[Long term results after cochlear implantation in elderly patients]

Quality of Life and Audiological Benefits in Pediatric Cochlear Implant Users in Romania: Systematic Review and Cohort Study

Profound sensorineural hearing loss (SNHL) can be successfully treated with a cochlear implant (CI), and treatment is usually accompanied by increased quality of life (QoL). Therefore, the aim of this study was to investigate generic and health-related QoL, as well as the level of audiological outcomes, of CI users, in addition to whether Qol can be restored to the extent of those with normal hearing. Furthermore, different implantation timepoints were compared (early vs. late), and a possible correlation between health and generic QoL questionnaires was investigated. The outcomes from 93 pediatric CI users from Romania were analyzed in the study. Two QoL questionnaires (SSQ12, AQoL-6D), as well as the HSM sentence test and Soundfield measurements, were assessed. The outcomes revealed that the CI users were able to achieve the same QoL as their age- and-gender matched peers with normal hearing, and hearing was restored with good speech comprehension. No significant difference between early- and late-implanted children was detected, although a tendency of a better Word Recognition Score (+10%) in the early-implanted group was discovered. A moderate and significant correlation between the generic and health-related Qol questionnaire was observed. Audiological examinations are still the standard practice by which to measure the benefit of any hearing intervention; nonetheless, generic and health-related QoL should be assessed in order to provide a full picture of a successful and patient-satisfactory cochlear implant procedure.

CI decision making and expectations by older adults

OBJECTIVE

To document and analyze the cochlear implant (CI) decision-making process of hearing-impaired older adults. The aim of this study is to assess what support could be helpful during this process in order to improve care delivery.

METHODS

32 older adult CI recipients (≥ 60 years) with severe to profound sensorineural hearing loss were interviewed about their CI decision-making process 3-12 months after obtaining their first CI.

RESULTS

Minimal information was provided to CI candidates by hearing aid acousticians or patient associations. High to very high expectations were reported by patients concerning issues beyond hearing improvement per se. Even though not all expectations were fulfilled by the CI, nearly all recipients who used an implant for at least six months would recommend a CI to others.

DISCUSSION

We identified an opportunity for those professionals to play a greater role in supporting older CI candidates during the decision-making process. It is desirable to establish a comprehensive network of hearing care professionals to collaborate with CI clinics.

CONCLUSION

In order to support older patients adequately in deciding about CI, intensive training should be offered to hearing care professionals in order to provide realistic expectations and reduce fear and uncertainty about the implantation process. These topics need to be communicated in a professional manner and adapted to the candidate's age and personality.

Auditory performance in a group of elderly patients after cochlear implantation

Purpose

The retrospective case review investigated the effect of cochlear implantation in subjects aged 61 years or older with respect to their auditory performance. The study also analysed the effect of age on the performance, and it drew a comparison between the outcomes of older and younger adults.

Methods

The outcome in a group of 446 patients aged 61 to 89 years at the time of unilateral cochlear implantation was compared with the outcome in a group of 110 patients aged 17 to 42 years. Auditory performance was measured with open-set monosyllabic word testing and sentences in quiet and in noise.

Results

In the monosyllabic word recognition test, the group of older adults performed significantly better after cochlear implantation compared with their scores prior to implantation (p < 0.001; r = 0.59). Their auditory performance correlated negatively with their age. However, the correlation was of small strength. Significant differences in auditory performance were detected between sexagenarians and octogenarians (p < 0.001; r = 0.27). Additionally, a statistically significant difference was revealed between the groups of older and younger adults in the monosyllabic word test (p = 0.001; r = 0.15).

Conclusion

Elderly cochlear implant recipients can benefit significantly from cochlear implantation. Although higher age correlates negatively with auditory performance, its influence in the presented sample is small.

Assessing Cognitive Abilities in High-Performing Cochlear Implant Users

Despite being considered one of the most successful neural prostheses, cochlear implants (CIs) provide recipients with a wide range of speech perception performance. While some CI users can understand speech in the absence of visual cues, other recipients exhibit more limited speech perception. Cognitive skills have been documented as a contributor to complex auditory processing, such as language understanding; however, there are no normative data for existing standardized clinical tests assessing cognitive abilities in CI users. Here, we assess the impact of modality of presentation (i.e., auditory-visual versus visual) for the administration of working memory tests in high-performing CI users in addition to measuring processing speed, cognitive efficiency and intelligence quotient (IQ). Second, we relate performance on these cognitive measures to clinical CI speech perception outcomes.

Methods: Twenty one post-lingually deafened, high-performing, adult CI users [age range: 52–88 years; 3 unilateral CI, 13 bimodal (i.e., CI with contralateral hearing aid), 5 bilateral CI] with clinical speech perception scores (i.e., AzBio sentences in quiet for the first-ear CI) of ≥60% were recruited. A cognitive test battery assessing auditory-visual working memory (AVWM), visual working memory (VWM), processing speed, cognitive efficiency and IQ was administered, in addition to clinical measures of speech perception in quiet (i.e., AzBio sentences in quiet). AzBio sentences were assessed in two conditions: first-ear CI only, and best-aided everyday wearing condition. Subjects also provided self-reported measures of performance and benefit from their CI using standardized materials, including the Glasgow Benefit Inventory (GBI) and the Nijmegen Cochlear Implant questionnaire (NCIQ).

Results: High-performing CI users demonstrated greater VWM than AVWM recall. VWM was positively related to AzBio scores when measured in the first-ear CI only. AVWM, processing speed, cognitive efficiency, and IQ did not relate to either measure of speech perception (i.e., first-ear CI or best-aided conditions). Subjects’ self-reported benefit as measured by the GBI predicted best-aided CI speech perception performance.

Conclusion: In high-performing CI recipients, visual presentation of working memory tests may improve our assessment of cognitive function.

Age-dependent variations of scalp thickness in the area designated for a cochlear implant receiver stimulator

Objective

The integrity of the scalp overlying a cochlear implant receiver stimulator (RS) is critical for the long‐term survival of the implant. Exposure or extrusion of the device will likely result in the need for its removal. There is a global trend of acceleration of population aging, thus raising the prevalence of cochlear implantation (CI) in the elderly. The aim of this study was to define age‐dependent changes in scalp thickness and discuss the implication of that anatomical characteristic for CI in the geriatric population.

Methods

Scalp thickness over the location of the RS in the temporo‐parietal area was measured directly with a needle in patients of various ages.

Results

Two‐hundred thirty‐six temporo‐parietal scalps were measured in patients aged 18 to 85 years. A strong inverse correlation was found between age and scalp thickness (rs = ‐0.723, P < .001). Scalp thickness decreased with age from a mean of 8 mm in the third decade of life to 5 mm in the ninth decade of life.

Conclusion

The human scalp thins with age and most likely undergoes a reduction in its strength. As a consequence, implantable hearing devices that are shielded by the scalp can be at increased risk of exposure and extrusion in the aging recipient. This needs to be taken into account when considering an implantation procedure, the surgical approach and patient instructions on need for and venues for continuing care over time.

Level of Evidence

2B

What to Do When Cochlear Implant Users Plateau in Performance: a Pilot Study of Clinician-guided Aural Rehabilitation

HYPOTHESIS

For experienced adult cochlear implant (CI) users who have reached a plateau in performance, a clinician-guided aural rehabilitation (CGAR) approach can improve speech recognition and hearing-related quality of life (QOL).

BACKGROUND

A substantial number of CI users do not reach optimal performance in terms of speech recognition ability and/or personal communication goals. Although self-guided computerized auditory training programs have grown in popularity, compliance and efficacy for these programs are poor. We propose that CGAR can improve speech recognition and hearing-related QOL in experienced CI users.

METHODS

Twelve adult CI users were enrolled in an 8-week CGAR program guided by a speech-language pathologist and audiologist. Nine patients completed the program along with pre-AR and immediate post-AR testing of speech recognition (AzBio sentences in quiet and in multitalker babble, Consonant-Nucleus-Consonant words in quiet), QOL (Nijmegen Cochlear Implant Questionnaire, Hearing Handicap Inventory for Adults/Elderly, and Speech, Spatial and Qualities of Hearing Scale), and neurocognitive functioning (working memory capacity, information-processing speed, inhibitory control, speed of lexical/phonological access, and nonverbal reasoning). Pilot data for these nine patients are presented.

RESULTS

From pre-CGAR to post-CGAR, group mean improvements in word recognition were found. Improvements were also demonstrated on some composite and subscale measures of QOL. Patients who demonstrated improvements in word recognition were those who performed most poorly at baseline.

CONCLUSIONS

CGAR represents a potentially efficacious approach to improving speech recognition and QOL for experienced CI users. Limitations and considerations in implementing and studying aural rehabilitation approaches are discussed.

The Enigma of Poor Performance by Adults With Cochlear Implants

OBJECTIVE

Considerable unexplained variability and large individual differences exist in speech recognition outcomes for postlingually deaf adults who use cochlear implants (CIs), and a sizeable fraction of CI users can be considered "poor performers." This article summarizes our current knowledge of poor CI performance, and provides suggestions to clinicians managing these patients.

METHOD

Studies are reviewed pertaining to speech recognition variability in adults with hearing loss. Findings are augmented by recent studies in our laboratories examining outcomes in postlingually deaf adults with CIs.

RESULTS

In addition to conventional clinical predictors of CI performance (e.g., amount of residual hearing, duration of deafness), factors pertaining to both "bottom-up" auditory sensitivity to the spectro-temporal details of speech, and "top-down" linguistic knowledge and neurocognitive functions contribute to CI outcomes.

CONCLUSIONS

The broad array of factors that contribute to speech recognition performance in adult CI users suggests the potential both for novel diagnostic assessment batteries to explain poor performance, and also new rehabilitation strategies for patients who exhibit poor outcomes. Moreover, this broad array of factors determining outcome performance suggests the need to treat individual CI patients using a personalized rehabilitation approach.

Cortical Auditory Evoked Potentials to Evaluate Cochlear Implant Candidacy in an Ear With Long-standing Hearing Loss: A Case Report

OBJECTIVES

We describe a novel use of cortical auditory evoked potentials in the preoperative workup to determine ear candidacy for cochlear implantation.

METHODS

A 71-year-old male was evaluated who had a long-deafened right ear, had never worn a hearing aid in that ear, and relied heavily on use of a left-sided hearing aid. Electroencephalographic testing was performed using free field auditory stimulation of each ear independently with pure tones at 1000 and 2000 Hz at approximately 10 dB above pure-tone thresholds for each frequency and for each ear.

RESULTS

Mature cortical potentials were identified through auditory stimulation of the long-deafened ear. The patient underwent successful implantation of that ear. He experienced progressively improving aided pure-tone thresholds and binaural speech recognition benefit (AzBio score of 74%).

CONCLUSIONS

Findings suggest that use of cortical auditory evoked potentials may serve a preoperative role in ear selection prior to cochlear implantation.

[Inpatient rehabilitation of adult CI users: Results in dependency of duration of deafness, CI experience and age]

BACKGROUND

Cochlear implants (CI) have proven to be a highly effective treatment for severe hearing loss or deafness. Inpatient rehabilitation therapy is frequently discussed as a means to increase the speech perception abilities achieved by CI. However, thus far there exists no quantitative evaluation of the effect of these therapies.

METHODS

A retrospective analysis of audiometric data obtained from 1355 CI users compared standardized and qualitative speech intelligibility tests conducted at two time points (admission to and discharge from inpatient hearing therapy, duration 3-5 weeks). The test battery comprised examination of vowel/consonant identification, the Freiburg numbers and monosyllabic test (65 and 80 dB sound pressure level, SPL, free-field sound level), the Hochmair-Schulz-Moser (HSM) sentence test in quiet and in noise (65 dB SPL speech level; 15 dB signal-to-noise ratio, SNR), and a speech tracking test with and without lip-reading.

RESULTS

An average increase of 20 percentage points was scored at discharge compared to the admission tests. Patients of all ages and duration of deafness demonstrated the same amount of benefit from the rehabilitation treatment. After completion of inpatient rehabilitation treatment, patients with short duration of CI experience (below 4 months) achieved test scores comparable to experienced long-term users. The demonstrated benefit of the treatment was independent of age and duration of deafness or CI experience.

CONCLUSION

The rehabilitative training program significantly improved hearing abilities and speech perception in CI users, thus promoting their professional and social inclusion. The present results support the efficacy of inpatient rehabilitation for CI recipients. Integration of this or similar therapeutic concepts in the German catalog of follow-up treatment measures appears justified.

The role of post-operative imaging in cochlear implant surgery: a review of 220 adult cases

OBJECTIVES

To determine the incidence of abnormal radiological findings after cochlear implantation and their effect on clinical outcomes.

METHODS

Retrospective review of 220 adult cochlear implants. Clinical records and post-operative plain X-rays were reviewed and compared with pre-operative and 6-month post-operative City University of New York (CUNY) speech scores.

RESULTS

There were no cases of extra-cochlear array misplacement. Imaging showed 20 cases of incomplete array insertion (9.2%), 3 cases of kinking of the array (1.4%), 2 cases of tip rollover (0.9%), and 1 case of apparent array fracture (0.5%). Patient management was not altered by abnormal imaging. Patients with abnormal radiological findings had slightly minor improvements (median 39 vs. 56%) in City University of New York (CUNY) speech discrimination scores at 6 months (Mann-Whitney U test, P = 0.043).

CONCLUSION

All abnormalities on post-operative imaging were minor and did not alter patient management. The future role of post-operative imaging is discussed.

Comprehensive management of presbycusis: central and peripheral

The prevailing otolaryngologic approach to treatment of age-related hearing loss (ARHL), presbycusis, emphasizes compensation of peripheral functional deficits (ie, hearing aids and cochlear implants). This approach does not address adequately the needs of the geriatric population, 1 in 5 of whom is expected to consist of the "old old" in the coming decades. Aging affects both the peripheral and central auditory systems, and disorders of executive function become more prevalent with advancing age. Growing evidence supports an association between age-related hearing loss and cognitive decline. Thus, to facilitate optimal functional capacity in our geriatric patients, a more comprehensive management strategy of ARHL is needed. Diagnostic evaluation should go beyond standard audiometric testing and include measures of central auditory function, including dichotic tasks and speech-in-noise testing. Treatment should include not only appropriate means of peripheral compensation but also auditory rehabilitative training and counseling.

Long-term performance of cochlear implants in postlingually deafened adults

OBJECTIVE

To evaluate the stability of long-term hearing performance after cochlear implantation (CI) in postlingually deafened adults and to explore the boundaries and limitations of the present test batteries for adult CI patients.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A cohort of 1005 postlingually deafened adult cochlear implantees, who received their implants after age 18 years, was unilaterally implanted and had no inner ear malformations or cochlear ossification. Hearing performance with cochlear implant was evaluated with the help of 5 standard German speech tests.

RESULTS

The average performance improved significantly during the first 6 months in all tests (learning phase) and afterward entered a plateau phase in which no statistically significant improvements or deteriorations were observed for more than 20 years of follow-up. For each test, the average performance of the cohort, the ceiling effect, and the average results for high and low performers are presented.

CONCLUSIONS

In this study, postlingually deafened adults required about 6 months to learn how to process the artificial signals delivered by the cochlear implant. After this learning phase, the hearing performance entered a stable plateau phase for more than 20 years. This stability reveals the long-term reliability of the technology and the biological stability of the electrode-nerve interface over years. In this study, the authors also evaluated the "ceiling effect" with 5 standard German speech tests, used for evaluation of postlingually deafened adult CI patients.

Visualization and contractile activity of cochlear pericytes in the capillaries of the spiral ligament

Pericytes, mural cells located on microvessels, are considered to play an important role in the formation of the vasculature and the regulation of local blood flow in some organs. Little is known about the physiology of cochlear pericytes. In order to investigate the function of cochlear pericytes, we developed a method to visualize cochlear pericytes using diaminofluorescein-2 diacetate (DAF-2DA) and intravital fluorescence microscopy. This method can permit the study of the effect of vasoactive agents on pericytes under the in vivo and normal physiological condition. The specificity of the labeling method was verified by the immunofluorescence labeling of pericyte maker proteins such as desmin, neural proteoglycan (NG2), and thymocyte differentiation antigen 1 (Thy-1). Superfused K(+) and Ca(2+) to the cochlear lateral wall resulted in localized constriction of capillaries at pericyte locations both in vivo and in vitro, while there was no obvious change in cochlear capillary diameters with application of the adrenergic neurotransmitter noradrenaline. The method could be an effective way to visualize cochlear pericytes and microvessels and study lateral wall vascular physiology. Moreover, we demonstrate for the first time that cochlear pericytes have contractility, which may be important for regulation of cochlear blood flow.

Opinions on Cochlear Implant Use in Senior MED-EL Patients

This study assessed the subjective benefits of cochlear implants in senior patients wearing a MED-EL device. Data was compared with previous studies to assess the influence of recent speech-coding strategies and behind-the-ear speech processors; users of the behind-the-ear device and the body-worn device were also compared. An adaptation of the Nucleus 22-channel survey was sent to 141 cochlear implant users. The survey assesses perception of the device, communication benefits, handling the device and quality of life. Ninety-five surveys were returned. Results demonstrate that advanced technology provides greater benefit now than 9-13 years ago, notably: improved listening across noise, better understanding on the telephone and better speech perception. Users of the behind-the-ear device did not report more difficulties than body-worn device users but demonstrated better performance. Results show a positive outcome for cochlear implantation in a MED-EL seniors group.

Quality-of-Life Benefit from Cochlear Implantation in the Elderly

OBJECTIVE

To compare the audiologic results of geriatric patients receiving cochlear implants with younger age groups and to evaluate the quality of life after cochlear implantation in the geriatric population by means of validated quality-of-life questionnaires.

STUDY DESIGN

Cross-sectional study involving 89 postlingually deafened cochlear implant subjects.

SETTING

Tertiary referral center.

PATIENTS

A total of 89 postlingually deafened patients were included in the study, among which were 25 patients who were aged 70 years or older.

INTERVENTIONS

All patients received a cochlear implant. Subjects were implanted with either the Laura, Nucleus 24, or Med-el Combi 40+ cochlear implant systems implementing the SPEAK, ACE, CIS, or CIS+ coding strategies.

MEAN OUTCOME MEASURES

Speech recognition was determined by means of phonetically balanced monosyllabic word lists. The Hearing Handicap Inventory for Adults, the Glasgow Benefit Inventory, and the scale for the prediction of hearing disability in sensorineural hearing loss were used to quantify the quality of life.

RESULTS

Mean audiologic performance for the three groups increased significantly after implantation (p < 0.001). Postoperative audiologic performance of the geriatric population led to useful hearing, but these scores were significantly lower than for the younger age groups (p = 0.002). However, the quality-of-life outcomes for the geriatric group were similar to those of the younger age groups (p = 0.411 for the Hearing Handicap Inventory for Adults; p = 0.886 for the Glasgow Benefit Inventory).

CONCLUSION

The results of this study prove that cochlear implantation in the elderly provides improvements in quality of life and speech understanding, similar to those for younger adult cochlear implant recipients.