Hearing Aids Can Halve the Risk for Cognitive Decline and Dementia; ACHIEVE Study Highlighted at ADA Conference

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Lin reviewed three previous epidemiological studies from the past decade that link hearing loss with reduced cognitive wellness, starting with his own research in 2011 that found mild hearing loss doubles your risk for cognitive decline, while moderate and severe hearing loss triples and quintuples your risk, respectively. A year later, John Gallacher and a team of UK researchers reported similar findings using a different method and study population. Epidemiologist Jennifer Deal and a US team of researchers in 2017 found that moderate-to-severe hearing loss increases the risk of developing dementia in older adults.

Yet, data has been lacking about whether hearing care and treatment with hearing devices can reduce the risk of cognitive decline. Some studies, including a 2022 meta-analysis published in JAMA Neurology, have indicated hearing aids and cochlear implants are associated with a decreased chance of cognitive decline. But other studies were less supportive of this idea. A large-scale randomized trial was sorely needed to show if there was an actual causative relationship.

ACHIEVE study set-up for 3-year randomized trial

In the 3-year ACHIEVE study, close to a thousand older adults ages 70-84 with untreated mild-to-moderate hearing loss and normal cognitive function participated. Importantly, these subjects were assembled from two distinct groups: 739 community volunteers were recruited by ads and online—meaning these people were mentally active, health-conscious, and motivated enough to volunteer and commit to a long-term clinical trial focused on ways to promote healthy aging. Lin likened them to people concerned enough about their health to worry themselves into wellness ("worried well"), and they are known in the study as the De Novo group.

A second group of 238 people were already enrolled in the Atherosclerosis Risk in Communities (ARIC) study. These individuals had been monitored for their cardiovascular problems since 1987 and were at greater risk for cognitive decline and dementia. They had distinctly different health metrics and attitudes, as well as baseline cognitive scores, than the "worried-well" De Novo group.

It's also unclear how lengthy a study of this type needs to be. Symptoms of dementia can emerge over many years. Is a more extended timeframe than 3 years required to fully understand the effects of hearing intervention? The potential impact of waiting to adopt a hearing treatment is also interesting. Does a 3+ year wait to obtain hearing aids have a negative effect on subsequent health benefits compared to earlier intervention? The ACHIEVE study has now been funded and extended into a 6-year investigation.

Also, how might over-the-counter (OTC) hearing aids influence cognitive decline and dementia compared to the prescriptive hearing aid model used in the study? With the advent of OTC hearing devices, a three-tiered system appears to be emerging: 1) self-directed care using OTC hearing aids, 2) a hybrid approach of self-directed care with professional assistance via telecare or office visits when needed, and 3) the traditional "gold standard" prescriptive hearing aid with treatment from an audiologist or hearing aid specialist. How might each of these affect the trajectory of the disease?

It's important to note that ACHIEVE used a very detailed patient care program using audiology best-practice protocols. Dr. Sanchez presented specifics on this intervention program detailed in a 305-page electronic searchable manual with step-by-step instructions and scripted language to be used by audiologists throughout the treatment. The intervention included comprehensive hearing assessment and service delivery while targeting specific person-centered goals. She emphasizes there is no “one-size-fits-all” approach to audiological care. The program also resulted in the Toolkit for Self-Management, which assists in educating adult hearing aid users about their hearing loss and customizing the intervention to the individual’s specific goals and health literacy.

So, what can clinicians, like audiologists, do with information from the ACHIEVE study? It’s agreed that the research shouldn’t be weaponized into scare tactics to drive people toward hearing care; however, the data is important and must be responsibly disseminated to the public. Doubtlessly, this will be a central task in the future, with white papers, recommendations, and guidelines to come. In fact, Phonak and ADA assisted in convening a daylong meeting of experts in numerous areas, including researchers and clinicians like Reed and Sanchez, as well as neurologists, psychologists, gerontologists, economists, and others.

“Dementia is scary. Dementia is complex. Most people don't really understand dementia,” said Reed. “We talk about dementia as a cognitive condition. But the real definition of dementia is not just the cognitive component; it's functional, it’s about people in their daily living…You're no longer able to live independently, you're no longer able to bathe or dress yourself. It's about real, functional, daily life, not just cognition.

“So people are fearful of it. And I think this is one of those conversations in which it's important that a clinician understands the literature. It’s important that we explain broadly how hearing care fits into [the picture], and I don't think that's easy to do.” For example, he noted that amplification may not just improve communication, but could also decrease cognitive load or increase social engagement—concepts not always easy to explain to a patient during a short consultation.

Sanchez emphasized that it all comes down to patient-centered care. “Our patients come to the clinic for different reasons, right? Not everyone's coming into the clinic saying, ‘I'm afraid of dementia.’ And not everyone's coming into the clinic [only wanting] to hear better. There are so many different reasons, and I think we need to meet patients where they are. If we tell every patient about the connection between hearing loss, cognition, and the ACHIEVE trial, that's probably not the right approach if the patient isn’t looking for that information…Patient conversations differ. If you do have a patient who is worried about cognitive health and resilience, then it's very appropriate to have that conversation. What does the research tell us? What do we know? What don't we know? Don't over-interpret and don't under-interpret. But each patient probably needs a little bit different messaging, depending on why they're in your clinic and how you can help them the most.”

All of the above hints at a future where hearing intervention might evolve into more specific and individualized treatments based on a person’s history, communication goals, current cognitive status, risk factors, etc. Precision medicine is used to optimize efficiency or therapeutic benefit for particular groups of patients. “I really don't want to discount the fact that we can move toward a model of precision audiology,” said Reed. “And maybe there is a study in the future where specific cognitive measures change the way we fit and literally change the [hearing aid] settings or aural rehabilitation planning.”

While emphasizing that much more work is needed, given the complexity of dementia and the relatively early stages of their work, Lin, Reed and Sanchez think the future is bright for more revealing findings in the coming years from the ACHIEVE research.

Hearing Aids Can Halve the Risk for Cognitive Decline and Dementia; ACHIEVE Study Highlighted at ADA Conference

A deeper dive into the ACHIEVE study

Why are hearing loss and dementia linked?

ACHIEVE study set-up for 3-year randomized trial

Implications for people concerned about cognitive decline and dementia

Implications for Medicare and policy-makers

Implications for clinicians and “precision audiology”

Karl Strom