Abstract
Background
Engagement in cognitively stimulating activities is associated with decreased rates of cognitive decline in older adults. However, most cognitively stimulating tasks require good vision, potentially affecting the ability of visually impaired adults to engage in these activities. We examined the relationship between vision and participation in cognitively stimulating activities.
Method
Data from the Health, Aging, and Body Composition study (1999–2005) were analyzed. Associations between visual function (visual acuity [VA], contrast sensitivity [CS], and stereo acuity [SA] impairments) and annual rates of change in number of cognitively stimulating activities (by self-report) performed at least once a month were examined.
Results
Analyses included 924 participants aged 75.2 ± 2.8 years. At baseline, impaired CS (27%) and SA (29%) were associated with participation in fewer cognitive activities (β = −0.33, 95% CI = −0.63, −0.03 and β = −0.32, 95% CI = −0.61, −0.03, respectively), while VA (8%) was not (β = −0.34, 95% CI = −0.81, 0.13). In longitudinal models, groups with and without VA, CS, and SA impairments exhibited declines in monthly cognitive activities over time. Annual rates of decline were relatively higher in the VA (β = −0.16, 95% CI = −0.26, −0.05) and CS (β = −0.14, 95% CI = −0.19, −0.09) impaired groups than observed in the respective unimpaired groups (no VA: β = −0.12, 95% CI = −0.15, −0.10; no CS: β = −0.12, 95% CI = −0.15, −0.09), but did not achieve statistical significance. Stereo acuity (β = −0.13, 95% CI = −0.17, −0.09) and no SA (β = −0.13, 95% CI = −0.16, −0.10) groups had similar rates of decline.
Conclusions
Visually impaired older adults participate in fewer cognitive activities and although participation decline is similar to the non-impaired, lower overall participation indicates a need to identify cognitively stimulating activities accessible to visually impaired older adults.
Keywords: Cognition, Cognitive Aging, Sensory, Vision loss
The relationship between engagement in cognitively stimulating activities and cognitive function among older adults has been well documented. Collectively, these studies conclude that more frequent engagement in cognitively stimulating tasks is associated with a decreased rate of cognitive decline (1–8). The nature of these tasks varies greatly and range from high (ie, doing crossword puzzles), to moderate (ie, cooking), to low levels of stimulation (ie, watching television). Nevertheless, the majority of cognitively stimulating tasks require vision.
Reading is commonly affected by vision loss (9–12) and is among the primary complaints of patients with low vision (13). Additionally, older adults with vision loss participate less in social and religious activities (14) and engage in less physical activity than normally sighted older adults (15–20). Since prior research has shown that older adults with vision loss are at greater risk of cognitive decline (21,22), it is imperative to understand whether this elevated risk can be attributed to lower participation in cognitive activity, which has been posited as a potentially modifiable mediator of this relationship (23). Remarkably few studies measure the frequency and level of participation in cognitively stimulating activities among older adults and evaluate associations with vision loss. Of the few studies, one cross-sectional study found older adults with age-related macular degeneration (AMD) and glaucoma participated in fewer cognitive activities than individuals with normal vision (24).
We sought to build on this work by examining cross-sectional and longitudinal relationships between 3 measures of visual function—visual acuity (VA), contrast sensitivity (CS), and stereo acuity (SA)—and participation in cognitively stimulating activities among older adults, using data from the Health, Aging, and Body Composition (Health ABC) study. We hypothesized that older adults with vision impairment would engage in fewer activities at baseline and experience greater rates of disengagement from these activities over time. This work will lay the foundation for guiding future research aimed at determining if and to what extent participation in cognitive activities affects the vision–cognition relationship in older adults.
Method
Study Population
The Health ABC study is a prospective cohort including 3075 community-dwelling, high-physical functioning older adults aged 70–79 years at enrollment, residing in Pittsburgh, Pennsylvania, or Memphis, Tennessee. Study participants comprised a random sample of white and all black Medicare-eligible community residents. Baseline study visits took place in 1997–1998, and follow-up continued for 16 years (25). Prior studies have described the Health ABC study eligibility and enrollment criteria (21,26). The institutional review boards of the University of Pittsburgh and the University of Tennessee, Memphis, approved the study protocols, and all participants provided informed written consent.
The analytic sample was restricted to participants in the Cognitive Vitality Substudy (CVS), Years 3–9 (1999–2005) who were administered a supplemental activity assessment every other year and who had data on vision measures which were initiated in Year 3. A total of 927 CVS participants completed the Year 3 exam (baseline for these analyses), but cross-sectional analyses were limited to 887 participants who had vision testing (924/927 had VA and CS testing, 898/927 had SA), did not have dementia in Year 3 (37 participants had dementia), and had data on participation in cognitive activities. In this sample, only 4 participants at baseline had missing covariate data (n = 3 for education, n = 1 for smoking, and n = 1 for diabetes), and complete case analyses were performed in the cross-sectional models given these low rates of missingness. For the longitudinal analyses, of the 887 participants with data on participation in cognitive activities and all covariates, 56/883 (6.3%) were lost to follow-up after Year 3.
Vision Assessments
Vision was measured only in Year 3 (1999–2000) (27) and served as the baseline assessment for these analyses. Three measures of visual function were assessed: (i) Presenting VA was measured using high-contrast Bailey–Lovie chart (28,29) at a 10- or 5-feet testing distance with participants wearing habitual correction when available. The total number of letters read correctly was recorded and VA was calculated in logarithm of the minimum angle of resolution (logMAR) units. Visual acuity impairment was defined as VA of 20/40 or worse in the better eye. The VA impairment cutoff was chosen based on clinically meaningful criteria as previously used (30,31). (ii) Contrast sensitivity was measured using a Pelli–Robson chart (32,33), also at a 10- or 5-feet testing distance with participants wearing habitual correction when available. The total number of letters read correctly was recorded and CS was calculated as logContrast units, indicating the lowest contrast threshold discerned. Contrast sensitivity impairment was defined as CS <1.55 log contrast units, that is, 2 SD below the average in adults aged 60 years and older (34). (iii) Stereo acuity was measured with the Frisby stereo test (35) at a 40- 80-cm testing distance. Participants were presented with stereo images of decreasing depth differentials over 3 trials (340, 170, and 85 seconds of arc), and the smallest depth disparity that was correctly discerned was recorded as the SA value. Stereo acuity impairment was defined as SA >85 seconds of arc (arcsec), that is, the inability to ascertain the smallest depth differential presented (27).
Cognitive Stimulating Activities
Participation in cognitively stimulating activities was determined at Years 3, 5, 7, and 9. In the Activity Assessment subsection of the CVS, participants were queried about how often in the past year they had participated in a list of 12 activities (Supplementary Table 1). For each activity, there were 8 answer options: not at all, once or twice only, less than once a month, at least monthly, less than once a week, at least every week, several times a week, or daily. The total number of monthly activities were calculated based on self-report of any participation in an activity at least once a month. Of note, the Year 3 questionnaire was 22 questions long, and in subsequent years, some questions were combined to yield a 12-question survey. Therefore, for analysis, we pooled Year 3 questions to reflect the 12-question survey.
Other Covariates
Sociodemographic details including age, sex, race (white or black), and education were recorded from Year 3 data. Smoking status (current, former, or never smoker) was recorded from Year 3 data, and diabetes (yes or no) was determined by self-report from Year 1, 2, and 3 data. The study sites were Pittsburgh, Pennsylvania, or Memphis, Tennessee.
Statistical Analyses
Each of the 3 vision impairment categories were compared across key predictors, including age, sex, race, education, diabetic status, smoking status, and study site. These population characteristics were summarized using t tests and chi-squared tests for continuous and categorical variables, respectively. Rates of monthly participation in each of the 12 cognitive activities were compared across groups with and without respective vision impairments using chi-squared tests and expressed as percentages.
Normality of total cognitive activity levels was examined using Q-Q plots and we determined that our data could be appropriately modeled by a Gaussian distribution. Multivariable linear regression analyses were used to examine the cross-sectional associations between the vision variables (categorical VA, CS, and SA impairments, continuous logMAR VA and logContrast CS, and any vision impairment [ie, either VA, CS, or SA impairment vs no vision impairment]) and total number of activities performed at least once a month at Year 3, adjusting for age, sex, race, years of education, smoking, diabetes, and study site.
All longitudinal analyses of cognitive activity data were from Years 3, 5, 7, and 9. The yearly rate of decline in the number of cognitively stimulated activities at least once a month was estimated using linear regression models with time as the independent variable. Models included an interaction between time and visual impairment status and were adjusted for age, sex, race, education, current smoking, self-reported history of diabetes, and study site. All covariates were assessed at Year 3. The generalized estimating equation (GEE) approach was used to account for the correlation of repeated measures over time. Annual rates and 95% confidence intervals stratified by visual impairment categories are reported. Additional analyses were conducted stratified by the median baseline level of activity, to examine if baseline level of engagement predicted participation over time. Participants were stratified into low (<5) and high (≥5) monthly activity groups, accordingly.
Finally, a similar modeling approach was taken to examine the impact of baseline participation in cognitive activities on changes in cognitive function (as assessed by the Modified Mini-Mental State Examination [3MS] score) (36) over time. Predictors in the model included time, the number of cognitive activities at baseline, and their interaction. The model was adjusted for baseline (Year 3) age, sex, education, race, diabetes, smoking, any visual impairment (VA, CS, or SA impairment), and study site. The 3MS was administered in Years 1, 3, 5, 7, 9, 10, and 11, and is a global test of cognitive function with a maximum score of 100 (cognitive impairment defined as a score <80).
All analyses were performed using SAS statistical software v9.4 (SAS Institute Inc, Cary, North Carolina).
Sensitivity Analyses
In sensitivity analysis, adding in depression as a covariate in the models did not change the results, and it was left out for parsimony. Negative binomial regression, modeling number of cognitive activities as a count, were also explored and yielded similar inferences to the linear regression. For ease of interpretation, we chose to show linear regression models. In regression models examining rate of change in weekly activities (instead of monthly), similar patterns were noted.
Results
Population Characteristics
A total of 887 participants from baseline Year 3, with a mean age of 75.2 (SD = 2.8) years were included in this analysis. About half the participants were female (50.5%) and white (51.4%). Of the total baseline population, 8.2% had VA impairment, 26.8% had CS impairment, and 28.2% had SA impairment. Overall, participants with visual impairments were older than those without vision impairments. Participants with CS and SA impairments were more likely to be black and have less than a high school education than participants without these impairments. Participants with CS impairment were also more likely to have diabetes than participants without CS impairment (Table 1).
Table 1.
Demographic and Clinical Characteristics at Baseline: Health, Aging, and Body Composition Study, Year 3 (1999–2000)
| Total Population, N = 887 | No VA Impairment (>20/40), n = 814 | VA Impairment (≤20/40), n = 73 | No CS Impairment (≥1.55 log unit), n = 649 | CS Impairment (<1.55 log unit), n = 238 | No SA Impairment (≤85 arcsec), n = 618 | SA Impairment (>85 arcsec), n = 243 | |
|---|---|---|---|---|---|---|---|
| Demographics | |||||||
| Age, mean (SD) | 75.2 (2.8) | 75.2 (2.7) | 76.3 (2.9) | 74.8 (2.6) | 76.4 (2.9) | 75.0 (2.6) | 75.9 (3.0) |
| Sex, n (%) | |||||||
| Female | 448 (50.5) | 416 (51.1) | 32 (43.8) | 330 (50.8) | 118 (49.6) | 339 (53.2) | 109 (44.9) |
| Male | 439 (49.5) | 398 (48.9) | 41 (56.2) | 319 (49.2) | 120 (50.4) | 289 (46.8) | 134 (55.1) |
| Race, n (%) | |||||||
| White | 456 (51.4) | 421 (51.7) | 35 (48.8) | 351 (54.1) | 105 (44.1) | 327 (52.9) | 112 (46.1) |
| Black | 431 (48.6) | 393 (48.3) | 38 (52.0) | 298 (45.9) | 133 (55.9) | 291 (47.1) | 131 (53.9) |
| Education, n (%) | |||||||
| <High school | 186 (21.0) | 167 (20.6) | 19 (26.0) | 123 (19.0) | 63 (26.6) | 116 (18.9) | 63 (25.9) |
| High school | 280 (31.7) | 257 (31.7) | 23 (31.5) | 210 (32.5) | 70 (29.5) | 198 (32.2) | 79 (32.5) |
| Post-secondary | 418 (47.3) | 387 (47.7) | 31 (42.5) | 314 (48.5) | 104 (43.9) | 301 (48.9) | 101 (41.5) |
| Study site, n (%) | |||||||
| Pittsburgh | 477 (53.8) | 440 (54.0) | 37 (50.7) | 369 (56.9) | 108 (45.4) | 344 (55.7) | 123 (50.6) |
| Memphis | 410 (46.2) | 374 (46.0) | 36 (49.3) | 280 (43.1) | 130 (54.6) | 274 (44.3) | 120 (49.4) |
| Health measures | |||||||
| Diabetes, n (%) | |||||||
| No | 734 (82.8) | 679 (83.5) | 55 (75.3) | 550 (84.9) | 184 (77.3) | 519 (84.0) | 190 (78.5) |
| Yes | 152 (17.2) | 134 (16.5) | 18 (24.7) | 98 (15.1) | 54 (22.7) | 99 (16.0) | 52 (21.5) |
| Smoking, n (%) | |||||||
| Current | 56 (6.3) | 48 (5.9) | 8 (10.9) | 37 (5.7) | 19 (8.0) | 33 (5.3) | 21 (8.6) |
| Former | 411 (46.4) | 380 (46.7) | 31 (42.5) | 304 (46.9) | 107 (45.0) | 293 (47.5) | 103 (42.4) |
| Never | 419 (47.3) | 385 (47.4) | 34 (46.6) | 307 (47.4) | 112 (47.0) | 291 (47.2) | 119 (49.0) |
Note: CS = contrast sensitivity; SA = stereo acuity; VA = visual acuity. Bolded values test for differences at p <.05 between groups with and without respective vision impairments by category.
Baseline Participation in Cognitive Activities
Participants with VA (5.1 vs 4.4), CS (5.2 vs 4.6), and SA (5.2 vs 4.6) impairments engaged in a greater (mean) number of cognitively stimulating activities per month than those without the respective impairments (Figure 1; Supplementary Table 1). Group differences in monthly participation for each of the 12 activities are listed in Supplementary Table 1 and Supplementary Figure 1a–c.
Figure 1.
Baseline cognitive activity level by visual impairment status.
In the fully adjusted cross-sectional models, CS (β = −0.36, 95% CI = −0.65, −0.08), SA (β = −0.32, 95% CI = −0.63, −0.02), and any vision (β = −0.36, 95% CI = −0.64, −0.09) impairments were associated with participation in fewer cognitively stimulating activities per month relative to those without the respective impairments. Impaired VA as a dichotomous measure was not associated with activity participation. When evaluated on a continuous scale, however, both worse VA and CS were associated with less frequent participation in cognitive activities (VA: β = −0.11, 95% CI = −0.21, −0.02; CS: β = −0.11, 95% CI = −0.19, −0.04; Table 2).
Table 2.
Cross-sectional Association Between Visual Impairment and Participation in Cognitively Stimulating Activities at Baseline: Health, Aging, and Body Composition Study, Year 3 (1999–2000)
| Number of Activities At Least Once a Month | |||
|---|---|---|---|
| Visual Function | Interval | β (95% CI) | p-Value |
| Visual acuity | |||
| Categorical VA impairment | vs No VA impairment | −0.40 (−0.89, 0.07) | .10 |
| Continuous VA | per 0.1 logMAR worse | −0.11 (−0.21, −0.02) | .016 |
| Contrast sensitivity | |||
| Categorical CS impairment | vs No CS impairment | −0.36 (−0.65, −0.08) | .024 |
| Continuous CS | per 0.1 log units worse | −0.11 (−0.19, −0.04) | .004 |
| Stereo acuity | |||
| Categorical SA impairment | vs No SA impairment | −0.32 (−0.63, −0.02) | .034 |
| Any vision impairment | vs No vision impairment | −0.36 (−0.64, −0.09) | .010 |
Note: CI = confidence interval; CS = contrast sensitivity; logMAR = logarithm of the minimum angle of resolution; SA = stereo acuity; VA = visual acuity. Adjusted for age, sex, race, education, smoking, diabetes, and study site. Bold: significance set at p value < .05.
Annualized Change in Participation in Cognitive Activities
In the fully adjusted longitudinal models examining annualized rate of change in number of monthly activities (slope of time) by impairment status, both those with and without VA, CS, SA, and any vision impairments declined in activity over time (Table 3). Rates of decline appeared relatively higher in the VA, CS, any vision impaired groups than the unimpaired groups but did not achieve statistically significance.
Table 3.
Vision Impairment and Annual Rate of Change in Monthly Participation in Cognitively Stimulating Activities: Health, Aging, and Body Composition Study, Years 3, 5, 7, and 9 (1999–2005)a
| Rate of Change in Number of Activities At Least Once a Month (slope of time) | ||
|---|---|---|
| Visual Function in Year 3 | β (95% CI) | p-Value |
| Visual acuity | ||
| Non-impaired | −0.12 (−0.15, −0.10) | <.0001 |
| Impaired | −0.15 (−0.26, −0.04) | .007 |
| Contrast sensitivity | ||
| Non-impaired | −0.12 (−0.15, −0.09) | <.0001 |
| Impaired | −0.14 (−0.19, −0.09) | <.0001 |
| Stereo acuity | ||
| Non-impaired | −0.13 (−0.15, −0.10) | <.0001 |
| Impaired | −0.13 (−0.17, −0.08) | <.0001 |
| Any vision impairment | ||
| Non-impaired | −0.12 (−0.15, −0.09) | <.001 |
| Impaired | −0.13 (−0.17, −0.10 | <.001 |
Notes: CI = confidence interval. Adjusted for baseline age, gender, race, education, diabetes, smoking, and study site.
aGeneralized estimating equation (GEE) repeated measures over time.
In longitudinal models stratified by the median monthly baseline activity, among participants who engaged in 5 or more activities per month, groups with or without VA, CS, SA, and any vision impairments had declines in activity over time (Table 4). Rates of decline appeared relatively higher in the VA, CS, SA, and any vision impairment groups than the unimpaired groups, but did not achieve statistically significance. Among participants who engaged in fewer than 5 activities per month, the group with SA impairment had stable participation relative to the group without SA impairment which showed increased participation over time. No other group differences emerged.
Table 4.
Vision Impairment and Annual Rate of Change in Monthly Participation in Cognitively Stimulating Activities, Stratified by Baseline Activity Level: Health, Aging, and Body Composition Study, Years 3, 5, 7, and 9 (1999–2005)a
| Rate of Change in Number of Activities At Least Once a Month (slope of time) | Rate of Change in Number of Activities At Least Once a Month (slope of time) | |||||
|---|---|---|---|---|---|---|
| Baseline Rate ≥5 Activities | Baseline Rate <5 Activities | |||||
| Visual Function in Year 3 | N b | β (95% CI) | p-Value | N b | β (95% CI) | p-Value |
| Visual acuity | ||||||
| Non-impaired | 469 | −0.24 (−0.27, −0.21) | <.0001 | 345 | 0.05 (0.02, 0.08) | .027 |
| Impaired | 34 | −0.33 (−0.49, −0.17) | <.0001 | 39 | 0.04 (−0.07, 0.16) | .45 |
| Contrast sensitivity | ||||||
| Non-impaired | 383 | −0.24 (−0.27, −0.20) | <.0001 | 266 | 0.05 (0.02, 0.09) | .003 |
| Impaired | 120 | −0.29 (−0.36, −0.22) | <.0001 | 118 | 0.04 (−0.02, 0.10) | .18 |
| Stereo acuity | ||||||
| Non-impaired | 367 | −0.25 (−0.28, −0.21) | <.0001 | 251 | 0.07 (0.028, 0.11) | .001 |
| Impaired | 121 | −0.26 (−0.32, −0.19) | <.0001 | 122 | 0.01 (−0.04, 0.06) | .73 |
| Any vision impairment | ||||||
| Non-Impaired | 305 | −0.24 (−0.28, −0.20) | <.001 | 206 | 0.07 (0.03, 0.11) | .001 |
| Impaired | 198 | −0.26 (−0.31, −0.21) | <.001 | 178 | 0.02 (−0.02, 0.07) | .29 |
Notes: Adjusted for baseline age, gender, race, education, diabetes, smoking, and study site. Values italicized: interaction term (Stereo acuity impairment status * Rate of change in activities), p = .049. Bold: significance set at p value < .05.
aGeneralized estimating equation (GEE) repeated measures. bN = number of subjects contributing with at least one visit.
Association With Cognitive Performance
In a model examining the impact of baseline participation in cognitive activities on changes in cognitive function over time, the baseline number of activities was associated with the 3MS; 0.36 (95% CI = 0.17, 0.55, p < .001) higher points on the 3MS per 1 unit increase in baseline activity. However, the yearly decline in 3MS was not significantly associated with the number of cognitive activities that participants reported engaging in at baseline (ie, interaction between baseline number of activities and yearly decline in 3MS (time) was 0.006 [95% CI = −0.02, 0.03, p = .70]).
Discussion
Our results show that vision impairment in either of 3 domains, VA, CS, and SA, is associated with less frequent participation in cognitively stimulating activities. Additionally, this study is among the first to explore the longitudinal relationship between vision and participation in cognitive activities, and our results suggest that older adults with vision impairments have similar declines or “disengagement” in cognitive activity participation as older adults without vision impairments. Furthermore, when examining groups stratified by level of baseline activity, irrespective of vision, individuals that had lower baseline activity tended to increase their activity over time, while those with higher baseline activity tended to reduce participation over time. We also found that greater baseline participation in activities was associated with higher cognitive function but was not associated with protection from cognitive decline. Regardless, these results highlight that visual impairment may be a risk factor for lower participation in cognitively stimulating tasks and support the need to better understand the relationship between vision impairment and cognitive function.
Our findings are consistent with a previous study that quantified participation in an array of 40 cognitively stimulating activities in participants with and without age-related eye disease. Varin et al. found that patients with bilateral late-stage AMD participated in 4.2 fewer cognitive activities per month than those with normal vision, and those with bilateral primary open-angle glaucoma participated in 1.8 fewer activities (24). The authors determined that both eye conditions largely influenced physical activities and activities requiring novel information processing like reading books, and doing crossword puzzles. Although we did not group activities by type, we observed that individuals with vision impairments reported less frequent participation in crossword or jigsaw puzzles, reading newspapers or magazines, and handcrafts, needlework, painting etc. (Supplementary Table 1), all activities that are vision-dependent. Another study by Naël et al. (37) found that near-vision impairment (binocular presenting near VA was assessed) was associated with lower engagement in cognitively stimulating activities (monthly frequency of engagement in up to 12 activities was assessed). They noted decrements in engagement scores (standardized Z-scores) with worsening near vision (−0.14 for mild vision impairment and −0.38 for moderate/severe vision impairment).
Contrary to our hypothesis that older adults with vision impairment would experience greater rates of disengagement from cognitively stimulating activities over time, we did not observe any differences in rates of decline between groups with and without vision impairment. Since older adults with vision impairment had lower levels of cognitive activity participation at baseline than older adults without vision impairment, it is possible that the lack of between-group differences over time may be due to a “floor effect” where participants with vision impairment are starting at lower activity levels and therefore limited in their declines
Regardless, engagement in fewer cognitively stimulating activities may put older adults with vision impairment at a greater risk of cognitive impairment. A longitudinal study conducted in a population-based sample of healthy older women determined that each additional activity performed per month was associated with an 11% lower risk of incident Mini-Mental State Examination (MMSE) defined cognitive impairment (8). Each additional activity per month also reduced the risk of incident impairment by 9% and 8% on the Hopkins Verbal Learning Test (HVLT) immediate and delayed recall components, respectively. Furthermore, prior research has shown that older adults with VA, CS, and SA impairments are more likely to have cognitive decline, and are at increased risk of developing cognitive impairment than those without these impairments, in a study with nearly a decade of follow-up (21). Taking together these 2 threads of existing research, we need to next determine whether lower levels of participation in cognitively stimulating activities puts older adults with vision impairments at risk of cognitive decline.
Recent research seems to suggest that participation in social/cognitive activities weakly modifies the effects of sensory decline on cognitive decline, suggesting that such engagement has modest benefits on cognitive function. Naël et al., while noting associations between vision loss and increased dementia risk, found that less engagement in cognitively stimulating activities slightly diminished the vision–dementia associations (37). Similar findings were reported from the Canadian Longitudinal Study on Aging cohort, where social engagement, as measured by participation in the number of types and frequency of social activities (among other social factors), only weakly mediated the vision–cognitive relationship (38). Perhaps activity assessment needs to be more comprehensive as some activities that require good vision may not necessarily be considered “cognitive in nature,” but nevertheless have been found to support retained cognitive function. Physical exercise, for example, has been shown to benefit cognitive function; a meta-analysis reported a 28% reduction in incident dementia with higher physical activity (39).
This study has limitations to consider when interpreting the results. First, data on vision measures were only collected at one time point, at Year 3. Therefore, we were unable to explore how changes in vision over time affect participation in cognitive activities. Second, best-corrected VA, which can provide information on optimal acuity possible with appropriate spectacle correction, were not available. However, presenting VA indicates functional acuity that an individual is likely utilizing while participating in daily activities. Third, as discussed in the “Method” section, the 22-item questionnaire from Year 3 was condensed to 12 items in following years, and we had to pool Year 3 questions to reflect the subsequent 12-item questionnaire. Therefore, the rate of change in monthly activities (slope of time estimates from Table 3) may be related to the modification of the questionnaire. Fourth, participants who were lost to follow-up were more likely to be male, black, and a smoker, had lower participation in cognitive activities, and had worse VA or CS at baseline. Nonetheless, our estimates are likely conservative due to this survivor bias related attrition. Finally, the activities included in these analyses are likely of varying cognitive challenge and engage different cognitive processing skills, which were not separately examined by subtype. But, Carlson et al. determined that participation in a variety of activities was more predictive than level of cognitive challenge offered with regard to risk of incident impairment (8). Future studies should address these limitations by assessing vision at multiple time points, allowing a more robust modeling of the longitudinal relationship between vision and participating in cognitive activities.
In conclusion, our results indicate that among a population of high-physical functioning older adults, impairments in CA and SA are associated with lower levels of participation in cognitive activities. These findings suggest that good vision is important for engagement in cognitively stimulating activity, which other studies have in turn shown are integral to cognitive health and outcomes among older adults. These results support the need to identify and/or develop alternative cognitively stimulating activities for visually impaired older adults, and highlight the need for subsequent research to examine the impact of interventions to optimize vision and to increase participation in cognitive activities on improving cognitive outcomes in older adults.
Funding
This work was supported by the National Institutes of Health (Intramural Research Program of the NIA, and NIA K01AG052640), and the Dr. Jane Kroger fund. The National Institutes of Health was not involved in the design and conduct of the study; the analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Conflict of Interest
None declared.
Author Contributions
V.V.: drafting of the manuscript; B.M.: data analysis; E.M.S.: critical feedback; and B.K.S.: conceived the idea, supervision, and critical feedback.
Supplementary Material
References
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