Cognitive Tests, Cognition and Audition, and Speech-in-Noise: Interview with Kathleen Pichora-Fuller, PhD
Douglas L. Beck, AuD, spoke with Dr. Pichora-Fuller about attention-shifting, the Mini-Mental State Exam, Montreal Cognitive Assessment, and more.
Academy: Hi, Kathy. Always a pleasure to chat with you! I’d like to spend a few moments catching up with you with regard to your ongoing work in cognition and audition.
Pichora-Fuller: Sure thing—that’s one my favorite topics! Let’s start with the very familiar concept of bottom-up processing. As we all know, sounds come into the ear and multiple acoustic, mechanical, and bio-electric phenomena occur, and, eventually the encoding of the signal makes it to the brain…and the extremely important point is that sensory information doesn’t exist in isolation. That is, the sensory information is interpreted and processed by the brain within context-dependent constraints and expectations so there is also top-down processing according to the listener’s knowledge and goals in the particular situation.
Academy: And so in the final analysis, each person likely hears sounds in a unique way, as their auditory perception is based on the integration of their sensory input and their top-down, cognitive processing?
Pichora-Fuller: Yes, that’s correct. And for the most part, everything we hear has been conditioned or prepped based on what we heard before. Further, we have expectations—and these also impact our auditory sensations. Now to be clear, what goes on in a sound booth with pure tones or artificial stimuli may be a bit different, but I am talking about what goes on in everyday life.
Academy: Thanks for that clarification. To me, this is a really important point, and one that I often make, too. Specifically, it’s of monumental importance to separate out diagnostic tests (pure tones, SATs, SRTs, WRS, tympanograms, reflexes, ABR, etc.) that are performed for the purpose of rendering a differential diagnosis, from functional tests, which reflect how the patient perceives sounds in the real world! And, of course, speech-in-noise is the primary thing we need to address with regard to functional tests. Nonetheless, please tell me more about how the patient’s expectations influence what they perceive?
Pichora-Fuller: Here’s the way it works…sometimes the expectation of what you think you’re about to hear is so strong that it can actually over-ride what you actually hear. And as you mentioned, speech-in-noise has been, and remains the frontier we need to address, to make it easier for people to listen in noisy environments. However, when I think about hearing in everyday life, and with due respect and gratitude for those audiologists who are testing speech in noise ability – there’s still a problem.
Academy: I think I know where this is going, but please continue!
Pichora-Fuller: Well, the thing is, when the audiologist says to the patient something such as, “Here’s the task, please listen for THIS talker coming from the front, and ignore the other people speaking from the back or sides…” we’ve set-up conditions in which the patient’s expectations are controlled. That is, when we give him or her instructions, we’re creating an artificial test environment that he or she is listening for one voice, perhaps from one location, while dismissing other sounds, and then we test them. And so, the test includes directions and expectations that would not be typical in the real world.
Academy: And so, the directions and expectations present an artificial test environment that may approximate their real-world listening situation in terms of acoustics, but it still represents an artificial protocol, not necessarily representative of the real world?
Pichora-Fuller: Exactly—it is very important to distinguish between how people hear signals used in a test from what they do with those signals when they are trying to complete a task. Performance can be affected by the amount of noise, but also by the type of task or the degree to which a listener’s knowledge and expectation are guiding listening. This is a very important point when we are testing older listeners. Our research indicates that the problems of older listeners depend on both the type of signal and the type of task. Fortunately, the problem that our tests do not use very realistic tasks has a relatively simple solution, one we could easily fix!
In other words, rather than saying “do this” or “attend to that,” we can simply change the protocol to better approximate the real -world listening environment by sometimes asking the listener to search for the target. Let me make another very important point, for anyone not employing speech in noise tests in their standard audiometric battery, they should start doing that immediately because it provides important information that we can’t get from the audiogram and also because clients want us to test them in the conditions where they feel they have difficulty. So, I’m not saying don’t do speech in noise, I am saying absolutely do speech-in-noise, but perhaps we can easily make these same tests even more representative of the real world!
Academy: In other words, rather than assuming the person we want to pay attention to is the loudest person in the room and is sitting right in front of us, we need to accommodate the fact that sometimes people tap you on the shoulder and speak to you from the left or right side, and sometimes they speak from behind you or maybe you don’t expect somebody to start talking to you…and if can we incorporate these situations into the test protocol, we’ll get a more realistic view of the patient’s listening skills and abilities. Is that right?
Pichora-Fuller: Right. The ability to “shift attention as needed” to rapidly deal with the unexpected should be a part of rehabilitative training because that’s how the world really works. And admittedly, there is no test available right now to test the listener’s ability to shift attention to focus on particular voices or directions when in noise, but it’s an area we’d like to investigate further with an eye toward seeing if we can create a test that would be useful in the future.
Further, we might also want to evaluate reaction time. That is, when someone responds quickly, it generally means it was easier for them to process information and of course, when one responds more slowly, it might mean it was more difficult to process the same information. Reaction time is an easy to measure metric, and it, too, would likely add to our overall analysis as to how patients perform in the real world where they might be having a hard or easy time even if they are not making a lot of errors recognizing words.
Academy: Another pervasive question in clinical audiology is the issue of whether or not we should test cognitive function. As a psychologist, what are your thoughts on that?
Pichora-Fuller: It might be a good idea. However, there are many important aspects to cognitive function, and we probably should start by defining the purpose of the test first. One purpose for using a cognitive screening test is simply to assess whether or not the patient is performing in a range that would be considered to be normal or not. That is, audiologists would not undertake a full blown psychological profile or analysis or a treatment plan for those who are not performing normally, but they might use a screening test simply if they want to ask and answer the question, “Is this person functioning normally with respect to their cognitive ability?”
Academy: And if the answer is yes (the patient is performing normal cognitively), then we proceed with addressing their auditory and listening needs, and if the answer is no, we may still proceed, but we may also add appropriate referrals and recommendations to accommodate their cognitive abilities?
Pichora-Fuller: Exactly. And so, the two tools that I would recommend as screening tools for cognitive function are the Mini Mental State Exam (MMSE).
Academy: I’m glad you mentioned the MMSE, as it’s a standard test used by ER personnel, nurses, occupational therapists, and many other professionals. Here’s a link that explains the basics and has a copy of the test from the Hartford Institute for Geriatric Medicine: And what’s the other cognitive screening tool you recommend?
Pichora-Fuller: The other screening tool is the Montreal Cognitive Assessment. This test is very useful when we try to differentiate people with Mild Cognitive Impairment (MCI) and dementia. The MMSE is not designed to identify people who have MCI, although it will certainly indicate dementia, as a screening tool.
Academy: And both of these screening tests are validated, verified, and well-recognized as screening tests for dementia?
Pichora-Fuller: Yes. These are dementia-screening tests, so they are appropriate for audiologists or other health professionals to use. Importantly, if you are going to use these screening tools, then you must have a protocol. That is, as with any screening test, it’s important to understand what you’re going to do when someone fails these screening tools. You need to have a plan for matters such as referring the patient to an appropriate resource or taking the result into consideration when you make your own rehabilitative recommendations for the person and also their significant others.
Academy: Great point. And of course the referral options are not trivial as you may need to refer to the GP, a local psychologist or psychiatrist, or whomever the most appropriate professional is for that patient in that particular situation.
Pichora-Fuller: And, Doug, as you know, more people with hearing loss, do, in fact, develop cognitive impairments than age-matched peers without hearing loss.
Academy: Yes, and that’s been documented by Frank Lin, George Gates, and many others. In fact, I would recommend the recent article you and I co-authored in 2012 with Brent Edwards, Larry Humes, Ulrike Lemke, Thomas Lunner and Frank Lin.
Pichora-Fuller: Absolutely. And we now know that hearing loss does indeed place people at greater risk for dementia than peers with normal hearing.
Academy: I read Frank Lin’s JAMA paper on that earlier in 2013, and I believe you’re exactly right. The thing we don’t know as of yet is whether aural rehabilitation and/or amplification will alter the course of dementia.
Pichora-Fuller: Exactly. That’s the huge question, and I suspect we’ll have objective data on this question in the next few years. In the meantime, it seems like hearing care is certainly important for this population, but audiologists should be careful not to make claims that are not justified by solid evidence.
Academy: Okay, well for now, let’s end on that thought. Kathy, it’s always a pleasure chatting with you and I am very grateful for your time and knowledge!
Pichora-Fuller: Thank you, Doug. I appreciate your interest and exploration of this area, too!
Kathleen Pichora-Fuller, PhD, is a professor in the Department of Psychology at the University of Toronto. She is also an adjunct scientist at the Toronto Rehabilitation Institute, an adjunct scientist at the Rotman Research Institute in Toronto, Canada, and a guest professor at Linköping University in Sweden.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor at the American Academy of Audiology.
For More Information, References, and Recommendations
Beck DL, Edwards B, Pichora-Fuller MK. (2011) Exploring the maze of the cognition-audition connection Hearing Journal 64 (10):21-24.
Beck DL, Edwards B, Humes LE, Lemke U, Lunner T, Lin FR, Pichora-Fuller MK. (2012) Expert roundtable: issues in audition, cognition, and amplification. Hearing Review.
Goy H, Pelletier M, Coletta M, Pichora-Fuller MK. (in press). The effects of semantic context and the type and amount of acoustical distortion on lexical decision by younger and older adults. Journal of Speech, Language and Hearing Research. Published online July 23, 2013.
Lin FR. (2013) JAMA: Hearing Loss May Be Related to Cognitive Decline in Older Adults. Hearing Review. 8:44.
Pichora-Fuller MK. (2008) Audition and Cognition – Where Lab Meets Clinic. ASHA Leader. August 8.
Pichora-Fuller MK, Dupuis K, Reed M, Lemke U. (2013) Helping older people with cognitive decline communicate: hearing aids as part of a broader rehabilitation approach. Seminars in Hearing 34(4).
Singh G, Pichora-Fuller MK, Schneider BA. (in press; accepted in April 2013). The time course and cost of misdirecting auditory spatial attention in younger and older adults. Ear and Hearing.