Aims: The aim of this study was to investigate the associations between symptomatic hearing loss (HL), neuropathy, and nephropathy in subjects with Type 2 diabetes mellitus (T2DM). Furthermore, the study evaluated whether HL was associated with chronic low-grade inflammation, assessed based on plasma levels of tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hsCRP), and explored potential sex-specific differences. Materials and Methods: We included 4245 subjects with T2DM from The Danish Centre for Strategic Research in Type 2 Diabetes cohort. Symptomatic HL was defined using ICD-10 codes. In 2016, a questionnaire was sent out to evaluate neuropathy using the Michigan Neuropathy Screening Instrument (MNSI ≥ 4). Nephropathy was defined as urinary albumin-to-creatinine ratio (UACR) >30 mg/g. Plasma levels of TNF-α, IL-6, and hsCRP were measured at enrolment from 2010 to 2016. Multivariable logistic regression was used, adjusting for covariates. Results: Neuropathy was significantly associated with HL (OR = 1.83, 95%CI [1.42, 2.35], p < 0.001), and the association was stronger in women (OR = 2.74 [1.81, 4.14], p < 0.001) compared to men (OR = 1.44 [1.04, 1.99], p < 0.05) (P-interaction = 0.020). No significant association was found between nephropathy and HL. Among inflammatory markers, only the highest tertile of TNF-α levels was significantly associated with HL compared to the lowest tertile (OR = 1.40 [1.07, 1.82], p < 0.05) without any sex interaction. Conclusions: In subjects with T2DM, neuropathy was associated with symptomatic HL, and the association seemed to be stronger in females. Among chronic low-grade inflammation markers, only TNF-α was significantly associated with symptomatic HL. Additionally, no significant association was found between nephropathy and HL.

OBJECTIVE:To compare the health-related quality-of-life (HRQoL) outcomes of a bimodal solution using a cochlear implant (CI) and a hearing aid (HA) versus new replacement HAs in patients with asymmetric hearing loss (AHL). DESIGN:A prospective randomised controlled trial with CI candidates with AHL randomly assigned 1:1 to either undergo CI surgery after one month of new replacement HAs or continue the new HAs use for an additional three months. HRQoL was assessed with the Nijmegen Cochlear Implant Questionnaire (NCIQ). STUDY SAMPLE:Sixty-three CI candidates (mean age: 63.4, range: 23-83 years). RESULTS:The mean NCIQ total score significantly improved with a mean change of 14.25 scale points (95% CI 9.83;18.68, p < 0.001) when comparing the original HAs with the bimodal solution three months after cochlear implantation. Additionally, HRQoL significantly improved when comparing the original HAs to the new replacement HAs with a mean change of 3.39 scale points (95% CI 0.27;6.51, p = 0.033) though the prolongation of the HAs did not have a significant impact on NCIQ scores. CONCLUSIONS:The bimodal solution improves HRQoL compared to new well-fitted HAs in CI candidates with AHL. Extending the use of new optimally fitted HAs before CI surgery is unnecessary.

OBJECTIVE:Cochlear implant (CI) non-use and minimal-use are important, but sparsely investigated parameters. This study investigates the risk of becoming a CI non-user or a minimal-user in a post-lingual deafness adult population. STUDY DESIGN:Retrospective cohort study. SETTING:Tertiary medical institution. MATERIALS AND METHODS:All adult patients (18 years or above) who received CI surgery at a single center from 2010 to 2022 (n=599) were invited to participate in a questionnaire study concerning the CI usage after surgery. The questionnaire information was combined with data from medical records. Non-use was defined as never/rarely usage of the device. Minimal-users were patients who reported <4 hours of daily use, and patients considering ceasing to use their device, and not included in the non-use group. RESULTS:In total, 472 (78.8%) patients replied to the questionnaire regarding CI usage. Hereof, 20 patients (4.2%) were non-users and 26 patients (5.5%) were minimal-users with mean follow-up times of 8.4±3.4 years. Rehabilitation was provided for 97% of the participants by a speech-language pathologist for 6 to 12 months. Abnormal cochlear anatomy was associated with CI non-use (odds ratio=5.7, 95% confidence interval [1.1-30.8], P=0.04). No additional correlations were found between non-users, minimal-users, and CI users. CONCLUSION:The CI non-user rate was 4.2% and these patients experienced lower QoL compared with CI users. In addition, 5.5% of the patients were minimal-users. In adults with abnormal cochlear anatomy, an increased risk of non-use was identified, reflecting the need for thorough information regarding surgical outcomes in this specific subgroup of patients.

OBJECTIVE:This study aimed to evaluate the user-operated audible contrast threshold (U-ACT) test as an automated, language-independent proxy for the manual ACT test and for aided speech-in-noise perception. DESIGN:An equivalence study was conducted where U-ACT results were compared to manual ACT results and aided speech reception thresholds (SRTs) measured with the Hearing in Noise Test (HINT). Agreement between U-ACT and ACT was assessed using intraclass correlation (ICC), while the relationship with SRTs was evaluated using Pearson's correlation. STUDY SAMPLE:Thirty adults (aged 46-78) with hearing loss were recruited from a university hospital clinic. Participants were selected to ensure variation in audiometric thresholds and speech discrimination scores, representing a clinically diverse population. RESULTS:U-ACT demonstrated excellent agreement with the manual ACT test (ICC = 0.87). U-ACT also showed a strong and significant correlation with aided speech-in-noise perception (r = 0.69). This correlation was identical to that observed for the manual ACT test, indicating equivalent predictive validity. CONCLUSION:U-ACT is a reliable user-operated test that serves as an effective proxy for speech-in-noise perception. As an automated, language-independent measure of supra-threshold hearing ability, U-ACT can be implemented in audiology clinics to improve efficiency and support personalised hearing rehabilitation.

OBJECTIVE:To compare replacement hearing aids (HA) with a cochlear implant (CI) and a HA in the bimodal solution using the Signal to Noise Ratio (SNR) at 70% correct Speech Reception Threshold (SRT70) measured with the Hearing in Noise Test (HINT), Word Recognition Scores (WRS) in quiet and noise and patient reported outcome using Speech Spatial and Quality (SSQ-12) questionnaire. DESIGN/STUDY SAMPLE:Prospective randomised controlled trial between bimodal use and continuous HA use for additional three months. STUDY SAMPLE:Sixty-three CI candidates (mean age: 63.4, range: 23-83 years) with asymmetric hearing loss (AHL) fulfilling CI candidacy criteria on one ear. RESULTS:No difference was found between the original and new replacement HAs after one month. However, comparing the bimodal solution with new replacement HAs mean SRT70 improved by -10.26 dB SNR (95%CI:-15.38;-5.13), WRS in quiet by 18.56% (95%CI:9.48;27.64), WRS in noise by 18.18% (95%CI:8.84;27.53), and SSQ12 total scores improved by 2.67 scale points (95%CI:1.81;3.53). CONCLUSION:Extended use of HAs offers no additional benefit; CI surgery can proceed once one month of acclimatisation is achieved as the addition of a CI outperforms new replacement HAs in CI candidates with AHL.

OBJECTIVE:Individuals with near-normal audiograms can experience hearing difficulties and could therefore benefit from hearing aids (HAs). The current study examined self-reported hearing difficulties, before and after HA provision, in a clinical sample tested as part of the Danish "Better hEAring Rehabilitation" (BEAR) project. DESIGN:Self-reported hearing abilities were assessed using the 12-item Speech, Spatial and Qualities of Hearing Scale (SSQ12) and compared before and after HA intervention. International Outcome Inventory for Hearing Aids (IOI-HA) scores and daily HA usage data were also examined. STUDY SAMPLE:New bilateral HA users who sought treatment at two large public hearing clinics were segregated into three groups according to their better-ear four-frequency pure-tone average hearing loss (PTA4): (1) normal hearing (N = 51), (2) mild hearing loss (N = 435), and (3) moderate hearing loss (N = 430). RESULTS:Pre-intervention SSQ12 scores were comparable for the three groups. The group with PTA4-based normal hearing showed aided outcomes comparable to those of the group with mild hearing loss, while the group with moderate hearing loss showed greater benefit. CONCLUSIONS:PTA4-based normal hearing should not automatically preclude individuals from consideration for HA treatment. When assessing HA candidacy, self-reported hearing difficulties should also be considered.

Under- and overamplification of sound is a common problem in hearing aid fitting. This paper describes the implementation of two new variants of the hearing in noise test for quantifying aided hearing at the lower and upper ends of the range of everyday-life sound levels. We present results from experiments carried out with 30 adult hearing aid users to determine the respective test–retest reliabilities. Participants completed a test battery consisting of the standard Danish hearing in noise test, a variant targeting the lower threshold of audibility and a variant targeting the limit of loudness discomfort. The participants completed the test battery twice for reliability analysis. The results revealed a significant difference between test and retest for both the hearing in noise test and the two hearing in noise test variants. However, the effect sizes for the differences were all very small. A calculation of Pearson correlation coefficients showed that both the hearing in noise test and the two new hearing in noise test variants had significant and strong correlations between test and retest. The within-subject standard deviations were determined to be 0.8 dB for hearing in noise test, 0.9 dB for lower-end test, and 2.2 dB for upper-end test. The findings demonstrate that both the lower-end test and upper-end test have high test–retest reliabilities, and thus can provide consistent and reliable results.

BACKGROUND:Ménière's disease is a chronic inner ear disorder characterized by recurrent vertigo, tinnitus, aural fullness, and fluctuating sensorineural hearing loss. For patients with debilitating symptoms unresponsive to conservative treatment, intratympanic gentamicin is a therapeutic option. However, its efficacy and safety remain uncertain. AIMS/OBJECTIVES:This systematic review aims to evaluate the effectiveness and safety of intratympanic gentamicin in Ménière's disease, focusing exclusively on randomized controlled trials (RCTs). MATERIAL AND METHODS:A comprehensive literature search was conducted to identify RCTs comparing intratympanic gentamicin with placebo or no treatment. Primary outcomes included vertigo frequency and severity, quality of life, and incidence of serious adverse events. Data were analyzed using the GRADE approach to assess risk of bias and certainty of evidence. RESULTS:Three RCTs were included, demonstrating a significant reduction in vertigo frequency and severity in patients treated with intratympanic gentamicin compared to placebo. However, the evidence quality was rated very low due to small sample sizes and methodological limitations. CONCLUSIONS AND SIGNIFICANCE:Findings suggest that intratympanic gentamicin may reduce vertigo in Ménière's disease. However, due to the limited certainty of the evidence, further research with larger sample sizes and standardized outcome measures is necessary to clarify its benefits and risks.

OBJECTIVE:This study compared the accuracy of automated user-operated and manual non-audiologist driven audiometry, two potential alternatives for test settings with limited audiologist resources. The accuracy was investigated by assessing the two test methods with gold-standard manual audiometry conducted by trained audiologists. DESIGN:This comparative study was conducted in a clinical setting. The audiometry conducted by non-audiologist operators took place at the participants' local Ear, Nose, and Throat specialists. Both the user-operated and gold-standard audiometry were conducted on the same day at Odense University Hospital, approximately one month after the initial assessment using the non-audiologist driven audiometry. STUDY SAMPLE:221 adults (median age of 69 years) referred for hearing-aid treatment. RESULTS:Both test methods showed statistically significant differences from the gold standard, but the user-operated audiometry demonstrated closer agreement at all tested frequencies. Across frequencies, user-operated audiometry differed by -0.1 dB (95% CI -0.9 to 0.8) to 2.6 dB (95% CI 1.7-3.5), while non-audiologist driven audiometry differed by 6.2 dB (95% CI 5.5-6.9) to 11.1 dB (95% CI 10.0-12.3). CONCLUSION:The accuracy of automated user-operated audiometry was within general measurement uncertainty for gold-standard audiometry, whereas the manual non-audiologist driven audiometry may introduce additional variability.

The identification of congenital hearing loss using Transient Evoked Otoacoustic Emissions and Automatic Auditory Brainstem Response in a newborn hearing screening program is crucial for initiating early rehabilitation with hearing aids or cochlear implants. Specific genetic causes, such as Pendred syndrome, connexin-26, stereocilin, and otoferlin-associated deafness, can be identified today using gene panels. Specifically, for otoferlin-associated deafness, it may be possible to offer gene therapy as a novel treatment for this specific genetic type of hearing loss.

OBJECTIVES:Otitis media (OM) is among the most common childhood diseases. Many studies have suggested that recurrent OM episodes during early childhood can have long-lasting adverse effects on essentially every level of the auditory system. However, the literature on this topic is heterogeneous and results are mixed. Hence, a need exists to structure the available evidence. Here, a scoping review was conducted, aiming to (1) map the many different outcome measures used to assess the long-term impact of OM, (2) appraise the quality of the available OM documentation, and (3) provide a summary of the available evidence and its potential link with OM documentation. DESIGN:Original articles were identified through systematic searches in the PubMed, Embase, and Cochrane Library databases. To be included, studies were required to assess the long-term impact of resolved early childhood OM on hearing abilities. Two reviewers independently screened studies for inclusion. A data charting form, developed by author LVY, was used to extract information about the publication (year, journal, country of data collection) and study characteristics (sample size, outcome measures, OM documentation). RESULTS:The search identified 16,267 records, out of which 94 articles were included. Most of the current evidence is based on retrospective data from high-income countries, using a wide range of outcome measures. The retrospective study design poses challenges for thorough OM documentation, especially regarding OM history of the controls. A narrative synthesis showed consistently elevated audiometric thresholds in the extended high-frequency range and poorer gap detection abilities in children with a history of early childhood OM. Mixed results were found in terms of speech perception and binaural unmasking. CONCLUSIONS:This scoping review demonstrates the breadth of the literature on this topic. A wide range of outcome measures have been used, and the quality of OM documentation varies greatly across studies. Variability of the literature results may-at least to some extent-be explained by inadequate OM documentation, recruitment bias, and variability in the time since the last OM episode. Recommendations for future research are provided.

Background/Objectives: Advances in cochlear implant (CI) technology have led to the expansion of the implantation criteria. As a result, more CI candidates may have greater residual hearing in one or two ears. Many of these candidates will perform better with a CI in one ear and a hearing aid (HA) in the other ear, the so-called bimodal solution. The bimodal solution often requires patients to switch to HAs that are compatible with the CI. However, this can be a challenging decision, not least because it remains unclear whether this impacts hearing performance. Our aim is to determine whether speech perception in noise remains unchanged or improves with new replacement HAs compared to original HAs in CI candidates with residual hearing. Methods: Fifty bilateral HA users (mean age 63.4; range 23–82) referred for CI were recruited. All participants received new replacement HAs. The new HAs were optimally fitted and verified using Real Ear Measurement (REM). Participants were tested with the Hearing in Noise Test (HINT), which aimed at determining the signal-to-noise ratio (SNR) required for a 70% correct word recognition score at a speech sound pressure level (SPL) of 65 dB. HINT testing was performed with both their original and new replacement HAs. During HINT, pupillometry was used to control for task engagement. Results: Replacing the original HAs with new replacement HAs after one month was not statistically significant with a mean change of SRT70 by −1.90 (95% CI: −4.69;0.89, p = 0.182) dB SNR. Conclusions: New replacement HAs do not impact speech perception scores in CI candidates prior to the decision of cochlear implantation.

Background/Objectives: This study aimed to (i) cross-culturally adapt the Inventory of Hyperacusis (IHS) into Danish and (ii) assess its usability, validity, and reliability in Danish adults with hyperacusis. Methods: The translation followed established guidelines for adapting hearing-related questionnaires. A two-phase design ensured linguistic and cultural adaptation and evaluated test-retest reliability and construct validity. The IHS, consisting of 25 items, was translated and tested in seven participants through cognitive debriefing. In phase two, temporal consistency was assessed in 32 patients. Results: Thirty-two participants (twenty-eight female; mean age 49.8 years) completed the study over 2-4 weeks (mean 22 days). Eight used hearing aids, and twenty-four reported tinnitus. The Danish IHS showed good reliability (Cronbach's alpha = 0.95) and acceptable test-retest reliability, except for the General Loudness factor. While no systematic score changes occurred, significant variability in score changes were noted. Conclusions: The Danish IHS appears to be a reliable and valid tool for assessing hyperacusis. Further research is needed, but the IHS-DK shows potential as an effective clinical and research tool for evaluating hyperacusis impact and treatment outcomes.

Introduction  The Nijmegen cochlear implant questionnaire (NCIQ) is a quantifiable self-assessment health-related quality of life (HRQoL) tool used internationally to determine quality of life (QoL) in cochlear implant (CI) users and to evaluate the implant's subjective benefits. Objective  This study aimed to validate the Danish version of the questionnaire (DA-NCIQ) with a test-retest including 60 participants (30 CI users and 30 CI candidates). Methods  The intraclass correlation coefficients (ICC) were calculated to evaluate the temporal stability of the participants' answers and the internal consistency of the questionnaire domains was determined using the Cronbach alpha in order to compare these results with the NCIQ's other language versions. Results  The DA-NCIQ was found to have Cronbach alpha coefficients between 0.7 and 0.91, as well as test-retest reliability with ICC values between 0.7 and 0.92. These findings were similar to the original and other language versions of this questionnaire. The Cronbach alpha coefficients varied between 0.73 and 0.89, while the ICC test-retest reliability varied between 0.64 and 0.85. Furthermore, the present study found that participants with CIs had an improved HRQoL in all subdomains, except for the advanced sound perception one, when compared to the CI candidates. Conclusion The results supported the DA-NCIQ as a reliable instrument to measure the subjective benefits of CIs in postlingually deafened/hearing-impaired adults.

ObjectiveThe speech intelligibility index (SII) is used to quantify the audibility of the speech. This study examined the relationship between self-reported hearing aid (HA) outcomes and the difference in aided SII (SIIA) calculated from the initial fit (IF) gain and that prescribed as per the second generation of National Acoustic Laboratory Non-Linear (NAL-NL2).DesignA prospective observational study.Study sampleThe study included 718 first-time and 253 experienced HA users. All users had a valid real-ear measurement (REM) at three input levels (55, 65 and 80 dB SPL).ResultsThe gain provided by IF was lower than NAL-NL2 at 55 and 65 dB SPL. IF gain exhibited reduced compression than NAL-NL2 as input levels increased from 55 to 80 dB SPL. On average, the SIIA provided by IF was significantly lower than that for NAL-NL2 at all input levels. The difference in SIIA between IF and NAL-NL2 at 80 dB SPL input level with 0 dB signal-to-noise ratio (SNR) turned out to be a predictor for self-reported outcome for first-time HA users.ConclusionThe study suggests that an SIIA close to that provided by NAL-NL2 at high input levels would be preferred to obtain a better self-reported outcome.

Osteogenesis imperfecta (OI) is a group of rare hereditary collagen disorders. Hearing loss (HL) is a known complication linked to changes in the bones of the middle ear seen in OI. We aimed to determine the prevalence, age at debut, incidence, and risk of HL, surgery on bones of the middle ear, and use of hearing aids. A Danish nationwide, register-based cohort study. Data were extracted from the Danish National Patient register. Anyone with an OI diagnosis between January 1st 1977 and December 31st 2018, matched 1:5 with a reference population (Ref.Pop) on birthyear and sex, were included. 864 persons (487 women) with OI were included in the study and 4276 (2330 women) in the Ref.Pop. The sub-hazard ratio (SHR) for any HL was 4.56 [95% CI 3.64-5.71], with a prevalence of 17.0% and 4.0% in the OI cohort and Ref.Pop. Median age at debut was 42 and 58 years, respectively. The risk of otosclerosis and/or surgery was higher in the OI cohort (SHR 22.51 [95% CI 12.62-40.14]), with a median age at debut of 43 and 32 years in the OI cohort and Ref.Pop, respectively. Hearing aid use was more frequent in the OI cohort (SHR 4.16 [95% CI 3.21-5.40]) than in the Ref.Pop. The median age at debut was 45 and 60 years in the OI cohort and Ref.Pop, respectively. Persons with OI have a higher risk and prevalence of HL, hearing aids, and surgery, debuting younger, and prevalence increases with age.

ObjectiveTo evaluate a novel user-operated audiometry method allowing users full control in determining their pure-tone hearing thresholds.DesignComparative study. Participants were recruited from a hearing clinic after undergoing manual audiometry (six frequencies). They then performed test-retests of a new test (slider audiometry, eight frequencies) and completed the System Usability Scale questionnaire.Study sample37 adult participants, including 30 hearing-impaired and seven normal-hearing individuals.ResultsMean (SD) threshold differences for octave frequencies between 250 to 2000 Hz between manual and slider audiometry ranged from -7.8 (6.6) to -5.7 (6.5) dB and were significant. For 4000 and 8000 Hz mean differences were -0.3 (8.4) and 0.0 (9.7) dB and insignificant. Standard deviations ranged from 6.5 to 9.7 dB across six tested frequencies. Slider test-retest mean threshold differences ranged from -1.4 (4.7) to 0.3 (6.0) dB across eight tested frequencies, with standard deviations ranging from 4.1 to 8.5 dB. The average usability score for the slider audiometry was 88.3.ConclusionWhen compared to manual audiometry, the slider audiometry demonstrated validity at 4000 and 8000 Hz but found significantly lower thresholds for octave frequencies between 250 to 2000 Hz. Test-retests of the new method revealed small mean differences and acceptable SDs.

INTRODUCTION:There is a worldwide need to enhance the capacity of audiometry testing. The objective of this study is to compare the User-operated Audiometry (UAud) system with traditional audiometry in a clinical setting, by investigating if hearing aid effectiveness based on UAud is non-inferior to hearing aid effectiveness based on traditional audiometry, and whether thresholds obtained with the user-operated version of the Audible Contrast Threshold (ACT) test correlates to traditional measures of speech intelligibility. METHODS AND ANALYSIS:The design will be a blinded non-inferiority randomised controlled trial. 250 adults referred for hearing aid treatment will be enrolled in the study. Study participants will be tested using both traditional audiometry as well as the UAud system and they will answer the questionnaire Speech, Spatial and Qualities of Hearing Scale (SSQ12) at baseline. Participants will be randomly divided to receive hearing aids fitted based on either UAud or traditional audiometry. Three months after participants have started using their hearing aids, they will undergo a hearing in noise test with hearing aids to measure their speech-in-noise performance and answer the following questionnaires: SSQ12, the Abbreviated Profile of Hearing Aid Benefit and the International Outcome Inventory for Hearing Aids. The primary outcome is a comparison of the change in SSQ12 scores from baseline to follow-up between the two groups. Participants will undergo the user-operated ACT test of spectro-temporal modulation sensitivity as part of the UAud system. The ACT results will be compared with measures of speech intelligibility from the traditional audiometry session and follow-up measurements. ETHICS AND DISSEMINATION:The project was evaluated by the Research Ethics Committee of Southern Denmark and judged not to need approval. The findings will be submitted to an international peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER:NCT05043207.

Importance Hearing loss has been suggested as a risk factor for dementia, but there is still a need for high-quality research to better understand the association between these 2 conditions and the underlying causal mechanisms and treatment benefits using larger cohorts and detailed data. Objective To investigate the association between hearing loss and incident dementia, as well as how hearing aid use contributes to this association. Design, Setting, and Participants This population-based cohort study was conducted in Southern Denmark between January 2003 and December 2017 and included all residents 50 years and older. We excluded all persons with dementia before baseline as well as those who did not live in the region 5 years before baseline, with incomplete address history, or who had missing covariate information. Exposures Individual hearing status based on the Hearing Examinations in Southern Denmark database, which contains data on all pure-tone audiometry examinations performed at public hearing rehabilitation clinics in Southern Denmark. Main Outcomes and Measures Incident cases of dementia and Alzheimer disease as identified from national registries. Results The study population comprised 573 088 persons (298 006 women [52%]; mean [SD] age, 60.8 [11.3] years) with 23 023 cases of dementia and mean (SD) follow-up of 8.6 (4.3) years. Having a hearing loss was associated with an increased risk of dementia, with an adjusted hazard ratio (HR) of 1.07 (95% CI, 1.04-1.11) compared with having no hearing loss. Severe hearing loss in the better and worse ear was associated with a higher dementia risk, with an HR of 1.20 (95% CI, 1.09-1.32) and 1.13 (95% CI, 1.06-1.20), respectively, compared with having no hearing loss in the corresponding ear. Compared with people without hearing loss, the risk of dementia was higher among people with hearing loss who were not using hearing aids than those who had hearing loss and were using hearing aids, with HRs of 1.20 (95% CI, 1.13-1.27) and 1.06 (95% CI, 1.01-1.10), respectively. Conclusions and Relevance The results of this cohort study suggest that hearing loss was associated with increased dementia risk, especially among people not using hearing aids, suggesting that hearing aids might prevent or delay the onset and progression of dementia. The risk estimates were lower than in previous studies, highlighting the need for more high-quality longitudinal studies.