epidemiologi och kognition Ulf Rosenhall kHz 0.25 0.5 1 2 4 8 - - PowerPoint PPT Presentation

Ulf Rosenhall

Presbyacusis – aspekter avseende epidemiologi och kognition

Hur hör vi i Sverige?

2 epidemiologiska us. Kvinnor och män, 20 till 90 år gamla

20 40 60 80 100

dB HL

0.25 0.5 1 2 4 8

kHz

90 85 80 75 70 70 60 50 40 30 20

Men, 20 - 90 years

Johan sson & Arlinger, 2002 L,R Jönsson & Rosenhall, 1998a,b, L 20 40 60 80 100

dB HL

0.25 0.5 1 2 4 8

kHz

90 85 80 75 70 70 60 50 40 30 20

Johan sson & Arlinger, 2002 L,R Jönsson & Rosenhall, 1998a,b, L

Women, 20-90 years

Åldershörselnedsättning Presbyacusis Age-related hearing loss ARHL el. ARHI Förekomst? Orsaker? Åtgärder?

Jönsson & Rosenhall 1998 Hederstierna et al, 2007

20 40 60 80 100

dB HL

0.25 0.5 1 2 4 8

kHz Women, 70 - 90 y Left ear

20 40 60 80 100

dB HL

0.25 0.5 1 2 4 8

kHz

90 88 85 81 79 75 70

Men, 70 - 90 y Left ear

Rudin et al, 1988 Pedersen et al, 1989

50 60 Women, 51.3 y Men, 50 – 60 y

Three Swedish Epidemiological Studies

1)The Gerontological and Geriatric Population Study in Gothenburg: H70 (1971-2005) 2) The Study of Men born in 1913 and 1923 (1973) 3) Health and Psychosocial Work Conditions in Middle Aged Women (2005)

1 1 2 3

Men and women, 70 - 80 y 5 epidemiological studies from Europe and USA Unscreened populations

10 20 30 40 50 60 70 80 90 dB HL 0.25 0.5 1 2 3 4 6 8 kHz

Engdahl et al. 2005 Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Davis 1995 Gates et al. 1990

Women, L ear, 70-80/75 years

10 20 30 40 50 60 70 80 90 dB HL 0.25 0.5 1 2 3 4 6 8 kHz

Engdahl et al. 2005 Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Davis 1995 Gates et al. 1990

Men, L ear, 70-80/75 years

Remarkable good agreement between different studies from developed countries

Men and women, 80 - 90 y 6 epidemiological studies from Europe and USA Unscreened populations

10 20 30 40 50 60 70 80 90 dB HL 0.25 0.5 1 2 3 4 6 8 kHz

Engdahl et a. 2005 Hietanen et al. 2004 Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Parving et al. 1997 Gates et al. 1990

Men, L/B ear, 80-90/85 years

10 20 30 40 50 60 70 80 90

dB HL

0.25 0.5 1 2 3 4 6 8 kHz

Engdahl et al. 2005 Hietanen et al. 2004 Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Parving et al. 1997 Gates et al. 1990

Women, L/B ear, 80-90/85 years

The prevalence of child and adult hearing impairment is substantially higher in middle- and low-income countries than in high-income countries, demonstrating the global need for attention to hearing impairment Stevens et al, 2013

• 10
• 5

5 10 15 20 25 dB 0.25 0.5 1 2 3 4 6 8 kHz Gender Difference, 70-80 years

Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Davis 1995 Pearson et al. 1995 Gates et al. 1990

• 10
• 5

5 10 15 20 25 dB 0.25 0.5 1 2 3 4 6 8 kHz Gender Difference, 80-90 years

Hietanen et al. 2004 Cruickshanks et al. 1998 Jönsson & Rosenhall 1998 Parving et al. 1997 Pearson et al. 1995 Gates et al. 1990

Gender differences 70 - 80 y, 80 - 90 y

Hörselskadade i Sverige

Självskattad hörselnedsättning >1 milj. (HRF/SCB) Beräknat antal med HNS enligt tonaudiometri Svår HNS – dövhet ~130 000 Måttlig HNS (M4: 40-64 dB): >0,5 milj. Lätt HNS (M4: 20-39 dB): ~1,4 milj. Totalt: >2 milj. 20-70 år 70+ 1/3 2/3 2/3 1/3 Beräkning 2014

Antal svenskar med hörselnedsättning (tusental) Lätt Måttlig – svår M4 20-39 dB

M4 ≥40 dB

0 – 20 år 43t 5t 20 - 50 år 229t 45t 51 – 70 år 629t 161t >70 år 474t 430t

Sveriges befolkning 31/12 2013

Sveriges befolkning 31/12 2013

Sveriges befolkning 31/12 2013

Ålder, år Beräknat behov, Hörselrehab 60 ~ 5% 70 10 – 20% 80 40 – 45% 90 60 – 70%

Andel av befolkningen i Sverige 2009 2015 2060 65+ 15% 17% 25% 80+ 4% 9%

65+ 2,7 milj. 2060

50y 60y 70y 80y 90y PTA <20 dB PTA <20 dB PTA 20-39 dB PTA 20-39 dB PTA +40 dB

Men 50+ 1.6 m Women 50+ 1.8 m

Sweden 2006

+70 y More women than men have hearing loss

Vad händer med hörseln på lång sikt?

Är hörseln konstant? Försämras hörseln? Förbättras hörseln?

WHO 2002 - 2030

DALYs (Disability-Adjusted Life Years) Adult onset hearing loss: 2002 ranking # 13 globally Year 2030 estimated ranking # 9 (2.5 DALYs) High-income countries # 7 (4,1 DALYs) Middle-income countries # 9 (2,9 DALYs) Low-income countries < #10 Mathers & Loncar, 2006

Ökar eller minskar incidensen av hörselproblem? Den pessimistiska synen: Hörselproblemen ökar globalt

The pessimistic view

11.7

11.3% 10.8% 10.2% 9.9%

2 4 6 8 10 12 14 16 Percent

84-85 86-87 88-89 90-91 92-93 94-95 96-97 98-99 00-01 02-03 2004 2005

Year

Self-assessed hearing loss 1984 - 2005 Statistics Sweden, SCB

Total Men Women

10.5 % 14 %

Marke Trak VIII Kochkin, 2005 Increases in prevalence of hearing loss in adolescents from 15% to 19.5% from 1988–1994 to 2005–2006 NHANES Shargorodsky et al, 2010 In the Alameda County Study prevalence rates of self-reported trouble with hearing nearly doubled from 1965 to 1994 Wallhagen et al, 1997

Prevention

NIHL – prevention Vaccination programmes ARHL – life-style factors

The optimistic view

”Americans hear as well or better today compared with 40 years ago” NHANES, NHES Hoffman et al, 2010 Persons from later birth cohorts had lower prevalences of hearing impairment than those from earlier birth cohorts Beaver Dam Study, EHLS Zhan et al, 2010

Men 75 Right Ear

10 20 30 40 50 60 70 80 90 0,25 0,5 1 2 4 6 8 kHz dB HL 1RE 2RE 4RE 6RE

Women 75 Right Ear

10 20 30 40 50 60 70 80 90 0,25 0,5 1 2 4 6 8 kHz dB HL 1RE 2RE 4RE 6RE

75-year olds over three decades: No audiometric changes The Gerontological and Geriatric Population Study in Gothenburg, Sweden Rosenhall et al, 2013

The optimistic view

2 4 6 8 10 12 14 16 18 1971 1976 1981 1986 1991 1995 2000 2005 Prevalence, % Year

Prevalence any threshold >= 25 dB HL any ear 3,4 or 6 kHz

HNS-prevalens 3 - 6 kHz, något öra, 1971 – 2005 18-åriga mönstrande svenska män

Förändras hörseln från generation till generation?

Både bättre och sämre

(men mest bättre)

Muhr et al, 2016

Lätt, måttlig och svår HNS i diskantområdet 1971 – 2004 (-2010), ett eller båda öronen 18-åriga mönstrande svenska män

Histopathology of ARHL

Cochlear degeneration

• OHC degeneration in basal and apical coil
• IHC degeneration in basal coil
• Strial degeneration
• Alterations and derangement of hair bundles
• Intracellular inclusions

Types of ARHL 1

1) Sensory

2

2) Neural

3

3) Strial (metabolic)

4

4) Cochlear conductive 5) Mixed 6) Indeterminate

Schuknecht & Gacek, 1993

hypothetical uncommon, <1%

PARAN Gates et al, 2000

Engström et al. 1987

Woman 75 y Man 74 y

Sensory type

Schuknecht’s classification

Strial type

Schuknecht, 1994 A reduction in the EP is presumed

Presbyacusis Woman 67 y Presbyacusis Woman 83 y

Strial (metabolic) type

Schuknecht’s classification

Gates & Mills, 2005

Engström et al. 1987

Presbyacusis Man 73 y

Mixed: sensory + strial types

Age, Cohort, and Period Effects

Causes of ARHL

Intrinsic causes – Age, Cohort Effects Biological ageing

Biological ageing is probably only a minor contributor to ARHL of ”younger elderly people”, but increases in importance in advanced age, 80+ Telomeres?

Genetic factors

Important contributors to ARHL

Mutation in mtDNA

The 4,977-bp deletion

Bai et al, 1997; Ueda et al, 1998

Genetic influences of ARHL in man

• ARHL has a multifactorial aetiology
• Familial aggregations occur for sensory and strial ARHL

phenotypes

• Heritability: 35-55% (sensory type)
• The heritability estimate was greater for the strial than the sensory

phenotypes

• Women: Genetic effect on ARHL
• Men: Mixed, genetically/aquired ARHL

Gates et al, 1999

• Candidate genes in man:

10q26, 11q13.5, 11q25 (DFNB20), 11p, 14q, 18q KCNQ4, DFNA18

DeStefano et al, 2003; Fransen et al, 2003; Garringer et al, 2006; van Eyken et al, 2006; a.o.

Genetics and ARHL – Twin Studies

Audiometric Study of Male Twins Variation in high frequency hearing is related to genetic and extrinsic factor. Heritability: 47%, 64+ years, men The environmental effect becomes more important with age Karlsson et al, 1997 Danish Twin Registry Heritability for self-reported hearing loss 40%, 75+ years Christensen et al, 2001 NAS-NRC Twin Panel Heritability: 60% (self-reported). HI susceptibility locus on chromosome 3, DFNA18 locus Reed et al, 2000; Garringer et al, 2006 Finnish Twin Study on Aging Heritability: >60%, measured hearing, 63-76 years, women Self-reported hearing related to environmental factors Viljanen et al, 2007

Causes of ARHL

Environmental, acquired Period Effects Vocational noise exposure Ototoxic drugs Solvents, other chemicals e.g. carbon monoxide Traumatic hearing loss Infections Middle ear disease Heavy metals (Hg)

20 40 60 80

dB HL

0.25 0.5 1 2 3 4 6 8

kHz

Unsc ree ned Noise scr eened Highly scr eened

Noise – Unscreened Men, 75 y (70-80 y) Compilation of 8 studies

Highly screened for otological disease and noise (green) Screened for noise only (blue) Unscreened studies, noise exposed populations (red)

10 20 30 40 50 60 70 80

dB HL

0.25 0.5 1 2 4 8

The Göteborg Gerontol. Study Noise +15y No Noise n: 137 NN n: 100 N+15y

Occupational Noise - No Noise Men, 70 y

No noise (blue) vs

• ccupational noise (red)

H70

Interactions between Noise-Induced Hearing Loss and ARHL

Additive effect

(adopted by ISO 1999)

Less-than-additive effect

Mills et al, 1996; 1998

More-than-additive effect

Miller et al, 1998

Combined effect

Less ARHI in NIHL-frequencies (4-6 kHz) Increased ARHI in neighbouring frequencies, - 2 kHz

Gates et al., 2000

0,25 0,5 0,75 1 1,25 1,5 1,75

Annual Decline, dB/y LE

0.25 0.5 1 2 3 4 6 8

kHz Noise No Noise

Animal research indicates a sensitising effect of noise

Kujawa & Liberman, 2006

Annual decline dB/year

Three longitudinal studies

H70 Noise vs No Noise

Hederstierna, Rosenhall, 2015

BLSA Noise vs No Noise Pearson et al, 1995 MUSC No Noise

Lee et al, 2005

Causes of ARHL

Environmental, extrinsic Life style factors Every day noise exposure Leisure time noise exposure, e.g. music, shooting Smoking Alcohol (severe abuse) Diet Physical fitness

Interfererande sjukdomar

Kognitiva störningar – Demens Metabolt syndrom – DM2

AD: 3 – 10% - 65 y 25 – 50% >85 y

Hörsel och kognition hos äldre

Presbyacusis – interaktion med kognitiva störningar

Lin et al, 2013; Lin & Albert, 2014

Positiv effekt av hörselrehabilitering vid presbyacusis och demens

Amieva et al, 2016

20 30 40 50 60 70 80 90

20

10 20 30 40 50 60 70 80

High Frequency Pure Tone Average, dB HL

Speech in Noise Test

80 70 60 50 40 30 20

Age, Years Speech Perception, %

Barrenäs, Wikström 2000 Magnusson, 1996

Hörsel och kognition hos äldre

Centrala auditiva störningar Central Auditory Processing Disorder (CAPD) CAPD har påvisats vid demens och vid impressiv afasi

Gates et al, 1996, 2002, 2008; Idrizbegovic et al, 2011; 2013 Ramsing et al, 1996

Pure tone audiometry Speech audiometry PB words in quiet (SPQ) In noise (SPN) 4 dB S/N Dichotic digits test (DDT) Central Auditory Processing (CAP) dysfunction is highly evident in early AD, and even in MCI Evaluation of CAP might provide an auditory diagnostic complement in monitoring the progression of AD and MCI

Auditory function in early Alzheimer’s disease and Mild Cognitive Impairment

Idrizbegovic et al, 2011 136 subjects, mean age: 64 years (range 50-78) 1) AD; 2) MCI; 3) SMC