July 21, 1995 Number 117

Assisting Residents Who Are Hearing Impaired

Many nursing home residents suffer from hearing impairment, a debilitating condition which affects their functional ability, self-sufficiency, and self-esteem. According to the Office of Technology Assessment, at least 25% of those aged 65 to 74 have some degree of hearing impairment, and almost 40% of those over 75 suffer from hearing loss. The following article has been written to help caregivers better understand the challenges of hearing impairment and to provide helpful strategies for improving residents' quality of life.

Understanding the Hearing Process

The ear is an amazing piece of design, a complicated structure which is comprised of three major divisions. The external part of the ear is a funnel-shaped canal through which sound waves hit the eardrum, or the tympanic membrane. The vibrating eardrum then sets in motion the three small bones of the middle ear (hammer, anvil, and stirrup). These structures transmit sound vibrations to a snail-shaped structure called the cochlea, which is part of the inner ear. This fluid-filled chamber is filled with 15,000 hair cells, called the stereocilia, each of which is connected to a nerve ending.

Detecting various frequencies of sound, these hair cells convert what they sense into electrical impulses which are carried to the brain by the auditory nerve. The brain decodes these impulses and interprets the sounds.

Several types of problems can arise in these three major divisions of the ear. If there is a complication with the external part of the ear, the conduction of sound waves becomes impaired, leading to conductive hearing loss. Most conductive hearing loss occurs in childhood and is often treated with antibiotics or ear surgery.

Problems in the cochlea can affect the hair cells themselves, causing sensory hearing loss, or the nerve may be damaged, resulting in neural or nerve deafness. The number one cause of nerve deafness is prolonged exposure to loud noise, which blasts away and kills the hair cells. Problems that occur in the brain can cause central hearing loss. Most hearing impairments are the result of sensory hearing loss and nerve deafness. They are usually irreversible and require the help of hearing aids

Hearing Impairment and the Elderly

The most common causes of hearing loss are noise and aging, which contribute to what the medical experts call presbycusis, or old hearing. Other factors leading to hearing impairment include injury, medications, disease, and heredity.

A common misperception about hearing loss is that it is deafness, which is not true. Deaf people hear very little to no sound. The hard of hearing still hear some sounds well.

Many times, it isn't a matter of loudness for the elderly, but of the frequency of the sound. They often have difficulty in hearing high-frequency sounds, such as the "s" and "z" sounds. As Robert A. Dobie, MD, professor of otolaryngology at the University of Washington Medical School explains, "The effects of aging and noise are similar. The process of hearing loss first involves losing the ability to hear sounds of a high frequency. People can still hear the sounds, but they have trouble understanding the words."

Psychological Effects of Hearing Impairment

"Blindness separates people from things, but deafness separates them from other people."

This insight from Helen Keller goes to the very heart of hearing loss. It is a disability of communication, an inability to exchange ideas and feelings with others. Hearing loss can threaten a resident's social and intellectual well-being.

Many persons experiencing hearing loss try to hide the truth from themselves and others by using defense mechanisms. They may try deny their condition by saying "There's nothing wrong with my hearing. I can hear you perfectly." They may blame the problem on others who supposedly don't speak loudly enough, saying that they are mumbling.

They may become paranoid that others are purposely excluding them or speaking softly to hide information. Finally, they may withdraw from daily activities. They may try to stay in their rooms where they feel more secure, rather than risk embarrassment of not being able to hear others.

Hearing loss can lead to feelings of isolation, anxiety, insecurity, confusion, self-doubt, and anger. Cultural stereotypes of the hearing impaired can be devastating. Phrases such as "deaf and dumb" can contribute to a resident's lack of self-esteem. Society does not encourage people to admit to a hearing loss. While it is acceptable for a person to wear eyeglasses, wearing a hearing aid can make a person feel stigmatized.

Adapting the Resident's Living Environment

Nursing home environments can greatly exacerbate a resident's hearing problems. The facility's interior noise can be greatly reduced through the use of carpeting, matte surfaces on walls and floors, draperies, and sound absorbent ceiling tiles. Placing a rug or tapestry on a wall can also help to muffle sound.

Caregivers should carefully monitor background noise when communicating with hearing impaired residents. This effort may involve turning down television and radio noise, closing room doors during conversations to reduce corridor noise, minimizing the use of the intercom system, and monitoring the noise levels of fans and heaters during conversations.

Because hearing impaired residents rely on lip-reading, be sure that there is adequate lighting during conversations. The light should shine directly on the speaker. Arrange furniture to face the room's available light sources. To make conversations easier, place couches and chairs close together and facing each other, so that residents can see each others' faces.

Hearing Aids and Other Assistive Devices

Residents who are experiencing difficulties with hearing loss should have a medical evaluation by a physician, particularly one who specializes in diseases of the ear. The physician may later refer the resident to an audiologist or a hearing aid dispenser, for a hearing aid evaluation.

Unlike glasses, which can restore vision to 20/20 acuity, hearing aids cannot cure or restore damaged hearing. Hearing aids are basically small, wearable personal amplification systems which increase sound intensity and expand the range of sounds and pitches heard.

Other types of assistive devices for the hearing impaired include television, telephone, and radio amplifiers; flashers for alarms; telecommunication devices for the deaf; and "closed captioning" for television screens. Nursing homes may consider investing in these types of assistive devices to maximize resident functioning and independence.

Communicating with Hearing-Impaired Residents

Because hearing impairment has such such a profound effect on a resident's communication abilities, every effort should be made to enable understanding during conversations. Self Help for Hard of Hearing People, an advocacy group for persons with hearing impairments, suggests the following guidelines to nursing home staff to sharpen their communication skills:

  1. Face the resident directly: Be sure to look directly at the residents; they must be able to see you to hear you. Avoid talking from behind the residents' backs or from another room and never turn away your face when speaking. Smiles, frowns, head shakes, and hand signals are great conversational aides.
  2. Spotlight your face. Face a window or a lamp so the light illuminates your mouth as you speak. If the room is dark, move to another area with more lighting. People with hearing loss rely a great deal on lip-reading.
  3. Avoid noisy backgrounds. A conversation is difficult to hear over background noises. Don't try to talk above loud noises. Ask residents to suggest things you can do, such as speaking to a better ear or moving to a better light, to facilitate communication.
  4. Get attention first. Be sure that residents are aware of you before you start talking. One can get their attention by gently touching them, flicking on a light switch, or moving a window shade.
  5. Don't shout. Shouting only makes things worse. It can distort the face, making lip-reading impossible. Also, shouting which is amplified by a hearing aid can greatly shock and upset the resident.
  6. Clearly speak at a moderate pace. Speak more slowly and pause occasionally to help the resident keep up with the word flow. Enunciate each word carefully and avoid mumbling. Don't mouth or exaggerate expressions, as this simply makes it harder for the resident to understand.
  7. Give clues when changing subjects. Hearing impaired residents may become confused if you change the subject without warning. Keep them on track by saying something like, "Now I want to talk to you about our upcoming family night" so that they can become ready for a new topic.
  8. Use longer phrases, which tend to be easier to understand and give more "meaning" clues than shorter phrases. For example, "Will you get me a drink of water?" presents much less difficulty than "Will you get me a drink?"
  9. Use a different choice of words. After repeating something a second time without the resident understanding, try a different choice of words for the third try.

Affecting millions of elderly, hearing impairment can directly impact their independence, communication skills, and functional abilities. By becoming more sensitive to the needs of residents with hearing impairments, nursing home staff can contribute greatly to their physical and emotional well-being.


The Council Close-Up is dedicated to the vital people who live and work in today's nursing homes. It is published by the Illinois Council on Long Term Care. We encourage Council member activity professionals to submit story ideas to our publication. We will arrange interviews and write stories for those ideas selected. Contact Myrtle Klauer, the Editor of Council Close-Up. Address: 3550 W. Peterson Ave., Suite 304, Chicago, IL 60659. Phone: 773/478-6613; Fax: 773/478-0843