Sound Advice on Diabetes Management and Hearing Care

Unravel the intricate ties between diabetes and hearing health with Dr. Kathy Dowd of the Audiology Project, our esteemed guest who brings a wealth of knowledge to the table. Your understanding of the critical interplay between chronic disease management and audiological care will be forever changed as we dissect how diabetes can precipitate auditory and balance disorders, and why managing this condition is essential for maintaining good hearing.

Throughout our discussion, we shed light on why simple hearing screenings fall short for diabetes patients, particularly those who are insulin-dependent, and the profound consequences of functional hearing loss that go undetected. Dr. Dowd champions the importance of regular, comprehensive audiometric evaluations. We also tackle the broader social implications, such as the effects of untreated hearing loss on social isolation and overall quality of life, underscoring the necessity for awareness and proper health care protocols.

Our conversation takes a poignant turn as we tackle the challenges faced in skilled nursing facilities, from the mismanagement of hearing aids to the need for thorough cognitive and audiometric evaluations. The impact of early dementia diagnosis and the role of audiology in improving patient outcomes highlight the episode's commitment to enhancing the quality of care. As we express gratitude for Dr. Dowd's dedication to bridging the gap between diabetes care and audiology, remember that this episode is not just about education—it's a call to action for the health of our ears and minds.

Transcript

Dr. Douglas L. Beck: 0:06

Hi, this is Dr Douglas Beck and you're listening to the Hearing Matters podcast. My guest today is Dr Kathy Dowd of the Audiology Project. Dr Dowd started the Audiology Project about 2016 or so and they've been focused on hearing healthcare as it relates to hearing imbalance diagnostics, disorders and outcomes in people with diabetes, so we'll be speaking about that in some depth today. Dr Dowd has been an audiologist for 46 years. She's worked in schools, nursing homes, medical clinics and she collaborated on the CDC guidelines for hearing imbalance, as well as studying and working to educate all of us on the impact of chronic diseases on hearing imbalance. So, without any further ado, it is my pleasure to introduce Dr Kathy Dowd.

Dr. Kathy Dowd: 0:57

Thank you so much for inviting me, Doug. I appreciate it.

Dr. Douglas L. Beck: 0:59

Glad to work with you. Why diabetes healthcare? What does that have to do with audiology?

Dr. Kathy Dowd: 1:06

It has a lot to do with audiology, but we may not know that. In 1995, I got a Medicare audit and they were very clear you have to have medical necessity for any tests that you do. So that includes illness, injury, trauma or complaint. So I did a deep dive at that point and there's a lot of chronic diseases with research already done that connects it to hearing loss or to auditory processing or to balance problems. So I never really did much with that until 2011 when my mother-in-law was diagnosed very late in life with diabetes and I was at her assisted living with another family member who's the head of the diabetes program in a state agency and I said we have to keep a closer check on her hearing. He said I've never heard of that before and I said who gives you your information? He said well, the American Diabetes Association and CDC.

Dr. Kathy Dowd: 2:11

So that's when I reached out, 2011 in the fall, to CDC and it just kind of evolved with a phone call in 2011 with Dr Pamela All-Weiss where she said none of my colleagues and I have never heard of this before. I started sending her a bibliography on all the research and it just went quiet for a few months and then she sent back research that CDC had sponsored. So it just moves so slow because it wasn't until 2016 that she said we're going to go ahead and make a recommendation that people will see a hearing specialist, and that's when I tried to flip it to audiologist so right, Right, well, so this is really a little bit overwhelming when you think about it, right?

Dr. Douglas L. Beck: 3:01

So we're dealing with the CDC 2011. We have the internet. The internet existed, and yet their own people are not connecting the dots between hearing loss and diabetes. Let me give a quick tutorial here. Why diabetes and audiology? So I was just reviewing some of my old notes and maybe they're out of date, but so diabetes is essentially too much glucose or not enough insulin.

Dr. Douglas L. Beck: 3:26

Insulin, of course, is a hormone that carries blood sugar, glucose to create energy, remember the Krebs cycle and all of that stuff. So diabetes, though when you have diabetes, that means that glucose, blood sugar, is not getting to all the organs, the blood vessels, the sensory system, the nerves, and so we have quite a bit of degradation that can occur. And, kathy, one of the things that you wrote about was the microvascular changes, and you were talking about that. With regard to I think you were talking about the inner ear, the primary artery is, of course, the labyrinthine artery, and when you have these diabetic changes, of course that artery the one that supplies the inner ear as far as hearing suffers and you get pretty much hearing loss as a result of having a lack of blood sugar getting to the inner ear. Is that right?

Dr. Kathy Dowd: 4:17

I'm not sure exactly what changes in the cochlea with the two clear fluids, the endolymph and perilymph in the cochlea. But if that's compromised at all with this microangiopathy, which is a disruption in the small blood vessels where they leak blood into surrounding tissues or they grow new tendrils, you can see it very clearly with diabetic retinopathy Because you can look in the back of the eye and see that disruption. We don't have the ability to look in that bone and see in the cochlea exactly what's happening and these are microvascular changes.

Dr. Douglas L. Beck: 4:54

They're really really tiny and they're hard to visualize, if not impossible. And then, of course, there's two types of diabetes. We should talk about type one and type two. Type one is about 8% 10%, and that would be when the body, in particular the pancreas, does not create insulin, and some people think of that, and I think of it, as an autoimmune disease, also called juvenile diabetes in some circles. And then you have type two, which is the one that is associated with obesity and overeating and lack of exercise and all of that stuff. That's called type two, and in that one the pancreas does not create enough insulin and again, insulin is a hormone that transports blood sugar throughout the body. So when we're talking about type one and type two diabetes, again type one is roughly 8% to 10%. Type two is probably 90 to 92% of all diabetes that's diagnosed. Is the hearing loss, the vestibular changes. Are they different in type one or type two diabetes?

Dr. Kathy Dowd: 5:51

From what I understand, it's the same. It still impacts hearing in the same way, and you can get a low frequency hearing loss. You can get a high frequency hearing loss if you don't manage and control your A1C or your glucose sugar level. So that's why diabetes education is really really important for persons with diabetes, so they can learn more about what to eat, how to exercise, how to take their insulin, how to measure if they need to take medicine. So that's very, very important. But I think it affects both. And, for hearing, you can get a high frequency hearing loss. You're not going to know if there's a problem unless it's tested. I mean, you can't look at somebody and say, oh my God, I think your hearing's going down. I can see it in your face. You can't do that.

Dr. Douglas L. Beck: 6:45

You talk about low frequency hearing loss. My experience with diabetic patients goes back about 30, 35 years. I was at St Louis University and I was very fortunate. I was on the medical school faculty with brilliant, brilliant researchers and clinicians. Dr John Gladney was the chairman just before I got there. Dr John Gladney is a very interesting fellow because he was the first black chairman of the Department of Otolaryngology had neck surgery, I think in the US. I'm pretty sure that's true. Then John, as he was retiring, was replaced by Dr Michael Mades. Michael Mades went on to be the American Medical Association president and Michael was my chairman. John Gladney was still in the department when I got there.

Dr. Douglas L. Beck: 7:27

John said to me one day I'd really like to explore the audiology associated with diabetic care. As a nodular oncologist he had noticed for decades that his diabetic patients I had generally and the majority of them would have mild to moderate sensory neural high frequency loss. So we didn't see that much in the way of low frequency loss. I don't doubt that. But then I started looking for it and for about six months to 12 months we were working with the Department of Endocrinology, which was a floor below us, and they were managing diabetic patients. So we did a study where the diabetic patients who were insulin dependent would come up and see me. I would do an audio in depth, not just airborne and speech, but we would do speech and quiet speech, noise, reflexes, temps, all of that stuff.

Dr. Douglas L. Beck: 8:18

John Gladney and I presented that paper in 90 or 91 at the American Academy of Otolaryngology had neck surgery in San Diego, actually I think it was. What year would that have been? 90 or 91, I think is when we presented that. So we've known about and that was the American Academy of Otolaryngology, so we've known about this stuff for a long time. But we've been very bad at disseminating this information through to physicians and to patients. Because if the patient says I've been treated for diabetes, I am insulin dependent, I would like an audiologic evaluation.

Dr. Douglas L. Beck: 8:53

Don't ask for screening. The screening isn't going to tell you squat. Screenings need to go away. The only screening that I endorse is the newborn infant hearing screening. Very, very important. You cannot replace that. That is invaluable, but hearing screenings almost silly. What we need to do is get an in-depth analysis. We need to do the entire comprehensive audiometric evaluation. That's where we're going to find the problems.

Dr. Douglas L. Beck: 9:20

In fact, in the USA right now it's 2024, there's 335 million people in the USA. 38 million have hearing loss on an audiogram, but there's another 23 to 26 million who have no hearing loss whatsoever, but they have listening disorders. They have problems understanding speech and noise. They cannot understand what was just said and they may or may not. Well, there's 23 to 26 million don't have any hearing loss. They have what's called functional hearing loss or subclinical hearing loss or super threshold listening disorders.

Dr. Douglas L. Beck: 9:51

I suspect that a lot of people with significant diabetes who are insulin dependent you're going to see it there first. You're going to see that they have speech and noise problems. They can't tell exactly what somebody just said, and that'll show up before hearing loss. I think that that's going to be true because we've seen that already in noise-induced hearing loss, where we have veterans who come back from battles, who complain about tinnitus, which is ringing in the ears or having a hard time understanding speech, and then a few years later their audiometric profile, their hearing loss does develop. But we also know that if we detect it and treat it early, we can improve the quality of life of those people. That's a little bit off topic, but your turn Okay. So let's go back to diabetes in particular, but this is why I recommend the Complete Audiometric Evaluation.

Dr. Kathy Dowd: 10:38

Well, and you're right, in line with CDC, because what the recommendation is for the guidelines is you get a baseline audiological evaluation at the time of diagnosis and then annually thereafter. They don't talk about screen first and then refer. That's a speech therapist's role. But for diabetes you just do an audiological evaluation whether you think there's a problem or not, and so trying to evaluate if you think somebody has a problem in advance of referring, no, just refer, that's it Right, and this is the old medical school I mean, I taught at medical schools for decades and diagnosis first, treatment second.

Dr. Douglas L. Beck: 11:24

You're not going to get a diagnosis if you're doing a screening that can't capture the information. You have to dig deeper. You have to see the entire audiometric profile to see are the reflexes normal? Is the patient able to understand speech and noise? Is their auditory system being compromised when there's background noise? Can the patient understand into oral loudness differences, into oral timing differences? Is the head shadow effect obliterating their ability to understand? So these things are very, very important. But then we have the NCQA, which you told me about in an earlier discussion, which I found very frustrating. So the NCQA is the National Committee for Quality Assurance and my understanding is they are the ones who essentially write the guidelines for physicians.

Dr. Kathy Dowd: 12:03

So physicians say we have this You're going to be certified by NCQA. Not every physician wants to be certified by them, but it is a kind of a gold badge that you're looking out for diabetes, for heart issues and that sort of thing, yes, yeah, but the NCQA guidelines don't mention audiology.

Dr. Douglas L. Beck: 12:23

Or am I wrong on that?

Dr. Kathy Dowd: 12:24

No, you're correct. And in 2014, I went to my Welcome to Medicare visit with my doctor and I said why are you not I was still in practice why are you not referring your patients with diabetes to me? And he said well, hearing aids are too expensive.

Dr. Kathy Dowd: 12:41

I said well, they're not all going to need hearing aids. Yeah, so you can't ignore it, it's just part of life. But so when he said if it was on the NCQA list, I'd have to do it, I reached out to NCQA and they basically and I'd had conversations with them back in 2014. And they said, no, no, there's nothing about that. If we had information about that, we would look at it, but nothing is on that. So I tried sending them information, but then the door closed.

Dr. Kathy Dowd: 13:11

And even now that we do have CDC guidelines and I have a huge bibliography on the effects of diabetes and other chronic diseases which I've sent to them and there was some intimation that they were going to add it. But again, even in the very beginning, there's a very well-known physician who, when I mentioned this to him early on, he was on the American Diabetes Association Board. He said, oh, that's just too much. You just don't understand. Patients with diabetes have a lot of things they have to take on and you're going to expect them to do this hearing. I said, yeah, but I do understand. I did join a listserv for persons with diabetes and I watched their conversations.

Dr. Douglas L. Beck: 14:06

They do have a lot on their shoulders, but communication is primary and if they don't have the ability to communicate effectively and easily, the quality of life declines substantially and rapidly. This is the thing. Right is, when you have a chronic condition and you can't communicate well, you become socially isolated. When you're socially this is not new the Surgeon General for the USA. He said six months ago that we actually have and some people will snark at this, but we have a loneliness epidemic. People in the USA, we have more people living alone than ever before. We have more people in poverty. We have a loneliness epidemic. That's the Surgeon General of the United States of America. That's not some crazy person who doesn't know what he's talking about. That's a well-informed, knowledgeable, very bright person saying loneliness epidemic. So what does that mean? Well, that means we're socially isolated, that means the quality of our interactions is depressed. That means we're depressed, that means we're anxious, that means we're lonely and that means that the quality of life for many Americans is not very good. And it's even worse when you have a chronic condition, such as diabetes, and you can't expressively or receptively communicate.

Dr. Douglas L. Beck: 15:18

But you did mention you know your bibliography and I think this is very important. If you go to the audiology project and I was looking at it this morning. Here's a list of some of the papers and I'm not going to read all of them, but epidemiology of diabetes and hearing loss is there? Hearing loss associated with diabetes CDC 2009 is there? Diabetes mellitus Dr Parker article in audiology practice is at the audiology project.

Dr. Douglas L. Beck: 15:43

What you need to know hearing and vestibular consequences of diabetes. And, to be clear, diabetes does not just impact the hearing end of the auditory system. It is vestibular and it can impact tendons as well. Diabetes and the auditory vestibular pathology. By Spankovich and Alangavan I'm not sure that I said Alangavan correctly, but I know Chris Spankovich and I know I said that one correctly Audio vestibular functions of non-insulin diabetic patients Research article falls in balance with type 2 diabetes research. So my point is that all of these are available at the audiology project and I hope that people will go there and read about this. Because diabetes when you have diabetes I think I read from the American Diabetes Association If you have diabetes, your chance of hearing loss is twice what it is if you don't have diabetes. Is that correct?

Dr. Kathy Dowd: 16:31

Well, on a Medicare data pool that Ian Winmell and Barry Freeman did, it shows up as about 30% incidence of hearing loss with diabetes, and that's exactly what Catherine Bainbridge found with her research on the NHANES study back in 2004. It was about 30%. So I think we're tracking pretty much the same. Now, if you have multiple chronic diseases, that's going to increase the incidence of hearing loss. One thing to mention, other than the microangiopathy, is that there is neural degeneration, so the myelin sheath of the eighth nerve, which attaches to both the balance system and the hearing system, is disappearing. In addition to the microangiopathy, the disruption of the blood vessels leaking blood into the clear fluid of the brain. I mean that has to have an impact on the auditory signal and the vesticular system signal.

Dr. Douglas L. Beck: 17:28

Yeah, yeah, absolutely. I'm really glad you mentioned that. What I'd like to do because I know we have limited time, kathy, and I appreciate your time with us I want to switch gears a little bit and talk about cognition and skilled nursing facilities and audiometric evaluations, and I know this is a topic you've been on top of for a couple of years now because of state association issues, but I think it's bigger than that. I was looking up. I wrote an article just this past year on hospice and the need for audiology and hearing health care in hospice facilities. I'm not going to go into that article right now, but a lot of this overlaps with skilled nursing facilities, even though you know different diagnosis, different outcomes. But in general, I think the point is that older people who are in care facilities and who need additional care are not necessarily getting that care as well as those of us not in those facilities might think.

Dr. Douglas L. Beck: 18:25

Listen, that work is incredibly difficult, that work is very stressful. It's very trying, horribly difficult to take care of another person when they're ill. That is without a doubt. But when you're looking at skilled nursing facilities and there's about 15 to 25,000, I looked online a few days ago and it just depends whose estimate you want to use. So let's say that there's 20,000. 71% of them are for profit, which means about you know, 29% are not for profit and the individuals own about half of them and organizations own about half. So that's all fine. But the average cost to be in a skilled nursing facility in the USA right now is about $8,000 a month. So, supposing that you go into a skilled nursing facility, are there any physical entrance evaluations that happen or are supposed to happen?

Dr. Kathy Dowd: 19:12

Yes, there is a federal law that was written in 1987. It's called the Omnibus Budget and Reconciliation Act of 1987. What that says is the facility, within four days of admission, must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. So, in addition to their capability to perform daily life functions and significant impairments in functional capacity, I mean it's very, very targeted. And then some states, like I'm in North Carolina North Carolina says within two weeks you must have a hearing assessment.

Dr. Douglas L. Beck: 19:55

It's not happening. Let me go back with you. Just, the federal law says that you must have an overall assessment, but it didn't specify audiometric evaluation, right?

Dr. Kathy Dowd: 20:05

It does specify hearing further down. Yeah, what assessments you need to do? Now, in talking with CMS about this, basically what I was trying to let them know is they developed a CMS MDS hearing assessment, which is a minimum data set hearing assessment, so they call it a hearing assessment. It basically is, though, the assessment nurse going to the resident and saying, hi, mr Smith, can you hear me? Okay, and so one-on-one, face-to-face, in a quiet room, he probably says, yeah, here, you're pretty good, and then they're off. And if he doesn't respond, then they say, oh, he has a cognitive issue.

Dr. Douglas L. Beck: 20:48

So we're jumping to an assumption, a cognitive assumption, without a cognitive screening or a cognitive diagnostic test. We're ignoring the hearing loss. This reminds me so much and I've shared this with you before. But I got out of the Air Force 51 years ago and I remember when I went into the Air Force I was at Houston Street with the rest of the world pronounce it like Houston, by the way heads up New York. But I went to Houston Street and I did my intake there and you had to do a physical and so I was 1A, so I was draft material and a long story.

Dr. Douglas L. Beck: 21:20

I'm not going to go into that. But the physical was amazing. I walked in, I sat down on the Group W bench that's a shout out to Arlo Guthrie and I'm sitting there on the bench and this guy comes up to me wearing like a white lab coat and he says a Douglas bag, and I said yes, and he said which door did you come in? And I said I came in from that door over there and he said oh okay, hearing, normal vision, normal tactile I mean that's what you're saying is going on at skilled nursing facilities. I mean there's not a formal or an appropriate assessment, which happens more often than not. Is that true?

Dr. Kathy Dowd: 21:56

Well, the minimum data set. Now CMS did last fall send an email to Senator Burr's office and said, first of all, yes, we're very aware of Kathy Dowd and what she's doing, but they said the minimum data set, the MDS, requires a subjective hearing screening to determine if additional hearing screenings or interventions aimed at enhancing communication and care are needed. So what they're doing is kind of backpedaling. It's not really a hearing assessment, it is a subjective observation. Basically is what they said.

Dr. Douglas L. Beck: 23:20

So I guess my question is you know, and I don't mean to make fun of them If they're doing a great job, then they deserve kudos. That's due and I'm respectful of that.

Dr. Kathy Dowd: 23:28

Let me read you one more thing from CMS. So it says the MDS is not a tool to test hearing, nor is the MDS designed to define professional guidelines or care standards. We note that every professional providing services in nursing homes must adhere to the standards of care defined by their profession and requirements of their licensing body, which is outside of the purview of CMS.

Dr. Douglas L. Beck: 23:55

That's fine, because AAA and the American Academy of Audiology, American Speech Language Hearing Association, the International Hearing Society, would say that adults should have an audiometric evaluation, which is not, you know, a screening, it's a comprehensive audiometric evaluation, which is exactly 92557 in Medicare speak right, that's the CPT code for comprehensive audiometric evaluation. When we're doing screenings, we're not going to find these subtle microvascular changes until they're very significant. We want to catch them earlier. So then maybe we can give a shout out to the attending physicians and say hey, listen, we're seeing a mild to moderate sensory neural high frequency loss in this patient, and he or she is not complaining about hearing loss yet because they are not able to yet detect it in their own life, but we're detecting it. So maybe we have to address that as far as their insulin care or their diabetes or their exercise or their diet or something else.

Dr. Kathy Dowd: 24:49

Yeah, you can only expect what you inspect, and so if you don't inspect the hearing, you're not going to have an idea. And the person themselves has anisognosia, the true neurological deficit, where they deny that they have a problem.

Dr. Douglas L. Beck: 25:05

You know this is an important point is that many people with hearing loss have no idea they have hearing loss. So audiologists, hearing and dispensers or the learning colleges see this every day. We do tests on people. We say you have a mild to moderate high frequency loss. We say you have a ski slope loss, which is a precipitous sensory neural high frequency loss. We say A, b or C and they say well, no, I didn't. I have no idea that I had hearing loss. Of course you didn't, because you can't hear what you can't hear. You can't, for instance and you know, I'm colorblind there are certain colors I can't see, and I didn't know about that until I was an adult. Because how would I know what I can't see, right? And so the whole idea that a subjective hearing analysis is enough. I want to know in what other area of medicine would they permit that sort of laissez-faire attitude?

Dr. Kathy Dowd: 25:54

Well, what I explained. When I had the meeting with the CMS Division of Nursing Home Triage team and they were like six nurses I said would you do that for blood pressure? Would you look at somebody and say, oh my God, you look like your blood pressure is fine, I'm going to take you off your medicine? No, you have to put an objective blood pressure cuff on and take the reading. Or would you look at somebody and say, oh, I think your A1C is high, I'm going to double your medication without taking a blood sample to measure what their A1C is? I mean, that's crazy ludicrous.

Dr. Douglas L. Beck: 26:29

And it's 2024. And you know, we know that there are physical issues, right when we have, you know, number one killer is a court heart disease. Number two is cancers. Number three, you know, I've seen Alzheimer's in the number three spot, but I've also seen COVID in there, so it. But the point is, yeah, these are physical disease processes, and hearing loss is not necessarily a disease, but it's degenerative, and hearing loss will impact your ability to communicate. And so are we only concerned with the physical well-being, or should we start to concern ourselves as well with psychological, emotional, cognitive well-being? Because these people that you're talking about, in particular people with diabetes, people in skilled nursing facilities, they're compromised. That's part of who they are. They are compromised medically, health-wise, psychologically or whatever. And then when we deny them communication, diagnostics and treatment, we're just making it worse.

Dr. Kathy Dowd: 27:32

Well, what happened in 2019, and I don't know what brought this on, but CMS heightened awareness and services for cognitive issues in nursing homes.

Dr. Douglas L. Beck: 27:44

Right, so you would think that would be attended to. So what did you actually tell us?

Dr. Kathy Dowd: 27:47

Well, and so what happened is speech therapists jumped all over it. They call it cognitive communication evaluations. Now, speech therapists, their professional guidelines state that they should screen hearing, and if they're unable to screen hearing before they do anything else, they're supposed to refer. That's fallen apart. Let me read to you what a speech therapist said to a medical director they use gross. This is what they told the medical director. They use gross screening on their assessments. None of them, to my knowledge, uses a formal tool for screening. They all liked the audiology project screening tool but admitted they wouldn't use it and would commonly refer out for formal testing if their gross assessment demonstrated a deficit. So this thing about gross assessment, I'm sure is a subjective observation. You look like you have a hearing problem. I'm going to refer you. Well, you don't see it until it becomes severe.

Dr. Douglas L. Beck: 28:53

Of course. I mean, why would you do a gross assessment? You have cognitive view thrive. You have the mini mental state exam, you have the Montreal Cognitive Assessment, you have the St Louis University Mental Health Scale the slums. You have all of these and some of them are free. You can get them online, and yet people are subjectively evaluating somebody else's cognitive ability. I don't understand that and I don't think that's appropriate medical care. It's certainly not the best medical care In my own brain.

Dr. Kathy Dowd: 29:21

it is fraudulent, it's egregious that they're doing this and it should not be happening.

Dr. Douglas L. Beck: 29:28

Which gets us back to diagnosis first, treatment second, I mean, if you're treating the patient, you're doing cognitive rehab or something like that and yet you don't have a cognitive diagnosis, that might be something that should be flagged. I mean, maybe before we do cognitive rehab we should make sure the person actually has failed a cognitive screening and has gone on to have a discussion with a physician who hopefully has ordered a cognitive diagnostic test on appropriate patients. Because we do know that, according to the GEMMA, the Journal of the American Medical Association, when you hit age 65 in the USA, about 22 percent of those people are going to have mild cognitive impairment 22 percent of Americans over age 65. By the time you hit age 85 in the USA, one out of three people has Alzheimer's. Dementia is a huge topic because right now, globally, we have about 55 million people with a diagnosis of dementia, but by 2050, in a mere 26 years, there will be 150 to 160 million people with dementia. And when we say dementia, we are talking about Alzheimer's, we're talking about frontotemporal disease, we're talking about people with vascular dementia, parkinson's. With dementia, we're talking about Lewy body disorders. These are people above and beyond mild cognitive impairment, and it's so important to diagnose this early, because the only time that we can really really really impact the trajectory in a meaningful way thus far is going to intervene at mild cognitive impairment.

Dr. Douglas L. Beck: 30:58

Now, if you go back to the Lancet study of 2020, gil Livingston and colleagues are about 25 co-authors. They said what is your chance of having dementia? And the answer to it in 2020 in the Lancet was this the number one and two cause of dementia is aging and your DNA, your deoxyribonucleic acid. You can't change any of those. But then there's 12 potentially modifiable risk factors. Of those 12 potentially modifiable risk factors, hearing loss was number one. So their point was if we were to intervene early when somebody has mild cognitive impairment and we intervene on all 12 of these factors, and these include factors like air pollution, drug abuse, alcoholism, social isolation. We talked about that earlier today.

Dr. Douglas L. Beck: 31:43

Hearing loss. What didn't make the list, which is really interesting, is vision loss, because we know that visual loss also is a significant potential factor in dementia, and I did a series of interviews with Dr James Galvin. He is a neurologist out of Florida, one of the Lewy body experts in the world, and he was saying those 12 modifiable risk factors are brilliant. That's not all, there's more, and he brought vision to my attention. Now in audiology we've known about vision because of the work of Pierce Dawes and his colleagues, where he talks about not just auditory attenuation but he talks about bimodal. So you have auditory and visual problems which increase your risk of dementia even more.

Dr. Kathy Dowd: 32:28

And you can understand 30% to 40% better if you can lip read. So during COVID, when everybody wore masks, I mean that was a huge issue, but just making sure the person and that may fall on audiologists if we ever get into skilled nursing facilities Right now they're holding us off. They don't. In fact, this same doctor told me that if people come into his facilities with hearing aids, the staff, the nurses, are sending the hearing aids home with the family because they don't want to lose them and I just it's like a stab in me in the heart. You can't do that.

Dr. Douglas L. Beck: 33:06

What do they do if the patient comes in with oxygen tanks? Oh my gosh.

Dr. Kathy Dowd: 33:12

I know that makes too much noise, let's get rid of it. It's like the same thing with glasses. They worry about having to take care of the glasses, but regardless, we can fix that. I mean, when I worked in nursing homes I trained them, I helped them troubleshoot and learn what they needed to know and we have to be out there at least on an annual basis to monitor.

Dr. Douglas L. Beck: 33:37

They may have a sudden sensory neural hearing shift in just from medication earlier than that and hopefully they'll report it, but the idea of taking their hearing aids because they might get lost is ludicrous and it's cruel and unusual.

Dr. Kathy Dowd: 33:50

It's a violation of ADA, basically.

Dr. Douglas L. Beck: 33:53

Yeah, I'll bet. And the thing is right, these people need these hearing aids. That's why they're wearing them. Far more people should be wearing them than are wearing them. And you're sort of penalizing that guy who went out, raised his hands, that I have hearing loss, I paid for hearing aids or I got them through whatever, and now you're taking them because I'm in your facility so I can't communicate. So that's great, but listen, kathy, it's been a joy.

Dr. Douglas L. Beck: 34:18

I love our discussions because I always learn so much. Number one, but I think that you are very elegant and eloquent and you just you speak from knowledge and authority and I'm just a crazy person. But I love speaking to you because I learned so much and I think this is so important that audiologist, hearing aid dispensers, otolaryngologist we got to get more involved with diabetes because it's a very, very common health problem. In the USA it's certainly within the top five or top 10. And yet most of us, when we have diabetes patients, we don't dig deeper. You know we might just do that pure tone screening and that's not enough. All right, well, listen, I want to thank you for your time. We wish you a joyous day and thank you for the fights that you fight, and I should also mention that, for those of us who are fans, you can go to the audiology project and you can donate some cash, which is always useful because the fine work with Dr Dowd and Alex do so. Thank you very much, dr Dowd.

Dr. Kathy Dowd: 35:13

I wish you a joyous afternoon. Appreciate it, Dr Beck.