Guest Columns

Dual sensory impairment can impair ADLs

Renee Kinder
Renee Kinder

Aging is often associated with changes hearing and vision. While individual sensory loss in each area has significant impact on function and and quality of life, presence of both hearing and visual impairments known as dual sensory impairment can be especially devastating.

One in six Americans over age 70 has impaired vision and one in four has impaired hearing. The prevalence of combined visual and hearing impairment more than doubles among those over age 80 when compared to those between the ages of 70 and 79.

At least 1.7 million people report DSI, according to the Centers for Disease Control and Prevention. Research specifically investigating the prevalence of DSI in older adults has estimated the prevalence of DSI from 3% to those under age 69 to almost 22% in those over age 80. DSI has been associated with health declines, reduced independence and participation in activities and withdrawal from communication-based and social activities. Studies have shown the impact on mental health, including depression.

When researchers have compared individuals with DSI to individuals without sensory impairment, participants who reported DSI also had more difficulties conducting ADLs such as difficulty walking, shopping, and preparing meals.

Furthermore, studies have found that impacts associated with DSI are often poorly documented in medical records. As a result, there can be a lack of appropriate implementation of treatment for these individuals.

Interprofessional practice for individuals with DSI should include involvement between audiologists, optometrists, and primary care providers for diagnosis which is followed by care planning and interventions from nursing, and rehab teams including physical, occupational, and speech therapy.

Recognizing the signs

Hearing loss

Presbycusis, or hearing loss associated with aging, may affect almost half of adults over age 75. This percentage increases for the very old and for those in long-term care. Presbycusis results in the inability to understand comfortably loud speech, especially in a noisy background, and difficulty distinguishing high-pitched sounds.

The following are the most common symptoms of age-related hearing loss:

  • Complaints that the speech of others sounds mumbled or slurred

  • Difficulty distinguishing high-pitched sounds, such as "s" or "th"

  • Difficulty understanding conversation with the presence of background noise

  • Reports that men's voices are easier to hear than women's

  • Tinnitus (ringing in the ears) which may occur in one or both ears


Skilled nursing facilities can begin the identification process by examining findings within MDS Section B0200: Hearing.

The current measures include:

Code 0, adequate: No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities.

Code 1, minimal difficulty: Difficulty in some environments (e.g., when a person speaks softly or the setting is noisy). The resident hears speech at conversational levels but has difficulty hearing when not in quiet listening conditions or when not in one-on- one situations. The resident's hearing is adequate after environmental adjustments are made, such as reducing background noise by moving to a quiet room or by lowering the volume on television or radio.

Code 2, moderate difficulty: Speaker has to increase volume and speak distinctly. Although hearing-deficient, the resident compensates when the speaker adjusts tonal quality and speaks distinctly; or the resident can hear only when the speaker's face is clearly visible.

The presence or absence of hearing aids is screened in Section B0300 Hearing Aids.

Reduced vision

Presbyopia, which causes age-related changes in near vision, can impact geriatrics along with other age-related vision disorders, including macular degeneration, glaucoma, cataracts, or diabetic retinopathy. By age 80, almost a fourth of people will have a visual impairment. Individuals presenting with neurological disease processes may have additional changes associated with progression.

Normal age-related vision changes can include presbyopia as well as decreased light trans- mission, decreased pupil size, losses in contrast sensitivity, greater sensitivity to and delayed recovery from glare, delayed dark adaptation, and reduced visual field and color discrimination.

Macular degeneration is the most common age-related pathologic condition which results in vision loss and accounts for 54.4% of blindness. Cataracts and glaucoma contribute to blindness and result in the inability to see fine detail or to read fine print, dependence on high luminance, and difficulties seeing distant objects.

Currently, skilled nursing facilities screen vision within MDS Section B1000 coded as below:

Code 0, adequate: if the resident sees fine detail, including regular print in newspapers/books.

Code 1, impaired: if the resident sees large print, but not regular print in newspapers/books.

Code 2, moderately impaired: if the resident has limited vision and is not able to see newspaper headlines but can identify objects in his or her environment.

Code 3, highly impaired: if the resident's ability to identify objects in his or her environment is in question, but the resident's eye movements appear to be following objects (especially people walking by).

Code 4, severely impaired: if the resident has no vision, sees only light, colors or shapes, or does not appear to follow objects with eyes.

Intervention

According to the Centers for Disease Control over one-half of those with impaired vision could improve their eyesight by using glasses or by getting a corrected prescription. For those with hearing problems, 72% might benefit from a hearing aid, but do not use one.

Strategies for communicating with geriatrics with hearing loss include promoting use of personal hearing devices and hearing aids and modifying the acoustical environment. That can include reduction of background noise and use of soundproofing materials. Hearing aid use should be encouraged and caregivers should ensure device batteries are in working order and the device is inserted properly and turned on. Communication partners should also approach the individual in their visual field and announce themselves to avoid startling. Background noise can be reduced by turning off the radio, television, or any competing noise. presence of competing noise.

Aural rehabilitation

Speech-language pathologist can provide AR services as outlined in the Medicare Benefit Policy Manual Chapter 15 Section 230.3.

The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lip reading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system.

  • Auditory processing evaluation and treatment may be covered and medically necessary. Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to process sound. Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment.

  • Evaluation and treatment for disorders of the auditory system may be covered and medically necessary, for example, when it has been determined by a speech- language pathologist in collaboration with an audiologist that the hearing impaired beneficiary's current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient's functional communication needs. Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologists may provide treatment.

Examples of rehabilitation include but are not limited to treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiary's performance in both clinical and natural environments should be considered.

Vision therapy

Many normal age-related changes are not amenable to correction; consequently, strategies that are environmental, design based, or compensatory are required. Skilled therapy clinicians including occupational and physical therapists can often provide interventions to assist with implementing the appropriate compensations.

Physical therapists play a crucial role in evaluating and treating individuals with low vision as there are direct impacts on mobility and balance associated with vision. Notably, there are challenged directly associated with gait and ambulation as age related vision changes impact ability to see low-contrast items. Therefore, basic ability to perceive stair risers and one's ability to go up and down stairs in additional to ability to navigate curbs on the sidewalk can be affected. Low vision also creates difficulty in determining how wide a hallway is, which can lead to balance problems. Additionally, ~20 percent of the eye's nerves interact with the bodies vestibular system.

Occupational therapists are experts in environmental modification and can assist individuals with vision impairments complete specific daily tasks by modifying the tasks and/or the environment to minimize or remove barriers that inhibit participation, safety, and independence.

For example, an occupational therapist may restructure a task to remove a vision-dependent step, such as programming a telephone to speed dial emergency numbers or the therapist may recommend adding lighting and contrast to increase visibility in the environment, reorganizing the kitchen to increase ease of accessibility and safety when preparing meals, or removing a hazard to reduce the risk of falls. Additionally, OTs may use adaptive devices and assistive technology to enable older adults to use optical and non-optical devices to complete ADLs. For example, OTs may recommend use of an optical device such as a hand-held magnifier to complete shopping, or a non-optical device such as a talking glucometer to complete diabetes self-management (American Occupational Therapy Association).


Renee Kinder, MS, CCC-SLP, RAC-CT currently serves as Director of Clinical Education for Encore Rehabilitation and acts as Editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association (ASHA).

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

ALL MCKNIGHT'S BLOGS