14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

1. Presbycusis and Hearing Loss

Presbycusis is age-related sensorineural hearing loss: bilateral, symmetric, high-frequency predominant, with disproportionate difficulty understanding speech in background noise. Patients characteristically say they can hear but cannot understand, and consonants — which carry most of the information in speech — are lost first.

Why it matters far beyond the ear:

• Social withdrawal and isolation
• Depression
• Accelerated cognitive decline; hearing loss is one of the largest potentially modifiable risk factors for dementia at a population level
• Falls
• Misdiagnosis as dementia — a patient who cannot hear the questions performs poorly on cognitive testing. Always ensure the patient can hear before interpreting a cognitive assessment, using an amplifier if necessary.

Evaluation: otoscopy to exclude cerumen impaction, which is common and immediately correctable, followed by formal audiometry. Whispered voice and finger rub tests are screening tools only.

Red flags requiring urgent evaluation:

• Sudden sensorineural hearing loss — an otologic emergency. Prompt systemic or intratympanic corticosteroids improve recovery, and delay costs hearing permanently.
• Asymmetric or unilateral loss — evaluate for vestibular schwannoma with MRI.
• Unilateral tinnitus, or hearing loss with neurologic findings.

Management: hearing aids (including over-the-counter devices for mild to moderate loss), assistive listening devices, communication strategies, and cochlear implantation for severe loss. Ototoxic drugs — aminoglycosides, cisplatin, loop diuretics, high-dose salicylates — should be reviewed.

2. Ophthalmology in the Elderly

A named blueprint subsection listing cataracts, age-related macular degeneration, ischemic optic nerve or retinal disease, and glaucoma.

The functional consequence is what the exam tests: visual impairment contributes to falls, driving hazard, medication errors, social isolation and depression, and cataract surgery is one of the few interventions shown to reduce fall and fracture risk. Delaying cataract surgery in an older adult because of age alone is not supported.

Dual sensory impairment — combined hearing and vision loss — produces disproportionate functional and cognitive impact and requires both to be addressed.

3. Dizziness and Vertigo in the Elderly

A named blueprint subsection. Dizziness in older adults is usually multifactorial rather than attributable to a single cause, which is itself the diagnostic insight.

Contributors to identify and treat:

• Medications — antihypertensives, alpha-blockers, sedatives, anticholinergics, antidepressants
• Orthostatic hypotension — measure supine and standing at 1 and 3 minutes
• Benign paroxysmal positional vertigo — brief vertigo triggered by head position change; diagnosed by the Dix-Hallpike maneuver and treated with the Epley canalith repositioning maneuver, which is highly effective and takes minutes
• Vestibular hypofunction — improves with vestibular rehabilitation
• Peripheral neuropathy and visual impairment — degraded balance inputs
• Cardiac causes — arrhythmia, aortic stenosis
• Anxiety and depression

Two practical rules: first, benign paroxysmal positional vertigo is common, easily diagnosed and immediately treatable and should be actively sought rather than assumed absent. Second, vestibular suppressants such as meclizine should be avoided for chronic dizziness in older adults — they are anticholinergic, impair central compensation, and increase falls.

Acute persistent vertigo requires the HINTS examination and consideration of posterior circulation stroke, as discussed with cranial neuropathies.

4. Psychiatry in the Elderly

A named blueprint subsection listing depression in the elderly, sleep disorders in the elderly and neuropsychological testing of the elderly.

Late-life depression

Presentation differs from that in younger adults. Older patients less often report sadness and more often present with somatic complaints, anxiety, irritability, cognitive slowing, loss of interest and social withdrawal. Screening with a validated instrument is warranted because it will otherwise be missed.

Depression versus dementia:

The two frequently coexist, and depression is also a prodrome of dementia. When uncertain, treat the depression and reassess cognition after remission.

Suicide risk is highest in older men, who use more lethal means and have often seen a physician in the weeks before death — which makes direct inquiry a high-yield clinical act.

Treatment: SSRIs are generally first-line, starting low and titrating slowly. Watch for hyponatremia from SIADH, which is more common in older adults, increased fall and fracture risk, and drug interactions. Psychotherapy is effective, and electroconvulsive therapy is highly effective for severe, psychotic or refractory late-life depression.

Neuropsychological testing is useful for distinguishing depression from dementia, characterizing a cognitive profile in atypical presentations, assessing decision-making capacity in complex cases, and evaluating in the setting of high premorbid function or low education where brief screens perform poorly.

5. Elder Mistreatment

An enumerated blueprint topic and a mandatory-reporting matter in most jurisdictions.

Types: physical abuse, psychological or emotional abuse, sexual abuse, financial exploitation (the most common form), neglect (by a caregiver), and self-neglect.

Risk factors:

Clinical clues:

• Injuries inconsistent with the explanation, or in unusual locations (inner arms, neck, torso)
• Delays in seeking care; multiple emergency visits to different facilities
• Untreated pressure injuries, poor hygiene, dehydration, malnutrition, medication non-adherence with unexplained missing prescriptions
• A caregiver who answers for the patient, refuses to leave the room, or is dismissive or hostile
• Unexplained financial changes, new names on accounts, sudden changes to a will or power of attorney

Assessment technique matters: interview the patient alone, in private, using open non-judgmental questions. A caregiver who insists on staying is itself a warning sign. Document findings objectively, including verbatim statements and photographs of injuries where appropriate.

Reporting: most states impose mandatory reporting of suspected elder mistreatment to adult protective services. Reasonable suspicion — not proof — triggers the obligation, and reporting does not require the patient's consent, though this creates real tension with autonomy in a patient who has capacity and declines intervention. A patient with decision-making capacity may refuse services; the report is still made where the law requires it, and safety planning and continued engagement are offered.

Self-neglect is the most frequently reported category to adult protective services and is often bound up with cognitive impairment, depression, substance use and isolation. Capacity assessment is central: a person with capacity may make choices others consider unwise.

6. Nursing Home and Home Care

Both are enumerated blueprint topics.

Nursing home care

Distinct clinical considerations arise in the long-term care setting:

• Infections are the leading cause of transfer to hospital: pneumonia, urinary tract infection, skin and soft tissue infection, and outbreaks of influenza, COVID-19, norovirus and scabies. Antimicrobial stewardship is critical, and asymptomatic bacteriuria must not be treated.
• Advance care planning should be documented on admission and revisited, with actionable orders that travel with the resident.
• Deprescribing — residents frequently take medications whose time to benefit exceeds their life expectancy, such as intensive glycemic or lipid control.
• Restraint minimization — physical and chemical restraints increase injury, delirium and mortality and are regulated.
• Antipsychotic reduction in dementia is a national quality target because of increased mortality in this population.
• Pressure injury prevention and vaccination programs.

Home care

Home-based care and house calls serve homebound patients who cannot access clinics. The home visit yields information unavailable in the office: medication reconciliation from the actual bottles (frequently revealing duplicates, expired drugs and non-adherence), fall hazards (loose rugs, poor lighting, absent grab bars, stairs), food availability, hygiene and safety, and the realities of caregiver support.

Caregiver assessment is part of the patient assessment. Caregiver burden predicts nursing home placement, and caregivers themselves have elevated rates of depression, poor health and financial strain. Asking how the caregiver is doing is a clinical act, not a courtesy.

7. Sexual Function in the Elderly

An enumerated blueprint topic that is routinely omitted from history-taking. Many older adults remain sexually active, and clinicians who do not ask miss treatable problems and fail to counsel on risk.

Points that generate exam items:

• Sexually transmitted infections occur in older adults, and rates have risen. Age is not a reason to omit sexual history-taking or testing, and postmenopausal women may forgo barrier methods once pregnancy is no longer a concern.
• Genitourinary syndrome of menopause causes dyspareunia and responds to low-dose vaginal estrogen.
• Erectile dysfunction is common and often medication-related or a marker of vascular disease; phosphodiesterase-5 inhibitors are contraindicated with nitrates.
• Medications — SSRIs, beta-blockers, thiazides, antiandrogens, finasteride — are frequent contributors.
• Chronic illness, arthritis pain, dyspnea and functional limitation affect sexual activity and can often be accommodated.
• Sexual expression in cognitive impairment raises capacity and consent questions requiring careful, individualized assessment rather than blanket prohibition.