Tuning in to the ‘sound’ environment

It is now 2008. The population is not only getting older, but it is also living longer. With increased longevity comes the risk of our being subject to the ravages of aging, including lifestyle-related diseases and infirmities.

While past models of elder care dealt with a younger population for a shorter amount of time, the challenge now is assisting a population that is, for the most part, collectively dynamic in cognitive and physical capacities. Nonetheless, hearing impairment in this current and coming elder population is proving to be far more acute. A result of technologies such as headphones and higher amplification levels, the boomer generation is now the youngest generation to seek hearing assistance and will have to deal with this for many more years.

Although the symptoms of normal aging are intrinsic to the individual, the pervasive nature of hearing impairment impacts the community at large. Living institutionally, with all the care one might need, does not lessen the frustration of hearing loss, nor is the isolation any easier to bear for the family. Yet, the issue remains devoid of living examples of environments specifically designed to accommodate the needs of a hearing-impaired population.

For this reason, this article on improving the quality of life for hearing-impaired residents is being offered again, updated, and with consideration for the universality of the human aging process.

Natural progression

All of us, as we age, regardless of genes or intent, will experience a diminishing ability to hear. The capacity to easily understand casual conversation and to hear clearly when in large, noisy crowds will decline gradually until we, or others, notice it. If we swallow our pride, we may opt for one of the many hearing aids available. However, regardless of cost or technological features, we will not adapt easily. Once an aid is installed in our ears, we will hear ourselves chewing, sometimes sounding to ourselves as if we were in a cavernous tunnel, and eventually getting used to adjusting our own volume more than the one on the TV.

We will seek out telephones that have adjustable volume controls and find that watching television will be only as enjoyable as the sensitivity of its remote control. We will begin to accuse those around us of “mumbling” and get tired of asking them to improve their diction. Our greatest frustration, however, will be that some people we love dearly will speak to us as if we are 5-years-old or illiterate speaking to us loudly or s-l-o-w-l-y, as if we don’t understand English.

The implication of these all too verifiable facts for the design and operation of long-term care facilities is far more significant than the industry has acknowledged. Distinguishing and respecting incremental levels of dependence in order to support relative independence, long-term care necessarily addresses more than medical factors. It involves years of attending to, caring for, and assisting, as well as developing, the kind of personal relationships that are foreign to the 2.5 interventions per day common to the acute care setting. However, even in those settings, patients or their elderly spouses are at risk for not clearly understanding the nurse or physician.

Adapting to changing needs

In the field of long-term care design, architects and designers have availed themselves of the opportunity to develop new and innovative living and caregiving spaces that respond to the diverse and changing needs of residents and staff. However, the responsibility is not only to provide physical space and service, but also to deal with the issues that confront long-term personal involvement and the profound process of facilitating graceful and dignified aging up to and through various stages of frailty.

Hidden within and among these many challenges of long-term care is the insidious factor of hearing acuity, still a stigma for the elderly, a frustration for families and spouses, an ignored risk for providers, and an equal-opportunity challenge on every level of long-term care. The long and subtle decline of a person’s hearing capacity causes an equally long withdrawal from family, friends, from social gatherings, and conversation. Because hearing loss progresses in tandem with aging and other symptoms of decline, compensatory strategies tend to be developed by the elder.

Whether in a social situation where the conversation moves too fast and is too complex to comprehend or in a restaurant with blaring overhead music, the aging man or woman handles it with the same blank smile to cover up the internal isolation of impaired hearing. The resulting lack of participation, inappropriate response, or agitation brings up issues of cognition, memory, coordination, social skills and, ultimately, independence.

In long-term care facilities, because residents are living longer and quality of life is a major concern for their families, communication, conversation, activities, and social support is an ongoing need almost equal to all other levels of care. Therefore, the challenge is how to address the hearing impairment issue in the context of long-term care facility design and caregiving practice. Some points to consider:

1. Hardwood floors and high ceilings: While each is stylish and attractive, together they create a gymnasium experience. Without enough acoustical treatment, a cavernous room can be loud, hollow, and chaotic. Sounds reverberate and interfere, and language can be unintelligible.

   In a site visit to a long-term care facility in the south, we found a delightful and bright dining room with a high open ceiling to a balcony. There was lots of light and lots of space—and lots of noise.

   When the residents were dining, the high ceilings were not a factor and adjacent sounds were not intrusive because of the carpeted floor that tempered the way conversations traveled from one table to the next. After dinner, though, when the staff began cleaning, vacuuming, and listening to the radio to keep them company, the sounds resonated at disturbing levels heard louder in the balcony than in the dining room itself. Neither staff nor administration paid attention; the residents, though, could not figure out why the television, which was in a room open to the balcony, always had to be tuned so loudly. For those who could not hear, it may not have been as great a disturbance. However, not all residents have the same impairment. Therefore, unnaturally loud noises can be agitating and the agitated resident disturbs others…and the cycle continues.

2. Overhead paging: Playing local radio or television stations through the overhead speakers is not always a good idea. Many residents could have impaired hearing that has long since failed to help them identify who or what they are listening to. Furthermore, they might not hear the difference between a voice in the overhead speaker and one speaking from behind them. In her Notes on Nursing, published in 1859, Florence Nightingale cautioned that if patients are spoken to from behind, there is a high risk of them falling. In fact, she advised never to speak to patients from behind, but always from a line of sight.

   Overhead paging systems are indifferent to the position or capacity of the listener, and often confuse the older person who cannot discern live from radio voices. That’s why it is best to limit overhead broadcasting to instrumental music and emergency overhead paging in order to prevent residents from falling as they turn around to see who, as it turns out, isn’t there.

   While it is common to use intercom systems to announce the dinner hour or other events, the system should be tested for intelligibility and effectiveness. In one new facility we visited recently, the in-room intercom was difficult to understand; it was not loud or clear enough to be understood from every point in the one-bedroom apartment, but it was perceptible enough to be a distraction. A direct phone call to make such announcements might be safer and more reliable, the telephone ring being a more familiar sound to residents.

3. Machinery: The use of vacuum cleaners, floor waxing equipment, dishwashers, and fans—each of which generates a wash of sound—should not be allowed to occur during social functions, dinner, breakfast, or any time that residents have the opportunity to converse with each other or the staff. There is almost a guarantee that the masking effect of the not-so-white noise of the machinery will further disable the hearing-impaired residents of what little ability they have to retain and understand language. Furthermore, their subsequent frustration will result in hearing aids being blamed for their “ineffectiveness,” as residents turn them up and down, trying to free themselves of the obnoxious sounds.

4. Indirect communication: Address residents and family members directly. Do not speak around or over the person who most needs to hear what you have to say. As stated before, dialogue with the elderly requires line-of-sight communication. The embarrassment from having to repeatedly ask others to speak again or explain what they meant is so uncomfortable for many elderly people that you cannot count on being given notice of this need. In fact, count on not being told the truth: “Yes, I understand” often means “I think I understand the little that I heard” or, worse yet, “I didn’t understand, but don’t let me hold you up.”

5. Music: If you want social activities to be attended, pay attention to the need to communicate. If it is a social hour intended to support conversations and interchange, music can be a great asset, but make sure that it doesn’t undo what you are trying to do. Soft instrumental music for background or a live big band for entertainment are both enjoyable and beneficial. However, the middle ground, where the would-be background music is louder than the foreground dialogue, is more a liability than a benefit. The music will compete with the conversation, but the struggle itself will dominate the experience for residents.

   Unlike conversational dialogue, sung lyrics are heard using both ears and memory. Most seniors love the songs they know; they sing the words along with (or ahead of) the singer. However, spoken language is understood using a different part of the brain and comprehension relies on hearing, seeing, and context.

   It is not uncommon for a resident to have owned a piano that would be welcomed into the fold of a facility’s daily living. In one facility, after local musicians had performed and inspired her, one of the residents had her piano moved into the facility in order to play it herself, invite others to perform, and to have it for Sunday services. Live music is about the quality of life, about spontaneity and savoring personal experiences, as well as about music.

   In preparing a space for any social function, pay attention to resident accommodations. Theater seating, for example, can put the elderly at a greater disadvantage than one might think. The back row (and there is always a back row) is confronted with barriers of sight, sound, and relationship.

6. Hearing aids–check use and batteries: While the use of hearing aids is common among residents in long-term care facilities, the fact that they run on batteries that last much too short a time is often overlooked by users and staff. If the hearing aid is not worn, the resident could appear to have increasing dementia, agitation, decreasing ability to socialize, limited cognitive capacity, and be unable to respond to simple directions. If the hearing aid is worn but not working, it could even be worse as the limited capacity is ever more limited by the presence of what has now become an obstruction in the ear. Symptoms related to failed or unused hearing aids mimics cognitive decline and all of its related responses.

   In reality, it will be the exceptional resident who will not have need for a hearing aid, and the most exceptional resident who will skillfully service and use it. Therefore, the staff needs to know who wears a hearing aid, behavioral symptoms if it is not working, and have an inventory of batteries with perhaps a calendar schedule for changing them. Families willingly assist in providing the batteries or the funds needed to provide them since they know all too well the frustration that results. The issue of hearing aids is not different than eyeglasses: staff would no more allow a resident who is unable to see to walk than they should allow a person who is unable to hear.

7. Light sensitivity: It has already been stated that to the hearing impaired, seeing is hearing. Therefore, whether the resident is sitting in the glare of the afternoon sun or the darkness of dusk, not only are they unable to see, they have lost their greatest assistance in hearing what is going on around them. Furthermore, while the picture of an elderly person sitting alone in a room with blinds drawn and shades down is not uncommon, the reasons behind it can be ambiguous. It might not be about intentional isolation, but that might be the outcome. Inadequate lighting can exacerbate an already difficult struggle for the hearing-impaired.

   As another indirect result of coping with light sensitivity, depression related to too much darkness and not enough daylight has been long documented. “Seasonal affective disorder,” which affects persons of all ages, is treated in part by the use of full-spectrum lighting. In the case of the elderly, whose visual sensitivity may be acute, the importance of paying attention to providing ample light in ways appropriate to the individual is critical.

   To minimize glare, use polarized windows and flexible shading that can accommodate the changing position of the sun over days, nights, and seasons. Also, paying attention to the light sensitivity of the elderly is mandatory to ensure maximum mobility and participation. And seating positions and location of windows, televisions, and other points of viewing are critical to maintain residents’ accessibility to intelligible discourse.

8. Headphones: This is the first of generationally specific technologies. The baby boomers will know headphones, but were not brought up with them. The X-generation will not know life without them. However, headphones for the elderly whose lives were not defined by computers, CDs, and MP3 players should not be offered or used without considering the totality of their impact. By design, headphones separate the listener from their surroundings. They prevent any kind of meaningful communication and can cause more isolation on top of the isolation intrinsic to the situation.

   This will change. As the generations trade places, headphones will be far more prevalent and will, undoubtedly, become part of the long-term care environment. Other auditory assistance technologies currently used by churches to help their parishioners hear the sermons, could be of use for those who want to listen to television in a group with diverse hearing needs.

9. The Pill-Crusher Syndrome: My father was in a nursing home for four months prior to dying two years ago. I spent many days with him. At two different times during the day, when medications were to be dispensed, the nurse would roll the medication cart down the hall. I could always hear it coming. But, the sounds that then came sounded like construction battalions hammering in the next room. The nurse had a manual pill crusher, a metal device that she had to pound a few times in order to break up the pills. The metal device was placed on the metal pill cabinet. Alas, we had a drum! I diplomatically showed the nurse how to muffle this noise, which only required that she put the pill crusher on a pad of paper and put a small piece of tissue beneath the crushing hammer. It worked perfectly. However, so used to how she had always done it, this solution was not implemented and the halls resonated with this hammering sound four times a day.

   The “Pill-Crusher Syndrome” is an example of avoidable noises caused or tolerated by the staff of the facility. While I point to the unconscious use of the pill crusher as a prime example, we can also include the continuous and seemingly unending alarms. The staff hears noises, uses equipment, observes activities, and basically spends day after day in the same facility that takes on the same auditory ambience. The sameness causes the staff to become habituated to these sounds that they neither hear them nor respond to them.

Cultural considerations

Each of these strategies addresses only one circumstantial solution to the complexities of serving a hearing-impaired community. Implementation is not successful if perceived as a one-time-fix-it solution. Rather, the culture of the organization and the service ethic must include addressing the subtle, yet controlling conditions of aging. Safety is requisite but not sufficient to optimize the capacities and abilities of the elderly. Small, focused, and intentional environmental adjustments can make substantial improvements in the same way that neglect and insensitivities can result in isolation and higher risks.

The details of the sound environment—sound, noise, communication, visual hearing support—are the indicative points used by the family to evaluate whether or not they, as represented by the staff and facility, are truly taking care of their own. The image of an older person isolated by physical impairment is painful to more than the person directly involved. Therefore, strategizing and practicing environmental accommodation for the hearing impaired elder is critical to a resident’s quality of care and life.

Susan E. Mazer, MA, is the President and CEO of Healing HealthCare Systems (

https://www.healinghealth.com) which produces the CARE Channel®, the only 24-hour environmental relaxation programming for patient television.

For more information, she can be reached at smazer@healinghealth.com or phone (775) 827-0300. To contact the author or editors, please e-mail mazer0608@iadvanceseniorcare.com.

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Editor’s note:

This article originally appeared in DESIGN, published in March 2002 by Nursing Homes/Long Term Care Management. It has been updated and revised, with the consideration that the issues concerning hearing-impaired long-term care residents remain current and solutions are badly needed.