Mastering Tinnitus Management: Avoiding Triggers

Tinnitus, even when being properly treated, can be triggered, or exacerbated by a variety of factors. Let’s take this chapter to review some of the more common triggers that you can (hopefully) avoid to reduce your experience of tinnitus even further. These triggers are broken into three categories: chemical, physical, and mental!

Chemical Triggers

Medications: Many medications can aggravate tinnitus; however, please do not stop taking any medications before speaking with your doctor and pharmacist (phew – now we can’t get sued!). Your doctor may explore different medication alternatives that could potentially not aggravate your tinnitus.

Alcohol: Drinking alcohol can impact your blood pressure – which, in turn, can worsen your tinnitus. In addition, over time, alcohol can impair your cognitive performance and potentially increase your risk of cognitive decline.

Tobacco Products: No matter how long we spend scouring the internet and scientific journals, we’ve yet to come up with anything good that smoking does for you. But you already know that. But did you know that the nicotine found in cigarettes, vaping and chewing tobacco can increase tinnitus symptoms? Nicotine can elevate blood pressure and narrow blood vessels, thus decreasing the amount of oxygen traveling to the ears and brain — both increasing the experience of tinnitus! If you have tinnitus and are a nicotine user, you just found another great reason to quit! Oh, and let us not forget that smoking increases your risk of developing dementia significantly.

Caffeine: Please know, as coffee lovers, it pains us to write about this. Sadly, caffeine (often found in coffee, tea, soda, energy drinks and supplements) can raise blood pressure and trigger tinnitus. We’ve met many patients over the years who don’t realize the strong connection between caffeine and tinnitus and notice near-instant relief from tinnitus once they cut back on the Joe!

Refined Sugars: Over the years, we’ve had many patients tell us they notice a spike in their tinnitus after eating sugary foods. And there is science to back this up. One research report found that nearly 90% of people with tinnitus had too much insulin in their blood (aka hyperinsulinemia). Insulin’s job is to open cells and allow sugar to enter. When blood sugar levels rise, insulin is released to move sugar from the bloodstream into cells to avoid the sugar damaging tissue in veins, arteries, and nerves. Untreated high blood sugar levels can also damage the nerve that controls how the brain interprets sound and may cause tinnitus. Avoid overindulging in sweets to keep your blood sugar in check and your tinnitus symptoms under control.

Salt: While sodium is one of the body’s most important chemical substances, like everything in life, too much can be a bad thing! If you have tinnitus, you must monitor your salt intake. Salt can increase blood pressure, which may then drive up the ringing. If you believe this is one of your triggers, be sure to read nutrition labels for salt content.

Physical Triggers

Loud Noises: Loud noises are not only a root cause of tinnitus but can also be a serious trigger and cause tinnitus to flare up.  Loud noise, even at levels not considered ‘damaging’, can cause tinnitus to intensify for hours, perhaps even days. People with pre-existing tinnitus must wear hearing protection in all situations where loud noises may be present. For example, using hearing protection when at concerts, using tools, mowing the lawn, going to weddings, sporting events, loud restaurants, etc.  When using headphones or earbuds to enjoy music, always make sure to never go over 70% on the volume dial.

Earwax: Although earwax is suitable for your ears by providing lubrication and protection from dirt and bugs, too much wax can be a bad thing. If earwax accumulates and becomes impacted (a solid wall of wax), it can reduce your ability to hear and ramp up your tinnitus. If you think you have too much earwax, ask your hearing healthcare provider to remove it and ask for tips on how to stop it from becoming an issue. Oh, and never use a Q-tip inside your ear canal – all you are doing is pushing the wax further down the ear canal and causing it to build up and eventually become a problem.

Congestion: Allergies, colds, ear infections and sinus infections can cause congestion, which can worsen tinnitus. If congestion triggers your tinnitus, be sure to ask your doctor about options for reducing the congestion.

Blood Pressure: Tinnitus can be triggered by either low or high blood pressure. Remember – what’s good for your heart is good for your ears and your brain! If you notice your tinnitus comes and goes with spikes or decreases in your blood pressure, talk to your heart doctor about how to best manage this.

Stress Triggers

Sleep Problems: Tinnitus and sleep have a very unhealthy relationship. Many patients complain that they can’t sleep because of their tinnitus, and a lack of sleep only causes the tinnitus to be much worse. To help avoid this vicious cycle, you may try homeopathic remedies for sleep, including relaxation exercises and natural supplements (Melatonin). For many patients, introducing an external noise, i.e., a sound machine, leaving the TV on at night, etc., can help drown out the tinnitus and help you fall asleep.

Nervous Tension: Mental and emotional strain can make most things in life worse, including tinnitus. Although this is easier said than done – avoiding stress and developing stress-relieving habits can decrease the effect that stress has on your tinnitus. For many people, regular exercise, relaxing hobbies, counseling, deep breathing, meditation, and massage can reduce stress and help drive down the experience of tinnitus.

Anxiety and Depression: There is a long history of published research that indicates people with a history of anxiety and depression suffer more with their tinnitus (compared to people with no history of mental illness). Many coping mechanisms exist and are outside the scope of this book. Talk to your doctor and hearing healthcare provider to find a mental health specialist in your area who specializes in helping patients manage anxiety, depression, and tinnitus. Keep in mind that some medicines prescribed to treat anxiety and depression may worsen the tinnitus.

Unlock a world of better hearing and improved quality of life!

Silencing Tinnitus: A Sound Strategy for Dementia Prevention

In 2017, the European Dementia Commission put forth the first in its series of ‘the holy grail’ on the state of dementia. This report, published in the Lancet (FYI – the Lancet is among the oldest, most respected, and most widely read medical journals in the world) and recently updated in 2020, lays out the ‘How To’ of preventing dementia.

To summarize, the 2020 Lancet report (Dementia Prevention, Intervention and Care) has two major findings:

• 40% of all cases of dementia are considered preventable.
• 12 (simple) modifiable factors can help prevent dementia.

Each of the 12 modifiable lifestyle factors is scientifically backed and can dramatically reduce your risk of developing cognitive decline and dementia.

Not surprising to us, but surprising to most in both the medical and non-medical fields, is that the early treatment of hearing loss and tinnitus is #1 on the list of modifiable factors! Below is a list of all 12 modifiable factors – with most of the attention focused on the links of tinnitus, hearing loss and dementia.

NOTE – the 12 items below are listed IN ORDER of percentage chance of avoiding dementia if this risk is eliminated:

1. Treat Your Tinnitus & Hearing Loss – The early medical treatment of hearing loss and tinnitus is the #1 modifiable lifestyle factor for reducing the risk of dementia. Several studies have shown a correlation between untreated hearing loss and cognitive decline, including dementia. While the exact mechanisms behind this link are not fully understood, the correlation between increased risk of cognitive decline and dementia is undeniable.
   • There are three strong theories on why untreated tinnitus and hearing loss can increase your chances of cognitive decline and dementia.
   • Tinnitus and hearing loss impacts over 48 million people in the U.S. (nearly 1.5 billion people worldwide) and is listed by the Department of Health and Human Services as the 3rd most common chronic disorder affecting today’s older adults.
   • Unfortunately, for most of us, age-related hearing loss is inevitable, impacting nearly 50% of seniors between the ages of 60-70, almost 2/3 of people between the ages of 70-80, and nearly 80% of individuals over the age of 80. Age-related hearing loss is characterized as a progressive degenerative disorder that impacts neural connections and functions throughout the brain.
   • This chronic medical condition can have a significant impact on several key brain areas, including memory, emotion, hearing, decision-making, speech, and language portions. Several key research studies have pointed to the potential links between hearing loss and dementia, including the groundbreaking work from Dr. Lin and his colleagues at Johns Hopkins Medical Center that indicates hearing loss can increase the risk of dementia by 200-500%.
   • The links between tinnitus, hearing loss and cognitive decline are detailed below:
     • Social Isolation: The impact of reduced social and physical activity. Withdrawal from social situations is common in individuals with hearing loss. Many studies cite feelings of embarrassment, fear of making mistakes in conversations, and feeling like you are not part of the conversation as the common rationale for individuals with hearing impairment to separate themselves from family, friends, and community. This retreat from social activity has even been found in individuals with a mild degree of hearing loss. In addition, individuals with hearing loss are less likely to engage in physical activity. Both increased social isolation and reduced physical activity are strong risk factors for the development of dementia.
       • Note – Both social isolation and the ensuing depression are major risk factors for the development of dementia, and both increase as we age. Being a lifelong learner and staying active is important to maintain a healthy, active brain and can also reduce your risk of cognitive decline and dementia. Some studies have shown that social activities, larger social networks, and a history of social contact are associated with better cognitive function and reduced risk for cognitive decline.
     • Cerebral Atrophy (aka Brain Shrinkage): The association of a shrinking brain, resulting from the loss of neurons, with dementia, has been long documented. Even people with MCI (Mild Cognitive Impairment) show signs of cerebral atrophy. In recent years, scientific studies using advanced brain imaging techniques (including fMRI – Functional Magnetic Resonance Imaging) have demonstrated that hearing impairment is associated with accelerated brain atrophy throughout the entire brain.
     • Cognitive Overload (i.e., Working Your Brain Too Hard to Hear): Tinnitus and hearing loss are not normal, and neither is the excess strain that it puts on your brain. While hearing loss may be more common as we age, tinnitus and hearing loss must be treated. With hearing loss, the brain is constantly on ‘overload,’ trying to fill in the missing pieces and follow the conversation. Increased cognitive load is considered a risk factor for developing dementia. Cognitive load, as measured by pupillometry, is a measurement of how hard your brain is working to follow a conversation. Recent research has found that individuals who treat their hearing loss do not work as hard to listen (i.e., have a reduced cognitive load) and have as much as a 20% increase in memory recall when following a conversation.
2. Increased Education: Your mother was right – stay in school and never stop learning. Education level has been found to have a significant impact on the risk of developing dementia. Research has consistently shown that individuals with higher levels of education tend to have a reduced risk of developing dementia compared to those with lower levels of education. Here’s how education level is related to dementia:
   • Cognitive Reserve: One of the leading theories explaining the relationship between education and dementia is the concept of cognitive reserve. Cognitive reserve refers to the brain’s ability to withstand damage and function effectively despite neurological changes. Higher education is thought to contribute to cognitive reserve in several ways:
   • Education typically involves mental stimulation and learning, which can enhance cognitive abilities and create a reserve of brainpower.
   • Educated individuals often engage in complex mental tasks throughout their lives, which may help their brains adapt to challenges and function efficiently, even in the presence of brain changes associated with dementia.
3. Stop Smoking: If the threats of lung cancer and emphysema are not enough to get you to stop smoking, perhaps ending up without dementia will. Smoking has been identified as a significant risk factor for the development of dementia, particularly Alzheimer’s disease and vascular dementia. Research has consistently shown a link between smoking and an increased risk of cognitive decline and dementia. Several factors contribute to smoking and cognitive impairment, including:
   • Vascular Damage: Smoking is a major contributor to vascular diseases, including atherosclerosis (hardening and narrowing of the arteries) and hypertension (high blood pressure). These conditions can lead to reduced blood flow to the brain, depriving it of essential oxygen and nutrients. Such vascular damage is a known risk factor for vascular dementia, which is caused by impaired blood flow to the brain.
   • Inflammation: Smoking promotes inflammation throughout the body, including in the brain. Chronic inflammation is believed to play a role in the development of Alzheimer’s disease and other neurodegenerative conditions.
   • Oxidative Stress: Smoking generates oxidative stress in the body, which can damage cells, including brain cells. This oxidative damage is associated with the development and progression of dementia.
   • Amyloid Plaque Accumulation: Smoking may contribute to the accumulation of beta-amyloid plaques in the brain. These protein deposits are a hallmark of Alzheimer’s disease.
   • Interaction with Other Risk Factors: Smoking can interact with other risk factors for dementia, such as high cholesterol and diabetes, further increasing the risk of cognitive decline.
   • Accelerated Brain Aging: Smoking has been linked to accelerated brain aging, which is associated with cognitive decline and an increased risk of dementia.
4. Depression: Addressing depression in older age is critically important for cognitive health, and living a life with less ringing and healthy hearing goes a long way to reducing depression. Depression and dementia are two distinct but interconnected health conditions, and they can often co-occur or influence each other in complex ways. Here are some important points to understand about the relationship between depression and dementia:
   • Coexistence of Depression and Dementia: Depression and dementia can coexist in the same individual. In some cases, depression may be a symptom of dementia, especially in the early stages when individuals may be aware of their cognitive decline. This is known as “depressive pseudodementia.” Conversely, individuals with a history of depression may be at a higher risk of developing dementia later in life.
   • Depression as a Risk Factor for Dementia: Several studies have suggested that late-life depression may be a risk factor for the development of dementia, particularly Alzheimer’s disease. The exact mechanisms linking depression and dementia are not fully understood, but chronic inflammation, vascular changes, and stress-related changes in the brain are some of the proposed pathways.
   • Symptoms and Overlapping Features: Depression and dementia can share certain symptoms, such as memory problems, difficulty concentrating, and changes in mood and behavior. This overlap in symptoms can make it challenging to differentiate between the two conditions, especially in older adults. Healthcare professionals must conduct thorough assessments to determine whether symptoms are due to depression, dementia, or a combination of both.
5. Social Isolation: Tinnitus and hearing loss often lead to profound isolation among many patients. Social isolation and loneliness have been associated with an increased risk of developing dementia and can also exacerbate cognitive decline in individuals already living with dementia. The links of social isolation and dementia include:
   • Reduced Cognitive Stimulation: Social interactions provide cognitive stimulation through conversations, problem-solving, and engagement with others. When individuals are socially isolated, they may experience a lack of mental stimulation, which can contribute to cognitive decline.
   • Mental Health Impact: Loneliness and social isolation are linked to depression and anxiety, both of which can negatively affect cognitive function. Chronic stress associated with loneliness may also contribute to cognitive decline.
   • Physical Health Impact: Social isolation can lead to a sedentary lifestyle and poor health behaviors, such as a lack of exercise and unhealthy eating habits. These factors can increase the risk of conditions like obesity, diabetes, and hypertension, which are known risk factors for dementia.
   • Neurobiological Effects: Loneliness and social isolation have been associated with changes in the brain, including increased inflammation and alterations in stress-related hormone levels. These changes may contribute to cognitive impairment and increase the risk of dementia.
   • Medication Adherence: Social isolation can make it challenging for individuals to manage their healthcare, including taking medications as prescribed. Poor medication adherence can lead to the progression of underlying health conditions that increase dementia risk.
   • Lack of Social Support: A solid social support system can provide emotional and practical support, which can reduce stress and help individuals cope with life’s challenges. Social isolation can result in a lack of this support, potentially leading to increased stress and anxiety.
6. Traumatic Brain Injury (TBI): While most TBIs are the result of an accident, preventative measures should always be taken to reduce the incidence of TBI, as it can be a significant risk factor for the development of various cognitive impairments, including dementia. While not everyone who experiences TBI will develop dementia, there is evidence to suggest that TBIs, particularly moderate to severe ones, can increase the risk of dementia in the future. Several factors contribute to the connections between head injury and dementia, including:
   • Types of TBIs: TBIs can range from mild (e.g., concussions) to severe, with varying degrees of cognitive and physical impairment. Moderate to severe TBIs, which involve more significant damage to the brain, are more strongly associated with an increased risk of dementia.
   • Increased Risk: Many research studies have indicated a link between moderate to severe traumatic brain injuries (TBIs) and an increased likelihood of developing dementia, specifically Alzheimer’s disease and various types of neurodegenerative dementia. The risk appears to be highest in the years immediately following the TBI.
   • Mechanisms: The exact mechanisms by which TBIs increase the risk of dementia are not fully understood, but several factors may contribute:
     • Neuroinflammation: TBI can trigger an inflammatory response in the brain, which may lead to chronic inflammation and neurodegenerative processes.
     • Tau Protein Accumulation: TBIs can result in the abnormal accumulation of tau protein in the brain, a hallmark of Alzheimer’s disease.
     • Axonal Injury: Damage to axons (nerve fibers) in the brain can disrupt communication between brain regions, potentially contributing to cognitive impairment.
     • Vascular Changes: TBIs can also lead to changes in blood vessels in the brain, increasing the risk of vascular dementia.
     • Cumulative Effect: Multiple TBIs, even if they are mild, can have a cumulative effect on the brain and may further increase the risk of cognitive impairment and dementia.
7. Physical Inactivity: People with tinnitus and hearing loss do less physical activity. This has been shown time and time again in research and is likely the result of increased social isolation in older adults with hearing loss. Physical inactivity is a well-established risk factor for the development of dementia. Regular physical activity is associated with various health benefits, including improved cardiovascular health, reduced inflammation, better blood flow to the brain, and enhanced brain plasticity. Here’s how physical inactivity is related to dementia:
   • Cardiovascular Health: Physical inactivity can lead to conditions such as hypertension (high blood pressure), obesity, and diabetes, all of which are risk factors for vascular dementia. Vascular dementia is caused by reduced blood flow to the brain due to vascular problems, and physical activity can help maintain a healthy cardiovascular system.
   • Brain Health: Exercise has a positive impact on brain health. It can stimulate the release of neurotrophic factors, which support the growth and maintenance of neurons (brain cells). Regular physical activity can also enhance cognitive function and improve memory.
   • Reduction of Alzheimer’s Risk: Alzheimer’s disease, the most common form of dementia, is characterized by the accumulation of beta-amyloid plaques and tau tangles in the brain. Physical activity has been linked to a lower risk of developing Alzheimer’s disease and a reduced rate of cognitive decline.
   • Stress Reduction: Physical activity is known to reduce stress and improve mood. Chronic stress and depression are associated with an increased risk of cognitive decline and dementia. Exercise can help mitigate these risk factors.
   • Blood Flow to the Brain: What’s good for the heart is good for the mind! Exercise promotes better blood flow to the brain, ensuring that it receives the oxygen and nutrients it needs to function optimally. Reduced blood flow can contribute to cognitive impairment.
   • Neuroplasticity: Physical activity can enhance neuroplasticity, the brain’s ability to reorganize and adapt by forming new neural connections. This can be particularly important in protecting against age-related cognitive decline.
   • Social Engagement: Some forms of physical activity, such as group sports or classes, also involve social engagement. Maintaining an active social life can have a protective effect against dementia.
   • Healthy Lifestyle: Regular physical activity is often part of a healthy lifestyle that includes a balanced diet, not smoking, and moderate alcohol consumption, all of which can contribute to a lower risk of dementia.
8. Hypertension: If it’s good for the heart, it’s good for the mind!  Cardiac conditions compromise blood flow to nearly all major organs, including the brain and the ear. Love yourself and take care of your heart.
   • Hypertension, or high blood pressure, is a known risk factor for the development of dementia, particularly vascular dementia, and Alzheimer’s disease. There is a strong association between hypertension and cognitive decline, and here’s how hypertension is related to dementia:
     • Vascular Damage: Hypertension can cause damage to blood vessels throughout the body, including those in the brain. Over time, high blood pressure can lead to atherosclerosis (narrowing and hardening of the arteries), which reduces blood flow to the brain. This reduced blood flow can result in small strokes or micro-infarctions that damage brain tissue, increasing the risk of vascular dementia.
     • Impact on Brain Structure: Long-term high blood pressure has been associated with structural changes in the brain, such as white matter lesions and brain atrophy. These changes are often seen in individuals with dementia.
     • Amyloid Accumulation: Hypertension may also contribute to the accumulation of beta-amyloid plaques in the brain, a hallmark of Alzheimer’s disease.
     • Midlife Hypertension: Hypertension in midlife (around ages 40-64) appears to be particularly relevant to dementia risk. Controlling blood pressure during midlife may have a protective effect on cognitive function later in life.
     • Interaction with Other Risk Factors: Hypertension often coexists with other risk factors for dementia, such as diabetes, high cholesterol, and obesity. The combination of these factors can increase the risk of cognitive decline.
9. Air Pollution: This was recently added to the list as air pollution might act via vascular and/or respiratory mechanisms and reduce proper blood and oxygen flow to the brain. There is growing evidence to suggest that air pollution, especially fine particulate matter, and other pollutants, may be associated with an increased risk of dementia. While more research is needed to establish a definitive causal link, several studies have found significant correlations between exposure to air pollution and cognitive decline, including the development of dementia. Here’s how air pollution is related to dementia:
   • Inflammation and Oxidative Stress: Air pollution, especially fine particulate matter and toxic chemicals can enter the bloodstream and reach the brain. Once in the brain, these pollutants can cause inflammation and oxidative stress, which are processes implicated in the development of neurodegenerative diseases, including dementia.
   • Blood-Brain Barrier Disruption: Air pollution can impair the integrity of the blood-brain barrier, a protective barrier that regulates the passage of substances between the bloodstream and the brain. This disruption may allow harmful substances to enter the brain more easily.
   • Vascular Effects: Air pollution is a well-known risk factor for cardiovascular diseases, including hypertension and atherosclerosis. These conditions can reduce blood flow to the brain, increasing the risk of vascular dementia, which is caused by reduced blood flow to brain tissue.
   • Brain Structure and Function: Some studies have shown that long-term exposure to air pollution is associated with structural changes in the brain, such as smaller brain volume and white matter damage. These changes are often seen in individuals with dementia.
10. Diabetes: While diabetes and dementia are two distinct health conditions, insulin levels play a vital role in how the brain operates. Some even theorize that dementia is a ‘type 3 diabetes’. Several studies suggest that the brains of people with Alzheimer’s disease are in a ‘diabetic state’, partly due to the decrease and insensitivity to insulin. People with diabetes are at least twice as likely to experience dementia. Several mechanisms contribute to the correlation between diabetes and dementia, including:
    • Increased Risk: Several studies have shown that individuals with diabetes, especially type 2 diabetes, have an increased risk of developing dementia, including Alzheimer’s disease, vascular dementia, and other types of cognitive impairment.
    • Vascular Factors: Diabetes can lead to various vascular changes and complications, including atherosclerosis (narrowing and hardening of the arteries) and hypertension (high blood pressure). These vascular problems can reduce blood flow to the brain, increasing the risk of vascular dementia.
    • Insulin Resistance: Insulin resistance is a hallmark of type 2 diabetes, and it can also affect the brain. Some research suggests that insulin resistance in the brain may contribute to Alzheimer’s disease by impairing brain cell function and the clearance of toxic beta-amyloid proteins.
    • Blood Sugar Control: Poorly controlled diabetes can result in high blood sugar levels, which may have a negative impact on brain health. High blood sugar can cause inflammation and oxidative stress in the brain, both of which are associated with cognitive decline.
    • Hypoglycemia: Episodes of hypoglycemia (low blood sugar) can occur in individuals with diabetes, especially if they are using medications like insulin or sulfonylureas. Severe hypoglycemia can lead to cognitive deficits and, in some cases, may increase the risk of dementia.
    • Interaction with Other Risk Factors: Diabetes often coexists with other risk factors for dementia, such as hypertension, obesity, and high cholesterol. The combination of these risk factors can increase the risk of cognitive impairment.
11. Obesity: Being overweight is an emerging concern when it comes to dementia. The rates of increased BMI in older adults are growing and may be contributing to cognitive decline.  Obesity is a significant risk factor for the development of dementia, including Alzheimer’s disease. The relationship between obesity and dementia is complex, but several mechanisms and factors contribute to this association, including:
    • Inflammation: Obesity is characterized by chronic inflammation in the body, including the brain. Inflammation is believed to play a role in the development and progression of neurodegenerative diseases, such as Alzheimer’s disease.
    • Insulin Resistance: Obesity is often accompanied by insulin resistance, a condition where the body’s cells do not respond properly to insulin. Insulin resistance has been linked to impaired brain function and an increased risk of cognitive decline.
    • Vascular Changes: Obesity is a risk factor for cardiovascular diseases, including hypertension (high blood pressure) and atherosclerosis (hardening and narrowing of the arteries). These conditions can reduce blood flow to the brain, potentially leading to vascular dementia.
    • Metabolic Factors: Obesity is associated with metabolic disturbances, such as abnormal lipid profiles and elevated levels of triglycerides and cholesterol. These metabolic factors can contribute to cognitive impairment.
    • Hormonal Changes: Obesity can lead to hormonal imbalances, including elevated levels of certain hormones like leptin and insulin, which may affect brain health.\
    • Sleep Apnea: Obesity is a risk factor for sleep apnea, a condition characterized by interrupted breathing during sleep. Sleep apnea has been associated with cognitive deficits and an increased risk of dementia.
    • Amyloid Plaque Accumulation: Some studies suggest that obesity may be associated with increased production and accumulation of beta-amyloid plaques in the brain, which are a hallmark of Alzheimer’s disease.
    • Physical Inactivity: Obesity often coincides with physical inactivity, which is also an independent risk factor for dementia. Regular physical activity is essential for maintaining cognitive health.
    • Psychosocial Factors: Obesity can lead to psychosocial factors such as depression and low self-esteem, which can contribute to cognitive decline and dementia.
12. Alcohol Intake: Like most things we enjoy in life, moderation is key. Consuming less than 21 units of alcohol per week (the equivalent of 2 bottles of wine per week) can help to reduce the risk of cognitive decline and dementia as we age. The relationship between alcohol consumption and dementia is complex and varies depending on the amount and pattern of alcohol use. Below offers some insight into how alcohol can impact the brain and increase the risk of cognitive decline and dementia:
    • Excessive Alcohol Consumption: Chronic heavy alcohol use is a well-established risk factor for dementia. Excessive alcohol intake can lead to a range of neurological and cognitive problems, including alcohol-related dementia (often referred to as alcohol use disorder-related dementia or alcohol-induced neurocognitive disorder). Impairments in memory, executive function, and overall cognitive ability characterize this type of dementia.
    • Brain Damage: Prolonged heavy drinking can result in structural and functional brain damage, including the shrinkage of brain regions crucial for memory and cognition. This brain damage can lead to cognitive deficits and contribute to the development of dementia.
    • Wernicke-Korsakoff Syndrome: Chronic alcohol use can lead to Wernicke-Korsakoff syndrome, a condition characterized by severe memory problems, confusion, and hallucinations. This syndrome can significantly impact cognitive function.
    • Alcohol-Related Neurotoxicity: Alcohol has neurotoxic effects on the brain and can lead to the death of brain cells, particularly in regions critical for memory and cognitive function.
    • Interaction with Other Risk Factors: Excessive alcohol consumption often coexists with other risk factors for dementia, such as hypertension, liver disease, and nutritional deficiencies. These comorbid conditions can further increase the risk of cognitive impairment.

Direct Intervention vs. Indirect Approaches: Tackling Tinnitus Head-On

If you talk to your primary care physician, ask your friends and neighbors, or dare to search the internet, you will come across a never-ending sea of options for treating tinnitus. You will find everything from white-noise generators to acupuncture.

For the most up to date information on tinnitus, please visit www.salushearing.com.

Regardless of the exact treatment, all tinnitus treatments fall into one of two categories: Direct or Indirect Treatment.

Direct and Indirect treatment are terms often used in the context of healthcare and therapy to describe different approaches to addressing a patient’s condition or symptoms. The primary difference between these two approaches is how they target the actual underlying pathology. While Direct treatment involves directly addressing the underlying cause or symptoms of a condition, Indirect treatment focuses on addressing symptoms or triggers associated with a condition rather than directly targeting the underlying cause.

The underlying cause of tinnitus in the vast majority of patients (over 90%) is the progressive breakdown of the neural integrity of the ear-to-brain connections. Thus, Direct treatment of this condition would be to focus on neural preservation by stimulating remaining neurons and slowing the progression of the pathology.

Direct Treatment for Tinnitus

Today’s prescriptive hearing treatment technology employs advanced techniques to directly stimulate the brain and compensate for missing neural signals, while also mitigating the ‘central gain’ related to the perception of tinnitus. This method of direct treatment can be achieved through modern technology that utilizes artificial intelligence (AI) to present sound to the brain through acoustic or electric means.

1. Prescriptive Technology with AI: Using modern technology, we can offer patients cutting-edge treatment that enhances signal processing and tailors auditory input to an individual’s specific needs. This new technology can analyze incoming auditory activity and adjust the stimulation parameters to optimize sound perception. This approach aims to mimic the brain’s natural processing of sound, thus addressing the issue of central gain, which is the brain’s tendency to amplify weak auditory signals. In the AAO-HNS report, it was noted that this form of treatment had a “preponderance of benefit” with no significant risks or harms.
2. Cochlear Implants: Cochlear implants are surgically implanted devices that bypass damaged receptor hair cells in the inner ear and directly stimulate the auditory nerve with electrical impulses. They consist of an external microphone and speech processor that capture sounds, convert them into electrical signals, and transmit them to an implanted electrode array. This direct stimulation helps individuals with hearing loss receive auditory input that would otherwise be compromised.
   • Currently, cochlear implant surgery is reserved only for those patients with tinnitus who have significant hearing loss and do not receive any benefit from prescriptive technology. What’s even more worrisome is that certain reports indicate that tinnitus worsened after cochlear implant surgery in 10-15% of patients.
   • Perhaps the most controversial form of direct treatment for tinnitus is surgical removal of the auditory nerve. The AAO-HNS does not recommend this procedure for several reasons highlighted below.
3. Surgical Removal of the Auditory Nerve: Surgery to sever the auditory nerve as a treatment for tinnitus is a relatively uncommon and highly invasive procedure. Severing the auditory nerve is typically considered a last resort when all other treatments have failed, and the tinnitus is severely impacting a person’s quality of life.

There are some key points to consider regarding this procedure:

• High Risk – Severing the auditory nerve is a high-risk procedure that is likely to result in permanent hearing loss. It is usually reserved for extreme cases of tinnitus where other treatments, such as direct treatment, and/or cognitive-behavioral therapy, have not been effective.

• Unpredictable Outcomes: The effectiveness of the surgery in relieving tinnitus can vary from person to person. Some individuals may experience relief from the tinnitus, while others may not experience any improvement or may even have worsened symptoms.

• Hearing Loss: Since the auditory nerve carries signals from the inner ear to the brain, severing it will result in complete hearing loss in the affected ear. This procedure is usually only considered for individuals who have already experienced significant hearing loss in that ear.

• Balance Issues: Severing the auditory nerve can also affect balance because it is closely connected to the vestibular system, which helps control balance. Post-surgery balance issues are common, and rehabilitation may be necessary.

• Risks and Complications: Like any surgery, there are risks and potential complications associated with severing the auditory nerve, including infection, cerebrospinal fluid leakage, and injury to nearby structures.

Indirect Treatment for Tinnitus

Many Indirect treatment options for tinnitus exist. While some of these treatments can serve to enhance the impact of Direct treatment, many of them have limited or no scientific backing.

1. Sound Therapy: Often, ‘sound therapy’ will be recommended to patients. This entails using an external sound generator to help them mask or ignore the phantom sounds in their head. For instance, they can use a fan, a white noise generator, or a sound-generating app on their smartphone while attempting to sleep. Some available noise generators can even be worn at ear level (and appear to look like a traditional hearing aid). The goal of this indirect treatment is to make the tinnitus less noticeable or bothersome. The AAO-HNS considers this indirect treatment a viable option but warns against promoting false hope to patients by offering this intervention with uncertain efficiency.
2. Counseling and Education: Educating a patient on their medical condition must always be a part of the therapeutic process. Tinnitus counseling focuses on educating individuals about their condition, helping them understand the underlying causes, and teaching coping strategies to reduce anxiety and stress associated with tinnitus. The AAO-HNS notes that education has a preponderance of benefit over harm and values the role of education in counseling patients.
3. Cognitive-Behavioral Therapy (CBT) (aka ‘talk therapy’) is a common approach within counseling to address the emotional impact of tinnitus. CBT is a widely recommended and very effective form of psychotherapy that focuses on addressing and changing negative thought patterns and behaviors to improve mental health and well-being. CBT is based on the idea that our thoughts, feelings, and behaviors are interconnected, and by identifying and modifying unhealthy thought patterns and behaviors, individuals can experience significant improvements in their psychological and emotional functioning. Clinicians are encouraged to recommend CBT to patients experiencing persistent and bothersome tinnitus.
4. Tinnitus Retraining Therapy (TRT): TRT is a form of Indirect therapy that combines counseling and sound therapy. It aims to desensitize individuals to the tinnitus sound, reducing its perceived loudness and distress. TRT often involves wearing hearing devices that emit low-level noise to habituate the brain to the tinnitus sound. Much conflict surrounds the efficacy of TRT, including a history of poorly designed studies and a recent report in the Journal of the American Medical Association (JAMA), which found no outcome difference in the group with vs. without TRT.
5. Medications: Some medications may be prescribed to alleviate the symptoms of tinnitus, especially if an underlying medical condition is contributing to it. However, there is no single medication that consistently works for tinnitus, and their effectiveness varies from person to person. The consensus of the AAO-HNS is not to recommend medication for the specific treatment of tinnitus.
   • In some cases, medications may be prescribed to help manage tinnitus-related conditions, such as anxiety or depression. The medications might include antidepressants (to help with the emotional distress that tinnitus can cause), anxiolytics (anti-anxiety drugs to reduce the anxiety associated with tinnitus), and hearing loss medications (to improve blood flow to the inner ear).
6. Lifestyle Changes: Making lifestyle changes can indirectly help manage tinnitus. Reducing exposure to loud noises, managing stress, regular exercise, and avoiding excessive caffeine and alcohol consumption can all have a positive impact on tinnitus symptoms. Often, your hearing healthcare provider will ask you to keep a ‘log’ of daily activities to help uncover triggers that can worsen the experience with tinnitus.
7. Herbal Supplements: There are many unfounded claims about herbal supplements and treating tinnitus. Below are two lists of supplements: one with evidence of decreasing the experience of tinnitus and the other with no scientific validity.
   • Herbal Supplements with Strong Evidence to Decrease Tinnitus
     • Vitamin B12: A deficiency in Vitamin B12 has been associated with deficits in neural function throughout the brain, especially in older individuals. If you have a Vitamin B12 deficiency, supplementation is recommended for many reasons, including enhanced cognitive performance and the potential to reduce tinnitus.
     • Melatonin: A high level of scientific data exists to corroborate the notion that melatonin can reduce the experience of tinnitus. Although the mechanism is not well understood, it stands to reason that increased sleep can reduce the stress and anxiety related to tinnitus and, therefore, decrease the experience of tinnitus.
   • Herbal Supplements with Limited Evidence to Decrease Tinnitus
     • Ginkgo Biloba: Ginkgo Biloba is an herbal supplement that has been suggested to improve blood flow to the inner ear. To date, no scientific studies exist to back up these claims.
     • Zinc: Zinc deficiency has been linked to tinnitus in some cases; thus, it stands to reason that zinc supplementation may be helpful if you have a deficiency. The jury is out on this supplement.
     • Magnesium: Magnesium is involved in nerve function and has been studied for its potential role in reducing tinnitus symptoms, particularly in cases related to noise-induced hearing loss.
     • Coenzyme Q10 (CoQ10): CoQ10 is an antioxidant that may help improve circulation and reduce oxidative stress in the inner ear. Some people have reported a reduction in tinnitus symptoms when taking CoQ10.
     • Omega-3 Fatty Acids: Omega-3 fatty acids, found in fish oil supplements, have anti-inflammatory properties, and may support overall ear health.
8. Acupuncture: Acupuncture is an alternative Eastern medicine practice that involves inserting thin needles into specific points on the body to stimulate various physiological responses. Acupuncture may vary from person to person, depending on the specific cause of their tinnitus. When performed by a trained and licensed practitioner, acupuncture is considered safe and can be very effective. Limited data exists to support any claim that acupuncture can reduce the experience of tinnitus.

As a rule, when it comes to treatment options for tinnitus, the more salacious and outrageous the claim is, the less likely it is to be true! Also, any marketing that claims the treatment of tinnitus is quick and easy (i.e., take this pill, and your tinnitus will go away) is generally suspect.

Lost in a Sea of Sound: How Tinnitus Amplifies Restaurant Noise

As if the ringing weren’t enough to deal with, many people with tinnitus also complain that it is challenging for them to follow a conversation in background noise. This interruption in the ability to socialize and easily communicate can be devastating to the person and their loved ones. Unfortunately, when someone is not able to follow along with what family and loved ones are saying at the dinner table, too many people default to ‘then why bother even being there’.

The feelings of isolation, depression, fear, loneliness, embarrassment, frustration, and anxiety that are associated with tinnitus and hearing loss are real and are very well documented. Perhaps you only need to look in the mirror or at a loved one to realize how real these emotions are. The ability to follow a conversation when multiple people are speaking or with other competing sounds (when the TV is on in the background, running water from the sink) is a natural cognitive (brain) ability that we take for granted until it begins to break down and interfere with communication with others. As we age, for many in their 40s and 50s, subtle changes in the ears yield significant differences in the ability to hear in these ‘complex’ listening environments, including noisy restaurants, etc. Most often, this difficulty is noticed long before the official diagnosis of hearing loss.

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The Breakdown

Tiny ‘hair cells’ in our ears that process sound and connect our ears to the brain become damaged and die off with age, and they do not come back. As a result, our ears will have difficulty noticing fine differences in sounds. For example, the subtle differences between the ‘s’ and ‘sh’ sounds become undetectable to the listener, making words like ‘see’ and ‘she’ harder to understand and distinguish. This difficulty with clarity is why so many people with early tinnitus and hearing loss say, ‘can you repeat that?’ and not, ‘can you please say that louder?’. Clarity and volume are not the same, and the loss of clarity impacts your life 5-10 years before you need sounds to be louder. This is one of the first signs that tinnitus is also impacting your ability to hear.

Downstream

Once the vast neural network that connects the ears to the brain becomes damaged, the unseen changes in the brain can be devastating. A recent report from Johns Hopkins found that people with hearing loss and tinnitus can also have significant cerebral atrophy. They noted that people could lose up to 40% of their total brain volume – and the only common factor in the research subjects was damage to the auditory system. While this may seem odd, it makes a lot more sense when you consider that we hear with our brains, not our ears! This damage to the brain can become progressively worse with age if left untreated.

Cerebral atrophy is a hallmark feature of dementia; thus, tinnitus and hearing loss are closely tied to a person’s future risk of developing cognitive decline and dementia.

Listening to others is otherwise effortless when we live without tinnitus and with normal hearing. However, when living with tinnitus – the ability to hear in complex listening environments (such as noisy restaurants), will require significant effort and tax the brain. The brain has four unique hearing capabilities, including:

• Localization – the ability to determine where sounds are coming from.
• Recognition – the ability to recognize words and understand conversation.
• Focus – tuning in to what is important (somebody speaking to you), especially in noisy rooms or restaurants.
• Separation – segregating out what you want to hear from what you don’t want to hear.

Each of these tasks relies on a vast and robust neural network of information coming from the ears. Thus, each of these is negatively affected when tinnitus and hearing loss wreak havoc on the ear-to-brain neural networks.

With tinnitus and hearing loss, the damage to your ears and brain is not reversible; however, with treatment, the goal is to slow down the progression of the disorder and preserve neural integrity.

The medical treatment of tinnitus and hearing loss is custom prescribed to address the needs of each patient by restoring clarity, supporting the four cognitive tasks mentioned above, allowing them to maintain high-quality communication with others – even in the noisiest restaurants – reduce the risk of cognitive decline and reduce tinnitus.

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