Self-reported vision and hallucinations in older adults: results from two longitudinal US health surveys

Association of Visual Impairment With Neuropsychiatric Symptoms of Dementia

BACKGROUND

Visual impairment is a risk factor for cognitive impairment and hallucinations in older adults, but associations with other neuropsychiatric symptoms (NPS) of dementia have not been examined.

METHODS

We analyzed cross-sectional data from the Aging, Demographics, and Memory Study (ADAMS), a nationally representative sample of the US population aged 70+ years. Vision was measured by self-report and using a near card. Dementia was ascertained through cognitive testing with expert consensus, and NPS were screened using the Neuropsychiatric Inventory. We used logistic regression to measure the association between visual impairment and prevalent NPS adjusting for sociodemographic factors and comorbidities. Analyses incorporated sample weights to account for the complex survey design of ADAMS.

RESULTS

Of 624 participants with dementia, 332 (53%) had self-reported visual impairment and 193 (31%) had best-corrected acuity of 20/40 or worse. In unadjusted models, self-reported visual impairment was significantly associated with hallucinations (OR 2.88; 95% CI 1.12-7.44), depression (OR 2.79; 95% CI 1.7-4.57), and agitation (OR 1.61; 95% CI 1.05-2.48). Reduced visual acuity was associated with hallucinations (OR 10.13; 95% CI 2.93-34.98), psychosis (OR 6.69, 95% CI 2.53-17.7), and mania (OR 5.92, 95% CI 1.77-19.82). However, these associations did not remain significant after covariate adjustment.

CONCLUSIONS

Visual impairment was associated with hallucinations, depression, agitation, psychosis, and mania in patients with dementia, but at least some of this relationship is explained by age, comorbidities, and other factors.

Disparities in glaucoma and macular degeneration healthcare utilization among persons living with dementia in the United States

PURPOSE

Dementia is common among patients with primary open angle glaucoma (POAG) and neovascular age-related macular degeneration (nAMD). This study compares visit frequency, diagnostic test utilization, and treatment patterns for POAG and nAMD among persons with vs. without dementia.

METHODS

Optum's de-identified Clinformatics® Data Mart Database (January 1, 2000-June 30, 2022) was used for this study. Two cohorts were created from newly diagnosed POAG or nAMD patients. Within each cohort, an exposure cohort was created of newly diagnosed dementia patients. The primary outcome was the number of visits to an eye care provider. Secondary analyses for the POAG cohort assessed the number of visual field tests, optical coherence tomography (OCT), and glaucoma medication prescription coverage. The secondary analysis for the nAMD cohort included the number of injections performed. Poisson regression was used to determine the relative rates of outcomes.

RESULTS

POAG patients with dementia had reduced rates of eye care visits (RR 0.76, 95% CI: 0.75-0.77), lower rates of testing utilization for visual fields (RR 0.66, 95% CI: 0.63-0.68) and OCT (RR 0.67, 95% CI: 0.64-0.69), and a lower rate of glaucoma prescription medication coverage (RR 0.83, 95% CI: 0.83-0.83). nAMD patients with dementia had reduced rates of eye care visits (RR 0.74, 95% CI: 0.70-0.79) and received fewer intravitreal injections (RR 0.64, 95% CI: 0.58-0.69) than those without dementia.

CONCLUSIONS

POAG and nAMD patients with dementia obtained less eye care and less monitoring and treatment of their disease. These findings suggest that this population may be vulnerable to gaps in ophthalmic care.

Interaction between visual impairment and genetic risk of dementia and psychosis in older adults

BACKGROUND

Visual impairment (VI) is associated with dementia and other neuropsychiatric outcomes, but previous studies have not considered genetic sources of confounding or effect modification.

METHODS

We analysed data from the Health and Retirement Study, an ongoing nationally representative survey of older US adults, a subset of whom underwent genetic testing from 2006 to 2012 (n = 13 465). Using discrete time proportional hazards models and generalised estimating equations, we measured the association between VI and dementia, depression and hallucinations adjusting for demographics and comorbidities, ancestry-specific principal components and polygenic risk scores (PRS) for Alzheimer's disease, major depressive disorder or schizophrenia. Effect modification was assessed using VI-PRS interaction terms and stratified analyses.

RESULTS

VI was associated with dementia, depression and hallucinations after adjusting polygenic risk and other confounders. There was no VI-PRS interaction for dementia or depression. However, the association between VI and hallucinations varied by genetic risk of schizophrenia. Within the bottom four quintiles of schizophrenia PRS, VI was not associated with hallucinations among White (OR 1.16, 95% CI: 0.87-1.55) or Black participants (OR 0.96, 95% CI: 0.49-1.89). In contrast, VI was strongly associated with hallucinations among White (OR 2.08, 95% CI: 1.17-3.71) and Black (OR 10.63, 95% CI: 1.74-65.03) participants in the top quintile of schizophrenia PRS.

CONCLUSIONS

The association between VI and neuropsychiatric outcomes is not explained by shared genetic risk factors, and there is a significant interaction between VI and polygenic risk of hallucinations in older adults.

Self-reported Visual Difficulty, Age-related Eye Disease, and Neuropsychiatric Outcomes in Older Adults

PURPOSE

Self-reported visual difficulty is consistently associated with dementia and other neuropsychiatric outcomes, but studies of specific age-related eye diseases have yielded conflicting results.

METHODS

We conducted a retrospective cohort study using data from The National Health and Aging Trends Study, an ongoing nationally representative survey of older U.S. adults (n = 10,089). All subjects are screened for self-reported visual difficulty annually. Using linked Medicare claims data, we identified subjects with age-related macular degeneration (AMD), primary open-angle glaucoma (POAG), diabetic retinopathy, and cataract. For each condition, controls with complete Medicare eligibility and at least one eye care encounter were selected. We used semiparametric discrete time proportional hazards models to measure associations with incident dementia, and generalized estimating equations to examine longitudinal associations with depression, anxiety, and hallucinations, adjusting for baseline demographics and time-varying comorbidities.

RESULTS

Self-reported visual difficulty was associated with dementia (HR 1.16, 95% CI: 1.00-1.34), depression (OR 1.14, 95% CI: 1.04-1.26), anxiety (OR 1.17, 95% CI: 1.06-1.29), and hallucinations (OR 1.54, 95% CI: 1.29-1.84). Diabetic retinopathy was associated with depression (OR 1.31, 95% CI: 1.05-1.64), and cataracts were associated with a lower risk of depression (OR 0.84, 95% CI: 0.74-0.95) and anxiety (OR 0.86, 95% CI: 0.75-0.99). There were no other associations between age-related eye disease and neuropsychiatric outcomes.

CONCLUSION

Self-reported visual difficulty is associated with dementia and other neuropsychiatric outcomes to a greater degree than age-related eye disease. These findings highlight the distinction between self-reported vision and clinically diagnosed eye disease with regard to health outcomes in older adults.

Association between visual impairment and psychosis: A longitudinal study and nested case-control study of adults

BACKGROUND

Theories propose that visual impairment might increase the risk of psychosis, and vice versa. We aimed to investigate the relationship between visual impairment and psychosis in the UK Biobank cohort.

STUDY DESIGN

In a nested case control study of ~116,000 adults, we tested whether a Schizophrenia Spectrum Disorder (SSD) diagnosis as exposure was associated with visual impairment. We also tested longitudinally whether poorer visual acuity, and thinner retinal structures on Optical Coherence Tomography (OCT) scans in 2009 were associated with psychotic experiences in 2016. We adjusted for age, sex, depression and anxiety symptoms; and socioeconomic variables and vascular risk factors where appropriate. We compared complete case with multiple imputation models, designed to reduce bias potentially introduced by missing data.

RESULTS

People with visual impairment had greater odds of SSD than controls in multiply imputed data (Adjusted Odds Ratio [AOR] 1.42, 95 % Confidence Interval [CI] 1.05-1.93, p = 0.021). We also found evidence that poorer visual acuity was associated with psychotic experiences during follow-up (AOR per 0.1 point worse visual acuity score 1.06, 95 % CI 1.01-1.11, p = 0.020; and 1.04, 95 % CI 1.00-1.08, p = 0.037 in right and left eye respectively). In complete case data (15 % of this cohort) we found no clear association, although confidence intervals included the multiple imputation effect estimates. OCT measures were not associated with psychotic experiences.

CONCLUSIONS

Our findings highlight the importance of eye care for people with psychotic illnesses. We could not conclude whether visual impairment is a likely causal risk factor for psychosis.

Investigating the association between schizophrenia and distance visual acuity: Mendelian randomisation study

BACKGROUND

Increased rates of visual impairment are observed in people with schizophrenia.

AIMS

We assessed whether genetically predicted poor distance acuity is causally associated with schizophrenia, and whether genetically predicted schizophrenia is causally associated with poorer visual acuity.

METHOD

We used bidirectional, two-sample Mendelian randomisation to assess the effect of poor distance acuity on schizophrenia risk, poorer visual acuity on schizophrenia risk and schizophrenia on visual acuity, in European and East Asian ancestry samples ranging from approximately 14 000 to 500 000 participants. Genetic instrumental variables were obtained from the largest available summary statistics: for schizophrenia, from the Psychiatric Genomics Consortium; for visual acuity, from the UK Biobank; and for poor distance acuity, from a meta-analysis of case-control samples. We used the inverse variance-weighted method and sensitivity analyses to test validity of results.

RESULTS

We found little evidence that poor distance acuity was causally associated with schizophrenia (odds ratio 1.00, 95% CI 0.91-1.10). Genetically predicted schizophrenia was associated with poorer visual acuity (mean difference in logMAR score: 0.024, 95% CI 0.014-0.033) in European ancestry samples, with a similar but less precise effect that in smaller East Asian ancestry samples (mean difference: 0.186, 95% CI -0.008 to 0.379).

CONCLUSIONS

Genetic evidence supports schizophrenia being a causal risk factor for poorer visual acuity, but not the converse. This highlights the importance of visual care for people with psychosis and refutes previous hypotheses that visual impairment is a potential target for prevention of schizophrenia.

Association Between Childhood Visual Acuity and Late Adolescent Psychotic Experiences: A Prospective Birth Cohort Study

A cross-sectional association between visual impairment and psychosis exists, but longitudinal evidence from children and young people is limited. We investigated whether childhood visual acuity was associated with subsequent psychotic experiences. Our sample was 6686 individuals from the Avon Longitudinal Study of Parents and Children (ALSPAC). We investigated whether our primary exposures, best corrected visual acuity at ages 7 and 11, were associated with psychotic experiences at ages 17 and 24. We also tested whether the following exposures at ages 7 and 11 were associated with subsequent psychotic experiences: requiring glasses, presence of any visual impairment, and between-eye visual acuity difference; and at age 7: strabismus, measures of binocular vision, history of eye patch, near vision impairment, and abnormal saccadic or pursuit eye movements. Analyses used multilevel models before and after adjusting for confounders. Odds of psychotic experiences increased with each 0.1-point deterioration in visual acuity score at age 11 (adjusted odds ratio [AOR] 1.23; 95% confidence interval [CI] 1.06-1.42), and at age 7 (AOR 1.18; 95% CI 1.00-1.40). Wearing glasses and visual impairment at age 11 were associated with psychotic experiences (AOR 1.63; 95% CI 1.21-2.19; AOR 1.64; 95% CI 1.23-2.19, respectively). There was no evidence of an association with other visual exposures. Visual acuity impairment in childhood is associated with psychotic experiences in late adolescence. Future research should aim to elucidate the nature of this association.

Vision loss and hallucinations: perspectives from neurology and ophthalmology

PURPOSE OF REVIEW

The aim of this article is to summarize the evidence for visual impairment as a risk factor for visual hallucinations in neurologic disease and recent advances in our understanding of the central visual pathways that mediate this association.

RECENT FINDINGS

Recent studies have described the prevalence Charles Bonnet syndrome and questioned its lack of association with cognitive impairment, used advanced neuroimaging to show that disinhibition of the occipital lobe is involved in the pathogenesis of visual hallucinations in Parkinson's disease, and demonstrated that visual impairment because of eye disease is a consistent risk factor for visual hallucinations across a number of different neurodegenerative disease populations.

SUMMARY

Through connections between the primary visual cortex and other brain structures, visual function is closely tied to visual hallucinations. Given that the vast majority of vision loss is caused by ophthalmic disease, much of which is preventable or treatable, the detection and treatment of vision loss in at-risk populations may reduce the burden and consequences of visual hallucinations in older adults.

Associations between psychosis and visual acuity impairment: A systematic review and meta-analysis

OBJECTIVES

Several theories propose that visual acuity impairment is associated with psychosis. Visual impairment could lead to psychosis or the converse, or they may share underlying pathology or risk factors. In the first evidence synthesis in this area for over 25 years, we collated studies measuring the association between visual acuity impairment and psychosis.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, and Web of Science databases for studies published from 1992 to 2020, using the Newcastle Ottawa Scale to assess risk of bias. We narratively synthesized findings and meta-analyzed sufficiently homogenous results.

RESULTS

We included 40 papers, which reported on 31 studies. Evidence from seven cohort studies was inconsistent, which precluded meta-analysis of this study design. These contradictory results also made it difficult to draw conclusions regarding a temporal association. We found evidence for an association from eight cross-sectional studies treating visual acuity impairment as the exposure and psychosis as the outcome [pooled odds ratio (OR) =1.76, 95% confidence interval (CI): 1.34-2.31], and four with the reverse exposure and outcome (OR: 1.85, 95% CI: 1.17-2.92). Seven case-control studies with mixed findings were found, but only two primarily addressed our research question, and these findings were mixed.

CONCLUSIONS

Although evidence supports a cross-sectional association between visual acuity impairment and psychosis, further research is needed to clarify the temporal direction, given the mixed findings in cohort studies. Understanding the association may give insights into prevention strategies for people at risk of visual acuity impairment and psychosis.