Screening for Dementia in Audiology Clinics – Advantages, Pitfalls, and Recommendations

Over the age of 65 years, one in four people has hearing impairment while one in ten people has dementia. Because of common comorbidity of hearing loss with dementia, some advocate routine cognitive screening to identify audiology patients with dementia. 1,2 Identifying patients with dementia may inform provision of additional person-centred adaptations for hearing assessment, selection of amplification devices, support with device use and long-term care planning. 3www.shutterstock.com.We recently surveyed UK audiologists in relation to working with patients with dementia. 4 Audiologists reported being aware that dementia was common among their adult patients but were not aware of appropriate cognitive screening tools or felt they have the expertise to administer them. UK audiologists reported not knowing how to use the results of cognitive screening in relation to hearing rehabilitation or knowing of referral pathways for dementia. IDENTIFYING PATIENTS WITH DEMENTIA Symptoms of dementia are much like the symptoms of hearing impairment; comprehension difficulties, repeating questions, difficulty following conversations, and social isolation. Some people with dementia are very good at compensating for cognitive difficulties, such that audiologists may not be able to reliably identify whether the person has dementia based on their clinical impression. Case history or referral information could be used to identify patients with dementia. Unfortunately, referral sources might not mention dementia, or dementia may have a recent onset. Further, up to 40% of people with dementia never receive a formal diagnosis. 5 Among those who are diagnosed, the average time between noticing symptoms and specialist diagnosis of dementia is four years. 6 And 20% of people who have been diagnosed with dementia do not report having dementia when asked. 7 Because of the limitations of identifying patients with dementia based on clinical impression, referral information and case history, audiologists may choose to use cognitive screening tools to identify patients with dementia and to distinguish between hearing issues and cognitive problems. ACCEPTABILITY TO PATIENTS The audiologists in our survey mostly reported they thought cognitive screening would be acceptable to patients. 4 However, some patients may not agree to a cognitive assessment that they could perceive as being intrusive and threatening. Audiologists should be appropriately trained in explaining the purpose of cognitive screening and discussing the results. 1,2 Instead of calling it ‘dementia screening,’ audiologists should explain that the cognitive screening is to rule out other issues that may cause communication difficulties. COGNITIVE SCREENING TOOLS Various screening tools are available (e.g. the Montreal Cognitive Assessment 8 (MoCA) or the Mini Mental State Examination 9 (MMSE)). These tests are designed to briefly assess several aspects of cognition, to be sensitive to cognitive difficulties across various types of dementia. Alzheimer’s disease is the most common form of dementia, characterized by memory problems. Language, behavior or other cognitive abilities are first affected in atypical forms of Alzheimer’s disease or other types of dementia (e.g. frontotemporal dementia). Cognitive screening tools are designed to detect pronounced impairment, not to detect subtle changes in specific cognitive abilities, or to discriminate between types of dementia. So, if a patient performs poorly on a cognitive screening tool, then hearing assessment will probably be affected. Appropriate training and expertise are needed to administer, interpret, and discuss the results of cognitive screening with patients. Performance on cognitive screening tools is impacted by various factors including, educational level, age, and mood, as well as hearing and vision impairment. Unfortunately, most cognitive screening tests rely on the patient having good hearing. Hearing impairment affects performance on screening and other cognitive tests. 10,11 People have tried to adapt cognitive screening tools for people with hearing impairment, but the reliability of these adapted tools for identifying cognitive impairment has typically not been established 12 or is inadequate. 13 A version of the MoCA has been adapted and validated for people with hearing impairment 14,15 and is freely available (mocacognition.com). Although the MoCA is free, users must register and either complete online training (at small cost) or be supervised by an appropriately qualified person (e.g., a clinical neuropsychologist). A tool that avoids the confound with hearing loss and does not require training or supervision is the informant interview version of the General Practitioner assessment of cognition (http://gpcog.com.au/index/informant-interview; GPcog). This tool is completed by the patient’s partner (or anyone who has known the patient for several years), with the informant asked about changes in the patient’s cognition over time. Poor performance on a cognitive screening tool indicates that the patient needs further detailed cognitive assessment. A full cognitive evaluation involves detailed assessment of multiple cognitive domains (e.g., attention, perception, executive functions, memory, language, social cognition). Full cognitive evaluations are time consuming and expensive, and there are wait lists to see expert clinicians. Carers of people living with dementia report that not having a diagnosis is distressing and that a clear diagnosis made it easier to manage because they could then receive advice and support. However, lack of evidence for the benefits for carers or patients with earlier detection of dementia and the potential for causing distress means that routine screening of asymptomatic adults for dementia is currently not advised by national health organizations. 16,17 CONCLUSION AND RECOMMENDATIONS To enable person-centered care, it is useful to know if your patient is living with dementia. Identifying those with dementia is appropriately done via case history taking with the patient and their care partner and/or referral information. We do not recommend routine cognitive screening in audiology clinics, following national guidance against routine screening for dementia among asymptomatic adults. 16,17 Cognitive screening tests should only be used with specific patients in cases where the audiologist needs to check whether a cognitive issue may contribute to a patient’s communication difficulties. If audiologists do cognitive screening, they must ensure that they allow sufficient additional time to do cognitive screening, discuss the results, and address questions from the patient. Audiologists must ensure that appropriate referral pathways to memory clinics are in place, including when and where to refer and what information is included in the referral. 18 Audiologists must also ensure that they have proper training in administering and interpreting an appropriate test (e.g., the MoCA-H or the GPcog informant version) and are prepared and able to discuss the results with the patient. 1,2 Recommendations for providing person-centred hearing care are available to optimize quality of life for people living with dementia and hearing impairment. 3,19

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