Associations of Dual Sensory Impairment with Incident Mobility and ADL Difficulty

Nicole M Armstrong; Camila Vieira Ligo Teixeira; Colby Gendron; Willa D Brenowitz; Frank R Lin; Bonnelin Swenor; Jennifer A Deal; Eleanor M Simonsick; Richard N Jones

doi:10.1111/jgs.17764

. Author manuscript; available in PMC: 2023 Jul 1.

Published in final edited form as: J Am Geriatr Soc. 2022 Mar 28;70(7):1997–2007. doi: 10.1111/jgs.17764

Associations of Dual Sensory Impairment with Incident Mobility and ADL Difficulty

Nicole M Armstrong ¹, Camila Vieira Ligo Teixeira ², Colby Gendron ³, Willa D Brenowitz ⁴, Frank R Lin ^5,^6,^7,⁸, Bonnelin Swenor ^5,^9,¹⁰, Jennifer A Deal ^5,^7,⁸, Eleanor M Simonsick ², Richard N Jones ¹

¹Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA

²Intramural Research Program, National Institute on Aging, Baltimore, MD, USA

³Department of Economics, Brown University, Providence, RI, USA

⁴Department of Psychiatry and Behavioral Sciences and Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, CA, USA

⁵Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁶Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁷Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

⁸Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁹Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA

¹⁰Johns Hopkins Disability Health Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA

Author Contributions: Study concept and design; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; study supervision: Nicole Armstrong. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Camila Vieira Ligo Teixeira. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Colby Gendron. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Willa Brenowitz. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Frank Lin. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Bonnelin Swenor. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Jennifer Deal. Study concept and design; analysis and interpretation of data; acquisition of data; critical revision of the manuscript for important intellectual content: Eleanor Simonsick. Study concept and design; analysis and interpretation of data; critical revision of the manuscript for important intellectual content: Richard Jones.

^✉

Corresponding Author: Nicole Armstrong, PhD, MPH, Associate Director, Quantitative Science Program, Departments of Psychiatry and Human Behavior, and Neurology, Warren Alpert Medical School, Brown University, Butler Hospital (Duncan 256), 345 Blackstone Boulevard, Box G-BH, Providence, Rhode Island 02906, nicole_armstrong@brown.edu, Tel: (401) 444-1943

PMCID: PMC9283239 NIHMSID: NIHMS1791439 PMID: 35343588

Abstract

Background:

There is a dearth of studies examining the associations of objectively measured dual sensory impairment (DSI) with incident mobility and activities of daily life (ADL) difficulty longitudinally.

Methods:

Cox proportional hazards models were used to examine the associations of DSI and single sensory impairment (hearing, vision) with incident mobility difficulty (many problems or inability to walk ¼ mile and/or climb 10 steps) and ADL difficulty up to six years of follow-up among 2,020 participants of the Health, Aging and Body Composition Study, a cohort of older adults aged 70–79 years from Pittsburgh, PA and Memphis, TN. Vision impairment (VI) was defined as impaired visual acuity (20/50 or worse on Bailey-Lovie distance test) and contrast sensitivity (<1.3 log units on Pelli-Robson test), and hearing impairment (HI) was defined as pure-tone average in better-hearing ear >25 decibels. Models were adjusted by age, race, sex, education, diabetes, depressive symptoms, hypertension, gait speed from 20-meter walk, global cognition score, prevalent cardiovascular disease, and body mass index.

Results:

There were 23% with DSI (n=459). DSI was associated with increased risk of both incident report of mobility (Hazard Ratio [HR]=2.25, 95% Confidence Interval [CI]: 1.47, 3.43) and ADL difficulty (HR=2.26, 95% CI: 1.50, 3.40). Neither VI nor HI alone were associated with risk of either outcome.

Conclusions:

DSI is associated with increased risk of incident mobility and ADL difficulty. Rehabilitation and adaptive environmental changes for individuals living with DSI may be important to maximize mobility and daily function.

Keywords: dual sensory impairment, hearing, vision, difficulty, functional limitations

Introduction

Approximately 15.7 million Americans aged ≥65 years and older have at least one functional difficulty.^{1, 2} Mobility difficulty, severe problems to walk ¼ mile or climb one flight of stairs, is the most common difficulty reported among older adults.^{1, 2} ADL difficulty is characterized as experiencing problems in performing activities that are essential to independent living, i.e., eating, bathing, getting dressed, toileting, and transferring.³

Dual sensory impairment (DSI) of hearing and vision impairment is prevalent among older US adults^{4, 5}, and it may increase risk of mobility and ADL difficulty, as older adults with sensory impairments have decreased physical activity.^6–9 Processing of sensory information is important for mobility. Co-occurring impairments may be associated with poorer function when compared to single sensory impairments alone.¹⁰ Vision impairment (VI) has been linked to an increased risk of mortality, hip fracture, mobility difficulty, and functional difficulty.^{11, 12} The prevalence of VI is about 9% among adults aged ≥60 years.¹³ About two-thirds of adults aged ≥70 years have hearing impairment (HI)¹⁴, and the prevalence of HI doubles with every decade of life.^{15, 16} Those with HI are more likely to have poorer objective physical functionality.¹⁷

For individuals with DSI, there is often no clear path on rehabilitation and preventative strategies, further leading to a heightened risk of adverse outcomes.⁷ Environments in which we live are largely not inclusive and accessible for people with difficulties, including those with hearing and vision impairments. Given the dearth of studies on the longitudinal associations of objectively measured DSI with incident mobility and ADL difficulty, accurate understanding of how HI and VI predict mobility and ADL difficulty is important for risk stratification and targeting interventions to prevent mobility and ADL difficulties in older adults. We aimed to examine prospective associations among older adults without baseline functional limitations. We hypothesize that older adults with DSI will be associated with increased risk of incident mobility and ADL difficulty, as compared to those with HI and VI separately and without HI and VI. As an exploratory analysis, we examined whether sex and/or race modified these associations.

Methods

Characteristics of the Study Sample

Participants were from the Health Aging and Body Composition (HABC) study, a longitudinal cohort study designed to evaluate changes in physical function and body composition in older Black and white adults aged 70–79 years at enrollment. Enrollment procedures are described elsewhere.^{18, 19} Briefly, 3,075 older Black and white adults without mobility limitations or ADL difficulties were randomly selected from a Medicare-eligible population in Pittsburgh, PA and Memphis, TN between 1997 and 1998. Each participant was required to sign a written consent form and the study was approved by institutional review boards at each study location (Pittsburgh, PA and Memphis, TN).

The sample was further restricted to 2,020 participants who had both hearing and vision measures four and two years after enrollment respectively and longitudinal data on mobility and ADLs without having mobility and ADL difficulty four years after enrollment (baseline, Year 5).

Sensory Impairment

Hearing impairment.

From 2001 to 2002 (Year 5), audiometric assessments were conducted in a sound-treated booth to 2,206 participants. Due to the progression of hearing impairment being slow²⁰, audiometric assessment at Year 5 is an appropriate approximation of hearing status, and it is treated as a time-fixed variable. Reasons why participants were excluded from audiometric tests were death, loss to follow-up, and missed study visits.

Pure-tone air conduction thresholds were assessed by a trained technician in both ears using TDH-39 headphones (Telephonics Corporation) and an audiometer (MA40; Maico Diagnostics) calibrated to the standards of the American National Standards Institute (53.6–1996). Pure-tone average (PTA) was calculated from audiometric threshold at 0.5, 1, 2, and 4 kHz for the better hearing ear. A PTA >25 decibels hearing level (dB HL) is defined as any HI, since previous studies using HABC data have used this cut-off.^21–23

Vision impairment.

From 1999 to 2000 (Year 3), visual acuity and contrast sensitivity measurements were administered to 2,191 participants.¹² Both tests allowed participants to wear habitual correction when available. The Bailey-Lovie distance visual acuity test, converted to Snellen equivalents was used, with an acuity equivalent of 20/50 or worse in the better presenting eye being defined as impaired.^{24, 25} Additionally, Pelli-Robson contrast sensitivity was used, with ≤1.3 log units being defined as impaired (log Contrast units, higher values = better sensitivity).^{26, 27} Participants were asked about any conditions that may impact their vision, such as cataracts, glaucoma, and/or retinopathy. VI was defined as impaired visual acuity and/or contrast sensitivity.

Dual sensory impairment.

Using the definitions listed above for HI and VI, we created a categorical variable to examine dual impairment: HI and VI, HI, VI, and neither HI nor VI.

Incident Mobility and ADL Difficulty

The two study outcomes were time to (i) incident mobility difficulty and (ii) incident ADL difficulty. Incident mobility difficulty was defined as two consecutive reports of having a lot of difficulty or inability to walk ¼ mile and/or climb 10 steps.²⁸ These measures were ascertained semiannually between 1997–2011. Incident ADL difficulty was defined as any difficulty performing ADL (i.e., bathing or showering, dressing, and transferring from bed to chair) from initial report. From 1998 to 2002, ADL difficulty was ascertained annually from 1998 to 2002 and then semiannually from 2002 to 2011. Final determinations of difficulty were assessed through participant interviews, hospital records, and/or proxy interviews.²⁸ For this study, we assessed incident outcomes after Year 5.

Adjustment Covariates

Adjustment covariates included baseline demographic characteristics (age, sex [female vs. male], race [Black vs. white], postsecondary education [attained vs. not]), history of diabetes and hypertension, body mass index (BMI), depressive symptoms, prevalent cardiovascular disease, usual speed (meters per second) to complete a 20-meter walk¹⁸, and Modified Mental State Examination (3MS)²⁹ score at baseline (Year 5). Age, BMI, 20-meter walk speed, and 3MS score were mean-centered. History of diabetes was ascertained by self-reported diagnosis of diabetes, use of diabetes drugs, or fasting glucose ≥126 mg/dL. History of hypertension was ascertained by having systolic blood pressure ≥140 mm Hg, diastolic blood pressure >90 mm Hg, or by self-report of diagnosis of hypertension with or without antihypertensive medication use. BMI was defined as objectively measured weight in kilograms divided by height meters squared. Depressive symptoms were from the Center for Epidemiologic Studies – Depression Scale.³⁰ 3MS is a global test consisting of orientation, concentration, language, praxis, and memory, and the maximum score is 100.²⁹ Prevalent cardiovascular disease (CVD) was defined as history of acute myocardial infarction, angina pectoris, or congestive heart failure by self-report, medication use, and/or Health Care Finance Administration (HCFA) data from Centers for Medicare and Medicaid Services prior to Year 5. HCFA data was only used at study enrollment (Year 1). Difficulty from instrumental ADLs, i.e., shopping and meal preparation, housecleaning and home maintenance, and management of finances, transportation, medications, and communication, was excluded, given its proximity to the outcomes of interest. Grip strength was not measured at the in-clinic visit of the main study in Year 5.

Statistical Analysis

We evaluated differences in baseline covariates by DSI category (DSI, HI, VI, and neither), using analysis of variance for continuous variables and χ² tests for categorical variables. Kaplan-Meier survival curves were used to show the unadjusted differences in the proportions of incident mobility and ADL difficulty by DSI category.

We used discrete-time Cox Proportional Hazards models³¹ with Efron ties to estimate hazard ratios of incident mobility difficulty and ADL difficulty and 95% confidence intervals (CI) of each sensory impairment group with persons without HI and VI being the reference group. The proportional hazards assumptions for the Cox models were confirmed formally by Schoenfeld’s tests. The time scale was years since hearing assessment, which was four years after study enrollment (baseline). Models were adjusted by baseline demographic characteristics, history of diabetes and hypertension, body mass index (BMI), prevalent CVD, and depressive symptoms. We calculated the relative excess risk due to interaction (RERI) and the synergy index (SI) to assess the biological interaction between HI and VI on an additive scale.³² RERI >0 and SI>1means that there is a positive interaction or more than additivity; RERI<0 and SI<1 means negative interaction or less than additivity; RERI=0 and SI=1 means no interaction or exactly additivity.

In a separate model, we evaluated the two-way interaction between HI and VI to see if there was a multiplicative interaction that was associated with increased risk of incident mobility difficulty and ADL difficulty. As secondary analyses, models with two-way interactions of race and sex with DSI were used to examine if sex and race modified these associations. We then stratified the samples by sex and race separately to examine the within-group risks of difficulty. Additionally, we excluded those with prevalent dementia four years after enrollment to determine whether inferences remained. As a sensitivity analysis, we added hearing aid use as a covariate, since HI correction may reduce risk of adverse outcomes. Risk ratios (RR) and risk differences (RD) of ever incident mobility and ADL difficulty as a function of DSI category were calculated from log-binomial (RR) and probit (RD) models. The unadjusted and adjusted estimates are included in Supplementary Table 1. Stata 16.0 was used for the analyses.³³

Results

Sample Characteristics

Table 1 shows the overall sample characteristics from HABC. Those with DSI were, on average, older and more likely to be male and white, than the other groups. Additionally, they were more likely to use a hearing aid and have depressive symptoms, impaired visual acuity and contrast sensitivity, history of cataracts, glaucoma, and macular degeneration when compared to the other groups. Figure 1 shows the crude Kaplan–Meier survival curves comparing the risk of incident mobility and ADL difficulty, respectively, as a function of DSI, single sensory impairment, and neither HI nor VI. There were 225 participants with incident mobility difficulty and 224 participants with incident ADL difficulty. The overall sample contributed 10,120 person-years. On average, people were followed for 7.7 years (range from 5 to 11 years). From log-rank tests, there were differences in the frequency of incident mobility difficulty (χ²=39.4, P<0.001) and incident ADL difficulty (χ²=44.9, P<0.001) among the DSI categories.

Table 1.

Baseline sample characteristics from the Health Aging and Body Composition Study (N=2,020)

	Overall	No Hearing or Vision Impairment	Hearing Impairment Only	Vision Impairment Only	Dual Sensory Impairment
Sample Characteristics	N=2020	n=528	n=720	n=313	n=459
Age, mean (SD)	77.5 (2.8)	76.4 (2.5)	77.5 (2.8)	77.3 (2.8)	78.6 (2.9)
Female, n (%)	1,093 (51.4)	338 (64.0)	305 (42.4)	178 (56.9)	218 (47.5)
Whites, n (%)	1,294 (64.1)	306 (58.0)	539 (74.9)	155 (49.5)	294 (64.1)
Postsecondary Education, n (%)	932 (46.1)	246 (46.6)	346 (48.1)	149 (47.6)	191 (41.6)
Married, n (%)	1,071 (53.0)	258 (48.9)	426 (59.2)	148 (47.3)	239 (52.1)
Current Smoking Status, n (%)	156 (7.7)	36 (6.8)	48 (6.7)	34 (10.9)	38 (8.3)
Body Mass Index, in kg/m², mean (SD)	27.3 (4.6)	27.4 (4.9)	27.1 (4.4)	27.4 (4.8)	27.3 (4.4)
Type II Diabetes Mellitus, n (%)	338 (16.7)	71 (13.5)	115 (16.0)	58 (18.5)	94 (20.5)
Hypertension, n (%)	1,258 (62.3)	324 (61.4)	432 (60.0)	211 (67.4)	291 (63.4)
Depressive Symptoms, mean (SD)	4.9 (4.2)	4.8 (4.2)	4.6 (4.1)	4.7 (4.0)	5.6 (4.4)
Modified Mini Mental State Examination score, mean (SD)	91.0 (8.1)	92.8 (6.5)	91.8 (7.0)	89.3 (9.6)	88.6 (9.5)
Prevalent Cardiovascular Disease, n (%)	609 (30.2)	126 (23.9)	236 (32.8)	104 (33.2)	143 (31.2)
Usual Speed from 20-Meter Walk, mean (SD)	1.1 (0.2)	1.1 (0.2)	1.1 (0.2)	1.1 (0.2)	1.1 (0.2)
Hearing aid use, n (%)	260 (12.9)	5 (1.0)	163 (22.6)	0 (0.0)	92 (20.0)
Pure-tone average, in decibels of hearing level, mean (SD)	30.2 (13.5)	17.9 (5.0)	38.9 (11.1)	18.5 (5.0)	39.0 (10.1)
Impaired visual acuity, n (%)	81 (4.0)	0 (0.0)	0 (0.0)	31 (9.9)	50 (10.9)
Impaired contrast sensitivity, n (%)	765 (37.9)	0 (0.0)	0 (0.0)	308 (98.4)	457 (99.6)
History of Cataracts, n (%)	1,086 (53.8)	259 (49.1)	351 (48.8)	186 (59.4)	290 (63.2)
History of Glaucoma, n (%)	254 (12.6)	41 (7.8)	80 (11.1)	52 (16.6)	81 (17.7)
History of Macular Degeneration, n (%)	116 (5.7)	22 (4.2)	23 (3.2)	25 (8.0)	46 (10.0)
Years on Study, mean (SD)	9.9 (1.9)	10.3 (1.7)	10.0 (1.8)	9.7 (2.0)	9.4 (2.2)
Number of Visits, n (%)
4	2020 (100.0)	528 (100.0)	720 (100.0)	313 (100.0)	459 (100.0)
5	1962 (97.1)	520 (98.5)	707 (98.2)	308 (98.4)	436 (95.0)
6	1674 (82.9)	466 (88.2)	622 (86.4)	254 (81.1)	350 (76.3)
7	1525 (75.5)	444 (84.1)	561 (77.9)	225 (71.9)	307 (66.9)
8	1431 (70.8)	405 (76.7)	516 (71.7)	198 (63.3)	260 (56.6)

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SD – standard deviation. Note: Vision impairment is defined as impaired visual acuity and contrast sensitivity. Hearing impairment is defined as >25 decibels of hearing level. Depressive symptoms were assessed by the 10-item Center for Epidemiology Studies-Depression Scale. Prevalent cardiovascular disease was defined as acute myocardial infarction, angina pectoris, or congestive heart failure by self-report, medication use, and/or Health Care Finance Administration data from Centers for Medicare and Medicaid Services (HCFA data used for definition at study enrollment) prior to four years since study enrollment. Baseline was set to four years after baseline, so participants had to be in the study for both hearing and vision assessments. There was missingness on post-secondary education (n=4), current smoking status (n=2), marital status (n=133), Type 2 Diabetes Mellitus (n=1), hypertension (n=7), depressive symptoms (n=5), hearing aid use (n=7), visual acuity (n=3), history of cataracts (n=16), history of macular degeneration (n=21), history of glaucoma (n=9), usual speed from 20-meter walk (n=13), Modified Mini Mental State Examination (n=3).

Figure 1. — Note: Magenta (top line) – dual impairment; black (second top line) – vision impairment; lavender (third top line)–hearing impairment; gray (bottom line) – normal (no sensory impairment)

Association of Dual Sensory Impairment with Risk of Incident Difficulty

Incident Mobility Difficulty.

Table 2 shows the results of the models evaluating the associations of DSI with risk of type of incident difficulty. After covariate adjustment, DSI was associated with 2.25 times the risk of incident mobility difficulty (95% CI: 1.47, 3.43). VI was marginally associated with risk of incident mobility difficulty (HR=1.55, 95% CI: 0.96, 2.50), but HI was not significantly associated with risk of incident mobility difficulty (HR=1.26, 95% CI: 0.83, 1.91) (Table 2). The RERI was 0.43 (95% CI: −0.38, 1.24), and the SI was 1.53 (95% CI: 0.00, 3.06). The estimate when combining HI and VI was 1.96 (95% CI: 0.40, 3.51), suggesting that DSI did not contribute more than the sum of the individual sensory impairments. Adding hearing aid use to the model did not change inferences (Supplementary Table 2).

Table 2.

Associations of dual sensory impairment with incident mobility difficulty and difficulty of activities of daily living (ADL) (N=2020).

	Incident Mobility Difficulty		Incident ADL Difficulty
Type of Sensory Impairment	Hazard Ratio	95% Confidence Interval	Hazard Ratio	95% Confidence Interval
Model 1
No Hearing or Vision Impairment	REF	REF	REF	REF
Hearing Impairment Only	1.26	(0.83, 1.91)	1.11	(0.73, 1.67)
Vision Impairment Only	1.55	(0.96, 2.50)	1.26	(0.78, 2.05)
Dual Sensory Impairment	2.25	(1.47, 3.43)	2.26	(1.50, 3.40)
Model 2
Hearing Impairment	1.26	(0.83, 1.91)	1.11	(0.73, 1.67)
Vision Impairment	1.55	(0.96, 2.50)	1.26	(0.78, 2.05)
Hearing Impairment * Vision Impairment	1.15	(0.65, 2.03)	1.62	(0.91, 2.88)

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Note: All discrete-time Cox Proportional Hazards models with Efron ties were adjusted by the following covariates: baseline age, sex (female vs. male), race (Black vs. white), post-secondary education (attained vs. not), body mass index, history of diabetes and hypertension, clinically relevant depressive symptoms (10-item Center for Epidemiologic Studies – Depression Scale ≥8 vs. <8), Modified Mini Mental State Examination score, prevalent cardiovascular disease, and speed from 20-meter walk. The main independent variable of interest for Model 1 was dual impairment defined as a variable with four categories: neither hearing nor vision impairment; hearing impairment only, vision impairment only, and dual sensory impairment. The main independent variables of interest for Model 2 were hearing impairment, vision impairment, and the two-way interaction between hearing and vision impairment. All continuous covariates were mean-centered. Baseline was defined as four years since study initiation (Year 5). Bolded values indicate that the 95% confidence interval did not overlap with 1.0.

We examined the associations of DSI with incident mobility difficulty after excluding prevalent dementia cases four years after study initiation, and our inferences remained the same. HI was not significantly related to incident mobility difficulty (HR=1.26, 95% CI: 0.81, 1.96). VI was marginally associated with increased risk of incident mobility difficulty (HR=1.51, 95% CI: 0.91, 2.51). DSI was associated with increased risk of incident mobility difficulty (HR=2.48, 95% CI: 1.58, 3.90).

We evaluated the two-way interaction between HI and VI in a separate model, and the interaction term was not significant (HR=1.15, 95% CI: 0.65, 2.03). VI was marginally associated with increased risk of incident mobility difficulty (HR=1.55, 95% CI: 0.96, 2.50), HI was not statistically significantly related to incident mobility difficulty (HR=1.26, 95% CI: 0.83, 1.91) (Table 2).

When examining whether sex and race modified associations between DSI and mobility difficulty, there were no statistically significant two-way interactions of sex and race with HI (sex: HR=1.01, 95% CI: 0.43, 2.42; race: HR=0.98, 95% CI: 0.41, 2.36), VI (sex: HR=1.70, 95% CI: 0.66, 4.39; race: HR=1.63, 95% CI: 0.62, 4.27), and DSI (sex: HR=1.85, 95% CI: 0.72, 3.73; race: HR=1.40, 95% CI: 0.61, 3.20). We further stratified the models by sex and race (Table 3). For both males and females, DSI, not HI and VI, was associated with increased risk of mobility difficulty (males: HR=1.77, 95% CI: 1.03, 3.04; females: HR=3.26, 95% CI: 1.64, 6.47). In whites, DSI was associated with increased risk of mobility difficulty (HR=1.84, 95% CI: 1.07, 3.16). In Blacks, both VI (HR=2.30, 95% CI: 1.14, 4.67) and DSI (HR=3.38, 95% CI: 1.70, 6.70) were associated with increased risk of mobility difficulty. Supplementary Table 1 shows that the DSI increases risk of incident mobility difficulty (RR=1.94, 95% CI: 1.30, 2.90), but not in excess risk (RD=0.016, 95% CI: −0.020, 0.052), after covariate adjustment.

Table 3.

Associations of dual sensory impairment with incident mobility and ADL difficulty stratified by sex and race.

	Mobility Difficulty		ADL Difficulty
	Hazard Ratio	95% Confidence Interval	Hazard Ratio	95% Confidence Interval
*Sex Stratified Analyses*
Males Only (n=964)
No Hearing or Vision Impairment	REF	REF	REF	REF
Hearing Impairment Only	1.18	(0.71, 1.98)	1.02	(0.61, 1.72)
Vision Impairment Only	1.30	(0.68, 2.46)	1.16	(0.61, 2.20)
Dual Sensory Impairment	1.77	(1.03, 3.04)	1.79	(1.06, 3.04)
Females Only (n=1,008)
No Hearing or Vision Impairment	REF	REF	REF	REF
Hearing Impairment Only	1.19	(0.58, 2.44)	1.06	(0.53, 2.11)
Vision Impairment Only	1.98	(0.96, 4.07)	1.42	(0.69, 2.96)
Dual Sensory Impairment	3.26	(1.64, 6.47)	3.08	(1.62, 5.86)
*Race Stratified Analyses*
Whites Only (n=1,262)
No Hearing or Vision Impairment	REF	REF	REF	REF
Hearing Impairment Only	1.19	(0.71, 1.99)	1.15	(0.69, 1.92)
Vision Impairment Only	1.20	(0.61, 2.37)	0.99	(0.49, 2.01)
Dual Sensory Impairment	1.84	(1.07, 3.16)	2.02	(1.19, 3.43)
Blacks Only (n=702)
No Hearing or Vision Impairment	REF	REF	REF	REF
Hearing Impairment Only	1.30	(0.62, 2.69)	0.94	(0.45, 1.97)
Vision Impairment Only	2.31	(1.14, 4.67)	1.76	(0.88, 3.50)
Dual Sensory Impairment	3.38	(1.70, 6.70)	3.00	(1.57, 5.73)

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Note: All discrete-time Cox Proportional Hazards models with Efron ties were adjusted by the following covariates: baseline age, sex (female vs. male), race (Black vs. White), post-secondary education (attained vs. not), body mass index, history of diabetes and hypertension, clinically relevant depressive symptoms (10-item Center for Epidemiologic Studies – Depression Scale ≥8 vs. <8), Modified Mini Mental State Examination score, prevalent cardiovascular disease, and speed from 20-meter walk. All continuous covariates were mean-centered. Baseline was defined as four years since study initiation (Year 5). Bolded values indicate that the 95% confidence interval did not overlap with 1.0.

Incident ADL Difficulty.

In adjusted models, as compared to the other groups, DSI was associated with risk of incident ADL difficulty (HR=2.26, 95% CI: 1.50, 3.40) (Table 2). HI (HR=1.11, 95% CI: 0.73, 1.67) and VI (HR: 1.26, 95% CI: 0.78, 2.05) were not associated with incident ADL difficulty. The RERI was 0.89 (95% CI: 0.16, 1.62), and the SI was 3.39 (95% CI: −3.66, 10.44). The estimate of both HI and VI (HR=1.40, 95% CI: 0.30, 2.50) was less than the estimate for DSI (HR: 2.26), suggesting the presence of DSI contributed more risk than the two sensory impairments individually. After excluding prevalent dementia cases four years after study initiation, our inferences remained the same. DSI (HR=2.34, 95% CI: 1.53, 3.57), but not HI (HR=1.04, 95% CI: 0.68, 1.60) and VI (HR=1.21, 95% CI: 0.73, 2.01) was associated with increased risk of incident ADL difficulty. Adding hearing aid use to the model did not change inferences (Supplementary Table 2).

We evaluated the two-way interaction between HI and VI in a separate model, and the interaction term was not significant (HR=1.61, 95% CI: 0.91, 2.88). In this model, neither HI (HR=1.11, 95% CI: 0.73, 1.67) nor VI (HR=1.26, 95% CI: 0.78, 2.05) were associated with increased risk of incident ADL difficulty (Table 2).

When examining whether sex and race modified associations between DSI and ADL difficulty, there were no two-way interactions of sex and race with HI (sex: HR=1.05, 95% CI: 0.45, 2.44; race: HR=0.78, 95% CI: 0.32, 1.90), VI (sex: HR=1.35, 95% CI: 0.52, 3.53; race: HR=1.62, 95% CI: 0.61, 4.28), and DSI (sex: HR=1.62, 95% CI: 0.74, 3.53; race: HR=1.29, 95% CI: 0.59, 2.84) (Table 2). We then stratified the analyses by sex and race (Table 3). For males, DSI was associated with increased risk of incident ADL difficulty (HR=1.79, 95% CI: 1.06, 3.04), but HI and VI were not associated with incident ADL difficulty. For women, DSI (HR=3.08, 95% CI: 1.62, 5.86) was associated with increased risk of incident ADL difficulty. In whites, DSI was associated with increased risk of incident ADL difficulty (HR=2.02, 95% CI: 1.19, 3.43), while in Blacks, DSI (HR=3.00, 95% CI: 1.57, 5.73) was associated with increased risk of ADL difficulty. Supplementary Table 1 shows that DSI increases risk of incident mobility difficulty (RR=2.00, 95% CI: 1.36, 2.95), but not in excess risk (RD=0.004, 95% CI: −0.032, 0.039), after covariate adjustment.

Discussion

This study suggests that older adults with DSI have greater risk of mobility and ADL difficulty than those with a single impairment or no impairment. DSI was highly prevalent in this sample, with 23% of the sample having both HI and VI. The prevalence of DSI increases with age.^{34, 35} Sex and race did not modify associations between DSI and type of difficulty. While HI and VI separately have been noted to increase risk of difficulty^{12, 36}, those with DSI seemed to have a greater risk longitudinally. This work highlights that those with DSI are a potentially high-risk subgroup for incident risk of mobility and ADL difficulty, while those with individual impairments are not significantly higher risk than those without sensory impairments.

In this study, we examined the associations of DSI categories with risk of incident mobility and ADL difficulty among older adults. We found that DSI was associated with increased risk of mobility difficulty. Previous studies have reported that there is an increased risk of mobility difficulty among older adults with DSI, as compared to those without HI and VI, but these studies relied on self-reported HI and VI.^{37, 38} In contrast to our study design, one study was cross-sectional³⁷, while the other included one year of follow-up³⁸. Keller, Morton, Thomas and Potter³⁹ examined the estimated effects of HI and VI separately and together on overall functional status in a frail older patient population cross-sectionally and found that DSI had a greater estimated effect on poorer functional status than single sensory impairments.

Similar to results reported from Brennan, Su and Horowitz⁶, we found that DSI was associated with risk of incident ADL difficulty. In contrast to Brennan, Su and Horowitz⁶, we did not find associations with VI only and increased risk of ADL difficulty, which could have been due to the healthy aging sample. Additionally, there was a difference in study designs. Brennan et al. (2006) was a cross-sectional study, while ours was a longitudinal study that examined temporality.

Sex and race did not modify associations of DSI with incident mobility and ADL difficulty. Among males and females separately, DSI was associated with increased risk of incident mobility and ADL difficulty. In contrast to these findings, Jacob et al. (2017) found that there was an increased risk of incident difficulty in females, as compared to males. Additionally, two previous studies found that DSI was associated with greater risk of functional decline among older women, but these studies used data from two study visits.^{40, 41} One of the studies used self-reported measures, so these might not have precisely measured the impairments.⁴¹ Definitions of mobility and ADL difficulty differed between the two studies, as HABC definition required two consecutive reporting of difficulty rather than one. Blacks and whites did not differ in risk of incident mobility and ADL difficulty after covariate adjustment. After stratifying the sample by race, VI and DSI were associated with increased risk of incident mobility and ADL difficulty among Blacks, while DSI was associated with increased risk of incident mobility and ADL difficulty among whites.

The main strengths of the study were repeated measures on mobility and ADL difficulty among older adults for up to six years of observation from baseline and use of objective measures of hearing and vision. There were some limitations to our study. One limitation is the use of a healthier subset of the HABC cohort, thus limiting the generalizability of these findings. Also, our associations could be attenuated by those who died before reaching either endpoint (mobility or ADL difficulty). Other limitations include the sensory impairments being measured at two time points and the use of time-fixed sensory impairments. This could have led to some misclassification of sensory impairment, and we could not evaluate the change from normal to sensory impairment. The lack of significant results for HI could be related to shorter follow-up time, relative to that of VI, or it could be that HI may take more time to develop physical difficulties. In a previous HABC study, HI was associated with increased risk of incident mobility and ADL difficulty, but this study did not consider co-impairments of sensory function.²² In this present study, we found strong associations of DSI with increased risk of incident mobility and ADL difficulty. This warrants some caution for the lack of associations of single sensory impairments with these outcomes, as these estimates had wide and largely overlapping 95% confidence intervals. Additionally, there are several main, secondary, and sensitivity analyses, which may increase the risk of Type I error. The statistically significant findings should be interpreted with caution, and they warrant further investigation with the use of data from other cohort studies.

Given the high prevalence of DSI among older adults, few people who need them adopt hearing aids, due to costs and access to care, but this could be changing based on the 2017 OTC Hearing Aid Act to make hearing devices more readily available for public use. Besides hearing aids, cataract surgery may reduce falls⁴² and lower dementia incidence⁴³, since VI is an important risk factor of fall and injury. Each sensory impairment should be considered in the risk of incident mobility and ADL difficulty. Furthermore, audition and low vision rehabilitation, hearing aid use, and environmental modifications at home and in society can enhance mobility as people age with sensory impairments. Rehabilitation can introduce compensatory strategies, modifications in environment, and use of assistive tools if needed. These can promote better self-esteemed, self-confidence, postpone cognitive decline, leading to independent living for longer periods of time^{44, 45} and better quality of life⁴⁶. Additionally, previous studies have shown the link between mobility and ADL difficulty increasing risk of mortality among older adults^47–49, so modifying the onset of DSI may delay mobility and ADL difficulty, which in turn, could decrease the risk of mortality.

Supplementary Material

supinfo

Supplementary Table 1. Absolute and relative risk of incident mobility difficulty and difficulty of activities of daily living (ADL) as a function of dual sensory impairment (N=2020).

Supplementary Table 2. Association of dual sensory impairment with incident mobility and ADL difficulty after adjusting for hearing aid use (N=2020).

NIHMS1791439-supplement-supinfo.pdf^{(89.9KB, pdf)}

Key Points.

Dual sensory impairment (DSI) was associated with increased risk of mobility and ADL difficulty.
Vision impairment alone (VI) was not associated with risk of either outcome.
Hearing impairment alone (HI) was not associated with risk of either outcome.

Why does this matter?

Findings from this study suggest that dual sensory impairment is a risk factor for mobility and ADL difficulty. Recognition of dual sensory impairment as a risk factor that is prevalent among older adults may introduce rehabilitation and adaptive environmental changes to allow for more mobility and daily function.

Acknowledgments

We would like to thank the staff and participants of the Health Aging and Body Composition Study.

Funding:

This research was supported by National Institute on Aging (NIA) Contracts N01-AG-6-2101; R01-AG-6-2103; N01-AG-6-2106; NIA grant R01-AG028050, and NINR grant R01-NR012459. This research was funded in part by the Intramural Research Program of the NIH, National Institute on Aging. JAD was supported by NIH/NIA grant K01AG054693. WDB was supported by NIH/NIA K01AG062722.

Sponsor’s Role:

The authors’ sponsors had no role in the design, methods, data collection, analysis or preparation of this paper.

Footnotes

Note: Paper was presented at the annual Gerontological Society of America meeting in 2021 as a late-breaking poster presentation.

Conflicts of Interest: Frank R. Lin is a consultant to Frequency Therapeutics, received speaker honoraria from Caption Call, and director of the Cochlear Center for Hearing and Public Health—a public health research center funded in part by a philanthropic gift from Cochlear Ltd to the Johns Hopkins Bloomberg School of Public Health. All other authors have nothing additional to disclose.

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Associated Data

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

Supplementary Materials

supinfo

Supplementary Table 1. Absolute and relative risk of incident mobility difficulty and difficulty of activities of daily living (ADL) as a function of dual sensory impairment (N=2020).

Supplementary Table 2. Association of dual sensory impairment with incident mobility and ADL difficulty after adjusting for hearing aid use (N=2020).

NIHMS1791439-supplement-supinfo.pdf^{(89.9KB, pdf)}

[R1] 1.Wan H, Larsen LJ. Older Americans With a Disability: 2008–2012. vol U.S. Census Bureau, American Community Survey Reports. ACS-29. 2014. [Google Scholar]

[R2] 2.Zhao G, Okoro CA, Hsia J, Garvin WS, Town M. Prevalence of disability and disability types by urban–rural county classification—U.S., 2016. Am J Prev Med. 2019/December/01/ 2019;57(6):749–756. doi: 10.1016/j.amepre.2019.07.022 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R3] 3.Gobbens RJ, van Assen MA. The prediction of quality of life by physical, psychological and social components of frailty in community-dwelling older people. Qual Life Res. Oct 2014;23(8):2289–300. doi: 10.1007/s11136-014-0672-1 [DOI] [PubMed] [Google Scholar]

[R4] 4.Armstrong NM, Wang H, E J-Y, et al. Patterns of prevalence of multiple sensory impairments among community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2021;doi: 10.1093/gerona/glab294 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R5] 5.Swenor BK, Ramulu PY, Willis JR, Friedman D, Lin FR. The prevalence of concurrent hearing and vision impairment in the United States. JAMA Internal Medicine. 2013;173(4):312–313. doi: 10.1001/jamainternmed.2013.1880 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R6] 6.Brennan M, Su YP, Horowitz A. Longitudinal associations between dual sensory impairment and everyday competence among older adults. J Rehabil Res Dev. Sep-Oct 2006;43(6):777–92. doi: 10.1682/jrrd.2005.06.0109 [DOI] [PubMed] [Google Scholar]

[R7] 7.Saunders GH, Echt KV. An Overview of Dual Sensory Impairment in Older Adults: Perspectives for Rehabilitation. Trends in Amplification. 2007;11(4):243–258. doi: 10.1177/1084713807308365 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R8] 8.Loprinzi PD, Smit E, Lin FR, Gilham B, Ramulu PY. Accelerometer-assessed physical activity and objectively determined dual sensory impairment in US adults. Mayo Clin Proc. 2013/July/01/ 2013;88(7):690–696. doi: 10.1016/j.mayocp.2013.04.008 [DOI] [PubMed] [Google Scholar]

[R9] 9.Davidson JGS, Guthrie DM. Older adults with a combination of vision and hearing impairment experience higher rates of cognitive impairment, functional dependence, and worse outcomes across a set of quality indicators. Journal of Aging and Health. 2019/January/01 2017;31(1):85–108. doi: 10.1177/0898264317723407 [DOI] [PubMed] [Google Scholar]

[R10] 10.Mudie L, Varadaraj V, Gajwani P, et al. Dual sensory impairment: the association between glaucomatous vision loss and hearing impairment and function. PLoS One. 2018;13(7):e0199889. doi: 10.1371/journal.pone.0199889 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R11] 11.Swanson MW, McGwin G. Visual impairment and functional status from the 1995 National Health Interview Survey on Disability. Ophthalmic Epidemiol. Jul 2004;11(3):227–39. doi: 10.1080/09286580490514540 [DOI] [PubMed] [Google Scholar]

[R12] 12.Swenor BK, Simonsick EM, Ferrucci L, et al. Visual impairment and incident mobility limitations: the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2015;63(1):46–54. doi: 10.1111/jgs.13183 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R13] 13.Vitale S, Cotch MF, Sperduto RD. Prevalence of visual impairment in the United States. JAMA. 2006;295(18):2158–2163. doi: 10.1001/jama.295.18.2158 [DOI] [PubMed] [Google Scholar]

[R14] 14.Goman AM, Lin FR. Prevalence of hearing loss by severity in the United States. Am J Public Health. 2016;106(10):1820–1822. [DOI] [PMC free article] [PubMed] [Google Scholar]

[R15] 15.Cunningham LL, Tucci DL. Hearing loss in adults. N Engl J Med. Dec 21 2017;377(25):2465–2473. doi: 10.1056/NEJMra1616601 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R16] 16.Zhan W, Cruickshanks KJ, Klein BE, et al. Generational differences in the prevalence of hearing impairment in older adults. Am J Epidemiol. Jan 15 2010;171(2):260–6. doi: 10.1093/aje/kwp370 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R17] 17.Chen DS, Betz J, Yaffe K, et al. Association of hearing impairment with declines in physical functioning and the risk of disability in older adults. J Gerontol A Biol Sci Med Sci. May 2015;70(5):654–61. doi: 10.1093/gerona/glu207 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R18] 18.Simonsick EM, Newman AB, Nevitt MC, et al. Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the Health ABC Study. J Gerontol A Biol Sci Med Sci. Oct 2001;56(10):M644–9. doi: 10.1093/gerona/56.10.m644 [DOI] [PubMed] [Google Scholar]

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PERMALINK

Associations of Dual Sensory Impairment with Incident Mobility and ADL Difficulty

Nicole M Armstrong, PhD

Camila Vieira Ligo Teixeira, PhD

Colby Gendron

Willa D Brenowitz, PhD, MPH

Frank R Lin, MD, PhD

Bonnelin Swenor, PhD

Jennifer A Deal, PhD

Eleanor M Simonsick, PhD

Richard N Jones, ScD

Abstract

Background:

Methods:

Results:

Conclusions:

Introduction

Methods

Characteristics of the Study Sample

Sensory Impairment

Hearing impairment.

Vision impairment.

Dual sensory impairment.

Incident Mobility and ADL Difficulty

Adjustment Covariates

Statistical Analysis

Results

Sample Characteristics

Table 1.

Figure 1. Nelson-Aalen plots for both incident mobility difficulty and difficulty of activities of daily living (ADL) as a function of dual sensory impairment, single sensory impairment, and no hearing and vision impairment.

Association of Dual Sensory Impairment with Risk of Incident Difficulty

Incident Mobility Difficulty.

Table 2.

Table 3.

Incident ADL Difficulty.

Discussion

Supplementary Material

Key Points.

Why does this matter?

Acknowledgments

Funding:

Sponsor’s Role:

Footnotes

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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