Cognition, Audition, and Amplification feat. Dr. Douglas L. Beck | Oticon | Part 2

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. 

In this episode, Blaise Delfino discusses Cognition, Audition and Amplification with Dr. Douglas L. Beck, Vice President of Academic Sciences at Oticon.

Dr. Beck explains that the connection among cognition, audition and amplification is the human brain. The three are intertwined and cannot be separated. There are 26 million Americans who have no hearing loss but still cannot understand speech in noise. This can be caused by a traumatic brain injury, dyslexia, and many other conditions. An audiologist can determine if the problem is central auditory processing. 

Dr. Beck explains the term “cross-modal recruitment.” It occurs when one area of the brain is not stimulated, and another area of the brain takes it over. In a study done by Drs. Sharma and Glick, titled “Frontiers of Neuroscience,” the area of the brain that processes sound was not stimulated, and the part of the brain that processes sight took it over. Drs. Sharma and Glick found that by fitting patients who have hearing loss with hearing instruments reversed the cross-modal recruitment that had taken place in their brains. 

Hearing screenings are not something that Dr. Beck advocates. He believes that they are usually not done in sound-proof booths, the instructions are not well presented, and headphones are generally not used. He is in favor of Universal Newborn Screenings, however, which tests the hearing of all babies born in hospitals and birthing centers. He is also in favor of cognitive screenings in older adults who are having difficulty with speech in noise. He says once people reach a certain age there are many conditions that can cause hearing loss. Among them are neurovascular conditions that reduce blood flow to the brain.

Dr. Gregory Delfino adds that he has seen many patients over the past 20 years who have central auditory processing problems and have significantly improved with low-level amplification. 

Buying hearing instruments online or over the counter is not something Dr. Beck advises. He says a person may be experiencing hearing loss for any number of reasons, from a hair up against the ear drum or the bones in the ear malfunctioning to a brain tumor. The rule in medicine he says is first diagnose then treat. Without a diagnosis by a trained hearing healthcare professional, a person could do more harm than good by buying over-the-counter hearing aids. He adds that a person can get well-made hearing aids provided by a professional for as little as $1,000 per pair.     

Have questions? Let's hear em'!

Email: Blaise@audiologyservicesllcpa.com

Phone: 610.694.0141

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 hearing technology, best practices, and a growing national epidemic: hearing loss. If you joined us last week, we had the VP of Academic Sciences at Oticon Dr. Douglas Beck, and he is joining us again this week. We are so happy to have him back, and we will be discussing cognition, audition and amplification. Dr. Beck, welcome back to the Hearing Matters Podcast.

Dr. Douglas L. Beck: 0:40

Thank you, Blaise, it's a pleasure to be here.

Blaise Delfino: 0:42

It is so so awesome to have you back on the show, for lack of a better term. Dr. Beck, cognition, audition and amplification, what is the connection between all three?

Dr. Douglas L. Beck: 0:52

Well, the connection between all three is the human brain. And when you think about cognition, or dementia, mild cognitive impairment, when you think about cognitive decline, these are all things that intertwine and interconnect with auditory processing, with language, with cognition, all of these things are interdependent on each other. Dr. And Michael bust in 1949, just about when audiology was being formed, was talking about you can't really separate cognition, from audition from language. They're all pretty much intertwined sciences. And if you try to just separate out audition, you very quickly run into problems because you're gonna have somebody who doesn't understand speech and noise, as we were talking about last week that might have an auditory issue, they might have auditory processing disorders, but many people will have no hearing loss whatsoever. And they will have auditory processing problems. They might have auditory neuropathy spectrum disorder, they might have Cochlear Synapt pathy, they might have hid en hearing loss, they might hav ADD, ADHD dyslexia, they may ha e neurocognitive problems. An the number one thing that th y're going to tell an au iologist or a dispenser or an EN is they can't understand sp ech and noise. And so what ha pens is, we all look for that au iogram that might be co sistent with that complaint. We l, that makes good sense, be ause if they have audiometric he ring loss, then that would ex lain some of their auditory pr cessing because they're not pe ceiving the sounds as well as th y might. But then there's 26 mi lion other Americans right he e in the USA 26 million, who ha e no hearing loss whatsoever on an audiogram, but they can't un erstand speech and noise or th y have hearing difficulties. So this is what Harvey Dylan and wh t I also call supra th eshold listening disorders. Now the word Supra, s u p r a, means above threshold, when you think about most of the audiometric tests people are familiar with, or the very most basic ones that press the button when you hear the beep. And what we're trying to do there is establish the threshold that is the 50% point where they can hear or not hear. In other words, that very, very quiet sounds they can perceive. Well, that's interesting and hat's very useful iagnostically. Because when we ook at threshold test, we can ee otolaryngologic bnormalities, we can see tosclerosis in an audiogram, we an see many years disease in an udiogram, we can see a noise nduced hearing loss, we can see fluctuating low frequency loss hat might be consistent with anures disease. So that's why e do audiograms because they ine up really, really well with tolaryngologic disease. But ven if you have no hearing loss n an audiogram, that doesn't ean that you're free and clear, nd that there's nothing wrong. here's 26 million Americans who ave super threshold listening isorders. And in my mind, uditory processing disorders is ne of those many subsets. But t could be traumatic brain njury, could be dyslexia, could e Alzheimer's disease, could be million things that have mpacted a patient's ability to nderstand speech and noise, but ave not impacted their hearing hresholds.

Blaise Delfino: 3:38

Dr. Beck you interviewed Dr. Anu Sharma, and this was an interview that was released in February of 2020. Discussing cross modal recruitment.

Dr. Douglas L. Beck: 3:50

Right.

Blaise Delfino: 3:50

Can you share with our listeners exactly what Dr. Sharma was researching what she found, and how her findings related to cognition audition and amplification because Dr. Delfino here at Audiology Services, he will also work with patients who present with normal hearing, but difficulty understanding speech and noise but these findings that Dr. Sharma released incredible stuff.

Dr. Douglas L. Beck: 4:13

Incredible stuff. So a couple of references first, the stuff that Dr. Anu Sharma published is in conjunction with Dr. Hannah Glick. So I always like to make sure Hannah gets credit to their original publication was in frontiers of neuroscience, which came out in February 2020. Now, as a friend of both of them, I knew ahead of time that publication was coming out so I got a preprint. So that's how come in February 2020, we also publish the interview in hearing review, so they kind of came out at the same time we give them about a 30 day head start and then we publish the interview. The thing that was so amazing is a studied cross modal neuroplastic changes. So what that means, if I have a full complement of hearing like a normal healthy person with a normal healthy brain, so my brain is getting the full complement of sounds that humans can perceive which is 20 hertz to 20,000 hertz easy peasy. Bu as I get older and older, as I have more and more negati e events happen in my life, I lo e hearing. That's called a e related hearing loss. It occu s because we live in an industri l society, right off the ba, people say, Oh, you have heari g loss, that's normal for yo r age. No, there's no such thi g that is totally bogus thinkin, here's the thing. In the USA, e have 325 million people, we ha e 37 to 38 million people who ha e hearing loss on an audiogram. o the vast majority of America s don't have hearing loss, it s not normal. When you have it, t could be highly detrimenta. Because one of the most obvio s things is it leads to soci l isolation. People who can't he r well, who can't participate in conversations tend to s lf isolate, they don't go and ix with their peers, colleagu s, friends and family. So they s ay home. And that's very, very ad for your brain because you re not building up cognit ve reserve. Now, this podcast an go on for about six hours n w, because we're talking about he really important stuff. And w at happens is when we lose heari g, that part of the brain t at normally would perceive th se sounds good is that hearing is perceiving sound listening is making sense of sound. So hearing is perceived in a p rt of the brain called the super or temporal lobe. The scienti ts listening to this will know it as broadman, area 41 or 42. he audiologist may know it as heschl's gyrus, all of thos are the same. And so that par of the brain should b stimulated. But as you have ag related hearing loss as you hav acoustic trauma, as you hav noise induced hearing loss, a you have hearing loss fro biological processes, o ototoxic, drugs, things lik that, you don't generally hea the high frequencies very well So that part of the brain is n longer stimulated. Well, funn thing about brains, they ar incredibly plastic, they chang all the time. So if that part o the brain is not bein stimulated by sound that it n longer perceives another part o the brain may grab it. No typically, we think of th occipital lobe, which is in th back of your brain, that's wher vision is processed. And you occipital lobe could be reall aggressive and say, hey, there' a part of the superior tempora lobe not being used. So th occipital lobe may grabit, i could be the sensory motor stri that goes kind of from ear t ear where the homunculus lives And the homunculus could gra that area to start using i because it's not being use brains like space, I pour vacuum, when you're hearin sound, it's not 10% of you brain is being used, your entir brain is being used, your entir brain is being used brand ne study journal in neuroscience March 2021, when we thought th speech was just processed in th temporal lobes, we missed it b a mile, we have clinica evidence through EEG throu h functional MRI through P T scans, that the entire brain s involved in understanding sou d because you have emotion l involvement, you have visu l redundancy, you ha e understanding, you ha e emotional content in t e amygdala, the entire brain s responsible to understand spee h and noise. It's not just t e superior temporal lobe. And o where we are in 2021, is we' e trying to really make sure th t we give the brain all t e information that needs to ma e maximal sense out of sound. o with crossmodal, what happens s that one part of the brain s taking over for another becau e the original is not using t e anatomy. Dr. Sharma and Glic's study showed that when you it patients with hearing aids, w at they did was the Oticon, OPN S 1 for six months of daily use, the patient's brain was able to go back to how it started. So in other words, they reversed the cross modal neuroplasticity and o that becomes remarkably mportant. Now, here's the pplication of this. I think Dr. elfino and I would both look at patient with minimal hearing oss who's having no difficulty n speech and noise, no istening or communication isorder problems, and maybe say kay, well, you know, let's see ou back in a year or two and ee how you're doing. But now hen we have this study on cross odal neuroplasticity, it kind f cautions us if the patient's rain will negatively respond to lack of sound. And what octors Glick and Sharma did was hey stimulated those brains. nd rather than just waiting to ee what happens, their brains ent back to functioning ormally. And they were looking t things like executive unction, visual evoked otentials, and that's important ecause the visual part of the rain got better and better as hey lost more hearing. And hat's great for vision, but t's bad for the brain because e want the brain to be rocessing sound in the temporal obe and vision to be processing n the occipital lobe. So what appened was they saw changes it eflected the brain was going ack to its original resentation mode across ultiple centers, including the ccipital lobe and the temporal obes.

Blaise Delfino: 9:17

Dr. Beck, you report that you don't really believe in administering hearing screenings and I believe Dr. Delfino will definitely agree with your philosophy. Why should audiological evaluations be conducted versus a hearing screening where you just screen 500, 1, 2, and 4000 hertz?

Dr. Douglas L. Beck: 9:36

Well, we've been pushing that rock uphill for about 75 years. We started in World War Two saying everybody needs to be screened. And of course, it's a pure tone screening and of course, press the button when you hear the beep or whatever we're going to do. That has been remarkably insensitive to finding people with hearing loss. And the reason for that is it's not generally done in a soundproof booth. It's not done with headphones. It's not done with good instructions. It's a quick on the fly sort of thing and you're gone. When you talk about screening, you're trying to maximize bang for the buck, or you're not charging at all. You're just quick screening. Let's see if grandpa has a problem. Well, that's not likely to determine the answer. If you look at the peer reviewed literature from the American Speech Language Hearing Association, children who were screened in schools, it's about 50% sensitivity, it's not a very good protocol. And that's with, you know, school nurses and school audiologists doing it, because there's just too many areas where errors can occur. Now, there are some screenings that I totally endorse, number one, universal newborn hearing screenings, 99% of all children born in birthing centers and hospitals in the USA, and mom and dad probably don't know this, but the kid was screened for hearing loss at birth. And we've been doing that for about 25 years now. And that's brilliant and that's very important, because when we discovered children with hearing loss, we need to get amplification to their brain as soon as possible. The ear is a window to the brain. And if the child does not have that window open, we're not getting sensory information to the brain, the brain can't develop when it doesn't have information. So universal newborn hearing screening is absolutely brilliant, started at the University of Colorado and brilliant, brilliant stuff. So I'm so happy about that. I'm also a big fan of cognitive screening. I think this is very important because we have people with supra threshold listening disorders. And it's just as likely to be due to an auditory processing issue as it is to be from a neurocognitive issue. Because when you think about the older patients that we mostly take care of, I mean, hearing loss occurs in people at birth, it could be any age, but in general, it's older folks that we're taking care of. And when we have somebody 70, 75, 80, 85 90, and they can't understand speech noise, well, that could be hearing and it could be listening.

Blaise Delfino: 11:28

Absolutely.

Dr. Douglas L. Beck: 11:29

It could also be lots of other things that we mentioned earlier. Just a quick review. It could be mild cognitive impairment could be neurocognitive disorders could be dementia, could be traumatic brain injury, that they had 40 years ago, could be from meniere's disease, it could be from Alzheimers, it could be from Frontotemporal dementia, it could be from cochlear synaptopathy, it could be from hidden hearing loss, it could be from a million things that you don't have hearing loss, yet your brain is able to process out and what's the number one thing we do and this becomes apparent when you think about children, children with APD auditory processing disorders, in general have no hearing loss. What they can't do well, is take the sounds they're perceiving and apply meaning to it. So what audiologists have been doing for over 50 years is we give them FM systems, or we give them hearing aids or we give them some sort of assistive listening device, perhaps a pocket talker, so their brain understands what to focus on. And there are studies out of Australia that say if you effectively manage auditory processing disorders in children for a couple of years, pretty soon the child no longer needs that tool, because their brain because it's neuroplastic has learned what to pay attention to. So when a child with auditory processing disorders, is treated with an FM system or hearing aids or something like that. That's what they need right now to help their brain improve the signal to noise ratio to know who to listen to, to know what's important to focus on. So those are very, very beneficial. And we see at the other end of the scale as well with older folks, because once you're above 65, you're more likely to have chronic conditions. And you're more likely to have a hearing loss, age related hearing loss and cognitive decline are signs and symptoms that are typical in older folks. So one of the things is we try to figure out why both of these things happen. One of the reasons that's hypothesized is called the common cause hypotheses, which is pretty simple and makes good intuitive sense. Now, I don't want to suggest anybody listening, this is why they have hearing loss. The neuroscientists are trying to figure this out. And one of the most popular hypotheses is the common cause hypotheses, which says age related hearing loss and cognitive decline happen more often in older people than younger people. Why would that be? Well, one of the common cause things is neurovascular. In other words, you have your carotid arteries on the side of your neck, you have the vertebrobasilar artery is going up along your spine, they perfuse your brain, your brain has arterial blood flow that comes through these vessels. Well, as you age, we develop cholesterol and triglycerides, atherosclerosis, and so a vessel that was originally let's say, half a centimeter, its exterior stays the same, but the interior gets narrower and narrower and narrower, as more and more deposits build up so the blood pressure eventually increases, because your heart is responding to the fact that it has to perfuse the entire body. well as those vessels become more and more narrow blood pressure increases. Now think about that in terms of the labyrinthine artery, which is the artery that feeds your inner ear in your vestibular balance system. Well, if the large vessels are susceptible to all of this occlusion through life, from you know, not exercising, not eating healthy foods, excessive fats, excessive triglycerides, all this stuff. So if your carotid can become full of plaque and goo, what do you think happens to labyrinthine artery? Well, probably pretty much the same. So it could well be, although I wouldn't presume this to be true. But it could be theoretically, that the lack of blood flow to the brain and the inner ear could be why cognitive decline and hearing loss occur in older people. Do we know that to be true? No, we absolutely don't. I don't want to suggest that it's true. But these are the things that we're trying to work out as neuroscientists figure out. Why did these things happen to older people? And that's one of the most prominent theories and there are three or four others that I've written in a peer reviewed paper that's in the Journal of our laryngology do research and anybody who wants that can go to DouglasLBeck.com you'll find it there. I think it was published in 2020.

Blaise Delfino: 15:04

Dr. Delfino, Dr. Beck just shared so many great golden nuggets there truly for lack of a better term. And you've been specializing in working with patients who present with central auditory processing for well over 20 years and here at Audiology Services, you'll see patients on a weekly basis test them for central auditory processing. And of course, the recommendation is low gain hearing technology. What has your experience been with fitting these patients with this low gain hearing technology, and what have you found throughout the years working with patients who do present with central auditory processing?

Dr. Gregory Delfino: 15:39

The population is unique, it is much as often the parents will come. And they will we tell the story that their child has been tested, there is no hearing loss, they are in a quandary as to what's going on. So after I've gone through the complete peripheral auditory evaluation and gone into the auditory processing, we sit down, and we look at the specific areas of concern. And then we start to talk about some therapies or some interventions. And clearly, what I have found that works really well is some of this low level amplification. We always approach the parent and the child with it on a trial basis, because I believe it's got to come from them, their decision has to be whether or not this is going to work for them, they need to take it in the environment in which they're working to see whether or not in fact impacts the way in which they're functioning. The results we've seen are incredibly significant in that both parents children and off times learning support at the school have noticed a significant improvement in the way in which the child was able to function. We've seen children here whose self esteem has completely changed when we first sit down with them, they're shy, they don't want to share their experience. But after they've had the instruments on for a while they become verbose as a whole different child. And that just tells me we are moving in the right direction.

Dr. Douglas L. Beck: 16:47

And this is the essence of patient centered care, right is that you have to take each individual and you can't have this is what we do for these people, this is how we handle it, you know, each patient is individual. And that's why it's so important when you go through auditory processing disorders and you do appropriate intervention, you have to explore their listening and communication ability, because there was a study, National Council of Aging 1999, they looked at about 2000 people, it had corrected their hearing loss versus 2000 people who had hearing loss but didn't correct it. And they found very much the same thing that the people who corrected their hearing loss had less anxiety, less stress, were more sociable, and were able to engage in conversations much like these children you're speaking about. Now, they just all of a sudden emerge. Now some people say, well, that's evidence that they're undergoing positive neuro plastic cognitive changes. And that may well be but I think what it clearly is the starting point is to remove auditory deprivation, right? In other words, now that they can perceive the sound, now they can participate. You know, hearing is perceiving sound listening is making sense of sound. So what you're doing, I think, in your example, is you're allowing them to participate in the acoustic world, so they can thrive. And without that it's much more difficult.

Blaise Delfino: 17:52

Dr. Beck, we don't necessarily hear with our ears, we hear with our brain, can you just tell us a few reasons why patients need to visit an audiologist or licensed hearing healthcare professional, rather than just purchasing an amplifier online or over the counter? Well, so in medicine, we have a rule, and every physician listening to this will recognize this. It's called diagnosis first, treatment. Second, and this is a very, very important concept. Because when you have hearing loss, and you buy something over the counter or online, or you have listening difficulty and you buy something over the counter online, there's no diagnosis, there's just an appreciation that you're having difficulty. And it could be that if you come into an office, somebody looks in your ear, and they say, you know, right against your eardrum, there's a hair or there's Cerumen, which is also known as earwax, or you could have a foreign object in your ear, you could have a torn eardrum, you could have ossicular discontinuity, which means that the malleus, the incus, or the staples of the three little bones in the middle ear, are not functioning properly. It could be that you have a dangerous hearing loss because there are some of those they're called retro cochlear. And that could be the sign of some sort of a brain tumor. Now, I don't want to alert people and give you unnecessary fear. And you know, they're not common, but they do exist. Every year all of us see a couple of patients who have an acoustic neuroma, which is also called a vestibular schwannoma. And that's the fear that many of the professionals have is that when people go direct to just purchase an inexpensive device, there's no diagnosis, there's just treatment. And that's the problem. Because, you know, once you've been diagnosed, and we all know that you're okay, well, then let's figure out what to do about that. But diagnosis first, treatment second, and most people are not aware of the fact that you can go into almost any professional hearing care office, and you can probably walk out with a less expensive hearing aid with one or two years of follow up with a diagnostic test with somebody who knows what they're doing, who can program the hearing aid for you, it's probably going to cost you less than 1000 or 1200 bucks. And in some offices, it's less, some offices, you can get out for 800 900 bucks, but I think you're better off doing that with professional care and taking it upon yourself. I mean, once you know what you're doing once you're experienced and you know that you're safe then okay, maybe that's the time if you have a mild loss to explore some options direct to consumer fine. But I think skipping that diagnostic step is not a good idea. Think about that in any other realm, whether it's your teeth and you have teeth pain, and, you know, you just go ahead and you take Advil for it, and maybe it goes away, and you never ever problem again. So that's great, but maybe you need a root canal. And it would be really good to know that because these things get worse, left untreated, could be you have a headache, there's three things in medicine that we can prove, we can't prove everybody has a headache, we can't prove that anybody has lower back pain, and we can't prove that somebody has tinnitus. These are all subjective complaints, and you can't prove any of them. And so when you have a headache, and it doesn't go away, maybe it's a migraine, maybe it's something much more dangerous, you know, headaches, that go undiagnosed can become real problems. When you have back pain, and you don't get a diagnosis, you can have a very, very serious issue. And if all you do is buy a brace, or you take Advil or you take Tylenol or something over the counter, you can mask it. But maybe it's getting worse while you're masking it. And it's the same sort of fear with people who go and buy a product directly. It's not about the product, you have to understand the primary benefit of a premium hearing aid is the services that comes with it. Because you're going to an expert, you're going somebody who's been trained for multiple years is licensed by their state to manage this problem. And they're looking for all those red flags. And if they say that you're okay, then you're probably okay. That's the whole reason, when we have licenses in every state in the union. It's not because we need to be licensed for our benefit. All state licenses are there to protect the patient. That's the goal of the state guidelines is to protect the patient. So when we go around that and we don't involve a professional, we don't really know what's gonna happen. You're tuned into the Hearing Matters Podcast with Dr. Gregory Delfino, and Blaise Delfino of Audiology Services and Fader Plugs. Today we had Dr. Douglas Beck VP of Academic Sciences at Oticon, join us again this week and we discussed cognition, audition, and amplification. Tune in again next week where Dr. Beck and Dr. Delfino and myself will be discussing musicians and hearing protection. Until next time, hear life's story.