Vicki Notes

• Hearing loss is the third most frequently reported chronic problem in those 65 years old & older.
• In all older age groups, men have more hearing impairment than women.
• Hearing loss influences the quality of life in many older nursing home residents, as many as 70%.

• Hearing is the transmission of sounds from the external environment à through the ear à to the auditory (8^th cranial nerve) neural pathways of the brain's cortex.
• The outer ear consists of the - pinna, tragus & external ear canal.
• The middle ear consists of the - tympanic membrane, malleus, incus & stapes.
• The inner ear consists of the - cochlea, vestibule & semicircular canals.
• Hair cells act as auditory receptors in the cochlea.
• Lets review how hearing occurs:
• Sounds enter the outer ear à go through the canal à strike the tympanic membrane à which makes sound vibrate as neural impulses à to the middle ear (malleus, incus & stapes) à this activates the fluid in the cochlea of the inner ear (there are about 30,000 nerve fibers here) à which transmit to the brain à thus hearing occurs!

• Itching in the external ear & increase in cerumen impaction are related to changes in the number of sweat glands.
• Cerumen glands are modified sweat glands. Their reduction results in dry skin & dry & hard earwax.
• Itching can be controlled with regular, small amounts of baby oil (if no infection is present). Cerumen impaction can be avoided by monitoring for buildup.

• Middle ear changes are minimal.
• Inner ear changes are thought to affect the auditory processing system resulting in auditory processing & peripheral hearing sensitivity loss.
• With aging the cochlea loses hair cells, which is thought to contribute to hearing loss.

• Heredity, environmental insults (noise), nutrition, cholesterol & adaptation to stress is all thought to determine the life of the specialized cells of the auditory pathway.

• Presbycusis - describes hearing loss associated with normal aging, the loss includes:
• Decreased hearing sensitivity (due to cochlear defects), impairment for high-frequency tone, frequency discrimination, sound localization & speech discrimination. (Speech discrimination problems are due to a central auditory processing defect where words & sounds become jumbled, this in turn may lead to an inappropriate response by the impaired person).

• Sensory presbycusis - begins in middle age & progresses slowly, decreasing the ability to hear high frequency sounds.

• Neural presbycusis - refers to loss of speech discrimination where there is difficulty understanding speech even though sounds can be heard (occurs due to aging changes in the auditory centers of the brain).

• Deaf - refers to being born without hearing ability or loss of hearing before the advent of speech.
• Tinnitus - refers to continuous or intermittent sound (whistling or blowing) not caused by external sources. Often a complaint of those suffering hearing loss. Possible causes include:
• Noise exposure, wax buildup, medications (aspirin), ear or sinus infection, allergies, head or neck trauma.
• Alcohol, nicotine, caffeine & stress may worsen tinnitus.
• Possible treatments include - hearing aids, masking of noise, biofeedback, and cognitive-behavioral therapy.

• Without the ability to hear & differentiate the meaning of sounds, hearing-impaired older adults may lose communications skills & suffer social isolation.
• For many older adults with hearing loss, consonants such as sh,f, v,t,p and b are misheard leading to misunderstanding.
• Other symptoms related to hearing loss may include withdrawal from social activities & fatigue, suspiciousness & loneliness (these are clues to the onset of hearing loss, don't think they are 'normal behaviors related to aging!)
• They may have difficulty understanding radio & television, they can't understand 'quick comment's.'
• It is difficult to make new friends when hindered by hearing loss, which decreases communication.
• There is more dissatisfaction with life & more depression than in those with no hearing problem.
• Hearing loss is not uniform, some sounds are heard while others are not.
• It is worse for high frequency than low frequency.
• And worse for consonants than for vowels.

• Loudness recruitment - refers to a form of hearing loss where the sounds of normal speech must be made more intense to be understood BUT if the sound exceeds the person's hearing threshold it's heard with disturbing loudness (Example: You are asked to speak-up then receive complaint's that you are yelling).
• Teach patient's about their hearing impairments & assist them in taking an active part in structuring communication with others,

• Those who enter rehabilitation have usually experienced hearing loss for about ten years.
• The patient is assessed by an audiologist after the often-overlooked impacted cerumen & ear, nose & throat evaluation rule out other treatable conditions.
• Rehabilitation programs include:
• Listening devices (hearing aids)
• Instruction in speech reading (lip-reading)
• Motivational counseling

• Examine the external hear with the largest speculum (otoscope) for best visualization of the ear canal.
• Pull the auricle slightly upward & backward.
• For the best view of the ear canal have the patient tilt head toward the opposite shoulder. Stabilize the patient's head to prevent injury to the sensitive ear canal. You should be able to visualize the pearly gray tympanic membrane (if no cerumen is present - which would appear as brownish-yellow).
• The most common compounding cause of conduction hearing loss is accumulation of cerumen.

• Consists of three tests.
• Spoken Word test - to perform this stand a few feet away from the patient, cover your mouth & whisper a sentence. Ask the patient to repeat the sentence. Test both ears. Change the sentence with the second ear.
• Weber Test - to perform the strike a tuning fork & place the handle on the center of the patient's forehead in touch with the skull bone. Ask the patient where the sound vibration is heard.
• If there is a sensorineural hearing loss it's heard best in the better ear.
• If it's a conductive hearing loss they will hear sound in the impaired ear.
• Normal hearing - will hear sound equally in both ears.
• Rinne Test - to perform strike the tuning fork & place on the mastoid process. Have the patient tell you when sound is no longer heard à then place the tuning fork next to the anterior surface of the external ear. Have the patient tell you when sound is no longer heard (The principal here is air conduction is greater than bone conduction).
• Normal hearing will report longer sound with air conduction & report no difference in the loudness of sound.
• In conductive hearing loss the sound of the tuning fork is louder & longer at the mastoid process.

• There may be denial or lack of understanding related to hearing loss that may be attributed to negative stereotypic images.
• Focus on the person's ability to manage their deficit & to continue meaningful lives.
• Be alert for the depression associated with hearing loss.
• With the patient's permission include family in assessment.

• Assess placement and use of radios, televisions & telephones (make sure these are adjusted to the level that is comfortable for the patient)
• Assess the normal noise level or any changes in noise level.

• Economic status will impact the ability to purchase a hearing aid. Medicare currently does not cover eyeglasses or hearing aids!
• Behind-the-ear aids costs around $500 - $700 with more sophisticated hearing aids are about $2500.
• Hearing aids are not as individualized as glasses and adjustment to takes time & patience.
• Reason's older adults may be unsuccessful with hearing aids or chose not to purchase or use them include being able to manipulate the controls (may be r/t arthritis), unable to understand instructions (may be r/t dementia), aid is not always effective (as with listening to the television) unable to afford high cost, unwilling to accept the need to wear one.
• ALDs - Assistive Listening Devices can be used in addition to or instead of hearing aids. They enhance the ability to hear speech & are inexpensive. It is a hard-wired system with a microphone (held close to a sound source), an amplifier, transducer & headphone.

• Alteration in auditory perception r/t physical changes aeb: results of audiology testing, self-reports of hearing loss or reports of others concerning the patient's hearing loss.

• Impaired verbal communication r/t hearing loss aeb: test results, self-reports & reports by others, avoidance of individuals or groups, denial of hearing difficulties, reluctance to use hearing aid, blaming others for hearing difficulties, increased arguments & withdrawal from family.

• Self-esteem disturbance r/t hearing loss aeb: expression of feelings of diminished self-worth, avoidance of people or suspiciousness of others.
• Impaired social interaction and/or social isolation r/t hearing loss aeb: diminished activity level and avoidance of people.

• Not all-older adults are hard of hearing but the functional status of hearing should be a part of every nursing assessment.
• Take the time to explain to the patient in detail the reason for the test, the procedures involved in the test, and any other helpful information about the experience. Allow time for the patient to process the information. Also alert other staff to the patient's level of hearing loss.
• Use and teach the following steps to effective communication with hearing impaired older adults:
• Have the person's attention before beginning to speak.
• Face the person you are speaking to and stand reasonably close to the listener.
• Avoid standing in the glare of bright sunlight or other lights.
• Lower the pitch of your voice and Avoid background noise.
• Speak clearly and slowly and Use short sentences.
• Encourage the use of nonverbal communication, such as touch.
• Use written communication if you are unable to communicate verbally.

• Hearing loss may exacerbate the confusional states of many nursing home residents especially those with dementia.
• Emphasize to the staff members the importance of allowing time for the residents to respond, recognizing each resident's unique abilities, and acquiring & using communication skills that are effective with the hearing impaired.
• Accumulation of cerumen needs constant assessment. If there are no contraindications irrigation as a method of cleansing is found to be effective.
• Use either a dental waterpik or a bulb syringe. Water should be tepid (not hot or cold)
• If cerumen is difficult to dislodge drops of mineral oil or a mixture of hydrogen peroxide & mineral oil may be used to soften the accumulation.
• Person's head should be titled toward the shoulder with a towel draped to catch draining water.
• The ear canal should be viewed with an otoscope both before and after the irrigation which purpose is to clear the canal.

• Family members need to understand the type of hearing loss the older patient is experiencing and how it affects daily living.

• It is crucial for nurses always to include an evaluative statement in the documentation of care.

Aspirin, chloroquine, cisplatin, erythromycin, furosemide (Lasix), gentamicin, indomethacin, kanamycin, neomycin, quinidine, quinine, streptomycin, tobramycin & vancomycin.

• Adaptation to changes in hearing is difficult.
• Hearing loss may be unrecognized.
• Corrective devices (i.e. hearing aids) are not always effective.
• Many older people consider hearing aids to be a negative sign of aging & disability.

J