Effects of Tinnitus Severity on Cognitive, Emotional, and Sleep Outcomes in Older Adults with Controlled Age Related Hearing Loss

Effects of Tinnitus Severity on Cognitive, Emotional, and Sleep Outcomes in Older Adults with Controlled Age Related Hearing Loss | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Tinnitus Severity on Cognitive, Emotional, and Sleep Outcomes in Older Adults with Controlled Age Related Hearing Loss Gurbet İpek ŞAHİN KAMIŞLI, Songül AKSOY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8731512/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Tinnitus is associated with sleep disturbances, cognitive impairment, and mental health problems. This study examined sleep quality, depressive symptoms, and cognitive functioning in older adults with mild and severe tinnitus, controlling for hearing loss and excluding individuals who used hearing aids or received tinnitus therapy. Methods A total of 144 older adults (median age: 65 years) participated in the study. Hearing thresholds were assessed, and the Tinnitus Handicap Inventory(THI), Beck Depression Inventory(BDI), Pittsburgh Sleep Quality Index(PSQI), and Montreal Cognitive Assessment(MoCA) were administered. Based on THI scores, participants were classified into mild tinnitus(level 2) and severe tinnitus(level ≥ 3) groups. Results There was a difference between the groups in BDI and PSQI, MoCA scores and Memory Index Score(MIS) and Recall subtests. There was a medium correlation between THI and BDI(r= .658;p=.001), PSQI score(r=.303;p= .038), MoCA(r=-.472;p=.001), and MoCA-MIS(r=-.376;p=.008).This study revealed that increasing tinnitus level in older adults increases problems in sleep, depression, memory and recall. Conclusions Increasing tinnitus severity is associated with poorer sleep quality, greater depressive symptoms, and impaired cognitive performance—particularly working memory and delayed recall—in older adults. When hearing loss is controlled, tinnitus severity alone appears to negatively affect cognitive and emotional functioning, underscoring the need to consider tinnitus as an independent risk factor in the aging population. tinnitus severity cognition hearing loss sleep quality Introduction Hearing loss and tinnitus are among the most prevalent auditory complaints in older adults. Age-related hearing loss (ARHL), resulting from degenerative changes in the auditory system associated with ageing, is one of the three most common chronic health conditions affecting geriatric populations[ 1 ]. Its prevalence increases markedly with age, affecting approximately 49% of adults aged 60–69 years and more than 80% of individuals aged 85 years and older. ARHL is typically characterised as a bilateral, symmetrical, progressive sensorineural hearing loss that begins at high frequencies and gradually involves mid frequencies over time. Reduced hearing sensitivity and impaired speech perception—particularly in noisy, reverberant, or multi-talker environments—are the most frequently reported complaints[ 2 ]. Ageing is associated with degenerative changes not only in the peripheral auditory system but also in central auditory pathways and the central nervous system. These changes contribute to slowed central auditory processing, impaired sound localisation, and increased listening effort. Although ARHL is not life-threatening, untreated hearing loss significantly disrupts communication and social participation, leading to social isolation, frailty, emotional distress, and reduced quality of life. Moreover, ARHL has been associated with late-onset depression, cognitive decline, dementia, and increased medical morbidity[ 3 ]. In addition to its health-related consequences, ARHL imposes a substantial economic burden on individuals, families, and healthcare systems. Direct medical costs and productivity losses related to hearing loss in adults aged 65 years and older were estimated at approximately USD 9.5 billion, with projections suggesting that annual costs may rise to nearly USD 60 billion by 2030 due to increased life expectancy [ 4 ]. Consequently, ARHL represents a major and growing public health concern. As a permanent and irreversible condition, ARHL cannot be cured; therefore, management strategies focus on improving audibility, communication effectiveness, daily functioning, and safety. Hearing aids and cochlear implants remain the most widely used rehabilitative interventions. Tinnitus refers to the perception of sound without the presence of an identifiable external acoustic stimulus and one of the most common auditory symptoms accompanying untreated hearing loss in older adults. While tinnitus affects approximately 15% of the general population, its prevalence rises to nearly 30% among older individuals[ 5 , 6 ]. With the progressive aging of the global population, age-related hearing impairment is becoming more prevalent, suggesting that tinnitus will represent an increasingly important health complaint in older individuals. Multiple risk factors for tinnitus have been described, encompassing otologic and audiologic conditions, as well as personal, socioeconomic, and medical factors. Hearing impairment is widely recognised as one of the primary risk factors for tinnitus. It has been reported that individuals with hearing loss are approximately twice as likely to have tinnitus compared to those with normal hearing [ 5 ]. Although the pathophysiology of tinnitus has not been fully elucidated, proposed mechanisms include central gain enhancement following peripheral auditory deprivation, maladaptive neuroplasticity, neural hyperactivity, and disrupted excitation–inhibition balance within auditory and non-auditory neural networks [ 7 ]. Beyond peripheral and central mechanisms, the neurophysiological model proposed by Jastreboff highlights tinnitus as a condition involving complex interactions between the auditory system and limbic, autonomic, and cognitive networks[ 8 ]. Neuroimaging studies have demonstrated tinnitus-related neuroplastic changes in the limbic and paralimbic systems, prefrontal cortex, amygdala, hippocampus, thalamus, and auditory cortex, which may influence emotional regulation, attention, memory, and stress responses[ 9 ]. Ageing is also associated with increased vulnerability to mental health problems, particularly depression, which affects approximately 17–20% of individuals over the age of 65[ 10 , 11 ].Depression could lead social isolation, increase suicidal risks, dementia[ 10 ] and physical complaints and cognitive impairments in the older population. Late-life depression differs from depression in younger populations due to higher rates of medical comorbidity, cognitive impairment, and poorer prognosis[ 12 ]. Hearing loss has been consistently linked to depressive symptoms, primarily through communication difficulties and social withdrawal[ 13 ]. As hearing loss severity and tinnitus burden increase with age, the risk of depression appears to rise further[ 14 ]. Studies indicate that older adults with chronic or bothersome tinnitus are up to three times more likely to experience depressive symptoms compared to those without tinnitus[ 15 ]. Normal ageing is accompanied by gradual changes in cognitive functioning, influenced by factors such as education, lifestyle, and cultural background. Age-related cognitive decline typically affects processing speed, working memory, executive functions, and cognitive flexibility[ 16 , 17 ]. Accumulating evidence suggests that ARHL is associated with cognitive decline and may increase the risk of dementia, although longitudinal studies are required to clarify causality[ 18 ]. Similarly, bothersome tinnitus has been linked to impairments in working memory, attention control, and executive functioning[ 19 ]. Tinnitus-related reorganisation of neural networks connecting auditory and non-auditory brain regions may disrupt large-scale cognitive processing networks, potentially underlying difficulties in attention, memory, and concentration. Sleep disturbances are another common concern in older adults, affecting approximately 35–52% of this population[ 20 ]. Age-related changes in sleep architecture include lighter sleep, increased nocturnal awakenings, shorter nighttime sleep duration, and increased daytime napping[ 21 ]. Tinnitus has been shown to negatively affect sleep quality, particularly by prolonging sleep onset latency and increasing nocturnal arousal[ 22 , 23 ]. Cohort data indicate that tinnitus is associated with poorer sleep quality even among individuals who report minimal subjective tinnitus-related distress [ 24 ]. Several studies suggest that the impact of tinnitus on sleep quality, depression, anxiety, and cognitive functioning is more pronounced in older adults than in younger populations[ 12 ]. Older adults with tinnitus appear to be at increased risk for dementia, sleep problems, and affective disorders. Recent findings indicate that individuals over 60 years of age with tinnitus are more vulnerable to cognitive impairment compared to younger adults with tinnitus[ 25 ]. Meta-analytic evidence further supports associations between tinnitus and reduced executive function, processing speed, short-term memory, and cognitive flexibility [ 26 ]. However, because hearing loss is highly prevalent in older adults, disentangling the independent effects of tinnitus from those of hearing loss remains challenging. The lack of longitudinal studies and the failure to adequately control for hearing thresholds contribute to ongoing controversy regarding the relationship between tinnitus and cognitive, psychological, and sleep-related outcomes in older populations. Therefore, the present study aimed to examine the associations between tinnitus severity, sleep quality, depressive symptoms, and cognitive functioning in older adults with age-related hearing loss. To isolate the specific effects of tinnitus severity, participants were selected to have comparable pure-tone hearing thresholds, thereby minimising the confounding influence of hearing loss on the examined outcomes. Methods Study Design This study aimed to investigate the impact of tinnitus severity on sleep quality, depressive symptoms, and cognitive functioning in older adults with hearing loss and tinnitus. Ethical approval was obtained from the Ethical Committee Gazi University (protocol number: E-77082166-604.01.02-782677; research code: 2023–1256; approval date: 24 October 2023). Written informed consent was obtained from all participants prior to inclusion in the study. Participants Participants were recruited from individuals who presented to the audiology clinic with complaints of hearing loss and/or tinnitus and voluntarily agreed to participate in the study. A total of 114 older adults with bilateral sensorineural hearing loss and subjective chronic tinnitus (duration ≥ 6 months) were included. The sample consisted of 72 women (age range: 60–82 years) and 42 men (age range: 60–80 years) Inclusion criteria were as follows: literacy; native proficiency in Turkish; completion of at least primary school education; absence of current or previous neurological disorders, otologic diseases, or a history of ear surgery; no prior use of hearing aids; bilateral pure-tone average (PTA) thresholds between 500 and 4000 Hz of ≥16 dB HL; and sensorineural hearing loss with an air–bone gap not exceeding 10 dB. Individuals with a PTA ≥56 dB HL were excluded to reduce the potential confounding effects of more severe hearing loss on cognitive performance. Cochlear implant users and hearing aid users were also excluded due to the potential beneficial effects of auditory amplification on cognitive outcomes. Additionally, individuals who had previously received tinnitus-specific therapies, used rehabilitative devices such as sound generators, or employed hearing aids for tinnitus management were excluded. Participants who were unable to complete the administered questionnaires and cognitive tests were also excluded from the final analysis. Data Collection All participants underwent otoscopic examination prior to audiological testing. Pure-tone audiometry was performed in a sound-treated booth using a GSI AudioStar PRO clinical audiometer (Grason-Stadler, Eden Prairie, MN, USA) with Telephonics TDH-39P headphones. Air-conduction thresholds were measured at octave and inter-octave frequencies between 125 and 8000 Hz. Bone-conduction thresholds were obtained between 500 and 4000 Hz using a RadioEar B-71 bone vibrator. The pure-tone average (PTA) was calculated as the mean of air-conduction thresholds at 500, 1000, 2000, and 4000 Hz. Participants with slight, mild, or moderate sensorineural hearing loss were included in the study. The PTA of the better-hearing ear was determined and used for correlation analyses. Tinnitus evaluation: Tinnitus severity was assessed using the Turkish version of the Tinnitus Handicap Inventory (THI)[27]. The THI consists of 25 items evaluating the impact of tinnitus on quality of life across functional, emotional, and catastrophic subscales, providing an overall measure of tinnitus level and severity and[28]. Each item is scored as “yes” (4 points), “sometimes” (2 points), or “no” (0 points), yielding a total score ranging from 0 to 100, with higher scores indicating greater tinnitus severity. THI score categories were defined as follows: 0–16 (Level 1), 18–36 (Level 2), 38–56 (Level 3), 58–76 (Level 4), and 78–100 (Level 5). Only participants with THI scores of 18 or higher (Level 2 and above) were included in the study. Based on THI scores, participants were divided into two groups: those with Level 2 tinnitus were classified as the mild tinnitus group (MTG), while individuals with Level 3 or higher were classified as the severe tinnitus group (STG). Psychoacoustic tinnitus measures included tinnitus pitch matching, tinnitus loudness matching, minimum masking level (MML), and residual inhibition (RI). Evaluation of Sleep Quality. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) [29]. The PSQI comprises 24 items evaluating seven domains: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Nineteen items are self-rated by the participant, while five items are completed by a bed partner or roommate. Domain scores are summed to yield a global PSQI score ranging from 0 to 21. A global score of <5 indicates good sleep quality, whereas a score of ≥5 indicates poor sleep quality. Assessment of Depression Symptoms: Depressive symptoms were evaluated using the Beck Depression Inventory (BDI)[30]. The BDI is a 21-item self-report questionnaire, with each item scored from 0 to 3. Total scores ≤11 are considered within the normal range, while scores >11 indicate increasing levels of depressive symptom severity, classified as minimal, mild, moderate, severe, or extreme depression[31]. Cognitive assessment: The original Montreal Cognitive Assessment (MoCA)[32] in paper format (MoCA Full) Turkish version was applied for cognitive assessment. The test was administered by the certified author and written permission to use the MoCA was obtained from MoCA Test Inc., a Quebec-based company. The MoCA consists of 12 tasks assessing multiple cognitive domains, including visuospatial–executive functions, naming, attention, language, abstraction, delayed recall, orientation, and memory. The administration time is approximately 10–15 minutes, with a maximum possible score of 30 points, where higher scores indicate better cognitive performance. In clinical practice, a cut-off score of 26 is commonly used to differentiate mild cognitive impairment from normal cognition; however, for the Turkish population, a cut-off value of 21 is recommended[33]. Participants with 12 years of education or fewer received one additional point to adjust for educational level. The MoCA Memory Index Score (MoCA-MIS) was also calculated to provide a more sensitive measure of memory encoding and retrieval. The MoCA-MIS is derived by weighting free delayed recall, category-cued recall, and multiple-choice recall responses by three, two, and one points, respectively, yielding a total score ranging from 0 to 15[34]. The relationships between tinnitus severity and sleep quality, depressive symptoms, and cognitive functioning were analysed, as well as differences between tinnitus severity groups. Statistical Analysis The IBM SPSS v.24 software, New York, ABD, was used to analyse the study data. Normality of continuous variables was assessed using the Shapiro–Wilk test. As the data were not normally distributed, comparisons between two independent groups were performed using the Mann–Whitney U test. Continuous variables were presented as median and interquartile range (IQR). Categorical variables were analysed using the chi-square test. Effect sizes were calculated where appropriate, and a p value < .05 was considered statistically significant. Correlations between MoCA, THI, BDI, PSQI test scores and tinnitus duration were tested with Spearman’s correlation analysis. Results A total of 144 older adults with a median age of 65 years (IQR: 7) participated in the study. Participants with a THI score of level 2 were defined as MTG, and with a THI score of level 3 and above were defined as STG. The MTG comprised 66 older adults (36 males, 30 females), and the STG comprised 78 older adults (36 males, 42 females). The median age of the MTG was 65 years (IQR:5) and 65 (IQR:7) for the STG. There was no statistically significant difference in age between groups (Mann-Whitney U=2569.5, p>.986). Of 66 participants, 25 had an elementary, 29 had a high school, and 12 Bachelor’s degree in the MTG. Of 78 participants in the STG, 30 had an elementary degree, 33 had high school, and 15 had a Bachelor’s degree. The Chi-square test was used to compare the educational status between groups, and the test revealed that there were no statistically significant differences (χ²(2, N = 114) = 0.882, p = .658). There was no statistically significant difference between MTG (Median=24, IQR=71) and STG (Median=39, IQR=60) tinnitus duration (Mann-Whitney U= 2484.0 p=.718) in tinnitus duration. Tinnitus psychoacoustic properties are given in Table 1. There were no significant differences between the groups in terms of tinnitus frequency, tinnitus loudness, or minimal masking level (Mann–Whitney U test, all p > .05). Residual inhibition distributions differed significantly between the groups (Fisher’s exact test, p = .000). Tinnitus site was on the right in 9 (13%), on the left in 36 (54%), bilaterally or in the head in 21 (31%) in the MTG. In the STG, 9 (11%) were on the right, 30 (38%) on the left and 39 (50%) bilaterally or in the head. As shown in Table 2, comparisons between the mild and severe tinnitus groups were performed using the Mann–Whitney U test. No statistically significant differences were observed between groups in right ear pure-tone average (PTA), left ear PTA, or better-ear PTA (all p > .05). In contrast, the severe tinnitus group demonstrated significantly higher scores on the Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI) compared with the mild tinnitus group (both p < .001), indicating poorer sleep quality and more severe depressive symptoms. Additionally, Montreal Cognitive Assessment (MoCA) scores were significantly lower in the severe tinnitus group than in the mild tinnitus group (U = 2038.5, p = .031), suggesting reduced cognitive performance associated with greater tinnitus severity. Using the Mann–Whitney U test, MoCA subtest scores were compared between the mild and severe tinnitus groups (Table 3). No statistically significant differences were found between the groups in visuospatial–executive functions (trail making, cube copying, and clock drawing), naming, vigilance, verbal fluency, abstraction, or orientation subtests (all p > .05). Within the attention domain, the severe tinnitus group showed significantly lower performance on the backward digit span (U = 2151.0, p = .028) and serial subtraction tasks (U = 1390.5, p .05). In the language domain, sentence repetition scores were significantly lower in the severe tinnitus group (U = 1957.5, p < .001), while verbal fluency scores did not differ significantly between groups (p = .633). Furthermore, the severe tinnitus group demonstrated significantly poorer performance on the delayed recall subtest (U = 1620.0, p < .001) and had significantly lower MoCA Memory Index Scores (MoCA-MIS) compared with the mild tinnitus group (U = 1404.0, p < .001). These results indicate that increased tinnitus severity is associated with impairments primarily in attention, sentence repetition, and memory-related cognitive domains. As shown in Table 4, Spearman’s rank correlation analysis was used to examine the associations between Tinnitus Handicap Inventory (THI) scores and the other variables. THI scores were moderately and positively correlated with Pittsburgh Sleep Quality Index (PSQI) scores (r = .303, p = .038), indicating that greater tinnitus-related handicap was associated with poorer sleep quality. A strong positive correlation was observed between THI and Beck Depression Inventory (BDI) scores (r = .658, p < .001), suggesting that higher tinnitus severity was closely related to increased depressive symptoms. In contrast, THI scores demonstrated significant moderate negative correlations with cognitive measures, including the Montreal Cognitive Assessment (MoCA) (r = −.472, p = .001) and the MoCA Memory Index Score (MoCA-MIS) (r = −.376, p = .008), indicating that greater tinnitus-related handicap was associated with poorer global cognitive performance and memory function. No significant correlations were found between THI scores and tinnitus duration or better-ear pure tone average (PTA) (all p > .05). Discussion Tinnitus and ARHL are among the most common reasons for visits to otolaryngology clinics in the elderly population [ 35 ]. Previous studies have shown that older adults with bothersome tinnitus experience higher levels of depression and anxiety and poorer sleep quality [ 36 , 24 ]. Longitudinal studies, as well as a systematic review and meta-analysis, have demonstrated that hearing loss contributes to cognitive decline, whereas the use of hearing aids may attenuate this effect[ 37 – 39 ]. For this reason, individuals with moderate-to-severe hearing loss and hearing aid users were excluded from the present study, allowing us to specifically evaluate the effect of tinnitus severity. In addition, no statistically significant differences were observed between the groups in terms of tinnitus characteristics (Table 1 ). In the present study, the median THI score was 32 in the MTG and 71 in the STG. The absence of significant differences between groups with respect to PTA, age, and educational status enabled a focused examination of the independent effect of tinnitus severity on cognitive performance, anxiety, sleep quality, and depressive symptoms. Regarding sleep quality, a statistically significant difference was observed between the two groups. The median PSQI score was higher in the STG. In addition, a significant positive correlation was found between THI and PSQI scores (Table 4 ), indicating that deterioration in sleep quality increased with higher tinnitus severity. Previous studies have shown that individuals with tinnitus exhibit shorter mean nocturnal sleep duration and alterations in sleep architecture, particularly in rapid eye movement (REM) sleep. Furthermore, older adults generally experience poorer sleep quality, more frequent nocturnal awakenings, and increased daytime sleepiness, which may further exacerbate the negative impact of tinnitus on sleep[ 40 , 41 ]. In a cross-sectional study of middle-aged and older adults, Oosterloo et al. (2021) reported that tinnitus was associated with sleep disturbances even among individuals who stated that it did not interfere with their daily lives, and that these sleep-related complaints increased with greater tinnitus severity[ 24 ]. The degree of sleep disturbance is highly correlated with the tinnitus severity[ 42 , 43 ]. In this study, consistent with the existing literature, the STG demonstrated significantly poorer sleep quality. However, the finding that both groups were classified as having poor sleep quality suggests that even mild tinnitus may adversely affect sleep. Moreover, increasing tinnitus severity appears to exacerbate the degree of sleep impairment. As tinnitus severity increases, the percept becomes more difficult to ignore and less amenable to masking, which in turn disrupts sleep quality and sleep efficiency. This effect may be particularly pronounced in older adults, who already tend to experience lighter and shorter sleep durations. This study demonstrated a significant difference in BDI scores between the MTG and the STG, as well as a significant correlation between BDI and THI scores (Table 4 ). Previous studies have reported a higher lifetime and current prevalence of major depression in individuals with tinnitus compared with non-tinnitus control groups, higher depression and anxiety scores in individuals with chronic tinnitus, and a positive association between the severity of anxiety and depression and tinnitus severity[ 40 ]. Holgers et al. identified depression as an important predictor of tinnitus severity, with greater tinnitus severity being associated with more pronounced negative effects on daily life [ 44 ]. In chronic tinnitus, increased emotional reactivity and heightened activity within the limbic and autonomic nervous systems are thought to arise from the engagement of non-classical auditory pathways. As tinnitus severity increases, levels of stress, anxiety, and hopelessness also rise, forming a vicious cycle that exacerbates and perpetuates tinnitus perception[ 45 ]. These emotional responses and maladaptive associations contribute to the amplification and persistence of tinnitus over time. Chronic tinnitus increasingly becomes linked with anxiety and depressive symptoms. Stress-induced alterations in synaptic plasticity and cortisol release may further influence limbic system functioning[ 46 ] ,leading to neuroplastic changes and the formation of pathways distinct from classical auditory neural circuits[ 47 ]. The involvement of non-classical auditory pathways has been demonstrated in both animal models and human neuroimaging studies[ 48 – 50 ]. Moreover, widespread alterations within the central nervous system—including changes in neural networks, synaptic plasticity, and brain morphology—may affect emotional processing and contribute to the development of depression and other psychiatric disorders. A substantial body of evidence has demonstrated a significant association between ARHL and cognitive decline, with ARHL reported to accelerate cognitive deterioration and increase the incidence of cognitive impairment[ 51 , 52 ]. However, the extent to which tinnitus severity affects cognitive function in older adults, independent of hearing loss, remains controversial. In a large population-based study including approximately 15,000 participants, Butt et al. reported that tinnitus was associated with a 168% increased risk of dementia; however, the impact of tinnitus severity was not examined[ 53 ]. In the present study, a carefully selected sample was used to evaluate the effect of tinnitus severity on cognitive abilities, as the groups did not differ significantly in terms of age, educational level, hearing sensitivity, or hearing aid use. A statistically significant difference was observed between groups in total MoCA scores, with the STG scoring slightly below the cut-off value of ≥ 21 points considered normal for the Turkish population, whereas the MTG exceeded this threshold. Correlation analysis further demonstrated a significant negative association between MoCA and THI scores. Subtest analyses of the MoCA revealed no significant group differences in visuospatial–executive function, naming, abstraction, or orientation. In contrast, the STG showed significantly poorer performance on the recall subtest, the MoCA Memory Index Score (MoCA-MIS), sentence repetition in the language domain, and serial 7 subtraction in the attention domain (Table 3 ). These findings are consistent with previous studies reporting an association between tinnitus and deficits in working memory[ 54 – 56 ]. The serial 7 subtraction task is known to engage prefrontal cortex activity and is closely related to working memory processes. In the memory domain, participants performed relatively well on immediate recall, in which five words were repeated at 1-second intervals; however, substantial difficulty was observed during delayed recall approximately five minutes later. The mean delayed free recall score across participants was 2.1 ± 1.0 words, which is notably lower than the 3.73 words reported by Julayanont et al. in a cognitively normal control group [ 57 ]. This pattern suggests that individuals with tinnitus retain relatively preserved short-term memory but exhibit impairments in delayed recall. Such retrieval memory deficits are often associated with dysfunction in subcortical structures. Notably, recall impairment was more pronounced in the STG than in the MTG, indicating that recall performance deteriorates with increasing tinnitus severity. The observed recall deficits in tinnitus may be attributable to difficulties in attentional allocation, divided attention, and the suppression of irrelevant information, rather than to primary sensory processing deficits. The MoCA-MIS, which specifically assesses delayed verbal recall, has been proposed as a sensitive indicator of early central neural changes observed in the initial pathophysiological stages of mild cognitive impairment[ 34 ]. Consistent with this, our findings demonstrated a significant negative correlation between THI and MoCA-MIS scores (Table 4 ). Furthermore, the category and multiple-choice cueing components of the MoCA-MIS provide valuable information for distinguishing retrieval memory impairment—which improves with cueing—from encoding memory impairment, which does not[ 58 ]. In the present study, cueing failed to improve retrieval performance in the STG to the same extent as in the MTG. Although no group differences were observed in other language subtests, the STG exhibited significantly poorer performance on the sentence repetition task. Unlike other language measures, sentence repetition requires sustained attention and concentration to temporarily store and reproduce verbal information, processes that rely heavily on working memory support[ 58 ]. Our findings showed that higher tinnitus severity impairs memory and recall skills more. The psychological effects and emotional distress of tinnitus, which can worsen cognitive symptoms, could be one of the causes of the impairment in these abilities. The inability to ignore the constantly perceived sound directly disrupts cognitive processes. It has been suggested that the sound perceived as tinnitus noise may limit the capacity of the central system, and that paying attention to the tinnitus sound could impair the execution of automatic response sequences. In chronic tinnitus, the constant activation of the tinnitus-related thoughts and reactions in the brain negatively affects tasks that require inhibition of irrelevant ones, such as tasks requiring concentration and attention [59] . The fact that the memory and recall skills of the STG were worse in this study could indicate that this difficulty in inhibition may increase even more at high tinnitus levels. This study has several limitations. First, the MoCA is a screening instrument and is not intended for the formal diagnosis of cognitive impairment. Future studies may strengthen the evidence by examining the impact of tinnitus severity on cognitive function—particularly working memory and recall—using more comprehensive and sensitive neuropsychological assessments. Second, the relatively small sample size limits the generalizability of the findings; however, recruiting older adults with tinnitus who have not previously used hearing devices or undergone tinnitus-related therapy and who do not present with advanced hearing loss is inherently challenging. Third, sleep quality was assessed using a self-reported measure, which may be subject to reporting bias. Future research incorporating objective sleep assessments could provide more robust evidence regarding the relationship between tinnitus severity and sleep. In addition, group differences in sleep quality and depressive symptoms may have acted as confounding factors when evaluating the effect of tinnitus on cognitive performance. Although the pathophysiology of tinnitus remains incompletely understood and no definitive cure exists, various therapeutic approaches aim to reduce symptom burden and improve quality of life. Prior to treatment planning, comprehensive assessment of mental and emotional domains—such as sleep quality, depressive and anxiety symptoms, and cognitive functioning—may enhance treatment outcomes. The present findings indicate that sleep disturbances, mood symptoms, and impairments in memory and concentration are more prevalent in individuals with greater tinnitus severity. These domains should therefore be routinely assessed and monitored in patients with bothersome tinnitus, and referral to appropriate specialists should be considered when necessary. Addressing these symptoms alongside tinnitus-focused interventions may help mitigate symptom severity and reduce the overall negative impact of tinnitus on quality of life. Conclusion In conclusion, this study demonstrates that increasing tinnitus severity is associated with poorer sleep quality, greater depressive symptoms, and impaired cognitive performance—particularly in working memory and delayed recall—in older adults. Although age-related hearing loss is a well-established contributor to cognitive decline, the present findings indicate that tinnitus severity alone can negatively affect cognitive and emotional functioning when hearing loss is controlled. From a clinical perspective, these results highlight the importance of routinely assessing sleep quality, depressive symptoms, and cognitive functioning in older adults with tinnitus, even in the absence of significant hearing loss. Early identification and targeted management of tinnitus severity may help mitigate its adverse effects on mental health and cognitive outcomes, thereby improving overall quality of life in the aging population. Declarations Informed consent: Ethics committee approval was obtained from the Gazi University's Ethical Commission with the protocol number E-77082166-604.01.02-782677 and research code 2023 – 1256 (date:24.10.2023). The informed consent form was signed by each participant in the study. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflıct Of Interest Statement: The authors declared no conflict of interest. Funding Sources: This study was not supported by any sponsor or funder. Clinical trial number : Not applicable Data Availability Statement: The data supporting this study's findings are not publicly available because they contain information that could compromise the privacy of research participants. The data are available at reasonable request from the corresponding author. Ethics approval and consent to participate: Informed consent was obtained from all individual participants included in the study. This study has been approved by the Ethics Committee of Gazi University with the decision number E-77082166-604.01.02-782677 and research code number 2023 – 1256 and performed in line with the principles of the Declaration of Helsinki. Author Contribution consept and idea: equal Songül AKSOY and Gurbet İpek ŞAHİN KAMIŞLIdata collection and processing: Gurbet İpek ŞAHİN KAMIŞLIanalysing and interpretation: lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Songül AKSOYLiterature review : lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Songül AKSOYwriting the article:lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Songül AKSOYcritical review: equal Songül AKSOY and Gurbet İpek ŞAHİN KAMIŞLI References McKee MM, Stransky ML, Reichard A. Hearing loss and associated medical conditions among individuals 65 years and older. Disabil health J. 2018;11(1):122–25. Lin FR. Age-related hearing loss. N Engl J Med. 2024;390(16):1505–12. Bowl MR, Dawson SJ. Age-related hearing loss. Cold Spring Harb Perspect Med. 2019;9(8):a033217. Stucky SR, Wolf KE, Kuo T. The economic effect of age-related hearing loss: national, state, and local estimates, 2002 and 2030. J Am Geriatr Soc. 2010;58(3):618–19. 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Mental health care for older adults: recent advances and new directions in clinical practice and research. World Psychiatry. 2022;21(3):336–63. Mitchell AJ, Subramaniam H. Prognosis of depression in old age compared to middle age: a systematic review of comparative studies. Am J Psychiatry. 2005;162(9):1588–601. Shukla A, Harper M, Pedersen E, Goman A, Suen JJ, Price C, et al. Hearing loss, loneliness, and social isolation: a systematic review. Otolaryngology–Head Neck Surg. 2020;162(5):622–33. Gibrin PCD, Ciquinato DSA, Gonçalves IC, Marchiori VM, Marchiori LLM. Tinnitus and its relationship with anxiety and depression in the elderly: a systematic review. Revista CEFAC. 2019;21. Loprinzi PD, Maskalick S, Brown K, Gilham B. Association between depression and tinnitus in a nationally representative sample of US older adults. Aging Ment Health. 2013;17(6):714–17. Veríssimo J, Verhaeghen P, Goldman N, Weinstein M, Ullman MT. Evidence that ageing yields improvements as well as declines across attention and executive functions. Nat Hum Behav. 2022;6(1):97–110. Ghayedi Z, Banihashemian K, Shirdel S, Adineh Salarvand R, Zare M. A Review of the Comparison of Working Memory Performance, Cognitive Function, and Behavioral, and Psychological Symptoms across Normal Aging, Mild Cognitive Impairment, and Alzheimer's Disease. Neurol Lett. 2024;3:26–38. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214–20. Jafari Z, Kolb BE, Mohajerani MH. Age-related hearing loss and tinnitus, dementia risk, and auditory amplification outcomes. Ageing Res Rev. 2019;56:100963. Fernandes M, Antonucci M, Capecci F, Mercuri NB, Della-Morte D, Liguori C. Prevalence of sleep disorders in geriatrics: an exploratory study using sleep questionnaires. Geriatr Nurs. 2024;60:107–13. Gulia KK, Kumar VM. Sleep disorders in the elderly: a growing challenge. Psychogeriatrics. 2018;18(3):155–65. de Feijter M, Oosterloo BC, Goedegebure A, Luik AI. The cross-sectional association between tinnitus and actigraphy-estimated sleep in a population-based cohort of middle-aged and elderly persons. Ear Hear. 2023;44(4):732–39. Gallo KEB, Corrêa CC, Gonçalves CGO, Baran JBC, Marques JM, Zeigelboim BS, et al. Effect of tinnitus on sleep quality and insomnia. Int archives Otorhinolaryngol. 2023;27:197–202. Oosterloo BC, de Feijter M, Croll PH, de Jong RJB, Luik AI, Goedegebure A. Cross-sectional and longitudinal associations between tinnitus and mental health in a population-based sample of middle-aged and elderly persons. JAMA Otolaryngology–Head Neck Surg. 2021;147(8):708–16. Yang D, Zhang D, Zhang X, Li X. Tinnitus-associated cognitive and psychological impairments: a comprehensive review meta-analysis. Front Neurosci. 2024;18:1275560. Clarke NA, Henshaw H, Akeroyd MA, Adams B, Hoare DJ. Associations between subjective tinnitus and cognitive performance: systematic review and meta-analyses. Trends Hear. 2020;24:2331216520918416. Aksoy S, Firat Y, Alpar R. The Tinnitus Handicap Inventory: a study of validity and reliability. Int Tinnitus J. 2007;13(2):94–8. Newman CW, Jacobson GP, Spitzer JB. Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1996;122(2):143–8. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. Beck AT, Steer RA, Brown GK. Beck depression inventory. 1996. Beck AT, Steer RA, Brown G. Beck depression inventory–II. Psychol Assess; 1996. Hobson J. The montreal cognitive assessment (MoCA). Occup Med. 2015;65(9):764–65. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–99. Julayanont P, Brousseau M, Chertkow H, Phillips N, Nasreddine ZS. Montreal Cognitive Assessment Memory Index Score (MoCA-MIS) as a Predictor of Conversion from Mild Cognitive Impairment to A lzheimer's Disease. J Am Geriatr Soc. 2014;62(4):679–84. Alves CS, Santos M, Castro A, Lino J, Freitas SV, Almeida e Sousa C, et al. Geriatric otorhinolaryngology: reasons for outpatient referrals from generalists to ENT specialists. Eur Arch Otorhinolaryngol. 2023;280(1):461–67. Haider HF, Bojić T, Ribeiro SF, Paço J, Hall DA, Szczepek AJ. Pathophysiology of subjective tinnitus: triggers and maintenance. Front Neurosci. 2018;12:866. Amieva H, Ouvrard C, Giulioli C, Meillon C, Rullier L, Dartigues JF. Self-reported hearing loss, hearing aids, and cognitive decline in elderly adults: a 25‐year study. J Am Geriatr Soc. 2015;63(10):2099–104. Sarant J, Harris D, Busby P, Maruff P, Schembri A, Lemke U, et al. The effect of hearing aid use on cognition in older adults: can we delay decline or even improve cognitive function? J Clin Med. 2020;9(1):254. Yeo BSY, Song HJJMD, Toh EMS, Ng LS, Ho CSH, Ho R, et al. Association of hearing aids and cochlear implants with cognitive decline and dementia: a systematic review and meta-analysis. JAMA Neurol. 2023;80(2):134–41. Bhatt JM, Bhattacharyya N, Lin HW. Relationships between tinnitus and the prevalence of anxiety and depression. Laryngoscope. 2017;127(2):466–69. Gu H, Kong W, Yin H, Zheng Y. Prevalence of sleep impairment in patients with tinnitus: a systematic review and single-arm meta-analysis. Eur Arch Otorhinolaryngol. 2021:1–11. Asplund R. Sleepiness and sleep in elderly persons with tinnitus. Arch Gerontol Geriatr. 2003;37(2):139–45. Weber FC, Schlee W, Langguth B, Schecklmann M, Schoisswohl S, Wetter TC, et al. Low sleep satisfaction is related to high disease burden in tinnitus. Int J Environ Res Public Health. 2022;19(17):11005. Holgers K-M, Erlandsson SI, Barrenäs M-L. Predictive factors for the severity of tinnitus: factores predictivos de la severidad del tinnitus. Audiology. 2000;39(5):284–91. Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol. 1996;17(2):236–40. Patil JD, Alrashid MA, Eltabbakh A, Fredericks S. The association between stress, emotional states, and tinnitus: a mini-review. Front Aging Neurosci. 2023;15:1131979. Phillips JS, McFerran D. Tinnitus retraining therapy (TRT) for tinnitus. Cochrane database of systematic reviews. 2010 (3). Schlee W, Weisz N, Bertrand O, Hartmann T, Elbert TJPO. Using auditory steady state responses to outline the functional connectivity in the tinnitus brain. 2008;3(11):e3720. Adjamian P, Sereda M, Hall DAJH. The mechanisms of tinnitus: perspectives from human functional neuroimaging. 2009;253(1–2):15–31. Eggermont JJ. The auditory cortex and tinnitus–a review of animal and human studies. Eur J Neurosci. 2015;41(5):665–76. Lin FR, Yaffe K, Xia J, Xue Q-L, Harris TB, Purchase-Helzner E, et al. Hearing loss and cognitive decline in older adults. JAMA Intern Med. 2013;173(4):293–99. Uchida Y, Sugiura S, Nishita Y, Saji N, Sone M, Ueda H. Age-related hearing loss and cognitive decline—The potential mechanisms linking the two. Auris Nasus Larynx. 2019;46(1):1–9. Butt WW, Wieland DR, Wang H, Lin C-H, Wang J-J, Weng C-H. Tinnitus and dementia risk: a nationwide population-based case-control study. J Laryngology Otology. 2024;138(12):1170–75. Rossiter S, Stevens C, Walker G. Tinnitus and its effect on working memory and attention. 2006. Chu H-T, Liang CS, Yeh T-C, Hu L-Y, Yang AC, Tsai S-J, et al. Tinnitus and risk of Alzheimer’s and Parkinson’s disease: a retrospective nationwide population-based cohort study. Sci Rep. 2020;10(1):12134. Waechter S, Wilson WJ, Brännström JK. The impact of tinnitus on working memory capacity. Int J Audiol. 2021;60(4):274–81. Julayanont P, Nasreddine ZS. Montreal Cognitive Assessment (MoCA): concept and clinical review. Cognitive screening instruments. Springer; 2017. pp. 139–95. Julayanont P, Phillips N, Chertkow H, Nasreddine ZS. Montreal Cognitive Assessment (MoCA): concept and clinical review. Cognitive screening instruments: A practical approach. 2013:111 – 51. Saunders JC. The role of central nervous system plasticity in tinnitus. J Commun Disord. 2007;40(4):313–34. Tables Table 1 Tinnitus characteristics and comparison of groups. Mild tinnitus group N = 66 Severe tinnitus group N = 78 U p Median [IQR] Median [IQR] Tinnitus duration (months) 24 [71] 39 [60] 2484.0 .718 Frequency (Hz) 6102 [1632] 7985 [4990] 1845.0 .061 Loudness (dB SL) 54 [ 21 ] 52 [ 32 ] 2034.0 .302 Minimal masking level (dB SL) 4 [ 3 ] 5 [ 4 ] 1818.0 .043 n (%) n (%) Residual inhibition Partial 6(9.1) 27 (34.6) 0.000* Complete 57 (86.4) 39 (50.0) No 3 (4.5) 12 (15.4) IQR:Interquartile Range; Mann-Whitney U Test between the mild and severe tinnitus groups; ns., statistically non-significant (p > 0.05); Data are presented as n (%); Fisher’s exact test was used to compare residual inhibition between the two groups; statistically significant (p < 0.05) Table 2 Test scores of mild and severe tinnitus groups. Mild tinnitus group (N = 66) Severe tinnitus group (N = 78) U p Median [IQR] Median [IQR] PTA right 25 [ 14 ] 27 [ 22 ] 2316.5 .301 PTA left 27 [ 20 ] 30 [ 25 ] 2261.0 .209 Better ear PTA 27 [ 14 ] 30 [ 25 ] 2028.5 .082 PSQI score 6 [ 3 ] 8 [ 7 ] 1606.5 .000* BDI score 5 [ 6 ] 15 [ 8 ] 346.5 .000* MoCA score 21 [ 4 ] 20[ 6 ] 2038.5 .031* THI 32 [ 16 ] 71[ 18 ] .000 .000* IQR:Interquartile Range; Mann-Whitney U Test between the mild and severe tinnitus groups; *, statistically significant (p < 0.05). PTA, pure tone average; THI, Tinnitus Handicap Inventory; PSQI, Pittsburgh Sleep Quality Index; MoCA, Montreal Cognitive Assessment Table 3 MoCA subtest scores of the groups. Mild tinnitus group (N = 66) Severe tinnitus group (N = 78) U p Median [IQR] Median [IQR] Visuospatial-executive functions (0–5) Trail making(0–1) 1.0 [.00] 1.0[.00] 2547.0 .873 Copy cube (0–1) 1.0[.00] 1.0 [.00] 2286.0 .074 Draw clock(0–3) 2.0[1.0] 2.0[1.0] 2141.0 .051 Naming (0–3) 2.0 [1) 2.0 [1) 2376.0 .359 Attention (0–6) Forward digit span(0–1) 1.0[.00] 1.0[.00] 2475.0 .109 Backward digit span(0–1) 1.0[.00] 1.0[.00] 2151.0 .028* Vigilance(0–1) 1.0[.00] 1.0[.00] 2556.0 .835 Serial subtraction(0–3) 2.0[1.0] 1.0[.00] 1390.5 .000* Language (0–3) Sentence repetition(0–2) 1.0[.00] 1.0[.00] 1957.5 . 000* Verbal fluency(0–1) 1.0[.00] 1.0[.00] 2511.0 .633 Abstraction (0–2) 1.0[.00] 1.0[.00] 2421.0 .246 Delayed Recall (0–5) 2.5 [1.0] 2.0[1.0] 1620.0 .000* Orientation (0–6) 6 [1.0] 6 [1.0] 2484.0 .647 MoCA-MIS (0–15) 9 [ 2 ] 6 [ 5 ] 1404.0 .000* MoCA-MIS, MoCA memory index score. Mann-Whitney U Test between the mild and severe tinnitus groups; *, statistically significant (p < 0.05). Table 4 Correlation matrix of variables. Variables THI Tinnitus duration PSQ BDI MoCA MoCA-MIS Better ear PTA THI Correlation coefficient 1 Sig. (2-tailed) Tinnitus duration Correlation coefficient ns. 1 Sig. (2-tailed) PSQ Correlation coefficient .303 ns 1 Sig. (2-tailed) .038* BDI Correlation coefficient .658 ns .399 1 Sig. (2-tailed) .00* .007* MoCA Correlation coefficient − .472 ns. ns. − .466 1 Sig. (2-tailed) .001* .001* MoCA-MIS Correlation coefficient − .376 ns. ns. − .307 .566 1 Sig. (2-tailed) .008* .040* .00* Better ear PTA Correlation coefficient ns. ns. ns. .361 − .315 ns. 1 .017* .033* THI: Tinnitus Handicap Inventory; PSQI: Pittsburgh Sleep Quality Index; MoCA: Montreal Cognitive Assessment; MoCA-MIS: MoCA memory index score; PTA: pure tone average; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 Apr, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers invited by journal 17 Mar, 2026 Editor assigned by journal 16 Mar, 2026 Editor invited by journal 23 Feb, 2026 Submission checks completed at journal 20 Feb, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8731512","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607846460,"identity":"b538a3dd-e645-47c2-b354-607029c7bf28","order_by":0,"name":"Gurbet İpek ŞAHİN KAMIŞLI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYHACNiCWYGDgYT4AYTAkEKMlAaSFLQGh5QBhLUCKh8cAKkBAi3xE7rMHH39Y5PHznPn84scfCwZ+9hwD5o97cGsxvJFubjgjQaJYsrd3m2UPjwSDZM8bA4YDz/BomZHGJs2TIJG44TzvNgMeCQkGgxs5QC14XAbW8geoZf95nmeGfwwkGOwJaZGXAGphANnC28P8GGgdg4EEAS0GPM/YDXvSJIolzhwzY5Y5IMEjceZZwYEz+GxpT2N78MOmLo+/J/nxxzd/6uT425M3PqjAZwtULgGI2UDxyAPi4dEAtKUBoYX5Az6Vo2AUjIJRMHIBACZwUBHlWuVgAAAAAElFTkSuQmCC","orcid":"","institution":"Gazi University","correspondingAuthor":true,"prefix":"","firstName":"Gurbet","middleName":"İpek ŞAHİN","lastName":"KAMIŞLI","suffix":""},{"id":607846461,"identity":"75104c92-f8ba-462c-bbd0-afb28011bc63","order_by":1,"name":"Songül AKSOY","email":"","orcid":"","institution":"Hacettepe University","correspondingAuthor":false,"prefix":"","firstName":"Songül","middleName":"","lastName":"AKSOY","suffix":""}],"badges":[],"createdAt":"2026-01-29 12:25:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8731512/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8731512/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105034956,"identity":"7e6317bc-5924-4ea5-b268-78a093726b8b","added_by":"auto","created_at":"2026-03-20 07:24:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":886569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8731512/v1/860d9b5d-b368-4850-b603-24aefed6cf5d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Tinnitus Severity on Cognitive, Emotional, and Sleep Outcomes in Older Adults with Controlled Age Related Hearing Loss","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHearing loss and tinnitus are among the most prevalent auditory complaints in older adults. Age-related hearing loss (ARHL), resulting from degenerative changes in the auditory system associated with ageing, is one of the three most common chronic health conditions affecting geriatric populations[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its prevalence increases markedly with age, affecting approximately 49% of adults aged 60\u0026ndash;69 years and more than 80% of individuals aged 85 years and older. ARHL is typically characterised as a bilateral, symmetrical, progressive sensorineural hearing loss that begins at high frequencies and gradually involves mid frequencies over time. Reduced hearing sensitivity and impaired speech perception\u0026mdash;particularly in noisy, reverberant, or multi-talker environments\u0026mdash;are the most frequently reported complaints[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAgeing is associated with degenerative changes not only in the peripheral auditory system but also in central auditory pathways and the central nervous system. These changes contribute to slowed central auditory processing, impaired sound localisation, and increased listening effort. Although ARHL is not life-threatening, untreated hearing loss significantly disrupts communication and social participation, leading to social isolation, frailty, emotional distress, and reduced quality of life. Moreover, ARHL has been associated with late-onset depression, cognitive decline, dementia, and increased medical morbidity[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to its health-related consequences, ARHL imposes a substantial economic burden on individuals, families, and healthcare systems. Direct medical costs and productivity losses related to hearing loss in adults aged 65 years and older were estimated at approximately USD 9.5\u0026nbsp;billion, with projections suggesting that annual costs may rise to nearly USD 60\u0026nbsp;billion by 2030 due to increased life expectancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, ARHL represents a major and growing public health concern. As a permanent and irreversible condition, ARHL cannot be cured; therefore, management strategies focus on improving audibility, communication effectiveness, daily functioning, and safety. Hearing aids and cochlear implants remain the most widely used rehabilitative interventions.\u003c/p\u003e \u003cp\u003eTinnitus refers to the perception of sound without the presence of an identifiable external acoustic stimulus and one of the most common auditory symptoms accompanying untreated hearing loss in older adults. While tinnitus affects approximately 15% of the general population, its prevalence rises to nearly 30% among older individuals[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With the progressive aging of the global population, age-related hearing impairment is becoming more prevalent, suggesting that tinnitus will represent an increasingly important health complaint in older individuals. Multiple risk factors for tinnitus have been described, encompassing otologic and audiologic conditions, as well as personal, socioeconomic, and medical factors. Hearing impairment is widely recognised as one of the primary risk factors for tinnitus. It has been reported that individuals with hearing loss are approximately twice as likely to have tinnitus compared to those with normal hearing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although the pathophysiology of tinnitus has not been fully elucidated, proposed mechanisms include central gain enhancement following peripheral auditory deprivation, maladaptive neuroplasticity, neural hyperactivity, and disrupted excitation\u0026ndash;inhibition balance within auditory and non-auditory neural networks [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Beyond peripheral and central mechanisms, the neurophysiological model proposed by Jastreboff highlights tinnitus as a condition involving complex interactions between the auditory system and limbic, autonomic, and cognitive networks[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Neuroimaging studies have demonstrated tinnitus-related neuroplastic changes in the limbic and paralimbic systems, prefrontal cortex, amygdala, hippocampus, thalamus, and auditory cortex, which may influence emotional regulation, attention, memory, and stress responses[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAgeing is also associated with increased vulnerability to mental health problems, particularly depression, which affects approximately 17\u0026ndash;20% of individuals over the age of 65[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].Depression could lead social isolation, increase suicidal risks, dementia[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and physical complaints and cognitive impairments in the older population. Late-life depression differs from depression in younger populations due to higher rates of medical comorbidity, cognitive impairment, and poorer prognosis[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Hearing loss has been consistently linked to depressive symptoms, primarily through communication difficulties and social withdrawal[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As hearing loss severity and tinnitus burden increase with age, the risk of depression appears to rise further[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies indicate that older adults with chronic or bothersome tinnitus are up to three times more likely to experience depressive symptoms compared to those without tinnitus[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNormal ageing is accompanied by gradual changes in cognitive functioning, influenced by factors such as education, lifestyle, and cultural background. Age-related cognitive decline typically affects processing speed, working memory, executive functions, and cognitive flexibility[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Accumulating evidence suggests that ARHL is associated with cognitive decline and may increase the risk of dementia, although longitudinal studies are required to clarify causality[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, bothersome tinnitus has been linked to impairments in working memory, attention control, and executive functioning[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Tinnitus-related reorganisation of neural networks connecting auditory and non-auditory brain regions may disrupt large-scale cognitive processing networks, potentially underlying difficulties in attention, memory, and concentration.\u003c/p\u003e \u003cp\u003eSleep disturbances are another common concern in older adults, affecting approximately 35\u0026ndash;52% of this population[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Age-related changes in sleep architecture include lighter sleep, increased nocturnal awakenings, shorter nighttime sleep duration, and increased daytime napping[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Tinnitus has been shown to negatively affect sleep quality, particularly by prolonging sleep onset latency and increasing nocturnal arousal[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Cohort data indicate that tinnitus is associated with poorer sleep quality even among individuals who report minimal subjective tinnitus-related distress [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies suggest that the impact of tinnitus on sleep quality, depression, anxiety, and cognitive functioning is more pronounced in older adults than in younger populations[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Older adults with tinnitus appear to be at increased risk for dementia, sleep problems, and affective disorders. Recent findings indicate that individuals over 60 years of age with tinnitus are more vulnerable to cognitive impairment compared to younger adults with tinnitus[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Meta-analytic evidence further supports associations between tinnitus and reduced executive function, processing speed, short-term memory, and cognitive flexibility [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, because hearing loss is highly prevalent in older adults, disentangling the independent effects of tinnitus from those of hearing loss remains challenging. The lack of longitudinal studies and the failure to adequately control for hearing thresholds contribute to ongoing controversy regarding the relationship between tinnitus and cognitive, psychological, and sleep-related outcomes in older populations.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to examine the associations between tinnitus severity, sleep quality, depressive symptoms, and cognitive functioning in older adults with age-related hearing loss. To isolate the specific effects of tinnitus severity, participants were selected to have comparable pure-tone hearing thresholds, thereby minimising the confounding influence of hearing loss on the examined outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eThis study aimed to investigate the impact of tinnitus severity on sleep quality, depressive symptoms, and cognitive functioning in older adults with hearing loss and tinnitus. Ethical approval was obtained from the Ethical Committee Gazi University (protocol number: E-77082166-604.01.02-782677; research code: 2023\u0026ndash;1256; approval date: 24 October 2023). Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from individuals who presented to the audiology clinic with complaints of hearing loss and/or tinnitus and voluntarily agreed to participate in the study. A total of 114 older adults with bilateral sensorineural hearing loss and subjective chronic tinnitus (duration \u0026ge; 6 months) were included. The sample consisted of 72 women (age range: 60\u0026ndash;82 years) and 42 men (age range: 60\u0026ndash;80 years)\u003c/p\u003e\n\u003cp\u003eInclusion criteria were as follows: literacy; native proficiency in Turkish; completion of at least primary school education; absence of current or previous neurological disorders, otologic diseases, or a history of ear surgery; no prior use of hearing aids; bilateral pure-tone average (PTA) thresholds between 500 and 4000 Hz of \u0026ge;16 dB HL; and sensorineural hearing loss with an air\u0026ndash;bone gap not exceeding 10 dB. Individuals with a PTA \u0026ge;56 dB HL were excluded to reduce the potential confounding effects of more severe hearing loss on cognitive performance. Cochlear implant users and hearing aid users were also excluded due to the potential beneficial effects of auditory amplification on cognitive outcomes. Additionally, individuals who had previously received tinnitus-specific therapies, used rehabilitative devices such as sound generators, or employed hearing aids for tinnitus management were excluded. Participants who were unable to complete the administered questionnaires and cognitive tests were also excluded from the final analysis.\u003c/p\u003e\n\u003cp\u003eData Collection\u003c/p\u003e\n\u003cp\u003eAll participants underwent otoscopic examination prior to audiological testing. Pure-tone audiometry was performed in a sound-treated booth using a GSI AudioStar PRO clinical audiometer (Grason-Stadler, Eden Prairie, MN, USA) with Telephonics TDH-39P headphones. Air-conduction thresholds were measured at octave and inter-octave frequencies between 125 and 8000 Hz. Bone-conduction thresholds were obtained between 500 and 4000 Hz using a RadioEar B-71 bone vibrator.\u003c/p\u003e\n\u003cp\u003eThe pure-tone average (PTA) was calculated as the mean of air-conduction thresholds at 500, 1000, 2000, and 4000 Hz. Participants with slight, mild, or moderate sensorineural hearing loss were included in the study. The PTA of the better-hearing ear was determined and used for correlation analyses.\u003c/p\u003e\n\u003cp\u003eTinnitus evaluation: Tinnitus severity was assessed using the Turkish version of the Tinnitus Handicap Inventory (THI)[27]. The THI consists of 25 items evaluating the impact of tinnitus on quality of life across functional, emotional, and catastrophic subscales, providing an overall measure of tinnitus level and severity and[28]. Each item is scored as \u0026ldquo;yes\u0026rdquo; (4 points), \u0026ldquo;sometimes\u0026rdquo; (2 points), or \u0026ldquo;no\u0026rdquo; (0 points), yielding a total score ranging from 0 to 100, with higher scores indicating greater tinnitus severity. THI score categories were defined as follows: 0\u0026ndash;16 (Level 1), 18\u0026ndash;36 (Level 2), 38\u0026ndash;56 (Level 3), 58\u0026ndash;76 (Level 4), and 78\u0026ndash;100 (Level 5). Only participants with THI scores of 18 or higher (Level 2 and above) were included in the study. Based on THI scores, participants were divided into two groups: those with Level 2 tinnitus were classified as the mild tinnitus group (MTG), while individuals with Level 3 or higher were classified as the severe tinnitus group (STG).\u003c/p\u003e\n\u003cp\u003ePsychoacoustic tinnitus measures included tinnitus pitch matching, tinnitus loudness matching, minimum masking level (MML), and residual inhibition (RI).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvaluation of Sleep Quality. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) [29]. The PSQI comprises 24 items evaluating seven domains: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Nineteen items are self-rated by the participant, while five items are completed by a bed partner or roommate. Domain scores are summed to yield a global PSQI score ranging from 0 to 21. A global score of \u0026lt;5 indicates good sleep quality, whereas a score of \u0026ge;5 indicates poor sleep quality.\u003c/p\u003e\n\u003cp\u003eAssessment of Depression Symptoms: Depressive symptoms were evaluated using the Beck Depression Inventory (BDI)[30]. The BDI is a 21-item self-report questionnaire, with each item scored from 0 to 3. Total scores \u0026le;11 are considered within the normal range, while scores \u0026gt;11 indicate increasing levels of depressive symptom severity, classified as minimal, mild, moderate, severe, or extreme depression[31].\u003c/p\u003e\n\u003cp\u003eCognitive assessment: The original Montreal Cognitive Assessment (MoCA)[32] in paper format (MoCA Full) Turkish version was applied for cognitive assessment. The test was administered by the certified author and written permission to use the MoCA was obtained from MoCA Test Inc., a Quebec-based company. The MoCA consists of 12 tasks assessing multiple cognitive domains, including visuospatial\u0026ndash;executive functions, naming, attention, language, abstraction, delayed recall, orientation, and memory. The administration time is approximately 10\u0026ndash;15 minutes, with a maximum possible score of 30 points, where higher scores indicate better cognitive performance.\u003c/p\u003e\n\u003cp\u003eIn clinical practice, a cut-off score of 26 is commonly used to differentiate mild cognitive impairment from normal cognition; however, for the Turkish population, a cut-off value of 21 is recommended[33]. Participants with 12 years of education or fewer received one additional point to adjust for educational level. The MoCA Memory Index Score (MoCA-MIS) was also calculated to provide a more sensitive measure of memory encoding and retrieval. The MoCA-MIS is derived by weighting free delayed recall, category-cued recall, and multiple-choice recall responses by three, two, and one points, respectively, yielding a total score ranging from 0 to 15[34].\u003c/p\u003e\n\u003cp\u003eThe relationships between tinnitus severity and sleep quality, depressive symptoms, and cognitive functioning were analysed, as well as differences between tinnitus severity groups.\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe IBM SPSS v.24 software, New York, ABD, was used to analyse the study data. Normality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. As the data were not normally distributed, comparisons between two independent groups were performed using the Mann\u0026ndash;Whitney U test. Continuous variables were presented as median and interquartile range (IQR). Categorical variables were analysed using the chi-square test. Effect sizes were calculated where appropriate, and a p value \u0026lt; .05 was considered statistically significant. Correlations between MoCA, THI, BDI, PSQI test scores and tinnitus duration were tested with Spearman\u0026rsquo;s correlation analysis.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 144 older adults with a median age of 65 years (IQR: 7) participated in the study. Participants with a THI score of level 2 were defined as MTG, and with a THI score of level 3 and above were defined as STG. \u0026nbsp;The MTG comprised 66 older adults (36 males, 30 females), and the STG comprised 78 older adults (36 males, 42 females). The median age of the MTG was 65 years (IQR:5) and 65 (IQR:7) for the STG. There was no statistically significant difference in age between groups (Mann-Whitney U=2569.5, p\u0026gt;.986). Of 66 participants, 25 had an elementary, 29 had a high school, and 12 Bachelor\u0026rsquo;s degree in the MTG. Of 78 participants in the STG, 30 had an elementary degree, 33 had high school, and 15 had a Bachelor\u0026rsquo;s degree. The Chi-square test was used to compare the educational status between groups, and the test revealed that there were no statistically significant differences (\u0026chi;\u0026sup2;(2, N = 114) = 0.882, p = .658).\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between MTG (Median=24, IQR=71) and STG (Median=39, IQR=60) tinnitus duration (Mann-Whitney U= 2484.0 p=.718) in tinnitus duration. Tinnitus psychoacoustic properties are given in Table 1. There were no significant differences between the groups in terms of tinnitus frequency, tinnitus loudness, or minimal masking level (Mann\u0026ndash;Whitney U test, all p \u0026gt; .05). Residual inhibition distributions differed significantly between the groups (Fisher\u0026rsquo;s exact test, p = .000). Tinnitus site was on the right in 9 (13%), on the left in 36 (54%), bilaterally or in the head in 21 (31%) in the MTG. In the STG, 9 (11%) were on the right, 30 (38%) on the left and 39 (50%) bilaterally or in the head.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs shown in Table 2, comparisons between the mild and severe tinnitus groups were performed using the Mann\u0026ndash;Whitney U test. No statistically significant differences were observed between groups in right ear pure-tone average (PTA), left ear PTA, or better-ear PTA (all p \u0026gt; .05). In contrast, the severe tinnitus group demonstrated significantly higher scores on the Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI) compared with the mild tinnitus group (both p \u0026lt; .001), indicating poorer sleep quality and more severe depressive symptoms. Additionally, Montreal Cognitive Assessment (MoCA) scores were significantly lower in the severe tinnitus group than in the mild tinnitus group (U = 2038.5, p = .031), suggesting reduced cognitive performance associated with greater tinnitus severity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUsing the Mann\u0026ndash;Whitney U test, MoCA subtest scores were compared between the mild and severe tinnitus groups (Table 3). No statistically significant differences were found between the groups in visuospatial\u0026ndash;executive functions (trail making, cube copying, and clock drawing), naming, vigilance, verbal fluency, abstraction, or orientation subtests (all p \u0026gt; .05). Within the attention domain, the severe tinnitus group showed significantly lower performance on the backward digit span (U = 2151.0, p = .028) and serial subtraction tasks (U = 1390.5, p \u0026lt; .001), whereas no significant group differences were observed for forward digit span or vigilance (p \u0026gt; .05). In the language domain, sentence repetition scores were significantly lower in the severe tinnitus group (U = 1957.5, p \u0026lt; .001), while verbal fluency scores did not differ significantly between groups (p = .633).\u003c/p\u003e\n\u003cp\u003eFurthermore, the severe tinnitus group demonstrated significantly poorer performance on the delayed recall subtest (U = 1620.0, p \u0026lt; .001) and had significantly lower MoCA Memory Index Scores (MoCA-MIS) compared with the mild tinnitus group (U = 1404.0, p \u0026lt; .001). These results indicate that increased tinnitus severity is associated with impairments primarily in attention, sentence repetition, and memory-related cognitive domains.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs shown in Table 4, Spearman\u0026rsquo;s rank correlation analysis was used to examine the associations between Tinnitus Handicap Inventory (THI) scores and the other variables. THI scores were moderately and positively correlated with Pittsburgh Sleep Quality Index (PSQI) scores (r = .303, p = .038), indicating that greater tinnitus-related handicap was associated with poorer sleep quality. A strong positive correlation was observed between THI and Beck Depression Inventory (BDI) scores (r = .658, p \u0026lt; .001), suggesting that higher tinnitus severity was closely related to increased depressive symptoms. In contrast, THI scores demonstrated significant moderate negative correlations with cognitive measures, including the Montreal Cognitive Assessment (MoCA) (r = \u0026minus;.472, p = .001) and the MoCA Memory Index Score (MoCA-MIS) (r = \u0026minus;.376, p = .008), indicating that greater tinnitus-related handicap was associated with poorer global cognitive performance and memory function. No significant correlations were found between THI scores and tinnitus duration or better-ear pure tone average (PTA) (all p \u0026gt; .05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTinnitus and ARHL are among the most common reasons for visits to otolaryngology clinics in the elderly population [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Previous studies have shown that older adults with bothersome tinnitus experience higher levels of depression and anxiety and poorer sleep quality [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Longitudinal studies, as well as a systematic review and meta-analysis, have demonstrated that hearing loss contributes to cognitive decline, whereas the use of hearing aids may attenuate this effect[\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. For this reason, individuals with moderate-to-severe hearing loss and hearing aid users were excluded from the present study, allowing us to specifically evaluate the effect of tinnitus severity. In addition, no statistically significant differences were observed between the groups in terms of tinnitus characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the present study, the median THI score was 32 in the MTG and 71 in the STG. The absence of significant differences between groups with respect to PTA, age, and educational status enabled a focused examination of the independent effect of tinnitus severity on cognitive performance, anxiety, sleep quality, and depressive symptoms.\u003c/p\u003e \u003cp\u003eRegarding sleep quality, a statistically significant difference was observed between the two groups. The median PSQI score was higher in the STG. In addition, a significant positive correlation was found between THI and PSQI scores (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), indicating that deterioration in sleep quality increased with higher tinnitus severity. Previous studies have shown that individuals with tinnitus exhibit shorter mean nocturnal sleep duration and alterations in sleep architecture, particularly in rapid eye movement (REM) sleep. Furthermore, older adults generally experience poorer sleep quality, more frequent nocturnal awakenings, and increased daytime sleepiness, which may further exacerbate the negative impact of tinnitus on sleep[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In a cross-sectional study of middle-aged and older adults, Oosterloo et al. (2021) reported that tinnitus was associated with sleep disturbances even among individuals who stated that it did not interfere with their daily lives, and that these sleep-related complaints increased with greater tinnitus severity[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The degree of sleep disturbance is highly correlated with the tinnitus severity[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In this study, consistent with the existing literature, the STG demonstrated significantly poorer sleep quality. However, the finding that both groups were classified as having poor sleep quality suggests that even mild tinnitus may adversely affect sleep. Moreover, increasing tinnitus severity appears to exacerbate the degree of sleep impairment. As tinnitus severity increases, the percept becomes more difficult to ignore and less amenable to masking, which in turn disrupts sleep quality and sleep efficiency. This effect may be particularly pronounced in older adults, who already tend to experience lighter and shorter sleep durations.\u003c/p\u003e \u003cp\u003eThis study demonstrated a significant difference in BDI scores between the MTG and the STG, as well as a significant correlation between BDI and THI scores (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Previous studies have reported a higher lifetime and current prevalence of major depression in individuals with tinnitus compared with non-tinnitus control groups, higher depression and anxiety scores in individuals with chronic tinnitus, and a positive association between the severity of anxiety and depression and tinnitus severity[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Holgers et al. identified depression as an important predictor of tinnitus severity, with greater tinnitus severity being associated with more pronounced negative effects on daily life [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In chronic tinnitus, increased emotional reactivity and heightened activity within the limbic and autonomic nervous systems are thought to arise from the engagement of non-classical auditory pathways. As tinnitus severity increases, levels of stress, anxiety, and hopelessness also rise, forming a vicious cycle that exacerbates and perpetuates tinnitus perception[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. These emotional responses and maladaptive associations contribute to the amplification and persistence of tinnitus over time. Chronic tinnitus increasingly becomes linked with anxiety and depressive symptoms. Stress-induced alterations in synaptic plasticity and cortisol release may further influence limbic system functioning[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] ,leading to neuroplastic changes and the formation of pathways distinct from classical auditory neural circuits[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The involvement of non-classical auditory pathways has been demonstrated in both animal models and human neuroimaging studies[\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Moreover, widespread alterations within the central nervous system\u0026mdash;including changes in neural networks, synaptic plasticity, and brain morphology\u0026mdash;may affect emotional processing and contribute to the development of depression and other psychiatric disorders.\u003c/p\u003e \u003cp\u003eA substantial body of evidence has demonstrated a significant association between ARHL and cognitive decline, with ARHL reported to accelerate cognitive deterioration and increase the incidence of cognitive impairment[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. However, the extent to which tinnitus severity affects cognitive function in older adults, independent of hearing loss, remains controversial. In a large population-based study including approximately 15,000 participants, Butt et al. reported that tinnitus was associated with a 168% increased risk of dementia; however, the impact of tinnitus severity was not examined[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In the present study, a carefully selected sample was used to evaluate the effect of tinnitus severity on cognitive abilities, as the groups did not differ significantly in terms of age, educational level, hearing sensitivity, or hearing aid use. A statistically significant difference was observed between groups in total MoCA scores, with the STG scoring slightly below the cut-off value of \u0026ge;\u0026thinsp;21 points considered normal for the Turkish population, whereas the MTG exceeded this threshold. Correlation analysis further demonstrated a significant negative association between MoCA and THI scores. Subtest analyses of the MoCA revealed no significant group differences in visuospatial\u0026ndash;executive function, naming, abstraction, or orientation. In contrast, the STG showed significantly poorer performance on the recall subtest, the MoCA Memory Index Score (MoCA-MIS), sentence repetition in the language domain, and serial 7 subtraction in the attention domain (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These findings are consistent with previous studies reporting an association between tinnitus and deficits in working memory[\u003cspan additionalcitationids=\"CR55\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The serial 7 subtraction task is known to engage prefrontal cortex activity and is closely related to working memory processes. In the memory domain, participants performed relatively well on immediate recall, in which five words were repeated at 1-second intervals; however, substantial difficulty was observed during delayed recall approximately five minutes later. The mean delayed free recall score across participants was 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 words, which is notably lower than the 3.73 words reported by Julayanont et al. in a cognitively normal control group [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. This pattern suggests that individuals with tinnitus retain relatively preserved short-term memory but exhibit impairments in delayed recall. Such retrieval memory deficits are often associated with dysfunction in subcortical structures. Notably, recall impairment was more pronounced in the STG than in the MTG, indicating that recall performance deteriorates with increasing tinnitus severity.\u003c/p\u003e \u003cp\u003eThe observed recall deficits in tinnitus may be attributable to difficulties in attentional allocation, divided attention, and the suppression of irrelevant information, rather than to primary sensory processing deficits. The MoCA-MIS, which specifically assesses delayed verbal recall, has been proposed as a sensitive indicator of early central neural changes observed in the initial pathophysiological stages of mild cognitive impairment[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Consistent with this, our findings demonstrated a significant negative correlation between THI and MoCA-MIS scores (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Furthermore, the category and multiple-choice cueing components of the MoCA-MIS provide valuable information for distinguishing retrieval memory impairment\u0026mdash;which improves with cueing\u0026mdash;from encoding memory impairment, which does not[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. In the present study, cueing failed to improve retrieval performance in the STG to the same extent as in the MTG. Although no group differences were observed in other language subtests, the STG exhibited significantly poorer performance on the sentence repetition task. Unlike other language measures, sentence repetition requires sustained attention and concentration to temporarily store and reproduce verbal information, processes that rely heavily on working memory support[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings showed that higher tinnitus severity impairs memory and recall skills more. The psychological effects and emotional distress of tinnitus, which can worsen cognitive symptoms, could be one of the causes of the impairment in these abilities. The inability to ignore the constantly perceived sound directly disrupts cognitive processes. It has been suggested that the sound perceived as tinnitus noise may limit the capacity of the central system, and that paying attention to the tinnitus sound could impair the execution of automatic response sequences. In chronic tinnitus, the constant activation of the tinnitus-related thoughts and reactions in the brain negatively affects tasks that require inhibition of irrelevant ones, such as tasks requiring concentration and attention\u003csup\u003e[59]\u003c/sup\u003e. The fact that the memory and recall skills of the STG were worse in this study could indicate that this difficulty in inhibition may increase even more at high tinnitus levels.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the MoCA is a screening instrument and is not intended for the formal diagnosis of cognitive impairment. Future studies may strengthen the evidence by examining the impact of tinnitus severity on cognitive function\u0026mdash;particularly working memory and recall\u0026mdash;using more comprehensive and sensitive neuropsychological assessments. Second, the relatively small sample size limits the generalizability of the findings; however, recruiting older adults with tinnitus who have not previously used hearing devices or undergone tinnitus-related therapy and who do not present with advanced hearing loss is inherently challenging. Third, sleep quality was assessed using a self-reported measure, which may be subject to reporting bias. Future research incorporating objective sleep assessments could provide more robust evidence regarding the relationship between tinnitus severity and sleep. In addition, group differences in sleep quality and depressive symptoms may have acted as confounding factors when evaluating the effect of tinnitus on cognitive performance.\u003c/p\u003e \u003cp\u003eAlthough the pathophysiology of tinnitus remains incompletely understood and no definitive cure exists, various therapeutic approaches aim to reduce symptom burden and improve quality of life. Prior to treatment planning, comprehensive assessment of mental and emotional domains\u0026mdash;such as sleep quality, depressive and anxiety symptoms, and cognitive functioning\u0026mdash;may enhance treatment outcomes. The present findings indicate that sleep disturbances, mood symptoms, and impairments in memory and concentration are more prevalent in individuals with greater tinnitus severity. These domains should therefore be routinely assessed and monitored in patients with bothersome tinnitus, and referral to appropriate specialists should be considered when necessary. Addressing these symptoms alongside tinnitus-focused interventions may help mitigate symptom severity and reduce the overall negative impact of tinnitus on quality of life.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrates that increasing tinnitus severity is associated with poorer sleep quality, greater depressive symptoms, and impaired cognitive performance\u0026mdash;particularly in working memory and delayed recall\u0026mdash;in older adults. Although age-related hearing loss is a well-established contributor to cognitive decline, the present findings indicate that tinnitus severity alone can negatively affect cognitive and emotional functioning when hearing loss is controlled.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, these results highlight the importance of routinely assessing sleep quality, depressive symptoms, and cognitive functioning in older adults with tinnitus, even in the absence of significant hearing loss. Early identification and targeted management of tinnitus severity may help mitigate its adverse effects on mental health and cognitive outcomes, thereby improving overall quality of life in the aging population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed consent:\u0026nbsp;\u003c/strong\u003eEthics committee approval was obtained from the Gazi University\u0026apos;s Ethical Commission with the protocol number E-77082166-604.01.02-782677 and research code 2023 \u0026ndash; 1256 (date:24.10.2023). The informed consent form was signed by each participant in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflıct Of Interest Statement:\u003c/strong\u003e The authors declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources:\u003c/strong\u003e This study was not supported by any sponsor or funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data supporting this study\u0026apos;s findings are not publicly available because they contain information that could compromise the privacy of research participants. The data are available at reasonable request from the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all individual participants included in the study. This study has been approved by the Ethics Committee of Gazi University with the decision number E-77082166-604.01.02-782677 and research code number 2023 \u0026ndash; 1256 and performed in line with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003econsept and idea: equal Song\u0026uuml;l AKSOY and Gurbet İpek ŞAHİN KAMIŞLIdata collection and processing: Gurbet İpek ŞAHİN KAMIŞLIanalysing and interpretation: lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Song\u0026uuml;l AKSOYLiterature review : lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Song\u0026uuml;l AKSOYwriting the article:lead Gurbet İpek ŞAHİN KAMIŞLI, supporting Song\u0026uuml;l AKSOYcritical review: equal Song\u0026uuml;l AKSOY and Gurbet İpek ŞAHİN KAMIŞLI\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcKee MM, Stransky ML, Reichard A. 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Cochrane database of systematic reviews. 2010 (3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchlee W, Weisz N, Bertrand O, Hartmann T, Elbert TJPO. Using auditory steady state responses to outline the functional connectivity in the tinnitus brain. 2008;3(11):e3720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjamian P, Sereda M, Hall DAJH. The mechanisms of tinnitus: perspectives from human functional neuroimaging. 2009;253(1\u0026ndash;2):15\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEggermont JJ. The auditory cortex and tinnitus\u0026ndash;a review of animal and human studies. Eur J Neurosci. 2015;41(5):665\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin FR, Yaffe K, Xia J, Xue Q-L, Harris TB, Purchase-Helzner E, et al. Hearing loss and cognitive decline in older adults. 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Sci Rep. 2020;10(1):12134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaechter S, Wilson WJ, Br\u0026auml;nnstr\u0026ouml;m JK. The impact of tinnitus on working memory capacity. Int J Audiol. 2021;60(4):274\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJulayanont P, Nasreddine ZS. Montreal Cognitive Assessment (MoCA): concept and clinical review. Cognitive screening instruments. Springer; 2017. pp. 139\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJulayanont P, Phillips N, Chertkow H, Nasreddine ZS. Montreal Cognitive Assessment (MoCA): concept and clinical review. Cognitive screening instruments: A practical approach. 2013:111\u0026thinsp;\u0026ndash;\u0026thinsp;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders JC. The role of central nervous system plasticity in tinnitus. J Commun Disord. 2007;40(4):313\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTinnitus characteristics and comparison of groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMild tinnitus group\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSevere tinnitus group\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;78\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTinnitus duration\u003c/strong\u003e (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 [71]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e39 [60]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2484.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.718\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (Hz)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6102 [1632]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7985 [4990]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1845.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoudness (dB SL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e52 [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2034.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.302\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimal masking level (dB SL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5 [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1818.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidual inhibition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e39 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e12 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eIQR:Interquartile Range; Mann-Whitney U Test between the mild and severe tinnitus groups; ns., statistically non-significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05); Data are presented as n (%); Fisher\u0026rsquo;s exact test was used to compare residual inhibition between the two groups; statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTest scores of mild and severe tinnitus groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild tinnitus group (N\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSevere tinnitus group\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePTA right\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2316.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePTA left\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2261.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBetter ear PTA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2028.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.082\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSQI score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1606.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e346.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoCA score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2038.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.031*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTHI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eIQR:Interquartile Range; Mann-Whitney U Test between the mild and severe tinnitus groups; *, statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). PTA, pure tone average; THI, Tinnitus Handicap Inventory; PSQI, Pittsburgh Sleep Quality Index; MoCA, Montreal Cognitive Assessment\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMoCA subtest scores of the groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild tinnitus group (N\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSevere tinnitus group\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian [IQR]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eVisuospatial-executive functions (0\u0026ndash;5)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrail making(0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 [.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2547.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCopy cube (0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 [.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2286.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDraw clock(0\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0[1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0[1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2141.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNaming (0\u0026ndash;3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0 [1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0 [1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2376.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttention (0\u0026ndash;6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eForward digit span(0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2475.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBackward digit span(0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2151.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.028*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVigilance(0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2556.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.835\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSerial subtraction(0\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0[1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1390.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguage (0\u0026ndash;3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSentence repetition(0\u0026ndash;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1957.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003cstrong\u003e000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVerbal fluency(0\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2511.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.633\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbstraction (0\u0026ndash;2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0[.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2421.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed Recall (0\u0026ndash;5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0[1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1620.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrientation (0\u0026ndash;6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2484.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoCA-MIS (0\u0026ndash;15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1404.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eMoCA-MIS, MoCA memory index score. Mann-Whitney U Test between the mild and severe tinnitus groups; *, statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorrelation matrix of variables.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTHI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTinnitus duration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePSQ\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBDI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMoCA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMoCA-MIS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBetter ear PTA\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eTHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eTinnitus duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003ePSQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.038*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eBDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.658\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.00*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eMoCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eMoCA-MIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.566\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.040*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.00*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eBetter ear PTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003ens.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.033*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\"\u003eTHI: Tinnitus Handicap Inventory; PSQI: Pittsburgh Sleep Quality Index; MoCA: Montreal Cognitive Assessment; MoCA-MIS: MoCA memory index score; PTA: pure tone average;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"tinnitus severity, cognition, hearing loss, sleep quality","lastPublishedDoi":"10.21203/rs.3.rs-8731512/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8731512/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTinnitus is associated with sleep disturbances, cognitive impairment, and mental health problems. This study examined sleep quality, depressive symptoms, and cognitive functioning in older adults with mild and severe tinnitus, controlling for hearing loss and excluding individuals who used hearing aids or received tinnitus therapy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 144 older adults (median age: 65 years) participated in the study. Hearing thresholds were assessed, and the Tinnitus Handicap Inventory(THI), Beck Depression Inventory(BDI), Pittsburgh Sleep Quality Index(PSQI), and Montreal Cognitive Assessment(MoCA) were administered. Based on THI scores, participants were classified into mild tinnitus(level 2) and severe tinnitus(level\u0026thinsp;\u0026ge;\u0026thinsp;3) groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was a difference between the groups in BDI and PSQI, MoCA scores and Memory Index Score(MIS) and Recall subtests. There was a medium correlation between THI and BDI(r= .658;p=.001), PSQI score(r=.303;p= .038), MoCA(r=-.472;p=.001), and MoCA-MIS(r=-.376;p=.008).This study revealed that increasing tinnitus level in older adults increases problems in sleep, depression, memory and recall.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIncreasing tinnitus severity is associated with poorer sleep quality, greater depressive symptoms, and impaired cognitive performance\u0026mdash;particularly working memory and delayed recall\u0026mdash;in older adults. When hearing loss is controlled, tinnitus severity alone appears to negatively affect cognitive and emotional functioning, underscoring the need to consider tinnitus as an independent risk factor in the aging population.\u003c/p\u003e","manuscriptTitle":"Effects of Tinnitus Severity on Cognitive, Emotional, and Sleep Outcomes in Older Adults with Controlled Age Related Hearing Loss","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 13:26:57","doi":"10.21203/rs.3.rs-8731512/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-10T08:43:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318929817654151883776115803767307432082","date":"2026-03-31T14:51:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T11:16:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T08:49:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T11:40:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-20T07:40:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-02-20T07:34:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ca74fdd-9ffd-48d3-832b-71295b334942","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T13:26:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 13:26:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8731512","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8731512","identity":"rs-8731512","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}