The Role of Speech in Noise Testing In Treating Hearing Loss

Hi, I’m Jim Cuddy and this is Ask the Hearing Doctors, and I’m joined today by Dr. Ana Anzola, doctor of audiology and principal of Hearing Doctors, the Washington, D. C. area’s highest rated audiology practice with over 2,500 5-star reviews.
Also joining us today, Dr. Douglas Beck, doctor of audiology, vice president of clinical sciences at Cognivue, adjunct clinical professor of communication disorders at the State University of New York at Buffalo, and senior editor of clinical research of Hearing Review. Ana, Doug, great to be with you both.

Thanks for having us.

So, I’m going to start off in a way that we typically don’t start off as a true false question. Hearing is not the same thing as listening.

True.

Okay. Obviously, people come into Hearing Doctors all the time. They want to get their hearing checked. I’m guessing they’re not coming in to get their listening checked. How do you differentiate between hearing and listening?

Yeah, this is a great question and it’s very important to understand. Hearing is just detecting sound like right now everybody can hear that. That’s detecting a sound. Listening goes to processing that sound. Listening goes to making sense of sound. The number one complaint that Ana would tell you about that her patients come in for, number one complaint that people seek audiology counsel across the world is they can’t understand speech in noise. That’s the single most difficult thing. You’re at a cocktail party, a restaurant, maybe an airport and you can’t understand what people are saying. That’s listening. You’re aware of it. You can hear it. You know somebody saying something, but you can’t comprehend it. So, that’s listening and, of course, listening is built on hearing. That’s a given, so what we often do in audiology practices, we measure people’s hearing ability and oftentimes, they have hearing loss so we have to correct that through different technologies that we have available to us, primarily hearing aids. We correct the hearing, but that’s not the end. The end is, can we improve the listening? Can we make it easier to understand speech and noise?

Do you see, Ana, specific signs when somebody comes in, they’re coming in to get their hearing checked, as I mentioned at the top, but do you automatically say, “You know what? Hearing may not be your issue. It may be a listening situation”?

Yeah, of course. So, what we do now is part of the protocol is to actually have an assessment, get a baseline with the cognitive screening, and this is a tool that really allows me to understand or better understand how they’re listening, how they’re processing, so I can then complement that with the findings that we get from a sound perfume, which is typically where we get the actual measurements of somebody’s hearing ability and then create a program and treatment plan that would then significantly improve their quality of life.

And there’s some important numbers that go along with this is that in the USA, there’s about 38 million people who have hearing loss on a hearing test, but there’s another 26 million beyond that that have no hearing loss whatsoever, but they have listening difficulties, and they might describe it as speech and noise. They might describe it as inattentive. They might describe it as hearing difficulty, and these are very important things that the audiologist can test to see which problem is it and is that the only problem, which is what Ana’s talking about. Oftentimes, people will have information processing problems, which you can test with a device such as the Cognivue Thrive, which is a screening test that tells you that yes, this is almost entirely an audiology issue, a hearing or listening problem, or it might be something else. There’s many other things that parade as listening problems. You could have attention deficit disorder, attention deficit hyperactivity disorder, auditory neuropathy spectrum disorder, auditory processing disorders, cochlear synaptopathy, traumatic brain injury. You could have mild cognitive impairment, you could have some sort of a neurocognitive disorder like an Alzheimer’s frontotemporal disorders, Lewy body disorders. It could be Parkinson’s with dementia. All of these things we can screen for and that tells us if the primary issue is the patient can’t understand speech and noise. That gives us a direction and that gives us a focus so we as audiologists don’t treat neurocognitive disorders, but then we would refer you back to your physician for that.

It starts with a hearing test. We’ve got to know that baseline first, right?

Right.

Okay. When somebody does have difficulty listening and noise then that is a disorder, a specific disorder, or is it sort of in an umbrella?
Unfortunately, it’s an umbrella term and the national organizations that address these issues recognize it, but that doesn’t mean the people on the street do. For instance, the American Academy of Audiology, the American Speech Language Hearing Association, the International Hearing Society, all of them say that best practice involves for audiologists is not just doing hearing diagnostics, just the hearing test, the detection test, but go into listening and they recommend speech and noise testing. All three of the national organizations say that’s best practice because that’s how you’re going to start to detect and recognize those other 26 million people that would otherwise be invisible. So, the professionals, the doctors here at Hearing Doctors, if they weren’t doing the QuickSIN, which is a speech and noise test that they do here, they would not be able to diagnose or treat or manage those disorders because they wouldn’t be aware of them.

There is something that I’ve read recently, it’s a super threshold disorder. What are super threshold disorders?

Sure. So, when we do hearing tests, what we’re doing is we’re determining your threshold. We’re determining the quietest sound you can hear at multiple frequencies or multiple pitches. Well, unfortunately, conversations don’t occur at threshold. Those are the quietest sounds you can hear. Right now, I’m speaking at about 50, 55 decibels, but there’s multiple decibel scales, but the one that we use in audiology the most is HL. Then there are the physical scales like SPL, sound, pressure level. Those are also measured in decibels and it gets very confusing very quickly, so what we have to do is we have to be aware of how much louder people need sound than their threshold. The analogy that I often use about hearing tests, we’re measuring thresholds, loudness across pitch, and from that, we make a lot of decisions, but to show you how limited that is, imagine if we did that in vision, if we said, here are colors red, orange, yellow, green, blue, indigo, and violet, right? ROYGBIV or something like that so you measure the minimal amount of light somebody needs to detect that. That would tell you nothing about their ability to read. That would tell you nothing about if they’re nearsighted or farsighted. That would tell you nothing about how they’re processing visual information and all of those are the reasons that we get glasses, so we need to go beyond threshold testing in order to get comprehensive assessment that tells us how is the patient doing in the real world in which they live.

When these traditional types of tests that you’re doing, let’s say they don’t address the patient signs. What additional things can you do when hey, you’re coming up blank here on these initial tests that you’re conducting?

Yeah, this is a great question because people are just used to press the button when you hear the beep. That’s 5% of audiology. What best practices require are hearing and listening and communication assessments so the hearing stuff, that’s familiar to many people. Listening, we have lots of different tools for this. We have something called the International Outcomes Inventory, which is a Likert scale, so it’s graded one through seven or one through ten, and it gives you all these scenarios where the patient will fill in the questionnaire and then the doctor would look at that and say, “Oh, you have difficulty in noise in restaurants,” or, “You have difficulty at cocktail parties,” and that will help us identify what the patient perceives as the problem. You see, when you’re going to a place like Hearing Doctors, when you’re going to a very, very good premium local practice, what they’re looking to do is to understand what are the deficits that you perceive because simply solving your audiogram is not going to make it better. What we have to do is understand where are the difficulties in your life, so we have International Outcomes Inventory. We have something called the COSI, which is the Client Oriented Scale of Intervention. We have the Hearing Healthcare Inventory for elderly. We have the SSQ, which is Speech and Spatial Qualities. There’s lots of these assessments that we have and we put all that together with the hearing test, with the cognitive screener, and that gives us an overview so we have patient centered care. We have a holistic approach so that we know what the patient is going through and what their goals and objectives are. You see, back in the old days, it was just you’d look at a hearing test and you’d try to make everything louder. Well, that’s passed. That’s a great starting point 75 years ago. Now what we try to do is make it easier to communicate. We try to make sound clear and to make the sound more clear, we have to improve the signal to noise ratio, and that’s a lot more sophisticated management of hearing loss than we’ve seen in the 60s, 70s, and 80s.

So, we’ve learned it’s not just hearing. There’s a lot more to it and a lot it’s very systemic. It goes all over the place. You’re seeing this all the time. That’s why people can come to Hearing Doctors and get that cognitive test. We did it for demonstration purposes. I was the testee. Let’s just say, I was going to say guinea pig, but that wouldn’t be appropriate, but it’s pretty fascinating, and some of the things and we just kind of touched on it just to sort of visually let people see how it works. Go into it a little bit more in depth. What are you looking for in a Cognivue test?

Well, the three domains that we test most often, visual spatial ability helps us to understand where we are in space and that can impact balance, which also so audiology is hearing, listening, tinnitus, and balance. Those are the big areas in audiology, so in the Cognivue test, the thrive, which is the screener, that allows us to look at visual spatial ability, then we’re looking at memory or recall, and then we’re looking at executive function and executive function is decision making in real time.

How much has Cognivue, being able to offer that in the office, help you get a better understanding of just of the patients that are coming in the door?

Again, I don’t think it’s just about getting the scores and then just leaving it there. It’s about engaging, having a different conversation with our patients, letting them know or our primary care physicians who might have referred them to us in the first place. Sure, and it’s part of the education. So actually, patients now come in and they’re like, “I want to do it again every six months. Did I do better?” Because we do implement something that is more of a brain training listening exercises to complement the use of the hearing aid. We have a baseline, we use the questionnaires, and it’s a management protocol. It doesn’t just end with the hearing aid and here you go. It’s actually the most optimal way to really adjust the hearing aid in certain ways that we’re going to optimize the results.

Yeah and there are specific management techniques in hearing aids, how hearing aids might be set better for people who are having difficulty processing information and as a matter of fact, we covered that in our discussions earlier today based on the consensus statement of 129 audiologists who see patients all day long that have difficulty processing information.

We often talk about hearing, the sooner you take care of it, the sooner you address whatever problem you have, the better. I would have to imagine that’s the same thing for any sort of cognitive disorder as well.

Oh my gosh, yeah. If you have a cognitive disorder and we can catch it early, there’s evidence in The Lancet 2020 that shows the risk of dementia if you catch it. Well, your risk of dementia overall is about 60% due to your age and your DNA, your deoxyribonucleic acids. 40% of your risk of dementia is potentially due to twelve modifiable risk factors. The single largest of all of those is hearing loss, so yes, it’s very important to address hearing loss because it might change the trajectory of that individual as he or she goes through their life because once somebody has full blown dementia, it’s a much more difficult, much more challenging situation. If we can address it early on, when they’re showing signs and symptoms that might be consistent with mild cognitive impairment, then the chance of managing it more effectively increases dramatically.

The bottom line is get tested, get tested, get tested.

Sure. Absolutely. The thing is that when you’re getting these screening tests, they are very, very good indications, but audiologists are not neurologists, we’re not neuropsychologists, we don’t treat this sort of thing. What we’re doing is we’re screening because ultimately, people who have information processing problem and people who have hearing loss have the same signs and symptoms. They’re the same age groups. We’re looking at people over age 55, 65, they’re going to have difficulty with memory, they’re going to have difficulty understanding speech and noise, they’re going to have difficulty focusing, so they come in with the exact same signs and symptoms and it becomes the hearing doctor’s challenge to figure out, okay, what’s going on with this patient and if we’re just doing the basic press the button when you hear the beep, that’s not going to tell you what’s going on with the patient, that’s going to tell you their hearing detection thresholds, which is important. Sure, certainly not the whole issue.

But again, if you’re having some sort of issue and you keep putting it off and you put it off, that issue becomes a much bigger issue and much harder to manage.

And much harder to manage.

Great information. Dr. Ana Anzola, Dr. Douglas Beck, thank you very much for your time.

My pleasure.

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