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How Can You Remember What You did not Hear?

A lot of effort goes into alerting people to the symptoms of Alzheimer’s disease and other causes of dementia. Organizations such as the Alzheimer Society have done a commendable job in helping the lay public as well as health care professionals as to what the symptoms and signs are in people showing evidence of possible cognitive impairment and urging them to see seek assistance, assessment and advice. Among the cardinal symptoms that most people now recognize as potentially pointing to such a clinical problem is memory impairment. In fact for many lay people their concept of dementia focuses almost exclusively in memory rather than the various behavioural symptoms that may also be indicators of underlying cognitive impairment such as depression, agitation, easy irritation and a wide range of other apparently “mental health symptoms”.

It is well recognized that hearing impairment is a common phenomenon in the older population. Many individuals have at some time in the their later years recognized a degree of hearing impairment and many do seek advice and may eventually undergo hearing enhancement and routine follow-up by qualified health care professionals in the field of hearing such as audiologists and Ear Nose and Throat physicians who may provide regular monitoring in addition to what may be done by a family physician. There are however a great many elders who deny that they have a problem or who, for one reason or another, choose not to wear hearing aids and they and their family members may just accept the need to raise one’s voice and repeat things in order to communicate. It is this group that may present with a concern about cognitive impairment that health care providers as well as family members must be alert to in order to provide proper interventions and to avoid erroneous assumptions about their cognitive status.

It was a bit of an unusual clinical situation, two patients in a row that I was evaluating because of concerns about dementia based on observations by family members of apparent problems with memory demonstrated significant problems with their hearing. In one situation the hearing issue was evident as soon as I started doing my interview but in the second circumstance it took a while and some probing to ascertain that hearing impairment was an ongoing issue but did not on the surface to cause much in the way of problems, at least according to the patient and family.

In both situations after my interviews which included seeing the difference between speaking to the patient face on so my lips could be read and speaking to them “sideways” which of course occurs commonly during various types of conversations it became apparent that they were “filling in” the gaps from their hearing using other clues such as body language and lip reading.

It reminded me of the long process of getting my late father to acknowledge that he had a hearing problem and finally accede to some sort of amplification system. For the years that he was still living alone in Brooklyn when I would phone on a weekly basis to “catch-up” on his progress and function it was clear that he was having problems hearing the phone conversation even after we had the phone modified with an amplification device. On one of his visits to Toronto I arranged a formal audiology examination and the result confirmed the hearing impairment. I had explained to the audiologist that my father was an engineer and very knowledgeable about how things “worked” and claimed that his hearing was fine so that convincing him of a problem would not be easy. A the end of the examination the audiologist demonstrating her respect for his knowledge and understanding said to him, “Mr. Gordon, you are correct that your hearing is adequate, but your discrimination is very poor, that is your ability to distinguish between the different sounds creating a problem in your ability to actually interpret what you are hearing.” He accepted the explanation but remained resistant to any amplification system such as a hearing aid.

In both of the patients that I saw on that morning, they had in the past been tried with hearing aids but rejected them because they were either “uncomfortable” to use or had a lot of “noise” that made them difficult to tolerate. The children acknowledged some attempts in the past but just accepted that the rejection of the devices was the end of the story and did not associate what was clear to me to be significant hearing impairment to their current complaints of memory deficiency. Each of the families were especially concerned that when they had conversations in person or on the phone, sometime after the parent acted as if there had not been a conversation and could not remember “what was said or agreed to when for example a meeting was being arranged.”

The formal mental status examination in both cases revealed some deficiencies but not of a degree that might necessarily warrant medication intervention or a firm diagnosis of dementia. I then put on each patient a Pocketalker which is a simple amplification device that through earphones and a small amplifier the size of a pack of cards allows conversations to be amplified. The device I use in my office is in fact the one that eventually I obtained for my father and for more than a year it improved his hearing and quality of life substantially.

In each case, with the device in place and the volume turned up modestly there was a look of surprise on the face of the patients and an acknowledgement that they could hear better and they could answer questions without the previously noted hesitation prior to wearing the amplifier.

Each family promised to rent for a trial or purchase the device and see how things were over the following few months after which I would do another assessment. Whether the amplifier will resolve the apparent memory problem completely remains to be seen, but as I have often said to families and patients, “If you did not hear it, you cannot remember it.” Even if there were a component of cognitive impairment along with the hearing deficiency, improving the ability to hear would only enhance whatever other interventions would occur to improve cognition and function.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Late-Stage Dementia: Promoting Comfort, Compassion, and Care and previous two books being Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com