Qual Life Res DOI 10.1007/s11136-014-0657-0

Sensory impairments and their associations with functional disability in a sample of the oldest-old Verena R. Cimarolli • Daniela S. Jopp

Accepted: 20 February 2014 Ó Springer International Publishing Switzerland 2014

Abstract Purpose Research focusing on the consequences of sensory impairments for the everyday competence of the oldest-old is emerging. The two main goals of this study were to document the prevalence of self-reported vision, hearing, and dual sensory impairment and to explore associations of these impairments with functional disability in near-centenarians and centenarians. Methods Centenarians and near-centenarians (N = 119; average age = 99) were recruited, with about 80 % living in the community. In-person interviews included self-ratings of vision and hearing impairment and functional disability conceptualized as having difficulties performing personal and instrumental activities of daily livings (PADLs and IADLs). Results Based on self-report ratings, 17 % of participants were classified as having a visual impairment only, 18 % as having a hearing impairment only, and 38 % with both a visual and hearing impairment (dual sensory impairment). Regression analyses demonstrated that having a vision impairment only and being dual sensory impaired were the strongest predictors of functional disability. They were associated with higher levels of functional disability over and above higher levels of depressive symptomatology, interference of health with desired activities, and living in a nursing home. V. R. Cimarolli (&) Research Institute on Aging, The Guild Center for Research in Vision and Aging, Jewish Home Lifecare, 120 West 106th Street, New York, NY 10025, USA e-mail: [email protected] D. S. Jopp Department of Psychology, Fordham University, 441 East Fordham Road, Bronx 10458, NY, USA

Conclusions Sensory impairments—especially dual sensory impairment—are prevalent in the oldest-old. Having dual sensory impairment or a single visual impairment among other factors are strongly associated with lessoptimal everyday functioning in the oldest-old. Keywords Centenarians  Oldest-old  Dual sensory impairment  Visual impairment  Hearing loss  Functional disability

Introduction Age-related visual impairment and hearing loss are common chronic conditions among older adults, and their prevalence is increasing with age. Approximately 15–20 % of adults age 65 and older and more than one-fourth of those aged 75 and older have functional problems due to age-related vision loss [1–3]. Hearing loss is even more prevalent and is experienced by 20–43 % of older adults with its prevalence doubling with each age decade [4, 5]. Dual sensory impairment is also common with 9–34 % of older adults having both vision and hearing impairment concurrently [1, 6–8]. Age-related vision and hearing loss are both associated with a heightened risk for functional disability [9–16]. Given this relationship between sensory impairments and disability in later life, it is not surprising that, for example in the case of vision impairment, prior research has consistently documented high rates of depression in older adults experiencing vision loss [e.g., 17–21]. Another common negative consequence of both vision and hearing includes reduced social interaction [9–16, 21]. In addition, vision impairment is associated with increased risk for falls [22] and hip fractures [23], cognitive decline [24], and even

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mortality risk [25]. Research has also shown that older adults with dual sensory impairments have a higher risk for functional disability, social isolation, depression as well as mortality risk when compared to those who have a single impairment only and those with no impairment [1, 6, 8, 26– 28]. While we do know that progressive sensory impairments are common in the 65 ? age group and that the resulting functional, social, and psychological consequences negatively affect the well-being of the age groups of the young– old (65–79 years) and old–old (80–94 years), there is a very little research available on individuals aged 95 and older. In particular, there is very little research involving this age group on determining the contributions of these sensory impairments to functional disability. Given that the oldest-old is the fasted growing segment of the population in developed countries around the world, studies are urgently needed that investigate the prevalence of these sensory impairments in very advanced age, and their specific and additive (i.e., dual sensory impairment) impact on the everyday competence (i.e., functional disability) of this age group. The USA is the country with the largest number of very old individuals. The US Census documented about 53,000 centenarians in 2010, and the numbers of individuals reaching their 100th birthday in the USA are expected to increase to about 600,000 in 2050. Following the urgent need to learn more about this rapidly growing segment of the population, the study of very old individuals, especially near-centenarians and centenarians, has been emerging over the past decade [29–32]. Given that some centenarians seem to be healthier than younger age groups, possibly due to a specific genetic makeup [33], one important question is whether the trend of increasing prevalence of vision and hearing impairment continues from young–old to old–old age. Furthermore, other studies involving centenarians have identified factors such as advanced age, being female, an increased number of health problems, reduced physical activity, and reduced positive affect to be associated with increased functional disability [34–36]. Yet, little is known about the specific and additive consequences of sensory impairments for the everyday functioning of near-centenarians and centenarians. Hence, the purpose of our study was twofold: [1] to document the prevalence of self-reported vision, hearing, and dual sensory impairment and [2] to explore associations of these impairments with functional disability in near-centenarians and centenarians. We relied on the World Health Organization’s [WHO; 37] model of functioning, disability and health as the conceptual framework for studying the effects of sensory impairment status on the everyday functioning of the oldest-old. The model postulates that how an individual can perform an activity (execution of a task or action) depends on interactions between

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health conditions (diseases, disorders, and injuries), body functions and structures (impairments represent problems with body functions and structures), participation or involvement in life situations (participation restrictions represent problems in involvement in life situations), and contextual factors. Contextual factors include external environmental factors (e.g., social structures) and internal personal factors (e.g., gender). Guided by the model, we aimed to explore the unique contributions of vision, hearing, and dual sensory impairments in predicting levels of functional disability when controlling for other factors identified in the model including other impairments (i.e., cognitive impairments, depressive symptomatology, and comorbidity), participation restriction, as well as contextual factors (personal and environmental factors).

Methods Participant selection and recruitment We recruited individuals 95 years old or older living in three diverse boroughs of New York City from a list provided by the Voters Registry and from three collaborating geriatric health care organizations. We used the list of the Voters Registry with the goal of obtaining a more representative sample of the true population of the oldest-old and to reduce self-selection bias. We invited 320 eligible target individuals, and 116 (47 %) agreed participation. Main reasons for refusal included being too busy or being concerned that participation would be too stressful. This recruitment approach resulted in 101 interviews (as several potential participants experienced illness downturns or deceased before the interview could be conducted), and data of 93 interviews were used (data from seven individuals had to be excluded due to cognitive restrictions putting in question its reliability). Since our recruitment approach made it somewhat more difficult to get in touch with individuals living in institutionalized care settings (e.g., these individuals often have no own phone number), we recruited an additional 18 individuals with the support of five collaborating geriatric health care organizations. The final sample included 119 individuals with ages ranging between 95 and 107 years. All study procedures and protocols were approved by two Institutional Review Boards, and all participants provided written consent after being read the details of study procedures, potential risks and benefits, and the use of data. After participants provided consent, interviews were scheduled in two sessions and conducted at the participant’s place of residence to minimize interview strain. Participants were compensated $25 (US) for study participation.

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Measures

Outcome variable

Predictor variables

Functional disability was assessed with items of the Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire [41]. Seven items each were used to assess personal (basic) as well as instrumental activities daily living (PADL and IADL, respectively). Respondents were asked how much difficulty they had performing these 14 activities of daily living by rating them on a four-point scale (1 = no difficulty; 4 = can’t do without help). The point ratings of the 14 items were summed to create total scores for activities of daily living ranging between 14 and 56.

Impairments Self-rated vision and hearing status were assessed with one item each. Participants were asked to rate their eyesight and hearing on a five-point scale (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor). Based on these ratings, participants were classified as having ‘no sensory impairments’ (ratings of 3–5 on both vision and hearing items), having a ‘hearing impairment only’ (ratings of 1–2 on the hearing item and ratings of 3–5 on the vision item), having a ‘vision impairment only’ (ratings of 1–2 on the vision item and ratings of 3–5 on the hearing item), or as having a ‘dual sensory impairment’ (ratings of 1–2 on both vision and hearing items). Cognitive functioning was assessed with 13 items of the Mini-Mental State Examination (MMSE) [38] to ensure age–fair testing. Scores on this shortened version can range between 0 and 21. Specifically, we used the following subscales: Orientation (range 0–10 points), Registration (range 0–3 points), Attention (range 0–5 points), and Recall (range 0–3 points). Therefore, comparisons of the scores on these subscales are possible. This shortened version is recommended in research with near-centenarians and centenarians to account for sensory and tactile impairments that could potentially prevent successful completion of certain items/tasks and result in ‘method-induced’ lower cognitive functioning [e.g., folding paper; 39]. Depressive symptomatology was assessed with the 15-item version of the Geriatric Depression Scale (GDS) [40]. Participants are asked to report the occurrence of depressive symptoms by answering yes (1) or no (0) in reference to how they have been feeling recently. Scores can range from 0 to 15 with higher scores indicating more depressive symptomatology. Number of health problems was assessed by presenting participants with a list of 15 health problems and by asking if they currently had any of them. The list, for example, included diabetes, heart problems, and stroke. Participation restriction To obtain an indicator of participation restriction, we asked participants to report how often they feel their health gets in the way of doing things they want to do (1 = never; 5 = always). Contextual factors One-item indicators were utilized to assess personal factors (i.e., gender, race, and education) and environmental factors (i.e., income adequacy, residency status [living in a nursing home yes/no]).

Statistical analyses Descriptive analyses were run on all study variables. We computed a correlation matrix to examine the interrelationships between the independent variables with the outcome variable functional disability. Guided by the WHO model of functioning, disability and health [37], the independent variables included impairments/problems with body functions (i.e., sensory impairments status, depressive symptomatology, cognitive functioning, and number of health problems), participation restriction (i.e., interference of health with desired activities), personal factors (.i.e., gender, race, and education), and environmental factors (i.e., income adequacy and living in nursing home). Then, we used multiple regression analysis for testing the effects of independent variables on the outcome functional disability. In the regression analysis, we only included independent variables (with the exception of hearing impairment because of our focus on sensory impairments) that were significantly correlated with functional disability. Finally, we conducted a set of hierarchical regression analyses to determine the independent (unique) variance in functional disability explained by significant predictor variables (i.e., determine the change in R2 for a specific predictor while controlling for all other predictors). In preparation for the regression analyses, standardized residuals were inspected. Multicollinearity was considered using VIF and tolerance criterion. All analyses were performed with Statistical Package for Social Sciences (SPSS version 20.0).

Results Table 1 summarizes sociodemographic and sensory impairment-related characteristics. The average age of the sample was 99 with ages ranging from 95 to 107. Not surprisingly, the vast majority (78 %) was women representing the typical gender distribution in very advanced

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Qual Life Res Table 1 Sociodemographic, sensory impairment, and other healthrelated characteristics (N = 119) Variable

n

%

Age (Range 95–107; n = 119) Gender (female; n = 119)

Independent variables

Mean (SD) 99.25 (2.50)

93

Table 2 Bivariate correlations of study variables with the outcome

78.2

Impairments Vision impairment only (Yes)

Race (n = 119)

Hearing impairment only (Yes)

Non-Hispanic white

92

77.3

Dual sensory impairment (Yes)

Non-Hispanic black

23

19.3

Cognitive functioning

4

3.4

23 59

19.3 49.6

Number of chronic health problems Participation restriction

No college education

57

50.4

Personal factors

College education or higher

56

49.6

Can’t make ends meet/Just manage to get by

43

40.6

Have enough money with extra/Money no problem Subjective vision impairment (n = 117)

63

59.4

Hispanic Living in nursing home (n = 119) Living alone in community (n = 119)

Depressive symptomatology

Education (n = 113)

Degree of interference of health with desired activities Age

Income adequacy (n = 106)

32

27.4

32

27.4

Good

31

26.5

Very good

15

12.8

Excellent

7

6.0

Poor

17

14.5

Fair

48

41.0

Good

36

30.8

Very good

13

11.1

Excellent

3

2.6

No impairment

32

27.4

Vision impairment only Hearing impairment only

20 21

17.1 17.9

Dual sensory impairment

44

37.6

Subjective hearing impairment (n = 117)

2.46 (.96)

16.48 (4.03)

Depressive symptomatology (GDS; range 1–12; n = 107)

4.42 (2.83)

Number of chronic health problems (range 0–9; n = 108)

3.00 (2.04)

Functional disability (range 14–55; n = 109)

26.72 (11.08)

age. About half of respondents reported living alone in the community. While about 50 % each reported ‘poor’ or ‘fair’ vision and hearing, the remaining reported either ‘good,’ ‘very good,’ or ‘excellent’ vision and hearing.

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.47** .31** .41** .07 .17

Race (White)

.07 -.12

Living in a nursing home (yes) Income adequacy

.24* -.15

* p \ .05, ** p \ .01

Sensory impairment status (n = 117)

Cognitive functioning (MMSE; range 5–21; n = 119)

.26** -.16

Environmental factors 2.42 (1.19)

Fair

.25* -.10

Gender (female) Educational level

Poor

Functional disability

Based on our classification system for sensory impairments, we found that the most common sensory impairment status was dual sensory impaired (about 38 % of the sample) followed by no impairment (28 %), hearing impairment only (18 %), and vision impairment only (17 %). Table 2 depicts bivariate relationships between independent variables and our outcome functional disability. On a bivariate level, higher functional disability was significantly associated with having a vision impairment only, having the dual sensory impairment, higher depressive symptomatology, a higher number of chronic health problems, higher levels of interference of health with desired activities, and with living in a nursing home. The regression of functional disability on independent variables accounted for 46 % of the variance (see Table 3). There was also no indication for inflation of the variance due to multicollinearity. Having a vision impairment only, having a dual sensory impairment, higher depressive symptomatology, higher levels of interference of health with desired activities, and living in a nursing home each contributed a unique portion of the variance in functional disability. Participants who reported having a vision impairment only, having a dual sensory impairment, more depressive symptoms, higher levels of interference of their health with desired activities, and living in a nursing home were more likely to be more functionally disabled. Determining the amount of independent variance (see Fig. 1) demonstrated that vision impairment only was the strongest

Qual Life Res Table 3 Summary of multiple regression analyses predicting functional disability B

SE B

b

Vision impairment only (Yes)

9.09

2.79

.31**

Hearing impairment only (Yes)

2.26

2.70

.08

Dual sensory impairment (Yes)

6.56

2.37

.29**

Depressive symptomatology

.99

.35

.25**

Number of chronic health problems

.83

.47

.15

1.71

.69

.22*

6.61

2.22

.24**

Independent variables Impairments

Participation restriction Degree of interference of health with desired activities Environmental factor Living in a nursing home (yes) R2

.46

F

10.50***

* p \ .05, ** p \ .01, *** p \ .001

predictor of functional disability and explained almost 7 % of unique variance followed by nursing home residency, depressive symptoms, dual sensory impairment, and activity interference.

Discussion Our study of the oldest-old showed that the prevalence of self-reported dual sensory impairment is substantially higher than in younger age groups. Using similar self-report measures to determine sensory impairment status like in the present study, Brennan and colleagues [6], for example, found in a sample with an average age of 78 years that about one-fifth of participants had dual sensory impairment, which

is about half of the rate (close to 40 %) revealed in our study. Our findings suggest that moving into very advanced age dramatically increases the risk of developing a dual sensory impairment. Interestingly, the prevalence rate of vision impairment only and hearing impairment only in the present study was with about 20 % similar to the rate for younger age groups in prior studies [6]. Although a smaller proportion of our participants appeared to be free of sensory impairment compared to previous research with younger age groups (30 vs. 40 %), it seems remarkable that such a substantial minority of the oldest-old reported no impairment with respect to both hearing and vision. Given the advanced age of our participants and the typical course of progressively worsening sensory impairments, this finding was unexpected. Comparing the prevalence rates found in our study with those from other studies of near-centenarians and centenarians is somewhat difficult, given that these studies do not consider dual sensory impairment but assess the prevalence of vision and hearing impairment independent from each other and given that some of these studies used objective measures of vision and hearing rather than subjective self-report measures [e.g., 31, 42]. Using the WHO model of functioning, disability and health [37] as the conceptual framework for studying the effects of sensory impairment status on the everyday functioning proved successful, as shown by a notable proportion of individual differences explained by the chosen predictors. Regarding our sensory impairment-related predictors of functional disability, we found that having a vision impairment only or being dual sensory impaired was negatively linked with everyday competence but hearing impairment was unrelated. In fact, having a vision impairment only was the predictor with the strongest explanatory value in terms of functional disability and the explanatory value of dual

Fig. 1 Independent (unique) variance in functional disability explained by significant predictor variables

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sensory impairment was as strong as that of depressive symptoms. Firstly, this confirms the relationship of sensory impairment and disability found in research with younger age groups [e.g., 6, 9, 13] and highlights the importance of considering sensory impairment status for everyday functioning. Given that maintenance of independence is of high importance for most individuals, ensuring that individuals are enabled to perform everyday activities despite a sensory loss is essential. Secondly, we also confirmed the link between depression and disability established for younger age groups that points to disability typically maintaining an independent relationship with depression severity, even when other important correlates of depression, such as education and income, are controlled [43]. Furthermore, we demonstrated that higher perceived participation restriction—another important component of the WHO model of functioning, disability and health [37]—was associated with more functional disability which is in line with previous research that found, for example, that lower social participation levels were associated with increased everyday functioning limitations [e.g., 13]. Our final finding was that out of the contextual factors considered as part of our conceptual model, only ‘living in a nursing home’ (one of our environmental factors) was related to higher disability. This was in line with our expectations as nursing home residents are commonly those with a high need for help with everyday tasks due to increased comorbidity. In summary, it appears that when relying on the WHO model as a conceptual framework utilizing our predictor variables of choice to operationalize the various constructs of model, impairment variables are the most prominent contributors to disability. As a study limitation, we need to mention that the prevalence rates we found may not represent the true prevalence rates of sensory impairment among the oldestold as our sample of centenarians and near-centenarians represents a positive selection of these oldest-old individuals. Our sample likely included those in better physical and mental health when compared to the near-centenarians and centenarians who did not choose to participate in the study. However, we tried to minimize this bias by recruiting our sample from a Voters Registry list and not via self-nomination or nomination through relatives, the common recruitment approach of most US centenarian studies which is likely to result in a more positive selection. Another study limitation is that for the purpose of minimizing participant burden, this study used a subjective one-item ratings and did not include objective assessments of participants’ vision and hearing status like other studies [e.g., 8]. However, this may have been an advantage given that the relationship between objective vision and hearing indicators and well-being outcomes has been found to be less strong. For example, there is evidence for a weak

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relationship between the objective severity of the vision loss (typically measured by visual acuity) and depression [44] and a nonsignificant relationship between objective measurements of vision loss (visual acuity and contrast sensitivity) and functional disability [45]. Hence, when studying the impact of sensory impairments on everyday competence of older adults, subjective assessments of sensory impairments may in fact be more effective in capturing the full extent of their impact. A final limitation is that the present study is cross-sectional in nature and therefore, does not permit causal interpretations of the findings. It would be important to determine causal pathways linking sensory impairments, depression, participation restriction, contextual factors, and functional disability in this advanced age population. Hence, future studies should attempt to collect longitudinal data regarding the development of functional disability in the oldest-old over time.

Conclusions This study demonstrates the high prevalence of sensory impairments—especially dual sensory impairment—and their strong negative association with everyday competence of the oldest-old—the near-centenarians and centenarians. Having a single visual impairment or a dual sensory impairment has the most pronounced negative impact on carrying out tasks of daily living. Like younger age groups, this group could likely benefit from interventions, such as vision and audiological rehabilitation, that have the potential to maximize older adult’s independent functioning and adjustment to progressive sensory loss. Acknowledgments The Fordham Centenarian Study was made possible by a Brookdale Leadership in Aging Fellowship to Dr. Jopp and funding by Fordham University.

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Sensory impairments and their associations with functional disability in a sample of the oldest-old.

Research focusing on the consequences of sensory impairments for the everyday competence of the oldest-old is emerging. The two main goals of this stu...
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