RP309 - Cognitive Screening in Audiology: A Cautionary Tale

Abstract:
This study characterized the outcomes of three hearing aid service levels, varying in professional assistance, with the goal of facilitating accessible and affordable hearing healthcare. 250 adults with mild-to-moderate hearing loss were evaluated in a double-blinded randomized controlled trial design. Participants performance on a cognitive screening tool (MoCA) was evaluated as a predictor of outcomes within and across levels of service. More than 25% of participants “failed” cognitive screening; however, screener performance was not significantly related to hearing aid outcomes either within or between levels of service. Potential implications for using cognitive screening in clinical practice will be discussed.

Summary:
Background. There is an increasing emphasis on modifying hearing aid related services to better meet individual patients’ needs and/or to improve affordability and accessibility. In addition, there has been considerable recent interest in the association between hearing loss intervention including hearing aids, and cognitive decline. The interest in cognitive decline is due, in part, to the fact that the number of people living with Alzheimer’s Disease and Related Dementias is increasing as the world’s population continues to age and because many older adults who experience cognitive decline are likely to experience hearing loss first, or concomitantly. While considerable research supports hearing loss treatment as a low-risk intervention for improved communication, reduced listening effort, and increased social engagement (all of which support healthy aging), the potential effects on cognitive decline are less clear. While research exploring hearing loss and cognitive decline continues, some have advocated for the use of cognitive screening within audiology practice.

Design and Purpose. The authors previously reported the hearing aid outcomes of a two-site double-blinded randomized control trial conducted at the University of Iowa and Vanderbilt University Medical Center; during which 250 participants with mild-to-moderate hearing loss were randomly assigned to one of six parallel arms. These arms included factorial combinations of three service-delivery models, ranging from Audiologist best practices to no professional services, and two levels of hearing aid technology. Prior to the hearing aid intervention, several baseline measures were collected which included cognitive screening via the Montreal Cognitive Assessment (MoCA); however, performance on these measures was not used as part of study inclusion/exclusion criteria. Patient outcomes were collected 6-7 weeks post fitting. As previously reported, while all participant groups demonstrated hearing aid benefits and satisfaction, participants who received best practices interventions had significantly better outcomes than those assigned to groups with limited or no professional services. The purpose of this investigation was to determine if performance on a cognitive screener was related to the previously reported hearing aid outcomes either within or across hearing aid service-delivery models or technology levels.

Results. 61% of participants had MoCA scores in the “normal” range (25-30) and 29% had scores between 11 to 24, indicating a risk for mild to moderate cognitive impairment. Using a more conservative MoCA cut-off score of less than 23, 13.6% of participants failed to “pass” cognitive screening. While severity of hearing loss, self-perceived hearing handicap and hearing aid expectations were significantly related to hearing aid outcomes in this study, linear mixed model analysis indicated MoCA performance was not. MoCA performance was also not significantly related to differential performance across the three service models (no significant interaction).

Conclusions. Overall, the results of this analysis suggest that performance on a cognitive screener is not related to self-perceived hearing aid benefit or satisfaction. Further, cognitive screener performance did not have predictive utility regarding the level of professional service needed to optimize hearing aid benefits. These findings are perhaps not surprising given that cognitive screeners do not provide diagnostic information; their potential clinical utility will be discussed.

Brief Summary of Clinical Takeaways:
Some limitations of implementing cognitive screening in clinical practice will be described.