Cognitive Screening in Audiology Practice and ADA Panel Discussion

Amyn Amlani 0:10
Welcome to a special edition of This Week in Hearing. My name is Amyn Amlani. Over the months we have shared content that scours hearing care from all angles, technology innovations to gene therapy, and practice management and legislative issues. In today’s session, we are pleased to partner with the Academy of Doctors of Audiology. To bring you a recording of the panel session titled, ‘Understanding the Relationship Between Cognitive Decline and Hearing Loss’ that occurred during the recent AuDacity ‘Audiology Unleashed’ conference held in Portland, Oregon, on October 26th. This Week in Hearing would also like to recognize and thank Cognivue for sponsoring this event.

Laurel Gregory 0:57
All right, everybody’s here good, hey, this is gonna be a really great end of the day. And I think it’s I think it’s I don’t want to say it’s hot topic. But I think it’s a really, really important topic when we talk about expanding our practices. And so we’re going to be talking about the relationship between cognitive decline, and hearing loss. I’m Laurel Gregory, and I’m director of training and development from sales for Entheos Audiology Cooperative. And I’ll be moderating this fine group of people up here. And so we’re going to introduce each panelist, and they’re going to come up and they’re going to talk to you a little bit about their journey on this whole cognitive decline and hearing loss. So we’re going to go from the very beginning, like ‘why?’ Why are we looking at cognitive decline? All the way through – can we be looking at cognitive decline? So hopefully, we’ll do the whole gamut. After they, each of our panelists gets up here and, and talks to you for a few minutes. At the very end of that, we’re going to open up to questions. So we’re gonna have a lot of times for questions for you for the panelists. So get ready, write your questions down, and then race to the mics. All right. So we’re gonna start with Pamela Souza, Dr. Pamela says, and unfortunately, she’s not able to be with us. But she did record herself and her presentation. So let me tell you a little bit about Dr. Souza. She’s a professor at Northwestern University. Her research and clinical interests include speech recognition, hearing aids, and effects of aging on communication. A recurring theme in our scientific work is understanding individual auditory, and cognitive abilities in order to customize hearing aid treatment. So with that, let’s let’s welcome Dr. Pamela Souza.

Pamela Souza 2:55
On understanding the relationship between cognitive decline, hearing loss, my name is Pamela Souza. I am a researcher and clinical audiologist at Northwestern University. And I’ll be giving a brief introduction to the topic followed by discussion with my colleagues. We can think first about what our motivation is as audiologists to consider cognitive assessment and discussion of cognitive abilities in practice. Over the last decade, there have been a considerable number of studies that have showed that hearing loss, especially untreated hearing loss, is associated with cognitive decline. In fact, a recent review paper found that hearing loss was the largest modifiable risk factor for dementia, and it contributes about percent of the overall risk in dementia to older adults, which is more than many other health issues. Now, as a profession, we also practice care that is centered around our patient. And certainly a lot of us would say that talking about cognition, and perhaps screening for cognitive decline, are part of communication for these patients. Now, we also know that the scope of practice of audiology is evolving. Very soon, it looks like we are going to have over the counter hearing aids. So that will produce changes in some practices. And it’s also a motivation for thinking about a more holistic approach to communication to cognition and to treatment. So when we talk about cognitive impairment and dementia, what we’re talking about is evidence of significant cognitive decline from a previous level of performance and this would be a cognitive decline that is not explained by something else like depression or delirium. We often think of this as being memory loss, but it doesn’t have to just be memory. There can also be changes in personality, mood, ability to make decisions, language and communication. Even visual perception, and these are often concerns that are first raised by the patient or by family of the patient. And hopefully that leads to some appropriate evaluation, which might be neuropsychological testing or some other type of clinical evaluation. There have also been some recent developments, we may soon have effective blood tests, at least for some stages of dementia. Now, a key distinction between mild cognitive impairment and dementia is that in MCI that person maintains their independence in everyday activities, where in dementia, these cognitive deficits have progressed to the point where they’re interfering independence in everyday activities. So it’s also worth mentioning that dementia is not all Alzheimer’s disease, there are a number of different disorders that can lead to dementia. There can also be mixed dementias with more than one cause. And each of these can have different early clinical symptoms, again, ranging from mood changes to memory changes to changes in judgment or communication. Now as audiologists this is something that is very likely to affect us because there are effects on so many individuals. So we know that MCI affects about 25% of adults who are over 60. The older they are, the higher the percentage that may be affected. And then dementia is affecting about 11% of adults over 65 years. By the time we’re talking about older ages over 85, it can be as many as one in three adults. So given that a lot of audiologists are focusing on older adults as those who have more hearing loss, we’re also very likely to be seeing patients with these disorders. We also know from research studies that it sometimes takes quite a bit of time to be diagnosed. So the time from symptoms to diagnosis may be as much as several years. And as many as 50% of patients with these disorders may not be being identified through primary care. And there can be a lot of reasons for that up to an including that the patient themselves or their family are not bringing it to the attention of their care providers or ready to engage in the medical testing and follow up that would be suggested. But regardless, you know, we as audiologists who spend a lot of time with our patients have an opportunity here to fill a gap.

So how often are audiologists screening for cognitive decline? There have been a few surveys about this. The numbers that I’m showing you are from a 2020 survey of 1100 audiologists. What we found was that the screening varied with the practice. So among audiologists in university practices, about 30% are screening. Nonprofit clinics about 23%, private practice about 12%, audiologists who were inside a hospital or medical center about 8% and in physicians offices, which in the survey were primarily otolaryngology practices 6%. So overall, about 12% of audiologists are doing formal cognitive screening as part of their assessment. But you’ll probably notice that this aligns with the time that you might expect to have so university practices we can probably assume have a little bit more time per appointment, and an otolaryngology practice, a little bit less. And this is one thing that’s going to come up today in the discussion, what do we have time to do? Now another topic that you’ll hear about today is which screener you could use if you did want to do assessment here. So there are many screeners and in many different forms, ranging from pencil and paper forms to computer based. And as you’ll hear during the discussion, the decision of which screener to use depends on your practice your patient population and what you’re actually screening for. But one way to make this choice is to think about the time that you have to accomplish the screening and the sensitivity of the screener for what you are screening for. So for example, if you have 10 minutes available and you’re interested in screening for patients with mild cognitive impairment, you can choose among screeners with different levels of sensitivity. And keeping in mind that there is usually going to be a trade off where the quicker the test, the less sensitive it is. Now, also in a clinical environment, we have to consider the different factors that fit this into our appointment structure. So these are some of the things that you will hear discussed today, ranging From the time available in the appointment, the expertise that is needed to administer that particular screener all the way to the counseling strategies and referral. These are all important decisions, and they’re going to be unique to each practice. So without further delay, I invite you to join the conversation and discuss this with my colleagues, each of whom has had experiences including this into their practice. Thank you.

Laurel Gregory 10:28
Well, how about we give her a round of applause? She’s not here, but we can tell her right. That was a great introduction of you know, why – why are we looking at cognitive decline? And why should we be doing that, and what’s going to happen next? So I have the privilege of introducing Dr. Alicia Spoor and she’s a familiar face, right. I mean you’ve seen her quite a bit here at ADA already. So we get to her again. She’s the owner of Designer Audiology in Highland, Maryland. And as often as possible, she promotes the unbundling, pricing model of her business and functional and communication needs assessment. In her free time, guess what she does? Dr. Spoor chairs, the ADA advocacy committee and works on Maryland issues as the state’s legislative chair. So with that, I’m going to invite Dr. Spoor up.

Alicia Spoor 11:27
Thank you very much. I’m happy to be up here again, although it’s been pointed out I think Dr. Amlani has me beat for stage time today. So I’ll work on that tomorrow. So I want to talk a little bit Dr. Souza did just an amazing job with her presentation and kind of giving the overview. And I feel like if she was here, she probably could give this entire presentation herself and so much more, because she is really one of our subject matter experts in cognition and the profession of Audiology. So I’m a little bummed she’s not here for questions, but we’re gonna send all those questions to Dr. Davis that, yes, she just found out today too. So with that, I really want to talk a little bit about who we should be screening and when we should be screening them. So if any of you have three and a half hours to listen to my Functional and Communication Needs Assessment recording from last year, it’s time probably not well spent. But it’s available, and it’s recorded for you. But I go into that a lot about how I do my cognitive screenings during that round. But I think with all of the information that’s been coming up recently, just doing that, when you’re looking at the old fashioned hearing aid evaluation is probably not good enough anymore. With the statistics that Dr. Souza just mentioned, were one in four of patients over the age of 65 are at risk. And the PCPs are not taking the time, nor do they have the time to do cognitive screenings. This is where we come into play. And I don’t know that Dr. Giorgio, this morning knew what we were going to talk about was when she was talking about the patients trusting us. How many of you think patients trust us? Like a lot, right? Because if they didn’t trust us, they probably wouldn’t number one be in our office to hear bad news, as we often say. And number two, they probably wouldn’t be motivated to move forward with our recommendations for treatment, whether it be vestibular, APD, hearing, whatever that might be. So there’s the big question about do we do some type of screening for all diagnostic procedures? And I think the answer is really going more towards Yes, you should be doing something at that point in time. And if you don’t have 10 minutes to spend on the MOCA, which is kind of more of that gold standard, then you’re looking at something like the mini cog. And as we all know how many people realize that a lot of people are identified as being MCI, but they really just couldn’t hear.

And who better to figure out how well they’re hearing before you do a cognitive impairment, then an audiologist? So when we have those pure tone thresholds, and we know what their word recognition scores are, that’s when we can actually go back and figure out “oh, I can give you a cognitive screener” because now I know what level to present those three words in the mini cog to make sure that you have the audibility to then actually figure out if you have the cognitive impairment. Right? That makes total sense. And if you’re doing it with every single patient that walks into your practice, and you physically don’t have time – We’re strapped for time, we know Medicare doesn’t pay us a lot of money to do a hearing test and a lot is probably an over exaggeration. Right? What other staff members can we do, to, can we utilize to be doing this – does it have to be pen and paper, I see a huge deaf population. Doing audibility probably does me no good with my Deaf – capital D – patients. At that point, I need something written, I need something visual. That’s just the realm of these patients and what we’re going through. So I think we really need to look at the differentiation between hearing and cognition, which is what we’re doing anyways. But then we also need to be looking at are we doing this every single time for every single patient? And again, what I used to say a year ago was like “No, put that to an F&CNA maybe comes into play of like, yeah, maybe we really do need to be doing this all the time. And scope of practice is going to come at the end. And then we can talk billing, without talking prices, you know, much later. But the other thing that I would really talk about is that when you see these patients, let’s say you start doing your screenings on every single person that comes into your practice, but you haven’t seen Mr. Johnson for five years for hearing tests, but it keeps coming back because his hearing aids aren’t working well. That’s the perfect time to be screening these people again. Because if they’re in some type of treatment plan, whatever that plan is – AR, cochlear implants, bone anchored devices, traditional amplification, and they’re not progressing along the spectrum. That’s when you need to be looking at that cognitive side of things to make sure that there isn’t something else coming into play in that regard. So I kind of see this as a two pronged approach. And you’re going to hear Dr. Davis talk a little bit about this in a minute. Not only about taught, right, what you’re doing initially, but then also what some of these outcomes might be, which are pretty interesting. So I have this idea of like, Good idea, bad idea. I grew up with Animaniacs when I was I don’t know, 12 years old, right? And then we said good idea. Bad idea. So good idea – You screen people who have symptoms consistent with MCI. And I think we know what those are. I feel like I can’t remember quite as well, you know, oh, I was late, because I couldn’t find my car keys. Really? Where were they in the freezer? Hmm, that’s not quite normal, right? people over the age of 65. We just heard Dr. Souza. All right, that should be the biggest red flag as to when you start screaming that people who complain about hearing within normal limits or people that have complaints, but their hearing is within normal limits. That’s the time that you need to be doing extra things, you need to be doing speech in noise, you need to be doing high frequency audiometry, you need to be looking at outer hair cell function, you need to be looking at cognitive issues at that point in time. So maybe you’re not ready to jump in with every single patient, because you don’t quite know what to do when you have those patients which Dr. Hill’s gonna tell you in just a minute. But when you see those patients where they are normal, that’s when maybe you start implementing this. And then again, I talked about the lack of amplification. And I use amplification very broadly, because I don’t think it to just air conduction hearing aids, we talked about Osseo. Bad idea – I learned this the hard way – don’t screen somebody that you already know they have dementia. Even if you want the practice, just don’t do it, their caretakers, their family members, they already know what’s going on, don’t do it, they get kind of mad, even if the patient doesn’t get mad, they get kind of mad, even when you say like, oh, this is gonna bother me just don’t do it. If you don’t have the training, obviously, that’s really important. And you saw MOCA is kind of the gold standard. It comes with an hour training that cost $125. If you haven’t gone through that just don’t do it. It would be like somebody doing a 92557. And they don’t know how to read an audiogram. Just don’t do it, go get the training and actually put the time and effort in. Obviously, if you’re not comfortable integrating the results and counseling, which I feel like is where the hiccup is, we can be the technician and give a screener. But then we don’t know what to do. And I look at these Facebook posts and people say like, oh, how do you tell a patient when they fall in the yellow line? Well, if you don’t know what to do, maybe don’t do it yet. Maybe go figure out what to do in the continuum and then start to implement it. And again, I think the next presenter is going to really help in that situation. And if you don’t have a referral system, don’t be screening for MCI and cognition. You have to have somebody to send these people to – that’s negligence on our part, if you’re not comfortable sending somebody for a vision test, because you don’t have an optometrist, don’t screen their vision.

That seems simple. But if you don’t have that referral system number one, go get it because it’s a great referral source. But then number two, make sure that you’re comfortable sending your patients over to them and counseling them, which is again that next step as to why they need to be going there. So I’m going to pause at that point. And I’m going to turn it over to my next colleague and then hopefully your questions are starting to formulate, you’re starting to get some ideas and we can have a great discussion as well.

Laurel Gregory 19:55
All right. Thank you Alicia. So now we’ve got the patient in the door, we decided to do a screening. And I’m going to introduce to you Dr. Heidi Hill. She’s the owner of Hearing Health Clinic in Osseo, Minnesota for the last 14 years. She’s been in audiology for over 25 years. Sorry about that. Dr. Hill specializes in testing and treating hearing loss in a more functional, real world way that looks at hearing from ear to brain, ear to brain. Dr. Hill is the creator of CogniHear, a company that provides education resources, and cognitive ear certification and the practical application of current research into best practices of Audiology. So with that, come on up.

Heidi Hill 20:44
All right, if you guys need to stand up, feel free, it’s casual. And it’s the end of the day. So and hopefully you don’t have too many questions for me, because we are between you and the exhibit hall and drinks, I suppose. I want to talk to you about cognitive screening in 2019. I came to ADA and Dr. Davis and I didn’t know each other at that time. But we both met Cognivue at that time and really transformed our practices. But the story actually started for both of us before that point, we had already been doing some things in our practice. And so for me, in my practice, I was I’m very passionate about age related hearing loss and looking at the entire auditory system – ear to brain, the peripheral and the central because we don’t just hear and listen and communicate with our ears. Our brain is, and the auditory system as a part of that. So I really took on cognitive screening in my practice as a part of audiological care not just to screen to see if my patients have cognitive decline. And then referring of course, I do that. But it was really to gather more information about the auditory system. So we see obviously many patients who have the comorbidity of both. As Dr. Spoor says we need to do some differential diagnosis. So it’s really important that we’re testing, not just the air, but also a little bit of cognition or screening cognition. How I utilize this, and I actually do the cognitive screening right away. Because as I’m thinking about this patient, and I’ve had them do their questionnaires, and they’ve told me their story and why they’re here. And we formulated goals based on all of that. I want to know does my patient have a cognitive processing necessary to compensate for the hearing loss that they have. So it’s really about bottom up, top down processing that we learned in school long ago. And most of us sitting in this room learned the auditory system is an afferent processing system. It goes ear to brain. And actually what we know now is it’s not just bottom up processing, it’s bottom up and top down. And its that efferent nervous system. And in fact, the efferent nervous system is now thought to be more important than the afferrant nervous system for people who have hearing loss because if you’re not getting a good signal coming up, you’re relying on your system coming down to compensate for that. So does my patient have those top down processing skills necessary to compensate for poor bottom up signals? If they do, I’ve done a screening and cognition is looking good. Oh, I didn’t mean to push the button sorry. There’s a high probability that that patient thinks they can manage without. And if we think about the fact that we have not helped over 70% of people who need help. And of those, those patients with mild to moderate hearing loss, high frequency hearing loss, we’re only helping 3% to 4%. This is why – they have good cognition. So they can manage without, but at what cost? They’re overworking the frontal area. They’re working harder than they need to and you all tell patients that, but it’s very different between telling a patient that and showing a patient that. So what I found in this approach, is I’m able to say you know you’re missing the sounds. Your brains not getting them. The good news is your brain processes very well. And so you’re able to compensate for that. But it’s costing you cognitive reserves, you have a high score on your listening effort in noise. And I don’t know about you, but I don’t need to waste my cognitive reserves on listening, when I need them for remembering, and thinking and reasoning. And your patient’s like, yeah, absolutely. So what I found in that approach with these patients is they’re like, let’s do it. That’s not fear based. That is education. And I need to know, as the audiologist, is this, why you’re hesitant to move forward?

If they don’t have good processing, I know there’s a high probability of unmet expectations. Wouldn’t you like to know that up front, poor performance in noise, lack of participation and engagement will continue. And we will have under utilization of the hearing aids, even if they do move forward. Dr. Harvey Dillon just published a study in 2020, that half the people are under utilizing hearing aids – 20% are in the drawer. So let’s think about that we’re only helping 17% of people who need it. And of those, half aren’t utilizing their hearing aids the way that we know that they should be. So as their audiologist, I need to know that up front, are you at risk for under utilizing your hearing aids? My whole approach with that patient is going to be very different. What hearing aid considerations do I need to make given their cognition? If they’ve got poor cognition, there’s some research that I can utilize to make some decisions. Hearing aids have the potential to increase, rather than decrease, cognitive effort. Let that sink in. You’re fitting the hearing aids, your patient sitting in front of you, you might actually be decreasing, rather than increasing their cognitive effort based on how you’re programming the hearing aids. Over signal processing. Too much signal processing isn’t good if your patient has poor cognition shouldn’t be doing too much of anything. WDRC can make it worse. Noise Reduction can make it worse. Did y’all know that? I mean, it’s shocking to me. Low MPOs, high compression ratios, those all distort the signal. And if you don’t have good top down processing, you can’t figure it out. So I need to be aware of my patients cognition and make these kinds of decisions. So again, it’s compression, noise reduction, frequency compression. Those are all things that have potential of increasing the cognitive load. Our goal as audiologists knowing what we know now about hearing and cognition, needs to be reducing cognitive load. We need to know cognition to make other rehabilitative considerations. Does my patient need a remote mic? For the love of all things? Yes. If you don’t have the top down processing, to compensate for a poor signal coming up, because you’re in noise, you need help to do that. I don’t care what the hearing aid does. It’s not enough. So if you have poor cognition, and one of your goals is to be able to participate when my family comes over and it’s noisy. Okay, if I’m to help you meet that goal, and you have poor cognition, it’s not about the hearing aid. That’s a piece of it. It’s about remote mic and FM. I fit maybe two three a year before. I believed in them. I told patients about them. Oh, no, I don’t want that. I don’t want one more thing. But now that I do this more functional approach. At least half my patients are getting remote microphones. It’s awesome. Other streaming devices, these patients need more social support. Do they have it and are you helping their social support system? Are you helping their family members? Are you giving them strategies to communicate and to help their patient who has cognitive decline, to engage and stay socially active? Decision making. If my patient has poor executive function, they’re not a good decision maker. You need good executive function to make decisions. Are they there alone? Maybe I need to reschedule this patient, so that a family member can be present if they’re alone. I also need to know how I’m talking to them matters. How much technology can this patient handle? Are we talking about a phone?

Are we talking about captioning? When I do the remote microphone? Am I talking to the patient about the remote microphone? Or am I talking to the family member about the remote microphone? It’s really the family member that’s going to be using it. Does my patient need auditory training? Not everybody does. Some people do. Dr. Davis is going to talk about that. What other communication strategies do we need to be utilizing? Do we need to be teaching to the family? And what environment or environmental modifications need to be made to be meeting the goals based on hearing and cognition? And what visual support materials do we need to be utilizing? When we’re with our patients? Things to consider. Patients with higher cognitive abilities might acclimate faster and may not require as much rehabilitative intervention. As we’re making decisions. Most of us in this room are private practice owners. And we’re thinking about do we want to participate with third party? Do we want bundled or do we want to unbundle – these are things we need to be considering. That’s going to vary based on my patient’s cognition. Those with better cognitive function have greater awareness of hearing aid benefits compared to those with lower cognitive functioning. Patients with lower cognitive abilities may require more rehabilitation activities. You need to be learning about active listening training, speech tracking, group rehab, visuals, my hearing wellness journey, auditory training, 5 Keys, there’s so many tools available to us now. We need to be utilizing more assistive technology. Melissa, a little bit ago talked about how it’s about a rehabilitative plan and hearing aids a part of that we’ve been saying that forever. But are we really doing it? And cognition matters when we’re thinking about how much our patient needs. Now, I’m not trying to plug this, but I don’t like going to talks and hearing somebody talk and they have a lot of great ideas. And I want to know more. So I did put together a program that teaches the science about cognitive hearing science and neural coding, and my functional hearing assessment, and how to utilize that data that you’re collecting in a better way. So if you’re interested, I have that. And with that, I’m going to turn it over so that you can learn from Dr. Davis, who’s amazing.

Laurel Gregory 33:32
All right. Thank you, Heidi. So next we have Dr. Jill Davis. And she’s the owner of Victory Hearing & Balance in Austin, Texas, and the creator of the Victory Brain Training Program. That’s a music based auditory training program. She has a passion for improving communication, and believes music has a significant impact on our ability to understand speech. So come on up, Dr. Jill.

Jill Davis 34:02
Thank you so much. Um, I wanted to hopefully address a lot of questions by just showing you what it looks like in the office when you’re implementing the cognitive screening because what I found in my practice that it really is the missing piece that supports our recommendations to make a stronger suggestion and get it right the first time. So I want to kind of show you the the cases that I see most often and what I put together that will hopefully make sense to you and you implement the cognitive screening. And so I put together this recipe for success. So when I have these ingredients, I can create a more appropriate treatment plan for these patients. And so I use the handicap inventory to look at their motivation. I’m testing them, speech in noise testing on every single patient. The cognitive screening tells me if the score on the speech in noise test is because of their ears, their hearing loss or is the brain involved in causing that problem? So I have a clearer idea if I’m working with ear or brain or both. And then the comorbidities, we do a screener just to ask what other underlying conditions can be contributing to this score. So those are the primary ingredients, secondary is the audiogram. So I’m moving away from the audiogram. Yes, it’s important, yes, we’re going to look at that. But it’s not the driving force for my recommendations now that I have these other tools, and then acceptable noise level, to determine level of technology for them. So I know it’s pretty small, hard to see. But this is, when I was looking for examples. This is what I come across all the time, it’s actually hard to not find this report. And for those of you who are not familiar with Cognivue, what we’re looking at the report on the right, it breaks down three cognitive domains. So it looks at memory, visual, spatial and executive function. And then there’s two speed performance parameters, which is Reaction Time and Processing Speed. So this gentleman who I inherited him, when I purchased my practice, he had hearing aids that his wife made him get, you know, they were sitting in the drawer for four years. And he actually came in because he thought his memory was starting to go. And it was just time for his annual hearing test, his federal benefit renewed and he wanted to talk about maybe trying hearing aids again. So his QuickSIN score is, I believe, seven and a half, pretty high, his handicap inventory was 56, on a scale of zero to 100. That’s pretty high. For that loss, I thought. And so looking together at his motivation, 56 is high the speech in noise score seven and a half, he really is struggling and background noise. And then on the Cognivue report, his memory is a bit low, we want that score to be 77 or higher. Everything else falls within the normal limits. But how I explained that to him is it does look like you’re working harder than you should have to, you know, I’m relating it to the cognitive load theory that he you know, with that untreated hearing loss, his brain has started to change to compensate for that. And he’s just struggling more than he should have to. And so, for him, you know, we talked about better technology, let’s put you in something try again, and I’m going to test again in 60 days, that’s when his trial window is up. So in my experience, most of the time, they do improve at that second test, but he felt the memory change, we confirmed that with the screening along with the other tools, we could make a more stronger recommendation for him.

This is a patient she is 69 years old, and she lives alone and did not feel like she had hearing loss. She was referred to me from a physician for cognitive screening, she had talked to her doctor that she thought she was starting to lose her memory. But her handicap inventory was a 10, on a scale of 100, she just turns the TV up, that’s what’s important to her and she can turn it up and she can compensate, she did not know that she had hearing loss. She has diabetes, that self reported is not controlled. And if you just look at the audio, we’d probably think that’s a pretty easy hearing loss to fit, most of us get excited when we see that loss. And we can put some aids on and she’s gonna do great. However, her speech in noise score is 11 and a half on the QuickSIN and her scores are pretty low on the Cognivue. So now that I know what I’m working with, I’m going to make a better recommendation of a hearing aid that’s probably going to be slower, it’s not going to have your frequency compression, those those points that Heidi talked about with better hearing aid parameters for someone with low cognitive function, I want to treat her sooner than later because she is going back to her primary care doctor for a full cognitive workup. And so I want to make sure that she’s going to be able to hear the verbal instructions that will be given to her. And so I will stress the importance of the connection between hearing loss and cognitive decline. So even though she did not feel that she had a hearing loss, when we put some technology on her, it will be life changing. However, it may take her a little bit longer to adjust to that signal. So I want to clean it up as soon as possible to her. And then next is the one that we really like because this is a normal Cognivue. And this person is struggling just because of his hearing loss. So he actually has unaided QuickSIN is five and a half. He also had hearing aids that he was not wearing for three years for whatever reason. He said he wanted something direct Bluetooth, he didn’t like wearing his his loop around his neck, but he also had self reported hearing loss, he came in because I had sent out a database mailer about the auditory training program that I offer that can improve our ability to hear in background noise and our memory. And he came in because he thought he had memory loss. And so what I could tell him was, it’s actually your entry to hearing loss that’s causing you to feel like you’re missing things. And the good news is that you know, your cognition looks great today, however, you’re probably working harder than you should have to with that degree of hearing loss. So we need to treat you sooner than later so we can preserve this cognitive function. And then lastly, this is someone who came in for tinnitus specifically. So I did the tinnitus handicap inventory, which was 40. That’s pretty high. Level 3. He is a 58 year old male who is a musician and a tattoo artist, and did not think he had hearing loss, I had to counsel him on the connection between hearing loss and tinnitus. But he took some convincing to let him know that he he had a loss. His executive function as low, that score should be 75. But the rest were within normal limits. And his speech in noise was just outside. I think it was three and a half on QuickSIN, but he is reporting social isolation. He’s borderline depressed, because he’s a musician, and he hasn’t been able to practice and play with COVID. And so he, he reported some social isolation with him, you know, we we counseled and I talked about the handicap score that 40, the elevated QuickSIN response. And the low cognitive performance tells me that we should probably start some intervention sooner than later. And I put him in some demos, because again, he still did not feel like he had hearing loss. And he wrote me this email two days later. And so he was pretty impressed by the sound that he was hearing. Again, not convinced, but I could use, you know, those ingredients to convince him that let’s try something. After 60 days, he came back, I call that my graduation appointment. So in my clinic, we have that, you know, trial window, and I’ll bring everyone back in and we address the handicap inventory, we do unaided, aided, QuickSIN, and we do the Cognivue again. And so everything went up to normal, his memory really shot up there, it’s hard to get 99 on memory, but his executive function up to 80. So I know that even though when he came in, he didn’t pass completely. I know that this was an ear issue, and not a brain issue. Because now that we’ve treated the hearing, he’s very, very happy handicap inventory went down to four. And he’s, you know, going to be a patient forever. So one of my favorites.

So if I rescreen at the 60 days, and a lot of the patients, we did a statistical analysis and 80% of the time their scores improve, it doesn’t always go up to normal. And some people actually get worse on some of those domains. However, if it doesn’t go up to normal, that’s when I’m going to implement an auditory training program. I talked to them about the comorbidities and the other things that could be contributing to the low score. And so I’ve treated your ears and that’s a big deal, because that’s the number one modifiable risk. So we’ve done our part to treat the hearing loss. Now let’s look at other things that could be contributing to that low score. So you’ll find that they have polypharmacy, they’re on more than five medications. They have hypertension, maybe uncontrolled diabetes, sleep disorders, depression, social isolation, it’s all listed. And we can go through that together to come up with a plan because, you know, most of them might not have dementia, most of them will not have it, but they are just not doing as well as they should. So let’s talk to your doctor about what else could be causing this. And I know that they’re still going to struggle in background noise, because you need to have good cognition to hear and background noise. So I need to implement a training program to help them here in this challenging environments. And so this is one who she also reached out when I had mentioned the training program, and she has just mild high frequency hearing loss but felt that her memory was slipping. And she passed the Cognivue the first time her unaided and aided QuickSIN in was fantastic. But her handicap inventory was 34. For a mild hearing loss, it’s kind of a lot. So she did the training, and it’s at home training. I do music based, where they play a keyboard at home three days a week, 30 to an hour, 30 minutes to an hour for three months. And then I tested her again. And although she started off pretty great, she got even better. I mean negative on the QuickSIN is pretty fantastic and improved her cognitive scores as well and also lowered that handicap. So this was her pre and post test. And her report was that she’s more coordinated. She can play without looking at her hands, and she has more energy. So even though we’re not really changing the hearing and the audibility, we improve her quality of life by you know, maybe taking off the load of it and helping her and increased her memory specifically. That’s what I had.

Laurel Gregory 44:55
All right. Thank you, Jill. And our last panel is, speaker is Dr. Amyn Amlani. He’s president of Otolithic LLC, a consulting firm that provides competitive market analysis and support strategy, economic and fiscal and financial assessments, segment targeting strategies and tactics, professional development and consumer insights. Dr. Armani is here in the, in hearing care for over 25 years, with extensive professional experience in the independent and medical audiology practice channels, and an academic and scholar and in industry, and he’s also been up on the stage a heck of a lot today. So we’re gonna bring them up again, come on up, Amyn.

Amyn Amlani 45:45
All right, well, thank you. Alright, so what I was asked to talk about is, “is cognitive screening a part of our scope?” And so we looked at it from two different places, we looked at it professionally. And then we looked at it from the state point of view – your licensure. So let’s start out by looking at scope. So here’s the scope of practice 2018 by ASHA, there’s the QR code if you want to download it onto your phone. And I’m just going to pull out a couple of different pieces here. And oh, boy, this is hard for me to see. Responsible for you can’t hear me. Let me take that, okay, cuz I can’t see anything over here. Even with glasses that can help audio just responsible for the assessment of hearing balance and other related disorders, including tinnitus, and auditory processing across the lifespan that includes and on here in the the second or third bullets, the third bullet: administration interpretation of diagnostic screening that includes and measures detection of the presence of hearing, balance, and other related disorders, additional screening measures of mental health and cognitive impairment should be used to assess, treat, and refer. So it is part of your scope of practice as it relates to ASHA. Now, AAA has a version of this too, but it’s too old. So I didn’t put it in here. It’s 2006. My understanding is they’re creating one, but I haven’t seen it yet. Here’s page seven, it talks about the role of the audiologist and the second one is screen for possible cognitive disorders. Okay, so I’ve proven it to you from the professional standpoint, state licensure is a whole nother ball of wax. And so what we ended up doing, and I should preface this by saying that this was commissioned by Cognivue, okay, so I’m a consultant for cognitive view. And so what we did was we went through and we did two things. So it’s a two layered approach. We went through first and looked at all of the state licensure documents that are available online. In cases where it wasn’t clear, then we started contacting the state licensure boards, and I’m going to show you some of the emails that I received. So this was easy. This is a yes, this is I believe, is from the state of Arkansas. And I believe it’s the second one that says, hey, cognitive screenings are part of the state licensure process for this. For the licensees within this state. This was easy. We got a no, in this, I’m showing you the email here. This is from the District of Columbia. And so we went in looked at the state licensure didn’t make any sense. We emailed them. And they basically came back and told us that right now the licensing board is saying that it’s not part of the scope of practice here. So pretty clean cut. So now we have a couple of yeses. And we’ve differentiated these into two different kinds of yeses. One is yes, but okay. And when we say yes, but there’s a caveat that’s attached to the Yes. In most of these cases, it is, do you have some sort of credential, whether it’s on your academic transcript, or is through your continuing education that tells us – us being the state licensing board – that you know, what cognitive screening is, you know, how to interpret it, and those kinds of things. Okay. So there are some states and I’m going to show you a map in just a minute of where that exists.

And then you have what we call your neutrals, and these are states that are having these discussions at this point in time. They’re not a yes. They’re not a yes, but and they’re not a no. And so what we did was we contacted these individuals and said, Okay, what are you guys thinking? In terms of cognitive screening, we notice on your website, that it’s not a yes, it’s not a no, what’s going on? And then they would tell us, you know, we’re still having these conversations. I’ve attended many of these sessions virtually, to figure out what they’re doing. And in the cases of the neutral, what we’re doing at Cognivue is they’re sending a letter that highlights the things that I’m sharing with you, the professional organizations are saying it’s part of your scope of practice. These are the things that you can do, assessment of the individual ear to brain, you can do pre and post measurements to see how they’re functioning just as Jill did. You can talk about hearing aids, and then this is vetted through an attorney, hey, please give me the opportunity as an individual. If somebody comes back and says, Hey, I didn’t contact you. Yes, I did. Give me a yes. And let me try this. And let me see what happens. And we’ve been successful at this. In about four states that I’m aware of, one was Oklahoma, you heard that a little bit earlier today. And this is the map that’s been compiled. And I’m colorblind, but I’ll do the best that I can here, even though I created this graph. Okay. The yeses are in green. I’m assuming that’s yellow. So that’s Yes. With the exception. And you’ll see the exceptions are down here at the bottom. The blue, the blues are the neutral states. So these are the ones we’re sending the letters to. And the states that are a no. Well, we’re hoping that they have those discussions. Now Georgia just had a meeting it, cognitive screening was not on that docket, I did have a conversation afterwards with the group. And it’s going to be on their docket come early 2022. So this kind of gives you a an idea of where we’re at with your state, you’re allowed by your professional organization. And, again, it’s up to you as the provider to double check and make sure that you’re okay with your state licensure as you perform these duties. Thank you.

Laurel Gregory 52:04
All right, thank you Amyn, hey, I, it occurred to me, as you’re up here, that letter that you showed that was drafted by Cognivue, that’s really specifically for the audiologist to send to their state boards, right? Because it’s you guys who are going to make the change. It’s not Cognivue, you it’s not, you know, a single person out here. So if your state is in the, the neutral, or in the, I guess, even the know, send it to, send it to your boards, right. So we’re, we’ve got about 35 minutes, 36 minutes for questions from all of you for our panel. So I’m gonna let you kind of think about those things. But I have a question for the panel while you guys are getting ready to, you know, shoot some things at them. It occurred to me as you guys were all talking through this. So what do we do? If the results on their screening is not so great? How do we talk to them?

Heidi Hill 53:09
You’re looking at, they’re looking at me. Lovely. So it depends. One of the things that I like on Cognivue is there’s kind of a range. So what I find is the most common is kind of a somewhat lower score on memory, executive function and processing speed. Guess what are the three cognitive areas most important for hearing? Memory, executive function and processing speed. And then I find that visual spatial is usually pretty good and so’s reaction time. And so because I see this, so often, I can tell them, this is a very common scenario with my patients. But this is, you know, indicating this isn’t as high as we would like it to be. Again, I think that if you’re approaching doing this, from an audiological perspective, you don’t have to get caught up in the uncomfortable conversations. So I don’t have to be talking. First of all, I can assure them I’m not. This is a screening. I’m not looking for dementia, I’m not looking for Alzheimer’s, that’s not what this is about. I am looking to see how your brain is processing in areas important for hearing, especially in noise. I have to you know, have to know that to figure out how I can help you in the real world in the situations where you’re wanting help. So when I’m going through those results, I can say this isn’t where we you know, you’re having some challenges here and then relate it back to their hearing, can your brain compensate? And I have a very particular way of coming counseling the patient about how we hear utilizing cognitive hearing science that they really understand. Well, my point is the conversations doesn’t get derailed by the cognitive screening. It’s all about hearing and their performance in the real world. And I’m making recommendations about seeing their primary care neurologist. And if they asked me if it’s very poor, well, what could this mean? I simply say we don’t know. That’s the whole point of you going to see a neurologist, this isn’t a test this is this, this isn’t enough information, nor isn’t my expertise. So that’s why you need to go elsewhere. Or you need to follow up with your primary care physician, I’m gonna give them a call. They might, you know, it’s up to them what they’ll do, they might just do blood work. This could be anything this could be you didn’t have a good night’s sleep, you’re stressed out your vitamin deficient, could be a number of things. I don’t know, this doesn’t tell me that. That’s why I’m sending you to somebody else.

Alicia Spoor 56:05
There’s a long answer. So yeah, so I’ll jump in even though you just asked Dr. Davis, I do not use Cognivue, I use the mini cog quite often with my patients. And so I don’t have a range that comes into play. So with my patients, and with myself, as many of you know, I’m a little blunt at times, and I tell them very honestly, right, I look at the entire quality of life, and I look at their entire body system. And so we’re screening for hypertension, we’re screening for cognition, we’re screening for dexterity, we’re screening for a lot of things when we do that F&CNA type of test. And so I often tell them, You’re going to go home with an entire list of recommendations. And some of them, you’re going to think I’m crazy for recommending to you, but it all relates to your quality of life. And that is my goals to improve your quality of life. And yes, ears are part of them. Eyes are part of them. You know, when we work with patients, sometimes they get a little too comfortable with us. And they tell us a little too much information. And I might refer them to other places with that too much information like marriage counseling, amongst other things, but I often tell them, if this is whole person and whole center care, which is where the profession of medicine and healthcare is moving, we can’t just look at this, and we can’t just look at this, we have to look at that entire system. And so like Dr. Hill mentioned, I’m never telling them oh, well, you know, you might have a brain tumor. And leave it at that we wouldn’t do that if we have, you know, a positive acoustic reflux decay. But I’m also saying, I can help with this, but it’s not going to be as good as it possibly could be. And so we’re going to take a whole team approach, and part of that team approach is I want you to see these other professionals as well. And so we’re going to start working on this, you’re going to do your homework on these people, and then we’re going to come back together and make your life better. Dr. Davis,

Dr. Davis 58:13
um, so I implement the cognitive screening after the hearing tests, and after I’ve put them through the speech in noise testing. And we look at the results together right after they’re finished. And when they’ve gone through the speech in noise test. They feel like that was difficult. And we are finding some strong connections between the speech in noise and the Cognivue scores to where when we pull up the report, and it’s not within normal limits, like we like we say, it looks like you’re working harder than you should have to. And we need good performance here to hear well in background noise, when you were taking that test that was difficult, wasn’t it? And they say, oh, yeah, and I say, Well, let me go and review the results with you. We’re going to go over our findings and talk about next steps. And so it’s just a quick I kind of know the numbers I’m looking for, I know if it’s normal or not. And I just always tie it back to their performance in the booth because that’s why they came there in the first place is hearing. So after we’ve treated them and we’ve gone through the testing again, if they still are not where we need to be, that’s where we get to dive into the discussion of what else could be going on. And you learn a whole lot about your patients and all these other underlying conditions that they have. And they know that you know, you’re looking out for them and then you can send them on from there.

Laurel Gregory 59:35
Okay, here’s another big question for you guys. Now without specifically talking about what to charge, you guys are spending a lot of extra time with your patients. So how do you get paid for it?

Alicia Spoor 59:49
appropriately. Alright, so I’ll start we’ll go down the line in the state of Maryland I can use the evaluation and management codes. And I do that with all of my patients. So I do have those e&m codes available to me. And so a very quick cognitive screening, if I’m doing that with 92557, with just a hearing evaluation, is bundled into my e&m code as part of that evaluation and management. If the patient is coming in for a functional and Communication Needs Assessment, which is my version of a holistic hearing aid evaluation, which I don’t like that is a 92700, it’s a unlisted diagnostic procedure. And that is built at my hourly rate, I spend an hour with them, and therefore it is billed at my hourly rate. So it’s a little different depending on when I’m implementing that, and what I what they need, if they needed quick screening, or if I’m doing a full MOCA with them in that 10 minute category and something more sufficient, but I’m using my hourly rate and adjusting it in that way. So if you’re in the state of Maryland, you have the option of E&Ms with the caveat of Medicare does not recognize us for e&m codes, and therefore, you’re charging the same whether they’re in or out of network, and so your Medicare patients may be paying out of pocket.

Heidi Hill 1:01:17
Yeah, I have, I do charge, but it’s bundled in with a functional hearing assessment. So I charge for the whole ear to brain, I do quite a bit of speech in noise testing, noise tolerance, all sorts of things. So it sets me apart, it differentiates me, it gives me the information I need, I could, I don’t want to ever have to make the decisions I make for patients without having this information again. So they pay that fee, it’s out of pocket, it’s 92700.

Dr. Davis 1:01:54
Very similar, I’m a network with all insurance. And in Texas, we can only use the e&m code with BlueCross BlueShield. So anyone else coming in, they’re gonna sign the 92700. And I’m going to charge my hourly. But every patient that comes in for a hearing test gets the full evaluation. So when they call to make the appointment, my front desk says there’s a charge associated with the visit. It’s not covered by your insurance, it’s going to be this amount. Some of them say, Well, what is that, and that’s essential, explain that we do a little bit more testing, it covers the office visit. And so they’re prepared before they even get there that there will be a charge, in addition to what we’re billing their insurance.

Heidi Hill 1:02:33
And I’ll add one more thing, you if you’re making better clinical decisions for your patient upfront, that’s less chair time in the future. And more set, higher satisfaction. Also, a better experience is going to give the patient a lot more clarity. And they’re going to feel much more comfortable moving forward. So considering those things as well.

Alicia Spoor 1:03:00
And one more thing for me too, I think what Dr. Davis says really hits the nail on the head too, is that when the patients are calling or scheduling online, that’s your first maybe your first direct touch point from them. And if you’re honest with them about what that charge might be, and pumpkin planting my entire office, very in a very drawn out process, those aren’t your pumpkins, sometimes if they don’t want to pay, we’re not going to talk about access, which was the last panel. But sometimes you have to know like you can’t spend three or four hours with a patient because they’re not progressing. And maybe they’re not using things and you’re missing that diagnostic component. Because you know, in the long run that that’s going to be detrimental to them. But at the same time, if you’re honest with them, and they can make an informed decision. That’s great. And I use a lot of videos and ABN forms and emails and things like that. And so having those videos and having that explanation makes a big difference, because then they can watch it at their leisure on YouTube, things like that, too. So I think that’s big.

Laurel Gregory 1:04:10
Okay, thank you. Make sure there’s nobody out there. Alright, so I have another question. Dr. Davis, you just kind of said, well, everyone, when they call gets a goes through the whole program. So can you all speak to that? Who gets a cognitive screener? I mean, do you all do it? I know, I know. We had Pam Souza, who mentioned 65, You know, we had at 65 we have that huge amount of people with cognitive decline starting. So maybe we should start then? But what are you guys doing? It doesn’t sound like that’s what you’re doing.

Jill Davis 1:04:49
I need to know if I’m working with the ear or the brain and brain issues. Auditory Processing Disorder can happen earlier than 65. I’m not really looking for dementia. I I’m trying to figure out why are they struggling to hear in background noise, because that’s the number one complaint coming in my office every day. And, you know, I get that from my concussion folks, my auditory processing disorder, the folks that are normal on the audio, 0 to 20. And they have an elevated QuickSIN, or they don’t pass the Cognivue, you know, then I have the folks that have hearing loss, normal cognition like that I know what I’m working with there. And then the others, the 55%, that come in, I’m testing everyone over the age of 18, on the Cognivue, and, you know, again, I’m just looking, what’s going on here, like, why are you working harder than you should have to, and then we get to talk more holistic. So I do it on everyone, just because I feel like I’m flying blind without it to know is this ear or brain.

Alicia Spoor 1:05:51
So when a patient comes into my practice, and they’re scheduled for an initial evaluation, in their chief complaint, Stacey I see you, we will get to you, hearing balance, tinnitus, whatever that might be and it with the intention that they’re scheduled for that initial comprehensive audiologic evaluation, I’m using my own clinical decision making skills to know whether or not I need to screen them at that point in time. That is what I believe I’m doing based off of their symptoms, their case, history, the interview that we go through which full disclosure takes me a good half an hour, even if they’ve done their paperwork ahead of time. That case history gives me a lot. So I’m making that clinical decision as a doctor of audiology as to whether or not I need that when they come in for that initial one. If they come in to see me and we are doing a functional communication needs assessment, everybody is getting it at that point in time. Because at that point in time, I know that they are interested in some sort of treatment program. And that’s what I want to make sure we’re looking at the full body.

Heidi Hill 1:06:56
So I’m similar to Dr. Davis, and it’s really a part of my counseling to to help the patient understand, even if their cognition is really good, I want to be able to show them that it’s really about collecting data about the entire auditory system, which is ear to brain. And so it helps me to explain, you know, your brain up in your memory is is poised and looking at the at the ears in the periphery, and trying to make matches of what’s stored there. And what’s coming in, and your hearing loss is causing it to not get as much information. And so there’s this mismatch there and the good, you know, so your brain has to work harder. The good news is, is your cognition is good, and you’re able to do that. But there’s a cognitive load to that there’s increased listening effort. So it’s a big counseling tool for me as well. And I’m really trying not to make as many as I’ve been collecting data. I’m trying not to make so many assumptions. And I’m surprised, quite honestly, how many assumptions I was making before I started doing all this testing. There’s just some, some things I don’t know unless I collect the data and the information.

Laurel Gregory 1:08:19
Alright, thank you. So we do have a question.

audience 1:08:22
Hello, oh, thank you so much for so freely sharing this information, and a couple years ago with the information and having Cognivue at ADA. And then many of you online sharing freely has just allowed so many great things to come and applying it clinically. Question for Jill, on the musical training. I mean, everything’s better with music, right. So can you speak a little bit to that? And do you make it available for everyone here if they want to learn? And do you have a keyboard in your office,

Jill Davis 1:09:02
I do have a keyboard. I use it to test cochlear dead regions. I also get them set up on the auditory training and I think everyone should have a keyboard in their office. So I was looking for an auditory training program that my patients would actually follow through with I had a hard time implementing a program with them. And if they did get started, they didn’t stick with it. And so I was looking for alternatives and music was the answer. I found, you know, Nina Kraus’s lab and she was a big inspiration for me to take a look at the benefits of music training for our processing in background noise. And turns out it improves memory and executive function as well. And so I’m presenting tomorrow on this if y’all want more information, but what the the big thing that I found is that some of those brain training apps and the auditory training programs, they have improvements that occur after training, but the improvements don’t stick. So and increase cognition and increase performance and background noise, it doesn’t stick around and even across as do a refresher course. But the thing about music is that even if you trained as a child and you haven’t played in 40 years, you still hear better in background noise than someone who’s never played music. And so that’s where I’m only recommending music training unless they’re a musician, which I live in Austin, Texas, and almost every patient is a musician. And so if they tell me that they’ve played an instrument, then I’m going to recommend the other programs. But for those who, you know, I want them to have the same benefit as the folks that have played music, we’re gonna start learning.

audience 1:10:43
Now, the question, mean, you talked about the licensing boards, asking about the training that we have in certification? Do you have any idea what they’re asking for on that? What kind of requirements we need to be looking for?

Amyn Amlani 1:10:59
Yeah, that’s a good question. So if you’re in a yes, state, it’s easy, right? You qualify based on on what the licensure gives you, you’ve already got the blessing from the professional organization. And ASHA, if you’re in the no state, just means the state licensing board has not yet ruled on it. And they’re reluctant at this point to give a neutral. So they’ve shut it down. And Georgia and Washington DC at this point are the only two. Although as I mentioned, Georgia starting to have these discussions, which will start up in 2022. It’s the yes. But in the neutrals that get a little bit tricky. So on the Cognivue slide, it actually lists out those states. So there’s, I think, six or eight of them that say, Hey, we want to see that you actually have this on your transcript. And they’re asking for three credit hours, or they’re asked for two credit hours, or we need this many in continuing education hours to show that you’ve taken this coursework. So you we know you have a basic knowledge in this area. So again, there are six or eight states there, there are states that are neutral. And what that means is they’re in the process of having these discussions, but they haven’t ruled. Now, here’s where it gets tricky with the neutrals. The board can say yes, we agree. But until it’s actually part of the statute, you can’t do anything. And that’s where that letter comes in. Because now you’re getting permission. Think of it as a hall pass, until classes let go or until this licensing board actually approves it. So the folks at Cognivue and Entheos has this as well can walk you through this, me email me, I’m happy to share with you what we know. We’ve built this out in a cloud, that folks at Cognivue can pull out. And I’ve simplified it by just putting it on a map. But there’s intricacies in beneath beneath that. We can share those with you. Absolutely.

Alicia Spoor 1:12:59
And I’m going to put the plug in this is why being a part of your state association is so important, which I know many of you are but a lot of the state associations quite a few years ago when PTRS was around now MIPs. And we needed to start doing depression screening with our tinnitus patients. This is when a lot of the screening questions started to come up. And so it was the state boards and your state audiology associations that were trying to start to tackle that unless you were blessed to be somewhere where somebody wrote the MIPS measure, and they went and did it for you. So I know I’m preaching to the choir, but this is why you should all be part of your state association. And I am biased because I am the legislative chair.

Laurel Gregory 1:13:45
Another question?

audience 1:13:46
Hi. First

of all, I think I speak for everyone here. Thank you for your time again. And thank you for sharing what you have my particular questions for Dr. Spoor, when you said you did a dexterity screening, what does that mean? How are you administering that? I have questions.

Alicia Spoor 1:14:04
I have answers. And it sounds like maybe some of it should be done with a bottle of bourbon. However, just very briefly, because I’m happy to dive into this as much. Dr. Baxter and I were talking about this a little bit earlier too. We’re using the Purdue pegboard test. And it is available online, you can go buy it, it’s a nominal fee. I don’t remember who it was. But again, if you have three hours, I have that price in my webinar from $100, $100. Thank you. I’m glad somebody paid attention. I just put it on the credit card and figure it out later. It is an actual system where it’s a timed test. It’s got a board and you have to pick up pegs and put them in the board with your dominant hand your non dominant hand, you have to switch them and then you have to make a little thing. It’s just bolts and washers essentially. And it’s all based on normative data. Now the normative data is a little old and sexist because it’s based on like The average female and how quickly she could do something in order to be a seamstress. But it is normative data. And right now it is one of the few things that we have to do that. So I’m using that a lot with my patients who say, Well, I really want like a small device, or you know, I can live at home and I can pick those things up. And I’m like, really prove that to me. Because maybe you can’t live by yourself anymore. Maybe you do need something bigger. Maybe the cane isn’t where we need to be going in. You need a physical Walker, because your hands aren’t working quite as well. And so that we’re that’s where it gets into neuropathy, tingling in their limbs. I’m looking at if there’s tingling in again, Dr. Baxter, and Jane and I were talking about this, right, if you have tingling in your fingers might have tingling in your feet. And then we’ve got vestibular concerns. Right, so that’s where I’m looking at on that Purdue pegboard. Are you doing the pegboard test? Do you want to chime in.

Jill Davis 1:15:58
So there was a manufacturer that had hearing aids that would get stuck in the charger that our patients couldn’t pull out. And I wanted to address those problems before they happen. So I will sometimes if I’m concerned, put them through that just so I know what the best charger may be.

Alicia Spoor 1:16:14
Does that answer that question? Yes. Thank you. You’re very welcome. Always happy to help. I’m all up for talking over bourbon. Thank you. Drinks are on Amyn.

Laurel Gregory 1:16:27
Okay. That’s a big one.

Amyn Amlani 1:16:31
Am I invited?

Alicia Spoor 1:16:32
You’re buying

Amyn Amlani 1:16:33
Oh I’m buying?

Thought you said they were on you know,

Alicia Spoor 1:16:41
on Amyn, on Dr. Amlani. Okay.

Laurel Gregory 1:16:45
So onward. Looks like my turn again, which is great. So I got another question for you. Now you guys kind of skirted around the issue. Okay. So I’m going to go right there. Your patient totally bombed on your screener? What do you do?

Dr. Davis 1:17:08
depends on their hearing loss, and their speech in noise score and everything together. I if they need hearing aids, we’re gonna set up appropriate devices for them based on that score. We’re gonna circle back to their comorbidity screening and talk about everything that they checked, that’s on there. And I’m going to talk to their physician, I’m gonna write a report of what we found and tell them I’m going to address the hearing loss, but it looks like something might be going on and send them the report.

Laurel Gregory 1:17:39
And what do you say to the patient? What do you say to the patient,

Dr. Davis 1:17:43
it looks like you’re working harder than you should have to. Something is causing you to struggle. And you reported that on your handicap inventory. And we saw it in the booths when you were in background noise that was really hard for you. And we need to figure out what’s causing you to perform worse on this test. If they really want details, I will say we need good memory and executive function to hear well and background noise. And those two scores were a little bit low. That’s about as deep as I go anything out of there’s not in my scope. So.

Heidi Hill 1:18:17
So I will, first of all, ask, are there concerns about memory cognition? What’s really been surprising is if they do really poorly 100% of the time, those patients go no, I don’t think so. And they look at their significant other who’s going. And so I mean, that be aware of that, like, it’s not enough just to ask because it really indicates to me at some point, they get to a point where they don’t realize that they’re having problems anymore, but their family members do. I’ve also found, especially with adult children, it’s just kind of a relief that they have. Somebody actually addressed it in a health care facility. They’ve been waiting for this, their mom, their dad, they’ve been in denial, and they need somebody to help advocate for, for them. And so it’s pretty powerful, too. If, if it’s really, really poor, sometimes I will simply hand it to the family member and say, you know, or the family member watched them do the Cognivue and knows how poor it is. And then I’m just having a very different conversation with the family members. And if there isn’t a family member with them. You know, maybe we’re going to reschedule to talk about some rehabilitative options with family member present.

Alicia Spoor 1:19:58
Usually go something like like this, Dr. Hill, we did a lot of screenings today to make sure to get you the best treatment we possibly can. I’ve written them all down for you, and I’m gonna send you home with that. One of them was related to your cognition levels. And in that test or in that screener, you didn’t do quite as well as I want you to. So what I would like to do to make sure that we’re taking care of you as a whole person is I’m going to send you to Dr. Carter, who is my neuropthotologist and he can look at the brain, the ear in the eyes, and make sure we’re doing as well as we can in that system. At the same time that you’re going to come back and work with me for treatment or you can go wherever you’d like for that treatment. I’ll let your primary care doctor know but we can schedule with Dr. Carter before you leave today. And then if they’re open to it and they’re not like hell no. Right like there I’ll we’ll make that appointment on the report that goes back to the referring provider and the physician i right. Cognitive screen, right refer slash did not pass MOCA mini cog follow up required. And then my recommendation, say patient was provided information for Dr. Nathaniel Carter appointments scheduled or will be scheduled by patient and caregiver. And then I send the report to Dr. Carter.

Laurel Gregory 1:21:17
So what was the name of that kind of doctor?

Alicia Spoor 1:21:19
He is no joke. He is a neuro optho otologist. So I eyes, ears and brain is that Johns Hopkins satellite, which happens to be down the street from

Laurel Gregory 1:21:30
me. So it doesn’t sound like a very common type of

Alicia Spoor 1:21:34
I use him all the time. He’s probably one of my top referrals behind dermatology.

Laurel Gregory 1:21:40
So Dr. Davis and Dr. Hill, have you found? Well, maybe not that specific type of physician because that sounds pretty pretty specialized? Do you guys have those kinds of or anything similar to that in your communities?

Dr. Davis 1:21:56
I found that the best physician to reach out to is the MD VIP primary care doctors because they are more preventative and they spend more time with the patients. They are not contracted with insurance. So they’re already doing hearing and cognitive screening. So I went to one and I said what do you do for cognitive screening? And he said, the MMSE. And I hate it because it only finds dementia. And I said oh, well, I have one that I use and talk to him about cognitive you being computerized. So we don’t rely on the ears And he’s one of my biggest referrals now because he doesn’t have to do cognitive screening anymore. So when they send them to me, I don’t do just cognitive screening, they get a whole hearing evaluation. But I would reach out to the primary care doctors as well, the doctors of my patient and I say I’m doing cognitive screening now. What do you want me to do when they don’t pass and they said, go straight to neurology. Those doctors were too busy. They weren’t going to have the time to do a full workup. They say just go straight to neurology. So I said, Do you have one that you use? And they said, Yeah, go talk to Dr. Bertelsen. So I knocked on his door. And he said, I’m doing the screening. And so it just helped me create that position referral network, you just have to ask what they’re doing and what they want with the results. And then you can kind of find your your crew.

Laurel Gregory 1:23:17
Great. All right, my question again. So we got six minutes. So this is a big question up. Heidi, you kind of touched on it a little bit fast. So I’m going to throw it out to all three of you. What do you do for your hearing aid fittings? How are you going to modify those fittings first fits really good, right? Punch and go? Oh, no.

Amyn Amlani 1:23:42
Okay, we talk about this. Okay, so

Alicia Spoor 1:23:47
wait, wait, wait, when’s the last time you fit a hearing? As long lay it on the lines, the

Amyn Amlani 1:23:52
last time actually put a hearing aid on a patient? Yeah. 1843. All right.

Alicia Spoor 1:23:58
And you’re 25.

Amyn Amlani 1:24:00
And I was 25 years old yeah. And that’s right. Theoretically. So theoretically, if you go back to 2004, ’05, ’06, and you remember some of the literature that was coming out when we were looking at cognition, working memory in particular, and the distortion that comes off of a hearing aid, you had somebody who had high working memory, it didn’t matter whether the signal was fast acting compression or slow acting compression, the person had the cognitive resources to pull apart that that information and process it. For those individuals who had low working memory. fast acting, compression actually has more distortion because you take the loud peaks and you compress and you take the soft sounds and you increase them. So the spectral contrast is a lot narrower, meaning that there’s no distortion. Those individuals struggle with that. But when you had nice modulations, like slow it compression, they were able to function with those devices. And so to go to your question here and at Cognitive screening has the potential, we’re still trying to figure this out. We don’t have all the data here yet. What it will let you do is it will guide you as to whether or not this person is high functioning, middle functioning or low functioning. If they’re low functioning, fast acting, compression won’t work. If they’re high functioning, you could fit just about anything. And if the kind of in the middle, well, we’ll have to figure out what that is. And so Jill and I are working together on a single subject design study, where we’re trying to assess this before we do a larger scale study, for two reasons. One, does the technology that kept cognitive screening technology, allow for this sensitivity. And then number two, it’s really hard to find a hearing aid that allows for you to change from the attack and release times. And so we were able to find one because now they’ve moved to adaptive compression. That’s a whole nother conversation. And so we’re hoping that we have enough information to share with folks about how you could potentially use this. And as the data comes in, we’ll be able to refine this and use it more and more clinically.

Alicia Spoor 1:26:09
Jill, are you talking about that tomorrow too.

Heidi Hill 1:26:15
There’s a variety of things to consider. And it’s not just cognition, it’s also tolerance to noise, is a really big huge, actually. So the acceptable noise level tests is something that I do, it really gives a lot of information about is this patient speech focus, noise focused, so I need to consider that as well. So the cognitive piece is really a piece of the puzzle. And there’s other pieces as well. So compression speeds, one thing I consider also compression ratios. Anything that distorts the signal is going to be difficult for a patient with poor cognition, most likely, for the same reasons. So frequency compression, compression ratios, even too much noise reduction. So really, signal processing can be a great thing, advanced signal processing. But if we go too far, and we don’t really look at everything, and we don’t take those considerations, we may actually be making it harder for the patient rather than easier. Also, if your patient has poor cognition, and they’ve already been wearing hearing aids, and you’re trying to move them into new technology, that might not be so simple for them. And they may have difficulty acclimating to that change. So perhaps you don’t like that manufacturer, you don’t like their new hearing aid, that they’ve been of the brand that they’ve been wearing. But it might be in that patient’s best interest to stay in that brand. Because now you have that information about their cognitive processing.

Alicia Spoor 1:28:05
You also said something when you were presenting to Dr. Hill, remote microphones cannot be understated. And these people, right and so looking beyond the actual hearing aid can make a huge difference in these patients. So while you may want to upgrade them, the option may be, don’t upgrade them and start to look at captioning to start looking at accessories, presuming they’re compatible and going the route of remote microphones.

Laurel Gregory 1:28:35
Alright, thank you. And I just want to take on to that remote mic thing I’ve heard Heidi say over and over to her patients to the adult children. This is not, this is not for your mom, this is for you. So you need to take responsibility for the remote microphone, which is such a huge relief, right. So we’re at the end of the hour, hour and a half. On behalf I think of all of you. I really want to thank our panelists for sharing your knowledge with everybody. I’m sure there’s lots more questions out there. And so thank you very much for your time.