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Int J Geriatr Psychiatry. 2018 Jul;33(7):972-979. doi: 10.1002/gps.4880. Epub 2018 Mar 25.

Screening an elderly hearing impaired population for mild cognitive impairment using Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA).

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Department of Otolaryngology, Head and Neck Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Department of Otolaryngology, Head and Neck Surgery, National University Hospital, Singapore.



To determine if there is an association between hearing loss and poorer cognitive scores on Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) and to determine if poor hearing acuity affects scoring on the cognitive screening tests of MMSE and MoCA.


One hundred fourteen elderly patients (Singapore residents) aged between 55 and 86 years were sampled. Participants completed a brief history questionnaire, pure tone audiometry, and 2 cognitive screening tests-the MMSE and MoCA. Average hearing thresholds of the better ear in the frequencies of 0.5, 1, 2, and 4 kHz were used for data analysis.


Hearing loss was significantly associated with poorer cognitive scores in Poisson regression models adjusted for age. Mini-Mental State Examination scores were shown to decrease by 2.8% (P = .029), and MoCA scores by 3.5% (P = .013) for every 10 dB of hearing loss. Analysis of hearing-sensitive components of "Registration" and "Recall" in MMSE and MoCA using chi-square tests showed significantly poorer performance in the hearing loss group as compared to the normal hearing group. Phonetic analysis of target words with high error rates shows that the poor performance was likely contributed by decreased hearing acuity, on top of a possible true deficit in cognition in the hearing impaired.


Hearing loss is associated with poorer cognitive scores on MMSE and MoCA, and cognitive scoring is likely confounded by poor hearing ability. This highlights an important, often overlooked aspect of sensory impairment during cognitive screening. Provisions should be made when testing for cognition in the hearing-impaired population to avoid over-referral and subsequent misdiagnoses of cognitive impairment.


MMSE; MoCA; cognitive impairment; cognitive screening; hearing impairment; hearing loss


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