Overview Hearing Loss & Healthy Aging › academics › MiniMedSchool 2011... · 10/27/2011 · damage the cochlear hair cells and stria vascularis, ... Perceptual Processing Requirements

11/10/2011

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Hearing Loss & Healthy AgingHearing Loss & Healthy Aging

Frank R. Lin, M.D. Ph.D.

Assistant ProfessorJohns Hopkins Department of Otolaryngology-HNS

Core FacultyJohns Hopkins Center on Aging & Health

27 October 2011

Hearing Loss & Healthy AgingHearing Loss & Healthy AgingOverviewOverview

•• Why study hearing loss?Why study hearing loss?

•• Hearing physiology & measurementHearing physiology & measurement

•• Epidemiologic research on hearing loss & Epidemiologic research on hearing loss & agingaging

•• Treatment options for hearing lossTreatment options for hearing loss

•• Future research directionsFuture research directions

Fountain of YouthFountain of YouthLucas Lucas KranachKranach 15461546

Healthy AgingHealthy Aging Healthy Aging

Maintaining Physical Mobility & Activity

Avoiding InjuryKeeping Socially Engaged & Active

Healthy Aging

Cognitive Vitality & Avoiding Dementia

Preventing Illness andDisease

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“Decades later, I can see many of the central themes of my thinking about judgment in that old experience. One of these themes is that people who face a difficult question

often answer an easier one instead”

-Daniel Kahneman, NYTimes Magazine, 10/23/11

EpidemiologicEpidemiologicA i tiA i ti

Clinical & PublicClinical & PublicH lth I tH lth I t

??AssociationsAssociations Health ImpactHealth Impact

What does this mean What does this mean for me?for me?

Healthy Aging



Avoiding Injury


Keeping Socially Engaged & Active

Hearing Loss

Prevalence of Hearing LossPrevalence of Hearing Loss in the in the United United StatesStates, 2001, 2001--20082008

Hearing loss defined as a bilateral PTA of 0.5Hearing loss defined as a bilateral PTA of 0.5--4kHz tones > 25 dB4kHz tones > 25 dB

Lin et al. , Arch Lin et al. , Arch IntInt Med. 2011Med. 2011

Prevalence of Prevalence of Hearing LossHearing Loss & & Hearing AidHearing Aid Use in the U.S. , 1999Use in the U.S. , 1999--20062006


Chien and Lin, 2011Chien and Lin, 2011

Hearing Loss & Healthy AgingHearing Loss & Healthy AgingStrikes against Hearing Loss as a Research FocusStrikes against Hearing Loss as a Research Focus

•• Ubiquitous = InconsequentialUbiquitous = Inconsequential

Silent disability of very gradual onsetSilent disability of very gradual onset•• Silent disability of very gradual onsetSilent disability of very gradual onset

•• Historical evolution of otology as a fieldHistorical evolution of otology as a field

Hearing

Causes

• Cochlear/Hair cell physiology

A dit

Paradigm for Hearing Loss Paradigm for Hearing Loss ResearchResearch Effects

• Communication• Quality of life

•Dementia & Cognition?

NIDCDHearing

Research

Hearing Loss

• Auditory Processing

• Epidemiologic risk factors

•Genetic causes

• Physical functioning?

• Social Isolation?

• Morbidity & Mortality?

• Health care costs?

NIAAging

Research

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Principles of Principles of Auditory PhysiologyAuditory Physiology

#1 Hearing depends on #1 Hearing depends on peripheral transduction & peripheral transduction &

central processingcentral processing

Inte

nsity

“Sunday”

St iStria vascularis

Hair Cells

Principles of Auditory PhysiologyPrinciples of Auditory Physiology

#2 Multiple different factors can progressively damage the cochlear hair cells and stria vascularis, leading to age-related hearing loss that is characterized by increased hearing thresholds and poor frequency resolution.

Hearing Loss

Genetics

Infection

Medications

Noise

Systemic Factors

Intrinsic Inner Ear Diseases

Aging & Presbycusis

CongenitalAnomalies

Ryan A F PNAS 2000;97:6939-6940

Hair cell Injury

Gates 2005

Vascular damage to stria vascularis

Epidemiologic Factors & Hearing LossEpidemiologic Factors & Hearing LossStrength of AssociationStrength of Association

Strong

Age & Family HistorySexRaceNoise Exposure

Intermediate

Weak

HypertensionStrokeOtotoxic drugsHigh cholesterol

Bone mineral densitySmokingDiabetes

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ensi

ty

Speech sounds are complex!Speech sounds are complex!

Increased hearing thresholds and poor frequency resolution.

Int

Principles of Auditory PhysiologyPrinciples of Auditory Physiology#3 Audiometry is the gold-standard method for assessing the cochlea’s ability to detect & encode sound

Principles of Auditory PhysiologyPrinciples of Auditory Physiology

PTA = Pure tone PTA = Pure tone average of 0.5, 1, average of 0.5, 1, 2, & 4 KHz tones 2, & 4 KHz tones

in the betterin the better--hearing earhearing ear







Healthy Aging



Avoiding Injury



Hearing Loss

Alzheimer’s DiseaseProjected U.S. Prevalence from Projected U.S. Prevalence from

2000 to 20502000 to 2050

Alzheimer’s Association, 2011

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Hearing Loss & DementiaHearing Loss & DementiaCommon Cause Common Cause or or Modifiable Risk FactorModifiable Risk Factor

Hearing Loss

Cognitive Decline &

?Loss

Dementia

Common pathological process

Inte

nsity

“Sunday”

Presbycusis & Presbycusis & Cochlear impairmentCochlear impairment

Increased hearing Increased hearing thresholds & poor thresholds & poor

frequency resolutionfrequency resolution

“Effortful listening”“Effortful listening”


Cognitive Load

Hearing Loss

Cognitive Decline & Dementia


Hearing Loss & Cognitive LoadHearing Loss & Cognitive Load

Cognitive Resource Capacity

•• KahnemanKahneman model of shared attention and model of shared attention and resource capacityresource capacity

Available Cognitive Resources

For Performance of Tasks

Age-RelatedDecline

Auditory Perceptual Processing

Requirements


Poorer hearing is associated with reduced gray Poorer hearing is associated with reduced gray matter in the auditory cortices.matter in the auditory cortices.

Peele et al, J. Peele et al, J. NeurosciNeurosci, 2011, 2011


Poorer hearing is Poorer hearing is associated with: associated with:

A. Reduced A. Reduced languagelanguage--driven driven activity in primary activity in primary auditory pathwaysauditory pathwaysauditory pathwaysauditory pathways

B. Increased B. Increased compensatory compensatory languagelanguage--driven driven activity in preactivity in pre--frontal frontal cortical areascortical areas

Peele et al, J. Peele et al, J. NeurosciNeurosci, 2011, 2011

Grossman et al, Brain Lang, 2002Grossman et al, Brain Lang, 2002

B

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Cognitive Load

Hearing Loss

Cognitive Decline & Dementia


Social Isolation

Hearing Loss & Cognition/DementiaHearing Loss & Cognition/DementiaRecent Epidemiologic StudiesRecent Epidemiologic Studies

# 1 Hearing loss and cognition# 1 Hearing loss and cognition•• Baltimore Longitudinal Study of Aging Baltimore Longitudinal Study of Aging

(BLSA)(BLSA)( )( )

•• National Health and Nutritional Examination National Health and Nutritional Examination Surveys (NHANES)Surveys (NHANES)

# 2 Hearing loss and incident dementia# 2 Hearing loss and incident dementia•• BLSABLSA

Hearing Loss & CognitionHearing Loss & CognitionBackgroundBackground

–– MemoryMemory•• Free and cued selective reminding test (FCSRT)Free and cued selective reminding test (FCSRT)

–– Executive FunctionExecutive Function•• Trail Making BTrail Making B

St Mi dSt Mi d These tests are•• Stroop MixedStroop Mixed•• Digit symbol substitutionDigit symbol substitution

–– Psychomotor/processing speedPsychomotor/processing speed•• Trail Making ATrail Making A•• StroopStroop colors and wordscolors and words

–– Verbal function & languageVerbal function & language•• Category/Letter FluencyCategory/Letter Fluency

These tests are not strongly

dependent on receptive verbal communication

Hearing Loss & CognitionHearing Loss & CognitionMemory: Free and Cued Selective Reminding Test Memory: Free and Cued Selective Reminding Test

(FCSRT)(FCSRT)

•• Subjects are presented Subjects are presented with 16 items over 4 with 16 items over 4 cards.cards.

•• Subjects are then asked Subjects are then asked to recall the 16 items to recall the 16 items over 3 trials, with over 3 trials, with category cueing as category cueing as neededneeded

Hearing Loss & CognitionHearing Loss & CognitionExecutive Function: Trail Making BExecutive Function: Trail Making B

Trail Making BTrail Making B

1

75

C

H

BE

Trail Making BTrail Making B 8

6

1

4

3

2

D

A

H

G

F

Hearing Loss & CognitionHearing Loss & CognitionExecutive Function: Stroop MixedExecutive Function: Stroop Mixed

1

GREEN

RED

StroopStroop

RED

YELLOW

RED

GREEN

BLUE

BLUE

GREEN

StroopStroopMixedMixed

GREEN

BLUE

RED

YELLOW

BLACK

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Hearing Loss & CognitionHearing Loss & CognitionExecutive Function: Digit Symbol Substitution Test (DSST)Executive Function: Digit Symbol Substitution Test (DSST)

DSST: DigitDSST: DigitDSST: Digit DSST: Digit Symbol Symbol

Substitution Substitution TestTest

Association of age and hearing loss with cognition in 347 adults >60 years in the Baltimore

Longitudinal Study of Aging

Lin et al., Lin et al., NeuropsychNeuropsych., 2011., 2011

Models adjusted for age, sex, race, education, diabetes, smoking, hypertensionModels adjusted for age, sex, race, education, diabetes, smoking, hypertension

Association of hearing loss and DSST scores in 605 adults 60-69 years in NHANES

75

100

DigitDigit

Lin, J. Lin, J. GerontGeront. Med. Sci., 2011. Med. Sci., 2011

025

50

gy

0 25 50 75 100

ggSymbolSymbolTestTest

Hearing Loss (speechHearing Loss (speech--frequency PTA)frequency PTA)

Association of age and hearing loss with cognition in 605 adults 60-69 years in NHANES

Lin, J. Lin, J. GerontGeront. Med. Sci., 2011. Med. Sci., 2011

Hearing Loss & CognitionHearing Loss & CognitionConclusionsConclusions

•• Hearing loss is independently associated with Hearing loss is independently associated with lower scores on tests of memory and executive lower scores on tests of memory and executive function in both BLSA and NHANESfunction in both BLSA and NHANES

•• The magnitude of the reduction in cognitive The magnitude of the reduction in cognitive performance associated with hearing loss is performance associated with hearing loss is clinically significant: 25 dB hearing loss ≈ 7 clinically significant: 25 dB hearing loss ≈ 7 years of age on tests of executive functionyears of age on tests of executive function

Hearing Loss & Incident DementiaHearing Loss & Incident DementiaBackgroundBackground

If hearing loss is associated with poorer cognitive performance,If hearing loss is associated with poorer cognitive performance,

is it also associated with the risk of developing dementia?is it also associated with the risk of developing dementia?

Memory Memory b i tb i t

FCSRTFCSRTMemoryMemoryScoreScore

Years before dementia diagnosisYears before dementia diagnosis

Grober et al., J. Grober et al., J. IntInt NeuropsychNeuropsych., 2008., 2008

begins to begins to decline 7 decline 7

years before years before dementia dementia diagnosisdiagnosis

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Hearing Loss & Incident DementiaHearing Loss & Incident DementiaBLSA CohortBLSA Cohort

BLSA participants with audiometry and cognitive testing1990 to 1994N = 749

Excluded subjects:‐ 58 subjects with prevalent dementia‐ 39 with > 3 errors on Blessed‐ 13 with MCI

Baseline study cohort1990 to 1994

N = 639

58 subjects with incident all‐cause dementia‐ 37 with Alzheimer’s disease

1991 to 2008

Hearing Loss & Incident Dementia Hearing Loss & Incident Dementia in the BLSAin the BLSA

Lin et al., Arch Lin et al., Arch NeuroNeuro., 2011., 2011

Hearing Loss & Incident DementiaHearing Loss & Incident Dementia

HR 95% CI p

Mild 1.89 1.00 – 3.58 0.05

Hazard ratio of incident all-cause dementia (compared to normal hearing)a

Moderate 3.00 1.43 – 6.30 .004

Severe 4.94 1.09 – 22.4 .04

a Adjusted for age, sex, race, education, DM, smoking, & hypertension


Hearing Loss & Incident DementiaHearing Loss & Incident DementiaRisk of Incident AllRisk of Incident All--Cause Dementia by HLCause Dementia by HL

d

Adjusted for sex, age, race,

Hearing Loss (PTA dB)

Haz

ard

education, diabetes, smoking, and hypertension


Hearing Loss & Incident DementiaHearing Loss & Incident DementiaConclusionsConclusions

•• Hearing loss is independently associated with Hearing loss is independently associated with allall--cause dementia & the risk of allcause dementia & the risk of all--cause cause dementia increases linearly with HL severity dementia increases linearly with HL severity after 25dBafter 25dB

•• If HL is causallyIf HL is causally--associated with dementia, we associated with dementia, we estimate that the dementia risk attributable to estimate that the dementia risk attributable to HL in our cohort > 60 y is 36.4% (95% CI: 12.8 HL in our cohort > 60 y is 36.4% (95% CI: 12.8 –– 58.6)58.6)

Healthy Aging



Avoiding Injury



Hearing Loss

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Conceptual Model of Conceptual Model of Consequences of HL in AgingConsequences of HL in Aging

H i M bilit & F ti l

Cognitive Load

Hearing Loss

Mobility & Functional Decline

Social Isolation


Physical FunctioningPhysical FunctioningGait Speed as a Predictor of SurvivalGait Speed as a Predictor of Survival

Physical FunctioningPhysical FunctioningGait Speed as a Predictor SurvivalGait Speed as a Predictor Survival

StudenskiStudenski et al, JAMA, 2011et al, JAMA, 2011

Cross-sectional association of age and hearing loss with gait speed in participants aged 50-69

years, NHANES 1999-2002 (n = 1138)

1.5

2/s

) 1.5

2

Li and Lin, 2011Li and Lin, 2011

.51G

ait

Sp

eed

(m/

50 55 60 65 70Age ( years )

.51

0 20 40 60 80Hearing Loss ( dB HL )

Association of gait speed per year of age or 25 dB of hearing loss in participants aged 50-69 years

Li and Lin, 2011Li and Lin, 2011

Healthy Aging



Avoiding Injury



Hearing Loss

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Falls as a Public Health ProblemFalls as a Public Health Problem

•• 1/3 of older adults >65 y has a fall every year resulting 1/3 of older adults >65 y has a fall every year resulting in:in:–– 2.2 M non2.2 M non--fatal injuriesfatal injuries

–– 20,000 deaths from fall20,000 deaths from fall--related injuriesrelated injuries

–– Approximately $28.2 billion in direct medical costsApproximately $28.2 billion in direct medical costs

Cognitive Load

Hearing Loss

Poor Awareness of Environment

Cognitive LoadPoor Balance

& Falls


Association of Hearing Loss with Association of Hearing Loss with Reporting Falls over the Previous Year in Reporting Falls over the Previous Year in

Adults 40Adults 40--69 years, NHANES 200169 years, NHANES 2001--0404

Lin & Ferrucci, Arch Lin & Ferrucci, Arch IntInt Med 2011Med 2011

Healthy Aging



Avoiding Injury



Hearing Loss

Hearing Loss & Healthy AgingHearing Loss & Healthy AgingCommon Cause Common Cause or or Modifiable Risk FactorModifiable Risk Factor

Cognitive Load

Hearing Loss

HealthyAging


Social Isolation

Can treating hearing loss delay cognitive Can treating hearing loss delay cognitive decline & dementia?decline & dementia?The Billion Dollar QuestionThe Billion Dollar Question

•• Only one 1 randomized study of hearing aids ever Only one 1 randomized study of hearing aids ever performed that explores outcomes beyond performed that explores outcomes beyond communication and HRQLcommunication and HRQL

•• No other studies have ever been performed to examine No other studies have ever been performed to examine the possible impact of hearing rehabilitative treatment on the possible impact of hearing rehabilitative treatment on older adultsolder adults







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Prevalence of Prevalence of Hearing LossHearing Loss & & Hearing AidHearing Aid Use in the U.S. , 1999Use in the U.S. , 1999--20062006


Chien and Lin, 2011Chien and Lin, 2011

Why are hearing aids so seldom used?Why are hearing aids so seldom used?

•• Lack of health insurance reimbursement for aural Lack of health insurance reimbursement for aural rehabilitative services and devicesrehabilitative services and devices

•• A general perception that hearing loss is an A general perception that hearing loss is an inconsequential part of the aging processinconsequential part of the aging process

•• Lack of evidence that therapies for hearing loss can Lack of evidence that therapies for hearing loss can impact critical downstream outcomes (e.g. social impact critical downstream outcomes (e.g. social isolation, cognition)isolation, cognition)

•• A current model of hearing health care that focuses on A current model of hearing health care that focuses on simply dispensing a hearing aid rather than on simply dispensing a hearing aid rather than on comprehensive aural rehabilitation.comprehensive aural rehabilitation.

Comprehensive Hearing Comprehensive Hearing RehabilitationRehabilitation

•• Properly fitted hearing aids/cochlear Properly fitted hearing aids/cochlear implantsimplants

•• Assistive Listening Devices (ALDs)Assistive Listening Devices (ALDs)–– Amplified telephonesAmplified telephones

–– Hearing loop systemsHearing loop systems

•• Aural rehabilitative counselingAural rehabilitative counseling

•• Gain processing & Digital compressionGain processing & Digital compression

•• Feedback reductionFeedback reduction

•• Noise reduction algorithmsNoise reduction algorithms

•• Speech enhancement algorithmsSpeech enhancement algorithms

A Hearing Aid That Cuts Out All the Clatter

By JOHN TIERNEY

After he lost much of his hearing last year at age 57, the composer Richard Einhorn despaired of ever really enjoying a concert or musical again. Even using special headsets supplied by the Metropolitan Opera and Broadway theaters, he found himself frustrated by the sound quality, static and interferencestatic and interference. Then, in June, he went to the Kennedy Center in Washington, where his “Voices of Light” oratorio had once been performed with the National Symphony Orchestra, for a performance of the musical “Wicked.”

TelecoilsTelecoils & Hearing Loops& Hearing Loops

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Cochlear ImplantsCochlear Implants







Future Research DirectionsFuture Research Directions

•• SMART I Study at Johns HopkinsSMART I Study at Johns Hopkins–– Studying Multiple Outcomes after Aural Rehabilitative Treatment Studying Multiple Outcomes after Aural Rehabilitative Treatment

StudyStudy

S fS f•• SMART 2: currently in the planning stages of a large SMART 2: currently in the planning stages of a large randomized controlled trial of comprehensive hearing randomized controlled trial of comprehensive hearing rehab to examine effects on cognition and other rehab to examine effects on cognition and other functional outcomes functional outcomes

•• Pharmacologic therapies for hearing lossPharmacologic therapies for hearing loss–– MelanocyteMelanocyte--stimulating hormone for hearing preservation?stimulating hormone for hearing preservation?

–– Drugs to boost hearing function on a transient basis?Drugs to boost hearing function on a transient basis?

For more information:For more information:

www.thesmartstudy.orgwww.thesmartstudy.org

[email protected]@jhmi.edu

Documents

Overview Hearing Loss & Healthy Aging › academics › MiniMedSchool 2011... · 10/27/2011 · damage the cochlear hair cells and stria vascularis, ... Perceptual Processing Requirements