Quantify and Qualify HL

- Degree of HL

- Type of HL

- Configuration of HL

Audiometric Assessment: Components

Tones

- Air conduction

- Bone conduction

Speech

- % understood

Checks validity of entire ear system

Tests one ear at a time

Bone vibrator on mastoid process

Checks validity of the inner ear

HL resulting from disorder of the outer and or middle ear which interfere with transmission of the sound

Usually temporary and medically treatable

Age related changes:

Outer and Middle Ear

- Tympanic membrane becomes stiffer

- Calcifications of the jounts and ossification of the middle ear ossicular chain

- Atrophy/degeneration of the fibers

- Calcification of the cartilage supposrting the Eustachian tube

- Increased production of cerumen

- Changes in physical properties of the skin

- Enloargement

Eardrum Perf

Otitis Media

Wax Impaction

Otosclerosis

Cholesteotoma

HL resulting from damage to the inner hair cells of hearing n.

Permanent and not medically treatable

Congenital

Genetic

Head trauma

Ototoxic drugs

Acoustic Neuroma

Meniere's Dz

Viral Dz

Vascular problems

Sudden attacks of vertigo, tinnitus, vomiting, unilateral SNHL

Onset 40-60 yoa

Tx: NO known cure, manage sxs

- Diuretics

- Corticosteriods

- Anti-vertigo meds

- Amplification

- Vestibular rehabilitation therapy

- Surgical

Aminoglycosides

- gentamicin, kanamycin, neomycin, streptomycin, tobramycin

Antineoplastic drugs

- cisplatin, carboplatin, nitrogen mustard

Diuretics (Loop)

- Lasix

Salicylates

- Aspirin

Quinine

- Malaria

general deterioration of the iner ear and its structures associated with the again process

Most common cause of HL due to aging.

Sensory

Neural

Strial

Cochlear conductive

Mixed

Intermediate

Compare AC to BC with pure tone thresholds

BC responces should be </= 10dB fo AC responces

General atrophy

Decreased neural size

Decrease in central body size

Decrease in supporting structures

Reduction in dendrites

Decreased attention

Decreased speed of processing info

Decreased memory

Overall negative impact on communication behaviors

Strain on family relationships

Limits daily activities

Interferes with telephone use

Safety/security Issues!

Speech Understanding Test

Quantification in word recognition ability

%s

100-80 : good

79-60 : fair

< 59 : poor

Proportion of persons w/ difficulty understanding speech doubles per decade after 60yoa

16%@60, 34%@70, 64%@80

Degree of HL and Speech Understanding:

(table)

Level of HL v Everyday speech understanding

HL     v     Speech understanding

Mild  -  difficultly hearing quiet voices

Mod  -  understand spoken voice from front & close

Mod/Sev  -  Conversations must be loud

Severe  -  Only hear loud close voices

Profound   -   No understanding

Hypothesis of Speech Understanding Difficulties:

3 theories

Peripheral: encoding the sound before it is sent to the brain, aging/damage introduces and distorted signal to brain

Age related: transmission and processing slows

Cognitive: cortical function decline, processing and storage retrieval decline

Cost

Stigma

Neg attitude

Concern about ability to handle technology

"getting old"

Completely in Canal (CIC)

In the Canal (ITC)

In the Ear (ITE)
Behind the Ear (BTE)

Open fit

Severe to Profound SNHL bilaterally

Pre-operative sentence recognition scores of 50% or less

Pre-linquistic or post-linquistic onset of HL

No medical CI

Desire to be part of the hearing world

Impact of HL

(continuum)

Pre-linqual

Post-linqual

Congenital

Defened

longer duration has greater impact than shorter duraiton HL

Age at intervention

Frustration

Anxiety

Impatience

Anger

Loss of competence/self-esteem

Self-pity

Guilt

Withdrawal

Increase:

- proportion of persons who have had a hearing exam on schedule

- # of persons who are reffered by their primary care for hearing eval and tx

- use of appropriate ear protection devices, equipment, & practices

- Do you have HL in one or both ears?

- Have you had an illness that could have caused our hearing to decline? or taken meds for an illness that caused your hearing to decline?

- Was your HL sudden onset?

- Do you have any recent discharge or drainage?

- Do you have any pain, fullness, or discomfort?

Otoscopy

Questionairres

- Hearing Handicap Inventory

- Self Assessment of Communication

Pure Tone Test

Frequencies (Hz)

- 1000, 2000, & 4000

Level (dB)

- 25

Ear

- R or L

1-2 sec in duration

Increase in 5dB incraments till subject hears tone

After recognition, reduce 10dB and repeat tone once

Changes in aging

Compliance/Adherence

Polypharm

Unclear medication regimine

Inappropriate dx/ignoring ADR

Tx of sxs v Tx of dz

Lack of understanding

Barriers to communication

Complex regimine

Differing doses

inconvienient scheduling

Lack of percieved need

ADRs

Cost

Social isolation

Pharm Compliance/Adherence:

Medical record & actual use

51% are taking meds NOT recorded in chart

29% are NOT taking a recorded med

20% taking a different dose then recorded

Polypharm in Eldery:

Causes

- More chronic conditions, more meds

- Feeling from pts and providers to "do something" about ailment

- Doctor shopping

- Meds for ADRs of other meds

- Save or borrow meds & self-medicate

Absorption

Distribution

Metabolism

Excretion/Elimination

PK Changes in Elderly:

Absorption

- Decreased by less SA and blood flow in GI

- Increased by slowing of GI motility

(effectively no change)

- Increased pH in stomach has most profound effect on drugs that require an acidic environment

PK changes in the Elderly:

Distribution

- Protein Binding

Decreased albumin with age resulting in lower doses of drug (less albumin, less bound drug, more active drug)

Increased alpha1acid glycoprotein & lipoproteins (need higher dose of basic protein bound drugs)

PK changes in Elderly:

Distribution

- Drugs affected by albumin

Digoxin

Theophiline

Phenytoin

Warfarin

Diazepam

(LOWER dose)

PK changes in Elderly:

Distribution

- Volume distribution

Less water content (lower dose of hydrophilic drugs)

Higher fat content (depot effect on lipophilic drugs, lower dose)

Lower lean mm mass

PK changes in Elderly:

Distribution

- Hydrophilic drugs

Lithium

Aminoglycosides

Ethanol

(LOWER dose)

PK changes in Elderly

Distribution

- Lipophilic drugs

Phenothiazines

Phenytoin

Diazepam

Barbituates

Propranolol

(LOWER dose)

PK changes in Elderly:

Metabolism

Reduced hepatic flow (reduced amount of drug is metabolised, increasing bioavailablility)

Reduced hepatic mass & number functioning hepatocytes (decline in phase 1 metab)

PK changes in Elderly:

Metabolism

-Drugs affected by reduced hepatic flow

CCB

BB

Narcotics

Nitrates

Tricyclics

Hydralazine

Labetalol

PK changes in the Elderly:

Metabolism

- Drugs affected by decline in Phase I metab

Diazepam

Alprazolam

Chlordiaepoxide

Amitriptyline

Pharm in Elderly:

BZDP Pearl

Use LOT

Lorazepam, Oxazepam & Temazepam

PK changes in Elderly:

Elimination

Renal function decline

CrCl decreases ~10% per decade after 40yoa in 2/3 persons

PK changes in Elderly:

Elimination

-Drugs affected by decline in renal function

Allopurinol

Ranitidine

Famotadine

Nizatidine

Ciprofloxacin

Meperidine

Mg

Metformin

Aminoglycosides

ACE-I

Digoxin

Lithium

Diuretics

Pharm in Elderly:

Renal function Pearl

SCr is NOT a good indicator of renal function in the elderly! SCr is the product of mm breakdown.

CrCl is the better indicator of renal function

Pharm in Elderly:

Renal function

-Calc CrCl

(140-age) x Wt(kg)

_________________

72 x SCr

x0.85 for females

Pharm in Elderely:

Beers List of Potentially inappropriate medications

Propoxyphene     Indomethacin

M Relaxants     Amitryptiline

Meperidine     Flurazepam

Anticholinergics     Antihistamines

Chlordiazepoxide     L.A. BZDP

GI Antispasmodics   Diphenhydramine

Ticlopidine     Barbituates (exp for seizure)

Pharm in Elderly:

Zhan Criteria for Potentially Inappropiate Medications

Always avoid: 11

Rarely appropriate: 8

Some indication: 14

Pharm in elderly:

ADR Risk Factors

Advanced age     Dementia

Female    Lower SES

Hepatic/Reanl insufficiency

Live alone     Multiple Rx

Lower body wt   LT use

Polypharmacy   Mult Chronic Dz

Regular EtOH use   Prior ADR

Recent hospitalization

Pharm in eldery:

ADR Pearl

All of these are considered an ADR intil proven otherwise

Fall     GI distress     Incontinence

Constipation     Anxiety     Depression

Confusion     Insomnia

Pharm in Elderly:

Common dz states associated w/ high risk drug interactions

Autoimmune

CVD

GI

Infection

Psyc

Respiratory

Seizure

Pharm in Elderly:

Preventable drug interactions account for ___ of ADRs

Pharm in Elderly:

Pearls of safe medication use

Every drug has clearly defined indication

Pt education

Record complete medication review

Therapeudic endpoint must be monitored

Annual drug regimen review

Pharm in Elderly:

Drug regimen review checklist

Indications ?

Effectiveness ?

Safety ?

Monitored ?

Error ?

Cost ?

Hospice:

Definition and Goals

Care for pts of limited life expectancy at home

Pallative rather than currative care

Team approach

Quality of life not quantity of life

Hospice:

Team

typically includes a physician,

a nurse,

a home health aide,

a social worker,

a chaplain

a volunteer.

A writing signed and dated by the grantor declaring an intent to revoke

The grantor's oral statement of an intent to revoke make in the presence of two witnesses, one of whom is a health care provider

 Destruction of the document by the grantor or another at the grantor's direction.

-Honor decisions of grantor as expressed in advanced directive

-Make healthcare decisions for grantor if the grantor becomes incompetent

-Consider physicians reccomendations

-2+ surrogates each decision much be unanimous

-Right to resign

- Physician or Healthcare facility

- Other healthcare providers