Chapter 14

Sensation: Hearing, Vision,

Taste, Touch, and Smell
 Intact Senses
• Allows older adult to accurately perceive
the environment
• Remain involved with other people, places
and objects
• Helps keep older adult saft
 Sensory Changes Occur
Naturally as Persons Age
• sensory dysfunction may suffer
– Functional impairment
– Injury
– Social isolation
– Depression
Normal Age-Related Changes of
the Eye

• Normal age-related changes in vision

occur gradually; however, over time
these changes can limit the functional
ability of the older adult
Normal Age-Related Changes of
the Eye
• External changes
• Graying and thinning of the
eyebrows and eyelashes
• Subcutaneous tissue atrophy 
wrinkling of skin surrounding the
eyes
• Decreased orbital fat  sunken
appearance of eye + sagging of
eyelids
FIGURE 14-2 Normal changes of aging in the eye include a thinning of skin surrounding the eye. Source: National
Eye Institute, National Institutes of Health, 2004.
Normal Age-Related Changes of
the Eye
• Internal changes
– Cornea and lens
• Less endothelial cells on cornea  reduced ocular
sensitivity  decreased pain response
• Lipid deposits around peripheral cornea  arcus senilis
• Lenses thicken + harden
– Yellowish appearance + opacity
– Light to scatter  interference with color discrimination
– Increase risk for falls and dangerous night driving
– Reduced space for drainage of aqueous humor 
glaucoma
– Impedes accommodation presbyopia
Normal Age-Related Changes of
the Eye
• Internal changes
– Pupil
• Decreased dilation and constriction
• Delayed response  difficulty responding to
changes in light
• INCREASED FALL RISK
• Diameter is decreased  decreased light
reaching retina
– Iris
• Loses color eyes appear gray or light blue
Normal Age-Related Changes of
the Eye
• Visual acuity
– Diminishes gradually after age 50
– Decreases rapidly after age 70
• Light sensitivity declines with age
– Brightness contrast
– Dark adaptation
– Recovery from glare
 Visual Impairment
• Linked with four causes
– Cataracts
– Macular degeneration
– Glaucoma
– Diabetic retinopahy
• Visual impairment = visual acuity 20/20 by
Snellen chart at 20 feet
– Increases with age
• Legal blindness = visual acuity 20/200 by
Snellen chart at 20 feet
– Increases with age
– Peaks at 85 years
FIGURE 14-1 The Snellen chart, used to measure visual acuity. Source: National Eye Institute, National Institutes of
Health, 2004.
 Visual Impairment
• Personal cost for older person with
visual impairment
– Loss of independence
– Social isolation
– Depression
– Decreased quality of life
 Visual Impairment
• Signs of difficulty with vision
– Squinting or tilting head to see
– Changes in ability to drive, read, watch television,
or write
– Holding objects closer to the face
– Difficulty with color discrimination and walking up
or down stairs
– Hesitation in reaching for objects
– Not being able to find something
(American Society on Aging, 2003)
 Age-Related Macular
Degeneration (ARMD)
• Two types
1. Dry (atrophic form)- age related
– Gradual blocking of retinal capillaries
which leads to ischemia and necrotic
macula
– Rods and cones die
• Atrophy
• Retinal pigment degeneration
• Slow progression of visual loss
2. Exudative (wet)
– Serous detachment of pigment epithelium in
the macula occurs
– Fluid and blood collection under the macula
– Results in scar formation and visual distortion
 Risk Factors for ARMD
• Age (above the age of 50)
• Cigarette smoking
• Family history of ARMD
• Increased exposure to ultraviolet light
• Caucasian race and light colored eyes
• Hypertension or cardiovascular disease
• Lack of dietary intake of antioxidants and
zinc
(Uphold, 2003; Fine, 2000)
FIGURE 14-3 A. Amsler grid as it appears to a person with normal vision. Source: National Eye Institute, National
Institutes of Health, 2004.
FIGURE 14-3 (continued) B. Amsler grid as it appears to a person with macular degeneration. Source: National
Eye Institute, National Institutes of Health, 2004.
FIGURE 14-4 A. Simulation of vision with macular degeneration. Source: National Eye Institute, National Institutes
of Health, 2004.
FIGURE 14-4 (continued) B. Normal vision. Source: National Eye Institute, National Institutes of Health, 2004.
 Treatment for ARMD
• Steroid injections
• Plasmapheresis
• Radiation therapy
• No treatments for the dry form of ARMS
• Wet form may benefit from laser tx to stop
neovasularization and stop leaking blood
vessels
• Surgery- but benefits are limited
 ARMD Preventive Measures
• Nurses should encourage
– Wearing ultraviolet protective lenses in sun
– Smoking cessation
– Exercising routinely
– Eating a healthy diet consisting of fruits and
vegetables
– Taking vitamins in divided doses twice a day to
delay progression
• Zinc oxide 80 mgm
• Cupric oxide 2 mg
• Beta carotene 15 mgm
• Vitamin C 500 mgm
• Vitamin E 400 IU
 Cataracts
• Lens clouding  decreased light to
retina  limited vision
• Development is slow and painless
• Leading cause of blindness in the world
• > 50% of adults > 65 years have
cataracts  visual problems
 Cataracts
• Risk factors
– Increased age
– Smoking and alcohol
– Diabetes, hyperlipidemia
– Trauma to the eye
– Exposure to the sun and UVB rays
– Corticosteroid medications
 Cataracts
• Symptoms
– Blurred vision
– Glare
– Halos around objects
– Double vision
– Lack of color contrast or faded colors
– Poor night vision
Education for Older Persons with
Cataracts
• Explanation about cataracts and their
causes
• Symptoms
• No medications available to treat
• Treatment options
– Surgery
 Surgery recommended when:
• Visual acuity is 20/50 or less with symptoms of
loss of functional ability
• Visual acuity is 20/40 or better with disabling
glare or frequent exposure to low light situations
or occupational needs
• Cataract removal will treat another lens-induced
disease such as glaucoma
• Cataract exists with other diseases of the retina,
like diabetic retinopathy
 Surgery
• Out patient surgical procedure
• Removal of affected lens and insertion of an
artificial lens or intraocular lens
• May do a partial iridectomy
• Usually nonemergency procedure
• Contraindicated when:
– Pt wishes to avoid surgery
– Glasses or visual aids provide satisfactory vision
– pt lifestyle is compromised
– Pt has been diagnosed with medical problems that
make surgery a high risk procedure
 Post surgical procedure
• No lifting heavy objects
• No straining for bowel movements
• No bending at the waist
• Eye drops need to be done several times a day
• HOB 30-45 degrees
• Sleep on back or non operative side
• Eye patch
• Patient belongings on non operative side
 Complications of Cataract
Surgery
• Infection
• Wound dehiscence
• Hemorrhage
• Severe pain
• Uncontrolled, elevated intraocular pressure
• Special concerns
– Patients with cognitive impairments  careful
supervision for at least 24 hours after surgery
• Pt with cognitive impairment must be carefully
supervised for at least 24 hours after surgery to
ensure that they do not remove the protective
eye patch or rub their eye

• If both eyes need to be done, one is done first

and the next one after a month or later

• Adequate home care and support is needed

 Education Regarding Cataract
Prevention
• Wearing hats and sunglasses when in
the sun
• Smoking cessation
• Eat a low-fat diet
• Avoid ocular injury
• Education regarding eye drop
administration
 Glaucoma
• Increase in intraocular pressure (IOP)
 optic nerve damage  vision loss
• Open angle
– Slowed flow of aqueous humor through
trabecular meshwork  build up
increased IOP  damage to optic nerve
fiber  loss of vision
– Painless vision loss
• Midperipheral visual field loss
 Glaucoma
• Open angle “normal-tension”
– Normal IOP but still damaged optic nerve
 visual changes
– Symptoms
• Enlargement of the optic cup
• Nicking of the neuroretinal rim
• Small hemorrhages near the optic disc
 Glaucoma
• Angle-closure
– Angle of the iris obstructs drainage of
aqueous humor through trabecular
meshwork  increased IOP  visual
changes
– Symptoms
• Unilateral headache
• Visual blurring
• Nausea and vomiting
• Photophobia
 Risk Factors for Glaucoma
• Increased intraocular pressure
• Normal 10-21 mm Hg
• 50-70 mmHg is very high
• Older than 60 years of age
• Family history of glaucoma
• Personal history of myopia, diabetes,
hypertension, or migraines
• African American ancestry
FIGURE 14-6 A. Simulated glaucoma vision. Source: National Eye Institute, National Institutes of Health, 2004.
 Interventions
• Treat acute glaucoma as a medical
emergency
• Medications to lower intraocular pressure
• Peripheral iridectomy- allows aqueous
humor to flow from posterior to anterior
chamber
• Life long eye drops
• Client should wear a medical alert band
• Avoid anticholonergic medications
 Interventions
• Client should report
– Eye pain
– Halos around the eyes
– Changes in vision
• If meds fail, need to have surgery
• Surgery is trabeculoplasty- to facilitate aqueous
humor drainage
• surgery is trabeculectomy-to drain into the
conjunctival space
 Diabetic Retinopathy
• Microvascular disease of the eye 
damage to the ocular microvascular
system  impairing transportation of
oxygen and nutrients to the eye in
diabetics
• Two forms
• Nonproliferative
• proliferative
 Diabetic Retinopathy
• Nonproliferative
– Endothelial layers of blood vessels in eye
are damaged + development of
microaneurysms  leakage  edema
near macula  impaired vision
 Diabetic Retinopathy
• Proliferative
– Damaged blood vessels  retinal ischemia 
decreased blood supply + nutrient supply to retina
 neovascularization  fragile blood vessels +
RBC leakage  hemorrhage + vision obscured
– Tension exertion on retinal surface + vitreous
body  retinal detachment + further damage to
surrounding blood vessels  hemorrhage
– Neovascularization of the iris impaired drainage
of the aqueous humor  Neovascular glaucoma
 Diabetic Retinopathy
• Symptoms
– Gradual vision loss
– Generalized blurring
– Areas of focal vision loss
FIGURE 14-8 A. Simulated diabetic retinopathy vision. Source: National Eye Institute, National Institutes of Health,
2004.
 Prevention of Diabetic
Retinopathy
• Tight glycemic control
– Average postparandial 80 to 120 mgm/dL
– Average bedtime capillary blood glucose
100 to 140 mgm/dL
– HbA1c < 7
• Manage hypertension
• Manage hyperlipidemia
Education of Patients with Diabetes
• Proper nutrition
– Low-carbohydrate diet
– Low-cholesterol diet
• Exercise
• Monitoring glucose
 Nursing Diagnoses for Vision-
Impaired Older Patients
• Sensory/perceptual alterations: visual
– Encompasses a variety of nursing goals
and interventions communication
• Safety
• Mobility
• Self-care activities
• Mood assessment
 Eye Examinations
• Healthy older adults
– Complete eye examination every year
• Visual acuity
• Retina
• Intraocular pressure
• Diabetics
– Complete eye examination every 6 -12
months
 Assessment of Vision
• Observe appearance
– Clothing cleanliness
– Self-care
– Indications of bumps and bruises
 Interview
• Adequacy of vision
• Recent changes in vision
• Visual problems
– Red eye
– Excessive tearing or discharge
– Headache or feeling of eyestrain when reading or doing close work
– Foreign body sensation in the eye
– New onset of double vision or rapid deterioration of visual acuity
– New onset of haziness, flashing lights, or moving spots
– Loss of central or peripheral vision
– Trauma or eye injury
– Date of last exam
– Inspection
– Movement of eyelids
– Abnormally colored sclera
– Abnormal or absent papillary response
 Visual Aids
• Helpful aids for visually impaired
– Low-vision clinics for suggestions
– Telescopic lenses
– Books in Braille
– Computer scanners and readers
– Tinted glasses to reduce glare, large print books and
magazines
– Seeing eye dogs
– Canes
• Often rejected because of the stigma attached
• Very expensive and not covered by Medicare
• Register with Commission for the Blind
– Books on tape and tape player
– Telephones with large numbers
– High-intensity lights
 Visual Difficulties May Limit
Independence
• Interference with ability to drive
• Trouble reading and writing
Identification of Safety Problems
at Home
• Provide adequate lighting in high-traffic areas
• Recommend motion sensors to turn on lights
when an older person walks into a room
• Look for areas where lighting is inconsistent;
use proper lampshades to prevent glare
• Use contrast when painting so that walls,
floors, and other structural elements of the
environment can be discriminated easily
• Avoid reflective floors
 Identification of Safety
Problems at Home
• Use “hot” colors, such as red, orange, and yellow for
signage
• Urge the use of supplementary lamps near work and
reading areas
• Use red colored tape or paint on the edges of stairs
and in entryways to provide warning and signal the
need to step up or down
• Avoid complicated rug patterns that may overwhelm
the eye and obscure steps and ledges
• Teach the importance of walking slowly when
entering a room
 Motor Vehicle Accidents and
Accidental Death
• Leading cause for persons > age 65
• Second leading cause after falls if >
age 75
• Accompany older person to assess
driving
• AARP offers 8-hour safe driving course
• Effects of aging on driving
• Unsafe drivers should be reported to
DMV for road test
 Medications with Side Effects of
Visual Disturbance
• Hydroxychloroquine (Plaquenil)—retinopathy,
blurred vision, and difficulty focusing
• Tamoxifen (Nolvadex)—decreased visual acuity
and blurred vision
• Thioridazine (Mellaril)—blurred vision, impaired
night vision, and color discrimination problems
• Levadopa—blurred vision
• Propranolol—dry eyes, visual disturbances
Ophthalmic Solutions with Potential
Adverse Effects
• Beta-blockers (Betagan, Timoptic, Ocupress) (blue or
yellow bottle caps)—bradycardia, congestive heart
failure, syncope, bronchospasm, depression, confusion,
sexual dysfunction

• Adrenergics (Lopidine, Alphagan, Epinal) (purple bottle

caps)—palpitation, hypertension, tremor, sweating

• Mitotics/cholinesterase inhibitors (pilocarpine, Humorsol)

(green bottle caps)—Bronchospasm, salivation, nausea,
vomiting, diarrhea, abdominal pain, lacrimation
Ophthalmic Solutions with Potential
Adverse Effects
• Carbonic anhydrase inhibitors (Trusopt,
Azopt) (orange bottle caps)—fatigue, renal
failure, hypokalemia, diarrhea, depression,
COPD exacerbation

• Prostaglandin analogues (Xalatan,

Lumigan) —changes in eye color and
periorbital tissues, itching
 Hearing
• External ear
– Auricle wrinkles and sages
– Increased cerumen production
• Dry  pruritis
• Hard
• Decreased apocrine gland activity accumulation
• Inner ear
– Atrophy of organ of Corti and cochlear neurons
– Loss of sensory hair cells
– Degeneration of the stria vascularis
 Hearing Loss
• > 30% aged 65 to 76 years
• 50% >75 years
• Older men > older women
• Caucasian men and women > African
American men and women
 Hearing Loss
• Risk Factors
– Long-term exposure to excessive noise
– Impacted cerumen (ear wax)
– Ototoxic medications (myosin medicatons
antibiotics)
– Tumors
– Diseases that affect sensorineural hearing
– Smoking
– History of middle ear infection
– Chemical exposure (e.g., long duration of
exposure to trichloroethylene)
 Hearing Loss
• Temporary threshold shift (TTS)
– Sounds < 75 dB(A)  temporary hearing
loss
– Sounds > 85 dB(A) for 8hrs/day + many
years  permanent loss
 Conductive Hearing Loss
• Sound unable to be transmitted  poor
reception + amplification
– Site of problem
• External or middle ear
 Conductive Hearing Loss
• Cause
– Otitis externa
– Impacted cerumen
• Most common and reversible
– Otitis media
– Benign tumors
– Tympanic membrane perforation
– Foreign bodies
– Otosclerosis
 Sensorineural Hearing Loss
• Problems with cochlea + auditory nerve 
sound distortion
• Causes
– Presbycusis
• Hearing impairment as a result of aging
• Bilateral
• Impaired ability to hear high pitches
• Rare, severe hearing loss or deafness
– Damage as a result of excessive noise exposure
– Meniere’s disease (Meniere's disease is an inner
ear disorder that affects balance and hearing.)
– Tumors
– Infection
 Hearing Loss
• Assessment
– History
– Physical examination
• Inspection
• Examination of ear canal
– Childhood ear infections  ruptured eardrum 
jagged white scars on tympanic membrane in elderly
– Hearing Handicap Inventory for the Elderly
(HHIE-S)
• Talk with family members
 Common Hearing Problems in
Older Persons
• Tinnitus
– Objective—pulsatile sounds with turbulent blood
flow through the ear
• Hypertension
• Anemia
• Hyperthyroidism
– Subjective—perception of sound without sound
stimulus
• Medications
• Infections
• Neurological conditions
• Disorders related to hearing loss
 Nursing Diagnoses Associated
with Hearing Impairment
• Assessment
– Ability to perform activities of daily living
• Communication
• Driving or taking public transportation
• Safety awareness including the ability to hear
alarms, doorbells
• Engaging in leisure and recreational activities
 Drugs with Risk of Hearing
Changes
• Aminoglycoside antibiotics (gentamycin)—
ototoxic
• Antineoplastics (cisplatinum)—ototoxic
• Loop diuretics (Furosemide)—ototoxic
• Baclofen—tinnitus
• Propranolol (Inderal)—tinnitus and hearing
loss
 Nursing Diagnoses Associated
with Hearing Impairment
• Diagnosis
– Sensory/perceptual alterations: hearing
with a variety of nursing goals and
interventions
• Communication
• Safety
• Self-care activities
• Mood
• Recreation and leisure activities
 Cerumen Impaction
• Hygiene
• Cerumen removal
– Currette
– Lavage or irrigation
FIGURE 14-10 The tip of a bulb irrigation syringe is placed into the external canal.
 Hearing Aids
• Documentation on admission
– Type
– Model number
– Serial number
 Hearing Aids
• Assessment
– Integrity of the ear mold: Are there cracks or rough
areas? Is there a good fit?
– Battery: Use a battery tester if you have one. Are the
contacts clean? Inserted correctly with + on battery
matched to + in compartment?
– Dials: Are they clean? Easily rotated? Does the
patient report variation of volume when the volume
dial is moved?
– Switches: Do they easily turn on and off? Is there
excessive static or feedback?
– Tubing for behind the ear aids: Are there cracks? Is
there good connection to the earpiece?
 Hearing Aids
• Care of hearing aids
– Remove and clean at bedtime
• Warm water or saline
– NO alcohol or harsh soaps
• Use cotton pad
• Carefully remove cerumen
– Disengage battery
– Store in safe place
 Hearing Aids
• Other devices
– Cochlear implants
– Assistive listening devices
• Amplifiers in theaters
• Telephone device for the deaf (TDD)
 Taste
• Normal changes associated with aging
– Diminished sense of taste
– Thresholds are ~2.5 to 5 times higher in older adults
» Protein
» Salt
» Sweetness
 Taste
• Contributing factors to taste alterations
– Oral condition
– Olfactory function
– Medications
– Diseases
– Surgical interventions
– Environmental exposure
– Medical conditions
 Taste
• Oral status can affect gustatory function
– Poor dentition  improper chewing  less
flavor release
– Improperly fitting dentures  obstruction
of palate  decreased taste perception
– Oral infections  release of acidic
substances  altered taste + impaired
salivary stimulations  decreased ability
for food to dissolve  diminished flavor
 Taste
• Medications can alter taste sensation by
affecting peripheral receptors and
chemosensory pathways

• Focused assessment for taste disturbances

– Head and neck
– Mucous membranes
– Interview with focus on past dietary habits
 Taste
• Education
– Implications of inability to distinguished
between salt and sugar
– Decreased taste  lack of motivation to
prepare + eat  malnutrition
 Xerostomia
• Cause
– Systemic diseases
– Radiation
– Medications
– Sjogren’s syndrome
• Implications
– Altered taste
– Difficulty swallowing  Risk for aspiration pneumonia
– Periodontal disease
– Speech difficulties  embarrassment  social isolation
– Dry lips + dry mucosa  increased infection + dental caries
– Halitosis
– Sleeping problems
 Nursing Diagnoses Associated
with Taste Impairment
• Sensory/perceptual alterations:
gustatory
• Intake less than necessary for caloric
requirements
 Smell
• Thresholds for common odors ~11
times higher for older people
• Structural alterations contribute to loss
of sense of smell
– Upper airway
– Olfactory tract and bulb
– Hippocampus
– Amygdaloid complex
– Hypothalamus
 Olfactory Dysfunction
• Statistics
– Males > females
• Causes
– Nasal and sinus disease
– Upper respiratory infection
– Head trauma
– Secondary
• Chemotherapy or other medications
• Radiation
• Current or past use of cocaine or tobacco
• Poor dentition
 Olfactory Dysfunction
• Special concerns
– Safety related to smoke and fire
• Malnourishment
• Sense of smell fails to be detected because it
is not adequately tested
– Use three familiar smells
– Repeat with both nostrils, in different orders
• Nursing diagnoses associated with hyposmia
– Sensory/perceptual alterations: olfactory
 Nursing Assessment

• Assess safety and preventive measures

• Some medications affect the sense of smell.
• Additional assessment
– Nutrition
– Patient safety
• Date and label all foods
• Place natural gas detectors in the home (for gas heat)
• Place smoke detectors in strategic locations
• Establish schedules for personal hygiene and house
cleaning
• Remove kitchen waste every evening
 Strategies to Relieve Xerostomia
• Nonpharmacological
– Diet low in sugar
– Sugar-free candies
– OTC artificial saliva
– Drinking fluids, especially with meals
– Humidifiers
• Pharmacological
– Anticholinergics during the day
– Dividing doses from once a day to twice a day
 Appetite Enhancement Strategies
• Coffee stimulates the appetite
• Add flavors
• Check dentures for fit and cleanliness
• Inspect mouth for ulcers or gingivitis
• Review medications
• Encourage fluids
• Maintain bowel records
• Assess palatability of food
 Appetite Enhancement Strategies
• Provide a pleasant environment in which
to eat
• Seat residents with others of similar
functional and cognitive levels
• Provide pleasant background music
• Allow for appetizing smells
• Provide clean table settings
• Position small bunch of flowers here and
there
 Tactile Sensation
• Diminishes with age
• Decreased ability to detect temperature
extremes

Nursing diagnosis for changes in physical sensations

Sensory/perceptual alterations: tactile
 Need for Touch
• Tactile sense interpretation
• Environmental orientation
• Psychological benefits
– Comfort
– Love
• Communication
• Protective by stimulating withdrawal
• Touch can decrease dementia-associated
problems
 Nursing Interventions for Older
Persons with Tactile Impairment
• Continuous monitoring of the intactness of the
skin,
– Diabetics should place a mirror on a wall close to floor
 examine the bottom of their feet
• Assessment of safety risks
• Development of a safety plan with instructions to
minimize injury
• Water heaters turned down to 110° F.
• Implement teaching guidelines for patients and
families with sensory impairments