Hearing intervention versus health education control to reduce cognitive decline in older adults with hearing loss in the USA (ACHIEVE): a multicentre, randomised controlled trial.

BACKGROUND: Hearing loss is associated with increased cognitive decline and incident dementia in older adults. We aimed to investigate whether a hearing intervention could reduce cognitive decline in cognitively healthy older adults with hearing loss. METHODS: The ACHIEVE study is a multicentre, parallel-group, unmasked, randomised controlled trial of adults aged 70-84 years with untreated hearing loss and without substantial cognitive impairment that took place at four community study sites across the USA. Participants were recruited from two study populations at each site: (1) older adults participating in a long-standing observational study of cardiovascular health (Atherosclerosis Risk in Communities [ARIC] study), and (2) healthy de novo community volunteers. Participants were randomly assigned (1:1) to a hearing intervention (audiological counselling and provision of hearing aids) or a control intervention of health education (individual sessions with a health educator covering topics on chronic disease prevention) and followed up every 6 months. The primary endpoint was 3-year change in a global cognition standardised factor score from a comprehensive neurocognitive battery. Analysis was by intention to treat. This trial was registered at ClinicalTrials.gov, NCT03243422. FINDINGS: From Nov 9, 2017, to Oct 25, 2019, we screened 3004 participants for eligibility and randomly assigned 977 (32·5%; 238 [24%] from ARIC and 739 [76%] de novo). We randomly assigned 490 (50%) to the hearing intervention and 487 (50%) to the health education control. The cohort had a mean age of 76·8 years (SD 4·0), 523 (54%) were female, 454 (46%) were male, and most were White (n=858 [88%]). Participants from ARIC were older, had more risk factors for cognitive decline, and had lower baseline cognitive scores than those in the de novo cohort. In the primary analysis combining the ARIC and de novo cohorts, 3-year cognitive change (in SD units) was not significantly different between the hearing intervention and health education control groups (-0·200 [95% CI -0·256 to -0·144] in the hearing intervention group and -0·202 [-0·258 to -0·145] in the control group; difference 0·002 [-0·077 to 0·081]; p=0·96). However, a prespecified sensitivity analysis showed a significant difference in the effect of the hearing intervention on 3-year cognitive change between the ARIC and de novo cohorts (pinteraction=0·010). Other prespecified sensitivity analyses that varied analytical parameters used in the total cohort did not change the observed results. No significant adverse events attributed to the study were reported with either the hearing intervention or health education control. INTERPRETATION: The hearing intervention did not reduce 3-year cognitive decline in the primary analysis of the total cohort. However, a prespecified sensitivity analysis showed that the effect differed between the two study populations that comprised the cohort. These findings suggest that a hearing intervention might reduce cognitive change over 3 years in populations of older adults at increased risk for cognitive decline but not in populations at decreased risk for cognitive decline. FUNDING: US National Institutes of Health.

Hearing loss and cognition: A protocol for ensuring speech understanding before neurocognitive assessment.

INTRODUCTION: Many neurocognitive evaluations involve auditory stimuli, yet there are no standard testing guidelines for individuals with hearing loss. The ensuring speech understanding (ESU) test was developed to confirm speech understanding and determine whether hearing accommodations are necessary for neurocognitive testing. METHODS: Hearing was assessed using audiometry. The probability of ESU test failure by hearing status was estimated in 2679 participants (mean age: 81.4 ± 4.6 years) using multivariate logistic regression. RESULTS: Only 2.2% (N = 58) of participants failed the ESU test. The probability of failure increased with hearing loss severity; similar results were observed for those with and without mild cognitive impairment or dementia. DISCUSSION: The ESU test is appropriate for individuals who have variable degrees of hearing loss and cognitive function. This test can be used prior to neurocognitive testing to help reduce the risk of hearing loss and compromised auditory access to speech stimuli causing poorer performance on neurocognitive evaluation.

Association Between Adult-Onset Hearing Loss and Income: A Systematic Review.

INTRODUCTION: Hearing loss has been shown to be associated with both negative health outcomes and low socioeconomic position, including lower income. Despite this, a thorough review of the existing literature on this relationship has not yet been performed. OBJECTIVES: To evaluate available literature on the possible association between income and adult-onset hearing loss. DESIGN: A search was conducted in eight databases for all relevant literature using terms focused on hearing loss and income. Studies reporting the presence or absence of an association between income and hearing loss, full-text English-language access, and a predominantly adult population (≥18 years old) were eligible. The Newcastle-Ottawa Quality Assessment Scale was used to assess risk of bias. RESULTS: The initial literature search yielded 2994 references with three additional sources added through citation searching. After duplicate removal, 2355 articles underwent title and abstract screening. This yielded 161 articles eligible for full-text review resulting in 46 articles that were included in qualitative synthesis. Of the included studies, 41 of 46 articles found an association between income and adult-onset hearing loss. Due to heterogeneity among study designs, a meta-analysis was not performed. CONCLUSIONS: The available literature consistently supports an association between income and adult-onset hearing loss but is limited entirely to cross-sectional studies with the directionality remaining unknown. An aging population and the negative health outcomes associated with hearing loss, emphasize the importance of understanding and addressing the role of social determinants of health in the prevention and management of hearing loss.

The association of hearing loss with frailty among community-dwelling older adults: findings from the National Health and Aging Trends Study.

BACKGROUND: The identification of modifiable risk factors is crucial for the prevention and/or reversal of frailty, which is associated with significant morbidity and mortality. Hearing loss affects two-thirds of older adults in the United States (U.S.) and is associated with physical and cognitive decline which may increase frailty risk. We investigated the association of hearing loss and hearing aid use with frailty and pre-frailty in a nationally representative sample of older adults in the U.S. METHODS: Cross-sectional analysis of the National Health and Aging Trends Study (2021 round). The better-hearing ear pure-tone average (BPTA) at speech-frequencies (0.5-4 kHz) was modeled continuously (per 10 dB) and categorically (no ≤ 25 dB, mild 26-40 dB, moderate or greater > 40 dB hearing loss). Hearing aid use was self-reported. The physical frailty phenotype (frail, pre-frail, robust) was determined based on Fried criteria: unintentional weight loss, exhaustion, low physical activity, weakness, slow walking speed. We used multinomial multivariable regression adjusted for sociodemographic and health characteristics (odds ratios [95% Confidence Intervals]). RESULTS: Among 2,361 participants (mean age = 81 years, 56% female, 19% Black), 860 (36%) had mild and 864 (37%) had moderate or greater hearing loss. Worse hearing was associated with greater odds of being frail versus robust (OR = 1.20 [1.05-1.38] per 10 dB difference). Categorically, moderate or greater hearing loss was associated with greater odds of being frail (OR = 1.84 [1.01-3.08]) and pre-frail (OR = 1.46 [1.01-2.10]) versus robust. Among 1,724 participants with hearing loss, compared to hearing aid users (N = 522), nonusers had greater odds of being frail (OR = 2.54 [1.54-4.18]) and pre-frail (OR = 1.51 [1.05-2.17]) versus robust, and frail versus pre-frail (OR = 1.68 [1.04-2.72]). CONCLUSIONS: In a nationally representative sample of older adults in the U.S., using gold-standard hearing measures and a validated frailty phenotype, hearing loss and lack of hearing aid use was cross-sectionally associated with frailty and pre-frailty. Future longitudinal studies are needed to establish if hearing loss is a risk factor for frailty, which may have significant clinical importance.

Development, assessment, and monitoring of audiologic treatment fidelity in the aging and cognitive health evaluation in elders (ACHIEVE) randomised controlled trial.

OBJECTIVE: Studies investigating hearing interventions under-utilise and under-report treatment fidelity planning, implementation, and assessment. This represents a critical gap in the field that has the potential to impede advancements in the successful dissemination and implementation of interventions. Thus, our objective was to describe treatment fidelity planning and implementation for hearing intervention in the multi-site Ageing and Cognitive Health Evaluation in Elders (ACHIEVE) randomised controlled trial. DESIGN: Our treatment fidelity plan was based on a framework defined by the National Institutes of Health Behaviour Change Consortium (NIH BCC), and included strategies to enhance study design, provider training, and treatment delivery, receipt, and enactment. STUDY SAMPLE: To assess the fidelity of the ACHIEVE hearing intervention, we distributed a checklist containing criteria from each NIH BCC core treatment fidelity category to nine raters. RESULTS: The ACHIEVE hearing intervention fidelity plan satisfied 96% of NIH BCC criteria. Our assessment suggested a need for including clear, objective definitions of provider characteristics and non-treatment aspects of intervention delivery in future fidelity plans. CONCLUSIONS: The ACHIEVE hearing intervention fidelity plan can serve as a framework for the application of NIH BCC fidelity strategies for future studies and enhance the ability of researchers to reliably implement evidence-based interventions.

Satisfaction With Quality of Health Care Among Medicare Beneficiaries With Functional Hearing Loss.

BACKGROUND/OBJECTIVES: Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries. METHODS: Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample. RESULTS: Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively. CONCLUSIONS: Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment.

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD. OBJECTIVE: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center. DESIGN, SETTING, AND PARTICIPANTS: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017. OUTCOME MEASUREMENTS: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia. RESULTS: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89). CONCLUSION: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.

Hearing impairment and missing cognitive test scores in a population-based study of older adults: The Atherosclerosis Risk in Communities neurocognitive study.

INTRODUCTION: Hearing impairment is associated with poor cognitive test performance in older adults. However, hearing's impact on cognitive test completion is poorly described, and missing cognitive data due to hearing impairment could misestimate the association. METHODS: We investigated if hearing impairment is associated with missing neurocognitive scores in 3678 adults (72-94 years). Hearing impairment was defined by the better-ear pure tone average of speech-frequency thresholds (0.5-4 kHz) >25 decibels. RESULTS: Hearing impairment was associated with greater missingness on all auditory-only tests, including Logical Memory (prevalence ratio [PR] comparing ≥ moderate impairment vs normal hearing:1.68, 95% confidence interval [CI] 1.26, 2.25) and Digits Backwards (PR 1.62; 95% CI 1.21, 2.17); and two non-auditory tests, Boston Naming (PR 1.61; 95% CI 1.21, 2.17) and Trail Making B (PR 1.55; 95% CI 1.29, 1.86). Models that imputed missing cognitive scores showed the strongest hearing-cognition associations. DISCUSSION: Older adults with hearing impairment are less likely to complete cognitive testing, thereby underestimating the hearing impairment-cognition relationship.

The Hearing Intervention for the Aging and Cognitive Health Evaluation in Elders Randomized Control Trial: Manualization and Feasibility Study.

OBJECTIVES: This work describes the development of a manualized best-practice hearing intervention for older adults participating in the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) randomized controlled clinical trial. Manualization of interventions for clinical trials is critical for assuring intervention fidelity and quality, especially in large multisite studies. The multisite ACHIEVE randomized controlled trial is designed to assess the efficacy of a hearing intervention on rates of cognitive decline in older adults. We describe the development of the manualized hearing intervention through an iterative process that included addressing implementation questions through the completion of a feasibility study (ACHIEVE-Feasibility). DESIGN: Following published recommendations for manualized intervention development, an iterative process was used to define the ACHIEVE-hearing intervention elements and create an initial manual. The intervention was then delivered within the ACHIEVE-Feasibility study using one-group pre-post design appropriate for assessing questions related to implementation. Participants were recruited from the Tampa, Florida area between May 2015 and April 2016. Inclusion criteria were cognitively healthy adults aged 70 to 89 with symmetrical mild-to-moderately severe sensorineural hearing loss. The ACHIEVE-Feasibility study sought to assess the implementation of the manualized hearing intervention by: (1) confirming improvement in expected outcomes were achieved including aided speech-in-noise performance and perception of disease-specific self-report measures; (2) determining whether the participants would comply with the intervention including session attendance and use of hearing aids; and (3) determining whether the intervention sessions could be delivered within a reasonable timeframe. RESULTS: The initial manualized intervention that incorporated the identified best-practice elements was evaluated for feasibility among 21 eligible participants and 9 communication partners. Post-intervention expected outcomes were obtained with speech-in-noise performance results demonstrating a significant improvement under the aided condition and self-reported measures showing a significant reduction in self-perceived hearing handicap. Compliance was excellent, with 20 of the 21 participants (95.2%) completing all intervention sessions and 19 (90.4%) returning for the 6-month post-intervention visit. Furthermore, self-reported hearing aid compliance was >8 hr/day, and the average daily hearing aid use from datalogging was 7.8 hr. Study completion was delivered in a reasonable timeframe with visits ranging from 27 to 85 min per visit. Through an iterative process, the intervention elements were refined, and the accompanying manual was revised based on the ACHIEVE-Feasibility study activities, results, and clinician and participant informal feedback. CONCLUSION: The processes for the development of a manualized intervention described here provide guidance for future researchers who aim to examine the efficacy of approaches for the treatment of hearing loss in a clinical trial. The manualized ACHIEVE-Hearing Intervention provides a patient-centered, yet standardized, step-by-step process for comprehensive audiological assessment, goal setting, and treatment through the use of hearing aids, other hearing assistive technologies, counseling, and education aimed at supporting self-management of hearing loss. The ACHIEVE-Hearing Intervention is feasible in terms of implementation with respect to verified expected outcomes, compliance, and reasonable timeframe delivery. Our processes assure intervention fidelity and quality for use in the ACHIEVE randomized controlled trial (ClinicalTrials.gov Identifier: NCT03243422).

Diet quality and hearing loss among middle-older aged adults in the USA: findings from National Health and Nutrition Examination Survey.

OBJECTIVE: To examine the associations between overall diet quality and hearing function among middle-older aged adults in the USA. DESIGN: Cross-sectional analysis. Diet quality was examined using the Mediterranean Diet Score (MDS), using data from a single 24 h dietary recall. Hearing function was objectively measured by audiometry assessments and hearing loss, including high- and low-frequency hearing loss, was defined as pure-tone averages at specific ranges of hearing frequencies >25 dB. Weighted logistic regression analyses were performed to examine the associations of MDS (scored 0-9, categorized at the median as ≤3 or >3) with hearing loss and high- and low-frequency hearing loss. SETTING: National Health and Nutrition Examination Surveys 2000-2006 and 2009-2012. PARTICIPANTS: Adults aged ≥50 years (n 1639) with valid dietary and audiometry assessments. RESULTS: After adjusting for potential confounders, a non-significant trend for a protective association of higher MDS was observed for hearing loss (OR = 0·78; 95 % CI 0·49, 1·23). A significant inverse association was observed for high-frequency hearing loss (OR = 0·64; 95 % CI 0·43, 0·95). No association was found for low-frequency hearing loss among women; however, higher MDS was significantly associated with higher odds of low-frequency hearing loss among men (OR = 2·63; 95 % CI 1·39, 4·95). CONCLUSIONS: Among middle-older aged adults, adherence to a Mediterranean-style diet was inversely associated with hearing loss, including those at high hearing frequencies, among older adults. However, a detrimental association was observed at low hearing frequencies among men. Future investigations with a longitudinal design are needed to clarify the associations between diet quality and hearing loss.

Accompaniment to healthcare visits: the impact of sensory impairment.

BACKGROUND: Millions of older adults in the United States experience hearing, vision, and dual sensory impairment (concurring hearing and vision impairment) yet little research exists on their needs in interactions with the healthcare system. This piece aims to determine the use of accompaniment in healthcare interactions by persons with sensory impairment. METHODS: These cross-sectional analyses included data from the 2015 Medicare Current Beneficiaries Survey and survey weighting provided by Centers for Medicare and Medicaid Services. Adjusted odds of reporting accompaniment to healthcare visits and given reasons for accompaniment among United States Medicare beneficiaries with self-reported sensory impairment (hearing, vision, and dual sensory impairment) were examined. RESULTS: After excluding observations with missing data, 10,748 Medicare beneficiaries remained representing a 46 million total weighted nationally representative sample, of which 88.9% reported no sensory impairment, 5.52% reported hearing impairment, 3.56% reported vision impairment, and 0.93% reported dual sensory impairment. Those with vision impairment and dual sensory impairment had 2.139 (95% confidence interval [CI] =1.605-2.850) and 2.703 (CI = 1.549-4.718) times the odds of reporting accompaniment to healthcare visits relative to those without sensory impairment. A secondary analysis suggests communication needs as the primary reason for accompaniment among persons with hearing loss, while those with vision impairment were more likely to indicate transportation needs. CONCLUSIONS: Healthcare accompaniment is common for persons with sensory loss and healthcare systems should consider accommodations for and leveraging accompaniment to improve healthcare for persons with sensory impairments. In light of the current COVID-19 pandemic, as hospitals limit visitors to reduce the spread of infection, arrangements should be made to ensure that the communication and transportation needs of those with sensory impairment are not neglected.

Impact of neuroendocrine morphology on cancer outcomes and stage at diagnosis: a UK nationwide cohort study 2013-2015.

BACKGROUND: The diagnosis of neuroendocrine neoplasms (NENs) is often delayed. This first UK population-based epidemiological study of NENs compares outcomes with non-NENs to identify any inequalities. METHODS: Age-standardised incidence rate (ASR), 1-year overall survival, hazard ratios and standardised mortality rates (SMRs) were calculated for all malignant NENs diagnosed 2013-2015 from UK national Public Health records. Comparison with non-NENs assessed 1-year overall survival (1YS) and association between diagnosis at stage IV and morphology. RESULTS: A total of 15,222 NENs were identified, with an ASR (2013-2015 combined) of 8.6 per 100,000 (95% CI 8.5-8.7); 4.6 per 100 000 (95% CI, 4.5-4.7) for gastro-entero-pancreatic (GEP) NENs. The 1YS was 75% (95% CI, 73.9-75.4) varying significantly by sex. Site and morphology were prognostic. NENs (predominantly small cell carcinomas) in the oesophagus, bladder, prostate, and female reproductive organs had a poorer outcome and were three times more likely to be diagnosed at stage IV than non-NENs. CONCLUSION: Advanced stage at diagnosis with significantly poorer outcomes of some NENs compared with non-NENs at the same anatomical site, highlight the need for improved access to specialist services and targeted service improvement.

Access to adults' hearing aids: policies and technologies used in eight countries.

As the proportion of older adults in the world's total population continues to grow, the adverse health outcomes of age-related hearing loss are becoming increasingly recognized. While research has shown that age-related hearing loss is the single greatest modifiable risk factor for dementia, use of hearing aids remains low worldwide, even in many middle- and high-income countries. Reasons for poor uptake of hearing aids are likely to involve a combination of factors, ranging from increasing costs of hearing aid technology to a widespread lack of insurance coverage. This article aims to identify the current state of access to hearing aids, focusing on eight middle- and high-income countries. We discuss how to facilitate greater access to hearing aids for patients by addressing changes in how devices are regulated, technological advancements in hearing devices, the need to adjust reimbursement schemes and the importance of adaptation among the community workforce for hearing-care.

Alors que la proportion de personnes âgées au sein de la population mondiale totale continue à croître, les effets néfastes sur la santé de la perte de l'acuité auditive liée à l'âge sont de plus en plus reconnus. Bien que la recherche ait démontré que la perte de l'acuité auditive liée à l'âge est le principal facteur de risque modifiable de la démence, l'utilisation de prothèses auditives reste limitée à l'échelle mondiale, y compris dans de nombreux pays à revenu intermédiaire et élevé. Les raisons de ce recours limité aux prothèses auditives tiennent probablement à une combinaison de facteurs qui vont des coûts croissants de la technologie des appareils auditifs à un manque généralisé de couverture médicale. Cet article vise à déterminer l'état actuel de l'accès aux prothèses auditives en se concentrant sur huit pays à revenu intermédiaire et élevé. Nous étudions comment permettre aux patients d'accéder plus facilement aux prothèses auditives en tenant compte de la réglementation applicable aux appareils, des progrès technologiques relatifs aux appareils auditifs, de la nécessité d'ajuster les systèmes de remboursement et de l'importance de l'adaptation au sein de la main-d'œuvre locale pour les soins auditifs.

A medida que la proporción de adultos mayores en la población total del mundo continúa creciendo, los resultados adversos para la salud de la pérdida de audición relacionada con la edad son cada vez más reconocidos. Aunque las investigaciones han demostrado que la pérdida de audición relacionada con la edad es el mayor factor de riesgo modificable para la demencia, el uso de audífonos sigue siendo bajo en todo el mundo, incluso en muchos países de ingresos medios y altos. Las causas de la escasa aceptación de los audífonos pueden ser una combinación de factores, que van desde el aumento de los costes de la tecnología de los audífonos hasta la falta generalizada de cobertura de seguro. Este artículo pretende identificar el estado actual del acceso a los audífonos, centrándose en ocho países de ingresos medios y altos. Discutimos cómo facilitar un mayor acceso a los audífonos para los pacientes abordando los cambios en cómo se regulan los dispositivos, los avances tecnológicos en los audífonos, la necesidad de ajustar los esquemas de reembolso y la importancia de la adaptación entre los trabajadores de la comunidad para el cuidado de la audición.

Age-Related Hearing Loss and the Listening Environment: Communication Challenges in a Group Care Setting for Older Adults.

Ensuring that older adults in long-term care settings can effectively communicate is important. The goal of this study was to characterize key modifiable factors that could affect verbal communication in an adult day care setting, namely prevalence of audiometric hearing loss and the acoustic characteristics in the activity hall. The prevalence of age-related hearing loss among participants (n=51) was 71%, although only 15% of enrollees at the group care setting (n=21 of 140) used amplification. The noise and reverberation characteristics of the activity hall revealed signal-to-noise ratios of -3.1 decibels (dB) and -2.4 dB during morning activity and lunch, respectively, which are poorer than the recommended levels for understanding speech in background noise. Older adults attending adult day services are likely to spend the day in a room with acoustics that are too challenging to understand speech clearly. Opportunities to improve listening environments in group care settings for older adults are discussed.

A common classification framework for neuroendocrine neoplasms: an International Agency for Research on Cancer (IARC) and World Health Organization (WHO) expert consensus proposal.

The classification of neuroendocrine neoplasms (NENs) differs between organ systems and currently causes considerable confusion. A uniform classification framework for NENs at any anatomical location may reduce inconsistencies and contradictions among the various systems currently in use. The classification suggested here is intended to allow pathologists and clinicians to manage their patients with NENs consistently, while acknowledging organ-specific differences in classification criteria, tumor biology, and prognostic factors. The classification suggested is based on a consensus conference held at the International Agency for Research on Cancer (IARC) in November 2017 and subsequent discussion with additional experts. The key feature of the new classification is a distinction between differentiated neuroendocrine tumors (NETs), also designated carcinoid tumors in some systems, and poorly differentiated NECs, as they both share common expression of neuroendocrine markers. This dichotomous morphological subdivision into NETs and NECs is supported by genetic evidence at specific anatomic sites as well as clinical, epidemiologic, histologic, and prognostic differences. In many organ systems, NETs are graded as G1, G2, or G3 based on mitotic count and/or Ki-67 labeling index, and/or the presence of necrosis; NECs are considered high grade by definition. We believe this conceptual approach can form the basis for the next generation of NEN classifications and will allow more consistent taxonomy to understand how neoplasms from different organ systems inter-relate clinically and genetically.

Hearing Loss and Dementia Prevalence in Older Adults in the US.

This study assesses the association of audiometric hearing loss and hearing aid use with dementia among community-dwelling older US Medicare beneficiaries.

Implications of Hearing Care Policy for Nurses.

Hearing loss (HL) becomes increasingly common with age and can lead to multiple negative outcomes, including isolation, falls, depression, altered social relationships, and altered cognitive functioning. HL also can affect patient-provider communication and lead to misunderstandings. Despite the negative effects that HL has on multiple domains, less than 20% to 25% of individuals who might benefit from amplification devices and/or hearing aids own them. Barriers to use include stigma, cost, and access. Nurses can play a critical role in promoting appropriate care for individuals with HL and providing access for those who need hearing aids. The current article (a) briefly reviews how history and policies, especially Medicare and Medicaid, but also those defining the practice of audiology and dispensing of hearing aids, affect insurance coverage for hearing care; (b) reviews how a combination of forces brought the need for accessible and affordable hearing care to national attention and resulted in the Over-the-Counter (OTC) Hearing Aid Act; and (c) discusses the implications of the OTC Act for nurses and nursing practice. [Journal of Gerontological Nursing, 44(9), 9-14.].

HPV status and favourable outcome in vulvar squamous cancer.

It is universally accepted that high-risk human papillomavirus (HR-HPV) is the cause of cervical dysplasia and cancer. More recently, it has been shown that HPV is also a marker of clinical outcome in oropharyngeal cancer. However, contemporary information is lacking on both the prevalence of HPV infection in vulvar cancer (VSCC), its precursor lesion, vulvar intraepithelial neoplasia (VIN) and the influence of HPV-status on the prognosis of this malignancy. We have conducted a detailed population-based study to examine rates of progression of VIN to VSCC, type-specific HPV prevalence in vulvar disease and the influence of HPV status on clinical outcome in VSCC. We observed that the age at which women are diagnosed with VSCC is falling and there is a significant time gap between first diagnosis of VIN and progression to invasive disease. HR-HPV infection was detected in 87% (97/112) cases of VIN and 52% cases (32/62) of VSCC. The presence of HR-HPV in squamous intraepithelial lesion was associated with lower rates of progression to invasive cancer (hazard ratio, 0.22, p = 0.001). In the adjusted analysis, HR-HPV was associated with improved progression-free survival of VSCC compared to those with HPV negative tumours (hazard ratio, 0.32, p = 0.02).

Neuroendocrine tumours of the gynecological tract.

PURPOSE OF REVIEW: The purpose of this article will be to review neuroendocrine tumours (NETs) of the gynaecological tract. NETs are generally considered to be uncommon and primary tumours in the gynaecological tract on arrival rare or very rare. It is important to distinguish true primary tumours from metastatic as the management is very different. These tumours ranged from highly aggressive small cell carcinomas (SCCs) sometimes associated with secretion of neuropeptides that may be functional and cause distinctive syndromes. On the other hand, the well differentiated low-grade NETs generally behave in a very indolent manner with an excellent prognosis. Very recent new data have identified a molecular marker for small cell carcinomas of the ovary although as yet there is no associated candidate drug. RECENT FINDINGS: Recent developments include the identification of a molecular marker for small cell carcinomas of the ovary of hypercalcaemic type; this will help to identify these tumours more confidently. New therapeutic developments for well differentiated NETs include mammalian target of rapamycin pathway inhibitors and peptide receptor radionuclide therapy. SUMMARY: In summary, these are rare tumours with a low incidence although higher prevalence. They require a multidisciplinary approach to management and should be supervised by specialist teams familiar with NETs.