DOES HEARING AID USE SLOW COGNITIVE DECLINE?
Deal, J., Sharrett, A., Albert, M., Coresh, J., Mosley, T., Knopman, D., Wruck, L. & Lin, F. (2015). Hearing impairment and cognitive decline: A pilot study conducted within the Atherosclerosis Risk in Communities Neurocognitive Study. American Journal of Epidemiology 181 (9), 680-690.
This editorial discusses the clinical implications of an independent research study and does not represent the opinions of the original authors.
Recent evidence has suggested that cognitive decline and hearing impairment may have more of a connection beyond simple co-occurrence in the older population. Certainly, as individuals age, they become more likely to exhibit reduced cognitive function and also more likely to have hearing loss. It has been proposed that hearing loss may be correlated with temporal lobe and whole brain atrophy (Lin & Albert, 2014; Peelle, et al., 2011; Lin et al., 2014). Whether the two conditions are related to a shared underlying cause is not known, but a number of studies have indicated that hearing loss may put older individuals at higher risk of cognitive decline (Lin, 2011; Lin et al., 2011; Lin, et al., 2013). The effect of hearing loss on cognition may be mediated by social isolation and loneliness or increased listening effort required to process speech via an impaired peripheral auditory system (McCoy, et al., 2005; Tun, et al., 2009). Conversely, cognition affects every-day communication and recent research has shown that hearing aid users with reduced cognitive capacity may have poorer speech recognition ability in noise, be more susceptible to the effects of distortion and noise and may also take a longer time to adapt to new hearing aids (Lunner, 2003; Lunner et al., 2009; Ng et al., 2014)
The work of Deal and colleagues aimed to determine whether older individuals with hearing loss show poorer cognitive performance and experience a more rapid rate of cognitive decline than those with normal hearing. Subjects were recruited from a population originally recruited in 1987-1989 for a longitudinal study called Atherosclerosis Risk in Communities (ARIC). Of the 15,792 ARIC subjects, 253 participated in this study on cognition and hearing, with a mean age of 76.9 years. Approximately 39% of the subjects were men, 61% were women. At the 2013 session, 48% of the total participants reported ever smoking, 34% had diabetes and 71.9% had hypertension. About 60% of the subjects had fewer than 12 years of education and 40% had more than 12 years of education.
The ARIC subjects completed a battery of neuropsychological tests on in three domains – memory, language and processing speed/attention – in 1990-1992 and again in 1996-1998. Memory was tested with the Delayed Word Recall Test (DWRT; Knopman et al., 1989), the Incidental Learning Test (Kaplan et al., 1991) and the Logical Memory Tests I and II (Wechsler, 1945). Language was examined using the Word Fluency Test (Benton et al., 1994), Animals Naming Test (Goodglass & Kaplan, 1983) and the Boston Naming Test (Saxton et al., 2000). Processing speed and attention were assessed with the Digit Symbol Substitution and Digit Span Backwards Tests (Wechsler, 1981) and Trail Making Tests I and II (Spreen & Strauss, 1991; Reitan, 1958). For the purpose of the present study, these neuropsychological tests were administered again in 2013.
Pure tone air conduction thresholds were obtained for all 2013participants and they were categorized according to degree of loss indicated by the pure tone average (PTA) in the better ear: normal (lower than 25dB), mild (26-40dB), moderate/severe (greater than 40dB). Only 5 individuals had PTAs greater than 70dB, so these individuals were included in the moderate/severe group. Of the total population, 34% had moderate/severe hearing loss, 37% had mild hearing loss and 29% had normal hearing. Hearing aid users made up approximately 20% of the total subject population. Hearing aid use was loosely defined as the self-reported use of a hearing aid in either or both ears during the month prior to the experimental session. The duration of hearing aid use ranged from less than 1 year to 48 years, with most aided participants reporting hearing aid use for a period of 3 to 7 years.
All of the groups showed a decline in cognitive performance over the 20 years of the study, but the hearing loss groups declined faster than the normal hearing group. The subjects with moderate/severe hearing loss were slightly older and slightly more likely to be male and to have hypertension. However, after correcting for these variables, the subjects with moderate/severe hearing loss still declined significantly faster than the normal hearing group.
Approximately 51% of the subjects with moderate/severe hearing loss wore hearing aids. The individuals who did not wear hearing aids had significantly poorer performance on the cognitive tests and demonstrated a significantly faster rate of decline compared to those in the moderate/severe group who did wear hearing aids. The rate of 20-year memory decline for the unaided individuals in this group was twice the average rate of decline reported in national studies of cognitive change in older adults (Salthouse, 2010; Hayden et al., 2011). In comparison, the hearing aid users in this study with moderate/severe hearing loss showed a rate of cognitive decline that was only slightly higher than the rate for subjects with normal hearing.
The authors point out that because hearing was not assessed at earlier experimental sessions, they cannot rule out the possibility that cognitive decline had a causative effect on the measured hearing loss. However, this is unlikely because they corrected for co-occurring diseases and conditions in their analysis. Furthermore, conditions affecting cognition are not known to have any effect on the peripheral auditory system and cognitive deficits were not expected to have influenced the validity of the audiometric test results.
Many have proposed that hearing loss may increase risk of cognitive decline, via increased social isolation, increased perceptual effort and changes in brain volume. Unaided hearing loss is known to increase the risk of social isolation, which in turn has been associated with increases in blood pressure and corticosteroid levels, which could in turn affect brain structure (Mick et al., 2014; Hawkley & Cacioppo, 2010). Similarly, several studies have indicated that hearing loss increased effortful listening, thereby increasing the cognitive demands required to process speech (Rabbitt, 1968; Tun et al., 2009; McCoy et al., 2005).
The outcomes of this study are in agreement with other reports in which hearing impaired individuals demonstrated poorer performance on cognitive tests and faster rates of cognitive decline (Lin, 2011; Lin et al., 2011; Lin, et al., 2013). Other reports also indicate a relationship between hearing loss and subsequent dementia over years of follow-up evaluations (Gallacher et al., 2012; Lin et al., 2011). The current outcome that hearing aid use had a mitigating effect on cognitive performance and rate of decline is fascinating and supports the need for further investigation on the relationship between cognition and hearing loss.
Though this is an emerging area of study, the results reported here offer strong support for the proposal that the risk of cognitive decline by hearing loss may be reduced, at least partially, by the correction of peripheral hearing loss with hearing aids. This underscores the importance of amplification for older individuals and clinicians should be prepared to counsel their patients that hearing aids are an effective way to improve communication, decrease social isolation and may slow or decrease the risk of cognitive decline.However, clinicians should be cautious not to suggest that hearing aids will prevent cognitive decline. Although the authors are careful not to claim a causal relationship between hearing loss and cognitive decline, it is clear that the two conditions are related and because hearing loss is easily treatable it may be one of the few ways in which individuals can proactively manage their risk of cognitive decline.
References
Benton, A., Hamsher, K., & Sivan, A. (1994). Multilingual Aphasia Examination 3rd ed. Iowa City, IA: AJA Associates.
Deal, J., Sharrett, A., Albert, M., Coresh, J., Mosley, T., Knopman, D., Wruck, L. & Lin, F. (2015). Hearing impairment and cognitive decline: A pilot study conducted within the Atherosclerosis Risk in Communities Neurocognitive Study. American Journal of Epidemiology 181 (9), 680-690.
Gallacher, J., Ilubaera, V. & Ben-Shlomo, Y. (2012). Auditory threshold, phonologic demand and incident dementia. Neurology 79(15), 1583-1590.
Goodglass, H. & Kaplan, E. (1983). The Assessment of Aphasia and Related Disorders 2nd ed. Philadelphia, PA: Lea and Febiger: 102, 31.
Hawkley, L. & Cacioppo, J. (2010). Loneliness matters: a theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine 40(2), 218-227.
Hayden, K., Reed, B. & Manly, M. (2011). Cognitive decline in the elderly: an analysis of population heterogeneity. Age and Aging 40(6), 684-689.
Kaplan, E., Fein, D. & Morris, R. (1991). WAIS as a Neuropsychological Instrument. San Antonio, TX: The Psychological Corporation.
Knopman, D. & Ryberg, S. (1989). A verbal memory test with high predictive accuracy for dementia of the Alzheimer type. Archives of Neurology 46(2), 141-145.
Lin, F. (2011). Hearing loss and cognition among older adults in the United States. The Journals of Gerontology A: Biological Sciences and Medical Sciences 66 (10), 1131-1136.
Lin, F. & Albert, M. (2014). Hearing loss and dementia – who is listening? Aging and Mental Health 18(6), 671-673.
Lin, F., Ferrucci, L. & Metter, E. (2011). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology 25(6), 763-770.
Lin, F., Yaffe, K., & Xia, J. (2013). Hearing loss and cognitive decline in older adults. Journal of the American Medical Association Internal Medicine 173 (4), 293-299.
Lunner, T. (2003). Cognitive function in relation to hearing aid use. International Journal of Audiology 42, (Suppl. 1), S49-S58.
Lunner, T., Rudner, M. & Ronnberg, J. (2009). Cognition and hearing aids. Scandinavian Journal of Psychology 50, 395-403.
McCoy, S.L., Tun, P.A. & Cox, L.C. (2005). Hearing loss and perceptual effort: downstream effects on older adults’ memory for speech. Quarterly Journal of Experimental Psychology A, 58, 22-33.
Mick, P., Kawachi, I. & Lin, F. (2014). The association between hearing loss and social isolation in older adults. Otolaryngology Head Neck Surgery 150(3), 378-384.
Ng, E.H.N., Classon, E., Larsby, B., Arlinger, S., Lunner, T., Rudner, M., Ronnberg, J. (2014). Dynamic relation between working memory capacity and speech recognition in noise during the first six months of hearing aid use. Trends in Hearing 18, 1-10.
Peelle, J., Troiani, V. & Grossman, M. (2011). Hearing loss in older adults affects neural systems supporting speech comprehension. Journal of Neuroscience 31(35), 12638-12643.
Rabbitt, P. (1968). Channel-capacity, intelligibility and immediate memory. Quarterly Journal of Experimental Psychology 20(3), 241-248.
Reitan, R. (1958). Validity of the Trail Making Test as an indicator of organic brain damage. Perceptual and Motor Skills 8, 271-276.
Salthouse, T. (2010). Major Issues in Cognitive Aging. Vol. 49, New York, NY: Oxford University Press: 246.
Saxton, J., Rafcliff, G. & Munro, C. (2000). Normative data on the Boston Naming Test and two equivalent 30-item short forms. Clinical Neuropsychology 14(4), 526-534.
Spreen, O. & Strauss, E. (1991). A Compendium of Neuropsychological Tests: Administration, Norms and Commentary. 2nd ed. New York, NY: Oxford University Press.
Tun, P., McCoy, S. & Wingfield, A. (2009). Aging, hearing acuity and the attentional costs of effortful listening. Psychology and Aging 24(3), 761-766.
Wechsler, D. (1945). A standardized memory scale for clinical use. Journal of Psychology 19(1), 87-95.
Wechsler, D. (1981). Wechsler Adult Intelligence Scale – Revised. New York, NY: The Psychological Corporation.