Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Jul 1.
Published in final edited form as: Arch Gerontol Geriatr. 2024 Mar 5;122:105397. doi: 10.1016/j.archger.2024.105397

Social Engagement and Cognitive Impairment among Nursing Home Residents: The Role of Sensory Impairment

Shu Xu 1,2, William M Jesdale 2, Catherine E Dubé 2, Natalia N Nielsen 2, Emily A McPhillips 2, Kate L Lapane 2
PMCID: PMC11073896  NIHMSID: NIHMS1979291  PMID: 38484670

Abstract

Background and Objectives:

Using US national nursing home data, this cross-sectional study sought to evaluate 1) the association between lack of social engagement and level of cognitive impairment; and 2) the extent to which this association differs by hearing and visual impairment.

Research Design and Methods:

Our sample included 793,846 nursing home residents aged ≥ 50 years. The Index of Social Engagement was categorized as none/lower levels (0, 1, 2) or higher (3 through 6). Cognitive Performance Scale was grouped as intact/mild (0, 1, 2), moderate (3, 4), or severe (5, 6). Multinomial models provided adjusted odds ratio (aOR) and 95% confidence intervals (CI) between none/lower social engagement and cognitive impairment. We estimated relative excess risk due to interaction (RERI) to quantify the joint effects of social engagement and sensory impairment types.

Results:

Overall, 12.6% had lower social engagement, 30.3% had hearing impairment, and 40.3% had visual impairment. Compared to residents with high social engagement, those with lower social engagement were more likely to have moderate/severe cognitive impairment (aORmoderate=2.21, 95% CI 2.17–2.26; aORsevere=6.49, 95% CI 6.24–6.74). The impact of low social engagement on cognitive impairment was more profound among residents with hearing impairment and/or visual impairment (RERIhearing=3.89, 95% CI 3.62–4.17; RERIvisual=25.2, 95% CI 23.9–26.6)).

Discussion and Implications:

Residents with lower social engagement had higher levels of cognitive impairment. Residents with sensory impairments are potentially more susceptible to the negative impact of lower levels of social engagement on level of cognitive impairment.

Keywords: social isolation, cognition, visual impairment, hearing impairment, long term care

1.1. INTRODUCTION

Having important relationships, along with experiencing a sense of community and participation in meaningful activities, is important for improved quality of life among older adults (Herzog, 2002; Holt-Lundstad, 2022), particularly for those living in nursing homes and assisted living facilities (Bradshaw, 2012; Kang et al., 2020). Social engagement may be an important modifiable risk factor for adverse mental health outcomes for older adults living in nursing homes and assisted living facilities (Lim et al., 2023). In nursing homes, deficits in social connectedness may be felt most acutely among residents who are cognitively impaired (Bova et al., 2021; Cahill, 2011). Extant literature shows that social engagement is associated with cognitive function; however, the association between social engagement and cognitive impairment within nursing homes remains understudied (Lim et al., 2023). Given that more than 70% of long-stay nursing home residents have some cognitive impairment, and half are moderately to severely impaired (Thomas et al., 2017), there is a need to gain a deeper understanding of how social engagement may affect cognitive function among older nursing home residents.

Sensory impairment usually refers to impairment of vision or hearing that causes difficulty in daily living (Abdullah et al., 2021). Among Americans aged ≥ 65 years, approximately one in ten persons has a visual impairment and nearly half have a hearing impairment (Goman & Lin, 2016; Friedman et al., 2012). The prevalence of sensory impairment increases with age (Dillion et al., 2010) and is higher among older people living in nursing homes than community-dwelling older adults (Wang et al., 2001) with over half of nursing home residents with visual impairment and 70%–90% with some degree of hearing impairment (Jupiter, 2012; Monaco et al., 2023). Compared to community-dwelling older adults, nursing home residents have 3 to 15 times higher rates of visual impairment (Owsley et al., 2007). Having sensory impairment is associated with loneliness and social isolation (Coyle et al., 2017; Schneider et al., 2011) and has profound effects on a variety of health outcomes including cognitive decline and dementia in community-dwelling older adults (Ehrlich et al., 2021; Swenor et al., 2019). The role that sensory impairment plays in the relationship between social engagement and cognitive impairment remains unclear.

According to the Convoy Model of Social Relations, social relationships contribute to an individual’s well-being throughout the life course and social interaction has significant ramifications for mental health (Antonucci et al., 2014). Reduced social connectedness may have generated increased mental health concerns among older people, especially for those in nursing homes. Since people with sensory impairment are less likely to have functional independence and may experience unique challenges in daily life, they may have smaller social networks and may be at a greater risk of reduced social engagement than those without sensory impairment (Hodge & Eccles, 2013). Thus, research is needed to better understand the association between social engagement, cognitive impairment, and sensory impairment and its potential implications for older adults in nursing homes.

This cross-sectional study used a national data resource including virtually all US nursing home residents to evaluate the association between low social engagement and increased level of cognitive impairment, and to evaluate the extent to which this association differs in relation to sensory impairment status. We hypothesized that residents with lower social engagement would have higher levels of cognitive impairment and that the combined impact of having lower social engagement coupled with sensory impairment would place residents at increased risk of cognitive impairment relative to having either lower social engagement (in the absence of sensory impairment) or sensory impairment (in the absence of lower social engagement). To our knowledge, no study has attempted to quantify the excess risk of cognitive impairment attributed to the joint effects of lower social engagement and sensory impairment.

1.2. METHODS

This study was approved by our Institutional Review Board.

1.2.1. Data Source

We conducted a cross-sectional study using Minimum Data Set 2.0 (MDS 2.0) data from 10/1/2009 to 9/30/2010. This was the last year in which the MDS 2.0 was used in the United States. While studies in other countries/regions continued to measure social engagement using MDS 2.0-related instruments, such as Taiwan, Hong Kong, the Czech Republic, England, Finland, France, Germany, Israel, Italy, and the Netherlands (Chen et al, 2014; Lou et al., 2013; Yamada et al., 2016), the more recent MDS 3.0 in the United States, implemented in October 2010, no longer includes social engagement measures.

The MDS is a federally mandated, comprehensive clinical assessment of all residents in Medicare- or Medicaid-certified nursing home facilities (approximately 96% of U.S. nursing homes). MDS 2.0 is a validated (Gambassi et al., 1998; Lawton et al., 1998) and reliable (Hawes et al., 1995) assessment that collects information on sensory status and communication, cognitive and behavioral patterns, psychosocial well-being, informal and formal support services, physical functioning, and medical diagnoses (Morris et al., 1990; Morris et al., 2005). The assessments are conducted by healthcare professionals at each nursing home and include information gained by reviewing discharge notes and obtaining information from residents, nursing staff caring for the residents, and family members or other caregivers. Full assessments are conducted at admission and annually and a subset of items are included in quarterly assessments, or an assessment conducted after a significant change in resident health occurs (Morris et al., 2005).

1.2.2. Sample

Our sample included nursing home residents who (1) had at least one annual MDS 2.0 assessment; (2) were aged ≥ 50 years; (3) were not comatose at the time of assessment; and (4) had valid data for vision, hearing, cognitive impairment, the social engagement index, and all covariates included in our models. Residents who had lengths of stay of at least one year were included to ensure they have had time to adjust and acclimate to the social environment after nursing home admission. With these selection criteria applied, the study sample included 793,846 residents (Supplemental Figure 1).

1.2.3. Measures

1.2.3.1. Primary determinant – Social Engagement

Social engagement was defined using the Index of Social Engagement, which describes the resident’s sense of initiative and social involvement within the facility. This 7-point scale includes six items: 1) at ease interacting with others, 2) at ease doing planned or structured activities, 3) at ease doing self-initiated activities, 4) establishes own goals, 5) pursues involvement in the life of the facility, 6) accepts invitations into most group activities. Each item is answered with 1 or 0 (“yes” or “no”). Responses are totaled to provide a summary score reflecting the level of resident social engagement. Scores range from 0, indicating no/low social engagement, to 6, indicating high social engagement. Validity and reliability of the Index of Social Engagement are high (Mor et al., 2011). Our primary determinant classified residents into two groups of social engagement: 1) none or lower levels of social engagement: Index of Social Engagement 0, 1, 2; or 2) higher social engagement: Index of Social Engagement 3 through 6. This way of operationalizing the index of social engagement has been conceptually substantiated (Resnick et al., 1997) and used in earlier studies (Morris et al., 1999; Tsai et al., 2009).

1.2.3.2. Primary Outcome Variable- Level of Cognitive Impairment

The primary outcome variable of interest was level of cognitive impairment. This was measured by the MDS Cognitive Performance Scale (CPS), a five-item scale including comatose status, short-term memory, cognition skills for daily decision-making, expressive communication, and self-performance in eating. Short-term memory was collected as a dichotomous variable (1 = yes, 0 = no). Expressive communication and capacity for decision-making were scored from 0 to 4, with higher scores indicating a greater impairment. Eating was scored from 0 to 8, with higher scores indicating an increasing need for assistance. The CPS has high interrater reliability and has been validated against the Mini-Mental State Examination (MMSE) and the Test for Severe Impairment (TSI; Morris et al., 1994). Higher scores indicate more severe cognitive impairment (ranging from 0 [cognitively intact] to 6 [severe cognitive impairment]). Previous research provides evidence of validity that people with an increasing score on the CPS have a higher prevalence of dementia diagnosis than people with less impaired performance (Jones et al., 2010). The primary outcome variable was a three-level variable based on the Cognitive Performance Scale: 1) intact/mild (0, 1, 2); 2) moderate cognitive impairment (3, 4); or 3) severe cognitive impairment (5, 6).

1.2.3.4. Moderator – Sensory Impairments

We considered two types of sensory impairment – visual and hearing – as potential moderators of the association between lower social engagement and cognitive impairment. Hearing and vision were assessed while residents were using any corrective hearing or vision devices they would typically use (e.g., hearing aid, glasses) and scores were assigned by nursing home staff. Hearing status was coded as 0 (adequate), indicating no difficulty in normal conversation; 1 (mildly impaired), indicating difficulty when not in a quiet setting; 2 (moderately impaired), indicating ability to hear in special situations only—e.g., speaker has to adjust tonal quality and speak distinctly; and 3 (highly impaired), indicating absence of useful hearing. The hearing impairment criterion correlates with the Hearing Handicap Inventory screener, indicating that it is a valid measure of a person’s perceptions of the effects of hearing impairment on their emotional well-being and their capacity for everyday activities (Morris et al., 2004).

The vision item was coded as 0 (adequate), indicating able to see fine details; 1 (mildly impaired), indicating able to see large print but not regular print in newspapers; 2 (moderately impaired), indicating limited vision—not able to see newspaper headlines but able to identify objects; 3 (highly impaired), indicating object identification in question but eyes appear to follow objects; and 4 (severely impaired), indicating no vision or sees only light, colors, or shapes and eyes do not appear to follow objects. We categorized hearing and vision as dichotomous variables (adequate vs. moderate-severe impairment; Resnick et al., 1997).

1.2.3.5. Potential confounders

We generated a list of potential confounders based on our literature review and a directed acyclic graph. We included resident sociodemographic characteristics such as age group (54–64; 65–74; 75–84; 85+ years), female, racial-ethnic identity (White [reference group], Black, Hispanic, Asian/Pacific Islander, American Indian/Alaskan Native), and marital status (married, divorced/separated, widowed, or never married). Health characteristics considered included functional status, number of medications per week (0–5; 6–10; 10–15; 16+), and chronic medical comorbidities. Residents’ functional status was assessed based on the Activities of Daily Living (ADL) Hierarchy Scale (Morris et al., 1999). This scale groups ADL performance levels into discrete stages of loss (early loss: personal hygiene; middle loss: toileting and locomotion; late loss: eating). ADL limitations were scored from 0 to 6 and categorized as the following: 0–2 (none/mild), 3–4 (moderate), and 5–6 (dependency in ADLs). Chronic medical comorbidities were also considered as potential confounders (Petrovsky et al., 2019). We included Alzheimer’s disease and dementia other than Alzheimer’s disease as potential confounders as they have been shown to be associated with sensory impairment among older adults (Crews et al., 2017; Zheng et al., 2017).

1.2.4. Analytic approach

Our first aim was to quantify the association between social engagement and level of cognitive impairment. To evaluate this aim, we first performed descriptive statistics overall and stratified by level of social engagement. Since very large sample sizes result in statistically significant differences that are often trivial, we considered absolute differences between categories of at least 5% as noteworthy. We also calculated the distribution of cognitive impairment across each level of social engagement (0 through 6). We developed two multinomial logistic models to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to evaluate the association of social engagement on the 3-level primary outcome of interest-level of cognitive impairment. The first model included a binary term for level of social engagement (none/lower versus higher) and the second model retained the entire social engagement index (coded as 0 to 6). These models were adjusted for age, gender, race/ethnicity, ADL limitations, number of medications per week, Alzheimer’s disease, and dementia other than Alzheimer’s disease. We evaluated and ruled out multicollinearity by reviewing the standard errors as new variables were added to the model.

Our second aim sought to evaluate the extent to which the association between social engagement and level of cognitive impairment was modified by hearing and visual sensory impairments. To evaluate this aim, we first described the distribution of cognitive impairment across hearing impairment levels and vision impairment levels separately. To provide a greater understanding of the extent of sensory impairments experienced by the long-stay nursing home residents, we evaluated the extent to which the residents were affected by both visual and hearing impairments, and the proportion of each group that used assistive devices/appliances. We estimated relative excess risk due to interaction (RERI) to quantify the joint effects of social engagement and sensory impairment to evaluate the extent to which the association differs as a function of sensory impairment status (Van der Weele, 2015). We dichotomized CPS in two groups to maximize contrast: those with none/mild cognitive impairment and those with severe cognitive impairment. SAS version 9.4 (SAS Institute, Inc., Cary NC) was used for statistical analyses.

1.3. RESULTS

1.3.1. Sample characteristics, overall characteristics and stratified by level of social engagement

Of the 793,846 long-stay residents, 46.3% were aged ≥ 85 years; 71.4% were women; 79.7% were non-Hispanic White; half were widowed; nearly one-third were dependent in ADLSs; 88.8% took more than five medications per week; 20.3% had Alzheimer’s disease; and 45.6% had dementia other than Alzheimer’s disease (Table 1). Nearly 13% of residents lacked any social engagement, whereas 5.0% had the highest level of social engagement. While age, sex, and marital status were similar regardless of level of social engagement, the prevalence of dependency in ADLs and Alzheimer’s disease and related dementias were higher in those who lacked or had little social engagement relative to residents with higher levels of social engagement. Residents with highest level of social engagement were more likely to be non-Hispanic white (86.3%) than residents who lacked social engagement (73.1%). Residents who lacked social engagement were more likely to be married with a living spouse (lowest: 21.7%, highest level of social engagement: 13.7%), to be dependent in ADLs (lowest: 61.1%, highest level of social engagement: 7.0%), and to have dementia (i.e., Alzheimer’s disease (lowest: 32.0%, highest level of social engagement: 8.9%); other dementias (lowest: 53.3%, highest level of social engagement: 30.6%).

Table 1.

Characteristics of Nursing Home Residents by Social Engagement (n=793,846)

Social engagement
Full sample (N=793,846) 0 (None) (n=99,684) 1 (n=146,849) 2 (n=158,611) 3 (n=173,980) 4 (n=108,705) 5 (n=66,584) 6 (Highest) (n=39,433)
Percentage
Age group (years)
 50 to 64 11.6 11.1 10.6 10.6 11.2 12.6 14.3 15.3
 65 to 74 13.6 14.0 13.2 12.9 13.1 14.0 15.2 16.0
 75 to 84 28.4 30.0 29.2 28.3 28.0 27.7 27.3 27.8
 ≥85 46.3 44.9 47.0 48.2 47.7 45.6 43.3 40.9
Female 71.4 72.4 70.3 70.2 71.2 71.4 73.0 75.3
Male 28.6 27.6 29.7 29.8 28.8 28.6 27.0 24.7
Race/Ethnicity
 Non-Hispanic White 79.7 73.1 75.4 79.2 81.8 83.4 84.2 86.3
 Non-Hispanic Black 13.8 17.2 16.9 14.0 12.5 11.5 11.0 10.1
 Hispanic of any race(s) 4.4 6.8 5.3 4.6 3.8 3.4 3.1 2.3
 Non-Hispanic Asian/Pacific Islander 1.7 2.5 2.0 1.8 1.4 1.3 1.1 0.8
 Non-Hispanic American India/Alaskan Native 0.5 0.4 0.4 0.4 0.5 0.5 0.6 0.6
Marital status
 Married 17.4 21.7 19.1 17.7 16.3 15.4 14.0 13.7
 Divorced/separated 13.2 12.2 12.5 12.9 13.4 13.9 14.5 14.8
 Widowed 52.0 48.9 51.3 52.4 53.3 52.7 52.7 52.4
 Never married 17.4 17.2 17.0 16.9 17.0 18.0 18.8 19.1
ADL limitations
 None/mild 25.7 8.9 16.1 21.4 29.1 36.0 43.3 48.0
 Moderate 44.2 30.0 40.5 46.0 49.4 49.3 47.1 44.9
 Dependent 30.2 61.1 43.5 32.6 21.6 14.8 9.6 7.0
Number of medications per week
 0–5 11.2 18.2 13.5 11.6 9.3 8.1 7.5 6.0
 6–10 36.6 43.1 40.0 37.8 35.1 32.8 31.4 28.7
 11–15 34.1 28.6 32.5 34.1 35.8 36.3 36.4 37.2
 16+ 18.1 10.1 14.1 16.6 19.8 22.9 24.7 28.2
Alzheimer’s disease 20.3 32.0 24.8 21.6 17.8 14.3 12.5 8.9
Dementia other than Alzheimer’s disease 45.6 53.3 51.1 48.9 44.5 39.0 36.2 30.6
Open in a new tab

1.3.2. Level of cognitive impairment by level of social engagement

Supplemental Table 1 shows that 19.9% of long-stay residents were borderline or cognitively intact, and eight of ten residents had some degree of cognitive impairment (mild impairment: 10.9%; moderate impairment: 15.7%; moderate to severe impairment: 35.2%; severe impairment: 9.3%; very severe impairment: 9.0%). Moderate to very severe cognitive impairment was more prevalent in residents with lower levels of social engagement. Residents with higher levels of social engagement had a higher prevalence of intact and borderline intact cognition.

1.3.3. Association between social engagement and cognitive impairment

The association between social engagement and cognitive impairment is presented in Table 2. Compared to residents with higher social engagement, those with no/lower social engagement had greater odds of moderate cognitive impairment (aOR = 2.21, 95% CI =2.17–2.26) and severe cognitive impairment (aOR = 6.49, 95% CI =6.24–6.74) than no/mild cognitive impairment. The association between each level of social engagement and level of cognitive impairment is shown. With respect to moderate versus intact/mild cognitive impairment, each one-unit reduction in social engagement was associated with increased odds of moderate cognitive impairment, with greater strength of association observed in social engagement 3 (aOR: 2.35; 95% CI: 2.25–2.45) to 0 (aOR: 6.98; 95% CI: 6.55–7.43). With respect to severe cognitive impairment versus intact/mild cognitive impairment, each one unit reduction from 6 showed an increased odds relative to the next highest score (e.g., aORsocial engagement=5: 3.20; 95% CI: 2.67–3.85; aORsocial engagement=4: 4.75; 95% CI: 3.97–5.67).

Table 2.

Association of social engagement on cognitive impairment among 793,846 long-stay nursing home residents

Moderate cognitive impairment (Cognitive Performance Scale 3–4) Severe cognitive impairment (Cognitive Performance Scale 5–6)
Ref. no/mild cognitive impairment (Cognitive Performance Scale 0–2)
Adjusted Odds Ratio a 95% Confidence intervals Adjusted Odds Ratio a 95% Confidence intervals
Social engagement
None or low social engagement (0–2) (n=405,144) 2.21 (2.17–2.26) 6.49 (6.24–6.74)
Higher social engagement (3–6) (n=388,702) 1.0 -- 1.0 --
Social engagement
0 (No engagement) 6.98 (6.55–7.43) 138 (114–166)
1 4.24 (4.04–4.45) 38.3 (31.9–46.1)
2 3.33 (3.18–3.48) 20.3 (16.9–24.3)
3 2.35 (2.25–2.45) 9.64 (8.05–11.6)
4 1.69 (1.63–1.76) 4.75 (3.97–5.67)
5 1.48 (1.42–1.54) 3.20 (2.67–3.85)
6 (Highest level) 1.0 -- 1.0 --
Open in a new tab
a

Adjusted for age, gender, race, marital status, ADL limitations, number of medications per week, Alzheimer’s disease, dementia other than Alzheimer’s disease.

1.3.4. Prevalence of sensory impairment and use of assistive devices

With respect to hearing impairments, 1.5% of residents were highly impaired, 8.2% were moderately impaired, and 20.6% were mildly impaired. Supplemental Table 2 shows that among those with high and moderate levels of hearing impairments, use of hearing appliances was common (high: 39.4%, moderate: 35.8%). With respect to visual impairments, 2.2% were severely impaired, 9.5% were highly impaired, 7.5% were moderately impaired, and 21.2% were mildly impaired. Use of vision appliances were more common with lower levels of visual impairment (moderate: 54.5%, mild or no visual impairment: 65.8%) relative to higher levels of visual impairment (highly: 33.8%, severely: 17.5%).

1.3.5. Sensory impairment and level of cognitive impairment

Supplemental Table 3 shows that residents with no hearing impairment had the highest prevalence of intact and borderline intact cognition than residents with hearing impairment. Compared to other hearing impairment groups, residents with severe hearing impairment were the most likely to experience severe cognitive impairment (14.6%) and very severe cognitive impairment (25.4%); respondents with moderate hearing impairment were the most likely to experience moderate to severe cognitive impairment (40.8%). Compared to other visual impairment groups, residents with high visual impairment were the mostly likely to experience severe cognitive impairment (21.9%) and very severe cognitive impairment (40.8%); residents with moderate visual impairment were the most likely to experience moderate to severe cognitive impairment.

Table 3 shows that across sensory impairment levels, the association of no/low social engagement and moderate cognitive impairment was qualitatively similar, regardless of level of hearing impairment or visual impairment. While the association of no/low social engagement and severe cognitive impairment was qualitatively similar regardless of level of hearing impairment, it was higher among residents with severe visual impairment (aOR: 8.84, 95% CI: 7.55–10.4).

Table 3.

Association of no/low social engagement on moderate and severe cognitive impairment stratified by visual and hearing impairment levels

Moderate cognitive impairment Severe cognitive impairment
Ref. no/mild cognitive impairmenta
Odds Ratio 95% Confidence intervals Odds Ratio 95% Confidence intervals
No/low social engagementb 2.21 (2.17–2.26) 6.49 (6.24–6.74)
Hearing impairment
No impairment (n=552,963) 2.19 (2.14–2.24) 6.44 (6.17–6.71)
Mildly impaired(n=163,853) 2.27 (2.19–2.35) 6.44 (6.08–6.82)
Moderately impaired(n=65,065) 2.24 (2.12–2.36) 6.34 (5.85–6.88)
Highly impaired(n=11,974) 2.11 (1.86–2.38) 6.73 (5.67–8.00)
Visual impairment
No impairment(n=473,774) 2.12 (2.07–2.18) 5.60 (5.36–5.85)
Mildly impaired(n= 168,091) 2.16 (2.09–2.24) 5.42 (5.09–5.77)
Moderately impaired(n=59,664) 2.46 (2.32–2.60) 5.84 (5.38–6.34)
Highly impaired(n=75,130) 2.39 (2.21–2.60) 6.69 (6.03–7.43)
Severely impaired(n=17,187) 2.44 (2.22–2.69) 8.84 (7.55–10.4)
Open in a new tab

Notes: N = 793,846. Models adjusted for age, gender, race, marital status, ADL limitations, number of medications per week, Alzheimer’s disease, dementia other than Alzheimer’s disease.

a

Cognitive impairment: none/mild (CPS 0–2), moderate (CPS 3–4), and severe (CPS 5–6).

b

Reference group: high social engagement (INDEX OF SOCIAL ENGAGEMENT 3–6).

Significant additive interaction between social engagement and sensory impairments on cognitive impairment was detected (Table 4). Results are shown separately for residents with hearing impairment and visual impairment. Compared to residents without hearing impairment who had high social engagement, residents with moderate/severe hearing impairment who had low social engagement had a higher risk of severe cognitive impairment (aOR = 11.3, 95% CI: 10.7–11.9). The joint association of hearing impairment and low social engagement was more than expected by the sum of their separate associations with severe cognitive impairment, where the adjusted odds ratio of individual association of hearing impairment was 1.54 (95% CI: 1.45–1.65) and the adjusted odds ratio of the individual association of low social engagement was 6.84 (95% CI: 6.60–7.10). The estimated 95% confidence intervals of the RERI for the joint effects of social engagement and hearing impairment were 3.89 (3.62–4.17).

Table 4.

Social engagement and sensory impairment in relation to cognitive impairment

Hearingb Visualc
Parameter Odds Ratio 95% Confidence intervals Odds Ratio 95% Confidence intervals
Sensory impairment only 1.54 (1.45–1.65) 4.10 (3.87–4.35)
Low Social engagement onlya 6.84 (6.60–7.10) 5.58 (5.36–5.82)
Both sensory impairment + low social engagement 11.28 (10.7–11.9) 33.9 (32.2–35.8)
RERI 3.89 (3.62–4.17) 25.2 (23.9–26.6)
Open in a new tab

Notes: Models adjusted for age, gender, race, marital status, ADL limitations, number of medications per week, Alzheimer’s disease, dementia other than Alzheimer’s disease.

a

Social engagement: low (INDEX OF SOCIAL ENGAGEMENT 0–2) vs high (INDEX OF SOCIAL ENGAGEMENT 3–6) social engagement; cognitive impairment: severe (CPS 5–6) vs. none/mild (CPS 0–2).

b

N = 318,018. Hearing impairment: moderate/severe (2–3) vs. no impairment (0).

c

N =321,209. Visual impairment: moderate/severe (2–4) vs. no impairment (0).

With respect to visual impairment, the joint effects of social engagement and moderate/severe visual impairment appeared to have a more profound effect on severe cognitive impairment. Compared to residents without visual impairment who had high social engagement, residents with visual impairment who had low social engagement had a higher risk of severe cognitive impairment (aOR = 33.9, 95% CI = 32.2–35.8). The estimated RERI and 95% confidence intervals for the joint effects of social engagement and vision impairment were 25.2 (95% CI: 23.9–26.6).

1.3.6. Co-occurrence of visual and hearing sensory impairments

The co-occurrence of visual and hearing sensory impairments was common (Supplemental Table 4). For those with no hearing impairments, 16.1% had moderate to severe visual impairments. Among those with mild hearing impairments, 21.6% had moderate to severe visual impairment. Thirty-four percent of those with moderate hearing impairments also had moderate to severe visual impairment, as did 46.2% of residents who were highly hearing impaired. For those with no visual impairments, fewer residents were also moderate to highly hearing impaired (no visual impairment: 6.4% had moderate to severe visual impairments; severe visual impairment: 22.4% were moderate to highly hearing impaired).

Supplemental Table 5 shows the results of analyses stratified by type of sensory impairment (hearing, visual) among residents with or without the other sensory impairment (e.g., hearing impaired without visual impairments). For those with moderate/severe hearing impairments, departures from additivity were observed for those with moderate/severe visual impairments (RERI: 1.62; 95% CI: 1.41–1.87). Excess risk for interaction was present in those with moderate/severe visual impairments with (RERI: 16.4; 95% CI: 14.6–18.6) or without moderate/severe hearing impairment (RERI: 28.2; 95% CI: 26.5–30.0).

1.4. DISCUSSION

The purpose of this study was to investigate associations between social engagement, sensory impairment, and cognitive impairment among nursing home residents. Our findings demonstrated that, among nursing homes residents, lower social engagement was associated with higher odds of cognitive impairment. It is possible that social engagement may be protective against the risk of cognitive decline (Freeman et al., 2016) and our findings support this. In previous research on community-dwelling older adults and residents in long-term care facilities, greater social engagement was associated with delayed cognitive decline (Freeman et al., 2016; Zunzunegui et al., 2003). However, the overall impact of social engagement on cognitive impairment in older adults living in nursing homes is unknown (Lapane et al., 2023) and few studies evaluated the associations between social engagement and cognition among nursing home residents with visual or hearing impairment. We found that the association between social engagement and cognitive impairment was large across all sensory impairment levels. Furthermore, this association was stronger among residents with hearing or visual impairment than those without such impairments. Our findings support the Convoy Model of Social Relations that social relationships are fundamental for maintaining mental health and the risk of cognitive impairment is influenced by lower levels of social engagement (Antonucci et al., 2014). While the underlying mechanisms behind this association are unknown, it is possible that engaging in activities may stimulate various domains of intelligence, such as verbal, musical, or emotional abilities, potentially impeding cognitive decline (Park et al., 2014). Cognitive stimulation through social activities and interpersonal interactions might contribute to the enhancement of specific cognitive reserves in the brain. These reserves enable individuals to better manage age-related or pathological changes, potentially delaying the development of cognitive impairment (Lee et al., 2016; Stern, 2012).

Our study also contributes to existing evidence regarding the joint association of social engagement and sensory impairment with cognition. To the best of our knowledge, no previous studies have explored whether exposure to both low social engagement and hearing or visual impairment impacts cognitive impairment above independent effects. We found that the individual effects of low social engagement and having moderate to severe sensory impairment on severe cognitive impairment were substantive. A synergistic interaction of social engagement and sensory impairments on cognitive impairment was observed. Our findings suggested that the joint effects of low social engagement and having sensory impairment were greater than the effect that is expected if each were acting independently and the sum of their individual effects. Specifically, residents with low social engagement and moderate to severe hearing or visual impairment were more likely to have severe cognitive impairment in comparison to residents with high social engagement and no hearing or visual impairment. Sensory impairment is a key factor influencing social engagement in nursing home residents (Resnick 1997). Older adults with visual impairment often rely on touch and tactile senses to perform routine activities, requiring closer or more tactile engagement with surfaces, objects, and people. Those with hearing impairment have difficulty understanding what is being communicated. Thus, older people with sensory impairment may experience unique challenges and more difficulties in interacting and developing relationships with other residents in nursing homes due to their sensory limitations (Cook et al., 2006). Any resulting reduction in social engagement can be especially detrimental for them. It is possible that residents with sensory limitations may have less fulfilling social interactions and tend to withdraw from social events and participation in activities, which can cause loss of social abilities and further result in reduced cognitive stimulation (Ray et al., 2019).

Our results suggest that visual impairment and social engagement have a stronger synergistic effect on cognitive impairment than hearing impairment and social engagement. These findings remained when we attempted to parse out the potential influence of the concurrent hearing and visual impairments on our findings. It is possible that people with limited vision experience unique challenges in active social participation. Their vision limitations can create barriers to awareness of the presence of other people and the ability to recognize other people (Berry et al., 2004). Visual limitations and their interference with effective social interactions or communication can lead to restricted social movement and lower frequency of contact with others (Crews & Campbell, 2001). People with hearing issues engaging in social activities can rely on visual information like facial expressions and lip reading to help them understand what is being communicated or to know who they are interacting with.

In addition, it has been found that there was heterogeneity in current cohort studies in terms of the proportion of participants with no or low social engagement (Lapane et al., 2023). The rate of no social engagement was reported to range from 6.6% (Kiely & Flacker, 2003) to 33% (Vetrano et al., 2018), while we found a rate of 12.6%. The distribution of Index of Social Engagement in our study also supported the observations of previous studies that reported that approximately 30% of nursing home residents had no/low social engagement (index of social engagement 0–1; Freeman et al., 2016) and 50% had lower levels of index of social engagement (0, 1, and 2; Achterberg et al., 2003). The rates of hearing and visual impairments in our study represented 30.3% and 40.3% of nursing home residents, respectively. The proportion of residents with sensory impairments was lower than that found in other published research, which reported a rate of 66% visual impairment and a rate of over 70% hearing impairment among older adults in nursing homes (Jupiter, 2012; Monaco et al., 2023). It is likely due to the fact that the assessments of sensory impairments in previous studies were based on objectively measured visual acuity and pure tone hearing screenings (Jupiter, 2012; Monaco et al., 2023), while our study looked at self-reported functional impairment which allowed the use of hearing aids, glasses, and other appliance/technologies.

1.4.1. Limitations

Our findings demonstrated that nursing homes residents with lower social engagement had increased odds of cognitive impairment. It is possible that cognitive function could be a key factor affecting social engagement. We are unable to distinguish the causal direction between sensory impairments, social engagement, and cognitive impairment due to the cross-sectional design of our study. Longitudinal studies are warranted.

Because the social engagement scale was not included in MDS 3.0, we used data from the final year of MDS 2.0. The MDS 2.0 provides a rich source of information about older adults in nursing homes. Yet, as with any existing dataset, we were limited to the data elements available. However, given the lack of research in the relationships between social engagement, cognitive impairment, and sensory impairment in nursing homes, our study offers valuable insights to the existing literature and lays the groundwork for future analyses. Sensory impairments relied on staff observation, discussion with family, and residents. It would be ideal to have both self-reported and objective measures of audiometric/visual impairment to better capture sensory function. However, the objective measure of audiometric/visual acuity were not available in the MDS 2.0 data. In addition, previous studies have indicated self-reported sensory impairment as a significant indicator of social isolation risk (Coyle et al., 2017) and this measure may capture a distinct and valuable construct and may better uncover the lived experiences and unique environments that influence health in later life (De Lott et al., 2022; Ehrlich et al., 2022). We believe that it is valuable to utilize a self-reported measure for sensory impairment in examining its relationship with social engagement and cognitive impairment in nursing homes. There is likely little error in cognitive impairment, hearing, and vision measurements given that these are readily perceptible to nursing staff, of high salience to nursing home care, and well-specified in MDS instrument documentation.

The Index of Social Engagement used was based on staff interpretations of resident behavior, particularly in relation to other residents and group activities, and thus may discount social interactions with staff, often key social interactions in nursing home settings. Alternately, because item coding is based on staff observations, residents’ social engagement with other residents that is not observed by staff would be underestimated. Systematic differences in the Index of Social Engagement measurement may occur between nursing homes, due to the intensity with which staff monitors and recognizes resident social interactions. Future research is needed to examine the association between social engagement and cognitive function using patient-reported social engagement.

1.4.2. Implications for Policy and Practice

The findings of this study have practical implications for healthcare professionals who care for nursing home residents. Anyone involved in the care of nursing home residents should be aware of the risks of low social engagement and sensory loss and monitor for decreased social engagement and isolation in residents, especially for those with sensory limitations since they are under-identified and under-treated in nursing homes (Pryce & Gooberman-Hill, 2013). To enhance hearing and vision support for individuals in nursing homes, it would be beneficial to promote collaborative work between audiologists, optometrists, volunteers, health professionals, and staff, and to offer cross-discipline training and guidelines to improve assessment and care pathways (Dawes et al., 2021; Leroi et al., 2019). To enhance social engagement, special consideration for hearing and vision impairment and strategies such as new uses of technology should be considered (McDonnall et al., 2016). There is a lack of recognition of the significance of screening for hearing and vision impairments (Andrusjak et al., 2021) to improve social engagement providing appropriate assistance to optimize residents’ social participation. Regular optometric and audiological assessments may help with early diagnosis and intervention. In addition, the limited coverage of sensory aids by Medicare can restrict their use among older adults, leading to reduced quality of life due to untreated sensory impairments (Forum on Aging, Disability, and Independence, 2014). Expanding Medicare coverage for sensory aids could potentially improve wellbeing of older adults, as well as reduce healthcare costs by preventing more serious health issues from developing.

Adaptations to the nursing home environment to support residents with hearing and vision loss are important in improving their social capabilities. Meaningful person-centered activities and beneficial environmental modifications for residents with hearing and vision needs should be designed to support socially engaged activities. Guidelines are needed for nursing home staff to coordinate tailored social activities to facilitate social participation and connection with others for residents with sensory impairments. For example, one-on-one visits or group activities in quiet spaces, such as the indoor gardening program, have been found to increase social networking among nursing home residents (Tse, 2010). Nursing home staff can invite sensory-impaired individuals who are at risk of social isolation to participate in recreational programs and provide environmental modification, such as limiting background noise for residents with hearing issues to facilitate conversations or changing different positions and wattage of lighting to find what works best for those with vision issues (Capezuti et al., 2020; Wallhagen et al., 2006).

The assessment of cognition often depends on good hearing and vision functioning, and cognitive impairment can make it difficult to accurately assess sensory impairment (Wolski et al., 2019). Timely and accurate detection and assessment are needed to ensure the most appropriate care and management for individuals with both sensory impairment and cognitive impairment. The UK’s National Institute of Health and Clinical Excellence recognizes the need for early identification of cognitive impairment at vision or hearing assessments and for easy access to interventions while the College of Optometrists in the UK also provides guidance to adapt assessments for people with both vision impairment and dementia (The College of Optometrists, 2016). International, interdisciplinary practice recommendations to guide the development of multidisciplinary services and policy to improve the lives of people with dementia and hearing and vision impairment have been developed and provide pragmatic options for implementation for six domains including “awareness and knowledge,” “recognition and detection,” “evaluation,” “management,” “support,” and “services and policies” (Littlejohn et al., 2022). National or international care standards for effectively detecting, assessing, treating, and managing concurrent hearing and/or vision, and cognitive impairment are currently not widely available. It is essential to provide guidance to professionals and care partners to better support residents with sensory loss and cognitive impairment in managing their health and social needs, enabling them to maintain their independence and participate in daily activities.

1.5. CONCLUSION

We found that residents with lower levels of social engagement were more likely to have higher levels of cognitive impairment. We identified a substantial additive interaction between social engagement and sensory impairment on cognitive impairment. Nursing home residents with sensory impairments are potentially more susceptible to the negative impact of less social engagement on cognitive performance. Future research should examine dual sensory impairment (concomitant impairment of hearing and vision) in relation to social engagement and the development or worsening of cognitive impairment. It is crucial that those who provide care for these residents be aware of signs of decreased social engagement, as well as vision and hearing loss, and to inform the healthcare team of any changes. Early detection and intervention could have a significant and enduring positive impact on the health and overall well-being of nursing home residents.

Supplementary Material

1

Highlights:

  • Based on self-reported functional impairment (rather than objective measures).

  • Lower social engagement was associated with higher odds of cognitive impairment.

  • Social engagement may be protective against the risk of cognitive decline.

  • Large association between social engagement and cognitive impairment at all levels.

Funding

This study was supported by a grant from the National Institute on Aging to Dr. Lapane (5R01AG071692).

Footnotes

Conflict of Interest

None declared.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Data Availability Statement

We are unable to share our data under the terms of our data use agreement with the Centers for Medicare and Medicaid Services. Scientists may access these data by obtaining a data use agreement through RESDAC.

REFERENCES

  1. Abdullah N, Low KEY, Feng Q. Sensory Disability. Encyclopedia of Gerontology and Population Aging. Published online 2021:4468–4473. doi: 10.1007/978-3-030-22009-9_480 [DOI] [Google Scholar]
  2. Achterberg W, Pot AM, Kerkstra A, Ooms M, Muller M, Ribbe M. The effect of depression on social engagement in newly admitted Dutch nursing home residents. Gerontologist. 2003;43(2):213–218. doi: 10.1093/geront/43.2.213 [DOI] [PubMed] [Google Scholar]
  3. Andrusjak W, Barbosa A, Mountain G. Hearing and vision care provided to older people residing in care homes: a cross-sectional survey of care home staff. BMC Geriatr. 2021;21(1):32. Published 2021 Jan 8. doi: 10.1186/s12877-020-01959-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Berry P, Mascia J, Steinman BA. Vision and hearing loss in older adults: “Double trouble”. Care Manag J. 2004;5(1):35–40. doi: 10.1891/cmaj.5.1.35.61260 [DOI] [PubMed] [Google Scholar]
  5. Bova C, Jesdale B, Mbrah A, Botelho L, Lapane K (2021). Development and psychometric evaluation of the Social Connectedness Index in nursing home residents with Alzheimer’s disease and dementia using the Minimum Data Set 3.0. Geriatr Psych. 36(7), 1110–1119. 10.1002/gps.5516 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bradshaw SA, Playfor ED, Riazi A. Living well in care homes: a systematic review of qualitative studies. Age Ageing. 2012;41(4), 429–440. [DOI] [PubMed] [Google Scholar]
  7. Cahill S, Diaz-Ponce AM. ‘I hate having nobody here. I’d like to know where they all are’: Can qualitative research detect differences in quality of life among nursing home residents with different levels of cognitive impairment? Aging Ment Health,. 2011;15(5), 562–572. [DOI] [PubMed] [Google Scholar]
  8. Capezuti E, Zwicker D, Fulmer TT, Boltz M, O’Meara A, editors. Evidence-based Geriatric Nursing Protocols for Best Practice. Fifth edition. New York, NY, Springer Publishing Company, LLC, 2011: 56–60 [Google Scholar]
  9. Cohen-Mansfield J, Taylor JW. Hearing aid use in nursing homes. Part 1: Prevalence rates of hearing impairment and hearing aid use. J Am Med Dir Assoc. 2004;5(5):283–288. doi: 10.1016/S1525-8610(04)70017-1 [DOI] [PubMed] [Google Scholar]
  10. Cook G, Brown-Wilson C, Forte D. The impact of sensory impairment on social interaction between residents in care homes. Int J Older People Nurs. 2006;1(4):216–224. doi: 10.1111/j.1748-3743.2006.00034.x [DOI] [PubMed] [Google Scholar]
  11. Coyle CE, Steinman BA, Chen J. Visual acuity and self-reported vision vtatus. J Aging Health. 2017;29(1):128–148. doi: 10.1177/0898264315624909 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Crews JE, Campbell VA. Health conditions, activity limitations, and participation restrictions among older people with visual impairments. Journal of Visual Impairment & Blindness. 2001;95(8):453–467. doi: [DOI] [Google Scholar]
  13. Crews JE, Chou CF, Sekar S, Saaddine JB. The prevalence of chronic conditions and poor health among people with and without vision impairment, aged ≥65 years, 2010–2014. Am J Ophthalmol. 2017;182:18–30. doi: 10.1016/j.ajo.2017.06.038 [DOI] [PubMed] [Google Scholar]
  14. Dalby DM, Hirdes JP, Stolee P, et al. Development and psychometric properties of a standardized assessment for adults who are deaf-blind. Journal of Visual Impairment & Blindness. 2009;103(1):7–16. doi: [DOI] [Google Scholar]
  15. Dawes P, Leroi I, Chauhan N, et al. Hearing and vision health for people with dementia in residential long term care: Knowledge, attitudes and practice in England, South Korea, India, Greece, Indonesia and Australia. Int J Geriatr Psychiatry. 2021;36(10):1531–1540. doi: 10.1002/gps.5563 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. De Lott LB, Kolli A, Zhou Y, Hu M, Ehrlich JR. Development and Validation of a Novel Indicator of Visual Disability in the National Health and Aging Trends Study. Innov Aging. 2021;5(2):igab018. 2021 Jun 10. doi: 10.1093/geroni/igab018 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Dillon CF, Gu Q, Hoffman HJ, Ko CW. Vision, hearing, balance, and sensory impairment in Americans aged 70 years and over: United States, 1999–2006. NCHS Data Brief. 2010;(31):1–8. [PubMed] [Google Scholar]
  18. Ehrlich JR, Hu M, Zhou Y, Kai R, De Lott LB. Visual Difficulty, Race and Ethnicity, and Activity Limitation Trajectories Among Older Adults in the United States: Findings From the National Health and Aging Trends Study. J Gerontol B Psychol Sci Soc Sci. 2022;77(Suppl_1):S39–S50. doi: 10.1093/geronb/gbab238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Ehrlich JR, Swenor BK, Zhou Y, Langa KM. The Longitudinal Association of Vision Impairment With Transitions to Cognitive Impairment and Dementia: Findings From the Aging, Demographics and Memory Study. J Gerontol A Biol Sci Med Sci. 2021;76(12):2187–2193. doi: 10.1093/gerona/glab157 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Forum on Aging, Disability, and Independence; Board on Health Sciences Policy; Division of Behavioral and Social Sciences and Education; Institute of Medicine; National Research Council. Hearing Loss and Healthy Aging: Workshop Summary. Washington (DC): National Academies Press (US); July 30, 2014. [PubMed] [Google Scholar]
  21. Freeman S, Spirgiene L, Martin-Khan M, Hirdes JP. Relationship between restraint use, engagement in social activity, and decline in cognitive status among residents newly admitted to long-term care facilities. Geriatr Gerontol Int. 2017;17(2):246–255. doi: 10.1111/ggi.12707 [DOI] [PubMed] [Google Scholar]
  22. Friedman DS, O’Colmain B, Mestril I. Vision Problems in the U.S, Fifth Edition. Prevent Blindness America: Washington DC. 2012: 18–21 [Google Scholar]
  23. Gambassi G, Landi F, Peng L, et al. Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. Med Care. 1998;36(2):167–179. doi: 10.1097/00005650-199802000-00006 [DOI] [PubMed] [Google Scholar]
  24. Goman AM, Lin FR. Prevalence of Hearing Loss by Severity in the United States. Am J Public Health. 2016;106(10):1820–1822. doi: 10.2105/AJPH.2016.303299 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Guthrie DM, Davidson JGS, Williams N, et al. Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: Analysis of interRAI data for home care and long-term care recipients in Ontario. PLoS One. 2018;13(2):e0192971. Published 2018 Feb 15. doi: 10.1371/journal.pone.0192971 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hawes C, Morris JN, Phillips CD, Mor V, Fries BE, Nonemaker S. Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS). Gerontologist. 1995;35(2):172–178. doi: 10.1093/geront/35.2.172 [DOI] [PubMed] [Google Scholar]
  27. Herzog AR, Ofstedal MB, & Wheeler LM (2002). Social engagement and its relationship to health. Clin Geriatr Med., 3(18), 593–609. [DOI] [PubMed] [Google Scholar]
  28. Holt-Lunstad J (2022, Apr 5). Social Connection as a Public Health Issue: The Evidence and a Systemic Framework for Prioritizing the “Social” in Social Determinants of Health. Annu Rev Public Health, 43, 193–213. 10.1146/annurev-publhealth-052020-110732 [DOI] [PubMed] [Google Scholar]
  29. Jones K, Perlman CM, Hirdes JP, Scott T. Screening cognitive performance with the Resident Assessment Instrument for Mental Health Cognitive Performance Scale. Can J Psychiatry. 2010;55(11):736–740. doi: 10.1177/070674371005501108 [DOI] [PubMed] [Google Scholar]
  30. Jupiter T Cognition and screening for hearing loss in nursing home residents. J Am Med Dir Assoc. 2012;13(8):744–747. doi: 10.1016/j.jamda.2012.07.010 [DOI] [PubMed] [Google Scholar]
  31. Kang B, Scales K, McConnell ES, Song Y, Lepore M, Corazzini K Nursing home residents’ perspectives on their social relationships. J Clin Nurs, 2020;29(7–8), 1162–1174. 10.1111/jocn.15174 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Kiely DK, Flacker JM. The protective effect of social engagement on 1-year mortality in a long-stay nursing home population. J Clin Epidemiol. 2003;56(5):472–478. doi: 10.1016/s0895-4356(03)00030-1 [DOI] [PubMed] [Google Scholar]
  33. Lawton MP, Casten R, Parmelee PA, Van Haitsma K, Corn J, Kleban MH. Psychometric characteristics of the minimum data set II: validity. J Am Geriatr Soc. 1998;46(6):736–744. doi: 10.1111/j.1532-5415.1998.tb03809.x [DOI] [PubMed] [Google Scholar]
  34. Lee SH & Kim YB Which type of social activities may reduce cognitive decline in the elderly?: A longitudinal population-based study. BMC Geriatr. 2016;16, 165. 10.1186/s12877-016-0343-x. Return to ref 27 in article [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Leroi I, Himmelsbach I, Wolski L, et al. Assessing and managing concurrent hearing, vision and cognitive impairments in older people: an international perspective from healthcare professionals. Age Ageing. 2019;48(4):580–587. doi: 10.1093/ageing/afy183 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Lim E, Nielsen N, Lapane LL, Barooah A, Xu S, Qu S, McPhillips E, Dube CE, Lapane KL Health effects of social connectedness in older adults living in congregate long-term care settings: A systematic review of quantitative and qualitative evidence. (2023, in press Int J of Older People Nursing) [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Littlejohn J, Bowen M, Constantinidou F, et al. International Practice Recommendations for the Recognition and Management of Hearing and Vision Impairment in People with Dementia. Gerontology. 2022;68(2):121–135. doi: 10.1159/000515892 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. McDonnall MC, Crudden A, LeJeune BJ, Steverson A, O’Donnell N. Needs and Challenges of Seniors with Combined Hearing and Vision Loss. Journal of Visual Impairment & Blindness. 2016;110(6):399–411. doi: [DOI] [Google Scholar]
  39. Monaco W, Qureshi R, Arif A, Aggarwal S, Meng H. Risk Factors for Vision Loss among Nursing Home Residents: A Cross-Sectional Analysis. J Am Med Dir Assoc. 2023;24(1):105–112.e1. doi: 10.1016/j.jamda.2022.10.018 [DOI] [PubMed] [Google Scholar]
  40. Mor V, Intrator O, Unruh MA, Cai S. Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0. BMC Health Serv Res. 2011;11:78. Published 2011 Apr 15. doi: 10.1186/1472-6963-11-78 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Morris JN, Hawes C, Fries BE, et al. Designing the national resident assessment instrument for nursing homes. Gerontologist. 1990;30(3):293–307. doi: 10.1093/geront/30.3.293 [DOI] [PubMed] [Google Scholar]
  42. Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol. 1994;49(4):M174–M182. doi: 10.1093/geronj/49.4.m174 [DOI] [PubMed] [Google Scholar]
  43. Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci. 1999;54(11):M546–M553. doi: 10.1093/gerona/54.11.m546 [DOI] [PubMed] [Google Scholar]
  44. Morris JN, Jones RN, Fries BE, Hirdes JP. Convergent validity of minimum data set-based performance quality indicators in postacute care settings. Am J Med Qual. 2004;19(6):242–247. doi: 10.1177/106286060401900603 [DOI] [PubMed] [Google Scholar]
  45. Morris JN, Murphy K, Nonemaker S. Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, November 2005. [on-line]. Available at www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/Downloads/RAI-Manual-Table-of-Contents.pdf Accessed February 10, 2023.
  46. Owsley C, McGwin G, Scilley K, Meek GC, Dyer A, Seker D. The visual status of older persons residing in nursing homes. Arch Ophthalmol. 2007;125(7):925–930. doi: 10.1001/archopht.125.7.925 [DOI] [PubMed] [Google Scholar]
  47. Park DC, Lodi-Smith J, Drew L, et al. The impact of sustained engagement on cognitive function in older adults: the Synapse Project. Psychol Sci. 2014;25(1):103–112. doi: 10.1177/0956797613499592 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Petrovsky DV, Sefcik JS, Hanlon AL, Lozano AJ, Cacchione PZ. Social Engagement, Cognition, Depression, and Comorbidity in Nursing Home Residents With Sensory Impairment. Res Gerontol Nurs. 2019;12(5):217–226. doi: 10.3928/19404921-20190627-01 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Pryce H, Gooberman-Hill R. Foundations of an intervention package to improve communication in residential care settings: A mixed methods study. Hearing, Balance and Communication. 2013;11(1):30–38. doi: 10.3109/21695717.2012.756224 [DOI] [Google Scholar]
  50. Ray M, Dening T, Crosbie B. Dementia and hearing loss: A narrative review. Maturitas. 2019;128:64–69. doi: 10.1016/j.maturitas.2019.08.001 [DOI] [PubMed] [Google Scholar]
  51. Resnick HE, Fries BE, Verbrugge LM. Windows to their world: the effect of sensory impairments on social engagement and activity time in nursing home residents. J Gerontol B Psychol Sci Soc Sci. 1997;52(3):S135–S144. doi: 10.1093/geronb/52b.3.s135 [DOI] [PubMed] [Google Scholar]
  52. Saunders GH, Echt KV. An overview of dual sensory impairment in older adults: perspectives for rehabilitation. Trends Amplif. 2007;11(4):243–258. doi: 10.1177/1084713807308365 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Schneider JM, Gopinath B, McMahon CM, Leeder SR, Mitchell P, Wang JJ. Dual sensory impairment in older age. J Aging Health. 2011;23(8):1309–1324. doi: 10.1177/0898264311408418 [DOI] [PubMed] [Google Scholar]
  54. Stern Y Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol. 2012;11, 1006–1012. 10.1016/S1474-4422(12)70191-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Swenor BK, Wang J, Varadaraj V, et al. Vision Impairment and Cognitive Outcomes in Older Adults: The Health ABC Study [published correction appears in J Gerontol A Biol Sci Med Sci. 2019 Jan 14;:]. J Gerontol A Biol Sci Med Sci. 2019;74(9):1454–1460. doi: 10.1093/gerona/gly244 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. The College of Optometrists (2016). Examining patients with dementia or other acquired cognitive impairment. [cited 2023 Mar 10]. Available from: https://www.college-optometrists.org/clinical-guidance/guidance/knowledge,-skills-and-performance/examining-patients-with-dementia-or-other-acquired
  57. Thomas KS, Dosa D, Wysocki A, Mor V. The Minimum Data Set 3.0 Cognitive Function Scale. Med Care. 2017;55(9):e68–e72. doi: 10.1097/MLR.0000000000000334 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Tsai CF, Ouyang WC, Chen LK, et al. Depression is the strongest independent risk factor for poor social engagement among Chinese elderly veteran assisted-living residents. J Chin Med Assoc. 2009;72(9):478–483. doi: 10.1016/S1726-4901(09)70411-3 [DOI] [PubMed] [Google Scholar]
  59. Tse MM. Therapeutic effects of an indoor gardening programme for older people living in nursing homes. J Clin Nurs. 2010;19(7–8):949–958. doi: 10.1111/j.1365-2702.2009.02803.x [DOI] [PubMed] [Google Scholar]
  60. VanderWeele TJ, 2015. Explanation in Causal Inference: Developments in Mediation and Interaction. Oxford University Press, New York City, NY. 10.1093/ije/dyw277. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Vetrano DL, Collamati A, Magnavita N, et al. Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study. Maturitas. 2018;107:19–25. doi: 10.1016/j.maturitas.2017.09.014 [DOI] [PubMed] [Google Scholar]
  62. Wallhagen MI, Pettengill E, Whiteside M. Sensory impairment in older adults: Part 1: Hearing loss. Am J Nurs. 2006;106(10):40–49. doi: 10.1097/00000446-200610000-00030 [DOI] [PubMed] [Google Scholar]
  63. Wang JJ, Mitchell P, Smith W, Cumming RG, Leeder SR. Incidence of nursing home placement in a defined community. Med J Aust. 2001;174(6):271–275. doi: 10.5694/j.1326-5377.2001.tb143267.x [DOI] [PubMed] [Google Scholar]
  64. Wolski L, Leroi I, Regan J, et al. The need for improved cognitive, hearing and vision assessments for older people with cognitive impairment: a qualitative study. BMC Geriatr. 2019;19(1):328. Published 2019 Dec 3. doi: 10.1186/s12877-019-1336-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Zheng Y, Fan S, Liao W, Fang W, Xiao S, Liu J. Hearing impairment and risk of Alzheimer’s disease: a meta-analysis of prospective cohort studies. Neurol Sci. 2017;38(2):233–239. doi: 10.1007/s10072-016-2779-3 [DOI] [PubMed] [Google Scholar]
  66. Zunzunegui MV, Alvarado BE, Del Ser T, Otero A. Social networks, social integration, and social engagement determine cognitive decline in community-dwelling Spanish older adults. J Gerontol B Psychol Sci Soc Sci. 2003;58(2):S93–S100. doi: 10.1093/geronb/58.2.s93 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1979291-supplement-1.docx (141.2KB, docx)

Data Availability Statement

We are unable to share our data under the terms of our data use agreement with the Centers for Medicare and Medicaid Services. Scientists may access these data by obtaining a data use agreement through RESDAC.

RESOURCES