 Hello and welcome to this talk entitled, I don't understand aging, hearing loss and dementia. My name is Dr. Sarah Esther Cader, and I am an audiologist at Old Bridge Medical Center, part of Hackensack Meridian Health. And this talk is part of our celebration this month of May, which is better hearing and speech month. If you can grab a pencil and paper, there's just one part of the talk where you might want to jot down some of your own answers to some questions. So that's what I mean by be ready to write. Just to outline what I'm going to be talking about today. So first I want to talk a little bit about hearing loss and aging and my expertise is on the hearing loss aspect of this but I'm also going to talk a little bit about dementia. I'm going to focus on how dementia and hearing loss interact and even answer the question, or at least postulate some theories about why hearing loss and cognitive impairment coexist. And then we're going to end with some practical what can we do about it, talking about treatment as far as hearing aids memory program, etc. So when we talk about hearing loss and aging, we know that hearing loss is the third most common chronic health condition in older Americans 40% of us will have hearing loss at age 65, and that number rises quickly to 80% more than 80% that has hearing loss at 80 and older. Of course that does mean that there are people 80 and older 20% who actually have normal hearing so not everybody who is older has hearing loss but hearing loss becomes very common. Even though those numbers are so high. We also know that only 12.3% of adults, older adults will have a hearing screening during their physical. What is hearing loss, I think that we all think back to the days maybe in school or maybe some other time where we had to listen to the beeps and raise our hands. When we heard it but hearing beeps and determining how loud the beeps have to be in order to heat for the patient to hear them is really only a small part of the story. Audio metric thresholds, the level at which you can hear a beep doesn't really reflect communication difficulties always so hearing difficulty in the presence of multiple talkers with competing noise can even be present in people with normal hearing. So they might be able to hear all the beeps at a normal level, but when there's a lot of people talking when there's noise in the background, they still might have trouble. And let's get a little bit semantic about it. Let's talk about listening versus hearing. So hearing is more passive. I hear the sound, whereas listening is active because listening refers to the act of making a conscious effort to perceive sound. And listen and hearing is more the act of perceiving sound through your ear. So hearing does not require conscious effort but listening does making listening voluntary and hearing involuntary. So here's where I wanted you to grab some pen and paper. And I thought that maybe we could just have everybody go through and you can fill this out for yourself. Or maybe you have a family member that you're worried about their hearing you can fill it out your perception about what they experience, or maybe you have a patient, whoever whatever your relationship is. So this is a screening called the hearing handicap inventory for the elderly is also valid for people who are not elderly. And you're going to answer each question with yes, sometimes or no. And I'm just going to ask you if you avoid a situation because you have hearing loss, don't skip the item. Just that's a yes. Okay, so question number one. Just again jot down yes, sometimes or no. Number one, does a hearing problem cause you to feel embarrassed when you meet new people. Number two, does a hearing problem cause you to feel frustrated when talking to members of your family. Not frustrated just because of your members of your family but the hearing problem causing you to feel frustrated. Number three, do you have difficulty hearing when someone speaks in a whisper. Yes, sometimes or no. Number four, do you feel handicapped by hearing problem. Number five, does a hearing problem cause you difficulty when visiting friends relatives or neighbors. Number six, does a hearing problem cause you to attend religious services less often than you would like. Number seven, does a hearing problem cause you to have arguments with family members. Number eight, does a hearing problem cause you difficulty when listening to TV or radio, or a podcast anything you'd like to listen to. Do you feel that any difficulty with your hearing limits or hampers your personal or social life. And number 10, does a hearing problem cause you difficulty when in a restaurant with relatives and friends and I know not all restaurants are created equal index when it comes to communication and noise. So you can choose your food, but just choose average. Okay, so we have 10 questions, and you have yes, sometimes or no. Now you can go through and score your answers. So for every yes, you score yourself for points for every no, get no points and for sometimes you get two points. You can add up all your points and you'll get a raw score. Now what do we do with that raw score. There's two things we can do with it. One thing is we can use that number to kind of predict how likely it is that you or the person you filled it out with them in mind has hearing loss. So if the score is zero to eight, there's only a 13% probability that there's hearing loss. If the score is 10 to 24, there's a 50% probability of hearing loss. If the score is 26 to 40, there's an 84% probability of hearing loss. That's one thing we can do. Another thing we can do is we can say, how much is your hearing problem affecting you. So some people can have can have two patients with identical hearing loss. One is very affected by the hearing loss. It really bothers them. It really causes them difficulty. And the other person has the same hearing loss and yet they function fine. It doesn't affect them so much. And that's the handicap. So again, if your score is zero to eight, we would expect not much handicap at all 10 to 24 mile to moderate handicap and 26 to 40 severe handicap. So that's just a little score, a little, a little screening to see kind of where you fall. Okay, now I'd like to talk a little bit about a little bit more about how hearing loss makes you feel. I get to talk to patients often about their hearing loss and the feelings that they, that they experience. Unfortunately, this is not a live audience. So I can't ask you for how hearing loss makes you feel, but I often hear lots of different answers, and people talk about feeling lonely and feeling frustrated and feeling old. So there's lots of different feelings that people experience from their hearing loss, but really the, the term and the expression and the feeling that I hear about the most is frustration. Really, almost every person will talk about being frustrated, the patients talk about being frustrated, frustrated, their families talk about being frustrated. We can also know that we can see sadness, depression, worry, anxiety, paranoia, emotional turmoil and insecurity. Here's a little infographic, and it has eight consequences of untreated hearing difficulties. So number one is that your mental sharpness suffers so untreated hearing impairment can put you anywhere between 29 and 57% greater risk of cognitive impairment. We'll talk more about that as we go along. We're also going to talk about how hearing loss doubles your risk of developing dementia. Number three, untreated hearing loss actually can impair your memory. Number four, conversations are just not as fun. And of course, as a corollary to that number five, your social life may suffer. So seniors with untreated hearing loss are 20 to 24% less likely to participate in social activities. Their hearing loss may make them feel anxious and insecure. There's been a lot of research in the last few years about auditory fatigue and how tiring it is to listen when you have a hearing loss. So somebody might be managing fine, but they're working so hard to fill in the blanks to figure out what people are saying to really make educated decisions and it can be really exhausting. And actually number eight, all of these, because of all of these things, untreated hearing loss can actually impact your earning potential as well. There's no guarantee on that one. I can't promise but it can't. We also know that hearing loss has been associated with lots of different medical conditions. And this little graphic kind of talks about some of those. So hearing loss and cardiovascular disease are definitely linked. And maybe when we see hearing loss we need to check for cardiovascular disease, Alzheimer's and dementia, which is really the topic of our of our talk today. Diabetes. Another talk that I have. Hospitalizations are 32% more likely for older adults with hearing loss. Excuse me, even mortality so hearing loss is tied to a greater risk of dying specifically for older meth. Chronic kidney disease is associated with a 43% increased risk of hearing loss falls hearing loss tied to a three fold risk of falling and depression symptoms go down quality of life goes up with hearing aid use. So how would you know that you have hearing loss and also corollary to that how would your physician know. Physicians think they know when patients have hearing loss, but actually only one out of 84 medical textbooks even mentions hearing loss and asking a patient if they have hearing losses only somewhere between one and 51% accurate. Even bedside screenings are not that accurate so five to 61% accuracy on a screening done in your doctor's office. Probably that big variation is probably related to kind of the variety of screenings. Remember, starting a job once and as an audiologist, and I had a physical as part of the, the entrance to that job. And I really had to laugh when the physician who was examining me walked across the room eight feet and said, can you hear me whispered to me. And that was his hearing screening so obviously that's not going to be the most accurate hearing screening, maybe screening with an actual test would be a little bit more sensitive hearing loss is both under diagnosed and under treated. 9% of internists offer hearing tests for patients age 65 years and older, and 25% of hearing impaired older patients who could benefit from hearing aids use them. So when we think about this really low number of people that are having hearing tests Medicare does have a recommendation that when you enter Medicare, your hearing should be screened. Again, what kinds of screening is kind of left up to the physician and hearing loss is under treated. So, this graphic looks at different degrees of hearing loss so when we look at hearing loss we talk about how severe it is. So we have 75% of people with hearing loss fall in the mild to moderate hearing loss range. 20% fall in the moderate to severe range, and only 5% fall into the profound range or sometimes we call it residual hearing because they just have a little bit left. And when you look at those groups, and you look at how many of them have hearing aids, you see something else. When you look at the profound group, 70% of those patients do have hearing aids and probably the 30% who don't, don't because their hearing aids don't help them at all, or perhaps culturally they've decided to rely on sign language and not hearing aids. When you look at the moderate to severe range, 50-50. So these are people that really have very poor access to speech, yet only 50% of them use hearing aids. And when you look at the mild to moderate population, only 10%. We're going to come back to that mild to moderate population at the end when we talk about hearing aids and we'll touch also on the news with over-the-counter aids as well. So hearing aid adoption, how many people use hearing aids? Hearing loss affects millions. One in eight people in the United States age 12 years or older has hearing loss in both ears based on a hearing test. 28.8 million U.S. adults could benefit from using hearing aids and men are twice as likely as women to have hearing loss among adults age 20 to 69. When we look at adults age 70 or older with hearing loss, who could benefit from hearing aids? Fewer than one in three has ever used them. And that's a pretty low number. Why? Let's talk about some of the barriers to treatment. First of all, a lot of people who have hearing loss don't know that they have hearing loss. So there's a lack of recognition that their hearing loss exists. Second, there's a perception that hearing loss is a normal part of aging. Well, if you by normal, you mean that it's fairly common. That is true. But if by normal, you mean that it's something you need to accept and live with, that is not true at all. And then there's the fact that even sometimes patients who do have hearing aids don't or are recommended to have hearing aids don't buy them or don't use them. And there's a lot of different reasons. Stigma, cost, inconvenience, disappointing initial results, and there are some other factors. Here's a survey that looked at adults ages 35 to 65 years who had hearing loss and asked them, why don't you wear hearing aids? 35% say they don't want to admit that they have hearing loss in public. I often tell my patients and another 30, again, 35% said that they were too noticeable. I often tell my patients, you may think that hearing aids are noticeable and they're not very noticeable today. But you may think that they're noticeable, but you know it's even more noticeable when you can't hear. So trust me, the people around you are realizing when you say, hmm, I didn't get that or trying to guess they're noticing. But yet 34% of people are too embarrassed to wear their hearing aids. 31% think that hearing aids make them look disabled and old. 29% are too proud to wear their hearing aids. 29% think people will make fun of them or treat them differently. 26% think that hearing aids make you look weak and feeble. 22% say that they think people will treat them differently and think that mentally they are slow. All right, let's pause for a moment and talk a little bit about dementia and I don't claim to be an expert in dementia and really talking primarily about the overlap I just want to talk about a little bit of some of the statistics. 1.7 million Americans over age 65 have cognitive impairment. So there's a 10% prevalence that is estimated and that means that one in four people think about the group attending this this talk today. One in four of us knows somebody with the disease, and one in 10 has a relative with the disease. 60 to 80% of long term care residents so that means people in nursing homes other long term facilities have dementia. Yet, only half of the people who actually have dementia are diagnosed, and only half of those diagnosed that means a quarter of the total receive treatment. There's a Lancet commission model that talks about some of the risk factors for hearing loss, and what it does is it divides the risk factors look at the bottom right corner into potentially non modifiable risk modifiable risk factors so risk factors that you can't know anything about and potentially potentially modifiable risk factors, and there are 35% of the risk factors for dementia that are things that we may be able to do something about that sounds good. If we look at early life. There is a gene that perhaps can be avoided with pre implantation genetic diagnosis or something like that. That is one 7% respect 7% have that risk factor. We can reduce the risk that way 8% less education so when we take our children and we send them to school and they say why do we need to learn this one of the reasons is because the more education that you need to get the more education that you have. That decreases your risk for dementia later in life. I'm going to skip down to the later in life ones. And these are kind of the things that even when you're at the age where dementia is diagnosed you can still do something about it. And that is smoking, depression, physical and activity, social isolation and diabetes, all things that increase your risk for dementia and something that you can do something about. So let's go to the mid life. Factors, and those are obesity, hypertension and hearing loss. What's really interesting is that hearing loss actually has 9%, which is the highest percentage reduction in new cases of dementia, if the risk is eliminated. So let's talk about hearing loss, compared to all the other modifiable risk factors that we can have the biggest impact by treating hearing loss. Okay, so now let's talk about hearing loss and dementia together. So just overall dementia is more common among people with untreated hearing loss, people with untreated hearing loss tend to develop cognitive decline earlier than peers with normal hearing. People with untreated hearing loss report more concerns about their memory than people with normal hearing. Let's look at some of the symptoms. So, first let's look at some symptoms of dementia and for each of these you see there is a reference of a study that showed this. So, with dementia there was increased social isolation, decreased comprehension, inability to understand, repeating questions, short term memory problems, stereotyped inappropriate word use, so using words in an inappropriate way, this is some difficulty following conversation. Symptoms of dementia. Now look what happens. We can put right next to that symptoms of untreated hearing loss. And again, different studies, but found similar things for this other diagnosis of untreated hearing loss. So, social isolation again, decreased understanding, repeating questions, working memory problems, stereotyped inappropriate word use, and difficulty following conversation. Fascinating. So, two things, dementia is more prevalent in patients with hearing loss. And hearing loss is more prevalent in patients with dementia. Let's look at some of the research that looked at that. First of all, there was a study that looked at self perception of hearing loss. And it looked at how much hearing loss did you have to have in order to notice it and it looked at two different groups it looks at looked at hearing loss in the mid frequencies. So that would be sounds like P's, T's, K's, G's, and then high frequency hearing loss. So that would be more sounds like S, F, TH, SH. And it found that if you're hearing loss in the mid frequencies was at around 16 decibels, give or take, 10. You had a likelihood to deny that you had any problem. Whereas if you had a hearing loss in the 23 decibel range, then you probably would notice it. With higher frequency hearing loss, you actually need to have more hearing loss to notice it. So even if your hearing loss was as poor as 33 decibels, there was a tendency to deny hearing loss. And however, once it reached like 46 decibels, then you would notice it. And when we look at take that study together with this information and we look at whether you noticed your hearing loss and whether you noticed a trouble with hearing. And what we see is that this last group over here, those with more high frequency hearing loss had a real tendency to also notice cognitive dysfunction. Here we look at an adjusted odds ratio. So how much more likely are people with hearing loss to have dementia. And we see that they are more likely, even with mild hearing loss, 1.5 times more likely to have dementia. So that as the hearing loss get worse, the odds of having dementia get become greater. So with moderate mild hearing losses of 1.5 adjusted odds ratio moderate hearing loss 2.2 adjusted odds ratio and moderately severe 4.1 adjusted odds ratio. And what they did in the study was they did adjust that odds ratio for some other factors family history of dementia depression diagnosis their number of medications, lots of different things, and they still were able to show this very clearly. And the reference for that is in the lower right hand corner. Now let's look at it the other way let's look at patients who are already diagnosed with dementia. So this study by Weinstein and her colleagues. At patients who already had a dementia diagnosis so this was an institutionalized elderly population probably in a nursing home, and they reviewed all the patients with a dementia diagnosis, 83% of them had at least mild hearing loss. So here was another study that looked at patients in a memory disorder clinic, 52 patients 30 had a probable Alzheimer's disease diagnosis 22 had other cognitive impairments, and then they screen their hearing 49 of the 52 failed the hearing screening so hearing loss is much more common. When we look at older individuals with memory disorders than in the general population of adults. Very interesting factor. So one of the tools that is very commonly used in dementia diagnosis is a test called the mini mental state exam examination, MMS E. And it's very commonly used by 77.1% of psychiatrists and 90% primary care physicians that are screening for dementia in their offices. This is what the test looks like. It's a long test it's just a screening, and it asks some questions to the patient it asks them if they know what where we are date time day of the week. It asks for some memory questions. It asks them to repeat a phrase no ifs ands or buts. It asks them to copy a picture. There's a problem with this test. The problem with this test is that people who don't hear well, have poorer scores on the MMS E. And so that means that they can end up with either a misdiagnosis or more commonly with a diagnosis of more severe dementia than they truly have. So many Jorgensen colleagues simulated hearing loss into five groups that there are four hearing tests pictured here those were for the groups and then the fifth one was normal hearing. And using these fake audiograms, they were able to calculate what percent of speech sounds patients with this type of hearing loss would have access to, and how that would affect their scores. What they found was that patients who had high speech intelligibility index scores so in other words they were able to hear most of the speech sounds. 0.99 out of one. Right, they could hear most of them. They had a most they were most likely to have normal cognition on the test, maybe some mild dementia patients who had 0.42 so a little less than half of access on their speech intelligibility index. Well, most likely to have normal cognition, maybe some mild or moderate dementia. But once the scores fall even lower you start to see more and more dementia correlated with the hearing loss. This study by Jorgensen took 100 patients. And of those patients reviewed their charts 13 patients of the 100 were asked if they had hearing loss these are patients who were being evaluated for dementia so they're having their initial evaluation to see if they have dementia 13 of the 100 patients they looked at were even asked if they had any hearing problem. Of those patients who were asked, three of them said yes I do have hearing loss and 10 said I do not. 87 patients were not even asked. Six of those did have hearing loss, 81 had never been diagnosed or reported hearing loss. And of the six who had been diagnosed with hearing loss to had hearing aids and for did not report hearings. One more study. So hearing loss and dementia diagnosis. This is again an institutionalized elderly population reviewed the charts, 83% had at least mild hearing loss. And here's what they did. They retested their mental status, but this time they gave them a personal amplifier a little device that just made things a little bit louder like a microphone. And they redid the tests that they had been given maybe it was the MMSC. And they found that 33% of patients were reclassified to less severe dementia so really made a difference for them to hear the test better, which makes perfect sense. What can we do about it. Well, one thing is, maybe we need to start using different tests. This test is called the mocha stands for Montreal cognitive assessment. It's much less affected by hearing. It's one thing we can do. Another thing we can do is when we are diagnosing patients with a diagnosis of dementia we can make sure to check their hearing first and address their hearing loss before we lock in that diagnosis and the severity of the cognitive disorder. Okay, so so far I think what we've proven and what we see over and over again in the studies is that hearing loss and dementia coexist. But coexisting. A lot of things coexist and it doesn't mean that one causes the other doesn't even mean that one affects the other they just might both be present. Maybe there's more. So why do hearing loss and dementia coexist. And there are three theories. The first theory is the cascade hypothesis. Second one is called the common cause hypothesis, and the third is common burden, cognitive burden just want to talk about those briefly. The cascade postulate is that prolonged reduction in hearing function leads to insufficient stimulation. I can't hear, and therefore I'm not being stimulated. So the auditory deprivation cascades into decreased social interactions impoverished cortical sensory input, we are not stimulating the brain and the decreased interactions cascade into cognitive decline. So little cycle. We have the inability to communicate successfully. And because of that, it's not very much fun to participate because there's a lower award. And because of that, there's withdrawal from social activities. Susan Pinker has a TED talk, and she talks about the secret to living longer. And guess what the number one factor that is a secret to living longer social integration. And she talked now about social isolation a little bit and its effects. So there was a health omnibus survey survey in in Southern Australia, and they looked at the likelihood of self perceived social isolation. And they saw that it increases with the number of chronic conditions so if you have a lot of stuff going on, you're more likely to be socially isolated okay that makes sense. And they found that the strongest association with social isolation was depression. Sure, you're feeling depressed you're not getting out of bed to go anywhere. But the second strongest correlation was with self reported hearing difficulties. So hearing impaired older adults are at increased risk of experiencing emotional distress and restrictions and social engagement after five years. Hearing ability and noise is significantly associated with incidents social and emotional loneliness. Self perceived hearing handicap and difficulty understanding distorted speech relate to loneliness and social isolation. Finally, emotional loneliness increases with hearing decline among persons who have recently lost a life partner hearing aid use has a protective effect. To use hearing aids, we don't see it as much, but only among non hearing users does poor hearing lead to more loneliness. Okay. And finally, also with the cascade postulate. Marani and Dawes and Nazru found a decline in episodic memory. So memory skills were declined. And that led to more cognitive decline a higher rate of cognitive decline for people with hearing loss and less a slowing in the rate of that decline. Once they began to use hearing aids. So, when we look at modifiable risk factors for dementia. We know that we can improve the risk for dementia. If we increase social isolation, and we know that we can increase social isolation by providing help for hearing aids with hearing aids. So, second theory is the common cause postulate common cause postulate says that maybe one doesn't cause the other, but maybe the loss of input from hearing loss, combined with cognitive decline from dementia are coming from the same neuro degenerative process in the aging brain So as we get older, some common cause is causing some degeneration in the brain, and that is affecting both hearing impairment and cognitive decline. Unfortunately, according to that hypothesis hearing aids may not affect cognition because if we're seeing an overall common cause, then we might not see any improvement. I thought this was a cute little picture that talks about cognitive burden brain overload and we all experienced this sometimes that when we are trying to do too many things at once, each task becomes difficult. So if we give somebody difficulty with hearing and difficulty with cognition together, we're going to see more difficulty and we can think about it this way. So how hard I have to work in order to listen is going to be affected by these three factors, the motivation. So do I want to hear my spouse telling me to take the garbage out. Tognitive demands. It's somebody boring me like I am with lots of statistics and dry information. And acoustic challenge. Let's talk a little bit about what acoustic challenge means. So acoustic challenge has three specific aspects, we have acoustic challenge to the listener to the speech itself and to the environment. So acoustic challenges to the listener are like you have a hearing problem. Maybe you're not so good at the language that you're listening in. Maybe your processing of rapid information is, is impaired that's what temporal processing means so your ability to, to hear things when they're fast is affected. So those internal deficits are the acoustic challenges to the listener, but there are also acoustic challenges to the listener to the speech. So if your person that is speaking has an unfamiliar accent under articulation is a real fancy way of saying the person is mumbling and or an unfamiliar speaker, those are also going to be acoustic challenges. And finally there are the acoustic challenges to the environment. So those are going to be things like background noise, competing speakers to people speaking at once, five people speaking at once. And whether an assistive device is being used. So those are going to be your environmental acoustic challenges. So, what happens when we have more effort and listening, maybe you're listening to this and you're saying well that's okay. People can work hard there's nothing wrong with effort. I don't mind working a little harder than I, than I have to. Well, when we look at listening effort and when listening effort goes up, we see a couple of things. First of all, neuro imaging actually shows the brain actually working harder. So you can see that we also could see some physiologic changes so when people are working really hard to listen their pupils dilate, we see them sweating through a galvanic skin response. We see the stress hormones go up and behaviorally we also see changes we see that if they're listening really hard. They can't their memory gets compromised. They can't answer as fast the response time slows down. And again, it's just more effort. I want to talk about from a practical sense. How can we help. And I want to talk about three things today, want to talk about an early memory loss program, want to talk about hearing aids, and I want to talk about some listening strategies. So, a early memory loss program is for patients who have a diagnosis of mild cognitive impairment or dementia. They may still be working or driving but the memory loss is starting to impact performance. So maybe the patient, or maybe the patient doesn't realize in their family is noticing that the patient is forgetting to take medications they're missing appointments they're have difficulty managing their finances. So this type of program might have 12 sessions I'm going to talk about one program in specific 8 to 12 week program, it's going to be highly customized because everybody's cognition is a little bit different, everyone's needs are a little different so we have to be patient and family centered, but the early memory loss program is going to teach strategies, which can be used to improve. To, to get better at the things at the deficits so it's going to be things like using a calendar bill pay medication management tasks, activities of daily living and cooking. So, I'm going to talk specifically about the program at JFK. I've been working at JFK for 15 years before I came to Old Bridge, and the speech pathology department there has a program for early memory loss, and they stimulate in the areas of memory word finding word fluency and problem solving. And they have found that eight out of eight patients. This was their initial assessment I think it's much bigger now have shown improvement in word finding and communication skills as demonstrated on pre and post post test with the mocha in order to participate with that program. You do need a prescription from your physician. And if anyone needs more information, I can provide that. Okay, let's talk about hearing aids hearing aids come in many different shapes and sizes. But first, do hearing aids even help. And the answer is yes, I think that sometimes hearing aids get a very bad rep, possibly because people have expectations of having their normal hearing restored. And in actuality even the best fit hearing aid probably won't do that, but still hearing aids can definitely make a difference in this graph. We look at quality of life. And by degree of hearing loss, and you can see that as the hearing loss gets into even just the mild range there is an improvement of quality of life with hearing aids versus the lower line which represents without hearing aids. Okay, and this is I think the research that has really taken taken the news by storm, and that is hearing aids and cognitive decline. So here you see a graph, and the graph is showing the memory score and the age, and you see that as the person gets older their memory is declining and there's a very defined slope to that decline, certain amounts of memory decline as we age, but look what happens, we put hearing aids on. And as the patient got a hearing aid, we can see that the slope of the progression really changes. So is the cognition still declining, it is still declining, but at a much slower rate. So even though time is still passing, we haven't continued at this steeper trajectory, we have less progression over time. But are hearing aids appropriate for patients with cognitive impairment? Let's talk about pros and cons. The problem is that patients with cognitive impairment have trouble doing new things. So, giving them something new to master and learn how to work with can be very difficult. There are hearing aids today are extremely complex and sophisticated and sometimes the accessories and the features can be difficult for patients. And these are patients that lose things and hearing aids are expensive to lose them so will they be lost. On the other hand, we have improved communication, increased socialization, which we know is super important, increased brain stimulation also super important. So in general, it's going to be the level of the dementia that is going to predict the success with standard hearing aids. So patient with a mild cognitive impairment will usually be successful with hearing aids. Maybe they're going to need a little bit extra support, but they will be successful. When you get to the patients with severe cognitive impairment, they probably won't be able to use a standard hearing aid. Although sometimes I see that the patients who've been wearing them for years, they're already used to it and they define, but they might be able to use some simple alternates. Definitely want to choose the right hearing aid. So you want to choose a hearing aid that's easy to insert, that is simple. There's even research that suggests that even the automatic features of the hearing aid should not be making so many changes for patients with cognitive impairment. When you worry about losing hearing aids, there are things called retention clips, which basically tether the hearing aid to the patient so it's not as easily lost. And of course, the caregivers of the patient need to be engaged because they're going to take the primary role. Here's a little question I found online. Somebody asks, my mom, 86 recently moved to assisted living and lost her hearing aid the first week. She's 86. Very hard of hearing for vision and dementia. I'm working on replacing your hearing aid and they say she needs to now because her hearing is so bad. Her dementia has worsened since the loss of the hearing aid and of course, some of it could be the new assisted living environment. It's probably both. I'm worried she's going to lose her new one. How can I prevent or reduce the chances of it being lost? She does wear it all the time except for sleeping and bathing and I'm going to say that's a really important thing because losers, which is what I call patients who lose their hearing aids, often tend to not wear their hearing aids consistently. Because when you wear your hearing aids consistently, it's much harder to lose them. Think about people with glasses. People who wear glasses only as needed, constantly losing them. People who don't step out of bed without their glasses do not lose their glasses because they always know where they are. So wearing it consistently is definitely a big part of the battle. Like I said, tethering the hearing aid is probably a good one. And ultimately, for a patient like this, I would always suggest making sure that your hearing aid is insured. Because if you do lose it, you'll be able to replace it. So keep it under insurance. And that one thing I definitely want to talk about because it's made a lot of headlines is over the counter hearing aids. And the difference between it over the counter hearing aid and a prescription hearing aid. So, first of all, generally over the counter hearing aids by definition are being fit by the patients themselves, whereas a prescription hearing aid is going to be fit by a licensed audiologist, hopefully or hearing a dispenser with lots of training in how to do that well. It varies. So certainly over the counter hearing aids are going to be less expensive overall usually less than $1000 for a pair, whereas prescription hearing aids are going to range pretty big range depending on the technology that you choose. When you look at what ages can be fit with over the counter hearing aids, they're only for adults, whereas prescription hearing aids can be for all ages. So this is a degree of hearing loss over the counter hearing aids are only for mild to moderate hearing losses. Remember that slide way back in the beginning where we said only 10% of patients with mild to moderate hearing loss have hearing aids. Great, let's get those patients over the counter hearing devices so they can see that it makes a difference. Ultimately, if the hearing gets worse, or once they see the difference, they may want a better hearing aid and then they could always change if they need to. Prescription hearing aids have lots of options as far as style, whereas over the counter hearing aids are always one size fits some. And return policies are mandated for prescription hearing aids, but not for over the counter hearing aids so buyer beware on that. And I think one of the very important aspects of fitting hearing aids is hearing aid verification so hearing aids should always be fit and verified and that means that a microphone is placed into the patient's ear with the hearing aid to measure the levels and to optimize the settings and if that's not done as part of the hearing aid fitting, you really run the risk of having a hearing aid that is not fit well, and then is not as helpful. Again, we talked about the degree of hearing loss, and as far as the counseling and selection process, obviously you're going to get a lot more when you get a prescription hearing aid. So those are the differences and if you want to know what you're paying the extra money for, that's what it is. There's also something even not quite an over the counter hearing aid called an amplifier so an amplifier, unlike an over the counter hearing aid is not FDA approved. There are even lower costs than a traditional hearing aid and maybe even lower costs than over the counter hearing aid. And they can be ordered through the mail. They might be in a drug store. There's very few adjustments that can be made and there's also limited research on performance and safety. But sometimes it's necessary. Sometimes, you know, the patient is very demented and won't keep anything in their ears, but you can put an amplifier into their ears when the doctor comes to talk to them so that the doctor can have a conversation with them. And just for that limited time and then take it off so sometimes we do find that these can be very helpful tool. I also want to talk about listening strategies because there are a lot of strategies that can be used to optimize listening. So these are things that people with hearing loss wish that others understood. First of all, I can't hear you if you cover your mouth. So make sure that I can see your mouth when you're speaking. I also can't hear you well if you don't face me. Please turn around. I can't hear you if you mumble. I explained to patients that cleared speech. It's the kinds of speech that you use when you're giving a speech, a little bit slower, not distorting the words but just a little bit slower and enunciating everything. And also speak one at a time. Your family is anything like mine that doesn't happen at family gatherings, but that makes it really difficult for patients with hearing loss to understand. They really want to get the listeners attention before starting the conversation. So don't just jump in with your question but first get their attention and make sure they're listening. Also giving people the topic of conversation can be really helpful. You want to use a normal volume so you don't want to shout because shouting tends to distort the speech. And you also want to be very aware of background noise. So if it's noisy. I often encourage my patients to use the magic words. The magic words are, I really want to hear what you have to say. So the magic words, and then they should be followed by, here's what you can do to help me. So I really want to hear what you have to say, let's move away from the band. I really want to hear what you have to say, can you say it again now that I'm paying attention. People are willing to help you when they know you want to listen. If you're the person who has the hearing loss there's some things you can do as well. So first of all where your devices. Second of all, like I said, tell the speaker what tips will help you understand. Don't bluff to very tempting to try to guess or pretend you heard what was being said, but it can really get you in trouble. So better technique is to confirm what you heard. Thank you said, and that will set a realistic goal for understanding. So that is the end of my talk, lots of references here. So again, thank you Dr cater and all the participants. And again, please reach out with any questions to Dr Peter. Thank you very much Kalen for setting this up and happy better hearing and speak once to everybody.