This video, introduced by audiologist Matthew Allsop, features an expert panel that discusses the latest science surrounding the link between hearing loss and dementia and includes researchers involved in the ongoing ACHIEVE and ENHANCE studies. Closed captions are available on this video. If you are using a mobile phone, please enable captions clicking on the gear icon.
The data on hearing loss and cognitive decline, dementia, and Alzheimer’s disease is as compelling as it is incomplete. But with every new study, the case continues to mount for hearing healthcare as being one of the most impactful things a person can do to reduce their risk for cognitive decline and dementia. In fact, The Lancet Commission in 2017 and 2020 showed that hearing loss is the number-one “modifiable risk factor” in middle life, and is linked to around 8% of worldwide dementia cases. And, two weeks ago, the landmark ACHIEVE study was published, suggesting that hearing aids combined with hearing care may reduce the risk for dementia in some patient populations (see below).
What’s the most appropriate and responsible way to inform patients about all the emerging information about the links between hearing care intervention and better cognitive health? What do you do with patients whom you suspect might benefit from cognitive testing and referral? Phonak has recently developed the Enhancing Cognitive Health via Hearing Optimization (ECHHO) program to equip hearing care professionals (HCPs) with resources so they can better integrate the topic of cognitive health into their discussions with clients. This article looks at this complex issue and the new ECHHO program.
Data published on July 17 in The Lancet shed new light on the subject. The ACHIEVE study was a randomized controlled trial where researchers in several different clinics throughout the United States investigated the effects of hearing intervention on cognitive decline. Audiological care and hearing aids were provided to two groups of older adults (average age of 77): one healthy group, and another group consisting of people who were also enrolled in a long-term study of cardiovascular health (Atherosclerosis Risk in Communities or the “ARIC group”) and who were at a higher risk for cognitive decline and dementia.
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Frank Lin, MD, PhD, who is the lead-author of the ACHIEVE study and several other papers dealing with hearing loss and cognitive decline, is Director of Cochlear Center for Hearing and Public Health at Johns Hopkins Bloomberg School of Public Health.
The results after only 3 years—a relatively short period given the gradual progression of cognitive decline—revealed intriguing differences across the two study populations. While hearing aids and hearing intervention had no significant effect when combining both groups, stratified analysis showed they “can reduce cognitive change within 3 years when implemented in older age for adults at increased risk for cognitive decline.” In fact, the ARIC group exhibited a remarkable 48% reduction in 3-year global cognitive decline following the hearing intervention, while no substantial effect was observed in the healthy group.
While ACHIEVE is a landmark study due to its size, duration, and high-quality clinical protocol, many other studies point to similar outcomes. The research was partly supported by Sonova, the parent company of Phonak, which supplied an in-kind donation of hearing aids for the project and also supported earlier work that suggested treatment of hearing loss with hearing aids might delay cognitive decline.
More recently, a 2023 study from an international team of researchers shows that people with hearing loss not using hearing aids had a 42% higher risk of all-cause dementia compared to those with normal hearing; notably, this same study found that people with hearing loss who used hearing aids had no increased risk for dementia, even after controlling for other factors.
At least three ACHIEVE study researchers from Johns Hopkins—lead author Frank Lin and co-authors Nicholas Reed and Jennifer Deal—have been involved in numerous studies that point to an association between hearing loss and higher risk for cognitive decline. For example, in 2011, Lin and colleagues found that mild hearing loss doubled the dementia risk, moderate loss tripled the risk, and people with severe hearing loss were five times more likely to develop dementia.
As more information linking hearing health to brain health is published in the mainstream media, consumers are inquiring about its implications.
“Recently, we asked a group of HCPs how important the topic of cognition is for them in their everyday clinical counseling and clinical practice,” says Stacey Rich, Manager of Audiology Leadership & Education at Phonak. “We found that 89% said it was either ‘very’ or ‘extremely’ important. Additionally, 71% said it's ‘often’ or ‘always’ a topic of concern in their appointments. There has been a lot of evidence and media attention about this issue, even in the past 3 years. And factoring in all the studies and the landmark Lancet Commission findings, we hypothesize it's starting to influence consumer behavior.”
Rich believes this could be a significant factor in the reduced waiting time between when people first notice hearing difficulty and getting their first hearing aids. MarkeTrak 2022 showed that the waiting time has shrunk to 4 years compared with 6 years in 2019.
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Could concerns about mental acuity and hearing loss already be spurring the hearing aid market? MarkeTrak 2022, a large-scale U.S. survey of people with hearing loss, showed a reduction in the time between self-identification of hearing difficulty (HD) and a first visit to an HCP (1 year sooner compared to 2019), as well as procurement of a first hearing aid (2 years) and second hearing aid (1 year). Source: Hearing Industries Assn.
Beyond the emotional and human toll of dementia, hearing loss has enormous economic consequences for medicine and our aging global population. The World Health Organization (WHO) estimates that the annual cost of unaddressed hearing loss is in the range of $750-790 billion globally, and a 2019 study estimated that 14.6 million people in the United States live with untreated disabling hearing loss with a cost of $133 billion each year.
So, with all the previous and emerging information about hearing loss and cognitive health, how do hearing care professionals (HCPs) responsibly educate their patients about it—without scaring them to death or being perceived as opportunists of this critical emerging science?
A new program developed by Phonak for hearing healthcare professionals called ECHHO—or Enhancing Cognitive Health via Hearing Optimization—aims to empower hearing care professionals (HCPs) with the knowledge and tools to better integrate the cognitive health aspect into their discussions with clients. The ECHHO program, which the company will roll out in Fall 2023, includes comprehensive training for hearing care professionals.
“Certainly, the idea of hearing healthcare and its relationship to general physical and mental healthcare is not new; it's been a theme for Phonak for more than a decade, and research we’ve been involved with goes back even longer than that,” says Stefan Launer, Vice President of Audiology & Health Innovation at Sonova. “But the obvious question is, ‘What's the benefit of all of this? How can we apply it in clinical practice?’ While there are still many unknowns, it’s not possible at this point to make specific product recommendations or hearing aid fitting adjustments for treatment based on the current science—and, of course, we and others are exploring all the research implications. But, right now, it's about how we deliver the message to the consumer. It's about how we talk about hearing loss, how we share what we know about the research, and present hearing care in the broader context of healthy living and aging.
“In 2020, Phonak launched the ‘Well-Hearing is Well-Being’ framework,” continues Launer. “And you can see ECHHO as an extension of that. I’ve spoken with Dr. Lin and many others about how we can talk about cognitive health retention in the context of clinical practice. It’s important to give HCPs a tool to guide them on this subject—and to avoid implying 'Hearing aids are a cure for dementia, so you should buy hearing aids.' Certainly, that’s not an acceptable approach. It comes down to giving consumers the correct information, framing the right message, and maintaining a positive voice so they feel empowered to make informed decisions.”
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Manager of Audiology Leadership & Training Stacey Rich and Sonova Senior VP of Audiology & Health Innovation Stefan Launer.
Phonak has developed the ECHHO training program to encourage HCPs to integrate cognitive health into their audiological counseling with their clients. Ultimately, this will help strengthen the patient's understanding of the benefits of hearing technology beyond just hearing better. According to Phonak, the program will include:
“At Phonak, we recognize the profound impact that hearing health can have on cognitive well-being,” says Phonak Senior of Director Audiology Angela Pelosi. “We believe that by proactively addressing hearing loss and promoting healthy living, we can help mitigate the risk of cognitive decline and positively impact the overall well-being of individuals. The ECHHO program represents our dedication to advancing the field of holistic hearing care and underscores our commitment to providing life-changing solutions for our clients.”
There is debate within the audiology community about how the topic of hearing loss and dementia should be presented to patients. A recent commentary by Jan Blustein, Barbara Weinstein, and Joshua Chodosh titled “It is time to change our message about hearing loss and dementia” warns that the general public isn’t well-informed about the medical concept of “risk.” They contend that consumers shouldn’t be prodded into believing hearing loss is a “harbinger of dementia,” and they even assert that the trigger word “dementia” might not be used at all. Instead, the clinician’s overall message should be more like, “Hearing better can help you think better.”
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Framing the conversation about hearing loss and cognitive health with the consumer might be better addressed from a more positive standpoint on what the cards say about the overall benefits of better hearing and early intervention.
Thus, ECHHO boils down to a delicate balancing act between conveying the hard facts of what consumers need to know versus the possibility of inserting—either accidentally or deliberately—inaccurate information or scare tactics about the links between hearing loss and dementia.
“I think we need a two-pronged approach,” says Rich about the ECHHO program. “We want to equip HCPs so they can integrate more holistic care—again not exactly a new concept given Phonak has been addressing well-being for years. And, frankly, I think this idea is presented well by most clinicians. But HCPs may not be so comfortable talking about cognition and cognitive decline, and how the ears and the brain have a kind of partnership in brain health. They don't always know how to integrate this type of information into the conversation, along with the overall well-being aspect. So that's really what we want to do with ECHHO.
“We’re at a critical junction to capture the current and incoming data,” continues Rich, “and we want to help HCPs better understand the existing evidence, then explain it appropriately without using scare tactics or negative motivation. I was a clinician for many years, and sometimes you see a patient where, over a period of time, you start to recognize the signs [of a cognitive problem]. What do you do then? How do you approach the issue within our scope of practice? What's the best way to get them to a professional who can support them? What's the procedure in your clinic and how do you refer? What information do you make sure is transferred to the referring professional? I think ECHHO will be a valuable resource that can help inform this decision-making.”
As Launer notes, there is not yet enough scientific evidence to make special adjustments in hearing aid programming or recommend one processing strategy over another to enhance cognitive performance. At least for now, he believes the future will rely more on professional counseling than the products being offered, and cognitive health will steadily find its way into best practices and counseling. As with today, the knowledge, skills, and counseling abilities, combined with technology, will drive successful outcomes.
But some facets of hearing aid use relative to possible factors in brain health are already being explored, such as listening fatigue. “Researchers are investigating what parameters make you either fatigued or not fatigued when using hearing aids, as well as optimal settings in certain conditions,” says Launer. “As we gain more understanding about the links between hearing loss and cognition, many more studies will be needed—not just looking into cognitive decline but also cognitive performance. Although there is so much we still need to understand at a basic level, it’s easy to see how this could become an important facet of future product development.
“With ECHHO, what we are trying to push now based on published results is to change the narrative about hearing loss, hearing care, and hearing aids—and demonstrate how important they may be. When we think about social participation, social interactions, and engaging with friends, family, and coworkers, it relies mostly on hearing. Listening well—with the prerequisite step being hearing well or audition—is so fundamental to social engagement. So these are more of the areas on which HCPs can concentrate their counseling efforts and paint a more holistic picture of hearing healthcare.”
Rich adds, "In circling back to the ECHHO program, our recommendations are really centered around taking a positive approach, and not using words that may be unsettling for clients like cognitive decline and dementia—and certainly not using scare tactics to motivate patients into taking action. We need to positively frame the messaging around the benefits of hearing healthcare and hearing aids for staying socially engaged, physically active, supporting brain health, and overall well-being and healthy aging. We also want to encourage hearing care professionals to focus on counseling and asking questions about cognitive health, and of course, if noticing signs of concern regarding cognitive health, then providing referrals to local medical experts in the area.”
Stay tuned for more updates on this issue by visiting the Phonak ECHHO website.
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Editor in Chief
Karl Strom is the Editor in Chief of HearingTracker. He has been covering the hearing aid industry for over 30 years.
