Hearing loss and activities of daily living

20. Forsen L, Waaler N, Vuillemin A et al. Physical activity questionnaires for elderly: a systematic review of measurement properties. Sports Med 2010; 40: 565600.
Received 24 January 2011; accepted in revised form 25 August 2011

Age and Ageing 2012; 41: 195200 The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society. doi: 10.1093/ageing/afr155 All rights reserved. For Permissions, please email: journals.permissions@oup.com Published electronically 29 November 2011

Severity of age-related hearing loss is associated with impaired activities of daily living
BAMINI GOPINATH1, JULIE SCHNEIDER2, CATHERINE M. MCMAHON3,4, ERDAHL TEBER1, STEPHEN R. LEEDER2, PAUL MITCHELL1
Downloaded from http://ageing.oxfordjournals.org/ by guest on October 5, 2013

Centre for Vision Research, Department of Ophthalmology and Westmead Millennium Institute, University of Sydney, Hawkesbury Rd, Westmead, NSW 2145, Australia 2 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW, Australia 3 Centre for Language Sciences, Linguistics Department, Macquarie University, Sydney, NSW, Australia 4 HEARing Co-operative Research Centre, Melbourne, VIC, Australia Address correspondence to: P. Mitchell. Tel: (+61) 2 9845 7960; Fax: (+61) 2 9845 6117. Email: paul_mitchell@wmi.usyd.edu.au

Abstract
Background: age-related hearing loss is a common chronic condition; hence, it is important to understand its inuence on the functional status of older adults. We assessed the association between hearing impairment with activity limitations as assessed by the activities of daily living (ADL) scale. Methods: a total of 1,952 Blue Mountains Hearing Study participants aged 60 years had their hearing levels measured using pure-tone audiometry. A survey instrument with questions on functional status as determined by the Older Americans Resources and Services ADL scale was administered. Results: one hundred and sixty-four (10.4%) participants reported ADL difculty. A higher proportion of hearing impaired than non-impaired adults reported difculties in performing three out of the seven basic ADL and six out of the seven instrumental ADL tasks. After multivariable adjustment, increased severity of hearing loss was associated with impaired ADL (Ptrend = 0.001). Subjects with moderate to severe hearing loss compared with those without, had a 2.9-fold increased likelihood of reporting difculty in ADL, multivariate-adjusted odds ratio (OR): 2.87 [95% condence interval (CI): 1.595.19]. Participants aged <75 years with hearing loss compared with those without, had 2-fold higher odds of impaired ADL. Having worn or wearing a hearing aid was also associated with a 2-fold increased likelihood of impaired ADL. Conclusion: functional status as measured by a common ADL scale is diminished in older hearing impaired adults. Our ndings suggest that severely diminished hearing could make the difference between independence and the need for formal support services or placement.
Keywords: age-related hearing loss, activities of daily living, Blue Mountains Hearing Study, hearing aid, elderly

Introduction
It is well established that age-related hearing loss is associated with several indicators of negative well-being including reduced quality of life, social isolation and depressive symptoms [13]; however, there is a paucity of population-

derived data on the association between hearing loss and functional disability. Activities of daily living (ADL) measures are widely used to assess older adults for disability in carrying out daily functions (functional disability), including basic ADL such as washing and eating, and instrumental

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ADL required to function in the community, such as shopping and housework [4]. Previously, hearing-impaired older adults have demonstrated greater functional disability than non-impaired adults [59], although, this has not been a consistent nding [10, 11]. Moreover, only a few studies, like the Epidemiology of Hearing Loss Study (EHLS) [6] were population-based and used standardized audiometric testing to conrm the presence of hearing loss. Given the projected growth in the older population and the high prevalence of hearing loss, it is important to understand how hearing impacts on the functional status of older adults in order to effectively develop interventions to delay the onset of functional disability [7]. Therefore, we used a large, representative population-based sample of older adults aged 60 years to address the following aims and testable hypotheses: Aim 1: to determine whether hearing loss is associated with impaired ADL, and whether the severity of the hearing impairment is associated with ADL scores. Testable hypotheses: older hearing-impaired adults, particularly those with moderate to severe hearing impairment have a higher likelihood of experiencing difculties in performing ADL, after adjusting for potential confounders such as age, cognitive impairment, probable depression and hospital admission. Aim 2: to establish whether severity of hearing handicap is associated with difculty in performing ADL. Testable hypotheses: presence of severe hearing handicap will be associated with impaired ADL. Aim 3: to determine whether the use of hearing aids is linked with impaired ADL. Testable hypotheses: hearing aid use will be associated with higher odds of self-reported difculty in ADL. performed, leaving 1,572 participants available for analyses. Those who did not have complete hearing data were more likely to be female (P = 0.01), older (P < 0.0001), and cognitively impaired (P < 0.0001), and to have type 2 diabetes (P < 0.0001) compared with those who had complete audiological data.

Questionnaire and physical examination

At face-to-face interviews with trained interviewers, a comprehensive medical history was obtained from all participants. History of cardiovascular disease was based on self-report of physician-diagnosed acute myocardial infarction or angina. Diabetes was dened either by history or from fasting blood glucose 7.0 mmol/l. Cognitive decline was assessed using the Mini-Mental State Examination (MMSE) questionnaire [15]. Participants with scores <24 were considered cognitively impaired. The Mental Health Index is a component of the 36-Item Short-Form Survey (SF-36). Scores were calculated as the sum of questions one to ve multiplied by 25 and the result divided by 100, i.e. (MH15) 25/100. A cut-off score of 59 out of 100 was used to dene persons with probable depression [16].

Audiological examination

Methods
Study population

The Blue Mountains Hearing Study (BMHS) [12, 13] is a population-based survey of age-related hearing loss conducted during the years 19972004 among participants of the Blue Mountains Eye Study (BMES) cohort [14]. During 199294, 3,654 participants 49 years or older were examined (82.4% participation; BMES-1). Surviving baseline participants were invited to attend 5-year followup examinations (199799, BMES-2) and 10 years (200204, BMES-3), at which 2,334 (75.1% of survivors) and 1,952 participants (75.6% of survivors) were re-examined, respectively. The current study uses data collected from BMES-3, i.e. when participants were aged 60 years. Of the 1,952 participants, 29 subjects were excluded because they reported a history of otosclerosis, conductive hearing loss or had hearing loss from birth. Of the remaining, 351 did not have complete audiometric data as they did not have pure-tone audiometry

An audiologist asked questions including history of any self-perceived hearing problem (e.g. acquired or congenital hearing loss, otosclerosis), and if a hearing aid had been provided. Questions related to hearing aid use included: (i) Do you or have you ever worn a hearing aid? (ii) Do you have hearing aids now? and (iii) On average how many hours per week do you wear at least one hearing aid? The Hearing Handicap Inventory for the Elderly Shortened version (HHIE-S), developed by Ventry and Weinstein [17], was also administered. The HHIE-S includes 11 questions and a response of yes is given 4 points; sometimes is given 2 points, and no is given 0 points. Scores >8 were taken to indicate the presence of a handicap [18]. Pure-tone audiometry was performed by an audiologist in sound-treated booths, using standard TDH-39 earphones and Madsen OB822 audiometers (Madsen Electronics, Copenhagen, Denmark). Audiometric thresholds for air-conduction stimuli in both ears were established for frequencies at 250; 500; 1,000; 2,000; 4,000; 6,000 and 8,000 Hz, with 3,000 Hz added if a 20-dB difference existed between the 2,000- and 4,000-Hz thresholds. We determined hearing impairment as the pure-tone average of audiometric hearing thresholds at 500; 1,000; 2,000 and 4,000 Hz (PTA0.54 kHz), dening any hearing loss as >25 dB hearing level (HL) [18], mild hearing loss as PTA0.54 KHz 2640 dB HL and moderate to severe hearing loss as PTA0.54 KHz >40 in the better of the two ears. This dened hearing loss as bilateral.

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ADL scale

The Older American Resources and Services (OARS) ADL scale [19] includes 14 items: seven items assess basic ADL (eating, dressing and undressing, grooming, walking, getting in and out of bed, bathing and continence) and seven items assess instrumental ADL (using the telephone, travel, shopping, meal preparation, housework, taking medicine and management of nances). Each item was rated on a 3-point scale: performs the activity without help (2), performs the activity with some help (1) or completely unable to perform the activity (0), hence, higher the score the more independent the person is. Participants reporting that they needed help with any of the activities or were completely unable to perform any of the activities were considered to have impaired ADL.
Statistical analysis

Table 1. Descriptive characteristics of study participants by hearing loss (>25 dB HL)

Characteristics Participants (n = 1,572) No hearing loss, n = 886 (56.4%) 70.4 (6.6) 360 (40.6) 127 (46.4) 178 (20.2) 142 (16.2) 424 (48.6) 111 (14.0) 81 (10.7) 21 (2.4) Hearing loss, n = 686 (43.6%) 77.2 (7.0) 305 (44.5) 285 (75.2) 196 (28.8) 147 (21.8) 384 (56.5) 101 (16.9) 76 (13.6) 35 (5.2) P-value

........................................
Mean age SD (years) Men HHIE-S score >8 Admission to hospital in past 12 months History of cardiovascular disease History of arthritis History of diabetes Probable depressiona Cognitive impairmentb <0.0001 0.13 <0.0001 <0.0001 0.01 0.002 0.14 0.12 0.003

SAS software (SAS Institute, Cary, NC, USA) version 9.1 was used for the analysis including t-tests, 2 tests and logistic regression. Age-related hearing loss was the dependent variable and impaired ADL was the independent variable. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (OR) and 95% condence intervals (CI). Multivariable regression models were rst adjusted for age and sex, and then further adjusted for potential confounders that were found to be signicantly associated with impaired ADL (i.e. cognitive impairment, probable depression and hospital admission in the past 12 months). P-values < 0.05 were considered statistically signicant.

Data are presented as mean (standard deviation, SD) or n (%), unless otherwise specified. HHIE-S: Hearing Handicap Inventory ElderlyShortened version. a Mental Health Index score 59. b Mini-Mental State Examination score <24.

Results
Participants with hearing loss (n = 686) compared with those without hearing loss (n = 886) were more likely to be older, have a hearing handicap, to have been admitted to hospital in the past 12 months, and to have a history of cardiovascular disease and arthritis and to be cognitively impaired (Table 1). One-hundred and sixty-four (10.4%) participants selfreported impaired ADL. A signicantly higher proportion of hearing-impaired than non-impaired adults reported difculties in performing three out of the seven basic ADL and six out of the seven instrumental ADL tasks (Table 2). We observed highly statistically signicant differences in the frequency of those with and without hearing loss reporting difculties with the following instrumental ADL: (i) Can you get to places out of walking distance; (ii) Can you go shopping for groceries or clothes and (iii) Can you do your housework (Table 2). After adjusting for age, sex, cognitive impairment, probable depression and admission to a hospital in the past 12 months, increasing severity of hearing loss was associated with impaired ADL (Ptrend = 0.001). Specically, those with moderate to severe hearing loss were almost three times as likely to report difculties with ADL as persons without

hearing loss. However, HHIE scores were not associated with impaired ADL (Table 3). Additionally, we stratied the subjects by age group. Those aged <75 years with a hearing loss were twice as likely to experience impaired ADL as those without impaired hearing, multivariate-adjusted OR 2.57 (95% CI: 1.195.59). After multivariate-adjustment those aged <75 years with moderate to severe hearing loss had a 8-fold higher odds of difculty in ADL compared with those without hearing loss, OR: 8.60 (95% CI: 3.1223.70). Signicant associations were not observed in the 75 years and over age-group. After multivariate-adjustment, those who reported having worn or to be wearing a hearing aid (n = 285) were more likely to have impaired ADL compared with those not wearing/worn an aid (n = 1,272), multivariate-adjusted OR: 2.14 (95% CI: 1.363.36). Duration of current hearing aid use [i.e. frequent (>1 h/day) and infrequent use (1 h/ day)] was not associated with impaired ADL.

Discussion
Our study demonstrates an independent association between severity of hearing loss and functional disability. Hearing-impaired subjects reported restrictions in routine activities such as grocery/clothes shopping, preparing meals and doing household chores. Compared with persons with normal hearing, those with impaired hearing reported more difculty performing instrumental ADL tasks such as shopping and going to places. By comparison, the impact of hearing loss on basic ADL such as eating and grooming was modest. This is in agreement with the everyday competence model that hypothesizes that sensory resource loss such as deafness will have a differential effect on functional ability; specically,

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Table 2. Participants response to activities of daily living (ADL) questions stratified by hearing loss (>25 dB HL)
No hearing loss n % Any hearing loss n % P-value

........................................
1. Can you use the telephone No help 744 98.3 540 Some help/completely unable 13 1.7 28 2. Can you get to places out of walking distance No help 730 96.2 501 Some help/completely unable 29 3.8 67 3. Can you go shopping for groceries or clothes No help 730 96.2 491 Some help/completely unable 29 3.8 75 4. Can you prepare your own meals No help 716 94.3 503 Some help/completely unable 43 5.7 64 5. Can you do your housework No help 603 80.0 370 Some help/completely unable 151 20.0 195 6. Can you take your own medications No help 736 98.5 538 Some help/completely unable 11 1.5 21 7. Can you handle your own money No help 740 97.5 545 Some help/completely unable 19 2.5 23 8. Can you eat No help 757 99.3 562 Some help/completely unable 5 0.7 5 9. Can you dress and undress yourself No help 754 99.1 557 Some help/completely unable 7 0.9 10 10. Can you take care of your own appearance No help 758 99.6 562 Some help/completely unable 3 0.4 4 11. Can you walk No help 749 98.6 545 Some help/completely unable 11 1.5 22 12. Can you get in and out of bed No help 759 99.7 559 Some help/completely unable 2 0.3 5 13. Can you take a bath or shower No help 751 98.7 548 Some help/completely unable 10 1.3 17 14. Do you ever have trouble getting to bathroom on time No 686 90.3 485 Yes or has a colostomy/catheter 74 9.7 80 95.1 4.9 88.2 11.8 86.8 13.3 88.7 11.3 65.5 34.5 96.2 3.8 96.0 4.1 99.1 0.9 98.2 1.8 99.3 0.7 96.1 3.9 99.1 0.9 97.0 3.0 85.8 14.2 0.001

<0.0001

<0.0001

0.0002

<0.0001

0.01

0.11

0.64

0.18

0.44

0.005

0.12

0.03

0.01

complex tasks will be more severely affected than basic tasks [20]. Thus, loss of competence would initially be manifested in instrumental ADL tasks, before it impacted on simpler self-care ADL tasks [20]. Further, basic ADL such as eating compared with instrumental ADL such as using the telephone, rely less on auditory than visual input [8]. Strong, independent associations were observed between hearing loss and difculty in ADL in adults aged <75 years, but not among those older than 75. This decreasing effect with age suggests that hearing loss per se is not the most important cause of impaired ADL in the oldest old [21]. This is plausible, as a variety of competing causes accumulate over a lifetime contributing to functional

disability; hence, detecting an association with hearing loss could be more difcult. Older persons with a greater degree of hearing loss (>40 dB HL) in our study had a higher likelihood of experiencing functional disability. This nding concurs with the EHLS [6] and another US population-based study of 2,461 adults aged 50 + years [9] that reported individuals with moderate to severe hearing loss were more likely than those without hearing loss to have impaired ADL. There are several possible pathways by which severe hearing loss could lead to reduced functional independence. First, impaired hearing correlates with impaired postural balance which may underlie mobility decline [22], and thus, cause functional disability. Second, auditory cues have been shown to be important for spatial orientation [23]. A signicant decrease in environmental acoustic information due to hearing loss could emerge as uncertainty and poorer functioning in ADL tasks [22]. Third, as communication is an important aspect of daily living and in particular to perform instrumental ADL tasks, such as shopping and using the telephone, it is not surprising that hearing loss with its resulting communication problems would be associated with difculty in performing these activities [22] which typically involve higher levels of competing noise. Older adults who have worn or wearing a hearing aid had a 2-fold increased odds of difculty performing ADL. This nding concurs with data from a Norwegian study that showed an association between previous hearing aid experience and activity limitation [24]. Wearing a hearing aid is not likely to be the direct cause of this reduced everyday competence. It is more plausible that hearing aid use is a marker of hearing loss severity, that is, persons with worse hearing are more likely to wear an aid. Another explanation could be related to the non-acceptance of a hearing impairment, which is a well-known phenomenon [25] that could mask the persons perception of activity limitation and participation restriction [24, 26]. This is in line with other research that has shown that undiagnosed subjects tend to view their health situation more optimistically than those who have already been diagnosed [24]. Nevertheless, it needs to be highlighted that hearing aid use has been shown to improve the ability to communicate and, thus, improve quality of life, and prevent social isolation and hearing-related depression [2729]. Future studies on the health implications of our study ndings are warranted, and could focus on the implications of hearing impairment including the impact on physical conditioning by difculty in walking [5] and the greater likelihood of experiencing functional impairment overall. This requires further conrmation of our ndings by other large, prospective studies of older adults. Our data also indicate that older adults with moderate to severe hearing loss are possibly at a higher risk of experiencing reduced capacity for independent living. This in turn implies that hearing rehabilitation programmes need to examine current practices in order to optimize training and assistance with ADL [20].

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Table 3. Association between Measured Hearing Loss, Hearing Handicap Inventory for Elderly (HHIE) Scores and Activities of Daily Living (ADL)
Mean ADL score (SD) Impaired ADL, OR (95% CI) Age-sex adjusted Multivariate-adjusteda

....................................................................................
Presence of hearing loss No hearing loss (25 dB HL), n = 886 Any hearing loss (>25 dB HL), n = 686 Severity of hearing loss No hearing loss (25 dB HL), n = 886 Mild hearing loss (2640 dB HL), n = 476 Moderate to severe hearing loss (>40 dB HL), n = 212 Ptrend Severity of hearing handicap No handicap (HHIE <8), n = 350 Moderate handicap (HHIE 824), n = 319 Severe handicap (HHIE 26), n = 88 Ptrend
a

27.14 (2.10) 26.34 (2.94) 27.14 (2.10) 26.67 (2.55) 25.59 (3.59)

1.0 (reference) 1.46 (0.952.25) 1.0 (reference) 1.12 (0.691.81) 2.39 (1.414.05) 0.003 1.0 (reference) 0.83 (0.501.40) 2.17 (1.144.10) 0.05

1.0 (reference) 1.53 (0.952.48) 1.0 (reference) 1.12 (0.651.91) 2.87 (1.595.19) 0.001 1.0 (reference) 0.94 (0.521.69) 2.11 (1.004.43) 0.10

26.83 (2.41) 26.54 (2.45) 25.20 (3.79)

OR, odds ratio; CI, confidence interval; SD, standard deviation. Further adjusting for cognitive impairment, probable depression and admission to a hospital in the past 12 months.

The current study has several strengths including its representative large cohort, high participation rate and use of standardized, audiometric testing to measure hearing sensitivity. However, some limitations also deserve discussion. First, these data are cross-sectional; hence, we cannot infer that hearing loss preceded the development of functional disability. While it is highly unlikely that difculty in ADL would cause hearing loss, it is more likely that both hearing function and physical ability decrease with ageing so that hearing impairment accompanies functional disability [30]. We also cannot rule out the possibility of selection bias as there were signicant differences in some of the baseline characteristics between those who had complete audiometric data versus those who did not, which could have inuenced our results. Finally, measures of handicap and disability were obtained by self-report, which could have led to an overestimation or underestimation of function depending on contextual factors [20]. However, these measures were obtained by using standardized instruments that are well documented in the literature [6]. In summary, our ndings indicate that for older adults, the presence of a moderate to severe hearing loss could make the difference between independence and the need for formal support services or placement. These ndings reinforce previous literature showing that hearing loss is associated with poorer health outcomes, and highlight the need for effective aural rehabilitation to preserve functional independence in later life.

Research Council (Grant Nos. 974159, 991407, 211069, 262120). The authors also acknowledge nancial support from the HEARing CRC, established and supported under the Australian Governments Cooperative Research Centres Program.

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Conflicts of interest
None declared.

Funding
The Blue Mountains Eye and Hearing Studies were supported by the Australian National Health and Medical

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Received 22 February 2011; accepted in revised form 4 July 2011

Age and Ageing 2012; 41: 200206 doi: 10.1093/ageing/afr174 Published electronically 4 January 2012

The Author 2012. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Why do geriatric outpatients have so many moderate and severe vertebral fractures? Exploring prevalence and risk factors
HANNA C. VAN DER JAGT-WILLEMS1, MARIKE VAN HENGEL2, MARIJN VIS3, BARBARA C. JOS P. C. M. VAN CAMPEN1, LINDA R. TULNER1, WILLEM F. LEMS3
1 2

VAN

MUNSTER4,5,

Department Department 3 Department 4 Department 5 Department

of of of of of

Geriatrics, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands Geriatrics, Hofpoort, Woerden, The Netherlands Rheumatology, VUMC, Amsterdam, The Netherlands Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands

Address correspondence to: H. C. van der Jagt-Willems. Tel: +31 20 5125208; Fax: +31 20 5125209. Email: h.vanderjagt@slz.nl

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