Self-reported hearing difficulties and changes in life-space mobility among community-dwelling older adults: a Two-year follow-Up study

Difficulty in hearing is common among older adults [1]. The prevalence of hearing difficulties rises markedly with increasing age [2‐4], affecting about two-thirds of people aged 70 years [5] and 90 % of adults aged 80 or above [2]. Most often older adults’ hearing difficulties result from degenerative changes in cochlear structure and the auditory pathway [6], although other factors such as exposure to noise, ototoxic drugs and a number of medical conditions, such as diabetes, may induce deterioration in hearing [7].

Previous studies have suggested that hearing difficulties can complicate engagement in everyday life situations; especially those requiring communication with other people [8, 9]. Difficulty in following conversations is one of the most common worries among older adults [10], especially in challenging listening conditions such as in the presence of background noise or sound-reverberating environments [11]. It has also been shown that older people with hearing difficulty experience more walking difficulties [12, 13], poorer postural balance, higher risk for falls [14] and fear of falling [15], than those without hearing impairment, factors which may also compromise possibilities for participation in everyday activities.

Life-space mobility reflects the size of the spatial area a person moves through in daily life, the frequency of moving and the need for assistance [16, 17]. While the assessment of mobility limitations or disabilities reflect a person’s potential capacity to perform the particular activities [18, 19], it does not reflect actual participation in activities in question [20, 21]. Life-space mobility, in turn, reflects what people actually do, as it describes total mobility, thereby providing us with a broad picture of a person’s engagement with the community [16, 20, 22, 23]. Life-space mobility is a measure of the balance between an individual’s resources (e.g. physiological and psychological capacity) and the demands of the environment in the context of a person’s real-life situation [16, 19].

We are aware of only one earlier study that has investigated the association between hearing problems and life-space mobility. After adjustment for potential confounders, Allman et al. found that hearing difficulty did not predict decline in life-space mobility in a 18-month follow-up [24].

The aim of our study was to examine whether self-reported hearing is associated cross-sectionally with life-space mobility among 75 to 90-year-old community-dwelling older adults and, whether self-reported hearing difficulties at baseline predict changes in life-space mobility at follow-up one and two years later.

Our results showed that hearing difficulties were associated with poorer life-space mobility in community-dwelling older adults. Life-space mobility declined steadily in all the hearing categories over the two-year follow-up period. However, persons who did not have hearing difficulties at baseline had significantly higher life-space mobility score both at baseline and at the two-year follow up compared to those who reported hearing difficulties, even when controlling for the presence of chronic medical conditions and the influence of cognitive functioning, age and sex. It is likely that this trend existed before the cohort was followed up. Thus, although the changes observed in the life-space mobility score between the hearing categories were modest, the results indicate that hearing problems may contribute to restrictions in life-space mobility over time among older adults.

According to previous studies [18, 23], a score of 60 and higher on the life-space assessment represents unrestricted life-space, defined as a “person’s ability to get out of one’s neighborhood independently” and thus is a marker of independent mobility and resilient aging [20]. Our findings suggest that older adults with hearing difficulties reach this critical threshold for restricted life-space mobility sooner than older adults without hearing difficulties.

To our knowledge, the 18-month follow-up study of Allman and colleagues [24] is the only previous study to examine the association between hearing problems and life-space mobility. In their study, the correlation between hearing difficulties and decline in life-space mobility was attenuated when adjusted for other health conditions. It is possible that their study lacked the power needed to observe an association, as their sample contained significantly fewer people who were categorized as having hearing problems.

There may be several explanations for our findings. According to earlier studies, communication problems are the most prevalent participation restrictions mentioned by older adults with hearing difficulties [8]. For older adults, the desire to interact with other people is typically one of the main reasons for going outside the home [34]. However, challenges in communication may cause feelings of frustration, embarrassment and being left out of things, which in turn may lead to social withdrawal [10, 26, 35‐37] and reduce participation in social activities [9, 13], thereby reducing life-space mobility. Older adults with a higher frequency of social participation and greater number of social networks are more likely to have larger life space than those with less social contacts [22, 38]. As life-space mobility reflects individuals’ actual mobility and frequency of participation in activities outside the home, it may be that poorer life-space mobility is indicative of a decreased desire among older persons with hearing difficulties to be active and exploit community amenities and engage in social activities. Thus changes in life-space mobility can also reflect the adaptations [18] older adults make in response to impaired hearing. For example, a person may not withdraw completely from situations that pose a challenge to hearing, but engage in them less often [9].

Hearing difficulties not only impede communication with other people, but may also impair the ability to observe environmental hazards. Acoustic information supports observation of the environment while moving [39], and hence its reception is important, e.g., in preparing for elements of danger such as motor vehicles. Hearing difficulties compromise the ability to localize sounds reliably [6, 10], which may make it difficult to piece together what to monitor in the environment, leading eventually to reluctance to expose oneself to such challenging situations and thus reduced activity outside the home. Hearing difficulties have also been reported to be associated with higher rates of walking difficulties [35] and decreased walking speed and postural balance as well as mobility decline and falls [12‐14]. Walking and balance difficulties together with inaccurate environmental acoustic information may further impair safe mobility and reduce the desire of older adults to go outdoors, resulting in reduced life-space mobility. Avoidance of challenging acoustic environments may lead to a detrimental cycle where restrictions on life-space mobility cause further decline in physical ability and social relationships.

This study included a large population-based sample of community-dwelling older adults and there were very few missing data in the sample. Although the participants were rather well-functioning, the sample also included people with health problems [25]. It is thus reasonable to assume that the associations found here most likely represent those prevalent among the general population of comparable age. We used multiple questions to assess hearing difficulties in situations that are typically challenging for persons with age-related hearing impairment and we also asked the participants to evaluate the perceived degree of their hearing difficulties. This approach may yield a more comprehensive picture of the extent of hearing difficulties than that gained by using a single question.

A potential limitation of our study is that hearing was self-reported. However, self-reports of hearing are commonly used in epidemiological studies, and previous studies support the validity of self-reported measures of hearing impairment [26, 28, 35, 40]. Furthermore, self-reports are relevant since they make use of information about the difficulties older adults perceive in their everyday situations [41]. A short follow-up is another potential limitation of our study. All of our participants were at least 75 years old at baseline. As hearing decline is usually a gradual process, it is likely that the influence of hearing difficulties on life-space mobility were already present before the cohort was initiated. However, the age range between 75 and 90, of our participants corresponds to that when people are increasingly vulnerable to decline in life-space mobility due underlying changes in health, and in sensory and physical functions [24, 42]. Our results did not show a more accelerated decline in life-space mobility among those with hearing difficulties; however, the logistic regression with restricted life-space mobility as the outcome suggests that hearing difficulties precedes restrictions in life-space mobility. Although we may not have definitely established causation, it is unlikely that limitations in life-space mobility lead to self-reported hearing difficulties. However, we cannot exclude the possibility of residual confounding to the results caused by unmeasured factors.

Further studies with longer follow-ups starting from middle-age are needed to confirm the associations reported in this study. Also, some persons were excluded from the study because they were not able to communicate due to hearing problems during the initial telephone screening or home interview. Therefore, it is likely that the number of persons with severe hearing impairment in this study was under-represented. The associations observed between hearing and life-space mobility might have been stronger had these persons participated.

To conclude, the present study provides new information on longitudinal changes in life-space mobility among older people with and without hearing difficulties. Given the increasing proportion of older adults in the population, it is particularly important to understand the role of hearing difficulties as a risk factor for restricted life-space mobility and consequent decreased participation in society. Our findings emphasize the need for early assessment and recognition of hearing difficulties in order to diminish the likelihood of subsequent losses in functional capacity. In future, additional attention should also be given to the balance between individual resources and environmental demands in older adults who have hearing difficulties. More specifically, it would be important to know more precisely how the acoustic characteristics of the environment and environmental noise affect older persons’ possibilities to maintain social relationships and active participation in daily life in real world situations.