Cerebrum Fall 2020

Counter Hearing Aid Act was passed, which, by 2021, will open up rket to the consumer technology industry, incentivizing companies like Bose and Apple to innovate and sell hearing aids and related technologies directly to consumers.

such well-recognized risk factors as smoking (five percent) and hypertension (two percent). This conclusion, while striking, comes with a substantial caveat— potentially modifiable. Although hearing loss tops the Lancet list of risk factors, how much it matters depends on whether treating hearing loss makes an actual difference. In early studies investigating hearing-aid use in older adults, some investigators have shown a reduced risk of dementia, but these findings must be interpreted with caution: individuals who choose to use hearing aids (and more importantly, have the financial means and are sufficiently health conscious to do so) are different from those who don’t use them. Whether it’s the use of hearing aids, or the factors underlying their use, that drives the association with better outcomes cannot be fully disentangled even with the most sophisticated epidemiological models. To isolate the specific effect of hearing loss treatment on cognition would require a clinical trial in which a large group of older adults are randomly assigned to hearing intervention or a control condition. I’m involved in such a trial, which is now in progress and led by the Johns Hopkins Bloomberg School of Public Health in collaboration with six other universities and supported by the National Institute on Aging. For this trial (the Aging and Cognitive Health Evaluation in Elders ( ACHIEVE ), we recruited nearly 1,000 older adults in their 70s and early 80s with mild-to-moderate hearing loss (approximately half of all older adults in this age range have such deficits) and randomly assigned them to receive hearing intervention or a healthy aging education control intervention. When this study is completed in 2023, after all participants have been followed for three years, we’ll have a clearer sense of whether treating hearing loss can actually reduce cognitive decline and dementia risk. Back to the Clinic As a practicing otologic surgeon, I see patients weekly who are concerned about their hearing and seeking advice and solutions. One question often stated bluntly is, “Doc, are you telling me that I’m going to develop dementia?” The answer, of course, is no—epidemiological studies provide insights about average effects across populations, but individual prediction is impossible. What often follows is, “Doc, will hearing aids reduce my risk of dementia, and if so, how am I going to afford them?” The answers to these questions are unsatisfying for all concerned: “We don’t know yet. And I’m sorry that the costs of hearing aids are so high.” My best efforts to relieve their concerns are of little help to patients who are struggling to hear, isolated from family. As a surgeon used to making clinical decisions from a risk-benefit perspective, I also find it frustrating: Hearing aids for older adults may well carry benefits for cognitive health and appear to pose zero medical risk. Wouldn’t that argue for treating all

older adults with hearing loss? The problem is that while hearing aids carry no medical risk, the barriers to care are substantial. They are rarely covered by insurance, and with the average cost in the U.S. of at least $4,000, they represent for many people the third largest material purchase in life after a house and a car. This cost is coupled with the time needed to make multiple visits to a hearing-care provider to get tested and fitted. And all this for a condition that is prevalent in nearly two-thirds of older adults over 70. With this in mind, over the past five years, through collaborations with the National Academy of Medicine and the White House (ending in 2017), and using epidemiological data to demonstrate the potential effect of hearing loss on cognitive health in older adults, my collaborators and I have begun to have an impact on systemic policy barriers, which may ultimately reduce the personal and societal costs of treating hearing loss. Presently, only licensed healthcare professionals are allowed to sell hearing aids, according to federal regulations, and the entire worldwide hearing aid marketplace is dominated by just six companies, keeping costs high. In 2017, the federal Over-the-Counter Hearing Aid Act was passed, which beginning in 2021 will open up the hearing aid market to the consumer technology industry, incentivizing companies like Bose and Apple to innovate and sell hearing aids and related technologies directly to consumers. In parallel, we’ve begun to advance federal legislation through the House of Representatives to require Medicare to cover hearing-related services. As a clinician, I can’t reduce the medical risk of hearing aids beyond zero, but our research is spurring changes to federal policies that will reduce their personal and societal costs. Between this progress and the results from the ACHIEVE trial coming in 2023, I’m hopeful that the gaping disparity between the management of pediatric and adult hearing loss that I first noted over ten years ago may start to narrow. More importantly, I’m hugely relieved that rather than providing my patients with a diagnosis that only leads to further health and financial concerns, I’ll soon be able to provide them with evidence-based answers to questions they’ve been asking me for years and steer them toward accessible solutions. l

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