An invisible disability: Communication, patient safety and dual sensory impairment in older persons

Nurses play a critical role in ensuring patient safety in health care settings, yet often fail to recognize a common but poorly recognized disability in older persons, dual sensory impairment (DSI). DSI significantly impacts health care communication, patient safety and quality of care and is invisible in health care narratives, policy and practice. Our role as health care professionals and researchers in the intersectional space of older age and disability combine advocacy, qualitative research and a drive to improve patient safety through better health care communication for those with DSI. Our work is embedded in the living realities of DSI, one author lives with DSI; their greatest fear is hospitalization.

1. DUAL SENSORY IMPAIRMENT IN OLDER PERSONS

Age‐related sensory (hearing and vision) losses are significant causes of non‐fatal disease burden in Australia and increasingly prevalent in older populations worldwide (Australian Institute of Health and Welfare, 2021). Individually, vision and hearing loss have significant negative impacts on physical and psychosocial functioning; in combination (referred to as DSI), they present unique and complex challenges to older adults that compromise the capacity of older persons to age in place. DSI sits at the intersection of ageing and disability, a complex situation that obscures access to appropriate services and is influenced by a hierarchy of needs that prioritizes medical conditions, often more amenable to treatment, over complex, progressive and age‐related disabilities (such as DSI).

Recognition of DSI in older adults in Australia remains poor and lagging behind other OECD nations; recent WFDB reports from 2018 and 2023 (World Federation of the Deafblind, 2018) note that DSI is identified as a distinct disability in only 37% of nations surveyed (n = 50), which limits the availability of international data. In Australia, poor recognition extends to hospital and community health care settings and professionals involved in the care of older adults with DSI. For older adults themselves, recognition of DSI is obscured by the complexities of ageing, with poor vision and hearing normalized as part of ageing. While the prevalence of late life acquired DSI in those older than 65 years has increased sharply, current data are most likely an under‐representation of the true extent given the lack of diagnostic clarity of DSI, and poor representation of data from some population groups, for example, First Nations peoples, veterans, prisoners, those with multiple disabilities and residents in aged care facilities.

2. MULTIDIMENSIONAL IMPACT ON OLDER ADULTS

Research consistently demonstrates that the consequences of DSI extend beyond daily function and communication, with links to depression, reduced quality of life, cognitive impairment and social isolation (Mick et al., 2018). The loss of the compensatory mechanism of one sense over the other and the interruption to physical and social interactions (through communication disruption and increased social stress) compromises function and fosters dependence on others, usually family members. There are significant pervasive and intersectional barriers to participation for those with DSI. Ageism, stigma and personal concerns about increasing dependency limit social participation, reduce access to large organizations (such as health care systems) and create need for accompaniment to health care appointments. Moreover, increased dependency and care needs, while generally met by family (informal) carers, are poorly translated in health care interactions and hospitalisations (Dunsmore et al., 2020). Health and patient safety consequences include falls, decreased public health message awareness, episodes of delirium and particularly, poorer quality health care and hospital experiences (Watharow, 2021). Communication failure underpins some of these consequences with resulting high financial cost. Approaches that improve health care communication for those living with DSI and their families will have both personal and broader economic savings.

There is growing evidence suggesting that appropriate services for those with DSI and their family are limited, in Australia and internationally, and that sensory impairment is poorly documented in medical records. Lack of acknowledgement and recognition of DSI in health care, and other settings impacts access to available resources and services, and nurse education on appropriate and person‐centred communication for those with DSI.

3. OLDER PERSONS AND PATIENT SAFETY IN HEALTH CARE

Two Royal Commissions in Australia demonstrate ongoing systems of neglect that highlight the invisibility and poor social recognition of older adults generally, and, specifically, those with a disability. Despite measures, such as the Australian National Safety and Quality Health Service Standards (ANSQHS), designed to protect patient safety, improve communication and minimize adverse events, the health care experiences of older persons with DSI reflect an ongoing loss of ontological security and situational vulnerability. Recent healthcare experiences during Covid‐19 draw attention to this vulnerability—those with DSI rely on physical touch, close proximity and lip reading simply to communicate and public health measures such as social distancing and mask wearing serve to exacerbate the isolation and vulnerability already experienced by older persons with DSI in health care settings. Advances in digital healthcare, such as telehealth, can further amplify the digital divide for older adults with DSI, who may not use assistive devices such as hearing aids (HAs), have access to the internet, or the dexterity and familiarity to use effectively in a health care context.

4. COMPLEX HEALTH CARE INTERACTIONS AND PATIENT SAFETY

To date, the increasing research interest in DSI has not translated to positive health care experiences for clients and patients with DSI in primary care and the health care system. Several factors intersect here to act as barriers to communication between clients and health care professionals, particularly medical specialists, GPs and nurses. Watharow's study (2021) found that hospitalisations and health care interactions were fraught and time limited, with resulting adverse events, patient safety incidents and mistrust in the system.

Some key factors are well established; sensory loss is associated with higher health care use and higher associated costs (Hajek & König, 2020); sensory loss is also associated with poor health care communication (Shukla et al., 2019), increased need for accompaniment to health care visits and potential for adverse health outcomes. Poor communication translates to a lack of documentation in health care records and Watharow (2021) notes that even if accurately documented, staff may fail to (i) read those records and (ii) plan person‐centred communication strategies accordingly.

Broadly, the lack of interdisciplinary support suggests that those who are directly involved in the care of DSI clients in health care settings, such as nurses, lack support and the specific education required to assist with complex communication. Limited resources exist and although those with DSI in older age may be supported at multiple levels, for example, through primary care (general practitioners (GP), Registered Nurses (RN) and aged care services), these services are not necessarily tailored to the complex needs associated with DSI. In fact, Pesonen et al.'s recent review of the relationship between sensory impairment and older patients' nursing care time in Finland notes that less time is spent on nursing care activities for older persons with DSI than those with single sensory impairment (Pesonen et al., 2023). This finding is not unusual‐ those involved in caring for this cohort are often ill‐equipped to use alternative communication strategies, are time restricted and concerningly, (in the absence of appropriate screening techniques), may assume cognitive decline. In this context, nurses play a central role in improving quality of care and communication for older persons with DSI at all levels of health care provision.

With ageing, there is increased prevalence of other complex health issues in the presence of both vision and hearing impairment, either as single or dual sensory loss, which lead to more interactions with health care providers, and more opportunity for adverse patient safety events. Communication is critical in this context to minimize misinformation and maximize trust and safety; the health care setting presents additional challenges to effective interaction for those with DSI. Poor communication devalues person centred care, shared decision‐making and informed consent. Lived experience research suggests that AMW's fear of hospitalization is not unique and for those living with DSI who are hospitalized, vulnerability is situational, dynamic and dependent on the health care environment they find themselves in.

5. ROADMAP

In this commentary, we discuss the implications of DSI on patient safety and health care communication in older adults accessing health care services. Most of the research in DSI in older cohorts has focused on quantifying DSI and its associated negative impacts. The recent increase in qualitative research is a welcome shift from quantifying to understanding DSI. At this stage, there is little movement towards intervention‐based studies, other than the few situated in residential aged care, such as Roets‐Merken and colleagues' studies (Roets‐Merken et al., 2016). The studies in residential aged care, while important, do not address patient safety and health care communication in the acute health care setting; this presents a real opportunity for nurses to address this gap in knowledge at the intersection of ageing and disability in a DSI context. There is growing evidence of the adverse events experienced by those with DSI in health care settings. We have found that transitions in health care settings, such as hospital admission and discharge, are particularly complex in a DSI context, with lived experience narratives confirming that even access is problematic. For example, online admission forms are inaccessible; discharge planning is not conveyed in an accessible way, and concerningly, some with DSI ‘signed the consent form, not knowing what was on it’ (Watharow, 2021). This is disempowering for those with DSI, leads to disengagement in health care, and the very real risk of adverse events. Patient safety in health care settings is compromised by excluding those with DSI from the opportunity to contribute to planning, and the limited understanding on how to communicate in these complex situations may explain staff avoidance:

Staff talk over you, not to you. They talk to someone else and here I am thinking, I'm the patient! Speak to me please! I might be too hard for them to bother to take the time to explain what is going on. (Watharow, 2021)

Our roadmap focuses on the role Registered Nurses can play in navigating the complex Australian health care system and preventing older adults with DSI ‘falling through the cracks’ in this setting. To improve patient safety in health care, an immediate priority is improving complex communication skills for health care professionals through education and micro credentialling—this will support the development of, for example, better discharge planning and accessible documentation, as well as support the additional time required for care and communication that not only improves patient safety but also fosters independence, empowerment and inclusion for older adults with DSI.

AUTHOR CONTRIBUTIONS

Moira Dunsmore, Annmaree Watharow and Julie Schneider conceptualised this study. Moira Dunsmore, Annmaree Watharow and Julie Schneider prepared the manuscript. All authors have met the authorship criteria and agree with the submission and content of this manuscript.

Funding Information

No specific sources of funding were used.

CONFLICT OF INTEREST STATEMENT

None.

Dunsmore, M. E. , Watharow, A. , & Schneider, J. (2025). An invisible disability: Communication, patient safety and dual sensory impairment in older persons. Journal of Advanced Nursing, 81, 5623–5626. 10.1111/jan.16159

Data availability statement

De‐identified data can be made available on request.