Hearing loss: A treatable cause of cognitive impairment

Clinical pearls for front-line PCPs

Philip A. Bain

A 78-year-old man presents after his wife makes an appointment because her husband has become more withdrawn and depressed.

The patient has previously been diagnosed with type 2 diabetes, hypertension and mild cognitive impairment. He is currently taking metformin and lisinopril.

 

Source: Philip A. Bain, MD, FACP

As part of the rooming process, the medical assistant (MA) notices that his wife answers nearly all of the questions directed to the patient. Per protocol, the MA performs a PHQ-9, and the patient scores a 12 (consistent with moderate depression). The MA also performs the Montreal Cognitive Assessment (MoCa) and he scores a 24 out of 30 (consistent with mild cognitive impairment), though the test was difficult as the patient is quite hard of hearing. His score is slightly worse than the 26 out of 30 at his wellness exam last year.

Because the patient is quite hard of hearing, the astute MA examines the external auditory canals (EACs) bilaterally per protocol and finds no significant ear cerumen. She then performs a whisper test, which is grossly abnormal. She retrieves the office-owned Pocket Talker and shows the patient and his wife how to use it. She notes that he seemed to “perk up” a bit after using it.

She summarizes her findings using the smartphrase “HEARINGLOSSMA” and then reviews the information with the physician:

“Doc, the patient’s wife thinks that his memory is getting worse and that he is more depressed. His PHQ-9 is consistent with moderate depression and his MoCa is slightly worse compared with last year’s wellness exam MoCa. What struck me is how hard of hearing he is. I checked for wax — none there — and did a whisper test, which he failed miserably. I got him the Pocket Talker and he seemed to almost immediately perk up.”

The PCP reviews the MA’s documentation and goes in to discuss the test results. He confirms that no cerumen is present in either EAC and uses a 512 Hz tuning fork (astutely put out for him by the MA) and performs Weber and Rinne tests, both of which were normal. He recalls that the patient has been more passive and withdrawn at his last two visits, especially compared with the current visit with use of Pocket Talker. He refers the patient for an audiogram and audiology visit. He then documents the visit using the “HEARINGLOSSPCPexam” and “HEARINGLOSSdxPCP” smartphrases. He gives the patient an after-visit summary, which includes the “HEARINGLOSSAVS” smartphrase that contains tips for better communication, resources and options to improve hearing. In a week, he receives the audiogram report, and the audiologist’s findings were consistent with moderately significant sensorineural hearing loss. She discussed options with the couple, and they elected to do a hearing aid trial. The audiologist also documents that she discussed hearing rehabilitation tips and resources with them.

The PCP sees the patient back in 3 months and a repeat MoCa was 27, PHQ-9 was 7, and when the PCP entered the exam room, the patient and his wife were laughing about a story from a vacation that they took a few years back.

Lessons learned:

1. Untreated hearing loss is very common in elders and can significantly affect mood, function and cognition.
2. The MA suspected significant hearing loss, ruled out cerumen impaction and did a whisper test that was grossly abnormal.
3. The PCP referred the patient for an audiology evaluation and audiogram, which confirmed significant hearing loss.
4. The hearing aid trial was well tolerated and successful.
5. Numerous non-hearing aid options, including amplification devices, technology devices and smartphone apps, are available if the patient is reluctant or unable to afford hearing aids.
6. Many tips are available to optimize communication with a hearing-impaired person and were provided in the after-visit summary.

References:

• Anastasiadou S, Khalili YA. StatPearls. 2022; Hearing Loss.
• Geriatrics at Your Fingertips. https://geriatricscareonline.org/ProductAbstract/geriatrics-at-your-fingertips-2022/B064. Accessed March 15, 2023.
• Hearing loss: Tips to improve communication with people with hearing loss. https://my.clevelandclinic.org/health/articles/4050-hearing-loss-tips-to-improve-communication-with-people-with--hearing-loss. Accessed March 15, 2023.
• Michels TC, et al. Am Fam Physician. 2019;100(2):98-108.
• The 13 best hearing aids of 2023. https://www.ncoa.org/adviser/hearing-aids/best-hearing-aids/. Accessed March 15, 2023.