age-related hearing explored.pdf

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G E R O N T O L O G I C L N U R S IN G

Geronto logica l nurs ing

4 :

age related hear ing explored

Debbie Toison M ike N olan

T

his scries h.is h ighl i^ lucJ the

tor developing the role uf the luirsu m

H K -

c.irc l it nlJer people in acute,

con i -

muni t \ and nursin g hom e ^ettlngs. 11 this

porcti t ial IS to be realized it i*. impor tan t th.u

expl ici t examples oí how dcvelnpiiH -nts rnig ln

realistically

be

acluevcd

arc

presented,

as

changing practice cliallenges both the indiv id-

ual nurse and the organizarional infrastructure

(Stock ing, 1992). Therefore, pract i t ioners

must be enabled to begin the process oí

reíormii ig care, motivated primari ly b\ the

desire

Tn

im pr o\ e surxices

lor

older people

rather than simply trying to k irthe r the , ispira-

tions ot the nursing protessum ( Nt i lan , 1944).

K nowing where

and how

best

to

begin

a

process of reform is challenging, especially given

the vague and imprecise way m wbich gemnto-

logic.ll nursing

is

defined (McLormaek

and

Ford, 1944). However, underpinning geronto-

logical nursing is an mteragency approach to

person-centred, humanistic caring \\ Inch

requires an in-depth undersranding o\ the needs

oí older people and an ahilit>' to deliver care that

extends far beyond tbat traditiona lly p rovided

by UK nursL's. This necessitates a reco nsk itrario n

of the conceptual basis

ot

care, challenging nurs-

es to move away from a largely problem -orien t-

ed,

activities of l i \ in g and medical ized approach,

to one based more

on

assessment and interven-

tion (McC:ormack and Ford, 1444).

Such a position is supported b\ Gueldner et

al (1995) who endorse the view ih at healtb

workers from

all

disciplines must come to geth-

er to achieve meaningful reform. This, they

argue, can only begin when tradit ional patho-

logical views

of

ageing shift towards models

which acknowledge the expe ctation ot wel l -

ness, even in the presence of chronic illness and

substantive impairment. One

of

the

few

exam-

ples of an existing generic nursing model whicb

achieves this

is tbe Roy

Adapta t ion Mode l

(Roy and Andrews, 1991)

but

this

is not

w ide-

Abstrac t

in the previous three articles In this series Voi 9 1): 39-42; Voi 9 2): 10

Voi

9 3): 157-60), nurses have been chalienged

to

reconsider their app

towards the care of older

people.

T o facilitate this it is heipful to provide

specific examples of how expert practice mi^t be achieved. sing one

the most prevalent but n eglected problems

of

old

age.

hearing

disability

authors describe ho w nurses can contribute to the health of older peopl

maximize the therapeutic component within gerontologicai nursing.

Arguing that many existing nursing models

are inailei.]u.îte. Porter tl '-'4>li) criticizes

Ame rican gerontologica nurses for unhelpful

"tl ieon shopping" with ou t fully understanding

tbe conceprual basis

ot

tbe care

ot

older people.

Tbe same could be said of L K nurses wh o .ldopt

a plethora ot i in\erified and frequently compet-

ing models, few are person centred iReed, h'^'M),

and most are not properl) understood (Toison

and Mclnto sb, I9H 6| . Moreo\er, to focus only

on nursing models

is

unhelpful

in

tbe context

of

interdisziplinär) practice iNolan et al, 14*^^)

and,

as (.jark (1945) argues, there is a need to

develop

an

approacb

to

care which transcends

disciplinary boundaries and recognizes the

indi -

xiduals experience o| illness and frai l t). To

acbie\e such a reconstruction

of

practice requires

specific examples. Tb is article considers h ow tbe

nursing contribution

Ut

the healtb needs of older

people can

be

im pr ow d using age-related bear-

in g loss, a com mon and frequeniK neglected sen-

sor)'

impa irme nt, as an example (Toison, 1996).

Good gerontological care requires tbe recog-

nit i i )n of a car ing opportuni r \ ; vi accessible

knowledge base, a motivated and knowledge-

able practitioner, a will ing recipient and tbe nec-

essar\ resources. Kacb element

of

tbis equation

IS

addressed in tu rn , seeking evidence to supp« »rt

a case for gerontological nurses proacti \el \

belping people with age-related bearing, staning

wi th the nature and extent of the problem.

AGE-RELATED H EARING LOSS

Toknn iç Profess

uf Gcrnniologiiial Nursin

Departmtni ot Nursing; a

Communiiy H ealth,

Calcdoni.in Llnivi;rsit\,

a

Mike Nolan is Norccn

Edwards f"h,iir

In

Gcrontiili>i;iLMl NursinR,

School

ot

Nursing,

Midwifery

jnd

H calih

Studies. Lnivcrsir.

of

Vl i



Ihc insidious

onset ol age-

elderK people

that a problem

a major

to initiating

a

qualitA of

dependent

i > . . i i t

, .1

p i i i n r i i i

I I I

I I * . I l u t e

o t

i i i . i i i v

mmlcK ,Mul

i.imK.il

iissi-ssitu-iil h i n k

( t . insWi l l . i l k ' i l Lt .ll, l* '*-'" . l l n u i v t T , to

ili.sii;ii .ippropri.Hc tiiriT\iiitions, .i rlioroiigh

iinJi-isi.iiuliiii; ol I1K' rt'l.ili'ci C.UISL'S ot lic.irm^;

^hs.ihilitv Is n\ | i i i r i t .

lilt |Ml In ill >I;K .ll IviMs ol

\<¿y

H ' I . UCI I iuMr-

IIIL; loss Is MIKICII I I .row inn^. l Sh) Imi il is

iii.iniks[ III .1 i .omp U\ ssmlrnim- of ruiiiicciJ

l u M i i n j ; .uuii\. p.nrKuKiiK ol I U I Í I K T tr(.\|iifii-

c\ siuiiiiis, iôiipLiI uu li .1 in,irki.il Ji t t knl l\

in speech i l iscnini i iat ioi i thr ough noise

il'itooks,

l* S* ii

As .1 coi is tqucncc, as pcnpk-

.ii;i.- iliLN m,i\ L\[HrK-iKi.- p ro hl cn is in tnllow-

IIIL; spiiLh, p.irin-iil.irK in

i;roiip

lo rn t rs . i i ion

,iiul

n o i s \

ci niroi iiiKi us such .is hospirol

u.irjs jrui coinnniii.il d.u ro o ms in mirsmi;

hotnts (Stephens, IMS?; Toison, 14*^51. Ihesc

d i s . i h i l i t u ' s i i i \L - nsi. rii p r i i i i . n v h . i i i i . l i i . . ip s

su ch ,1s r t s t n c t i i i so ci .i l p , i r t n . i p .u i o n .md

ri.LÍiKt.d (-nullt) ol in t t r . Kt ion w h ielt i iu iy

resu l t in s i . i .ond , i r \ h . i ndk . ips suc h js t.itii;ue

, inJ lonel iness (S tephens . l i id Hetu , 19*^1) .

I l ie esr iin .U L d p rew ikn ue o t he. i r inp imp. i i r -

riK-nt anioiii; the i;enfr,il [•»opuKuion M\er,ii:ed

.i t 11,^—Ikll/ <:2^Jr> IS i ~ " , . in ihe ,iê

h.ind

(>

l - ~ü \c . i r s , es^j l . i t i i i i ; to bO", . be twe en

"I . ind SO vears (Dav is . 1^95). F i g u res for

p eo p l e o \ e r t h e ag e of SO \ea rs a re nor avai l -

a t i l t . ' wi t lu i i j j cruT. i l popul .u io i i es tun . i tes

(Davis, l'-'H'ïi. Ihe only existing UK data on

hospitaiiiêil dependent elderly patienrs ulenti-

tied a hearini; aid candulature rate ot S(l ' ' . . in

people agetl "I-SiI \ears risint; to '•''^"ó in peo-

ple who were ai;ed SI \ ea r s and ahovc

I lol so n. I'•''•*. ; Toison an d Step hen s, |4'-)~),

All authors ai;ree that .ii;t-related hearing;

loss IS an unw eL ouie aiul ne.c.une phi'iionie-

non that has a detrimental effect on the suffer-

er and his/her Kimily. Cowie et al (

I -ÍST)

exam-

meJ the experiences of^ people livniii with pro-

tiiiiiKl -UHI innder.ite hea ring losses aiul loun J

that while predictable problems such as tamily

tension Were évident, the magnitude

ot

these

problems diti not seem related to the level

ot

the he.irin>; impairment (Cowie et al, I^ST). A

possible explanation may lie within the fami-

lies'

resources and other colleetne responses tn

ihc members' ditfKulties.

Hem et

A\

(1993) provitie a review ot rhe lit

crature which exánimes how hearinj; loss aftects

In hnht ot the potential detrimental imp

winch impaired hearin^; may h.ive

tor

h

tile siilferer .md his/her family, it is essen

thai nurses who aspire towards hiplisric c

reto^nize problctiis where tliey exist and

knowledgeable about care solut ions.

.•\i"ScS5»/i.'

need

Ihe insidiuiis fitiset ot age-related hearing

^xwS Its assoc iation with senility is though

account for under reporting and the failur

m.in\' elderly people

to

seek help (Cilh

Herbst. h'SJÎ). Such reticence or failure

either recognize or admit that a problem ex

IS

a

ma|or hurdle to initiating care and re

sents

a

lust opportunity to improve qualit

life as the benefits ol mtcr\enrion. c\en for v

dependent people, are considerable (Toi

l'-í'-'S). Indeed,

the

Kellog Internatio

C

ummittee went

as

far as

tn

state that; "

ability to commLinicate is frequently a de

ing iacTor

in

J e t ennm i ng

a

person's auto

nn, independence, and overall wellbeing

h.ippiness' iSaloiimn. l^'Sh). Salom(>n

.irgiie j that : Societ\ has a moral ducy to

se r\e or e \en inipr(i\x' the «.¡uality o í liíe m

age. an d w hen ot he r ptiss ibihries for self-r

i/ation are decreasing, the abiliry to com

nicate with others are preconditions to w

being and happiness' (Salomon, 19S6|.

(iivcn the reluct.ince of older people to ad

to hearing difficulties it is particularly impor

that nurses include this aspect

of

care

in

assessment. To achieve this, however, practit

ers nnisr posses the necessar\ assessment ski

Nurses should beware oí relying on

a

gle questHm about hearing during an ass

mi'iit inrer\'ie\v;

a

useful appri-)ach

is

to

the person whether he/she can hear the t

Msum when it is turned up loud enough

suit other people. If he/she needs to turn it

louder this is a good indication oí a prob

(lo lso n and Sw an. l*-)'- ). A more reha

intormal test

oí

hearing

is

the 'whispe

soice tesr ' (Swan

and

Browning, 19

Macphee et al, 1988) which is simple to

form following initial expert demonstrat

and supervision.

Adopting such pract ices requires l i

effort and nimitiial cost, adding only min

to the overall process of assessment. N

equipment other than

a

quiet en\ iro nm



G E R O N T O L O G IC A L N U R S I N G : A G E R E L A T E D H E A R IN G E X P L O

Besond such simple tests the most accurate

and reliable measure oí hearing impairment is

obtained using audiometry which determines a

person's ability to hear loncs at vat^ ing pitches

(irequencies) (British Society oí Audiology

(BSA),

l^SI). Audiometry is not rraditionalK

undertaken b\' nurses, but with the de\elo|v

ment of portable instruments the necessary

skills can be learnt quickly with minimal

instruction. However, interpretation of the clin-

ical data demands ,KÍditional expertise.

Assesstiient oí hearing handicap and disabil-

ir>'

is less clenr cut and an arra)' ot question-

naires and scales are available. Examples of

popular instruments for use with elderly peo-

ple include rhe Mearing Handicap Inventor\'

for the Elderly and the Nursing Home Hearing

Handicap Index (Schow and Nerbonne, 1977;

Smyth and Hickson, 1989; Toison, 1995).

Hence, there are .i variety of approaches to

problem identification that could he incorpo-

rated into routine assessment and health

screening. However, the utility of the infor-

mation gathered depends ni:)t only on the

ability of the nurse to collect the J.ita but also

on the wider support oí tbe multidisciplinary

team, particularly those with responsibility

ior prescribing and issumg hearing aids.

RcbiibiUtatii L options

Mo st attention in the specialist literature has been

devoted to personal hearing aids

w

hich appe ar to

oííer the greatest benefit tor elderly people

(Brooks, 1989}. The adva ntages of amplification

ma\ be enhanced through rehabilitation pro-

grammes and additional help in the use of envi-

ronmental aids (e.g. loud door Itells) after the ini-

tial hearing aid fining. A number ot listening

devices are described in the literanire, including

communicators (sound aniplitiers with standard

earpiece and microphone ior the speaker), ampli-

fied telephone headsets and loud doorbells

(Royal Na non a Insntute for rhe Deaf 19M2).

The development of hearing tactics ami commu-

nication skills, such as lip reading, is given some

anention but this strategy has not been examineJ

among very elderK' populations and is likely tit

In.-

of questionable value (Stephens, 19S3; Brooks,

I9S9;

Field and Haggard, 1989).

Fitting a hearing aid is only the first step and

it IS important that it is used appropriately.

Many factors appear to influence the use of

an d professional support duriiig the ad|U'.rmeni

phase lo listening tn .miplifietl sound (Sorri et

al. I'-'S'Í; Toison, l'^'^'S). Unfortunately, com-

plete reiection oí hearing aids seems a particu-

lar problem among elderly people. However,

this problem ma) be <i\ercotne through the ere

ation of a suitable listening en\ ironrnent .nul

the provision of suppiprtive c.ire regimes for

new he.iring aid users I'lnlson, 1995).

T O W A R D S A MO D E L O F C A R E

The Aiidiological Care Model for Nursmg

offers .1 pathway of care irom problem recogni-

tion through to evaluation (Toison and

Stephens, 19M~). involving both the hearing-

impaired person .md his/her regular coniniuni-

cation partner, which for people in insriturional

care might be their named nurse. Inter\entions

are based on measuring and describing the hear-

ing problem, unde rstanding rhe person's lifestyle

and identii\ ing other factors which could influ-

ence the outcome of intcr\ention including

lus/her norm al listening en\'iron nienr. (, areful

tonsideranon is .ilso gi\en to the impact ot the

hearing difficulties on the primar\ communica-

tion partner. "Ihe attitude and expectations of

care of hoth parties are examined.

Pre rehabilitation counselling could l^e used

h> nurses during the problem evaluation stage

111 inform peo ple a bo ut c.ire options and pro-

mote their participation in care decisions.

Remediation (rehabilitation where the environ-

ment IS ada pted to suit the individual) of the

hearing disability is depicted as beginning with

the provision ot information and counselling.

Remediation is further divided into three key

areas: modification of the listening en\iron-

inent; instrumentation; .md skill huilding.

Listening circumstances ma\ require modi-

fication where these are noisy or disruptive

and where competing sounds interfere and

limit a person's opportuni t \ to hear clearly.

Listening oppt)rtunity .ind the social environ-

ment are clearK intertwined. Understanding

th e hearing impaired person's unique experi-

ence of his/her listening circumstances may be

difficult if his/her mental functioning is ci_im-

promised. However, the person's views, an d

those oí any other occupants , should be

sought and considered when planning any

modifications to an en\ iron[nei i t .

...fitting a hea

aid is only the

first step and it is

important that it

used appropriatel

Many factors app

to influence the u

of hearing aids,

including persona

and lifestyle, nois

levels within the

home, severity of

hearing impairme

expectations of

hearing aid benef

and professional

support during th

adjustment phase

to listening to

amplified

sound...



ONTOUX lCAL NllRSlNC

Y PO NTS

I

Age related hearing

toss IS a

Significant cause

of

disability and

handicap among

older people and

IS

an area in which

nurses could do

much to improve

current practice.

I

Nurses working

with older people

need a good basic

understanding of

age related hearing

l oss.

Its

assessment and

treatment.

The

Audiological

Care Model for

•ng

provides a

lor ll piiteireil. Asvision and hearing are

mtrinsKalK hnkeil m a person's overall .ibilit>'

to i.oiiiiiiunicate. It IS .liso w ise (n ensure tli.it

\

I Sinn ISproperh assesseil ani.1 managed.

iVpeiKhng on iheperson's li\ing arrange-

ments.

eiiMronmental aiils such as loop induc-

tion s\ sieiiis (a s\s;ein nt .iiiipliÍKalinn using a

loop t>t wire and .1 microphone or direct t.<iii-

nection to the source (tt the sound) shouk be

i-tinskleieil MU\ provided where desired.

Skill building tocuses oncommunication

training torboth

the

he.iring-disabled person

and Ins/her conimuiiK.ilioii p.irtner. Ihis

requires sensiti\

it\

.nu should take due

.CC»

mill

ol

le\els

ol

underst.mding

.md

coinpre-

hensioii.

.\s a

niininium. instruction should

he

i:i\en

both

to the

person .i ti j hiv/her con ii iumi-

«.ation partner ahout

lin\\' tn get the

best Inmi

,1 hearing

aid , e.g. the

need toreduce hack-

ground nnisL*

or ii>

speak without slmuting.

Tn .Rhie\e the greatest benelit and iiuiepen-

dence there is aneed tounderstand the basic

timctions and cnntrois ol the hearing

aiel,

and

to be able to identiK when the an. is not work-

int; properl\, as might result from a dead bat-

riTs nr asplit in theliibing. I'urtberniore,

releariiing

the

skill

t)í

listening t:,m

be

exhaust-

ing and strategies to support people during the

earl>' phases ot adaptation to listening to ampli-

fied sound should be sought (lolson , I ' - ' ' - '5L

During the e\aluation ol care, particular atten-

tion should be gi\en to measuring the impact of

the intervention on the hearing disabilit).

ON LUSION

.•\ge-related hearing loss presents considerable

but not insurmountable problems (Toison,

|49h)

and

i

.111 impttrtant component

oí evi-

dence-hased gerontological care. The

Audiological Care ,\lodel

for

Nursing (lolson

,md S[e|-)liens, I t'-C) provides practitioners with

the opportunit\

to

improve this important area

oí

care. I

lowever,

the

ch.illenge,

as \\\n

.Maanen

I 1 4401 noted, IS whether nursing

is

ready

ior the

role ot trendsetter". There is

now

agrowing

knowledge base

to

guide reform

in

ger«)nto|ogi-

cal care which nurses

are

well placed

to

capital-

i/e

upon.

The

íinal article

in

this series will con-

sider

how

gerontological nurses might more

hilly realÍ7.e their current potential. UiU

Uinoks DN (U SM)

AJiiii Aiirjl H. l>jhililiiiK

I h.inin.in .nul I l.ill, I orultiii

( ins \Vrli,illm \VM< M. KirkstM A. IW-nsnR JM (19

I l u ' ml.-

(it

i.<iii)iiiiiiiK.uiiiii

in

nursing t.irc ffir cld

piKpli':

,1 riTiiw

tif

tlu' linr.itiirc.

/

AJv Nurs 25: ^1 S

t

l.irk ( I

(l^JVS) IJii.ility

III

Ilk-, v.ilms .ind tciiuwn

111 m-n.iirii.

L.iri'i

ilti

we

mmmuiik.iti ' wli.it

nuMii.' C,Vrn»ifi./í.i,'/sí 1S( l l: 4(1>-I 1

(. owic

K.

Dounl.is-t ..wk-

K,

Stfwjri I (iy«7)

T

c\iuTii-iKi.' lit ln-i-nmni; (Jc.if.

In :

Kyle

|(i,

.'Xj/ii^l'iioit

III

/1< i/M/rci/ ik'iirin^

¡.tiss.

Centre

I H M I Sludics. Krislnl; hS-S(l

D.ivis .\ t l''*i>i Hrjrin\i in AJults. Wluirr. Lcmdiin

laid DI . I ji;j;.ird MT ( r'S* ') Kniiwlcüt;c of hea

t.KfKs (I I: .is'.t.s'.iiK-iit liy qiicsrionnairc and inv

rorv. lir IAiiJi..tU: 144- 4

(rilfiiinu'

Herbst K 11'S3) .Xi. 1111 red hcirinj; loss in .id

nt cm ploy UK-lit

,i f; i ':

S IHIIL- M ILI. I I implicitio

Lit »nil ill IS I Kit Ctit) iliesis, linivcrsirv'

ut I

ondon

(•nctJiHi

S

Hr.ul BA.

K.Rscr'l ct a

(19

CiLTiintiilnmc.il nursing issues .ind demands beyo

tbt- >e.ir :iMlv / (jir'<nl>>l \iirs 2Hh|:

6-9

I letii li , liines

I ,

( letty

L {l '•f \

The impact uf jcuui

lif.irinn imp.iirnu-nt an intim.irc rcl.uiiinbhips:

im

CJiKns

Inr

nli.ilntit.Uinn- Anjinln} ' 32: 3S3-H1

Md <'rni.n.k B. Hont T 11^'*'') Impruvinj; the qu.ilir>

cjrt-

tnr

nldtT pi-nple. Siirs TiniiS 95(22): 42-.Ï

MjcptK-v (.JA.

(

n.wther JA. McApline CH (U'SS

simple '>cre-11n ; itst Inr licarinn impairmcnt

elderK p.itients. t^ c jnA};ai}}; 17: 347-51

NoLin Nt

11

^A\ (.erutric nursing: .in idci whose ti

h.is uniiL-? A polemc. /A,lr Nun 2(1: • Íi9-'ih

Nol.in

M,

Lundli

U.

Titsclielman C [1448| Nurs

knnuli.di;e b.isi-: does it have

to he

unique'

B

2

l'onur 1.1

11 ' vi) A phenomennlogitMl .iltemativc to

'AUI a-scarch tr.idition'.

/

Áfi¡fi¡f Health 7( 1 ): 24

Porter I | (l'*'-' h) Nnn-cquilibrium systems theor

G

Reed hi '*'' ) Models ot nursinR: their relevance to

i .u\: nt elderly people.

_/

Adv Nurs Id : 1 350-7

liny i, Andrews HA (I 'l^lt The Kay Adjplaú

Álruy,/.

The

Dctinilnc StJicntent. Âppleton

a

L.iiine, Norw.ilk. Connecticut

Kny.il N.itinn.il liisriture

tor

rlie Deal (P^ lll

Do}

a

H.irJ

'<

Hdiriufi Pa-l'U:

The

lioyal N.itiu

insiiiiitc ttir rhe Dcit", 1 oiutm

S.ilnmnii

(,

il^Shi HLjriiiv; problems and the elde

U.ini l-

.\Ic<//ÍN//33(Suppkment

I) : -l

Schow

K,

Nerboiiiie

MA

I

\^>~T\

Assessment

ot

he

h.indic.ip

b\

iiiirsmp home rciiidents and srat

.\cjJ kchj- Ai>Ji.,nuh 1-12

Sm\ih \ ; Ilicksod I (l^N'^l f/ v AsstiSiihiU of Hejn

i.'iiMiiiil Hi-jriiii; HjnJiiJl> itt th e iiUcrlyin RcsiJo

Cffc; A

i\'nc

Ál'proJíh- Penartment

of

Spetvh

Hi-Mfini;,

Universin

ot

QuiriisLind. Australia

Sorn M,

I

outonen .\1,1..ii(.ik.iri

K

1 l''S4i Use and

ust-

ot

hearm; .iids.

Br

/ IU ÍKJ I IS : ib' -'l

Sri'pheiis

I)

( 14¿~) Peoples complauits

ot

tieannR

d

culties.

In:

Kyle JG.

ed.

Aüiiisínnit

ta

Ai\jti

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