This virtual issue aims to provide a resource for ENT surgeons and physicians with responsibility for the care of older adults, and draws together relevant articles from the last decade or so of issues from The Journal of Laryngology & Otology to give an up-to-date survey of the field.
Demographics
The demographics of the developed world have changed during the late twentieth and early twenty-first centuries such that the care of older adults has assumed ever more importance. In the UK in 2016, there were 11.8 million residents aged 65 years and over, representing 18 per cent of the total population; 25 years before, there were 9.1 million, accounting for 15.8 per cent of the population. The projection is that by 2066, this will have risen to 26 per cent of the population.
Not only are adults living longer, but they have longer ‘active’ lives and are often also economically productive.Reference Storey1 The reasons for this are numerous and well documented: better nutrition, medical care and fewer wars; a rise in retirement ages well beyond 60 years for both men and women in most Western countries; young families with two working parents; a reduced proportion of young adults in the population compared to older adults; economic barriers to the provision of adequate pensions; and both older adult and child care provision, with the potential this brings for intergenerational conflict. The result is that the later period in a person's life is unlikely to be spent principally in gardening (‘growing cabbages’, as a retired Roman Emperor was described).
An ‘elderly’ person will spend some of their time in the world of work, whether paid or voluntary, and have an important role in caring for spouses, children or grandchildren, and friends, often in combination with work.Reference Storey, Coombs and Leib2 These activities require a fully functioning physiology. Therefore, specialties such as ENT and the healthcare of older adults must strive to limit or ideally abolish disability and handicap in older patients, to allow them to function in these important roles. Both specialties are as much involved in improving quality of life as in extending the lifespan of their patients.
Hearing loss (and olfaction)
Hearing loss in older adults is multifactorial, with the legacy of occupational hearing loss receding as a consequence of the decline of heavy industry, and with current aetiologies dominated by mainly recessive polygenic factors and the numerous lifestyle risk factors for degenerative vascular disorders.Reference Bentur, Valinsky, Lemberger, Ben Moshe and Heymann3
Most older adults will require diagnosis and treatment for hearing loss. Even in developed countries, there are deficiencies in the provision of an early diagnosis and treatment,Reference Chew and Yeak4 although this provision is much starker in low- and middle-income countries,Reference Nieman and McMahon5,Reference Graydon, Waterworth, Miller and Gunasekera6 some of which have little or no audiology or otology service.
Rehabilitative devices such as bone-anchored hearing aids and cochlear implants,Reference Hilly, Hwang, Smith, Shipp, Nedzelski and Chen7 with indications for the latter widening, are increasingly used in older adult patients, and this can be achieved safely. Active research is under way in regenerative medicine, but this is still a long way off from offering practical therapies to restore damaged inner-ear cells.Reference Jackler and Jan8
With the rise in dementia and cognitive disorders in the population, attention has focused on the relationships between hearing impairment, the auditory brain and cognitive decline.Reference Lau, Dimitriadis, Mitchell, Martyn-St-James, Hind and Ray9 Improved afferent inputs from the use of hearing aids, for example, may have a role in limiting cognitive decline, so there is every reason to seek help for hearing loss. Screening for acoustic neuroma (vestibular schwannoma) is often age-limited, but this needs to be considered on an individual basis.Reference Basu, Youngs and Mitchell-Innes10,Reference Gair, Borsetto, Donnelly, Axon, Bance and Tysome11 A relationship between cognitive decline and olfaction has been established, in parallel with the relationship with hearing loss, and hyposmia is very common in dementia patients.Reference Gros, Manera, De March, Guevara, König and Friedman12
Tinnitus
Tinnitus and its inter-dependent relationship with psychological ill health is well recognised;Reference Pinto, Marcelos, Mezzasalma, Osterne, de Melo Tavares de Lima and Nardi13 both conditions are common in the general population and especially in older adults. Rehabilitative treatments are effective for tinnitus in many cases. Mental health services are under great strain, and audiological rehabilitation cannot entirely compensate for this deficiency.
Necrotising otitis externa
An important, and often overlooked and misdiagnosed condition of the older age group (usually diabetic), is necrotising (‘malignant’) otitis externa. This condition usually presents with unpleasant and severe ear pain. The condition is on the rise because of increasingly virulent organisms and an increasing prevalence of diabetes mellitus, and is really best described as a ‘skull base osteomyelitis’.
‘Otitis externa’ as a term is misleading, as it is all too easily dismissed as a minor condition. Necrotising otitis externa is often misdiagnosed as a stroke or a ‘Bell's palsy’ if cranial nerves are involved. Awareness of this treacherous condition among physicians is important as it is associated with significant morbidity and mortality, with the ability to produce lower cranial nerve palsies if it remains untreated. The financial burden of necrotising otitis externa on health services is considerable.Reference Stapleton and Watson14–Reference Godbehere, Hutson and Watson16
Dizziness and imbalance
Dizziness and imbalance result from disorders and degeneration of peripheral inputs (inner ears, joint and muscle position sense, vision), as well as central nervous system disorders, and any vascular or metabolic upsets that can affect central function.
Managing dizziness and imbalance in older patients often involves many specialties working together, and requires skilled diagnosis and rehabilitation. Studies from many countries show the size of the problem.Reference Soto-Varela, Faraldo-García, Del-Río-Valeiras, Rossi-Izquierdo, Vaamonde-Sánchez-Andrade and Gayoso-Diz17,Reference Lasisi and Gureje18 Simple conditions with a quick and effective treatment such as benign positional vertigo are easily overlooked,Reference Lindell, Karlsson, Johansson, Magnusson and Finizia19 but many cases are multifactorial. There is also a link between presbyacusis and vestibular deficiency (sometimes referred to as presbyastasis).Reference Tan, Tang, Lo and Yeak20 The importance in managing this effectively is amplified if an older person needs to be able to drive.Reference Sinnott, Mahoney, Wilkinson and Broomfield21
Swallowing problems
Swallowing problems in older adults are common for neurological or malignant reasons, and there is the interesting condition of pharyngeal pouch.Reference Stewart and Sen22 Pharyngeal pouches are eminently treatable, but carry high mortality due to aspiration and chest infection if overlooked. Isolated cricopharyngeal dysfunction is another niche condition that is amenable to therapy.Reference Ashman, Dale and Baldwin23 In addition, patients have considerable swallowing difficulties after partial laryngectomy, and following treatment for laryngeal and oropharyngeal cancer.Reference Seino, Miyamoto, Nakayama, Yamashita, Miles and Allen24,Reference Burnip, Owen, Barker and Patterson25 The recent coronavirus disease 2019 (Covid-19) pandemic has introduced a whole new range of swallowing problems in older patients, either due to the infection or the treatment.Reference Dawson, Capewell, Ellis, Matthews, Adamson and Wood26
The assessment and treatment of voice and swallowing problems are labour-intensive with respect to speech and language therapy services, and such services are usually under-resourced for the wide variety of conditions of all ages that they treat. This includes a wide variety of malignant and non-malignant causes of swallowing dysfunction.Reference Hanna and Randall27,Reference Kwon, Villegas, Ouyoung and Sinha28
Voice problems
Voice problems in older adults, although common, are somewhat amplified if the patient has a role that involves voice use, which encompasses many occupations, as well as family responsibilities and leisure activities. Most choirs have an older demographic in their membership, and charity shops, and National Trust properties and their guided tours, are staffed largely by retired volunteers. There is a close relationship between voice and hearing function; hence, it is particularly important that hearing rehabilitation takes place in a person who relies on their voice, so that both voice and hearing function are optimised.Reference Rodrigues Dias, Santos, Sousa, Azevedo, Sousa e Castro and Freitas29
Salivary gland obstruction and sialadenitis
Salivary gland obstruction and sialadenitis are common problems in older adults, with hospital in-patients and care home residents being at particular risk, often due to dehydration and poor oral intake. A recent article in The Journal reviews the management of this distressing condition.Reference Familiari, Ferrario, Giordano, Di Santo, Indelicato and Battista30
Nose bleeds
Nose bleeds (epistaxis) in older adults have always been associated with significant mortality, often related to associated co-morbidities and the deleterious effects on the cardio-respiratory system of nasal packing and bed rest.Reference Corr, Tikka, Douglas and Marshall31,32 This difficult problem has been rendered even more difficult by the rise in prescriptions for anticoagulant agents,Reference Ho, Bari and Riffat33 particularly the newer oral anticoagulants (‘NOACs’).
Surgical treatment options
The days when ‘lifestyle’ surgery, or other ENT, head and neck or thyroid surgical procedure, performed in older adults is dismissed as an option simply because of age are long gone, if they ever existed. The recognition that outcomes are good, and that morbidity and mortality can be reduced to acceptable levels by techniques such as local anaesthesia, has encouraged older adult patients to be offered a wide variety of surgical options, from endoscopic nasal surgeryReference Casale, Costantino, Sabatino, Luchena, Moffa and Cassano34 to major head and neck surgery,Reference Subramaniam, Balasubramanian, Rka, Rathod, Murthy and Vidhyadharan35 although there are times when conservatism is best encouraged, such as for some thyroid cancers.Reference Megwalu36 One problem when optimising head and neck cancer care in older adults is that such individuals are often left out of cancer trials.Reference Abbasi37 The topic of head and neck cancer care in the ‘elderly’ is covered in a very recent article in The Journal.Reference Iqbal, Navarro-Rodriguez, Munro, Ozalp and Kelly38
Head and neck cancer diagnosis
The diagnosis of head and neck cancer aims to be rapid in order to facilitate early treatment, but administrative systems such as the ‘two-week-wait’ clinics have had limited success, and delays in diagnosis are all too common.Reference Mettias, Charlton and Ashokkumar39,Reference Nash, Hughes, Sandison, Stewart, Clarke and Mace40 These clinics have a disappointing detection rate, and as many cancer patients are diagnosed in the ‘routine’ system – so getting routine waiting times down to acceptable levels is just as important if timely cancer treatment is the real aim. The Covid-19 pandemic has introduced further barriers to early cancer diagnosis.Reference Taylor, Omakobia, Sood and Glore41
Liam Flood has reviewed a useful book by Sataloff and Johns which would make good reading for any physician with an interest in the care of older adults,Reference Flood42 as would perusing some of the articles cited in this virtual issue.
