Sensorimotor and psychosocial determinants of 3-year incident mobility disability in middle-aged and older adults

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1 Age and Ageing 2014; 43: doi: /ageing/aft135 The Author Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please Sensorimotor and psychosocial determinants of 3-year incident mobility disability in middle-aged and older adults NANDINI DESHPANDE 1,JEFFREY E. METTER 2,JACK GURALNIK 3,STEFANIA BANDINELLI 4,LUIGI FERRUCCI 5 1 School of Rehabilitation Therapy, Queen s University, Kingston, ON, Canada 2 Clinical Research Branch, National Institute on Aging, Baltimore, MD, USA 3 School of Medicien, University of Maryland, Baltimore, MD, USA 4 Azienda Sanitaria Firenze, Geriatric Unit, Firenze, Italy 5 National Institutes of Health, National Institute on Aging, Baltimore, MD, USA Address correspondence to: N. Deshpande. Tel: ; Fax: ; nandinijd@yahoo.com Abstract Objective: to identify sensorimotor and psychosocial determinants of 3-year incident mobility disability. Design: prospective. Setting: population-based sample of community-dwelling older persons. Participants: community-living middle-aged and older persons (age: years) without baseline mobility disability (n = 622). Measurements: mobility disability, defined as self-reported inability to walk a quarter mile without resting or inability to walk up a flight of stairs unsupported, was ascertained at baseline and 3-year follow-up. Potential baseline determinant characteristics included demographics, education, social support, financial condition, knee extensor strength, visual contrast sensitivity, cognition, depression, presence of chronic conditions and history of falls. Results: a total of 13.5% participant reported 3-year incident mobility disability. Age 75 years, female sex, knee extensor strength in the lowest quartile, visual contrast sensitivity <1.7 on the Pelli Robson chart or significant depressive symptoms (CESD score >16) were independent determinants of 3-year incident mobility disability (ORs ). Conclusions: low visual contrast sensitivity, poor knee extensor strength and significant depressive symptoms are independent determinants of future onset of mobility disability. Keywords: mobility, disability, depression, vision, muscle strength, older people Introduction Mobility is defined as the ability to walk safely and independently in one s natural environment [1] and thus, is a prerequisite for one s independence in activities of daily living (ADLs and IADLs) [2], preserving social interactions and for maintaining overall quality of life [3]. In older persons, disability usually occurs first in mobility and sets a downward spiral of progressively more severe disablement [4]. It is generally accepted that detecting mobility disability during an early or pre-clinical stage is likely an important opportunity for implementing preventive measures [5]. However, the pathway to this initial stage of disablement process in older persons, unless preceded by a catastrophic event, is not well understood. The incidence of mobility disability increases with ageing even when not accompanied by overt co-morbid conditions [6] and compared with older men, the rate of incidence is higher in older women [7]. Several studies have independently shown that poor lower limb muscle strength [8], body mass index (BMI) >35 [9] and lower education in women [10] are a significant predictor of mobility disability. Although motor control studies have demonstrated the impact of poor visual contrast sensitivity on measures of balance control during various physical tasks (e.g. during stepping [11]orwalking [12]), the evidence for the association between mobility disability and visual impairment is not available. Similarly, although 64

2 many studies have reported a relationship between depressive symptoms and advanced stage of disability (disability in ADL) [13], how depression modulates or contributes to the initiation of disablement process is not known. Since the available evidence is predominantly sporadic from independent studies focusing on specific parameters, the purpose of this study was to perform a comprehensive analysis to identify sensorimotor (visual contrast sensitivity and knee extensor strength) and psychosocial (depression, cognition, perceived financial status and social support) factors that are independent determinants of future incident mobility disability. Methods Participants The InChianti study population represents the population living in the Chianti region of Tuscany, Italy. The study design and data collection have been described previously [14]. The study protocol was approved by the ethical committee of the Italian National Institute of Research and Care of Aging and complies with the Declaration of Helsinki. All participants signed an informed consent. The present study used the data as baseline data and the data as the 3-year follow-up. A total of 873 participants between the ages of 50 and 85 years attended baseline interview session. In the final analysis, the participants who had a complete data set for the interview and the physiological measures and with no severe cognitive impairment [Mini-Mental State Examination score (MMSE) <18 [15]] or self-reported mobility disability at baseline were included (n = 622). InChianti participants over the age of 85 years were excluded as majority of them reported mobility disability at baseline leaving a very small sample size representing that the age group. Outcome measures Mobility disability was identified using the established approach (self-reported inability to walk a quarter mile without resting or inability to walk up a flight of stairs unsupported [16]). Mobility disability was ascertained at baseline and at the 3-year follow-up. The potential determinants of incident mobility disability were measured at baseline. Demographic variables included age, sex and BMI (kg/m 2 ). Education was recorded as the years of formal education. Social support was determined by the number of persons completely available, if need be, from the following nine categories of people: spouse, son, daughter, son-in-law, daughter-in-law, other relatives and other non-relatives. The question do you think your current income is adequate for your needs? was developed for the InChianti study to determine self-perceived financial condition. The options were adequate, barely adequate and inadequate. The replies were dichotomised into inadequate (barely adequate and inadequate) and adequate. Center for Epidemiological Studies Depression scale (CES-D) [17] and MMSE [18] quantified depressive symptoms Sensorimotor and psychosocial determinants and global cognition, respectively. Knee extensor strength was measured using a hand-held dynamometer that was placed on the anterior side of the shin 10 cm above the lateral malleolus. Three trials were performed bilaterally and the maximum value of the weaker leg was recorded [19]. The Pelli Robson chart [20] was used to assess binocular visual contrast sensitivity. The presence of chronic disease/s was recorded from participants self-report and medical records and self-reported history of fall/s in the previous year was noted. Statistical analysis The baseline differences between the participants who reported 3-year incident mobility disability and those who did not report it were determined using a general linear model or a Chi-square test, as appropriate, for the demographics, psychosocial and sensorimotor characteristics, presence of chronic diseases and a history of falls in the previous year. The variables that were different between the two groups (P < 0.1) were included in the binary logistic regression analysis to identify significant independent determinants of 3-year incident mobility disability. For this analysis, age was classified into three groups (50 64, and years) and the age group years was used as the reference group. Low education was identified as education less than the high school level [21]. Poor cognition and significant depressive symptoms were defined as MMSE score <24 [15] and CES-D scale score >16 [17], respectively. The suggested lowest normal Pelli Robson test score for older persons is 1.5 logmar [22]. However, at baseline there were only 11 participants with score <1.5 logmar. Therefore, a cut-off level of 1.7 logmar, which is a reported average score in older persons [23], was used. Since clinically relevant cut-off points are not clear in literature for knee extensor strength, the sex-specific lowest quartile was used as a demarcation point. Data were analysed using IBM SPSS version19. A P < 0.05 was considered statistically significant. Results Out of the 873 participants initially included, 677 participants did not report mobility disability at baseline. Out of these 677 participants 622 participants attended the followup and were included in the final analysis. Of these 622 participants, 3.5% had a history of stroke, 2.9% had myocardial infarction, 4.5% reported angina pectoris, 47.7% had hypertension, 11.4% had diabetes and 2.5% had peripheral arterial disease; 1.7% reported hip replacement, 21.5% had either hip or knee pain requiring medication and 4.6% reported severe deafness. A total of 82 participants were between the ages of years, 320 participants were between 65 and 74 years and 220 participants were years old. The 55 participants who did not come at the follow-up were older [72.5 (7.0) versus 74.3 (5.8) years, P = 0.005]. However, they were not different in sex distribution (P = 0.497). A total of 84 participants reported mobility disability at the 3-year follow-up (total 13.5%, men 8.7%, women 65

3 N. Deshpande et al. 17.6%). The gender-specific distribution of incident mobility disability in each age group was as follows: age group years men 0%, women 2.3%, age group years men 6.0%, women 9.9%, age group years men 16.2%, women 33.9%. Those who reported mobility disability at the follow-up were older and had higher proportion of women, less formal education, more depressive symptoms, lower knee extensor strength and worse visual contrast sensitivity at baseline (P < 0.10) (Table 1). The results of the model 1 binary logistic regression analysis assessed for demographic characteristics demonstrated that women and those 75 years and older were significantly more likely to report incident mobility disability. Next, the variables that were different between those who reported and those who did not report incident mobility disability (Table 1) were dichotomised using known cut-off points and included in the final model of binary logistic regression analysis (model 2). The final model demonstrated that participants with significant depressive symptoms (CES-D > 16) [17] were almost twice as likely to report incident mobility at the follow-up. Further, those with poor visual contrast sensitivity (Pelli Robson score <1.7) [20] were 2.4 times as likely and who were in the lowest quartile of knee extensor strength (men <17.7 kg, women <11.7 kg) were 2.8 times as likely to report 3-year incident mobility disability. Even in this fully adjusted model, being 75 years of age or being a woman was highly indicative of incident mobility disability. The MMSE scores <24 or not having at least high school level education were not independently associated with incident mobility disability (Table 2). Discussion Using the population-based data, this comprehensive study demonstrated independent sensorimotor and psychological determinants of 3-years incident mobility disability. The results demonstrated that the middle aged and older persons with lesser knee extensor strength, poor visual contrast sensitivity or significant depressive symptoms were highly likely to report incident mobility disability in 3 years. To our knowledge, this is the first study that demonstrated independent role of visual contrast sensitivity in predicting incident mobility disability. The contrast sensitivity that declines with increasing age has been shown to be associated with poor balance control and falls in the elderly [24]. Further, poor contrast sensitivity is also associated with the need to use handrails while using the staircase [25] suggesting that optimum contrast sensitivity is necessary for visual processing while negotiating stairs. Considering that one of the two questions that are commonly asked for ascertaining mobility disability specifically focuses on the stair climbing ability without using support, it is clear why poor contrast sensitivity can be the independent determinant of incident mobility disability. Optimum vision is also critical when one independently ventures in complex community environments. It is suggested that compared with those with normal vision, persons with poor vision ( poor visual field and contrast sensitivity) travel less on foot independently and avoid activities [26]. Particularly, decreased ability to detect edges due to poor contrast sensitivity may impose challenge while encountering steps, curbs and pavements commonly found in the community. When asked about ability to walk a quarter mile, it is highly likely that participants envision walking in the community or neighbourhoods rather than walking in an inert experimental environment. Therefore, visual contrast sensitivity could be a determining factor whether they choose to or are able to walk a quarter mile independently. Although the cut-off level for the normal Pelli Robson test score of older persons is suggested to be 1.5 logmar [23], our results indicate that the cut-off point of 1.7 logmar is useful for predicting mobility disability in future. Therefore, Table 1. Baseline differences in the demographic, sensorimotor and psychosocial characteristics between those with and without 3-year incident mobility disability Variable No incident mobility disability (n = 538/622) Incident mobility disability (n = 84/622) F or X 2 and P-value... Age (years) 70.7 ( ) 76.4 ( ) , <0.001 Sex (women %) , BMI (kg/m 2 ) 26.3 ( ) 26.8 ( ) 1.438, Years of education 6.5 ( ) 5.3 ( ) 7.266, Social support 2.7 ( ) 2.4 ( ) 1.840, Perceived inadequate financial condition (%) , Cognition (MMSE) 26.8 ( ) 25.5 ( ) , <0.001 Depressive symptoms (CESD) 13.2 ( ) 16.8 ( ) , <0.001 Contrast sensitivity (Pelli Robson score) 1.69 ( ) 1.66 ( ) , <0.001 Knee extensor strength (kg) 17.6 ( ) 13.7 ( ) , <0.001 Presence of chronic disease (%) , History of falls in previous year (%) , The group differences were identified using general linear model or Chi-square analysis, as appropriate. Accordingly, mean (95% confidence interval) and % values are provided. BMI, body mass index, MMSE, Mini-Mental State Examination, CES-D, Center for Epidemiological Studies Depression scale. 66

4 Sensorimotor and psychosocial determinants Table 2. The predictors of 3-year incident mobility disability Variable Model 1 Model 2 B (SE) P-value OR (CI) B (SE) P-value OR (CI)... Age group (overall) <0.001 <0.001 Age group 1 (65 74 years) (1.028) ( ) (1.039) ( ) Age group 2 (75 85 years) (1.019) ( ) (1.036) ( ) Sex (women) (0.266) ( ) (0.287) ( ) Low education a (0.433) ( ) Poor cognition b (0.317) ( ) Significant depressive symptoms c (0.268) ( ) Poor contrast sensitivity d (0.384) ( ) Knee extensor strength lowest quartile e (0.268) < ( ) Constant (1.025) < (1.068) < Model 1 included only demographic variables (age group, sex). In addition to demographics, model 2 also included baseline variables that were different (P < 0.100) between the participants with and without 3-year incident mobility disability. Odds ratios (OR) and respective 95% confidence intervals (CI) are reported. a Low education: education less than high school level (n = 521 had low education). b Poor cognition: Mini-Mental State Examination score <24 (n = 88 had poor cognition). c Significant depression: Center for Epidemiological Studies Depression scale score >16 (n = 204 had significant depression). d Poor contrast sensitivity: Pelli Robson Score <1.7 (n = 44 had poor contrast sensitivity). e Knee extensor strength lowest quartile: men <17.7 kg, women <11.7 kg (n = 142, 72 males and 70 females, had strength in the lowest quartile. middle-aged and older persons with common vision pathologies that particularly impact contrast sensitivity in the early stages (e.g. cataract, glaucoma) should be specifically monitored for maintaining mobility. Very few studies have investigated the role of lower limb strength for predicting self-reported incident mobility disability using a prospective study design. Visser et al. [27] have demonstrated similar findings in an older cohort of a narrower age-range (70 79 years). Our results indicate that compared with the rest of the participants, the participants in the lowest quartile were twice as likely to report mobility disability at the 3-year follow-up in the much broader age spectrum of years. The incidence of mobility disability in our populationbased sample was twice in women compared with men even after adjusting for other possible confounding variables. When we used the quartiles of the overall strength data (i.e. for all 622 participants disregarding the sex), it was noted that those in the lowest quartile of the overall strength data (knee extensor strength <13 kg) were twice as likely to report incident mobility disability (data not presented). More importantly, the association of the sex and incident mobility disability disappeared after adjusting for the overall knee extensor strength. When data were explored further, it was noted that only 6.5% men had the knee extensor strength <13 kg (lowest overall quartile cut-off). In contrast, 40.1% women s knee extensor strength was <13 kg suggesting that higher incidence of mobility disability in women can be explained by innate lower muscle strength. Our findings raise the question whether implementing sexspecific strength-related thresholds are appropriate for clinical decision-making. The relationship between depressive symptoms and prevalence [13] and recovery [28] of ADL-related disability has been examined. Our findings demonstrated that the presence of significant depressive symptoms may play a crucial role even in the onset of disablement process. To understand clinical impact of these findings intervention studies are warranted to investigate whether timely intervention of depressive symptoms can avert or significantly postpone the initiation of disablement process in older persons. Vincent et al. [9] have shown that when adjusted for other covariates the association of BMI and mobility disability exists only for BMI >35. In the present cohort only 10 out of 622 participants had BMI >35. Therefore, possibly, the relationship with BMI was not extracted. The evidence also suggests the relationship of poor cognition and ADL-related disability. However, this relationship has been more frequently established for executive function and not for the global cognition as measured by MMSE [29]. The data were re-analysed by lowering the MMSE cut-off point to 21 (instead of 24 as relatively fewer participants were high school graduates [30]). This re-allocation of MMSE cut-off level did not alter the results. Similarly, in the fully adjusted model, low education was not independently associated with incidence of mobility disability. Previous studies have identified low education as a predictor of adverse health-related outcomes [21]. However, many of these studies focused primarily from the socio-economic perspectives. It is possible that inclusion of cognition, depression, vision and strength addressed the possible risk factors associated with low education thus, rendering the low education as not significant. The limitation of this study is that the population primarily comprised Caucasian older people living in small towns with the low level of education and therefore, may not completely represent a racially mixed and possibly, highly educated older cohort living in metro/city areas. Additionally, the mobility disability assessment was performed using a dichotomous variable and not a continuous variable. However, the method of mobility disability assessment used in this study is the most commonly used approach primarily in the longitudinal studies of ageing. 67

5 N. Deshpande et al. Further, the fall history, perceived social support and a total number of chronic diseases were not found to be predictors of mobility disability. However, no fall-related diary was maintained by participants to confirm self-reported falls in the previous year. Further, the reliability of the social support outcome measure used in this study has not been established and the diagnosis of chronic disease/s was not re-established in the study. Therefore, it is possible that these measures were rendered methodologically less robust. In conclusion, when several potential determinants are taken into consideration, poor visual contrast sensitivity, low knee extensor strength and significant depressive symptoms were independent determinants of the 3-year onset of mobility disability. Adults over the age of 50 years should seek timely intervention if they have these sensorimotor deficits or depression related problems. Identifying modifiable sensorimotor and psychological factors that may contribute to incident mobility disability can have direct impact on primary prevention of the onset of mobility disability. The incidence of mobility disability was significantly higher in women and in those 75 years of age even after adjusting for multiple factors. Therefore, the mobility status of particularly older women should be monitored on a routine basis. Key points Older persons with vision pathologies affecting contrast sensitivity should be monitored for maintaining mobility. Higher incidence of mobility disability in women may be explained by innate lower muscle strength. Having significant depressive symptoms is an independent predictor of the initiation of the disablement process. Conflicts of interest None declared. Funding The InCHIANTI study was supported as a targeted project (ICS 110.1\RS97.71) by the Italian Ministry of Health and in part, by National Institute on Aging Contracts N01-AG , N01-AG , N01-AG and NIA Grant R01 AG and the Intramural Research Program, National Institute on Aging, NIH. References 1. Patla A, Shumway-Cook A. Dimensions of mobility: defining the complexity and difficulty associated with community mobility. J Aging Phys Act 1999; 7: Hirvensalo M, Rantanen T, Heikkinen E. Mobility difficulties and physical activity as predictors of mortality and loss of independence in the community-living older population. J Am Geriatr Soc 2000; 48: Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 1995; 332: Fried LP, Bandeen-Roche K, Chaves PH, Johnson BA. Preclinical mobility disability predicts incident mobility disability in older women. J Gerontol A BiolSci Med Sci 2000; 55: M Rivera JA, Fried LP, Weiss CO, Simonsick EM. At the tipping point: predicting severe mobility difficulty in vulnerable older women. J Am Geriatr Soc 2008; 56: Allman RM, Baker PS, Maisiak RM, Sims RV, Roseman JM. Racial similarities and differences in predictors of mobility change over eighteen months. J Gen Intern Med 2004; 19: Avlund K, Vass M, Hendriksen C. Onset of mobility disability among community-dwelling old men and women. The role of tiredness in daily activities. Age Ageing 2003; 32: Hicks GE, Shardell M, Alley DE et al. Absolute strength and loss of strength as predictors of mobility decline in older adults: The InCHIANTI Study. J Gerontol A Biol Sci Med Sci 2012; 67: Vincent HK, Vincent KR, Lamb KM. Obesity and mobility disability in the older adult. Obes Rev 2010; 11: Gregory PC, Szanton SL, Xue QL, Tian J, Thorpe RJ, Fried LP. Education predicts incidence of preclinical mobilitydisability in initially high-functioning older women. The Women s Health and Aging Study II. J Gerontol A Biol Sci Med Sci 2011; 66: Anand V, Buckley JG, Scally A, Elliott DB. Postural stability changes in the elderly with cataract simulation and refractive blur. Invest Ophthalmol Vis Sci 2003; 44: Deshpande N, Patla AE. Visual-vestibular interaction during goal directed locomotion: effects of aging and blurring vision. Exp Brain Res 2007; 176: DalleCarbonare L, Maggi S, Noale M et al. Physical disability and depressive symptomatology in an elderly population: a complex relationship. The Italian Longitudinal Study on Aging (ILSA). Am J Geriatr Psychiatry 2009; 17: Ferrucci L, Bandinelli S, Benvenuti E et al. Subsystems contributing to the decline in ability to walk: bridging the gap between epidemiology and geriatric practice in the InCHIANTI study. J Am Geriatr Soc 2000; 48: Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the state of patients for the clinician. J Psychiatr Res 1975; 12: Gill TM, Allore HG, Hardy SE et al. The dynamic nature of mobility disability in older persons. J Am Geriatr Soc 2006; 54: Fava GA. Assessing depressive symptoms across cultures: Italian validation of the CES-D self-rating scale. J Clin Psychol 1983; 39: Magni E, Binetti G, Bianchetti A, Rozzini R, Trabucchi M. Mini-mental State Examination: a normative study in Italian elderly population. Eur J Neurol 1996; 3: Bandinelli S, Benvenuti E, Del Lungo I et al. Measuring muscular strength of the lower limbs by hand-held dynamometer: a standard protocol. Aging ClinExp Res 1999; 11: Pelli DG, Robson PG, Wilkins AJ. The design of a new letter chart for measuring contrast sensitivity. Clin Vision Sci 1988; 2: The effects of education on health. The national bureau of economic research. html (9 April 2013, date last accessed). 22. Elliott DB, Whitaker D. Clinical contrast sensitivity chart evaluation. Ophthalmic Physiol Opt 1992; 12:

6 Impairments in hearing and vision impact on mortality in older people 23. Mäntyjärvi M, Laitinen T. Normal values for the Pelli-Robson contrast sensitivity test. J Cataract Refract Surg 2001; 27: Lord SR. Visual risk factors for falls in older people. Age Ageing 2006; 35(Suppl. 2): ii Tiedemann AC, Sherrington C, Lord SR. Physical and psychological factors associated with stair negotiation performance in older people. J Gerontol A Biol Sci Med Sci 2007; 62: Turano KA. Getting around with visual impairment: people who could benefit from rehabilitation. Available at (26 October 2011, date last accessed). 27. Visser M, Goodpaster BH, Kritchevsky SB et al. Muscle mass, muscle strength, and muscle fat infiltration as predictors of incident mobility limitations in well-functioning older persons. J Gerontol A BiolSci Med Sci 2005; 60: Age and Ageing 2014; 43: doi: /ageing/aft Al Snih S, Markides KS, Ostir GV, Ray L, Goodwin JS. Predictors of recovery in activities of daily living among disabled older Mexican Americans aging. Clin Exp Res 2003; 15: McGough EL, Kelly VE, Logsdon RG et al. Associations between physical performance and executive function in older adults with mild cognitive impairment: gait speed and the timed up & go test. Phys Ther 2011; 91: Leveille SG, Guralnik JM, Ferrucci L, Corti MC, Kasper J, Fried LP. Black/white differences in the relationship between MMSE scores and disability: the Women s Health and Aging Study. J Gerontol B Psychol Sci Soc Sci 1998; 53: P Received 2 December 2012; accepted in revised form 1 May 2013 Published by Oxford University Press on behalf of the British Geriatrics Society This work is written by (a) US Government employee(s) and is in the public domain in the US. Impairments in hearing and vision impact on mortality in older people: the AGES-Reykjavik Study DIANA FISHER 1,CHUAN-MING LI 2,MAY S. CHIU 2,CHRISTA L. THEMANN 3,HANNES PETERSEN 4,5, FRIÐBERT JÓNASSON 4,6,PÁLMI V. JÓNSSON 4,7,JOHANNA EYRUN SVERRISDOTTIR 8,MELISSA GARCIA 9, TAMARA B. HARRIS 9,LENORE J. LAUNER 9,GUDNY EIRIKSDOTTIR 8,VILMUNDUR GUDNASON 4,8, HOWARD J. HOFFMAN 2,MARY FRANCES COTCH 1 1 Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, MD, USA 2 Division of Scientific Programs, Epidemiology and Statistics Program, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA 3 Hearing Loss Prevention Team, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH, USA 4 Faculty of Medicine, University of Iceland, Reykjavik, Iceland 5 Department of Otolaryngology, Head and Neck Surgery, Landspitali University Hospital, Reykjavik, Iceland 6 Ophthalmology, Landspitali University Hospital, Reykjavik, Iceland 7 Department of Geriatrics, Landspitali University Hospital, Landakot, Reykjavík 101, Iceland 8 Icelandic Heart Association, Kopavogur, Iceland 9 Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA Address correspondence to: D. Fisher. Tel: , Fax: diana.fisher@nih.gov Abstract Objective: to examine the relationships between impairments in hearing and vision and mortality from all-causes and cardiovascular disease (CVD) among older people. Design: population-based cohort study. 69