1. Hearing Loss & Healthy Aging: A Public Health Perspective
Frank R. Lin, M.D. Ph.D.
Associate Professor of Otolaryngology, Geriatric Medicine,
Mental Health, & Epidemiology
Johns Hopkins University
Baltimore, Maryland

2. Prevalence of Hearing Loss in the United States, 2001-2008
Hearing loss defined as a better-ear PTA of 0.5-4kHz tones > 25 dB
Lin et al., Arch Int Med. 2011

3. Hearing Loss & Hearing Aid Use Prevalence in the U.S. , 1999-2006
Chien W et al, Arch Int Med, 2012

4. Age-Related Hearing Loss (ARHL) Basic Questions
What are the consequences of ARHL for older adults?
What is the impact of treating ARHL on older adults?
How can ARHL be effectively addressed in the community?

5. Healthy Aging

6. Healthy Aging Hearing Loss Avoiding Injury Cognitive Vitality
& Avoiding Dementia
Maintaining Physical
Mobility & Activity
Healthy Aging
Keeping Socially
Engaged & Active
Health Resource
Utilization
Hearing Loss

7. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor?
Cognitive & Physical Functioning
Hearing Loss
Common pathological process

8. “Effortful listening”
Hearing Loss & Cochlear impairment
Frequency
Time 
Intensity 
Decreased sensitivity & distortion in sound encoding
“Sunday”
“Effortful listening”

9. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor
Cognitive Load
Add in brain aging, kahneman, and voxel based image
Then overview with epi results
Then box with RCT
Myth 2 HL can be succesfully treated by any audiologist??
Then slide
Then case presentation
Cognitive & Physical Functioning
Hearing Loss
Common pathological process

10. Hearing Loss & Cognitive Load
Kahneman model of shared attention and resource capacity (D. Kahneman, Attention & Effort,1973)
Cognitive Resource Capacity
Available Cognitive Resources
For Performance of Tasks
Age-Related Decline
Auditory Perceptual Processing
Requirements

11. Hearing Loss & Cognitive Load
Poorer hearing is associated with: A. Reduced language-driven activity in primary auditory pathways B. Increased compensatory language-driven activity in pre-frontal cortical areas
D: areas activated to a
greater degree by elderly poor comprehenders than by elderly good comprehenders.
In contrast with this area of reduced activation, subtracting
the activation pattern of the poor comprehenders from
that of the good comprehenders, shown in Fig. 3D, revealed
the poor comprehenders to be upregulating dorsolateral
prefrontal cortex to a degree not shown by the good comprehenders.
Dorsolateral prefrontal cortex is often activated
during general problem-solving activities, regardless of the
verbal or nonverbal nature of the material (Paulus et al.
2001; Prabhakaran et al. 2001; Ramnani and Owen 2004).
This prefrontal region is not activated in young adults
during sentence-comprehension tasks. This would suggest
that the older adults who are less successful in their comprehension
of grammatically complex sentences were attempting
to understand these sentences by adopting a general-
purpose problem-solving approach to the task.
Peelle et al, J. Neurosci, 2011 B
Grossman et al, Brain Lang, 2002

12. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor
Cognitive Load
Cognitive & Physical Functioning
Hearing Loss
Brain structure/function
Common pathological process

13. Double Hit Theoretical Model Hearing Loss & Brain Structure/Function
Microvascular
Disease
Alzheimer’s
Neuropathology
1021
Structure/
Function
Hearing
Impairment
F. Lin & M. Albert, Aging & Mental Health, 2014

14. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor
Cognitive Load
Cognitive & Physical Functioning
Hearing Loss
Brain structure/function
Social Isolation
Common pathological process

15. Health Behavioral Pathways Psychological Pathways
Cognitive & Physical Functioning
Social Isolation
Health Behavioral Pathways
Smoking
Adherence to medical tx
Diet
Exercise
Psychological Pathways
Self-esteem
Self-efficacy
Coping
Sense of well-being
Physiologic Pathways
HPA axis response
Immune system fxn
Cardiovascular reactivity
Social isolation is associated with upregulation of pro-inflammatory genes & increased inflammation
Cole & Cacioppo, Genome Biology, 2007
Cole & Cacioppo, PNAS, 2011

16. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor
Cognitive Load
Cognitive & Physical Functioning
Hearing Loss
Brain structure/function
Social Isolation
Common pathological process

17. Hearing Loss & Healthy Aging Datasets for Epidemiologic Analyses
NHANES: National Health and Nutritional Examination Surveys
Cross-sectional, representative sample of U.S. population
BLSA: Baltimore Longitudinal Study of Aging
Ongoing prospective study of older adults since 1958
HealthABC: Health, Aging, & Body Composition Study
Prospective, population-based study of ~3000 adults 70 years and older

18. Healthy Aging Hearing Loss Avoiding Injury Cognitive Vitality
& Avoiding Dementia
Maintaining Physical
Mobility & Activity
Healthy Aging
Keeping Socially
Engaged & Active
Health Resource
Utilization
Hearing Loss

19. Projected Worldwide Prevalence of Dementia 2010-2050
Alzheimer’s Disease International, 2009

20. Hearing Loss & Cognition Background
Memory
Free and cued selective reminding test (FCSRT)
Executive Function
Trail Making B
Stroop Mixed
Digit symbol substitution
Psychomotor/processing speed
Verbal function & language
These tests are not dependent on hearing.

21. Hearing Loss & Cognition Executive Function: Trail Making B8 7 6 5 1 4 3 2 C E B
Trail Making B H F G D A

22. Hearing Loss & Cognition Executive Function: Stroop Mixed
GREEN
RED
BLUE
RED
YELLOW
BLUE
GREEN
BLACK
Stroop Mixed

23. DSS: Digit Symbol Substitution Test
Hearing Loss & Cognition Executive Function: Digit Symbol Substitution Test (DSS)
DSS: Digit Symbol Substitution Test

24. Hearing Loss and Cognition Cross-Sectional Studies
NHANES
N = 605 adults years
Lin, J. Geront. Med. Sci., 2011
BLSA
N = 347 adults >60 years
Lin et al., Neuropsych., 2011
Models adjusted for age, sex, race, education, diabetes, smoking, hypertension

25. Hearing Loss & Cognitive Decline
HealthABC
Adjusted DSS scores by years of follow-up and hearing loss status in 1,966 adults > 70 years followed for 6 years
32% faster rate of cognitive decline in DSS scores in HL vs. NH
Adjusted for age, sex, race, education, study site, smoking status, hypertension, diabetes, and stroke history
Lin et al. JAMA Int Med. 2013

26. Risk of incident all-cause dementia (compared to normal hearing)a
Hearing Loss & Incident Dementia Dementia incidence in 639 adults followed for >10 years in the BLSA
Risk of incident all-cause dementia (compared to normal hearing)a HR
95% CI p
Mild
1.89
1.00 – 3.58
0.05
Moderate
3.00
1.43 – 6.30
.004
Severe
4.94
1.09 – 22.4
.04
a Adjusted for age, sex, race, education, DM, smoking, & hypertension
Lin et al., Arch Neuro., 2011

27. Hearing Loss & Incident Dementia Dementia Incidence in 1057 Men Followed for 17 years in the Caerphilly Prospective Study (U.K.)
J. Gallacher et al., Neurology, 2012

28. Healthy Aging Avoiding Injury Avoiding Injury Cognitive Vitality
& Avoiding Dementia
Maintaining Physical
Mobility & Activity
Maintaining Physical
Mobility & Activity
Healthy Aging
Keeping Socially
Engaged & Active
Keeping Socially
Engaged & Active
Health Resource Utilization/Mortality
Health Resource
Utilization/Mortality
Cognition/Dementia/Brain Aging
J Gerontol A Biol Sci Med Sci Apr 12.
Am J Epidemiol May 1;181(9):
Aging Ment Health. 2014;18(6):671-3.
Neuroimage Apr 15;90:84-92.
JAMA Intern Med Feb 25;173(4):293-9.
Neuropsychology Nov;25(6):
Gerontol A Biol Sci Med Sci Oct;66(10):
Arch Neurol Feb;68(2):
Injury/Physical Functioning
J Aging Health Aug;28(5):
J Aging Health Jun;28(4):
J Am Geriatr Soc Apr;64(4):906-8.
J Gerontol A Biol Sci Med Sci May;70(5):
J Am Geriatr Soc Aug;62(8):
J Am Geriatr Soc Jun;62(6):
Am Geriatr Soc May;62(5):850-6.
Gait Posture May;38(1):25-9.
Health Economics/Mortality
J Aging Health Feb;28(1):68-94.
JAMA Otolaryn Head Neck Surg Oct;141(10):944-6.
J Am Geriatr Soc Jun;63(6):
J Gerontol A Biol Sci Med Sci Jan;70(1):85-90.
J Am Geriatr Soc Nov;62(11):
J Am Geriatr Soc Jun;62(6):
JAMA Jun 12;309(22):
Social Engagement/Mental Health
J Aging Health Sep;28(6):
J Gerontol B Psychol Sci Soc Sci May;71(3):400-4.
J Aging Health Feb 24.
Otolaryngol Head Neck Surg Mar;150(3):
J Am Geriatr Soc Sep;61(9):

29. Hearing Loss & Healthy Aging Common Cause or Modifiable Risk Factor
Cognitive Load
Add in brain aging, kahneman, and voxel based image
Then overview with epi results
Then box with RCT
Myth 2 HL can be succesfully treated by any audiologist??
Then slide
Then case presentation
Cognitive & Physical Functioning
Hearing Loss
Brain structure/function
Social Isolation
Common pathological process

30. Age-Related Hearing Loss (ARHL) Basic Questions
What are the consequences of ARHL for older adults?
What is the impact of treating ARHL on older adults?
How can ARHL be effectively addressed in the community?

31. The question of whether treating hearing loss could delay cognitive/physical decline or dementia remains unknown
There has never been a randomized controlled trial of treating hearing loss to explore effects on reducing the risk of cognitive decline/dementia

32. Hearing Loss & Cognition Mechanistic Pathways
Intervention
Cognitive
Load
Changes in
brain
structure
Reduced Social
Engagement
Cognitive
Functioning
Hearing Loss
Hearing loss intervention could:
Reduce the cognitive load of processing degraded sound
Provide increased brain stimulation
Improve social engagement
Role of HL as a potentially modifiable, late-life risk factor for cognitive decline & dementia

33. Conceptual Model for the Aging, Cognition, and Hearing Evaluation in Elders
(ACHIEVE) RCT
In collaboration with J. Coresh, M. Albert, N. Glynn, T. Chisolm, ARIC Study Team (T. Mosley, K. Bangdiwala, K. Hayden, J. Pankow)
Non-pharmacologic cognitive training intervention
Proximal/Mediating
Outcomes
Proximal/Mediating
Outcomes
Primary
Outcome
Primary
Outcome
Secondary
Outcomes
Secondary
Outcomes
Intervention
Intervention
HRQL
Social/Leisure Activities
Daily
Functioning
Mobility
Brain structure (MRI)
Audibility of speech & environmental sounds
Best-Practices Hearing Rehabilitative Treatment
Vs.
Successful Aging Control
Cognitive
Functioning
Enhanced Verbal Communication & Social Engagement
NIA R34AG064548

34. The ACHIEVE RCT will be Nested within the ARIC Neurocognitive Study
Operational Efficiency & Scientific Power
Atherosclerosis Risk in Communities (ARIC)
1987-present; n=15,792
Supported by National Institutes of Health
NHLBI with ancillary studies by NCI, NEI, NIA, NIAAA, NIDCD,
NIDDK, NIEHS, NINDS, NCRR & NIH Roadmap

35. ACHIEVE Trial Design Timeline & Overview of RCT
RCT planning process (R34AG046548)
- Pilot study, development of protocol/operations manual, etc.
2016 $16M grant for full trial under review
Recruitment at field sites
Follow-up
Participants: ~ y.o., healthy, cognitively normal community-dwelling adults with untreated mild-moderate HL
Intervention: Randomization to best-practices hearing rehabilitative treatment vs. successful aging intervention control
Outcome: Study powered to detect 0.3 effect-size difference in rates of cognitive decline between the two groups at 3 years post-randomization
NIA R34AG064548

36. Age-Related Hearing Loss (ARHL) Basic Questions
What are the consequences of ARHL for older adults?
What is the impact of treating ARHL on older adults?
How can ARHL be effectively addressed in the community?

37. Hearing Loss & Hearing Aid Use Prevalence in the U.S. , 1999-2006
Arch Int Med, 2012

38. Barriers to Hearing Health Care (HHC)
Cost/Affordability
Access to Services
&Technology

39. Current (only) gold-standard model of hearing care:
Access to Services
&Technology
Current (only) gold-standard model of hearing care:
Repeat clinic-based visits with audiologist/dispenser for evaluation, counseling, fitting of amplification
Federal & State regulations restrict direct access to hearing aids
For politzer—use slide in back

40. Barriers to Hearing Health Care (HHC)
Cost/Affordability
Awareness &
Understanding
Access to Services
&Technology
Technology Design
& Utility

41. How can ARHL be effectively addressed in the community
How can ARHL be effectively addressed in the community? Current & Future Trends
Understanding & approaching hearing loss in the context of healthy aging/public health
 National Academies of Science, Engineering, & Medicine (NASEM) Workshop on hearing loss & healthy aging
 White House Conference on Aging & President’s Council of Advisors on Science & Technology – 2015
 NASEM Hearing Loss Consensus Study–
  Food & Drug Administration re-regulation of hearing aids,
Federal Trade Commission workshop, Congressional bill for OTC hearing aids
Innovations in hearing health care/technology
Affordable technology & Accessible services

42. “Are you telling me that I’m going to develop dementia?”
What are the consequences of hearing loss for older adults?
What is the impact of treating hearing loss on older adults?
How can hearing loss be effectively addressed in the community?
Hypertension  Heart attack & stroke
Intervention: Medication, Lifestyle modification
Hearing loss  Cognitive decline, dementia, poorer physical functioning
Intervention: Comprehensive hearing tx?

43. Acknowledgments Johns Hopkins Jennifer Deal
Joe Coresh
Carrie Nieman
Marilyn Albert
Jon Suen
Sara Mamo
Nick Reed
Josh Betz
NIA
Luigi Ferrucci
Susan Resnick
Yang An
Eleanor Simonsick
ARIC Study Team
R34AG R01HL R33DC P30AG Triological Society & American College of Surgeons Clinician Scientist Award Eleanor Schwartz Charitable Foundation NIA Intramural Research Program

46. Innovations in Hearing Health Care Affordable Amplification Options are Needed
Hearing Aids:
Regulated as medical devices by the FDA
$800 to $3000 per device
Minimal insurance benefit (no Medicare benefit)
Accepted gold standard of care
Personal Sound Amplification Products (PSAPs):
Unregulated by the FDA
Cost $ per device
E-commerce
Tremendous recent advances paralleling consumer electronics industry
For politzer—use slide in back

47. Mean AZ Bio Scores Across Conditions
Results (N = 33)
Nick Reed
Nick Reed
Mean AZ Bio Scores Across Conditions
+5 dB SNR

48. Innovations in Hearing Health Care Affordable & Accessible “Stepping Stones” are Needed for Hearing Health Care
Technology – Personal sound amplifiers (PSAP)
Over-the-counter “hearing aids” with in-situ testing & verification
Cost < $
Services - Community health care workers
Community-based hearing screening
Counseling, education, & provision of sound amplifiers & other assistive technologies
Referral as needed
For politzer—use slide in back

49. Access HEARS: Hearing care Equality through Accessible Research & Solutions
BaltimoreHEARS
Low-income minority older adults inner city Baltimore
HEARS Intervention
1) Hearing Loss Screening
2) Device Orientation:
- Self-fit amplification device
- Individual programming
3) Counseling:
- Expectation management
- Communication Strategies
Pilot Studies in Multiple Populations
Carrie Nieman
Insert graphic
Older Adults with Cognitive Impairment or Dementia
Sara Mamo
Korean-American Older Adults – Korean Martyrs Catholic Church
Carrie Nieman
Janet Choi
Definitive Trials
Licensing & Dissemination
Non-profits
Local government
Pilot Studies
Multiple Communities
Outcomes in participant & communication partner
Social Engagement
Communication
Activities
HRQL
Intervention
Development
2013

50. Carrie Nieman

51. Carrie Nieman
$200

64. Baltimore HEARS Pilot (n = 15)
Change in Hearing Handicap Inventory
Carrie Nieman
Mean change = - 9.5
Effect Size = -0.96
Hearing aids = -8 to -16
None
Mild Moderate
Significant
HHIE - Baseline

65. Scores after HEARS Intervention
Memory Clinic HEARS Project Results (N = 20) of Neuropsychiatric Inventory
Scores after HEARS Intervention
Sara Mamo
September 17, 2018

66. Memory Clinic HEARS Project Feedback – Son-in-law of a 91 yo woman with MMSE of 17
Sara Mamo

67. How can ARHL be effectively addressed in the community? Future Trends
Understanding & approaching hearing loss in the context of healthy aging
 National initiatives now from White House PCAST, NASEM, FDA, FTC, Congress
Innovations in hearing health care/technology
Accessible services & affordable technology
Third-party reimbursement of hearing health care
Unbundling of hearing health care
Coverage for audiologic rehabilitative services (not devices)

68. Hearing Loss & Accelerated Brain Volume Decline BLSA
Hypothesis: Hearing loss is associated with accelerated atrophy in the superior, middle, and inferior temporal gyri
126 participants (56-86 yrs) in the neuroimaging substudy of the BLSA
Mean follow-up duration of 6.4 years
1.5T MRI performed annually

69. Faster decline in brain volume in HL vs. NH
Region of Interest &
Voxel-Based
Analyses
HL is associated with accelerated atrophy over Right superior, middle, & inferior temporal gyri L
Faster decline in brain volume in HL vs. NH
Lin et al., Neuroimage 2014

70. Double Hit Theoretical Model Hearing Loss & Brain Structure/Function
Microvascular
Disease
Alzheimer’s
Neuropathology
1021
Structure/
Function
Hearing
Impairment
F. Lin & M. Albert, Aging & Mental Health, 2014