By Natalie Benafield, Au.D., CCC-A
Communication Sciences and Disorders
University of Central Arkansas

Most of us associate aging with a decline in hearing acuity, with good reason. Two-thirds of individuals over 70 years of age have a loss in hearing that would be considered clinically significant. Communication obviously suffers, causing frustration for both the person with the hearing loss and their family members. However, it is estimated that less than one-quarter of individuals with age-related hearing loss seek treatment. Evidence is mounting that ignoring hearing as you age can have detrimental effects that go beyond difficulty communicating with others.

As far back as 1989, scientists have suggested that age-related hearing loss may contribute to cognitive decline in seniors. A pivotal study published in the Journal of the American Medical Association (Uhlmann, et.al.,1989) suggested that hearing loss in older adults was associated with a higher risk of dementia. For the past several years, other researchers have been conducting research in this area and have come to similar conclusions. Dr. Frank Lin, at Johns Hopkins University, and his team followed 639 individuals from the ages of 36-90 for twelve years to investigate the link between hearing loss and dementia. After adjustment for other factors including age, gender, educational level, diabetes, smoking and hypertension, their research suggested that those with hearing loss experiences a 30-40% accelerated rate of cognitive decline (Lin, et al., 2013). More recently a large-scale review of epidemiologic studies of age-related hearing loss and cognitive function from twelve countries was conducted. The researchers found that age-related hearing loss was significantly association with a decline in all main cognitive domains, except for Alzheimer’s disease and vascular dementia. They concluded that hearing loss related to aging is a modifiable risk factor for cognitive decline and dementia in seniors (Loughrey, et al., 2018).

While the exact mechanism underlying the relationship between age-related hearing loss and cognitive decline has not been identified, there are several theories. Some have suggested that hearing loss and cognitive decline may be caused by the same general neurodegenerative process (Stahl, 2017). Neuroimaging studies have suggested that similar changes in the temporal regions of the brain have been noted in individuals with hearing loss and with cognitive decline (Lin, et al., 2014). Other researchers suggest that hearing loss (i.e., the lack of sensory input) causes individuals to use additional cognitive resources to process auditory input, resulting in chronic cognitive “multitasking” and overload. (Tun, McCoy, & Wingfield, 2009). Exacerbating the condition may be that untreated hearing loss often leads to social isolation and even depression, which in turn leads to reduced cortical input over time, hastening atrophy in certain regions of the brain.

Will hearing aid use slow cognitive decline? It makes sense that the use of hearing devices such as hearing aids could increase auditory input, lessen cognitive load, and decrease social isolation, thereby slowing cognitive decline (Sarampalis, et al., 2009). However, we need more large-scale, longitudinal studies before being confident of that claim. Current studies have failed to show a robust protective relationship between hearing aid use and cognitive function. One recent small-scale study found that individuals with evidence of auditory- to- visual cross-modal reorganization in the brain showed evidence of reversal of the re-organization in the auditory cortex, with additional gains in speech perception and cognitive performance (Glick & Sharma, 2020).

What does this mean for current clinical care of older adults? Health care providers often see hearing loss as normal part of aging as they must focus on the numerous urgent medical needs of older adults. This research suggests that clinicians should take a proactive, rather than reactive approach to hearing health in the aging population. Rather than waiting until a patient complains of difficulty hearing, encourage early hearing screening, evaluation, and treatment for those 60 and older. Most patients will not understand the importance of their hearing to brain health. While we lack the evidence to suggest that hearing aids can reduce cognitive decline, we have plenty of evidence to say that hearing loss is not good for the brain. Early hearing evaluation and treatment is risk-free, and evidence is mounting that appropriate treatment of age-related hearing loss could have a positive impact on cognitive decline.

References

Glick, H. A., & Sharma, A. (2020). Cortical Neuroplasticity and Cognitive Function in Early-Stage, Mild-Moderate Hearing Loss: Evidence of Neurocognitive Benefit From Hearing Aid Use. Frontiers in Neuroscience, 1.

Lin, F. R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T. B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H. N., Ferrucci, L., & Simonsick, E. M. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), 293–299. https://doi.org/10.1001/jamainternmed.2013.1868

Lin, F. R., & Albert, M. (2014). Hearing loss and dementia – who is listening? Aging & Mental Health, 18(6), 671–673. https://doi.org/10.1080/13607863.2014.915924

Loughrey, D. G., Kelly, M. E., Kelley, G. A., Brennan, S., & Lawlor, B. A. (2018). Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis. JAMA Otolaryngology– Head & Neck Surgery, 144(2), 115–126. https://doi-org.ucark.idm.oclc.org/10.1001/jamaoto.2017.2513

Sarampalis A, Kalluri S, Edwards B, & Hafter E. (2009). Objective measures of listening effort: effects of background noise and noise reduction. Journal of Speech, Language & Hearing Research, 52(5), 1230–1240. https://doi.org/1092-4388(2009/08-0111)

Tun PA, McCoy S, Wingfield A, Tun, P. A., McCoy, S., & Wingfield, A. (2009). Aging, hearing acuity, and the attentional costs of effortful listening. Psychology & Aging, 24(3), 761–766. https://doi.org/10.1037/a0014802

Uhlmann, R.F., Larson, E.B., Rees, R.S., Koepsell, T.D., Duckert, L.G. (1989). Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. Journal of the American Medical Association 261(13), 1816-1919.

Weinstein, B.E., (2018). A primer on dementia and hearing loss. Perspectives of the ASHA Special Interest Groups, 3(6), 18-27.

By Kevin Rowell, PhD
Department of Psychology and Counseling
University of Central Arkansas

As with the implementation of the Affordable Care Act in 2017, U.S. health care continues to develop the patient-centered medical home model as a way of efficiently coordinating health care delivery. Especially for older patients where complexity of health care is the norm, the weight of responsibility in providing effective, safe, and lower cost interventions rests squarely on the primary care practitioner (PCP).  Now that baby boomers have reached late life, it is estimated that approximately one-fourth of patients seen in primary care clinics are over age 65. Although most are in good health, the natural decline in health with aging results in a greater presence of physical illness and dysfunction such that most older adults have at least two chronic conditions, as well as developing acute illnesses at prevalence rates similar to younger adults (CDC, 2013, as cited in Hunter et al, 2017).

While the public clearly understands that primary care is designed to be the first line of help in the case of medical illness and that most treatment is rendered therein, the majority of people do not realize that primary care practitioners are very often the first line of treatment for mental health issues as well (O’Donohue et al, 2005). People struggling with common disorders involving depression, anxiety, and substance abuse will more likely seek help from their PCP before considering intervention from a psychiatrist, psychologist, counselor, or clinical social worker. In fact, roughly one-third of the visits to PCPs is due to a mental health concern, and another one-third of visits involve a medical diagnosis that has a significant mental health component (Blount, 2003). The reasons are attributed to familiarity with the PCP, greater access to a PCP as compared to specialists (especially in rural areas), and fear of stigmatization in visiting a mental health clinic (Hunter, et al, 2017).

Research has shown that the most prevalent mental disorders are major depression, generalized anxiety, somatization, and substance abuse. Other common mental health issues include relationship conflict, stress, sleep disturbance, and fatigue. Not surprisingly, women are much more likely than men to report issues with mental health, which is a very consistent trend across most health care settings. Regarding patients over 65, other mental health issues involve cognitive decline, sexual dysfunction, grief/loss, isolation/loneliness, and lower motivation in managing chronic diseases (Hunter et al, 2007).

Whereas the PCP is able to provide appropriate intervention for many of these issues, usually through medication and perhaps brief consultation, a myriad of factors limits the effectiveness of the PCP in addressing primary mental health disorders and secondary mental health issues in chronic disease management. For example, diagnosing some mental disorders usually necessitates somewhat lengthy interviews and often a screening test, yet the high volume of patients scheduled daily in primary care clinics limits the time a PCP can spend with an individual patient. Furthermore, 60-85 percent of PCPs reported being under-trained in diagnosis and treatment of mental disorders. Additionally, when PCPs decide for a referral to a mental health specialist such as a psychiatrist or psychologist, wait times for appointments can be weeks and the likelihood of the patient following through with the appointment is less than 25 percent. Finally as previously mentioned, many people, especially older adults, with mental health concerns feel stigmatized in visiting a mental health clinic and will often refuse to seek help rather than potentially feel embarrassed or shameful (Blount, 2003, Hunter et al., 2017).

To address these issues, the fully integrated behavioral health model calls for the placement of a full-time behavioral health clinician (BHC) to be employed in primary care. Typically the BHC is a licensed psychologist, professional counselor, or clinical social worker who has received special training in integrated care behavioral health. Advantages of the behavioral health clinician are many. Of utmost importance is the presence of a mental health expert in primary care whose function is to identify primary and secondary mental health issues in patients and then to collaborate with the PCP and other staff in providing effective evidence-based interventions for patients. Through research backed behavioral interventions, BHCs can address stress reduction, mindfulness, sleep hygiene, maladaptive thoughts, as well as adaptive, healthy life style changes like exercise, relaxation, diet changes, smoking cessation, and decreased alcohol/substance use, all of which directly improve mental health and chronic disease management (Hunter et al, 2017). For the older patient, BHCs can conduct screenings for dementia and other cognitive problems, address social isolation, and help with sexual dysfunction.

Research indicates that when a full-time BHC is employed in primary care, treatment effectiveness increases, patient and staff satisfaction increase, and treatment and medication costs decrease (Blount, 2003; Ogbeide, Stermensky II, & Rolin, 2016). For example, one consistent finding is that patients with mood (depression) and anxiety disorders show significant improvement, often without medication, when they work closely with a BHC. Furthermore, when a referral to a mental health specialist is necessary, patients are much more likely to meet the appointment, particularly if the BHC can meet briefly with them during the wait time before the first appointment. The BHC is also freed from the standard 8-10 minute PCP appointment duration to better gather interview information, discuss treatment goals, and even implement brief 15-20 minute follow up appointments to reinforce interventions that are working and to make adjustments where needed.

Older adult patients should be encouraged by the addition of a BHC member to the PCP staff. Such a health care provider is able to better address so many more issues than one’s PCP, and the fact that the BHC has been called in to meet with the older patient in no implies that the patient should be embarrassed or stigmatized. It simply means that he or she will be receiving optimal holistic care that has been shown to have significant benefits.

References:

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, and Health, 21, 121-134.

Centers for Disease Control and Prevention (2013). The stage of aging and health in America 2013. Retrieved from http://www.cdc.gov/health/state_of_aging_and_health_in_America_2013.pdf.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2^nd ed.). Washington DC, American Psychological Association: Washington, D.C.

O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Brunner-Rutledge.

Ogbeide, S., Stermensky II, G. & Rolin, S. (2016). Integrated primary care behavioral health for the rural older adult. Practice Innovations, 1, 145-153.