The single biggest problem in communication is the illusion that it has taken place.
Introduction
A great part of effectiveness in care processes is related to good information exchange. In perioperative care of the elderly, the complexity of surgical processes and the amount of information that is needed by patients to understand what is going on may encounter a major obstacle in the high rate of sensory impairment (SI) that is reported among older subjects. Per se, SI represents a disabling condition that may affect quality of life (QoL), is a source of anxiety and is associated, among other conditions, with cognitive deterioration.
In the geriatric surgical setting, a state of SI should be systematically investigated, as this condition is associated with an increased rate of postoperative complications and comprehension errors.
Sensorial Deficits in the Elderly
A large number of studies (Weinstein and Ventry 1982, Branch et al. 1989, Carabellese et al. 1993) have consistently demonstrated that – when relevant –SI affecting visual or hearing function may be associated in the elderly with a reduced QoL. Indeed, SI may exert a detrimental effect on cognitive functions (Peters et al. 1988, Uhlmann et al. 1989a) and may be associated with disability, depressive symptoms, impaired social relationships (Laforge et al. 1992, Apollonio et al. 1996) and increased overall mortality (Thompson et al. 1989, Apollonio et al. 1995). Conversely, treating sensory deprivation can restore sensory acuity, even in very old individuals and improve QoL (Brenner et al. 1993). Interestingly, when compared with subjects having non-corrected sensory impairment, subjects that use sensory aids show higher mood level, richer social relationships and better functional performance; moreover, their QoL profile is similar to that of subjects with no SI (Apollonio et al. 1995). On the whole, early SI recognition seems to be relevant in order to preserve both QoL and independence, and to reduce mortality in elderly people.
Visual Impairment
Over 75 years, cataracts predominantly cause visual impairment, while macular degeneration is the major cause of blindness. A study evaluating visual acuity in a large cohort of older people representative of the British population (Evans et al. 2002) found that visual impairment was 12.4%. The risk of visual impairment (i.e. low vision and blindness) increases steeply with age, with a dramatic increase after the age of 90 years (36.9%). The authors estimated that over 500,000 people with low vision (128,000 over 90 years), and 103,000 blind people (29,000 over 90 years) live in the UK. The majority of the burden exerted by visual impairment in the elderly was borne by women (Evans et al. 2002). In the Rotterdam study (Klaver et al. 1998), the rate of visual impairment respectively evaluated by WHO and US criteria was 9–28.1% in men aged 75–84 and 12.5–30.4% in women aged 75–84.
Hearing Impairment
Hearing loss is the third most common chronic condition reported by elderly people (Cruickshanks et al. 1998). The WHO estimated the prevalence of disabling hearing loss in the over 65s in Central/Eastern Europe to be 36.1%. In a systematic review in Europe, a hearing loss of 30 dB HL or more was reported to affect about 30% of men and 20% of women by age 70 years, and 55% of men and 45% of women by age 80 years (Roth et al. 2011).
However, despite such a high prevalence of hearing loss among the elderly, only about 20% of them utilize hearing aids; furthermore, about 30% of hearing aid owners are dissatisfied with their instruments, and approximately one-sixth of hearing aid owners report never using their aids (Gordon-Salant 2005).
Sensorial Impairment and the Surgical Setting
During their daily life, people with sensorial impairment experience many barriers and, to cope with them, elaborate a range of defensive measures that may become insufficient in challenging situations. Hospital admission for surgery is a hard experience for them and represents a source of possible complications ranging from troubles in communication and discomfort in interfacing with both operators and other patients, to postoperative delirium (POD) or falls.
Impact on Communication
Understanding whether an elderly patient undergoing surgery suffers from any SI is a basic task, as such disturbances may have a deleterious effect in all those actions where communication is necessary. To help reciprocal understanding, adequate communication tools should be available, such as large letter information leaflets or voice recognition programs operating on a computer.
The most challenging circumstances are:
scheduling appointments
completing medical history
informing about surgery and obtaining informed consent
instructing and preparing for surgery
entering the operating room
managing postoperative phases
planning and instructions for discharge.
Information support offering both vision-based and hearing-based tools should be available in centers where high volumes of geriatric surgery are performed. With the increasing rate of elderly hospitalized patients, operators should at least be educated on how to adjust their communication strategies to patients’ needs. Asking them what support they prefer, using their preferred communication method and obtaining collaboration from a relative or caregiver can substantially improve communication and reduce the risk of misunderstanding or loss of information. The information that a patient suffers from an SI should be shared among the staff and reported on the medical record.
Association with POD
Delirium is a common condition in old age, has multifactorial pathogenesis and its incidence has been associated with a number of risk factors (Fong et al. 2009), including vision and/or hearing impairment (George et al. 1997). When occurring after surgery, POD may have both short- and long-term severe detrimental effects, mostly because it is frequently overlooked, especially when occurring in its hypoactive form (See Chapters 14 and 38). In 2017, a guideline on POD prevention and treatment was issued by the European Society of Anaesthesiology (ESA 2017). Hearing loss was found to be a predisposing factor for POD in three studies and was mentioned in three reviews; the latter two reviews and one additional study on internal patients additionally mentioned visual impairment as a risk factor for POD. In patients admitted to an orthopedic clinic, self-reported vision (but not hearing) impairment was associated with POD (Andersson et al. 2001). In a systematic review on preoperative risk factors for POD in subjects undergoing hip fracture repair, vision impairment was associated with delirium incidence (but only in univariate analysis; Oh et al. 2015).
Recently, Hshieh et al. (2015) evaluated the effect of multicomponent non-pharmacological interventions in reducing delirium incidence. Non-pharmacological interventions included cognition/orientation, early mobility, hearing (10 studies), sleep-wake cycle preservation, vision (9 studies), and hydration. On the whole, multicomponent non-pharmacological interventions were found to be effective in reducing delirium incidence and also in preventing falls.
Sensorial Evaluation in Practice
Hearing Deficits
More than 90% of hearing loss is sensorineural (presbycusis). Patients with presbycusis typically have difficulty filtering background noise, which makes listening in common social settings especially challenging. Because no treatment is available, presbycusis is typically treated with amplification devices. Some important behavioral signs that might indicate the presence of hearing loss include speaking in an inappropriately loud voice, leaning close to the speaker or cupping hand over the ear during conversations, inappropriate responses to questions, comments unrelated to the discussion and increasing the volume on the television/radio.
It should be remembered that some patients are embarrassed about their impairment and tend to avoid conversations; consequently, they may appear insecure, angry or aggressive.
In order to test the auditory function in a standardized mode, the Whispered Voice Test can be performed by examiners who whisper words from behind the patient at varying distances (Macphee 1988, Uhlmann et al. 1989b). Alternatively, a simple self-administered instrument is the Hearing Handicap Inventory for the Elderly – Screening version (HHIE-S), a 10-item, 5-minute questionnaire that measures the degree of social and emotional handicap from hearing loss (Weinstein 1986). Finally, it should be underlined that, for some otologic abnormalities resulting in substantial hearing loss, easy and simple effective treatment is available. For instance, cerumen impaction, which can be found in up to 30% of elderly patients with hearing loss, may be easily removed by several simple techniques.
Visual Impairment
Vision problems might also be disclosed by typical behavioral signs such as unsure movements, inability to find small objects, holding material very close or inability to recognize faces. Visual acuity testing is the usual screening method for recognizing visual impairment in a primary care setting, while screening questions are not as accurate as a visual acuity test. The standard tool used in clinical practice is the Snellen chart (Colenbrander 2013). However, Snellen chart testing is time-consuming in a busy clinical setting, and may be difficult to apply in patients with cognitive impairment associated with language problems. The Cardiff Visual Acuity Test (CAT) was originally developed to assess vision in toddlers and young children (Woodhouse et al. 1992). It consists of a set of 11 gray cards, each with a simple picture, consisting of a white line drawing, with the white lines surrounded by a black line of half the width. When applied to frail elderly or confused patients, CAT was shown to be reliable, valid and highly acceptable (Johansen et al. 2003). Consequently, it may be useful in clinical settings such as hospitals, where some older patients may present cognitive problems or dysphasia.
How to Approach Elderly Patients with SI
As mentioned above, the search for a possible SI should always be included in the general management of an elderly patient undergoing surgery (see Table 7.1). This can be done by:
medical history, revealing the presence of a known visual/hearing impairment and/or the use of a prosthetic device (glasses or amplification device)
patient’s self-report or an informant’s report of communication difficulty
previously reported communicative behavioral signs
direct evaluation during medical examination.
| Action | Always | Impairment | ||
|---|---|---|---|---|
| Hearing | Visual | |||
| 1. | Medical history searching for sensorial impairment and prosthetic devices | X | ||
| Verify the in-hospital correct use of functional aids | X | |||
| Medical examination including basic evaluation of vision and hearing | X | |||
| Reduce background noise | X | |||
| Reduce number of interlocutors | X | |||
| Take the time necessary for communicating | X | |||
| 2. | Before speaking, make sure you have the patient’s attention | X | ||
| Introduce yourself and your role | X | |||
| Address the patient by her/his name | X | |||
| Speak clearly, at a moderate rate of speed | X | |||
| If necessary, decrease your distance from the patient | X | |||
| Use everyday language | X | |||
| Pause or wait to allow the patient to participate in the dialog | X | |||
| Be willing to ask for help (relatives, caregiver) | X | |||
| Be patient and positive | X | |||
| Share what you have learned with other staff members | X | |||
| 3. | Stay in front of the patient and look at her/him directly when speaking | X | ||
| Use facial expressions | X | |||
| Ask the patient to repeat the concept you have just stated | X | |||
| Rephrase if the message is not understood | X | |||
| 4. | Check that lighting is adequate | X | ||
| Touch the patient’s hand gently | X | |||
| Tell the patient when you are leaving the room | X | |||
| Tell the patient if someone new has entered the room | X | |||
The minimum components of the pre-operative geriatric assessment specific to anesthesia suggested by the Association of Anaesthetists of Great Britain and Ireland includes the use of all functional aids such as visual, hearing, mobility and dentures (AAGBI 2014). Although a full hearing/vision test and a possible aid prescription would be best completed post hospital discharge, some specific behaviors and environmental strategies should be implemented from hospital admission in order to support the older patient with SI.
In case of proven SI, it is important that the patient is allowed the benefit of his/her own prosthetic device all through the hospitalization; thus, verifying whether glasses or amplification devices have been brought from home and are correctly worn in hospital is mandatory.
Whenever possible, the place where the patient is accommodated should be quiet (reducing background noise is important) and well lit, and the contemporary presence of only a few interlocutors is recommended, in order to reduce the stress related to communicating with different persons at the same time.
Communicating with an elderly patient with SI will take time. Before speaking, it is important for staff to have the patient’s attention and to introduce themselves and their role. The patient should be addressed by her/his name, speaking should be clear and of a moderate speed, simple everyday language should be used and the distance from the patient should be reduced when necessary. Being patient and positive about the conversation, pausing and waiting to allow the patient to participate in the dialog is good practise.
Especially when approaching important issues (e.g. description of the intervention, anesthesia, techniques, risks related to interventions, etc.) the presence of a relative (i.e. spouse, daughter, son) or a caregiver should be encouraged, as this will improve communication. With the aim of reducing the need for reiterating or duplicating questioning, the information obtained during the patient interview by one staff member should be diffused to the rest of the team.
In case of significant hearing impairment, the physician/nurse should stay in front of the patient, look her/him in the eyes, speak slowly and clearly and talk with a suitably loud voice, always avoiding emphatic attitudes, too high a voice or signs of annoyance. Accompanying appropriate facial expressions could be useful, as well as asking the patient to repeat/summarize the concept just stated, in order to check the level of comprehension. If not understood, the message should be clearly rephrased.
In cases of severe visual impairment, it is essential to check that lighting in the room is adequate to the patient’s needs. With no visual contact, gently touching the patient (e.g. touching his/her arm with the hand) will strengthen the patient/staff member relationship. Always informing the patient that the interlocutor is leaving and/or someone new has entered the room is essential. All these precautions are useful to maintain throughout the patient’s hospital stay.
Checking the correct use of any prosthetic devices and allowing the continual presence of a relative/caregiver as much as possible will be essential to ensure the best level of communication, especially during the recovery phase.
References
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