Life with hearing loss in elderly - a case study

1. Life with hearing loss in elderly - a case study And Information for patients

2. acknowledgement The case study narrated in first few slides is real. I wish to sincerely thank the family of the patient for giving me the permission to share the case with larger audience to create awareness

3. contents • The case of an elderly gentleman with hearing loss • Hearing loss in elderly • What is it and how common? • Common cause/reason • Other causes • Signs and symptoms • Social and psychological impact • Serious medical problems • Link to depression and dementia • What can be done? • Consultation and treatment • Support from family and friends • Take it seriously – tips and summary • References

4. The case: life before hearing loss • This gentleman lived in class 3 city in India near Mumbai. He superannuated after 40 years of career in government service, his wife too was in government job in education sector • Both retired with comfortable savings, regular pension, their own house with well settled son. • The gentleman, throughout his life, was outgoing, committed to his work • Additionally, was very active in social work – helpful to people around, tireless in working for social causes of the town without seeking any personal benefits, active political worker (again without seeking any position/benefit for himself) • The social activities continued with great dedication and enthusiasm post retirement well in to his seventies and early eighties • He had no major health issues/chronic illnesses

5. After hearing loss set in: initial days • As happens with many elderly, his hearing diminished in his early eighties • To begin with, he was noticed to ask people to repeat what they said, would turn on TV volume loud, would himself speak loudly • He consulted ENT specialist and was prescribed hearing aid • He tried number of aids (including some latest, expensive ones), each for a few days to weeks before discarding them as he did not feel comfortable (too loud sounds, cumbersome to manage etc) • After few attempts, he stopped using the hearing aid all together and became resistant to all attempts to coax him to use the aid by his family

6. Slow and steady deterioration • Next four to five years: • He developed significant limitations in his day to day life. As he could not hear well, his family was afraid to let him go out of house by himself • He would feel dizzy, that posed another risk and curtailed his outings • He could not go for his daily marketing, walks with his friends, could not continue with his social work – slowly became home bound and lost his freedom • Due to refusal to wear hearing aid, he could not enjoy television programs (a major source of entertainment to elderly in India), so it was difficult to pass time for someone who was so active and out going • Could not hear what his family, friends were saying, would answer something different and argue • Slowly his personality changed, he became paranoid and abusive to his immediate family, so much so that it put immense stress on his near and dear ones in the last couple of years

7. End stage: last 12 -15 months • The deterioration in the last few months was swift • He became extremely uncooperative, abusive and confrontational • He showed signs of cognitive decline and dementia • Would not get up from bed, a full time attendant was hired to tend to him • He refused to eat nutritious food, developed protein deficiency and family had to be vigilant to make sure he does not develop bed sores • When cold weather set in, poor nutrition and lack of activity led to pneumonia in both lungs to which he succumbed. • While he died at the age of 91, he was a sad caricature of his former self! • He suffered a lot (despite having no significant illness) and so did his family

8. Hearing loss in elderly: what is it and how common? • Hearing loss is sudden or gradual decrease in how well one is able to hear • Most people above 70 years (about 2/3rd) have at least mild hearing loss • Hearing loss in elderly is the third most common physical condition after arthritis and heart disease • Slow and steady hearing loss in elderly is called as “Prebycusis” and is caused by aging related changes in the inner ear which lead to gradual loss of sensory cells and nerve endings that receive and do initial processing of sound • It is not known why it happens to some people more than the others, but seems to run in the families

9. Other causes and factors that may lead to hearing loss • Viral/bacterial infections of ear • Stroke • Head injuries or brain tumours • Medications: • antibiotics such as streptomycin, kanamycin • High doses of aspirin, paracetamol • Diuretics (increase urine formation) • Antimalarial drugs • Chemotherapy agents used in treatment of cancer • Many of these medicines are commonly used in elderly

10. Signs and symptoms – the beginning • Initially the elderly person may not notice/admit about diminished hearing • However, observant family members/friends can notice odd/changed behaviour • The early signs include: • Unable to hear alarms, doorbells, phone – difficulty in understanding the conversation on phone • Answering something else than what is expected • Frequently asking people to repeat what they said or complaining that people are not speaking clearly • Trouble following conversation when two or more people talk at the same time (common habit in India) • Unable to hear the conversation when sitting near/in a noisy place – for e.g., restaurant • Turning the TV volume too high • Speaking very loudly • Slowly avoiding social gathering due to embarrassment

11. Consequences of hearing loss: Social and psychological impact

12. Hearing loss: more serious health consequences:A study linking hearing loss to depression • A study was carried out by researchers in Columbia University in the New York City • Information collected from > 5200 adults over 50 years of Latin American origin • Each participant was given hearing test and screened for depression • Results: • People with mild hearing loss were about twice more likely to have significant depression compared to people with normal hearing • People with severe hearing loss were more than four times likely to have depression, compared to those with normal hearing • Conclusion: • While the study does not prove that hearing loss can cause depression, there is a strong association and it is possible that it could lead to some depressive symptoms • Hearing loss makes people socially isolated which can lead to depression

13. Hearing loss linked to mental decline • Study conducted at John Hopkins University, USA, as a part of aging and health study that started in late 1990s • 2000 men and women in their 70s and 80s participated • Hearing was tested in year 5 of the study and men and women underwent series of tests over next six years to assess hearing and decline in memory and thinking • Results: • People with hearing loss showed evidence of mental decline that was 30 to 40% faster than people with normal hearing • Those with a greater hearing loss had steeper decline • Again this study did not definitely prove that hearing loss causes mental decline, but there was a strong association • Several theories have been put forward to explain the association

14. Theories to explain link between hearing loss and mental decline • Excess cognitive load on brain: With impaired hearing, brain may need to spend more energy on processing sounds that are now difficult to hear, sparing relatively less energy on things like memory and thinking. Thus struggle to hear on the part of brain may come at the cost of cognitive decline • Brain atrophy: Long term hearing impairment could contribute to faster rates of wasting away the parts of the brain that process sound, these parts also help with memory and senses • Social isolation due to deafness increases the risk of cognitive and mental decline

15. Consultations and treatment • Whom to go to? • Through primary care physician (GP), get an appointment of ENT surgeon (Ear, Nose, Throat specialist) to get thorough evaluation • Another key professional is audiologist: • They are specialized in identifying and measuring the type and degree of hearing loss • They can recommend treatment options • They can help in fitting suitable hearing aid and work with patients till they get comfortable with the aid

16. What can help? • Hearing aids: • Electronic instruments to be worn in or behind the ear • They make the sound louder, this aids in hearing • It takes time to adjust to using hearing aid, things sound different, may be louder • It is common for people to abandon using hearing aid • It is, therefore, important to work with the audiologist to identify the aid that is most suitable and also get comfortable using it • Cochlear implants: • Electronic devices implanted by surgery in the inner ear – help provide sense of sound • Generally reserved for very severe hearing loss • Lip or speech reading: • Helps understanding the conversation • Close attention needs to be paid to others when they talk, watching how their mouth and body moves

17. Can family or friends help? – yes! • The elderly person should share openly that he/she is hard of hearing • Request people to face you when they talk so that you can see their faces • Request them to speak more clearly and loudly, but not shout • In noisy public places, sit away from noise – for e.g., kitchen in a restaurant, a band playing music • Turn off TV, radio if you are not actively listening

18. Take it seriously – tips and summary • Hearing loss is often written off as normal part of aging – not taken seriously by the patient and family • However, progressive hearing loss can affect every aspect of life – from physical well being to emotional health and family relationships • Treatment is not sought early, when hearing loss in elderly is actually easy to diagnose and treat • Unfortunately, majority of elders who need hearing aid do not use them, as the use may be complex • Proper fitting, counselling, ongoing care of the device needed to ensure smooth functioning and continuous use • It is important to address both hearing and vision loss in elderly • Evaluating and treating these sensory impairments may be important for an aging person’s overall well being, independence • Solution needs to be worked out by the patient and family taking support from the professionals

19. References: • Drugs.com, Jan 05, 2019. Listen up! Hearing loss tied to late life depression • Hearing loss linked to mental decline in elderly. Salynn Boyles. Web MD Health News, Jan 22, 2019 • Hearing loss and elder adults. US Department of Health and Human Services, National Institute of Health (NIH), National Institute of Deafness and other Communication Disorders (NIDCD). http://www.nidcd.nih.ogv/health/hearing-loss-older-adults • Hearing aid upkeep often out of reach for the poor. Drugs.com Jan 08, 2019 • www.healthinaging.org/aging-and-health-atoz/topic:hearing-loss