® CURRENT CONCEPTS Aging and Sensory Senescence NEIL J. NUSBAUM, MD, New Orleans, La present, Sensory decline can lead to depression, social isolation, and even to hallucinations. ‘Methods. I reviewed the medical literature via computer, focusing on recent findings. Results. Sensory changes with aging are common yet often go unrecognized and untreated. Declines in sensory function often reflect the combined effect of age-related changes in both the sensory organ and the central nervous system processing of sensory information. Combin; ions of defects in several sensory modalities are often found in the older individual. Conclusions. Correct diagnosis is important for management so that correctable causes of sensory decline are not overlooked. AGING has a global impact on sensory function in the older individual. The aging process manifests itself in many systems. Decrements occur in vision, hearing, taste, olfaction, and may also occur in other sensory modalities. Deficits may occur slowly in individuals who may otherwise seem in good health and, by virtue of their gradual onset, may be subtle in presentation. Physicians must be careful not to misdiagnose dementia in a patient whose higher intellectual function is relatively intact, but whose performance is impaired by sensory deficits. Treatment of sensory deficits can have a profound impact on the patient's quality of life. Showing the effect of such treatment on life expectancy is a more difficult enterprise, but I believe that correcting some of these sen- sory deficits may indirectly increase life expectancy. VISION ‘A decline in vision can happen anywhere along the process from stimulus to perception. The process can be broken down into the many possible stages where things can go wrong, to produce a decrease in visttal ability! Potential etiologies range from cataracts, to From the New Orleans VA Medical Center, Department of Medicine, Section of Ceriatries, Tulane University School of Medicine, New Orleans, La, Reprint requests 10 Neil J. Nusbaum, MD, Department of Medline S113, Section of Geriatrics, 1480 Tulane Ave, New Orleans, LA 701122698. glaucoma, to loss of the central visual field with macular degeneration. Even with the normal aging process, we may see a variety of changes in visual functions such as dark adaptation. Sometimes these problems are managed by simple changes, such as avoiding driving at night, a strategy that many older individuals adopt on their own initiative. A common problem in the study of the physiology of aging is to distinguish the nor- mal physiologic changes of healthy aging from the changes superimposed by disease pro- cesses that more commonly occur as we get, old. An example in the research setting is suudy of the ability to. detect motion in the visual field, which declines not only with nor- mal aging” but also with glaucoma. Although the distinction is difficult, it may yield impor- tant diagnostic clues. Psychophysical testing can pick up early changes of glaucoma in both central vision’ and in the peripheral visual fields.' To increase the sensitivity of a test for sensory deficits, test for sensory skills that are particularly vulnerable to early damage, such as requiring the subject to detect motion (rather than just testing the ability to perceive a static visual image). Such tests can bring deficits to attention early and show pathol when global visual defects’ have not yet mani- fested. Disease processes can also manifest their effects on other components of the visual Nusbaum + AGING AND SENSORY SENESCENCE 267TABLE. Key Points Regarding Sensory Senescence Gained defecis Tm multiple sensory modaliies are ofen Towa inthe oder ncn + Defeeis at both enorgan level and lve of the central nervous system ave commonly seen. Sensory impairment affects quality of fe andl functional sts ‘+ Manifestations ofthe impairment may be subtle, expecially if dlficiis of gradual onset. presence of the impairment i often overlooked by patient ao an lyst, + Physicians need to avold mistaking sensory impairment for stementis, + Therapeutic interventions are often of bench, expecially regarde Ing vs impairment, experience. In Parkinson’s disease, dopamin- ergic neurons are affected in the brainstem and in the retina. Psychophysical testing on rkinsonian patients can show subtle defects in the ability to detect color contrasts, particu- larly when the test wavelengths were chosen to make the test particularly challenging (ie, using a test wavelength that called on the abili- ties of the small cone subpopulation of shor wavelength-sensitive cells, rather than the entire population of cone cells),* A decline in the ability to detect color contrasts has also been suggested as an early sign of macular degeneration” HEARING Hearing, like vision, is subject to defects at any point along the information chain. Age- related decline in hearing is often neither rec- ognized nor treated, but is extremely com- mon. Hea loss sufficient to cause functional impairment is present in ~ 25% of the “young old” (ages 65 to 74), in ~ 40% of those over age 75, and in nearly 70% of those living in nursing homes. Deficits typically are the most prominent in the hight frequency range. Most of those who need hearing aids do not have them, and many of those who do have them are dissatisfied with them and do not use them. It is not simply a matter of yanity, not wanting to be seen with a hearing aid, though that is sometimes an issue, ‘We need to recognize that simply amplify the outside sound ypically does not fully rect the auditory defect. The limited capa- bility of a hearing aid to improve hearing is what we might expect if the hearing deficit is multifactorial, with a central and a peripheral component. These typically complex hearing deficits in the elderly are most manifest when the hearing task is most difficult, such as ask- ing the individual to distinguish among words that are near-homonyms or asking the listener to distinguish words when spoken by several different speakers. Older individuals tend to do poorly on these tasks and more poorly than anticipated, based on their peripheral audi- tory ability to detect less complex sounds.” ‘The nature of the central abnormality may vary. The presence of symptoms such as ver- tigo or unsteadiness in combination with hear- ing loss may prompt a central nervous system a. Magnetic resonance imaging (MRI) can sometimes show a struc- tural intracranial abnormality, such as a hem- orthage or tumor that may affect the auditory pathways, In other cases, a CNS abnormality can be shown by functional testing. Adjusting the strength of an auditory stimulus test according to the subject's auditory threshold can show differences in central auditory processing. In ‘one study, a loud test noise was used to elicit a startle reflex in younger and older individuals, Even after the intensities of the test sounds were adjusted to compensate for the older individual's higher auditory threshold, the older individuals tended to have lower ampli- tude on their auditory-evoked potentials on electroencephalogram (EEG) monitoring, and showed less of a blink response to the noise."” A few causes of hearing loss are amenable to corrective management at the bedside. The most obvious perhaps is treatment of cerumen impaction in the canal, a common finding that will diminish auditory acuity. Medications have a relatively little role to play in treating hearing loss, although there are select situa- tions where they may be of value for specific problems, such as endolymphatic hydrops." Hearing loss has a major neural compo- nent, and’so it resembles many neurologic conditions. The best approach is prevention, where possible, of damage (from noise dam- age or from exposure to ototoxic drugs). ‘Once damage occurs, what we mostly have to offer is recognition of the deficit and referral for hearing devices. Even the best and most sophisticated hearing devices, however, often leave patients dissatisfied. OLFACTION AND TASTE Most clinicians are used to seeing the clini- cal neurologic examination of cranial nerves II through XI, but what about number I? Olfaction is one of those sensations primary providers may tend to overlook as relatively 268 March 1998 + SOUTHERN MEDICAL JOURNAL » Vol. 92, No.3unimportant and which appears to have attracted less academic interest than other sensory modalities in the older individual." Loss of sense of smell is rarely fatal, but it can sometimes be. In one geriatric series of 50 individuals, 19 had some olfactory deficit, and 9 could not even smell smoke—obviously these latter individuals would be at particular risk ifa fire broke out when they were in bed at night. Olfactory dysfunction can impair quality of life and may be a marker for other deficits and illnesses. The nose and the olfac- tory system show age-related changes. The rocess of decline of olfactory function, at least in men, appears to begin even in middle age. Ability to identify odors declines in old age in both sexes, and the process of decline appears to be progressive into extreme old age. Different study populations show roughly similar trends." An individual's ability to smell is usually studied by asking the person to identify odor- ant substances on a scratch and sniff test, such as the UPSIT (University of Pennsylvania smell, identification test). The test has 40 questions; all are multiple choice with four choices. (Even if a person cannot smell at all, he should get an average score of 10 correct just by chance, Scores of some individual in their 70s and 80s may show quite serious deficits. UPSIT scores decline with age, even in healthy subjects having no medical treatment and tak- ing no medications." Some studies have identified olfactory deficits in association with neurologic dis- ease." Olfactory deficits have been identified in parkinsonian patients and appear to vary in frequency according to which odorants are used for testing purposes. Olfactory function shows less impairment in some atypical parki sonian syndromes than it does in idiopathic Parkinson's disease." Olfactory deficits are also seen in other degenerative neurologic disorders, notably in Alzheimer’s disease.” Even patients with early ‘Alzheimer’s disease show deficits in odor iden- tification (distinguishing among odorants on the Pennsylvania smell test), and this deficit worsens as dementia progresses. Subjects with more advanced Alzheimer’s also show deficits in the ability to do a less complex olfactory task, detecting whether any test odor was pré- sent or absent." The olfactory bulb in Alzheimer’s patients shows many morphologic changes seen in the Alzheimer’s brain as a whole.” A variety of sophisticated imaging studies have been used to study olfaction, including computed tomography (CT), MRI, and single photon emission computed tomography stud- ies” An olfactory loss can take place at many steps along the sensory pathway; in a younger patient who uses cocaine, it can be as periph- eral a problem as damage to the nose from snorting cocaine or as centrally located an event as a hypertensive CNS bleed. In the typi- cal older individual with a history of non-acute olfactory loss, localization of the site of olfac- tory loss is usually not of clinical importance. In the clinical setting, radiologic studies are probably most relevant when an ear, nose, and throat or CNS tumor is suspected as the cause of the olfactory loss, and the imaging study is designed to look for an anatomic lesion. ‘There is an association between nutritional status and olfactory ability in the elderly, but it is unclear to what extent poor olfaction predis- poses to poor nutritional intake and to what extent the reverse relationship holds.” Olfactory input is an important component of the pleasurable sensation from eating; the lack of taste of food may decrease the individual's interest in food intake and lead to malnutri- tion. If the individual also has defects in taste bud sensation, the problem might be further compounded. Conversely, the lack of sensory feedback from eating could lead the individual to eat, more and become obese. Another speculative concern is that individuals may change the composition of their diet, perhaps increasing their dietary intake of salt or sugar to maxi- mize the sensations from their taste buds. The potential associations between sensory decline and dietary change, and their possible clinical importance, seem worthy of further explo- ration. Perhaps they may explain in part the difficulty in meeting the dietary prescriptions in the older individual. ToucH The sense of touch has received much less attention in the literature than have the other sensory modalities, but it too shows an age- related decline. In fact, the decline in tactile sensory ability may begin quite early in the life span. A Japanese study examined more than 2,000 individuals for their abilities on several sensory tasks, including two-point discrimina- tion. The test used a caliper and measured the smallest separation between the two points of, the caliper the subject could detect on the Nusbaum * AGING AND SENSORY SENESCENCE 269palm of the hand. Performance declined with age even in adolescence and continued to decline at least through middle age. Ability to detect a vibratory stimulus shows an age-related decline even in normal individ- uals." The process of decline is accelerated in the presence of diabetes. Other investigators have used more sophisticated tests of the sense of touch in smaller study populations and have confirmed the pattern of decline in acu- ity with age. These decrements in sensation may be important in limiting sensory feedback to aid the subject in fine motor tasks (writing, sewing, using eating utensils, etc). Given that sensory decline can be an impor- tant marker and perhaps a partial cause of overall decline in functional status, it is impor- tant to consider how we should best measure the rate and extent of the sensory decline. Thomson et al” studied aspects of the sense of, touch in some 200 individuals, consisting of 100 subjects (median age, 77) hospitalized without diabetes or other illness likely to cause peripheral neuropathy, and another 100 patients (median age, 76) who were living in the community. The average older patient had either no deficit or a deficit only in the distal foot, even in advanced old age, when the modalities studied were pinprick, tempera- ture, or light touch. Vibratory sensation, hove ever, showed an age-related decline in percep- tion even in these nondiabetic individuals. The participants in the study also showed a trend toward an age-related loss of the ankle jerk reflex. At least in the healthy elderly, the ability to perceive painful stimuli is relatively well pre- served." On the other hand, the ability to detect a hot object may be impaired even in younger subjects who are hyperinsulinemic, even if they are normoglycemic and have a normal glucose tolerance test.” The ability to detect heat is important to enable the elderly to initiate protective actions, such as recogniz- ing the need to withdraw from a hot stove. OF course, the speed of the protective withdrawal may be limited by the elderly individual's motor disability. PREVALENCE OF SENSORY DEFICITS Kaye et al” looked at the neurologic status of individuals 85 and older who were thought clinically to be in good health and described themselves as being in good health. Even in this select group of older individuals, a variety of neurologic abnormalities (both sensory and motor) were seen more commonly than in those in their late 60s and early 70s. These old- est old individuals overall maintained a good cognitive state with only minimal difference on the Mini Mental Status Examination. The most outstanding differences were seen in the decline in ability to smell. Half the oldest old dividuals failed an olfactory test that asked them to distinguish between the odors of cof fee, cinnamon, and air. Even in these healthy individuals there was a noticeable decline in their ability on balance testing, though their overall walking speed slowed only modestly. The oldest old also showed a decrease in the range of gaze, particularly limitation of gaze in the upward direction. This group of patients however maintained good corrected visual acuity even past age 85. (It should be noted that these were oldest old individuals who were particularly selected for their overall good health, and that what was being evalu- ated was corrected visual acuity.) This survey also showed defects related to the sense of touch and the findings were more noticeable on neurologically more demanding tasks. Proprioception showed some trend toward decline in the oldest old, as did the ability to recognize double simultaneous stimulation. The neurologic decline on stereognosis and on vibratory sensation was much more signifi- cant, ‘SENSORY PROCESSING AND INTEGRATION Older individuals differ from younger indi- viduals not merely in their ability to receive individual sensory inputs, but also in their ability to process and integrate information from a variety of sensory modalities. One experimental trial used a task in which young and old individuals were asked to land a stylus on a test target by hand movement. They trained on the task by using visual input watch- ing their hand motion, and getting proprio- ceptive input. The experimental conditions then variously manipulated whether they con- tinued to get visual information on their hand movement or just proprioceptive feedback. The younger subjects did better overall, but they were more sensitive to loss of the visual information. The data suggest as one interpre- tation that the younger individuals learned the task by integrating the various sensory information (visual and proprioceptive) together to achieve their high performance, while the older individuals tended to use inputs from the two sensory modalities in a 270 March 1999 + SOUTHERN MEDICAL JOURNAL » Vol, 92, No. 3less integrated fashion." Other experiments from the same investigators suggest that the strategies used by older individttals to accom- plish the task become more similar to those used by younger individuals if the available response time is extended,™ presumably because the extra time allows the older ind- vidual enough time to do the integrative task. ‘The older individual's difficulty in process- ing multimodality sensory information is seen most strikingly when there is rapid fluctuation in the nature and quality of the sensory infor- mation that he receives from the environ- ment. A recent study* showed this in an exper- imental model. The investigators used various combinations of sequences of goggles to obscure visual input and used vibratory devices over the ankle tendons to obscure pro- prioceptive input. Both young and old showed decreased postural stability when they were deprived of sensory inputs, but the decre- ments were most noticeable in the elderly. One of the most interesting differences between the young and the old subjects came when additional sensory input was provided again, after having been previously withheld from the experimental subjects. The younger subjects were able rapidly to use the additional visual and/or proprioceptive information to improve their performance on maintaining stable posture; the older individuals showed a transient decline in performance on the task when they were given additional information. This suggests that the older individuals may have limitations in their ability to process changing sensory information and may have a decline in performance accordingly on tasks that require use of information from a chang- ing array of sensory sources. ‘These experimental situations are obviously somewhat artificial ones, but they may be ane ogous to many situations that occur clinically. ‘An Australian study looked at gait in a sample of non-institutionalized women to identify fac- tors associated with performance on various elements of the task of walking." There was an age-dependent decrease in walking velocity, but other variables proved even more useful than age in predicting gait performance. Visual acuity for low contrast visual situations and vestibular function were both extremely important in this model, The data suggest that older individuals with sensory deficits may walk more slowly as they reduce the length of their stride, making the task of interacting with their environment a less challenging on Another relevant example may be the demands for processing rapidly a mixture of sensory inputs when driving an automobile. Some sensory clues may come from a tactile sensation as the driver’s body experiences the forces associated with making a turn, while the visual inputs are rapidly changing during the turn. This task is further complicated if the older individual has a decreased range of gaze mobility. If an unexpected additional sensory input, such as the honking of a car horn, is, superimposed, this creates a complex integra- tive task in which an older individual may have difficulty in rapid and successful performance. PSYCHOLOGIC IMPACT OF SENSORY IMPAIRMENTS The lack of sensory information can predis- pose to psychologic symptoms. A recent report by Teunisse et al" from the Netherlands notes that more than 10% of patients with severe visual disability (mean age, 75) experienced visual hallucinations. These patients retained insight into the fact that their hallucinations were not real. Most did not experience emo- tional distress over the hallucinations, most did not seek medical attention for the prob- lem, and most of those who sought medical attention reportedly were not correctly diag- nosed. These patients retained good insight and only needed reassurance that their hallu- cinations did not represent mental illness. ‘Auditory and visual impairment can have more potent psychologic effects in association with dementia, if the patient lacks the cogni- tive skills to have insight into the effect of sen- sory impairment. A British case series looked at the associated risk factors for psychotic symptoms in patients with mild-to-moderate lementia."* Of the 124 geriatric dementia patients in this series, two-thirds had psychotic symptoms. Visual hallucinations were associ- ated with the presence of severe visual impair- ment. Deafness was associated with the pres- ence of delusions. In another British study that used a case control approach, elderly patients with late life psychosis with a paranoid symprom complex were four times as likely as he controls to have hearing impairment.” Olfactory hallucinations are common with a variety of psychiatric diagnoses, including not only schizophrenia, but also with major depression and with eating disorders. In these situations, however, the presence of hallucina- tions did not correlate well with the presence of impairments in olfactory ability." In these cases, at least, we cannot attribute the olfac- Nusbaum * AGING AND SENSORY SENESCENCE 271tory hallucinations to olfactory sensory depri- vation, Sensory ability is strongly correlated with intelligence level in old age. One explanation is that the same central processes that lead toa decline in sensory ability also may lead to a decline in intellectual function. Another spec- ulation is that severe sensory impairment can lead to deprivation of sensory intellectual stimulation and ultimately to intellectual decline." There is some evidence of cross talk between various sensory modalities, such as vision and smell. Experimental subjects may associate various test odors with particular col- ors. (A trivial explanation could be that the color would be the color of a substance they knew that had that smell, but the association held even when testing with unfamiliar chen cal odors.)" It has been suggested that if one sensory modality fails, other modalities become more acute, In practice, there is not much evidence to support this proposition; one recent study suggests that blind individu: als do no better than sighted individuals on tests of taste and smell.‘" Many geriatric patients must deal with simultaneous dysfunc- tion of several sensory modalities. ‘SCREENING FOR SENSORY IMPAIRMENT Sensory impairments also can affect the older individual's ability to participate in inter- personal activities. This is illustrated by recent data from the nursing home setting.® Nursing home residents with visual impairment were less likely to interact socially or to participate in nursing home activity. Hearing impairment when severe had similar effects, though it appears that the disability in these spheres from hearing loss is not quite as profound as that produced by visual impairment. In this study it was noteworthy that routine bedside assessment showed that only a little more than half of the nursing home patients had ade- quate vision and that less than two-thirds had adequate hearing ability to engage in commu- nication tasks (conversation, listening to televi- sion, talking on the telephone). In many cases, the nursing home residents with visual or auditory impairment have not received the corrective devices that might have improved their vision or hearing. Medicare does not typically cover glasses and hearing aids." In the German system of health care, which provides more generous hearing aid benefits, the provision of a hearing aid is successful in reducing the individual seléper- ceived hearing disability, but is not successful in producing more general improvement in social function. ‘The manpower cost of screening tests and other health interventions can often be reduced if several interventions are done at the same health care encounter. The typical older individual will be a candidate for an eye exami- nation for glasses; this contact with an ophthal- mologist or optometrist offers a convenient time to screen for elevated intraocylar pres- sure, to evaluate diabetic and other patients for retinopathy, and to educate patients about how age-related vision changes may impair skills for such tasks as driving at night. We expect the elderly to be more frail than the young and the elderly in a nursing home to be more frail than those living in the com- munity. Considering the size of the problem, it should be more often addressed. Tielsch et al" looked at nursing home patients in Baltimore and found that 17% were legally blind (best corrected vistial acuity of 20/300 or worse) in both eyes. For those under 60, the rate was 15%, but for those 90 and older the rate was 29%. The biggest single cause of legal blind- ness was cataracts, something highly treatable. THERAPEUTIC INTERVENTIONS Many studies have looked at impairment of individual senses, but a few have considered the effect of combined sensory impairments, A large Italian study" looked at older individu als as separated into (1) those without visual or hearing impairment, (2) those with an impairment corrected by a sensory aid (pre- dominantly individuals who had poor vision corrected by glasses), and (8) thobe who had an uncorrected impairment of vision or hear ing. Three quarters of their study population had either hearing and/or visual impairment. Most patients with visual impairment had eye- glasses; most patients with hearing impair- ment did not use a hearing aid. The group with uncorrected impairment had nearly twice the mortality of the other two groups (no sen- sory impairment, or impairment corrected with a sensory aid). The finding that mortality is higher with a sensory deficit is not surprising, and we could argue that a sensory deficit is just a marker of frailty. On the other hand, individuals without, impairment and those who had their impair- ment corrected by a sensory aid were similar in mortality. The subjects with corrected 272) March 1998 + SOUTHERN MEDICAL JOURNAL + Vol. 82, No.3impairments also did much better on quality- of life measures (mood, social interaction level, ability to do the activities of daily living) than did those with uncorrected impairment. ‘The study treated visual impairment and hear- ing impairment together, but it seems to speak predominantly to the value of glasses. It is not a randomized study, which makes the interpre- tation of the data a bit more difficult. Perhaps those with poor vision but who were otherwise healthy were more likely to seek out glasses for themselves, so the sensory aid group might have somewhat healthier people. This is not, the kind of topic where we can readily do ran- domized trials, but I believe this nonrandom- ized, observational study shows the benefit of glasses for the elderly beyond just improving vision. Patients with more profound visual loss may benefit from more comprehensive services than just spectacles, We should consider not merely spectacles and hearing aids, but all sen- sory aids (and other support services) for the patient Some of these may be devices hand- held by the patient, such as magnifying glasses.” Even with a comprehensive ap- proach to low vision visual rehabilitation that produces immediate gains for the patient in functional ability, long-term follow-up may show considerably less patient satisfaction with the functional outcome than initially reported. Such individuals may also have broader support needs beyond vision services. In some cases, the aid may come in environ- ments designed for the patient. At the individ- ual level, this may involve architectural modifi- cations to the patient's home. At the societal level, it involves designing public buildings and environments frequented by those wit sensory impairments, particularly places like nursing homes. It may involve designing ade- uate ihumination without glare help vi lly impaired individuals navigate safely.” UNRECOGNIZED SENSORY DECLINE Sensory decline can be subile, if itis gradual and if the individual gradually alters what he tries to do to conform to what he can do. Ifa person with poor vision stops reading, then he may no longer note problems with reading, so his history may include not only the tasks he has difficulty doing, but also the tasks he may have stopped doing and what made him stop. Clinicians need to consider both signs and symptoms in evaluating sensory loss. In decid- ing if cataract needs to be removed, the issue is not merely whether the lens has poorer light transmission, but whether the impact on the patient is clinically important enough to the patient that surgery is desirable to relieve the symptoms, Older individuals may often under- state their true sensory loss. An example is offered by a French study of more than 1,200 women 75 years of age and over. Data were collected on whether the patients wore glasses and/or hearing aids. Data were collected as well regarding patient self-reports of “serious visual difficulty” and “serious hearing difficulty” in following a con versation (even with a hearing aid) involving several people. Most subjects wore glasses but, only a very modest number reported major visual problems. In contrast, only about 1 woman in 9 wore a hearing aid, but 40% of the hearing aid users.nevertheless described major hearing difficulty. It is of particular interest to compare the patient frequency of self reports of serious hearing difficulty with the frequency of such reports by the study nurse, based on how frequently the nurse noted difficulty in interviewing the patient. The study nurse reported serious hearing diffi- culty far less frequently than patients self reported such a problem, and most of the cases where the nurse made such a report involved patients who were not fully indepen- dent in the instrumental activities of daily liv- ing (eg, grocery shopping, paying bills, doing housework). ‘The modest number of self reports of hear ing difficulty suggests that patients may not be fully eporting their symptoms. Also, nursins personnel infrequently noted hearing diffi- culty. At least one possible interpretation is that the nursing personnel were not attuned to suspecting hearing difficulty in individuals who were otherwise managing to function independently at home. The nurse or, simi- larly, the physician may be insensitive as a case- finder for hearing difficulty if the only screen used is the patient's difficulty in understand- ing the one-on-one conversation between patient and clinician. The ability to hear in a quiet conversation between two people is a substantially less challenging task than the ability to hear when there are multiple speak- ers in the same conversation. It is not surpris- ing therefore that the patient often self reports hearing difficulty when the clinician does not notice any obvious difficulty during a clinical history and physical. ‘The French study of community-dwelling, Nusbaum * AGING AND SENSORY SENESCENCE 273elderly women shows that we can easily under- estimate the frequency of sensory impairment if we rely only on casual impression du contact with the patient and that the patient history may be a more sensitive indicator. Patient history is most easily obtained in elderly individuals who are not cemented and at high functional levels overall; they are the atients who would have the most to gain rom correction of a sensory impairment. Patients at a lower functional level however may also have sensory impairments of con- cern. Bowen et al*' looked at patients newly diagnosed with Alzheimer’s disease. One pre- dictor of earlier mortality from Alzheimer's disease was more severe dementia at the time of initial diagnosis. In their multivariate mod- els, the next strongest factor associated with decreased survival was a sensory impairment that interfered with the ability to read. Hearing impairment in their model was not as strong a predictor of impaired survival. An Italian study also addressed the possible association between vision and hearing impair- ment and mortality, looking at 1,140 commu- nity-dwelling men and women in their early ‘70s. The door-to-door study, testing auditory acuity by the ability to hear a whispered voice and visual acuity by eye chart, included both men and women. The study suggested an asso- ciation overall of hearing deficits and/or visual deficits with increased mortality, particu- larly in men. Association does not prove causation. Sensory impairments that interfere with read- ing may be due toa combination of factors, including neurologic changes as a component of the total dementing process. As Alzheimer's disease progresses and the patient’s general intellectual function deteriorates, the patient may lose interest in reading and the intellec- tual ability to accomplish the task. There is no proof that improving corrected visual acuity will improve the clinical course of the dement- ing process. Perhaps more relevant, sensory impair ments are common in the elderly, including patients with dementing illnesses. Because of their intellectual dysfunction, these patients may have difficulty in providing clear self reports of sensory impairment. Patients who lack sensory input can become depressed and neglect self-care. Their communication deficits may make them less capable of report- ing symptoms of hunger, thirst, or physical ill- ness to family caregivers or physicians. The patients’ quality of life may be im- proved if they can interact visually and other wise with their environment for their enjo ment of the world around them. Patients early in their dementing illness are likely to be most cooperative in carrying out testing for vision and hearing impairment. Patients with advanced dementia may not be candidates for major eye surgery or the like, but measures such as providing eyeglasses may allow them to enjoy watching television, to navigate more safely, and to better follow instructions from their caregiver. SUMMARY Sensory deficits are common with aging. ‘Their gradual onset can make them less obvi- ous, unless explicitly sought out by the physi- cian by history taking, physical examination, and clinical testing. Some sensory deficits are amenable to treatment; hearing aids and, even more so, eyeglasses can help many patients to a substantial degree. These interventions involve expense but no risk and should be considered in almost all patients with hearing or visual deficits. Correction of sensory deficits where feasible is an important quality-of life issue. These corrections may even contribute indirectly to improving life expectancy. Rateronces Se eel ta rn SSE sin ce aa esha 274 March 1999 + SOUTHERN MEDICAL JOURNAL + Vol. 82, No. 32, 13, 20, 21 2 8, % 26, 27, 28 20, 30, 31. 3, Laryngoscope 1906; TO na 1991; 148:357-360 aa 41:267-272 in and diabetes melas on nerve fonction. | Aut Gait So decline wih aging Yevedted by repeated threshold teaing 1993; 10:843-846 ca! Aggie abate Prydel Sl Sor Sa 1986; BL HOSES of the normal nose in adults, Daniel SE: Olfactory dysfune- J Newol Nowrosing Psychiatry ub 3 34 55. 36. 37 38, 20. 40, a 42, a. 8, 1906; 35:202907 Moet eae ina Peay Baten DS espa aie om i see oe ng como Bela 54:649-655 P ees sarin PCa ga rot Sane a pon Kae mer degeneration Pe aera cn ge et Se ier geet See acl ts GAO sl ers Paychotie state aie: the tole of sk factors. Nusbaum + AGING AND SENSORY SENESCENCE 275