www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Speech
perception
in
noise
in
the
elderly:
interactions
between
cognitive
performance,
depressive
symptoms,
and
education
夽
Laura
Maria
Araújo
de
Carvalho
a,
Elisiane
Crestani
de
Miranda
Gonsalez
b,∗,
Maria
Cecília
Martineli
Iorio
caUniversidadeFederaldeSãoPaulo(UNIFESP),ProgramaPós-graduac¸ãoemDistúrbiosdaComunicac¸ãoHumana,SãoPaulo,SP,
Brazil
bFaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brasil
cUniversidadeFederaldeSãoPaulo(UNIFESP),DepartamentodeFonoaudiologia,SãoPaulo,SP,Brazil
Received27January2016;accepted11March2016 Availableonline27April2016
KEYWORDS
Cognition; Depression; Elderly;
Speechinnoisetest
Abstract
Introduction:Thedifficultytheelderlyexperienceinunderstandingspeechmayberelatedto severalfactorsincludingcognitiveandperceptualperformance.
Objective: Toevaluatetheinfluenceofcognitiveperformance,depressivesymptoms,and edu-cationonspeechperceptioninnoiseofelderlyhearingaidsusers.
Methods:Thesampleconsistedof25elderlyhearingaidsusersinbilateral adaptation,both sexes,meanage69.7years.SubjectsunderwentcognitiveassessmentusingtheMini-Mental StateExaminationandtheAlzheimer’sDiseaseAssessmentScale-cognitiveanddepressive symp-tomsevaluationusingtheGeriatricDepressionScale.Theassessmentofspeechperceptionin noise(S/Nratio)wasperformedinfreefieldusingthePortugueseSentenceListtest.Statistical analysisincludedtheSpearmancorrelationcalculationandmultiplelinearregressionmodel, with95%confidenceleveland0.05significancelevel.
Results:Inthestudyofspeechperceptioninnoise(S/Nratio),therewasstatistically signif-icantcorrelationbetweeneducationscores(p=0.018),aswellaswiththeMini-MentalState Examination(p=0.002),Alzheimer’sDiseaseAssessmentScale-cognitive(p=0.003),and Geri-atricDepressionScale(p=0.022)scores.Wefoundthatforaone-unitincreaseinAlzheimer’s DiseaseAssessmentScale-cognitivescore,theS/Nratioincreasedonaverage0.15dB,andfor anincreaseofoneyearineducation,theS/Nratiodecreasedonaverage0.40dB.
夽
Pleasecitethisarticleas:deCarvalhoLM,GonsalezEC,IorioMC.Speechperceptioninnoiseintheelderly:interactionsbetween cognitiveperformance,depressivesymptoms,andeducation.BrazJOtorhinolaryngol.2017;83:195---200.
∗Correspondingauthor.
E-mail:elisiane.miranda@fcmsantacasasp.edu.br(E.C.Gonsalez).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
http://dx.doi.org/10.1016/j.bjorl.2016.03.017
Conclusion:Levelofeducation,cognitiveperformance,anddepressivesymptomsinfluencethe speechperceptioninnoiseofelderlyhearingaidsusers.Thebetterthecognitivelevelandthe highertheeducation,thebetteristheelderlycommunicativeperformanceinnoise.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Cognic¸ão; Depressão; Idoso;
Testedefalaem ruído
Reconhecimentodefalanoruídodeidosos:interac¸õesentredesempenhocognitivo, sintomatologiadepressivaeescolaridade
Resumo
Introduc¸ão:A dificuldadenacompreensãodefaladosidosospodeestarrelacionadaavários fatores,comoodesempenhocognitivoeperceptual.
Objetivo:Avaliarainfluenciadodesempenhocognitivo,sintomasdepressivoseescolaridade noreconhecimentodefalanoruídodeidososusuáriosdeprótesesauditivas.
Método: A amostraconstituiu-se de25 idososusuários de prótesesauditivas em adaptac¸ão bilateral,deambosossexos eidademédiade69,7anos. Osindivíduosforamsubmetidosà avaliac¸ãocognitivapormeiodoMini-ExamedoEstadoMental(MEEM)eaEscaladeAvaliac¸ão daDoenc¸a deAlzheimer-Cognitiva(ADAS-Cog)e avaliac¸ãode sintomatologiadepressivapor meiodaEscaladeDepressão Geriátrica(EDG). Jáapesquisadoreconhecimentodefalano ruído (relac¸ão S/R)foirealizada,em campo livre,pormeiodoteste ListadeSentenc¸asno Português(LSP).Aanáliseestatísticaincluiuocálculodecorrelac¸ãodeSpearmanemodelode regressãolinearmúltiplo,sendoadotadocoeficientedeconfianc¸ade95%eníveldesignificância de0,05.
Resultados: No estudo do reconhecimento de sentenc¸as no ruído (relac¸ão S/R) houve correlac¸ão,comsignificânciaestatística,entreaescolaridade (p=0,018);assim como,com osescoresdostestesMEEM(p=0,002);oAdas-Cog(p=0,003)eoEDG(p=0,022).Observou-se que,paraumaumentodeumaunidadenoescoredoAdas-Cog,arelac¸ãoS/Raumenta, em média; 0,15dBe para um aumentode um anona escolaridade,arelac¸ãoS/R diminui, em média;0,40dB.
Conclusão:Oníveldeescolaridade,odesempenhocognitivoesintomasdepressivosinfluenciam oreconhecimentodefalanoruídodeidososusuáriosdepróteseauditiva.Quantomelhoronível cognitivoemaioraescolaridademelhoréodesempenhocomunicativodoidosonoruído. © 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Auditory function deterioration and cognitive decline are conditionscommonly found in the elderly population and may compromise the aging process. Hearing loss due to aging is characterized by decreased hearing sensitivity mainly for high frequency sounds, andspeech perception difficulties.1---3
Theuseofhearingaidsisaprimarymeansinthe reha-bilitationofhearingloss.4However,duetothecombination ofperipheralandcentralchanges,elderlypeopleoftendo notachievesatisfactoryimprovementinspeechrecognition incompetitivenoisesituationsusingamplification.
Severalstudieshaveshownthattheunderstandingof sen-tencesinnoiseisimpairedinpatientswithdementia.5,6This deficitmaybeattributedtothedifficultyinprocessing gram-maticaland/orsemanticinformation,aswellastoahigher cognitivedemandrequiredfordecodingandunderstanding thespeechsignalinnoise.7
Cognitiveabilities,suchasattention,memoryand lan-guage, are involved in the process of speech detection, discrimination, understanding, and organization. Under-standingtheinteractionofcognitivefunctionswithsensory functionscanassistintherehabilitationoftheelderlywith difficultyinadaptingtohearingaids,aswellasguidingthe technologicaladvancementinthefieldofprosthetics.8,9
Itisknownthatacognitiveimpairmentmaybeassociated with history of depressive symptoms. The most frequent cognitive impairments in depressedelderly are the exec-utivefunction,intentionaldeficits,andreducedprocessing speed.Becausedepressioncansimulatedementia,10,11 the investigation of depressive symptoms in elderly patients withhearingaidsisappropriatesincethepresenceofthese symptoms can interfere negatively in the communication process.
presence of depressivesymptoms. Thus,this study aimed toevaluatethe effectofcognitive anddepressivefactors onthespeech perceptionin noise performanceof elderly hearingaidsusers.
Methods
Ethicalconsiderations
This is an experimental study withnon-probabilistic con-veniencesample.ThestudywasapprovedbytheResearch EthicsCommitteeoftheinstitution,andparticipantswere informedabouttheobjectivesandmethodologyofthe pro-posed study, agreed to participate voluntarily and gave writteninformedconsent.
Selectionofsubjectsandcaseseries
Thesamplewasselectedaccordingtothefollowing eligibil-itycriteria:
• Ageequaltoorgreaterthan60years;
• Have sensorineural, symmetrical, mild to moderately
severeacquiredhearingloss,accordingtotheLloydand Kaplanclassification,1978;
• User hearing aids in bilateral adaptation, identical
models,in-the-earorbehind-the-earhearingaid;
• Effectiveuser ofamplificationforat leastthreemonths
(afteracclimatization);
• Absence of obvious impairment (neurological, speech
and/orverbalfluency).
Accordingtotheeligibilitycriteria, 25individualswere calledbyphonetoparticipateinthisstudy,9malesand16 females,agedbetween60and85years(mean69.7years).
Procedures
Allpatientsunderwentassessmentofcognitiveand depres-siveaspects,aswellasthesignal-to-noiseratio(S/N)ofthe PortugueseSentenceListtest.Theseprocedureswere per-formedinasingleevaluationsessionlastingabout90min.
Cognitiveassessment
The cognitive assessment was performed using the Mini-MentalStateExamination (MMSE)and Alzheimer’sDisease AssessmentScale(ADAS-Cog)tests.
MMSEisascreeningtestusedtomeasurecognitive func-tion; in Brazil, it was adapted by Bertolucci et al.12 The testevaluateseightcognitiveparametersdividedintoseven categories: temporal and spatial orientation, short-term memoryandrecallofwords, calculation,praxis,language andvisuospatialabilities. Thetest scoreranges from0to 30points.Thelowerthescore,thegreater thechanceof theindividualtopresentchangesincognitiveability.Inthis study,weusedthescoringclassificationofBruckietal.13
In this study, the cognitive session of Alzheimer’s dis-easeAssessment Scale(ADAS-Cog) wasalsoused,whichis composedof11itemsthatassessmemory(recognitionand
recall), language (speech and understanding), and praxis (copyandideomotor).Thescorewasclassifiedaccordingto theeducationofthesubject, andthoseoutsidetherange equivalenttothemeanplustwostandarddeviationswere consideredabnormal.14
Itshouldbenotedthatthesescaleswereusedtoratethe cognitiveperformanceofindividualsinnormalorabnormal category,accordingtotheireducation.Noparticipanthad adiagnosisofAlzheimer’sdisease.
Depressionscreening
For depressive symptoms evaluation, the shorter version of the Geriatric Depression Scale (GDS-15) was applied, consistingof 15questionswithalternative closedanswers (‘‘yes’’or‘‘no’’).Foranalysisofresults,thescoringcriteria suggestedbyAlmeidawereemployed,11 withscoresabove 5consideredasabnormal.
Signal-to-noiseratio(S/N)ofthePortuguese SentenceListtest
To evaluate the S/N ratio,the Portuguese Sentences List test15 wasused,which consists of lists with10 sentences each,anda background noiseof speechspectrum.Inthis assessment,thetestapplicationwasinfreefieldinan acous-ticallytreatedenvironment,withthesubjectpositionedat 1m from the soundsource oncondition 0◦ azimuth, that
is,infrontofthesubject.Sentencepresentationfollowed theascending-descending strategy.16 Noise level waskept constantduringsentencepresentation,onlymodifyingthe presentationintensityofsentences.TheinitialS/Nratiowas establishedat+5dB.TocalculatetheS/Nratio,theaverage valueofSRTNwassubtractedfromthenoiseintensitylevel. Thus,the S/N ratiocorresponded tothe differencein dB betweenthevalueofSRTNandcompetitivenoise.
Statisticalanalysis
TostudythecorrelationbetweenthetestsandS/Nratiowith Age,Education,andPSADusagetime;scatterdiagramswere constructed and Spearman correlation coefficients were calculated.17Thesameprocedureswereusedinthestudyof correlationbetweentests(twobytwo)andbetweentests andS/Nratio.Aregressionmodel17wasadjusted,havingas variabletheresponsetoS/Nratioandaspossible explana-tory variables the tests and education.Forward stepwise procedurewasusedintheselectionoftheexplanatory varia-bles.Mean scoresinthefourtestswerealsoestimatedby range,adoptinga95%confidencelevel.Inhypothesis test-ing,0.05significancelevelwassetandthesignificantvalues weregraphedwithanasterisk(*).
Results
Initially,ananalysisofdescriptivestatisticswasperformed forAge,Education,andPSADusagetime(Table1).
Table1 Descriptivestatisticsforage(years),education(years),andPSADusagetime(months).
Variable n Mean Standarddeviation Minimum Median Maximum
Age 25 69.7 7.6 60 67 85
Education 25 4.5 3.1 0 4 11
PSADtime 25 10.2 6.5 3 7 27
PSAD,personalsoundamplificationdevices.
Table 2 Values of Spearman correlation coefficients16 betweenS/NratioandPSADtime,education,andage.
S/Nratio R P
PSADtime −0.13 0.536
Education −0.47 0.018*
Age −0.22 0.286
PSAD,personalsoundamplificationdevices.
Table 3 Values of Spearman correlation coefficients16 betweenS/NratioandMMSE,ADAS-Cog,andGDS.
MEEM ADAS-cog GDS
S/Nratio
R −0.57 0.58 0.46
P 0.003* 0.002* 0.022*
Table 4 Multiple linear regression model between S/N ratioandADAS-Cogandeducationvariables.
ExpectedS/Nratio=−0.037+0.15×ADAS-Cog−0.40 ×Education
statisticallysignificant correlation between S/N ratioand education;thatis,thehighertheeducation,thelowerthe S/Nratio(Table2).
Table3showsthecorrelationbetweenthePSLS/Nratio andthescoresof MMSE,ADAS-Cog,andGDS.Therewasa significant correlation between the S/N ratio and studied tests.Thus,thehighertheMMSEscore,thelowerthe ADAS-Cog andGDS scores, the lowerthe S/N ratio for the PSL test.
Amultiplelinearregressionmodelwasconductedfrom therelationship betweenthe S/NratioandADAS-Cogand educationvariables(Table4).
From the ADAS-cog and education coefficients in the adjusted model,we found that for a one-unitincrease in ADAS-Cogscore,theS/Nratioincreasesonaverage0.15dB andforanincreaseofoneyearineducation,theS/Nratio decreasesonaverage0.40dB.
Discussion
Understandingspeechis mostoften impaired by competi-tivenoise.Complaintsofdifficultiesinunderstandingspeech innoisyenvironmentsamongelderlyhearingaidsusersare becomingmorecommon.18,19Inthisstudy,wechosetouse phrasesrecognitiontestswiththepresenceofacompetitive
stimulus (noise) in free field, in order to evaluate these individuals,simulatingcommunication conditionscloserto thosefoundineverydaylife.
The elderly subjects were randomly selected from a concessionserviceofhearingaidsinthemetropolitancity. The population looking for that service consistsmostly of lowincomeandloweducationpatients,reflectingthe socio-economicprofileofthemajorityofelderlypeoplelivingin developingcountries.Inthecurrentsample,therewasalow level of educationamongtheparticipants and,moreover, theS/NratioobtainedinthePSLtesttendtoincreasethe lowerthelevelofeducation,demonstratingthatolder peo-plewithlesseducationhaveworseperformanceindifficult listeningconditions.
It is important to note that a low educational level can directly affect the performancein cognitive tests,as reportedbyBertoluccietal.12 Even inpeoplewhohadno evidenceofcognitiveimpairment,thelowertheeducational level,thelowerthescoresoncognitivetests.12,13,20,21
AccordingtoPichora-Fuller,22 in ordertobetter under-standtheinfluenceofhearingontheparticipationofdaily life activities of an individual, one should consider the variableagewiththedifferencesin cognitiveand percep-tualperformance.Difficultiesinspeechunderstandingare increasedbyfactors suchasnoise andmemory.Moreover, the significance of these processes will depend on socio-emotionalcharacteristicspresentedbyeachindividual.
Thepresentstudyfoundcorrelationbetweenthescores ofthePSLS/NratioandMMSEandADAS-Cogcognitivetests, and the lower the cognitive level, the worse the hearing performanceoftheelderlyinnoise.Speechrecognitionin noiseisataskthatrequirestheuseofmemory,attention, andtheclosingability,becausethelistenerneedsto iden-tifythemessagedistortedbynoiseandseekinformationof speechinmemory.23,24 ThestudybyPichoraFulleretal.25 showedthattheworkingmemorycapacityisreducedwhen thenoiselevelisincreasedrelativetothesignal.
Lunner,26Akeroyd,27Gatesetal.,24Miranda,28andBesser et al.7 found correlationsbetween cognitive performance andtheabilitytorecognizespeechinnoise, andthe indi-vidualswithbetterperformanceoncognitivetestsshowed better results in speech recognition task.Several studies intheliteratureindicatedthatspeechrecognitioninnoise requiresademandofcognitiveskills, whichareindecline intheelderly.26,27,29---32
Theregressionmodelproposedinthisstudyisatoolthat canandshouldbeusedintheclinic,especiallywhenthere arenotechnologicalresourcesthatenabletheapplicationof speechtestsinthepresenceofcompetitivenoise.Fromthe ADAS-cogandeducationcoefficientsintheadjustedmodel, it is concluded that for a one-unit increase in ADAS-cog score,S/N ratio increasesonaverage 0.15dB,and for an increaseof oneyear ineducation,S/Nratiodecreases on average0.40dB.
In additiontocognitive deficits,depression isalso one of the most common health problems in the elderly.33---35 Depressionisacommonsymptomintheelderlywith hear-ingloss duetofunctionallimitations that thisdeprivation causesindailylife.36---38Itisknownthatdepressioninterferes significantlyinthecognitiveperformanceofthepatient.39
Inthecurrentsample,acorrelationwasfoundbetween depressive symptoms and speech in noise recognition. Depressedelderlymayhavechangesinexecutivefunction, attention deficits,and decreasedprocessing speed10; itis believed thatthese changesmay consequentlyimpair the communicativeperformanceofelderlyhearingaidsusersin difficultlisteningenvironments.
From the findings of this study,it is believed that the applicationofaspeechinnoiserecognitiontestcanbean importanttooltohelpmonitorthebenefitsofthe adapta-tiontohearingaidsintheelderly.Intheexaminationofthe elderly population withhearing loss, it is difficult tofind completelyhealthyindividuals,soitisappropriateto inves-tigatetheinfluenceoffactorscommonlyfound inthisage groupthatmaynegativelyimpacttheauditoryrehabilitation process,suchascognitivedeclineanddepressivesymptoms.
Conclusion
Levelofeducation,cognitiveperformance,anddepressive symptomsinfluence the recognition of speechin noiseby elderlyhearingaidusers.Thehigherthecognitiveand edu-cational levels,the better wasthe speech recognition in noiseperformanceintheelderlyhearingaidusers.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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