Download Hearing Loss in the Elderly

Sensory Impairment
Treatment Options
Module 3
Brenda K. Keller, MD
Geriatrics and Gerontology
University of Nebraska Medical Center
Objectives Module 3
Review treatment options for common
vision and hearing disorders
Understand techniques to improve function
for older people with low vision and hearing
loss.
Treatments for Visual Disorders
Cataracts
Treatment: Surgical Extraction
90% of patients achieve vision ≥ 20/40
Cataract extraction is one of the leading operations
performed on persons over 65 yrs of age1.5 million surgeries are performed annually in
US.
Local or topical anesthesia, small incision
sonographic breakdown and aspiration of the lens,
placement of an artificial lens
Age Related Macular Degeneration
Treatment
 Vitamins, antioxidants, zinc AREDS study
showed vitamins decrease risk of advanced
ARMD by 25% ( Dry)
• 500mg Vit C, 400 Vit E, 15 mg Beta Carotene, 80
mg zinc oxide, 2 mg cupric oxide
 Laser or intraocular pharmacotherapy
(wet)
Glaucoma
Management:
Intraocular pressure-lowering medications
 Local (eg, Xalatan, timolol, Alphagan)
 Systemic (eg, Diamox)
Argon laser trabeculoplasty
Intraocular surgery ± antimetabolites (mitomycin-C)
Drainage devices
Ciliary body destructive procedures
Diabetic Retinopathy
Treatment/prevention
Prevention:
Tight glucose control (A1C < 7 %)
and
BP control (≤140/80)
Treatment: laser photocoagulation to decrease
macular edema and inhibit growth stimulus for
neovascularization
Vision Rehabilitation
Available to those with vision worse than 20/60
Hearing Loss: Options for Treatment
Prosthesis: hearing aides
Assistive listening devices
Environmental changes
Cochlear implant
Hearing Rehabilitation
Hearing Aides
 Behind the ear
 In the ear
 In the canal
 Programmable
Hearing Aids
Two are better than one
Not everyone benefits, ie, those with:
 Central auditory processing problems
 Poor speech discrimination
 Dementia
Two types:
 Analog (less expensive)
 Digital (smaller, customizable)
Many available styles
Assistive Listening Devices
Pocket-sized, personal amplifiers
Telephone equipment: amplifiers, vibrating and flashing
ringer alert devices, text telephones (TTY)
Television listening devices
Vibrating and flashing devices for alarm clocks,
smoke alarms, doorbells, and motion sensors
Cochlear Implant
Electronic device that bypasses the function of
damaged or absent cochlear hair cells by providing
electrical stimulation to cochlear nerve fibers
Implantation requires extensive pre-implant testing,
post-implant training, and general anesthesia
Costs are partially covered by most Medicare carriers
and insurance companies; may require authorization
Outcomes for adults >65 years are comparable to
those of younger adults, with excellent audiologic
and quality-of-life measures
Improving Communication with
hearing impaired elderly
Be certain to have the person’s attention
Speak face-to-face
Repeat by paraphrasing
Speak at normal level to slightly louder
Speak a little more slowly
Stand within 2 - 3 feet
Improving Communication
with hearing impaired elderly
Reduce background noise
Pause at end of sentences
Avoid appearing frustrated
Write down key words if the person can
read
Have the person repeat to be certain
message was understood
Summary
Acknowledgments
Slides adapted with permission from the
American Geriatrics Society, Geriatric
Review Syllabus teaching slide set.
Permission granted 1-10-07
Post-test question 1
An elderly couple is seen in outpatient geriatric assessment
at the prompting of the wife. The 78-year-old husband was
diagnosed as having occupational hearing loss following
his retirement as a printing press operator 10 years ago, at
which time he purchased by mail a left-side in-the-ear
hearing aid. Initially he used the aide regularly; after he
lost the unit, however, he did not get a replacement. Since
then his wife feels that he has become more reclusive,
refusing to accompany her to social gatherings. He
declined an offer from his children to purchase a new aid
as a holiday gift, saying that the last one "didn't seem to
help that much." The wife feels both angry with his
recalcitrance to obtain another hearing aid and concerned
about his possible depression.
Which of the following would be most appropriate to
stress in advising the patient about going for formal
hearing evaluation?
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.
Which of the following would be most appropriate
to stress in advising the patient about going for
formal hearing evaluation?
A. Bilateral hearing aids may significantly
help with speech recognition.
B. Newer, "hidden" in-the-canal hearing-aid
models provide the loudest amplification.
C. His prior experience with the older hearing
aid means he will do well with another one.
D. His wife should repeat misunderstood
phrases more loudly
Correct Answer: A. Bilateral hearing aids may
significantly help with speech recognition.
Use of hearing aids remains an underutilized rehabilitative
strategy for many elderly persons who otherwise might
gain important health benefits from some form of
amplification. Men typically underestimate both the degree
and the consequences of their hearing impairment.
Reinforcement by the physician of the need to improve
poor hearing is an important step. Speech discrimination is
one of the most important benefits than can result from
binaural amplification. While doubling the cost, two aides
may jointly allow a lower, more tolerable level of
amplification with better overall speech perception due to
an improved signal-to-noise ratio.
The most appropriate type of hearing aid for a
patient is best determined after audiologic
assessment. The latest technology features very
small units placed inside the auditory canal with
only a small "tail" used for retrieval. Such units
are appealing cosmetically; however, they require
considerable manual dexterity to operate and are
easily lost, a recurring problem for this patient. In
addition, a person's prior successful use of one
type of hearing aid may not predict how well he
will tolerate new types of amplification devices.
Altered speech is rarely an effective way to
improve overall speech recognition in a hearingimpaired person because it distorts the facial
expressions, intonations, and nonverbal cues. Most
meaningful portions of speech are contained in
higher-pitch consonant sounds. As these higher
frequencies are often missed with the common
causes of hearing loss in older age (eg,
presbycusis), repeating the exact phrases initially
missed by the hearing-impaired person is often not
effective. A better strategy is to attempt to rephrase
the statement using words that sound different but
convey the same meaning.
Post-test question 2
Which of the following is the most appropriate
device for an older patient who is primarily
homebound and has a severe bilateral, symmetric
sensorineural hearing loss; moderately severe
rheumatoid arthritis of the hands; and a strong
desire to minimize health care costs?
A. Body-worn hearing aid
B. Behind-the-ear hearing aid
C. Hard-wired system such as a Pocket Talker
D. Completely in-the-canal hearing aid
E. In-the-ear hearing aid
Correct Answer: C. Hard-wired system such as a
Pocket Talker
Feedback:
The major complaints of persons with presbycusis are
difficulty hearing in noisy environments and when the
speaker is at a distance. Hearing assistive devices,
rehabilitative technologies, or assistive technologies are
devices that improve communication efficiency in quiet,
noisy, and reverberating environments when hearing aids
are not appropriate or are not sufficient. To explain, the
intensity of the desired signal relative to the intensity of
background noise is referred to as the signal-to-noise ratio.
The more favorable the ratio, the better speech
understanding. A well-recognized strategy for improving
speech recognition in rooms is the use of personal room
amplification systems or hearing assistive devices.
A hard-wired system is a device wherein a wire connects
the microphone of the speaker to the amplifier and the
amplifier to the receiver used by the listener. Thus, there is
a direct physical connection or hard wiring between the
sound source and the individual. These devices have
proven beneficial for persons who cannot manage hearing
aids because of manual dexterity problems or dementia.
Some advantages include their inexpensiveness, their
helpfulness for patients who cannot use hearing aids, their
utility in physicians' offices to ease communication with
hard-of-hearing patients, and their ease of connection, use,
and purchase. A body-worn hearing aid would be a poor
choice for this patient. These devices are presently limited
in their availability; in addition, they are bulky and too
costly for the person described in the case.
Behind-the-ear hearing aids (analog, programmable, or
digital) are excellent for active older adults with severe
sensorineural hearing loss who have significant
communication demands and who can afford the device.
This patient is unlikely to be able to manipulate such a
hearing aid comfortably and would likely find such a
choice too expensive. Completely in-the-canal and in-theear hearing aids are excellent for persons with significant
communication demands or severe hearing loss, but they,
too, are too costly for persons on a limited income and too
difficult for persons with manual dexterity problems to
manipulate independently. Medicare does not pay for
hearing aids. The average price of traditional units in 1999
ranged from $782 for an analog nonprogrammable behindthe-ear unit (the most simple) to $1270 for an analog
nonprogrammable completely in-the-canal unit to $2673
for a completely in-the-canal unit that is digital signalprocessing programmable. The clinician must consider a
host of factors, both audiologic and nonaudiologic, when
recommending hearing aids for a particular patient. End
Vision Acknowledgments
Co-Editors:
Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Authors:
David Sarraf, MD
Anne L. Coleman, MD, PhD
GRS6 Question Writer:
Gwen K. Sterns, MD
Medical Writer:
Barbara B. Reitt, PhD, ELS (D)
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society
Hearing Acknowledgments
Co-Editors:
Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Author:
GRS6 Question Writer:
Priscilla Faith Bade, MD, MS
Barbara E. Weinstein, PhD
Medical Writer:
Barbara B. Reitt, PhD, ELS (D)
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society