Housekeeping Welcome to Hearing Loss and Dementia: Current Trends and Opportunities Presenter: Brian Taylor, AuD Senior Director of Clinical Affairs Hypersound This presentation is being recorded CE credit is available! Visit ihsinfo.org for details Note taking handouts are available at ihsinfo.org on the webinar page. Feel free to download now! IHS Organizers Ted Annis Senior Marketing Specialist Fran Vincent Marketing and Membership Manager Agenda Brian Taylor s Disclosures Basic principles of dementia and ARHL Interconnectedness of HL and dementia: underlying mechanisms Dementia and hearing aid use Clinical implications: Should I screen for dementia? How can I modify my clinical approach? Besides hearing aids are there alternative remediation strategies? Senior Director, Clinical Affairs, Hypersound Consultant, Fuel Medical Adjunct Professor, A.T. Still Univ. Editor, Audiology Practices Editor, HHTM Hearing News Co-author, Selecting & Fitting Hearing Aids, 2 nd Edition released, September, 2016 Why is this topic important? I. Basic Principles The population is rapidly aging: 10,000 people per day in the US turn 65 Population of people aged 80 and above expected to double between 2010 and 2050 Increased risk of hearing loss and dementia Dementia is recognized as a significant public health problem: - ~5 million Americans aged 65 and over have dementia today - This number is expected to nearly triple by 2050 Sources: 1.) US Census Bureau. The Next 4 Decades: The Older Population in the US 2010 to 2050. Issued May, 2010. 2.) Hardy, et al (2016) Hearing & dementia. J Neurol 1
Hearing loss prevalence Prevalence of hearing loss in oldest old Significant hearing loss ( >20 db HL PTA bilaterally) affects ~40% of individuals 65 and older More than 80% of persons aged 85 and above have hearing loss Hearing loss >25 db HL PTA bilaterally has an effect on cognitive deterioration equivalent to ~ 7 years JAMA Otolaryngology, Sept 2016 647 patients 80 106 years of age 100% with hearing loss Rate of change greatest in LF for those 90 and above 59% used hearing aids Sources: Gates & Mills (2005) and Lin et al (2011) Some things to know about dementia Chien & Lin, 2012 9 Dementia defined 3 Ds What is dementia? A progressive global impairment in thinking, understanding, learning and remembering Per DSM-V, diagnosis is a three-step process: Patient (or family member) must report significant cognitive decline Patient must score significantly low on test of dementia A complete medical work up to rule out depression and delirium Involves some combination of cognitive deficits in the following areas: - Language ability, fine-motor skills, memory, executive function (planning, organizing, sequencing, abstracting thinking) 1. Depression 2. Delirium acute onset, often medication related 3. Dementia progressive in nature Medical evaluation is needed to rule out treatable conditions of depression and delirium 2
Dementia: Prevalence and Incidence Dementia Worldwide Incidence (# of new cases per year): 35.6 mil in 2012 60 mil in 2030 114 mil in 2050 Prevalence of dementia doubles every 5 years after the age of 60: ~5% of individuals 65 and over have dementia 40% to 50% of individuals 85 and over have dementia 25% to 45% of community dwelling elders over 85 have dementia Over 50% of elders aged 85 and older in nursing homes 60% to 70% of dementia cases are due to Alzheimer s disease 30% to 40% stem from other causes: - Vascular diseases (e.g., stroke) - Parkinson s disease - Lewy body dementia There is a range of cognitive function in the elderly Important Point There is a range of cognitive function in the elderly. Normal Aging: Perform tasks more slowly, slower reaction times compared to younger person Mild Cognitive Impairment: Subjective memory complaint, borderline low score on test of dementia Dementia: Deficits on multiple domains of cognitive function, diagnosed by physician Hearing loss is a risk factor for dementia Important Point Hearing loss is one of several risk factors for cognitive decline. A history of one or more of these conditions increases the chance of acquiring dementia: Advanced age (80 + years old) Smoking Depression Diabetes Head injury Vascular diseases (heart disease, stroke) Senile cataract Hearing loss Sources: Wen, et al 2016; Gurgal, et al 2016; Lin et at 2013 3
Screening for dementia MMSE Mini-Mental States Exam (MMSE) is most common Scored on a 30 point scale: 27-30: normal cognition function 20-26: mild cognitive function 10-19: dementia 10 or less: severe dementia Requires the perception of auditory language to complete Not as sensitive for detection of mild dementia 1. Orientation 5 ( ) What is the (year) (season) (date) (day) (month)? 5 ( ) Where are we (state) (country) (town) (hospital) (floor)? 2. Registration 3 ( ) Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record. Trials 3. Attention and Calculation 5 ( ) Serial 7 s. 1 point for each correct answer. Stop after 5 answers. Alternatively spell world backward. 4. Recall 3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer. 5. Language 2 ( ) Name a pencil and watch. 1 ( ) Repeat the following No ifs, ands, or buts 3 ( ) Follow a 3-stage command: Take a paper in your hand, fold it in half, and put it on the floor. 1 ( ) Read and obey the following: CLOSE YOUR EYES 1 ( ) Write a sentence. 1 ( ) Copy the design show Screening for dementia Montreal Cognitive Assessment (MoCA) 30 point scale: 26-30: normal 19-25: MCI 18 or less: Dementia More sensitive for identifying MCI or early Alzheimer s Screening for dementia Mini-Cog (www.mini-cog.com) (https://consultgeri.org/trythis/general-assessment/issue-3.1) Give 3 words from list & recall the words (3 pts) Draw clock (2 pts) 2-minutes to complete Score: 0 Positive for cognitive impairment 1-2 Abnormal CDT then positive for cognitive impairment 1-2 Normal CDT then negative for cognitive impairment 3 Negative screen for dementia (no need to score CDT) Important Points: 1. During the case history inquire (and document) about these risk factors. 2. Preventing, improving or eliminating as many of these risk factors is likely to lessen chances of acquiring dementia. 4
Aging, hearing loss and dementia II. Interconnectedness of aging, hearing loss and dementia Common scenario: An older adult reports speech understanding difficulties that exceed those reported by younger adults with similar degrees of hearing loss. Example Interconnectedness explained 1. Declines in hearing and cognition are symptomatic of widespread neural degeneration (common cause hypothesis) Patient A: 56 years old WRS: 88% both ears Patient B: 86 years old WRS: 56% both ears Interconnectedness explained 2. Cognitive decline results in perceptual decline (cognitive load hypothesis) 5
Interconnectedness explained Interconnectedness explained 3. Perceptual decline results in permanent cognitive decline (deprivation hypothesis) 4. Impoverished perceptual input results in compromised cognitive performance (social isolation hypothesis) Bottom-Up and Top-Down Processing Real world functional correlates Effortful Listening - Bottom-up processing less efficient - Top-down processing more necessary Bottom-up (ear to brain) - Analysis of acoustic signal - Better signal (faster) - Poorer signal (slower) - @ amount and type of distortion Top-down (brain to ear) - Priming (pre-signal) - expectations facilitate recognition (faster) - Disambiguation (post-signal) - knowledge constrains alternatives (slower) - Repair (post-signal) - fill in gaps or correct errors (slower) Source: Pichora-Fuller, 2014 Degraded audibility Distorted signal: I can hear but I can t understand Poorer memory Slower processing Hearing loss may masquerade as dementia Effect of hearing loss on diagnosing dementia Effect of hearing loss on diagnosing dementia Jorgensen et al, JAAA, 2016 125 young normal-hearing participants randomly assigned to 1 of 5 degrees of simulated hearing loss MMSE cognitive screener was conducted verbally16% of participants with mild-tomoderately severe simulated hearing loss were misdiagnosed with dementia Dupuis, et al Neuropsychol Dev Cogn B Aging, 2015 301 participants with hearing loss and/or vision impairment 66% of those with normal hearing had normal scores on the MOCA Only 6% of those with hearing loss scored in the normal range on the MOCA Implications of these two studies: Those with hearing loss are at a significant disadvantage on tests of cognitive ability. Hearing acuity needs to be accounted for prior to test. 6
Link between dementia and hearing loss What is the relationship between hearing loss and dementia? Lin et al (2013): 1,984 individuals, average age of 77 Those with hearing loss had a 30% to 40% greater cognitive decline after 6 years Lin et al (2011): 639 individuals followed over 12 to 18 year period The worse the hearing loss, the more likely the person was to develop dementia Moderate loss has triple the risk of having hearing loss Link between dementia and hearing loss Link between dementia and hearing loss Gurgal et al (2016) At baseline: 4,463 individuals aged 65 without dementia, 836 of which had hearing loss were followed for approximately 18 years Of those with hearing loss 16.3% developed dementia, compared to 12.1% of those without hearing loss Mean time to dementia for HL group: 10.3 years, mean tine to dementia for non-hl group: 11.9 years Gallacher, et al (2012) 1,057 men followed over a 17 year period Those with hearing loss were more than twice as likely to acquire dementia compared to those with normal hearing at the beginning of the 17 year period Deal et al (2016) Evaluated 387 well-functioning adults, aged 70-79 for 9 years 20% had mod/severe loss, 38% has mild hearing loss Hearing loss was associated with increase risk of dementia Individuals with hearing loss had poorer baseline memory performance, no associations were observed between HL and rates of domain-specific cognitive change during 7 years of follow up Fischer et al (2016) 1,887 adults, average age of 66.7 years without cognitive impairment were followed over a 10 year period 85% of hearing impairment, 91% with visual impairment and 76% with olfactory impairment did not develop cognitive impairment during 10 year period All sensory systems are linked to decline in cognitive performance, entire brain is aging What do these results mean? 1. There is no evidence that hearing loss causes dementia Not every older person with a hearing loss acquires dementia 2. However, for individuals aged 65 and older that have hearing loss, they are more likely to acquire dementia, compared to individuals of same age with normal hearing III. Do hearing aids prevent cognitive decline? 7
Dementia and hearing aid use Dementia and hearing aid use Amieva, et al (2015) 3,670 individuals over a 25-year period Self-reported hearing loss into 3 categories: normal, moderate or major Divided into 3 groups: normal hearing, non-hearing aid users (with HL) and hearing aid users Hearing aid users had the highest (best) MMSE scores, nonhearing aid users had the lowest MMSE score No difference among the two groups with hearing loss Dawes et al (2015) 4,541 individuals between ages of 48 and 92 living in Beaver Dam, Wisconsin and followed for 11 years Of this group, 666 has moderate HF loss (or worse) 666 participants were divided into 2 categories: new hearing aid user, non-user group at baseline Hearing aid use had no significant impact on cognitive function at the end of the 11 years Hearing aid users had better score than non-users on measures of physical health Dementia and hearing aid use Dementia and hearing aid use Lalwani, et al (2016) 100 adults with hearing loss between ages of 80 and 99 Compared 2 groups: 34 were regular hearing aid users to 66 non-hearing aid users Hearing aid users score 1.9 points better on the MMSE compared to non-hearing aid users On another test of executive function (TMT-B): no significant difference in scores between the two groups Among non-users, participants with greater HL had lower (worse) MMSE scores Conclusions: 1. No evidence to suggest hearing aids slow down cognitive decline 2. Hearing aids do seem to improve psychosocial behaviors and activity levels for individuals with hearing loss 3. Hearing aid wearers are likely to be more socially active, indirectly hearing aid may help minimize day-to-day consequences of dementia and improve quality of life 4. Hearing aids (along with diet, exercise and social engagement) are an important part of staying as active and healthy as possible as people age Should I screen for dementia? IV. Clinical implications Inside and outside the clinic Considerations: How would you use the results to make clinical decisions about the patient? Would I treat a dementia or MCI patient differently than one with normal cognition? Mini Cog is best bet as a screener If you decide to screen, do it routinely for patients aged 85 + Referral network in place for those failing the screener: Neurology, Geriatric Nursing Specialist 8
Dementia or MCI patient Considerations inside your clinic Complex Case: More time needed at each visit More direct family/caretaker involvement Provide written and video instructions Alternative technologies that target specific listening situations: Telephone (Amplifier) Television (Hypersound) Relaxation and music enjoyment (smartphone coupled to customer ear buds) One-on-one small groups (Pocketalker, hearing aids) Apply proven hearing aid selection and fitting principles: Primary goal: optimize audibility of speech Match a prescribed fitting target Verify with probe mic measures Ensure proper physical fit Recommend assistive technology as needed Involve family and caretaker Modify and Involve Music and TV Modify with Alternative Approaches: Enjoyment of music Watching TV Relaxation (sound therapy) Involve: Family Caretaker Staff at long term care facility HyperSound Further considerations inside your clinic Memory complaints in people with hearing loss should be referred to neurology/geriatric specialists Be more vigilant of the cognitive status of each patient prior to fitting hearing aids. It s ok to use a research-based cognitive screener (mini-cog) Conduct a comprehensive functional communication assessment on each patient and devise an individualized plan: Assistive devices Smartphone apps Think about alerting devices, enjoyment of music 9
Considerations outside your clinic Bottom line Network with physicians/nurses: Physicians need to be aware of hearing status of patients before a cognitive test is administered Encourage physicians/nurses who administer these tests to use PSAPs/Pocketalker/Apps during evaluation to improve audibility Educate about link between hearing loss and cognitive decline: All adults over the age of 55 should have their hearing screened every 1-2 years Better Hearing = Healthy Living Hearing aids when properly prescribed and fitted work. Hearing aids allow people to stay active and engaged. Active people are healthy people! References References US Census Bureau. (2010) The next 4 decades: The older population in the US 2010 to 2050. Hardy, et al (2016) Hearing & dementia. J Neurol Gates & Mills (2005) Presbycusis. Lancet 366, 1111-1120 Lin et al (2011) Hearing loss & incident dementia. Arch Neurol Wattamwar, et al (2016) Increases in the rate of age-related hearing loss in the older old. JAMA-Otolargol. Wen et al (2016) A Bayesian approach to identifying new risk factors for dementia. Medicine. 95, 21, 1-6. Gurgal, et al (2015) Relationship of hearing loss and dementia: a prospective population-based study. Otol Neurotol 35, 5 Dupuis, et al (2015) Effects of hearing and vision impairments on the MOCA. Neuropsychol Dev Cogn B Aging. 22,4, 413-437. Jorgensen, et al (2016) The effect of decreased audibility on the MMSE. JAAA. 27, 4, 311-323. Lin et at (2011) Hearing loss and cognition amner older adults in the US. J Gerontol A Biol Sci Med Sci. 66, 1131-1136 Lin et al (2013) Hearing loss and cognitive decline in older adults. JAMA Internal Med. 1-7 Gallacher, et al (2012) Auditory threshold. Phologic demand and incident dementia. Neurology. 79, 1583-1590. Deal et al (2015) Hearing impairment and incident dementia and cognitve decline in older adults. J Gerontol A Biol Med Sci Fischer, et al (2016) Age-related sensory impairment & risk of cognitive impairment. J Am Ger Soc References Questions Lalwani, et al (2016) Hearing aid use is associated with better mini-mental state exam performance. Amer J Ger Psych Amieva et al (2015) Self-reported hearing loss, hearing aids, and cognitive decline in elderly adults: A 25-year study. J Am Geriatr Soc. 63, 10, 2099-2104 Dawes et al (2015) Hearing loss and cognition: the role of hearing AIDS, social isolation and depression. PLOS One. 11, 10, 3. Sweetow R (2015) Screening for cognitive disorders in older adults in the audiology clinic. Audiology Today 27, 4, 38 43. Enter your question in the Question Box on your webinar dashboard 10
Contact Brian Taylor, AuD brian.taylor.aud@gamil.com For more info on obtaining a CE credit for this webinar, visit www.ihsinfo.org Thank you for attending! 11