WESTBOROUGH, MA July 16, 2018 I have recently been taking care of a couple of men who have experienced significant hearing loss as they aged. The loss of any sensory system contributes to a significant change in independence and satisfaction in life. In this systematic review and meta-analysis of 36 epidemiologic studies and 20 264 unique participants, age-related hearing loss was significantly associated with decline in all main cognitive domains and with increased risk for cognitive impairment and incident dementia. Increased risks for Alzheimer disease and vascular dementia were not statistically significant.
“Hearing loss may have a profoundly detrimental effect on older people’s physical and mental well-being, and even health care resources,” says senior study investigator and Johns Hopkins otologist and epidemiologist Frank Lin, M.D., Ph.D.
“Our results underscore why hearing loss should not be considered an inconsequential part of aging, but an important issue for public health,” says Lin, an assistant professor at the Johns Hopkins University School of Medicine and the university’s Bloomberg School of Public Health. According to Lin, as many as 27 million Americans over age 50, including two-thirds of men and women aged 70 years and older, suffer from some form of hearing loss.
“Dr Frank Lin says social isolation resulting from hearing loss may explain the physical and mental declines – as well as the cognitive deficits – that afflict older adults. This, in turn, may lead to more illness and hospitalization, he says. His team already has further research under way to see if treating hearing loss with counseling and hearing aids can reduce people’s risk of cognitive decline and dementia”.
Tinnitus is sometimes associated with hearing loss. Tinnitus is also known as ringing in the ears and is described by many as a constant high pitched sound or whistling noise. It is sometimes attributed to “trauma” from years of employment or working in an industry that required no hearing protection.
I have begun using a new protocol in my biofeedback session for those most bothered by tinnitus. Neurofeedback is a non- invasive neuromodulation technique which records a subject’s neuronal activity, extracts relevant aspects of brain processes by means of real time signal processing and returns feedback to the subject as visual or auditory stimuli. The aim of neurofeedback is to change behavioral traits or medical conditions associated with altered neural activity as demonstrated for chronic tinnitus.”
“Subjective tinnitus has been described as the constant perception of an auditory sensation that does not correlate to any external acoustic stimulus (Stouffer and Tyler, 1990). It can be perceived as either pitch or noise-like sound and its perception may be unilateral, bilateral or spread out in the whole head (De Ridder et al., 2014b).”
Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA. Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;144(2):115–126. doi:10.1001/jamaoto.2017.2513
Güntensperger D, Thüring C, Meyer M, Neff P and Kleinjung T (2017) Neurofeedback for Tinnitus Treatment – Review and Current Concepts. Front. Aging Neurosci. 9:386. doi: 10.3389/fnagi.2017.00386
De Ridder, D., Fransen, H., Francois, O., Sunaert, S., Kovacs, S., and van de Heyning, P. (2006). Amygdalohippocampal involvement in tinnitus and auditory memory. Acta Otolaryngol. 126, 50–53. doi: 10.1080/03655230600895580
Stouffer, J. L., and Tyler, R. S. (1990). Characterization of tinnitus by tinnitus patients. J. Speech Hear. Disord. 55, 439–453. doi: 10.1044/jshd.55 03.439
WESTBOROUGH, MA July 2, 2018 Simple tasks become more difficult and often are impossible. Tasks like copying a simple design or making simple line drawings become cognitively onerous
You can see from the drawing above that the 90 year old woman had difficulty initiating and executing the task. “Draw-a-clock” seems simple enough. I have been using this technique for over 20 years with very interesting findings. The
The task relies on existing internal template of clock along with enduring problem solving and self-monitoring. The second drawing was initiated at her own choosing. When given the choice she asked to draw the bicycle. That drawing is shown below. Both posts are tiny in size – only 2-3 cm and reveal just how lost the self-monitoring component of cognition has become for this interesting patient.
The most interesting piece of this illustration is the diamond shape. We had just stopped working on drawing shapes from the Mattis Dementia Rating Scale. The final shape is a diamond. Shortly afterward I gave her the standard instructions to draw a clock. I have published many clocks in these pages to illustrate the complexity of the task. She initiated the task by constructing another diamond and began putting the numbers in the contour of the diamond – rather than the typical circular drawing. This is the first time I ever had the clock drawn in a diamond and this is an example of a contaminated response whereas one task intrudes into the next task as I just described. These types of errors are common in patients with dementia. I have attached the link to the actual video taken of the task as she created the clock. Here is the link to the video taken of this clock drawing.
Westborough, MA June 28, 2018 Michael Schumacher is a former Formula 1 race car driver and champion. He was severely injuryed in a skiing accident in French Alps near Switzerland 4 years ago in late 2013. He was treated at a trauma center in Grenoble, France. His wife and family were on a holiday. They are devastated by the loss of Michael who is now is a minimally responsive condition that was once called near coma state. He continues to receive daily therapies including physical and occupational therapy. Information about Michael is released infrequently because the family is very private. His care has cost over 20 million Euros since the accident.
F1 fans are also still keeping Schumacher close in their thoughts – with the official Ferrari supporters club unfurling a massive 30-metre long banner at pre-season testing in Spain ahead of the 2018 season.
Little is known about the day-to-day condition of this once great Formula 1 athlete except he is no longer able to function at the same level as he once did as a result of the tragic accident in late 2013. His family stands with him and continues to look for treatment options. There is some thought to move Michael to Texas in the US where he owns a ranch. There are recovery services that may be offered to him that may afford Schumacher some improvement in his functioning and provide more hope for his loving and supportive family. Both his son and daughter have gone on to their adult lives and are successful adult athletes.
On Father’s Day 2017, his son Mick Schumacher reported “My role model is my dad. Simply because he is the best – my idol.” Meanwhile, his 20-year old daughter Gina-Marie has gone on to a career in the equestrian sport. At the Audi Generation Awards she said “I would like to thank the jury, but especially my parents for the love they give me every day,” she said, after revealing she used to go karting with her legendary father but chose a different career path because “horses are better”.
WESTBOROUGH, MA June 21, 2018 The clock of the week was drawn by a 74-year old female patient suffering from a right hemisphere cerebral vascular accident (CVA) with a significant number of cognitive behavioral changes from her pre-illness baseline. As you can see from the scanned drawing, it took two attempts for her to be satisfied with the effort. Both drawings are quite small (micrographia) – 1.8 cm in size (0.7 inches). Why?
There are several reasons for micrographia that have to do with visual processing and self-monitoring. When a task is given such as the clock drawing the subject must be able to process the directions using existing linguistic functions. Once done there is an element of planning, e.g. “how do I start this process”?, and finally the initiation and execution of the task from first step through the final drawing. This clock was barely over 1/2 inch in size. The female used the space provided very sparingly and talked her way through the task suggesting a verbal strategy was helpful. However, as you see form the top drawing she was unsuccessful. Immediately afterward, seeing that she failed in the task, she drew the bottom left clock and felt she had done a better job.
It is always interesting to see for yourself how these tasks are completed and to what extent brain injuries interfere with the drawing of common objects like the clock. My interpretation of this clock suggests to me that her frontal feedback loop was decreased in its efficiency. It would have provided her with immediate, on-going feedback and real-time monitoring and adjustment of her work. In the second draft, she may have planned a larger circle and placed the numerals in their correct juxtaposition of one another. Finally, she may have thought for a moment and set the hands correctly for ten past eleven.
I have had discussions with speech pathologists with whom I regularly consult about the next generation of patients that are given this task as they get older and may not have learned how to construct the face of a clock when first learning to tell the time. Perhaps at some point we will ask them to draw the face of their cell phone as a screening test of current cognitive functioning.
WESTBOROUGH, MA Here is the “clock of the week” drawn by a well educated 77-year old woman undergoing rehabilitation at the hospital after she sustained a fall and broke some ribs. The clock represents her best effort at completing the 3 step problem I have described so often in these pages. Clocks are interesting and fun. They can be used to put the patient at ease when first getting started. Some patients become quite defensive when they are referred for neuropsychological assessment. It is important to establish rapport prior to initiating the battery of tests so that you may obtain the best possible result.
These data are turned into the report that physicians will use to access services and needed intervention to assist with return to functional independence whenever possible. In this case, the woman had had two prior CVA’s one on the
Right middle cerebral artery – effecting her visual motor integration and spatial awareness and the second stroke effecting her language area – including verbal fluency and word choice during free speech. I have also added a sample of her written language. Patients are all asked to “write a sentence” that I dictate to them. I have used the same 2 sentences for over 20 years and find them useful.
“Baseball players are tough”
The sentence reads Baseball players are tough. It illustrates the impact of CVA on written language. This interesting lady could no longer write checks or sign her name. Graphic formulation of words requires both the left and right sides of the brain for success. The frontal lobe is also brought in automatically to initiate, plan, and execute the verbiage and organize the thoughts into a coherent message.
During the hours of assessment I learned that this patient had sustained a fall just 5 months earlier resulting in a head strike and 3-5 days of concussion-like symptoms that slowly evaporated returning her to her baseline. This leaves her more vulnerable to cognitive change with any illness including infection or pain syndrome from fractured ribs.
Westborough, MA May 20, 2018 Biofeedback has been the subject of my posts for a few years and I am excited to publish this paper on using the Heart Rate Variability (HRV) protocol together with EEG Neurofeedback to reduce the duration and severity of symptoms of post-concussion syndrome (PCS). “Sometimes vague physical symptoms create an overwhelming emotional response that comes from the lingering resentment patients feel when seeing doctors who seem unable to understand their needs. Sometimes the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. This can leave a patient with feelings of embitterment and confusion. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation.” as posted in a concussion blog by Michael Sefton in 2015.
Biofeedback is not new nor is it still considered a novice, untested treatment. There are scores of peer reviewed papers on both physiologic and neurofeedback for a variety of clinical syndrome including epilepsy, chronic pain, hypertension, alcoholism, ADHD, and concussion among others. The key for those suffering with the effects of concussion is early referral into treatment rather than referring as a last resort after three years of chronic suffering. Happily I can report that only a tiny percentage of people who sustain a concussion have symptoms that last greater than 6 months. Nevertheless, the number of post-concussion sufferers is substantial and all too often are overwhelmed by symptoms months after their injury. There are a number of reasons why this seems to occur and many of these relate to the response of the body to stress and its associated physical sequelae. The photograph shows a TBI patient working on peak performance training using both EEG neurofeedback and physiologic biofeedback for HRV and paced breathing. Given the extent of her brain injury, she has done very well and is improving.
“Relaxation and mindfulness have existed for over 60 years bringing together the conscious effort to control bodily systems that were once thought to be automatic and “not correctable.” Research into chronic stress illustrates how damaging it can be on physical functioning and longevity. Concussion is described as an invisible injury yet it has an undeniable impact on sleep, concentration, and emotional well being.” Michael Sefton, 2016
One key indicator for how a person recovers from concussion closely relates to their prototypic response to other stressful events in their lives. According to the American Psychological Association “resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems, serious health problems or workplace and financial stressors. It means “bouncing back” from difficult experiences.Psychological resilience is required when “knocked down” by a concussion and to bounce back into a fully functioning, integrated person. Where are all of these people right? When this fails and symptoms are prolonged for 6 months or more the likelihood of returning to full employment drops precipitously. Heart rate variability training (HRV) can assist with lowering feelings of pain and tension that make the recovery from concussion more complex. Coupled with this is training to reduce the post-concussive embitterment often described going from doctor to doctor looking for discovery and validation for what has befallen them.
“Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed in anyone.” APA The biofeedback I am offering helps patients reduce autonomic overload while helping build resilience. When individual goals are attained using biofeedback people see for themselves that they have control and can learn to lower the tension and pain they feel.
Coincident Stress and Trauma
In the Journal of Neurology, Neurosurgery, and Psychiatry, a 2011 study suggested that pre-incident trauma may confound the recovery from concussion. “Several potentially life-altering stressful events were endorsed by at least 25% of participants as having been experienced prior to injury. The incidence of stressful life events was a significant predictor of all four outcome variables.” I have started taking data from people I see asking about trauma occurring at the same time e.g. loss of job, divorce, major health scare, family trouble.
There needs to be secondary care for the emotional loss and stress associated with PCS to reduce the impact of an abnormal emotional or psychological response to concussion. Especially when symptoms go on and on. “Cognitive behavioral therapy works best along with both physiologic feedback and EEG neurofeedback for reduced sympathetic arousal – from stress hormones that have gone into overdrive” from my recent blog post in which I cite Sonia Coelho Mosch, Ph.D. A re-exertion plan along with physical therapy, aquatics, and mindfulness are components of a complete plan of action for recovery from concussion and reduced feelings of helplessness.
I sometimes see patients who exhibit such embitterment about what they believe they have “lost” they cannot move on. It is these cases who are involved in litigation and cannot allow themselves to move on with their lives. They become emotionally stuck – reliving their loss and growing bitter about having lingering symptoms whether it is headaches, sensitivity to sound or light, inability to multi-task, or other cognitive change. Education at the time of injury may mitigate the long-term effects of concussion.
Resilience affords the patient greater coping skill and the underlying confidence that they will get better. Patients must take responsibility for their recovery and avoid being overburdened by bitterness and resentment. Moderate physical activity and physical support is essential following a concussion. Biofeedback can help reduce the autonomic overload that slowly rises when patients feel constant tension, stress, and pain. Certainly, by obtaining greater control over the unbridled fight-flight imbalance athletes and patients alike learn to balance their parasympathetic system with the unappreciated physical and cognitive threat associated with post-concussion syndrome. “Bitterness is a prolonged, resentful feeling of disempowered and devalued victimization. Embitterment, like resentment and hostility, results from the long-term mismanagement of annoyance, irritation, frustration, anger or rage. ” according to Steven Diamond, Ph.D. who publishes on the Psychology Today website.
The APA article says several additional factors are associated with resilience, including:
The capacity to make realistic plans and take steps to carry them out.
Skills in communication and problem solving.
A positive view of yourself and confidence in your strengths and abilities.Skills in communication and problem solving.
The capacity to manage strong feelings and impulses.
All of these are factors that people can develop in themselves and lead to improved coping and may reduce the impact of concussion.
APA. Road to Resilience. http://www.apa.org/helpcenter/road-resilience.aspx. Taken May 12, 2018
Diamond, S. (2009) Anger Disorder (Part Two): Can Bitterness Become a Mental Disorder? Can Bitterness Become a Mental Disorder? PT blog https://www.psychologytoday.com/us/blog/evil-deeds/200906/anger-disorder-part-two-can-bitterness-become-mental-disorder. Taken May 13, 2018
Sefton, M. (2016) Coincident Stress may prolong symptoms of Concussion. https://concussionassessment.wordpress.com/2016/09/26/ Taken May 13, 2018