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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
Maintaining Physical Mobility & Activity
Cognitive Vitality & Avoiding Dementia
Avoiding Injury
Preventing Illness andDisease
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
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
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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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
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
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
Healthy Aging
Maintaining Physical Mobility & Activity
Cognitive Vitality & Avoiding Dementia
Avoiding Injury
Preventing Illness andDisease
Keeping Socially Engaged & Active
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”
Hearing Loss & DementiaHearing Loss & DementiaCommon Cause Common Cause or or Modifiable Risk FactorModifiable Risk Factor
Cognitive Load
Hearing Loss
Cognitive Decline & Dementia
Common pathological process
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
Hearing Loss & Cognitive LoadHearing Loss & Cognitive Load
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
Hearing Loss & Cognitive LoadHearing Loss & Cognitive Load
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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Hearing Loss & DementiaHearing Loss & DementiaCommon Cause Common Cause or or Modifiable Risk FactorModifiable Risk Factor
Cognitive Load
Hearing Loss
Cognitive Decline & Dementia
Common pathological process
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
Lin et al., Arch Lin et al., Arch NeuroNeuro., 2011., 2011
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
Lin et al., Arch Lin et al., Arch NeuroNeuro., 2011., 2011
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
Maintaining Physical Mobility & Activity
Cognitive Vitality & Avoiding Dementia
Avoiding Injury
Preventing Illness andDisease
Keeping Socially Engaged & Active
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
Common pathological process
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
Maintaining Physical Mobility & Activity
Cognitive Vitality & Avoiding Dementia
Avoiding Injury
Preventing Illness andDisease
Keeping Socially Engaged & Active
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
Common pathological process
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
Maintaining Physical Mobility & Activity
Cognitive Vitality & Avoiding Dementia
Avoiding Injury
Preventing Illness andDisease
Keeping Socially Engaged & Active
Hearing Loss
Hearing Loss & Healthy AgingHearing Loss & Healthy AgingCommon Cause Common Cause or or Modifiable Risk FactorModifiable Risk Factor
Cognitive Load
Hearing Loss
HealthyAging
Common pathological process
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
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
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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
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
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
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
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