Hear ye? Hear ye! Successful auditory aging.

Age-related hearing loss (presbycusis) is a multifactorial process that affects nearly all people in their senior years. Most cases are due to a loss of cochlear hair cell function and are well mediated by communication courtesy and modern amplification technology. Severe hearing loss is generally due to cochlear problems or age-related diseases and may require speech reading, assistive listening devices, and cochlear implants, depending on the degree of loss. Presbycusis may seriously impair communication and contribute to isolation, depression, and possibly dementia. Accurate diagnosis and prompt remediation are widely available but are frequently underused. Geriatric health care and well-being is enhanced by the detection and remediation of communication disorders.

Hearing loss and antiretroviral therapy in patients infected with HIV-1.

OBJECTIVE: To explore the association between hearing loss and antiretroviral therapy in human immunodeficiency virus type 1 (HIV-1)-infected persons. DESIGN: Case-control study. SETTING: University-based HIV clinic. PARTICIPANTS: Volunteer sample of 99 HIV-infected patients. INTERVENTIONS: Standardized interview focusing on risks for hearing loss, review of clinic pharmacy records, and hearing tests by portable audiometry. MAIN OUTCOME MEASURE: Hearing loss, defined as threshold of more than a 25-dB hearing level at 4000 Hz in 1 or both ears. RESULTS: Hearing loss was common, seen in 29 subjects (29%). It was significantly associated with age and history of ear infection and tended to be more common in subjects prescribed antiretroviral agents. An interaction existed between age and antiretroviral therapy; the association between hearing loss and antiretroviral therapy was significant for subjects aged 35 years or older, but not for subjects younger than 35 years. In subjects aged 35 years or older, this association remained significant using a multivariate model that included those variables found to have the greatest potential for confounding (odds ratio, 4.6; 95% confidence interval, 1.0-20.5; P = .05). CONCLUSIONS: Hearing loss is common among HIV-infected individuals and is associated with antiretroviral therapy in those aged 35 years or older.

Visual impairment and cognitive dysfunction in Alzheimer's disease.

OBJECTIVE: To determine whether impaired visual acuity is associated with dementia and cognitive dysfunction in older adults. DESIGN: Paired case-control comparisons of the relative frequencies of visual impairment in demented cases and nondemented controls. Cohort analyses of correlation between visual acuity and cognitive functioning in demented cases. SETTING: Internal medicine clinics at two academically affiliated medical centers. PARTICIPANTS: Eighty-seven consecutively selected patients greater than or equal to 65 years of age with mild-to-moderate, clinically diagnosed Alzheimer's disease (cases) and 87 nondemented controls matched to the cases by age, sex, and education. MEASUREMENTS AND MAIN RESULTS: The prevalence of visual impairment was higher in cases than in controls [unadjusted odds ratio for near-vision impairment = 2.7 (95% CI = 1.4, 5.2); unadjusted odds ratio for far-vision impairment = 2.1 (95% CI = 1.02, 4.3); odds ratios adjusted for family history of dementia, depression, number of medications, and hearing loss were 2.5 (95% CI = 1.1, 10.5) for near-vision impairment and 1.9 (95% CI = 0.8, 4.6) for far-vision impairment]. When further stratified by quartiles of visual acuity, no statistically significant "dose-response" relationship between vision impairment and dementia risk was observed. Among cases, the degree of visual impairment was significantly correlated with the severity of cognitive dysfunction for both near and far vision (adjusted ps less than 0.001). CONCLUSIONS: Visual impairment is associated with both an increased risk and an increased clinical severity of Alzheimer's disease, but the increased risk may not be consistent with a progressive dose-response relationship. Further studies are needed to determine whether visual impairment unmasks and exacerbates the symptoms of dementia or is a marker of disease severity.

Relationship of hearing impairment to dementia and cognitive dysfunction in older adults.

We conducted a case-control study in 100 cases who had Alzheimer's-type dementia and 100 age-, sex-, and education-matched, nondemented controls to evaluate the hypothesis that hearing impairment contributes to cognitive dysfunction in older adults. The prevalence of a hearing loss of 30 dB or greater was significantly higher in cases than in controls (odds ratio, 2.0; 95% confidence interval, 1.2 to 3.4), even when adjusted for potentially confounding variables. In addition, we observed a dose-response relationship in which greater hearing loss was associated with a higher adjusted relative odds of having dementia. Hearing loss was also significantly and independently correlated with the severity of cognitive dysfunction, as measured by the Mini-Mental State Examination, in nondemented as well as demented patients. These results demonstrate an association between hearing impairment and dementia and lend support to the hypothesis that hearing impairment contributes to cognitive dysfunction in older adults.

Validity and reliability of auditory screening tests in demented and non-demented older adults.

The validity and reliability of auditory screening tests were evaluated in 34 demented and 31 non-demented elderly outpatients. In reference to an audiometric gold standard (40-dB HL hearing loss in speech frequencies), 512-Hz and 1024-Hz tuning forks, finger rub, and whispered voice tests performed well (ROC curve areas = 0.82 to 0.94). Simultaneously high (greater than 0.80) sensitivities and specificities were achievable for all these tests in demented patients. In non-demented patients, however, only the whispered voice test achieved simultaneously high specificity and sensitivity. The most accurate rule for air conduction screening audiometry was the inability to hear greater than or equal to two of four 40-dB HL speech frequencies (sensitivity = 1.0, specificity = 0.75 in non-demented patients; sensitivity = 0.97, specificity = 0.74 in demented patients). Interobserver/test-retest reliability was generally high for tuning forks, finger rub, and whispered voice tests (range of intraclass correlation coefficients = 0.38 to 0.90), and was somewhat higher in demented than in non-demented patients. These results suggest that some of the simple, traditional methods of auditory screening may have considerable validity and reliability in demented and non-demented older adults.

Impact of mild to moderate hearing loss on mental status testing. Comparability of standard and written Mini-Mental State Examinations.

Mild to moderate hearing loss has been hypothesized to decrease performance on verbally-administered cognitive tests as an artifact of testing. To evaluate this hypothesis, we conducted a randomized trial of a written version of the Mini-Mental State Examination (MMSE), a cognitive screening instrument which, in its standard form, is primarily verbally administered. After baseline standard MMSE testing, 71 outpatients with Alzheimer's type dementia, 39 of whom (55%) had mild to moderate hearing deficits, and 32 of whom (45%) had normal hearing, were randomly assigned to receive either a written or standard MMSE. Hearing-impaired patients exhibited lower standard MMSE scores than hearing-unimpaired patients at baseline (P = .005). Contrary to expectation, however, on experimental administration, written MMSE scores were somewhat lower than standard MMSE scores in hearing-impaired patients (P not significant). Furthermore, written MMSE scores were slightly higher than standard MMSE scores in hearing-unimpaired patients (P not significant). These results suggest that the diminished cognitive performance associated with mild to moderate hearing loss is not necessarily an artifact of cognitive testing. In addition, these results provide preliminary evidence that a written MMSE is comparable to the standard MMSE and, thus, deserves further consideration for cognitive screening of profoundly hearing-impaired individuals.

Electrical tinnitus suppression: a double-blind crossover study.

A wearable device for transcutaneous electrical tinnitus suppression (ETS) has recently been reported to be effective for relief of tinnitus. Twenty patients with sensorineural hearing loss and tinnitus participated in a double-blind crossover study. Both active devices and internally disconnected placebo devices, supplied by the manufacturer, were used. Reduction in severity of tinnitus was reported by 2 of 20 patients (10%) with the active device and by 4 of 20 (20%) with the placebo device. Fifteen of 20 (75%) had no relief with either device. Those who preferred the placebo device, however, reported only minimal relief, while one of the two who preferred the active device stated it had reduced tinnitus severity by 70% to 80%. This patient was recalled for a series of one-hour test sessions, during which either an active or placebo device was used, according to a random schedule. On each of four on trials, the score for severity of tinnitus for each ear decreased by at least 50% (median = 70%), while in three off trials, the severity of tinnitus was unchanged or decreased by up to 30% (median = 16%). We conclude that the Theraband headset is effective for a small proportion of patients with sensorineural hearing loss and tinnitus.

Placebo effect in tinnitus management.

Masking devices, lidocaine, and analog oral forms of lidocaine have all been reported as being effective forms of therapy to relieve tinnitus. Many studies, however, have used single-blind protocols and were possibly biased by placebo effects. To investigate the contributions of a placebo effect in clinical tinnitus studies, 25 tinnitus patients who had received a placebo injection in a previous double-blind lidocaine study were contacted on the pretense that they would receive a test dose of lidocaine; the 20 who responded were included in this study. A 5 cc bolus of placebo saline solution instead of lidocaine was then administered to each patient. Forty percent of the patients reported a change in their tinnitus following the placebo injection. The results of this study serve to point out the inherent flaws in straight clinical trials, and that the success rates achieved in such uncontrolled clinical investigations may be biased by the placebo effects.

Treatment of tinnitus with intravenous lidocaine: a double-blind randomized trial.

Several recent reports have suggested that intravenous (IV) lidocaine is an effective form of therapy to relieve tinnitus; however, many of these studies were not well controlled. A double-blind randomized trial to assess the effectiveness of IV lidocaine on tinnitus was conducted at the University of Washington-affiliated hospitals on a total of 50 patients. Tinnitus was evaluated before and after injection by subjective assessment and audiometric matching. Although 40% of the lidocaine group reported a decrease in tinnitus, over 30% of the lidocaine group reported increased tinnitus after administration of the drug. There was also a high incidence of side effects, including disequilibrium, slurred speech, numbness, and tingling of the extremities in the drug group. The results of the study suggest that the clinical usefulness of IV lidocaine in relieving tinnitus may be less than was previously reported.

Posttraumatic endolymphatic hydrops.

A case of posttraumatic endolymphatic hydrops that was confirmed by a positive glycerin test is reported. Although head trauma has been implicated as a cause of hydrops, few such cases are reported in the literature. Careful consideration of perilymphatic fistula must be accorded before a diagnosis of posttraumatic hydrops is made.

Tympanometry in middle ear disease.

Tympanometry is an objective procedure which can aid in the identification of middle ear disease and eustachian tube dysfunction. This paper reviews its rationale, operation, and applications. The test procedure is simple and can be performed by trained personnel. The test is valid and reliable and can be used with children without discomfort. The results of tympanometry are quantifiable, recordable, and easy to interpret. The routine use of tympanometry in the family physician's office would offer a valuable tool in the identification and management of middle ear problems.