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Addressing cognitive health in hearing services for older adults

Diya Vaid

Supervisors: Prof Anne GM Schilder, Prof Fiona Stevenson, Dr Sergi Costafreda-Gonzalez, Dr Nathan Davies University College London, Ear Institute

Agenda

Background

01

PhD aim & objectives

02

03

Progress till date

Next steps

04

Background

Ray, et al. 2019. Wittenberg, et al. 2019. Livingston, et al. 2017, 2020. Lin, et al. 2023

Background

8-9%

Hearing Care

Modifying hearing loss has potential to reduce dementia risk

Emerging evidence suggests hearing care (hearing aids, tailored hearing support) may reduce dementia risk

Livingston, et al. 2017, 2020. Lin, et al. 2023.

National Survey

135

• Asking current practice and views regarding cognitive assessment in hearing aid clinics and hearing assessment in memory clinics, for older adults
• Distributed between July 2021 and March 2022

32%

NHS memory health care professionals

68%

156

Audiologists

Audiologists (NHS & Private)

Omar, et al. 2023

National Survey Results

Barriers for audiologists:

• Lack of time, training, resources

Omar, et al. 2023

Aim of PhD

To identify barriers and facilitators experienced by patients and professional stakeholders in terms of addressing cognitive health in hearing services for older adults

Objectives

1. Map international recommendations and practice regarding how cognitive health is addressed hearing services for older adults, via a narrative review and survey of professional organisations2. Map stakeholders involved in hearing and dementia care pathways in the UK 3. Understand the expectations and experiences of older adults, and their care givers, attending NHS hearing services in terms of addressing memory, through semi-structured interviews 4. Understand the barriers and facilitators involved in commissioning, providing and giving guidance on hearing care whilst also addressing cognitive health, in clinical services for older adults, through semi-structured interviews.

Objective 1. Map international reccomendations (narrative review)

Aim: To provide an overview of the evidence on how hearing loss and cognitive health are related and, if and how they are currently addressed as co-morbidities in clinical practice globally.

Objective 1. Map international reccomendations (narrative review)

Research questions:

1. What is the evidence regarding the association between hearing loss and cognitive decline/dementia in terms of epidemiology, proposed nature of the association and what effect the mechanisms of the association may have on the potential approaches to health care practice?
2. How can cognition be addressed in people with hearing loss, and how can hearing health can be addressed in those with cognitive decline/dementia, in terms of assessments?
3. How is cognitive health currently addressed in hearing services for older adults internationally?
4. What are the evidence gaps in the research and next research steps that would need to be taken to prepare for in the implementation of addressing cognitive health in hearing services for older adults in the UK?

Objective 1. Map international reccomendations (narrative review)

Methods:

Grey literature search

Scientific literature search

RQ3

RQ1RQ2 RQ3

Objective 1. Map international reccomendations (narrative review)

RQ1: What is the evidence regarding the association between hearing loss and cognitive decline/dementia in terms of epidemiology, proposed nature of the association and what effect the mechanisms of the association may have on the potential approaches to health care practice?

Key findings

1st hypothesis:

• Increased cognitive load
• Brain structural and functional changes
• Social isolation leading to decrease in cognitive stimulation

2nd hypothesis:

• Neurodegeneration has an impact on the auditory pathway, affecting the ability to process speech and sound

3rd hypothesis:

• External factor causes both hearing loss and dementia

Panza, et al. 2015. Lin, et al. 2014. Mick, Kawachi and Lin. 2014. Johnson, et al. 2021. Shen, et al. 2018

Objective 1. Map international reccomendations (narrative review)

RQ2: How can cognition be addressed in people with hearing loss, and how can hearing health can be addressed in those with cognitive decline/dementia, in terms of assessments?

Key findings

In those with a cognitive impairment that may also have a hearing loss, adapted cognitive tests are required

• Adaptations attempted (MoCA and MMSE)
• Important to not compromise the sensitivity and specificity

Hearing assessments alone i.e. PTA, are not a good measure of hearing in those with potential cognitive impairment

Hill-Briggs, et al. 2007, North, et al. 2021, Dawes et al. 2019, Utoomprurkporn, et al. 2021

Objective 1. Map international reccomendations (narrative review)

RQ3: How is cognitive health currently addressed in hearing services for older adults internationally?

Scientific literature search findings

• 16 studies found
• impact of a hearing intervention on cognition
• hearing aids, cochlear implants, hearing care packages

No studies found which investigated addressing cognition in hearing services

Objective 1. Map international reccomendations (narrative review)

RQ3: How is cognitive health currently addressed in hearing services for older adults internationally?

Scientific literature search findings

• Years: Ranging from 2005 - 2023
• Type of study: Mix of longitudinal cohort, pilot, feasibility, RCT
• Countries: 6/16 US, & others
• Intervention: 6/16 hearing aids

Objective 1. Map international reccomendations (narrative review)

RQ3: How is cognitive health currently addressed in hearing services for older adults internationally?

Key findings

• ACHIEVE RCT
• HA's & audiological counselling reduces cognitive decline, by 48%, in a subgroup population of older adults who were at an increased risk of cognitive decline

• SENSE-Cog Asia feasibility trial
• Tailored adapted hearing support intervention consisting of hearing assessment, hearing aid fitting and home-based support
• Neuropsychiatric symptom load decreased
• Burden and stress of caregivers reduced

Lin, et al. 2023. Sheikh, et al. 2020

Objective 1. Map international reccomendations (narrative review)

RQ3: How is cognitive health currently addressed in hearing services for older adults internationally?

Grey literature search findings

Specific guidelines

France, England, Australia, US

4/100

Objective 1. Map international reccomendations (narrative review)

RQ4: What are the evidence gaps in the research and next research steps that would need to be taken to prepare for in the implementation of addressing cognitive health in hearing services for older adults in the UK?

Key findings

Ongoing research on adapting assessments

Literature on type of association between HL and Dementia

No literature exploring both the barriers and facilitators of addressing cognitive health in hearing services in the UK

Studies investigating hearing intervention on cognition, none the other way around

Objective 1. Map international reccomendations (survey of international organisations)

Aim: To provide an overview of international guidelines or recommendations for clinical audiologists on how to address cognitive health in hearing services for older adults.

Objective 1. Map international reccomendations (survey of international organisations)

• 23 countries
• Spread across continents
• HIC and LMIC
• Mixture of health care types

Objective 1. Map international reccomendations (survey of international organisations)

Q1

Has your organisation (or another national organisation) issued clinical guidance for audiologists on how to address cognitive health in hearing services for older adults?Are you aware of any national, regional or local protocols for audiologists on how to address cognitive health in hearing services for older adults?

Q2

Objective 1. Map international reccomendations (survey of international organisations)

Key findings

France, Australia, US

Specific guidelines

US practice portal

Objective 2. Map stakeholders involved in hearing and dementia care pathways in the UK

Aim: To map stakeholders involved in hearing and dementia care pathways in the UK, including patients and their family members, health care professionals, charities and professional organisations

Objective 2. Map stakeholders involved in hearing and dementia care pathways in the UK

14

Charities & Organisations

Healthcare professionals

Older adults, family members, care givers

Commissioners & policy makers

10

Healthcare professionals

Charities & Organisations

Objective 2. Map stakeholders involved in hearing and dementia care pathways in the UK

Next Steps

1. Map international recommendations and practice regarding how cognitive health is addressed hearing services for older adults, via a narrative review and survey of professional organisations2. Map stakeholders involved in hearing and dementia care pathways in the UK 3. Understand the expectations and experiences of older adults, and their care givers, attending NHS hearing services in terms of addressing memory, through semi-structured interviews 4. Understand the barriers and facilitators involved in commissioning, providing and giving guidance on hearing care whilst also addressing cognitive health, in clinical services for older adults, through semi-structured interviews.

Next Steps

Interviews

Ethics

Application of ethics for semi-structured interviews with patients who access hearing services (+ care givers) and professional stakeholders

Semi-structured interviews addressing views, expectations, barriers and facilitators regarding addressing cognitive health in hearing services

Co-production

Analysis

Thesis written and, in the future, PhD findings to be used to help inform the development of practical guidance for patients and healthcare professionals

Reflexive thematic analysis

Timeline

Jan 2025 - Sept 2025

Dec 2023-Jan 2024

Submission to ethics

Analysis and write up

Feb 2024 - Dec 2024

Interviews and intial analysis

PPIE

References

• Hill-Briggs, F., Dial, J.G., Morere, D.A. and Joyce, A., 2007. Neuropsychological assessment of persons with physical disability, visual impairment or blindness, and hearing impairment or deafness. Archives of clinical neuropsychology, 22(3), pp.389-404.
• Johnson, J.C., Marshall, C.R., Weil, R.S., Bamiou, D.E., Hardy, C.J. and Warren, J.D., 2021. Hearing and dementia: from ears to brain. Brain, 144(2), pp.391-401.
• Lin, F.R. and Albert, M., 2014. Hearing loss and dementia–who is listening?. Aging & mental health, 18(6), pp.671-673.
• Lin, F.R., Pike, J.R., Albert, M.S., Arnold, M., Burgard, S., Chisolm, T., Couper, D., Deal, J.A., Goman, A.M., Glynn, N.W. and Gmelin, T., 2023. Hearing intervention versus health education control to reduce cognitive decline in older adults with hearing loss in the USA (ACHIEVE): a multicentre, randomised controlled trial. The Lancet, 402(10404), pp.786-797.
• Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C. and Costafreda, S.G., 2020. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), pp.413-446.
• Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S.G., Huntley, J., Ames, D., Ballard, C., Banerjee, S., Burns, A., Cohen-Mansfield, J. and Cooper, C., 2017. Dementia prevention, intervention, and care. The lancet, 390(10113), pp.2673-2734.
• Mick, P., Kawachi, I. and Lin, F.R., 2014. The association between hearing loss and social isolation in older adults. Otolaryngology–Head and Neck Surgery, 150(3), pp.378-384.
• North, C., Desai, R., Saunders, R., Suárez-González, A., Bamiou, D., Costafreda, S.G., de Haan, G., Halls, G., Heutink, J., O'Nions, E. and Utoomprurkporn, N., 2021. Neuropsychological deficits in Posterior Cortical Atrophy and typical Alzheimer's disease: A meta-analytic review. Cortex, 143, pp.223-236.
• Omar, R., Kuo, L., Costafreda, S.G., Hall, A., Forbes, M., O’Brien, J.T. and Schilder, A.G., 2023. Managing comorbid cognitive impairment and hearing loss in older adults: a UK survey of audiology and memory services. Age and Ageing, 52(5), p.afad080.
• Panza, F., Solfrizzi, V. and Logroscino, G., 2015. Age-related hearing impairment—a risk factor and frailty marker for dementia and AD. Nature Reviews Neurology, 11(3), pp.166-175.
• Ray, M., Dening, T. and Crosbie, B., 2019. Dementia and hearing loss: A narrative review. Maturitas, 128, pp.64-69.
• Sheikh, S., Tofique, S., Zehra, N., Amjad, R., Rasheed, M., Usman, M., Lal, S., Hooper, E., Miah, J., Husain, N. and Jafri, H., 2021. SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia. Frontiers in Neurology, p.896.
• Shen, Y., Ye, B., Chen, P., Wang, Q., Fan, C., Shu, Y. and Xiang, M., 2018. Cognitive decline, dementia, Alzheimer’s disease and presbycusis: examination of the possible molecular mechanism. Frontiers in neuroscience, 12, p.394.
• Utoomprurkporn, N., Stott, J., Costafreda, S.G. and Bamiou, D.E., 2021, June. Lack of association between audiogram and hearing disability measures in mild cognitive impairment and dementia: what audiogram does not tell you. In Healthcare (Vol. 9, No. 6, p. 769). MDPI.
• Wittenberg, R., Hu, B., Barraza-Araiza, L. and Rehill, A., 2019. Projections of older people with dementia and costs of dementia care in the United Kingdom, 2019–2040. London: London School of Economics, 2.

Acknowledgements

• Supervisors (Primary: Prof Anne GM Schilder, Secondary: Prof Fiona Stevenson)
• Thesis committee (Dr Sergi Costafreda-Gonzalez, Dr Nathan Davies)
• evidENT team
• Fellow PhD students & Ear Institute
• NIHR UCLH BRC: Hearing Health Theme
• NIHR ARC NT: Innovation and Implementation Science Theme
• Special thanks: Dr Christian Füllgrabe

• LMIC = India, Brazil, South Africa, Thailand
• HIC = 19 others
• Service type: governemt, co-pay, private