How can the DiCoDi<Superscript>®</Superscript> (Digital Cognitive Diagnostics) be used as a cognitive test in everyday practice?

zaud000082 10.3205/zaud000082 urn:nbn:de:0183-zaud0000826 Short Report How can the DiCoDi<Superscript>®</Superscript> (Digital Cognitive Diagnostics) be used as a cognitive test in everyday practice? Wie kann der DiCoDi® (Digital Cognitive Diagnostics) als kognitiver Test im Praxisalltag eingesetzt werden? Ballasch Ballasch Isabell I

KOJ Hearing Network, Germany Department of Medical Psychology | Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany

isabell.ballasch1@uk-koeln.de author Meka Meka Marietta M

KOJ Hearing Network, Germany

m.meka@khrc.info author Schmid Schmid Jan-Patric JP

KOJ Hearing Network, Germany

jps@koj.training author Kalbe Kalbe Elke E

Department of Medical Psychology | Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany

elke.kalbe@uk-koeln.de author Vorstius Vorstius Christian C

Institute of Psychology, University of Wuppertal, Germany

vorstius@uni-wuppertal.de author Kessler Kessler Josef J

Department of Neurology, University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, GermanyDepartment of Medical Psychology | Neuropsychology & Gender Studies, Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, GermanyDepartment of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany

josef.kessler@uk-koeln.de author German Medical Science GMS Publishing House

Düsseldorf

610 cognitive test cognitive impairments dementia hearing loss digital technology kognitiver Test kognitive Beeinträchtigung Demenz Schwerhörigkeit digitale Technologie 20260217 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2628-9083 8 GMS Zeitschrift für Audiologie - Audiological Acoustics GMS Z Audiol (Audiol Acoust) 05 Eine Schwerhörigkeit kann einen potenziellen Risikofaktor für eine spätere Demenz darstellen. Gleichzeitig sind bestehende Kognitionstests meist auditiv basiert und setzen ein intaktes Sensorium voraus, wodurch die kognitiven Leistungen von schwerhörigen Menschen nur unzureichend erfasst werden. Vor diesem Hintergrund wurde der Digital Cognitive Diagnostics (DiCoDi®) entwickelt. Der DiCoDi® wurde an 200 Kontrollpersonen und 173 Personen mit Schwerhörigkeit hinsichtlich Validität und Reliabilität evaluiert. Zusätzlich wurde eine ausführliche neuropsychologische Testbatterie durchgeführt. Es korrelierten alle DiCoDi®-Subtests signifikant mit ihrem dazugehörigen Paper&Pencil-Äquivalent (p>0.001), während sie mit einem Depressionsfragebogen nicht signifikant assoziiert waren (p>0.05). Zudem zeigte sich eine hohe Test-Retest-Reliabilität (p>0.0005). Dementsprechend ist der DiCoDi® ein valides und reliables Instrument zur Früherkennung kognitiver Defizite. Er kann zusätzlich zur herkömmlichen audiologischen Diagnostik in HNO-Praxen und Hörakustiker-Fachgeschäften sowie von Neurologen, Neuropsychologen und in Gedächtniskliniken eingesetzt werden. Hearing loss can be a potential risk factor for later dementia. At the same time, existing cognitive tests are mostly auditory-based and rely on intact sensory function, which limits their ability to accurately assess cognitive performance in individuals with hearing loss. Against this background, the Digital Cognitive Diagnostics (DiCoDi®) test was developed. DiCoDi® was evaluated for validity and reliability in 200 control participants and 173 individuals with hearing loss. Additionally, a comprehensive neuropsychological test battery was administered. As expected, all DiCoDi® subtests correlated significantly with their corresponding paper-and-pencil equivalents (p<0.001), while showing no significant association with a depression questionnaire (p>0.05). The test also demonstrated high test-retest reliability (p<0.0005). Accordingly, DiCoDi® is a valid and reliable tool for the early detection of cognitive deficits. It can be used alongside standard audiological diagnostics in ENT clinics and hearing aid centers, as well as by neurologists, neuropsychologists, and memory clinics. IntroductionIncreasing age is associated with a rise in sensory impairments . Among those aged 60 to 69, nearly 20% can be classified as hearing impaired, while in the 70 to 79 age group, the proportion is about twice as high at 42%. In individuals aged 80 and above, around 72% are affected by hearing loss . Besides hearing loss, cognitive impairments such as dementia also increase with advancing age. In 2021, approximately 1.8 million people in Germany were living with dementia .Hearing loss in midlife is linked to an evaluated risk of developing dementia and represents a potential risk factor for later dementia , . Among 14 modifiable risk factors for dementia, hearing loss in midlife was identified as the most significant modifiable risk factor for future cognitive decline, alongside high LDL cholesterol . Possible mechanisms linking hearing loss and dementia include a causal effect of hearing loss on cognition – either directly via reduced auditory input affecting cognitive brain regions, or indirectly through increased isolation, lower self-efficacy, reduced physical activity, or less cognitive engagement , , , . Alternatively, cognitive decline may itself contribute to hearing impairment . Although some studies suggest beneficial effects of hearing aid or cochlear implant use in this context, conclusive evidence is still lacking. Systematic reviews (e.g. , ) and large randomized controlled trials (e.g. ) highlight limitations in terms of generalizability. Furthermore many individuals delay or avoid using hearing aids due to stigma and perceived barriers, leading to a higher threshold for seeking compensation . Moreover, the cognitive performance of individuals with hearing loss is often inadequately assessed, underestimated, or even misdiagnosed (false positives), as most of these cognitive tests are primarily auditory and assume an intact sensory system . In suboptimal listening conditions – such as those caused by hearing loss – early speech processing requires greater cognitive effort, leaving fewer resources for encoding auditory information into memory . Individuals with hearing loss tend to perform significantly worse on cognitive tests under unaided conditions, and the use of hearing amplification does not substantially improve test performance . These findings highlight the need for cognitive assessments adapted for individuals with hearing loss, such as the HI-MoCA, MoCA-HI, MMSE for the hearing impaired, O-DEM, and DemTectEar. Due to limited validation and lack of German norms, only MoCA-HI and O-DEM are suitable for hearing-impaired individuals, though their complexity and paper-pencil-based format restricts use to specialized clinical settings and demands substantial resources. To overcome these limitations, digital tools such as the tablet-based CANTAB and the ALACog battery offer promising alternatives, though their use in routine care remains limited due to lengthy administration, required expertise, and the need for specialized training . Against this background, the Digital Cognitive Diagnostics (DiCoDi®) was developed as a cognitive test for individuals with and without hearing loss. This short article aims to present the DiCoDi® and its application in everyday practice. MethodDiCoDi®The DiCoDi® is a digital cognitive test (see Figure 1 ) consisting of nine subtests that cover a wide range of cognitive domains (see Table 1 ). The subtests were selected based on the following criteria: a) comprehensive assessment of cognitive status, b) highest sensitivity within the cognitive domain, c) adaptability for tablet use, d) complete independence from hearing ability, and e) time efficiency and practical feasibility. The subtests were developed based on existing cognitive tests. The DiCoDi® takes 20 to 30 minutes to complete. Instructions and stimuli are presented visually (minimum font size 12). The participant operates the tablet independently, though the test administrator should be present to monitor the process. Evaluation is fully computer-based and automatic. Sample and assessmentThe DiCoDi® was evaluated in a sample of 373 individuals aged 40 years and older, including 200 participants in the control group (age: M=67.48, SD=12.2; women: n=116 [58.0%]) and 173 participants in the group with hearing loss (age: M=72.86, SD=8.7; women: n=81 [46.8%]) between 2022 and 2023. Hearing impairments in the control group were assessed based on self-reported history, four-point self-rating scale and the examiner’s evaluation. Individuals with hearing loss underwent ear-specific pure-tone audiometry at frequencies ranging from 250 to 8,000 Hertz. The mean hearing threshold was 44.06 dB (11.6) for the right ear, 42.89 dB (10.6) for the left ear, and 43.27 dB (10.2) averaged across both ears. According to the WHO the hearing loss group comprised 93 individuals with mild (53.9%), 77 with moderate (44.5%), 2 with severe (1.2%), and 1 with profound hearing loss or deafness (0.6%).The control group was recruited by trained medical and psychology students in the greater Cologne area, Germany. Individuals with hearing loss were assessed in the hearing aid branches of the company KOJ in Switzerland by trained psychology students.In addition to the DiCoDi®, a comprehensive neuropsychological test battery was administered to validate the DiCoDi® subtests.Test-retest reliability of the DiCoDi® was examined in a separate control group (n=71; age: M=59.86, SD=9.5; women: n=40 [56.3%]), with a mean interval of nine weeks between assessments. The study was approved by the ethical committee of the University of Wuppertal, Germany (reference number: MS/AE 220614), and was conducted in compliance with national laws and the 1975 Declaration of Helsinki. All participants gave their informed consent.Statistical analysisThe statistical analyses were conducted using SPSS Statistics 29.0. Descriptive statistics, ANCOVAs with age and education as covariates, and two-tailed Spearman rank correlations were conducted. ResultsTable 2 shows the descriptive statistics and results of the ANCOVA for all DiCoDi® subtests. For subtests measured in seconds, the results include medians and interquartile ranges in addition to means and standard deviations. The control group and individuals with hearing loss demonstrated descriptively similar performances on the DiCoDi® subtests. ANCOVA results showed significant group differences in two subtests (Trail Making A and Time Estimation; p>0.001), with small to large effect sizes (pη²=0.05–0.24).Regarding convergent validity, all DiCoDi® subtests showed a significant moderate to strong correlation with their respective paper-and-pencil equivalents (rs=0.24–0.67; p>0.001). Additionally, none of the subtests showed a significant correlation with Beck’s Depression Inventory V (p>0.05), demonstrating the divergent validity of the DiCoDi®.Furthermore, all DiCoDi® subtests except the Color Figure Test showed significant correlations between the first and second test session, indicating high test-retest reliability (see Table 3 ). DiscussionThe present study examined the applicability, reliability, and validity of the DiCoDi® in individuals with and without hearing loss. The results suggest that the DiCoDi® is a valid and reliable measure for assessing cognitive impairments in both populations. The group comparison revealed similar performance between the control group and the hearing loss group across most DiCoDi® subtests. Interestingly, the hearing loss group showed slightly better performance than the control group on two DiCoDi® subtests: Trail Making A and Time Estimation. Regarding Time Estimation, both groups performed within the normative range for 1-minute estimation, as defined by Meyers et al. . However, time estimation in individuals with hearing loss remains understudied, warranting further research. Additionally, a significant difference emerged between groups in the Trail Making A subtest, which primarily measures cognitive processing and visual scanning. To confirm the robustness of this effect, an ANCOVA with bootstrapping (5,000 resamples) was conducted. The bias-corrected and accelerated (BCa) confidence intervals indicated a significant effect, corroborating the initial finding. Nevertheless, descriptive statistics based on median and interquartile range suggested that the magnitude of this group diff</PlainText></TextGroup>ere<TextGroup><PlainText>nce was small, and a nonparametric Mann–Whitney-U test</PlainText></TextGroup> did not confirm a significant difference (p=0.117). These results therefore point to a modest yet statistically robust difference when age and education are controlled for. One possible explanation for the superior performance of the hearing loss group lies in their increased reliance on visual information. Individuals with hearing impairment often compensate for reduced auditory input through enhanced visual attention and faster visual processing. Supporting this, Campbell and Sharma <TextLink reference="20"></TextLink> demonstrated cross-modal cortical reorganization in adults with mild-to-moderate hearing loss. Using electroencephalography (EEG), they found that hearing-impaired adults exhibited significantly larger visual evoked potential amplitudes and shorter latencies compared to normal-hearing controls. This indicates recruitment of auditory cortical areas for visual processing, reflecting adaptive cross-modal plasticity. Such cross-modal plasticity possibly underlies the subtle advantage observed in the visual scanning components of the Trail Making A task in the hearing loss group. Future studies should further investigate these findings.</Pgraph><Pgraph>As expected, the DiCoDi<Superscript>®</Superscript> subtests showed significant correlations with their paper-based counterparts and no associations with unrelated measures, supporting convergent and divergent validity. Further research is needed to compare the DiCoDi<Superscript>®</Superscript> with cognitive tests for individuals with hearing loss.</Pgraph><Pgraph>All DiCoDi<Superscript>®</Superscript> subtests except the Color Figure Test showed high test-retest reliability. The absence of a significant correlation in the Color Figure Test may result from low standard deviations despite highly similar mean scores across sessions, as minimal variability makes it harder to detect associations <TextLink reference="21"></TextLink>.</Pgraph><SubHeadline>Application</SubHeadline><Pgraph>The DiCoDi<Superscript>®</Superscript> can serve as a relevant diagnostic tool for the early detection of cognitive deficits in people aged 40 years and older. It can supplement routine audiological assessments in ENT practices and hearing aid centers and can be used by neurologists, neuropsychologists, and in memory clinics. Proper training is required to administer the DiCoDi<Superscript>®</Superscript>. When the DiCoDi<Superscript>®</Superscript> reveals indications of cognitive impairment, a comprehensive follow-up assessment is recommended. Suitable points of referral include general practitioners, neurologists, and memory clinics. If no signs of cognitive impairment are detected, it is advisable to repeat the test after approximately one year to monitor for any emerging subjective cognitive complaints. The DiCoDi<Superscript>®</Superscript> does not replace a medical diagnosis or a full neuropsychological evaluation.</Pgraph><SubHeadline>Strenghts and limitations</SubHeadline><Pgraph>A strength of this study is its large sample size, which enhances the generalizability of the findings. However, objective hearing data are lacking for the control group, as only self-assessments have been collected. Furthermore, most participants with hearing loss had only mild to moderate impairments, highlighting the need for further research on DiCoDi<Superscript>®</Superscript>’s applicability in more severe cases. The tablet-based, standardized administration and automated scoring make the DiCoDi<Superscript>®</Superscript> especially suitable for routine use in resource-limited clinical settings by minimizing examiner bias.</Pgraph></TextBlock> <TextBlock name="Conclusion" linked="yes"> <MainHeadline>Conclusion</MainHeadline><Pgraph>The DiCoDi<Superscript>®</Superscript> is a reliable and valid digital cognitive test for individuals with and without hearing loss. It is intended to improve the early detection of cognitive impairments in ENT settings. While it does not replace a full neuropsychological test battery, it can offer preliminary insights into possible cognitive deficits. Future research should examine the psychometric property of the DiCoDi<Superscript>®</Superscript> and its applicability in diverse clinical populations, although the large and representative sample suggests a high degree of data stability.</Pgraph></TextBlock> <TextBlock name="Notes" linked="yes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Conference presentation</SubHeadline><Pgraph>This contribution was presented at the 27<Superscript>th</Superscript> Annual Conference of the German Society of Audiology and published as an abstract <TextLink reference="22"></TextLink>.</Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>Prof. Dr. Josef Kessler and Prof. Dr. Elke Kalbe developed the DiCoDi<Superscript>®</Superscript> in cooperation with the KOJ Hearing Network, Germany, which provided the tablets, audiometric assessments, software programming, and facilities for data collection in the hearing-impaired group. Furthermore, the KOJ Hearing Network is handeling the distribution of the DiCoDi<Superscript>®</Superscript>. Isabell Ballasch and Marietta Meka are part-time employees of KOJ Hearing Network. Jan-Patric Schmid is the Managing Director of KOJ Hearing Network. </Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Völter C</RefAuthor> <RefAuthor>Thomas JP</RefAuthor> <RefAuthor>Maetzler W</RefAuthor> <RefAuthor>Guthoff R</RefAuthor> <RefAuthor>Grunwald M</RefAuthor> <RefAuthor>Hummel T</RefAuthor> <RefTitle>Sensory Dysfunction in Old Age</RefTitle> <RefYear>2021</RefYear> <RefJournal>Dtsch Arztebl Int</RefJournal> <RefPage>512-20</RefPage> <RefTotal>Völter C, Thomas JP, Maetzler W, Guthoff R, Grunwald M, Hummel T. Sensory Dysfunction in Old Age. Dtsch Arztebl Int. 2021 Jul 26;118(29-30):512-20. 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DOI: 10.3205/25dga032</RefTotal> <RefLink>https://doi.org/10.3205/25dga032</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Overview of DiCoDi</Mark1><Mark1><Superscript>®</Superscript></Mark1><Mark1> subtests and their cognitive domains</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Table 2: Descriptive statistics and results of the ANCOVA for the DiCoDi</Mark1><Superscript>®</Superscript><Mark1> subtests</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Table 3: Test-retest reliability of the DiCoDi</Mark1><Superscript>®</Superscript><Mark1> subtests</Mark1></Pgraph></Caption> </Table> <NoOfTables>3</NoOfTables> </Tables> <Figures> <Figure width="668" height="1074" format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Example illustration of DiCoDi</Mark1><Mark1><Superscript>®</Superscript></Mark1><Mark1> subtests</Mark1><LineBreak></LineBreak><Mark1>A: Remembering word pairs. B: Attention. C: Circle tapping task</Mark1><LineBreak></LineBreak><Mark1>(Figure available in German only)</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>1</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>