to the webinar, Hearing Loss and Dementia, Current Trends and Opportunities. We're so glad that you could be here today to learn more about the most current hearing loss and dementia data and protocols. Your moderators for today are me, Ted Ennis, Senior Marketing Specialist. And me, Fran Vincent, Marketing and Membership Manager. Our expert presenter today is Brian Taylor, AUD. Brian is the Senior Director of Clinical Affairs for Hypersound, as well as a Clinical Audiology Advisor for the Fuel Medical Group. Brian is an Adjunct Professor for Practices, the quarterly journal of the Academy of Doctors of Audiology. In 2015, Brian was appointed Editor of the Hearing News Section of Hearing Healthcare and Technology Matters. He's written four books, including Marketing in an Audiology Practice, and the second edition of Hearing Aid Selection and Fitting. We're very excited to have Brian as our presenter today. But before we get started, we have just a few housekeeping items. Please note that we're recording today's presentation so that we may offer it on demand through the IHS website in the future. This webinar is available for one continuing education credit through the International Hearing Society. We've uploaded the CE quiz to the handout section of the webinar dashboard, and you may download it at any time. You can also find out more about receiving continuing education credit at our website, ihsinfo.org. Click on the webinar banner on the homepage, or choose webinars from the navigation menu. You'll find the CE quiz along with information on how to submit your quiz to IHS for credit. If you'd like a copy of the slideshow from today's presentation, you can download it from the handout section of the webinar dashboard, or access it from the webinar page on the IHS website. Feel free to download the slides now. Tomorrow, you will receive an email with a link to a survey on this webinar. It is brief, and your feedback will help us create valuable content for you moving forward. Today, we'll be covering the following topics. Basic principles of dementia and age-related hearing loss. The interconnectedness of hearing loss and dementia and the underlying mechanisms. The role of dementia in hearing aid use. And then we'll get into clinical implications. At the end, we'll move on to a Q&A session. You can send us a question for Brian at any time by entering your question in the question box on your webinar dashboard, usually located to the top of the right of your webinar screen. We'll take as many questions as we can in the time we have available. Now, I'm gonna turn it over to Brian, who will guide you through today's presentation. Take it away, Brian. Thanks, Ted. It's great to be here. I hope everyone's having a good day. Coming to you from my home office in Minneapolis. And Ted already showed you the agenda, so we're gonna go ahead and get started. Just a note on my disclosures. Ted already mentioned some of the organizations I'm affiliated with. You see those listed here on this slide. And we'll go ahead and get right at it. So the first item on my agenda is to talk about some of the basic principles related to both age-related hearing loss and dementia. And I think it always is important at the beginning to kind of talk about why a topic like this is so timely and so important. And if there's one single reason to talk about this topic, it's really because the population that we see in our practices is rapidly aging. Some people call this the baby boomer effect. Others call it the silver tsunami. But what we do know is that approximately 10,000 people every day in the United States are turning 65. And with that, of course, is an increased likelihood of acquiring a hearing loss. We also know that that population, especially those above the age of 80, is expected to double over the next 30 plus years. And of course, with that comes an increased risk of hearing loss and dementia, two conditions that are intimately related to the aging process. And over the last few years, dementia has been recognized as a significant public health problem. There's an increased likelihood of increase in cost associated with taking care of people with dementia. So as you might imagine, with this increase in the aging population comes this increased possibility in rising costs and other complications. Let's take a look at hearing loss prevalence. We know, of course, that hearing loss is directly related and linked to the aging process. And we know, for example, that significant hearing loss affects almost half of individuals 65 and older. And for those that are over the age of 85, the increase goes up to, in prevalence, 80%. And we know that, from some research that I'll talk about in a little bit, that there's a relationship between hearing loss and cognitive deterioration. One particular study that a lot of people have cited in the literature, I've seen this in marketing pieces, is that cognitive deterioration is equivalent to about seven years of aging. And of course, when you see those kinds of statistics, we need to pay attention to them. Just in the last month or so, one of the medical journals did a nice updated study on prevalence of hearing loss in the oldest old. That's kind of an unusual term. You're seeing that more and more in the literature just because of the rising number of people that live beyond the age of 80 and into their 100s. So you see this increase in the oldest old population, and it helps to have some data when you're making clinical decisions. So in this one particular study that I'm citing, they looked at 647 patients, all between the ages of 80 and 106. And they found that 100% of these patients had a hearing loss, which I guess is not too surprising given their age. One of the interesting things they noted is after the age of 90, the high frequency thresholds on the audiogram had a tendency to plateau. They didn't get any worse. But there was a further deterioration in hearing thresholds for the low frequencies, which I thought was kind of interesting in this study. Another interesting finding in this study was that almost 60% of this population used hearing aids. But an interesting point about this study, it was conducted in a relatively affluent area, which might drive some of the hearing aid use higher than we might expect. Because when I compare the prevalence of hearing loss and the oldest old in this study, when we look at hearing aid use being at 59% for this group, we can compare that to a previous study that was published back in 2012, looking at hearing aid use prevalence as a function of age. And for our purposes, I want to pay attention to the top of this upside down pyramid, the top in blue. And what that tells us is that there are approximately 7.3 million Americans aged 80 and above that have a hearing loss. And of that group, according to this study, just 22% of them use hearing aids. So one study is telling us that 59% of the population is using hearing aids and the other is telling us 22. Either way, whatever data you decide to look at, there's still room for improvement as far as hearing aid use is concerned with this older population. If I look at this study and as I relate it to the findings around dementia, I think one of the things we have to think about as clinicians is how do we increase the use rate of hearing aids in a population that not only suffers from hearing loss, but often suffers from the effects of dementia. So dementia might be one of the reasons that drives the relatively low hearing aid use rate that you see on this slide. So those are kind of an overview of the rapidly aging population, hearing aid use and hearing loss prevalence amongst the older old. Let's talk about another condition that many of them are afflicted with and that is dementia. So let's look at some things that are good to know about dementia. So just some of the very basics here. When somebody wonders what is dementia, the medical definition is shown here on this slide. It's a progressive global impairment in thinking, understanding, learning, and remembering. And a lot of those skills are what are defined as executive functioning, the ability to plan, organize, to use abstract thinking. And when it comes to the diagnosis of dementia, it's really a three-step process. First, either the patient or more often than not, a family member must report to the physician or the nurse that there has been some observation of a significant cognitive decline. Usually it's impaired memory. And then once that report has been given, patients must score lower than, significantly low on a test of dementia. And we'll talk about three commonly used screening tests for dementia. And then finally, once that red flag has been given that they failed a dementia test, then a complete medical workup is often done to rule out some other conflicting afflictions such as depression or delirium. We actually call that the three Ds. And the point here is when somebody comes in with memory impairments or with some other issues related to executive function, it's usually one of these three Ds, depression, delirium, or dementia. And there's some important differences between delirium and dementia. For example, we know that delirium usually is of acute onset. And more often than not, that can occur with some change in medication. But oftentimes, delirium and dementia and depression kind of look the same. We might observe similar symptoms in each of them. So it's important to sort them out. And we do that through a medical evaluation. Because if a person is diagnosed with delirium or depression, those are treatable conditions. Usually with a change in medication or with a new medication or maybe with some therapy in the case of depression. But the thing to know about dementia is it's progressive in nature. And there's no quote unquote cure for dementia. Unlike the other two things which are known to be treatable conditions. Let's look at the prevalence and incidence of dementia. And when you're looking at the data on this slide, we can compare this information to what we know about the prevalence of hearing loss that I've already covered. Let me point out first that there is a difference between incidence and prevalence. Incidence is the number of new cases reported every year. And as you can see from the data on the slide, we expect to go up to 60 million new cases of dementia worldwide by the year 2030. And 114 million by the year 2050. When it comes to prevalence, which is really how common the condition is out there, we expect it to double every five years for patients or individuals over the age of 60. So we know, for example, that approximately 5% of individuals over the age of 65 have dementia. But when a person gets into their mid 80s and beyond, the prevalence of dementia moves to between 40 and 50%. And of course, if somebody's over the age of 85 in a nursing home, the chances of that person who's confined to a nursing home or residential facility, those typical individuals are over 50% prevalence compared to community dwellers, people living at home independently over the age of 85, it's likely that 25 to 45% of them will have dementia. So the point here is that the prevalence, as we would expect, increases rather dramatically with age. Another question might be, what are some of the underlying causes of dementia? We know from the literature that between 60 to 70% of dementia cases are due to Alzheimer's disease. And we won't get into the details of what the definition of Alzheimer's disease is, but it's a specific medical condition that can be diagnosed. And of course, dementia is one of its symptoms. And we know that between 30 to 40% of the other causes are from conditions such as vascular diseases, from stroke or heart disease, Parkinson's disease, and something called Lewy body dementia, which can afflict people in their 40s and 50s and 60s. Luckily, that's a condition that's relatively rare. One of the important points that I want you to take from this webinar today is that there's a range of cognitive function in the elderly that we have to be able to... We really need to appreciate this range of function. And what I mean by that is on this continuum depicted by these three boxes, there's what we would consider normal aging, which is somebody has a slower reaction time. Maybe their memory is a little bit slower than average. And it's really the difference between the cognitive ability of a 40-year-old compared to maybe a 90-year-old. That 90-year-old is gonna be slower in all modalities compared to the 40-year-old. But for a 90-year-old, they may be normal for their age, even though they're a little bit slow in their thinking processes. And then we move into the bucket called mild cognitive impairment, which is sometimes a red flag for early Alzheimer's, but it's usually a borderline low score on a test of dementia. And then on the far right, we have the bucket of the classic diagnosis of dementia, where there's a deficit on several domains of cognitive function, and it's been diagnosed by a physician. But I think it's important to appreciate this range of cognitive function. And you think of the last or the next 10 85-year-olds that you see in your practice, and probably a third will have normal aging, and a third will be mildly cognitively impaired, and another third will be in the dementia category, somewhere along those lines. But they'll be in one of those three buckets. Another important point is that hearing loss is one of several risk factors for cognitive decline. When you look at all of the possible risk factors for dementia, the list is actually quite long. And you see the first risk factor might seem relatively obvious, and that is advanced age. So over the age of 80 would be a risk factor for acquiring dementia. But smoking, diabetes, depression, vascular diseases, head injuries, a condition called senile cataract, which affects the eyes. And finally, hearing loss has all been shown in the research to be risk factors for increasing the likelihood of acquiring dementia. So let's go ahead and look at some of the screening tools that we can use for finding out if a patient might be at risk for developing or acquiring dementia. Now remember here, these tools I'm gonna share with you don't diagnose dementia, but they give you a red flag, a positive indication if somebody fails one of them. And of course, if somebody fails one of these tests, it would be, the next logical task would be to refer these patients to a physician or a medical professional who could actually make the formal diagnosis. The first screener is called the Mini Mental States Exam, the MMSE. This one has been around for about 40 years. Many medical professionals think of this screener as kind of the gold standard for screening for dementia. You'll notice it's on a 30-point scale. And as you'll learn for all of these tests, the patient's ability to hear is very important in the final score that they obtain on the test or on the screening. So we have the Mini Mental States. It actually evaluates around five modalities you see in bold here, orientation, registration, attention and calculation, recall and language. And we don't have to get into the details of this one, but this is one that many clinics around the country that specialize in geriatric care utilize. Another screening tool, one that is a little bit more sensitive for identifying both early Alzheimer's or mild cognitive impairment is called the MOCA, which is also known by its longer title of the Montreal Cognitive Assessment. And like I said, this is known to be a little bit more sensitive for identifying cases of mild cognitive impairment. You'll also notice it's on a 30-point scale and there are the, how that breaks out as far as the test is concerned. 26 to 30 is normal, 19 to 25 is mild cognitive impairment. A score of 18 or less would be considered to be a red flag for dementia. Here's a screenshot of the Montreal Cognitive Assessment. You see, it's very similar to the MMSE and we won't get into the detail to administer this test, but it is available. You can learn about it online. A lot of non-medical professionals use this as a screening tool for patients who might be at risk for dementia. And then finally, the last screening tool I wanna mention is what's called the Mini-COG. And you see a couple of websites there where you can find the Mini-COG and learn how you would administer it. And this is one that actually has a lot of practicality in a busy clinic that's maybe seeing patients who, a lot of patients that are at risk for acquiring dementia. You know, patients that are 85 and older would fall into that category. This test, unlike the others, that take about 10 minutes to complete, this one takes about two minutes to complete and it's a very simple two-step process. The first process is you... the first step is you have the patient recall three words from a list that's found on the MINICOG scoring sheet which is available on the website you see there. You give the patients, you say them to the patient and have the patient recall those three words and if they recall the three words, they've passed the test. But if they miss one or two of the words, the next step is you have them draw a clock. And the first step of doing that would be to have them draw a circle and then have them draw the numbers on the clock and then give them a time like 1145 and ask them to draw the two hands on the clock. And if they score abnormally on that part of the test that would be a red flag for dementia and you would probably refer that patient. But the point is it's very simple to do this test, very quick. The test has been normed so it has some research to validate its effectiveness. So based on what I've said so far regarding risk factors and screening, I think one of the takeaways for a hearing care professional would be during the case history, it's really important to acquire about a lot of the risk factors that I mentioned. Diabetes, heart conditions, head injuries, all of those eye issues, all of those things are risk factors for acquiring dementia and would make sense for us to inquire and document about them during the case history portion of our appointment. And of course another important point would be that if we can prevent, if we can eliminate or improve a lot of these risk factors, especially when a patient is younger, like in their late fifties, early sixties, even into their seventies, if we can eliminate or prevent a lot of those risk factors, it lessens the chances that the patient will acquire dementia. And the point I want to make there is good hearing is really essential to healthy living, that it's all kind of intertwined and our ability to help somebody hear better certainly has an impact on leading a healthier lifestyle. So speaking of intertwined, I wanted to spend a little bit of time talking about the interconnectedness between aging, hearing loss, and dementia. And without getting into too much of the science here, I wanted to kind of help you appreciate that there is a lot of science going on in this area. We don't completely understand this interconnectedness yet, but over the last few years I think we've made a lot of progress in how we understand how these processes influence one another. In order to talk about this, I wanted to use the springboard of a very common clinical scenario, and that is an older adult, we see this all the time in our clinics I think, an older adult comes in reporting speech understanding difficulties that might exceed those reported by an adult with the same amount of hearing loss, but is much younger. And what I mean by that is kind of depicted here on this slide. I'm just showing you the left ear for both patients, but let's just imagine that the losses are symmetrical and I have on the left patient A, who is 56 years old, and he has that sloping mild to moderate high-frequency hearing loss, and on the right I have patient B, who is 86 years old, that has exactly the same thresholds. And what you'll notice here, and I think we see this fairly often in our clinics, is patient A on the left, who is younger, has excellent word recognition ability in both ears, and patient B, who is 86 on the right, their word recognition scores are quite poor. And that's a good example of how aging affects the auditory system. It doesn't always affect the thresholds, but it can certainly affect areas in the cortex that process language, and it looks this way on our test results. And there's actually four theories that explain this interconnectedness. And like I said, we're not going to get into too much detail here, but it's good to at least touch on these. The first theory is what's called the common cause hypothesis, which really is trying to explain that neural degeneration happens throughout the entire system. This neural degeneration could be resulting or could be sped up through the way we, through diet, lack of diet, or poor diet, poor exercise habits, and some of these long-term chronic conditions that crop up that cause neural degeneration. And that's kind of depicted here on this slide, and we won't get into the details. But another theory that explains this interconnectedness is called the cognitive load hypothesis, which really is the system gets tired out faster because, or your higher levels of the cortex, your thinking ability gets tired out faster because you have to spend more time trying to think, or because your hearing is not as good as it could be. Another theory is called the deprivation hypothesis, which is really a decline in hearing sensitivity results in permanent cognitive decline, so you're starving the language centers of the brain because your hearing is not as good as it could be. And then finally there's what's called the social isolation hypothesis, which means that a person, because they're not able to hear, or they're maybe not able to comprehend as well, they have a tendency to stay away from social activities, isolate themselves. So my best guess, based on the research, is that this interconnectedness between aging, hearing loss, and dementia, probably a little bit of all four of these theories have a role in what's going on at the brain. One of the leading researchers that's really looked at this systematically over the last several years is up in Canada. Her name is Catherine Pachora-Fuller, I've seen that name, but she's done a lot of outstanding research that looks at bottom-up and top-down processing. And the bottom line is that ear-to-brain and brain-to-ear processing complement one another, and both of them can be impacted through dementia and just a normal aging process. And when a person shows up in your clinic, let's say over the age of 85, some of the things that you're likely to find are degraded audibility, which is a hearing loss on the audiogram, a distorted signal, which a patient doesn't hear very well in noise, which another manifestation is poor memory, slower processing, it takes them longer to process their thoughts. And a really important point that I want to get into next here is that a typical age-related hearing loss oftentimes can masquerade as dementia. Now remember I showed you those and we reviewed three cognitive screeners, and all three of those cognitive screeners rely on the patient's ability to follow the directions of the tester who's administering the screener, which means if a person has a hearing loss and they can't hear the person doing the testing and follow the instructions of the test, they're more likely to fail it because they can't hear, and if they get a poor score it might be because of the hearing loss, not because the patient has acquired dementia. And there's actually been two studies that have looked at this. One of them is by an audiologist who's now at the University of South Dakota, her name is Lindsay Jorgensen, and this is a really interesting study because she actually took 125 normal hearing young adults and she assigned them one of five degrees of simulated hearing loss. And after they simulated a hearing loss on these normal hearing adults, they found when they administered the MMSE cognitive screener that 16 percent of them that had a mild to moderate severe hearing loss that was simulated actually scored so low on the test that they would have been classified as having dementia. So here's an example of how you can essentially have someone score with having dementia just by giving them a hearing loss. So it shows you the impact that hearing has on a test of dementia. There was another similar study conducted up in Canada, published last year, that showed similar findings. They found that only six percent of those that had a hearing loss scored normal on the MoCA, which is one of the other cognitive screeners. And really the bottom line from both of these studies is that hearing loss, that individuals that have hearing loss are at a significant disadvantage on any test of cognitive ability. And prior to having the test conducted, whomever's conducting the test really needs to account for the hearing ability of the individual. In other words, if a person has a hearing loss and they score poorly on one of these cognitive screeners, they could be scoring poorly because of the hearing loss and not because of the dementia, which I find to be very problematic. And that's something that we definitely need to communicate to colleagues and other medical specialties that work with geriatric patients. I think another germane question is what is the relationship between hearing loss and dementia? And again, I won't go into too many details here. There's been six studies that have looked at this relationship between dementia and hearing loss. And the thing to know about these studies is they were all were called observational studies or longitudinal studies looking at patients over a long period of time. Some of them about six years, others more than 15 years. And all of these studies say more or less the same thing, which is there's a link between untreated hearing loss and dementia. I showed you the two Lynn studies on one page. And on this one I'm showing you again similar things. Over a long period of time, those that have hearing loss are more likely to develop dementia compared to a similar group of patients with normal hearing. So all of those studies I'm showing you more or less say the same thing. And what those results really mean is it's very important to note that there's no evidence that says that hearing loss causes dementia. There are people out there that are older with a hearing loss that actually don't have... in other words, not every older person with a hearing loss acquires dementia. However, we do know that for individuals age 65 and older that have a hearing loss, they are more likely to acquire dementia. It is a risk factor and it's something that we need to consider. But I think what we can't do is we can't say that hearing loss causes dementia. That would be an erroneous statement. But we can say that hearing loss is linked to dementia and it's a risk factor for acquiring dementia. Another hot topic is do hearing aids prevent cognitive decline? And there's been at least three studies that have looked at this very carefully. And some of these studies have gotten quite a bit of media attention within our own industry press. The first one comes from France. This was published in a geriatric medicine journal and I think it got some press in our industry. And it looked at individuals over a 25-year period of time. It looked at individuals that had normal hearing and two groups that had hearing loss. One were non-hearing aid users and the other were hearing aid users. And after they corrected for some things in the study, they found that there was no difference among the two groups with hearing loss. In another study, this was called the the Beaver Dam study because the information came from Beaver Dam, Wisconsin. They followed individuals over an 11-year period and they found that hearing aid use had no significant impact on cognitive function at the end of the 11-year period. And then in a study that was published earlier this year, looking at individuals between the ages of 80 and 99, they found that hearing aid users scored about two points better on the MMSE compared to non-hearing aid users. But on another test of executive function, there was no significant difference between the two groups on MMSE scores. If you look at the big picture here, it's really too big a leap to say that hearing aids prevent cognitive decline. But I think it's okay for us to say that hearing aids may slow it down. If anything, hearing aids do seem to improve psychosocial behaviors and physical activity levels. And indirectly, I think there's some evidence that hearing aids improve quality of life in patients that are in that age group where they are more likely to acquire dementia. So let's spend the rest of our time talking about some clinical implications because I think it would be a mistake after listening to this webinar to kind of take a business as usual approach to individuals aged 85 and older. So let's look at some clinical implications both inside and outside your clinic. The first question that I'd like you to consider is should you screen for dementia? I mentioned three possibilities. And before you answer the question and think about it, really some other questions might be how would you use this information from a cognitive screener to make better clinical decisions in your practice about patients? And would you treat patients that were screened and scored poorly on the test any differently than patients of the same age that had normal cognition? So those are some things to consider. If you're going to screen, I would recommend knowing as much as possible about the mini-cog. And some of those websites I shared with you a few minutes ago go into a lot of detail on how to administer that test and what the results mean. If you decide that you do want to screen for cognitive function in your practice, I would do it routinely for patients that are aged 85 and older. And if you start screening in your practice, before you do so, I think it's really important to establish a referral network for those that fail the screener. And that referral network, of course, could include neurology or any other medical specialty that works with geriatric nursing, any type of specialty that works with geriatric patients in a long-term kind of way. Another consideration when it comes to patients with dementia or mild cognitive impairment is it's kind of a blanket statement to say it's a more complex case. These patients, for obvious reasons, are going to take more of your clinic time. You're going to probably have to repeat instructions in written and in video format. It's a good idea to involve direct family members or caretakers whenever possible. It might mean establishing a relationship with a residential facility. And it also means if you're dealing with a more complex case that alternative or complementary technologies may be in order. And you see some of those listed there on the slide. And we'll talk about those in a little bit more detail in a second. Some other considerations inside your clinic. I don't see any reason why proven hearing aid selection and fitting principles would not be used. I think making sure that we optimize audibility of speech, especially of familiar voices. And that usually requires matching a prescribed target, verifying that that match is close with probe mic measures, ensuring that the hearing aids fit properly, any modifications are necessary and how the patient would insert them into their ears. And obviously getting the family and caretakers involved. But my mantra for patients that might already be diagnosed with mild cognitive impairment or dementia, my mantra would be modify and involve. And what I mean by modify is there's some alternative approaches. I think our primary goal for somebody that has dementia could be just in helping them enjoy music or helping them in creating a more relaxing environment using sound. There's a lot of literature out there that shows patients that have been diagnosed with dementia have less agitation, are more relaxed when they're able to listen to their favorite music on demand. Or it could be as simple as making the television viewing experience more enjoyable. And of course along with modifying, we need to involve any other caretakers or family members that are with that patient on a daily or weekly basis. So some of the alternatives out there that help with the enjoyment of music and television would be maybe it's as simple as an iPad or some other device that allows you to stream music directly into both ears with custom earphones. It could be the use of the Tunity app, which is a smartphone app that allows you to turn your smartphone into an assistive device for the television. You plug a set of wired earphones into your smartphone. You pair the smartphone to the television and it streams the audio directly through your smartphone into the earphones. And that works great for people that want to watch television along with the product that I'm involved with called Hypersound, which is simply a device that allows the patient to sit down in front of the television and hear the television very clearly without wearing anything on or around their ears. So those are some alternatives that would work, I think, nicely for those patients that have hearing loss and dementia and want to enjoy music or television or just simply relax with a family member when they're visiting them. Some other considerations as we wrap things up here. Memory complaints in people of any age that have a hearing loss should be referred directly to neurology or to a geriatric specialist. And it's also important to be more vigilant of the cognitive status of each patient prior to fitting hearing aids. Like I said, I think it's okay, it's not out of bounds for us to use some type of a research-based cognitive screener to sort out those patients that might be at risk for acquiring dementia and needing further workup. And like any other patient, I think it's important to conduct some type of a comprehensive functional communication assessment and then devise an individualized plan, not only around hearing aids, but assistive devices, smartphone apps. Think about the use of alerting devices and the enjoyment of music. A tool that can help target areas for improvement, I know a lot of us use the COSI. Another tool that's quite helpful is called the Telegram. You'll notice it's on a one-to-five rating scale, so you can have the patient and their caretaker or family members rate their ability to communicate in a number of areas. And one thing I really like about the Telegram, with respect to older patients that may have dementia, is there's one item there where you can evaluate alarms. Especially those patients that are still living at home, afraid to lose their sense of independence, one thing that a hearing care professional could provide is a sense that they're being taken care of with alarms for the doorbell, the smoke alarm, and things like that. And I think hearing care professionals play a role. So in addition to what goes on inside your clinic, I think there's some real opportunities outside of our clinic to build some referral networks and some really, I think, strong partnerships with physicians, nurses, anybody that comes into routine contact with geriatric patients. As I've already said, I think physicians and nurses need to be aware of the hearing status of their patients prior to giving them a cognitive test. That a patient can fail those tests because they have a hearing loss, and that's a real shame. I'm also a big believer that we need to encourage medical staff that administer these tests to use off-the-shelf types of products, PSAPs, pocket talkers, and apps during the evaluation process to improve the audibility of their patients. There's nothing wrong with taking one of these, as long as it's a high-quality device, and having the patient wear it during the administration of a cognitive screener so that the patient performs with relatively decent audibility. Then, of course, I think it's imperative for all of us to educate the medical professions and the public at large about the link between untreated hearing loss and cognitive decline. My mantra would be that all adults over the age of 55 need to have their hearing screened at least every couple of years. When patients get into their 80s, they should have their hearing screened on an annual basis. Now, we can talk about how they screen maybe during the discussion period, but the bottom line is better hearing is better living or healthy living. Hearing care professionals play a vital role in patients maintaining an active, healthy, and vibrant lifestyle as they move into their 80s and 90s, into that age range when they're more likely to acquire dementia. It's imperative and incumbent upon our profession to ensure that they receive comprehensive, patient-centered care that's appropriate for the condition that they've been diagnosed with. Hearing aids, of course, when they're properly prescribed and fitted by the professionals, work for all patients regardless of cognitive ability. Of course, you have to make some modifications and get others involved with some of these older patients that have dementia, because we know that hearing aids allow patients to stay active and healthy and engaged while they're wearing them per your recommendation. So, that's the end of my spiel. I hope that you found this information useful. Here's a rundown of many of the references I used today, and I'll open it up to any questions that you may have. Great, thanks Brian. Brian, we're so excited that we've had over 250 of your fellow colleagues that have joined us today in this webinar. As Brian said, we do have some time for questions. If you have a question for Brian, please enter it in the question box on your webinar dashboard. And Brian, our first question comes from Nancy, and Nancy asks, wouldn't the difference of word recognition scores be different if the older adult waited later to get hearing aids than lost speech prior to being fitted with hearing aids? Okay, can you repeat the question for me please? I think I may have missed part of it. Certainly. Nancy asks, wouldn't the difference of word recognition scores be different if the older adult waited later to get hearing aids than those that lost speech prior to be fitted with hearing aids? Okay, I'm not sure if I completely understand the question, but I think what she's asking is related to auditory deprivation, meaning the longer somebody waits to get help, the more likely they are for their word recognition score to decrease. And there is evidence to support that. There was quite a few studies done back in the 80s and early 90s that showed patients that had a hearing loss that did not use hearing aids for an extended period of time had poor word recognition scores relative to patients with the same loss that started using hearing aids sooner. So I think that answers your question. Great, thanks Brian. Let's see, Brian, our next question comes from Samantha and Samantha asks, you mentioned that at the age of 90, high frequency loss plateaus, but low frequency continues to decline. We know that heart disease is a factor in low frequency loss. Does the research account for that? The study that I'm citing was published a month or so ago and I'm trying to recall. I don't think in the study they made any mention of what some of the possible causes could be. I think that that theory would be a good one, that conditions that affect the circulatory system, the heart, could also be affecting the inner ear and lead to that progression in hearing loss in the low frequencies. But I don't know of any specific study that looked at that. Great, thanks Brian. Brian, our next question comes from Jim. Jim asks, as far as hearing aid fittings are concerned, what should he do differently for a 90-year-old with dementia compared to a 90-year-old with normal cognitive function? Well, I think part of it depends on where they're living. So for example, and how progressed the dementia has become. If somebody has got more advanced dementia and they're no longer independent, then I think you need to focus on goals that are more simple, like enjoyment of music and relaxation, maybe in one-on-one communication. In the office, I think it just probably takes more time. You have to, I think, get the caretaker more involved or the family member more involved. So I think as a general term or as a general strategy, patients that have dementia are more complex cases that take more time and others need to be involved. So I think from a clinical standpoint, it's knowing that you need to spend a little bit more time with that person. You have to say it differently. You have to use some different strategies to get the message across and you have to simplify the goals of your fitting when the patient's home. So I think that's a really good question and probably one that we need to spend a little bit more time as a profession discussing and coming up with some alternative strategies. Thank you, Brian. Brian, our next question is from Melinda and Melinda would like to know if you have any information on any studies that support rehabilitation of auditory deprivation with patients having dementia. Off the top of my head, I don't know of any studies, but if you go to PubMed, you Google PubMed, you can find it. It's the NIH website that has all of the peer-reviewed studies. You could do your own literature review and find one, but I don't know any off the top of my head, unfortunately. Thanks, Brian. Brian, our next question is from Nicole. Nicole asks, are there certain advanced hearing aid features that work better for patients with dementia or cognitive decline? Well, I know there's been a couple studies out there that have looked at features around compression speed that the findings are essentially that an older person, and this is, from what I remember, it's not related to cognitive function, it's mainly based on age. Older people have a tendency to benefit from compression speeds that are slower. So I think there's even been a couple hearing aids over the years that have had the ability to change the attack and the release times, I think, not the attack time, but the release time of the compression based on the age of the patient. But when it comes to dementia per se, I don't know of any features that are designed specifically for those patients. Great, thanks, Brian. Brian, our next question comes from Steve. Steve says, you mentioned three tests that screen for cognitive function. Which one would you recommend for hearing instrument specialists and why? Okay, the one I would recommend, if you're going to do this, and I do think that's a debatable issue, but if you're going to do screening, I would recommend the MINICOG. And the reason I would recommend that is because it's shorter, it's been validated, which means that when you look at the scoring, it's been run on dozens of patients so we know when somebody gets a certain score where they fall. So it's got some science behind it and it's relatively simple to do. You could even do the MINICOG as part of speech audiometry. You could do it under headphones if you wanted to. The only modification you'd have to make is prior to administering your audiogram and your speech testing, you'd have to have the patient have a pencil and paper handy where they could write and draw out the clock as you instruct them. But take a look at the websites I put on that slide. There's even a video, I think, on one of the websites that talk about how you administer it. Great, thanks Brian. Brian, our next question is from Melissa. Melissa asks, you had mentioned a recent study from France that compared hearing aid users to non-hearing aid users on measures of cognitive decline. When that study was released a year or so ago, I thought I had read somewhere that the study said hearing aids prevent cognitive decline. Is that true? I think that was a very liberal interpretation of the study. I have the study right here, actually. It was published in the October 2015 issue of the Journal of the American Geriatric Society. What they say in the study, when you go to the discussion section, is after controlling for all of the factors, social networking variables, depression, drug use, comorbidities, etc. After controlling for all of those factors, the difference in cognitive decline was no longer significant for any of the groups reporting hearing loss. So I think that that's a good example of how science and marketing battle out the messages that get published. That's not just in our field, but just in general. When an interesting study comes out, oftentimes the headlines are a little bit misleading and then when you dig down and look at the study more carefully, you realize that the findings maybe aren't as spectacular as what was reported in the media. Another part of that study, if you have it, and I'd be happy if anyone wanted to get in touch with me, I'd send you the study. There's a figure in the study that shows over the 25-year period the change in the scores on the MMSE and it was done every five years. It's a good example of there might be some statistical significance, but clinically when there's only a score difference of maybe one point, it's not clinically significant. So figure one in that paper I think tells the story rather well. There's really no change across the three groups. Great, thanks Brian. Brian, our next question comes from Patrice and Patrice asks, how would you handle the situation where a family member is questioning spending the money on hearing aids for a dementia patient, even though that that particular patient probably still won't hear very well after being fitted? Well, I'll give you my opinion on that. That's where other alternatives might be a better solution, like a pocket talker or a smartphone that has a hearing amplifier app on it connected to the person with wired headphones or earphones. You might have to customize the earphones so they fit properly. So some of these alternative technologies, especially for somebody who has very simple communication goals, one-on-one conversation, listening to music, enjoying music, listening to sound for relaxation purposes, a pocket talker may be a perfectly okay possibility. I think the argument or the discussion really needs to be around the pros and cons of wired technology. What I'm talking about, you know, smartphone apps paired to wired earphones or a pocket talker versus the portability of hearing aids. And of course, the pros associated with hearing aids are they're portable, you wear them all the time or as much as needed, but the cons would be they're easy to lose. You know, of course, there's modifications there too. I know that you can, like those construction workers wear with the earplugs that are connected with the cord around the neck. I think it'd be very easy to do something like that with a pair of hearing aids. That's a modification that an audiologist or a hearing instrument specialist could do in their practice, I think, rather easily. So that's an excellent question and there's no simple answer to it. It's a matter of weighing out the pros and the cons. Great. Thanks, Brian. Brian, we have a question from Pat. Pat would like to know if you have any tips on good approaches to having someone take a cognitive test. Well, I think that the first thing you have to do is get really comfortable with how the test is administered. It's not something that you just read about and then do. I think you have to practice it a few times. I think it becomes matter-of-fact and just say, we screen for this in the practice and then just go ahead and administer the screening test. It's just really a matter of getting comfortable with seamlessly incorporating it into your existing battery of tests. Thanks, Brian. Brian, we have time for one more question and it comes from Samantha. And Samantha asks, with the information we have about hearing loss, increasing misdiagnosis of dementia, why is there a screener that uses vision? She says that she screens using the MoCA, but only after having been fit with hearing aids slash ALD to help her with hearing impairment factors. I mean, my answer to that would be that hearing is directly related to language in many ways more so than vision. So it's really difficult to modify the test to a point where it's that it's valid without having an auditory component because hearing is so intimately tied to language comprehension. You know, that's why we talk so much easier than we write. You know, if vision was more important than hearing for language comprehension, then people would be reading cue cards all the time and not talking as much, I guess. Great. Thanks, Brian. Brian, I'd like to thank you for an excellent presentation today and I'd like to thank everyone for joining us today on the IHS webinar, Hearing Loss and Dementia, Current Trends and Opportunities. If you'd like to get in contact with Brian, you may email him at brian.taylor.aud at gmail.com. For more information about receiving a continuing education credit for this webinar through IHS, visit the IHS website at IHSinfo.org. Click on the webinar banner or find more information on the webinar tab on the navigation menu. IHS members receive a substantial discount on CE credits, so if you're not already an IHS member, you will find more information at IHSinfo.org. Please keep an eye out for the feedback survey you will receive tomorrow via email. We ask that you take just a moment to answer a few brief questions about the quality of today's presentation. Thank you again for joining us today and we will see you at the next IHS webinar.

hearing loss

dementia

older adults

aging population

interconnectedness

screening tools

cognitive decline

hearing aids

quality of life

clinical implications