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US and Canada: 1-800-790-4001 Email: info@genigraphics.com [This sidebar area does not print.] The Impact of Cochlear Implantation on Cognition in Older Adults: A Systematic Review of Clinical Evidence Gina Miller, BS 1, Craig Miller, MD 2, Nicole Marrone, PhD, CCC-A 1, Carol Howe, MD, MLS 3, Mindy Fain, MD 4, Abraham Jacob, MD 5 University of Arizona Speech, Language, and Hearing Sciences 1, The University of Arizona College of Medicine; The University of Arizona Department of Surgery – Division of Otolaryngology 2, Arizona Health Sciences Library; University of Arizona College of Medicine 3 ; The University of Arizona College of Medicine; Arizona Center on Aging 4 ; The University of Arizona Ear Institute; The University of Arizona College of Medicine; The University of Arizona Department of Surgery; The University of Arizona Cancer Center; The University of Arizona Bio5 Institute 5 INTRODUCTION DISCUSSION/CONCLUSION RESULTS Figure 1. Flowchart of the process of literature search and extraction of studies meeting the inclusion criteria. ABSTRACT METHODS AND MATERIALS REFERENCES CONTACT Objective: Hearing loss (HL) is the 3 rd most prevalent chronic condition faced by the elderly population and has been linked to difficulties in speech perception, activities of daily living, and social interaction. Recent studies have suggested a correlation between duration/severity of hearing loss and an individual’s cognitive function; however, it was unclear whether a causative link has been established. Because prolonged auditory deprivation is common prior to cochlear implantation, we performed a systematic review to determine whether cochlear implantation’s potential influence on cognition in the elderly population has been studied. Data sources: 3,886 articles related to cochlear implants, cognition, and older adults were reviewed. Study selection: Inclusion criteria were as follows (1) elderly patients >65, (2) intervention with cochlear implantation, and (3) cognition as the primary outcome measure of implantation. Data extraction: Systematic review. Out of 3,886 studies selected, 3 met inclusion criteria. Data synthesis: No statistical techniques required. Conclusions: While many publications have shown that cochlear implants improve speech perception, social functioning, and overall quality of life, we found no studies in the English literature that have prospectively evaluated changes in cognitive function after cochlear implantation in the elderly. Because prolonged auditory deprivation is common in older adults before they receive a cochlear implant, investigating whether cochlear implantation improves cognition may help to establish a causative link between hearing and cognitive function. 5057 articles were found through database searching and 6 additional articles through citation analysis of the most relevant articles Of the 3892 articles which remained after duplicates were removed, 3858 were excluded because of irrelevance to the topic (Fig 1). Strict inclusion/exclusion criteria were applied to 34 articles. Of these, only 3 studies met the full criteria for population ≥ 65 years, using cochlear implants, and outcomes evaluating cognition rather than quality of life, psychosocial parameters, or solely hearing and spoken language outcomes (Fig 1). The three studies that we examined for the systematic review included cognitive measures in older adults, but were inconclusive in terms of cognitive benefit provided by cochlear implantation. Although these studies show evidence that quality of life for individuals with cochlear implants is significantly improved when compared to those with hearing aids, effects on cognition were not shown. The 1977 study by Vega assessed neuropsychological status of 13 subjects with single-channel cochlear implants with an age range of 23-67 years (mean=48 years). Pre-implantation studies were not performed, so it is unclear whether cognition improved or stayed stable. 11 of the 13 subjects scored within normal limits. Crary et al analyzed psychometric data from 46 postlingually deafened adults who underwent cochlear implantation with a single-electrode device in order to assess psychological and cognitive effects of cochlear implantation. Ages ranged from 19 to 75 years (mean=48 years). Cognitive testing was performed pre- implantation for all subjects; follow-up testing was done one year post-implantation; and for some subjects at two years or more post-implantation. The results indicated that there was no damage in cognitive functioning post-implantation. Numerous individuals showed improvement in several of the cognitive tests, which was thought to be a direct effect of cochlear implantation. Aplin examined the psychological status pre- and post-implantation of 30 adult recipients of a multi-channel cochlear implant with profound postlingual hearing loss. The age range of subjects was 14-80 years (mean=49 years). Results from the study revealed that subjects reported improvements in their communication abilities early after implantation. There were no adverse effects on intellectual ability, personality, or motivation. The small number of subjects and lack of long-term follow-up in this study did not allow for a definitive conclusion about group performance post- implantation in regards to cognition. We conclude that there is both need and rationale for well- designed studies that assess cognitive outcomes and monitor whether elderly cochlear implant recipients modify their expected trajectories for cognitive decline based on rehabilitating severe to profound hearing loss. Despite an extensive search of the literature, our review identified only three dated studies that considered neurocognitive outcomes following cochlear implantation in adults over age 65 years. Our finding was surprising, given the remarkable importance of cognitive health in successful aging and known interaction between auditory perception and cognitive processes including focused attention, executive functioning, learning, and memory. Within the three studies reviewed here, the primary rationale for the examination of cognitive outcomes was to document any adverse effects of cochlear implant surgery itself on global intellectual ability. Surgical procedures in cochlear implantation have far advanced since these early studies, and it is now well established that cochlear implantation is a safe surgical procedure across the lifespan. Conclusions from the three extant studies are also limited by the fact that the participants received technology that would now be considered obsolete. Individuals in the Vega and Crary studies were implanted with single-channel devices, which would have provided a far poorer representation of auditory signals as compared to modern multi- channel arrays. Although such early implants would provide some auditory information, single-channel devices were generally inadequate for speech perception without visual cues. Individuals in the study by Aplin used a multi-channel electrode; yet the patterns of neural activation for speech with this implant would be relatively more coarse in spectral and temporal representation as compared to today’s cochlear implant technology. Although the impact of cochlear implantation on cognitive processes has been relatively unexplored, its efficacy as a medical treatment and its impact on spoken language understanding has been well documented with this age group. A recent systematic review performed by Clark et al evaluating cochlear implant outcomes in patients over 65 years of age found evidence that supported cochlear implantation as an effective means of hearing rehabilitation in older adults with severe to profound sensorineural hearing loss, and that implantation was associated with improved communication, social participation, and quality of life. However, consistent with findings from our own systematic review, their work did not find literature specifically examining the effects of cochlear implantation on cognitive function in older adults. Cognitive decline among older adults is multifactorial, and frequently devastating to patients and families. In normal cognitive aging, most adults over 65 years will not develop dementia or mild cognitive impairment. Thus, older adults with untreated moderate to profound hearing loss may needlessly suffer from potentially preventable cognitive impairment, and cochlear implant rehabilitation may provide a reasonable alternative. However, based on our systematic review of literature, we conclude that there is a lack of meaningful published data on the effects of aural rehabilitation with cochlear implants on cognitive function in older adults. Further studies may help us better understand the potentially causal relationship between hearing and cognitive function, and provide guidance for optimizing the management of severe hearing loss in older adults with this safe and effective treatment option. A systematic literature review was planned and performed using methods specified in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic review. Initial search terms were compiled and iteratively refined by content experts in the fields of Otology, Neurotology, & Cranial Base Surgery; Speech, Language, and Hearing Sciences; Library Science and Geriatrics. Both controlled vocabulary terms (e.g. MeSH) and key words were used to search the following databases for articles related to cochlear implants, cognition, and older adults: MEDLINE/PubMed, Cochrane Library, Web of Science, PsycINFO, and CINAHL. Literature searches were completed in March, 2013. The complete MEDLINE/PubMed Search strategy, upon which the other database searches were also built, is available in Appendix A. Reference lists of citations to the ultimately included articles were also searched for articles that would meet inclusion criteria. Inclusion criteria were (1) Population: study had to include at least some individuals aged ≥ 65 years. (2) Intervention: cochlear implants (i.e. studies that looked only at hearing aids were excluded). (3) Outcomes: Cognition (i.e. studies that looked only at Quality of Life parameters or spoken language outcomes were excluded). Two independent reviewers performed the study selection (CM, GM). In case of disagreements, a third reviewer (AJ) cast the deciding vote. Titles and abstracts of retrieved references were screened for inclusion and full texts of potential articles were further analyzed to see if they met inclusion criteria. Case reports, letters, and systematic reviews were excluded. After inclusion, study characteristics, research goals and findings with respect to cochlear implantation and cognition in older adults were reviewed and analyzed. Hearing loss is one of the most common human sensory disabilities. The prevalence of hearing loss increases with age. In the US, the prevalence of hearing loss in adults over the age of 65 years is 42-47% in one or both ears. Nearly 90% of persons over age 80 years of age have a degree of hearing loss of mild or worse severity. Presbycusis is sensorineural, progressive, typically affects both ears, and is associated with central auditory deficits as well as tinnitus. Hearing loss has become the 3 rd most prevalent chronic health condition faced by older adults, with its prevalence expected to increase. The impact of acquired hearing loss in older adults is far-reaching, including communication difficulties, social isolation, depression, an association with falls, declines in physical functioning, and decreased quality of life. For decades it has been recognized that auditory acuity affects performance on verbal and non-verbal cognitive assessments. Yet only recently has a link been established between hearing impairment and cognitive decline. Baseline levels of cognition of individuals with hearing loss tend to be lower, and their cognitive decline progresses more quickly, than in individuals with normal hearing. With appropriate use of amplification devices to aid hearing, the improvement in one’s ability to perceive sound may increase the potential for improved cognition. In fact, hearing aids have been shown to somewhat improve cognitive abilities and to reduce listening effort. Unfortunately, with more severe levels of hearing loss, conventional hearing aids often increase auditory awareness without substantially improving speech discrimination or communicative ability. Among many older individuals with greater degrees of hearing loss and poor speech recognition abilities, cochlear implantation might offer a more effective intervention and may improve cognitive function. Compared to individuals fit with hearing aids, cochlear implant recipients show twice the improvement in overall quality of life measures. These findings may indicate that cognitive improvements could be greater for individuals with cochlear implants as well. Only 5-10% of adult cochlear implant candidates in the US have received cochlear implants, despite the fact that Medicare and many insurance carriers currently pay for the procedure. Should there be a direct and causal link between hearing loss and cognitive decline, a population suffering the most severe degree of auditory deprivation over time would be the purest group in which to study the question. To determine whether such studies had already been done, we systematically surveyed the medical and psychological literature for studies investigating the effect of cochlear implantation on cognitive abilities in post-lingually deafened older adults 1.Clark JH, Yeagle J, Arbaje AI, Lin FR, Niparko JK, Francis HW: Cochlear implant rehabilitation in older adults: Literature review and proposal of a conceptual framework. Journal of the American Geriatrics Society 2012;60:1936-1945. 2.Lin FR, Metter EJ, O'Brien RJ, Resnick SM, Zonderman AB, Ferrucci L: Hearing loss and incident dementia. Archives of neurology 2011;68:214-220. 3.Lin FR, Yaffe K, Xia J, Xue QL, Harris TB, Purchase-Helzner E, Satterfield S, Ayonayon HN, Ferrucci L, Simonsick EM: Hearing loss and cognitive decline in older adults. JAMA Intern Med 2013;173:293-299. 4.Vega A: Present neuropsychological status of subjects implanted with auditory prostheses. Ann Otol Rhinol Laryngol Suppl 1977;86:57-60. 5.Crary WG, Wexler M, Berliner KI, Miller LW: Psychometric studies and clinical interviews with cochlear implant patients. Ann Otol Rhinol Laryngol Suppl 1982;91:55- 58. 6.Aplin DY: Psychological assessment of multi-channel cochlear implant patients. J Laryngol Otol 1993;107:298-304. Abraham Jacob, MD University of Arizona College of Medicine Email: ajacob@surgery.arizona.edu Phone: (520) 626-3553 Website: http://surgery.arizona.edu/faculty- profile/abraham-jacob-md Records identified through database searching (n =5057) Screening Included Eligibility Identification Records after duplicates removed (n =3892) Records screened (n =3892) Records excluded (n =3858) Full-text articles assessed for eligibility (n =34) Full-text articles excluded (n=31) Reasons  Population not ≥65 years (n=3)  Cochlear implants not addressed (eg only hearing aids n=19)  Cognition not addressed ( n=9) Studies included in final qualitative synthesis (n = 3) Full-text articles that met initial inclusion criteria (n=3) Additional records identified through other sources (hand searching references in key articles) (n=6)