Hearing, a sensory modality vital for effective human interaction and for orientation and adaptation to the environment, is progressively lost with age. It is estimated that 55% of those over age 65 have some degree of hearing loss and that by age 80, 66% have a serious hearing loss.1 When hearing loss occurs, it interferes with one's ability to participate in the communication process and limits the information received for orientation to the environment, and compromises one's ability to respond to unsafe situations. The loss of hearing can also cause isolation, maladjustment, anxiety, and depression.2 Furthermore, prevalence of delusions of persecution and other paranoid symptoms have been noted among hearingimpaired elderly.3
Although hearing impairment is considered to be the most prevalent chronic health problem in the United States, detection and treatment of this health problem may be lacking.4 Several factors may account for this oversight. Research data indicate that many elderly persons tend to underestimate their own degree of hearing loss.5 In addition, the health professional may not be able to assess the problem visually with any degree of reliability. Furthermore, the equipment needed to diagnose the hearing deficit accurately, the audiometer, is expensive and requires training to master its use. Given the prevalence of hearing impairment in the elderly population, the significant effect this loss can have on lifestyle, and the frequent failure to identity the impairment accurately, it is imperative that hearing assessment be included in the nursing assessment process.
With the need for hearing assessment in mind, plans for a hearing assessment booth were integrated into the third annual health fair sponsored by members of the nursing division at a major long-term care facility. The health fair is conducted for older adults living in the community and, in keeping with Orem's model of self-care, aims to provide resources or experiences that promote individual responsibility for health. Self-care is defined as "those processes that permit people to take information, to take responsibility, and to function effectively in developing their own potential for growth."6
The objective of the hearing assessment was to detect hearing impairment and to share information on the hearing process with the participants so that self-care practices might be more fully implemented. Since many hearing problems can be successfully addressed through healthcare treatment or aural rehabilitation, early detection of hearing impairment can be of particular value for the older adult. It was hoped that sharing knowledge of hearing impairment would provide individuals with an incentive to pursue a more complete diagnostic workup and treatment program.
Traditionally, an otoscope and tuning forks are used when conducting a hearing assessment. The otoscope allows visualization of the ear canal and tympanic membrane so that problems such as excessive wax buildup and inflammation or perforation of the eardrum can be detected. Although the otoscope does not test for hearing loss , it is useful in detecting problems associated with the tympanic membrane and middle and outer ear.
Tuning forks can help differentiate between conductive and sensorineural hearing loss through performing the Weber and Rinne tests. With the Weber test, a vibrating tuning fork is placed midline on the client's forehead. The client is then asked if he or she hears the tone equally well in both ears, which is considered a normal finding. If the sound is heard better in one ear, it suggests a conductive hearing loss; however, this result is not conclusive and does not rule out the possibility of a sensorineural hearing loss.
The Rinne test compares the client's responses to bone conduction and air conduction of sound. A vibrating tuning fork is held against the client's mastoid process until the client indicates that he or she is no longer able to hear the tone, which tests bone conduction. Then, the vibrating fork is quickly moved in front of the ear canal , so that air conduction can be discerned. The person should hear the air-conducted tone twice as long or longer than the bone-conducted tone. A sensorineural hearing loss or a conductive hearing loss can be suspected if the bone-conducted tone is heard as long as the airconducted tone. However, both the Weber and Rinne tests are nonspecific for the degree of hearing loss and can only suggest that the client has a hearing problem. They cannot determine the exact type or degree of hearing loss and are dependent upon the person's ability to understand and foliow directions.7
The audioscope is comparable to an otoscope; however, it combines a screening audiometer with a viewing screen. The viewing screen permits simultaneous visualization of the ear canal and the tympanic membrane so that problems associated with the outer and middle ear can be detected. The audiometer tests frequencies of 500, 1,000, 2,000, and 4,000 Hz at an intensity of 25 dBHL, which are the standard criteria for screening for hearing loss. (Human speech is usually heard below 2,000 to 3,000 Hz range.) Results of the field testing of the audioscope show that the instrument is a highly valid screening device when compared against standard audiometrie threshold testing as done by a certified audiologist.8,9
A healthcare professional can learn to operate the audioscope and implement the procedure with relative ease. The Figure outlines the procedure for use of the audioscope. Although the audioscope would not be used exclusively for determining the exact etiology and degree of hearing loss, it does offer a more sophisticated method for screening early detection of hearing loss. The decision was therefore made to use this instrument at the health fair since it offered a simple, fast, and accurate method for screening hearing impairment.
Results of Hearing Screening
Approximately 200 persons from the community attended the health fair. The hearing assessment booth was located in a small, quiet room off the main thoroughfare. Participants were free to choose any booths, with such topic areas as hypertension, diabetic screening, anemia screening, flu prevention, exercise, and self-medication, available to them. Sixteen persons came to have a hearing check. The low number of participants may have been a reflection of the waiting time involved; it took an average of ten minutes per person to complete the screening process. In addition, the batteries of the audioscope weakened toward the end of the program, which led to the early closing of the booth. After clients were screened for hearing loss, pamphlets on hearing and hearing aids were distributed and discussed with the participants.
Clients were initially asked their ages and if they were aware of any hearing loss. The results of this inquiry are outlined in Table 1 . The ear canal and tympanic membrane were visualized and the testing of hearing ability was performed at the four frequency levels. Results of the hearing assessment can be seen in Table 2.
Although the sample size is small, it is interesting to compare these results with those reported in the literature. As noted earlier, many elderly with hearing impairment tend to underestimate their degree of hearing loss. As might be anticipated, nearly half the persons screened denied an awareness of hearing loss. None of the participants, however, were able to discern all frequency tones. It is interesting that none of the males verbalized an awareness of hearing loss, yet only one male was able to hear any of the frequency tones.
With age, earwax thickens and becomes more difficult to remove.10 The prevalence of wax buildup in the ear was therefore expected. However, it was surprising to learn that many people were uncertain as to how to rectify this problem. The home remedies that were used to treat the problem were disconcerting; some mentioned using bobby pins, needles, and toothpicks, to name a few techniques. Others were concerned that their personal physicians had communicated to them that they "didn't do wax removal" anymore. This is an unfortunate problem because this type of conductive hearing loss is easily corrected. It also should be mentioned that wax, which significantly occludes the tympanic membrane, can result in inaccurate audioscope readings. This may have been responsible for the percentage of persons with reduced hearing sensitivity, as the accuracy of audioscope results is dependent on a clean ear canal.
Presbycusis, the gradually occurring auditory hearing loss for high-frequency tones, is described as the most prevalent hearing problem for the elderly.1 Based on this information, it was predicted that many people would have difficulty discriminating the highfrequency tones. Nevertheless, it was surprising to discover that all persons tested were unable to hear a frequency of 4,000 Hz. Self-selection may have played a part in the extensive findings. Persons who are consciously or unconsciously aware of a hearing problem may be more likely to seek a hearing assessment test. The advanced age of the participants also may have influenced the results because hearing loss does increase with age.
DEMOGRAPHIC AND SELF-ASSESSMENT DATA
RESULTS OF HEARING ASSESSMENT
Implications for Nursing
Hearing impairment is a major problem for a large percentage of elderly persons, yet the problem may be unsuccessfully addressed through nursing assessment and intervention. Screening for hearing loss can serve as a primary step for early detection, referral, and treatment. The use of the audioscope as a means of screening for hearing loss is recommended because it allows for visualization of the external ear and tympanic membrane, and provides a precise determination of the degree of hearing deficit. Although a single test is inconclusive and should be repeated one week later, testing can provide valuable information that can be useful in subsequent evaluation and follow-up sessions. This is particularly important since the presence of hearing loss also can be indicative of other medical problems such as eighth nerve tumors, otitis media, and Meniere's disease.
Removal of earwax is a simple procedure that can be performed by a skilled nurse. Since impacted cerumen can result in a conductive hearing toss, removal of wax can give the gift of hearing back to the client.
Health teaching on ear care should include such suggestions as the need to keep foreign objects out of the ear (including hairpins, Q-tips, paper clips, or keys). Such instruction could prevent hazards, such as perforated eardrums, from occurring. In addition, it is recommended that individuals be advised to have earwax regularly evaluated and to seek immediate attention if drainage from the ear is detected or sudden hearing loss, pain, or dizziness is experienced.
By conducting hearing assessments, the nurse can serve as a catalyst for effective intervention. The audioscope is particularly recommended because it provides a fast, simple, and accurate hearing assessment. Through hearing assessment, the nurse can actively assist the older person with health promotion, early detection, and prompt intervention and can enhance the older person's capability for hearing today and tomorrow.
- 1. Heller B, Gaymor S: Hearing loss and aural rehabilitation of the elderly, in Wells J (ed): Aging and Health Promotion. Maryland, Aspen Publications, pp 21-29.
- 2. Meyerson M: The effects of aging on communication. J Gerontol 1976; 31(l):29-38.
- 3. Post F: Persistent Persecutory States of the Elderly. London, Pergamon Press, 1966.
- 4. Schein JD, DeIk MT: The Deaf Population. Silver Springs, Maryland, National Association of the Deaf, 1974.
- 5. Yurik AG, et al: The Aged Person and the Nursing Process. New York, Appleton-Century-Crofts, 1980.
6. Norris C: Self-care. American Journal of Nursing 1979; 486-489.
- 7. Nursing Pholobook: Assessing Your Patterns. Pennsylvania, Intermediate Communications, 1980.
- 8. Hawke M, Mansfield D: Clinical evaluation of a screening and audiometer and an integral otoscope. Modern Medicine of Canada 1984; 39(February). 200-202.
- 9. Griffin RH, Borderick RM, Vemon M: The audioscope and family practice: Field testing of an instrument and a look at hearing loss in family practice. Maryland State Medical Journal 1984; 33(ApriI):285-287.
- 10. Saxon SV, Etten MJ: Physical Change and Aging. New York, Tiresias Press, 1978.
DEMOGRAPHIC AND SELF-ASSESSMENT DATA
RESULTS OF HEARING ASSESSMENT