otoneurology
Otolaryngologists’ role
in improving cognitive decline
Cristina Maria Abstract
Blebea,
Laszlo Peter Longevity is expected to rise in the following years, therefore
neurological problems become a global health concern.
Ujvary, Dementia and hearing loss are highly prevalent pathologies
Maximilian in the older population, and a possible association be­t­ween
George them was studied in recent years. Dementia is still con­si­dered
Dindelegan, an incurable disease, but the evolution of the symp­toms is
Violeta Necula, considered manageable by addressing the risk factors. In the
latest studies, hearing loss has been con­sidered a modifiable
Alma Aurelia risk factor for cognitive decline, along with obesity, smoking,
Maniu hypertension, depression and physical inactivity. This paper
ENT Departament, presents the potentially pi­vo­tal role hearing loss might
“Iuliu Hațieganu” University have in the evolution of cog­ni­tive decline and a summary
of Medicine and Pharmacy,
Cluj-Napoca, Romania of studied theories regarding the relationship between
Corresponding author:
these pathologies. The recent guide­line of the World Health
Ujvary Laszlo Peter Organization regarding cognitive de­cline management
E-mail: ujvarypeter@outlook.com; involves otolaryngologists in the ef­fort of improving
ujvary.laszlo@umfcluj.ro
outcomes.
Keywords: hearing loss, cognitive decline, dementia, risk
factor
Submission date:
2.09.2021 Rolul medicului otorinolaringolog în îmbunătățirea declinului cognitiv
Acceptance date: Suggested citation for this article: Blebea CM, Ujvary LP, Dindelegan MG, Necula V, Maniu AA. Otolaryngologists’ role in improving cognitive decline.
15.09.2021 ORL.ro. 2021;52(3):18-20.
Introduction
Increased longevity worldwide, along with fertility
decline, give rise to the phenomenon known as popula­
tion aging. The global population will continue to grow,
and by 2050 will reach approximately 10 billion. What
is notable is that the population aged 60 years old or
over will grow faster than all younger age groups(1). As
the world’s population increases in age, the neurological
problems are considered one of the significant causes of
disability among older adults worldwide.
Dementia is a pathology that is considerably corre­
lated with age, with around 50 million people suffering
from it worldwide, of which almost two-thirds live in
low- and middle-income countries. The number of people
who will develop dementia is expected to increase, with
nearly 10 million new cases every year(2).
Hearing loss is another highly prevalent neurologic
condition in older adults which – like dementia – impacts
the quality of life. Hearing loss is considered at this mo­
ment to be the third most common health condition af­
fecting older adults. Noteworthy is that more than 58%
of moderate or higher grade hearing loss is experienced
by the adult population above 60 years of age, affecting
one-third of the people over 65 years old and two-thirds
of those aged over 70(3).
18
Rezumat
Longevitatea populației globale se așteaptă să crească în
ur­mă­torii ani, prin urmare afecțiunile neurologice devin
o pro­ble­mă globală de sănătate. Demența și hipoacuzia
sunt pa­to­lo­gii cu o prevalență înaltă la populația în vârstă,
în ultimii ani fiind studiată o posibilă asociere între ele.
De­men­ța este con­si­de­rată o boală incurabilă, dar evoluția
simptomelor poa­te fi gestionată prin abordarea factorilor
de risc. În ultimele stu­dii, hipoacuzia este considerată factor
de risc modificabil pen­tru declinul cognitiv, împreună cu
obezitatea, fumatul, hi­per­ten­siu­nea, depresia și inactivitatea
fizică. Această lucrare pre­zin­tă rolul potențial pe care hipo­
acuzia îl poate avea în evo­lu­ția declinului cognitiv și un
re­zu­mat al teoriilor studiate cu pri­vire la relația dintre aceste
două patologii. Ghidul pu­bli­cat de Organizația Mondială
a Sănătății cu privire la ges­tio­na­rea declinului congnitiv la
populația în vârstă implică oto­ri­no­la­rin­go­logii în efortul de a
îmbunătăți rezultatele.
Cuvinte-cheie: hipoacuzie, declin cognitiv, demență, factor
de risc
Dementia and hearing loss can present to the clini­
cian with common symptoms, such as not following a
line of conversation, difficulty concentrating, commu­
nication changes, fatigue, irritation and social isolation.
Therefore, a high susceptibility must be taken, not to
misdiagnose hearing loss as dementia or to consider
symptoms of dementia worsening.
Where is hearing loss standing regarding
dementia?
Age-related hearing loss is a multifactorial disease
caused by genetic factors that can be affected by many
conditions, including diabetes mellitus, hypertension,
cardiovascular disease, and noise-induced inner ear
damages.
Dementia is also a heterogeneous disease, and its
evolution is also influenced by risk factors like cardio­
vascular disease, cerebrovascular disease, metabolic and
psychiatric factors, education, lifestyle and diet. The
Lancet Commission on Dementia Prevention, Interven­
tion and Care results suggest that 65% of dementia risk
factors are potentially non-modifiable – age, genetics,
apolipoprotein E (ApoE 4). On the other hand, around
35% of dementia is assignable to a combination of nine
risk factors(4).
ORL.ro No. 52 (3) 2021 • Year XIV • ISSN 2067-6530
 Model of contribution of risk factors to dementia Figure 1. Percentage
distribution of risk
factors for dementia

Poor e
7.5%
ducati
Obe
sity

on
Hy
pe

0.8
rte

%
n
sio
n2

Early li
%
Hea
ring

fe
loss
9.1
%
Mi
dli
fe

Diabetes
1.2%
Social isolation 2.3
%

Physical inactivity
2.6%
Late life Age and
Pote genetic
n s
n 4% mod tially n
De pressio ifiab o
le 65 n-
%

%
5.5
ng
oki
Sm
7%
4
oE
Ap

Potentially non-modifiable 65% Midlife Late life Early life

As prevention is preferable to cure, there is a grow­ reduction of cognitive decline and dementia, hearing
ing interest in controlling these modifiable risk fac­ loss is recognized as a risk factor for dementia. Also, the
tors present during a patients’ life span. The Lancet guideline grants priority to hearing loss interventions
Commission on Dementia Prevention, Intervention in the management of those at risk of cognitive impair­
and Care published in 2017 a list of nine potential risk ment, as they can substantially improve the outcomes
factors related to early life, midlife, or later life peri­ for older people in multiple domains(13).
ods. Hearing loss has been distinguished as one of the
Commission’s main potentially modifiable risk factors What does research on dementia
for dementia. and hearing loss reveal?
Although the risk ratio (RR) of hearing loss is com­ Although epidemiological studies have demonstr­a­
parable with other risk factors, it is a highly prevalent ted this association, the underlying mechanism of how
pathology, occurring in 32% of individuals older than hearing loss increases the risk of cognitive decline and
55 years of age; hence, it explains the high population dementia is not yet precise. Wayne et al.(14) reviewed the
attributable fraction (PAF) of 9%. literature and summarized four possible hypotheses.
As the number of studies that consider a possible The cognitive load hypothesis considers that cog­
relationship between these two conditions is growing, nitive decline may reduce the cognitive resources avail­
the results suggest that their interrelation may consist able for auditory perception, clinically manifested as
of that hearing loss may be a risk factor for the develop­ hearing loss. The evidence supporting this hypothesis
ment of dementia in older adults. is limited.
Several studies(5-8), reviews(9,10) and meta-analyses(11) The information degradation hypothesis advo­
showed that hearing loss is an independent risk factor cates that sensory deficits may be compensated by older
for dementia in older adults. Lin et al.(12) also indicated adults via increased reliance on cognitive resources. Toil­
that the risk of developing dementia increased linearly some listening, present when the accuracy of the audi­
with baseline hearing loss severity (1.27 times increased tory input is poor, seems to place greater demands on the
risk per 10 dB of hearing loss). executive function and working-memory resources(15).
Therefore, in the latest guideline published in 2019 By activating this mechanism, the cognitive resources
by the World Health Organization (WHO) regarding risk available for other tasks are reduced, but this can be a

ORL.ro No. 52 (3) 2021 • Year XIV • ISSN 2067-6530

19
otoneurology
potentially reversible byproduct of devoting cognitive
resources to perception.
In order to assess hearing loss, pure-tone audio­metry
remains the gold standard, but audiometry cannot de­
tect age-related synaptopathies. Medium- and low-
spontaneous rate auditory nerve fibers are believed to
be essential for temporal coding fidelity, and therefore a
precise representation of frequency information. As they
appear susceptible to noise damage, their degradation
may underlie the speech in noise difficulties experienced
by older listeners and can precede pure-tone audiometry
threshold elevations.
The sensory deprivation hypothesis is considered
the irreversible variant of the information-degradation
mechanism, with more permanent cognitive declines as
a result of chronic auditory deprivation. Atrophy and
reorganization of cortical auditory areas are the implied
potential mechanisms of this hypothesis.
A common cause or shared neurobiological pa-
thology hypothesis, in which both pathologies are
potentially a joint product of a generalized neurodegen­
erative process, is also considered. In this case, hearing
loss can be considered simply an early manifestation of
dementia during its preclinical stage.
Genetic involvement in dementia is complex, and
at the moment the ApoE4 allele is the only known ge­
netic factor that significantly increases susceptibility to
late-onset Alzheimer’s disease(4). Research conducted by
Morita et al. and other prior studies investigating hear­
ing loss and ApoE4 allele status found no association
between ApoE4 Allele and hearing loss(16).
Microvascular pathology and older age increase the
risk for hearing loss and dementia and might, therefore,
confound the association.
1. United Nations, Department of Economic and Social Affairs, Population Division.
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20
Do hearing aids improve cognitive decline?
While dementia is not curable, many manifestations
of it are now considered to be manageable, with an im­
provement of the course of the disease. Though hearing
loss is considered a risk factor for cognitive decline, it is
not fully established whether correction – such as hear­
ing aids – can delay or prevent the outset of dementia.
Preliminary studies have shown some degree of stead­
iness and, in some cases, the improvement of cognitive
function six months after cochlear implantation(17,18).
In 2016, Taljaard and Olathe published a meta-anal­
ysis on the relationship between hearing impairment
and cognitive function. An association between hear­
ing loss and dementia was confirmed in this study, but
noteworthy was also the observation that treating hear­
ing impairment significantly improved the cognitive
function(19).
Based on this early research, although not sufficient,
the World Health Organization considers that hearing
screening of older adults and early intervention may
become more relevant, and addressing hearing loss
through hearing devices may have a positive influence
on the individual’s cognition(3).
Conclusions
By this time, hearing aids have been clearly demon­
strated to be efficacious in patients with sensorineural
hearing loss. However, there is still a great need for stud­
ies to determine the role of routine hearing screening in
improving patient’s outcomes, given that the symptoms
of hearing loss can be mistaken for dementia. n
Conflicts of interests: The authors declare no con­
flict of interests.
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ORL.ro No. 52 (3) 2021 • Year XIV • ISSN 2067-6530
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