Barbara Weinstein’s “Downstream Consequences of Aging” appears bi-monthly at HearingHealthMatters.org. Today’s post is part 2 of a series on reframing the clinical conversation with older adults.
Numerous top down initiatives directly impact how we may wish to reframe the conversation about ARHL and scope of audiologist practice. Two initiatives most relevant to audiologists are:
- The recommendation that health professional schools and professional societies develop and disseminate core competencies, curricula and continuing education opportunities that focus on cognitive health and aging (IOM, 2015).
- The decision on behalf of the Lancet International Commission on Dementia Prevention, Intervention and Care (Livingston et al. 2017) to extend the list of modifiable risk factors for addressing dementia to include hearing loss.
It is the latter initiative to which I would like to focus my attention today.
Modifiable Risk Factors for Dementia
In the Lancet report, authored by 24 international experts on dementia, Livingston and colleagues (2017) shared the results of their review and meta-analysis of recent advances in dementia research. They concluded that based on the evidence and their calculations, close to a third of dementia cases might be preventable.
They proposed mechanisms linking potentially modifiable risk factors to dementia and concluded that at an individual level, older adults have the potential to reduce their risk of cognitive decline, and possibly forestall the onset of dementia, by adopting healthful behavior changes. Consistent with the philosophy that prevention is better than cure, the experts concluded that detecting modifiable risk factors for dementia would be cost effective and to this end they proposed a novel life-course model to dementia based on modifiable risk factors.
Social Isolation and Hearing Loss
The risk factors they included in their analysis were those listed in the UK National Institute of Health and Care Excellence (NICE) report and the US National Institutes of Health (NIH) guidelines (NICE, 2015; Daviglus et al, 2010). Of relevance to audiologists is that NICE and NIH identified social isolation and peripheral hearing loss as potentially modifiable dementia risk factors. While the mechanisms remain unclear, the experts acknowledged that hearing loss may add to the cognitive load of a vulnerable brain and/or may lead to social disengagement or depression accelerating brain atrophy.
The team of experts underscored that evidence is lacking at present as to whether hearing aids can alleviate or forestall onset of cognitive decline. However, in their life course model they advocated for identifying hearing loss in mid-life as one of many approaches to earlier identification of dementia or reduction of risk of developing dementia. This recommendation is justified since longitudinal studies on incident dementia suggest a time course of between ten to fifteen years between recognition of hearing loss and onset of dementia in selected individuals (Lin, et al., 2011; Gallacher et al, 2012).
Social Engagement and Successful Aging
A report authored by Ballard, and colleagues (2017) revealed that patient centered activities combined with as little as one hour a week of social interaction could improve quality of life and reduce agitation experienced by older adults with dementia living in care homes. These results underscore the potential for our auditory interventions to play a role in promoting communication and, in turn, social connectedness.
In fact, according to Kim & Park (2017) social engagement has a strong relationship with successful aging. They concluded that health professionals should help older adults by recommending interventions designed to enhance psychological adaptation and prolong social engagement.
Herein lies the opportunity for audiologists to be part of the solution.
Lifestyle Intervention to Optimize Communication and Promote Social Engagement
As eloquently stated by Wilson and colleagues (2017) the reach of hearing loss extends far beyond sensory impairment. In fact sensory function is a basic measure of brain “integrity” serving perhaps to affect cognitive performance (Lindenberger & Baltes, 1994).
In keeping with the life course model proposed in the Lancet report, the benefits of early screening and perhaps reframing management of hearing loss as a lifestyle intervention may yield significant benefits with few risks. Let us:
- Be proactive and underscore how our interventions have the potential to enable active engagement with life so important to cognitive well-being. When advocating for hearing enhancements and auditory rehabilitation, it is critical that we quantify and enumerate the social benefits (including engagement with others) that are so important to physical activity levels and cognitive well being.
- Move out of the sound treated room and emphasize the value added of early identification and treatment and our potential role in promoting cognitive health and the maintenance of cognitive functioning (Fisher et al. 2017). We audiologists are the experts to assist with environmental enrichment and optimizing social interactions and engagement. The potential intervention window to delay onset and reduce incidence and prevalence of dementia is narrow.
- Since hearing loss is a possible modifiable risk factor, perhaps we should seriously consider engaging indirectly in case finding, or identifying and referring to specialists individuals with whom we work who may be presenting with behaviors consistent with dementia, notably memory problems or changes in social functioning. As timely diagnosis of dementia allows people to plan for their future, making the appropriate referral may help to reduce or delay the progression of disease. Earlier identification and management of hearing loss may be a lifestyle intervention whose time has finally come.
Ballard C et al. (2017). One social hour a week in dementia care improves lives and saves money. Retrieved July 31, 2017 from
Daviglus M et al. (2010). NIH state-of-the-science conference statement: preventing Alzheimer’s disease and cognitive decline. NIH Consens State Sci Statements. 27: 1–30.
Fisher G et al. (2017). Cognitive Functioning, Aging, and Work: A Review and Recommendations for Research and Practice. Journal Of Occupational Health Psychology. 22: 314-336.
Gallacher J et al. (2012). Auditory threshold, phonologic demand, and incident dementia. Neurology, 79: 1583 1590.
IOM (Institute of Medicine). (2015). Cognitive aging: Progress in understanding and opportunities for action. Washington, DC: The National Academies Press.
Kim S & Park S. (2017). A Meta-Analysis of the Correlates of Successful Aging in Older Adults. Research on Aging. 39: 657–677.
Lin FR et al. (2011). Hearing loss and incident dementia. Archives of Neurology, 68: 214-220.
Lindenberger U & Baltes PB. (1994). Sensory functioning and intelligence in old age: A strong connection. Psychology and Aging, 9, 339–355.
Livingston et al. (2017). Dementia prevention, intervention, and care. Lancet published online July 20.
National Institute for Health & Care Excellence NICE (2015). Dementia, disability and frailty in later life—mid-life approaches to delay or prevent onset. London: National Institute for Health and Care Excellence, 2015.
Wilson B et al. (2017). Global hearing health care: new findings and perspectives. The Lancet. July 10 2017.
Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly. Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.
feature photo courtesy of shannon christy