Original Research Article

Association between Social Activity andDevelopment of Dementia in Hearing
Impairment: A Cohort Study in Japan fromJapan Gerontological Evaluation StudyGerontology & Geriatric Medicine
Volume 8: 1–11
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/23337214221100621
journals.sagepub.com/home/ggm

Kaori Kojima, MS1 , Eisaku Okada, PhD1,2, Toshiyuki Ojima, MD, PhD1,
Jun Aida, DDS, PhD3, Yoshimune Hiratsuka, MD, MPH, PhD4, andKatsunori Kondo, MD, PhD5,6

Abstract
We aimed to clarify the association between social activity and the development of dementia in older adults by hearing-impaired(HI) status. We applied a community-based prospective cohort study over 6 years as part of the Japan Gerontological Evaluation
Study. The study included 53,549 participants aged 65 years and older who did not require long-term care. A baseline
questionnaire survey was conducted; explanatory variables included physical and social activities, and the objective variable wasdementia onset assessed by standardized protocol. Cox regression models were used to calculate hazard ratios (HRs) for
dementia stratiﬁed by HI status. During the follow-up period, 6013 (11.2%) participants developed dementia. Analyses revealed
increased dementia risk for participants with HI who participated in the following activities less than once a month: sport groups(HR 2.17, 95% CI 1.53-3.08), hobby groups (HR 1.70, 95% CI 1.34-2.17), going out (HR 2.19, 95% CI 1.51-3.17), and meetingwith friends (HR 1.27, 95% CI 1.06-1.53). HI and lack of social activity increase the risk of dementia. The study results indicatethat there is an association between low social activity and the development of dementia in people with HI; the strongest
associations were found for low participation in sports and hobby groups.
Keywords
older adults, dementia, hearing impairment, longitudinal study, dementia risks
Manuscript received: March 2, 2022; ﬁnal revision received: April 21, 2022; accepted: April 26, 2022.
1

Introduction
Hearing impairment (HI) is one of the risk factors for dementia (Livingston et al., 2017). HI, even when mild, increases the long-term risk of developing dementia (Daniele
et al., 2018). Among the preventable risk factors for dementia, HI has been identiﬁed as the most important modiﬁable risk factor (Livingston et al., 2017).
In addition to dementia, HI can lead to depression (Liet al., 2014), apathy (Sugawara et al., 2011), and limited
participation in daily activities due to reduced stimulus input,
negative impact on family relationships and social interactions (Servidoni & Conterno, 2018), social isolation due toDepartment of Community Health and Preventive Medicine, Hamamatsu
University School of Medicine, Hamamatsu City, Japan
2
Faculty of Social Policy & Administration, Hosei University, Machida, Japan3
Department of Oral Health Promotion, Graduate School of Medical and
Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Japan
4
Department of Ophthalmology, Juntendo University Graduate School of
Medicine, Bunkyo-ku, Japan
5
Department of Social Preventive Medical Sciences, Center for Preventive
Medical Sciences, Chiba University, Chiba, Japan
6
Department of Gerontological Evaluation, Center for Gerontology andSocial Science, National Center for Geriatrics and Gerontology, Obu City,
Japan
Corresponding Author:
Toshiyuki Ojima, Department of Community Health and Preventive
Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama,
Higashi-ku, Hamamatsu city 431-3192, Japan.
Email: ojima@hama-med.ac.jp

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2

impaired communication (Strawbridge et al., 2000), andadverse effects on the degree of social interactions (Ogawa
et al., 2019). The possibility of a causal relationship between
the inhibition of social interaction, depletion of cognitive
reserve, social isolation, environmental changes, and a
combination of these factors with dementia has also beenreported (Ives et al., 1995).
Recently, the importance of social participation in the
cognitive functioning of older adults has been widely
highlighted. Social participation has been deﬁned by various
other researchers (Putnam, 1995; Berkman, 1995). Previous
studies have shown that social activity among older adults is
associated with reduced risk for long-term care and death(Kanamori et al., 2014; Murata et al., 2017; Saito et al., 2019;
Aida et al., 2011; Kawachi et al., 1996).
Older adults with high social participation have higher
cognitive function than those with low social participation(Barnes et al., 2004; Holtzman et al., 2004), and social
participation suppresses the decline of cognitive function(Uchino, 2006). The strength of social networks, such as social
activities and socializing with friends and family, is associatedwith cognitive functioning and prevents dementia (Holtzman
et al., 2004). Decreased social participation increases the risk ofdeveloping dementia (Saczynski et al., 2006), and people withfewer social networks have a higher risk of cognitive impairment(Nemoto et al., 2017). Moreover, living alone and having no
personal connections doubles the risk of developing dementia in
3 years (Fratiglioni et al., 2000). However, to our knowledge, nostudy has revealed the relationship between the type of social
participation and dementia among older people with HI. In thisstudy, we used large-scale longitudinal data over 6 years toclarify the association between activities performed by older
adults with HI and the risk of developing dementia in Japan.

Gerontology & Geriatric Medicine

long-term care” that included the onset of dementia and the“data on the levy of long-term care insurance” that included
mortality for 6 years to determine the presence of dementia or
the need for long-term care.
To reduce the effect of the reversal of causality, we excluded 835 individuals whose follow-up period was less than
365 days. Deaths within 365 days were also excluded. Finally, 53,549 participants (24,534 men and 29,015 women)
were included in the analysis. The follow-up status of theparticipants is shown in Figure 1.

Variables
Outcome Variable. HI was deﬁned as those who selected selfreported HI as a disease under treatment during the baseline
survey.
The outcome variable of the development of dementia wasdetermined if a participant was certiﬁed as requiring support orcare and classiﬁed as IIa (Hisano, 2009; Noda et al., 2018) or
higher for “level of independence in daily living for the elderlywith dementia” deﬁned by the Ministry of Health, Labor andWelfare. The IIa level is assigned when symptoms, behaviors, or
difﬁculties in communication, related to dementia, that interferewith daily life are observed; the person can be independent if
someone pays attention to them. Symptoms of dementia include
frequently getting lost, noticeable errors in shopping, ofﬁce work,
money management, and other things that were previously
possible. This dementia index is strongly correlated with theMini-Mental State Examination (r = 0.74) (Hisano, 2009). The
dementia scale was an effective indicator for the clinical diagnosis; reported sensitivity and speciﬁcity were 73% and 96% forrank II dementia, respectively (Noda et al., 2018).

Explanatory and Covariates Variables
Methods
Study Design and Participants
The study design was a community based prospective cohort
study from the Japan Gerontological Evaluation Study(JAGES). The baseline survey was conducted from August2010 to January 2012 by distributing questionnaires to
95,827 randomly-selected older adults who had not beencertiﬁed as requiring support or long-term care and resided in
13 municipalities in seven prefectures in Japan.
We excluded 7889 people who had missing sex or age
information on the self-administered questionnaire, whose
answers were inconsistent with the list received from themunicipalities, who returned the personal identiﬁcation code
detached from the questionnaire, and who did not giveconsent for the use of their data for research. Therefore, valid
data at baseline was 54,537. We further excluded 153 people
with reduced activities of daily living (ADL) who reported
difﬁculty in caring for themselves. We followed up with thesepeople using the “data on the certiﬁcation of the need for

Explanatory variables about social activities included thefrequency of activities and the presence of leisure activities.
The frequency of going out (twice a week or more, once aweek to once a month or more, once a month or less), frequency of meeting friends, and participation in hobby andsport groups (once a month or more) were surveyed (WillieTyndale et al., 2016). Covariates to be adjusted included age,sex, self-rated health, ADL, depressive symptoms assessedby geriatric depression screening scale-15 (GDS) (Brinket al., 1982), smoking status, education, equivalent income,marital status, and living arrangement. Age was categorized
into ﬁve groups: 65–69, 70–74, 75–79, 80–84, and 85 years
and older. Self-rated health was categorized into good (verygood, fair) and poor (not so good, poor). ADL responses wererequested in the following categories: no assistance, partial
assistance, and full assistance. Level of depressive symptoms
was categorized using the GDS: 0–4 points as no depression,
5–9 points as mild depression, and 10–15 points as depression.
Smoking status was categorized into non-smoking (neversmoked, quit more than 5 years ago, and do not smoke now)

Kojima et al.

3

Figure 1. Flow of participants for analytic sample.

and smoking (quit less than 5 years and do not smoke now, stillsmoking). Equivalent income was categorized into less than 2
million yen, 2–4 million yen, and 4 million yen or over).
Equivalent income was calculated by dividing the total annual
income of the entire household by the square root of thenumber of household members. Education was categorized by
years of education: less than 10 years, 10 years or more.

Statistical Analyses
We described the distribution of each variable used in theanalysis; the proportion of people who developed dementia
by each attribute is expressed in the HI group and normal
hearing group, and the chi-square test was used to compare
the percentages by each attribute.

To examine the association between social activities andthe development of dementia, hazard ratios (HRs) and 95%
conﬁdence intervals (95% CIs) were calculated using the Cox
proportional hazards model after stratiﬁcation into twogroups: HI and normal hearing. The group with higher
participation in each social activity was set as the reference inall the analyses. Samples with missing values in the covariates were included in the analysis by setting the missing
categories, i.e. missing-indicator method.
Factors that were signiﬁcant at the p < 0.10 level in univariate regression were used. In addition, we used factors
whose explanatory variables have been suggested to be associated with hearing impairment and dementia in previous
studies (Emmett & Francis, 2015; Kochkin, 2007; Yamada
et al., 2011; Wayne & Johnsrude, 2015; Uchida et al., 2019;4

Panza et al., 2015; Amieva et al., 2018). Covariates of age andsex were included in Model 1, self-rated health, ADL, current
smoking, and depressive symptoms, living arrangement,
equivalent income, education, and marital status were included
in Model 2. We performed analyses using IBM SPSS Statistics
version 24. The statistical signiﬁcance level was set at p < 5%.

Ethical considerations
The JAGES protocol was reviewed and approved by the
Ethics Committee on Research of Human Subjects at Nihon
Fukushi University (approval No. 1005) and the Ethics
Committee of the Chiba University Faculty of Medicine(approval No. 2493).

Results
The mean age (standard deviation, SD) of the participants was
73.62 (SD 5.78) years. The mean age of participants classiﬁed
by gender was 73.27 (SD 5.60) years for males and 73.89 (SD5.89) years for females. The mean follow-up period was
2063 days (2025 days for men and 2095 days for women).
The number of participants who developed dementia during
the follow-up period was 6013 (11.2%) (2577 [10.0%] men
and 3436 [11.8%] women). The demographics of the study
subjects were divided according to the hearing status (Table
1). Among the participants, 3369 were HI, and 44,487 hadnormal hearing. Those who developed dementia were 860(21.3%) in HI, and 5153 (10.4%) in normal hearing. Signiﬁcant differences were found for all variables in normal
hearing, and almost all variables except for living arrangement in HI. Not shown in the table, the hazard ratio fordementia comparing normal hearing with hearing loss was(1.28, 95%Cl 1.19-1.38), adjusted for sex and age. Hazard
ratios of the development of dementia by social activities areshown in Table 2. In Model 2 in the HI group, signiﬁcantly
higher HRs were observed for going out less than once amonth (2.19, 95% CI 1.51-3.17), participation in sport groups
less than once a month (2.17, 95% CI 1.53-3.08), hobby
groups less than once a month (1.70, 95% CI 1.34-2.17),
leisure activities (1.57, 95% CI 1.31-1.88), and meeting withfriends less than once a month (1.27, 95% CI 1.06-1.53). The
HRs were higher for sport groups and hobby groups in HI
compared with the normal hearing group, while it was almost
the same for leisure activities.

Discussion
In this cohort study, we revealed an association betweensocial activities and the development of dementia in people
with HI. This is the ﬁrst study to show the association inolder people with HI to the best of our knowledge. After
adjusting for factors such as age, sex, physical factors,
mental factors, educational background, and living

Gerontology & Geriatric Medicine

conditions, there was an association between social interaction and social activities with the development of dementia in people with HI. Stronger associations were foundfor participation in sport and hobby groups, which involve
deeper interaction and communication.
The crude incidence of dementia was more than twice as
high. After adjusting for gender and age, the incidence was
1.28 times higher than in healthy subjects. The results were
the same as in the previous study (Michalowsky et al., 2019).
Preventing cognitive decline is very important for older
people with HI.
Hazard ratio of people with HI were higher for those who
participated in sports (HR2.17 vs. 1.28) and hobby (HR1.70
vs. 1.34) groups less than once a month compared with people
with normal hearing. For other social activities, the difference
between people with normal hearing and HI people wasminimal. Leisure activities had a lower HR than hobby andsports groups. This is because leisure activities include pachinko, gardening, painting, and other activities that do not
require communication and can be enjoyed individually.
Dementia was not associated with participation in social
activities once a month. Instrumental Activities of Daily
Living (IADL) limitations were reported to be associated witha long-term risk of developing dementia (Bennett et al.,2006). A decline in ADL may be associated with dementia
in older adults with HI. For the HI in Table 1, there was no
association with living arrangement. Even if HI people live
alone, having social activity opportunities and interaction
may prevent dementia. Participation in socially interactive
activities with others and physical activities is important in
reducing the risk of dementia.
Hazard ratio of meeting with friends less than once amonth was high in this study. HI, cognitive function, isolation, and depression are interrelated (Dawes et al., 2015).
Therefore, social activities may prevent isolation and depression and prevent cognitive impairment for people with
HI. Previous studies have reported that social networks
prevent dementia in general older people (Levasseur et al.,2010), which is consistent with reports from longitudinalstudies, which found that lack of social connections was
associated with an increased risk of dementia (Uchino, 2006).
Social networks may facilitate access to healthy behaviors for
HI people, which in turn may help prevent dementia. In a
study that analyzed the relationship between social relationships between HI people and older adults, the researchers
found that HI people tended to have smaller networks, and HI
was one of the factors associated with social relationships inolder adults (Pérès et al., 2008). It is important for HI people
to widen their social networks
Social activities in congenital HI and profound acquired
HI are different. There are many reports on social activities in
HI people with congenital HI (Moog et al., 2011; Bat-Chavaet al., 2005). The use of cochlear implants at an early age has
been reported to improve students’ participation in club
activities, sports meetings, communication, and social skills.

Kojima et al.

5

Table 1. Characteristics of the Surveyed Participants.
Hearing impairment
Variables

Dementia n(%)

No dementia
(%)

Total
(n = 4039)

860 (21.3)

3179 (78.7)

4039

Male

381 (19.9)

1536 (80.1)

1917

Female480 (22.6)

1642 (77.4)

2122

65-69

31 (6.8)422 (93.2)

453

70-74

65 (7.8)771 (92.2)

836

75-79

188 (16.5)

952 (83.5)

1140

80-84

296 (29.4)

673 (70.6)

953

85 and older

296 (45.1)

361 (54.9)

657>1 month≤1 month

46 (9.2)552 (22.5)

454 (90.8)
1904 (77.5)

500
2456

Missing

262 (24.2)

75.8

1083

>1 month

118 (12.5)

825 (87.5)

94≤1 month

481 (22.7)

1636 (77.3)

2117

Missing

261 (26.7)

718 (73.3)

979>2 times aweek>1 times amonth≤1 time amonth
Missing>1 month

617 (18.8)

2663 (81.2)

3280

113 (29)276 (71)389

1400(12.5)
1516
4685 (75.6)(24.4)
1115
1619 (59.2)(40.8)<0.01 537 (6.0) 8437 (94)
3169
26685
(10.6)(89.4)
1447
9235 (86.5)(13.5)<0.01 1004 (6.6)
14180(93.4)
2796
22165(11.2)(88.8)
1353
8012 (85.6)(14.4)<0.01 3999 (9.2)
39395(90.8)
569 (20.6) 2196 (79.4)

46 (51.1)

44 (48.9)

90

180 (35.5) 327 (64.5)

507

84 (30)481 (18.8)

196 (70)
2080 (81.2)

280
2561

2844
35,133≤1 month

250 (24.1)

787 (75.9)

1037

MissingYes

129 (29.3)
279 (15.9)

312 (70.7)
1478 (84.1)

441
1757

No

486 (25.6)

1414 (74.4)

1900

MissingGood

95 (24.9)428 (18.3)

287 (75.1)
1915 (81.7)

382
2343

Poor

406 (25.6)

1181 (74.4)

1587

Missing
Independent

26 (23.9)750 (20)83 (76.1)
2996 (80)

109
3746

405 (14.2) 2439 (85.8)<0.01 3182 (9.1)
31951(90.9)
1360
9441 (87.4)(12.6)
611 (17.1) 2965 (82.9)<0.01 1900 (7.1)
24853(92.9)
16267
2719(14.3)(85.7)
534 (14.2) 3237 (85.8)<0.01 3376 (8.5)
36297(91.5)
1563
7132 (82.0)(18.0)
214 (18.7) 928 (81.3)<0.01 4694 (9.9)
42894(90.1)

Categories

Dementia
Sex

Age

Sport group

Hobby group

Going out

Meeting withfriends

Leisure activities

Self-rated health

Activities of dailylivingNomal hearing
pvalueDementia

5149(10.4)<0.01 2196 (9.7)

<0.01

2957
(11.0)
321 (2.3)
801 (5.3)

Nodementia

Total(n = 49510)

44361(89.6)
20421(90.3)
23936(89.0)
13835(97.7)
14396(94.7)
9822 (87.5)

49,51022,617

pvalue<0.01

26,893
14,156<0.01

15,197
11,222
6201
2734
8974
29,854<0.01

10,682
15,184<0.01

24,9619365
43,394

<0.01

2765

<0.01

10,8013576
26,753<0.01

18,9863771
39,673

<0.01

8695
1142
47,588<0.01(continued)

6Gerontology & Geriatric Medicine

Table 1. (continued)
Hearing impairment

Nomal hearing

Categories

Dementia n(%)

No dementia
(%)

Total
(n = 4039)

Minimum assist
MissingYes

73 (46.8)
37 (27.0)
624 (20.7)

83 (53.2)
100 (73.0)
2386 (79.3)

156
4039
3010

No
Missing
No depression

104 (20.3)
132 (25.5)
235 (18.7)

408 (79.7)
385 (74.5)
1023 (81.3)

512
517
1258

Mild depression

532 (21.7)

1921 (78.3)

2453

Depression
MissingMarried83 (27.6)
10 (37.0)
448 (17.9)

218 (72.4)
17 (63.0)2051 (82.1)

301
27
2499

Others412 (26.8)

1128 (73.2)

1540

Living alone

116 (21.4)

425 (78.6)

541

Living withothers≤10 years

744 (21.3)2754 (78.7)

3498

548 (22.1)

1937 (77.9)

2485>10 years

251 (18.0)1143 (82.0)

1394

Missing
Equivalent income Low

61 (38.1)
267 (21.7)

99 (61.9)965 (78.3)

160
1232

Middle207 (17.7)

961 (82.3)

1168

308 (23.4)
1467(12.4)
1464 (8.7)

High

175 (19.1)

741 (80.9)9161212 (8.5)

Missing

211 (29.2)

511 (70.8)

723

1009
(15.7)

Variables

Current smoking

Depressive
symptoms

Marital stetus

Livingarrangement

EduationpvalueDementiaNodementia

237 (38.7)
222 (16.9)
0.04
3722
(10.1)
728 (9.8)703 (13.6)<0.01 1762 (7.7)

375 (61.3)
1008 (83.1)
33218(89.9)
6678 (90.2)
4461 (86.4)
21028(92.3)
3072
21693(12.4)(87.6)
273 (16.4) 1390 (83.6)
46 (15.8) 246 (84.2)<0.01 2876 (8.2)
32146(91.8)
2277
12211(15.7)(84.3)
0.92 781 (12.9) 5277 (87.1)

<0.01

4373
(10.1)
2820 (12)2024 (8.2)

<0.01

39079
(89.9)
20636(88.0)
22712(91.8)
1010 (76.6)
10407(87.6)
15405(91.3)
13128(91.5)
5418 (84.3)

Total(n = 49510)

pvalue612
1310
36,940

<0.01

7406
5164
22,790<0.01

24,7651663
292
35,002<0.01

14,4886058<0.01

43,452
23,456<0.01

24,7361318
11,874<0.01

16,86914,3406427

The total number of participants is shown as a percentage. Comparisons were made using the chi-square test.
For missing values, missing categories were created and included in the analysis.

Many people with congenital HI who do not use cochlear
implants have learned sign language and use it to communicate with others. They are often socially active within
the community of congenital HI. On the other hand, it is
difﬁcult for people with profound acquired HI to learn sign
language and join the community of HI. Limited communication at home and with friends has been associatedwith social introversion and loneliness (Knutson &Lansing, 1990). HI has many negative effects on daily
life, including depression (Li et al., 2014) and apathy(Sugawara et al., 2011). Social networks have been associated with factors that affect brain function, such as stressand depression (Dori et al., 1994), and neuroendocrine
measures of stress have been associated with dementia(Brice & Strauss, 2016).

Thus, social activities may be an effective way to maintaincommunication opportunities while covering the HI of older
adults in the community. People should start social activities
such as sport or hobby clubs early, from the time their hearing
function was normal and should continue them even if hearing
function declines. A longstanding relationship will be useful formutual understanding in the club. Moreover, the use of hearing
aids and consultations with audiologists will be effective for the
HI to more deeply interact and communicate with others. Financial assistance for hearing aids and the development of better
hearing aids should be promoted. It is also important to advise
people on how to access these services.
Our ﬁndings suggest that providing opportunities forsocial activities and interaction for the hearing-impaired older
adult is a viable intervention to promote social participation

Kojima et al.

7

Table 2. Hazard Ratios (HR) to Develop Dementia by Social Activities.
Crude Model
Hearingstatus

Explanatory
variables

Model 1Model 2Categories

HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value>1 month≤1 month

Reference
2.73(2.02-3.69)
Reference
1.99(1.63-2.44)
Reference
1.78(1.46-2.19)
3.71(2.75-5.00)
Reference
1.40(1.20-1.63)
Reference
1.78(1.54-2.06)

Hearing impairment
Sport group

Hobby group

Going out

>1 month≤1 month>2 times a week
>1 times a month≤1 time a month

Meeting with friends

Leisure activities>1 month≤1 month
Yes
No

<0.01

<0.01

0.02
<0.01

<0.01

<0.01

Reference
2.17(1.61-2.94)
Reference
1.70(1.39-2.08)
Reference
1.28(1.05-1.57)
2.32(1.71-3.14)
Reference
1.35(1.15-1.58)
Reference
1.53(1.32-1.78)

<0.01

<0.01

0.02
<0.01

<0.01

<0.01

Reference
2.17(1.53-3.08)
Reference
1.70(1.34-2.17)
Reference
1.29(1.01-1.64)
2.19(1.51-3.17)
Reference
1.27(1.06-1.53)
Reference
1.57(1.31-1.88)

<0.01

<0.01

0.04
<0.01

0.01

<0.01

Nomal hearing
Sport group

Hobby group

Going out

>1 month≤1 month>1 month≤1 month>2 times a week
>1 times a month≤1 time a month

Meeting with friends

Leisure activities>1 month≤1 month
Yes
No

Reference
1.83(1.67-2.01)
Reference
1.76(1.64-1.89)
Reference
2.44(2.23-2.66)
5.07(4.37-5.89)
Reference
1.48(1.39-1.58)
Reference
2.14(2.02-2.28)

<0.01

<0.01

<0.01
<0.01

<0.01

<0.01

Reference
1.52(1.39-1.67)
Reference
1.55(1.44-1.66)
Reference
1.53(1.40-1.67)
2.56(2.20-2.98)
Reference
1.36(1.28-1.45)
Reference
1.78(1.68-1.89)

<0.01

<0.01

<0.01
<0.01

<0.01

<0.01

Reference
1.28(1.16-1.42)
Reference
1.34(1.23-1.45)
Reference
1.44(1.29-1.59)
2.09(1.75-2.51)
Reference
1.24(1.15-1.34)
Reference
1.55(1.45-1.67)

<0.01

<0.01

<0.01
<0.01

<0.01

<0.01

Model1:adjusting for age, sex.
Model2 further adjusting for self-rated health, activity of daily living, current smoking, and depressive symptoms as physical factorsliving arrangement, equivalent
income, education, and marital status as social factors.
HR: hazard ratio, CI: conﬁdence interval.

among the elderly in Japan and may be effective in preventing
the onset of dementia. Future research should investigate thetypes and details of social activities and interactions, such as
sports and hobbies. This could contribute to the prevention ofdementia in the hearing impaired.

than 50 thousand total participants analyzed, and more than fourthousand participants with HI. According to the large scale
study, we revealed the relationship between social activities andthe development of dementia in hearing-impaired older people.

Limitations
Strengths
The strengths of this study include its cohort design, which
provides more convincing evidence than a cross-sectional
design. Another strength is the large sample size of more

This study had several limitations. First, self-administeredquestionnaires were used as the data collection tool, which
may have led to information bias. The HI was assessed based ona questionnaire survey that uses responses to whether HI is being

8

treated. We were unable to exactly ascertain the severity of the
HI in the participants, but we saw the HI level of participants asthat which required treatment. There is a difference between thesubjective assessment of hearing test results (Kamil et al., 2015)
and the underestimation of HI (Uchida et al., 2003) in older
adults. Second, information on the use of hearing aids and otherdevices that assist hearing function is missing. Among thosereceiving treatment for HI, it was not possible to discern who
used hearing aids and other devices and who did not. Further
research is needed to conﬁrm these ﬁndings. Finally, this study
did not consider factors in the community or the environment.
Community-based intervention studies have shown that social
capital effectively prevents the onset of disabilities and cognitive
impairment (Hikichi et al., 2016; Hikichi et al., 2015).
Community-level social capital has been associated withindividual-level health outcomes (Tsuji et al., 2018; Tsuji et al.,2019; Fujihara et al., 2019). Urban areas, railroad tracks, airports, and highways are noisy, and the possibility of noiseinduced HI cannot be ruled out (Chen et al., 2017). Environmental
factors may also affect social activities, such as differences between urban and rural areas. In the future, it will be necessary to
examine the differences between regions to determine how toaddress these issues at the community level.
In conclusion, this cohort study suggests that social interaction and social activities are related to cognitive
function in people with HI. Maintaining opportunities forsocial communication and activities may help prevent
dementia.
Acknowledgments
This study used data from the JAGES. We are extremely grateful to
all the study participants for their personal data. We would like toexpress our deepest gratitude to everyone who participated in thesurvey.

Declaration of Conﬂicting Interests
The author(s) declared no potential conﬂicts of interest with respect
to the research, authorship, and/or publication of this article.

Gerontology & Geriatric Medicine

Authorship
Kaori Kojima (1) Substantial contributions to the conception ordesign of the work, or acquisition, analysis or interpretation of data
for the work; (2) Drafting the work or revising it critically forimportant intellectual content; (3) Final approval of the version tobe published; (4) Agreement to be accountable for all aspects of thework in ensuring that questions related to the accuracy or integrityof any part of the work are appropriately investigated and resolved.
Meeting these criteria should provide each author with sufﬁcientknowledge of and participation in the work that he or she canaccept public responsibility for the report. Eisaku Okada (1)Substantial contributions to the conception or design of the work,or acquisition, analysis or interpretation of data for the work; (3)Final approval of the version to be published; (4) Agreement to beaccountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work areappropriately investigated and resolved. Meeting these criteria
should provide each author with sufﬁcient knowledge of andparticipation in the work that he or she can accept public responsibility for the report. Toshiyuki Ojima (1) Substantial contributions to the conception or design of the work, or acquisition,
analysis or interpretation of data for the work; (3) Final approval ofthe version to be published; (4) Agreement to be accountable for all
aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Meeting these criteria should provide eachauthor with sufﬁcient knowledge of and participation in the workthat he or she can accept public responsibility for the report. Jun
Aida (2) Drafting the work or revising it critically for important
intellectual content; (3) Final approval of the version to be published. Yoshimune Hiratsuka (2) Drafting the work or revising it
critically for important intellectual content; (3) Final approval ofthe version to be published. Katsunori Kondo (2) Drafting the workor revising it critically for important intellectual content; (3) Finalapproval of the version to be published.

ORCID iD
Kaori Kojima  https://orcid.org/0000-0002-9593-5479

Funding

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Science) KAKENHI Grant Number (15H01972, 18H03047,
19H03860, 20H00557, 21K02001,21K19635), Health Labour
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