Geriatric Nursing and Sensory Changes in Old Age

Sensory Changes in Old Age Sensory Neural Changes in Old Age: Assessment, Evaluation, Nursing Care, and Education

Learning Objectives

Upon completion of this topic, the reader should be able to:

1. Describe the normal changes of aging that affect the senses in the older adult.
2. Identify common disorders that impact the senses in the older adult.
3. Determine how best to assess sensory status in the older adult.
4. Identify nursing strategies to manage sensory impairment in the older adult.
5. Collaborate with interprofessional team members who can assist older adults with sensory impairment.

Background and Statement of Problem

Individuals experience and interact with their environments through their senses. Vision, hearing, smell, taste, and peripheral sensation allow us to safely experience and enjoy the world around us. As people age, they often experience changes in their sensory function (vision, hearing, smell, taste, and peripheral sensation). These sensory changes can negatively impact older adults’ ability to interact with their environment, decreasing their quality of life. For example, changes in hearing can impact an older person’s communication skills; changes in vision can impact their health literacy, limiting their ability to take medications safely.

Healthy People 2020 emphasizes the importance of healthy senses, including vision, hearing, balance, smell, and taste. Vision and hearing abilities are essential to language, whether spoken, signed, or read (US Department of Health and Human Services (USDHHS), 2010). Decreases in the sense of smell can interfere with an older adult’s ability to smell smoke in a fire or recognize spoiled food. Many adults report a decrease in taste that impacts their desire to eat. Decreased peripheral sensation increases the risk of falls.

How to Assess Sensory Deficits

Understanding how to assess the senses and manage sensory deficits is essential to holistic nursing. A goal of Healthy People 2020 is to decrease the prevalence and severity of disorders of vision, hearing, balance, smell, and taste, as well as voice, speech, and language (USDHHS, 2010). This chapter on sensory changes addresses common age-related changes associated with the senses, as well as disease states and injuries to the senses that occur more commonly with aging. Nursing care related to the Healthy People 2020 goals regarding sensory changes will also be addressed.

Normal Changes of Aging Senses

The senses—vision, hearing, taste, smell, balance, and peripheral sensation—change with aging, usually presenting primarily with a slowing of function. A summary table is presented describing the changes that occur and the functional outcomes for each sense.

Vision

Several changes occur with vision as people age. The eyelids start to lag, potentially obscuring vision; the pupil takes longer to dilate and contract, slowing accommodation; and presbyopia is widespread.

Presbyopia

A loss of elasticity in the lens and stiffening of the muscle fibers of the eye’s lens leads to a decrease in the eye’s ability to change the lens’s shape to focus on near objects, such as fine print, and decreases the ability to adapt to light (National Eye Institute [NEI], 2004a; Whiteside, Wallhagen, & Pettengill, 2006).

Hearing

Normal changes of aging impacting hearing include the decrease in function of the hair fibers in the ear canal that normally aid in the natural removal of cerumen and the protection of the ear canal from external elements.

Presbycusis

Presbycusis is the most common form of hearing loss in the United States (Bagai, Thavendiranathan, & Detsky, 2006). This high-frequency sensorineural hearing loss is a multifactorial process that varies in severity and is associated with aging (Gates & Mills, 2005). Presbycusis usually has a bilateral progressive onset and is caused by gradual loss of hair cells and fibrous changes in the small blood vessels that supply the cochlea. Risk factors include heredity, environmental exposure, free radical, and mitochondrial deoxyribonucleic acid (DNA) damage (Huang & Tang, 2010).

Presenting clinical symptoms of this irreversible condition include high-frequency hearing loss and difficulty hearing high-pitched sounds such as /t/, /p/, /k/, /s/, /z/, /sh/, and /ch/ (Huang & Tang, 2010; Wallhagen, Strawbridge, Shema, & Kaplan, 2004). Background noise further aggravates this hearing deficit.

Smell

Changes in smell are common as we age but are not considered a normal part of aging. Frequently, older adults complain of distortions of smell. Factors associated with loss of sense of smell include age and sex, with older males being more prone to smell loss (Hoffman, Cruickshanks, & Davis, 2009). The environment, trauma, diseases, or illness can diminish the sense of smell (Hoffman et al., 2009). Changes in the sense of smell have also been found to correlate with neurological conditions such as Parkinson’s disease and Alzheimer’s disease (Albers, Tabert, & Devanand, 2006; Wilson, Arnold, Schneider, Tang, & Bennett, 2007).

Taste

Common changes in taste include a decreased ability to detect the intensity of taste but not somatic sensations such as touch and burning pain in the tongue when compared to younger adults (Fukunaga, Uematsu, & Sugimoto, 2005). However, complete loss of taste is rare, and changes in taste are more often related to dental concerns, diseases, or illnesses such as rhinitis, allergies, or infections, and medications or cancer treatments to the head and neck (Fukunaga et al., 2005; Hoffman et al., 2009).

Peripheral Sensation

Peripheral nerve function that controls the sense of touch declines slightly with age. Two-point discrimination and vibration sense both decrease with age. The ability to perceive painful stimuli is preserved in aging. However, there may be a slowed reaction time for pulling away from painful stimuli with aging (Linton, 2007).

Assessment of the Problem

Vision

The prevalence of visual impairment increases with age and the settings in which older adults live. Data from the National Health and Nutrition Examination Survey (NHANES; Dillon, Gu, Hoffman, & Ko, 2010) in older adults aged 70 years and older identified that 15.4% were visually impaired, but this varied by race and ethnicity, with non-Hispanic Whites (13.8%), non-Hispanic Blacks (21.19%), and Mexican Americans (24%). In adults aged 80 years and older, 24.6% were found to be visually impaired (Dillon et al., 2010). In another study, adults aged 80 years and older accounted for 7.7% of cases, but 69% of blindness cases (Congdon et al., 2004). This is worrisome because this is the fastest-growing segment of our population.

Studies evaluating older adults in long-term care settings demonstrate prevalence rates from 27% to 54% of older adults with visual impairment (Bron & Caird, 1997; Cacchione, Culp, Dyck, & Laing, 2003). Uncorrected refractive error was also found to be common in visually impaired older adults. In one study, 8.8% of the older adults were visually impaired, and 59% of those were impaired due to uncorrected refractive error (Vitale, Cotch, & Sperduto, 2006).

Leading causes of blindness by race and ethnicity were found to be macular degeneration in Whites, cataracts and open-angle glaucoma in Blacks, and open-angle glaucoma in Hispanic persons (Congdon et al., 2004). Cataracts, one of the leading causes of blindness, are characterized by unilateral or bilateral clouding of the crystalline lens that presents as painless, progressive loss of vision (NEI, 2004a).

What is Visual Impairment?

The definition of visual impairment varies by different groups and by country (Agency for Healthcare Research and Quality (AHRQ), 2004). The United States defines low vision as best-corrected visual acuity:

• Normal vision: visual acuity of 20/20 or better
• Mild vision impairment: 20/25 to 20/50
• Moderate visual impairment: 20/60 to 20/160
• Severe visual impairment (legally blind): 20/200 to 20/400
• Profound vision impairment: 20/400 to 20/1,000
• Near-total vision loss: less than or equal to 20/1,250
• Total blindness: no light perception

Low vision can also be defined based on visual field limitations. Severe visual impairment is defined as a best-corrected field of less than or equal to 20 degrees (legal blindness). Profound visual impairment is defined as a visual field of less than or equal to 10 degrees (AHRQ, 2004).

Nursing Assessment of Vision

The health history is an essential part of vision assessment. Several health conditions predispose older adults to visual impairment. Diabetes is a common cause of disease-related blindness due to diabetic retinopathy, with 6% of diabetics older than 65 years developing diabetic retinopathy (Baker, 2003; NEI, 2004b). Hypertension carries the risk of hypertensive retinopathy. A thorough baseline health history with yearly reviews and updates is essential to maintaining visual health. Health questions related to visual health are shown in Table 4.2 (Cacchione, 2007; Wallhagen, Pettengill, & Whiteside, 2006).

Examination of the Eye

The external structures can cause decreased vision if the eyelids lag due to the skin’s laxity in the upper eyelid. Lid lag can interfere with visual acuity and fields, which may require surgery. A decreased level of tear function can negatively impact visual acuity. Cataracts in severe cases can be visible with the naked eye and appear as a whitish gray pupil instead of black. Cloudiness of the whole cornea of the eye indicates a corneal problem, not a cataract. If the person has had cataract surgery, the lens implant may be visible on close inspection.

• Fundus Exam: Using an ophthalmoscope, a nurse can visualize the red reflex and, with experience and practice, the fundus of the eye. This is often difficult with small pupils. Darkening the room may help with dilating the pupils. Optometrists and ophthalmologists dilate the pupils to allow for a better view of the fundus. Cataracts will appear as a dark shadow in the anterior portion of the lens in front of the retina.
• Vision Testing: Vision testing should be completed before the eyes are dilated and completed with both uncorrected and corrected (with glasses) vision.
  • Distance Vision: The “gold standard” in eye charts, the Snellen chart, is one of the most commonly used to assess distance vision. Visual acuity is tested at 20 ft. The individual is asked to read the letters on the chart until they miss more than two on a line of acuity. Acuity equals the line above the line with more than two errors. Acuity measures range from 20/10 to 20/800 on the Snellen chart.

Retinopathy and Treatment

• Early Treatment Diabetic Retinopathy Study: The Early Treatment Diabetic Retinopathy Study (ETDRS; Ferris, Kassoff, Bresnick, & Bailey, 1982) eye chart is also frequently used and can be used at a distance of 4 m. At this distance, the greatest visual acuity measured is 20/200, the equivalent of legal blindness.
• Pin-Hole Test: With the best vision, with or without glasses, a card with a small pinhole or a multiple pin-hole occlude can be placed in front of the eye, and the vision is tested again at the last line the individual was able to read. This test identifies the refractive error of the peripheral cornea of the lens of the eye by allowing only perpendicular light to the lens (Kalinowski, 2008). If the individual can read farther down the chart with the pinhole, their vision may be improved with better refraction of their eyeglasses or, if they do not have glasses, with eyeglasses.
• Near Vision: Near vision is important for health literacy, especially regarding reading food or medication labels. There are several ways to assess near vision. Two commonly used tools are the Rosenbaum Pocket Eye Screener and the Lighthouse for the Blind Near Vision Screener. The Rosenbaum Pocket Eye Screener is a non-copyrighted tool based on the Snellen chart that can be useful in assessing near vision in acute care and primary care settings. The Rosenbaum is true to scale when compared with the Snellen chart at the 20/200, 20/400, and 20/800 acuity levels. However, the other levels are slightly too large, causing an overestimation of visual acuity (Horton & Jones, 1997).
  • Lighthouse for the Blind Near Vision Screener: This handheld vision screener has a cord that can be used at 40 and 20 cm to measure the proper distance for testing near vision. This near vision screener mimics the ETDRS eye chart in a smaller version but is not pocket size. It does not, however, have the concern over the scale matching of the ETDRS distance acuity level. For research purposes, it has the added feature of the cord for measuring a consistent distance.
• Sensitivity: Contrast sensitivity is often compromised by aging and diseases or conditions of the eye. Decreases in contrast sensitivity occur with cataracts, glaucoma, and retinopathies (Mäntyjärvi & Laitinen, 2001; Wilensky & Hawkins, 2001). Contrast sensitivity provides information on how well an individual may perform in real-life conditions. Decline in contrast sensitivity impacts one’s ability to distinguish when one step ends and another begins, identify light switches on the wall, read materials not made in high-contrast font, or identify the buttons on the remote. Intact contrast sensitivity is important for day-to-day safety and function within the environment.
  • The Pelli-Robson Contrast Sensitivity Chart (Pelli, Robson, & Wilkins, 1988) is read at the 1- or 3-m distance. All letters are presented at the 20/200 acuity level but in decreasing shades of black to gray. The Pelli-Robson Contrast Sensitivity Chart is widely used in practice and works well for older adults who are experienced in recognizing letters (Hirvelä & Laatikainen, 1995; Morse & Rosenthal, 1997). The Vistech Contrast Sensitivity Test, another contrast sensitivity measure, has four patches of gray circles with lines in different directions (Kennedy & Dunlap, 1990). The person being examined points to the direction the lines within the circle are pointed (Morse & Rosenthal, 1997).
• Visual Fields: Fields of vision refer to the area of peripheral vision visible when the individual is focusing straight ahead (Cassin & Rubin, 2001). Vision in visual fields can be affected by many eye conditions, as well as neurological disorders that inhibit eye movement or affect the blood supply to the optic nerve. Intact visual fields are important to function safely in one’s environment. In assessing visual fields by confrontation, a gross clinical measure of visual fields, the examiner faces the patient and determines if the patient can identify the examiner’s moving fingers as they move into their field of view (Seidel, Dains, Ball, & Benedict, 2003). Although subjective and dependent on the examiner having normal fields of vision, the confrontation test is useful in quickly identifying large losses in visual fields.
  • The Humphrey Visual Field Test is completed by an ophthalmologist and assesses visual fields using a static type of perimetry (Gianutsos & Suchoff, 1997). This measure provides a more reliable measure of functional visual fields. The Goldman V14e kinetic perimetry visual field testing, on the other hand, assesses kinetic types of functional visual fields (Gillmore, 2002). Kinetic perimetry entails the introduction of a moving stimulus from a non-visible area toward the fixed point of view. The Goldman VI4e kinetic perimetry visual field testing is hard to standardize because it is operator-dependent (Gillmore, 2002). Because these automated methods are more widely used, the location of the visual field deficit may clue the examiner about the type of eye condition. For example, unilateral visual field deficits may be related to a cerebrovascular accident, glaucoma will affect the peripheral fields, and macular degeneration has associated central field of vision loss.
• Stereopsis: Stereopsis is the process where humans have the ability to use the different viewpoints provided by their eyes to produce a vivid perception of depth and three-dimensional shapes (Norman et al., 2008; Read, Phillipson, Serrano-Pedraza, Milner, & Parker, 2010). There are multiple methods of measuring stereopsis, and it is not thought to be affected by aging but may be negatively impacted by distance acuity and eye injuries (Norman et al., 2008).
• Visual Function Questionnaire-25: The NEI Visual Function Questionnaire (VFQ) is a 25-item survey that assesses the functional impact of visual impairment. It provides a subjective report on 12 functional subscales: General Vision, Near Vision, Distance Vision, Driving, Peripheral Vision, Color Vision, Ocular Pain, General Health, Vision-Specific Role Difficulties, Dependency, Social Function, and Mental Health (Revicki, Rentz, Harnam, Thomas, & Lanzetta, 2010). The NEI VFQ-25 has sound psychometric properties in cognitively intact older adults (Mangione et al., 2001).

Diseases That Alter Vision Seen More Frequently as People Age

• Cataracts: Clouding of the crystalline lens presents either unilaterally or bilaterally as painless, progressive loss of vision (NEI, 2009). Cataracts are usually age-related but can be secondary to glaucoma, diabetes, Alzheimer’s disease, congenital, injury-related, or related to medications or radiation (NEI, 2009). Management includes early identification and monitoring followed by surgical extraction and lens implantation once vision is affected.
• Macular Degeneration: Involves the development of drusen deposits in the retinal pigmented epithelium and is the leading cause of central vision loss and legal blindness in older adults (Revicki et al., 2010). Macular degeneration is more common in fair-haired, blue-eyed individuals. Other risk factors include smoking and excessive sunlight exposure. There are wet and dry forms of macular degeneration. The wet form is more easily treated than the dry form. Newer treatments, including expensive injectable medications, are available to slow the progression of dry macular degeneration.
• Glaucoma: A progressive, serious form of eye disease that can damage the optic nerve and result in vision loss and blindness (NEI, 2009). Primary open-angle glaucoma is the most common form of glaucoma in older adults (Linton, 2007). Increased intraocular pressure causes atrophy and cupping of the optic nerve head, leading to visual field deficits that can progress to blindness. Vision changes include loss of peripheral vision, intolerance to glare, decreased perception of contrast, and decreased ability to adapt to the dark.
• Diabetic Retinopathy: Results from end-organ damage from diabetes causing retinopathy and spotty vision. Risk can be reduced by tight blood sugar control. Almost 6% of diabetics aged 65-74 years old develop diabetic retinopathy (NEI, 2004a). Diabetic retinopathy starts as mild non-proliferative retinopathy with microaneurysms on the retina and progresses to moderate-to-severe non-proliferative retinopathy where blood vessels in the retina are blocked, depriving the retina of adequate blood supply, then progressing to proliferative retinopathy where the growth of new abnormal blood vessels that leak can cause blindness (NEI, 2009).
• Hypertensive Retinopathy: Caused by end-organ damage from poorly controlled hypertension causing background and eventual proliferative retinopathy. Hypertensive retinopathy is usually treated with laser photocoagulation and tight blood pressure control.
• Temporary Arteritis: An autoimmune disorder that causes inflammation of the temporal artery, also known as giant cell arteritis. It presents as malaise, scalp tenderness, unilateral temporary headache, jaw claudication, and sudden vision loss (usually unilateral). This vision loss is a medical emergency but is potentially reversible if identified immediately. The client should see an ophthalmologist or go to the emergency room immediately if symptoms develop.
• Detached Retina: A condition that can occur in patients with cataracts or recent cataract surgery, trauma, or occur spontaneously. A detached retina presents as a curtain coming down across a patient’s line of vision. An individual experiencing this should see an ophthalmologist or proceed to the closest emergency room immediately. See Table 4.3 for the implications of vision changes on an older adult’s function.

Interventions and Care Strategies

Vision

The nurse should obtain a past medical history to avoid disruption in the management of chronic eye conditions, assuring continuation of ongoing regimens such as eye drops for glaucoma. Without the continuation of the individual’s eye drops, eye pressures could precipitously increase, causing an acute exacerbation of their glaucoma, potentially dramatically limiting their vision. If an acute change in an individual’s vision occurs, the primary care provider should be notified immediately. Depending on the signs and symptoms present, the individual may need to see an ophthalmologist or go to the emergency room to receive treatment to restore the vision or limit the deterioration.

• Lighting: Lighting is important in an individual’s environment. Too little light can limit an individual’s vision. Too much light, depending on the individual’s eye condition, such as cataracts or macular degeneration, may cause eye pain and glare. It is important to ascertain whether an individual is sensitive to light. If they are, indirect light and night lights may help provide a safe environment. Most older adults benefit from improved lighting. To avoid glare, directing incandescent lamps directly on a task such as sewing or reading often improves visual acuity and is well tolerated. Glare occurs when a light shines directly into the eye or reflects off a shiny surface. Low vision specialists recommend trying different positions and wattages of lighting to find what works best for each individual (Community Services for the Blind and Partially Sighted, 2004).
• Eyeglasses and Magnification: Encourage the use of the person’s eyeglasses. Older adults’ eyeglasses should be labeled with the person’s name so they can be reconnected to their owner if they are set down and left behind. Even with eyeglasses, magnification may be helpful. Have family provide lighted magnification if needed (large lighted magnifiers are available at low vision centers). A low vision optometrist or specialist can assist in recommending appropriate levels of magnifiers.
• Contrast Sensitivity: Contrast sensitivity is a problem with several eye conditions, including cataracts, glaucoma, and macular degeneration. Adding contrast to the edge of each step, fixtures in the home, light switches that blend into the wall, or faucets that blend into the sink can create a safer and more functional environment.
• Screening and Eye Exams: Annual mass screening is not recommended in the older adult (Chou, Dana, & Bougatsos, 2009). However, nurses should encourage an annual dilated eye exam either with an optometrist or ophthalmologist. This is crucial for people with a diagnosis of diabetes or hypertension (NEI, 2009). Nurses are members of the interprofessional team responsible for preventing unnecessary disability. Therefore, nurses should ensure a mechanism is in place to trigger these visits annually.

Hearing Impairment

Surveys to identify older adults with hearing impairment often suffer from underreporting on self-report instruments. The latest version of the NHANES included audiometric testing in older adults and found a prevalence rate of 26.3% in those older than age 70 years and 45.4% in those older than age 80 years (Dillon et al., 2010). Hearing loss has been found to be greater in men and progresses more quickly than in women (Chao & Chen, 2009; National Institute on Deafness and Other Communication Disorders (NIDCD), 2007). This dramatic increase in prevalence rates is magnified in the nursing home population. Prevalence rates of hearing impairment in the nursing home are similar to rates of visual impairment, approximately 24% (Warnat & Tabloski, 2006). When hearing is tested through audiometry, the prevalence rates increase to 42%-90% (Bagai et al., 2006; Cacchione et al., 2003; Tolson, Swan, & Knussen, 2002).

The American Academy of Audiology defines hearing loss based on decibels or loudness and hertz or the pitch of sound. Normal speech is at the 0- to 25-dB level, mild hearing loss is defined as hearing at the 25- to 40-dB level. Hearing between 40 and 70 dB is considered moderate hearing loss. Severe hearing loss is between 70 and 90 dB. Greater than 90 dB is considered profound hearing loss (Mehr, 2007). Aging impairs the processing of sound through the ear canal as well as the central nervous system processing of sounds, making it more difficult to hear higher frequencies, including women’s and children’s voices (Huang & Tang, 2010).

Assessment of Hearing

Often, it is easy to determine when an older adult is hard of hearing just by having a conversation with them. The older adult may lean closer in an attempt to hear better, turn their head to their “good ear,” or cup their hand behind their ear. Older adults may have to ask for things to be repeated; they may report having trouble hearing their grandchildren’s or others’ high-pitched voices. Older adults often complain that people are mumbling. Any or all of these signs may be present. Regardless of whether any of these signs are present, all older adults should have their hearing screened annually at their primary care visit (Bagai et al., 2006). Primary care providers play an important role in screening for hearing loss and making appropriate referrals for older adults (Johnson, Danhauer, Bennett, & Harrison, 2009). Methods of screening are described herein.

• Hearing Handicap Inventory for the Elderly Screen: The Hearing Handicap Inventory for the Elderly-Screen (HHIE-S; Ventry & Weinstein, 1983) is a 10-item scale to determine how hearing impacts an older adult’s daily life and assist in identifying who might benefit from a hearing aid and an audiology referral. The scale takes approximately 5 minutes to complete and is targeted for community-dwelling older adults. This scale is available online through the Hartford Foundation Institute for Geriatric Nursing “Try This Best Practices in Care for Older Adults” (Demers, 2001). The HHIE-S has reported excellent sensitivity and specificity for severe hearing loss, but the sensitivity and specificity decrease as the level of hearing impairment lessens (Adams-Wendling, Pimple, Adams, & Titler, 2008).
• Whisper Test: The whisper test involves covering or rubbing one ear canal, and from a distance of 2 ft., whispering a three-syllable word on an exhale that the patient either correctly or incorrectly repeats back. An incorrect response triggers a repeat attempt to see if the older adult can identify a different three-syllable word. The consistency of the level of the whispered word makes this test difficult to compare from examiner to examiner. However, despite this difficulty, it has been found to be a valid and reliable test to screen for hearing loss (Bagai et al., 2006).
• Handheld Audioscope: The handheld audioscope is a device developed specifically for screening hearing impairment. It has a test tone that is presented at the 60-dB level. The decibel levels that may be tested include the 20-, 25-, and 40-dB levels at the 500-, 1,000-, 2,000-, and 4,000-Hz levels (Yuch et al., 2007). The audioscope has an otoscope that allows for the direct inspection of the tympanic membrane or cerumen impactions that can result in conductive hearing loss, which is present in up to 30% of older adults (Lewis-Cullinan & Janken, 1990; Yuch, Shapiro, MacLean, & Shekelle, 2003). Testing using the audioscope should be performed in a quiet setting and may not be as useful in a long-term care environment with high noise levels.
• Pure Tone Audiometry: This is the gold standard of hearing tests, particularly if completed in a sound-proof booth with 92% sensitivity and 94% specificity in detecting sensorineural hearing loss (Frank & Petersen, 1987). Pure tone audiometry allows for testing of a wide range of decibels and hertz levels or loudness and pitch or frequencies, allowing for testing at the 5- to 120-dB level and 250-4,000 Hz. Portable pure tone audiometers with noise-reduction earphones are available and can be used in community, outpatient, and long-term care settings when access to an audiologist is limited. This wide range of tones allows for a better understanding of the individual’s functional hearing. Pure tone audiometry by an audiologist is the next step after screening has identified a hearing deficit (Yuch et al., 2003).
• Tuning Fork Tests: Two tuning fork tests have been used in hearing screenings, although a recent systematic review discouraged their use because they were found to be unreliable with limited accuracy (Bagai et al., 2006). The tuning fork should be either 256 or 512 Hz (MI Wallhagen, personal communication, 2006). The Rinne test is meant to differentiate whether an older adult hears better by bone or air conduction and can help determine if an individual has sensorineural or conductive hearing loss. The Weber test is used to help identify unilateral hearing loss.

Hearing Changes Common in Older Adults

• Conductive Hearing Loss: Usually involves abnormalities of the middle or external ear, including the ear canal, tympanic membrane, and ossicular chain of bones in the middle ear (Marcincuk & Roland, 2002; Yuch et al., 2003). Causes of conductive hearing impairment include cerumen impactions or foreign bodies, ruptured eardrum, otitis media, and otosclerosis (Wallhagen et al., 2006; Yuch et al., 2003).
• Sensorineural Hearing Loss: The most common form of hearing loss in older adults (Linton, 2007) involves damage to the inner ear, the cochlea, or the fibers of the eighth cranial nerve. Sensorineural hearing loss is usually a bilateral progressive onset and is caused by a gradual loss of hair cells, and fibrous changes in the small blood vessels that supply the cochlea. Risk factors include heredity, environmental exposure, free radicals, and mitochondrial DNA damage (Huang & Tang, 2010). Additional causes of sensorineural hearing loss include viral or bacterial infections, trauma, tumors, noise exposure, cardiovascular conditions, ototoxic drugs, and Ménière’s disease (Wallhagen et al., 2006).
• Central Auditory Processing Disorder: An uncommon disorder that includes an inability to process incoming signals and is often found in patients with stroke and older adults with neurological conditions such as Alzheimer’s disease and Parkinson’s disease (Pekkonen et al., 1999). The person’s hearing is intact, but their ability to process sound is impaired.
• Tinnitus: Also known as ringing in the ear, it is of two types: subjective and objective. Subjective tinnitus is a condition where there is perceived sound in the absence of an acoustic stimulus (Ahmad & Seidman, 2004; Lockwood, Salvi, & Burkard, 2002). Objective tinnitus is considered rare and presents as ringing in the ear that is audible to the individual and others. It is thought to have a vascular or neurological condition or Eustachian tube dysfunction (Crummer & Hassan, 2004). Subjective ringing in the ears may fluctuate and can be caused by damage to the hair receptors of the cochlear nerve and age-related changes in the organs of hearing and balance. Patients with tinnitus should be referred to an ear, nose, and throat (ENT) specialist.
• Ménière’s Disease: Characterized by fluctuating hearing loss, dizziness, vertigo, tinnitus, and a sensation of pressure in the affected ear (NIDCD, 2001). Unfortunately, the fluctuating hearing loss can become permanent over time. Possible causes of Ménière’s disease include hypothyroidism, diabetes, and neurosyphilis.

Implications of Hearing Changes

Older adults with hearing impairment experience a decreased quality of communication, social isolation, low self-esteem, and generally lower quality of life. Decreased hearing impacts an individual’s word recognition, decreasing their ability to communicate. This, in turn, can lead to significant safety issues. For example, if patient education about medication administration is provided only verbally, key information can be misheard and misinterpreted. Difficulty understanding the spoken word can lead to fatigue and speech paucity of friends and loved ones.

• Speech Paucity: Described as decreased attempts to have meaningful conversations due to the difficulty of getting the message through to a hearing-impaired loved one (Wallhagen et al., 2006). Speech paucity leads to social isolation of the hearing-impaired because only the necessary information is transferred, and no everyday social information is shared (Wallhagen et al., 2004). This can lead to depression and low self-esteem in the hearing-impaired individual and the partner. Other factors that lead to social isolation in hearing-impaired older adults include the inability to hear the phone or the doorbell ringing or knocking at the door.

Ideally, an older adult who develops hearing loss will see an audiologist and obtain unilateral or bilateral hearing aids to improve their ability to communicate with the people around them. Unfortunately, stigma, cost, and delay in pursuing hearing solutions may prevent this.