Using Objective Vision Measures to Explore the Association of Vision Impairment With Cognition Among Older Adults in the United States

COVID-19 Testing and Vaccination Among US Older Adults with Vision Impairment: The National Health and Aging Trends Study 2021

PURPOSE

To examine the associations between vision impairment (VI) and COVID-19 testing and vaccination services in older US adults.

METHODS

This cross-sectional study assessed data from adults ≥ 65 years who participated in the National Health and Aging Trends Study (year 2021), a nationally representative sample of Medicare beneficiaries. Exposure: Distance VI (<20/40), near VI (<20/40), contrast sensitivity impairment (CSI) (<1.55 logCS), and any VI (distance, near, or CSI). Outcomes: Self-reported COVID-19 testing and vaccination.

RESULTS

Of 2,822 older adults, the majority were female (weighted; 55%) and White (82%), and 32% had any VI. In fully-adjusted regression analyses, older adults with any VI had similar COVID-19 vaccination rates to adults without any VI (OR:0.77, 95% CI:0.54-1.09), but had lower odds of COVID-19 testing (OR:0.82, 95% CI:0.68-0.97). Older adults with distance (OR:0.47, 95% CI:0.22-0.99) and near (OR:0.68, 95% CI:0.47-0.99) VI were less likely to be vaccinated for COVID-19, while those with CSI were less likely to test for COVID-19 (OR:0.76, 95% CI:0.61-0.95), as compared to peers without respective impairments. The remaining associations were not significant (p > .05).

CONCLUSIONS AND RELEVANCE

These findings highlight inequities in the COVID-19 pandemic response for people with vision disability and emphasize the need for equitable prioritization of accessibility of healthcare services for all Americans.

Longitudinal Changes in Visual Acuity and Contrast Sensitivity and Incident Dementia

PURPOSE

To evaluate the impact of baseline and change in vision on the risk of developing dementia.

DESIGN

Retrospective cohort study.

METHODS

This longitudinal analysis utilized data from the 2021 and 2022 National Health and Aging Trends Study. Binocular presenting vision was assessed, including distance (DVA) and near (NVA) visual acuity, and contrast sensitivity (CS). Dementia status was defined based on: (1) medical diagnosis of dementia, (2) dementia score, or (3) poor cognitive test performance.

RESULTS

Of the 2,159 adults included in this study, weighted mean (SD) age was 77.9 years (5.2), with the majority being female (weighted: 54%), and White (88%). The baseline median (interquartile range [IQR]) DVA was 0.08 (0-0.20) logMAR, NVA was 0.17 (0.09-0.26) logMAR, and CS was 1.80 (1.65-1.85) logCS. Over the 1-year follow up period, 192 (6.6%) adults developed dementia. In time-to-event analyses, baseline DVA (HR: 1.08 [95% CI: 1.02-1.14], per 0.1 logMAR), NVA (HR: 1.07 [95% CI: 1.01-1.13], per 0.1 logMAR), and CS (HR: 1.09 [95% CI: 1.03-1.15], per 0.1 logCS) were associated with greater likelihood of incident dementia. Further, change in CS (HR: 1.14 [95% CI: 1.04-1.25], per 0.1 logCS worse/year), but not VA, was associated with greater likelihood of incident dementia.

CONCLUSIONS

Worse baseline VA and CS are associated with greater likelihood of incident dementia. Further, worsening CS over time, but not VA, was associated with higher likelihood of incident dementia. Future work is needed to study interventions targeted at improving vision deficits and examine their impact on decreasing dementia risk.

The Quantitative Impact of Visual Function on Accelerometer-measured Physical Activity in Older United States Adults: A Nationwide Cross-sectional Analysis

Purpose

To explore the impact of objective vision measures on novel metrics of objectively-measured physical activity (PA) in a nationally representative sample of United States (US) older adults.

Design

Cross-sectional analysis using data from the National Health and Aging Trends Study.

Participants

Adults had their distance and near visual acuity (VA) and contrast sensitivity (CS) tested. Any objective vision impairment (VI), defined as any VI in distance VA, near VA, or CS, was the primary exposure. Physical activity data were collected using the Actigraph CentrePoint Insight Watch worn for 7 days.

Methods

Multivariable regression models were used to investigate the association between vision and PA measures. All analyses accounted for the survey design and models were adjusted for age, sex, race, living arrangement, education, and comorbidities.

Main Outcome Measures

Physical activity metrics included (1) total daily activity (active minutes per day, number of active bouts, and mean length of active bouts), (2) activity fragmentation, and (3) time until 75% activity. An active bout was defined as ≥ 1 consecutive active minute. Activity fragmentation was defined as the probability of an active minute being followed by a sedentary minute, with higher values indicating more fragmented activity. Time until 75% activity was defined as the time taken to complete 75% of daily PA starting from their first active bout.

Results

Among 723 participants, sampled from 10 443 338 older adults in the US, 30% had any objective VI. Any objective VI was significantly associated with lower number of active minutes per day (7.8% fewer [95% confidence interval {CI}: -13.6% to -1.7%]), shorter active bouts (7.0% shorter [95% CI: -12.3% to -1.4%]), and greater activity fragmentation (2.5% [95% CI: 0.8% to 4.2%]), while no associations were found with number of active bouts. Time until 75% activity did not significantly differ between adults with any objective VI and those without (P = 0.34).

Conclusions

Older US adults with any objective VI displayed lower total daily activity, as well as more fragmented, shorter periods of PA, despite having a similar number of active bouts compared to their normally sighted counterparts. Implementing interventions that increase bout duration may help promote PA in adults with VI.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Concordance between Self-Reported Visual Difficulty and Objective Visual Impairment: The National Health and Aging Trends Study

PURPOSE

To examine the performance of self-reported visual difficulty (VD) in predicting objective visual impairment (VI) in older adults and explore factors that influence discordance.

DESIGN

Cross-sectional analysis of the National Health and Aging Trends Study (2022).

METHODS

Participants reporting blindness or difficulties with distance or near vision were characterized as having VD. Presenting binocular distance visual acuity (VA), near VA, and contrast sensitivity (CS) were assessed. Objective VI was defined as having VI in distance VA (worse than 20/40), near VA (worse than 20/40), or CS (worse than 1.55 logCS). Receiver operating characteristic analysis was used to compare performance of VD in predicting VI. To investigate factors that influence discordance, we limited our sample to adults with VI and used a multivariable logistic regression model to identify factors associated with not reporting VD. Similar analyses were performed to explore factors associated with reporting VD in adults without VI.

MAIN OUTCOME MEASURES

Discordance factors.

RESULTS

Four thousand nine hundred ninety-nine adults were included in the 2022 cohort. Visual difficulty achieved an area under the curve (AUC) of 56.0 (95% confidence interval [CI], 55.2-56.9) in predicting VI, with a sensitivity of 15.8 (95% CI, 14.2-17.5) and specificity of 96.3 (95% CI, 95.5-96.9). Characteristics associated with not reporting VD in adults with VI included female gender (odds ratio [OR], 0.64 [95% CI, 0.42-0.99]), Hispanic ethnicity (OR, 0.49 [95% CI, 0.31-0.78), higher income (≥75 000, OR, 1.99 [95% CI, 1.14-3.45]), ≥4 comorbidities (OR, 0.46 [95% CI, 0.29-0.72]), and depressive symptoms (OR, 0.49 [95% CI, 0.25-0.93]). Factors associated with self-reporting VD in the absence of VI included Hispanic ethnicity (OR, 2.11 [95% CI, 1.15-3.86]), higher income (≥$75 000, OR, 0.27 [95% CI, 0.12-0.63]), and anxiety symptoms (OR, 3.05 [95% CI, 1.56-5.97]).

CONCLUSIONS

Self-reported VD is a distinct measure assessing disability and has limited ability in predicting objective VI. Caution is advised when using self-reported VD as a surrogate measure for objective VI in epidemiological studies, although it may still be an effective way to capture risk of current or future disability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Digital Technology Use Among Older Adults With Vision Impairment

Importance

Telehealth has the potential to improve health for older adults, but many access disparities exist, including for those with vision impairment (VI).

Objective

To examine the associations between VI and digital technology access measures in US older adults.

Design, Setting, and Participants

This was a cross-sectional study that included Medicare beneficiaries 65 years and older. Beneficiary data were obtained from the National Health and Aging Trends Study (NHATS) 2021; data collection was conducted from June 2020 through January 2021. Data were analyzed September 2023.

Exposure

VI, measured on categorical (distance and near VI [>0.30 logMAR], contrast sensitivity impairment [CSI; <1.55 logCS], and any VI [distance VI, near VI, or CSI]), and continuous (distance and near acuity [logMAR] and contrast sensitivity [logCS]) scales.

Main Outcomes

Self-reported outcomes of digital technology access from the technological environment component of the NHATS.

Results

Of the 2822 Medicare beneficiaries (mean [SD] age, 78.5 [5.6] years; 1605 female [54.7%]) included in this study, patients self-identified with the following race and ethnicity categories (weighted percentages): 575 non-Hispanic Black (8.0%), 132 Hispanic (7.0%), 2019 non-Hispanic White (81.7%), and 63 non-Hispanic other race (3.4%), which included American Indian, Alaska Native, Asian, multiracial, Native Hawaiian, Pacific Islander, or other specified race. A total of 1077 of 2822 patients (32.3%) had any VI. In multivariable logistic regression models, older adults with any VI had lower odds of having or knowing how to use a cellphone (odds ratio [OR], 0.58; 95% CI, 0.38-0.88), computer (OR, 0.61; 95% CI, 0.47-0.79), or tablet (OR, 0.68, 95% CI = 0.54-0.85) than peers without VI. In other models, near VI was associated with lower odds of having and knowing how to use a phone (OR, 0.56; 95% CI, 0.36-0.87), computer (OR, 0.57; 95% CI, 0.44-0.75), or tablet (OR, 0.65; 95% CI, 0.52-0.81) compared with no near VI. CSI was associated with lower odds of having and knowing how to use a phone (OR, 0.66; 95% CI, 0.45-0.99) or computer (OR, 0.72; 95% CI, 0.55-0.93) compared with no CSI. Distance VI was only associated with lower odds of having and knowing how to use a cellphone (OR, 0.63; 95% CI, 0.41-0.95). Any VI and individual categorical VI measures were not associated with other outcomes of digital health- and nonhealth-related experiences. Similar associations were noted when vision was examined on a continuous scale. However, worse distance acuity (per 0.1 logMAR) was associated with being less likely to visit with family or friends on a video call (OR, 0.91; 95% CI, 0.84-0.98) and to order or refill prescriptions online (OR, 0.90; 95% CI, 0.83-0.97).

Conclusions and Relevance

Results suggest that older US adults with VI were less likely to have access to digital technology than peers without VI, although no differences were noted in the report of digital health- and nonhealth-related activities. These findings highlight the potential for inequities that may arise in telehealth for older adults with VI and the necessity to develop strategies to improve accessibility of telemedicine for all.