Hearing is an integral part of communication and provides us with a safe awareness of our surrounding environment. Yet, this is often taken for granted and hearing loss is commonly viewed as an unfortunate by-product of ageing (Wallhagen and Reed, 2018). Hearing loss is prevalent in the population, affecting over 9 million people in England (Ftouh et al, 2018). Hearing loss can be categorised as sensorineural (inner ear), conductive (middle and outer ear) or mixed (sensorineural and conductive components) (Harkin and Kelleher, 2011). It is a debilitating condition that affects communication, which in turn may impact on employment opportunities and cause significant reduction in an individual's quality of life (Ftouh et al, 2018). A lack of early detection and diagnosis of hearing loss, due to stigma towards deafness (Wallhagen and Reed, 2018), results in inadequate communication with health professionals (Newton and Shah, 2013). Hearing loss is now widely recognised as a primary preventable risk factor of dementia and Alzheimer's disease. It is thought to be mediated by social disengagement and consequent depression, and precipitating accelerated brain atrophy (Livingston et al, 2017).
Practice nurses who support individuals with hearing loss carry a vital role in overseeing their care. Nurses trained in ear care carry out around two million consultations a year in the UK (Ftouh et al, 2018). The overall economic burden associated with hearing loss, including extra GP visits, increased social care, lost earnings and reduced quality of life, is currently estimated to be more than £30 billion per year in the UK, and this could be reduced with timely review and intervention (Ftouh et al, 2018). Fundamentally, practice nurses with dedicated clinics can educate patients in ear care and raise ear awareness, therefore increasing overall patient satisfaction and support (Fall et al, 1997).
Risk factors for hearing loss
There are several recognised risk factors for hearing loss in adults that practice nurses should be aware of.
Presbycusis—progressive sensorineural hearing loss secondary to age-related ear changes—is the leading cause of adult onset hearing loss (Cunningham and Tucci, 2017). Continued exposure to loud noise is one of several contributing factors to presbycusis. The prevalence of hearing loss is particularly high in occupations which are subject to loud noises (noise induced hearing loss [NIHL]) (Eliopoulos, 2013).
Ototoxicity—the pharmacological adverse reaction affecting the auditory nerve or the inner ear—has the potential to cause harm and may lead to significant morbidity (Ganesan et al, 2018). More than 130 drugs are known to be ototoxic and adversely affect the auditory system, examples include aminoglycoside antibiotics such as gentamicin (toxic to sensory hair cells), salicylates such as aspirin (delay excretion of the drug), and chemotherapy agents such as cisplatin (outer and inner hair cell damage) (Harkin and Kelleher, 2011; Campbell and Fox, 2016; Cunningham and Tucci, 2017). The result of ototoxicity is sensorineural hearing loss, imbalance or both. While these effects are often temporary, in some cases, such as after chemotherapy, hearing loss may be permanent (Harkin and Kelleher, 2011).
Cardiovascular disease risk factors, such as smoking, central obesity and poorly controlled diabetes mellitus, are associated with hearing loss and are an indication that vascular changes may also contribute to hearing loss in adults (Eliopoulos, 2013; Cruickshanks et al, 2015). Additionally, trauma and chronic ear infections may also play a role (Eliopoulos, 2013).
Identifying hearing loss
It is important to ensure that adults with hearing loss have the same access to healthcare services as adults with normal hearing. Unfortunately, this is often not the case (Nursing Practice Project, 2012). The average patient suffers for years with hearing problems before attending a hearing aid or rehabilitation clinic (Stephens et al, 1990). One explanation for this delay could be that the hearing loss may be overshadowed by various comorbidities which conceal the auditory symptoms. Stigma towards ageing and deafness often perpetuates further neglect of the disorder. Previously, only around 50% of elderly people who sought help with reported hearing loss were offered onward referral to hearing services for further evaluation (Humphrey et al, 1981).
As hearing loss has been identified as a key preventable primary risk factor for mental health issues, such as dementia and depression, and can lead to significant impairment in quality of life, consideration of the patient's social life and mental wellbeing is paramount (Wallhagen et al, 2006; Ftouh et al, 2018). Therefore, it is vital that practice nurses have the training and skill set to provide timely review and effective interventions, as they are an invaluable asset in coordinating a multidisciplinary team approach to hearing loss.
Otoscopy allows visual inspection of the ear canal for wax, infection, foreign bodies or obstruction using an otoscope
Examining hearing loss
There are a number of methods that can be used to investigate hearing loss in adults.
Otoscopy
Otoscopy allows visual inspection of the ear canal for wax, infection, foreign bodies or obstruction using an otoscope. By direct visualisation, we may also assess for middle ear pathology such as effusion, tympanic membrane perforation or cholesteatoma (abnormal collection of keratinising squamous epithelium in the middle ear or mastoid air cells, with the potential to expand and erode neighbouring structures) (Seddon et al, 2012).
Whisper test
The whisper test is a simple and accurate test for detecting hearing impairment. The examiner stands at arm's length (approximately 0.6 m) behind the seated patient (to prevent lip reading) and whispers a combination of numbers and letters before asking the patient to repeat the sequence. Individuals who perceive the whispered voice can be classified as having a low chance of significant clinical hearing loss, while those unable to perceive the voice require further evaluation (Pirozzo et al, 2003; Bagai et al, 2006). Other screening tests for hearing loss include smartphone applications, and basic audiometers.
Tuning fork tests
The Rinne test and Weber test are two commonly used tuning fork tests which work together to differentiate between sensorineural and conductive hearing loss. The Weber test involves striking a 512Hz tuning fork which is then placed on the patient's forehead. The patient is then asked which ear (if any) the sound is loudest in. The Rinne test involves striking (the same as above) a tuning fork and then placing the stem on the mastoid prominence on one side (behind ear) before transferring it so it is in line with the external ear canal of the same ear (without touching the patient's ear). The patient is then asked whether the sound is loudest when pressed on the mastoid process or when placed next to the ear. The Rinne test is found to be positive if it is louder next to ear (this is a normal result as sound travels louder through air). If sound was louder through bone, it is either due to conductive hearing loss in that ear or complete sensorineural hearing loss. The Weber test can be used in this situation—if conductive hearing loss, the Weber test would be loudest in the tested ear, but if sensorineural, it would be louder in the contralateral ear (Browning et al, 1989; Bayoumy and Ru, 2020).
Hearing screening tests
Several hearing screening tests are available for nurses to assess and evaluate for hearing impairments. Questionnaires such as The Hearing Handicap Inventory for Elderly-Screening (HHIE-S) (a self-report questionnaire with 10 questions) and Nursing Home Hearing Handicap Index (NHHI) (a nursing home specific questionnaire with 10 questions answered by the patient and 10 by a staff member) are available to gain hearing loss specific details in a sensitive and focused manner (Ventry and Weinstein, 1982; Nilforoush et al, 2012; Tomioka et al, 2013). Yueh et al (2003) advocates the use of questionnaires as they are inexpensive and accurate in detecting hearing loss.
‘It is vital that practice nurses have the training and skill set to provide timely review and effective interventions, as they are an invaluable asset in coordinating a multidisciplinary team approach to hearing loss.’
Managing hearing loss
There are several strategies that can be used to help manage hearing loss, including communication strategies, patient education, nurse-led clinics, social support, reviewing medication and timely referrals.
Communication strategies
For effective communication, it is important for the patient to use their preferred communication method (eg written/lip reading/hearing aids) and that the patient is ideally seated at the same level as the person they are communicating with to allow optimal eye contact. Body language provides useful cues and can help in localizing the side of defect (eg tilting head to one side).
Common signs of hearing loss include complaints of difficulty hearing against a noisy background, as well as having to ask people to repeat what they have said. Patients with hearing loss will often mention hearing difficulties in various settings such as at home, at work, on the telephone and also during normal conversations. Identifying patients with hearing impairments and noting communication strategies so other staff members are also aware may ease frustration and minimise miscommunication (Burk et al, 2006). It would also be useful to equip patients with the skills necessary for communication, such as lip-reading classes and loop systems for telephone and television. Environmental modifications such as minimising background noises and improving room lighting would allow the patient to visualise the speaker better when lip reading without feeling overwhelmed.
Patient education
Hearing aids, which improve the audibility of sounds, are the customary treatment for hearing loss and can significantly improve patients' quality of life, especially in older adults. Audiologists can assist patients in optimising their hearing aid according to the severity of the hearing loss. The use of hearing aids has been associated with longer life expectancy and retention in the workplace, as well as reduced depression (McMahon et al, 2013). An auditory implant may be considered in cases where a hearing aid cannot be used. Examples of an auditory implant device include bone anchored hearing aids (BAHA), middle ear implants and cochlear implants. BAHA implants are useful for patients who have conductive, single-sided sensorineural hearing loss or mixed hearing loss. A cochlear implant is an electronic implanted device available for patients with severe to profound hearing loss that cannot be effectively treated with hearing aids (Harkin and Kelleher, 2011).
Educating the patient about the risk factors and contributors to hearing loss may benefit them in the long run. Interventions targeting reductions in obesity, smoking and better glycaemic control in individuals with diabetes mellitus may help prevent or delay the onset of hearing loss (Cruickshanks et al, 2015). Additionally, teaching staff members about the importance of early identification and early referral may also alleviate the stigma towards deafness and ageing.
Nurse-led ear care clinics
Nurse-led ear care clinics are increasingly in demand in both primary and secondary care settings. Nurses can explain optimum ear care to the patient. They can explain and advise about wax build-up, which can cause hearing loss and reduce the performance of hearing aids. Routine ear care for patients with wax accumulation is crucial for the patient's hearing and for them to achieve optimal benefit from their hearing aids (Kochkin, 2005). Nurses may be trained in microsuction or irrigation to clear wax from ears.
Nurse-led clinics are also an opportunity to offer ear care advice; for instance, advising against using cotton buds as the ear is self-cleaning and cotton buds adversely affect this process. Minor ear infection or irritation can be treated with over-the-counter acetic acid preparations. Hard wax may benefit from topical olive oil or sodium bicarbonate preparations. Ear care clinics also provide a platform to explain to the patient what they can expect, such as the potential need for hearing amplification devices.
Social support
It is important to lead a discussion about involving close family members, friends and work colleagues, in order to boost the patient support network and quality of life. Together with a multidisciplinary approach, family and friends can work together through any potential communication barriers (Leite et al, 2008).
Hearing loss can affect the general emotional state of a patient, which in return can lead to a negative impact and ultimately withdrawal from daily activities in a vicious cycle. Independently from the hearing loss, studies have demonstrated that better social support was associated with lower levels of anxiety, depression and stress (Veiga et al, 2015).
Medication
Gaining a detailed history of patients' medication use is fundamental, as various ototoxic drugs, such as aspirin and furosemide, can adversely affect the auditory system. If the patient is identified as currently taking an ototoxic drug, the decision to withdraw this drug should be made cautiously and with consultation with the prescriber, as only a certain proportion of the patients' hearing will be notably affected.
Referrals
Upon timely detection of hearing loss symptoms, the patient may be referred to audiologists, ear, nose and throat (ENT) specialists or to the accident and emergency department if urgent (National Institute for Health and Care Excellence, 2019). Appropriately placed direct referrals are advocated by the NHS as they reduce waiting times for ENT surgical appointments and are more cost effective (Eley and Fitzgerald, 2010).
Conclusion
As a fundamental part of the frontline healthcare team, practice nurses play a key role in identification, assessment and management of adults with hearing loss. The negative effects of hearing loss are increasingly being recognised, and so addressing this problem is more important than ever. Societal changes have meant that hearing aids are seen in a more positive light than previously. With an ageing population, it is likely that the volume of consultations for hearing loss will increase in coming years; and it is predicted that many of these patients will be seen in nurse-led clinics.
CPD reflective practice:
- How can hearing loss affect a person's life and health?
- What strategies could you use to help your patients with hearing loss communicate more effectively?
- Reflecting on your practice, what changes would you make after reading this article?
Key Points
- Hearing loss is now widely recognised as a primary preventable risk factor of dementia and Alzheimer's disease
- Practice nurses play a key role in identification, assessment and management of adults with hearing loss
- Early intervention is key for alleviating stigma towards hearing loss
- Nurse led ear care clinics reduce waiting times and permit early detection
- Societal changes have meant that hearing aids are seen in a more positive light than previously