In March, 1940, Dr. Harry Chambers was called to the home of eleven-year-old Timothy Scheffer. “Little Timmy,” as he was known, had developed a “terrible cough and chills” several days before, and, more ominously, a bright red rash had emerged on his back earlier that day. His mother feared the worst. Dr. Chambers arrived at the Scheffer’s house about 4 o’clock in the afternoon and examined Little Timmy. It was nothing to worry about, he assured Mrs. Scheffer. Timmy just had a mild bacterial infection—nothing a little bit of medicine couldn’t fix. The rash was merely a heat rash caused by the several blankets Mrs. Scheffer had piled onto her son in an attempt to relieve his chills. Within a few days, Timmy was feeling better and, much to his chagrin, had to return to school. There was nothing extraordinary about Timothy Scheffer’s case. In fact, Dr. Chambers, like thousands of other doctors across America at the time, made house calls such as these quite frequently.

Up until the mid-1950s, house calls accounted for about 40% of all patient physician interaction. There are literally thousands of historical examples of doctors treating their patients outside of a “doctor’s office.” While many doctors had an office, primary patient care was more likely to be given at the patient’s home, especially before the 1870s. Hospitals are by no means a new invention, yet only recently has the idea of the hospital been merged with the idea of the doctor. Prior to the mid-1850s, doctors were most often what we would now refer to as “administrators” in hospitals, they set general care guidelines but offered very little in terms of actual patient care. It is no surprise, then, that many people regard the house call as the foundation of the American medical profession.

Since the 1950s, however, the number of house calls made by traditional medical professionals in the United States has fallen off to less than 0.5%. Those individuals who still remember this old-fashioned practice often lament its demise. It is hard to understand why such a popular practice has declined by such a large extent. There are a few reasons that can be pointed out. First, the advancement of medical technologies brought with it large, expensive diagnostic and treatment machines that required centralized storage and use. It became impossible to use such equipment in a patient’s home, meaning that the patient had to schedule appointments at hospitals and doctors’ offices for certain tests and treatments. This shifted the focus from patient care at home to patient care outside of the home. Secondly, at the same time, doctors were learning more and more about fundamental biological processes. This new scientific knowledge led to a marked increase in medical specialization, which further shifted the site of care from the home to the office.

Recently, however, the house call has begun to experience a comeback of sorts. More and more primary care providers are realizing the potential benefits of treating patients at home. Patient care tends to be more focused on individual needs, and treatments are more tailored to the patient. Additionally, patients are typically more satisfied with the level and quality of care they receive when they are treated at home. Ironically, the same type of technological
advancements that shifted patient care from the home to the office may now
provide a way back. The digital revolution has led to many changes. Bulky, awkward medical machines have largely been replaced by smaller, lighter, more accurate computerized ones. For instance, x-ray machines that once weighed thousands of pounds and required a whole room for storage now fit conveniently in the back of a minivan. Other digital diagnostic tools do not require vast amounts of energy and can now be performed quickly in the field. Digital prescriptions can be uploaded directly from a physician’s computer to nearly any pharmacy, anywhere in the United States, all at the touch of a button. The relative low cost of digital machines make them a very attractive purchase for doctors, as well. For these reasons, it seems very likely that the future of American medicine will be found in the resurgence of an old-fashioned practice —the traditional house call of Dr. Harry Chambers and his bygone era.

Metro Medical
704-333-6642 (MMHC)
www.treatmentathome.com

In the beginning, the effects of gradual hearing loss are barely perceived. So what if you occasionally ask the bank teller to repeat himself, or you have to turn up the volume on the television a few extra bars. It happens to the best of us right? Then one day you notice your hearing loss is causing more than the occasional misunderstanding. You find yourself asking for clarification more often than before. You opt out of your weekly bridge game because your hearing loss causes more frustration than fun. And even worse, close friends and family members are beginning to notice. So you run to your local electronics store to purchase a body-worn, personal amplifier- a little headset hardwired to a processor and a microphone ought to add the boost to your hearing you need. After all, the effects of your hearing loss are only occasionally noticed. Soon you notice that while at times beneficial, a personal amplifier alone may not always to the trick. Hearing aids may be what you require.

How hearing aids and personal amplifiers differ?
A personal amplifier is a form an assistive listening device. According to the American Academy of Audiology, “Assistive listening devices (ALDs) expand the functionality of hearing aids and cochlear implants by helping you separate the sounds you want to hear from background noise, and by enabling you to hear when the speaker is more than a few feet away”. While not always used in conjunction with hearing aids, ALDs are the perfect companion to hearing aids in order to facilitate better hearing. Some key differences exist between an ALD and a hearing instrument. They include microphone placement, processing and programmability.

The typical body worn personal amplification system consists of a set of headphones that are hard-wired to a processor which houses a microphone. Sound entering this microphone is routed to the headphones and into the ears at equal levels. Since our brains use the timing and volume differences of sound in order to interpret their location, the ability to pinpoint the origin of a sound (from the left or from the right) becomes diminished with a body-worn ALD. There are times when this is acceptable. For example if you are at a lecture and attending to the same sound source for a long period of time. On the other hand, the ability to localize sound becomes more important when someone is yelling to get your attention from across the room. Also microphone placement is important when considering phone use. Phone use using a body-worn personal amplifier is nearly impossible. Most hearing aids have a magnet that communicates directly with a telephone. This makes telephone use more pleasant.

Another key difference between personal amplifiers and hearing aids is the method of sound processing. In general, body-worn personal listening devices use analog technology whereas hearing aids use digital technology to amplify sound. The ability to separate speech sounds from background noise and employ other advanced features which aid in improved listening comfort and better speech understanding, are made possible using digital technology. Digital technology also leads to better sound quality and enables a hearing aid professional to tailor the sound to match exactly the user’s hearing loss. Body-warn, personal amplification devices amplify all sounds by the same amount and do not account for the individuals hearing loss for various sounds. A typical hearing configuration requires more high-pitch amplification than low-pitch amplification. . Thus, users may report an annoyance in the sound quality of the personal amplification device because it is amplifying all sounds- even unwanted ones.

Hearing loss can offer challenges and obstacles that make everyday tasks you once enjoyed seem almost impossible, and a trip to your local electronics store can seem like a quick fix. However, hearing loss is a complex issue. It is difficult to find a solution that is both effective and affordable. Hearing aids don’t always offer the perfect fix, and oftentimes it is necessary to use a hearing aid in conjunction with an assistive listening device.

If you suspect you may suffer from hearing loss, instead of taking matters into your own hands, it is necessary to seek the guidance of your medical doctor or ENT. A physician can provide medical clearance for the use of amplification and ensure there are no underlying medical complications. The advice of a local hearing care professional can assist in selecting the level of technology which suites your hearing and lifestyle needs as well as assist in determining if you are a candidate for assistive technology, traditional hearing aids or, more often than not; both.

Natalye M. Faison Au.D.- A native of Denver, CO, she received her B.A. in Communicative Sciences and Disorders from Hampton University then pursued her doctoral degree at Gallaudet University. Upon graduation Dr. Faison worked in both hospital and private ENT settings before transitioning to industry as an inside Audiologist and Trainer. She is currently Inside Audiologist for Panasonic Corporation of North America- Hearing Aid Division in Secaucus, NJ. Her professional interests include geriatric amplification and assistive listening devices. Dr. Faison currently resides in New Jersey and enjoys traveling.

Their are different types of Pet Sitting Options. First lets define the two basic type of care in question:

A) On-Going Care – For people that wish/need someone to come in during the day to feed, take-out, walk, care for their animals. Often times it is due to employment hours of the “owner” that help is needed.

B) Respite Care – This is more often for owners leaving on a business trip or a vacation that need assistance just for the period of time that they are gone.

Some of the most frequent that we are involved with include the following:

1. Pet Sitting – A pet sitter can come into a home and walk, take out, play with, feed, etc. a pet in their care. This can happen once a day, a few times a day, or could involve overnight or all day care. Often times we get calls from two types of clients. Pricing is usually based on per time increment (ie, 20 or 30 minutes). Breaks are given to those clients with more than one pet.

2. Private Pet Kenneling – This has started to grow throughout the USA. This option includes dropping off, or having someone pick-up, a pet to be private boarded at the pet sitters’ private residence/home. Most often it is cheaper than “Kenneling” a dog at a local Kennel. And, even more importantly, it is usually one-on-one care for the pet with the pet sitter or sometimes the pet sitters family. This can reduce the chance of injuries of illnesses resulting from interaction with other animals within a more “public” kennel. Pricing for this option is quoted per day with, again, a break given to those with more than one pet.

3. Live-In Care – A pet sitter can come in and live at the home/apartment/condo of the owner and be with the pet during the time in question. Often times this is requested due to anxiety/stress of a pet in question or sometimes due to a medical condition.

4. Additional Services (for additional fee’s) – Some of these can include things like bathing, grooming, nail clippings, shots (ie, diabetic pets), poop scoop service etc.

Phil Koch
President/Owner
Pet Sitters of Charlotte (PSOC)
www.petsittersofcharlotte.com
Tel: 704.543.0588

Considerations for patients who have hearing and vision problems.

As many as 1 in 5 people ages 70 years or older have both hearing and vision loss. This article examines dual sensory loss, and provides recommendations for better serving the needs of this unique and growing patient population.

The demographics of the world population are changing, with the segment of adults 65 years of age and older growing rapidly. By 2040, it is estimated that older adults will constitute 20% of the US population.

As people age, there are normal age-related changes in the auditory and visual mechanisms. Dual sensory loss—or hearing and vision loss combined is increasing and will continue to do so as the number of seniors grows during the next several decades. As a result, hearing care providers need to ensure that their services are accessible to this segment of the population.

Debra Busacco, PhD is a national audiology consultant based in the greater Washington, DC area, and an adjunct professor teaching online classes in health care management for Trident International University. She is the former director of the George S. Osborne College of Audiology at Salus University in Philadelphia, and has also worked as director of the Center for Teaching and Learning Excellence at the University of Scranton (Pa) and as the director of academic affairs at the American Speech Language Hearing Association (ASHA), Rockville, Md.

In dual sensory loss, the degree of vision and hearing loss is reported to be significant enough to result in communication problems that go beyond difficulties experienced for either sensory loss alone.2 Estimates of the percentage of people with dual sensory loss in those age 70 years and older range between 9% to 21%.3 The incidence of dual sensory loss varies, depending on the definitions used to define hearing loss and vision loss, as well as on the method of data collection.

Age-Related Sensory Changes

Hearing loss is the third most chronic health condition affecting older adults. Approximately 30% of those over age 65 have some degree of hearing loss, with estimates ranging from 70% to 90% of those over age 85, which is the fastest growing segment of the population in the world.4

Presbycusis, age-related changes in auditory function, is caused by anatomical and physiological changes to the entire auditory pathway.5 However, the aging of the auditory system is not uniform throughout the mechanism. Age-related changes in the peripheral and central auditory pathways impact speech understanding ability, especially in degraded listening conditions, such as in the presence of noise, reverberation, or temporally-altered speech.6

Age-related changes in the visual mechanism are known as presbyopia. Normal age-related changes in vision include decrease in pupil size, loss of color sensitivity, glare sensitivity, delayed ability to adapt to the dark, reduced peripheral visual fields, and loss of depth perception.7

Approximately 10% of Americans are legally blind. The definition of legal blindness is visual acuity with the best correction in the better eye equal to or worse than 20/200, visual fields less than 20°, or both. About 3 million Americans are reported to have low vision—a term implying that an individual has significant vision loss but can accomplish tasks with the use of assistive technology and environmental modifications.8

Causes of Low Vision in Older Adults

The four most-common causes of vision loss are age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma:9

Age-related macular may take one of two forms; dry macular degeneration and wet macular degeneration. Dry macular degeneration is more common, and is associated with deposits of drusen (tiny yellow or white accumulations of extracellular material) on the macula. Wet macular degeneration is characterized by the formation of abnormal blood vessels that leak fluid and cause scar tissue to form on the macula. degeneration

Age-related macular degeneration results in a loss of vision to the central visual fields. This disorder has significant implications for speechreading and sign language, as fine details may not be visible. Age-related macular degeneration also may cause problems reading fine print, seeing faces, viewing objects at a distance, and possibly some delay in adapting to the dark.10

Diabetic retinopathy will continue to be a growing problem due to the 23 million Americans diagnosed with Type 2 diabetes, and many more individuals who will be diagnosed in the future. In uncontrolled diabetes, there are problems with the capillaries of the blood vessels in the eyes. This results in problems related to decreases in visual acuity, blurred or hazy vision, glare sensitivity, decreases in contrast sensitivity, and decreases in color discrimination.11

Cataracts result in blurred visual acuity, and can impact all facets of vision depending on the stage of the ocular disease. Typically, cataracts are binocular. Cataracts are removed with a surgical procedure that generally restores vision to normal or near normal. If left untreated, a cataract can cause permanent blindness.10

Glaucoma is the result of an increase in the intraocular pressure in the eye, which can result in degeneration of the optic nerve. Untreated glaucoma can result in permanent blindness. This eye disease impacts visual acuity and visual fields, depending on the stage of the disease.10

These ocular conditions may exist in isolation or coexist. For example, a diabetic may have diabetic retinopathy, and glaucoma or cataracts. The subpopulation of older adults who have a pathological condition as well as normal age-related visual changes may report significant impact on communication abilities, especially if they are not able to use visual cues to compensate for degraded auditory information.

Dual Sensory Loss Individuals with dual sensory loss report poorer self-health, depression, reduced quality of life, and less interaction with social networks.12 Older adults with dual sensory loss are more likely than their non-impaired peers to need help with instrumental activities of daily living, such as personal care, medication management, or phone use. They also are more likely to need help with mobility and shopping, and are more likely to live with family members.13

People with dual sensory loss may have greater risks for falls than those with single sensory loss. This is a significant problem for the elderly, as falls are the third leading cause of death in this population.14 While balance typically is considered a vestibular function, vision and somatosensory information also play a significant role. Professionals should observe patients for balance issues, as well as review this area during the case history intake. When a balance problem is present, the clinician should refer the individual to an appropriate health care professional and work in conjunction with the vision specialist (and, possibly, a physical therapist) to design the most appropriate intervention plan. Orientation and mobility training should address falls and fall prevention to avoid injuries that can be devastating for seniors with coexisting conditions.15

Rehabilitation Recommendations

Amplification and implant technologies. When dealing with dual sensory loss, it is imperative that information is maximized through each sensory system so that additional auditory and visual compensatory cues are available. It is critical that an older adult with dual sensory loss obtain amplification for safety and to improve their quality of life. Amplification should include bilateral hearing aids coupled, whenever possible, with a personal listening device, such as an FM or infrared system. The controls on the hearing aid should be minimal with as many automatic features as possible.7

Recently, a programmable hearing instrument, the JZ, was introduced by Panasonic Corporation of North America.16 It was introduced with the target market as older adults with vision and/or motoric problems. The JZ is easy to operate, as it has large controls and a large LCD screen. In addition, it has a rechargeable battery so battery insertion is not problematic. The JZ requires minimal training for the client and caregiver. It has four different programs with features such as noise reduction, feedback suppression, and wind noise management.

Weinstein4 stated that cochlear implants, preferably bilateral, should be considered for those older adults who meet the qualifying criteria. Following cochlear implantation, a comprehensive auditory rehabilitation program that includes auditory-visual speech perception training, listening training, and communication skills enhancement such as cued speech to supplement audition and psychosocial counseling should be implemented.

Hearing assistive devices. The recommendation of a variety of visual and auditory devices makes seniors more confident, and often allows them to live independently. Wireless pagers used in the home can help with identification of environmental sounds, such as smoke alarms, alarm clocks, telephones, and doorbells. A hearing dog can help a person identify sounds, increase independence, and live safely.

AR program A comprehensive auditory rehabilitation program should be developed and implemented in consultation with family, significant others, and professionals using an interdisciplinary team approach. Professionals who may be members of the team include a low vision specialist, geriatrician, occupational therapist, social worker, physical therapist, psychologist, and speech-language pathologist. The members of the interdisciplinary team will vary depending on the unique medical and rehabilitation needs of the older adult and the family.

Auditory and Visual Strategies to Improve Accessibility

Office accessibility. Given that a number of older patients with dual sensory loss will seek hearing and balance services, it is important that a hearing care practice be physically accessible. Although this may require an initial monetary investment, such accommodations will likely result in patients reporting greater customer satisfaction with hearing health care services. The positive “word of mouth” marketing that will be the outcome of the physical accessibility of the practice will offset the initial investment, especially as older adults are the primary users of hearing aids and are an untapped market for hearing care services.

Vision assistive devices. Low-vision assistive technology that is helpful for patients with vision loss include hand held magnifiers, lamps with magnification, portable readers, handheld telescopes, and closed circuit television (CCTV).17 These assistive vision devices can help patients see controls of amplification devices. In addition, auditory rehabilitation education materials can be magnified. It is also recommended that video materials available for patients be captioned to maximize auditory and visual information.

By having several of these vision devices available in the hearing care practice for demonstration, the older adult with vision loss becomes more confident in learning about hearing aid technology and is more likely to use the devices independently and successfully.

Lighting. Lighting is crucial in testing and counseling areas. Whenever possible, dimmers should be used as well as incandescent lighting. Lighting issues for those with vision loss may include sensitivity to glare and light, color discrimination, and reduced contrast sensitivity.

Furniture should be placed strategically with ample space for navigation with a cane or a guide dog. Office support staff ought to orient the patient with dual sensory loss to the physical space. In addition, providing the patient with detailed verbal instructions throughout the session is very beneficial and reduces the patient’s anxiety.

Printed materials. Forms—case history, contracts, education materials, hearing handicap scales, and communication scales— should be printed in fonts of size 14 or larger. Printed materials should have good contrast, with black print on a white background of non-glossy paper as the preferred choice to maximize contrast sensitivity. If the hearing care practice is providing services to individuals who are legally blind, then Braille materials should be available.

Understanding the extent of vision loss. According to Kricos,7 time will be better managed if information, such as the case history intake, is sent out in advance of the hearing or balance evaluation. It also may be helpful to ask the patient to provide reports from vision specialists so that the hearing care provider is informed about the extent of vision loss. At the time of the evaluation, a quick vision screening can be performed by using the Snellen chart to obtain information on visual acuity status. The Pelli-Robinson chart can be used to assess low contrast vision required for reading printed materials and for seeing fine details required for speechreading.

Ensuring overall vision/hearing access. Every hearing care practice should have assistive listening devices available for use during case history intake and counseling sessions, especially when dealing with a patient who has a moderate or greater degree of hearing loss. The use of these devices increases conversational fluency, demonstrates the technology available, and illustrates communication benefits.

Frequent verbal and physical interaction with the patient during the test session is important. It may be wise to use an audiology assistant or ask a family member to remain in the test booth to make the patient more comfortable during the evaluation.

If the hearing care practice has a professional Web site, then steps can be taken to maximize its accessibility for those with vision loss. Features of an accessible Web site include the ability to change the font size, ample spacing between the letters and words, best color for contrast sensitivity, and good visibility of images. Every image should be accompanied by text descriptions in the event that a patient accesses the Web site using speech synthesis software.

Enlisting help from a vision specialist. It is beneficial to ask a vision specialist to visit the Web site and hearing care practice to provide feedback about its accessibility to patients with significant vision loss. In exchange, you may offer your assistance in making their practice more hearing accessible.

ADDITIONAL ONLINE RESOURCE:

Each patient with dual sensory loss should have an individual audiologic rehabilitation plan that involves both hearing and vision professionals working in tandem so that the most appropriate assistive technology and rehabilitation will be recommended.

At this time, there is limited research on dual sensory loss in the elderly population. Some possible topics for future research include:

• Best practice models for auditory rehabilitation with this population;
• Effective educational models for vision, hearing professionals, and consumers; and
• The role of preventative medicine in reducing the incidence of dual sensory loss.

Such research information will allow the hearing care provider to offer the most effective services to improve the quality of life for individuals with dual sensory impairments and their families.

Grace is a word often heard in the context of Chrisitianity. Yet, its deepest meaning is often overlooked and not fully applied in daily living. We can sit in church and hear sermons about it. We can discuss the concept of grace more fully in Sunday School discussions, but do we understand it enough, or better yet believe in grace enough, that we apply in the way we interact with others?

Grace may be defined as unmerited mercy, a concept that is a combination of love and forgiveness rolled into one, or some other blend of attributes that hint at its nature. Most of the time, we acknowledge grace mainly as a gift bestowed by God to us when we don’t rightly deserve it.

Let’s push the concept of grace a step further. How do we practice grace in our relationships with other human beings? How often do we offer an act of unmerited mercy when someone has made a mistake or committed an offense against us… even in the little things?

A few weeks ago, I was traveling to a retreat setting located about a four-hour drive from Charlotte. I was to arrive between one and four o’clock in the afternoon. Though I was rushed, my trusty GPS estimated I would arrive about 3:30. I don’t like to be late and with 30 minutes to spare, I was still somewhat worried. My worry was not unwarranted because about one hour from the site, the traffic slowed to a crawl. A major accident had blocked part of the highway leaving me no option but to remain in the flow and endure the pain of watching the clock tick away at the “cushion time” I had put into my travel schedule.

Interestingly, I was listening to an audio CD of a book in which the author was talking about grace and its application in daily living. I thought to myself, “I certainly hope the host at the retreat will have a little grace for me if I arrive past the registration deadline.” After I passed the site of the accident, I travelled as quickly, yet prudently, as I could to arrive on time. When I pulled up to the registration center, the clock read 4:06. I was six minutes late. So, I said a quick prayer, “Lord, may this host show me a little grace today because I did not want to be late.” When I walked through the door, a thin baldheaded man peered over his wire-rimmed glasses with a glare and said, “You must be Mark.” “Yes, I’m so sorry for being late,” I replied. “I encountered a terrible accident, which slowed me down quite a bit.” I should have known from the terse look upon his face that he was not amused and definitely was not in the mood to send much grace my way. It was confirmed with his reply. “That’s why I instructed you in the email to allow plenty of time because these things happen from time to time.” He proceeded to treat me like a first grader by showing me the map to the retreat center and asking me to point out buildings and trace my finger along the path to show how I would go from the registration building to the dorm where I would be staying. I felt like being in the principal’s office in elementary school. Sure, we all do things wrong. Often right after we do something wrong, we acknowledge it and try not to do it again. But we live in a society that seems to want to focus more on punishment than grace.

As a pastor, I encounter numerous situations in church, community and even home life, where punishment or retribution seems to characterize a reaction to someone who has done something wrong. Where’s the grace? Where’s the love and forgiveness? Where’s the unmerited mercy? It may materialize in some fashion, but often only after a time of chastisement or “rubbing one’s nose” into the situation. Later that evening, upon reflecting upon the audio CD and my experience with the host, I began to ponder how I offer grace to others, even in the simple encounters. I reflected upon John 1:11-21, particularly upon verse 16: “From his fullness we have all received grace upon grace.” Like all gifts from God, we are gifted not for our personal well-being, but to share them with others. If God can show us grace, I believe we are called to show and share grace with others. Following this encounter, I’ve become more keenly aware of how I can offer grace-filled responses to others who have done something wrong, particularly against me. It may be simply acceptance of an apology with a smile. It could be an unmerited act of kindness. Maybe simply, listening to the person’s story. A grace-filled response certainly does more to build up a relationship and definitely is more reflective of the Christ-like way of life we are called to live.

Just try it… even in the little unexpected things. And, experience the joy that results!

Rev. Mark L. Barden is the former Director of Communications of the Western N.C. Conference of The United Methodist Church based in Charlotte, N.C. He has just been appointed to serve as pastor of First UMC in Elkin, N.C. Barden’s spouse, Barbara is Minister of Adult Education at Myers Park UMC, Charlotte.