Editor’s note: Ear to the Ground is a new monthly column from Dr. Brian Taylor, offering timely reflections on research, technology, clinical practice, and emerging trends in hearing care. You can read last month’s column here.
By now, it’s likely all hearing care professionals have some familiarity with the ACHIEVE study, which was a randomized controlled trial that asked this question: Can reducing the cognitive burden of untreated hearing loss through hearing intervention slow cognitive decline?
The ACHIEVE study, published in 2023, got a lot of attention (rightly so) in our profession. Although a benefit was not observed across the entire study population during the initial 3-year follow-up, the results suggest hearing treatment may slow cognitive decline in older adults who are already at elevated risk. Ongoing analyses by the ACHIEVE research team are examining longer-term outcomes beyond the initial 3-year follow-up, including incidence of dementia, brain health, health care utilization, and other age-related outcomes.
Another study with a similar name, ACTIVE, didn’t get nearly as much attention in hearing care circles as the ACHIEVE study, perhaps because it was published in the journal Alzheimer’s & Dementia, probably not read by too many audiologists. However, the results of this ACTIVE study do warrant a careful look. That’s the focus of this month’s Ear to the Ground.
The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study examined whether cognitive training in later life affects the long-term risk of a clinical diagnosis of Alzheimer’s disease and other related forms of dementia. The study was a multicenter, randomized controlled trial involving 2,021 participants who were enrolled in Medicare. The intervention took place in the early 2000s when brain training exercises were becoming popular, and the analysis took place some 20 years later.
The ACTIVE study, published in early 2026, asked this question: Can improving cognitive function through targeted brain training increase cognitive reserve and delay dementia?
Participants, all ≥65 years of age without dementia, were assigned to one of four groups:
- Speed-of-processing training
- Memory training
- Reasoning training
- No-training control group.
The brain training exercises consisted of up to ten sessions (60–75 minutes each, conducted over 4 to 6 weeks). Participants completed at least eight sessions and had the option to receive booster training at 11 and 35 months later (up to four sessions for each booster).
Results were determined by evaluating Medicare claims data ~20 years post-training to identify the participants who may have been diagnosed with dementia over a 20-year period after the start of brain training.
The principal finding was that only speed-of-processing training was associated with a lower long-term risk of a Medicare-based dementia diagnosis, and only among participants who received booster sessions. Participants who received speed-of-processing training and completed booster sessions had a significantly lower risk of receiving a Medicare claims-based diagnosis of dementia. Memory training and reasoning training did not show a similar effect.
Why the ACTIVE Study Matters
The significance of the ACTIVE study is not that it proves hearing aids prevent dementia—this study did not address hearing loss treatments.
Rather, the results of this study strengthen the broader concept that specific forms of cognitive-perceptual training can have long-term effects on dementia risk, and that the type of training matters.
“The type of training matters—and structured cognitive-perceptual training may have long-term implications for brain health.”
Implications for Hearing Care Professionals
The ACTIVE study has some relevant implications for clinicians who work with older adults.
Auditory training deserves renewed attention
Historically, audiologists have talked about the importance of auditory training and aural rehabilitation, but these services are often underutilized compared with fitting hearing aids.
The ACTIVE findings suggest that targeted cognitive-perceptual training can produce measurable long-term brain-health outcomes. While auditory training is not the same intervention as the speed training used in the ACTIVE study, it suggests that aural rehabilitation may be more effective when it includes certain types of auditory or brain training rather than amplification alone.
Processing speed may be an important factor in successful communication
Audiology focuses heavily on audibility and speech recognition, and rightly so, but the findings of the ACTIVE study highlight the importance of processing speed to overall brain health.
This may encourage clinicians to incorporate training that challenges listening speed. One example of this is the Rapid Speech module in the Lace Pro auditory training program.
Encouraging all older patients to complete Rapid Speech exercises with a booster at 12–36 months may be beneficial to long-term brain health, if the results of the ACTIVE study hold true.
Training effects have long-term benefits
Although the ACTIVE study did not involve hearing aid wearers, it suggests to us that overall cognitive health depends on active engagement and training.
Simply improving audibility through hearing aid use is only one part of the intervention. Audiologists must view hearing care as holistic care that looks like this (a focus of June’s ETTG):
Amplification + cognitive-perceptual training + ongoing engagement and counseling
The ACTIVE study also provides evidence that structured training programs can have benefits extending far beyond the training period.
While the study was not conducted in populations with hearing loss, it supports the general principle that brain or auditory training exercises can produce durable changes in cognitive aging trajectories.
DTx: A New Era in Patient Care?
For decades, luminaries such as Raymond Carhart, Robert Sweetow, and Nancy Tye-Murrey have argued that aural rehab should include brain/auditory training, not just the provision of devices.
The ACTIVE study provides evidence that certain forms of training can have remarkably long-lasting effects on cognitive health, lending credibility to the broader rehab model that has long been part of audiology. Whether cognitive-perceptual training specifically can achieve similar dementia-related outcomes remains an important research question, one yet to be answered. But encouraging patients to complete a clinical dose of “brain training” exercises with some booster training a year or two later may have lasting effects that contribute to better overall quality of life.
With the evolution of user-friendly digital therapeutics (DTx), older adults hold the ability to improve their brain-hearing health in the palm of their own hand. A topic ETTG will cover in coming months.
And His Head in the Clouds……
Thoughts on the Updated NAL Prescriptive Gain Targets
It’s hard to believe that the NAL prescriptive fitting approach has been around for 50 years. It’s now on its fourth iteration (NAL-NL3). A recently posted open access article reviews the evolution of the NAL targets from the original NAL for linear hearing aids to the most recent NAL-NL3 for modern devices.
As these gain formulas have evolved, one thing remains the same: The NAL prescriptive target is a known starting point that clinicians can rely on and use to then fine-tune the hearing aids to better meet the needs of the individual (interested readers can check out Andrew Bellavia’s deep dive into NL3 here)
Although prescriptive approaches have been a standard of care for generations, they replaced the so-called comparative methods, one leading manufacturer is looking to bring back an approach that relies on patient preference, something more akin to the comparative methods from decades past. It will be interesting to see if their approach has merit.
In the meantime, it is important to remember that when clinicians rely on patient preference, many new hearing aid wearers “prefer” the sound of the open unaided ear canal. This speaks to the importance of a clinician’s counseling ability as well as her reliance on an established starting point for gain, validated with 50+ years of science. These provide strong reasons to stick with the NAL approach.
References
- Coe NB, Miller KEM, Sun C, et al. Impact of cognitive training on claims-based diagnosed dementia over 20 years: evidence from the ACTIVE study. Alzheimer’s Dement. 2026;12:e70197.
https://doi.org/10.1002/trc2.70197 - Kitterick, P. T., Zakis, J. A., & Edwards, B. (2026). Evolving the philosophy: from the NAL rule to NAL-NL3. International Journal of Audiology, 1–10. Advance online publication. https://doi.org/10.1080/14992027.2026.2690236
Brian Taylor is a contributing editor to HHTM. He is also the VP of Clinical Research and Professional Relations for Neurotone. Opinions expressed here are his own. He can be contacted at [email protected].
