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RESEARCH AND PRACTICE |
John E. Crews and Vincent A. Campbell are with the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.
Correspondence: Requests for reprints should be sent to John E. Crews, DPA, Centers for Disease Control and Prevention, 1600 Clifton Road, F-35, Atlanta, GA 30333 (e-mail: jcrews{at}cdc.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We investigated the health, activity, and social participation of people aged 70 years or older with vision impairment, hearing loss, or both.
Methods. We examined the 1994 Second Supplement on Aging to determine the health and activities of these 3 groups compared with those without sensory loss. We calculated odds ratios and classified variables according to the International Classification of Functioning, Disability and Health framework.
Results. Older people with only hearing loss reported disparities in health, activities, and social roles; those with only vision impairment reported greater disparities; and those with both reported the greatest disparities.
Conclusions. A hierarchical pattern emerged as impairments predicted consistent disparities in activities and social participation. This population’s patterns of health and activities have public health implications.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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70 years, 18% report blindness in 1 or both eyes or some other trouble seeing, 33.2% report problems with hearing, and 8.6% report problems with both hearing and seeing.1 Precisely because these experiences are so common, they are often overlooked or dismissed.2 Moreover, normal age-related changes in hearing and vision may be confused with abnormal sensory changes that can compromise function. Likewise, abnormal changes due to eye and ear pathology may be confused with normal age-related sensory changes. Hearing and vision problems are not manifest disabilities, and both can lead to misdiagnosis or misunderstanding. For example, an older person with vision problems may appear timid, hesitant, or confused, especially when confronted with a new situation.3 Similarly, older people with hearing loss may miss the nuances of conversation and appear confused, creating unjustified impatience on the part of those with whom they are speaking.4 These experiences may lead to isolation, disappointment, and frustration.5
When decrements in vision and hearing exceed normal age-related changes that are due to eye pathology, they may begin to compromise an older person’s ability to carry out routine activities that define social roles and quality of life.6 Either hearing or vision loss can affect the most common and simple tasks. Sensory decline may compromise one’s ability to hear whispered conversation or side remarks, write notes, read the newspaper, and recognize facial expressions.
The relation between vision and various health conditions and activity limitations among older people is well documented, but few studies are population based. Diminished vision is associated with decreases in leisure activities,7,8 Instrumental Activities of Daily Living (IADL) performance and social function,2 Activities of Daily Living (ADL),9 and compromised mobility10,11; it is also associated with increases in hip fractures,12 falls,13 depression,14,15 physician visits and hospitalizations,16 mortality,17 and family stress.18–20
Hearing loss is associated with decreased functional and psychosocial impairments21; increased social isolation,22 depression,23,24 and rates of dementia25; it is also associated with accelerated cognitive decline in dementia.26 Declines in vision and hearing are associated with decreased quality of life,27 increased physical disability measured by IADL among women,28 imbalance,29,5 falls,30,31,13 hip fracture,12 and mortality.32,33
Few investigators have examined the discrete concerns associated with sensory loss as defined by hearing loss, vision impairment, and both vision impairment and hearing loss. Two recent articles are of particular interest. Keller et al.34 examined ADL and IADL among a group of 576 older people seen at the University of Nebraska Medical Center. Vision impairment was defined as a near visual acuity of 20/70 or less, and hearing was measured by a whisper test. In this study, 51% of subjects were classified as having a hearing impairment only; 5% had a vision impairment only; 13% had a dual sensory impairment, and 32% had none. These 4 groups were compared in terms of mean ADL and IADL scores. Participants with sensory impairments showed diminished functional status as measured by ADL and IADL. Those with combined vision impairment and hearing loss demonstrated the greatest differences in functional status. The sample was not population based.
A population-based investigation, however, by Reuben et al.35 examined the National Health and Nutrition Examination Survey (NHANES I) to determine the relation between vision and hearing loss within a 10-year period and mortality and overall functional decline. The NHANES I provided a large sample (n = 5677) whose subjects, aged 55–74 years, were followed for a decade. Those with hearing loss, vision impairment, and both vision impairment and hearing loss demonstrated higher rates of mortality, ADL dependency, and IADL dependency than did people without sensory impairment 10 years after collection of baseline data. Those with combined vision and hearing problems demonstrated the greatest declines in function and the greatest rates of mortality. Those who acquired vision and hearing problems after baseline data were collected were not identified, and thus changes in their function were not recorded.
Comprehension of the magnitude of sensory problems in the older US population and the impact of these changes on this population’s behaviors are important public policy and public health concerns in terms of surveillance, research, and intervention design.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Data for the SOA-II were obtained from 4 sources: (1) the 1994 National Health Interview Survey (NHIS) Core Questionnaire, (2) the Access to Care Supplement to the 1994 NHIS, (3) Phase 1 of the National Health Interview Survey on Disability (NHIS-D), and (4) Phase 2 of the NHIS-D. Information for the first 3 sources was gathered during 1994. Data for the NHIS-D were collected in 2 phases. Phase 1 data were collected in 1994, and a series of screening criteria were used to identify people selected for the second phase of the NHIS-D, also known as the Disability Followback Study. Data for the NHIS-D were collected 7–17 months after the initial survey.
A total of 9447 people were interviewed for the SOA-II; all participants were aged 70 years. The SOA-II provides selfreported information from older, noninstitutionalized civilians. Proxy responses (14.4% of the total) were accepted when a respondent was incapable of completing the interview. Data were weighted for age, sex, race, and nonresponse in order to produce national estimates. Due to the complex stratified cluster sampling design employed by the SOA-II, SUDAAN37 was used to analyze data. The Taylor linearization "with replacement" design option was used to calculate standard error in order to provide more accurate variance estimates.
Sensory Impairment Variables in the SOA-II
For this study, we created 4 groups for analysis: those reporting hearing problems only, those reporting vision problems only, those reporting both vision and hearing problems, and those reporting no vision or hearing problems. The SOA-II contains 11 variables regarding vision. Two questions, respectively, concern diagnosis (cataract and glaucoma), blindness (in 1 or both eyes), and eyeglasses (used and prescribed); additional questions apply to cataract surgery, lens implant(s), contacts, and use of magnifiers. A global question deals with "trouble seeing even with glasses." For this analysis, we created a summary variable for vision problems that includes a positive response to the following characteristics: "blindness in one eye," "blindness in both eyes," and "trouble seeing even with glasses."38,39
The SOA-II contains 6 questions about hearing, including "deafness in one ear," "deafness in both ears," "any other trouble hearing," "used hearing aid in past 12 months," "used hearing aid in past 2 weeks," and "cochlear implant." For this analysis, we created a summary variable for "hearing problem" for any positive response to the variables "deafness in one ear," "deafness in both ears," and "any other trouble hearing." No single variable characterizes both hearing and vision loss; therefore, we have used a positive response to both the hearing and vision summary variables to define compromised hearing and vision. For the estimated population, 58.0% reported no sensory impairment; 24.4% reported hearing impairment only, 9.4% reported vision impairment only, and 8.2% reported both vision and hearing impairment. Of the total estimated population, 89.9% were White, 7.7% Black, and 2.4% "other"; 52.6% were married; 36.9% were widowed; and 40.1% were males (Table 1
).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Older people with vision impairment only were less likely to report their health as "excellent" (9.5% vs 16.4%) or "very good" (18.5% vs 26.1%) than were those who do not report sensory problems (Table 2). In addition, older people who reported vision problems were more likely to report their health as "poor" than people without sensory problems (15.3% vs 6.7%). Similarly, older people reported hearing loss only also were less likely to report their health as "excellent" (14.4% vs 16.4%) or "very good" (21.7% vs 26.1%) than were those without sensory loss. Older people who reported both vision impairment and hearing loss reported much lower rates of excellent health (7.7% vs 16.4%) and higher rates of poor health (18.5% vs 6.7%).
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compares older people who reported sensory impairment (vision problems only, hearing problems only, and vision and hearing problems only) with older people who did not report sensory impairments, in terms of comorbid and related conditions. In all cases, a higher proportion of people with vision problems reported comorbid and secondary conditions. They were 1.8 times more likely to have experienced a fall in the past 12 months (26.0% vs 16.5%), 1.7 times as likely to have experienced a broken hip (6.3% vs 3.8%), and 2.6 times more likely to have experienced a stroke (15.0% vs 6.4%). Heart disease (28.8% vs 16.7%) and hypertension (54.3% vs 42.5%) were reported in higher proportions among those with vision problems.
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Older people with both vision and hearing loss were 3.0 times more likely to have fallen in the past 12 months than were people without vision or hearing problems (37.6% vs 16.5%), and 2.1 times more likely to have broken a hip (7.4% vs 3.8%). They were 1.5 times more likely to report hypertension (53.2% vs 42.5%), 2.4 times more likely to report heart disease (32.6% vs 16.7%), and 3.6 times more likely to have had a stroke (19.7% vs 6.4%).
Older people with visual impairment were 2.0 times more likely to report being frequently depressed or anxious than were older people without sensory problems (12.0% vs 5.8%). Although not significant, those with hearing loss only reported slightly higher rates of depression (8.0% vs 5.8%) than did people without sensory loss, and people with both vision and hearing loss only were 2.7 times more likely to report depression.
Activity Limitations
The ICF defines activity as "the nature and extent of performance of a function by a person" and activity limitations as "problems of the performance of activities in nature, duration, and quality."40 Older people with vision impairments only were 3.0 times as likely to report difficulty walking than people without sensory problems (39.0% vs 17.8%), while those with vision problems were 3.3 times more likely to report difficulty getting outside than people without sensory problems (25.1% vs 9.3%) (Table 3
). Likewise, people with vision impairments were 2.8 times more likely to report difficulty getting into and out of a bed or chair (19.4% vs 8.0%), 3.1 times more likely to report difficulty managing medication (10.8% vs 3.7%), and 3.5 times more likely to report difficulty preparing meals (19.2% vs 6.3%).
Older people with hearing loss only also reported greater difficulties with activities than did people without sensory problems. These limitations were not as great as those among older people with vision impairments. One fourth (24.5%) of people with hearing loss reported difficulty walking compared with 17.8% of those who did not report hearing loss. In addition, people who reported hearing loss were 1.3 times more likely to report difficulty getting outside (11.8% vs 9.3%), 1.5 times more likely to report difficulty getting into and out of a bed or chair (11.7% vs 8.0%), and 1.6 times more likely to report difficulty managing medication (5.7% vs 3.7%) than were people without sensory problems.
Older people with both vision and hearing impairment were 4.3 times more likely to report difficulty walking (48.2% vs 17.8%), 4.7 times more likely to report difficulty getting outside (32.4% vs 9.3%), and 3.8 times more likely to report difficulty getting into or out of a bed or chair (24.8% vs 8.0%). In addition, this group was 4.7 times more likely to report difficulty preparing meals (23.9% vs 6.3%) and 4.0 times more likely to report difficulty managing medication (13.5% vs 3.7%).
Participation Restrictions
Differences in social participation were substantial, although more modest than differences in activity limitations (Table 3). Older people reporting sensory problems were less likely to report visiting friends in the past 2 weeks. Nearly 74% of older people without sensory loss reported visiting friends; 70.9% of those with hearing loss only reported visiting friends; 66.8% of those with vision impairment only reported visiting friends; and 63.4% of those with both vision impairment and hearing loss reported visiting friends. There were no significant differences among the 4 groups regarding visiting with relatives. Older people with hearing loss only were as likely to eat out as those without sensory impairment, but people reporting vision or vision and hearing problems were about two thirds as likely to eat out at a restaurant. Older people with both hearing loss and vision impairment reported substantial difficulty sustaining social participation activities; they were, for example, half as likely to phone friends and about two thirds as likely to attend church.
In addition, the SOA-II asked about desired level of social activity—whether the amount of social activity was "too much," "about enough," or if the respondent "would like to do more" (Table 4). About one fifth (21.6%) of older people without sensory loss reported having too little social activity. By contrast, about one fourth (25.1%) of older people with hearing loss reported "would like to do more" and about one third of those with vision impairment (31.0%) or vision impairment and hearing loss (33.7%) reported that they "would like to do more." These responses were consistent with the social participation measures discussed above.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Because of the confounding relation between comorbidities and activity limitations, neither vision impairment nor hearing loss alone defines the experience of older people who reported sensory impairment. Vision impairment or hearing loss rarely occur in isolation; instead, they occur in the context of other age-related physiologic and psychosocial changes.
One would expect activity limitations to become translated into societal participation restrictions. For example, difficulties in travel would probably increase the difficulty in maintenance of social relationships. The hierarchical patterns among older people who reported hearing loss, vision loss, or both hearing and vision loss were repeated in the selected societal participation measures in this analysis.
The societal participation measures must be interpreted with care because all of the participation questions asked an individual whether he or she had performed a function within the past 2 weeks. Therefore, a positive response to getting together with friends may mean that a respondent has only been with 1 friend once in 2 weeks. Moreover, participation measures inquiring about "visiting with friends" and "visiting with relatives" were broadly phrased. These questions did not capture the active or passive nature of these encounters. For example, whether the respondent left home to visit (an active role) or whether others came to the respondent’s home to visit (a passive role) is unknown.
In terms of social involvement, obvious differences exist between having a relative drop in once in 2 weeks and having daily interactions. These questions were not sufficiently sensitive to gauge social interaction. The question about level of social activity ("about enough," "too much," or "would like to do more") may be a useful summary measure of social participation. Additionally, it is important to remember that this analysis reports the correlations from cross-sectional data; therefore, the causal sequence cannot be inferred.
These findings underscore the importance of the recently published Healthy People 201041 goals of primary prevention and rehabilitation in both vision and hearing (Chapter 28) as well as objectives to increase social participation and life satisfaction among all people with disabilities and the removal of environmental barriers (Chapter 6). Common eye conditions, especially diabetic retinopathy, glaucoma, and cataract, respond well to treatment.42,43 Similarly, routine audiometric screenings or questionnaires remain effective strategies for early identification of hearing problems.44 Moreover, those in the aging network, which serves a broad range of concerns among older people, need to be mindful of the particular circumstances of older persons’ sensory impairment. Finally, the national vision rehabilitation program (funded under Title VII, Chapter 2 of the Rehabilitation Act of 1973, as amended) may be required to address multiple health and functional concerns.
Further examination of the health implication of these data may be productive given the relation between sensory loss and activity limitations and our hypothesized impact on health outcomes. Examples include examination of the implications of visual impairment on difficulty in meal preparation and nutritional outcomes, the impact on physical conditioning by difficulty in walking, and the ability to manage medication to achieve pharmacologic compliance. These findings also point to concerns regarding older persons’ management of their environment, a concept advanced in the ICF. For example, Long et al.10 demonstrated the presence of sidewalks as a predictor of walking outside for people with diminished vision. Moreover, standard print size may impede the ability of visually impaired elders to comply with drug therapies.45 Improvement of the acoustical characteristics of environments by modification of reverberant rooms and noisy ventilation systems is associated with increased capacity to use residual hearing.5
In addition, these findings indicate that social roles of older people with bimodal sensory loss may be compromised. Kemp46 and Gignac and Cott47(p743) refer to social participation roles as "valued activities." These data do not indicate the kinds of strategies older people employ to sustain valued activities in the face of multiple impairments.
These findings suggest 3 areas requiring additional inquiry.
Activity limitations and secondary conditions.
Additional attention should be given to the relation between activity limitations and conditions and circumstances secondary to sensory impairment. That is, what are the health relations among older people with vision impairment between difficulty walking and general conditioning to hypertension and heart disease? What is the relation among older people with vision impairment between difficulty preparing meals and nutrition?
Environment and behavior.
Additional attention should be given to the relation of the environment and the behaviors of people who have sensory problems. That is, would the presence of sidewalks and larger print on medicine bottles make a difference in the general health and activities of older people with vision problems? How does environmental noise hinder elders with hearing impairment from understanding conversations?
Strategies for participation.
Additional attention should be given to understanding the strategies used by older people to sustain participation in the community. That is, how do older people with activity limitations arrange their lives to continue social participation? What is the nature of the social interactions for elders with sensory impairments? Although not different quantitatively, are these relations qualitatively more dependent in nature than for nonimpaired elders?
The untangling of relations among sensory loss, comorbidities and secondary conditions, activity limitations, and restrictions in participation pose significant public health challenges.
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Footnotes |
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Human Participant Protection
No protocol was needed for this study. The National Center for Health Statistics’ National Health Interview Survey, 1994: Second Supplement on Aging, a publicly available data set, contains no individual identifiers.
Accepted for publication January 15, 2003.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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 A. J. Caban, D. J. Lee, O. Gomez-Marin, B. L. Lam, and D. D. Zheng Prevalence of Concurrent Hearing and Visual Impairment in US Adults: The National Health Interview Survey, 1997-2002 Am J Public Health, November 1, 2005; 95(11): 1940 - 1942. [Abstract] [Full Text] [PDF]
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D. J. Lee, B. L. Lam, O. Gomez-Marin, D. D. Zheng, and A. J. Caban Concurrent Hearing and Visual Impairment and Morbidity in Community-Residing Adults: The National Health Interview Survey, 1986 to 1996 J Aging Health, October 1, 2005; 17(5): 531 - 546. [Abstract] [PDF]
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 B. Yueh, J. A. McDowell, M. Collins, P. E. Souza, C. F. Loovis, and R. A. Deyo Development and Validation of the Effectiveness of Auditory Rehabilitation Scale Arch Otolaryngol Head Neck Surg, October 1, 2005; 131(10): 851 - 856. [Abstract] [Full Text] [PDF]
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 M. Brennan, A. Horowitz, and Y.-p. Su Dual Sensory Loss and Its Impact on Everyday Competence Gerontologist, June 1, 2005; 45(3): 337 - 346. [Abstract] [Full Text] [PDF]
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