Tinnitus is a common problem among patients and clients seen for auditory problems. Defined as the perception of internal sounds that have no external origin, tinnitus is present in at least 10% of the adult population. Among patients seen for hearing aid fitting, a majority (60%) will report tinnitus, which is largely explained by a relatively strong association between tinnitus and hearing loss.1 As with hearing impairment, there is an association between increasing age and the presence of tinnitus.
Fortunately, only a minority of people with tinnitus are bothered by it to any significant degree. However, at least 20% of them will report major distress because of tinnitus in the domains of annoyance, insomnia, auditory intrusions, and concentration problems. For some patients seen for hearing aid fitting, tinnitus is more distressing than the hearing loss, which renders tinnitus a problem that must be addressed in most hearing aid fitting settings. Hearing healthcare professionals should also understand how tinnitus may aggravate and be aggravated by psychological problems.
COGNITIVE PROBLEMS IN TINNITUS PATIENTS
How common are concentration problems among persons with tinnitus? In a research study by Tyler and Baker, respondents were asked to list the problems they had with their tinnitus.2 The third highest response was concentration difficulties. In our own studies, we have asked directly in an interview, “Does tinnitus affect your concentration?” and as many as 70% responded that it did.3
It is unclear from the literature what kind of cognitive problems persons with tinnitus experience. A common complaint in my clinical experience is that tinnitus makes it more difficult for listeners to focus attention during conversations. While the role of hearing loss in understanding conversation is fairly obvious, many patients find that it is tinnitus more than hearing loss that makes communication more difficult.
As with most problems (e.g., pain), tinnitus tends to fluctuate, and this is also the case with the cognitive problems associated with tinnitus. For example, people with tinnitus may report that they can't concentrate on watching television after a long day at work. Another common complaint is that tinnitus makes it more difficult to read a book or newspaper. These difficulties are reflected in statements like this one: “I do not notice my tinnitus so much during the day. It is when I get home and sit down in front of the television that it becomes worse. I cannot concentrate or focus on anything but the tinnitus. Reading is impossible. I usually put on some music instead.”
Memory can also be affected, in particular in older patients who experience memory decline that may have nothing to do with the tinnitus. Some persons with tinnitus report that their mind wanders and they start thinking about other things than what they are trying to focus on, such as the newspaper they are reading. When tinnitus is annoying, the person is more likely to attend to it. Some patients monitor their tinnitus several times a day to check if it is louder, different, or in any way changing. This can become very distracting because tinnitus tends to fluctuate in loudness anyway and the loudness experience is also affected by attention. In other words, when patients listen to their tinnitus they may perceive it as louder.
In addition, tinnitus distress is linked with emotional distress (e.g., anxiety and depression). It is not uncommon for cognitive distraction to be caused by other things, such as problems at work that can preoccupy a person and make it more difficult to concentrate on a task, even a relaxing one like reading a book. Nevertheless, problems of concentration are attributed to tinnitus more often than to anxiety or depression. Thus, the person begins by focusing attention on the tinnitus and this distraction interferes with concentration on other tasks while also leading to difficulties remembering information.
Sometimes cognitive problems arise from other causes such as hearing loss or emotional distress, but the person assumes that tinnitus is the cause of their cognitive problems. Whether tinnitus is the actual cause or merely the perceived cause of cognitive problems, there is no doubt that the connection between tinnitus and cognitive performance is important for hearing healthcare professionals to understand and learn more about.
CAUSES OF COGNITIVE PROBLEMS IN TINNITUS PATIENTS
There are several possible reasons why tinnitus patients report concentration problems. These reasons are not mutually exclusive. For example, emotional distress and hearing impairment can both be part of the same clinical picture. Among the plausible reasons for concentration problems is, first and foremost, hearing loss.
Many people with tinnitus also have hearing loss and for many this is as problematic as the tinnitus, but for other reasons. Hearing loss can give rise to communication problems, which can be highly noticeable in social settings where communication breakdowns can occur and misunderstandings are frequent. Often hearing aids will help, but they are not a cure and residual problems can persist, especially in noisy environments.
For some patients whom I see in my clinic it can be hard to determine whether problems are caused by tinnitus or if they should be attributed to hearing loss. In fact, it seems likely that both problems interact so concentration is even more difficult when there is a combination of hearing loss and tinnitus.
Finding it hard to concentrate and maintain a conversation is a challenge for many individuals with impaired hearing. Even mild hearing loss can lead to fatigue, which is another common reason for concentration to fail. Straining to hear might make the patient tired, which can affect the ability to maintain focus for sustained periods of time. Some patients tend to focus on their tinnitus instead of the environment, particularly in difficult listening situations.
When we talk to tinnitus patients about concentration problems, we need to be careful because some problems might be the result of hearing loss and hence require solutions that incorporate ways to improve listening and communication. Not only hearing loss can cause fatigue. A significant proportion of tinnitus patients have insomnia,4 and in more severe cases of tinnitus this figure exceeds 50%. Loss of sleep can sometimes be the cause of perceived concentration problems.
As mentioned above, another factor that can interfere with the ability to concentrate is psychological distress. We know from research that many people with severe tinnitus are depressed and anxious. For some patients these problems can be so great that they might meet the criteria for a psychiatric diagnosis of major depression and/or an anxiety disorder.5 It is well known that depression and anxiety can have a negative influence on concentration abilities.6 For example, depressive disorders often involve concentration difficulties and memory problems. Anxiety, and in particular health anxiety, may affect concentration because it draws patients' attention toward things they fear or worry about, such as fear of their tinnitus becoming worse.
Medication, medical conditions
Another aspect of the problem relates to the effects of medication and the role of other medical conditions. For example, diabetes can be associated with impaired concentration. Some commonly prescribed medications can cause fatigue and concentration problems as side effects. While not necessarily related to a medical condition, old age can result in concentration and memory problems.
There are also cases in which other undetected medical problems can cause concentration problems. Early-onset dementia is one such problem. For the clinician, it may be necessary to refer to a neurologist or neuropsychologist to get a detailed assessment of the patient's cognitive problems and to establish if they are related to tinnitus.
Depending on the characteristics of the cognitive problems, different treatment options could be considered.7
For hearing professionals it is obviously important to consider the role of auditory impairment and the potential benefit from hearing aids. My clinical experience is that some patients benefit immensely from the increased auditory input provided by hearing aids and that this input sometimes leads to reduced awareness of tinnitus and also reduced concentration problems in relatively easy listening and communication situations.
Far from all patients fitted with hearing aids experience relief from tinnitus and it may be important to counsel patients not to have exaggerated expectations of what hearing aid(s) may do for their tinnitus.
When working in a multidisciplinary team, it is important to provide adequate descriptions of the treatments provided, including a rationale for how they may work. Some patients with cognitive problems may have difficulty understanding and remembering the session, so it is preferable for their significant others to be involved. Indeed, a special kind of memory deficit relating to episodic memory can sometimes be impaired in tinnitus patients.8 There are, however, many ways to support patients by helping them recall the material covered in treatment consultations. Summaries can be provided and text material can be used as handouts. For example, this is suitable when giving advice and exercises relating to insomnia.
Cognitive therapy techniques can be used to help patients get a better understanding of tinnitus and adjust maladaptive thoughts and beliefs regarding tinnitus.9
In the treatment protocol we have developed in Sweden, we include advice regarding concentration problems. This involves structuring information, taking pauses, repetition, and memory aids (e.g., notes). Also important is a proper description and understanding of memory and concentration. For example, it can be helpful to describe the difference between encoding (taking in information) and later recall of the information since misunderstandings could arise either because the information was not heard or not understood in the first place or because it was not remembered.7
INTEGRATING APPROACHES TO MANAGEMENT AND RESEARCH
The current trend in tinnitus research is mostly focused on finding a cure. I am very positive about these efforts and a cure would certainly be welcome. However, we are not yet there, and even if it becomes possible someday to cure some forms of tinnitus, there will most likely still be a need for rehabilitation in a multidisciplinary setting. Therefore, we need to better understand the mechanisms behind tinnitus annoyance. Cognition is probably important. Research on the cognitive aspects of tinnitus is still sparse, but promising new studies on working memory are being published,10 though not all show clear results.11
We proposed a model outlining three pathways through which cognition influences tinnitus annoyance,12 as shown in Figure 1. According to the model, tinnitus is likely to become a real problem when it interferes with the patient's thinking capacity, when his or her general outlook in life is either anxious or pessimistic, and when tinnitus is seen as the cause of associated problems (e.g., insomnia).
The model also suggests that there might be “escape routes.” For example, it is not sufficient that the patient attend to his/her tinnitus, as many people with tinnitus will not be disturbed much by their tinnitus even if they hear it clearly. However, when tinnitus is appraised as a serious problem and as the cause of other problems (including insomnia and lack of concentration), this is a sufficient and necessary condition for it to become annoying. The clinical management of tinnitus has probably not fully realized the importance of taking cognitive problems into account during assessment or incorporated cognitive behavior therapy during treatment to the extent that could be optimal. Much more research is needed, including investigations into the brain mechanisms involved in annoyance from tinnitus.13
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10. Rossiter S, Stevens C, Walker G: Tinnitus and its effect on working memory and attention. J Sp Hear Lang Res 2006;49:150–160.
11. Andersson G, Edsjö L, Kaldo V, Westin V: Tinnitus and short-term serial recall in stable versus intermittent masking conditions. Scand J Psychol, In press.
12. Andersson G, McKenna L: The role of cognition in tinnitus. Acta Otolaryngol 2006;126:39–43.
13. Eggermont JJ: Tinnitus: Neurobiological substrates. Drug Discovery Today 2005;10:1283–1290.
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