Family physicians are keenly aware of the joy that comes from interacting with the world around them. Many elderly patients are deprived of parts of this world because of hearing and vision impairment. Sensory impairment affects up to two-thirds of the geriatric population. Identification, evaluation, and treatment of these conditions (Table 44-1) may improve patients’ quality and quantity of life.

The impact of sensory impairments is significant. The same objective level of sensory function can result in different levels of disability, depending on the needs and expectations of patients. Vision and hearing impairments have been linked with the wish to die in elderly patients. Poor hearing is associated with depression as well as decreased quality of life, mental health, and physical, social, and cognitive functioning. Vision impairment increases the risk of death and is associated with an elevated risk of falling and hip fracture, depression, medication errors, and problems with driving.

Given the functional impact of undetected and untreated sensory impairments, many arguments have been made for population-based screening. Research has yet to demonstrate that community-based screening of asymptomatic older people results in improvements in vision or hearing. The US Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians (AAFP) recommend screening for hearing difficulties by questioning elderly adults about hearing impairment and counseling them regarding the availability of treatment, when appropriate. Although, in 2009 update, AAFP and USPSTF concluded that there is inadequate direct evidence that screening for impairment of visual acuity by primary care physicians improve functional outcomes in elderly, they found adequate evidence that early treatment of refractive error, cataracts, and AMD improves or prevents loss of visual acuity.

Presbycusis

Essentials of Diagnosis

• Age-related high-frequency sensorineural hearing loss.
  
• Difficulty with speech discrimination.

General Considerations

Presbycusis is the most common form of hearing loss in the elderly, although it often goes unrecognized. It occurs more frequently with advancing age and in patients with a positive family history. This multifactor disorder is due to a combination of structural and neural degeneration and genetic predisposition. Risk factors for presbycusis include noise exposure, smoking, medications like amino glycoside antibiotics, loop diuretics, and cardiovascular risk factors like hypertension. Presbycusis is a diagnosis of exclusion.

Prevention

Until the exact pathophysiology of presbycusis is understood, attempts at prevention will be limited. Limitation of noise exposure may reduce the hearing loss. Although several studies have evaluated the role of vitamins, antioxidants, smoking cessation, and diet in preventing presbycusis, there have been no conclusive findings in humans.

Clinical Findings

Patients with this disorder may present with a chief complaint of hearing loss and difficulty understanding speech. However, presbycusis is often diagnosed only after complaints are raised by close patient contacts, or hearing loss is noted on routine screening in a patient without hearing-related complaints. The Hearing Handicap Inventory of the Elderly Screening Version (HHIE-S) is a widely accepted subjective screening tool for hearing disability. Abnormalities of the whisper test are found as the level of hearing loss increases. Results of the Weber tuning-fork test remain normal as long as the hearing loss is symmetric. Results of Rinne testing are normal, because presbycusis is a sensorineural hearing loss and not a conductive one.

An audiogram of a patient with presbycusis typically shows bilaterally symmetric high-frequency hearing loss.

Treatment

The treatment of presbycusis consists of hearing rehabilitation, which often involves fitting for binaural hearing aids. Patients are more likely to perceive benefit from hearing aids if they view their hearing loss as a problem. Cochlear implantation is reserved for patients with profound hearing loss that is unresponsive to hearing aids. Additional tools include lip-reading classes; television closed captioning; sound-enhancing devices for concerts, church, or other public gatherings; and telephone amplifiers. A combined approach involving the patient, hearing loss specialist, family physician, and close contacts of the patient is likely to produce the best overall treatment plan.

Suggested topics for patient education include patient self-advocation as well as the proper use of hearing aids and other assistive devices.

Prognosis

The expectation of slow progression of this hearing loss should be communicated to the patient. Complete deafness, however, is not typical of presbycusis.

Noise-Induced Hearing Loss

Essentials of Diagnosis

• History of occupational or recreational noise exposure.
  
• Bilateral notch of sensorineural hearing loss between 3000 and 6000 Hz on audiogram.
  
• Problems with tinnitus, speech discrimination, and hearing in the presence of background noise.

General Considerations

Noise-induced hearing loss is the second most common sensorineural hearing loss (Table 44-2) after presbycusis. Up to one-third of patients with hearing loss have some component of their deficit that is noise induced. The degree of hearing loss is related to the level of noise and the duration of exposure. Excessive shear force from loud sounds or long exposure results in cell damage, cell death, and subsequent hearing loss.

Prevention

Hearing protection programs are prevalent in industrial settings and typically include the use of earplugs, intermittent audiograms, and limiting exposure. Patient commitment to the use of hearing protection is critical for the success of prevention programs.

Clinical Findings

Patients may present with tinnitus, decreased speech discrimination, and difficulty hearing when background noise is present. Patients identified through hearing protection programs may be asymptomatic. Results of the whisper test or office-based pure-tone audiometry may be normal or abnormal, depending on the degree of hearing loss.

Audiometric evaluation of noise-induced hearing loss reveals a bilateral notch of sensorineural hearing loss between 3000 and 6000 Hz.

Treatment

When prevention fails, treatment involves hearing rehabilitation, as previously outlined in the treatment of presbycusis. Education about the risks of loud noise exposure should begin when patients are young, because hearing loss can occur from significant recreational noise. The importance of adhering to hearing protection programs should also be emphasized.

Prognosis

Nothing can be done to reverse cell death from noise-induced hearing loss; however, some patients exposed to brief episodes of loud noise exhibit only hair cell injury and may recover hearing over time. These patients are more susceptible to noise-induced hearing loss on reexposure.

Cerumen Impaction

Essentials of Diagnosis

• Mild, reversible conductive hearing loss.
  
• Cerumen buildup in ear canal, limiting sound transmission.
  
• Direct visualization of wax plug confirms diagnosis.

General Considerations

Impaction of wax in the external auditory canal is a common, frequently overlooked problem in the elderly. Removal of cerumen has been shown to significantly improve hearing ability. The incidence of cerumen impactions increases in the elderly population. Chronic skin changes lead to loss of normal migration of skin epithelium leading to exfoliated cell debris accumulation. Cerumen gland atrophy results in drier wax that is more likely to become trapped by the large tragi hairs in the external ear canal. The likelihood of impaction is increased by hearing aid or earplug use.

Prevention

Cerumen impactions may be prevented by the regular use of agents that soften wax. Readily available household agents such as water, mineral oil, cooking oils, hydrogen peroxide, or glycerin may be used. Commercially available ceruminolytic compounds, such as carbamide peroxide, triethanolamine polypeptide, and docusate sodium liquid are also efficacious, but not more so than less-expensive options.

Clinical Findings