Welcome back, everyone. Welcome back. Our next session is about cognition and brain health with Dr. Douglas Beck. Dr. Beck began his career in Los Angeles at the House Ear Institute in cochlear implant research and intraoperative cranial nerve monitoring. By 1988, he was appointed to the medical school faculty as director of audiology at St. Louis University. Later, he co-founded an audiology and hearing aid dispensing practice in St. Louis, Missouri. In 1999, he became president and editor-in-chief of audiologyonline.com, speechpathology.com, and healthyhearing.com. Dr. Beck joined Oticon Inc. in August, 2005. In December, 2019, he was promoted to vice president of academic sciences at Oticon. While employed at Oticon, he also served as web content editor for the American Academy of Audiology, senior editor for clinical research at the Hearing Review, and adjunct clinical professor of communication disorders at the State University of New York at Buffalo. Dr. Beck is a prolific author with over 215 publications in audiology. Although he officially retired from Oticon in March, 2022, he became VP of clinical sciences for Cognivue, Inc. in April, 2022. Dr. Beck is a sought-after lecturer globally and has presented more than 1,000 lectures, keynote addresses, webinars, and other professional presentations. We are thrilled to have him join us here today. And now let's go ahead and begin the session. Take it away, Doug. So, you know, I've been doing this for 40 years and these online presentations now for probably five or 10, but I swear to you, every time I do it, it's different, so thank you for tolerating that. I want to thank Sierra Sharp. Those of you who don't know, Ms. Sharp has been just pivotal in the development and growth of IHS, and she's a dear friend of mine for many years. Annette, thank you for your brief notes earlier today. Alyssa, thank you. Nashley, Dr. Nashley Bergman, one of my heroes in audiology, and Tara and everybody involved. So thank you so much for being here and for doing the work that you do, which is primarily and often behind the scenes, but certainly worthy of praise. I want to see if I can switch this over here. So I'm going to tell you a little bit about me to begin with because I'm sort of required to do that. I have financial relationships and I have non-financial relationships. So the ones that I should tell you is that I'm a full-time employee at Cal Newton. I am a consultant and or a contractor for various private companies. I am senior editor of Peer Review, as Sierra mentioned. And I do a lot of things that I don't get any financial involvement with. One is I'm an adjunct clinical professor at the State University of New York at Buffalo in the Department of Communication Disorders. I'm a full professor there. And I'm a peer reviewer for lots of different journals. So it's important to disclose that because when people are speaking and presenting, it's good to know who's paying them to do that. So those are my financial relationships. Now, I want to apologize if I cough and clear my throat. I'm getting a little bit of a respiratory infection, which I think I'll be fine, but bear with me if I have to cough a little bit. My website is douglaslbeck.com. The reason I tell you that, I make no money off this website. In fact, it cost me a fortune. But the thing of it is, if you go to douglaslbeck.com, you'll get links and PDFs, which is in the upper right. And then you click in there, you'll see a couple of hundred of my articles. They're free. You can download them. You can make fun of them. You can draw mustaches on some of them, you know, whatever you want to do. But I set that website up many years ago for my students. And then I just started posting all of my music in there. And I started posting all of my articles and my bio and stuff like that. So it's all in there. The reason I mentioned that is I'm going to mention a lot of articles today. And if you want copies of them, I believe IHS may have them in this website. If Sierra needs them, she'll let me know and I'll certainly grant access to all of them. But in the meantime, you could just go to douglaslbeck.com. Also, as a preface, you might want to have your phone ready. And if I mention an article or a topic that you're interested in, take a screenshot of it. And then you can always ask me about that later. My email is very simple. It's just doug at cognitive.com. Okay. So I'm going to start really super simple and we're going to get really deep, very fast. Everybody here is pretty much a hearing care professional. And so we all know that hearing is not the same thing as listening. Hearing is just detecting sound. Hearing is what we measure pretty much, kind of, sorta on an audiograph. Hearing is perceiving or detecting sound. That's it. When you talk about listening, this gets into what Dr. Nashville Grogan was talking about earlier, that the number one complaint of all patients of all time is speech and noise, the inability to understand speech and noise. And as that is such a overwhelmingly difficult problem, we have to really understand that it's actually not necessarily a hearing problem. Listening, it can be defined as assigning meaning to sound. Listening is comprehending or decoding sound. When you think about people who have hearing loss, if we go back to this slide, of the 325 million people in the USA, I'm sorry to my Canadian colleagues, I have no idea what your population is. I think it's about 45 million, but I could be way wrong. So I'm going to give you USA stats because I'm familiar with it. So in the USA, we have about 325, 330 million people. Of those, about 38 million will have hearing loss on an audiogram. But more importantly, for the purposes of this discussion, is to understand that there's another 26 million people in the USA have no hearing problems whatsoever. They have listening problems. And when we say that, what are we talking about? Well, it could be auditory processing disorders. It could be auditory neuropathy spectrum disorder. It could be cochlear synaptopathy. It could be hidden hearing loss. It could be ADD, it could be ADHD. It could be traumatic brain injury. It could be Meniere's disease. It could be mild cognitive impairment. It could be major neurocognitive disorders like Alzheimer's, like Lewy body disorders, like vascular dementias, like lots of different, like Parkinson's with dementia. And they don't necessarily mandate that you have any hearing loss, but you could have very substantial listening problems as do 26 million people in the USA. No hearing loss, pure listening problems. And how do you detect those? How would you know? Because if you're just doing airborne speech, those 26 million people are invisible to you. You're not detecting that they have a problem. And in fact, you probably think, well, subclinical hearing loss, also called functional hearing loss, also called SUPRA, S-U-P-R-A, supra-threshold listening disorder. But you won't see any of those if you're not doing a full, comprehensive audiometric evaluation. The reason I bring this up, I wrote an article recently for ASHA. They asked me to write a 500-word op-ed and it became 5,000 words, as one does. And it was in the November, December ASHA leader. And I argued in that, that we should never do screenings. We just shouldn't. Because the only screenings I endorse are newborn infant screenings. And that not only do I endorse, I totally think 100% every child wants to be screened at birth. But hearing screening in adults, I am totally opposed. When somebody has hearing difficulty, listening disorder, they need a comprehensive audiometric evaluation. When we say we're, press the button, when you hear the beep, you already missed 26 million people. Yeah. And so it doesn't make any sense to me because they're all gonna complain about speech and noise. They're all gonna complain about hearing difficulty. They're all gonna complain about these same things. And I'll show you in a few moments. Patricia Krikos, my dear friend who unfortunately died five or 10 years ago, Patricia was at University of Florida, Gainesville. And she made the point that cognitive disorders and listening disorders can parade as each other. They masquerade as each other. They look like each other. And if you're not doing a comprehensive evaluation, they all look the same to you. And that's why it's so important to understand. IHS has gone to pains to develop a very comprehensive best practice model. It's very similar to AAA and to ASHAs. And I had the honor of being on that writing committee. I think I was on that committee with Sierra Sharp for about six, seven, eight years. It felt like 27 years. I don't know, but it was a joy because we were able to look at the AAA model. We were able to look at the ASHA model. And then we devised a best practice model for IHS which then we brought to the membership. It must've been five, six, seven years ago. And it was standing remotely in this classroom that we did at the national meeting. And we said, here are the points we wanna make. What do you think? An overwhelming support. I mean, probably 97% of the hundreds of people in that room said, yes, we need this. So you actually have this best practice model that says, you gotta do your diagnostic stuff, right? Error bone speech, impedance, temps, OAEs, whatever you need to do for diagnostics and referral. But also in that best practice model, it's very clear. You have to do a listening and communication assessment. Now, Dr. Brogan was talking about, I think she was using the international outcomes or the HHIE or HHIA, and those are brilliant. There's others. There's the COSI, which is the Client-Oriented Scale of Intervention. There's the International Outcomes Inventory, the Hearing Healthcare Inventory for Adults, Hearing Healthcare Inventory for Elderly, the SSQ, the AFAB. There's a bazillion of them. The thing is, if you're not using any of them, you're missing 26 million patients. The other thing that all three of the major professional organizations have in their best practice model is of course a speech and noise test. Oh, I don't do speech and noise. Everybody complains about speech and noise. That's why you should be doing it because when they come in, the number one complaint is speech and noise, and most of us don't measure it. In fact, 85% of hearing care professionals don't measure it, which is a huge mistake, huge, absolutely stunningly bad mistake to make. Why? Well, because if you were to measure their speech and noise and quantify it, which takes two minutes, it would tell you exactly what technology to fit. Now, we'll get into that discussion a little bit. Excuse me. Okay, so it's all about the brain, actually. We can make anybody hear, but we can't make anybody listen. Hearing is, you know, it's a pretty easy thing for your central nervous system, right? You know, stimuli response. You know, it's like, you know, tactile, like smell, like taste, like vision, pretty straightforward. The bigger thing is listening. Hearing is just perceiving or detecting sound. Listening means we're gonna take your psychological wellbeing, your cognitive wellbeing, your memory, your pronunciation, your vocabulary, your emotional state. We're gonna put all that together with your memory, your working memory, your executive function, and you have to then take what you hear and apply meaning to it. So when you think about speech and noise, most common complaint of all time, because, you know, obviously, most common complaint is not, I have hearing loss, right? So of the 38 million people in the USA with hearing loss, only about 40% would ever seek help. The other 60%, they don't know they have hearing loss. They don't care. It's not, you know, the whole idea that, oh, we have to screen everybody. No, we don't. We have to do a comprehensive audiometric evaluation on people who have hearing complaints, hearing difficulty, people who complain about speech and noise, people who have signs and symptoms of hearing loss. We should be doing comprehensive evaluations. That's the only way we're gonna identify who has hearing and who has listening problems, because as dispensers, as audiologists, as EMTs, the auditory system is our area of expertise, right? So we can't make anybody hear. I'm sorry, I said that so poorly. We can make anybody hear, right? We have hearing aids. We have cochlear implants. We have brainstem implants. We have, you know, we have telecoils. We have loop systems. We have assistive devices. We have pocket talkers. We have FM. We have digital remote mics. We have a lot of ways to make you hear, but we can't make anybody listen because that's a whole brain event. When you talk about hearing, most of you are very familiar with the anatomy and physiology, but the simple version, right? There's these little air molecules moving out here. They bounce around into your pinna and into your external auditory canal, and men have an external auditory canal whose primary canal resonance is about 2,700 hertz. Females, about 3,100 hertz. And then once those sound representations hit your eardrum, then, you know, malleus and castapes start bouncing around, and then, you know, the footplate in the oval window moves, and you have fluids moving, and you look at the paralim, along with the scala media, scala tympani, scala vestibuli, and then you have, you know, the auditory nerve meets up with the inner hair cell. The inner hair cell, the synapse there, goes up brainstem, and, you know, it's passing along the way. The lateral meniscus, inferior colliculate, medial geniculate, and then we hit the superior olivary complex, which is where everything crosses over. And then it kind of lands in the superior temporal lobe. Superior temporal lobe is also called Broadman's area 41 to 42. It's also called Heschel's gyrus. But basically, you know, hearing occurs here, right? Superior temporal lobe. Listening is a whole brain event, because now I hear it, but for me to hear that sound, my brain has to process that information, make sense of it, apply meaning to it. So it's pulling on my vocabulary. Right now, most of you are watching me, which is goofy, but still, right? That's the occipital lobe back here where vision is processed. And all of this stuff goes through what's called the thalamus, right? Which you may have learned in high school. It's called also the relay station, because all of your sensory information with the exclusion of your nose goes through the thalamus. So that's where all of this information from all of your senses comes together, and your brain has to make sense of it. Now, with hearing, chump change, pretty easy, not a big whoop. It's just, you know, detecting a signal, but not necessarily processing it or making sense of it. Processing enough to detect it, yes, but to assign meaning, no. So we can make anybody hear, but we can't make anybody listen. So the ear, and I'm stealing this from my dear friends, Jane Maydell and Carol Flexer. I love these people. They are the best pediatric audiologists, among the very best in the world. And we've all been friends for, oh, I guess, about 40 years. And they use this analogy that the ear is a door or a window to the brain. And, you know, that's really how it is. Hearing and listening occur in the brain, not in the ear. And I know Nashley covered that, so we'll leave that there. Excuse me. This is one of those papers you just really have to have. I recommend downloading, not right now, but after the lesson, after the class. And you can just Google this. And this, if you look carefully, there's 25 co-authors on this. And in 2018, this was the most popular article written in the Hearing Review. And the 25 of us from all five continents and all sectors of audiology, you know, from commercial to business, to private practice, to speech and hearing clinics, to ENT practices. You know, we all contributed to this. And it, you know, the title kind of says it all, right? Audiologic considerations for people with normal hearing sensitivity, yet they have hearing difficulty or speech and noise problems. This is such a good article for you to have. So when you're being referred patients and you test them and they have normal hearing and you go, well, the good news is, don't do that. Stop doing that right away. We've all been trained to do that. It's silly. It's kind of antithetical to our best practice models. But it says, when you are finished finding out that they have normal hearing sensitivity, you're supposed to do a listening and communication assessment. You're supposed to do a speech and noise. And had you done those, you would, of course, find most of their deficits. But when not doing it, you're not gonna find any of those things. So this is a great article because it tells you step-by-step what to test, what to do with that information, what it means. And this is a great article to send to your physicians or your colleagues that you work with, maybe in an educational system or whatever, because it explains in detail, and it has, I don't know, 125 references, so they can learn more about this. But it's very important. And most EMTs don't get involved with this, right? And no cut on EMTs. Some of my best friends in life, you've heard me say this before, are neurotologists. Excuse me. And they are very, very smart people, but they're not audiologists or hearing aid dispensers. And as a result, and as makes good sense, right? They're looking out for medical and surgical problems. They're looking for those problems that they can solve. But only about three to 5% of all patients with hearing loss or listening disorders have a medical problem. The other 95% have an audiology problem or an audiologic problem. And those are things that you and I would take care of. So I'm totally opposed to that whole line of thought where people say, oh, the good news is you have normal hearing. Let's get you back in the ear. Bogus, totally bogus. That means they're complaining about speech noise. They're complaining about hearing difficulty. And you or I have failed to discover exactly the nature of that problem because we didn't do a listening and communication assessment. We didn't do a speech and noise assessment. And all of those are recommended very strongly by the International Hearing Society as well as AAA, actually. So, you know, we could keep doing the same thing. And you know the definition of insanity, doing the same thing over and over and expecting a different result. And I feel like sometimes we do spin our wheels. You know, you or I may see a patient that somebody else told, oh, the good news is everything's normal. But yeah, they can't get by in the world. And if you did these appropriate tests that are recommended, you would find out why, and then you could manage it. And, you know, there are certainly some people who say, oh, I would never put hearing aids on somebody with normal thresholds. And I would say, well, that's goofy, you know, because most people who have functional hearing loss, most people have super threshold listening disorders. Most patients who have subclinical hearing loss, most of them would benefit tremendously from an improved signal to noise ratio. And, you know, you're not even given the opportunity to try that if you're opposed to amplification. Now, everybody doesn't need premium hearing aids. You know, they just don't. You can get really, really good mid-level hearing aids that can improve the signal to noise ratio by two or three or four dB. And if you add an FM system or a digital remote mic to one of those, you improve the signal to noise ratio by 12 to 15 dB, which is way beyond what any hearing aid can do. And so, you know, when we talk about premium hearing aids, there's a time and a place for them. I'm not opposed to them. I think some of them are quite good. And I endorse some of them at the right time and the right place. But does everybody need that? No, they don't. OTCs, you know, listen, there are certainly some good OTCs, but the better ones are like 500, 700 US dollars. Why don't you just get a mid-level or an inexpensive hearing aid fitted by a professional with a warranty, with hearing tests, with the hearing aids program, with a two or three-year warranty? I don't understand people saying, oh, I'm going to get an over-the-counter hearing aid because it's only $700. Well, and if you buy two, that's 1,400. And I will just bet you that in most of your offices for $2,000, you can get two very inexpensive hearing aids with professional advice, warranties, counseling, retests, programming, all that stuff included. So, you know, I've never been opposed to OTC. I'm not opposed to it now. But I think, and maybe there's a time and a place. But for me, the single biggest thing is, you know, what we teach in med school, every class, you know, diagnosis first, treatment second. And when people just go out and treat hearing loss, well, to them it's hearing loss, but it might be, you know, a listening disorder or a functional disorder, just like 26 million Americans have. So for people to go out and spend any money at all on an OTC without an appropriate diagnosis, I think is a misstep. Now it's legal. I know the FDA approves it. Well, I don't approve of what the FDA did there. I still think that everybody should see a professional first and that they should then, you know, with their professional counselor, whether it's an audiologist, an ENT, a hearing aid dispenser, then they can decide what the appropriate, you know, pathway is after they have a diagnosis. But as a doctor of audiology, as a licensed healthcare professional, you know, I feel the same with glasses. For 15 or 20 years, I wore cheaters, but before I wore cheaters, I went to an optometrist and I got a diagnosis to make sure that everything was okie-dokie. It turns out it was, you know, I just couldn't see. But, you know, so then I had cheaters for many years and now I've advanced to a much better quality glasses, but I don't mind people getting cheaters after they have a diagnosis. See an optometrist first. You might have, you know, a million things going on with your eyes that you just see as vision loss because you're not an optometrist or an ophthalmologist, same with hearing. Anyway, this is another one of those papers I think you should download. I think you should keep it in your computer. Jeff Danhower and I wrote this one. This is amplification for adults with hearing difficulty, speech and noise problems, and normal thresholds. But the big difference here, this one's about 17,000 words, take you a half an hour to read it. And this is published in Hearing Review, so very easily accessible. This one is a peer review. This is in the Journal of Otolaryngology ENT Research. And the reason Jeff and I published it there was we wanted when an ENT or a physician is in Google Scholar or PubMed or the peer-reviewed libraries that are free, that if they put in speech and noise problems, normal hearing, this paper pops up. So that's why we bothered to do peer review. This is kind of the whole idea. This is something that Carol Flexer and I published in 2011. Those of you who don't know Carol, not only is she a brilliant pediatric audiologist, past president of the American Academy of Audiology and a professor emeritus at the University of Ohio at Akron in communication disorders. So she and I published this idea 12 years ago. Listening is where hearing meets brain. And when you think about it, that's the essence of speech and noise problems. You must perceive it. It's got to be audible. You have to hear it, but that's not enough. You have to have a brain that can process it. So this idea of listening is where hearing meets brain. It's kind of the whole thing. Now, with regard to cognitive disorders and cognitive screenings and stuff like that, not a new area in audiology at all in 1949, for those of you keeping score, that's even before I was born. In 1949, Dr. Michael Buss published in the Asher publication, the Journal of Speech and Hearing Disorders. He said a problem in differential diagnosis is determining how much of a communicative disorder, a hearing or listening disorder is due to hearing and how much is due to other factors. So this is 74 years ago. And Michael Buss was talking about, when people complain that they can't understand speech and noise, they can't remember what somebody just told them, they're not sure what somebody just said, some of that could be hearing, some of that could be listening, and most likely it is. But how do you know something else isn't involved? Diagnosis first, treatment second. So Michael Buss was making this argument that when you are practicing audiology, you have to lean on psychology, psychiatry, and education to come up with the right answer. It's a brilliant paper. It's a very quick read. If you Google it, you'll find it. I think it's Helmer, H-E-L-M-E-R is his first name, Helmer Michael Buss, 1949. So I mentioned Dr. Krikos a little while ago, and she published in the peer-reviewed literature back in 2006 in Trends and Amplification, age-related changes in cognition does impact speech perception in older folks. Simply testing their peripheral hearing is not sufficient. Let me say that again about 85 more times. Simply testing their peripheral hearing is not sufficient because the source of their problem may be a combination of cognitive and auditory processing impairments. Who else said that? 1949, Dr. Helmer Michael Buss, yeah. For older folks, performance on auditory processing was more related to differences in their cognitive function rather than their auditory function. And that comes from the work by Larry Humes. Larry and I have done a couple of papers together back in 2015 and a couple of panels together in the AAA back then. And Larry's work on this stuff is really stellar. And this is the idea that for people in their 60s, 70s, 80s, 90s, their performance on speech and noise and other auditory processing has more to do with their cognitive function rather than auditory function. And that's just a take-home lesson that you gotta learn right now. Dr. Krikos went on to say, symptoms of hearing loss and cognitive decline are the same. It might be similar, it might overlap. Neither hearing loss or cognitive decline is a silo. You can certainly have a mild to moderate sensory neurohypertensive loss and a mild cognitive impairment. And many people do. I'll go over the numbers with you in a bit. These symptoms may occur together or in isolation. And hearing and listening problems may and often do parade as cognitive problems and vice versa, often leading to an incorrect diagnosis and inappropriate or no treatment. So when somebody is complaining mild, moderate sensory neurohyperventilating loss, you're looking for that. And the primary chief complaint is speech and noise and you don't find a mild to moderate sensory loss, you're not done. You know, if you're an IHS member, the best practice model says, keep looking because there's probably something there, but you know, you can't find what you don't look for. And that's why that best practice statement just kicks butt. It's a really good statement. You should read it and you can get it for free. You can go to the International Hearing Society website and go into the best practice statement. And it was up to, I think the last update was about 18 months ago, maybe 24 months ago. Didn't change in substance, changed in some specific recommendations, but you should definitely have a copy of that and you should work from that when you're seeing patients. Because that's what the true subject matter experts in hearing healthcare recommend that we all should be doing. So why do people seek our help? Well, the single largest complaint, as you've heard me say, and you heard Dr. Brogan say, the single largest complaint that we hear from people is the inability to understand speech and noise. When you go into the literature and you look at my dear friend, Dr. Jason Goldster wrote this in 2018, I guess. The goal of modern hearing aids is not really to make things louder. It's to make things clearer, to improve speech understanding for the rarer. And we all spend a lot of time tweaking hearing aids, adjusting the gain in a channel here or there, changing compression ratios and release times and things like that. Those are important. I'm not saying don't do that. But I'm saying the number one thing you do to make things clearer has very little to do with that. The number one thing you can do is you have to improve the signal to noise ratio. As a matter of fact, Ray Carhart, the founder of audiology, and Dr. Tillman in 1970 said speech and noise testing should be part of the standard test battery. And ASHA agreed, AAA agreed, IHS agreed. But again, only about 15% of us are offering that to our patients, which is why we're missing so much in hearing loss, superthreshold and disorders, functional hearing problems, subclinical. All of them can be recognized if only we do the work. In JAAA back in 2011, Rich Wilson did this very famous study on 3,430 veterans in the U.S. And he said pretty simply, speech and quiet doesn't tell you anything about speech and noise. When you're doing word recognition scores, NU6 and CIDW22, stuff like that, and the ENT or somebody else in the clinic looks at it and says, oh, 100%, well, you should be doing better. And then we give these three little sage pieces of advice, right? We say, sit closer, better lighting, and pay more attention. Are you kidding me? You know, that's usually what happens after diagnostics, but before listening and communication assessment, because if you had done that other work, you would know they have a substantial problem. And it's not about sitting closer and it's not about giving them more auditory deprivation for another year while you're hoping they develop some hearing loss so you might be able to find it. Wrong way to do it. It's absolutely wrong. What you should be doing, have I said that I mentioned this? You should be doing best practices every patient, every time. And then, you know, we'd start to figure out who's who and what's what and exactly where their deficit is. Because it's probably not for many people that they need things louder. They need things clearer. And that is based on a speech and noise score. Anyway, so speech and quiet does not predict speech and noise. You can't say, oh, I have 100% of the TDAH39s are inserts, so he should be doing fine. He's just not trying. That's all baloney. That's all baloney. Those of us in hearing healthcare for a couple of decades who are, you know, doing the peer-reviewed articles, who are working for IHS, who are doing the subject matter experts, who are, you know, designing and reviewing the peer-reviewed literature and coming up with these recommendations for best practice, what we've decided is that, you know, these people are right. They know what the heck they're talking about. Speech and quiet and speech and noise, different domains of brain function. And what that means is that hearing is perceiving or detecting sound. Listening is making sense of sound. So speech and quiet is really easy. It's just pretty much, you know, say the word went, say the word shoo. Well, that's called parroting. You know why? Because your brain doesn't really have to process it very much. Your brain can just hear that and repeat it. And as a matter of fact, it is so simple that, you know what, a parrot can do it. You go, you know, those of you who have large minor birds or, you know, other giant birds, and you know very well that you could say, I love you a thousand times to your bird and your bird eventually will say, I love you. And it doesn't love you. It doesn't know a thing about that. But, you know, it can parrot it, it can repeat it because it takes very, very little brain. In fact, it's a bird brain that can do that, right? It's not a real sophisticated test. And if you look up test, retest and word recognition scores, they're horrible. It started with Thornton and Rafferty back in 77, 78, in the Journal of the Acoustical Society of America, showing that, you know, you could have 92% in your first year with a mild to moderate loss. And what would be significantly different in the left ear? Well, it'd have to be below about 72%. And you know very well, if you've been in practice 10 years, the patient comes in next week, those scores could flip. And it might be all of a sudden now you have 92 in one ear and 84 in the other. It's a very weak test. It's not a good test. And you have to do it. You know, it's required by many third-party payers, right? It's word rate. And I'm not saying don't do it, but I'm saying give it the appropriate weighting. You know, it's a gross measure of clarity in an idealized situation, under headphones, in a booth, no noise, 30 decibels SL, you know, sensational. Patients don't have those benefits in the real world. They're in noise. The signal-to-noise ratio is often zero to five. There's other distractions in life. And so it doesn't measure, you know, pragmatically what the patient can do. So that's this idea, speech and quiet, and speech and noise, very different domains of auditory function. So if you wanna know how anybody's gonna do in the real world, you have to do a stress test. You have to do a speech and noise test. And it's not predictable at all. Speech and quiet does not predict speech and noise. So, and this was one of my favorites. You know, this is the one that came up in 2019 in ear and hearing by Dr. Shub and colleagues looking at, they looked at 5,000 people, and these are first responders like cops, like firefighters, like EMTs, like air traffic control tower guys and women. And they said this, the audiogram is a relatively insensitive predictor of performance on speech and noise. Yeah, right there, black and white. 5,487 people with hearing critical tasks. The audiogram didn't tell you much about how they do in speech and noise. If you wanna know how they do in speech and noise, you gotta test speech and noise. Harvey Dillon in 2012 points out that as hearing loss increases, the required signal to noise ratio increases. Now, this gets complicated pretty quickly. I'm gonna give you some examples. I'm gonna try and work you through it, but please feel free to look up these references because this is important stuff. So you know that those categories that we use, zero to 25, normal, 26 to 40, mild, 41 to 70, moderate, 71 to 90, severe, 91 and above, profound. Well, those are not scientific categories at all. Those are categories of convenience. They have almost no weight in the real world. They are just simple boxes we use to explain things to patients. They are not scientifically bound, and you know this very well. Somebody with a 23 dB hearing loss is not statistically significantly different from somebody with a 27. But, oh, one's normal, one's mild. Stop that. Those categories are goofy to begin with. But we could do a much better job. One day we'll put together a think tank. Maybe IHS will organize this, and we'll actually figure out realistic categories. The worst is, of course, mild, right? Somebody hears, oh, you have a 38 dB loss. You have a mild loss. So you know they can't hear a squat, right? But they think, oh, it's just mild, right? Horrible categories. We don't do ourselves or the patients any favor with those. But anyway, so as you go from zero to 25, let's presume, knowing full well it's not true, but let's presume that's normal hearing. And let's presume 26 to 40 is mild, 41 to 70 moderate. Let's presume those are true. And let's presume everybody has a perfect brain, which we also know is not true. What Harvey is saying here is that for every 10 dB of hearing loss, you have to improve the signal-to-noise ratio by three dB just to maintain intelligibility. So theoretically, somebody with zero to 25 is normal, but let's pretend they are. So they don't need amplification. We're taking their brains out of the picture. And then we'll say somebody with a 35 dB loss, so they have 10 dB sensation level loss. If zero to 25 is normal, your patients hear at 35, so they have a 10 dB sensation level loss. So what does that mean? That means you have to provide for them another three dB signal-to-noise ratio for them to maintain their unaided intelligibility. That's kind of tricky. Now, most directional and beamformer mics with domes are gonna give you three, two, three, four dB improvement in signal-to-noise ratio. That's about it. That's about it. And so, and even with premiums. And so then what happens is you get somebody with a 45 dB loss. So zero to 25 is normal. Your patient's coming in at a 45 dB loss, so they have about 20 dB of hearing loss. So they need an additional six dB signal-to-noise ratio. Most hearing aids can't get anywhere near that. So what do you do with that patient? Well, that's when you have to start talking about assistive listening devices, right? Pocket talkers, T-coils, loop systems, FM systems, digital remote mic systems. These things are extraordinarily valuable, useful for a patient who needs a better signal-to-noise ratio. And this is why so many of the patients that we see that we fill with premium hearing aids, but with domes, they'll come back and they'll say, well, I did fine in the office with you, but then when I was at dinner with my significant other, I couldn't tell what he or she was saying. So I took the hearing aids out and I heard better. They do that all the time, right? Why would they hear better? Well, they're getting a full 360 degrees of localization cues that they can use to help identify and locate where to focus the brain. They are no longer constrained by your two or three compression ratio, right? So right now, my voice is varying by about 30 decibels. If you were running it through a hearing aid and you set the compression at two to one, that patient is only getting 15 dB. Or if you set it for, good Lord, three to one compression ratio, they're only getting 10 dB difference. You like to have 30, so your brain has more information to operate on, right? And we take that away from patients when we compress sound and we reduce the 360 degrees. And we focus primarily on the directional or the beam former direction or the azimuth. And that's giving us a two or three dB advantage, but your patient needs six, right? So that's a problem. So this is a very important concept to get that Harvey Dillon wrote about over 10 years ago. As hearing loss increases, you have to increase the signal to noise ratio because it's not about making stuff louder. I mean, let's be honest, they can go online and buy an OTC or go to Walmart or Walgreens or whatever they want. They make things louder, but that's pretty much nobody's goal. The goal is almost always to make it clearer and that involves a better signal to noise ratio. This is the original chart that Mead Killian published on this. And this is genius level work. So Mead published this over 20 years ago. This is how it works. These are people with normal hearing. That's the solid line here. And so what you can see is people with normal thresholds need a two dB signal to noise ratio to get half the words correct. So that's pretty straightforward, pretty easy. But people with a mild to moderate loss, that's a huge category, but in general, they need about an eight dB signal to noise ratio to get half the words correct. That is called an SNR50, the signal to noise ratio to get half the words correct. You will hear other people call it SRT50, speech reception threshold to get 50% of the words correct. I don't use SRT50 at all. I think it's a terrible name because we already have an SRT and it just confuses things. So most contemporary authors refer to it as an SNR50, which is what Mead Killian originally called it. And that to me is a very, very useful term. Excuse me. So what I want to do, the goal of a speech and noise test is to get unaided speech and noise score, every patient, every adult patient. They come in, you do your diagnostics, you have a speaker in front, a speaker in back. We'll talk about that in a minute. And you give them words at about 70 dB SPL, and all you're going to vary is the background noise. Again, we'll go into detail in a few minutes. And you want to establish unaided, what is their SNR50? And people with normal thresholds, you're going to see that if the speech is at 70, you can put the background noise at like 68 and they're going to get half the words correct. Pretty easy. But people with a mild to moderate loss, if it's at 70 is your presentation, you go above about 62, which is an 8 dB signal to noise ratio, and they're in trouble, they can't do it. And so that's the essence of speech and noise testing is you want to figure out kind of like a pure tone audiogram, like you're doing Houston Westlake, right? You're going up and down in fives and tens. It's kind of the same idea, but you're doing speech at a stable, comfortable level. Somebody asked Dr. Bergen earlier at what point do you not do a speech and noise test? So here are my rules for the road. When somebody has word recognition less than 50% unaided, you're probably not going to get, you're just going to frustrate the heck out of them by doing a speech and noise test. They have terrible speech and noise problems to begin with. So less than 50%. I might try it, you know, if it's 52% or 48, I might, if it's below 40, I definitely wouldn't because you know, they can't do it. And people with a severe to profound loss, unless it's conductive, I wouldn't do it because it's going to be too challenging, too difficult. And again, there's no point in frustrating and annoying the patient. The people who are mostly interested in speech and noise tests, normal, mild, moderate, moderately severe. Those are the categories. And word recognition, certainly better than 50 and sometimes better than 40. If their speech, if their word recognition score idealized in a booth with TDAs, 39s or inserts is 32%, this isn't going to tell you anything. You already know they're in trouble. So these are, this is a definition that I wrote a couple of years ago. You might want to take a picture of this. If you're new to speech and noise testing, excuse me, these are two examples. So an SNR 50 of five means the listener correctly repeats half the words when the signal to noise ratio is five. So, but it doesn't necessarily have to be a loudness level. In other words, it has to be audible. They have to hear it, but you might be able to do this. We recommend in the test that I wrote that there's no point in testing below 70 dB SPL, which is about 55 HL, because you want it to be essentially conversational. And 70 dB SPL is a little bit loud for conversational, but you want it to be audible. And the challenge shouldn't be hearing it. The challenge is listening to it. The challenge is, can they make sense of it when you're introducing the noise? And in SNR 50 of 12, there's the example there. So assuming that you've taken that photo, I'm going to move on. These are Mead-Killian's categories. And again, absolutely brilliant work from 20 years ago. So people with normal thresholds, you expect them to have a zero to two dB signal to noise ratio loss. People with a mild loss, again, we're talking 26 to 40 dB, you're expecting a three to six dB SNR loss. People with a moderate loss, so 41 to 70, you're expecting a seven to 12 dB SNR loss. And severe or profound, it's going to be greater than 12 dB. So the loudness becomes a secondary concern. The primary concern is the signal to noise ratio. How much louder is the primary signal than the background noise? There's a bunch of tests you can look at. If you look carefully, you'll see these all take about two minutes, three minutes. This is the hearing and noise test, the QuickSend, the BKB, which is the Bramford-Mills, and the words and noise test. So these are all brilliant, absolutely stellar. The one I recommend is free. And it's not really a test, you don't buy anything. It's a protocol. And Dr. Lauren Benitez and I wrote this protocol about four years ago, excuse me, and we published it at the American Academy of Audiology. You can just Google this, a two-minute speech and noise test, and you'll get it. It's free. Or you can go to dugandselbeck.com, or you can go to audiology.org, which is AAA's website. But it's free, and there's nothing to buy. And I'm going to work you through how to do this. It takes two minutes, and it goes something like this. Now, I'm going to go step-by-step. This is the Beck-Benitez speech and noise protocol. At the very end, I'll show you quickly. At the very end, okay, that's when you want to take the picture. Let me work you through to the point of taking one picture, so you don't have to take one other step. And I'll leave it on the last one for a few seconds when we take that picture. In front, about a meter, so you put an X on the floor, you put the patient in a chair on the X, about a meter in front or a yard in front, you're going to put an X on the floor, you're going to put an X behind them, you're going to buy a speaker stand. Oh gosh, you got to spend 29 bucks at Amazon. Yeah, just do that. Get a speaker stand, get a cheap speaker, as long as it's a flat response speaker from about 30, 35, 40 hertz up to about 10,000 or 12,000 hertz, it's fine. You have to match those speakers to the impedance of your audiometer. I know this gets a little technical. Most of them are going to be four or eight ohms. It's pretty straightforward. Look on the back of the audiometer. It's going to say eight ohms or four ohms or whatever. And you want to make sure the speaker is appropriate. And then you do have to have it calibrated. You can't just hook stuff up. So when you have your annual calibration for your audiometer, your sound field system, your impedance audiometer, whatever, you need to have this calibrated professionally. You can spot check it with your phone. If you have an iPhone, you can go to the app store and you can just look up free sound pressure meter, sound level meter. And if you go to the Play Store, whatever it is in Google Play or something like that, you do the same. You just put in free, the first word you put in, free sound level meter. It's not going to be accurate enough to calibrate, but it's good enough to spot check it so that when you turn it on with every patient, you can just turn your phone on and make sure, oh, this should be 70. Oh yeah, 69.5, pretty good. But if it's 51, you're in trouble. So you have the primary talker is in front. Now, people will immediately say, oh, but speech in the front, noise in the back. That's not realistic. No, it's not. It's the best we can do clinically, not realistic. You could, like some sophisticated labs do around the world, have a speaker every 10 degrees, right? You could have 36 speakers around the patient and you could do a couple of minutes worth of work after it's calibrated and then you have to recalibrate. And so you're never going to have totally realistic, not going to happen. So what we generally do is we have speech in front, noise in back. Can you have a speaker in front left, front right? Not a good idea. No, you want the brain to have to separate where the sound is coming from and focus on the specifics. If you read the paper that I just shared with you, the one by Beck and Benitez, if you get this paper, we go into all of the rationales. But all of these speech tests basically are doing speech in front, noise in back. And there's a reason. It's clinically pragmatic. It's efficient. Is it perfect? No, no, it's not at all perfect, but it's the best we can do clinically in a two or three minute test. So what we do here is we're going to have a speech in front and we're going to start that at about 70 dB with normal, mild, moderate, or moderately severe loss. And if 70 dB is not loud enough, you go to MCL or maybe MCL plus five, so that you're sure it's normal. In the back, the rear speaker is at 55 dB. So that's a 15 dB signal to noise ratio. So going back to Mead-Killian's guidelines, people with normal thresholds need two or three. You're giving them 15. So that's going to be easy. People with mild to moderate loss need eight. You're giving them 15. So that's going to be easy. You're giving them three words, recorded, digitized. Say the word went. Say the word shoe. Say the word thought. They get all three right. You know what you do? Because it's going to be real easy because that's 15 dB SNR. So now you're just going to crank up the rear speaker five dB. So now the front speaker stays the same. You never change that. The back one is 60. So now it's a 10 dB SNR. Again, you gave three words. You're going to give three more words. Easy peasy. They're going to get it because most of them have a mild to moderate loss. They need eight. But now, so you've done three words, three words. Now, by the time you get done with nine words, you know, with the next set of three words, most of your patients are going to have difficulty because that's only an SNR of five. And people with mild to moderate loss generally need eight. Yeah. So what do you do now? Well, Hughes and Westlake, now what you're going to do, if they don't get it right, you're going to make it easier. Maybe you go down to 63 and you're just going to bracket just like you do with pure tones. Now, at this point, you've only given nine words. And then once you find their pain point where they can't perform, if this is the example, you're going to go five dB steps and then three dB steps and then two and then one. And then you repeat the last one to make sure it's correct. That's it. So this is a good time to take a picture. So what you're doing is you're keeping the speech at a constant level and you're varying the background and you're finding that point where they get two out of three correct. And if you make it a little bit more difficult, they can't do it. That's their SNR 50. So whatever it is, unaided, when they're wearing their hearing aids, they should do better. If they're not doing better, you made stuff louder, but you didn't make it clearer. And this is a particularly useful knowledge when you have people with OTC hearing aids, right? Since they don't have a diagnosis, they don't have a treatment plan. They don't have a professional looking at their situation. I would tell them, bring in your OTCs and you test them aided with their OTC and unaided. And I'll bet you a lot of them do worse with OTCs that are not professionally fitted. Some will do okay. I'm not saying they're all bad. They're not. Some of the very expensive ones are probably pretty darn good. But most patients aren't buying those. They're buying the cheap stuff, right? That's why they went to OTC to begin with. Because I never bought that whole affordability and access thing. I thought that was silly. Excuse me one second. And there are peer reviewed papers that said it was never about affordability and access. I know the FDA said it was. Again, I disagree. When you go to the paper by Mike Valente and Amin I think it was 2017, they pointed out that in places where hearing aids are free, the EU, the UK, Scandinavia, Canada, for some people, New Zealand, Australia, the uptake is about 40% where people with hearing loss will get hearing aids supplied by the government. In the U.S., the most expensive place to buy hearing aids in the world, it's about 30, 32%. It's not like it's day and night. Oh, if they're free, everybody wants them. No, they don't. Still, two-thirds don't. Even in places where it's government assisted for those, 60% of people say, oh, it's free. Yeah, I don't want that. And access, right? Access is a killer. They would say the argument was, well, you can't get hearing aids in enough places. It's really hard to find a place to buy them. I don't know. But if you look on your smartphone, you put in hearing aids, you'll find 1 million plus places to buy them online. And you know what? That was true before the OTC law came into play. Gary Rosenblum and I wrote an article on this. I think it was 2019. And we pointed out that at that time, at that time in 2019, there were about 12 to 15,000 hearing aid centers, speech and hearing clinics, hospitals, ENT offices, places where you could buy hearing aids before OTC. No, there were 20,000. I'm sorry. 20,000. And then the question we asked, you know how many hospitals there are? There was only 8,000 hospitals. So there's almost two and a half times as many places to buy hearing aids as you needed to go for emergency medical care. And now, right, access and affordability. I mean, you could, back then, even in 2010, you could go to Walmart.com and buy hearing aids for $99. That's it. And, oh, we don't have enough access. Yeah, because there aren't enough Walmarts, right? Yeah, sure. Okay. So I'm a little bit disturbed about how that whole thing went down. I'm not opposed to it. But I don't think it was ever very well scientifically founded or really well explained to anybody as to why we're doing this, other than political nonsense. That's what I think it was about. Just my own personal opinion. So anyway, Flexer et al., 2014, said, performance with technology actually determines the functional outcome. When people say all hearing aids are the same, that generally means they haven't read the peer-reviewed literature on hearing aids. If you read Ear and Hearing or JAAA or you read, you know, any of the ASHA publications or the International Journal of Audiology, every one of those, every edition of their hearing aid study is showing vast differences among hearing aids. That whole line of thought that, oh, it doesn't matter which one you get, that's just totally wrong. Totally wrong. So let's talk a little bit about dementia. So, you know, in hearing loss, here are the numbers. By the time you're age 65, CRI, about four more hours, right? Just making sure. So by the time you're age 65 in the USA, I know I'm finishing in less than half an hour. In the USA, by age 65, about one-third of all people have hearing loss on an audiogram. 26 million people have no hearing loss on an audiogram in the USA, but they have functional or super-threshold listening disorders. By the time you're 75 years of age in the USA, about two-thirds of all Americans will have hearing loss on an audiogram. Well, mild cognitive impairment, that's when somebody has difficulty remembering things. They don't have dementia. MCI is the stage between normal healthy aging and dementia. MCI is right in the middle there. And 22% of Americans over age 65 have mild cognitive impairment. You may say, oh, that can't be. That's ridiculously high. Well, JAMA, Journal of the American Medical Association, November 2022, says 22% of Americans over age 65 have mild cognitive impairment. That's one out of five people. And those people will complain, as Dr. Krikos mentioned, speech and noise. Can't remember what somebody just said. Not sure that I heard that correctly. Hearing difficulty, speech and noise problems, things like that. It could be mild cognitive impairment. It could be hearing loss. It could be listening disorders. We don't know if we don't test. Diagnosis first, treatment second. Dementia is a very different thing. Dementia is when things have really gotten bad. And if you go to the American Alzheimer's Association, you'll see that Alzheimer's is one of about 200 different types of major neurocognitive disorders. Alzheimer's for people over age 80 to 85 in the USA is one out of three people. And Alzheimer's is very devastating. It takes about 20 to 25 years from the time you get cellular changes in your biology, in your own genome, until it manifests. So when people have a diagnosis of Alzheimer's, it was about 20 or 25 years before that when things started to change in their brain at the cellular level. Often with Alzheimer's, you'll find patients who have high levels of amyloid plaques and tau proteins and things like that. But those aren't a one-to-one relationship. Somebody can have very high levels of amyloid and not have any signs of dementia. But they are biomarkers, and they are important. Because when we see those on fMRIs, or we see those in blood tests, or we see those in medical reports that they have a lot of amyloid and tau proteins, we start to become very suspicious, and particularly if it's APO4, which is a legal genetic protein marker. So Alzheimer's is two-thirds of all major neurocognitive disorders. When somebody has dementia, two-thirds of those would be Alzheimer's. The other third are primarily four or five different diagnoses. Again, there's 200, but Alzheimer's is two-thirds of all of them. And then you have things like Lewy body disorders. You have vascular dementias. You have Parkinson's with dementia. You have all of those types of things, and those are roughly a third. Now, what's the difference then between mild cognitive impairment, which you see here, and dementia, which would be Alzheimer's, Lewy body disorders, vascular disorders, Parkinson's with dementia, frontotemporal disorders? What's the difference? Well, ADLs, activities of daily living. You see, the important thing is that if you catch mild cognitive impairment and you refer for that because you've done a cognitive screening and you've noticed this patient performed non-normatively, the chance of changing it is reasonable. There was a paper in 2020 by Gil Livingston and colleagues in The Lancet, which is the world's premier medical journal, showing on the topic of dementia, right, your dementia risk, 60% of that is due to your age and your deoxyribonucleic acids, your DNA. But 40% of your risk is due to 12 potentially modifiable risk factors. Those risk factors of all of them, the number one in 2020 was hearing loss at 8.2% PAF, which is the population of triggered poor factor. So when you take that in proper perspective, you might argue that about 91% of your risk for dementia has really nothing to do with hearing loss. And we need to keep that in mind. It's very substantial. It's the largest potentially modifiable risk factor, but simply having hearing loss does not mean you're going to have dementia. And that whole train of thought is just important, but keep it in perspective. 91% of dementias, not because of hearing loss. So ADL, activities of daily living, these are, when you report to your physician, and this is generally true, not always true, but you say, well, do you, mom is having difficulty with memory. You know, what you're going to hear often is, oh, that comes with aging. Everybody goes through that, blah, blah. And it's wrong. It's wrong. The right answer is, well, you know, that could be a sign of mild cognitive impairment. Let's investigate. Diagnosis first, treatment second. And if we investigate through a cognitive screening, some people are going to perform non-normatively. If you have a non-normative finding on a cognitive screening, the best thing is refer back to the GP, the internal medicine doctor, family practitioner, or whoever sent the patient to you and say, you know, here are the hearing test results. Oh, he has hearing loss. We're going to address that through hearing aids, starting a 30-day trial, blah, blah, blah. However, as you know, because Mr. Smith is above age 70, we did a cognitive screening because cognitive screenings and cognitive disorders and hearing and listening disorders often mimic each other. By the way, here's a paper by Dr. Beck and colleagues. And here's a peer-reviewed version from the Journal of Otolaryngology ENT Research. And here's Dr. Krikos' work on this, right? Because they're not going to, they won't know any of this stuff unless, you know, they study this stuff, which most don't. They're not going to be familiar with the fact that these are well-known comorbidities. And so you send them those papers. You tell them, hey, we did a cognitive screening. They didn't perform normally. So we are referring to you for further guidance. Now, the wise physician will make a decision and will say, you know, I'm not really concerned about it in this patient, given the rest of their medical history and all these other things that I know about the patient. Cool. Or they may say, you know, I'm glad you flagged that because we're going to order a neuropsych battery, you know, a diagnostic test, because screenings aren't diagnostic. It's no more, no more diagnostic than a hearing screening. You know, you fail a hearing screening, you go get a diagnostic test. That's the same with cognitive screening, failing cognitive screening. And somebody asked earlier in the first session, you know, how do you handle that in a way that's not traumatic for the patient? And what I do is I only talk about it in terms of information processing. I've never told a patient we're going to do a cognitive screening. What I say, because I'm an audiologist, is, you know, we're going to do a screening that tells me how you process information, tells me how you remember things, how you prioritize things, how you organize things. I never say, this is how your brain works. Oh, my gosh, I would never say that. I would never say, gee, your brain is working really hard. Never. Don't even talk about their brain. Talk about information processing. You might want to talk about auditory processing. It depends, you know, on if you're trained to do that. You know, Dr. Brogan is trained to do that. I'm trained to do that. You know, my, one of my three mentors in life was Jack Katz, who, you know, in auditory processing disorders is the guru. And I love Jack. He's brilliant. What kindest man you've ever met. But, so I talk about it in terms, I steal this from Jack. Jack wrote this in the early 60s. He was talking about auditory processing disorders. And he said, APD is what you do with what you hear, right? How your brain acts on what your brain is perceived. And I like that a lot. I use that to describe super threshold listening disorders or functional listening disorders or functional hearing loss or subclinical hearing loss. What you do with what you hear. And Jack, massive kudos for thinking that through. And again, he applied it to APD. I apply it to super threshold listening disorders. Maybe I'm wrong, but I do it. So this is the original Lancet article in 2020. These are the 12 modifiable risk factors, which make up potentially 40% of your risk for dementia. So if these are all managed well, you potentially change the trajectory for the patient. And you and I are not going to be experts in air pollution, perhaps, or diabetes or depression or hypertension. But the point is that the people who have less education are at higher risk for dementia. The people who have uncontrolled hypertension, higher risk. People who smoke, higher risk. People who are depressed, higher risk. You get the idea. But the most important out of all of them was hearing impairment at an 8.2% population attributable factor. And the authors in the Lancet pointed out that lifelong education reduces the risk of dementia. And it's most important to have a good childhood education, which is why I guess part of my title for this talk was brain health. And the bottom line on brain health is that everything good for your heart is good for your brain. And there's no shortcuts. It's not OK to eat garbage food. It's not. I mean, you could do it. That's on you. You get to eat whatever you want. Frankly, unless I know you personally, it's not a big deal in my life. But your heart will respond to cholesterol and triglycerides and all of these things and diabetes. And they lead to other comorbid issues. I mean, the number one issue in the USA is obesity. And that's a real problem because it often leads to diabetes and higher blood pressure and all these other things. And so everything good for your heart is good for your brain. And I'm not going to sit up here and tell you what to do with your life. You get to do whatever you want. But if you're asking for recommendations, exercise every single day. Eat healthy foods. Don't eat a lot of garbage foods because you are what you eat and your body keeps score. So that's all I'm going to say. I'm not preaching. I'm just telling you that with regard to brain health, that's a good way to understand that what you're doing is good for your brain. If it's good for your heart, it's good for your brain. Then in 2022, the Journal of the American Medical Association published new guidelines on modifiable risk factors. And you know what they said? In 2022, the single largest risk factor for dementia is midlife obesity. And they said physical inactivity and low education. So this shouldn't be a surprise because all of these were identified by Livingston and colleagues in 2020. The difference is that Neonago and colleagues looked at 378,000 people. So this is a much larger pool of participants in the data collection. And so we've seen this over and over that obesity is just really damaging, potentially damaging for cognitive health. This is a Mayo Clinic study just came out about six months ago. They looked at 1,200 people over age 79, half male, half female. They followed them for seven years and 207 developed dementia. So that's interesting, right? Over seven years. So that's about 17 or 18% of these people over age 79 developed dementia, which you would expect because I told you that by 80 to 85, about a third of Americans actually have Alzheimer's. And what they found is that when the loved one, a subjective informant like a loved one, a mother, father, sister, brother, girlfriend, boyfriend, carer, when they say to the doctor, gee, there's something wrong, there's almost always something wrong. And that was actually more significant than their cognitive screening tests. Because they're screeners, they're benign, they take five, 10 minutes, and they're really important. But what was even more accurate than that was a loved one saying, he's having difficulty. Does amplification matter? Does it impact cognition? Does it change the trajectory? There's a very famous study from 2015, over 3,000 people. And Dr. Amiva looked at them over 25 years with a cognitive screener called the MMSE, the Mini Mental State Exam. And these people all self-elected, right? So 1,276 said they had hearing loss out of 3,600. So that's about a third. 2,400 said they had no hearing loss. So of the 1,276, some of them got hearing aids, some didn't. And they watched them with the Mini Mental State Exam for 25 years. So the people who self-reported hearing loss had a lower baseline Mini Mental State Exam. They went into the study with a worse cognitive screening score. And they declined more rapidly over the 25 years, more significantly and more rapidly. And the people who wore hearing aids, they looked just like the normal controls. Does that mean hearing aids stop or slow down? Nope, doesn't. These are averages for a large group. That's very, very little to do with one specific patient. Conclusion. Now this is Dr. Amiva eight years ago from Bordeaux, France. self-reported hearing loss is associated with accelerated cognitive decline in older adults, and hearing aid use attenuates or reduces that decline. So she didn't say causes, she said it's associated with, and I would say she's right. This is a brand new study from Johns Hopkins, came out January 10th, 2023, 2,400 people, 80 years and older. The prevalence of dementia among people with moderate to severe hearing loss was 61% higher than people who had normal hearing. And the hearing aid use was associated with about a one-third lower prevalence of dementia in people with moderate to severe hearing loss. So these, you know, I'm not showing you all the studies from the last 20 years, I'm just showing you the most recent because they're pretty revealing. This is Dr. Gaeta's work, and this is 2022. Hearing loss negatively affects cognitive screening test measures. So if somebody has substantial hearing loss, you would expect they're not gonna do well on a cognitive screening. Doesn't mean that they have cognitive decline. It could well mean that their hearing and listening disorder is interrupting their ability to perceive and understand the test. And by the way, the person giving the test, they might have, you know, an undiagnosed mild cognitive impairment as well, or hearing loss. And so there's problems with the pencil and paper test that you're depending on the person giving the test to have normal hearing and normal cognitive ability, as well as the person taking the test. That's a problem. There are some, I'm not gonna do a commercial, but I'll tell you that the company I work for, Cognivue, does make a screener. It's the only words I'll say, you know, is the Cognivue Thrive, that the patient can take the test electronically, no auditory cues necessary. So that's really good for people with hearing loss because they can take this test in five or 10 minutes. It's on the screen. They move a little wheel around and they get a score on their memory, on their executive function, and on spatial relationships, visual spatial relationships. And that will be pass or fail. And, you know, if there's a non-normative result, I'm not gonna rescreen them and I'm not gonna put hearing aids on them and rescreen them. It doesn't make any sense. Hearing aids will provide more sensory information. Of course, the patient should do better, but that's not a cognitive change. That's a sensory change. You made it so they can hear. If we're lucky, you made it so they can listen better because you've improved their signal-to-noise ratio. So doing a cognitive screening a month or two months later, nobody recommends that. Mocha doesn't recommend that. Cognivue doesn't recommend that. MMSC doesn't. Nobody says do that. People do it, but they do it, I think, more as a sales tool. And I'm sort of opposed to that. I don't think it's a good idea. I think if somebody fails a screening, you should refer. That's the professional correct thing to do. And then it's like, if you failed a hearing screening, are you gonna rescreen them after they get hearing aids? No, no. You're gonna, you know, you went on, you did a diagnostic eval, you treated it, and then you have your outcomes measures. So, you know, listen, hearing, you know, treating their hearing loss may indeed, over the long-term, give them a cognitive benefit. That makes sense to me. You're not gonna see that in a month or two. You're not gonna see that in three months. Those are, what you've done in that period of time is you've reduced their auditory deprivation. They should be doing better in a world where they can better understand speech sounds. They should respond better. But to me, that's not necessarily a cognitive change. And you have no way to know that without doing a cognitive diagnostic test through a neuropsychologist, psychologist, psychiatrist, a social worker who might do that sort of thing. But you and I don't do diagnostic tests. So to say, oh, look, they're doing better. So it must be the hearing aids that's changed their cognitive ability. That's not a really logical conclusion in my mind. What you should have done is improve them because you're providing better, more comprehensive auditory cues so their brain has much more information to work with so they can do a better job comprehending the world. Anyway, so this is Cognitive Screening Test Scores by Dr. Gaeta. And she pointed out that almost anything you do, she compared hearing aids to assistive listening devices. You know what happened? All the patients did better, even with a pocket doctor. So, you know, of course they did better because now they have a much better auditory signal so they can function better. The National Council on Aging back in 1999 did a study about 2000 people aided, 2000 unaided, right? And the people who were aided, lower depression, lower anxiety, lower stress. And the hearing aids weren't a stress reduction tool. The patient was better able to participate in their life. So their anxiety went down, their stress went down, their depression went down because they could better perform because now they had a complete auditory signal to deal with, just my own interpretation. David Pozzoni, my pal in Indiana, wrote a book on this called The Handbook of Speech Perception in 2021. And in 2023, he did an article in the January, 2023 Hearing Review on information processing and cognitive ability. And I'd recommend, go to hearingreview.com, look up Pozzoni and Herbert. Herbert is the first author, he's an audiologist. And you'll see the information processing approach to cognition says that information processing takes time, has capacity limits, but the most important problems that you and I might discover through an appropriate cognitive screening are memory and attention problems. And if you wanna use other screeners, that's on you. They take longer, they don't necessarily spit out a report, you have to interpret stuff. I like having everything automated. I like the patient sitting down on the computer, the computer spits out a report, you send that to the physician and that's it. It makes good sense. Look into that, see what you can find. Why does this matter to us? Because the primary reason that people come to see us is they can't understand speech and noise. And the question then is how do you know if it's auditory or non-auditory or both, which is what Dr. Michaelbus was talking about in 1949. All right, so, and there's lots of audiology papers that have looked at this over the years. This is 2016, this is Dr. Erhardt and Pam Souza looking at this and saying that audiologists should train and recognize abnormalities in older clients' cognitive status so we can provide timely referral to optimize outcomes. And Brian Taylor pointed out in 2022, the link between hearing loss and cognitive decline may begin when their hearing is within the normal range, which is exactly what we said in these two papers, right, this one in 2018 and this one in 2019. I showed these two earlier. There are guidelines on how to program hearing aids for people who have neurocognitive disorders. I don't have time today to go into this. Perhaps IHS Canada will schedule another session. We should spend an hour on this topic. If you're interested, please mention to your governors yes, I'd like to do that or not want to do this paper with you. But this is the only paper I've ever seen and it's peer-reviewed based on 129 audiologists in Holland who work with people with neurocognitive disorders and mild cognitive impairment, saying these are the specific concerns and considerations for how to program these hearing aids. And again, it's a one-hour lecture. I'd be happy to do it with you, for you, together with you, but we don't have time today. But you should know this paper exists. Take a picture of it. And you can find this at ASHA, the American Speech Language Learning Association. Again, I'm not going to go through it because of time constraints. And the last thing I want to say about speech and noise, back in 2014, Dave Moore, Pierce Dawes, Kevin Monroe, these guys are all pals of mine that we've been hanging out for years, but they wrote this paper in 2014, saying that people who had a bad speech and noise score, that might be a first warning of a need for intervention. This is peer-reviewed, 2014. Keep that in mind when I tell you the next paper come out in 2022. Oh, well, this is why I wrote it, I'm not going to go through that one. In 2022, Dr. Stevenson and colleagues were looking at speech and noise based on the UK United Kingdom Biobank study, 82,000 people. And they said that people who had bad speech and noise scores over the course of about 10 years had a hazard ratio of 61% for developing dementia. Now, let me explain, a hazard ratio does not mean you're going to get dementia. A hazard ratio says you have 82,000 people, you're observing them for 10 years, and at the end of that 10-year period, the people with the worst speech and noise score had a 61% chance of developing dementia. So a hazard ratio is not a guarantee, and it's not a fixed fraction, it's over a period of time, but the authors report speech and noise hearing impairment is independently associated with incident dementia. In a brand new paper that's being published, I think this week or next week in the hearing review, Carol Flexer and Ron Wohlworth and myself, we talk about this in depth, and we wonder, instead of measuring hearing on all of these studies that look at hearing loss versus dementia, had we measured listening, we probably would have found a much higher correlation, not that it's not high enough to begin with, it is, but it might've been higher if we looked at functional measures rather than pure chance. Speech and noise is definitely not a surrogate for cognitive screening, you have to do both, my opinion. Cognitive screening, not a surrogate for speech and noise, you have to do both. Hazard ratio, for those of you interested, take this picture and it explains what a hazard ratio is, so hazard ratio of 0.5, half as many people in the treatment group experience an event. 1.0, that means all people will experience an event. And again, the Stevenson 2022 Biobank study said people with bad speech and noise over a 10 to 12 year period of time had about a 0.61% hazard ratio, so pretty substantial. Cognitive screeners, there's a bunch of them. I would just say, take this picture if you wanna know a little bit about them. And this is very useful because everybody's not gonna wind up with the same one, much like hearing aids or audiometers or impedance audiometers, you know, investigate, see which ones you think are the most efficient, the quickest, the most accurate, that's the one you wanna use. These are some of my recent publications over the last two or three years. Again, we don't have time to go into detail, but just take a photo of that, click, and there's a couple of more articles that I wrote. This one's particularly important, I think, for hearing aid dispensers, and it's about turf wars. And I published it in the hearing review. So you might wanna get a copy of this one. This is the Astro Leader. This is the one where I wrote that 5,000 word article about why I don't think it's appropriate to screen adults for health and comprehensive audiometric evaluations. And this is one I just published in January of 2023 on cognition and audition. So final thoughts. You should read, you should train, you should do CEUs. You know, MOCA training is brilliant, and they recommend at least two hours. If you're gonna do a Cognivue Thrive screening, cognitive screening, I recommend at least eight to 10 hours of training. That includes the session we're doing now, that's a one hour training, but you need to take more CEUs, you need to attend workshops, you need to practice, you need to learn, it's not see one, do one. And to really be appropriate for your patients, you're never gonna say these words, you failed a cognitive screening. That is scary, and that is dramatic, and you change their life, and you get in trouble real fast. It's scary, it's intense, it's dangerous, and you cannot undo it. Now, there are some people who say that. I have a very dear friend, Dr. Keith Darrow up in Boston. Keith is a PhD neuroscientist, and he's an audiologist. So he approaches this differently. And I think with his expertise, one can approach it differently. I generally say to most dispensers and most audiologists, the most comfortable way for me to do it is to talk about information processing, because screenings are not diagnostic, they are not standalone, and a failed screening, which I referred to earlier as non-normative, should be referred. You're still gonna take care of the patient for their hearing and listening disorders, but refer them so that there's a 40% potential probability that somebody identified early might get benefit. When you wait till somebody has full-blown dementia, there's really not much we can do. The new drugs are great. They also don't help the majority of patients. We can talk about that some other time. So I like to say things like, this information processing screening helps me understand how you process information, how you attend, how you organize, how you prioritize, how you remember things. And we worked really hard to do that speech and noise test. So we'll send the results to your doctor and we'll see what he or she thinks. So I'm gonna end it there, but I am hopeful there are some questions. I'm free for the next four or five hours, so I can stick around if we have questions. If not, I'm gonna pour a vodka. But Sierra, welcome back. Okay, so as you said, we'll go ahead and take some questions. So first question here, Doug, is from somebody, Sandra, who's wondering, what, if anything, should we be telling our patients about that link between hearing loss and cognitive decline? And what are the appropriate words to say? What is the appropriate message to deliver? You know, and great question, and it varies with who your patient is. You know, I wouldn't say the exact same thing to a PhD electrical engineer that I would say to other patients. But I think you're fair saying things like this. There are well-known secondary impacts that hearing loss has. Untreated hearing loss has been shown to exacerbate cognitive decline. What we do in our clinic is we try to identify people who are at risk, and, you know, we'll try a trial and see if you're doing better, if you feel more comfortable, if maybe you're noticing less memory problems, if those things are good, great. So I use that sentence all the time. I've published it probably three or four times. It is well-known that hearing loss has the potential to exacerbate cognitive decline. So we're gonna do a screening to see how you're doing, because we know you have hearing loss, you know, if they do have hearing loss, of course. And if they don't have hearing loss, I'm totally comfortable saying, you know, a lot of people, 26 million people in the US have listening disorders that don't have hearing loss. And so what we wanna do, we're gonna do as IHS recommends, we're going to do a listening and communication assessment, we're gonna do a speech and noise test, and we're gonna also add in a cognitive screener just to see how you're doing with regard to information processing. Are you remembering things? Are you prioritizing things appropriately? And if you are, fantastic. And if not, there's a lot we can do if we catch these things early. So those are the types of things that I would say to a patient but I would not say we're gonna do a cognitive screening to see how your brain works. I absolutely wouldn't say that. I also wouldn't say, and then we'll retest your cognitive screening in eight weeks and see if there's an improvement. It doesn't matter if there is or isn't, it's a screener. It was never diagnostic to begin with. I'm sorry, Sierra, I lost your vocal there. Oh, I'm sorry. I just said we're not using the cognitive screeners to validate or verify our hearing aid fitting. Right. Thank you. Next question, Doug, is from an anonymous attendee who asks, as a hearing care professional, which specific cognitive skills tests are appropriate to be conducted by us, staying within our scope and competence level, and at what point should the hearing care professional recommend a referral? So kind of what's that line? Are the tests or the screeners that you showed us, are those appropriate for hearing care professionals to use? What are your thoughts on that? You know, first of all, you have to always practice within your license, right? And in Canada, you know, you have the different provinces, so you have to make sure that you are acting in accordance with your license as issued by the issuing governmental body. I can't tell you that it's appropriate or not. For instance, and this is very real world, the American Speech Language Hearing Association says that through audiologists, it is within your scope of practice to do cognitive screening. The American Academy of Audiology says the same thing. However, if you are a Canadian audiologist, I don't know what the Canadian Academy of Audiology says about that. I can tell you that AAA certainly says in their April 2023 document that cognitive screening is within the scope and practice of audiology. That doesn't mean that you're licensed to do that, right? You still have to make sure from your state license in the US or your license in Canada that you're allowed to do that. So that's the authority in that. That's not me. That's not any of the people who make the MOCA or the MMSC or the Cognivue. It's your state license that determines what you can do. Number two, are they appropriate? So assuming it is appropriate and that you're allowed to do it and that it makes good sense, then I think any of these screeners will cover executive function and memory. And this is very important because the primary reason people come to see us, right, is they can't understand speech and noise. And that's often reflected in their memory. That's often reflected in their speech and noise scores. Now, the thing you have to know about executive function is that if you're looking at executive function as derived by the MOCA, Montreal Cognitive Assessment, the Mini Mental State Exam, the SLUM, St. Louis University Mental Scale, the Cognivue, they all have a little different formula. It's like if Sierra Sharp were to make a chocolate cake and Nashville Grogan makes a chocolate cake and I make a chocolate cake, you would all be able to taste those and go, oh, that's a chocolate cake. But I can almost guarantee each of the three of us made it from a different recipe, right? So it's important to understand that executive function, when ruled like on a, the MOCA uses, for instance, a 30-point scale, right? The Cognivue Thrive uses 100. So on the MOCA, you might have a difference of one or two, but on the Thrive, that might be four or six because it's a different scale. So you have to always consider these things. And I would use the one that is most intuitive. I would use the one that is easiest. I would use the one that is fast. I would use the one that prints out a report. I would use the one that the patient can self-drive because frankly, so my SNR50 is six. I have no hearing loss, but I am a professional musician and I was in the military and listened to a lot of munitions and all that stuff. So I have no hearing loss, but I need a six dB signal-to-noise ratio to function well. And so if I'm giving you the MOCA, we're all hoping that I understand what it was you said when you're responding, because I'm writing it down and I'm the one scoring you. That's the point, right? So I want to use one that eliminates these potential sources of error. Thank you very much. And last question, Doug, is from Bob. Bob says, I understand that using highly compressed MP3 word recognition score files as opposed to uncompressed files will not affect those WordRec test results. Would you agree that the same holds for speech and noise test files? It's a great question. So anytime you compress any sound, you distort it. And MP3s distort like crazy. Most people will not recognize that an MP3 is more distorted than a CD. A CD or a DVD has about a 90 dB signal-to-noise ratio. It's the best you can buy commercially. There's better studio quality stuff. But when you're playing a CD at home, you have about a 90 dB signal-to-noise ratio. And they really loud, right? So this doesn't happen on an MP3. On an MP3, everything is compressed and your dynamic range varies with, you know, the speed at which it was recorded, the quality with which it was recorded. So Bob's point is very well taken. The best stimuli that you can use, and you're not gonna find it, I don't think you're gonna find it, is a linear recording. So there's no compression whatsoever. And the words float as they do, because right now, if we were in a natural conversation, that would be happening. When you're using the prerecorded WordLess, when it's an NU6, a CIDW22, they are compressed through whatever system you play them through. Does that matter a lot? Well, those tests just aren't that accurate to begin with. So I would use them without too much concern for any of these factors. I really would, because it's a gross estimate of how the patient is doing. And as long as we accept it for what it is, okay. But, you know, Ben Hornsby and Gus Mueller wrote this brilliant article in 2019, where they were looking at NU6 and CIDW22 versus random words from the dictionary, and they found virtually no difference. So, and you know, I'm a big fan of Gus and a big fan of Ben Hornsby, and I think they're right. And it goes exactly to what Thornton and Raffensat said in 77 and 78. Those words, you know, they were never really designed for that. I mean, when you think about monosyllabic words, the reason that that came out of AT&T Bell Labs back in the 40s in Murray Hill, New Jersey, was to decide what was the bandwidth needed on a telephone line to transmit speech. That's what that was about. It wasn't about how clearly you hear, you know, so. Thank you very much, Dov. That is all the time that we have for questions. I appreciate your presentation and your time, as always, Dov, always a pleasure. Thank you so much. It's a joy to work with you, Sarah. Thank you. To our attendees, we are going to go ahead and take an hour break for lunch before we proceed with our afternoon speakers. So join us back here at 2 p.m. Eastern. We will begin at two o'clock sharp. Enjoy your lunch.

Dr. Douglas Beck

hearing abilities

listening abilities

normal hearing sensitivity

listening difficulties

auditory processing disorders

hidden hearing loss

speech and noise testing

signal-to-noise ratio

word recognition scores

speech and noise difficulties

cognitive screening

research and training