn positively influence the perception of one s overll helth sttus. This is supported y our oservtion tht the CI group reported significntly greter improvement in the perception of their helth sttus (multi-ttriute HUI) nd, thus, qulity of life thn the for qulity of life. However, in contrst, there ws no significnt difference etween the reported helth utility for HA users compred to the untreted. This study demonstrtes tht the influence of hering disility upon dily life increses with incresed hering loss. As expected, ptients with profound hering loss endure more limittions in their dily lives due to the hering loss thn ptients with moderte-severe hering loss. The negtive consequences of hering loss on qulity of life nd perceived hndicp demonstrted in our cohort suggest tht timely nd ppropritely dministered sound mplifiction cn potentilly mitigte the resounding effects of hering loss for the individul. These findings gree with dt pulished y Lin et l. [212] stting tht hering loss my potentilly increse the risk of depression nd socil isoltion due to communiction impirment. They propose tht significnt hering loss my provoke further cognitive decline through the inherent cognitive lod tht, in turn, cn negtively influence physicl nd dily functioning. As socil isoltion nd cognitive lod increse nd physicl conditions decrese, the risk of dementi nd incidence of moriditymortlity cn increse. These findings re confirmed y reserch demonstrting tht significntly reduced uditory input is ssocited with cognitive dysfunction nd decline nd, in extreme cses, with ge-relted dementi [Kricos, 26]. Furthermore, it hs een demonstrted tht good cognitive function is extremely importnt in processing uditory informtion when mde ville vi hering tretment [Mosnier et l., 215]. Therefore, not only does hering loss hve negtive impct on cognitive function, cognitive impirment hs negtive impct on hering function. While not custive, hering loss is lso n unrelted risk fctor for dementi linked to chrcteristic uditory pttern [Gimeno-Vilr nd Cerver-Pz, 212]. Conclusion Our study hs shown tht hering tretment with CI or HA cn provide significnt dvntges to hering function tht remins stle over time in elderly ptients. Significnt improvements for CI ptients with profound SNHL re oserved for qulity of life nd show trend towrds reduced perceived hering hndicp. Ptients with n untreted profound hering loss demonstrte significntly poorer qulity of life nd show trend for higher levels of nxiety, depression nd the perceived hndicp thn comprle ptients treted with CI. In contrst, the significnt effects eyond hering function were not demonstrted etween HA users nd their respective with untreted moderte-severe hering loss. In view of the inherent progressive nture of presycusis nd the oserved reltion etween significntly reduced uditory input upon socio-emotionl nd overll helth domins, hering loss should lwys e treted in dults older thn 65 yers. 34 Audiol Neurotol 216;21(suppl 1):29 35 DOI: / Mnrique-Hurte/Clvi/Hurte Irujo/ Girón/Mnrique-Rodríguez

7 Acknowledgements Specil thnks go to Slome Snruno nd Chro Lezun, the nurses who helped in recruiting ptients nd ssisted with completing the tests. The study ws funded y the grnt Jun Gssó Bosch. Disclosure Sttement The uthors declre no conflict of interest. References Clrk J, Yegle J, Arje A, Lin F, Niprko J, Frncis H: Cochler implnt rehilittion in older dults: literture review nd proposl of conceptul frmework. JAGS 212; 6: Frncis HW, Chee N, Yegle J, et l: Impct of cochler implnt on the functionl helth sttus of older dults. Lryngoscope 22; 112: Frncis HW, Yegle J, Thompson C: Clinicl nd psychosocil risk fctors of hering outcome in older dults with cochler implnt. Lryngoscope 215; 125: Gimeno-Vilr C, Cerver-Pz FJ: Enfermedd de Alzheimer y pérdid uditiv. Rev Neurol 21; 5: Gopinth B, Schneider J, Hrtley D, Teer E, Mc- Mhon CM, et l: Incidence nd predictors of hering id use nd ownership mong older dults with hering loss. Ann Epidemiol 211; 21: Kricos PB: Audiologic mngement of older dults with hering loss nd compromised cognitive/psychocoustic uditory processing cpilities. Trends Amplif 26; 1: Leke PA, Stkhovsky O, Hrdek GT, Hetherington AM: Fctors influencing neurotrophic effects of electricl stimultion in the defened developing uditory system. Her Res 28; 242: Lenrz M, Sönmez H, Joseph G, Büchner A, Lenrz T: Cochler implnt performnce in geritric ptients. Lryngoscope 212; 122: Lin F, Chien W, Li L, Clrret D, Niprko J, Fncis H: Cochler implnt in older dults. Medicine 212; 91: Mosnier I, Beer JP, Mrx M, Frysse B, Truy E, Lin-Grnde G, Mondin M, Sterkers-Artières F, Bordure P, Roier A, Godey B, Meyer B, Frchet B, Poncet-Wllet C, Bouccr D, Sterkers O: Improvement of cognitive function fter cochler implnttion in elderly ptients. JAMA Otolryngol Hed Neck Surg 215; 141: Olze H, Gräel S, Förster U, Zirke N, Huhnd LE, Hupt H, Mzurek B: Elderly ptients enefit from cochler implnt regrding uditory rehilittion, qulity of life, tinnitus nd stress. Lryngoscope 212; 122: Pfeiffer E: A short portle mentl sttus for the ssessment of orgnic rin in elderly ptients. J Am Geritr Soc 1975; 23: Popelk MM, Cruickshnks KJ, Wiley TJ, Tweed TS, Klein BE, et l: Low prevlence of hering id use mong older dults with hering loss: the Epidemiology of Hering Loss Study. J Am Geritr Soc 1998; 46: Sito H, Nishiwki Y, Michikw T, Kikuchi Y, Mizutri K, et l: Hering hndicp predicts the development of depressive symptoms fter 3 yers in older community-dwelling Jpnese. J Am Geritr Soc 21; 58: Spitzer RL, Kroenke K, Willims JB, Löwe B: A rief mesure for ssessing generlized nxiety disorder: the GAD-7. Arch Intern Med 26; 166: Sprinzl GM, Riechelmnn H: Current trends in treting hering loss in elderly people: review of the technology nd tretment options mini review. Gerontology 21; 56: Ventry IM, Weinstein BE: The hering hndicp inventory for the elderly: new tool. Er Her 1984; 3: Vuorilho A, Krinen P, Sorri M: Effect of hering ids on hering disility nd qulity of life in the elderly. Int J Audiol 26; 45: Yesvge JA, Brink TL, Rose TL, Lum O, Hung V, Adey MB, Leirer VO: Development nd vlidtion of geritric depression screening scle: preliminry report. J Psychitr Res 1983; 17: Hering Loss Tretment mong the Elderly: Outcomes Audiol Neurotol 216;21(suppl 1):29 35 DOI: /