Hearing Loss and Dementia; Burden of Death From Bacterial Infections

This post originally appeared on MedPage Today: Pain Management.

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include stopping cervical cancer screening, low-dose opioids for breathlessness in COPD, the burden of death from bacterial infections worldwide, and hearing loss and dementia.

Program notes:

0:40 The global burden of bacterial infections and death

1:40 Four times as many deaths in low income countries

2:40 Treating the right bacteria

3:10 Can we associate hearing loss with dementia?

4:12 1,200 participants

5:12 Three previous studies

6:12 Social withdrawal and depression

6:45 Breathlessness in COPD

7:45 Treated over 3 weeks with low-dose opioids

8:30 Skipping cervical cancer screening

9:30 How many women still being screened?

10:30 Two normal HPV tests

11:30 If you’ve had negative screening before

12:33 End


Elizabeth: Is it okay to stop cervical cancer screening when you’re older than 65?

Rick: Global mortality associated with different bacterial infections.

Elizabeth: Is hearing loss associated with the development of dementia?

Rick: And can low-dose morphine cure breathlessness in people with COPD?

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we start first with yours? That’s one taking a look at this bacterial infections and death.

Rick: This is the first time we have reported on bacterial infections worldwide — 33 different pathogens, 11 different infectious syndromes — because we have just now recently had the data to do that, using data that’s fairly recent from 2019. What they discovered in looking at over 343 million individual records is there were 7.7 million deaths associated with bacterial infections. It’s the second leading cause of death worldwide.

Of the 33 different pathogens, over 55% of the infections were due to five specific bacteria: Staph aureus, E. coli, Strep pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. There was a tremendous amount of regional variability. For example, most of the bacterial infections occurred in sub-Sahara Africa and in low and middle-income countries as compared to high-income countries. In fact, there were four times as many deaths from bacterial infections.

Elizabeth: Remind me again, which journal this was in?

Rick: This was reported in The Lancet.

Elizabeth: I guess I’m just a little bit surprised that it’s taken this long to get our arms around this and I would ask you to just reflect on what you know clinically. Are you surprised that it is such a really common cause of death?

Rick: I am, Elizabeth, because we live in obviously a high-income country. We don’t see quite as many deaths as are reported worldwide. I was struck by the enormity — to think that this is the second leading cause of death behind ischemic heart disease. Many of these deaths are preventable. Preventing infections: that means sanitation, access to healthcare, identifying bacterial infections when they occur, what antibiotics might be effective, and appropriate use of antibiotics.

Elizabeth: I’m also wondering with our increasing problem with antimicrobial resistance, which we’re also seeing worldwide — I’m wondering if we’re going to be expanding that list of pathogens that are especially problematic.

Rick: We clearly have spent a lot of time talking about treating the right bacteria with the right antibiotics for the right duration of time. But many of these individuals that die just don’t have access to antibiotics at all.

Elizabeth: The other piece of data that I would really like to have here would be some analysis of comorbidity.

Rick: Unfortunately, we don’t have all that information when you’re looking at 343 million individual records, although it’s clear that there are geographic and social disparities.

Elizabeth: Since we’re in The Lancet, let’s stay there and let’s take a look at this perennial issue — becoming a perennial issue — of, can we associate hearing loss with the development of dementia? Over the years, we have reported that in fact there was an association there and we thought, or at least I thought, that was pretty well established. This study seems to cast some doubt on that hypothesis.

This is a study that’s from the Mayo Clinic Study of Aging. It’s a prospective population-based study looking at mild cognitive impairment and dementia in Olmsted County, Minnesota, which is a high-income place with a lot of healthy lifestyle kind of people. They have neuropsychological testing and enrollment in every 15 months. They also, in this study, had formal behavioral audiometric evaluation by an audiologist.

They had two measures: what’s called pure-tone average (PTA) and word recognition scores (WRS). They looked at this relationship between those and the development of dementia. There were 1,200 eligible participants and the mean age at enrollment was 79 years. During this time, of course, we watched these ends drop substantially. [A total of] 207 developed dementia during a mean period of follow-up of 7 years.

The surprising upshot of this study is that neither decline in pure-tone average or word recognition scores was associated with the development of dementia. However, they did note that informant-based — so I’m assuming that that’s your spouse or your significant other — hearing difficulties assessed by the participant’s study partner were significantly associated with the development of dementia.

What was impacted by these declining scores was poor performance on cognitive testing. It casts some doubt on this notion that, gosh, if we improve somebody’s hearing we can potentially stave off dementia.

Rick: I agree with you. There were three previous studies that suggested there was an association between hearing loss and dementia. As you mentioned, there were 1,200 individuals followed over the course of at least 7 years — these are people that would be at increased risk — and very formal hearing testing. That’s why this study differs from some of the other ones. Now, what we need to do is we need to say, “What’s the association between hearing loss and cognitive impairment or cognitive decline? How can we ameliorate that?”

Elizabeth: What’s the difference between cognitive decline and dementia? It seems to me that it’s just earlier on the continuum.

Rick: That’s one possibility, although I think we would agree that there is a vast difference between the two. A lot of people will say, “Well, this hearing loss is associated with cognitive loss or dementia; therefore, we need to improve the hearing and therefore we’ll delay those.” But there is no evidence that that’s the case either. Slapping a pair of hearing aids in someone may not prevent their cognitive decline or their dementia.

Elizabeth: However, I think that we could agree that most of the evidence anyway right now suggests that as people’s hearing declines and they have social withdrawal, incidence of things like depression and anxiety go up. I think there is pretty good compelling evidence that doing something about it is probably a good thing.

Rick: There is evidence, as you said, an association with decreased communication and isolation, loneliness, and depression. But a lot of people with hearing loss, they change their social behavior. It is nice to know now that you don’t need to have a prescription to get hearing aids. It’s relatively inexpensive now; people can correct some of their hearing loss.

Elizabeth: And stay engaged, because we know that that’s helpful as we age.

Rick: Yeah. Let’s move on to JAMA and let’s talk about a condition — that is, breathlessness — that frequently occurs in people that have chronic obstructive pulmonary disease. That breathlessness is a chronic condition, and oftentimes that persists despite the treatment. It affects their daily living; it affects their quality of life. Because of the breathlessness, they have decreased physical activity so they get deconditioned, and it makes the breathlessness even worse.

What these authors noted was that when people have acute, severe, end-stage COPD, oftentimes morphine is given to decrease that sense of breathlessness. What about administering it in low-dose, but an extended-release morphine — can that actually improve breathlessness in this population?

They looked at 160 people and they were randomized to receive either placebo or 8 mg daily of sustained-release morphine, or 16 mg. They looked at them after a week. Then after a week, they increased the dose, and even after the third week. People could be getting anywhere from zero amounts to as much as 64 mg of morphine over the course of 3 weeks. They measured breathlessness and they also measured their ability to walk.

I’m sorry to report that it didn’t matter what dose was given — there was no improvement in shortness of breath and that people did not increase their physical activity at all.

Elizabeth: This is so disappointing, isn’t it? Because I just wonder about the positive feedback loop that’s represented by breathlessness and inactivity, and how to interrupt that.

Rick: We know that pulmonary rehabilitation and physical therapy can improve their exercise capacity and can actually reduce dyspnea, even though their lung function is not normal.

Elizabeth: I guess that’s good news because as we know right now there is substantial resistance for prescription of opiates of any type.

Rick: Absolutely. There is no rationale for using it for these patients.

Elizabeth: Finally, let’s turn to JAMA Internal Medicine, something else that we can give a miss to. This was a look at Medicare beneficiaries and whether they were still being screened for cervical cancer, largely using pap smears but also using HPV testing.

They used data over 21 years for women aged 65 to 114 years old who were Medicare fee-for-service recipients and their outcome measures were testing modalities including cytology, cytology plus HPV testing, or HPV testing alone, to see after the age of 65 how much of this were you still getting.

They did note that women who received at least one cytology or HPV test decreased from almost 19% in 1999 to 8.5% in 2019. Colposcopy and cervical procedures decreased 43% and almost 65% respectively.

However, when you took a look at, all right, how many women were still getting it and what was the cost to the system, the total Medicare expenditure for all of these services in 2019 was at $83.5 million. That’s a lot of money that’s being expended on testing that really is not indicated.

Rick: I agree with you; the USPSTF recommends that women over the age of 65 do not need to be continued to be screened if they have followed the normal screening patterns beforehand and they have never had a high-grade lesion before.

Unfortunately, what this study says is there are a lot of women over 65 that received screening, but it doesn’t tell whether that was appropriate or inappropriate. The current recommendations is that all women with a cervix should begin screening starting at age 21 or 25 years of age. If all the results are normal and the woman has had at least 3 normal pap smears or 2 normal HPV tests during the past 10 years, then over the age of 65 they don’t need to be screened. But if they haven’t had those, let’s say someone comes to your office at age 66 or 67 and says, “Well, I didn’t have that,” they actually do need to be screened.

If a woman has had a high-grade lesion on pap smear, then that woman needs to be followed for 25 years, regardless if even that extends past the age of 65. The message I want our listeners to get is, yes, if you’ve been properly screened and you’ve never had a high-grade lesion, over the age of 65 you don’t need to have it.

Elizabeth: I think it’s easy for us to sort of grab people and say, “Wow, we’ve got you into the medical system and because we have you let’s go ahead and screen because we know that the yield of screening is usually much better because we can identify cancers early.” But I think it does result in a lot of overuse of these services.

Rick: I suspect, Elizabeth, some of those are overused. Unfortunately, this study doesn’t give us that information. But what I don’t want our women listeners to go away thinking is, “Gosh, just because I turned 65 I don’t need to be screened.” No. If you had negative screening before in the previous 10 years multiple times, you’re fine.

Elizabeth: And two other situations where screening may still be appropriate are women who have had in utero exposure to diethylstilbestrol or if they have a compromised immune system. In those women, if they are HPV positive, it could result in cervical cancer even later on in life. Those women also might want to consider this and discuss it with their provider.

Rick: Right. Again, the best way to prevent cervical cancer is two things. One is get the appropriate screening before the age of 65 and vaccinate people ages 9 to 14, and even up to age 26 years, with the HPV vaccine. We know that’s effective too.

Elizabeth: Exactly. Lots of good news there. On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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This post originally appeared on MedPage Today: Pain Management.