Can cochlear implantation improve neurocognition in the aging population?

Cognitive Changes Up to 4 Years After Cochlear Implantation in Older Adults: A Prospective Longitudinal Study Using the RBANS-H

OBJECTIVES

Hearing loss is a worldwide health problem that currently affects around 20% of the world's population. Untreated hearing loss can have a significant impact on daily life, it can cause social isolation, loneliness, frustration, and higher anxiety and depression rates. Furthermore, older adults with hearing impairment have a higher risk for accelerated cognitive decline compared with normal-hearing individuals. Previous research indicated a positive effect of cochlear implantation on Health-related Quality of life (HRQoL) and cognitive functioning 1 year after cochlear implantation. The aim of this study was to evaluate the long-term effect of cochlear implantation on cognition and HRQoL in older adults with severe-to-profound hearing loss.

DESIGN

All included subjects were 55 years or older with postlingual, bilateral, severe-to-profound hearing loss, and received a unilateral cochlear implant. Cognition was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status for Hearing Impaired Individuals (RBANS-H), and HRQoL was evaluated using the following five questionnaires: Nijmegen Cochlear Implant Questionnaire (NCIQ); Hearing Implant Sound Quality Index (HISQUI); Speech, Spatial, and Qualities of Hearing Scale (SSQ12); Hospital Anxiety and Depression scale (HADS); and Type D questionnaire (DS14). Individuals were evaluated preoperatively, and annually up to 4 years after CI activation.

RESULTS

After cochlear implantation an improvement in hearing, cognition, and HRQoL was observed. When comparing preoperative and 12 months postoperative results a significant improvement was observed in the total RBANS-H score (mean [SD], 92.78 [±15.08] versus 98.35 [±14.18], p < 0.001) and the subdomain scores for "Immediate Memory" (94.13 [±18.75] versus 105.39 [±19.98], p = 0.005), "Attention" (86.17 [±19.02] versus 91.57 [±15.35], p = 0.048), and "Delayed memory" (97.91 [±14.51] versus 103.83 [±14.714], p = 0.017). When comparing preoperative results with 4 years postoperative results, a significant improvement was observed in "Immediate Memory" (94.13 [±18.75] versus 101.91 [±16.09], p = 0.020) and a significant decline was observed in "Visuospatial Memory" (97.04 [±17.47] versus 87.26 [±13.41], p = 0.013). Compared with the preoperative results, no significant improvement was observed in the total RBANS-H score 4 years after implantation. A significant improvement was observed for the HRQoL questionnaires, that is, NCIQ, HISQUI19, SSQ12, HADS, and DS14, 1 year after cochlear implantation. When comparing preoperative results with 4-year postoperative results, significant improvement was observed for the NCIQ and DS14 social inhibition scores. Long-term results of the SSQ12 and HISQUI19 were lacking.

CONCLUSIONS

Unilateral cochlear implantation in an adult population with bilateral severe-to-profound sensorineural hearing loss has a positive effect on cognitive functioning and HRQoL 1 year after activation. This positive effect on cognitive functioning was no longer observed 4 years after cochlear implantation. Further research is needed to explain individual variation in the evolution of cognitive functioning.

A Scoping Review and Meta-Analysis of the Relations Between Cognition and Cochlear Implant Outcomes and the Effect of Quiet Versus Noise Testing Conditions

OBJECTIVES

Evidence continues to emerge of associations between cochlear implant (CI) outcomes and cognitive functions in postlingually deafened adults. While there are multiple factors that appear to affect these associations, the impact of speech recognition background testing conditions (i.e., in quiet versus noise) has not been systematically explored. The two aims of this study were to (1) identify associations between speech recognition following cochlear implantation and performance on cognitive tasks, and to (2) investigate the impact of speech testing in quiet versus noise on these associations. Ultimately, we want to understand the conditions that impact this complex relationship between CI outcomes and cognition.

DESIGN

A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on published literature evaluating the relation between outcomes of cochlear implantation and cognition. The current review evaluates 39 papers that reported associations between over 30 cognitive assessments and speech recognition tests in adult patients with CIs. Six cognitive domains were evaluated: Global Cognition, Inhibition-Concentration, Memory and Learning, Controlled Fluency, Verbal Fluency, and Visuospatial Organization. Meta-analysis was conducted on three cognitive assessments among 12 studies to evaluate relations with speech recognition outcomes. Subgroup analyses were performed to identify whether speech recognition testing in quiet versus in background noise impacted its association with cognitive performance.

RESULTS

Significant associations between cognition and speech recognition in a background of quiet or noise were found in 69% of studies. Tests of Global Cognition and Inhibition-Concentration skills resulted in the highest overall frequency of significant associations with speech recognition (45% and 57%, respectively). Despite the modest proportion of significant associations reported, pooling effect sizes across samples through meta-analysis revealed a moderate positive correlation between tests of Global Cognition (r = +0.37, p < 0.01) as well as Verbal Fluency (r = +0.44, p < 0.01) and postoperative speech recognition skills. Tests of Memory and Learning are most frequently utilized in the setting of CI (in 26 of 39 included studies), yet meta-analysis revealed nonsignificant associations with speech recognition performance in a background of quiet (r = +0.30, p = 0.18), and noise (r = -0.06, p = 0.78).

CONCLUSIONS

Background conditions of speech recognition testing may influence the relation between speech recognition outcomes and cognition. The magnitude of this effect of testing conditions on this relationship appears to vary depending on the cognitive construct being assessed. Overall, Global Cognition and Inhibition-Concentration skills are potentially useful in explaining speech recognition skills following cochlear implantation. Future work should continue to evaluate these relations to appropriately unify cognitive testing opportunities in the setting of cochlear implantation.

A Comparison of Montreal Cognitive Assessment Scores among Individuals with Normal Hearing and Cochlear Implants

OBJECTIVES

The Montreal Cognitive Assessment (MoCA) is a cognitive screening tool that has 4 of 10 test items heavily dependent on auditory input, potentially leaving hearing-impaired (HI) individuals at a disadvantage. Previous work found that HI individuals scored lower than normal-hearing (NH) individuals on the MoCA, potentially attributed to the degraded auditory signals negatively impacting the ability to commit auditory information to memory. However, there is no research comparing how cochlear implant (CI) recipients perform on the MoCA relative to NH and HI individuals. This study aimed to (1) examine the effect of implementing three different hearing-adjusted scoring methods for a group of age-matched CI recipients and NH individuals, (2) determine if there is a difference between the two groups in overall scores and hearing-adjusted scores, and (3) compare scores across our CI and NH data to the published HI data for all scoring methods. We hypothesized that (1) scores for CI recipients would improve with implementation of the hearing-adjusted scoring methods over the original method, (2) CI recipients would score lower than NH participants for both original and adjusted scoring methods, and (3) the difference in scores between NH and CI listeners for both adjusted and unadjusted scores would be greater than that reported in the literature between NH and HI individuals due to the greater severity of hearing loss and relatively poor spectral resolution of CIs.

DESIGN

A total of 94 adults with CIs and 105 adults with NH were initially enrolled. After age-matching the two groups and excluding those who self-identified as NH but failed a hearing screening, a total of 75 CI participants (mean age 61.2 y) and 74 NH participants (mean age 58.8 y) were administered the MoCA. Scores were compared between the NH and CI groups, as well as to published HI data, using the original MoCA scoring method and three alternative scoring methods that excluded various auditory-dependent test items.

RESULTS

MoCA scores improved for all groups when two of the three alternative scoring methods were used, with no significant interaction between scoring method and group. Scores for CI recipients were significantly poorer than those for age-matched NH participants for all scoring methods. CI recipients scored better than the published data for HI individuals; however, the HI group was not age matched to the CI and NH groups.

CONCLUSIONS

MoCA scores are only partly affected by the potentially greater cognitive processing required to interpret degraded auditory signals. Even with the removal of the auditory-dependent items, CI recipients still did not perform as well as the age-matched NH group. Importantly, removing auditory-dependent items significantly and fundamentally alters the test, thereby reducing its sensitivity. This has important limitations for administration and interpretation of the MoCA for people with hearing loss.

The Benefits of Cochlear Implantation for Adults: A Systematic Umbrella Review

OBJECTIVES

The uptake of cochlear implants among adults who could benefit (based on pure-tone audiometry) in developed countries is estimated to be less than 10%. Concerns about potential surgical complications, fear of losing residual hearing, and limited awareness about the benefits of this intervention contribute to the low adoption rate. To enhance quality of life and improve the uptake of cochlear implants, it is essential to have a clear understanding of their benefits.

DESIGN

This umbrella review aims to summarize the major benefits of cochlear implant usage in adults, by synthesizing findings from published review articles. A comprehensive search of databases including MEDLINE, EMBASE, PsycINFO, and Google Scholar, was conducted. The search was limited to English-language review articles published between 1990 and 2022, focusing on cochlear implant outcomes in at least 5 adults (aged ≥18 years). Two independent reviewers screened titles, abstracts, and full-text articles, and conducted a quality assessment using the Joanna Briggs Checklist for Systematic Reviews and Research Syntheses.

RESULTS

Forty-two articles were included in this review. There were 15 systematic reviews with meta-analysis, 25 systematic reviews without meta-analysis, and 2 systematic scoping reviews. All 42 articles underwent quality assessment using the Joanna Briggs Institute Checklist for Systematic Reviews and Research Syntheses, of which 40% (n = 17) satisfied 9 out of 11 quality criteria. This umbrella review shows that cochlear implants are associated with improvements in speech perception and recognition as well as improved quality of life and cognition. These benefits are observed in a significant proportion of adults undergoing the procedure, highlighting its effectiveness as a viable intervention for individuals with severe to profound hearing loss.

CONCLUSIONS

The potential benefits of cochlear implantation appear to outweigh the risks and complications associated with the procedure. It is recommended that adults with severe to profound hearing loss in particular, engage in informed discussions with healthcare professionals to consider cochlear implantation as a viable treatment option.

Clinical Practice Guideline: Age-Related Hearing Loss

OBJECTIVE

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

The Chronological Evolution of Cochlear Implant Contraindications: A Comprehensive Review

Cochlear implantation has emerged as a transformative intervention in addressing profound hearing loss, offering a paradigm shift in auditory rehabilitation for individuals with restricted auditory function. Throughout its history, the understanding of contraindications for cochlear implant (CI) surgery has evolved significantly. This review comprehensively analyzes the chronological advancements in the understanding of CI contraindications, examining studies conducted from historical timelines to the present. Recent research has revealed significant developments in the field, prompting a reevaluation of established criteria and resulting in expanded indications for CI. The chronological evolution of contraindications underscores the transformative nature of the field, offering potential improvements in outcomes and enhancing the quality of life for individuals with profound hearing loss. In conclusion, this narrative review emphasizes the dynamic nature of the field, where the reevaluation of contraindications has created new opportunities and broader indications for CI. The emerging prospects, including improved outcomes and enhanced quality of life, hold promise for individuals with profound hearing loss.

Improving quality of life in the elderly: hearing loss treatment with cochlear implants

BACKGROUND

Hearing loss impacts health-related quality of life and general well-being and was identified in a Lancet report as one of the largest potentially modifiable factors for the prevention of age-related dementia. There is a lack of robust data on how cochlear implant treatment in the elderly impacts quality of life. The primary objective was to measure the change in health utility following cochlear implantation in individuals aged ≥ 60 years.

METHODS

This study uniquely prospectively recruited a large multinational sample of 100 older adults (mean age 71.7 (SD7.6) range 60-91 years) with severe to profound hearing loss. In a repeated-measures design, pre and post implant outcome measures were analysed using mixed-effect models. Health utility was assessed with the Health Utilities Index Mark III (HUI3). Subjects were divided into groups of 60-64, 65-74 and 75 + years.

RESULTS

At 18 months post implant, the mean HUI3 score improved by 0.13 (95%CI: 0.07-0.18 p < 0.001). There was no statistically significant difference in the HUI3 between age groups (F[2,9228] = 0.53, p = 0.59). The De Jong Loneliness scale reduced by an average of 0.61 (95%CI: 0.25-0.97 p < 0.014) and the Lawton Instrumental Activities of Daily Living Scale improved on average (1.25, 95%CI: 0.85-1.65 p < 0.001). Hearing Handicap Inventory for the Elderly Screening reduced by an average of 8.7 (95%CI: 6.7-10.8, p < 0.001) from a significant to mild-moderate hearing handicap. Age was not a statistically significant factor for any of the other measures (p > 0.20). At baseline 90% of participants had no or mild depression and there was no change in mean depression scores after implant. Categories of Auditory perception scale showed that all subjects achieved a level of speech sound discrimination without lip reading post implantation (level 4) and at least 50% could use the telephone with a known speaker.

CONCLUSIONS

Better hearing improved individuals' quality of life, ability to communicate verbally and their ability to function independently. They felt less lonely and less handicapped by their hearing loss. Benefits were independent of age group. Cochlear implants should be considered as a routine treatment option for those over 60 years with bilateral severe to profound hearing loss.

TRIAL REGISTRATION

ClinicalTrials.gov ( http://www.

CLINICALTRIALS

gov/ ), 7 March 2017, NCT03072862.

Hearing Impairment and Cognitive Function: Mediating Role of Social Isolation and Depression

ObjectivesTo examine the relationship between hearing impairment and cognitive function and the mediating role of social isolation and depression. Methods: Data came from the 2018 China Health and Retirement Longitudinal Study wave. A self-reported item, a composite index, the 10-item Center for Epidemiological Studies Depression Scale, and the Mini-Mental State Exam were used to measure hearing impairment, social isolation, depression, and cognitive function, respectively. Mediation analysis was performed. Results: 6799 participants were included. For participants reporting mild hearing impairment and severe hearing impairment, there were significant direct and indirect effects on cognitive function. Social isolation mediated 2.75% and 6.33% of the relationship between mild hearing impairment, severe hearing impairment, and cognitive function, respectively. The direct effect of hearing impairment outweighed the mediation effect of social isolation on cognitive function. Conclusions: Decreased cognitive function linked to hearing impairment might benefit from addressing hearing impairment and social isolation in older adults.

Quality of Life and Audiological Benefits in Pediatric Cochlear Implant Users in Romania: Systematic Review and Cohort Study

Profound sensorineural hearing loss (SNHL) can be successfully treated with a cochlear implant (CI), and treatment is usually accompanied by increased quality of life (QoL). Therefore, the aim of this study was to investigate generic and health-related QoL, as well as the level of audiological outcomes, of CI users, in addition to whether Qol can be restored to the extent of those with normal hearing. Furthermore, different implantation timepoints were compared (early vs. late), and a possible correlation between health and generic QoL questionnaires was investigated. The outcomes from 93 pediatric CI users from Romania were analyzed in the study. Two QoL questionnaires (SSQ12, AQoL-6D), as well as the HSM sentence test and Soundfield measurements, were assessed. The outcomes revealed that the CI users were able to achieve the same QoL as their age- and-gender matched peers with normal hearing, and hearing was restored with good speech comprehension. No significant difference between early- and late-implanted children was detected, although a tendency of a better Word Recognition Score (+10%) in the early-implanted group was discovered. A moderate and significant correlation between the generic and health-related Qol questionnaire was observed. Audiological examinations are still the standard practice by which to measure the benefit of any hearing intervention; nonetheless, generic and health-related QoL should be assessed in order to provide a full picture of a successful and patient-satisfactory cochlear implant procedure.

Emerging Relations among Cognitive Constructs and Cochlear Implant Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVE

Hearing loss has a detrimental impact on cognitive function. However, there is a lack of consensus on the impact of cochlear implants on cognition. This review systematically evaluates whether cochlear implants in adult patients lead to cognitive improvements and investigates the relations of cognition with speech recognition outcomes.

DATA SOURCES

A literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating cognition and cochlear implant outcomes in postlingual, adult patients from January 1996 to December 2021 were included. Of 2510 total references, 52 studies were included in qualitative analysis and 11 in meta-analyses.

REVIEW METHODS

Proportions were extracted from studies of (1) the significant impacts of cochlear implantation on 6 cognitive domains and (2) associations between cognition and speech recognition outcomes. Meta-analyses were performed using random effects models on mean differences between pre- and postoperative performance on 4 cognitive assessments.

RESULTS

Only half of the outcomes reported suggested cochlear implantation had a significant impact on cognition (50.8%), with the highest proportion in assessments of memory & learning and inhibition-concentration. Meta-analyses revealed significant improvements in global cognition and inhibition-concentration. Finally, 40.4% of associations between cognition and speech recognition outcomes were significant.

CONCLUSION

Findings relating to cochlear implantation and cognition vary depending on the cognitive domain assessed and the study goal. Nonetheless, assessments of memory & learning, global cognition, and inhibition-concentration may represent tools to assess cognitive benefit after implantation and help explain variability in speech recognition outcomes. Enhanced selectivity in assessments of cognition is needed for clinical applicability.

Bilateral simultaneous cochlear implantation is a safe method of hearing rehabilitation in adults

PURPOSE

Bilateral cochlear implantation is an effective treatment for patients with bilateral profound hearing loss. In contrast to children, adults mostly choose a sequential surgery. This study addresses whether simultaneous bilateral CI is associated with higher rates of complications compared to sequential implantation.

METHODS

169 bilateral CI surgeries were analyzed retrospectively. 34 of the patients were implanted simultaneously (group 1), whereas 135 patients were implanted sequentially (group 2). The duration of surgery, the incidence of minor and major complications and the duration of hospitalization of both groups were compared.

RESULTS

In group 1, the total operating room time was significantly shorter. The incidences of minor and major surgical complications showed no statistically significant differences. A fatal non-surgical complication in group 1 was particularly extensively reappraised without evidence of a causal relationship to the chosen mode of care. The duration of hospitalization was 0.7 days longer than in unilateral implantation but 2.8 days shorter than the combined two hospital stays in group 2.

CONCLUSION

In the synopsis of all considered complications and complication-relevant factors, equivalence of simultaneous and sequential cochlear implantation in adults in terms of safety was found. However, potential side effects related to longer surgical time in simultaneous surgery must be considered individually. Careful patient selection with special consideration to existing comorbidities and preoperative anesthesiologic evaluation is essential.

Cochlear implantation impact on health service utilisation and social outcomes: a systematic review

BACKGROUND

Hearing loss can have a negative impact on individuals' health and engagement with social activities. Integrated approaches that tackle barriers and social outcomes could mitigate some of these effects for cochlear implants (CI) users. This review aims to synthesise the evidence of the impact of a CI on adults' health service utilisation and social outcomes.

METHODS

Five databases (MEDLINE, Scopus, ERIC, CINAHL and PsychINFO) were searched from 1st January 2000 to 16 January 2023 and May 2023. Articles that reported on health service utilisation or social outcomes post-CI in adults aged ≥ 18 years were included. Health service utilisation includes hospital admissions, emergency department (ED) presentations, general practitioner (GP) visits, CI revision surgery and pharmaceutical use. Social outcomes include education, autonomy, social participation, training, disability, social housing, social welfare benefits, occupation, employment, income level, anxiety, depression, quality of life (QoL), communication and cognition. Searched articles were screened in two stages ̶̶̶ by going through the title and abstract then full text. Information extracted from the included studies was narratively synthesised.

RESULTS

There were 44 studies included in this review, with 20 (45.5%) cohort studies, 18 (40.9%) cross-sectional and six (13.6%) qualitative studies. Nine studies (20.5%) reported on health service utilisation and 35 (79.5%) on social outcomes. Five out of nine studies showed benefits of CI in improving adults' health service utilisation including reduced use of prescription medication, reduced number of surgical and audiological visits. Most of the studies 27 (77.1%) revealed improvements for at least one social outcome, such as work or employment 18 (85.7%), social participation 14 (93.3%), autonomy 8 (88.9%), education (all nine studies), perceived hearing disability (five out of six studies) and income (all three studies) post-CI. None of the included studies had a low risk of bias.

CONCLUSIONS

This review identified beneficial impacts of CI in improving adults' health service utilisation and social outcomes. Improvement in hearing enhanced social interactions and working lives. There is a need for large scale, well-designed epidemiological studies examining health and social outcomes post-CI.

Cochlear implants: the effects of age on outcomes

INTRODUCTION

Cochlear implants (CIs) provide access to sound for children and adults who do not receive adequate benefit from hearing aids. Age at implantation is known to affect outcomes across the lifespan.

AREAS COVERED

The effects of age on CI outcomes are examined for infants, children, adolescents, and older adults. A variety of outcome measures are considered, including speech perception, language, cognition, and quality of life measures.

EXPERT OPINION/COMMENTARY

For those meeting candidacy criteria, CIs are beneficial at any age. In general, younger age is related to greater benefit when considering pre-lingual deafness. Other factors such as additional disabilities, may mitigate this effect. Post-lingually deafened adults demonstrate similar benefit regardless of age, though the oldest individuals (80+) may see smaller degrees of improvement from preoperative scores. Benefit can be measured in many ways, and the areas of greatest benefit may vary based on age: young children appear to see the greatest effects of age at implantation on language measures, whereas scores on cognitive measures appear to be most impacted for the oldest population. Future research should consider implantation at extreme ages (5-9 months or > 90 years), unconventional measures of CI benefit including qualitative assessments, and longitudinal designs.

Responsible Imputation of Missing Speech Perception Testing Data & Analysis of 4,739 Observations and Predictors of Performance

OBJECTIVE

To address outcome heterogeneity in cochlear implant (CI) research, we built imputation models using multiple imputation by chained equations (MICEs) and K-nearest neighbors (KNNs) to convert between four common open-set testing scenarios: Consonant-Nucleus-Consonant word (CNCw), Arizona Biomedical (AzBio) in quiet, AzBio +5, and AzBio +10. We then analyzed raw and imputed data sets to evaluate factors affecting CI outcome variability.

STUDY DESIGN

Retrospective cohort study of a national CI database (HERMES) and a nonoverlapping single-institution CI database.

SETTING

Multi-institutional (32 CI centers).

PATIENTS

Adult CI recipients (n = 4,046 patients).

MAIN OUTCOME MEASURES

Mean absolute error (MAE) between imputed and observed speech perception scores.

RESULTS

Imputation models of preoperative speech perception measures demonstrate a MAE of less than 10% for feature triplets of CNCw/AzBio in quiet/AzBio +10 (MICE: MAE, 9.52%; 95% confidence interval [CI], 9.40-9.64; KNN: MAE, 8.93%; 95% CI, 8.83-9.03) and AzBio in quiet/AzBio +5/AzBio +10 (MICE: MAE, 8.85%; 95% CI, 8.68-9.02; KNN: MAE, 8.95%; 95% CI, 8.74-9.16) with one feature missing. Postoperative imputation can be safely performed with up to four of six features missing in a set of CNCw and AzBio in quiet at 3, 6, and 12 months postcochlear implantation using MICE (MAE, 9.69%; 95% CI, 9.63-9.76). For multivariable analysis of CI performance prediction, imputation increased sample size by 72%, from 2,756 to 4,739, with marginal change in adjusted R2 (0.13 raw, 0.14 imputed).

CONCLUSIONS

Missing data across certain sets of common speech perception tests may be safely imputed, enabling multivariate analysis of one of the largest CI outcomes data sets to date.

Streamlining experiment design in cognitive hearing science using OpenSesame

Auditory science increasingly builds on concepts and testing paradigms originated in behavioral psychology and cognitive neuroscience - an evolution of which the resulting discipline is now known as cognitive hearing science. Experimental cognitive hearing science paradigms call for hybrid cognitive and psychobehavioral tests such as those relating the attentional system, working memory, and executive functioning to low-level auditory acuity or speech intelligibility. Building complex multi-stimuli experiments can rapidly become time-consuming and error-prone. Platform-based experiment design can help streamline the implementation of cognitive hearing science experimental paradigms, promote the standardization of experiment design practices, and ensure reliability and control. Here, we introduce a set of features for the open-source python-based OpenSesame platform that allows the rapid implementation of custom behavioral and cognitive hearing science tests, including complex multichannel audio stimuli while interfacing with various synchronous inputs/outputs. Our integration includes advanced audio playback capabilities with multiple loudspeakers, an adaptive procedure, compatibility with standard I/Os and their synchronization through implementation of the Lab Streaming Layer protocol. We exemplify the capabilities of this extended OpenSesame platform with an implementation of the three-alternative forced choice amplitude modulation detection test and discuss reliability and performance. The new features are available free of charge from GitHub: https://github.com/elus-om/BRM_OMEXP .

Listening with an Ageing Brain - a Cognitive Challenge

Hearing impairment has been recently identified as a major modifiable risk factor for cognitive decline in later life and has been becoming of increasing scientific interest. Sensory and cognitive decline are connected by complex bottom-up and top-down processes, a sharp distinction between sensation, perception, and cognition is impossible. This review provides a comprehensive overview on the effects of healthy and pathological aging on auditory as well as cognitive functioning on speech perception and comprehension, as well as specific auditory deficits in the 2 most common neurodegenerative diseases in old age: Alzheimer disease and Parkinson syndrome. Hypotheses linking hearing loss to cognitive decline are discussed, and current knowledge on the effect of hearing rehabilitation on cognitive functioning is presented. This article provides an overview of the complex relationship between hearing and cognition in old age.

Response shift in hearing related quality of life after cochlear implantation - effect size and clinical significance: a then-test study

BACKGROUND

Quality of life questionnaires are often used in the assessment of rehabilitation of hearing-impaired patients with a cochlear implant. However, a prospective study with a systematic retrospective evaluation of the preoperative quality of life after surgery has not yet been conducted and may reveal a change in internal standards, such as a response shift, due to the implantation and hearing rehabilitation.

METHODS

The Nijmegen Cochlear Implant Questionnaire (NCIQ) was used for assessing hearing related quality of life. It has three general domains (physical, psychological and social) and six subdomains. Seventeen patients were tested before (t₀) and retrospectively (then-test; pre-t₁) and acutely postoperative (post-t₁) after cochlear implantation. Observed changes, then-test changes, response shifts and effect sizes were calculated. Non-parametric statistical methods were used.

RESULTS

The NCIQ total score was 52.32 ± 18.69 (mean, standard deviation) for t₀, 59.29 ± 14.06 for pre-t₁ and 67.65 ± 26.02 for post-t₁ questioning. The observed change was statistically significant in all domains but in speech production. Response shift was statistically significant in the total score and in part of the domains. The effect sizes for the response shift were moderate (> 0.5) in the total score, psychological, social general scores and subdomains.

CONCLUSIONS

In this study we found that response shift does exist in adults with severe to profound hearing loss undergoing cochlear implantation. By advising the participants to deactivate the implant for the then-test, recall bias and noise were minimized. The clinical significance of the response shift was present in the total score and in the social and psychological domains.

TRIAL REGISTRATION

This study was retrospectively registered with the German Clinical Trial Register, TRN DRKS00029467, on 07/08/2022.

Patient perceptions of cognitive screening in adult audiology services: A qualitative exploration

Introduction

Both hearing loss and dementia are extremely pervasive, especially amongst older adults. As hearing loss and dementia have common symptoms, misdiagnosis can be common, and failure to address hearing loss for people with dementia could accelerate cognitive decline. The timely detection of cognitive impairment is clinically important, however the use of cognitive assessments in adult audiology services is a hotly debated topic. Although the early detection of cognitive impairment may improve patient care and quality of life, patients attending audiology services for hearing assessment might not expect to be asked questions about their cognition. The aim of this study was to qualitatively explore patient and public perspectives and preferences on the use of cognitive screening within adult audiology services.

Methods

Quantitative and qualitative data were gathered from an online survey and a workshop. Descriptive statistics were applied to quantitative data and an inductive thematic analysis was performed on free-text responses.

Results

In total, 90 respondents completed the online survey. Overall, cognitive screening in audiology was reported to be acceptable to participants (92%). A reflexive thematic analysis of the qualitative data reported four themes: i) knowledge of cognitive impairment and screening, ii) implementation of cognitive screening, iii) impact of screening on patient and iv) contributions to future care and research. A workshop was held with five participants to discuss and reflect on the findings in more detail.

Discussion

Participants found cognitive screening to be acceptable within adult audiology services providing audiologists had suitable training, and sufficient explanation and justification were provided. However, implications such as additional time and staff resource and supplementary training for audiologists would be required to address participants concerns.

Cochlear Implant Adult Speech Perception Outcomes: Seniors Have Similar Good Outcomes

OBJECTIVE

The primary aim was to analyze the speech perception outcomes of patients with cochlear implants 65 years and older, compared with those younger than 65 years. The secondary aim was to analyze if preoperative hearing levels, severe compared with profound, had an effect on speech perception outcomes in senior citizens.

STUDY DESIGN

Retrospective case review of 785 patients, between 2009 and 2016.

SETTING

A large cochlear implant program.

PATIENTS

Cochlear implant adult recipients younger than 65 years and 65 years and older at the time of surgery.

INTERVENTIONS

Therapeutic-cochlear implant.

MAIN OUTCOME MEASURES

Speech perception outcomes, using City University of New York (CUNY) sentences and Consonant-Nucleus-Consonant (CNC) words. Outcomes were measured preoperatively and postoperatively at 3, 6and 12 months for cohorts younger than 65 years and 65 years and older.

RESULTS

Adult recipients younger than 65 years compared with those 65 years and older had comparable outcomes for CUNY sentence scores outcomes (p = 0.11) and CNC word scores (p = 0.69). The preoperative four-frequency average severe hearing loss (HL) cohort was significantly better compared with the profound HL cohort, for both the CUNY sentence scores (p < 0.001) and CNC word scores (p < 0.0001). The four-frequency average severe HL cohort had better outcomes irrespective of age.

CONCLUSIONS

Senior citizens have similarly good speech perception outcomes as adults younger than 65 years. Those with preoperative severe HL have better outcomes than profound loss. These finds are reassuring and can be used when counseling older cochlear implant candidates.

Plasticity After Hearing Rehabilitation in the Aging Brain

Age-related hearing loss, presbycusis, is an unavoidable sensory degradation, often associated with the progressive decline of cognitive and social functions, and dementia. It is generally considered a natural consequence of the inner-ear deterioration. However, presbycusis arguably conflates a wide array of peripheral and central impairments. Although hearing rehabilitation maintains the integrity and activity of auditory networks and can prevent or revert maladaptive plasticity, the extent of such neural plastic changes in the aging brain is poorly appreciated. By reanalyzing a large-scale dataset of more than 2200 cochlear implant users (CI) and assessing the improvement in speech perception from 6 to 24 months of use, we show that, although rehabilitation improves speech understanding on average, age at implantation only minimally affects speech scores at 6 months but has a pejorative effect at 24 months post implantation. Furthermore, older subjects (>67 years old) were significantly more likely to degrade their performances after 2 years of CI use than the younger patients for each year increase in age. Secondary analysis reveals three possible plasticity trajectories after auditory rehabilitation to account for these disparities: Awakening, reversal of deafness-specific changes; Counteracting, stabilization of additional cognitive impairments; or Decline, independent pejorative processes that hearing rehabilitation cannot prevent. The role of complementary behavioral interventions needs to be considered to potentiate the (re)activation of auditory brain networks.

Cochlear Implantation in Patients With Known Cognitive Impairment: What Are the Benefits?

OBJECTIVE

To evaluate the outcomes of cochlear implantation (CI) in adults with preoperatively diagnosed cognitive impairment.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary-care academic center.

PATIENTS

Adults undergoing CI with preexisting cognitive impairment.

INTERVENTIONS

Cochlear implantation.

MAIN OUTCOME MEASURES

1) Hearing improvement after CI; 2) morbidity and mortality associated with surgery.

RESULTS

Eight patients met inclusion criteria with mean age 77.8 years (SD, 9.6 y) at time of implantation; 7 were included in subsequent analysis as one did not have speech recognition scores. Average preoperative MoCA cognitive score of 22.6 (SD, 3.9, ≤25 demonstrates cognitive impairment). Average follow-up was 29.0 months (SD, 33.3 mo). Two patients passed away at an average 58.0 months (SD, 31.1 mo) after surgery. Median preoperative pure tone average was 86.3 dB HL ( interquartile range 31.3 dB HL) compared with 33.8 dB HL (IQR 5.0 dB HL) postoperatively ( p = <0.001). Median preoperative speech testing score (AzBio/HINT) was 21% (IQR, 24%) compared with 44% (IQR, 21%) postoperatively ( p = <0.001). There were no observed surgical complications during the follow-up period.

CONCLUSIONS

This study demonstrates that patients with cognitive impairment before CI can experience improved hearing, no increased risk of complications, and good longevity after CI. Further prospective studies are needed to further define the utility of CI in patients with impaired cognition.

Association of Baseline Frailty Status and Age With Postoperative Complications After Cochlear Implantation: A National Inpatient Sample Study

OBJECTIVE

To conduct a national registry-based evaluation of the independent associations of chronological age and frailty, as measured by 5- and 11-factor modified frailty index (mFI-5, mFI-11) score, on postoperative outcomes of participants undergoing cochlear implantation (CI).

STUDY DESIGN

Cross-sectional analysis.

SETTING

Multicenter national database.

PARTICIPANTS

Adults 18 years or older who underwent CI during 2001 to 2018.

MAIN OUTCOME MEASURES

Any postoperative complications (determined as the presence of major, minor, or implant-specific), extended hospital length of stay (eLOS) (≥75th percentile of study population), and nonhome discharge destination.

RESULTS

There were 5,130 participants included with a median age of 60 years (interquartile range, 44-73 y) and slight female predominance (53.5%). Under mFI-5 scoring, there were 2,979 (58.1%) robust (mFI-5 = 0), 1710 (33.3%) prefrail (mFI-5 = 1), 362 (7.1%) frail (mFI-5 = 2), and 78 (1.5%) severely frail (mFI-5 ≥ 3) participants. Three hundred twenty-eight (6.49%) participants experienced a postoperative complication, with 320 (6.2%) discharged to a nonhome destination. Multivariate analysis showed no statistically significant correlation between increasing participant age or frailty status and postoperative complications; however, increasing baseline frailty tier showed an independent association with risk of eLOS (severely frail: odds ratio, 4..83; 95% confidence interval, 3.00-7.75; p < 0.001) and nonhome discharge (severely frail: odds ratio, 6.51; 95% confidence interval, 3.81-11.11; p < 0.001). The mFI-11 showed very similar trends.

CONCLUSION

Among those evaluated, this study demonstrates that CI is a low-risk procedure in participants of all ages. Increasing frailty does not predispose to postoperative complications. However, frail patients are at additional risk for an eLOS and nonhome discharge. Short follow-up time, hospital-coding errors, and selection bias of more robust patients may limit the true results of this study.

Preoperative Reading Efficiency as a Predictor of Adult Cochlear Implant Outcomes

HYPOTHESES

1) Scores of reading efficiency (the Test of Word Reading Efficiency, second edition) obtained in adults before cochlear implant surgery will be predictive of speech recognition outcomes 6 months after surgery; and 2) Cochlear implantation will lead to improvements in language processing as measured through reading efficiency from preimplantation to postimplantation.

BACKGROUND

Adult cochlear implant (CI) users display remarkable variability in speech recognition outcomes. "Top-down" processing-the use of cognitive resources to make sense of degraded speech-contributes to speech recognition abilities in CI users. One area that has received little attention is the efficiency of lexical and phonological processing. In this study, a visual measure of word and nonword reading efficiency-relying on lexical and phonological processing, respectively-was investigated for its ability to predict CI speech recognition outcomes, as well as to identify any improvements after implantation.

METHODS

Twenty-four postlingually deaf adult CI candidates were tested on the Test of Word Reading Efficiency, Second Edition preoperatively and again 6 months post-CI. Six-month post-CI speech recognition measures were also assessed across a battery of word and sentence recognition.

RESULTS

Preoperative nonword reading scores were moderately predictive of sentence recognition outcomes, but real word reading scores were not; word recognition scores were not predicted by either. No 6-month post-CI improvement was demonstrated in either word or nonword reading efficiency.

CONCLUSION

Phonological processing as measured by the Test of Word Reading Efficiency, Second Edition nonword reading predicts to a moderate degree 6-month sentence recognition outcomes in adult CI users. Reading efficiency did not improve after implantation, although this could be because of the relatively short duration of CI use.

Can cochlear implantation prevent cognitive decline in the long-term follow-up?

Cognitive function and hearing are known to both decline in older adults. As hearing loss is proposed to be one modifiable risk factor for dementia, the impact of auditory rehabilitation on cognitive decline has been gaining increasing attention. Despite a large number of studies, long-term data are still rare. In a large prospective longitudinal monocentric study, 50 adults (aged ≥ 50 years) with severe postlingual bilateral hearing loss received a cochlear implant (CI). They underwent comprehensive neurocognitive testing prior to implantation (T1), at 12 months (T2) and up to 65 months (T3) after implantation. Various cognitive subdomains such as attention, inhibition, working memory, verbal fluency, mental flexibility and (delayed) recall were assessed by the computer-based non-auditory test battery ALAcog©. The observed trajectories of two exemplary cognitive subdomains (delayed recall and working memory) were then fitted over time using multilevel growth models to adjust for sociodemographic covariates and compared with 5-year longitudinal data from a sample of older adults from the representative Survey of Health, Aging and Retirement in Europe (SHARE) study. Postoperatively, auditory functions improved from 6.98% (SD 12.83) to 57.29% (SD 20.18) in monosyllabic speech understanding. Cognitive functions significantly increased from T1 to T3 in attention (p = 0.001), delayed recall (p = 0.001), working memory (OSPAN; p = 0.001), verbal fluency (p = 0.004), and inhibition (p = 0.002). A closer look at follow-up revealed that cognitive improvement could be detected between T1 and T2 and thereafter remained stable in all subtests (p ≥ 0.06). Additional longitudinal analysis confirmed these findings in a rigorous multilevel approach in two exemplary cognitive subdomains. In contrast to the SHARE data, there was no evidence for age-differential associations over time in CI recipients. This suggests that older adults benefit equally from cochlear implantation. CI users with worse preoperative cognitive skills experienced the most benefit (p < 0.0001). Auditory rehabilitation by cochlear implantation has a stimulating effect on cognitive functions beyond an improvement in speech understanding and an increased well-being. Large multicenter studies using standardized protocols have to be undertaken in the future to find out whether hearing restoration might help to prevent cognitive decline.

Cognitive and behavioral effects of hearing loss

PURPOSE OF REVIEW

Hearing loss is one of the largest modifiable risk factors for developing dementia, accounting for up to 9% of the overall modifiable risk. The neuropsychologic and psychosocial impacts of hearing loss are becoming increasingly appreciated. The objective of this review is to explore the recent literature regarding the cognitive and behavioral effects of hearing loss and the role of hearing rehabilitation, particularly in older adults.

RECENT FINDINGS

Cognitive decline may begin while patients have subclinical hearing loss, earlier than previously thought. Hearing rehabilitation, either via hearing amplification, middle ear surgery, or cochlear implantation, likely plays a role in preventing or slowing the rate of cognitive decline in patients with hearing loss. Hearing loss can increase the likelihood of social isolation, loneliness and depression in older adults, but it is unclear at this time what effect hearing rehabilitation has on these domains.

SUMMARY

Hearing loss is one of the largest modifiable risk factors for cognitive decline, and hearing rehabilitation can play a significant role in preserving cognitive function. Understanding the cognitive and psychosocial impact of hearing loss can help facilitate the development of approaches for prevention and treatment.

Considering hearing loss as a modifiable risk factor for dementia

INTRODUCTION

Accumulating evidence links hearing loss to impaired cognitive performance and increased risk for dementia. Hearing loss can lead to deafferentation-induced atrophy of frontotemporal brain regions and dysregulation of cognitive control networks from increased listening effort. Hearing loss is also associated with reduced social engagement, loneliness, and depression, which are independently associated with poor cognitive function.

AREAS COVERED

We summarize the evidence and postulated mechanisms linking hearing loss to dementia in older adults and synthesize the available literature demonstrating beneficial effects of hearing remediation on brain structure and function.

EXPERT OPINION

: Further research is needed to evaluate whether treatment of hearing loss may reduce risk of cognitive decline and improve neural consequences of hearing loss. Studies may investigate the pathologic mechanisms linking these late-life disorders and identify individuals vulnerable to dementia, and future clinical trials may evaluate whether hearing treatment may reduce the risk for dementia.

Is there benefit from the use of cochlear implants and hearing aids in cognition for older adults? A systematic review

Objectives

The aim of the study was to assess whether hearing aids (HA) and cochlear implants (CI) bring benefits to cognition or mitigate cognitive decline in older adults.

Methods

This is a systematic literature review registered on the International Prospective Register of Systematic Reviews (PROSPERO) and based on the criteria recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The Population, Intervention, Comparison, Outcome, and Study type (PICOS) strategy was used to define eligibility. Studies that met the criteria were included in the qualitative synthesis. We assessed the risk of bias through the Joanna Briggs Institute Critical Appraisal Checklists.

Results

A total of 3,239 articles, found in eight databases, addressed the relationship between HA, CI, and cognition. We selected 30 experimental articles reporting measures of cognitive outcomes for older adults to include in the qualitative analysis. Of those, 23 studies reported a significant improvement in outcome and seven reported no significant change.

Conclusions

This systematic review indicates that CI and HA can bring benefits to cognition in older adults.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021273690.

Cochlear Implantation in Hearing-Impaired Elderly: Clinical Challenges and Opportunities to Optimize Outcome

Cochlear implant (CI) overall provides a very good outcome, but speech comprehension outcome in the elderly is more variable. Several clinical factors play an important role. The management of residual hearing, the presence of comorbidities, and especially the progression of cognitive decline seem to be the clinical parameters that strongly determine the outcome of cochlear implantation and need to be discussed prospectively in the consultation process with the elderly hearing impaired. In the context of this review article, strategies for dealing with these will be discussed. Timely cochlear implantation should already be considered by hearing aid acousticians or practicing otolaryngologists and communicated or initiated with the patient. This requires intensive cooperation between hearing aid acousticians and experts in the clinic. In addition, residual hearing and comorbidities in the elderly need to be considered to make realistic predictions about speech comprehension with CI. Long-term aftercare and its different implementations should be discussed preoperatively, so that the elderly person with hearing impairments feels well taken care of together with his or her relatives. Elderly patients with hearing impairments benefit most from a CI in terms of speech comprehension if there is a large cochlear coverage (electrical or acoustic electrical) and the therapy is not hampered by comorbidities, especially cognitive decline.

Cochlear implantation outcomes in the older adult: a scoping review

OBJECTIVES

The current study aimed to identify and map the available evidence surrounding cochlear implantation (CI) in older adults. Five outcomes were evaluated: speech perception scores, perioperative complications, neurocognitive outcomes, quality of life outcomes and vestibular dysfunction and fall rates after surgery.

METHODS

A scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews and included patients over the age of 60.

RESULTS

Ninety-seven studies met inclusion criteria, encompassing 7,182 patients. Mean (SD) speech perception scores in quiet and in noise pre-and postoperatively were 7.9% (6.7) and 52.8% (14.3) and 8.0% (68.1) and 68.1% (15.9) respectively. Postoperative cardiac arrhythmias, urinary retention, and delirium occurred slightly more frequently in older adults. In terms of cognition, most studies noted stability or improvement one year after implantation. A majority of studies indicated better quality of life post-CI. Rates of fall after surgery were rarely reported, and there was a general paucity of data surrounding vestibular function changes after CI.

DISCUSSION

This scoping review identifies many positive outcomes linked to CI in older adults. No findings suggest a single patient characteristic that would warrant refusal to consider evaluation for cochlear implantation.

Changes in cognitive performance after cochlear implantation in adults and older adults: a systematic review and meta-analysis

OBJECTIVES

To conduct critical assessment of the literature on the effects of cochlear implantation on adults' cognitive abilities.

DESIGN

PubMed, Scopus, Lilacs, Web of Science, Livivo, Cochrane, Embase, PsycInfo, and grey literature were searched. Eligibility criteria: age 18 or over with severe-to-profound bilateral hearing loss, cochlear implantation, cognitive test before and after implantation. Risk of bias was assessed using ROB, ROBINS-I and MASTARI tools. Meta-analysis was performed.

STUDY SAMPLE

Out of 1830 studies, 16 met the inclusion criteria.

RESULTS

On AlaCog test, significant improvement was found after implantation [MD = -46.64; CI95% = -69.96 to -23.33; I² = 71%]. No significant differences were found on the Flanker, Recall, Trail A and n-back tests (p > 0.05). For MMSE, no significance was found [MD 0.63; CI 95% = -2.19 to 3.45; I² = 88%]. On TMT, an overall significant effect with a 9-second decrease in processing speed post-implantation [MD = -9.43; CI95% = -15.42 to -3.44; I² = 0%].

CONCLUSION

Cognitive improvements after cochlear implantation may depend on time and the cognitive task evaluated. Well-designed studies with longer follow-up are necessary to examine whether cochlear implantation has a positive influence on cognitive abilities. Development of cognitive assessment tools to hearing-impaired individuals is needed.

Cognition and Cognitive Reserve in Cochlear Implant Recipients

At present, dementia is a hot topic. Hearing loss is considered to be a modifiable risk factor for cognitive decline. The underlying mechanism remains unclear and might be mediated by socioeconomic and psychosocial factors. Cochlear implantation has been shown not only to restore auditory abilities, but also to decrease mental distress and to improve cognitive functions in people with severe hearing impairment. However, the promising results need to be confirmed. In a prospective single-center study, we tested the neurocognitive abilities of a large group of 71 subjects with bilateral severe hearing impairment with a mean age of 66.03 (SD = 9.15) preoperatively and 6, 12, and 24 months after cochlear implantation using a comprehensive non-auditory computer-based test battery, and we also assessed the cognitive reserve (CR) [Cognitive Reserve Index (CRI)], health-related quality of life (QoL) (Nijmegen Cochlear Implant Questionnaire), and depression (Geriatric Depression Scale-15). Cognitive functions significantly increased after 6 months in attention (p = 0.00004), working memory (operation span task; p = 0.002), and inhibition (p = 0.0002); and after 12 months in recall (p = 0.003) and verbal fluency (p = 0.0048), and remained stable up to 24 months (p ≥ 0.06). The CR positively correlated with cognitive functions pre- and post-operatively (both p < 0.005), but postoperative improvement in cognition was better in subjects with poor CR (p = 0.003). Depression had only a slight influence on one subtest. No correlation was found among cognitive skills, quality of life, and speech perception (each p ≥ 0.05). Cochlear implantation creates an enriched environment stimulating the plasticity of the brain with a global positive impact on neurocognitive functions, especially in subjects with poor preoperative cognitive performance and low cognitive reserve.

Effect of cochlear implantation on cognitive decline and quality of life in younger and older adults with severe-to-profound hearing loss

Purpose

(a) To measure the change in cognition, the improvement of speech perception, and the subjective benefit in people under and over 60 years following cochlear implantation. (b) To assess the relationship between cognition, demographic, audiometric, and subjective outcomes in both age groups.

Methods

28 cochlear implant (CI) users were assigned to the < 60y group and 35 to the ≥ 60y group. Cognition was measured using the Repeatable Battery for the Assessment of Neuropsychological Status for Hearing impaired individuals (RBANS-H); subjective benefit was measured using the Nijmegen Cochlear Implant Questionnaire (NCIQ); the Glasgow Benefit Inventory (GBI); the Hearing Implant Sound Quality Index (HISQUI₁₉); Speech, Spatial and Qualities of Hearing Scale (SSQ₁₂); and the Hospital Anxiety and Depression Scale (HADS).

Results

Prior to surgery: the RBANS-H total score positively correlated with the domains “Advanced sound”, “Self-esteem”, and “Social functioning” of NCIQ, and negatively with HADS scores. 12 months post-implantation: the RBANS-H total score increased in the < 60y (p = 0.038) and in the ≥ 60y group (p < 0.001); speech perception and subjective outcomes also improved; RBANS-H total score positively correlated with “Self-esteem” domain in NCIQ. Age and the RBANS-H total score correlated negatively in the ≥ 60y group (p = 0.026).

Conclusions

After implantation, both age groups demonstrated improved cognition, speech perception and quality of life. Their depression scores decreased. Age was inversely associated with cognition.

The Impact of Cochlear Implantation: Cognitive Function, Quality of Life, and Frailty in Older Adults

This review examines the relationship between cochlear implantation and cognition and quality of life in older adults, as well as how frailty affects outcomes for older patients with cochlear implants. A growing body of evidence suggests that there is a strong association between hearing loss and cognitive impairment. Preliminary studies suggest that cochlear implantation in older adults may be protective against cognitive decline. While studies have observed a positive impact of cochlear implantation on quality of life, currently it is unclear what factors contribute the most to improved quality of life. Frailty, as a measurement of general health, likely plays a role in complication rates and quality-of-life outcomes after cochlear implantation, though larger prospective studies are required to further elucidate this relationship.

Cross-cultural adaptation of the Nijmegen cochlear implant questionnaire into Turkish language: validity, reliability and effects of demographic variables

Purpose

The purpose of this study was to evaluate the validity and reliability of the Turkish version of the Nijmegen Cochlear Implant Questionnaire (Tr-NCIQ) and reveal the demographic factors contributing to the outcomes.

Methods

A group of 118 cochlear implant users aged between 18 and 70 years filled the Tr-NCIQ and the Turkish Hearing Handicapped Inventory for Adults (the Tr-HHI-Adult) via electronic survey. Cross-cultural adaptation of the Tr-NCIQ was performed. The reliability and validity of the questionnaire were evaluated utilizing internal consistency coefficient, split-half method, and predictive validity.

Results

The overall Cronbach’s alpha coefficient of the scale was 0.91, and the Spearman-Brown coefficient was 0.91. A moderately significant and negative correlation was present between the basic sound perception, speech production, self-esteem, activity, and social interactions subdomain scores and the HHI-Adult scores. Patients with post-lingual onset of hearing loss had significantly better results than those with pre-lingual onset, in the advanced sound perception subdomain. In addition, bilateral cochlear implant users had better results than the unilateral and bimodal users in the speech production subdomain and then the bimodal users in the self-esteem subdomain. There was no effect of age, duration of implant use, age at implantation, and the daily usage of cochlear implant (CI) on the quality-of-life outcomes.

Conclusion

The Tr-NCIQ is a reliable and valid tool to evaluate the subjective quality of life in CI users. In addition, as a standardized instrument, it can be easily self-administered both in clinical practice and for research purposes.

Can Cochlear Implantation in Older Adults Reverse Cognitive Decline Due to Hearing Loss?

INTRODUCTION

Older adults with late-onset hearing loss are at risk for cognitive decline. Our study addresses the question of whether cochlear implantation (CI) can counteract this potential influence. We investigated whether cognitive performance in older adults with severe and profound hearing loss improves 12 months after CI to a level comparable to controls with normal hearing, matched for age, sex, and education level.

DESIGN

This cohort study was performed at two tertiary referral centers. The study included 29 patients, of age between 60 and 80 years, with adult-onset, severe to profound bilateral sensorineural hearing loss and indication for CI (study group), as well as 29 volunteers with age-adjusted hearing abilities, according to the norm curves of ISO-702 9:2000-01, (control group). Before CI and 12 months after CI, participants completed a neurocognitive test battery including tests of global cognition, verbal and figural episodic memory, and executive functions (attentional control, inhibition, and cognitive flexibility).

RESULTS

Twelve months after CI, the performance of the study group improved significantly in global cognition, compared to the situation before CI. Differences in verbal episodic memory, figural episodic memory, and executive function were not significant. Moreover, the improvement of the study group was significantly larger only in global cognition compared to the control group. Noninferiority tests on the cognitive performances of the study group after CI revealed that comparable levels to normal hearing controls were reached only in global cognition, figural episodic memory (immediate recall), and attentional control. The improvement in global cognition was significantly associated with speech recognition 3 months after CI, but not with speech recognition 12 months after CI.

CONCLUSION

One year after CI, cognitive deficits in older individuals with adult-onset hearing loss, compared to normal-hearing peers, could only improve some cognitive skills.

Hearing Loss and Cognitive Impairment: Epidemiology, Common Pathophysiological Findings, and Treatment Considerations

In recent years, there has been increasing research interest in the correlation between hearing impairment and cognitive decline, two conditions that have demonstrated a strong association. Hearing loss appears as a risk factor for cognitive impairment, especially among certain populations, notably nursing home residents. Furthermore, hearing loss has been identified as a modifiable age-related condition linked to dementia, and it has been estimated that midlife hearing loss, if eliminated, might decrease the risk of dementia in the general population. Several mechanisms have been suggested to explain the pathologic connections between hearing loss and dementia; however, clear evidence is missing, and the common pathophysiological basis is still unclear. In this review, we discussed current knowledge about the relationship between hearing loss and dementia, and future perspectives in terms of the effects of hearing rehabilitation for early prevention of cognitive decline.

[How the brain perceives the world in old age with all senses]

BACKGROUND

Aging is a multidimensional process that may lead to physical, psychological and social changes. This is predominantly due to a decline of sensory functions and their central processing.

MATERIAL AND METHODS

Selective literature search in Medline and the Cochrane Library.

RESULTS

In addition to specific disorders of the sensory organs, unspecific age-related degenerative processes are responsible for the high prevalence of sensory limitations in older people. This can lead to a significant reduction in the quality of life. Balance impairment, decreasing function of hearing, vision, smell and the somatosensory system are associated with an increased risk of falling and an increased mortality in older people. Furthermore, there is evidence for a link between hearing loss and cognitive decline. In addition to the functional ability of every sense on its own, the integration of multiple sensory perceptions plays an increasing role in age-related sensory limitations.

CONCLUSION

Sensory impairments have to be considered when working with older people. Early detection and an interdisciplinary therapeutic approach can reduce the negative consequences. Multimodal stimulation appears to stimulate brain plasticity which helps to compensate age-related changes.

Improvement of Working Memory and Processing Speed in Patients over 70 with Bilateral Hearing Impairment Following Unilateral Cochlear Implantation

Several studies demonstrated the association of hearing disorders with neurocognitive deficits and dementia disorders, but little is known about the effects of auditory rehabilitation on the cognitive performance of the elderly. Therefore, the research question of the present study was whether cochlear implantation, performed in 21 patients over 70 with bilateral severe hearing impairment, could influence their cognitive skills. The measuring points were before implantation and 12 months after the first cochlear implant (CI) fitting. Evaluation of the working memory (WMI) and processing speed (PSI) was performed using the Wechsler Adult Intelligence Scale 4th edition (WAIS-IV). The audiological assessment included speech perception (SP) in quiet (Freiburg monosyllabic test; FMT), noise (Oldenburg sentence test; OLSA), and self-assessment inventory (Oldenburg Inventory; OI). Twelve months after the first CI fitting, not only the auditory parameters (SP and OI), but also the WMI and PSI, improved significantly (p < 0.05) in the cohort. The presented results imply that cochlear implantation of bilaterally hearing-impaired patients over 70 positively influences their cognitive skills.

Rapid Assessment of Non-Verbal Auditory Perception in Normal-Hearing Participants and Cochlear Implant Users

In the case of hearing loss, cochlear implants (CI) allow for the restoration of hearing. Despite the advantages of CIs for speech perception, CI users still complain about their poor perception of their auditory environment. Aiming to assess non-verbal auditory perception in CI users, we developed five listening tests. These tests measure pitch change detection, pitch direction identification, pitch short-term memory, auditory stream segregation, and emotional prosody recognition, along with perceived intensity ratings. In order to test the potential benefit of visual cues for pitch processing, the three pitch tests included half of the trials with visual indications to perform the task. We tested 10 normal-hearing (NH) participants with material being presented as original and vocoded sounds, and 10 post-lingually deaf CI users. With the vocoded sounds, the NH participants had reduced scores for the detection of small pitch differences, and reduced emotion recognition and streaming abilities compared to the original sounds. Similarly, the CI users had deficits for small differences in the pitch change detection task and emotion recognition, as well as a decreased streaming capacity. Overall, this assessment allows for the rapid detection of specific patterns of non-verbal auditory perception deficits. The current findings also open new perspectives about how to enhance pitch perception capacities using visual cues.

White Matter Lesions as Possible Predictors of Audiological Performance in Adults after Cochlear Implantation

The presented prospective study investigated whether structural brain damage, measured with the Fazekas score, could predict hearing rehabilitation outcomes with cochlear implantation (CI). With a follow-up period of 24 months, this study included 49 bilaterally, postlingually hearing impaired CI candidates for unilateral CI (67.3 ± 8.7 years; 20 men, 29 women) older than 50 at the time of implantation. The differences in the predictive value between two age groups, 50-70 year-olds (mid-age; n = 26) and over 70-year-olds (elderly; n = 23), were analyzed. The patients were evaluated using speech perception (SP) measured in quiet (Freiburg monosyllabic test; FMT) and noise (Oldenburg sentence test; OLSA). The subjective hearing ability was assessed using Oldenburg inventory (OI). The Fazekas PVWM score predicted postoperative speech perception two years after CI in the mid-age population. The periventricular white matter lesions (PVWM) could explain 27.4% of the speech perception (FMT) variance. Our findings support the hypothesis about the influence of pre-existing WMLs on CI outcome. We recommend the evaluation of Fazekas score as a predictive factor for post-implantation hearing ability.

Age-Related Hearing Loss and the Development of Cognitive Impairment and Late-Life Depression: A Scoping Overview

Age-related hearing loss (ARHL) has been connected to both cognitive decline and late-life depression. Several mechanisms have been offered to explain both individual links. Causal and common mechanisms have been theorized for the relationship between ARHL and impaired cognition, including dementia. The causal mechanisms include increased cognitive load, social isolation, and structural brain changes. Common mechanisms include neurovascular disease as well as other known or as-yet undiscovered neuropathologic processes. Behavioral mechanisms have been used to explain the potentially causal association of ARHL with depression. Behavioral mechanisms include social isolation, loneliness, as well as decreased mobility and impairments of activities of daily living, all of which can increase the risk of depression. The mechanisms underlying the associations between hearing loss and impaired cognition, as well as hearing loss and depression, are likely not mutually exclusive. ARHL may contribute to both impaired cognition and depression through overlapping mechanisms. Furthermore, ARHL may contribute to impaired cognition which may, in turn, contribute to depression. Because ARHL is highly prevalent and greatly undertreated, targeting this condition is an appealing and potentially influential strategy to reduce the risk of developing two potentially devastating diseases of later life. However, further studies are necessary to elucidate the mechanistic relationship between ARHL, depression, and impaired cognition.

Cognitive Functions in Adults Receiving Cochlear Implants: Predictors of Speech Recognition and Changes After Implantation

HYPOTHESES

Significant variability in speech recognition outcomes is consistently observed in adults who receive cochlear implants (CIs), some of which may be attributable to cognitive functions. Two hypotheses were tested: 1) preoperative cognitive skills assessed visually would predict postoperative speech recognition at 6 months after CI; and 2) cochlear implantation would result in benefits to cognitive processes at 6 months.

BACKGROUND

Several executive functioning tasks have been identified as contributors to speech recognition in adults with hearing loss. There is also mounting evidence that cochlear implantation can improve cognitive functioning. This study examined whether preoperative cognitive functions would predict speech recognition after implantation, and whether cognitive skills would improve as a result of CI intervention.

METHODS

Nineteen post-lingually deafened adult CI candidates were tested preoperatively using a visual battery of tests to assess working memory (WM), processing speed, inhibition-concentration, and nonverbal reasoning. Six months post-implantation, participants were assessed with a battery of word and sentence recognition measures and cognitive tests were repeated.

RESULTS

Multiple speech measures after 6 months of CI use were correlated with preoperative visual WM (symbol span task) and inhibition ability (stroop incongruent task) with moderate-to-large effect sizes. Small-to-large effect size improvements in visual WM, concentration, and inhibition tasks were found from pre- to post-CI. Patients with lower baseline cognitive abilities improved the most after implantation.

CONCLUSIONS

Findings provide evidence that preoperative cognitive factors contribute to speech recognition outcomes for adult CI users, and support the premise that implantation may lead to improvements in some cognitive domains.

How Does Cochlear Implantation Lead to Improvements on a Cognitive Screening Measure?

Purpose Cognitive screening tools to identify patients at risk for cognitive deficits are frequently used by clinicians who work with aging populations in hearing health care. Although some studies show improvements in performance on cognitive screening exams when hearing loss intervention is provided in the form of a hearing aid or cochlear implant (CI), it is worth examining whether these improvements are attributable to increased auditory access to test items. This study aimed to examine whether performance and pass rate on a cognitive screening measure, the Montréal Cognitive Assessment (MoCA), improve as a result of CI, whether improved performance on auditory-based test items drives changes in MoCA performance, and whether postoperative MoCA performance relates to post-CI speech perception ability. Method Data were collected in adult CI candidates pre-implantation and 6 months postimplantation to examine the effect of intervention on MoCA performance. Participants were 77 CI users between the ages of 55 and 85 years. Participants completed the MoCA, administered audiovisually, and speech perception testing with monosyllabic (CNC) words at both intervals. Results Compared to 31 participants pre-operatively, 45 participants passed the MoCA postoperatively, which was a significant difference in pass rate. An improvement in MoCA scores could be attributed primarily to improvement in the "Delayed Recall" test domain, which was auditory based. Post-CI MoCA performance was related to post-CI CNC speech perception performance. Conclusions Improved performance and pass rates were demonstrated on the traditional MoCA test of cognitive screening from before to 6 months after CI. Improvements could primarily be attributed to better performance on a delayed recall task dependent on auditory access, and post-CI MoCA scores were related to post-CI speech perception abilities. Further studies are needed to investigate the application of cognitive screening tools in patients receiving hearing loss interventions, and these interventions' impact on patients' real-world functioning.

The impact of cochlear implantation on health-related quality of life in older adults, measured with the Health Utilities Index Mark 2 and Mark 3

PURPOSE

To determine the usefulness of the Health Utilities Index (HUI) in older cochlear implant (CI) recipients, the primary aims were: (1) to assess health-related quality of life (HRQoL), measured with HUI, in older CI candidates while comparing with age- and gender-matched normal-hearing controls; (2) to compare HRQoL after CI with the pre-operative situation, using HUI and the Nijmegen cochlear implant questionnaire (NCIQ). The difference between pre- and postoperative speech intelligibility in noise (SPIN) and in quiet (SPIQ) and the influence of pre-operative vestibular function on HRQoL in CI users were also studied.

METHODS

Twenty CI users aged 55 years and older with bilateral severe-to-profound postlingual sensorineural hearing loss and an age- and gender-matched normal-hearing control group were included. HRQoL was assessed with HUI Mark 2 (HUI2), HUI Mark 3 (HUI3) and NCIQ. The CI recipients were evaluated pre-operatively and 12 months postoperatively.

RESULTS

HUI3 Hearing (p = 0.02), SPIQ (p < 0.001), SPIN (p < 0.001) and NCIQ (p = 0.001) scores improved significantly comparing pre- and postoperative measurements in the CI group. No significant improvement was found comparing pre- and postoperative HUI3 Multi-Attribute scores (p = 0.07). The HUI3 Multi-Attribute score after CI remained significantly worse (p < 0.001) than those of the control group. Vestibular loss was significantly related to a decrease in HUI3 Multi-Attribute (p = 0.037) and HUI3 Emotion (p = 0.021) scores.

CONCLUSION

The HUI is suitable to detect differences between normal-hearing controls and CI users, but might underestimate HRQoL changes after CI in CI users over 55.

Effects of the Conductive Component of Hearing Loss on Speech Discrimination Ability

OBJECTIVES

Effects of decreasing auditory activity on speech discrimination ability are not fully understood. To investigate influence of decrease in auditory activity due to conductive and sensorineural components of hearing loss (HL) on speech discrimination ability.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients with suspected HL at Kitasato University Hospital in 2017 and 2018. Patients were divided according to pure-tone audiometry findings: no HL (N-HL), conductive HL (C-HL), sensorineural HL (S-HL), and mixed HL (M-HL) groups.

RESULTS

In total, 149 patients (224 ears) were eligible. The maximum speech discrimination score (SDSmax) for all ears significantly negatively correlated with age (r = -0.29, p<0.0001) and bone conduction (BC) threshold (r = -0.55, p<0.0001). For patients aged <50 years in N-HL and C-HL groups, SDSmax was nearly 100%, with no significant difference. SDSmax was significantly lower for older patients (≥50 years) in the M-HL group than in the S-HL group, even though there were no significant differences in age and BC thresholds between groups.

CONCLUSION

Decrease of auditory activity due to the conductive component of M-HL may worsen speech discrimination ability. Early treatment of M-HL would be desirable for the preservation of auditory function.

Cochlear Implantation

BACKGROUND

Hearing impairment that is too severe to be adequately treated with conventional hearing aids can lead, in children, to severe developmental disturbances of hearing and language, and, in adults, to communicative and social deprivation. Recent advances in medical device technology and in microsurgical techniques have led to an expansion of the indications for cochlear implantation (CI) for adults with progressive hearing loss in older age, and to a restructuring of the process of care for these patients in Germany.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, as well as on the CI guidelines and CI "white book" of the German Society of Otolaryngology and Head and Neck Surgery.

RESULTS

Early and accurate diagnosis is crucial for the successful auditory rehabilitation of high-grade hearing impairment. In children, a key role is played by newborn auditory screening, which is mandatory in Germany and enables the provision of a CI in the first year of life when necessary. 86% of the children receiving a CI achieve linguistic comprehension of fluently spoken sentences. For adults, positive prognostic factors for hearing after the provision of a CI include a highly motivated patient, "postlingual" onset of the hearing impairment (i.e., after the acquisition of language), and a brief duration of deafness. Auditory rehabilitation is associated with significant improvement, not just of hearing and of the comprehension of spoken language, but also of quality of life, particularly in elderly patients. For patients of any age with bilateral hearing loss, CIs should be provided on both sides, if possible. The more common complications of the procedure, with a probability of 2-4% each, are technical implant defects, dizziness, and wound-healing disturbances.

CONCLUSION

Cochlear implantation, performed in specialized centers, is a safe and reliable technique and regularly enables the successful rehabilitation of hearing in both children and adults.

[New ways in hearing rehabilitation after cochlear implantation]

INTRODUCTION

After cochlear implantation, auditory and speech training is usually necessary. Up until now, this has been performed on an out- or inpatient basis in direct contact with a therapist. Due to technical advances but also particularly because of an increasing use of digital media and a desire for mobility and independence, the demand for digital training programs is increasing in the field of hearing rehabilitation.

MATERIALS AND METHODS

In a first step, the most important elements of auditory training were determined on the basis of commonly used auditory and speech processing models, and the core features of a computer-based teletherapeutic hearing platform were defined. This process considered motivational elements and adaptive mechanisms as regularly used in educational and speech and language therapy. In a second step, an initial prototype of the "train2hear" teletherapeutic hearing platform was developed by an interdisciplinary research team.

RESULTS

The core of the train2hear platform is an initial analysis according to the International Classification of Functioning, Disability, and Health (ICF), on the basis of which an individual training plan is designed. Various adaptive mechanisms enable the level of difficulty to be continually adapted to the individual user's learning progress. A videoconference tool enables contact between the patient and the therapist.

CONCLUSION

The train2hear platform represents a first prototype of a computer-based auditory rehabilitation program in German. Further evaluation and development in a clinical study are needed to determine the feasibility and efficacy of the platform.

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.

The effect of cochlear implantation on autonomy, participation and work in postlingually deafened adults: a scoping review

Purpose

This scoping review examines the available evidence on the effect of unilateral cochlear implantation (CI) in adults with postlingual bilateral hearing loss on societal-related outcomes in terms of work, autonomy and participation.

Methods

Five databases were searched (Pubmed, Web of Science, Embase, PsycINFO and Cochrane Library). Publications were screened in three steps on inclusion criteria. Of the 4230 screened publications, 110 met the inclusion criteria and were assessed for data extraction regarding outcomes “work”, “autonomy”, “participation”. Study characteristics and key findings are presented and narratively described.

Results

Twenty-seven publications were included and categorized into retrospective (n = 3), cross-sectional (n = 18) or prospective (n = 6) study designs. Measurement or identification of number of outcomes (no) were related to work (no = 20), participation (no = 9) and autonomy or independency (no = 10). Most studies indicated benefits of CI on these outcomes. However, some studies did not or indicated additional barriers for benefits. Eleven publications primarily aimed to study one or more of our primary outcomes.

Conclusion

In this literature search, scientific databases are reviewed. The results indicate that there is a relatively small body of evidence regarding the effect of CI on the outcomes “work”, “autonomy” and “participation”. Even though there are some limitations of the current study including some overlap in outcome definitions, most included studies indicate a beneficial effect of CI on work, autonomy and participation. The lack of consensus in definitions and the small body of evidence indicates a need for additional prospective studies investigating the societal outcomes of CI in postlingually deafened adults.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06490-x) contains supplementary material, which is available to authorized users.