Cognitive assessment in hearing aid clinics: Is it feasible to implement in a National Health Service (NHS) setting?

Abstract

Background

Cognitive impairment is common in older adults and negatively affects hearing aid use. Audiologists hold the opportunity to identify signs of undiagnosed cognitive impairment and tailor care to optimise hearing aid use.

Objective

To assess the feasibility of introducing a brief cognitive assessment in hearing aid appointments for older adults.

Methods

Prospective feasibility cohort study incorporating quantitative and observational data. Participants were patients aged ≥65 years, new or existing hearing aid users, attending an NHS community hospital hearing aid clinic. Clinical audiologists were trained to conduct the Ascertain Dementia 8 (AD8) and visually-adapted shortened version of the Montreal Cognitive Assessment (mini-MoCA). A research audiologist took informed consent, observed appointments recording outcomes and followed up participants at 3 months. Feasibility was assessed using the following outcome measures: practicality of implementation in a clinical setting and resource requirements; acceptability in terms of recruitment/completion rates; onward care; experiences through standardised intensity scoring of observed emotions and analysis of free-text observations of participant reactions, participants’ comments and informal conversations with clinical audiologists.

Results

Twenty patients were recruited, average age 78.6 years, 14 (70%) attended alone. All completed cognitive assessment, average duration was 14 minutes. AD8 and mini-MoCA average scores were 2.4 (range: 0–7) and 12.8 (range: 8–15), respectively. Ten (50%) participants had AD8 scores and one (5%) a Mini-MoCA score indicating potential cognitive impairment. Four of those (40%) contacted their GP, three were referred for further cognitive evaluation, one was diagnosed with dementia, two were awaiting appointments.

Conclusions

Introducing cognitive assessment in hearing aid clinics seems feasible and may provide an opportunity for identifying cognitive impairment in older adults, though further research is needed to establish its clinical utility and impact on care pathways. There are considerable resource implications, highlighting the importance of involving professional organisations, healthcare funders and policy makers early in this discussion.

Keywords

Hearing loss dementia cognitive impairment cognitive function geriatrics

Introduction

The Lancet Commission on Dementia Prevention, Intervention, and Care identified hearing loss acquired in mid-life as one of the largest potentially modifiable risk factors for dementia, contributing to an estimated 7% of dementia risk.¹ Whilst emerging evidence suggests potential benefits of hearing intervention on cognitive outcomes, the relationship is complex and evidence on this topic is incomplete. Some studies provide supporting evidence for the protective effect of hearing aid use against dementia and cognitive decline in older adults,^2–5 while others showed mixed⁶ or conflicting⁷ evidence, and research is ongoing. Effective hearing aid use relies on cognitive skills including attention, working memory, executive function and the ability to adapt and learn new sounds. There is evidence that hearing aid use in the general population worldwide remains low, well below the proportion of the people who would benefit from this intervention.^8,9 In the UK, only 43%–65% of older adults aged ≥55 with self-reported hearing loss adopt the use of hearing aids, despite free provision on the National Health Service (NHS).¹⁰ The evidence for specific difficulties with hearing aid use in those with cognitive impairment is more limited but it does point to increased difficulties in obtaining and regularly using hearing aids, as there may be a lack of awareness of the benefits of hearing aids and issues with forgetting to use or misplacing them.^11–14

Audiologists have opportunities to identify signs of cognitive impairment in older patients in whom cognitive changes have not yet been clinically diagnosed, and provide tailored hearing care to optimise hearing aid use to those who need it. In line with the broader approach of the Making Every Contact Count (MECC): Consensus Statement 2016 for healthcare workers,¹⁵ audiologists could utilise their interactions with older adults to have a conversation about memory and encourage those who express concern or show signs of memory problems to consult their GP, opening the door to more timely diagnosis, support and treatment.^16,17 A recent study using the Mini-Cog test in private hearing aid dispensers in the Netherlands found that approximately one in five older adults had results suggesting the presence of cognitive impairment.¹⁸ In the memory service setting, patients with mild cognitive impairment (MCI) undergoing an audiology assessment routinely as part of their memory clinic assessment reported satisfaction with this process.¹⁹ However, there remains a lack of integration between NHS hearing and memory service pathways. Our survey among UK audiologists²⁰ identified that 75% of respondents estimate that more than a quarter of their older adult patients may have significant cognitive impairment. However, only 4.5% address this topic with their patients and 2.6% perform a cognitive assessment as part of their practice. Barriers cited include a lack of training, time, and resources and uncertainty about what to do with the results.

To better understand these barriers and initiate change, we introduced two brief instruments to assess early cognitive impairment in older adults attending a NHS hearing aid clinic and studied its feasibility in terms of recruitment and completion, impact on service and onward care, and explored patient and professional views on this intervention.

Methods

We conducted a prospective cohort study assessing the feasibility of introducing a brief cognitive assessment in NHS routine hearing aid appointments for older adults, incorporating quantitative and observational data. The study was conducted in accordance with the Helsinki Declaration of 1975 as revised in 2013. All patient details have been de-identified.

Participant selection involved a pragmatic convenience sample of patients attending hearing aid clinics, supporting the generalisability of our findings. Eligible were male or female patients aged 65 years and over, either new or existing hearing aid users and scheduled for an NHS hearing aid assessment appointment in Edgware Community Hospital, part of University College London Hospitals NHS Trust audiology services. The rationale for including patients aged ≥65 years is that 65 years is the age where cognitive impairment becomes more prevalent. For instance, prevalence of dementia is 1–2/1000 in those younger than 65 years of age, while it is 5%–7% in those 65 and older.²¹ There is also greater clinical need and urgency for early cognitive assessment in older adults.²² Additionally, this age group aligns with NHS audiological services’ main user demographic.^23,24 The inclusion of both new and experienced hearing aid users was chosen to reflect the real-world clinical population in hearing aid clinics in which we would foresee to introduce this service innovation. Patients were excluded if they lacked capacity to consent to the study, as assessed by the researcher. The researcher conducting the consenting process is experienced in research consent and assessed that all participants were able to demonstrate understanding of the study and provide informed consent themselves. We did not specifically exclude those with cognitive impairment if it did not result in lack of capacity to consent.

The sample size was 20, chosen pragmatically based on feasibility study guidance suggesting 12–30 participants for preliminary feasibility assessment and taking into consideration our available resources and time-frame.²⁵ This was not a powered sample size but aimed to provide initial insights into implementation challenges.

Feasibility outcomes were selected to address key implementation questions in preparation for a wider NHS service innovation project, in accordance with the conceptual framework for feasibility studies in healthcare implementation research.^26,27

Practicalities (to assess resource implications):

time to approval of NHS audiology service managers to conduct the study and deliver the intervention.

training requirements for clinical audiologists to perform the cognitive assessment.

impact of the intervention on the clinical service, i.e. staff and space requirements, duration of appointments.

Recruitment and completion (to assess acceptability):

proportion of patients accepting to take part in the study and undergo a cognitive assessment.

proportion of patients completing the cognitive assessment.

Impact on onward care (to evaluate pathway integration):

follow-on actions regarding onward care of those identified with potential cognitive impairment.

Experiences (to understand stakeholder perspectives):

views of patients, their companions, audiologists and referring clinicians on the intervention.

We chose the Ascertain Dementia 8 (AD8) questionnaire²⁸ and a shortened version of the Montreal Cognitive Assessment (mini-MoCA) adapted specifically for individuals with hearing loss where visual presentation replaces verbal instruction.^29,30 These are brief instruments validated to screen for dementia, selected to assess different aspects of cognitive function – the AD8 for informant-reported functional changes and the mini-MoCA for direct cognitive assessment. The AD8 was completed on an iPad by an accompanying person or carer, or by the patient if they attended the clinical appointment alone. The clinical audiologist provided support as required. The mini-MoCA adapted for visual delivery was presented on a computer screen by the clinical audiologist, who guided the patient to read the instructions, progressed the slides and recorded the results. This is a distinct instrument from the original full MoCA, and has been validated and published separately for use in hearing-impaired populations by our research team.²⁹ All clinical audiologists received structured training in administering this adapted tool, including standardised scoring procedures, as part of our study protocol.

From October 2021 audiology service leads were approached for guidance on how to embed the study into the clinical service. Local approval was granted in March 2022 to add 15 minutes for cognitive assessment to the 60-minute routine hearing aid assessment appointments at the end of a morning and afternoon clinic session. Between 4 May 2022 and January 2023, the lead researcher (RO), an audiovestibular physician with expertise in hearing health and its relationship with cognition, provided an hour-long one-to-one training to four out of the team of clinical audiologists on the association between hearing loss and dementia, study design and processes, and how to conduct the cognitive assessment and discuss its result. No training or guidance was given on whether or how to tailor hearing care to those identified with potential cognitive impairment. The clinical audiologists each spent another hour of self-directed training on hearing loss and cognitive impairment, which included structured online modules about hearing-cognition relationships and cognitive assessment procedures (Appendix 2).

Potentially eligible patients were identified from referrals in the UCLH Epic electronic health record system and selected consecutively. They were sent a study participant information sheet between one to three weeks in advance of their hearing aid appointment. Upon arrival at their clinic appointment, the research audiologist met them in a separate clinic room, explored their interest in the study, verified they had received and read the participant information sheet, explained the study and procedures, answered questions and obtained signed informed consent.

The clinical audiologist conducted the appointment as follows: standard audiological history, explanation and completion of the AD8 and mini-MoCA and discussion of their results, audiological assessments, aural impressions, demonstration of hearing aids. For new hearing aid users, a follow-up appointment was made for hearing aid fitting.

The research audiologist observed the appointment and documented the emotions displayed by the patient on a 4-point scale of emotion intensity (1 = very low to 4 = very high) for each of four canonical emotions³¹: happiness/contentment, anger, fear/anxiety and sadness. This emotion intensity scale was used as an exploratory observational tool, scored based on the subjective rating of the observing research audiologist, and was not a validated instrument. Impressions of reactions displayed by the patient, companion and clinician during the cognitive assessment and discussion of results were documented as free text. They also recorded the timings of the cognitive and audiological assessments and discussion of results and any other observations about the appointment as free text. Data were transferred to an electronic Case Report Form (CRF) (Appendix 1).

Patients whose AD8 or mini-MoCA score indicated potential cognitive impairment, i.e. an AD8 score higher than one out of eight²⁸ or mini-MoCA score lower than nine out of 15²⁹ or who expressed concern about their memory, were advised to contact their GP. Informed consent for the study included permission to send the results of the cognitive assessment to the GP, and participants were reminded of this prior to the results being sent to their GP. Decisions on onward referral for further cognitive evaluation were left to the discretion of the GP.

A telephone follow-up was arranged for all participants 3 months after the hearing aid appointment, during which the research audiologist recorded whether they had contacted the GP about the outcome of the cognitive assessment, whether any further cognitive evaluation had taken place and its outcome. Participants and their companions were also asked to provide feedback on their experience with the study intervention. These included how acceptable the cognitive assessment was on a 4-point scale, and standard follow-up questions recorded as free text on how they felt about the routine introduction of a cognitive assessment in hearing aid appointments, focussed on feasibility outcomes including duration and timing of the cognitive assessment, impact on the appointment, explanation of results and any concerns. The lead researcher (RO) collected feedback from clinical audiologists on their experience with the study through informal conversations, recorded as free text.³² Free text comments were presented within our pre-defined feasibility framework in terms of practicalities, acceptability and impact of service delivery, integrating quotes to provide a more complete picture of implementation challenges and opportunities. Descriptive statistics are used to present numerical results. This approach of exploratory qualitative data collection rather than formal qualitative research reflects our study's primary aim of assessing feasibility of clinical implementation while making appropriate use of participant and clinician perspectives to inform future service development. While this approach was appropriate for our feasibility objectives, future studies focusing specifically on stakeholder experiences would benefit from formal qualitative methodology.

We acknowledge subjectivity in our data collection and interpretation which could lead to potential biases and preconceptions. Researcher reflexivity statements are provided in the ‘Statements and Declarations’ section below.

The reporting of this study conforms to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines.³³

Results

Practicalities

Time of approval of NHS audiology service managers to conduct the study and deliver the intervention was 5 months. Training for clinical audiologists involved a one-hour face-to-face session and one hour of self-directed learning. Clinical audiologists commented on the importance of training on how to bring up the topic of cognition when taking a history from their patients, and that the training provided for the study equipped them with the necessary knowledge and skills to conduct the tests effectively: ‘You need to learn how to talk to patients about it (memory loss), like how we've learnt to talk to patients about hearing loss and counsel them on hearing loss’. (Audiologist 1)

A separate clinic room was required for taking informed consent, and 15 minutes extra time was added to specific clinic slots at the end of a morning and afternoon clinic session. Whilst the audiologists did not feel the extra time for the cognitive assessment significantly impacted the smooth running of the appointment, implementing this routinely would require restructuring of workflow and allocation of appropriate time and resources. They also questioned how willing audiologists would be to adopt this in practice:

I don't know how accepting clinicians would be of it because they'd just find it another step. A whole other part that they have to do. If it was the newer generation of audiologists who are taught through university this is the structure of the appointment, it might be different. (Audiologist 2)

Recruitment and completion

Between 6 July 2022 and 24 February 2023, 130 potential participants were identified in the UCLH Epic system. Twenty-five were sent the study participant information sheet ahead of their hearing aid appointment and approached by the research audiologist upon arrival at their clinic appointment. Twenty consented to take part (see Figure 1).

Figure 1.

Recruitment and follow-up.

Table 1 summarises the demographic characteristics of the participants. Their ethnicities reflecting the diverse North London community served by Edgware Community Hospital.

Table 1.

Demographic characteristics of participants. Better-ear data are presented as this is most relevant for cognitive assessment performance.

Variable	Statistic
Age (years)	Mean (SD)	78.6 (5.7)
	Range	68–85
Sex, n (%)	Male	12 (60%)
	Female	8 (40%)
Ethnicity, n (%)	Asian Indian	9 (45%)
	Asian Pakistani	1 (5%)
	Black African	1 (5%)
	Black Caribbean	1 (5%)
	White British	7 (35%)
	White Irish	1 (5%)
Experienced hearing aid user	Yes	18 (90%)
	No	2 (10%)
Companion	None	14 (70%)
	Child	2 (10%)
	Spouse	4 (20%)
Pure tone average, dB (SD)	Right ear at 0.25 kHz	41.6 (26.4)
	Right ear at 0.5 kHz	46.8 (30.8)
	Right ear at 1 kHz	50.8 (28.3)
	Right ear at 4 kHz	68.1 (21.5)

All 20 participants completed the cognitive assessment. Table 2 shows the duration of the various components of the appointment. The cognitive assessment and discussion of its results took on average 14 minutes, the AD8 4 minutes, Mini-MoCA 8 minutes, and discussion of results 2 minutes, respectively.

Table 2.

Duration of components of the hearing aid appointment.

Component	Duration (min)
Component	Mean (SD)	Range
Audiology history	13.1 (8.1)	5–38
Cognitive assessment
AD8	4.4 (4.8)	1–18
Mini-MoCA	8.2 (4.4)	4–23
Discussion of results	1.8 (1.3)	1–6
Hearing care
Audiology assessments	14.2 (5.3)	8–26
Discussion of results	3.0 (2.7)	1–11
Aural impressions, hearing aid demo	7.2 (6.0)	1–30
Total duration appointment	51.0 (20.5)	23–94

The average AD8 score was 2.4 (range: 0–7); 10 (50%) participants had an AD8 score indicating potential cognitive impairment. The average Mini-MoCA score was 12.8 (range: 8–15); 1 (5%) patient had a Mini-MoCA score indicating potential cognitive impairment. Two (10%) participants had a prior diagnosis of mild dementia and attended accompanied by a companion. Both scored in the impaired range of the AD8, however one of these had a Mini-MoCA score within the normal range. The former participant took 23 minutes to complete the Mini-MoCA (compared to the average of 8.2 minutes), the latter participant completed the Mini-MoCA in 4 minutes.

Impact on onward care

At 3 months we spoke over the phone with 17 participants directly and with two via their companion. One of those had a prior diagnosis of dementia and did not recall the hearing aid appointment so their son answered our questions on their behalf. The other participant could not hear well over the telephone, so their spouse answered our questions. Four out of the 10 participants whose assessment indicated potential cognitive impairment contacted their GP following the hearing aid appointment. Of these, three were referred for further cognitive evaluation; one participant was subsequently diagnosed with dementia and the other two were still awaiting an appointment. Of the remaining six participants whose assessment indicated potential cognitive impairment, one was not contactable, five did not contact their GP because they had either a known dementia diagnosis (n = 2) or disagreed with the result and felt there were no cognitive concerns (n = 3). One commented,

I felt it was a simple test but when the results were discussed I did not agree with them as I think my memory is better than what the audiologists suggested. It made me aware that I may need to concentrate more. As far as I am concerned, I think my memory is pretty good, although my wife may disagree. (Participant 5)

Two of those reported that the audiologists’ calm manner explaining the limitations of the assessment was reassuring.

All 17 participants and companions contacted reported that they felt it would be acceptable to have a cognitive assessment as part of hearing aid appointment. Six participants commented that they felt a cognitive assessment might be potentially useful in highlighting the association between hearing and cognitive health, something they were not aware of before the study. One commented, ‘I felt it was very reassuring to have my memory checked. As you get older you can get lapses here and there with your memory’ (Participant 8). Some expressed initial surprise when approached, with one participant commenting,

I was surprised because in my head going to the hospital was just to have a hearing test…because I've never heard of anybody having to do a memory test (at a hearing aid appointment), but when I got told more about it and read the information sheet, it's nice to know people could be checked…it could help everybody. (Participant 18)

and a companion commenting,

I was surprised they were going to have a memory test as well, I thought it was just for hearing. I now understand the two are linked. I thought that went really well and I am pleased (their memory) was checked out. (Companion 5)

For those whose assessment did not indicate cognitive impairment, they felt encouraged to seek ways to optimise cognitive health following the appointment: ‘It was a very positive experience and straight-forward. If I have to follow-on with something after something like this, I will follow-on. Since then, I have been doing a lot of crosswords puzzles…trying to improve my memory’ (Participant 4). Others mentioned issues relating to staffing, resources and patient needs that require addressing more widely within the NHS, which impact follow-on action: ‘I haven’t been to my GP in a while because it is difficult to get an appointment. I am not concerned about my memory, but I will ask about it when I next see my doctor’ (Participant 19).

Experiences

During the mini-MoCA assessment, patients’ emotion intensity scores were ranged between 3–4 for happiness/contentment and 1–3 for the negative emotions anger, fear/anxiety and sadness. In terms of reactions observed, 16 out of 20 appeared comfortable performing the test. Four participants scored 3 for fear/anxiety, one of whom had a known mild dementia diagnosis, one commenting that English was not their first language, another trying to rush through the questions, and the fourth seeking reassurance from their companion. With reassurance and minimal guidance from the clinical audiologist, three of these participants completed the mini-MoCA and scored within the normal range. The participant with a known dementia diagnosis struggled with the assessment and scored in the abnormal range. Another participant with a known dementia diagnosis, however, was observed to be calm with no signs of frustration or anxiety completing the assessment.

The AD8 was completed by 14 participants who attended alone, and by companions for the other 6. All were observed to be comfortable answering the AD8 questions, with emotion intensity scores ranging from 3–4 for happiness/contentment and 1 for the negative emotions anger, fear/anxiety and sadness, with one companion scoring 2 for fear/anxiety asking for clarification on some of the questions before answering.

Nineteen out of 20 participants and all 6 companions were observed to appear calm and comfortable when the results of the cognitive assessment were discussed, with emotion intensity scores ranging from 3–4 for happiness/contentment and 1 for the negative emotions anger, fear/anxiety and sadness. One participant, whose AD8 was answered by their spouse and indicated potential cognitive impairment, scored 2 for happiness/contentment and for fear/anxiety and 3 for anger and sadness, expressing disagreement with the results.

The research audiologist observed that all four clinical audiologists appeared calm and confident while conducting the cognitive assessment and discussing the results. On three occasions, the clinical audiologists sought input from the research audiologist regarding the scoring of the cognitive assessment.

Clinical audiologists acknowledged the potential relevance of an assessment to identify undiagnosed cognitive impairment in their work with older adults. They felt training was important, and that the training provided for the study equipped them with the necessary knowledge and skills to conduct the tests effectively. One audiologist reported that they felt uncomfortable feeding back test results when they were abnormal, however they felt their confidence improved during the study when they developed more experience conducting the cognitive assessment:

The patients who didn't have any cognition problems were fine, but the patients who did…I felt a little awkward saying it. I thought it wasn't the most natural, easy thing to say. After the first one or two I was definitely more confident and knew what I was doing. (Audiologist 1)

In terms of further evaluation for patients identified with potential cognitive impairment, audiologists highlighted the need to streamline hearing and memory pathways and suggested direct referral from hearing services to memory clinics rather than relying solely on GPs to make the referral: ‘If we (the audiologist) detected something, it would have probably been nicer if we could have … just done an internal referral. Rather than them having to go back to their GP’ (Audiologist 1).

Discussion

This study aimed to assess the feasibility of introducing a brief cognitive assessment in NHS routine hearing aid appointments for older adults, in terms of practicalities to assess resource implications, recruitment/completion rates, impact on onward care and experiences of patients, their companions, audiologists and referring clinicians on the intervention. We demonstrated preliminary evidence of acceptability and viability for the intervention, taking into account the limitations of generalisability given our small sample size and single-site design which will be discussed further in this section. All participants in our study completed the cognitive assessment within the allocated time frame, indicating its practicality in a clinical setting. Furthermore, the positive feedback from six patients who explicitly stated that the cognitive assessment enhanced their hearing aid appointment experience suggests potential acceptability among service users.

The recruitment data (20 from 130 identified patients) offers important insights about service delivery requirements and implementation challenges. That 68% of appointments could not accommodate cognitive assessment highlights the need for careful planning for the introduction of cognitive assessments in clinic such as restructuring of appointment schedules and additional clinical resources. These implementation barriers identified through our feasibility study will inform resource planning for wider rollout.

Our study highlights the need for comprehensive professional development and support for audiologists implementing cognitive assessment. This need is also reflected in our previous survey of audiologists.²⁰ With basic training, our audiologists showed confidence in both administering the assessment and discussing its results with patients. Beyond technical training in administering assessments, audiologists need skills in communicating sensitively about cognitive concerns and managing potentially challenging conversations about test results. This includes developing competency in explaining the hearing-cognition relationship and providing appropriate support when cognitive concerns are identified. Guidance for clinicians on how to communicate this was recently issued in the British Society of Audiology (BSA), British Academy of Audiology (BAA) and British Society of Hearing Aid Audiologists (BSHAA) joint position statement November 2024.³⁴

The goal should also be to facilitate transition to memory services for further assessment of issues identified. Services thus need to establish clear referral pathways between audiology and memory services, with explicit protocols for when and how to refer patients for further cognitive evaluation. Additionally, evidence-based guidelines for tailoring hearing care for patients with cognitive concerns need to be developed and implemented alongside any cognitive assessment programme.

The cognitive assessment added an average of 15 minutes to each hearing aid appointment, indicating significant resource implications that require careful consideration for sustainable routine NHS implementation. This extra time has broader implications for staffing requirements, service capacity and waiting times. Several approaches could help address these challenges. Different service delivery models could be explored, such as a risk-stratified approach where cognitive assessment is offered based on specific criteria. Integration with existing pathways could improve efficiency, though this requires careful coordination between services. A health economic evaluation would be essential before wider implementation to assess cost-effectiveness and sustainability within the NHS framework.^35,36 This evaluation should consider both direct costs (staff time, training) and potential long-term benefits of earlier cognitive impairment identification and of hearing aid use on preservation of cognitive function. It is therefore important that stakeholders including professional organizations, healthcare funders, and policymakers are involved early in such discussions.

Half of our participants were found to have AD8 scores suggestive of early cognitive changes – a higher proportion than expected in this population.^18,37 While both self-reported and informant-reported answers are permissible for the AD8, informant report is preferred because dementia often involves a lack of insight into functional limitations that can compromise the validity of self-report. Here, an informant report was only possible for six of our participants as 14 attended alone and answered the questions themselves. This highlights a need for a two-pronged approach in future studies: encouraging older patients to bring a companion to hearing aid appointments when possible, while also developing strategies to effectively assess and support those who attend alone.

In retrospect, we should have excluded patients with a prior dementia diagnosis from this feasibility study. The purpose of the assessment is to identify cognitive impairment in individuals who have not received a clinical diagnosis, making these tests redundant for those already diagnosed with dementia. Our planned follow-on project, which will include additional sites, will refine the choice of cognitive assessment tools and introduce guidelines for tailoring care to those showing signs of cognitive impairment.³⁸

Whilst our participants did not always agree with the results of our cognitive assessment, four consulted their GP following the hearing aid appointment and one of them subsequently received a dementia diagnosis. This suggests that addressing cognitive health in older adults attending hearing clinics has the potential to contribute to identification of cognitive impairment that has yet to be picked up through other healthcare pathways, enabling earlier dementia diagnosis, support and treatment.

Our study's primary strength lies in its pragmatic approach, embedding the intervention within a routine NHS hearing aid clinic that serves a diverse local population. This real-world implementation, where clinical audiologists performed the cognitive assessments, closely reflects genuine clinical practice. The comprehensive data collection by our research team, recording a broad set of feasibility measures, offers a holistic view of the intervention's practicality. Furthermore, the study's multidisciplinary nature, bringing together expertise from audiology and cognitive health, fostered an integrated approach to patient care.

However, several limitations should be noted. The small sample size means our observations, while encouraging, are tentative and may not be generalisable to other settings. There is potential for selection bias, as the overall positive experiences reported by patients and clinical audiologists may reflect the fact that all participants were informed and consented to be involved in the study. The research audiologist's observations and classification of emotions, although structured using a standardised classification system, were inherently subjective. While our study focused on feasibility within routine audiology services, future studies would benefit from psychology expertise in designing and analysing emotion responses. The absence of multiple raters for assessing emotional intensity is also a limitation. As our primary focus was on feasibility outcomes, we used exploratory qualitative data collection rather than formal qualitative research methods. As a single-site study conducted in one NHS clinic, the findings may not be fully applicable to other healthcare settings or regions. The follow-up period of 3 months after the initial appointment was selected to allow reasonable time for the patient to consult with their GP and for potential onward specialist referral. This timeframe may have been too short given current NHS waiting times, and as noted, two participants were still waiting for memory clinic appointments at their 3-month follow-up. Longer follow-up might be needed in future studies to capture complete care pathways and long-term impacts or challenges of implementing cognitive assessments in hearing aid clinics. The lack of a control group limits our ability to definitively attribute any observed changes solely to the intervention. Lastly, the presence of a research audiologist during appointments may have influenced the behaviour of both clinicians and patients, potentially introducing a Hawthorne effect. We acknowledge these methodological constraints and suggest more robust qualitative methods such as semi-structured interviews and formal thematic analysis for future studies examining stakeholder views and experiences of cognitive assessment in hearing aid clinics.

Conclusion

This feasibility study demonstrates that introducing a brief cognitive assessment in hearing aid appointments for older adults seems possible and acceptable. Our findings suggest this approach could improve earlier identification of cognitive impairment in individuals whose cognitive changes have not been clinically diagnosed, and help determine appropriate support levels in audiology services. However, implementation has significant resource implications that require careful consideration, highlighting the importance of involving professional organisations, commissioners and policy makers early in this discussion. Larger-scale evaluation in a service innovation project will be needed before routine implementation can be considered. Work is in progress to develop consensus on how best to detect cognitive impairment in an audiology service setting and to tailor hearing care for those with signs of cognitive impairment.

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Footnotes

Researcher reflexivity statement

RO (lead researcher) is a consultant audiovestibular physician with expertise in hearing health and its relationship with cognition, having worked in a cognitive disorders clinic where she received expert training in clinical management of patients with dementia. She obtained a Neurology MD(Res) through research involving recruitment and neuropsychological assessment of patients with dementia. Her current role involves seeing older adult patients with complex hearing and balance disorders in an outpatient setting. MF (research audiologist) is an audiologist with a Master's degree in Healthcare Science (Audiology) and experience working in the NHS as a clinical audiologist seeing adults with hearing disorders in hearing aid and diagnostic testing clinics. Within her research role, she has received specific training in dementia including consent and recruitment into research studies.

ORCID iDs

Rohani Omar

Sergi G Costafreda

Ethical considerations

Ethical approval was received from the London Riverside Research Ethics Committee (22/LO/0180). The study was registered with ISRCTN (ISRCTN12354959) and adopted for support by the National Institute for Health and Care Research Clinical Research Network (CPMS 52139).

Consent to participate

Written informed consent was obtained from all participants in this study.

Author contributions/CRediT

Rohani Omar contributed to conception, data acquisition, data analysis, data interpretation, drafting of manuscript; Marina Forbes contributed to data acquisition, data analysis, drafting of manuscript; Diya Vaid contributed to data analysis, data interpretation; James Crawley contributed to conception, data acquisition; Dawn Clare contributed to conception, data acquisition; Sergi G Costafreda contributed to conception, data interpretation, critical revision of the manuscript; Anne G.M. Schilder contributed to conception, data interpretation, critical revision of the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by an ENT UK Foundation research grant and a Sonova Hearing Care Solutions research grant.

Conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The data will be made available from the corresponding author on reasonable request.

Supplemental material

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