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Perda sensorial dupla e declínio cognitivo: evidências do estudo EpiFloripa Idoso
Dual sensory loss and cognitive decline: evidence from the EpiFloripa Aging study
Pérdida sensorial doble y deterioro cognitivo: evidencias del estudio EpiFloripa Idoso


Danúbia Hillesheim
https://orcid.org/0000-0003-0600-4072
Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina.
nubiah12@yahoo.com.br

Thamara Hubler Figueiró
https://orcid.org/0000-0001-6502-1396
Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina.
thamara.hf@gmail.com

Viviane Nogueira de Zorzi
https://orcid.org/0000-0002-6555-8772
Programa de Pós-Graduação em Educação Física, Universidade Federal de Santa Catarina.
vivianedezorzi24@gmail.com

Anna Quialheiro
https://orcid.org/0000-0002-4168-6585
Instituto Politécnico de Saúde do Norte de Portugal, CESPU.
annaqas@gmail.com

Ana Luiza Curi Hallal
https://orcid.org/0000-0003-4761-0001
Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal de Santa Catarina.
anacuri@gmail.com

Eleonora d´Orsi
https://orcid.org/0000-0003-2027-1089
Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina.
eleonora.dorsi@ufsc.br

RESUMO
O objetivo deste estudo foi estimar a associação entre perda sensorial dupla (auditiva e visual) e declínio cognitivo em pessoas idosas do sul do Brasil. Trata-se de uma pesquisa transversal, realizada com dados da 3ª onda do estudo EpiFloripa Idoso (2017/2019), envolvendo pessoas com 60 anos ou mais que vivem em áreas urbanas de Florianópolis, SC. A variável dependente foi o declínio cognitivo, avaliado através do Mini Exame do Estado Mental, enquanto a variável independente principal foi a perda sensorial. Realizou-se análise de Regressão Logística. Participaram 1.335 idosos, observando-se maior frequência de mulheres (63,0%) e indivíduos de raça/cor branca (88,3%). Em relação à perda sensorial, 10,8% dos indivíduos apresentaram perda sensorial dupla e 20,5% declínio cognitivo. No modelo final, indivíduos com perda sensorial dupla apresentaram uma chance 4,21 vezes maior (IC95%: 2,06 – 8,59) de declínio cognitivo. Indivíduos com perda auditiva isolada (OR: 1,98; IC95%: 1,13 – 3,45) também tiveram maior probabilidade do desfecho. Pessoas idosas com perda auditiva e visual apresentaram 321% maior chance de ter declínio cognitivo. Esses resultados sugerem que a perda simultânea de duas funções sensoriais pode potencializar o impacto na capacidade cognitiva de pessoas idosas.
Palavras-chave: Privação Sensorial; Estudos Transversais; Cognição; Idoso; Envelhecimento.

ABSTRACT
The aim of this study was to determine the association between dual sensory loss (hearing and vision) and cognitive decline in older adults living in the South of Brazil. We conducted a cross-sectional study using data from the third wave of the EpiFloripa Aging study (2017/2019), involving individuals aged 60 years and over living in urban areas of Florianópolis, in the state of Santa Catarina. The dependent variable was cognitive decline, assessed using the Mini-Mental State Examination, while the main independent variable was sensory loss. Logistic regression analysis was performed. A total of 1,335 older adults participated, most of whom were women (63.0%) and white (88.3%). The findings show that 10.8% of the respondents had dual sensory loss and 20.5% had cognitive decline. In the final model, individuals with dual sensory loss had 4.21 times higher odds (95% CI: 2.06–8.59) of cognitive decline. Participants with just hearing loss (OR: 1.98; 95% CI: 1.13–3.45) also had higher odds of the outcome. Respondents with combined hearing and vision loss had 321% higher odds of having cognitive decline. These findings suggest that combined loss of two sensory functions may exacerbate the impact of sensory loss on the cognitive capacity of older adults.

Keywords: Sensory Deprivation; Cross-Sectional Studies; Cognition; Older People; Aging.

RESUMEN
Este estudio evaluó la asociación entre pérdida sensorial doble (auditiva y visual) y deterioro cognitivo en mayores del sur de Brasil. Se realizó un análisis transversal con datos de la tercera ola del estudio EpiFloripa Idoso (2017/2019), abarcando adultos de 60 años o más en Florianópolis, SC. El deterioro cognitivo, variable dependiente, se midió mediante el Mini Examen del Estado Mental, y la pérdida sensorial fue la principal variable independiente. Se aplicó regresión logística. Participaron 1.335 personas, mayoritariamente mujeres (63,0%) y de raza blanca (88,3%). El 10,8% tenía pérdida sensorial doble, y el 20,5% deterioro cognitivo. En el modelo final, individuos con pérdida sensorial doble tuvieron una probabilidad 4,21 veces mayor (IC95%: 2,06–8,59) de deterioro cognitivo. Aquellos con pérdida auditiva aislada (OR: 1,98; IC95%: 1,13–3,45) también mostraron mayor riesgo. Los mayores con pérdida sensorial combinada tuvieron un 321% más de probabilidad de deterioro cognitivo, indicando que la pérdida simultánea de dos funciones sensoriales incrementa significativamente el impacto en la cognición.
Palabras clave: Privación sensorial; Estudios transversales; Cognición; Anciano; Envejecimiento.

INTRODUCTION

Estimates show that, by 2030, 1 in 6 people in the world will be aged 60 years or over1. In Brazil, in 2021, this age group represented 14.7% of the resident population, totaling approximately 31.23 million2. These changes in the population age structure are posing challenges to health systems and social policy at the global level3.
The aging process is usually accompanied by a decline in physical, immunological and sensory function4,5,6, especially hearing and vison. With aging, there is a growing tendency towards vision and hearing impairment7, with over 65% of adults above 60 years of age experience hearing loss8. In addition, the number of individuals affected by age-related eye conditions is expected to rise significantly. The number of people with glaucoma, for example, is projected to increase from 76 million in 2020 to 95.4 million in 2030 (25.5%), while the numbers of cases of age-related macular degeneration is estimated to increase from 195.6 million to 243.4 million in the same period (24.4%)9.
These types of sensory impairments not only adversely affect quality of life10 but are also strongly associated with a number of other health conditions, including cognitive decline7, which is prevalent among older people. In 2019, in Brazil, 1,757,480 older people were living with dementia and at least 2,271,314 individuals had some degree of cognitive impairment11.
Previous studies have reported that both hearing loss and visual loss are risk factors for cognitive decline12-15. The 2024 update of the report of the Lancet Commission on dementia included untreated vision loss among the risk factors for dementia, along with hearing loss, as previously reported, highlighting that preserving sensory health is a key strategy for reducing dementia risk16.
However, international evidence suggests that combined vision and hearing impairment, commonly termed dual sensory loss (DSL) or dual sensory impairment (DSI)7, can substantially increase the risk of cognitive decline in older people17. No studies investigating the prevalence of DSL or exploring this specific relationship in the older population in Brazil were found. In addition, there is a gap in evidence from low and middle-income countries, with the characteristics and challenges faced by older people in these countries differing significantly from those observed in high-income nations7.
In light of the above, the aim of this study was to determine the association between DSL (vision and hearing) and cognitive decline in older people living in the South of Brazil.

METHODS

Study design and type
We conducted a cross-sectional study using data from the EpiFloripa Aging study (https://epifloripaidoso.paginas.ufsc.br). The EpiFloripa Aging study is a population/household-based cohort of people aged 60 years and over living in urban areas in the municipality of Florianópolis, Santa Catarina. The data used for the present study were collected in the third wave, consisting of 1,335 household interviews conducted with elderly people between 2017 and 2019. The data were restricted to this wave because it was the only period in which information was collected on the interviewees\' self-perception of vision.
Details of the sampling plan, operational aspects of the household interviews and strategies employed in the third wave of the survey (2017-2019) can be found in Confortin et al. (2023)18.

Dependent variable
The dependent variable was cognitive decline, which was assessed using the Mini-Mental State Examination19. Scores of ≤19 in older people without any education and ≤23 among those with education were deemed to indicate cognitive decline20.

Independent variable
The main independent variable was DSL based on self-reported hearing loss21 and self-reported vision loss, assessed using a Likert scale, as proposed by previous publications22-23. Self-reported hearing loss was assessed used the following question: “In general [considering the use of hearing aids], would you say that your hearing is excellent, very good, good, fair, bad or very bad?”. Self-reported vision loss was assessed using the following question: “In general [considering the use of glasses], would you say that your vision is excellent, very good, good, fair, bad or very bad?”. These two measures of auditory and visual function were used to indicate sensory loss, where “excellent”, “very good” and “good” were considered to be without sensory loss and “fair”, “bad” and “very bad” were considered to be presence of sensory loss. The “sensory loss” variable was categorized as follow: without sensory loss (vision or hearing), just hearing loss, just vision loss and DSL.

Covariables
The following variables were selected as confounding factors based on the literature24,25: sex (male; female); age group (60-69; 70-79; 80 years or older); race/skin color (white; brown; black; yellow; indigenous); and per capita income in minimum wages (≤1; 1.1-5; 5.1-10; 10 or more). Given that both sensory aspects and cognitive function can be affected by behavior and health status26-29, we also included the following variables: smoking; alcohol abuse; degree of disability in activities of daily living (ADLs); presence or absence of systemic arterial hypertension and diabetes mellitus; and leisure-time physical activity.
Smoking was assessed using the question “Do you or have you ever smoked cigarettes?” (no; former smoker; smoker). Alcohol abuse was assessed using the Alcohol Use Disorders Identification Test-Concise (AUDIT-C)30, which consists of three questions with a total score of 12, where a score of six or more indicates high risk and alcohol abuse in both sexes for the purposes of this study. The presence of some degree of disability in ADLs was assessed using the Brazilian Multidimensional Function Assessment Questionnaire, adapted from the Old Americans Resources and Services (BOMFAQ/OARS) questionnaire31. The variable was moderate or severe dependency in ADLs (no; yes [≥4 ADLs]). The presence of diabetes mellitus (no; yes) and systemic arterial hypertension (no; yes) was assessed using the question: “Has a doctor or health professional ever told you that you have/had…”. Finally, moderate to vigorous physical activity (MVPA) during leisure time was defined as at least 150 minutes per week, with the variable being categorized as insufficiently active and active32.

Data analysis
The qualitative variables were described using absolute and relative frequencies and their respective 95% confidence intervals (95% CI). Differences in proportions across sample characteristics in relation to cognitive decline were determined using Pearson’s chi-square test. When the test assumptions were not met, Fisher\'s Exact Test was used. Participant characteristics were also described according to sensory status.
Strength of association was measured using odds ratios (OR), calculated by performing logistic regression analysis. The main exposure variable was adjusted for all the covariates, regardless of the p-value, using the ‘enter’ input method and adopting a 5% significance level. All analyses were performed using Stata version 14.0 (https://www.stata.com), considering the study design and database sample weight (svy command). Post-estimation analysis was performed based on the result of the Hosmer-Lemeshow test, which indicated adequate fit (Prob > chi2 = 0.9519).

Ethical aspects
The third wave of the EpiFloripa Aging study was approved by the Federal University of Santa Catarina’s Human Research Ethics Committee on March 9, 2017 (reference code CAAE 16731313.0.0000.0121, 1.957.977). The study was conducted in accordance with the ethical norms and standards set out in National Health Council Resolution 466 (December 12, 2012) and all participants signed an informed consent form.

RESULTS

The study sample consisted of 1,335 older people, most of whom were female (63.0%), white (88.3%) and had a per capita income of between 1.1 and 5 minimum wages (56.0%). More than half of the participants were non-smokers (59.8%) and did not abuse alcohol (94.6%). In addition, 34.4% of the respondents had moderate or severe levels of dependency in ADLs and only 12.0% were active (moderate to vigorous leisure time physical activity) (Table 1).
Approximately one quarter of the respondents (25.7%) reported having diabetes mellitus and 59.5% had hypertension. With regard to hearing and visual loss, 10.8% had DSL and 20.5% had probable cognitive decline. Prevalence of cognitive decline was higher among women (22.1%), people aged 80 years and over (38.6%), people who self-declared as black (38.6%) and people with a low income (36.7%) (Table 1).
Prevalence of cognitive decline was also higher among individuals with moderate or severe dependency in ADLs (39.8%), when compared to those with no dependency (10.3%) (p<0.001). The presence of diabetes mellitus and hypertension was also associated with higher frequencies of the outcome, with prevalence rates of 26.2% (p=0.012) and 23.1% (p=0.009). Insufficiently active individuals also showed a higher prevalence of cognitive decline (21.0%) than those who were physically active (9.0%) (p=0.001). Prevalence of cognitive decline was 46.5% in individuals with DSL, which is considerably higher than the rate among those without sensory loss (9.2%) (p<0.001) (Table1).



Table 2 shows the sample distribution according to the occurrence of sensory impairment. The findings show that 19.8% of individuals aged 80 or over had DSL, compared to only 6.2% in the 60-69 age group. Prevalence was highest in brown people (24.5%), while 16.7% of individuals with a low income (≤1 minimum wage) had DSL. The results show that 29.2% of individuals with probable cognitive decline had DSL, compared to only 7% among those without cognitive decline (Table 2).



Table 3 shows the results of the crude and adjusted logistic regression, conducted to determine the association between sensory loss and cognitive decline, with emphasis on DSL. In the crude analysis, individuals with DSL had 8.62 times higher odds (95% CI: 4.60 - 16.14) of having cognitive decline than individuals without loss. This difference was statistically significant. Older persons with just vision loss (OR: 2.84; 95% CI: 1.77 – 4.55) or just hearing loss (OR: 2.85; 95% CI: 1.65 – 4.93) were also more likely to have cognitive decline.
In the adjusted analysis, the magnitude of the association between DSL and cognitive decline decreased (OR: 4.21; 95% CI: 2.06 – 8.95) and the confidence intervals narrowed, suggesting increased precision of the estimates. Having just hearing loss also remained significantly associated with the outcome (OR: 1.98; 95% CI: 1.13-3.45). The crude and fully adjusted measures of association are also presented graphically in Figure 1 (Table 3 and Figure 1).

DISCUSSION

Overall prevalence of cognitive decline among individuals in the EpiFloripa Aging study 2017/2019 was 20.5% and 10.8% of the respondents had DSL. The findings also show that individuals with DSL were more likely to have cognitive decline. Respondents with just hearing loss were also more likely to have cognitive decline, although the magnitude of the association was lower.
The overall prevalence rate observed by this study is consistent with previous studies in Brazil that used the same instrument to assess cognitive decline33,34. Por example, a study with older persons in the state of Bahia found a prevalence rate of 18.7%33, while a study in Bagé, in the state of Rio Grande do Sul, reported a considerably higher prevalence rate of 34.1%34. With regard to international studies, a study using data from the Korean Longitudinal Study of Aging in South Korea reported that prevalence of cognitive decline was 11.4%35, while a systematic review of global data revealed a large variance of cognitive decline prevalence, ranging from 5.1% to 41% (median of 19.0%). The review highlighted the diversity of study contexts, the different diagnostic methods used and the complexity of making direct comparisons36.
Our findings show that prevalence of DSL was 10.8%. In contrast, in a study of individuals from European countries aged 50 years, Viljanen et al. (2014)37 found that overall prevalence was 5.9%. When the countries were assessed separately, Italy (10.3%) and Spain (9.4%) had prevalence rates similar to those in Brazil, while Switzerland (1.6%) and Sweden (1.7%) showed considerably lower levels. A study in the United States using data from the Health and Retirement Study (HRS), involving 19,618 participants, found that the prevalence of DSL was 5%24. The above findings suggest that prevalence of cognitive decline and DSL varies across different regions and populations. These variations may reflect differences in culture, socio-economic status and access to health services, as well as the use of different data collection methods.
Our findings show that individuals with DSL were more likely to have cognitive decline (OR: 4.21) than those without sensory loss. The magnitude of this association was greater than that found for just hearing loss (OR: 1.98) or just vision loss (OR= 1.75), suggesting that a possible additive interaction between these sensory impairments increases the odds of cognitive decline. The association between having just hearing loss and greater likelihood of cognitive decline (OR:1.98) was expected, being corroborated by a previous study using data from the EpiFloripa Aging study21. These results are consistent with those of studies with samples of older people in the United States38, South Korea35 and China22. A nationally representative study of 5.4 million American older adults aged 65 and over showed that DSI was associated with substantially higher odds of cognitive impairment, with older adults who had DSI having 8 times higher odds of cognitive impairment (OR= 8.16; 95% CI= 8.07, 8.25)17.
The results of this study can be explained by different mechanisms, including the hypothesis of sensory deprivation, proposed by researchers in a study using data from a longitudinal study in England39. According to this hypothesis, vision and hearing loss can negatively impact cognitive function over time by reducing opportunities to engage in cognitively stimulating interactions with the environment, which in turn can accelerate the decline of cognitive functions40,41. Another hypothesis is information degradation, which occurs when sensory signals are adversely affected, as in the case of hearing or vision loss. In this situation, the brain requires additional cognitive resources to interpret this impaired information, leading to a reduction in the resources available for other cognitive tasks, which can result in poorer cognitive performance. This hypothesis focuses on the immediate impact that reduced sensory input quality has on cognitive ability, suggesting that the additional cognitive effort required to process degraded sensory signals overloads the cognitive system41,42.
Despite these explanations, the literature has yet to fully clarify these mechanisms and their influence. A study using data from a cohort study in England found that individuals with cognitive impairment in the previous wave had 10% increased odds of self-reported bad hearing over time43. This suggests that there is a complex interaction between cognitive impairment and auditory perception, underlining the need for further research, especially longitudinal studies, to obtain a better understanding of these relationships and their impacts.
Despite the lack of understanding of these complexities, visual and hearing difficulties can be early indicators of cognitive decline39 and should be recognized as modifiable risk factors12. It is therefore essential that health services closely monitor for the onset of DSL in older people and consider this segment of the population a risk group for cognitive decline. Investments in therapeutic interventions need to be made, such as properly adjusted personal sound amplification devices (PSADs) and strategies to improve visual health, encompassing both clinical approaches and surgical procedures. Such measures can contribute to improving quality of life and the preservation of cognitive health among people with sensory impairments.
A meta-analysis found that the use of hearing restorative devices was a protective factor for cognitive decline, being associated with a 19% decrease in long-term cognitive decline and a 3% improvement in short-term cognitive test scores assessing general cognition geral44. The use of hearing aids has also been associated with a decrease in depressive symptoms and improved quality of life45. With regard to vision loss, a study in Japan showed that cataract surgery improved cognitive impairment in older patient46, while a 13-year follow-up of a longitudinal study of aging showed that cataract surgery was positively associated with a lower rate of cognitive decline among older adult47.
This study has some limitations. First, since self-perception of vision was only collected during the third wave of the EpiFloripa Aging study, it was not possible to conduct a longitudinal analysis, meaning that it was necessary to use a cross-sectional design, which could result in a risk of bias due to reverse causality. Second, hearing and visual loss were self-reported. However, previous studies have shown that self-reporting can be a valid alternative with a good level of sensitivity and specificity48,49. One of the strengths of this research is that it is the first study to investigate the relationship between DSL and cognitive decline among older people in Brazil, providing a basis for the development of interventions and public policies targeting this population.
The results suggest that there is an association between DSL and cognitive decline in older people living in the South of Brazil. Participants with hearing and visual loss had 321% greater odds of having cognitive decline, suggesting that the combination of these two conditions may have a greater impact than each condition in isolation in this sample of older people from Florianópolis. Further research is needed to investigate these relationships, especially longitudinal studies, to provide more evidence to support interventions that are capable of preventing or delaying sensory impairments and preserving cognitive functions in older people.

ACKNOWLEDGEMENTS
We are grateful to the Economic and Social Research Council (ESRC) for the funding that made the third wave of the EpiFloripa Aging study possible and to all the study participants for their collaboration. We would also like to thank the Coordination for the Development of Higher Education Personnel (CAPES/Brasil) for the support provided in the form of post-graduate scholarships.

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Saúde de Crianças, Mulheres e Adolescentes: estudos sobre políticas e cuidado no campo da Saúde Coletiva
Vol. 31 N.8 - SETEMBRO/2026

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Hillesheim, D, Figueiró, TH, Zorzi, VN, Quialheiro, A, Hallal, ALC, d´Orsi, E. Perda sensorial dupla e declínio cognitivo: evidências do estudo EpiFloripa Idoso. Cien Saude Colet [periódico na internet] (2025/mai). [Citado em 13/09/2026]. Está disponível em: http://cienciaesaudecoletiva.com.br/artigos/perda-sensorial-dupla-e-declinio-cognitivo-evidencias-do-estudo-epifloripa-idoso/19624

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