Expert Tips for Integrating Cognitive Screening in Audiology Practices

Unlock the secrets to preserving cognitive health and enhancing quality of life with insights from Dr. David Fabry of Starkey and groundbreaking research studies. This episode promises to shed light on the intricate connections between hearing loss, cognition, and comorbidities such as cardiovascular disease and diabetes. Learn how untreated hearing loss can exacerbate cognitive decline in at-risk populations, especially older adults, and discover the potential benefits of hearing amplification from key studies like the ACHIEVE study from Johns Hopkins.

Ever wondered why speech in noise testing is crucial for diagnosing cognitive disorders and hearing loss? Dr. Beck shares his perspective on the limited efficacy of current drugs targeting amyloid plaques. We shift the focus to audiology, underscoring the importance of cognitive screening as a standard practice. Learn how poor speech-in-noise scores correlate with increased dementia risk and why comprehensive testing should be a priority, despite common resistance due to time constraints.

Get practical advice on best audiology practices with actionable tips you can implement right away. Discover the simplicity of administering quick and effective speech in noise tests using Mead Killian's grading scale. We also discuss the importance of cognitive screenings for older patients and those with significant hearing loss. Finally, explore valuable resources available on the Hearing Matters podcast to support hearing health and maintain meaningful communication as we age. Join us for an episode packed with vital information to help you better address hearing and cognitive health for yourself or your loved ones.

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Chapters

• 0:00 Hearing Loss, Cognition, and Amplification
• 10:39 Speech in Noise Testing Importance
• 18:39 Audiology Best Practices and Tools
• 26:12 Sharing Resources for Communication Enhancement

Transcript

Dr. Dave Fabry:

I hope, out of this discussion, that at least one or two clinicians says, "Okay. Finally I'll consider, within the context of all of the interest in cognition, that as you said, do a speech in noise test first."

Blaise Delfino, M.S. - HIS:

You are tuned into the Hearing Matters podcast, the show that discusses hearing technology, best practices, and a global epidemic, hearing loss. Before we kick this episode off, a special thank you to our partners. Redux, faster, drier, smarter, verified. Sycle, built for the entire hearing care practice. Fader Plugs, the world's first custom adjustable earplug. Welcome back to another episode of The Hearing Matters podcast. I'm your founder and host, Blaise Delfino. As a friendly reminder, this podcast is separate from my work at Starkey.

Dr. Douglas L. Beck:

Good afternoon. This is Dr. Douglas Beck. I am one of the hosts of the Hearing Matters podcast, and today we're interviewing my dear friend, Dr. David Fabry, with Starkey. He is the Chief Hearing Health Officer at Starkey, and we're going to turn the tables a little bit and David's going to ask me questions regarding cognition, hearing health, amplification, things like that. Dave, thanks for being here. It's great to see you.

Dr. Dave Fabry:

Cool, Doug. Hey, thanks for the opportunity. I really enjoy this, where I get to pepper you with questions. I'll take on the role of host, at least temporarily.

Dr. Douglas L. Beck:

Go for it, and be kind, because I'm not really that smart.

Dr. Dave Fabry:

All right. Well, I'll be the judge of that.

Dr. Douglas L. Beck:

I know you will.

Dr. Dave Fabry:

We've both been at this a while. I think you and I have known each other about 35 years. We've both been active clinicians, as well as research along the way for both of us, and now you're a podcast host and I get to be one. I get to play one at work too.

One of the issues I think that we've both seen is hearing loss does not occur in a vacuum, even though many people outside our discipline think of it that way. I can remember the first time I saw studies that linked hearing loss and cardiovascular disease more than 20 years ago. It was really when the NHANES database started, that national health surveys, that are done about every five years, around the turn of the millennium started to incorporate hearing testing. Just prior to, I think. In '97 or so in earnest, they started doing audiologic testing along with the other battery of tests that they were doing. Early on, there was high comorbidity that was found between untreated hearing loss and cardiovascular disease.

More recently, attention has been focused on cognition, really beginning back around 2010 when Dr. Frank Lin of Johns Hopkins began to postulate, on smaller sample sizes, that there is a link between untreated hearing loss and cognition. My first question for you then, what do we know? What have we learned in the last nearly 15 years about the relationship between hearing loss and cognition?

Dr. Douglas L. Beck:

The relationship is a correlation. First thing to know, it's not causative. It's not that hearing loss causes cognitive decline. It's that untreated hearing loss tends to exacerbate cognitive decline in people who are at risk. Now, when I say at risk, what I mean, perfectly consistent with the ACHIEVE study and the ENHANCE study, which we can talk about later, people at risk would be older adults. They would be people with greater levels of hearing loss. They would be people who are lower socioeconomic groups, and they're going to be people with multiple comorbidities.

Now, you mentioned cardiovascular disease, which we know is a big factor, also diabetes, and in the U.S. diabetes runs rampant. This is thought to be similar to visual problems because you have microvascular changes in diabetes that impact the retina, and we think the same thing is probably going on in the cochlea as well. What we know about the relationship is that as people age, as they have more hearing loss or as they have less options socioeconomically, as they have more comorbidities, they're at higher risk for cognitive decline.

One of the things that's so important is to understand the difference between cognitive decline and mild cognitive impairment. In the USA, if you go back to October of 2022 in the JAMA, the Journal of the American Medical Association, they said that by the time you are 65 years old in the USA, or older, about 22%, or one out of five people, have MCI, mild cognitive impairment. Now that is not necessarily going to lead to dementia, although often it does. Those are the numbers for MCI, 22% of the population over age 65. The numbers that have Alzheimer's are kind of spectacular. By the time you're age 85 in the USA, one out of three people has Alzheimer's.

Now, Alzheimer's is just one of 200 different types of dementia, and it's very important that we don't just call them all Alzheimer's, because they're not. However, about two-thirds of all dementias are Alzheimer's. That's why it's used almost as a generic term for dementia, but it's not. When we talk about dementia, Alzheimer's is number one, but then we have Lewy body disorders. That's what Robin Williams had. We have frontotemporal disorders. We have Parkinson's disease with dementia. There's lots and lots and lots of types of dementia. We know that as your hearing loss gets worse as you're aging, your risk of dementia increases with untreated hearing loss.

Dr. Dave Fabry:

You bring up a lot of points there. We have this Bermuda triangle, if you will, of multiple comorbidities between hearing loss, cardiovascular disease and cognition that came out of the ACHIEVE study, that subset that were at risk for diabetes, hypertension and the atherosclerosis risk group. Also, that group with hearing loss showed that they preserved their cognitive function on those 10 scales that they used 48% better than the group that wasn't fitted with amplification. Can we use that as a segue into this discussion of what about amplification and cognition?

Dr. Douglas L. Beck:

The point you raised is absolutely correct. That was the ACHIEVE study out of Johns Hopkins, almost a thousand people in that study at four sites. I don't think anybody's challenging their results. There was also the ENHANCE study that came out of Australia at about the same time, and that one was very, very similar in what they did. They followed these patients for three years just like the ACHIEVE study did, and they found that the people who were treated with hearing aids for their hearing loss, none of them had any degradation over the three years. Whereas the people who chose not to get hearing aids but they had hearing loss, they got worse over the three-year period.

We've seen this time and time and time again. Now, it does not mean everybody with hearing loss needs to wear hearing aids to prevent dementia. That's just silly. The numbers on that run like kind of like this. Gil Livingston and his colleagues in 2020 published in The Lancet a very, very important study on dementia, and their point was this. What is your risk for dementia? They said about 60, 65% of your risk is due to age and DNA, deoxyribonucleic acid, so you can't change either of those.

They said, "Now, 40% of your risk for dementia is based on 12 potentially modifiable risk factors." Of those 12, hearing loss was the largest, but you have to be very careful here because it was only 8.2%, and they refer to that as a PAF, population-attributable factor. That does mean that roughly 91% of your risk is not hearing loss. It's very, very large among the potentially modifiable risk factors, but it's not the biggest issue. The biggest issues are your age and your DNA.

Dr. Dave Fabry:

Exactly.

Dr. Douglas L. Beck:

The other issue that I think, as an audiologist, I want to use this as a reminder to those patients who have diabetes, who have hypertension or other cardiovascular risk factors. As a discussion point, just to be aware of the benefits of not delaying the decision to move forward with amplification, and knowing full well that, as you mentioned, in any study, it's open to criticism. You could argue that there is comorbidity between cognition and cardiovascular disease, and then separating out the hearing loss component from that is one that I think we need additional studies to confirm and replicate those results coming out of the ACHIEVE or the ENHANCE study.

I think it's also really interesting, and an aside, that with the introduction of Ozempic and the other drugs designed to treat diabetes, they are starting to see correlative reductions in some other health areas. You wonder if a medication that produces weight loss in some individuals who are diabetic ... obesity is an issue that plagues society ... if it could in turn reduce obesity, reduce cardiovascular risk, maybe even help combine in reducing some of these risks and comorbid risks as well.

Yeah, and this is a big discussion point going on globally I'm sure. The FDA has approved a couple of drugs that actually specifically reduce amyloid. Let's go back to Alzheimer's specifically. Alzheimer's takes about 25, 30 years from the time you have first microcellular changes until you manifest Alzheimer's signs and symptoms. During that period of time, amyloid plaque, tau tangles and all these other things go wrong with the brain, where we start to develop lots and lots of amyloid plaques. There are medicines that have been geared specifically towards reducing amyloid plaques, and that's fascinating because they actually work pretty well.

I've done a series of interviews with Dr. James Galvin, and Jim Galvin is one of the Lewy body disorder neurology experts in the world. Dr. Galvin was saying that, even though these drugs can reduce amyloid plaques and reverse some of that, we haven't seen anybody who has regained their memory or really had a substantially lengthened lifespan. It may improve things for three to six months. It may give them that extra time, and that's not trivial. That's important. It's a good stepping stone, but it hasn't been a day-and-night, evidence-based outcome on these patients. I'm not saying don't take those meds. I think those meds are very important. I think they're going to lead to better meds as time goes on. When we talk about Zampak and things like that, boy, the jury is way out.

Dr. Dave Fabry:

Way out. I mean, it's way early in that process to know what any negative consequences are, but let's then bring it back to our discipline and talk about within audiology or with hearing instrument specialists, and knowing that hearing loss doesn't occur in a vacuum. There are other issues and other tools available to practitioners that could assist them in not only assessing audiologic factors, but what about cognitive screenings? What's your opinion and what do the data say with regards to whether use of cognitive screening measures should be within the standard operating procedures, best practice, for audiologists and hearing instrument specialists?

Dr. Douglas L. Beck:

This is a fascinating question, and it's on everybody's mind who has a license in audiology. First thing you should know is ASHA and AAA both say it's within scope of practice to do cognitive screening. Now, as far as scope of practice goes, it's interesting, because you and I have had many conversations even recently on audiologists and hearing aid dispensers who don't necessarily practice to scope of practice, so here's the thing.

Within AAA and within ASHA and even within IHS scope of practice, it says you do your diagnostics ... you know, airborne speech impedance, reflexes, temps, whatever you need to do ... and then it says you're supposed to be doing a speech in noise test. Now, fewer than 15 or 20% of all hearing care professionals do that, so hold onto that for a minute. Then it also says, in scope of practice, you're supposed to do listening and communication assessments. Could be International Outcome Inventory, SSQ, the COSI, whichever. There's a dozen of them, pick one and do it.

Now, why speech in noise? Why did I flag that? Well, there was a study out of the UK Biobank by Stevenson and colleagues, which involved 81 or 82,000 people. What they found is over a 10- to 12-year period of time, people who presented with poor speech in noise scores 10 to 12 years later had a 61% increase in dementia attributes, and so that's pretty startling. People who have a poor speech in noise score might have a 61% risk 10 to 12 years later of starting to demonstrate signs and symptoms of dementia.

That was published. It's peer reviewed. It's 81, 82,000 people. It came out I think in 2022, might've been 2021. What this means is that, for the people who are not practicing best practices, this information would be invisible to you, because the patient may have 96% or 100% word recognition score in quiet, but if you don't test them in noise, you have no idea how bad they are.

Dave, you and I talked about this years ago. I think it was 2011 when the study came out by Rich Wilson, 3,500, 3,600 people, who they were all veterans and they were tested for speech in noise versus speech in quiet. The data goes something like this. I may get this a little bit wrong, but I'll be pretty close. Of the 3,500 people, something like 70 or 80% of them had good to excellent word recognition in quiet, 88, 92, 96, 100%. Of those, 70% had terrible scores in noise.

The point is that an excellent speech in quiet score or word recognition score does not tell you at all who's going to do poorly in noise. That's why it's so important to do a signal-to-noise test, because first of all, we can quantify and replicate the situation that the patient is complaining of. That's the number-one reason they come to see us, is they can't understand speech in noise. I think it's critically important, truly critically important, to replicate that, and to show them that we know what that is and to assign a number on it. When we know that their SNR-50, the signal-to-noise ratio, they need to get 50%. When we know that's 10 or 6 or 2, that helps guide us in our amplification decisions.

Dr. Dave Fabry:

No question. I can tell you, as an early adopter for speech in noise testing, many patients would come to me and say, "That was the first time anyone has ever tested me in the situation where I have difficulty, because otherwise they lock me into a sound-isolated booth, bombard me with tones, and then hit me with words in quiet." The patients know it. They say, "That doesn't really reflect where I have trouble." Why have we been so resistant to adopting speech in noise testing despite the fact that we've had tools in the form of the HINT, the QuickSIN, the Words in Noise test, other clinically efficacious measures? Yet if you talk to many clinicians, they say, "I don't have time for that," and yet many are using half or full word lists, delivered in quiet with live voice.

Why is it that we've been so slow to pull that in, despite there've been working groups within each of the professional associations that have identified it as a measure that can link not only, as you say, to cognition, which is what we're talking about here today, and some of those interesting results predicting that people with very big deficits may be at risk in the longer run? Beyond that, even for selecting whether to use directional microphones, whether to use accessories, it can even help with regards to making decisions about form factors and products that you're going to fit with. Why don't we do this?

Dr. Douglas L. Beck:

Well, that's a great question, and Dr. Lauren Benitez and I looked at that very seriously in 2019. In our casual survey of audiologists, we found that there were one or two reasons that came up. I don't know that they're true, they may have been excuses, but people don't want to pay for a speech in noise test, professionals and patients. It takes too long and all these other things.

What we did is we came up with the Beck-Benitez Speech in Noise Test. AAA published it in 2019. It's free. You don't have to buy anything. It's got an appendix that shows how to calibrate a room or a booth. It doesn't have to be done in a booth, and you don't have to buy anything. It's so simple, it's so easy, it's so inexpensive. I recommend, if you're using the QuickSIN or you're doing AzBio or you're doing the words in noise, any of those, keep doing it. That's great if you're doing well with that, but if you're not doing it because it's expensive and because you don't feel you have time, this is literally called the two-minute speech in noise test.

The goal is to compare the patient's unaided speech in noise score to their aided speech in noise score. We use Mead Killion's grading scale, which is an SNR-50. We don't have time to go into that today, but it's all explained in the paper, and I think that'll make it much easier for people to get into it. There's a lot of nuance in a speech in noise test. I think the important thing when you're picking a speech in noise test is to make sure that it's apples to apples. Always do it the same way. Always do it in the same acoustic environment. It does not have to be done at all in a sound booth.

Now, one question I didn't answer, Dave ... and I appreciate you asked it, but I neglected it earlier ... you said what about cognitive screenings, how do you know. If you're doing best practices and you have an older patient with a more significant hearing loss, and they have comorbidities and they're concerned and you're concerned, and maybe you've said to them, "Gee, do you feel like you're having memory issues or you're having a difficult time remembering things," if that points you towards this might be an at-risk patient, first thing I would do is a speech in noise test.

I'd make sure that I did that, because if their speech in noise score is not good, is not within the normal range, that would be somebody that I would consider at risk, and that would be somebody who I would say, audiologically, I now have a reason to do a cognitive screening. Whether you do the MoCA, which is the Montreal Cognitive Assessment, or the Mini Mental State Exam, or the Cognivue Thrive, or the Saint Louis University scale which is called SLUMS ... Saint Louis University Mental Scale, I think is what it stands for ... they're all good. It's not like any of them are bad. I would say pick the one that's most convenient for you.

Then the single most important thing about giving a cognitive screening is to be very well-trained. You can't just download it and do it. That's a huge mistake. You're going to get in trouble. You're going to scare patients, and there's no reason to do any of that. Just like when we started getting involved with ABR. You can't just stick electrodes on people and start giving them signals in their ears, right?

When we started doing impedance, because you and I were both there when we first did tympanograms and ipsi and contra reflexes. You can't just do it. I mean, we would spend a whole semester studying ipsilateral and contralateral reflexes, and what the different indications were for different pathologies. Same with tympanograms. You have to learn to do it. I would take it just as seriously as I would take any subtest or diagnostic test in audiology. I wouldn't do it unless I was an expert.

Dr. Dave Fabry:

Yeah. I think you really have to commit to learning how to do it. Look at the literature. Select the best measures that will fit into your best practice, whether it is for cognitive screening. Again, you've mentioned that professional associations have said this is a part of the scope of practice, given the interconnections between hearing loss, cognition, et cetera, but also for speech in noise testing.

I mean, whether it's the Beck-Benitez measure as you've done, or I'll put a plug in for Matt Fitzgerald at Stanford, who won the Editor's Award from Ear and Hearing in 2023 from the thousands and thousands of patients. It's a standard part of their battery. They've done a masterful job of setting a case for, as you mentioned, two patients with the same audiogram may have very different capabilities in terms of their speech in noise test, and they defend it with data. She who has data hath no need to shout, in my mind ...

Dr. Douglas L. Beck:

I love that.

Dr. Dave Fabry:

... when you're considering what's a part of best practice.

Dr. Douglas L. Beck:

Finally, the question is how does this impact anything we do, right? The answer is that these are patients who are seeing us because they can't remember what somebody said. They're not sure what somebody just said. They have speech in noise difficulty. If we start to sort that out and we elect the correct patients, the correct candidates, make sure we do a speech in noise because that's been scope of practice for 40 years, and then the people who don't do well there, I would go on and do a cognitive screening.

The reason we do that is because if somebody fails a cognitive screening, we must refer. That gets back to where you started. If you intervene quickly enough, early in the process, then you have results, much like the ENHANCE study, much like the ACHIEVE study. If you do nothing, that's going to be the answer. Nothing's going to happen. If you identify these people earlier ... and I would never say to a patient, "Gee, you failed a cognitive screening. You're going to have dementia." That's just ludicrous.

I would say, "You didn't do so well on that test. What I'm going to do is send the results to your doctor, let him or her take a look at it, and we'll see what they think. Because if they think that you're a good candidate, we can do things like memory training. We can put you in a speech language program. We can put you into all sorts of online and in-person rehab that may be beneficial." The literature shows that when we catch these things early for the right candidate, the people who are most at risk, we can change the trajectory on many of them.

Dr. Dave Fabry:

Right. As you said at the start of this, it's correlative data. We don't want to be advertising, "Wear hearing aids and prevent dementia." I mean, it really is up to the scope of practice of the audiologist, the dispenser that's working with them, using the tools that they have available.

Then I think also, a reminder that best practice is not a static set of tools. When you and I began, you already alluded, we didn't have admittance available easily. Certainly even Real Ear was in its very early stages when I was a young professional. Word recognition in quiet was the standard of care because, at the time that you and I both became audiologists, about 80% of hearing aids were fitted monaurally. Word recognition in quiet was done to look at the channel capacity for the left ear and the right ear to determine which ear we were going to fit. Regard best practice as evolving. It's a standard of that changes over time.

I hope, out of this discussion, that at least one or two clinicians says, "Okay. Finally I'll consider, within the context of all of the interest in cognition, that as you said, do a speech in noise test first," finally. Consider which tool might be the best for you among those we've discussed on the basis of the literature, and then use that as a one-two punch supplementing the audiologic data, to determine the speech in noise deficit.

It even does give you, as I mentioned, another course of action to help select directional microphones, form factors, technology tier levels, accessories. It helps you, for those who are working with patients and selecting amplification, but it also helps you focus on the needs of the patient as an overall individual, not just as a pair of ears to be matched. I think the conversation and the highlights and the tips that you've provided, consideration that you provided, are very important to standard of care.

Dr. Douglas L. Beck:

I appreciate that. Well, thank you, David. I appreciate that, and it's always a joy to work with you. The last thing I'd like to say, for people who are looking for any of those articles, if they go to a Hearing Matters podcast there's a library section, and in that library, free access. Whoever wants it can have copies of it. Any of the articles with my name on it, you have my permission to use them for educational purposes free.

Dr. Dave Fabry:

Excellent. Well, I really appreciate you allowing us to sit in and jam with you. Instead of musical instruments this time, to just riff back and forth about a topic that is of keen interest to us, and to professionals and to aging baby boomers as we both are out there, about how we can live our best life at every age throughout our life. A lot of that goes by ensuring that we can continue to engage and communicate with each other.

Dr. Douglas L. Beck:

Absolutely. David, thank you so much for your time. I wish you a joyful day.

Dr. Dave Fabry:

My pleasure.