uh this is the second half of Courtney Volkers and our cochlear implant program Rebecca Lewis unbelievably accomplished. She is a doctor of audiology, she's going to talk about the importance of hearing loss as we age. Thank you. Thank you. Dr Griffiths, I'm very fortunate to be a part of this team. I joined uh pacific neuroscience Institute just a few months ago and I can already tell that this is a great home for for me and I'm very lucky to work with such talented physicians that we're hearing from today. Um So today I was tasked with talking to you about the importance of hearing loss as we age. I hope I can keep you awake after the food comas. And I know we've got our exciting keynote speakers right after this. So I'll try to do my best. So today I wanted to talk briefly about how prevalent hearing losses and I know dr Volker touched upon this as well. And so why is this so important? What are the effects of not treating hearing loss? And how can we help our patients by by treating it? By getting them the right type of help. So just to touch base on the audio graham or the chart of how we plot hearing on a graph this audio graham, I know you all are familiar with audio grams, but this audio graham has speech sounds overlaid on top of it. So you can tell you know where specific high frequency constants are and those softer high frequency areas versus vowel sounds are a little bit louder in the lower pitches. So if we were to overlay this hearing loss on the audio graham. This patient would have a moderate to severe hearing loss and really no access to the everyday speech sounds. So if you can imagine for your patients, sorry about that. There we go. If you can imagine for your patients that have this degree of hearing loss, they are missing out on conversation. There there's a great deal of auditory deprivation that's occurring, making it very difficult for people to communicate over time. Hearing loss is the third most prevalent chronic health condition in americans after hypertension and arthritis. And with the demographic of 70 year olds and older half of them have a significant hearing loss. Oh goodness, there we go. Hearing loss is one of the leading causes of disability worldwide and it's rising significantly over the next several decades. Hearing loss is also related to our vascular health. The inner ear is extremely sensitive to changes in blood flow, so inadequate blood flow to the inner ear can actually contribute to greater degrees of hearing loss. Um, diabetics are twice as likely to have a significant hearing loss and the same metabolic processes that occur in our inner ears actually occur in our kidneys as well. So, individuals with chronic kidney disease are also really likely to have a significant hearing loss as dr Volker mentioned. The older the patients, 70 and older, very few of them are seeking treatment. So fewer than 30% of these patients are getting hearing AIDS. And in younger adults The numbers are even poorer. Less than 16% have actually tried hearing AIDS. And when it comes to cochlear implants um Basically 5% 5-8% of patients who could benefit from a cochlear implant actually receive them. So this is a really major opportunity to reach patients. There's so many patients out there so many years to go around and so many ways that we can help these people. So what are the effects of not treating caring loss? As you imagine, quality of life? Uh even patients with just a mild to moderate hearing loss, perceive their hearing loss as a severe handicap like Dr Volker mentioned, loss of the ability to work, loss of independence, increased feelings of loneliness, isolation, depression, even suicidal ideation. Especially after the last few isolating years of the pandemic. And this is, this not only impacts the patient, this impacts their community, their family, their friends. While it isolates the individual, it also is affecting the people around them. Individuals with hearing loss also have a three times more likely risk of falling. And that risk of falls actually increases with each 10DB increase in hearing loss. So it's also something that we need to keep in mind as we know. Um falling contributes to embarrassment and hip fractures and all these things with our older adults. Something that's not talked about too frequently are the economic costs of hearing loss. There are some studies that show untreated hearing loss can decrease annual income by as much as $30,000. And the unemployment rates for untreated severe hearing loss are double that of individuals with normal hearing or treated hearing loss. So there's also the societal cost because of the underemployment of people with hearing loss. We also know that hearing loss is related to as we age. Hearing loss and dementia are more common because they're linked right? There are few proposed mechanistic pathways linking hearing loss and cognitive function. So, to put it in simplistic terms, the peripheral auditory system encodes the signal and sends it to the brain for processing and when that signal is fragmented because of a significant hearing loss that may require the brain to recruit other brain areas to process that sound and that could be at the detriment of other higher function processes like working memory. Additionally, there have been M. R. I. Studies to show that with increased rates of hearing loss, um there's actually increased rates of brain volume loss. So contributing to overall brain aging and then very intuitively to all of us as health care professionals. Hearing loss is associated with social isolation and social isolation is a strong predictor of cognitive decline for our patients. So there are many studies showing this link between age related hearing loss and dementia. This particular study I wanted to talk about today because they looked at this relationship over a period of 10 years and they had a huge sample they had a huge database of patients to pull information from. And unsurprisingly, incidence of dementia was significantly higher among those with age related hearing loss. But some of the conclusions from this study were really interesting. In particular age related hearing loss preceded the onset of clinical dementia by 5 to 10 years, making it a possible noninvasive biomarker for cognitive decline and probably one of the largest modifiable risk factors for cognitive decline because we just really need to give these patients access. So what are the benefits of giving these patients access or treating hearing loss? So the risk of false decreases. Actually there have been studies um actually of cochlear implant recipients where they They were wearing these um inertial sensors that while standing in the dark for 30 seconds with their cochlear implants on and then with them off and they found that they were greater there's greater stability with the cochlear implants on. Also when the cochlear implant was accompanied by music or sound input, that risk of falls further decline. Um And again we know risk of falls increases the risk of hip fracture and anxiety, embarrassment for these older adults but hearing can actually positively affect that there have been a lot of studies also to show the long term impacts of cochlear implants on various measures like cognition, speech perception, speech perception and noise um and just overall quality of life measures. So this particular study looked at these three measures Over a pretty good period of time and they found significant benefits at 62 months to a year post cochlear implantation. And these results remain stable even at seven years post. But it was pretty interesting was that pre pre cochlear implant testing showed That about 45% of the patients in the study had a mild cognitive, sorry, what does that mean? I had a mild cognitive impairment before they got their cochlear implant. And of that group 32% of them returned to normal cognition at seven years post cochlear implantation. And what's also pretty interesting is that while 54% of them had normal cognition pre implant, None of them had 0% developed dementia at seven years post cochlear implantation. So this is you're showing this link between having the correct amount of auditory access and cognitive health. And it also tells me that tells all of us that even individuals with a mild cognitive impairment should be considered for a cochlear implant. They shouldn't be. We shouldn't just decide that they couldn't benefit from this treatment because of any kind of cognitive decline and also that hearing rehabilitation has a positive effect on neurocognitive functioning. This study is really exciting because it was actually the first of its kind to show neurocognitive benefit from using hearing aids and I know we were just discussing hearing aids a little bit. So this cross modal reorganization is a form of cortical compensation observed in deafness and even with lesser degrees of hearing loss. So the auditory cortex actually gets repurposed by in tech visual and somatosensory modalities. So this study investigated if clinical treatment with hearing aids could actually modify neurocognitive outcomes. And they the study used high density E. G. To record responses to visually evoked potentials. They assessed cognitive function and then they did this speech perception and quiet and the noise. And they looked at 28 adults with untreated, mild to moderate age related hearing loss. They had aged matched normal hearing peers and then they assessed this group with age related hearing loss um at baseline and then six months after a proper hearing aid use. And I know we were talking a little bit about hearing aids before so I just wanted to add some of the fitting protocols that go into you know properly fit. Hearing aids makes a big difference um ensuring physical fit when when these patients see an audiologist for a significant hearing loss they need to make sure that the hearing aids are fit appropriately that they're verified and that they help orient the patient to how they work. And then of course talking about this auditory rehabilitation and acclimatization and when I say verification this is what it looks like in an audiology office or this is a equipment called real ear measurements or verification of the hearing aids where they actually put a little probe in the ear with the hearing aid to measure the output of the hearing aid to make sure it meets prescriptive um formula. They use a prescriptive formula to make sure it meets those targets to ensure proper aud ability. So in this study they insured properly fit hearing aids. And these hearing aid users were good users that wore them all day every day. They were not compensated but they still or they were compensated by the study. But so maybe that improved their hearing aid use at baseline before the hearing a trial. The brain this shows that the first column column A. These are nor the normal hearing peers and column B. Shows that the brain is recruiting and repurposing the auditory cortex for other brain functions. So this is before the hearing aid trial. And then following the six month hearing a trial there was an actual reversal in cross modal reorganization of the auditory cortex. Um And this actually reflected more normal organization of the cortex that was very similar to the normal hearing um subjects at baseline. So this is exciting because this is actual evidence to show that treating hearing loss can lead to neuro plastic changes in the brain and have cognitive benefits and even have this reversal in effect treating hearing loss with hearing aids or cochlear implants. Clearly we've demonstrated really helps patients um better sound signal reduces the cognitive load reduces the listening effort and fatigue it stimulates the brain to prevent volume changes. Some studies have even shown that even with three weeks worth of hearing aid use patients perceived a dramatic reduction in their psychosocial handicap and then there's these economic benefits that are really not spoken about much. So people ask us a lot what's better hearing aids or cochlear implants. And for adults who are cochlear implant candidates, cochlear implantation is better than hearing aids. They've done studies regarding speech perception measures educational opportunities, employment opportunities, quality of life measures for patients who are candidates for cochlear implant and not everyone is obviously so for those patients who are candidates that cochlear implants always outperform hearing aid use. And cochlear implants are cost effective for the patient in particular. They might be going through several sets of hearing aids and hearing aids are basically amplifying sounds and already damaged hearing system. So there's a narrow dynamic range, meaning the difference between what they hear soft and what they hear loud is very narrow and it makes it there's this high amount of recruitment meaning what it's barely audible is very close to what's uncomfortably loud so they're cost effective also for the for you and for the for the healthcare providers because having proper amplification can reduce depression isolation. All these other health risks that we talked about earlier. The problem with cochlear implants like dR Volker mentioned is that adoption is low even though we've gone a long way from these vintage cochlear implants that are very large um and had to be worn on the body to these off the ears, very sophisticated, bluetooth compatible processors. The penetration of cochlear implants is really only 5- 8%. What else is important? Of course, compensatory strategies and rehabilitation is very important for these patients lip reading using good um good visual cues of course good communication strategies. Um in terms of, you know, auditory rehabilitative strategies. Dr Volker talked about audio books which is great and we always recommend that also ted talks are fun because nowadays you can find a ted talk on anything that interests you and they have real time closed captioning without the delays that are TVs have. So they can re they can really strengthen those neural pathways between what the words that they're seeing and what they're hearing through their technology, other types of things to make life easier for your patients. Um Capital phones aren't readily given to patients for some reason but they are free from the state of California, you just need a professional to authorize them. So I do this with basically every patient that I see for a cochlear implant. So they're just free phones that will transcribe everything that's being said. Even voicemails, they get really excited about the voicemail part. Um remote microphone technology is used all the time for Children and not used very much for adults but it really helps here and background noise and they're they're accessible from hearing aids and cochlear implants. Um So there's a lot more that we can do. There's transcription apps like Eva and then also empowering your patients to use. Self advocacy is really important, helping them with these resources to know about their hearing loss. Let people know research the accommodations that are appropriate for them in the workplace, understanding where to position themselves in a restaurant. For instance instead of sitting in the middle of the restaurant where noises all around them sitting with their back like in a booth to the wall so that the noise is directed in only one direction. Um you know support groups are always helpful and then full time use of technology is really important. And unfortunately a lot of patients don't realize this but your brain needs to acclimate to hearing more sound, especially if there's been a longer duration of deafness. Um So full time use is always associated with better outcomes for hearing aids and cochlear implants. So obviously hearing loss, we've we've demonstrated very highly prevalent untreated. Hearing loss has a lot of health risks associated with it and we know now that hearing loss is a modifiable risk factor for dementia and cognitive decline and we can maybe even reverse some of these effects of cognitive client with appropriately fit amplification. Hearing aids and cochlear implants. Just encouraging patients to use technology. Um access auditory rehabilitation and just practice this. These self advocacy techniques can really help individuals. We've seen pretty miraculous changes in quality of life and with many of our patients. So our cochlear implant um program email is live now. So if you have referrals or patients that you need seeing you can send it here. That's our clinic phone number and that's my personal email address. If you have questions or just want to run ideas past us about some of your patients that you're struggling with. We're happy to help you any questions. I think there's one question. I was fascinated by the idea that playing music in the ear. It helps you from falling I think having the spatial or having the auditory access also improves your spatial awareness. So just by wearing them improved their balance but also by having that auditory input that further improved their balance because they could sort of assess their their body in space. Yeah but it's pretty nice. Yeah. Thank you. Um Becky. That was fantastic.