Cognition, Audition, and Amplification feat. Dr. Douglas L. Beck

About The Hearing Matters Podcast
The Hearing Matters Podcast discusses hearing technology (more commonly known as hearing aids), best practices, and a growing national epidemic - Hearing Loss. The show is hosted by father and son - Blaise Delfino, M.S. - HIS and Dr. Gregory Delfino, CCC-A. Blaise Delfino and Dr. Gregory Delfino treat patients with hearing loss at Audiology Services, located in Bethlehem, Nazareth, and East Stroudsburg, PA.

On this episode, Blaise and Dr. Delfino welcome Dr. Douglas L. Beck as their featured guest! Dr. Douglas L. Beck earned his undergraduate degree (B.A.) in Communication Disorders & Sciences (1982) and his master's degree in audiology from the University of Buffalo (1984) and his doctorate  (Au.D., Doctor of Audiology) from the University of Florida, Gainesville (2000).

His professional career began in Los Angeles at the House Ear Institute in clinical audiology, cochlear implant research, and intraoperative cranial nerve monitoring.  In 1988, he was appointed Director of Audiology at Saint Louis University in the department of Otolaryngology - Head and Neck Surgery. Eight years later he co-founded a multi-office hearing aid dispensing practice in St. Louis, Missouri.  In 1999, he became President and Editor-In-Chief of; AudiologyOnline.com, SpeechPathology.com and HealthyHearing.com. 

Dr. Beck joined Oticon in August, 2005. In December, 2019 he was promoted to Vice President of Academic Sciences at Oticon Inc.

Dr. Beck is among the most prolific authors in audiology with 188 publications and more than 1275 abstracts, interviews, and op-eds written for the AAA (2008-2015), Hearing Review (1990- 2020) and Audiology Online (1999-2005) addressing a wide variety of audiology and professional topics including; audiology, the profession of audiology, pediatric audiology, cognition, hearing aids, audition, counseling and more.

On this episode we discuss: 

• Cognition, Audition, and Amplification 
• Top Down, Bottom Up Approach as it Pertains to Hearing Aid Fittings
• Pragmatics and Hearing Aid Fittings 
• Velox S Platform Findings 
• Understanding Speech on Par with Individuals with Normal Hearing Sensitivity 
• The Importance of Real Ear Measurement (and why you should visit a hearing healthcare provider who conducts REM on a regular basis) 
• The Essentials of a Successful Hearing Aid Fitting
• The Importance of Conducting Speech in Noise Testing 
• Going Beyond the Decibel 
• The Importance of Visiting Your Hearing Healthcare Provider Annually 

Are you new to wearing hearing aids?

Welcome to your new hearing world! You made the important decision to increase your speech understanding and decrease your overall listening effort. Moving forward with hearing aids can be scary. Maybe you've heard stories of friends or family purchasing hearing aids and wearing them in the drawer. However, when patients are fit with hearing aids using best practices (real ear measurement, outcome measurements, etc.) they adapt to their

Transcript

Blaise Delfino: 0:06

You're tuned into the hearing matters podcast with Dr. Gregory Delfino and Blaise Delfino of Audiology Services and Fader Plugs. The show that discusses best practices, hearing technology, and a growing national epidemic- Hearing Loss. On today's episode, we're going to be discussing cognition, audition, and amplification. And ladies and gentlemen, I have to say Dr. Delfino and I are so excited for this episode because we have a very special guest on air with us today. His name is Dr. Douglas Beck. Now, Dr. Beck's professional career began in Los Angeles at the House Ear Institute in clinical audiology, cochlear implant research and intra operative cranial nerve monitoring. In 1988, he was appointed director of Audiology at St. Louis University in the department of otolaryngology head and neck center. Eight years later, he co-founded an audiology and hearing aid dispensing practice in St. Louis, Missouri. And in 1999, he became president and editor in chief of AudiologyOnline.com, SpeechPathology.com and HealthyHearing.com. Dr. Beck is among the most prolific authors in audiology, with 186 publications and almost 1300 abstracts. That is absolutely incredible. And today, Doug Beck is the Vice President of Academic Sciences at Oticon. Welcome to hearing matters, Doug! How are you?

Dr. Douglas L. Beck: 1:45

Thank You Blaise. Thank you, Greg. It's a joy. And I am fantastic.

Dr. Gregory Delfino: 1:49

Great to hear Doug. You're across the country from us. And we're all kind of itching to get out and get a little bit more social. And it's it's so great to hear a nice familiar voice and a chance to, to catch up and get into a very professional but personal way as well.

Dr. Douglas L. Beck: 2:07

Absolutely. I've been looking forward to this for weeks. And thank you guys for the kind invitation. It's very, very nice of you, and I hope that the conversation will be useful for your audience, which I know is vast and spans across the country.

Blaise Delfino: 2:21

Dr. Beck now, reading your bio, and I am a younger and newer clinician in the hearing healthcare world, I guess you could say I'm genetically predisposed, but I have to say, reading your biography, when do you find the time to sleep? Because you're you're doing all this stuff. That it's it's absolutely incredible.

Dr. Douglas L. Beck: 2:43

Well, you know that old saying that when you do when you when you work at something that you really like when you find your passion i life, you never work in you life. Well, I am I am probabl the luckiest audiologist on th planet because my jo description at Oticon is read write, research, repeat publish. That's it. It's lik five words, and that's what do. But you know, it's so muc fun for me, because every year it gets more interesting. Ever year, we uncover new phenomen related to hearing and listenin and you know, you can never sto learning, you know, you have t be an adult learner. Becaus when you get to that point whe e you say, "Oh, I know all of th s", then you become the most bo ing person on the planet and I d n't want to be that

Blaise Delfino: 3:25

So for any of the newer clinicians listening right now, if you do what you love, you will never work a day in your life. Now, Dr. Beck, today we're going to be talking about cognition, audition, and amplification. So for our listeners right now, can you just briefly in layman's terms define cognition and audition?

Dr. Douglas L. Beck: 3:46

Yeah, so and Greg, feel free to jump in here because Greg's an expert in the same area. But, you know, cognition is your ability to know. Cognition is your your self awareness and cognition. There's no one singular definition that meets all the needs of the people who use the term. When we talk about cognition, human beings are spectacularly different from all other animals. What do you think about things like hearing, listening, cognition, language - this is what separates us it's not our hearing. human hearing is quite poor in the animal kingdom, it's 20 hertz to about 20,000 hertz. Well, my dog that you may hear whining that's a 70 pounds of German Shepherd. She is, she can hear at about 38 40,000 hertz whales, dolphins porpoises can hear you know, hundred hundred and 40,000 to human hearing is not very good in the animal kingdom or mammals or, or any such being but if you think about our listening, well, that's a different world because we can assign meaning to sound. We can take language and there's hundreds of languages across the globe. And we can talk about the past the future we can talk about ideas and concepts, and you know, dogs and cats and cattle and horses, you know, They're kind of limited to alerting to sounds, or maybe, you know, they make a purring sound if they're happy, but they don't have language anywhere near like what we have. And that's what separates us. So cognition is all of that and more, it's your ability to take in sensory information from your five senses and to use it to your own advantage by thinking, and by thinking deep thoughts that allow you to assign meaning to sound. So that's cognition, audition is what you do with what you're hear. You know, everybody hears a little bit differently, we have ranges of normal hearing, but they're not really scientifically based. They're convenience based. And and so audition is what you do with what you hear how your brain responds, how your brain processes sound. And then, so we take hearing, which is just perceiving sound. And if everything is working properly, then we can listen we can assign meaning to sound. And that contributes tremendously to our cognitive abilities.

Blaise Delfino: 5:57

Doug. Today, patients really live in a world where cognition, attention, memory, and hearing each play critical roles. In listening now, we're going to be talking about language, which is a code in which ideas are shared and speech, which is a neuromuscular process. But when we talk about listening, Doug, passive and active listening, especially with that cognition, that top down, bottom up approach, there's a lot of terms we're going to throw out today. So thank you for defining in those layman's terms, the difference between cognition and audition now dug out of curiosity, and for our patients and clinicians listening right now, let's dive into the top down bottom up approach, especially when it comes into terms of fitting patients with hearing aids, how essential is, as a clinician our understanding of that top down bottom up approach?

Dr. Douglas L. Beck: 6:56

Yeah, well, it's very important because it says, that's a great question. I haven't been asked that in a while. The bottom up idea is you have five senses. Now in reality, humans have about 15 senses, but but you know, the five primary ones you learned about high school or grade school. So you have vision you have hearing you have touch, smell, and taste. So those are your five primaries? Well, all when you're born, you know, we're kind of a blank slate and and all the information your brain takes in, comes in through those five senses, from what you hear what you see what you touch, what you smell, what you taste. And your brain then has to organize all of that, well, if you have a relatively normal brain and normal ability, we can kind of predict how that's going to go. But there are people who have extraordinarily good ability, you think about somebody like a Mozart or Beethoven composing symphonies at age nine, you know that that's an extraordinary ability that most of us don't have. And did they have better sensory perception than the rest of us? Probably not. But you know, what they had, they had a brain that was able to organize information and use it quite differently, and in an advanced form. So when you think about people like Steve Jobs, or you think about people like Einstein, their sensory perception was probably not much better than yours or mine. But what they could do is organize and use that information differently, they probably got the same information that you and I get. So bottom up, is your sensory input to your brain. top down, is what your brain does with what it gets, so that's where the sensory information becomes kind of cognitive, right? Your brain organizes it makes sense of it assigns meaning to it. Now, in particular, when you ask about how does that work with hearing aids? Well, the more the more and hearing aid is able to replicate the sounds around you, the better it is for your brain, for instance, most people just think, well, you just need to hear louder. Now, that's not at all. That's what we thought 75 years ago, when you know, audiology started in World War Two, so 75 years ago. And it used to just be that if you could make things loud enough, if you can make them Audible, that people with hearing loss would be happy, well, not so much. Because what happens when you just make it louder, you lose the spatial cues. Now the spatial cues, sound a little bit weird. But here's here's how that works. Your left and right your actually do not hear the same thing. Your left ear is supposing a sound is coming from your left side, your left ear hears it first. That's a tremendous cue to your brain as to where the sound was coming from. So you know where to pay attention. Now, the other thing that happens here is and that's called a timing difference, is there's also an internal loudness difference. So Greg and I were talking about this last time I was in Pennsylvania, actually at a conference you guys ran. And what happens is, if somebody's speaking to me from my left ear, if I were to measure the sounds at five, six and 7000 hertz at my left ear, and my right ear, it is 20 decibels louder in my left ear. Now, all of those cues, those differences between the left and the right ear, that tells me where to pay attention. So what you're looking for in a hearing aid fitting. Are hearing aids that don't just make things louder. I mean, louder is better. You know, in that regard, if you have hearing loss once we can make it so you can hear sounds, of course, that's better. But that's not the end game, the end game is making sense out of what you hear the end game is listening. And very few hearing aids can maintain those inter-aural loudness and inter-aural timing differences. So when I say inter-aural I mean, between the ears, the differences between the left and right ear. That's how people with normal hearing and normal brains can understand speech and noise. And that's the problem that so many people with hearing loss have is that they're hearing aids, they generally get are making things louder, and they can perceive them. But they don't appear to be much clearer, because we were not delivering the cues that the brain needs to make sense, the sounds around you so that oticon we call that brain hearing is supplying the brain with all of the acoustic information it needs to make sense out of the sounds in natural space, so that you get three dimensional hearing.

Blaise Delfino: 11:50

Wow, Doug, that that is literally, I have to say, I am so excited because number one between your knowledge and your experience, and Dr. Delfino's knowledge and his experience, right now, I feel like I'm on the call of a lifetime. It's been, you know, over 65 years of combined experience. I mean, that is incredible. And, Doug, when you talk about that top down, bottom up approach, and understanding that everyone sort of processes sounds and their sensory information differently. And then when you talk about noise, Doug, so noise, of course, the presence of sound without meaning, if we increase our patient's hearing world, right, and we just make everything louder. Most often patients will reject that amplification. And of course, with the abbreviated profile of hearing a benefit, we have that sub scale that talks about aversive ness. Okay, and I want to make the connection here with pragmatics. Okay, because I thought this was so interesting in one of the articles that you were co author on his pragmatics, which is the social use of language. Now, what I found incredible and what Dr. Delfino and I thought was amazing is that the parallel between pragmatics and hearing aid outcomes. Now, of course, this all ties into that cognition, audition and amplification. Can you expand on that with the pragmatics and hearing aid outcomes that individuals will actually have more appropriate pragmatics with a successful hearing aid fitting?

Dr. Douglas L. Beck: 13:23

Yeah, you said that really well. And I don't think I could say it any better. The issue here is it when hearing aids make sounds louder, and they don't do it selectively. They make all sounds louder in general. And when that happens, the background noise gets louder, too. So there's a concept that's so important to understand, which is signal to noise ratio. And I know for some of the listeners, that's a tough one, but a signal to noise ratio, it exists in virtually all areas of physics, and in sound in particular. So what happens with sound? Supposing that we're at a restaurant and we measure the background sound, let's suppose it's 60. And it could be 60. Anything, let's use decibels. So it's 60 decibels. Okay? So that might be conversational speech, loudness, well, then if Dr. Delfino and I are having a conversation at a table in that restaurant, and he and I are just 24 inches from each other, not socially distanced, but But truly, you know, in a regular conversation, but both of us are wearing masks, so it's okay. So we might be at 75 decibels. So our conversation is quite a bit louder to 15 decibels louder than the background noise. Okay, so that's signal to noise ratio, he and I are speaking at 75, the background noise is at 60. Now, that gives us a 15 decibels signal to noise ratio. So that makes it easy to understand because people need, you know, to understand conversational speech, it gets comfortable about eight or 10 signal to noise ratio, eight or 10 decibels. And more than that is better. But when the hearing aids can't tell who you want to pay attention to, the signal and the noise become the same, because it's not differentiating. So what we're looking for an advanced signal processing is the ability to what we call it as multi speaker access technology MSAT. And what that enables you to do is to selectively attend to the person you want to listen to where depending on the brain to make sense of it if we give it the right information. And there's there's two or three studies already in the peer reviewed literature that are quite fascinating on this one shows that when you get multi speaker access technology and you're able to selectively attend to the person you want to listen to, your listening effort goes down tremendously. And this is not. This is not a trivial issue. When it's easy to listen, it's more pleasant to listen and you engage in conversations that otherwise you would shut way from because you can participate easily. And there are studies that have looked at this. And you could find, well, I won't go into the studies, but but send Blaise an email. And if he, he can, he can ask me and I'll send him the study that he can dispense it. But we know that listening effort is quite a bit less when we use multi speaker access technology. And this is not a brand new finding, by the way, in 1964, is the first time that anybody showed listening effort improvements based on pupilometry. And again, it's kind of weird science. But it was pushed forward by this guy, Daniel Kahneman, who won the Nobel Prize in Economics, which is even more astounding, because he happens to be a psychologist, you know, so a psychologist winning a Nobel Prize in Economics. He's a pretty bright guy, obviously. And in 64, he started writing about how you could measure somebody's effortful thinking, effortful thinking, by measuring how wide their pupil was, anyway, it's a very long story. But we applied that in our labs in Denmark, to what happens when people listen to speech and noise in difficult situations with different hearing aids. And we found that the listening effort was most decreased with advanced technology like multi speaker access technology. And that came out of a paper that was in Amsterdam. So that was available if you want to see a copy of it. Another thing that's so important, remember, we're talking about selective attention. So Dr. Delfino and I are at that restaurant where I tried to have a conversation, people are speaking all around us, it's noisy as all get out. But because we both have pretty reasonably good brains, we can selectively attend to each other, which means we can determine where the sound is coming from and pay attention to it. Now, that's also been shown to be tremendously improved. With EEG recordings, there are some recordings that we've done out of Denmark, where we take all sorts of different people, 22 different people with hearing loss, we check their EEG listening to a primary talker and the secondary torture, we've watched their brain activity. And then when you put the same multi speaker access technology on their ears, they're better able to attend to the secondary and the primary speaker and more importantly, the noise that their brain is tracking decreases by 50%. Because it's very effective noise reduction. So these are great questions. And I know we don't have very much time, but each one of these is worth a three hour answer. So I, I'll try to stop there. But but I do think these are great questions. very insightful.

Blaise Delfino: 18:22

We'll have to dovetail off all of this information in future episodes. For sure. Listen, we, you're you're a friend of, you know, hearing matters. And we love having you on and we love sharing you. You know, we love the fact that you're sharing your wealth of knowledge, not only with our listeners, but even future clinicians listening to this episode. Doug, you touched upon, of course, decreasing listening effort and increasing speech understanding now, Dr. Delfino, we have fit patients at audiology services with different levels of technology. And we're currently conducting our own in house research study. And it's actually concluded and we're sharing those findings with Doug. So we're so excited about that. But what have you found with fitting our patients with the Opn S platform? And how are they performing in those noisy situations? Because again, what we're doing is we are fitting our patients with this specific platform ship, released by oticon, the Velox S platform, and we are seeing a decrease in listening effort and increase in speech understanding Dr. Delfino What, what have some of your findings? And what are some of your thoughts on that?

Dr. Gregory Delfino: 19:31

What we've done is really look well beyond the audiogram that we use that obviously is as a base, but I think the speech testing that we do speech and noise speech in quiet, I do some additional testing for auditory processing as well, some dichotic digits, and some gap detection. And again, it's all in preparation for the moment when we sit down and discuss what is best for our patients. It gives us the tools that we need to make the kinds of recommendations for rehabilitation that are going to work because our patients come to us as many do to other other clinics. And their concern is I not only have trouble hearing, I have trouble understanding. And that's really why I'm here. And that's what I want to do. And what I have found is when we input all the clinical data that we have along with real ear measure, we get such an excellent picture of what's going on in their ear. And you can see the excitement in the patient's faces as many of them for the first time. They're hearing like they did many, many years ago. So it's incredibly rewarding. And I love the way in which this oticon instrument is working it has made a huge difference in so many people's lives.

Blaise Delfino: 20:40

Absolutely and and Doug they're essentially not only hearing but they're listening and understanding speech. on par with individuals with normal hearing,

Dr. Douglas L. Beck: 20:49

is that correct? Yeah, that we we've seen that a couple of times over. And I think that the trend is that when you're wearing better noise reduction, when you're wearing products that allow your brain to have more information, you can start to approach better hearing in whether or not that's in alignment with normal it depends on who we're talking about. So it's not a black and white Yes, we can make you hear like normal that that would be a little too aggressive, a little aggressive, but what we could say is that many people, when they're wearing, well fitted hearing aids, can do remarkably better. Now, one of the things that Dr. Delfino mentioned is this idea of real ear measures. And for people not familiar with that most hearing aids in America and across the world are not fit with real ear, they're fit with, you know, what the clinicians do is they set it to where it's comfortable, where everybody likes it and where it sounds natural. So that's okay. I mean, there's nothing really wrong with that. However, there are decades of research that show fitting algorithms. So in other words, you take a given hearing loss. And if you look that hearing loss off, you can see how much gain which is how much louder to make something without going too loud. Because we know if we make it too loud, people are going to find it adverse, which is absolutely bad they'll not wear a hearing aid if it's too loud. So you have to get that sweet spot between how much power do they need a different frequencies. And that's called how much gain do they get, versus the output. So we have to be very cognizant of that, well, here's the funny thing. There are no two ears that are the same. So when we use a universal fitting program, we get close. When we use real ear, we get exact, and there there's at least three or four studies that I can tell you off the top of my head, that have compared first fittings just using more of a universal approach, versus a person specific approach, which is called a real ear or probe mic real ear system. When you're doing what Dr. Delfino is doing, you're adding exactly the right amount of sound. Now, the funny thing about that is sometimes when you're a brand new patient, and you're being fitted with exactly what your brain needs, y u may say, Well, that soun s tinny, or that sounds funny, a d you know what it does, becau e you're not used to it, and t takes about 30 days of weari g it all day to get used to i, and then your brain will be ab e to use that informati n maximally. If we tuned it do n to where you say it s comfortable, you're going o like it immediately. That s totally true. But the probl m with that is, we're not givi g you everything that your bra n needs, because your brain h s forgotten those sounds. And o they sound a little bit foreig, they sound a little bit unusua, because you're not used to the. And we know this. And so wh n I'm dealing with patients fr m all over the world, I will te l them that when I fit you t e first day is going to be a really weird day. To heari g this stuff. If I said for y u tell me it's total y comfortable. Well, if you' e going to have me set it o where, where it is, without yo r hearing aids, that's what you' e comfortable with. The problem s that if I set it that way, yo r brains not being enriched wi h the sounds that your ears y themselves are not sending o your brain. So we need to ma e it sound a little bit unusual, a little foreign, so that yo r brain is getting that ext a information, which is why y u came in to begin with so th t real ear idea that Dr. Delfi o was talking about two things n that if I may, consumers repo t says if you go there Janua y 2020 publication, they say, y u know, you should only thi k about getting hearing aids wh n people are doing real e r measures to that's the only w y that they're being fitt d properly. And again, not to s y the others are bad, but this s the best, this is the way th t we do it scientifically. And H A the Hearing Loss Association f America says the same thin, that you really, really want o seek the use of real e r measures when you're getting n w hearing aids because it makes a huge differenc

Blaise Delfino: 24:35

Doug to dovetail off that it really does make a huge difference. And this is what we found out audiology services in 2019. We had zero returns, no hearing instruments were returned 2000 and 2020. Now granted, we were open maybe a total of six and a half months, seven months now, zero returns, we are conducting real ear measurement on every single patient for whether they're new, new fittings or re you know, re evaluated patients. But what we found as well is at times, of course, we'll conduct that real ear measurement. But what we'll do is go into the sound controls and start them at experience manager one but at least we have a picture of where we're going to go in the next three weeks, four weeks, of course, every individual essentially acclimates maybe a little quicker than others to that hearing technology. And this absolutely is a great segue into the essentials to a hearing aid fitting, Doug. You know, again, with that cognition, audition and amplification. There's three essentials counseling or rehabilitation and the amplification itself, can you bring us through those three essentials to that successful hearing aid fitting?

Dr. Douglas L. Beck: 25:54

Yes, I want to go back to something you said the first, when you talk about adaptation over three or four weeks, at oticon, we've been doing that now for about 20 years we have in our products and they called adaptation manager. And what that's about is exactly what Blaise was saying, so that we set it, even though we know what the target is, we know we want to get you up to the full prescription, because that's where your brain will probably do best, we started quite a bit lower and let it adapt automatically over time. So when you go into the office, they can reset it. And if you can't make it back to the office, you can set it to do it by itself. So all kinds of ways to help you manage through that adaptation period, all of which are very important, because this place that everybody does it differently, which is exactly right. Okay, so the question on counseling, how important is counseling? Well, there are a lot of studies that have looked at people with hearing aids with counseling and without, and conversely, there are people who we looked at their cognitive issues, using counseling by itself, and using counseling plus hearing aids. And in one of the I have a brand new article coming out in hearing review in January 2021. And we talked about in that article, that the people who got counseling and hearing aids, had better retention of memory tassets, than people who just got counseling. So and there are other examples as well. And these are not research studies that I have personally performed. These are from the peer reviewed literature that I basically read, learned about reviewed, and then wrote about them, because they're so fascinating that these are studies that are peer reviewed, and get all the references will be in the January 2021 hearing review. But it's so important to understand that when you take a patient, and you just give them good counseling, well, that's great. I mean, that is awesome. But if they have hearing loss, what we find really benefits, most of the patients most of the time is to get them back into the hearing world where their brain is getting maximal auditory stimulation. And that combined with counseling usually is the most effective. Now, there's a bunch of caveats that I have to say, you know, we can't just say that we're going to put hearing aids on somebody to, you know, improve their brain or their memory or anything like that, you know that it does seem to work on some of the people some of the time, but we're just at the beginning of these studies. And we can't make any promises or commitments. We do know that in the long term studies. And again, there's probably, you know, five or six that have been going on for 10 or 20 years now. And indeed, the people who get hearing aids who have hearing loss, tend to have better aspects of cognitive function later, can't be promised, can't guarantee it. But when you look through the peer reviewed literature, that is one of the things that seems to be pretty much apparent most of the time is that if somebody has hearing loss, and they don't treat it, their their expected decline is more rapid than somebody who has hearing loss and does treat it with amplification that's appropriately fit with, you know, excellent hearing aids and with real ear measures and, and other validation measures, like the APHAB to make sure that the fitting has met the goals of the patient, because we don't just do this in isolation, to make things louder, and to make it make the world clearer. We want to make sure and this this is so important that when you when you're talking about getting hearing aids, you want to find somebody who's doing these outcomes and these listening and communication measures, like audiology services, because when they're doing that, they can assure that they're meeting your goals, not just hitting targets. So that's the whole idea of the AFAB and that stands for the abbreviated profile of hearing aids benefit. So they're actually looking at it from the patient's perspective, what is what what are the benefits the patient is getting related to their hearing aid fitting, so critically important to measure, not just these physical measures that Dr. Delfino, or that Blaise will measure, not just that, but the patient's perception as to how they're doing, because that's ultimately what matters most.

Blaise Delfino: 29:59

Absolutely. Wow, this is this. I'm having so much fun. This episode. I really am. Doug, you are, you are awesome. Thank you so much for that incredible explanation. And of course we've touched counseling, aural rehabilitation and amplification. But of course, when we talk about amplification, we alway s say we fit to the need of the patient. And how do we know if we're fitting the patient correctly if we don't know what that patient's speech and noise score is, or even that quick SIN score because of course, we know that people who perform poorly on cognitive tests will essentially or at a higher likelihood of performing poorly in speech and noise and Dr. Delfino, I want to pass this off to you. And then Doug, why is it so Important to test speech in noise and to collect that quick sin percentage, of course, you've been an audiologist for over 30 years as Dr. Beck, why is it so important? And why are most offices not conducting speech i noise testing.

Dr. Gregory Delfino: 31:05

One of the areas of Audiology that I've enjoyed tremendously is auditory processing. And certainly part of that, that workup is speech and noise. And what I continually saw in children, and in adults as well is that difficulty with speech in noise was that at times that was one of the reasons why they were being referred for a workup was just poor speech and noise scores. So I knew early on that this, this is an important bit of information, this is really going to tell me how well they're going to hear in a classroom or in a playground, a playground. So I always wanted to add that to our evaluations, because it's important enough. And it It highlights enough of how one is going to communicate in their real world. So for me, it's always been a part of my evaluation. The quick SIN I find helps me with determining the level of additive technology that they need, but again, in tandem, gives me a good profile as to what I want to recommend for this patient to be successful.

Blaise Delfino: 32:09

Absolutely, because if the patient presents with a severe quick SIN score, we need to talk about advanced premium level technology, because that has the most aggressive speech and noise relief, right? It's going to decrease the listening effort of that patient and increase their speech understanding. Now, Doug, you talk about going beyond the decibel, and the importance of speech and noise testing. Why is speech and noise testing so important?

Dr. Douglas L. Beck: 32:36

Yes, thinking is the only real measure we get when you think about you're in a sound booth and press the button when you hear the beep for those beeps are called pure tones. They don't exist in the real world, you never hear them outside of the sound booth. Okay, so those are used for diagnostic purposes. And I'm not trying to belittle pure tones, the number one reason we do it happens to be the most important reason of all is to make sure that the patient is healthy, and that there's no ear disease or a problem that we would refer to a physician. So the reason we do pure tone testing and this line really, really well, but otolaryngologic disease, mutual audiograms could have dangerous things going on. So that's why we do pure tones, but keep in mind the patient versus those in the real world. So what we what we do with speech and noise, is we're saying, Okay, give me an environment that sounds kind of like a cocktail party or restaurant or an airport or a wedding reception, because that's the noise that bothers people. So we want to we artificially create that interrupts I have the sound booth. And we determined your ability to perceive speech in that environment. Well, that's remarkably different than pure tones. And in fact, you could have normal hearing our pure tones and have a horrible problem understanding speech and noise. So that's why Blaise was saying it's so important to to quantify your speech noise problem, because the score you get on a speech and noise test, tells us how much help you need. And I'm Stephens doctoral student asked me about why don't just assume that everybody does poorly with speech and noise just fit them all maximally? Well, because it's expensive, because it wastes and because we can, there's some people who only need a little help, some need moderate, some need a lot. And if we can figure that out, which only takes about five minutes clinically, then we know exactly what their solution is. So and Dr. Delfino was talking about, you know, auditory processing disorders. And this is such an important concept because it's not just children, of course, it's adults as well. And and it brings up this big issue. Remember, we talked a little while hearing is perceiving sound listening is making sense of sound. So there are so many people in the US that have hearing loss on an audiogram or a hearing test, there'll be about 38 million of them in the USA. But there's another 26 million who have listening problems by listening problems. I mean, things like traumatic brain injury, I mean, auditory processing disorders, auditory neuropathy spectrum disorder, ADD and ADHD and dyslexia, alzheimers disease, other neurocognitive disorders. And so some of these people, blast injury people, people that noise exposure, they may actually have no normal hearing on a pure tone test. But on the speech and noise test, 26 million of them will not do so well. They're going to show up with deficits, because they don't really need it louder. It needed clearer, which is the whole focus of some of these technologies and and it makes a world of difference in the patient's quality of life because then you're able to participate in in normal, healthy social situations. There was an amazing study that came out in 2013 in The Lancet and the Lancet is the world's foremost Medical Journal. Well, the authors of that were Dr. Livingston and colleagues. And they were looking at what causes dementia. And they found that two thirds of your dementia risk is due to DNA, which is your deoxyribonucleic acid so that there's nothing you can do about that your DNA is your DNA. But one third of your risk is due to about nine factors, which includes things like hearing loss and diabetes and alcohol abuse and drug addiction and less education and, and social isolation, things like that. So of all of those nine things, now, there's 12, they added three more things like smoking and air pollution, things like that. So of the 12, things that add to your dementia risk, the largest one is hearing loss. And how big is hearing loss in this realm? Well, it's 9%. So it's called PAF population attributable factor. So the PAF for hearing loss, as a precursor to dementia is about 9%. And that makes total sense with the peer reviewed literature on this. Not everybody with hearing loss is going to have cognitive issues, and Dementia,most won't, some will. And if we catch it early enough that we treat it effectively, for those, those 9%, for whom it might be a precursor to dementia, you know, we can slow that path in many of them. So it's totally you know, all new science. We've all been looking at this stuff seriously, for the last five or 10 years. But it's extraordinarily productive. And it's very, very different. There are other studies, Dr. Otto Sharma and Dr. Hannah Glick in University of Colorado, looked at people who had hearing loss, and they couldn't process sound very well. And then what they did even with myofascial system, with the same hearing aids, that the Dr Delfino and Blaise were using the OPN S1, and some of those people were able to have their brains return to the function that they had prior to hearing loss. Now, it's a big statement, and then there's a lot in there to unpack, but but it's called cross. I'm trying to think of a simple term for the so it's neuroplasticity, and maybe some of you're familiar with that. But it's having brain changes over time, based on the stimulation. So when we talk about cortical neural plasticity, we're talking about how your brain responds, and how your brain changes based on the stimuli changing. So when you have hearing loss, your brain is stimulated as fully as it once was, with sound to your brain attached to that. So that could be a negative, cortical neuroplasticity, your brain is now using less sound, because it has less well, they found that by fitting hearing aids on some of these people, they could reverse that negative cortical neuroplasticity. So I know that's a little bit difficult. I have quite a few papers that I've written on that. And the easiest way to get a copy of what that's about. If you go to hearingreview.com and put in Anu Sharma, A N U first name, and Dr. Sharma spells her last name S H A R M A, they'll pull up the interview I did was in February of 20, which is the same week that our peer reviewed article came out on that. And it talks about these cross modal effects and cross modal means when your brain is getting listed in relation, because of hearing loss, the part that's not stimulated of your brain might be used by another function like vision. And if that happens, and if you're lucky enough to get fit early, that could reverse back to all auditory. So the brain, the parts of the brain that we're supposed to use the auditory sound, get to do that, again, in many people can't promise can't guarantee. But we can say that there's a lot of positive studies that have shown these types of effects. And that's what we're going for when we talk about fitting brains scientifically, using real ear measures, maintaining aural tightness differences, maintaining inter-aural timing differences, giving the brain the full complement of sounds, we start to allow some of these things to occur naturally and to stimulate the brain in a more natural way. So the brain is better able to use the information that it's getting.

Blaise Delfino: 39:54

well and again, it's it's the signal coming in Dr. Delfino If you want to dovetail off off Dr. Back,

Dr. Gregory Delfino: 40:00

what what you've said Dr. Beck is is incredibly true to form just even in our own practice. We have been experimenting with adults that have experienced exactly that they've got essentially normal hearing, but speech and noise they struggle with and they've come to our clinic asking for help, and they're tired of hearing what you're hearing is normal, and there's nothing there's nothing else that we can do to see the impact that these instruments have made on these people's lives is mind blowing. We've had many a tearful session, because it's the first time someone has heard what they've said we've made an attempt to remediate what was going on and for many, the results have been incredible and your explanation of this is is wonderfully in depth. And I think a lot of people are going to be able to benefit and enjoy further exploration

Dr. Douglas L. Beck: 40:52

That's fantastic. I appreciate that. And I, I think that you know what happens, your clinic is the most important thing what we do in research labs. And when we go through peer reviewed paper, they do something called a scoping review. That's very important. But that doesn't help an individual, the individual is helped when they come to the office, and they get to try these technologies. That's where the rubber meets the road. And that's where reality starts to, you know, really matter. You know, we can talk about these studies till the cows come home, but until you hear it and you can actually listen to the difference in your own ability to understand speech and noise. It's just a concept. But once you once you've heard it, it becomes reality.

Blaise Delfino: 41:30

Doug, On today's episode, we talked about cognition, audition, and amplification. And again, I can't thank you enough for coming on the hearing matters podcast and sharing your wealth of knowledge again, between you and my father, Dr. Delfino, I feel like I'm in such I'm so grateful for the position I'm in because I get to learn from the industry experts, and that allows us at audiology services to better serve our patients. Now, Doug, in closing, why is it so important for our patients to visit our office for annual hearing evaluations? Again, I think this entire episode sums that up with decreasing listening effort and increasing speech intelligibility. But as we come into 2021, and as we enter this new year, why is it going to be so important for patients, whether they're current users or future hearing aid users to go and get their hearing tested?

Dr. Douglas L. Beck: 42:28

You know, that's a really interesting question, the average time it takes between somebody noticing they have a hearing loss, and doing something about it, we used to think it was seven years. That's not right, it's 10 years, there's peer reviewed literature that's come out yeah, it just came out about six months ago, eight months ago, saying that they revisited that seven year concept, and it's about 10 years, from the time someone notices a hearing loss until they do something about it. So this is really important is for all of us to understand that it changes so slowly that we can't perceive the change, it's very common for people to come in and say, Well, I don't even have hearing loss, you know, it's just people mumble. And, you know, we've heard all of this before, and then we test them and son of a gun, they absolutely do have hearing loss, but they're not aware of it. Because it happens so slowly. And while it's happening, your brain is adapting to it. So I think it's important that once you know you have hearing loss, and once you're wearing hearing aids, you should go in once a year and get a check, because it was a tiny change, you're not going to know about it most likely. And if there is a tiny change, then it can be documented. And it's Dr. Delfino feels that it's something that needs medical attention, he'll refer for that. But by the same token, he may say, you know, with this little change, it doesn't look dangerous at all. However, let me change the hearing aid a little bit, because it might, it might improve it even more for you. Because we have seen a little change in your hearing. Now this, you know, it's always a qualitative thing, we can never promise or show somebody that they've got to come in, in 12 months, it could be six months, it could be 18 months, but the most important thing is patient notices change, absolutely come in and get a check. And even if they don't, you really should come in annually, much like you know, once. Once you are an adult, you should get your eyes checked every year, you should get your hearing checked every year, you should get teeth checked every year, you know, because slight changes can mean important changes. And you can't always be aware of it, you know, it's hard to know that you've got a cavity developing, until it really hurts, right? And then it's too late, you've got a cavity. Now, it's kind of the same thing with hearing in with vision, you know, when you first start to wear reading glasses, which pretty much everybody needs by the time they're 45 or 50. There's some people who are 52-53. And they say, Oh, I can be fine, but then they put on glasses and they say Holy cow, why didn't I do this 10 years earlier, right? Because, you know, they're getting used to it. And they can maybe focus just enough to read, but it's really effortful. And when they put on a pair of reading glasses for the first time, it's like, wow, I should have done this 10 years earlier. And it's the same with hearing aids, you know, it's just, we get used to things, and we don't think about it anymore. But yeah, I think it's important, particularly once you know, if you have a hearing loss is keep an eye on because you know, it could change and you may not notice it. And then if you know it could be a medical issue, chances are it's not but it could be and when you go to a practice, you know, like audiology services, they're gonna do a diagnostic test make sure that everything's okay if it's okay, great. just adjust the hearing aids or not depends on how big a change and and what the patient's perception of that is. But if there is a dangerous change, and of course we want to refer as quickly as possible, and let an Otolarynologist do an evaluation to make sure everything's okay.

Blaise Delfino: 45:33

Absolutely preventative health care. Right, Doug, we get our eyes checked and our teeth cleaned. Let's get our hearing evaluated.

Dr. Douglas L. Beck: 45:40

Absolutely. It's much much easier to maintain health than to repair health.

Blaise Delfino: 45:44

Doug, Dr Delfino, and the Entire hearing matters team just want to thank you so much for dedicating this time for sharing your wealth of knowledge and again in joining us on our journey to raise awareness of overall hearing health care.

Dr. Douglas L. Beck: 45:57

Absolutely. Listen, it's a joy working with you guys and I look forward to the next time.

Blaise Delfino: 46:01

Ladies and gentlemen,You're tuned into the Hearing Matters Podcast with Dr. Gregory Delfino, Blaise Delfino and our special guest, Dr. Doug Beck, who is the Vice President of Academic Sciences at Oticon. Until next time, Hear Life's Story!