Abstract
Background
Existing estimates for the prevalence of dual sensory loss (vision and hearing) among older adults are either based on self-reported measures or aggregated for older age groups. Current and detailed estimates based on objective measures are needed for public health, clinical, and policy decision-making.
Methods
We estimated the prevalence of dual sensory loss (DSL) using National Health Aging Trends Study (NHATS) Round 11 data (2021). We restricted to community-dwelling adults aged ≥71 years with complete sensory testing data (N=2579). Hearing loss was defined by a 4-frequency (0.5,1,2,4 kHz) pure tone average for the better-hearing ear (>25 decibel hearing level). Vision loss was defined by the presence of distance, near (logarithm of the minimum angle of resolution>0.30), or contrast sensitivity loss (log contrast sensitivity <1.55). Participants were categorized into three groups: no sensory loss, single sensory loss (vision or hearing loss), and DSL (hearing and vision). Sensory loss prevalence was estimated by age group and sociodemographic characteristics.
Results
In weighted analyses, among older Medicare beneficiaries (53% female, 7% Black, 6% Hispanic), 28% had no sensory loss and 22% had DSL. Prevalence of DSL increased with age. Most adults aged ≥90 years experienced DSL (59%), as opposed to single (39%) or no sensory loss (2%). DSL prevalence was greater among older adults with low education attainment (34%) and household income (43%). A higher proportion of older adults with a college education (17%), or from wealthier households (16%), had no sensory loss.
Conclusions
1 in 5 community-dwelling Medicare beneficiaries aged ≥71 years have DSL, increasing to 3 in 5 for those aged ≥90 years. Prevalence is higher among older adults with low education attainment and from low-income households, characteristics associated with low treatment. Policies increasing access and affordability of vision and hearing care could benefit millions of older Americans experiencing sensory loss.
INTRODUCTION
Vision and hearing are important for the health of older adults. Sensory loss is independently associated with increased risk of reduced social engagement,1 increased risk of dementia,2,3 poorer physical function,4 and increased healthcare costs.5 Concurrent vision and hearing loss (dual sensory loss; DSL), may exacerbate these adverse associations by preventing use of sensory compensatory mechanisms in daily activities (e.g., lip reading or using visual cues in the presence of significant hearing loss). For example, individuals with DSL are at a higher risk of dementia as compared to individuals with single sensory loss.6
Accurate estimates of the prevalence of sensory loss are needed for public health planning and decision-making. However, most estimates treat vision7 and hearing8 separately. Among studies that do examine DSL, estimates rely on non-representative population samples9 and/or self-reported data which may underestimate sensory loss, particularly in the oldest old.10 Most recent estimates for the U.S. using objective measures used data that is nearly two decades old (1999–2006 National Health and Nutritional Examination Survey; NHANES).11 Moreover, prevalence DSL estimates were aggregated into only two groups – 70–79 (3%) and ≥80 years (12%) – limiting understanding of prevalence in narrower age ranges and among the oldest old.
Here we provide DSL prevalence estimates using objective sensory measures for older adults ages ≥71 years using a nationally representative sample of community-dwelling Medicare beneficiaries from the 2021 round of the National Health and Aging Trends Study (NHATS).
METHODS
Study Participants
The NHATS is an ongoing nationally representative longitudinal study of U.S. Medicare beneficiaries aged ≥65 years. Starting in 2011, participants are surveyed annually.12 To maintain national representativeness, the study last replenished its sample in 2015, meaning that data for those aged 65–70 years was not available. NHATS was approved by the Johns Hopkins University IRB with all participants providing written informed consent. As secondary analysis of publicly available de-identified data, this study did not require IRB approval.
In Round 11, all 3817 participants surveyed were offered hearing and vision testing during June to November 2021. For our study we excluded non-community dwelling individuals (N=732), and those with incomplete visual or hearing (N=506) data (n=222 had missing vision and hearing, n=243 were missing only hearing, and n=41 were missing only vision data), yielding an analytic sample of N=2579. Additionally, some participants were excluded for stratified analyses by race/ethnicity (N=28) and education (N=25) for missing data.
Hearing Loss
Pure-tone air conduction audiometric testing was performed without hearing aids and a 4-frequency (0.5,1,2, and 4 kHz) pure tone average (PTA) for the better-hearing ear was computed. Consistent with previous population-level studies, participants were classified by hearing loss status (hearing loss if PTA>25 dB HL) and severity (mild, 25<PTA≤40 dB HL; moderate, 40<PTA≤60 dB HL; severe or greater, PTA>60 dB HL).8,11,13
Vision Loss
Vision loss was ascertained with binocular testing. For all assessments, respondents were asked to wear glasses or contacts if they normally wear them. The logarithm of the minimum angle of resolution for distance (logMARD) and near acuity (logMARN), and the logarithm of contrast sensitivity (logCS) were computed. Distance and near vision loss were defined by logMARD>0.30 and logMARN>0.30 (Snellen equivalent worse than 20/40). While these cutoffs are well established,14 thresholds for contrast sensitivity vary. In primary analysis, we defined contrast sensitivity vision loss as logCS<1.55.15 In sensitivity analyses, we implemented a previously proposed threshold (logCS < Sample Mean (μ)-Standard Deviation; 1.36).7 For our main results, vision loss was defined by the presence of distance, near, or contrast sensitivity vision loss. In sensitivity analyses we considered alternative definitions of vision loss, one excluding contrast sensitivity, and one considering only distance vision loss.
A detailed description of the sensory testing protocols can be found elsewhere.16 Based on the presence of vision and hearing loss, we classified participants in three groups: no sensory loss, single sensory loss, and DSL. We chose this approach given that the individual estimates for hearing and vision7,8 loss have been previously reported.
Other Participant Characteristics
Demographics included age group (71–74, 75–79, 80–84, 85–89, ≥90 years), self-reported gender (female, male), race/ethnicity (Hispanic, Black non-Hispanic, White non-Hispanic, and Other, including participants reporting multiple groups or those from other race/ethnicity), education level ( ≤high school, some college, ≥college), and household income (relative to the 2021 poverty line17 for a two person (≥65 years) household: <100% PL, 100%–200%, ≥200%). Household income was obtained from participant self-report, and when missing, from the mean of NHATS-provided imputations.
Statistical Analysis
We described characteristics of participants by sensory loss, and between participants excluded and included in our analytic sample. We estimated the prevalence of sensory loss by age, sex, race/ethnicity, education, and income. We used Round 11 survey weights to account for NHATS complex survey design. To obtain national estimates, survey weights were age- and sex- standardized to the population of 71 years and older living in the continental U.S. using data from the 2020 Census Bureau, American Community Survey, per NHATS recommendations.18
In secondary analyses, among participants with DSL, we computed prevalence by hearing loss severity and type of vision loss. In sensitivity analyses we computed the prevalence of sensory loss using the most recent WHO19 guidelines for hearing loss (PTA ≥20 dB HL) and the alternative definitions for vision loss. Statistical analyses were performed from February to April 2023 using Stata/SE, version 17.0 (StataCorp LP).
RESULTS
In our analytic sample (N=2579), most participants identified as non-White (34% vs 17%), reported at most a high school education (57% vs. 34%), and a household income below the poverty line (50% vs 43%). Further, 3% of the analytic population were older than 90 years, 53% identified as female, and 7% as Black non-Hispanic, and 6% as Hispanic. Overall, 28% had no sensory loss, 50% had either hearing or vision loss, and 22% had DSL (Table 1). Compared to our analytic sample, community dwelling participants excluded due to incomplete data (N=506) were older (32% vs. 39% aged 71–74 years) and poorer (25% vs. 12% had household income below poverty line) (Supplemental Table S1).
Table 1.
Characteristics of N=2579 Community Dwelling Participants in Round 11 of the NHATS by Sensory Loss Status. Survey weighted percentages and 95% confidence intervals.
| Analytic Sample % (95% CI) | No Sensory Loss % (95% CI) | Single Sensory Loss % (95% CI) | DSL % (95% CI) | |
|---|---|---|---|---|
| N | 2579 | 515 | 1,277 | 787 |
| Total | 86.2 (83.7,88.5) | 27.8 (24.9,30.8) | 50.0 (47.5,52.5) | 22.2 (20.0,24.6) |
| Age (years) | ||||
| 71 – 74 | 39.2 (36.3,42.2) | 53.7 (47.5,59.8) | 37.0 (33.1,40.9) | 26.2 (20.4,32.1) |
| 75 – 79 | 37.0 (33.9,40) | 36.7 (31.2,42.3) | 38.5 (34.4,42.6) | 33.7 (28.6,38.9) |
| 80 – 84 | 13.5 (12.2,14.8) | 8.0 (6,10.1) | 15.0 (13.3,16.7) | 16.9 (14.1,19.8) |
| 85 –89 | 7.1 (6.3,7.8) | 1.3 (0.6,2) | 6.9 (5.6,8.2) | 14.6 (12.1,17.1) |
| 90+ | 3.2 (2.8,3.7) | 0.2 (0,0.5) | 2.5 (1.9,3.1) | 8.5 (7,10) |
| Sex | ||||
| Male | 47.0 (44.2,49.7) | 40.2 (33.6,46.7) | 50.6 (47,54.3) | 47.3 (41.5,53) |
| Female | 53 (50.3,55.8) | 59.8 (53.3,66.4) | 49.4 (45.7,53) | 52.7 (47,58.5) |
| Race a\ | ||||
| White | 82.9 (80,85.8) | 84.1 (79.7,88.6) | 83.9 (80.7,87.1) | 79.1 (73.6,84.6) |
| Black | 7.3 (6.1,8.6) | 7.2 (4.9,9.5) | 6.9 (5.5,8.2) | 8.5 (6.3,10.6) |
| Hispanic | 6.4 (4.3,8.6) | 5.6 (2.7,8.5) | 5.8 (3.4,8.2) | 9.0 (4.5,13.5) |
| Other | 3.3 (1.9,4.7) | 3.1 (0.5,5.7) | 3.4 (1.7,5.1) | 3.4 (0.8,6) |
| Education b\ | ||||
| At most HS | 34.4 (31,37.7) | 22.5 (17.2,27.7) | 35.9 (32.1,39.8) | 45.6 (39.4,51.8) |
| Some college | 30.4 (27.6,33.3) | 33.2 (27.1,39.3) | 32.3 (28.7,35.9) | 22.8 (18.4,27.1) |
| College or more | 35.2 (31.1,39.3) | 44.3 (38,50.7) | 31.7 (27.1,36.4) | 31.7 (25.9,37.4) |
| Income to Poverty Ratio | ||||
| < 100% | 11.6 (10.1,13.2) | 4.8 (2.2,7.4) | 11.9 (9.9,14) | 19.6 (15.5,23.6) |
| 100%-200% | 19.8 (17.6,22.1) | 16.0 (11.8,20.1) | 18.9 (15.8,22) | 26.8 (21.2,32.3) |
| > 200% | 68.5 (65.6,71.4) | 79.3 (75.4,83.2) | 69.1 (65.1,73.2) | 53.7 (47.6,59.8) |
Abbreviations: DSL, dual sensory loss; CI, confidence interval; HS, high school
A total of N=42 participants had missing information about race and ethnicity. N=14 for the excluded group and N=28 for the included group.
A total of N=41 participants had missing information about education. N=16 for the excluded group and N=25 for the included group.
At younger ages (<85 years), most participants had a single sensory loss (prevalence ranging from 47% to 56% across age groups) (See Supplemental Table S2 for sensory specific prevalence). The prevalence of DSL increased with age. A 15% prevalence among those aged 71–75 years increased to 46% for those 85–90 years, a proportion similar to the prevalence of single sensory loss (49%) in that age group. For those aged ≥90 years, DSL was more prevalent than single sensory loss (59% vs. 39%). The proportion of individuals with no sensory loss decreased with age, from 38% for those aged 71–75 years to 2% for those aged ≥90 years (Figure 1).
Figure 1.
Prevalence of Sensory Loss among N=2,579 Study Participants with Complete Vision and Audiometric Data in Round 11 of the NHATS by Age Group
Abbreviations: CI, confidence interval; DSL, dual sensory loss.
* Value estimated with less than 10 observations.
Females were less likely to have single sensory loss than males (24% vs. 31%), but the prevalence of DSL was similar (22%) (Table 2). DSL was more common in Black (26%) and Hispanic (31%) participants, compared to White participants (21%). Individuals with the lowest educational attainment (at most high school) and lower income (<100% PL) had the highest levels of DSL (29% and 37%, respectively).
Table 2.
Prevalence of Sensory Loss among N=2,579 Study Participants with Complete Vision and Audiometric Data in Round 11 of the NHATS by Selected Characteristics
| No Sensory Loss % (95% CI) |
Vision or Hearing Loss % (95% CI) |
Dual Sensory Loss % (95% CI) |
|
|---|---|---|---|
| Sex | |||
| Male | 23.7 (19.2,28.3) | 53.9 (49.5,58.3) | 22.4 (19,25.7) |
| Female | 31.3 (27.4,35.3) | 46.6 (43.7,49.4) | 22.1 (18.8,25.4) |
| Race a\ | |||
| White | 28.1 (24.5,31.6) | 50.8 (48,53.7) | 21.1 (18.7,23.5) |
| Black | 27.2 (21.1,33.2) | 47.3 (40.9,53.6) | 25.6 (20.8,30.4) |
| Hispanic | 24.1 (14.3,33.8) | 45.1 (33.1,57) | 30.9 (19.4,42.4) |
| Other | 25.5 (7.5,43.5) | 51.8 (37.1,66.6) | 22.7 (6.9,38.4) |
| Education b\ | |||
| At most HS | 18.0 (14.2,21.8) | 52.6 (48.4,56.8) | 29.4 (25.7,33.1) |
| Some college | 30.0 (25.1,35) | 53.4 (48.3,58.5) | 16.6 (13.5,19.7) |
| College or more | 34.7 (29.6,39.7) | 45.4 (40.7,50) | 19.9 (16,23.9) |
| Income to Poverty Ratio | |||
| < 100% | 11.4 (5.5,17.2) | 51.3 (44.7,57.9) | 37.30(30,44.7) |
| 100%-200% | 22.3 (16.6,28.1) | 47.7 (41.5,53.9) | 30.0 (24.2,35.8) |
| >200% | 32.1 (28.7,35.6) | 50.5 (47.2,53.7) | 17.4 (14.8,20) |
Abbreviation: HS, high school
A total of N=28 participants had missing information about race and ethnicity.
A total of N=25 participants had missing information about education.
Values estimated with less than 10 observations per cell.
Among participants with DSL, 50% had mild, 42% had moderate, and 8% had severe or worse hearing loss. 30% had distance, 67% had near, and 65% had contrast sensitivity vision loss (Supplemental Tables S3 and S4). Increasing prevalence of DSL with age was robust to different definitions of sensory loss. With respect to vision loss, overall prevalence of DSL was lower when excluding contrast sensitivity (17%), when considering only distance vision loss (7%), or when using the logCS<μ-SD cutoff for contrast sensitivity (19%). Interestingly, estimates using the latest WHO guidelines for hearing loss yielded similar prevalence estimates for DSL (Supplemental Tables S5–S7).
DISCUSSION
In a nationally representative sample of 2579 adults aged ≥71 years, prevalence of DSL increased with age such that by age ≥90 years, 3 in 5 adults had DSL, representing around 1.1 million Americans. Critically, the remaining 2 in 5 adults had either vision or hearing loss, leaving almost no adults ≥90 years living without sensory loss (~2%). Furthermore, the prevalence of DSL was larger among older adults identifying as Black or Hispanic, and those with low educational attainment and household income. Higher household income and a college education are associated with preservation of sensory function.
When compared to studies using objective measures in older populations around the world,20 our estimates are similar to those from Australia (21%) and Denmark (22%), but higher than those from South Korea (6%), Malaysia (11%), and even prior estimates from the US. For example, previous work from NHANES reports DSL prevalence was 2% and 11% for those aged 70–79 and ≥80 years, respectively.11 We estimated 13% and 16% of older adults aged 71–74 and 75–79, respectively (14% for the combined 71–79 age-group), and 32% for participants ≥80 years. These differences may be attributed to vision loss being measured using distance visual acuity only in NHANES (best-corrected distance visual acuity worse than 20/40 in the better-seeing eye) as opposed to our broader classification using distance, near, and contrast sensitivity vision loss. Importantly, contrast sensitivity has been associated with higher risk for falls,21 traffic accidents,22 and lower health related quality of life.23 Hence, and because of its availability in NHATS, we decided to include it in our definition of vision loss.
When considering only distance vision loss, our estimates for DSL were closer, but slightly higher, potentially due to NHATS assessments occurring in participants’ homes, which may have allowed participation of individuals who otherwise could not have been observed for reasons related to sensory loss. Excluding these participants in prior studies may have underestimated DSL prevalence.
Our findings are consistent with documented associations of vision and hearing loss with older age, low education attainment and household income. DSL was more common among Hispanic and Black Americans compared to White Americans. As Black race is associated with lower levels of hearing loss,24 perhaps because melanocytes in the inner ear (thought to offer biological protection against hearing loss) are correlated with skin color,25 differences in DSL prevalence by race/ethnicity are therefore likely driven by differences in vision loss prevalence, which is more common among Hispanic and Black older adults.7
Most cases of sensory loss can be treated with non-invasive interventions such as eyeglasses and hearing aids. While treatment for some types of vision loss is relatively affordable (for example, reading glasses for near-vision loss), the cost of other types of glasses, vision rehabilitation, or other treatments for refractive error might prevent treatment.26 For hearing aids, an average cost of around $4,700 a pair,27 represents a catastrophic expense for 77% of Americans with hearing loss.28 Notably, Medicare, the largest insurer of older Americans, does not provide benefits for refractive correction or hearing aids. People with DSL facing combined costs for addressing hearing and vision loss may be forced to choose between treatments. Given the association between sensory loss with greater risk of incidence dementia6, falls29, health care utilization and expenditures5, coverage of vision and hearing care by Medicare could translate into a more efficient use of its resources.30,31
Given the nationally representative nature of the study sample and its oversampling of the oldest Americans, the NHATS provides a unique opportunity to estimate the prevalence of sensory loss among community-dwelling older adults in the US. NHATS dedication to in-home data collection is also a strength, and likely allowed inclusion of participants with greater severity of sensory loss. Unlike some earlier work, our prevalence estimates rely on objective vision testing and audiometric data. Moreover, the inclusion of multiple vision measures allowed us to not solely rely on distance acuity and to also include older adults with near and contrast sensitivity vision loss in our estimates. Despite this broader definition we recognize that our measure is still limited as there are other aspects of vision loss that are not included such as field of vision, color, and stereovision, to mention just a few.
Our work also has limitations. Our calculations excluded non-community dwelling adults (those living in long-term care settings) and those missing hearing and vision data. Compared to the entire population of community dwelling Medicare beneficiaries surveyed by NHATS, participants in our study are younger, have higher education attainment, and are less likely to live in low-income households (Supplemental Table S1). As a result, even though this work is an improvement over previously published studies, our findings are likely still underestimated, as the excluded individuals, particularly older participants, are at a higher risk for sensory loss. In addition, NHATS only collects data within the continental US, so our estimates may not be generalizable to older Americans living in Alaska, Hawaii, and Puerto Rico. Furthermore, since the study cohort has not been replenished since 2015, these results pertain only to older adults ≥71 years. Data for those ages 65–70 years will be available only after the next study replenishment taking place during 2022–2023.
CONCLUSIONS
One in 5 community-dwelling Medicare beneficiaries aged ≥71 years have both hearing and vision loss, increasing to 3 in 5 for those aged ≥90 years. Prevalence of DSL is higher among older adults with low education attainment and who live in low-income households. This research provides updated and robust estimates to inform clinicians, policy makers, and other stakeholders of the number of Americans experiencing sensory loss who could potentially benefit from policies that increase access and affordability of vision and hearing related treatment and services.
Supplementary Material
Key points.
In a nationally representative sample of 2579 community-dwelling Medicare beneficiaries aged ≥71 years, we estimated the prevalence of concurrent vision and hearing loss (referred to as dual sensory loss; DSL) by age groups and selected sociodemographic characteristics.
1 in 5 community-dwelling older Americans experience dual sensory loss. Prevalence of DSL increased with age to 3 in 5 adults aged ≥90 years.
Prevalence of DSL was higher among older adults with low educational attainment (at most high school) and household income below the poverty line.
Why does this paper matter?
Because of the negative health related consequences associated with dual sensory loss (hearing and vision), recent prevalence estimates are needed to inform the practice of clinicians, policy makers, and other stakeholders of the proportion of older Americans experiencing sensory loss.
ACKNOWLEDGMENTS
NHATS (U01AG032947), Dr. Reed (K23AG065443), and Dr. Deal (K01AG054693) are funded by the National Institute on Aging.
Funding Statement
NHATS (U01AG032947), Dr. Reed (K23AG065443), and Dr. Deal (K01AG054693) are funded by the National Institute on Aging. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
ROLE OF THE FUNDER/SPONSOR:
The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
CONFLICT OF INTEREST
Dr. Reed reports sitting on the advisory board of Neosensory. Dr. Ehrlich has consulted for MetLife. Dr. Lin is a consultant to Boehringer-Ingelheim, Cochlear Ltd, and Amplifon. All other authors have nothing to report.
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