Tinnitus and insomnia: is hyperarousal the common denominator?

Day-night hyperarousal in tinnitus patients

Tinnitus, which affects 12-30 % of the population, is associated with sleep disturbances and daytime dysfunction, yet the neural mechanisms that link wake-up states remain unclear. This study investigated electroencephalographic (EEG) characteristics of 51 tinnitus patients and 51 controls across wakefulness (eyes-open, eyes-closed, mental arithmetic) and sleep stages (N1, N2, N3, REM) to clarify day-night pathological mechanisms. The key findings showed persistent hyperarousal in tinnitus: wakefulness revealed enhanced gamma power (30-45 Hz) in eyes-closed and task states, while sleep demonstrated elevated gamma/beta power across all stages accompanied by reduced delta/theta power in deep sleep (N2/N3).). An analysis of sleep structure indicates impaired stability in maintaining the N2 stage among tinnitus patients, corroborating a reduction in N3 duration and an increased proportion of the N2 stage. From the wake states to the sleep stages, group × state interactions for the delta/theta power suggest an impaired state regulation capacity in tinnitus patients. Correlation clustering further revealed aberrant integration of wake-related gamma/beta activity into non-rapid eye movement sleep, indicating neuroplastic overgeneralization of wake hyperarousal into sleep. These results extend the so-called loss-of-inhibition theory to sleep, proposing that deficient low-frequency oscillations fail to suppress hyperarousal, impairing sleep-dependent neuroplasticity, and perpetuating daytime symptoms. Furthermore, this study establishes sleep as a critical therapeutic target to interrupt the 24-h dysfunctional cycle of tinnitus.

Relationship Between Chronicity and Severity of Tinnitus and Sleep-Related Issues

OBJECTIVES

Growing evidence suggests a potential link between tinnitus and sleep-related disturbances. This study aimed to explore this association in a large-scale population-based data.

STUDY DESIGN

Cross-sectional study.

SETTING

The 6,951 subjects with data on demographics, sleep patterns, sleep-related symptoms, and otologic assessments were selected from the eighth and ninth Korea National Health and Nutrition Examination Surveys (2019, 2020, and 2022), a database representing the general population.

MAIN OUTCOMES MEASURES

Subjects were classified into tinnitus and nontinnitus groups, with the tinnitus group subdivided by chronicity (acute/chronic) and severity (mild/severe), and their association with sleep issues was analyzed.

RESULTS

The chronic tinnitus group had shorter sleep durations (weekdays, p < 0.001; weekends, p < 0.001) and higher proportions of sleep deprivation (weekdays, p = 0.001; weekends, p < 0.001), fatigue (p < 0.001), and witnessed obstructive sleep apnea (p = 0.026) compared to the nontinnitus group. They also exhibited shorter sleep duration (p = 0.027) and more sleep deprivation (p = 0.025) on weekends than the acute tinnitus group. The severe tinnitus group showed shorter sleep durations (weekdays, p = 0.004; weekends, p < 0.001), more sleep deprivation (weekdays, p = 0.025; weekends, p = 0.001), and higher levels of fatigue (p = 0.001) compared to the nontinnitus group, as well as more fatigue than the mild tinnitus group (p = 0.001).

CONCLUSION

The chronicity and severity of tinnitus were significantly associated with sleep problems. Chronic and severe tinnitus are strongly associated with sleep disturbances, emphasizing the need for targeted management.

Systematic review and meta-analysis of the correlation between tinnitus and mental health

OBJECTIVE

This paper assesses the correlation between tinnitus and mental health, including depression, anxiety, stress, insomnia, and suicide through meta-analysis.

METHODS

Web of Science, Embase, PubMed, and Cochrane databases were searched until January 2024. After article screening, data extraction, and quality evaluation, meta-analysis was performed using Stata 15.1.

RESULTS

22 papers were enrolled, including 5 case-control studies, 8 cohort studies, and 9 cross-sectional studies. Meta-analysis uncovered that tinnitus was associated with depression (OR = 1.92, 95 % CI: 1.56, 2.36), anxiety (OR = 1.63, 95 % CI: 1.34, 1.98), stress (OR = 1.17, 95 % CI: 1.01, 1.36), insomnia (OR = 3.07, 95 % CI: 2.36, 3.98), and suicide (OR = 5.31, 95 % CI: 4.34, 6.51).

CONCLUSION

A correlation is indicated between tinnitus and mental health. Therefore, it is critical to incorporate psychological interventions in tinnitus treatment and to implement a comprehensive treatment program.

A U-shaped relationship between sleep duration and tinnitus incidence: analysis of 13,871 participants from NHANES

Sleep duration is associated to various health impairments, while its comprehensive association with tinnitus is rarely investigated. The current study aimed to explore the relationship between sleep duration and tinnitus incidence, and to determine the optimal sleep duration relating to the lowest tinnitus risk. Data of participants from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2012 and 2015 to 2018 were retrieved. A total of 13,871 participants were eligible and included in the analysis. Generally, sleep duration was lower in participants with tinnitus compared to those without (7.15±1.76 vs 7.30±1.51 h, P<0.001). After adjustment by demographics, lifestyle, and chronic diseases, a U-shaped relationship between sleep duration and tinnitus incidence was observed, with the inflection point at 8.5 h. Interestingly, in participants with sleep duration <8.5 h, sleep duration exhibited an independent negative correlation with tinnitus risk [OR=0.88 (95%CI: 0.84-0.93), P<0.001], while in participants with sleep duration ≥8.5 h, sleep duration had an independent positive association with tinnitus risk [OR=1.16 (95%CI: 1.04-1.28), P=0.006]. In conclusion, a U-shaped relationship was found between sleep duration and tinnitus incidence, with a sleep duration of about 8.5 h being associated with the lowest tinnitus risk.

Music Combined with Cognitive Behavioral Therapy Enhanced Functional Integration within the Frontal-Parietal-Temporal Brain Network in Patients with Chronic Subjective Tinnitus

BACKGROUND

This study was aimed at investigating the effectiveness of music combined with cognitive behavioral therapy (music-CBT) and its underlying therapeutic mechanisms in treating chronic subjective tinnitus.

METHODS

Twenty-seven participants with chronic subjective tinnitus who underwent a 3-month music-CBT were initially involved in this retrospective study. The resting-state electroencephalograms (EEG) and behavioral assessments of pre- and post-music-CBT, including tinnitus handicap inventory (THI), tinnitus functional index (TFI), visual analog scales (VAS), Pittsburgh sleep quality index (PSQI), and Hamilton depression rating scale (HAMD-24) were collected and analyzed.

RESULTS

Following music-CBT, there was a significant reduction in global behavioral assessment scores, with median changes of ΔTHI = 26.0 (p < 0.001), ΔTFI = 23.7 (p < 0.001), ΔVAS = 2.0 (p < 0.001), ΔPSQI = 2.0 (p = 0.002), and ΔHAMD-24 = 2.0 (p < 0.001). Enhanced functional connectivity was seen among the frontal, parietal, and temporal cortices and significantly decreased characteristic path length (ΔCPL in delta = 0.016, p = 0.031; ΔCPL in theta = 0.012, p = 0.013), increased global efficiency (ΔGE in delta = -0.014, p = 0.037; ΔGE in theta = -0.006, p = 0.021), and local efficiency (ΔLE in delta = -0.015, p = 0.037; ΔLE in theta = -0.012, p = 0.015) were also noted. Additionally, associations were identified between ΔPSQI and ΔTHI (rho = 0.546, p = 0.003) and ΔTFI (rho = 0.462, p = 0.015); between ΔHAMD-24 and ΔCPL (rho = -0.389, p = 0.045), ΔGE (rho = 0.395, p = 0.041), and ΔLE (rho = 0.405, p = 0.036).

CONCLUSION

Optimized cognitive and emotional responses to tinnitus are linked to functional integration within the frontal-parietal-temporal brain network. Early node indicators for tinnitus relief may be the precuneus, middle frontal gyrus, middle temporal gyrus, and the right inferior parietal lobule.

Noise annoyance due to different sources is associated with tinnitus presence and distress in the general population

BACKGROUND

The pathophysiology of tinnitus is not yet fully understood. Although there is a large amount of evidence associating traffic noise exposure with non-auditory health outcomes, there is no evidence regarding the impact of noise annoyance on auditory disorders such as tinnitus.

OBJECTIVE

Thus, we aimed to investigate the association between noise annoyance due to different sources and tinnitus presence and distress in the general population.

METHODS

Data of 6813 participants from a large German population-based cohort were used (Gutenberg Health Study). Participants were asked about the presence of tinnitus and how much they were bothered by it. In addition, information on annoyance from road traffic, aircraft, railways, industrial, and neighborhood noise during the day and sleep was collected through validated questionnaires.

RESULTS

The prevalence of tinnitus was 27.3%, and the predominant sources of noise annoyance in these subjects were aircraft, neighborhood, and road traffic noise. Overall, logistic regression results demonstrated consistent positive associations between annoyance due to different noise sources and prevalent risk of tinnitus with increases in odds ratios ranging from 4 to 11% after adjustment for sex, age, and socioeconomic status. Likewise, consistent increases in odds ratios were observed for tinnitus distress in subjects with prevalent tinnitus. For instance, neighborhood noise annoyance during the sleep was associated with a 26% increase in tinnitus distress (OR 1.26, 95% CI 1.13; 1.39).

IMPACT

This is the first study investigating the association between noise annoyance and tinnitus presence and distress in a large cohort of the general population. Our results indicate consistent and positive associations between various sources of noise annoyance and tinnitus. These unprecedented findings are highly relevant as noise annoyance and tinnitus are widespread. The precise etiology and locus of tinnitus remain unknown, but excessive noise exposure is thought to be among the major causes. This study suggests that transportation and neighborhood noise levels thought merely to contribute to annoyance and non-auditory health effects may be sufficient to cause or exacerbate tinnitus.

Cortical evoked activity is modulated by the sleep state in a ferret model of tinnitus. A cross-case study

Subjective tinnitus is a phantom auditory perception in the absence of an actual acoustic stimulus that affects 15% of the global population. In humans, tinnitus is often associated with disturbed sleep and, interestingly, there is an overlap between the brain areas involved in tinnitus and regulation of NREM sleep. We used eight adult ferrets exposed to mild noise trauma as an animal model of tinnitus. We assessed the phantom percept using two operant paradigms sensitive to tinnitus, silent gap detection and silence detection, before and, in a subset of animals, up to six months after the mild acoustic trauma. The integrity of the auditory brainstem was assessed over the same period using auditory brainstem response recordings. Following noise overexposure, ferrets developed lasting, frequency-specific impairments in operant behaviour and evoked brainstem activity. To explore the interaction between sleep and tinnitus, in addition to tracking the behavioural markers of noise-induced tinnitus and hearing impairment after noise overexposure, we evaluated sleep-wake architecture and spontaneous and auditory-evoked EEG activity across vigilance states. Behavioural performance and auditory-evoked activity measurements after noise overexposure suggested distinct degrees of tinnitus and hearing impairment between individuals. Animals that developed signs of tinnitus consistently developed sleep impairments, suggesting a link between the emergence of noise-induced hearing loss and/or tinnitus and sleep disruption. However, neural markers of tinnitus were reduced during sleep, suggesting that sleep may transiently mitigate tinnitus. These results reveal the importance of sleep-wake states in tinnitus and suggest that understanding the neurophysiological link between sleep and tinnitus may provide a new angle for research into the causes of phantom percepts and inform future treatments.

Association between sleep and tinnitus in US adults: Data from the NHANES (2007-2012)

We evaluated the relationship between sleep factors and tinnitus risk using data from the US National Health and Nutrition Examination Survey (2007-2012), focusing on adults aged 20 to 80 years. Our analysis included 4354 participants, with sleep patterns categorized as healthy, intermediate, or poor. We observed that both short (odds ratio [OR]: 1.43) and long (OR: 1.48) sleep durations increased the risk of tinnitus compared with the healthy range (7-9 hours). Additionally, sleep disturbances were significantly correlated with tinnitus (OR: 1.52), with the strongest association occurring in individuals with poor sleep patterns (OR: 1.71). The results of the weighted logistic regression analysis underscored these findings.

A cross-sectional study on predictors of patients' tinnitus severity

Objective

To identify factors that influence the severity of tinnitus via a hierarchical multiple linear regression model.

Methods

The study was a retrospective cross-sectional analysis. The study included 331 patients experiencing tinnitus as their primary concern, who visited Shanghai Changzheng Hospital of the Navy Medical University between 2019 and 2021. Data on general health status and disease characteristics were collected from all patients. With their consent, participants underwent audiological evaluatons and completed questionnaires to analyze the characteristics of their tinnitus and the factors influencing its severity.

Results

The correlation analysis showed a positive relationship between tinnitus frequency, tinnitus loudness, SAS scores, and PSQI scores with THI scores (P < 0.05) among nine examined variables (gender, handedness, employment status, age, BMI, tinnitus frequency, tinnitus loudness, SAS scores, and PSQI scores). The variables that were extracted from the multiple regression were; for the constant; β = -51.797, t = -4.484, P < 0.001, variable is significant; for the tinnitus loudness; β = 0.161, t = 2.604, P < 0.05, variable is significant; for the tinnitus frequency; β = 0.000, t = 1.269, P = 0.206, variable is not significant; for the SAS scores; β = 1.310, t = 7.685, P < 0.001, variable is significant; for the PSQI scores; β = 1.680, t = 5.433, P < 0.001, variable is significant. Therefore, the most accurate model for predicting severity in tinnitus patients is a linear combination of the constant, tinnitus loudness, SAS scores, and PSQI scores, Y(Tinnitus severity) = β 0 + β 1 (Tinnitus loudness) + β 2 (SAS scores) + β 3 (PSQI scores). β 0, β 1, β 2, and β 3 are -51.797, 0.161, 1.310 and 1.680, respectively.

Conclusion

Tinnitus severity is positively associated with loudness, anxiety levels, and sleep quality. To effectively manage tinnitus in patients, it is essential to promptly identify and address these accompanying factors and related symptoms.

Results of two cross-sectional database analyses regarding nap-induced modulations of tinnitus

The influence of naps on tinnitus was systematically assessed by exploring the frequency, clinical and demographic characteristics of this phenomenon. 9,724 data from two different tinnitus databases (Tinnitus Hub: n = 6115; Tinnitus Research Initiative (TRI): n = 3627) were included. After separate analysis of the databases, these results were then compared with each other. In the Tinnitus Hub survey database, a total of 31.1% reported an influence on tinnitus by taking a nap (26.9% in the TRI database), with much more frequent worsening after a nap than improvement (23.0% a little or a lot worse; TRI: 17.7% worse; 8.1% a little or a lot better; TRI: 9.2% better). The influence of napping on tinnitus was associated in both databases with other clinical features, such as the dependence of tinnitus on night quality, stress and somatosensory maneuvers. The present study confirms the clinical observation that more tinnitus sufferers report worsening after a nap than tinnitus sufferers reporting an improvement. It was consistently shown that tinnitus sufferers reporting nap-induced modulation of tinnitus also report more frequently an influence of night sleep on their tinnitus. Further clinical and polysomnographic research is warranted to better understand the interaction between sleep and tinnitus.

The Prevalence of Insomnia Among Patients With Chronic Tinnitus in the General Population of the Kingdom of Saudi Arabia

BACKGROUND

 Tinnitus is a perception of sound without external sound stimulation. Subjective tinnitus is the most common type and is unrelated to external sounds. It is a symptom, not an illness, and is often linked to various psychological factors like anxiety and depression. Insomnia is a personal sense of difficulty falling asleep and issues with sleep initiation, length, consolidation, or quality while having ample chance to sleep, which impairs one's ability to function during the day. Sleep problems are prevalent in individuals with chronic tinnitus.

OBJECTIVE

 We aimed to assess insomnia prevalence in chronic tinnitus patients in Saudi Arabia.

METHOD

 Our study, an online cross-sectional survey, included 434 Saudi participants with chronic insomnia, utilizing a Google Forms questionnaire (Google LLC, Mountain View, California, United States).

RESULTS

 A total of 434 participants responded to the online survey. The most represented age group was 18-25 years, and 319 (73.5%) of the respondents were female. Approximately one-third (34.6%, n=150) were from the southern region. In the sample, 184 (42.4%) participants had bilateral tinnitus, and 105 (24.2%) had had tinnitus for over two years. Around 62.7% of the participants suffered from insomnia due to tinnitus. In terms of sleep quality, 174 (40.1%) participants took over 40 minutes to fall asleep, 85 (19.5%) were often afraid to sleep due to disturbed sleep, and 63 (14.5%) frequently used sleep pills.

CONCLUSION

 Our study of over 400 Saudi chronic tinnitus patients revealed that a large percentage of tinnitus patients have insomnia, influenced by geographic region and tinnitus duration. Our findings offer valuable insights, emphasizing the necessity for additional research to inform interventions aimed at enhancing the quality of life of individuals with chronic tinnitus.

Conceptual framework for tinnitus: a cognitive model in practice

Tinnitus is a conscious attended awareness perception of sourceless sound. Widespread theoretical and evidence-based neurofunctional and psychological models have tried to explain tinnitus-related distress considering the influence of psychological and cognitive factors. However, tinnitus models seem to be less focused on causality, thereby easily misleading interpretations. Also, they may be incapable of individualization. This study proposes a Conceptual Cognitive Framework (CCF) providing insight into cognitive mechanisms involved in the predisposition, precipitation, and perpetuation of tinnitus and consequent cognitive-emotional disturbances. The current CCF for tinnitus relies on evaluative conditional learning and appraisal, generating negative valence (emotional value) and arousal (cognitive value) to annoyance, distress, and distorted perception. The suggested methodology is well-defined, reproducible, and accessible, which can help foster future high-quality clinical databases. Perceived tinnitus through the perpetual-learning process can always lead to annoyance, but only in the clinical stage directly cause annoyance. In the clinical stage, tinnitus perception can lead indirectly to distress only with experiencing annoyance either with ("I n d - 1 C " = 1.87; 95% CI 1.18-2.72)["1st indirect path in the Clinical stage model": Tinnitus Loudness → Attention Bias → Cognitive-Emotional Value → Annoyance → Clinical Distress]or without ("I n d - 2 C "= 2.03; 95% CI 1.02-3.32)[ "2nd indirect path in the Clinical stage model": Tinnitus Loudness → Annoyance → Clinical Distress] the perpetual-learning process. Further real-life testing of the CCF is expected to express a meticulous, decision-supporting platform for cognitive rehabilitation and clinical interventions. Furthermore, the suggested methodology offers a reliable platform for CCF development in other cognitive impairments and supports the causal clinical data models. It may also enhance our knowledge of psychological disorders and complicated comorbidities by supporting the design of different rehabilitation interventions and comprehensive frameworks in line with the "preventive medicine" policy.

How people with tinnitus-related insomnia experience group CBT-for-insomnia (CBTi): a thematic analysis

Objective: Although insomnia often compounds tinnitus, sleeping problems in people experiencing tinnitus are rarely treated. This study investigates the experiences of participants receiving Cognitive Behavioural Therapy for insomnia (CBTi) as part of a randomised controlled trial for managing tinnitus-related insomnia. The aim of this study is to gain detailed insight into participants' perceptions and experiences of this treatment.Design: Semi-structured interviews were conducted via phone or in-person by one of the two clinical psychologists who facilitated the CBTi sessions. Reflexive thematic analysis with semantic inductive approach was used for analysis to keep the research question theoretically flexible.Study samples: Eight participants (three females, age range 32-69 years) were interviewed six months after CBTi completion.Results: Three superordinate themes were identified: "Common humanity and transcending individual distress," "Changing the things I can" and "Accepting the things I cannot change." The group environment helped participants to normalise their experiences. Reliable tinnitus/sleep information and robust behavioural change techniques helped participants to respond and relate to their condition differently.Conclusion: Generally, participants reported long-term benefits from CBTi to treat tinnitus-related insomnia, particularly increased confidence, and getting on with life. CBTi is multi-component, so clinicians need to respond to individual preferences and lifestyles.

Health position paper and redox perspectives - Disease burden by transportation noise

Transportation noise is a ubiquitous urban exposure. In 2018, the World Health Organization concluded that chronic exposure to road traffic noise is a risk factor for ischemic heart disease. In contrast, they concluded that the quality of evidence for a link to other diseases was very low to moderate. Since then, several studies on the impact of noise on various diseases have been published. Also, studies investigating the mechanistic pathways underlying noise-induced health effects are emerging. We review the current evidence regarding effects of noise on health and the related disease-mechanisms. Several high-quality cohort studies consistently found road traffic noise to be associated with a higher risk of ischemic heart disease, heart failure, diabetes, and all-cause mortality. Furthermore, recent studies have indicated that road traffic and railway noise may increase the risk of diseases not commonly investigated in an environmental noise context, including breast cancer, dementia, and tinnitus. The harmful effects of noise are related to activation of a physiological stress response and nighttime sleep disturbance. Oxidative stress and inflammation downstream of stress hormone signaling and dysregulated circadian rhythms are identified as major disease-relevant pathomechanistic drivers. We discuss the role of reactive oxygen species and present results from antioxidant interventions. Lastly, we provide an overview of oxidative stress markers and adverse redox processes reported for noise-exposed animals and humans. This position paper summarizes all available epidemiological, clinical, and preclinical evidence of transportation noise as an important environmental risk factor for public health and discusses its implications on the population level.

The potassium channels: Neurobiology and pharmacology of tinnitus

Tinnitus is a widespread public health issue that imposes a significant social burden. The occurrence and maintenance of tinnitus have been shown to be associated with abnormal neuronal activity in the auditory pathway. Based on this view, neurobiological and pharmacological developments in tinnitus focus on ion channels and synaptic neurotransmitter receptors in neurons in the auditory pathway. With major breakthroughs in the pathophysiology and research methodology of tinnitus in recent years, the role of the largest family of ion channels, potassium ion channels, in modulating the excitability of neurons involved in tinnitus has been increasingly demonstrated. More and more potassium channels involved in the neural mechanism of tinnitus have been discovered, and corresponding drugs have been developed. In this article, we review animal (mouse, rat, hamster, and guinea-pig), human, and genetic studies on the different potassium channels involved in tinnitus, analyze the limitations of current clinical research on potassium channels, and propose future prospects. The aim of this review is to promote the understanding of the role of potassium ion channels in tinnitus and to advance the development of drugs targeting potassium ion channels for tinnitus.

Association of Sleep Characteristics with Tinnitus and Hearing Loss

Objective

The impact of poor sleep on tinnitus has been mainly attributed to central processes. There is an association between sleep disorders and hearing loss, but whether hearing levels mediate the association between sleep disorders and tinnitus is unknown. This study investigates the association between sleep characteristics, tinnitus, and hearing loss.

Study Design

Cross-sectional.

Setting

National Health and Nutrition Examination Survey (NHANES).

Methods

Study cohort includes 9693 adults (≥20 years) from the NHANES 2005 to 2018 who completed audiometric testing and questionnaires on tinnitus and sleep characteristics. Multivariable regression analyses were performed to quantify associations between sleep characteristics, tinnitus, and hearing loss.

Results

In this cohort, 29% (95% confidence interval [CI]: 28%-31%) reported trouble sleeping and 9% (95% CI: 8%-10%) reported being diagnosed with sleep disorders. Negative sleep characteristics (less hours of sleep, diagnosis of a sleep disorder, trouble sleeping, or OSA symptoms) were not associated with audiometry-measured hearing loss in multivariable models adjusted for demographics and comorbidities but were significantly associated with bothersome tinnitus. This association remained significant without substantial attenuation in multivariable models additionally adjusting for hearing levels: sleeping <8 h/day (vs ≥8) (odds ratio [OR]: 1.28 [95% CI: 1.08-1.52]), trouble sleeping (OR: 1.78 [95% CI: 1.45-2.19]), diagnosis of sleep disorders (OR: 1.57 [95% CI: 1.14-2.15]), and report of OSA symptoms (OR: 1.42 [95% CI: 1.08-1.88]).

Conclusion

Negative sleep characteristics were associated with tinnitus while there was no clinically meaningful association between sleep and hearing loss. Our findings suggest that the relationship between poor sleep and tinnitus is likely contributed by central processes without a major role of mediation via the peripheral auditory system.

An Exploratory Study of the Effect of Tinnitus on Listening Effort Using EEG and Pupillometry

OBJECTIVE

Previous behavioral studies on listening effort in tinnitus patients did not consider extended high-frequency hearing thresholds and had conflicting results. This inconsistency may be related that listening effort is not evaluated by the central nervous system (CNS) and autonomic nervous system (ANS), which are directly related to tinnitus pathophysiology. This study matches hearing thresholds at all frequencies, including the extended high-frequency and reduces hearing loss to objectively evaluate listening effort over the CNS and ANS simultaneously in tinnitus patients.

STUDY DESIGN

Case-control study.

SETTING

University hospital.

METHODS

Sixteen chronic tinnitus patients and 23 matched healthy controls having normal pure-tone averages with symmetrical hearing thresholds were included. Subjects were evaluated with 0.125 to 20 kHz pure-tone audiometry, Montreal Cognitive Assessment Test (MoCA), Tinnitus Handicap Inventory (THI), Visual Analog Scale (VAS), electroencephalography (EEG), and pupillometry.

RESULTS

Pupil dilation and EEG alpha band in the "coding" phase of the sentence presented in tinnitus patients was less than in the control group (p < .05). VAS score was higher in the tinnitus group (p < .01). Also, there was no statistically significant relationship between EEG and pupillometry components and THI or MoCA (p > .05).

CONCLUSION

This study suggests that tinnitus patients may need to make an extra effort to listen. Also, pupillometry may not be sufficiently reliable to assess listening effort in ANS-related pathologies. Considering the possible listening difficulties in tinnitus patients, reducing the listening difficulties, especially in noisy environments, can be added to the goals of tinnitus therapy protocols.

[Chronic tinnitus: An interplay between somatic and psychological factors]

Chronic tinnitus is a common, sometimes highly distressing phenomenon that can be triggered and maintained by an interplay of physical and psychological factors. Partnering with clinical psychology and psychosomatic medicine, modern otolaryngology integrates both medical (e.g., hearing loss) and psychological influences (e.g., interactions between biographical experiences, personality traits, subjective evaluation of intrapsychic and interpersonal stimuli, emotional states, and intrapsychic or interpersonal emotion regulation strategies). Both groups of variables can influence the intensity and course of chronic tinnitus symptomatology both directly and indirectly, whereby the quality and relative degrees of psychological and physical components in a person's self-experience can fluctuate. With this in mind, the present article distinguishes between chronic tinnitus symptomatology with or without hearing loss-and strongly advocates for an integrated understanding of the symptomatology within a holistic psychological frame of reference. After a brief introduction to the principles of psychosomatic medicine and psychotherapy, the article discusses psychological case conceptualization using a vulnerability-stress-coping (VSC) model as an example, outlines clinical aspects and diagnostics of chronic tinnitus symptomatology, and concludes with a conceptualization of chronic tinnitus-related distress as a function of person-centered VSC interactions.

The Cross-Sectional Association Between Tinnitus and Actigraphy-Estimated Sleep in a Population-Based Cohort of Middle-Aged and Elderly Persons

OBJECTIVES

Tinnitus is a common and burdensome disease, often accompanied by complaints of poor sleep. However, associations of tinnitus with objective estimates of sleep remain unclear, particularly in the general population. We assessed these associations in a population-based cohort of middle-aged and elderly persons.

DESIGN

This study included 1456 participants (mean age: 65.0 ± 7.1 years, 52% women) from the population-based Rotterdam Study. Tinnitus was self-reported and in those who reported tinnitus daily, symptom severity was assessed with the Tinnitus Handicap Inventory. We used actigraphy to estimate sleep and 24-hour activity rhythms objectively and sleep diaries to assess self-reported sleep. We estimated the difference in sleep and 24-hour activity rhythms first between those with and those without tinnitus and secondly with tinnitus severity.

RESULTS

Tinnitus, reported by 341 (23%) participants, and tinnitus severity, assessed in 194 participants with daily tinnitus, were not associated with actigraphy-estimated sleep or 24-hour activity rhythms, but were associated with a longer self-reported sleep onset latency (adjusted difference tinnitus = 2.36, 95% confidence interval [CI] = 0.95-3.78, adjusted difference tinnitus severity = 0.27, 95% CI = 0.013-0.54). After stratification for hearing loss, tinnitus was associated with longer self-reported sleep onset latency (adjusted difference = 2.26, 95% CI = 0.98-3.53) and less stable 24-hour activity rhythms (adjusted difference = -0.02, 95% CI = -0.04 to -0.00) in those with hearing loss. In those without hearing loss, tinnitus was associated with more stable rhythms (adjusted difference = 0.03, 95% CI = 0.01-0.05).

CONCLUSIONS

Having tinnitus is associated with a longer self-reported sleep onset latency, but not with objective estimates of sleep, suggesting that the subjective experience of sleep may be particularly disturbed in those with tinnitus. In addition, hearing loss may modify the association of tinnitus and 24-hour activity rhythms.

REM Sleep Impairment May Underlie Sleep-Driven Modulations of Tinnitus in Sleep Intermittent Tinnitus Subjects: A Controlled Study

(1) Background: Poor sleep and fragmented sleep are associated with several chronic conditions. Tinnitus is an auditory symptom that often negatively combines with poor sleep and has been associated with sleep impairment and sleep apnea. The relationship between tinnitus psychoacoustic characteristics and sleep is still poorly explored, notably for a particular subgroup of patients, for whom the perceived loudness of their tinnitus is highly modulated by sleep. (2) Methods: For this observational prospective study, 30 subjects with tinnitus were recruited, including 15 "sleep intermittent tinnitus" subjects, who had reported significant modulations of tinnitus loudness related to night sleep and naps, and a control group of 15 subjects displaying constant non-sleep-modulated tinnitus. The control group had matching age, gender, self-reported hearing loss grade and tinnitus impact on quality of life with the study group. All patients underwent a polysomnography (PSG) assessment for one complete night and then were asked to fill in a case report form, as well as a report of tinnitus loudness before and after the PSG. (3) Results: "Sleep Intermittent tinnitus" subjects had less Stage 3 sleep (p < 0.01), less Rapid-Eye Movement (REM) Sleep (p < 0.05) and more Stage 2 sleep (p < 0.05) in proportion and duration than subjects from the control group. In addition, in the "sleep Intermittent tinnitus" sample, a correlation was found between REM sleep duration and tinnitus overnight modulation (p < 0.05), as well as tinnitus impact on quality of life (p < 0.05). These correlations were not present in the control group. (4) Conclusions: This study suggests that among the tinnitus population, patients displaying sleep-modulated tinnitus have deteriorated sleep quality. Furthermore, REM sleep characteristics may play a role in overnight tinnitus modulation. Potential pathophysiological explanations accounting for this observation are hypothesized and discussed.

Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: a randomised controlled trial

Insomnia is a significant difficulty and is reported by large proportion of people with tinnitus. Although cognitive behavioural therapy for insomnia (CBTi) might be an effective treatment, no controlled studies had been conducted to date. This randomised controlled trial evaluated the benefits of CBTi on a sample of 102 people with tinnitus-related insomnia. Participants were randomised to 1) CBTi, 2) Audiology-Based Care (ABC) or 3) Sleep Support Group (SSG). Primary outcomes included insomnia, sleep efficiency and total sleep time. Secondary outcomes measured sleep onset latency, sleep quality, tinnitus distress, psychological distress, functioning and quality of life. CBTi was superior at reducing insomnia and increasing sleep efficiency compared to ABC post-intervention and at 6-month follow-up. ABC was superior at reducing insomnia and increasing sleep efficiency compared to SSG. Both CBTi and ABC reported increased total sleep time compared to SSG at 6-month follow. More than 80% of participants in the CBTi group reported clinically meaningful improvements compared to 47% in ABC and 20% for those receiving social support. CBTi was more effective in reducing tinnitus distress and improving sleep quality, functioning and some aspects of mental health. CBTi and ABC offer effective treatments for tinnitus-related sleep disorder but CBTi offers a sizeable benefit.

Transportation Noise and Risk of Tinnitus: A Nationwide Cohort Study from Denmark

BACKGROUND

There is a growing body of evidence linking residential exposure to transportation noise with several nonauditory health outcomes. However, auditory outcomes, such as tinnitus, are virtually unexplored.

OBJECTIVES

We aimed to investigate the association between residential transportation noise and risk of incident tinnitus.

METHODS

We conducted a nationwide cohort study including all residents in Denmark age ≥30y, of whom 40,692 were diagnosed with tinnitus. We modeled road traffic and railway noise at the most (Ldenmax) and least (Ldenmin) exposed façades of all Danish addresses from 1990 until 2017. For all participants, we calculated 1-, 5-, and 10-y time-weighted mean noise exposure and retrieved detailed information on individual- and area-level socioeconomic covariates. We conducted analyses using Cox proportional hazards models.

RESULTS

We found positive associations between exposure to road traffic noise and risk of tinnitus, with hazard ratios of 1.06 [95% confidence interval (CI): 1.04, 1.08] and 1.02 (95% CI: 1.01, 1.03) per 10-dB increase in 10-y Ldenmin and Ldenmax, respectively. Highest risk estimates were found for women, people without a hearing loss, people with high education and income, and people who had never been in a blue-collar job. The association with road Ldenmin followed a positive, monotonic exposure-response relationship. We found no association between railway noise and tinnitus.

DISCUSSION

To our knowledge, this is the first study to show that residential exposure to road traffic noise may increase risk of tinnitus, suggesting noise may negatively affect the auditory system. If confirmed, this finding adds to the growing evidence of road traffic noise as a harmful pollutant with a substantial health burden. https://doi.org/10.1289/EHP11248.

Objective multidisciplinary measurements of sleep disturbance and autonomic dysfunction as risk factors for chronic subjective tinnitus

PURPOSE

This observational study assessed sleep disturbance and autonomic dysfunction as risk factors for chronic subjective tinnitus through polysomnography (PSG) and autonomic function tests.

METHODS

Adult patients with chronic subjective tinnitus who visited the department of otolaryngology in our hospitals (n = 40), along with controls without tinnitus (n = 80), were recruited. Individuals with an average hearing threshold level (HL) exceeding 25 dB HL and a known diagnosis of insomnia were excluded. Objective assessments comprised pure-tone audiometry, PSG, and autonomic function tests (e.g., the cold pressor test).

RESULTS

Patients with prolonged sleep latency, lower sleep efficiency, and sympathetic hyperactivity had significantly higher risks of developing tinnitus. No interaction effect between poor sleep quality and sympathetic hyperactivity on tinnitus was detected.

CONCLUSION

This is the first study to administer PSG and autonomic function tests to patients with chronic subjective tinnitus. Poor sleep quality and autonomic dysfunction were implicated as risk factors for tinnitus. PSG and the autonomic function tests helped identify tinnitus-related comorbidities and inform tinnitus treatment. Sleep disturbance and autonomic dysfunction did not exert an interaction effect on tinnitus. Further studies with a larger sample size and the inclusion of patients with more severe tinnitus are warranted.

The association between stress, emotional states, and tinnitus: a mini-review

Extensive literature supporting the view of tinnitus induced stress in patients is available. However, limited evidence has been produced studying the opposite, that is, does stress cause tinnitus? The hypothalamus pituitary adrenal axis, one of the main neuroendocrine systems involved in stress response, is commonly disturbed in tinnitus patients. Patients with chronic tinnitus have been shown to develop abnormal responses to psycho-social stress, where the hypothalamus pituitary adrenal axis response is weaker and delayed, suggesting chronic stress contributes to the development of chronic tinnitus. The sympathetic branch of the autonomic nervous system also plays a major role in stress response and its chronic hyperactivity seems to be involved in developing tinnitus. Psycho-social stress has been shown to share the same probability of developing tinnitus as occupational noise and contributes to worsening tinnitus. Additionally, exposure to high stress levels and occupational noise doubles the likelihood of developing tinnitus. Interestingly, short-term stress has been shown to protect the cochlea in animals, but chronic stress exposure has negative consequences. Emotional stress also worsens pre-existing tinnitus and is identified as an important indicator of tinnitus severity. Although there is limited body of literature, stress does seem to play a vital role in the development of tinnitus. This review aims to highlight the association between stress, emotional states, and the development of tinnitus while also addressing the neural and hormonal pathways involved.

The Relationship Between Sleep Traits and Tinnitus in UK Biobank: A Population-Based Cohort Study

OBJECTIVES

Understanding the association between sleep traits and tinnitus could help prevent and provide appropriate interventions against tinnitus. Therefore, this study aimed to assess the relationship between different sleep patterns and tinnitus.

DESIGN

A cross-sectional analysis using baseline data (2006-2010, n = 168,064) by logistic regressions was conducted to evaluate the association between sleep traits (including the overall health sleep score and five sleep behaviors) and the occurrence (yes/no), frequency (constant/transient), and severity (upsetting/not upsetting) of tinnitus. Further, a prospective analysis of participants without tinnitus at baseline (n = 9581) was performed, who had been followed-up for 7 years (2012-2019), to assess the association between new-onset tinnitus and sleep characteristics. Moreover, a subgroup analysis was also carried out to estimate the differences in sex by dividing the participants into male and female groups. A sensitivity analysis was also conducted by excluding ear-related diseases to avoid their confounding effects on tinnitus (n = 102,159).

RESULTS

In the cross-sectional analysis, participants with "current tinnitus" (OR: 1.13, 95% CI: 1.04-1.22, p = 0.004) had a higher risk of having a poor overall healthy sleep score and unhealthy sleep behaviors such as short sleep durations (OR: 1.09, 95% CI: 1.04-1.14, p < 0.001), late chronotypes (OR: 1.09, 95% CI: 1.05-1.13, p < 0.001), and sleeplessness (OR: 1.16, 95% CI: 1.11-1.22, p < 0.001) than those participants who "did not have current tinnitus." However, this trend was not obvious between "constant tinnitus" and "transient tinnitus." When considering the severity of tinnitus, the risk of "upsetting tinnitus" was obviously higher if participants had lower overall healthy sleep scores (OR: 1.31, 95% CI: 1.13-1.53, p < 0.001). Additionally, short sleep duration (OR: 1.22, 95% CI: 1.12-1.33, p < 0.001), late chronotypes (OR: 1.13, 95% CI: 1.04-1.22, p = 0.003), and sleeplessness (OR: 1.43, 95% CI: 1.29-1.59, p < 0.001) showed positive correlations with "upsetting tinnitus." In the prospective analysis, sleeplessness presented a consistently significant association with "upsetting tinnitus" (RR: 2.28, p = 0.001). Consistent results were observed in the sex subgroup analysis, where a much more pronounced trend was identified in females compared with the males. The results of the sensitivity analysis were consistent with those of the cross-sectional and prospective analyses.

CONCLUSIONS

Different types of sleep disturbance may be associated with the occurrence and severity of tinnitus; therefore, precise interventions for different types of sleep disturbance, particularly sleeplessness, may help in the prevention and treatment of tinnitus.

Associations Between Physical Activity, Tinnitus, and Tinnitus Severity

OBJECTIVES

To examine the associations between physical activity and tinnitus development and physical activity and tinnitus severity in a large representative sample of US adults.

DESIGN

Data were obtained from 3826 eligible participants (20 to 69 years) in the National Health and Nutrition Examination Survey between 2015 and 2016. Physical activity was assessed using a Global Physical Activity Questionnaire. We used multivariable logistic regression to test the associations of physical activity (without physical activity, with physical activity) and amount of physical activity (min/week, in quartiles) with tinnitus symptoms. Adults with depressive symptoms were excluded, and the models were controlled for relevant sociodemographic, lifestyle, and health-related covariates. A restricted cubic spline was used to explore the dose-response relationship between the amount of physical activity and tinnitus.

RESULTS

Overall, 12.8% of the population who engaged in physical activity reported tinnitus, compared with 18.5% of the population who did not ( p = 0.005). Subgroup analysis based on the amount of physical activity showed that participants who performed physical activity (150 to 300, 310 to 540, and 550 to 4800 min/week) had lower risks of tinnitus than those with no physical activity (odds ratio = 0.72, 0.56, and 0.62, respectively), after adjusting for covariates. However, no correlation was observed between physical activity and tinnitus severity in the present study. The dose-response analysis showed a nonlinear relationship (P for nonlinearity = 0.04) between the amount of physical activity and the risk of tinnitus.

CONCLUSIONS

Physical activity may be associated with a reduced risk of tinnitus. Further research using a longitudinal design is required to confirm these findings and clarify the direction of causation.

Tinnitus, sound intolerance, and mental health: the role of long-term occupational noise exposure

PURPOSE

Whereas chronic noise exposure (CNE) is a known risk factor for tinnitus, little is known about how a history of CNE impacts tinnitus characteristics and its comorbid symptoms.

METHODS

Seventy-five participants with chronic tinnitus (59m/16f, 22-78 years, 48 with sensory-neural hearing loss, and 27 with a normal audiogram) including 43 individuals with (Tin-CNE group) and 32 without (Tin group) a history of long-term occupational noise exposure were studied. Tinnitus characteristics were rated by a visual analog scale, and tinnitus comorbid symptoms were scored using self-assessment questionnaires.

RESULTS

The Tin-CNE group showed reduced uncomfortable loudness level (ULL), sound tolerance, and quality of life (QoL), and increased tinnitus loudness, tinnitus handicap, anxiety, depression, insomnia severity, and tinnitus annoyance scores compared to the Tin group. Higher tinnitus loudness and a lower anxiety score were observed in participants with hearing loss relative to those without. Using a stepwise regression model also showed that tinnitus-related characteristics, hyperacusis, and tinnitus comorbid symptoms enhance one another.

CONCLUSIONS

The findings were in support of accumulative evidence indicating the adverse auditory and non-auditory effects of CNE, including exacerbated sound intolerance and tinnitus-related psychiatric symptoms. The results also showed that tinnitus alone can affect mental health regardless of hearing loss.

The Efficacy and Safety of Acupuncture for Tinnitus-Associated Insomnia: A Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Tinnitus accounts for a significant proportion of the factors that cause insomnia, and insomnia, in turn, aggravates tinnitus. Given that tinnitus and insomnia have a bidirectional relationship, tinnitus-associated insomnia is prevalent. Nonetheless, current treatments including medication and psychological therapies for tinnitus-associated insomnia do not yield satisfactory efficacy, thereby making it challenging to manage. Although acupuncture is a potentially effective treatment option, the current evidence on the efficacy and safety of acupuncture for tinnitus-associated insomnia remains inconclusive. Therefore, this systematic review and analysis protocol aims to investigate whether acupuncture is beneficial for tinnitus-associated insomnia with an acceptable safety profile.

METHODS

Nine mainstream English-language and Chinese-language databases will be searched to include qualified RCTs and meta-analyses will be conducted by combining extracted data using RevMan 5.3. The risk of bias 2.0 tool recommended by Cochrane will be adopted to evaluate the methodological quality of the included RCTs. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be utilized to appraise the strength and certainty of evidence. Where available, we will also perform sensitivity analyses, publication bias and subgroup analysis.

DISCUSSION

Expected results from our systematic review and meta-analysis will verify the efficacy and safety of acupuncture in tinnitus-associated insomnia. The evidence generated by this review will help patients and clinicians make informed treatment decisions.

Low Sleep Satisfaction Is Related to High Disease Burden in Tinnitus

Previous studies have shown a high prevalence of sleep disturbances in tinnitus patients. However, no study has yet evaluated subjective sleep satisfaction. The present study aimed to investigate associations of self-reported sleep satisfaction with sociodemographic factors, tinnitus-related distress, depression, and self-reported quality of life. This is a retrospective analysis of 2344 outpatients with tinnitus presenting at a tertiary German tinnitus clinic from 2010 to 2020. Patients who filled in five questionnaires (Tinnitus Handicap Inventory (THI), Tinnitus Questionnaire (TQ), Major Depression Inventory (MDI), Tinnitus Sample Case History Questionnaire (TSCHQ), and the World Health Organization Quality of Life Brief Version (WHOQOL-Bref)) were included. Based on the question about sleep satisfaction in the WHOQOL-Bref, group classification into (I) sleep-satisfied, (II) neither satisfied or dissatisfied, and (III) sleep-dissatisfied patients was performed. Associations between sleep satisfaction and quality of life, depression, tinnitus distress, and tinnitus characteristics were analyzed by group differences and a multinomial regression model with elastic net penalization. A total of 42.38% of patients were satisfied or very satisfied with sleep, whereas 40.91% of patients were dissatisfied or very dissatisfied with sleep. The remaining patients reported being neither satisfied nor dissatisfied with sleep. Sleep-dissatisfied patients were significantly more burdened in questionnaires on depressive symptoms (MDI), tinnitus distress (TQ, THI), and quality of life (WHOQOL-Bref). In addition, they suffered significantly more often from comorbidities such as headache, neck pain, or temporomandibular joint disorder (TMJ). The elastic net regression based on sum scores of THI, TQ, MDI, the four domains of WHOQOL-Bref, as well as all individual questions from the TSCHQ was able to classify patients satisfied with their sleep with an accuracy of 79%, 87.8% sensitivity, and 70.4% specificity. The model could not identify patients indifferent with the quality of their sleep (neither satisfied nor dissatisfied) (sensitivity: 0%; specificity: 100%). The accuracy of the model to predict patients dissatisfied with their sleep was 80.7%, with 83% sensitivity and 78.4% specificity. Poor physical and mental health (Domain I/II WHOQOL-Bref) as well as tinnitus distress were the strongest predictors of sleep dissatisfaction. Conversely, for sleep satisfaction, good physical and mental health as well as low tinnitus distress were the strongest predictors. The division into sleep-satisfied and sleep-dissatisfied tinnitus patients allows a very good discrimination regarding disease burden as indicated by depression, tinnitus distress, quality of life, and pain-related comorbidities. Physical and mental health as well as tinnitus distress seem to be strongly related to sleep satisfaction underscoring the concept of "tinnitus" versus "tinnitus disorder", but also the importance of sleep satisfaction as a global health indicator. Moreover, these data indicate the relevance of addressing sleep disorders in the therapeutic management of chronic tinnitus patients.

Recovering Hidden Responder Groups in Individuals Receiving Neurofeedback for Tinnitus

The widespread understanding that chronic tinnitus is a heterogeneous phenomenon with various neural oscillatory profiles has spurred investigations into individualized approaches in its treatment. Neurofeedback, as a non-invasive tool for altering neural activity, has become increasingly popular in the personalized treatment of a wide range of neuropsychological disorders. Despite the success of neurofeedback on the group level, the variability in the treatment efficacy on the individual level is high, and evidence from recent studies shows that only a small number of people can effectively modulate the desired aspects of neural activity. To reveal who may be more suitable, and hence benefit most from neurofeedback treatment, we classified individuals into unobserved subgroups with similar oscillatory trajectories during the treatment and investigated how subgroup membership was predicted by a series of characteristics. Growth mixture modeling was used to identify distinct latent subgroups with similar oscillatory trajectories among 50 individuals suffering from chronic subjective tinnitus (38 male, 12 female, mean age = 47.1 ± 12.84) across 15 neurofeedback training sessions. Further, the impact of characteristics and how they predicted the affiliation in the identified subgroups was evaluated by including measures of demographics, tinnitus-specific (Tinnitus Handicap Inventory) and depression variables, as well as subjective quality of life subscales (World Health Organization—Quality of Life Questionnaire), and health-related quality of life subscales (Short Form-36) in a logistic regression analysis. A latent class model could be fitted to the longitudinal data with a high probability of correctly classifying distinct oscillatory patterns into 3 different groups: non-responder (80%), responder (16%), and decliner (4%). Further, our results show that the health-related wellbeing subscale of the Short Form-36 questionnaire was differentially associated with the groups. However, due to the small sample size in the Responder group, we are not able to provide sufficient evidence for a distinct responder profile. Nevertheless, the identification of oscillatory change-rate differences across distinct groups of individuals provides the groundwork from which to tease apart the complex and heterogeneous oscillatory processes underlying tinnitus and the attempts to modify these through neurofeedback. While more research is needed, our results and the analytical approach presented may bring clarity to contradictory past findings in the field of tinnitus research, and eventually influence clinical practice.

Tinnitus: at a crossroad between phantom perception and sleep

Sensory disconnection from the environment is a hallmark of sleep and is crucial for sleep maintenance. It remains unclear, however, whether internally generated percepts—phantom percepts—may overcome such disconnection and, in turn, how sleep and its effect on sensory processing and brain plasticity may affect the function of the specific neural networks underlying such phenomena. A major hurdle in addressing this relationship is the methodological difficulty to study sensory phantoms, due to their subjective nature and lack of control over the parameters or neural activity underlying that percept. Here, we explore the most prevalent phantom percept, subjective tinnitus—or tinnitus for short—as a model to investigate this. Tinnitus is the permanent perception of a sound with no identifiable corresponding acoustic source. This review offers a novel perspective on the functional interaction between brain activity across the sleep–wake cycle and tinnitus. We discuss characteristic features of brain activity during tinnitus in the awake and the sleeping brain and explore its effect on sleep functions and homeostasis. We ask whether local changes in cortical activity in tinnitus may overcome sensory disconnection and prevent the occurrence of global restorative sleep and, in turn, how accumulating sleep pressure may temporarily alleviate the persistence of a phantom sound. Beyond an acute interaction between sleep and neural activity, we discuss how the effects of sleep on brain plasticity may contribute to aberrant neural circuit activity and promote tinnitus consolidation. Tinnitus represents a unique window into understanding the role of sleep in sensory processing. Clarification of the underlying relationship may offer novel insights into therapeutic interventions in tinnitus management.

[Key factors of the severity of chronic subjective tinnitus: a complex network analysis]

Objective:To investigate the key factors related to the severity of chronic subjective tinnitus through a complex network analysis. Methods:A retrospective study about patients with chronic subjective tinnitus presented to Peking Union Medical College Hospital from December 2019 to October 2020 was conducted. The demographic information, audiometric and tinnitus-related tests, and scores of Tinnitus Handicap Inventory（THI）, Hospital Anxiety and Depression Scale（HADS）, Pittsburgh Sleep Quality Index（PSQI） and Visual Analogue Scale（VAS） of tinnitus loudness and annoyance were set as nodes in a complex network which was conducted and analyzed through the R package. Results:A total of 183 patients were enrolled, including 99（54.1%） males and 84（45.9%） females, with an average age of（41.65±1.05） years. The results of the complex network analysis showed that anxiety and sleep disorder were closely related to THI score, and anxiety was more important than sleep disorder. There was a strong correlation between self-reported anxiety and insomnia. Demographic characteristics, audiologic and tinnitus-associated tests were not significantly related to THI score. Conclusion:Anxiety and sleep disturbance were key factors related to tinnitus severity, and anxiety played a more important role. There was an obvious correlation between sleep disorder and anxiety, and they might have a superimposed effect on tinnitus severity. Future therapies of tinnitus should pay more attention on releasing anxiety and insomnia.

Associations between Lifestyle Habits, Perceived Symptoms and Gastroesophageal Reflux Disease in Patients Seeking Health Check-Ups

Gastroesophageal reflux disease (GERD) is one of the most common diseases. It mainly causes the stomach contents to flow back to the esophagus, thereby stimulating the esophagus and causing discomfort. From the results of our research, we intend to provide the general public with information related to preventing gastroesophageal reflux disease and medical personnel with information on the treatment and care of patients with gastroesophageal reflux disease. This study aimed to investigate the association of lifestyle habits and perceived symptoms on GERD in patients who underwent routine health check-ups. This study was conducted as a retrospective cross-sectional design to collect GERD cases from the medical records containing the health questionnaires and the report of endoscopic findings on the day of the health check-up. A total of 5653 patients were enrolled between 1 January 2016, and 31 December 2018. About 60.2% (n = 3404) of patients with GERD were diagnosed based on endoscopic findings. Descriptive and multivariate logistic regression analyses were performed to identify the risk factors of the development of GERD. The results of the multivariate logistic regression analysis showed that age, sex, waist circumference, Areca catechu chewing habit, sleep disorders, otolaryngology symptoms, and hepatobiliary and gastrointestinal symptoms were significantly associated with GERD. In this study, our results can be used as a reference for public health care and clinicians. Because most GERD cases can be controlled and prevented by lifestyle modifications, health professionals should always obtain a detailed history regarding symptoms and lifestyle habits associated with GERD.

[Efficacy of percutaneous vagal stimulation in the treatment of chronic tinnitus]

Objective:The aim of this study is to investigate the efficacy of transcutaneous vagus nerve stimulation（taVNS） in the treatment of chronic tinnitus. Methods:taVNS was used to treat chronic decompensated tinnitus, 10 days as a course of treatment. Record and analyze the improvement of the patient's subjective symptoms during treatment. The THI, PSQI and DASS-21 scores were performed at 10 days, 3 months and 6 months after treatment. The improvement of tinnitus in taVNS group and control group at the above recorded time points was compared, and the THI score of taVNS group was compared before and after treatment. Results:① During the taVNS treatment, 93.65% of the patients achieved improvement in subjective symptoms, and 28.6% of the patients voluntarily accepted the second course of taVNS treatment; ② The sleep improvement was optimal when the treatment was 10 days, and some patients had poor sleep status after 3 or 6 months; ③ The anxiety of taVNS group was improved during and after treatment, and the best effect time was 3 months and 6 months after treatment; ④ There was no significant difference in THI score between the two groups, but there was significant improvement in taVNS group at 3 months and 6 months after treatment. Conclusion:taVNS treatment can significantly improve the sleep disorder, anxiety disorder and tinnitus disturbance of tinnitus patients, and the curative effect is good after 3 months and 6 months of prevention.

Prevalence of Tinnitus and Association with Self-Rated Health among Military Personnel Injured on Combat Deployment

INTRODUCTION

Tinnitus is an auditory problem frequently reported by military personnel and is currently responsible for 1 billion dollars annually in disability compensation. Recent military conflicts in Iraq and Afghanistan saw high levels of combat exposure coupled with a surge in blast weaponry, both of which can adversely affect hearing. The present study explored the prevalence of tinnitus and the association with self-rated health among military personnel injured during combat deployment.

MATERIALS AND METHODS

A total of 1,026 U.S. military personnel who sustained an injury during operations (592 battle blast, 73 battle nonblast, 361 nonbattle) in Iraq were identified from clinical records. Post-Deployment Health Assessments administered at two separate points in time were used to identify self-reported tinnitus symptoms and self-rated health within 1 year of injury.

RESULTS

Those with a battle blast injury had the highest prevalence of tinnitus with 19.1% and 31.3% on the first and second health assessments, respectively. In a multivariate model adjusting for combat exposure, concussion, posttraumatic stress disorder, and other covariates, tinnitus was associated with lower self-rated health for both the first (odds ratio [OR] = 3.31, 95% confidence interval [CI] = 2.07-5.30, P < 0.001) and second assessments (OR = 2.52, 95% CI = 1.76-3.61, P < 0.001).

CONCLUSIONS

Tinnitus is a common source of impairment among military personnel injured during combat deployment and is associated with poorer self-rated health. Future research should determine whether timing of assessment is linked to symptom recognition or reporting, and what interventions are best suited for ameliorating the negative impact of tinnitus.

Impact of TBI, PTSD, and Hearing Loss on Tinnitus Progression in a US Marine Cohort

INTRODUCTION

Mild TBI (TBI) is associated with up to a 75.7% incidence of tinnitus, and 33.0% of tinnitus patients at the US Veterans Administration carry a diagnosis of post-traumatic stress syndrome (PTSD). Yet factors contributing to new onset or exacerbation of tinnitus remain unclear.

MATERIALS AND METHODS

Here we measure intermittent and constant tinnitus at two time points to ascertain whether pre-existing or co-occurring traumatic brain injury (TBI), hearing loss, or post-traumatic stress disorder (PTSD) predicts new onset, lack of recovery and/or worsening of tinnitus in 2,600 United States Marines who were assessed before and after a combat deployment.

RESULTS

Ordinal regression revealed that constant tinnitus before deployment was likely to continue after deployment (odds ratio [OR] = 28.62, 95% confidence interval [CI]: 9.84,83.26). Prior intermittent tinnitus increased risk of post-deployment constant tinnitus (OR = 4.95, CI: 2.97,8.27). Likelihood of tinnitus progression increased with partial PTSD (OR = 2.39, CI: 1.50,3.80) and TBI (OR = 1.59, CI: 1.13,2.23), particularly for blast TBI (OR = 2.01, CI: 1.27,3.12) and moderate to severe TBI (OR = 2.57, CI: 1.46,4.51). Tinnitus progression also increased with low frequency hearing loss (OR = 1.94, CI: 1.05,3.59), high frequency loss (OR = 3.01, CI: 1.91,4.76) and loss across both low and high frequency ranges (OR = 5.73, CI: 2.67,12.30).

CONCLUSIONS

Screening for pre-existing or individual symptoms of PTSD, TBI, and hearing loss may allow for more focused treatment programs of comorbid disorders. Identification of those personnel vulnerable to tinnitus or its progression may direct increased acoustic protection for those at risk.

Positive Correlation between Tinnitus Severity and Poor Sleep Quality Prior to Tinnitus Onset: a Retrospective Study

The objective of this study was to investigate the correlation of tinnitus severity and sleep quality prior to tinnitus onset in a Chinese population.We recruited patients with primary tinnitus from a tertiary teaching hospital in southwest China, retrospectively. The Pittsburgh Sleep Quality Index (PSQI) and the Mandarin version of the Tinnitus Handicap Inventory (THI-M) were employed to assess tinnitus severity and sleep quality of past, respectively. A battery of hearing tests was also administered to subjects, including TEOAE, pure tone audiometry, and tympanometry, for hearing evaluation.We enrolled 190 patients and nine were excluded. Subjects were divided into two groups: group A (PSQI <7) and group B (PSQI ≥7). The mean duration of tinnitus in both groups was above 6 months. There was a significant difference between THI-M global scores of group A and group B (P < 0.001). The difference in tinnitus severity ranks between the two groups was also significant (P = 0.006). The proportion of severe tinnitus levels in group B was higher than that of group A. Spearman's correlation analysis did not show correlation between the scores of THI-M and that of the PSQI in group A (P = 0.077); in verse, a positive correlation between THI-M and PSQI scores was found in group B (P < 0.001).The tinnitus severity is positively correlated with sleep quality before tinnitus onset, suggesting that the sleep quality of the past may have an impact on tinnitus occurrence.

Development and internal validation of a depression severity prediction model for tinnitus patients based on questionnaire responses and socio-demographics

Tinnitus is a complex condition that is associated with major psychological and economic impairments – partly through various comorbidities such as depression. Understanding the interaction between tinnitus and depression may thus improve either symptom cluster’s prevention, diagnosis and treatment. In this study, we developed and validated a machine learning model to predict depression severity after outpatient therapy (T1) based on variables obtained before therapy (T0). 1,490 patients with chronic tinnitus (comorbid major depressive disorder: 52.2%) who completed a 7-day multimodal treatment encompassing tinnitus-specific components, cognitive behavioural therapy, physiotherapy and informational counselling were included. 185 variables were extracted from self-report questionnaires and socio-demographic data acquired at T0. We used 11 classification methods to train models that reliably separate between subclinical and clinical depression at T1 as measured by the general depression questionnaire. To ensure highly predictive and robust classifiers, we tuned algorithm hyperparameters in a 10-fold cross-validation scheme. To reduce model complexity and improve interpretability, we wrapped model training around an incremental feature selection mechanism that retained features that contributed to model prediction. We identified a LASSO model that included all 185 features to yield highest predictive performance (AUC = 0.87 ± 0.04). Through our feature selection wrapper, we identified a LASSO model with good trade-off between predictive performance and interpretability that used only 6 features (AUC = 0.85 ± 0.05). Thus, predictive machine learning models can lead to a better understanding of depression in tinnitus patients, and contribute to the selection of suitable therapeutic strategies and concise and valid questionnaire design for patients with chronic tinnitus with or without comorbid major depressive disorder.

Tinnitus-related distress after multimodal treatment can be characterized using a key subset of baseline variables

BACKGROUND

Chronic tinnitus is a complex condition that can be associated with considerable distress. Whilst cognitive-behavioral treatment (CBT) approaches have been shown to be effective, not all patients benefit from psychological or psychologically anchored multimodal therapies. Determinants of tinnitus-related distress thus provide valuable information about tinnitus characterization and therapy planning.

OBJECTIVE

The study aimed to develop machine learning models that use variables (or "features") obtained before treatment to characterize patients' tinnitus-related distress status after treatment. Whilst initially all available variables were considered for model training, the final model was required to achieve highest predictive performance using only a small number of features.

METHODS

1,416 tinnitus patients (decompensated tinnitus: 32%) who completed a 7-day multimodal treatment encompassing tinnitus-specific components, CBT, physiotherapy and informational counseling were included in the analysis. At baseline, patients were assessed using 205 features from 10 questionnaires comprising sociodemographic and clinical information. A data-driven workflow was developed consisting of (a) an initial exploratory correlation analysis, (b) supervised machine learning to predict tinnitus-related distress after treatment (T1) using baseline data only (T0), and (c) post-hoc analysis of the best model to facilitate model inspection and understanding. Classification methods were embedded in a feature elimination wrapper that iteratively learned on features found to be important for the model in the preceding iteration, in order to keep the performance stable while successively reducing the model complexity. 10-fold cross-validation with area under the curve (AUC) as performance measure was implemented for model generalization error estimation.

RESULTS

The best machine learning classifier (gradient boosted trees) can predict tinnitus-related distress in T1 with AUC = 0.890 using 26 features. Subjectively perceived tinnitus-related impairment, depressivity, sleep problems, physical health-related impairments in quality of life, time spent to complete questionnaires and educational level exhibited a high attribution towards model prediction.

CONCLUSIONS

Machine learning can reliably identify baseline features recorded prior to treatment commencement that characterize tinnitus-related distress after treatment. The identification of key features can contribute to an improved understanding of multifactorial contributors to tinnitus-related distress and thereon based multimodal treatment strategies.

Evidence for an Association Between Hearing Impairment and Disrupted Sleep: Scoping Review

Purpose Hearing impairment (HI) is the most common sensory impairment and may negatively impact sleep through reduced auditory input. Factors associated with HI such as anxiety regarding communication in daily life may also adversely impact an individual's sleep. Here, research on the relationship between HI and sleep disruption was catalogued using scoping review methodology. Method A systematic strategy was employed to search various electronic databases. This review is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Scoping Review Extension. Results Sixteen records met inclusion criteria. Studies have investigated sleep in HI as a primary aim in noise-exposed workers or large surveys in older participants. Experimental and quasi-experimental studies report alterations to sleep architecture of potential neuroplastic origins. Studies reporting sleep as a secondary aim generally report poorer sleep in HI participants. Conclusions This scoping review has catalogued evidence that altered or negatively impacted sleep may be associated with HI. Potential confounding factors, mechanisms, and considerations for future research are discussed. Supplemental Material https://doi.org/10.23641/asha.9968369.

Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: protocol for a randomised controlled trial

Background

A significant proportion of patients with chronic tinnitus report clinical levels of sleep disturbance (insomnia). Despite the significant health and functioning implications of this, no rigorous trials have investigated treatments that target tinnitus-related insomnia. This is the first randomised controlled trial evaluating Cognitive Behavioural Therapy for insomnia (CBTi) in tinnitus compared with other psychological treatments.

Methods/design

The study will test the efficacy of group CBTi as a treatment for tinnitus-related insomnia in a single-centre randomised controlled trial. Participants will be 102 patients with chronic, clinically significant tinnitus and insomnia in the absence of organic sleep disorders. Participants will be randomised to one of three intervention arms: six sessions of CBTi or six sessions of sleep support group or two sessions of audiologically based care. The primary outcomes will be changes in sleep as measured on the Insomnia Severity Index and key outcomes on a 2-week sleep diary (sleep efficiency and total sleep time). Outcomes will be collected 3, 10, 14 and 34 weeks post-randomisation. Secondary measures include sleep quality, sleep beliefs, tinnitus severity, psychological distress and quality of life. A sub-sample of participants will provide two weeks of actigraphy data at the same time points. Data on satisfaction and treatment experience will be collected at 10 and 34 weeks post-randomisation from all participants.

Discussion

Findings from the study will be submitted to a peer-reviewed journal. It is anticipated that findings may inform future clinical practice in the treatment of tinnitus-related insomnia.

Trial registration

ClinicalTrials.gov, NCT03386123. Retrospectively registered on 29 December 2017.

A study on the epidemiology of tinnitus in the United Kingdom

PURPOSE

Subjective tinnitus is a common symptom with potentially negative impact on quality of life. More research is required to gain a deeper understanding of the disease and its clinical presentation. To estimate the incidence of tinnitus and to describe patient-related characteristics such as lifestyle factors and comorbidities.

PATIENTS AND METHODS

Using the Clinical Practice Research Datalink, we calculated incidence rates of first-time diagnosed tinnitus in an adult population between 2000 and 2016. We stratified incidence rates by sex, age, and year of diagnosis. Additionally, we performed a 1:1 matched case-control study comparing body mass index, lifestyle factors and selected comorbidities between patients with incident tinnitus and tinnitus-free controls.

RESULTS

We identified 109 783 adults with a first-time diagnosis of tinnitus between 2000 and 2016, yielding an overall age-standardized incidence rate of 25.0 new tinnitus cases per 10,000 person-years (95% CI: 24.6-25.5). There was a steady increase in tinnitus incidence throughout the study period. Approximately 80% of tinnitus cases were diagnosed at age 40 years or older. We observed the highest incidence rate in individuals aged 60-69 years (41.2 per 10,000 person-years, 95% CI: 40.7-41.7). Smokers and alcohol drinkers were at lower risk of being diagnosed with tinnitus compared with non-smokers and non-drinkers, respectively. The occurrence of tinnitus was strongly associated with a recent diagnosis of several otological and vestibular disorders as well as head and neck disorders.

CONCLUSION

The present observational study found an increasing incidence of tinnitus over time, emphasizing the continuously growing health burden. The findings on patient characteristics, lifestyle factors, and selected comorbidities contribute to a better understanding of risk factors for tinnitus.

Risks of tinnitus, sensorineural hearing impairment, and sudden deafness in patients with non-migraine headache

Tinnitus and hearing impairment are prevalent among headache patients. This study aims to investigate the risk of tinnitus, sensorineural hearing impairment, and sudden deafness in patients with non-migraine headache. Participants included 43 294 patients with non-migraine headache (non-migraine headache cohort) and 173 176 patients with no headache of any type (control cohort) frequency-matched with respect to 10-year age interval and sex from the Longitudinal Health Insurance Database 2005 of the Taiwan National Health Insurance Research Database. The mean age of the non-migraine headache cohort was 28.4 ± 14.9 years, and 58.5% of this cohort was male. The incidence rates of tinnitus, sensorineural hearing impairment, and sudden deafness were compared between cohorts using the Kaplan–Meier method with the log-rank test. A Cox proportional hazard model was used to examine the association of tinnitus, sensorineural hearing impairment, and sudden deafness with non-migraine headache, with adjustment for all covariates. The combined risk of either tinnitus, sensorineural hearing impairment, or sudden deafness was higher in the non-migraine headache cohort than in the control cohort (adjusted odds ratio [aHR], 2.73; 95% confidence interval [95% CI], 2.62–2.84; p < 0.0001). Subgroup analysis showed that patients in the non-migraine headache cohort were at significantly higher risk of developing tinnitus (aHR, 3.05; 95% CI, 2.91–3.19; p < 0.0001), sensorineural hearing impairment (aHR, 1.89; 95% CI, 1.74–2.05; p < 0.0001), and sudden deafness (aHR, 2.14; 95% CI, 1.77–2.59; p < 0.0001) than were controls. In this population-based study, the risks of tinnitus, sensorineural hearing impairment, and sudden deafness were found to be significantly higher in patients with non-migraine headache than in those without headache.

Cognitive behavioural therapy for tinnitus-related insomnia: evaluating a new treatment approach

OBJECTIVE

Insomnia frequently occurs alongside distressing tinnitus, and greater tinnitus severity is associated with more sleep disturbance. Insomnia and tinnitus probably share common underlying processes and sleep studies show striking similarities between primary and tinnitus-related insomnia. This is the first study to evaluate outcomes following insomnia-specific Cognitive Behavioural Therapy (CBTi) for tinnitus-related insomnia in a "real world" clinic.

DESIGN

Treatment was six-sessions of group-based CBTi. Measures of insomnia, sleep diaries, tinnitus distress, psychological distress, anxiety and depression were completed pre-intervention, post-intervention and at six-weeks follow up.

STUDY SAMPLE

Participants were 24 adults with chronic, distressing tinnitus and associated sleep disturbance. Twenty-two completed treatment.

RESULTS

CBTi was associated with significant improvements from pre-intervention to post-intervention maintained at follow up in insomnia, sleep-diary measures, tinnitus distress, psychological distress, anxiety and depression, largely maintained at follow-up. Reliable improvements were reported in insomnia (by 67% of patients), tinnitus distress (by 50% of patients) and psychological distress (by 38% of patients) post-intervention.

CONCLUSIONS

The results suggest that CBTi is associated with reduced insomnia and distress for patients reporting chronic and distressing tinnitus with related insomnia. Further research into CBTi for this population, using utilising robust, randomised controlled designs, is warranted.

Polysomnographic Findings in Patients With Chronic Tinnitus

Objectives:

Tinnitus is an auditory sensation in the absence of any external stimulus. It has a negative impact on quality of life and interferes with concentration, sleep, social activities, and even emotional stability. The aim of this study was to compare sleep architecture in patients with and without chronic subjective tinnitus.

Methods:

This was an observational, noninterventional, and prospective study. The sample consisted of 50 individuals of both sexes aged 20 to 60 years. Twenty-five patients with tinnitus constituted the study group, and for comparison, a control group consisting of 25 patients without reported tinnitus was formed. The patients underwent polysomnography and were administered the Epworth Sleepiness Scale, Tinnitus Handicap Inventory, and visual analog scales.

Results:

The group with tinnitus had higher mean values in sleep stages 1 and 2, and lower mean values in stage 3 and in rapid eye movement (REM) sleep, compared with the control group, and this difference was significant only for REM sleep ( P = .031). This demonstrates that patients with tinnitus remained longer in shallow sleep and spent less time in deep sleep (stage 3) and REM sleep.

Conclusions:

This study shows that patients with tinnitus have significant alterations in REM sleep latency as well as the REM sleep phase.

An Examination of the Relationship Between Insomnia and Tinnitus: A Review and Recommendations

Tinnitus is a prevalent medical disorder which frequently becomes chronic and severe. Furthermore, quality of life can become compromised with many experiencing comorbid insomnia. We hypothesize that insomnia is a highly prevalent symptom and diagnostic category accompanying tinnitus. Our article reviews the tinnitus literature examining the prevalence of insomnia, the sleep disturbances found, and any methodological issues. Our literature search included a number of databases such as PubMed, Cochrane, and Embase. We found that 16 prior studies had sufficient data presented that allowed for an assessment of the prevalence rate of insomnia in tinnitus; the prevalence rate ranged from 10% to 80% (most rates were over 40%). The overwhelming majority of these studies inadequately defined insomnia as a diagnosis but described it only as a symptom. They focused predominantly on questionnaires (sent via the mail) asking only 1 to 4 questions on whether tinnitus disturbs sleep. Frequently, the only question asked was whether tinnitus disturbed a patient’s sleep without clarifying whether there were problems with daytime functioning. Thus, a valid insomnia diagnosis could not be established. Even in the few studies that asked the necessary information to establish a diagnosis of insomnia, only 1 study provided it. The presence of insomnia in tinnitus was associated with a more severe form of tinnitus. Alarmingly, insomnia was mainly untreated despite evidence supporting that successful treatment of insomnia might also help comorbid tinnitus. Because insomnia is significantly prevalent in tinnitus patients and appears to potentially further impact negatively on one’s quality of life, clinicians should address this possibility with a detailed clinical evaluation; incorporating self-rating questionnaires on sleep could be clinically helpful. If insomnia is present, therapy should be considered.

Korean survey data reveals an association of chronic laryngitis with tinnitus in men

The association between chronic laryngitis and tinnitus is not a well-studied topic, unlike the association of these two conditions with many other disorders. Cross-sectional data of 11,347 adults (males: 4,934; females: 6,413), who completed the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 2012 were used to investigate this association. Lifestyle patterns, including smoking and alcohol habits, regular exercise, physical and mental health status, socioeconomic status, nutritional status, and other chronic diseases, were analyzed. Chronic laryngitis and tinnitus were diagnosed by field survey teams, which included otolaryngologists, who conducted chronic disease surveillance using a health status interview, a nutritional status questionnaire, and a physical examination. Chronic laryngitis was significantly associated with age, education beyond high school, depressed mood, voice change, metabolic syndrome, and tinnitus in men. In women, chronic laryngitis was associated with body mass index and diabetes mellitus. Chronic laryngitis in men was significantly associated with tinnitus (odds ratio 1.671, [95% confidence interval: 1.167-2.393]) after adjusting for age, body mass index, smoking status, alcohol intake, regular exercise, metabolic syndrome, education beyond high school, and depressed mood. Additionally, the prevalence of chronic laryngitis increased with increasing severity of tinnitus in men alone (P = 0.002). The study revealed a significant association between chronic laryngitis and tinnitus.

Hallucinations in Healthy Older Adults: An Overview of the Literature and Perspectives for Future Research

KEY POINTS

➢ Studies suggest a substantial minority of healthy older adults have hallucinatory experiences, in line with existing evidence on hallucinations in other age groups, though it is still unclear if hallucination prevalence increases or declines with age in older cohorts.

➢ Stigma attached to both hallucinations and ageing leads to considerable under-reporting of these experiences in healthy older adults and may negatively bias how professionals, family members, and the public respond.

➢ Why and when hallucinations in healthy older adults remit, persist, or progress to other clinical disorders remains poorly understood.

➢ Current evidence points to a range of factors associated with hallucinations in older adults including decline in sensory or cognitive functioning, poor sleep, and psychosocial stressors (e.g., social isolation, loneliness, and bereavement), highlighting the need for accurate assessment and tailored interventions.

Hallucinations, though common in youth and younger adults, are not the preserve of these age groups. Accumulating evidence shows that hallucinatory experiences are also present at surprisingly high rates in healthy older adults in the general community. Furthermore, stigma and misunderstanding of hallucinations, together with ageism, may lead to under-reporting of these experiences by older adults, and misdiagnosis or mismanagement by health and mental health practitioners. Consequently, improved public and professional knowledge is needed about the nature and significance of hallucinations with advancing age. The purpose of this review is to provide a comprehensive overview, and critical analysis, of research on the prevalence, psychosocial, and neurobiological factors associated with hallucinations in people aged 60 years and over. To the best of our knowledge, this is the first review of its kind in the literature. The evidence supports a dynamic conceptualization of hallucinations, in which the emergence of hallucinations is viewed as a balance between the sensory, cognitive, or social impairments accompanying advancing age and the degree to which compensatory processes elicited by these impairments are successful. We briefly summarize the implications of the literature for aged care services and interventions, and stress that far more studies are needed in this important field of research.