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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Eyes & Ears

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

E=Eyes & Ears

Related Issues:

Hearing, sight/vision, depth perception, communication

Why Eyes/Ears are Important:

  • Decreased visual acuity can increase risk of injury and falls (Mohapatra, 2012)
  • Impaired visual acuity due to uncorrected refractive error, cataracts, and age-related macular degeneration is common in adults and the prevalence increases with age (Popescu, 2011)
  • Age-related macular degeneration (AMD) remains the leading cause of blindness in older North Americans; AMD affects the macula, the posterior aspect of the retina responsible for central visual acuity; it is estimated that approximately 13 million to 14 million Americans have a form of AMD and by 2020, this number is expected to increase by 50% (Spaide, 2009)
  • Loss of vision and/or hearing can be associated with decreased functional capacity, decreased quality of life, and depression (Adelam & Green, 2010; Popescu, 2011)
  • Presbycusis or decreased hearing of higher frequency sounds is one of the most common significant sensory changes and affects 70-80% of older adults (Parham et al., 2011)
  • Loss of hearing and/or vision can negatively impact learning/pt education and communication (Huang, 2012)
  • Dry eye is especially common in the elderly, occurring in approximately 5-30% of the general elderly population, affecting women more commonly than men (Sharma & Hindman, 2014)
  • When vision is lost with dry eye syndrome (DES), the risk of falling is increased 2-fold, the risk of depression is increased 3-fold, and the risk of hip fracture is increased 4-fold (Sharma & Hindman, 2014)

Normal Age-Related Changes:

Eyes

  • Eyelid lag and yellowing of lens of eye altering color discrimination
  • Pupil takes longer to dilate and contract, decreasing one's ability to adapt to changes in lighting
  • Loss of elasticity in the lens decreases the eye's ability to change in illumination and with night vision
  • Drusen (small yellow accumulations of material in membrane on eye) can lead to macular degeneration
  • Lacrimal secretions decrease, causing dry eye without increasing tearing to compensate
  • Increased presence of floaters and decreased visual field

Ears

  • Decreased blood supply, loss of hair cells in cochlea contribute to presbycusis (reduced hearing sensitivity and speech understanding in noisy environments, especially high frequencies)
  • Eardrum thickens and increased incidence of cerumen impactions

Older adults are at increased risk if they have any of the following:

Conditions

  • Presbyopia -- loss of elasticity of lens decreasing the eye's ability to focus on near objects and adapt to light
  • Cataracts -- painless and progressive clouding of crystalline lens
  • Macular degeneration -- deposits in retinal pigmented epithelium
  • Glaucoma -- increased intraocular pressure; damage to optic nerve
  • Conductive hearing loss -- cerumen impaction or foreign body, ruptured eardrum, otitis media, and otosclerosis
  • Sensorineural hearing loss -- (most common) damage to inner ear, cochlea or 8th cranial nerve, caused by heredity, infections, trauma, tumors, noise exposure, drugs, Meniere's disease, and cardiovascular conditions
  • Central auditory processing disorder -- inability to process sound due to stoke or Alzheimer's disease
  • Tinnitis -- ringing sound that fluctuates
  • Meniere's disease -- hearing loss, dizzines, vertigo, and tinnitus
  • Dry Eye Syndrome
  • Others -- diabetic retinopathy, hypertensive retinopathy, temporal arteritis, detached retina, Multiple Sclerosis

Behavioral Risk Factors

  • Smoking (macular degeneration and cataract development)
  • Alcohol use (cataract development)
  • Noise exposure (occupational or recreational)

Medication-Related Risk Factors

  • Ears: antibiotics (aminoglycosides): gentamicin, tobramycin or streptomycin, loop diuretics, salicylates
  • Eyes: corticosteroids (cataracts)

Chemotherapy-Related Risk Factors

  • Ears: cisplatin, carboplatin
  • Eyes:
  • Increased tearing/watery eyes: 5-Fluorouracil, capecitabine, cytarabine, doxorubicin
  • Conjunctivitis: capecitabine, high-dose Ara-c, carmustine, epirubicin, methotrexate, oprelvekin (IL-11)
  • Dry-eye syndrome: isotretinoin, tretinoin (ATRA), 5-Fluorouracil
  • Retinal vein occlusion: MEK (Mitogen-activated protein Kinase) Inhibitors (trametinib, selumetinib, cobimetinib)

Surgery-Related Risk Factors

  • Eye or ear surgery
  • Brain resection near auditory or visual centers

Radiation Therapy (RT) Related Risk Factors

  • RT to eye
  • RT to occipital lobe brain or to ear/inner ear

Cancer Diagnosis

  • Ocular lymphoma
  • Brain tumors or metastases affecting vision or hearing

Assessment:

1. Screening Questions

  • Any changes in your vision or difficulty with vision: blurred? nighttime? reading up-close or far away? adapting from sunlight to indoor lighting?
  • Any tearing, dryness, redness, or itching eye?
  • Difficulty hearing?

2. Observations

  • Does the patient squint to see far away items?
  • Need to hold objects extremely close to read items?
  • Close or cover one eye to improve vision?
  • Ask you to repeat questions? Ask you to speak up? Appear not to have heard you?
  • Lean forward or turn head when listening?

3. Screening Tests

Eyes

  • Snellen Exam: Assesses visual acuity--the ability of patients to recognize letters of different sizes arranged in rows from a pre-specified distance (typically 20 feet); roughly speaking, a person with 20/100 vision according to the Snellen chart would need to be 20 feet away to read the smallest letters that someone with "normal" (20/20) vision could read at 100 feet
  • Visual field testing: Stand in front of patient; ask patient to look with both eyes into yours; place your hands about two feet apart, lateral to patient ears; instruct the patient to point to your fingers as soon as they are seen, and slowly move your fingers around the head towards the line of gaze; the patient should see both sets of fingers at the same time; a visual field cut is the "blind area" the patient cannot visualize your fingers
  • Ishihara’s test for color blindness
  • Amsler grid: Consists of evenly spaced horizontal and vertical lines (making squares) on a sheet (provided below); it is used to detect retinal defects affecting central vision including ARMD, which can be associated with distortion (wavy lines) in the boxes on the grid or blank areas in the grid (scotomas); the Amsler grid can also be used by patients as a self-monitoring tool for early signs or progression of macular disease

Cover one eye and note the dot in the center; while keeping your eye trained on the dot, notice the lines which cross over the rest of the box; ask yourself the following questions:

  • Are you able to see the corners and sides of the square?
  • Do you see any wavy lines?
  • Are there any holes or missing areas?

Repeat this test on your other eye; if the lines are bent or missing you may have a vision problem in that eye and you should schedule an appointment with your retinal specialist for a dilated eye exam

Ears:

  • Whisper test: To perform a whispered voice test, stand at arm's length behind the patient (to prevent lip reading) and mask hearing in one ear by occluding the ear canal and rubbing the tragus with a circular motion; whisper a short sequence of letters and numbers and ask the patient to repeat them; test the other ear in a similar manner
  • HHIE-S (Hearing Handicap for the Elderly Screen): 10 item self questionnaire that is valuable as a substitute for pure-tone audiograms screening in the elderly; the higher the score, the greater the handicapping effect of hearing impairment
  • Tuning Fork:
  • Rinne Test: Differentiates whether an older adult has sensorineural or conductive hearing loss
  • Weber Test: Used to identify unilateral hearing loss

4. Physical Assessment: Standard examination with special focus on:

  • Eyes, examine:
  • External structures: lid lag, swelling, discharge, redness
  • Internal structures: PERRLA, color and clarity of pupil (presence of cataracts, cloudiness of cornea, redness
  • Conjunctiva-jaundice or pale?
  • Fundus exam: red reflex
  • Ears, examine:
  • Outer Canal: any discharge or inflammation present?
  • Inner Canal: Use otoscope to assess for cerumen

E-Eyes & Ears

Nursing Intervention:

  • Determine underlying etiology of identified problem if possible and the impact of reduced vision and hearing on quality of life
  • Initiate and coordinate appropriate referrals
  • Ophthalmology or Audiology Referral for further evaluation and treatment
  • Help obtain assistive devices (glasses, magnifiers, amplifiers, hearing aids)
  • Assess safety of home: arrange caregiver assistance (HHA) is indicated
  • Provide education to patient and caregivers regarding:
  • Vision aids, illumination, safety
  • Contribution of smoking and other CV risks factors to development of AMD (control hypertension, lipids, triglycerides)
  • Administration of eye drops
  • Encourage use of patient’s eyeglasses and/or hearing aids at all medical appointments and during hospitalizations/treatments
  • For patients with hearing impairments:
  • Use a lower tone of your voice rather than shouting or raising total volume
  • Reduce background noise as much as possible (close exam room doors/windows)
  • Establish good eye contact
  • Speak slow and steady
  • Rephrase rather than repeat misunderstood wording
  • Ensure all printed information is legible (bold, at least 14 point font, in contrasting colors)
  • Collaborate with all other healthcare providers to control comorbidities such as diabetes
  • Evaluate effectiveness of interventions and modify as needed
  • Check for ear wax and remove if excessive

References

Adelam, R., & Green, M. (2010). Communication challenges with the elderly. In Kissane, D.W., Bultz, B.D., Butow, P.M., & Finlay, I.G. (Eds.) Handbook of Communication In Oncology and Palliative Care (pp. 531-45), New York: Oxford University Press.
Huang, Q., & Tang, J. (2010). Age-related hearing loss or presbycusis. European archives of oto-rhino-laryngology, 267(8), 1179-91. 
Mohapatra, S. (2012). The effect of decreased visual acuity on control of posture. Clinical neurophysiology, 123(1), 173-82.
Parham, K., McKinnon, B.J., Eibling, D., & Gates, G.A. (2011). Challenges and Opportunities in Presbycusis. Otolaryngology--head and neck surgery, 144(4), 491-5. 
Popescu, M.L. (2011). Age-Related Eye Disease and Mobility Limitations in Older Adults. Investigative Ophthalmology & Visual Science, 52(10), 7168-74.
Sharma, A. & Hindman, H.B. (2014). Aging: a predisposition to dry eyes. Journal of Opthamology, 2014, 1-8.
Spaide, F. (2009). Enhanced Depth Imaging Optical Coherence Tomography of Retinal Pigment Epithelial Detachment in Age-related Macular Degeneration. American journal of ophthalmology, 147(4), 644-52.