1. Diseases and Disorders of the Special Senses Module 2
Brenda K. Keller, MD
Geriatrics and Gerontology
University of Nebraska Medical Center
Hello. This is Brenda Keller from the Section of Geriatrics and Gerontology at the University of Nebraska Medical Center.
In this module, we will review the Sensory Changes of Aging.

2. PROCESS Series of 3 modules and questions on
1. Sensory Changes of Aging
2. Diseases and Disorders of the special senses
3. Treatments for vision and hearing impairment
Step #1 Power point module with voice overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a break
Our process will be for you to complete a series of 3 modules and questions on Sensory Changes of Aging. If you have not completed the first module, please do so at this time and then return to this module. These modules will utilize power point with voice overlay. Each module will be followed by case-based questions with answers that will explain the right and wrong responses. Then you will have the option to continue with the next module or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed on the main page of the minifellowship to indicate your completion.

3. Objectives for Module 2 Vision Hearing
Recognize the functional impact of disease of the special senses
Vision
Refractive Error
Cataracts
Age related macular degeneration
Diabetic Retinopathy
Glaucoma
Dry Eyes
Lid abnormalities
Herpes Zoster
Hearing
Sensorineural
Conductive
The objectives of module two are to recognize the functional impact of disease of the special senses. For vision, we will review the effects of Refractive Error, Cataracts, Age related macular degeneration, Diabetic Retinopathy, Glaucoma, Dry Eyes, Lid abnormalities, and Herpes Zoster.
In hearing, we will review the impact of Sensorineural hearing loss and conductive hearing loss.

4. Refractive Error Leading cause of visual impairment
Treatment: eyeglasses, contact lenses, laser refractive surgery
92% of people over age 70 wear glasses
Ametropia
Myopia (nearsightedness)
Hyperopia (farsightedness)
Astigmatism (visual distortion)
Presbyopia ( ability to focus at near objects)
Begins after age 40
Caused by gradual hardening of the lens and decreased muscular effectiveness of the ciliary body
We will begin our discussion with the most common cause of visual impairment and that is refractive error.
This is certainly the leading cause of visual impairment and treatment is quite easy. Eyeglasses, contact lenses and laser refractive surgery. Over 92% of people over the age of 70 wear glasses. There are different types of visual impairment that respond to refractive error. Ametropia which involves myopia or nearsightedness – the difficulty of seeing near. Hyperopia or farsightedness is the difficulty to see close. And Astigmatism or a visual distortion of the vision. We also have presbyopia which is the decreased ability to focus on near objects. It begins after the age of forty and is caused by gradual hardening of the lens and decreased muscular effectiveness of the ciliary body.

5. Cataracts Symptoms include  glare
 contrast sensitivity  visual acuity
Risk factors:  vitamin intake, light (ultraviolet B) exposure,
-smoking,
-alcohol use,
-long-term corticosteroid use,
-diabetes mellitus
Cataracts are increasingly prevalent as we age. Over twenty percent of people over the age of 65 years and fifty percent of the people over the age of 75 years have had cataracts. Symptoms include increasing difficulty dealing with glare, poor contrast sensitivity and decrease visual acuity. As we can see from the picture of the family and their dog, there is a haziness to the picture which simulates what a person with cataracts would see. Risk factors for cataracts include decrease in vitamin intake, excess exposure to ultraviolet ‘B’ lighting, smoking, alcohol use, long-term corticosteroid use, and diabetes mellitus.
Percentage of population with cataracts

6. Age-Related Macular Degeneration
Most common cause of blindness among older adults in developed world
Classic symptom is loss of central vision
Risk factors: age, genetics, smoking, hypertension, fair skin
Diagnosis: presence (dry) of drusen and (wet) of choroidal neovascularization
Monitor with dilated eye exams, Amsler grid
Macular Degeneration is the most common cause of blindness among older European Americans. The classic symptom is loss of central vision, but there may also be a description of a waving of lines. Risk factors are similar to those of cataracts including smoking. There are some genetic factors as well such as fair skin and hypertension. Diagnosis is made through the critical symptoms of loss of central vision, presence of dry drusen and the wet choroidal neovascularization.
Macular degeneration should be monitored with dilated eye exams on a regular basis and used with an Amsler grid. In this checkerboard grid, the patient is asked to focus on the central dot of the grid and notice if there is any lapse of vision along the lines of the grid they should seek the care of their ophthalmologist.

7. Glaucoma
Defined as characteristic optic nerve head damage and visual field loss- generally loss of peripheral vision.
Elevated intraocular pressure is a major risk factor
Affects >2.25 million Americans aged >40 years
Second most common cause of blindness worldwide; most common cause among African Americans
$1 billion for glaucoma-related Medicare and Medicaid payments and disability
Glaucoma is defined as optic nerve head damage and visual field loss – generally this is associated with loss of peripheral vision. Increased intraocular pressure as a major risk factor. As you can see from the picture in the top corner, our family is even less easily viewed and only the central field is clear. This is a complete opposition to that that was seen in the macular degeneration where primarily, the central field is lost.
Glaucoma affects over 2.25 million Americans over the age of forty. It is the second most common cause of blindness worldwide and is the most common cause of vision loss among African Americans. One billion dollars is spent for glaucoma-related to Medicare and Medicaid payments and disability payments for those individuals suffering from this disease.

8. Glaucoma Primary open-angle glaucoma is most common
Slow aqueous drainage leads to chronically elevated intraocular pressure
Patients are asymptomatic and may suffer substantial visual field loss before consulting a physician
Causes are multifactorial and polygenic
Requires monitoring of visual fields and intraocular pressure
Although glaucoma may be open or closed angle, primary open-angle glaucoma is the most common. There is slow aqueous drainage which leads to chronically elevated intraocular pressure. Patients are generally asymptomatic and may suffer substantial visual field loss before consulting a physician. The causes are multifactorial and polygenic. This requires monitoring of visual fields and intraocular pressure in order to maintain stability of this disease process.

9. Diabetic Retinopathy
Epidemiology: Among persons who have had type 2 diabetes at least 10 years:
70% show retinopathy
Nearly 10% show proliferative disease.
Most important risk factors: Duration of disease and control of blood sugar
Prevention: Tight glucose control (A1C < 7 %) and BP control (≤140/80)
Visual loss spotty, occurring in areas of edema and hemorrhage
In diabetic retinopathy, a person who has had diabetes at least ten years shows retinopathy in over 70% and nearly 10% will show proliferative disease. The most important risk factor includes duration of the disease and control of blood sugar. Prevention is done with tight control of blood sugars and blood pressure control with desired blood pressure of less than 140/80. In general, the visual loss is spotty, occurring in areas of edema and hemorrhage. As we see the picture in the top, right corner, the black areas represent the spotty loss of visual fields due to hemorrhages.

10. Keratitis Sicca (Dry Eyes)
Tear production decreases with age
Characteristics: redness, foreign body sensation, and reflex tearing
Management: replacement of tears (artificial tears during daytime and ointment at bedtime)
Temporary or permanent punctal plugs may retard tear egress in severe cases
Another common occurrence is Keratitis Sicca or dry eyes. This occurs when tear production decreases with age. Characteristic symptoms include redness, foreign body sensation and reflex tearing. Management is replacement of tears with artificial tears during daytime and ointment at bedtime. Temporary or permanent plugs may retard tear egress in severe cases.

11. Eye Lid Abnormalities Common among older adults
Gradual loss of elasticity and tensile strength that develops with age
Blepharochalasis (drooping of the brow) and blepharoptosis (drooping of the eyelid) may cause cosmetic deformity and, if severe, impair vision
Lid ectropion (eversion) or entropion (inversion) may cause discomfort
Treatment: surgery
Eye Lid Abnormalities are common among older adults and are caused by the gradual loss of elasticity and tensile strength of tissues that develops with age. Blepharochalasis (or the drooping of the brow) and blepharoptosis (or the drooping of the eyelid), may cause cosmetic deformity and if severe, it may impair vision. Lid ectopion (or eversion) and entropion (or inversion) may cause discomfort and chronic irritation, redness and tearing of the effected eye. Treatment for these conditions is surgical in nature and is often an outpatient procedure.

12. Herpes Zoster Ophthalmicus
Painful reactivation of varicella zoster virus
Dermatomal distribution of weeping vesicles affecting the ophthalmic division of the trigeminal nerve
Hutchinson’s sign: lesions on the tip of the nose
Oral acyclovir may shorten the course
Post-herpetic neuralgia may be debilitating; treat with local ointments (capsaicin, lidocaine) or systemic medications (corticosteroids, tricyclic antidepressants)
Herpes Zoster Ophthalmicus is a painful reactivation of the zoster virus. The dermatomal distribution of weeping vesicles affecting the ophthalmic division of the trigeminal nerve. Hutchinson’s sign is marked with legions on the tip of the nose. Oral acyclovir may shorten the course faster. Post-herpetic neuralgia may be debilitating and treatment with ointments or systemic medications may be required for months or years after the initial outbreak. BK DO YOU WANT TO ADVOCATE TCA’S FOR THIS WHEN PERHAPS GABAPENTIN OR LYRICA COULD BE SAFER? DEFINING WHERE STEROIDS ARE USED, ACUTE? RATHER THAN CHRONIC. I DID COVER PHN IN THE “SKIN MODULES” WHICH YOU COULD REFER TO

13. Common Hearing Impairments
Conductive Hearing Loss
Sensory Hearing Loss
In our discussion of common hearing impairments, we will discuss Conductive Hearing Loss and Sensory Hearing Loss.

14. Sensorineural Hearing Loss
Due to cochlear or retrocochlear pathology
Pure tone audiograms show decreased thresholds for both air and bone conduction
Presbycusis the most common type in elders
Other etiologies: ototoxic meds; infection, trauma ,vascular events or tumors of 8th nerve; Meniere’s disease
Sensorinueural Hearing Loss is due to cochlear or retrocochelear pathology. In this condition, the pure tone audiogram shows decreased threshold for both air and bone conduction. Presbycusis is the most common type of sensorineural hearing loss in elders. Other causes include ototoxic medications, infections, trauma, vascular events or tumors of the eighth nerve. Meniere’s Disease can also present a sensorineural hearing loss.

15. Sensorineural Hearing Loss
This Audiogram shows the classic presentation of sensorineural hearing loss. Across the Y access, is the gradually increasing decibels (or intensity) of sound. Along the X access, is the gradually increasing frequency (or pitch) of sound. In general, the low pitch sounds in the 250 Hz range are well-preserved with hearing thresholds around decibels; however, as we progress along the gradually increasing frequencies, especially around 2,000-4,000 HZ, there is a dramatic decline in the ability to hear the high tones. In sensorineural hearing loss, both ear and bone conduction thresholds are the same. ( BK I THINK WE NEED TO TELL THEM WHICH LINE IS AIR AND WHICH IS BONE)

16. Conductive Hearing Loss
2nd most common cause of hearing loss
Sound transmission to inner ear is impaired
On audiogram bone conduction much better than air conduction
Conductive hearing loss is the second most common cause of hearing loss. Sound transmission to the inner ear is impaired. On an audiogram, bone conduction is much better than air conduction. On the next slide, we will examine some of the causes

17. Conductive Hearing Loss Causes:
External ear pathology
Ceruminosis- a factor in 80% of cases
Foreign body
Skin diseases
Middle-ear pathology
Otosclerosis
Paget’s disease
Cholesteatoma
Tympanic membrane perforation
Middle ear effusion
The conductive hearing loss etiologies much more widespread and can be as simple as ceruminosis or blockage of the external auditory canal by wax. This can be a factor in eighty percent of cases. A foreign body or an accumulation of dried skin due to skin diseases such as psoriasis can also block the external auditory canal. Middle ear pathology such as otosclerosis, Paget’s disease, Cholesteatoma,Tympanic Membrane Perforation, as well as Middle ear effusion also impede the sound travel from the external auditory canal to the cochlea.

18. Conductive Loss Audiogram
The Conductive Loss Audiogram shows the difference in air conduction thresholds which are generally greater than bone conduction scores. Some type of middle ear pathology most likely is causing this type of hearing loss.

19. Summary
In summary, we have seen that there are several different types of visual disorders that contribute to loss of eyesight and how they each affect vision in a slightly different way. We’ve also noted that hearing loss is quite common in this population and is due to a variety of factors which can be discriminated by the use of pure tone audiograms. You may now precede to your case questions in regard to hearing and vision evaluation. TO COMPLETE THE QUESTION FOR CREDIT, CLOSE OUT THIS MODULE, CLICK ON QUESTION 2, ANSWER THE QUESTION AND REVIEW THE ANSWER. After you complete the questions, you may begin the next module or take a break. It is recommended that you complete a module before disengaging. When the modules and questions are completed, click on “Mark Reviewed” on the main page of the Minifellowship to indicate your completion.

20. Acknowledgments
Slides adapted with permission from the American Geriatrics Society, Geriatric Review Syllabus teaching slide set.
Permission granted

21. Post-test question 1
A 70-year-old black American man notes gradually decreasing vision in the right eye. He has a 10-year history of non-insulin-dependent diabetes mellitus and a 3-year history of hypertension. Current medications are two oral hypoglycemic agents, a diuretic, and an angiotensin-converting enzyme inhibitor. He checks his blood glucose weekly and does not follow a strict diet. Cardiopulmonary, abdominal, and musculoskeletal findings are normal except for obesity. Neurologic examination shows decreased touch sensation in the fingertips. Urinalysis shows mild proteinuria. Fingerstick blood glucose level is greater than 200 mg/dL. Hgb A1c is 10.2%. Which of the following is the least likely cause of the vision loss?
A.Cataract
B.Vitreous hemorrhage
C.Macular edema
D.Macular ischemia
E.Age-related macular degeneration

22. Correct Answer: E. Age-related macular degeneration
Age-related macular degeneration is the most common cause of vision loss in the elderly white population but is rare in black persons, who may be protected by their pigmentation. The most likely cause is longstanding, poorly controlled diabetes. Cataract is more prevalent among diabetic persons, in whom typical senile lenticular changes may develop earlier than in the nondiabetic persons. Caution must be exercised with cataract extraction in diabetic patients, who are more prone to develop visually debilitating macular edema. Vitreous hemorrhage may cause severe visual loss in diabetic patients with proliferative retinopathy.
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

23. Panretinal photocoagulation or laser destruction of the peripheral retina will inhibit the stimulus for growth of new blood vessels (neovascularization). Vitrectomy may be indicated for a dense, nonclearing hemorrhage that has been present longer than 3 months. Macular edema is a common cause of moderate visual loss in diabetic patients. Argon laser therapy is beneficial in stabilizing or improving visual acuity. Macular ischemia may result from capillary nonperfusion and is not directly amenable to therapeutic intervention. Argon laser therapy also is indicated for ischemia associated with macular edema, although the prognosis for visual improvement is poor.

24. Post-test question 2
69-year-old woman presents for a pre-employment physical examination for work in a child-care center. Her general health is good; an occasional "water pill" for dependent edema is her only medication. She mentions worsening hearing when around her preschool grandchildren, although conversational hearing with her husband at home appears less affected. There is no family history of hearing loss. Physical examination of the external ear canals reveals no wax accumulation. On handheld audiometric screening she misses the 2000 and 4000 Hz frequencies at 40 dB of amplification bilaterally. Subsequent audiology testing shows bilateral upper-frequency hearing loss along with significant speech discrimination difficulties. Which of the following conditions most likely underlies this woman's hearing loss?
A. Meniere's disease
B. Eighth cranial nerve damage
C. Presbycusis
D. Ototoxic medication effect

25. Correct Answer: C. Presbycusis
Bilateral higher-frequency hearing loss with poor speech discrimination is characteristic of presbycusis. The higher pitch of children's voices and the greater degree of background noise often make child-care settings particularly difficult for persons with presbycusis. Meniere's disease is a cause of lower-frequency hearing loss and is often unilateral. It is often accompanied by disabling vertigo and tinnitus. Though the latter symptoms often improve with time and treatment, the hearing losses may not improve and are a major source of chronic disability. Damage to the eighth cranial nerve from either ototoxic medication or from trauma causes a clinical picture of sensory neural hearing loss. This hearing loss is often of abrupt onset and affects a broad range of frequencies. Loop diuretic agents are among the most common offending medications causing sensorineural hearing loss when used routinely. End

26. Vision Acknowledgments
Co-Editors: Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Authors: David Sarraf, MD
Anne L. Coleman, MD, PhD
GRS6 Question Writer: Gwen K. Sterns, MD
Medical Writer: Barbara B. Reitt, PhD, ELS (D)
Managing Editor: Andrea N. Sherman, MS
© American Geriatrics Society

27. Hearing Acknowledgments
Co-Editors: Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Author: Priscilla Faith Bade, MD, MS
GRS6 Question Writer: Barbara E. Weinstein, PhD
Medical Writer: Barbara B. Reitt, PhD, ELS (D)
Managing Editor: Andrea N. Sherman, MS
© American Geriatrics Society