Noise Affects Performance on the Montreal Cognitive Assessment

Does the presence of chronic pain affect scores on cognitive screening tests/brief cognitive measures for dementia? A systematic review and meta-analysis

OBJECTIVE

Cognitive screening tests can identify potential dementia by indicating a concerning level of cognitive impairment. The older populations for whom this is most relevant are more likely to experience chronic pain, which also impairs cognitive function, but pain's impact on cognitive screening tests specifically remains unknown.

METHOD

We conducted a systematic review and meta-analysis (SR/MA) following PRISMA guidelines evaluating cognitive screening scores in studies involving participants with chronic pain compared with a pain-free control group. Our question was whether the presence of chronic pain (self-reported or based on diagnosis) was associated with poorer performance on these screens, and to identify the heterogeneity across groups and screens.

RESULTS

The 51 studies identified yielded 62 effect size estimates. The pooled g was 0.76 (95% confidence interval 0.57 to 0.95). Heterogeneity was high for the full model (= 93.16%) with some reductions in sub-analyses. Around half of the studies were identified as being at a low risk of bias. There was no evidence of publication bias.

CONCLUSIONS

As a whole, this analysis suggests medium to large effect sizes on cognitive screen performance when people are living with chronic pain. We suggest that clinicians should consider the effect of chronic pain when cognitive screens are employed to investigate dementia. Further research could clarify the effect pain has on different screen sub-domains to aid their effective use with these populations.

Evaluation of a non-auditory neurocognitive test battery in hearing-impaired according to age

PURPOSE

Due to the demographic shift, the number of older people suffering from hearing loss and from cognitive impairment increases. Both are closely related and hard to differentiate as most standard cognitive test batteries are auditory-based and hearing-impaired individuals perform worse also in non-auditory test batteries. Therefore, reference data for hearing-impaired are mandatory.

METHODS

The computer-based battery ALAcog assesses multiple cognitive domains, such as attention, (delayed) memory, working memory, inhibition, processing speed, mental flexibility and verbal fluency. A data set of 201 bilaterally hearing-impaired subjects aged ≥ 50 (mean 66.6 (SD 9.07)) was analysed. The LMS method, estimated curves for the 10th, 25th, 50th, 75th and 90th percentile were calculated, and classified according to age, starting from the age of 50.

RESULTS

Cognitive function shows a decline in all subtests as people age, except for verbal fluency, which remains almost stable over age. The greatest declines were seen in recall and delayed recall and in mental flexibility. Age and hearing ability did not correlate (p = 0.68). However, as people age, inter-subject variability of cognitive test results increases. This was especially the case for inhibition. Cognitive function was not correlated with hearing ability (each p ≥ 0.13).

CONCLUSION

The present results make an approach to establish reference data for a comprehensive non-auditory test battery in a large sample of elderly hearing-impaired people which can be used as a simple tool to better contextualise cognitive performance beyond mean and median scores.

Probability Distributions for Associations Between Cognitive Screening and Pure-tone Thresholds in Older Adults

OBJECTIVES

Lower general cognitive function is frequently reported in older adults with elevated pure-tone thresholds. Here, we examined reason(s) for this association, including whether this relationship is dependent on the frequency range or extent of hearing loss and cognitive screening performance.

DESIGN

Linear regression was used to examine associations between better-ear pure-tone thresholds and Mini-Mental Status Exam (MMSE) performance in a cross-sectional sample of relatively healthy older adults (N = 508; 68% women, 60-89+ years; M age = 72). Quantile regression was also used to identify the ranges of 0.5 and 4.0 kHz thresholds and MMSE scores where these variables exhibited significant associations.

RESULTS

MMSE scores and pure-tone thresholds exhibited small but significant associations, particularly for better-ear 0.5 kHz thresholds. This hearing threshold and cognitive screening association was present among participants with better hearing, including the oldest older adults. There was limited evidence for mediating health condition effects on this association. An item analysis of the MMSE revealed that the MMSE and pure-tone threshold associations were largely due to the delayed recall item of the MMSE.

CONCLUSIONS

Together, the small effect results are consistent with the extant literature and suggest that there are multiple reasons for modest pure-tone threshold and cognitive screening performance associations.

Intelligibility of medically related sentences in quiet, speech-shaped noise, and hospital noise

Noise in healthcare settings, such as hospitals, often exceeds levels recommended by health organizations. Although researchers and medical professionals have raised concerns about the effect of these noise levels on spoken communication, objective measures of behavioral intelligibility in hospital noise are lacking. Further, no studies of intelligibility in hospital noise used medically relevant terminology, which may differentially impact intelligibility compared to standard terminology in speech perception research and is essential for ensuring ecological validity. Here, intelligibility was measured using online testing for 69 young adult listeners in three listening conditions (i.e., quiet, speech-shaped noise, and hospital noise: 23 listeners per condition) for four sentence types. Three sentence types included medical terminology with varied lexical frequency and familiarity characteristics. A final sentence set included non-medically related sentences. Results showed that intelligibility was negatively impacted by both noise types with no significant difference between the hospital and speech-shaped noise. Medically related sentences were not less intelligible overall, but word recognition accuracy was significantly positively correlated with both lexical frequency and familiarity. These results support the need for continued research on how noise levels in healthcare settings in concert with less familiar medical terminology impact communications and ultimately health outcomes.

Binaural processing deficit and cognitive impairment in Alzheimer's disease

Speech comprehension in noisy environments depends on central auditory functions, which are vulnerable in Alzheimer's disease (AD). Binaural processing exploits two ear sounds to optimally process degraded sound information; its characteristics are poorly understood in AD. We studied behavioral and electrophysiological alterations in binaural processing among 121 participants (AD = 27; amnestic mild cognitive impairment [aMCI] = 33; subjective cognitive decline [SCD] = 30; cognitively normal [CN] = 31). We observed impairment of binaural processing in AD and aMCI, and detected a U-shaped curve change in phase synchrony (declining from CN to SCD and to aMCI, but increasing from aMCI to AD). This improvement in phase synchrony accompanying more severe cognitive stages could reflect neural adaptation for binaural processing. Moreover, increased phase synchrony is associated with worse memory during the stages when neural adaptation apparently occurs. These findings support a hypothesis that neural adaptation for binaural processing deficit may exacerbate cognitive impairment, which could help identify biomarkers and therapeutic targets in AD.

T-MoCA: A valid phone screen for cognitive impairment in diverse community samples

INTRODUCTION

There is an urgent need to validate telephone versions of widely used general cognitive measures, such as the Montreal Cognitive Assessment (T-MoCA), for remote assessments.

METHODS

In the Einstein Aging Study, a diverse community cohort (n = 428; mean age = 78.1; 66% female; 54% non-White), equivalence testing was used to examine concordance between the T-MoCA and the corresponding in-person MoCA assessment. Receiver operating characteristic analyses examined the diagnostic ability to discriminate between mild cognitive impairment and normal cognition. Conversion methods from T-MoCA to the MoCA are presented.

RESULTS

Education, race/ethnicity, gender, age, self-reported cognitive concerns, and telephone administration difficulties were associated with both modes of administration; however, when examining the difference between modalities, these factors were not significant. Sensitivity and specificity for the T-MoCA (using Youden's index optimal cut) were 72% and 59%, respectively.

DISCUSSION

The T-MoCA demonstrated sufficient psychometric properties to be useful for screening of MCI, especially when clinic visits are not feasible.

Impact of Hearing Loss on Geriatric Assessment

Background

Due to the aging society, the incidence of age-related hearing loss (ARHL) is strongly increasing. Hearing loss has a high impact on various aspects of life and may lead to social isolation, depression, loss of gain control, frailty and even mental decline. Comorbidity of cognitive and sensory impairment is not rare. This might have an impact on diagnostics and treatment in the geriatric setting.

Objective

The aim of the study was to evaluate the impact of hearing impairment on geriatric assessment and cognitive testing routinely done in geriatrics.

Material and Methods

This review is based on publications retrieved by a selective search in Medline, including individual studies, meta-analyses, guidelines, Cochrane reviews, and other reviews from 1960 until August 2020.

Results

Awareness of sensory impairment is low among patients and health professionals working with elderly people. The evaluation of the hearing status is not always part of the geriatric assessment and not yet routinely done in psychiatric settings. However, neurocognitive testing as an important part can be strongly influenced by auditory deprivation. Misunderstanding of verbal instructions, cognitive changes, and delayed central processes may lead to a false diagnosis in up to 16% of subjects with hearing loss. To minimize this bias, several neurocognitive assessments were transformed into non-auditory versions recently, eg the most commonly used Hearing-Impaired Montreal Cognitive Assessment (HI-MoCA). However, most of them still lack normative data for elderly people with hearing loss.

Conclusion

Hearing loss should be taken into consideration when performing geriatric assessment and cognitive testing in elderly subjects. Test batteries suitable for ARLH should be applied.

Benefits of Cochlear Implantation in Middle-Aged and Older Adults

Introduction

Nowadays cochlear implantation (CI) is the treatment of choice in adults in case conventional hearing devices fail. Besides speech perception, an improvement in quality of life and in cognitive performance has been reported. Thereby, the study focused on the impact of age.

Participants and Methods

Thirty middle-aged (MA) between 50 and 64 years and 41 older subjects (OA) aged 65 and older with bilateral severe hearing loss performed a comprehensive computer-based neurocognitive test battery (ALAcog) pre- and 12 months post-implantation. Besides, monosyllabic speech perception in quiet (Freiburg monosyllabic speech test), health-related quality of life (HR-QoL, Nijmegen Cochlear Implant Questionnaire) and depressive symptoms (GDS-15) have been assessed.

Results

Both age groups significantly improved in all three categories after 12 months. No differences were evaluated between MA and OA regarding speech perception and HR-QoL pre- and post-operatively. In contrast, cognitive performance differed between the age groups: pre-operatively OA performed worse in most neurocognitive subdomains like working memory (p=0.04), inhibition (p=0.004), processing speed (p=0.003) and mental flexibility (p=0.01), post-operatively MA outperformed OA only in inhibition (p=0.01). Age only slightly influenced cognitive performance in MA, whereas in OA age per se tremendously impacted on working memory (p=0.04), inhibition (p=0.02), memory (p=0.04) and mental flexibility (p=0.01). Educational level also affected processing speed, mental flexibility (p=0.01) and working memory (p=0.01). This was more pronounced in OA. In both age groups, hearing status had a strong effect on attentional tasks (p=0.01). In MA, depressive symptoms were more influential on cognitive functioning and on HR-QoL than in OA. Improvement in quality of life (p=0.0002) and working memory (p=0.001) was greater for those with a higher pre-operative depression score.

Conclusion

Speech perception and HR-QoL improved in hearing impaired, independently of age. Pre-operative differences in cognitive performance between OA and MA clearly attenuated 12 months after CI. Impact of comorbidities differed between age groups.

Hearing-impaired population performance and the effect of hearing interventions on Montreal Cognitive Assessment (MoCA): Systematic review and meta-analysis

BACKGROUND

Older adults are at high risk of developing age-related hearing loss (HL) and/or cognitive impairment. However, cognitive screening tools rely on oral administration of instructions and stimuli that may be impacted by HL. This systematic review aims to investigate (a) whether people with HL perform worse than those without HL on the Montreal Cognitive Assessment (MoCA), a widely used screening tool for cognitive impairment, and what the effect size of that difference is (b) whether HL treatment mitigates the impact of HL.

METHOD

We conducted a systematic review and meta-analysis including studies that reported mean MoCA scores and SDs for individuals with HL.

RESULTS

People with HL performed significantly worse on the MoCA (4 studies, N = 533) with a pooled mean difference of -1.66 points (95% confidence interval CI -2.74 to -0.58). There was no significant difference in MoCA score between the pre- vs post-hearing intervention (3 studies, N = 75). However, sensitivity analysis in the cochlear implant studies (2 studies, N = 33) showed improvement of the MoCA score by 1.73 (95% CI 0.18 to 3.28).

CONCLUSION

People with HL score significantly lower than individuals with normal hearing on the standard orally administered MoCA. Clinicians should consider listening conditions when administering the MoCA and report the hearing status of the tested individuals, if known, taking this into account in interpretation or make note of any hearing difficulty during consultations which may warrant onward referral. Cochlear implants may improve the MoCA score of individuals with HL, and more evidence is required on other treatments. J Am Geriatr Soc 68:-, 2020.

Cognitive Screening of Adults With Postlingual Hearing Loss: A Systematic Review

Objective

To systematically review the evidence for the use of cognitive screening tools for adults with postlingual hearing loss.

Data Sources

PubMed, Embase, Scopus, PsycINFO (EBSCO), CINAHL (EBSCO), and CENTRAL (Cochrane Library) electronic databases were searched from inception until October 4, 2018.

Review Methods

Articles were reviewed for inclusion by 2 independent reviewers. The references of included articles were hand-searched for additional relevant articles. Data were extracted by 2 independent extractors.

Results

Of 2092 articles imported from the search, 81 were included for the review. Nearly a third (31%, n = 25) included patients with profound hearing loss. In total, 23 unique tools were used for 105 unique applications. The Mini Mental Status Exam (MMSE) was the most commonly used (54%, n = 55), followed by the Montreal Cognitive Assessment (MoCA) (19%, n = 10). Nearly half of the tools were used to define patient inclusion or exclusion in a study (48%, n = 50), followed by examination of a change after an intervention (26%, n = 27). Two articles attempted to study the validity of the MMSE and MoCA for screening patients with mild to moderate hearing loss and found mixed effects of the auditory components. There were no validation studies identified from the search.

Conclusion

Many different cognitive screening tools have been used to study patients with postlingual hearing loss. The effects of the auditory components of these tools may be deleterious but ultimately remain unclear from the available evidence. To date, there has been no validation of any cognitive screening tool to be used for adults with postlingual hearing loss.

Sensitivity to Interaural Phase in Older Hearing-Impaired Listeners Correlates With Nonauditory Trail Making Scores and With a Spatial Auditory Task of Unrelated Peripheral Origin

Interaural phase difference (IPD) discrimination upper frequency limits and just-noticeable differences (JNDs), interaural level difference (ILD) JNDs, and diotic intensity JNDs were measured for 20 older hearing-impaired listeners with matched moderate sloping to severe sensorineural hearing losses. The JNDs were measured using tone stimuli at 500 Hz. In addition to these auditory tests, the participants completed a cognitive test (Trail Making Test). Significant performance improvements in IPD discrimination were observed across test sessions. Strong correlations were found between IPD and ILD discrimination performance. Very strong correlations were observed between IPD discrimination and Trail Making performance as well as strong correlations between ILD discrimination and Trail Making performance. These relationships indicate that interindividual variability in IPD discrimination performance did not exclusively reflect deficits specific to any auditory processing, including early auditory processing of temporal information. The observed relationships between spatial audition and cognition may instead be attributable to a modality-general spatial processing deficit and/or individual differences in global processing speed.

Agreement on the use of sensory screening techniques by nurses for older adults with cognitive impairment in long-term care: a mixed-methods consensus approach

OBJECTIVE

Based on two scoping reviews and two environmental scans, this study aimed at reaching consensus on the most suitable sensory screening tools for use by nurses working in long-term care homes, for the purpose of developing and validating a toolkit.

SETTING

A mixed-methods consensus study was conducted through two rounds of virtual electronic suitability rankings, followed by one online discussion group to resolve remaining disagreements.

PARTICIPANTS

A 12-member convenience panel of specialists from three countries with expertise in sensory and cognitive ageing provided the ranking data, of whom four participated in the online discussion.

OUTCOME MEASURES

As part of a larger mixed-methods project, the consensus was used to rank 22 vision and 20 hearing screening tests for suitability, based on 10 categories from the Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire. Panellists were asked to score each test by category, and their responses were converted to z-scores, pooled and ranked. Outliers in assessment distribution were then returned to the individual team members to adjust scoring towards consensus.

RESULTS

In order of ranking, the top 4 vision screening tests were hand motion, counting fingers, confrontation visual fields and the HOT-V chart, whereas the top 4 hearing screening tests were the Hearing Handicap Inventory for the Elderly, the Whisper Test, the Measure of Severity of Hearing Loss and the Hyperacusis Questionnaire, respectively.

CONCLUSIONS

The final selection of vision screening tests relied on observable visual behaviours, such as visibility of tasks within the central or peripheral visual field, whereas three of the four hearing tests relied on subjective report. Next, feasibility will be tested by nurses using these tools in a long-term care setting with persons with various levels of cognitive impairment.

Test Administration Methods and Cognitive Test Scores in Older Adults with Hearing Loss

In light of the high prevalence of hearing loss and cognitive impairment in the aging population, it is important to know how cognitive tests should be administered for older adults with hearing loss. The purpose of the present study is to examine this question with a cognitive screening test and a working memory test. Specifically, we asked the following questions in 2 experiments. First, does a controlled amplification method affect cognitive test scores? Second, does test modality (visual vs. auditory) impact cognitive test scores? Three test administration conditions were created for both Montreal Cognitive Assessment (MoCA) and working memory test (a word recognition and recall test): auditory amplified, auditory unamplified, and visual. The auditory administration was implemented through a computer program to control for presentation level while the visual condition was implemented through timed computer slides. Data were collected from older individuals with mild-to-moderate sensorineural hearing loss. We did not find any effect of amplification or test modality on the total score of the cognitive screening test (i.e., MoCA). Amplification improved working memory performance as measured by word recall performance, but test modality (auditory vs. visual) did not. These results are consistent with literature in demonstrating a downstream effect of audibility on working memory performance. From a clinical perspective, these findings are informative for developing clinical administration protocols of these tests for older individuals with hearing loss.

Longitudinal Relationships Between Decline in Speech-in-Noise Recognition Ability and Cognitive Functioning: The Longitudinal Aging Study Amsterdam

Purpose Various directional hypotheses for the observed links between aging, hearing, and cognition have been proposed: (a) cognitive load on perception hypothesis, (b) information degradation hypothesis, (c) sensory deprivation hypothesis, and (d) common cause hypothesis. Supporting evidence for all 4 hypotheses has been reported. No studies have modeled the corresponding 4 causal pathways into 1 single model, which would be required to evidence that multiple directional hypotheses apply. The aim of the current study was to tease out which pathways apply for 5 different cognitive measures. Method Data from 1,029 respondents of the Longitudinal Aging Study Amsterdam were used spanning a maximum follow-up of 7 years (3 measurements). Speech-in-noise recognition ability (digit triplet speech-in-noise test) was included as a measure of auditory function. Cognitive measures included global cognitive functioning, fluid intelligence, information processing speed, and verbal memory (immediate recall and retention). Bivariate dual change score modeling was used to model the causal pathways between hearing, cognition, and baseline age. Results For information processing speed, global cognitive functioning, fluid intelligence, and memory-immediate recall, all pathways except for the sensory deprivation pathway were supported. For memory-retention, only the common cause and the sensory deprivation pathways were supported. Conclusions Causal pathways corresponding to all 4 hypotheses were supported. Support for the common cause hypothesis, the information degradation hypothesis, and the cognitive load on perception hypotheses was found for 4 of 5 cognitive measures. This was unexpected in some cases (e.g., support for the information degradation pathway for cognitive measures that do not rely on auditory stimuli). The sensory deprivation pathway that emerged for memory-retention might point toward processes related to early stages of dementia. In summary, the results show that the links between decline in auditory function, cognition, and aging are complex and most likely are captured by pathways belonging to various directional hypotheses.

Considering Age-Related Hearing Loss in Neuropsychological Practice: Findings from a Feasibility Study

La perte auditive représente une problématique répandue chez la population âgée. Cela peut poser des défis pour les neuropsychologues, étant donné que les méthodes d’intervention doivent être présentées oralement et donc entendues avec précision. Dans cette étude, le statut auditif de 20 clients (âge moyen= 71 ans) a été évalué au sein d’une clinique de neuropsychologie en milieu hospitalier et l’impact de cette évaluation sur la pratique des neuropsychologues a été étudié. Un assistant de recherche a administré un bref test de dépistage des troubles auditifs à chacun des clients. Nous avons demandé à quatre neuropsychologues de commenter le statut auditif de leurs clients avant et après leur avoir présenté les résultats des tests de dépistage. Le dépistage a révélé que la majorité des clients présentait au moins une perte auditive légère et que les neuropsychologues étaient relativement précis (60 %) dans leur estimation du statut auditif de leurs clients. Enfin, les neuropsychologues ont utilisé l’information sur le statut auditif de leurs clients en vue de les diriger vers des services en audiologie, ainsi que pour renseigner les clients et les familles sur la perte auditive et la communication.

A re-examination of Montreal Cognitive Assessment (MoCA) cutoff scores

OBJECTIVE

The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) is a cognitive screening tool that aims to differentiate healthy cognitive aging from Mild Cognitive Impairment (MCI). Several validation studies have been conducted on the MoCA, in a variety of clinical populations. Some studies have indicated that the originally suggested cutoff score of 26/30 leads to an inflated rate of false positives, particularly for those of older age and/or lower education. We conducted a systematic review and meta-analysis of the literature to determine the diagnostic accuracy of the MoCA for differentiating healthy cognitive aging from possible MCI.

METHODS

Of the 304 studies identified, nine met inclusion criteria for the meta-analysis. These studies were assessed across a range of cutoff scores to determine the respective sensitivities, specificities, positive and negative predictive accuracies, likelihood ratios for positive and negative results, classification accuracies, and Youden indices.

RESULTS

Meta-analysis revealed a cutoff score of 23/30 yielded the best diagnostic accuracy across a range of parameters.

CONCLUSIONS

A MoCA cutoff score of 23, rather than the initially recommended score of 26, lowers the false positive rate and shows overall better diagnostic accuracy. We recommend the use of this cutoff score going forward. Copyright © 2017 John Wiley & Sons, Ltd.

Disregarding hearing loss leads to overestimation of age-related cognitive decline

Aging is associated with cognitive and sensory decline. While several studies have indicated greater cognitive decline among older adults with hearing loss, the extent to which age-related differences in cognitive processing may have been overestimated due to group differences in sensory processing has remained unclear. We addressed this question by comparing younger adults, older adults with good hearing, and older adults with poor hearing in several cognitive domains: working memory, selective attention, processing speed, inhibitory control, and abstract reasoning. Furthermore, we examined whether sensory-related cognitive decline depends on cognitive demands and on the sensory modality used for assessment. Our results revealed that age-related cognitive deficits in most cognitive domains varied as a function of hearing loss, being more pronounced in older adults with poor hearing. Furthermore, sensory-related cognitive decline was observed across different levels of cognitive demands and independent of the sensory modality used for cognitive assessment, suggesting a generalized effect of age-related hearing loss on cognitive functioning. As most cognitive aging studies have not taken sensory acuity into account, age-related cognitive decline may have been overestimated.