Tuning Into the Sound Environment
By Susan E. Mazer, MA

Facilities Can Avoid Needlessly Isolating the Hearing-Impaired Resident by Attending to Some Basic Details

Note: This article originally appeared in DESIGN, published in March 2002 by Nursing Homes Long Term Care Management. Copies of the publication can be purchased for $20 by calling 216.391.9100.

As we age, all of us, 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 control 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 five years old or illiterate— loudly, 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 per day interventions common to the acute care setting.

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 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. Without a doubt, the subtle decline of a person’s hearing capacity brings into question issues of cognition, memory, coordination, social skills and, ultimately, independence.

How should we address the hearing 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 are 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 un-intelligible.

In a recent 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 loud.

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 more familiar sound to residents.

3. Machinery: The use of vacuum cleaners, floor waxing equipment, dish washers 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 hearing-impaired residents of what little ability they retain to understand language. Furthermore, their subsequent frustration will result in hearing aids being blamed for their “ineffectiveness,” as residents turn them up and down, trying the free themselves of the noxious 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, as well, 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 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, symptomatically the resident could appear to have increasing dementia, agitation, decreasing ability to socialize, limited cognitive capacity, 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.

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 of 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 that know all too well the frustration that results. The issue of hearing aids is not different than eye glasses: staff would nor more allow a resident to walk unable to see than they should allow a person to be 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.

In conclusion, 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. Awareness of the sound environment is critical to a resident’s quality of care and life.