Archives of Gerontology and Geriatrics 104 (2023) 104834

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Self-reported hearing and vision impairment and incident frailty inJapanese older people: A 3-year longitudinal analysis of the Japan
Gerontological Evaluation Study
Kenjiro Kawaguchi a, *, Noriyuki Abe a, Yoshimune Hiratsuka b, Kaori Kojima c,
Katsunori Kondo a, da

Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba, Chiba 263–8522, Japan
Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo 113–8431, JapancMedical Sciences Graduate School, Hamamatsu University School of Medicine, Shizuoka 431–3192, Japand
Department of Geriatric Evaluation, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi 474–8511, Japanb

A R T I C L E I N F O

A B S T R A C T

Keywords:
Vision impairment
Hearing impairment
Frailty
Older people
Aged

Background: We examined the associations and interactions of hearing impairment (HI) and vision impairment(VI) with frailty.
Methods: We performed a 3-year longitudinal analysis of the Japan Gerontological Evaluation Study (JAGES), a
nationwide prospective cohort study of functionally independent Japanese older people (age ≥ 65 years). Frailty
status at baseline and follow-up was defined according to the Kihon Checklist. HI and VI at baseline were selfreported. Logistic regression models were used to examine the main and interaction effects of HI and VI on
incident frailty during a 3-year follow-up period.
Results: Of the 7,852 participants (mean age 73.2 years, standard deviation 5.6; 50.7% women), 9.7%, 5.3%, and1.9% reported HI, VI, and concurrent HI and VI, respectively. After adjusting for possible confounders and theother sensory impairment, VI (odds ratio [OR] 2.50, 95% confidence interval [CI] 1.62–3.85, p < 0.001), but not
HI (OR 1.29, 95% CI 0.97–1.72, p = 0.081), was significantly associated with incident combined pre-frailty andfrailty from a robust baseline. No interaction was observed between HI and VI (OR 0.83, 95% CI 0.38–1.81, p =0.636). We observed no significant associations between sensory impairments and incident frailty from a pre-frail
baseline (HI: OR 1.26, 95% CI 0.88–1.80, p = 0.205; VI: OR 1.44, 95% CI 0.90–2.31, p = 0.127; interaction
between HI and VI: OR 1.16, 95% CI 0.53–2.53, p = 0.718).
Conclusions: VI, rather than HI, may be an independent risk factor for frailty, without any interaction between thetwo.

1. Introduction(Apóstolo et al., 2018; Puts et al., 2017). Preventing and delaying theonset of frailty by interventions aimed at potentially modifiable risk
factors is a key public health concern, as frailty imposes burdens on
individuals and society (Shinkai et al., 2016).
With the increasing lifespan and population aging, a growing num­
ber of people have sensory impairments. Worldwide, more than 1.5
billion people have some type of hearing impairment (HI), and morethan 65% of people aged ≥ 60 years have HI (World Health Organiza­
tion, 2021). In contrast, at least 2.2 billion people suffer from near or
distance vision impairment (VI), and people aged ≥ 50 years comprise

Frailty is defined as a geriatric syndrome that is caused by a decline
in physiological systems and results in an increased vulnerability toexternal stressors (Clegg et al., 2013; World Health Organization, 2015).
Frail older people are at a higher risk for adverse health outcomes, suchas falls, hospitalization, institutionalization, and mortality (Cheng &Chang, 2017; Chu et al., 2021; Kojima et al., 2018). Furthermore, frailty
is recognized as an intermediate state between robustness and disability
as well as a reversible state when effective interventions are undertaken

Abbreviations: ADL, activities of daily living; CI, confidence interval; ELSA, English Longitudinal Study of Ageing; HI, hearing impairment; JAGES, Japan
Gerontological Evaluation Study; KCL, Kihon Checklist; OR, odds ratio; SE, standard error; VI, vision impairment.
* Corresponding author.
E-mail address: kawaguchikenjiro@chiba-u.jp (K. Kawaguchi).
https://doi.org/10.1016/j.archger.2022.104834
Received 13 May 2022; Received in revised form 1 September 2022; Accepted 7 October 2022
Available online 17 October 2022
0167-4943/© 2022 Elsevier B.V. All rights reserved.

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Archives of Gerontology and Geriatrics 104 (2023) 104834

70–80% of individuals with VI (World Health Organization, 2019). BothHI and VI are increasingly recognized as crucial modifiable risk factors
for frailty among older people. According to meta-analyses, HI (Tanet al., 2020; Tian et al., 2021) and VI (Tan et al., 2020) increase the odds
of older people developing frailty.
Concurrent HI and VI are common among older people. More than
10% of adults aged ≥ 80 years have both HI and VI (Swenor et al., 2013),
which are considered to comprise several common underlying pathways
to frailty, such as depression (Cosh et al., 2018; Li et al., 2014), social
isolation (Brunes et al., 2019; Shukla et al., 2020), and reduced physicalactivity (Martinez-Amezcua et al., 2022; Ong et al., 2018). Thus, con­current HI and VI may be more strongly associated with incident frailty
than either HI or VI alone. However, the few earlier studies conductedon this topic investigated the relationship between HI and VI
cross-sectionally (Buttery et al., 2015; Eyigor et al., 2015; Herr et al.,2018; Ng et al., 2014). Furthermore, to our knowledge, no longitudinalstudies have investigated concurrent HI and VI with regard to incident
frailty. Therefore, it remains unclear whether individuals who have both
HI and VI are at a greater risk of frailty than those who have either HI or
VI alone, or whether concurrent HI and VI induce a synergistic effect on
incident frailty. A clear understanding of the risks posed by sensory
impairment for the development of frailty is crucial for the design ofeffective interventional strategies to reduce the frailty burden in older
people.
This study examined the associations of HI and VI with incident
frailty over 3 years. Specifically, we investigated whether: (1) HI and VI
were independent risk factors after adjusting for one another and otherpossible confounders, and (2) a significant interaction of HI and VI on
frailty was observable.

dependence for activities of daily living (ADL; n = 537) or frailty (n =2351) at baseline. Consequently, 7852 of the 10,752 eligible partici­
pants were included in our analysis (Fig. 1).
2.3. Frailty status
We used the Kihon Checklist (KCL) to determine frailty status atbaseline and at the 3-year follow-up. The KCL was originally designed by
the Japanese Ministry of Health, Labour, and Welfare to identify
community-dwelling older people at higher risk of becoming disabled(Arai & Satake, 2015). However, a systematic review reported that the
KCL is also a reliable tool for assessment of the frailty risk among older
people (Sewo Sampaio et al., 2016). The KCL consists of 25 items andassesses seven domains of daily living functions: instrumental activities
of daily living, physical strength, nutritional condition, oral, social, andcognitive functions, and depressed mood, using simple dichotomous
responses (yes = 1; no = 0; total score range: 0–25, with a higher scoreindicating worse functioning) (Arai & Satake, 2015). Each of the seven
KCL domains is related to frailty status. A systematic review, forexample, indicates that oral health is an important predictor of frailty
because poor oral health leads to a decrease in oral intake and physicalfunction (Hakeem et al., 2019). According to another systematic review,
depression is associated with an increase in the prevalence of frailty as aresult of physical inactivity (Soysal et al., 2017).
A previous study (Satake et al., 2016) validated whether or not the
total KCL score could identify frailty status defined by Fried phenotype
criteria (Fried et al., 2001), the most widely accepted criteria forassessment of frailty, which consists of five items: unintentional weight
loss, self-reported exhaustion, low levels of activity, weak grip strengthand slow walking speed. A KCL cut-off value of 7/8 had sensitivity of
89.5% and specificity of 80.7% for determining frailty, respectively. At a
KCL cut-off value of 3/4 for pre-frailty, sensitivity and specificity were
70.3% and 78.3%, respectively. Based on this study, frailty status wasclassified into three categories: robust (0–3 points), pre-frail (4–7
points), and frail (8–25 points).
In our study, the incidences of pre-frailty and frailty were combined
as “any frailty” as there were few new-onset frailty cases during thefollow-up period among participants with HI or VI at the robust baseline(n = 21 for HI and n = 15 for VI).

2. Material and methods
2.1. Data sources
This study involved a secondary analysis of data from the Japan
Gerontological Evaluation Study (JAGES) (Kondo & Rosenberg, 2018), alongitudinal nationwide cohort study that aims to investigate health,social, and behavioral issues among noninstitutionalized Japanese older
people. Approximately every three years since 2003, surveys on healthbehaviors, psychological factors, and a wide range of socioeconomic
factors have been conducted of older people aged 65 years or older
without any long-term care need certification under the JapaneseLong-Term Care Insurance. In this study, we used data from the 2016
and 2019 waves for the baseline and outcome analyses, respectively.

2.4. Disability and all-cause mortality
We included the respondents at baseline who became disabled ordeceased during the follow-up period in the analytic sample to reduce
the risks of selection bias and underestimation of the effects of sensory
impairments on incident frailty. Because frail status is a strong predictor
for disability (Kojima, 2017) and death (Kojima et al., 2018), as asensitivity analysis, we considered the transition from a robust baseline
to any level of frailty, disability, or death at follow-up (“worsening
frailty”), and the transition from a pre-frail baseline to frailty, disability,
or death at follow-up (“worsening pre-frailty”).
Disability was defined as the initial certification of long-term careneed. An individual’s level of long-term care need (seven levels: Pre­ventative Support Level 1 or 2, or Long-term Care Levels 1 through 5) isassessed by a 74-item questionnaire about ADL. This information isreviewed and finalized by the Certification Committee of Needed LongTerm Care, which comprises experts from the health, medical care, andwelfare domains (Tamiya et al., 2011). Information on all-cause mor­tality was obtained from the administrative records. Participants whodied after being certified as requiring long-term care were grouped withthe deceased.

2.2. Participants
The baseline survey was conducted between October 2016 andJanuary 2017. Self-reported questionnaires were mailed to 279,661
functionally independent older people aged 65 years or older without along-term care need certification, and 196,438 adults responded to thequestionnaire (response rate: 70.2%). The survey questionnaire
comprised the core questions and one of eight modules with various
thematic questions based on the researchers’ interests (Fig. A1) (Kondo& Rosenberg, 2018). The one module included the questions about
eyesight and hearing and was randomly distributed to one-eighth of thetarget cohort (34,571 of 279,661 individuals), of whom 24,313 in­dividuals answered the questionnaires (response rate: 70.3%). A
follow-up survey was conducted between November 2019 and January
2020. Of the 24,313 respondents to the baseline survey, 9345 replied to
the follow-up survey questionnaire. In our analysis, we included thebaseline questionnaire respondents who were subsequently censoredduring the follow-up period because of death (n = 577) or certificationof long-term care requirement (n = 1206). Thus, 10,752 individuals
were eligible for our analysis (follow-up rate: 48.2%). We excluded in­dividuals with invalid information on age (n = 12) as well as those with

2.5. Vision and hearing impairments
We assessed VI using a single item consistent with the one used in the
English Longitudinal Study of Ageing (ELSA) (Marmot et al., 2003):
2

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Archives of Gerontology and Geriatrics 104 (2023) 104834

Fig. 1. Flowchart showing participation in the Japan Gerontological Evaluation Study surveys of 2016 and 2019.

“How is your eyesight? If you normally use eyeglasses, please describe
your eyesight while wearing them.” Moreover, HI was assessed using asingle item consistent with the one used in the ELSA (Marmot et al.,2003): “How is your hearing? If you use a hearing aid, please describe
your hearing ability while wearing it.” Possible responses for both items
were: excellent, very good, good, fair, or poor. These responses weredichotomized as indicating good vision or hearing (excellent, very good,or good) and poor vision or hearing (fair or poor). Self-reported HI and
VI were previously validated by comparing functions based on objective
measures (Ferrite et al., 2011; Zimdars et al., 2012).

and/or frailty without considering VI (Model 1), and vice versa(Model 2). In Model 3, we considered the HI and VI variables simulta­
neously to test whether each sensory impairment was independently
associated with frailty. Additionally, we added a product term of HI and
VI in Model 3 to test whether associations between one sensory
impairment and frailty were modified by another (Model 4).
In a sensitivity analysis, we examined the associations between
sensory impairments and frailty using “worsening robustness” and“worsening pre-frailty” as outcome measures.
The proportions of missing values across all variables varied from 0%
to 15.1% (household income). A total of 1868 (23.8%) participants were
missing data. We performed multiple imputation by chained equations
to impute incomplete variables and created 20 imputed datasets. We
obtained the estimates and standard errors (SEs) in each imputed dataset
separately using logistic regression analyses and combined them byapplying Rubin’s rules (Rubin, 1996).
Statistical analysis was performed using Stata/SE 16.0 (StataCorp,
College Station, TX, USA). All p-values were two-sided, and a 0.05
threshold of statistical significance was used.
This study was approved by the Ethics Committee of the National
Center for Geriatrics and Gerontology (No. 992) and the Ethics Com­mittee of Chiba University (No. 2493). Informed consent was obtainedby requiring all respondents to select an acceptance checkbox on thequestionnaire before returning it.

2.6. Covariates
We considered the following 13 factors as possible confounders: age,sex, educational attainment, employment status, marital status, living
arrangements, equivalized household income, drinking, smoking, andcomorbidities (hypertension, stroke, heart disease, and diabetes). Par­
ticipants were categorized into four subgroups, by age: 65–69, 70–74,
75–79, and ≥ 80 years; and three subgroups, by educational attainment:≤ 9, 10–12, and ≥ 13 years. Employment status was dichotomized as
employed or unemployed, marital status as married or single, and living
arrangements as living alone or living with others. Equivalized house­
hold income was calculated by dividing the household’s total income by
the square root of the number of members in the household and wasclassified into three categories: < USD20,000, USD20,000–39,999, and≥ USD40,000 per year (1 USD equals 100 yen) (Mochida et al., 2018).
Drinking and smoking were classified as currently smoking/drinking or
not. Comorbidities were ascertained from the following self-reported
medical conditions (Liljas et al., 2017): hypertension, stroke, heart dis­ease, and diabetes.

3. Results
Table 1 shows the baseline characteristics of the participants, with amean age of 73.2 years (standard deviation 5.6); 50.7% were women.
Among 7852 participants, 5464 (69.6%) were robust and 2388 (30.4%)
were pre-frail at baseline. The prevalences of HI, VI, and the concurrenceof HI and VI were 9.7% (n = 730), 5.3% (n = 400), and 1.9% (n = 146),
respectively. Regarding a sample of the respondents excluded owing totheir frail status at baseline (n = 2351), the prevalences of HI, VI, and theconcurrence of HI and VI were 18.6% (n = 437), 13.8% (n = 325), and6.6% (n = 155), respectively.
Participants with HI and/or VI were more likely than those without
HI and/or VI to develop any frailty from robustness (HI: 30.8% vs.
21.5%, VI: 40.5% vs. 21.4%, HI and VI: 44.2% vs. 21.8%) and frailty
from pre-frailty (HI: 23.6% vs. 17.4%, VI: 24.2% vs. 17.7%, HI and VI:
27.4% vs. 18.0%; Fig. 2A, 2B).
Figs. 3 and 4 depict the results of logistic regression analyses of theassociations between sensory impairments and incident pre-frailty and/or frailty. Compared with participants who reported no HI or VI, those

2.7. Statistical analysis
We initially described the baseline characteristics of the participants.
Next, we presented the distributions of frailty status at follow-up inrobust and pre-frail participants by sensory impairments. Then, logistic
regression models were used to examine associations between sensory
impairments and the incidence of any frailty among robust participants
and of frailty among pre-frail participants during the 3-year follow-up
period. We first calculated crude odds ratios (ORs) and 95% confi­
dence intervals (95% CIs). We then estimated ORs with 95% CIs after
adjusting for all possible confounders. We used four models to system­
atically examine the associations between sensory impairments andfrailty. We examined associations between HI and incident pre-frailty
3

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Archives of Gerontology and Geriatrics 104 (2023) 104834

Table 1
Characteristics of the study participants who were robust or pre-frail at baseline(N = 7852).
Variable

Category

Total, n (%)

Age (years)

65–69
70–74
75–79
≥80
Female≤9
10–12≥13Unemployed
Employed
SingleMarriedLiving alone
Living with others<20,000
20,000–39,999≥40,000
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
RobustPre-frail

2586 (32.9)2321 (29.6)
1776 (22.6)
1169 (14.9)
3983 (50.7)
1903 (24.3)
3486 (44.5)
2451 (31.3)
5434 (71.5)
2162 (28.5)
1812 (23.1)
6040 (76.9)
1070 (13.6)
6782 (86.4)
2849 (42.8)
2977 (44.7)
838 (12.6)
3245 (41.9)
768 (9.8)3239 (43.1)
166 (2.2)
671 (8.9)
977 (13.0)
730 (9.7)400 (5.3)
146 (1.9)5464 (69.6)
2388 (30.4)

Sex
Educational attainment (years)
Employment status
Marital status
Living arrangement
Equivalized income (USD per year)
Drinking
Smoking
Hypertension
StrokeHeart disease
Diabetes
Hearing impairment
Vision impairment
Hearing and vision impairments
Frailty status

Fig. 3. Odds ratios and 95% confidence intervals (CIs) of logistic regression
analysis for hearing impairment (HI) and vision impairment (VI) at the robust
baseline and their interaction on the incidence of any frailty at follow-up.
Models 1 and 2 included HI and VI alone, respectively. Model 3 included
both HI and VI. Model 4 included HI, VI, and an interaction term between HI
and VI (HI*VI). The models were adjusted for age, sex, educational attainment,
employment status, marital status, living arrangement, equivalized income,drinking, smoking, hypertension, stroke, heart disease, and diabetes.

Fig. 4. Odds ratios and 95% confidence intervals (CIs) for logistic regression
analysis of hearing impairment (HI) and vision impairment (VI) at the prefrail
baseline and their interaction with the incidence of frailty at follow-up. Models
1 and 2 included HI and VI alone, respectively. Model 3 included both HI and
VI. Model 4 included HI, VI, and an interaction term between HI and VI (HI*VI).
The models were adjusted for age, sex, educational attainment, employment
status, marital status, living arrangement, equivalized income, drinking,smoking, hypertension, stroke, heart disease, and diabetes.

Fig. 2. Distribution of frailty status at follow-up by hearing impairment (HI)and vision impairment (VI) at the robust (A) and pre-frail (B) baseline.

those reporting no HI or VI, were more likely to develop frailty from a
pre-frail baseline. When considering both HI and VI, the odds of incident
frailty were significantly higher among the participants who reported VI(OR 1.52, 95% CI 1.04–2.21, p = 0.031), but not HI (OR 1.30, 95% CI
0.94–1.78, p = 0.109), than among those who did not report either HI or
VI (Model 3). However, the relationship between frailty and VI did not
remain significant in Model 4, which included the product term of HI
and VI in Model 3 (HI: OR 1.26, 95% CI 0.88–1.80, p = 0.205; VI: OR
1.44, 95% CI 0.90–2.31, p = 0.127; HI*VI: OR 1.16, 95% CI 0.53–2.53, p= 0.718).
The results from the sensitivity analysis using worsening robustness
and pre-frailty indicated the same directions as the results of the primary
analysis (Tables A1 and A2). There was one notable exception: we foundstatistically significant association of HI with worsening pre-frailty in
Model 3 (OR 1.28, 95% CI 1.01–1.72, p = 0.043).

who reported HI (crude: OR 1.70, 95% CI 1.32–2.18, p < 0.001; Model
1: OR 1.43, 95% CI 1.10–1.85, p = 0.007) and VI (crude: OR 2.65, 95%
CI 1.88–3.74, p < 0.001; Model 2: OR 2.51, 95% CI 1.77–3.57, p <0.001) were significantly associated with higher odds of incident any
frailty from robustness. The associations of VI (Model 3: OR 2.36, 95%
CI 1.65–3.39, p < 0.001; Model 4: OR 2.50, 95% CI 1.62–3.85, p <0.001), but not HI (Model 3: OR 1.26, 95% CI 0.96–1.65, p = 0.093;
Model 4: OR 1.29, 95% CI 0.97–1.72, p = 0.081), remained significant
even after considering the effects of both HI and VI. We did not observe asignificant interaction term between HI and VI (OR 0.83, 95% CI
0.38–1.81, p = 0.636).
Similar results were obtained for the relationships between sensory
impairments and incident frailty from the pre-frail baseline (Fig. 4).
After adjusting for confounders, the participants with HI (crude: OR
1.78, 95% CI 1.33–2.38, p < 0.001; Model 1: OR 1.39, 95% CI
1.02–1.89, p = 0.037) and VI (crude: OR 1.71, 95% CI 1.21–2.43, p =0.003, Model 2: OR 1.61, 95% CI 1.11–2.33, p = 0.011), compared with4

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Archives of Gerontology and Geriatrics 104 (2023) 104834

4. Discussion(Steinmetz et al., 2021). However, few studies have examined the effects
of interventions for VI on incident frailty. A longitudinal study(Graue-Hernandez et al., 2017) found that approximately 70% and 20%of adults who were frail and pre-frail at baseline reversed to pre-frailty
and robustness, respectively, 1 month after cataract surgery. More­over, cataract surgery is reportedly related to a reduction in the inci­
dence of dementia, depression, and falls (Ishii et al., 2008; Scott, 2005),
which may prevent incident frailty. Further interventional studies areneeded to examine whether treatments for VI could prevent the inci­
dence of frailty.
Our study has several strengths, including the large sample of older
people and the follow-up of censored cases in the sensitivity analysis to
more accurately estimate the risks of HI and VI on incident frailty andobtain robust results. Nonetheless, our study has several limitations.
First, frailty was not assessed based on clinical diagnostic criteria, whichmight result in the misclassification of frailty status despite using ahighly validated frailty assessment tool. For instance, such misclassifi­
cation may partially account for the finding that 15%–25% of the prefrail participants at baseline became robust at the follow-up (Fig. 2).
Second, assessments of HI and VI depended on self-reporting by theparticipants, implying that we may have underestimated the prevalenceof sensory impairments compared with objectively measured impair­ments. Nonetheless, these self-reported data provided significant find­ings. Third, we did not consider some relevant clinical features of
sensory impairments, such as the duration of the impairments, use ofhearing or vision aids, changes in the impairments over time, and causes
and characteristics of the impairments (e.g., refractive error or eye
disease, near or distance VI), which might have led to biases in our es­
timates. Fourth, we might have underestimated the effects of sensory
impairments on incident frailty owing to the low follow-up rate (48.2%).
In general, individuals at risk for developing frailty are less likely torespond to follow-up surveys. This could induce a selection bias that
decreases the percentages of frail participants at the follow-up, eventhough we sought to lower the dropout rate by including the participants
who became disabled or deceased during the follow-up period in the
final sample.

In this study, we examined the associations between self-reported HI
and VI and the incidences of pre-frailty and frailty. To the best of ourknowledge, this is the first longitudinal study to examine the associa­
tions and interactions of HI and VI with frailty and to investigate thecumulative risk of frailty in older people with concurrent HI and VI.
After adjusting for possible confounders, our findings revealed that older
people with VI or HI were more likely to become pre-frail and frail thanthose without VI or HI. However, when adjusting for another sensory
impairment and possible confounders, we found a statistically signifi­
cant association between VI and frailty, but not between HI and frailty.
Additionally, no significant interactions between HI and VI wereconsistently identified, which means that there was no excess risk forfrailty, even when HI was present.
According to the findings of the present study, VI was an independentrisk factor for pre-frailty or frailty in robust participants at baseline.
Previous studies of the association between VI and frailty have reported
similar results. Several longitudinal studies (Liljas et al., 2017; Trevisan
et al., 2017) demonstrated that self-reported VI was related to anincreased risk of frailty. Similarly, other longitudinal studies using
objective measurements of visual acuity (Kamil et al., 2016; Lor­enzo-Lopez et al., 2019; Swenor et al., 2020) reported significant effectsof VI on frailty. However, these studies did not take the effects of HI into
account. Therefore, we believe that the findings of the present study
provide new insight into the relationship between VI and frailty.
In contrast, on controlling for VI along with the potential con­founders, the associations between HI and frailty did not remain sta­tistically significant. A systematic review and meta-analysis (Tian et al.,2021) revealed that older people with HI had a 1.5-fold greater risk ofincident frailty, which is similar to the results that we obtained in Model
1. However, no longitudinal studies included in the meta-analysis
analyzed the effects of concurrent HI and VI on incident frailty, whichindicates that those studies probably did not exclude the confounding
effect of VI on the relationship between HI and frailty. In other words,
previously reported associations between HI and frailty might have been
confounded by VI. Our findings suggest that VI could be a relevant
confounder in the relationship between HI and frailty. Future researchon sensory impairments should investigate the effects of HI and VI
together, rather than individually, to obtain a better understanding of
the links between sensory impairments and frailty.
Hearing and vision are both important for effective functioning.
However, the two may function differently, depending on the circum­
stances. According to an earlier study, vision is more necessary forengagement with the physical and spatial environment, whereas hearing
is more immediately required for interaction with the social environ­ment (Saunders & Echt, 2007). Thus, VI may be more likely than HI to
disrupt interaction with the physical and spatial environment anddecrease physical activity in daily life. Accordingly, VI may lead more
directly to a decline in physical function (Enoch et al., 2019; Scott et al.,2016). There is a paucity of information on the different influences of HI
and VI on incident frailty. Further research is required to better under­
stand the underlying mechanisms of incident frailty caused by HI and VI,
with a particular emphasis on their interactions.
Both HI and VI are widespread among older people but often remain
overlooked (Crews & Campbell, 2004). The findings of this study suggestthat effective management of VI might prevent and delay the incidence
and progression of frailty. VI screening in the healthcare setting may
facilitate the early identification of VI among older people, which could
facilitate early intervention, such as the use of glasses, cataract surgery,or sensory rehabilitation. Accordingly, these may mitigate the detri­mental effects of VI and delay the occurrence of frailty. In particular,
cataract surgery seems to be a promising intervention to reduce theincidence of frailty. Worldwide, cataracts are one of the leading causesof VI. According to estimates, 15.2 million people aged ≥50 years areblind, and 78.8 million have mild to severe VI due to cataracts

5. Conclusions
In conclusion, we found that VI, but not HI, was independently
associated with the incidence of frailty from a robust and pre-frail
baseline in a nationwide sample of independent older people in Japan.
In comparison to having VI alone, having both HI and VI did not increase
the risk of developing frailty. The prevention and treatment of VI in later
life may help delay the onset of frailty. Further research is required to
explore preventive interventions for VI that may provide a substantial
benefit in reducing the risk of frailty.
Funding
This work was supported by Grants-in-Aid for Scientific Research(15H01972, 15H04781, 15H05059, 15K03417, 15K03982, 15K16181,
15K17232, 15K18174, 15K19241, 15K21266, 15KT0007, 15KT0097,
16H05556, 16K09122, 16K00913, 16K02025, 16K12964, 16K13443,
16K16295, 16K16595, 16K16633, 16K17256, 16K17281, 16K19247,
16K19267, 16K21461, 16K21465, 16KT0014, 17K04305, 17K04306,
25,253,052, 25,713,027, 26,285,138, 26,460,828, 26,780,328,
18H03018, 18H04071, 18H03047, 18H00953, 18H00955, 18KK0057,
19H03901, 19H03915, 19H03860, 19K04785, 19K10641, 19K11657,
19K19818, 19K19455, 19K24060, 19K20909, and 20H00557) from theJapan Society for the Promotion of Science; by Health Labour Sciences
Research Grants (H26-Choju-Ippan-006, H27-Ninchisyou-Ippan-001,
H28-Choju-Ippan-002, H28-Ninchisyou-Ippan-002, H30-Kenki-Ippan006,
H29-Chikyukibo-Ippan-001,
H30-Jyunkankinado-Ippan-004,
19FA1012, 19FA2001, 21FA1012, and 21K19635); by a research project
on health and welfare promotion for the elderly funded by the Ministry5

K. Kawaguchi et al.

Archives of Gerontology and Geriatrics 104 (2023) 104834

of Health, Labour and Welfare, Japan; by the Research and Development
Grants for Longevity Science from the Japan Agency for Medical
Research and Development (AMED; JP18dk0110027, JP18ls0110002,
JP18le0110009,
JP20dk0110034,
JP21lk0310073,
andJP21dk0110037); by the Research Funding for Longevity Sciences fromthe National Center for Geriatrics and Gerontology (24–17, 24–23,
29–42, 30–30, 30–22, 20–19, and 21–20); by the Open Innovation
Platform with Enterprises, Research Institute and Academia(JPMJOP1831) from Japan Science and Technology; by grants from theJapan Foundation For Aging And Health (J09KF00804), the Innovative
Research Program on Suicide Countermeasures (1–4), the Sasakawa
Sports Foundation, the Japan Health Promotion & Fitness Foundation,and the Chiba Foundation for Health Promotion & Disease Prevention;by the 8020 Research Grant for fiscal year 2019 from the 8020 Pro­
motion Foundation (adopted number: 19–2–06); and by grants from
Meiji Yasuda Life Foundation of Health and Welfare. This work was also
supported by AMED (JP20dk0310108, JP21dk0310108h0002) and The
Ministry of Education, Culture, Sports, Science, and Technology(JP21K02001, JP21H03157). The funders had no role in study design; inthe collection, analysis and interpretation of data; in the writing of thereport; or in the decision to submit the article for publication.

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Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
We would like to thank Editage (www.editage.com) for English
language editing.
Supplementary materials
Supplementary material associated with this article can be found, inthe online version, at doi:10.1016/j.archger.2022.104834.
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