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Systematic Review of Factors Associated With Hearing Aid Use in People Living in the Community With Dementia and Age-Related Hearing Loss

  • Emma Hooper
    Correspondence
    Address correspondence to Emma Hooper, MSc, Department of Rehabilitation and Sport Science, Institute of Health, University of Cumbria, Lancaster LA1 3JD, United Kingdom.
    Affiliations
    Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, United Kingdom

    Department of Rehabilitation and Sports Science, Institute of Health, University of Cumbria, United Kingdom
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  • Laura J.E. Brown
    Affiliations
    Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, United Kingdom

    Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
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  • Hannah Cross
    Affiliations
    Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, United Kingdom
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  • Piers Dawes
    Affiliations
    Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, United Kingdom

    School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, University of Queensland, Australia
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  • Iracema Leroi
    Affiliations
    Global Brain Health Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
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  • Christopher J. Armitage
    Affiliations
    Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom

    Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom

    NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, United Kingdom

    NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Open AccessPublished:August 18, 2022DOI:https://doi.org/10.1016/j.jamda.2022.07.011

      Abstract

      Objectives

      To investigate factors that influence hearing aid use according to the Theoretical Domains Framework (TDF). The TDF is a behavioral science framework that aids understanding of factors that influence behavior.

      Design

      Systematic review.

      Setting and Participants

      People living in the community with dementia and age-related hearing loss who have air conduction hearing aids.

      Methods

      Systematic literature review following PRISMA guidelines. We searched for studies in 9 databases, including Ovid MEDLINE, Scopus, and OpenGrey. We undertook an interpretive data synthesis by mapping findings onto the TDF. We assessed confidence in the findings according to the GRADE-CERQual approach.

      Results

      Twelve studies (6 quantitative, 3 qualitative, and 3 mixed methods) were included in the review. The majority of these were rated low-moderate quality. We identified 27 component constructs (facilitators, barriers, or noncorrelates of hearing aid use) nested within the 14 domains of the TDF framework. Our GRADE-CERQual confidence rating was high for 5 findings. These suggest that hearing aid use for people living in the community with dementia and hearing loss is influenced by (1) degree of hearing aid handling proficiency, (2) positive experiential consequences, (3) degree of hearing aid comfort or fit, (4) person-environment interactions, and (5) social reinforcement.

      Conclusions and Implications

      Hearing aid interventions should adopt a multifaceted approach that optimizes the capabilities of people with dementia to handle and use hearing aids; addresses or capitalizes on their motivation; and ensures their primary support network is supportive and encouraging of hearing aid use. The findings also emphasize the need for further high-quality research that investigates optimal hearing aid use, influencing factors, and interventions that support hearing aid use.

      Keywords

      Hearing impairment affects up to 90% of older adults who are living with dementia,
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      Functional status of elderly people with hearing loss.
      The negative consequences of combined hearing and cognitive impairment include reduced quality of life, and increased social isolation and dependency on others.
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      Hearing loss among individuals with dementia: barriers and facilitators to care.
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      Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: analysis of interRAI data for home care and long-term care recipients in Ontario.
      Previous research suggests that treating hearing impairment with hearing aids represents an important opportunity to improve quality of life for people with dementia.
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      Interventions for hearing and vision impairment to improve outcomes for people with dementia: a scoping review.
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      Hearing loss treatment in older adults with cognitive impairment: a systematic review.
      Research within the general population has identified a range of factors associated with hearing aid use. Lack of perceived need for, or benefit from, hearing aids; difficulty adjusting to use; and problems with the fit or comfort of the devices are all barriers to use.
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      Determinants of hearing-aid adoption and use among the elderly: a systematic review.
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      Why do people fitted with hearing aids not wear them?.
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      Factors affecting older adults’ hearing-aid use.
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      The non-use of hearing aids in people aged 75 years and over in the city of Kuopio in Finland.
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      Self-reported reasons for the non-use of hearing aids among Hispanic adults with hearing loss.
      Conversely, increased age and severity of hearing loss are both positively associated with use of hearing aids.
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      Technology, expectations, and adjustment to hearing loss: predictors of hearing aid outcome.
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      Incidence and predictors of hearing aid use and ownership among older adults with hearing loss.
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      What keeps older adults with hearing impairment from adopting hearing aids?.
      In addition, motivation to use hearing aids may make people more likely to tolerate initial difficulties with hearing aids to become regular users of them.
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      • Vahlberg T.
      • Jero J.P.
      • Isoaho R.
      Hearing aid compliance in the elderly.
      People who report that they experience disabling effects of hearing loss are most likely to use hearing aids,
      • Ng J.H.Y.
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      Determinants of hearing-aid adoption and use among the elderly: a systematic review.
      ,
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      • Nielsen C.
      • et al.
      Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: a review of the literature.
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      • Munro K.J.
      • et al.
      Correlates of hearing aid use in UK adults: self- reported hearing difficulties, social participation, living situation, health, and demographics.
      • Hickson L.
      • Meyer C.
      • Lovelock K.
      • et al.
      Factors associated with success with hearing aids in older adults.
      and the support of family or friends has also been identified as a facilitating factor for hearing aid use.
      • Hickson L.
      • Meyer C.
      • Lovelock K.
      • et al.
      Factors associated with success with hearing aids in older adults.
      ,
      • Meyer C.
      • Hickson L.
      • Lovelock K.
      • Lampert M.
      • Khan A.
      An investigation of factors that influence help-seeking for hearing impairment in older adults.
      One might expect that using hearing aids could be more challenging for people with dementia than in the general population because of the deterioration in cognitive and functional abilities associated with dementia. For example, awareness of hearing loss is an important correlate of hearing aid use,
      • Ng J.H.Y.
      • Loke A.Y.
      Determinants of hearing-aid adoption and use among the elderly: a systematic review.
      ,
      • Knudsen L.V.
      • Öberg M.
      • Nielsen C.
      • et al.
      Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: a review of the literature.
      ,
      • Sawyer C.S.
      • Armitage C.J.
      • Munro K.J.
      • et al.
      Correlates of hearing aid use in UK adults: self- reported hearing difficulties, social participation, living situation, health, and demographics.
      yet loss of self-awareness commonly occurs in dementia.
      • Mograbi D.C.
      • Huntley J.
      • Critchley H.
      Self-awareness in dementia: a taxonomy of processes, overview of findings, and integrative framework.
      Furthermore, people living with dementia may have increased difficulties in using hearing aids because of dementia-related factors such as reduced cognitive, visuospatial, and executive function abilities
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      and increased apathy.
      • Leung D.K.Y.
      • Chan W.C.
      • Spector A.
      • Wong G.H.Y.
      Prevalence of depression, anxiety, and apathy symptoms across dementia stages: a systematic review and meta-analysis.
      These factors may negatively influence a person’s ability to manipulate and maintain hearing aids, as well as their ability to persevere through difficulties such as initial discomfort.
      • Allen N.H.
      • Burns A.
      • Newton V.
      • et al.
      The effects of improving hearing in dementia.
      People with dementia may also require support in order to use hearing aids successfully.
      • Pichora-Fuller M.K.
      • Dupuis K.
      • Reed M.
      • Lemke U.
      Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach.
      ,
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      For those living in the community, family support may be of greatest relevance.
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      Previous reviews of factors that influence hearing aid use have not considered the distinct needs of people living with dementia. Identifying barriers and facilitators to hearing aid behavior is therefore a crucial first step in developing interventions that support hearing aid use in this population.
      • Regan J.
      • Frison E.
      • Collin F.
      • et al.
      Individualised sensory intervention to improve quality of life in people with dementia and their companions (SENSE-Cog trial): study protocol for a randomised controlled trial.
      ,
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: A Guide to Designing Interventions.
      The Theoretical Domains Framework (TDF)
      • Cane J.
      • Connor D.O.
      • Michie S.
      Validation of the theoretical domains framweork for use in behaviour change and implementation research.
      is a proven behavioral science framework that provides a comprehensive framework for understanding determinants of behavior,
      • Cox N.S.
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      • Lahham A.
      • Holland A.E.
      Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework.
      ,
      • Shaw R.L.
      • Holland C.
      • Pattison H.M.
      • Cooke R.
      Patients’ perceptions and experiences of cardiovascular disease and diabetes prevention programmes: a systematic review and framework synthesis using the Theoretical Domains Framework.
      and identifying factors that need to be addressed to effect behavior change.
      • French S.D.
      • Green S.E.
      • O’Connor D.A.
      • et al.
      Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.
      It was chosen as a framework for data synthesis in this review because there may be a range of factors that influence hearing aid use.
      • Coulson N.S.
      • Ferguson M.A.
      • Henshaw H.
      • Heffernan E.
      Applying theories of health behaviour and change to hearing health research: time for a new approach.
      The objective of this literature review was therefore to identify, evaluate, and synthesize literature on factors that are associated with the use of hearing aids in people with dementia, according to the TDF.

      Methods

      The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      guided the methodology of this review. The protocol for this study was pre-registered on the PROSPERO international prospective register of systematic reviews (CRD42020173094).

      Eligibility Criteria

      Studies were eligible for inclusion, regardless of design, if the study
      • 1.
        included people diagnosed with dementia and age-related hearing loss who had received air conduction hearing aids and were living in the community;
      • 2.
        reported data related to hearing aid use and/or factors that influence use; and
      • 3.
        was primary research
      We did not impose any restrictions in relation to language or publication date.

      Search Strategy

      We searched the following electronic databases in May 2021: Ovid MEDLINE, Scopus, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Additionally, we undertook searches of the Cochrane Databases of Systematic Reviews, reference lists of relevant papers, trial registers ClinicalTrials.gov and the World Health Organization international clinical trials registry platform (ICTRP), and unpublished “gray” literature via OpenGrey and Evidence Search.
      We identified search terms based on free text words, Medical Subject Headings (MeSH), and reviews of relevant literature. Search terms were adapted, where necessary, to meet the requirements of the databases.

      Study Selection

      Two reviewers independently screened a sample of the titles and abstracts. Following consensus discussion, clarification of the inclusion criteria, and further independent screening, we achieved perfect interrater agreement (Cohen κ = 1.00). The first author then screened the remaining titles and abstracts. Once screening was complete, 2 reviewers independently appraised the full text of all potentially relevant studies against the full inclusion and exclusion criteria.

      Data Extraction

      We performed the data extraction using a bespoke form. We contacted the authors of the 2 included conference abstracts to request missing data, 1 of whom responded to our request.

      Quality Assessment

      We critically appraised the quality of the selected studies using the Mixed Methods Appraisal Tool (MMAT).
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      ,
      • Pluye P.
      • Gagnon M.P.
      • Griffiths F.
      • Johnson-Lafleur J.
      A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in Mixed Studies Reviews.
      Within the MMAT, reviewers appraise each included study against core validity criteria for differing study designs (qualitative, quantitative RCT, quantitative nonrandomized, quantitative descriptive, or mixed methods). The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) framework
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      was used to appraise and categorize the studies according to the level of research evidence (Level I, experimental; II, quasi-experimental; III, nonexperimental or qualitative; IV, practice guidelines or position statements; or V, case reports).

      Data Synthesis

      Because this is a mixed methods review, quantitative and qualitative data were treated with equal status and analyzed concurrently, according to the A−QUAL + QUAN framework.
      • Heyvaert M.
      • Maes B.
      • Onghena P.
      Mixed methods research synthesis: definition, framework, and potential.
      An interpretive data synthesis was undertaken by mapping extracted findings to the 14 domains of the Theoretical Domains Framework.
      • Cane J.
      • Connor D.O.
      • Michie S.
      Validation of the theoretical domains framweork for use in behaviour change and implementation research.
      ,
      • Michie S.
      • Johnston M.
      • Abraham C.
      • et al.
      Making psychological theory useful for implementing evidence based practice: a consensus approach.
      Any determinants of hearing aid use that did not fit into the domains of the TDF were categorized as “other” to ensure completeness of the synthesis.
      Confidence in the findings was assessed according to the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      For this, we assessed each finding in relation to methodologic limitations, coherence, adequacy, and relevance. The outcomes of these appraisals informed an overall assessment of confidence in the findings, according to the GRADE-CERQual criteria of high, moderate, low, or very low. Further details of the methods are outlined in Supplementary Material 1.

      Results

      The combined database and hand searches resulted in 2987 returned records. Following deduplication, 1915 unique records remained. After screening the titles and abstracts, we retained 125 records for full-text review against the eligibility criteria. Of these, 112 were excluded, resulting in final inclusion of 13 records (Supplementary Figure 1). Two journal articles presented relevant results from the same study. The final 13 records therefore represented 12 studies with data of relevance to the present review.

      Study Characteristics

      Supplementary Table 1 presents characteristics of the included studies. Six quantitative or mixed methods intervention studies, 3 quantitative descriptive observational studies, 2 qualitative case reports, and 1 qualitative phenomenologic study were included. Sample sizes ranged from 1 to 647 participants. Ages of the participants ranged from 49 to 96 years. Care partners, such as spouses or adult children, were included in all of the intervention studies, 1 of the quantitative descriptive studies, and 2 of the qualitative studies.
      Participants had varying degrees of cognitive impairment, from mild to advanced dementia. Hearing status was reported according to a variety of parameters in 9 of the 12 studies. Degree of hearing impairment varied from mild to severe hearing loss. Whether or not hearing aids were being used was reported in a variety of ways, including caregiver report (6 studies), researcher descriptions (3 studies), identification in clinical records (2 studies), and participant report (1 study). Frequency and/or duration of hearing aid use was measured in 4 studies using caregiver logs. No studies used data logging, despite this being a feature of most hearing aids.
      • McMillan A.
      • Durai M.
      • Searchfield G.D.
      A survey and clinical evaluation of hearing aid data-logging: a valued but underutilized hearing aid fitting tool.

      Quality Appraisal

      Evidence levels and quality varied across the included studies. The majority (8) of the included studies were of Level III evidence. Of these, Gregory et al’s
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      qualitative study, and Leroi et al’s
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      and Sheikh et al’s
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      mixed methods studies were rated as high quality. However, the participant sample that received the extended intervention, which yielded data of most relevance to the present review in Leroi et al’s
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      study, was small (n = 4 dyads). Palmer et al’s
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      qualitative case study, and Nirmalasari et al’s
      • Nirmalasari O.
      • Mamo S.K.
      • Nieman C.L.
      • et al.
      Age-related hearing loss in older adults with cognitive impairment.
      and Kim et al’s
      • Kim A.S.
      • Amjad H.
      • Lin F.R.
      • et al.
      Association of hearing loss with neuropsychiatric symptoms in older adults with cognitive impairment.
      quantitative descriptive studies were rated as moderate quality. The remaining Level III studies were rated as low quality, with limitations in the reporting (Nieman et al
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ) or trial design and conduct that resulted in high researcher subjectivity and risk of bias (Hutchison et al
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ).
      There were 2 Level II studies (Dupuis et al
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      and Palmer et al
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ). These quantitative nonrandomized studies were both rated as low quality, with small sample sizes and incomplete outcome data. There was 1 Level 1 study, a randomized controlled trial (Nguyen et al
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      ), which was rated as moderate quality because of a lack of complete outcome data and adherence to the intervention. Additionally, lack of a power calculation or justification of sample size rendered the adequacy of the included sample unclear. The final case report (Hawkins
      • Hawkins D.B.
      Less can be more.
      ) was Level V evidence and rated as low quality. The full MMAT quality
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      and JHNEBP
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      quality and evidence levels appraisals are presented in Supplementary Table 2.

      Influences on Hearing Aid Use According to the TDF

      Extracted data were mapped to all domains of the TDF. Three additional findings did not fit within the TDF domains and were categorized as “other.” Summary findings, along with GRADE-CERQual
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      ratings of confidence in the findings are presented in Table 1.
      Table 1Findings Summary Table
      FindingGRADE-CERQual Confidence RatingStudies Contributing to the Review FindingTDF Domain (Definition Provided for First Occurrence)
      • Cane J.
      • Connor D.O.
      • Michie S.
      Validation of the theoretical domains framweork for use in behaviour change and implementation research.
      Degree of hearing aid–handling proficiency influences hearing aid use: difficulty in handling inhibits use, whereas being able to handle aids proficiently enablesHigh confidence
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Hawkins D.B.
      Less can be more.
      Skills

      (An ability or proficiency acquired through practice)
      Experiencing positive consequences of hearing aids is associated with their useHigh confidence
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Reinforcement

      (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)
      Degree of fit and comfort influences hearing aid use: problems with fit are a barrier whereas finding them comfortable is an enablerHigh confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      Reinforcement
      Factors related to person-environment interactions influence hearing aid use: excessive noise or perceived lack of need in differing listening situations lead to reduced useHigh confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      Environmental context and resources

      (Any circumstances of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior)
      Receiving social reinforcement enables hearing aid useHigh confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Social influences

      (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors)
      Standard manufacturer guidance does not enable hearing aid useModerate confidence
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Knowledge

      (An awareness of the existence of something)
      Misplacing hearing aids is a barrier to their use; having a set place for storage is an enablerModerate confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Memory, attention, and decision processes

      (The ability to retain information, focus selectively on aspects of the environment, and choose between 2 or more alternatives)
      Mindset toward the visibility of hearing aids influences their use: concern about their visibility is a barrier, whereas welcoming their visibility is an enablerModerate confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      Social/professional role and identity

      (A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting)
      Absence of—or negative—expectancy about the outcomes of hearing aids are barriers to their useModerate confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      Beliefs about consequences

      (Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation)
      Degree of intent influences hearing aid use: lack of intent is a barrier whereas positive intent is an enablerModerate confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Intentions

      (A conscious decision to perform a behavior or a resolve to act in a certain way)
      Negative emotional responses to hearing aids are a barrier to their use, whereas positive impact on affective state resulting from hearing aid use is an enablerModerate confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Kim A.S.
      • Amjad H.
      • Lin F.R.
      • et al.
      Association of hearing loss with neuropsychiatric symptoms in older adults with cognitive impairment.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Hawkins D.B.
      Less can be more.
      Emotion

      (A complex reaction pattern, involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)
      Lack of care partner hearing aid knowledge is a barrier; presence of care partner knowledge, skills, and optimism are enablersModerate confidence
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      Social influences
      Degree of procedural knowledge influences hearing aid use: lack of knowledge impedes use whereas improvement in knowledge enables useLow confidence
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Knowledge
      Awareness of the presence of disabling hearing loss is associated with hearing aid useLow confidence
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Knowledge
      Degree of self-confidence in ability to handle hearing aids influences their use: low confidence is a barrier whereas increasing confidence is an enablerLow confidence
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Beliefs about capabilities

      (Acceptance of the truth, reality or validity about an ability, talent, or facility that a person can put to constructive use)
      Proactive care partner support with handling and maintaining hearing aids enables their useLow confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Social influences
      Severity of cognitive impairment does not appear to be associated with hearing aid useLow confidence
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Memory, attention, and decision processes
      Forgetting to use hearing aids is a barrier to their use; implementing compensatory strategies is an enablerLow confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      Memory, attention, and decision processes
      Developing habitual routines enables hearing aid useLow confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      Behavioral regulation

      (Anything aimed at managing or changing objectively observed or measured actions)
      Degree of adaptation to hearing aids influences their use; perseverance is an enablerLow confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Behavioral regulation
      Resistance to change is a barrier to hearing aid useLow confidence
      • Hawkins D.B.
      Less can be more.
      Behavioral regulation
      Optimism about efficacy of hearing aids enables their useLow confidence
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      Optimism

      (The confidence that things will happen for the best or that desired goals will be attained)
      Identification of goals relating to hearing aids enables their useLow confidence
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      Goals

      (Mental representations of outcomes or end states that an individual wants to achieve)
      Lack of financial resources are a barrier to hearing aid useLow confidence
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Environmental context and resources
      Age may not influence hearing aid useLow confidence
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Other
      Degree of hearing loss may not influence hearing aid useLow confidence
      • Nirmalasari O.
      • Mamo S.K.
      • Nieman C.L.
      • et al.
      Age-related hearing loss in older adults with cognitive impairment.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Other
      Ethnicity influences hearing aid use; non-White ethnic groups are less likely to use hearing aidsLow confidence
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      Other
      In total, 27 component constructs (facilitators, barriers, or noncorrelates of hearing aid use) nested within the 14 domains of the TDF framework. Of these, our confidence rating was high for 5 constructs, moderate for 7, and low for 15. Further detail of the GRADE-CERQual
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      assessment outcomes are presented in Supplementary Table 3.
      The key findings of this review are those for which there is the strongest current evidence and in which we have the highest confidence. These are as follows:
      • 1.
        A person’s degree of hearing aid handling proficiency influences hearing aid use; difficulty in handling inhibits use whereas being able to handle aids proficiently enables use. Hearing aid skills difficulties that we identified related to insertion, removal, adjustment, and maintenance. This finding maps into the TDF domain skills.
      There was high confidence in this finding because although there were methodologic limitations in some of the studies, a body of evidence across 7 studies formed the finding.
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Hawkins D.B.
      Less can be more.
      Some studies in our review sought to aid the development of hearing aid handling skills.
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      Because of a lack of controlled studies, we were unable to determine whether providing additional support to develop hearing aid handling skills increased hearing aid use compared with standard care pathways. None of the included studies adopted cognitive rehabilitation strategies within their skills development approaches.
      • 2.
        Experiencing positive consequences of hearing aids is associated with their use. A range of positive consequences of hearing aid use was reported in the included studies. However, no study reported whether these consequences directly influenced hearing aid use. This finding maps into the TDF domain reinforcement.
      The greatest amount of evidence mapped to this finding, across 8 of the included studies.
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Although there were moderate concerns about the methodologic quality and relevance of the studies that contributed to this finding, there were only minor concerns about coherence and no concerns about adequacy, rendering overall confidence as high.
      • 3.
        The degree of fit and comfort of hearing aids influences their use; problems with fit are a barrier whereas finding them comfortable is an enabler. This finding also maps into the TDF domain reinforcement.
      Although only represented in 2 of the included studies,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      leading to moderate concerns about adequacy, the data were rich enough to support the interpretation, and came from high-quality, relevant studies.
      • 4.
        Factors related to person-environment interactions influence hearing aid use; excessive noise or perceived lack of need in differing listening situations lead to reduced use. This finding maps into the TDF domain environmental context and resources.
      Although evidence for this finding came from just 1 study,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      it was a high-quality, relevant study and there were no concerns about coherence.
      • 5.
        Receiving social reinforcement in the form of prompts and encouragement enables hearing aid use. This finding maps into the TDF domain social influences.
      Evidence that contributed to this finding were drawn from 3 relevant studies of good-high quality,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      with only minor concerns about threats to coherence and adequacy.

      Discussion

      This systematic review has identified factors that are associated with hearing aid use in people living in the community with dementia and age-related hearing loss. Mapping of data from 12 relevant studies to the TDF revealed 27 different constructs for hearing aid use. The strongest evidence mapped to the skills, reinforcement, environmental context and resources, and social influences domains of the TDF.
      Our findings suggest that people with dementia experience similar determinants of hearing aid use as the general population. In particular, similar barriers relating to hearing aid handling skills difficulties,
      • McCormack A.
      • Fortnum H.
      Why do people fitted with hearing aids not wear them?.
      ,
      • Knudsen L.V.
      • Öberg M.
      • Nielsen C.
      • et al.
      Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: a review of the literature.
      fit and comfort of the devices,
      • McCormack A.
      • Fortnum H.
      Why do people fitted with hearing aids not wear them?.
      and difficulty in tolerating amplified background noise
      • Salonen J.
      • Johansson R.
      • Karjalainen S.
      • Vahlberg T.
      • Jero J.P.
      • Isoaho R.
      Hearing aid compliance in the elderly.
      ,
      • Gallagher N.E.
      • Woodside J.V.
      Factors affecting hearing aid adoption and use: a qualitative study.
      ,
      • Aazh H.
      • Prasher D.
      • Nanchahal K.
      • Moore B.C.J.
      Hearing-aid use and its determinants in the UK National Health Service: a cross-sectional study at the Royal Surrey County Hospital.
      were evident. Equally, similar facilitators relating to self-perceived benefit
      • Ng J.H.Y.
      • Loke A.Y.
      Determinants of hearing-aid adoption and use among the elderly: a systematic review.
      and social support
      • Hickson L.
      • Meyer C.
      • Lovelock K.
      • et al.
      Factors associated with success with hearing aids in older adults.
      were evident. Our findings therefore indicate that these factors are at least as important for people with dementia as the general population, suggesting that intervention approaches should account for this. However, there was insufficient evidence in the current literature to evaluate the impact of cognitive, functional, and spatial challenges on hearing aid use. These may represent critical differences between people with dementia and the general population, and so warrant further investigation.
      In relation to intervention approaches, there was some evidence in our findings that people with dementia may benefit from learning strategies to optimize their hearing aid handling skills, such as those offered by cognitive rehabilitation.
      • Clare L.
      • Kudlicka A.
      • Oyebode J.R.
      • Jones R.W.
      • et al.
      Individual goal-oriented cognitive rehabilitation to improve everyday functioning for people with early-stage dementia: a multicentre randomised controlled trial (the GREAT trial).
      In these respects, our findings suggest that hearing aid care pathways require flexibility and a skilled workforce. However, standard pathways lack the flexibility to support the specific needs of people with dementia,
      • Littlejohn J.
      • Bowen M.
      • Constantinidou F.
      • et al.
      International practice recommendations for the recognition and management of hearing and vision impairment in people with dementia.
      and audiologists report that they lack formal training in dementia.
      • Wright N.
      • Stickley T.
      • Mulla I.
      • et al.
      Hearing loss and dementia: an exploratory study of the views of audiologists.
      Additionally, our findings suggest that social support plays a critical role in supporting hearing aid use in dementia. This is congruent with advice in clinical papers, which recommend that family members of people with dementia participate in audiology appointments so that they can support the effective use of hearing aids.
      • Pichora-Fuller M.K.
      • Dupuis K.
      • Reed M.
      • Lemke U.
      Helping older people with cognitive decline communicate: Hearing aids as part of a broader rehabilitation approach.
      ,
      • Dawes P.
      • Littlejohn J.
      • Bott A.
      • et al.
      Hearing assessment and rehabilitation for people living with dementia.
      ,
      • Souza P.
      Hearing loss and aging: implications for audiologists. American Speech-Language-Hearing Association.
      However, a recent study revealed that 18% of people with dementia that live in the community received little or no support for their daily living needs.
      • Clare L.
      • Martyr A.
      • Henderson C.
      • et al.
      Living alone with mild-to-moderate dementia: findings from the IDEAL cohort.
      There may therefore be around a fifth of people with dementia living in the community who do not have adequate social support for their hearing aid use. In these cases, our findings suggest that it may be useful for hearing professionals to explore other options to provide social support around hearing aid use, such as within home care plans. Given that recognizing and managing changes to a person with dementia’s social support over time (such as following the death of a spouse) has been highlighted as an important way to support continued hearing aid use,
      • Wright N.
      • Stickley T.
      • Mulla I.
      • et al.
      Hearing loss and dementia: an exploratory study of the views of audiologists.
      our findings suggest that regular reviews of the presence and effectiveness of support systems is also crucial.

      Strengths and Limitations

      Strengths

      In this systematic review, we used the TDF framework to collate barriers and enablers to hearing aid use in dementia. An advantage of using the TDF is that it provides theoretically informed direction about ways in which interventions can be targeted.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: A Guide to Designing Interventions.
      ,
      • French S.D.
      • Green S.E.
      • O’Connor D.A.
      • et al.
      Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.
      ,
      • Michie S.
      • van Stralen M.M.
      • West R.
      The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
      Additionally, use of an existing framework to organize the findings engenders confidence in the validity of the framework and enables integration into the wider literature base.
      We also conducted a broad search of the literature in order to be as inclusive as possible. We did not exclude studies because of quality, and did not impose any restrictions on language or publication date. Use of the MMAT,
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      JHNEBP,
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      and GRADE-CERQual
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      frameworks provided structure to our assessments of quality and confidence in the findings.

      Limitations

      There was limited published literature that directly addressed our research question. The level of evidence was predominantly low, and the quality of evidence was largely of a low-moderate grade. The studies that met the inclusion criteria generally had small sample sizes and represented a perspective in predominantly high-income, English-speaking countries (with the exception of Sheikh et al’s
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      feasibility study in South Asia). There was a lack of controlled studies or overt exploration of influences on hearing aid use, which limited our ability to understand causal factors affecting hearing aid use. These factors limit the generalizability of our findings.

      Future research

      Michie et al
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: A Guide to Designing Interventions.
      propose 3 incremental stages in the design of behavior change interventions: first, understanding the behavior; second, identifying intervention options; and third, identifying intervention content and implementation options. Although this review represents a starting point in understanding factors that influence the behavior of hearing aid use in people with dementia, there was insufficient evidence to evaluate the impact of cognitive, functional, and spatial challenges on hearing aid use. There was also insufficient evidence to evaluate whether the onset of dementia affected hearing aid use in established hearing aid users. Furthermore, the target behavior for optimal hearing aid use remains unknown in this population, and also lacks consensus in the general population.
      • Laplante-Lévesque A.
      • Jensen L.D.
      • Dawes P.
      • Nielsen C.
      Optimal hearing aid use: focus groups with hearing aid clients and audiologists.
      Therefore, there is a critical need for a program of high-quality research that investigates (1) optimal hearing aid use and (2) influencing factors of hearing aid use in dementia. Once a robust understanding of the target behavior and influencing factors exists, identification of intervention options, development of intervention content, and identification of implementation options can follow.

      Conclusions and Implications

      Our findings suggest that the determinants of hearing aid use in dementia are multifaceted. Intrinsic determinants include a person’s skills in handling hearing aids and motivating factors related to the consequences and comfort of hearing aids. Extrinsic determinants include the listening context and presence of external prompts and encouragement. Within these constructs, both facilitators and barriers to hearing aid use are evident.
      Our findings suggest that enhanced support pathways that tailor to the abilities and motivators of the individual with dementia while also accounting for their social support systems over time represent the best opportunity to optimize hearing aid use. Further robust research to establish parameters of the target behavior of optimal hearing aid use, and to generate further understanding of influencing factors, is indicated.

      Supplementary Material 1. Methods

      Inclusion and Exclusion Criteria

      Tabled 1
      Inclusion CriteriaExclusion Criteria
      PopulationDiagnosed dementia

      Age-related hearing loss

      Living in the community

      Has air conduction hearing aids
      Mild cognitive impairment/no dementia

      Congenital deafness

      Living in long-term care

      Does not have air conduction hearing aids
      Phenomenon of interestThe use of air conduction hearing aidsOther audiological devices including cochlear implants, bone conduction hearing aids, or assistive listening devices
      OutcomeHearing aid use

      Factors that influence use
      Other outcomes not related to the present review
      Study typeQuantitative studies

      Qualitative studies

      Mixed methods studies

      Search Strategy

      Electronic databases: Ovid MEDLINE, Scopus, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).
      Additional searches: Cochrane Databases of Systematic Reviews, reference lists of relevant papers, trial registers ClinicalTrials.gov and the World Health Organization international clinical trials registry platform (ICTRP), and unpublished “gray” literature via OpenGrey and Evidence Search.
      The full search syntax used for the Ovid MEDLINE search was: (exp DEMENTIA/OR dement∗ OR Alzheimer∗ OR Vascular∗ OR ‘Lewy Bod∗’ OR (Parkinson∗ AND (dementia∗ or disease)), OR Frontotemporal dement∗ OR ((cogniti∗ OR memory) AND (impair∗ OR deficit∗ OR disord∗))) AND (exp HEARING/OR ‘hearing loss’ OR ‘hearing disord∗’ OR ‘hearing deficit∗’ OR ‘hearing impair∗’ OR ‘auditory impair∗’ OR presbycusis OR presby∗) AND (exp ‘HEARING AIDS’/OR ‘hearing aid∗’ OR ‘correction of hearing impairment’).

      Study Selection

      A sample of 12% of the titles and abstracts were independently screened by the first author and a second reviewer (H.C.), resulting in moderate interrater agreement (Cohen κ = 0.44). These were reassessed following consensus discussion and clarification of the inclusion criteria, and substantial agreement was reached (Cohen κ = 0.63). During this process, we retained any papers that remained unclear for further appraisal. Screening of a further 6% of the returned search resulted in perfect agreement (Cohen κ = 1.00). The first author then screened the remaining titles and abstracts.
      Once the title and abstract screening was complete, the first author and second reviewer independently appraised the full text of all potentially relevant studies against the full inclusion and exclusion criteria. Disagreements between the 2 reviewers were resolved through discussion, and with the input of another member of the review team (P.D.).

      Data Extraction

      The primary researcher performed the data extraction using a bespoke form. The second reviewer checked this for accuracy. The primary researcher contacted authors of the 2 included conference abstracts to request missing data, which were provided by one of these.

      Quality Assessment

      The first author and second reviewer independently critically appraised the quality of the selected studies using the Mixed Methods Appraisal Tool (MMAT).
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      ,
      • Pluye P.
      • Gagnon M.P.
      • Griffiths F.
      • Johnson-Lafleur J.
      A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in Mixed Studies Reviews.
      The same reviewers then used the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) framework
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      to appraise and categorize the studies according to the level of research evidence. Throughout this process, any discrepancies were resolved through discussion, and with the input of another member of the research team (L.B.).

      Data Synthesis

      Because this is a mixed methods review, quantitative and qualitative data were treated with equal status and analyzed concurrently, according to the A−QUAL + QUAN framework.
      • Heyvaert M.
      • Maes B.
      • Onghena P.
      Mixed methods research synthesis: definition, framework, and potential.
      An interpretive data synthesis was undertaken by mapping extracted findings to the 14 domains of the Theoretical Domains Framework.
      • Cane J.
      • Connor D.O.
      • Michie S.
      Validation of the theoretical domains framweork for use in behaviour change and implementation research.
      • Michie S.
      • Johnston M.
      • Abraham C.
      • et al.
      Making psychological theory useful for implementing evidence based practice: a consensus approach.
      Any determinants of hearing aid use that did not fit into the domains of the TDF were categorized as “other” to ensure completeness of the synthesis.
      Confidence in the findings was assessed according to the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      For this, the first author and second reviewer independently assessed each finding in relation to methodologic limitations, coherence, adequacy, and relevance. The outcomes of these appraisals informed an overall assessment of confidence in the findings, according to the GRADE-CERQual criteria of high, moderate, low, or very low.
      Supplementary Table 1Characteristics of Included Studies
      Author (Year), Country of OriginType of PublicationStudy Design
      Categorized according to the Mixed Methods Appraisal Tool (MMAT).37
      Evidence Level
      Based on the Johns Hopkins Nursing Evidence-Based Practice framework (JHNEBP).39
      /Quality Rating
      Categorized according to the Mixed Methods Appraisal Tool (MMAT).37
      Inclusion CriteriaParticipant CharacteristicsStudy DescriptionHA UseCorrelates of HA Use
      Dupuis et al (2016)
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.


      Canada
      Conference abstract and posterQuantitative nonrandomized interventionLevel II/LowNot reportedSample size: n = 4 dyads

      Age: mean 90 y (range 80-92)

      Gender: 50% male

      Cognitive status: mean MoCA score 16.75 (SD 4.03) – indicative of moderate cognitive impairment/mild dementia.

      Dementia type: 25% diagnosed with AD; 25% other dementia variant; 50% MCI variants

      Hearing status: mean BEA = 40.4 dB (SD 5.58)

      Living circumstances: 50% cohabiting with spouse; 25% cohabiting with adult child; 25% alone

      Socioeconomic status: Not reported

      Ethnicity: Not reported
      Aim: To examine the impact of including significant others in audiologic rehabilitation of people with cognitive impairment

      Intervention: HAs (mixture of ITE and BTE, monaural and binaural) and audiologic rehabilitation

      Control: No control condition

      Duration: 3 mo
      Data source:

      Researcher report

      Data type:

      Qualitative (descriptive)

      Outcome: “Successful use” for all participants
      Enablers:

      Identification of goals relating to listening and communication;

      Positive consequences of use (reduced listening and communication difficulties, increased safety in the home, increased engagement in participatory activities).

      Barriers:

      Lack of procedural knowledge (difficulty differentiating, naming, and comprehending parts);

      Difficulty with handling skills (incorrect battery insertion).

      Noncorrelates:

      None reported
      Gregory et al (2020)
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.


      UK
      Peer-reviewed journalQualitative phenomenologicLevel III/

      High
      Aged 50+ y

      Diagnosed mild AD or MCI (sMMSE score ≥21)

      Confirmed hearing loss

      Provided with HAs

      Exclusion:

      Not fluent in English

      Lack capacity to consent
      Sample size: n = 10

      Age: Range 75-86 y

      Gender: 60% male

      Cognitive status: sMMSE score range 21-28, indicative of mild cognitive impairment/mild dementia

      Dementia type: 80% AD; 20% MCI

      Hearing status: not reported

      Living circumstances: not reported

      Socioeconomic status: not reported

      Ethnicity: 50% White British, 50% White Irish, Black, Asian, Punjabi
      Aim: To explore the experiences of HA use in people with dementia or mild cognitive impairment via semistructured interviewData source: Participant report

      Data type: Qualitative (descriptive)

      Outcome: Selective use related to situations, motivation, and consequences
      Enablers:

      Incorporation into everyday routine;

      Keeping aids in a set location when not in use;

      Perseverance;

      Welcoming visibility of HAs in aiding communication awareness of others;

      Optimism about efficacy;

      Positive consequences of use (increased confidence, feeling protected, finding them helpful)

      Comfortable fit;

      Support of care partner to insert aids;

      Social reinforcement (reminders and encouragements from family)

      Barriers:

      Lack of knowledge and handling skills (HA insertion);

      Misplacing and losing aids;

      Forgetting to use them;

      Stigma related to visibility;

      Belief that HA use could lead to overreliance on them;

      Ambivalence about need;

      Influence of environmental factors (excessive noise, demands of the listening situation)

      Noncorrelates:

      None reported
      Hawkins (2011)
      • Hawkins D.B.
      Less can be more.


      USA
      Practitioner MagazineQualitative case reportLevel V/

      Low
      Not reportedSample size: n = 1

      Age: 89 y

      Gender: male

      Cognitive status: moderate to advanced dementia; cognitive assessment score not reported

      Dementia type: mixed dementia

      Hearing status: mild to moderate hearing loss

      Living circumstances: cohabiting with spouse

      Socioeconomic status: not reported

      Ethnicity: not reported
      Aim: To report difficulties encountered in the provision of replacement HAs for a person with dementiaData source:

      Researcher report

      Data type:

      Qualitative (descriptive)

      Outcome: Rejection of replacement HAs
      Enablers:

      None reported

      Barriers:

      Deterioration of knowledge and skills (affecting comprehension of HA controls and device maintenance);

      Manufacturer’s manual triggering anxiety about complexity of aids;

      Immovable mindset precipitating resistance to changing aids;

      Lack of confidence in capabilities, agitation arising from this

      Noncorrelates:

      None reported
      Hutchison et al (2012)
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      and (2012)
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.


      USA
      Peer-reviewed journalMixed methods interventionLevel III/

      Low
      Aged 65+ y

      Diagnosed mild to moderate dementia (MMSE score 14-24)

      Mild to moderate hearing loss (determined by HHIE-S score)

      No cerumen blockage

      No history of middle ear surgery

      Little to no HA experience

      Living independently or with family within commuting distance of the research facility
      Sample size: n = 10

      Age: median 86.5 (range 82-94) y

      Gender: 20% male

      Cognitive status: MMSE score not reported. Researcher-determined 70% with “moderate dementia”; 30% “no dementia”

      Dementia type: not reported

      Hearing status: 50% moderate to severe hearing loss; 50% mild to moderate

      Living circumstances: 60% alone; 30% cohabiting with spouse; 10% cohabiting with other family

      Socioeconomic status: Not reported

      Ethnicity: not reported
      Aim: To ascertain the viability of treatment, impact of hearing loss treatment on behavioral symptoms and psychosocial factors for people with dementia, and willingness of caregivers to provide support

      Intervention: Binaural BTE HAs

      Control: No control condition

      Duration: 4 wk
      Data source:

      Caregiver log

      Data type:

      Quantitative (continuous)

      Outcome: Data for n = 7; median 211.5 hours over 4 wk (range 114-419.5)

      n = 1 rejected HAs
      Enablers:

      Positive consequences of HA use (improved ability to engage in social, leisure, and religious activities, increased connection with the internal or external auditory environment; improved participation in communication);

      Improved affective state (increased morale: Hedges g 1.47 on Lawton Morale Scale, large effect; signs of decreased depression and joy);

      Care partner assistance (successfully supported HA use in 9/10 participants)

      Barriers:

      Lack of awareness of hearing loss;

      Resistance to using HAs;

      Difficulty with HA insertion;

      Concerns about affordability (2 of 10 participants believed they were affordable)

      Noncorrelates:

      Hearing threshold was not associated with use (Hedges g 0.07)
      Kim et al (2021)
      • Kim A.S.
      • Amjad H.
      • Lin F.R.
      • et al.
      Association of hearing loss with neuropsychiatric symptoms in older adults with cognitive impairment.


      USA
      Peer-reviewed journalQuantitative descriptive observationalLevel III/

      Moderate
      Attendees at a community memory assessment clinic

      Completed audiometric and neurocognitive testing
      Sample size: 101

      Age: mean 76.3 (range 49-93) y

      Gender: 44% male

      Cognitive status: mean MMSE score 23.1 (SD 4.4), indicative of mild dementia

      Dementia type: 52% AD or related dementias; 27% MCI; 21% other cognitive disorders

      Hearing status: mean BEA 31.4 dB HL (SD 13.3)

      34% unimpaired hearing; 44% mild loss; 20% moderate loss; 3% severe loss

      Living circumstances: not reported

      Socioeconomic status: not reported

      Ethnicity: 82% White, 18% Black
      Aim: Chart review to examine the association between objective hearing loss and neuropsychiatric symptoms (NPSs) among people with varying degrees of cognitive impairmentData source:

      Clinical records

      Data type:

      Quantitative (categorical binary) Outcome: 20% of sample used HAs:

      5.9% of those with no hearing loss (n = 2);

      16% of those with mild hearing loss (n = 7);

      48% of those with moderate to severe hearing loss (n = 11)
      Enablers:

      HA use was inversely associated with both the number and severity of NPS

      Barriers:

      None reported

      Noncorrelates:

      None reported
      Leroi et al (2020)
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.


      Cyprus, France, and UK
      Peer-reviewed journalMixed methods interventionLevel III/

      High
      Aged 60+ y

      Diagnosed with mild to moderate dementia (AD, VaD, mixed) (MoCA score ≥12)

      Hearing loss >35 dB HL over 1-3 kHz in better ear

      Community dwelling

      Study partner available

      Capacity to consent

      Exclusion:

      Congenital hearing loss

      Unstable medical or psychiatric condition
      Sample size: n = 19 dyads

      Age: median 76 (range 63-88) y

      Gender: 63% male

      Cognitive status: mean MoCA score 17.3 (range 12-23), indicative of moderate cognitive impairment or mild dementia

      Dementia type: 47% diagnosed with AD; 47% VaD; 5% mixed

      Hearing status: mean Better Ear Hearcheck score = 3.8

      Living circumstances: 79% cohabiting with study partner

      Socioeconomic status: not reported

      Ethnicity: not reported
      Aim: To field-trial a prototype hearing and vision intervention in dementia

      Intervention: Binaural digital BTE HAs, troubleshooting support. Glasses for comorbid vision loss

      n = 4 dyads received an additional extended “sensory intervention” from a Sensory Support Therapist (SST)

      Control: No control condition

      Duration: 4 wk (basic intervention) or 12 wk (extended intervention)
      Data source:

      Caregiver report

      Data type:

      Quantitative (continuous)

      Outcome: Data for n = 4: 4-12 h/d; 4-7 d/wk
      Enablers:

      Improvement in knowledge, and skills in HA use;

      Becoming confident in HA wear and care;

      Setting goals related to device use, device care, communication, function, and social inclusion;

      Positive consequences of HA use (increased confidence, increased engagement in social and leisure activities, improved communication);

      Fostering of positive affect;

      Building care partner device knowledge and skills (8% improvement in knowledge and 24% improvement in skills on HASK assessment);

      Care partner encouragement

      Barriers:

      Lack of awareness of the presence of hearing loss (HHIE-S mean baseline score 7.87, indicative of no perceived hearing loss);

      Extraneous information within manufacturer manual;

      Experiencing problems with device fit

      Noncorrelates:

      None reported
      Nguyen et al (2017)
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.


      France
      Peer-reviewed journalQuantitative RCT intervention with semicrossover designLevel I/

      Moderate
      Aged 65+ y

      Diagnosed mild to moderate AD (MMSE score 10-28)

      Bilateral sensorineural hearing loss (21-80 dB HL)

      No HAs in last 2 y

      Able to tolerate HAs for at least 1 h/d

      Living with caregiver.

      Exclusion:

      Not AD

      Recent introduction or dose change of AD treatment

      Break/lose HA twice or more during the study
      Sample size: n = 51 (randomized)

      Age: mean 82.6 (SD 6.69) y

      Gender: 40% male

      Cognitive status: mean MMSE score 19.52 (SD 4.51), indicative of moderate dementia

      Dementia type: AD

      Hearing status: mean hearing threshold 48.75 dB (SD 10.48)

      Living circumstances: all cohabiting

      Socioeconomic status: not reported

      Ethnicity: not reported
      Aim: To assess the efficacy of HA provision on the cognitive status of people with Alzheimer’s disease and hearing loss

      Intervention: Binaural digital HAs and audiologic rehabilitation

      Control: Dummy HAs that were activated at 6 mo in a semicrossover design

      Duration: 12 mo. (primary outcomes at 6 mo)
      Data source:

      Caregiver log

      Data type:

      Quantitative (continuous and categorical)

      Outcome:

      Of the total sample, 31.6% were categorized as bad or moderate users and 68.4% as good or very good users at 6 mo

      Of the bad or moderate users, 66.7% were in the control group; of the good or very good users, 46.2% were in the control group.

      Daily use for 73.7% of active group and 59.1% of control group at 6 mo.
      Enablers:

      Younger age was associated with good compliance (mean age was 80.3 y for good or very good users and 86 y for bad or very bad; Hedges g 0.88, large effect)

      Barriers:

      Insufficient audiological gain (66.7% of the bad or moderate HA users were in the control group)

      Noncorrelates:

      Stage of cognitive decline was not associated with compliance (Hedges g 0.1);

      Hearing threshold was not associated with HA compliance (Hedges g 0.19)
      Nieman et al (2018)
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.


      USA
      Conference abstractQuantitative descriptive observationalLevel III/

      Low
      Meet diagnostic criteria for dementia

      Community-dwelling

      Reliable study partner
      Sample size: n = 647

      Age: ≥65 y

      Cognitive status: Mild cognitive impairment/mild dementia (MMSE score 21-30) 38%; moderate dementia (MMSE score 11-21) 40%; severe dementia (MMSE score 0-10) 18%.

      Dementia type: Not specified.

      Hearing status: Not reported

      Living circumstances: not reported

      Socioeconomic status: 15% low income (<$11,000); 28% middle income ($11,000-$24,999); 57% high income (>$25,000)

      Ethnicity: 44% White, 50% African American, 6% other
      Aim: To establish the prevalence of proxy-rated hearing loss and HA use of community-dwelling people with dementiaData source:

      Proxy report

      Data type:

      Quantitative (categorical binary)

      Outcome:

      Use according to age:

      0% of 65-75 y;

      17% of 75-85 y;

      31.3% of 85+ y.

      Use according to cognition:

      25.6% of mild dementia;

      16% of moderate dementia;

      21.7% of severe dementia.

      Use according to income:

      0% of <$11,000;

      23.5% of $11,000-$24,999;

      23.7% of >$25,000.

      Use according to ethnicity:

      27.5% of White; 5.6% of African American; 0% of other
      Enablers:

      None reported

      Barriers:

      Use was lower among participants with lower socioeconomic status (effect size calculation not possible);

      Use was lower among younger participants (effect size calculation not possible);

      Use was lower among non-White participants (effect size calculation not possible)

      Noncorrelates:

      Stage of cognitive decline was not associated with compliance (effect size calculation not possible)
      Nirmalasari et al (2017)
      • Nirmalasari O.
      • Mamo S.K.
      • Nieman C.L.
      • et al.
      Age-related hearing loss in older adults with cognitive impairment.


      USA
      Peer-reviewed journalQuantitative descriptive observationalLevel III/

      Moderate
      Aged 50+ y

      Diagnosed cognitive impairment

      Hearing screened

      English speaking
      Sample size: n = 100

      Age: mean 76 (SD 9.3) y

      Gender: 42% male

      Cognitive status:

      mean MMSE score 21.8 (SD 5.4), indicative of mild dementia

      Dementia type: 68% unspecified dementia; 32% MCI or other

      Hearing status: mild loss 32%; moderate 25%; severe 3%

      Living circumstances: not reported

      Socioeconomic status: not reported

      Ethnicity: 68% White; 32% non-White
      Aim: Chart review to establish the prevalence of hearing loss in a memory clinic, and to investigate rates of HA use and demographic associations within thisData source:

      Clinical records

      Data type:

      Quantitative (categorical binary)

      Outcome: 21% of sample used HAs:

      8% of those with no loss (n = 3);

      9% of those with mild loss (n = 3);

      54% of those with moderate to severe loss (n = 15)
      Enablers:

      People with greater severity of hearing loss were more likely to use HAs (effect size calculation not possible)

      Barriers:

      None reported

      Noncorrelates:

      None reported
      Palmer et al (1998)
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.


      USA
      Peer-reviewed journalQualitative case studyLevel III/

      Moderate
      Not reportedSample size: n = 1

      Age: 78 y

      Gender: male

      Cognitive status: MMSE score 18, indicative of moderate dementia

      Dementia type: mixed dementia

      Hearing status: BEA 58-dB HL over 0.5, 1, 2 kHz

      Living circumstances: Cohabiting with spouse

      Socioeconomic status: not reported

      Ethnicity: White
      Aim: To report the impact of a hearing intervention on a person with dementia

      Intervention: Monaural ITE HA, audiological training support and troubleshooting

      Control: No control condition

      Duration: 6 wk preintervention; 8 wk postintervention
      Data source:

      Caregiver log

      Data type:

      Quantitative (continuous)

      Outcome: 15 h/d
      Enablers:

      Awareness of hearing loss (baseline HHIE score 35);

      Identification of listening situation goals;

      Positive consequences of use (reduced hearing-related disability, significant reduction in HHIE score to 11 at follow-up, increased enjoyment in listening situations, increased communication);

      Care partner support with maintenance and use

      Barriers:

      Lack of troubleshooting knowledge for care partner

      Noncorrelates:

      None reported
      Palmer et al (1999)
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.


      USA
      Peer-reviewed journalQuantitative nonrandomized interventionLevel II/

      Low
      Diagnosed mild to moderate AD

      (MMSE score 12-24)

      HHIE-P score >18%

      Bilateral sensorineural hearing loss appropriate for amplification

      Living at home with spouse or adult child

      Exclusion:

      Significant h/o alcohol abuse, schizophrenia, Parkinson’s, head trauma, or cardiovascular accident

      English not first language
      Sample size: n = 8 dyads

      Age: mean 79 (range 71-89) y

      Gender: 62% male

      Cognitive status: mean MMSE score 14 (range 5-18), indicative of moderate dementia

      Dementia type: AD

      Hearing status: mean 40.4-dB HL over 0.5, 1, 2 kHz (range 21.7-56.6)

      Living circumstances: all cohabiting: 50% with spouse; 50% with adult child

      Socioeconomic status: not reported

      Ethnicity: not reported
      Aim: To ascertain the impact of HA provision on caregiver-identified problem behaviors of people with dementia

      Intervention: Monaural ITE HA, audiological training support and troubleshooting

      Control: No control condition

      Duration: 6-10 wk preintervention; 8 wk postintervention
      Data source:

      Caregiver log

      Data type:

      Quantitative (continuous)

      Outcome: median 9 h/d (range 4-13)
      Enablers:

      Severity of cognitive impairment (participants with greater impairment wore aids for longer per day: Hedges g 0.28, small effect);

      Positive intention for use;

      Positive consequences of use (reduced hearing-related disability—significant positive change scores on HHIE for 3 of 4 participants, improved ability to engage in social and leisure activities, improved communication in 6 of 8 participants);

      Severity of hearing loss (participants with greater severity of hearing loss wore HAs for longer - Hedges g 0.58, medium effect)

      Barriers:

      Difficulty with handling skills (evident in two-thirds of sample);

      Misplacing HAs;

      Incomplete adaptation;

      Noncorrelates:

      Age was not associated with HA use (Hedges g 0.10)
      Sheikh et al (2021)
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.


      Pakistan
      Peer-reviewed journalMixed methods interventionLevel III/HighAged 60+ y

      Diagnosed with AD, VaD, or mixed AD + VaD, or evidence of undiagnosed dementia

      Mild to moderate cognitive impairment (MoCA score ≥10)

      Adult-acquired bilateral hearing loss worse than 35-dB HL at ≥1 kHz in the better ear

      Capacity to consent

      Living at home

      Has a steady partner or informal caregiver ≥18y old

      Exclusion:

      Congenital hearing impairment

      Profound hearing loss

      Unstable medical or psychiatric condition

      Participating in trial of cognitive enhancing intervention
      Sample size: 15

      Age: median 64 y, range 60-80 y

      Gender: 47% male

      Cognitive status: mean MoCA score 15 (SD 2.9) range 10-20 (n = 14), indicative of moderate cognitive impairment or mild dementia

      1 participant with score ≥26 (normal cognition)

      Dementia type: AD (n = 1), VaD (n = 1), undiagnosed (n = 13)

      Hearing status: not reported

      Living circumstances: all cohabiting—50% with spouse, 40% with other family

      Socioeconomic status: not reported

      Ethnicity: not reported
      Aim: To culturally adapt and evaluate the feasibility, acceptability, and impact of a multifaceted hearing support intervention to enhance quality of life for persons with dementia in Pakistan

      Intervention: HAs (type not reported), training and support in HA use, goal setting, communication training, dementia awareness training (study partner)

      Control: No control condition

      Duration: ≤13 wk
      Data source:

      Researcher report

      Data type:

      Qualitative (descriptive)

      Outcome: All participants were willing to use their prescribed aids; no report of frequency or duration.
      Enablers:

      Awareness of hearing loss (mean baseline HHIE score 66.7 [SD 17.9], significant perceived hearing disability);

      Increased confidence in using and handling HAs;

      Positive consequences (reduced hearing-related disability: HHIE change score Hedges g 3.50, very large effect, improved ability to engage in social and leisure activities, improved communication);

      Fostering of positive affect (PHQ-9 Hedges g 1.62, large effect;

      GAD-7 Hedges g 1.89, large effect);

      Improvement in care partner’s device knowledge and skills;

      Care partner optimism about HAs

      Barriers:

      Negative perception of hearing loss as a disability;

      Lack of awareness that HAs may help

      Noncorrelates:

      None reported
      AD, Alzheimer’s disease; BEA, better ear average; BTE, behind the ear; GAD-7, Generalized Anxiety Scale–7
      • Spitzer R.L.
      • Kroenke K.
      • Williams J.B.W.
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      ; HA, hearing aid; HASK, Hearing Aid Skills and Knowledge Test
      • Saunders G.H.
      • Morse-Fortier C.
      • McDermott D.J.
      • et al.
      Description, normative data, and utility of the hearing aid skills and knowledge test.
      ; HHIE-P, Hearing Handicap Inventory for the Elderly–Proxy
      • Newman C.W.
      • Weinstein B.E.
      Judgments of perceived hearing handicap by hearing-impaired elderly men and their spouses.
      ; HHIE-S, Hearing Handicap Inventory for the Elderly–Screening
      • Weinstein B.E.
      • Ventry I.M.
      Audiometric correlates of the hearing handicap inventory for the elderly.
      ; ITE, in the ear; MCI, Mild Cognitive Impairment; MoCA, Montreal Cognitive Assessment
      • Nasreddine Z.S.
      • Phillips N.A.
      • Bédirian V.
      • et al.
      The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
      ; PHQ-9, Patient Health Questionnaire–9
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.W.
      The PHQ-9: validity of a brief depression severity measure.
      ; sMMSE, Standardized Mini Mental State Examination
      • Folstein M.F.
      • Folstein S.E.
      • McHugh P.R.
      “Mini-Mental State”. A practical method for grading the cognitive state of patients for the clinician.
      ; VaD, vascular dementia.
      Categorized according to the Mixed Methods Appraisal Tool (MMAT).
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      Based on the Johns Hopkins Nursing Evidence-Based Practice framework (JHNEBP).
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      Supplementary Table 2MMAT Quality
      • Hong Q.N.
      • Pluye P.
      • Fàbregues S.
      • Bartlett G.
      • et al.
      Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide.
      and JHNEBP
      • Dang D.
      • Dearholt S.
      Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
      Quality and Evidence Level Appraisals
      Dupuis et al (2016)
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      Gregory et al (2020)
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      Hawkins (2011)
      • Hawkins D.B.
      Less can be more.
      Hutchison et al (2012
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      and 2012
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      )
      Kim et al (2021)
      • Kim A.S.
      • Amjad H.
      • Lin F.R.
      • et al.
      Association of hearing loss with neuropsychiatric symptoms in older adults with cognitive impairment.
      Leroi et al (2020)
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      Nguyen et al (2017)
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Nieman et al (2018)
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      Nirmalasari et al (2017)
      • Nirmalasari O.
      • Mamo S.K.
      • Nieman C.L.
      • et al.
      Age-related hearing loss in older adults with cognitive impairment.
      Palmer et al (1998)
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      Palmer et al (1999)
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Sheikh et al (2021)
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      MMAT Checklist
       Screening
      Clear research question?YesYesNoYesYesYesYesCan’t tellYesCan’t tellYesYes
      Collected data addresses research question?Can’t tellYesCan’t tellYesYesYesYesCan’t tellYesCan’t tellYesYes
       Qualitative
      Appropriate approach?YesCan’t tellYes
      Adequate data collection methods?YesCan’t tellYes
      Findings adequately derived?YesCan’t tellCan’t tell
      Results sufficiently substantiated?YesCan’t tellYes
      Coherence?YesNoCan’t tell
       Quantitative RCT
      Randomisation performed appropriately?Yes
      Groups comparable at baseline?Yes
      Complete outcome data?No
      Assessor blinding?Yes
      Adherence to intervention?No
       Quantitative nonrandomized
      Participants representative of target?YesNo
      Measurements appropriate?Can’t tellYes
      Complete outcome data?NoNo
      Confounders accounted for?Can’t tellCan’t tell
      Intervention administered as intended?Can’t tellCan’t tell
       Quantitative descriptive
      Relevant sampling?Can’t tellCan’t tellYes
      Representative sample?Can’t tellCan’t tellYes
      Appropriate measurements?YesNoNo
      Low risk of nonresponse bias?YesCan’t tellYes
      Appropriate statistical analysis?YesCan’t tellYes
       Mixed methods
      Adequate rationale for mixed methods?NoYesYes
      Effective integration of components?YesYesYes
      Adequate interpretation of components?NoYesYes
      Divergencies and inconsistencies adequately addressed?YesYesYes
      Adherence to quality criteria?NoYesYes
      JHNEBP results
      Evidence levelLevel IILevel IIILevel VLevel IIILevel IIILevel IIILevel ILevel IIILevel IIILevel IIILevel IILevel III
      Quality ratingCA/BCCBABCBCCA
      Quality CategoryLowHighLowLowModerateHighModerateLowModerateModerateLowHigh
      Supplementary Table 3GRADE-CERQual
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      Outcomes
      TDF DomainComponent ConstructStudies Contributing to the ConstructAssessment of Methodologic LimitationsAssessment of CoherenceAssessment of AdequacyAssessment of RelevanceOverall Assessment of ConfidenceExplanation of Judgment
      KnowledgeAwareness of the presence of disabling hearing loss is associated with hearing aid use
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Moderate concernsModerate concernsModerate concernsMild concernsLow confidenceLow confidence due to moderate concerns in relation to coherence, adequacy, and methodology
      Degree of procedural knowledge influences hearing aid use: lack of knowledge impedes use whereas improvement in knowledge enables use
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Moderate concernsModerate concernsModerate concernsModerate concernsLow confidenceLow confidence due to moderate concerns in relation to coherence, adequacy, relevance, and methodology
      Standard manufacturer guidance does not enable hearing aid use
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Moderate concernsMinor concernsModerate concernsMinor concernsModerate confidenceModerate confidence due to moderate concerns in relation to adequacy and methodology
      SkillsDegree of hearing aid–handling proficiency influences hearing aid use: difficulty in handling inhibits use whereas being able to handle aids proficiently enables
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Hawkins D.B.
      Less can be more.
      Moderate concernsMinor concernsNo or very minor concernsMinor concernsHigh confidenceHigh confidence because despite some methodologic limitations, there was a body of relevant data to support the finding
      Memory, attention, and decision processesSeverity of cognitive impairment does not appear to be associated with hearing aid use
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Substantial concernsMinor concernsModerate concernsMinor concernsLow confidenceLow confidence due to substantial methodologic limitations of the studies and moderate concerns about adequacy
      Misplacing hearing aids is a barrier to their use; having a set place for storage is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Moderate concernsModerate concernsModerate concernsMinor concernsModerate confidenceModerate confidence due to moderate concerns about adequacy and methodologic quality
      Forgetting to use hearing aids is a barrier to their use; implementing compensatory strategies is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      No or very minor concernsModerate concernsSerious concernsMinor concernsLow confidenceLow confidence due to substantial concerns about adequacy and moderate concerns about coherence
      Behavioral regulationDeveloping habitual routines enables hearing aid use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      No or very minor concernsModerate concernsSerious concernsMinor concernsLow confidenceLow confidence due to substantial concerns about adequacy and moderate concerns about coherence
      Degree of adaptation to hearing aids influences their use; perseverance is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Moderate concernsMinor concernsSerious concernsMinor concernsLow confidenceLow confidence due to substantial concerns about adequacy and moderate concerns about methodology
      Resistance to change is a barrier to hearing aid use
      • Hawkins D.B.
      Less can be more.
      Substantial concernsMinor concernsModerate concernsMinor concernsLow confidenceLow confidence due to substantial concerns about methodology and moderate concerns about adequacy
      Role and identityMindset toward the visibility of hearing aids influences their use: concern about their visibility is a barrier whereas welcoming their visibility is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      No or very minor concernsModerate concernsModerate concernsMinor concernsModerate confidenceModerate confidence due to moderate concerns about coherence and adequacy
      Beliefs about capabilitiesDegree of self-confidence in ability to handle hearing aids influences their use: low confidence is a barrier whereas increasing confidence is an enabler
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Hawkins D.B.
      Less can be more.
      Moderate concernsModerate concernsModerate concernsMinor concernsLow confidenceLow confidence due to moderate concerns in relation to coherence, adequacy, and methodology
      OptimismOptimism about efficacy about hearing aids enables their use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      No or very minor concernsModerate concernsSerious concernsMinor concernsLow confidenceLow confidence due to substantial concerns about adequacy and moderate concerns about coherence
      Beliefs about consequencesAbsence of—or negative—expectancy about the outcomes of hearing aids are barriers to their use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      No or very minor concernsModerate concernsModerate concernsMinor concernsModerate confidenceModerate confidence due to moderate concerns about coherence and adequacy
      IntentionsDegree of intent influences hearing aid use: lack of intent is a barrier whereas positive intent is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Moderate concernsNo or very minor concernsModerate concernsMinor concernsModerate confidenceModerate confidence due to moderate concerns about adequacy and methodology
      GoalsIdentification of goals relating to hearing aids enables their use
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      Moderate concernsSubstantial concernsModerate concernsModerate concernsLow confidenceLow confidence due to substantial concerns about coherence and moderate concerns about adequacy, relevance, and methodology
      ReinforcementExperiencing positive consequences of hearing aids is associated with their use
      • Dupuis K.
      • Lemke U.
      • Reed M.
      • Pichora-Fuller M.K.
      Treatment of hearing impairment in older adults with cognitive impairment: importance of including significant others.
      ,
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Moderate concernsMinor concernsNo concernsModerate concernsHigh confidenceHigh confidence because although there were moderate concerns about relevance and methodology, there were only very minor concerns about coherence and adequacy
      Degree of fit and comfort influences hearing aid use: problems with fit are a barrier whereas finding them comfortable is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      No or very minor concernsMinor concernsModerate concernsMinor concernsHigh confidenceHigh confidence because although there were moderate concerns about adequacy due to low quantity, the data were rich enough to support this interpretation
      EmotionNegative emotional responses to hearing aids are a barrier to their use, whereas positive impact on affective state resulting from hearing aid use is an enabler
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Kim A.S.
      • Amjad H.
      • Lin F.R.
      • et al.
      Association of hearing loss with neuropsychiatric symptoms in older adults with cognitive impairment.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 1: can you hear the music of life?.
      ,
      • Hawkins D.B.
      Less can be more.
      Moderate concernsMinor concernsNo or very minor concernsModerate concernsModerate confidenceModerate confidence due to moderate concerns about relevance and methodology
      Environmental context and resourcesFactors related to person-environment interactions influence hearing aid use: excessive noise or perceived lack of need in differing listening situations lead to reduced use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      No or very minor concernsNo or very minor concernsMinor concernsMinor concernsHigh confidenceHigh confidence because although it was only represented in 1 study, this was a high-quality, relevant study and there were no concerns about coherence
      Lack of financial resources negatively influence hearing aid use
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Substantial concernsMinor concernsMinor concernsSubstantial concernsLow confidenceLow confidence due to substantial concerns in relation to relevance and methodologic quality of the studies
      Social influencesProactive care partner support with handling and maintaining hearing aids enables their use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      Moderate concernsMinor concernsModerate concernsModerate concernsLow confidenceLow confidence due to moderate concerns in relation to adequacy, relevance, and methodologic quality
      Lack of care partner hearing aid knowledge is a barrier; presence of care partner knowledge, skills and optimism are enablers
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Sheikh S.
      • Tofique S.
      • Zehra N.
      • et al.
      SENSE-Cog Asia: a feasibility study of a hearing intervention to improve outcomes in people with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Durrant J.D.
      • et al.
      Managing hearing loss in a patient with Alzheimer disease.
      Minor concernsModerate concernsMinor concernsModerate concernsModerate confidenceModerate confidence due to moderate concerns about coherence and relevance
      Receiving social reinforcement enables hearing aid use
      • Gregory S.
      • Billings J.
      • Wilson D.
      • et al.
      Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study.
      ,
      • Leroi I.
      • Simkin Z.
      • Hooper E.
      • et al.
      Impact of an intervention to support hearing and vision in dementia: the SENSE-Cog Field Trial.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      Minor concernsMinor concernsMinor concernsMinor concernsHigh confidenceHigh confidence because there were only minor concerns in each domain
      OtherDegree of hearing loss may not influence hearing aid use
      • Nirmalasari O.
      • Mamo S.K.
      • Nieman C.L.
      • et al.
      Age-related hearing loss in older adults with cognitive impairment.
      ,
      • Hutchison B.
      • Covan E.K.
      • Bogus J.C.
      Presbycusis, part 2: can you hear the music of life?.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Moderate concernsModerate concernsMinor concernsModerate concernsLow confidenceLow confidence due to moderate threats to coherence, relevance, and methodologic limitations
      Age may not influence hearing aid use
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      ,
      • Palmer C.V.
      • Adams S.W.
      • Bourgeois M.
      • et al.
      Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting.
      ,
      • Nguyen M.F.
      • Bonnefoy M.
      • Adrait A.
      • et al.
      Efficacy of hearing aids on the cognitive status of patients with Alzheimer’s disease and hearing loss: a multicenter controlled randomized trial.
      Substantial concernsModerate concernsMinor concernsMinor concernsLow confidenceLow confidence due to moderate threats to coherence and substantial methodologic limitations
      Ethnicity influences hearing aid use: non-White ethnic groups are less likely to use hearing aids
      • Nieman C.L.
      • Plaat K.
      • Johnston D.
      • et al.
      Dementia and hearing care disparities: prevalence of proxy-rated hearing loss and hearing aid use in a community-dwelling cohort of diverse older adults with dementia.
      Substantial concernsNo or very minor concernsModerate concernsModerate concernsLow confidenceLow confidence due to moderate concerns about adequacy and relevance, and substantial methodologic concerns

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