Loneliness, Social Networks and Hearing Loss: An Update on the ACHIEVE study

Hello, and welcome to another episode of This Week in Hearing. I’m Brian Taylor. This week our topic is loneliness, social networks, and hearing loss. And here to discuss those topics is Dr. Alison Huang, a senior research associate in the John Hopkins Bloomberg School of Public Health. Welcome to This Week in Hearing. Alison, it’s great to have you with us. Great. Thank you for the invitation. Well, before we get started I thought it’d be great if you could tell us a little bit about your background in research and some of your roles at John Hopkins University. Sure. so briefly, I would call myself both an epidemiologist and a gerontologist. I did my PhD in mental health at Johns Hopkins University, and that’s a department that sits within the School of Public Health. So it’s kind of unique. No other school has a department of mental health within their school of public Health. So the training I have is looking at mental health from more of a population level, public health perspective, as opposed to kind of an individual level at the clinic training. methodologically, I’m trained in epidemiology, and the population I focus on is older adults, specifically in the area of cognitive mental health and hearing loss. And currently I’m faculty in the department of Epidemiology within the Cochlear Center for Hearing and Public Health, where I work primarily on the ACHIEVE study, which is the randomized trial testing the effect of hearing intervention on cognitive decline and other health. And I can’t wait to dive into that topic. We’ll get to the ACHIEVE study a little bit later, but I thought we could start by talking about just sort of big picture, how prevalent is social isolation and loneliness in the US and around the world. Yeah. So social isolation and loneliness are really prevalent, particularly among older adults. one in four older adults report being socially isolated, while one in three report feeling lonely. And during COVID which was a time where probably all of us felt a touch of isolation and loneliness, that prevalence nearly doubled among older adults. That’s unbelievable. So, I don’t know. I’m not an epidemiologist, obviously, but it sounds like that might be sort of epic proportions. besides Covid, are there other reasons why those numbers are so high? Yeah, so I think there’s a couple of reasons. So, Covid definitely increased social isolation, but it also brought some awareness to social isolation, loneliness. Before that, I think isolation, loneliness were something that we talked about a little bit, but really, Covid brought it to the forefront of public health. you saw headlines in mainstream news in the New York Times, I think even now every week I hear a story on NPR about social isolation and loneliness. so I think know close had kind of increased isolation, loneliness, but also brought it into the forefront of people’s minds and really gave people the language to kind of identify a feeling or a situation and really put it on the map as a health and mental health outcome instead of just something that happens and that we kind of just kind of see and move on. so I think that’s one reason why there’s just a little more discussion and just more of that recognition and awareness of isolation and loneliness. People may be just reporting as well, more isolation and loneliness. so aside from COVID and this big spike that was relatively temporary for those couple of years where we were really locked down, and it might just also be a greater awareness, given that we’re able to talk about it more as a feeling and an outcome makes sense. We’ve already kind of used these terms social isolation and loneliness interchangeably. But I know there is a difference. Can you tell us the difference between those two terms? Yeah, and that’s a good question. they’re related, but they’re actually quite distinct constructs. So social isolation is more of an objective structural evaluation of social connection. So these are things like how large is your social network? how many people do you talk to at least once every two weeks things like living situation, whether an older adult lives alone or not marital status. These are all more structural, objective parts of isolation. And even when we measure social isolation, the questions are just more objective. It’s how many people or how many family members do you talk to? How many friends do you talk to? That kind of thing. loneliness, on the other hand, is a more subjective feeling about your social connection. So it’s more how often do you feel left out, or how often do you feel alone? It’s more of a subject of evaluation of quality, quantity, how someone feels about their social connections. and there really is the case where you could be lonely, but not isolated. And this kind of comes in the context, especially with hearing loss. And this is anecdotally, my grandmother had hearing loss, and we would have the situation where she would be at the Thanksgiving dinner table surrounded by family, families chatting all over the place, but she couldn’t hear well, so she wasn’t able to engage in conversations. she couldn’t really follow what was going on and kind of just started to withdraw and kind of was just sitting there which breaks your heart to see, but that’s kind of a situation where you could have so many people around you but actually feel quite lonely. and you can have the opposite where you’re isolated, you don’t have many people in your network, but you’re not lonely at all. so they overlap, and you could have both. You could be isolated and lonely at the same time. So they are quite related, but we talk about them as distinct constructs. Well, thank you for clarifying that. you already mentioned hearing loss. Tell us about some of the research out there that looks at the relationship between social isolation, loneliness, and hearing loss. Yeah, so there is a connection, and I will say in the epidemiologic studies, there isn’t too much research, but there is a lot of consistency in the research. there is consistency that there is a relationship. There is an association here between hearing loss and social isolation, loneliness. Mainly, the worse you’re hearing is, the more isolated, the more prevalent loneliness that we see in older adults. And this kind of takes the form of activity restricting activity participation. So if an older adult participates in clubs or religious activities, we see some restriction in those kinds of areas as well as kind of the living situation but even in achieve at baseline. So prior to receiving any intervention we saw that in this cohort of older adults with hearing loss worse audiometrically measured hearing was associated with almost a 20% greater prevalence of loneliness, and even with other measures of hearing, like speech and noise, or hearing handicapped, so a measure of hearing related quality of life, we saw associations with more constricted social network size, so a smaller social network and more loneliness with worse speech in noise and worse hearing related quality of life. and there’s a couple of mechanisms that could explain this. One is that hearing is such an integral component of your ability to communicate. So with hearing loss, it may be harder to follow. Conversations might take longer because there’s a lot of effort going into just this effortful listening. so, of course, through the communication pathway, that hearing loss could lead to more isolation, loneliness but also through other health outcomes. There’s a strong association between hearing loss and lower physical activity, worse physical function. And all of that could affect your ability to kind of go out and do the things you like to do and participate in the day to day activities also through cognition. So I’m sure we’ve talked about before that hearing loss is strongly related to cognition and dementia and that could also affect your ability to converse, kind of follow conversations that cognitive load and effortful listening can lead to a lot of fatigue as well. So it might take a lot out of you to really engage with others and go out and do activities and then also through other mental health outcomes. So like hearing losses related to depression and anxiety and all of that can really influence the relationships that you have. So could influence the quality of your relationships when maybe cause a relationship strain and the support around you. So there’s several different pathways by which hearing loss is related to isolation and loneliness and we see an association here in the observational literature. There has been a little bit of research on hearing aids in the epidemiologic research, and it’s a little bit mixed, and there’s many different reasons for that. One is people who own hearing aids are typically healthier, wealthier have better health care access. And these are all things that could benefit social health. So it’s difficult to disentangle whether if we see a benefit, is it because of the hearing aid itself or is it because of some of these other factors that are tied up in relation to hearing aid use. So it’s a little mixed in the literature, and the follow up we’ve seen in those studies is also quite shorter. so we do need, broadly, we need more research in this area with different populations, definitely more international studies, but also studies with longer follow up and looking at isolation, loneliness over time and how that changes. It’s not linear, it kind of goes up and down that sometimes you can feel lonely and other times not. So it is a little more tricky to quantify. but we do need a little bit of a better understanding of how those things change over time in relation to hearing loss. Yeah, it would seem kind of complicated to study given that loneliness can kind of wax and wane. Yeah. And I think there’s many different kinds of studies. You can do it quantitatively where you measure it with a questionnaire, but there’s also a host of qualitative studies that really dig in a little deeper and get at those constructs that you can’t really get at with quantitative research. Good to know. you mentioned the ACHIEVE study, and I think our viewers are somewhat aware of the study and how it’s looked at the relationship between cognitive decline, dementia, hearing loss and hearing aid use. I know it’s gotten a lot of publicity inside of the field. maybe tell us a little bit about the larger aims of that study some of the questions you’re trying to address, and then with respect to loneliness and social network size, how you’ve tried to go about studying that. Yeah, so the ACHIEVE study definitely made a splash in the hearing world in the last couple of months. so, broadly, the ACHIEVE study is a randomized trial. They recruited 977 older adults that were randomized to hearing intervention or a health education control. And both the intervention and control were four sessions and they had consisted of one on one contact with either a study audiologist in the hearing intervention or a certified health educator in the control. The hearing intervention involved provision of hearing aids as well as education and counseling over these four sessions. And the health education control was health education sessions on topics related to healthy aging, like nutrition or physical activity. And participants were 70 to 84 years they had untreated hearing loss and were without substantial cognitive impairment and were recruited from two populations. So about a quarter were recruited from an existing longitudinal study called the atherosclerosis risk and community study. This is a study started in the heart health, which has expanded in cognition in recent years but about a quarter of participants were participants of that study and then recruited to be part of the achieve study. So, essentially, ACHIEVE is partially nested within the ARIC study. the other three quarters of participants were newly recruited. We call it de novo which means they were newly recruited from the communities. And this was done at four sites. It’s Jackson, Mississippi Forsyth County, North Carolina Minneapolis, Minnesota, and Washington County, Maryland. So participants came from those that were co enrolled in the ARIC study from those four sites or newly recruited from the communities surrounding those four sites. And the primary outcome of achieve is cognitive change over three years in global cognition. But we also measure a host of other outcomes, other health outcomes that the team is interested in seeing the effect of hearing intervention on, of course, social isolation and loneliness, but also physical function, activity, falls, hospitalization. So while the primary outcome is cognition, we do have an interest in some of these other outcomes as well but for the primary outcome for cognitive decline when we analyze these two populations, the ARIC group and the de novo cohort together we didn’t see actually an effect of hearing intervention on cognitive change. We saw no difference between hearing intervention and the control But when we analyzed the ARIC cohort and the de novo cohort separately, we saw in the ARIC cohort that hearing intervention was associated with a 48% reduction in the rate of cognitive decline over three years, and we didn’t see that in the de novo cohort. we didn’t see any difference between hearing, intervention and control. so that begs the next question is why are we seeing it in one cohort, in one population but not the other? and there’s a couple of reasons. There are two distinct populations. So the ARIC started in the 80s as a random sample of older adults at these four communities, and participants were recruited in the 80s, and have been participating in the study since then. so you can imagine this population is quite different from the de novo group, who are 70 to 84 years old now and are eager to join a new clinical trial. and you can see that reflected in their participant characteristics. The de novo cohort is younger, more highly educated, higher income healthier on a number of measures and conditions. and their rate of cognitive decline over the three years is quite slow. So there is not much cognitive change with the de novo cohort. but in ARIC, we see that their rate of cognitive decline is actually more consistent with a moderate rate of cognitive decline. So we’re seeing a greater, faster rate of decline in the ARIC cohort. so when we’re trying to slow cognitive decline with an intervention, it is hard to slow something that’s already slow in the de novo cohort and it’s not to say that hearing intervention doesn’t have an effect in that cohort, or it may just take more than three years to see. Our trial was only three years. at the moment, we do have funding for another three years for a total of six years of follow up, so we might be able to see something there. but, yeah, there’s a couple of reasons. The de novo cohort is overall healthier and the ARIC cohort may be more reflective of kind of the broader population. but that’s the primary results. for isolation and loneliness, we have two measures. So we have the Cohen Social Network Index, so that is a measure of social network size. there’s also a domain of network diversity, which is how many different types of contexts you have in your social network. So is that friends or family or neighbors or other types of members. and we also have a measure of social network embeddedness. So that’s how deep are you embedded in a particular domain. So it’s measured by, if you have four or more people in the family domain, you’re considered embedded into that domain. and then for loneliness, we have, it’s called the UCLA loneliness scale, which is 20 questions related to loneliness. And that work is still being, as we speak, it’s still being analyzed and written up. but we did see in the ACHIEVE pilot study. So this was a much smaller sample done several years ago with only a six month follow up. But we do see a benefit of hearing intervention on social network characteristics in the pilot study which is quite encouraging for kind of the results of the full trial. Now, the pilot you’re referring to is what was published in the Journal of Gerontology. is that right? No, this was in Alzheimer’s and Dementia. Okay. and what really piqued my curiosity around this was you were the lead author of loneliness and social networks characteristics among older adults with a hearing loss in the ACHIEVE study. yeah, so that’s a baseline paper. So that’s in this 977 cohort for the full ACHIEVE study. But that was just at baseline. So this is prior to any intervention that has happened. but in study we found that even just in this group that we recruited, they’re all people with hearing loss that worse, audiometrically measured hearing was related to higher prevalence of loneliness, almost a 20% higher prevalence and same with speech in noise and how hearing related quality of life related to both loneliness and social network characteristics. One of the things I thought was really interesting about that paper that we’re talking about now is social network size and hearing in noise ability. Uh-huh. Could you maybe talk just a little bit about the reflect on what you found in that paper? I thought that was really interesting from a clinical standpoint. Yeah. So speech in noise, in terms of being able to hear words when presented in the presence of background noise and social network characteristics. And I think this really kind of gets at more of the functional aspects of hearing loss. You may have audiometric hearing loss, but if you can’t understand speech in the presence of background noise, I think that’s really related to your desire or ability to go out and engage with people in settings like restaurants or places of worship, things like that. And I think that really affects the number of contacts you have and the people that you engage with. Well, and if I remember right, the QuickSIN was used, right? Yes. And I think that more and more clinicians, as far as I know, are using that test, and it’s just another reason why that test gives you such great information as far as functional ability is concerned. Yeah, I think it really kind of sits in the middle of more of, like, this objective measure of hearing on the spectrum of this objective, to kind of subjective, functional. It really sits in the middle there and gets that. I think the ability to understand speech in noise is just so critical to the ability to kind of navigate this world where it is noisy. It is quite noisy, and you need that ability to navigate. Well, now, the next couple of questions, I think, are going to kind of probe at your expertise, which is epidemiology. And so one of the challenges that I see with all of this fantastic research that comes from the ACHIEVE study is we see these headlines, 48% increase in likelihood of dementia or whatever it might be. I don’t want to misinterpret the findings, but my point is, you see these percentages around risk, and I want to get your perspective on how a clinician should interpret those findings when they’re sitting down with a patient. How do they apply those findings to what they do clinically? Yeah, and that’s a great question. And for clinicians, I think it’s important to note that when you see this 48% reduction in the rate of cognitive decline that’s all at the population level. So we’re doing research at the population level, not at a one on one, like, case study level. So you can’t necessarily apply those estimates directly to the patient sitting in front of you. It would be inappropriate to say, like, for you, if you wear hearing aids, you would have a 48% reduction in cognitive decline. And that’s not true. It’s all at the population level, which. Means, just to clarify for our listeners, when we talk about population, you’re talking about the entire, like, the city of wherever you might be practicing in, versus the individual that’s in front of you at this time. Exactly. Or even just the whole of people with hearing loss, older adults with hearing loss, the country, across the world, we’re talking at that level versus this one on one. So you really can’t apply these estimates and these numbers to the person that’s sitting in front of you. but what we’re starting to do is really understand more of for whom the intervention may be most beneficial. So we saw this 48% reduction, cognitive decline in the ARIC cohort, and we’re starting to understand for whom and what kind of characteristics of these individuals that the intervention may be most effective for. but I think in the end, when you’re talking to a patient, hearing intervention is a relatively lowest intervention. it can be implemented in later life. Which is unique. Not all of these cognition and dementia interventions are kind of late life interventions. So it’s not too late that you can still do something in later life. and they could potentially benefit cognition, but also has benefits for kind of a broad spectrum of health. So I think, in the end, that’s kind of the take home message. And whether the person sitting in front of you would see a benefit in cognition, I think that’s still something we’re working on, kind of understanding more precisely who does this benefit. But I think, overall, it’s a low risk intervention. could benefit cognition for this patient. could also have a broad benefit for many of these other kinds of things. Right. And it sounds like that would be the same message for we have viewers out there who are just consumer savvy older adults that might be wanting to have an interest in this topic. Anything else that you would share with them? Yeah. So I think, in terms of older adults in general, anecdotally, I think the hope is to really increase awareness of hearing health and treatment of hearing loss. we’re hoping these findings may destigmatize hearing intervention a little bit. and I’ve seen in the news that people say they don’t want to wear hearing aids, they don’t feel like wearing them, but now that they know there could be some possibility of benefiting cognition, well, that’s a reason for them to maybe start wearing them or keep wearing them. And I think that’s the goal here, is to really increase hearing awareness maybe encourage hearing, a use for people who it may be beneficial for. that’s for older adults, I think people with hearing loss, but for more middle aged adults, for younger adults, I think it’s also spurring some conversations about the importance of hearing health and more about thinking about protecting hearing and doing things like wearing earplugs or earmuffs when you’re in places with loud music. really considering hearing as part of overall health and not kind of something to think about later. And I think with everyone with age, hearing will degrade, but I think there are things that middle or younger age older adults can do to kind of protect their hearing now that could benefit them in the long run. Exactly. It’s good to start the conversation or plant the seed at an earlier age, for sure. Yeah. one final question for you, Alison. That is, if you could tell us a little bit more on some of the upcoming projects that you and your colleagues at Johns Hopkins are working on when it comes to the ACHIEVE study, what are some things we can expect down the road? Yeah, so the team is really, right now, as we speak, focused on analyzing and writing up some of these other trial results. So mostly around some of these other outcomes. Social isolation and loneliness is a big one. we have measures of physical activity and physical function falls, fatigue, hospitalizations some mental health ones, like depression, and health related quality of life. So the team is really working on looking at the effect of hearing intervention on all these other outcomes to see, really get a good picture of this. What are the benefits? What are these broad benefits of hearing intervention in addition to cognitive health? And that’s really the focus right now. And personally because my interest is in mental health and social health I’m planning to dive more into these social mental health measures to really further understand how the hearing intervention is working. Is it improving or is it benefiting cognition through the pathway of social isolation and loneliness? and could people who are lonely at the outside benefit more? So, there are just some more questions that dive deeper and really further understand this effect of hearing intervention in the context of social mental health as well. Well, we look forward to seeing more publications from your esteemed group. Great. Yeah, we’re looking forward to getting these results out there. I know it seems like every month there’s something new from your group that we can talk about. Yeah, that’s great. Yeah, we’re working hard over here. and I’ll also point you to the achievestudy.org website, where a lot of these achievestudy.org, where a lot of know results and findings know pop up so you can see them all in one place. So, Dr. Alison Huang, a senior research associate at John Hopkins Bloomberg School of Public Health thank you so much for taking time out of your busy schedule to be with us today. Thank you. This was great.