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Eriksholm Workshop on Hearing Impairment and Cognitive Energy

Pichora-Fuller, M. Kathleen; Kramer, Sophia E.

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doi: 10.1097/AUD.0000000000000306
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This special issue is the product of the Eriksholm Workshop on Hearing Impairment and Cognitive Energy held June 3 to 5, 2015, at the Eriksholm Research Centre, Denmark. It was the fifth Eriksholm Workshop. The purpose of the Eriksholm workshops has been to foster expert discussion and develop consensus on emerging topics of importance in audiology. Previous workshops produced consensus articles on the topics of auditory deprivation and acclimatization in 1996 (Arlinger et al. 1996), self-report outcome measures in audiological rehabilitation in 1999 (Cox et al. 2000), candidature and delivery of audiological services for the special needs of older people in 2001 (Kiessling et al. 2003), and wideband absorbance measures of the middle ear in 2012 (Feeney et al. 2013). The present workshop built on the prior workshops. In particular, it built on the work of the third Eriksholm Workshop (Kiessling et al. 2003) that highlighted the need to take both auditory and cognitive factors into account when considering age-related changes in hearing, listening, comprehending, and communicating.

Traditionally, audiologists have been concerned mostly with peripheral auditory processing. Basic assessment has relied on tests using simple stimuli and tasks, such as detecting pure tones and repeating isolated words. In contrast, participating in society is far more complex. Research on cognition began to converge with hearing research because of increasing awareness that we need to understand more about how (older) listeners function in ecologically realistic communication situations. New models were proposed to explain how sensory loss affects cognitive processing during language understanding in noise. Furthermore, researchers tried using various behavioral and physiological methods to measure listening effort; however, inconsistent results suggest that these measures do not all index the same thing. Conceptual confusion prevails, and no model can adequately explain what underpins the complaints of people who are older and/or hard of hearing when they report that it is effortful or fatiguing to listen.

Recognizing the importance of this topic, Graham Naylor and Thomas Lunner applied for and received funding from the Oticon Foundation for an Eriksholm Workshop. They chose the general term cognitive energy for the title in the hopes that it would facilitate the broadest possible discussion of the topic. A similar term, psychic energy, had been used over a century ago by Titchener (1908) to refer to the notion that limited mental resources can be flexibly allocated among perceptual and cognitive activities. We were invited to be the independent scientific co-convenors of the workshop. We assumed full responsibility for it, including selecting and inviting experts and planning the agenda. Our aim was to consolidate information and develop consensus about what is known on the topic, gaps in knowledge, the use of terminology, research priorities, and implications for practice. Funding covered the expenses of the workshop participants and the publication of this special issue. The 16 workshop participants included experts from different relevant disciplines, including audiology, engineering, neuroscience, speech perception, gerontology, philosophy, and many subfields of psychology: cognitive psychology, neuropsychology, motivational psychology, social psychology, and health psychology. We decided to include four experts working in industry (Edwards, Lemke, Lunner, and Naylor) because of their relevant scientific research contributions. Ben Hornsby was invited to be a workshop participant, but because he was unable to attend, his co-author Graham Naylor participated instead.

The workshop was organized around three areas: (1) theories, models, concepts, definitions, and frameworks; (2) methods and measures; and (3) knowledge translation. Participants presented articles during the first half of the workshop, and the second half was used for consensus development. After the workshop, manuscripts were prepared based on the articles that had been presented. The articles offer different perspectives and vary in format, including reviews and empirical studies. The organization of the articles in the special issue appears in Table 1. Each manuscript was reviewed by at least three workshop participants. As a supplement to Ear and Hearing, the contents of this issue have not undergone the regular peer-review process, but they have been scrutinized and commented on by members of the Editorial Board of Ear and Hearing, with the goal of ensuring clarity and coherence. This nontraditional method of peer review was preferred because the articles form a collection of interrelated works sharing the common context of the workshop. The same procedure had been used for previous special issues on Eriksholm Workshops.

The articles in the Special Issue on the Eriksholm Workshop on Hearing Impairment and Cognitive Energy are listed with brief summaries. The first article is the consensus article and the remaining articles are organized into three categories as shown below.


The first three articles in the collection set the stage for the rest of the articles. The first is written from the perspective of philosophical theories of motivation. Matthen (2016, this issue, pp. 28S–34S) suggests that pleasure can motivate effortful listening. He challenges audiologists to consider how people who are hard of hearing might be trained to enjoy the pleasure of listening, thereby achieving motivational balance in demanding situations when the positive value of listening warrants the effort spent. (Dis)pleasure in listening (the hardness of hearing) is illustrated by comparing two individuals whose experience of hearing loss differs. One of them is Furness whose photo (see Matthen 2016, this issue, pp. 28S–34S) illustrates that, despite his hearing loss, he is motivated to enjoy conversing with his grandchild while using an ear trumpet. Next, Wingfield (2016, this issue, pp. 35S–43S) synthesizes the history of models of cognitive energy and recommends that, rather than proposing yet another model, it would be more advantageous to recognize the core ideas common across models. Phillips (2016, this issue, pp. 44S–51S) extends the review of cognitive models to consider the everyday functioning and clinical management of special populations, including bilinguals and older adults who have cognitive impairments or dementia.


The next six articles address the behavioral research on cognition and listening. The first three articles in this section provide experimental evidence focused on sensory-cognitive interactions and cognitive studies of speech understanding. Humes and Young (2016, this issue, pp. 52S–61S) review evidence of a link between speech understanding and age-related sensory and cognitive declines. Sommers and Phelps (2016, this issue, pp. 62S–68S) use N-back memory measures to show that the audiovisual advantage of speechreading reduces perceptual effort more for younger than for older adults. Rudner (2016, this issue, pp. 69S–76S) describes three experimental tests of cognitive spare capacity that reveal the influence of interindividual differences in linguistic and cognitive abilities and intraindividual differences due to input-related demands as conditions vary in terms of the quality of the speech signal, background noise, and/or hearing aid processing. The fourth article in this section explores different concepts and uses of the term listening effort, especially as they apply to older adults (Lemke & Besser 2016, this issue, pp. 77S–84S). The fifth article in this section broadens the focus on listening effort beyond speech understanding to include listening to nonspeech signals (e.g., music and environmental sounds) and demands related to auditory scene analysis (Edwards 2016, this issue, pp. 85S–91S). The final article in this set examines possible connections between cognitive and social factors that could modulate listening effort (Pichora-Fuller 2016, this issue, pp. 92S–100S).


In this section, five articles showcase physiological research on listening effort. Eckert et al. (2016, this issue, pp. 101S–110S) explain how the neuroeconomics of listening relates to effort and fatigue. They use functional brain imaging to show that the cingulo-opercular system is crucial in adaptive control and monitoring the outcomes of listening. Richter (2016, this issue, pp. 111S–117S) draws on Motivational Intensity Theory and uses cardiovascular reactivity to show how success importance moderates the investment of effort to meet listening demands. Mackersie and Calderon-Moultrie (2016, this issue, pp. 118S–125S) review studies of autonomic nervous system reactivity in which the measures of heart-rate variability and skin conductance are used to index sympathetic and parasympathetic activity during the performance of auditory tasks. Kramer et al. (2016, this issue, pp. 126S–135S) present the results of a pilot study revealing differential effects on subjective and physiological measures of cognitive load or stress, including pupillary responses and two endocrine stress biomarkers (cortisol and chromogranin A), during speech testing in listeners with normal or impaired hearing. In the final article in this section, Hornsby et al. (2016, this issue, pp. 136S–144S) outline a taxonomy of fatigue concepts and explain how these might be related to hearing loss.


The special issue concludes with two articles on knowledge translation. These articles consider the clinical implications of advances in research and possible applications in rehabilitation. Lunner et al. (2016, this issue, pp. 145S–154S) demonstrate how memory measures can be used to compare the effectiveness of two types of bone-anchored hearing aids in ecologically plausible signal-to-noise conditions where word recognition is an insensitive measure because accuracy is at ceiling. Tremblay and Backer (2016, this issue, pp. 155S–162S) take the perspective of the rehabilitative audiologist in discussing why future research should be pursued and what remains to be learned before measures of listening effort will be ready for clinical implementation.


The pleasure of engaging in stimulating discussions about this topic motivated us to sustain a high level of effort during the workshop as we defended divergent viewpoints and tried to resolve contentious points. In the months after the workshop, discussions continued in e-mails and conversations among the workshop participants and other colleagues at three conferences held in October 2015: the meeting of the International Collegium of Rehabilitative Audiology in Berkeley, California; the Aging and Speech Communication Conference in Bloomington, Indiana; the Canadian Academy of Audiology Conference in Niagara Falls, Ontario. A consensus emerged in favor of a paradigm shift that would integrate and adapt existing concepts, theories, and models in a new Framework for Understanding Effortful Listening (FUEL). We considered prior models and decided that, at least for now, it would be most advantageous to adapt the model described in the seminal book Attention and Effort by Kahneman (1973) in which he tackles both the cognitive and physiological aspects of mental effort. Matthen’s example of Furness (Matthen 2016, this issue, pp. 28S–34S), who uses an ear trumpet in the famous photo, is about more than age, hearing loss, cognition, the accuracy of word recognition, or the use of technology (whether ear trumpet or modern hearing aid) (Figure 1 in Matthen 2016, this issue pp. 28S). Importantly, the pleasure of communicating motivates Furness to expend listening effort. Our proposed FUEL illustrates how the amount of listening effort allocated to a task depends on the sorts of demands that are familiar to audiologists, but also on the listener’s motivation or arousal. The three-dimensional figure (Fig. 2) in the consensus article (Pichora-Fuller et al. 2016, this issue, pp. 5S–27S) illustrates that effort depends on both demands and motivation. Similar to Kahneman’s allocation policy, at the core of our FUEL is the listener’s evaluation of the importance of success in communication and social participation. Motivation has been largely overlooked in recent research on listening effort, but it is an important mediating or moderating factor that may go a long way to explaining why listeners quit or persist in challenging situations.

Fig. 1.
Fig. 1.:
Back row (left to right): Thomas Lunner, Ulrike Lemke, Mitch Sommers, Graham Naylor, Brent Edwards, Larry Humes, Michael Richter, Mark Eckert, Carol Mackersie, and Mohan Matthen; Front Row (left to right): Natalie Phillips, Sophia Kramer, Kathy Pichora-Fuller, Art Wingfield, Mary Rudner, and Kelly Tremblay.

In conclusion, we hear with our ears, we listen with our brains, and we exert listening effort because we are motivated to communicate. We hope that this special issue provides a useful account of current knowledge and that the priorities we identified inspire future research. We look forward to ongoing discussions and hope that our FUEL will fuel advancing research and practice to improve the lives of the many people who find it effortful to listen.


We thank the workshop participants for their hard work, the Oticon Foundation for their financial support, and staff at Eriksholm for facilitating the workshop. We wish to acknowledge the excellent feedback we received from many colleagues who were not workshop participants. Alexander Francis shared information from the special sessions he organized on “Listening Effort” at the 169th Meeting of the Acoustical Society of America, May 2015. Erv Hafter and Frederick Gallun provided helpful comments about the applicability of a signal-detection approach to listening effort. Dorothea Wendt helped to create the 3D figure for the consensus article.

M. Kathleen Pichora-Fuller
Department of Psychology
University of Toronto
Mississauga, Ontario, Canada
[email protected]

Sophia E. Kramer
Department of Otolaryngology-Head and Neck Surgery
Ear and Hearing Section and the EMGO Institute for Health and
Care Research
VU University Medical Center
Amsterdam, The Netherlands


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