Age-related macular degeneration: a randomized clinical trial of a self-management intervention

Low vision rehabilitation in improving the quality of life for patients with impaired vision: A systematic review and meta-analysis of 52 randomized clinical trials

BACKGROUND AIM

Low vision rehabilitation optimizes the use of residual vision after severe vision loss, but also teaches skills to improve visual functioning in daily life. These skills promote independence and active participation in society. This meta-analysis was designed to evaluate the efficacy of low vision rehabilitation in improving the quality of life (QoL) in visually impaired adults.

METHODS

We searched the Cochrane Library, PubMed, EMBASE, and Web of Science up to January 1, 2020. Randomized controlled trials (RCTs) that compared rehabilitation interventions with active or inactive controls were included. The standardized mean difference (SMD) with a 95% confidence interval (CI) was estimated to compare outcomes. Two reviewers extracted data and assessed trial quality independently. All statistical analyses were performed using the standard statistical procedures of RevMan 5.2.

RESULTS

A total of 52 RCTs with 6,239 participants were included in this meta-analysis. Compared to inactive comparators including waiting list or no care, low vision rehabilitation improved vision-related QoL, visual functioning (QoL: psychological aspect), and self-efficacy or self-esteem (QoL: psychological aspect), with pooled SMDs of -0.61 (95% CI -0.95 to -0.26; P = .0006), -1.14 (95% CI -1.69 to -0.59; P < .0001), and -0.84 (95% CI -1.47 to -0.22; P < .0001), respectively. Compared to active comparators, low vision rehabilitation improved vision-related QoL (SMD -0.26; 95% CI -0.46 to -0.06; P = .01) and activities of daily living (QoL: physical aspect) (SMD -0.39; 95% CI -0.67 to -0.12 P < .0001). However, no significant difference in health-related QoL and adaptation to vision loss (QoL: psychological aspect) was found between low vision rehabilitation and inactive comparators.

CONCLUSIONS

This meta-analysis indicated that low vision rehabilitation interventions, particularly psychological therapies and methods of enhancing vision, may improve vision-related QoL and visual functioning in people with sight loss compared to usual care. Further studies should explore longer maintenance effects and the costs of several types of low vision rehabilitation. Studies characterizing the mechanisms of rehabilitation interventions in different settings, including low-income countries, are also required.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

Mastery and self-esteem mediate the association between visual acuity and mental health: a population-based longitudinal cohort study

BACKGROUND

With deteriorating eyesight, people often become dependent on others for many aspects of their daily lives. As a result, they feel less 'in control' and experience lower self-esteem. Lower sense of mastery and self-esteem are known to predict depression, but their roles in people with visual impairment have only marginally been investigated. Therefore, this study aimed to determine the influence of mastery and self-esteem on the relationship between visual acuity and mental health.

METHODS

A longitudinal cohort study was performed using data from the Longitudinal Aging Study Amsterdam (LASA), collected between 2001 and 2012. A community-based population of 2599 older adults were included, who were randomly selected from population registers. Outcomes of interest were the Pearlin Mastery Scale, Rosenberg Self-Esteem Scale, Center for Epidemiologic Studies - Depression scale and the Hospital Anxiety Depression Scale - Anxiety subscale. Linear mixed models were used to establish the association between visual acuity and mental health over time.

RESULTS

Mean age was 72 years, 56% was female and 1.2% qualified as having low vision. Visual impairment was associated with a lower sense of mastery (β = - 0.477, p < 0.001), lower self-esteem (β = - 0.166, p = 0.008) and more depression (β = 0.235, p < 0.001). No significant association between visual acuity and anxiety was found. The relationship between visual acuity and depression was mediated by self-esteem (25%) and sense of mastery (79%).

CONCLUSIONS

Vision loss was associated with depression. This association was mediated by self-esteem and sense of mastery. This provides us with new possibilities to identify, support and treat those at risk for developing depression by aiming to increase their self-esteem and sense of mastery.

WITHDRAWN:The efficacy of low vision rehabilitation in improving the quality of life for patients with impaired vision: a systematic review and meta-analysis of 46 randomized clinical trials

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Self-Care and Health-Information-Seeking Behaviours of Diabetic Patients in Singapore

Patients in Singapore with chronic conditions such as diabetes are encouraged to participate in patient-professional partnership activities because of rising health care costs and a shortage of infrastructure and human resources. This study explores the self-care and health information seeking behaviors of diabetic patients in Singapore, as well as factors related to health and information carriers that might influence those behaviors. A pilot-tested online survey was developed based on the Comprehensive Model of Information Seeking (CMIS) and notified to the members of the Diabetic Society of Singapore (DSS) through their newsletter in January 2016. In total, 60 usable responses from the DSS members were collected. The survey revealed that more than 30% of the patients did not strictly follow doctors' instructions to regularly exercise, self-monitor blood sugar, and pay attention to type of food prepared at home. However, it was found that the majority of them had consciously limited their sugar intake. It was also revealed that respondents' most frequently used sources of health information were authoritative sources such as doctors/nurses and pamphlets/leaflets from hospitals/clinics. Understandably, respondents experiencing less distress caused by diabetes tended to report better health status, less worries, and stronger beliefs in the efficacy of their methods for diabetes control.

Low vision rehabilitation for better quality of life in visually impaired adults

BACKGROUND

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

OBJECTIVES

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

SEARCH METHODS

We searched relevant electronic databases and trials registers up to 18 September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies. Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07). Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence). Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

AUTHORS' CONCLUSIONS

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators. The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up, Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

Delineating the concept of self-management in chronic conditions: a concept analysis

OBJECTIVES

Self-management is a concept frequently used within healthcare but lacks consensus. It is the aim of this study to clarify the concept.

DESIGN

Concept analysis according to Walker and Avant, comprises eight steps: select concept, determine purpose, identify uses, determine defining attributes, identify model case, identify additional cases, identify antecedents and consequences and define empirical referents.

SOURCES USED

PubMed, Scopus and Web of Science.

RESULTS

Ten attributes delineating the concept have been identified and organised into three groups. Group (a): person-oriented attributes: the person must (1) actively take part in the care process, (2) take responsibility for the care process and (3) have a positive way of coping with adversity. Group (b): person-environment-oriented attributes: (4) the person must be informed about the condition, disease and treatment and self-management, (5) should be individualised, which entails expressing needs, values and priorities, (6) requires openness to ensure a reciprocal partnership with healthcare providers and (7) demands openness to social support. Finally, Group (c): summarising attributes: self-management (8) is a lifetime task, (9) assumes personal skills and (10) encompasses the medical, role and emotional management.

CONCLUSIONS

The findings of this study recognise the complexity of the concept, but also show the need for further investigation to make the concept more measurable. Clarity about the concept will enhance understanding and facilitate implementation in self-management programmes for chronic conditions.

The Relationship Between Hearing Loss Self-Management and Hearing Aid Benefit and Satisfaction

Purpose Hearing loss self-management refers to the knowledge and skills people use to manage the effects of hearing loss on all aspects of their daily lives. The purpose of this study was to investigate the relationship between self-reported hearing loss self-management and hearing aid benefit and satisfaction. Method Thirty-seven adults with hearing loss, all of whom were current users of bilateral hearing aids, participated in this observational study. The participants completed self-report inventories probing their hearing loss self-management and hearing aid benefit and satisfaction. Correlation analysis was used to investigate the relationship between individual domains of hearing loss self-management and hearing aid benefit and satisfaction. Results Participants who reported better self-management of the effects of their hearing loss on their emotional well-being and social participation were more likely to report less aided listening difficulty in noisy and reverberant environments and greater satisfaction with the effect of their hearing aids on their self-image. Participants who reported better self-management in the areas of adhering to treatment, participating in shared decision making, accessing services and resources, attending appointments, and monitoring for changes in their hearing and functional status were more likely to report greater satisfaction with the sound quality and performance of their hearing aids. Conclusion Study findings highlight the potential for using information about a patient's hearing loss self-management in different domains as part of clinical decision making and management planning.

Effectiveness of the "living successfully with low vision" self-management program: Results from a randomized controlled trial in Singaporeans with low vision

OBJECTIVE

To determine the effectiveness of the "Living Successfully with Low Vision" (LSLV) self-management program to improve patient-reported outcomes in Singaporeans.

METHODS

In this randomized controlled trial, 165 participants with low vision (LV) were recruited and assigned to usual care (LV aid training only; N = 82) or LSLV program (N = 83). The LSLV program focuses on problem solving, coping mechanism and anticipation/preparation for future needs. The primary outcome was vision-related quality of life (VRQoL; measured using the Impact of Vision Impairment [IVI] questionnaire), while secondary outcomes included health-related quality of life; mental health; and self-efficacy, assessed at baseline, 2-weeks and 6-months post-intervention. Within- and between-group comparisons were conducted using paired t-tests and repeated measures analysis of covariance, respectively.

RESULTS

A total of 128 individuals (77.6%) completed all assessments. At 2 weeks, LSLV participants alone experienced a significant within-group improvement in the mean IVI Emotional score (P = 0.05) but not at 6 months. No other within- or between-group effects were observed.

CONCLUSION

While SM programs have shown promising results in the management of many chronic diseases, our findings suggest that the LVSM program was not an effective approach for LV rehabilitation in Singapore.

PRACTICE IMPLICATION

Other evidence-based strategies to improve QoL in patients with LV may be warranted.

Psychosocial Intervention for Age-Related Macular Degeneration: A Pilot Project

This study evaluated an emotion-focused and a problem-focused intervention designed for patients with age-related macular degeneration. It found a limited decrease in depression in the emotion-focused group and an increase in active problem orientation and in adaptation to vision loss in the problem-focused group.

The Effectiveness of a Multi-Disciplinary Group Rehabilitation Program on the Psychosocial Functioning of Elderly People who are Visually Impaired

Introduction

The pilot study reported here determined the effectiveness of a multidisciplinary group rehabilitation program, Visually Impaired Elderly Persons Participating (VIPP), on psychosocial functioning.

Methods

The single-group pretest–posttest pilot study included 29 persons with visual impairments (aged 55 and older) who were referred to a low-vision rehabilitation center. The VIPP intervention (20 weekly meetings) consisted of four components (practical training; education, social interaction, counseling, and training in problem-solving skills; individual and group goal setting; and a home-based exercise program). Psychosocial adaptation to vision loss, helplessness, self-efficacy, mental health, and fear of falling were used as indicators of psychosocial functioning and were assessed at the baseline, halfway, immediately after completion of the intervention, and at the six-month follow-up.

Results

Directly after the intervention, the participants’ adaptation to vision loss (ES = 0.57), self-efficacy (ES = 0.50), and mental health (ES = 0.39) improved compared to the baseline. Moreover, helplessness and a generic and vision-specific fear of falling decreased (ES = 0.26, ES = 0.20, and ES = 0.24, respectively). The six-month follow-up measure indicated improved adaptation to vision loss (ES = 0.54), a lesser feeling of helplessness (ES = 0.53), better mental health (ES = 0.22), and a lesser vision-specific fear of falling (ES = 0.27). In contrast, a decrease in self-efficacy (ES = 0.14) and an increase in the generic fear of falling (ES = 0.18) were found.

Discussion

The tentative conclusion of this small-scale pilot study is that the VIPP program benefits psychosocial functioning in both the short and long term.

Implications for practitioners

The study showed that low-vision rehabilitation centers could implement multidisciplinary group rehabilitation programs, such as VIPP, to improve the psychosocial functioning of elderly people who are visually impaired.

Measurement of Perceived Stress in Age-Related Macular Degeneration

PURPOSE

To validate the Perceived Stress Scale (PSS) in patients with age-related macular degeneration (AMD) using Rasch analysis.

METHODS

Study participants with AMD were recruited from the retina service of the Department of Ophthalmology at the Ohio State University during clinical visits for treatment or observation. Visual acuity with habitual distance correction was assessed. A 10-item version of the PSS was administered in large print or by reading the items to the patient. Rasch analysis was used to investigate the measurement properties of the PSS, including fit to the model, ability to separate between people with different levels of perceived stress, category response structure performance, and unidimensionality.

RESULTS

A total of 137 patients with a diagnosis of AMD were enrolled. The mean (±SD) age of participants was 82 ± 9 years. Fifty-four percent were female. Median Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity of the better eye was 65 letters (Snellen 20/50), with a range of approximately 20/800 to 20/15. Forty-seven percent of participants were receiving an anti-VEGF injection on the day of the study visit. The response category structure was appropriate. One item, "How often have you felt confident in your ability to handle your personal problems?" was removed due to poor fit statistics. The remaining nine items showed good fit to the model, acceptable measurement precision as assessed by the Rasch person separation statistic, and unidimensionality. There was some evidence of differential item functioning by age and visual acuity.

CONCLUSIONS

The Perceived Stress Scale demonstrated acceptable measurement properties and may be useful for the measurement of perceived stress in patients with AMD.

Psychosocial interventions to improve mental health in adults with vision impairment: systematic review and meta-analysis

PURPOSE

To systematically assess the literature on psychosocial interventions to improve mental health (i.e. depression, anxiety, mental fatigue, loneliness, psychological stress and psychological well-being) in visually impaired adults (≥18 years).

METHODS

The databases Medline, Embase and Psychinfo were searched for relevant studies, which were categorised into randomised controlled trials (RCTs), non-RCTs and before and after comparisons (BA). The Cochrane Collaboration Risk of Bias Tool was used to assess study quality. Standardised mean differences (SMD) were calculated to quantitatively summarise the outcomes of the RCTs and non-RCTs in a meta-analysis. Meta-regression was used to explore sources of heterogeneity in the data.

RESULTS

The search identified 27 papers (published between 1981 and 2015), describing the outcomes of 22 different studies (14 RCTs, four non-RCTs, and four BAs). Pooled analyses showed that interventions significantly reduced depressive symptoms (SMD -0.30, 95% confidence interval (CI) -0.60 to -0.01), while effects on anxiety symptoms, mental fatigue, psychological stress and psychological well-being were non-significant. Meta-regression analyses showed homogeneity in effect sizes across a range of intervention, population, and study characteristics. Only a higher age of participants was associated with less effective results on depressive symptoms (b = 0.03, 95% CI 0.01 to 0.05), psychological stress (b = 0.07, 95% CI 0.01 to 0.13) and psychological well-being (b = -0.03, 95% CI -0.05 to 0.01). However, after removing a clear outlier the overall effect on depressive symptoms and the influence of age on depressive symptoms and psychological stress were no longer significant, while the influence of age on psychological well-being remained.

CONCLUSIONS

There is currently only limited evidence for the effectiveness of psychosocial interventions in the field of low vision. More well-designed trials are needed with specific attention for interventions tailored to the needs of elderly patients.

Should family and friends be involved in group-based rehabilitation programs for adults with low vision?

This qualitative study investigates the views of clients with low vision and vision rehabilitation professionals on the involvement of family and friends in group-based rehabilitation programs. Both groups outlined advantages and disadvantages to involving significant others, and it is essential that clients are given the choice. Future work is needed to examine the uptake, process and outcomes of rehabilitation programs in which clients are able to invite family and friends.

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

This article aims to facilitate optimal management of cataracts and age-related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer-reviewed English-language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age-related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age-related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low-vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low-vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.

Anxiety and depression in patients with advanced macular degeneration: current perspectives

Age-related macular degeneration (AMD) - despite advances in prevention and medical treatment options - remains prevalent among older adults, often resulting in functional losses that negatively affect the mental health of older adults. In particular, the prevalence of both anxiety and depression in patients with AMD is high. Along with medical treatment options, low vision rehabilitation and AMD-specific behavioral and self-management programs have been developed and have demonstrated effectiveness in improving the mental health of AMD patients. This article reviews the prevalence of anxiety and depression in patients with advanced AMD, discusses potential mechanisms accounting for the development of depression and anxiety in AMD patients, presents the state-of the-art of available interventions for addressing anxiety and depression in AMD patients, and delineates recommendations for eye care professionals regarding how to screen for these two prevalent mental health problems and how to facilitate appropriate treatment for patients with AMD.

Do problem-solving interventions improve psychosocial outcomes in vision impaired adults: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of problem-solving interventions on psychosocial outcomes in vision impaired adults.

METHODS

A systematic search of randomised controlled trials (RCTs), published between 1990 and 2013, that investigated the impact of problem-solving interventions on depressive symptoms, emotional distress, quality of life (QoL) and functioning was conducted. Two reviewers independently selected and appraised study quality. Data permitting, intervention effects were statistically pooled and meta-analyses were performed, otherwise summarised descriptively.

RESULTS

Eleven studies (reporting on eight trials) met inclusion criteria. Pooled analysis showed problem-solving interventions improved vision-related functioning (standardised mean change [SMC]: 0.15; 95% CI: 0.04-0.27) and emotional distress (SMC: -0.36; 95% CI: -0.54 to -0.19). There was no evidence to support improvements in depressive symptoms (SMC: -0.27, 95% CI: -0.66 to 0.12) and insufficient evidence to determine the effectiveness of problem-solving interventions on QoL.

CONCLUSION

The small number of well-designed studies and narrow inclusion criteria limit the conclusions drawn from this review. However, problem-solving skills may be important for nurturing daily functioning and reducing emotional distress for adults with vision impairment.

PRACTICE IMPLICATIONS

Given the empirical support for the importance of effective problem-solving skills in managing chronic illness, more well-designed RCTs are needed with diverse vision impaired samples.

Predictors of anti-VEGF treatment response in neovascular age-related macular degeneration

Currently available evidence on predictors of anti-vascular endothelial growth factor (VEGF) treatment response in neovascular age-related macular degeneration was reviewed. No meta-analysis of results is possible because of a lack of controlled and randomized trials, varying treatment regimes and outcome measures used, as well as suboptimal reporting. For genetic factors, most evidence to date has been generated for single nucleotide polymorphisms (SNPs) in the complement factor H (CFH), and VEGF-A genes. Just under half of the SNPs assessed in the CFH gene and 15% of the SNPs assessed in the VEGF gene were found to be associated with visual outcomes or the number of injections required during follow-up. Some evidence suggests association of worse treatment outcomes as well as a younger age at treatment onset with an increasing number of risk alleles in known risk genes (CFH and ARMS2/HTRA1) and polymorphisms in the VEGF-A gene. Clinical factors such as higher age, a better visual acuity (VA), a larger choroidal neovascularization (CNV) lesion at baseline, and a delay between symptom onset and initiation of treatment of more than 3 weeks also impact outcomes. Conversely, a worse acuity at baseline predicted more gain in vision. Overall, patients presenting with good acuity at baseline were more likely to have good VA at follow up, but the gain afforded by treatment was impacted by a ceiling effect. Most available evidence suggests a strong association of clinical factors such as age, baseline VA, and CNV lesion size with anti-VEGF treatment outcomes. No behavioral factors such as smoking influence treatment outcomes. Based on the studies conducted so far, the evidence suggests that underlying genotype of known AMD risk associated genes or of the VEGF-A gene have a limited effect, whereas presenting clinical factors appear to be more important in determining treatment outcomes.

Occupational Therapy Interventions to Improve Leisure and Social Participation for Older Adults With Low Vision: A Systematic Review

This systematic review examined evidence regarding the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in leisure and social participation for older adults with low vision. We identified and reviewed 13 articles that met the inclusion criteria. Four themes related to interventions to improve leisure and social participation emerged from the literature review: using a problem-solving approach, delivering a combination of services, providing skills training, and making home visits and environmental adaptations. The strongest evidence supports using a problem-solving approach to improve leisure and social participation for older adults with low vision. Evidence was moderate supporting the delivery of a combination of services, either by one professional or through an interdisciplinary approach. Results for the effectiveness of skills training and home visits and home adaptations were mixed. Implications for practice, education, and research are discussed.

Can we associate the hours of clinical services at the rehabilitation outcomes? The case of the visual impairment rehabilitation program

The purpose of this study was to determine the effects on the elderly of clinical interventions by professionals from a visual impairment rehabilitation program, more specifically, the effects on their daily life and the extent to which such interventions encourage social participation. In accordance with the conceptual framework of the Disability Creation Process, the clinical results of a population study group of 100 persons with various types of visual impairment enrolled in a rehabilitation program were analyzed as per the intensity of the clinical interventions (eg, hours of clinical services provided and dispensed by professionals). The results of the study tend to show that the hours of services accorded to a patient positively contribute to the progression of his or her Functional Global Profile as per the rehabilitation outcomes progression measures. In contrast, age and the spreading of services negatively contribute. The contributions of the study are innovative for assessing clinical effectiveness. For instance, the understanding of the relationship between the measurement of a patient's clinical results and the services that he or she has received should help us improve the practices and methods used in visual impairment rehabilitation.

Tango programme for individuals with age-related macular degeneration

Recent research shows that tango dance is an absorbing and effective strategy to reduce levels of depression, while also increasing well-being. This study investigates the feasibility, acceptability, and adherence to a tango programme for individuals with age-related macular degeneration (ARMD). Depression is closely intertwined with the ARMD diagnosis, since the loss of central vision has a profoundly negative impact on the person’s quality of life. Seventeen participants were randomised to tango dance (1.5 h, 2 times/week for 4 weeks) or wait-list control condition. Demographic questions and Visual Function Questionnaire were taken at pre-test. Self-rated symptoms of depression, self-esteem, and satisfaction-with-life were assessed at pre-test and post-test. Tango group participants showed significant reductions in depression and significantly increased satisfaction-with-life and self-esteem at post-test relative to the controls, and reported physical improvement, including increased balance. Tango dance was demonstrated to be a feasible and positive activity for this population.

Computer use among patients with age-related macular degeneration

PURPOSE

Age-related macular degeneration (AMD) is the leading cause of incurable vision loss in older adults in industrialized countries and is on a trajectory to disable a growing number of persons as societies age. To assess the potential of using telemedicine for expansion of an in-person AMD self-management program, we examined the extent of computer use in a sample of older adults with AMD.

METHODS

160 older adult volunteers (mean age = 76 years; female = 51%) with AMD (mean visual acuity in better eye: 20/40; worse eye: 20/90) were randomly selected from members of the San Diego County AMD Registry. Computer use was assessed with a Health and Impact Questionnaire. Dependent measures were Snellen visual acuity, National Eye Institute-Visual Function Questionnaire, the AMD Self-Efficacy Questionnaire, and the Geriatric Depression Scale.

RESULTS

Overall 70.6% reported computer use at least once per month. By age and gender stratum, 76.5% of men aged 60-74 years, 73.3% of men aged 75 years and over, 74.3% of women aged 60-74 years, and 60.9% of women aged 75 years and over used computers. In logistic regression analyses controlling for age and gender, computer use was associated with better visual acuity (P = 0.029), higher education (P = 0.002), and self-efficacy for communication (P = 0.027).

CONCLUSION

The majority of older adults with AMD in our sample used computers, with use highest among more educated and visually intact patients. Computer use to access the Internet is feasible in AMD patients and should be encouraged. The inclusion of computer use in measures of AMD-related functioning appears warranted.

The a"MAZE"ing world of lung-specific transgenic mice

The purpose of this review is to give a comprehensive overview of transgenic mouse lines suitable for studying gene function and cellular lineage relationships in lung development, homeostasis, injury, and repair. Many of the mouse strains reviewed in this Perspective have been widely shared within the lung research community, and new strains are continuously being developed. There are many transgenic lines that target subsets of lung cells, but it remains a challenge for investigators to select the correct transgenic modules for their experiment. This review covers the tetracycline- and tamoxifen-inducible systems and focuses on conditional lines that target the epithelial cells. We point out the limitations of each strain so investigators can choose the system that will work best for their scientific question. Current mesenchymal and endothelial lines are limited by the fact that they are not lung specific. These lines are summarized in a brief overview. In addition, useful transgenic reporter mice for studying lineage relationships, promoter activity, and signaling pathways will complete our lung-specific conditional transgenic mouse shopping list.

Psychosocial interventions for the prevention of depression in older adults: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of psychosocial interventions for the prevention of depression in older people.

METHOD

Systematic review and meta-analysis of prospective controlled trials.

RESULTS

Thirty studies were included. Overall, psychosocial interventions had a small but statistically significant effect on depressive symptoms (17 trials, standardized mean difference = -0.17, 95% CI = -0.31 to -0.03). In comparison with no-intervention controls, social activities were effective in reducing depressive symptoms, but results should be interpreted with caution due to the small number of trials. No statistically significant effect on depressive symptoms was found for physical exercise, skill training, reminiscence, or for multicomponent interventions.

DISCUSSION

Psychosocial interventions have a small but statistically significant effect in reducing depressive symptoms among older adults. The current evidence base for psychosocial interventions for primary prevention of depression in older people is weak, and further trials warranted especially for the most promising type of interventions evaluated, that is, social activities.

Survey of optometric low vision rehabilitation training methods for the moderately visually impaired

PURPOSE

The goal of this survey study is to determine the low vision rehabilitation training practices of optometrists who prescribe near magnifying devices for low vision patients who have moderate visual impairment from age-related macular degeneration.

METHODS

A total of 2,028 surveys were sent electronically or by mail. A total of 136 optometrists reporting a special interest in low vision rehabilitation responded to an 18-item survey about practice mode, educational background, affiliations, and other demographic information. They were queried on methodology, frequency, and specific strategic content of rehabilitation training.

RESULTS

Sixty-eight percent of the 136 respondents were private practitioners. Fifty-four percent of all respondents agreed that they train patients for 1 hour or less. Nine percent provided 3 or more training visits and were more likely to utilize an occupational therapist. Forty-six percent of respondents reported using various other personnel to perform the training. The majority of respondents spend 25% of their time examining low vision patients. Eighteen percent of all respondents were low vision residency trained.

CONCLUSIONS

Descriptions of current practice patterns are difficult to ascertain without consensus on terminology and management criteria among low vision practitioners. This survey and accompanying literature review support the need for clinical research and education that will establish an efficacious and cost-effective model for private outpatient low vision rehabilitation for individuals with various levels of vision impairment to determine the true availability of low vision rehabilitation care in the United States.

[Quality of life by limited vision in old age: the example of age-related macula degeneration]

Age-related macula degeneration (AMD) is accompanied by considerable consequences regarding the psychosocial quality of life. A considerable body of research literature now indicates, for instance, an increased rate of depression and substantial loss of everyday capabilities in AMD patients. However, inter-individual differences are large and part of the explanation lies in differences in the ability to cope with and detach oneself from aims in life. The negative impact of AMD on the qualify of life is associated with a need for psychosocial support, but this need is barely met at present. A series of studies nevertheless supports the view that successful intervention is possible even with very old patients. In this respect the problems at present have less to do with recognition than with application and implementation.

Self-management programs for adults with low vision: needs and challenges

OBJECTIVE

To explore the needs of individuals with low vision in order to inform the contents of a low vision self-management (SM) program and determine potential barriers to participation.

METHODS

Semi-structured interviews were conducted with 48 participants with low vision resulting different from eye conditions. Qualitative analysis was conducted in order to identify major themes.

RESULTS

All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interaction and emotional distress. Less than half were interested in attending a SM program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program.

CONCLUSION

SM programs for low vision are a promising way to help address the range of difficulties experienced by this population if barriers to participation can be overcome.

PRACTICE IMPLICATIONS

SM programs should include vision-specific strategies, training in generic problem-solving and goal setting skills and how to cope with emotional reactions to vision impairment. Programs should be delivered and promoted in such a way to enhance access and encourage uptake by those with a range of vision loss in the community.

Quality of life in age-related macular degeneration: a review of the literature

BACKGROUND

The Age-related Macular Degeneration Alliance International commissioned a review of the literature on quality of life (QoL) in macular degeneration (MD) with a view to increasing awareness of MD, reducing its impact and improving services for people with MD worldwide.

METHOD

A systematic review was conducted using electronic databases, conference proceedings and key journal hand search checks. The resulting 'White Paper' was posted on the AMD Alliance website and is reproduced here.

REVIEW

MD is a chronic, largely untreatable eye condition which leads to loss of central vision needed for tasks such as reading, watching TV, driving, recognising faces. It is the most common cause of blindness in the Western world. Shock of diagnosis, coupled with lack of information and support are a common experience. Incidence of depression is twice that found in the community-dwelling elderly, fuelled by functional decline and loss of leisure activities. Some people feel suicidal. MD threatens independence, especially when comorbidity exacerbates functional limitations. Rehabilitation, including low vision aid (LVA) provision and training, peer support and education, can improve functional and psychological outcomes but many people do not receive services likely to benefit them. Medical treatments, suitable for only a small minority of people with MD, can improve vision but most limit progress of MD, at least for a time, rather than cure. The White Paper considers difficulties associated with inappropriate use of health status measures and misinterpretation of utility values as QoL measures: evidence suggests they have poor validity in MD.

CONCLUSION

There is considerable evidence for the major damage done to QoL by MD which is underestimated by health status and utility measures. Medical treatments are limited to a small proportion of people. However, much can be done to improve QoL by early diagnosis of MD with good communication of prognosis and continuing support. Support could include provision of LVAs, peer support, education and effective help in adjusting to MD. It is vital that appropriate measures of visual function and QoL be used in building a sound evidence base for the effectiveness of rehabilitation and treatment.

The Impact of Assistive Device Use on Disability and Depression Among Older Adults With Age-Related Vision Impairments

OBJECTIVE

One can conceptualize adaptive technology as a resource used by disabled older adults in order to maintain competence in everyday life. This study examined the independent relationships between optical and adaptive device utilization and change in functional disability and depression among older adults with age-related vision impairments.

METHODS

We interviewed older adults (n = 438) with a recent vision impairment applying for vision rehabilitation services both pre-service and at the 6-month follow-up. We conducted hierarchical regression analyses with functional disability and depressive symptoms as criteria. In order to identify their independent direct effects, we entered optical and adaptive device use into the final step, preceded by Time 1 criterion scores, demographics, baseline disability or depression (depending on criterion), and total rehabilitation service hours.

RESULT

Optical, but not adaptive, device use was significantly associated with declines in functional disability and depressive symptoms over time.

DISCUSSION

We propose that these differential effects result from the fact that optical devices optimize residual vision and thus allow for greater continuity in the way tasks are accomplished (i.e., reading still performed visually), whereas use of adaptive aids (e.g., talking books) involves learning new methods in order to compensate for lost functions and thus is not as desirable either functionally or psychologically.

Age-related macular degeneration: treating the whole patient

Ophthalmologists can help to improve the quality of life for patients with age-related macular degeneration (AMD) by treating the whole patient. Patients should be encouraged to seek psychiatric care for depression, especially if symptoms are persistent. They may also cope better with their vision loss by participating in AMD support groups. For earlier diagnosis of AMD, patients at high risk should be screened; if large drusen are present, nutritional suggestions can be made. Until treatments to prevent vision loss or to restore vision are available, these approaches provide optimal care.

The Application of Self-Efficacy Principles to Audiologic Rehabilitation: A Tutorial

Purpose

The purpose of this tutorial is to provide a comprehensive overview of the self-efficacy framework and its application to audiologic rehabilitation.

Method

A literature review was conducted on self-efficacy and its relevance to successful interventions in several health domains. Specific recommendations were presented for audiologic rehabilitation procedures that will enhance self-efficacy.

Conclusions

As is the case in other health domains, clinical intervention by audiologists will be more effective when incorporating a self-efficacy framework in the audiologic rehabilitation process.

The effectiveness of a bibliotherapy in increasing the self-management ability of slightly to moderately frail older people

OBJECTIVE

Self-management ability (SMA) is the ability to obtain those resources necessary for the production of well-being. With age, SMA becomes increasingly important, if one has a large variety of resources, physical and psychosocial losses due to the aging process can be substituted or compensated for. This study examined whether an increase in SMA would ensure sustainable levels of positive well-being among slightly to moderately frail older people.

METHODS

A bibliotherapy was developed to increase the SMA of slightly to moderately frail older people, and to help these persons to sustain a certain level of well-being. The effectiveness of this bibliotherapy was examined by comparing the SMA, mastery, and subjective well-being of 97 older people participating in the bibliotherapy to those of 96 older people in a delayed-treatment control condition.

RESULTS

The bibliotherapy resulted in a significant increase in SMA and mastery compared to the delayed-treatment control condition, and for SMA, this effect still existed 6 months after the intervention. The increase in SMA among older people who received the bibliotherapy prevented a decline in well-being as expected, but only in the short-term.

CONCLUSION

The current findings show that it is possible to counteract an age-related decline in well-being, even with only slight to moderate levels of frailty.

PRACTICE IMPLICATIONS

Cheap and easily accessible interventions, like the self-management bibliotherapy described in this article, may provide a useful addition to more traditional gerontological interventions.

Visual Function in Patients With Choroidal Neovascularization Resulting From Age-Related Macular Degeneration: The Importance of Looking Beyond Visual Acuity

PURPOSE

A detailed understanding of overall quality of vision may help primary care physicians, optometrists, and general ophthalmologists to improve the care of patients with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD).

METHODS

Published literature was reviewed using Medline searches and the authors' knowledge of the field.

RESULTS

Both visual acuity and contrast sensitivity are strongly associated with the ability to perform vision-related activities of daily living. CNV resulting from AMD often leads to scotoma, which is also strongly associated with the ability to perform everyday activities such as reading and driving. Contrast sensitivity and visual field extent may be better predictors of many abilities than visual acuity. Laser photocoagulation, verteporfin therapy, and pegaptanib sodium have been proven to reduce the risk of visual acuity loss in patients with CNV resulting from AMD. Laser photocoagulation frequently causes scotoma, but data on its effects on other aspects of overall quality of vision are scarce. Verteporfin therapy has been shown to also reduce the risk of contrast sensitivity loss and has been associated with stabilization or reduction of scotoma size. Treatment effects beyond visual acuity have not been investigated for pegaptanib. Detailed assessment of overall quality of vision also aids the design of vision rehabilitation programs tailored to the needs of individual patients.

CONCLUSIONS

Understanding the impact of vision loss on patients with CNV resulting from AMD and assessing treatment benefits requires assessment of overall quality of vision. Primary care physicians and optometrists have an important role in ensuring that patients receive the best possible care, which can be aided by prompt referral to an ophthalmologist or retina specialist and collaboration with low-vision specialists and optometrists who together can make detailed assessments of overall quality of vision, implement appropriate treatment, and design effective rehabilitation strategies.

[The emotional sensitivity of elderly people--validation of the Profile of Mood States for people over 60 years]

The German short version of the "Profile of Mood States (POMS)" with 35 items (seven-point response scale; rating related to the past 24 hours) was psychometrically tested in a sample of elderly people of 60 years of age and older (n=690; 57% female). The internal structure of the POMS with four factors (dejection, fatigue, displeasure, vigour) could largely be replicated, even though the first three factors are intercorrelated. Reliability of the scales appears to be very good. The convergent validity of the POMS scales could be proved by correlations with the Beck Depression Inventory and the SF-36. Specific norms are presented for four age groups, men and women and elderly living in Eastern and Western Germany. So it seems appropriate to use the German short version of the POMS as a valid and economic instrument for gerontological studies.

Quality of Life in Patients With Age-related Macular Degeneration: Impact of the Condition and Benefits of Treatment

Age-related macular degeneration (AMD) is a chronic, progressive, degenerative disease of the macula and is the leading cause of central vision loss among elderly people in the western world. Traditionally, clinical studies of AMD have described the impact of AMD, and treatments for AMD, in terms of the patient's visual acuity. However, visual acuity alone does not provide information about a patient's perception of his or her quality of life. Researchers have used a variety of instruments to measure quality of life. Several studies have shown that AMD can severely impair quality of life and that increasing vision loss is associated with increasing impairment of quality of life and frequently causes depression. Interestingly, patients with only one eye affected may become more depressed than those with both eyes affected, possibly because of uncertainty surrounding future vision loss in patients with one eye affected and a greater acceptance of the condition in those with both eyes affected. Studies also have provided some information on the possible quality of life benefits of therapy for AMD. By incorporating measurements of quality of life into the design of future prospective studies, clinical researchers may be able to obtain more comprehensive data on the impact of AMD on patients and the relative benefits of different therapies.

[A psychosocial training program for elderly patients with age-related macular degeneration: findings of a pilot evaluation study]

The purpose of this work was to develop and evaluate a psychosocial intervention aimed to improve quality of life of AMD patients. A total of 22 outpatients (age 62 to 80 years) treated in the University Eye Clinic in Heidelberg were divided into an intervention group (n=14) and a comparison group without intervention (n=8). The intervention program was based on six modules carried out in five weekly group sessions. These modules included: (1) progressive muscle relaxation, (2) exchange of disease-related experiences, (3) connection between thought, emotion, and behavior, (4) activation of available resources, (5) general problem solving skills and (6) information exchange. Pre-post assessment addressed a set of standardized emotional and behavioral outcome measures. Findings revealed that the intervention group showed improvement or prevention of additional loss in emotional as well as in behavioral outcomes, while the comparison group did not. Results are interpreted as initial evidence that the developed program is able to improve the quality of life in patients suffering from AMD.

Development and Pilot Evaluation of a Psychosocial Intervention Program for Patients With Age-Related Macular Degeneration

PURPOSE

The psychosocial needs of patients suffering from severe visual loss associated with advanced age-related macular degeneration (ARMD) are generally ignored in the clinical routine. The aim of this study was to develop and evaluate a psychosocial intervention program for ARMD patients. This intervention program was based on six modules carried out in five weekly group sessions. These modules included (a) progressive muscle relaxation; (b) exchange of disease-related experiences; (c) understanding the connections among thought, emotion, and behavior; (d) description of and emphasis on the use of available resources; (e) improvement of general problem-solving skills, and (f) information exchange on ARMD-related treatment and rehabilitation options.

DESIGN AND METHODS

A preliminary evaluation of this intervention program was performed with the aid of a preintervention-postintervention comparison-group research design, which included 14 individuals (mean age of 73.1 years) in the interventional group and 8 participants (mean age of 72.6 years) in the comparison group. The preintervention-postintervention assessment addressed a set of emotional (e.g., positive and negative affect) as well as behavioral (e.g., limitations to activities and instrumental activities of daily living) outcome measures.

RESULTS

Although the sample size of the pilot evaluation test was small, our results demonstrate the usefulness of this pilot program. A statistical analysis comparing the interventional group with the comparison group revealed that the intervention group benefited from the program in five out of six outcome measures.

IMPLICATIONS

Psychosocial group intervention is a promising approach to improve the quality of life in patients suffering from ARMD.