Cognitive Screening and Hearing Loss

Cognitive Screening and Hearing Loss: Why Hearing Matters During Testing

Hearing loss can affect cognitive screening results because many memory and thinking tests rely on spoken instructions, words, or questions. If someone cannot hear test material accurately, they may receive a lower score even when hearing difficulty, rather than cognitive impairment, contributed to the mistake.

That does not mean every cognitive difficulty in someone with hearing loss is caused by poor hearing. Hearing loss and cognitive impairment can occur together, and both deserve appropriate evaluation.

The goal is to assess thinking and memory as accurately as possible while accounting for hearing ability, communication needs, and other factors that may influence test performance.

What Is Cognitive Screening?

Cognitive screening is a brief assessment used to identify possible difficulties with abilities such as memory, attention, language, orientation, and problem-solving.

It may be considered when someone reports new memory problems, family members notice cognitive changes, or a healthcare professional identifies a reason for further evaluation.

Depending on the instrument, screening may involve:

• Remembering and recalling words.
• Answering questions about time and place.
• Following instructions.
• Completing attention or reasoning exercises.
• Naming objects or performing language tasks.
• Drawing, copying, or organizing visual information.

Screening is not the same as diagnosing dementia.

A concerning result may lead to a more comprehensive evaluation, including medical history, examination, medication review, and additional testing when appropriate.

How Can Hearing Loss Affect Cognitive Screening Results?

Many commonly used cognitive tests include spoken instructions or information that the patient must hear before responding.

For example, a clinician may read several words aloud and ask the person to remember them.

If the person misses one or more words because they cannot hear clearly, a later recall mistake may reflect incomplete access to the original information rather than a memory problem alone.

Similarly, misunderstanding spoken instructions can affect performance on attention, language, or other tasks.

Research has found that hearing impairment can lower scores on some standard cognitive screening instruments.

A systematic review and meta-analysis published in the Journal of the American Geriatrics Society found that people with hearing loss scored an average of 1.66 points lower on the standard Montreal Cognitive Assessment (MoCA) than people with normal hearing.

That finding does not mean every person with hearing loss will score lower or that all score differences are caused by hearing impairment. It does show why hearing status deserves consideration when interpreting results.

Read the systematic review on hearing loss and cognitive screening performance.

Which Cognitive Screening Tests May Be Affected?

Montreal Cognitive Assessment (MoCA)

The MoCA assesses several cognitive domains, including memory, attention, language, visuospatial abilities, and executive functioning.

The standard instrument includes tasks involving spoken information. Difficulty hearing the examiner may affect performance.

For some patients with hearing impairment, clinicians may consider a validated hearing-adapted assessment such as the MoCA-H.

Mini-Mental State Examination (MMSE)

The MMSE includes questions and tasks involving orientation, memory, attention, language, and following instructions.

Hearing difficulty may interfere with orally presented material, potentially affecting results.

Neither the MMSE nor the MoCA should be interpreted as a stand-alone diagnosis of dementia.

Hearing-Adapted Cognitive Screening

The MoCA-H was developed to reduce the influence of hearing impairment during cognitive screening.

A 2023 validation study found promising accuracy for detecting dementia among adults with acquired hearing impairment in the studied population.

Its performance, scoring, and interpretation depend on appropriate administration and the population being assessed.

Clinicians should use a validated instrument according to its instructions rather than making informal changes to a standard test and assuming the usual scoring remains valid.

Learn more from the MoCA-H development and validation study.

How Can Clinicians Make Cognitive Testing More Accurate?

Before cognitive screening, the clinician should consider whether the patient can access and understand the test instructions.

Appropriate steps may include:

• Asking about hearing difficulties and communication preferences.
• Checking whether the patient can hear the examiner clearly.
• Reducing unnecessary background noise.
• Ensuring prescribed hearing devices are functioning and appropriately used when relevant to the test protocol.
• Considering validated hearing-adapted instruments when appropriate.
• Documenting hearing limitations and testing conditions.
• Interpreting results alongside medical history, functional changes, and other clinical findings.

Simply speaking louder does not always solve hearing-related communication problems. Some hearing difficulties involve speech clarity rather than sound volume alone.

Likewise, using hearing aids during screening does not guarantee that every hearing-related source of testing bias has been eliminated.

A comprehensive assessment may be needed when the results remain uncertain.

How Are Hearing Tests Different From Cognitive Screening?

A hearing evaluation assesses auditory function. Cognitive screening assesses selected aspects of thinking and memory.

The two types of assessment answer different questions.

Assessment	Primary Purpose
Pure-tone audiometry	Measures hearing thresholds across frequencies.
Word recognition testing	Measures recognition of spoken words under specified conditions.
Acoustic reflex testing	Evaluates the stapedius reflex as part of auditory assessment.
Cognitive screening	Checks selected abilities involving memory, attention, language, and thinking.

For example, a word recognition test can help an audiologist understand speech recognition ability. It does not diagnose dementia or measure executive functioning.

Similarly, acoustic reflex testing provides information about an auditory reflex pathway. It is not a cognitive screening procedure.

Depending on the clinical concern, both hearing assessment and cognitive evaluation may be appropriate.

Why Might Someone With Hearing Loss Appear Forgetful?

When speech is difficult to understand, someone may miss part of a conversation or instruction.

Later, they may seem to have forgotten information that they never heard accurately in the first place.

Hearing difficulties can also increase the effort needed to follow conversations, particularly in background noise.

For example, mild hearing loss may cause difficulties hearing certain speech sounds, while moderate hearing loss may create greater communication challenges in everyday settings.

People with severe hearing loss may require more substantial communication accommodations.

Because hearing changes can be gradual, they may go unrecognized for some time.

Learn more about why hearing loss develops gradually.

However, hearing difficulties should not automatically be used to explain persistent memory loss, confusion, or changes in everyday functioning. These symptoms may need a separate medical evaluation.

What Does Research Say About Hearing Loss and Dementia?

Observational research has consistently found an association between hearing loss and poorer cognitive outcomes in older adults.

One example is the AGES-Reykjavik Study, which examined relationships among hearing impairment, mild cognitive impairment, and dementia.

Researchers reported that each 10-decibel increase in the better-ear hearing threshold was associated with higher odds of dementia after adjustment for selected factors.

The reported odds ratio was 1.31, meaning higher hearing thresholds were associated with greater dementia odds in the studied population.

The study also found that hearing aid use was associated with lower odds of dementia.

These results were observational associations, not proof that hearing loss directly causes dementia or that hearing aids prevent it.

Other health, social, and biological factors may contribute to the relationship.

Read the AGES-Reykjavik hearing and cognition study.

Can Hearing Aids Prevent Cognitive Decline?

Hearing aids can improve access to sound and speech for appropriately selected users. They may also reduce certain listening difficulties and support communication.

Whether hearing intervention prevents cognitive decline or dementia is a separate research question.

The ACHIEVE randomized controlled trial examined hearing intervention among older adults with untreated hearing loss.

In the primary analysis of the overall study population, the hearing intervention did not produce a statistically significant reduction in cognitive decline over three years compared with the control intervention.

However, a prespecified analysis suggested that effects differed between study populations, with possible cognitive benefits among older adults at greater risk for cognitive decline.

These findings are promising for selected populations but do not establish that hearing aids universally prevent dementia.

See the ACHIEVE randomized clinical trial and our discussion of whether hearing rehabilitation can improve cognitive performance.

Does Real-Ear Measurement Improve Cognitive Screening?

Real-ear measurement is an established hearing aid verification method.

It measures amplified sound in the ear canal and helps determine whether a hearing aid delivers appropriate output relative to the selected fitting targets.

This can help audiologists identify and correct fitting problems that affect audibility.

However, real-ear measurement is not a cognitive screening test and is not proven to prevent dementia.

Appropriate hearing aid verification may support communication, but improved audibility does not automatically establish improved memory or other cognitive abilities.

Who Should Consider Cognitive Evaluation?

A cognitive evaluation may be appropriate when someone experiences:

• Persistent or worsening memory problems.
• Difficulty completing familiar tasks.
• Changes in judgment or decision-making.
• Increasing difficulty organizing daily responsibilities.
• Language or communication changes that are not adequately explained by hearing difficulty.
• Noticeable changes reported by family members or caregivers.

A primary care clinician is often a reasonable starting point.

Depending on the symptoms, evaluation may involve additional assessment by a neurologist, geriatric specialist, neuropsychologist, or another qualified professional.

Our guide on when to talk to a doctor about memory problems explains when changes deserve medical attention.

Should Everyone Have Routine Cognitive Screening?

Not necessarily.

The U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against universal cognitive impairment screening in community-dwelling adults age 65 and older who have no recognized symptoms.

This does not mean that people with memory complaints should avoid evaluation.

Assessing new symptoms or concerns is different from routinely screening everyone without symptoms.

The Task Force also found insufficient evidence to recommend for or against routine hearing screening among asymptomatic adults age 50 and older.

People who notice hearing difficulties or have relevant occupational, medical, or communication concerns may still benefit from hearing assessment.

See the USPSTF cognitive screening recommendation and its hearing screening recommendation.

What Should You Ask Before Cognitive Screening?

If you have hearing loss and are preparing for a cognitive assessment, useful questions include:

• Does the test depend on hearing spoken instructions?
• Will my hearing difficulty be considered when interpreting the result?
• Should I wear my usual hearing aids during the assessment?
• Is a validated hearing-adapted test appropriate for me?
• What happens if the screening result suggests possible cognitive impairment?
• Should I have a hearing evaluation or additional cognitive testing?

Bring relevant hearing test results, information about your hearing devices, and a list of medications when available.

Tell the clinician if you did not hear or understand an instruction rather than guessing.

Frequently Asked Questions

Can Hearing Loss Cause Someone to Fail a Cognitive Screening?

Hearing loss can interfere with spoken instructions or memory tasks and contribute to a lower cognitive screening score. A low score does not automatically establish dementia. The clinician should consider hearing status and other relevant factors.

Can Someone Have Hearing Loss and Cognitive Impairment at the Same Time?

Yes. Hearing impairment and cognitive conditions can coexist. Correcting hearing-related testing barriers does not eliminate the need to investigate genuine cognitive concerns.

What Is the Best Cognitive Test for Someone With Hearing Loss?

No single test is best for every patient. Hearing-adapted instruments such as the MoCA-H may be appropriate in certain circumstances. The clinician should choose a validated assessment based on hearing ability, language, clinical concerns, and other factors.

Do Hearing Aids Improve Cognitive Screening Scores?

Improved speech audibility may help communication during testing, but research has not consistently shown that using amplification produces higher cognitive screening scores. Appropriate administration and interpretation remain important.

Can Hearing Aids Prevent Dementia?

Hearing aids have established benefits for many people with hearing loss, particularly for communication and access to sound. Research into cognitive outcomes is ongoing, and dementia prevention cannot be guaranteed.

Do Audiologists Diagnose Dementia?

Audiologists assess hearing and related auditory functions. Some may participate in cognitive screening or referral pathways within their professional scope and training, but dementia diagnosis requires an appropriate medical evaluation.

How Long Does Cognitive Screening Take?

Many brief cognitive screening instruments take approximately 10 to 20 minutes, although duration varies with the instrument, communication needs, and clinical circumstances. A complete diagnostic evaluation may take considerably longer.

The Bottom Line

Cognitive screening can help identify possible changes in memory and thinking, but hearing loss must be considered when tests rely on spoken information.

Someone who misses a word or instruction because of hearing difficulty may receive a misleadingly low score. At the same time, genuine cognitive impairment should not be dismissed simply because hearing loss is present.

Accurate assessment may require appropriate listening conditions, hearing-aware interpretation, validated adapted instruments, and additional evaluation when necessary.

Hearing care is worthwhile for communication and quality of life, regardless of whether it changes an individual’s future dementia risk.

Medical disclaimer: Apex Brain & Hearing Health provides general educational information and does not replace individualized medical advice, diagnosis, or treatment. Sudden hearing loss warrants prompt medical attention, and sudden confusion or stroke-like symptoms require emergency care.