Intrapersonal Aspects of Hearing Loss in Persons Who Are Older.

Hearing loss is one of the four leading chronic conditions for older persons (U.S. Department of Health and Human Services, 1991). The rate of occurrence of this condition increases dramatically with age (Wax & Di Pietro, 1984). Census figures for 1989 report the rate of hearing loss among people age 45 to 64 to be approximately 13%, age 65 to 74 to be 24%, and age 75+ to be 36% (National Center for Health Statistics, 1990). Other researchers have found the prevalence of hearing impairment in older adults to be much higher than that suggested by the Census, with estimates ranging from 50% (Wax & Di Pietro) to 74% (Davis, 1983).

Because the percentage of older persons who have hearing losses is large, service providers, family members, and persons in this older age range need to be familiar with the experiential and phenomenological aspects of this condition. The purpose of the current article is to provide information regarding intrapersonal experiences and psychosocial implications associated with late onset hearing loss. It is hoped that such information will result in increased sensitivity to the emotions and challenges faced by older persons who experience hearing loss.

Background

Although a number of terms have been used to describe hearing loss that occurs in adulthood (i.e., adventious deafness, late deafness, acquired hearing loss); the term, presbycusis, is generally used to describe the hearing loss of older persons (Agnew, 1986; Brooks, 1989; Kampfe & Smith, 1997, in press; 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). Hearing loss in older people is thought to be the result of a combination of a variety of factors. These include an accumulation of many degenerative changes that relate to the aging process itself (Agnew; Brooks; McFarland & Cox; Williams), to zinc deficiency (Shambaugh, 1989), to medication (Agnew; Brooks), to heredity, to environmental conditions, and to other health conditions (McFarland & Cox,). The deterioration of heating associated with degenerative changes is thought to progress at such a slow rate that the individual usually is not aware that the heating loss is occuring or of the extent of its effects (Stein & Bienenfeld).

Because of the variety of physiological changes associated with this degenerative condition, a diagnosis of presbycusis fails to communicate much information about the disorder. Although several hypotheses exist regarding the physiological aspects of presbycusis; the inner ear, specifically the cochlea, and nerve pathways leading to the brain are generally and most often considered to be the primary sites of the degenerative process. Damage in the inner ear creates a sensorineural loss and results in difficulty in hearing high frequency sounds (Brooks, 1989; McFarland & Cox, 1985; Williams, 1984). A high frequency loss affects the ability to hear consonants; and because consonants are important elements of speech, the high frequency loss can cause difficulty in understanding spoken conversation, especially when there is background noise (Hallberg, Erlandsson, & Carlsson, 1992). The psychosocial effects of such loss can easily be contemplated by considering the difference in communication that may result when the person understands the missing word in the sentence, "I'm really--!" to be "bad" or "mad."

Typically, the loss of hearing associated with presbycusis occurs in both ears (Williams, 1984), but the extent of loss in each ear may vary. For example, one ear may be exposed to environmental conditions such as right ear exposure to mechanical noise while working with a machine that is on the worker's right hand side. Deterioration associated with this noise-induced hearing loss may occur either separately or in addition to other deterioration related to aging/use.

In addition to difficulty in actual hearing, persons with sensorineural hearing loss will experience distortions in what they do hear. As a result, even when they hear speech, they may not be able to understand it or they may misunderstand it (McFarland & Cox, 1985). Furthermore, external sounds may be misinterpreted resulting in misconceptions of environmental cues (Hull, 1977; Luey, 1980; Ramsdell, 1978). These problems result in differential hearing (i.e., seeming to hear sometimes and not other times). Variance in perceived hearing may result from differing environmental conditions, differing personal conditions, or differing interpersonal conditions. Common environmental conditions that may exacerbate problems with hearing acuity include inappropriate lighting (Kampfe, 1990), distortion of sound waves bouncing off of certain materials (Brinson, 1983), and introduction of extraneous sounds such as group conversations or background noises (i.e., air conditioners, dishwashers, vaccuum cleaners, music) (Hallberg, et al., 1992; Thomsett & Nickerson, 1993). Personal variables that can influence heating acuity include familiarity with the context of the conversation (Kampfe; Thomsett & Nickerson), current energy level (Luey; Orlans, 1987; Thomsett & Nickerson), medication (Thomsett & Nickerson), visual acquity (Brinson; Luey, Belser, & Glass, n.d.), and other psychological and physical factors (Luey; Thomsett & Nickerson). Comprehension can also be greatly affected by interpersonal variables such as the expressiveness, clarity, and rapidity of the speaker (Kampfe) and familiarity and relationship with the speaker (Orlans; Thomsett & Nickerson).

Two frequently occuring problems associated with presbycusis are vertigo and tinnitus (Agnew, 1986; David & Trehub, 1989; Thomas, 1984). Vertigo is a disturbance in balance that ranges from mild to severe (Rakel, 1994). Tinnitus is a sensation of noise in one or both ears or in the head itself that also has a broad range of severity (Hallberg & Erlandsson, 1993). Both tinnitus and vertigo can be extremely debilitating (Agnew; Gant & Kampfe, 1997; Rakel).

Meniere's disease is one common condition associated with tinnitus and vertigo. Meniere's disease is singled out here because it is relatively well defined and somewhat different from other causes of late onset hearing loss. This condition involves excess fluid in the inner ear that results in tinnitus, vertigo, and a progressively diminishing ability to hear low frequencies in one ear (Gant & Kampfe, 1997; Martin, 1994; Miyamoto, 1986; Rakel, 1994). An individual may experience the multiple conditions of presbycusis and Meniere's disease. Such individuals are likely to have a heating loss in both the high and low frequencies as well as tinnitus and vertigo.

Psychosocial Considerations

Psychosocial considerations relevant to presbycusis naturally fall into two categories: intrapersonal and interpersonal. Because of space limitations, this article focuses only on intrapersonal considerations (e.g., those within the self). While some interpersonal aspects of heating loss are briefly mentioned or implied, a thorough discussion of interpersonal aspects occurs in Smith and Kampfe (1997) and Kampfe and Smith (in press).

Functions of Hearing

Understanding the impact of a heating impairment might best be accomplished by first considering the functions of normal hearing. Ramsdell (1978) has outlined three psychological levels of heating: primitive, signs or warnings, and symbolic.

Primitive level. The primitive level of heating involves an unconscious awareness of one's own body noises (i.e., breathing, body movements) and of other background sounds (i.e., ticking clock, creaking chairs) that provides individuals with a sense of self and of being a part of the environment (Ramsdell, 1978). Without the primitive level of heating a person may feel a sense of detachment from oneself and from the world. Such detachment can result in a profound experience of isolation and/or "deadness" that affects the individual in a pervasive and constant manner. Depression may, therefore, be associated with this undefined, unconscious loss of the primitive level of heating (Luey, 1980; Ramsdell).

Signs or warnings level. The signs or warnings level involves a conscious awareness of the environment that is outside the visual field (Ramsdell, 1978). At this level, sound is used as a signal of events about to happen (e.g., approaching footsteps, brakes squeaking). Awareness at this signs or warnings level serves to alert the individual not only to the presence of environmental events, but also to the direction and pervasiveness of these events. Such awareness affords the individual the opportunity to make decisions regarding environmental threats and to take appropriate and protective action. Without this signs or warnings level of heating persons may feel a sense of disorientation and vulnerability, creating ongoing apprehension or stress (Brinson, 1983; Hull, 1977; Luey, 1980; Ramsdell).

At the signs or warnings level, sound also contributes to aesthetic experiences in life (e.g., music, running water, and the sound of birds). Without this level of heating, persons may lose a sense of enjoyment that they previously experienced (Luey, 1980; Ramsdell, 1978; Williams, 1984). They may also lose the ability to use various relaxation techniques (i.e., either tapes or natural experiences) available to other persons to reduce stress and anxiety.

Symbolic level. The symbolic level involves communication with others and is the level that most people associate with hearing loss (Ramsdell, 1978). Because older adults' language skills have already been developed prior to the loss (Schein & Delk, 1974), the heating impairment should have a limited effect upon speech. Some difficulties, however, may occur. Because the hearing loss affects the ability to appropriately assess one's own volume/loudness and breathy sounds such as "sh," "f", and "s," speech may become louder or softer than required of the situation or somewhat distorted. Distorted speech is more typical of an individual who has had a heating loss for quite some time (Silverman & Calvert, 1978).

As mentioned earlier, presbycusis can significantly affect speech comprehension, particularly if severe losses of heating occur. Decreased speech comprehension ultimately affects the ability to understand and communicate fully with others. Loss of heating at the symbolic level can, therefore, have a devastating impact on the individual's social-emotional life (Brinson, 1983; Hull, 1977; Kampfe & Smith, in press; Ramsdell, 1978; Smith & Kampfe, 1997; Williams, 1984). Significant isolation, frequent miscommunication, and decreased contact with friends and family may occur. These might be accompanied by feelings of frustration, anger, resentment, and helplessness (Kampfe & Smith; Luey, 1980; Orlans, 1987).

With a loss of hearing, people who are older lose a functional capacity by which they have defined themselves (Glass, 1985; Kampfe & Smith, 1997; Ramsdell, 1978). Because the richness and complexity of conversations are reduced (Brinson, 1983; Luey, 1980; Oyer & Oyer, 1985), information about physical diagnoses, surgeries, medications, investments, or banking may not be available to them resulting in a lack of ability to make truly informed medical or financial decisions (Kampfe & Smith; Smith & Kampfe, 1998). Information about philosophical issues, news items, or family concerns may go unheard, resulting in the inability to engage in meaningful conversations or family decisions. For example, an older person who has always been informed, sympathetic, or a complex thinker may find him/her self operating in a world of simplistic concrete communications about basic life needs or logistics. If the person additionally experiences an energy or visual loss, the solace of some compensation through reading may not be practical (Luey, et al., n.d.).

Response to Loss

The loss of a faculty upon which one has depended and the concommitant other losses associated with late onset hearing impairment (i.e., sense of self, sense of safety, enjoyment of environmental sounds and music, easy interaction with others) may need to be grieved or mourned. Grief is considered to be a natural response to hearing deterioration, and may be necessary for the many associated losses to be resolved (Elliot, 1978). Responses to the changes associated with late onset hearing loss might be examined using theories of reaction to crisis (Kubler-Ross, 1969; Shontz, 1965) or related notions regarding the mourning process of hearing parents whose children are deaf (Luterman, 1979).

Although the literature is inconsistent regarding terminology, order of the process, and number of stages, many writers describe emotional states or stages associated with a loss (Kubler-Ross, 1969; Livneh, 1991; Luterman, 1979; Shontz, 1965). Emotional states associated with loss include shock, realization, defensive retreat, acknowledgement, and adaptation (Shontz). A detailed discussion of these stages/states, as they relate specifically to presbycusis, can be found in Kampfe and Smith (1997).

Shock is thought to occur immediately after a significant event and is often described as a feeling of numbness (Shontz, 1965). Persons with presbycusis are unlikely to experience this stage of the mourning process because the condition is progressive, and therefore gives individuals the opportunity to gradually adjust to the hearing loss. Realization or recognition is considered to be a time when individuals begin to realize that their condition is permanent and severe, and therefore experience a multitude of feelings such as fear, guilt, depression, helplessness, confusion, embarrasssment, and/or anger (Luey, 1980; Orlans, 1987; Schontz). Defensive retreat, also called denial, is a time when individuals withdraw from the painful feelings associated with their losses (Luey). Denial may be prevalent in persons with presbycusis, partially because the condition is slowly progressive and, therefore, less easy to recognize (Stein, & Bienenfeld, 1992). Acknowledgement is characterized by a realistic understanding of the hearing loss and a reduction of the extreme feelings of the recognition stage. Adaptation involves constructive coping with the hearing loss during which individuals identify ways to adjust to the limitations imposed by that hearing loss (Shontz).

Individuals may experience these states in varied order or simultaneously (Kalish, 1977; Kampfe & Smith, 1997; Luey, 1980; Luterman, 1979). Some persons may never reach adaptation, and even those who achieve this stage may revert to initial stages in situations that threaten their adjustment (Luey). Others may never need to mourn, depending upon a variety of other variables that influence their perceptions of their hearing loss (Kampfe, 1998; Kampfe & Smith). Perhaps, then, it is more important for the rehabilitation professional to expect individuals to respond to their hearing loss in their own unique way rather than to expect them to respond in a "typical" way.

Requirement of Energy

Coping with hearing loss for older persons requires a great deal of energy and concentration (Luey, 1980; Orlans, 1987; Rezen & Hausman, 1985). Older persons with good cognitive and adaptive skills generally learn to pace themselves and to increase efficiency in their utilization of energy (Butler & Lewis, 1977). Thus, although they may already have experienced some general decrease in energy level with the aging process, older persons often are quite able to develop compensatory coping mechanisms. Conversely, a person with a hearing loss may need to utilize more energy than before the loss because of the extra energy required to interact with the environment (Rezen & Hausman; Thomas, 1984). When effects of hearing loss are combined with general aging or with other disability effects, less energy is available, in general (Smith, 1986). With the addition of other stressors such as the emotional reactions to several losses and coping with reactions of family and friends, a great deal of unavailable energy may be required. Older persons in such a situation may become exhausted quickly and may give up or refuse to try because the energy demands are so great and their resources are so depleted (Thomas). Thus, in general, older persons with hearing loss may be less active than previously because of the increased energy demands accompanying the hearing loss. Energy depletion for a specific individual may, of course, vary with a wide range of factors.

Summary

Because of the prevalence of hearing loss among older persons and because of its pervasive effects, family members, service providers, and older persons themselves can benefit from understanding the potential intrapersonal effects of and psychosocial implications of a hearing loss. In addition to degenerative changes in hearing and other changes associated with aging, older persons with a hearing loss may also experience tinnitus and vertigo. The loss of the functions of hearing at the primitive level, signs or warnings level, and symbolic level have particular implications for older persons. The older person who experiences losses of the functions of hearing may respond with states/stages of loss analogous to those presented in other literature focusing on death, adaptation to disability, or adjustment of parents to deafness of a child. Reactions to tinnitus, reactions to vertigo, and requirements of energy necessary to cope with decreased hearing all have special implications for older persons experiencing hearing loss.

Throughout this article, references have been made to the variability of severity of the conditions associated with the degenerative process of the ear and the variation in responses to these conditions. Each person with a hearing loss should, therefore, be considered to be an individual who may or may not experience the intrapersonal aspects of a hearing loss as described.

Given the ever-increasing number and proportion of older persons in our population, presbycusis is likely to escalate. With the likelihood that rehabilitation professionals will be seeing a growing number of persons who experience this condition, the intrapersonal effects of presbycusis should continue to gain emphasis in rehabilitation research and literature.

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Charlene M. Kampfe, Ph.D., NCC, NCGC, CRC, Department of Special Education and Rehabilitation, College of Education, University of Arizona, Tucson, AZ, 85721

Charlene M. Kampfe S. Mae Smith University of Arizona