Cognitive effects on speech perception and how these might be addressed (and other stories) Melanie Ferguson, PhD NIHR Nottingham Hearing Biomedical Research Unit, UK BSHAA AGM and Development Day 14 th November 2015
Nottingham The UK s interdisciplinary hub for hearing research Basic Translational Clinical Advancing insight, innovation, and impact
Habilitation for hearing loss Aim: To promote healthy hearing by reducing activity limitations and participation restrictions using a holistic habilitation approach Optimal delivery Listening and cognition Self-management and telehealth Healthy hearing Outcome measures Health behaviour Patient-centred care
Talk outline Overview of our research and key studies Cognition and speech perception Auditory and cognitive training Other stories C2Hear Online Audiology meets health psychology James Lind Alliance on mild-moderate HL
Consequences of hearing loss Hearing Access to acoustic stimulation Listening Hearing with attention and intention Comprehension Interpretation of acoustic / linguistic information Psychosocial consequences Impaired Hearing Impaired Social Engagement Impaired Communication Communication Effective use and transmission of information Impaired Wellbeing (Kiessling et al., 2003) (Dalton et al., 2003; Kramer et al., 2002)
Listening and cognition
Speech intelligibility and other factors Speech perception, particularly in noise, becomes more difficult with age Hearing loss explains only part of the story (Kraus)
Speech intelligibility and other factors Speech perception, particularly in noise, becomes more difficult with age Hearing loss explains only part of the story What do we mean by cognition? (Kraus) Role of cognition has emerged over the last decade
Role of cognition But what is the nature of the relationship between speech perception and cognition? which aspects of cognition are important for speech complexity? What do we mean by cognition? Attention: Ability to actively process specific information present in our environment Working memory: Ability to simultaneously store and process task-relevant information (Daneman & Carpenter, 1980) 2 sides of the same coin
Of course, the story is more complex than just that Model of executive functioning e.g. monitoring, attention-switching, memory updating (Diamond, 2013)
So, what have we done? Research question: Which aspects of cognition are important for speech perception? Approach: Exploration of baseline data collected previously from two auditory training studies Auditory I RCT Phoneme in quiet Non-HA users n=44 Training = ~6 hrs (4wks) Auditory II Repeated measures Phoneme in noise Existing HA users n=30 Training = ~3.5 hrs (1wk) (Ferguson et al, Ear and Hearing, 2014) (Henshaw & Ferguson, ISAAR, 2014)
Speech tests Increasing speech test complexity Phoneme Discrimination (/a/-/e/) Digit triplet (word) in noise Sentence in noise Broad range of responses mild hearing loss
Complex Simple Divided attention Executive function Single attention Auditory I: Cognitive outcome measures Attention Working memory Simple-span Digit span backwards Repeat in reverse order 1 3 4 7 Complex-span Visual letter monitoring Identify 3-letter words F U T O P
Hearing and cognition what s important? words words sentence sentence sentence Hearing sensitivity correlates with words and sentences, but not cognition Attention and WM correlate with sentences only
Hearing and cognition what s important? Hierarchical regression analyses with 1) PTA and 2) Attention & WM Digit Triplet (VS) Digit Triplet (VN) ASL Step R 2 F Sig 1 Hearing PTA 0.24 11.76 0.002 2 Cognition WM 0.25 0.25 0.62 Att 0.26 0.44 0.51 1 Hearing PTA 0.22 10.7 0.002 2 Cognition WM 0.23 0.08 0.78 Att 0.23 0.24 0.63 1 Hearing PTA 0.15 6.64 0.01 2 Cognition WM 0.18 1.12 0.30 Att 0.29 5.68 0.02
Hearing and cognition what s important? Increasing speech test complexity Phoneme discrimination Hearing Cognition Digit triplet (word) in noise Hearing Cognition Sentence in noise Hearing Cognition Contributions of hearing sensitivity and cognition vary according to the complexity of the speech tests Relationship between speech performance and cognition is likely to be specific to the tests used referring simply to speech and cognition may overlook important distinctions What does this mean to you? Clinicians and practitioners need to be aware of these relationship when deciding which tests are used to assess speech
Future directions Relationship between speech perception, cognition and self-report Speech Cognition Self-report Exploratory testing these results in a second auditory training study Focussed on test of complex cognition In hearing aid users with mild-moderate hearing loss Paper in prep (Heinrich, Henshaw & Ferguson Frontiers Psychology) Hypothesis-driven research to probe specific questions
What does this mean to you?
Interventions for hearing loss (Boothroyd, 2007) Sensory management to optimize auditory function Perceptual training to improve speech perception and communication Instruction in the use of technologies and control of the listening environment Counselling to enhance participation
Listening and cognition Auditory and cognitive training
Top-down Cognitive control Bottom-up sensory refinement Auditory training: How does it work? Teaching the brain to listen through active engagement with sounds Bottom-up vs. top-down Near vs. far transfer Near transfer Far transfer Trained task different talker Untrained task Untrained task different modality Real-world benefit
(Ferguson & Henshaw, Frontiers in Cognitive Neuroscience, 2015) Does it work? the evidence On-task learning Transfer of learning Systematic review: (Henshaw & Ferguson, PLOS ONE, 2013) People with mild-moderate hearing loss, 50-74 years, at-home training Auditory I RCT Phoneme in quiet Non-HA users n=44 Training = ~6 hrs (4wks) Auditory II Repeated measures Phoneme in noise Existing HA users n=30 Training = ~3.5 hrs (1wk) Working Memory RCT Cogmed WM Existing HA users n=57 Training = ~15 hrs (5 wks)
Executive processes Auditory I: transfer of learning to complex but not simple outcomes RCT Simple Complex Communication Watching TV Conversation with people in a group Cognition Single attention Simple-span WM (digit span) Divided attention Complex-span WM (visual letter monitoring) Speech perception Energetic masking (speech in noise) Informational masking (competing speech) For listening abilities, improvements in complex cognition may be more important than the refinement of sensory skills (Ferguson, Henshaw, Clarke, Moore, Ear & Hearing, 2014)
Auditory II: transfer of learning to competing speech Modified Coordinate Response Measure (MCRM) *p <.05 * d =.47 n=30 T1 T2 T3 (Henshaw & Ferguson, ISAAR proceedings, 2014)
Participant reported benefits Post-training feedback questionnaire (n=44) The best aspect(s) of your experience with the training programme? Improved listening, concentration and attention (23%) Increased awareness of hearing difficulties (18%) Two representative focus groups (n=10) Increased awareness of the role of attention and concentration in HL I ve got to pay attention and focus more than I used to...when you are concentrating you can hear more. Improved concentration and listening post-training. [the training] made me want to listen to the one person I was facing You could do that better you ve not been listening before. Now you re listening (Henshaw, McCormack, Ferguson Frontiers Psychology, 2015)
Auditory training: summary and conclusions We listen with our brains Post-training improvements were shown for complex but not simple measures of communication, cognition and speech perception For the transfer of learning, complexity counts and improvements appear to draw upon executive processes Benefits of training were evident for challenging tasks Outcomes to assess benefit should be appropriately challenging to the effects of training. Outcomes should be sensitive to the intended mechanism(s) of benefit Could training cognition offer a more direct route to patient benefit?
Cognitive training study: visual working memory Double blind RCT n= 62 hearing aid users (n=57 completed) Adaptive training Active control (Henshaw & Ferguson, Trials 2013)
Outcome measures Near transfer Far transfer Digit span (trained task, different talker) Visual letter monitoring task (untrained WM task) Dual-task listening and memory Unpublished data removed to avoid future publishing conflicts Self-reported hearing (GHABP/HHIE) High/low predictability sentences Competing speech (MCRM)
Working memory training: summary and conclusions Improvements were seen for the trained tasks (on-task learning) in a trained WM task in auditory domain (near transfer) No improvements in cognitively demanding speech perception task (no far transfer real world everyday listening). It is unlikely that training cognition in isolation outside of the context of speech perception will provide real world benefits Future direction: might training on speech tasks that draw upon elements of executive processing optimise everyday listening for adults with hearing loss? Joined up thinking and listening Watch this space
Highlights from my team and other collaborators 2015
Telehealth and self-management
Interactive multimedia educational programme for hearing aid users Introduction Get to know Insertion Expectations Acclimatisation Communication tactics Phone & ALDs HA care Troubleshooting Retubing
Acclimatisation Learning outcome: be aware of how you adapt to listening with your hearing aids See NHBRU website http://www.hearing.nihr.ac.uk/ for sample clips
Hearing aid insertion recognise the shape of your earmould with the shape of your ear - reinforcements and consequences See NHBRU website http://www.hearing.nihr.ac.uk/ for sample clips
Testimonials: communication partners hearing loss is not visible in anyway See NHBRU website http://www.hearing.nihr.ac.uk/ for sample clips
Successful intervention? Take-up and adherence Self-management Knowledge HA outcomes Quality of life Valued by users Health economics (Ferguson et al, Ear Hear 2015; AJA 2015)
Freely available Official launch at BAA 25 th Nov SoMe campaign join in! Google Analytics
Further developments Spring 2016 Future m-rlos communication partners Individualised m-rlos hearing aid users
Patient-centred care
Audiology meets Health Psychology Application of health psychology theory to hearing loss research & practice is relatively new (Manchaiah, 2012) Transtheoretical Model Health Belief Model (Laplante-Lévesque et al., Ear Hear 2013) (Saunders et al., 2013) Self-regulatory model (Heffernan, Ferguson et al in press, IJA) COM-B model (Barker et al, in press, IJA) Guest editors: Ferguson, Henshaw, Coulson, Heffernan) Early 2016
The Mild-moderate HL Priority Setting Partnership UK charity for people with hearing loss, their families and friends
Top 10 priority Q s MMHL in adults 1 What adverse effects are associated with not treating mild to moderate hearing loss in adults? 2 Does the early fitting of hearing aid(s) result in increased patient benefit and/or improved costeffectiveness of the service? 3 Does the early fitting of hearing aids slow the rate of cognitive decline? 4 What are the reasons for low hearing aid uptake, use and adherence? 5 Can new technologies replace hearing aids? 6 Can stem cell therapy offer a cure for mild to moderate hearing loss in adults? 7 8 9 10 Does early identification, diagnosis and treatment of mild to moderate hearing loss prevent further deterioration of hearing? Could new developments to digital hearing aids offer improved speech perception in noisy environments? How realistic are hearing tests for assessing the everyday hearing abilities of adults with mild to moderate hearing loss? Could the use of real-world sounds to help program hearing aids in clinic (rather than tones or beeps) improve hearing aid effectiveness? BSA lightning update October 2015, NHBRU website (Henshaw, Ferguson et al, in press
Ear and Hearing Editors Award 2014 Ferguson M.A., Henshaw H., Clark D. & Moore D. 2014. Benefits of auditory training in a randomised controlled trial of 50-74 year olds with mild hearing loss. Ear and Hearing, 35(4), e110-e121