Journal of Gerontological Nursing

CERUMEN IMPACTION Prevalence and Detection in Nursing Homes

Diane Feeney Mahoney, PhD, RN, C, GNP

Abstract

Cerumen impaction is a reversible, frequently overlooked cause of a conductive hearing loss. Elders may not realize that their hearing is reduced from impacted cerumen and may not seek treatment. Rubin (1989) recommends evaluating every patient presenting with hearing loss for cerumen impaction. In a convenience sample of 123 community residing older adults, 34% had cerumen impaction (Mahoney, 1987). Similar results (35%) were found among a randomized sample of hospitalized elderly (Lewis-Cullinan, 1990). Unknown at present is the prevalence of cerumen impaction in the institutionalized elderly population.

The underlying theoretical basis for this study lies within the philosophy of gerontological nursing. There is a unifying belief among gerontological nurses, and it is applied within the American Nurses' Association (ANA) standards of gerontological nursing practice, that nurses should strive to maximize older adults' achievable independence in everyday living (ANA, 1987). Treatable disorders in nursing home residents are important to discover in order to optimize their present functional status and reduce excess disability. The purpose of the present study was to determine the prevalence of impacted cerumen in a population of elderly nursing home residents, evaluate the difference in hearing perception after the removal of impacted cerumen, and identify the factors in the nursing home setting that impede or promote the detection and treatment of cerumen impaction.

HEARING LOSS AS A MAJOR GERIATRIC PROBLEM

In contrast to the multitude of research on hearing conducted in primary care settings, few studies have occurred in nursing homes. Estimates indicate that 70% to 90% of nursing home residents exhibit a hearing impairment (Glass, 1986; Weinstein, 1986a). Humphrey (1981) suggests that many people, including health care professionals, believe that hearing loss is a normal part of aging and that little can be done to improve older adults' hearing. If the staff and physicians believe that hearing loss among nursing home residents is expected due to advanced age, then the likelihood of further evaluation of hearing impairments is minimal. There are, however, three hearing disorders common in the older population:

* Presbycusis, the progressive irreversible bilateral loss of high tone perception often associated with aging;

* Central deafness, which occurs from nerve damage within the brain; and

* Conduction deafness that results from blockage or impairment of the mechanical movement in the outer or middle ear (National Institute on Aging, 1983).

The first two disorders may result in permanent hearing loss. Conduction deafness can be reversed if it is due to a treatable disorder such as cerumen impaction.

Hearing loss is a serious health problem among the elderly. Social isolation, depression, acting out inappropriately, and paranoia have been related to impaired hearing (Ebersole, 1989; Ham, 1983). Older adults with hearing loss may think that people around them are mumbling or deliberately excluding them from the conversation (Sanders, 1971). If ignored, a hearing impairment can cause older adults to become inappropriately labeled as "confused" or "uncooperative" when they misinterpret communication and respond improperly (National Institute on Aging, 1983). In a recent multivariate study of 153 noninstitutionalized elderly, Bess (1989) found that poor hearing was associated with functional - as well as psychosocial - impairment. Consequently, it is important that treatable causes of hearing loss, such as cerumen impaction, are identified and treated. Four questions guided this research:

* What is the prevalence of cerumen impaction among a random sample of elderly nursing home residents?

* Is there a significant difference in demographic and health care characteristics between residents with and without cerumen impaction?

* Is there a measurable difference in hearing perception after the removal of impacted cerumen?

* What factors in the nursing home setting impede or…

Cerumen impaction is a reversible, frequently overlooked cause of a conductive hearing loss. Elders may not realize that their hearing is reduced from impacted cerumen and may not seek treatment. Rubin (1989) recommends evaluating every patient presenting with hearing loss for cerumen impaction. In a convenience sample of 123 community residing older adults, 34% had cerumen impaction (Mahoney, 1987). Similar results (35%) were found among a randomized sample of hospitalized elderly (Lewis-Cullinan, 1990). Unknown at present is the prevalence of cerumen impaction in the institutionalized elderly population.

The underlying theoretical basis for this study lies within the philosophy of gerontological nursing. There is a unifying belief among gerontological nurses, and it is applied within the American Nurses' Association (ANA) standards of gerontological nursing practice, that nurses should strive to maximize older adults' achievable independence in everyday living (ANA, 1987). Treatable disorders in nursing home residents are important to discover in order to optimize their present functional status and reduce excess disability. The purpose of the present study was to determine the prevalence of impacted cerumen in a population of elderly nursing home residents, evaluate the difference in hearing perception after the removal of impacted cerumen, and identify the factors in the nursing home setting that impede or promote the detection and treatment of cerumen impaction.

HEARING LOSS AS A MAJOR GERIATRIC PROBLEM

In contrast to the multitude of research on hearing conducted in primary care settings, few studies have occurred in nursing homes. Estimates indicate that 70% to 90% of nursing home residents exhibit a hearing impairment (Glass, 1986; Weinstein, 1986a). Humphrey (1981) suggests that many people, including health care professionals, believe that hearing loss is a normal part of aging and that little can be done to improve older adults' hearing. If the staff and physicians believe that hearing loss among nursing home residents is expected due to advanced age, then the likelihood of further evaluation of hearing impairments is minimal. There are, however, three hearing disorders common in the older population:

* Presbycusis, the progressive irreversible bilateral loss of high tone perception often associated with aging;

* Central deafness, which occurs from nerve damage within the brain; and

* Conduction deafness that results from blockage or impairment of the mechanical movement in the outer or middle ear (National Institute on Aging, 1983).

The first two disorders may result in permanent hearing loss. Conduction deafness can be reversed if it is due to a treatable disorder such as cerumen impaction.

Hearing loss is a serious health problem among the elderly. Social isolation, depression, acting out inappropriately, and paranoia have been related to impaired hearing (Ebersole, 1989; Ham, 1983). Older adults with hearing loss may think that people around them are mumbling or deliberately excluding them from the conversation (Sanders, 1971). If ignored, a hearing impairment can cause older adults to become inappropriately labeled as "confused" or "uncooperative" when they misinterpret communication and respond improperly (National Institute on Aging, 1983). In a recent multivariate study of 153 noninstitutionalized elderly, Bess (1989) found that poor hearing was associated with functional - as well as psychosocial - impairment. Consequently, it is important that treatable causes of hearing loss, such as cerumen impaction, are identified and treated. Four questions guided this research:

* What is the prevalence of cerumen impaction among a random sample of elderly nursing home residents?

* Is there a significant difference in demographic and health care characteristics between residents with and without cerumen impaction?

* Is there a measurable difference in hearing perception after the removal of impacted cerumen?

* What factors in the nursing home setting impede or promote the detection and treatment of cerumen impaction?

METHODS

Subjects

The study sample consisted of 104 residents randomly chosen from eight Massachusetts nursing homes. The nursing homes were randomly chosen from the Massachusetts State listing of adult long-term care facilities for 1990. Facilities were excluded if they had less than 50 residents, since small homes are less likely to have an adequate pool of eligible residents and tend to have unique characteristics that limit generalizibility. Residents were prescreened and excluded from randomization if they did not speak English, were acutely ill, or were under age 62. Also, a mental status exam was part of the prescreening in order to assess the residents' capacity to give consent approval and follow audiologic testing directions. Five residents did not meet one of the prescreening criteria. Of the 107 residents eligible for the study, 104 (97%) agreed to participate.

The study occurred in two phases. Initially, all the subjects were examined to determine the prevalence rate for cerumen impaction in the nursing home population. Then, to assess if a measurable difference occurs when impacted cerumen is removed, a pretest /post-test two group comparison design was employed. The subjects with impacted cerumen comprised the study group and the subjects without impacted cerumen were designated as the comparison control group. Subjects in both groups would receive an initial and then a second hearing test after the impacted cerumen was removed from the study group.

Approval for research on human subjects was obtained from the Institutional Review Board, University of Massachusetts at Boston. Administrative permission to conduct research in the nursing home was obtained from the administrator and/ or director of nursing; individual written consent was obtained from the residents or their legal guardians.

Data Collection and Instruments

Subjects were interviewed and examined by a specially trained nurse research assistant to determine their eligibility to participate, their level of cerumen impaction, and their hearing perception. Participants with hearing aids wore them during the interview. The individual's medical record was reviewed to ascertain eligibility, demographic, behavioral, medication, and treatment data. Cerumen impaction was determined through otoscopy and measured as the percentage of tympanic membrane that could not be seen due to wax obstruction. Descriptive features concerning the type of impaction were coded according to pre-established categories (Mahoney, 1987). Mental status was assessed using the ten item Mental Status Questionnaire (MSQ) by Kahn (1960) and the number of errors were recorded. Preference was given to the MSQ over other tools because of its established validity and reliability, succinctness, and ease of administration. The data collection measures were chosen for obtaining the most relevant information while limiting the burden on the resident. Speech discrimination, a test for conversational hearing ability, was determined by the percentage of correct responses to a standard list of ten phonetically balanced monosyllabic words (Butler, 1975).

The audiometry was conducted according to a standardized protocol using a Beltone Model D portable pure-tone audiometer. The type of audiometer chosen has been used in other field settings and it permits objective, numerical calibrations of hearing ability to be recorded for comparative purposes (Corbin, 1984; Ohta, 1981). The audiometer was calibrated to American National Standards Institute specifications immediately prior to use in the field.

The audiometer produces and measures tones of varying frequency and intensity. The frequency is measured in Hertz (Hz), or cycles, per second, and is perceived as pitch. Human hearing ranges from approximately 20 to 20,000 Hz. Intensity is measured in decibels (dB) and is perceived as loudness. Measurements are made by air conduction where the sound is introduced through a headset into the ear. Threshold is the faintest sound which an average listener can just hear in the quiet. Pure tone thresholds (PTTs) were measured at the frequencies found in the speech range of 500, 1000, 2000 and 4000 Hz using the standard 10-down 5-up bracketing technique. The participants thresholds were recorded for each frequency and ear. Thresholds were interpreted as: normal (025 dB), mild hearing loss (26-40 dB), moderate (41-55 dB), moderately severe (56-70 dB), or profound (>70 dB) (Weinstein, 1986b). Duplicate assessments were incorporated in the testing as a reliability check on the residents' responses. Also, the mean three frequency pure-tone average (500, 1000, and 2000 Hz) in the participants better ear was calculated. Persons with pure tone averages in excess of 40 dB are considered to be hearing impaired.

A charge nurse in each facility was interviewed using a semistructured questionnaire to obtain information about the factors that promote or impede the detection and treatment of cerumen impaction in the nursing home. An administrative representative shared data on the characteristics of the nursing home which were validated by state data (Goldman, 1990).

RESULTS

Prevalence of Cerumen Impaction

Impacted cerumen was observed in 26 out of the 104 nursing home residents for a prevalence rate of 25%. Of the 104 residents, 21 had cerumen unilaterally (20%) and 5 had both ears occluded (4.8%). Moreover, an additional 18 (23%) of the 78 people without impaction had a strong potential to develop the condition; that is, at the time of the study the cerumen in the canals was greater than 75% but less than the criteria of 100% necessary to be categorized as impaction. Taken together, 42% of the residents had severe to complete cerumen impaction.

Table

TABLE 1Characteristics of Cerumen Impacted and Nonimpacted Residents

TABLE 1

Characteristics of Cerumen Impacted and Nonimpacted Residents

Characteristics

Personal characteristics mentioned in the literature as being associated with impacted cerumen were compared among those with and without cerumen impaction. Characteristics are reported using mean values (±SD) or percentages where applicable (Table 1). The only notable difference between the two groups occurred with speech discrimination in which those with impacted cerumen scored significantly worse (t-test, P= .05, t= 2.0).

Prevalence of Hearing Impairment

The majority of the nursing home residents were hearing impaired. Only a minority (4%) had hearing levels within normal limits while the majority (55%) were moderately to profoundly hearing impaired. If those with mild hearing loss are included, the overall prevalence rate of residents with any hearing loss was 96%.

The level of hearing ability was compared among the residents with and without impacted cerumen. The mean three frequency pure-tone average in the better ear was 44.2 dB with a range of 18 dB to 77 dB (SD 12). Although the mean level at 47 dB was higher in impacted residents then the 43 dB level in nonimpacted residents, the difference was not statistically significant.

Post-Test

The second hearing evaluation scheduled to be performed after the cerumen removal was unable to be conducted because of two major problems:

* There was difficulty in obtaining the necessary physicians' orders that would permit nursing home nurses to administer ceiximinoly tic ear drops; and

* Of those who did receive treatment, the vast majority of residents' ears remained impacted.

Two residents were unable to be treated because their physician never responded despite numerous telephone calls to his office. Even when this physician visited another resident in the same nursing home, he refused to remove their cerumen impaction, or even write the orders allowing the nurses to do so, because it would have taken too much time. Moreover, of the 17 residents who received treatment for cerumen impaction, 12 remained 100% impacted, 4 were greater than 75% impacted, and one was greater than 50% impacted. One resident was referred by his physician and sent by ambulance to an ear, nose, and throat specialist for the cerumen removal (at a cost of $350). Nevertheless, this resident returned to the facility diagnosed as hearing impaired with a referral to an audiologist, but still 100% impacted. One resident refused treatment, two residents died during the study period, one was hospitalized, and two others became impacted in their opposite ears by the end of the field period.

Cerumen Impaction Factors

The key charge nurse in each nursing home was interviewed using a combination of structured questions, probes, and open ended opportunities to discern the factors affecting the assessment and treatment of cerumen impaction. The nurses (N = 8) were all female, were all employed full time, were primarily LPNs (62%), and were on average 40 years old. They had worked 14 years in longterm care and none had any additional educational preparation in gerontological nursing. They were primarily supervisors (100%), with the majority administering medications (75%), and only a minority providing direct care (25%). The major obstacles to detecting cerumen impaction that they reported are listed in Table 2; the factors that facilitate detection are outlined in Table 3.

The typical nursing home in this study was for-profit (75%), was part of a chain (62%), had 99 licensed beds, had a 99% occupancy rate, and was in operation for 43 years. The nursing homes represented all traditional levels of skilled care and the majority of their residents (73%) were on Medicaid. None of the homes employed or contracted the services of a gerontological nurse practitioner (GNP). They all were served by private physicians (100%), and all had their own medical director (100%). One home had both a gerontological clinical nurse specialist (CNS) and a RN certified in gerontology. This home had no problems with cerumen impaction. Compared to the other nursing homes in the sample, the facility with the gerontological nurses was the newest (5 years old). It was of private non-profit ownership, was fully occupied (100%), and was slightly smaller (82 beds), but had more level II (100%) and Medicaid residents (90%) than the other homes.

Table

TABLE 2Nurse Impressions of Impediments to Detecting Cerumen Impaction

TABLE 2

Nurse Impressions of Impediments to Detecting Cerumen Impaction

Table

TABLE 3Nurse Impressions of factors that Promote the Detection/Treatment of Cerumen Impaction

TABLE 3

Nurse Impressions of factors that Promote the Detection/Treatment of Cerumen Impaction

Table

TABLE 4Practice Recommendations Related to Cerumen Impaction

TABLE 4

Practice Recommendations Related to Cerumen Impaction

DISCUSSION

Although one-quarter of the nursing home residents were found to have impacted cerumen, this may be a conservative finding. One of the nursing homes uniquely differed from the others because no residents had cerumen impaction. This was the only home that employed two nurses who had specialty preparation in gerontological nursing. Interestingly, if that home had been excluded, the impaction rate would have been 34%, supporting prior findings in the community (Mahoney, 1987) and the hospital setting (Lewis-Cullinan, 1990).

Surprisingly, many of the characteristics alluded to in the literature as being associated with greater potential for cerumen impaction were not statistically significant in this study. In particular, it is frequently reported that being older, being male, wearing a hearing aid, and being in frail health predisposes an elder to increased cerumen production. These variables did not emerge as important features, perhaps due to the small number of residents in this sample who wore hearing aides (15%), or were men (20%). Of interest would be a replication study in a predominantly male institutionalized population.

In order to gain entry into multiple nursing homes and reduce concerns about liability, it was necessary to rely on the nursing home staff to coordinate the residents' treatment for cerumen impaction. Initially, three months were allowed for this process; however, treatment could not be effectively rendered within a six month period. Newman (1990), in a European study of hospitalized elders, also reported difficulty in having hospitalized elders treated for cerumen impaction. The researcher found that British physicians were neither skilled in ear irrigations nor saw themselves as responsible for the procedure - yet hospital policy prevented the nurses from performing the treatment.

Similar practice and policy conflicts appear to exist in long-term care. Physicians were reluctant to personally perform ear irrigations and the nurses reported that they were unable to independently administer ceruminolytic ear drops, use an otoscope, or perform ear irrigations. Yet, otologic examination and treatment for cerumen impaction has become part of professional nursing practice (Burke, 1992; Larsen, 1976) and in particular part of the role of nurses in advanced practice (Palumbo, 1990). Most commonly, however, LPNs without assessment skills were in charge. Even RNs lacked these skills because their education pre-dated the physical assessment courses common in today's professional nursing curriculum and they had no additional formal education. Although this study was limited to one state, these findings may be applicable in other regions. Data from the National Nursing Home Survey revealed that nursing home RNs tend to be older, less educated, less likely to perform hands-on care, and more likely to stay in the same setting longer than the average nonnursing home RN (Strahan, 1988). Consequently, the practice recommendations (Table 4) are made considering these constraints.

The findings from this study portray a striking difference in clinical practice between the nursing home with gerontological nurses and the other facilities. Unintentionally, this study documented objective evidence that access to physician services for cerumen impaction is a problem. This problem did not exist in the home where the gerontological clinical nurse specialist performed otoscopies and ear irrigations. In the other homes, residents who received treatment remained impacted, even after ceruminolytic ear drops were administered. One possible explanation for this phenomenon may be that the four or five ear drops typically administered daily for two to four days was inadequate to dissolve hard, impacted cerumen. More intensive treatment with the ear drops or an ear irrigation to complement the ear drops probably would have been effective.

These nurses, however, do not perform ear irrigations. Furthermore, their inability to use an otoscope prevented them from evaluating the effects of the treatment. The assumption was made that the treatment was appropriate when in reality the impaction was never removed.

Quality of care in nursing homes has been, and continues to be, of concern to policymakers, providers, and users of long-term care services (Institute of Medicine, 1986). The Nursing Home Reform Act of 1987 (1987) is evidence of the government's attempt to improve clinical practices within nursing homes. The act states that a resident must be given "appropriate treatment and services to maintain or improve on his or her ability to ambulate, dress, feed, groom, bathe, toilet, transfer, and communicate." The findings from this study document that physician and professional nursing services to treat cerumen impaction are lacking. Clearly the residents' ability to maintain or improve their hearing and communication is not helped by this situation. As demonstrated in this study, professional gerontological nurses in the nursing home made a positive difference. It is time for legislators to support policies that encourage the use of gerontological nurses, clinical specialists, and nurse practitioners with salary differentials, prescriptive privileges, and independent reimbursement.

Although it was disappointing that a post-cerumen hearing evaluation could not be conducted, Morley (1990), in an institutional study started after this research, did find that almost 50% of the 40 hearing impaired patients with cerumen impaction had their hearing restored after removal of the cerumen. This finding supports findings of prior studies in which removing cerumen impaction from a hospitalized elderly sample improved hearing scores for 75% of the ears (LewisCullinan, 1990). These two studies lend credence to the contention that removing impacted cerumen can improve older adults' hearing. Given the prevalence of hearing loss and cerumen impaction among the elderly, greater attention to the detection and removal of impacted cerumen is warranted.

REFERENCES

  • American Nurses' Association. Standards and scope of gerontological nursing practice. Kansas City, Kansas: Author, 1987.
  • Bess, F., Lichtenstein, M. Logan, S., Burger, C, Nelson, E. Hearing impairment as a determinant of function in the elderly. / Am Geriatr Soc 1989; 37:123-128.
  • Burke, M., Walsh, M. Gerontologie nursing: Care of the frail elderly. St Louis, Missouri: MosbyYear Book, 1992.
  • Butler, P.M. Physical appraisal of the ear and hearing. In J. Sana, R. Judge (Eds.), Physical Appraisal Methods in Nursing Practice. Boston: Little, Brown, and Co., 1975, pp. 121-139.
  • Corbin, S., Reed, M., Nobbs, H., Eastwood, K., Eastwood, M. Hearing assessment in homes for the aged: A comparison of audiometrie and self-report methods. / Am Geriatr Soc 1984; 32(5):39f^400.
  • Ebersole, P., Hess, P. Toward healthy aging. St Louis: CV. Mosby, 1989.
  • Glass, L. Rehabilitation for deaf and hearingimpaired elderly. In S. Brody, G. Ruff (Eds.), Aging and rehabilitation. New York: Springer, 1986, pp. 218-237.
  • Goldman, D., Veisbergs, B. (Eds.), Guide to nursing and rest homes in Massachusetts, 1990/ 91, 13th ed. Boston: Women's Educational and Industrial Union and Massachusetts Department of Public Health, 1990.
  • Ham, R. Primary care geriatrics. Boston: John Wright, 1983.
  • Humphrey, C. Some characteristics of the hearing impaired elderly who do not present themselves for rehabilitation. Br J Audiol 1981; 15(25):3-6.

Institute of Medicine. Improving the quality of care in nursing homes. Washington, D.C.: National Academy Press, 1986.

  • Kahn, R., Goldfarb, ?., Pollack, M., Peck, A. Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 1960; 117:326-328.
  • Larsen, G. Removing cerumen. Am J Nurs 1976; 76:264-265.
  • Lewis-Cullinan, C, Janken, J. Effect of cerumen removal on the hearing ability of geriatric patients. / Adv Nurs 1990; 15:594-600.
  • Mahoney, D.F. One simple solution to hearing impairment. Geriatr Nurs 1987; 8(5):242245.
  • Morley, J.E., Kahl, M.J., Peak. M. Hearing impairment in the nursing home. Gerontologist 1990; 30:296.
  • National Institute on Aging. Hearing and the elderly. (Publication No. 1983-416-520). Washington, DC: U.S. Government Printing Office, 1983.
  • Newman, D. Assessment of hearing loss in elderly people: The feasibility of a nurse administered screening test. / Adv Nurs 1990; 15:400409.
  • Ohta, R., Carlin, M., Harmon, B. Auditory acuity and performance on the mental status questionnaire in the elderly. J Am Geriatr Soc 1981; 29(10):476-478.
  • Palumbo, M. V. Hearing Access 2000: Increasing awareness of the hearing impaired. Journal of Gerontological Nursing 1990; 16(9):26-31.
  • Rubin, I., Dwyer, F. Management of the geriatric population. In I. Rubin, A. Crocker (Eds.), Developmental Disabilities. Philadelphia: Lea and Febiger, 1989, pp. 128-139.
  • Sanders, D. Aural rehabilitation. Englewood Cliffs, NJ: Prentice-Hall, 1971.
  • Strahan, G. Characteristics of registered nurses in nursing homes: Preliminary data from the 1985 National Nursing Home Survey. Advance data from Vital and Health Statistics. (No 152 (PHS)88-1250). Hyattsville, MD: Public Health Service, 1988.
  • Weinstein, B. Validity of a screening protocol for identifying elderly people with hearing problems. American Speech-LanguageHearing Association (ASHA) 1986b; 28(5):41-45.
  • Weinstein, B., Amstel, L. Hearing loss and senile dementia in the institutionalized elderly. Clinical Gerontologist 1986a; 4(3):3-15.
  • 1987 Nursing Home Reform Act, PL-100-203, as incorporated into the Omnibus Budget Reconciliation Act (OBRA) of 1987 (1987).

TABLE 1

Characteristics of Cerumen Impacted and Nonimpacted Residents

TABLE 2

Nurse Impressions of Impediments to Detecting Cerumen Impaction

TABLE 3

Nurse Impressions of factors that Promote the Detection/Treatment of Cerumen Impaction

TABLE 4

Practice Recommendations Related to Cerumen Impaction

10.3928/0098-9134-19930401-06

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