Tuesday, July 13, 2010

Hearing Health and Alzheimer's Disease

by Max Stanley Chartrand, PhD

Today’s headlines are replete with warnings about the coming “tidal wave” of patients suffering from Alzheimer’s disease. Yet, little is currently being done to understand the correlation between presbycusis and the disease. This article looks at correlations between hearing loss and Alzheimer’s disease and suggests steps that need to be undertaken for these patients.

Almost like an orchestrated plan designed to scare the unwilling into submission, daily headlines scream about the coming “Tidal Wave of Alzheimer’s Cases.”1 Indeed, reported incidences of this difficult-to-diagnose malady do seem to increase daily, and are expected to reach nearly 9 million in the United States by the year 2020.2

But the rest of the story is that much- needed hearing health care, along with its powerful cognitive, communicative and psychosocial implications, is virtually being ignored within the mental health/medical diagnostic battery.3 Meanwhile, a growing number of studies reveal a strong correlation between unmitigated hearing loss and dementia in older adults.4,5,6

The signs of increasing dementia are not so much an increase in actual pathology as they are a demographic reflection of the rapid increase of people living longer than those generations before them. Furthermore, these larger numbers of seniors appear to be exhibiting far more serious hearing loss, yet are not as routinely referred for aural rehabilitation as they should be.7

Fig. 1 shows that there will soon be a virtual groundswell of those living past 65 years of age in the United States, the age group in which the vast majority of dementia cases occur.8,9 This constitutes most of the so-called “tidal wave.” Here the largest demographic advance is in the 85 years and over group. The growth of both of these age groups (i.e., over 65 and over 85) correlates strongly with the increased incidence of Alzheimer’s disease (AD) and serious hearing loss, as shown in Figs. 2 and 3, revealing a logical statistical parallel.

Accordingly, in comparing symptoms of AD and unmitigated hearing loss in Table 1, striking correlations are observed—correlations which should make thinking persons sit up and take notice. Currently, there is an alarmingly low hearing instrument penetration rate among the 28-million strong hearing- impaired population in the U.S. at each level of impairment. Since 1992, this trend has continued downward relative to a rapidly growing market of those needing hearing help, but who are not seeking it.

Field reports show that too few older patients who present with complaints of possible AD are tested and treated for hearing loss. Many have been told that they were not candidates for hearing instruments without so much as a test of their hearing; others have been advised to seek hearing care “on a trial basis.” This may explain why only 10% of those within the most medically and clinically intensive portion of the older adult population—those reporting AD complaints—who need hearing correction actually use it, compared to a 60% usage rate among the hearing-impaired non-AD population.10

This is particularly striking when studies indicate that the rate of need for hearing instrument use among those with AD may actually be higher than the non-AD population. Of 52 elderly patients diagnosed with memory disorders in a 1996 University of South Florida study, for example, 49 (94%) were found to suffer from serious uncorrected hearing impairment.11 Statistics like these have broad implications for hearing health care in general. For example, current pharmaceutical clinical trials under crash-program status need to look into the inclusion of hearing health status in their protocols, or risk losing objectivity in outcomes.

For the AD population there is persuasive evidence that hearing instrument use, combined with proper aural rehabilitation (in a multidisciplinary setting), can be a cost-effective approach to alleviating many AD-identified symptoms in patients who have AD and hearing loss.12-14 In this case, such a program has been found to lessen many debilitating symptoms, including depression, passivity, negativism, disorientation, anxiety, social isolation, feelings of helplessness, loss of independence and general cognitive decline.11

Removable Barriers

A research team at the University of Pittsburgh, in their composite review of studies on the subject of AD and hearing loss,10 concluded that there existed several professional and institutional barriers that prevent AD patients who suffer from hearing loss from receiving the hearing health care they need:
  1. Lack of medical referral;
  2. Difficult-to-test stereotype bias;
  3. Lack of efficacy data;
  4. Inappropriate diagnosis and technology;
  5. Lack of access to ongoing care.
Each of these barriers can be overcome with an intensified education program on AD at every level of the physical and mental health care disciplines, especially in the front lines with primary care physicians. Medical and clinical higher education programs need to include principles of the interrelationship between cognition and aural rehabilitation. Mental health professionals and researchers (including those conducting pharmacology trials) need to require hearing evaluations as part of the early diagnostic battery. No diagnosis for AD should be rendered without ascertaining the auditory component of the patient’s health profile.
Obviously, the campaign needs to include hearing instrument specialists and dispensing and clinical audiologists. Dispensing programs should include comprehensive, multidisciplinary approaches to true aural rehabilitation. These would feature: Coping and communication repair strategies, assistive devices, cochlear implantation, and in-depth patient education, as well as hearing instrument use. Professionals can further ease the burden by counseling about the resources afforded under the Americans with Disabilities Act (ADA) of 1990. This will help raise the quality of life for all hearing-impaired patients, especially those with AD overlay who are in danger of losing their ability to be a part of larger society.

Most hearing aid patients need 90-120 days for neurological and physical acclimatization.15,16 Certainly, dementia overlay cases require 6-12 month monitored programs to achieve appreciable goals of enhanced quality of life and personal independence.17 But as a result of 30-day trial policies, the industry has created an entire generation of hearing-impaired non-users today who think “hearing aids don’t work” for them, because they couldn’t achieve desired outcomes in the impossible space of 30 days. This also places the reasonable business expectations of professionals at odds with those they serve, causing a forfeiture of needed but uncompensated aftercare services.

Alzheimer’s Disease Untreated Hearing Loss
Depression, anxiety, disorientation Depression, anxiety, feelings of isolation
Reduced language comprehension Reduced communication ability
Impaired memory (esp. short-term memory) Reduced cognitive input
Inappropriate psychosocial responses Inappropriate psychosocial responses
Loss of ability to recognize (agnosia) Reduced mental scores
Denial, defensiveness, negativity Denial, heightened defensiveness, negativity
Distrust and suspicion regarding other’s motives Distrust and paranoia (e.g., belief that others may be talking about them)
Table 1. Symptomatic similarities of Alzheimer’s disease and untreated hearing loss.
We also need to develop and implement better hearing care evaluation and rehabilitation models for those who also suffer from dementia. This would include educational materials to share with allied professionals with whom we might work in meeting the needs of hearing aid patients. Doing so will effectively bring several other professionals into the circle of care, including occupational therapists, geriatricians and eldercare professionals.17

Hearing Help and Alzheimer's

The literature is replete with conclusive evidence that unmitigated hearing loss increases the risk for depression, hypertension, heart conditions, dementia, long-term convalescence, income loss and the breaking of familial bonds. Yet far too many of those needing hearing care to assist in the prevention and/or amelioration of accompanying dementia are not receiving it. A steady, coordinated drumbeat of professional and consumer education can significantly pierce through the wall of public, professional and governmental misconceptions.

Over the years the author has had the opportunity to visit numerous long-term nursing facilities. Invariably, the question “How many of your patients suffer from dementia?” is asked. Almost without variation the answer comes back, “Well, most of them, actually. That’s why they’re here.”

The caregivers are then asked, “How many suffer from serious hearing loss?”, to which a typical reply might be: “Well, let’s see, Mr. Jones has a hearing aid, and Mrs. Smith has two…that’s all I can think of…the rest of our residents seem to hear fine.” However, hearing screening tests, when administered to the entire residential population, generally reveal that every resident there suffers from a bilateral loss greater than 30 dB PTA, with many in excess of 65 dB PTA. And what about the two patients who already have hearing aids? Mr. Jones’ hearing aid was lost in the wash six months ago, and Mrs. Smith’s aids were plugged solidly with cerumen, each sporting a dead, crusted-over zinc-air battery requiring a pocket knife to remove. In essence, Mrs. Smith has been wearing ear plugs for several weeks.

Obviously, the distance between informed mental/hearing health management and today’s current standards of care appear to be far apart. Closing the gap will require ongoing research and education, motivational marketing and unyielding commitment by all healthcare professionals. Hopefully, appropriate measures can be implemented in time to help stem and appropriately administer to the anticipated “tidal wave” of Alzheimer’s patients.

Max Chartrand, PhD, serves as director of research for DigiCare® Hearing Research & Rehabilitation, Rye, CO, and is a faculty member of the International Institute for Hearing Instruments Studies and the American Conference of Audioprosthology.
Correspondence can be addressed to HR or Max Chartrand, DigiCare Hearing Research & Rehabilitation, P.O. Box 706, Rye, CO 81069; email: Mchartran@aol.com.

1. The coming tidal wave of Alzheimer’s. USA Today: March 22, 2000.
2. Aural Rehab Concepts: A survey of the literature on the prevalence of Alzheimer’s. Rye, CO, 2000.
3. Chartrand MS: Alzheimer’s & hearing loss. Professional education course, International Institute for Hearing Instruments Studies, Livonia, MI, 2000.
4. Ulmann R, Larson E, Rees T, Koepsell T & Duckert L: Relationship of hearing impairment to dementia and cognitive function in older adults. JAMA 1989; 261: 1916-1919.
5. Peters C Potter J & Scholer S: Hearing impairment as a predictor of cognitive decline in dementia. J Am Geriatric Soc 1988; 36: 981-986.
6. Ventry I & Weinstein B: The hearing handicap for the elderly: A new tool. Ear & Hearing 1982; 3: 128-133.
7. Chartrand MS: Demographics in hearing healthcare. Continuing education course, Livonia, MI: International Institute for Hearing Instruments Studies, 1999.
8. U. S. Bureau of the Census: U.S. Bureau of the Census Report, 1998.
9. Aural Rehab Concepts: Statistical projection for Alzheimer’s in the U.S. Population 2000-2020. Rye, CO, 2001.
10. Palmer C, Adams S, Durrant J, Bourgeouis M & Ross M: Managing hearing loss in patient with Alzheimer’s disease. J Am Acad Audiol 1998; 9 : 275-284.
11. Gold M: Hearing loss in a memory disorders clinic: A specially vulnerable population. Archives of Neurology 1996; 53: 922.
12. Durrant J, Gilmartin J, Holland A, Kamerer D & Newall P: Hearing disorders management in Alzheimer’s disease patients. Hear Instrum 1990; 42: 32-35.
13. Hardick E: Aural rehabilitation programs for the aged can be successful. J Acad Rehab Audiol 1977; 10: 51-67.
14. Ratcliffe D: (Citation) Task Force on the National Strategic Research Plan of the National Institute on Deafness and Other Communication Disorders: Costs, benefits, and quality of life. Hear Jour 1992; 45 (9):11-18.
15. Palmer C: Deprivation, acclimatization, adaptation: What do they mean for your hearing aid fittings? Hear Jour 1995; 47(5):10, 41-45.
16. Chartrand M & Chartrand G: Sherlock & Watson on solving the mysteries of aural rehabilitation. Continuing education course. Livonia, MI: International Institute for Hearing Instruments Studies, 2001.
17. Gatehouse S & Killion M: HABRAT: Hearing Aid Brain Rewiring Accommodation Time. Hear Instrum 1993; 44 (10): 29-32.

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