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Purpose: Low patient activation is associated with poor patient outcomes. People with vision impairment may have low patient activation as a result of communication and access barriers. We examined the association of patient activation with vision impairment., Methods: Cross-sectional study using the 2016 Medicare Current Beneficiary Survey. Older Medicare beneficiaries, without dementia, who completed the topical patient activation questionnaire were included. The primary exposure was self-reported vision impairment (no vision impairment, a little vision impairment, a lot of vision impairment), and the secondary exposure was dual sensory impairment (no sensory impairment, vision impairment only, hearing impairment only, dual sensory impairment). Patient activation scores were categorized as low, moderate, or high based on their distribution around the mean. Multivariable-adjusted ordinal regression models examined the association of patient activation with vision impairment, and then with dual sensory impairment., Results: In total, 6,683 participants were included. Those with a little vision impairment had 20% lower odds of higher patient activation (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.71-0.90), and those with a lot of vision impairment had 26% lower odds of higher patient activation (OR = 0.74, 95% CI = 0.55-0.98). In the second model, having vision or hearing impairment only was associated with lower odds of higher activation than having no sensory impairment. Having dual sensory impairment was associated with even lower odds of higher activation., Conclusion: Older Medicare beneficiaries with sensory impairment may be a group to target to improve patient activation levels, which could potentially improve health outcomes and health care utilization patterns in this population.

Objectives: Vision and hearing impairments are highly prevalent conditions among older adults, and well-established links exist between sensory impairment and household, mobility, and self-care activity limitations. However, studies examining the impact of unmet long-term services and supports (LTSS) needs have not considered the role of vision and hearing impairment on the risk of experiencing adverse consequences, including wetting or soiling oneself., Method: Using Rounds 1 and 5 of the National Health and Aging Trends Study, a nationally representative survey of Medicare beneficiaries aged 65 and older, we examine the association of vision and hearing impairment on the odds of experiencing an adverse consequence while accounting for other sociodemographic and health status factors., Results: Among a weighted population of 49,770,947 community-living older adults with limitations in household, mobility, or self-care activities, 20.1% (95% CI: 19.2-21.0) experienced an adverse consequence as a result of unmet LTSS needs. In the fully adjusted regression, individuals with vision or hearing impairment had 96% (odds ratio [OR]: 1.96; 95% CI: 1.64-2.34) and 43% increased odds (OR: 1.43; 95% CI: 1.24-1.65), respectively, of experiencing any adverse consequence. Hearing impairment was associated with higher odds of household or self-care adverse consequences, while vision impairment was associated with higher odds of mobility or self-care adverse consequences., Discussion: Sensory impairment may increase the risk for adverse consequences for older adults with unmet LTSS needs. Activities that support older adults living safely in the community should consider the role of sensory impairment and how to address the unique needs of those with hearing or vision impairment., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Late-life depression is a comorbidity that may co-occur in older adults with hearing loss-each has prevalent and independent modifiable risk factors for dementia., Methods: Using data from 1,820 Health, Aging and Body Composition study participants (74 ± 2.8 years, 38% Black race), we compared the hearing loss-dementia/cognitive decline relationship between those with normal hearing/mild hearing loss and those with moderate or greater hearing loss. Using linear mixed-effects and Cox proportional hazard models, we investigated if the associations between hearing loss and cognitive decline or dementia (Modified Mini-Mental State [3MS] Examination and Digit Symbol Substitution Test [DSST]) differed by the presence or absence of depressive symptoms. Depressive symptoms were defined as Center for Epidemiologic Study-Depression scale 10 ≥10 at one or more visits from Years 1-5. Algorithmic incident dementia was defined using medication use, hospitalizations, and cognitive test scores. Audiometric hearing loss was measured at Year 5 and categorized as normal/mild versus moderate or greater hearing loss., Results: Having both hearing loss and depressive symptoms (vs. having neither) was associated with faster rates of decline in 3MS Examination (β = -0.30; 95% confidence interval [CI]: -0.78, -0.19) and DSST (β = -0.35; 95% CI: -0.67, -0.03) over 10 years of follow-up. Having both hearing loss and depressive symptoms (vs. neither) was associated with increased risk (hazard ratio [HR]: 2.91; 95% CI: 1.59, 5.33 vs. HR: 1.54; 95% CI: 1.10, 2.15 hearing loss only and HR: 2.35; 95% CI: 1.56, 3.53 depressive symptoms only) of incident dementia in multivariable-adjusted Cox proportional hazards models., Discussion: Comorbid conditions among hearing-impaired older adults should be considered and may aid in dementia prevention and management strategies., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Audiology is experiencing pressure from market forces that may change the profession's nature. Research suggests that understanding resistance needs to change and organizational culture may provide insights that can facilitate change., Purpose: This study was designed to examine audiologists' resistance to change, organizational culture, and clinical practices related to hearing aid pricing and audiology assistants., Research Design: This study utilized a cross-sectional and nonexperimental survey design., Study Sample: Participants were 205 U.S. audiologists, representing diversity across experience, work setting, and location., Data Collection: This survey examined demographics and clinical practice strategies. Resistance to change (RTC) scale examined disposition toward change. Organizational culture profile (OCP) examined organizational culture perspectives., Results: The majority (52%) of respondents use bundled pricing but 42% of these repondents anticipate transitioning to unbundling. Use of hybrid pricing is increasing. Service-extender personnel were reported by 41%. Although the majority (66%) do not work with audiology assistants currently, 32% of these participants anticipate they will do so in the future. Results indicated lower RTC and greater years of experience were associated with more positive perceptions about organizational culture. Pricing structure was related to experience., Conclusion: Trends indicate use of bundled pricing is decreasing, use of hybrid pricing is increasing, and employment of audiology assistants is increasing. Experienced audiologists are more likely to report unbundled and hybrid pricing compared with less experienced audiologists., Competing Interests: None declared., (American Academy of Audiology. This article is published by Thieme.)

Importance: People with disabilities experience disparities in health care access and outcomes, and inaccessible health care facilities are major barriers to health care access. Methods to collect accessibility request information are needed to improve health care outcomes for patients with disabilities., Objective: To evaluate an electronic health record (EHR)-based questionnaire designed to identify accessibility requests for patients with disabilities at an eye clinic., Design, Setting, and Participants: This cross-sectional pilot study implemented an EHR questionnaire and prospectively collected data on accessibility requests at a university-based eye clinic. The study included 55 722 patients making appointments at the Johns Hopkins Wilmer Eye Institute from April 1, 2019, to March 31, 2020., Main Outcomes and Measures: The Wilmer Eye Institute staff were trained to assess accessibility requests of patients making appointments in-person or via telephone using a standardized script and entering patient responses into the EHR. Data were later extracted for analysis and used to determine the proportion of patients making eye appointments who reported a disability accessibility request (physical, sensory, or intellectual) during their clinic visit., Results: Accessibility request data were collected from 250 932 patient encounters. Patients had a mean (SD) age of 61.9 (20.6) years; most were women (146 846 [58.5%]) and were White individuals (162 720 [64.9%]). Of these, 23 510 (9.4%) encounters were associated with an accessibility request. The most reported accessibility request was mobility related (18 857 [7.5%]) (needing a cane, crutches, motorized scooter, walker, wheelchair, stretcher, assistance standing, or transport services), followed by sensory-related (2988 [1.2%]) (visual, hearing, or speech impairment), intellectual (353 [0.1%]), and other (1312 [0.5%]) (assistance with filling forms or service animal) requests. Patients with an accessibility request compared with those without, were older (72.6 vs 60.8 years), less likely to be White individuals (59.7% vs 65.4%), and more likely to be women (62.6% vs 58.1%), receiving Medicare (69.6% vs 41.5%), and have vision impairment (41.3% vs 13.6%) (P < .001 for all)., Conclusions and Relevance: In this cross-sectional study, a substantial proportion of patients making eye appointments reported having accessibility requests as captured using a new EHR-based questionnaire. Such standardization of data collection for disability-related accessibility requests in EHR is scalable, could be expanded to other clinical settings, and has the potential to improve accessibility of health care interactions for patients with disabilities.

Background: Item response theory (IRT) methods for addressing differential item functioning (DIF) can detect group differences in responses to individual items (e.g., bias). IRT and DIF-detection methods have been used increasingly often to identify bias in cognitive test performance by characteristics (DIF grouping variables) such as hearing impairment, race, and educational attainment. Previous analyses have not considered the effect of missing data on inferences, although levels of missing cognitive data can be substantial in epidemiologic studies., Methods: We used data from Visit 6 (2016-2017) of the Atherosclerosis Risk in Communities Neurocognitive Study (N = 3,580) to explicate the effect of artificially imposed missing data patterns and imputation on DIF detection., Results: When missing data was imposed among individuals in a specific DIF group but was unrelated to cognitive test performance, there was no systematic error. However, when missing data was related to cognitive test performance and DIF group membership, there was systematic error in DIF detection. Given this missing data pattern, the median DIF detection error associated with 10%, 30%, and 50% missingness was -0.03, -0.08, and -0.14 standard deviation (SD) units without imputation, but this decreased to -0.02, -0.04, and -0.08 SD units with multiple imputation., Conclusions: Incorrect inferences in DIF testing have downstream consequences for the use of cognitive tests in research. It is therefore crucial to consider the effect and reasons behind missing data when evaluating bias in cognitive testing., (© 2022. The Author(s).)

Background: To measure the association between individual life-course socioeconomic position (SEP) and hearing aid use, we examined childhood and adulthood socioeconomic variables collected at the Atherosclerosis Risk in Communities (ARIC) study baseline visit (1987-1989)/Life Course Socioeconomic Status study (2001-2002) and hearing aid use data collected at visit 6 (2016-2017)., Methods: ARIC is a prospective cohort study of older adults (45-64 years) recruited from 4 U.S. communities. This analysis included a subset of 2 470 participants with hearing loss at visit 6 (≥25 decibels hearing level [dB HL] better-ear) with complete hearing aid use data. Childhood SEP variables included parental education, parental occupation, and parental home ownership. Young and older adulthood SEP variables included income, education, occupation, and home ownership. Each life epoch was assigned a score ranging from 0 to 5 and then summed to calculate the individual cumulative SEP score. Multivariable-adjusted logistic regression was used to estimate the association between individual cumulative SEP and hearing aid use. Missing SEP scores were imputed for participants with incomplete socioeconomic data., Results: Of the 2 470 participants in the analytic cohort (median [interquartile interval] age 79.9 [76.7-84.0], 1 330 [53.8%] women, 450 [18.2%] Black), 685 (27.7%) participants reported hearing aid use. Higher cumulative SEP was positively associated with hearing aid use (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.04-1.14), and slightly stronger for childhood (OR = 1.09, 95% CI: 1.00-1.20) than older adulthood SEP score (OR = 1.06, 95% CI: 0.95-1.18)., Conclusions: In this community-based cohort of older adults with hearing loss, higher individual life-course SEP was positively associated with hearing aid use., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Sleep characteristics might be associated with hearing loss through disturbed energy metabolism and disrupted cochlear blood flow, but prior evidence is limited. This study aims to investigate cross-sectional associations of sleep duration and signs/symptoms of sleep-disordered breathing with hearing in a nationally representative cohort of US older adults aged 70 and older., Methods: We studied 632 older adults aged 70 and older from the 2005-2006 cycle of the National Health and Nutrition Examination Survey. Hearing thresholds were measured using pure-tone audiometry and were averaged to create speech-frequency (0.5-4 kHz), low-frequency (0.5-2 kHz), and high-frequency (4-8 kHz) pure-tone averages (PTAs) in better-hearing ear, with higher values indicate worse hearing. Sleep duration and signs/symptoms of sleep-disordered breathing (snoring, snorting/stopping breathing, excessive sleepiness) were collected through questionnaires. Multivariable-adjusted spline models with knots at 6 and 8 hours were fitted for associations between sleep duration and PTAs. Multivariable-adjusted linear regression was used for associations between sleep-disordered breathing and PTAs. Primary models adjusted for demographic and lifestyle factors, secondary models additionally adjusted for cardiovascular factors., Results: When sleep duration exceeded 8 hours, every additional hour of sleep duration was marginally associated with higher(poorer) high-frequency PTA (primary: 2.45 dB in hearing level, 95% CI: -0.34 to 5.24; secondary: 2.89 dB in hearing level, 95% CI: 0.02-5.76). No associations were observed between sleep-disordered breathing and hearing., Conclusions: Longer sleep duration is marginally associated with poorer high-frequency hearing among older adults sleeping more than 8 hours. However, we cannot infer temporality given the cross-sectional design. Future longitudinal studies are needed to establish temporality and clarify mechanisms., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Lower physical activity (PA) levels have been proposed as a mechanism to explain the association between hearing loss and various adverse outcomes of aging. But whether hearing loss is associated with lower PA is poorly understood., Objective: To evaluate whether hearing loss is associated with lower levels of PA., Design, Setting, and Participants: This cross-sectional analysis was conducted in a representative sample of US adults (aged 30-69 years) who participated in the 2011-2012 cycle of the National Health and Nutrition Examination Survey (NHANES). Data analysis was conducted from July to September 2021., Exposures: Hearing was assessed, in dB, by pure-tone audiometry and summarized as the better hearing ear's pure-tone average (BPTA) of 4 speech frequencies (500, 1000, 2000, and 4000 kHz); a higher BTPA indicates worse hearing. Hearing was also categorized into normal (BPTA ≤25 dB), mild hearing impairment (>25 to 40 dB), and moderate or greater hearing impairment (>40 dB)., Main Outcomes and Measures: Total 24-hour movement activity was measured using wrist accelerometers worn at all times for 7 consecutive days and summarized in monitor-independent movement summary units (MIMS) units (higher MIMS units indicate more movement). The association between BPTA and MIMS units was evaluated using a multivariable-adjusted (demographic characteristics and chronic conditions) piecewise spline regression (knot at 15 dB). Mean differences in MIMS units across hearing categories compared with normal hearing were estimated., Results: The study included 2490 participants (mean [SE] age, 48.9 [0.3] years; 900 [weighted percentage, 69.3%] White individuals, 1248 [weighted percentage, 50.8%] female participants). Before the knot at 15 dB, we found that each 10-dB higher BPTA was associated with 860.4 (95% CI, 444.8-1276.1) higher MIMS units. Conversely, after the knot, each 10-dB higher BPTA was associated with 458.6 (95% CI, 27.7-889.4) lower MIMS units. The difference in MIMS units across hearing categories was not statistically significant., Conclusions and Relevance: In this cross-sectional study, in the range of hearing sensitivity of BPTA of 15 dB or greater, worse hearing was associated with lower MIMS units. Lower PA may be a mechanism contributing to the association between hearing impairment and adverse health.

Importance: The implications of cigarette smoking and smoking cessation for hearing impairment remain unknown. Many studies on this topic have failed to account for attrition among smokers in their findings., Objective: To assess the association of cigarette smoking patterns with audiometric and speech-in-noise hearing measures among participants of the Atherosclerosis Risk in Communities Study., Design, Setting, and Participants: This cross-sectional study included participants of the Atherosclerosis Risk in Communities Study from 4 US communities. The analysis includes data from visit 1 (1987-1989) through visit 6 (2016-2017); data were analyzed from March 16 through June 25, 2021. Audiometric hearing and speech-in-noise testing was offered to all participants at visit 6. Participants with incomplete audiometric data or missing data for educational level, body mass index, drinking status, a diabetes or hypertension diagnosis, or occupational noise were excluded. In addition, individuals were excluded if they self-reported as having other than Black or White race and ethnicity, or if they self-reported as having Black race or ethnicity and lived in 2 predominantly White communities., Main Outcomes and Measures: Smoking behavior was classified from visit 1 (1987-1989) to visit 6 (2016-2017) using group-based trajectory modeling based on self-reported smoking status at each clinic visit. Hearing was assessed at visit 6. An audiometric 4-frequency (0.5, 1, 2, 4 kHz) pure-tone average (PTA) was calculated for the better-hearing ear and modeled as a continuous variable. Speech-in-noise perception was assessed via the Quick Speech-in-Noise Test (QuickSIN) and modeled continuously. Attrition during the 30 years of follow-up was addressed by inverse probability of attrition weighting., Results: A total of 3414 participants aged 72 to 94 years (median [IQR] age, 78.8 [76.0-82.9] years; 2032 [59.5%] women) when hearing was measured at visit 6 (2016-2017) were included in the cohort; 766 (22.4%) self-identified as Black and 2648 (77.6%) as White individuals. Study participants were classified into 3 smoking groups based on smoking behavior: never or former smoking at baseline (n = 2911 [85.3%]), quit smoking during the study period (n = 368 [10.8%]), and persistent smoking (n = 135 [4.0%]). In fully adjusted models, persistent smoking vs never or former smoking was associated with an average 2.69 (95% CI, 0.56-4.81) dB higher PTA (worse hearing) and 1.42 (95% CI, -2.29 to -0.56) lower QuickSIN score (worse performance). Associations were stronger when accounting for informative attrition during the study period (3.53 [95% CI, 1.14-5.93] dB higher PTA; 1.46 [95% CI, -2.52 to -0.41] lower QuickSIN scores). Smoking cessation during the study (vs never or former smoking) was not associated with changes in hearing., Conclusions and Relevance: In this cross-sectional study, persistent smoking was associated with worse audiometric hearing and speech-in-noise perception. Hearing measures among participants who quit smoking during the study period did not differ from those for never or former smokers, indicating that smoking cessation (as opposed to persistent smoking) may have benefits for hearing health.

Although a causal association remains to be determined, epidemiologic evidence suggests an association between hearing loss and increased risk of dementia. If we determine the association is causal, opportunity for targeted intervention for hearing loss may play a fundamental role in dementia prevention. In this discussion, we summarize current research on the association between hearing loss and dementia and review potential casual mechanisms behind the association (e.g., sensory-deprivation hypothesis, information-degradation hypothesis, common cause). We emphasize key areas of research which might best inform our investigation of this potential casual association. These selected research priorities include examination of the causal mechanism, measurement of co-existing hearing loss and cognitive impairment and determination of any bias in testing, potential for managing hearing loss for prevention of dementia and cognitive decline, or the potential to reduce dementia-related symptoms through the management of hearing loss. Addressing these research gaps and how results are then translated for clinical use may prove paramount for dementia prevention, management, and overall health of older adults., Competing Interests: NR reports being a scientific advisory board member of Shoebox Inc and Neosensory. FL reports being a consultant to Frequency Therapeutics, speaker honoraria from Caption Call, and being the director of a public health research center funded in part by a philanthropic gift from Cochlear Ltd to the Johns Hopkins Bloomberg School of Public Health. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Powell, Oh, Reed, Lin and Deal.)

Background: Hearing loss is highly prevalent among older adults with cognitive impairment and may exacerbate neuropsychiatric symptoms and affect interactions with others. Although audiometry is the gold standard for measuring hearing, it is not always used in research or clinical settings focused on the care of individuals with cognitive impairment. Subjective assessments of hearing, both self- and proxy-rated, are widespread but may not adequately capture the presence of hearing loss as compared to audiometry. This study investigates the concordance between subjective and objective hearing assessments among older adults with and without cognitive impairment and evaluates factors associated with concordance., Methods: Participants were a subset of the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS), a prospective cohort study representing four US communities with adjudicated cognitive diagnoses and audiometric data, totaling 3326 self-rated and 520 proxy-rated hearing assessments. Sensitivity and specificity were calculated, and multivariable logistic regression estimated the magnitude of the association between the concordance of hearing assessments and variables of interest., Results: Sensitivity and specificity for self-rated hearing status were 71.2% and 85.9% among cognitively normal older adults, 61.1% and 84.9% among persons with MCI, and 52.6% and 81.2% among persons with dementia, respectively. For proxy-rated hearing, sensitivity and specificity were 65.7% and 83.3% for persons with MCI and 73.3% and 60.3% for persons with dementia, respectively. Female sex was positively associated with concordance for self-rated hearing assessments., Conclusions: The low sensitivity of self- and proxy-rated hearing assessments compared to audiometry suggests that hearing loss among older adults with cognitive impairment may go underreported and unaddressed in subjective assessments. Clinicians and researchers should recognize the limitations of using self- and proxy-rated hearing assessments as measures of hearing status and incorporate objective audiometric evaluation whenever possible., (© 2021 The American Geriatrics Society.)

Objectives: Vision and hearing impairments affect 55% of people aged 60+ years and are associated with lower cognitive test performance; however, tests rely on vision, hearing, or both. We hypothesized that scores on tests that depend on vision or hearing are different among those with vision or hearing impairments, respectively, controlling for underlying cognition., Methods: Leveraging cross-sectional data from the Baltimore Longitudinal Study of Aging (BLSA) and the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS), we used item response theory to test for differential item functioning (DIF) by vision impairment (better eye presenting visual acuity worse than 20/40) and hearing impairment (better ear .5-4 kHz pure-tone average > 25 decibels)., Results: We identified DIF by vision impairment for tests whose administrations do not rely on vision [e.g., Delayed Word Recall both in ARIC-NCS: .50 logit difference between impaired and unimpaired (p = .04) and in BLSA: .62 logits (p = .02)] and DIF by hearing impairment for tests whose administrations do not rely on hearing [Digit Symbol Substitution test in BLSA: 1.25 logits (p = .001) and Incidental Learning test in ARIC-NCS: .35 logits (p = .001)]. However, no individuals had differences between unadjusted and DIF-adjusted measures of greater than the standard error of measurement., Conclusions: DIF by sensory impairment in cognitive tests was independent of administration characteristics, which could indicate that elevated cognitive load among persons with sensory impairment plays a larger role in test performance than previously acknowledged. While these results were unexpected, neither of these samples are nationally representative and each has unique selection factors; thus, replication is critical.

Introduction: Awareness of heart attack symptoms and the best response is a national public health priority, especially among those at higher risk of heart disease. Adults with sensory loss are more likely to develop heart disease than those without and may be at risk of poor heart attack knowledge owing to limited patient-provider communication and access to health information. The aim of this study is to examine the association between sensory loss and heart attack knowledge., Methods: Cross-sectional, nationally representative data from the 2014 and 2017 National Health Interview Survey were used. Analyses were conducted in 2021. Participants aged ≥20 years were included (N=61,168). Being aware of heart attack symptoms and the best response was considered as recognizing the 5 examined symptoms of heart attacks and the proper emergency response, as defined in the Healthy People 2020 objectives. Functional hearing and vision losses were defined as self-reported difficulty in hearing and seeing., Results: Overall, 16.2% reported functional hearing loss, and 10.1% reported vision loss. Having vision loss was associated with a lack of knowledge of heart attacks symptoms or the best response (prevalence ratio=1.08, 95% CI=1.06, 1.11). In a separate model, having vision loss only and dual sensory loss (concurrent vision and hearing loss) were associated with not having this knowledge (prevalence ratio=1.09, 95% CI=1.06, 1.12 and PR=1.08, 95% CI=1.01, 1.15, respectively), but having hearing loss only was not (prevalence ratio=1.03, 95% CI=0.99, 1.06)., Conclusions: Non-institutionalized adults with sensory loss may represent a group to target for improving the knowledge of heart attacks in the population., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Evidence conflicts on the association between sensory difficulty and depression. Few studies have examined this association using longitudinal or population-based data. We used data from Rounds 1-9 of the nationally representative National Health and Aging Trends Study to evaluate the longitudinal association between self-reported visual, hearing, and dual sensory difficulties and clinically significant depressive symptoms. Multivariable Cox regression models were used to evaluate the hazard of incident depressive symptoms. Group-based trajectory modeling identified depressive symptom trajectories (DSTs). Multinomial logistic regression was used to examine the association between sensory status and DSTs. A total of 7,593 participants were included: 56.5% were female, 53.0% were 65-74 years old, 19.0% (95% CI 17.9-20.2%) had hearing, 5.6% (4.9-6.4%) had visual, and 3.3% (2.9-3.8%) had dual sensory difficulties at baseline. Hazard ratios for depressive symptoms in those with visual, hearing, and dual sensory difficulties were 1.25 (95% CI 1.00-1.56, p = 0.047), 0.98 (95% CI 0.82-1.18, p = 0.82), and 1.67 (95% CI 1.29-2.16, p < 0.001), respectively, relative to those without sensory difficulty. A model with four trajectory groups best fit the data. Group 1 (35.8% of the sample, 95% CI: 34.1-37.4) had persistently low risk of depressive symptoms; Group 2 (44.8%, 43.4-46.3) had low but increasing risk; Group 3 (7.1%, 6.2-8.3) had moderate risk; and Group 4 (12.4%, 11.5-13.3) had moderate to high risk that increased. Compared to those without sensory difficulties, individuals with each difficulty were significantly more likely to belong to a group other than Group 1. This study reveals associations between sensory difficulties and mental health that can inform public health interventions., Competing Interests: NR sits on the advisory boards of Shoebox Inc., Good Machine Studio, and Neosensory. JE has consulted for MetLife. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Killeen, Xiang, Powell, Reed, Deal, Swenor and Ehrlich.)

Background: Research on burnout in audiologists is limited, especially in the United States. Recent changes to the profession may have increased burnout., Purpose: The purpose was to investigate burnout in the U.S. audiologists in diverse work settings., Research Design: This study used three surveys: demographics/workplace stressors, Maslach Burnout Inventory (MBI), and professional quality of life (ProQOL)., Study Sample: Participants were 149 U.S. audiologists. Participants were diverse regarding experience, work setting, and location., Data Collection and Analysis: The first survey provided demographics, perspectives on over-the-counter (OTC) hearing aids, stressors, and stress rating. The MBI assessed three dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. The ProQOL assessed burnout, compassion fatigue, and compassion satisfaction. Analyses included descriptive and inferential statistics of quantitative data and thematic analysis of qualitative data., Results: Audiologists had low burnout, low compassion fatigue, and high compassion satisfaction. Experience was not related to stress rating; however, more experienced audiologists had greater compassion satisfaction and lower burnout, emotional exhaustion, and depersonalization compared with less experienced audiologists. Concern about OTC hearing aids was associated with stress rating. Thematic analysis identified 11 stressors, with 50% of stressors classified under work duties, time, and patients., Conclusion: The U.S. audiologists had low burnout rates. Burnout was greatest in less experienced audiologists. Stress was not related to experience. Stressors included insufficient time to see patients, heavy caseload, time-consuming administrative tasks, pressure to sell hearing aids, and stressful interpersonal communication., Competing Interests: None declared., (American Academy of Audiology. This article is published by Thieme.)

Purpose: This letter serves to underscore the importance of understanding the relationship between hearing loss treatment and falls and to provide additional clarity and commentary on the interpretation of the results by Riska et al. (2021). With the salience of falls for older adults, clear interpretation of results in context is necessary to understand the evidence available and need for future studies.

Objective: Hearing aids are costly for many Australians with hearing loss who are not eligible for public funding, and are not widely used. The purpose of this article is to describe a recent policy shift from the United States (US) that might improve access to hearing devices and services in Australia. Type of program or service: In 2017, the US legislated the Over-the-Counter Hearing Aid Act of 2017, directing the Food and Drug Administration (FDA) to develop regulations for over-the-counter sale of hearing aids for mild to moderate hearing loss., Findings: Changes in the development of hearing devices and changes to service delivery were well underway in the US prior to anticipated release of new FDA regulations, with new technology entrants in the 'hearables' market. For Australians with hearing loss not eligible for public funding, the current hearing health system is expensive and device-centred. If Australia follows suit with regulatory changes for a class of over-the-counter hearing aids, consumers are likely to benefit from access to safe and affordable devices. Additional policies to support access to hearing services are also likely to be needed., Lessons Learnt: The hearing health system in Australia will undergo tremendous change in the coming years because of the introduction of over-the-counter hearing aids in the US. For Australians to benefit, changes to regulations of devices, as well as hearing services and device provision, will be required., Competing Interests: IB has received funding from the Cochlear–Macquarie Partnership Scheme, and has been paid expenses to attend an Audiology Australia conference as a guest speaker (2018–19). AW has received grant funding from the Johns Hopkins Cochlear Center for Hearing and Public Health. FL has received consultancy fees from Cochlear Ltd, Amplifon and Boehringer Ingleheim. NR has received funding from NIH/NIA, one-time consultancy fees from Helen of Troy and is an advisory board member to audiometry company Shoebox and Neosensory.

Background: Vision and hearing impairments often co-exist with dementia, and all are independently associated with limitations in daily activities. Our aim was to examine the association of dual sensory impairment with functional limitations, and further examine the combined estimated association of sensory impairment and dementia with these functional limitations., Methods: Cross-sectional analysis of the National Health and Aging Trends Study (NHATS), a population-based cohort of Medicare beneficiaries, was performed. Participants were selected from the 2015 round. Survey weighted Poisson regression models adjusted for dementia, demographics, and health status variables examined the association of self-reported dual sensory impairment (no sensory impairment, single sensory impairment, dual sensory impairment) with scores of limitations in mobility, self-care, and household activities. Models were repeated to take into account the combined effects of dual sensory impairment and dementia., Results: Overall, 7124 participants representative of Medicare beneficiaries 65 years or older were included. Of them, 43.9% were 75 years or older and 55.3% were female. Older adults with dual sensory impairment had greater limitations with mobility (prevalence rate ratio [PRR] = 1.45, 95% CI = 1.28-1.63), self-care (PRR = 1.41, 95% CI = 1.25-1.59), and household activities (PRR = 1.54, 95% CI = 1.37-1.72) compared with those without sensory impairment. They also had greater limitations than those with a single sensory impairment across the different activity categories. In models taking into account the combined estimated effect of both sensory impairment and dementia, those with dual sensory impairment and dementia had greater limitations than those without sensory impairment or dementia in each category (mobility: PRR = 1.85, 95% CI = 1.59-2.14, self-care: PRR = 1.86, 95% CI = 1.59-2.18, household: PRR = 2.41, 95% CI = 2.09-2.77)., Conclusions: Older adults with dual sensory impairment had greater functional limitations compared with those without sensory impairment and those with a single sensory impairment. Strategies to improve visual and/or hearing function (e.g., sensory aids, rehabilitation) could potentially help prevent or minimize disability, even among those with dementia., (© 2021 The American Geriatrics Society.)

Background/Objectives: Low-uptake of hearing aids among older adults has long dogged the hearing care system in the U.S. and other countries. The introduction of over-the-counter hearing aids is set to disrupt the predominantly high-cost, specialty clinic-based delivery model of hearing care with the hope of increasing accessibility and affordability of hearing care. However, the current model of hearing care delivery may not be reaching everyone with hearing loss who have yet to use hearing aids. In this study, we examine the group of people who do not use hearing aids and describe their characteristics and health care utilization patterns. We also consider what other healthcare pathways may be utilized to increase access to hearing treatment. Design: Cross-sectional, the 2017 Medicare Current Beneficiary Survey. Setting: Non-institutionalized adults enrolled in Medicare, the U.S. public health insurance program for older adults (65 years and older) and those with qualifying medical conditions and disabilities. Participants: A nationally representative sample of 7,361 Medicare beneficiaries with self-reported trouble hearing and/or hearing aid use. Measurements: Survey-weighted proportions described the population characteristics and health care utilization of those with hearing loss by hearing aid use, and the characteristics of those with untreated hearing loss by health care service type utilized. Results: Women, racial/ethnic minorities, and low-income Medicare beneficiaries with self-reported hearing trouble were less likely to report using hearing aids than their peers. Among those who do not use hearing aids, the most commonly used health care services were obtaining prescription drugs (64%) and seeing a medical provider (50%). Only 20% did not access either service in the past year. These individuals were more likely to be young and to have higher educational attainment and income. Conclusion: Alternative models of care delivered through pharmacies and general medical practices may facilitate access to currently underserved populations as they are particularly high touch-points for Medicare beneficiaries with untreated hearing trouble. As care needs will vary across a spectrum of hearing loss, alternative models of hearing care should look to complement not substitute for existing access pathways to hearing care., Competing Interests: AW reports receiving a speaker honorarium from the American Speech-Language-Hearing Association and consulting honorarium from BioMedical Insights. CN serves on the non-profit board of directors for Access HEARS and the Hearing Loss Association of America. NR is a scientific advisory board member of Shoebox, Inc and Good Machine Studio but does not receive financial compensation. FL reports being a consultant to Frequency Therapeutics, receiving speaker honoraria from Caption Call, and being the director of a public health research center funded in part by a philanthropic gift from Cochlear Ltd to the Johns Hopkins Bloomberg School of Public Health. CM is on the scientific advisory board for Good Machine Inc but does not receive financial compensation. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Willink, Assi, Nieman, McMahon, Lin and Reed.)

Introduction: Hearing impairment is associated with poor cognitive test performance in older adults. However, hearing's impact on cognitive test completion is poorly described, and missing cognitive data due to hearing impairment could misestimate the association., Methods: We investigated if hearing impairment is associated with missing neurocognitive scores in 3678 adults (72-94 years). Hearing impairment was defined by the better-ear pure tone average of speech-frequency thresholds (0.5-4 kHz) >25 decibels., Results: Hearing impairment was associated with greater missingness on all auditory-only tests, including Logical Memory (prevalence ratio [PR] comparing ≥ moderate impairment vs normal hearing:1.68, 95% confidence interval [CI] 1.26, 2.25) and Digits Backwards (PR 1.62; 95% CI 1.21, 2.17); and two non-auditory tests, Boston Naming (PR 1.61; 95% CI 1.21, 2.17) and Trail Making B (PR 1.55; 95% CI 1.29, 1.86). Models that imputed missing cognitive scores showed the strongest hearing-cognition associations., Discussion: Older adults with hearing impairment are less likely to complete cognitive testing, thereby underestimating the hearing impairment-cognition relationship., (© 2021 the Alzheimer's Association.)

Objective: Hearing loss is associated with higher health expenditures and poor healthcare utilization. This study aims to build on these findings by characterizing the association between hearing status and healthcare-seeking behaviors among Medicare beneficiaries. Methods: Cross-sectional log-binominal regression was used to assess the association between self-report hearing and healthcare-seeking behaviors (avoidance or delay of care, personal health concerns, and sharing health status) using the 2016 Medicare Current Beneficiary Survey ( N = 12,140). Results: Beneficiaries with trouble hearing had significantly higher risks of avoiding and delaying health care compared to those without trouble hearing. Conversely, trouble hearing was not associated with concern for health status or sharing health status. Discussion: These findings may help explain higher costs associated with hearing loss as avoidance of care can exacerbate health problems. Further work is needed to understand underlying causes and whether addressing hearing loss modifies the observed association.

Background: Although hearing impairment (HI) is linked to poorer physical functioning, the longitudinal associations between HI and higher-level functional measures are unclear., Method: Data are from the Baltimore Longitudinal Study of Aging (2012-2019). Using pure-tone audiometry, we categorized hearing into normal, mild, and moderate or greater HI. Physical function was assessed with the expanded Short Physical Performance Battery (eSPPB) and walking endurance with time to walk 400 m. Multivariable and mixed-effects linear models tested the hypotheses that participants with HI, at baseline, have poorer physical performance and walking endurance, and faster decline over time (up to 6 measurements). In a subset (n = 526), we further adjusted for vestibular function. Among participants with HI, we evaluated the differences in eSPPB scores and walking endurance between hearing aid users and nonusers., Results: Of 831 participants, 26% had mild, and 17% moderate or greater HI. After adjustment for demographics and medical history, moderate or greater impairment versus normal hearing was associated with poorer function (0.17 [95% CI: 0.09, 0.26] lower eSPPB score, and 13.3 [95% CI: 3.31, 23.4] seconds slower 400-m walk time) and faster decline in these parameters over 6 years. Adjustment for vestibular function did not attenuate these associations. Hearing aid users walked 400 m 24 seconds faster than nonusers (p = .001)., Conclusion: Moderate or greater HI is associated with poorer initial and greater decline in higher-level physical performance. The observation that hearing aid users had better walking endurance suggests that screening for and treatment of HI may delay or slow progression of hearing-related functional decline., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: In the United States, up to two-thirds of older adults have hearing loss. Untreated hearing loss can have significant health outcomes, yet less than 20% of adults with hearing loss use hearing aids. In this study, we examined potential factors associated with hearing aid use, including detailed measures of health status, access to care, patient engagement, and technology use, in a nationally representative sample of Medicare beneficiaries., Research Design and Methods: Cross-sectional study using the 2017 Medicare Current Beneficiary Survey. Participants with self-reported hearing loss were included. The primary outcome was hearing aid use. Factors potentially associated with hearing aid use included: sociodemographics, health determinants, access to care, patient activation, and technology access/use., Results: Overall, 5,146 participants were included. Of them, 27% reported using hearing aids. In a multivariable logistic regression model, predisposing factors associated with greater odds of hearing aid use included older age, identifying as a man, identifying as White, having completed college, having 3 or more chronic conditions, having dementia, not having trouble seeing, not having limitations in activities of daily living, having moderate relative to low information-seeking scores, and having a personal computer at home (range of odds ratios [ORs]: 1.22-4.46). Enabling factors associated with greater odds of hearing aid use included higher income, living alone relative to living with family members other than a spouse, and having a usual source of care (range of ORs: 1.43-1.54)., Discussion and Implications: In addition to addressing previously identified factors associated with hearing aid use, improving access to health care, technology, and information about hearing aids may improve the uptake of hearing aids. These findings help further inform our understanding on how to address low treatment levels of hearing loss in the community by identifying new populations to target and potentially modifiable risk factors for hearing aid use., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Importance: Hearing impairment, a common treatable condition, may contribute to poorer physical function with aging., Objective: To assess whether hearing impairment is associated with poorer physical function, reduced walking endurance, and faster decline in physical function., Design, Setting, and Participants: In this cohort study, cross-sectional and longitudinal analyses were performed using data from the 2011 to 2019 period of the Atherosclerosis Risk in Communities study, a population-based study of community-dwelling adults at 4 sites in the US., Exposures: Hearing thresholds (per 10 dB) assessed with pure tone audiometry and categorized as normal hearing or mild, moderate, or severe hearing impairment., Main Outcomes and Measures: Physical function was assessed using the short physical performance battery (SPPB), with composite scores ranging from 0 to 12. A composite score of 6 or less and a score for each component (balance, gait speed, and chair stands) of 2 or less indicated poor performance. Walking endurance was assessed using a 2-minute fast-paced walk test. Tobit regression models adjusted for sociodemographic factors and medical history were used to calculate the mean differences in SPPB composite scores; logistic regression models, to estimate the odds ratios (ORs) of low SPPB composite and component scores; and linear mixed-effects models, to estimate the mean rate of change in SPPB composite scores over time., Results: Of the 2956 participants (mean [SD] age, 79 [4.6] years) who attended study visit 6 between 2016 and 2017, 1722 (58.3%) were women, and 2356 (79.7%) were White. As determined by pure tone audiometry, 973 (33%) participants had normal hearing, 1170 (40%) had mild hearing impairment, 692 (23%) had moderate hearing impairment, and 121 (4%) had severe hearing impairment. In the Tobit regression model, severe hearing impairment was associated with a lower mean SPPB score (β, -0.82; 95% CI, -0.34 to -1.30) compared with normal hearing. In fully adjusted logistic regression models, hearing impairment was associated with higher odds of low physical performance scores (severe impairment vs normal hearing: OR for composite physical performance, 2.51 [95% CI, 1.47-4.27]; OR for balance, 2.58 [95% CI, 1.62-4.12]; OR for gait speed, 2.11 [95% CI, 1.03-4.33]). Over time (2 to 3 visits; maximum, 8.9 years), participants with hearing impairment had faster declines in SPPB compared with those with normal hearing (moderate hearing impairment × time interaction, -0.34 [-0.52 to -0.16]). In adjusted models for walking endurance, participants with moderate or severe hearing impairment walked a mean distance of -2.81 m (95% CI, -5.45 to -0.17 m) and -5.31 m (95% CI, -10.20 to -0.36 m) than those with normal hearing, respectively, during the 2-minute walk test., Conclusions and Relevance: In this cohort study, hearing impairment was associated with poorer performance, faster decline in physical function, and reduced walking endurance. The results of the longitudinal analysis suggest that hearing impairment may be associated with poorer physical function with aging. Whether management of hearing impairment could delay decline in physical function requires further investigation.

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD., Objective: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center., Design, Setting, and Participants: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017., Outcome Measurements: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia., Results: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89)., Conclusion: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS., (Copyright © 2020 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

The high prevalence of hearing loss among older adults creates a perception that it is simply a benign consequence of aging, which leads to unaddressed communication needs. Strategies to address hearing loss as part of routine clinical care are pertinent to the geriatric care setting where hearing loss is prevalent in two out of every three patients 70 years and older. Our objectives are to briefly discuss the pathophysiology of hearing loss, describe the epidemiologic prevalence and impact, identify statutory barriers facing older adults in accessing hearing care, discuss current progress on legislation to address accessibility issues, and provide actionable strategies for addressing hearing loss as a barrier to effective communication. Simple steps can be taken to improve hearing care accessibility for older adults with hearing loss and can optimize understanding in daily communication, re-engage patients in being actively involved in their care, and promote patient autonomy in informed decision- making., (© 2021 The American Geriatrics Society.)

Hearing loss is associated with higher health care spending and use, but little is known about the unmet health care needs of people with hearing loss or difficulty. Analysis of 2016 Medicare Current Beneficiary Survey data for beneficiaries ages sixty-five and older reveals that those who reported a lot of trouble hearing in the past year were 49 percent more likely than those who reported no trouble hearing to indicate not having a usual source of care. Compared with those who reported no trouble hearing, those who reported some trouble hearing were more likely to indicate not having obtained medical care in the past year when they thought it was needed, as well as not filling a prescription, with the risk for both behaviors being greater among those reporting a lot of trouble hearing versus a little. Interventions that improve access to hearing services and aid communication may help older Medicare beneficiaries meet their health care needs.

Importance: Impairments in vision or hearing are common and have been independently linked to higher risk of dementia in older adults. There is a limited understanding of the prevalence of concurrent functional vision and hearing impairment (dual sensory impairment) and its contribution to dementia risk., Objective: To examine the age-specific prevalence of functional dual sensory impairment among older adults, and to investigate the cross-sectional and 7-year longitudinal associations between functional dual sensory impairment and dementia., Design, Setting, and Participants: This cohort study of 7562 older adults used data from the US National Health and Aging Trends Study (NHATS), a nationally representative cohort study of community-dwelling, Medicare beneficiaries aged 65 years and older in the US. Participants in the study with complete data on hearing, vision, and dementia were included in analysis. Data were collected between 2011 and 2018, and between March 2018 and May 2020., Exposures: Self-reported functional sensory impairments (ie, no sensory impairment, functional vision impairment only, functional hearing impairment only, and functional dual sensory impairment)., Main Outcomes and Measures: Age-specific prevalence of functional sensory impairments was calculated. Generalized linear regression with a complementary log-log link and a discrete time proportional hazards model with a complementary log-log link were used to assess the cross-sectional and 7-year longitudinal hazard of dementia., Results: Of 7562 participants, 3073 (40.7%) were ages 80 years or older and 4411 (58.3%) were women. Overall, 5.4% (95% CI, 4.7%-6.1%) of participants reported functional vision impairment only, 18.9% (95% CI, 18.9%-17.8%) reported functional hearing impairment only, and 3.1% (95% CI, 2.7%-3.5%) reported functional dual sensory impairment (prevalence estimates are weighted). Participants reporting sensory impairments were older (no impairment: age ≥90 years, 2.12% [95% CI, 1.79%-2.46%] vs functional dual sensory impairment: age ≥90 years, 20.06% [95% CI, 16.02%-24.10%]), had lower education (no impairment:

Objectives: Investigate the cross-sectional association between hearing loss (HL), hearing aid use, and depressive symptoms in community-dwelling older adults., Method: The analytic sample consisted of 3,188 participants (age range 71-94 years) in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS). Multivariable logistic regression was used to evaluate the association of audiometric hearing status and self-reported hearing aid use with depressive symptoms (11-item Center for Epidemiologic Studies Depression scale)., Results: 4.6% of participants had depressive symptoms. Forty percent had mild HL and 27% had moderate or greater HL. In multivariable-adjusted models, mild HL was associated with 1.90 times higher odds (95% confidence interval [CI] 1.20-3.01) and moderate or greater HL with 2.42 times higher odds (95% CI 1.44-4.07) of depressive symptoms compared to normal hearing. Each 10dB increase in HL was associated with 1.30 higher odds of depressive symptoms (95% CI 1.14-1.49). Hearing aid use was not associated with depressive symptoms among those with mild (odds ratio [OR] 0.94, 95% CI 0.35-2.54) or moderate or greater (OR 1.12, 95% CI 0.60-2.11) HL., Discussion: Older adults with HL have higher odds of depressive symptoms compared to adults with normal hearing. Future studies are needed to assess whether hearing care is protective against depressive symptoms in older adults., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Maintenance of visual and auditory function is important for preventing the onset of activity limitations and preserving quality of life in later life. To date, national panel studies focused on health and aging have mostly collected subjective (self-reported) measures of visual and auditory function. The National Health and Aging Trends Study (NHATS), a study of Medicare beneficiaries ages sixty-five and older, recently developed a protocol for measuring objective visual and auditory function for its annual, in-home data collection conducted by trained interviewers. The protocol includes three vision tests-distance and near acuity and contrast sensitivity-and one hearing test-pure-tone audiometry-conducted using a tablet platform with results recorded in a scannable booklet. To identify operational issues and evaluate data quality for the proposed set of vision and hearing tests, NHATS incorporated a pilot study into its 2019 round ( N  = 417 participants and N  = 9 interviewers). Using these pilot study data, the objectives of this paper are to: (1) describe the NHATS protocols to collect objective measures of visual and auditory function; (2) evaluate the quality of the data collected; and (3) assess whether results are influenced by interviewers. We found that respondents were highly likely to participate, with cooperation rates for each test about 90 percent. Data were high quality, with low rates of missingness, test results significantly associated with age and self-reported items, and percentages with poor vision or hearing consistent with prior population-based studies. Objective measures were more likely than self-reports to classify participants as having visual and auditory impairments and had stronger relationships with demographic correlates. Interviewer effects were small and not statistically significant in this small sample. Results of this study have demonstrated that objective visual and auditory functioning can be successfully incorporated into an interviewer-administered home-based protocol., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Association for Public Opinion Research. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To estimate the national prevalence of asymmetric hearing among adults through applying two distinct audiometric criteria., Study Design: National cross-sectional survey., Setting: Ambulatory examination centers within the National Health and Nutrition Examination Survey (NHANES)., Patients: Non-institutionalized adults in the United States from the 2001 to 2012 cycles of NHANES aged 20 years and older with pure tone audiometric and tympanometric data (n = 6,190)., Intervention: Standardized protocol for pure tone audiometry and tympanometry., Main Outcome Measure: Proportion of asymmetric hearing according to two distinct audiometric criteria. One criterion (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS]) specifies asymmetry as a difference between pure tone averages (PTA) greater than 15 dB, and the other (Veterans Affairs [VA]) specifies asymmetry as a difference greater than/equal to 20 dB across two contiguous frequencies or 10 dB across three contiguous frequencies. Analyses included sampling weights to account for the epidemiologic survey's complex sampling design., Results: Using a definition from the AAO-HNS, overall prevalence was 2.77 and 9.46% when calculating the PTA with 0.5 to 4 kHz and 4 to 8 kHz, respectively. In contrast, through a working definition used within the VA, overall prevalence was 25.05% across 0.5 to 8 kHz. Estimates differed across sex and age, with men and older age cohorts exhibiting higher prevalence., Conclusions: A nationally-representative sample of US adults indicates higher prevalence of asymmetric hearing among men and older adult cohorts. There is currently no standard audiometric criterion for defining asymmetry, and prevalence estimates vary markedly depending on which audiometric criteria is used. Given the potentially high prevalence of asymmetry depending on criterion, clinicians should also consider other supplementary clinical data when recommending medical referral., Competing Interests: Conflicts of Interest: J.J.S. declares no conflicts. J.B. declares no conflicts. N.S.R. reports being a scientific board member (non-financial) for SHOEBOX Ltd., Ottawa, Ontario, Canada and a consultant to Helen of Troy. J.A.D. declares no conflicts. F.R.L. reports being a nonprofit board member for Access HEARS, a consultant for Boehringer Ingelheim and Amplifon, receiving speaker honoraria from Caption Call, receiving reimbursed travel from Cochlear Ltd., and being the director of a research center at the Johns Hopkins Bloomberg School of Public Health funded in part by a philanthropic gift from Cochlear Ltd.. A.M.G. reports being a consultant to Cochlear Ltd and Auditory Insight., (Copyright © 2020, Otology & Neurotology, Inc.)

This article aims to evaluate a hearing loss intervention versus an aging education intervention on activity engagement in the Aging and Cognitive Health Evaluation in Elders pilot (ACHIEVE-P). Forty adults (70-84 years) with hearing loss recruited from the Atherosclerosis Risk in Communities Study and de novo participated. Participants were randomized 1:1 to a best practices hearing intervention or a successful aging intervention. Hearing was measured with pure-tone audiometry. The Community Healthy Activities Model Program for Seniors questionnaire measured self-reported time engaging in activities at baseline and 6-month follow-up. At baseline, greater hearing loss was associated with reduced time per week on mental activities (-3.0 hours per 10 dB of hearing loss, 95% confidence interval: -5.8, -0.2). Mental activity engagement increased (mean: +1.3 hours, SD = 6.6) for the hearing intervention group but decreased (mean: -1.1 hours, SD = 4.8) for the aging education group (Cohen's d : 0.41). Hearing loss may be associated with reduced engagement in mental activities. Whether hearing loss treatment impacts activity will be studied in the full-scale ACHIEVE trial., Competing Interests: Conflict of Interest A.M.G. reports being a consultant to Cochlear Ltd. N.S.R. reports being an advisor to Clearwater Clinical. F.R.L. reports being a consultant to Boehringer-Ingelheim and Autifony Inc., and a Scientific Advisory Board member for Autifony Inc., (Thieme. All rights reserved.)

Background/objectives: Age-related hearing loss (ARHL) is a widely prevalent yet manageable condition that has been linked to neurocognitive and psychiatric comorbidities. Multiple barriers hinder older individuals from being diagnosed with ARHL through pure-tone audiometry. This is especially true during the COVID-19 pandemic, which has resulted in the closure of many outpatient audiology and otolaryngology offices. Smartphone-based hearing assessment apps may overcome these challenges by enabling patients to remotely self-administer their own hearing examination. The objective of this review is to provide an up-to-date overview of current mobile health applications (apps) that claim to assess hearing., Design: Narrative review., Measurements: The Apple App Store and Google Play Store were queried for apps that claim to assess hearing. Relevant apps were downloaded and used to conduct a mock hearing assessment. Names of included apps were searched on four literature databases (PubMed/MEDLINE, EMBASE, Cochrane Library, and CINAHL) to determine which apps had been validated against gold standard methods., Results: App store searches identified 44 unique apps. Apps differed with respect to the type of test offered (e.g., hearing threshold test), cost, strategies to reduce ambient noise, test output (quantitative vs qualitative results), and options to export results. Validation studies were identified for seven apps., Conclusion: Given their low cost and relative accessibility, smartphone-based hearing apps may facilitate screening for ARHL, particularly in the setting of limitations on in-person medical care due to COVID-19. However, app features vary widely, few apps have been validated, and user-centered designs for older adults are largely lacking. Further research and validation efforts are necessary to determine whether smartphone-based hearing assessments are a feasible and accurate screening tool for ARHL. Key Points Age-related hearing loss is a prevalent yet undertreated condition among older adults. Why Does this Paper Matter?     Smartphone-based hearing test apps may facilitate remote screening for hearing loss, but limitations surrounding app validation, usability, equipment calibration, and data security should be addressed., (© 2020 The American Geriatrics Society.)

With the aging of the population, vision (VL), hearing (HL), and dual-sensory (DSL, concurrent VL and HL) loss will likely constitute important public health challenges. Walking speed is an indicator of functional status and is associated with mortality. Using the Health and Retirement Study, a nationally representative U.S. cohort, we analyzed the longitudinal relationship between sensory loss and walking speed. In multivariable mixed effects linear models, baseline walking speed was slower by 0.05 m/s (95% confidence interval [CI] = 0.04-0.07) for VL, 0.02 (95% CI = 0.003-0.03) for HL, and 0.07 (95% CI = 0.05-0.08) for DSL compared with those without sensory loss. Similar annual declines in walking speeds occurred in all groups. In time-to-event analyses, the risk of incident slow walking speed (walking speed < 0.6 m/s) was 43% (95% CI = 25-65%), 29% (95% CI = 13-48%), and 35% (95% CI = 13-61%) higher among those with VL, HL, and DSL respectively, relative to those without sensory loss. The risk of incident very slow walking speed (walking speed < 0.4 m/s) was significantly higher among those with HL and DSL relative to those without sensory loss, and significantly higher among those with DSL relative to those with VL or HL alone. Addressing sensory loss and teaching compensatory strategies may help mitigate the effect of sensory loss on walking speed., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Epidemiology is the science of public health. The focus of this discussion is to present a brief overview of how epidemiology approaches questions of disease causation, including why it sometimes gets things wrong, and so to provide a framework for how we consume and use this type of research, particularly when it comes to patient care., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

This article aims to investigate the association between hearing and nonfatal injury or falls in a nationally representative sample of adults from the National Health Interview Survey (NHIS) utilizing over 20 years of participant surveys. We conducted a pooled cross-sectional analysis of participant surveys (aged 50 years and older) from 1997 to 2017. Self-report hearing difficulty, history of injury over the last 3 months, reported injury from fall over the last 3 months, and reported reason for fall (including due to balance/dizziness) were collected. Using logistic regression, we investigated the odds of injury, injury from fall, and fall due to balance/dizziness by self-report hearing status. In secondary analysis, we investigated the odds of each outcome by reported hearing aid use. Models were adjusted for demographics, year of study, vision difficulty, diabetes, employment, and cardiovascular disease. Reported moderate or greater difficulty hearing demonstrated a significantly greater odds of injury (odds ratio [OR]: 1.29; 95% confidence interval [CI]: 1.18, 1.42) or fall due to balance/dizziness (OR: 1.26; 95% CI: 1.00, 1.60) compared with reported excellent/good hearing. A dose-response association was seen across levels of reported difficulty hearing for all outcomes. In this nationally representative study of adults aged 50 years and older, greater reported difficulty hearing was significantly associated with increased odds of injury and suggests greater odds of falls or fall due to balance/dizziness compared with reported good hearing. Results suggest hearing loss should be considered as a possible risk factor for both injury and fall prevention studies and programming in older adults., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Several studies have recently illuminated the relationship between hearing loss and hospitalizations, but little is understood as to why hearing loss is associated with greater risk for hospitalizations. This study examines the role of patient-provider communication as the mechanism by which those with hearing loss are more likely to be hospitalized, using the self-reported data from 12,654 Medicare beneficiaries from the 2016 Medicare Current Beneficiary Survey (MCBS) Cost and Use File. Multivariable logistic regression was used to model the odds of any hospitalization in the past year and negative binomial regression to model the incident rate ratio of hospitalization based on number of hospitalizations in the past year. It was found that Medicare beneficiaries who experience impaired communication with their physician due to trouble hearing have greater odds of hospitalization and a higher rate of all hospitalization over a 1-year period. Understanding the complex relationship between hearing loss, patient-provider communication, and hospitalizations may provide health care professionals with a better rational to address not only hearing loss but also impaired communication in the care of an individual., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background/objectives: Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries., Methods: Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample., Results: Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively., Conclusions: Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.

Objectives: Hearing loss is common in older adults and limits communication. We investigated the independent association between functional hearing loss and social engagement in a nationally representative sample of older adults., Methods: Using data from the 2015 Medicare Current Beneficiaries Survey, we modeled the cross-sectional association between self-reported hearing ability and limitation in social activity over the past month using multivariable logistic regression., Results: The majority of the study population was female (54.8%) and non-Hispanic white (74.3%). Participants (40.4%) reported "a little trouble" hearing and 7.4% reported "a lot of trouble" hearing. Those who reported any trouble hearing had higher odds of limited social engagement in the past month. After adjustment for demographic, clinical, and functional covariates, those who reported "a lot of trouble" hearing had 37% higher odds of limited social activity in the past month compared to those with normal hearing., Discussion: These results suggest that hearing loss may be an important risk factor for limited social engagement and downstream negative health consequences, independent of other disability and health conditions., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Preventive care is associated with decreased morbidity and mortality among older adults. Vision impairment may be a barrier to accessing care and health promotion information and therefore may contribute to decreased preventive care uptake., Objective: To examine the association between self-reported vision impairment and uptake of preventive care services (ie, breast and colon cancer screenings and influenza and pneumococcal vaccinations)., Design, Setting, and Participants: Cross-sectional study using the 2015 and 2018 National Health Interview Survey (NHIS) and 2016 and 2018 Behavioral Risk Factor Surveillance System (BRFSS) data, national surveys of US residents conducted through in-person household interviews in NHIS, and state-based telephone interviews in BRFSS. Participants included respondents 50 years and older based on eligibility for each preventive care service examined., Exposures: Vision impairment, defined as self-reported trouble seeing, in NHIS, and self-reported blindness/serious difficulty seeing in BRFSS., Main Outcomes and Measures: Self-reported uptake of breast cancer screening (women aged 50-74 years), colon cancer screening (aged 50-74 years), influenza vaccination (50 years and older), and pneumococcal vaccination (65 years and older). Multivariable regression models adjusted for relevant confounders, including age, were used to examine the uptake of each preventive care service by vision impairment status., Results: Among NHIS participants, older US individuals with vision impairment (prevalence between 14.3% and 16.3% in the different age groups; n = 12 120-29 654) were less likely to report breast cancer screening (odds ratio [OR], 0.82; 95% CI, 0.71-0.96) and colon cancer screening (OR, 0.89; 95% CI, 0.79-0.99) but not influenza (OR, 1.06; 95% CI, 0.97-1.15) and pneumococcal vaccination (OR, 1.03; 95% CI, 0.91-1.16), as compared with their counterparts without vision impairment. In BRFSS (n = 228 649-530 027), those with vision impairment (5.9%-6.8%) were less likely than those without vision impairment to report breast cancer screening (OR, 0.67; 95% CI, 0.59-0.75), colon cancer screening (OR, 0.70; 95% CI, 0.65-0.76), and pneumococcal vaccination (OR, 0.89; 95% CI, 0.81-0.99) but not influenza vaccination (OR, 0.95; 95% CI, 0.89-1.00)., Conclusions and Relevance: Older Americans with vision impairment may be less likely to use cancer-related preventive services as compared with their counterparts without vision impairments. These findings suggest that interventions to improve access to health information and health care services for individuals with vision impairment may be needed to improve cancer screening among this population.

Importance: Perceived everyday discrimination is a psychosocial stressor linked to adverse health outcomes, including mortality., Objective: To assess the association of vision impairment (VI), hearing impairment (HI), and dual sensory impairments (DSI) with everyday discrimination., Design, Setting, and Participants: Cross-sectional analysis of the Health and Retirement Study 2006 and 2008 surveys, a US population-based survey that included noninstitutionalized adults 51 years and older. Analyses were weighted to account for complex sample design and differential nonresponse. Data were analyzed between October 2019 and November 2019., Exposures: Participants rated their vision and hearing, using eyeglasses and/or hearing aids if applicable, on a Likert scale (poor, fair, good, very good, and excellent). Sensory impairment was defined as poor or fair ability in the relevant modality, and sensory impairment was categorized as neither sensory impairment (NSI), VI alone, HI alone, and DSI., Main Outcomes and Measures: Perceived everyday discrimination was measured on the validated 5-question Williams scale (range 0 to 5). Linear regression models estimated differences in discrimination scores by sensory categories, adjusting for age, sex, race, ethnicity, non-US birth, body mass index, relationship status, net household wealth, and number of chronic diseases (among diabetes, hypertension, heart disease, stroke, lung disease, nonskin cancer, and arthritis)., Results: The sample included 13 092 individuals. After weighting the sample to be representative of the US population, 11.7% had VI alone, 13.1% HI alone, and 7.9% DSI. In the fully adjusted model, participants with VI alone (β [change in discrimination score], 0.07; 95% CI, 0.02-0.13), HI alone (β = 0.07; 95% CI, 0.02-0.11), and DSI (β = 0.23; 95% CI, 0.16-0.29) perceived greater discrimination compared with participants with NSI. The DSI group perceived greater discrimination than VI alone or HI alone., Conclusions and Relevance: Older adults with VI or HI in the United States perceive greater everyday discrimination than older adults with NSI, and those with DSI perceive even more discrimination than those with either VI or HI alone. These results provide insight into the social impact of sensory loss and highlight a need to identify and address reasons for discrimination toward older adults with VI and HI.