IMPAIRMENTS
One of the greatest challenges in the geriatric population is their ability to communicate their problems, needs, and desires in a medical setting. Hearing and visual impairments can hamper a patient's ability to express himself or herself clearly or to understand questions or commands.
This is an enormous burden on the patient, the caregiver, and the physiatrist as they work to achieve rehabilitation goals. Addressing these issues on the patient's initial visit can ameliorate problems and prevent frustration and further difficulties.
AUDITORY IMPAIRMENT
How many times have you had to shout at a patient? The likelihood that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years.
The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly.
Not all hearing impairments are reversible.
Examples of impairments that are potentially reversible involve cerumen, cholesteatomas, or acoustic neuromas. These conditions should be recognized and the patient referred to an appropriate subspecialist, such as an ear, nose, and throat (ENT) specialist or a neurosurgeon.
Initial otoscopic examination for cerumen or serous otitis is essential.
Cerumen obstruction often contributes to hearing loss, and its removal can dramatically improve auditory acuity. This examination should be performed prior to any testing for hearing loss.
Otosclerosis or noise-related cochlear damage can be surgically treated with bone removal or cochlear implants, respectively.
However, gradual decline in hearing acuity, or presbycusis, is due to degeneration of the organ of Corti, and it can simply be a result of aging. Most people acquire a conductive hearing loss with a narrow range of audibility, an inability to hear high-frequency sound, and difficulty in discriminating complex sounds.
Hearing deficits are associated with paranoia, and they can also lead to depression, anxiety, and insecurity. Safety concerns are also an issue in the hearing impaired, and these issues need to be addressed as a part of aural rehabilitation.
CONSEQUENCES OF AUDITORY IMPAIRMENT
Hearing loss has a major contribution to communication and quality-of-life issues. People who use hearing aids are more likely than others to report improvements in their physical, emotional, and social comfort. In a study by Keller et al, patients with intact hearing scored 2 points higher than did patients with hearing impairment. The investigators also found that patients with intact hearing also scored 6 points higher for instrumental ADLs (IADLs).
IADLs include pertinent life tasks, such as writing checks and interacting with the public during financial transactions (ie, grocery shopping). These findings represent a significant difference in ADLs and IADLs and shows that hearing loss can affect a person's functional status.
This possibility for improved function emphasizes the need for hearing evaluations and treatment to help the patient make the maximal gains possible during rehabilitation. The individual's ADL functional level in the rehabilitation setting often determines his or her need for in-home supervision, assistance (eg, during bathing), and ancillary services (eg, those provided by social service organizations such as the Department on Aging and Meals on Wheels).
Again, enhanced communication during therapy is important because entire functional independence measure (FIM) scores can be upgraded with this measure alone.
Hearing loss can result in withdrawal, poor self-concept, depression, frustration, irritability, cognitive impairment, isolation, loneliness, and compromised physical mobility. Solutions to hearing impairment positively affect one's daily functioning and psychosocial well-being.
Improvement is noted in various areas: communicating the needs of daily living, telephone communication (social and emergency situations), psychosocial behavior, family relationships, enjoyment of leisure activities, and ability to live independently and safely.
Screening for hearing loss is a valuable tool for early intervention. It is useful to ask patients and their family members about any changes in the patient's hearing, the onset and progression of impairments, and the sidedness of symptoms (ie, whether they are unilateral or bilateral).
Further investigation can reveal a patient's difficulty in understanding women and children (because of the higher frequency of their voices), telephone conversations, television sounds, or voices when more than 1 person is speaking. Also, an avoidance of family functions, movies, and religious services because of changes in hearing is an important indicator of the severity of the disease. Such behavior indicates a significant functional loss.
Hearing acuity can be tested by using simple methods such as asking the patient to identify the presence of 2 fingers rubbing together by his or her ear.
Difficulties with speech comprehension can be evaluated by using the whisper test, in which one whispers 10 words while standing 6 inches behind the patient. If the patient cannot repeat 50% of the words, he or she may have dysfunctional auditory processing. Unfortunately, the whisper test has only moderate repeatability.
When a hearing impairment is established, a formal consultation with an audiologist and the involvement of a speech and language pathologist are pertinent.
Speech therapists can begin cognitive testing and provide continuous enhancement of a patient's communication skills during audiologic assessment and aural rehabilitation. There are a growing number of underserved individuals with a combination of multiple sensory, physical, and cognitive impairments, and all of these issues must be identified in the rehabilitation setting.
MANAGEMENT OF AUDITORY IMPAIRMENT
Audiologists perform quality control, physical fitting, and performance assessment of hearing aids to ensure that treatment goals have been met.
Audiologists instruct patients and their families about proper use and care of hearing aids. Audiologists must also train allied health professionals and support staff who work in rehabilitation facilities regarding daily monitoring as part of a comprehensive hearing support program.
If the patient's vision is adequate, speech therapists often incorporate speech (lip) reading and the use of hand signs, gestures, writing boards, and/or magnetic boards to overcome communication barriers. A well-lit environment is effective for augmenting auditory input to a patient who also requires visual cues.
It is important for the physician and staff to establish good visual contact while facing the patient, to reduce background noise, to rephrase misinterpreted words instead of simply repeating them, and to pause at the end of phrases or ideas. Standing 0.75-1 m from the patient and speaking slightly louder also facilitates communication.
Most patients achieve a substantial benefit with speech reading and audiovisual integration training; for example, recognition can be improved by as much as 26%, as Grant reported. The amount of visual influence is correlated with enhanced auditory recognition. Also, simple modifications, such as carpeting common areas to reduce reverberation and establishing quiet areas, can improve communication with the patient.
Assistive listening devices such as closed-captioned television and telephone amplifiers may help patients in performing their ADLs. Safety is also a focal rehabilitation issue because many warning signs (eg, cars on the road, ambulances, fire alarms) are auditory.
Addressing safety issues is salient in ordinary and emergency situations, and adaptive devices that vibrate or that have flashing lights (eg, adapted fire alarms, telephones, doorbells) should be incorporated into the patient's home and rehabilitation setting.
In geriatric patients, the primary treatment for loss of auditory sensitivity caused by sensorineural hearing loss is the use of a hearing aid, as part of a total aural rehabilitation program. Modern hearing-aid technology has been advancing, and current aids can help in reducing the communication problems of individuals with hearing impairment.
Hearing aids consist of the following components: a microphone (to pick up a signal), an amplifier (to make sounds louder), a receiver (to deliver sounds), a battery, and an ear mold with tubing. Different types of hearing aids include conventional analog; programmable; and digital types, which have the least amount of distortion.
Audiologists must conduct a thorough evaluation, including impedance audiometry to assess the patient's middle-ear function and a check of the acoustic reflex to match the appropriate external and internal features of the hearing aid to the needs of the patient.
Psychologically, patients are good candidates for hearing aids if they are not concerned about the possible stigma attached to the cosmesis of hearing aids. Socially, patients should have support networks, which can assist them with the insertion, removal, and adjustment of the hearing aid if needed.
In hearing-impaired patients, rehabilitation comprises the provision of a custom-fitted hearing aid and instruction on its use and maintenance. Progress during rehabilitation depends on patient and family education to help the patient adjust to the hearing loss and the use of hearing aids.
Family training with a speech therapist is also crucial to teach them about auditory enhancement techniques and communication skills.
Improving the geriatric patient's ability to hear can lead to significant gains in terms of rehabilitation and the patient's overall quality of life. Physicians should evaluate their patient's hearing on a regular basis and consider the management of hearing deficits as they care for their patients.
VISUAL IMPAIRMENT
With aging, the gradual deterioration of sensory modalities, including vision, can interfere with one's daily activities. Nearly 7% of patients admitted to inpatient rehabilitation units have a severe visual impairment.
A visual impairment is defined as visual acuity of 20/40 or worse and legal blindness is defined as visual acuity of 20/200 or worse.
Testing for near vision is performed independently in each eye, with the aid of glasses (if worn). The patient holds the Rosenbaum card at a reading distance of 14 in. Or, if the Lighthouse near-acuity test is used instead, the card is held at 16 in.
Far-vision testing can be accomplished with the Snellen wall chart at a distance of 20 ft. The patient's visual fields should also be checked for peripheral vision, hemianopsia, and other conditions. The extraocular muscles should be evaluated during the physical examination as well.
An ophthalmoscopic evaluation for drusen, hemorrhages, and ischemia should be performed.
If any change in vision is noted or if the patient reports a functional deficit, follow up with an ophthalmologist is warranted to evaluate and issue the proper low-vision aids.
Prevention is managed by performing biennial full-eye examinations in people older than 65 years, with annual evaluations in those with diabetes.
The most common visual change with increasing age is a gradual loss of the ability to focus on near objects (presbyopia). By the age of 75 years, 92% of individuals have presbyopia. Cataract formation (lens opacity) occurs to some degree in 95% of people older than 65 years.
Geriatric patients are also prone to further visual impairments such as glaucoma (intraocular pressure >21 mm Hg), which can be medically or surgically managed; age-related macular degeneration (ARMD), which involves atrophy of the central macular cells in the retinal pigment; and diabetic retinopathy (eg, microaneurysms, dot hemorrhages), which can be managed with glycemic control or laser surgery.
The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night.
CORRECTION AND MANAGEMENT OF VISUAL IMPAIRMENT
In the majority of the geriatric population, eyeglasses are sufficient to correct the visual impairments described above. However, for those who have become legally blind, the adjustment is difficult.
Unlike individuals who were blind from an early age and who learned Braille as part of their developmental language, those who become legally blind in adulthood rarely master Braille for communication purposes.
They focus primarily on tactile interpretation for face-to-face communication. Speech therapists are instrumental in improving the patient's communication skills in this situation.
Low-vision rehabilitation includes the use of adaptive optical devices that improve illumination and increase contrast and magnification. Transitional-lens eyeglasses reduce the symptoms of glare and photosensitivity and automatically adjust to the ambient light so that the patient does not need to have separate pairs of glasses for inside and outside use.
Prism glasses can aid in expanding the patient's visual field. Binoculars or clip-on monocular telescopes are conventionally used to observe sporting events or for bird watching. Low-vision aids are an effective means of visual rehabilitation, helping almost 9 of 10 patients with an impaired ability to read.
Large-print material and devices (eg, telephone with large numbers) can facilitate the patient's daily activities. Similarly, talking clocks and watches are also useful. Handheld or standing magnifying glasses are inexpensive and effective for reading small print, such as that on price tags or financial statements.
Tactile feedback is important in patients with visual impairment; therefore, raised-dot dials on kitchen appliances are a preventive safety measure. Auditory assistance is also important. Books on audiotapes and closed-circuit televisions are available for the patient's leisure.
In patients with ARMD, the presentation of 1 word at a time in the center of a display screen is easier than scrolling across the screen to read filtered text. Text filtering can help in enhancing images shown on digitally based viewing devices (eg, televisions, computers) and can be helpful in those with visual impairments; such text filtering should be tailored to the needs of the particular patient.
An occupational therapist, rehabilitation nurse for the blind, or teacher can instruct the patient about how to use labeling systems to identify their clothes and medication, among other items, and patient can learn to fold their money in various ways to indicate the denomination.
Other environmental considerations include the use of floor lamps to reduce glare and the installation of motion sensors to turn on lights. Mobility aids include a long cane, a guide dog, or a friendly arm.
CONSEQUENCES OF VISUAL IMPAIRMENT
Vision impairment exerts a more wide-ranging impact on functional status than does hearing impairment. Visual impairment is associated with increased physical disability, increased social isolation, low employment rates, reduced self-image, and depression.
Physical disabilities include a decreased ability to perform ADLs and IADLs decreased physical endurance and mobility, and a lack of participation in activities.
Vision, proprioception, and vestibular function are the 3 main components of sensory feedback to maintain normal upright stance.
Therefore, a loss of vision is associated with an increased risk of falling with a consequent increased risk of hip fractures. The patient's mental health can also deteriorate with vision loss, and the effects can include depressive episodes. Social isolation, in which the person feels left out and lonely, can lead to depression.
Neuropsychologists may alert physicians about the patient's mood. The patient's primary physician should be aware of any vision impairment that might be improved with devices or environmental changes; these treatment approaches must not be overlooked in the rehabilitation setting.
Utilization of healthcare resources and assistance increases in the geriatric population with visual impairment because of their decreased level of function overall.
The degree of visual impairment prevents most of these individuals from performing many ADLs and IADLs. Keller et al note an 18% visual impairment rate in a large cross-section of the geriatric population in one clinic. Mean functional status scores for patients with good visual acuity are higher than those with visual impairment; scores are 2 points higher on ADL assessment and 6 points higher on IADL assessment, which includes an evaluation of the person's ability to manage his or her finances, medication regimen, meal preparation, housekeeping, shopping, uses of a telephone, and transportation.
Low vision frequently coexists with other disabilities, including hearing loss, cognitive impairments, and mobility limitations. Dual sensory loss involving visual and hearing impairments is associated with a significant decrease in function, compared with the effect of a single sensory loss.
The geriatric population with dual visual and hearing impairments is 2 times more likely than those without such impairments to have difficulty with ambulation, transferring, meal preparation, and managing their medication regimen.
According to the 1999 Surveillance for the Sensory Impaired study, older adults who reported vision and hearing loss were more likely than those without sensory impairment to have had the following:
(1) A fall during the preceding year (37.4% vs 19.8%)
(2) A hip fracture (7.6% vs 4.5%)
(3) A higher reported prevalence of hypertension (53.4% vs 44.3%)
(4) A higher rate of heart disease (32.2% vs 20.6%)
In addition, these older adults with dual impairments were twice as likely as the others to have a stroke (17.4% vs 7.3%).
CONCLUSION
Greater attention to sensory impairments by clinicians, public health advocates, and researchers, as well as patient and family education and compliance, are needed to enhance function and progressive rehabilitation in the geriatric population.