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      Sensory Impairments and Cardiovascular Disease Incidence and Mortality in Older British Community‐Dwelling Men: A 10‐Year Follow‐Up Study

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          Abstract

          To the Editor: Hearing and vision impairments are common in older age. Evidence suggests that these sensory impairments are associated with incident cardiovascular disease (CVD) (myocardial infarction (MI), stroke),1 but previous studies have been undertaken mostly in specific subgroups of individuals with sudden sensorineural hearing loss or with stroke and in middle‐aged populations rather than community‐dwelling older adults.2, 3, 4, 5, 6, 7 Therefore, the association between self‐reported hearing and vision impairment and incident CVD, MI, and stroke and CVD mortality was examined in older men. Methods Community‐dwelling men aged 63 to 85 (N = 3,981, 82% of the British Regional Heart Study cohort alive in 2003) were followed for 10 years, until 2013.8 Information on lifestyle factors, comorbidities, hearing, and vision was obtained through postal questionnaires. Self‐reported hearing aid use and ability to hear the television at a volume others find acceptable allowed for four categories of hearing: could hear (n = 2,851), could hear and used aid (n = 482), could not hear and no aid (n = 424), and could not hear and used aid (n = 168). Vision impairment was defined as not being able to recognize a friend across the street (n = 124). Dual sensory impairment (n = 57) consisted of hearing impairment (could hear with aid, could not hear and no aid, could not hear and used aid) and vision impairment. Follow‐up for CVD (nonfatal and fatal) was through general practice records and mortality registers. Survival analysis was used to examine the association between sensory impairments and incident CVD and mortality. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) using no hearing impairment and no vision impairment (individually and combined) as reference groups. Prevalent CVD cases were excluded. Results During the 10‐year follow‐up, 1,463 deaths occurred, including 408 CVD deaths. In 3,466 men free of prevalent CVD, 489 CVD events, 288 MIs, and 216 strokes occurred during follow‐up. In age‐adjusted analyses, men who could not hear and did not use a hearing aid had greater risks of incident CVD, incident stroke, and CVD mortality compared to men who could hear (Table 1). These associations remained statistically significant after adjustment for social class, diabetes mellitus, hypertension, obesity, smoking, and physical activity. The adjusted hazards ratio (95% CI) were 1.50 (1.14–1.98), 1.56 (1.04–2.34), and 1.39 (1.00–1.93) for incident CVD, stroke, and CVD mortality, respectively. These associations remained statistically significant after adjustment for social class, diabetes mellitus, hypertension, obesity, smoking, and physical activity. Vision impairment and dual sensory impairment were not associated with CVD incidence or CVD mortality. Table 1 Risk of Outcome According to Sensory Impairment in Men Aged 63 to 85 in 2003 from the British Regional Heart Study Sensory Impairment Incident CVD Incident Myocardial Infarction Incident Stroke CVD Mortality Rate/1,000 (n) HR (95% CI) Rate/1,000 (n) HR (95% CI) Rate/1,000 (n) HR (95% CI) Rate/1,000 (n) HR (95% CI) Hearing Could hear 17 (330) 1.00 9 (191) 1.00 7 (149) 1.00 10 (257) 1.00 Could hear, used aid 20 (59) 0.91 (0.68–1.20) 13 (40) 1.09 (0.77–1.55) 7 (23) 0.76 (0.49–1.19) 17 (68) 1.15 (0.88–1.51) Could not hear, no aid 25 (69) 1.42 (1.09–1.84)a 13 (38) 1.35 (0.95–1.91) 11 (32) 1.46 (1.00–2.14)a 15 (52) 1.37 (1.02–1.85)a Could not hear, used aid 22 (22) 1.10 (0.71–1.70) 14 (14) 1.26 (0.73–2.17) 8 (8) 0.88 (0.43–1.80) 15 (20) 1.11 (0.71–1.76) Vision Could see 18 (467) 1.00 10 (273) 1.00 8 (209) 1.00 12 (383) 1.00 Poor vision 24 (16) 1.20 (0.73–1.97) 16 (11) 1.41 (0.77–2.57) 7 (5) 0.85 (0.35–2.06) 19 (17) 1.42 (0.87–2.30) Dual Could hear and could see 17 (326) 1.00 9 (185) 1.00 8 (151) 1.00 10 (254) 1.00 Dual impairment 26 (8) 1.40 (0.69–2.83) 13 (4) 1.23 (0.46–3.31) 13 (4) 1.52 (0.56–4.12) 22 (9) 1.73 (0.89–3.36) a Remained statistically significant after further adjustment for social class, obesity, smoking, physical activity, hypertension, and diabetes mellitus. CVD = cardiovascular disease; HR = hazard ratio; CI = confidence interval. John Wiley & Sons, Ltd Discussion Men who could not hear and did not use a hearing aid had greater risks of incident CVD, particularly incident stroke, and CVD mortality than men who could hear. Previous research suggests that the associations between hearing impairment and CVD could be attributed to smoking and atherosclerosis,9 but in the current study, the associations remained significant after adjustment for smoking and CVD‐related comorbidities. Not all hearing impairment groups were associated with CVD incidence, suggesting that hearing per se may not underlie the observed associations. One possible mechanism could be cognitive impairment, which is related to hearing impairment and stroke.10 Other possible explanations could be atherosclerotic or inflammatory changes, which could not be taken into account in the analyses.9 Moreover, hearing impairment based on self‐report could be subject to inaccurate reporting of hearing impairment because of unawareness, denial of hearing problems, or use of hearing aid. Any inaccurate reporting may have underestimated the influence of hearing impairment on CVD and may also explain the inconsistent associations between the hearing impairment groups. Although the findings are consistent with those of earlier studies that found objectively measured hearing impairment to be associated with incident stroke,2, 3 and CVD mortality,1 another study found no association between objective hearing impairment and incident stroke.5 These inconsistent findings could be due to different pathologies that underlie different types of hearing impairment, such as sensorineural (sudden) or age‐related (gradual) hearing loss. The lack of association between vision impairment and incident CVD and CVD mortality could be due to the definition of vision impairment used, which may have identified severe vision impairment only, thus underestimating the true prevalence of vision impairment. Similarly, dual sensory impairment was not associated with CVD incidence or mortality, which could be due to the small number of men with dual sensory impairment. Conclusions Hearing impairment in older men was associated with greater risks of incident stroke and CVD mortality. Early detection of hearing impairment in older adults could help prevent CVD. Further research is warranted into the possible mechanisms underlying these associations.

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          Most cited references11

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          Current concepts in age-related hearing loss: epidemiology and mechanistic pathways.

          Age-related hearing loss (AHL), also known as presbycusis, is a universal feature of mammalian aging and is characterized by a decline of auditory function, such as increased hearing thresholds and poor frequency resolution. The primary pathology of AHL includes the hair cells, stria vascularis, and afferent spiral ganglion neurons as well as the central auditory pathways. A growing body of evidence in animal studies has suggested that cumulative effect of oxidative stress could induce damage to macromolecules such as mitochondrial DNA (mtDNA) and that the resulting accumulation of mtDNA mutations/deletions and decline of mitochondrial function play an important role in inducing apoptosis of the cochlear cells, thereby the development of AHL. Epidemiological studies have demonstrated four categories of risk factors of AHL in humans: cochlear aging, environment such as noise exposure, genetic predisposition, and health co-morbidities such as cigarette smoking and atherosclerosis. Genetic investigation has identified several putative associating genes, including those related to antioxidant defense and atherosclerosis. Exposure to noise is known to induce excess generation of reactive oxygen species (ROS) in the cochlea, and cumulative oxidative stress can be enhanced by relatively hypoxic situations resulting from the impaired homeostasis of cochlear blood supply due to atherosclerosis, which could be accelerated by genetic and co-morbidity factors. Antioxidant defense system may also be influenced by genetic backgrounds. These may explain the large variations of the onset and extent of AHL among elderly subjects. This article is part of a Special Issue entitled "Annual Reviews 2013". Copyright © 2013 Elsevier B.V. All rights reserved.
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            Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study.

            No previous study has investigated the incidence or risk of cerebrovascular diseases developing after the sudden sensorineural hearing loss (SSNHL). This study sets out to estimate the risk of stroke development among SSNHL patients during a 5e-year follow-up period after hospitalization for acute episodes of SSNHL. Our study design features a study cohort and a comparison cohort. The study cohort consists of all patients hospitalized with a principal diagnosis of sudden hearing loss (n=1,423), whereas the control cohort comprised all patients hospitalized for an appendectomy in 1998 (n=5692) as a surrogate for the general population. Each patient was tracked from hospitalization in 1998 until the end of 2003. Cox proportional hazard regressions were performed as a means of computing the 5-year stroke-free survival rates after adjustment for possible confounding factors. Of the total sample, 621 patients (8.7%) had strokes during the 5-year follow-up period: 180 (12.7% of the SSNHL patients) from the study cohort and 441 (7.8% of patients undergoing an appendectomy) from the control cohort. After adjusting for other factors, the hazard of stroke during the 5-year follow-up period was 1.64-times (95% CI, 1.31 to 2.07; P<0.001) greater for SSNHL patients than for appendectomy patients. Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.
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              Associations between hearing impairment and mortality risk in older persons: the Blue Mountains Hearing Study.

              To assess whether hearing loss predicts an increased risk of mortality. The Blue Mountains Hearing Study examined 2956 persons (49+ years) during 1997 to 2000. The Australian National Death Index was used to identify deaths until 2005. Hearing loss was defined as the pure-tone average (0.5-4 kHz) of air-conduction hearing thresholds greater than 25 dB HL. Associations between hearing loss and mortality risk were estimated using Cox regression and structural equation modeling (SEM). When we used Cox regression, we discovered that hearing loss was associated with increased risk of cardiovascular (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.84) and all-cause (AC) mortality (HR 1.39, 95% CI 1.11-1.79) after adjustment for age and sex but not after multivariable adjustment. SEM pathway analysis, however, revealed a greater AC mortality risk (HR 2.58, 95% CI 1.64-4.05) in persons with hearing loss, which was mediated: cognitive impairment (HR 1.45, 95% CI 1.08-1.94) and walking disability (HR 1.63, 95% CI 1.24-2.15). These variables increased mortality both directly and indirectly through effects on self-rated health. Hearing loss was associated with increased AC mortality via three mediating variables: disability in walking, cognitive impairment, and self-rated health. It is important to recognize that persons with combined disabilities are at increased risk of cardiovascular and AC mortality. Copyright 2010 Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                J Am Geriatr Soc
                J Am Geriatr Soc
                10.1111/(ISSN)1532-5415
                JGS
                Journal of the American Geriatrics Society
                John Wiley and Sons Inc. (Hoboken )
                0002-8614
                1532-5415
                18 February 2016
                February 2016
                : 64
                : 2 ( doiID: 10.1111/jgs.2016.64.issue-2 )
                : 442-444
                Affiliations
                [ 1 ] Department of Primary Care and Population HealthUniversity College London LondonUK
                [ 2 ] Population Health Research Centre Division of Population Health Sciences and EducationSt George's University of London LondonUK
                [ 3 ] Research Department of Epidemiology and Public HealthUniversity College London LondonUK
                Article
                JGS13975
                10.1111/jgs.13975
                4855682
                26889851
                a761e175-85d1-42f8-9a4b-a39ce08f8930
                © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society

                This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                Page count
                Pages: 3
                Funding
                Funded by: British Heart Foundation
                Award ID: RG/08/013/25942
                Funded by: National Institute for Health Research School for Public Health Research
                Award ID: 509546
                Funded by: UK Medical Research Council Fellowship
                Award ID: G1002391
                Categories
                Letters to the Editor
                Letters to the Editor
                Research
                Custom metadata
                2.0
                jgs13975
                February 2016
                Converter:WILEY_ML3GV2_TO_NLMPMC version:4.9.1 mode:remove_FC converted:23.06.2016

                Geriatric medicine
                Geriatric medicine

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