Research in Gerontological Nursing

Empirical Research Supplemental Data

Social Engagement, Cognition, Depression, and Comorbidity in Nursing Home Residents With Sensory Impairment

Darina V. Petrovsky, PhD, RN; Justine S. Sefcik, PhD, RN; Alexandra L. Hanlon, PhD; Alicia J. Lozano, MS; Pamela Z. Cacchione, PhD, CRNP

Abstract

Sensory impairment, explicitly vision and hearing impairment, among nursing home (NH) residents decreases their ability to socially engage. However, it is not known to what extent visual, hearing, or dual impairment is associated with social engagement. The aims of the current retrospective, cross-sectional descriptive study were to determine the relationship between social engagement and (a) levels of sensory impairment (vision, hearing, and dual); (b) depression; and (c) cognition. The authors analyzed baseline data from 213 NH residents with sensory impairment from the I-SEE study. Multivariable model results demonstrated that sensory impairment was not associated with social engagement when adjusting for all covariates. Greater social engagement was associated with less depression, better cognition, and greater comorbidity. Clinicians should be aware of these risks to social engagement in NH residents with sensory impairment and monitor for decreased social engagement and isolation in residents with less comorbidities, higher depression levels, and poorer cognition.

[Res Gerontol Nurs. 2019; 12(5):217–226.]

Abstract

Sensory impairment, explicitly vision and hearing impairment, among nursing home (NH) residents decreases their ability to socially engage. However, it is not known to what extent visual, hearing, or dual impairment is associated with social engagement. The aims of the current retrospective, cross-sectional descriptive study were to determine the relationship between social engagement and (a) levels of sensory impairment (vision, hearing, and dual); (b) depression; and (c) cognition. The authors analyzed baseline data from 213 NH residents with sensory impairment from the I-SEE study. Multivariable model results demonstrated that sensory impairment was not associated with social engagement when adjusting for all covariates. Greater social engagement was associated with less depression, better cognition, and greater comorbidity. Clinicians should be aware of these risks to social engagement in NH residents with sensory impairment and monitor for decreased social engagement and isolation in residents with less comorbidities, higher depression levels, and poorer cognition.

[Res Gerontol Nurs. 2019; 12(5):217–226.]

There are >15,000 nursing homes (NHs) in the United States with more than 1.4 million residents (U.S. Department of Health and Human Services, 2015). Hearing and vision loss in NH residents are often overlooked and not sufficiently assessed (McCreedy, Weinstein, Chodosh, & Blustein, 2018). Numerous adverse effects are associated with sensory loss, including communication problems (Yamada et al., 2014), decreased cognitive function (Jupiter, 2012), depression, functional decline and falls (Li et al., 2011), and a higher incidence of behavioral symptoms (Yamada et al., 2015). Dual impairment is associated with increased morbidity and mortality (Gopinath et al., 2013). In addition, sensory impairment may contribute to social isolation among NH residents, which can negatively affect their quality of life (Resnick, Fries, & Verbrugge, 1997).

Social engagement among NH residents has been associated with cognition, comorbidity, and depression. Previous research consistently reported that greater cognition was associated with greater social engagement in NH residents (Guthrie et al., 2018). Greater comorbidity was associated with greater engagement in NH residents with dementia (Cohen-Mansfield, Marx, Regier, & Dakheel-Ali, 2009). Studies exploring the association between social engagement and depression reported mixed results. Previous studies reported a negative association (i.e., lower depression associated with higher social engagement) (Achterberg et al., 2003; Kang, 2012); whereas, van Beek, Frijters, Wagner, Groenewegen, and Ribbe (2011) found no relationship between depressive symptoms and social engagement in 502 NH older adults once they accounted for resident characteristics. Further research is needed to better understand social engagement among NH residents, including a specific focus on residents with sensory impairment.

Vision Impairment

Normal 20/20 vision diminishes with aging, and visual impairment is common among older adults living in NHs (Owsley et al., 2007). Studies have revealed that 37% (Friedman et al., 2004) to 70% (Elliott, McGwin, & Owsley, 2013) of older adults in NHs or assisted living have visual acuity worse than 20/40 in the better-seeing eye. Mild visual impairment is considered between 20/25 and 20/50, moderate impairment 20/60 to 20/160, legally blind 20/200 to 20/400, and profound vision impairment is considered 20/400 to 20/1,000 (Agency for Healthcare Research and Quality, 2004). The most common causes for blindness or vision impairment in NH residents include cataracts, pathologic myopia, and age-related macular degeneration (Sainz-Gómez et al., 2010). Visual impairment in NH residents is associated with decreased health-related quality of life (Dev, Paudel, Joshi, Shah, & Subba, 2014) and cognitive impairment (Mitchell, Hayes, & Wang, 1997).

Hearing Impairment

The American Speech-Language-Hearing Association defines hearing loss by decibel levels: normal (10 to 15 dB), slight (16 to 25 dB), mild (26 to 40 dB), moderate (41 to 55 dB), moderately severe (56 to 70 bB), severe (71 to 90 dB), and profound (≥91 dB) (Clark, 1981). The prevalence of hearing impairment in NH residents varies between 54% and 90% (Bagai, Thavendiranathan, & Detsky, 2006; Cacchione, Culp, Dyck, & Laing, 2003). The most frequent types of age-associated hearing impairment are sensorineural and conductive (Huang & Tang, 2010). Hearing impairment in NH residents is associated with higher rates of limited communication, fatigue, and balance problems (Yamada et al., 2014), decreased cognitive function (Jupiter, 2012), and decreased quality of life (Cacchione, 2012; Resnick et al., 1997).

Dual Impairment

Dual impairment includes older adults with both visual and hearing impairments. Prevalence of dual sensory impairment in NH residents varies between 9.7% and 33.9% (Cacchione et al., 2003; Guthrie, Declercq, Finne-Soveri, Fries, & Hirdes, 2016; Yamada et al., 2014). NH residents with dual impairment are likely to be diagnosed with dementia of Alzheimer's type, experience cognitive impairment, functional disability, and communication difficulties (Guthrie et al., 2016). Furthermore, dual impairment in NH residents is associated with a higher incidence of behavioral symptoms (Yamada et al., 2015), and a greater risk for clinical issues, such as communication problems, fatigue, balance problems, and sleep disruptions, compared to NH residents with a single impairment (Yamada et al., 2014).

Social Engagement

Social engagement has been defined as the “degree of participation in a social setting and the ability to initiate and to be receptive to social interactions” (Dupuis-Blanchard, Neufeld, & Strang, 2009, p. 1187). The presence of social interactions has been linked to positive health benefits, including psychological well-being (Yeung, Kwok, & Chung, 2013) and reduced loneliness (Drageset, Kirkevold, & Espehaug, 2011); however, lack of social engagement is detrimental to the health of NH residents. For example, in a study of 30,070 NH residents, residents with higher levels of social engagement had longer 1-year survival rates compared to residents with lower levels of social engagement (Kiely & Flacker, 2003). Social engagement is an important aspect of NH residents' lives and predicts mortality in this highly vulnerable population.

Sensory Impairment and Social Engagement of Nursing Home Residents

Single sensory and dual sensory impairment may limit social engagement in NH residents. In past studies, vision impairment has been associated with decreased social engagement in NH residents with dementia (Kang, 2012). One study of 2,851 older adults in NHs found residents not involved in everyday activities had 51% higher mortality compared to residents who engaged in everyday activities (Yamada et al., 2016). Previous NH studies examining the relationship between sensory impairment and social engagement relied on subjective measures of sensory impairment without an objective clinical assessment of sensory impairment. In addition, less is known about the relationship between social engagement and comorbidity in NH residents with sensory impairment. Therefore, the purpose of the current study was to examine the associations between social engagement and the different levels of sensory impairments, depression, and cognition in NH residents. The guiding research question was: Controlling for comorbidity, what is the relationship between social engagement, levels of sensory impairment in vision and hearing (individually and combined), depression, and cognition in NH residents with sensory impairment?

Method

The current descriptive study is a secondary analysis of baseline data from an intervention study, Nursing Interventions for LTC Elders with Sensory Impairment (parent study [R01 N008777]). The parent study was a randomized prospective clinical trial with a two-group design (an individualized-sensory enhancement for the Elderly [I-SEE] intervention group and an attention control [AC] group) to test the efficacy of the I-SEE intervention to improve hearing and vision, cognitive performance, depression, and social engagement in addition to other health outcomes pertaining to older adults residing in NHs, described elsewhere (Cacchione, Willoughby, Langan, & Culp, 2011). The I-SEE group received individualized care planning for older adults based on the nursing assessments of NH residents' sensory status, followed by individualized nursing interventions and referrals to interprofessional colleagues to improve older adults' vision and hearing, delivered three times per week. The AC group received a 15-minute social visit and both groups were screened for delirium three times per week.

Screening and Enrollment Procedure

The parent study enrolled older adults with sensory impairment from seven nursing homes in the Midwest. Participants were randomly selected based on a list from a random numbers table and the resident's room and bed location. Older adults were consented, and then screened for eligibility. Inclusion criteria were: age 65 and older; no more than moderate cognitive impairment as measured by a Blessed Orientation and Concentration Test score <26 (scores range from 0 to 28; higher scores indicate worse cognitive impairment, with a score of 26 indicating advanced cognitive impairment); best corrected distance vision of 20/50 or worse on the Early Treatment of Diabetic Retinopathy Study (ETDRS) eye chart (Ferris, Kassoff, Bresnick, & Bailey, 1982); and failure to hear the test tone at 40 dB, 1,000 Hz on the Madsen portable audiometer. Exclusion criteria were: aphasia; scoring as delirious on the NEECHAM Confusion Scale; inability to hear the test tone at 80 dB in both ears; and no light perception in both eyes.

The consent process entailed reviewing the consent form with each participant followed by four questions: “What is the purpose of the study; what are the risks; what are the benefits; and how do you contact the investigator?” If the potential participant was able to answer three of the four questions correct, they were deemed able to provide their own consent. If they could not answer three of four questions but still wanted to participate, consent was obtained from their responsible party listed in the chart.

A total of 526 participants consented or assented to participate. Approximately 225 participants met the inclusion criteria and were enrolled in the parent study. This secondary analysis reflects 213 of the 225 enrolled participants (11 were dropped due to meeting inclusion criteria at the screening visit but scoring within the normal range of sensory impairment on baseline assessments, and one due to missing data for scores used to identify sensory impairment). Their baseline assessments were used for this study. The parent study received Institutional Review Board approval from the Saint Louis University and the University of Pennsylvania. The baseline visits entailed two 1-hour visits to complete evaluations of vision and hearing, cognition, depression, delirium, social engagement, comorbidity, and physical performance.

Measures

All measures were completed by research nurses who were trained as a group at the beginning of the current study until interrater reliability reached at least 90% on all measures. Interrater reliability checks were completed at the start of each baseline assessment in each NH by assessing three participants as a group with remedial training provided. Vision was assessed using the ETDRS, which was originally developed for the early detection of diabetic retinopathy (Pelli & Robson, 1988). NH residents were visually impaired if their best corrected visual acuity was worse than 20/50 on the ETDRS in both eyes.

Hearing impairment was measured with the Madsen 304 portable audiometer at the 40 dB 1,000 Hz level, calibrated to the standards of the American National Standards Institute (1989). Participants were designated as hearing impaired if they could not hear the test tone at 40 dB and 100 Hz in both ears. Further testing was carried out at 20, 25, 40, 60, 70, and 80 dB with standard frequencies of 500, 1,000, 2,000, and 4,000 Hz to calculate a pure tone average.

To better describe the level of impairment in each sense, the authors categorized vision impairments as mild (best ETDRS in both eyes 33 to 35 letters), moderate (best ETDRS in both eyes 8 to 32 letters), and legally blind (best ETDRS in both eyes ≤7 letters). The authors categorized participants' hearing impairment based on average pure tone audiometry levels in their best ear as: moderate (41 to 55 dB), moderately severe (56 to 70 dB), and severe (>71 dB), consistent with the American Speech-Language-Hearing Association (Clark, 1981). To describe levels of dual impairment, the authors created nine new categories: (a) mild vision to moderate hearing; (b) mild vision to moderately severe hearing; (c) mild vision to severe hearing; (d) moderate vision to moderate hearing; (e) moderate vision to moderately severe hearing; (f) moderate vision to severe hearing; (g) legally blind to moderate hearing; (h) legally blind to moderately severe hearing; and (i) legally blind to severe hearing.

Social engagement was measured using the Brief Assessment of Social Engagement (BASE), a 20-item scale from the Nottingham Longitudinal Study of Activity and Aging (NLSAA; Morgan, 1998). This self-report scale measures 20 positive social engagement activities including: telephone calls; attending religious services; voting; taking a holiday; use of public library; access to a car; attendance at group meetings; contacts with family and friends; employment; and newspaper, magazine, radio, and television use. In addition, the BASE identifies if the person ambulates, shares a room, gets out and about, and the presence of frequent loneliness. Each item is answered with 1 or 0 (yes or no). Items are added to give a summative continuous score (of 20) reflective of older adults' participation in activities (Morgan, 1998). Higher scores indicate higher social engagement and the capacity to initiate social interaction. The scale has a high alpha coefficient of 0.7 (Morgan, 1998). Test–retest reliability was established in the NLSAA study (Morgan, 1998). This scale has been determined to be a valid measure for social engagement in NH older adults (Resnick et al., 1997).

Depression was measured using the Geriatric Depression Scale, which was originally developed to assess depressive symptoms in community-dwelling older adults (Yesavage et al., 1982). The measure comprises 30 yes or no items measuring symptoms of depression during 2 weeks prior to the interview. The scale was reported to have high internal consistency; Cronbach's alpha coefficient of 0.94, high test–retest reliability (0.85), and high correlation with other depression measures establishes its validity. Higher scores correlate with higher levels of depression in older adults (Yesavage et al., 1982).

Cognition was measured using the Mini-Mental State Examination (MMSE), a 30-item scale that measures orientation, registration, attention, calculation, recall, and language in older adults (Folstein, Folstein, & McHugh, 1975). The maximum score is 30 with lower scores indicating greater severity of cognitive impairment. The MMSE has a sensitivity of 0.87 and specificity of 0.82 for detecting cognitive impairment (Folstein et al., 1975).

Comorbidity was measured using the Cumulative Illness Rating Scale (CIRS; Linn, Linn, & Gurel, 1968), which rates all 13 body systems on a scale from 1 (no impairment) to 5 (life-threatening impairment) without the use of specific diagnoses. Range of possible scores is 0 to 70, with higher scores indicating greater comorbidity (Linn et al., 1968). The CIRS includes an item on eye and ear problems. The CIRS was used as a covariate and was initially proposed to distinguish biological from chronological aging. This scale has been validated for use in NH settings (Parmelee, Thuras, Katz, & Lawton, 1995) and is superior to the Charlson Comorbidity Index in complex older adult populations (Rochon et al., 1996). The CIRS was collected via chart review by the principal investigator (P.Z.C.), a nurse scientist and gerontological nurse practitioner.

Analysis

Preliminary analyses included generating descriptive statistics for all baseline measures to characterize the sample. All continuous variables were normally distributed and were described using means and standard deviations. Dichotomous and categorical variables were described with frequencies and percentages. A one-way analysis of variance (ANOVA) test examined the differences in social engagement across the sensory impairment groups.

General linear modeling assessed the effects of sensory impairment, cognition, and depression on social engagement. The authors generated simple general linear models for each independent predictor, followed by a full model regressing social engagement on all three predictors, while adjusting for comorbidity. The authors generated a final multivariable model for social engagement using backwards selection methods, where predictors were removed one at a time until all those remaining in the model were significant at the 0.05 level. Statistical significance was set at the 0.05 level. All analysis was conducted in SAS version 9.4.

Results

Two hundred thirteen participants were included in the analysis. Participants were mostly female (n = 158, 74.2%) and Caucasian (n = 196, 92%) with a mean age of 86.38 (SD = 7.32) years. All participants had hearing (n = 103, 48.4%), visual (n = 29, 13.6%), or dual impairment (n = 81, 38%), with a mean MMSE score of 22.7 (SD = 4.81), consistent with mild cognitive impairment. The mean GDS score was 8.58 (SD = 5.72), corresponding to a negative depression screen. The mean CIRS score was 28.66 (SD = 3.99). The most common participant diagnoses were hypertension, arthritis, dementia, depression, gastric esophageal reflux disease, coronary artery disease, and diabetes. Descriptive statistics for this sample are summarized in Table 1. On average, participants reported a mean BASE score of 12.08 of 20 possible points (SD = 3.04). A one-way ANOVA test demonstrated that social engagement varied by sensory impairment group. Residents with hearing (mean = 12.50, SD = 2.62) and visual (mean = 12.45, SD = 2.82) impairment were statistically more socially engaged than residents with dual impairment (mean = 11.42, SD = 3.51) (p = 0.046) (Table 2).

Baseline Characteristics of I-SEE Participants (N = 213)

Table 1:

Baseline Characteristics of I-SEE Participants (N = 213)

Descriptive Statistics of Social Engagement by Sensory Impairment Group (N = 213)

Table 2:

Descriptive Statistics of Social Engagement by Sensory Impairment Group (N = 213)

Simple general linear models that adjusted for comorbidity (i.e., CIRS) demonstrated that depression (p < 0.0001) and cognition (p = 0.031) were independently associated with social engagement (Table 3). For each unit increase in the depression scale (i.e., GDS), there was a 0.16 decrease in social engagement, adjusting for comorbidity. In addition, there was a 0.09 increase in social engagement for each unit increase in cognition (i.e., MMSE), adjusting for comorbidity. Overall, sensory impairment was not independently associated with social engagement (p = 0.069) when adjusted for comorbidity, although significant differences were found in social engagement residents with hearing and dual impairment (p = 0.027) (Table 3). In the full model, sensory impairment remained non-significant (p = 0.277) (Table 3).

General Linear Models of Social Engagement Regressed on Type of Sensory Impairment, Depression, and Cognition; Controlling for Comorbidity (N = 213)

Table 3:

General Linear Models of Social Engagement Regressed on Type of Sensory Impairment, Depression, and Cognition; Controlling for Comorbidity (N = 213)

No association was found between sensory impairment and social engagement, but significant relationships were noted between depression and cognition; therefore, a final multivariable model was created consisting only of significant predictors of social engagement. Using a backwards elimination method, depression (p < 0.0001), cognition (p = 0.008), and comorbidity (p = 0.024) remained significant predictors of social engagement (Table 4). For each unit increase in depression, there was a 0.17 decrease in social engagement. There was a 0.11 increase in social engagement for each unit increase in cognition. In addition, for each unit increase in comorbidity, there was a 0.11 increase in social engagement.

Backwards Selection Multivariable Model for Social Engagement, Adjusting for Comorbidity (N = 213)

Table 4:

Backwards Selection Multivariable Model for Social Engagement, Adjusting for Comorbidity (N = 213)

Discussion

The purpose of the current study was to examine the associations between social engagement and the different types of sensory impairments, depression, and cognition in NH residents with sensory impairment. Findings demonstrated social engagement in NH residents with sensory impairment were not associated. However, less depression, better cognition, and greater comorbidity were associated with greater social engagement. Results indicate that factors, such as depression, cognition, and comorbidity were stronger predictors of social engagement in NH residents compared to sensory impairment.

Findings are in contrast with previous research that found an association between social engagement and vision impairment in NH residents with dementia (Kang, 2012). Kang (2012) enrolled NH residents with severe cognitive impairment compared to the current sample that included residents with intact to moderate cognitive impairment. In addition, lack of an association between sensory impairment and social engagement in the current study may be due to the limited variation in social engagement scores by type of sensory impairment. To further examine the associations between social engagement and sensory impairment, the authors ran additional analyses using the actual sensory impairment scores. Vision impairment was defined as number of letters on the ETDRS. The degree of hearing impairment was measured using the pure-tone average (PTA) in the best ear. In addition, the authors also analyzed the standardized score of the ETDRS and PTA (created first by standardizing each score and then taking the sum), but the conclusions did not differ (Table A, available in the online version of this article).

General Linear Models of Social Engagement regressed on Visual acuity (# of letters), Hearing impairment (PTA), Depression, and Cognition, Controlling for Comorbidity (N = 213)

Table A:

General Linear Models of Social Engagement regressed on Visual acuity (# of letters), Hearing impairment (PTA), Depression, and Cognition, Controlling for Comorbidity (N = 213)

Significant associations between residents' social engagement, cognition, comorbidity status, and depression level are consistent with previous findings. NH residents with increased levels of cognitive impairment were less likely to be socially engaged compared to NH residents with less cognitive impairment (Achterberg et al., 2003; Guthrie et al., 2018). Cognitive impairment may limit their ability to engage in activities, such as talking on the telephone, attending religious services, or voting, as these activities rely on short-term memory. Like previous research in NH residents (Cohen-Mansfield, Dakheel-Ali, & Marx, 2009), the authors found that greater comorbidity was associated with greater social engagement in NH residents with sensory impairment. The previous study hypothesized that NH residents who experience increased burden from comorbid conditions may have intact cognition. Therefore, they may rely on their cognition more than their senses when participating in social activities (Cohen-Mansfield, Dakheel-Ali, et al., 2009). The current authors confirmed this hypothesis by examining the relationship between comorbidity and cognition and found that in this sample more comorbidities were associated with better cognition (p = 0.005) (Table B, available in the online version of this article). When examining an association between depression and social engagement, the current authors found that higher levels of depression were associated with lower levels of social engagement. Findings were consistent with previous research examining social engagement in Dutch NH residents (Achterberg et al., 2003), NH residents with dementia (Kang, 2012), and long-term care facility residents in Hong-Kong (Lou, Chi, Kwan, & Leung, 2013). NH residents who feel sad or depressed may not engage or may withdraw from group activities.

General Linear Model of Cognition regressed on Comorbidity (N = 213)

Table B:

General Linear Model of Cognition regressed on Comorbidity (N = 213)

Limitations

The current study has limitations. First, the BASE instrument did not assess the frequency in which NH residents participated in social activities. In addition, some of the BASE questions might not apply to NH residents. For example, questions asking older adults about taking a holiday, using the public library, or access to a car may not be applicable to NH residents. Although meant to be brief, 20 questions might be too many for NH residents. Second, the authors did not assess for other confounders such as pain. Although this secondary analysis had limitations, the strengths of the current study include the use of objective, well-defined sensory assessments and a comorbidity scale that gauges impairment in body systems, rather than the number of diagnoses.

Although the current study explored social engagement in a large sample of NH residents, the findings should be replicated in larger and more ethnically diverse samples of NH residents. The current study should also be replicated comparing samples of NH residents with and without sensory impairments. Future studies should consider both the frequency and level of social engagement among NH older adults. For instance, using the Social Engagement Index (derived from items on the Minimum Data Set record), which does not rely on self-report, might be more appropriate for use in NHs to gauge social engagement (Mor et al., 1995). The highly validated three-item UCLA loneliness scale (Hughes, Waite, Hawkley, & Cacioppo, 2004) might also provide more insights into social engagement in this population. Direct observations of social interactions may be more accurate in capturing social engagement among NH residents; however, it is the most time-intensive approach (Abbott, Sefcik, & Van Haitsma, 2017). In addition, NHs track attendance at activities; therefore, one could pull attendance of NH residents in activities for a certain time period and take an average weekly attendance. Another approach would be tracking visitors to see who has visited specific residents and if there is a pattern to those visits. These approaches track contacts with activities and visitors but may not identify meaningful social engagement for the individual. A combination or mixed methods approach would provide a greater understanding of NH residents' meaningful social engagement.

Implications

The current findings have important implications for clinical care. Clinicians should be aware of these risks to social engagement in NH residents with sensory impairment and monitor for decreased social engagement and isolation in residents with less comorbidities, higher depression levels, and poorer cognition. The I-SEE intervention to address vision and hearing impairment provides a guide for NH staff to enhance residents' sensory impairment, allowing staff to coordinate tailored social events to engage residents with sensory impairment to facilitate interactions with others (Cacchione, 2007). These tailored events may include one-on-one visits in a quiet space or small group activities, such as an indoor gardening program, which has been found to improve life satisfaction and social network and decrease perceptions of loneliness of NH residents (Tse, 2010). NH staff should proactively invite individuals with sensory impairment at risk for decreased social engagement to recreational programs that align with the residents' interest and provide environmental modifications (e.g., decreased environmental noise, enhanced lighting) or use adaptive techniques to enhance participation (e.g., use of planters that highly contrast with the plants, pocket amplifiers). Residents' care plans should include information on person-centered meaningful activities and beneficial environmental modifications to implement to support social engagement activities.

In addition, care planning for residents with visual impairment should include individualized attention to lighting type and levels to support residents' lighting needs, including residents with sensitivity to light (Cacchione, 2012). Proper care of glasses should be given, including cleaning lenses and engraving names on the frames. For residents with hearing impairment, interventions include caring for assistive devices (i.e., labeling hearing aids or pocket amplifiers with resident name), checking if devices are in place, and that batteries are functional (Wallhagen, Pettengill, & Whiteside, 2006). Environmental modifications include limiting background noise and rearranging furniture to facilitate conversations (Wallhagen et al., 2006).

Because eye conditions and hearing loss are seen more frequently in older adults, providers and nurses should complete routine vision and hearing assessments, including assessing health histories; considering diseases or conditions that negatively impact vision and hearing; testing distance and near vision and contrast sensitivity; checking ears for cerumen; and completing pure-tone audiometry, hand-held audio scope testing, or the finger rub test (Cacchione, 2012; Wallhagen et al., 2006). Attempts should be made to correct deficits with assistive devices and maintain consistent treatment for any pre-existing conditions (e.g., use of eye drops for glaucoma) (Cacchione, 2012).

Conclusion

The current study examined the relationship between social engagement, sensory impairment, depression, and cognition in NH residents. The authors found that residents' depression, cognition, and comorbidity were stronger predictors of social engagement in NH residents compared to sensory impairment. These findings have implications for health care providers, including nurses, involved in assessing sensory impairment and clinical conditions in NH residents. It is important for anyone involved in the care of NH residents to monitor for decline in social engagement and to alert the health care team of these changes. Addressing these concerns early may have a lasting positive effect on health and well-being of NH residents.

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Baseline Characteristics of I-SEE Participants (N = 213)

Characteristicn (%)
Gender
  Female158 (74.2)
  Male55 (25.8)
Race
  White196 (92)
  Black16 (7.5)
  Other1 (0.5)
Sensory impairment
  Vision29 (13.6)
    Mild8 (27.6)
    Moderate14 (48.3)
    Legally blind7 (24.1)
  Hearing103 (48.4)
    Moderate55 (53.4)
    Moderately severe41 (39.8)
    Severe7 (6.8)
  Dual81 (38)
    Mild vision—moderate hearing9 (11.1)
    Mild vision—moderately severe hearing5 (6.2)
    Mild vision—severe hearing3 (3.7)
    Moderate vision—moderate hearing30 (37)
    Moderate vision—moderately severe hearing15 (18.5)
    Moderate vision—severe hearing4 (4.9)
    Legally blind—moderate hearing10 (12.4)
    Legally blind—moderately severe hearing4 (5)
    Legally blind—severe hearing1 (1.2)
Mean (SD) (Range)
Age (years)86.38 (7.32) (65 to 101)
Visual acuity (# of letters)—ETDRS33.64 (15.31) (0 to 59)
Hearing (dB)—PTA52.41 (11.81) (17.5 to 83.75)
Combined standardized ETDRS and PTA scores0.04 (1.54) (−4.37 to 3.49)
Comorbidity—CIRS28.66 (3.99) (17 to 37)
Cognition—MMSE22.7 (4.81) (9 to 30)
Depression—GDS8.58 (5.72) (0 to 25)
Social engagement—BASE12.08 (3.04) (1 to 18)

Descriptive Statistics of Social Engagement by Sensory Impairment Group (N = 213)

Sensory ImpairmentnMean (SD) (Range)p Value
Vision2912.45 (2.82) (5 to 18)0.046
Hearing10312.50 (2.62) (7 to 18)
Dual8111.42 (3.51) (1 to 18)

General Linear Models of Social Engagement Regressed on Type of Sensory Impairment, Depression, and Cognition; Controlling for Comorbidity (N = 213)

ModelVariableEstimate (SE)95% CIp Value
1Sensory impairment0.069
  Vision0.96 (0.65)[−0.31, 2.24]0.138
  Hearing0.99 (0.45)[0.11, 1.87]0.027
  DualREFREF
Comorbidity—CIRS0.11 (0.05)[0.01, 0.22]0.029
2Depression—GDS−0.16 (0.03)[−0.23, −0.09]<0.0001
Comorbidity—CIRS0.14 (0.05)[0.04, 0.24]0.006
3Cognition—MMSE0.09 (0.04)[0.01, 0.18]0.031
Comorbidity—CIRS0.10 (0.05)[−0.002, 0.20]0.054
4Sensory impairment0.277
  Vision0.74 (0.62)[−0.47, 1.96]0.228
  Hearing0.63 (0.43)[−0.22, 1.48]0.148
  DualREFREF
Depression—GDS−0.17 (0.03)[−0.23, −0.10]<0.0001
Cognition—MMSE0.10 (0.04)[0.01, 0.18]0.022
Comorbidity—CIRS0.11 (0.05)[0.01, 0.21]0.029

Backwards Selection Multivariable Model for Social Engagement, Adjusting for Comorbidity (N = 213)

VariableEstimate (SE)95% CIp Value
Depression—GDS−0.17 (0.03)[−0.24, −0.10]<0.0001
Cognition—MMSE0.11 (0.04)[0.03, 0.19]0.008
Comorbidity—CIRS0.11 (0.05)[0.02, 0.21]0.024

General Linear Models of Social Engagement regressed on Visual acuity (# of letters), Hearing impairment (PTA), Depression, and Cognition, Controlling for Comorbidity (N = 213)

ModelVariableEstimate (SE)95% CIP-value
1Visual Acuity (# of letters) – ETDRS0.02 (0.01)[−0.01, 0.05]0.139
Co-morbidity – CIRS0.12 (0.05)[0.02, 0.22]0.021
2Hearing (dB) – PTA−0.02 (0.02)[−0.05, 0.02]0.356
Co-morbidity – CIRS0.12 (0.05)[0.02, 0.22]0.021
3Combined standardized ETDRS and PTA scores0.05 (0.14)[−0.21, 0.32]0.694
Co-morbidity – CIRS0.12 (0.05)[0.02, 0.23]0.018
4Visual Acuity (# of letters) – ETDRS0.01 (0.01)[−0.01, 0.04]0.319
Hearing (dB) – PTA−0.02 (0.02)[−0.05, 0.02]0.293
Depression – GDS−0.17 (0.03)[−0.24, −0.10]<.0001
Cognition – MMSE0.10 (0.04)[0.01, 0.18]0.022
Co-morbidity – CIRS0.11 (0.05)[0.01, 0.21]0.028
5Combined standardized ETDRS and PTA scores−0.003 (0.13)[−0.25, 0.25]0.979
Depression – GDS−0.17 (0.03)[−0.24, −0.10]<.0001
Cognition – MMSE0.11 (0.04)[0.03, 0.19]0.008
Co-morbidity – CIRS0.11 (0.05)[0.01, 0.21]0.024

General Linear Model of Cognition regressed on Comorbidity (N = 213)

VariableEstimate (SE)95% CIP-value
Co-morbidity – CIRS0.23 (0.08)[0.07, 0.39]0.005
Authors

Dr. Petrovsky is Postdoctoral Research Fellow, Dr. Sefcik is Postdoctoral Research Fellow, Dr. Cacchione is Ralston House Endowed Term Chair in Gerontological Nursing, Associate Professor of Geropsychiatric Nursing, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; and Dr. Hanlon is Practice Professor of Biostatistics, and Ms. Lozano is Research Associate, Virginia Tech, Roanoke, Virginia.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Research reported in this publication was funded by the National Institute of Nursing Research of the National Institutes of Health (NIH) (R01 N008777). Dr. Petrovsky is a Ruth L. Kirschstein Postdoctoral Fellow (F32 AG060630) through the NIH, National Institute on Aging. Dr. Sefcik is also supported by the NIH (T32 NR009356).

Address correspondence to Pamela Z. Cacchione, PhD, CRNP, Ralston House Endowed Term Chair in Gerontological Nursing, Associate Professor of Geropsychiatric Nursing, University of Pennsylvania School of Nursing, Room 410 Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104; e-mail: pamelaca@nursing.upenn.edu.

Received: January 08, 2019
Accepted: April 22, 2019
Posted Online: July 09, 2019

10.3928/19404921-20190627-01

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