Bidirectional associations of vision and hearing loss with anxiety: prospective findings from the Three-City Study

Bidirectional associations of vision and hearing loss with anxiety: prospective findings from the... Abstract Objective the aim of this study was to examine the bidirectional association of vision loss (VL) and hearing loss (HL) with anxiety over a 12-year period. Design this was a prospective population-based study. Setting community-dwelling French adults. Participants the study included 3,928 adults aged 65 and above from the Three-City study. Methods the relationships of VL, as assessed by near visual acuity and self-reported HL to a diagnosis of generalised anxiety disorder (GAD) were assessed over 12 years. A further objective was to explore whether sensory loss has a differential relationship with GAD than with anxiety symptoms, assessed by the Spielberger's State-Trait Anxiety Inventory. Results at baseline, HL [odds ratio (OR) = 1.41, 95% confidence interval (CI) 1.02–1.96, P = 0.04], but not mild or moderate to severe VL, was associated with self-reported anxiety symptoms (OR = 1.07 95% CI 0.63–1.83, P = 0.80; OR = 0.66 95% CI 0.12–2.22, P = 0.50, respectively). Neither vision nor HL was significantly associated with incident GAD. Baseline GAD was related to increased risk of incident HL (OR = 1.17, 95% CI 1.07–1.28, P < 0.001), but not mild or moderate to severe vision loss (OR = 1.01, 95% CI 0.96–1.06, P = 0.81; OR = 0.97, 95% CI 0.89–1.05, P = 0.45, respectively). Conclusions increased anxiety symptoms were observed in older adults with HL, whereas we found no evidence for an association between VL and anxiety. Anxiety was prospectively associated with increased risk of reporting HL. Improved detection of anxiety in older adults with HL may improve quality of life. anxiety disorders, generalised anxiety disorder, mental well-being, sensory impairment, older adults Sensory losses are highly prevalent amongst older adults [1] and are amongst the top 10 contributors to burden of disease [2]. Older adults with sensory loss experience poorer mental health and reduced quality of life [3, 4]. An increased risk of depression in older adults with hearing loss (HL) [5] and vision loss (VL) [6] has been established, with some evidence also suggesting that the prevalence of anxiety is higher than that for depression amongst older adults with VL [7, 8]. Indeed, the prevalence of anxiety disorders in older adults is consistently reported to be higher than the prevalence of depression [9, 10], and anxiety and depression are highly co-morbid, with anxiety frequently preceding the onset of depression [11]. Yet, there remains a dearth of research examining anxiety in sensory loss and older adults [4, 11]. Notably, in other chronic conditions, treatment of anxiety rather than depression has yielded better physical and psychological outcomes [12, 13], underscoring that unidentified and untreated anxiety might also underlie relationships between physical ill health and mental well-being. Accordingly, a better understanding of anxiety disorders amongst older adults with sensory loss is needed. Of the few anxiety and sensory loss studies to date, cross-sectional associations between anxiety with VL [8, 14, 15] have been reported, although findings remain equivocal [16, 17]. Limited cross-sectional studies also indicate an increased risk of anxiety in older adults with HL. However, longitudinal explorations of an association between sensory loss and anxiety are lacking. Further gaps in the anxiety and sensory loss literature remain. Most studies have examined anxiety symptoms; however, less is known about anxiety disorders. To date, the anxiety measures utilised typically fail to distinguish between threshold and subthreshold anxiety, yet varied prevalence rates of threshold and subthreshold disorders in sensory losses have been observed [15]. Moreover, the measures used assess a broad range of symptoms rather than assessing symptoms characteristic of any specific anxiety disorder. Thus, little is known about the extent to which relationships are limited to broad anxiety symptoms or are specific to (threshold) anxiety disorders. Generalised anxiety disorder (GAD), characterised by the hallmark feature of worry, is among the most prevalent anxiety disorders in older persons [18], and has a deleterious impact on quality of life [9]. Whether the diagnosis of GAD has a differential association with sensory loss compared with self-reported anxiety symptoms remains unclear. Furthermore, especially in younger adults, those with sudden sensorineural HL reported higher rates of having previously experienced an anxiety disorder than healthy controls [19], and adults with tinnitus retrospectively reported higher rates of worry (characteristic of GAD) than controls [20]. In addition, anxiety has been shown to decrease the ability to manage HL, leading to a worsening of the loss [21]. Despite these emergent findings, prospective explorations of an association between anxiety and incident sensory loss are lacking. Therefore, this study aims to: (i) examine the bidirectional longitudinal association of near VL and self-reported HL with GAD diagnosis and (ii) explore whether sensory loss has a differential relationship to GAD diagnosis compared with the relationship to self-reported anxiety symptoms. Method This study forms part of the SENSE-Cog multiphase research programme, funded by the European Union Horizon 2020 programme. SENSE-Cog aims to promote mental well-being in older adults with sensory and cognitive impairments (http://www.sense-cog.eu/). Sample This study examines data from the Three-City study [22], a prospective cohort study of 9,294 community-dwelling French adults aged 65 years and over. Participants were recruited via the electoral rolls of three French cities (Bordeaux, Dijon and Montpellier). The initial acceptance rate was 37%. Data from the Bordeaux and Montpellier sites are examined (n = 4,363), where baseline assessment for GAD was undertaken in 1999–2001. The Three-City study protocol was approved by the Ethics Committees of the University-Hospitals of Bicêtre and Nîmes (France), and written informed consent was obtained from participants. Participation included a face-to-face interview and clinical examinations. Participants were followed-up at 2–3 year intervals for up to 12 years. Among the initial sample, 3,953 (90.6%) have been followed-up at least once over the 12-year period; 116 had died before the first follow-up and 1,411 by the end of the 12-year period. Anxiety measures GAD diagnosis was ascertained by the Mini International Neuropsychiatric Interview (MINI) [23]. Both current and lifetime history of GAD, based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition) criteria, were assessed by trained nurses or psychologists. The MINI was administered at baseline, as well as at 7, 10 and 12 years (435 participants not assessed at baseline were excluded). Prevalent cases were those with a current diagnosis of GAD and, at each follow-up visit, incident cases were defined as those presenting with a new (and current) diagnosis among those free of GAD at baseline. Self-report anxiety symptoms were measured at baseline only using the Spielberger’s State-Trait Anxiety Inventory (STAI), a well-validated and reliable measure of anxiety symptomatology [24]. Form Y was used to assess trait anxiety symptomatology, assessed by 20 questions rated on a 4-point Likert scale. Scores range from 20 to 80, with higher scores indicative of greater symptom severity. Although varying cut-off scores have been proposed, a cut-off of 54 has been shown to have good sensitivity in older adults [25]. The STAI was administered as part of a self-completed questionnaire. Only participants who completed the STAI (n = 2934) were included in anxiety symptom analyses. Sensory loss measures Sensory loss was assessed at each follow-up. Binocular near visual acuity (presenting vision) was assessed using the Parinaud scale with a standardised reading distance of 33 cm. Mild VL was classified as Parinaud 3 or 4 (Snellen equivalent 20/30–20/60) and moderate to severe VL as Parinaud >4 (Snellen equivalent <20/60). HL was based on one question with four response categories, and was classified as self-reported deafness or difficulty understanding a conversation. Socio-demographic and health variables Socio-demographic and health-related information was collected during the standardised interview, including education (elementary, secondary school or higher education), monthly income (<€760, €760–2280 or >€2280), marital status, alcohol consumption (<10, 10–40 or >40 g per day), tobacco use (current-, past—or non-smoker) and falls in the past year. A composite score representing functional ability was also calculated based on the Rosow–Breslau scale, Lawton–Brody Brody Instrumental Activities of Daily living (IADL) scale and the Katz Index of Independence in Activities of Daily Living (categorised as autonomous, mobility limitations, mobility and IADL limitations, and limitations in three or more areas) [26]. During the medical questionnaire, history of stroke, myocardial infarction, depression diagnosis (MINI), diabetes and use of psychotropic medication (ATC codes: N05A-C and N06A-B) was obtained. A medical examination assessed body mass index (BMI) (≤25 or >25), and blood pressure was measured using a digital electronic tensiometer OMRON M4. Hypertension was defined as 140/90 mmHg or treatment with blood pressure-lowering drugs. Cognitive functioning was assessed using the Mini-Mental State Examination (MMSE; <16, 16-23, ≥24). Statistical analysis Socio-demographic and health characteristics were compared by sensory loss using χ2 and one-way analysis of variance (ANOVA). Logistic mixed models [27] were used to explore the bidirectional relationships between sensory loss and GAD. Logistic mixed models are optimal for exploring reversible binary outcomes given that they take into account within-subject correlation and model the individual time evolutions of the outcome (incident GAD or incident sensory loss) across follow-up, thus allowing for reversibility of symptoms. Mixed models also allow for greater flexibility to model time effects and handle missing data. In participants free of GAD at baseline, we examined whether baseline VL or HL was associated with incident GAD. We systematically searched for potential interactions between VL and HL, as well as each sensory loss with sex and education. Logistic mixed models were also undertaken to explore the effect of baseline anxiety on incident HL in those free of HL at baseline, and on incident VL in those free of VL at baseline. Additional models tested whether a lifetime history of GAD prior to baseline predicted subsequent VL or HL. To examine whether there is a cross-sectional relationship between anxiety symptoms and GAD with sensory loss, logistic regression analyses assessed whether baseline VL or HL was associated with baseline presence of anxiety symptoms or GAD. For each analysis, three models were produced: model 1 adjusted for time (longitudinal analyses only), sex, study centre and age; model 2 also adjusted for education, income, marital status and use of psychotropic medication; and model 3 further adjusted for MMSE, functional ability, falls, BMI, hypertension, diabetes, smoking, alcohol, depression, and history of stroke and myocardial infarction. Analyses were conducted using SAS 9.4 (SAS Institute, Inc., Cary, NC, USA). Results Of the 3,921 eligible participants, mean age at baseline was 73.7 (SD = 5.2) and the majority was female (n = 2,343; 59.8%). Baseline prevalence of mild VL was 11.7% (n = 460), moderate to severe VL was 2.6% (n = 104), and prevalence for HL was 36.1% (n = 1419). Those with sensory loss were older than those with no loss and in poorer health on all the health characteristics examined (see Appendix 1 available in Age and Ageing online). Those with VL were also less educated and had lower incomes. At baseline, 97 (2.5%) participants met criteria for current GAD, with 220 reporting a lifetime history of GAD. Those with and without a GAD history had few demographic differences, although participants with GAD were more likely to be female (70.9% versus 50.1%, P < 0.001) and were more highly educated (P < 0.001). Sensory loss and anxiety: cross-sectional analysis At baseline, VL was not associated with anxiety symptoms (Table 1). HL, however, was significantly associated with anxiety symptoms [odds ratio (OR) = 1.41, 95% confidence interval (CI) 1.02–1.96, P = 0.04]. Neither VL nor HL had significant cross-sectional associations with current GAD. Table 1. Cross-sectional association of baseline type of sensory loss (predictor variables) with anxiety symptoms (STAI) and GAD diagnosis (outcome variables): Three-City Study 1999–2001 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 OR, odds ratio; CI, confidence interval. Model 1: STAI n = 2,934, GAD n = 3,892; adjusted for sex, age and centre. Model 2: STAI n = 2,800, GAD n = 3,695; adjusted for sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: STAI n = 2,540, GAD n = 3,328; adjusted for sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Table 1. Cross-sectional association of baseline type of sensory loss (predictor variables) with anxiety symptoms (STAI) and GAD diagnosis (outcome variables): Three-City Study 1999–2001 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 OR, odds ratio; CI, confidence interval. Model 1: STAI n = 2,934, GAD n = 3,892; adjusted for sex, age and centre. Model 2: STAI n = 2,800, GAD n = 3,695; adjusted for sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: STAI n = 2,540, GAD n = 3,328; adjusted for sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Sensory loss and anxiety: longitudinal analysis Of the 3,824 participants without current GAD at baseline, incident GAD was detected in 82 individuals during follow-up. Neither mild nor moderate to severe VL (OR = 0.73, 95% CI 0.22–2.43, P = 0.60; OR = 0.77, 95% CI 0.12–4.86, P = 0.78, respectively) predicted GAD onset (Table 2). HL was also unrelated to GAD onset (OR = 1.13, 95% CI 0.59–2.17, P = 0.71). Table 2. Baseline type of sensory loss (predictor variables) and incident GAD (outcome variable) over 12 years Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1: n = 3,798; adjusted for time, sex, age and centre. Model 2: n = 3,604; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: n = 3,242; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Table 2. Baseline type of sensory loss (predictor variables) and incident GAD (outcome variable) over 12 years Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1: n = 3,798; adjusted for time, sex, age and centre. Model 2: n = 3,604; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: n = 3,242; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Anxiety and sensory loss onset Onset of any VL was noted in 1,122 participants without VL at baseline. Neither current nor lifetime history of GAD was associated with incident VL (Table 3). In those free of HL at baseline, 1,256 participants reported HL onset during follow-up. Both a current diagnosis of GAD and a lifetime history of GAD were associated with self-reported HL onset (OR = 1.17, 95% CI 1.07–1.28, P < 0.001; OR = 1.07, 95% CI 1.01–1.13, P = 0.02, respectively). Baseline anxiety symptoms were not associated with incident sensory loss. All tested interactions were non-significant. Table 3. Anxiety (predictor variables) and incident sensory loss (outcome variables) over 12 years OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 Model 1: VL and GAD n = 2,988, VL and STAI n = 2,433, HL and GAD n = 2,299, HL and STAI n = 1,707; adjusted for time, sex, age and centre. Model 2: VL and GAD n = 2,864, VL and STAI n = 2,353, HL and GAD n = 2,192, HL and STAI n = 1,651; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: VL and GAD n = 2,610, VL and STAI n = 2,159, HL and GAD n = 1,992, HL and STAI n = 1,524; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression and history of stroke and myocardial infarction. Table 3. Anxiety (predictor variables) and incident sensory loss (outcome variables) over 12 years OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 Model 1: VL and GAD n = 2,988, VL and STAI n = 2,433, HL and GAD n = 2,299, HL and STAI n = 1,707; adjusted for time, sex, age and centre. Model 2: VL and GAD n = 2,864, VL and STAI n = 2,353, HL and GAD n = 2,192, HL and STAI n = 1,651; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: VL and GAD n = 2,610, VL and STAI n = 2,159, HL and GAD n = 1,992, HL and STAI n = 1,524; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression and history of stroke and myocardial infarction. Discussion To our knowledge, this study provides the first longitudinal examination of the bidirectional association between anxiety and sensory loss. HL was associated with self-reported anxiety symptoms, but not prevalent or incident GAD, while VL was not associated with anxiety. Both a current diagnosis and a lifetime history of GAD were associated with increased likelihood of reporting HL over the 12 years of follow-up. Consistent with the limited literature, HL was associated with increased anxiety symptomatology [28, 29]. Vision was not found to be related to anxiety, nor was the VL and HL interaction significant, in agreement with previous results showing that anxiety is more common in HL than in VL [17]. An association with HL but not an interaction with VL suggests that anxiety in HL may be due to social isolation and communication difficulties [28]. No observed association between VL and anxiety in our data builds on the currently equivocal literature [14–16]. The heterogeneity of anxiety measures used might explain the conflicting results. Different symptoms of anxiety, often reflecting different underlying anxiety disorders, are examined across the anxiety measures used. Agoraphobia and social phobia are reported to be the most prevalent anxiety disorders amongst older adults with VL [15]; therefore, vision may be associated only with specific symptoms or anxiety disorders that were not assessed in our study. Although a relationship between HL and anxiety symptoms was observed, neither VL nor HL was associated with current or incident GAD. Due to the self-reported assessment of HL in our study, an inverse causation cannot be excluded to explain the results; however, our finding that HL was associated with increased symptoms but not GAD diagnosis may be a reflection of older adults frequently having elevated, yet subthreshold, mental health symptoms [11, 15]. This may be due, at least partially, to the difficulty in diagnosing anxiety disorders in later life, including in research settings [11]. Anxiety in older age can manifest differently from that seen in younger adults and, additionally, symptoms such as avoidance and excessive worry can be perceived to be normative parts of ageing [11]. Alternatively, the association of HL with increased anxiety symptoms, but a non-significant association with GAD, might be explained by the symptoms examined. The STAI assesses a range of affective and physiological anxiety symptoms, not only those specific to GAD. It is possible that HL is more closely related to other anxiety disorders. In particular, given the communication limitations, specific situations such as social interactions and going out alone may be more anxiety provoking, thus social phobia and agoraphobia might be more common in HL. The contrasting anxiety and sensory loss findings to date, as well as the differential relationship between HL with anxiety symptoms and GAD, further underscore the need for ongoing disorder-specific research in sensory loss. Disorder-specific examinations will provide a clearer picture of the mental health needs of older adults with sensory loss, and will enable better comparison across studies. Notably, although sensory loss was not associated with GAD onset, we found that both a current diagnosis and a lifetime history of GAD were associated with a small but significant increased risk of reporting HL. Adults with sudden sensorineural HL have a greater history of anxiety disorders than controls, although the relationship decreased with age [19]. Similarly, adults with sudden-onset HL or tinnitus retrospectively reported higher rates of worry—a central feature of GAD—than controls, although this was no longer significant after adjustment [20]. Our findings suggest that links between anxiety and worry with hearing are not limited to sudden HL and that, amongst the elderly, a prospective relationship between GAD and HL exists. The observed relationship between GAD and incident HL could be explained by several mechanisms. Cardiovascular risk factors are frequently associated with GAD [30], as well as HL in older adults [31]. Another pathway is through inflammatory processes or impaired hypothalamic–pituitary–adrenal (HPA) axis function. GAD is associated with elevated inflammatory markers [32], and inflammatory markers are also involved in the pathogenesis of HL [19]. It has also been proposed that increased HPA axis activity observed in GAD might impact hearing [15]. Unhealthy lifestyle and behavioural factors possibly also underlie this relationship. Additionally, social restriction and avoidance are common in anxiety, which may impact hearing via sensory deprivation [28]. Alternatively, anxious people might be more likely to self-report HL over time. The relationships between anxiety and HL further highlight the importance of identifying and treating anxiety in older adults; elevated symptoms that remain subclinical cause substantial distress [33]. However, older adults with anxiety underutilise mental health services [9, 18] and are rarely diagnosed [11]. Thus, targeted interventions would be beneficial. Communication skills training has reduced psychological distress in older adults with HL [34]. Internet-based therapies for the treatment of psychological distress in older adults, especially those with HL, might also be a valuable avenue [35]. Strengths and limitations This study substantially contributes to the limited literature examining anxiety in older adults with sensory loss. Strengths include the large sample, length of follow-up and the exploration of both VL and HL, as well as an anxiety diagnosis in addition to self-report symptoms. Limitations include that HL was self-reported, using a single item. Such self-reports may represent underestimates of actual HL, due to perceptions that hearing decline is a natural part of ageing. Conversely, those who have anxiety might be more likely to self-report HL onset, although self-reported vision did not have a relationship to anxiety (see Appendix 2 available in Age and Ageing online). Ongoing research with objective assessments of HL would be invaluable to corroborate such associations. A further limitation of this study was that the STAI was administered only at baseline, thus the long-term trajectory of anxiety symptoms could not be examined. Longitudinal differences between anxiety symptoms and GAD diagnosis remain unexplored. Only GAD was assessed; whether there are relationships between other anxiety disorders with sensory loss should be examined in the future. Furthermore, incident GAD was assessed only during follow-up interviews, thus remitted cases of GAD were not included in incident analyses. Power was low for the analysis of incident GAD, especially in VL, thus precluding definitive conclusions. Whilst our findings highlight the presence of an association between anxiety and sensory loss, we cannot determine causality because of the longitudinal cohort design and infrequent measures of VL, HL and GAD. Conclusions HL was significantly associated with anxiety. Older adults with HL were more likely to have elevated anxiety symptoms, although they were not at increased risk of GAD. Other anxiety disorders are likely to be more prevalent in older adults with sensory loss. In addition, GAD was prospectively associated with self-reporting the onset of HL. Better detection of anxiety in older adults with HL may improve their quality of life and, concomitantly, ageing adults with a history of GAD may benefit from screening for HL. Key points HL in older adults is associated with increased anxiety symptoms. We found no evidence of a longitudinal association between VL and anxiety. A history of GAD increases risk of self-reporting new onset of HL in older adults. This study provides the first longitudinal examination of relationships between sensory loss and anxiety. Supplementary Data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Conflict of interest The authors declare no conflicts of interest. Funding SENSE-Cog has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement no. 668648. The Three-City study is conducted under a partnership agreement between the Institut National de la Santé et de la Recherche Médicale (INSERM), the University Bordeaux 2 Victor Segalen and Sanofi-Aventis. The Fondation pour la Recherche Médicale funded the preparation and initiation of the study. The Three-City study is also supported by the Caisse Nationale Maladie des Travailleurs Salariés, Direction Générale de la Santé, MGEN, Institut de la Longévité, Conseils Régionaux d’Aquitaine et Bourgogne, Fondation de France, Ministry of Research-INSERM Programme ‘Cohortes et collections de données biologiques’, Agence Nationale de la Recherche ANR PNRA 2006 and LongVie 2007 and the ‘Fondation Plan Alzheimer’ (FCS 2009-2012). References 1 WHO . Mortality and budren of diseases . Geneva : World Health Organisation , 2012 . 2 Wittchen HU , Jacobi F , Rehm J et al. . The size and burden of mental disorders and other disorders of the brain in Europe 2010 . Eur Neuropsychopharmacol 2011 ; 21 : 655 – 79 . Google Scholar CrossRef Search ADS PubMed 3 Chia EM , Mitchell P , Rochtchina E , Foran S , Golding M , Wang JJ . Association between vision and hearing impairments and their combined effects on quality of life . Arch Ophthalmol 2006 ; 124 : 1465 – 70 . Google Scholar CrossRef Search ADS PubMed 4 Heine C , Browning CJ . Mental health and dual sensory loss in older adults: a systematic review . Front Aging Neurosci 2014 ; 6 : 83 . Google Scholar CrossRef Search ADS PubMed 5 Gopinath B , Wang JJ , Schneider J et al. . Depressive symptoms in older adults with hearing impairments: the Blue Mountains Study . J Am Geriatr Soc 2009 ; 57 : 1306 – 8 . Google Scholar CrossRef Search ADS PubMed 6 Carriere I , Delcourt C , Daien V et al. . A prospective study of the bi-directional association between vision loss and depression in the elderly . J Affect Disord 2013 ; 151 : 164 – 70 . Google Scholar CrossRef Search ADS PubMed 7 Yokoi T , Moriyama M , Hayashi K et al. . Predictive factors for comorbid psychiatric disorders and their impact on vision-related quality of life in patients with high myopia . Int Ophthalmol 2014 ; 34 : 171 – 83 . Google Scholar CrossRef Search ADS PubMed 8 Court H , McLean G , Guthrie B , Mercer SW , Smith DJ . Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study . BMC Med 2014 ; 12 : 181 . Google Scholar CrossRef Search ADS PubMed 9 Byrne GJ , Pachana NA . Anxiety and depression in the elderly: do we know any more? Curr Opin Psychiatry 2010 ; 23 : 504 – 9 . Google Scholar CrossRef Search ADS PubMed 10 Ritchie K , Artero S , Beluche I et al. . Prevalence of DSM-IV psychiatric disorder in the elderly French population . Br J Psychiatry 2004 ; 184 : 147 – 52 . Google Scholar CrossRef Search ADS PubMed 11 Bryant C , Mohlman J , Gum A et al. . Anxiety disorders in older adults: looking to DSM5 and beyond . Am J Geriatr Psychiatry 2013 ; 21 : 872 – 6 . Google Scholar CrossRef Search ADS PubMed 12 Tully PJ , Harrison NJ , Cheung P , Cosh S . Anxiety and cardiovascular disease risk: a review . Curr Cardiol Rep 2016 ; 18 : 120 . Google Scholar CrossRef Search ADS PubMed 13 Tully PJ , Selkow T , Bengel J , Rafanelli C . A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discrete effects of cognitive behavioral therapy, exercise, and psychotropic medication . Disabil Rehabil 2015 ; 37 : 585 – 92 . Google Scholar CrossRef Search ADS PubMed 14 Kempen GI , Zijlstra GA . Clinically relevant symptoms of anxiety and depression in low-vision community-living older adults . Am J Geriatr Psychiatry 2014 ; 22 : 309 – 13 . Google Scholar CrossRef Search ADS PubMed 15 van der Aa HP , Comijs HC , Penninx BW , van Rens GH , van Nispen RM . Major depressive and anxiety disorders in visually impaired older adults . Invest Ophthalmol Vis Sci 2015 ; 56 : 849 – 54 . Google Scholar CrossRef Search ADS PubMed 16 Evans JR , Fletcher AE , Wormald RP . Depression and anxiety in visually impaired older people . Ophthalmology 2007 ; 114 : 283 – 8 . Google Scholar CrossRef Search ADS PubMed 17 Bernabei V , Morini V , Moretti F et al. . Vision and hearing impairments are associated with depressive–anxiety syndrome in Italian elderly . Aging Ment Health 2011 ; 15 : 467 – 74 . Google Scholar CrossRef Search ADS PubMed 18 Mackenzie CS , Reynolds K , Chou KL , Pagura J , Sareen J . Prevalence and correlates of generalized anxiety disorder in a national sample of older adults . Am J Geriatr Psychiatry 2011 ; 19 : 305 – 15 . Google Scholar CrossRef Search ADS PubMed 19 Chung SD , Hung SH , Lin HC , Sheu JJ . Association between sudden sensorineural hearing loss and anxiety disorder: a population-based study . Eur Arch Otorhinolaryngol 2015 ; 272 : 2673 – 8 . Google Scholar CrossRef Search ADS PubMed 20 Schmitt C , Patak M , Kroner-Herwig B . Stress and the onset of sudden hearing loss and tinnitus . Int Tinnitus J 2000 ; 6 : 41 – 9 . Google Scholar PubMed 21 Hogan A , Phillips RL , Brumby SA , Williams W , Mercer-Grant C . Higher social distress and lower psycho-social wellbeing: examining the coping capacity and health of people with hearing impairment . Disabil Rehabil 2015 ; 37 : 2070 – 5 . Google Scholar CrossRef Search ADS PubMed 22 The 3C Study Group . Vascular factors and risk of dementia: design of the Three-City Study and baseline characteristics of the study population . Neuroepidemiology 2003 ; 22 : 316 – 25 . CrossRef Search ADS PubMed 23 Sheehan DV , Lecrubier Y , Sheehan KH et al. . The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 . J Clin Psychiatry 1998 ; 59 : 22 – 33 . quiz 34–57. Google Scholar PubMed 24 Spielberger CD , Gorsuch RL , Lushene R , Vagg PR , Jacobs GA . Manual for the State-Trait Anxiety Inventory. Palo Alto. In: CA . Consulting Psychologists Press , 1983 . 25 Kvaal K , Ulstein I , Nordhus IH , Engedal K . The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients . Int J Geriatr Psychiatry 2005 ; 20 : 629 – 34 . Google Scholar CrossRef Search ADS PubMed 26 Barberger-Gateau P , Rainville C , Letenneur L , Dartigues JF . A hierarchical model of domains of disablement in the elderly: a longitudinal approach . Disabil Rehabil 2000 ; 22 : 308 – 317 . Google Scholar CrossRef Search ADS PubMed 27 Carriere I , Bouyer J . Choosing marginal or random-effects models for longitudinal binary responses: application to self-reported disability among older persons . BMC Med Res Methodol 2002 ; 2 : 15 . Google Scholar CrossRef Search ADS PubMed 28 Contrera KJ , Betz J , Deal J et al. . Association of hearing impairment and anxiety in older adults . J Aging Health 2017 ; 29 : 172 – 84 . Google Scholar CrossRef Search ADS PubMed 29 Mehta KM , Simonsick EM , Penninx BW et al. . Prevalence and correlates of anxiety symptoms in well-functioning older adults: findings from the health aging and body composition study . J Am Geriatr Soc 2003 ; 51 : 499 – 504 . Google Scholar CrossRef Search ADS PubMed 30 Tully PJ , Cosh SM , Baune BT . A review of the affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart disease . Psychol Health Med 2013 ; 18 : 627 – 644 . Google Scholar CrossRef Search ADS PubMed 31 Lazarini PR , Camargo AC . Idiopathic sudden sensorineural hearing loss: etiopathogenic aspects . Braz J Otorhinolaryngol 2006 ; 72 : 554 – 561 . Google Scholar CrossRef Search ADS PubMed 32 Chrousos GP . Stress and disorders of the stress system . Nat Rev Endocrinol 2009 ; 5 : 374 – 381 . Google Scholar CrossRef Search ADS PubMed 33 Chachamovich E , Fleck M , Laidlaw K , Power M . Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults . Gerontologist 2008 ; 48 : 593 – 602 . Google Scholar CrossRef Search ADS PubMed 34 Oberg M , Bohn T , Larsson U . Short- and long-term effects of the modified Swedish version of the Active Communication Education (ACE) program for adults with hearing loss . J Am Acad Audiol 2014 ; 25 : 848 – 58 . Google Scholar CrossRef Search ADS PubMed 35 Molander P , Hesser H , Weineland S et al. . Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: study protocol for a randomized controlled rial . Am J Audiol 2015 ; 24 : 307 – 10 . Google Scholar CrossRef Search ADS PubMed Appendix Sense-Cog WP1 consortium: Geir Bertelsen1,2, Suzanne Cosh3, Audrey Cougnard-Grégoire3, Piers Dawes4, Cécile Delcourt3, Fofi Constantinidou5, Catherine Helmer3, M. Arfan Ikram6,7, Caroline C.W. Klaver6,8, Iracema Leroi9, Asri Maharani9,10, Magda Meester-Smor6,8, Unal Mutlu6,8, Virginie Nael3,11,12, Neil Pendleton9,10, Henrik Schirmer13, Gindo Tampubolon14, Henning Tiemeier6,15, Therese von Hanno16,17 1Department of Community Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 2Department of Ophthalmology, University Hospital of North Norway, N-9038 Tromsø, Norway 3Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, team LEHA, UMR 1219, F-33000 Bordeaux, France 4School of Health Sciences, University of Manchester, Manchester Centre for Audiology and Deafness, Manchester, UK 5Department of Psychology, Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus 6Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands 7Departments of Neurology and Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands 8Department of Ophthalmology, Erasmus Medical Centre, Rotterdam, The Netherlands 9Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester, UK 10Academic Health Science Centre, University of Manchester, Manchester, UK 11INSERM, CNRS, Vision Institute, Sorbonne University, UMPC University of Paris 06, F-75012 Paris, France 12R&D Life and Vision Science, Essilor International, F-75012 Paris, France 13Department of Clinical Medicine, Cardiovascular Research Group-UNN, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 14Global Development Institute, University of Manchester, Manchester, UK 15Department of Psychiatry, Erasmus Medical Centre, Rotterdam, The Netherlands 16Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 17Department of Ophthalmology, Nordland Hospital, N-8092 Bodø, Norway © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Bidirectional associations of vision and hearing loss with anxiety: prospective findings from the Three-City Study

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© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
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Abstract

Abstract Objective the aim of this study was to examine the bidirectional association of vision loss (VL) and hearing loss (HL) with anxiety over a 12-year period. Design this was a prospective population-based study. Setting community-dwelling French adults. Participants the study included 3,928 adults aged 65 and above from the Three-City study. Methods the relationships of VL, as assessed by near visual acuity and self-reported HL to a diagnosis of generalised anxiety disorder (GAD) were assessed over 12 years. A further objective was to explore whether sensory loss has a differential relationship with GAD than with anxiety symptoms, assessed by the Spielberger's State-Trait Anxiety Inventory. Results at baseline, HL [odds ratio (OR) = 1.41, 95% confidence interval (CI) 1.02–1.96, P = 0.04], but not mild or moderate to severe VL, was associated with self-reported anxiety symptoms (OR = 1.07 95% CI 0.63–1.83, P = 0.80; OR = 0.66 95% CI 0.12–2.22, P = 0.50, respectively). Neither vision nor HL was significantly associated with incident GAD. Baseline GAD was related to increased risk of incident HL (OR = 1.17, 95% CI 1.07–1.28, P < 0.001), but not mild or moderate to severe vision loss (OR = 1.01, 95% CI 0.96–1.06, P = 0.81; OR = 0.97, 95% CI 0.89–1.05, P = 0.45, respectively). Conclusions increased anxiety symptoms were observed in older adults with HL, whereas we found no evidence for an association between VL and anxiety. Anxiety was prospectively associated with increased risk of reporting HL. Improved detection of anxiety in older adults with HL may improve quality of life. anxiety disorders, generalised anxiety disorder, mental well-being, sensory impairment, older adults Sensory losses are highly prevalent amongst older adults [1] and are amongst the top 10 contributors to burden of disease [2]. Older adults with sensory loss experience poorer mental health and reduced quality of life [3, 4]. An increased risk of depression in older adults with hearing loss (HL) [5] and vision loss (VL) [6] has been established, with some evidence also suggesting that the prevalence of anxiety is higher than that for depression amongst older adults with VL [7, 8]. Indeed, the prevalence of anxiety disorders in older adults is consistently reported to be higher than the prevalence of depression [9, 10], and anxiety and depression are highly co-morbid, with anxiety frequently preceding the onset of depression [11]. Yet, there remains a dearth of research examining anxiety in sensory loss and older adults [4, 11]. Notably, in other chronic conditions, treatment of anxiety rather than depression has yielded better physical and psychological outcomes [12, 13], underscoring that unidentified and untreated anxiety might also underlie relationships between physical ill health and mental well-being. Accordingly, a better understanding of anxiety disorders amongst older adults with sensory loss is needed. Of the few anxiety and sensory loss studies to date, cross-sectional associations between anxiety with VL [8, 14, 15] have been reported, although findings remain equivocal [16, 17]. Limited cross-sectional studies also indicate an increased risk of anxiety in older adults with HL. However, longitudinal explorations of an association between sensory loss and anxiety are lacking. Further gaps in the anxiety and sensory loss literature remain. Most studies have examined anxiety symptoms; however, less is known about anxiety disorders. To date, the anxiety measures utilised typically fail to distinguish between threshold and subthreshold anxiety, yet varied prevalence rates of threshold and subthreshold disorders in sensory losses have been observed [15]. Moreover, the measures used assess a broad range of symptoms rather than assessing symptoms characteristic of any specific anxiety disorder. Thus, little is known about the extent to which relationships are limited to broad anxiety symptoms or are specific to (threshold) anxiety disorders. Generalised anxiety disorder (GAD), characterised by the hallmark feature of worry, is among the most prevalent anxiety disorders in older persons [18], and has a deleterious impact on quality of life [9]. Whether the diagnosis of GAD has a differential association with sensory loss compared with self-reported anxiety symptoms remains unclear. Furthermore, especially in younger adults, those with sudden sensorineural HL reported higher rates of having previously experienced an anxiety disorder than healthy controls [19], and adults with tinnitus retrospectively reported higher rates of worry (characteristic of GAD) than controls [20]. In addition, anxiety has been shown to decrease the ability to manage HL, leading to a worsening of the loss [21]. Despite these emergent findings, prospective explorations of an association between anxiety and incident sensory loss are lacking. Therefore, this study aims to: (i) examine the bidirectional longitudinal association of near VL and self-reported HL with GAD diagnosis and (ii) explore whether sensory loss has a differential relationship to GAD diagnosis compared with the relationship to self-reported anxiety symptoms. Method This study forms part of the SENSE-Cog multiphase research programme, funded by the European Union Horizon 2020 programme. SENSE-Cog aims to promote mental well-being in older adults with sensory and cognitive impairments (http://www.sense-cog.eu/). Sample This study examines data from the Three-City study [22], a prospective cohort study of 9,294 community-dwelling French adults aged 65 years and over. Participants were recruited via the electoral rolls of three French cities (Bordeaux, Dijon and Montpellier). The initial acceptance rate was 37%. Data from the Bordeaux and Montpellier sites are examined (n = 4,363), where baseline assessment for GAD was undertaken in 1999–2001. The Three-City study protocol was approved by the Ethics Committees of the University-Hospitals of Bicêtre and Nîmes (France), and written informed consent was obtained from participants. Participation included a face-to-face interview and clinical examinations. Participants were followed-up at 2–3 year intervals for up to 12 years. Among the initial sample, 3,953 (90.6%) have been followed-up at least once over the 12-year period; 116 had died before the first follow-up and 1,411 by the end of the 12-year period. Anxiety measures GAD diagnosis was ascertained by the Mini International Neuropsychiatric Interview (MINI) [23]. Both current and lifetime history of GAD, based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition) criteria, were assessed by trained nurses or psychologists. The MINI was administered at baseline, as well as at 7, 10 and 12 years (435 participants not assessed at baseline were excluded). Prevalent cases were those with a current diagnosis of GAD and, at each follow-up visit, incident cases were defined as those presenting with a new (and current) diagnosis among those free of GAD at baseline. Self-report anxiety symptoms were measured at baseline only using the Spielberger’s State-Trait Anxiety Inventory (STAI), a well-validated and reliable measure of anxiety symptomatology [24]. Form Y was used to assess trait anxiety symptomatology, assessed by 20 questions rated on a 4-point Likert scale. Scores range from 20 to 80, with higher scores indicative of greater symptom severity. Although varying cut-off scores have been proposed, a cut-off of 54 has been shown to have good sensitivity in older adults [25]. The STAI was administered as part of a self-completed questionnaire. Only participants who completed the STAI (n = 2934) were included in anxiety symptom analyses. Sensory loss measures Sensory loss was assessed at each follow-up. Binocular near visual acuity (presenting vision) was assessed using the Parinaud scale with a standardised reading distance of 33 cm. Mild VL was classified as Parinaud 3 or 4 (Snellen equivalent 20/30–20/60) and moderate to severe VL as Parinaud >4 (Snellen equivalent <20/60). HL was based on one question with four response categories, and was classified as self-reported deafness or difficulty understanding a conversation. Socio-demographic and health variables Socio-demographic and health-related information was collected during the standardised interview, including education (elementary, secondary school or higher education), monthly income (<€760, €760–2280 or >€2280), marital status, alcohol consumption (<10, 10–40 or >40 g per day), tobacco use (current-, past—or non-smoker) and falls in the past year. A composite score representing functional ability was also calculated based on the Rosow–Breslau scale, Lawton–Brody Brody Instrumental Activities of Daily living (IADL) scale and the Katz Index of Independence in Activities of Daily Living (categorised as autonomous, mobility limitations, mobility and IADL limitations, and limitations in three or more areas) [26]. During the medical questionnaire, history of stroke, myocardial infarction, depression diagnosis (MINI), diabetes and use of psychotropic medication (ATC codes: N05A-C and N06A-B) was obtained. A medical examination assessed body mass index (BMI) (≤25 or >25), and blood pressure was measured using a digital electronic tensiometer OMRON M4. Hypertension was defined as 140/90 mmHg or treatment with blood pressure-lowering drugs. Cognitive functioning was assessed using the Mini-Mental State Examination (MMSE; <16, 16-23, ≥24). Statistical analysis Socio-demographic and health characteristics were compared by sensory loss using χ2 and one-way analysis of variance (ANOVA). Logistic mixed models [27] were used to explore the bidirectional relationships between sensory loss and GAD. Logistic mixed models are optimal for exploring reversible binary outcomes given that they take into account within-subject correlation and model the individual time evolutions of the outcome (incident GAD or incident sensory loss) across follow-up, thus allowing for reversibility of symptoms. Mixed models also allow for greater flexibility to model time effects and handle missing data. In participants free of GAD at baseline, we examined whether baseline VL or HL was associated with incident GAD. We systematically searched for potential interactions between VL and HL, as well as each sensory loss with sex and education. Logistic mixed models were also undertaken to explore the effect of baseline anxiety on incident HL in those free of HL at baseline, and on incident VL in those free of VL at baseline. Additional models tested whether a lifetime history of GAD prior to baseline predicted subsequent VL or HL. To examine whether there is a cross-sectional relationship between anxiety symptoms and GAD with sensory loss, logistic regression analyses assessed whether baseline VL or HL was associated with baseline presence of anxiety symptoms or GAD. For each analysis, three models were produced: model 1 adjusted for time (longitudinal analyses only), sex, study centre and age; model 2 also adjusted for education, income, marital status and use of psychotropic medication; and model 3 further adjusted for MMSE, functional ability, falls, BMI, hypertension, diabetes, smoking, alcohol, depression, and history of stroke and myocardial infarction. Analyses were conducted using SAS 9.4 (SAS Institute, Inc., Cary, NC, USA). Results Of the 3,921 eligible participants, mean age at baseline was 73.7 (SD = 5.2) and the majority was female (n = 2,343; 59.8%). Baseline prevalence of mild VL was 11.7% (n = 460), moderate to severe VL was 2.6% (n = 104), and prevalence for HL was 36.1% (n = 1419). Those with sensory loss were older than those with no loss and in poorer health on all the health characteristics examined (see Appendix 1 available in Age and Ageing online). Those with VL were also less educated and had lower incomes. At baseline, 97 (2.5%) participants met criteria for current GAD, with 220 reporting a lifetime history of GAD. Those with and without a GAD history had few demographic differences, although participants with GAD were more likely to be female (70.9% versus 50.1%, P < 0.001) and were more highly educated (P < 0.001). Sensory loss and anxiety: cross-sectional analysis At baseline, VL was not associated with anxiety symptoms (Table 1). HL, however, was significantly associated with anxiety symptoms [odds ratio (OR) = 1.41, 95% confidence interval (CI) 1.02–1.96, P = 0.04]. Neither VL nor HL had significant cross-sectional associations with current GAD. Table 1. Cross-sectional association of baseline type of sensory loss (predictor variables) with anxiety symptoms (STAI) and GAD diagnosis (outcome variables): Three-City Study 1999–2001 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 OR, odds ratio; CI, confidence interval. Model 1: STAI n = 2,934, GAD n = 3,892; adjusted for sex, age and centre. Model 2: STAI n = 2,800, GAD n = 3,695; adjusted for sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: STAI n = 2,540, GAD n = 3,328; adjusted for sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Table 1. Cross-sectional association of baseline type of sensory loss (predictor variables) with anxiety symptoms (STAI) and GAD diagnosis (outcome variables): Three-City Study 1999–2001 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Self-report anxiety symptoms  Mild vision loss 1.26 0.82–1.93 0.30 1.09 0.68–1.75 0.72 1.07 0.63–1.83 0.80  Moderate to severe vision loss 1.37 0.67–2.83 0.39 1.49 0.68–3.26 0.32 0.66 0.12–2.22 0.50  Hearing loss 1.61 1.23–2.10 0.001 1.57 1.19–2.07 0.002 1.41 1.02–1.96 0.04 GAD diagnosis (current)  Mild vision loss 1.34 0.64–2.81 0.44 1.33 0.63–2.80 0.46 1.49 0.69–3.20 0.31  Moderate to severe vision loss 0.29 0.02–4.75 0.39 0.29 0.02–4.57 0.38 0.30 0.02–4.60 0.39  Hearing loss 1.30 0.85–2.00 0.23 1.31 0.85–2.00 0.23 1.08 0.68–1.71 0.76 OR, odds ratio; CI, confidence interval. Model 1: STAI n = 2,934, GAD n = 3,892; adjusted for sex, age and centre. Model 2: STAI n = 2,800, GAD n = 3,695; adjusted for sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: STAI n = 2,540, GAD n = 3,328; adjusted for sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Sensory loss and anxiety: longitudinal analysis Of the 3,824 participants without current GAD at baseline, incident GAD was detected in 82 individuals during follow-up. Neither mild nor moderate to severe VL (OR = 0.73, 95% CI 0.22–2.43, P = 0.60; OR = 0.77, 95% CI 0.12–4.86, P = 0.78, respectively) predicted GAD onset (Table 2). HL was also unrelated to GAD onset (OR = 1.13, 95% CI 0.59–2.17, P = 0.71). Table 2. Baseline type of sensory loss (predictor variables) and incident GAD (outcome variable) over 12 years Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1: n = 3,798; adjusted for time, sex, age and centre. Model 2: n = 3,604; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: n = 3,242; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Table 2. Baseline type of sensory loss (predictor variables) and incident GAD (outcome variable) over 12 years Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1 Model 2 Model 3 OR 95% CI P OR 95% CI P OR 95% CI P Incident GAD  Mild vision loss 0.67 0.20–2.20 0.51 0.65 0.20–2.15 0.48 0.73 0.22–2.43 0.60  Moderate to severe vision loss 1.24 0.29–5.30 0.78 1.17 0.27–5.04 0.84 0.77 0.12–4.86 0.78  Hearing loss 1.32 0.72–2.42 0.36 1.31 0.71–2.39 0.39 1.13 0.59–2.17 0.71 Model 1: n = 3,798; adjusted for time, sex, age and centre. Model 2: n = 3,604; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: n = 3,242; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression, and history of stroke and myocardial infarction. Anxiety and sensory loss onset Onset of any VL was noted in 1,122 participants without VL at baseline. Neither current nor lifetime history of GAD was associated with incident VL (Table 3). In those free of HL at baseline, 1,256 participants reported HL onset during follow-up. Both a current diagnosis of GAD and a lifetime history of GAD were associated with self-reported HL onset (OR = 1.17, 95% CI 1.07–1.28, P < 0.001; OR = 1.07, 95% CI 1.01–1.13, P = 0.02, respectively). Baseline anxiety symptoms were not associated with incident sensory loss. All tested interactions were non-significant. Table 3. Anxiety (predictor variables) and incident sensory loss (outcome variables) over 12 years OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 Model 1: VL and GAD n = 2,988, VL and STAI n = 2,433, HL and GAD n = 2,299, HL and STAI n = 1,707; adjusted for time, sex, age and centre. Model 2: VL and GAD n = 2,864, VL and STAI n = 2,353, HL and GAD n = 2,192, HL and STAI n = 1,651; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: VL and GAD n = 2,610, VL and STAI n = 2,159, HL and GAD n = 1,992, HL and STAI n = 1,524; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression and history of stroke and myocardial infarction. Table 3. Anxiety (predictor variables) and incident sensory loss (outcome variables) over 12 years OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 OR 95% CI P Mild vision loss  Current GAD   Model 1 1.02 0.97–1.07 0.38   Model 2 1.01 0.9–1.06 0.58   Model 3 1.01 0.96–1.06 0.81  Lifetime GAD   Model 1 1.00 0.97–1.04 0.89   Model 2 1.00 0.97–1.03 0.93   Model 3 0.99 0.96–1.03 0.66  Self-report anxiety symptoms   Model 1 1.26 0.99–1.65 0.10   Model 2 1.18 0.89–1.56 0.25   Model 3 1.05 0.74–1.47 0.80 Moderate to severe vision loss  Current GAD   Model 1 0.97 0.90–1.05 0.51   Model 2 0.97 0.90–1.05 0.49   Model 3 0.97 0.89–1.05 0.45  Lifetime GAD   Model 1 1.00 0.95–1.06 0.88   Model 2 1.00 0.95–1.05 0.91   Model 3 1.00 0.95–1.06 0.96  Self-report anxiety symptoms   Model 1 0.98 0.59–1.64 0.95   Model 2 1.03 0.61–1.74 0.92   Model 3 1.03 0.55–1.91 0.93 Hearing loss  Current GAD   Model 1 1.16 1.07–1.25 0.001   Model 2 1.17 1.08–1.27 <0.001   Model 3 1.17 1.07–1.28 <0.001  Lifetime GAD   Model 1 1.07 1.02–1.13 0.01   Model 2 1.07 1.02–1.13 0.01   Model 3 1.07 1.01–1.13 0.02  Self-report anxiety symptoms   Model 1 1.23 0.75–1.69 0.56   Model 2 1.18 0.78–1.79 0.43   Model 3 1.30 0.81–2.11 0.28 Model 1: VL and GAD n = 2,988, VL and STAI n = 2,433, HL and GAD n = 2,299, HL and STAI n = 1,707; adjusted for time, sex, age and centre. Model 2: VL and GAD n = 2,864, VL and STAI n = 2,353, HL and GAD n = 2,192, HL and STAI n = 1,651; adjusted for time, sex, age, centre, education, income, marital status and psychotropic medication use. Model 3: VL and GAD n = 2,610, VL and STAI n = 2,159, HL and GAD n = 1,992, HL and STAI n = 1,524; adjusted for time, sex, age, centre, education, income, marital status, psychotropic medication use, MMSE, functional ability, falls, body mass index, hypertension, diabetes, smoking, alcohol consumption, depression and history of stroke and myocardial infarction. Discussion To our knowledge, this study provides the first longitudinal examination of the bidirectional association between anxiety and sensory loss. HL was associated with self-reported anxiety symptoms, but not prevalent or incident GAD, while VL was not associated with anxiety. Both a current diagnosis and a lifetime history of GAD were associated with increased likelihood of reporting HL over the 12 years of follow-up. Consistent with the limited literature, HL was associated with increased anxiety symptomatology [28, 29]. Vision was not found to be related to anxiety, nor was the VL and HL interaction significant, in agreement with previous results showing that anxiety is more common in HL than in VL [17]. An association with HL but not an interaction with VL suggests that anxiety in HL may be due to social isolation and communication difficulties [28]. No observed association between VL and anxiety in our data builds on the currently equivocal literature [14–16]. The heterogeneity of anxiety measures used might explain the conflicting results. Different symptoms of anxiety, often reflecting different underlying anxiety disorders, are examined across the anxiety measures used. Agoraphobia and social phobia are reported to be the most prevalent anxiety disorders amongst older adults with VL [15]; therefore, vision may be associated only with specific symptoms or anxiety disorders that were not assessed in our study. Although a relationship between HL and anxiety symptoms was observed, neither VL nor HL was associated with current or incident GAD. Due to the self-reported assessment of HL in our study, an inverse causation cannot be excluded to explain the results; however, our finding that HL was associated with increased symptoms but not GAD diagnosis may be a reflection of older adults frequently having elevated, yet subthreshold, mental health symptoms [11, 15]. This may be due, at least partially, to the difficulty in diagnosing anxiety disorders in later life, including in research settings [11]. Anxiety in older age can manifest differently from that seen in younger adults and, additionally, symptoms such as avoidance and excessive worry can be perceived to be normative parts of ageing [11]. Alternatively, the association of HL with increased anxiety symptoms, but a non-significant association with GAD, might be explained by the symptoms examined. The STAI assesses a range of affective and physiological anxiety symptoms, not only those specific to GAD. It is possible that HL is more closely related to other anxiety disorders. In particular, given the communication limitations, specific situations such as social interactions and going out alone may be more anxiety provoking, thus social phobia and agoraphobia might be more common in HL. The contrasting anxiety and sensory loss findings to date, as well as the differential relationship between HL with anxiety symptoms and GAD, further underscore the need for ongoing disorder-specific research in sensory loss. Disorder-specific examinations will provide a clearer picture of the mental health needs of older adults with sensory loss, and will enable better comparison across studies. Notably, although sensory loss was not associated with GAD onset, we found that both a current diagnosis and a lifetime history of GAD were associated with a small but significant increased risk of reporting HL. Adults with sudden sensorineural HL have a greater history of anxiety disorders than controls, although the relationship decreased with age [19]. Similarly, adults with sudden-onset HL or tinnitus retrospectively reported higher rates of worry—a central feature of GAD—than controls, although this was no longer significant after adjustment [20]. Our findings suggest that links between anxiety and worry with hearing are not limited to sudden HL and that, amongst the elderly, a prospective relationship between GAD and HL exists. The observed relationship between GAD and incident HL could be explained by several mechanisms. Cardiovascular risk factors are frequently associated with GAD [30], as well as HL in older adults [31]. Another pathway is through inflammatory processes or impaired hypothalamic–pituitary–adrenal (HPA) axis function. GAD is associated with elevated inflammatory markers [32], and inflammatory markers are also involved in the pathogenesis of HL [19]. It has also been proposed that increased HPA axis activity observed in GAD might impact hearing [15]. Unhealthy lifestyle and behavioural factors possibly also underlie this relationship. Additionally, social restriction and avoidance are common in anxiety, which may impact hearing via sensory deprivation [28]. Alternatively, anxious people might be more likely to self-report HL over time. The relationships between anxiety and HL further highlight the importance of identifying and treating anxiety in older adults; elevated symptoms that remain subclinical cause substantial distress [33]. However, older adults with anxiety underutilise mental health services [9, 18] and are rarely diagnosed [11]. Thus, targeted interventions would be beneficial. Communication skills training has reduced psychological distress in older adults with HL [34]. Internet-based therapies for the treatment of psychological distress in older adults, especially those with HL, might also be a valuable avenue [35]. Strengths and limitations This study substantially contributes to the limited literature examining anxiety in older adults with sensory loss. Strengths include the large sample, length of follow-up and the exploration of both VL and HL, as well as an anxiety diagnosis in addition to self-report symptoms. Limitations include that HL was self-reported, using a single item. Such self-reports may represent underestimates of actual HL, due to perceptions that hearing decline is a natural part of ageing. Conversely, those who have anxiety might be more likely to self-report HL onset, although self-reported vision did not have a relationship to anxiety (see Appendix 2 available in Age and Ageing online). Ongoing research with objective assessments of HL would be invaluable to corroborate such associations. A further limitation of this study was that the STAI was administered only at baseline, thus the long-term trajectory of anxiety symptoms could not be examined. Longitudinal differences between anxiety symptoms and GAD diagnosis remain unexplored. Only GAD was assessed; whether there are relationships between other anxiety disorders with sensory loss should be examined in the future. Furthermore, incident GAD was assessed only during follow-up interviews, thus remitted cases of GAD were not included in incident analyses. Power was low for the analysis of incident GAD, especially in VL, thus precluding definitive conclusions. Whilst our findings highlight the presence of an association between anxiety and sensory loss, we cannot determine causality because of the longitudinal cohort design and infrequent measures of VL, HL and GAD. Conclusions HL was significantly associated with anxiety. Older adults with HL were more likely to have elevated anxiety symptoms, although they were not at increased risk of GAD. Other anxiety disorders are likely to be more prevalent in older adults with sensory loss. In addition, GAD was prospectively associated with self-reporting the onset of HL. Better detection of anxiety in older adults with HL may improve their quality of life and, concomitantly, ageing adults with a history of GAD may benefit from screening for HL. Key points HL in older adults is associated with increased anxiety symptoms. We found no evidence of a longitudinal association between VL and anxiety. A history of GAD increases risk of self-reporting new onset of HL in older adults. This study provides the first longitudinal examination of relationships between sensory loss and anxiety. Supplementary Data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Conflict of interest The authors declare no conflicts of interest. Funding SENSE-Cog has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement no. 668648. The Three-City study is conducted under a partnership agreement between the Institut National de la Santé et de la Recherche Médicale (INSERM), the University Bordeaux 2 Victor Segalen and Sanofi-Aventis. The Fondation pour la Recherche Médicale funded the preparation and initiation of the study. The Three-City study is also supported by the Caisse Nationale Maladie des Travailleurs Salariés, Direction Générale de la Santé, MGEN, Institut de la Longévité, Conseils Régionaux d’Aquitaine et Bourgogne, Fondation de France, Ministry of Research-INSERM Programme ‘Cohortes et collections de données biologiques’, Agence Nationale de la Recherche ANR PNRA 2006 and LongVie 2007 and the ‘Fondation Plan Alzheimer’ (FCS 2009-2012). References 1 WHO . Mortality and budren of diseases . Geneva : World Health Organisation , 2012 . 2 Wittchen HU , Jacobi F , Rehm J et al. . The size and burden of mental disorders and other disorders of the brain in Europe 2010 . Eur Neuropsychopharmacol 2011 ; 21 : 655 – 79 . Google Scholar CrossRef Search ADS PubMed 3 Chia EM , Mitchell P , Rochtchina E , Foran S , Golding M , Wang JJ . Association between vision and hearing impairments and their combined effects on quality of life . Arch Ophthalmol 2006 ; 124 : 1465 – 70 . Google Scholar CrossRef Search ADS PubMed 4 Heine C , Browning CJ . Mental health and dual sensory loss in older adults: a systematic review . Front Aging Neurosci 2014 ; 6 : 83 . Google Scholar CrossRef Search ADS PubMed 5 Gopinath B , Wang JJ , Schneider J et al. . Depressive symptoms in older adults with hearing impairments: the Blue Mountains Study . J Am Geriatr Soc 2009 ; 57 : 1306 – 8 . Google Scholar CrossRef Search ADS PubMed 6 Carriere I , Delcourt C , Daien V et al. . A prospective study of the bi-directional association between vision loss and depression in the elderly . J Affect Disord 2013 ; 151 : 164 – 70 . Google Scholar CrossRef Search ADS PubMed 7 Yokoi T , Moriyama M , Hayashi K et al. . Predictive factors for comorbid psychiatric disorders and their impact on vision-related quality of life in patients with high myopia . Int Ophthalmol 2014 ; 34 : 171 – 83 . Google Scholar CrossRef Search ADS PubMed 8 Court H , McLean G , Guthrie B , Mercer SW , Smith DJ . Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study . BMC Med 2014 ; 12 : 181 . Google Scholar CrossRef Search ADS PubMed 9 Byrne GJ , Pachana NA . Anxiety and depression in the elderly: do we know any more? Curr Opin Psychiatry 2010 ; 23 : 504 – 9 . Google Scholar CrossRef Search ADS PubMed 10 Ritchie K , Artero S , Beluche I et al. . Prevalence of DSM-IV psychiatric disorder in the elderly French population . Br J Psychiatry 2004 ; 184 : 147 – 52 . Google Scholar CrossRef Search ADS PubMed 11 Bryant C , Mohlman J , Gum A et al. . Anxiety disorders in older adults: looking to DSM5 and beyond . Am J Geriatr Psychiatry 2013 ; 21 : 872 – 6 . Google Scholar CrossRef Search ADS PubMed 12 Tully PJ , Harrison NJ , Cheung P , Cosh S . Anxiety and cardiovascular disease risk: a review . Curr Cardiol Rep 2016 ; 18 : 120 . Google Scholar CrossRef Search ADS PubMed 13 Tully PJ , Selkow T , Bengel J , Rafanelli C . A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discrete effects of cognitive behavioral therapy, exercise, and psychotropic medication . Disabil Rehabil 2015 ; 37 : 585 – 92 . Google Scholar CrossRef Search ADS PubMed 14 Kempen GI , Zijlstra GA . Clinically relevant symptoms of anxiety and depression in low-vision community-living older adults . Am J Geriatr Psychiatry 2014 ; 22 : 309 – 13 . Google Scholar CrossRef Search ADS PubMed 15 van der Aa HP , Comijs HC , Penninx BW , van Rens GH , van Nispen RM . Major depressive and anxiety disorders in visually impaired older adults . Invest Ophthalmol Vis Sci 2015 ; 56 : 849 – 54 . Google Scholar CrossRef Search ADS PubMed 16 Evans JR , Fletcher AE , Wormald RP . Depression and anxiety in visually impaired older people . Ophthalmology 2007 ; 114 : 283 – 8 . Google Scholar CrossRef Search ADS PubMed 17 Bernabei V , Morini V , Moretti F et al. . Vision and hearing impairments are associated with depressive–anxiety syndrome in Italian elderly . Aging Ment Health 2011 ; 15 : 467 – 74 . Google Scholar CrossRef Search ADS PubMed 18 Mackenzie CS , Reynolds K , Chou KL , Pagura J , Sareen J . Prevalence and correlates of generalized anxiety disorder in a national sample of older adults . Am J Geriatr Psychiatry 2011 ; 19 : 305 – 15 . Google Scholar CrossRef Search ADS PubMed 19 Chung SD , Hung SH , Lin HC , Sheu JJ . Association between sudden sensorineural hearing loss and anxiety disorder: a population-based study . Eur Arch Otorhinolaryngol 2015 ; 272 : 2673 – 8 . Google Scholar CrossRef Search ADS PubMed 20 Schmitt C , Patak M , Kroner-Herwig B . Stress and the onset of sudden hearing loss and tinnitus . Int Tinnitus J 2000 ; 6 : 41 – 9 . Google Scholar PubMed 21 Hogan A , Phillips RL , Brumby SA , Williams W , Mercer-Grant C . Higher social distress and lower psycho-social wellbeing: examining the coping capacity and health of people with hearing impairment . Disabil Rehabil 2015 ; 37 : 2070 – 5 . Google Scholar CrossRef Search ADS PubMed 22 The 3C Study Group . Vascular factors and risk of dementia: design of the Three-City Study and baseline characteristics of the study population . Neuroepidemiology 2003 ; 22 : 316 – 25 . CrossRef Search ADS PubMed 23 Sheehan DV , Lecrubier Y , Sheehan KH et al. . The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 . J Clin Psychiatry 1998 ; 59 : 22 – 33 . quiz 34–57. Google Scholar PubMed 24 Spielberger CD , Gorsuch RL , Lushene R , Vagg PR , Jacobs GA . Manual for the State-Trait Anxiety Inventory. Palo Alto. In: CA . Consulting Psychologists Press , 1983 . 25 Kvaal K , Ulstein I , Nordhus IH , Engedal K . The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients . Int J Geriatr Psychiatry 2005 ; 20 : 629 – 34 . Google Scholar CrossRef Search ADS PubMed 26 Barberger-Gateau P , Rainville C , Letenneur L , Dartigues JF . A hierarchical model of domains of disablement in the elderly: a longitudinal approach . Disabil Rehabil 2000 ; 22 : 308 – 317 . Google Scholar CrossRef Search ADS PubMed 27 Carriere I , Bouyer J . Choosing marginal or random-effects models for longitudinal binary responses: application to self-reported disability among older persons . BMC Med Res Methodol 2002 ; 2 : 15 . Google Scholar CrossRef Search ADS PubMed 28 Contrera KJ , Betz J , Deal J et al. . Association of hearing impairment and anxiety in older adults . J Aging Health 2017 ; 29 : 172 – 84 . Google Scholar CrossRef Search ADS PubMed 29 Mehta KM , Simonsick EM , Penninx BW et al. . Prevalence and correlates of anxiety symptoms in well-functioning older adults: findings from the health aging and body composition study . J Am Geriatr Soc 2003 ; 51 : 499 – 504 . Google Scholar CrossRef Search ADS PubMed 30 Tully PJ , Cosh SM , Baune BT . A review of the affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart disease . Psychol Health Med 2013 ; 18 : 627 – 644 . Google Scholar CrossRef Search ADS PubMed 31 Lazarini PR , Camargo AC . Idiopathic sudden sensorineural hearing loss: etiopathogenic aspects . Braz J Otorhinolaryngol 2006 ; 72 : 554 – 561 . Google Scholar CrossRef Search ADS PubMed 32 Chrousos GP . Stress and disorders of the stress system . Nat Rev Endocrinol 2009 ; 5 : 374 – 381 . Google Scholar CrossRef Search ADS PubMed 33 Chachamovich E , Fleck M , Laidlaw K , Power M . Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults . Gerontologist 2008 ; 48 : 593 – 602 . Google Scholar CrossRef Search ADS PubMed 34 Oberg M , Bohn T , Larsson U . Short- and long-term effects of the modified Swedish version of the Active Communication Education (ACE) program for adults with hearing loss . J Am Acad Audiol 2014 ; 25 : 848 – 58 . Google Scholar CrossRef Search ADS PubMed 35 Molander P , Hesser H , Weineland S et al. . Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: study protocol for a randomized controlled rial . Am J Audiol 2015 ; 24 : 307 – 10 . Google Scholar CrossRef Search ADS PubMed Appendix Sense-Cog WP1 consortium: Geir Bertelsen1,2, Suzanne Cosh3, Audrey Cougnard-Grégoire3, Piers Dawes4, Cécile Delcourt3, Fofi Constantinidou5, Catherine Helmer3, M. Arfan Ikram6,7, Caroline C.W. Klaver6,8, Iracema Leroi9, Asri Maharani9,10, Magda Meester-Smor6,8, Unal Mutlu6,8, Virginie Nael3,11,12, Neil Pendleton9,10, Henrik Schirmer13, Gindo Tampubolon14, Henning Tiemeier6,15, Therese von Hanno16,17 1Department of Community Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 2Department of Ophthalmology, University Hospital of North Norway, N-9038 Tromsø, Norway 3Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, team LEHA, UMR 1219, F-33000 Bordeaux, France 4School of Health Sciences, University of Manchester, Manchester Centre for Audiology and Deafness, Manchester, UK 5Department of Psychology, Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus 6Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands 7Departments of Neurology and Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands 8Department of Ophthalmology, Erasmus Medical Centre, Rotterdam, The Netherlands 9Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester, UK 10Academic Health Science Centre, University of Manchester, Manchester, UK 11INSERM, CNRS, Vision Institute, Sorbonne University, UMPC University of Paris 06, F-75012 Paris, France 12R&D Life and Vision Science, Essilor International, F-75012 Paris, France 13Department of Clinical Medicine, Cardiovascular Research Group-UNN, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 14Global Development Institute, University of Manchester, Manchester, UK 15Department of Psychiatry, Erasmus Medical Centre, Rotterdam, The Netherlands 16Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway 17Department of Ophthalmology, Nordland Hospital, N-8092 Bodø, Norway © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Age and AgeingOxford University Press

Published: May 3, 2018

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