Alzheimer's is predicted to afflict almost epidemic
proportions of the elderly in the coming decades, yet
the medical community in general still ignores the
cognitive and health impact of unmitigated hearing
loss.Reader inquiries may be directed to "Contact Us" or
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From the archives of Hearing Health Magazine:
Alzheimer's Tidal Wave A Hearing Connection?
By Max S. Chartrand, Director of Research
There’s a tidal wave coming all right – the exponential
growth of an aging population. Since risk of developing
Alzheimer’s disease (AD) increases with age, it has the
potential to become the epidemic of the new century.
Worldwide, the number of people with AD is projected to
increase to 22 million by 2025 and 45 million by 2050.
Making matters worse, mental processing difficulties
among older adults are so strongly identified with AD
that many seniors are either unaware or in deep denial
about the most pervasive forces behind cognitive
disconnection: hearing loss and central auditory
processing disorders.
When considering the mental health of the elderly, the
measurement of hearing and auditory deficits is sorely
neglected. Instead, these should be explored before
other possible contributing factors to perceived
problems with mental processing. Unfortunately, without
these considerations, the feared cognitive disconnect
will become self-fulfilling reality.
The Demographics of Aging
An alarming increase in the number of people living past
the age of 65 in the U.S. is imminent. This is the age
where most AD cases occur. Further, in the 85+ age
group, an even greater demographic advance will be seen.
Matching the growth of these age groups with increased
incidence of hearing loss, we find startling parallels
between uncorrected hearing loss and the number of
clinically suspected cases of AD.
Because the symptoms of uncorrected hearing loss mimic
outward behavior characteristics of early onset
Alzheimer’s, only a team that includes hearing and
mental health professionals would be able to ascertain
overlay components.
The predicted increase of AD also tracks the aging of
America. In 1999 there were 36 million people over age
65 in the U.S., 4.2 million of whom were diagnosed with
AD. By 2020, 52 million people will be over 65, with 8.9
million AD cases.
Lack of Professional Awareness
Hearing impairment among the AD population is twice that
of the non-AD population, when matched for age and
gender. This has been found in study after study. Yet
fewer than 10 percent of hearing-impaired AD patients
utilize amplification, compared to six in 10
hearing-impaired persons in the non-AD population. This
means that those who most need aural rehabilitation tend
to be the least likely to receive it.
Substantial professional and institutional barriers
prevent people with AD and hearing loss from receiving
hearing care. Among them are:
1) Lack of medical referral
2) Difficult-to-test stereotype
3) Lack of effective data
4) Inappropriate diagnosis and technology
Lack of access to ongoing care
Public Awareness
Only four percent of people with mild hearing loss use
hearing aids. Few are aware that they have an impairment
because they typically respond normally to the
low-frequency vowel sounds of speech. High-frequency
consonants, however, present more problems, particularly
in noise or at distances. Professionals tend to
underrate mild impairments, not realizing that this is
where a marked cognitive disconnect begins in the older
adult.
Still more tragic is the fact that in the moderate loss
ranges, only 36 percent are using hearing technology.
People in this category often find their lives
dramatically altered through broken social bonds,
reduced vocational and personal aspirations and, in many
cases, depression, hypertension and underlying anxiety.
Far too many are treated pharmacologically rather than
receiving aural rehabilitation.
But the real tragedy is that only 54 percent of people
with severe and profound hearing impairment in the U.S.
utilize hearing aids, cochlear implants, and assistive
devices. For the remaining 46 percent, lack of public
and professional awareness of recent technological and
clinical advancements has fostered dependence upon
society and prevented achievement of their true
potential.
Devil’s in the Details
A 1996 study at the University of South Florida found
that 49 of 52 elderly persons diagnosed with memory
disorders also had unmitigated severe hearing loss
(called “serious hearing loss” in the study).
Their conclusion:
“Undiagnosed hearing loss interferes with learning, and
makes people seem distracted, confused, disoriented and
unresponsive, traits that might suggest Alzheimer’s
disease.”
Other studies of elderly patients with uncorrected
hearing loss indicate “feelings of helplessness,
depression, passivity, and negativism.” Rapid and
accelerated decline in various dementias were found due
to uncorrected hearing loss in older adults. Social
isolation and depression are found in yet other studies
too numerous to cite here.
Hearing deficits, when uncorrected, can exacerbate
memory and cognitive disorders. For instance, the memory
pathways of the brain allow one to remember at the end
of a sentence what was said at the beginning, a mental
acrobatic feat that only humans can perform.
Putting Aural Rehab into the Picture
Nursing and administrative personnel who care for the
majority of AD cases in institutions for the elderly
claim that nearly all of their patients suffer from
dementias of various etiologies. When queried about
hearing aid use in their facilities, most respond that a
few of their patients have hearing aids.
Upon closer examination, however, it is found that the
“few” really don’t benefit from their instruments
because of dead batteries, wax in the receivers or
inappropriate control settings. “It’s just too much
trouble to keep up with,” comes the refrain of those who
most often must spend their finite resources regulating
medication, meals and basic life care. Yet most
individuals with AD would be on fewer medications, enjoy
more independence in daily activities and, most of all,
lead happier, more productive lives if their hearing
health were on par with their other health needs.
Allow me to propose a more logical and effective pathway
in the clinical protocols during the early stages of
symptoms that point to AD and other dementias:
Individuals come first to their primary physician
because of attentional and/or mild memory problems. The
doctor performs the appropriate physical to exclude
obvious physical/pharmacological contributors.
Physician refers the patient to a hearing health
professional for a full hearing and speech evaluation.
If a hearing loss is detected, treatment with hearing
aids and aural rehabilitation is instituted.
If cognitive symptoms persist after a 90-day interval of
aural rehabilitation, the patient is referred to a
mental or neurological health professional trained in
diagnosing and treating dementia.
The mental health professional refers the patient for
nutritional analysis and counseling in tandem with the
work of the other professionals.
Perhaps a speech-language pathologist is also indicated
for treatment of possible perceptive or expressive
aphasia, central auditory processing or other
communicative problems. The services of a geriatrician
or occupational therapist might also be warranted and
enlisted.
Through a team approach, these professionals then work
together for the benefit of the patient, recognizing the
important contribution each will make in the
rehabilitative process.
Conclusion
Hearing and mental health are intricately
interconnected. The sense of “hearing” actually occurs
in the brain, not the periphery apparatus. Hearing
requires normal communication function in the brain in
order to process appropriately. Likewise, in order for
the human brain to function normally, good hearing
health is required.
There is a glaring oversight in today’s clinical and
medical model when diagnosing and treating AD. The most
pervasive sensory filter of all, the vital sense of
hearing, is totally ignored in current protocols.
Meanwhile, billions of dollars are wasted, uncountable
hours of medical resources squandered and millions of
lives are held hostage. Needlessly so.
The (Economic) Toll of Alzheimer’s Disease
By Max Chartrand, Ph.D.
Persons with Alzheimer’s disease (AD) cost Medicare
approximately 2.6 times more money than those who do not
have the diagnosis, according to a recently released
study sponsored by the AARP Andrus Foundation. The
annual tab for a person with AD was around $18,500 if
s/he was living in a community setting versus $33,500
when living in a nursing home.
Researchers at Duke University, under the direction of
Donald Taylor, Ph.D., tabulated these figures using
information from 18,000 respondents to the 1994 National
Long Term Care Survey, a nationally representative
sample of persons 65 and over.
The average paid by Medicare in 1994 was determined from
the actual fees incurred for inpatient, outpatient, home
health, skilled nursing facility, hospice and services
such as physician payments and items such as durable
medical equipment.
Medicare financed care, the study found, was influenced
by how long a person had been diagnosed with AD – the
longer diagnosed, the lower the costs. Once diagnosed,
costs decreased by 10 percent each additional year,
suggesting that fewer medical resources are invested in
persons with a formal diagnosis of AD as their life
expectancy drops, net of other variables.
Medicare costs represented only one-fourth of the total
cost of caring for a person with AD.
Finding the Keys ... and a Cure?
As prognosticators broadcast the potential for disaster
in a burgeoning population at greater risk for
Alzheimer’s, researchers are racing to solve its
mysteries. Leaders in the fields of neurology, genetics
and medicine are making important discoveries daily.
None is yet the definitive solution but each fills in a
piece of the puzzle. And the new knowledge has enabled
pharmaceutical companies to develop and test new
forumlas for treatment and prevention.
Whether any of these breakthroughs can be significant
enough and soon enough to avert an Alzheimer’s crisis is
unclear. There are reasons to be optimistic, however.
Among them is a growing collaboration between
researchers, practitioners and caregivers. The first
ever global summit was held in July 2000, World
Alzheimer Congress 2000 (WAC), drew thousands of experts
to Wash., D.C. By the time the July 9-18 conference was
over, several bold new approaches were on the table.
The most promising research is honing in on the cause,
perhaps ending a century-long debate. First identified
in 1906 by Dr. Alois Alzheimer, one of two markers in
brain tissue damaged by the disease has been considered
the culprit. But which is it? Plaque, made up of the
protein amyloid, which litters the space between brain
cells that control memory and behavior? Tangles of
another protein (tau) that aggregate within the cells?
Or is it a combination of both?!
The most recent evidence clearly points to plaque,
suggesting that it may be toxic to surrounding neurons,
and that the amount of amyloid buildup does indeed
correlate with the degree of dementia. Basing their work
on this research, neurobiologists from Elan
Pharmaceuticals reported at WAC that they have developed
a vaccine which, in mice, prevents buildup of the
protein and decreases existing plaque. Clinical
investigations of whether it has the ability to prevent
or cure the disease in humans could begin late this
year. Meanwhile, a newly developed oral drug has
demonstrated the ability to inhibit the buildup of
plaque in animals and will also enter human trials soon.
In the therapeutic arena, findings unveiled at the
conference offer hope for the first time of slowing the
progression of more advanced Alzheimer’s. Researchers
from the New York Univ. School of Medicine described the
effects of a six-month treatment with the drug memantine
on people with moderately severe and severe cases.
Overall, although the disease was not reversed by the
end of the study, those who received the drug performed
significantly better in cognition and in daily life
activities than those in a control group who had taken a
placebo.
Other promising avenues under investigation are:
Finding genetic variants that put people at greater risk
for Alzheimer’s.
Utilizing brain imaging technology to identify
structural or functional variations which precede
symptoms.
Investigating the relationship of cardiovascular risk
factors with the incidence of Alzheimer’s (e.g., whether
or not high-fat diets elevate risk or exercise, eating
vegetables high in antioxidants or other “heart-healthy”
actions decrease risk).
Whatever the near future brings, Dr. Dennis Selkoe, a
leader in the battle against this elusive disease,
predicts that “sooner than one might have dared to hope,
Alzheimer’s will shed the veneer of invincibility that
makes it such a terrifying affliction.” He also believes
that practitioners will shortly have on hand not one but
several drugs capable of slowing and perhaps halting the
progress of the disease.
If Dr. Selkoe and others who share his optimism are
right, this is heartening news indeed.
--------------------------------------------------------------------------------
Dr. Max Chartrand, a staff writer for Hearing Health,
has studied Alzheimer’s for almost three decades. He is
the director of DigiCare Hearing Research &
Rehabilitation. digicarenet@aol.com
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