Hearing, speech, and vision allow communication, learning, and moving about. They are important for self-care, work, and most activities. They also are important for safety and security needs. For example, you see dark clouds and hear tornado warning sirens. You know to seek shelter. With speech, you can alert others.

Many people have some degree of hearing or vision loss. Common causes are birth defects, accidents, infections, diseases, and aging.

Ear disorders

The ear functions in hearing and balance. To review the structures and functions of the ear, see Chapter 9.

Otitis media

Otitis media is infection (itis) of the middle (media) ear (ot). It often begins with infections that cause sore throats, colds, or other respiratory infections that spread to the middle ear. Viruses and bacteria are causes.

Otitis media is acute or chronic. Chronic otitis media can damage the tympanic membrane (eardrum) or the ossicles (Chapter 9). These structures are needed for hearing. Permanent hearing loss can occur.

Fluid builds up in the ear. Pain (earache) and hearing loss occur. So do fever and tinnitus. Tinnitus is a ringing, roaring, hissing, or buzzing sound in the ears or head. An untreated infection can travel to the brain and other structures in the head. The doctor orders antibiotics, drugs for pain relief, or drugs to relieve congestion.

See Residents With Dementia: Otitis Media.

RESIDENTS WITH DEMENTIA

Otitis Media

Some persons with dementia cannot tell you about pain or when something is wrong. Be alert for behavior changes. Report the following to the nurse. They may signal otitis media:

• Unusual irritability

• Problems sleeping

• Tugging or pulling at one or both ears

• Fever

• Fluid draining from the ear

• Balance problems

• Signs of hearing problems (p. 580)

Meniere’s disease

Meniere’s disease involves the inner ear. It is a common cause of hearing loss. Usually one ear is affected. Symptoms include:

• Vertigo (dizziness)

• Tinnitus

• Hearing loss

• Pain or pressure in the affected ear

With Meniere’s disease, there is increased fluid in the inner ear. The increased fluid causes swelling and pressure in the inner ear. Symptoms occur suddenly. They can occur daily or just once a year. An attack can last several hours.

An attack usually involves vertigo, tinnitus, and hearing loss. Vertigo causes whirling and spinning sensations. The dizziness causes severe nausea and vomiting.

Drugs, fluid restriction, a low-salt diet, and no alcohol or caffeine decrease fluid in the inner ear. Safety is needed during vertigo. The person must lie down. Falls are prevented. Bed rails are used according to the care plan. The person’s head is kept still. The person avoids turning the head. To talk to the person, stand directly in front of him or her. When movement is necessary, move the person slowly. Sudden movements are avoided. So are bright or glaring lights. Assist with walking. The person should not walk alone in case vertigo occurs.

Hearing loss

Hearing loss is not being able to hear the normal range of sounds associated with normal hearing. Losses are mild to severe. Deafness is the most severe form. Deafness is hearing loss in which it is impossible for the person to understand speech through hearing alone.

Hearing loss occurs in all age-groups. According to the National Institute on Deafness and Other Communication Disorders (NIDCD), about one third (33%) of Americans between ages 65 and 74 have hearing problems. About half (50%) of persons age 75 years and older have hearing loss. Hearing loss is more common in men than in women.

Common causes of hearing loss are:

• Damage to the outer, middle, or inner ear

• Damage to the auditory nerve

Risk factors that can damage ear structures include:

• Aging

• Exposure to very loud sounds and noises—job-related noises, loud music, loud engines from vehicles, shooting firearms

• Drugs—antibiotics, too much aspirin

• Infections

• Reduced blood flow to the ear caused by high blood pressure, heart and vascular diseases, and diabetes

Temporary hearing loss can occur from earwax (cerumen). Hearing improves after the earwax is removed.

Clear speech, responding to others, safety, and awareness of surroundings require hearing. Many people deny hearing problems. They relate hearing loss to aging.

See Focus on Communication: Hearing Loss.

FOCUS ON COMMUNICATION

Hearing Loss

The National Association of the Deaf (NAD) uses the terms deaf and hard-of-hearing to describe persons with hearing loss. Do not use the terms “deaf and dumb,” “deaf-mute,” or “hearing-impaired.” Such terms offend persons who are deaf or hard-of-hearing.

See Promoting Safety and Comfort: Hearing Loss.

PROMOTING SAFETY AND COMFORT

Hearing Loss

Safety

Do not try to remove earwax. This is done by a doctor or a nurse. Do not insert anything, including cotton swabs, into the ear.

Effects on the person

A person may not notice gradual hearing loss. Others may see changes in the person’s behavior or attitude. They may not relate the changes to hearing loss. Obvious signs and symptoms of hearing loss include:

• Speaking too loudly

• Leaning forward to hear

• Turning and cupping the better ear toward the speaker

• Answering questions or responding inappropriately

• Asking for words to be repeated

• Asking others to speak louder or to speak more slowly and clearly

• Having trouble hearing over the phone

• Finding it hard to follow conversations when two or more people are talking

• Turning up the TV, radio, or music volume so loud that others complain

• Thinking that others are mumbling or slurring words

• Having problems understanding women and children

Psychological and social changes are less obvious. People may give wrong answers or responses. Therefore they tend to shun social events to avoid embarrassment. Often they feel lonely, bored, and left out. Only parts of conversations are heard. They may become suspicious. They think others are talking about them or are talking softly on purpose. Some control conversations to avoid responding or being labeled “senile” because of poor answers. Straining and working hard to hear can cause fatigue, frustration, and irritability.

Hearing is needed for speech. How you pronounce words and voice volume depend on how you hear yourself. Hearing loss may result in slurred speech. Words may be pronounced wrong. Some have monotone speech or drop word endings. It may be hard to understand what the person says. Do not assume or pretend that you understand what the person says. Otherwise, serious problems can result. See “Speech Disorders” on p. 583.

Communication

Persons with hearing loss may wear hearing aids or lip-read (speech-read). They watch facial expressions, gestures, and body language. Some people learn American Sign Language (ASL) (Figs. 37-1 and 37-2). ASL uses signs made with the hands and other movements such as facial expressions, gestures, and postures. To promote communication, practice the measures in Box 37-1, p. 582. (Different sign languages are used in different countries and regions. For example, British Sign Language is different from ASL.)

Fig. 37-1 Manual alphabet. (Courtesy National Association of the Deaf, Silver Spring, Md.)

Box 37-1

Measures to Promote Hearing

The environment

• Reduce or eliminate background noises. Turn off radios, stereos, music players, TVs, air conditioners, fans, and so on.

• Provide a quiet place to talk.

• Have the person sit in small groups or where he or she can hear best.

The person

• Have the person wear his or her hearing aid. It must be turned on and working.

• Have the person wear needed eyeglasses or contact lenses. The person needs to see your face for lip-reading (speech-reading).

You

• Gain attention. Alert the person to your presence. Raise an arm or hand, or lightly touch the person’s arm. Do not startle or approach the person from behind.

• Position yourself at the person’s level. If the person is sitting, you sit. If the person is standing, you stand.

• Face the person when speaking. Do not turn or walk away while you are talking. Do not talk to the person from the doorway or another room.

• Stand or sit in good light. Shadows and glares affect the person’s ability to see your face clearly.

• Speak clearly, distinctly, and slowly.

• Speak in a normal tone of voice. Do not shout.

• Adjust the pitch of your voice as needed. Ask the person if he or she can hear you better:

• If the person does not wear a hearing aid, lower the pitch if you are a female. Women’s voices are higher-pitched and harder to hear than lower-pitched male voices.

• If the person wears a hearing aid, raise the pitch slightly.

• Do not cover your mouth, smoke, eat, or chew gum while talking. Mouth movements are affected.

• Keep your hands away from your face. The person must be able to clearly see your face.

• Stand or sit on the side of the better ear.

• State the topic of conversation first.

• Tell the person when you are changing the subject. State the new subject of conversation.

• Use short sentences and simple words.

• Use gestures and facial expressions to give useful clues.

• Write out important names and words.

• Say things in another way if the person does not seem to understand.

• Keep conversations and discussions short. This avoids tiring the person.

• Repeat and rephrase statements as needed.

• Be alert to messages sent by your facial expressions, gestures, and body language.

Some people have hearing assistance dogs (hearing dogs). The dog alerts the person to sounds. Phones, doorbells, smoke detectors, alarm clocks, sirens, and on-coming cars are examples.

Hearing aids

Hearing aids are electronic devices that fit inside or behind the ear (Fig. 37-3). They make sounds louder. They do not correct, restore, or cure hearing problems. Hearing ability does not improve. The person hears better because the device makes sounds louder. Background noise and speech are louder. The measures in Box 37-1 apply.

Fig. 37-3 A hearing aid. (Courtesy Siemens Hearing Instruments, Inc., Piscataway, NJ.)

Hearing aids are battery-operated. Sometimes they do not seem to work properly. Try these simple measures:

• Check if the hearing aid is on. It has an on and off switch.

• Check the battery position.

• Insert a new battery if needed.

• Clean the hearing aid. Follow the nurse’s directions and the manufacturer’s instructions.

Hearing aids are turned off when not in use. And the battery is removed. These measures help prolong battery life. The person should not use hair spray or other hair care products while wearing a hearing aid. They can damage the device.

Hearing aids are costly. Handle and care for them properly. When not in the person’s ear, store a hearing aid in its case. Place the case in the top drawer of the bedside stand. Report lost or damaged hearing aids to the nurse at once.

Other hearing devices

Other devices can help the person with hearing loss. They include:

• Telephone amplifying devices. Special telephone receivers make sounds louder. Some phones work with hearing aids.

• TV and radio listening systems. These can be used with or without hearing aids. The person does not have to turn the TV or radio volume up high.

Speech disorders

Speech is used to communicate with others. Speech disorders result in impaired or ineffective oral communication. Hearing loss, developmental disabilities (Chapter 45), and brain injury are common causes. The following are common problems.

• Aphasia. See “Aphasia.”

• Apraxia means not (a) to act, do, or perform (praxia). The person with apraxia of speech cannot use the speech muscles to produce understandable speech. The person understands speech and knows what to say. However, the brain cannot coordinate the speech muscles to make the words. Apraxia is caused by damage to the motor speech area in the brain.

• Dysarthria means difficult or poor (dys) speech (arthria). It is caused by damage to the nervous system. Mouth and face muscles are affected. Slurred speech, speaking slowly or softly, hoarseness, and drooling are other problems that can occur.

To communicate with the speech-impaired person, practice the measures in Box 37-2.

Box 37-2

Measures to Communicate With the Speech-Impaired Person

The person

• Ask the person to repeat or rephrase statements if necessary.

• Repeat what the person has said. Ask if your understanding is correct.

• Ask the person to write down key words or the message.

• Ask the person to point, gesture, or draw to communicate key words.

You

• Follow the care plan. A consistent approach is needed.

• Provide a calm, quiet setting. Turn off the TV, radio, music, and other distractions.

• Include the person in conversations.

• Listen, and give the person your full attention.

• Use short, simple sentences.

• Repeat what you are saying as needed.

• Write down key words as needed.

• Speak to the person in a normal, adult tone. Do not treat or talk to the adult in a babyish or child-like way.

• Ask the person questions to which you know the answers. This helps you learn how the person speaks.

• Allow the person plenty of time to talk.

• Determine the topic being discussed. This helps you understand main points. Watch the person’s lip movements.

• Watch facial expressions, gestures, and body language. They give clues about what is being said.

• Do not correct the person’s speech.

See Focus on Rehabilitation: Speech Disorders.

FOCUS ON REHABILITATION

Speech Disorders

Some persons need speech rehabilitation. The goal is to improve the person’s ability to communicate. A speech-language pathologist and other health team members help the person:

• Improve affected language skills

• Use remaining abilities

• Restore language abilities to the extent possible

• Learn other methods of communicating

• Strengthen the muscles of speech

The amount of improvement possible depends on many factors. They include the cause, amount, and area of brain damage and the person’s age and health. The person’s willingness and ability to learn are other factors.

Aphasia

Aphasia is the total or partial loss (a) of the ability to use or understand language (phasia). Aphasia is a language disorder. It results from damage to parts of the brain responsible for language. Stroke, head injury, brain infections, and cancer are common causes. Most people who have aphasia are middle-aged adults and older.

Expressive aphasia (motor aphasia, Broca’s aphasia) relates to difficulty expressing or sending out thoughts. Thinking is clear. The person knows what to say but has difficulty or cannot speak the words. There are problems speaking, spelling, counting, gesturing, or writing. The person may: