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Using Cognivue to Navigate Cognitive Dysfunction in Patients with Hearing Loss
Taylor Spurgeon-Hess • Feb 1, 2022 • 54 hits
With a steady rise in life expectancy, new challenges face medical professionals as they attempt to navigate conditions that become more prevalent with age. While hearing loss on its own creates a diminished quality of life for the patients it affects, comorbid cognitive dysfunction introduces a whole new set of challenges. Otolaryngologists in particular are having to engage in difficult conversations with patients and families about cognitive dysfunction, and are required to set realistic expectations after taking cognitive decline into account. Despite these challenges, cognitive testing as a part of audiologic care may positively influence treatment plans and facilitate better outcomes for patients.
This article features excerpts from the BackTable ENT Podcast. Otolaryngologist Dr. Jed Grisel shares how he utilizes Cognivue cognitive testing to help increase quality of life for hearing loss patients at his clinic. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Adaptive and self-administered testing devices, such as Cognivue, can easily and efficiently measure cognition in-office, and can screen for cognitive dysfunction in patients.
• Cognitive testing may be offered in an ENT clinic to help recognize deficits and allow the topic of cognition to enter the conversation when addressing hearing loss in patients. Often, patients’ cognition scores improve after their hearing loss has been properly addressed and treated.
• In patients with hearing loss, the strain of attempting to process degraded sound signal increases the cognitive load on the brain over time, and this can lead to a decrease in cognitive function, which may be reversed if the hearing loss is addressed.
• Patients with severe cognitive decline may not see cognition improvements upon treatment of hearing loss, but setting clear expectations with the family may help to prepare them for the nuances of this comorbidity.
Table of Contents
(1) The Utility of Cognitive Testing in Hearing Loss Patients
(2) Auditory Function and the Impact of Cognitive Load
(3) Difficult Conversations Surrounding Cognitive Dysfunction
The Utility of Cognitive Testing in Hearing Loss Patients
An increasing volume of research points toward a link between cognitive dysfunction and hearing loss. Accordingly, some ENT offices have implemented in-office cognitive testing for their at risk patients. While some otolaryngologists and audiologists may express skepticism, due to the added challenge of discussing a cognitive deficit with a patient, many physicians stand by the utilization of devices like the Cognivue which can provide self-administered, adaptive tests to patients. This provides a baseline for cognition and can guide treatment by indicating whether or not to involve other specialties in care, such as primary care or neurology. Often, when a patient’s test results indicate cognitive decline, treatment for hearing loss can improve their cognition and the metrics can be monitored through the testing software. If their cognition fails to improve, the patient can work with their primary care physician, while the problem is still mild, to address potential other causes.
[Jed Grisel MD]
And that's kind of an interesting challenge because it's not in our scope of practice either within ENT or audiology. To be diagnosing dementia. I think this is a really important thing, and some of the people that are skeptical with doing cognitive testing in the office, they're like, well what if we find a patient that has a deficit, what do we do then? And it's very nerve-wracking for the audiologist. And so what we're finding is that there's a small percentage of patients that have normal cognitive function and they have hearing loss. Okay. And so those patients, obviously we treat their hearing loss and that's fine.
And then there's a group of patients who, most of our patients, because we only do this cognitive screening on patients who are considering an intervention. So most of the patients, they have some level of hearing loss and they have some level of cognitive decline, they're performing that well, that's most of our patients. And so the first thing that we do is we know that hearing loss and cognition are related through a lot of different studies. And so we treat that, we treat their hearing loss then, and then post-intervention. And our definition of post-intervention is 60 days for a hearing aid and six months for a cochlear implant. So post-intervention, we do another assessment. If the patient's cognition has improved then great. The patient’s excited, we've reduced their cognitive load. They can perform mental tasks on a daily basis better. And everyone's happy. If they struggle, then we have a list of health problems that can present as cognitive impairment and it's like a form letter and we send that to their primary care physician. And that form letter, it's got, thyroid dysfunction, depression, interestingly can present as mild cognitive impairment. There's a whole list of these. But also polypharmacy. If you look at the list of medications that can cause cognitive impairment, I mean, it's a lot, we'll just say. So we created a list of the most common of these. And if at the very minimum we help the patient go to their primary doc and clean up their meds so that they don't have quite this problem with polypharmacy, then I think we've done good for this patient, you know?
[Walter Kutz MD]
Yeah, Jed, what automated machine do you use for the cognitive screening? What's the name of it?
[Jed Grisel MD]
The name of the device that we use is called Cognivue. This is a company that has been around. I mean, so the technology has been around for a long time. It was actually some NIH work that created the science behind the testing. And then only in the last couple of years, has it been commercialized.
And so this is, it's like I mentioned, it's sort of a kiosk format that the patient sits in self-administered and it's, it's what they call adaptive. And so what that means. The first couple of tests on the Cognivue are learning how the patient is going to respond. So it checks their dexterity and their vision. And if they are not performing well, then the test gets easier. Like when it actually gets to the real cognitive test. And if the patient is knocking it out of the park then the tests is harder. So it's like adaptive to meet the needs of the patient and there've been multiple studies validating this test in multiple ways, from a test retest reliability to comparing it to other validated measures on the market. And so it's kind of a big player in the cognitive screening arena.
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Auditory Function and the Impact of Cognitive Load
Patients with hearing loss face a higher risk of conditions such as dementia and depression, and current theories address the mechanism by which this occurs. The idea of cognitive load may help to explain how a condition like hearing loss could lead to dementia. Dr. Grisel relates cognitive load to an overloaded computer, and explains, “Our brain is like a computer and there's only so much processing power, like your RAM, there's only so many things that your brain can do at any given time.” When the brain allocates resources to hearing, despite a degraded sound signal, instead of using those resources for day to day activities, it follow that patients would experience the fatigue and exhaustion that has been reported in cases of hearing loss with cognitive decline. The stress on the system ultimately takes a toll on the patient, and this helps to explain why often after treating the hearing loss, the cognition scores greatly improve and the exhaustion decreases.
[Jed Grisel MD]
Yeah, there’s a lot of research right now trying to understand. We know that patients with hearing loss have higher risks of dementia and they have a higher risk of depression and falls and these different things. But understanding how those are related is really important.
And so there's these different theories, these different mechanisms and one of those, that relate how explicitly does someone who has untreated hearing loss lead to dementia. And so one of those is this idea of cognitive load. And I think the way that I explained this to my patients is that our brain is like a computer and there's only so much processing power, like your RAM, there's only so many things that your brain can do at any given time.
And so, being able to process a degraded sound signal, if you've got hearing loss and there's this degraded sound signal, coming to your brain. That requires more energy by your brain and it uses more cognitive resources than it does somebody who's got normal hearing. And so cognitive load is this idea that you have to have cognitive skills and mental abilities to go about your day and do your activities. But then you also are using some of those resources to process this degraded sound signal. And of course, we've all seen these patients that, by the end of the day, they're exhausted.
They have that listening fatigue and they're exhausted. And so cognitive load is this idea that you're stressing the system and over days and weeks and months and years, that cognitive load is just taxing the resources of the brain. And so we've seen this, I mean, we had a patient recently who scored, below 50%. So just how this test works, the cognitive test works, that it measures three different domains of cognition: working memory, executive function, and visual-spatial processing. And we had a cochlear implant patient that was actually quite young, for a cochlear implant patient. I think in her fifties. And she was always so exhausted at the end of the day and tired. And we treated her with a cochlear implant and her preoperative scores were below 50%, on every one of those domains. And so then in six months we repeated the test and the patient was doing well and she was excited that she could hear and participate in her life. But having that number to show her that look now your executive function and your working memory and your visual-spatial process, they were all in the normal range, which is over 75%. Now there's a lot of skeptics who will say, well your cognition can change from day to day. If you come in and you're tired and you didn't sleep well, your cognition can be poor.
But over time, if we measure this a lot on every patient, we start to see these trends and it gives us a number that we can show the patient. We say, this is part of the reason why you feel better because your brain is not having to work harder than it should be. To perform the tasks that you do during your day. And so it really kind of reinforces for the patient with real data that they're on the right track.
Difficult Conversations Surrounding Cognitive Dysfunction
In patients with both severe hearing loss and dementia, treatment options and expectations may differ significantly from patients who only have hearing loss. Oftentimes, treatment still includes placing a cochlear implant, but patients with cognitive decline can expect a lower performance than those without. Additionally, determining which aspects of a condition are hearing loss related and which are cognition related can be enigmatic in patients who fail to engage in their environment. Speaking to families about these unique challenges often proves difficult. Often, the best way to address these difficult conversations revolves around setting clear expectations upfront. Physicians may benefit from explaining that placing a cochlear implant remains a safe and established surgery but in some patients, especially those with cognitive decline, it may not help to substantially increase hearing in both noise and in quiet. This can go a long way in managing the dialogue with a patient’s family.
[Walter Kutz MD]
Yeah, let's talk a little about the patient, with more severe to profound hearing loss, maybe they have early dementia. and then the family comes in and then you're talking about, “Hey, your loved one,” or you’re talking to the patient, “you're probably a cochlear implant candidate at this point.” And then there's some worry about general anesthesia and, worsening dementia by undergoing general anesthesia. And then you kind of balance that with placing a cochlear implant. And we know that patients with dementia probably are not going to have performance that someone without dementia is going to have with a cochlear implant.
How do you discuss that with a family? That's always a tricky topic. I think.
[Jed Grisel MD]
I think it is a really tricky topic. And, like in the Lancet study, which was this big study that showed all of these different modifiable risk factors for dementia. It showed that controlling for hearing loss was the modifiable risk factor was the most impact on dementia development.
Now the problem with that was it, it wasn't really getting causal relationships. And also that study was talking about treating hearing loss in midlife. Forties fifties, sixties, not late life. So I mean, probably if somebody comes in with profound hearing loss and dementia, you're going to help that patient with sound awareness and with communication ability. But whether you're going to reverse those is a challenge. But then the other topic comes in is when a patient's sitting there and they're not engaging their environment, how much of that is cognitive dysfunction and how much of that is they can't hear. And teasing that apart is difficult for patients.
And so we're working on a study right now where kind of a clinical evaluation of us and two other sites where we're trying to look at like, how do those things tease out? And one of the things we've noticed is that what we're starting to learn is that, if a patient has poor cognitive function, preoperatively, well, let me tell you the other way, if the patient has good, cognitive function, preoperatively, we have high confidence that we're going to help you here in quiet. And we're going to help you here in noise. But now we know it's like helping us preoperatively define those patients. And so we say, look Mrs. Jones, or whatever, your family members, we're going to help you. You're going to hear, you're going to detect sound better, but we need to be prepared that you might need remote mics. You might need auditory training. We need to throw the kitchen sink at you because you're one of these patients that may have, we may not have all of those skills.
So then it's not that we're not going to implant that patient, but it's a totally different preoperative counseling discussion. We definitely feel good about that patient. Anybody could implant that patient and they probably aren't going to need a lot of aural rehab and they're going to do well. Right? So it's like, yay. We can all celebrate if the patient comes in and they're a cochlear implant candidate, but they have poor cognitive function, what we're seeing is that we're doing a good job of improving those patients' audibility. So there are CNC and they're hearing it quiet is getting better, but they're hearing in noise it struggles. So cognitive testing has become an integral part of our CI process.
[Walter Kutz MD]
Yeah. I mean, that's excellent, I think with cochlear implants and a lot of things we do it is all about expectations. And if you don't set those expectations at the initial visit and before surgery, it's going to be very difficult to explain why this Mrs. Jones isn't doing as well as the family or Mrs. Jones may have thought she's doing, so that's a great point.
And most of these patients that we're going to implant, they're going to have severe to profound loss. And in general, we're not taking away a lot of functions. So this a surgery you and I do a lot in, and it's very established, safe surgery. So I think setting the expectations is critical, especially in the patients who already have some cognitive decline and we've seen that really helped these patients in practice, but just setting the expectations that they are not going to be a superstar, cochlear implant user.
[Jed Grisel MD]
Yeah. And I think that it's much easier to have that discussion beforehand. And then afterward, they may not be performing the way that other patients are, we are like, “Remember we talked about this.” And so we're going to do that. And that's a much easier discussion than them expecting to be doing everything like normal, and then they're mad at you, you know? So it gets help in that regard for sure.
Dr. Jed Grisel
Dr. Jed Grisel is a practicing otolaryngologist in Wichita Falls, Texas.
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 16). Ep. 37 – Hearing Loss and Cognitive Decline [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.