More than Half of the Visually Impaired Seniors also have a Hearing Impairment

Forelæsning afholdt på International Conference on the Needs of Blind and Low Vision Seniors, Heidelberg, Tyskland, marts 2000 og på den nordiske kongres for synsrehabilitering, Göteborg, Sverige, maj 2000 af Ole E. Mortensen, Videnscentret for Døvblindblevne

At the Information Center for Acquired Deafblindness in Denmark we have focused very much on elderly with a combined visual and hearing impairment during the last five years, and what I will present in this paper is based on this work.

In the following I will give some information about the estimated numbers of elderly with a hearing and vision impairment, and in the end I will mention – based on our own experiences – two things that we have found are essential for the help to visually impaired seniors who also have a hearing impairment.

That half of the visually impaired elderly also have a hearing impairment may sound like a suprising high number, but this estimate is based on several surveys.

The RNIB did an interview survey in 1991 that among other things showed that almost half of the interviewed visually impaired persons over the age of 75 had problems hearing normal speech even in a quiet room with no background noise etc., and even when wearing their hearing aid (if they had one). In the report the RNIB said:

"These figures suggest that people and organisations in contact with very old registrably visually impaired people are justified in assuming that half of the individuals they deal with will be hard of hearing."

("Blind and partially sighted adults in Britain: the RNIB survey – Volume 1" by Ian Bruce, Aubrey McKennell, and Errol Walker, HMSO, 1991.)

If a person has problems hearing normal speech in a quiet room he has a considerable hearing loss, and about half of the elderly persons in this survey had a hearing loss of this magnitude. Other international figures show that if you consider all hearing problems, from mild to profound, more than half of the population over the age of 70 is affected by a hearing loss to some degree.

A British survey suggested in 1989 that as many as 70% of all elderly over the age of 70 had a hearing impairment. ("The Prevalence of Hearing Impairment and Reported Hearing Disability among Adults in Great Britain" by A. C. Davies, International Journal of Epidemiology, 1989, volume 4, pp. 911-917.)

And visually impaired seniors are in an even greater risk of having hearing problems than the rest of the elderly population. In 1997 an American study of 3600 people proved a clear relation between age-related macular degeneration and age-related hearing loss. ("Is Age-Related Maculopathy Related to Hearing Loss?" by Ronald Klein, Karen J. Cruickshanks, Barbara E. K. Klein, David M. Nondahl, and Terry Wiley, Archives of Ophthalmology, March 1998, volume 116, pp. 360-365.)

This study showed that elderly persons with age-related macular degeneration were more than three times more likely to have an age-related hearing loss than others!

And 39,5 % of all participants over the age of 75 had signs of both age-related maculopathy and hearing loss!

The age-related hearing loss is progressive and the prevalence increases with age. Few elderly become totally deaf due to an age-related hearing loss, but it becomes increasingly difficult for them to hear certain sounds in the spoken language.

The hearing loss starts in the high register. The ability to hear birds' song is among the first to disappear. And in spoken communication this makes it difficult to distinguish for instance between sounds like /f /and /s/, /p/ and /t/ to begin with. As the hearing loss progresses still more speech sounds become difficult to hear, and it may become impossible to understand speech – although the person will still be able to hear that someone is talking.

Naturally, a hearing impaired person normally relies a lot on his vision as a support for his hearing. A person with a functional hearing loss of 30 % is considered to be able to compensate almost fully by help of lip-reading and other visual information and communicate without significant problems using his vision. So it is easy to imagine that for visually impaired people it only takes a moderate hearing impairment to create really big problems in communication.

For some of these elderly their hearing and vision loss is so severe that they are in fact deafblind, according to the definition of deafblindness. The Nordic definition that all five Nordic countries use is also being used in other countries. It is a functional one that says that:

"A person is deafblind when he/she has a severe degree of combined visual and auditory impairment. Some deaf-blind people are totally deaf and blind, while others have residual hearing and residual vision.

(…)

Deafblindness must therefore be regarded as a separate disability which requires special methods of communication and special methods for coping with functions of everyday life."

The total impact of a vision AND a hearing impairment is far greater than the sum of the two individual impairment. The situation could be described like this: 1 + 1 = 3!

When a vision loss and a hearing loss occur together is not just a vision and hearing loss – it is something more.

We have found in Denmark that many elderly people in this situation live a life of lesser quality than necessary, simply because they don't get the help and support they need. And there are two requirements for these people to get the adequate help: awareness and coordination of services.

The first thing that is required is that the people around the elderly persons become aware that the person may have both a visual and hearing impairment – often called a dual sensory loss. This means that staff working with elderly people – in this case especially visually impaired elderly – should be very much aware of a possible hearing impairment. This goes for family members as well.

It may be difficult to notice a progressive hearing loss such as the age-related hearing loss that develops slowly over maybe 5 or 10 years. In some situations you may be able to communicate practically without problems with the person with a dual sensory impairment – if there is no background noise, if you are sitting close to each other, if you have good light on your face when you speak and so on. But as soon as the situation changes – for instance if you turn your away head while you speak – the conditions for communication changes as well.

For people who have only little experience with visually impaired it may be especially difficult to detect a hearing impairment if there is already a vision impairment present. If something is "out of the ordinary" it may take more to notice something else, that is "out of the ordinary". This means that in some cases it can be more difficult for the untrained eye – family members, home helpers and other non-specialists – to detect a hearing impairment in a visually impaired person because of the visual impairment.

And if someone notices that an elderly person has both a vision and a hearing problem, the reaction will often be thinking "Well, that's the way it goes when you get older" – and do nothing about it.

But there is something to be done! Once the person is identified as having a dual sensory loss, he or she can get the appropriate help and support in the form of for instance 

• a number of technical and other aids for hearing and vision
• support services for help with communication, access to information and orientation and mobility (this could be a so called contact person as we have in Denmark or another paid or voluntary helper, that may assist the elderly person with a dual sensory loss in going shopping, going to the bank, reading mail, reading the news paper etc.)
• different rehabilitation efforts that are available to elderly, such as Daily Living Skills training

But if these aids, services and actions are to have any effect, it is essential that the intiatives tasken by the vision rehabilitation system and the hearing rehabilitation system is coordinated. Too many times we have experienced, that for instance a technical aid compensating for the hearing loss is useless or too difficult to use for a person with a visual impairment – and the other way around.

A classic example: The hearing rehabilitation worker arranges for a loop system to be installed in the home of the elderly person and connected to tv and radio so that he or she may again hear the tv and the radio. But the loop system is not being connected to the tape player, that the person uses for audio books, simply because the hearing specialist does not know that this is an important technical aid for a visually impaired person.

Another example is telephones. Some phones have big numbers and are easy to see and use, but are not suitable for hearing impaired people. Others are excellent for hearing impaired people, but are difficult to use for the visually impaired because of small keys etc. Guess for yourself wihch one the hearing rehabilitation worker will recommend if he does not realize the impact of the visual impairment.

In Denmark there are rather well functioning units for vision and hearing rehabilitation in every county, but until now there has been no tradition for the two units for working together. Our Center did an interview survey with 30 elderly people with a severe visual and hearing loss a couple of years ago.

They were all living in the county with probably the best vision and hearing rehabilitation units in Denmark, and all of them were in contact with both units. But in just one of 30 cases had there been a contact between the vision and hearing rehabilitation unit!!!

In some counties the two units even are situated in the same building, but the picture is the same. There is simply no tradition for cooperation. But we have found that in the case of people with both a vision and a hearing loss it is absolutely necessary with a coordination of the initiatives from the two units in order for the individual to get a help and support that takes it starting point in the person in stead of the eye one day and the ear the next.

This coordination does not have to cost much, maybe just the time spent at an initial meeting between the units setting up a procedure – and then coordination meetings throughout the year where clients are discussed.

This holistic effort will result in an optimized help that will improve the quality of life for this group of people – that may be larger than we have thought until now – who are in the very difficult situation of having a hearing impairment as well as a visual impairment.