Vision and Hearing

VISION AND HEARING PROBLEMS IN THE OLDER ADULT

Reviewed by E. Hopson, RN, MSN-Ed, CNE, & L. Templeton, DNP

VISION

Sensory Changes and Their Impacts

  • As individuals age, sensory changes in vision occur incrementally.

  • These changes can lead to several adverse outcomes, including:

    • Functional impairment: Difficulties in performing daily activities due to reduced vision quality.

    • Injury: Increased risk of falls and accidents attributed to diminished visual capabilities.

    • Social isolation: People may withdraw from social activities due to inability to see well.

    • Depression: Loss of independence in vision-related activities may lead to mental health issues.

NORMAL AGE-RELATED CHANGES IN VISION

Key Changes

  1. Visual Acuity

    • Gradually diminishes after age 50 and decreases rapidly after age 70.

  2. Light Sensitivity

    • Declines with age affecting the ability to adapt to differing light conditions.

      • Brightness Contrast: Difficulty distinguishing objects with varying degrees of light.

      • Dark Adaptation: Slower recovery from bright to dim conditions.

      • Glare Recovery: Increased time required for recovery from glare exposure.

  3. Lens Changes

    • Lenses thicken, harden, and acquire a yellowish hue, becoming opaque over time.

  4. Medications Impact

    • Medications for other chronic conditions can impair normal eye function.

EYE CONDITIONS

Abnormal Eye Changes

  • Cataracts

  • Glaucoma

  • Macular Degeneration

  • Diabetic Retinopathy

  • Detached Retina

  • Floaters

CATARACTS

Overview

  • A common cause of curable blindness in adults:

    • Generally affects individuals over the age of 50, with increased prevalence in those with diabetes and a family history.

  • Cataracts often develop bilaterally and are characterized by:

    • Clouding of the lens: Leads to gradual vision loss.

Cataract Development

  • The process is slow and painless:

    • Mechanism: Lens clouding results in decreased light reaching the retina, ultimately limiting vision.

  • Cataracts are the leading cause of blindness worldwide and are highly reversible.

  • Notably, more than 50% of adults over 65 years are reported to have cataracts.

Risk Factors for Cataracts

  • Increased age

  • Lifestyle factors: smoking and alcohol use

  • Obesity

  • Chronic illnesses: diabetes, hyperlipidemia, and hypertension

  • Eye trauma or previous eye surgery history

  • UV exposure

  • Long-term use of corticosteroids

  • Ethnic Background: Higher incidence in Caucasians

Prevention Measures

  • Protective measures against cataracts include:

    • Wearing hats and sunglasses with UVA & UVB protective coatings when outdoors.

    • Quitting smoking.

    • Consuming a low-fat diet, rich in antioxidants and vitamins E & C.

    • Using protective eyewear to avoid ocular injuries.

Symptoms of Cataracts

  • Symptoms manifest as a painless and gradual blurring of vision.

  • Other notable symptoms:

    • Increased sensitivity to glare,

    • Perception of halos around objects,

    • Loss of visual acuity varying from dimness to distortion,

    • Difficulty reading and driving at night,

    • Decreased color perception.

  • Clinical signs:

    • Lens haziness,

    • Inability to view the fundus,

    • Absence of a red reflex.

Treatment Options

  • Treatment is dependent on the level of functional difficulty experienced by the patient; this is crucial as lens opacity does not always correlate with functional status.

  • Primary Treatment: Surgical removal of the cataract is considered the best option when symptomatic.

Types of Outpatient Surgery

  1. Intra Capsular Surgery: Involves the removal of the lens with its capsule through a wide corneal incision.

  2. Extracapsular Surgery: Involves aspirating the contents of the lens through a small incision while leaving the posterior lens capsule intact; an intraocular lens (IOL) is implanted following this procedure.

Phacoemulsification Technique

  • A common surgical method where the cataract lens is fragmented and removed in small pieces, followed by implantation of a new plastic lens to replace the natural lens.

Lens Replacement Requirements

  • Post-cataract surgery, all patients need some form of lens replacement:

    • Options include intraocular implanted lenses, contact lenses, or eyeglasses.

    • Eyeglasses are the simplest solution but may result in difficulties with depth perception and peripheral vision.

Pre and Post-Operative Care

  • Pre-Operative Care: Include fasting (NPO), voiding, utilizing measures to decrease intraocular pressure (IOP), and ensuring all consents are signed.

  • Post-Operative Care: Involves:

    • Positioning (e.g., semi-Fowler's position),

    • Monitoring for nausea/vomiting,

    • Administering eye drops (antibiotics, anti-inflammatories, pupil constricting drops), and minimizing light exposure.

Complications of Cataract Surgery

  • Patients may face some complications, such as:

    • Infection,

    • Wound dehiscence,

    • Hemorrhage,

    • Severe pain,

    • Uncontrolled, elevated intraocular pressure.

  • Patients with cognitive impairments require careful supervision for at least 24 hours post-surgery.

Cloudy Vision Post-Surgery

  • If clouding of the posterior capsule occurs after surgery due to cell growth, treatment involves utilizing a YAG laser to create an opening so light can pass freely to the retina.

Patient Discharge Teaching

  • Post-operative instructions for patients include:

    • Monitoring for signs of infection, bleeding, or elevated IOP,

    • Reporting any drainage or visual disturbances,

    • Wearing protective eye shields at night for 2-3 weeks,

    • Recommendations for activity restrictions such as avoiding heavy lifting or straining for a few days.

GLAUCOMA

Overview

  • Glaucoma is the leading cause of irreversible blindness, particularly in adults over 40 years old, and is characterized by increased intraocular pressure (IOP).

  • It consists of a group of ocular conditions that damage the optic nerve, often described metaphorically as a 'thief in the night' due to its subtle onset.

Mechanism of Glaucoma

  • Increased IOP results from slow aqueous humor flow through the trabecular meshwork, leading to optic nerve damage and eventual vision loss.

  • Symptoms vary but include painless vision loss and mid-peripheral visual field loss.

Normal Intraocular Pressure and Symptoms

  • Average normal IOP should range between 10-21 mmHg.

    • Elevated IOP may lead to significant symptoms:

    • Damage to the optic disc and loss of visual field.

Risk Factors for Glaucoma

  • Increased age: Screening recommended starting at age 40.

  • Personal or family history of glaucoma.

  • Conditions like myopia, diabetes, hypertension, or migraines.

  • Ethnicity: particularly higher in African Americans.

Types of Glaucoma

1. Primary Open Angle Glaucoma (POAG)

  • Characteristics:

    • Slow, progressive, painless obstruction of aqueous outflow causing increased IOP and destruction of optic nerve fibers.

    • Loss of peripheral vision is a late sign associated with symptoms like blurred vision and halos around lights.

    • Central acuity usually remains intact until late-stage.

  • Diagnosis: Measure IOP and visual acuity.

  • Treatment: i.e. Beta-Adrenergic Blockers like Timolol to decrease aqueous humor production.

    • Consider caution in patients with asthma or congestive heart failure as it may cause bradycardia.

    • Cholinergic drugs like Pilocarpine which constrict the pupil and increase aqueous fluid flow provide treatment options, but early diagnosis is crucial as damage cannot be reversed.

2. Angle Closure Glaucoma

  • Mechanism: The angle of the iris obstructs drainage of aqueous humor resulting in increased IOP and visual changes.

  • Symptoms include unilateral headache, visual blurring, nausea and vomiting, and photophobia.

  • Rare but categorized as an ophthalmic emergency necessitating treatment with oral or IV Diamox and possibly surgical procedures such as iridectomy or laser iridotomy.

Open Angle Glaucoma Teaching

  • Patients are required to strictly adhere to medication schedules.

  • Awareness of potential drug interactions and side effects is necessary.

  • When multiple medications are prescribed, wait 5 minutes between applications to prevent washout.

Alternative Treatment Strategies

  • If medications fail, surgical interventions such as Laser Trabeculoplasty may be implemented.

  • This involves creating thermal burns in the trabecular meshwork, promoting aqueous humor outflow.

  • Antimetabolites like 5-FU and mitomycin C may be utilized to prevent fibrosis of the new opening,

  • This often is combined with medications to control visual loss.

AGE-RELATED MACULAR DEGENERATION (AMD OR ARMD)

Overview

  • The macula or retina is essential for vision, containing the fovea with the highest visual acuity, and is the leading cause of blindness in adults over 65.

  • Various factors contribute to AMD, including decreased blood supply and nutritional deficiency, among others.

Risk Factors for ARMD

  • Age, particularly above 50,

  • Smoking,

  • Family history of ARMD,

  • Increased UV exposure,

  • Caucasian ethnicity and/or light-colored eyes,

  • Hypertension or cardiovascular disease,

  • Dietary deficiency in antioxidants and zinc.

Preventive Measures

  • Recommendations for healthcare providers include:

    • Encouraging the use of ultraviolet protective lenses,

    • Smoking cessation,

    • Lifestyle changes including exercise,

    • Nutritional interventions focusing on fruits, vegetables, and supplements (i.e. zinc oxide, cupric oxide, beta carotene, vitamin C, vitamin E).

Types of AMD

  1. Dry AMD (Atrophic Form)

    • Characterized by retinal pigment degeneration, drusen accumulation, and slow progression of visual loss.

  2. Wet AMD (Neovascular Exudates)

    • Involves bleeding or serum leakage from new blood vessels beneath the retina, leading to scar formation and visual problems.

    • Symptoms may include increased light necessity for reading, blurred vision, central scotomas, and metamorphopsia.

Symptoms of AMD

  • Generally present with:

    • Blurred vision,

    • Darkening of the center of vision,

    • Central visual loss leading to impaired reading and object recognition while maintaining peripheral vision capacity.

  • Conventional eyewear fails to assist, necessitating low-vision aids for improvement of life quality.

DIABETIC RETINOPATHY

Overview

  • A microvascular disease affecting the ocular microvascular system, leading to impaired transport of oxygen and nutrients.

  • Exists in two forms: proliferative and nonproliferative.

Prevention of Diabetic Retinopathy

  • Key management strategies include:

    • Maintaining tight glycemic control, with recommended postprandial levels of 80 to 120 mg/dL and average bedtime glucose at 100 to 140 mg/dL, HbA1c < 7.

    • Effective management of hypertension and hyperlipidemia.

DETACHED RETINA

Signs and Symptoms

  • Key indicators of a detached retina include:

    • Abrupt onset of floaters,

    • Flashes of light,

    • Blurred vision,

    • Gradual reduction in peripheral vision,

    • Curtain-like shadow over the visual field.

Treatment for Detached Retina

  • Treatment modalities may include gas bubble placement and surgical repairs addressing retinal tears.

NURSING DIAGNOSES FOR VISION-IMPAIRED OLDER PATIENTS

Assessment Considerations

  • Evaluation should consider:

    • Functional ability in daily living activities,

    • Safe mobility and navigation,

    • Ability to engage in recreational and social activities,

    • Management of necessary tasks like shopping and cooking while ensuring safety.

VISUAL AIDS

Helpful Aids for the Visually Impaired

  • Availability of various tools and resources:

    • Low-vision clinics for individualized suggestions,

    • Telescopic lenses,

    • Braille books,

    • Computer scanners and readers,

    • Tinted glasses to reduce glare,

    • Large print publications,

    • Seeing-eye dogs and canes (noting societal stigmas that may lead to rejection despite their utility).

  • Patients may register with the Commission for the Blind for further resource assistance, such as tapes and specialized telephones.

HEARING

Age-Related Changes

  • Changes in the external ear include:

    • Auricular wrinkles and sagging,

    • Increased cerumen (earwax) production,

    • Dryness and itchiness,

    • Accumulation due to decreased apocrine gland activity.

  • Changes in the inner ear involve:

    • Atrophy of the organ of Corti and cochlear neurons,

    • Loss of sensory hair cells,

    • Degeneration of the stria vascularis.

Hearing Loss Prevalence

  • Approximately over 30% of individuals aged 65-76 years experience hearing loss.

  • This proportion increases to around 50% for those over 75, with older men being at higher risk than older women.

Risk Factors for Hearing Loss

  • Long-term exposure to loud noise (e.g., musicians, factory workers), impacted cerumen, ototoxic medications, tumors, viral infections, autoimmune conditions, smoking, and history of chronic middle ear infections.

TYPES OF HEARING LOSS

Conductive Hearing Loss

  • Definition: Occurs when transmission of sound waves is obstructed in the external or middle ear, preventing sound from reaching the inner ear.

  • Causes include:

    • Otitis externa,

    • Impacted cerumen,

    • Otitis media,

    • Benign tumors,

    • Tympanic membrane perforation,

    • Foreign bodies,

    • Otosclerosis (abnormal bone growth).

Cerumen Impaction Treatment

  • Treatment typically involves:

    • Hygienic practices for ear care,

    • Removal using currettes or lavage/irrigation techniques.

Sensorineural Hearing Loss

  • Issues related to cochlear or auditory nerve impacting sound quality, most commonly associated with aging (presbycusis).

  • Symptoms include:

    • Impaired hearing of high-frequency sounds,

    • Noise exposure damage.

Ototoxic Drugs

  • Certain medications carry risks of causing hearing loss, such as:

    • Aminoglycoside antibiotics (e.g., mycin drugs),

    • Antineoplastics (cisplatin),

    • Loop diuretics (Furosemide),

    • Propranolol (Inderal, which can cause tinnitus), and

    • ASA and NSAIDs (which can also lead to tinnitus).

Assessment of Hearing Impairment

  • Assessment parameters should include:

    • Ability to carry out daily activities,

    • Ease of communication,

    • Safety awareness concerning alarms and other auditory warnings,

    • Participation in leisure and recreational activities.

CARE OF HEARING AIDS

Care Recommendations

  • Recommended practices for hearing aids:

    • Remove and clean devices nightly,

    • Avoid harsh cleaning agents,

    • Use damp cloths with water or saline for maintenance,

    • Safely remove cerumen,

    • Disengage batteries and store devices properly.

Other Hearing Devices

  • Alternative devices include:

    • Cochlear implants,

    • Assistive listening devices,

    • Theater amplifiers,

    • Telecommunication devices for the hearing impaired (TDD).

REFERENCES

  • University of Iowa Healthcare. (2019). Retrieved from:
    http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/post-op-cataract-complications.html