Development of the Canadian Digit Triplet Test in English and French

The multilingual digits-in-noise (DIN) test: development and evaluation

OBJECTIVE

To develop a methodologically uniform digits-in-noise (DIN) test in 17 different languages.

DESIGN

The DIN test was developed for Android devices as an extension to the open-access Hearing Test™ app, available on the Google Play store. It utilised professionally recorded female speech, speech-shaped noise, a digit scoring method and a variable step size. The test was adaptively optimised and evaluated as the results of tests taken online by users of the app became available.

STUDY SAMPLE

Optimisation using 35,534 ears, evaluation using 6012 ears.

RESULTS

Optimisation improved the slopes of the psychometric functions for all languages by an average of 6.8%/dB. Evaluation included calculation of normative speech reception thresholds (SRTs) and estimation of test-retest standard deviations. Normative values for SRTs ranged from -14.2 dB SNR (95% CI -14.3 to -14.0) for Chinese to -11.2 dB SNR (95% CI -11.3 to -11.1) for Japanese, with reliability estimates ranging from 0.48 dB (95% CI 0.36-0.64) for Portuguese to 0.91 dB (95% CI 0.73-1.21) for Romanian.

CONCLUSIONS

The optimisation of each language version was confirmed by the improvement in the slopes of the psychometric functions. The normative values obtained from the test evaluation were in agreement with literature data.

TRIAL REGISTRATION

Science Support Centre of Wroclaw Medical University BW-59/2020.

The Chinese Zodiac-in-Noise Test: An Internet-Based Speech-in-Noise Test for Large-Scale Hearing Screening

OBJECTIVES

Motivated by the growing need for hearing screening in China, the present study has two objectives. First, to develop and validate a new test, called the Chinese Zodiac-in-noise (ZIN) test, for large-scale hearing screening in China. Second, to conduct a large-scale remote hearing screening in China, using the ZIN test developed.

DESIGN

The ZIN test was developed following a similar procedure as the digits-in-noise test but emphasizes the importance of consonant recognition by employing the 12 zodiac animals in traditional Chinese culture as speech materials. It measures the speech reception threshold (SRT) using triplets of Chinese zodiac animals in speech-shaped noise with an adaptive procedure.

RESULTS

Normative data of the test were obtained in a group of 140 normal-hearing listeners, and the performance of the test was validated by comparisons with pure-tone audiometry in 116 listeners with various hearing abilities. The ZIN test has a reference SRT of -11.0 ± 1.6 dB in normal-hearing listeners with a test-retest variability of 1.7 dB and can be completed in 3 minutes. The ZIN SRT is highly correlated with the better-ear pure-tone threshold ( r = 0.82). With a cutoff value of -7.7 dB, the ZIN test has a sensitivity of 0.85 and a specificity of 0.94 for detecting a hearing loss of 25 dB HL or more at the better ear.A large-scale remote hearing screening involving 30,552 participants was performed using the ZIN test. The large-scale study found a hearing loss proportion of 21.0% across the study sample, with a high proportion of 57.1% in the elderly study sample aged over 60 years. Age and gender were also observed to have associations with hearing loss, with older individuals and males being more likely to have hearing loss.

CONCLUSIONS

The Chinese ZIN test is a valid and efficient solution for large-scale hearing screening in China. Its remote applications may improve access to hearing screening and enhance public awareness of hearing health.

Visual and cognitive functioning among older adults with low vision before vision rehabilitation: A pilot study

Introduction

The occurrence of age-related vision changes is inevitable. However, some of these changes can become pathological. Research indicates that vision and hearing loss is correlated with age-related cognitive decline, and with a higher risk of developing dementia due to Alzheimer's disease. Low vision rehabilitation could possibly be a protective factor against cognitive decline, as it provides the clients with compensatory strategies to overcome their visual deficits.

Objectives and hypothesis

The aim of this pilot study was to assess correlations between visual and cognitive functions in older adults referred for low vision rehabilitation. We hypothesized that more severe impairment of visual acuity and contrast sensitivity would be correlated with more advanced levels of cognitive impairment. The second objective was to examine which of these correlations would remain significant once established variables that influence cognition are statistically removed (e.g., age, education).

Methods

Thirty-eight older adults (age range: 66-97 years old) with a visual impairment (acuity <20/70) were recruited before the onset of their low vision rehabilitation. They underwent vision (reading acuity, reading speed, contrast sensitivity), hearing (audiogram, speech-in-noise perception) and cognitive (global cognition, memory, executive functions) testing, and demographic information was obtained.

Results and discussion

Correlations among global cognition and visual aid use, memory and reading speed, memory and contrast sensitivity, memory, and visual aid use, and between executive functions and contrast sensitivity were significant. Correlations between contrast sensitivity and memory, as well as between global cognition and visual aid use remained significant after controlling for age and education. The present study is relevant to clinicians who are assessing the cognitive status of older adults, such as neuropsychologists, because it highlights the importance of considering low vision when administering neuropsychological tests, especially to persons who have not yet received rehabilitation for their visual impairment.

Sex-Specific Interactions Between Hearing and Memory in Older Adults With Mild Cognitive Impairment: Findings From the COMPASS-ND Study

OBJECTIVES

Hearing loss (HL) in older adults is associated with a decline in performance on cognitive tasks and the risk of developing dementia. However, very few studies have investigated sex-related effects on these associations. A previous study of cognitively healthy older adults showed an association between HL and lower cognitive performance in females only. In the present study, we examined the effects of sex and hearing on cognition in individuals with mild cognitive impairment (MCI). We predicted that females with HL would be more likely to show poorer performance on the cognitive measures compared to females with normal hearing (NH), while cognitive performance in males would not depend on hearing. We further predicted that these auditory-cognitive associations would not depend on test modality, and would thus be observed in females for both auditory and visual tests.

DESIGN

Participants were 101 older adults with amnestic MCI (M = 71 years, 45% females) in the Canadian Consortium on Neurodegeneration in Aging (CCNA) COMPASS-ND study. Performance on the Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning (RAVLT), and Brief Visuospatial Memory Test-Revised (BVMT-R) was analyzed to investigate sex-related differences and/or hearing-related differences. Participants were categorized as having NH or HL using two different measures: pure-tone hearing screening results (normal based on a pure-tone threshold < 25 dB HL at 2000 Hz in the worse ear) and speech-in-noise speech reception thresholds (SRTs; normal < -10 dB SNR on the Canadian Digit Triplet Test [CDTT]).

RESULTS

Males and female groups did not differ in age, years of education, or other relevant covariates. Yet, females with better hearing on either pure-tone or speech-in-noise measures outperformed their worse hearing counterparts on the MoCA total score. Additionally, females with better hearing were more likely to recall several words on the MoCA delayed recall trial relative to those with worse hearing. Females with NH showed significant correlations between CDTT SRTs and both MoCA and RAVLT scores, while no correlations were observed in males. In contrast, males but not females showed an effect of hearing group on BVMT-R test status.

CONCLUSIONS

There were sex-specific differences in auditory-cognitive associations in individuals with MCI. These associations were mostly observed in females and on auditory tests. Potential mechanisms and implications are discussed.

The Relationship Between Hearing and Mild Behavioral Impairment and the Influence of Sex: A Study of Older Adults Without Dementia from the COMPASS-ND Study

Background

Hearing loss and mild behavioral impairment (MBI), both non-cognitive markers of dementia, can be early warning signs of incident cognitive decline.

Objective

We investigated the relationship between these markers and reported the influence of sex, using non-dementia participants (n = 219; 107 females) from the Canadian Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND).

Methods

Hearing was assessed with the 10-item Hearing Handicap for the Elderly-Screening (HHIE-S) questionnaire, a speech-in-noise test, screening audiometry, and hearing aid use. MBI symptoms were assessed using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Multivariable linear regressions examined the association between hearing and MBI symptom severity and multiple logistic regressions examined the association between hearing and MBI domains.

Results

HHIE-S score was significantly associated with greater global MBI symptom burden, and symptoms in the apathy and affective dysregulation domains. Objective measures of audiometric hearing loss and speech-in-noise testing as well as hearing aid use were not associated with global MBI symptom severity or the presence of MBI domain-specific symptoms. Males were older, had more audiometric and speech-in-noise hearing loss, higher rates of hearing-aid use, and showed more MBI symptoms than females, especially apathy.

Conclusion

The HHIE-S, a subjective self-report measure that captures emotional and social aspects of hearing disability, was associated with informant-reported global MBI symptom burden, and more specifically the domains of affective dysregulation and apathy. These domains can be potential drivers of depression and social isolation. Hearing and behavior change can be assessed with non-invasive measures, adding value to a comprehensive dementia risk assessment.

Usability and Accessibility of the ArtontheBrain™ Virtual Recreation Activity for Older Adults With Low Vision Due to Age-Related Macular Degeneration

Experiencing visual art can inspire, be an overall positive leisure activity, and has been linked to improved cognition, especially in older adults. Access to artwork in a museum environment can comprise a variety of barriers, including difficulties linked to its visual experience for persons that are visually impaired. The present study explored the barriers and facilitators experienced by 15 older adults (age 65 to 93) living with age-related macular degeneration when using an iPad to access ArtontheBrain™, a virtual art museum recreation experience created by members of this team. Using the Concurrent Think Aloud method, participants were asked to continuously comment on their experiences with the application while being audio/video recorded. Indeed, codes were determined by identifying frequently stated and emphasized ideas or behaviors of participants using the ArtontheBrain™ application. Transcripts underwent thematic analysis and indicated that the main access barriers were linked to control of the contrast, magnification, and the tactile interface on the tablet device. The learn and play activities as well as the text-to-speech feature were identified as facilitators for ArtontheBrain™ engagement. The present findings should also be considered in the larger context of application development, as this study provides insight pertaining to the needs of low vision individuals regarding usability and accessibility.

Speech-in-Noise Audiometry in Adults: A Review of the Available Tests for French Speakers

<b><i>Background:</i></b> Difficulty understanding speech in background noise is the reason of consultation for most people who seek help for their hearing. With the increased use of speech-in-noise (SpIN) testing, audiologists and otologists are expected to evidence disabilities in a greater number of patients with sensorineural hearing loss. The purpose of this study is to list validated available SpIN tests for the French-speaking population. <b><i>Summary:</i></b> A review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and Scopus databases were searched. Search strategies used a combination of 4 keywords: speech, audiometry, noise, and French. There were 10 validated SpIN tests dedicated to the Francophone adult population at the time of the review. Some tests use digits triplets as speech stimuli and were originally designed for hearing screening. The others were given a broader range of indications covering diagnostic or research purposes, determination of functional capacities and fitness for duty, as well as assessment of hearing amplification benefit. <b><i>Key Messages:</i></b> As there is a SpIN test for almost any type of clinical or rehabilitation needs, both the accuracy and duration should be considered for choosing one or the other. In an effort to meet the needs of a rapidly aging population, fast adaptive procedures can be favored to screen large groups in order to limit the risk of ignoring the early signs of forthcoming presbycusis and to provide appropriate audiological counseling.

Efficacy of the Digit-in-Noise Test: A Systematic Review and Meta-Analysis

Background and Objectives

Although the digit-in-noise (DIN) test is simple and quick, little is known about its key factors. This study explored the considerable components of the DIN test through a systematic review and meta-analysis.

Materials and Methods

After six electronic journal databases were screened, 14 studies were selected. For the meta-analysis, standardized mean difference was used to calculate effect sizes and 95% confidence intervals.

Results

The overall result of the meta-analysis showed an effect size of 2.224. In a subgroup analysis, the patient’s hearing status was found to have the highest effect size, meaning that the DIN test was significantly sensitive to screen for hearing loss. In terms of the length of the presenting digits, triple digits had lower speech recognition thresholds (SRTs) than single or pairs of digits. Among the types of background noise, speech-spectrum noise provided lower SRTs than multi-talker babbling. Regarding language variance, the DIN test showed better performance in the patient’s native language(s) than in other languages.

Conclusions

When uniformly developed and well validated, the DIN test can be a universal tool for hearing screening.

A Comparison Between the Korean Digits-in-Noise Test and the Korean Speech Perception-in-Noise Test in Normal-Hearing and Hearing-Impaired Listeners

Background and Objectives

The purpose of the present study was to validate the performance and diagnostic efficacy of the Korean digits-in-noise (K-DIN) test in comparison to the Korean speech perception-in-noise (K-SPIN) test, which is the representative speech-in-noise test in clinical practice.

Subjects and Methods

Twenty-seven subjects (15 normal-hearing and 12 hearing-impaired listeners) participated. The recorded Korean 0-9 digits were used to form quasirandom digit triplets; 50 target digit triplets were presented at the most comfortable level of each subject while presenting speech-shaped background noise at various levels of signal-to-noise ratios (-12.5, -10, -5, or +5 dB). Subjects were then instructed to listen to both target and noise masker unilaterally and bilaterally through a headphone. K-SPIN test was also conducted using the same procedure as the K-DIN. After calculating their percent correct responses, K-DIN and K-SPIN results were compared using a Pearson-correlation test.

Results

Results showed a statistically significant correlation between K-DIN and K-SPIN in all hearing conditions (left: r=0.814, p<0.001; right: r=0.788, p<0.001; bilateral: r=0.727, p<0.001). Moreover, the K-DIN test achieved better testing efficacy, shorter average listening time (5 min vs. 30 min), and easier performance of task according to participants’ qualitative reports than the K-SPIN test.

Conclusions

In this study, the Korean version of digit triplet test was validated in both normal-hearing and hearing-impaired listeners. The findings suggest that the K-DIN test can be used as a simple and time-efficient hearing-in-noise test in audiology clinics in Korea.

Extended High-frequency Hearing Impairment Despite a Normal Audiogram: Relation to Early Aging, Speech-in-noise Perception, Cochlear Function, and Routine Earphone Use

OBJECTIVES

Humans can hear up to 20 kHz. Emerging evidence suggests that hearing in the extended high frequencies (EHFs; >8 kHz) contributes to speech perception in noise. The objective of the present study was to describe the features of EHF hearing impairment in young adults with normal standard audiograms (0.25-8 kHz). Specifically, the study goals were to: (1) characterize the EHF hearing impairment and identify potential risk factors; (2) elucidate the age-related changes in EHF hearing; (3) determine the effect of EHF hearing impairment on speech-in-noise recognition; and (4) examine the extent to which EHF hearing impairment influences cochlear functioning in the standard frequencies.

DESIGN

Hearing thresholds at standard frequencies and EHFs (10, 12.5, 14, and 16 kHz), and speech recognition thresholds (SRTs) using digit triplets in multi-talker babble were measured in both ears from 222 participants (19-38 years; n = 444 ears) with normal audiograms (≤20 dB HL at standard frequencies). Test-retest measurement of hearing thresholds was obtained in a subset of 50 participants (100 ears), and clinical distortion product otoacoustic emissions (f2 frequency = 2, 3, 4, and 5 kHz) were recorded in 49 participants (98 ears).

RESULTS

Forty-two of 222 participants had EHF hearing impairment (>20 dB HL for at least one EHF in either ear). Only seven individuals with EHF impairment had significant case history and/or listening-in-noise complaints. A breakpoint in the threshold-age function was observed for the EHFs for males but not for females. Linear mixed models revealed a significant effect of age, pure-tone averages for speech frequencies (0.5, 1, 2, and 4 kHz), and EHFs and group (NH versus EHF hearing impairment) independent of each other on the SRTs. Individuals with EHF hearing impairment had less measurable emissions and when present, had a lower magnitude of otoacoustic emissions relative to NH controls. There was no difference in hearing thresholds, SRTs, or otoacoustic emissions between earphone users and nonusers.

CONCLUSIONS

The hearing thresholds for the EHFs exhibit signs of early auditory aging. Age-related deterioration in auditory function can be observed in the third decade of human life. A breakpoint in the threshold-age function suggests that rapid aging processes are operational at a relatively younger age (21 years) for males. The audibility of EHFs contributes to speech-in-noise recognition. EHF hearing impairment independent of age and speech frequencies can affect speech-in-noise recognition. Reduced distortion product otoacoustic emissions in the standard frequencies may suggest preclinical cochlear degeneration in individuals with EHF hearing impairment.

Self-report Measures of Hearing and Vision in Older Adults Participating in the Canadian Longitudinal Study of Aging are Explained by Behavioral Sensory Measures, Demographic, and Social Factors

OBJECTIVES

Our objectives were to (1) determine the prevalence of self-reported hearing, vision, and dual sensory (both vision and hearing) difficulties in older Canadian adults; (2) examine the association between self-report and behavioral sensory measures; and (3) controlling for behavioral sensory measures, examine variables that might explain the self-reported sensory difficulty, including age, sex, cultural background, socioeconomic status, nonsensory comorbidities, cognitive function, and social factors.

DESIGN

We used baseline data collected from the 30,097 participants of the comprehensive cohort of the Canadian Longitudinal Study on Aging. Participants who were 45 to 85 years of age (mean age = 63 years, SD = ± 10.25) were recruited using provincial health registries and random-digit dialing. Analyses were conducted for the sample as a whole or stratified by age. Behavioral sensory data for hearing (pure-tone audiometry) and vision (pinhole-corrected visual acuity) were collected at 11 data collection sites. Self-reported sensory and personal data were obtained through in-person interviews. "Difficulty" was defined as a response of "fair" or "poor" (versus "excellent," "very good" or "good") to questions about hearing ability (using a hearing aid if used) and vision (using glasses or corrective lenses if used). Individuals with both hearing and vision difficulties were defined as having dual sensory difficulties. Variables associated with self-reported sensory difficulties were analyzed with multiple regression models.

RESULTS

Objective 1. The prevalence of impairments based on behavioral measures was higher than the prevalence of difficulties based on self-report measures. The prevalence based on both types of measures increased with age, but the increase was steeper for behavioral measures. Objective 2. In addition to the expected positive associations between self-report and behavioral measures of hearing [odds ratio (OR) = 2.299)] and vision (OR = 15.247), self-reported sensory difficulty was also explained by other within-modality sensory variables, such as the symmetry of impairment and the use of aids. Objective 3. Controlling for behavioral measures of hearing (better-ear pure-tone average) or vision (better-eye visual acuity), older participants were significantly less likely than younger participants to self-report sensory difficulty. Sensory difficulties were reported more often by males and by those with more comorbid health conditions. Compared to those who did not report vision difficulties, those who did report them were more likely to also report hearing difficulties (OR = 2.921) and vice versa (OR = 2.720). There were modality-specific associations with variables relevant to social participation; for example, independent life space was associated with hearing difficulties, and perceived availability of social support and loneliness with vision difficulties.

CONCLUSIONS

The low prevalence of self-reported sensory difficulties relative to the behavioral measures of sensory impairments indicates that (a) a simple screening question about sensory ability may not be sufficient to identify older adults who are in the early stages of sensory decline, and (b) self-reported sensory ability is associated with sensory and nonsensory factors. Age, gender, and comorbidities are the most notable nonsensory predictors for both self-reported hearing and vision. These findings shed light on how the self-reported sensory difficulties of older adults may reflect clinical measures of sensory impairment as well as nonsensory factors.

Optimization of the Speech Test Material in a Group of Hearing Impaired Subjects: A Feasibility Study for Multilingual Digit Triplet Test Development

Background: The development of the global digit-in-noise test requires optimization of each language version on a group of normal-hearing native-speakers. An alternative solution may be an adaptive optimization during ongoing tests in a group of subjects with unknown hearing impairments. The objective of the research was to compare the optimization results between these groups. Methods: Digit triplets consisting of three pseudo-randomly selected digits were presented in speech-shaped noise at various signal-to-noise ratios (SNRs), according to the protocol of the final speech test. Digit-specific and position-specific speech reception thresholds (SRTs) were determined and compared between groups. Results: The study sample consisted of 82 subjects, 26 normal-hearing subjects and 56 patients with diverse hearing disorders. Statistically significant differences in digit-specific SRTs between the control and the investigated group were obtained for three digits in continuous noise (digits 0, 4, 6; p-value of 0.04, 0.03, 0.05) and two in modulated noise (digits 1 and 6; p-value of 0.05 and 0.01). An analysis including only ears with SRTs within the range of the normal hearing control group showed no statistically significant differences between digits. Conclusion: Optimization of speech material can be carried out in a group of subjects with unknown hearing impairments, provided the ears with scores outside normal range are rejected.

Effect of Reading Rehabilitation for Age-Related Macular Degeneration on Cognitive Functioning: Protocol for a Nonrandomized Pre-Post Intervention Study

BACKGROUND

Age-related vision impairments and dementia both become more prevalent with increasing age. Research into the mechanisms of these conditions has proposed that some of their causes (eg, macular degeneration/glaucoma and Alzheimer's disease) could be symptoms of an underlying common cause. Research into sensory-cognitive aging has provided data that sensory decline may be linked to the progression of dementia through reduced sensory stimulation. While hearing loss rehabilitation may have a beneficial effect on cognitive functioning, there are no data available on whether low vision rehabilitation, specifically for reading, could have a beneficial effect on cognitive health.

OBJECTIVE

The research questions are: (1) Does low vision rehabilitation reduce reading effort? (2) If so, does reduced reading effort increase reading activity, and (3) If so, does increased reading activity improve cognitive functioning? The primary objective is to evaluate cognition before, as well as at 6 months and 12 months after, 3 weeks of low vision reading rehabilitation using magnification in individuals with age-related macular degeneration, with or without coexisting hearing impairments. We hypothesize that improvements postrehab will be observed at 6 months and maintained at 12 months for participants with vision loss and less so for those with dual sensory loss. The secondary objective is to correlate participant characteristics with all cognitive outcomes to identify which may play an important role in reading rehabilitation.

METHODS

We employ a quasiexperimental approach (nonrandomized, pre-post intervention study). A 3x3 design (3 groups x 3 time points) allows us to examine whether cognitive performance will change before and after 6 months and 12 months of a low vision reading intervention, when comparing 75 low vision and 75 dual sensory impaired (vision & hearing) participants to 75 age-matched healthy controls. The study includes outcome measures of vision (eg, reading acuity and speed), cognition (eg, short-term and long-term memory, processing speed), participant descriptors, demographics, and clinical data (eg, speech perception in noise, mental health).

RESULTS

The study has received approval, and recruitment began on April 24, 2019. As of March 4, 2021, 38 low vision and 7 control participants have been enrolled. Lockdown forced a pause in recruitment, which will recommence once the COVID-19 crisis has reached a point where face-to-face data collection with older adults becomes feasible again.

CONCLUSIONS

Evidence of protective effects caused by reading rehabilitation will have a considerable impact on the vision rehabilitation community and their clients as well as all professionals involved in the care of older adults with or without dementia. If we demonstrate that reading rehabilitation has a beneficial effect on cognition, the demand for rehabilitation services will increase, potentially preventing cognitive decline across groups of older adults at risk of developing macular degeneration.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04276610; Unique Protocol ID: CRIR-1284-1217; https://clinicaltrials.gov/ct2/show/NCT04276610.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19931.

Hearing loss is associated with gray matter differences in older adults at risk for and with Alzheimer's disease

Using data from the COMPASS-ND study we investigated associations between hearing loss and hippocampal volume as well as cortical thickness in older adults with subjective cognitive decline (SCD), mild cognitive impairment (MCI), and Alzheimer's dementia (AD). SCD participants with greater pure-tone hearing loss exhibited lower hippocampal volume, but more cortical thickness in the left superior temporal gyrus and right pars opercularis. Greater speech-in-noise reception thresholds were associated with lower cortical thickness bilaterally across much of the cortex in AD. The AD group also showed a trend towards worse speech-in-noise thresholds compared to the SCD group.