Hearing Conditions Associated with Aging

If any hearing loss is suspected, individuals should visit their primary care physician (PCP) to be screened and/or treated for any other underlying pathological processes.⁵ The term presbycusis is often used when diagnosing elders with hearing loss. According to the National Institute on Deafness and Other Communication Disorders (NIDCD),¹² the term presbycusis is the gradual loss of hearing as an individual grows older. Generally, hearing losses are divided into the three following areas: sensorineural, conductive, and mixed. These conditions may affect one or both ears.

The most common type of presbycusis or hearing loss in elders is the result of sensorineural damage to the hearing organ itself or to the peripheral or central nervous system (or both).¹² Although elders rarely have just one type of sensorineural loss, the most common type of loss is caused by hair cell damage or loss of the sensory hair cells of the cochlea. As individuals age, these hair cells are slowly lost, and the ability to hear high-frequency sounds is diminished. One of the most frustrating and handicapping aspect of this loss is the ways sounds are changed or distorted. Although the elder may hear someone speaking, the signals that allow him or her to understand what is being said are not clear. Such losses can have serious consequences in both social and therapeutic settings. For example, at a party someone may say, “How are you?” and the elder may respond, “Eighty-one.” An elder in a clinic setting who is asked to hand the COTA a “dime” may respond with the correct “time.” Such responses often raise questions about mental status and often lead to a loss of confidence in interacting with others.^12,13 In such situations, the COTA should seek assistance to rule out the presence of sensorineural loss before questioning the elder’s orientation or ability to follow directions. If proper audiological services are not available, the elderly individual can experience decreased mobility, social isolation, and increased cognitive decline.¹⁴ In addition, because women’s voices are usually higher pitched than men’s, female COTAs must understand that their voices could contribute to decreased comprehension by elders.

Elders living in areas with low exposure to loud or high-pitched noise levels may experience less sensorineural hearing loss than those living in noisy, industrial areas. Although those with better overall health seem less likely to experience this type of loss, some sensorineural loss eventually affects elders regardless of environmental conditions. However, continued exposure to loud noises for long periods may cause permanent damage.¹⁵ For instance, current research indicates that 15% of college graduates exhibit hearing loss equal to or greater than that of their parents due to exposure to high volume MP3 music players.¹⁶

Three types of sensorineural hearing loss have been identified: sensory, neural, and mechanical.^13,15 Sensory loss is caused by atrophy and degeneration of the hair cells at the base of the basilar membrane. It produces a loss of high-frequency sounds but does not interfere with the discrimination of speech. Neural loss is caused by the loss of auditory nerve fibers. It affects the ability to distinguish speech sounds, especially in the higher frequencies, but does not affect the ability to hear pure tones. Mechanical loss is characterized by the degeneration of the vibrating membrane within the cochlea. This type of loss leads to the gradual impairment of hearing in all frequencies. In situations where several sounds in various frequencies are present at the same time, the ability to distinguish between the sounds becomes increasingly difficult. Table 16-1 lists common hearing conditions of elders.

TABLE 16-1 Common Hearing Conditions of Elders

A sensorineural hearing loss may be unnoticed in the early stages because the high-frequency tones that are initially lost are above the functional range used in most environments. As the condition progresses, elders may notice that they cannot hear the ringing of the telephone, the buzz of the doorbell, the ticking of a clock, or the water dripping from a faucet. With further progression, the sounds of certain consonants such as s, z, t, f, and g become increasingly difficult to distinguish. Eventually, elders may strain to hear and understand conversations and one-syllable words.^13,15

A second hearing condition, conductive hearing loss, results in an inability of the external ear to conduct sound waves to the inner ear. Conductive hearing losses may be related to the buildup of cerumen (earwax), fluid accumulation in the middle ear from eustachian tube dysfunction, or an upper respiratory infection. These conductive problems often can be corrected by cleaning the ear, administering medications, or performing surgery. Hearing aids may be effective for persons who have an untreatable or residual conductive hearing loss. A hearing aid amplifies incoming sound and requires functioning hair cells and an intact nerve to transmit the sound to the central auditory pathways. For older adults whose residual hearing is greatly limited because of an absence of hair cells, cochlear implants may be considered.⁴ Cochlear implants are appropriate when only minimal or no benefit is possible when a conventional hearing aid is used. Cochlear implants are prosthetic replacements for the functions of the lost hair cells by converting mechanical energy (sound waves) into electrical energy capable of exciting the auditory nerve. Cochlear implants are placed within the inner ear. They bypass the hair cells of the cochlea and directly stimulate the endings of the auditory nerve. The system consists of an external microphone, processor, and transmitter, and an internal receiver–stimulator and electrode. Figure 16-1 shows the external (Figure 16-1, A) and internal (Figure 16-1, B) placements for a cochlear implant.

FIGURE 16-1 Cochlear implant. A, External placement. B, Internal placement.

(Courtesy of Cochlear Ltd, Englewood, CO.)

Tinnitus is a subjective auditory problem consisting of a ringing, whistling, buzzing, or roaring noise in the ears. Tinnitus may occur as part of a conductive or sensorineural hearing loss. It may also be associated with Ménière’s disease, otosclerosis, sensorineural loss, an accumulation of cerumen pressing on the eardrum, tympanic membrane lesions, and fluid in the middle ear. Medications such as the doses of aspirin prescribed for arthritis or other medical conditions can be additional contributing factors.¹⁵ Before planning interventions to mask the symptoms of tinnitus, possible underlying conditions such as cardiovascular disease, anemia, and hypothyroidism should be ruled out by a physician.

Tinnitus is often most noticeable at night when other noises are reduced. Ear or masking of environment noises may be an effective strategy. A radio, tape recording, or appropriate hearing aid may mask the tinnitus so the individual can fall asleep. Other therapeutic interventions may include relaxation techniques and biofeedback.^2,15

Psychosocial Aspects of Hearing Impairments

Even though much information about the environment is learned through the sense of hearing, the importance of hearing during travel, while working, and in personal and social situations often goes unnoticed. Some researchers suggest that when hearing loss is the only loss elders experience, they can adjust well.¹³ Others suggest that a hearing loss may lead to isolation and even paranoia.^2,17 Unfortunately, many elders experience other losses or lifestyle changes at the same time hearing loss occurs. Retirement may lead to a loss of role identity, income, and social contacts. Adjusting to the death of a spouse or undergoing changes in vision or mobility may take priority over a loss of hearing. Elders who are predisposed to loneliness or have difficulty in initiating or maintaining relationships may become more isolated or avoid interpersonal relationships if they experience a hearing loss. This can result in an increased sense of loneliness or isolation, especially if the hearing impairment is associated with other losses.¹³ Early assessment of a perceived hearing loss and recommendations for adaptations may help reduce an elder’s sense of loneliness.

The elder with a hearing loss often guesses at or misses the content of conversations, is reluctant to ask for clarification, or is embarrassed when mistakes are made because of a misunderstanding. This can occur when an elder with a hearing impairment is traveling. Studies involving elderly airline travelers have found that misunderstanding or not hearing overhead paging information has resulted in missed flights.¹⁸ Hearing changes also make it difficult to detect and understand speech in crowded and stressful situations. Limited hearing may decrease an elder’s sense of security and increase feelings of vulnerability, making travel more difficult. As a result, some elders may either limit their travel or stop engaging in that occupation.²

Communication can be exhausting for elders with a hearing impairment. For example, an 85-year-old man registering for occupational therapy (OT) interventions at a rehabilitation clinic will likely be embarrassed if he misinterprets the receptionist’s request for his address as a request to undress. He may also experience isolation if his accompanying family member interrupts and answers all remaining questions. Repeated frustrating and embarrassing experiences can contribute to feelings of vulnerability, insecurity, and doubts related to self-esteem that can lead to withdrawal from travel, social, cultural, and family contacts.

Some elders with hearing impairments may hear well at home and only struggle to hear in other social settings. Others may be isolated not only from family and friends but also from the broader world because they cannot get information from television, radio, movies, and even telephone conversations. Elders may become increasingly frustrated as family, friends, and even health care workers begin to make decisions for them.

An age-related hearing loss may only further complicate the effects of illnesses and mental health conditions such as Alzheimer’s disease. Hearing loss in elders can lead to or exacerbate paranoid ideas, suspicions, and loss of contact with reality, and related tendencies.¹³ Corso¹⁹ stated that a hearing loss can magnify previously existing paranoid personality attributes. Continued expression of suspicions, hostilities, and accusations of lying may result in friends and family members avoiding the hearing-impaired elder.

Rehabilitation and theHearing-Impaired Elder

Hearing loss usually accompanies other conditions and should be considered in intervention to facilitate a successful experience. Interventions based on the Occupational Therapy Practice Framework (2^nd ed.)¹⁰ address areas of occupations that have value and meaning for elders.

Managing hearing loss is about much more than the simple provision of a hearing aid. Rehabilitation for the hearing-impaired individual examines the individual’s participation in a variety of activities and functions.²⁰ The effectiveness of rehabilitation for maximizing occupational independence is based on many factors. Those related to hearing loss may include age-related changes at the time of onset of the hearing impairment, such as vision and mobility losses, retirement, death of a spouse, and loss of clearly defined life roles. Other factors include the severity and rapidity of the loss, the degree of residual hearing, the presence of other medical conditions, and the involvement of the individual and family members in the rehabilitative process.

COTA and registered occupational therapist (OTR) teams may work together along with others on the treatment team to identify elders who have hearing impairments through an observation of behaviors (Box 16-1). The Self-Rating Hearing Inventory also can be an effective tool for assessing the effects of a hearing impairment on perceived occupational performance.²¹ The American Academy of Otolaryngology–Head and Neck Surgery has developed a 5-minute hearing test to determine the need for a referral to a hearing specialist (Figure 16-2). Beyond the scope of therapy practice for more profound hearing losses, a consultation and referral to a hearing specialist regarding the use of a hearing aid, individual or computerized training in speech reading (lip reading), and instruction regarding the use of an ALD may be needed. In addition, referrals for accessing both formal and informal support services through public and community agencies may be beneficial. Individuals for whom none of these interventions are effective may be candidates for cochlear implants.

FIGURE 16-2 Five-minute hearing test.

(Courtesy of the American Academy of Otolaryngology–Head and Neck Surgery, Alexandria, VA.)

COTAs are involved in direct interventions for other primary reasons than for hearing impairment but regardless they should address hearing issues as they impact engagement in occupations. They may also assist in adapting environments for individuals, groups, or institutional facilities. The skills and experience of COTAs may be directed toward designing and implementing individual or institutional activities. These recommendations, intended to promote successful adaptation for hearing-impaired elders, also can assist families, friends, and institutional personnel. As always, safety is a consideration with intervention. Please refer to Box 16-2 for safety tips.

Recommendations for Improving Elder Communication

Psychosocial issues associated with hearing impairments often affect family members and friends, as well as the hearing-impaired elder. Information and education about the various types of age-related hearing losses and conditions may help COTAs in assisting elders to develop coping strategies.¹⁵ The COTA should encourage family members and friends to be involved in the education and consultation process so that conversational and environmental adaptations that encourage inclusion of the elder can be promoted.

Hearing-impaired elders may need to gain confidence in requesting adaptations that help them adjust to their hearing losses. Having elders role-play situations in which they request specific needs or adaptations may increase self-confidence for reentering social situations that they may have been avoiding.

Environmental adaptations should first center on identifying and minimizing the influence of background noises because competing background noises are considered to be a difficult listening condition.¹⁷ With a hearing difficulty, background noises greatly limit enjoyment of conversations and often contribute to an elder’s avoidance of social gatherings.²² Common sources of background noise in institutions include music, conversations on television or of persons in the room, dishes being clanked, fans in use, outside traffic, overhead intercoms in use, and ice machines in use. Personnel shifts and changes in the institutional environment may also create background noise.

COTAs can recommend environments that reduce background noise. Examples include going to restaurants during times that they are less crowded, requesting to sit in less crowded areas, or sitting away from distracting background noises such as kitchen traffic or music (Table 16-2). When traveling, to help compensate for difficulty in hearing overhead paging systems, elders can be encouraged to frequently check overhead flight monitors, or check in with airport staff, or both. Using theaters and church communities that offer ALDs that amplify specific sounds is another way to reduce interference from background noises in public spaces.

TABLE 16-2 Environmental Adaptations for the Hearing-Impaired Elder

Personal environmental modifications for reducing background noise include adding carpet to floors and acoustical tiles to ceilings, hanging drapes on windows, hanging banners from high ceilings, and replacing wood or metal furniture with upholstered furniture. Although these recommendations are intended to help absorb sound, they also can add aesthetic appeal to a home or institution.²²

Additional interior modifications to reduce background noise within institutions include adding insulated sheetrock around noisy areas such as kitchen, maintenance, and mechanical areas, and tightening window weather seals. COTAs can assist individuals, families, and facility administrators in weighing the benefits of certain recommendations against the expenses of purchasing them. COTAs also can point out that, in some situations, background noises may provide helpful cues to locations of activity rooms, lounges, and beauty shops.

Environmental safety issues and concerns may center on the difficulties that hearing-impaired elders may have in locating the source of sounds in their home. The inability to locate sounds may contribute to a sense of insecurity in an individual’s own environment and to the possibility of auditory illusions. This can lead to a decrease in the person’s safety. For instance, elders may not be able to hear alarms or people moving about around them.¹⁵ Fire and smoke alarms tend to have high-pitched sounds that are difficult for persons with sensorineural losses to hear.⁴ Adding visual cues such as flashing lights is recommended for alarms.¹⁷ Flashing lights, lower-pitched rings, or low-toned musical chimes are also available options for telephones and doorbells. COTAs should recommend adapting telephones with volume and tone controls for persons who need these modifications. Cell (portable) phones, although convenient for some individuals, may add to the confusion and frustration for persons with hearing impairments. The ring of the phone may not be heard or the phones may be difficult to locate if needed for an emergency.²³ Putting a cell phone on a vibration setting or trying text messaging with elders who can read the screen and have adequate finger dexterity might be a good communication option. Elders can download their own ring tone and set it on “loud” for recognition. Some cell phones can be adapted for hearing aids and for amplification of sound. Cell phones can also be adapted to be used with a TTY or Voice Carry Over devise.

Research indicates hearing loss can increase the individuals risk of falling when compared to individuals who are not hearing-impaired.^3,24 Studies indicate that instruction in ways to substitute visual cues for hearing cues reduces the incidence of falls. COTAs also should make family members and health care providers aware that approaching hearing-impaired elders from the back and talking to and touching them may startle them and possibly cause them to lose balance. COTAs should recommend that hearing-impaired individuals be approached from the front, where visual contact can be made before beginning a conversation or expecting a response to a question.

To enhance conversations in areas where groups gather, COTAs should recommend that hearing-impaired individuals stay away from windows and plaster walls. Standing or sitting near soft materials that absorb sound, such as draperies, bookshelves, and upholstered furniture, also is recommended. Sitting in high-backed, upholstered chairs can help shield background noise. Focusing on the speaker’s lips during conversation can help increase comprehension. If an individual has more impairment in one ear than the other, the individual can find the position that maximizes hearing with the unaffected ear.¹³

For family members and friends who want to improve communication with hearing-impaired elders, COTAs should recommend that they position themselves in the elder’s field of vision and get the elder’s attention before speaking. While conversing, they should look directly at the elder, reduce the rate of speech, and speak distinctly with a low tone. Additional recommendations include asking the elder to repeat what was said and providing written instructions to reinforce verbal directions. COTAs should stress that a hearing impairment does not reduce an individual’s intelligence. Accommodations for the hearing impairment should not be over exaggerated or simplified to the point that elders with hearing loss feel that their intelligence or judgment is in question.

Because sensorineural hearing loss and its corresponding reduction in the ability to hear high-pitched sounds is the most common hearing disorder in elders, lowering the voice is especially important for women who address hearing-impaired elders. Increasing volume only increases tone and contributes to personal and social embarrassment (Box 16-3).

In restaurants and institutional dining rooms, seating no more than four persons at a table so eye contact can be easily made can enhance the social aspects derived from conversations during meals. In larger dining rooms, padded room dividers between tables can absorb sounds from surrounding tables. General recommendations regarding reduction of background noises also should be considered.

The effects of glare on the visual and nonverbal cues that enhance auditory communication should be considered when speaking with hearing-impaired elders. Sources of glare may include windows, lights, and glass surfaces either from behind the person speaking or reflected from eyeglasses. Before beginning a conversation, the COTA, family member, or friend should adjust blinds or shades, adjust lighting, and reposition seating arrangements as needed (see Chapter 15 for more information on visual adaptations with aging).

Entertainment through television, music, websites with sounds on the internet, and radio offers opportunities for stimulation that are not dependent on other people. When elders control the times and selections for television and radio programs and music, the cognitive stimulation can be rewarding. When televisions and radios are on constantly or programs selected are not those the elder would choose, they become an additional source of background noise rather than a source of stimulation.^4,23 Closed-captioned television is an additional option to suggest. COTAs should identify and reduce sources of glare on the screen when positioning elders for television viewing. ALDs offer a means of controlling the volume for the hearing-impaired elder without disturbing others. Adjusting the volume and sound for music for those individuals with sensorineural hearing loss requires increasing the bass and decreasing the treble. Developments in technology have made the cost of these devices quite reasonable when weighed against the potential benefits.²³ Refer to Table 16-2 for ideas for environmental adaptations.

Providing Assistive Hearing Devices

One of the most common assistive devices for persons with a hearing impairment is a hearing aid. An audiologist assists in determining whether a hearing aid would be appropriate. If a hearing aid would be beneficial, the audiologist works with the individual to choose the type of hearing aid that will maximize the individual’s hearing and understanding of speech based on the individual’s type of hearing loss.¹² Additionally, the audiologist also determines whether other factors associated with aging, lifestyle, and personality are compatible with a hearing aid. COTAs may refer elders to a physician or audiologist for assessment and evaluation. Advise patients to find out whether insurance will cover the cost of a hearing aid, and tell patients to ask whether a trial period is allowed so that the product can be tried out before it is purchased. Several visits to an audiologist may be required to get everything correct so the device is comfortable and the individual is comfortable using the hearing aid.²⁵

Recent improvements in hearing aid technology have made hearing aids more acceptable. The improved devices are smaller and fit in the ear and therefore are more cosmetically appealing (Figure 16-3). In addition, hearing aids dampen certain frequencies. Some evidence indicates that younger individuals report more satisfaction than do elders with hearing aids.^26-28 This increased satisfaction may result from several factors. The onset of age-related hearing loss is often gradual, and elders may have accommodated to their hearing loss over an extended period, eventually finding the sudden amplification of all sound to be invasive and disturbing. In addition, the fine finger-and-hand dexterity required to manipulate volume and frequency controls and change batteries makes the hearing aid difficult to operate. Possible cognitive changes and short-term memory loss may affect the elder’s ability to remember to turn the device on and off. The cost of replacement batteries and the elder’s acceptance of new technologies are other factors to consider when determining the appropriateness of a hearing aid.^23,28 Goals for an elder who uses a hearing aid may include identifying alternative ways of operating it, building handles for tools used with the controls, changing or testing batteries with less difficulty, and learning the proper way to insert the device. (See the Appendix for additional information on hearing aids.)

FIGURE 16-3 Hearing aids.

(From Bingham, B. J. G., Hawke, M., & Kwok, P. [1991]. Atlas of clinical otolaryngology. St. Louis, MO: Mosby.)

Even with improved technology, hearing aids may not be effective for some individuals. For others, sound distortions may be louder with a hearing aid. When hearing aids are not effective, ALDs may be used. ALDs consist of a microphone to capture spoken sounds, an amplifier to increase sound volume, and a headset worn by the hearing-impaired person (Figure 16-4, A and B). Because the amplified sound from an ALD reaches the ear directly, background noises are reduced.²⁹ ALDs can augment hearing in a noisy clinic or hospital room. When an ALD is plugged into a television, the sound is amplified for the hearing-impaired person only. Use of an ALD also should be considered when visual impairment does not allow the elder to read lips or to supplement hearing loss by responding to other nonverbal cues. In addition to ALDs, there are some newer options for the hearing impaired such as computer assisted real-time transcription (CART), visual and tactile alarms, and volume controlled or caption phones.³⁰ COTAs can inform the elder with a hearing impairment about Telecommunications Relay Services. These services available throughout the United States allow the person to place telephone calls with the use of computers or other technology. Operators (communication assistants) facilitate these calls by converting text to voice or vice versa. There is a variety of methods available to do this type of telephone communication to meet the needs of the hearing-impaired population.³¹

FIGURE 16-4 Listening devices.

A, Certified occupational therapy assistants may need to instruct elders on maintenance of assisted listening devices such as cleaning and battery change. B, An assisted listening device helps this elder participate more fully in social interactions.

Conclusion

As the number of elders with hearing impairments increases, the challenges and opportunities for COTAs continue to grow. The occupational performance and psychosocial and environmental issues that surround a hearing impairment demand that COTAs are informed and able to recommend appropriate interventions. COTAs can assist elders in attaining both performance and quality of life expectations by identifying limitations in hearing, referring elders for additional evaluation and intervention, and providing appropriate interventions.

Case Study

Joe is an 89-year-old man who has resided at the Garden View Nursing Home for the past 7 years. His diagnoses include dementia (early stages), diabetes, congestive heart failure, and most recently an increase in hearing loss. Until recently, Joe’s social history had been active and included participation in recreational activities and daily socializing with staff and other patients. At a recent care conference, the recreation director reported that Joe’s participation in activity groups had decreased from nine to four groups a week. The nurse working with Joe stated that he was less social during meals and had started to sleep in the afternoons. The social worker shared her current assessments of Joe and stated that he seemed to be isolating himself from others, including his roommate. When the social worker and other staff asked him how he was doing, he seemed to have difficulty understanding the question and changed the subject to talk about the weather. The staff thought his dementia could be contributing to the confusion or perhaps to changes in the level of his hearing loss. The team recommended referrals for a professional hearing evaluation and an OT assessment. The referral for OT included an evaluation of Joe’s current level of occupational functioning and suggestions for adapting his environment. In addition, staff was seeking suggestions from OT on how staff and others might interact more effectively with Joe. The OTR is a new graduate and has been at the Garden View Nursing Home for 2 months only. She has asked the COTA who has worked at the nursing home for 5 of the 7 years that Joe has been a resident at the home to assist her with the assessment.

Case Study Questions

1. Using information from the case study and the chapter, identify why staff would think that Joe’s hearing loss might have an effect on his social interaction with others.

2. Describe how Joe’s recent decrease in social interaction may be influencing his mood.

3. As the long-standing COTA member of the OT department, what assistance can you provide for the OTR? For Joe?

4. Using information from the chapter, identify assessments that may be useful for Joe.

5. What recommendations would you consider to adapt Joe’s environment to make it more purposeful and accommodating for him?

6. What types of assistive devices would be considered for Joe?

7. You have been asked to prepare an in-service on hearing impairments and elders and provide recommendations that will assist all staff to be more effective when interacting with those who have a hearing impairment.

How will you organize this in-service?

What information do you think would be most helpful for staff?

How will you engage the staff in the learning process?