Download Hearing Loss in the Elderly

Sensory Changes of Aging
module 1
Brenda K. Keller, M.D.
Geriatrics and Gerontology
University of Nebraska Medical Center
PROCESS
Series of 3 modules and questions on
1. Sensory Changes of Aging
2. Diseases and Disorders of the special senses
3. Treatments for vision and hearing
impairment
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a break
Objectives
Recognize physiologic changes in the
sensory system.
Describe the epidemiology of sensory loss.
Demonstrate how to screen for sensory loss
Age Related Changes in Vision
Decreased accommodation
 hard to focus on close objects
 Caused by gradual hardening of the lens and decreased
muscular effectiveness of the ciliary body
Yellow tint to vision
 discoloration of the cornea
 decreased sensitivity of blue-yellow
receptors
Reduced tolerance for glare
Decreased contrast sensitivity
Contrast Sensitivity
Vision Changes with Aging
Slower adaptation to low light
 Pupil size decreases allowing less light into the
eye.
Decreased night vision
 Fewer light sensing cells
 Increased need for
illumination in elderly
Normal Hearing
Sound energy is transmitted through the external ear
to the tympanic membrane and auditory ossicles
Malleus, incus, and stapes transmit vibrations to the
oval window of the cochlea
Fluid waves stimulate hair cells and generate sensory
potential
An excitatory postsynaptic potential is generated
When threshold is reached, impulses are sent via
cochlear neurons to the cochlear nuclei and then to
auditory pathways in the brain
Age-Related Changes That Can
Interfere With Hearing
External ear canal: Walls thin
Cerumen: Becomes drier, more tenacious
Eardrum: Thickens, appears duller
Cochlea: Hair cells are lost, basilar membrane stiffens,
auditory structures calcify, cochlear neurons are lost
Stria vascularis: Capillaries thicken, endolymph production
decreases, Na+ K+ ATPase activity decreases
Brain: Atrophic changes in temporal auditory cortex
Visual Impairment
Visual impairment (acuity < 20/40)
 Prevalence increases with age
 Affects 20% to 30% of those aged 75+ years
Blindness (acuity < 20/200)
 Prevalence: 2% of those aged 75+ years
 50% of blind population is aged 65 and older
Most common cause of blindness in the elderly US
population is ARMD; other causes are refractive error,
cataract, diabetic retinopathy, glaucoma
Epidemiology of Hearing Loss
Prevalence increases with age
% of population
25
20
15
10
5
0
Age 65-75
Age >75
50%–100% of nursing home residents have hearing
loss
Smokers have higher rates of hearing loss
The Impact of Hearing Loss
The 4th most common chronic disease among elderly
persons
Often considered benign, but profoundly affects
quality of life
May contribute to family discord, social isolation,
loss of self-esteem, anger, depression
Treatment can improve quality of life by facilitating
interaction with family, friends, and caregivers
Screening for Vision Loss
Near vision: Rosenbaum Card, 16 inches
Far vision: Snellen Chart, 20 feet
Fundoscopic evaluation
Questionnaires
Screening for Hearing Loss
Whisper test
Hand held audioscope
Questionnaires: HHIE
Full audiometric testing- pure tone
audiogram, Speech discrimination
Hearing Handicap Inventory for
Elderly
Identifies social and emotional impact of hearing loss.
Emotional
Embarrassment
Frustration
Handicap
Family arguments
Hampered social life
Social
Difficulty hearing
• Whispers
• Family conversations
• Television
Troubles due to
hearing at:
• Religious services
• Restaurants
Adapted from Ventry IM, Weinstein BE; Indentification of elderly people with hearing problems, American Speech-LanguageHearing Association 25:37,1983
When to Refer
Routine visit to Ophthalmologist q 1-2
years, tonometry, slit lamp, full dilated
exam*
Refer sooner if vision worse than 20/40
* By the American Academy of Ophthalmology
and USPSTF
When to Refer
Otolaryngologist
 Consult for asymmetrical hearing loss, which may
indicate tumor of posterior pharynx blocking eustachian
tube or auditory nerve tumor
Audiologist
 Consult to determine the presence and type of hearing
loss, recommend and fit hearing aids, and provide
auditory rehabilitation
 Assessment includes evaluation of pure-tone thresholds
for both air and bone conduction, speech-recognition
thresholds, speech discrimination, and middle-ear
function
Mild
Moderate
Moderately severe
Severe
Profound
Permission to use
applied for 1-12-07
Summary
Age related changes with vision and
hearing
Epidemiology
Screening techniques
Acknowledgments
Slides adapted with permission from the
American Geriatrics Society, Geriatric
Review Syllabus teaching slide set.
Permission granted 1-10-07
Post-test question one
A 74-year-old woman has difficulty seeing when
she drives. Six months ago, ophthalmologic
examination revealed small bilateral cataracts that
did not interfere with her corrected vision, which
was 20/30 in the right eye and 20/40 in the left
eye. She had no signs of glaucoma or macular
degeneration. Current examination confirms
corrected vision of 20/30 in the right eye and
20/40 in the left eye. What is the most appropriate
next step?
A. Observation
B. Measurement of visual acuity in ambient light
C. Slitlamp examination
D. Automated perimetry
E. Applanation tonometry
Correct Answer: B. Measurement of visual
acuity in ambient light
This patient has normal visual acuity when it is
measured in the office setting, but outdoor light
may create a disabling glare when she is driving.
Visual acuity testing in ambient sunlight will
reveal the extent of this visual disability and its
cause. The need for cataract surgery should be
based on the extent of visual disability
experienced by the patient. Cataract surgery is
justified and appropriate when subjective,
objective, and educational criteria are met.
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
If the best correctable visual acuity in the affected eye is
20/50 or worse and the cataract is responsible for this
impairment, then objective criteria for cataract surgery are
met. However, subjective criteria are equally as important.
If, as in this case, visual disability fluctuates as a result of
the environment (eg, effects of glare, such as lights of
oncoming cars or bright sunlight), there may be additional
justification for cataract surgery. The differences between
measured acuity in a darkened room (and high-contrast
chart) and that with ambient light producing glare and
reduction of functional acuity need to be documented.
When such a verifiable reproducible loss of vision can be
documented mimicking the patient's vision disturbance, the
patient should be considered for cataract surgery.
In addition to the subjective and objective criteria
for cataract surgery, educational criteria must also
be met. The patient should be educated about the
risks and benefits of cataract surgery, including
treatment alternatives. The patient must determine
if the expected reduction in disability outweighs
the potential risk, cost, and inconvenience of
surgery. As a general rule, the better the Snellen
acuity, the greater the need for verification and
documentation of functional disability. Additional
reasons that patients may note functional disability
with Snellen testing of 20/40 or better include
visual disparity between the two eyes, monocular
diplopia or polyopia, or the need but inability to
obtain an unrestricted driving license.
A slitlamp consists of a microscope and a special
light source. Slitlamp examination, also known as
biomicroscopy, is indicated for any condition of
the eyelids or eyeball, such as dendritic keratitis or
a corneal foreign body, that can be better
diagnosed and treated after evaluation using a
well-illuminated and highly magnified view of the
area involved. This type of examination is not
appropriate for this patient. Automated perimetry
is used to measure visual fields and is useful in the
detection of peripheral field deficits encountered
with glaucoma and for monitoring the course of
glaucoma. Applanation tonometry measures the
force required to flatten a small area of the central
cornea in order to measure intraocular pressure. It
is useful in detecting and monitoring glaucoma.
Post-test question 2
Which of the following is the most common
pattern of hearing loss among older
Americans?
A. Symmetric high-frequency sensorineural
B. Symmetric high-frequency conductive
C. Asymmetric high-frequency conductive
D. Symmetric low-frequency sensorineural
E. Asymmetric high-frequency sensorineura
Correct Answer:
A. Symmetric high-frequency sensorineural
Hearing loss associated with aging affects nearly 40% of
persons aged 65 and over. The prevalence is as high as
80% among nursing-home residents. Cross-sectional and
longitudinal studies consistently reveal that hearing
sensitivity declines with age, more prominently in high
than in low frequencies. Presbycusis is the bilateral,
symmetric, high-frequency sensorineural hearing loss that
affects older adults. This tends to be gradual in onset and
mild to moderate in severity. Risk factors include noise
exposure and elevated systolic blood pressure. Overall,
men have poorer hearing than women.
Presbycusis is associated with difficulty
understanding speech, especially in the presence
of noise. Hence, the primary complaint of older
adults is that they have difficulty understanding
others, especially in a noisy room or when the
speaker is standing at a distance. Older adults
often blame hearing loss on an accumulation of
cerumen, but this usually is not responsible.
Asymmetric hearing loss raises concerns about
less common conditions, such as acoustic
neuroma. End