BackTable / ENT / Podcast / Transcript #37

Podcast Transcript: Hearing Loss and Cognitive Decline

with Dr. Jed Grisel and Dr. Joe Walter Kutz

Dr. Joe Walter Kutz talks with Dr. Jed Grisel about practice patterns treating patients with hearing loss, as well as the correlation between hearing loss and cognitive decline, and how best to screen these patients. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Challenges Facing ENT Private Practice

(2) The Potential Impact of Over-The-Counter Hearing Aids

(3) Cognitive Function Testing for Patients with Hearing Loss

(4) Addressing Cognitive Dysfunction in the Hearing Loss Patient

(5) Impact of Cognitive Load on Auditory Function

(6) Collaboration with Neurology and Primary Care

(7) Treatment for Mild Hearing Loss

(8) Navigating Difficult Conversations with Patients and Families

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Hearing Loss and Cognitive Decline with Dr. Jed Grisel and Dr. Joe Walter Kutz on the BackTable ENT Podcast)
Ep 37 Hearing Loss and Cognitive Decline with Dr. Jed Grisel and Dr. Joe Walter Kutz
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[Gopi Shah MD]
Hello, everyone. Welcome to the back table ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. Today, our guest host is Dr. Walter Kutz, a professor in neurotology at the University of Texas Southwestern Medical School here in Dallas, Texas.

[Walter Kutz MD]
Welcome to the BackTable ENT. Today we have Jed Grisel who’s a private practice otolaryngologist from Wichita Falls, Texas. I’ve known Jed for, I guess, about 15 years now, or more. And, I consider him a friend and a colleague, really enjoy phone calls discussing patients.

[Jed Grisel MD]
Good morning, Walter. Thank you so much for having me.

[Walter Kutz MD]
Awesome. So you've done some incredible work with cognitive dysfunction and hearing loss, which is a very hot topic right now in otology. Tell me about what programs you have going on in your clinic up in Wichita Falls.

(1) Challenges Facing ENT Private Practice

[Jed Grisel MD]
Well, thanks Walter. Probably just as a brief introduction of who I am and where I am. I’m a private practice otolaryngologist ENT in Wichita Falls, Texas, which is a town of about little over a hundred thousand. We're about two hours from Dallas. And in my practice, we are six physicians, five audiologists.

We're actually part of a larger group that consists of about 20 doctors throughout Texas, but we're in Wichita falls and I really enjoy it. I enjoy the opportunity to take care of the patients in our community. I enjoy the opportunity to have to kind of control the setting that we practice in.

And I think that one of the things that's interesting is I've been here. I've been in Wichita Falls for 10 years. And one of the things that's interesting is just understanding the stresses and the challenges that face private practice ENT. And I think we're going to get into the cognitive testing here in a bit and talk about how, how that's differentiating our practice.

But I think it's important also to just to think about what's going on in private practice ENT as we think about having a successful practice and business. And every year that we go on in our practice, we see that the challenges of running a practice, and let's face it, it's a business, like running a small business. Those challenges get more complex. The challenges of getting paid and the complexity of managing payer contracts and the complexity of IT, EHR complexity and all those things that we have to manage in addition to seeing patients.

And one of the things that really helps our practice do well is sort of these robust, healthy, ancillary streams, whether it be allergy or in office procedures or audiology. And so audiology is a very important part of our practice. And that's where I think the cognitive testing has really been helpful.

[Walter Kutz MD]
Great. Yeah. It's very different than my practice. I'm an academic otolaryngologist at UT Southwestern. So, I take for granted a lot of these issues that are very real issues out in the private practice world. So, related to that, what are some of the challenges that ENT clinics are having as it relates to hearing care.

[Jed Grisel MD]
Yeah, thanks for that question. In my opinion, ENT/audiology clinics like the practice that we have, where we have otolaryngologists and audiology in the same practice, to me, we are and should be the pinnacle of healthcare delivery in our communities Right? We have the diagnostic and treatment options that really surpass any other delivery channel.

We do traditional diagnostic testing and we do amplification and we do conductive devices and we do cochlear implants. And, so we should really be that sort of top. There are some good and bad things that are happening in hearing healthcare world, on the positive side, I think there's a lot of innovation and technology that's coming to really help patients and improve access to care on the other side, the market is getting more crowded, right? And the ability to maintain a healthy hearing clinic is more challenging and competitive. And so I think some of the challenges that we're seeing on that side is direct to consumer options for patients, and where they can call and get a hearing aid online and have it programmed remotely.

There are over-the-counter hearing aid options that are coming. I think we should talk about a little bit. And so change is hard for people. And so I think people see that as potentially a threat, but it's just change and I think there's some opportunities in there as well.

[Walter Kutz MD]
Yeah. I mean, it's complex with the hearing rehabilitation options. I mean, even speaking to the patient on a bone conduction device, I mean it's a long conversation. There's so many options out there. And then you throw in hearing aids, CROS hearing aids BiCROs hearing aids, maybe cochlear implant candidacy. It can be very complex and time-consuming.

It's interesting. The over-the-counter hearing aids recently were approved by the FDA for patients with mild to moderate hearing loss. It seems to me that may create some challenges, with keeping your clinic healthy with hearing aid cells and really taking care of patients.

Because now maybe the patients could just go to a brick-and-mortar store unrelated to your clinic. How do you see over-the-counter hearing aids affecting your practice?

(2) The Potential Impact of Over-The-Counter Hearing Aids

[Jed Grisel MD]
Yeah. I mean, I think it's a big topic that everyone's talking about. I mean, I think we should take a step back for a minute and just say, okay, there's 50 million Americans who need treatment for hearing loss and by 2040, that'll be like 80 million Americans. So this is a blossoming growing market and there are a lot of people currently who do not participate in that market. Like only about 20% of the people that need treatment for hearing loss are actually engaged. And so I think an interesting analogy would be to look at the vision care optometry market. For years and years and years, you had to have a prescription to get glasses. And then reader glasses came on where they sort of pre prescribed glasses. You could without a doctor of optometry, you could go to Walmart and get some glasses.

And what did that do to the vision care market? Right? It did it, the optometrists didn't go out of business because reader glasses came on. What it did is it widened the funnel and suddenly millions of more Americans had access to low cost vision that they could go to Walmart. And I think what we hope of course is that that's the case, many of these patients who struggle, but they're not ready to make that first step to treating their hearing loss that now there's this sort of gateway opportunity for them. So what we hope of course is that we grow that entire market and the challenge for us as otolaryngologists in our hearing clinics is of course to figure out how do we position ourselves so that they come to us, so that we have this portfolio of treatment options for them. And that they see us as the true experts and that they can access, whether it be OTC aid or a programmable device or an implantable device. We are that resource for them.

[Walter Kutz MD]
Yeah. I mean, I think the cost of hearing devices really prevents many patients from even choosing them. I mean, a pair of hearing aids can be four, six, $7,000 or more. And so I think for patients with mild to moderate hearing loss an over the counter hearing aid will decrease that financial barrier to use hearing aids. So how do you, how do you think as an otolaryngology clinic, we can improve care over maybe if a patient decides to buy hearing aids online or, they go to some store that just sells hearing aids really without audiology, otolaryngology, what sort of things, can we differentiate ourselves as otolaryngologists and audiologists?

(3) Cognitive Function Testing for Patients with Hearing Loss

[Jed Grisel MD]
I think that is a great question. I think that, on the one hand, if you think about where we want to position ourselves as being that premier delivery channel, I think that if a patient can go to Costco and they can get the same experience that they can get in our clinic, then why would they come?

I think that the way that we do this is that we redefine the experience for our patients, so that it's something that they can only get with us. And so that's a good segue to kind of talk about where cognitive testing I think comes in because it's interesting. The audiogram was developed around world war II, right?

And so the audiogram in itself is a diagnostic test to help us understand how the cochlea detects sound with pure tones. And then it also has a little bit of speech understanding and quiet. But that test shines only a partial light with the knowledge that we've had probably for the last 25 years about the connection between hearing and cognitive function. An audiogram only shines partial light on a patient's communication abilities or listening abilities. And so I think that when we have these patients that come in and we're using the audiogram, as the end all be all diagnostic tests to determine whether they need a hearing tests and to follow them.

We're only getting a partial picture. And then when patients struggle and they're frustrated with this device that they just spent $4,000 on, we're sort of at a loss for being able to understand those challenges. So cognitive testing in our practice is becoming such an important differentiator in our community, but also tool to help us better, counsel patients and treat their hearing.

[Walter Kutz MD]
Yeah that's interesting. At UT Southwestern, we're not necessarily screening all patients for cognitive dysfunction, but we do have a few studies going on right now led by Jacob Hunter, one of my colleagues and an otologist. I guess one of the concerns of adding cognitive testing is of course that's time. And you know that someone's going to have to administer that test. How do you approach that in your clinic? Justify that extra time with a patient, I'm sure you have a very busy practice. How are you able to manage that and make it worthwhile for you and the patient?

[Jed Grisel MD]
Yeah, I think that anytime we talk about doing something different or bringing in a new service line, there's so many logistics and historically, cognitive testing, I think has been relegated to the research arena because it's hard, you have to have a trained administrator of the test.

The traditional test had been paper pencil. So previous tests have been like the mini mental status exam and MoCA, and some of these different tests that are helpful, but the problem with them is there are some challenges with them that they take time, you have to have a trained administrator, and also if the patient is old and they don't have good dexterity or their vision is poor that affects their outcome. And so now you're testing the patient's vision and dexterity and not their cognitive abilities. And so the game changer for us to implement this in our practice has been the ability to have an automated self administered version of a cognitive test.

And that's what we've been using for the last year. And so this is a test that sits like a little kiosk in the office. It takes about five minutes for the patient to do. It's self administered. So, a technician, not a trained audiologist or even an audiology tech. In fact, our receptionists can, before they see the audiologist, can sit them in the location where we have the test and get the patient started and then the patient does everything else.
And this test has been, kind of rigorously studied and in terms of its repeatability and how valid the test is from patient to patient and from test to test. And so you kind of get rid of some of those distractions that would make the test invalid.

[Walter Kutz MD]
Interesting. Yeah that sounds like an efficient way to do that and get over some of those barriers. so let's say that a patient does have some cognitive dysfunction on the test, do you counsel them about how they may do with hearing aids or when would you send them to a neurologist or for further testing?

(4) Addressing Cognitive Dysfunction in the Hearing Loss Patient

[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, the polypharmacy's amazing. The patient probably sees different specialists, primary care, and all of a sudden they're on 15 medications that cause cognitive decline, but they also cause other things we see - dizziness, tinnitus - and that's a great point to bring up just in general. You brought up cognitive load. Tell me your thoughts on the challenges with cognitive load and patients with hearing loss.

(5) Impact of Cognitive Load on Auditory Function

[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.

[Walter Kutz MD]
Yeah, and this, I guess it's pretty similar to what the ACHIEVE trials are looking at. They're looking at aging and cognitive health and elderly, and hopefully those results are going to be in. Do you know when they're planning on publishing that?

[Jed Grisel MD]
I think that if I remember right. I think that in 2023, we should get some. And so just for the listeners to understand, so Franklin and his group at Hopkins are doing this trial, it's called the ACHIEVE because in the literature, there are many retrospective studies that are showing that, everyone knows that there's this connection between hearing loss and cognition, but the big question is how powerful is an intervention in altering that trajectory of dementia development? Because of course, we all know it's not going to be that every single patient that we treat with hearing loss, they're going to avoid developing dementia. Right. We know that's not the case, but we also know, know that there is some impact.

And so being able to put a number and understand, so this is very important. And so this is an NIH-funded study that's I think 800 and some odd patients multicenter. And half of them are being, put in a study where they're undergoing successful aging, like other healthy aging strategies. And then in the research group there, they're treating their hearing loss and then they measure over time how they developed dementia. And so what we're doing in our clinic, we try to avoid that discussion with patients of showing them their cognitive performance and saying, “Okay, Mrs. Jones, now you're probably going to develop dementia,” because that's not a smart strategy. I mean, it scares patients, honestly. And we're still waiting on the data. We don't really know that. So that's where this cognitive load discussion has become very helpful because we can show the patients how they're improving and then say, look, you know what, whether whatever happens in the future, we'll get to that. But what I can tell you is that on this day, compared to, before we treated your hearing loss, on this day, your brain has more ability to perform important tasks. And so that it's sort of a more proximate outcome that we can show patients of how they're doing.

[Walter Kutz MD]
Does word get around you community that you're doing the cognitive testing and you've had referrals coming from patients that have seen you?

[Jed Grisel MD]
It's starting to. We haven't really been aggressively discussing with the community because we're trying to figure out the flow, what it really means. So we're still kind of looking at some things internally, but the neurologist certainly know. And so I think that's helped cause we probably are doing, more than even– well, they do a more intense version of how they assess cognition.

But the neurologists are figuring out and I have some colleagues, who, throughout the state who are doing this, who have audiology only practices, and that's a primary driver for them, of how they get referrals. It's really setting themselves apart as sort of being this ear-brain specialist.

(6) Collaboration with Neurology and Primary Care

[Walter Kutz MD]
So by doing this, have you collaborated with some neurologists in your community that will see patients if there's a concern? I mean, if I were a patient and I did a cognitive test and it was showing some decline that I was concerned about, I'd probably say, what do I do next? You mentioned maybe starting the primary care, but do you have any neurology colleagues you work with?

[Jed Grisel MD]
Yeah, there's one in town, she has sort of a Parkinson's Dementia clinic and that knows about this and that we work with. The problem with this, it's a little bit complex because remember what we're doing with the cognitive screen, it's sort of like blood pressure, I think of this oftentimes, blood pressure is a biometric reading, it's like a surrogate indicator for your cardiovascular health. But if a patient came into your office as an ENT and their blood pressure was high, without any further investigation or studies, oftentimes we'd probably have them go to their primary doc first, right?

Because 90% of those problems they’re going to be able to manage. And then the primary doc can address the low-hanging fruit and get it managed and whatever. And then if there's this continued problem, they would send them on. It doesn't mean that doing blood pressure testing in our office is invalid just because were not cardiovascular specialists. It’s still a valid biometric reading that we get from patients. And so I see cognitive testing that same way. If every patient that didn't perform well on the cognitive tests we sent to neurology, I think that they would be like, stop, please stop.

[Walter Kutz MD]
Yeah. Yeah, no kidding.

[Jed Grisel MD]
And 90% of these patients, you clean up their meds or you address some issues and it strengthens your bond with your primary care colleagues, you know?

And then I think that if they have a problem then, I think that going further is helpful because the neurologists are the real experts and they're going to be doing, the full in-depth battery of tests that are required to diagnose dementia. so it's an interesting nuance.

[Walter Kutz MD]
Yeah, that's a good point. I mean a neurology visit is going to take an hour, hour and a half, it was a very thorough and there's just not a neurology time to do that. So that makes a lot of sense to work with our primary care colleagues.

[Jed Grisel MD]
Well, one other thing I'd say about this is that, so the question is who do we screen? Right? Because it also is a time commitment for us when they come in. And so I think it's important just to kind of know, kind of the pathway of what we do. So like most ENT clinics, when a patient comes in the office, on the ENT side, and then they get sent for diagnostic, like an audiogram hearing tests.

If the patient's scheduled, like we don't do the cognitive testing right then in the midst of my busy, I'm seeing 20 patients in a half day, and then you start inserting this. I did do that for a little while and it was just cause I wanted to understand the test, but it's just kind of not very feasible. So what we do is when the patient comes in, at first we do that test. I mean first we do their audiogram and we do a QuickSIN and I would be a huge proponent for the listeners of QuickSIN. This is very easy, we do it in sound field, not ear specific and it's just a hearing and noise test. It would be sort of like the equivalent of a very quick AzBio with background noise but it's very quick. And the reason why it's helpful is that cognitive skills are needed to be able to perform well in noise. And so a patient, this happens to me all the time, where patients came in, they were complaining that they struggled in noise.

We do an audiogram only, and they have very mild loss or maybe they have a supra-threshold listening disorder, right. Like ADHD or some other supra-threshold listening disorder and so they'll come in and they'll say that. And without that QuickSIN, I'm not addressing that patient's concern. They came because they couldn't hear a noise and they come into my office and I test them in quiet and they say, “Oh, you look pretty good, right?'' And so the QuickSIN helps me address their concern. And also it gives us a little tip-off that there may be a cognitive problem here.

And then when the patient needs to be scheduled for a hearing aid evaluation, they come in and before they see the audiologist, it's on a different day. When they go to see the audiologist, the technician that brings them back or the receptionist that brings it back does that test before they see the audiologist and then the audiologist has that information, and then they include that. So it's just, I think it's important to see that, we've kind of tried to over the last year, tried to work this out so it has a minimal impact on our flow and we don't test everyone. The other person that we don't test to get back to our discussion about the neurologist is if a patient already has dementia.

The cognitive screen is really keyed statistically to pick up mild cognitive impairment, which is good for us because it's kinda at the early stages at a stage where we may be able to do something about it. So if I have an 80 year old that comes in and they clearly have been diagnosed with dementia, it's kind of a moot point. And it's an exercise in frustration for all of us to just do that test. So we don't, we don't test people that already have known dementia.

(7) Treatment for Mild Hearing Loss

[Walter Kutz MD]
Yeah. Kind of going on a little bit of a side note here, let's say you do have a patient that has maybe loosely defined as a central processing disorder, or they're having a difficult time hearing and noise, but then you test them and the hearing is normal, very mild hearing loss. And, you don't think a hearing aid necessarily going to be helpful.

What do you do with those patients? Do you have them meet with audiology for counseling and some rehabilitation, some lifestyle things they can do or how do you approach those patients?

[Jed Grisel MD]
Well, I'll tell you this is where the QuickSIN and the cognitive tests have really added to our counseling abilities. because there are, so before we started doing all this, we would never have considered, we would say, well, go online and get a peace app. That was my strategy before, we'd say go online and get it because maybe it'll help you if you're struggling, that's a low-cost thing to do. And so we would do that, but now I've actually had some patients. We've at least let them try. Right? Like we put up, we say, look, even though your thresholds, this partial test of audiogram shows that you're very mild in loss, these other tests are really showing that there's a deficit there. Your QuickSIN is poor and you're struggling with noise. And these are patients that we'll let them try, low gain, just to bump up their signal to noise ratio, it can be helpful. And that's good for the patient. They're happy because they didn't leave disappointed. It's good for your business because you sold a hearing aid, and everyone's happier. But, before I would've felt, I just didn't have the tools to be able to counsel that patient.

And one of my colleagues in Austin has musicians that will come in and they'll be struggling because they use their ears all day long and they're struggling. And in that music scene down there, and these are patients that before this was being done would never really have been given options and now they get low gain hearing aids or an entry-level device and they're happy, you know? So, and then if that doesn't work, then we have to start thinking of other things that could be going on.

[Walter Kutz MD]
Yeah, that's a good approach. It's easy to see those patients and just, well, there's not a lot we can do for you. And then they're frustrated and you're really not helping anybody by doing that. So it's interesting. I wonder if over-the-counter hearing aids, will be useful for some of these, these patients that have problem in noise, but their thresholds aren't too poor. It'll be interesting to see as those devices roll out.

[Jed Grisel MD]
Definitely.

[Walter Kutz MD]
So, another thing that I see my practice is a patient, maybe they already have dementia, they're probably elderly. And, they're really struggling with their hearing. They may even be a cochlear implant candidate and they're being taken care of by their family members or caregivers. And a lot of times the patient may not be as concerned about the hearing loss as the caregiver. I think there's really a caregiver burden from significant hearing loss. The son or daughter or family member wants to take care of their loved one with dementia, but it's very challenging when he can't communicate well.

Do you see some of that in your practice? And it seems like that sometimes by treating the patient, I think it really helps the caregiver and the family maybe as much or more than the patient in some ways.

[Jed Grisel MD]
That's a great point, Walter, and I think, from a societal standpoint, I think about these weird things sometimes that if you were born in the year 1900, your life expectancy was like 40, right? So if you live to be, I mean, and we know that the incidence of, from a population standpoint, the incidence of hearing loss really starts to tick up in our fifties. And so if you live to start developing hearing loss, you were like the old person that has managed to not get killed in a war or get an infection. And so now you're like the old person and it's rare. Right. But now. In my generation, our generation, like half of us will live to be a hundred, you know?

And so it's weird because we're doing this like social experiment where we've taken millions and millions of Americans and given them decades of sensory deprivation. And then we're like, okay, well, let's see what happens now. And so while we're living longer and that's great, we now have to start wrapping our minds around of how do we live longer better, you know? And so more and more of Americans will live into their late decades with multiple chronic illnesses. And those multiple chronic illnesses are expensive. They take a tax on our quality of life and hearing losses fits right into one of those, and I think with dementia, I think it's the, I have to go back and look, but I think the statistic is something like 85% of the cost burden of dementia is born by the families.

And it's born in the terms of paying for care facilities when patients lose their independence. And it's born by lost wages by having to take off to take care of family members and the emotional toll of dealing with family members. And so, so to me, this is a discussion that we have to, and what I've noticed is that when we bring up this ear-brain connection with patients, when I do with my patients, you can see on the face of the patient and their families, the discussion change, right. Whereas before it was sort of, “Okay, you have this problem that nobody wants to go buy a device that nobody wants to pay money for.” And now we're talking about our brain health and being able to stay independent longer and being able to release the burden or improve the burden on families. And so when we have that discussion, suddenly, the families are like, how quickly can we schedule an appointment? It just changes the discussion, especially for treatment intervention. Oftentimes it's born by the family and insurance payment for hearing aids is variable. And so, we have to really have a rational discussion with families to why this intervention makes sense for you. And that discussion makes sense to people.

(8) Navigating Difficult Conversations with Patients and Families

[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, 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.

[Walter Kutz MD]
Yeah, Jed, what automated machine do you use for the cognitive screening? What's the name of the–

[Jed Grisel MD]
The name of the device that we use is called Cogniview. 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 Cogniview 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.

[Walter Kutz MD]
Well, Jay, this has been a great conversation on a hot topic right now with hearing loss and dementia and cognitive dysfunction. Are there any last words or advice or comments you have?

[Jed Grisel MD]
No, I appreciate you Walter for having me. I would just say that I think ENT is a great specialty. It's a great field. And I think that as we continue to kind of adapt and evolve, that we can kind of maintain the role that we played for years and years of being kind of leaders in our spaces. And I think we need to continue that. So thank you for having me on today.

[Walter Kutz MD]
No, thank you very much. That's been very informative and I've learned a lot.

[Jed Grisel MD]
Thanks Walter.

[Ashley Agan MD]
Thank you so much for listening. If you haven't already make sure to subscribe, rate the podcast five stars and share with a friend. If you have any questions or comments, direct messages @_BackTableENT on Instagram, LinkedIn, or Twitter. BackTable ENT is hosted by Gopi Shaw and Ashley Agan.

Podcast Contributors

Dr. Jed Grisel discusses Hearing Loss and Cognitive Decline on the BackTable 37 Podcast

Dr. Jed Grisel

Dr. Jed Grisel is a practicing otolaryngologist in Wichita Falls, Texas.

Dr. Joe Walter Kutz discusses Hearing Loss and Cognitive Decline on the BackTable 37 Podcast

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.

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Topics

Learn about Audiology on BackTable ENT
Cochlear Implantation Procedure Prep
Cognitive Decline Condition Overview
Cognitive Testing Procedure Prep
Dementia Condition Overview
Hearing Loss Condition Overview