Cognition (i.e., the ability to reason, plan, remember, and direct tasks) has gained our professional attention, motivated in part by findings that hearing loss is associated with greater likelihood of cognitive decline (Lin et al, 2011; Lin et al, 2013) and is a major modifiable factor contributing to dementia risk (Livingston et al, 2017).   

Providers within and outside audiology have asserted that screening and awareness of cognitive decline is within our scope of practice and should be part of treatment decisions (Valente et al, 2006; Remensnyder, 2012; Maslow and Fortinsky, 2018). Under-standing how an individual’s cognitive ability affects communication is also consistent with providing whole patient care (Taylor and Weinstein, 2015).  

The goal of cognitive screening is to identify patients who may have mild cognitive impairment (MCI), a modest cognitive decline from previous performance that does not interfere with independence in everyday activities, or dementia, a severe decline that interferes with independence (American Psychiatric Association, 2013).  

Several paths are open to providers, including making referrals for further evaluation when patients, family members, or the providers themselves note cognitive concerns during clinical care and/or formal screening whereby the need for referral can be determined in a quantitative way. Such practices are in widespread use in primary care (Alzheimer's Association, 2019; Raymond et al, 2020), but less common among audiologists (Martin et al, 2018). This article describes the results of a survey created to gain insight into how audiologists are responding to cognitive concerns in their patients. 

FIGURE 1. Distribution of practice settings for respondents.
FIGURE 1. Distribution of practice settings for respondents.

Methodology

A 21-question survey was developed using Qualtrics software. The survey and study methodology were reviewed by the local institutional review board and determined to be exempt research. The questions addressed three areas: cognitive screening practice, professional knowledge regarding cognitive issues, and recommendation and referral. The survey link was distributed to 9,700 audiologists via a professional listserv (Audiologist Resources Inc.) and completed by 1,104 audiologists, for a response rate of 11 percent.  

Results

The respondents represented a range of practice settings (FIGURE 1). Among respondents, 82 percent reported having an AuD, 12 percent reported a master’s degree, and 6 percent reported a PhD. All responses were anonymous and respondents were not compensated for their time.

Cognitive Screening 

Most respondents (88 percent) reported that they do not administer formal cognitive screening, although this varied widely by practice setting (TABLE 1). Across all respondents, the most common reasons given for not screening were: not being comfortable administering screening questionnaires (19.8 percent), not having time (19 percent), or that such screening was not in the audiologist’s scope of practice (10 percent). 

TABLE 1. Percentage of respondents administering cognitive screening by practice type.

PRACTICE TYPE

PERCENTAGE ADMINISTERING COGNITIVE SCREENING

College or university

29.6%

Nonprofit clinic

23.1%

Hearing aid manufacturer

17.4%

Audiology private practice

12.4%

Hospital/medical center

7.9%

Veterans Administration or military

7.5%

Physician's office

5.6%

Franchise or retail chain

4.2%

Primary or secondary school

0.0%

Among audiologists who use screening instruments, the most commonly reported screeners were the Mini-Mental State Exam (MMSE) (Folstein et al, 1975) and Montreal Cognitive Assessment (MoCA) (Nasreddine et al, 2005) (TABLE 2).  

TABLE 2. Percentage of respondents reporting use of specific screeners.

SCREENING INSTRUMENT

PERCENTAGE USING THE SCREENING INSTRUMENT

Mini-Mental State Exam (MMSE)

42.3%

Montreal Cognitive Assessment (MoCA)

38.2%

Clock-Drawing Test

17.1%

Mini-Cog Test

16.3%

Three-Word Recall Test

13.8%

Six-Item Cognitive Impairment Test (6CIT)

10.6%

Professional Knowledge Regarding Cognitive Issues

Across all respondents, 80 percent reported they had received training to distinguish age-typical from abnormal cognition and 41 percent reported they had received training to administer cognitive screeners. The type of training varied according to length of professional experience (FIGURE 2). Audiologists who received their clinical degree more recently were more likely to report receiving such training as part of their graduate program.

FIGURE 2. Percentage of respondents reporting that they received training to identify potential cognitive problems (left panel) or training in the use of screening instruments (right panel).
FIGURE 2. Percentage of respondents reporting that they received training to identify potential cognitive problems (left panel) or training in the use of screening instruments (right panel). The bar color indicates if respondent received no formal training, training as part of their graduate program, training during professional continuing education, or training during both graduate school and professional continuing education.  

Referrals and Recommendations

When there are concerns about cognitive ability, the majority of audiologists (70 percent) refer patients for further evaluation. Of those, most (42 percent) refer to the patient’s primary care physician and, less commonly, to other specialty providers including neurologists (19 percent), psychologists (12 percent), otolaryngologists (10 percent), and geriatricians (9 percent). 

One-third of survey respondents also recommend patients use at-home training tools. The most common specific recommendations were the Listening and Communication Enhancement program (LACE) (70 percent) and Lumosity Brain Training (26 percent).  

Discussion

The study results indicate several themes. Consistent with calls by professional leaders for increased attention to cognitive ability, there were signs that training opportunities are increasing. 

For example, the number of audiologists who reported they were trained to perform cognitive screening during their graduate education has more than doubled within the past 10 years. Of those  entering practice in the past five years, 44 percent reported such training, compared to 20 percent of those entering practice in the previous five years. 

With regard to how many audiologists conduct cognitive screening using validated assessments, previous surveys of up to a few hundred audiologists have reported values from 5 to 25 percent (Anderson et al, 2018; Martin et al, 2018; Raymond et al, 2020). The present data from a larger sample suggest that the range may vary by type of practice; specifically, as shown in Table 1, clinics with more time per appointment or greater flexibility in their appointment structure, such as college, university, and nonprofit clinics, have incorporated screening to a greater extent.   

For audiologists who conduct cognitive screening, a screening instrument that is sensitive to MCI is likely to be a high priority. MCI is more prevalent than dementia among older adults, affecting up to one in five adults over 65 years of age (Langa and Levine, 2014). Most adults with MCI continue to function independently and are less likely to have come to the attention of their other health providers (Mitchell et al, 2011; Nogueras et al, 2016). Therefore, older audiology patients may present to audiologists with undiagnosed MCI.

Forty-two percent of audiologists (Raymond et al, 2020) and 80 percent of physicians (Alzheimer's Association, 2019) reported screening with the MMSE. While this measure may be familiar to providers, recent work suggests that it is less sensitive to MCI than other instruments (Breton et al, 2019). Screening instruments with higher sensitivity to MCI include the MoCA and the St. Louis University Mental Status Examination (SLUMS), each of which takes less than 15 minutes to administer.  

Even if formal screening is not conducted, most clinicians (70 percent) reported referring when history or interactions with the patient present a concern for cognitive decline. Most commonly, this referral is to primary care. 

An interesting segment is made up of audiologists who reported they do not refer for cognitive concerns—30 percent in the present study and 39 percent in Raymond et al (2020). These surveys are not informative on reasons for non-referral, but the possible reasons could include discomfort discussing cognitive symptoms or screening results (Martin et al, 2018; Clark and English, 2019) or uncertainty as to the appropriate referral pathway (Martin et al, 2018).  

Next Steps

The results of this survey suggest several opportunities for incorporating cognitive screening into audiology practice. Free, quick, validated screening instruments are available and an increasing number of in-person and online continuing education options provide training for those instruments. 

There is also a need to develop referral pathways so that patients identified with possible cognitive decline (whether via screening or observation) can obtain the necessary follow-up.  

Training clinicians to counsel patients regarding cognition can support patient care, as well as the role of cognition in everyday communication.