A member of the SENSE-Cog team in the UK, Dr Littlejohn provides an overview of multidisciplinary recommendations for diagnosis, management and care of older adults with hearing loss, vision loss and dementia. She underscores how consideration of hearing status when working with persons with dementia, has the potential to positively influence the care pathway.
Concurrent sensory loss (hearing and vision) and cognitive problems are common in the ageing population, with prevalence increasing with age. Recent research efforts have focused on uncovering the links between sensory loss and dementia and understanding why hearing loss is a leading risk factor for developing dementia .
Given the scale and impacts of combined sensory and cognitive loss, the SENSE-Cog project (www.sense-cog.eu) was launched in 2016. The primary aim was to comprehend better the impact of sensory loss and dementia, in order to promote early diagnosis, and plan health services and interventions to allow people to live well with dementia.
Practice guidelines for work with persons with poor sensory function and dementia
Despite knowledge of the prevalence of these comorbid conditions, relatively little effort has been afforded to understanding how to best support people when they have combined sensory and cognitive problems. Poor sensory function for people with dementia (PwD) in particular may exacerbate the impacts on a range of different outcomes including functional ability, behavioural disturbances and quality of life . In parallel, care providers and professionals often overlook sensory loss in PwD, due to lack of specific training and inter-disciplinary work . A project born from SENSE-Cog work was the development of international practice recommendations for the recognition and management of hearing, vision and cognitive impairment . We brought together a multidisciplinary team of healthcare professionals, academics, PwD and their carers from across the globe to develop best practice evidence-based recommendations directed at clinicians involved in the diagnosis, management and care of hearing, vision and dementia.
“A project born from SENSE-Cog work was the development of international practice recommendations for the recognition and management of hearing, vision and cognitive impairment”
We presented broad recommendations across six domains to increase (D1) awareness & knowledge (D2) recognition & detection (D3) evaluation (D4) management (D5) support (living well) and (D6) services & policies for people with sensory loss and dementia. This work also highlighted pragmatic options for implementation of each of the domains, for example optimising the living environment of the person living with HVC impairment to foster safety and independence (D5) and taking into account the impacts of hearing and vision impairment when professionals assess cognition as part of the cognitive evaluation (D3).
COVID impacts on persons with PwD
The lockdown and physical distancing restrictions brought about by the COVID-19 pandemic posed challenges when winding down our work with an already vulnerable and high-risk population. The need to pivot and work remotely demanded that we adapt some of our existing protocols while remaining focused on the needs of caregivers and persons with sensory loss and dementia. Our team was inspired to explore the effects of the pandemic on the relationship between hearing loss, mental health, and cognitive function, in the UK in particular.
“Our team was inspired to explore the effects of the pandemic on the relationship between hearing loss, mental health, and cognitive function”
We prepared an online survey to be completed remotely, which allowed us to explore the effects of the pandemic on the relationship between hearing loss, mental health and cognitive function in persons living in the UK. We found that people with greater self-reported hearing difficulties - as measured by the short form of the Speech, Spatial and Qualities of Hearing Scale (SSQ-12) - were more likely to also experience greater feelings of loneliness and depression and exhibit poorer cognitive function . Alongside this, many respondents believed their memory had changed for the worse during the pandemic, with increased odds associated with greater hearing difficulties. Follow-up work is ongoing to investigate whether the effects are sustained for the longer term. We are curious to learn whether the pandemic drives further cases of combined hearing loss and dementia, possibly through this psychosocial pathway.
Many limitations remain in terms of the evidence base for specific guidance aimed at hearing care professionals working with people with cognitive impairments. Information on ways in which hearing loss is best identified in this group of people, and how to choose the most appropriate management for an individual basis is sparse and not well understood by healthcare professionals in general and members of the audiology profession in particular.
A smaller international taskforce, made up of academics and clinicians working within the fields of clinical hearing and/or dementia, have collaborated on the preparation of a manuscript to guide hearing professionals when working with PwD. Here we were able to provide specific evidence and clinical opinions to aid members of the audiology profession in: (1) their understanding of the importance of person-centred care; (2) how to work with persons with PwD; (3) how to best adapt or modify hearing assessments to estimate thresholds; and (4) how to choose the right form of hearing management (including hearing aid use and verification as well as use of communication strategies and alternative hearing assistance devices). We placed considerable emphasis on the need for long-term care plans and provided specific examples of how these might look .
“Many respondents believed their memory had changed for the worse during the pandemic, with increased odds associated with greater hearing difficulties”
We are optimistic that once disseminated, this information will help augment hearing care professionals’ knowledge of and confidence in their ability to better support this growing client group. By recognising four important practices including: (1) the role of earlier identification and intervention; (2) the critical contributions of family/ caregivers; (3) the importance of clinician flexibility; and (4) the need for individualised goal setting, hearing healthcare professionals will hopefully gain the confidence and skills to successfully evaluate and manage the hearing healthcare needs of PwD. We are optimistic that our work will inspire greater appreciation on the part of healthcare professionals that adequate hearing is essential to effective communication, and to goal setting when working with PwD.
1. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396(10248):413-46.
2. Haque R, Abdelrehman N, Alavi Z. ‘There’s a monster under my bed’: hearing aids and dementia in long-term care settings. Annals of Long-Term Care: Clinical Care and Aging 2012;20(8):28-33.
3. Leroi I, Himmelsbach I, Wolski L, et al. Assessing and managing concurrent hearing, vision and cognitive impairments in older people: an international perspective from healthcare professionals. Age Ageing 2019;48(4):580-7.
4. Littlejohn J, Leroi I, The International Hearing, Vision and Dementia Practice Recommendations’ Task Force. Development of international practice recommendations for the recognition and management of hearing, vision and cognitive impairment. Supplement: Dementia Care and Psychosocial Factors 2020;16(S7):e036831.
5. Vercammen C. Interview with Jenna Littlejohn: Coronavirus, hearing loss and mental health. Phonak Audiology Blog 2020.
6. Littlejohn J, Bott A, Brennan, S, et al. Hearing assessment and rehabilitation for adults living with dementia. (In submission 2020).