Visual functioning in nursing home residents: information in client records

Impact of an intervention for avoidable vision loss on visual function in the elderly-The Hyderabad Ocular Morbidity in Elderly Study (HOMES)

BACKGROUND/OBJECTIVES

To report the impact of interventions for avoidable vision impairment (VI) on the visual function of elderly residents in 'homes for the aged' in India.

METHODS

Participants aged ≥60 years were recruited. A comprehensive eye examination was conducted by trained examiners and interventions were provided. Trained social investigators administered the Indian Vision Function questionnaire (INDVFQ) to assess visual function before and after the intervention (spectacles, cataract surgery or laser capsulotomy). Lower scores on IVFQ imply better visual function. VI was defined as presenting visual acuity worse than 6/18 in the better eye. VI due to cataract, uncorrected refractive errors, and posterior capsular opacification after cataract surgery were considered avoidable VI.

RESULTS

The mean age of the participants (n = 613) was 73.8 years (standard deviation: 8.1 years) and 378 (62.2%) were women. 64/103 (62.1%) participants who had avoidable VI at baseline were evaluated after the intervention. Significant gains were observed in all four domains of visual function. There was a 14.9% improvement in mobility scores (33.8 versus 28.8; p = 0.03), a 19.9% improvement in the activity limitations score (36.8 versus 29.5; p < 0.01), a 10.9% improvement in the psychosocial impact score (41.1 versus 36.6; p < 0.01) and a 13.6% improvement in the visual symptoms score (49.2 versus 42.5 p < 0.01). Overall, the mean IVFQ score improved by 16.4% (47.6 versus 39.8; p < 0.01).

CONCLUSION

Elderly individuals in residential care with avoidable VI had a significant improvement in visual function after relatively low-cost interventions such as spectacles and cataract surgery. Strategies are needed to provide these interventions for the elderly in 'homes for the aged' in India.

Prevalence of sensory impairments in home care and long-term care using interRAI data from across Canada

BACKGROUND

In the general population, sensory impairments increase markedly with age in adults over 60 years of age. We estimated the prevalence of hearing loss only (HL), vision loss only (VL), and a combined impairment (i.e., dual sensory loss or DSL) in Canadians receiving home care (HC) or long-term care (LTC).

METHODS

Annual cross-sectional analyses were conducted using data collected with one of two interRAI assessments, one used for the HC setting (n = 2,667,199), and one for LTC (n = 1,538,691). Items in the assessments were used to measure three mutually exclusive outcomes: prevalence of VL only, HL only, or DSL. Trends over time for each outcome were examined using the Cochran-Armitage trend test. A negative binomial model was used to quantify the trends over time for each outcome while adjusting for age, sex and province.

RESULTS

In HC, there was a significant trend in the rate for all three outcomes (p < 0.001), with a small increase (roughly 1%) each year. In HC, HL was the most prevalent sensory loss, with a rate of roughly 25% to 29%, while in LTC, DSL was the most prevalent impairment, at roughly 25% across multiple years of data. In both settings, roughly 60% of the sample was female. Males in both HC and LTC had a higher prevalence of HL compared to females, but the differences were very small (no more than 2% in any given year). The prevalence of HL differed by province after adjusting for year, age and sex. Compared to Ontario, Yukon Territory had a 26% higher rate of HL in HC (relative rate [RR] = 1.26; 95% confidence interval [CI]:1.11, 1.43), but LTC residents in Newfoundland and Labrador had a significantly lower rate of HL (RR: 0.57; CI: 0.43, 0.76).When combined, approximately 60% of LTC residents, or HC clients, had at least one sensory impairment.

CONCLUSIONS

Sensory impairments are highly prevalent in both HC and LTC, with small sex-related differences and some variation across Canadian provinces. The interRAI assessments provide clinicians with valuable information to inform care planning and can also be used to estimate the prevalence of these impairments in specific population sub-groups.

Identifying and Managing Hearing and Vision Loss in Older People in Care Homes: A Scoping Review of the Evidence

BACKGROUND AND OBJECTIVES

Poor identification of sensory impairments in care homes can be due to multiple factors. This scoping review identifies and synthesizes the literature into the detection of hearing and vision loss in the care home environment, and the management of these sensory losses once identified.

RESEARCH DESIGN AND METHODS

A scoping review methodology was used to identify primary research of any design published from 1985 to September 2018. Six electronic databases were searched, and articles were also sourced from reference lists, relevant charity organizations and published experts.

RESULTS

Six electronic databases and multiple gray literature sources identified 51 articles for inclusion. The evidence confirmed that lack of knowledge in care home staff, poor management of assistive aids, unsuitable environment, lack of connections with optometrists and audiologists, underuse of effective screening tools, and the added complexity of assisting those with dementia are all barriers to effective practice. Conversely, flexible training programs, availability of a variety of assistive aids, simple screening tools, and adaptions to the environment are effective facilitators.

DISCUSSION AND IMPLICATION

This review acknowledges that the barriers to identification and management of hearing and vision loss in care homes are multifaceted and that collaboration of multiple stakeholders is required to implement change and improve the residents' ear and eye care. Recommendations are offered to support more effective service provision tailored to meet the needs of people with sensory impairments living in care homes, and this could subsequently improve best practice.

Prevalence and risk factors for visual impairment among elderly residents in 'homes for the aged' in India: the Hyderabad Ocular Morbidity in Elderly Study (HOMES)

Background/Aim

To investigate the prevalence, causes and risk factors of visual impairment (VI) among the elderly in ‘home for the aged’ in Hyderabad, India.

Methods

Individuals aged ≥60 years were recruited from 41 ‘homes for the aged’. All participants had complete eye examinations including presenting visual acuity, refraction, slit-lamp examination, intraocular pressure measurement and fundus imaging by trained clinicians. VI was defined as presenting visual acuity worse than 6/18 in the better eye. Multivariate logistic regression was used to determine the risk factors associated with VI.

Results

1512 elderly residents from 41 homes for the aged were enumerated, of whom 1182 (78.1%) were examined. The mean age of examined participants was 75.0 years (SD 8.8 years; range: 60–108 years); 35.4% of those examined were men. The prevalence of VI was 30.1% (95% CI 27.5 to 32.8). The leading cause of VI was cataract (46.3%, n=165), followed by uncorrected refractive error (27.0%, n=96), posterior capsular opacification (14.9%, n=53) and posterior segment disease (6.5%, n=23). Overall, 88.2% of the VI was either treatable or correctable. In multiple logistic regression, those aged 80 years and older (OR: 1.7, p<0.01), living in ‘free’ homes (OR: 1.5, p<0.01) and who were immobile/bedridden (OR: 3.02, p<0.01) had significantly higher odds of VI. Gender was not associated with VI.

Conclusions

VI was common and largely avoidable in residents of ‘homes for the aged’ in Hyderabad, India. Screening for vision loss in ‘homes for aged’ and the provision of appropriate services should become routine practice to achieve the goal of healthy ageing in India.

Hyderabad Ocular Morbidity in Elderly Study (HOMES) - Rationale, Study Design and Methodology

Purpose: To describe the study design, interobserver variability of the questionnaires and clinical procedures of Hyderabad Ocular Morbidity in Elderly Study (HOMES) designed to, (a) to investigate the prevalence, causes and risk factors for visual impairment, and (b) to assess the impact of dispensing spectacles and cataract surgery on visual functions, fear of falls (FOF) and depression among the elderly in India.Methods: Individuals aged ≥60 years are considered elderly. The non-clinical protocol was administered by two trained investigators and included collection of personal, sociodemographic information, ocular and systemic history, Indian Visual Function Questionnaire (IND-VFQ33), Patient Health Questionnaire (PHQ9), Mini-Mental State Examination (MMSE) questionnaire, Hearing Handicap Inventory for the Elderly Screening (HHIE), Short Falls Efficacy Scale (SFES) questionnaire. The eye examination was conducted by a trained optometrist and vision technicians in clinics set-up in the homes and included visual acuity (VA) assessment for distance and near, anterior segment examination and fundus examination, and imaging. The reliability assessments were carried out among 138 participants.Result: The intraclass correlation (ICC) coefficients for MMSE, PHQ9, HHIE, SFES was 0.73 (95% CI: 0.62-0.81), 0.67 (95% CI: 0.54-0.77), 0.63 (95% CI: 0.48-0.74) and 0.70 (95% CI: 0.58-0.79) respectively. The ICC for INDVFQ domains ranged from 0.66 (95% CI: 0.55-0.74) for Psychosocial Impact to 0.88 (95% CI: 0.84-0.91) for activity limitation. The ICC for VA was 0.94 (95% CI: 0.92-0.96).Conclusion: All questionnaires demonstrated acceptable reliability and can be applied in the main study. HOMES is expected to provide data that will help plan strategies to contribute towards 'healthy aging' in India.

Exploring the sensory screening experiences of nurses working in long-term care homes with residents who have dementia: a qualitative study

BACKGROUND

The prevalence of vision and hearing loss is higher amongst older individuals with dementia, as well as higher in long-term care settings than in the wider community. However, the incidence of sensory impairment is underreported and often goes untreated. In this study, we aimed to understand nurses' current experiences of screening and caring for long-term care residents who have dementia and sensory impairment.

METHODS

As part of a larger study on the sensory screening of long-term care residents with dementia, an environmental scan was conducted with front-line healthcare providers. We report here on the findings from the content analysis of individual, semi-structured interviews with nurses working in two long-term care homes in Southern Ontario, Canada. Twenty regulated nurses, including designated resident assessment coordinators, working full- or part-time with individuals who have dementia, participated across the two sites. All interviews were transcribed, and their contents reviewed and coded for themes by means of inductive thematic analysis.

RESULTS

Following a systematic and recursive approach, three analysts identified several themes relating to: 1) the sensory screening process, 2) communication strategies, and 3) quality of life, sensory loss, and dementia. Participants reported on the strengths and limitations of screening procedures, what improvements should be made, which informal strategies are effective, and the continued professional development that is needed.

CONCLUSIONS

Nurses demonstrated insight into the facilitators and barriers to effective screening and care of residents with dementia and sensory impairments, and expressed the need for further education, more suitable screening tools, and formalised accountability within the screening process for vision and hearing loss in these long-term care residents.

Recommendations for successful sensory screening in older adults with dementia in long-term care: a qualitative environmental scan of Canadian specialists

OBJECTIVES

This study aimed to identify screening tools, technologies and strategies that vision and hearing care specialists recommend to front-line healthcare professionals for the screening of older adults in long-term care homes who have dementia.

SETTING

An environmental scan of healthcare professionals took place via telephone interviews between December 2015 and March 2016. All interviews were audio recorded, transcribed, proofed for accuracy, and their contents thematically analysed by two members of the research team.

PARTICIPANTS

A convenience sample of 11 professionals from across Canada specialising in the fields of vision and hearing healthcare and technology for older adults with cognitive impairment were included in the study.

OUTCOME MEASURES

As part of a larger mixed-methods project, this qualitative study used semistructured interviews and their subsequent content analysis.

RESULTS

Following a two-step content analysis of interview data, coded citations were grouped into three main categories: (1) barriers, (2) facilitators and (3) tools and strategies that do or do not work for sensory screening of older adults with dementia. We report on the information offered by participants within each of these themes, along with a summary of tools and strategies that work for screening older adults with dementia.

CONCLUSIONS

Recommendations from sensory specialists to nurses working in long-term care included the need for improved interprofessional communication and collaboration, as well as flexibility, additional time and strategic use of clinical intuition and ingenuity. These suggestions at times contradicted the realities of service provision or the need for standardised and validated measures.

Effectiveness of a nurse-supported self-management programme for dual sensory impaired older adults in long-term care: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse-supported self-management programme to improve social participation of dual sensory impaired older adults in long-term care homes.

DESIGN

Cluster randomised controlled trial.

SETTING

Thirty long-term care homes across the Netherlands.

PARTICIPANTS

Long-term care homes were randomised into intervention clusters (n=17) and control clusters (n=13), involving 89 dual sensory impaired older adults and 56 licensed practical nurses.

INTERVENTION

Nurse-supported self-management programme.

MEASUREMENTS

Effectiveness was evaluated by the primary outcome social participation using a participation scale adapted for visually impaired older adults distinguishing four domains: instrumental activities of daily living, social-cultural activities, high-physical-demand and low-physical-demand leisure activities. A questionnaire assessing hearing-related participation problems was added as supportive outcome. Secondary outcomes were autonomy, control, mood and quality of life and nurses' job satisfaction. For effectiveness analyses, linear mixed models were used. Sampling and intervention quality were analysed using descriptive statistics.

RESULTS

Self-management did not affect all four domains of social participation; however. the domain 'instrumental activities of daily living' had a significant effect in favour of the intervention group (P=0.04; 95% CI 0.12 to 8.5). Sampling and intervention quality was adequate.

CONCLUSIONS

A nurse-supported self-management programme was effective in empowering the dual sensory impaired older adults to address the domain 'instrumental activities of daily living', but no differences were found in addressing the other three participation domains. Self-management showed to be beneficial for managing practical problems, but not for those problems requiring behavioural adaptations of other persons.

TRIAL REGISTRATION NUMBER

NCT01217502; Results.

Problems identified by dual sensory impaired older adults in long-term care when using a self-management program: A qualitative study

OBJECTIVE

To gain insights into the problems of dual sensory impaired older adults in long-term care. Insights into these problems are essential for developing adequate policies which address the needs of the increasing population of dual sensory impaired older adults in long-term care.

METHODS

A qualitative study was conducted in parallel with a cluster randomized controlled trial. Dual sensory impaired older adults in the intervention group (n = 47, age range 82-98) were invited by a familiar nurse to identify the problems they wanted to address. Data were taken from the semi-structured intervention diaries in which nurses noted the older adults' verbal responses during a five-month intervention period in 17 long-term care homes across the Netherlands. The data were analyzed using descriptive statistics and qualitative content analysis based on the Grounded Theory.

FINDINGS

The 47 dual sensory impaired older adults identified a total of 122 problems. Qualitative content analysis showed that the older adults encountered participation problems and problems controlling what happens in their personal environment. Three categories of participation problems emerged: (1) existential concerns of not belonging or not being able to connect with other people, (2) lack of access to communication, information and mobility, and (3) the desire to be actively involved in care delivery. Two categories of control-in-personal-space problems emerged: (1) lack of control of their own physical belongings, and (2) lack of control regarding the behavior of nurses providing daily care in their personal environment.

CONCLUSIONS

The invasive problems identified indicate that dual sensory impaired older adults experience great existential pressures on their lives. Long-term care providers need to develop and implement policies that identify and address these problems, and be aware of adverse consequences of usual care, in order to improve dual sensory impaired residents' autonomy and quality of life.

Evaluation of nurses' changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study

OBJECTIVES

To gain insights into the process of nurses' changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions.

DESIGN

Qualitative study alongside a cluster randomised controlled trial.

SETTING

17 long-term care homes spread across the Netherlands.

PARTICIPANTS

34 licensed practical nurses supporting 54 dual sensory impaired older adults.

INTERVENTION

A 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care.

PRIMARY OUTCOMES

Nurses' perceptions on relevance and feasibility of the self-management programme collected from nurses' semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers' reports.

RESULTS

Nurses' initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults' autonomy needs. However, nurses' initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not.

CONCLUSIONS

Longitudinal data collection enabled exploration of nurses' changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond 'protocol thinking', discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time.

TRIAL REGISTRATION NUMBER

NCT01217502, Post-results.

Screening for hearing, visual and dual sensory impairment in older adults using behavioural cues: a validation study

OBJECTIVE

This study investigated the psychometric properties of the Severe Dual Sensory Loss screening tool, a tool designed to help nurses and care assistants to identify hearing, visual and dual sensory impairment in older adults.

DESIGN

Construct validity of the Severe Dual Sensory Loss screening tool was evaluated using Crohnbach's alpha and factor analysis. Interrater reliability was calculated using Kappa statistics. To evaluate the predictive validity, sensitivity and specificity were calculated by comparison with the criterion standard assessment for hearing and vision. The criterion used for hearing impairment was a hearing loss of ≥40 decibel measured by pure-tone audiometry, and the criterion for visual impairment was a visual acuity of ≤0.3 diopter or a visual field of ≤0.3°. Feasibility was evaluated by the time needed to fill in the screening tool and the clarity of the instruction and items. Prevalence of dual sensory impairment was calculated.

RESULTS

A total of 56 older adults receiving aged care and 12 of their nurses and care assistants participated in the study. Crohnbach's alpha was 0.81 for the hearing subscale and 0.84 for the visual subscale. Factor analysis showed two constructs for hearing and two for vision. Kappa was 0.71 for the hearing subscale and 0.74 for the visual subscale. The predictive validity showed a sensitivity of 0.71 and a specificity of 0.72 for the hearing subscale; and a sensitivity of 0.69 and a specificity of 0.78 for the visual subscale. The optimum cut-off point for each subscale was score 1. The nurses and care assistants reported that the Severe Dual Sensory Loss screening tool was easy to use. The prevalence of hearing and vision impairment was 55% and 29%, respectively, and that of dual sensory impairment was 20%.

CONCLUSIONS

The Severe Dual Sensory Loss screening tool was compared with the criterion standards for hearing and visual impairment and was found a valid and reliable tool, enabling nurses and care assistants to identify hearing, visual and dual sensory impairment among older adults.

Effectiveness of a self-management program for dual sensory impaired seniors in aged care settings: study protocol for a cluster randomized controlled trial

BACKGROUND

Five to 25 percent of residents in aged care settings have a combined hearing and visual sensory impairment. Usual care is generally restricted to single sensory impairment, neglecting the consequences of dual sensory impairment on social participation and autonomy. The aim of this study is to evaluate the effectiveness of a self-management program for seniors who acquired dual sensory impairment at old age.

METHODS/DESIGN

In a cluster randomized, single-blind controlled trial, with aged care settings as the unit of randomization, the effectiveness of a self-management program will be compared to usual care. A minimum of 14 and maximum of 20 settings will be randomized to either the intervention cluster or the control cluster, aiming to include a total of 132 seniors with dual sensory impairment. Each senior will be linked to a licensed practical nurse working at the setting. During a five to six month intervention period, nurses at the intervention clusters will be trained in a self-management program to support and empower seniors to use self-management strategies. In two separate diaries, nurses keep track of the interviews with the seniors and their reflections on their own learning process. Nurses of the control clusters offer care as usual. At senior level, the primary outcome is the social participation of the seniors measured using the Hearing Handicap Questionnaire and the Activity Card Sort, and secondary outcomes are mood, autonomy and quality of life. At nurse level, the outcome is job satisfaction. Effectiveness will be evaluated using linear mixed model analysis.

DISCUSSION

The results of this study will provide evidence for the effectiveness of the Self-Management Program for seniors with dual sensory impairment living in aged care settings. The findings are expected to contribute to the knowledge on the program's potential to enhance social participation and autonomy of the seniors, as well as increasing the job satisfaction of the licensed practical nurses. Furthermore, an extensive process evaluation will take place which will offer insight in the quality and feasibility of the sampling and intervention process. If it is shown to be effective and feasible, this Self-Management Program could be widely disseminated.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, NCT01217502.

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.