MNZAS Senior Audiologist Bay Audiology

Transcription

1 Mr Ryan Johnson-Hunt MNZAS Senior Audiologist Bay Audiology 16:30-17:25 WS #167: Understanding the Relationship Between Hearing Loss and Dementia 17:35-18:30 WS #179: Understanding the Relationship Between Hearing Loss and Dementia (Repeated)

2 Understanding the Relationship Between Hearing Loss and Dementia Ryan Johnson-Hunt Audiologist MNZAS

3 Outline for Today 1. Hearing system refresher 2. The (very close) link between hearing and the brain 3. How hearing loss changes the brain 4. The association between hearing loss and dementia 5. What can we do about it? 6. Hearing loss in General Practice 7. Question Time

4 Disclosure Statement I am employed by Bay Audiology, which is part of the Amplifon Group. We are independent of any Hearing Aid Manufacturer. CME sessions will not promote products, brands or incentives, and will give a balanced view of all therapeutic options available for good quality patient management. Information presented is unbiased and based on scientific evidence.

5 Why should you listen to me?

6 Part 1: Hearing System Refresher

7 Part 1: Hearing System Refresher

8 Conductive Hearing Loss Wax Eustachian tube dysfunction Cholesteatoma Otitis media Otosclerosis Ossicular disorders

9 Otitis Media

10 Otosclerosis

11 Sensorineural Hearing Loss Aging/Presbycusis Noise Induced Hearing Loss (NIHL) Hereditary Virus Ototoxic drugs

12 Healthy Hair Cells

13 Normal Sensory Nerves

14 Damaged Hair Cells

15 Damaged Auditory Nerves

16 Presbycusis Audiogram Age Related and wear & tear Bilateral Hair cell damage, high frequency hearing affected first Affects clarity/speech intelligibility first, then volume later Prevalence: Over 60 1 in every 2 (55%) Over 80 9 out of 10 (93%)

17 Noise Induced Hearing Loss (NIHL) Audiogram Mainly high frequencies Usually bilateral Historically difficult to correct Problem with clarity/speech intelligibility Volume is not usually affected

18 Part 2: The (very close) link between hearing and the brain

19 Left: map of cerebral cortical areas that perform several sensory and motor functions, as known until a few years ago. Right: Revised map of the brain indicating multiple areas that respond to hearing.

20 The different colours on the semantic map define areas where the various word clusters are located based on meaning Every word lights up the various areas are present in many parts of the cortex and in both hemispheres. Sensory auditory stimuli have a widespread semantic and cognitive correlate in the entire brain (Huth et al., Nature 2016)

21 A study on people aged 50 to 79 included testing peripheral hearing levels, central auditory processing and cognitive skills. The most predictive factor of speech comprehension in a noisy environment was central processing of sound information, followed by cognitive skills (such as working memory and short-term memory), and by life experiences. (Anderson et al., 2013)

22 72 first-time hearing aid users were tested for speech recognition in noise with and without hearing aids. Cognitive function was assessed by tests of working memory and verbal information-processing speed. Results showed high cognitive performance was associated with high performance in the speech recognition task, even after controlling for age and hearing loss. Significant correlations exist between the measures of cognitive performance and speech recognition in noise, both with and without hearing aids. (Lunner 2009)

23 In summary, there is a dual track association between hearing and cognition. On the one side auditory stimuli are important because they activate the entire cerebral cortex, and on the other, cognitive processes influence how we hear

24 Part 3: How hearing loss changes the brain

25 Reduced volume of the Auditory Cortex Epidemiologist and ENT Frank Lin of Johns Hopkins University analyzed brain volume measurements from magnetic resonance brain scans of individuals with normal hearing versus hearing impairment scanned annually for 10 years as part of the Baltimore Longitudinal Study of Aging (n=126) Peripheral hearing impairment was independently associated with accelerated brain atrophy in whole brain and regional volumes concentrated in the right temporal lobe (Lin 2014)

26 Reduced integrity of neuronal connections Magnetic resonance diffusion tensor imaging technique analyses the diffusion and direction of water molecules in tissues in vivo to study of the microstructural architecture of the brain (to map connections and reconstruct the 3D structure of the white matter). This has revealed that the integrity of white matter networks in the hearing area is altered in people with hearing loss (Chang Y, 2004)

27 Increased Cognitive Load Hearing loss has a negative impact on neuronal resources used for cognitive control which effects the capacity to perceive and process sounds. Greater cognitive effort is needed to suppress irrelevant information in auditory signals (background noise) and other types of sensory signals leaving a lower percentage of residual attention for the remaining cognitive activities (Cardin 2013) People with a hearing loss present a 24% higher probability of demonstrating impairment in cognitive skills such as concentration, memory and planning capacity (Lin 2013) Green: Grey matter volume reduction, and Red: Compensatory increments in people with unilateral hearing loss (Wang et al., 2016)

28 The complex vicious circle that leads to hearing loss and cognitive decline

29 Part 4: The Association Between Hearing Loss and Dementia

30 Prof Frank Lin monitored, for twelve years, more than 600 older adults with no initial diagnosis of dementia. He found that a mild, moderate or severe hearing loss was associated with a risk of cognitive decline that was respectively two, three and five-fold higher than in people who had no hearing disorders. The correlation remained even taking into account other risk factors, including age, sex, diabetes, hypertension

31 Data collected on a group of men who were monitored for 17 years indicated a strong association between hearing loss, cognitive decline and dementia. The risk of developing dementia was 2.7-fold higher for every 10 db of hearing loss (Gallacher J. et al, 2012) A study on almost 600 people without dementia who were monitored for a mean period of eight years. People diagnosed with dementia had a hearing problem in 77% of cases versus 46% of those who did not present cognitive disorders. After accounting for confounding factors, such as age, gender and lifestyle, the presence of age-related hearing loss was associated with an over 3-fold increase in the probability of manifesting dementia (Meusy A. et al, 2016) A survey on more than 3,600 people aged 65+ tested hearing at beginning the study, monitored and reassessed the presence of cognitive disorders every two years, confirming that worse hearing was associated with lower cognitive efficiency scores and with greater decline in cerebral activity over a period of 25 years (Amieva H. et al, 2015)

32 This study used a longitudinal sample of 154,783 people aged 65+ from claims data of the largest German health insurer (containing 14,602 incident dementia diagnoses between 2006 and 2010) Reduction in the percentage of patients without dementia related to hearing impairment (HI) under treatment or not with an ENT (who prescribe hearing aids in Germany) (Fritze 2016)

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34 Part 5: What can we do about it?

35 Emerging Evidence for Amplificaton Emerging evidence that treatment of hearing impairment through hearing solutions is effective in delaying the onset of cognitive impairment while maintaining good cerebral function. Pioneered by Prof Frank Lin in study that the use of hearing aids in people between 60 and 65 years old was associated with a higher score on cognitive tests (Lin 2011).

36 Emerging Evidence for Amplificaton Supported by a study with analysis of a larger sample of people aged 65+ who were monitored over 25 yrs in the Personnes Agées QUID Study (n=3,670) Results revealed self-reported hearing loss is associated with accelerated cognitive decline in older adults; hearing aid use attenuates such decline. (Amieva H. et al, 2015) Those with hearing loss who wear hearing aids demonstrated trajectories of cognitive decline which were comparable to those who had no hearing loss.

37 Prof Hélène Amieva, University of Bordeaux, stated during her lecture at the UNSAF congress in Paris in March 2017: one of the few modifiable risks to prevent the early onset of dementia is treating hearing loss with professional hearing care

38 In the event of severe and profound hearing loss, solving the hearing problem clearly contributes to cognitive benefits. A study of 94 people subjected to cochlear implantation for one year observed that cognitive capacity (measured by testing attention, memory, mental flexibility, executive function and other skills) improves after the intervention. Eighty-one percent of patients with cognitive impairment prior to implantation showed an overall improvement in cognitive functions, while the other 19% remained stable. Moreover, among patients with the best cognitive performance before implantation, 76% remained stable and only 24% showed a very slight decline

39 Over the course of time the use of cochlear implant improves all parameters related to the perception of sound and to the production of speech as well as elements such as social interaction or self-esteem (Mosnier et al. 2015)

40 Hearing Therapy Listening strategies

41 Assistive Listening Devices Amplified telephones Wireless headphones for TV Integrated home systems

42 Amplification through Hearing Aids Open Fit Behind the Ear Receiver in the Ear Behind the Ear In the Ear In the Canal In the Canal

43 Advances in Hearing Aid Technology Smaller, lighter Better feedback management (SQUEALING) Faster processing Better performance in crowds and background noise Water and dust resistance Wireless - Mobile phones, TV CROS and BiCROS systems

44 Levels of Hearing Aid Technology

45 Part 6: Hearing Loss in General Practice

46 Role of the GP in Hearing Related Issues Long term relationship of trust - refer to audiologist Widespread impact on overall health, wellbeing and independence. Promotes healthy ageing

47 How can you detect hearing loss in your patients? Some questions you could ask: Do you often think people mumble? Do you ask others to repeat themselves? Do your family members tell you the TV is too loud? Do you have difficulty hearing when someone faces away from you? Do you find that background noise frequently overwhelms your ability to hear conversation Do you feel like you miss out on the conversation in a group, miss the punch lines, or have difficulty keeping up?

48 Hearing Aid Subsidy (Ministry of Health) Available for ALL NZ citizens and permanent residents $511 per aid ($1022 for pair), eligible again 6 years later This alone will cover basic entry level hearing aids - good option if finances very limited or reluctant to commit to amplification

49 Hearing Aid Funding Scheme (Ministry of Health) Hearing aid(s) fully funded, patient pays a fixed clinical management fee ($1200-$1500) often with WINZ help NZ citizens and permanent residents that fit one of these criteria for extra assistance: 1. Have had a significant hearing loss from childhood 2. Have a dual disability (eg blind, disabled) 3. Have a Community Services Card and meet certain criteria (eg caring for dependants, job seeking, volunteering)

50 War Pensions (Veterans Affairs NZ) Eligible if have served overseas in a recognised conflict and had hearing loss recognised as a result of their service Audiologist liaises directly with Veterans Affairs regarding the Veterans needs Fully funded hearing aids and repairs, receive money in pension for batteries

51 ACC For NIHL, Trauma and Medical Misadventure Claims GP to start claim process using ACC45 form, no prior HT necessary ACC allocates lump sum based on % loss work related (different criteria for trauma or medical claims), 3 funding bands: approx $3000, $4000, $5000 Topping up optional - ALWAYS a no top up option

52 WINZ Loan (Work and Income) WINZ often provide a grant or an advance, where patient pays back small amount each week from their benefit. Maximum limit is on a case by case basis, but $1500 is common, $3000+ with justification.

53 Who can receive a cochlear implant in New Zealand? Severe to profound hearing loss in both ears. Hearing isn't helped by standard (acoustic) hearing aids. Have been assessed as likely to benefit from a cochlear implant. Eligible for publicly funded health and disability services. Live permanently in New Zealand. Also ACC, Private

54 It is recommended that any patient over the age of 55 years old has a hearing check (baseline) Patient concerns about hearing When to refer to an Audiologist Tinnitus assessment Unilateral hearing loss or tinnitus Sudden loss Refer earlier rather than later, no matter the level of difficulty.

55 Feel free to contact me for a copy of the presentation or for any audiology enquiries: Ryan.johnsonhunt@bayaudiology.co.nz Any Questions?