A cross-cultural study of the Montreal Cognitive Assessment for people with hearing impairment.

BACKGROUND: Cognitive screening tools enable the detection of cognitive impairment, facilitate timely intervention, inform clinical care, and allow long-term planning. The Montreal Cognitive Assessment for people with hearing impairment (MoCA-H) was developed as a reliable cognitive screening tool for people with hearing loss. Using the same methodology across four languages, this study examined whether cultural or linguistic factors affect the performance of the MoCA-H. METHODS: The current study investigated the performance of the MoCA-H across English, German, French, and Greek language groups (n = 385) controlling for demographic factors known to affect the performance of the MoCA-H. RESULTS: In a multiple regression model accounting for age, sex, and education, cultural-linguistic group accounted for 6.89% of variance in the total MoCA-H score. Differences between languages in mean score of up to 2.6 points were observed. CONCLUSIONS: Cultural or linguistic factors have a clinically significant impact on the performance of the MoCA-H such that optimal performance cut points for identification of cognitive impairment derived in English-speaking populations are likely inappropriate for use in non-English speaking populations. To ensure reliable identification of cognitive impairment, it is essential that locally appropriate performance cut points are established for each translation of the MoCA-H.

Do people with cognitive impairment benefit from cochlear implants? A scoping review.

PURPOSE: To identify and evaluate the evidence for the benefits of cochlear implants for people with cognitive impairment or dementia in terms of speech recognition, quality of life, behavioural and psychological symptoms of dementia, cognition, function in daily life, mental well-being, and caregiver burden. METHODS: Ten electronic databases were searched systematically from inception to December 2023 for studies reporting on outcomes for cochlear implants that included adults identified with cognitive impairment, mild cognitive impairment, or dementia. RESULTS: Thirteen studies were included in this review with a combined total of 222 cochlear implant patients with cognitive impairment, mild cognitive impairment. Two studies were non-randomised controlled design, the remainder were single group studies, case series or single case studies. Evidence suggested that people with cognitive impairment benefit in terms of improved speech recognition from cochlear implants, although they may benefit less than those with healthy cognition and the degree of benefit depends on the level of cognitive impairment. There was no evidence for increased adverse events among those with cognitive impairment. There was limited or no evidence for any other outcome. CONCLUSION: People with cognitive impairment or dementia do benefit from cochlear implants. To inform policy and clinical practice, further data are needed about the broader benefits of cochlear implants for people with cognitive impairment or dementia, and referral, eligibility, and cochlear implant support needs for people with cognitive impairment and their caregivers.

What are the Correlates of Hearing Aid Use for People Living With Dementia?

OBJECTIVES: To identify correlates of hearing aid use in people with dementia and age-related hearing loss. METHODS: Bivariate and multivariate logistic regression analyses of predictor variables from 239 participants with dementia and hearing loss in the European SENSE-Cog Randomized Controlled Trial (Cyprus, England, France, Greece, and Ireland). RESULTS: In multivariate analysis, four variables were significantly associated with hearing aid use: greater self-perceived hearing difficulties (OR 2.61 [CI 1.04-6.55]), lower hearing acuity (OR .39 [CI .2-.56]), higher cognitive ability (OR 1.19 [CI 1.08-1.31]), and country of residence. Participants in England had significantly increased odds of use compared to Cyprus (OR .36 [CI .14-.96]), France (OR .12 [CI .04-.34]) or Ireland (OR .05 [CI .01-.56]) but not Greece (OR 1.13 [CI .42-3.00]). CONCLUSIONS: Adapting interventions to account for cognitive ability, country of residence, self-perceived hearing difficulties, and hearing acuity may support hearing aid use in people with dementia.

Hearing Loss and Dementia: Where to From Here?

Victorian era psychologists were the first to comment on associations between sensory and cognitive function. More recently, hearing loss has been shown as a marker of risk for dementia. However, it is not known whether this association represents a causal impact of hearing loss, nor whether treating hearing loss may help prevent dementia. Most studies on relationships between hearing loss and cognitive outcomes are observational, are at risk of confounding, and cannot reach conclusions about causation. A recent high quality randomized controlled trial, relatively uncommon in audiology, reported no impact of a comprehensive hearing intervention in mitigating cognitive decline in older adults. Although secondary analysis revealed potential benefits in a sub-sample of adults, this finding may be spurious. Encouraging policymakers, patients, and other health care practitioners to address hearing loss in terms of dementia prevention may be inappropriate on the grounds of both relevance at individual level and lack of clear evidence of benefit. In addition, advocating need to address hearing loss in terms of mitigating dementia risk may reduce the importance of addressing hearing loss in its own right. Linking hearing loss to dementia risk may also exacerbate the stigma of hearing loss, inadvertently discouraging people from seeking help for hearing. We suggest that treating hearing loss may have important benefits in preventing or delaying diagnosis of dementia via improving orientation and functioning in daily life, without changing the underlying pathology. Rather than linking hearing loss to dementia risk, we suggest a positive message focusing on the known benefits of addressing hearing loss in terms of improved communication, quality of life, and healthy aging.

Enablers and Barriers to Hearing aid Use in People Living With Dementia.

Hearing loss is highly prevalent in dementia; however, people with dementia are less likely to use hearing aids consistently than people with intact cognition are. This qualitative study is the first of its kind to explore factors that influence hearing aid use from the perspective of community-living people with mild to moderate dementia and their care partners. Eleven UK-based dyads from the European SENSE-Cog Randomized Controlled Trial of a sensory intervention for people with dementia completed semi-structured interviews based on the Theoretical Domains Framework (TDF). Our findings suggest that the TDF domains environmental context and resources, behavioral regulation, reinforcement, and social influences are of greatest relevance to hearing aid use in dementia. Within these domains, we identified a range of factors that may influence the target behavior of hearing aid use. The findings suggest that adoption of multifaceted, flexible intervention approaches may support hearing aid use in dementia.

Developing a prototype web-based decision aid for adults with hearing loss.

OBJECTIVE: To develop a prototype of a decision aid to be used on a website for adults with hearing loss. Design: Development was guided by the International Patient Decision Aid Standards (IPDAS) and included a survey and think-aloud process. STUDY SAMPLE: A total of 153 participants completed a survey about what to include in the decision aid (111 adults with hearing loss, 21 family members of adults with hearing loss, and 21 professionals). Six adults with hearing loss and six family members participated in a think-aloud process to provide feedback as they used an initial version of the decision aid. RESULTS: In the survey, 26 of the 38 potential items were identified as being highest priority and were included in the initial version of the decision aid. This initial version was then tested in the think-aloud sessions and a prototype of a web-based version was developed based on participant responses related to: 1) information on the decision aid, 2) ease of use, 3) layout and orders of the items, 4) satisfaction, 5) areas for improvement (e.g., need for graphics). CONCLUSIONS: The methodologies used in this study are recommended for developing decision aids for adults with acquired hearing loss.

A comparison of automated verification using paediatric hearing aids.

OBJECTIVE: Best-practice guidelines recommend the use of hearing aid verification in children; however, this is not always performed. Automated hearing aid verification has been reported to be more accurate and efficient than manual verification in adults, but it is not known if this transfers to the paediatric population. DESIGN: A within-group design compared manual and automated hearing aid verification on four measures; fitting accuracy, prescription targets, completion time, and the speech intelligibility index. SAMPLE: Twenty paediatric patient hearing aid profiles (M = 8.25 years) with unilateral or bilateral hearing aids. RESULTS: A Wilcoxon-signed rank test indicated manual verification achieved a significantly closer match to target at 0.5 kHz, by an average of 1 dB. There were no significant differences at any other frequency. Across 80 comparisons (four frequencies measured in 20 listeners), 82.5% of automated verifications were identical to, or within 1 dB of, manual verifications. A paired-samples t-test confirmed automated verification to be an average of 91.9 seconds faster than manual verification. CONCLUSION: Automated verification was able to provide an accurate match to target within recommended tolerances for hearing aid fittings and was significantly quicker than manual verification. These data suggest that automated verification of hearing aids could play a role in paediatric audiological management.

Attitudes towards hearing, hearing loss, and hearing protection in university students.

OBJECTIVE: Young adults are at risk for hearing loss caused by exposure to loud music. Intervention at this stage provides opportunities to support lifelong hearing protection use. This study explores attitudes related to hearing, hearing loss, and hearing protection among university students. DESIGN: Qualitative interview design, supplemented by quantitative questionnaire data. STUDY SAMPLE: 18 university students, aged 18-24 years. RESULTS: Students were uncertain about mechanisms of noise-induced hearing loss, did not feel vulnerable to permanent hearing damage from loud music, were unconvinced of hearing protection efficacy, and reported barriers to hearing protection use. Students emphasised the positive effects of loud music and reported an increased likelihood of using hearing protection were it used by peers. Music students appeared more aware of the negative effects of loud music exposure. Students reported conflicting attitudes regarding government regulation of hearing protection use. CONCLUSION: Young adults require education about hearing protection from multiple, credible sources and need to understand the mechanisms behind noise-induced hearing loss in a way that makes it of high personal relevance.

Hearing care services for adults with hearing loss in Malaysia: a scoping review.

OBJECTIVE: This scoping review aimed to identify knowledge gaps in relation to access to, and outcomes from, hearing care services for adults in Malaysia. DESIGN: Scoping review. STUDY SAMPLE: 1261 studies from 4 databases (PubMed, CINAHL, Embase and Scopus) and 7 studies from grey literature were identified. After removing duplicates, 647 studies were screened for title and/or abstract, and five studies met the criteria and were included. RESULTS: Audiologists reported offering a range of diagnostic assessment and rehabilitation services, including hearing aids, assistive listening devices, auditory training, and counselling. However, the uptake of hearing services was low; rates of hearing aid use among people with at least mild hearing loss were around 2.7%-4.4%; 6.5%-7.3% for those with at least moderate loss. There were no data on the outcomes from hearing services. CONCLUSIONS: This scoping review highlighted the limited uptake of hearing services among adults in Malaysia, despite the existence of services. Furthermore, it revealed a lack of information about the factors contributing to this limited uptake. To address the burden of hearing loss, there is an urgent need to identify barriers to access, improve access and uptake, and evaluate the benefits of adult hearing services in Malaysia.

Validation of the German Montreal-Cognitive-Assessment-H for hearing-impaired.

Background: Hearing loss and dementia are highly prevalent in older age and often co-occur. Most neurocognitive screening tests are auditory-based, and performance can be affected by hearing loss. To address the need for a cognitive screening test suitable for people with hearing loss, a visual version of the Montreal-Cognitive-Assessment was developed and recently validated in English (MoCA-H), with good sensitivity and specificity for identifying cases of dementia. As the MoCA is known to perform differently across languages, revalidation of the German MoCA-H was necessary. The aim of the present study was to assess the diagnostic accuracy of the German MoCA-H among those with normal cognition, mild cognitive impairment (MCI) and dementia and to determine an appropriate performance cut- off. Materials and methods: A total of 346 participants aged 60-97 years (M = 77.18, SD = 9.56) were included; 160 were cognitively healthy, 79 with MCI and 107 were living with dementia based on the GPCOG and a detailed medical questionnaire as well as a comprehensive examination by a neurologist in case of cognitive impairment. Performance cut-offs for normal cognition, MCI and dementia were estimated for the MoCA-H score and z-scores using the English MoCA-H cut-off, the balanced cut-off and the Youden's Index. Results: A mean score of 25.49 (SD = 3.01) points in the German MoCA-H was achieved in cognitively healthy participants, 20.08 (SD = 2.29) in the MCI and 15.80 (SD = 3.85) in the dementia group. The optimum cut-off for the detection of dementia was ≤21 points with a sensitivity of 96.3% and a specificity of 90%. In the MCI group, a cut-off range between 22 and 24 points is proposed to increase diagnostic accuracy to a sensitivity and specificity of 97.5 and 90%, respectively. Conclusion: The German MoCA-H seems to be a sensitive screening test for MCI and dementia and should replace commonly used auditory-based cognitive screening tests in older adults. The choice of a cut-off range might help to better reflect the difficulty in clinical reality in detecting MCI. However, screening test batteries cannot replace a comprehensive cognitive evaluation.

"We're just winging it". Identifying targets for intervention to improve the provision of hearing support for residents living with dementia in long-term care: an interview study with care staff.

PURPOSE: Hearing loss and dementia are common in long-term care home (LTCH) residents, causing communication difficulties and worsened behavioural symptoms. Hearing support provided to residents with dementia requires improvement. This study is the first to use the Behaviour Change Wheel (BCW) to identify barriers and propose interventions to improve the provision of hearing support by LTCH staff. METHODS: Semi-structured interviews with 10 staff members were conducted. Transcripts were analysed according to the BCW's Theoretical Domains Framework alongside reflective thematic analysis. Relevant intervention functions and exemplar interventions were proposed. RESULTS: Staff believed hearing support to be beneficial to residents (Beliefs about Consequences) but lacked knowledge of hearing loss management (Knowledge). Poor collaborations between LTCHs and audiology (Environmental Context and Resources), led to despondency, and apprehension about traditional hearing aids for residents (Optimism). Despite feeling responsible for hearing support, staff lacked personal accountability (Social/Professional Role and Identity). CONCLUSIONS: Future interventions should include staff Training (on hearing support), Education (on the consequences of unsupported hearing loss), Enablement (dementia-friendly hearing devices), Incentivisation and Modelling (of Hearing Champions) and Environmental Restructuring (flexible audiology appointments to take place within the LTCH). Interventions should be multi-faceted to boost the capabilities, opportunities and motivations of LTCH staff.

Hearing support for care home residents with dementia:Long-term care staff report inadequate knowledge and awareness of how to support residents' hearing needs and a lack of personal accountability for providing hearing support.They also report poor collaborations with audiologists and apprehension about traditional hearing aids.Barriers to hearing support stem from gaps in the capabilities, opportunities and motivations of staff, therefore, interventions should be designed to target all three constructs.Interventions to aid hearing support provision should target staffs' education, training, enablement, persuasion, modelling, incentivisation and environmental restructuring to boost staff capabilities, opportunities and motivations to provide hearing support.

Assessing the pool activity level (PAL) checklist for use with people with hearing and vision loss.

BACKGROUND: The PAL is a career-completed assessment that indexes cognitive functional ability to inform individualised support. As hearing and vision loss are prevalent, we assessed the PAL for potential bias with hearing or vision impairment. METHODS: We collected PAL responses for 333 adults aged over 60 years in the UK, France, Canada, Greece and Cyprus. All participants had normal cognition based on self-reported status and normal range scores on a cognitive screening test. Using a Kruskal-Wallis test, we compared PAL item response distributions for people with assessed hearing or vision loss compared to those with normal sensory function. RESULTS: There were no differences in response distributions between hearing or vision impaired groups versus those with normal sensory function on any PAL item. CONCLUSION: The PAL reliably indexes cognitive functional ability and may be used to inform support tailored to individual cognitive level amongst older adults with prevalent hearing and vision impairments.

Capabilities, opportunities and motivations of staff to provide hearing support to long-term care home residents with dementia.

OBJECTIVE: Many long-term care home (LTCH) residents have dementia and hearing loss, causing communication difficulties and agitation. Residents rely on staff for hearing support, but provision is often inconsistent. This study used the Behaviour Change Wheel's Capability, Opportunity and Motivation model to understand why LTCH staff do or do not, provide hearing support to residents with dementia who they believe could benefit from it. DESIGN: An online survey exploring hearing support provision, capabilities, opportunities, motivations and demographics. Data were analysed using descriptive statistics, within-participants ANOVA and multiple linear regression. STUDY SAMPLE: 165 LTCH staff. RESULTS: Staff provided hearing support to 50% of residents with dementia who they thought would benefit. Self-reported physical and psychological capabilities (skills/knowledge) were significantly higher than physical opportunity (having time/resources). The physical capability was significantly higher than social opportunity (collaborative working) and reflective motivation (feeling motivated). Lower levels of hearing support provision were predicted by LTCH funding (private vs. local authority), job role (care assistant vs. nurse) and fewer physical opportunities. CONCLUSIONS: Boosting capabilities through training alone may not be as effective as increasing opportunities via environmental restructuring. Opportunities may include strengthening working relationships with audiologists and ensuring hearing and communication aids are available within LTCHs.

Association between hearing loss and deprivation among Welsh adults: a cross-sectional observational study.

OBJECTIVE: To index levels of hearing loss with respect to area-level indices of deprivation in a Welsh population. DESIGN: A cross-sectional observational study of all adults (aged >18) that attended Abertawe Bro Morgannwg University (ABMU) Health Board audiology services between 2016 and 2018. Service access, first hearing aid fitting appointment rates and hearing loss at time of first hearing aid provision were used to index population hearing loss versus area-level indices of deprivation based on patient postcode. SETTING: Primary and secondary care. PARTICIPANTS: 59 493 patient entries met the inclusion criteria. Patient entries were grouped by age (18-30, 31-40, 41-50, 51-60, 61-70, 71-80, >80 years) and deprivation decile. RESULTS: The interaction between age group and deprivation decile predicted access rate to ABMU audiology services (b=-0.24, t(6858) = -2.86, p<0.01) with audiology services accessed more frequently by the most deprived versus the least deprived decile in every age group (p<0.05), except the >80 years. First hearing aid fitting rates were highest among the most deprived in the four youngest age groups (p<0.05). Severity of hearing loss at the time of first hearing aid fitting was worse among the most deprived in the five oldest age groups (p<0.01). CONCLUSIONS: Hearing health inequalities are prevalent among adults accessing ABMU audiology services. Our findings suggest that deprivation increases the likelihood of developing hearing loss, brings earlier onset of hearing loss and is linked to delays in getting help for hearing problems. However, it is not possible to know the true scale of these disparities without knowing the hearing health of the Welsh adult population including those who do not seek help for hearing problems.

Do hearing loss interventions prevent dementia?

Hearing loss has been identified as a potentially modifiable risk for dementia. This discussion paper reviews studies examining the impact of hearing loss interventions on cognitive decline and incident cognitive impairment, identified the challenges for research on the cognitive impacts of hearing interventions, and the likely benefits of hearing interventions for healthy aging and mental well-being.

Socioeconomic Inequality in Hearing Impairment Among Working-Age Australians: Evidence From a Cross-Sectional and Longitudinal Analyses.

OBJECTIVES: The objective of this study was to analyze the spatial and temporal association between socioeconomic gradient in hearing impairment among working-age Australians. DESIGN: We modeled the cross-sectional and longitudinal associations between individual- and area-level socioeconomic status (SES) and hearing impairment among working-age Australians using longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey for 10,719 working-age adults aged between 15 and 64 years surveyed between 2008 and 2018. Associations between self-reported hearing impairment and education, income, employment status, and area-level SES were estimated using a multivariate logistic regression model and Cox proportional hazards regression, controlling for age, sex, and a range of other sociodemographic factors. RESULTS: Among 10,719 participants, the prevalence of hearing impairment was higher among individuals with lower income, occupational status and socioeconomic disadvantage. The odds ratio (OR) of those with the lowest income quintile versus highest income quintile (OR = 2.10, 95% confidence interval [CI] = 1.40 to 3.14); for blue-collar occupation versus white-collar (OR = 1.92, 95% CI = 1.39 to 2.66) and most disadvantaged area quintile versus most advantaged area quintile (OR = 1.76, 95% CI = 1.10 to 2.83) were associated with higher odds of prevalence of hearing impairment. For the 10,046 participants without hearing loss at baseline, income quintile 1 versus quintile 5 (hazard ratio [HR] = 1.44, 95% CI = 1.33 to 1.56), ≤ year 11 versus ≥ bachelor's degree (HR = 2.15, 95% CI = 1.98-2.34) blue-collar occupation versus white collar (HR = 1.15, 95% CI = 1.07 to 1.25) and most disadvantaged area quintile versus most advantaged quintile (HR = 1.49, 95% CI = 1.37 to 1.63) was positively associated with incident hearing impairment. CONCLUSIONS: Lower individual-level and area-level SES was associated with an increased risk of prevalence and incidence of hearing impairment among working-age Australians. These findings are particularly concerning since working-age Australians are mostly not eligible for socially subsidized hearing-related health care in Australia. This lack of access to affordable hearing services could exacerbate the negative consequences of hearing impairment and increase social inequality.

A Narrative Review of Lifestyle Risk Factors and the Role of Oxidative Stress in Age-Related Hearing Loss.

Age-related hearing loss affects a significant proportion of adults aged 60 years and above, with a prevalence of 65%. This condition has a negative impact on both physical and mental well-being, and while hearing interventions can help alleviate the effects of hearing loss, they cannot completely restore normal hearing or halt the progression of age-related hearing loss. Oxidative stress and inflammation have been identified as potential contributors to this condition. By addressing modifiable lifestyle risk factors that exacerbate oxidative stress, there may be an opportunity to prevent hearing loss. Therefore, this narrative review provides an overview of the major modifiable lifestyle risk factors associated with age-related hearing loss, that is, exposure to noise and ototoxic chemicals, smoking, diet, physical activity, and the presence of chronic lifestyle diseases, and offers an overview of the role of oxidative stress in the pathophysiology of this condition.

Development and validation of the Montreal cognitive assessment for people with hearing impairment (MoCA-H).

BACKGROUND: Hearing impairment is common among older adults and affects cognitive assessments for identification of dementia which rely on good hearing function. We developed and validated a version of the Montreal Cognitive Assessment (MoCA) for people with hearing impairment. METHODS: We adapted existing MoCA 8.1 items for people with hearing impairment by presenting instructions and stimuli in written rather than spoken format. One Attention domain and two Language domain items required substitution by alternative items. Three and four candidate items respectively were constructed and field-tested along with the items adapted to written form. We used a combination of individual item analysis and item substitution to select the set of alternative items to be included in the final form of the MoCA-H in place of the excluded original items. We then evaluated the performance and reliability of the final tool, including making any required adjustments for demographic factors. RESULTS: One hundred and fifty-nine hearing-impaired participants, including 76 with normal cognition and 83 with dementia, completed the adapted version of the MoCA. A further 97 participants with normal hearing completed the standard MoCA as well as the novel items developed for the MoCA-H to assess score equivalence between the existing and alternative MoCA items and for independence from hearing impairment. Twenty-eight participants were retested between 2-4 weeks after initial testing. After the selection of optimal item set, the final MoCA-H had an area under the curve of 0.973 (95% CI 0.952-0.994). At a cut-point of 24 points or less sensitivity and specificity for dementia was 92.8% and 90.8%, respectively. The intraclass correlation for test-retest reliability was 0.92 (95%CI 0.78-0.97). CONCLUSION: The MoCA-H is a sensitive and reliable means of identifying dementia among adults with acquired hearing impairment.

Trajectories of self-reported hearing and their associations with cognition: evidence from the United Kingdom and United States of America.

OBJECTIVE: This study aimed to investigate the relationships between trajectories of change in self-reported hearing over eight years with subsequent effects on cognition, measured using episodic memory. METHODS: Data were drawn from 5 waves (2008-2016) of the English Longitudinal Study of England (ELSA) and the Health and Retirement Study (HRS), involving 4,875 individuals aged 50+ at the baseline in ELSA and 6,365 in HRS. The latent growth curve modelling was used to identify trajectories of hearing over eight years, and linear regression models were performed to investigate the relationship between hearing trajectory memberships and episodic memory scores, controlling for confounding factors. RESULTS: Five trajectories of hearing (stable very good, stable fair, poor to fair/good, good to fair, and very good to good) were retained in each study. Individuals whose hearing remains suboptimal and those whose hearing deteriorates within suboptimal levels throughout eight years have significantly poorer episodic memory scores at follow-up than those with stable very good hearing. Conversely, individuals whose hearing declines but is within an optimal category at baseline do not see significantly poorer episodic memory scores than those with consistently optimal hearing. There was no significant relationship between individuals whose hearing improved from suboptimal baseline levels to optimal by follow-up and memory in ELSA. However, analysis using HRS data shows a significant improvement for this trajectory group (-1.260, P < 0.001). CONCLUSIONS: Either stable fair or deterioration in hearing is associated with worse cognitive function, both stable good or improving hearing is associated with better cognitive function specifically episodic memory.