Key Points
Question
Is hearing loss associated with declining functional status, and does hearing aid use modify the association?
Findings
In this cross-sectional study of 3142 older adults from the Atherosclerosis Risk in Communities study, moderate or greater hearing loss was associated with poorer functional status cross-sectionally and a faster decline in functional status longitudinally compared with no hearing loss. Among older adults with hearing loss, hearing aid users and nonusers did not differ in their functional decline.
Meaning
The results of this study suggest that hearing loss may contribute to declining functional status in older adults, and hearing aid use alone did not attenuate the association.
Abstract
Importance
Hearing loss may contribute to poor functional status via cognitive impairment and social isolation. Hearing aids may play a protective role by attenuating these downstream outcomes. However, population-based evidence is lacking.
Objective
To examine the association of hearing loss and hearing aids with functional status.
Design, Setting, and Participants
This cross-sectional (2016-2017) and longitudinal (2016-2022) analysis of data from the Atherosclerosis Risk in Communities cohort study included older, community-dwelling adults with complete data. Data were analyzed from June to December 2023.
Exposures
The better-hearing ear’s pure tone average (BPTA) at speech frequencies (0.5-4 kHz) was modeled categorically (no [BPTA ≤25 dB], mild [26-40 dB], and moderate or greater hearing loss [>40 dB]). Hearing aid use was self-reported.
Main Outcomes and Measures
Difficulties in activities of daily living (ADLs; eg, dressing and eating), instrumental activities of daily living (IADLS; eg, household chores and meal preparation), and heavier tasks (eg, walking a quarter of a mile) were self-reported at visit 6. The ability to perform usual activities, walk a half mile, walk up and down stairs, and do heavy housework without help were collected in follow-up surveys. Linear and logistic regression models were used that were adjusted for sociodemographic and health covariates.
Results
Among 3142 participants (mean [SD] age, 79.3 [4.6] years; 1828 women [58.2%]), 1013 (32.2%) had no hearing loss, 1220 (38.8%) had mild hearing loss, and 909 (29.0%) had moderate or greater hearing loss. Moderate or greater hearing loss was cross-sectionally associated with difficulty in 1 or more ADLs (odds ratio [OR], 1.27; 95% CI, 1.02-1.58), IADLs (OR, 1.34; 95% CI, 1.05-1.71), and heavier tasks (OR, 1.29; 95% CI, 1.04-1.62) compared with no hearing loss. Over time (mean [SD] follow-up, 1.9 [1.8] years), moderate or greater hearing loss was associated with a faster decline in the number of activities participants were able to do (β = −0.07 per year; 95% CI, −0.09 to −0.06) and greater odds of reporting inability to do 1 or more of the 4 activities (OR, 1.14; 95% CI, 1.05-1.24). Hearing aid users and nonusers did not differ.
Conclusions and Relevance
The results of this study suggest that moderate or greater hearing loss was associated with functional difficulties and may contribute to a faster decline in function longitudinally independent of sociodemographic and health covariates. Hearing aids did not change the association among those with hearing loss.
This cross-sectional study examines the association of hearing loss and hearing aids with functional status.
Introduction
Hearing loss affects nearly two-thirds of adults in the US who are older than 70 years.1 Understanding how hearing loss may be associated with different aspects of aging, including physical function, is essential given the projected increase of older adults during the next few decades.2 Previous studies have found hearing loss to be associated with poor physical activity,3walking endurance,4 and lower extremity performance.4,5 However, evidence on the association of hearing loss with functional status (ie, a person’s ability to engage in activities required to meet basic needs, fulfill usual roles, and maintain health and well-being)6 remains scarce among older adults in the US.
Functional status is commonly measured by assessing one’s level of difficulty in performing basic activities of daily living (ADLs; including eating, dressing, and moving across a room), instrumental activities of daily living (IADLs; including cooking, shopping, and managing finances), and other physical tasks (including walking a quarter of a mile, walking up steps, and doing heavy work). Poor functional status is associated with reduced life expectancy,7,8 making identifying modifiable risk factors important.
There are mixed results in previous studies that investigated the association of hearing loss with functional status; some studies found an association9,10,11,12,13 while others did not.14,15,16 Studies varied in hearing measures (self-report11,12,16 vs audiometry13,17) and study population (community-based vs clinical). Additionally, most studies were limited to cross-sectional analyses, and few examined modification by hearing aid use.17
We investigated the association of audiometric hearing loss and hearing aid use with functional status in a cohort of community-dwelling older adults in 4 geographically distinct communities in the US. We hypothesized that older adults with hearing loss, as compared with those without hearing loss, would have worse functional status and a steeper decline in function over time. We also hypothesized that among those with hearing loss, those who do not use hearing aids would have worse functional status and a faster decline over time compared with hearing aid users.
Methods
Study Population
The Atherosclerosis Risk in Communities (ARIC) study is a prospective cohort study of 15 792 adults aged 45 to 64 years at baseline (1987-1989) from 4 US communities: Forsyth Country, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; and Washington County, Maryland. The ARIC study design has been described previously.18 Study procedures include examination visits with follow-up telephone surveys in between. Hearing was measured at visit 6 (2016-2017). Among 4003 participants at visit 6, 3690 had data on hearing and functional status. We excluded 527 participants for missing covariates (education [n = 6], body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] [n = 40], smoking [n = 300], diabetes [n = 124], and hypertension [n = 57]) and 21 participants with self-reported race other than Black or White and Black participants from Minnesota and Maryland (due to small numbers). The analytic sample for cross-sectional analyses included 3142 participants. Longitudinal data from follow-up telephone surveys conducted from 2016 to 2022 were available for 3089 participants (12 940 observations; mean [range] of 4 [1-7] observations per participant; mean [SD] follow-up time, 1.9 [1.8] years after visit 6). The institutional review board approved the ARIC study at each site. All participants provided written informed consent. Consent covered data use for analyses approved by the study publications committee, and data were deidentified. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies.
Functional Status
Cross-Sectional Analyses
Functional status was operationalized at visit 6 by a standardized 12-item physical ability questionnaire (PAQ) assessing the level of difficulty performing ADLs, IADLs, and heavier tasks that was adapted from validated questionnaires.19,20,21,22 Participants were asked if they had any difficulty performing tasks (yes/no), and if they responded yes they were asked how much difficulty they had (a little difficulty, much difficulty, or unable to do). Individual items were dichotomized into a binary variable (no difficulty vs any difficulty/inability). We grouped items into 3 domains: (1) ADLs (dressing, eating, walking from one room to another in the house, getting in and out of bed, and standing up from an armless chair), (2) IADLs (performing household chores, meal preparation, and managing finances), and (3) heavier physical tasks (walking a quarter of a mile; walking up 10 steps without resting; stooping, crouching, or kneeling; and lifting 10-pound objects). We derived 2 outcomes: (1) a numerical score corresponding to the sum of items participants were able to do (range, 0-12; a lower score indicated greater difficulty), which we refer to as the PAQ score from here onwards, and (2) a binary variable of having difficulty in individual domains (no difficulty vs any difficulty/inability in any of the activities within the domain). For sensitivity analyses, we derived a mobility domain (walking a quarter of a mile and walking up 10 steps without resting) to compare findings with literature using this categorization and derived a binary variable of having difficulty with mobility (no difficulty vs any difficulty/inability in any of the activities within the domain).11
Longitudinal Analyses
Functional status was assessed in follow-up telephone surveys according to a Rosow-Breslau functional status questionnaire.20 Participants reported their ability (yes/able vs no/unable) to perform 4 activities: (1) usual activities, such as work around the house or recreation; (2) walking a half a mile (about 8 ordinary blocks) without help; (3) walking up and down the stairs without help; and (4) doing heavy work around the house, like shoveling snow or washing windows, walls, or floors, without help. We derived 2 outcomes: (1) a score of the sum of activities participants were able to do23 (range, 0-4, for which higher scores represented better function), which we refer to as the functional status score from here onwards, and (2) a binary variable of having difficulty with any of the functional measures (yes/able to do all activities without difficulty vs difficulty/inability to perform at least 1 of the activities).
Hearing Loss
Hearing was assessed at visit 6 of the ARIC study using pure-tone audiometry in a soundproof booth using insert earphones (EARTone 3a; 3M) and the Interacoustics AD629 audiometer. Portable audiometers with supra-aural headphones were used for participants in long-term care facilities or at home (Shoebox Audiometry). The air conduction thresholds at speech frequencies (0.5, 1.0, 2.0, and 4.0 kHz) were measured, and the 4-frequency pure tone average (PTA) was calculated for each ear. We used the better-hearing ear PTA (BPTA) continuously per 10 dB (dB) and categorically (no hearing loss [BPTA <26 dB], mild hearing loss [BPTA, 26-40 dB], and moderate or greater hearing loss [BPTA >40 dB]). Self-reported hearing aid use (yes or no) was collected at visit 6.
Covariates
Sociodemographic covariates were self-reported and included age (years, continuous), sex (female or male), educational attainment (collected at visit 1 from 1987 to 1989; less than high school, high school or vocational, or more than high school), and race (Black or White); a race–study site variable was derived (Black individuals in in North Carolina, White individuals in North Carolina, Black individuals in Mississippi, White individuals in Minnesota, and White individuals in Maryland). Race, which is a social construct, was included as a confounder given its association with the exposure and outcome. Health covariates collected at visit 6 included BMI (<25, 25-29, or ≥30), smoking status (current, former, or never), diabetes (fasting blood glucose level ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555], nonfasting blood glucose level ≥200 mg/dL, or use of diabetes medication), and hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mmHg or use of antihypertensive medication).
Statistical Analysis
Sample Characteristics
We described participants' characteristics at visit 6 across hearing categories using means and standard deviations for continuous variables and frequencies and proportions for categorical ones.
Cross-Sectional Analysis
We used linear regressions to examine the difference in PAQ scores with every 10-dB difference in BPTA and across hearing loss categories (no hearing loss = reference) and presented β coefficients with 95% CIs. We used a logistic regression to evaluate the odds of reporting difficulty within each domain (ADLs, IADLs, and heavier physical tasks) with every 10-dB difference in BPTA and across hearing loss categories (no hearing loss group = reference) and presented odds ratios (ORs) with 95% CIs. Furthermore, among 2129 participants with hearing loss (BPTA >25 dB), we investigated the association of hearing aid use with functional status. We compared hearing aid nonusers with users and quantified the mean difference in PAQ scores using a linear regression and the odds of reporting difficulty within each domain using a logistic regression. We adjusted for sociodemographic covariates (age, sex, race, study site, and education) and health covariates (BMI, smoking status, diabetes, and hypertension).
Longitudinal Analysis
Linear mixed-effects models with an unstructured covariance matrix estimated the mean rate of change in functional status scores and logistic mixed-effects models estimated the mean rate of change in the odds of reporting any difficulty with the functional measures (years, 2016-2022) by hearing categories. We included an interaction term between hearing and the time coefficient to estimate the mean differences in outcomes across hearing categories over time. In a secondary analysis restricted to 2086 participants with hearing loss (BPTA >25 dB), we assessed differences in rates of change in outcomes by hearing aid use. For longitudinal analyses, we used predictive margins following our regressions to generate estimates and CIs for our figures. All analyses were conducted using Stata, version 18.0 (StataCorp).
Sensitivity Analyses
First, we investigated the rate of change in the functional status score across hearing categories using a linear spline model on the time variable to account for potential nonlinearity in the association during the studied period. Second, we explored the association of hearing loss with mobility to compare our findings with the existing literature.
Results
Sample Characteristics
Among 3142 participants, 1013 (32.2%) did not have hearing loss, 1220 (38.8%) had mild hearing loss, and 909 (29.0%) had moderate or greater hearing loss (Table 1). Compared with participants with no hearing loss, those with moderate or greater hearing loss were older (mean [SD] age, 81.4 [4.9] vs 77.5 [3.7] years, respectively) and a greater proportion were male (515 [56.7%] vs 272 [27.0%]), White (807 [88.8%] vs 689 [68.0%]), and had a high school education or less (543 [59.7%] vs 489 [48.3%]). Around 11.6% of participants with mild and 55.9% of those with moderate or greater hearing loss reported hearing aid use. In unadjusted comparisons, there was a slightly lower mean (SD) PAQ score in those with moderate or greater hearing loss compared with no hearing loss (8.6 [3.3] vs 9.0 [3.2], respectively). Compared with participants with no hearing loss, a greater proportion of those with moderate or greater hearing loss had difficulty with ADLs (363 [39.9%] vs 319 [31.5%]), IADLs (234 [25.7%] vs 215 [21.2%]), and heavier physical tasks (632 [69.5%] vs 654 [64.6%]).
Table 1. Sociodemographic and Health Characteristics of 3142 Study Participants from Visit 6 of the Atherosclerosis Risk in Communities Study as Stratified by Hearing Status.
| Characteristic | No. (%) | |||
|---|---|---|---|---|
| Total | Hearing loss | |||
| None | Mild | Moderate or greater | ||
| Observations | 3142 (100) | 1013 (32.2) | 1220 (38.8) | 909 (29.0) |
| Age, mean (SD), y | 79.3 (4.6) | 77.5 (3.7) | 79.2 (4.5) | 81.4 (4.9) |
| Female | 1828 (58.2) | 739 (73.0) | 695 (57.0) | 394 (43.3) |
| Male | 1314 (41.8) | 274 (27.0) | 525 (43.0) | 515 (56.7) |
| Black individuals | 655 (20.8) | 324 (32.0) | 229 (18.8) | 102 (11.2) |
| White individuals | 2487 (79.2) | 689 (68.0) | 991 (81.2) | 807 (88.8) |
| Study site | ||||
| Forsyth County, NC | 702 (22.3) | 191 (18.9) | 300 (24.6) | 211 (23.2) |
| Jackson, MS | 610 (19.4) | 307 (30.3) | 209 (17.1) | 94 (10.3) |
| Minneapolis, MN | 975 (31.0) | 281 (27.7) | 400 (32.8) | 294 (32.3) |
| Washington County, MD | 855 (27.2) | 234 (23.1) | 311 (25.5) | 310 (34.1) |
| Educational attainment | ||||
| <High school | 370 (11.8) | 104 (10.3) | 131 (10.7) | 135 (14.9) |
| High school or vocational | 1290 (41.1) | 385 (38.0) | 497 (40.7) | 408 (44.9) |
| >High school | 1482 (47.2) | 524 (51.7) | 592 (48.5) | 366 (40.3) |
| BMI | ||||
| <25 | 889 (28.3) | 285 (28.1) | 333 (27.3) | 271 (29.8) |
| ≥25 to <30 | 1225 (39.0) | 378 (37.3) | 477 (39.1) | 370 (40.7) |
| ≥30 | 1028 (32.7) | 350 (34.6) | 410 (33.6) | 268 (29.5) |
| Smoking status | ||||
| Current | 236 (7.5) | 83 (8.2) | 82 (6.7) | 71 (7.8) |
| Former | 1697 (54.0) | 505 (49.9) | 691 (56.6) | 501 (55.1) |
| Never | 1209 (38.5) | 425 (42.0) | 447 (36.6) | 337 (37.1) |
| Diabetes | 1049 (33.4) | 333 (32.9) | 416 (34.1) | 300 (33.0) |
| Hypertension | 2476 (78.8) | 805 (79.5) | 947 (77.6) | 724 (79.6) |
| Hearing aid use | 662 (21.1) | 13 (1.3) | 141 (11.6) | 508 (55.9) |
| PAQ score (0-12), mean (SD) | 9.0 (3.2) | 9.0 (3.2) | 9.1 (3.1) | 8.6 (3.3) |
| Difficulty with ADLs | 1096 (34.9) | 319 (31.5) | 414 (33.9) | 363 (39.9) |
| Difficulty with IADLs | 722 (23.0) | 215 (21.2) | 273 (22.4) | 234 (25.7) |
| Difficulty with heavier physical tasks | 2098 (66.8) | 654 (64.6) | 812 (66.6) | 632 (69.5) |
Abbreviations: ADL, activities of daily living; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); IADL, instrumental activities of daily living; MD, Maryland; MN, Minnesota; MS, Mississippi; NC, North Carolina; PAQ, physical ability questionnaire.
Cross-Sectional Findings
Worse hearing (increasing BPTA) and moderate or greater hearing loss were associated with poorer functional status scores after adjustment for sociodemographic and health covariates (Table 2). Specifically, every 10-dB higher BPTA was associated with a 0.15 lower PAQ score (β = −0.15; 95% CI, −0.23 to −0.07), while moderate or greater hearing loss compared with no hearing loss was associated with a 0.58 lower score (β = −0.58; 95% CI, −0.86 to −0.29). Similarly, every 10-dB higher BPTA was associated with greater odds of reporting difficulty with ADLs (OR, 1.07; 95% CI, 1.01-1.14) and heavier physical tasks (OR, 1.08; 95% CI, 1.02-1.15). The association with IADLs was similar to that observed for ADLs, but not statistically significant (OR, 1.06; 95% CI, 0.99-1.14) (Table 2). Across hearing categories, moderate or greater hearing loss was associated with greater odds of reporting difficulty with ADLs (OR, 1.27; 95% CI, 1.02-1.58), IADLs (OR, 1.34; 95% CI, 1.05-1.71), and heavier physical tasks (OR, 1.29; 95% CI, 1.04-1.62), while the associations with mild hearing loss were not statistically significant.
Table 2. Cross-Sectional Association of Hearing Loss with Functional Status Among Older Adults in the Atherosclerosis Risk in Communities Studya.
| Factor | OR (95% CI) | |||
|---|---|---|---|---|
| Hearing loss | ||||
| Continuous | Categoriesb | |||
| BPTA, per 10 dB | None | Mild | ≥Moderate | |
| Difference in functional status score, β (95% CI)c | −0.15 (−0.23 to −0.07) | 1 [Reference] | −0.20 (−0.45 to 0.05) | −0.58 (−0.86 to −0.29) |
| Odds of perceiving difficulties in activities of daily living | 1.07 (1.01 to 1.14) | 1 [Reference] | 1.07 (0.88 to 1.29) | 1.27 (1.02 to 1.58) |
| Odds of perceiving difficulties in instrumental activities of daily living | 1.06 (0.99 to 1.14) | 1 [Reference] | 1.12 (0.90 to 1.39) | 1.34 (1.05 to 1.71) |
| Odds of perceiving difficulties in heavier physical tasks | 1.08 (1.02 to 1.15) | 1 [Reference] | 1.12 (0.93 to 1.35) | 1.29 (1.04 to 1.62) |
Abbreviations: BPTA, better-hearing ear pure tone average; OR, odds ratio.
Estimates were from a model adjusted for age, sex, race, study site, education, body mass index, smoking status, diabetes, and hypertension.
Hearing status was defined as no hearing loss (BPTA <26 dB), mild hearing loss (BPTA 26-40 dB), and moderate or greater hearing loss (BPTA >40 dB).
Physical ability questionnaire score from 0 to 12, in which a lower score indicates greater difficulties (ie, poorer functional status).
Among participants with hearing loss (BPTA >25 dB) who did not use hearing aids, the PAQ score (β = −0.06; 95% CI, −0.38 to 0.27) and odds of having difficulty with ADLs (OR, 0.88; 95% CI, 0.69-1.12), IADLs (OR, 0.85; 95% CI, 0.64-1.11), and heavier physical tasks (OR, 0.82; 95% CI, 0.64-1.05) did not differ from users.
Longitudinal Findings
During a 6-year period, participants with moderate or greater hearing loss had steeper rates of decline in functional status score (−0.07 points per year; 95% CI, −0.09 to −0.06) compared with those with no hearing loss (Table 3 and Figure 1). Furthermore, the odds of reporting difficulty with any of the functional measures increased at a faster rate for those with moderate or greater hearing loss (OR, 1.36; 95% CI, 1.28-1.45) (Table 3 and Figure 2). Among participants with hearing loss (BPTA >25 dB), there was no significant difference in the rate of change in scores and the odds of functional difficulties between hearing aid users and nonusers, although findings were in the direction of slower rates for nonusers (eTable 1 in Supplement 1).
Table 3. Association of Hearing Status With Rate of Change in Functional Status Score and Odds of Having Difficulty with Functional Measures Over Time Among 3089 Older Adultsa.
| Rate of change | Hearing loss categories, OR (95% CI) | ||
|---|---|---|---|
| None | Mild | ≥Moderate | |
| Functional status score b | |||
| Estimated annual rate of change in functional status score | −0.05 (−0.06 to −0.04) | −0.06 (−0.07 to −0.05) | −0.07 (−0.09 to −0.06) |
| Difference in the annual rate of change | 1 [Reference] | −0.01 (−0.02 to 0.01) | −0.02 (−0.04 to −0.004) |
| Odds of functional difficulties c | |||
| Estimated annual rate of change in odds of having functional difficulties | 1.19 (1.13 to 1.26) | 1.22 (1.16 to 1.28) | 1.36 (1.28 to 1.45) |
| Difference in the annual rate of change | 1 [Reference] | 1.02 (0.95 to 1.10) | 1.14 (1.05 to 1.24) |
Abbreviations: BPTA, better-hearing ear pure tone average; OR, odds ratio.
Estimates were from a model adjusted for age, sex, race, study site, education, body mass index, smoking status, diabetes, and hypertension.
Score from 0 to 4, with a low score indicating greater functional difficulties.
Binary variable (no functional difficulties vs difficulty with at least 1 of the following: doing usual activities, walking half a mile without help, walking up and down stairs without help, and doing heavy work around the house without help).
Figure 1. Estimated Mean Functional Status Score Over Time Across Hearing Categories.
Estimates were derived from a linear mixed-effects regression model adjusted for age, sex, race, study site, education, body mass index, smoking status, diabetes, and hypertension. Hearing was tested at visit 6, which was conducted between 2016 and 2017, and semiannual follow-up telephone surveys were conducted from 2016 to 2022.
Figure 2. Estimated Probability of Functional Difficulties Over Time Across Hearing Categories.
Estimates were derived from a logistic mixed-effects regression model adjusted for age, sex, race, study site, education, body mass index, smoking status, diabetes, and hypertension. Hearing was tested at visit 6, which was conducted between 2016 and 2017, and semiannual follow-up telephone surveys were conducted from 2016 to 2022.
Sensitivity Analysis
The rate of decline in functional status scores was greater 2 years after visit 6 (eFigure in Supplement 1). However, compared with no hearing loss, only the rate of decline for mild hearing loss was significantly greater. Every 10-dB difference in BPTA and moderate or greater hearing loss was associated with greater odds of reporting difficulty with mobility (eTable 2 in Supplement 1).
Discussion
In this cross-sectional study of community-dwelling older adults, worse hearing was associated with worse functional status (ie, greater difficulties with ADLs, IADLs, and heavier physical tasks). Longitudinally, older adults with moderate or greater hearing loss experienced a steeper decline in functional status over time compared with those with no hearing loss. Among those with hearing loss, functional status did not differ with hearing aid use. Overall, these findings suggest that older adults with hearing loss may be at greater risk of experiencing difficulties in their functional status.
Previous studies have investigated the association of hearing loss with functional status in older adults using various designs, measures of hearing (subjective/objective), functional status measures, and study population. Generally, findings have been consistent with an association between hearing loss and poorer functional status, although different function categories may be affected differently. One cross-temporal study of adults from the Alameda County Study found that self-reported hearing loss at baseline was associated with difficulties in ADLs and heavier tasks 1 year later,11 but not with IADLs or mobility, whereas we found associations with all outcomes, similar to other cross-sectional studies using audiometry.9,17,24 Among 2 longitudinal studies, 1 did not find an association between baseline audiometric hearing loss and functional decline after 2 years, which was defined based on the ability to walk, climb stairs, prepare meals, shop, and do housework.25 However, this study was restricted to women and defined hearing loss as an inability to hear a tone of 40 dB or greater at 2 kHz. Our study included Black and White men and women and examined hearing ability as no hearing loss, mild hearing loss, or moderate or greater hearing loss. The second cross-temporal study found that baseline audiometric hearing loss, defined by a 40-dB loss at 1- or 2-kHz frequency, was associated with dependence in heavier tasks but not ADLs and IADLs after 10 years in a nationally representative sample of US adults aged 56 to 74 years.13 Our work used established thresholds for hearing loss categories and a longitudinal study design and potentially adds to the existing literature with findings that moderate or greater hearing loss was associated with steeper rates of decline in functional measures over time.
Multiple mechanisms may explain the association of hearing loss with poorer functional status. It may be a result of a causal, indirect pathway mediated by high cognitive load26 and social isolation.27,28 Hearing loss impairs the encoding of sounds, which is followed by distorted auditory signals that are associated with increased cognitive load from sound processing.29,30 Thus, older adults with hearing loss have reduced attentional resources, which is associated with an increased difficulty in performing activities simultaneously, including mobility and postural stability.10,31 In a direct causal pathway, hearing loss may affect balance and mobility since auditory cues are important for spatial orientation while moving.32,33,34 Lastly, there may be a common cause, such as cardiovascular diseases,35,36 although we adjusted for cardiovascular risk factors. In addition, damage to the inner ear, which houses the cochlear (hearing) and vestibular (balance) organs, may cause dysfunction to both and be associated with hearing loss and imbalance. We did not have the data to adjust for vestibular function, but a previous study found that vestibular dysfunction did not confound the association between hearing loss and physical performance.4
Contrary to our hypothesis, we did not find that hearing aid use was associated with better functional status among older adults with hearing loss. Previously, 1 study found that hearing aid users had a 2-fold increased difficulty in performing ADLs and IADLs.17 However, the sample was not restricted to those with hearing loss. Similarly, another study of adults at an audiology clinic found that perceived activity limitation was greater among patients with hearing aid experience.37 Additionally, Chen et al24 found that aids were associated with ADL impairments. However, a study of community-dwelling older adults found that users and nonusers did not differ in their ability to engage in ADLs and IADLs during a period of 11 years, although users had improved self-perceived quality of physical health.38 Despite mixed findings, it is unlikely that hearing aids are directly associated with poorer functional status. One potential explanation is that aids may be a proxy for more severe hearing loss. Additionally, it may be difficult for older adults to accept wearing aids, restricting their activity and social participation. It is also possible that aids are a proxy for diagnosed hearing loss, in which case persons without a diagnosis (nonusers) may view their health situation more optimistically.39,40 Future randomized clinical studies are necessary to understand the association with functional status.
Strengths and Limitations
The strengths of this study were the use of a clinical standard measure of hearing, longitudinal nature of the analysis (mean of 4 observations per participant), findings on hearing aid use and functional status over time, and inclusion of a population of Black and White men and women from 4 US sites. The limitations included the single measure of hearing in longitudinal analyses. However, age-related hearing loss progresses slowly at a rate of 1 to 2 dB per year,41,42 and hearing was likely relatively constant during the study period. Second, the longitudinal outcome measure did not distinguish between different domains of functional status. Third, the hearing aid use measure was binary, lacking variability in duration and pattern of use. Lastly, there may have been residual confounding from unmeasured variables, including vestibular function, subclinical cardiovascular disease, and socioeconomic status (especially in the hearing aid analysis).
Conclusions
In this cross-sectional study, moderate or greater hearing loss was associated with lower functional status and a steeper decline in status over time. Future longitudinal studies are needed to establish the association of hearing interventions with the functional status of older adults.
eTable 1. Association of Hearing Aid Use at Visit 6 of ARIC with Rate of Change in Functional Status Score and Odds of Functional Difficulties Over Time Among 2,086 Older Adults with Mild or Greater Hearing Loss
eTable 2. Cross-Sectional Association of Hearing Loss with Mobility Among 3,142 Older Adults at Visit 6 of ARIC
eFigure. Estimated Mean Functional Status Score Over Time Across Hearing Categories
Data sharing statement
References
- 1.Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011;171(20):1851-1852. doi: 10.1001/archinternmed.2011.506 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Goman AM, Reed NS, Lin FR. Addressing estimated hearing loss in adults in 2060. JAMA Otolaryngol Head Neck Surg. 2017;143(7):733-734. doi: 10.1001/jamaoto.2016.4642 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Martinez-Amezcua P, Suen JJ, Lin F, Schrack JA, Deal JA. Hearing impairment and objectively measured physical activity: a systematic review. J Am Geriatr Soc. 2022;70(1):301-304. doi: 10.1111/jgs.17529 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Martinez-Amezcua P, Kuo PL, Reed NS, et al. Association of hearing impairment with higher-level physical functioning and walking endurance: results from the Baltimore Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci. 2021;76(10):e290-e298. doi: 10.1093/gerona/glab144 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Yévenes-Briones H, Caballero FF, Struijk EA, et al. Association between hearing loss and impaired physical function, frailty, and disability in older adults: a cross-sectional study. JAMA Otolaryngol Head Neck Surg. 2021;147(11):951-958. doi: 10.1001/jamaoto.2021.2399 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Leidy NK. Functional status and the forward progress of merry-go-rounds: toward a coherent analytical framework. Nurs Res. 1994;43(4):196-202. doi: 10.1097/00006199-199407000-00002 [DOI] [PubMed] [Google Scholar]
- 7.Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med. 1995;332(9):556-561. doi: 10.1056/NEJM199503023320902 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Keeler E, Guralnik JM, Tian H, Wallace RB, Reuben DB. The impact of functional status on life expectancy in older persons. J Gerontol A Biol Sci Med Sci. 2010;65(7):727-733. doi: 10.1093/gerona/glq029 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Choi JS, Betz J, Deal J, et al. A comparison of self-report and audiometric measures of hearing and their associations with functional outcomes in older adults. J Aging Health. 2016;28(5):890-910. doi: 10.1177/0898264315614006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Viljanen A, Kaprio J, Pyykkö I, Sorri M, Koskenvuo M, Rantanen T. Hearing acuity as a predictor of walking difficulties in older women. J Am Geriatr Soc. 2009;57(12):2282-2286. doi: 10.1111/j.1532-5415.2009.02553.x [DOI] [PubMed] [Google Scholar]
- 11.Wallhagen MI, Strawbridge WJ, Shema SJ, Kurata J, Kaplan GA. Comparative impact of hearing and vision impairment on subsequent functioning. J Am Geriatr Soc. 2001;49(8):1086-1092. doi: 10.1046/j.1532-5415.2001.49213.x [DOI] [PubMed] [Google Scholar]
- 12.Yamada M, Nishiwaki Y, Michikawa T, Takebayashi T. Self-reported hearing loss in older adults is associated with future decline in instrumental activities of daily living but not in social participation. J Am Geriatr Soc. 2012;60(7):1304-1309. doi: 10.1111/j.1532-5415.2012.04039.x [DOI] [PubMed] [Google Scholar]
- 13.Reuben DB, Mui S, Damesyn M, Moore AA, Greendale GA. The prognostic value of sensory impairment in older persons. J Am Geriatr Soc. 1999;47(8):930-935. doi: 10.1111/j.1532-5415.1999.tb01286.x [DOI] [PubMed] [Google Scholar]
- 14.Rudberg MA, Furner SE, Dunn JE, Cassel CK. The relationship of visual and hearing impairments to disability: an analysis using the longitudinal study of aging. J Gerontol. 1993;48(6):M261-M265. doi: 10.1093/geronj/48.6.M261 [DOI] [PubMed] [Google Scholar]
- 15.Harada S, Nishiwaki Y, Michikawa T, et al. Gender difference in the relationships between vision and hearing impairments and negative well-being. Prev Med. 2008;47(4):433-437. doi: 10.1016/j.ypmed.2008.06.011 [DOI] [PubMed] [Google Scholar]
- 16.Tomioka K, Okamoto N, Morikawa M, Kurumatani N. Self-reported hearing loss predicts 5-year decline in higher-level functional capacity in high-functioning elderly adults: the Fujiwara-Kyo Study. J Am Geriatr Soc. 2015;63(11):2260-2268. doi: 10.1111/jgs.13780 [DOI] [PubMed] [Google Scholar]
- 17.Gopinath B, Schneider J, McMahon CM, Teber E, Leeder SR, Mitchell P. Severity of age-related hearing loss is associated with impaired activities of daily living. Age Ageing. 2012;41(2):195-200. doi: 10.1093/ageing/afr155 [DOI] [PubMed] [Google Scholar]
- 18.Wright JD, Folsom AR, Coresh J, et al. The ARIC (Atherosclerosis Risk In Communities) study: JACC focus seminar 3/8. J Am Coll Cardiol. 2021;77(23):2939-2959. doi: 10.1016/j.jacc.2021.04.035 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Nagi SZ. An epidemiology of disability among adults in the United States. Milbank Mem Fund Q Health Soc. 1976;54(4):439-467. doi: 10.2307/3349677 [DOI] [PubMed] [Google Scholar]
- 20.Rosow I, Breslau N. A Guttman health scale for the aged. J Gerontol. 1966;21(4):556-559. doi: 10.1093/geronj/21.4.556 [DOI] [PubMed] [Google Scholar]
- 21.Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914-919. doi: 10.1001/jama.1963.03060120024016 [DOI] [PubMed] [Google Scholar]
- 22.Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186. doi: 10.1093/geront/9.3_Part_1.179 [DOI] [PubMed] [Google Scholar]
- 23.Kucharska-Newton A, Griswold M, Yao ZH, et al. Cardiovascular disease and patterns of change in functional status over 15 years: findings from the Atherosclerosis Risk in Communities (ARIC) study. J Am Heart Assoc. 2017;6(3):e004144. doi: 10.1161/JAHA.116.004144 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Chen DS, Genther DJ, Betz J, Lin FR. Association between hearing impairment and self-reported difficulty in physical functioning. J Am Geriatr Soc. 2014;62(5):850-856. doi: 10.1111/jgs.12800 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Lin MY, Gutierrez PR, Stone KL, et al. ; Study of Osteoporotic Fractures Research Group . Vision impairment and combined vision and hearing impairment predict cognitive and functional decline in older women. J Am Geriatr Soc. 2004;52(12):1996-2002. doi: 10.1111/j.1532-5415.2004.52554.x [DOI] [PubMed] [Google Scholar]
- 26.Coppin AK, Shumway-Cook A, Saczynski JS, et al. Association of executive function and performance of dual-task physical tests among older adults: analyses from the InChianti study. Age Ageing. 2006;35(6):619-624. doi: 10.1093/ageing/afl107 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Barnes LL, Mendes de Leon CF, Wilson RS, Bienias JL, Evans DA. Social resources and cognitive decline in a population of older African Americans and whites. Neurology. 2004;63(12):2322-2326. doi: 10.1212/01.WNL.0000147473.04043.B3 [DOI] [PubMed] [Google Scholar]
- 28.Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med. 2012;172(14):1078-1083. doi: 10.1001/archinternmed.2012.1993 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wingfield A, Tun PA, McCoy SL. Hearing loss in older adulthood: what it is and how it interacts with cognitive performance. Curr Dir Psychol Sci. 2005;14(3):144-148. doi: 10.1111/j.0963-7214.2005.00356.x [DOI] [Google Scholar]
- 30.Lin FR, Ferrucci L, Metter EJ, An Y, Zonderman AB, Resnick SM. Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology. 2011;25(6):763-770. doi: 10.1037/a0024238 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Foster JI, Williams KL, Timmer BHB, Brauer SG. The association between hearing impairment and postural stability in older adults: a systematic review and meta-analysis. Trends Hear. 2022;26:23312165221144155. doi: 10.1177/23312165221144155 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Campos J, Ramkhalawansingh R, Pichora-Fuller MK. Hearing, self-motion perception, mobility, and aging. Hear Res. 2018;369:42-55. doi: 10.1016/j.heares.2018.03.025 [DOI] [PubMed] [Google Scholar]
- 33.Cornwell T, Woodward J, Wu M, et al. Walking with ears: altered auditory feedback impacts gait step length in older adults. Front Sports Act Living. 2020;2:38. doi: 10.3389/fspor.2020.00038 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Ashmead DH, Davis DL, Northington A. Contribution of listeners’ approaching motion to auditory distance perception. J Exp Psychol Hum Percept Perform. 1995;21(2):239-256. doi: 10.1037/0096-1523.21.2.239 [DOI] [PubMed] [Google Scholar]
- 35.Windham BG, Harrison KL, Lirette ST, et al. Relationship between midlife cardiovascular health and late-life physical performance: the ARIC study. J Am Geriatr Soc. 2017;65(5):1012-1018. doi: 10.1111/jgs.14732 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Curhan SG, Eavey R, Wang M, Stampfer MJ, Curhan GC. Body mass index, waist circumference, physical activity, and risk of hearing loss in women. Am J Med. 2013;126(12):1142.e1-1142.e8. doi: 10.1016/j.amjmed.2013.04.026 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Helvik AS, Jacobsen G, Wennberg S, Arnesen H, Ringdahl A, Hallberg LRM. Activity limitation and participation restriction in adults seeking hearing aid fitting and rehabilitation. Disabil Rehabil. 2006;28(5):281-288. doi: 10.1080/09638280500160311 [DOI] [PubMed] [Google Scholar]
- 38.Dawes P, Cruickshanks KJ, Fischer ME, Klein BEK, Klein R, Nondahl DM. Hearing-aid use and long-term health outcomes: hearing handicap, mental health, social engagement, cognitive function, physical health, and mortality. Int J Audiol. 2015;54(11):838-844. doi: 10.3109/14992027.2015.1059503 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Joore MA, Potjewijd J, Timmerman AA, Anteunis LJC. Response shift in the measurement of quality of life in hearing impaired adults after hearing aid fitting. Qual Life Res. 2002;11(4):299-307. doi: 10.1023/A:1015598807510 [DOI] [PubMed] [Google Scholar]
- 40.Moum T, Naess S, Sørensen T, Tambs K, Holmen J. Hypertension labelling, life events and psychological well-being. Psychol Med. 1990;20(3):635-646. doi: 10.1017/S0033291700017153 [DOI] [PubMed] [Google Scholar]
- 41.Echt KV, Smith SL, Burridge AB, Spiro A III. Longitudinal changes in hearing sensitivity among men: the Veterans Affairs Normative Aging Study. J Acoust Soc Am. 2010;128(4):1992-2002. doi: 10.1121/1.3466878 [DOI] [PubMed] [Google Scholar]
- 42.Wiley TL, Chappell R, Carmichael L, Nondahl DM, Cruickshanks KJ. Changes in hearing thresholds over 10 years in older adults. J Am Acad Audiol. 2008;19(4):281-292. doi: 10.3766/jaaa.19.4.2 [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
eTable 1. Association of Hearing Aid Use at Visit 6 of ARIC with Rate of Change in Functional Status Score and Odds of Functional Difficulties Over Time Among 2,086 Older Adults with Mild or Greater Hearing Loss
eTable 2. Cross-Sectional Association of Hearing Loss with Mobility Among 3,142 Older Adults at Visit 6 of ARIC
eFigure. Estimated Mean Functional Status Score Over Time Across Hearing Categories
Data sharing statement
