Cognition & Audition

Presenter:

Douglas Beck, AuD

Director of Professional Relations

Oticon, Inc.

dmb@oticonusa.com

http://www.audiology.org/news/Pages/20140305.aspx Kochkin S. (2014): A Comparison of Consumer Satisfaction…Associated w/ Traditional & Direct-Mail Hearing Aid Use. The Hearing Review. January:16 – 26.

n=2300.

Mail Order ASP =$299

Traditional = $1500.

Direct Mail & Traditional: wear their hearing aids nine hours daily, nearly equivalent overall satisfaction

nearly equivalent perceived benefit,

sound quality statistically equivalent.

Direct mail customer rates their purchase "higher on value…."

Unscheduled Changes in Audiology, Internet Sales, and Direct Mail:

Interview with Kim Cavitt, AuD http://www.audiology.org/news/Pages/20140521.aspx

We need to focus on the

practice more than the products!

http://hearinghealthmatters.org/hearingeconomics/files/2013/06/logo-hearing-economics1.png “The Unraveling of Hearing Healthcare Delivery” Parts 1 and 2. HHTM Hearing Economics Editor Holly Hosford-Dunn presents Jerry Northern, Ph.D. as guest editor for a two part-article in June, 2014.

Dr. Jerry Northern on survival of our profession….

As hearing aids morph into “consumer electronics” the consumer can acquire reasonable devices almost anywhere.

Freeman BA. (2014) The Future of Hearing Care—What Survival Lessons Can We Learn From Other Professions. Audiology Today. 26(2):31-36. http://www.audiology.org/news/Pages/20140619.aspx

Professional Survival and Lessons Learned

Audiologists (and dispensers) generally bundle their prices, which has kept costs high, leading to "the emergence of discounted retailers like big-box stores who focus on the sale of products and not professional services."

Excerpts from Dr. Lucille Beck at JDVAC meeting…

The goal is to provide veterans personalized, proactive, patient-driven health care….VA Health Care partners with each Veteran to create a personalized, proactive strategy to optimize health and well being…

Hearing aids have been traditionally fit without patient involvement… they have been fit to the patient, not with the patient.

How’s that working?

Not working so well!

Kochkin (2009): MarkeTrak VIII, Hearing Review, October 2009. Beck & Kochkin: (2013) Amlani (2010) : Market Penetration Rate. Audiology Today 22(3):40-46 Taylor (2009): Survey of Current Business Practices in Hearing Journal, September 2009 Institute of Medicine (2014)

35 million people (USA) with hearing loss.

17.5 million with true need for amplification.

15% of people with hearing loss will walk thru the door.

1 of 2 people who walk thru the door get amplification.

35/2= 17.5 million people need HAs

(.15) = 2.6 million walk in the door

2.62 (.5) = 1.3 million people received HAs (2013)

(assume binaural rate @85%)

1.3 (1.85) = 2.4 million units

Insanity… Doing the same thing

over and over and expecting

a different result…

PERSONALIZATION MATTERS….

Using technology to solve a problem

perceived by the patient.

What problem do they perceive?

Speech In Noise.

Not their audiogram!

Lou Reed 2013: “I know the way I like things to sound”

I can pick a shoe in your size,

but…

SMART PHONE?

LAPTOP?

TABLET?

Personalization Matters!

What’s the first thing you do when you get a new….

Why Personalize?

Patient Involvement.

Patient Responsibility.

Respects patient preferences.

Demonstrates the value of HCP.

Helps SATISFY the patient.

Builds TRUST.

Satisfaction? http://blog.clientheartbeat.com/why-customer-satisfaction-is-important/

Why SATISFACTION is important:

1- leading indicator of loyalty.

2- differentiation.

3- increases customer lifetime value.

4- reduces bad PR (word of mouth).

5- cheaper to retain pts than

acquire new ones!

Carhart, R. (1946): Tests for the Selection of Hearing Aids. Laryngoscope, Volume 56, pages 780-794. Johnson, EE. (2013): An Initial Fit Comparison of Two Generic Hearing Aid Prescriptive Methods (NAL0NL2 and CAM2) to Individuals Having Mild to Moderately Severe High Frequency Hearing Loss. Journal of the American Academy of Audiology. Volume 24, Pages 138 to 150.

Johnson states “allowing patients to compare validated hearing aid prescriptions at the time of the initial fitting is another step toward enabling the patient to direct his/her treatment within a range of reasonable options…The implementation of such comparisons would bring hearing aid fitting processes full circle back to the Comparative Approach

(Carhart, 1946).

We need a “Plan B”

Audiology

Cognition

Amplification

http://www.theaustralian.com.au/news/world/before-we-get-into-something-we-must-know-how-to-get-out/story-fnb64oi6-1226710792081 BY:DANIEL FINKELSTEIN From: The Times September 05, 2013

The Nobel prize-winning behavioral economist Daniel Kahneman described his great intellectual breakthrough as …the realization that social science experts often rely on research using samples that are too small, prompting highly unreliable conclusions.

Do audiologists ever take a small data sample and apply it to predict the entire universe?

GUILTY

Dead Zones?

Cochlear Dead Regions and Hearing Aid Fittings Cox, Alexander, Johnson, Rivera (2011): Cochlear Dead Regions in Typical Hearing Aid Candidates: Prevalence and Implications for Use of High-Frequency Speech Cues. Ear & Hearing 32(3):339-348

170 adults evaluated for dead regions (DRs) from 500 to 4000 Hz using the Threshold Equalizing Noise test (TENS). 1/3rd (58) had dead regions. QuickSIN (speech in noise as the metric)

LESSON ONE: One cannot tell DR or no-DR via audiogram (substantial overlap).

LESSON TWO: Those who were positive for DRs performed better when

more high frequency cues were available.

DOES NOT support limiting/reducing high frequency gain for DRs.

Clinicians should use best practice recommendations for these

patients based on evidence-based prescriptive measures.

Frequency Lowering?

Harvey Dillon, HEARING AIDS (text book, 2012). Frequency Lowering on Pgs 226-239

Both FL protocols (transposition and compression) provide audibility of high frequency sounds…yet they do not guarantee better intelligibility as speech components shifted downward may interfere with speech components originally dominant in the lower frequency range…Worse still, for some people, excessive amplification of the high frequency parts of speech (via frequency lowering) can DECREASE their ability to recover useful information from the mid and low frequency parts of the speech signal….

Chart from AudiologyOnline, Feb 2014.

What happens to the information that was ALREADY there?

Dillon, Ching & Golding, M. (2014): “Hearing Aids For Infants and Children.” Chapter 20, pages 209 to 227, in Pediatric Audiology Diagnosis, Technology and Management. 2nd Edition. Eds; Madell & Flexer. Thieme.

Frequency lowering can sometimes increase intelligibility but not all frequency lowering schemes have positive results.

The need for effective frequency lowering hearing aids has been reduced while availability has increased.

To be clear…

I am NOT opposed to FL.

I would like to see the science (RCT, control vs experimental groups in peer reviewed journals) which validates and verifies the outcomes for adults and children.

There are case studies which demonstrate benefit now and then, here and there.

I am looking for CONTROL vs EXPERIMENTAL groups in which the MAJORITY of pts do better in SIN with FL.

As best I am aware…Distortion is bad. Distortion doesn’t satisfy the patient…loudness, spectral, temporal…Distortion is not what the brain wants to hear…

Some other things that matter….

Audiograms

Word Recognition Scores

The best PT audiogram…

250, 500, 750, 1000, 1500, 2000, 3000,

4000, 6000, 8000 Hz = 10 data points

19,980 Hz, 10 data points =

0.0005% sample size.

How large a sample?

http://www.surveysystem.com/index.htm

20-20,000 Hz = 19,980 range

1400 discernible pitches

Confidence level +/- 5% (error)

Confidence Interval 95% (certainty)

302 samples required

Count The Dots

Mueller and Killion,

Hearing Journal January 2010

For Speech….71 dots (%) at or above 1000 Hz

88 Keys on a piano. 63/88 keys <1000 Hz,

For music, 72% of fundamental frequencies < 1000 Hz

Word Recognition Issues:

W-22 & NU-6, not real world,

not very useful, not well

administered….

(don’t even try to defend MLV!)

Speech Audiometry, Word Recognition, and Binomial Variables: Interview with Gary Lawson, PhD http://www.audiology.org/news/Pages/20120125.aspx

Academy: Present a 25 word list, first score obtained on the left ear is 88 percent, what is the statistical range of scores that would be the same on the other ear?

Lawson: The range for a SAME second score is 68 to 100 percent.

Primary Complaint of 99.99%?

Speech In Noise

Which one of these tells us ANYTHING the patient’s ability to listen to speech in noise?

Audiograms SRT

SAT Tympanograms

Reflexes ABR

OAEs WRS (SDS)

What is it we do to assess the

perceptual complaint?

Insanity… Doing the same thing

over and over and expecting

a different result…

Speech-in-Noise Testing: A Pragmatic Addendum to Hearing Aid Fittings Hearing Review May 2013 Beck & Nilsson

Incorporate a simple-to-administer, statistically meaningful, real-life “speech-in-noise” (SIN) test and protocol to evaluate one’s “baseline” ability to understand speech-in-noise.

Speech in Noise Tests for Validation/Verification

Speech Perception in Noise (SPIN)

QuickSIN

Hearing in Noise Test (HINT)

Words in Noise

We need a “Plan B”

Audiology

Cognition

Amplification

Balancing Act between TD & BU processes:

When BU sensory-input is compromised,

TD must work harder to

maintain

balance.

Working Memory OpEd

www.audiology.org March 2014

Humans are Dynamic

In 1800, 37 years.

In 1900, 50 years.

In 2009, 79 years.

Life expectancy DOUBLED in 200 yrs.

The Singularity –When Humans Transcend Biology. Ray Kurzweil, 2005

CDC 2008

Alzheimer’s Disease:

Above age 85, 50% have AD.

Lin, FR., Yaffe, K., Xia, J. et al June 2013, JAMA Intern Med Volume 173, pages 293-299 HEARING LOSS AND COGNITIVE DECLINE in OLDER ADULTS

Hearing Loss is independently associated with accelerated cognitive decline…in older adults.

Further studies are needed to investigate whether hearing rehabilitative interventions could affect cognitive decline.

Patients live in a world where cognition, attention, memory and hearing interact - and each plays a critical role in listening.

It ain’t all about hearing!

To be at the TOP OF THE FOOD- CHAIN depends more on LISTENING than HEARING!

Cute? Perhaps… Good at Listening? Not so much!!!

“How Cognition Might Influence Hearing Aid Design, Fitting and Outcomes” Pichora-Fuller, K. November 2009, Hearing Journal

LISTENING is more challenging for

people who perform less well on

cognitive tests, and they do even

worse in noisy backgrounds.

“ATTENTION IS THE HOLY GRAIL”

Outdoors and Out of Reach, NY Times. M. Richtel. Quoted David Strayer PhD,

Professor of Psych, University of Utah, N.Y.Times, August 15, 2010

Where you attend is how you will do!

(Beck, 2010)

Brain Training:

Lumosity

LACE

NAL Listen & Learn

Posit Science

Earobics

Fast Forward

Our Challenge:

Beyond hearing.

Improve the opportunity for

Listening Success!

MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE MAJOR ISSUE

Should HCPs

screen COGNITIVE ABILITY?

(not all patients, some, now and then,

when indicated….)

59

Mueller, Ricketts & Bentler: Modern Hearing Aids, 2014. Plural Publishing

Cognitive Tests (page 193):

We…agree…the patient’s cognitive function will

impact the hearing aid fitting process and will influence our counseling…

It seems reasonable, to …include a cognitive text

in our pre-fitting battery…

THE CARE and FEEDING of the BRAIN.

Feeding the brain a healthy acoustic diet…

Maximize bandwidth. Maximize dynamic range. Maximize preservation of speech detail. Maximal SNR. Maximize audibility. Minimize distortion. Mandate a binaural system (compare/contrast) in which HEARING AIDS TALK TO EACH OTHER in real time TO ACCOMPLISH BRAIN HEARING! And BTW…What works is personal!

We need a “Plan B”

Audiology

Cognition

Amplification

Technology’s Role?

If we maximize BU signal,

TD functions are easier & more efficient.

Yost & Nielsen, 1985

Inner Hair Cells

Normal IHC

Damaged IHC

Damaged & Aided

Intelligent Application of Automatics:

Engage (if and only if) SNR improves

Effects of Digital Noise Reduction on Speech Perception for Children With Hearing Loss (2010). Stelmachowicz, Lewis, Hoover… Ear & Hearing, Vol 31, No 3

16 children ages 5 to 10 yrs w/mild-to-moderately severe SNHL

Goal: To examine the effects of digital noise reduction.

Test Stimuli: Nonsense Syllables, Words, Sentences in Noise

CONCLUSION:

Consistent with previous studies

NR does not have negative

effect on perception of nonsense syllables or

words or sentences for children using SNRs of 0.

Pittman A. (2011) Age-Related Benefits of Digital Noise Reduction for Short-Term Word Learning in Children With Hearing Loss. Journal of Speech, Language and Hearing Research 54 (October):1448-1463.

Pittman (2011) examined word learning rates with regard to children with normal hearing (n = 41) and children with hearing loss (n = 26) in quiet and noisy backgrounds and she examined the effect of DNR across younger/older children with hearing loss.

For older children listening with DNR engaged,

DNR was beneficial and contributed significantly to

word learning rates for the older children.

Dillon, Ching & Golding (2014): “Hearing Aids For Infants and Children.” Ch 20, pgs 209 to 227, in Pediatric Audiology Diagnosis, Technology and Management. 2nd Ed. Editors Madell and Flexer. Thieme Medical Publishers, Inc.

Dillon, Ching and Golding…adaptive noise reduction should be used for all children…We recommend noise reduction systems be routinely enabled for children of all ages just like adults!

Extended Bandwidths in Hearing Aids Beck & Olsen, Hearing Review, October 2008

Improved spatiality.

Improved Speech-in-Noise.

Improved Word Recognition Scores.

Improved music perceptions.

Improved sound quality.

Speech Effort, Speech Production in Noise, and Listening in Noise: Interview with Andrea Pittman, PhD http://www.audiology.org/news/Pages/20130619.aspx American Academy of Audiology June, 2013

Directional technology is most beneficial when

the person wearing the hearing aids physically places himself between the signal of interest (i.e., speech) and the noise source (i.e., background noise).

Harvey Dillon, HEARING AIDS (text book, 2012). Published by Boomerang Press/Thieme

All hearing aid wearers are candidates for Dir Mics because all HA wearers need a better SNR than people with normal hearing…There seems to be no reason not to prescribe directional mics for all clients, provided the hearing aids automatically switch…

Dillon, Ching, & Golding, M. (2014): “Hearing Aids For Infants and Children.” Ch 20, pgs 209 to 227, in Pediatric Audiology Diagnosis, Technology and Management. 2nd Ed. Eds Madell & Flexer. Thieme.

Hearing aids are available which switch automatically from omni to directional mode (if and only if) the directional mode has a superior signal-to-noise ratio (SNR). All children …should be fitted with automatic switching directional microphones as a matter of course.

Connectivity in 2011: Enhancing the Human Experience Hearing Review, March 2011 Beck & Holmberg http://www.hearingreview.com/all-news/17080-connectivity-in-2011-enhancing-the-human-experience

REMOTE MICS

WHY REMOTE MICs?

(based on Beck, Doty-Tamasula and Sexton 2006)

Reduces effect of background noise

Reduces the effects of distance

Reduces the effect of reverb

Maximize SNR

Harvey Dillon, HEARING AIDS (text book, 2012). See Page 7. Boomerang Press/Thieme

MAJOR CHANGE IN PHILOSOPHY:

For every 10 dB of hearing loss (4fPTA), a 1 to 3 dB increase in SNR is required to maintain intelligibility.

As hearing loss increases, the required SNR increases.

Dillon, Ching, & Golding, M. (2014): “Hearing Aids For Infants and Children.” Ch 20, pags 209 to 227, in Pediatric Audiology Diagnosis, Technology and Management. Second Edition. Eds; Madell & Flexer. Thieme.

Wireless remote-microphone hearing aids…anytime children need to listen attentively from more than a meter away.

“a wireless signal can easily offer as much as a 20 dB improvement in SNR over acoustic reception.”

Beck 2010…

Knowing WHERE TO LISTEN matters.

Spatial Hearing and Understanding Speech in Complex Environments. Neher, Behrens & Beck. Hearing Review, Nov 08

Kidd et al (2005)

Schneider et al (2007)

KARL STROM THANK YOU!!!!!!!! ILDs can be 5 dB at 1kHz, and 20dB at 6 kHzBased on Sivonen and Ellermeier (2006). (from Behrens, 2008, Hearing Review, Vol 15, No 3, Pages 94-102)