Cognivue Technology is as Effective as MoCA: What Does this Mean to Audiologists, Their Practices, and Patients?

AudiologyOnline: What is the opportunity for audiologists in the connection between hearing and cognitive health?

Regina Presley, AuD: Audiologists are crucial to the early identification of and management of individuals with hearing loss not only to ensure good hearing health, but also to improve the overall health of patients and reduce the cost of healthcare. 

The World Health Organization reports that cognitive decline poses one of the greatest global challenges for health and social care in the 21^st century.¹ So, when the Lancet Commission reported that hearing loss is the #1 modifiable risk factor for the prevention of dementia², it identified audiologists as key players who can positively impact the reduction and prevention of cognitive decline.

By identifying patients who would benefit from hearing intervention and/or a referral to a physician, audiologists can have a positive effect not only on the hearing health and cognitive health of their patients, but also their overall quality of life by providing holistic, integrated, patient-centered care.

AudiologyOnline: What cognitive screeners are used in an audiology office, and what are the advantages and disadvantages of these other screeners?

Regina Presley, AuD: With the link established between hearing health and cognitive health, our practice began to search for an effective and efficient tool to assist in screening our patients’ cognitive status. A survey conducted in 2020, by Black and Souza, identified the Mini Mental State of Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) as the most commonly utilized screener by audiologists.³ Research has repeatedly confirmed that the MMSE is not as sensitive to mild cognitive impairment as other screeners⁴ and it is associated with misclassifications due to biases⁵. We selected the Montreal Cognitive Assessment Test (MoCA) due to its prevalent use as screening tool within the audiology community and for its recognition for identifying mild forms of cognitive impairment. However, upon implementation we experienced several challenges. The screenings took 15 minutes to conduct and required someone to administer it 1:1 with the patient. As a result, both providers and administrative staff conducted the screenings. We observed tester bias among our team impacting outcomes of the MoCA screening results, which is consistent with the literature on test administrator effects for MMSE⁶ as well. In addition, individuals with lower education or from ethnically diverse populations were at a disadvantage for this screener based on the nature of the materials present within this screening tool. Administration of the MoCA, like other cognitive screeners such as the Mini Mental State Examination (MMSE) and the Saint Louis University Mental Status Examination (SLUMS), rely on verbal administration, placing patients with hearing loss at a disadvantage and potentially skewing results for this patient population. The MoCA assessment given remained the same at each administration and due to this design, patients technically could practice prior to an assessment or re-assessment, impacting the validity of the screening. Lastly, additional clinical time, tester bias, and consistent scoring stimulated an ongoing search for another screener. Cognivue Thrive provided us with a screening option that was independently completed, required no auditory skills, eliminated patient and tester bias, while providing individual subtest scores to assist in interpreting the data and devising an appropriate effective management plan.

AudiologyOnline: How and why can the implementation of Cognivue technology as a screening tool ensure comprehensive, quality care to your patients?

Regina Presley, AuD: Clinical validation identifying Cognivue technology as equally effective as the MoCA,⁷ allowed us to confidently move forward utilizing it as a new screening tool within our practice. On the Cognivue Thrive, patients independently complete the assessment within 10-minutes, eliminating the need for additional provider administration and scoring time, test administrator bias, and potential inconsistent administration due to time constraints of the providers. The screening is completed on a laptop like device and all instructions are provided auditorily as well as via closed captioning on the screen. Practice sessions are provided throughout the test, ensuring accurate understanding of the tasks prior to completing the screening, yet not affecting the outcome of the screening results because the content cannot be learned. The screening tool consists of testing 3 cognitive domains including memory, visuospatial, and executive function and 2 performance tests assessing reaction time and speed processing abilities. The Cognivue technology was designed to reduce the impact of education, ethnicity, auditory acuity, and familiarity of the English language. 

Unlike the other cognitive screeners, Cognivue Thrive provides performance information regarding each domain tested. Providers can utilize this valuable information to guide recommendations and help define an appropriate rehabilitative plan. These results, which are compiled into a user-friendly report available immediately after the screening, can provide insight into the need for additional rehabilitative services, highlight concerns regarding compliance, indicate that the use of a caregiver would be advantageous, suggest that additional simple written materials may support issues of poor memory, music may be a good option to assist with enhancing memory and executive function in rehabilitation, just to name a few. As you can see, subtest findings will lead to the comprehensive implementation of a patient-centered management approach. 

AudiologyOnline: How does your practice communicate the benefits of Cognivue to patients and caregivers?

Regina Presley, AuD: Since the utilization of cognitive assessment is a more recent component to the Audiology scope of practice⁸, developing the proper communication took thoughtful planning. Comprehensive care requires a patient-centered approach that demonstrates the “why” behind procedures and recommendations. Our experiences have demonstrated that most individuals have minimal knowledge regarding cognitive health, and most are anxious about the thought of an assessment of their cognitive function. It is imperative that we explain that research indicates that good brain health requires early and proper management of hearing loss. We begin this dialogue when scheduling our initial candidacy appointment. 

Lin et. al. reported that individuals with untreated hearing loss were 2x more likely to experience cognitive decline.⁹ Patients are informed that a screening provides us with information as to whether any additional testing is warranted, allowing us to make the appropriate referral. Results also provide opportunities to encourage patients regarding additional influencing factors on their brain health such as hypertension, diabetes, and smoking. A holistic approach to care demonstrates our commitment to our patients and provides an opportunity for a multidisciplinary approach. This approach may lead to increased referrals and collaboration among other professionals.

AudiologyOnline: How does the practice use the report/results of the screening?

Regina Presley, AuD: The Cognivue system provides a user-friendly printout appropriate for use with the patient, other healthcare professionals, such as primary care physicians or neurologists, and for medical records documentation. This report is a simple representation of the screening results and is easily interpreted by the viewer. Documentation provides patient performance on each domain tested along with a normative range for comparison, and a detailed description of the domain assessed.

Screening results not only guide clinical decision making such as accessory use, discontinuation of an accessory, programming changes of the cochlear implant, recommended types of instruction, support materials at home for equipment management, or the need to engage family or facility assistance with daily equipment management, but also serve to initiate appropriate referrals. Cognivue findings are part of the development a comprehensive plan for patient care to optimize performance. 

AudiologyOnline: How can Cognivue technology be utilized in clinical research moving forward?

Regina Presley, AuD: There is significant research available linking cognitive health and hearing health. As a field, we have the opportunity to continue gathering data regarding proper implementation of how to utilize screening data for optimal patient-centered care and to develop protocols and guidelines for consistent standard of care for all patients. Our practice is currently collecting data regarding consistent implementation, subtest guided management, impact of screening results as it relates to proceeding with implantation, effectiveness of our referral process, impact of hearing restoration on Cognivue Thrive outcomes, impact on cognitive performance based on hearing history and comorbidities, and patient management pre and post implantation as it relates to aural rehabilitation, audiologic management, and a multidisciplinary approach. As additional research, some of which has been announced publicly, is conducted and published, it will be exciting to see how the field and evidence evolves.

Want to learn more?

Register for live, virtual CEU courses February 15 and February 25, or peruse the on-demand CEU course library to learn more about incorporating cognitive screening into an audiology practice.

References:

1. WHO-Guidelines.pdf (cognivue.com)
2. https://doi.org/10.1016/S0140-6736(17)31363-6
3. Black, S. & Souza, P., (2020). Cognitive-Screening Practices Among Audiologists. Audiology Today, (September/October).
4. Breton A, Casey D, Arnaoutoglou N. (2019) Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: meta-analysis of diagnostic accuracy studies. Int J Geriatr Psych 34:233–242. 
5. Ranson JM, Kuzma E, Hamilton W, et al.: Predictors of dementia misclassification when using brief cognitive assessments. Neurol Clin Pract 2019; 9:109–117
6. Marieclaire Overton, Mats Pihlsgård & Sölve Elmståhl, (2016) Test administrator effects on cognitive performance in a longitudinal study of ageing, Cogent Psychology, 3:1, 1260237, DOI: 10.1080/23311908.2016.1260237
7. Ma F, Cahn-Hidalgo D (2021) Clinical Validation of Cognivue – A Computerized Alternative to the Montreal Cognitive Assessment Test. Neurol Sci Neurosurg, Volume 2:2. 116.
8. American Speech-Language-Hearing Association. (2018). Scope of Practice in Audiology [Scope of Practice]
9. Lin FR, Metter J, O'Brien R. Hearing loss and incident dementia. Archives of Neurology. 2011;68:214–220.