Using The Cognivue Screening Test to Navigate Cognitive Dysfunction

[Jed Grisel MD]
And that's kind of an interesting challenge because it's not in our scope of practice either within ENT or audiology. To be diagnosing dementia. I think this is a really important thing, and some of the people that are skeptical with doing cognitive testing in the office, they're like, well what if we find a patient that has a deficit, what do we do then? And it's very nerve-wracking for the audiologist. And so what we're finding is that there's a small percentage of patients that have normal cognitive function and they have hearing loss. Okay. And so those patients, obviously we treat their hearing loss and that's fine.

And then there's a group of patients who, most of our patients, because we only do this cognitive screening on patients who are considering an intervention. So most of the patients, they have some level of hearing loss and they have some level of cognitive decline, they're performing that well, that's most of our patients. And so the first thing that we do is we know that hearing loss and cognition are related through a lot of different studies. And so we treat that, we treat their hearing loss then, and then post-intervention. And our definition of post-intervention is 60 days for a hearing aid and six months for a cochlear implant. So post-intervention, we do another assessment. If the patient's cognition has improved then great. The patient’s excited, we've reduced their cognitive load. They can perform mental tasks on a daily basis better. And everyone's happy. If they struggle, then we have a list of health problems that can present as cognitive impairment and it's like a form letter and we send that to their primary care physician. And that form letter, it's got, thyroid dysfunction, depression, interestingly can present as mild cognitive impairment. There's a whole list of these. But also polypharmacy. If you look at the list of medications that can cause cognitive impairment, I mean, it's a lot, we'll just say. So we created a list of the most common of these. And if at the very minimum we help the patient go to their primary doc and clean up their meds so that they don't have quite this problem with polypharmacy, then I think we've done good for this patient, you know?

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[Walter Kutz MD]
Yeah, Jed, what automated machine do you use for the cognitive screening? What's the name of it?

[Jed Grisel MD]
The name of the device that we use is called Cognivue. This is a company that has been around. I mean, so the technology has been around for a long time. It was actually some NIH work that created the science behind the testing. And then only in the last couple of years, has it been commercialized.

And so this is, it's like I mentioned, it's sort of a kiosk format that the patient sits in self-administered and it's, it's what they call adaptive. And so what that means. The first couple of Cognivue tests are learning how the patient is going to respond. So it checks their dexterity and their vision. And if they are not performing well, then the test gets easier. Like when it actually gets to the real cognitive test. And if the patient is knocking it out of the park then the tests is harder. So it's like adaptive to meet the needs of the patient and there've been multiple studies validating this test in multiple ways, from a test retest reliability to comparing it to other validated measures on the market. And so it's kind of a big player in the cognitive screening arena.

[Walter Kutz MD]
Yeah, let's talk a little about the patient, with more severe to profound hearing loss, maybe they have early dementia. and then the family comes in and then you're talking about, “Hey, your loved one,” or you’re talking to the patient, “you're probably a cochlear implant candidate at this point.” And then there's some worry about general anesthesia and, worsening dementia by undergoing general anesthesia. And then you kind of balance that with placing a cochlear implant. And we know that patients with dementia probably are not going to have performance that someone without dementia is going to have with a cochlear implant.

How do you discuss that with a family? That's always a tricky topic. I think.

[Jed Grisel MD]
I think it is a really tricky topic. And, like in the Lancet study, which was this big study that showed all of these different modifiable risk factors for dementia. It showed that controlling for hearing loss was the modifiable risk factor was the most impact on dementia development.

Now the problem with that was it, it wasn't really getting causal relationships. And also that study was talking about treating hearing loss in midlife. Forties fifties, sixties, not late life. So I mean, probably if somebody comes in with profound hearing loss and dementia, you're going to help that patient with sound awareness and with communication ability. But whether you're going to reverse those is a challenge. But then the other topic comes in is when a patient's sitting there and they're not engaging their environment, how much of that is cognitive dysfunction and how much of that is they can't hear. And teasing that apart is difficult for patients.

And so we're working on a study right now where kind of a clinical evaluation of us and two other sites where we're trying to look at like, how do those things tease out? And one of the things we've noticed is that what we're starting to learn is that, if a patient has poor cognitive function, preoperatively, well, let me tell you the other way, if the patient has good, cognitive function, preoperatively, we have high confidence that we're going to help you here in quiet. And we're going to help you here in noise. But now we know it's like helping us preoperatively define those patients. And so we say, look Mrs. Jones, or whatever, your family members, we're going to help you. You're going to hear, you're going to detect sound better, but we need to be prepared that you might need remote mics. You might need auditory training. We need to throw the kitchen sink at you because you're one of these patients that may have, we may not have all of those skills.

So then it's not that we're not going to implant that patient, but it's a totally different preoperative counseling discussion. We definitely feel good about that patient. Anybody could implant that patient and they probably aren't going to need a lot of aural rehab and they're going to do well. Right? So it's like, yay. We can all celebrate if the patient comes in and they're a cochlear implant candidate, but they have poor cognitive function, what we're seeing is that we're doing a good job of improving those patients' audibility. So there are CNC and they're hearing it quiet is getting better, but they're hearing in noise it struggles. So cognitive testing has become an integral part of our CI process.

[Walter Kutz MD]
Yeah. I mean, that's excellent, I think with cochlear implants and a lot of things we do it is all about expectations. And if you don't set those expectations at the initial visit and before surgery, it's going to be very difficult to explain why this Mrs. Jones isn't doing as well as the family or Mrs. Jones may have thought she's doing, so that's a great point.

And most of these patients that we're going to implant, they're going to have severe to profound loss. And in general, we're not taking away a lot of functions. So this a surgery you and I do a lot in, and it's very established, safe surgery. So I think setting the expectations is critical, especially in the patients who already have some cognitive decline and we've seen that really helped these patients in practice, but just setting the expectations that they are not going to be a superstar, cochlear implant user.

[Jed Grisel MD]
Yeah. And I think that it's much easier to have that discussion beforehand. And then afterward, they may not be performing the way that other patients are, we are like, “Remember we talked about this.” And so we're going to do that. And that's a much easier discussion than them expecting to be doing everything like normal, and then they're mad at you, you know? So it gets help in that regard for sure.