Association between unilateral or bilateral hearing loss and multimorbidity among the oldest old in China
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摘要:
目的 探讨我国高龄老年人单侧和双侧听力损失与12种慢性疾病及多重慢病的关联，并分析左耳或右耳听力损失与慢性疾病关联的差异。 方法 从中国健康与长寿纵向调查（CLHLS）2018年横断面数据中选取符合要求的7 437名年龄≥80岁的老年人作为研究对象。分别以12种慢性疾病及多重慢病为结局变量，以听力损失为自变量，以社会人口学特征、家庭因素、生活方式相关信息为协变量，采用多因素logistic回归探究单侧（左、右耳）、双侧听力损失与慢性疾病及多重慢病的关联性，并进行趋势性分析。 结果 存在左侧、右侧、双侧听力损失的高龄老年人分别有205名（2.76%）、227名（3.05%）、3 598名（48.38%）。在调整了混杂因素后，与听力功能完好者相比，有左侧、双侧听力损失者面临着更高的多重慢病患病风险，OR（95%CI）分别为2.14（1.58~2.90）、1.27（1.13~1.43），未观察到右侧听力损失与多重慢病患病风险的关联（P＞0.05）。趋势性分析结果显示，多重慢病的患病风险随着听力损失从无到单侧再到双侧递增（P＜0.001）。 结论 听力损失可能与高龄老年人多重慢病的患病风险增加有关，双侧听力损失者面临的患病风险更高，建议关注老年人听力损失的预防和治疗。 Abstract:Objective To investigate the associations between unilateral or bilateral hearing loss and 12 chronic diseases as well as multimorbidity among the oldest old in China, and to identify disparities in these associations of left- and right-side hearing loss with chronic diseases. Methods Totally 7 437 people aged ≥80 years old were selected from the Chinese Longitudinal Health and Longevity Survey (CLHLS) 2018 cross-sectional data. With 12 chronic diseases and multimorbidity as outcome variables, the hearing loss as explanatory variable, socio-demographic characteristics, family factors, and lifestyle as covariates, the correlations of unilateral (left- or right-side) and bilateral hearing loss with chronic diseases and multimorbidity were analyzed using multivariate logistic regression model, and the trend analyses were carried out. Results There were 205 (2.76%), 227 (3.05%) and 3 598 (48.38%) old people with left-side, right-side and bilateral hearing loss, respectively. After adjusting for confounders, the oldest old with left-sided or bilateral hearing loss had a greater risk of multimorbidity compared with those with normal hearing function, with odds ratio (95% confidence interval) of 2.14 (1.58-2.90) and 1.27 (1.13-1.43), respectively, while no association between right-sided hearing loss and multimorbidity was observed (P > 0.05). Trend analysis showed that the risk of multimorbidity increased with hearing loss from none to unilateral and then to bilateral (P < 0.001). Conclusion Hearing loss may be related to the increased risk of multimorbidity in the oldest old, and the risk of those with bilateral hearing loss is higher. More attention should be paid to the prevention and treatment of hearing loss in the oldest old. -
Keywords:
- hearing loss /
- multimorbidity /
- the oldest old /
- cross-sectional studies /
- regression analysis
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多重慢病是指个体同时存在2种或2种以上慢性疾病，老年人的多重慢病已成为一个全球性的公共卫生问题[1]。超过45%的老年人患有多重慢病，且患病率随年龄增长而增高[2]。多重慢病的患者面临着生活质量下降、频繁就医、死亡风险增加等问题，不仅给个人带来身心双重负担，也给家庭和社会造成沉重的经济负担和卫生资源压力[3-4]。因此，加强多重慢病的预防和管理对于老年人生活质量和健康水平的提升具有重要意义。
听力损失是致残的主要原因之一，而老年人通常经历着不同程度的听力下降[5]。听力损失对社会交往、心理健康及个人生活质量等产生着深远的影响[6-9]。有听力障碍的老年人更可能出现功能、心理和认知缺陷，有更差的生存率[10]。有研究探讨了老年人听力损失与痴呆、脑卒中、癌症等单一慢性疾病的关联，且集中在发达国家[11-15]，但很少关注听力损失与多重慢病的关联性。美国一项基于433名80岁及以上人群的队列研究显示，听力损失与心血管合并症有关[16]。中国一项关于12 711名中老年人的纵向研究显示，听力损失合并糖尿病与记忆类疾病的发病风险升高有关[17]。在中国，80岁及以上高龄老年人听力损失的发生率高达82%[10]。然而，对于我国高龄老年群体来说，听力损失是否与更高的多重慢病患病风险相关仍有待探索。
本研究利用中国老年健康影响因素跟踪调查（Chinese Longitudinal Healthy Longevity Survey，CLHLS）2018年数据，探讨我国高龄老年人听力损失与12种常见慢性疾病及多重慢病之间的关系，旨在为多重慢病的预防和管理提供科学依据，从而促进老年人健康和幸福。
1 资料和方法
1.1 资料来源
本研究使用了CLHLS（https://doi.org/10.18170/DVN/WBO7LK）2018年的横断面数据。CLHLS是由北京大学健康老龄与发展研究中心开展的具有广泛代表性的队列调查，在中国23个省采用多阶段、分层的整群抽样设计进行调查，收集了关于健康状况、社会经济特征、生活方式、心理状况及医疗保健服务等方面的可获得信息。在受访者无法回答问题时，可由代理受访者代为回答（通常为配偶或近亲）。调查对象为65岁及以上老年人和其35~64岁成年子女，累计访户约11万人次，其中80岁及以上老年人占67%[18]。CLHLS研究经北京大学研究伦理委员会审核批准（IRB00001052-13074），所有参与者或其代理受访者均提供书面知情同意。2017－2018年进行的调查共采访了15 874名65岁及以上老年人。本研究纳入、排除标准：（1）纳入80岁及以上的老年人；（2）排除听力功能、慢性疾病相关变量缺失的样本；（3）排除协变量缺失的样本。最终纳入7 437例样本。
1.2 资料分析方法
1.2.1 自变量
通过问卷调查中“您是否存在听力困难？”“您哪只耳朵有听力困难？”这2个问题获得受访者的听力功能信息。基于受访者的回答，将其听力功能分为3类，分别为听力功能完好（指受访者没有听力困难，编码为0）、单侧听力损失（指受访者只有一侧耳朵存在听力困难，编码为1）、双侧听力损失（指受访者双侧耳朵均存在听力困难，编码为2）。当区分左、右耳听力损失时，受访者被分为听力功能完好、左侧听力损失、右侧听力损失、双侧听力损失4类，分别编码为0、1、2、3。在趋势性分析中，将听力功能三分类变量转换为有序资料，分别为听力功能完好（编码为1）、单侧听力损失（编码为2）、双侧听力损失（编码为3），在logistic回归分析中作为连续型变量。
1.2.2 结局变量
根据以往研究及国际疾病分类标准[10, 19-20]，结合问卷调查的内容，本研究涵盖了老年人中常见的12种慢性疾病。慢性疾病状况根据受访者的自我报告进行评估，受访者被问及“您目前是否患以下任何一种慢性疾病？”，包括高血压、糖尿病、癌症、关节炎、血脂异常、慢性肾炎、心血管疾病（心脏病或脑卒中）、呼吸系统疾病（支气管炎、肺气肿、肺炎或哮喘）、慢性胃病（胃、肠溃疡）、神经系统疾病（帕金森病或癫痫）、风湿（风湿病或类风湿性疾病）、胆道疾病（胆囊炎和胆石症合并为胆道疾病）。当受访者回答为“是”时，可以定义为相应的慢性疾病患者。在logistic回归分析中，先后分别将每一种慢性疾病和多重慢病作为二元变量进行编码，其中“有”该种慢性疾病编码为1，“无”该种慢性疾病编码为0。多重慢病定义为个体同时发生2种或2种以上慢性疾病[21]，编码为1，只有1种或没有慢性疾病的个体被定义为无多重慢病，编码为0。
1.2.3 协变量
参考以往研究[2, 4, 10, 19]，纳入调查对象的社会人口学特征、家庭因素、生活方式等资料。
（1）社会人口学特征指标分类和编码：年龄分为80~89岁、90~99岁及≥100岁3类，分别编码为0、1、2。性别分为男性和女性2类，分别编码为0和1。居住地分为城市和乡镇2类，分别编码为0和1。BMI以体重（kg）除以报告身高（m）的平方计算，本研究中BMI被分为正常（18.5~23.9 kg/m2）、体重过轻（＜18.5 kg/m2）、超重（24.0~27.9 kg/m2）和肥胖（≥28.0 kg/m2）4类，分别编码为0、1、2、3。
（2）家庭因素指标分类和编码：婚姻状况分为已婚和非在婚2类（非在婚包括离婚、丧偶、从未结婚），分别编码为0和1。居住状况分为与家人或他人同住和独居或在养老机构2类，分别编码为0和1。自评收入状况分为贫穷、普通、富裕3类，分别编码为0、1、2。
（3）生活方式指标分类和编码：吸烟情况分为当前不吸烟和吸烟2类，分别编码为0和1。规律锻炼情况分为当前经常锻炼和不经常锻炼2类，分别编码为0和1。当前是否经常规律锻炼协变量通过结构化、标准化问卷进行收集[22]。
1.3 统计学处理
采用Stata 17.0软件进行数据分析。计数资料采用频数和百分数进行描述，采用χ2检验评估老年人基本特征分布的差异。在患病情况分析中，患病率用于评估该高龄老年群体的慢性疾病患病情况，条件概率用于分析不同听力功能状态下的慢性疾病患病情况，采用χ2检验比较不同听力功能状态下的慢性疾病患病率。采用多因素logistic回归探究单侧（左或右耳）和双侧听力损失与慢性疾病和多重慢病的关联。为了分析听力损失严重程度与慢性疾病患病风险之间的潜在线性趋势，将听力功能由三分类变量转换为有序资料，在logistic回归中作为连续型变量进行趋势性分析。调整后的模型控制了人口统计学变量（年龄、性别、居住地、BMI）、家庭因素变量（婚姻状况、居住状况、自评收入状况）及生活方式变量（吸烟情况和规律锻炼情况）。双侧检验水准（α）为0.05。
2 结果
2.1 基本情况
在纳入的7 437名年龄≥80岁受访者中，听力功能完好者3 407人（45.81%）、单侧听力损失者432人（5.81%；左、右侧听力损失分别有205、227人）、双侧听力损失者3 598人（48.38%）。所研究受访者的平均年龄为（92.31±7.74）岁，其中女3 039人（40.86%）、男4 398人（59.14%），5 752人（77.34%）居住在农村，5 662人（76.13%）丧偶、离婚或未婚，1 583人（21.29%）独居或住在养老院，761人（10.23%）自评收入状况为贫穷，1 729人（23.25%）超重或肥胖，911人（12.25%）吸烟，5 642人（75.86%）不经常锻炼。将所研究人群按是否患多重慢病进行分组分析，结果显示，患多重慢病与未患多重慢病的高龄老年人在不同年龄分层、居住地、婚姻状况、居住状况、自评收入状况、BMI、吸烟情况、规律锻炼情况、听力功能状态等方面差异均有统计学意义（均P＜0.01）。见表 1。
表 1 高龄老年人的基本特征Table 1 Basic characteristics of the oldest oldn (%) Characteristic Total N＝7 437 Non-multimorbidity N＝5 300 Multimorbidity N＝2 137 χ2 value P value Age 223.885 ＜0.001 80-89 years old 2 838 (38.16) 1 771 (33.42) 1 067 (49.93) 90-99 years old 2 564 (34.48) 1 862 (35.13) 702 (32.85) ≥100 years old 2 035 (27.36) 1 667 (31.45) 368 (17.22) Gender 0.856 0.355 Female 3 039 (40.86) 2 148 (40.53) 891 (41.69) Male 4 398 (59.14) 3 152 (59.47) 1 246 (58.31) Residence 378.493 ＜0.001 Urban 1 685 (22.66) 883 (16.66) 802 (37.53) Rural 5 752 (77.34) 4 417 (83.34) 1 335 (62.47) Marital status 39.809 ＜0.001 Married 1 775 (23.87) 1 160 (21.89) 615 (28.78) Unmarrieda 5 662 (76.13) 4 140 (78.11) 1 522 (71.22) Living status 7.982 0.005 Living with family or others 5 854 (78.71) 4 217 (79.57) 1 637 (76.60) Living alone or in nursing home 1 583 (21.29) 1 083 (20.43) 500 (23.40) Self-rated income 27.027 ＜0.001 Poor 761 (10.23) 556 (10.49) 205 (9.59) Middle 5 190 (69.79) 3 766 (71.06) 1 424 (66.64) Rich 1 486 (19.98) 978 (18.45) 508 (23.77) Body mass index ＜18.5 kg•m－2 3 604 (48.46) 2 646 (49.92) 958 (44.83) 200.440 ＜0.001 18.5-23.9 kg•m－2 2 104 (28.29) 1 644 (31.02) 460 (21.53) 24.0-27.9 kg•m－2 1 185 (15.93) 674 (12.72) 511 (23.91) ≥28.0 kg•m－2 544 (7.31) 336 (6.34) 208 (9.73) Smoking status 27.237 ＜0.001 No 6 526 (87.75) 4 584 (86.49) 1 942 (90.88) Yes 911 (12.25) 716 (13.51) 195 (9.12) Regular exercise 36.735 ＜0.001 No 5 642 (75.86) 4 122 (77.77) 1 520 (71.13) Yes 1 795 (24.14) 1 178 (22.23) 617 (28.87) Hearing function 34.871 ＜0.001 Normal 3 407 (45.81) 2 394 (45.17) 1 013 (47.40) Left hearing loss 205 (2.76) 113 (2.13) 92 (4.31) Right hearing loss 227 (3.05) 158 (2.98) 69 (3.23) Bilateral hearing loss 3 598 (48.38) 2 635 (49.72) 963 (45.06) a: Unmarried refers to widowed, divorced, or never married. 2.2 不同听力功能状态下高龄老年人慢性疾病患病分布情况
7 437名高龄老年人的共病率（即多重慢病的患病率）为28.73%（2 137/7 437）。自我报告的12种慢性疾病的患病率由高到低依次为高血压（36.87%，2 742/7 437）、心血管疾病（16.05%，1 194/7 437）、呼吸系统疾病（11.07%，823/7 437）、关节炎（9.63%，716/7 437）、糖尿病（6.62%，492/7 437）、风湿（4.54%，338/7 437）、慢性胃病（4.22%，314/7 437）、神经系统疾病（3.85%，286/7 437）、血脂异常（3.66%，272/7 437）、胆道疾病（3.54%，263/7 437）、癌症（1.26%，94/7 437）、慢性肾炎（1.00%，74/7 437）。高血压、糖尿病、呼吸系统疾病、慢性胃病、神经系统疾病、关节炎、胆道疾病、血脂异常及多重慢病在不同听力功能状态人群中的患病率差异均有统计学意义（均P＜0.05，表 2）。
表 2 不同听力功能状态下高龄老年人慢性疾病的患病率比较Table 2 Comparison of prevalence of chronic diseases in the oldest old with different hearing function conditionsChronic disease Normal hearing function N＝3 407 Unilateral hearing loss N＝432 Bilateral hearing loss N＝3 598 χ2 value P value Hypertension 1 356 (39.80) 200 (46.30) 1186 (32.96) 52.660 ＜0.001 Diabetes mellitus 253 (7.43) 38 (8.80) 201 (5.59) 13.115 0.001 Cardiovascular disease 579 (16.99) 75 (17.36) 540 (15.01) 5.702 0.058 Respiratory disease 343 (10.07) 65 (15.05) 415 (11.53) 11.207 0.004 Cancer 42 (1.23) 6 (1.39) 46 (1.28) 0.087 0.958 Chronic gastropathy 148 (4.34) 28 (6.48) 138 (3.84) 6.909 0.032 Nervous system disease 76 (2.23) 6 (1.39) 204 (5.67) 63.460 ＜0.001 Arthritis 368 (10.80) 39 (9.03) 309 (8.59) 10.041 0.007 Rheumatism 157 (4.61) 23 (5.32) 158 (4.39) 0.832 0.660 Biliary disease 130 (3.82) 30 (6.94) 103 (2.86) 20.275 ＜0.001 Dyslipidemia 146 (4.29) 13 (3.01) 113 (3.14) 7.054 0.029 Chronic nephritis 41 (1.20) 6 (1.39) 27 (0.75) 4.367 0.113 Multimorbiditya 1 013 (29.73) 161 (37.27) 963 (26.76) 23.839 ＜0.001 a: Multimorbidity refers to having 2 or more chronic diseases. 2.3 高龄老年人单侧、双侧听力损失影响12种慢性疾病及多重慢病的多因素logistic回归分析
以听力损失为自变量，分别以不同的慢性疾病和多重慢病为因变量，进行多因素logistic回归分析。在调整了相关的混杂因素后，与听力功能完好的受访者相比，左侧听力损失与高血压（OR＝1.93，95%CI 1.43~2.59）、糖尿病（OR＝1.72，95%CI 1.07~2.78）、呼吸系统疾病（OR＝1.55，95%CI 1.03~2.34）及慢性胃病（OR＝2.35，95%CI 1.41~3.89）显著关联；而右侧听力损失仅与呼吸系统疾病（OR＝1.62，95%CI 1.10~2.38）和胆道疾病（OR＝2.07，95%CI 1.21~3.53）的关联有统计学意义；双侧听力损失与糖尿病（OR＝1.25，95%CI 1.01~1.55）、心血管疾病（OR＝1.17，95%CI 1.01~1.35）、呼吸系统疾病（OR＝1.36，95%CI 1.16~1.61）及神经系统疾病（OR＝2.13，95%CI 1.60~2.85）的患病风险密切关联。此外，左侧听力损失（OR＝2.14，95%CI 1.58~2.90）和双侧听力损失（OR＝1.27，95%CI 1.13~1.43）与多重慢病的关联均有统计学意义。见表 3。
表 3 高龄老年人单侧、双侧听力损失对12种慢性疾病及多重慢病影响的多因素logistic回归分析Table 3 Multivariate logistic regression analysis of unilateral or bilateral hearing loss affecting 12 chronic diseases and multimorbidity among the oldest oldOR (95%CI) Chronic disease Left-side hearing loss Right-side hearing loss Bilateral hearing loss Hypertension 1.93 (1.43, 2.59)** 1.13 (0.84, 1.50) 1.01 (0.91, 1.13) Diabetes mellitus 1.72 (1.07, 2.78)* 0.90 (0.51, 1.59) 1.25 (1.01, 1.55)* Cardiovascular disease 1.28 (0.89, 1.55) 0.84 (0.56, 1.24) 1.17 (1.01, 1.35)* Respiratory disease 1.55 (1.03, 2.34)* 1.62 (1.10, 2.38)* 1.36 (1.16, 1.61)** Cancer 1.16 (0.35, 3.83) 1.07 (0.33, 3.53) 1.43 (0.90, 2.26) Chronic gastropathy 2.35 (1.41, 3.89)** 0.99 (0.49, 1.97) 1.06 (0.82, 1.38) Nervous system disease 0.68 (0.21, 2.19) 0.53 (0.17, 1.71) 2.13 (1.60, 2.85)** Arthritis 0.98 (0.61, 1.58) 0.76 (0.46, 1.25) 0.99 (0.83, 1.18) Rheumatism 1.25 (0.66, 2.35) 1.29 (0.70, 2.36) 1.16 (0.91, 1.49) Biliary disease 1.71 (0.95, 3.11) 2.07 (1.21, 3.53)** 0.88 (0.66, 1.18) Dyslipidemia 0.99 (0.48, 2.01) 0.38 (0.14, 1.05) 1.20 (0.91, 1.59) Chronic nephritis 0.87 (0.21, 3.66) 1.51 (0.53, 4.30) 0.84 (0.49, 1.42) Multimorbiditya 2.14 (1.58, 2.90)** 1.12 (0.82, 1.54) 1.27 (1.13, 1.43)** After adjusting for age, gender, residence, marital status, living status, self-rated income, body mass index, smoking status, and regular exercise, the multivariate logistic regression analysis was conducted with normal hearing function as the reference. a: Multimorbidity refers to having 2 or more chronic diseases. *P＜0.05, **P＜0.01. OR: Odds ratio; 95%CI: 95% confidence interval. 2.4 高龄老年人单侧、双侧听力损失与2种慢性疾病及多重慢病关联性的趋势性分析
多因素logistic回归分析中左侧（或右侧）和双侧均有统计学意义的2种慢性疾病（糖尿病、呼吸系统疾病）及多重慢病被纳入趋势性分析，结果见表 4。将自变量由分类变量转换连续型变量，调整相关的混杂因素后，对于糖尿病、呼吸系统疾病及多重慢病趋势性分析结果均有统计学意义（均P＜0.001）。
表 4 高龄老年人单侧、双侧听力损失与2种慢性疾病及多重慢病关联性的趋势性分析Table 4 Trend analysis of associations between unilateral or bilateral hearing loss and 2 chronic diseases and multimorbidity among the oldest oldChronic disease Hearing function OR (95%CI) P for trend Diabetes mellitus Normal Reference ＜0.001 Unilateral hearing loss 1.27 (0.87, 1.86) Bilateral hearing loss 1.26 (1.01, 1.55)* Respiratory disease Normal Reference ＜0.001 Unilateral hearing loss 1.59 (1.19, 2.13)** Bilateral hearing loss 1.36 (1.16, 1.61)** Multimorbiditya Normal Reference ＜0.001 Unilateral hearing loss 1.55 (1.24, 1.94)** Bilateral hearing loss 1.27 (1.13, 1.43)** The trend analysis was conducted after adjusting for age, gender, residence, marital status, living status, self-rated income, body mass index, smoking status, and regular exercise. a: Multimorbidity refers to having 2 or more chronic diseases. *P＜0.05, **P＜0.01. OR: Odds ratio; 95%CI: 95% confidence interval. 3 讨论
本研究探讨了中国高龄老年人单侧、双侧听力损失与多重慢病之间的关联。结果显示，与听力功能完好的高龄老年人相比，左侧和双侧听力损失均与多重慢病患病风险增加存在关联，而右侧听力损失则未表现出类似关联。此外，多重慢病患病风险随着听力损失从无到单侧再到双侧呈现递增趋势。本项横断面研究为今后老年人的听力损失预防和慢性疾病管理提供了潜在的方向。
本研究观察到高龄老年人双侧听力损失与一些慢性疾病及多重慢病风险增加关联，且左侧听力损失的个体患多重慢病的风险更高。这一研究结果与既往研究一致，即听力损失可能通过多种途径增加慢性疾病负担[8, 22-28]。例如，大型队列研究的累积数据表明，年龄相关的听力损失与痴呆风险增加有关，且患病风险可能因听力损失的加重而增加[24, 27]。而本研究则补充了多重慢病与听力损失的关联性证据，可能的影响机制如下：首先，听力损失与耳蜗微血管病变有关，耳蜗供血不足可能提示全身血管状态异常，与糖尿病等慢性疾病密切关联[23]；其次，听力损失可能导致个体社交减少，抑郁、焦虑等心理问题增加，进而间接促进慢性疾病的发生和发展[24-26]。然而，听力损失与多重慢病之间也存在反向关联的可能，慢性疾病通常伴随着血管硬化和代谢紊乱[13, 29]，这可能导致耳内细胞微循环出现血流量不足和血管损伤，从而引起耳鸣和听力损失等问题[26-27, 30-31]。鉴于本研究的横断面性质，未来应前瞻性地调查听力损失与慢性疾病和多重慢病的因果关联。此外，在本研究中，对于高龄老年群体，患多重慢病、糖尿病及呼吸系统疾病的风险随着听力损失从无到单侧再到双侧递增而增加，提示听力功能可能是评估高龄老年人健康风险的重要指标，针对老年人的早期听力筛查尤为关键。
值得注意的是，之前很少有研究关注听力损失的左右耳差异，而本研究区分左右耳听力损失对健康的影响，发现左侧听力损失与高血压、糖尿病等慢性疾病显著相关，右侧听力损失与呼吸系统疾病和胆道疾病相关。一项前瞻性研究表明，阿尔茨海默病患者在二分句识别测试（dichotic sentence identification test，DSI）中的左耳得分明显低于右耳，且左耳DSI得分与大脑连接性下降有关，而右耳DSI得分则不存在这种关联[32]。这可能是由于“右耳优势”导致[33]，“右耳优势”是大脑不对称和半球优势的结果，听觉系统在左右耳蜗水平上的不对称反应可能解释了右耳听力损失对整体功能的影响较轻的现象，即左耳与更大的患病风险相关[34]。另一项基于儿童的研究也得出了类似的结果，表明左耳会受到更显著的噪声诱发听力损失的影响[35]。但未来仍需开展更多神经生理学研究进一步验证相关机制。
本研究存在以下局限性，第一，由于观察性研究的性质，未能阐明听力损失与多重慢病之间的因果关联，听力损失也可能是多重慢病的结果。第二，听力功能状态及慢性疾病患病情况是根据问卷中受访者的自我报告进行评估的，并未进行实际的测量，还可能存在回忆偏倚。第三，虽然本研究采用了具有高龄老年人代表性的大样本数据，但缺失数据可能对研究结果产生一定的影响。未来研究需要进一步探讨听力损失与多重慢病的纵向关联性及潜在机制。
老龄化已成为近年来公共卫生领域的一个重要课题。本研究结果表明，我国高龄老年人左侧或双侧听力损失与多重慢病患病风险增加相关，且患病风险随听力损失从无到单侧再到双侧呈现增加趋势。该结果提示，听力损失可能提示某些慢性疾病的存在，尤其是高龄老年人；建议将听力筛查纳入老年人常规体检；对于那些已经患有听力损失的老年人，及时佩戴助听器或进行听觉康复训练或许能够减轻听力损失产生的不利影响；此外，还需加强公众对听力保护的认识。总之，应重视老年人尤其是高龄老年人的听力状态并定期进行筛查，加大听力损失预防的宣传力度，鼓励患有听力损失的老年人佩戴助听器。此外，未来需要在高风险和弱势群体中开展相关的前瞻性研究，以进一步分析单侧、双侧听力损失对多重慢病的影响并探究潜在的生物学机制。
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表 1 高龄老年人的基本特征
Table 1 Basic characteristics of the oldest old
n (%) Characteristic Total N＝7 437 Non-multimorbidity N＝5 300 Multimorbidity N＝2 137 χ2 value P value Age 223.885 ＜0.001 80-89 years old 2 838 (38.16) 1 771 (33.42) 1 067 (49.93) 90-99 years old 2 564 (34.48) 1 862 (35.13) 702 (32.85) ≥100 years old 2 035 (27.36) 1 667 (31.45) 368 (17.22) Gender 0.856 0.355 Female 3 039 (40.86) 2 148 (40.53) 891 (41.69) Male 4 398 (59.14) 3 152 (59.47) 1 246 (58.31) Residence 378.493 ＜0.001 Urban 1 685 (22.66) 883 (16.66) 802 (37.53) Rural 5 752 (77.34) 4 417 (83.34) 1 335 (62.47) Marital status 39.809 ＜0.001 Married 1 775 (23.87) 1 160 (21.89) 615 (28.78) Unmarrieda 5 662 (76.13) 4 140 (78.11) 1 522 (71.22) Living status 7.982 0.005 Living with family or others 5 854 (78.71) 4 217 (79.57) 1 637 (76.60) Living alone or in nursing home 1 583 (21.29) 1 083 (20.43) 500 (23.40) Self-rated income 27.027 ＜0.001 Poor 761 (10.23) 556 (10.49) 205 (9.59) Middle 5 190 (69.79) 3 766 (71.06) 1 424 (66.64) Rich 1 486 (19.98) 978 (18.45) 508 (23.77) Body mass index ＜18.5 kg•m－2 3 604 (48.46) 2 646 (49.92) 958 (44.83) 200.440 ＜0.001 18.5-23.9 kg•m－2 2 104 (28.29) 1 644 (31.02) 460 (21.53) 24.0-27.9 kg•m－2 1 185 (15.93) 674 (12.72) 511 (23.91) ≥28.0 kg•m－2 544 (7.31) 336 (6.34) 208 (9.73) Smoking status 27.237 ＜0.001 No 6 526 (87.75) 4 584 (86.49) 1 942 (90.88) Yes 911 (12.25) 716 (13.51) 195 (9.12) Regular exercise 36.735 ＜0.001 No 5 642 (75.86) 4 122 (77.77) 1 520 (71.13) Yes 1 795 (24.14) 1 178 (22.23) 617 (28.87) Hearing function 34.871 ＜0.001 Normal 3 407 (45.81) 2 394 (45.17) 1 013 (47.40) Left hearing loss 205 (2.76) 113 (2.13) 92 (4.31) Right hearing loss 227 (3.05) 158 (2.98) 69 (3.23) Bilateral hearing loss 3 598 (48.38) 2 635 (49.72) 963 (45.06) a: Unmarried refers to widowed, divorced, or never married. 表 2 不同听力功能状态下高龄老年人慢性疾病的患病率比较
Table 2 Comparison of prevalence of chronic diseases in the oldest old with different hearing function conditions
Chronic disease Normal hearing function N＝3 407 Unilateral hearing loss N＝432 Bilateral hearing loss N＝3 598 χ2 value P value Hypertension 1 356 (39.80) 200 (46.30) 1186 (32.96) 52.660 ＜0.001 Diabetes mellitus 253 (7.43) 38 (8.80) 201 (5.59) 13.115 0.001 Cardiovascular disease 579 (16.99) 75 (17.36) 540 (15.01) 5.702 0.058 Respiratory disease 343 (10.07) 65 (15.05) 415 (11.53) 11.207 0.004 Cancer 42 (1.23) 6 (1.39) 46 (1.28) 0.087 0.958 Chronic gastropathy 148 (4.34) 28 (6.48) 138 (3.84) 6.909 0.032 Nervous system disease 76 (2.23) 6 (1.39) 204 (5.67) 63.460 ＜0.001 Arthritis 368 (10.80) 39 (9.03) 309 (8.59) 10.041 0.007 Rheumatism 157 (4.61) 23 (5.32) 158 (4.39) 0.832 0.660 Biliary disease 130 (3.82) 30 (6.94) 103 (2.86) 20.275 ＜0.001 Dyslipidemia 146 (4.29) 13 (3.01) 113 (3.14) 7.054 0.029 Chronic nephritis 41 (1.20) 6 (1.39) 27 (0.75) 4.367 0.113 Multimorbiditya 1 013 (29.73) 161 (37.27) 963 (26.76) 23.839 ＜0.001 a: Multimorbidity refers to having 2 or more chronic diseases. 表 3 高龄老年人单侧、双侧听力损失对12种慢性疾病及多重慢病影响的多因素logistic回归分析
Table 3 Multivariate logistic regression analysis of unilateral or bilateral hearing loss affecting 12 chronic diseases and multimorbidity among the oldest old
OR (95%CI) Chronic disease Left-side hearing loss Right-side hearing loss Bilateral hearing loss Hypertension 1.93 (1.43, 2.59)** 1.13 (0.84, 1.50) 1.01 (0.91, 1.13) Diabetes mellitus 1.72 (1.07, 2.78)* 0.90 (0.51, 1.59) 1.25 (1.01, 1.55)* Cardiovascular disease 1.28 (0.89, 1.55) 0.84 (0.56, 1.24) 1.17 (1.01, 1.35)* Respiratory disease 1.55 (1.03, 2.34)* 1.62 (1.10, 2.38)* 1.36 (1.16, 1.61)** Cancer 1.16 (0.35, 3.83) 1.07 (0.33, 3.53) 1.43 (0.90, 2.26) Chronic gastropathy 2.35 (1.41, 3.89)** 0.99 (0.49, 1.97) 1.06 (0.82, 1.38) Nervous system disease 0.68 (0.21, 2.19) 0.53 (0.17, 1.71) 2.13 (1.60, 2.85)** Arthritis 0.98 (0.61, 1.58) 0.76 (0.46, 1.25) 0.99 (0.83, 1.18) Rheumatism 1.25 (0.66, 2.35) 1.29 (0.70, 2.36) 1.16 (0.91, 1.49) Biliary disease 1.71 (0.95, 3.11) 2.07 (1.21, 3.53)** 0.88 (0.66, 1.18) Dyslipidemia 0.99 (0.48, 2.01) 0.38 (0.14, 1.05) 1.20 (0.91, 1.59) Chronic nephritis 0.87 (0.21, 3.66) 1.51 (0.53, 4.30) 0.84 (0.49, 1.42) Multimorbiditya 2.14 (1.58, 2.90)** 1.12 (0.82, 1.54) 1.27 (1.13, 1.43)** After adjusting for age, gender, residence, marital status, living status, self-rated income, body mass index, smoking status, and regular exercise, the multivariate logistic regression analysis was conducted with normal hearing function as the reference. a: Multimorbidity refers to having 2 or more chronic diseases. *P＜0.05, **P＜0.01. OR: Odds ratio; 95%CI: 95% confidence interval. 表 4 高龄老年人单侧、双侧听力损失与2种慢性疾病及多重慢病关联性的趋势性分析
Table 4 Trend analysis of associations between unilateral or bilateral hearing loss and 2 chronic diseases and multimorbidity among the oldest old
Chronic disease Hearing function OR (95%CI) P for trend Diabetes mellitus Normal Reference ＜0.001 Unilateral hearing loss 1.27 (0.87, 1.86) Bilateral hearing loss 1.26 (1.01, 1.55)* Respiratory disease Normal Reference ＜0.001 Unilateral hearing loss 1.59 (1.19, 2.13)** Bilateral hearing loss 1.36 (1.16, 1.61)** Multimorbiditya Normal Reference ＜0.001 Unilateral hearing loss 1.55 (1.24, 1.94)** Bilateral hearing loss 1.27 (1.13, 1.43)** The trend analysis was conducted after adjusting for age, gender, residence, marital status, living status, self-rated income, body mass index, smoking status, and regular exercise. a: Multimorbidity refers to having 2 or more chronic diseases. *P＜0.05, **P＜0.01. OR: Odds ratio; 95%CI: 95% confidence interval. -
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