 Now today's webinar is Combined Vision and Hearing Loss in the CLSA, Prevalence, Severity, and Relationship to Cognitive and Social Variables. Let me introduce our speaker Dr. Walter Wittich. Dr. Wittich is an Assistant Professor at the School of Optometry at the University of Montreal and a Resident Researcher at the CIRR Center for Re-Adaptation, MAB, Mckay-Doux, CS-Doux-Centres-Ouest-De-Lille-De-Montréal, as well as the CIRR, Institute-Nazaris-De-Louis-Braille-Doux-Ces-De-La-Mon-Regui Center. Following his Master's in Psychology, given at Concordia U, and a PhD in Visual Neuroscience at McGill, he completed a post-doctoral fellowship in audiology at the Center of Research at the Institute University de Georiatric de Montréal. Coming from a background in age-related vision loss, he now conducts research in dual sensory impairment and deaf blindness. His research domains include basic sensory science, as well as medical, psychosocial, and rehabilitation approaches to sensory loss. He recently became a fellow of the American Academy of Optometry and his Quebec's first certified low vision therapist, certified by the Academy for Certification of Vision Rehabilitation and Education Professionals. Thank you very much Dr. Wittich for joining us and giving your time to present our information for today's webinar. I'm going to go ahead and give you control over the webinar and invite you to start. Thank you very, very much. Thank you for inviting me to present today on our sensory data in the CLSA and to represent our team. Hello, good morning, good afternoon, depending on which time zone you're in. Let me start out with a mini disclaimer. When my team and I put this presentation together, we likely chewed off a little too much for what we could handle. And so you will see that I will spend the majority of my time today talking about dual sensory loss and prevalence and severity and as well as the relationship between the vision and hearing variables. I will give you a mini touch on some of our cognitive findings, but I believe we will run out of time to cover social variables. So for just as a mini disclaimer, as we go along. I also want to quickly appreciate all the people that give us money for the things we do and to have a mini disclosure that I have no conflicts of interest that are related to today's presentation. Now, always a good starting point specifically to our project here to appreciate the funding that received specifically from the Canadian Institutes of Health Research through a catalyst grant that was supplemented by the Quebec Research for Research in Aging. I also would like to appreciate the infrastructure and support that we have through the Canadian Consortium on Neurodegeneration and Aging specifically within Team 17, which looks at interventions at the sensory cognitive interface. And that is because all our team members for this project are also members of Team 17 in the CCNA. We of course appreciate the CLSA funding itself for the conducting the CLA study itself. And I want to just briefly acknowledge our collaborative data access with the Ithmarai and the Kaihai as well. Hi, Walter. I'm just going to interrupt because I don't believe you're sharing your presentation yet. Oh, look at that. So let me get out of here. I've been talking about all sorts of, I've been sharing, but I'm not sure what it is I'm not clicking to share. Oh, I see. So if you go to share and then my screen. Yes, of course, it would be useful to share my screen. There you go. Great. Thank you so much. This here is of course the excellent slide that you were unable to see before, but it summarizes everything I just told you about our data access and funding support. Now, to give you a mini introduction to Team 17, here is a brief overview of the members that are all interested in various aspects of sensory cognitive aging. And I want to give a specific shout out today to Ali Hamalain and who is our postdoctoral fellow who conducted the large majority of the work that I will be presenting today. And I also want to give a shout out to Paul Mick, who is the epidemiological brain on our team, who has been supervising a lot of this work. Now, to start out, a mini tip of the heart to the people that are the pioneers in the idea of studying sensory cognitive aging, specifically Lindenberger and Baltis who've done some of the seminal work that really got a status in this field who reported the first similarities that they observed in changes across the age range, visual measures, auditory measures as well as various levels of intellectual functioning and who were the first to then build models in order to try to understand how senses and cognition hang together, specifically in the context of aging. Their work has later on led to the development of various different models that are trying to explain how sensory and cognitive aging works, whether these are ideas of whether the aging progress process is affecting the sensory organs, which then downstream changes sensory and cognitive processing, whether this is an idea that there is an underlying cause here that will affect the central nervous system as a whole, which will then affect both cognitive and sensory aging. One of the theories that is still following this model today as well is the idea of frailty. And then, of course, there are some more complicated versions of looking at this. The sky is the limit for trying to add different variables that may express this process of sensory and cognitive interactions, whether they go through recruitment and declines in functioning, whether they are looking at aspects of compensating for existing losses. And so these models are still alive. They're still developing, and there are quite a few other models out there as well. But I just wanted to give this sort of as a mini starting point to see where we go in sensory, cognitive aging research right now. Since I'm talking about combined vision and hearing loss, I wanted to touch on a few items of vocabulary. I have to admit my preferred term is combined vision and hearing loss. However, what you will also come across is dual sensory impairment. And you will also sometimes find the term acquired deaf blindness, specifically in the context of vision and hearing loss that developed during the lifespan. It turns out that the term deaf blindness is actually used often as the umbrella term in a clinical environment specifically in the context of rehabilitation. And it is considered to describe the entire spectrum, no matter what the severity, the age, the age of onset or the order of onset. Researchers like to be more subtle at times or maybe more careful with their terminology. And so the phrase dual sensory impairment has made it into the literature. What might be problematic at times is that we're actually not specific about which two senses are defined by dual sensory loss, even though the understanding often is that we're talking about vision and hearing. Now, my favorite definition of dual sensory impairment or deaf blindness actually comes from the American Association of the Deaf Blind. Since it does not get stuck on some specific measurement of things, but they really want to consider the person as a whole and describe aspects of communication, the effect on access to information, social participation, employment, as well as general levels of maintenance of independence. And in that context, I also want to introduce you to the Nordic definition, for those of you who have not heard this before, because in the Nordic definition, one key element is that deaf blindness itself is considered a distinct ability, disability, separate from just adding vision to hearing loss. The reason this is done is that there's a very interesting breaking point, since these two most dominant senses for us are often used to compensate for the other. People with a vision loss will rely more on their hearing. People with hearing loss depend very much on their sense of vision. What ends up happening is when the impairments arrive together, there is some interesting breaking point where this compensation breaks down and suddenly one and one does not equal two anymore. So we are now looking at an impairment that is more multiplicative than it is additive. So in the context of studying aging and dual sensory impairment, we recently completed a book chapter that I recommend for those who would like to go a little bit further into this topic. There are quite a few reports now of how dual sensory loss may be linked to cognitive decline, potentially above and beyond the effects of any one of those impairments along. It is a bit more intuitive how dual sensory loss may be linked to social isolation. There is a quote that is said to come from Helen Keller who describes how vision loss will keep you from things and hearing loss will keep you from people. And so this isolation socially that is linked to the combined impairment of vision and hearing is relatively intuitive. From a more clinical perspective, studying aging and dual sensory adaptation is interesting because the professionals that work in this field traditionally are trained in their specialty. And so you may have vision impairment or vision health professionals that are not really that up to date with what goes on in hearing loss. On the other side, you will have hearing professionals that are not really all that clear about how to do with the vision impairment components. And so as an example, there are rehabilitation programs in Quebec where all the professionals in dual sensory rehabilitation receive a certain level of training in the other impairment, whether that is, for example, the existence of an optometrist who knows sign language. So it is this kind of more inclusive training that is required in order to be able to serve this group specifically. From the perspective of policy, I find it very interesting that we have many eligibility criteria for vision impairment, for hearing impairment, they are often treated separately. And there is not really a consideration of the one plus one does not equal to at the policy or eligibility level. So this is only work that is now slowly emerging. And there's still much work to be done. I love talking about this topic. So I just made a few dots here. So I decided to leave it here for now, but I could probably spend just an hour talking about why I think dual sensory impairment is interesting. But for today, I want to head on and give you a mini overview of what we know about prevalence at this point in time. If we look to the Federal, the World Federation of the Deaf Blind, dual sensory loss is roughly in about 0.2 to 2% in populations across the globe. And it may depend very much on how developed the country is, the more development, the more healthcare, the less prevalence of dual sensory loss. If we focus in specifically on aging and dual sensory impairment, specifically the question of age-related dual sensory impairment, and if we look at definitions that are based on visual acuity and audiograms, you'll see that across many studies, this averages out to around 5% among older adults. But there are some subpopulations where this prevalence is higher, whether this would be, for example, in residential care, in rural populations where access to healthcare is a little bit more difficult. Individuals with hip fractures, this value is even higher if you look at centenarians, since many of these impairments are, of course, age-related. I also wanted to point out some interesting work that has been done by one of our team members, Don Guthrie, that has access to the inter-right data in Ontario. And so here, specifically, what you see in the figures are the proportion or the percentage of people that are affected with a vision impairment, a hearing impairment, or a cognitive impairment in home care in Ontario or in long-term care in Ontario. Now, the overlap of any of these figures shows you the people that, for example, would have vision loss and hearing loss, that would have hearing loss and cognitive impairment, vision loss and cognitive impairment, or the triple threat by being affected by all three. When we now consider home care and long-term care a little bit on a continuum, meaning health may be declining going from home care to long-term care, an interesting tendency we see is that the number of people with just sensory loss, meaning vision, hearing, or dual, is actually declining when we look into long-term care. That is because there's an interesting and important increase of those sensory impairments as they are linked to cognitive impairment. So the double or triple threat that includes cognitive impairment seems to be going up quite a bit as health declines and people require long-term care. It does matter whether or not somebody is affected by combined vision and hearing loss specifically in the context of mortality. This is some work out of Iceland that has shown this link. I found it interesting also that this was very recently, just two months ago, considered in the context of vision impairment as well. However, what is fascinating is that this does not always easily replicate. And so here's a study, for example, that after controlling for various variables ends up indicating that only olfactory impairment stays related to mortality. The reason I'm bringing this up here is that even though our team focusing on sensory cognitive aging is vision, hearing dominant, one of the things we will need to consider are the other senses. And it turns out that the story may not just stop with vision and hearing, but considering senses like olfaction, for example, has become more common to be included in larger studies as well. Now back to vision and hearing in the CLSA. For those of you who are not that familiar with the measurement of these variables in the CLSA, for hearing there are performance-based measures including an audiogram, which is conducted across various frequencies. And so in such an audiogram you would see how the frequencies of the tones increases so the tones get higher as you go across the x-axis. And then as you go down here on the y-axis, the volume increases. And what you would basically measure is that a hearing loss of decibel zero would indicate normal hearing. As this curve sinks lower down, you have increased hearing loss as you require more volume to hear these pure tones. This S shape actually in the figure is a very classic shape that you would see with somebody who has each related hearing loss where the higher frequencies are affected much earlier before the lower frequencies are affected. In addition to this, we have self-reported hearing where people answer the question, is your hearing, using a hearing aid, if you use one, excellent, very good, good, very poor. And we have another interesting question which actually focuses on difficulties following a conversation if there is background noise such as TV radio or children playing even if using a hearing aid as usual. So this is a little bit different philosophically because hearing may actually be good under ideal conditions in an audio booth, for example, but life does not happen in an audio booth. And so this question is specifically designed to get a little bit more at the everyday functioning of these people. You will also see later on when we talk about pure tone averages, what is done is that some of these values across the audiogram are summed up and divided and that mean value is what we will be using. In terms of vision, people are reading an eye chart. Most people will be familiar with this. The performance on the vision chart in the CLSA is either provided both with habitual correction, which is basically what people wear when they come to the session, to data collection. And then there's also an alternative way of measuring this with pinhole, which basically solves an optical problem in case there is a problem with refraction just for the purpose of acuity measurement. So the pinhole is the physiologically best possible acuity, whereas the habitual correction is the acuity that people live with every day. They also have a vision self report question where we ask if your eyesight using glasses or corrective lenses if you use them is excellent, very good, fair or poor. I'm pointing out these objective and subjective measures because one of my central messages today will be that these two things are not at all the same and that we do want to look at them together and that is what we're going next. Now, the lovely Ellen Freeman and her lab have already done a lot of work on the vision data and have already Ellen herself has given CLSA talk about a year and a half ago and there have been two important publications that have come out of this data set. Two things, three things I want to highlight from this work is that specific issues working with an acuity cutoff of 2040 which is very common in epidemiology. This is a value that is often used and it is monocular in the better eye with pinhold correction which basically is the optimal best vision that is possible for these people in the study. Prevalence ranged quite a bit within Canada across the different provinces but we have an average of about 5.7% in our data set. I encourage you to look at this presentation because it's actually very, very good. It turns out there also was already a hearing presentation a little while ago, a year before Ellen, on some of the tracking cohort data and this was done by two members of our team, Kathy Curafuller and Paul Mick, also with a resulting publication that you can look up to and you can also access this presentation via YouTube directly and you'll see here for example some of the information about how the pure tone averages were calculated and across which frequencies. I will leave that here for now because I will be speaking more about the hearing measures later on. Then of course we come to this important question of how do we define our vision, hearing and dual sensory measures and we decided to be as open-minded and inclusive and creative as we could. It turns out since the focus of the team is very much on the functionality, the everyday life, the social experience of these individuals we decided to prioritize the habitual correction meaning the kind of vision that people have when they walk into the room with the glasses that they have on their face and to do this with binocular meaning both eyes are open to be as close to their everyday functioning as possible. The first threshold that we're dealing with at times is 0.2 log mar which is mild, mild visual impairment for those of you who are familiar with the clinical terms this would be an acuity of 2032 or 6 over 10. This usually would be an acuity that is interesting from a clinical perspective because if somebody demonstrates with the security and it is not refractable then we would investigate further. The second threshold we use is 0.3 which is very common in epidemiology also used by Ellen Freeman earlier on and then we used 0.48 which is very interesting in terms of the local impact because not only is it the definition of the World Health Organization for moderate vision impairment but it's also the eligibility criteria for example in Quebec for vision rehabilitation services. For hearing impairment now we're looking at unaided audiograms where we're looking at these decibel hearing loss values the average across four of these frequencies whereby values between 25 and 40 would be considered mild 40 to 60 moderate and then about 60 we would call them severe and this is also based on the World Health Organization and so now we can come up with various ways of combining these vision and hearing thresholds and what I need to point out is that the one that I of course being an impairment researcher would have found the most interesting are the combination of the most serious levels of impairment but it turns out in the CLSA data only 89 people fell into this category and so we were extremely limited with the kind of analyses that we could do however we decided to include this in our descriptives anyway since we have plans over the long term to see who ends up in this more severe category and why. All right for those of you who are new to the CLSA data we're specifically dealing with the comprehensive cohort in this analysis of around 30 000 people across the country that are between the ages of 45 and 85 they all came into one of the 11 data collection sites in order to have the vision and hearing measures administered so this is not data that comes through the telephone and because we require people that have both these performance of behavior based measures like acuity and audiogram as well as the self-report measures for both vision and hearing our total sample size for our analysis today was 29 000 and two participants which is 96.4 percent of the data so what I will show you today are the different distributions of these the prevalence of these impairments and then look at the objective for these these behavioral versus subjective measures how they hang together in vision hearing and dual sensory loss I hope by then I will have convinced you that you need to use both in order to get a better idea of what these people are experiencing and then at the end I will make a quick link to some of our cognitive analysis to give you sort of a taste for the next presentation that will hopefully be proposed by our team members as well so a little while ago at the very beginning we just decided to make sort of a scatter plot as you look across the x-axis here the pure tone averages get higher meaning which hearing impairment gets worse as you go across to the right same for vision it gets worse as you go across on the y-axis and so you can already tell from the distribution of the data that the large majority of the participants in the CSA actually have very good hearing and vision these are all thresholds for very mild impairment so in the aid the proportion of people that would have moderate or severe loss in both senses is extremely small so like I said earlier this limits a little bit of what we can do in terms of the analysis I also wanted to show you how this would compare for example with the population of people that are eligible and receiving dual sensory impairment rehabilitation in this case in Montreal so here the axes are the same hearing loss and vision loss increase and they are provided across the entire measurable range whereby at the very top right you would have classic cases of true deaf blindness people who have neither light perception nor sound perception if we now put our clsa data into this figure you will see that we are really very much on the high functioning very healthy range and there are very few people that actually would even be eligible or fall into the rehabilitation range but I will come back to this slide a little bit later because this is more important in the context of how we want to treat the data as we get additional waves over time so here we are in the world of prevalence to give you an idea of how the participants are distributed within the data and also how this might extrapolate to the Canadian population so what you will see here are dashed lines that give us an actual prevalence count and that is the left side of the axes and you will see that this is in thousands of the population because we're using our calculation to extrapolate how many thousands of people that would be in the Canadian population overall specifically age 45 to 85 you will have the solid lines which give you the proportion of the population and then we have males in blue and females in red so you can see that if we use the milder threshold of course the prevalence goes up quite a bit higher than we would with the moderate that is good news you know there are fewer people that have this moderate or severe impairment you can also see how this impairment starts roughly in the 65 to 70 range that is when the numbers really start going up if we now plot the data for vision you will see that the pattern is relatively similar again we have our milder threshold up here our more moderate to severe threshold a little bit lower and again the increase starts going up really more after the age of 65 70 where we see these numbers increase now these are people that only have a vision or only have a hearing impairment according to our objective measures of acuity and audiogram if we now put this together and look at the people that report both of these impairments you will see that the pattern is relatively simple similar however the numbers themselves and the percentages are lower so this population is much smaller but otherwise tendency in the trend is relatively the same again starting at around the age of 70 these numbers really start going up so now we were interested in how our objective and our subjective measures hang together what you will see in these graphs here is so we have a panel for each 10 years of age 45 to 54 55 64 65 to 74 and then above the age of 75 and so what we're plotting here are the answers to the qualitative question we asked is your eyesight in this case using glasses excellent very good good fair or poor now these answers are plotted as a function of their visual acuity in this case and so you will see the orange line is our mild threshold and the blue line is our moderate to severe threshold now something very interesting happens if you have normal acuity so this is good acuity according to our standards negative numbers actually mean that you have acuity that is a little better than 2020 you will see that there are people that fall into the normal acuity range in all age groups who tell us that their vision is fair or poor or non-existent however on their acuity measures they're doing well this happens in all age groups even though this happens less in the oldest group now the flip side to this is that we have people who according to our objective measures fall above the blue line so these are people that really have acuities that are you know not so great however when we ask them how's your vision they tell us that their vision is excellent very good or good now this is less likely to happen in the younger crowd this is more likely to happen in the older crowd and I will come back to this a little bit later because this finding appears in different contexts when we now look at the hearing story of course the graph is constructed the same way we have our four groups of participants here we're looking at the question of is your hearing using a hearing aid if you use one excellent very good good fair or poor and now what we're plotting on the y-axis are their pure tone averages where again a hearing loss of zero would indicate normal hearing negative numbers are actually better than normal here's our cutoff for the mild and our cutoff for the moderate to severe hearing loss and something similar happens if we look at people that fall into the normal audiogram range you can get any answer on their perception of their hearing loss and so it turns out that in the younger group this is rather prevalent all over the five possibilities you'll see that the trend in the oldest group goes in the direction that we would expect that people whose audiograms is poorer would also perceive it as poor but in the younger 45 to 765 group there's a lot of variability in here if we also now turn this upside down for those participants that perceive their hearing as poor right their personal perception of their hearing is poor they can have almost any value on the audiogram that is possible again we would expect that you know these values would generally be higher on the audiogram and we do see that in the oldest and the two oldest groups but again in the two youngest groups the range is quite large and it's quite interesting that our behavioral measures and our subjective reports can vary this much so now taking a different perspective on this entire dataset here we're looking at all 29 thousand and two participants and whether or not they self-report a sensory impairment and so the blue bars are the people that report no sensory impairment that's great we're just going to ignore that for now it is just another way of how this data set tells us that this is a rather healthy and happy population I'm now going to delete these blue bars and just take a closer look at the individuals that actually report some kind of vision hearing or do a lot so this is the same graph only removing people that do not report any sensory loss the first thing that we observe is that there's a slight increase in the perceived visual impairment as we go across age groups in this case the age groups are divided down into chunks of five years and you will see as we go up it's an increase in the proportion of the participants in the study we see a larger increase in perceived hearing impairment with each year this is where relevant replicating findings that are relatively well known so that's good to know that our people behave the way we would expect them to we see a relatively slight increase in the report of dual sensory loss but it is there so now the next step is instead of looking at all 29 000 I am really more interested in the people that have dual sensory loss and so these are people that have both poor audiograms and poor visual acuities there are only 1624 of them and the first thing that jumps out is that no matter what age group more than half of them report no sensory loss so a part of this might be able to be explained in this famous difference between pinhole acuity versus habitual correction because these may be people that just cross our mild threshold for vision loss for example but if we would properly refract them their acuity may actually be better so they may not actually have the perception of their dual sensory loss because for some proportion of these people they actually don't have it but it is quite large this difference between the people that perceive this and the people that don't the next thing that we were thinking is well it could also be that these people are not reporting their sensory loss because they have successfully adapted to it that is possible specifically here is the limitation that hearing impairment is measured on an audiogram without wearing the hearing aid however the questions that we ask are with their hearing aid and so they may actually not experience a self-reported impairment simply because the hearing aid or whatever other strategies they may employ actually correct the problems that they have it could be that some of them are in denial the psychologist in me says that's worthwhile investigating but there's also some interesting things that we can find in the literature to explain it some of this may have to do with response shifts whereby older adults have been known to do downward comparisons in terms of their health to those who are worse off and so even though they may experience part of their impairment they may also experience that it is not as bad as insert somebody who is worse off and so they perceive themselves as high functioning compared to those where it's worse this is also similar in the context of disability paradox for example where people that from the outside would be perceived as having very low quality of life themselves actually perceive that they have quite high quality of life because they also will engage in downward comparison this is definitely a field that I think is worthwhile to follow further and I'm very curious how this will develop as we have other measure waves of data as we go forward so the same story now view that from a slightly different perspective here again we're looking at the proportion of people with hearing loss now the orange bars represent their loss according to their audiogram and the little symbols their responses to the questions that we ask so the first thing we see is that both mild and moderate audiogram increases we're just now plotting the same data in a different way we also observe that you know the self-reported hearing increases problems increase with age and also the trouble with hearing in noise but it turns out that that is actually a much larger issue so it turns out this is also reported in you know at least 30% of the sample in people whose audiograms are quite lovely right so there are no problems according to the audiogram now something happens around age 60 where the audiogram percentage of people with trouble catches up with the self-report of people that have trouble hearing but then it reverses and it reports more trouble on the audiogram than is perceived by individual this is similar a point like this somewhere around 70 75 where this happens where the audiogram catches up with the perceived difficulty in noise what this really then means is could it be that somewhere here the audiogram is overestimating the self-perceived quality of the hearing and overestimating the trouble perceived in noise whereas before that it is underestimating these things and i'm putting these estimates in quotation marks because the the real question behind this is which one is the reality that we say is over or under and that depends very much on your perspective whether you start out from the perspective of the person who is experiencing this making their reality the gold standard or whether we start from a more medical measurement model where the objective or the behavioral measure is the starting point for the impairment if we look at the vision data we find something very similar here the orange bars are our habitual corrections acuity and the gray ones are the pinhole corrected acuities so the best possible acuities optically this is also the data that was reported by the freeman team already and so you will see that you know there is an increase again in both of these types of acuity in the prevalence and it is the difference between those two that is refractable so all people really would need to go get the right glasses to come down to that optimal level and again what we see is that there is this slight increase in self-reported visual impairment but by far not as much as we would expect according to the acuity measures and again we find something odd happening at the age of 60 where the self-report and the optimal acuity sort of catch up with each other and we then ask this question about what is oh sorry what is over and what is underestimating because up till here your refracted best possible acuity would actually underestimate the problems that are being experienced whereas thereafter they would overestimate if we now focus in on the dual sensory data so these are people that have both problems with acuity and uh audiogram we see the same type of pattern we have this exponential increase across the age groups and then we have this mild slow increase according to their self-report and surprise surprise somewhere around 60 again we find that breaking point where the objective measures and the behavioral measures somehow underestimate what the perception is of the participants whereas thereafter they overestimate so now i hope i have kind of convinced you that neither one of these measures alone is telling the entire story and so i want to give you just a brief mini preview into some of the cognitive work that we've been conducting uh specifically uh our team members have been working using a principal component analysis for the cognition measures the first one of these principal components focuses on executive function the tests that are included in this measure are animal fluency where people have to report a number of different animals within second 60 seconds the controlled all world association tests where you give a specific letter and ask people to list words that start with this letter as well as a mental alternation test where people are just asked to alternate numerical and alpha letters meaning one a two b three c and so on through the entire alphabet and finally there's a stoop test that is included where people are asked to report the color of the ink of the text not the the color itself that is written so in this case people would be asked to report yellow even though the words are green the second principal component measure that is included is the rate auditory verbal learning test which basically asks people to remember 15 words they get to recall them immediately and then they are also asked for a delayed recall after about five minutes and so these measures as well as their ratios are included in the principal component measure for memory so now when we put the cognition measures in the context of the sensory measures something interesting happens what you have here in the vision graph on the left is you have these include these increasing pure tone averages for the audiogram so as we go across to the right the audiogram gets poorer as we go up on the left we have the principal component score and up in this case is better so what ends up happening is that we see an association between a decline of the cognitive score as the audiogram gets worse so it seems to be that increased hearing impairment in this case is associated with a decrease in the executive function score we see a similar pattern when we look at pinhole corrected acuity in this case here however this effect is not as strong the slope of this line is not as steep but it is present so for the executive function component both vision and hearing demonstrate this association with declines in the principal component score when we now go to memory it turns out that we find the same pattern in the hearing data so as hearing impairment thresholds in this case decline they are associated with poorer memory scores for the principal component analysis but we do not see this change in the vision measure this is an interesting difference between the two senses and I think that in itself is worth a long conversation ideally with a glass of wine about why vision and hearing differ here there are some theories out there that are exploring for example the effect of listening effort and whether that is related to difficulties in encoding information I will leave it there for today given time but this is basically one of the starting points for the cognitive and social analysis that the rest of our team is conducting right now I want to end with a few mini extrapolations of the data to the Canadian population using our very mild thresholds our data would indicate that for males for example there would be roughly 1.5 million Canadians 45 to 85 that are affected with a mild hearing loss 1.8 with a mild vision loss in this component and 570,000 with both impairments keep in mind these are the numbers for the mild thresholds we see a similar pattern for females however we have a larger number in vision loss 2.2 and a smaller number in hearing loss so the hearing loss is more prevalent in men and then another 450,000 ladies that have both impairments in this case if we look at changes across the census data in Canada this would indicate that we have an increase in the prevalence of sensory loss from about 8.7 to 16.9 percent just between 2011 and 16 and so when you look at the hearing loss and the dual loss prevalence specifically the increase is more exponential and linear for vision for males we see that we are likely more to observe more hearing loss and dual sensory impairment whereas vision loss was more prevalent in females and that is also part of the presentation that was already given by Ellen Freeman the strengths of our project is that of course we have access to a large sample here and a white age range specifically in the context of mild sensory loss turns out this mild level is not that often studied and the reason we decided to pursue this is specifically whether we will be able in consecutive analyses over other data points to see how predictive this mild sensory loss may be it also turns out that most of those who have a sensory loss don't recognize report or experience this specifically only 8 percent of those who have poor audiograms and acutes actually report this impairment and this is a question that I personally want to pursue a little further as well the weaknesses in our analyses are of course that our measures of vision hearing are rather simplistic they are you know limited within the context of such a large study we are not able to do that many tests there is nothing on speech perception and noise contrast sensitivity visual field size all other things that could give us additional information from the sensory perspective it is actually interesting that the sample is a little bit biased because the protocol is not available for example in american sign language or long just in kebek so people with a hearing loss who are culturally deaf are not included in the sample another weakness a strength and a weakness is this very mild impairment at baseline people are very healthy which is for them excellent but that does not make them fully representative of our current population now here are the two manuscripts listed that we are currently have in the mill that contain most of the content that I showed you today we're also working on some specific analyses that go after the age effects in these in these data and of course now to point you towards the cognitive and social piece of the study there are a few manuscripts in the making that specifically focus on sensory cognitive and sensory cognitive social factors that I'm convinced will be part of another presentation at some point in the future I want to give a quick sales pitch for some of the work of our postdoc Andrea Urqueta Alfaro who is working with the inter-right data and is trying to link some of the patterns that we observe in the clsa with the inter-right as well so now the next steps we like it when life is complicated so we started exploring some questions about multi-morbidity the number of studies that clearly identify vision and hearing impairment in multi-morbidity models is still relatively small and so here Paul Mick has already started doing some analyses about the prevalence of vision loss hearing loss and problems with balance in the data set as well so there's more to come I spoke earlier about you know given that most people have relatively good senses I'm very interested how over the coming data sets these people may move further up in our dual sensory space here and which kind of variables might be predictive of this and also how these sensory variables may predict changes in cognitive decline social participation loneliness and the world is your oyster we can go further with this as we want now there's a bit of an open invitation for those of you who would like to include the vision and hearing measures in your study feel free to find any and all of us because we are quite in the spirit of collaborating with anybody who would like to and I thank a long list of numbers of people that have contributed to this work I only get to be the spokesperson today but the real work is done by many many others and that is my presentation for today all right now let me see how I can move myself back to the team I think you should leave your your slides up in case we want to talk through them for the question and answer session so thank you very much for that excellent presentation I thought it was really fabulous I've really really enjoyed that I'd like to open it up for questions now just a reminder we're muting remains on but enter your questions into the Q&A area in the bottom right hand corner of the WebEx window please go ahead and type in your questions and I will read them out and talk them through so while we're waiting for people to enter a couple of questions I guess I will ask one of my own so at the very very beginning you presented three views of kind of the cognition sensory loss connections do you have your do you have your own kind of theory or does this preliminary work begin to make you support one or the other are you developing your own as you go along yeah this is an excellent question and I think that the answer to this is different from week to week I am generally a believer that things are not as simple necessary as we would like them to be I find the common cause theory very interesting because especially envisioned it's very interesting that we see anatomical changes in the retina that have been correlated to various changes in cognition and that is fascinating from the perspective that the retina is really an observable component of the central nervous system so if this common cause view indeed carries then this would support this idea that the retina would change together with cognition that is as far as I'm going to that I'm going to commit today but I think that it's likely all of the above and likely a complicated picture and does that fit in for the the memory principal component analysis having the different connection the hearing yeah so that's this is where especially the memory component would speak against this because then we would of course want to see declines in both of those so I think that one of the questions we will need to ask here is whether different cognitive functions may have you know different relationships to the senses this is where I like this this idea of for example the energy that is allocated the effort that is engaged in listening to something with a hearing impairment the amount of energy that is required to this then is taken away from the ability to encode this information we don't have much data yet to see whether this also is the case in vision we're trying to do something like this right now that's really fabulous so we do have a question so Lawrence Martin asked is it possible that hearing and vision difficulties are not correlated to acuity and younger participants are really linked to other aspects of perception or processing for auditory and visual information and Dr. Wittish can you see the question there at the Q&A panel while I am screen sharing I don't see the questions I it's interesting to ask this question whether these relationships are different in the younger than the older crowd now I'm going to say by younger crowd I'm actually going to go younger than 45 and outside of the state context our expectation generally is in the younger population that there shouldn't really be much of a relation between vision and hearing given that they have the senses are so healthy it's really in the moment that some impairment sets on and one of the things that I have completely ignored today is the actual cause of this hearing loss or of this vision loss so if we go underneath and we look at conditions like glaucoma for example or macular degeneration that are actually attacking components of the nerve or of the retina itself this may be a very different relationship than if we look at impairments of the cornea right it is much harder to make a case for a neuro decline that is linked to changes in the cornea and so this would need a new level of subtlety in our analysis that we consider the sources of the impairment while we look at their relationships certainly well I would like to thank you again for such a fascinating presentation I look forward to your future work very significantly I'm going to go ahead and do our closing here but if you would like to stay on and we can continue to answer questions after the closing so I'd like to remind everyone that CLSA data access request applications are ongoing the next deadline for applications is on June 5th so coming out very soon please visit the CLSA website under data access to review available data further information and details about the application process I'd also like to remind everyone to complete their survey located in the polling option and present here if you have any questions or concerns that you can we can help you with write us in the chat box and we can help also remember that the CLSA promotes this webinar series using the hashtag CLSA webinar and we invite you to follow us on twitter finally we will have our final presentation of the 2018-2019 CLSA webinar series on CLSA dietary data descriptions and examples of youth and a study of dietary consumption and cognitive performance we'll welcome our next speakers Dr. Nancy Press a registered dietitian and assistant professor in the department of community health sciences and the University of Sherbrooke and Dr. Andrew Leigh Tessiar a registered dietitian in Quebec and a PhD candidate nutrition at McGill University please go to our CLSA website to register for our webinar series soon and join us for this next webinar thank you again for attending today's presentation and thank you so much Dr. Widdich for being here and sharing your work thank you thank you for having me so we'll go back to the Q&A questions and I don't see any other questions posted um for the next couple of minutes if anybody wants to post questions then we will plan on answering them and sending them out um through your email link so feel free to continue to ask questions yes there is a question under the chat box got it from Renu Minnes uh does the CLSA data have individuals calling to the client and if so how accurate is the self-reporting information on dual sensory impairment so I should be able to see this question now right if I'm looking I don't know I don't see it but um can you open the chat uh oh yeah yeah so uh CLSA does have individuals with cognitive decline so the question would be how accurate is the self-reporting information on dual sensory impairment in people that have a cognitive impairment that may be yeah so what's interesting about that is that we've actually addressed this in the interim data specifically where we look at responses to the Montreal cognitive assessment which is a screening tool for the presence of mild cognitive loss and we do this in people where we know that they have a confirmed vision loss only hearing loss only or dual sensory loss only to see whether there are differences across the ability to detect to detect their cognitive impairment so it turns out that the accuracy of the test itself is uh very good sensitivity and specificity are above 95 percent for uh the interrive measure in the context of comparing it uh what's also interesting is that across all our groups the percentage of failing the cognitive test is quantized it's relatively equal actually so uh we're still pursuing this a little bit further um it would intuitively make sense that people who have some cognitive issues may not be as good as identifying their sensory status mind you comparing that now to what I just showed you it turns out that people in general are quite variable about this so I do not yet have enough data to say that this is worse in case that it's a cognitive change thank you so Dr Wittich can you stay and answer a couple more questions or what if we'd like to yes oh great that's fabulous so Sabine dear asks wonderful talk Dr Wittich and you're talking mentioned the likelihood of action as a sense that may play more of a role than originally thought how can we explore this further and I'll I'll tack on my uh my question along this line as well which is um um maybe even taste taste problems and zero stomia as a as a sensory deficit yes so if we go back to this idea of the under of the all causing factor uh a good theory that the frail frailty people for example also pursue it would make complete sense that we should measure more than just vision and hearing because some of these changes may be very subtle especially early on I would go way beyond all faction at this point I would say that we've got multiple senses measures of balance could be extremely important here I would find it interesting to get measures of tactile ability whether these are static or dynamic because they may be indicating of some more peripheral losses specifically early peripheral losses in the fingers for example so I think that somehow we have a tiger by the tail here I think that the information that is available and the measurable at the sensory level may have the potential to become a really interesting biomarker for changes in cognition very interesting and the final question here from the Mesa A for the behavioral subjective measures you mentioned that younger people perceive difficulties hearing that are not captured by audiogram are there sex differences or just age differences so I think your final slides kind of reviewed that but if you could go over it again yeah so the sex differences that we see that we reported about the proportion of people that the vision impairments are definitely more prevalent among women and the dual and hearing is more prevalent with the men uh the and these are we're replicating Ellen Freeman's work and we're replicating other people's work as well here um the I've lost my train of thought now the question was about sex differences between the subjective versus objective yeah so the the we didn't there are no uh outstanding or outrageous differences in the self reports across the sexes uh that would become that were statistically significant in this case I think that we generally underestimate the level of impairment that people experience in noise you don't need to have a sensory impairment for noise to be an important factor anybody who's had dinner in a restaurant that is too noisy will be able to report on that so we did not find sex differences at that level and then I will answer I'll ask this very last question and then we'll say goodbye from Sin Tong Lao can you please go back to the slide where you compared memory performance I don't think that you're sharing your slides anymore but maybe you can talk through it where you compared memory performance with visual and hearing acuity can you please elaborate on how the memory tests were performed I'm curious to know that if the memory test involved more of an auditory component than a visual component I see for example listening to word stimuli rather than reading words and I also'd like to remind everybody that this recording of the webinar will be posted and sent to all attendees in the future yes so the answer to this question is actually quite complicated and I will refer people to the publication that will come out of this but we did very specifically look at all the cognitive measures to see whether or not the predominant sense required for the test includes hearing and or vision so for example we would quantify the stoop test as a visual task because the response depends on a visual component during testing however the rabble for example the auditory verbal learning test does not have a visual component it depends entirely on hearing only because people need to hear the word and encode them so this was considered and separated whenever possible so we have graphs that are similar to the ones that we have here that are separated by what kind of sensory capacity was necessary for for doing the test of course all of them require some level of hearing but some of them required vision in addition like the stoop so we will present that in much more detail interesting I see the the complexity there behind that question well thank you again and we really do appreciate your time and look forward to having you back to continue to talk about the subject particularly with the longitudinal data thank you again thank you everybody