Development of a novel screening tool for predicting Cochlear implant candidacy.

OBJECTIVES: Cochlear implantation (CI) is a well-established treatment for sensorineural hearing loss. Due in part to a lack of referral guidelines, CI technology remains underutilized, and many patients who could benefit from CI may not be referred for evaluation. This study aimed to develop a model for predicting CI candidacy using routine audiometric measures, with the goal of providing guidance to clinicians regarding when to refer a patient for CI evaluation. METHODS: Unaided three-frequency pure tone average (PTA), unaided speech discrimination score (SDS), and best-aided sentence recognition testing with AZBio sentence lists were collected from 252 subjects undergoing CIE. Candidacy was defined by meeting traditional (AZBio score ≤ 60%), or Medicare criteria (≤40%). A logistic regression model was developed to predict candidacy. Confusion matrices were plotted to determine the sensitivity and specificity at various probability thresholds. RESULTS: Logistic regression models were capable of predicting probability of candidacy for traditional criteria (P < .001) and Medicare criteria (P < .001). PTA and SDS were significant predictors (P < .001). Using a probability cutoff of .5, the models yielded a sensitivity rate of 91% and 78% for traditional and Medicare criteria, respectively. CONCLUSION: Probability of CI candidacy may be determined using a novel screening tool for referral. This tool supports individualized counseling, serves as a proof of concept for candidacy prediction, and could be modified based on an institution's philosophy regarding an acceptable false positive rate of referral. LEVEL OF EVIDENCE: 4.

Bottom-Up Signal Quality Impacts the Role of Top-Down Cognitive-Linguistic Processing During Speech Recognition by Adults with Cochlear Implants.

HYPOTHESES: Significant variability persists in speech recognition outcomes in adults with cochlear implants (CIs). Sensory ("bottom-up") and cognitive-linguistic ("top-down") processes help explain this variability. However, the interactions of these bottom-up and top-down factors remain unclear. One hypothesis was tested: top-down processes would contribute differentially to speech recognition, depending on the fidelity of bottom-up input. BACKGROUND: Bottom-up spectro-temporal processing, assessed using a Spectral-Temporally Modulated Ripple Test (SMRT), is associated with CI speech recognition outcomes. Similarly, top-down cognitive-linguistic skills relate to outcomes, including working memory capacity, inhibition-concentration, speed of lexical access, and nonverbal reasoning. METHODS: Fifty-one adult CI users were tested for word and sentence recognition, along with performance on the SMRT and a battery of cognitive-linguistic tests. The group was divided into "low-," "intermediate-," and "high-SMRT" groups, based on SMRT scores. Separate correlation analyses were performed for each subgroup between a composite score of cognitive-linguistic processing and speech recognition. RESULTS: Associations of top-down composite scores with speech recognition were not significant for the low-SMRT group. In contrast, these associations were significant and of medium effect size (Spearman's rho = 0.44-0.46) for two sentence types for the intermediate-SMRT group. For the high-SMRT group, top-down scores were associated with both word and sentence recognition, with medium to large effect sizes (Spearman's rho = 0.45-0.58). CONCLUSIONS: Top-down processes contribute differentially to speech recognition in CI users based on the quality of bottom-up input. Findings have clinical implications for individualized treatment approaches relying on bottom-up device programming or top-down rehabilitation approaches.

The Value of Speech-Language Pathologists in Auditory Rehabilitation for Adults With Cochlear Implants.

Background Standards for auditory rehabilitation are currently lacking for adults who receive cochlear implants. Speech recognition outcomes are highly variable, and many adults with cochlear implants present with suboptimal performance. Functional real-life communication abilities are not routinely measured clinically and are not strongly linked to performance on traditional measures of speech recognition. In fact, even individuals with relatively good speech recognition outcomes often present with persistent communication difficulties. In contrast to pediatric cochlear implant users, speech-language pathologists are not routinely involved in the rehabilitation of adults who receive cochlear implants. Purpose The purpose of this article is to describe the value of including a speech-language pathologist in a comprehensive approach to auditory rehabilitation for adults with cochlear implants. Method The theoretical and clinical foundations of incorporating a speech-language pathologist into an adult auditory rehabilitation program are discussed. A description of the skills and potential roles of the speech-language pathologist for providing adult cochlear implant rehabilitation services is presented, along with potential barriers to implementation. Conclusion Person-centered management of postlingually deafened adults with cochlear implants can be augmented by a more complete approach utilizing the skill set of a speech-language pathologist. Supplemental Material https://doi.org/10.23641/asha.14669652.

How Does Cochlear Implantation Lead to Improvements on a Cognitive Screening Measure?

Purpose Cognitive screening tools to identify patients at risk for cognitive deficits are frequently used by clinicians who work with aging populations in hearing health care. Although some studies show improvements in performance on cognitive screening exams when hearing loss intervention is provided in the form of a hearing aid or cochlear implant (CI), it is worth examining whether these improvements are attributable to increased auditory access to test items. This study aimed to examine whether performance and pass rate on a cognitive screening measure, the Montréal Cognitive Assessment (MoCA), improve as a result of CI, whether improved performance on auditory-based test items drives changes in MoCA performance, and whether postoperative MoCA performance relates to post-CI speech perception ability. Method Data were collected in adult CI candidates pre-implantation and 6 months postimplantation to examine the effect of intervention on MoCA performance. Participants were 77 CI users between the ages of 55 and 85 years. Participants completed the MoCA, administered audiovisually, and speech perception testing with monosyllabic (CNC) words at both intervals. Results Compared to 31 participants pre-operatively, 45 participants passed the MoCA postoperatively, which was a significant difference in pass rate. An improvement in MoCA scores could be attributed primarily to improvement in the "Delayed Recall" test domain, which was auditory based. Post-CI MoCA performance was related to post-CI CNC speech perception performance. Conclusions Improved performance and pass rates were demonstrated on the traditional MoCA test of cognitive screening from before to 6 months after CI. Improvements could primarily be attributed to better performance on a delayed recall task dependent on auditory access, and post-CI MoCA scores were related to post-CI speech perception abilities. Further studies are needed to investigate the application of cognitive screening tools in patients receiving hearing loss interventions, and these interventions' impact on patients' real-world functioning.

A Longitudinal Comparison of Environmental Sound Recognition in Adults With Hearing Aids Before and After Cochlear Implantation.

Purpose The aims of this study were (a) to longitudinally assess environmental sound recognition (ESR) before and after cochlear implantation in a sample of postlingually deafened adults and (b) to assess the extent to which spectro-temporal processing abilities influence ESR with cochlear implants (CIs). Method In a longitudinal cohort study, 20 postlingually deafened adults were tested with hearing aids on the Familiar Environmental Sound Test-Identification and AzBio sentences in quiet pre-CI and 6 months post-CI. A subset of 11 participants were also tested 12 months post-CI. Pre-CI spectro-temporal processing was assessed using the Spectral-temporally Modulated Ripple Test. Results Average ESR accuracy pre-CI (M = 63.60%) was not significantly different from ESR accuracy at 6 months (M = 65.40%) or 12 months (M = 69.09%) post-CI. In 11 participants (55%), however, ESR improved following implantation by 10.91 percentage points, on average. Pre-CI ESR correlated moderately and significantly with pre-CI and 12-month post-CI AzBio scores, with a trend toward significance for AzBio performance at 6 months. Pre-CI spectro-temporal processing was moderately associated with ESR at 6 and 12 months post-CI but not with speech recognition post-CI. Conclusions The present findings failed to demonstrate an overall significant improvement in ESR following implantation. Nevertheless, more than half of our sample showed some degree of improvement in ESR. Several environmental sounds were poorly identified both before and after implantation. Spectro-temporal processing ability prior to implantation appears to predict postimplantation performance for ESR. These findings indicate the need for greater attention to ESR following cochlear implantation and for developing individualized targets for ESR rehabilitation. Supplemental Material https://doi.org/10.23641/asha.13876745.

Can a Self-report Measure Be Used to Assess Cognitive Skills in Adults With Hearing Loss?

HYPOTHESES: Adult cochlear implant candidates would self-report their executive functioning abilities as poorer than normal-hearing peers. These executive function abilities would correlate with laboratory-based cognitive tests. Lastly, executive functioning (EF) abilities would be associated with hearing-related quality of life. BACKGROUND: Executive function refers to cognitive abilities involved in behavioral regulation during goal-directed activity. Pediatric and adult users have demonstrated delays and deficits in executive function skills compared with normal-hearing peers. This study aimed to compare self-report executive function in adult cochlear implant candidates and normal-hearing peers and to relate executive function skills to laboratory-based cognitive testing and hearing-related quality of life. METHODS: Twenty-four postlingually deaf adult cochlear implant candidates were enrolled, along with 42 normal-hearing age-matched peers. Participants completed self-reports of executive function using the Behavior Rating Inventory of Executive Function- Adult (BRIEF-A). Participants were also tested using laboratory-based cognitive measures, as well as assessment of hearing-related quality of life on the Nijmegen Cochlear Implant Questionnaire. Groups were compared on BRIEF-A scores, and relations between BRIEF-A and lab-based cognitive measures as well as Nijmegen Cochlear Implant Questionnaire scores were examined. RESULTS: Self-report executive function on the BRIEF-A was not significantly different between groups. Consistent relations of self-report executive function and nonverbal reasoning were identified. Strong relations were not found between self-report executive function and hearing-related quality of life. CONCLUSIONS: Executive function as measured by BRIEF-A demonstrates some relation with a laboratory-based metric of nonverbal reasoning, but not other cognitive measures. Hearing-impaired individuals did not report poorer EF than normal-hearing controls. EF additionally did not correlate with quality of life. Our findings provide preliminary, partial validation of the BRIEF-A instrument in the preoperative evaluation of adult cochlear implant candidates.

Assessment of Reliability and Validity of the Cochlear Implant Skills Review: A New Measure to Evaluate Cochlear Implant Users' Device Skills and Knowledge.

Purpose The Cochlear Implant Skills Review (CISR) was developed as a measure of cochlear implant (CI) users' skills and knowledge regarding device use. This study aimed to determine intra- and interrater reliability and agreement and establish construct validity for the CISR. Method In this study, the CISR was developed and administered to a cohort of 30 adult CI users. Participants included new CI users with less than 1 year of CI experience and experienced CI users with greater than 1 year of CI experience. The CISR administration required participants to demonstrate skills using the various features of their CI processors. Intra- and interrater reliability were assessed using intraclass correlation coefficients, agreement was assessed using Cohen's kappa, and construct validity was assessed by relating CISR performance to duration of CI use. Results Overall reliability for the entire instrument was 92.7%. Inter- and intrarater agreement were generally substantial or higher. Duration of CI use was a significant predictor of CISR performance. Conclusions The CISR is a reliable and valid assessment measure of device skills and knowledge for adult CI users. Clinicians can use this tool to evaluate areas of needed instruction and counseling and to assess users' skills over time.

Word and Nonword Reading Efficiency in Postlingually Deafened Adult Cochlear Implant Users.

HYPOTHESIS: This study tested the hypotheses that 1) experienced adult cochlear implants (CI) users demonstrate poorer reading efficiency relative to normal-hearing controls, 2) reading efficiency reflects basic, underlying neurocognitive skills, and 3) reading efficiency relates to speech recognition outcomes in CI users. BACKGROUND: Weak phonological processing skills have been associated with poor speech recognition outcomes in postlingually deaf adult CI users. Phonological processing can be captured in nonauditory measures of reading efficiency, which may have wide use in patients with hearing loss. This study examined reading efficiency in adults CI users, and its relation to speech recognition outcomes. METHODS: Forty-eight experienced, postlingually deaf adult CI users (ECIs) and 43 older age-matched peers with age-normal hearing (ONHs) completed the Test of Word Reading Efficiency (TOWRE-2), which measures word and nonword reading efficiency. Participants also completed a battery of nonauditory neurocognitive measures and auditory sentence recognition tasks. RESULTS: ECIs and ONHs did not differ in word (ECIs: M = 78.2, SD = 11.4; ONHs: M = 83.3, SD = 10.2) or nonword reading efficiency (ECIs: M = 42.0, SD = 11.2; ONHs: M = 43.7, SD = 10.3). For ECIs, both scores were related to untimed word reading with moderate to strong effect sizes (r = 0.43-0.69), but demonstrated differing relations with other nonauditory neurocognitive measures with weak to moderate effect sizes (word: r = 0.11-0.44; nonword: r = (-)0.15 to (-)0.42). Word reading efficiency was moderately related to sentence recognition outcomes in ECIs (r = 0.36-0.40). CONCLUSION: Findings suggest that postlingually deaf adult CI users demonstrate neither impaired word nor nonword reading efficiency, and these measures reflect different underlying mechanisms involved in language processing. The relation between sentence recognition and word reading efficiency, a measure of lexical access speed, suggests that this measure may be useful for explaining outcome variability in adult CI users.

Comprehensive auditory rehabilitation in adults receiving cochlear implants: A pilot study.

OBJECTIVE: In the United States, most adults who receive cochlear implants (CIs) do not undergo a comprehensive auditory rehabilitation (CAR) approach, which may result in suboptimal outcomes. The objectives of this pilot study were to demonstrate that a CAR approach incorporating auditory training (AT) by a speech-language pathologist (SLP) is feasible in adults receiving CIs and to explore whether this approach results in improved outcomes. METHODS: Twenty-four postlingually deaf adult CI candidates were serially assigned to one of three groups: (a) a "CAR group" that received standard of care implantation, programming by an audiologist, an additional preoperative counseling session, and eight one-hour AT sessions; (b) a "passive control" standard-of-care group; and (c) an "active control" group that also received the extra preoperative counseling session. Participants were tested preoperatively and 1, 3, and 6 months after CI using measures of word and sentence recognition in quiet and in babble, as well as measures of quality of life (QOL). RESULTS: The CAR approach was feasible, but this pilot study was underpowered to determine efficacy. Differential time courses of speech recognition improvement were seen for sentence and word recognition. All QOL measurements showed improvement from pre-CI to 1 month post-CI activation. Results revealed issues to consider for a larger-scale study of CAR revolving around participant selection, study measures, and sample size. CONCLUSION: The CAR approach is feasible in new CI users. A larger trial is needed to investigate whether CAR leads to better outcomes or faster improvement in this clinical population. LEVEL OF EVIDENCE: 2.

Development of the Basic Auditory Skills Evaluation Battery for Online Testing of Cochlear Implant Listeners.

Purpose Cochlear implant (CI) performance varies considerably across individuals and across domains of auditory function, but clinical testing is typically restricted to speech intelligibility. The goals of this study were (a) to develop a basic auditory skills evaluation battery of tests for comprehensive assessment of ecologically relevant aspects of auditory perception and (b) to compare CI listeners' performance on the battery when tested in the laboratory by an audiologist or independently at home. Method The battery included 17 tests to evaluate (a) basic spectrotemporal processing, (b) processing of music and environmental sounds, and (c) speech perception in both quiet and background noise. The battery was administered online to three groups of adult listeners: two groups of postlingual CI listeners and a group of older normal-hearing (ONH) listeners of similar age. The ONH group and one CI group were tested in a laboratory by an audiologist, whereas the other CI group self-tested independently at home following online instructions. Results Results indicated a wide range in the performance of CI but not ONH listeners. Significant differences were not found between the two CI groups on any test, whereas on all but two tests, CI listeners' performance was lower than that of the ONH participants. Principal component analysis revealed that four components accounted for 82% of the variance in measured results, with component loading indicating that the test battery successfully captures differences across dimensions of auditory perception. Conclusions These results provide initial support for the use of the basic auditory skills evaluation battery for comprehensive online assessment of auditory skills in adult CI listeners.

Explaining Speech Recognition and Quality of Life Outcomes in Adult Cochlear Implant Users: Complementary Contributions of Demographic, Sensory, and Cognitive Factors.

HYPOTHESES: Adult cochlear implant (CI) outcomes depend on demographic, sensory, and cognitive factors. However, these factors have not been examined together comprehensively for relations to different outcome types, such as speech recognition versus quality of life (QOL). Three hypotheses were tested: 1) speech recognition will be explained most strongly by sensory factors, whereas QOL will be explained more strongly by cognitive factors. 2) Different speech recognition outcome domains (sentences versus words) and different QOL domains (physical versus social versus psychological functioning) will be explained differentially by demographic, sensory, and cognitive factors. 3) Including cognitive factors as predictors will provide more power to explain outcomes than demographic and sensory predictors alone. BACKGROUND: A better understanding of the contributors to CI outcomes is needed to prognosticate outcomes before surgery, explain outcomes after surgery, and tailor rehabilitation efforts. METHODS: Forty-one adult postlingual experienced CI users were assessed for sentence and word recognition, as well as hearing-related QOL, along with a broad collection of predictors. Partial least squares regression was used to identify factors that were most predictive of outcome measures. RESULTS: Supporting our hypotheses, speech recognition abilities were most strongly dependent on sensory skills, while QOL outcomes required a combination of cognitive, sensory, and demographic predictors. The inclusion of cognitive measures increased the ability to explain outcomes, mainly for QOL. CONCLUSIONS: Explaining variability in adult CI outcomes requires a broad assessment approach. Identifying the most important predictors depends on the particular outcome domain and even the particular measure of interest.

Safety-relevant environmental sound identification in cochlear implant candidates and users.

OBJECTIVES/HYPOTHESIS: To compare the identification of safety-relevant environmental sounds between experienced cochlear implant (CI) users and CI candidates. STUDY DESIGN: Cross-sectional. METHODS: A sample of 19 adult, postlingually deaf CI candidates (CI-Cs), 47 experienced CI users (CI-Es), and a control group of 37 age-matched normal-hearing adults were assessed using the Familiar Environmental Sounds Test-Identification (FEST-I). A subset of 11 sounds relevant for safety were selected for analysis in the current study. RESULTS: Analysis of safety-relevant sound identification accuracy revealed no significant difference in safety-relevant environmental sound identification skills between CI-E and CI-C participants, with average scores of 68.1% and 67.9%, respectively. Both performed substantially lower than age-matched normal hearing adults (95.1%). A significant moderate negative correlation (-0.4) was found between safety-relevant sound accuracy and chronological age only in one group, the CI-E group (r = -0.4, P < .005). CONCLUSIONS: These findings fail to demonstrate superior performance in safety-relevant environmental sound identification among CI-Es compared with CI-Cs. Although preliminary, these findings suggest that identification of safety-relevant sounds is a significant area of weakness for both CI-Es and CI-Cs, both of whom may benefit from rehabilitation. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1547-1551, 2020.

Visual Reliance During Speech Recognition in Cochlear Implant Users and Candidates.

BACKGROUND: Adults with cochlear implants (CIs) are believed to rely more heavily on visual cues during speech recognition tasks than their normal-hearing peers. However, the relationship between auditory and visual reliance during audiovisual (AV) speech recognition is unclear and may depend on an individual's auditory proficiency, duration of hearing loss (HL), age, and other factors. PURPOSE: The primary purpose of this study was to examine whether visual reliance during AV speech recognition depends on auditory function for adult CI candidates (CICs) and adult experienced CI users (ECIs). STUDY SAMPLE: Participants included 44 ECIs and 23 CICs. All participants were postlingually deafened and had met clinical candidacy requirements for cochlear implantation. DATA COLLECTION AND ANALYSIS: Participants completed City University of New York sentence recognition testing. Three separate lists of twelve sentences each were presented: the first in the auditory-only (A-only) condition, the second in the visual-only (V-only) condition, and the third in combined AV fashion. Each participant's amount of "visual enhancement" (VE) and "auditory enhancement" (AE) were computed (i.e., the benefit to AV speech recognition of adding visual or auditory information, respectively, relative to what could potentially be gained). The relative reliance of VE versus AE was also computed as a VE/AE ratio. RESULTS: VE/AE ratio was predicted inversely by A-only performance. Visual reliance was not significantly different between ECIs and CICs. Duration of HL and age did not account for additional variance in the VE/AE ratio. CONCLUSIONS: A shift toward visual reliance may be driven by poor auditory performance in ECIs and CICs. The restoration of auditory input through a CI does not necessarily facilitate a shift back toward auditory reliance. Findings suggest that individual listeners with HL may rely on both auditory and visual information during AV speech recognition, to varying degrees based on their own performance and experience, to optimize communication performance in real-world listening situations.

Cognitive Functions in Adults Receiving Cochlear Implants: Predictors of Speech Recognition and Changes After Implantation.

HYPOTHESES: Significant variability in speech recognition outcomes is consistently observed in adults who receive cochlear implants (CIs), some of which may be attributable to cognitive functions. Two hypotheses were tested: 1) preoperative cognitive skills assessed visually would predict postoperative speech recognition at 6 months after CI; and 2) cochlear implantation would result in benefits to cognitive processes at 6 months. BACKGROUND: Several executive functioning tasks have been identified as contributors to speech recognition in adults with hearing loss. There is also mounting evidence that cochlear implantation can improve cognitive functioning. This study examined whether preoperative cognitive functions would predict speech recognition after implantation, and whether cognitive skills would improve as a result of CI intervention. METHODS: Nineteen post-lingually deafened adult CI candidates were tested preoperatively using a visual battery of tests to assess working memory (WM), processing speed, inhibition-concentration, and nonverbal reasoning. Six months post-implantation, participants were assessed with a battery of word and sentence recognition measures and cognitive tests were repeated. RESULTS: Multiple speech measures after 6 months of CI use were correlated with preoperative visual WM (symbol span task) and inhibition ability (stroop incongruent task) with moderate-to-large effect sizes. Small-to-large effect size improvements in visual WM, concentration, and inhibition tasks were found from pre- to post-CI. Patients with lower baseline cognitive abilities improved the most after implantation. CONCLUSIONS: Findings provide evidence that preoperative cognitive factors contribute to speech recognition outcomes for adult CI users, and support the premise that implantation may lead to improvements in some cognitive domains.

High- and Low-Performing Adult Cochlear Implant Users on High-Variability Sentence Recognition: Differences in Auditory Spectral Resolution and Neurocognitive Functioning.

BACKGROUND: Postlingually deafened adult cochlear implant (CI) users routinely display large individual differences in the ability to recognize and understand speech, especially in adverse listening conditions. Although individual differences have been linked to several sensory (''bottom-up'') and cognitive (''top-down'') factors, little is currently known about the relative contributions of these factors in high- and low-performing CI users. PURPOSE: The aim of the study was to investigate differences in sensory functioning and neurocognitive functioning between high- and low-performing CI users on the Perceptually Robust English Sentence Test Open-set (PRESTO), a high-variability sentence recognition test containing sentence materials produced by multiple male and female talkers with diverse regional accents. RESEARCH DESIGN: CI users with accuracy scores in the upper (HiPRESTO) or lower quartiles (LoPRESTO) on PRESTO in quiet completed a battery of behavioral tasks designed to assess spectral resolution and neurocognitive functioning. STUDY SAMPLE: Twenty-one postlingually deafened adult CI users, with 11 HiPRESTO and 10 LoPRESTO participants. DATA COLLECTION AND ANALYSIS: A discriminant analysis was carried out to determine the extent to which measures of spectral resolution and neurocognitive functioning discriminate HiPRESTO and LoPRESTO CI users. Auditory spectral resolution was measured using the Spectral-Temporally Modulated Ripple Test (SMRT). Neurocognitive functioning was assessed with visual measures of working memory (digit span), inhibitory control (Stroop), speed of lexical/phonological access (Test of Word Reading Efficiency), and nonverbal reasoning (Raven's Progressive Matrices). RESULTS: HiPRESTO and LoPRESTO CI users were discriminated primarily by performance on the SMRT and secondarily by the Raven's test. No other neurocognitive measures contributed substantially to the discriminant function. CONCLUSIONS: High- and low-performing CI users differed by spectral resolution and, to a lesser extent, nonverbal reasoning. These findings suggest that the extreme groups are determined by global factors of richness of sensory information and domain-general, nonverbal intelligence, rather than specific neurocognitive processing operations related to speech perception and spoken word recognition. Thus, although both bottom-up and top-down information contribute to speech recognition performance, low-performing CI users may not be sufficiently able to rely on neurocognitive skills specific to speech recognition to enhance processing of spectrally degraded input in adverse conditions involving high talker variability.

How Does Quality of Life Relate to Auditory Abilities? A Subitem Analysis of the Nijmegen Cochlear Implant Questionnaire.

BACKGROUND: Objective speech recognition tasks are widely used to measure performance of adult cochlear implant (CI) users; however, the relationship of these measures with patient-reported quality of life (QOL) remains unclear. A comprehensive QOL measure, the Nijmegen Cochlear Implant Questionnaire (NCIQ), has historically shown a weak association with speech recognition performance, but closer examination may indicate stronger relations between QOL and objective auditory performance, particularly when examining a broad range of auditory skills. PURPOSE: The aim of the present study was to assess the NCIQ for relations to speech and environmental sound recognition measures. Identifying associations with certain QOL domains, subdomains, and subitems would provide evidence that speech and environmental sound recognition measures are relevant to QOL. A lack of relations among QOL and various auditory abilities would suggest potential areas of patient-reported difficulty that could be better measured or targeted. RESEARCH DESIGN: A cross-sectional study was performed in adult CI users to examine relations among subjective QOL ratings on NCIQ domains, subdomains, and subitems with auditory outcome measures. STUDY SAMPLE: Participants were 44 adult experienced CI users. All participants were postlingually deafened and had met candidacy requirements for traditional cochlear implantation. DATA COLLECTION AND ANALYSIS: Participants completed the NCIQ as well as several speech and environmental sound recognition tasks: monosyllabic word recognition, standard and high-variability sentence recognition, audiovisual sentence recognition, and environmental sound identification. Bivariate correlation analyses were performed to investigate relations among patient-reported NCIQ scores and the functional auditory measures. RESULTS: The total NCIQ score was not strongly correlated with any objective auditory outcome measures. The physical domain and the advanced sound perception subdomain related to several measures, in particular monosyllabic word recognition and AzBio sentence recognition. Fourteen of the 60 subitems on the NCIQ were correlated with at least one auditory measure. CONCLUSIONS: Several subitems demonstrated moderate-to-strong correlations with auditory measures, indicating that these auditory measures are relevant to the QOL. A lack of relations with other subitems suggests a need for the development of objective measures that will better capture patients' hearing-related obstacles. Clinicians may use information obtained through the NCIQ to better estimate real-world performance, which may support improved counseling and development of recommendations for CI patients.

How does aging affect recognition of spectrally degraded speech?

OBJECTIVES/HYPOTHESIS: Cochlear implants (CIs) restore auditory sensation to patients with moderate-to-profound sensorineural hearing loss. However, the benefits to speech recognition vary considerably among patients. Advancing age contributes to this variability in postlingual adult CI users. Similarly, older individuals with normal hearing (NH) perform more poorly on tasks of recognition of spectrally degraded speech. The overarching hypothesis of this study was that the detrimental effects of advancing age on speech recognition can be attributed both to declines in auditory spectral resolution as well as declines in cognitive functions. STUDY DESIGN: Case-control study. METHODS: Speech recognition was assessed in CI users (in the clear) and NH controls (spectrally degraded using noise-vocoding), along with auditory spectral resolution using the Spectral-Temporally Modulated Ripple Test. Cognitive skills were assessed using nonauditory visual measures of working memory, inhibitory control, speed of lexical/phonological access, nonverbal reasoning, and perceptual closure. Linear regression models were tested for mediation to explain aging effects on speech recognition performance. RESULTS: For both groups, older age predicted poorer sentence and word recognition. The detrimental effects of advancing age on speech recognition were partially mediated by declines in spectral resolution and in some measures of cognitive function. CONCLUSIONS: Advancing age contributes to poorer recognition of degraded speech for CI users and NH controls through declines in both auditory spectral resolution and cognitive functions. Findings suggest that improvements in spectral resolution as well as cognitive improvements may serve as therapeutic targets to optimize CI speech recognition outcomes. LEVEL OF EVIDENCE: 3b Laryngoscope, 2018.

Cognitive Functions in Adult Cochlear Implant Users, Cochlear Implant Candidates, and Normal-Hearing Listeners.

OBJECTIVES: Increasing evidence suggests that hearing loss may be linked to cognitive decline, and that cochlear implantation may lead to improvements in cognition. The goal of this study was to examine the effects of severe-to-profound hearing loss and cochlear implantation in post-lingually deafened adults, compared with age-matched normal-hearing (NH) peers. Participants were tested on several non-auditory measures of cognition: working memory (WM) (digit span, object span, symbol span), non-verbal reasoning (Raven's progressive matrices), information-processing speed and inhibitory control (Stroop test), speed of phonological and lexical access (Test of Word Reading Efficiency), and verbal learning and memory (California Verbal Learning Test). Demographic measures were also collected. METHODS: Cohort study at tertiary neurotology center. Forty-three post-lingually deafened experienced CI users, 19 post-lingually deafened CI candidates, and 40 age-matched NH controls with no cognitive impairment were enrolled. Comparisons among the groups on the cognitive measures were performed. RESULTS: Adult CI users and CI candidates demonstrated worse (or a trend towards worse) performance as compared with NH peers on non-verbal reasoning, information-processing speed, speed of lexical access, and verbal learning and memory. However, after controlling for gender, socioeconomic status (SES), and vocabulary knowledge among groups, some of these differences were no longer significant. Similarly, large differences were not found in most cognitive abilities between experienced CI users and CI candidates. CONCLUSIONS: Adult CI users, CI candidates, and NH peers generally demonstrated equivalent non-auditory cognitive abilities, after controlling for gender, SES, and vocabulary knowledge. These findings provide support for a link between cognitive decline and hearing loss, but this association may be partly attributable to group differences in SES and vocabulary knowledge. LEVEL OF EVIDENCE: 2b.

What to Do When Cochlear Implant Users Plateau in Performance: a Pilot Study of Clinician-guided Aural Rehabilitation.

HYPOTHESIS: For experienced adult cochlear implant (CI) users who have reached a plateau in performance, a clinician-guided aural rehabilitation (CGAR) approach can improve speech recognition and hearing-related quality of life (QOL). BACKGROUND: A substantial number of CI users do not reach optimal performance in terms of speech recognition ability and/or personal communication goals. Although self-guided computerized auditory training programs have grown in popularity, compliance and efficacy for these programs are poor. We propose that CGAR can improve speech recognition and hearing-related QOL in experienced CI users. METHODS: Twelve adult CI users were enrolled in an 8-week CGAR program guided by a speech-language pathologist and audiologist. Nine patients completed the program along with pre-AR and immediate post-AR testing of speech recognition (AzBio sentences in quiet and in multitalker babble, Consonant-Nucleus-Consonant words in quiet), QOL (Nijmegen Cochlear Implant Questionnaire, Hearing Handicap Inventory for Adults/Elderly, and Speech, Spatial and Qualities of Hearing Scale), and neurocognitive functioning (working memory capacity, information-processing speed, inhibitory control, speed of lexical/phonological access, and nonverbal reasoning). Pilot data for these nine patients are presented. RESULTS: From pre-CGAR to post-CGAR, group mean improvements in word recognition were found. Improvements were also demonstrated on some composite and subscale measures of QOL. Patients who demonstrated improvements in word recognition were those who performed most poorly at baseline. CONCLUSIONS: CGAR represents a potentially efficacious approach to improving speech recognition and QOL for experienced CI users. Limitations and considerations in implementing and studying aural rehabilitation approaches are discussed.

"Product" Versus "Process" Measures in Assessing Speech Recognition Outcomes in Adults With Cochlear Implants.

HYPOTHESES: 1) When controlling for age in postlingual adult cochlear implant (CI) users, information-processing functions, as assessed using "process" measures of working memory capacity, inhibitory control, information-processing speed, and fluid reasoning, will predict traditional "product" outcome measures of speech recognition. 2) Demographic/audiologic factors, particularly duration of deafness, duration of CI use, degree of residual hearing, and socioeconomic status, will impact performance on underlying information-processing functions, as assessed using process measures. BACKGROUND: Clinicians and researchers rely heavily on endpoint product measures of accuracy in speech recognition to gauge patient outcomes postoperatively. However, these measures are primarily descriptive and were not designed to assess the underlying core information-processing operations that are used during speech recognition. In contrast, process measures reflect the integrity of elementary core subprocesses that are operative during behavioral tests using complex speech signals. METHODS: Forty-two experienced adult CI users were tested using three product measures of speech recognition, along with four process measures of working memory capacity, inhibitory control, speed of lexical/phonological access, and nonverbal fluid reasoning. Demographic and audiologic factors were also assessed. RESULTS: Scores on product measures were associated with core process measures of speed of lexical/phonological access and nonverbal fluid reasoning. After controlling for participant age, demographic and audiologic factors did not correlate with process measure scores. CONCLUSION: Findings provide support for the important foundational roles of information processing operations in speech recognition outcomes of postlingually deaf patients who have received CIs.