Recommendations for successful sensory screening in older adults with dementia in long-term care: a qualitative environmental scan of Canadian specialists

Abstract

Objectives

This study aimed to identify screening tools, technologies and strategies that vision and hearing care specialists recommend to front-line healthcare professionals for the screening of older adults in long-term care homes who have dementia.

Setting

An environmental scan of healthcare professionals took place via telephone interviews between December 2015 and March 2016. All interviews were audio recorded, transcribed, proofed for accuracy, and their contents thematically analysed by two members of the research team.

Participants

A convenience sample of 11 professionals from across Canada specialising in the fields of vision and hearing healthcare and technology for older adults with cognitive impairment were included in the study.

Outcome measures

As part of a larger mixed-methods project, this qualitative study used semistructured interviews and their subsequent content analysis.

Results

Following a two-step content analysis of interview data, coded citations were grouped into three main categories: (1) barriers, (2) facilitators and (3) tools and strategies that do or do not work for sensory screening of older adults with dementia. We report on the information offered by participants within each of these themes, along with a summary of tools and strategies that work for screening older adults with dementia.

Conclusions

Recommendations from sensory specialists to nurses working in long-term care included the need for improved interprofessional communication and collaboration, as well as flexibility, additional time and strategic use of clinical intuition and ingenuity. These suggestions at times contradicted the realities of service provision or the need for standardised and validated measures.

Strengths and limitations of this study.

• This study provides a unique opportunity for interprofessional knowledge translation by drawing on the clinical experience of experts in vision and hearing healthcare who specialise in providing services to older adults with dementia, in order to let nurses working in long-term care benefit from their expertise when screening for sensory impairments.

• By taking advantage of a qualitative research approach, this study is able to provide a description of directly applicable tools and strategies for sensory screening with older adults whose ability to respond to standardised traditional screening techniques may be impaired due to their cognitive limitations.

• The results highlight the challenge of bridging the gap between the professional expectations of rigour and standardisation in sensory assessment, and the realities of practice in a long-term care environment.

• Generalisation of the findings is limited by the small sample size (n=11), narrow recruitment region (Canada) and the focus on stakeholders in sensory care only.

Introduction

As we age, our sensory capacities decline, which is reflected in the increased prevalence rates of hearing and visual loss in older adults. Hearing loss has been estimated to affect up to 50% of individuals 65 years of age and older,¹ and vision impairment has been reported to affect 18% of those aged 70 years and over.² Together, vision and hearing loss, known as dual-sensory impairment (DSI), increases from a prevalence of less than 1% in persons younger than 70 years to 11.3% in adults aged 80 years or over, at which point over 80% of adults are affected by at least one sensory impairment.³ Impaired sensory abilities are seen to be significantly more prevalent in older adults who are also experiencing cognitive decline. The most common type of dementia is Alzheimer’s disease and is seen to increase dramatically in prevalence from 1.7%–3% of adults aged over 65 years to 32% among those aged 85 years and older, and above 40% in those older than over 95 years of age.^{4 5} Hearing loss has been found in over 90% of adults with cognitive impairment,⁶ and is highly correlated with the presence of cognitive problems,⁷ while visual impairment has been reported in more than 30% of individuals with dementia.⁸ The neurodegeneration that characterises dementia likely has multifactorial causes⁹ and involves and affects multiple cortical networks, including brain regions that support auditory and visual function.^10–12 Even though research on the underlying causal relationships between cognitive and sensory decline has not yet reached consensus,^{7 13} it is already clear that many factors related to ageing and frailty are involved.^14–16

Hearing and vision impairments continue to be underdiagnosed and undertreated in this vulnerable population of older adults with cognitive impairment,^{8 17} even though adapted rehabilitation interventions for individuals with sensory loss have been presented¹⁸ and evidence exists for the improvement of cognitive functioning after sensory interventions.^{19 20} The decline of older adults’ cognitive and functional status and the severity of their disabilities are reported risk factors for institutionalisation into nursing and long-term care homes (LTCHs).^21–23 In fact, the prevalence of impaired sensory capacity is disproportionately higher in people with dementia living in care homes⁸ than among older adults living in the community, with one-third of residents in this setting having a single sensory impairment and an additional third experiencing DSI.²⁴ Furthermore, over half of such cases have been shown to be unreported,²⁵ with underdiagnosis by the appropriate specialist due to lack of service usage⁸ or those documented being untreated due to underusage of rehabilitative services by older adults.^{26 27}

The importance of appropriately identifying the sensory capacity in individuals with dementia is underscored by their incommensurate prevalence rates and the need to accurately determine the person’s true cognitive status, but has been established as a healthcare and research priority by those living with dementia themselves.²⁸ Furthermore, nurses and other healthcare professionals responsible for the care of older adults with dementia have reported the difficulty of differentiating between sensory and cognitive impairment in affected residents.²⁹ Höbler et al and others have also requested the provision of more specific education on the appropriate methods of evaluating sensory impairment among residents.^{30 31} Prioritisation of identifying the sensory capacity of older adults is further supported by evidence of accelerated cognitive decline^{32 33} and increased risk of incident dementia in those with sensory impairment,^34–36 as hearing impairment in particular can impact on all domains of cognition.⁷ Moreover, residents with impairment of both vision and hearing demonstrate significantly higher incidence of new behavioural symptoms,²⁴ and accelerated cognitive decline due to lack of social engagement,³⁷ which is, in turn, significantly associated with untreated sensory loss.^38–40 A recent study has also shown that cognitive impairment is most common in long-term care residents with DSI and that these individuals are at increased risk of mortality.⁴¹

The process of screening, assessment and evaluation of sensory and cognitive impairment in older adults has been researched in a variety of ways. Some researchers have examined how to evaluate cognition in persons who have either a hearing or a vision loss, both of which can interfere with the administration of cognitive testing procedures.⁴² For example, Bertone et al⁴³ magnified subtests of the Wechsler Adult Intelligence Scale⁴⁴ in order to make them accessible and visible for persons with central vision loss due to age-related macular degeneration. Wittich et al⁴⁵ provided validation data for the Montreal Cognitive Assessment (MoCA)⁴⁶ in its blind version, which can be administered verbally only. Similarly, Lin et al⁴⁷ developed a procedure to administer the MoCA to individuals with severe hearing impairment by making the test instructions available as a PowerPoint presentation, thereby avoiding problems of audibility. Other researchers have focused on the reverse of this approach, whereby they examined how vision or hearing testing can be adapted to individuals with cognitive decline.^{48 49} Traditional testing procedures often require a response from the person tested as to whether the stimuli are seen or heard. However, in the presence of cognitive impairment, such ‘true’ responses are potentially impacted by a variety of factors, including attention, comprehension, recall, focus, impairment severity, only to mention a few and may need to be extrapolated in a different way. Therefore, the focus of the present study is on this adapted approach to sensory testing, and how nurses working in LTCHs may be able to facilitate screening for sensory loss.

Objectives

To address the urgent need of appropriate evaluation and treatment of sensory impairment in adults already experiencing cognitive decline, we conducted an environmental scan with professionals working in the field of health technology, optometry, ophthalmology, audiology and DSI, which was part of a larger mixed-methods project investigating suitable vision and hearing screening measures for older adults with dementia that could be used by nurses working in long-term care.⁵⁰ The main purpose of this environmental scan was to identify screening tools, old and new technologies, and assessment strategies that sensory healthcare specialists find suitable for screening older adults who have dementia, and was carried out complementary to an environmental scan with nurses who work with residents who have dementia in LTCHs.³¹

Methods

Following the completion of a review of the literature on hearing and vision screening tools as per our protocol,⁵⁰ this second step of the investigation was carried out in order to identify what tools, technologies and strategies are currently being used by vision and hearing professionals when serving older adults with cognitive impairment. To accomplish this, we employed an environmental scan. In healthcare research, the environmental scan is often employed as a needs-assessment tool for the purposes of improving and developing the efficiency of health service programmes and evidence-based policies.^{51 52} In using this approach, environmental or contextual factors are evaluated by reviewing existing data or actively collecting new data in the form of surveys or interviews, including a diversity of views and information, to determine the benefits, needs and efficiencies of practices within that environment.⁵¹ As in the literature review, a broad definition of measures and technologies was adopted, to include paper-based tests, software solutions such as apps and extensions for mobile devices, and higher-tech devices such as portable ophthalmic or audiometric equipment, as well as informal assessment strategies used with residents who had dementia or limited cognitive or communication abilities.

The scan was conducted by a clinically trained member of the research team (FH), who interviewed participating professionals about their thoughts and experiences of using tools, technologies and strategies to screen for vision or hearing impairment in persons who have dementia, the tools and strategies they have found to be most useful, the ways in which current measures could be improved, and what they consider to be key elements for inclusion in a sensory screening package (see box). This research was completed with the approval of the Research Ethics Boards of the University Health Network, Toronto, Canada, and in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.⁵³ All participants provided informed written consent before enrolling in the study.

Box. Interview questions.

• Do you administer hearing and vision screening tests to residents at this facility?

• How long have you been working with persons who have dementia?

• Please describe your experience of working with persons who have dementia, as well as persons with hearing and vision loss.

• How do you differentiate between residents who have difficulty understanding due to a hearing impairment and those with cognitive impairments?

• How are residents identified as being in need of assessment for vision and hearing impairment?

  • Is there a standard procedure in place, and, if so, what are the steps?

  • What is the procedure for referring residents to a hearing and/or vision specialist?

• What tools, technologies and strategies are you currently using to assess and/or detect vision and/or hearing in persons who have dementia?

• What approach is used or do you use in assessing persons who have dementia, for example, what combination of tools, technologies and strategies is being implemented?

• How do these tools, technologies and strategies identify a person as having hearing and/or vision impairments?

• What are the facilitators and barriers in implementing this approach and/or procedure?

  • Please list all the challenges in using these tools, technologies and strategies.

  • Please also list all the benefits to using these tools, technologies and strategies.

• In what way can these tools, technologies and strategies be improved?

• In your opinion, what are the key elements to include in a hearing and vision screening package for persons who have dementia?

• Do you have knowledge of or experience in using either of the following:

  • Peek application (turns a smartphone into an eye exam tool)? …or similar other apps?

  • uHear application (downloadable audiometer on to an iPod Touch as a test for hearing loss)? …or similar other apps?

Participants

A convenience sample of 11 professionals from across Canada with expertise in vision, hearing, DSI or healthcare technologies were recruited through their connections with members of the larger study team or through referral by participants already enrolled in or contacted about the study. Based on previous research with similar methodological approaches,^{54 55} the sample size was seen as sufficient for the data collection purposes of the present study. The research coordinator (FH) made initial contact with potential candidates via email or phone. Eleven participants agreed to take part in this study, while one candidate declined due to a perceived lack of expertise in the area and another due to time constraints during the data collection period. Participant characteristics of all interviewees included in this study are summarised in table 1.

Table 1.

Summary of participant characteristics (n=11)

Participant characteristics	n (%)
Categorical characteristics
Audiologist	2 (18)
Optometrist	4 (36)
Speech-language pathologist	1 (9)
Dual-sensory specialist	2 (18)
Hearing counsellor	1 (9)
Health technology specialist	1 (9)
Female	10 (91)
Continuous characteristics
Years’ experience working in dementia care (n=8)	14.56 (SD=10.0)

Data collection

By the use of a semistructured guide, the environmental scan interviews took place via telephone between December 2015 and March 2016. After receiving background information on the study, its purpose, as well as answers to any questions they had, written informed consent was received from all participants at the time of or prior to data collection via email or fax. The interview protocol was applied in relevance to the participants’ area of expertise (ie, vision, hearing or dual sensory loss), and participants were encouraged to offer any additional information they felt was applicable to the study’s objectives and/or that had not been covered by the semistructured interview script.⁵⁶ Two participants were interviewed together on request, resulting in a total of 10 interviews with 11 participants being conducted. There was no time limit applied to the interviews, with these having a mean duration of 40 min 30.66 s (SD=11.83 min, range 19–54 min).

Data analysis

All interviews were audio recorded, transcribed by a third party and proofed for accuracy by a member of the research team (FH). Following full anonymisation of the data sets, the transcribed contents of the interviews underwent thematic analysis.⁵⁷ Two members of the research team (WW, JJ) analysed all sets to identify data relating to the following: tools/strategies that work for screening (vision/hearing), tools/strategies that do not work for screening, and tools/strategies that may work. This data analysis followed a coding protocol in which data were first coded as a Tool or Strategy, and second whether it was reported to work or not, then as to whether it applied to vision or hearing screening. For example, ‘T+H’ denoted a measure that was reported to work well for hearing screening, or ‘S?V’ denoted a strategy that may work for vision. Additional codes related to information reported as: a ‘golden quote’, a sentence or paragraph that is striking or characteristic, the name of a tool when first mentioned (eg, Snellen chart), a barrier to sensory screening, a recommendation on what should be done according to the participant, other content of interest, as well as any ‘red flag’ or risk factor or other trigger for screening (eg, diabetes, missing hearing aid, missing glasses). During second level thematic analysis, the extracted data from the first level were again analysed for the identification of prominent themes in the interviews with participants. Agreement was achieved through the concurrent coding and discussion involving both analysts (WW, JJ), and differences in opinion when interpreting content were resolved face to face,⁵⁸ an approach that members of the team have previously used successfully.^59–62 These themes are reported below.

Findings

Following a two-step content analysis of interview data, coded citations were grouped into three main themes: (1) barriers, (2) facilitators and (3) tools and strategies that related to the screening of older adults with dementia. Here, we report on the information offered by participants within each of these themes. In addition, we present a summary of tools and strategies that work for screening older adults with dementia (see table 2). Direct participants’ quotes are presented below, whereby each quote is identified by the source code.

Table 2.

Tools and strategies for vision and hearing screening with older adults affected by dementia, as recommended by sensory specialists

	Hearing screening	Vision screening
Tools	‘Hear Mans’ (manikin head with headphones on used for a quick hearing test) Asking simple questions (does the patient wear hearing aids? does the patient have them?) Chart review Five min hearing test Hearing Dependent Daily Activities questionnaire Otoacoustic emissions Picture board Pocket Talker (how the person responds to using it) Pure-tone audiology Questionnaire devised by a former student of the interviewee’s Repeating no Speech testing Whisper test and finger rub	Autorefractor Case history Finger counting Health questionnaire Matching game Objective measures (prescription assessment, eye exam) Sentences on a board in different sized font Vision questionnaire Visual charts (letters, numbers, sentences, single words, pictures, tumbling Es)
Strategies	Ensure that cerumen (ear wax) has been removed Alternating between testing the left and right ear until you get an answer if no initial response to pitch testing Applying techniques developed for screening in children Asking basic questions as a form of hearing screening Bowing out of the screening gracefully if it could not be finished Choosing more meaningful stimuli than pure tones Choosing ‘pulsing beeps’ instead of ‘single beeps’ on the audiometer Choosing a quiet room Educating nurses and doctors on the importance of hearing and screening Frequently encouraging the client Gradually reducing the level of stimulus presentation to find their threshold Repeating measurements to ensure reliability of client self-report Rephrasing screening questions to avoid denial of the problem Starting with speech testing Taking breaks as needed Using a headset instead of ear buds Using ear buds instead of a headset Using sound amplification (eg, Pocket Talker) to facilitate communication	Bringing the eye chart closer than normal Distributing a vision form for caregiver to request examination or to help staff look at changes that would warrant a screening Emphasising that the purpose of the screening is to monitor the health of the individual Respecting their autonomy during the screening Staying away from the patient and moving around them with portable instruments

Facilitators

Our interviewees identified few facilitators, as they were more likely to share barriers to their work. The main enablers of sensory screening in residents with dementia were indeed other people. The clients themselves can become facilitators and advocates, as can family members, activation workers, as well as long-term care facility staff.

An audiologist pointed out that hearing screening clinics in long-term care facilities can be organised by a facility employee:

I’m thinking we could get called in to do a screening, we could have an activation worker in a long-term care facility say, ‘I would like to have a hearing screening clinic.’ (participant 4)

Local support by staff and residents can help bring awareness of hearing loss to others:

It’s not always possible for me, as an audiologist, to be everywhere and see everyone, so to have staff members also be advocates for hearing is very important and, you know, to have residents themselves be advocates for hearing. (participant 5)

The nurses, whose lack of availability was often branded as a barrier, were mentioned in a more positive context:

The nurse manager on that unit was very receptive to having some audiological intervention on her unit, and so we actually designed a simple screening programme there, because she wanted the nurses to be able to do the screening […]. And she felt that it was important to get the nurses on her unit involved in that screening. (participant 2)

Barriers

In the interviews with vision and hearing specialists on the subject of sensory screening in residents with a cognitive impairment, the two barriers to screening that were most often repeated were impaired communication and lack of staff involvement. Impaired communication can mean not knowing if a client’s answer is reliable; not being able to use traditional means of communication or not being able to communicate at all when the neurological condition is too advanced. One interviewee explained:

And when we are at the long-term care facility, […] some of [our residents] are completely unresponsive, which of course is a challenge and, other times, it’s just they require more encouragement, constant repetition to remind them of the task that we’re doing, that kind of thing. (participant 7)

Since many screening tests rely on self-report, impaired communication can jeopardise subjective assessments:

In the more advanced stages of dementia, it’s very difficult to get a pure-tone audiogram, because pure-tones become meaningless, so you have to use more meaningful stimuli. (participant 2)

Many sensory experts flagged the lack of staff involvement in the screening of persons for hearing and vision loss. Some reported that educating the staff on the need to screen for sensory loss was not helpful, as it is not a mandatory training activity for nurses. Participants speculated that this absence may, in part, be due to policies or regulations that do not include or promote sensory screening, lack of education and training on how to screen or not prioritising hearing and vision screening given the multiple demands on their time. Moreover, screening by staff is not always systematic:

We did find that the nurses, number one, only bothered to do […] their screening on 50% of the intake of the people that were admitted. And furthermore, failed to identify 40% of the people that the student identified with the more extensive screening. (participant 2)

Additional barriers that were less frequently mentioned were: hearing loss denial; lack of cooperation by the client’s family; discomfort vis-à-vis the physical closeness often required for sensory screening; environmental noises during hearing screening; the presence of a combined hearing and vision loss and the limitations of portable equipment often necessary for these on-location screenings.

Strategies and tools

Given the specific characteristics of people with a cognitive impairment, our specialists frequently suggested strategies to conduct sensory screening. We defined these as adaptations or behavioural accommodations in order to administer a particular screening tool, such as choosing a specific location or speed of administration. While certain strategies were unique to either vision or hearing screening, many such adaptations were mentioned by both groups of experts. By far the most common strategy was to improve communication. Many specialists highlighted the importance of establishing a friendly rapport with the client before screening and of reassuring and encouraging them throughout the procedure. Sometimes, repetition was key:

They require more encouragement, constant repetition to remind them of the task that we’re doing. (participant 7)

Often, according to our interviewees, the client may not provide the type of feedback traditionally required by the subjective screen, emphasising the value of flexibility. The response to ‘Can you see this?’ or ‘Can you hear this?’ can be a smile, a number of raised fingers or a movement of the eye:

I remember one woman that was singing constantly, but she would stop singing when she could hear me, so that was one way of finding information. (participant 2)

It may also mean playing along with a resident’s own understanding of the situation:

One man believed he was being assessed to join the Greek military and so he was reading all of the letters on the Snellen chart in Greek. And I don’t speak Greek and so we also bring a number chart with us. So, he was reading those out in Greek but at least there were only nine numbers for me memorize. So, I just started accepting Greek readings of the numbers instead and kind of learning Greek numeric system as we went. (participant 10)

The preference for familiarity was a recurring strategy mentioned by both hearing and vision specialists, such as choosing a familiar room and having a person the client trusts sitting by their side during the screening. Considerations of time were brought up as well: examples included screening on the right day, with breaks during the procedure and the possibility of resting or finishing another day:

Sometimes the assessment needs to be done over several appointments. (participant 5)

Finally, information can be gathered indirectly through staff, family and behaviour. The latter, we were told, can serve as a clue to impairment:

One of the most helpful things is having family there to at least give us a little bit of background about the resident, about things that they may have liked to have done when they were not at the long-term care facility such as reading or knitting, activities that they haven’t been doing lately which could be because of their vision problems, either glasses or having some sort of eye condition that needs to be treated. (participant 3)

A small number of strategies were mentioned exclusively by vision specialists, while a much longer list could be drawn from the input of the hearing experts (see table 2). Since hearing screening often relies on the playback of tones through headphones, it is interesting to note that interviewees disagreed among themselves as to whether or not ear buds were preferable to headsets for this population. Some clients may prefer the former:

If you come at somebody with a headset, often that’s a bit alarming and they immediately don’t want to cooperate; but I’ve found that they’re more compliant with insert phones. (participant 2)

while others are more at ease with the latter:

I haven’t had issues with people putting on headsets. […] I’m not sold on removing the idea of a headset. (participant 4)

The above-mentioned strategies highlight that no one method of screening works for everyone as some residents preferred headsets while others preferred ear phones. For both vision and hearing, experts spoke of numerous tools they considered either to work, to not work or to possibly work with this population (see table 2). On the hearing side, speech testing was often mentioned as providing more meaningful stimuli to a client with a cognitive impairment than a pure-tone audiogram: indeed, the latter test ended up being both recommended and rejected, depending on the interviewee. Meanwhile, for either sense, very few of our participants qualified themselves as knowledgeable on the topic of screening apps, such as Peek for vision testing. They often knew of these portable technologies but had rarely used them. These apps elicited the following concerns: that they were not designed or validated for use in a context of dementia; that they relied on batteries that need to be recharged and that the hardware (ie, cell phone or tablet screen and camera) is not of professional grade. Still, many interviewees wanted to see data on how they compared with traditional screening methods and were even willing to try them out for themselves.

A recurring comment on the part of audiologists spanned multiple coding categories, acting as a barrier, forming a recommendation and being suggested as a screening tool that works for hearing: the presence of wax and its removal following otoscopy. As one hearing expert put it:

I think all screening should be accompanied by otoscopic examination, because one other thing I’ve learned is that many seniors, especially those in the nursing homes, they don’t tend to get kind of routine ear exams, tend to have accumulations of wax that would definitely be possibly interfering with their hearing. So having that wax removed before you do any testing, is really important. […] Anybody who’s getting involved with screening of seniors’ hearing needs to have some training in cerumen management, certainly. (participant 2)

Discussion

The purpose of the present study was to explore the advice of specialists in the field of sensory healthcare for older adults with dementia, in order to develop recommendations for nurses working in long-term care facilities to be able to better screen their residents for the presence of vision and/or hearing loss. The participants reported on several facilitators and barriers, and how these can each be strengthened and overcome through adaptive strategies. Ideally, a screening protocol would be able to examine vision and hearing function simultaneously or during the same testing opportunity, because time is often sparse and the pressures on healthcare providers are many. However, one central theme, common among the suggested approaches, was to allow and encourage clients (and clinicians) to take their time when engaging in the testing of sensory functioning, as subtle information and behavioural cues often become the true source of information in sensory screening, and may then be lost if rigorously standardised (and fast) protocols are adhered to.

In this particular population, sensory screening methods need to be flexible enough to accommodate a range of cognitive resources, whereby individuals with mild cognitive impairments may well be able to complete normal testing procedures if given the chance and the time. Those with moderate to severe cognitive impairment, however, may require adjustments in the administration of screening measures and strategies, led by use of clinical judgement and intuition. Such approaches can easily be supplemented with the use of questionnaires (or a subsection of questions therein), as well as more objective measures in order to ensure reliability of test results. Ideally, the stimuli that are used are meaningful to the resident (eg, their name) and are speech-based because of their ecological importance over pure tones. When simplicity was important, the use of numbers (both for speech as well as vision testing) was recommended. In addition, the use of pictograms or picture-matching was a proposed possibility to elicit responses. Making sure the methods of screening aligned with the residents preferences (phones or headsets) is essential for a quality screening result. Finally, our respondents expressed openness to using and exploring the potential of new technologies, such as apps and devices, for screening purposes. However, their own experience with current technologies was limited and they expressed concerns about their validity and availability, thus, recommending that technologies require further development in order to serve this population.

A strength of the present study is its range of professionals and their level of expertise in providing services to older adults with sensory and cognitive impairments; despite their number being relatively small, data saturation was reached when assessed. In addition, this study tackles cross-disciplinary communication barriers by bringing specialist recommendations to the attention of nurses. We were able to replicate previous reports on the barriers and challenges that are encountered when providing sensory care to older adults in LTCHs, including difficulties in client’s willingness to participate in the assessment (at times expressed as aggression or anxiety) as well as communication difficulties linked to cognitive losses, resulting in confusion (both at the part of the client and the clinician).³⁰ Communication recommendations were in line with previous suggestions to adjust speech volume, speed and body positioning face to face.²⁹ In addition, the present data are in agreement with previous reports about the necessity for flexibility in the testing procedure, such as the need to determine the optimal time of day for each individual to be tested, the option to pause and continue testing as needed, along with taking care to avoid fatigue or frustration on the part of the client.⁴⁸

Our study needs to be viewed within certain limitations; for example, the logistics of data collection and imposed time and funding restrictions limited the recruitment scope, thereby only including participants within Canada, and those that were known within the professional network of the study team. This recruitment approach might have excluded practice perspectives more representative of other countries or service delivery systems. The scope of the study is further limited by the choice to focus on sensory health professionals, without including additional stakeholders. A parallel study is currently exploring the opinions of nurses working in LTCHs; however, including caregivers or primary care providers would provide further insights. The data-driven analysis approach revealed that the majority of strategies and tools mentioned were in the hearing domain, which is intuitively more closely linked to communication. Future studies may need to probe further into the use and usability of vision testing devices and strategies. They should provide additional background data on the participants that will allow for a better contextualisation of the findings. For example, the frequency and intensity of service delivery by the participating stakeholders would provide information about the level of expertise and experience in service delivery and strategy development. In addition, this limitation may also have had an effect on data saturation.

A remaining challenge is to reconcile the realities of nurses' workloads in LTCHs with the recommendations that have emerged from our specialist interviews. Specifically, the recommendations of our vision and hearing care professionals are likely to go beyond the resources available. Even though both groups agree that increased priority should be placed on the sensory assessment of residents in order to improve communication,⁴⁰ the reality of service provision in LTCHs rarely allows for this level of individualised attention.⁶³ For nurses working in LTCHs, the impact of regulations on nurse role flexibility and professional judgement and an underfunded system contributing to insufficient resources and staffing⁵⁵ influences their ability to find time and resources to screen effectively. In addition, the technologies, tools and abilities available versus the devices, techniques and skills that were recommended may not match. For example, LTCH nurses may not have access to the necessary tools and training to remove earwax, a potentially necessary step before hearing can truly be evaluated. Similarly, pocket-sized eye charts may be necessary for vision screening, but may not necessarily be available to all staff at any time, or staff may lack training to properly administer and interpret the results when presenting the test at a specific distance or under non-optimal lighting conditions. Previous research has provided educational content on vision and hearing screening, specifically with LTCHs in mind^64–66; however, knowledge transfer and implementation appear to still be lacking. Meanwhile, some of the tests that may be known and available to nurses may not hold up to the demands of rigour for sensory testing by the specialists. For example, the use of measures such as the whisper test and finger rub test that are evidenced as suitable tests in the literature⁶⁷ did not find the approval of the specialists in our study, given problems with standardisation and validation.

The next steps in the development of a sensory screening tool for older adults with dementia will include the integration of nurses’ recommendations³¹ along with recommendations from the experts who were interviewed for this environmental scan, as well as the results of a systematic review of the literature on this topic. The members of this research team will then develop and pilot test a screening tool for nurses to use in the LTCH to examine its feasibility, reliability and validity. The present data indicate that strategies and training in easy-to-use methods, as well as careful client observation, may play a prominent role in such a screening tool. It is also possible that these methods and adaptive strategies may take shape in a new technological application, which can be incorporated into portable devices such as cellphones or a tablet computer—both technologies that are becoming more available in the clinical environment.^{68 69} Mandated training on the use of such a screening tool and continuous efforts in knowledge translation would ensure its success, especially given its potential for far-reaching benefits to clients and clinicians alike in their care provision and interaction in LTCHs.