MGordon_MD
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Apr 4, 2011, 9:07 AM
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By Dr. Michael Gordon
The husband was clearly very upset. He brought his wife to me as he had done periodically for the previous 5 years, along with her granddaughter and full time personal care worker. She and her husband were Holocaust survivors and her progressive dementia was very difficult on him. He did everything in his power to maintain her at home with whatever help she needed and even when in the past things looked pretty hopeless during acute illnesses, usually infections, he was relentless in his determination to get her treated and in essence, “return to life” however limited her cognitive function was.
During the past year or more her communication had been limited to monosyllables which she would often repeat over and over again, such as “yes” but he felt that she continued to recognize him and people close to her and understand the essence of what he was saying. But now he was close to despondent. “She has become almost silent. She doesn’t say anything and I do not think she understands anything I am saying anymore.” Her granddaughter who was a graduate student in psychology concurred, “I was always very close to her and although I think she recognizes me when I come in, she no longer utters even single words to me.” She went on, “it is only if I call and my grandfather puts the phone to her and I say my name does he think that she recognizes my voice.”
The husband asked if a speech therapist would help and I explained that this was not something that would be amenable to speech therapy intervention. As I was speaking I was looking through her health record which was quite large by this time and noted that remotely she had used a hearing aid. I asked her husband about it and he said, “she stopped using it years ago, it bothered her very much and as she became more impaired it did not seem to be helpful.”
I took out the Pocket-Talker® that I keep in my office which replaced an old Whisper 2000® device from a discount store when they were going out of business which was a very simple and inexpensive amplifier with basic headphones. The Pocket-Talker® had been my father’s and I and my sister found it very useful during the last year of his life when along with his progressive cognitive impairment, his hearing which had been poor for awhile appeared to decline further. We believed that the modest amplification provided to him enhanced his ability to understand what we were saying to him even as his condition declined.
I explained to the husband and granddaughter what I was doing and put the more sophisticated earphones that come with the device into her ears and turned on the volume to the lowest level. I gave it to the granddaughter and asked her to ask “Who am I” which she framed as “Bubie (grandma in Yiddish), who am I?” as she very gently increased the volume. Suddenly there was a look on her grandmother’s face of response as she turned towards her granddaughter and mouthed her name. I took the device and gave it to her husband and asked him to do the same, to which the patient turned to him and mouthed his name. Tears came to both their eyes as she seemed to respond to various questions with the monosyllabic answers she had been used to giving which her husband said had not occurred in the previous six month. The family left the office and went to borrow a device from our audiology department which provides them from 2-4 weeks for clients to try before they decide to purchase one.
The story was one of many similar ones that I have experienced in my practice as a geriatrician over the years. It brought to mind an experience I had some months previously. It was one of many geriatric meetings that I have attended as part of my academic professional activities. The speakers and the audience were all of members of one of the many health care professionals committed to the care of the elderly.
At the particular session I was attending, which was focusing primarily on issues of driving and aging, the question of hearing and cognitive impairment came up. A member of the audience who was an audiologist questioned one of the speakers about the importance of assuring a patient’s hearing capacity before a decision could be made about their cognitive abilities. The person who answered the question, a well respected geriatrician, contrary to what I would have thought to be a reasonably suitable answer, literally discounted hearing as playing an important role in the symptomatology and evaluation of persons with cognitive impairment. The questioner reiterated her concern that it was an issue, expressing some degree of incredulousness at the physician’s answer and from the murmuring in the audience it seemed that she was not alone in her connecting compromised hearing with compromised cognition.
After the session I went up to the therapist and expressed my surprise at the answer and told her of our practice at Baycrest in which we try to evaluate whenever possible a person’s hearing as part of an assessment, at least initially, of a person with symptoms of cognitive impairment.
I was therefore elated to read recently of a research study that implicated hearing impairment in the development of dementia which is a step further removed from its importance in a person already experiencing cognitive decline and perhaps linked as one component to be considered in its causation. To quote Dr. Frank R. Lin of the Center on Aging and Health, Johns Hopkins Medical Institutions, first author of the study published the February 2011 issue of Archives of Neurology, "Whether hearing loss is a marker for early-stage dementia or is actually a modifiable risk factor for dementia deserves further study."
From an article by Megan Brooks published in Medscape Medical News on February 16, Dr. Lin is quoted as saying, “a number of mechanisms may be theoretically implicated in the observed association between hearing loss and incident dementia. Dementia may be over diagnosed in people with hearing loss; alternatively, people with cognitive impairment may be over diagnosed as having hearing loss. It's also possible that the 2 conditions share an underlying neuro-pathologic process.” He goes on to say, “Another option is that hearing loss may be causally related to dementia, possibly through exhaustion of cognitive reserve, social isolation, environmental deafferentation (a complex medical term that means the freeing of a motor-[movement]t- nerve from sensory components), or a combination of these pathways.”
How do we translate this into our ordinary clinical activities and how should individuals experiencing cognitive decline and their families address the issue? One important step in the assessment and evaluation of cognitive impairment is to ascertain the level of hearing and if there is any doubt whatsoever--have a proper audiology evaluation. Sometimes this is not possible for many reasons. A rough test of hearing that we sometimes use in the office is not enough as it is not just sound that must be tested in a proper hearing evaluation but the ability to discriminate sounds into words and meanings. If there is any question of hearing impairment, it is always worth addressing it even with a Pocket Talker® this relatively low-cost amplification device that can usually help determine if some degree of amplification will enhance hearing and at the same time cognitive capacity.
I suggest to and encourage all physicians who care for the older patient group to have one in the office and use it even if only to help during the interview process. Sometimes, as in the case described above, the results can be quite dramatic and very satisfying. For elders and their families, make sure whatever else is going on, that hearing is as good as it can be. The newer amplification devices are very sophisticated and can accomplish a great deal. But sometimes something simple and inexpensive will meet the needs of the older person, especially if cognitive impairment makes it difficult to properly use the more complex in-ear amplification devices. As for a hearing assessment when these are available, don’t hesitate, just get it done.
This article first appeared on bestthinking.com.
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Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto.
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Moments That Matter: Cases in Ethical Eldercare: A Guide for Family Members, is available online at Amazon.ca.
His latest release is Late-Stage Dementia: providing comfort, compassion and care. It is available at Amazon and Indigo.
Visit Dr. Michael Gordon's website.
(This post was edited by MGordon_MD on Apr 4, 2011, 1:48 PM)
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