Presbycusis

Hearing impairment among older persons in the United States is pervasive (Bayles & Kasniak, 1987). It has been found to be one of the four leading chronic conditions for older persons (Aging America, 1991) and the third most common chronic condition in non-institutionalized older persons (Jack, 1981). As much as 90% of older residents of long term care facilities have been found to have hearing impairments (Bayles & Kaszniak; Chafee, 1967).

Significant heating loss has been considered to have the greatest impact upon functioning of all perceptual impairments associated with aging (Butler & Lewis, 1982). Yet, family members, care providers, medical personnel, and older persons themselves may be unaware of and uninformed about intrapersonal and interpersonal implications of heating loss. Intrapersonal effects focusing on the experience of the individual and internal aspects of hearing loss for older persons have been discussed in another paper (Kampfe & Smith, 1997). The purpose of this article is to provide information regarding late onset hearing loss and common effects of that loss upon interpersonal functioning. It is hoped that such information will result in increased sensitivity to challenges faced by older persons who experience hearing loss and by persons who interact with them.

Background

Hearing level deteriorates with increasing age (Dayal & Nussbaum, 1971; Wax & DiPetro, 1984). The term, presbycusis, is generally used to describe the heating loss of older persons (Agnew, 1986; McFarland & Cox, 1985; Stein & Bienenfeld, 1992; Williams, 1984). Presbycusis refers to a wide range of problems associated with auditory deterioration (Hull, 1977; Stein & Bienenfeld; Williams 1984) and has been defined as the "alteration of hearing sensitivity associated with the normal aging of the auditory system" (Bayles & Kasniak, 1987, p. 150). Use of the collective term, "presbycusis" in diagnosis, however, fails to communicate much information about the actual physical condition or implications for functioning. Indeed, some authors accept the possibility of four types of presbycusis each having associated patterns of structural and functional losses (Birren & Schaie, 1985; Schuknecht, 1974).

While variability is common, overall results of research on presbycusis substantiate the belief that as deterioration associated with presbycusis advances, older persons experience increasing limitations in oral communication (Bayles & Kaszniak, 1987; Bergman, 1971; Pickett, Bergman, & Levitt, 1979; Plomp & Mimpen, 1979). Functional implications of such losses have included: lack of understanding of or distortions of verbal conversation (Davis & Silverman, 1970; Ebersole & Ness, 1994; Hallberg, Erlandsson, & Carlsson, 1992; McFarland & Cox, 1985; Pickett, Bergman, & Levitt, 1979; Thomesett & Nickerson, 1993), and misinterpretations of environmental cues resulting from misconceptions of environmental stimuli (Hull, 1977; Luey, 1980; Ramsdell, 1978). Variability in degree of or accuracy of hearing depends upon environmental conditions, stimulus frequency, and availability of other supporting interpretative cues (such as facial expressions or non-verbal movements) (Butler & Lewis, 1982). The ability to mask or differentiate competing sounds varies and is often influenced by fatigue, lighting or familiarity with the environment (Butler & Lewis). Variability in correct interpretation of speech is also influenced by placement of sounds within a phrase/sentence (i.e., whether sounds occurred in single spoken word utterances or connected speech/single sentences) (Birren & Schaie, 1985; Dorman & Marton, 1981; Hannley & Dobbins, 1981).

The hearing limitations associated with advanced age and their implications often have significant effects upon the interpersonal functioning and interpersonal relationships of the older person and others with whom she/he interacts. Some interpersonal/relationship implications are discussed in the following pages.

Interpersonal/Relationship Factors

The effects of hearing loss upon interpersonal relationshipsvary considerably with a number of factors (Kampfe, 1997; Smith & Kampfe, 1996; 1997; Vernon, 1984). Some factors which have implications for the interpersonal functioning of older persons with hearing loss (presbycusis) are included in this section.

Decrease in Energy/Fatigue

Older people typically experience multiple physical or emotional/social losses for which they need to develop adaptations or compensatory strategies (Burnside, 1976a; 1976b; Smith, 1982, 1986; Smith & Overbeck, 1985, 1986a). Even though the compensation for losses related to aging may be effective for a period of time, such compensations are likely to require the person with a hearing loss to utilize more energy in interacting with the environment than before the loss (Rezen & Hausman, 1985; Thomas, 1984). The older person with a hearing loss utilizes energy to compensate for the effects of the heating loss and for other effects of aging. Thus, less energy is available for general functioning. Other stressors may also deplete energy reserves such as the emotional reactions to the losses; coping with reactions of family and friends; and compensating for other age-related social and physical problems including death of a spouse, relocation, or physical restrictions (Bayles & Kaszniak, 1987). Thus, considerable energy may be required on a continuing basis (Thomas, 1984). A natural response to increased energy demands and depleted resources may be decreased interaction with friends and family. Another common response to decreased energy is variability in intensity/amount/quality of interaction with others depending upon the amount of energy accessible at the moment.

The older person's ability to compensate for or diminish effects of hearing loss will be significantly effected by the presence of other disabilities (Burnside, 1976a; Overbeck & Smith, 1985b, 1988; Smith & Kampfe, 1997; Smith & Overbeck, 1986b). Variability in available energy levels and compensations used for difficulties in interpersonal relationships results from variability in limitations imposed by other health conditions. Older persons with previous cognitive impairments may be especially limited in their ability to diminish effects of a hearing loss and may benefit from or require assistance to conceptualize or develop viable compensatory strategies (Moneyham & Scott, 1995; Overbeck & Smith, 1985a, 1983; Smith & Overbeck, 1985, 1986a, 1986b).

Isolation

A result of loss of hearing in later adulthood may be an overwhelming sense of isolation. Every human relationship can be affected (Luey, 1980; Oyer & Oyer, 1985; Thomas, 1984). Message s may be misunderstood (Hull, 1977; Luey), the ability to interact freely with significant others may be stifled (Luey; Oyer & Oyer), and intimacy may be difficult to achieve (Hull). As a result of these problems, old friends may avoid the person with a newly acquired hearing impairment (Lucy). Jack Ashley (1973) states this in a very personal way as follows:

While withdrawal from social contact may be a reasonable response to such experiences, this withdrawal can result in isolation and loneliness (David & Trehub, 1989; Luey, 1980; Thomas, 1984). The older person with a hearing loss may find him/herself repeatedly torn between the need for relief from the strain of communication and the need for socialization (Orlans, 1987). He or she may desperately want human contact, but not know how to achieve it. The extrovert may, in behavior, become the introvert. As a result, life may become confined to only a few one-on-one social visits with close friends or family, and may eventually end in solitude (Orlans).

Older persons with hearing loss are faced with an "invisible" disability (Wright, 1983). With the presence of an invisible disability, other persons may not immediately identify the source of a behavior to be actually disability related. Older persons with hearing loss are, therefore, vulnerable to being misunderstood and to experiencing social consequences of that misunderstanding. Butler and Lewis (1982, p. 47) believe that, "Hearing loss causes greater social isolation than blindness because verbal communication is so vital to human interaction.... the hard-of-hearing are given less consideration than the elderly blind, probably because their handicap is not so obvious to the onlooker." The isolation resultant of hearing loss for older persons and subsequent sequelae "can lead to early institutionalization" (Futrell, Brovender, McKinnon-Mullet, & Brower, 1980, p.356). As was observed by Futrell et al. (1980, p. 357), "The importance of cognitive stimui and sustained social contact cannot be overemphasized" for older persons with multiple sensory losses.

Decreased Recreational Outlets

After having experienced numerous embarrassing, frustrating, or tiring experiences while attempting to socialize, the person with a hearing loss may begin to withdraw from social activities (Orlans, 1987; Thomas, 1984). He or she may find that activities which were once enjoyed such as attending meetings at church or civic affairs, playing cards, watching television, going shopping, listening to music, going to parties, and talking over the telephone are no longer positive experiences. Significant decreases in recreational outlets and in shared recreational time may result (Bayles & Kaszniak, 1987). To the extent that this recreational time was shared by family or friends, reduction in time spent together and changes in relationships may occur.

Anxiety/Fear/Distrust

The older person with a hearing loss may begin to feel some distrust for old friends and family. People often talk about the person with hearing impairment rather than with him or her. Significant others often do not inform the older person with a hearing impairment of upcoming or significant events. The older person may respond with feelings of distrust. Such feelings of distrust - those resulting from actually being treated with disrespect by significant others - may be considered realistic rather than as an indication of paranoia or delusions (Butler & Lewis, 1977). When founded in realistic experiences, mistrust can be considered to be a healthy reaction to hearing impairment (Knapp, 1968).

Older persons with hearing impairment often misunderstand environmental noises (Granick, Kleban, & Weiss, 1976). When one sound is interpreted as another (e.g., thunder is thought to be a knock on the door) and the person reacts accordingly, this can lead to incidences that are unsettling to the person and to the family. Misunderstanding environmental noises, especially when coupled with communication difficulties with others, leads generally to embarrassment, fear, anxiety, and some form of withdrawal and/or unusual behaviors (Hull, 1977). Older persons may also project feelings outward to someone else as a means of reducing anxieties and fears (Butler & Lewis, 1982). Such projection signifies underlying stress and can increase unless the stressor is identified and reduced or mediated.

Presumption by Others That the Older Person is Experiencing Cognitive Deterioration

Because persons with a hearing loss often misinterpret or misunderstand spoken messages, they sometimes find themselves responding inappropriately to questions or comments (Hull, 1977; Orlans, 1987; Rezen & Hausman, 1985). The realization that they have exhibited such behavior may result in fear of appearing unintelligent (David & Trehub, 1989; Luey, 1980), and having diminished self esteem (David & Trehub; Luey). Inappropriate responses may also result in the older person presuming that he/she is "failing" (Granick, et al, 1976; Hull) or, as mentioned previously, by others viewing the older person as confused or senile (Becker, 1981; Butler & Lewis, 1982). Such behavior may even result in misdiagnosis of cognitive functioning (Bayles & Kaszniak, 1987; Butler & Lewis).

Since older persons with a significant hearing impairment are often at risk of being excluded from social activities by others, they may progressively become less and less informed about what is happening with family, friends, or in the environment. They may, as a result, appear less and less well oriented (Butler & Lewis, 1982). The natural loss of contact that may be a ramification of the hearing loss plus the tendency of others to interpret behavior based on less information as indicative of dementia increases the vulnerability of the older person with a hearing loss to inappropriate placement in a long-term care facility (Bayles & Kaszniak, 1987).

Family Dynamics

Family relationships may be substantially affected by the changes associated with late deafness/hearing loss (Alberti, 1987). Both the family and the older person with hearing impairment may become impatient and weary with trying to communicate (Orlans, 1987). Family members often do not understand the impact of the hearing loss, nor do they have techniques to deal with the problems associated with hearing impairment.

A common misconception of family members is a belief that the older family member with a hearing loss hears what or when she/he wants to hear (Schow, Christensen, Hutchinson, & Nerbonne, 1978). Resentment may occur as a result of attributing inaccurate meanings to the normal variability in behavior accompanying hearing loss associated with age. Because significant others may not understand how to interpret the normal variability they may conclude that the hearing loss is volitional. They may attribute various motives to the behavior such as, "He doesn't listen when he wants to make me angry"; or "She always tries to get attention from Harry by getting him to repeat everything." Thus, symptamology typically associated with the hearing loss may be misinterpreted as existing only to obtain secondary gains.

Another common misconception of family members is that wearing a hearing aid should result in good speech discrimination. Family members may not be educated about the disadvantages of hearing aids or of reasons that the older person may find them ineffectual in treating presbycusis (Butler & Lewis, 1982).

Family members and other hearing people may respond to the deaf person by becoming impatient or angry (Luey, 1980; Orlans, 1987); by excluding the person from discussions and decision-making (Luey); by talking about him/her in his/her presence (Luey; Rezen & Hausman, 1985); by withholding information (Luey); by neglecting to make accommodations for the hearing loss (Luey; Orlans); or by taking over responsibilities that the individual is capable of handling (Luey, Belser, & Glass, n.d.; Rezen & Hausman).

Anger felt by the older person with the hearing loss is likely to have an effect on his/her relationships with others (Orlans, 1987). Family and friends may not understand the source of the anger or may be offended by it, and permanent gaps in relationships may be created. Irritability and/or nonresponsiveness of the older family member may be perceived by other family members as rejection and may be responded to with corresponding rejection or anger.

Just as differences in environmental conditions may result in variability in hearing (Birren & Schaie, 1985), changes in characteristics of speakers may result in fluctuations in general ability to understand (Kampfe, 1990, 1994; Orlans, 1987). Thus, the older person may be most responsive to and interactive with the family member with the lowest frequency voice; who does not have a beard; who faces the older person directly when speaking; and who does not make major statements while eating, smoking cigarettes, or chewing gum. The older person may be most interactive in the relative's home that is freer of background noises or with the relative who enjoys eating a cozy dinner at home instead of dining in large, crowded, noisy restaurants. This variability in responsiveness may be interpreted by family members as preferential attention or affection for some family members versus other family members and may be responded to with hurt, anger, or feelings of resentment.

Depression

The relationship between hearing loss and depression has long been observed. The National Institute of Mental Health (NIMH) explored the connection in a study of older men and found a highly significant relationship between depression and decreased auditory acuity (Butler & Lewis, 1982).

While older persons may be increasingly at risk for depression as hearing loss increases (Butler & Lewis, 1982), common ways of reducing or coping with depression may be limited as a result of the hearing loss. As implied previously, such activities as listening to music, social interaction, telephone conversations with friends, a nature walk, relaxation tapes, taking a bus tour, etcetera may not be rewarding options for the older person with hearing loss (Kampfe & Smith, 1997). Thus, coping strategies for depression or coping strategies for adversity of any kind that an older person may have used throughout his/her entire life may no longer be workable because of the hearing loss. Although certain types of group therapy have been successful in treating depression (Beck, Rush, Shaw, & Emery, 1979; Butler & Lewis), such groups may not be workable for certain older persons with substantial hearing losses (Burnside, 1978). The older person with multiple losses such as hearing, vision, ambulation, and transportation may have significantly narrowed coping options.

Interpersonal functioning is traditionally altered in the presence of depression (Beck et al., 1979; American Psychiatric Association, 1994). Thus, the older person with heating loss may be coping with both the natural and logical effects of the loss upon relationships and interaction with others as well as with the normal effects of depression upon relationships and interaction with others.

Family/Personal Roles and Independent Functioning

Family roles may be substantially changed as a result of the occurrence of hearing loss for an older person. The older person may previously have managed family finances and/or medical care for a family member who was chronically ill or had a disability or who was not interested in having those responsibilities. That same caretaker with substantial hearing loss may, of necessity, relinquish such roles. Such changes in family roles may leave family members with unexpected demands not only from the older person with the hearing loss but from the other dependent family member as well.

The difficulty in obtaining accurate medical information through an interview process from older persons with hearing impairments has been discussed by a number of authors (Burnside, 1976a, 1976b; Domarad & Buschmann, 1995; Futrell et al., 1980; Mummah, 1975). However, the implications of hearing loss for older persons in serving as self-advocates or as family-member advocates in interacting with medical, legal, financial, and social service communities is largely neglected. It has been the experience of the authors that older persons with substantial hearing losses may become increasingly dependent upon others in attempting to obtain needed information and answers to questions related to these significant life areas. Indeed, the challenge of obtaining information and understanding options may become so energy demanding, embarrassing, or difficult that the previously quite independent older adult who acquires substantial hearing loss may fall into a helpless state in which he/she no longer pursues information but rather depends upon family, friends, or providers to make necessary decisions.

Living Environment

Prior reference has been made to the vulnerability of the older person with hearing loss to premature or unnecessary nursing home placement (Bayles & Kaszniak, 1987; Futrell et al., 1980). The combinations of isolation, decreased cognitive stimulation, decreased opportunities for reality testing, depression, decreased ability to ask and understand answers relevant to health care, and anxiety may all decrease the ability of the older person with a hearing loss to function independently in a home environment. In addition, the older person with a hearing loss is likely to experience decreased ability to recognize and respond effectively to safety hazards (Kampfe & Smith, 1997; Overbeck & Smith, 1983, 1985b).

As discussed previously, the older person with hearing loss may experience difficulties in maintaining friendships and an increase in family strife. These events may decrease options for living arrangements with family or for cooperative living arrangements with others. For older persons with hearing impairment who are placed in a long-term care facility, group activities have been identified as factors influencing quality of life (Kayser & Jones, 1990).

While physical and recreational environments within long-term care facilities have been found to be important to quality of life for older residents, human relationships and social contact appear to be more crucial to quality of life (Aller & Van Ess Coeling, 1995; Jones, 1987; Ross, 1990; Vocks, Gallagher, Langer, & Drinka, 1990). Aller and Van Ess Coeling have suggested that relationships and interaction between the nurse and long term care resident are pivotal for older adults. In their study, they identified both caring for oneself and helping others as being significant contributors to quality of life for older persons in long term care facilities. Thus, the older person with a hearing impairment living in a long term care facility may have the same needs for human interaction as prior to the institutional placement but may also experience disadvantages in that environment due to the hearing loss.

Relationship with World of Deafness

Hearing loss may also result in a loss of identity and difficulty in affiliating with either the heating population or the deaf population (David & Trehub, 1989; Luey, 1980). Deafened adults typically define themselves to their hearing friends as hearing persons; but difficulty in interacting with people who hear creates confusion in identifying the social group to which they now belong (Glass, 1985; Luey; Ramsdell, 1970). Deafened adults continue to be a part of the hearing population but may feel alienated because of the problems discussed previously. Because they are unfamiliar with the deaf community and with the language of American Sign Language, they typically do not wish to, or are unable to, or are not invited to identify with the group of people who are prelingually deaf (Elliot, 1978; Luey). In addition, older adults with hearing impairments may have visual limitations, energy limitations, arthritis, other neuro-muscular conditions or emotional responses which limit their ability to make use of sign language even if they were interested in mastering it.

General Suggestions

The purpose of this article has been to increase sensitivity of rehabilitation workers to possible effects of hearing loss for older persons upon relationships with others - friends, family, medical personnel and strangers. With an increase in awareness of potential interpersonal dynamics and difficulties, the rehabilitation worker will be enabled to use skills developed in other situations to assist the older person with hearing impairment. Of primary importance in working with this population is the rehabilitation worker's expression of empathy, validation, and willingness to work cooperatively with the older person toward individual and creative solutions. Older persons, their family members and professional persons who work with them may benefit from education about possible ramifications of the heating loss. The rehabilitation worker's knowledge and experience of psychosocial aspects of disability, such as stigma, states/stages of adjustment to disability, insider/outsider perspective and the coping versus succumbing frameworks (Wright, 1983), can be invaluable in understanding and developing strategies for individual client situations. Rehabilitation worker experience in assisting with strategies for assertive expression, energy conservation, environmental adaptations, mobilization of support, and compensation strategies can significantly enhance the coping strategies available to the older person with hearing impairment. Some resource information which may help in developing specific strategies to assist older persons with heating impairments include: Burnside (1976b, 1978); Domarad and Buschmann (1995); Ebersole and Hess (1994); Kampfe (1990, 1994); Orlans (1985); Rezen and Hausman (1985); and Smith and Kampfe (1997).

Summary

The effects of hearing loss upon older persons, their friends and families, and service needs are pervasive. Many older persons with hearing loss experience pronounced modifications in relationships and interpersonal functioning as a result of the hearing loss. Interpersonal/relationship implications of hearing loss for older persons include: decreases in energy/fatigue; isolation; decreased recreational outlets; anxiety/fear/distrust; presumption by others that the older person is experiencing cognitive deterioration; changes in family dynamics; depression; changes in family/personal roles and independent functioning; and limitations in living environment options. Effects of hearing impairment for older persons may be substantially increased by other concommitant disability factors. Being aware of the interpersonal/relationship problems associated with the type of hearing impairment experienced by older persons (presbycusis) may assist service providers in identifying and ameliorating the consequences of the hearing loss.

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Wright, B. (1983). Physical disability-A psychosocial approach (2nd ed.). New York: Harper & Row.

S. Mae Smith, Ed.D., CRC, Department of Special Education and Rehabilitation, College of Education, University of Arizona, Tucson, AZ 85721.

email: MSmith@Mail.Ed.Arizona.Edu3

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