Part VII:

Health Status of Older Americans

Relevance to Centers for Independent Living (CILs)

In this section, CILs will learn about the health status and medication consumption of older adults. CILs may wonder why it is important to know about the health status of an older adult. Is working with an older consumer (age 60+) the same as working with a younger consumer? No. Some older adults may develop multiple chronic conditions that affect their abilities to perform everyday activities. Some take numerous prescription medications to treat these conditions, which may have negative side effects. Some older adults may be dealing with age-related changes and an acquired disability. Others may have acquired a disability early in life, and now, are learning to live with age-related changes. This section provides CILs with basic information about age-related changes that affect activity performance.

For example, a 30-year-old consumer with lower body paralysis as a result of an automobile accident may seek advice about obtaining personal care assistance services, home modification services, or how to advocate for worksite modification. A 60+ consumer with lower body paralysis because of an automobile accident may be affected by age-related changes such as decreased vision, sensation, mobility and arthritis. The older consumer may need assistance in performing daily activities due to newly acquired disability and the age-related changes that affect functional ability.

Health Status of Older Americans | Sensory Changes | Vision | Hearing Changes | Cognitive Changes | Mobility Changes | Cardiopulmonary Changes

Part VII: Health Status of Older Americans

According to the U S Census Bureau (2001), 14.2% of the elderly population had difficulty performing at least one activity of daily living (ADLs) and 21.6% had difficulty with instrumental activities of daily living (IADLs). ADLs are those tasks that include bathing, dressing, feeding oneself, walking (getting around the home) and transferring (between chair and bed). IADLs are those tasks that include preparing meals, housekeeping, managing money, shopping, using the telephone and getting around the community.¹

The Administration on Aging (2002) reported that 35 million older Americans were age 65 years and over and this group represented 12.3% of the U.S. population. This number will increase dramatically as baby boomers reach age 65. By 2030, the total U. S. elderly population will rise to 70 million (38%).² The fastest growing segment of the older population is and will continue to be those persons over age 85.

Difficulty performing or completing ADLs and IADLs is usually the first indicator that an older person is having a problem and may need assistance. The reason for this difficulty can be associated with decreased muscle strength, decreased range of motion, stamina or increased pain. A large part of the problems older people have with declining function comes from chronic conditions and age-related changes.

As the person ages, so may the development of multiple chronic conditions. Therefore, it is important to know that when working with an older individual, this person's functional status may be affected by a combination of multiple conditions and by the multiple prescriptions consumed to treat the conditions.

Effects of Age-Related Changes on Functional Activities

Sensory Changes

Mobility Changes - (Neuro musculoskeletal Changes)

Cognitive Changes

Cardiopulmonary Changes

Urinary Changes

Gastrointestinal Changes

Integumentary Changes

Information extracted from Using Technology to Promote Independence for Older Adults - A RERC-Aging Workshop, funded by the National Institute of Disability & Rehabilitation Research³

Return to top

Sensory Changes

Everyone wants to live a long life with an independent lifestyle. Yet no one wants to think about getting older and needing help with activities of daily living. The definition of old age is very much debatable. A grandfather may be considered young at the age of 45, while an athlete at the same age would be considered old. The most important part about aging is our attitude about the process and how well we prepare and adapt to its changes.

Although we experience physical changes throughout our lifespan, we find it most difficult to accept those that occur later in life. Sensory changes, such as hearing and vision, touch, taste and smell, occur but not necessary at the same time for each individual.

Studies have indicated that these sensory changes accelerate at certain approximate age ranges:⁴

• Vision - mid 50s

• Hearing - mid 40s

• Touch - mid 50s

• Taste - mid 60s

• Smell - mid 70s

Return to top

Vision

Changes occur to the eye as we age but vision loss is not a normal part of aging. Visual disorders and diseases increase dramatically as we age. The shape of the lens changes while the lens and cornea become less transparent. The pupil becomes smaller and the field of vision shrinks. This makes it difficult to see an object or focus on objects at different distances. There is difficulty adjusting to sudden light level changes, distinguishing certain color intensities or correctly judging distances. A study conducted by Lighthouse International found that one in six adults age 45 reported some type of vision impairment.⁵ According to the American Society on Aging, older adults suffer severe consequences due to vision loss: disability, falls, dependency and isolation, and depression.⁶

Lighthouse International also reported that one-fourth of the people with vision problems had difficulty performing their everyday household activities, almost one-fifth reported problems using transportation, over one-third reported interference with leisure activities, and 31 percent reported that loneliness was a very or somewhat severe problem. It is expected that over the next three decades, the number of people with visual impairments will double.7

There are other common vision problems older adults experience that are not considered diseases or degenerative conditions. These problems are: presbyopia, floaters, glare, tearing, and difficulty with night vision.

Presbyopia

Presbyopia is a corrected condition and is not disabling. It is related to changes in the eye's focusing power. "Occurring in almost all people over age 45, the gradual loss of the eye's ability to change focus for seeing near objects. It happens because, with age, the lens inside the eye gradually loses its flexibility and focusing ability."⁸

Floaters

Floaters are tiny pieces of debris that block the light coming into the eye. They are formed when the vitreous humor condenses and congeals with age. "Vitreous Humor is the transparent, colorless mass of gel that lies behind the lens and in front of the retina and fills the center of the eyeball."⁹ It helps the eyeball maintain its shape. Floaters can obstruct central and peripheral vision.

Glare

Glare is "scatter from bright light that decreases vision."¹⁰ The cornea looses transparency and begins to scatter light. An example of this is driving a car with a dirty windshield into the bright sun.

Tearing

Tearing can be caused by several factors. The most common are dry eye or blepharitis. Tears help keep the eyes lubricated and wash away irritating foreign matter. When the eyes are unable to produce normal tears (Dry Eye), the dryness causes irritation and the eye thinks foreign matter is the cause and produces excess tears to wash it away. Blepharitis is a condition of the eyelashes. It is similar to dandruff and can irritate the eye. The person has to wash the eyelashes to remove it and use prescription medication (eye drops) to keep the eye moist.

Night vision

Night vision is the ability to see in decreased illumination, such as in the moonlight. According to the Ameritech, the loss of night vision is a result of a loss of sensitivity in the retina. The person is unable to see well in dim light and the eye needs more time to adjust to brightness.¹¹ An example of this is going out of a dark place like a movie theatre and into bright sunlight. It has been determined that it takes an adult age 60 and over, with normal vision, two to three times as much light to perform the same task as that of a 20-year-old.

According to the National Eye Institute, "a cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. It can occur in either or both eyes. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery."¹² The clouding reduces the amount of light that reaches the retina and can cause blurred vision.

Picture from St. LukesEye.com http://www.stlukeseye.com/FAQcataract.asp

The risk of getting cataracts increases with age. Other risk factors include certain diseases (diabetes), personal behavior (smoking), prolonged use of steroids, environment (long-term exposure to sunlight), eye injury, and high cholesterol / triglycerides.

Glaucoma

Glaucoma describes a group of eye diseases marked by increased pressure within the eyeball. If left untreated, glaucoma can damage the optic nerve and cause loss of vision. The person with glaucoma loses their peripheral vision but has central vision. Over time the person will eventually lose their central vision and become totally blind.

Picture from the National Eye Institute, http://www.nei.nih.gov/health/glaucoma/glaucoma_facts.htm#1

Glaucoma is known as the "silent thief" because vision is lost gradually and the person may not realize there is a problem until it is permanent. It is the leading cause of blindness. Although any person can develop glaucoma, persons at a higher risk are those with a family history of glaucoma, persons over the age of 60 (particularly Mexican Americans) and African-Americans over age 40. Those with a family history should have regular annual exams for glaucoma after age 30. Regular eye exams after age 45 are necessary for the majority of people.

Treatment for glaucoma can involve medications, surgery, or a combination. Treatment will not improve the sight that is already lost, but will help improve the remaining vision. It is important to lower the eye pressure in the early stages of glaucoma in order to slow the disease's progression and help save vision.

There are three types of glaucoma:

1. Primary glaucoma is the most common type. It includes:

• Open angle glaucoma is most common in the U. S. and can be detected during routine eye exams, and

• Closed angle glaucoma has a quick onset. People have a sudden increase of pressure behind the eye. Some complain of pain, nausea, blurred vision or redness of the eye.

2. Secondary glaucoma occurs due to complications that arise from diseases, injuries, and inflammation.

3. Congenital glaucoma occurs in children with a developmental defect of the eye's drainage mechanism.

Macular Degeneration

Macular Degeneration is a common eye disease that affects the sharp, central vision of the eye. For Americans over the age of 50, macular degeneration is the leading cause of vision loss and blindness and increases in prevalence with age. It is commonly known as Age-Related Macular Degeneration or AMD. It is caused by hardening of the arteries that provide nourishment to the retina. Central vision deteriorates because it does not receive the oxygen and nutrients it needs to function and thrive.

This example demonstrates what a patient with advanced macular degeneration sees.
Photo from: St.LukesEye.com
http://www.stlukeseye.com/Conditions/MacularDegeneration.asp

There are two types of macular degeneration: Dry and Wet

1. Most of those diagnosed with AMD have the dry type, in which there is a slow breakdown of light-sensing cells in the macula (a tiny area in the center of the retina that helps produce sharp, central vision) and a gradual loss of central vision. There is no treatment for dry AMD.

2. Wet AMD affects 10% of those diagnosed. "This type occurs when new vessels form to improve the blood supply to oxygen-deprived retinal tissue. However, the new vessels are very delicate and break easily, causing bleeding and damage to surrounding tissue."¹⁴

The most common sign of dry macular degeneration is blurred vision. For wet macular degeneration, vision is often distorted. Straight lines may appear crooked. One may notice that the size or colors of objects seen by each eye appear different.

For some people, treatment for AMD may involve laser surgery to stop the blood vessels leaking into the macula. But most people will need to learn to use low-vision aids (assistive technology) to continue their activities.

Diabetic Retinopathy

Diabetic Retinopathy is an eye condition caused by the effects of diabetes. It attacks the retina of the eye. Initially, the person will not exhibit any symptoms or notice any vision loss. Diabetic retinopathy has three phases:

1. Early phase is called background diabetic retinopathy: The retina's arteries become weakened and leak forming small hemorrhages. As a result, swelling and edema of the retina occur as well as decreased vision.

2. Second phase is called proliferative diabetic retinopathy: The retina becomes oxygen deprived due to circulation problems. New vessels form to supply the retina but hemorrhage easily causing blood to leak into the retina. This forms floaters or spots which cause further vision loss.

3. Final stage results in retinal detachment and glaucoma. This occurs as abnormal vessel growth continues and tissue scars.

Treatment for diabetic retinopathy may include laser surgery or vitrectomy. Laser surgery, also known as photocoagulation, involves making tiny burns on the retina to seal off the vessels and stop the leaks. Vitrectomy is performed when the blood vessels continue to leak after laser surgery. Vitreous is drawn out of the eyeball and is replaced with saline solution or another fluid.¹⁵

Other Causes of Vision Problems: Medication and Stroke

Common prescription drugs that can affect older adults' vision are: anti-anxiety drugs, antihistamines, barbiturates, diuretics, antidepressants, amphetamines, and pain reducers. Steroids are known to increase problems with cataracts and glaucoma. Usually, reducing or stopping the medication will eliminate the problem. Eyeglasses can correct the vision problem if the medication cannot be eliminated. Artificial tears (eye drops) can decrease irritation side effects of drugs causing dry eyes.

A stroke can affect peripheral vision. For example, if the stroke affects the right side of the body, the vision loss will occur on the right side of the left eye and the right side of the right eye. This is called a field cut (hemianopia). The person will have a tendency to bump into things on the affected side (in this case, the right side) or may have difficulty reading due to peripheral vision loss on the left side. (See examples below)¹⁶

Hearing Changes

Hearing changes occur as we age. Hearing changes are very gradual and are known to start at middle age.

Prebycusis

The elasticity of the eardrum decreases making it difficult to hear high frequencies and other sounds. This hearing change is called prebycusis. Sounds may be difficult to understand or may be muffled. Those with hearing difficulties find it has an impact on their emotional, physical and social well-being. A person with a hearing loss may deny having a problem or will be embarrassed to talk about it. They are more likely to report being depressed, dissatisfied with life, have reduced functional health or feel isolated.

The Better Hearing Institute reports that 10% of the American population (28 million) experiences some form of hearing loss. The baby boom generation (78 million) will probably experience a much greater incidence of hearing loss due to exposure to loud music.¹⁷ The prevalence of hearing loss increases with age up to 1 in 3 over age 65. Most hearing losses develop over a period of 25 to 30 years. For those over age 65, hearing loss is the third most prevalent, but treatable disabling condition, behind arthritis and hypertension. Ninety-five percent of those with a hearing loss are treated with hearing aids while 5% are treated through medical or surgical procedures.¹⁸

Causes of Presbycusis (Hearing Loss)

• Sensorineural hearing loss (or nerve-related deafness) involves damage to the inner ear caused by aging, pre-natal and birth-related problems, viral and bacterial infections, heredity, trauma, exposure to loud noise, fluid backup, or a benign tumor in the inner ear. Almost all sensorineural hearing loss can be effectively treated with hearing aids.

• Conductive hearing loss involves the outer and middle ear that may be caused by blockage of wax, punctured eardrum, birth defects, ear infection, or heredity, and often can be effectively treated medically or surgically.

• Mixed hearing loss refers to a combination of conductive and sensorineural loss and means that a problem occurs in both the outer or middle and the inner ear.

• Central hearing loss results from damage or impairment to the nerves or nuclei of the central nervous system, either in the pathways to the brain or in the brain itself. ¹⁹

Tinnitus

Tinnitus is defined as noises (ringing, whistling, booming, etc). in the ears.²⁰ The constant buzzing and ringing sounds are very real to the individual but cannot be heard by others. The constancy of these sounds can cause agitation and a feeling of "losing one's mind." The American Academy of Audiology estimates there are 40-50 million Americans who suffer with tinnitus. It can be caused by chronic ear or sinus infections, Meniere's disease, certain medications, head and neck trauma, circulatory problems or misalignment of the jaw. The condition continues to puzzle the medical scientists.²¹

The Hear-It Organization recommends the following ways to help tinnitus sufferers live with the condition:²²

• Learn to relax.

• Try to keep your mind occupied with activities or work.

• Try not to think about the ringing or buzzing sounds.

• Lower the intake of caffeine.

• Maintain a good sleeping pattern. Do not sleep during the day.

• Be aware of environmental noise levels.

Ten Ways to Recognize Hearing Loss²³

• Do you have a problem hearing over the telephone?

• Do you have trouble following the conversation when two or more people are talking at the same time?

• Do people complain that you turn the TV volume up too high?

• Do you have to strain to understand conversation?

• Do you have trouble hearing in a noisy background?

• Do you find yourself asking people to repeat themselves?

• Do many people you talk to seem to mumble (or not speak clearly)?

• Do you misunderstand what others are saying and respond inappropriately?

• Do you have trouble understanding the speech of women and children?

• Do people get annoyed because you misunderstand what they say?

Communication Tips²⁴

If you have a hearing loss caused by presbycusis or know someone who does, share these tips with family members, friends, and colleagues:

• Face the person who has a hearing loss so that he or she can see your face when you speak.

• Be sure that lighting is in front of you when you speak. This allows a person with a hearing impairment to observe facial expressions, gestures, and lip and body movements that provide communication clues.

• During conversations, turn off the radio or television.

• Avoid speaking while chewing food or covering your mouth with your hands.

• Speak slightly louder than normal, but don't shout. Shouting may distort your speech.

• Speak at your normal rate, and do not exaggerate sounds.

• Clue the person with the hearing loss about the topic of the conversation whenever possible.

• Rephrase your statement into shorter, simpler sentences if it appears you are not being understood.

• In restaurants and social gatherings, choose seats or conversation areas away from crowded or noisy areas.

Smell/Taste Changes

Our sense of smell changes very little as we age and our sense of taste changes slowly over time. It is estimated a person has 245 taste buds on each of the tongue's tiny elevations by age 30. But by age 70, the taste buds have declined to 88. Many older adults complain that the food they eat tastes bland. Sweet and salty tastes are the first to be affected. For those adults with high blood pressure or sodium-free diets, adding herbs to food is suggested to improve taste.

Touch

As we age, our skin's sensitivity decreases. Therefore, our sense of touch also decreases. The skin becomes thin, less taut and less elastic. Tissue loss occurs directly below the skin. The most common receptors we have are heat, cold, pain, and pressure or touch receptors. Pain receptors are probably the most important for safety because they protect the person by warning the brain that the body is hurt.²⁵ Due to the skin's changes and decreased sense of touch, the older person may not experience pain until the skin has already been injured (such as burns from hot bath water or bruises).

Return to top

Cognitive Changes

Cognition refers to the mental processes used for perceiving, remembering, and thinking. Research has determined that during our 30s and 40s, cognitive abilities and skills are at their greatest potential. During our late 50s and early 60s, cognitive abilities stay about the same and then begin to decline, but only to a small degree. An older adult may first begin to notice the effects of cognitive changes around age 70 and beyond.

Cognitive Factors

Our cognitive ability involves several factors. These are:

• Fluid and crystallized intelligence

• Attention span

• Processing speed

• Memory

Fluid Intelligence

Fluid intelligence involves the ability to think and reason. It includes the speed in which to analyze information, attention and memory. It is believed that fluid intelligence declines with age. Crystallized intelligence involves all the accumulated information acquired through education and everyday life experiences. It involves the ability to apply the skills and knowledge to problem solve.

Attention Span

Attention is necessary to be able to take in information, focus on bits of information and be able to pick and choose which to discard or use. Research has indicated that attention skills decline with age. Older adults find it difficult to distinguish between relevant and irrelevant information. They become easily distracted.

Processing Speed

Processing speed also slows down as we age. This involves the mental processing and reaction time to incoming information. It may take an older individual a longer period to complete a task than a younger person.

Memory

Memory is a complex function that can be divided into different types: short-term and long-term memory. Short-term memory, also known as immediate recall, is most affected by age. Short-term memory requires being able to retain information that must be manipulated or transformed in some way. It is the use of conscious memory of facts and events, looking up a number in a directory, closing the directory, and dialing it from memory. Long-term memory involves the ability to retain acquired skills and reflexes, such as driving a car. In general, memory tasks that are complex and require processing new information quickly may become more difficult with age.

Not everyone experiences cognitive changes. Some are affected by cognitive changes more than others. Some people with small cognitive changes found it did not cause a disabling effect on their daily activity functioning. Many are learning ways to compensate for their cognitive loss as well as regain lost function. Calendars, lists, voice recorders and other memory aids help minimize memory problems.²⁶

Return to top

Mobility Changes

Older adults experience changes in their posture and gait. Loss of muscle strength and muscle mass can make it difficult to move quickly, walk up stairs, and get in and out of a car, chair or bathtub. They may have a slower reaction time. Their walking pattern may become shorter and slower. Swinging of the arms may be less. Altered postural control and balance are also affected by changes in central neurological mechanisms.²⁷ The joints may become stiffer and less flexible. Fluid in the joints may decrease and the cartilage may begin to rub together and erode, causing pain and inflammation. Calcification (mineral deposits) may form in the joints. Muscles may become rigid and lose tone with age. These changes can cause higher risk for falls. Yet, functional mobility can be improved through participation in appropriate exercises.

Return to top

Cardiopulmonary Changes

With aging, there may be cardiovascular changes that can lead to a reduction in physical and mental ability and the development of heart and vascular disease. As the heart changes, it becomes more difficult to pump a sufficient amount of blood through the body, causing stress on the organ. Other cardiovascular changes include the loss of elasticity and increased stiffness of the large arteries (hardening of the arteries).

Pulmonary problems arise when the numbers of alveoli in the lungs decrease and the membranes thicken with age, making it difficult for gases to exchange. This can lead to shortness of breath, fatigue, and elevated blood pressure. In some cases, the individual may feel dizzy when changing positions such as moving from a sitting to a standing position (hypotension).

Aging may cause the muscles of the rib cage to deteriorate, further reducing the ability to breathe deeply, cough, and expel carbon dioxide. As a consequence, the older adult is more susceptible to drug toxicity, has slower rate of healing after illness, and a lower response to stress.

It is critical that the older adult include exercise in their daily activities. For an older adult, exercise increases the heart rate and blood pressure more than for a younger person. Also, the heart works harder to pump the blood and exertion comes more quickly. Consequences of cardiovascular changes are hypertension with the increased risk of stroke, heart attack, and congestive heart failure.

Studies have found that older people who are active and adequately conditioned have a heartbeat and blood pressure rate almost similar to that of younger people. Also, it is important to remember to lower the risks for cardiopulmonary disease by avoiding smoking, exercising moderately and consistently, and following a moderate caloric and low-fat diet.

Urinary Changes

For the older person, the kidney decreases in size causing a reduction in muscle tone and bladder capacity. This results in more frequent urination and may limit travel outside the home for long periods. This limitation causes poor self-esteem for many older adults. For men over 50, enlargement of the prostate gland can reduce the size of the channel for urine. Bladder infections may arise if urine remains in the bladder too long since it is reduced in size and has lost elasticity. "Due to neurological changes the time between the urge to void and the need to void has decreased-which means when older individuals feel the need to urinate they must do so quickly."²⁹

Constipation is a frequent problem for older people. Tissue changes cause the bowels to become sluggish. Also, changes in thirst sensations may cause a reduction in the amount of liquid intake. Drinking plenty of liquids, exercising, and eating plenty of roughage will help prevent constipation.

Gastrointestinal Changes

During the aging progress, the gastrointestinal system produces less hydrochloric acid, digestive enzymes, and saliva. There is also a decreased gag reflex. Mentioned earlier, there is also a reduction in the number of taste buds. All of these changes can cause the person to experience gastrointestinal distress, impaired swallowing, or delayed emptying of the stomach.

There is an impairment of the breakdown and absorption of food as well. Deficiencies of B, C, and K vitamins can occur and in most extreme cases, malnutrition. If the person is not treated for this, these deficiencies can result in weakening of the capillaries, bruising easily, muscle cramping, appetite reduction, weakness, and mental confusion and/or illness.²⁸

Integumentary Changes

The integumentary system involves the teeth and mouth. People over 55 have a tendency to develop decay in the neck of the tooth near the gum line. For the older person, saliva changes occur which can cause drying of the mouth. Due to this dryness, dentures do not fit well and can slip.

References*

¹U.S. Census Bureau. (2001, February). Americans with Disabilities, 1997, Current Population Reports, p70-73. Retrieved February 11, 2004, from http://www.census.gov/prod/2001pubs/p70-73.pdf

²U. S. Department of Health and Human Service, Administration on Aging. (n.d). A Profile of Older Americans: 2003. Retrieved February 11, 2004, from http://www.aoa.gov/prof/statistics/profile/2003/2003profile.pdf

³Information extracted from Using Technology to Promote Independence for Older Adults - A RERC-Aging Workshop, funded by the National Institute of Disability & Rehabilitation Research, 1999.

⁴Ohio Department of Aging. Senior Series: Sensory Changes, SS-174-00. Retrieved on February 11, 2004 from http://www.state.oh.us/age.

⁵Lighthouse International. Retrieved on March 1, 2004 from www.lighthouse.org

⁶American Society on Aging. Retrieved on March 1, 2004 fromwww.asaging.org/ameritech/.

⁷National Eye Institute. Prevent Blindness in America (2002). Vision Problems in the U.S. http://www.nei.nih.gov/eyedata/pdf/VPUS.pdf

⁸Retrieved on March 1, 2004 from www.vsp.com/source/html/glossary/htm.

⁹Retrieved on March 1, 2004 from http://www.visualhealth.com/content/glossary.htm.

¹⁰Retrieved on March 1, 2004 from www.vsp.com/source/html/glossary/htm.

¹¹Retrieved on February 11, 2004 from www.asaging.org/Ameritech.

¹²National Eye Institute. Retrieved on March 1, 2004 from http://www.nei.nih.gov/health/.

¹³St. LukesEye.com. Retrieved on March 1, 2004 from http://www.stlukeseye.com/FAQcataract.asp.

¹⁴Ibid.

¹⁵American Diabetes Association. Retrieved on March 1, 2004 from http://www.diabetes.org/type-1-diabetes/eye-complications.jsp.

¹⁶Lighthouse International. Retrieved on March 9, 2004 from http://www.lighthouse.org/Low_Vision_Information/resources_lv_hemianopia.htm.

¹⁷Better Hearing Institute. Facts about hearing loss available at http://www.betterhearing.org

¹⁸Self Help for Hard of Hearing People. Retrieved on March 9, 2004 from http://www.shhh.org.

¹⁹The National Institute on Deafness and Other Communication Disorders. Retrieved on March 9, 2004 from http://www.nidcd.nih.gov/health/hearing/presbycusis.asp#what.

²⁰Williams and Wilkins. Stedman's Medical Dictionary, 24th ed., 1982, p.1455.

²¹American Academy of Audiology. Consumer Guides, Tinnitus: Noises No One Else Can Hear. Retrieved on March 9, 2004 from http://www.audiology.org/consumer/guides/noises.php.

²²Hear-It Organization. Retrieved on March 9, 2004 from http://hear-it.org.

²³American Tinnitus Association. Retrieved on March 9, 2004 from http://www.ata.org.

²⁴Ibid.

²⁵Come to your senses. Retrieved on March 9, 2004 from http://library.thinkquest.org/3750.

²⁶American Federation for Aging Research. Retrieved on March 9, 2004 from http://www.infoaging.org/b-neuro-1-what.html.

²⁷University Extension. Physical Changes in Aging (1985). Human Environmental Sciences Publication GH6729. Retrieved on March 9, 2004 from http://muextension.missouri.edu/explore/hesguide/humanrel/gh6729htm

²⁸Retrieved on March 9, 2004 from http://www.aginginplace.org

²⁹Gerontology 130 Working with the Frail Elderly: Lesson Two-Normal Age Changes. Retrieved on March 9, 2004 from http://www.cvc3.org/modelcvc3courses/elliswaller/lesson2.htm.

*References were obtained in February and March of 2004. Due to frequent changes to websites, some links may no longer be active or available. Archival websites, such as http://www.archive.org/web/web.php may be used to find sites that are no longer active or available.

Resources