Hearing & Cognition
Long-term care facilities are paying greater attention to residents’ hearing health.
By Pam Chwedyk
Meeting the needs of residents with hearing loss and residents with dementia are two of the biggest challenges in long-term care, both for facility administrators and nursing staff. But those challenges have been compounded over the past 20 years by a steadily growing body of scientific evidence indicating that hearing loss and loss of cognitive functioning are somehow connected – even though researchers are still trying to figure out what exactly that connection is.
The latest pieces of the puzzle emerged in 2011 from the Baltimore Longitudinal Study of Aging (BLSA), the nation’s longest-running scientific study of human aging. Researchers, led by otolaryngologist Frank R. Lin, MD, PhD, of the Johns Hopkins Center on Aging and Health, analyzed hearing test and cognitive test data for 640 BLSA participants over a 12-year period. The result was the first-ever finding of a direct, independent association between hearing loss and diagnosis of dementia.1 Subsequent studies conducted by Lin in the BLSA and in other aging datasets have revealed similar associations between hearing loss and poorer cognitive functioning,2,3 as well as rates of cognitive decline.4
The risk of developing dementia also increases exponentially with the severity of hearing impairment, Lin and his team discovered. Compared to individuals with normal hearing, the dementia risk for people with mild hearing loss is about twice as high; for severe hearing loss, the risk soars to nearly five times as high.
When it comes to understanding why hearing impairment and cognitive impairment are so closely linked, investigators are still in the dark. Is hearing loss a marker for early-stage dementia? Or is it a modifiable risk factor that, if treated early, could help delay onset of the disease?
“At this point, we just don’t know,” Lin told ADVANCE. “Much more research still needs to be done to determine what the relationship is.”
However, his study includes some intriguing theories. For example:
- Depletion of cognitive reserve. For many older people with hearing loss, the problem is not that they can’t hear speech but that they have to struggle to understand it, due to their inability to hear certain sounds clearly. It’s possible that years of having to dedicate brain resources to auditory processing at the expense of other cognitive processes, such as memory, eventually takes its toll on the brain.
- Social isolation. Hearing loss makes it harder for people to engage with the world around them and participate in conversations and social activities. This can lead to or exacerbate social isolation in older adults, which in turn is associated with increased risk of dementia.
Developing a Hearing Health Plan
It may take years to unravel the mystery. But in the meantime, these findings provide a powerful incentive for LTC facilities to rethink the way they manage hearing loss.
“The focus,” said Lin, “has to be on getting comprehensive, effective hearing health programs in place, based on the knowledge that hearing loss, especially if untreated, could contribute to other negative outcomes – including negative cognitive outcomes – down the line.”
This is especially crucial in LTC because the prevalence of severe hearing loss in this population is disproportionately high compared with other older adults. Yet Lin, an assistant professor at Johns Hopkins School of Medicine and Bloomberg School of Public Health, believes too many facilities are not doing enough to address the issue.
“Audiology services are very underutilized in LTC,” he said. “Facilities need to have more awareness of these services and work with audiologists to assess, identify and treat hearing loss in residents.”
An audiologist can initially diagnose residents’ hearing problems and get them fitted with hearing aids. But, Lin cautions, hearing aids by themselves aren’t enough. “There is still too much of a perception that all you have to do is put in a hearing aid and the person is all ready to go,” he says. “It has to be part of an all-encompassing hearing rehabilitation program.”
Educating frontline staff is also key. “Nurses, nursing assistants and other direct caregivers need thorough education about what hearing loss is, how to recognize it in residents and how to respond to it effectively,” Lin emphasized. “LTC nurses receive a great deal of training in how to care for residents who have special medical needs, such as diabetes. But when it comes to treating hearing loss as a special need, the awareness and training aren’t there.”
Another advantage of working with audiologists is they can provide staff training services. In addition, the American Association for Long-Term Care Nursing offers an affordable online Understanding Hearing Loss continuing education course designed specifically for nursing assistants.
Closing the Hearing Loophole
Lin also advises LTC facilities to become familiar with assistive listening device (ALD) technologies, such as personal listening systems, which pick up where the limitations of hearing aids leave off.
“The ‘dirty little secret’ about hearing aids is that they only work for sounds that are up close,” he explained. “If you’re wearing a hearing aid and you’re sitting at the back of a crowded room trying to listen to someone speak, it’s not going to be much help.”
Lin especially recommends the use of hearing loops, a technology that’s widely utilized in Europe yet has been surprisingly slow to catch on in the U.S. A hearing loop is a wire that is installed around the perimeter of a room and connected to a sound system. When hearing aid wearers enter the room, they flip a switch on their device to pick up the loop’s signal. This allows the loop to magnetically transmit amplified sound directly to their ears.
EPOCH Assisted Living at Boylston Place, owned and operated by Waltham, MA-based EPOCH Senior Living, is the first assisted-living community in Massachusetts to use a hearing loop system. The community installed one in its auditorium in 2011 to help residents who were frustrated by not being able to clearly hear movies and presentations. The response was so positive that EPOCH plans to implement the technology in some of its other communities.
“It was very simple to install,” said Julie Bolt, the community’s marketing director, who spearheaded the project. “All we had to do was put a copper coil into the ceiling and hook it up to the sound system.”
Hearing loops can be particularly cost-effective for rooms that already have sound system equipment in place. “Installing it in our theater was relatively inexpensive because we just dropped it in and connected it to the existing equipment,” Bolt explained to ADVANCE. “Then we had to buy a few pieces of additional equipment, but it wasn’t that bad in terms of cost. If you have to put in a whole new sound system, that’s when it becomes more expensive.”
For facilities that are willing to make the investment in their residents’ hearing health, the results are worth it. According to Lin, “this technology is just tremendously effective. For people with hearing loss, the difference is like night and day. You walk into the room and suddenly everything sounds crystal clear.”
- Lin, F.R., et. al. (2011, February). Hearing loss and incident dementia. Archives of Neurology, 68(2), 214-220. Retrieved Aug. 13, 2012 from http://archneur.jamanetwork.com/article.aspx?articleid=802291
- Lin, F.R. (2011, October). Hearing loss and cognition among older adults in the United States. The Journals of Gerontology: Series A, Biological Sciences and Medical Sciences, 66(10), 1131-1136.
- Lin, F.R., et. al. (2011, November). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology, 25(6), 763-770.
- Lin, F.R., et. al. (in press). Hearing loss and cognitive decline among older adults. Archives of Internal Medicine.
Pam Chwedyk is a frequent contributor to ADVANCE