- Email: [email protected]
Cerumen, Hearing, and Cognition in the Elderly
Cerumen, Hearing, and Cognition in the Elderly Ann M. Moore, DO, John Voytas, MD, FACP, CMD, Debra Kowalski, RN, BSN, MSNc, and Michael Maddens, MD, CMD Objective: This investigation was performed to study the prevalence of cerumen impaction and evaluate its impact on hearing and cognition in elderly patients admitted to a skilled nursing facility (SNF). Design: Prospective clinical trial using a pretest-posttest design. Setting: A 160-bed skilled nursing facility. Subjects: Twenty-nine English-speaking residents over the age of 65 who were new admissions to a SNF. Intervention: Participants with cerumen that occluded 50% or more of the external auditory canal had cerumen removed with a cerumenolytic agent and tepid water irrigation. Measurements: A standardized Folstein Mini-Mental Status Exam (MMSE)1 and audiometric evaluation were administered to all participants before and after cerumen removal. Participants who did not have cerumen impaction served as controls. Hearing changes were scored as “⫹1” for an improvement, “0” for no change and “⫺1” for a loss at each frequency tested.
Hearing impairment is one of the most common disabilities affecting people aged 65 and older with an incidence of 31 to 100%.2–10 In studies of healthy, community-dwelling individuals, the prevalence ranges from 31 to 87%,2,7,10 whereas approximately 55%5,6 of individuals with dementia have hearing impairment. Residents of long-term care facilities have a reported incidence of 67 to 100%.4,7,9 Several studies indicate that the rate of hearing impairment increases with age.2,5,6,8,10 For example, a study conducted by Thomas and colleagues (1983) shows the rate of hearing impairment to increase six-fold from 25 to 44 years old to 65 to 74 years old and then almost double again for those 75 years or older. Many investigators report an association between hearing and cognitive impairment.2,5,6,9,11–15 Peters et al. (1988)
William Beaumont Hospital, Royal Oak, Michigan. Address correspondence to: Ann M. Moore, DO, Peabody Retirement Community, 400 West Seventh Street, North Manchester, IN 46962. E-mail: [email protected].
Copyright ©2002 American Medical Directors Association 136 Moore et al.
Results were compared using 2-tailed paired t tests. Results: Nineteen participants (65.5%) had cerumen in at least one ear. Following cerumen removal, hearing improved in 80% of impacted ears compared with 3% of nonimpacted ears (P ⬍ 0.001). The average change in hearing score following cerumen removal was 0.26 ⫾ 0.50 compared with an average change of 0 ⫾ 0.16 in the controls (P ⬍ 0.001). The average change in MMSE score was 1.05 ⫾ 1.6 for participants who had cerumen removed compared with ⫺0.30 ⫾ 0.95 for the controls (P ⬍ 0.01). Conclusions: This study found a majority of residents admitted to the SNF had cerumen impaction. Evaluation of hearing and mental status following removal of cerumen resulted in a statistically significant improvement in hearing and cognition when compared with controls. Removal of cerumen is a relatively safe and easy procedure that can be done at minimal cost and provide a significant benefit to residents of a SNF. (J Am Med Dir Assoc 2002; 3: 136–139) Keywords: Hearing impairment; cerumen impaction; long-term care; dementia
found individuals with hearing impairment had a greater decrease in mental status scores over time when compared with those without hearing impairment. In a study comparing the results of written and verbal mental status tests administered to hearing impaired participants, there was no difference in the scores.6 Other investigators have found no association between hearing loss and cognitive impairment.3,16 Hearing impairment has been found to adversely affect an individual’s emotional, psychosocial, and social functions as well as have a relationship to physical dysfunction. In a study evaluating quality of life and hearing impairment, 63% of the participants reported severe social and emotional handicap secondary to their hearing impairment.15 Studies evaluating the effect of hearing loss on psychosocial function report that people with hearing impairment are more depressed3,15 (as measured by the Yesavage Geriatric Depression Scale (GDS),17 and are more likely to score “borderline” or “neurotic” on an anxiety questionnaire.3 Progressive hearing loss in the elderly has also been related to physical disability.3,18 Hearing impairment may cause difficulties in social situations by making it difficult for individuals to understand verbal JAMDA – May/June 2002
communications and participate in conversations.15,18 In a study by Mulrow et.al. (1990), individuals who obtained and used hearing aids for 4 months had improved social function, emotional function, communication, Folstein Mini-Mental Status Exam (MMSE) and GDS scores. Cerumen impaction is a common reversible cause of conductive hearing loss in the elderly and has been reported in 9 to 58% of the population 65 and older.4,8,19 –21 Cerumen is produced by sebaceous and apocrine glands and functions to lubricate and protect the external auditory canal. It is propelled out of the canal by cilia and movements of chewing and talking.20,22 Some of the normal changes that occur within the external auditory canal with aging predispose the elderly to developing cerumen impaction. The hairs in the external auditory canal become longer and coarser, especially in men, and entrap cerumen.23 Cerumen also becomes drier in the elderly secondary to a decrease in the activity of the glands and thus becomes less easily propelled out of the ear canal.22,23 Cerumen can decrease hearing acuity by 40 – 45 dB by physically obstructing sound transmission.24 In an evaluation of cerumen impaction in individuals with hearing impairment, Flugrath et.al. (1993) reported cerumen impaction in 9% of 65- to 74-year-olds, 13% of 75- to 84-year-olds and 27% in those 85 and older. Cerumen impaction has been reported as occurring in 34% of the community-dwelling geriatric population21 and 23 to 58% of elder residents in long-term care institutions.4,21 A study of hospitalized older patients found that 35% of the ears examined had a cerumen impaction and, after removal of the impaction, hearing improved in 75% of the ears evaluated.19 Based on reports that hearing impairment is associated with cognitive impairment in the elderly and that cerumen impaction is a common cause of conductive hearing loss, we hypothesized that following removal of a cerumen impaction, an elderly individual would demonstrate an improvement in hearing and, thus, improve their performance on the MMSE. METHODS All residents over the age of 65 (or representatives holding durable powers of attorney for incompetent subjects) admitted to the skilled nursing facility (SNF) between December 1998 and March 1999 were informed about this study by the admissions department and asked to enroll in the study. Informed consent was obtained from all participants. Reasons for refusal to participate in the study were not recorded by the admissions staff. An interview with the staff revealed that the most common reason given for refusal to participate was the perception by the resident or their family member that the resident was too ill. Exclusion criteria were non-English speaking or aphasic, scoring less than 14 on the MMSE, use of hearing aids, residents who were acutely ill or who had lesions of the tympanic membrane or external auditory canal by history or on clinical exam. Twenty-nine newly admitted residents did qualify for and enroll in the study. The study subjects ranged in age from 68 to 92 (mean 82 ⫾ 6 years). Participants included 21 women and 8 men. Within 7 days of admission to the SNF, all participants were administered the standardized Folstein MMSE, underORIGINAL STUDIES
went hearing test by audioscope, and then received an otoscopic examination. Two examiners (a doctor of osteopathic medicine (DO) and a geriatric nurse practitioner) performed all testing, but each subject had all three measures administered by the same examiner. Hearing testing was performed using an audioscope to present pure tones at 20, 25, and 40 dB at 500, 1000, 2000, and 4000Hz, thus exposing the patient to 12 tones. Residents were instructed to raise their hand every time they heard a tone presented by the audioscope. The tones were presented to each ear three times and recorded as detected if the resident raised their hand at least two of the three times. Lichtenstein et al. report that the audioscope does yield reproducible results when compared with pure tone audiometry when used either in a primary care office or hearing center.25 The resident then had an otoscopic examination and if cerumen was occluding at least 50% of the external auditory canal, the resident was considered to have a cerumen impaction and the cerumen was removed. Cerumen was removed using a cerumenolytic agent followed by tepid water irrigation. If less than 50% of the external auditory canal was occluded by cerumen, no intervention was performed, and the participant was classified as a control. All data were found to have a normal distribution. Analyses of age, MMSE scores, MMSE score change, and change in hearing were performed using 2-tailed paired-samples t tests with unequal variance. The data were analyzed, using a Wilcoxson rank sum test, to compare the MMSE score of those individuals who had a unilateral impaction with those with a bilateral impaction to ensure that the observed improvement occurred equally among all intervention subjects. Comparison of baseline scores between the intervention and control groups was performed using independent-samples t tests. Since tones heard at different frequencies in a given ear may not be independent (and therefore may not meet the strict criteria for performing a t test), a log likelihood ratio was performed to evaluate the categorical (improved, worse, no change) change in performance in each ear. We were unable to perform a chi-square test due to the low frequency of cases in some cells (ie, ⬍5). RESULTS Of the new admissions to the SNF, 29 consented to participate in the study, and none of them met the exclusion criteria. After enrollment into the study and evaluation for cerumen impaction, participants were categorized as “occluded” or “control” based on the findings at the time of otoscopic exam. Nineteen participants (65.5%) had cerumen that occluded ⱖ 50% of the external auditory canal in at least one ear and were, thus, placed into the intervention group. Eight of the nineteen participants had bilateral cerumen impaction for a total of 27 ears with an impaction. All of the men who participated in the study had a cerumen impaction, thus there were no male controls. All of the impacted ears had cerumen removed. All of the controls were female, and 8 of the 19 (42.1%) participants with cerumen were male. The average age of all participants was 81 ⫾ 7 with no significant difference (P ⫽ 0.18) between the study participants (82 ⫾ 6) and the controls (79 ⫾ 7). Moore et al. 137
Fig. 2. Distribution of hearing changes in control (unimpacted) and study (impacted) ears after cerumen removal.
Fig. 1. Comparison of the average Mini-Mental Status Exam (MMSE) scores in the control (unimpacted) and study (impacted) groups before and after cerumen removal.
The pretest MMSE scores for controls was 25.6 ⫾ 5.2 and for those with cerumen was 25.8 ⫾ 4.6 (t ⫽ 1.09, P ⫽ 0.29). The average change in MMSE score was 1.05 ⫾ 1.6 for participants who had cerumen removed compared with ⫺0.30 ⫾ 0.95 for the controls (t ⫽ 2.5, P ⬍ 0.01) (Figure 1). Among residents who did not have cerumen removed, one participant heard two tones less and one heard one more tone when hearing was retested 24 hours later. Among residents who had cerumen removed, there was not a significantly different change in MMSE scores based on whether the impaction was unilateral or bilateral (Z ⫽ 1.09, P ⫽ 0.28). For those who had cerumen removed, there were 44 new tones heard. The average change in number of tones heard for all 27 ears following cerumen removal was 0.26 ⫾ 0.50 compared with an average change of 0 ⫾ 0.16 in the controls (t ⫽ 6.3, P ⬍ 0.001) by t test. In the impacted ears, 80% improved, 20% remained unchanged and 0% worsened, compared to the control ears in which 3% improved, 90% were unchanged and 7% worsened (G2⫽36.7, P ⬍ 0.001) (Figure 2). DISCUSSION We evaluated cerumen impaction among a small sample of newly admitted nursing home residents to one SNF. This study showed that following removal of a cerumen impaction, whether in one or both ears, participants had a statistically significant improvement in their MMSE scores as well as their ability to hear the audioscopic tones. In comparison, the MMSE total scores and the number of tones heard remained unchanged in the control group. 138 Moore et al.
It is unclear whether hearing loss is directly or indirectly associated with cognitive impairment. There may be a direct association through pathologic degenerative changes within the brain that results in impairment in hearing and cognition. There may also be an indirect relationship if hearing loss adversely affects an individual’s ability to hear and participate effectively in their environment. Our study was designed as a preliminary trial and as a result has some limitations. We included only a small number of participants because many of the new admissions refused to participate despite the minimally invasive nature of the study. Because of this, the significance of our findings may be limited. Our high rate of cerumen impaction may reflect that people who consented to participate may have done so because they felt they had a cerumen impaction. We did not control for other variables, including socioeconomic background, education level, medical history, medication use, or psychosocial issues that may have an impact on cognition as measured by the MMSE and hearing impairment level. The MMSE also has limitations in evaluating cognition because it was designed as a screening evaluation. We also did not blind the data collectors to whether or not the patient had cerumen because all of the data for an individual participant was collected by a single investigator. Although we were also unable to provide a space that did not have ambient noise, the pretest and posttest data were collected in the same place for all participants. The strengths of our study include the fact that this was a prospectively designed study. All the data for an individual were collected by only one investigator, thus any changes that were observed were more likely to be true rather than due to differences in technique. Our participants also served as their own controls in evaluation of hearing and MMSE score change. A significant number of the participants had an impaction in at least one ear indicating that cerumen impaction is relatively common in a hospitalized population transferred to a SNF. Our findings suggest that removal of cerumen impaction, which is a safe and easy procedure, would have a positive impact on the hearing ability and cognitive performance of elderly residents admitted to a SNF. Not only would this affect the residents, but it may also benefit the facility indirectly by making it easier for new residents to adjust to their JAMDA – May/June 2002
new environment and enable optimal communication between newly admitted residents and the nursing home staff. REFERENCES 1. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189 –198. 2. Thomas PD, Hunt WC, Garry PJ, et el. Hearing acuity in a healthy elderly population: Effects on emotional, cognitive, and social status. J Gerontol 1983;38:321–325. 3. Jones DA, Victor CR, Vetter J. Hearing difficulty and its psychological implications for the elderly. J Epidemiol Commun Health 1984;38:75– 78. 4. Hedner K, Broms P, Harris S, Steen B. Hearing in geriatric long-stay patients. Compr Gerontol 1987;1:69 –71. 5. Peters CA, Potter JF, Scholer SG. Hearing impairment as a predictor of cognitive decline in dementia. J Am Geriatr Soc 1988;36:981–986. 6. Uhlmann RF, Rees T, Mozlowski KJ, et al. Impact of mild to moderate hearing loss on mental status testing. J Am Geriatr Soc 1989;37:223–228. 7. Voeks SK, Gallagher CM, Langer EH, et al. Hearing loss in the nursing home: An institutional issue. J Am Geriatr Soc 1990;38:141–145. 8. Flugrath J, Lutz D, Hamdy RC. Hearing impairment and cerumen impaction in older patients. J Tenn Med Assoc 1993;7:301–302. 9. Flatau E, Syndulko K, Flatau Y, et al. Hearing impairment in residents of a long-term care facility: Prevalence and relationship to cognitive dysfunction. Ann Long-Term Care 1998;6:410 – 413. 10. Reuben DB, Walsh K, Moore AA, et al. Hearing loss in communitydwelling older persons: National prevalence data and identification using simple questions. J Am Geriatr Soc 1998;46:1008 –1011. 11. Granick S, Kleban MH, Weiss AD. Relationships between hearing loss and cognition in normal hearing aged persons. J Gerontol 1976;4:434–440. 12. Ohta RJ, Carlin MF, Harmon BM. Auditory acuity and performance on the Mental Status Questionnaire in the elderly. J Am Geriatr Soc 1981;32:476 – 478.
ORIGINAL STUDIES
13. Uhlmann RF, Larson E, Koepsell TD. Hearing impairment and cognitive decline in senile dementia of the Alzheimer’s type. J Am Geriatr Soc 1986;34:207–210. 14. Uhlmann RF, Larson E, Rees T, et al. Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA 1989;261:1916 –1919. 15. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment: a randomized trial. Ann Intern Med 1990;113:188 – 194. 16. Gennis V, Garry PJ, Haaland KY, et al. Hearing and cognition in the elderly: New findings and a review of the literature. Arch Intern Med 1991;151:2259 –2264. 17. Yesavage SA, Brink JL, Rose TL, et al. Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiatr Res 1983;17:37– 49. 18. Bess FH, Lichtenstein MJ, Logan SA, et al. Hearing impairment as a determinant of function in the elderly. J Am Geriatr Soc 1989;37:123– 128. 19. Lewis-Cullinan C, Janken J. Effect of cerumen removal on the hearing ability of geriatric patients. J Adv Nurs 1990;15:594 – 600. 20. Ney DF. Cerumen impaction, ear hygiene practices, and hearing acuity. Geri Nurs 1993;14:70 –73. 21. Mahoney DF. Cerumen impaction: Prevalence and detection in nursing homes. J Gerontol Nurs 1990;4:23–30. 22. Ruby RRF. Conductive hearing loss in the elderly. J Otolaryn 1986;15: 2445–2447. 23. Hanger HC, Mulley GP. Cerumen: Its fascination and clinical importance: A review. J Roy Soc Med 1992;85:346 –349. 24. Meador JA. Cerumen impaction in the elderly. J Geront Nurs 1995;21: 43– 45. 25. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA 1988;259: 2875–2878.
Moore et al. 139
Hearing impairment is one of the most common disabilities affecting people aged 65 and older with an incidence of 31 to 100%.2–10 In studies of healthy, community-dwelling individuals, the prevalence ranges from 31 to 87%,2,7,10 whereas approximately 55%5,6 of individuals with dementia have hearing impairment. Residents of long-term care facilities have a reported incidence of 67 to 100%.4,7,9 Several studies indicate that the rate of hearing impairment increases with age.2,5,6,8,10 For example, a study conducted by Thomas and colleagues (1983) shows the rate of hearing impairment to increase six-fold from 25 to 44 years old to 65 to 74 years old and then almost double again for those 75 years or older. Many investigators report an association between hearing and cognitive impairment.2,5,6,9,11–15 Peters et al. (1988)
William Beaumont Hospital, Royal Oak, Michigan. Address correspondence to: Ann M. Moore, DO, Peabody Retirement Community, 400 West Seventh Street, North Manchester, IN 46962. E-mail: [email protected].
Copyright ©2002 American Medical Directors Association 136 Moore et al.
Results were compared using 2-tailed paired t tests. Results: Nineteen participants (65.5%) had cerumen in at least one ear. Following cerumen removal, hearing improved in 80% of impacted ears compared with 3% of nonimpacted ears (P ⬍ 0.001). The average change in hearing score following cerumen removal was 0.26 ⫾ 0.50 compared with an average change of 0 ⫾ 0.16 in the controls (P ⬍ 0.001). The average change in MMSE score was 1.05 ⫾ 1.6 for participants who had cerumen removed compared with ⫺0.30 ⫾ 0.95 for the controls (P ⬍ 0.01). Conclusions: This study found a majority of residents admitted to the SNF had cerumen impaction. Evaluation of hearing and mental status following removal of cerumen resulted in a statistically significant improvement in hearing and cognition when compared with controls. Removal of cerumen is a relatively safe and easy procedure that can be done at minimal cost and provide a significant benefit to residents of a SNF. (J Am Med Dir Assoc 2002; 3: 136–139) Keywords: Hearing impairment; cerumen impaction; long-term care; dementia
found individuals with hearing impairment had a greater decrease in mental status scores over time when compared with those without hearing impairment. In a study comparing the results of written and verbal mental status tests administered to hearing impaired participants, there was no difference in the scores.6 Other investigators have found no association between hearing loss and cognitive impairment.3,16 Hearing impairment has been found to adversely affect an individual’s emotional, psychosocial, and social functions as well as have a relationship to physical dysfunction. In a study evaluating quality of life and hearing impairment, 63% of the participants reported severe social and emotional handicap secondary to their hearing impairment.15 Studies evaluating the effect of hearing loss on psychosocial function report that people with hearing impairment are more depressed3,15 (as measured by the Yesavage Geriatric Depression Scale (GDS),17 and are more likely to score “borderline” or “neurotic” on an anxiety questionnaire.3 Progressive hearing loss in the elderly has also been related to physical disability.3,18 Hearing impairment may cause difficulties in social situations by making it difficult for individuals to understand verbal JAMDA – May/June 2002
communications and participate in conversations.15,18 In a study by Mulrow et.al. (1990), individuals who obtained and used hearing aids for 4 months had improved social function, emotional function, communication, Folstein Mini-Mental Status Exam (MMSE) and GDS scores. Cerumen impaction is a common reversible cause of conductive hearing loss in the elderly and has been reported in 9 to 58% of the population 65 and older.4,8,19 –21 Cerumen is produced by sebaceous and apocrine glands and functions to lubricate and protect the external auditory canal. It is propelled out of the canal by cilia and movements of chewing and talking.20,22 Some of the normal changes that occur within the external auditory canal with aging predispose the elderly to developing cerumen impaction. The hairs in the external auditory canal become longer and coarser, especially in men, and entrap cerumen.23 Cerumen also becomes drier in the elderly secondary to a decrease in the activity of the glands and thus becomes less easily propelled out of the ear canal.22,23 Cerumen can decrease hearing acuity by 40 – 45 dB by physically obstructing sound transmission.24 In an evaluation of cerumen impaction in individuals with hearing impairment, Flugrath et.al. (1993) reported cerumen impaction in 9% of 65- to 74-year-olds, 13% of 75- to 84-year-olds and 27% in those 85 and older. Cerumen impaction has been reported as occurring in 34% of the community-dwelling geriatric population21 and 23 to 58% of elder residents in long-term care institutions.4,21 A study of hospitalized older patients found that 35% of the ears examined had a cerumen impaction and, after removal of the impaction, hearing improved in 75% of the ears evaluated.19 Based on reports that hearing impairment is associated with cognitive impairment in the elderly and that cerumen impaction is a common cause of conductive hearing loss, we hypothesized that following removal of a cerumen impaction, an elderly individual would demonstrate an improvement in hearing and, thus, improve their performance on the MMSE. METHODS All residents over the age of 65 (or representatives holding durable powers of attorney for incompetent subjects) admitted to the skilled nursing facility (SNF) between December 1998 and March 1999 were informed about this study by the admissions department and asked to enroll in the study. Informed consent was obtained from all participants. Reasons for refusal to participate in the study were not recorded by the admissions staff. An interview with the staff revealed that the most common reason given for refusal to participate was the perception by the resident or their family member that the resident was too ill. Exclusion criteria were non-English speaking or aphasic, scoring less than 14 on the MMSE, use of hearing aids, residents who were acutely ill or who had lesions of the tympanic membrane or external auditory canal by history or on clinical exam. Twenty-nine newly admitted residents did qualify for and enroll in the study. The study subjects ranged in age from 68 to 92 (mean 82 ⫾ 6 years). Participants included 21 women and 8 men. Within 7 days of admission to the SNF, all participants were administered the standardized Folstein MMSE, underORIGINAL STUDIES
went hearing test by audioscope, and then received an otoscopic examination. Two examiners (a doctor of osteopathic medicine (DO) and a geriatric nurse practitioner) performed all testing, but each subject had all three measures administered by the same examiner. Hearing testing was performed using an audioscope to present pure tones at 20, 25, and 40 dB at 500, 1000, 2000, and 4000Hz, thus exposing the patient to 12 tones. Residents were instructed to raise their hand every time they heard a tone presented by the audioscope. The tones were presented to each ear three times and recorded as detected if the resident raised their hand at least two of the three times. Lichtenstein et al. report that the audioscope does yield reproducible results when compared with pure tone audiometry when used either in a primary care office or hearing center.25 The resident then had an otoscopic examination and if cerumen was occluding at least 50% of the external auditory canal, the resident was considered to have a cerumen impaction and the cerumen was removed. Cerumen was removed using a cerumenolytic agent followed by tepid water irrigation. If less than 50% of the external auditory canal was occluded by cerumen, no intervention was performed, and the participant was classified as a control. All data were found to have a normal distribution. Analyses of age, MMSE scores, MMSE score change, and change in hearing were performed using 2-tailed paired-samples t tests with unequal variance. The data were analyzed, using a Wilcoxson rank sum test, to compare the MMSE score of those individuals who had a unilateral impaction with those with a bilateral impaction to ensure that the observed improvement occurred equally among all intervention subjects. Comparison of baseline scores between the intervention and control groups was performed using independent-samples t tests. Since tones heard at different frequencies in a given ear may not be independent (and therefore may not meet the strict criteria for performing a t test), a log likelihood ratio was performed to evaluate the categorical (improved, worse, no change) change in performance in each ear. We were unable to perform a chi-square test due to the low frequency of cases in some cells (ie, ⬍5). RESULTS Of the new admissions to the SNF, 29 consented to participate in the study, and none of them met the exclusion criteria. After enrollment into the study and evaluation for cerumen impaction, participants were categorized as “occluded” or “control” based on the findings at the time of otoscopic exam. Nineteen participants (65.5%) had cerumen that occluded ⱖ 50% of the external auditory canal in at least one ear and were, thus, placed into the intervention group. Eight of the nineteen participants had bilateral cerumen impaction for a total of 27 ears with an impaction. All of the men who participated in the study had a cerumen impaction, thus there were no male controls. All of the impacted ears had cerumen removed. All of the controls were female, and 8 of the 19 (42.1%) participants with cerumen were male. The average age of all participants was 81 ⫾ 7 with no significant difference (P ⫽ 0.18) between the study participants (82 ⫾ 6) and the controls (79 ⫾ 7). Moore et al. 137
Fig. 2. Distribution of hearing changes in control (unimpacted) and study (impacted) ears after cerumen removal.
Fig. 1. Comparison of the average Mini-Mental Status Exam (MMSE) scores in the control (unimpacted) and study (impacted) groups before and after cerumen removal.
The pretest MMSE scores for controls was 25.6 ⫾ 5.2 and for those with cerumen was 25.8 ⫾ 4.6 (t ⫽ 1.09, P ⫽ 0.29). The average change in MMSE score was 1.05 ⫾ 1.6 for participants who had cerumen removed compared with ⫺0.30 ⫾ 0.95 for the controls (t ⫽ 2.5, P ⬍ 0.01) (Figure 1). Among residents who did not have cerumen removed, one participant heard two tones less and one heard one more tone when hearing was retested 24 hours later. Among residents who had cerumen removed, there was not a significantly different change in MMSE scores based on whether the impaction was unilateral or bilateral (Z ⫽ 1.09, P ⫽ 0.28). For those who had cerumen removed, there were 44 new tones heard. The average change in number of tones heard for all 27 ears following cerumen removal was 0.26 ⫾ 0.50 compared with an average change of 0 ⫾ 0.16 in the controls (t ⫽ 6.3, P ⬍ 0.001) by t test. In the impacted ears, 80% improved, 20% remained unchanged and 0% worsened, compared to the control ears in which 3% improved, 90% were unchanged and 7% worsened (G2⫽36.7, P ⬍ 0.001) (Figure 2). DISCUSSION We evaluated cerumen impaction among a small sample of newly admitted nursing home residents to one SNF. This study showed that following removal of a cerumen impaction, whether in one or both ears, participants had a statistically significant improvement in their MMSE scores as well as their ability to hear the audioscopic tones. In comparison, the MMSE total scores and the number of tones heard remained unchanged in the control group. 138 Moore et al.
It is unclear whether hearing loss is directly or indirectly associated with cognitive impairment. There may be a direct association through pathologic degenerative changes within the brain that results in impairment in hearing and cognition. There may also be an indirect relationship if hearing loss adversely affects an individual’s ability to hear and participate effectively in their environment. Our study was designed as a preliminary trial and as a result has some limitations. We included only a small number of participants because many of the new admissions refused to participate despite the minimally invasive nature of the study. Because of this, the significance of our findings may be limited. Our high rate of cerumen impaction may reflect that people who consented to participate may have done so because they felt they had a cerumen impaction. We did not control for other variables, including socioeconomic background, education level, medical history, medication use, or psychosocial issues that may have an impact on cognition as measured by the MMSE and hearing impairment level. The MMSE also has limitations in evaluating cognition because it was designed as a screening evaluation. We also did not blind the data collectors to whether or not the patient had cerumen because all of the data for an individual participant was collected by a single investigator. Although we were also unable to provide a space that did not have ambient noise, the pretest and posttest data were collected in the same place for all participants. The strengths of our study include the fact that this was a prospectively designed study. All the data for an individual were collected by only one investigator, thus any changes that were observed were more likely to be true rather than due to differences in technique. Our participants also served as their own controls in evaluation of hearing and MMSE score change. A significant number of the participants had an impaction in at least one ear indicating that cerumen impaction is relatively common in a hospitalized population transferred to a SNF. Our findings suggest that removal of cerumen impaction, which is a safe and easy procedure, would have a positive impact on the hearing ability and cognitive performance of elderly residents admitted to a SNF. Not only would this affect the residents, but it may also benefit the facility indirectly by making it easier for new residents to adjust to their JAMDA – May/June 2002
new environment and enable optimal communication between newly admitted residents and the nursing home staff. REFERENCES 1. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189 –198. 2. Thomas PD, Hunt WC, Garry PJ, et el. Hearing acuity in a healthy elderly population: Effects on emotional, cognitive, and social status. J Gerontol 1983;38:321–325. 3. Jones DA, Victor CR, Vetter J. Hearing difficulty and its psychological implications for the elderly. J Epidemiol Commun Health 1984;38:75– 78. 4. Hedner K, Broms P, Harris S, Steen B. Hearing in geriatric long-stay patients. Compr Gerontol 1987;1:69 –71. 5. Peters CA, Potter JF, Scholer SG. Hearing impairment as a predictor of cognitive decline in dementia. J Am Geriatr Soc 1988;36:981–986. 6. Uhlmann RF, Rees T, Mozlowski KJ, et al. Impact of mild to moderate hearing loss on mental status testing. J Am Geriatr Soc 1989;37:223–228. 7. Voeks SK, Gallagher CM, Langer EH, et al. Hearing loss in the nursing home: An institutional issue. J Am Geriatr Soc 1990;38:141–145. 8. Flugrath J, Lutz D, Hamdy RC. Hearing impairment and cerumen impaction in older patients. J Tenn Med Assoc 1993;7:301–302. 9. Flatau E, Syndulko K, Flatau Y, et al. Hearing impairment in residents of a long-term care facility: Prevalence and relationship to cognitive dysfunction. Ann Long-Term Care 1998;6:410 – 413. 10. Reuben DB, Walsh K, Moore AA, et al. Hearing loss in communitydwelling older persons: National prevalence data and identification using simple questions. J Am Geriatr Soc 1998;46:1008 –1011. 11. Granick S, Kleban MH, Weiss AD. Relationships between hearing loss and cognition in normal hearing aged persons. J Gerontol 1976;4:434–440. 12. Ohta RJ, Carlin MF, Harmon BM. Auditory acuity and performance on the Mental Status Questionnaire in the elderly. J Am Geriatr Soc 1981;32:476 – 478.
ORIGINAL STUDIES
13. Uhlmann RF, Larson E, Koepsell TD. Hearing impairment and cognitive decline in senile dementia of the Alzheimer’s type. J Am Geriatr Soc 1986;34:207–210. 14. Uhlmann RF, Larson E, Rees T, et al. Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA 1989;261:1916 –1919. 15. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment: a randomized trial. Ann Intern Med 1990;113:188 – 194. 16. Gennis V, Garry PJ, Haaland KY, et al. Hearing and cognition in the elderly: New findings and a review of the literature. Arch Intern Med 1991;151:2259 –2264. 17. Yesavage SA, Brink JL, Rose TL, et al. Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiatr Res 1983;17:37– 49. 18. Bess FH, Lichtenstein MJ, Logan SA, et al. Hearing impairment as a determinant of function in the elderly. J Am Geriatr Soc 1989;37:123– 128. 19. Lewis-Cullinan C, Janken J. Effect of cerumen removal on the hearing ability of geriatric patients. J Adv Nurs 1990;15:594 – 600. 20. Ney DF. Cerumen impaction, ear hygiene practices, and hearing acuity. Geri Nurs 1993;14:70 –73. 21. Mahoney DF. Cerumen impaction: Prevalence and detection in nursing homes. J Gerontol Nurs 1990;4:23–30. 22. Ruby RRF. Conductive hearing loss in the elderly. J Otolaryn 1986;15: 2445–2447. 23. Hanger HC, Mulley GP. Cerumen: Its fascination and clinical importance: A review. J Roy Soc Med 1992;85:346 –349. 24. Meador JA. Cerumen impaction in the elderly. J Geront Nurs 1995;21: 43– 45. 25. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA 1988;259: 2875–2878.
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