[ANSWERED 2023] Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group)

Written By: Dan Palmer, RN

Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group)

Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group)

HPI: Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group); turns up radio or television louder to hear (also noted by family, friends, and neighbors); Mary complains of tinnitus; and she feels like people are “mumbling.”

PMH: Mary takes ramipril for hypertension (HTN), a baby aspirin for cardio protection, and a statin for hypercholesterolemia.

Vital signs are 120/88 P: 88 P02: 96% WT: 156 HT: 5’6″

ROS: Ask if Mary has had any exposure to ototoxic drugs or other otic damage in the past. Describe at least three.

PE: What examinations will you perform on the ear? Describe the areas of the ear you will evaluate and what you will expect to find.

You determine that Mary has a hearing deficit and tinnitus. What differential diagnoses do you want to consider? Describe at least three.

What will your treatment plan for this patient be?

What other recommendations will you make (i.e., screening)?

What referrals will you make?

Education: Name at least two things you will educate your patient about regarding their hearing.

Choose the ROS, PE, and DD and final diagnosis for this patient, and then write up your focused SOAP note

Expert Answer and Explanation

Focused SOAP Note

My wife seems to be having trouble hearingPatient Information:

MM, 88, Female, African American

S (subjective)

CC: “My wife has trouble hearing. She turns up the TV very loud when watching.”

HPI: MM is an 88-year-old African American (AA) female who was brought to the clinic for a hearing problem. The patient’s husband complains that MM does not hear him when he talks to her and turns the TV up so loud when watching. Associated symptoms include a feeling of people “mumbling” and tinnitus. She describes tinnitus as buzzing. Tinnitus worsens at bedtime. The patient has not stated the onset of trouble hearing. She has not reported any pain in the ear.

Current Medications: She has a statin for hypercholesterolemia, baby aspirin for cardioprotection, and ramipril for hypertension (HTN).

Allergies: No environmental, food, or medication allergies.

PMHx: She received the Tdap vaccine 7 years ago. She received a PCV15 shot six months ago. She also received the covid-19 vaccine. No past major surgery. He has hypertension.

Soc and Substance Hx: She is a retired banker. Denies using alcohol, tobacco, or any other substance abuse. She uses seat belts when in a car. She does not drive. She does not smoke. She has a strong support system comprising of her husband and children. She used to love gun shooting sport.

Fam Hx: Her mother had hypertension and died aged 68 from ovarian cancer. Her Father died when she was young from a car accident. Her eldest son has type diabetes and hypertension. My maternal grandfather died of throat cancer and her paternal grandmother died of type two diabetes.

Surgical Hx: No prior surgical procedures.

Mental Hx: No history of self-harm practices. She was diagnosed with depression when she was 65.

Violence Hx: No concerns about violence at home. No history of violence.

Reproductive Hx: She is in a menopause state. Not pregnant and do not use contraceptives. She is not sexually active.

ROS:

  • GENERAL: No chills, fever, fatigue, or weight loss.
  • HEENT: Eyes: No visual loss, double vision, or blurred vision. Ears, Nose, Throat: Complains of hearing loss. No congestion, sneezing, runny nose, or sore throat.
  • SKIN: No rash or itching.
  • CARDIOVASCULAR: No chest discomfort, pain, or pressure.
  • RESPIRATORY: No sputum, shortness of breath, or cough.
  • GASTROINTESTINAL: No vomiting, anorexia, diarrhea, or nausea.
  • GENITOURINARY: No burning on urination.
  • NEUROLOGICAL: No ataxia, headache, or dizziness.
  • MUSCULOSKELETAL: No joint or muscle pain and stiffness.
  • HEMATOLOGIC: No anemia.
  • LYMPHATICS: No enlarged nodes.
  • ENDOCRINOLOGIC: No polydipsia or reports of sweating, cold or heat intolerance.
  • REPRODUCTIVE: Not sexually active.
  • ALLERGIES: No history of, hives, asthma, rhinitis, or eczema.

O (objective)

Physical exam:

  • Vital signs: BP 120/88, P02: 96%, P 88, WT: 156 HT: 5’6”
  • General: The patient appears her stated age. She is oriented to place, time, and people. She is well-groomed and hygienic. She answers questions correctly.
  • Head: No scars or any abnormal features. The skull is of normal shape and size.
  • Ears: Outer ear intact. No inflammation in the ear. No excess earwax. No injury to the inner ear. No abnormal ear bone growth. No spams in inner ear muscles. Cardiovascular: No chest cracks. Chest edema. Regular heartbeats or rates.
  • Respiratory: No breathing distress. No fluids in the lungs. No wheezes.

Diagnostic results:

  • Audiometer test: The patient will wear earphones and be asked to hear words and sounds directed to each ear to find the quietest sound the patient can hear (van Beeck Calkoen et al., 2019). It is done by an audiologist.
  • Tuning fork test: Kelly et al. (2018) noted that a tuning fork test can help a doctor detect hearing loss. The test can be used to identify where ear damage has occurred.
  • Whisper test: A whisper test can be used by a doctor to evaluate patients’ ears for hearing. It identifies how well a patient hears and responds to words spoken at various volumes (O’Donovan et al., 2019).
  • Blood test: Blood can be used to test for ear infections.

A (assessment)

Differential diagnoses: 

  • Presbycusis: Presbycusis is the primary diagnosis for this case. Presbycusis is a hearing loss that occurs gradually as one ages (Wang & Puel, 2020). Symptoms of presbycusis include withdrawal from conversations, trouble hearing conversations, muffling sounds, difficulty understanding words and turning up the volume of radio or television (Wang & Puel, 2020). The patient experiences most of the symptoms making the presbycusis a primary diagnosis. The patient’s age also supports the diagnosis.
  • Ear infection: Ear infection has been included in the diagnosis because it causes hearing loss and tinnitus (Venekamp et al., 2020). However, it has been ruled out because a physical exam shows no inflammation of the outer or inner ears.
  • Muscle spasms in the inner ear: Muscle spasms can also result in hearing loss and tinnitus (Shi et al., 2019). This disorder can be ruled out because the physical exam showed no spams in the inner ear muscles.

P (plan) 

Diagnostic studies that will be obtained include audiometer, blood tests for infections, and tuning fork test. The patient will be referred to an audiologist for an audiometer test. The patient will be provided with hearing aids to help improve her hearing (Wang & Puel, 2020). The patient will also be given special fluid-filled ear muffs to prevent further hearing loss and reduce tinnitus.

Reflection

The patient’s hearing problem might be caused by her age. Thus, hearing aids can help her improve her hearing and reduce tinnitus. She should avoid loud sounds to prevent further ear problems.

References

Kelly, E. A., Li, B., & Adams, M. E. (2018). Diagnostic accuracy of tuning fork tests for hearing loss: A systematic review. Otolaryngology–Head and Neck Surgery, 159(2), 220-230. https://doi.org/10.1177/0194599818770405

O’Donovan, J., Verkerk, M., Winters, N., Chadha, S., & Bhutta, M. F. (2019). The role of community health workers in addressing the global burden of ear disease and hearing loss: A systematic scoping review of the literature. BMJ Global Health, 4(2), e001141. https://gh.bmj.com/content/4/2/e001141.abstract

Shi, Y., Li, Y., Gong, Y., Chen, B., & Chen, J. (2019). Cochlear implants for patients with inner ear malformation: experience in a cohort of 877 surgeries. Clinical Otolaryngology, 44(4), 702-706. https://doi.org/10.1111/coa.13360

van Beeck Calkoen, E. A., Engel, M. S. D., van de Kamp, J. M., Yntema, H. G., Goverts, S. T., Mulder, M. F., & Hensen, E. F. (2019). The etiological evaluation of sensorineural hearing loss in children. European Journal Of Pediatrics, 178(8), 1195-1205. https://link.springer.com/article/10.1007/s00431-019-03379-8

Venekamp, R. P., Schilder, A. G., van den Heuvel, M., & Hay, A. D. (2020). Acute middle ear infection (acute otitis media) in children. Bmj, 371. https://doi.org/10.1136/bmj.m4238

Wang, J., & Puel, J. L. (2020). Presbycusis: An update on cochlear mechanisms and therapies. Journal of Clinical Medicine, 9(1), 218. https://doi.org/10.3390/jcm9010218

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Presbycusis: Understanding Sensorineural Hearing Loss as You Age

Introduction

As we age, our bodies go through various changes, and one aspect that can significantly impact our quality of life is hearing. Presbycusis, commonly known as age-related hearing loss, affects millions of individuals worldwide. In this article, we will delve into the intricacies of presbycusis, exploring its causes, symptoms, diagnosis, management, and its impact on mental health. We will also debunk common myths surrounding hearing loss and aging, providing valuable insights into embracing this natural part of the aging process.

What is Presbycusis?

Presbycusis is a type of sensorineural hearing loss that occurs gradually as a person ages. It is one of the most common health conditions affecting older adults and can lead to difficulties in understanding speech and other sounds. The condition is a result of natural changes in the inner ear, auditory nerve, and other structures involved in hearing.

Causes of Presbycusis

Several factors contribute to the development of presbycusis, including genetic predisposition, prolonged exposure to loud noises, and the cumulative effects of aging on the auditory system. The degeneration of sensory cells in the inner ear, known as hair cells, and the reduced blood flow to the cochlea also play a role in causing presbycusis.

Signs and Symptoms

Recognizing the signs of presbycusis is crucial for early intervention. Common symptoms include difficulty understanding conversations, especially in noisy environments, asking others to repeat themselves frequently, and perceiving speech as mumbled or slurred. Additionally, affected individuals may experience tinnitus (ringing in the ears).

Diagnosing Presbycusis

Diagnosing presbycusis involves a comprehensive hearing evaluation performed by an audiologist. The evaluation may include pure-tone audiometry, speech tests, and other specialized assessments to determine the extent and nature of the hearing loss.

Prevention and Management

While presbycusis is a natural part of aging, there are steps one can take to mitigate its impact. Avoiding prolonged exposure to loud noises, protecting the ears in noisy environments, and maintaining a healthy lifestyle can help preserve hearing to some extent.

Hearing Aids and Assistive Devices

Hearing aids and other assistive listening devices can significantly improve the quality of life for individuals with presbycusis. Technological advancements have made modern hearing aids discreet and effective, amplifying sounds and enhancing speech clarity.

Coping with Presbycusis

Adjusting to life with presbycusis can be challenging, but adopting certain coping strategies can make the process smoother. Seeking support from loved ones, joining hearing loss support groups, and staying informed about new technologies are some ways to cope effectively.

Communication Strategies

Effective communication becomes vital for individuals with presbycusis. Both the affected individual and their communication partners can employ strategies like speaking clearly, facing each other during conversations, and reducing background noise to facilitate better understanding.

Lifestyle Adjustments

Presbycusis may necessitate certain lifestyle adjustments, such as using captioned televisions or relying on visual cues during conversations. Adapting daily routines and environments to accommodate hearing loss can greatly improve daily experiences.

Presbycusis Myths Debunked

There are several misconceptions surrounding presbycusis and hearing loss. We will debunk common myths and provide accurate information about this prevalent condition.

The Impact of Presbycusis on Mental Health

Hearing loss can have far-reaching effects on an individual’s mental well-being. We will explore the emotional and psychological impact of presbycusis and the importance of addressing mental health concerns.

Embracing Hearing Loss as Part of Aging

Acceptance and embracing hearing loss as a natural part of aging can empower individuals to seek help, stay socially engaged, and focus on the positive aspects of life.

Research and Future Directions

Ongoing research in the field of presbycusis aims to find innovative treatments and interventions to improve the lives of those affected. We will discuss some of the promising developments in this area.

Conclusion

Presbycusis, or age-related hearing loss, is a prevalent condition that affects many as they grow older. By understanding the causes, symptoms, and available management options, individuals can proactively address hearing loss and maintain a fulfilling life. Embracing the changes that come with aging, including hearing loss, can lead to better overall well-being and a positive outlook on life.

FAQs

  1. Is presbycusis preventable?
    • While presbycusis is a natural part of aging, certain preventive measures, such as protecting the ears from loud noises, can help delay its onset.
  2. Can hearing aids completely restore hearing?
    • While hearing aids can significantly improve hearing and speech comprehension, they may not fully restore hearing to normal levels.
  3. Are there any alternative treatments for presbycusis?
    • Some ongoing research explores alternative treatments like regenerative therapies, but they are still in experimental stages.
  4. Does presbycusis affect both ears equally?
    • Presbycusis typically affects both ears, but the degree of hearing loss may vary between ears.
  5. Are there support groups for individuals with presbycusis?
    • Yes, there are various support groups and organizations that provide resources and emotional support for those with presbycusis.

What Age Does Hearing Loss Begin?

Hearing loss can begin at any age, but it is more commonly associated with the natural aging process. The gradual decline in hearing abilities due to age-related changes in the auditory system is known as presbycusis. Presbycusis typically starts to manifest in individuals around the age of 50 or older, although it can vary from person to person.

However, it’s important to note that hearing loss is not limited to older adults. Various factors, such as exposure to loud noises, certain medical conditions, genetic predisposition, and ear infections, can cause hearing loss in individuals of all age groups, including children and young adults.

For younger individuals, hearing loss is often caused by factors like noise exposure from loud music, recreational activities, or occupational hazards. It’s essential to protect one’s hearing at any age by avoiding prolonged exposure to loud sounds and using hearing protection devices when necessary. Regular hearing check-ups with an audiologist can also help identify any hearing issues early on and facilitate timely intervention.

Presbycusis Conductive Hearing Loss

Presbycusis is a type of sensorineural hearing loss, not conductive hearing loss. Conductive hearing loss, on the other hand, is a different form of hearing impairment caused by problems in the outer or middle ear that interfere with sound conduction to the inner ear.

Let’s briefly differentiate between the two:

Presbycusis (Sensorineural Hearing Loss):

  • Presbycusis is the most common form of hearing loss associated with aging.
  • It occurs due to natural changes in the inner ear, auditory nerve, or other structures involved in hearing.
  • The degeneration of sensory cells, known as hair cells, in the cochlea is often a primary factor.
  • Symptoms include difficulty hearing high-pitched sounds, trouble understanding speech, and increased sensitivity to loud noises.
  • Hearing aids and assistive devices are often used to manage presbycusis.

Conductive Hearing Loss:

  • Conductive hearing loss is caused by issues in the outer or middle ear that prevent sound from reaching the inner ear.
  • Common causes include ear infections, earwax blockage, fluid buildup behind the eardrum, or abnormalities in the ear’s structure.
  • People with conductive hearing loss may experience reduced sound volume and have difficulty hearing soft sounds.
  • In many cases, conductive hearing loss is treatable, and medical intervention or surgery can help restore hearing.

It’s important to note that while both presbycusis and conductive hearing loss can impact an individual’s ability to hear, they are distinct conditions with different underlying causes. If you or someone you know is experiencing hearing difficulties, it is advisable to seek evaluation and guidance from a qualified audiologist or healthcare professional to determine the specific type of hearing loss and appropriate management options.

Presbycusis Definition

Presbycusis is a medical term used to describe age-related hearing loss. It is a common condition that occurs gradually as a person grows older. With presbycusis, there is a natural and progressive decline in hearing abilities, particularly in perceiving high-pitched sounds and understanding speech in noisy environments.

The primary cause of presbycusis is the natural aging process, which leads to changes in the delicate structures of the inner ear, including the cochlea and auditory nerve. These age-related changes can result in the loss of sensory cells, known as hair cells, and reduced blood flow to the auditory system, affecting the transmission of sound signals to the brain.

Individuals with presbycusis may find it challenging to follow conversations, especially in noisy settings, and may often ask others to speak louder or repeat themselves. The condition can have significant impacts on communication, social interactions, and overall quality of life for older adults.

While presbycusis is a common part of the aging process, it is essential to recognize the symptoms early and seek appropriate medical evaluation and intervention. Hearing aids and assistive listening devices can help individuals with presbycusis improve their hearing and enhance their ability to engage in daily activities and conversations effectively. Regular hearing check-ups with an audiologist are recommended to monitor hearing health and address any concerns promptly.

What is the Cause of Anacusis?

Anacusis, also known as total deafness, is the complete loss of hearing in both ears. The condition can be congenital (present from birth) or acquired later in life due to various factors. The causes of anacusis can be broadly categorized into two main types: congenital and acquired.

Congenital Causes:

  • Genetic Factors: Anacusis can be caused by inherited genetic mutations that affect the development and function of the auditory system.
  • Maternal Infections: Certain infections during pregnancy, such as rubella (German measles) or cytomegalovirus (CMV), can lead to congenital hearing loss in the baby.
  • Prematurity and Low Birth Weight: Babies born prematurely or with low birth weight may be at a higher risk of hearing loss, including anacusis.
  • Birth Complications: Anoxia (lack of oxygen) or other birth complications can also result in hearing loss in newborns.

Acquired Causes:

  • Infections: Severe or untreated infections of the ear, such as meningitis or chronic otitis media, can lead to acquired anacusis.
  • Noise Exposure: Prolonged exposure to loud noises, particularly without proper hearing protection, can cause irreversible damage to the auditory system and result in hearing loss, including anacusis.
  • Head Trauma: Severe head injuries or trauma to the head can damage the auditory nerves or other vital structures involved in hearing.
  • Ototoxic Medications: Certain medications, when taken in high doses or for an extended period, can have toxic effects on the auditory system and cause hearing loss.
  • Age-related Factors: While not typically associated with total anacusis, age-related changes in the inner ear can lead to varying degrees of hearing loss in older individuals.

It is important to note that anacusis is a severe and life-altering condition. If someone suspects they have significant hearing loss, it is essential to seek immediate medical evaluation from an audiologist or an ear, nose, and throat (ENT) specialist. Early detection and intervention can make a difference in managing hearing loss and improving overall quality of life. Treatment options may include hearing aids, cochlear implants, or other assistive devices, depending on the individual’s specific needs and circumstances.

What is the Deafness Machine Called?

The deafness machine is called a “cochlear implant.”

A cochlear implant is a medical device designed to help individuals with severe to profound hearing loss or deafness. Unlike traditional hearing aids, which amplify sound for individuals with residual hearing, cochlear implants bypass damaged parts of the inner ear (cochlea) and directly stimulate the auditory nerve. This stimulation allows the brain to perceive sound signals and helps the person with hearing loss understand speech and sounds.

A cochlear implant consists of two main components: an external part and an internal part. The external part includes a microphone, speech processor, and transmitter, which are worn behind the ear or on the body. The internal part is surgically implanted under the skin and includes an electrode array that is placed in the cochlea.

When sound is captured by the microphone and processed by the speech processor, the information is transmitted to the internal implant via a transmitter. The electrodes in the cochlea then stimulate the auditory nerve, which sends the signals to the brain for interpretation as sound.

Cochlear implants have been transformative for many individuals with profound hearing loss or those who do not benefit from traditional hearing aids. It allows them to regain access to the world of sound and significantly improve their communication and quality of life. However, not everyone with hearing loss is a candidate for a cochlear implant, and the decision to get one is based on several factors, including the severity and type of hearing loss and the individual’s overall health and communication needs. A thorough evaluation by an audiologist or an ear, nose, and throat (ENT) specialist is necessary to determine if a cochlear implant is a suitable option for a particular individual.

How Do Deaf Hearing Devices Work?

Deaf hearing devices, also known as assistive listening devices (ALDs), are designed to help individuals with hearing loss enhance their ability to hear and communicate in various listening situations. There are several types of deaf hearing devices, each serving different purposes and working in different ways. Here are some common types and how they work:

Hearing Aids:

  • Hearing aids are wearable devices that amplify sounds for individuals with mild to severe hearing loss.
  • A microphone in the hearing aid picks up sounds from the environment.
  • The processed sounds are then amplified by the hearing aid’s internal circuitry.
  • The amplified sounds are delivered to the ear through a speaker or receiver, making them easier for the wearer to hear.

Cochlear Implants:

  • Cochlear implants are surgically implanted devices designed for individuals with severe to profound hearing loss.
  • A cochlear implant consists of an external part worn behind the ear and an internal part implanted under the skin.
  • The external part captures sound and processes it through a speech processor.
  • The processed sound signals are sent to the internal part (the implant) via a transmitter.
  • The implant’s electrode array stimulates the auditory nerve directly, bypassing damaged parts of the inner ear (cochlea), and sends the signals to the brain for interpretation as sound.

Bone Conduction Devices:

  • Bone conduction devices are designed for individuals with conductive hearing loss or single-sided deafness.
  • The device transmits sound vibrations through the bones of the skull to the inner ear, bypassing the outer and middle ear.
  • A bone conduction device can be worn as a headband, on a pair of glasses, or as a surgically implanted bone conduction hearing aid.

FM Systems:.

  • FM systems consist of a transmitter and a receiver and are often used in educational settings or noisy environments.
  • The transmitter is placed near the sound source, such as a speaker or a teacher, and picks up their voice.
  • The receiver, which is worn by the individual with hearing loss, captures the transmitted signal wirelessly.
  • This allows the person with hearing loss to hear the speaker’s voice directly, reducing background noise and improving speech clarity.

Captioning Devices:

  • Captioning devices display text captions of spoken content, such as TV shows, movies, or live events.
  • They help individuals with hearing loss access information by providing written text of the dialogue and sounds.

Each type of deaf hearing device caters to specific hearing needs, and the suitability of a device depends on the individual’s type and degree of hearing loss, lifestyle, and communication preferences. It is crucial for individuals with hearing loss to undergo a comprehensive hearing evaluation by an audiologist to determine the most appropriate hearing device for their unique needs.

Types of Hearing Impairment

Hearing impairment, also known as hearing loss, can be categorized into different types based on the specific part of the auditory system that is affected and the severity of the loss. Here are the main types of hearing impairment:

Conductive Hearing Loss:

  • Conductive hearing loss occurs when there is a problem in the outer or middle ear that hinders sound conduction to the inner ear (cochlea).
  • Common causes include ear infections, earwax blockage, fluid buildup behind the eardrum, and abnormalities in the ear’s structure.
  • This type of hearing loss is often treatable and may be temporary or permanent, depending on the underlying cause.

Sensorineural Hearing Loss:

  • Sensorineural hearing loss results from damage to the inner ear (cochlea) or the auditory nerve that connects the inner ear to the brain.
  • It is the most common type of hearing loss and can be caused by various factors, including aging, noise exposure, genetics, infections, and certain medications.
  • Sensorineural hearing loss is often permanent, but it can be managed with hearing aids, cochlear implants, or other assistive devices.

Mixed Hearing Loss:

  • Mixed hearing loss is a combination of both conductive and sensorineural hearing loss.
  • Individuals with mixed hearing loss experience problems in both the outer or middle ear and the inner ear or auditory nerve.
  • Treatment options depend on the specific factors contributing to the hearing loss and may involve medical intervention, hearing aids, or other devices.

Central Hearing Loss:

  • Central hearing loss occurs due to damage or dysfunction in the central auditory pathways or the auditory processing centers of the brain.
  • It can result in difficulties understanding speech, particularly in noisy environments, even when the person’s hearing sensitivity is relatively normal.
  • Central hearing loss may be caused by brain injuries, strokes, or other neurological conditions.

Functional Hearing Loss (Pseudohypacusis):

  • Functional hearing loss is a condition in which an individual believes they have hearing loss but shows no organic or physiological basis for it.
  • It is often linked to psychological or emotional factors, and the individual may genuinely believe they cannot hear despite having normal hearing function.

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