When the Senses Go Silent

As nurse practitioners (NPs), we are trained to ask the right questions about pain, fatigue, sleep, and appetite. One pair of questions we rarely consider: How is your sense of smell? How does food taste to you? These questions seem trivial compared to blood pressure and glucose measurements. However, emerging science is changing how we think about smell and taste. Chemosensory disorders affect millions of Americans, and recent research has linked gustatory dysfunction to increased mortality risk.1,2 Dysfunction in the chemical senses can be an early warning sign for disease, signaling infection, neurodegenerative disease, metabolic imbalance, and medication side effects long before other symptoms manifest. For many patients, loss of smell and taste means loss of flavor, memory, and joy. The COVID-19 pandemic brought unprecedented attention to sensory loss, but public interest has waned even as millions continue to suffer. A recent study found that 45% of patients experiencing smell or taste disorders never consulted a health care provider. Among those who did seek care, many reported feelings dismissed.3 Patients plead for answers, often hearing that “It should come back on its own.” One patient recovering from COVID-19 described how food became unbearable: “Everything smells like gasoline.” She lost weight and spiraled into depression as her social life collapsed. Her laboratory results showed no abnormalities, while her quality of life remained severely impaired. Many patients suffer in silence because their sensory loss is often regarded as benign or “psychological.” But when we ask and act, outcomes can be meaningful. Olfactory dysfunction can be the first detectable sign of Parkinson disease, appearing years before motor symptoms. When identified early through simple screening, patients can begin treatment sooner, maintain function longer, and plan for their futures with clarity rather than in crisis. Research shows that olfactory decline can precede Parkinson disease by 5 to 10 years and Alzheimer disease by several years.4 Moreover, emerging evidence links gustatory dysfunction to increased mortality risk, underscoring that these sensory changes are not merely quality-of-life concerns but potential indicators of severe health decline.2 Changes in taste can point to nutrient deficiencies, medication toxicity, or chronic inflammation. For patients with diabetes, obesity, or autoimmune disease, these early signals can be critical for timely intervention. WHY IT MATTERS FOR NPs NPs are well-positioned to address chemosensory dysfunction. First, NPs conduct comprehensive wellness visits and manage patients with chronic conditions—the populations most at risk of poor health outcomes. Studies show that chemosensory dysfunction affects over half of adults between 65 and 80 years old and approximately three-quarters of those over age 80 years.2 Many of these patients are already in our panels. Second, NPs often manage conditions and medications that cause chemosensory problems. Diabetes, hypertension, chronic kidney disease, and neurological disorders increase risk, as do common drugs like angiotensin-converting enzyme inhibitors, calcium channel blockers, statins, and certain antibiotics. Screening creates opportunities to adjust problematic medications or identify disease progression. Third, addressing chemosensory dysfunction impacts outcomes NPs already track: nutrition, medication adherence, safety, and quality of life. Patients with smell loss face increased risks of food poisoning and an inability to detect gas leaks or smoke. Taste dysfunction contributes to poor appetite and difficulty managing therapeutic diets. Screening also validates patient experiences, signaling that these concerns deserve clinical attention. MAKING IT PRACTICAL Start with simple screening questions that you, as an NP, can easily integrate into your practice. Sensory screening does not require expensive equipment or lengthy protocols. During annual wellness visits or chronic disease follow-up, integrate these three questions into your review of systems: Have you noticed any changes in your sense of smell or taste in the past year? Does food taste different to you than it used to? Have you noticed that things like coffee, soap, or perfume smell weaker than they used to? If a patient answers “yes” to any of these questions, consider using a validated tool. One of them is the Brief Smell Identification Test (B-SIT), a 12-item scratch-and-sniff test that can be administered in under 5 minutes. The test provides objective data to support clinical decision-making. Document these findings in the problem list, just as you would hearing or vision changes. Sensory health deserves the same clinical attention as other vital functions. Currently, billing for chemosensory assessments can be challenging; however, documenting these concerns as part of the review of systems or as a chief complaint (ICD-10 codes R43.0-R43.9 for smell and taste disorders) establishes medical necessity for further evaluation. When patients report persistent chemosensory dysfunction, systematic referral is essential. Consider otolaryngology when dysfunction persists beyond 4 to 6 weeks, particularly with nasal congestion, sinus symptoms, or a history of head trauma. Neurological referral is warranted when olfactory or gustatory loss accompanies other neurological symptoms such as tremor, gait disturbances, or cognitive changes. Given that chemosensory dysfunction can precede motor symptoms in Parkinson disease by years, a low threshold for neurology consultation is appropriate in older adults with unexplained smell loss. Collaborate with speech-language pathologists when patients experience swallowing difficulties related to taste changes and with registered dietitians when sensory loss impacts nutrition or complicates chronic disease management. For patients experiencing depression or social isolation related to chemosensory loss, a mental health referral may be beneficial. CALL TO ACTION It's time to treat the chemical senses as vital signs of health. For practicing NPs, this means incorporating brief sensory screening into routine care and advocating for our patients when specialists dismiss their concerns. For educators, it means preparing the next generation of NPs to recognize the senses as integral to assessment, not afterthoughts. NP programs should prioritize sensory assessment in health assessment courses and clinical skills evaluations. For researchers, this means advocating for the inclusion of measures related to smell and taste in health outcomes studies. These sensory domains are conspicuously absent from most patient-reported outcome measures despite their profound impact on nutrition, safety, and mental health.5 We need more research on effective interventions, recovery trajectories, and long-term outcomes. For policymakers and professional organizations, this means advocating for awareness campaigns, developing clinical practice guidelines, and establishing clearer reimbursement pathways. Professional organizations should develop evidence-based recommendations that guide NP practice in chemosensory screening and management. Most of all, it means listening to the quiet cues our patients give us when they say, “Food doesn't taste right,” or “I can't smell my coffee anymore.” Those moments are opportunities not just for diagnosis, but for empathy, healing, and hope. The chemical senses are crucial to maintaining health, ensuring safety, and enhancing the quality of life. As NPs, we have both the opportunity and the responsibility to make chemosensory screening a routine practice.