Tinnitus patients with cognitive problems:
Causes and possible treatments
By Gerhard Andersson
Tinnitus is a common problem among patients and patients find that it is tinnitus more than hearing loss
clients seen for auditory problems. Defined as the per- that makes communication more difficult.
ception of internal sounds that have no external origin, As with most problems (e.g., pain), tinnitus tends to
tinnitus is present in at least 10% of the adult population. fluctuate, and this is also the case with the cognitive
Among patients seen for hearing aid fitting, a majority problems associated with tinnitus. For example, people
(60%) will report tinnitus, which is largely explained by with tinnitus may report that they can’t concentrate on
a relatively strong association between tinnitus and hear- watching television after a long day at work. Another
ing loss.1 As with hearing impairment, there is an asso- common complaint is that tinnitus makes it more dif-
ciation between increasing age and the presence of ficult to read a book or newspaper. These difficulties are
tinnitus. reflected in statements like this one: “I do not notice my
Fortunately, only a minority of people with tinnitus tinnitus so much during the day. It is when I get home
are bothered by it to any significant degree. However, at and sit down in front of the television that it becomes
least 20% of them will report major distress because of worse. I cannot concentrate or focus on anything but
tinnitus in the domains of annoyance, insomnia, auditory the tinnitus. Reading is impossible. I usually put on
intrusions, and concentration problems. For some patients some music instead.”
seen for hearing aid fitting, tinnitus is more distressing Memory can also be affected, in particular in older
than the hearing loss, which renders tinnitus a problem patients who experience memory decline that may have
nothing to do with the tinnitus. Some persons with tin-
nitus report that their mind wanders and they start think-
ing about other things than what they are trying to focus
“…hearing healthcare professionals on, such as the newspaper they are reading. When tin-
should understand how tinnitus may nitus is annoying, the person is more likely to attend to
it. Some patients monitor their tinnitus several times a
aggravate and be aggravated by day to check if it is louder, different, or in any way chang-
ing. This can become very distracting because tinnitus
psychological problems…” tends to fluctuate in loudness anyway and the loudness
experience is also affected by attention. In other words,
when patients listen to their tinnitus they may perceive
that must be addressed in most hearing aid fitting settings. it as louder.
Hearing healthcare professionals should also understand In addition, tinnitus distress is linked with emotional
how tinnitus may aggravate and be aggravated by psy- distress (e.g., anxiety and depression). It is not uncom-
chological problems. mon for cognitive distraction to be caused by other
things, such as problems at work that can preoccupy a
COGNITIVE PROBLEMS IN TINNITUS PATIENTS person and make it more difficult to concentrate on
How common are concentration problems among per- a task, even a relaxing one like reading a book. Never-
sons with tinnitus? In a research study by Tyler and Baker, theless, problems of concentration are attributed to tin-
respondents were asked to list the problems they had nitus more often than to anxiety or depression. Thus,
with their tinnitus.2 The third highest response was con- the person begins by focusing attention on the tinnitus
centration difficulties. In our own studies, we have asked and this distraction interferes with concentration on
directly in an interview, “Does tinnitus affect your con- other tasks while also leading to difficulties remember-
centration?” and as many as 70% responded that it did.3 ing information.
It is unclear from the literature what kind of cogni- Sometimes cognitive problems arise from other causes
tive problems persons with tinnitus experience. A com- such as hearing loss or emotional distress, but the person
mon complaint in my clinical experience is that tinnitus assumes that tinnitus is the cause of their cognitive prob-
makes it more difficult for listeners to focus attention lems. Whether tinnitus is the actual cause or merely the
during conversations. While the role of hearing loss in perceived cause of cognitive problems, there is no doubt
understanding conversation is fairly obvious, many that the connection between tinnitus and cognitive
NOVEMBER 2009 • VOL. 62 • NO. 11 C a r i n g fo r t h e Pa t i e n t w i t h a C o g n i t i v e D i s o rd e r THE HEARING JOURNAL 27
performance is important for hearing ways to improve listening and commu- concentration problems. Early-onset
healthcare professionals to understand nication. Not only hearing loss can cause dementia is one such problem. For the
and learn more about. fatigue. A significant proportion of tin- clinician, it may be necessary to refer to
nitus patients have insomnia,4 and in a neurologist or neuropsychologist to get
CAUSES OF COGNITIVE more severe cases of tinnitus this figure a detailed assessment of the patient’s cog-
PROBLEMS IN TINNITUS PATIENTS exceeds 50%. Loss of sleep can some- nitive problems and to establish if they
There are several possible reasons why times be the cause of perceived concen- are related to tinnitus.
tinnitus patients report concentration tration problems.
problems. These reasons are not mutu- TREATMENT POSSIBILITIES
ally exclusive. For example, emotional Distress Depending on the characteristics of the
distress and hearing impairment can both As mentioned above, another factor that cognitive problems, different treatment
be part of the same clinical picture. can interfere with the ability to concen- options could be considered.7
Among the plausible reasons for con- trate is psychological distress. We know
centration problems is, first and fore- from research that many people with Hearing technologies
most, hearing loss. severe tinnitus are depressed and anx- For hearing professionals it is obviously
ious. For some patients these problems important to consider the role of audi-
Hearing loss can be so great that they might meet the tory impairment and the potential
Many people with tinnitus also have criteria for a psychiatric diagnosis of benefit from hearing aids. My clinical
hearing loss and for many this is as experience is that some patients ben-
problematic as the tinnitus, but for efit immensely from the increased
other reasons. Hearing loss can give “…the clinical management auditory input provided by hearing
rise to communication problems, aids and that this input sometimes
which can be highly noticeable in of tinnitus has probably not leads to reduced awareness of tinni-
social settings where communica- tus and also reduced concentration
tion breakdowns can occur and mis- fully realized the importance problems in relatively easy listening
understandings are frequent. Often and communication situations.
hearing aids will help, but they are of taking cognitive problems
not a cure and residual problems Counseling
can persist, especially in noisy envi- into account...” Far from all patients fitted with hear-
ronments. ing aids experience relief from tin-
For some patients whom I see in my major depression and/or an anxiety nitus and it may be important to counsel
clinic it can be hard to determine whether disorder.5 It is well known that depres- patients not to have exaggerated expec-
problems are caused by tinnitus or if they sion and anxiety can have a negative tations of what hearing aid(s) may do for
should be attributed to hearing loss. In influence on concentration abilities.6 For their tinnitus.
fact, it seems likely that both problems example, depressive disorders often When working in a multidisciplinary
interact so concentration is even more involve concentration difficulties and team, it is important to provide adequate
difficult when there is a combination of memory problems. Anxiety, and in par- descriptions of the treatments provided,
hearing loss and tinnitus. ticular health anxiety, may affect con- including a rationale for how they may
centration because it draws patients’ work. Some patients with cognitive prob-
Fatigue attention toward things they fear or lems may have difficulty understanding
Finding it hard to concentrate and main- worry about, such as fear of their tinni- and remembering the session, so it is
tain a conversation is a challenge for tus becoming worse. preferable for their significant others to
many individuals with impaired hear- be involved. Indeed, a special kind of
ing. Even mild hearing loss can lead to Medication, medical conditions memory deficit relating to episodic
fatigue, which is another common rea- Another aspect of the problem relates memory can sometimes be impaired in
son for concentration to fail. Straining to the effects of medication and the role tinnitus patients.8 There are, however,
to hear might make the patient tired, of other medical conditions. For exam- many ways to support patients by help-
which can affect the ability to maintain ple, diabetes can be associated with ing them recall the material covered in
focus for sustained periods of time. Some impaired concentration. Some com- treatment consultations. Summaries can
patients tend to focus on their tinnitus monly prescribed medications can cause be provided and text material can be used
instead of the environment, particularly fatigue and concentration problems as as handouts. For example, this is suit-
in difficult listening situations. side effects. While not necessarily related able when giving advice and exercises
When we talk to tinnitus patients to a medical condition, old age can relating to insomnia.
about concentration problems, we need result in concentration and memory
to be careful because some problems problems. Cognitive therapy
might be the result of hearing loss and There are also cases in which other Cognitive therapy techniques can be
hence require solutions that incorporate undetected medical problems can cause used to help patients get a better
28 THE HEARING JOURNAL C a r i n g fo r t h e Pa t i e n t w i t h a C o g n i t i v e D i s o rd e r NOVEMBER 2009 • VOL. 62 • NO. 11
tinnitus will not be disturbed much by
their tinnitus even if they hear it clearly.
Tinnitus signal No annoyance However, when tinnitus is appraised as
a serious problem and as the cause of
Cognitive deficits other problems (including insomnia
e.g. attention, working memory, and lack of concentration), this is a suf-
resource limitations ficient and necessary condition for it to
become annoying. The clinical man-
agement of tinnitus has probably not
Emotional processing bias,
e.g depression and anxiety
fully realized the importance of taking
and/or cognitive problems into account dur-
ing assessment or incorporated cogni-
Negative appraisal of tinnitus tive behavior therapy during treatment
- seen as cause of problems to the extent that could be optimal.
Much more research is needed, includ-
Figure 1. A model of the road to annoyance via different levels of cognitive ing investigations into the brain mech-
functioning. anisms involved in annoyance from
Gerhard Andersson, PhD, is Professor in Clinical
understanding of tinnitus and adjust becomes possible someday to cure some Psychology at Linköping University and the Karoliniska
maladaptive thoughts and beliefs regard- forms of tinnitus, there will most likely Institute, Sweden. He is a member of the HEAD (Hearing
ing tinnitus.9 still be a need for rehabilitation in a mul- and Deafness) research group at the Swedish Institute for
Disability Research and collaborates with researchers funded
In the treatment protocol we have tidisciplinary setting. Therefore, we need
by the Oticon Foundation, Denmark. Readers can contact
developed in Sweden, we include advice to better understand the mechanisms Dr. Andersson at the Department of Behavioral Sciences
regarding concentration problems. This behind tinnitus annoyance. Cognition and Learning, Linköping University, SE-581 83 Linköping,
involves structuring information, taking is probably important. Research on the Sweden or at Gerhard.Andersson@liu.se.
pauses, repetition, and memory aids (e.g., cognitive aspects of tinnitus is still sparse,
notes). Also important is a proper descrip- but promising new studies on working REFERENCES
1. Andersson G, Baguley DM, McKenna L, McFerran
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