Elderspeak

Elderspeak is a form of ageism in which younger people alter their speech, based on the assumption that all older people have difficulty understanding and comprehending (Touhy and Williams, 2008). It is especially common in communication between health care professionals and older adults in hospitals and nursing homes, but occurs in non–healthcare settings as well (Williams et al., 2003, 2004,2008; Williams, 2006; Williams and Tappen, 2008; Herman and Williams, 2009). Elderspeak is similar to “baby talk,” which is often used to talk to very young children (Box 6-1).

Nurses may not be aware that they are using elderspeak, but research has shown that use of this form of speech is patronizing and conveys messages of dependence, incompetence, and control (Williams, 2006; Williams et al., 2008). Some features of elderspeak (speaking more slowly, repeating, or paraphrasing) may be beneficial in communication with older people with dementia, and further research is needed. Other examples of communication that conveys ageist attitudes are ignoring the older person and talking to family and friends as if the person were not present, and limiting interaction to task-focused communication only (Touhy and Williams, 2008).

Hearing Impairment

Although both vision and hearing impairment significantly affect all aspects of life, Oliver Sacks (1989), in his book Seeing Voices, presents a view that blindness may in fact be less serious than loss of hearing. Hearing loss interferes with communication with others and the interactional input that is so necessary to stimulate and validate. One elderly man said that a great annoyance of hearing loss is in the subtle aspects of living with a partner, who most probably has a hearing loss as well. “You must often repeat what you say, and in lovemaking, whispering sweet words becomes a gesture for yourself alone.” Helen Keller was most profound in her expression: “Never to see the face of a loved one nor to witness a summer sunset is indeed a handicap. But I can touch a face and feel the warmth of the sun. But to be deprived of hearing the song of the first spring robin and the laughter of children provides me with a long and dreadful sadness” (Keller, 1902).

Hearing loss is the third most prevalent chronic condition in older Americans and the foremost communicative disorder of older adults. The prevalence of hearing loss is 90% in those older than 80 years. Hearing loss is a common condition in middle-aged adults as well. Estimates are that 20.6% of adults aged 48 to 59 years have impaired hearing. A recent study suggests that cardiovascular disease risk factors may be important correlates of age-related auditory dysfunction. Hearing loss may not be an inevitable part of aging and if detected early, it may be a preventable chronic disease because the same healthy lifestyle changes that improve cardiovascular health may also prevent or delay hearing loss (University of Wisconsin School of Medicine and Public Health, 2011). In all age groups, men are more likely than women to be hearing-impaired.

Hearing loss diminishes quality of life and is associated with multiple negative outcomes including decreased function, miscommunication, depression, falls, loss of self-esteem, safety risks, and cognitive decline (Wallhagen and Pettengill, 2008). Hearing impairment increases feelings of isolation and may cause older adults to become suspicious or distrustful or to display feelings of paranoia. Because older persons with a hearing loss may not understand or respond appropriately to conversation, they may be inappropriately diagnosed with dementia. Older people may be initially unaware of hearing loss because of the gradual manner in which it develops (Box 6-2). The Better Hearing Institute (Washington DC) provides an online hearing test for older adults who want to check their own hearing (see http://www.betterhearing.org/hearing_loss/online_hearing_test/index.cfm).

Hearing impairment is underdiagnosed and undertreated in older people. Although screening for hearing impairment and appropriate treatment are considered an essential part of primary care for older adults, it is rarely done. A single question—Do you feel you have a hearing loss?—has been shown to have reasonable sensitivity and specificity for hearing impairment (Schumm et al., 2009). Findings of a study performed in 2008 (Box 6-3) suggest that hearing loss is “an overlooked geriatric syndrome in primary care settings—an assessment gap that can have significant negative consequences” (Wallhagen and Pettengill, 2008, p. 41).

The screening rate for hearing impairment among older adults is estimated to be as low as 12.9%, and only about 20% of persons with hearing impairments receive hearing aids (Ham et al., 2007; Wallhagen and Pettengill, 2008). Factors associated with lack of hearing aid use include cost, perceived lack of benefit, and denial of hearing loss. Wallhagen (2009) also suggests that the perceived stigma associated with hearing loss and use of hearing aids is another factor that should be examined. The cost of hearing aids is not covered under Medicare and other health plans, but screening for hearing loss is recommended as part of the comprehensive physical for older adults joining Medicare for the first time (Chapter 2).

Tinnitus

Tinnitus is defined as the perception of sound in one or both ears or in the head when no external sound is present. It is often referred to as “ringing in the ears” but may also manifest as buzzing, hissing, whistling, cricket chirping, bells, roaring, clicking, pulsating, humming, or swishing sounds. The sounds may be constant or intermittent and are more acute at night or in quiet surroundings. The most common type is high-pitched tinnitus with sensorineural loss; less common is low-pitched tinnitus with conduction loss such as is seen in Meniere’s disease.

Tinnitus generally increases over time. It is a condition that afflicts many older people and can interfere with hearing, as well as become extremely irritating. It is estimated to occur in nearly 11% of elders with presbycusis. Approximately 50 million people in the United States have tinnitus and about 2 million are so seriously debilitated that they cannot function on a “normal,” day to day basis The incidence of tinnitus peaks between ages 65 and 74 and is higher in men than in women; in men, the incidence seems to decrease after this age. Tinnitus is a growing problem for America’s military personnel and is the leading cause of service-connected disability of veterans returning from Iraq or Afganistan (American Tinnitus Association, 2010).

The exact physiological cause or causes of tinnitus are not known but there are several likely factors that are known to trigger or worsen tinnitus. Exposure to loud noises is the leading cause of tinnitus and the exposure can damage and destroy cilia in the inner ear. Once damaged, they cannot be renewed or replaced. See http://www.ata.org/for-patients/at-risk#Loud for a video of ways to mitigate noise exposure. Other possible causes of tinnitus include head and neck trauma, certain types of tumors, cerumen build-up, jaw misalignment, cardiovascular disease, and ototoxicity from medications. More than 200 prescription and nonprescription medications list tinnitus as a potential side effect, aspirin being the most common.

A hearing aid is a personal amplifying system that includes a microphone, an amplifier, and a loudspeaker. There are numerous types of hearing aids. The behind-the-ear hearing aid looks like a shrimp and fits around and behind the ear. It is less commonly used now than the small, in-the-ear aid, which fits in the concha of the ear (Figure 6-1). The appearance and effectiveness of hearing aids have greatly improved, and many can be programmed to meet specific needs. Most individuals can obtain some hearing enhancement with a hearing aid.

Although hearing aids generally improve hearing by about 50%, they do not correct hearing deficits. It is important that hearing-impaired elders understand that the goal of hearing aid use is to improve communication and quality of life, not to restore normal hearing.

Hearing aids necessitate a period of adjustment and training in correct use. In most states, the purchase of a hearing aid comes with a 30-day trial during which the purchase price is totally refundable. The investment in a good hearing aid is considerable, and a good fit is critical. Before a hearing aid can be purchased, medical clearance must be obtained from a physician. Hearing aids can range in price from about $500 to several thousand dollars, depending on the technology. Batteries are changed every 1 to 2 weeks, adding to overall costs. The cost of hearing aids is not usually covered by health insurance or Medicare.

It is important for nurses in hospitals and nursing homes to be knowledgeable about the care and maintenance of hearing aids. Many older people experience unnecessary communication problems when in the hospital or nursing home because their hearing aids are not inserted and working properly, or are lost. Box 6-5 presents suggestions for the use and care of hearing aids.

Cochlear Implants

Cochlear implants are increasingly being used for older adults who are profoundly deaf as a result of sensorineural hearing loss. A cochlear implant is a small, complex electronic device that consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin (Figure 6-2). Unlike hearing aids that magnify sounds, the cochlear implant bypasses damaged portions of the ear and directly stimulates the auditory nerve. Hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn. For persons whose hearing loss is so severe that amplification is of little or no benefit, the cochlear implant is a safe and effective method of auditory rehabilitation. Most insurance plans cover the cochlear implant procedure. The transplant carries some risk because the surgery destroys any residual hearing that remains. Therefore, cochlear implant users can never revert to using a hearing aid. Individuals with cochlear implants need to be advised not to undergo magnetic resonance imaging (MRI), and the U.S. Food and Drug Administration advises such individuals “not to even be close to a MRI unit since it may dislodge the implant or demagnetize its internal magnet” (Wallhagen et al., 2006, p. 47).

Vision Impairment

Blindness and visual impairment are among the 10 most common causes of disability in the United States and are associated with shorter life expectancy and lower quality of life. Visual impairment (low vision) is generally defined as a Snellen chart reading of worse than 20/40 but better then 20/200. Legal blindness is defined as a reading equal to or worse than 20/200.

For older adults, visual problems have a negative impact on quality of life, equivalent to that of life-threatening conditions such as heart disease and cancer. The leading causes of visual impairment are diseases that are common in older adults: age-related macular degeneration (AMD), cataract, glaucoma, diabetic retinopathy, and optic nerve atrophy. Vision loss is becoming a major public health problem and is projected to increase substantially with the aging of the population (National Eye Institute, 2010a).

Vision loss from eye disease is a global concern, particularly in the developing countries, where 90% of the world’s blind individuals live. Estimates are that more than 75% of the world’s blindness is preventable or treatable. Vision 2020 is a global initiative for the elimination of avoidable blindness, launched jointly by the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (http://v2020.org/default.asp).

Older adults represent the vast majority of the visually impaired population. More than two-thirds of those with visual impairment are over age 65. Although there are no gender differences in the prevalence of vision problems in older adults, there are more visually impaired women than men because, on average, women live longer than men. Racial and cultural disparities in vision impairment are significant. African Americans are twice as likely to be visually impaired than are white individuals of comparable socioeconomic status, and Hispanics also have a higher risk of visual complications than the white population. A recent survey conducted in the United States reported that among all racial and ethnic groups participating in the survey, Hispanic respondents reported the lowest access to eye health information, knew the least about eye health, and were the least likely to have their eyes examined (National Eye Institute, 2008).

Estimates of visual impairment among nursing home residents range anywhere from 3 to 15 times higher than for adults of the same age living in the community (Owsley et al., 2007). A study examining the effect of visual impairment among nursing home residents with Alzheimer’s disease reported that one in three were not using or did not have glasses that were strong enough to correct their vision. They had either lost their glasses or broken them, had prescriptions that were no longer adequate, or were too cognitively impaired to ask for help (Koch et al., 2005). Routine eye care is sorely lacking in nursing homes and is related to functional decline, decreased quality of life, and depression (Owsley et al., 2007).

Because visual impairment affects most daily activities, such as driving, reading, maneuvering safely, dressing, cooking, and social activities, assessing the effect of vision changes on functional abilities, safety, and quality of life is most important. Decreased vision has also been found to be a significant risk factor for falls. Results of one study (Rogers and Langa, 2010) suggested that untreated poor vision is associated with cognitive decline, particularly Alzheimer’s disease. Certain signs and behaviors of visual problems that should alert the nurse to action are noted in Box 6-7.

A new program focused on vision and aging has been developed by The National Eye Health Education Program (NEHEP) of the National Eye Institute. The program provides health professionals with evidence-based tools and resources that can be used in community settings to educate older adults about eye health and maintaining healthy vision (www.nei.nih.gov/SeeWellToolkit). The program emphasizes the importance of annual dilated eye examinations for anyone over 50 years of age and stresses that eye diseases often have no warning signs or symptoms, so early detection is essential. Clearly, prevention and treatment of eye diseases is an important priority for nurses and other health care professionals.

Glaucoma is a leading cause of blindness and visual impairment in the United States, affecting as many as 2.2 million people. An additional 2 million are unaware they have the disease. There are no symptoms of glaucoma in the early stages of the disease. Types of glaucoma include: congenital glaucoma, primary open-angle glaucoma, low tension or normal tension glaucoma, secondary glaucoma (complication of other medical conditions), and acute angle-closure glaucoma, which is an emergency. The etiology of glaucoma is variable and often unknown.However, when the natural fluids of the eye are blocked by ciliary muscle rigidity and the buildup of pressure, damage to the optic nerve occurs. Glaucoma can be bilateral, but it more commonly occurs in one eye.

Open-angle glaucoma accounts for about 80% of cases and is asymptomatic until very late in the disease, when there is a noticeable loss in visual fields. However, if detected early, glaucoma can usually be controlled and serious vision loss prevented. Signs of glaucoma can include headaches, poor vision in dim lighting, increased sensitivity to glare, “tired eyes,” impaired peripheral vision, a fixed and dilated pupil, and frequent changes in prescriptions for corrective lenses. Figure 6-3, A shows normal vision and Figure 6-3 B illustrates the effects of glaucoma on vision.

An acute attack of angle-closure glaucoma is characterized by a rapid rise in intraocular pressure (IOP) accompanied by redness and pain in and around the eye, severe headache, nausea and vomiting, and blurring of vision. It occurs when the path of the aqueous humor is blocked and intraocular pressure builds up to more than 50 mm Hg. If untreated, blindness can occur in two days. An iridectomy, however, can ease pressure. Many drugs with anticholinergic properties including antihistamines, stimulants, vasodilators, clonidine, and sympathomimetics, are particularly dangerous for patients predisposed to angle-closure glaucoma. Older people with glaucoma should be counseled to review all medications, both over-the-counter and prescribed, with their primary care provider.

Low tension or normal tension glaucoma is a type of glaucoma that also occurs in older adults. In this type, intraocular pressure is within normal range but there is damage to the optic nerve and narrowing of the visual fields. The cause is unknown, but risk factors include a family history of any kind of glaucoma, Japanese ancestry, and cardiovascular disease. Management consists of the same medications and surgical interventions that are used for chronic glaucoma (Glaucoma Research Foundation, 2008).

A family history of glaucoma, as well as diabetes, steroid use, and past eye injuries have been noted as risk factors for the development of glaucoma. Age is the single most important predictor of glaucoma, and older women are affected twice as frequently as older men. Among African Americans, glaucoma is the leading cause of blindness. African Americans develop glaucoma at younger ages, and the incidence of the disease is five times more common in African Americans than in whites and fifteen times more likely to cause blindness. Factors contributing to this increased incidence include earlier onset of the disease as compared with other races, later detection of the disease, and economic and social barriers to treatment (National Eye Institute, 2010b).

Cataracts

Cataracts are a prevalent disorder among older adults caused by oxidative damage to lens protein and fatty deposits (lipofuscin) in the ocular lens. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. When lens opacity reduces visual acuity to 20/30 or less in the central axis of vision, it is considered a cataract. Cataracts are categorized according to their location within the lens and are usually bilateral. They are virtually universal in the very old but may be only minimally visible, particularly in individuals with pale irises.

Cataracts are recognized by the clouding of the ordinarily clear ocular lens; the red reflex may be absent or may appear as a black area. The cardinal sign of cataracts is the appearance of halos around objects as light is diffused. Other common symptoms include blurring, decreased perception of light and color (giving a yellow tint to most things), and sensitivity to glare. Figure 6-3, C illustrates the effects of a cataract on vision.

The most common causes of cataracts are heredity and advancing age. They may occur more frequently and at earlier ages in individuals who have been exposed to excessive sunlight, have poor dietary habits, diabetes, hypertension, kidney disease, eye trauma, or history of alcohol intake and tobacco use. Cataracts are more likely to occur after glaucoma surgery or other types of eye surgery. There is some evidence that a high dietary intake of lutein and zeaxanthin, compounds found in yellow or dark leafy vegetables, as well as intake of vitamin E from food and supplements, appears to lower the risk of cataracts in women. Further research is indicated (Moeller et al, 2008).

When visual acuity decreases to 20/50 and the cataract affects safety or quality of life, surgery is recommended. Cataract surgery is the most common surgical procedure performed in the United States. Most often, cataract surgery involves only local anesthesia and is one of the most successful surgical procedures, with 95% of patients reporting excellent vision after surgery. The surgery involves removal of the lens and placement of a plastic intraocular lens (IOL). If the plastic lens is not inserted, the patient may wear a contact lens or glasses. This is not commonly done because the older adult may have difficulty placing and removing the contact lens, and the glasses would be very thick. Cataract surgery is performed with local anesthesia on an outpatient basis, and the procedure has greatly improved with advances in surgical techniques.

Nursing interventions when caring for the person experiencing cataract surgery include preparing the individual for significant changes in vision and adaptation to light and insuring that the individual has received adequate counseling regarding realistic postsurgical expectations. Postsurgical teaching includes covering the need to avoid heavy lifting, straining, and bending at the waist. Eye drops may be prescribed to aid healing and prevent infection. If the person has bilateral cataracts, surgery is performed first on one eye with the second surgery on the other eye a month or so later to ensure healing.

Although race is not a factor in cataract formation, racial disparities exist in cataract surgery in the United States, with African-American Medicare recipients only 60% as likely as whites to undergo cataract surgery (Miller, 2008; Wilson and Eezzuduemhoi, 2005). Cataracts are of even greater concern in Africa and Asia and account for at least half of the blindness in those countries despite the well known technology that can restore vision at an extremely low cost. Recommendations from Vision 2020 include reducing the backlog of the cataract-blind by increased training of ophthalmic personnel, strengthening of the health care infrastructure, and provision of needed surgical supplies in these countries (www.who.int/ncd/vision2020_actionplan/documents/V2020priorities.pdf2004).

Unfortunately, cataracts and other related eye diseases such as maculopathy, diabetic retinopathy, or glaucoma often occur simultaneously, which complicates the management of each. Individuals who have had cataract surgery are less likely to be effectively treated with surgery for glaucoma.