Presbyacusis aspekter avseende epidemiologi och kognition Ulf Rosenhall
db HL db HL khz 0 0.25 0.5 1 2 4 8 20 30 Hur hör vi i Sverige? 20 40 60 80 40 50 60 70 70 75 80 85 Johan sson & Arlinger, 2002 L,R Jönsson & Rosenhall, 1998a,b, L 2 epidemiologiska us. Kvinnor och män, 20 till 90 år gamla 100 Men, 20-90 years 90 khz 0.25 0.5 1 2 4 8 0 20 20 40 30 40 50 60 Johan sson & Arlinger, 2002 L,R 70 60 70 80 75 80 85 Jönsson & Rosenhall, 1998a,b, L 100 Women, 20-90 years 90
Åldershörselnedsättning Presbyacusis Age-related hearing loss ARHL el. ARHI Förekomst? Orsaker? Åtgärder?
db HL Three Swedish Epidemiological Studies db HL 1)The Gerontological and Geriatric Population Study in Gothenburg: H70 (1971-2005) 2) The Study of Men born in 1913 and 1923 (1973) 3) Health and Psychosocial Work Conditions in Middle Aged Women (2005) 0 20 40 60 80 100 khz 0.25 0.5 1 2 4 8 Women, 51.3 y Women, 70-90 y Left ear 3 1 0 20 40 60 80 100 khz 0.25 0.5 1 2 4 8 Men, 50 60 y Men, 70-90 y Left ear 2 1 50 60 70 75 79 81 85 88 90 Jönsson & Rosenhall 1998 Hederstierna et al, 2007 Rudin et al, 1988 Pedersen et al, 1989
db HL db HL 10 20 30 40 50 Men, L ear, 70-80/75 years khz 0.25 0.5 1 2 3 4 6 8 Gates et al. 1990 Davis 1995 Jönsson & Rosenhall 1998 Men and women, 70-80 y 5 epidemiological studies from Europe and USA Unscreened populations 60 70 Crui ckshanks et al. 1998 Engdahl et al. 2005 80 90 10 20 Women, L ear, 70-80/75 years khz 0.25 0.5 1 2 3 4 6 8 Remarkable good agreement between different studies from developed countries 30 40 50 60 70 80 Gates et al. 1990 Davis 1995 Jönsson & Rosenhal l 1998 Cruickshanks et al. 1998 Engdahl et al. 2005 90
db HL db HL Men, L/B ear, 80-90/85 years khz 0.25 0.5 1 2 3 4 6 8 10 20 30 40 Gates et al. 1990 Parving et al. 1997 Men and women, 80-90 y 6 epidemiological studies from Europe and USA Unscreened populations 50 60 70 Jönsson & Rosenhall 1998 Crui ckshanks et al. 1998 Hietanen et al. 2004 Engdahl et a. 2005 80 90 The prevalence of child and adult hearing impairment is substantially higher in middle- and low-income countries than in high-income countries, demonstrating the global need for attention to hearing impairment Stevens et al, 2013 10 20 30 40 50 60 70 80 90 Women, L/B ear, 80-90/85 years khz 0.25 0.5 1 2 3 4 6 8 Gates et al. 1990 Parving et al. 1997 Jönsson & Rosenhal l 1998 Crui ckshanks et al. 1998 Hietanen et al. 2004 Engdahl et al. 2005
db db 25 20 Ge nder Di ffe re nce, 70-80 years Gender differences 70-80 y, 80-90 y 15 10 Gates et al. 1990 Pearson et al. 1995 5 0 Davis 1995 Jönsson & Rosenhall 1998 Cruickshanks et al. 1998-5 -10 0.25 0.5 1 2 3 4 6 8 khz 25 20 Ge nder Di ffe re nce, 80-90 ye ars 15 10 Gates et al. 1990 Pearson et al. 1995 Parving et al. 1997 5 0 Jönsson & Rosenhall 1998 Cruickshanks et al. 1998 Hietanen et al. 2004-5 -10 0.25 0.5 1 2 3 4 6 8 khz
Hörselskadade i Sverige Självskattad hörselnedsättning (HRF/SCB) >1 milj. Beräknat antal med HNS enligt tonaudiometri Svår HNS dövhet ~130 000 Måttlig HNS (M4: 40-64 db): >0,5 milj. Lätt HNS (M4: 20-39 db): ~1,4 milj. 20-70 år 70+ 1/3 2/3 2/3 1/3 Totalt: >2 milj. Beräkning 2014
Antal svenskar med hörselnedsättning (tusental) Lätt M4 20-39 db Måttlig svår M4 40 db 0 20 år 43t 5t 20-50 år 229t 45t 51 70 år 629t 161t >70 år 474t 430t
Sveriges befolkning 31/12 2013
Sveriges befolkning 31/12 2013
Sveriges befolkning 31/12 2013
Ålder, år Beräknat behov, Hörselrehab 60 ~ 5% 70 10 20% 80 40 45% 90 60 70%
Andel av befolkningen i Sverige 2009 2015 2060 65+ 15% 17% 25% 80+ 4% 9% 65+ 2,7 milj. 2060
Sweden 2006 90y +70 y 70y 80y PTA +40 db More women than men have hearing loss 60y PTA <20 db PTA 20-39 db PTA 20-39 db PTA <20 db 50y Men 50+ 1.6 m Women 50+ 1.8 m
Vad händer med hörseln på lång sikt? Är hörseln konstant? Försämras hörseln? Förbättras hörseln?
Ökar eller minskar incidensen av hörselproblem? Den pessimistiska synen: Hörselproblemen ökar globalt WHO 2002-2030 DALYs (Disability-Adjusted Life Years) Adult onset hearing loss: 2002 ranking # 13 globally Year 2030 estimated ranking # 9 (2.5 DALYs) High-income countries # 7 (4,1 DALYs) Middle-income countries # 9 (2,9 DALYs) Low-income countries < #10 Mathers & Loncar, 2006
Percent The pessimistic view In the Alameda County Study prevalence rates of self-reported trouble with hearing nearly doubled from 1965 to 1994 Wallhagen et al, 1997 Increases in prevalence of hearing loss in adolescents from 15% to 19.5% from 1988 1994 to 2005 2006 NHANES Shargorodsky et al, 2010 Self-assessed hearing loss 1984-2005 Statistics Sweden, SCB Marke Trak VIII Kochkin, 2005 16 11.7 14 11.3% 12 10 8 6 10.5 % Women 14 % 9.9% 10.2% 10.8% 4 Men 2 Total 0 84-85 86-87 88-89 90-91 92-93 94-95 96-97 98-99 00-01 02-03 2004 2005 Year
The optimistic view Prevention NIHL prevention Vaccination programmes ARHL life-style factors Americans hear as well or better today compared with 40 years ago NHANES, NHES Hoffman et al, 2010 Persons from later birth cohorts had lower prevalences of hearing impairment than those from earlier birth cohorts Beaver Dam Study, EHLS Zhan et al, 2010
The optimistic view 75-year olds over three decades: No audiometric changes The Gerontological and Geriatric Population Study in Gothenburg, Sweden Rosenhall et al, 2013 db HL 0 db HL 0 10 Women 75 Right Ear 10 Men 75 Right Ear 20 20 30 30 40 1RE 40 1RE 50 2RE 50 2RE 60 70 4RE 60 70 4RE 80 6RE 80 6RE 90 0,25 0,5 1 2 4 6 8 khz 90 0,25 0,5 1 2 4 6 8 khz
Prevalence, % Förändras hörseln från generation till generation? 18-åriga mönstrande svenska män Prevalence any threshold >= 25 db HL any ear 3,4 or 6 khz 18 16 14 12 10 8 6 4 2 0 1971 1976 1981 1986 1991 1995 2000 2005 Year Både bättre och sämre (men mest bättre) HNS-prevalens 3-6 khz, något öra, 1971 2005 Muhr et al, 2016
18-åriga mönstrande svenska män Lätt, måttlig och svår HNS i diskantområdet 1971 2004 (-2010), ett eller båda öronen
Histopathology of ARHL Cochlear degeneration OHC degeneration in basal and apical coil IHC degeneration in basal coil Strial degeneration Alterations and derangement of hair bundles Intracellular inclusions
Types of ARHL 2 1 4 3 1) Sensory 2) Neural 3) Strial (metabolic) 4) Cochlear conductive 5) Mixed 6) Indeterminate uncommon, <1% PARAN Gates et al, 2000 hypothetical Schuknecht & Gacek, 1993
Woman 75 y Sensory type Schuknecht s classification Man 74 y Engström et al. 1987
Strial type Schuknecht, 1994 A reduction in the EP is presumed
Presbyacusis Woman 83 y Strial (metabolic) type Schuknecht s classification Presbyacusis Woman 67 y Gates & Mills, 2005
Presbyacusis Man 73 y Mixed: sensory + strial types Engström et al. 1987
Age, Cohort, and Period Effects
Causes of ARHL Intrinsic causes Age, Cohort Effects Biological ageing Biological ageing is probably only a minor contributor to ARHL of younger elderly people, but increases in importance in advanced age, 80+ Telomeres? Genetic factors Important contributors to ARHL Mutation in mtdna The 4,977-bp deletion Bai et al, 1997; Ueda et al, 1998
Genetic influences of ARHL in man ARHL has a multifactorial aetiology Familial aggregations occur for sensory and strial ARHL phenotypes Heritability: 35-55% (sensory type) The heritability estimate was greater for the strial than the sensory phenotypes Women: Genetic effect on ARHL Men: Mixed, genetically/aquired ARHL Candidate genes in man: 10q26, 11q13.5, 11q25 (DFNB20), 11p, 14q, 18q KCNQ4, DFNA18 Gates et al, 1999 DeStefano et al, 2003; Fransen et al, 2003; Garringer et al, 2006; van Eyken et al, 2006; a.o.
Genetics and ARHL Twin Studies Audiometric Study of Male Twins Variation in high frequency hearing is related to genetic and extrinsic factor. Heritability: 47%, 64+ years, men The environmental effect becomes more important with age Danish Twin Registry Karlsson et al, 1997 Heritability for self-reported hearing loss 40%, 75+ years NAS-NRC Twin Panel Christensen et al, 2001 Heritability: 60% (self-reported). HI susceptibility locus on chromosome 3, DFNA18 locus Reed et al, 2000; Garringer et al, 2006 Finnish Twin Study on Aging Heritability: >60%, measured hearing, 63-76 years, women Self-reported hearing related to environmental factors Viljanen et al, 2007
Causes of ARHL Environmental, acquired Period Effects Vocational noise exposure Ototoxic drugs Solvents, other chemicals e.g. carbon monoxide Traumatic hearing loss Infections Middle ear disease Heavy metals (Hg)
db HL db HL Noise Unscreened Men, 75 y (70-80 y) khz 0.25 0.5 1 2 3 4 6 8 Occupational Noise - No Noise Men, 70 y No Noise v s Occupational Noise The Göte borg Gerontol. Study 0 0 10 20 20 40 30 40 No Noise Noise +15y 60 Highly scr eened 50 60 n: 137 NN n: 100 N+15y Noise scr eened 70 80 Unsc ree ned 80 0.25 0.5 1 2 4 8 Compilation of 8 studies Highly screened for otological disease and noise (green) Screened for noise only (blue) Unscreened studies, noise exposed populations (red) khz No noise (blue) vs occupational noise (red) H70
Annual Decline, db/y LE Interactions between Noise-Induced Hearing Loss and ARHL 1,75 Noise and Presbyacusis Gates e t al., 2000 Additive effect (adopted by ISO 1999) 1,5 1,25 1 No Noise Less-than-additive effect Mills et al, 1996; 1998 0,75 0,5 0,25 0 0.25 0.5 1 2 3 4 6 8 khz Animal research indicates a sensitising effect of noise Kujawa & Liberman, 2006 Noise More-than-additive effect Miller et al, 1998 Combined effect Less ARHI in NIHL-frequencies (4-6 khz) Increased ARHI in neighbouring frequencies, - 2 khz Gates et al., 2000
Annual decline db/year Three longitudinal studies H70 Noise vs No Noise Hederstierna, Rosenhall, 2015 BLSA Noise vs No Noise Pearson et al, 1995 MUSC No Noise Lee et al, 2005
Causes of ARHL Environmental, extrinsic Life style factors Every day noise exposure Leisure time noise exposure, e.g. music, shooting Smoking Alcohol (severe abuse) Diet Physical fitness
Interfererande sjukdomar Kognitiva störningar Demens Metabolt syndrom DM2
AD: 3 10% - 65 y 25 50% >85 y
Hörsel och kognition hos äldre Presbyacusis interaktion med kognitiva störningar Lin et al, 2013; Lin & Albert, 2014 Positiv effekt av hörselrehabilitering vid presbyacusis och demens Amieva et al, 2016
Speech Perception, 20 % Speech in Noise Test 90 80 70 60 Age, Years 20 30 40 50 40 30 50 60 70 80 20 0 10 20 30 40 50 60 70 80 High Frequency Pure Tone Average, db HL Bar renäs, Wikstr öm 2000 Magnusson, 1996
Hörsel och kognition hos äldre Centrala auditiva störningar Central Auditory Processing Disorder (CAPD) CAPD har påvisats vid demens och vid impressiv afasi Gates et al, 1996, 2002, 2008; Idrizbegovic et al, 2011; 2013 Ramsing et al, 1996
Auditory function in early Alzheimer s disease and Mild Cognitive Impairment Idrizbegovic et al, 2011 Pure tone audiometry Speech audiometry PB words in quiet (SPQ) In noise (SPN) 4 db S/N Dichotic digits test (DDT) Central Auditory Processing (CAP) dysfunction is highly evident in early AD, and even in MCI Evaluation of CAP might provide an auditory diagnostic complement in monitoring the progression of AD and MCI 136 subjects, mean age: 64 years (range 50-78) 1) AD; 2) MCI; 3) SMC