Abstract
Background
Much is known about individual sensory deficits among older adults, but there is a dearth of information about the prevalence of multiple concurrent sensory deficits in this population.
Methods
We evaluated the prevalence of individual and multiple sensory impairments at the most recent clinic visit among participants aged 24 years and older in the Baltimore Longitudinal Study of Aging (BLSA) (hearing, vision, olfaction, proprioception, and vestibular function) and Atherosclerosis Risk in Communities Study (ARIC) (hearing, vision, olfaction). We compared observed prevalence of multiple sensory impairments with expected prevalence based on compounded probabilities of multiple impairments using Fisher Exact Tests. Also, we evaluated the comparability of different measures used between these two studies.
Results
In both studies, the prevalence of each individual sensory impairment was common (>10%), and higher with older age, and the most common pattern of co-occurring sensory impairments was hearing and visual impairments (17.4% [BLSA]; 50.2% [ARIC]). In BLSA, the pattern that differed the most between observed and expected prevalence was combined hearing, vision, and olfactory impairments (observed 5.2% vs 1.4% expected, p = .01). In ARIC, this difference was much smaller (observed 8.1% vs 7.2% expected, p = .49).
Conclusions
Although concurrent hearing and vision impairments were the most common co-occurring deficits, combined hearing, vision, and olfactory impairments are most likely to co-occur above chance, especially at older ages.
Keywords: Hearing, Older adults, Olfaction, Proprioception, Sensory impairment, Vestibular function, Vision
Individual impairments in sensory systems, for example, hearing, vision, olfaction, vestibular function, and proprioception, are highly prevalent in older U.S. adults (1–3). Hearing impairment is prevalent in an estimated two-thirds of adults aged 70 years and older (1–3). Vision impairment, due to an uncorrected refractive error, is prevalent in 59.5% of adults aged 60 years and older (4). The prevalence of olfactory impairment is 25% among adults aged 53–97 years (5). The prevalence of vestibular impairment in healthy older adults aged 26–92 years is estimated to be 50% (6–8). Deficits in proprioception have been estimated to occur in a third of older adults (9,10). Deficits in these individual sensory systems are associated with adverse health outcomes, for example, mobility disability and dementia (11–16).
The prevalence of the different sensory deficits differs by sex and race, and increases with age (9,17–19). Correia et al. (18) found that men were more likely to have 3 or more sensory impairments than women across all ages. Hearing impairment is more prevalent in men than women, due to a hypothesized protective effect of estradiol in women prior to onset of menopause (20). There could also be social factors that contribute to hearing impairment, that is, differences in job-related exposures between men and women. The prevalence of visual impairment is higher in older women than men across all ages (21,22). Race may also affect the prevalence of sensory deficits. Blacks have been shown to have a lower prevalence of hearing and vestibular impairment across the age range (6,23), with darker skin pigmentation associated with a lower prevalence of hearing impairment. Non-Hispanic whites have a high prevalence of visual impairment, as compared to African American, Asians, and Hispanic individuals (22). Odor identification (olfaction) worsens with age, often in older men, but there are no known racial differences in olfaction impairment (13).
Although previous studies have evaluated individual sensory deficits, there are gaps in the literature examining patterns of prevalence of multiple sensory deficits. Correia et al. (2016) reported that two-thirds of community-dwelling older adults aged 57–85 years had 2 or more sensory deficits. Liljas et al. (19) found that multiple sensory impairments were linked to poorer quality of life and greater odds of depressive symptoms. Older home care clients with combined vision, hearing, and cognitive impairments had the highest rates of functional impairments and difficulties with communication, as compared to those with only cognitive impairment (24). Furthermore, previous findings from the Baltimore Longitudinal Study of Aging (BLSA) suggest that multiple sensory impairments may influence physical performance in older adults aged 70–79 years (9). However, a definitive understanding of the prevalence and impact of multiple sensory deficits in older adults is lacking, given the sparse literature on this topic. Heterogeneity in assessing sensory function and defining impairment has limited comparison across studies. Therefore, we are focused on establishing patterns of prevalence among multiple sensory impairments across 2 studies.
The present study expands upon previous work conducted in the BLSA (9), by broadening the number of sensory systems to include vision, hearing, olfaction, proprioception, and vestibular function and defining each sensory impairment more comprehensively (eg, considering multiple aspects of visual function including acuity, contrast sensitivity, visual fields, and stereoacuity). To do this, we first calculated the overall prevalence of each sensory impairment and combinations of multiple sensory impairments, using standard thresholds, in each study. Then, we evaluated the patterns of sensory deficits by age decade, sex, and race. We also explored a comparison of the prevalence of multiple sensory impairment between the BLSA and the Arthrosclerosis Risk In Communities (ARIC) Study, a more racially diverse cohort with a greater burden of morbidity than the BLSA. By doing this, we attempted to generalize our findings to community-dwelling older U.S. adults.
Method
Study Participants
For this cross-sectional study, we used the most recent visit for all sensory measures embedded within the prospective cohort studies. For BLSA, visits were conducted between December, 2015 and December, 2018. There were 420 community-dwelling adults who completed all sensory assessments (hearing, vision, olfaction, vestibular function, proprioception) at their most recent BLSA visit. Participants ranged from 24 to 96 years of age. About 56% of the sample was female, and 62.4% of the sample was White (Table 1).
Table 1.
Proportions of Any Sensory Impairment in the Baltimore Longitudinal Study of Aging by Age, Sex, and Race (N = 420)
| Sensory System | Overall (N = 420) | Age < 60 (n = 92) | Age 60–69 (n = 87) | Age 70–79 (n = 133) | Age ≥80 (n = 108) | p-value for the Difference | Female (n = 235) | Male (n = 185) | p-value for the Difference | White (n = 262) | Black (n = 125) | p-value for the Difference |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Hearing | 171 (40.7) | 5 (5.4) | 21 (24.1) | 56 (42.1) | 89 (82.4) | <.001 | 75 (31.9) | 96 (51.9) | <.001 | 124 (47.3) | 38 (30.4) | .002 |
| Vision | 128 (30.5) | 9 (9.8) | 19 (21.8) | 40 (30.1) | 60 (55.6) | <.001 | 70 (29.8) | 58 (31.4) | .81 | 83 (31.7) | 34 (27.2) | .44 |
| Olfaction | 62 (14.8) | 2 (2.2) | 7 (8.0) | 24 (18.0) | 29 (26.9) | <.001 | 27 (11.5) | 35 (18.9) | .046 | 30 (11.5) | 21 (16.8) | .20 |
| Vestibular | 69 (16.4) | 1 (1.1) | 8 (9.2) | 24 (18.0) | 36 (33.3) | <.001 | 37 (15.7) | 32 (17.3) | .77 | 44 (16.8) | 18 (14.4) | .65 |
| Proprioception | 42 (10.0) | 4 (4.3) | 3 (3.4) | 9 (6.8) | 26 (24.1) | <.001 | 20 (8.5) | 22 (11.9) | .33 | 26 (9.9) | 13 (10.4) | 1.00 |
Notes: Definition of sensory impairments for BLSA: 1) vision (VS): a) presenting visual acuity: logMAR units >0.30; b) contrast sensitivity: log_CS (Pelli-Robson bilaterally) <1.55; c) visual field: >1 standard deviation of population mean score out of 96 points; d) stereo acuity: value>80; 2) hearing (H): pure-tone average >25 decibels of hearing level; 3) Olfaction (SML): Sniffin’ Sticks score ≤8 (Test A) or 7 (Test B); 4) Vestibular function (VES): a) cervical vestibular-evoked myogenic potential being bilaterally absent; b) mean vestibulo-ocular reflex < 0.7; 5) Proprioception (P): threshold for perception of passive movement > 2.2 degrees. Values represent a proportion (percentage).
For ARIC, we used data from Visit 6 from the overall cohort and data from the Eye Determinants of Cognition (EyeDOC) Study, a study nested within ARIC, to determine whether the patterns of sensory deficits for hearing, vision, and olfaction were similar to those in the BLSA. Of note, vestibular function and proprioception are not assessed in ARIC. Sensory function data were obtained at 2 of the ARIC sites (Washington County, Maryland and Jackson, Mississippi). There were 963 participants aged 71–93 years who completed all 3 sensory measures (hearing, vision, and olfaction) at their most recent study visit between June, 2016 and December, 2017. Approximately 62.8% of the sample was female, and about 56.2% of the sample was White.
Local institutional review boards approved the research protocol for each study. Written informed consent was obtained at each visit from all participants from both studies.
Sensory Assessments in the Baltimore Longitudinal Study of Aging
Hearing impairment
Pure-tone audiometric testing, a measure of the peripheral auditory system sensitivity (25), was conducted by a trained technician using insert earphones and with an Interacoustics AD-629 audiometer in a sound-attenuating booth. A speech-frequency pure-tone average (PTA) of air-conduction thresholds at 0.5, 1, 2, and 4 kHz was calculated for each ear. All thresholds were measured in decibel of hearing level (dB HL). Hearing was defined by the PTA > 25 dB HL in the better-hearing ear in accordance with World Health Organization guidelines.
Visual impairment
A composite visual impairment variable was defined as having any impairment on the following 4 tests: visual acuity, visual field, contrast sensitivity, and stereo acuity. Presenting, better-eye visual acuity was calculated using the early treatment of diabetic retinopathy study (ETDRS) chart by the lines where the participant could correctly read at least 3 out of 5 letters. Best-corrected visual acuity was also determined based on autorefractor data. Impaired visual acuity was defined as presenting visual acuity worse than 20/40 (26–28).
Impaired visual field was defined by greater than one standard deviation of the population mean score out of 96 points on the bilateral visual field test (29,30). Monocular visual fields were measured before binocular visual fields (29). Impaired contrast sensitivity was defined as log of the contrast units < 1.55 based on previous population-based studies of older adults ≥60 years, and it was measured using a Pelli-Robson chart to assess the ability to discern shades binocularly (31,32). Impaired stereo acuity was defined as the value >80 arcseconds on the Randot Stereo Test that assesses the minimum depth differential that the participant could see (12).
Impaired vestibular function
Vestibular function was assessed in 2 ways: using the cervical vestibular-evoked myogenic potential (cVEMP) for measurement of otolith (saccular) function and vestibulo-ocular reflex (VOR) gain for semicircular function, per published procedures in the BLSA (6,7). Impaired saccular function was defined by cVEMP being bilaterally absent. Impaired semicircular canal function was defined as a mean VOR gain <0.7. Both thresholds are clinical cutpoints. Impaired vestibular function was defined as impairment of either saccular function or semicircular canal function.
Impaired proprioception
Proprioception, in which a person judges the location of one foot in space relative to another, was measured as the threshold for perception of passive ankle movement (TPPM) (10,33). A total of 4 trials was performed in a set sequence of plantarflexion, dorsiflexion, dorsiflexion, and plantarflexion. TPPM was the average of the best plantarflexion and dorsiflexion. Impairment was defined as TPPM >2.2°, based on previously established thresholds in older adults (33).
Impaired olfaction
Olfaction was tested from the 16-item Sniffin’ Sticks Odor Identification Test (34,35). Two versions of this odor identification test were randomly administered at the initial olfaction administration to minimize potential learning effect over time. To be consistent with previous literature, we defined impaired olfaction, that is, anosmia, as <10th percentile on each test version in the BLSA sample. For Test A and B, scores of 8 and 7, respectively were at the 10th percentile. However, given that a number of participants had a score ≤8 on Test A (30 out of 208) and a score ≤7 on Test B (32 out of 212), the prevalence of participants scoring at the 10th percentile or below on both tests was 14.8% (higher than 10%). Twenty-two participants were not administered this test.
Sensory Assessments in the ARIC Study
Hearing impairment
PTA conduction audiometry was conducted in a sound-treated booth at Visit 6 (2016-17) (11,36). Air conduction thresholds in each ear were obtained at standard octaves from 0.5 kHz to 8 kHz by trained technicians using insert and an Interacoustics AD629 audiometer. PTA was calculated using 4 frequencies (0.5, 1, 2, and 4 kHz) in the better hearing ear. Hearing was defined by the PTA > 25 dB HL in the better-hearing ear, in line with the BLSA.
Visual impairment
Vision was defined as a composite of visual acuity and contrast sensitivity. Visual Acuity was measured at distance by having participants read letters from a backlit ETDRS chart using their normal refractive correction (if any). Eyes with a better presenting visual acuity of 20/40 or worse underwent subjective refraction with trial lenses to determine best-corrected visual acuity (14,26–28). Impaired presenting visual acuity was defined as logMAR units greater than 0.30 (ie, worse than 20/40), in line with the BLSA. Contrast sensitivity was evaluated using the MARS chart with participants wearing their presenting correction (37). Impaired contrast sensitivity was defined as log_CS (MARS unilaterally) <1.48, based on published thresholds (38).
Impaired olfaction
Olfaction was tested from the 12-item Sniffin’ Sticks Odor Identification Test, which is an abbreviated format of the 16-item Sniffin’ Sticks Odor Identification Test used in the BLSA (39). Olfactory impairment was defined as a score ≤6, based on published thresholds for the 12-item version of this test (40).
Statistical Analyses
We evaluated the proportion of each type of sensory impairment and the proportion of individuals with multiple (2–5) concurrent sensory impairments across age categories in participants (≤50, 60-69, 70-79, 80+ years). Participants were categorized into specific multiple sensory impairment categories, for example, hearing and vision impairment, without mutually exclusive categories. We compared the observed prevalence of multiple sensory impairment with the expected prevalence based on multiplying the prevalence of individual sensory impairments under the assumption of independence for the overall sample and by age decade, race, and sex. In both studies, birthdate, sex, and race were self-reported. Age at visit was calculated based on the difference between visit date and birthdate. Fisher’s exact tests were used to calculate the significance between observed and expected prevalence within each group. In supplement, we included the proportions of hypertension, diabetes, obesity, and current smoking status in the BLSA and ARIC. Definitions for these variables are in Supplementary Tables 1and 2. Significance was determined by p < .05. Analyses were done in R v-3.6.2 (41).
Sensitivity Analyses
We performed several sensitivity analyses to explore alternate definitions of sensory impairments, and also to make the BLSA and ARIC cohorts more comparable by age. First, we compared presenting versus best-corrected visual acuity in the BLSA and ARIC. Second, we created a more limited definition of visual impairment in the BLSA using only visual acuity and contrast sensitivity to make the definition comparable to the measures used in the ARIC study. Third, given the different age distribution in the 2 cohorts (age range 24–96 in BLSA vs 71–93 in ARIC), we used direct age standardization to calculate the prevalence of impairment controlling for differences in age distribution. In the direct age standardization, we generated the weighted average of the age-specific rates. We present these results in the Supplementary Material.
Results
Any Sensory Impairment in the Baltimore Longitudinal Study of Aging
Table 1 shows the prevalence of sensory impairments for the overall BLSA sample (N = 420) as well as by age decade. In the overall sample, 40.7% had hearing impairment, 30.5% had visual impairment, 16.4% had vestibular impairment, 10.0% had impaired proprioception, and 14.8% had olfactory impairment. The prevalence of each sensory impairment was higher with each decade of age, with those aged ≥80 years having significantly higher prevalence of all sensory deficits. Males and white participants had a significantly higher prevalence of hearing impairment relative to females and black participants, respectively (Table 1). The proportions for hypertension, diabetes, current smoking status, and obesity by type of sensory impairment for the BLSA and ARIC studies for additional information on sample characteristics for the future study of potential mechanisms are available in Supplementary Tables 1 and 2.
Multiple Sensory Impairments Within Baltimore Longitudinal Study of Aging
Table 2 shows the prevalence of 2 or more sensory impairments for the overall sample and by age decade. Table 3 shows the prevalence of 1–5 sensory impairments by sex and by race. Dual sensory impairment of combined hearing and visual impairment had the highest prevalence (17.4%). Other dual sensory prevalence estimates were below 10%. However, among participants age ≥ 80, the prevalence of all dual sensory impairments was high, reaching 45.4% for hearing and vision impairment, and above 20% for hearing and vestibular impairment; hearing and olfactory impairment; and vestibular and visual impairment. The observed prevalence of multiple impairments increased significantly by age decade across all available combinations (Table 2).
Table 2.
Proportions of Combined Sensory Impairments in the Baltimore Longitudinal Study of Aging by Age Decade (N = 420)
| Age Decades in Years | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall (N = 420) | <60 (N = 92) | 60–69 (N = 87) | 70–79 (N = 133) | ≥80 (N = 108) | ||||||||
| Number of Impairments | Sensory System | Observed N (%) | Expected N (%), p-value | Observed N (%) | Expected N (%), p-value |
Observed N (%) | Expected N (%), p-value |
Observed N (%) | Expected N (%), p-value |
Observed N (%) | Expected N (%), p-value | p-value Across Ages |
| Two or more | H + VES | 39 (9.3) | 28.1 (6.7), .2 | 0 (0) | 0 (0), 1 | 1 (1.1) | 1.9 (2.2), 1 | 9 (6.8) | 10.1 (7.6), 1 | 29 (26.9) | 29.7 (27.5), 1 | <.001 |
| H + VS | 73 (17.4) | 52.1 (12.4), .05. | 1 (1.1) | 0 (0), 1 | 4 (4.6) | 4.6 (5.3), 1 | 19 (14.3) | 16.8 (12.7), .86 | 49 (45.4) | 49.4 (45.8), 1 | <.001 | |
| H + P | 23 (5.5) | 17.1 (4.1), .42 | 0 (0) | 0 (0), 1 | 0 (0) | 0.7 (0.8), 1 | 3 (2.3) | 3.8 (2.8), 1 | 20 (18.5) | 21.4 (19.8), 1 | <.001 | |
| H + SML | 40 (9.5) | 25.2 (6.0), .07. | 0 (0) | 0 (0), 1 | 3 (3.4) | 1.69 (1.9), 1 | 12 (9.0) | 10.1 (7.6), .82 | 25 (23.1) | 23.9 (22.1), 1 | <.001 | |
| VES + VS | 32 (7.6) | 21 (5.0), .16 | 0 (0) | 0 (0), 1 | 0 (0) | 1.75 (2.0), .5 | 9 (6.8) | 7.2 (5.4), .8 | 23 (21.3) | 20 (18.5), .61 | <.001 | |
| VES + P | 13 (3.1) | 6.9 (1.6), .26 | 0 (0) | 0 (0), 1 | 0 (0) | 0.3 (0.3), 1 | 1 (0.8) | 1.6 (1.2), 1 | 12 (11.1) | 8.7 (8.0), .45 | <.001 | |
| VES + SML | 18 (4.3) | 10.2 (2.4), .18 | 0 (0) | 0 (0), 1 | 1 (1.1) | 0.6 (0.7), 1 | 7 (5.3) | 4.3 (3.3), .54 | 10 (9.3) | 9.7 (9.0), .94 | .003 | |
| VS + P | 20 (4.8) | 12.8 (3.0), .29 | 0 (0) | 0 (0), 1 | 1 (1.1) | 0.7 (0.8), 1 | 2 (1.5) | 2.7 (2.0), 1 | 17 (15.7) | 14.4 (13.4), .62 | <.001 | |
| VS + SML | 32 (7.6) | 18.9 (4.5), .08. | 0 (0) | 0 (0), 1 | 0 (0) | 1.5 (1.8), .5 | 12 (9.0) | 7.2 (5.4), .34 | 20 (18.5) | 16.1 (14.9), .48 | <.001 | |
| P + SML | 10 (2.4) | 6.2 (1.5), .45 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 1 (0.8) | 1.6 (1.2), 1 | 9 (8.3) | 7 (6.5), .6 | <.001 | |
| Three or more | H+VES+VS | 21 (5.0) | 8.6 (2.0), .04* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 3 (2.3) | 3 (2.3), 1 | 18 (16.7) | 16.5 (15.3), .78 | <.001 |
| H+VES+P | 9 (2.1) | 2.8 (0.7), .14 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0.68 (0.5), 1 | 9 (8.3) | 7.1 (6.6), .62 | <.001 | |
| H+VES+SML | 12 (2.9) | 4.2 (1.0), .07. | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 4 (3.0) | 1.8 (1.4), .68 | 8 (7.4) | 8 (7.4), 1 | .003 | |
| H+VS+P | 14 (3.3) | 5.2 (1.2), .06. | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 1.1 (0.9), 1 | 14 (13.0) | 11.9 (11.0), .66 | <.001 | |
| H+VS+SML | 22 (5.2) | 7.7 (1.8), .01* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 6 (4.5) | 3 (2.3), .5 | 16 (14.8) | 13.3 (12.3), .59 | <.001 | |
| H+P+SML | 8 (1.9) | 2.5 (0.6), .11 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0.68 (0.5), 1 | 8 (7.4) | 5.8 (5.3), .54 | <.001 | |
| VES+VS+P | 10 (2.4) | 2.1 (0.5), .04* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0.49 (0.37), 1 | 10 (9.3) | 4.8 (4.5), .16 | <.001 | |
| VES+VS+SML | 12 (2.9) | 3.1 (0.7), .03* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 4 (3.0) | 1.3 (1.0), .37 | 8 (7.4) | 5.4 (5.0), .46 | .003 | |
| VES+P+SML | 5 (1.2) | 1.0 (0.2), .22 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0.3 (0.2), 1 | 5 (4.6) | 2.3 (2.2), .31 | .002 | |
| VS+P+SML | 8 (1.9) | 1.9 (0.4), .11 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 1 (0.8) | 0.49 (0.37), 1 | 7 (6.5) | 3.9 (3.6), .33 | .001 | |
| Four or more | H+VES+VS+P | 8 (1.9) | 0.86 (0.2), .04* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0.21 (0.15), 1 | 8 (7.4) | 4 (3.7), .23 | <.001 |
| H+VES+VS+SML | 8 (1.9) | 1.3 (0.3), .04* | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 2 (1.5) | 0.55 (0.4), 1 | 6 (5.6) | 4.4 (4.1), .62 | .013 | |
| H+VES+P+SML | 4 (1.0) | 0.41 (0.1), .12 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 4 (3.7) | 1.9 (1.8), .38 | .008 | |
| H+VS+P+SML | 6 (1.4) | 0.77 (0.2), .12 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 6 (5.6) | 3.2 (3.0), .35 | <.001 | |
| VES+VS+P+SML | 5 (1.2) | 0.31 (0.07), .06. | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 5 (4.6) | 1.3 (1.2), .13 | .002 | |
| Five | H+VES+VS+P+SML | 4 (1.0) | 0.13 (0.03), .12 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 0 (0) | 0 (0), 1 | 4 (3.7) | 1.1 (1.0), .19 | .008 |
Notes: Fisher’s exact tests were used to calculate the significance between observed and expected prevalence within each group. Bolded and starred values indicate significance between observed and expected prevalence at p < .05 as well as observed significance across ages at p < .05. Expected value was calculated by combining prevalence estimates. Values represent a proportion (percentage).
Definition of sensory impairments for BLSA: 1) vision (VS): a) better presenting visual acuity: logMAR units >0.30; b) contrast sensitivity: log_CS (Pelli-Robson bilaterally) <1.55; c) visual field: >1 standard deviation of population mean score out of 96 points; d) stereo acuity: value>80; 2) hearing (H): pure-tone average >25 decibels of hearing level; 3) Olfaction (SML): Sniffin’ Sticks score ≤8 (Test A) or 7 (Test B); 4) Vestibular function (VES): a) cervical vestibular-evoked myogenic potential being bilaterally absent; b) mean vestibulo-ocular reflex < 0.7; 5) Proprioception (P): threshold for perception of passive movement > 2.2 degrees.
Table 3.
Proportions of Combined Sensory Impairments in the Baltimore Longitudinal Study of Aging by Sex and Race (N = 420)
| Female (N = 235) | Male (N = 185) | White (N = 262) | Black (N = 125) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of Impairments | Sensory System | Observed N (%) | Expected N (%), p-value | Observed N (%) | Expected N (%), p-value | p-value Between Sexes | Observed N (%) | Expected N (%), p-value | Observed N (%) | Expected N (%), p-value | p-value Between Races |
| At least two | H + VES | 19 (8.1) | 11.8 (5.0), .26 | 20 (10.8) | 16.6 (9.0), .73 | .43 | 29 (11.1) | 20.8 (7.9), .3 | 8 (6.4) | 5.5 (4.4), .6 | .2 |
| H + VS | 32 (13.6) | 22.3 (9.5), .19 | 41 (22.2) | 30 (16.3), .19 | .03 | 55 (21.0) | 39.3 (15.0), .09. | 15 (12.0) | 10.3 (8.3), .4 | .045 | |
| H + P | 11 (4.7) | 6.4 (2.7), .32 | 12 (6.5) | 11.4 (6.2), 1 | .55 | 16 (6.1) | 12.3 (4.7), .56 | 5 (4.0) | 4 (3.2), 1 | .54 | |
| H + SML | 16 (6.8) | 8.6 (3.7), .22 | 24 (13.0) | 18.2 (9.8), .41 | .05 | 25 (9.5) | 14.2 (5.4), .09. | 11 (8.8) | 6.4 (5.1), .32 | .96 | |
| VES + VS | 18 (7.7) | 11 (4.7), .25 | 14 (7.6) | 10 (5.4), .53 | 1 | 21 (8.0) | 14 (5.3), .29 | 8 (6.4) | 4.9 (3.9), .57 | .72 | |
| VES + P | 6 (2.6) | 3.1 (1.3), .5 | 7 (3.8) | 3.8 (2.1), .54 | .66 | 10 (3.8) | 4.4 (1.7), .17 | 2 (1.6) | 1.9 (1.5), 1 | .35 | |
| VES + SML | 10 (4.3) | 4.3 (1.8), .17 | 8 (4.3) | 6.1 (3.3), .79 | 1 | 8 (3.1) | 4.3 (1.6), .38 | 6 (4.8) | 3 (2.4), .5 | .39 | |
| VS + P | 10 (4.3) | 6 (2.5), .45 | 10 (5.4) | 6.9 (3.7), .62 | 1 | 12 (4.6) | 8.2 (3.1), .5 | 7 (5.6) | 3.54 (2.8), .54 | .86 | |
| VS + SML | 14 (6.0) | 8 (3.4), .27 | 18 (9.7) | 11 (5.9), .25 | .21 | 15 (5.7) | 9.5 (3.6), .41 | 12 (9.6) | 5.7 (4.6), .22 | .24 | |
| P + SML | 4 (1.7) | 2.3 (1.0), .69 | 6 (3.2) | 4.2 (2.2), .75 | .35 | 6 (2.3) | 3 (1.1), .5 | 3 (2.4) | 2.2 (1.7), 1 | 1 | |
| At least three | H+VES+VS | 11 (4.7) | 3.5 (1.5), .07. | 10 (5.4) | 5.2 (2.8), .29 | .82 | 17 (6.5) | 6.6 (2.5), .06. | 4 (3.2) | 1.49 (1.2), .37 | .27 |
| H+VES+P | 5 (2.1) | 1 (0.4), .22 | 4 (2.2) | 2 (1.1), .68 | 1 | 7 (2.7) | 2.1 (0.8), .18 | 2 (1.6) | 0.6 (0.5), 1 | .72 | |
| H+VES+SML | 6 (2.6) | 1.4 (0.6), .12 | 6 (3.2) | 3.1 (1.7), .5 | .77 | 6 (2.3) | 2.4 (0.9), .29 | 4 (3.2) | 0.9 (0.7), .37 | .73 | |
| H+VS+P | 6 (2.6) | 1.9 (0.8), .28 | 8 (4.3) | 3.6 (1.9), .38 | .41 | 10 (3.8) | 3.9 (1.5), .17 | 4 (3.2) | 1.1 (0.9), .37 | 1 | |
| H+VS+SML | 8 (3.4) | 2.6 (1.1), .22 | 14 (7.6) | 5.7 (1.9), .11 | .08. | 13 (5.0) | 3.9 (1.5), .045 | 7 (5.6) | 1.7 (1.4), .17 | .81 | |
| H+P+SML | 3 (1.3) | 0.7 (0.3), .62 | 5 (2.7) | 2.2 (1.2), .45 | .31 | 6 (2.3) | 1.4 (0.5), .12 | 2 (1.6) | 0.7 (0.5), 1 | 1 | |
| VES+VS+P | 6 (2.6) | 0.9 (0.4), .12 | 4 (2.2) | 1.2 (0.6), .37 | 1 | 7 (2.7) | 1.4 (0.5), .07. | 2 (1.6) | 0.51 (0.4), 1 | .72 | |
| VES+VS+SML | 6 (2.6) | 1.3 (0.5), .12 | 6 (3.2) | 1.9 (1.0), .28 | .77 | 6 (2.3) | 1.6 (0.6), .29 | 5 (4.0) | 0.8 (0.7), .21 | .34 | |
| VES+P+SML | 2 (0.85) | 0.4 (0.2), .5 | 3 (1.6) | 0.7 (0.4), .62 | .66 | 3 (1.1) | 0.5 (0.2), .25 | 1 (0.8) | 0.3 (0.25), 1 | 1 | |
| VS+P+SML | 3 (1.3) | 0.7 (0.3), .62 | 5 (2.7) | 1.3 (0.7), .21 | .31 | 4 (1.5) | 0.9 (0.4), .37 | 3 (2.4) | 0.6 (0.5), .62 | .69 | |
| At least four | H+VES+VS+P | 5 (2.1) | 0.3 (0.1), .06. | 3 (1.6) | 0.6 (0.3), .62 | 1 | 6 (2.3) | 0.7 (0.2), .12 | 2 (1.6) | 0.2 (0.1), .5 | 1 |
| H+VES+VS+SML | 4 (1.7) | 0.4 (0.2), .12 | 4 (2.2) | 1 (0.5), .37 | .74 | 5 (1.9) | 0.8 (0.3), .22 | 3 (2.4) | 0.25 (0.2), .25 | .72 | |
| H+VES+P+SML | 2 (0.85) | 0.1 (0.05), .5 | 2 (1.1) | 0.4 (0.2), .5 | 1 | 3 (1.1) | 0.2 (0.09), .25 | 1 (0.8) | 0.1 (0.08), 1 | 1 | |
| H+VS+P+SML | 2 (0.85) | 0.2 (0.09), .5 | 4 (2.2) | 0.7 (0.4), .37 | .41 | 4 (1.5) | 0.4 (0.2), .12 | 2 (1.6) | 0.2 (0.1), .5 | 1 | |
| VES+VS+P+SML | 2 (0.85) | 0.1 (0.05), .5 | 3 (1.6) | 0.2 (0.1), .25 | .66 | 3 (1.1) | 0.2 (0.06), .25 | 1 (0.8) | 0.1 (0.07), 1 | 1 | |
| Five | H+VES+VS+P+SML | 2 (0.85) | 0.03 (0.01), .5 | 2 (1.1) | 0.1 (0.06), .5 | 1 | 3 (1.1) | 0.07 (0.03), .25 | 1 (0.8) | 0.03 (0.02), 1 | 1 |
Notes: Fisher’s exact tests were used to calculate the significance between observed and expected prevalence within each group. Expected value was calculated by combining prevalence estimates. Bolded values indicate significance across groups at p < .05. Values represent a proportion (percentage).
Definition of sensory impairments for BLSA: 1) vision (VS): a) better presenting visual acuity: logMAR units >0.30; b) contrast sensitivity: log_CS (Pelli-Robson bilaterally) <1.55; c) visual field: >1 standard deviation of population mean score out of 96 points; d) stereo acuity: value>80; 2) hearing (H): pure-tone average >25 decibels of hearing level; 3) Olfaction (SML): Sniffin’ Sticks score ≤8 (Test A) or 7 (Test B); 4) Vestibular function (VES): a) cervical vestibular-evoked myogenic potential being bilaterally absent; b) mean vestibulo-ocular reflex < 0.7; 5) Proprioception (P): threshold for perception of passive movement > 2.2 degrees.
For any 2 sensory impairments, there were no significant differences between the observed and expected prevalence in the overall sample, or within subgroups based on age decade, sex, and race (Tables 2 and 3). The observed prevalence of dual vision and hearing impairment differed significantly between females and males, with males having a higher observed prevalence of dual vision and hearing impairment compared to females (Table 3). This combination was also marginally significantly different by race, with whites having a higher observed prevalence than blacks. All other observed prevalence estimates of the sensory combinations did not differ by sex and race (Table 3).
For the prevalence patterns involving 3 or more sensory impairments, overall prevalence estimates were low (reaching 5.0% for hearing, vestibular, and visual impairment), though higher in participants age ≥ 80 (16.7% for hearing, vestibular, and visual impairment). There were no significant differences in prevalence of multiple sensory impairments by sex or race. In the overall sample, 4 patterns of 3 sensory impairments had greater than expected prevalence estimates: hearing, vision, and olfactory impairments (5.2% observed vs 1.8% expected, p = .01); vestibular, vision, and olfactory impairments (2.9% observed vs 0.7% expected, p = .03); hearing, vision, and vestibular impairments (5.0% observed vs 2.0% expected, p = .04); vision, vestibular, and proprioception impairments (2.4% observed vs 0.5% expected, p = .04; Table 2).
As for prevalence of 4 and 5 sensory impairments, overall prevalence estimates were low (<2% in the total sample) and reached 7.4% in participants age ≥ 80 for combined hearing, vestibular, vision, and proprioceptive impairment. Only 4 participants (1%) had 5 sensory impairments, and all 4 were over age 80 (Table 2). There were 2 combinations of 4 sensory impairments whose prevalence was higher than expected by chance. These were combined hearing, vision, vestibular, and proprioception impairments (1.9% for observed and 0.2% for expected, p = .04) as well as combined hearing, vision, vestibular, and olfactory impairments (1.9% for observed and 0.3% for expected, p = .04).
Patterns of Sensory Impairments in the Atherosclerosis Risk in Communities Study
Table 4 shows the results for any sensory impairment in ARIC. The prevalence of hearing impairment in the overall sample (N = 963) was 59.0%. The prevalence of vision impairment was 72.4%, and the prevalence of olfactory impairment was 16.8%. Similar to the BLSA, each of these impairments was more prevalent at older ages, and hearing impairment was more prevalent in men than women. In ARIC, hearing and vision impairment were significantly more prevalent in whites compared to blacks, while olfactory impairment was more prevalent in blacks.
Table 4.
Proportions of Impaired Sensory Systems by Age, Sex, and Race in ARIC Study
| Sensory System | Overall (N = 963) | Age 71–79 (N = 637) |
Age ≥ 80 (N = 326) |
p-value Between Age Groups |
Female (N = 605) | Male (N = 358) | p-value Between Sexes | White (N = 541) | Black (N = 418) | p-value Between Races |
|---|---|---|---|---|---|---|---|---|---|---|
| Hearing | 568 (59.0) | 326 (51.2) | 242 (74.2) | <.001 | 314 (51.9) | 254 (70.9) | <.001 | 381 (70.4) | 185 (44.3) | <.001 |
| Vision | 697 (72.4) | 421 (66.1) | 276 (84.7) | <.001 | 444 (73.4) | 253 (70.7) | .42 | 424 (78.4) | 269 (64.4) | <.001 |
| Olfaction | 162 (16.8) | 89 (14.0) | 73 (22.4) | <.001 | 95 (15.7) | 67 (18.7) | .26 | 71 (13.1) | 91 (21.8) | <.001 |
Notes: Chi-squared tests were used to calculate the differences of sensory impairments by age, sex, and race. Bolded values indicate p < .05. Values represent a proportion (percentage).
Definition of sensory impairments for ARIC: 1) vision: a) better presenting visual acuity: logMAR units >0.30; b) contrast sensitivity: log_CS (MARS unilaterally) <1.48; 2) hearing: pure-tone average > 25 decibels of hearing level; 3) Olfaction: Sniffin’ Sticks score ≤6.
In the overall sample, combined hearing and vision impairment had the highest prevalence (44.3%), followed by vision and olfactory impairment (13.2%) and hearing and olfactory impairment (10.4%; Table 5). The prevalence of combined hearing, vision, and olfactory impairment was 8.1%. None of the observed prevalence estimates differed from expected within age decade, sex, or race (Table 5). Similar to the BLSA, the prevalence estimates of multiple impairments increased significantly by age decade across all available combinations of sensory impairment in ARIC (Table 5). In ARIC, as in the BLSA, the prevalence of dual hearing and vision impairments was significantly higher in males and in whites (Table 5).
Table 5.
Proportions of Multiple Impaired Sensory Systems by Age, Sex, and Race in ARIC Study (N = 963)
| Age Group in Years | Sex | Race | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall (N = 963) | 71–79 (n = 637) | ≥80 (n = 326) | Female (N = 605) | Male (N = 358) | White (N = 541) | Black (N = 418) | ||||||||||||
| Number of Impairments | Sensory System | Obs N (%) |
Exp N (%), p | Obs n (%) |
Exp n (%), p |
Obs n (%) |
Exp n (%), p |
p* for Age Groups | Obs n (%) |
Exp n (%), p | Obs n (%) |
Exp n (%), p |
p* for Sexes |
Obs n (%) |
Exp n (%), p |
Obs n (%) |
Exp n (%), p | p* for Race |
| Two or more | H+VS | 427 (44.3) | 411 (42.7), .49 | 220 (34.5) | 215 (33.8), .81 | 207 (63.5) | 205 (62.8), .94 | <.001 | 241 (39.8) | 230 (38.0), .56 | 186 (52.0) | 180 (50.1), .71 | <.001 | 302 (55.8) | 299 (55.2), .9 | 123 (29.4) | 119 (28.5), .82 | <.001 |
| H+ SML | 100 (10.4) | 96 (9.9), .41 | 47 (7.4) | 46 (7.2), .5 | 53 (16.3) | 54 (16.6), .58 | <.001 | 56 (9.3) | 49 (8.1), .27 | 44 (12.3) | 47.5 (13.3), .71 | .17 | 55 (10.2) | 50 (9.2), .34 | 45 (10.8) | 40 (9.6), .32 | .85 | |
| VS + SML | 127 (13.2) | 117 (12.2), .54 | 63 (9.9) | 59 (9.2), .78 | 64 (19.6) | 62 (19.0), .92 | <.001 | 76 (12.6) | 70 (11.5), .66 | 51 (14.2) | 47 (13.2), .74 | .52 | 61 (11.3) | 56 (10.3), .7 | 66 (15.8) | 59 (14.0), .56 | .051. | |
| Three | H+VS+ SML | 78 (8.1) | 69 (7.2), .49 | 32 (5.0) | 30 (4.7), .9 | 46 (14.1) | 46 (14.1), 1.0 | <.001 | 44 (7.3) | 36 (6.0), .42 | 34 (9.5) | 33.6 (9.4), 1.0 | .27 | 46 (8.5) | 39 (7.2), .5 | 32 (7.7) | 26 (6.2), .5 | .72 |
Notes: Exp = expected; H = hearing; Obs = observed; SML = olfaction; VS = vision.
Fisher’s exact tests were used to calculate the significance between observed and expected prevalence. Expected value was calculated by combining prevalence estimates. Bolded values indicate significance at p < .05. Values represent a proportion (percentage).
p* means that the p-value for the difference for the observed values of the particular group.
Definition of sensory impairments for ARIC: 1) vision: a) presenting visual acuity: logMAR units >0.30; b) contrast sensitivity: log_CS (MARS unilaterally) <1.48; 2) hearing: pure-tone average > 25 decibels of hearing level; 3) Olfaction: Sniffin’ Sticks score ≤6.
Sensitivity Analyses
Supplementary Table 3 compares the prevalence of sensory impairment between BLSA and ARIC when using impaired visual acuity or contrast sensitivity to define impaired vision. We observed a notable difference in the prevalence of visual impairment across studies: In BLSA, the prevalence of visual impairment was 27%, while in ARIC, the prevalence of visual impairment was 72.4%. Moreover, the prevalence of dual hearing and vision impairment in BLSA was 18.7%, while in ARIC, it was 44.3%. The prevalence of impairments in hearing, vision, and smell in BLSA was 7.1%, compared to 8.1% in ARIC.
Given the marked difference in prevalence of visual impairment between BLSA and ARIC, we further explored the vision variable by looking at its components—visual acuity and contrast sensitivity—separately. We observed that the driver of the difference in prevalence of visual impairment was a difference in prevalence of impaired contrast sensitivity, which was 1.2% in BLSA versus 71.0% in ARIC (Supplementary Table 4). Supplementary Table 5 shows the age-standardized prevalence estimates of impaired hearing, visual acuity, contrast sensitivity, and olfaction in samples restricted to participants over age 70 for both studies. After standardization, the prevalence of contrast sensitivity was still widely different between the 2 studies (1.0% in BLSA vs 70.8% in ARIC).
Discussion
Our results highlight the prevalence and patterns of multiple sensory deficits in 2 aging cohorts, BLSA and ARIC. Consistent with prior studies, we observed that multiple sensory impairments are highly prevalent in older adults (18,19). Additionally, we extended prior work by investigating the specific patterns of concurrent sensory deficits in 2 prospective cohort studies. In both studies, the most frequent pattern of multiple sensory impairment was concurrent vision and hearing impairment, with a 44.3% prevalence in ARIC, a sample representative of U.S. older adults and a 17.4% prevalence in the healthier BLSA cohort. Multiple sensory impairments were more common among the oldest participants. For example, in the BLSA, among participants aged ≥80 years, >10% had concurrent hearing/vision/vestibular impairment; hearing/vision/proprioception impairment; and hearing/vision/olfactory impairment. Moreover, multiple sensory impairments, specifically concurrent hearing and vision impairment, were significantly more common among males and whites in both the BLSA and ARIC, likely reflecting the higher rates of hearing impairment in these groups in both studies. Overall, these patterns may have varying impact on functionality, and they will naturally lead to different mechanisms for interventions to help restore functionality or maintain current functioning. Furthermore, future studies are needed to establish whether the greater prevalence of hearing and vision impairment reflects greater functional impairment in these senses.
We also investigated whether certain combinations of sensory impairments would be more prevalent than would be expected by chance if each sensory impairment occurred independently. Only in the BLSA did we find that the observed prevalence of several combinations of sensory impairments—hearing/vestibular function/vision/olfaction and hearing/vestibular function/vision/proprioception—was significantly higher than expected, suggesting that these sensory impairments could share a common biological mechanism and/or risk factor, notably aging. Prior studies have also observed that vision and olfaction, and to a lesser extent hearing, load onto a single global sensory index factor reflecting common risk factors such as older age (18). We have extended these findings by demonstrating that vestibular and proprioceptive impairment also co-occur with vision, olfactory, and hearing impairment in older adults. Interestingly, we did not observe significant differences between observed and expected prevalence rates of multiple sensory impairment in the ARIC cohort. Higher probability of co-occurrence is important, as it suggests that there are shared risk factors and/or biological mechanisms involved in sensory deficits. It is possible that in this cohort with a narrower range of ages and greater morbidity, the effect of sensory-specific risk factors (eg, diabetes for vision loss) may outweigh the impact of shared risk factors, such as age, vascular disease, or inflammation. A future direction would be to examine the associations of combined sensory deficits with risk factors.
Another notable finding from this work was the substantial variation in the prevalence of contrast sensitivity, part of the definition of visual impairment, between the BLSA and ARIC. The 2 studies used different measures of contrast sensitivity—Pelli-Robson bilaterally in BLSA versus MARS unilaterally in ARIC—and we employed published thresholds to define impairment in each cohort. Despite restricting the cohorts to the same age range and computing age-standardized prevalence estimates to account for differences in age distribution across cohorts, there was still a large difference in the prevalence of impaired contrast sensitivity between the 2 studies. It is unlikely that this difference (1.0% in BLSA vs 70.8% in ARIC) reflects underlying differences in morbidity and disease burden between populations. Further cross-walking studies are needed to facilitate greater comparability across tests. Ultimately, greater standardization of measures used across cohort studies would allow for greater comparability across studies and populations, as well as their associations with functional outcomes.
There were strengths and limitations of the study. BLSA has a variety of measures, but the sample may lack generalizability to socioeconomically diverse older adults, while ARIC has fewer measures but is a population-based sample. Moreover, the BLSA sample used in this study was a subset of the overall sample, as this was a complete case analysis and the prevalence at a given time. There was an average age difference of 2 years between BLSA participants who were included and excluded in this current study, given that certain exclusion criteria (eg, physical limitations to participate in study procedures) were more likely in older participants. This age difference may result in an underestimation in the prevalence estimates. Additionally, we employed methodologies to make the 2 studies as comparable as possible, including harmonization of sensory measures across studies and standardization of cohort structures (eg, age standardization). However, the differences in the measures of contrast sensitivity introduced a lot of variation in the estimates in vision impairment. Both studies used the same pure-tone audiometric test and similar olfactory measures.
Collectively, this work suggests the prevalence of concurrent sensory impairments is under-recognized in older adults. Screening for sensory impairments may help mitigate negative physical and health-related impacts that they can have on functionality and overall quality of life. Older adults have high prevalence of multiple sensory deficits, especially dual hearing and vision impairment, which may contribute to greater disability risk in terms of both physical and cognitive functioning. The higher than expected frequencies suggest that there are shared risk factors across sensory systems. Further studies are needed to delineate these associations, highlight opportunities for treatment and intervention in adverse functional outcomes, and examine the severity of multiple sensory impairments to determine the degree to which these co-occur with one another. This current study also demonstrated the lack of consistency of sensory measures across 2 prospective cohort studies and demonstrated the difficulties in standardization of measures that are evaluated differently. Uniformity in measurements across cohorts may facilitate a better understanding of the prevalence of sensory deficits and their associated effects on health and function with aging.
Supplementary Material
Acknowledgments
The authors of this manuscript include employees of the Intramural Research Program of the NIA. The authors thank the staff and participants of the BLSA and ARIC studies for their important contributions. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Contributor Information
Nicole M Armstrong, Department of Psychiatry and Human Behavior, Alpert Medical School in Brown University, Providence, Rhode Island, USA; Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA.
Hang Wang, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Jian-Yu E, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Frank R Lin, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Alison G Abraham, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Pradeep Ramulu, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Susan M Resnick, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA.
Qu Tian, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA.
Eleanor Simonsick, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA.
Alden L Gross, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Jennifer A Schrack, Department of Epidemiology, Biostatistics, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Luigi Ferrucci, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA.
Yuri Agrawal, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Funding
The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health,aDepartment of Health and Human Services, under Contract nos. (HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700004I, HHSN268201700005I). Funding for laboratory testing and biospecimen collection at ARIC Visit 6 was supported by grant R01DK089174 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH).
Author Contributions
N.M.A., A.G.A., P.R., S.M.R, E.S., Q.T., J.S., L.F., and Y.A. made substantial contributions to conception and design. S.M.R., E.S., A.G.A., P.R., F.R.L., and L.F. contributed to acquisition of data. H.W. and J.-Y.E. were responsible for data analyses. All authors contributed to the interpretation of data. N.M.A. drafted the article. All authors revised it critically for important content and approved of the final version to be published. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals.
Funding
This research was supported in part by the Intramural Research Program, National Institute on Aging, National Institutes of Health (N.M.A., Q.T., S.M.R., E.S., L.F.) and National Institute on Aging (R01 AG061786 01) (F.R.L., Y.A., J.A.S.).
Conflict of Interest
None declared.
References
- 1. Goman AM, Lin FR. Prevalence of hearing loss by severity in the United States. Am J Public Health. 2016;106(10):1820–1822. doi: 10.2105/AJPH.2016.303299 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Swenor BK, Ramulu PY, Willis JR, Friedman D, Lin FR. The prevalence of concurrent hearing and vision impairment in the United States. JAMA Intern Med. 2013;173(4):312–313. doi: 10.1001/jamainternmed.2013.1880 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Agrawal Y, Platz EA, Niparko JK. Prevalence of hearing loss and differences by demographic characteristics among US adults: data from the National Health and Nutrition Examination Survey, 1999-2004. Arch Intern Med. 2008;168(14):1522–1530. doi: 10.1001/archinte.168.14.1522 [DOI] [PubMed] [Google Scholar]
- 4. 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]
- 5. Murphy C, Schubert CR, Cruickshanks KJ, Klein BE, Klein R, Nondahl DM. Prevalence of olfactory impairment in older adults. JAMA. 2002;288(18):2307–2312. doi: 10.1001/jama.288.18.2307 [DOI] [PubMed] [Google Scholar]
- 6. Li C, Layman AJ, Carey JP, Agrawal Y. Epidemiology of vestibular evoked myogenic potentials: data from the Baltimore Longitudinal Study of Aging. Clin Neurophysiol. 2015;126(11):2207–2215. doi: 10.1016/j.clinph.2015.01.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Li C, Layman AJ, Geary R, et al. Epidemiology of vestibulo-ocular reflex function: data from the Baltimore Longitudinal Study of Aging. Otol Neurotol. 2015;36(2):267–272. doi: 10.1097/MAO.0000000000000610 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Agrawal Y, Zuniga MG, Davalos-Bichara M, et al. Decline in semicircular canal and otolith function with age. Otol Neurotol. 2012;33(5):832–839. doi: 10.1097/MAO.0b013e3182545061 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Gadkaree SK, Sun DQ, Li C, et al. Does Sensory function decline independently or concomitantly with age? Data from the Baltimore Longitudinal Study of Aging. J Aging Res. 2016;2016:1865038. doi: 10.1155/2016/1865038 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Ko SU, Simonsick E, Deshpande N, Ferrucci L. Sex-specific age associations of ankle proprioception test performance in older adults: results from the Baltimore Longitudinal Study of Aging. Age Ageing. 2015;44(3):485–490. doi: 10.1093/ageing/afv005 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Deal JA, Sharrett AR, Albert MS, et al. Hearing impairment and cognitive decline: a pilot study conducted within the atherosclerosis risk in communities neurocognitive study. Am J Epidemiol. 2015;181(9):680–690. doi: 10.1093/aje/kwu333 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Swenor BK, Wang J, Varadaraj V, et al. Vision impairment and cognitive outcomes in older adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci. 2019;74(9):1454–1460. doi: 10.1093/gerona/gly244 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Xu L, Liu J, Wroblewski KE, McClintock MK, Pinto JM. Odor sensitivity versus odor identification in older US adults: associations with cognition, age, gender, and race. Chem Senses. 2020;45(4):321–330. doi: 10.1093/chemse/bjaa018 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Zheng DD, Swenor BK, Christ SL, West SK, Lam BL, Lee DJ. Longitudinal associations between visual impairment and cognitive functioning: the Salisbury Eye Evaluation Study. JAMA Ophthalmol. 2018;136(9):989–995. doi: 10.1001/jamaophthalmol.2018.2493 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. E JY, Schrack JA, Mihailovic A, et al. Patterns of daily physical activity across the spectrum of visual field damage in glaucoma patients. Ophthalmology. 2021;128(1):70–77. doi: 10.1016/j.ophtha.2020.06.053 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Agrawal Y, Merfeld DM, Horak FB, et al. Aging, vestibular function, and balance: proceedings of a national institute on aging/national institute on deafness and other communication disorders workshop. J Gerontol A Biol Sci Med Sci. 2020;75(12):2471–2480. doi: 10.1093/gerona/glaa097 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Tielsch JM, Sommer A, Witt K, Katz J, Royall RM. Blindness and visual impairment in an American urban population. The Baltimore Eye Survey. Arch Ophthalmol. 1990;108(2):286–290. doi: 10.1001/archopht.1990.01070040138048 [DOI] [PubMed] [Google Scholar]
- 18. Correia C, Lopez KJ, Wroblewski KE, et al. Global sensory impairment in older adults in the United States. J Am Geriatr Soc. 2016;64(2):306–313. doi: 10.1111/jgs.13955 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Liljas AEM, Jones A, Cadar D, Steptoe A, Lassale C. Association of multisensory impairment with quality of life and depression in english older adults. JAMA Otolaryngol Head Neck Surg. 2020;146(3):278–285. doi: 10.1001/jamaoto.2019.4470 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Shuster BZ, Depireux DA, Mong JA, Hertzano R. Sex differences in hearing: probing the role of estrogen signaling. J Acoust Soc Am. 2019;145(6):3656. doi: 10.1121/1.5111870 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103(3):357–364. doi: 10.1016/s0161-6420(96)30684-2 [DOI] [PubMed] [Google Scholar]
- 22. Varma R, Vajaranant TS, Burkemper B, et al. Visual impairment and blindness in adults in the United States: demographic and geographic variations from 2015 to 2050. JAMA Ophthalmol. 2016;134(7):802–809. doi: 10.1001/jamaophthalmol.2016.1284 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Lin FR, Maas P, Chien W, Carey JP, Ferrucci L, Thorpe R. Association of skin color, race/ethnicity, and hearing loss among adults in the USA. J Assoc Res Otolaryngol. 2012;13(1):109–117. doi: 10.1007/s10162-011-0298-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Guthrie DM, Davidson JGS, Williams N, et al. Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: analysis of interRAI data for home care and long-term care recipients in Ontario. PLoS One. 2018;13(2):e0192971. doi: 10.1371/journal.pone.0192971 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Kimura D. Functional asymmetry of the brain in dichotic listening. Cortex. 1967;3(2):163–178. doi: 10.1016/S0010-9452(67)80010-8. [DOI] [Google Scholar]
- 26. Chou CF, Frances Cotch M, Vitale S, et al. Age-related eye diseases and visual impairment among U.S. adults. Am J Prev Med. 2013;45(1):29–35. doi: 10.1016/j.amepre.2013.02.018 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Ferris FL 3rd, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol. 1982;94(1):91–96. [PubMed] [Google Scholar]
- 28. Congdon N, O’Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477–485. doi: 10.1001/archopht.122.4.477 [DOI] [PubMed] [Google Scholar]
- 29. Nelson-Quigg JM, Cello K, Johnson CA. Predicting binocular visual field sensitivity from monocular visual field results. Invest Ophthalmol Vis Sci. 2000;41(8):2212–2221. [PubMed] [Google Scholar]
- 30. Swenor BK, Muñoz B, West SK. A longitudinal study of the association between visual impairment and mobility performance in older adults: the Salisbury Eye Evaluation Study. Am J Epidemiol. 2014;179(3):313–322. doi: 10.1093/aje/kwt257 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Pelli D, Robson J. The design of a new letter chart for measuring contrast sensitivity. Clin Vision Sci. 1988;2(3):187–199. [Google Scholar]
- 32. Mäntyjärvi M, Laitinen T. Normal values for the Pelli-Robson contrast sensitivity test. J Cataract Refract Surg. 2001;27(2):261–266. doi: 10.1016/s0886-3350(00)00562-9 [DOI] [PubMed] [Google Scholar]
- 33. Deshpande N, Simonsick E, Metter EJ, Ko S, Ferrucci L, Studenski S. Ankle proprioceptive acuity is associated with objective as well as self-report measures of balance, mobility, and physical function. Age (Dordr). 2016;38(3):53. doi: 10.1007/s11357-016-9918-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Hummel T, Sekinger B, Wolf SR, Pauli E, Kobal G. ‘Sniffin’ sticks’: olfactory performance assessed by the combined testing of odor identification, odor discrimination and olfactory threshold. Chem Senses. 1997;22(1):39–52. doi: 10.1093/chemse/22.1.39 [DOI] [PubMed] [Google Scholar]
- 35. Tian Q, Resnick SM, Studenski SA. Olfaction is related to motor function in older adults. J Gerontol A Biol Sci Med Sci. 2017;72(8):1067–1071. doi: 10.1093/gerona/glw222 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Deal JA, Albert MS, Arnold M, et al. A randomized feasibility pilot trial of hearing treatment for reducing cognitive decline: results from the aging and cognitive health evaluation in elders pilot study. Alzheimers Dement (N Y). 2017;3(3):410–415. doi: 10.1016/j.trci.2017.06.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Dougherty BE, Flom RE, Bullimore MA. An evaluation of the Mars Letter Contrast Sensitivity Test. Optom Vis Sci. 2005;82(11):970–975. doi: 10.1097/01.opx.0000187844.27025.ea [DOI] [PubMed] [Google Scholar]
- 38. Myers VS, Gidlewski N, Quinn GE, Miller D, Dobson V. Distance and near visual acuity, contrast sensitivity, and visual fields of 10-year-old children. Arch Ophthalmol. 1999;117(1):94–99. doi: 10.1001/archopht.117.1.94 [DOI] [PubMed] [Google Scholar]
- 39. Dong J, Pinto JM, Guo X, et al. The prevalence of anosmia and associated factors among U.S. black and white older adults. J Gerontol A Biol Sci Med Sci. 2017;72(8):1080–1086. doi: 10.1093/gerona/glx081 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Palta P, Chen H, Deal JA, et al. Olfactory function and neurocognitive outcomes in old age: the atherosclerosis risk in communities neurocognitive study. Alzheimers Dement. 2018;14(8):1015–1021. doi: 10.1016/j.jalz.2018.02.019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria; 2013. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.