Nursing and Elderly Diseases
samvera
HearingImpairmentfrombook.docxHearing Impairment
Hearing loss is the third most prevalent chronic condition and the foremost communicative disorder of older adults in the United States. Hearing loss is an underrecognized public health issue. Among adults between the ages of 60 and 69 years of age, 31% have bilateral hearing loss of at least mild severity. In those older than 70 years of age, the prevalence is 63%, and in those older than age 85, the prevalence is 80%. In all age groups, men are more likely than women to be hearing impaired, and black Americans have a lower prevalence of hearing impairment than either white or Hispanic Americans (Bainbridge & Wallhagen, 2014).
Age-related hearing impairment is a complex disease caused by interactions between age-related changes (see Chapter 3), genetics, lifestyle, and environmental factors.
Factors associated with hearing loss include noise exposure, ear infections, smoking, and chronic disease (e.g., diabetes, chronic kidney disease, heart disease) (Bainbridge & Wallhagen, 2014).
Hearing loss may not be an inevitable part of aging, and increased attention is being given to the links between lifestyle factors (e.g., smoking, poor nutrition, hypertension) and hearing impairment (Heine et al., 2013) (Box 19.5).
Box 19.5. Promoting Healthy Hearing
• Avoid exposure to excessively loud noises.
• Avoid cigarette smoking.
• Maintain blood pressure/cholesterol levels within normal limits.
• Eat a healthy diet.
• Have hearing evaluated if any changes are noticed.
• Avoid injury with cotton-tipped applicators and other cleaning materials.
Consequences of Hearing Impairment
The broad consequences of hearing loss have functional and clinical significance and should not be viewed as something a person accepts as part of aging. Hearing loss diminishes quality of life and is associated with multiple negative outcomes, including decreased function, increased likelihood of hospitalizations, miscommunication, depression, falls, loss of self-esteem, safety risks, and cognitive decline (Bainbridge & Wallhagen, 2014; Lin et al., 2013). Growing evidence supports an association between age-related hearing loss and cognitive decline and dementia (Bainbridge & Wallhagen, 2014; Lin, 2012; Lin et al., 2013).
Hearing impairment increases feelings of isolation and may cause older adults to become suspicious or distrustful or to display feelings of paranoia. Because older persons with hearing loss may not understand or respond appropriately to conversation, they may be inappropriately diagnosed with dementia. All of these consequences of hearing impairment further increase social isolation and decrease opportunities for meaningful interaction and stimulation.
Types of Hearing Loss
The two major forms of hearing loss are conductive and sensorineural.
1. Sensorineural hearing loss results from damage to any part of the inner ear or the neural pathways to the brain. Presbycusis (also called age-related hearing impairment or ARHI) is a form of sensorineural hearing loss that is related to aging and is the most common form of hearing loss. Presbycusis progressively worsens with age and is usually permanent. The cochlea appears to be the site of pathogenesis, but the precise cause of presbycusis is uncertain (Lewis, 2014).
Noise-induced hearing loss (NIHL) is the second most common cause of sensorineural hearing loss among older adults. Direct mechanical injury to the sensory hair cells of the cochlea causes NIHL, and continuous noise exposure contributes to damage more than intermittent exposure (Lewis, 2014). NIHL is permanent but considered largely preventable.
The rate of hearing impairment is expected to rise because of the growing number of older adults and also because of the increased number of military personnel who have been exposed to blast exposure in combat situations. Noise-induced hearing loss may be reduced through the development of better ear-protection devices, education about exposure to loud noise, and emerging research into interventions that may protect or repair hair cells in the ear, which are essential to the 259body's ability to hear (National Institute on Deafness and Other Communication Disorders [NIDCD], 2014).
2. Conductive hearing loss usually involves abnormalities of the external and middle ear that reduce the ability of sound to be transmitted to the middle ear.
Otosclerosis, infection, perforated eardrum, fluid in the middle ear, tumors, or cerumen accumulations cause conductive hearing loss.
Cerumen impaction is the most common and easily corrected of all interferences in the hearing of older people (Fig. 19.4). Individuals at particular risk of impaction are African Americans, individuals who wear hearing aids, and older men with large amounts of ear canal tragi (hairs in the ear) that tend to become entangled with the cerumen. When hearing loss is suspected, or a person with existing hearing loss experiences increasing difficulty, it is important first to check for cerumen impaction as a possible cause. After accurate assessment, if cerumen removal is indicated, it may be removed through irrigation, cerumenolytic products, or manual extraction.
Interventions to Enhance Hearing
Hearing Aids
A hearing aid is a personal amplifying system that includes a microphone, an amplifier, and a loudspeaker. There are numerous types of hearing aids with either analog or digital circuitry. The size, appearance, and effectiveness of hearing aids have greatly improved (decreasing stigma), and many can be programmed to meet specific needs. Digital hearing aids are smaller and have better sound quality and noise reduction, as well as less acoustic feedback; however, they are expensive. The behind-the-ear hearing aid looks like a shrimp and fits around and behind the ear; a small tube sits in the canal to direct the amplified sound. It is less commonly used now than the small, in-the-ear aid, which fits in the concha of the ear. Completely-in-the-canal (CIC) hearing aids fit entirely in the ear canal. These types of devices are among the most expensive and require good dexterity. Some models are invisible and placed deep in the ear canal and replaced every 4 months. New hearing aids can be adjusted precisely for noisy environments and telephone usage through software built into smartphones.
Most individuals can obtain some hearing enhancement with a hearing aid. The kind of device chosen depends on the type of hearing impairment and the cost, but most users will experience hearing improvement with a basic to midlevel hearing aid. The investment in a good hearing aid is considerable, and a good fit is critical. Hearing aids can range in price from about $500 to several thousand dollars per aid, depending on the technology. The cost of hearing aids is usually not covered by health insurance or Medicare, which can be a barrier to purchase.
Adjustment to Hearing Aids
Nearly 50% of people who purchased hearing aids either never wore them or stopped wearing them after a short period. Factors contributing to low hearing aid use after purchase include difficulty manipulating the device, annoying loud noises, being exposed to sensory overload, developing headaches, and perceiving stigma. Hearing aids amplify all sounds, making things sound different. People often delay acquiring hearing aids because the loss occurs gradually and they often ignore or deny the loss. Individuals wait on average 7 to 10 years between signs of hearing loss and audiological consultation (Lewis, 2014). This delay makes adjustment to the device even more challenging (Lane & Conn, 2013).
Age-related hearing loss (ARHL) is like any other physical impairment and requires counseling, rehabilitative training, environmental accommodations, and patience. Audiology centers, often attached to hospitals, medical centers, and universities, are excellent places for aural rehabilitation programs but costs are usually not covered by Medicare. The Internet may be a valuable tool for aural rehabilitation, as well as for improving adjustment to hearing aids and communication (Lewis, 2014).
It is important for nurses who work with individuals wearing hearing aids to be knowledgeable about the care and maintenance. They can teach the individual, family, or formal caregiver proper use and care of hearing aids (Box 19.6). Many older people experience unnecessary 260communication problems when in the hospital or nursing home because their hearing aids are not inserted and working properly, or they are lost.
Box 19.6 Tips for Best Practice
Hearing Aid Care and Use
• When a hearing aid is first purchased: Initially it is advisable to wear for 15 to 20 minutes per day until the person is adjusted to the new sounds.
• Gradually increase the wearing time to 10 to 12 hours.
• Be patient and realize that the process of adaptation is difficult but ultimately will be rewarding.
• Make sure your fingers are dry and clean before handling hearing aids. Use a soft dry cloth to wipe your hearing aids.
• Each day remove any earwax that has accumulated on the hearing aids. Use the brush that is included with the aid to clean difficult-to-reach areas.
• You will be instructed how to best insert the model you purchase.
• If it is not pre-programmed, adjust the volume to a level that is comfortable for you. You may be able to adjust the volume for different environments, depending on the model.
• Use great caution to avoid getting the aid wet; do not wear when swimming or taking a shower or bath.
• Also avoid use when around fine particles that can clog the microphone such as hair spray, make-up, or blowing sand and dirt.
• Many aids will slowly decrease in volume and may make a “peep” when it is time to change the battery. Check the battery by turning the hearing aid on, turning up the volume, cupping your hand over the ear mold, and listening. A constant whistling sound indicates that the battery is functioning. A weak sound indicates that the battery is losing power and needs replacement.
• Be sure to remove the battery and return the aid to its case when not in use. This will extend the life of the battery and protect the aid.
Cochlear Implants
Cochlear implants are increasingly being used for older adults with sensorineural loss who are not able to gain effective speech recognition with hearing aids. Cochlear implants are safe and well tolerated and improve communication. The surgery is now commonly done bilaterally (Lewis, 2014). A cochlear implant is a small, complex electronic device that consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin. Unlike hearing aids that magnify sounds, the cochlear implant bypasses damaged portions of the ear and directly stimulates the auditory nerve. Hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn. Most insurance plans cover the cochlear implant procedure. The transplant carries some risk because the surgery destroys any residual hearing. Therefore, cochlear implant users can never revert to using a hearing aid. Individuals with cochlear implants need to be advised to never have a magnetic resonance imaging (MRI) scan because it may dislodge the implant or demagnetize its internal magnet.
Assistive Listening and Adaptive Devices
Assistive listening devices (also called personal listening systems) should be considered as an adjunct to hearing aids or used in place of hearing aids for people with hearing impairment. These devices are available commercially and can be used to enhance face-to-face communication and to better understand speech in large rooms such as theaters, to use the telephone, and to listen to television. Many movie theaters have both sound amplifiers and personal subtitle devices available.
Other examples of assistive listening and adaptive devices include text messaging devices for telephones and closed-caption television. Alerting devices, such as vibrating alarm clocks that shake the bed or activate a flashing light, and sound lamps that respond with lights to sounds, such as doorbells and telephones, are also available. Special service dogs (“hearing dogs”) are trained to alert people with a hearing impairment about sounds and intruders. Dogs are trained to respond to different sounds, such as the telephone, smoke alarms, alarm clock, doorbell/door knock, and name call, and lead the individual to the sound.
The use of computers and email also assists individuals with hearing impairment to communicate more easily. Programs such as Skype and FaceTime are also beneficial because they may allow the person to lip read and to adjust volume. Pocket-sized amplifiers (available at retail stores) are especially helpful in improving communication in health care settings, and nurses should be able to obtain appropriate devices for use with hearing-impaired individuals.
Implications for Gerontological Nursing and Healthy Aging
1. Assessment
2.
Hearing impairment is underdiagnosed and undertreated in older people (Bainbridge & Wallhagen, 2014). Older people may be initially unaware of hearing loss because of the gradual manner in which it develops and, therefore, not report any problems. Screening for hearing impairment and appropriate treatment are considered an essential part of primary care for older adults. Assessment of hearing includes a focused history and physical examination and also screening assessment for hearing impairment. Ask the person if he or she has any difficulty understanding speech in noisy situations, during telephone use, or in daily conversation. Obtaining information from the significant other about hearing problems can also be useful.
Self-assessment instruments (Box 19.7) and the Hearing Handicap Inventory for the Elderly (HHIE-S) can also be included (Box 19.8). Question the patient about prolonged noise exposure, past ear injuries, and use of potentially ototoxic medications as well.
Box 19.7. Do I Have a Hearing Problem?
• Do I have a problem hearing on the telephone?
• Do I have trouble hearing when there is noise in the background?
• Is it hard for me to follow a conversation when two or more people talk at once?
• Do I have to strain to understand a conversation?
• Do many people I talk to seem to mumble (or not speak clearly)?
• Do I misunderstand what others are saying and respond inappropriately?
• Do I have trouble understanding the speech of women and children?
• Do people complain that I turn the TV volume up too high?
• Do I hear a ringing, roaring, or hissing sound a lot?
• Do some sounds seem too loud?
From National Institute on Deafness and Other Communication Disorders: Hearing loss and older adults, 2014. Available at http://www.nidcd.nih.gov/health/hearing/pages/older.aspx#2. Accessed October 31, 2014.
Box 19.8. Resources for Best Practice
Hearing Impairment
American Tinnitus Association: Sounds of tinnitus
Hartford Institute for Geriatric Nursing (Try This: General Assessment Series): Hearing handicap for the elderly: Screening version (HHIT-S)
NIDCD (National Institute on Deafness and Other Communication Disorders): Hearing loss and older adults; Interactive sound ruler: how loud is too loud (experience noise levels)
NIH Senior Health: Hearing loss (patient information)
Sight and Hearing Association: Unfair hearing test/filtered speech (experience presbycusis)
Physical examination includes assessing the external ear to determine any evidence of infection and using an otoscope to visualize the inner ear, looking for any possible causes of conductive hearing loss such as cerumen impaction or the presence of foreign objects.
Inspect the tympanic membrane (TM) for integrity. Depending on findings, the patient may need to be referred for follow-up by a specialist. If no problems are identified, perform a few basic screening tests.
These may include the Rinne and Weber tests to differentiate between conductive and sensorineural hearing loss. Other tests include the whisper and finger rub test.
3. Interventions
Nursing actions are based on assessment findings and may include referral to an audiologist, education on hearing loss (including prevention and consequences), and provision of information about hearing aids, assistive listening devices, and communication techniques. If cerumen impaction is found, cerumen removal may be indicated.
There are many evidence-based resources available that can be used to educate the patient and family and assist the nurse in designing educational materials (Box 19.8). Using the information presented in this chapter, nurses can play an important role in providing older adults the information they need to improve their hearing and avoid the negative consequences of untreated hearing loss.
Effective communication strategies when working with individuals who are hearing-impaired are presented in Box 19.9.
Box 19.9. Tips for Best Practice
Communicating with Elders Who Have Hearing Impairment
• Never assume hearing loss is from age until other causes are ruled out (infection, cerumen buildup).
• Inappropriate responses, inattentiveness, and apathy may be symptoms of a hearing loss.
• Face the individual and stand or sit on the same level; do not turn away while speaking.
• Gain the individual's attention before beginning to speak. Look directly at the person at eye level before starting to speak.
• Determine if hearing is better in one ear than another and position yourself appropriately.
• If hearing aid is used, make sure it is in place and batteries are functioning.
• Keep hands away from your mouth and project voice by controlled diaphragmatic breathing.
• Avoid conversations in which the speaker's face is in glare or darkness; orient the light on the speaker's face.
• Careful articulation and moderate speed of speech are helpful.
• Lower your tone of voice and articulate clearly.
• Label the chart, note on the intercom button, and inform all caregivers that the patient has a hearing impairment.
• Use nonverbal approaches: gestures, demonstrations, visual aids, and written materials.
• Pause between sentences or phrases to confirm understanding.
• When changing topics, preface the change by stating the topic.
• Reduce background noise (e.g., turn off television, close door).
• Utilize assistive listening devices such as pocket talker.
• Verify that the information being given has been clearly understood. Be aware that the person may agree to everything and appear to understand what you have said even when he or she did not hear you (listener bluffing).
• Share resources for the hearing-impaired and refer as appropriate.
Tinnitus
Tinnitus is defined as the perception of sound in one or both ears or in the head when no external sound is present. It is often referred to as “ringing in the ears” but may also manifest as buzzing, hissing, whistling, cricket chirping, bells, roaring, clicking, pulsating, humming, or swishing sounds. The sounds may be constant or intermittent and are more acute at night or in quiet surroundings. The most common type is high-pitched tinnitus with sensorineural loss; less common is low-pitched tinnitus with conduction loss such as is seen in Meniere's disease.
Tinnitus generally increases over time. It is a condition that afflicts many older people and can interfere with hearing, as well as become extremely irritating. It is estimated to occur in nearly 11% of elders with 263presbycusis. Tinnitus is a growing problem for America's military personnel and is the leading cause of service-connected disability of veterans returning from Iraq or Afghanistan (American Tinnitus Association, 2016).
The exact physiological cause or causes of tinnitus are not known, but there are several likely factors that are known to trigger or worsen tinnitus. Exposure to loud noises is the leading cause of tinnitus, and the exposure can damage and destroy cilia in the inner ear. Once damaged, the cilia cannot be renewed or replaced. Other possible causes of tinnitus include head and neck trauma, certain types of tumors, cerumen accumulation, jaw misalignment, cardiovascular disease, and ototoxicity from medications. More than 200 prescription and nonprescription medications list tinnitus as a potential side effect, aspirin being the most common. There is some evidence that caffeine, alcohol, cigarettes, stress, and fatigue may exacerbate the problem.
Interventions
Some persons with tinnitus will never find the cause; for others the problem may arbitrarily disappear. Hearing aids can be prescribed to amplify environmental sounds to obscure tinnitus, and there is a device that combines the features of a masker and a hearing aid, which emits a competitive but pleasant sound that distracts from head noise. Therapeutic modes of treating tinnitus include transtympanal electrostimulation, iontophoresis, biofeedback, tinnitus masking with alternative sound production (white noise), cochlear implants, and hearing aids. Some have found hypnosis, cognitive behavioral therapy, acupuncture, and chiropractic, naturopathic, allergy, or drug treatment to be effective.
Nursing actions include discussing with the client about times when the noises are most irritating and having the person keep a diary to identify patterns. Assess medications for possibly contributing to the problem. Discuss lifestyle changes and alternative methods that some have found effective. Also, refer clients to the American Tinnitus Association for research updates, education, and support groups (Box 19.8).
Key Concepts
• Vision loss is a leading cause of age-related disability.
• The leading causes of visual impairment in the United States are diseases that are common in older adults: age-related macular degeneration (AMD), cataracts, glaucoma, and diabetic retinopathy.
• Many causes of visual impairment are preventable, so attention to keeping eyes healthy throughout life and early detection and treatment of eye disease are essential.
• Nurses who care for visually impaired elders in all settings can improve outcomes by assessing for vision changes, adapting the environment to enhance vision and safety, communicating appropriately, and providing appropriate health teaching and referrals for prevention, treatment, and assistive devices.
• Age-related hearing impairment is a complex disease caused by interactions among age-related changes, genetics, lifestyle, and environment.
• Presbycusis (also called age-related hearing impairment or ARHI) is a form of sensorineural hearing loss that is related to aging and is the most common form of hearing loss.
• Hearing loss diminishes quality of life and is associated with multiple negative outcomes including decreased function, increased likelihood of hospitalizations, miscommunication, depression, falls, reduced self-esteem, safety risks, and cognitive decline.
• Screening for hearing loss is an essential component of assessment in older adults.
