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Hearing loss and cognitive function among Chinese older adults: the role of participation in leisure activities

Hearing loss and cognitive function among Chinese older adults: the role of participation in... Background: Hearing loss, a highly prevalent sensory impairment affecting older adults, is a risk factor for cognition decline. However, there were very limited studies on this association in low-resource countries. This study aimed to assess the association between self-reported hearing loss and cognitive decline, and whether engagement in leisure activities moderated this association among older adults in China. Methods: Data were obtained from two waves of the nationally representative survey of China Longitudinal Healthy Longevity Survey (CLHLS) between 2011/12–2014. Eight thousand eight hundred forty-four individuals aged 65 years old or above with a dichotomized measure of self-reported hearing status were included. Modified Mini-Mental Examination (MMSE) was used to measure global cognition. Fixed-effects models were used to estimate whether leisure activity engagement moderated the association of self-perceived hearing loss with global cognitive change in the overall sample and sex subsamples. Results: Self-reported hearing loss was associated with cognitive impairment, with an odds ratio of 2.48 [1.22, 5.06]. Sex difference in the association of hearing loss and cognitive impairment was not found. Self-reported hearing loss was associated with cognitive decline, with 8% increase in risk compared with those with normal hearing. Frequent engagement in leisure activities moderated the association between hearing loss and cognitive decline for the whole and male samples. Conclusion: Hearing loss was associated with cognitive decline, and leisure activities engagement moderated the association among males rather than females. Keywords: Hearing loss, Activities engagement, Cognitive function, Sex difference Background million people) by 2030 [4]. Cognitive impairment, charac- Dementia is a major global public health concern. It af- terized by the presence of weakening of one or more cogni- fected approximately 50 million people worldwide [1]. De- tive domains like immediate and delayed memory, may mentia prevalence is expected to rise in the near future, develop into dementia [5]. The prevalence of mild cognitive especially in China, where its prevalence in a population of impairment among Chinese adults aged ≥60 was 12.7% in 1.7 billion adults aged 60 or older [2] was 4.6% (8 million) 2010 [6]. Cognitive decline is more prevalent in older indi- in 2010 [3], which is expected to increase to 6.7% (23 viduals [7], and previous studies have shown that the pres- ence of chronic diseases, sensory loss, disengagement in physical, mental or social activity, and exposure to acute * Correspondence: [email protected] and chronic stress may be related to poorer cognitive per- China Center for Health Development Studies, Peking University, No. 38 formance in later life [8, 9]. Xueyuan Road, Haidian District, Beijing 100191, People’s Republic of China Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gao et al. BMC Geriatrics (2020) 20:215 Page 2 of 10 Hearing loss, a prevalent chronic condition in older of isolation among older adults via social interaction and adults, is a key risk factor of cognitive impairment and constructively spending time [27]. In addition to psycho- dementia [10–12]. Approximately 11% of adults aged social benefits, participating in mentally stimulated leisurely ≥60 were diagnosed with disabling hearing impairment activities may promote stability or enhance cognitive per- in China [13]. Dementia is a major source of disability formance. A recent study found that poorer hearing func- around the world, and no disease-modifying treatments tion may affect verbal memory performance and attention so far [14]. Age-related hearing loss may be associated to auditory stimuli among older adults [28], while another with an increased risk of dementia in later life, which study focusing on the association between leisurely activity has garnered increasing attention as a potentially modifi- and cognitive function in old age indicated that more able risk factors for dementia and cognitive decline [10– participation in self-improvement, intellectual, or cultural 12]. Evidence from a randomized controlled trial regard- activities was associated with better performance in verbal ing hearing support in dementia (i.e., SENSE-Cog Field ability and memory [29]. Maintaining a moderate or high Trial) demonstrated that employing a sensory interven- level of participation in leisurely activities may play a role in tion to support hearing, such as providing hearing aids, the relationship between hearing loss and cognition. En- communication training, and supplementary sensory gagement in leisurely activities makes up a considerable aids to enhance the home environment or foster social amount of daily activity among the Chinese elderly. Leisure inclusion, benefits people with dementia as well as their activities may be demographically or culturally specific, and partner by improving their quality of life, physical func- studies from Asian countries that have adopted Confucian tions, psychosocial health and relationship satisfaction culture suggested that the link between participating in leis- [15, 16]. Moreover, studies have indicated that hearing ure activities and cognitive performance may differ by sex aid use confers a mitigating effect on the trajectories of [30, 31], as the elderly may possess differences in lifestyle cognitive decline by maintaining cognitive function, such and social networks. Additionally, consequences resulting as episodic memory [17, 18]. from hearing loss, as well as the association between spe- Although the mechanisms underlying the association of cific leisure activity and cognition, may also vary by sex. For hearing loss with cognitive decline and dementia remain example, older men with hearing loss were more likely unclear, several hypotheses exist [19]. One possible mech- to be depressed than men with normal hearing, while anism is the shared pathologic etiology. The common fac- hearing loss did not affect the odds of depression in tor theory suggested that the association of sensory and older women [32]. In contrast, elderly women with cognitive performance is explained by a third common hearing loss tend to feel socially isolated, however, the factor, such as an aging brain [20, 21] or frailty syndrome association between hearing loss and social isolation [22]. The second hypothesis is biologically plausible given was not significant among men [33]. Cognitively stimu- the effects of hearing loss on cognitive load and cognitive lating and socially engaging activities, along with intel- reserve, which may be mediated by social isolation or lectual or cultural activities, were found to reduce the loneliness [12, 23]. One possible explanation for the asso- risks of dementia among elderly men and women [29]. ciation between social isolation, loneliness, and cognitive Though much research has documented that hearing function is that loneliness or social isolation is associated loss was associated with cognitive decline and dementia in with unhealthy behaviors or a plethora of chronic diseases developed countries, a very limited number of studies have related to poor cognition [24]. The third hypothesis is the been done in developing countries, and few have focused information-degradation hypothesis, which posits that in- on the role of engaging in leisurely activity. Maharani creased cognitive load from the compensation of auditory et al. [24] and Frank Lin et al. [12] put forward that the as- deficits may limit the resources available in performing sociation between hearing loss and cognitive decline other cognitive tasks [25]. among the elderly may be mediated by cognitive load and/ One potential way in modifying the association of or social isolation. However, whether efforts in maintain- hearing loss with cognitive decline and dementia may be ing engagement in leisurely activities or increasing the size through increased participation in activities. Previous of social networks may mitigate the impact of hearing loss studies indicated that older adults with hearing loss were on cognition are still unclear. Given the expected rise of more likely to have smaller social networks [26]. Since the aging population in China, a better understanding of the relationship between hearing loss and cognitive im- such relationships would provide valuable insights into pairment may be mediated by social isolation or loneli- potential approaches in preventing or delaying the onset ness [24], efforts to improve the social networks of of dementia. According to the “cognitive load theory” and hearing-impaired older adults may be beneficial in pre- “cascade hypothesis” [34], this study aimed to examine: 1) venting cognitive decline. Participation in leisurely activ- the association of self-perceived hearing loss with cogni- ities, i.e. gardening, reading or engaging in hobbies has tive function; 2) the role of engaging in leisurely activities shown positive effects in reducing loneliness and feelings as a potential moderator in this association; and 3) the Gao et al. BMC Geriatrics (2020) 20:215 Page 3 of 10 differences in these associations by sex among the Chinese participant’s consenting proxy. The relationship between elderly. the agent and the participant was included in the in- formed consent [35]. Details on the study design, sam- Methods pling, measures, and data quality of the CLHLS are Data source available elsewhere [37]. We obtained the data from the Chinese Longitudinal CLHLS included questions on self-reported hearing Healthy Longevity Survey (CLHLS), a dynamic cohort difficulties only in waves during 2011/12 and 2014. study that collected first-wave data in 1998, along with Therefore, the current study adopted two waves from six follow-up surveys with the replacement of deceased the CLHLS longitudinal data taken during 2011/2012 to elders in 2000, 2002, 2005, 2008, 2011 and 2014 [35]. 2014. Accordingly, 9765 and 7192 respondents were The CLHLS recruited a representative sample from 23 interviewed in 2011/12 and 2014, respectively. Of the of the 31 provinces within China [36], and in-person in- 9765 respondents interviewed in the 2011/12 survey, terviews were conducted by the researchers so as to ac- 6066 were followed up in the 2014 survey, but 820 re- quire data regarding demographics, socioeconomic spondents were lost to follow-up, while 2879 persons status, lifestyle, and health. Consent for participation died or were already deceased prior to the 2014 follow- was given via face-to-face interviews, where informed up survey. In addition to the 6066 follow-up respon- consent was presented to the selected participants prior dents, 1125 respondents were newly interviewed in 2014 to the in-person interview. The informed consent in- [38, 39]. Details concerning sample selection are pre- cluded information on the interview’s duration, contents, sented in Fig. 1. and purpose, and the elderly participants were asked if We restricted the study sample to 14,309 respondents they agreed to participate in the interview and be in- aged ≥65 years who completed the questionnaire on self- volved in a physical examination. If the participant de- reported hearing difficulties and cognitive function from clined to take the interview, the participate was allowed the 2011/12–14 CLHLS sample. Here, 8844 were from to ask his/her spouse, children or other relatives to an- the 2011/12 wave, while 5465 were part of the 2014 swer on his/her behalf. The participant signed the in- wave. Individuals were excluded if they were younger formed consent if he/she was capable to read and write, than 65 years of age, had died, or failed to respond to otherwise, the informed consent was signed by the items comprising the outcome variable. Fig. 1 flowchart of the study sample Gao et al. BMC Geriatrics (2020) 20:215 Page 4 of 10 Measures Covariates Self-reported hearing status Covariates included several sociodemographic character- Hearing impairment was defined by responses of self- istics, health behaviors and health conditions that were reported hearing difficulty. Participants were asked the fol- potentially associated with cognitive function as in previ- lowing question to check their hearing status (without ous studies [46]. These variables consisted of age (con- using hearing aids): “Do you have any difficulty with your tinuous), sex (male vs. female), residence (urban vs. hearing?”“YES” was coded as having hearing impairment, rural), education (illiterate vs. literate), smoking (never while “No” signified not having hearing impairment. smoking, ever smoking vs. current smoking), alcohol use (never drinking, ever drinking vs. current drinking), self- Global cognition reported general health status (good vs fair/poor), having Global cognition is measured using the Chinese version been diagnosed with hypertension (yes vs. no), and hav- of the Mini-Mental State Examination (MMSE). The ing been diagnosed with diabetes (yes vs. no). Chinese version of MMSE is comprised of 23 items and examines four aspects of cognitive function (orientation, Statistical analyses calculation, recall, and language), which was adapted Descriptive statistics were used for all study variables. from the original MMSE developed by Folstein et al. Fixed effect models were used to capture the within- [40]. Considering the cultural and socioeconomic condi- individual association between the occurrence of hearing tions among the Chinse elderly, several items were loss and cognitive function decline over time. The fixed modified or deleted to make the questions easily under- effect models are longitudinal models that were applied standable and answerable among the participants whose in the panel data, which confer benefits in treating unob- cognitive function was normal. For example, the respon- served confounders and time-invariant variables as a set dents were asked to name as many foods as possible ra- of fixed parameters to control effects pertaining to both ther than writing a complete sentence. The questions observed and unobserved time-invariant variables as well involving calculations were simplified, and one item per- as the effect of years on the dependent variable [47]. In taining to orientation to time and four items concerning this study, Hausman tests were conducted, where the orientation to place were excluded [41]. Several similar fixed effects model was shown to be more appropriate versions of the Chinese MMSE, which were all adopted than the random effects model with chi2 = 49.13 (p < according to Folstein’s version [40], have proven to be 0.005). Likelihood-ratio tests were also performed, which reliable and may be employed to study the Chinese eld- indicated that the fixed-effects model was more appro- erly [42, 43]. Scores on each item are normally binary priate than the mixed-effects model with LR chi2 = − (e.g. 1 for a correct and 0 for otherwise). The total pos- 3871.60 (p = 1.00). Moreover, the cognitive function was sible score on the MMSE is 30, with higher scores indi- initially treated as a binary variable using a cutoff point of cating better cognitive performance. In accordance with 18 (cognitively impaired vs. normal cognition). Fixed effect previous studies in China that suggested the use of 18 or logit models were conducted to estimate the average odds 19 as the cutoff score of MMSE when screening for de- ratios of cognitive decline related to the occurrence of mentia among populations with little or no formal edu- self-perceived hearing loss during the follow-up period. cation [43, 44], individuals who scored < 18 were The time-variant variables were adjusted in these models, considered to be cognitively impaired. Hence, the 23- including age, smoking, alcohol use, self-reported health, item used for the MMSE for Chinese elderly has demon- hypertension and diabetes. Second, the continuous form strated good validity [45]. of the cognitive function (the summed MMSE scores) was utilized as the dependent variable to estimate the average Leisure activity engagement change in MMSE scores associated with hearing loss dur- We used the frequency of participation in leisure activ- ing the follow-up period. Hausman tests indicated that ities to measure the level of engagement in such activ- fixed effects models were more appropriate in the estima- ities among older adults. Overall, the survey respondents tion compared to random effects models (chi2 = 167.06, were asked, “Do you now perform the following activ- p < 0.001). Furthermore, regarding the potential bias ities regularly? (please choose one from the frequency on caused by the missing data due to participants being de- the right)”. Each specific activity was indexed at five ceased or lost to follow-up, the characteristics of the miss- levels: 0 = never; 1 = not every month; 2 = not every ing data were reported, and a proportional hazard model week; 3 = not every day; and 4 = almost every day. To ob- was done for the mortality sample as well as a regression tain a general perspective on activity involvement, the analysis using an attribution indicator and baseline data- total sum of the scores regarding participation frequency set, as shown in the Supplementary document. All ana- in each activity was computed. Details concerning the lyses were conducted using the Stata 14.0 software. leisure activities are shown in Additional file 1. Gao et al. BMC Geriatrics (2020) 20:215 Page 5 of 10 Results women, with 77% (n = 3693) of females being illiterate (vs. Sample characteristics 32% male) in wave 1 and 73% (vs. 29% male) in wave 2, re- Table 1 presents the sample characteristics over two spectively. Details regarding the characteristics of the eld- waves of CLHLS. The mean MMSE scores slightly in- erly sex subgroups are presented in Table 1.With respect creased from 26.08 (SD = 5.35) in wave 1 to 26.51 (SD = to the sample that was excluded due to participants’ death 4.67) in wave 2. The proportion of participants having or loss to follow-up, elderly participants among the ex- cognitive impairment decreased from 8% (n = 749) to 6% cluded sample were more likely to have a higher mean age (n = 336) over two waves, while the proportion for hear- (91.3 years old), be hearing impaired, illiterate and have ing loss decreased from 44% (n = 3937) in wave 1 to 39% poorer self-reported health (see Supplementary). (n = 2137) in wave 2. The mean scores for all kinds of leisurely activities increased over time from 9.98 to 10.48 Association of hearing impairment and cognitive over two waves. The average age was 85.08 (SD = 10.98) impairment in wave 1 and 84.74 (SD = 9.99) in wave 2. Details re- Table 2 illustrates the results of the association between garding the sample characteristics are shown in Table 1. the co-occurrence of self-reported hearing loss and cog- Elderly females had a higher MMSE score than males in nitive impairment during the follow-up period using both waves. The proportion of cognitive impairment and fixed-effect models. The unadjusted model (Model 1) self-reported hearing loss was found to be higher among shows that hearing loss was significantly associated with older females than in males, with 12% (n =560) of females the occurrence of cognitive impairment. Compared to having cognitive impairment (vs. 5% for male) and 47% participants without hearing loss, those who reported (n = 2231) of females having hearing loss (vs. 42% for hearing loss during the follow-up period were 1.87 times male) in wave 1. In these two waves, the elderly male co- more likely to develop cognitive impairment (odds ratio hort were reported to frequently engage in leisurely activ- [OR] = 1.87, 95% confidence intervals [CI] = 1.28, 2.74). ities compared to females. Men were observed to have After adjusting with the time-variant covariates in Model higher average scores in physical outdoor activities, intel- 2, the association between hearing loss and cognitive im- lectual activities, recreational activities, and social activ- pairment was consistent, with OR = 2.48 (95%CI:1.22, ities, while women participated more in productive 5.06). An interaction between sex and hearing loss is in- activities. Older men attained better education than older troduced in Model 3, which demonstrates that the Table 1 Characteristics of participants by waves in CLHLS, 2011/2012 to 2014, mean (SD)/n (%) Variables Wave 1 Wave 2 Total (n = 8844) Male (n = 4089) Female (n = 4755) Total (n = 5465) Male (n = 2628) Female (2837) MMSE scores 26.08(5.35) 27.13(4.44) 25.19(5.88) 26.51(4.67) 27.46(3.88) 25.66(4.47) Cognitive impairment 749(8.47) 189(4.62) 560(11.78) 336(6.19) 97(3.69) 239(8.42) Self-reported HL 3937(44.52) 1706(41.72) 2231(46.92) 2137(39.38) 997(37.94) 1141(40.22) Activity engagement 9.98(6.62) 11.43(6.58) 8.73(6.39) 10.48(6.65) 11.61(6.64) 9.51(6.54) Productive activities 2.13(1.90) 2.04(1.88) 2.21(1.91) 2.27(1.88) 2.11(1.87) 2.43(1.88) Outdoor activities 2.21(1.84) 2.45(1.79) 2.01(1.85) 2.22(1.84) 2.39(1.81) 2.07(1.85) Intellectual activities 0.57(0.98) 0.87(1.13) 0.31(0.75) 0.61(1.02) 0.90(1.15) 0.35(0.80) Recreational activities 1.40(1.10) 1.61(1.07) 1.22(1.10) 1.49(1.09) 1.65(1.06) 1.35(1.10) Social activities 0.30(0.87) 0.38(0.96) 0.24(0.78) 0.32(0.89) 0.39(0.96) 0.27(0.83) Age 85.08(10.98) 82.84(10.06) 87.01(11.37) 84.74(9.99) 82.97(9.16) 86.13(10.63) Rural 4624(52.28) 2097(51.28) 2527(53.14) 2835(52.83) 1366(52.46) 1501(53.63) Illiterate 4987(56.39) 1294(31.65) 3693(77.67) 2825(52.05) 771(29.34) 2066(72.82) Ever smoking 1439(16.36) 1158(28.47) 281(5.94) 774(14.33) 654(24.99) 123(4.36) Current smoking 1639(18.64) 1370(33.68) 269(5.69) 977(18.09) 843(32.21) 144(5.11) Ever drinking 1270(14.51) 947(23.43) 323(6.86) 575(10.68) 463(17.72) 114(4.06) Current drinking 1520(17.37) 1142(28.26) 378(8.03) 876(16.28) 716(27.40) 167(5.95) Self-reported poor health 1501(17.22) 581(14.37) 920(19.69) 856(15.97) 366(14.04) 492(17.62) Hypertension 3126(50.76) 1388(49.62) 1738(51.71) 2167(56.97) 1011(55.19) 1168(58.43) Diabetes 1118(21.73) 528(22.34) 590(21.22) 904(28.99) 437(28.52) 476(29.55) a b variable being reported with mean (SD). variable being reported with number (proportion) Gao et al. BMC Geriatrics (2020) 20:215 Page 6 of 10 Table 2 Odds ratio and 95% confidence interval for fixed effects models on the association between hearing loss and cognitive decline during 2011 to 2014 Variables Model 1 Model 2 Model 3 Model 4 Self-reported HL 1.87(1.28,2.74) 2.48(1.22,5.06) 2.90(0.75,11.29) 2.84(1.00,8.13) Ever smoking 0.54(0.08,3.68) 0.57(0.08,4.09) 0.50(0.07,3.46) Current smoking 0.45(0.08,2.49) 0.45(0.08,2.49) 0.41(0.07,2.26) Ever drinking 4.56(0.92,22.60) 4.44(0.89,22.20) 3.96(0.78,20.13) Current drinking 0.21(0.05,0.89) 0.21(0.05,0.88) 0.18(0.04,0.82) Poor self-reported health 2.17(0.93,5.08) 2.15(0.92,5.04) 2.09(0.88,5.01) Hypertension 0.53(0.25,1.09) 0.52(0.25,1.08) 0.51(0.24,1.07) Diabetes 0.77(0.34,1.75) 0.77(0.34,1.77) 0.78(0.34,1.78) Self-reported HI * female 0.80(0.16,3.92) Self-reported HI * activity engagement 0.98(0.88,1.09) Year 1.69(1.38,2.07) 1.91(1.26,2.90) 1.90(1.25,2.89) 1.78(1.15,2.74) Observation 830 266 266 266 association of hearing loss and cognitive impairment did not identifying the impacts of hearing deprivation on cognitive differ by sex. In Model 4, we employed an interactive term decline, whether engaging in leisurely activities moderated of hearing loss and leisurely activity participation to test the link between hearing loss and cognitive function from whether participants who frequently participated in leisurely the perspective of gender was explored. To the best of our activities were found to have a mitigated association of hear- knowledge, this is the first study to report the empirical re- ing loss and cognitive impairment. However, the results sults of hearing loss in relation to cognitive function as well show that those who actively participated in leisurely activ- as the moderative role of leisurely activities from a longitu- ities were not found to have an association between hearing dinal survey in mainland China. It was found that elderly loss and the occurrence of cognitive impairment. males or females who reported as having a self-perceived The analysis regarding the association of self-reported hearing difficulty had a greater risk of cognitive impair- hearing loss and change in global cognition during the ment. Frequent participation in leisurely activities benefited follow-up period was further elucidated using linear fixed- older adults with hearing loss to perform better in cognitive effect models, which are presented in Table 3.After adjust- functioning, particularly in the male subgroup. ing for time-variant covariates, participants who reported The results of this study contribute to studies explor- hearing loss during the follow-up period suffered from a ing the association between hearing impairment and 0.81-point decrease in cognition score. This association re- cognitive function among the aging Chinese population. mains significant in both sex subgroups, with a 0.79-point Our findings align well with those of previous studies decrease in cognition scores among males and a 0.85-point [12, 46, 48], documenting a significant correlation be- decrease among females. An interactive term of hearing tween hearing difficulty and poorer cognitive perform- loss and leisurely activity participation was then used in the ance among the elderly. In contrast, other studies have adjusted models, which signified that frequently engaging yielded inconsistent findings [49, 50]. Poorer hearing in leisurely activities conferred a moderative role in the as- function may be related to certain domains of cognitive sociation between hearing loss and cognitive function. Ac- functional decline, especially concerning memory and cordingly, Table 3 shows that among those with normal executive function [51]. The variability in assessing cog- hearing in the baseline as well as those who reported hear- nitive function and how one may define hearing loss ing loss in the follow-up periods, individuals who frequently may result in conflicting findings [11]. In addition, past took part in leisurely activities had a less likelihood of cog- studies were conducted in non-representative popula- nitive decline. Similar results were found within the male tions, which may give rise to sample selection bias, lead- subgroup, however, the female subgroup demonstrated that ing to inaccurate results. the interactions of hearing loss on leisurely activities were Previous studies suggested that compared to men, not significantly associated with cognitive function. women are more easily affected by the risk factors of cognitive impairment, as women have more rapid de- Discussion clines in hearing sensitivity at certain ranges of fre- This study investigated the association between hearing quency [52], higher CVD (cardiovascular diseases) risks impairment and cognitive function in a nationwide [53] and an increased likelihood social isolation [28]. population-based survey on the Chinese elderly. After However, our results do not imply sex difference in the Gao et al. BMC Geriatrics (2020) 20:215 Page 7 of 10 Table 3 Estimated coefficients and 95% confidence interval for fixed effects models on the association of hearing loss and MMSE scores, 2011/12–2014 Variables Adjusted models Adjusted models + activity engagement Adjusted models+ interaction for HL and activity engagement Total Male Female Total Male Female Total Male Female Self-reported HL −0.81(−1.22, −0.79(−1.31,- −0.85(−1.49,- −0.82(−1.23, −0.82(−1.33, −0.84(−1.47, −1.45(−2.17,- −1.85(−2.80,- −1.15(−2.23,- −0.39) 0.27) 0.21) −0.41) −0.30) −0.21) 0.73) 0.89) 0.08) Activity engagement 0.09(0.06, 0.13) 0.08(0.04,0.12) 0.11(0.05,0.17) 0.07(0.03–0.11) 0.05(−0.001,0.09) 0.10(0.03,0.17) Interaction Activity 0.06(0.003,0.11) 0.09(0.02,0.16) 0.03(−0.05,0.12) engagement*HL Covariates Yes Yes Yes Yes Yes Yes Yes Yes Yes Constant 26.77 27.61 26.04 25.75 26.62 24.95 26.04 27.03 25.10 Observations 7942 3735 4207 7942 3735 4207 7942 3735 4207 Gao et al. BMC Geriatrics (2020) 20:215 Page 8 of 10 association between hearing loss and cognitive The current study has several important limitations. impairment. First, our measurement of hearing loss is based on a di- In the current study, frequent engagement in leisure chotomized measure of self-reported hearing loss and activities played a moderating role in the association be- verbal cognitive test, which may limit the accuracy of tween hearing loss and cognitive decline. Previous stud- our estimations among older adults due to measurement ies focusing on the relationship of hearing loss and bias. Although Kiely’s et al. (2012) study documented a cognition considered activities engagement or social iso- moderate association between self-reported and audio- lation as a mediator [23], or only tested the moderator metric hearing loss and suggested that self-reported role of hearing aids, length of time with treatment and hearing loss may indicate hearing disability, the dichoto- age [54], seldom regarding the activity engagement on mized measure of self-reported hearing loss does not the association between hearing health and cognition. provide a very accurate and reliable basis to some extent Communication breakdown caused by hearing loss may compared with audiometric hearing loss [62]. Moreover, affect the types and frequency of leisure activities that self-reported items may also be biased by correlated older adults participate in. Hearing-impaired older adults measurement error or same-source bias, such as age, sex may have to cope with verbal challenges and anxiety or cognitive function. Third, we do not have data on the stress in the presence of social gatherings. Therefore, duration of hearing loss and severity of hearing loss, thus performance of auditory function may affect older we are not able to identify the exact impact of hearing adults’ engagement in some social activities and hearing- loss on cognitive function. Further studies are needed related recreational activities (e.g. listening to music and with audiometric measures and sufficient information on watching television), which have been proved with cog- hearing function to understand the association of hear- nitive benefits [55, 56]. Moreover, hearing loss may give ing loss and cognitive function. The relatively short rise to basic and instrumental activities of daily living follow-up period for self-reported hearing loss and cog- loss [57]. Engagement in productive activities, such as nition contributes to another potential limitation by in- caregiving or doing housework, may require hearing- creasing the uncertainty of our estimates. A further impaired older adults more cognitive capacity to deal limitation to our main results may come from the poten- with complex cognitive tasks. Leisure activities involve tial bias related to sample attrition due to mortality and physical, mental, and social components [58]. Compared loss to follow-up. Approximately 38% of the sample to productive activities, engagement in leisure activities, from the wave 2011/12 died or lost to follow-up in wave such as personal slow walking or outdoor exercising, 2014, which may result in significant bias in our estima- may require less cognitive loads or social interaction tions. Although our analysis for missing data suggested burden. Active participated in leisure activities, such as that the association between hearing loss and cognitive reading or knitting, can benefit hearing-impaired older decline was not differed systematically by the follow-up adults’ cognition by fostering intellectual stimulation, sample or those known to be deceased (see Supplemen- mood improvement that are related to cognitive main- tary), some caution is still needed in interpreting these tenance [59]. results regarding the limitations mentioned above. Sex difference is shown in the moderating effect of Despite these limitations, strengths of our current are leisure activities between hearing loss and cognitive de- that our results are based on a nationally representative cline. Although frequent engaged in leisure activities sample, and a longitudinal analysis with fixed-effect model mitigated the effects of hearing loss on cognitive decline methods to avoid the potentially strong cross-sectional among older males, we did not find any statistically sig- confounding effects and fix problems on time-invariant nificant association between the interaction of various omitted variables to some extent. If our results are con- types of leisure activities on hearing loss and cognition firmed by a standard audiometric testing protocol and in among the female sample. The moderating effect of leis- other independent studies, our findings potentially have ure activities is more pronounced among older men than important implications in aging health. Our findings show women may be because women in China tend to have that hearing loss was negatively associated with cognitive lower education and less likely to accumulate socioeco- decline and of importance to highlight the role of leisure nomic resources [60], thus resulting in fewer cognitive activities engagement in moderating the association. This resources and less benefit from intelligence stimulating implies the Chinese policy maker to consider the role of activities, such as reading books or magazines. Addition- hearing aids and activity participation in cognition or de- ally, older women are generally more likely to sedentary mentia prevention program. or less active in leisure-time physical activity than men. Older women may perceive more barriers to outdoor ac- Conclusions tivities than men, especially in a condition of perceived Hearing impairment was negatively associated with cog- poor health status [61]. nitive function among older adults in China. Leisure Gao et al. BMC Geriatrics (2020) 20:215 Page 9 of 10 activity moderated the impact of hearing loss on cogni- Author details Guanghua School of Management, Institute of Strategy Research, Peking tive performance among older men rather than women. University, Beijing 100871, China. Laboratory of Behavioral Neuroscience, These findings lend support to the hypothesis that hear- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA. ing impairment may be a risk factor for cognitive dys- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. Center on Aging and Health, Johns function in older adults and that hearing aid use or Hopkins University School of Medicine, Baltimore, MD, USA. Department of proper leisure activity engagement could possibly reduce Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of this risk. Given the current lack of standardized audio- Medicine, Baltimore, MD, USA. Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. China metric assessment and mechanism identification, further Center for Health Development Studies, Peking University, No. 38 Xueyuan studies are needed to estimate whether hearing loss and Road, Haidian District, Beijing 100191, People’s Republic of China. leisure activity interventions could reduce cognitive de- Received: 20 December 2019 Accepted: 15 June 2020 cline in older adults. Supplementary information References Supplementary information accompanies this paper at https://doi.org/10. 1. World Health Organization. Dementia. https://www.who.int/en/news-room/ 1186/s12877-020-01615-7. fact-sheets/detail/dementia. Accessed 20 Sept 2019. 2. National Bureau of Statistics P. 2010 sixth national population census key data bulletin. http://www.stats.gov.cn/tjsj/tjgb/rkpcgb/qgrkpcgb/201104/t2 Additional file 1: Table 1. Classification of leisure activities. 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Hearing loss and cognitive function among Chinese older adults: the role of participation in leisure activities

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Abstract

Background: Hearing loss, a highly prevalent sensory impairment affecting older adults, is a risk factor for cognition decline. However, there were very limited studies on this association in low-resource countries. This study aimed to assess the association between self-reported hearing loss and cognitive decline, and whether engagement in leisure activities moderated this association among older adults in China. Methods: Data were obtained from two waves of the nationally representative survey of China Longitudinal Healthy Longevity Survey (CLHLS) between 2011/12–2014. Eight thousand eight hundred forty-four individuals aged 65 years old or above with a dichotomized measure of self-reported hearing status were included. Modified Mini-Mental Examination (MMSE) was used to measure global cognition. Fixed-effects models were used to estimate whether leisure activity engagement moderated the association of self-perceived hearing loss with global cognitive change in the overall sample and sex subsamples. Results: Self-reported hearing loss was associated with cognitive impairment, with an odds ratio of 2.48 [1.22, 5.06]. Sex difference in the association of hearing loss and cognitive impairment was not found. Self-reported hearing loss was associated with cognitive decline, with 8% increase in risk compared with those with normal hearing. Frequent engagement in leisure activities moderated the association between hearing loss and cognitive decline for the whole and male samples. Conclusion: Hearing loss was associated with cognitive decline, and leisure activities engagement moderated the association among males rather than females. Keywords: Hearing loss, Activities engagement, Cognitive function, Sex difference Background million people) by 2030 [4]. Cognitive impairment, charac- Dementia is a major global public health concern. It af- terized by the presence of weakening of one or more cogni- fected approximately 50 million people worldwide [1]. De- tive domains like immediate and delayed memory, may mentia prevalence is expected to rise in the near future, develop into dementia [5]. The prevalence of mild cognitive especially in China, where its prevalence in a population of impairment among Chinese adults aged ≥60 was 12.7% in 1.7 billion adults aged 60 or older [2] was 4.6% (8 million) 2010 [6]. Cognitive decline is more prevalent in older indi- in 2010 [3], which is expected to increase to 6.7% (23 viduals [7], and previous studies have shown that the pres- ence of chronic diseases, sensory loss, disengagement in physical, mental or social activity, and exposure to acute * Correspondence: [email protected] and chronic stress may be related to poorer cognitive per- China Center for Health Development Studies, Peking University, No. 38 formance in later life [8, 9]. Xueyuan Road, Haidian District, Beijing 100191, People’s Republic of China Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gao et al. BMC Geriatrics (2020) 20:215 Page 2 of 10 Hearing loss, a prevalent chronic condition in older of isolation among older adults via social interaction and adults, is a key risk factor of cognitive impairment and constructively spending time [27]. In addition to psycho- dementia [10–12]. Approximately 11% of adults aged social benefits, participating in mentally stimulated leisurely ≥60 were diagnosed with disabling hearing impairment activities may promote stability or enhance cognitive per- in China [13]. Dementia is a major source of disability formance. A recent study found that poorer hearing func- around the world, and no disease-modifying treatments tion may affect verbal memory performance and attention so far [14]. Age-related hearing loss may be associated to auditory stimuli among older adults [28], while another with an increased risk of dementia in later life, which study focusing on the association between leisurely activity has garnered increasing attention as a potentially modifi- and cognitive function in old age indicated that more able risk factors for dementia and cognitive decline [10– participation in self-improvement, intellectual, or cultural 12]. Evidence from a randomized controlled trial regard- activities was associated with better performance in verbal ing hearing support in dementia (i.e., SENSE-Cog Field ability and memory [29]. Maintaining a moderate or high Trial) demonstrated that employing a sensory interven- level of participation in leisurely activities may play a role in tion to support hearing, such as providing hearing aids, the relationship between hearing loss and cognition. En- communication training, and supplementary sensory gagement in leisurely activities makes up a considerable aids to enhance the home environment or foster social amount of daily activity among the Chinese elderly. Leisure inclusion, benefits people with dementia as well as their activities may be demographically or culturally specific, and partner by improving their quality of life, physical func- studies from Asian countries that have adopted Confucian tions, psychosocial health and relationship satisfaction culture suggested that the link between participating in leis- [15, 16]. Moreover, studies have indicated that hearing ure activities and cognitive performance may differ by sex aid use confers a mitigating effect on the trajectories of [30, 31], as the elderly may possess differences in lifestyle cognitive decline by maintaining cognitive function, such and social networks. Additionally, consequences resulting as episodic memory [17, 18]. from hearing loss, as well as the association between spe- Although the mechanisms underlying the association of cific leisure activity and cognition, may also vary by sex. For hearing loss with cognitive decline and dementia remain example, older men with hearing loss were more likely unclear, several hypotheses exist [19]. One possible mech- to be depressed than men with normal hearing, while anism is the shared pathologic etiology. The common fac- hearing loss did not affect the odds of depression in tor theory suggested that the association of sensory and older women [32]. In contrast, elderly women with cognitive performance is explained by a third common hearing loss tend to feel socially isolated, however, the factor, such as an aging brain [20, 21] or frailty syndrome association between hearing loss and social isolation [22]. The second hypothesis is biologically plausible given was not significant among men [33]. Cognitively stimu- the effects of hearing loss on cognitive load and cognitive lating and socially engaging activities, along with intel- reserve, which may be mediated by social isolation or lectual or cultural activities, were found to reduce the loneliness [12, 23]. One possible explanation for the asso- risks of dementia among elderly men and women [29]. ciation between social isolation, loneliness, and cognitive Though much research has documented that hearing function is that loneliness or social isolation is associated loss was associated with cognitive decline and dementia in with unhealthy behaviors or a plethora of chronic diseases developed countries, a very limited number of studies have related to poor cognition [24]. The third hypothesis is the been done in developing countries, and few have focused information-degradation hypothesis, which posits that in- on the role of engaging in leisurely activity. Maharani creased cognitive load from the compensation of auditory et al. [24] and Frank Lin et al. [12] put forward that the as- deficits may limit the resources available in performing sociation between hearing loss and cognitive decline other cognitive tasks [25]. among the elderly may be mediated by cognitive load and/ One potential way in modifying the association of or social isolation. However, whether efforts in maintain- hearing loss with cognitive decline and dementia may be ing engagement in leisurely activities or increasing the size through increased participation in activities. Previous of social networks may mitigate the impact of hearing loss studies indicated that older adults with hearing loss were on cognition are still unclear. Given the expected rise of more likely to have smaller social networks [26]. Since the aging population in China, a better understanding of the relationship between hearing loss and cognitive im- such relationships would provide valuable insights into pairment may be mediated by social isolation or loneli- potential approaches in preventing or delaying the onset ness [24], efforts to improve the social networks of of dementia. According to the “cognitive load theory” and hearing-impaired older adults may be beneficial in pre- “cascade hypothesis” [34], this study aimed to examine: 1) venting cognitive decline. Participation in leisurely activ- the association of self-perceived hearing loss with cogni- ities, i.e. gardening, reading or engaging in hobbies has tive function; 2) the role of engaging in leisurely activities shown positive effects in reducing loneliness and feelings as a potential moderator in this association; and 3) the Gao et al. BMC Geriatrics (2020) 20:215 Page 3 of 10 differences in these associations by sex among the Chinese participant’s consenting proxy. The relationship between elderly. the agent and the participant was included in the in- formed consent [35]. Details on the study design, sam- Methods pling, measures, and data quality of the CLHLS are Data source available elsewhere [37]. We obtained the data from the Chinese Longitudinal CLHLS included questions on self-reported hearing Healthy Longevity Survey (CLHLS), a dynamic cohort difficulties only in waves during 2011/12 and 2014. study that collected first-wave data in 1998, along with Therefore, the current study adopted two waves from six follow-up surveys with the replacement of deceased the CLHLS longitudinal data taken during 2011/2012 to elders in 2000, 2002, 2005, 2008, 2011 and 2014 [35]. 2014. Accordingly, 9765 and 7192 respondents were The CLHLS recruited a representative sample from 23 interviewed in 2011/12 and 2014, respectively. Of the of the 31 provinces within China [36], and in-person in- 9765 respondents interviewed in the 2011/12 survey, terviews were conducted by the researchers so as to ac- 6066 were followed up in the 2014 survey, but 820 re- quire data regarding demographics, socioeconomic spondents were lost to follow-up, while 2879 persons status, lifestyle, and health. Consent for participation died or were already deceased prior to the 2014 follow- was given via face-to-face interviews, where informed up survey. In addition to the 6066 follow-up respon- consent was presented to the selected participants prior dents, 1125 respondents were newly interviewed in 2014 to the in-person interview. The informed consent in- [38, 39]. Details concerning sample selection are pre- cluded information on the interview’s duration, contents, sented in Fig. 1. and purpose, and the elderly participants were asked if We restricted the study sample to 14,309 respondents they agreed to participate in the interview and be in- aged ≥65 years who completed the questionnaire on self- volved in a physical examination. If the participant de- reported hearing difficulties and cognitive function from clined to take the interview, the participate was allowed the 2011/12–14 CLHLS sample. Here, 8844 were from to ask his/her spouse, children or other relatives to an- the 2011/12 wave, while 5465 were part of the 2014 swer on his/her behalf. The participant signed the in- wave. Individuals were excluded if they were younger formed consent if he/she was capable to read and write, than 65 years of age, had died, or failed to respond to otherwise, the informed consent was signed by the items comprising the outcome variable. Fig. 1 flowchart of the study sample Gao et al. BMC Geriatrics (2020) 20:215 Page 4 of 10 Measures Covariates Self-reported hearing status Covariates included several sociodemographic character- Hearing impairment was defined by responses of self- istics, health behaviors and health conditions that were reported hearing difficulty. Participants were asked the fol- potentially associated with cognitive function as in previ- lowing question to check their hearing status (without ous studies [46]. These variables consisted of age (con- using hearing aids): “Do you have any difficulty with your tinuous), sex (male vs. female), residence (urban vs. hearing?”“YES” was coded as having hearing impairment, rural), education (illiterate vs. literate), smoking (never while “No” signified not having hearing impairment. smoking, ever smoking vs. current smoking), alcohol use (never drinking, ever drinking vs. current drinking), self- Global cognition reported general health status (good vs fair/poor), having Global cognition is measured using the Chinese version been diagnosed with hypertension (yes vs. no), and hav- of the Mini-Mental State Examination (MMSE). The ing been diagnosed with diabetes (yes vs. no). Chinese version of MMSE is comprised of 23 items and examines four aspects of cognitive function (orientation, Statistical analyses calculation, recall, and language), which was adapted Descriptive statistics were used for all study variables. from the original MMSE developed by Folstein et al. Fixed effect models were used to capture the within- [40]. Considering the cultural and socioeconomic condi- individual association between the occurrence of hearing tions among the Chinse elderly, several items were loss and cognitive function decline over time. The fixed modified or deleted to make the questions easily under- effect models are longitudinal models that were applied standable and answerable among the participants whose in the panel data, which confer benefits in treating unob- cognitive function was normal. For example, the respon- served confounders and time-invariant variables as a set dents were asked to name as many foods as possible ra- of fixed parameters to control effects pertaining to both ther than writing a complete sentence. The questions observed and unobserved time-invariant variables as well involving calculations were simplified, and one item per- as the effect of years on the dependent variable [47]. In taining to orientation to time and four items concerning this study, Hausman tests were conducted, where the orientation to place were excluded [41]. Several similar fixed effects model was shown to be more appropriate versions of the Chinese MMSE, which were all adopted than the random effects model with chi2 = 49.13 (p < according to Folstein’s version [40], have proven to be 0.005). Likelihood-ratio tests were also performed, which reliable and may be employed to study the Chinese eld- indicated that the fixed-effects model was more appro- erly [42, 43]. Scores on each item are normally binary priate than the mixed-effects model with LR chi2 = − (e.g. 1 for a correct and 0 for otherwise). The total pos- 3871.60 (p = 1.00). Moreover, the cognitive function was sible score on the MMSE is 30, with higher scores indi- initially treated as a binary variable using a cutoff point of cating better cognitive performance. In accordance with 18 (cognitively impaired vs. normal cognition). Fixed effect previous studies in China that suggested the use of 18 or logit models were conducted to estimate the average odds 19 as the cutoff score of MMSE when screening for de- ratios of cognitive decline related to the occurrence of mentia among populations with little or no formal edu- self-perceived hearing loss during the follow-up period. cation [43, 44], individuals who scored < 18 were The time-variant variables were adjusted in these models, considered to be cognitively impaired. Hence, the 23- including age, smoking, alcohol use, self-reported health, item used for the MMSE for Chinese elderly has demon- hypertension and diabetes. Second, the continuous form strated good validity [45]. of the cognitive function (the summed MMSE scores) was utilized as the dependent variable to estimate the average Leisure activity engagement change in MMSE scores associated with hearing loss dur- We used the frequency of participation in leisure activ- ing the follow-up period. Hausman tests indicated that ities to measure the level of engagement in such activ- fixed effects models were more appropriate in the estima- ities among older adults. Overall, the survey respondents tion compared to random effects models (chi2 = 167.06, were asked, “Do you now perform the following activ- p < 0.001). Furthermore, regarding the potential bias ities regularly? (please choose one from the frequency on caused by the missing data due to participants being de- the right)”. Each specific activity was indexed at five ceased or lost to follow-up, the characteristics of the miss- levels: 0 = never; 1 = not every month; 2 = not every ing data were reported, and a proportional hazard model week; 3 = not every day; and 4 = almost every day. To ob- was done for the mortality sample as well as a regression tain a general perspective on activity involvement, the analysis using an attribution indicator and baseline data- total sum of the scores regarding participation frequency set, as shown in the Supplementary document. All ana- in each activity was computed. Details concerning the lyses were conducted using the Stata 14.0 software. leisure activities are shown in Additional file 1. Gao et al. BMC Geriatrics (2020) 20:215 Page 5 of 10 Results women, with 77% (n = 3693) of females being illiterate (vs. Sample characteristics 32% male) in wave 1 and 73% (vs. 29% male) in wave 2, re- Table 1 presents the sample characteristics over two spectively. Details regarding the characteristics of the eld- waves of CLHLS. The mean MMSE scores slightly in- erly sex subgroups are presented in Table 1.With respect creased from 26.08 (SD = 5.35) in wave 1 to 26.51 (SD = to the sample that was excluded due to participants’ death 4.67) in wave 2. The proportion of participants having or loss to follow-up, elderly participants among the ex- cognitive impairment decreased from 8% (n = 749) to 6% cluded sample were more likely to have a higher mean age (n = 336) over two waves, while the proportion for hear- (91.3 years old), be hearing impaired, illiterate and have ing loss decreased from 44% (n = 3937) in wave 1 to 39% poorer self-reported health (see Supplementary). (n = 2137) in wave 2. The mean scores for all kinds of leisurely activities increased over time from 9.98 to 10.48 Association of hearing impairment and cognitive over two waves. The average age was 85.08 (SD = 10.98) impairment in wave 1 and 84.74 (SD = 9.99) in wave 2. Details re- Table 2 illustrates the results of the association between garding the sample characteristics are shown in Table 1. the co-occurrence of self-reported hearing loss and cog- Elderly females had a higher MMSE score than males in nitive impairment during the follow-up period using both waves. The proportion of cognitive impairment and fixed-effect models. The unadjusted model (Model 1) self-reported hearing loss was found to be higher among shows that hearing loss was significantly associated with older females than in males, with 12% (n =560) of females the occurrence of cognitive impairment. Compared to having cognitive impairment (vs. 5% for male) and 47% participants without hearing loss, those who reported (n = 2231) of females having hearing loss (vs. 42% for hearing loss during the follow-up period were 1.87 times male) in wave 1. In these two waves, the elderly male co- more likely to develop cognitive impairment (odds ratio hort were reported to frequently engage in leisurely activ- [OR] = 1.87, 95% confidence intervals [CI] = 1.28, 2.74). ities compared to females. Men were observed to have After adjusting with the time-variant covariates in Model higher average scores in physical outdoor activities, intel- 2, the association between hearing loss and cognitive im- lectual activities, recreational activities, and social activ- pairment was consistent, with OR = 2.48 (95%CI:1.22, ities, while women participated more in productive 5.06). An interaction between sex and hearing loss is in- activities. Older men attained better education than older troduced in Model 3, which demonstrates that the Table 1 Characteristics of participants by waves in CLHLS, 2011/2012 to 2014, mean (SD)/n (%) Variables Wave 1 Wave 2 Total (n = 8844) Male (n = 4089) Female (n = 4755) Total (n = 5465) Male (n = 2628) Female (2837) MMSE scores 26.08(5.35) 27.13(4.44) 25.19(5.88) 26.51(4.67) 27.46(3.88) 25.66(4.47) Cognitive impairment 749(8.47) 189(4.62) 560(11.78) 336(6.19) 97(3.69) 239(8.42) Self-reported HL 3937(44.52) 1706(41.72) 2231(46.92) 2137(39.38) 997(37.94) 1141(40.22) Activity engagement 9.98(6.62) 11.43(6.58) 8.73(6.39) 10.48(6.65) 11.61(6.64) 9.51(6.54) Productive activities 2.13(1.90) 2.04(1.88) 2.21(1.91) 2.27(1.88) 2.11(1.87) 2.43(1.88) Outdoor activities 2.21(1.84) 2.45(1.79) 2.01(1.85) 2.22(1.84) 2.39(1.81) 2.07(1.85) Intellectual activities 0.57(0.98) 0.87(1.13) 0.31(0.75) 0.61(1.02) 0.90(1.15) 0.35(0.80) Recreational activities 1.40(1.10) 1.61(1.07) 1.22(1.10) 1.49(1.09) 1.65(1.06) 1.35(1.10) Social activities 0.30(0.87) 0.38(0.96) 0.24(0.78) 0.32(0.89) 0.39(0.96) 0.27(0.83) Age 85.08(10.98) 82.84(10.06) 87.01(11.37) 84.74(9.99) 82.97(9.16) 86.13(10.63) Rural 4624(52.28) 2097(51.28) 2527(53.14) 2835(52.83) 1366(52.46) 1501(53.63) Illiterate 4987(56.39) 1294(31.65) 3693(77.67) 2825(52.05) 771(29.34) 2066(72.82) Ever smoking 1439(16.36) 1158(28.47) 281(5.94) 774(14.33) 654(24.99) 123(4.36) Current smoking 1639(18.64) 1370(33.68) 269(5.69) 977(18.09) 843(32.21) 144(5.11) Ever drinking 1270(14.51) 947(23.43) 323(6.86) 575(10.68) 463(17.72) 114(4.06) Current drinking 1520(17.37) 1142(28.26) 378(8.03) 876(16.28) 716(27.40) 167(5.95) Self-reported poor health 1501(17.22) 581(14.37) 920(19.69) 856(15.97) 366(14.04) 492(17.62) Hypertension 3126(50.76) 1388(49.62) 1738(51.71) 2167(56.97) 1011(55.19) 1168(58.43) Diabetes 1118(21.73) 528(22.34) 590(21.22) 904(28.99) 437(28.52) 476(29.55) a b variable being reported with mean (SD). variable being reported with number (proportion) Gao et al. BMC Geriatrics (2020) 20:215 Page 6 of 10 Table 2 Odds ratio and 95% confidence interval for fixed effects models on the association between hearing loss and cognitive decline during 2011 to 2014 Variables Model 1 Model 2 Model 3 Model 4 Self-reported HL 1.87(1.28,2.74) 2.48(1.22,5.06) 2.90(0.75,11.29) 2.84(1.00,8.13) Ever smoking 0.54(0.08,3.68) 0.57(0.08,4.09) 0.50(0.07,3.46) Current smoking 0.45(0.08,2.49) 0.45(0.08,2.49) 0.41(0.07,2.26) Ever drinking 4.56(0.92,22.60) 4.44(0.89,22.20) 3.96(0.78,20.13) Current drinking 0.21(0.05,0.89) 0.21(0.05,0.88) 0.18(0.04,0.82) Poor self-reported health 2.17(0.93,5.08) 2.15(0.92,5.04) 2.09(0.88,5.01) Hypertension 0.53(0.25,1.09) 0.52(0.25,1.08) 0.51(0.24,1.07) Diabetes 0.77(0.34,1.75) 0.77(0.34,1.77) 0.78(0.34,1.78) Self-reported HI * female 0.80(0.16,3.92) Self-reported HI * activity engagement 0.98(0.88,1.09) Year 1.69(1.38,2.07) 1.91(1.26,2.90) 1.90(1.25,2.89) 1.78(1.15,2.74) Observation 830 266 266 266 association of hearing loss and cognitive impairment did not identifying the impacts of hearing deprivation on cognitive differ by sex. In Model 4, we employed an interactive term decline, whether engaging in leisurely activities moderated of hearing loss and leisurely activity participation to test the link between hearing loss and cognitive function from whether participants who frequently participated in leisurely the perspective of gender was explored. To the best of our activities were found to have a mitigated association of hear- knowledge, this is the first study to report the empirical re- ing loss and cognitive impairment. However, the results sults of hearing loss in relation to cognitive function as well show that those who actively participated in leisurely activ- as the moderative role of leisurely activities from a longitu- ities were not found to have an association between hearing dinal survey in mainland China. It was found that elderly loss and the occurrence of cognitive impairment. males or females who reported as having a self-perceived The analysis regarding the association of self-reported hearing difficulty had a greater risk of cognitive impair- hearing loss and change in global cognition during the ment. Frequent participation in leisurely activities benefited follow-up period was further elucidated using linear fixed- older adults with hearing loss to perform better in cognitive effect models, which are presented in Table 3.After adjust- functioning, particularly in the male subgroup. ing for time-variant covariates, participants who reported The results of this study contribute to studies explor- hearing loss during the follow-up period suffered from a ing the association between hearing impairment and 0.81-point decrease in cognition score. This association re- cognitive function among the aging Chinese population. mains significant in both sex subgroups, with a 0.79-point Our findings align well with those of previous studies decrease in cognition scores among males and a 0.85-point [12, 46, 48], documenting a significant correlation be- decrease among females. An interactive term of hearing tween hearing difficulty and poorer cognitive perform- loss and leisurely activity participation was then used in the ance among the elderly. In contrast, other studies have adjusted models, which signified that frequently engaging yielded inconsistent findings [49, 50]. Poorer hearing in leisurely activities conferred a moderative role in the as- function may be related to certain domains of cognitive sociation between hearing loss and cognitive function. Ac- functional decline, especially concerning memory and cordingly, Table 3 shows that among those with normal executive function [51]. The variability in assessing cog- hearing in the baseline as well as those who reported hear- nitive function and how one may define hearing loss ing loss in the follow-up periods, individuals who frequently may result in conflicting findings [11]. In addition, past took part in leisurely activities had a less likelihood of cog- studies were conducted in non-representative popula- nitive decline. Similar results were found within the male tions, which may give rise to sample selection bias, lead- subgroup, however, the female subgroup demonstrated that ing to inaccurate results. the interactions of hearing loss on leisurely activities were Previous studies suggested that compared to men, not significantly associated with cognitive function. women are more easily affected by the risk factors of cognitive impairment, as women have more rapid de- Discussion clines in hearing sensitivity at certain ranges of fre- This study investigated the association between hearing quency [52], higher CVD (cardiovascular diseases) risks impairment and cognitive function in a nationwide [53] and an increased likelihood social isolation [28]. population-based survey on the Chinese elderly. After However, our results do not imply sex difference in the Gao et al. BMC Geriatrics (2020) 20:215 Page 7 of 10 Table 3 Estimated coefficients and 95% confidence interval for fixed effects models on the association of hearing loss and MMSE scores, 2011/12–2014 Variables Adjusted models Adjusted models + activity engagement Adjusted models+ interaction for HL and activity engagement Total Male Female Total Male Female Total Male Female Self-reported HL −0.81(−1.22, −0.79(−1.31,- −0.85(−1.49,- −0.82(−1.23, −0.82(−1.33, −0.84(−1.47, −1.45(−2.17,- −1.85(−2.80,- −1.15(−2.23,- −0.39) 0.27) 0.21) −0.41) −0.30) −0.21) 0.73) 0.89) 0.08) Activity engagement 0.09(0.06, 0.13) 0.08(0.04,0.12) 0.11(0.05,0.17) 0.07(0.03–0.11) 0.05(−0.001,0.09) 0.10(0.03,0.17) Interaction Activity 0.06(0.003,0.11) 0.09(0.02,0.16) 0.03(−0.05,0.12) engagement*HL Covariates Yes Yes Yes Yes Yes Yes Yes Yes Yes Constant 26.77 27.61 26.04 25.75 26.62 24.95 26.04 27.03 25.10 Observations 7942 3735 4207 7942 3735 4207 7942 3735 4207 Gao et al. BMC Geriatrics (2020) 20:215 Page 8 of 10 association between hearing loss and cognitive The current study has several important limitations. impairment. First, our measurement of hearing loss is based on a di- In the current study, frequent engagement in leisure chotomized measure of self-reported hearing loss and activities played a moderating role in the association be- verbal cognitive test, which may limit the accuracy of tween hearing loss and cognitive decline. Previous stud- our estimations among older adults due to measurement ies focusing on the relationship of hearing loss and bias. Although Kiely’s et al. (2012) study documented a cognition considered activities engagement or social iso- moderate association between self-reported and audio- lation as a mediator [23], or only tested the moderator metric hearing loss and suggested that self-reported role of hearing aids, length of time with treatment and hearing loss may indicate hearing disability, the dichoto- age [54], seldom regarding the activity engagement on mized measure of self-reported hearing loss does not the association between hearing health and cognition. provide a very accurate and reliable basis to some extent Communication breakdown caused by hearing loss may compared with audiometric hearing loss [62]. Moreover, affect the types and frequency of leisure activities that self-reported items may also be biased by correlated older adults participate in. Hearing-impaired older adults measurement error or same-source bias, such as age, sex may have to cope with verbal challenges and anxiety or cognitive function. Third, we do not have data on the stress in the presence of social gatherings. Therefore, duration of hearing loss and severity of hearing loss, thus performance of auditory function may affect older we are not able to identify the exact impact of hearing adults’ engagement in some social activities and hearing- loss on cognitive function. Further studies are needed related recreational activities (e.g. listening to music and with audiometric measures and sufficient information on watching television), which have been proved with cog- hearing function to understand the association of hear- nitive benefits [55, 56]. Moreover, hearing loss may give ing loss and cognitive function. The relatively short rise to basic and instrumental activities of daily living follow-up period for self-reported hearing loss and cog- loss [57]. Engagement in productive activities, such as nition contributes to another potential limitation by in- caregiving or doing housework, may require hearing- creasing the uncertainty of our estimates. A further impaired older adults more cognitive capacity to deal limitation to our main results may come from the poten- with complex cognitive tasks. Leisure activities involve tial bias related to sample attrition due to mortality and physical, mental, and social components [58]. Compared loss to follow-up. Approximately 38% of the sample to productive activities, engagement in leisure activities, from the wave 2011/12 died or lost to follow-up in wave such as personal slow walking or outdoor exercising, 2014, which may result in significant bias in our estima- may require less cognitive loads or social interaction tions. Although our analysis for missing data suggested burden. Active participated in leisure activities, such as that the association between hearing loss and cognitive reading or knitting, can benefit hearing-impaired older decline was not differed systematically by the follow-up adults’ cognition by fostering intellectual stimulation, sample or those known to be deceased (see Supplemen- mood improvement that are related to cognitive main- tary), some caution is still needed in interpreting these tenance [59]. results regarding the limitations mentioned above. Sex difference is shown in the moderating effect of Despite these limitations, strengths of our current are leisure activities between hearing loss and cognitive de- that our results are based on a nationally representative cline. Although frequent engaged in leisure activities sample, and a longitudinal analysis with fixed-effect model mitigated the effects of hearing loss on cognitive decline methods to avoid the potentially strong cross-sectional among older males, we did not find any statistically sig- confounding effects and fix problems on time-invariant nificant association between the interaction of various omitted variables to some extent. If our results are con- types of leisure activities on hearing loss and cognition firmed by a standard audiometric testing protocol and in among the female sample. The moderating effect of leis- other independent studies, our findings potentially have ure activities is more pronounced among older men than important implications in aging health. Our findings show women may be because women in China tend to have that hearing loss was negatively associated with cognitive lower education and less likely to accumulate socioeco- decline and of importance to highlight the role of leisure nomic resources [60], thus resulting in fewer cognitive activities engagement in moderating the association. This resources and less benefit from intelligence stimulating implies the Chinese policy maker to consider the role of activities, such as reading books or magazines. Addition- hearing aids and activity participation in cognition or de- ally, older women are generally more likely to sedentary mentia prevention program. or less active in leisure-time physical activity than men. Older women may perceive more barriers to outdoor ac- Conclusions tivities than men, especially in a condition of perceived Hearing impairment was negatively associated with cog- poor health status [61]. nitive function among older adults in China. Leisure Gao et al. BMC Geriatrics (2020) 20:215 Page 9 of 10 activity moderated the impact of hearing loss on cogni- Author details Guanghua School of Management, Institute of Strategy Research, Peking tive performance among older men rather than women. University, Beijing 100871, China. Laboratory of Behavioral Neuroscience, These findings lend support to the hypothesis that hear- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA. ing impairment may be a risk factor for cognitive dys- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. Center on Aging and Health, Johns function in older adults and that hearing aid use or Hopkins University School of Medicine, Baltimore, MD, USA. Department of proper leisure activity engagement could possibly reduce Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of this risk. Given the current lack of standardized audio- Medicine, Baltimore, MD, USA. Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. China metric assessment and mechanism identification, further Center for Health Development Studies, Peking University, No. 38 Xueyuan studies are needed to estimate whether hearing loss and Road, Haidian District, Beijing 100191, People’s Republic of China. leisure activity interventions could reduce cognitive de- Received: 20 December 2019 Accepted: 15 June 2020 cline in older adults. Supplementary information References Supplementary information accompanies this paper at https://doi.org/10. 1. World Health Organization. Dementia. https://www.who.int/en/news-room/ 1186/s12877-020-01615-7. fact-sheets/detail/dementia. Accessed 20 Sept 2019. 2. National Bureau of Statistics P. 2010 sixth national population census key data bulletin. http://www.stats.gov.cn/tjsj/tjgb/rkpcgb/qgrkpcgb/201104/t2 Additional file 1: Table 1. Classification of leisure activities. 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BMC Geriatrics – Springer Journals

Published: Jun 19, 2020

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