Prevalence of visual impairment in people aged 75 years and older in Britain: results from the MRC trial of assessment and management of older people in the community

Visually Impaired OLder people's Exercise programme for falls prevenTion (VIOLET): a feasibility study protocol

INTRODUCTION

In the UK, 1 in 5 people aged 75 and over live with sight loss. Visually impaired older people (VIOP) have an above average incidence of falls and 1.3-1.9 times more likely to experience hip fractures, than the general population. Older people with eye diseases are ∼3 times more likely than those with good vision, to limit activities due to fear of falling. This feasibility study aims to adapt the group-based Falls Management Exercise (FaME) programme to the needs of VIOP and carry out an external pilot trial to inform the design of a future definitive randomised controlled trial.

METHODS AND DESIGN

A UK based 2-centre mixed methods, randomised, feasibility study will be conducted over 28 months. Stakeholder panels, including VIOP, will make recommendations for adaptations to an existing exercise programme (FaME), to meet the needs of VIOP, promoting uptake and adherence, while retaining required effective components of the exercise programme. 80 VIOP aged 60 and over, living at home, ambulant with or without a walking aid, will be recruited in Newcastle (n=40) and Glasgow (n=40) through National Health Service (NHS) Trusts and third sector partners. Participants randomised into the intervention arm will receive the adapted FaME programme. Participants randomised into the control arm will continue with usual activity. Outcomes are, recruitment rate, adherence and validated measures including fear of falling and quality of life. Postintervention in-depth qualitative interviews will be conducted with a purposive sample of VIOP (N=10). Postural stability instructors will be interviewed, before trial-specific training and following the intervention.

ETHICS AND DISSEMINATION

Ethics approval was secured through the National Research Ethics Service (NRES) Committee North East, Newcastle and North Tyneside 2. Glasgow Caledonian University was approved as a non-NHS site with local ethics approval. Findings will be disseminated through peer-reviewed journals, national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN16949845.

The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives

Background

The prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.

Objectives

To measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.

Design

Stage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.

Setting

Stage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.

Participants

Stage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.

Interventions

Stage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).

Main outcome measures.

VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.

Results

Stage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.

Limitations

Sampling bias is possible owing to quota-sampling and response bias.

Conclusions

The prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Visual Impairment Screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle

OBJECTIVES

To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital.

DESIGN

Retrospective, observational cross-sectional, single-centre study.

SETTING

Institutional practice.

PARTICIPANTS

Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648).

MEASUREMENTS

Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups.

RESULTS

The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score.

CONCLUSION

The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

The causes of falls: views of older people with visual impairment

Background

Sight impairment increases with age and, compared with the general older population, older people with sight impairment are more likely to fall. There is a growing body of evidence on the views and perceptions of older people about falls, but little is published on the views of older people with sight impairment.

Objective

To explore what older people with sight impairment believe to be the causes of falls.

Design

A qualitative design was used, incorporating focus groups and interviews in which participants discussed falls and falls prevention. Framework analysis was employed to identify themes arising from participants' discussions of the causes of falls.

Setting and participants

Fifty‐four community dwelling men and women with sight impairment, aged 65 and over, were recruited from across Greater Manchester, UK.

Results

Five types of factors were identified that were believed to cause falls: (i) health issues and changes in balance caused by ageing; (ii) cognitive and behavioural factors; (iii) the impact of sight impairment on getting around the home; (iv) the impact of sight impairment on negotiating the environment away from home; and (v) unexplained falls.

Discussion and conclusions

Older people with sight impairment reported many researched risk factors previously identified by older people without sight impairment but also described many perceived risks unique to people with sight impairment. There are few interventions to prevent falls aimed at older people with sight impairment, and the results of this study allow further tailoring of such interventions based on views of older people with sight impairment.

Visual acuity thresholds associated with activity limitations in the elderly. The Pathologies Oculaires Liées à l'Age study

PURPOSE

Activity limitations, which induce loss of autonomy in the elderly, are a major public health problem. We investigated the associations between objectively determined visual impairments and activity limitations and assessed the visual acuity thresholds associated with these restrictions.

METHODS

The study sample consisted of 1887 people aged 63 years and over from a population-based cohort. Moderate to severe visual impairment was defined as presenting visual acuity lower than 20/70, according to the World Health Organization (WHO) definition. In addition, we studied mild visual impairment, defined as visual acuity [20/70-20/40]. Multivariate logistic regressions were used to estimate the associations between vision and instrumental activities of daily living (IADL) limitations. Using receiver-operating characteristic (ROC) curves, we identified visual acuity thresholds that maximized the Youden index ([sensitivity + specificity]-1) for predicting IADL limitations.

RESULTS

After adjustment for potential confounders, moderate to severe visual impairment and mild visual impairment were strongly associated with IADL limitations (odds ratio [OR] = 3.49; 95% confidence interval [CI] = 1.93, 6.32 and OR = 1.77; 95% CI = 1.07, 2.91, respectively). Visual acuity was a strong predictor of IADL limitations, with an area under the ROC curve of 0.72 (95% CI = 0.68, 0.76). The best discrimination between subjects with or without IADL limitations (global, physical and cognitive) was obtained for visual acuities around 20/40-20/50.

CONCLUSION

This study confirms major increased risk for IADL limitations in subjects with moderate to severe visual impairment. In addition, it suggests that milder visual impairments (in particular below 20/40) may also be related to an increased risk for IADL limitations and should be considered for early medical intervention, before the decline of the subject autonomy.

Economic inequalities in burden of illness, diagnosis and treatment of five long-term conditions in England: panel study

OBJECTIVE

We compared the distribution by wealth of self-reported illness burden (estimated from validated scales, biomarker and reported symptoms) for angina, cataract, depression, diabetes and osteoarthritis, with the distribution of self-reported medical diagnosis and treatment. We aimed to determine if the greater illness burden borne by poorer participants was matched by appropriately higher levels of diagnosis and treatment.

DESIGN

The English Longitudinal Study of Ageing, a panel study of 12,765 participants aged 50 years and older in four waves from 2004 to 2011, selected using a stratified random sample of households in England. Distribution of illness burden, diagnosis and treatment by wealth was estimated using regression analysis.

OUTCOME MEASURES

The main outcome measures were ORs for the illness burden, diagnosis and treatment, respectively, adjusted for age, sex and wealth. We estimated the illness burden for angina with the Rose Angina scale, diabetes with fasting glycosylated haemoglobin, depression with the Centre for Epidemiologic Studies Depression Scale, osteoarthritis with self-reported pain and disability and cataract with self-reported poor vision. Medical diagnoses were self-reported for all conditions. Treatment was defined as β-blocker prescription for angina, surgery for osteoarthritis and cataract, and receipt of predefined effective interventions for diabetes and depression.

RESULTS

Compared with the wealthiest, the least wealthy participant had substantially higher odds for illness burden from any of the five conditions at all four time points, with ORs ranging from 4.2 (95% CI 2.6 to 6.8) for diabetes to 15.1 (11.4 to 20.0) for osteoarthritis. The ORs for diagnosis and treatment were smaller in all five conditions, and ranged from 0.9 (0.5 to 1.4) for diabetes treatment to 4.5 (3.3 to 6.0) for angina diagnosis.

CONCLUSIONS

The substantially higher illness burden in less wealthy participants was not matched by appropriately higher levels of diagnosis and treatment.

Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study

BACKGROUND

Visual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions.

METHODS

We conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without.

RESULTS

Twenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)).

CONCLUSIONS

Patients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services.

Barriers to employment for visually impaired women

Purpose

– The purpose of this paper is to explore barriers to employment for visually impaired (VI) women and potential solutions to those barriers.

Design/methodology/approach

– Mixed methods, comprising three phases; first, exploratory interviews with VI women (n=6) and employers (n=3); second, a survey to assess the barriers to employment experienced by this group (n=96); and third, in-depth interviews with VI women (n=15). This paper reports phases 2 and 3.

Findings

– The most commonly reported barriers to work were: negative employer attitudes; the provision of adjustments in the workplace; restricted mobility; and having an additional disability/health condition. Significantly more barriers were reported by women: who reported that their confidence had been affected by the barriers they had experienced; with dependents under 16; and women who wanted to work.

Research limitations/implications

– Key solutions to these barriers included: training for employers; adaptive equipment; flexibility; better support; training and work experience opportunities; and more widely available part-time employment opportunities.

Originality/value

– This paper adds to the literature in respect of the key barriers to employment for VI women, together with providing key solutions to these barriers.

Relationship between Body Mass Index, Blood Pressure, and Visual Acuity in Residents of Esan West Local Government Area of Edo State, Nigeria

Aim. To study the relationship between body mass index (BMI) and blood pressure (BP) on visual acuity among apparently healthy residents of Ekpoma, Esan West Local Government Area of Edo State, Nigeria. Methodology. This is a cross-sectional descriptive study among 225 subjects (ages of 18–35 years) from whom BP, body weight, and height were collected. Visual acuity was measured using the Snellen chart following standard procedures of number of letters seen at 6-metre distance. The data were then analyzed using SPSS version 17. Results. The sampled population consists of 112 male and 113 female (mean age 31.72±14.2 years). Majority (180) of the respondents had normal visual acuity. However, compared with the respondents with normal BMI (R19.61±1.5; L19.67±1.70), visual acuity of underweight (R18.53±2.30; L18.53±2.70) and obese (R15.68±4.79; L17.73±1.70) were more deviated. Similarly, compared with respondent with normal BP (120–125/80–85 mmHg; R18.00±2.53; L18.07±3.11), hypotensive (R15.5±7.35; L15.00±10.20), and hypertensive (R15.01±21.25; L15.00±11.91) respondents had deviated visual acuity. Conclusion. Abnormal body weight (underweight and obese) and BP (hypotension and hypertension) have potential negative impacts on visual acuity. Based on the observed relationship between weights, BP, and visual acuity, eye examinations can be included as regular screening exercise for abnormal BMI and BP conditions.

Adherence to dietary guidelines and the 10-year cumulative incidence of visual impairment: the Blue Mountains Eye Study

PURPOSE

To assess whether adherence to dietary guidelines at baseline is associated with the incidence of visual impairment among older persons after 10 years.

DESIGN

A population-based cohort of 3654 participants of the Blue Mountains Eye Study were examined at baseline and were reexamined after 5 and 10 years.

METHODS

The incidence of visual impairment was defined as best-corrected visual acuity (VA)<20/40 at follow-up in 1 or both eyes. Dietary information was obtained at baseline using a validated food frequency questionnaire (FFQ). Total Diet Score (TDS) was calculated based on the Australian diet quality index. TDS includes components of diet quality; poor dietary habits; and energy balance. Discrete logistic regression models with time-dependant outcome variables were used to calculate hazard risk ratios (HR) and 95% confidence intervals (CI) associated with incidence of visual impairment for each unit/quartile increase in TDS, adjusting for potential confounders.

RESULTS

Of the 3654 baseline participants, 1963 had up to 10 years follow-up with completed FFQs. With each unit increase in TDS, the risk of visual impairment decreased (HR 0.94, 95% CI 0.88-1.00). The risk of developing visual impairment was lower among persons in the highest compared to the lowest TDS quartile (HR 0.71, 95% CI 0.47-1.05). This association was significant among persons aged 65+ years (HR 0.63, 95% CI 0.38-0.98) but not those aged <65 years (HR 0.95, 95% CI 0.46-1.97).

CONCLUSIONS

Compliance to dietary guidelines was associated with a decreased long-term risk of visual impairment in this sample of Australians aged 65+ years.

Vision impairment and dual sensory problems in middle age

PURPOSE

Vision and hearing impairments are known to increase in middle age. In this study we describe the prevalence of vision impairment and dual sensory impairment in UK adults aged 40-69 years in a very large and recently ascertained data set. The associations between vision impairment, age, sex, socioeconomic status, and ethnicity are reported.

METHODS

This research was conducted using the UK Biobank Resource, with subsets of UK Biobank data analysed with respect to self-report of eye problems and glasses use. Better-eye visual acuity with habitually worn refractive correction was assessed with a logMAR chart (n = 116,682). Better-ear speech reception threshold was measured with an adaptive speech in noise test, the Digit Triplet Test (n = 164,770). Prevalence estimates were weighted with respect to UK 2001 Census data.

RESULTS

Prevalence of mild visual impairment (VA >0.1 logMAR (6/7.5, 20/25) and ≥0.48 (6/18, 20/60)) and low vision (VA >0.48 (6/18, 20/60) and ≥1.3 (6/120, 20/400)) was estimated at 13.1% (95% CI 12.9-13.4) and 0.8% (95% CI 0.7-0.9), respectively. Use of glasses was 88.0% (95% CI 87.9-88.1). The prevalence of dual sensory impairment was 3.1% (95% CI 3.0-3.2) and there was a nine-fold increase in the prevalence of dual sensory problems between the youngest and oldest age groups. Older adults, those from low socioeconomic and ethnic minority backgrounds were most at risk for vision problems.

CONCLUSIONS

Mild vision impairment is common in middle aged UK adults, despite widespread use of spectacles. Increased likelihood of vision impairment with older age and with ethnic minorities is of concern given ageing and more ethnically diverse populations. Possible barriers to optometric care for those from low socioeconomic and ethnic minority backgrounds may require attention. A higher than expected prevalence of dual impairment suggests that hearing and vision problems share common causes. Optometrists should consider screening for hearing problems, particularly among older adults.

Area deprivation, individual socioeconomic status and low vision in the EPIC-Norfolk Eye Study

Background

Poor vision is associated with lower socioeconomic status, but less is known about its relationship to area deprivation.

Methods

The European Prospective Investigation into Cancer and Nutrition study Norfolk Eye Study was a cross-sectional study of 8563 participants with completed eye examinations. Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) was measured using standard protocols and low vision (LV) was defined as Snellen equivalent (VA) ≤6/12 in the better eye. Uncorrected refractive error (URE) was defined as improvement of VA by 2 logarithm of the minimum angle of resolution lines with pinhole. The lowest 5% of index of multiple deprivation rank was used to define the most deprived areas. The index of multiple deprivation is a composite measure using routine data from seven domains of deprivation to identify the most disadvantaged areas in England. Logistic regression was used to examine univariable and multivariable associations with LV.

Results

Ninety-six participants with missing data were excluded, leaving 8467 for analysis (98.9%). The mean age of the study group was 68.7 years (SD=8.1, range=48–92), with 55.1% women. LV was present in 263 participants (3.1%, 95% CI 2.7 to 3.5%). LV was associated with deprivation after adjusting for age, sex, education, social class and cataract surgery (OR=1.7, 95% CI 1.1 to 2.6, p=0.03), but this effect was mitigated by additionally adjusting for URE (OR=1.5, 95% CI 1.0 to 2.4, p=0.09).

Conclusions

People with LV are more likely to live in the most deprived areas; this association was independent of socioeconomic status and partly mediated by URE. Targeting URE in deprived areas may reduce health inequalities associated with LV.

Visual impairment and subsequent use of support services among older people: longitudinal findings from the Blue Mountains Eye Study

PURPOSE

To assess the impact of visual impairment and blindness on the incident use of community support services in the Blue Mountains Eye Study.

DESIGN

Population-based cohort.

METHODS

Of 3654 baseline participants (1992-1994), 2334, 1952, and 1149 were re-examined after 5, 10, and 15 years, respectively. Incident visual impairment was defined as subsequent development of visual impairment (visual acuity <20/40) in the better eye of subjects with best-corrected visual acuity ≥20/40 at baseline. Community support service use included regular use of Meals on Wheels, Home Care, or community nurse services. Informal support included assistance from family or friends. Discrete logistic regression models with time-dependent study and outcome variables were used to assess associations between visual impairment and subsequent use of support, adjusted for potential confounders.

RESULTS

Among participants with bilateral visual impairment at baseline, incident use of community services over 5-15 years was 41.7% compared to 19.4% in those without visual impairment at baseline (odds ratio, 1.39; 95% confidence interval, 0.54-3.60). Persons with incident bilateral visual impairment were more likely to subsequently need community support (odds ratio, 3.32; confidence interval 1.96-5.59) in 5 years, compared to persons without visual impairment during the entire follow-up period. Baseline older age, walking disability, receiving pension, and having 2+ hospital admissions within 12 months were also significantly associated with incident use of support services.

CONCLUSIONS

Development of bilateral visual impairment in this cohort was associated with greater likelihood of subsequent use of community or informal support services in 5 years, independent of physical comorbidities.

Why is tractable vision loss in older people being missed? Qualitative study

BACKGROUND

There is compelling evidence that there is substantial undetected vision loss amongst older people. Early recognition of undetected vision loss and timely referral for treatment might be possible within general practice, but methods of identifying those with unrecognised vision loss and persuading them to take up services that will potentially improve their eyesight and quality of life are not well understood. Population screening does not lead to improved vision in the older population. The aim of this study is to understand why older people with vision loss respond (or not) to their deteriorating eyesight.

METHODS

Focus groups and interviews were carried out with 76 people aged 65 and over from one general practice in London who had taken part in an earlier study of health risk appraisal. An analytic induction approach was used to analyse the data.

RESULTS

Three polarised themes emerged from the groups and interviews. 1) The capacity of individuals to take decisions and act on them effectively versus a collection of factors which acted as obstacles to older people taking care of their eyesight. 2) The belief that prevention is better than cure versus the view that deteriorating vision is an inevitable part of old age. 3) The incongruence between the professionalism and personalised approach of opticians and the commercialisation of their services.

CONCLUSIONS

The reasons why older people may not seek help for deteriorating vision can be explained in a model in which psychological attributes, costs to the individual and judgments about normal ageing interact. Understanding this model may help clinical decision making and health promotion efforts.

Environmental and behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people

BACKGROUND

Impairment of vision is associated with a loss of function in activities of daily living. Avoidance of physical activity and consequent reduced functional capacity is common in older people with visual impairment and an important risk factor for falls. Indeed, the rate of falls and fractures is higher in older people with visual impairment than age-matched visually normal older people. Depression and anxiety is common in older people with vision impairment and leads to further restriction of activity, reduced social contact and reduced quality of life. Possible mechanisms to reduce activity restriction and therefore improve mobility and activity include environmental and behavioural interventions delivered by a number of health professionals, including occupational therapists.

OBJECTIVES

The objective of this review was to assess the effectiveness of environmental and behavioural interventions in reducing activity limitation and improving quality of life amongst visually impaired older people.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to November 2012), EMBASE (January 1980 to November 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to November 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to November 2012), OT Seeker (inception to November 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 9 November 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) that compared environmental interventions, behavioural interventions or both, versus control (placebo control or no intervention or usual care), and trials comparing different types of environmental or behavioural interventions, in older people (aged 60 and over) with irreversible visual impairment living independently or in residential settings. To be eligible for inclusion the primary aim of studies must be reducing physical activity limitation and must include a measure of physical activity. Secondary outcome measures included falls, fear of falling, quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently read abstracts retrieved by the search to identify eligibility and study quality. We contacted study authors for additional information.

MAIN RESULTS

Our searches found no RCTs or Q-RCTs that met the eligibility criteria for this review.

AUTHORS' CONCLUSIONS

We are unable to reach any conclusion about the effectiveness of environmental or behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people, as no eligible studies were found. However a number of studies reviewed included only the secondary outcome measures of this review. Although behavioural interventions delivered by occupational therapists have been shown to reduce the rate of falls, we are unable to conclude if this is due to reduced activity restriction (increased mobility) or reduced activity (lessening exposure to risk). There are inconclusive and conflicting results from trials evaluating the effectiveness of behavioural and environmental interventions aimed at improving quality of life. Further research is necessary (such as ongoing Dutch and UK trials considering the effectiveness of orientation and mobility training on activity restriction, physical activity, falls, fear of falling and quality of life in older adults with low vision, and the effect of an occupational therapist delivering home safety modification, coping strategies and exercise with older people with low vision) before any conclusions can be reached.

The EPIC-Norfolk Eye Study: rationale, methods and a cross-sectional analysis of visual impairment in a population-based cohort

OBJECTIVES

To summarise the methods of the European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study, and to present data on the prevalence of visual impairment and associations with visual impairment in the participants.

DESIGN

A population-based cross-sectional study nested within an on-going prospective cohort study (EPIC).

SETTING

East England population (the city of Norwich and its surrounding small towns and rural areas).

PARTICIPANTS

A total of 8623 participants aged 48-92 years attended the Eye Study and underwent assessment of visual acuity, autorefraction, biometry, tonometry, corneal biomechanical measures, scanning laser polarimetry, confocal scanning laser ophthalmoscopy, fundal photography and automated perimetry.

OUTCOME MEASURES

Visual impairment was defined according to the WHO classification and the UK driving standard, and was based on presenting visual acuity. Summary measures of other ophthalmic measurements are also presented.

RESULTS

The prevalence (95% CI) of WHO-defined moderate-to-severe visual impairment and blindness was 0.74% (0.55% to 0.92%). The prevalence (95% CI) of presenting visual acuity worse than the UK driving standard was 5.87% (5.38% to 6.37%). Older age was significantly associated with visual impairment or blindness (p<0.001). Presenting visual acuity worse than UK driving standard was associated with older age (p<0.001), female sex (p=0.005) and lower educational level (p=0.022).

CONCLUSIONS

The prevalence of blindness and visual impairment in this selected population was low. Visual impairment was more likely in older participants, women and those with a lower educational level.

A cross-sectional study of visual impairment in elderly population in residential care in the South Indian state of Andhra Pradesh: a cross-sectional study

OBJECTIVE

To assess the prevalence and major causes of visual impairment (VI) in elderly residents of 'home for the aged' institutions in the Prakasam district in India.

DESIGN

Cross-sectional study.

SETTING

'Home for the aged' institutions in the Prakasam district in the South Indian state of Andhra Pradesh.

PARTICIPANTS

All 524 residents in the 26 'homes for aged' institutions in the district were enumerated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and causes of VI; visual acuity (VA) was assessed using a Snellen chart at a distance of 6 m. Pinhole VA was assessed if presenting VA was <6/18. Torchlight examination and direct ophthalmoscopy were performed. VI was defined as presenting VA <6/18 in the better eye.

RESULTS

Of the 494 participants examined (response rate 94.3%), 78.1% were women, 72.1% had no formal schooling. The mean age of participants was 70 years (SD ±8.6 years). VI was present in 280/494 individuals (56.9%; 95% CI 52.3 to 61.3). Over 80% of the VI was due to avoidable causes including cataract (57.1%) and uncorrected refractive errors (26.4%). Among 134 individuals who had undergone bilateral cataract surgery, only 78 (58.2%) individuals had presenting VA ≥6/18 and 13/134 (9.7%) participants were blind.

CONCLUSIONS

There is high prevalence of VI in the institutionalised elderly population in the Prakasam district in India. A significant proportion of this elderly population with VI can benefit from spectacles and cataract surgery. Strategies are required to provide high-quality services to this population.

Age-related visual impairments and perceiving linguistic stimuli: the rarity of assessing the visual abilities of older participants in written language research

BACKGROUND/STUDY CONTEXT: It is well established that declining visual abilities are widespread amongst older adults (aged 65 years and over) and are known to have profound effects on processing a range of visual stimuli. However, the incidence of assessing the visual abilities of older adults participating in written language research using visually presented linguistic stimuli (text, words, letters) is unknown.

METHODS

All 240 articles investigating perception of visually presented linguistic stimuli (text, words, letters) by older participants, published 2000-2010 in the three foremost journals in aging research, Experimental Aging Research, The Journals of Gerontology, Series B, and Psychology and Aging, were examined.

RESULTS

The majority of articles (68.0%) made no mention at all of participants' visual abilities (59.2%) or relied merely on participants' self-report (8.8%). Other articles (17.9%) reported participants' visual abilities without mentioning any assessment, and only 14.2% reported participants' visual abilities following appropriate assessment.

CONCLUSION

The indications are that appropriate assessments of visual abilities are used rarely in language research investigating perception of visually presented linguistic stimuli by older participants. Much greater use and reporting of these assessments is needed to help reveal the processes underlying perception of written language in older populations.

The small eye phenotype in the EPIC-Norfolk eye study: prevalence and visual impairment in microphthalmos and nanophthalmos

OBJECTIVE

To describe the prevalence and phenotypic characteristics of small eyes in the European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study.

DESIGN

Community cross-sectional study.

SETTING

East England population (Norwich, Norfolk and surrounding area).

PARTICIPANTS

8033 participants aged 48-92 years old from the EPIC-Norfolk Eye Study, Norfolk, UK with axial length measurements. Participants underwent a standardised ocular examination including visual acuity (LogMAR), ocular biometry, non-contact tonometry, autorefraction and fundal photography. A small eye phenotype was defined as a participant with one or both eyes with axial length of <21 mm.

OUTCOME MEASURES

Prevalence of small eyes, proportion with visual impairment, demographic and biometric factors.

RESULTS

Ninety-six participants (1.20%, 95% CI 0.98% to 1.46%) had an eye with axial length less than 21 mm, of which 74 (77%) were women. Prevalence values for shorter axial lengths were <20 mm: 0.27% (0.18% to 0.41%); <19 mm: 0.17% (0.11% to 0.29%); <18 mm: 0.14% (0.08% to 0.25%). Two participants (2.1%) had low vision (presenting visual acuity >0.48 LogMAR) and one participant was blind (>1.3 LogMAR). The prevalence of unilateral visual impairment was higher in participants with a small eye. Multiple logistic regression modelling showed presence of a small eye to be significantly associated with shorter height, lower body mass index, higher systolic blood pressure and lower intraocular pressure.

CONCLUSIONS

The prevalence of people with small eyes is higher than previously thought. While small eyes were more common in women, this appears to be related to shorter height and lower body mass index. Participants with small eyes were more likely to be blind or to have unilateral visual impairment.

The impact of visual impairment on Mini-Mental State Examination Scores in the Newcastle 85+ study

BACKGROUND

cognitive test scores and visual acuity are strongly associated in older people. This may be due to poor vision limiting performance on cognitive tasks specifically requiring vision, or an association between visual and neurodegenerative disorders.

OBJECTIVE

to explore, using data from the Newcastle 85+ cohort study, the impact of sight impairment (SI) on Mini-Mental State Examination (MMSE) scores and whether reduced scores among SI participants are limited to tasks requiring vision.

RESULTS

of 839 participants aged 85 years, 44 (5.2%) were registered SI. Median (inter-quartile range) sMMSE scores were 25 (22-29) for SI and 28 (25-29) for non-SI participants (P=0.006). SI participants had lower subscale scores on tasks requiring vision (P<0.001 for each) but also for some subscale scores not obviously requiring vision: orientation (P=0.018) and repetition (P=0.030). Excluding visual items, there was no significant difference in MMSE scores between those with/without SI.

CONCLUSION

SI may be an obstacle to older people completing cognitive assessments including tasks requiring vision. People with SI also scored lower on some tasks not obviously requiring vision. An association between cognitive impairment and SI may exist beyond simply being unable to see the test material in cognitive tests.

Ethnic variation in the prevalence of visual impairment in people attending diabetic retinopathy screening in the United Kingdom (DRIVE UK)

Purpose

To provide estimates of visual impairment in people with diabetes attending screening in a multi-ethnic population in England (United Kingdom).

Methods

The Diabetic Retinopathy In Various Ethnic groups in UK (DRIVE UK) Study is a cross-sectional study on the ethnic variations of the prevalence of DR and visual impairment in two multi-racial cohorts in the UK. People on the diabetes register in West Yorkshire and South East London who were screened, treated or monitored between April 2008 to July 2009 (London) or August 2009 (West Yorkshire) were included in the study. Data on age, gender, ethnic group, visual acuity and diabetic retinopathy were collected. Ethnic group was defined according to the 2011 census classification. The two main ethnic minority groups represented here are Blacks (“Black/African/Caribbean/Black British”) and South Asians (“Asians originating from the Indian subcontinent”). We examined the prevalence of visual impairment in the better eye using three cut-off points (a) loss of vision sufficient for driving (approximately <6/9) (b) visual impairment (<6/12) and (c) severe visual impairment (<6/60), standardising the prevalence of visual impairment in the minority ethnic groups to the age-structure of the white population.

Results

Data on visual acuity and were available on 50,331individuals 3.4% of people diagnosed with diabetes and attending screening were visually impaired (95% confidence intervals (CI) 3.2% to 3.5%) and 0.39% severely visually impaired (0.33% to 0.44%). Blacks and South Asians had a higher prevalence of visual impairment (directly age standardised prevalence 4.6%, 95% CI 4.0% to 5.1% and 6.9%, 95% CI 5.8% to 8.0% respectively) compared to white people (3.3%, 95% CI 3.1% to 3.5%). Visual loss was also more prevalent with increasing age, type 1 diabetes and in people living in Yorkshire.

Conclusions

Visual impairment remains an important public health problem in people with diabetes, and is more prevalent in the minority ethnic groups in the UK.

The circumstances of older people in England with self-reported visual impairment: A secondary analysis of the English Longitudinal Study of Ageing (ELSA)

One key challenge to those charged with tackling the social exclusion of visually impaired people is having information about the extent to which visual impairment is related to the ability to enjoy and participate in various aspects of life. Using data from the English Longitudinal Study of Ageing (ELSA), this article considers how self-reported visual impairment is related to older people’s physical health and cognitive abilities, their economic and housing conditions, their social engagement, as well as their emotional well-being and life-satisfaction. We find self-reported poor vision to be associated with multiple disadvantages in those outcome measures. Further research is needed to establish causal links between visual impairment and the various health, economic, social and emotional well-being experiences documented in this article. Nevertheless, secondary data analysis of ELSA offers a useful and cost-effective research approach.

Geographical variation in certification rates of blindness and sight impairment in England, 2008-2009

OBJECTIVES

To examine and interpret the variation in the incidence of blindness and sight impairment in England by PCT, as reported by the Certificate of Vision Impairment (CVI).

DESIGN

Analysis of national certification data.

SETTING

All Primary Care Trusts, England.

PARTICIPANTS

23 773 CVI certifications issued from 2008 to 2009.

MAIN OUTCOME MEASURES

Crude and Age standardised rates of CVI data for blindness and sight loss by PCT.

METHODS

The crude and age standardised CVI rates per 100 000 were calculated with Spearman's rank correlation used to assess whether there was any evidence of association between CVI rates with Index of Multiple Deprivation (IMD) and the Programme Spend for Vision.

RESULTS

There was high-level variation, almost 11-fold (coefficient of variation 38%) in standardised CVI blindness and sight impairment annual certification rates across PCTs. The mean rate was 43.7 and the SD 16.7. We found little evidence of an association between the rate of blindness and sight impairment with either the IMD or Programme Spend on Vision.

CONCLUSIONS

The wide geographical variation we found raises questions about the quality of the data and whether there is genuine unmet need for prevention of sight loss. It is a concern for public health practitioners who will be interpreting these data locally and nationally as the CVI data will form the basis of the public health indicator 'preventable sight loss'. Poor-quality data and inadequate interpretation will only create confusion if not addressed adequately from the outset. There is an urgent need to address the shortcomings of the current data collection system and to educate all public health practitioners.

Visual impairment and quality of life in the older European population, the EUREYE study

PURPOSE

To determine the prevalence of visual impairment (VI) in populations 65 year or older from six European countries and describe the association with vision-related quality of life. VI was defined according to WHO as best corrected visual acuity <6/18/log MAR >0,48 (World Health Organization (1992): International Statistical Classification of Diseases and Related Health Problems, 10th revised ed. Vol 1. Geneva).

METHODS

4166 participants in The European Eye study, 65 years and older selected randomly from the general census in the participating centres, were interviewed for vision-related quality of life and underwent an eye exam including distance visual acuity, refraction and fundus photography.

RESULTS

The prevalence of VI rose with increasing age and more so in women. There was a pattern of a higher prevalence of VI in the Mediterranean countries compared to Northern European countries with the exception of Tallinn (Estonia) which had higher VI prevalence rates than the other north European centres. The prevalence of low vision was 3% or less in all centres. Blindness prevalence varied from 2% to less than half a per cent. Vision-related quality of life was strongly associated with visual acuity and the presence of bilateral age-related macular degeneration.

CONCLUSION

The prevalence of visual impairment in the examined ageing European populations shows a definite increasing trend from north to south.

A cost-benefit analysis of cataract surgery based on the English Longitudinal Survey of Ageing

This paper uses the English Longitudinal Survey of Ageing to explore the self-reported effect of cataract operations on eye-sight. A non-parametric analysis shows clearly that most cataract patients report improved eye-sight after surgery and a parametric analysis provides further information: it shows that the beneficial effect is larger the worse was self-reported eye-sight preceding surgery so that those with very good or excellent eye-sight do not derive immediate benefit. Nevertheless, the long-run effect is suggested to be beneficial. Calibrating the results to existing studies of the effect of imperfect eye-sight on quality of life, the impact of cataract operations on Quality Adjusted Life Years is found to be similar to that established in previous studies and well above the costs of cataract operations in most circumstances.

Reading performance and central field loss

Age-related macular degeneration is a major cause of blindness in Europe and the U.S. and a leading cause of significant loss of visual acuity in elderly patients. Reading is a key visual task in everyday living involving a synthesis of a number of different motor, sensory and cognitive functions. When the centre of a reader's visual field is obscured, reading speed declines and oculomotor pattern differs, compared to normal reading. Improvement in the generation of visual stimuli using computer-generated images and projection/display systems as well as advances in eye movement recording techniques, including infrared pupil tracking and magnetic search coils, have contributed greatly to our understanding of these sensorimotor abnormalities. The developed reading strategies have been thoroughly investigated in individuals with central field loss either induced artificially or related to eye pathology.The following review aims at presenting the contemporary literature regarding the sensory and oculomotor deficits in reading ability, resulting from central field loss and should contribute to a greater understanding of the functional visual deficit caused by this visual impairment.

Geriatric drug therapy: neglecting the inevitable majority

Demographic evolution will considerably increase the number of people aged 65 years and beyond in the coming decades. The elderly not only represent the most heterogeneous population, but also are a major user group for prescribed medicines, a predominance that will continue to further increase. Medicines and medication management are much more complex and challenging in the elderly and can only be addressed through a multidisciplinary approach. There is strong evidence that the elderly are able to properly manage their medication; however, their medications require different features than the standard medications used by adults. The elderly are exposed to several chronic disease conditions and their treatments, as well as experience age-related changes and limitations that need to be reflected in their medication management strategies. Geriatric drug therapy remains a multidisciplinary task. The health care industry, physicians, pharmacists, nurses and care givers provide and guide the patient's therapy according to individual needs, while the health care system and regulatory authorities build the necessary framework of support and resources.Any realistic and significant enhancement to the elderly patients' medicines and medication management needs to be addressed by all disciplines and stakeholders involved since the absence of any of the stakeholders in the overall process negatively impacts the achievable enhancement in geriatric drug therapy.

Balancing independence and safety: the challenge of supporting older people with dementia and sight loss

BACKGROUND

dementia and visual impairment are common in older adults, and both conditions create a high risk of disability. Care professionals lack evidence on how best to support older adults with both conditions.

OBJECTIVE

the study investigated attitudes towards working with older adults with concurrent sight loss and dementia, the challenges involved and suggestions for service development.

METHODS

a qualitative study was conducted comprising 18 in-depth interviews and two focus groups with care professionals within mental health and low vision services.

RESULTS

care professionals were alert to the high levels of risk among patients with joint sight loss and dementia. In-depth interviews revealed that insufficient time and expertise can lead to an overcautious approach that prioritises the reduction of risk rather than the promotion of independence. Focus groups highlighted the role that joint working can play in supporting older adults' valued roles and activities. Barriers to joint working were identified alongside strategies to assist the process.

CONCLUSION

it is essential that care professionals and service providers acknowledge and respond to the complex needs of this population. Joint working was considered key to assessing risks and targeting interventions. The research workshop presented here provides a useful format for improving practice across inter-professional boundaries.

Visual loss and falls: a review

Falls are an important health issue. They cause significant morbidity and mortality particularly in older people, and also have marked psychological effects on the individual. The literature focuses particularly on older adults, an age group in which both visual impairment and falls are more prevalent, as is the associated morbidity. In this review, we summarise the current literature and point to further studies which need to be undertaken. The consequences of falls are well recognised, and there has been considerable work into identifying risk factors. Changes in visual components such as visual field, acuity, contrast sensitivity and stereopsis all have a part and the co-existence of other sensory impairments certainly increases the risk of falls. However there remain considerable gaps in our knowledge of the relationship between visual loss and falls, for example in patients with diabetic eye disease. Furthermore, there is also conflicting data as to the importance of different visual components. Various interventions, such as programmed inter-disciplinary involvement, have shown promise, however these need further confirmation of their efficacy and cost effectiveness. An added confounder may be that an intervention (eg, cataract extraction) paradoxically affects an individual's future activity level and behaviour, thereby increasing the risk of falling. With an ageing population the importance of this topic is likely to increase, as will the potential benefits of optimising our assessment and management of these patients.

Blindness and low vision in The Netherlands from 2000 to 2020-modeling as a tool for focused intervention

PURPOSE

To estimate the magnitude and causes of blindness and low vision in The Netherlands from 2000 to 2020.

METHODS

Recent population-based blindness surveys in established market economies were reviewed. Age and gender specific prevalence and causes of blindness and low vision were extracted and calculated for six population subgroups in The Netherlands. A mathematical model was developed to relate the epidemiologic data with demographic data for each subgroup for each year between 2000 and 2020.

RESULTS

In 2008 an estimated 311,000 people are visually impaired in The Netherlands: 77,000 are blind and 234,000 have low vision. With the current intervention the number may increase by 18% to 367,000 in 2020. Visual impairment is most prevalent among residents of nursing homes and care institutions for the elderly, intellectually disabled persons and people aged 50+ living independently. Of all people with visual impairment 31% is male (97,000) and 69% female (214,000). More than half of all visual impairment (56%; 174,000 persons) is avoidable. A variation of around 20% might be applied to the numbers in these estimates.

CONCLUSIONS

The aim of VISION 2020: The Right to Sight to reduce avoidable visual impairment is also relevant for developed countries like The Netherlands. Vision screening and awareness campaigns focusing on the identified risk groups can reduce avoidable blindness considerably. Regular updates of the model will ensure that the prognoses remain valid and relevant. With appropriate demographic data, the model can also be used in other established market economies.

Gender-specific associations of vision and hearing impairments with adverse health outcomes in older Japanese: a population-based cohort study

Background

Several epidemiological studies have shown that self-reported vision and hearing impairments are associated with adverse health outcomes (AHOs) in older populations; however, few studies have used objective sensory measurements or investigated the role of gender in this association. Therefore, we examined the association of vision and hearing impairments (as measured by objective methods) with AHOs (dependence in activities of daily living or death), and whether this association differed by gender.

Methods

From 2005 to 2006, a total of 801 residents (337 men and 464 women) aged 65 years or older of Kurabuchi Town, Gunma, Japan, participated in a baseline examination that included vision and hearing assessments; they were followed up through September 2008. Vision impairment was defined as a corrected visual acuity of worse than 0.5 (logMAR = 0.3) in the better eye, and hearing impairment was defined as a failure to hear a 30 dB hearing level signal at 1 kHz in the better ear. Information on outcomes was obtained from the town hall and through face-to-face home visit interviews. We calculated the risk ratios (RRs) of AHOs for vision and hearing impairments according to gender.

Results

During a mean follow-up period of 3 years, 34 men (10.1%) and 52 women (11.3%) had AHOs. In both genders, vision impairment was related to an elevated risk of AHOs (multi-adjusted RR for men and women together = 1.60, 95% CI = 1.05-2.44), with no statistically significant interaction between the genders. In contrast, a significant association between hearing impairment and AHOs (multi-adjusted RR = 3.10, 95% CI = 1.43-6.72) was found only in the men.

Conclusion

In this older Japanese population, sensory impairments were clearly associated with AHOs, and the association appeared to vary according to gender. Gender-specific associations between sensory impairments and AHOs warrant further investigation.

Effects and feasibility of a standardised orientation and mobility training in using an identification cane for older adults with low vision: design of a randomised controlled trial

BACKGROUND

Orientation and mobility training (O&M-training) in using an identification cane, also called symbol cane, is provided to people with low vision to facilitate independent participation in the community. In The Netherlands this training is mainly practice-based because a standardised and validly evaluated O&M-training in using the identification cane is lacking. Recently a standardised O&M-training in using the identification cane was developed. This training consists of two face-to-face sessions and one telephone session during which, in addition to usual care, the client's needs regarding mobility are prioritised, and cognitive restructuring techniques, action planning and contracting are applied to facilitate the use of the cane. This paper presents the design of a randomised controlled trial aimed to evaluate this standardised O&M-training in using the identification cane in older adults with low vision.

METHODS/DESIGN

A parallel group randomised controlled trial was designed to compare the standardised O&M-training with usual care, i.e. the O&M-training commonly provided by the mobility trainer. Community-dwelling older people who ask for support at a rehabilitation centre for people with visual impairment and who are likely to receive an O&M-training in using the identification cane are included in the trial (N = 190). The primary outcomes of the effect evaluation are ADL self care and visual functioning with respect to distance activities and mobility. Secondary outcomes include quality of life, feelings of anxiety, symptoms of depression, fear of falling, and falls history. Data for the effect evaluation are collected by means of telephone interviews at baseline, and at 5 and 17 weeks after the start of the O&M-training. In addition to an effect evaluation, a process evaluation to study the feasibility of the O&M-training is carried out.

DISCUSSION

The screening procedure for eligible participants started in November 2007 and will continue until October 2009. Preliminary findings regarding the evaluation are expected in the course of 2010. If the standardised O&M-training is more effective than the current O&M-training or, in case of equal effectiveness, is considered more feasible, the training will be embedded in the Dutch national instruction for mobility trainers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00946062.

"Out of sight, out of mind": a qualitative study of visual impairment and dementia from three perspectives

BACKGROUND

Dementia and visual impairment are among the most common medical conditions in later life. Almost nothing is known about the experiences and needs of older adults with both conditions.

METHOD

In this qualitative study using in-depth individual interviews, multiple perspectives were sought through a case-study approach. Fifty-two interviews were conducted: 17 with older adults with visual impairment and dementia, 17 with family caregivers, and 18 with care professionals.

RESULTS

Impaired memory and a lack of visual cues created profound disorientation and distress, which could be manifested in disruptive behavior. Visual hallucinations compounded older adults' disorientation, and caregivers were uncertain about how to manage them. Visual impairments reduced the ability of older adults to perform certain activities safely, while dementia impaired their ability to assess the risks accurately. Concerns about safety prompted family members to limit their relatives' activities even in early stages of dementia. Low-vision services perceived themselves to be ill equipped to manage dementia-related needs, while visual needs were accorded a low priority by dementia services. A lack of joint working by the two services led to an overcautious approach.

CONCLUSIONS

The research identified considerable unmet needs and opportunities to improve care. The provision of clear verbal communication and optimized visual inputs is likely to reduce disorientation, distress and agitated behavior, while one-to-one contact is needed to overcome feelings of isolation. Family caregivers require additional respite services and advice on managing hallucinations. Increased sharing of information and skills between mental health and low-vision professionals would help maximize older adults' independence.

The prevalence of Type 2 diabetes and its associated health problems in a community-dwelling elderly population

AIMS

Prevalence estimates of Type 2 diabetes and its associated health problems in elderly populations are rare, especially in the very elderly.

METHODS

A sample of 15 095 community-dwelling older people aged > or = 75 years were assessed. Type 2 diabetes and associated health problems were identified using self-reporting, general practitioner records, drug histories, and blood and urine measurements.

RESULTS

There were 1177 people identified as having Type 2 diabetes mellitus, giving an overall prevalence of 7.8% (95% confidence interval 7.1, 8.5), 9.4% (8.4, 10.5) for men and 6.8% (6.1, 7.6) for women. The age, sex and smoking adjusted odds ratios for various health problems, comparing people with and without diabetes were: low vision 1.6 (1.3, 1.9), proteinuria 1.7 (1.4, 2.1), chronic kidney disease stage 4 or 5 1.5 (1.0, 2.1), angina 1.3 (1.1, 1.6), myocardial infarction 1.5 (1.2, 1.8), cerebrovascular event 2.0 (1.8, 2.1) and foot ulceration 1.7 (1.2, 2.4).

CONCLUSIONS

The prevalence of Type 2 diabetes is not high in community-dwelling older people, but diabetes was a contributory factor to a number of health problems.

Causes of visual loss in uveitis

Background/Aim. Epidemiological studies of blindness in a working age population require a precise definition of the true connection of uveitis and visual damage. Since most patients with more severe types of uveitis are hospitalized in tertiary referral uveitis service, our aim was to determine whether age, sex and age of onset of uveitis, as well as duration of visual loss and its causes influence the degree of visual damage in patients with different types of uveitis. Methods. The data were collected from medical records of 237 patients at the Department for Uveitis of the Institute for Eye Diseases in Belgrade over a three-year period (March 2005 to March 2008). Results. Visual acuity reduction (? 0.3) was found in 161/237 (67.9%) patients, 85 of whom had visual acuity of ? 0.1 later. Working age patients (up to 60 years of age) most often suffered from uveitis (173/237; 73%). The highest number of patients with visual loss was in the group suffering from panuveitis (77/94; 81.91%). The age of onset of uveitis and sex have no statistically significant influence on visual loss. The most common causes of visual loss (34/161; 21.1%) were cystoid macular oedema (CMO) (43/161; 26.7%), cataract (28/161; 17.39%) and combination of CMO and cataract. Conclusion. The risk factors for severe visual loss (? 0.1) are panuveitis, bilateral inflammation, prolonged visual reduction and a significant number of relapses. The main causes of visual loss in 65.2% of our patients were CMO and cataract.

Visual impairment and vision-related quality of life in working-age adults: findings in the 1958 British birth cohort

PURPOSE

To describe the prevalence of impaired vision and its relative burden, together with the prevalence of impaired vision-related quality of life (VRQOL), and investigate associations with social outcomes in a contemporary and nationally representative population of working age adults.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

We included 9330 members of the 1958 British birth cohort at age 44 and 45 years.

METHODS

"Habitual" and "best achieved" distance visual acuity in each eye, binocular near vision acuity and stereoacuity (three dimensional/depth perception) were tested during a broader biomedical examination. VRQOL was assessed using the Vision-related Quality of Life Core Measure 1 (VCM1), a validated, 10-item, self-complete instrument. Logistic and proportional odds ordinal logistic regression were used to calculate odds ratios (ORs) of the association of VRQOL with visual acuities and social outcomes.

MAIN OUTCOME MEASURES

Distance, near, and stereo acuities and VRQOL and social outcomes.

RESULTS

Of the 1.3% (124) of those with visual loss that precluded driving, a further 0.75% (70) were visually impaired or severely visually impaired and 0.15% (14) blind, the latter accounting for 19% total population (all ages) burden of blindness. Impairment of VRQOL is strongly associated with impaired distance, near, and stereo vision, as well as with adverse occupational and other social outcomes. However, VRQOL impairment is also sometimes reported with unilateral or mild bilateral visual loss.

CONCLUSIONS

Although impaired vision in working age adults is relatively uncommon, it confers important adverse consequences for the "health and wealth" of the public. This may be captured best by assessment of VRQOL in addition to objective visual function. Ophthalmic disorders occurring or impacting in middle life should be given a higher priority than currently in national and international strategies against avoidable visual disability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Glaucoma: an area of darkness

This review of Primary Open Angle Glaucoma looks at the management of the condition today. It does this by looking at the following areas: (a) the size of the problem; (b) the position of IOP, with respect to its elevation and fluctuation; (c) optic nerve head changes; and (d) visual function changes. In doing so, it contrasts what is known now with ideas and concepts that were prevalent at the time of the two previous Bowman lecturers, Duke Elder and Drance, as well as noting concepts about the disease that were current at the time of William Bowman. The review concludes by suggesting challenges in this area that lie ahead.

Hospital admissions in older people with visual impairment in Britain

BACKGROUND

We aimed to assess the risk of hospital admission associated with visual impairment in a representative sample of older people living in the community in Britain.

METHODS

DESIGN

Prospective study of hospital admission in a population-based sample of community dwelling people aged 75 years and above in Britain.

SETTING

53 general practices.

PARTICIPANTS

14,394 participants in the MRC Trial of Assessment and Management of Older people in the Community.

MAIN OUTCOME MEASURE

Hospital admission.

RESULTS

Visually impaired older people had 238.7 admissions/1000 person-years compared to 169.7 admissions/1000 person-years in people with good vision: age and sex adjusted rate ratio (RR) 1.32 (95% CI 1.19 to 1.47). Adjusting for a wide range of potential explanatory factors largely eliminated this association: RR 1.06 (95% CI 0.94 to 1.20). However, adjusting for a more limited range of confounding factors, excluding those factors possibly a consequence of reduced vision, left a modest increased risk: RR 1.19 (95% CI 1.06 to 1.34).

CONCLUSION

The association between visual impairment and rate of hospital admission can be attributed to higher levels of co-morbidity and reduced functional ability among people with reduced vision. Visual impairment is likely to be an important contributor to reduced functional ability, but other factors may also be involved.

Prevalence of major eye diseases among US Civil War veterans, 1890-1910

OBJECTIVES

To estimate the prevalence of major eye diseases and low vision or blindness in a national sample of male US Union Army veterans from 1890 to 1910 and to compare these prevalence rates with contemporary rates for the same diseases and visual status.

DESIGN

Longitudinal histories of 16,022 white Union Army veterans receiving disability pensions from 1890 to 1910 were developed from pension board examination records. Prevalence rates of trachoma, corneal opacities, cataract, diseases of the retina and optic nerve, and low vision or blindness were calculated in 1895 and 1910. Changes in prevalence by age were examined.

RESULTS

By 1910, 11.9% of veterans had low vision or were blind in both eyes. Prevalence of cataract increased with age, resulting in 13.1% of veterans having had cataract in one or both eyes. Rates of trachoma were 3.2% in 1895 and 4.8% in 1910. Rates of corneal opacity were 3.0% and 5.1%, respectively. Glaucoma was rarely diagnosed from 1890 to 1910, but diseases of the optic nerve were reported in 2.0% of veterans in 1895 and 3.6% in 1910.

CONCLUSIONS

This study documents substantial reductions in the prevalence of low vision or blindness and changes in the composition of eye diseases from an era in which there were few effective therapies for eye diseases to the present.

Vision screening of older people

A recent systematic review found that between 20% and 50% of older people in the UK have undetected reduced vision and in most cases this is caused by refractive error or cataracts, and is correctable. Two approaches to improve the detection of these problems are to better publicise optometric services and to carry out community-based vision screening of older people. Screening programmes should pass the Wilson criteria and a consideration of these highlights three inter-related questions: 'Is vision screening effective at detecting correctable low vision in older people?'; 'Which tests should be included?' and 'Which venues are most appropriate?' We carried out a systematic review to investigate these questions. For the first question, only one study was found which met our selection criteria. The 'gold standard' eye examination in this study lacked several important components, and the vision screening method that was used was not found to be very effective. The review revealed other studies, which, although not meeting our selection criteria, included relevant information. The screening studies highlight the lack of agreement on the content of a gold standard eye examination and of the test(s) that should be used to screen vision. Visual function in older people is not adequately described by high contrast visual acuity (VA), nor by self-reports of visual difficulties. Other tests that may be relevant include visual field testing, low contrast VA, contrast sensitivity and stereo-acuity. The pinhole test has often been used in attempts to detect uncorrected refractive errors, but results from this test can be problematic and possible reasons for this are discussed. Appropriate venues for vision screening are contingent upon the format of the vision screening programme. There is still uncertainty over the battery of vision tests that are most appropriate. This, and optimum venues for screening, require further research before it can be fully determined whether vision screening of older people meets the Wilson criteria. If a vision screening programme using a battery of vision tests, perhaps computerised, can be established, then this should be tested to determine the sensitivity and specificity for detecting the target conditions. Ultimately, longitudinal studies are necessary to determine whether such a screening programme will lead to improved visual performance and quality of life in older people.

Prevalence and predictors of ocular manifestations of RA: is there a need for routine screening?

BACKGROUND

People with rheumatoid arthritis (RA) have an increased risk for eye problems caused by associated conditions or medication side-effects. Consequent visual impairment may increase the risk of falls or difficulties self-administering medications.

AIMS

The aim of the present study was to estimate the prevalence and predictors of ocular manifestations and visual impairment in a local sample of people with RA. The Visual Functioning Questionnaire (VFQ-25) was evaluated as a screening tool in people with RA.

METHODS

Seventy-five participants with RA attended a visual screening clinic. Demographic, medication and disease characteristics were recorded, a full ophthalmological assessment was performed by an expert ophthalmologist and the VFQ-25, Health Assessment Questionnaire and Self-administered Comorbidity Questionnaire were completed.

RESULTS

Twenty-nine participants (38.7%) had impaired visual acuity; this was correctable by appropriate refraction in 93.1%. The prevalence of cataracts was 22.7% and this was predicted by older age and steroid use. An abnormal Schirmer's test, suggesting dry eyes, was seen in 70.7% of participants but only 12.0% were using artificial tears. Answers to the VFQ-25 suggested misinterpretation of questions as relating to disability attributed to arthritis rather than caused by visual impairment.

CONCLUSIONS

Visual impairment does not appear to be particularly prevalent in RA, obviating the need for a screening programme. Utilization of the VFQ-25 as a screening tool in RA requires further consideration. The high prevalence of cataracts in participants on steroids emphasizes the need to prescribe the minimum required dose. The high prevalence of dry eyes suggests that a Schirmer's test should be performed regularly, with prescription of artificial tears if required.

The impact of blurred vision on cognitive assessment

The purpose of this study was to systematically assess the effect of blurred vision on several nonverbal neuropsychological measures commonly used as part of test batteries to assess the cognitive status of different patient populations. A total of 30 highly educated and healthy participants aged between 21 and 33 years were placed in one of three blurred vision groups, defined by their maximal visual acuity (20/20 or control group, 20/40, and 20/60). Blurred vision was simulated using positive diopters at a distance of 40 cm, the same distance as that at which tests were administered. Each participant was then assessed on a predetermined battery of nonverbal and verbal neuropsychological tests demanding different levels of acuity for optimal performance (i.e., tests whose items varied in terms of size and spatial frequency characteristics). In general, blurred vision significantly affected performance on nonverbal tests defined by small-sized/high-spatial-frequency items to a greater extent than on tests defined by larger sized/lower spatial-frequency items. As expected, blurred vision did not affect verbal test performance (Similarities, Information, and Arithmetic WAIS subtests). Our results are a clear indication of how even a "minimal" loss of visual acuity (20/40) can have a significant effect on the performance for certain nonverbal tests. In conclusion, such inferior performance is hypothetically interpretable as reflecting impaired cognitive functioning (i.e., attentional) targeted by a specific task (i.e., visual search) and suggests that the precision of the cognitive assessment and subsequent diagnosis are significantly biased when visuo-sensory abilities are not optimal, particularly for older patient populations where blurred vision resulting from correctable visual impairment is quite common.

The Newcastle 85+ study: biological, clinical and psychosocial factors associated with healthy ageing: study protocol

BACKGROUND

The UK, like other developed countries, is experiencing a marked change in the age structure of its population characterised by increasing life expectancy and continuing growth in the older fraction of the population. There is remarkably little up-to-date information about the health of the oldest old (over 85 years), demographically the fastest growing section of the population. There is a need, from both a policy and scientific perspective, to describe in detail the health status of this population and the factors that influence individual health trajectories. For a very large proportion of medical conditions, age is the single largest risk factor. Gaining new knowledge about why aged cells and tissues are more vulnerable to pathology is likely to catalyse radical new insights and opportunities to intervene. The aims of the Newcastle 85+ Study are to expose the spectrum of health within an inception cohort of 800 85 year-olds; to examine health trajectories and outcomes as the cohort ages and their associations with underlying biological, medical and social factors; and to advance understanding of the biological nature of ageing.

METHODS

A cohort of 800 85 year olds from Newcastle and North Tyneside will be recruited at baseline and followed until the last participant has died. Eligible individuals will be all those who turn 85 during the year 2006 (i.e. born in 1921) and who are registered with a Newcastle or North Tyneside general practice. Participants will be visited in their current residence (own home or institution) by a research nurse at baseline, 18 months and 36 months. The assessment protocol entails a detailed multi-dimensional health assessment together with review of general practice medical records. Participants will be flagged with the NHS Central Register to provide details of the date and cause of death.

DISCUSSION

The Newcastle 85+ Study will address key questions about health and health-maintenance in the 85+ population, with a particular focus on quantitative assessment of factors underlying variability in health, and on the relationships between health, nutrition and biological markers of the fundamental processes of ageing.

Depression and anxiety in visually impaired older people

PURPOSE

To investigate the association between visual impairment and depression and anxiety in older people in Britain.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Thirteen thousand nine hundred people aged 75 years and older in 49 family practices in Britain.

METHODS

Vision was measured in 13 900 people aged 75 years and older in 49 family practices taking part in a randomized trial of health screening that included depression (Geriatric Depression Scale [GDS-15]) and anxiety (General Health Questionnaire [GHQ-28]). Cause of visual impairment (binocular acuity less than 6/18) was assessed from medical records. Analysis was by logistic regression (odds ratio [OR] and 95% confidence interval [CI]), taking account of potential health and social confounders.

MAIN OUTCOME MEASURES

Levels of depression and anxiety.

RESULTS

Visually impaired people had a higher prevalence of depression compared with people with good vision. Of visually impaired older people, 13.5% were depressed (GDS-15 score of 6 or more) compared with 4.6% of people with good vision (age- and gender-adjusted OR, 2.69; 95% CI, 2.03-3.56). Controlling for potential confounding factors, particularly activities of daily living, markedly attenuated the association between visual impairment and depression (OR, 1.26; 95% CI, 0.94-1.70). There was little evidence for any association between visual impairment and anxiety. On the GHQ-28 scale, 9.3% of visually impaired people had 2 or more symptoms of anxiety compared with 7.4% of people with good vision.

CONCLUSIONS

Although cause and effect cannot be established in a cross-sectional study, it is plausible that people with visual impairment are more likely to experience problems with functioning, which in turn leads to depression.