The Eye & Ear Foundation’s January 24th webinar addressed a topic that frightens some people. Titled “Hearing Loss and Cognitive Decline,” Catherine V. Palmer, PhD, Chair of the Department of Communication Sciences and Disorders at the University of Pittsburgh and Director of Audiology at UPMC, acknowledged this at the outset and said she would try to make it less terrifying by sharing relatable data, actionable steps, and community programs.
Studies on Dementia and Hearing Loss
The first publication to really talk about the relationship between dementia (also referred to as cognitive decline) and hearing loss was in 1989. Uhlmann and colleagues published a study that found the prevalence of hearing loss was higher in people with dementia. The study also noted that hearing loss was correlated with severity of cognitive dysfunction as measured by the Mini Mental State Examination (MMSE).
Dr. Palmer explained that this was an observational study, which means people who are receiving routine care are observed over time. A study like this does not provide enough control to result in a lot of information to act on, but the information gets other researchers interested in the topic.
People started thinking about whether there are similar processes in dementia and hearing loss. Surprisingly, it took another 10 years before more research was reported.
Around 1998, the then-Director of Audiology, John Durrant, became interested in the clinical side of this, wondering what could be done. There was a common myth that people with cognitive decline or dementia could not complete a hearing test and would not wear hearing aids. Dr. Durrant, along with colleagues at the Eye & Ear Institute, did a study to see if people with different levels of dementia could still come into the clinic and have reliable hearing tests. The answer was they could.
A basic hearing test is a simple activity, in which you indicate whether you have heard tones. People can indicate in different ways as long as the audiologists are flexible.
The same year, Dr. Palmer’s group wanted to look at what they could do to help individuals and families, focusing more on the caregivers of people with dementia and hearing loss. This was related to another group’s work that Michelle Bougeois headed up, supporting the caregivers who are trying to care for loved ones with dementia at home. Dr. Palmer’s group hypothesized that treating hearing loss in individuals with dementia might support this goal of the caregivers.
“Why might that help?” Dr. Palmer asked. “When you look at some of the symptoms of dementia, they very much overlap with hearing loss.” This includes needing things repeated, which could be because you do not remember them, but also could be because you did not hear them correctly. They posed the question: If you can fit a person who has dementia with hearing aids, could you decrease some of those symptoms? Would this then lead to the caregiver being less frustrated and able to manage what they need to do?
The group went into people’s homes, tested hearing, fit hearing aids, and collected data. They found a decrease in many of the burdensome behaviors. For example, with the hearing aids, the person with dementia could focus more on a TV show. This would then give the caregiver 30-45 minutes to prepare dinner.
Around 2011, Dr. Frank Lin at Johns Hopkins University (JHU), and his colleagues reported one of the first really big studies looking at hearing loss and dementia. A large part of what this group does is look at big databases of information. They saw an association between cognitive decline and hearing loss. “Therefore, maybe you would want to do something about the hearing loss, because that’s something tangible we can do,” Dr. Palmer said.
From then until now, Dr. Nick Reed from JHU reports that there has been a 340% increase in publications. Having this topic in the public consciousness is often what motivates patients to come to the clinic seeking hearing health care.
In 2016, Dr. Lindsey Jorgensen, who was a PhD student in Dr. Palmer’s lab thought back to Uhlmann’s study and the report that patients with dementia and hearing loss scored poorly on the MMSE. In this cognitive evaluation, the health care provider asks questions, and the patient has to hear them to answer correctly. However, if they have untreated hearing loss and are not using amplification (which was the case in this study), they may not fully hear the questions well. Therefore, it would be hard to tease out what part of the score was due to dementia versus untreated hearing loss.
Dr. Jorgensen studied cognitively normal college students who were given different levels of simulated hearing loss and then responded to the MMSE questions provided similarly to how they would be provided in a clinic. These students scored on the MMSE as if they had dementia even with a mild to moderate simulated hearing loss. When more moderate to severe hearing loss was mimicked, they scored as if they had severe cognitive impairment.
Since this time, different groups have worked to modify these scales so they can be done differently to try to compensate for untreated hearing loss. One way to handle this is to use amplification with people while administering the test.
Hearing Aid Usage
Another study around this time received a fair amount of attention: Longitudinal Relationship Between Hearing Aid Use and Cognitive Function in Older Americans. The study looked at a group that did not have hearing aids, got hearing aids, and measured results over time. These data indicated that the progression of cognitive decline in this group slowed (did not stop) with the use of hearing aids. These results were compelling and motivating in terms of treating hearing loss.
Untreated Hearing Loss in Midlife
In 2020, the Lancet Commission – a well-respected group that pulls together large summaries of data to make statements – reported that untreated hearing loss in midlife is the largest modifiable risk factor for cognitive decline. A modifiable risk factor means if we do something about it, we can change or impact the outcome. “We aren’t claiming that you can just cure dementia, but the pathway would be altered in a positive way,” Dr. Palmer said.
Dr. Palmer cautioned about interpreting these data. It is not talking about one individual or that your risk can be reduced by a certain percent. It is looking at the world population and suggesting that: “At a population level, 8% of dementia would be gone if you removed hearing loss at the population level,” she said.
At the end of last year, the first results of the ACHIEVE trial were released. This is being conducted by Dr. Frank Lin’s group at JHU and is the first randomized controlled trial that has really looked at cognitive decline, hearing loss, and more specifically, treatment with well-fit hearing aids. The trial is continuing, and more data will be forthcoming. But the first data found that in older adults with increased risk for cognitive decline related to the use of well-fit hearing aids, suggesting hearing intervention might reduce cognitive change over three years (the length of the study so far). More time is needed to fully evaluate those at lower risk for cognitive decline.
There are two statements that people are saying which are not supported by current evidence. “If you hear this, you should reject it,” Dr. Palmer said.
- If you have hearing loss and you do not use hearing aids, you will experience dementia
- If you use hearing aids, you will not develop dementia
What is contributing to cognitive decline and health outcomes with untreated hearing loss? There is still lots of room for research in this area, Dr. Palmer said. Is something happening in tandem? As we age, is this more of a brain structure issue where cognition and hearing are both impacted? People are doing animal work in this area to help tease things out.
In the meantime, Dr. Palmer thinks more clinically and wants to figure out what can be done now. “That’s what we try really hard to do in our Department of Audiology, is give real evidence-based advice for what we know right now, and then we’re forever updating that when new information comes out,” she said.
What we do know is that untreated hearing loss is definitely related to depression, social isolation, reduced activity, and reduced access to health care. All of those can come together and have an impact on healthy aging in general and on cognition.
The other thing we know is that we have limited cognitive resources. If we do not hear well, we have to allocate more cognitive resources just to figure out what was said, because we are filling in the blanks. As adults, we have lots of language exposure and can use context to fill in what we didn’t hear, but it takes energy and effort. This means there are less cognitive resources for other things we need to do. “As we get older, we don’t want our cognitive resources being used up on just hearing when we can do something about hearing,” Dr. Palmer said.
Untreated hearing loss results in:
- Increased vulnerability to depression
- Increased odds of social isolation, decreased social participation
- Increased risk of not following the doctor’s treatment recommendations and increased medical adverse events
- Increased hospitalization and readmission and higher incidence of delirium
Data shows that using appropriately fit amplification decreases these issues. UPMC Audiology and The Eye & Ear Foundation team up to make a difference in a lot of these different areas. “How are older Americans getting their healthcare and what are the barriers to healthcare?” Dr. Palmer asked. “What becomes evident is having untreated hearing loss is a barrier to accessing healthcare.”
This results in people being less likely to see the doctor. Hearing loss alone is a barrier just for accessing care and being satisfied or happy with that care.
One program that is conducted across the entire UPMC system is providing simple amplifiers for inpatients. Anyone can identify someone with hearing loss – the family, nurse, doctor, PT, OT, SLP, or anyone else interacting with the patient. Once identified, the patient will be brought an amplifier. Audiology works with the nursing stations to make sure amplifiers are in stock.
In 2020, there was a surge in amplifier usage due to COVID. Everyone had masks on, which made many people realize they needed help hearing. The number was surpassed this year. As more health care providers know about this program, usage increases.
Because things in an inpatient room cannot be reused, people are encouraged to take the amplifiers home. They can be used in rehab or while recovering at home.
HearCare: Hearing for Communication and Resident Engagement
This program tries to make assisted living facilities more accessible. Once a month, an audiologist goes in to help people. Audiology recently conducted a study where a communication facilitator goes twice a week to help everyone in the building communicate better. That could mean helping with hearing aid upkeep, providing communication strategies, helping with hearing on the phone to stay connected to loved ones, or other kinds of simple low-cost amplifiers.
This is a big project that was initially funded by the Hearst Foundation and currently funded by PCORI (Patient Centered Outcomes Research Institute).
Thrive – Treating HeaRing and Improving Vision
EEF helped Audiology work with the Eden Hall Foundation for this brand-new program that is developing training in vision and hearing care for Community Health Workers in collaboration with the CHWs. CHWs are trusted members of communities who can help community members access the care they need.
Dr. Lori Zitelli started the TeleAudiology program during COVID (2020), where Audiology realized they needed to try to support patients at a distance. Some online hearing testing was done during this time to triage people to determine whether they needed to come into the clinic. These services have continued, but now are being expanded for people in rural communities. They can get hearing testing and hearing aid fitting when they literally cannot get to one of the clinics. This is all about using technology to everyone’s advantage.
Audiology is just teaming up with EEF and Brother’s Brother to create a hearing and communication mobile unit. This is another way to reach people, especially if they are not coming in for care. It also will be used to include underrepresented populations in important hearing and communication research.
“One thing we know in the different studies that are reported is that minorities are woefully left out of these studies,” Dr. Palmer said. “We don’t have information that could be really important in working with different groups of people.”
Racial and Ethnic Differences in Hearing Aid Use
Hearing aids are not covered by Medicare. It will take an act of Congress to change this. Thus, there are true health disparities in hearing aid access because they are typically an out-of-pocket expense or only have a little bit of coverage. It breaks down not just in terms of race, but socioeconomic status. Individuals who identify as white have a much higher probability of having a hearing aid compared to Black individuals, who have a lower hearing aid uptake on average. People are really struggling, even if they would be willing to come in and get help.
HEAR-UP: Hearing Education and Resources for Underserved Populations
A Pitt student, Rachel Fryatt, came up with this idea that has taken off. EEF is a huge part of this because its donations financially support these programs. Audiology runs three free clinics where they fit hearing aids. They do this once a month at the Birmingham Free Clinic, Catholic Charities, and in the Squirrel Hill Health Center. For the last two years, Audiology has also been part of Mission of Mercy. This past fall, 254 people received hearing aids over two days.
A new program thanks to the Hearst Foundation, this is being headed up by Dr. Jamie Katz. Over-the-counter hearing aids became available in October 2022. Although this was meant to make hearing aids more accessible for people with mild to moderate hearing loss, the endless choices have proven to be very confusing. The clEARdashboard is being developed to allow consumers to sort out what devices might be useful to them.
This website will help consumers sort through the hundreds of devices by answering questions and indicating preferences. Faculty at the University of Pittsburgh are putting together sophisticated laboratory tests to measure these devices on real people and be able to give a score related to expected function, called the ClearScore. This will allow consumers to compare features and performance and make it easier to find the right hearing aid if they want to pursue this pathway of self-care.
Urgency to Action
Typically, there is not urgency to action to get a baseline hearing test, unlike vision or dental care. Fewer adults get their hearing tested. PCPs should be recommending hearing tests when individuals turn 50 years of age or earlier if the person is concerned about their hearing. You can pursue a hearing test whether your PCP makes this recommendation or not.
Universal newborn screening helps catch hearing loss in newborns, which is critical to intervention. Although older adults have a much higher prevalence of hearing loss than children, there are no systematic hearing screening programs in place for adults. To address this, Dr. Palmer helped create LiDIA: Listening, Identification, and Immediate Amplification. EEF and the Pitt Innovation Institute have been a big part of this product development.
LiDIA is the first really inexpensive hearing screener that is accurate and can be done in real world conditions. When someone rolls in a cart to take vitals like blood pressure and temperature, hearing screening can be added. You count how many beeps you hear. Then if you do not hear as many as you should, you leave the headset on and it becomes an amplifier that helps you hear during your health care appointment.
The final product is being assembled and the first run is coming off the line this week. The Wiegand Entrepreneurial Research Award (through EEF) will help cover the devices and a half-time project director to deploy the devices in various settings for a year as Audiology conducts the final validation.
Guidance Based on Evidence
- Get a baseline hearing test
- If you have hearing loss, get hearing aids sooner rather than later. If you can’t, and you have a smartphone, you can make your smartphone function as a hearing aid
- If you have hearing aids, wear them during all waking hours for best result
- Hearing aids do not cure hearing loss and do not magically remove noise
- If you are a caregiver of someone in cognitive decline and the person you care for has hearing aids, work with the audiologist to keep these in good working order and if the hearing aids need to be replaced, get the exact same form factor. Don’t make changes. If they are familiar, leave everything familiar. “We can keep hearing aids working for many many years without needing to replace them,” Dr. Palmer said.
- If you are a caregiver of someone in cognitive decline, the audiologist can work with you to create solutions that support your caregiving; hearing aids may not be the best solution, but there are other support strategies to improve communication
Things That are Free:
- Amplified, captioned landline phones (Audiology can sign a form and you can get one of these phones. They come set it up, and teach you how to use it.)
- Speech to text on a smart phone
- Captioned mobile calls
- Smart phone as an amplifier
- Three free hearing aid clinics in Pittsburgh